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030-1056-70-000
o c) 0 n to O o N O 3- c d `r1 rD > > (D m o • cD i W 3 m 3 ' � 3 � ID rr Z O .Z1 cn N O • Z o CD n, a N ° W o `° 3 ° o' m � is ° -- m A 3 W n N � I °° N y n N C CD I O N ' :' N O 3 . O O Cl) CO 1 O N Q 3 co =r O =r ? 0 ! 7 C O p � C ! O N 0 0 O a y o 3 a rn m =3 S m CD W ° o o N N- O I pt 3 y _i E; a 3 I w cn Z D � a 3 m v, Z D � a 3 cn � D � (n m n D `n a v CD m p v v N W v Q °° C 0 C C W Cn a O CA CD - 0 0 4 -� 3 O o 00 �, O �' in _ i3 O N 4 000 C) ! O S I CL F3 S S ° O 0 N W W N N O O CD N .Or Q lr C C C .. M CD CD CD u O O O CD Z O O O CD O O O CD W v 6 T 0 0 O Q M G O co r '3 - 0 C O� m CD y ° m m m N a — -, Er y d l F 3 .. 3 °N ' c N N A M Cn a M N ;I Z o D D o V o D O J D co O O ° C 3 O n. a N ? (D (D O O N CD CD N • CD (D (D (n (D D) CD CL CL 7 n n 0 3 ' -1 fp C O N O in s .n N _ Na CL CL CL 0 -{ W w T G) a ` a° n(D ° o w -� Z 3 3 r O r: C '' C A X Z CD CD W W CD W C z > 0 a d�� I 3 Q 3 Q CD Q o : o : ! d� c I v c n CD a a o ! 0 4 CD N CL N CD a I CD c 0 � 3 c CD A N o I I I ( a o o o b CD CD CD too I p I o0 o O a I o g o CD oo i O o i Wisconsin Depa tment of Commerce PRIVATE SEWAGE SYSTEM County. St. Croix Safety and Builu, ig Division INSPECTION REPORT Sanitary Permit No: 430199 0 GENERA:. NFORMATION (ATTACH TO PERMIT) 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 X Township Parcel Tax No: Riemenschneider, Tim St. Joseph Township 030 - 1056 -70 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: GJD t �sD % S (� -�, 23.30.19.200B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing V Alt. BM Aeration Bldg. Sewer Holding SUHt Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD 9t- ► I fi +,> (•� q Septic (s Dt- Beltomp -} lr y,�Osr� Dosing Header /Man. ( /.q 1 , 3 A' S q - 3 . ?! Aeration Dist. Pipe Holding Bot. System CO - P 13to 9'2./ RA2 Qads 13•t6 al/ PUMP /SIPHON INFORMATION t 3.37 91,9 Manufacturer Demand St Cover GP Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain l l_engf Dia. ist. to Well SOIL ABSORPTION SYSTEM So BEDITRENCH Width Length 43. No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 2 q 'f 7 an s SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: ^ / i -7 91 � ! UNIT Model Number: DISTRIBUTION SYSTEM N` t! Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) /_ Length (�' Dia Length Dia Spacing V✓ SOIL COVER V tf a a 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 [� (� I 'I Yes � No Yes � ] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: b / 8 / Inspection #2: Location: 775 150th Ave New Richmond, WI L 54017 (NE 1/4 NE 1/4 23 T30N R19W) NA Lot 1 / Parcel No: 23.30.19.200B 1.) Alt BM Description =a - q.) I� j, 41,e 51 (, MI f ve L v( . oWt, w 46 1 2.) Bldg sewer length = .q,Vr {[ ^1t _h - amount of cover = � � �`J \1 1"� J �H- �` -�/1 f✓7^•4 0 pktw -- - - -- Plan revision Required? Yes No T Use other side for additional information. , SBD -6710 (R.3/97) r Date ( Insepctor's S ature ert. No. v ti� ln�'kc. ],'m1 S "b, - C, et vr� t{ 51-4- I°lwl„�e�-� Wisconsin Department of Co mmerce . PRIVATE SEWAGE SYSTEM County: St, Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 44 GENERAL INFORMATION (ATTACH TO PERMIT) 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 X Township Parcel Tax No: Riemenschneider, Tim I St. Jose eh Township 030 - 1056 -70 -000 CST BM Elev: Insp. BM Elev: I BM Description: ono It T TANK INFORMATION ELEVATION DATA J TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing�I. Alt. BM Aeration t. / Bldg. Sewer Holding VV St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet IOQS Q`` TANK TO P/L WELL SBLDGVenttoAirin1a e ROAD PHff ast let Septic Dt Bottom 11. zfl al{. 0 � Dosing Header /Man.— l 11• 3 Z wel �!•HS q 7! Aeration Dist. Pipe Holding Bot. System — t 1 3.20 O f 't r Final Grade PUMP /SIPHON INFORMATION 13 ? /lq Manufacturer p6mand St Cover GPM slvu -L /6 Model Number TDH Lift iction Loss System H TDH Ft ' Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM 0 BEDITRENCH Width t1 Length (41 . No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS .7y C0 37• S 5- SETBACK vn LAKE/S TREAM LEACHING Manufactur SYSTEM TO P/L BLDG WELL LAKE /S R / INFORMATION CHAMBE Typ Of System: � � � � y.� � � ! T Model Number:` DISTRIBUTION SYSTEM "rte Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake i( Pipe(s) Length A Dia Length Dia Spacing SOIL COVER (0 07� x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of /Sodded xx Mulched xx Seedad Bedrrrench Center Bedrrrench Edges Topsoil ❑ Yes Do No Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1" / 4 /0 �L Inspection #2: / / Location: 775 150th Avenue New Richmond, WI 54017 (NE 1/4 NE 1/4 23 T30N R19w) NA Lot 1 Parcel No: 23.39.19.200B A � r .�,, n . I,, - l r 1.) Alt BM Description = (a ) W (A" t iv 'Y 2.) Bldg sewer length = y l 6� L —q I ►•l / w ot port l ('� � - amount of cover = "'llliii s � /L ^I, I w � TK (0, k 1Vl�a,x. 7� . 3� Fi 144 U .k, W rt' -- ' " N tom. 'tv -- T Plan revision Required? oil Yes [No U 7 se other side for additional information _ Date • Insepctor's Signature Cart. No. SBD -6710 (R.3/97) s (4 G• Q u ii ' M ,^ r-7 7M5, 9tc-, f7 - � l __ �� � �o � � \� � 2 ��-� �''�'�,� .,vim o� � -- � - ,�� .. 4 �� � � � � <° ,- s s � � p' • o f O 0 Av � � isObc x �� ■ So!/ eta /ua�-- s a 0 0 p;� E leva6o� r 5cn /e: OD VI -e(e ✓AY f a Kc ►ti +�vu oG• vi 5 s�►�o fpm l Wieserrlht b,</(run /a /de evaMow co, -�► 'k iOd , 'CrCSEi(� o{ pr;mar?rSYSfem 4 'l babel A -ice r t��rles b� dYd�.,q Floew to tre��h 6 seoE;c t�n�C• vlSjl7� Agi'6u — drs ce! /re^`aved /SO Ale Bs 63 ■ � Dpi ! C.onc.r�tt a d r; ✓Cw < ri 1 � S /ape r _.t � EXr'st�n 36adre� i �e.5�denee t n -- f�SSu.�,ec! e lw� = ice. cam' Safety and Buildings Division County CC,, 201 W. Washington Ave., P.O. Box 7162 S-L - CrD I ,scons,n Madison, W1 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 Sanitary Permit Application State Plan LD. Number In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide maybe used for secondary purposes Privacy Law, sl5.04(1 xm) Project Address (if different than mailing a 1. Application Information - Please Print All Inforvt ation - w Property Owner's Name Parcel + # Lot # Block # l CO 7K. Gig ,j _ 0 � O$ti— — • Property Owner's Mailing Address groperty Location � CoOd �• /t7E `� 7 /�� ' /., nt' %., Section Z3 City, State -_ // Zip vie - phone Number _ ...