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U .2552 P 435 "76 123 t\
KATHLEEN H. WALSH
REGISTER DF DEEDS
Document Number Document TWO
ST. CROIX CO.. MI
RECEIVED FOR REGARD
St. Cr oix County RECEIVED
03:30P)i
Occupancy Affidavit AFFIDAVIT #
REC FEE; 11.00
TRANS FEE:
Name — (Owner) Typed or printed COPY FEE 2.
CC FEE:
being duly sworn , states, under oath, that: PAGES: i
1. He/she is the owner /part owner of the following parcel of land located in St.
Croix County, Wisconsin, recorded in Volume Zgy Wage #W Document
Number ? 3 (- Z St . Croix County Register of Deeds Office: Recordkw Area
Name and Return Address
A parcel of land located in thaS� % of the M_E %< of Section ` (� V ty)
T N - R 20 W, Town of :5r. "�O tt , St. Croix
County, Wisconsin, being duly described as follows (include lot no. and
subdivision/CSM or detailed legal description): A sO W X: 540
Parcel Identification Number (PIN)
As owner of the above described prope , I acknowledge that the septic system serving this residence is sized for a
:L bedroom home, or a design flow of Sa The design flow is calculated by assuming 150 gpd for 2
Individuals per bedroom. There are currently, occupants living In this residence; 42 occupants are permitted
based on the design flow. Therefore the septic system serving this residence is code compliant. However, I
understand that 9 there are intentions to exceed the number of permitted occupants, the system will need to be
modified to aecomodate any Increased wastewater flows and/or contaminant loads. I also acknowledge that I will make
this information available to any future parties interested In purchasing this property. :�"!�•.;,�
Dated this ' l `� day of
f .. t .
�
ice/ •' � �`
AUTHEN"CATION ACrNOWLEEWEN7.1
Signatures) STATE OF WISCONSIN
autheriitceted this day of St. Croix County.
Per came before me this 9 day o hpu —
* e SS S�°O
TITLE: MEMBER STATE BAR OF WISCONSIN
(if not, to me known to be the persons) who executed the f0rog0ir►9
autlwrized by § 706.06, Wis. Stats.) Instrument and admwledge the same.
THIS INSTRUMENT WAS DRAFTED BY
`
Notary Public. State of Wisconsin
(signatures may be authenticated or advwwledged. Both are not My Cotnnds ion perrnariord. it rwt, state expiratlor► date:
necessary.) Oats: r (,a O
'THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE"
This k9banOw moat be eampleted by subeilter. dgaiaLl �(j¢, mum d mMm sAdress. and f l (if required). other kdormation such as the
91014V draws, Msps►d s«OE M rata, may be pPsoed on ads lust pop ofdw dbow wd orawy be pfaosd on adgkod ropes of we
dootrnwrL MW Use of ads oc*WPepe adds one peps to your documerg and sIM to ,, 0951 tree_ Wlsoonslrl V*Wes. 59.617.
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
M M N p ■ - r���r ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
��•' -- - - Hudson, WI 54016 -7710
(715) 386 -4680 FAX (715) 386 -4686
April 21, 2004
Mr. Jess Seguin
1152 State Highway 35
Hudson, WI 54016
RE: House addition, Town of St. Joseph, St. Croix County
Dear Mr. Seguin,
You have requested the Zoning Office to review your remodeling/addition project for compliance with the
state sanitary code (COMM 83). When remodeling or adding onto a dwelling you are required to examine
whether or not the construction involves an increase of wastewater.
I have reviewed your construction/addition plans that were submitted to this office to verify compliance with
the septic system sizing requirements indicated in the state sanitary code. You have indicated that the net
result of the proposed addition will include two additional bedrooms, and an attached garage.
The sanitary permit for the septic system was installed on September 16, 1980. The system was sized for a 3-
bedroom residence, or 450 gpd (gallons per day) of wastewater generation. The house was originally built
with 3 bedrooms. One of the original bedrooms will only be used as a personal office. This project will add
three bedrooms in the addition, resulting in a total of 5 bedrooms. The Department of Commerce plumbing
codes will allow a septic system to be sized by the number of bedrooms or by the number of occupants. The
Commerce codes sizing is based on two persons per bedroom, or 150 gallons per day. You have indicated
there are four persons living in the residence at this time. A maximum of 6 persons will be allowed to reside
in this structure based upon the size of the installed septic system. Any additional occupants will cause the
septic system to be non - compliant and will it be required to be modified to accommodate the increase in
wastewater flows.
