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HomeMy WebLinkAbout030-2028-60-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) SAN-2018-160 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Parcel Tax No: Mark & Kristen Wallace TOWN OF SAINT JOSEPH 030-2028-60-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 22.30.20.440F2 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM 3f Ciu r G~ Bldg. Sewer Aeration 4Y Holding St/Ht Inlet + d St/Ht Outlet - TANK SETB INFORMATION TANK P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic t Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSI S No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ; t SETBACK SYSTEM TO P/L LDG WELL LAKE/STREAM ACHING facturer: INFORMATION umber Type Of System: C HA ER O UN Model N DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size ix Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ❑ Nc Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1404 HILLTOP RIDGE lL~V,,t k C ~_i 1.) Alt BM Description = ;r, g r;. tU 2.) Bldg sewer length - amount of cover = Plan revision Required? [7' Yes No c~ U Use other side for additional information. L - Date Insepctor's i Cert. No. SBD-6710 (R.3/97) L r l~ County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN \z~>> 1 accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT Perso al information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER * Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road Hudson, WI 54016-7710 2 Q ~-01~ (715)38 6-4680 Fax (715)386-4686 Cd c complete plans for the system on paper not less than 8-1/2 x 11 inches in size. a X pj4 i ary Permit # ec r~vious application r t ~ J I UP.✓ 1. Applicati § 3 ormation - Please Print all Information Location: Property Owner Name 1 /4 1/4, Sec 30 Mark & Kristen Wallace T 30 N, R 20 B((or) W Property Owner's Mailing Address Lot Number Block Number 1404 Hilltop Ridge (owner mailing adress 5791 Highlands Tr N Lake Elmo) 2 City, State Zip Code Phone Numer Subdivision Name or CSM Number Houlton, WI 54082 Holcomb J(6)• 3 1b, BZ.Z. II Type of Building: (check one) 1_ amity ❑ Village Town of U 1 or 2 Family Dwelling - No. of Bedrooms: 3 t)y' Pu SUVM' ~HL St Joseph ❑ Public/Commercial (describe use): y~ ~Aay\ ❑ State-owned Nearest Road If. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 1404 Hill Top Ridge Parcel Tax Number(s) A) 1.0 Repair f.0 Reconnection 3.❑ on-plumbing 4. ❑ Rejuvenation XXXX nitation 030-2028-60-000 B) Permit Number Date Issued ❑o6tate Sanitary Permit was previously issued 58868 10/08/1984 ype of Check all that apply) Fore Y AXPA Non-pressurized In-ground C VeftvrO ound 24 in. suitable soil ❑ Mound 24 in. suitable soil 11 Mound A+0 bvil d r~ S Ki ❑ Sand Filter ~ w t C ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation 1CX15v1V2:!F__ VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks 10 DO C ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) Plumber's Sig tur (n stamps): MP/MPRS No. Business Phone Number Countryside Plumbing & Heatin 664713 715-246-2660 Plumber's Address (Street, City, State, Zip Code) 321 Wisconsin Drive New Richmond WI 54017 VIII. County Use Only Disapproved Sanitary Permit Fee Date Issued I ing A nt Si nature ( o tamps) Approved 11~1' ii tial Adverse ] VD -7f T 7/ le, r~ urination YY'' I (~/l t/ IX. Conditions of Approval/Reasons for Disapproval: l ~l~C~~ct~e MUN9 JITZF Ind,, 1 ~xec4 r/f%s 42c~mi4! ~rvs,'v~ Co~fi-v ON lf7tt r7)e- SEC rcrv;icd ,i 2~pcJqcei~! Cep -~'~af►'c~ S-&)Mzn~ (eve o Rev: 8/05 S~/"CIOI a. ~nJp~r,~ian 9y ~ p/vw.de~1 O o fT1 L, D ip S On N X m T c O X m N m m cn ' cn ti m zo v m co 1 Dm zz!z O n m G1 m~ o _ Oro -ti D III - m T c ro o m > CAT >C >,o '1m 'n , T J T '1 ice. o <O OAS mZ0 oOz m ~ -mac O r O Iz ~m mzF ~~m vmm r Z O p ~O m m D<m z m m z Z m m x=T O ~ o =o f T -,1 C Z n: C c c D ~t cf, ~ C1 r Z N N cf) z m T o+>*O rm, z O M 1 G. OD~>< o. _ zlowr m~zC -4I -4 < ST. CROIX RIVER cOm - O Z> _ 680 = -AWL -s o'- 1V ~ of 71G O~ \ \ _ V A A C) F, M 0 2':, 4 m ~ V 84C ~m m \ - - - - - - - ~ III 1 ~ / X ' 2 ~ - 1 4C SETBACK FROM BLUFF LINE J\ _ 1 v p D~ - - - - - g o Zctt z o 100 SETBACK FROM BLUFF LINE D 23 z + _ 7 ti i o. C, Z m. MT m hm {m , m~z II (q<O ~~z i g I I' \ BE~d~~lao ~ cSFTa 9C~m 1 _ ~0~~.v DPW A o, to mio of of I ial Ti o °r ~ DCK DERRICK HOMES 0 a ra WALLACE RESIDENCE TOWN OF ST. JOSEPH. ST. CROIX COUNTY, WISCONSIN 'sID Wcooadl,u~.,~ L Aub-Consulting/associates gas, SITE ?LAN & PROFILE Wn k: .~aI ch - . ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mark Wallace Mailing Address 57 1 Highlands Trail N, Lake Elmo, MN 55042 404 Hillto~R'td~e-- - - - - - - - - _ Property Addre (Verification required from Planning & Zoning Department for new construction.) City/State Houlton, Wl Parcel Identification Number QeI-i.~all-w-wo LEGAL DESCRIPTION Property Location % , '/4 , Sec. 99-, T JN R_X W, Town of & ~ Subdivision Plat: Certified Survey Map Volume Page ~...._.....~.~_(be-#.ore-2MYo'1uTit~`e-....~..' Pt'agr# Spec house Dyeslf;Ko Lot lines identifiable Kes❑no Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic. tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(]) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my.!our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a rrant}` deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (RF,V. 04/12) Septic System and Well Inspection Report Bird Plumbing Inc 1432 120th St. New Richmond Wi 54017 715-246-4516 Sbird:@frontiernetin.et ! Shaun. Bird, certify that on 5118114 .l XXX Inspected the Septic System (POWTS) XXX Inspected the Well xxx Obtained a drinking-water sample Larry Horsch 1404 Hilltop Ridge Haulton Property OwnerlBuyer Site Address As a result of my inspecton, I certify.that: X7CX In my opinion, the septic system (POWTS) was, on the date of my inspection, in working order and.in compliance with the-standards setforth bythe Department of Safety and Proffesiona! Services. Last:date of pumping-91201201I System appears to be sized for _3_ Bedrooms In my opinion, the well at the date of my inspection, is in good condition and complies with all WDNR.standards. Water sample seat to Quality Water Testing Lab Somerset Wisconsin In my opinion, the septic system or well is not.working.or, not in compliance with the Departmet of Safety and Public Services or WDNR See comments on well and septic system. Septic System maintance information: Pump tank every 3 years, clean effluent filter once a year For further information, contact your Ioealzoning office. Disclosure: This testis not a guarantee of future performance but a proff sional opinion. Usage can change from. different owners. This is not a warranty of this system. 