�., u1 I t'1 S vl7 Jt7 24 ' O 7 T � K R e) U. Type of Building (check ah that apply) 1 or 2 Family Dwelling - Number of Bedrooms CSM Number ❑ Public/Commercial - Describe Use �� - , , S ❑ State Owned- Describe Use ❑City ❑Village l4lo wnLp of S6. mos" 111. Type of Permit: (Check only one box on line A. Complete line B if applicable) A ' 11 R New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New list Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl RIon - Pressurized in- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leachin mbar 11 Drip Line El Gravel-less Pipe ❑ Other (explain) V. Dispersal/Treatment rsal/Treatment Informatio 3.3 - S Q 31. 1 ; = ! 024. 30 5,f EX S A Design Flow (gpd) Design Soil Application to (gpdsf) Dispersal Area Required (sf) Dispersal Area Propose (sf) System Elevati on 4Sr7 ..t . 0.7 s G 3 Sq. / oZG. 30 sp I 9 .R. So' VI. Tank Info C in Total N 0 Manufactures Prefab Site Steel Fiber Plastic Gallons Gallons of Units , i �Q ,ev►S Concrete Constructed Glass Now Existing ��`— Tanks Tanks Septic or Holding Tank _ Acrobic Treatmcm Uoit `• �/� V11. Responsibility Statement - L the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) A )4, umber's Signa MP/MPRS Number Business Phone Number 3YL- A, -91- Plumber's Address (Street, City, State, Zip Code) / U 5W(o VI1L County/Department Use 661 v Approved ❑ Disapproved Mary Permit Fee (includes Groundwater Date Issued Issuing g ignature (No S s) Surcharge Fee) 25-ID O ❑ Owner Given Reason for Denial LX C onditions of Approval/Reasons for Disapproval , t> e_ .6�U inner 3(+ ► i ►mot Attach com plete pla (to the Couty nly) for th s nystem on paper not less than 81/2 x 11 Inches In size SBD -6398 (R. 01/03) �- - I_ ,- o W ■ So;/ e ✓a /c(a 6 ♦ Efel/a�on S { rtnc.Q C S of 3 X 3 7. Chan, borS�ir tr"Ck. One 'tii^CA " x tJ�,(C� e.AZe/yao, _ z ns6z i/ bk /��un ✓a /de � a / /aw Corr�a Q mb �riOd,C rc,$ ; o{ pr;►r+a+�l.Sys4em �- �'�a.bel A -ice y �'rutclts br dYcl��� t�e��/•�s °� Sib S� 8z 63 ■ * � e.on erect a d r; ✓cwayr < � twna.r Weil V If � y t o Slape r _.s EXrst�n, 36adrw n ' �e5�de n �rS6r'rxi � c�7o � ctJeel(' ■ Sof/ eVa /c<au ♦ E /ei/afxon ee It (k = 93.c>a'{ scYQ/ec� == te a; I 5 -k.mm Qts at 3' )f 3 7.5'w /�� SAr -t�tacQ.One t`s'114 a,--' 3' x /5.75'w/3 C -S• T.n /iSa Qi e,n ensc,(� e,dG� 6uu,(dS c A ZW9a0 zns6a l/ baNrar+ ✓tilde 6 a / /ow con6a, Q mb iodt rCS�7 C r prirncN'� S Ysiem wi a-6el A -ice y tr�•rtrles bar dYder�;Y,q Floca•to ��enc�/.rs � SCE efr iCt�n� 1 Fi lflw� E,Y.'s,6 coo� V CitOLI.�.ILC.. O �`"" W�C7C3 eo/7C/�c SepE:c t�nK. 6 iSt115? /B;c 36' 8Z 83 ■ *� tene.rctt o�. dry ✓two.�r� � xi. � + , ny W tt•V•n a,r We l � cJ rr �--- o S/ape r- j Exisf:M 3 badrw n n �j r3fi�q � � �o.F, ulcelf'S cancf e,& 5 e e, 6•f "e 1666 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 plan on paper not less than 8'/ x 11 inches in size. Plan must County 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- 1056 -70 -000 Please print all infonnation- ... _. gy q Date Personal information you provide may be used for secondary , S. 15.04 (1) (m)). 0 6 2 3 Property Owner Property Location Tim & Lisa Riemenschneidor Govt. Lot 4 NE 1/4 NE 1/4 S 23 T 30 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 775 150th Ave. 1 CSM Vol. 1, Pg. 45 City State Zip Code Phone Number,= _j City J Village _ J✓ Town Nearest Road New Richmond WI 54017 715 - 246 - 2707 St.Joseph 1 150Th Ave. I New Construction Use: V' Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD II Replacement J Public or commercial - Describe: Parent material Gla outwash Flood plain elevation, if applicable na General comments and reoommendationWnsufficient replacement system area available. Existing dispersal cell must be excavated and replacement trenches constructed as indicated on site plan, system elev. = 92.50 Boring # Boring t/ Pit Ground Surface elev. 98.37 ft. Depth to limiting factor >121" in• Soil 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 -8 10y13/3 none sil 2fcr mvfr as 2f,1 m 0.5 0.8 2 8 -16 7.5yr4/6 none gr sl 1 msbk mfr as 1fm 0.4 0.6 3 16 -28 10yr514 none sicl 2msbk mfr aw 1fm 0.4 0.6 4 28 -37 7.5yr4/6 none Is 0 sg ml cs - 0.7 1.2 5 37 -58 10yr4/6 none s 0 sg ml gs - 0.7 1.2 6 58 -121 10yr5/6 none s 0 sg ml - - 0.7 1.2 a Boring # _j Boring // Pit Ground Surface elev. 96.43 ft. Depth to limiting factor > 1 2" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -8 10yr3/3 none sil 2fcr mvfr as 2f,lm 0.5 0.8 2 8 -16 7.5yr4/6 none gr sl 1 msbk mfr cs 1fm 0.4 0.6 3 16 -28 7.5yr4/6 none gr Is 0 sg mfr gs - 0.7 1.2 4 28 -57 10yr4/6 none s 0 sg ml cs - 0.7 1.2 ��• 5 57 -112 10yr5/6 none s 0 sg ml - - 0.7 1.2 * Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 4L uent #2 = BOD < 30 mg/L and TSS < mg/L CST Name (Please Print) ignature: CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, 54020 7/152003 715 - 248 -7767 Property Owner Tim & Lisa Rlemenschneider Parcel ID # 030 - 1056 -70 -000 Page 2 of 3 M Boring # �ng #m Pit Ground Surface elev. 97.69 ft. Depth to limiting factor > 116" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots QP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 1 0-6 10yr3/3 none sil 2fcr mvfr as 2f,1m 0.5 0.8 2 6 -16 7.5yr4/6 none gr sl 1 msbk mfr as 1fm 0.4 0.6 3 16 -25 10yr5/4 none sicl 2msbk mfr aw 1fm 0.4 0.6 4 25-40 7.5yr4/6 none Is 0 sg ml cs - 0.7 1.2 (02� 5 4062 10yr4/6 none s 0 sg ml gs - 0.7 1.2 6 62 -116 10yr5/6 none s 0 sg ml - - 0.7 1.2 Soil pit evaluated to 109 ". Evaluation of soil conditions from 109'- 136' completed with hand auger. ❑ Boring # Boring Pit _j Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 ❑ Boring # Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 I * Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD -i30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777. ■ So,/ 9 on p ;4L- elwa6 I tl 8� 63 , ■ � Cane.rt,t� tWn Weld c/ f > AD% � t S /ape j EX/s 3badraDn r - t► �`GS �c�erlcz n E � GAD �a.F, GcIG¢!rS Sv 'c. ��! Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD- 10567 -P (R.6/99). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 28 1.