Jim Thomson, CST, evaluated the soils next to the existing system on April 8, 2004. Mr. Thompson
indicated the soils were compliant and there was no indication of failure of the system to the ground surface.
The property owner has met all the requirements of COMM 83.25(2)(c) and can proceed to obtain a
building permit for the proposed house addition.
As a reminder, to prolong the life of the system, remember to have the septic tank pumped once every three
years or when the tank becomes 1/3 full of sludge and scum. Other efforts to prolong the life of the system
could be as simple as fixing or replacing plumbing fixtures with water conserving fixtures, reducing shower
time, washing dishes when the dish washer is full, avoid using a garbage disposal, using a wash machine with
a suds saver feature, etc. Therefore, the prolonged life of this system may be dependent upon proper
maintenance of the system.
The addition shall comply with all applicable setback standards. Please contact the township to obtain a
building permit.
Should you have any questions, please contact this office.
Sincerely,
Kevin Grabau
Zoning Specialist
U ..2552 P 435 760123 t\
KATHLEEN H. WALSH
REGISTER OF DEEDS
• '
Document Number Document Title ST. CROIX CO., VI
RECEIVED FOR RECORD
St. Croix County 04/19/2004 93:30PH
Occupancy Affidavit AFFIDAVIT
EXEMPT #
r REC FEE: 11.00
U eS$ S���cc i /l TRANS FEE:
Owner
Name — T COPY FEE 2.00
� � Ty or p rinted CC FEE:
being duly sworn , states, under oath, that: PAGES: i
1. He/she is the owner /part owner of the following parcel of land located in St.
Croix County, Wisconsin, recorded in Volume ZyIZV' #M Document
Number 3- Z St. Croix County Register of Deeds Office: Recording Area
Name and Return Address
A parcel of land located in tha — %. of the N_�' /. of Section � ��� <��jQ � to
T� N — R 20 W, Town of S't'- ' Pit , St. Croix J
County, Wisconsin, being duly described as follows (include lot no. and L tS 2 H W K 3 S
subdivision/C SM or detailed legal description): tat9 w-v 590
Ciro
Paroel Identification Number (PIN)
As owner of the above described property, I acknowledge that the septic system serving this residence is sized for a
3 bedroom home, or a design flow of SD and The design flow is calculated by assuming 150 gpd for 2
individuals per bedroom. There are currently occupants Irving in this residence; ,o occupants are permitted
based on the design flow. Therefore the septic system serving this residence is code compliant. However, I
understand that 9 there are intentions to exceed the number of permitted occupants, the system will need to be
modified to accomodate any increased wastewater flows and /or contaminant loads. I also acknowledge that I will make
this information available to any future parties interested in purchasing this property.
Dated this day of
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
s
audw*cated this day of St. Croix County.
Mot Motly came before me this � day o �
e above nameQF� S-
TITLE: MEMBER STATE BAR OF WISCONSIN
ft executed the foregoing
(If not,
aurized by § 706.06. Wis. Stats.) '/ l Rj � came.
tho
THIS INSTRUMENT WAS DRAFTED BY G► //
(Signatures may be authenticated or aduwwiedgeC y K not, state expiration date:
neces sary.) J
"THIS PAGE IS •/ '
This Mbrm gon nxnt be conpteted by submdter. 1. oUrer Jnfamafion such as the VwAV afausea, leapef desarhaon, elc mey be F _ in addtbnd papas dfhe
document �; Use oft* cow page adds am taoonsih Statutes. sasf 7.