1 disclaim all.li 11 ! for any loss.caused by reliance-on this ce~fication.,Past problems with this system,( if any) need-to be discl t:by the seller.. i _ 5/19/14 Shaun Bird MP.RS/CSTM #226900 DNR# 7640`_ y Date___ Septic System: The septic system is sized.for 3 :bedrooms or up to.~6 persons to be allowed to live in this home at one time. The system is very large and has several drywells instal led'that are all'.cornpletely dry. A-home with greater than 3 bedrooms can be built but a:certificaterof occupancy would need to be filed with the county. This would allow up to 6 people to -live, in this house-at one time. Based on the size of the system, l believe the septic would last a long time with 4-5 people living In the home. When the septic tank is pumped,_ always pump all the drywelis if there is any water in them. i I by e o ~ ~ i qgt - ~ { 1 ~ f F li '•v III il'I ' L- p gg =i° 7 L 711 I I sf i it I ~ ~ I I - III g ICI a al - I I _ ; ~ I Is i o - I 7 I s - I i I I ICI„ I I °I B' °F T~ ~ _ III III III IJ I I a III Hlb =II' Tr h I I I - I I - a - II k ~f i i~' I I I'!I y - I'I i~l r / _ I!11 H III I III } F F g A ~ 4 F Ali ; e _ tr m! I ~ E Ss3aEIpE ➢ ~ R ¢ € s s ~~~a 6~~ DERRICK HOMES 715-246-2320 i o "~3f,df68 ~o~ c ~ z~.~ E. €~5es3dd z~. g~ g aF v WALLACE REEIDENCE ~ C!1 ~3~ °aE a £~e.s mll ~ ~@e¢€ € Y - 9gz a2 5'Qes~ A- ^'e e - b`,~< U4 ~~c r r o z ^--'r a W'"^ z s~F aL R b` R Rs ° < 8z I a ~ P R 4 ~I 5 ° I Fi A ga l ok t_ _ I F~ r ~ I, r la , ~I. b ~s -4I _Jl REM- Lc • I a? ~I4~ Q Icy - __f_ i I I - % i I ~r e T~ I k I F Ir P£~ a 11 NN ~b I y _ I aE-ass e 4 y ~g g8~x~ aI DERRICK HOMES 7,5-246-2320 I _-A WALLACE RESIDENCE a she F ~ a ~ P . s ; q s9aa Rr~ d I ~ I 1002 RI: t 41',~e : o s 8 - - - - - - - - - - - - - - - - - % /y•~ - P4z of i s I I mt l u II z g _ m Ie I~ P a ~.i' 47 { I' E 14 I ,v I +ro W m ~ soy DERRICK BIOMES 715-246-2320 lea g4€_ YIALLACE RESIDENCE ^„pR3~~ ae € E W, 7 Qi~ gs aE a a~~~ gq v E_ CIF ~ C 94 a~: fF •a2 ~ d S'- e E DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS DIVISION LABOR & HOMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING p!OrBOX %969 _71 MDOX 96 53707 ALTERNATIVE wale Plan LD Num xr 'CONVENTIONAL - a,;9neel D Holding Tank ❑ In-Ground Pressure E] Mound INSPECTION DATE. I NAME OF PERMIT HOLDER. ADDRESS OF PERM17 HOLDER: MN Stan Haniz,6 301 S. 3td St. , Sti iUWatet, REF. IT. . E ELEV.: CST REF. PT. ELE 1.. BENCH MARK IPermanem reference -nil DESCRIBE IF DIFFERENT FROM PLAN SE Sul, SEctan 22,T30N-R20W, Lot02,Hot-comb Sub,Tvwn v~ S- Joh ePh ~nrary Name P-., Number IMP/MPRSW Nc.' Coumv 58868 lumber. Dan Sch-mZt 3205 S Cnv~ x CO EF SEPTIC TANK/HOLDING TANK: LIQUID CAPACITY TAIN LcT ELEV TANK OUT' ET ELEV. WARNING LABEL LD MANUFACTURER P V YES O' 6 7y, 1~~ (6 YES ❑NO S N0 GH WATER NUMBER OF ROAD' RO IN PER Y (WEf LL 11-DING '1 . ANT TO FRESH BEDDING. LG IR INLET VENT MAIL IMI LARM ~ VENT olfjA ~A FEET FROM I C)r / ! V I l"' U V YFC, `I ❑ YES LJ NO NEAREST DOSING CHAMBER: UMPiSIP ON MANUFACTURER WARNING LABEL ING CO R MANUFACTURER BEDDING- tIOUI(J CAPACITY PUMF MODEL PROVIDED'. iDED: f 7-'YES DN Y NO L,JYES INC PROPER`?" L✓ WELL IL ING. , RESH