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for m i not recommended. Soil compaction may vegetative maintenance) over the system s p y hinder aeration of the infiltrative surface within months. Cold weather installations (October- ( the system and will promote frost penetration during cold weather o February) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 VIGIL TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan I f the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by removing biologically clogged adsorption and dispersal media and replacing said components as deemed necessary or by installing a new soil absorption cell to bring the system into proper operating condition. e directed to installing lumber Mike- NkDonell at (715) Questions on the operation or maintenance of the s $ p , � stem should b � Y 248 -7767, or the St. Croix County Zoning Department. Bio fuser Specifications 76 " coo 00 00 00 00 �o 00 0o coo �� OO OD OO OD OO OO OD DD Chamber 00 00 OCR OD OD DD OD OD OO 9 �,' OD DD DD OO OD DO �[� DD DO Hei ht OD c�� DD coo �[� oo DO ao DD _ "- coo 00 00 0o coo 00 00 00 oa O �D OQ OO OO DD D OD O � � s 44 � ' Chamber Height a t zit M. End View s 34 re uirect #6 - a 4 Knockout Universal End Cap Available Sizes 76" Width'4" ` 34" Height 14" 16" invert_ — , ,"' !"6 9 11.3 sad G 4 sf 5 f Q 3 CERTIFIED SURVEY MAP E AsT c /99.0 00 0 '� 122 O. J r fG N. L corner 1� °- °� o Se C. 23 - TO- / 9 1 ry 2/9.9 i h l o o 4 IRS, N�`/< i ?��z A .f',rndicofes ,trop pipe sfake a6/.s �o Part of Gov. Lot 4, Section 10 23, T 30 No R 19 W, further IM q described as follows; beginning 0 :� at a point on the north line 6� 0 r :., .: ? �� ° o of said Sec. 23 a distance of Wzs _r °• ' 1220 feet west of the north - 282.3 east corner of said Sec. 23; thence due South a distance of o- 526.2 feet, thence due West a / I distance of 282.3 feet, thence III i North 0° 00' East on a meander 0/� 1 line a distance of 532.6 along Sh o wn for N I the shore of Bass Lake, thence ti r•e fererrce Only n I due East along the north line of / *I said Sec 23 a distance of 199.0 3 yr N 1 feet to the point of beginning. I , All land between meander line and Bass Lake is part of the adjacent -_ u►. lot. — '- — — - 3_4•,3 c' �. I I certify that the above is a true and correct map of the parcel surveyed, mapped and described above and that I have complied with the provisions of SAC!_ ?IF _'3h of tlnA Wi ennnni rr i f 40 i X1 19 v `�!M r1 ` s • • _ p 'pas �zz -s *ON •SIM 4� 71� ~' • 696t -AON 'UOMIS 9WR JOJ PQSQA znS ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnenQWw -,'m 49 r:54 9 64� Mailing Address 775 /�� .�. Alk u1 Pc,k�naric ) 4 S0017 Property Address 5rx, s (Verification required from Planning Department for new construction) City /State Parcel Identification Number 630 - /OSYi - 740 - 4 W LEGAL DESCRIPTION Property Location 199 V 1?e V4, Sec. A3 . T 3o N -R Town of St • �'? o5vx . Subdivision , Lot # c)o 127- Pa S Certified Survey Map # 3 , Volume e # , / g Warranty Deed # 1/3 , Volume 796 , Page # Spec house ❑ yes 2 Lot lines identifiable 2'yes ❑ no SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Croix 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. I 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 Commerce 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 Zoning Office within 30 days of the ear expiration date. i SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I best of m our knowledge. I we am are the owner(s) of we cer that all statements on this form are true to the y ( our) g ( ) (are) ( ) fY the property d above, by a of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed LIML!,T NO STATE BAR OF WISCONSIN FORM 1 -1 TK1e a01AC9 a9s9a V9D FOR n9coaDlgo DATA WARRANTY DEED 432001 evcc l9brAc404 REGISTER'S OFFICE � This Deed maJ1 b.•twcen Judith A. hollhausen, ST. CROIX CO., VA formerly known as Judith Anne Simon, RedforRewd Nov. 10, 1987 Grantor. 9:00 A M a1.+ Timothy A. Riemenschneider, a single at man, Ri1�iiMrelO��i C,rr,ntre, Witllesseth, That the said Grantor, for a valuable cow ideration 1:911. TO .wn.• , tv Grrntcr the following; dreeribed teal estate to St. Croix 1 .,untl. State of N'tswnstn: Tax Parcel No: .............................. Lo Oo Cof the Certified Survey MaD recorded in Volume One ertified Survey Maps on Paae 45 as Document No. SOVT72, being a part of Government Lot Four (4), Section Twenty -three (23), Township Thirty (30) North, Rancle, Nineteen (19) West, including an ingress and egress road 12 feet in width to the above described property on the easterly side of the above described property which is an non - exclusive easement. � This 18. a0 t. homestead property. (is) Cis not) Together with all and singular the hereditament@ and rppurtrnsners thereunto belonginic; And grantor warrants that the title is `ood, indefeasible in for simple and rrcl• and clear of encurnhrawesgaW ,Ind 'A III warrant Sad defend the same. Dated this 7th day of November ly 87 4 /-/ 0,6 � iSEAL) (SEAL i Judith A. Dollhausen tSFAI.f ISEAI.f ADT9sNTICATION ACrNOW L =DOURNT Si gn aturels) .Of Judith A. Dollhausen. STATE OF WISCONSIN ' N. +� County. ...1. out t• this . day ... Y r 49-B7 P ersonally came b is this ... ..... day of „� • A�!!�r, 19 .... _ the above named • G. .-..Knutson ..... . ...... _..... .. TI TLE: �a�ylAfi7� /�A1"lcXft�fY0iII1i1Nt ' inNorts@d fi I ttary Public Ir.. -. • y' . op. is. StAU+ 8A g. t-, mr known to he the person who executed the �} ' •r.• otnyt instrument end acknowledge the same. THIS 1 N {T bV ♦ • T SD aV jot a-♦� BAKK$ 9NT A 1 .,, S SCHUMACHER, S. C. NewRLihmonsd •Y1 PO 17 �•,t :,• Public ( Win. rSit:ustu"s may le.autbwttkated or aeknowledc.vl fti.th >1• 1 .nnlwssion a p. n t!' not. rt 1tr esswration are not nrrrssary `- "Nary of Pera,as .tsalae to "r Ta, a..1) .R t. t,,... ..,..., .. , wA"ANTT testa @TAT► ras or wl.r•o%„Ile N. .• - ,,u. l.. Al 11140h Cu. Iwo rUkA Ne, 1 — Ives ............ f County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Personal 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 3 J (715)386-4680 Fax(715)386 -4686 Attach complete plans for the system on paper not less than 8 -1/2 x 11 inches in size. County Sanitary Permit # ❑ Check if revision to previous application py tsl (fi'''r i t. Application Information - Please Print all Infonmation Locatio Property Owner Name & 1/4 1/4, Sec . �« JUN 2 1 200 T 2 N, / R E (or) W Property Owners Mailing Address g7. CF U0,x COUNTY Lot Number Block Number ZONING OFFICE City, State Zip Code Phone Numer Subdivision Name or CSM Number 11 20 ,�LGV ,(�iC��►- >t�nc� !