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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 seconda s ST. CROIX COUNTY GOVERNMENT CENTER
[Privacy Law. S. 15.04(1)(m)] �� 1101 Carmichael Road
Hudson, WI 54016 -7710
(715)386 -4680 Fax (715)386 -4686
Attach complete plans for the system on paper not less tF&P@Ofr2 x 11 inches in size.
County Sanitary Permit # ❑ Check if revision to previous application
L Application Information - Please Print all Information Location:
Property Owner Name _ r= w S 1/4, Sec 3
C ' T a O N. R 19 LJ E (or) W
Property Owners Mailing Address n 20 { Lot Number Block Number
City, State Zip Code hone Subdivision Name or CSM Number
"A's 0-'N- Lt) _;5 wZ _14Y
11 Ty of Building: (check one) ❑ Villa S
pe y [xity Village Town of
1 or 2 Family Dwelling - No. of Bedrooms: _�`f�[, S I ✓l� `Y'
❑ Public/Commercial (describe use): ( J I _t
❑ State -owned Nearest Road
it. Type of Permit: (Check only one box on line A. Check box on line B if applicable) W _. ` S `, 0 4 ►
Parcel Tax Number(s)
A) 1.❑ Repair 2X Reconnection 3. ❑Non - plumbing ❑Rejuvenation
Sanitation
B) Permit Number Date I sued
State Sanitary Permit was previously issued Z 6 7- 4 11 1 Z q
IV. Type of POW System: (Check all that apply)
X Non- pressurized In- ground 'BeAJ 12 FZ " ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In-ground 9X&41'r `� ❑ Holding Tank C] Single Pass ❑ Drip Line
1 At-grade J ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other
V . Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals. /day /sq.ft.) (Min./inch) Elevation
o0 /goo /y yo ----' e-L z 9 .? /o . /
I. Tank Information Capaicty i Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing allons Tanks Concrete structed glass
Tanks
Zorn Zao ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
11. Responsibility Statement
1, the undersigned, assume responsibility for repair / reconnenction /rejuvenationrnstallation of non - plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the insta ation of non - plumbing sanitation system.
I, Igmbers Name (print) Plu s nature (no stamps : /MPRS No. B sin s P ne Number
Plumbers AdStres Str City, State, Zip e) ; 444 a ,l 12 05 S Lee �, 77LU.cJy�}7 f�'l O j .I �" 3 3')
Ill. County Use Only
Disapproved Sanitary Permit Fee Pate Issued ssuing ent Si nat o stamps)
Approved Owner Given Initial Adverse 4 � � . 03 Q
ED etennination
IX. Conditions of Approval /Reasons for Disapproval:
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STC - 10 4 - I ; ItlEg
AS BUILT SANITARY SYSTEM REPORT r` fJ
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OWNER . �c t �S ✓�� i "t t ,� C ��
ADDRESS
rZ�1.L�
1? j or
SUBDIVISION / CSM # �/`;� LOT #
SECTION - T -R ,Zl W, Town of / ,
ST. C OIX COUNTY, WISCONSIN
PLAN VIEW
SHOW-EVERYTHING WITHIN 100 FEET OF SYSTEM
� (5
eba'i
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
i
BENCHMARK.
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: �/� Liquid Capacity:
Setback from: Well y SI1 House 1'9 Other
Pump: Manufacturer Model# Size
Float seperation Gallons /cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop, line:
i
Setback from: well: 4A House l/S Other
ELEVATIONS
Building Sewer Z4Z7 ST Inlet. 1 ST outlet , LIZ_
PC inlet PC bottom Pump Off
Header /Manifold Bottom of system
Existing Grade /_ Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: 1s
INSPECTOR
3/93:jt
I
Wisconsin Department of Industry PRIVATE SEWAGE SYSTEM County:
Lab &rand Human Relations ST. CROIX
,Safety and Buildin Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
P%rAV , ROBERT ❑ City ❑ Village R Town of: State Plan ID No.: ST_ JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
GCJ .