GLLNS PER CYCLE, PUMP 4NO CONTROLS 0 E ATIONAL NUMBER OF NE 1 AI INLET. / FEET FROM / BETWEEN ❑YES NO NEAREST MON AND OFF) LENGTl1 DIAMETEF MATERIAL ANUMaRK Q SOIL ABSORPTION SYSTEM. Check the soil moisture aT the depth of owing FORCE or excavation. (I soil can be roiled into a wire, construction Shall cea.e until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: NSIDE DIA -PITS uoulD - LENGTH, ~t NO„ DISTR PIPE SPACING COVER D tj I J` l7/ $ED(TRENCH WIDTH (i T R=NC MATERIAL PIT DIMENSIONS f OF PROP RTY WELL UILDING VENT TO FRESH GRAVE DEPTH FILL DEPTH DIST R. P,P. gtSTR. PIP DISTR. PIPE MATERIAL'. NC. DISTR NUMBER LINE AIR INLET. PIPES- FEET FROM BELOW PIPES ABOVE COVER El EV I'MIL; - r FLEV EN NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material r PROVIDE A DIAGRAM OF SYSTEM TON REVERSE SIDE. ONS MEASURED. SHOW ELEVA- and furrows thrown upslope: mound systems to make certain t t it _ meets the criten medium sand. DYES NO PER ANEN7 MARKE i OBSER VAIION WELLS SOIL COVER TEXTURE / DYES ~JNO DYES ❑NO SEEDED MULCHEC / ~i pEP7H OVER THE NC H:BEC DEPTH OVEF TH ENCHiBF D DEPTH OF70PSOIj t DDED RENTER EDGES J ES NO DYES LJN0 ❑YES ~JNO i J PRESSURIZED DISTRIBUTION SYSTEM: f FILL DEPTH ABOVE COVER WIDTH LENGTH NO. OF LATEfR,' SPACING'. GHA L PTH BELOW PIPE BED/TRENCH TRENCHES t + DIMENSIONS 1 PUM° MANIFOLD D PIPE MANiFO ATERIAL NO DISTR DD'SATF PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELMAENVIFOLD ELEV. I MANIFOLD E V' PIPES . 1 ELEVATION AND DISTRIBUTION COVER MATERIAL V RRTICAL LIF? CORRESPONDS TO APPROVED SIZE HOLE SPACING DRILLED CORRE LY PLANS INFORMATION HOLE ❑YES DNO YES JNC NUMBER OF rROPERTY WELL ]BC COMMENTS: PERMANENT MARKERS IOBSERV ATION WELLS 'FEETFROM +LINE. ❑YES ❑ NO I YES ❑ NO NEAREST Retain In ounty file for audit. Sketch System on Reverse Side. TITLE - s c N Alj,lf>-E' j DI LHR SB D 67 10 1 R. 01 /62) -=W' J; J F SANITARY PERMIT COUNTY pppLICgT10N FOR wwwom-ow w!sconsln (PLB 67) UNIFORM SANITARY PERMIT r LHR OEOGWTTnEr1 BQp b HUrT1Rtl FIELF1T10`ZS ' IrlOUSTP V,LR d with s. H 63-M5, Wis. Adm. Code for the system, on PaPe'no*. less than 8'/ x 11 inches in size. acco' this application. PLEASE PRINT let plans ill ctions 1 tin st uctio -Attach comp for comp ° 9 MAILING ADDRE ~ 's ~LLC' _See reverse side for in. 1 PROPERT,,' OWNER 5,r ,q PLAN I.D. NUMBER ST AT OF LANMARK PROPERTY LOCATION 20E (Dr VII TOWN D PROPERTY ) NEAREST ROAD, LAKE ,114 S s ( NU ~I4 MBER BLOCK NUMBER SUBDI~~ N NAME LOT TYPE OF BUILDING OR USE SERVED Public (Specify): 1 1 or 2 Family Number of Bedrooms. Repair THIS PERMIT IS FOR A: Tank Replacement J Privy ` New System Revision Petition for Modification I Replacement Soil Absorption System J Reconnection Alternate System Holding Tank 51, Seepage Piti Pit Privy IF THIS IS A CONVENTIONAL SYSTEMS Op Trench THIS BLOC Vault Privy Seepage Bed ~in-Ground Pressure _ Issued System-I n-F III ected And Vs Compliant As Far As Soil Conditions. On File, Permit + Site Steel Fiberglass plastic Existing, For Which A Previous Permit Is That Has Been Insp Prefab. An Existing System Total ' °f Constructed Concrete Tank<_ Cc Galions Septic Tank Capacity' fi Litt pump Tank/Siphon Chamber aQ Holding Tank capacity _ ti In Ground Pressure ^ Mound Plastic ' Manufacturer. Site steel Fiberglass ipp