�,/ G 0 7/�' 7 �� ' 0 70 4 - ®1 A2 c 30612-z, 11 Type of Building: (check one) amity ❑ Village Town of 1 or 2 Family Dwelling - No. of Bedrooms: �— ❑ Public/Commercial (describe use): ❑ State -owned Nearest ad II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) d Parcel Tax Number(s) A) 1 1.[] Repair 1 2. ❑ Reconnection 3. []Non- plumbing 4.XRejuvenation Sanitation 030 /&<( 0 — 00 00 Permit Number Date Issued B) ❑ State Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ICI° Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other 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 � VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks 0 1 �/► G' py I ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair/ reconnenction /rejuvenationrinstallation of non - plumbing for the POWTS shoVXn_Qn the attached plans. A license is not required for terralift repair or the insteA of non - plumbing sanitation system. Plumber's Name (print) Plum s i na a (no stamps): MP /MPRS No. usiness Phone Number Plumber's Address (Street, City, State, Zip Code) VIII. County Use Only Disapproved Sanitary Permit Fee Date Issued Is g Agent Signature (No stamps) Approved Owner Given Initial Adverse �/a c 2 -21002— K, Determination IX. Conditions of Approval /Rea ns for Disapproval: tA1 ` L� S 5 i '^^� "erg- r Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code s't", Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must county C include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 0 - 5 to - -70 - 00 Please print all information. Re ewes by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 1� Property Owner perty Location { vL Lot N E1/4 N E 1/4 S 4 T 3o N R 9 E (or Property Owner's Mailin Address L # Block # Subd. Name or CSIy City State Zip Code Phon City ❑ Village ® Town Nearest Road 1Je-W Q� w1 S v i7 7f r. 'r a e 5 D -r ti A o r- 0 New Construction Use: ❑ Residential / s Code derived design flow rate y $ a GPD ❑ Replacement IR A e j u V [] Public or commercial - Describe: Parent material Q k Q.[. i m.. % in w t- Flood Plain elevation if applicable ft. General comments RrGSa r�"� 1$ 3 6 ' F- e-Icq- s•e -'I' Q-'t 9 $. $O � �h s r C. and recommendations: b ,. ; a� rt : h,� o� h & -b.. - b ; r S . s y St4tw• t 3 5 0 :4".. b te- fro f`t j u v c .r.,�,�k : a v� �� 5 !-e.vn a v ., S �'s-- •a o. err M Boring # © Boring q y ❑ Pit Ground surface elev. I a 1 I ft. Depth to limiting factor D `� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff# S -1 D 7.5 y L . 5 ` �. syRyl S t, 7S - 7610/ 7 5'� Jay 7.S YR `� y -'__- -_____ S — s F -1 Boring # [] Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil cation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 i Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = SOD < 30 mg/L and TSS < 30 mg/L T Name (Please Print Signature CST Number Ad dress ;10 0 � ti S+ Date Evaluation Conducted Telephone Number e" L.4-).r . to —I o- - O o� y e -3SS8 l Property Owner Parcel ID # Page of F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal AplAcation 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 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Appkation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 F-1 Boring # Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots G" in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 *Eff#2 I Effluent #1 = BOD, > 30 5 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD, < 30 mg/L and TSS _< 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (R,07 /00) c l NE'�y� NE'I.�� �3, rt'3oN Ri9�. -� '�oM✓�� �. S�'�.�t�- ztcr ��� ,ems i o'r i x 4�1 ?7S to Q Q f Vl s 7S, O w Gares a, h 1 0 P ` © �•�:S -E: r -- r4- V\ V— ®we ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the //m /�,,,, 1 sr/h n jl tl residence located at: j I %, JJE %, Sec. T R Town of l� St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced D/� •� Did flow back occur from absorption system? Yes No (if no, skip next line. Approximate volume or length of time: loo gallons minutes Capacity: /C)00 Construction: Prefab Concrete Y Steel Other Manufacturer (if known) : A11A Age of Tank (if known) : (Sig ture) (Name) Please 'Print A (Title) (License Number) Z . , - a0 . _.0 (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (excep for inspection opening over outlet baffle). Name /- �c,e+c_ Signature MP /MPRS ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address 72 ZL - 27 ,Cjr I Property Address (Verification required from Planning Department for new construction) City /State /fle a) 1?'cAm. 4 !r-, Parcel Identification Number CX?o /GSA' ' 40 55 LEGAL DESCRIPTION Property Location 1VEE %4, /G C V4, Sec. N -R. j E- W, Town of .��= 5r, • Subdivision Lot # �. Certified Survey Map # .3©d /mod. , Volume , Page It U< Warranty Deed # V'201 �`/ Volume 14 Page # � Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastcrplumber, 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 Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your 2ar 'ystem has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the xpiration date. S GNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) ceqjfX that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property d A above, by virtue of a warranty deed recorded in Register of Deeds Office. / 3 f I ATURE OF APPLICANT DATE « « « « «* Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. *« Include with this application: a stamped warranty deed from the Register of Deeds office reference is made in the warranty deed a copy of the certified survey map if re t3' v I 351 CS, KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX Co., WI RECEIVED FOR RECORD Document Number Docu nt Title' 1 06 -21 -2002 12:30 PH St. Cr oix Count)/ AFFIDAVIT EXEMPT # Affidavit of System Rejuv REC FEE 11.0® TRANS FEE: COPY FEE: I e S•C- L1 -\-a CCERT COPY FEE: Name - (Owner) Typed or printed AGES i being duly sworn, states, under oath, that: 1. He/she is the owner /part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume C iOS Page - �:L_ Document Number-12 t) St. Croix County Register of Deeds Office: Recordina Area I / A parcel of land located in the e% of the /V i/4 of Section d3 Name and Return Address , T N - R �! W, Town of fit. . - � , St. Croix County, Wisconsin, being duly described as follows (include lot no. and subdivision/CSM or detailed legal description): lot - j CS dog / 1 _ �( --� p_Co Parcel Iden ification Number (PIN) As owner of the above described property, I acknowledge that the septic system serving this residence (is /is not) undersized by current code standards. I understand that the issuance of a sanitary permit to allow the attempted rejuvenation of the septic system does not imply that the system meets current code sizing requirements, nor does it imply that the proposed procedure will be successful. I also acknowledge that I will make this information available to any future parties interested in pruchasing this property. Dated this 7th day of June 2002 ( ^ I I * * Lisa Riemenschneider AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. authenitcated this day of St. Croix County. ) Personally came before me this 7 t day of June 2002 the above named * TAga Rf em nschnei der TITLE: MEMBER STATE BAR OF WISCONSIN (if not, to me known to be the parson(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY * N ncy R. Fehrman Notary Public, State of Wisconsin (Signatures may be authenticated or acknowledged. Both are not My Commission is permanent. If not, state expiration date: F neces sary.) Date: 10 -13 -02 NANC.`Y RR "THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE" This information must be completed by submitter document title. name & return address. and PIN (if required). Other information such as the granting clauses, leagal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. Note: Use of this cover page adds one pace to vour document and $2.00 to the recordina fee. Wisconsin Statutes. 59.517. not:U.MENT NO STATE BAR OF WISCONSIN FORM 3 --1082 Tllia STAG[ RC1[ FOR RI�ORDINO DATA ii QUIT CLAIM DEED 470 - VOL 32 REGISTER'S OFFI Richard U. Simon and Angie C. Simon, ST. CROIX CO,, WI ...................... ............................... Rec'd for Record ������ wife � �• � -� ... ............................... _ ................. .... .... ........ ............... .......... ........................... ............................... I ................. ............................... JUNOT 199 quit- cl -tims to ...... Timothy...A. .,...Rieme. nsahne •ides., .................... a 8:30;� .A�MA� .........a. single. man..... ........... ........... _............. ... .. ..... .... .......................... .... . ... ................... ................. ' �W ............. I ................. - ............... e9 of �Qldj .......... I ..- ....... I... I ............................ ............... ............................... the followint' described real estate in ....... St•. ... C994K............. .. County, State of W;seonsir.: RITUR•, TD T:ix Parcel No: .............................. A parcel of land located in part of Government Lot 4 of Section 23, Township 30 North, Range 19 West, Town of St. Joseph, St. Croix County, Wisconsin described as fol'_ows: That nortion of land lying East of Lot 1 of Certified Survey Y g Y Map recorded in Volume 1 at page 45 as Document No. 300122 and West of a line being 6 feet distant from and parallel to the centerline of an existing roadway between the extensions cf the Northerly and Southerly lines of Lot 1 of said Certified Survey Map. The location of said centerline of existing roadway is g Y described as follows: Commencing at the Northeast corner of Section 23, Township 30 North, Range 19 West thence North 89°41'40" West 1214.56 feet thence S 00 West 29.58 feet; thence S 89 East 12.71 to the beginning of said centerline thence S 03 °45'09" West a distance of 196.00 feet. FG " This ............is........... homestead property. (is) (is not, Dated this - ?��� :; day of ..... _.. M ................. 19_91... .. ..... ..... (SEAL) �- ! (L.i l .: (SEAL) Richard D. Simon • ............................. .......... I....................... ............................. ............................... ...................... ............................... �1t.:f.cC .....-.�r� (SF.AL1 ...(SEAL) .....> ... , T. ......... �..' .................. .................................. I .............................. • ..Angie..C.... Simon ............... . AUTHENTICATION ACKNOWLEDGMENT / Signature(s) .......R3,.hard-. D _51mon..._.._... -_.. ` TATE OF WISCONSIN ss. ansi._11.n.J e.. t... ............. ( t 9r f� $'L :..CROL ........... tounty. I S authenticated thi / ...day of .... MY ............... 19...9. Perms any came before me this ... .e........ day of C[s YYI. .......... ........._ .. .................... ------ -- - - - - -- -- --- 199. ... the above named -- - - - - -- ..._Angie C. Simon dith A. Rem ngton ................................................... _ .. .... ........ . ..... TITLE: MEMBER STATE BAR OF WISCONSIN ............................... ........... ............................... (If not . ............................ ............................... authorized by j 906.06, Wis. State.) to me known to be a person who executed the foregoing instru at and acknowie a the same. THIS INSTRUMENT WAS DRAFTED BY � I ' Judith A. Remington ...�..�:. ! ►....`..... . ....... ....... .......... ................... ..... .. t R� T Lp, W opgg ' •....J ith.. A....Remingt......,. ;.... ! New 4017 1 No y Public .....S.t... CEO ..X. =. wn , Wis. .I C I (Signatures may be authenticated or acknowledged. Beth 9 . Commission is permanent.I,If not state expi ion, are not necessary.) .t'' ;? i date. ......_... •' _ CEBTIFIID S VEY MAP r _ �} �=. •o /220.5' fa N.E. corner 1 0. °►° 4 Sec. 23 - 30- / 9 r r �o � a .2 ao. hh ZI . '" ,+.flndicc�•fcs . Iron pipc.,,�}'gke: . �a Part of Gov. Lot 4, Section 10 23 T 30-No B 19W, further �A) 4 described as follows; beginning at a point on the north line I $0� ° o of said Sec. 23 a distance of, V_V e J T °• 1220.5 feet west of the north- east corner of said Sao. 23; s, thence due South a distance of 526.2 feet, thence due West a I distance of 282.3 feet, thence �i i North �* 00' East on a meander 0 b line a distance of 532.6 along Shawn for N I the shore of Bass Lake, thenoo �l V reference Ord K i due East along the north line of � +1 said. Sec. 23 a distance of 199.0 Z� N1 feet to the point of beginning. A� All land b meander line and 8 0 1 Bass Lake is part of the adjacent 11 4. , lot. r. I certify that the above is a true mnd correct.