•` ` ► e 12 P 4 $ 8 74�36�
SV ATE ?AR OF WISCONSIN FORM I - 2000 KATHLEEN H. WALSH
r WARRANTY DEED REGISTER OF DEEDS
Document Number 1 1 ST. CROIX Co., WI
This Deed, made between George Peter Gru and Jeanette RECEIVED FOR RECORD
Buys Gru, husband and wife as joint tenants, and 09/17/2003 01:15PM
Richard Bruce Gru, an unmarried person
Grantor, WARRANTY DEED
and Jess P. Sequin and Heidi M. Sime, each single EXEMPT #
persons as joint tenants REC FEE: 840 .00
COPY FEE:
Grantee. CC FEE:
Grantor, for a valuable consideration, conveys to Grantee the following PAGES: 2
described real estate in St. Croix County, State of
Wisconsin (the "Property ") (if more space is needed, please attach addendum):
See attached legal description
Recording Area
RICHARD BRUCE GRU IS JOINING IN THIS DEED TO RELEASE
Name and Return Address
ALL INTEREST IN RESERVATION OF LIFE ESTATE AS SHOWN
Title One Premier Group, Inc.
IN WARRANTY DEED DATED JUNE 9, 1999 AND RECORDED 706 19th Street South
NOVEMBER 17, 1999 IN VOLUME 1471 ON PAGE 398, AS Hudson, WI 54016
DOCUMENT NO. 613977.
TOPG FILE: 6287S
THIS IS HOMESTEAD PROPERTY FOR RICHARD BRUCE GRU.
THIS IS NOT HOMESTEAD PROPERTY FOR GEORGE PETER GRU 030 - 2017 -95
AND JEANETTE BUYS GRU. Parcel Identification Number (PIN)
Together with all appurtenant rights, title and interests. This HOC homestead property.
(is) (is not)
Grantor warrants that the title to the Property is good, indefeasible in fe: ;imple and free and clear of encumbrances except
Roadways, Easements, and Restrictions of Record.
Dated thi 12th day of September 2003
Geor a er Gru George eter Gru
Attorney -in -Fact for Richard Bruce Gru
*Je tte Buys Gru
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signature(s) ) ss.
v_.. V PA lin St. Croix County. )
authenticated this day of Personally came before me this 12th day of
N o tary September 2003 the above named
*
,cif Wisconsin Georg Peter Gru and
Jeanette Buys Gru
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the perso s who executed
authorized by §706.06, Wis. Stats.) the for g i tr ent a owledged the same.
THIS INSTRUMENT WAS DRAFTED BY
* K Plam
Michael H. Forecki, Attorney No dry Public, State of Wisconsin
Eau Claire Wisconsin My Commission is permanent. (If not, state expiration date:
( Signatures may be authenticated or acknowledged. Both are not necessary.) December 12 2003 .
*Names of persons signing in any capacity must be typed or printed below their signature.
WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1 -2000
ttorney Michael H Forecki 1830 Brackett Ave, Eau Claire WI 54701 -4627
Phone: (715) 835 -3029 Fax: (715) 835 -4112 Michael H. Forecki T4783904.ZFX
Produced with Zip Form- by RE FormsNel, LLC 18025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800) 383 -9805
1776
' Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations
Attach complete site an on r not less than 8 %x 11 inches in size. Plan must County
P PI P� St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.
030 - 2017 -95 -000
Please print all information. LReylewed By Date
Personal information you prowls may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Jess P. Seguin Govt. Lot SW 19 NE 19 S 1. T 29 N R 20 W
Property Owner's Mailing Address Lot # Black # Subd. Name or CSM#
1152 Hwy. 35 North
City State Zip Code Phone Number City J Village iOl Town Nearest Road
Hudson WI 1 54016 1 715 - 760 - 1976 St.Joseph I Hwy. 35
1+ New Construction Use: i+'' Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
_f Replacement _j Public or commercial - Describe:
Parent material Glacial outwash Flood plain elevation, if applicable na
General comments
and recommendations: Evaluation completed to verify location of existing dispersal cell and suitability of soil conditions to
accomodate addition to existing structure. System elev. = 93.35'
Boring # I Boring
Pit Ground Surface elev. 95.97 ft. > in. Sal
✓._..� Depth to limiting factor 82" Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in- Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-4 10yr3/3 none sl 2fsbk mvfr cs 2fm,1c 0.6 1.0
2 4 -24 10yr4/3 none Is 0 sg ml cs 2fmc 0.7 1.6
3 24-68 10yr5/6 none s 0 sg ml gs 1fm 0.7 1.6
4 68 -82 10yr6/4 none s 0 sg ml - 1fm 0.7 1.6
* Effluent #1 = BOD 5 > 30 < 220 mg/L and TS >30 < 150 mg/ nt #2:= BOD < 30 mg/L and TSS <_;0 mg/L
CST Name (Please Print) nature: CST Number
James K. Thompson �- - 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola, 4020 4/82004 715 - 248 -7767
,5. RECEIVED
r;
� APR 2 0 2004
STGRGIXCCUN .