of Pretab . IF THIS IS AN ALTERNATIVE SYSTEM COMP LE TE ota1HIS BLO C Concrete Constructed Galions ~ t Septic Tank Capacity Litt Pump/Siphon Chamber PPLY: Manutacturer: ABSORPTION AREA WATER SU ABSORPTION AREA PROPOSED (Square Feet 1: point Public PERCOLATION RATE REQUIRED (Square Feet: LVl Private - (Minutes Per inch)' 0 LJQ P a e s stem shown on the attached plans. private swag y W N'o : Phone Number. assume responsibility for installation of the P NI pRS - S c , ~/5 .S I, the undersigned, hereby S;gna~ 1 %Z- '5J Name o` Plumber (Print) Name of Designer: v Plumber's /Address: f'y LT 74 COUNTY/DEPARTMENT USE ONLY Disapproved Cate. Owner Given Initial Sig nature of issuing Age t: Fee G Approve Adverse Determination -(1 Reason for Disapproval'. I Alternate courseW of Action Available. DISTRIBUTION: Original to county, One Copy To, Bureau of Plumbing, Owner, Plumber pILHF-S8D-6398 (F.. 5162) -2 60 Form - S T C - 104 Vft AS BUILT SANITARY SYSTEM REPORT I ~ OWNER j / ( _ ~}1V S TOWNSHIP T C?SF fI SEC. T_30 N-R ;2LIW ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Z.TeLis (W 7-.41V r PRsu~- U r- \ C L f3~' i T~f~-~ i~~ ~t ~3~ v ~i l INDICATE NORTH ARROW z ? BENCHMARK: Describe the vertical reference point used FAFI ' SLH )P-eiw t' PUMP HAMBER Manu turer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: - Pump Size Elevation of inlet. _ Bottom of tank -evation: Pump off switch elevation. ons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from neare t`'rproperty line: ont, Side, o Rear, Ft. J~Numb" er of feet from well: Number of feet from building: (Include distances on plot plan). SOIL A ORPTION SYSTEM Bed: Trench: Width: Length: Numb of Lines: Area Built: Fill depth to top of pip Number of feet from near groper line: Front, O Side, o Rear,o Ft N4~eir of feet from wel . Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: 3G Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation:; Area Built: Has either a drop box 0 or distribution box ~ been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manu turer: Capacity: Number of ring sed: Elevation of bottom of Elevation of inlet: Number of feet from nearest >eer l' Front, O Side, O Rear, O Ft. Number of wel . Number of--feet from building: Nttmhar. nr faPt Frnm nnnroct ,-.,~.a ~ N _ • n N ~ ~ N? N N N 3 O Q ~ N W ~ ~ ~ ~ n n ~ > o vo ccso !!aN;q~ M COD 'M P- ~c?con mC*la' ~f I., 0 0, - CD Co tG ~ ~ fD ~ A ~ ~ m n 3 a o o ao - w 2.0 ~ f. C O N 3•Zc° c~ Q~ f o C 'o ~o o C m ~ (ID > N pp CD Q ;i N C p n Wr (n O Q R p. Q toil p n O D pt n n o g m e w ~ o u C o•f O a'C :3 .0w~ cmn C N _`A w ~mw~fm c z 9D CD mm0 ~?a a _ CDCDm 30=r*"to (a 03 m ~ Qai 0 m ui to 06 ? w 0 rn, (AW -1 M 3mc? o°mC7 Q" cad -%<a=cm a Sv N o C c ap tp N not Cnc E06 SO o m 01 ? G~ m _ n m N CL CL a?N ~ :E nom Q QUO •ccn °:m 3 U) O ro p m n N 0~ c c_ CL oa I 0 U3 Cca ~c 0) 0 00 °Q v c3 03 0 CL 0 M! wa> > a o< 0 CD z 0 Form - S T C 100 Owner of Property ta-/y Location of Property S-~5 54rl Section 22 T30 N R ZO W Township - Mailing Address Subdivision Name AM 1 AIL I? Lot Number Previous Owner of Property. X4, 4I p Total Size of Parcel 27 Date Parcel was Created 9 7 c' sue"t _ Are all corners identif//~Yable? 1---""YLS No Include with this application one of the following: Certified Survey Map Deed .Land Contract, or .Other Legal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. 