ca ' ✓U✓Yl L� Q-S
TANK INFORMATION ELEVATION DATA /
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �A cG�V? C Benchmark 5 0 75 �drJ, cv
Dosing I �� {. , d ►'Y? /ps 5lS
Aeration Idg. Sewer UJ /p /, 70
Hold St /Ht Inlet 5-5! O
TANK SETBACK INFORMATION St/ Ht Outlet 164, �
TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet '
A
Septic >�� ZS� ' NA Dt Bottom
Dosing NA Header tgan-_ 7 p(� e, 69
Aeration Dist. Pipe aa' 9g, 53 /
H Ing Bot. System r /0' 97(ps
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand f w des n z d
Model Numbe`i _ GPM
TDH Lift rLric S stem
` TDH Ft
Force In Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length , No -Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /a �° DIME NSION
SETBACK SYSTEM TO P/L BLDG WELL LAKE/ STREAM acturer:
INFORMATION Type Of z-- i , CHA R Mode Number.
NIT
DISTRIBUTION SYSTEM
Header/ d N Distribution Pipe s)� �� / x Hole Size x H pacing Vent To r Intake
i co
Length Dia Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At- ade Onl
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOC ,TIONz .ST.. JOSEPH_. 34-30-19W, NW, SE OAMOOD LANE
k S
t�,�C.r � p�
,.�
Plan revision required? ❑ Yes No
Use other side for additional information. o �---
SBD -6710 (R 05191) Date Inspector's Signature Cert. No.
B afetyandBuildin Watr D ivi s i o n
SANITARY PERMIT APPLICATION
Bureau of Building Water System!
201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O- Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size. /
• See reverse side for instructions for completing this application State Sanitary / � rmit Nu ber
The information you provide may be used by other government agency programs ec
Chk it r6icn C4evi s a/ tion
(Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prop ner me Prope Location
" Z P 10 t t /4,.5 T , N, R E (or)
Property Owner's Mailing Address L Number Block Number
Ci ate Zip Code F(P' one Number Subdivisi ame or CSM Number
) L
II. TYPE OF 'BUILDING: (check one) ❑ State Owned !t� Neares Road 2
Public 1 or 2 Family Dwelling - No. of bedrooms ° Town o
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 00 ~+� COM
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 box on line A. Check box on 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 Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 OSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6- System Elev. 7. Final Grade
Required (sq. ft -) Proposed (sq. ft_) (Gals/day /sq. ft.) (Mi -/inch) Elevation
S Feet Feet
VII.. TANK CapacttY site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank ,❑ ❑ ❑ ❑ E] ❑
Lift Pump Tank /Siphon Chamber ❑ El El ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, th undersigned, assume responsibility for in talla 'on ofAqonsite sewage system shown on the attached plans.