-map 'of,the parcel surveyed, mapped and described above and that I have complied with the provisions of Sec. 236.34 of the Wisconsin Statutes. Surveyed for Bay Simon, Nov. 1969. Carroll A. Grubb Wis. No. S -274 CA8001 t A. &RJR/ r Form - S T C - 104 AS BUILT SMT SYSTEM REPORT OWNER 1 G 2 T0N119HIP _f O 5� SEC. T N -R�W ADDRESS 5 dt'! ST. CROIX COUNTY, WISCONSIN SUBDIVISION i:('t LOT SIZE / PLAN VIEW Distances and dimensions to mef. t tcquirements of I•LHR 83 SHOW EVERYT11I1.4�.; WLTHIN 100 FEET OF SYSTEM t � I � h Form - S T C - 104 AS BUILT SA SYSTEM REPORT OWNER / 1 G 2n�� . TO,rN5HIP f / 0 SEC. ADDRES ST. CROIX COUNTY, WISCONSIN SUBDIVISION t: r t _ LOT SIZE PLAN VIEW Distances and dimensions to me(.'- te-.11iirements of I•LN.R 83 SHOW EVERYT11J.PG WITHIN 100 FEET OF SYSTEM ! e ale ozor � � h v INDICATE NORTH ARROW / BENCHMARK: Describe the vertical re "erenro point used 7, G(/ l Elevation of vertical reference Fein".: w 1/ 4 9 1 Proposed slope at site: w—' SEPTIC TANK: Manufacturer: IVIe 1 Liquid Capacity: or Number of rings used: Tank rianhole cover elevation: t/, •S Tank Inlet Elevation:�Yf' Outlet Elevation: ! 5 RQaI: Side Rear Number of feet from nearest Front, S d ,� , O feet From nearest property line Front, Side.0 Rear, 0 �,,y� feet Number of feet from: welt 19 building: �� (Include this informa.tJon o t }:e ;above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: y Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: Y6 ` Number of Lines: — Area Built: Fill depth to top of pipe: � D Number of feet from nearest property line: Front, O Side, n Rear,0 it Number of feet from well: Number of feet from building: 5�y (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems7 (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, © Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: L g Inspector• Dated: ✓ / Plumber on job: License Number: l 3/84:mj .DEPART%AENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS ', LABOR'& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING NE 4, 4, 7ec.23,T30 -R19 ( CONVENTIONAL ❑ALTERNATIVE State Plan l.D. Numb er Town Of St. Joseph E] Holding Tank ❑ In- Ground Pressure ❑ Mound ufassI9ned( 150th Ave. NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: r INSPECTION DA E: Richmond, aI Tim Riemenschneider 359 Odonah Ave. New c , BENCH MARK (Permanent reference po DESCRIBE IF DIFFERENT FROM PLAN. REF PT. V I /r' CST REF. PT. ELEV. Name of Plumber: I MP/MPRSW No "" "' San,ta Permit Number: Byron Bird Jr. 3318 St. Croix X35411 SEPTIC TANK /FF4NK: MANUFACTURER. LIOUI O C APACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER I r < n u PRO ED PROVIDED'. `��'C J �,�(ICIitr 7D.S , /D.o'J , 1/SIYES ❑NO DYES WNCE BEDDING: VE.N;- gf!}(: �' v VFNTn�os.+ �� HIGH WATER NU]jER OF `ROAD: PROPERTY WELL BUILDING. VENT TOFRESH // ALARM FEET FROM LINE (���J , AIR INLET. ❑YES NO ` `.. ,c "" ❑YES NO NEAREST 7� ' °� nA DOSING CHAMBER: MANUFACTURER = LIQUID CAPA(.I TY PUMP MODEL 1 111VP,SIPHON MANUF ACTIIHEH WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: NO E:] YES ❑NO i [- ONO GALLONS PER CYCLE: FP AND CONTROLS OPERATIONAL NUMBER OF " HOP WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LI AIR I NLET PUMP ON AND OFF) 1:1 YES ❑NO NEAREST -- 00 SOIL ABSORPTION SYSTEM. Check thesoil moistureat thedepth of plowing IIN(,TN I DIAMF TEH I MATE HIAL AND MARKIN( or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH J NO01 I DIST11 PIPE SPACINI, COVER .INSIDE DIA -PITS LIQUID BED /TRENCH THE NCH FS MAT L PIT I DEPTH DIMENSIONS RAVEL DEPTH - FILL DEPTH DISTIL PIPE UISTH PIPE DISTR PIPF r y1ATERIAL NO I ISTH NUMBER OF _PROPERTV t WELL BUILDING. VENT TO FRESH BELOW PIPES ABOVE COVER EI EV. INLE t ELEV. END �'� Y PIPES : LINE / AIR INLET - f 1 t" FEET FROM p�pp > _9s C� r -c� O7.>!o_9 �` / - ' i L� � ✓ �-� -� NEAREST- >_95 J MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- 1:1 YES El NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER I T EXTURE PEHMANF NT %1AHKFHS OBSERVATION WELLS _ 1:1 YES 1:1 NO ❑YES 1:1 NO DEPTH OVER TRENCH BED DEPTH OVFH TRENCH BE L1 SODUF U I SF F DUO MULCHED CENTER EDGES UEPTH OF TOPSOIL ❑YES. El NO 1:1 YES ❑NO OYES I- NO PRESSURIZED DISTRIBUTION SYSTEM: B ED /TRENCH WIDTH LENGTH TR E ES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIME NSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH DISTR. PIPE DISTHIBUT ION PIPE MATERIAL & MARKING ELEVATION AND ELEV.. ELEV. CIA ELEV. PIPES DIA.. DISTRIBUTION " INFORMATION HOLE SIZE HOLE SPACING CHILLED CORRECT L COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS 1:1 YES El NO 1:1 Y ES ❑NO COMMENTS: 1 1 PERMANENT MARKERS: J OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET'FRf?M LINE: DYES El NO 1:1 YES El NO NEAREST ry Sketch System on Retain in county file for audit. Reverse Side. SIGNAT E. I TITLE - DILHRSBD6710(R.01/82) [� SANITARY PERMIT APPLICATION D LHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY f C ✓C STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ / / 1 1 8% X 11 inches in size. C(eCR if revision to pr ous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION 7 r r� c t" Y �4 /4`Y' 1/4, S „''� T , N, R E PROPERTY OWNER'S MAILING ADDRESS LOT ,# , BLOCK # / _`- y - r y %ftr[ /f w� CI , STATE ZIP CODE PHONE NUMBER S BDIVISION NAME OR CSM NUMBER 7 AAA ! -e C 7 4 CITY NEAREST ROAD 11. TYPE OF BUILDING: (Check one) L1 State Owned n VILLAGE ; '/: SFh J � , ❑ Public V 1 or 2 Fam. Dwelling -# of bedrooms u , -70-- III. BUILDING USE: (If building type is public, check all that apply) 5� "?� / 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other"" 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure — -43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 13. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION l # 5,c-, , / - "� ; � Feet �;� ?� Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete structed Con- Steel glass Plastic A pp' Tanks I Tanks Septic Tank or Holdino Tank fr " "'` t- c' C Ll Lift Pump Tank/Siphon Chamber . To I ±E VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumbers Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: Plum s; ddress (Street, City, State, Zip Code IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ssuing Agent Signature (No Stamps) y : , surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination 7 X. GONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber . r C =� TRUCTIONS - 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permO may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be.applicable, 3. All revisions to this permit must be approved bX petart•,ssuing authority. 4. Changes in ownership or ptumber:requires a sanitaw Permit Transfer /Renewal Form-(SBD 6399) to be submitted to the county pirior to installation. Onsite sewage system$ mustbe•properly maintained. The septic - tank(s) must be pumped by a licensed - pumper whenever necessary, usually every 2 to 3 ydars. State of Wisconsin, Safetyerrling your onsite gluiidings Division, �- 266-3815. ator or the - 6. If you have questions:conc system, con, your local code administrator To be complete and accurate this sanitary permi!-S . pp"on must include:: ' ` . . • • °: - ' 1. propeigyy owner`s name ' and'mAiling address. Provide the-legal desorption andparoel -tax nu s}Of- where the system is to be installed. II. Type of building being served.-0mck•only one -and complete # of bedrooms if 1 or 2 Family Dwelgg III. Building use: If building type is Public, check ati.appropriate boxes that apply. - IV. Type of permit. Check only one in line A. CorAplate line B t_perrnit,ig;for tank replacement, recennect�ort, repair, Type of system. Check appropriate box depending on system type. 7 VP: Absorption system ' Provide all information requested in. #1 -7. 1 VII. Tank information. Fill in the capacity of every new and /or tank, list the fotal gallons, number - of ` tanks and manufacturer's names indicate prefab or aite cAmtruetisd iand tank; material. Complete for all : septic, pump /siphon and holdingAanks for this system :�Clteck experimental approval only if tanks received experimental product app gval from DILHR. Vfil. Responsibility statement. lnstaffing plumber is to-iiff-in name,ftense numberwvith appropriate prefix (e g. MP, etc.), address and phone number. Plumber must sign application form. = ` IX. County /Department Use Only. X. County/Department Use Only. Complete plans and specifications. not smaller than-8% x 11 1066igs"must be submitted to the &urity: The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location bf ;'e holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service;- streams and-lakes; pump or siphon - tanks; distributierrboxes; soil absorption systefns;; m replaceentsystem areas; and the location o1 the building served; B) horizontal and vertical elevatiort`rt#ference p6ittts C) comptete.spedfications for pemps and dontrol8; dose volume; elevation differences; friction lobs; pump performance curve; pump n ddel and pump Manufacturer; Dj cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. _ �_GRO UKDWATER SURCHARGE ' '• <: 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices whichgan effect groundwater: The monies collected through these surcharges are used for monitoring groundwater, ground - water contamination investigations and establishment of standards. M -6398 (R.11/88) D." LWL'I1 NQ STATE BAR OF WISCONSIN FORM 1 -1 4811 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 4 0 0 1. A ct tOOMt � REGISTER'S OFFICE OP This Deed made between Judith A. Dollhausen, ST. CROIX W., W1 formerly known as Judith Anne Simon, ftedfwlb oe Nuv. 10, 1987 Grantor, 9:00 A M Timothy A. Ri eme nschne i der, a single at man, modw of Do@& Grantee, lVlLlles5QLh, That the said Granter, for a valuable consideration [1L TO , r „nt.• to Grantee the followint; drscnbr,i reel estate in $t. C r oix r„u!:tN. State of Wisconsin: Tart Parcel No: ._ ............................ Lot Ore (1) of the Certified Survey Man recorded in Volume One (1) of Certified Survey (daps on Page 45 as Document No. 300122, being a part of Government Lot Four (4), Section Twenty -three (23), Township Thirty (30) North, RanOe Nineteen (19) West, including an ingress and egress road 12 feet in width to the above described property on the easterly side of the above described property which is an non - exclusive easement. 5E� This 1 S. n homestead property. ( is) (is no) Together with all and singular the hereditament• and .Appurtenances thereunto belonging; And yrantor warrants that the title is good, rndefsaatble in for simple and tree• and clear of encumhranlesjgtpt/6X and % ill warrant and defend the same. Iratrl this 7th day of November 19 87 (SEALI (SEAL) Judith A. Dollhausen 9SFAI.1 (SKAL) AUTUNNTICATION ACKNOWLZDGMZNT Simrature(s) OF J.ud.ith A. Dollhausen, STATE OF WISCONSIN ' M. County. St it h - this .�.. day v r A9...87 Personally came before me this ... day of t 1 19 the above named .... a - ..U►ttutfGll ........ ....... ....... TITLE: 1FPJF1l��lQ1'ICXk�f71�1t1Nt .... r; 41l assL t .Public Pr.:._. • i satho by'!'7� is. Ktata /d !E V' t,, me known to he the p►rsnn who execute-4 the 1 n !:••.•,any; instrument end acknowledge the game. THIN !NST{ltl rt ENT a3A AaAtrTSD RT BAKKI�, IJ�M�k�Q, i SCHUMACHER, S. C. 1200'4isrikedt” �f =ive . Newitir46slO -A -Ul. 017 �•.t• I'ubHc County, Win. 1Sicuaturrs may be autbwttkattd r aeknowlc 1y>'[d m.th �1 ( , rrnrruesinn a pen r f not, st Ate expiration are nut necrosis 0 49. •Narra of arww WARRANTT OR =D sTATt NAM of wt +1.11VetN w.. ,, u. Lrrl blank Cu lac VONA Ne. 1 —less �Li. „ it. Vaj . APPLICATION FOR SANITARY PERMIT STC 100 This application form is to be completed in full and signed by the ownez(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by completed trwhenr,theeCproperty then a second should retained this office with the appropriate deed recording. -------------------------- Owner of property ' G ,' , L" !S N -R j "l V Location of property _1% 1 /�, Section T_ Township 5 r_ : - e N Mailing address -S70 ST. Address of site •ubdivislon name Lot number / Previous owner of property .S�a ri� Total also of parcel Date parcel was created Are all corners and lot lines Identifiable? —IL— yes Is this property being developed fat resale (spec house) ?_ Yas _...