2k / ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have j obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County, Register of Deeds, as Document No. ) T ~ ~ i SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED I J 1~ j6VfT TFS7 d,,-- Nrk) A/~itpk) -2D /z- T' jiPof+ /jLU1tic Li,lJt TMENTOF SAFETY & BUILDINGS NQUS M REPORT ON SOIL BORINGS AND DIVISION ILQB?NDUSRTFANY S P11 PERCOLATION TESTS (115 / 6F P.O. BOX 7969 HUNAN RELATIONS pJ Z ~~/mss ADISON, WI 53707 lswr° (H63.09(1) & Chapter 145.045) 6r LOCATION: SECTION: / TOWNSHIPffWt+kt•etP~r y: L07 NO.: Z1- s Cf- -2- 03 SUBDIVISION NAME SF 1/ 11T3 N/R 1d E (or) W S/-! "7560 />~i 3 Fi COUN/TY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: S~ wo J S 3 o So . 3 J-/- J I,1114v 4 j-1,. %k4 v . USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILED S I IONS: ATIONTESTS: (Residence , ? XNew EIReplace E~J. / fj RATING: S= Site suitable for system U= Site unsuitable for system S~s \ % pJ~ ti~t,R~oW ~(F~~~((f CONVENTIONAL MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) S DU Es 11U &]s ou F]s ZU Ds ou r 6&3L7EA)g100AL DAYWdQ~s -DEEP j~~Ilq If Percolation Tests are NOT required DESIGN RATE: If, any portion o. the tested area is in the )under S.1-163.09(5) (b). indicate: CGS S r L uodF,iain, indicate Fioodpiain eievauon: i 'v • X4, T= 3 ni N r a~ i -"J (G PROFILE DESCRIPTIONS BORING' TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST, HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B / •33 124-6Y. s, /.s~ 43AJ .s -2 .o - ;Y~ 11 /5 as iCT) ~A d1-14 /s o `PEA f f,4,V,,F/ = cs M rx y.~ r O f 3. yd` > 4. p , z N. Ssp Q,, - ay. S!/ .2.0 L~• IS w oc~~e.fS C .5' B 3 12o.d" ' j >16• o •~3'~s,v-~y. s, N.- a . S / its T. A.vOf O B . S % PrVy fi..r S (w,d7n f, r. yE//o~ -Gy Z'fr PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. P RI D PER( D2 PEA( PER INCH P- OA~ L v ff ~,tJE L~IAS ES7 Evious -51 P- D E 7-S ly,~ ,gyp G0 7-4 L NF G(>~,pE 7lvLL.PG~¢iV P_ V 's'4 M L G Nl~ J o iG ccJ t-tA P- v v AJ s P- e: T ~'S tcl kFl kf~ /S Sv~r i2 c'o v Eti i D.e Lt>EG S. PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan, Show the surface elevation at all borings and the direction and percent of land slope. Igo OM f/S 0 2 f T. SYSTEM ELEVATION - This test site APPROVED ~C3T 8 ' y tnventior,ai septic s stem. E,P c oo,-tTioA~) 7_4-sT5 4-~ 6WE lE r/oN. iES (3 0 a ,j OF_ n R c.v Er/ s iN J -t~ 'L - TN y~ D S Y S r' /~-2 S I' D w r4 R E'~t _ S ; D'40r Al i ~,Q o h . Tit ii / ~ ~ ~ of ~1 ~/S G~'St/~6? SCS- r ~ ~iP~-1 ~1 ~ i L/?~ / •S _ R SOIL BORINGS T' PERCOLATION TESTS l i5- REPO T N Hof Z rRo-TEc ► S D. Pao r P tA~ DAT-C HOMES.i7E T'EST'ING CO. v'`". 3, 01NEIL ROAD BOB rw ON, wts. 54016 C s T ~.s 02 Yrz o~ r~toRE F~Po~r ~yLc TE51r f},PE~45. PR6PD5ED HoosE moor LIE z~ Fr, ne t..cct) h1G+r UGT 1 tF >;n FT i►ic a,nD~ 4AM ei TEST A.PC,4 r.W v J L r w r. ,-a. r v• ✓ ^ i vn r !7 r i t = 914c,"110E P/ r3 wQ = Ex~sr~~ 4C1F1-4- PE, C 10647-/ONf 11,4VP /?O9,CkeD of 54o4lEL 1.3otE5~ r = wo ei z . S M V rRTi cAL eE,,cS-R CA)6r Poi a 7- 5-fee~ FENCE l~051" P~Tr o Sr'D~J~~I< - RC~tR yf1~~ LE &E N D ~l~v~fo~v ob tleyl" &t f T /o o • o FT . 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