ZONING OFFICE
• PROPERTY OWNER: Jess P. Seguin SOIL AND SITE EVALUATION 1776 Page of 3
PARCEL I.D.# 030 - 2017 - 95-000 A.C.E. Soil & Site Evaluations
REPORT MEMO
Property owner is proposing an addition to the existing residence which is served by an existing POWTS installed in
1980. The POWTS consists of a 1,0� 00 gallon Wieser Concrete septic tank and an 18'X 36' aggregate dispersal cell
with 12" of aggregate beneath the distribution laterals. System elevation = 93� 35'.
All soil condition requirements pertaining to groundwater and bedrock separations and soil infiltrative capacity have
been met. All setbacks and other code requirements as specified by WI. Admin. Codes Chapters 82 - 85 (Register
January 2004), have been met or exceeded.
2� Z�
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OF WIS
uu y P 488
STATE ?AR CONSIN FORM 1 - 2000
KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
Document Number ST. CROIX Co. III
This Deed, made between George Peter Gru and Jeanette RECEIVED FOR RECORD
Buys Gru, husband and wife as joint tenants, and 09/17/2003 01:15PH
Richard Bruce Gru, an unmarried person
Grantor, WARRANTY DEED
and Jess P. Seguin and Heidi M. Sime, each single EXEMPT #
persons as joint tenants REC FEE: 13.00
TRANS FEE: 840.00
G COPY FEE:
Grantee.
CC FEE:
Grantor, for a valuable consideration, conveys to Grantee the following PAGES: 2
described real estate in St. Croix County, State of
Wisconsin (the "Property ") (if more space is needed, please attach addendum):
See attached legal description
Recording Area
RICHARD BRUCE GRU IS JOINING IN THIS DEED TO RELEASE
Name and Return Address
ALL INTEREST IN RESERVATION OF LIFE ESTATE AS SHOWN
Title One Premier Group, Inc.
IN WARRANTY DEED DATED JUNE 9, 1999 AND RECORDED 706 19th Street South
NOVEMBER 17, 1999 IN VOLUME 1471 ON PAGE 398, AS Hudson, WI 54016
DOCUMENT NO. 613977,
TOPG FILE: 6287S
THIS IS HOMESTEAD PROPERTY FOR RICHARD BRUCE GRU.
THIS IS NOT HOMESTEAD PROPERTY FOR GEORGE PETER GRU 030 - 2017 -95
AND JEANETTE BUYS GRU. Parcel Identification Number (PIN)
Together with all appurtenant rights, title and interests. This ADC homestead property.
(is) (is not)
Grantor warrants that the title to the Property is good, indefeasible in fey simple and free and clear of encumbrances except
Roadways, Easements, and Restrictions of Record.
Dated th' 12th day of September 2003
Geor a er Gru 4 George eter Gru
Attorney -in -Fact for Richard Bruce Gru
*je6dtte Buys Gru
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signature(s) ) ss.
% Palm St. Croix County. )
authenticated this day of N- !Eafy - Personally came before me this 12th day of
September 2003 the above named
I p� : f Wisconsin
Geora Peter Gru and
*
Jeanette Buys Gru
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the perso s who executed
authorized by §706.06, Wis. Stats.) the for g i tr =enta owledged the same.
THIS INSTRUMENT WAS DRAFTED BY
* Plam
Michael H. Forecki, Attorney No dry Public, State of Wisconsin
Eau Claire, Wisconsin My Commission is permanent. (If not, state expiration date:
( Signatures may be authenticated or acknowledged. Both are not necessa December 12 2003
*Names of persons signing in any capacity must be typed or printed below their signature.
WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1.2000
% ttorney Michael H Forecki 1830 Brackett Ave. Eau Claire WI 54701 -4627
Phone: (715) 835 -3029 Fax: (715) 835 -4112 Michael H. Forecki T4783904.ZFX
Produced with ZipForm- by RE FormsNel, LLC 18025 Fifteen Mile Road, Clinton Township, Michigan 48035,(800)383-98M
co a ?s
I
U 2412P 489
Part of the Southwest Quarter of the Northeast Quarter (SW' /4 of NE %a),
Section 1, Township 29 North, Range 20 West, Town of St. Joseph,
described as follows: Commencing at the center of said Section 1; thence
N.0° 12'W., on West line of said SW'/4 of NE'/4 211.59 feet; thence East
647.85 feet to SWIy line of State Trunk Highway 64 and 35; thence
Southeasterly 255.08 feet on said SWIy line, on arc of 1820.08 foot radius
curve, concave SWIy, long chord bearing S.35 °38'54 "E., 254.88 feet, to
South line of said SW' /4 of NE'/4; thence S.89 °40'35 "W., on said South line
795.67 feet to place of beginning.
TOWN iP �� 4 P �' , 1337 unty Road V
a � - /X Hudson I
ST J OSEP H ` ��4 715/549 -/549 - 6235 235
C X 715/549-6249
ST. CROIX COUNTY. WISCONSIN � F�CFT' F oWn j ®isd. ctt
c
0
Saturday, March 13, 2004
Jess & Heidi Seguin
1152 State Highway 35
Hudson, WI 54016
Dear Jess & Heidi:
Regarding your request for a building permit for the addition of two bedrooms and an
attached garage, I have enclosed the necessary forms for this purpose.
However, before submitting the forms you must contact Rod Eslinger of the St. Croix
County Zoning department so that he may determine if you are in the Riverway District
and if you will be disturbing slopes of 20% or more during the construction. Also he
must determine if your septic is adequate to handle the additional bedrooms or if you
need a new one. After his evaluation he will issue a letter to you stating what must be
done to continue this project. I will need a copy of this litter to issue the building permit.
If you have any questions please call me at 549.5203 any evening or on week ends.
*b
Dwight Farnham
— De Zoning Administrator
C: Rod Eslinger, Zoning
2
S y
C 5 ��
' L
AS BUILT SANITARY SYSTEM 4EPORT
OWNER ��)�,� TOWNSHIP �0 SEC T R
DDRESS ST. CROIX COUNTY WISCONSIN.
SUBDIVISION V a W 1
LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 160 FEET OF SYSTEM
ILI A4 49" 1
i
is
r r
I di a e o th Arrow
SC L i
SEPTIC TANK(5)MFGR. S t's CONCRETE STEEL
N0. o rings on cover Depth
PUMPING CHAMBER SIZE PUMP MFGR7 " MODEL NO.
GALLONS Per Cycle
TRENCHES NO. of width w — length area
BED N0. of lines - ? width length aw -r— area -- 6 --
depth to top oT pipe
NUMBER OF S F,PAG PITS Outsi 'e ameter total pit area
AGGREGATE A t 1VI q CA,
PERK RATE / AREA REQUIRED f AREA AS BUILT-6
Disclaimer: The inspection of this system by St. Croix County does not imply
complete compliance with State Administrative Codes. There are other areas•tha
it is not possible to inspect at this point of construction. St. Croix County
assumes no liability for system operation. However, i£ failure is noted the
County will make every effort to determine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM.
INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER /
441 .
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'RETORT OF INSPfCTION_INDIVIDUAL SEWAGE SYSTEM
San,itany Pehmit
State Sep.t.ic 5���
NAME / iLt�c? � ; ,� ���- Townahtip " St. Croix County
Locatiox / 'ZZ) Sec ion _ I
SEPTIC TANK
Size gattons. Numbetc o6 CompaAtmen.ts
Distance Fnom: Weft ':�Fv it. 12% on gtceate& tope it
Buitding it. Wextand.6 g
H ighwaten _ it.
DISPOSAL SYSTEM
Distance Ftcom: Wett CP 0 it. 12% on gtceat stope
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Bu.itd.ing it. Wettandb F t.