__ Volume �l] �o_ and Page Number ;V' as recorded with the Register of Deeds. --- - - - - -- -------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWINGS A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Cettlfled Survey Map shall also be required. ------------------------------------------------------------------------------- PROPERTY OWNER CERTIFICATION 1(We) certify that all statements on this form are true to the best of any (out) knowledge; that I (we) am (are) the ownet(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. Z/3 a00 /- ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, tot the construction of sold system, and the same has been duly recorded in the Office of the CCU y Reglstet of Deeds, as Document No. Y 3 ao 1. signature of Owner Signature of Co -Owner (If Applicable) C Dez "AV Date of Signature Date of Signature ST C- 105 r H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d OWNER /BUYER ) I wt C-mew_ ROUTE /BOX NUMBER 2T Fire Number 7�] S CITY/STATE N &1nJ z I P 5 VG/ 7 PROPERTY LOCATION: Section _ , T_0 N, Rl'/__W, I Town of St. Croix County, Subdivision Lot number • I I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con - sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents m_ y be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 r I /WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart - v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED D A E St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715- 796 -2239 or 715- 425 -8363 Sign, date and return to above address. DEPARTMENT OF R EPORT ON SOIL BORINGS AND SAFETY & BUILDINGS .D UST. Y, DIVISION LABOR HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: OWNSHI UNICIPALITY: LOT NO]BLK. NO.1 SUBDI VISION NAME: COUNTY: Al I LING AD ESS: USE DATES OBSERVATIONS MADE p NO. BEDRMS.: COMMERCIAL DESCRIPTION: PERCOLATION ESTS: Residence � „New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN- GROUND PRESSURE: rEis YSTEM -IN -FILL rEIS OLDING TANK: RECOMMENDED SYSTEM: (o ;01) S ❑u 'Es ❑u fps ❑u u 6�s If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09151(b), indicate Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P GROUND ATER- 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- B- rB- T 1 PERCOLATION TESTS TEST DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- P- 07 P- P- P- P- 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. SYS EM ELEVATION , - �1 - ts , e o .w } l ; E _ u�11� 3 - 4 tN 3 3 w r I, t undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the pr1 ceGuAand methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME print): r TESTS WERE COMPLETED ON: ��I> -n Z4 - — Z — T'Z ADDRESS. CERTIFICATION NUMBER: IPHONE NUMBER (optional): cn CST SI NAT E: r DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 10/83) – OVER – r INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. Aseparate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Texturos Other Symbols st — Stone (over 10 ") BR — Bedrock cob — Cobble (3 - 10 ") SS — Standstone gr — Gravel (under 3 ") LS — Limestone 's — Sand HGW — High Groundwater cs — Coarse Sand Perc — Precolation Rate med s — Medium Sand W — Well Is — Fine Sand Bldg — Building Is— Loamy Sand > — Greater Than 'sl — Loamy Sand 'c — Less Than '1 — Loam Bn — Brown 'sit — Silt Loam BI — Black si — Slit Gy — Gray cl — Clay Loam Y — Yellow scl — Sandy Clay Loam R — Red sicl — Silty Clay Loam mot — Mottles sc — Sandy Clay w/ — with sic — Silty Clay fff — few, fine, faint 'c — Clay cc — common, coarse pt — Peat mm — Many, Medium m — Muck d — distinct p — prominent HWL — High water level, surface water ' Six general soil textures BM — Bench Mark for liquid waste disposal VRP — Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. � J FLU 1 PLAN / 'PKJECT )�" & �� _ �_ /�ir���ADDRESS 1%4 1141S? )We N/R/ eW TOWN_ _CO TY eroice_ �5�c /�' M RS Byron Bird r. 18 DA E – BEDROOMJ CLASS PERC CONVENTIONAL, IN- GROUND ESSURE CONVENT16NAL LIFT _ MOU�_ HOLDI G TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA _. PERC RATE BED SIZE hL Benchmark V.R.P. Assume Elevation 100' Location of Benchmark 4o * H.R.P. — _Z'� a ^ a , O Borehole Q Well Scale = Feet 0 Perc Hole System Elevation Uent 12" GE de TYPAR COVERING 2 - 12" 3 4 6' O 3' 3' O 3' 6- Sewer Rock 12' 18' s-p c -' l ot / C19I14 , 0EP,A1 VMENT OF EpORT ON IL B IN A SAFETY & BUILDINGS INDUSTRY SO OR GS ND DIVISION LABOR AND r, PERCOLATION TESTS (115 P.O. BOX 7969 HUMAN RELATIONS MADISON, WI 53707 / (1-163.090) & Chapter 145.045) LOCATI N: SECTION. TOWNS HIP /MuDaC3 Y: IL OT NO.: BLK. N .: SUBDIVISI N NAME: NE �� NE�� 23 /T 30 N/R 19( or) W St . ,Joseph n/a n/� 45 COUNTY; OWNER'S BUYER'S NAME: MAILING ADDRESS: St. Croix Tim RiOmenschneider 359 Odanah Ave., Nevr7Richmond Wi. 54017 USE DATES OBSERVATIONS MADE O NO. BEDRMS.: COMMER IAL DES RIPTIO PROFILE NS: TESTS: Residence 2 n/a RINew ❑Replace 11 -10 -88 n a RATING: S= Site suitable for system U= Sito unsuitable For system CONVENTIONAL: MOUND: IN- GROUND•PRESSURE: S STEM- IN- FILLHOLDING TANK: RECOMMENDEDSYSTEM:(optional) ®S U ❑ S U DS EIS 9U [:]S CCU I 18x23 conventional) If Percolation Tests'are NOT required DESIGN RATE: I If any portion of the tested area is in the under s,H63.09(5)(b), indicate: class 1 Floodplain, indicate Floodplain elevation: n/g decimal' PROFILE DESCRIPTIONS page 34 l' BORING TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH= ELEVATION OBSERVED . I HE TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) 1.08bl.1. .42bn.l.s. 2.25bnc.s..w /.04bands of l.s B- 1 8.75 98.85 none >8.75 5.00bn.c.s. B -2 7.41 96.80 none >7,41 .58bl.1. 1.58bn.sil. 3.00bn.c.s. .50bn.l.s. 1.75b .r.- .s. B. 3 8.42 95.87 none >8.42 .75bl.1. 7.67bn.c.s. 6.4 6.50 92.00 none >6.50 .75bl.s.l. 1.00bn.c.s.fill .67bn.sil. 2.00bn.l.s. GIWS. B- 5 6.50 91.97 none >6.50 1.67bn.c.s. &bl.l.fill .83bn.sil. 4 00bn.c.s. B- PERCOLATION TESTS TEST DEPTH, WATER IN.HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES EiLING AFTERS INTERVAL -MIN. P RI D 1 PERIOD — . R PER INCH P - P_ see design rate P- P-. P- P- 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. SYSTEM ELEVATION 93.37 ar a f ~ -1 finis i j b o or tan el 97 87 for co I � I N ... . ... 1.... __. .._ I i Gov, '. I, the undersigned, 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: Gary L. Steel 11 -10 -88 ADDRESS: CERTIFICATION NUMBER: PHONE NUMB ER(optionai): 988 N. Shore Dr., New Richmond Wi. 54017 22981 p CST SI URE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) —OVER —