H ighwa #etc it. !
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FIELD DIMENSIONS:
Width o j thenc Depth o no ck b etow t.ite 7 ' .in.
Length o4 each tine 0 it. Depth o6 rack oven- t.ite ti n.
G � Numbet of tines Depth aj tite. be•Eow gnadeff--Lin.
Tota.r? .length of tines 5t. Stope ab trench - Z 7 � in pen 100 it.
D Distance between tines Depth to bedtcock
Totat ab.a otcbtion area FIQ 6t Depth to gnoundwaten
2 Type a Coven: Pa en an ttaw
Requited atcea � / �`� �� yp >� St
p
PIT DIMENSIONS:
Numben o6 pits Gnavet around p.itb ye.a no
Outside d,iameten it. Depth below .intet
2
Tota.2 abzonbtion atcea it A
Area nequ.ined t2 n1
'� INSPECTED B TLE
- APPROVED ,DATE 1
REJECTED , DATE 197_
1
EH 1 15 ` Rev. 9/18
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
•y WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES JUN 26��F8
P.O. BOX 309, MADISON, WISCONSIN 53701 o ION�jy 19/9
LOCATION: /a W ' r
/4, Section ,TZ N,R_E (or) W, Townshi or Municipality � 6)
Lot No. , Block No. County
f/PUC- ub ivision Name
Owner's / Buyers Name: 1
Mailing Address: 4° ENE ll/Ew a 5 .
TYPE OF OCCUPANCY: Residence —X —No. of Bedrooms 2 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT p ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS TyvE Z2 ? / PERCOLATION TESTS TU .2L I 9
SOIL MAP SHEET SGS T/ NAME OF SOIL MAP UNIT C d PERCOLATION TESTS
TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN /IN
BER , 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- / d /M %v
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- / 7l 4/0106 > 76 "SN. $'/ 13" /S f - 9A. 2(6 "C>if C
B- 2- d m gwe - b 4" IIN S/ /f''l7`•� S "S,wo �� o h0'r CS
B 3 NONE' > 7 /1'' AV S "ow-,dV / "Ow CS 3 G,p
B- .vD.v� > 1 "A S/ g 0'e' cs
B- 7(l QNE' 1> 7 G 11 8N "S/ "/S /0 "S/ 1( DiP• CS, -
B- i v ON > 7 1 / " �� N / "SANS C/q G ✓'/" USE . CS
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy 330 fOQ 7 ,&CN4 / .Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope, y/0 roll ArD
NO T TO SGi4 /E. Z o,4vcEY �c ti1 TE. St'cT / /4CeESS
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1, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods
specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my
knowledge and belief.
�o�F�P Z/ /6�Pi'eA7 ✓ �S"OZ 70
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Name (print) T Certification No.
Address
Name of installer if known SADDA /p05. , ex "C4
Copy A —Local Authority CST Signature
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PLB 6 7 State and County
State Permit #
Permit Application County Per 't #
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for Private Domestic Sewage Systems County.
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
€
B. LOCATION: '/4, Section T N, R ZQ E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
j iArqr./ � '� /�� Towns
C. TYPE OF OCCUPANCY: *Commercial / *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY I M70 Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete _ �I '/ Poured -in -Place Steel Fiberglass Other (specify)
New Installation T� Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Vyidth Depth Tile depth (top) No. of Trenches
Seepage Bed: �_ LengthWidth Depth ,3r� Tile depth (top) No. of Line
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land a a Distance from critical slope
WATER SUPPLY: Private'® Joint ❑ Community ❑ Municipal ❑
Owners name as Iisted on EH 115 if oth er than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Certif d Soil Tester, �r _
NAME 6 /C f
/ C.S.T. # —0 2 �i2 and other information
obtained from Ak v >/f Cd (owner / builder ).
Plumber's Signature �c - --MP /MPR W# Phone # &,5
Plumber's Address Al f.T s v
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE O « NL
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- Date of Application Fees Paid: State C �%'� County ' - -Date
Permit Issued /Rd (date) O ` Issuing Agent Name 7N4ott ' t i
Inspection Yes No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 J
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