Plu e s Name (Pr Plu er's S natu am MP /MPRSW No.: Business Phone Number:
P mber'sAddre trge C' y,Sta e,Zip de):
IX. COUNTY / DEPARTME USE ONLY
❑ Disapproved Sawtary Permit Fee (Includes Groundwater ate Iss Iss ng Agent N:K
Cj(�i Surcharge Fee) `U %f�
X Approved ❑Owner Given Initial
Adverse Determination C�
X. CONDITIONS OF APPROVAL / REASCJNS FOR DISAPPROVAL:
SBD -6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
;5
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of -
Wisconsin, Safety and Buildings Division, 608 - 266 - 3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with 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 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) 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.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , c DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(H63.09(1) &Chapter 145.045)
LOCATIO • SECTION: TOWNSHIP /QTY: OT NO.: BLK. NO.: SUBDIVISION NAME:
NN 1/ Se1/ 34 /T30 NCR 19 1E�or) W St. Joseph 11 n/a Deerfield
COUNTY: OWNER'S @6 NAME: MAILING ADDRESS:
St, Croix S. Henning & D. Norell 665 Tdalsh Rd., Hudson, Wi. 54016
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: 1COMMERCIAL DESCRIPTION: New ❑Rl
PROFILEDESCRIPTIONS: PERCOLATION TESTS:
?esidence 3 n/a epace 7 -10 -92 n/a
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM -IN-FILL HOLDING T ' � K:RECOMMENDED SYSTEM: (optional)
ES ❑ U U S I U ® S❑ U ❑ S E U EIS tau I conventio
If Percolation Tests are NOT required DESIGN RATE:
q If any portion of the tested area is in the n/a
under s.H63.09(5)(b), indicate: class 2 Floodplain, indicate Floodplain elevation: /
dprimnl PROFILE DESCRIPTIONS a e 42 JSB
BORING TOTAL D PTH T GROUNDWATER- INCHES CHARACTER OF SOIL WITH HICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
9 -19, 10yr5 , si 19-27,;
B- 1 89 102.10 none >89 7,5 r4 / 4,sl.; 27 -89, 7.5yr4/4, Is.
2 80 101.20 none >80 0 -12, 10yr4 3, L.; 12 -29, 1 r , Si l.; 29-50,;-
B- 7.5yr4/4,sl.; 50 -80, 10yr4/4, Co. S.
r ' L.; 16
B_ 3 80 101.18 none >80 7.5yr4 /6,S. , si .; - ,-
4 74 101.18 none >74 0 -6, 10yr4 /3, L.; 6-24, 7.5yr4/4, si .; 24-74,-
B_ I I 7.5yr4/4, Is.
B- 5 80 99.40 none >80 7.5yr4%4. 1s.L.' yr si .; 33
B_ 6 76 100.00 none >76 29 -76, 7.5yr4/4, sl. si . ;-
PERC TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD t PERIOD2 PER PER INCH
P-
P-
P_ See esigri rate
P -_
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable s as scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Sho u e t' all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 98 C b �F a
-4 41 k
E
W
c t
3
pd*
_ . _ -- ------ 1
E
E
_i - E
14 1 3 3
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 7 -10 -92
ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER (optional):
1554 200th AVe. , Few Richmond, Ili. 54017 2298 F15- 24#4200
CST SIGNAT E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR -SBD -6395 (R. 02/82) OVER —
/
^
. .
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INSTRUCTIONS FOR COMPLETING FORM 115 SBD '6385
Tohra complete and accurate soil test, your report must inc|odo:
� 1 Complete legal description;
2. The use section must clearly indicate whether this is residence or *omme/oim| project;
3, MAXIMUM number of bvdroumsor 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 0N SOIL CONDITIONS;
6� PLEASE use the abbreviations shown horc for writing pn`Ne descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating Your test locations. Drawing to scale is preferred. A
separate sheet may be used if desired;
8� Make sure your benchmark and vertical elevation reference point are doady shown, andare permanent;
9, Complete all appropriate boxes as to dates, nomns. addresses, flood plain data, poroo|n'ion test exemp-
tion, if appropriate;
10� If the information (such as flood plain, elevation) does riot apply, nb'e N.A�in the apprupriaie box;
1/� Sign the form and place your ourrent address and your certification numhen;
12. Make |eAib|u copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 20 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures OthorSymbo|x
st — Stone (over 10'') SR — Bedrock
nob — Cobble (3 10'') 5S — Gund�tpnw
g, — Gravel (Under 3") LS — Limestone
~s — Sand HGVV — HighGroun6wator
�
� ca — CoaomSond Pcn — Peuo|adnn Rate
m^ds — Medium San(] VV — vv�!||
I's — Fine Sand B|dO — Building
Is — Loamy Sand > — GmaterThun
°d — SmndyLoam ( — L*ssThan
°! — Loan 8n — Brown
°oi| — Silt Loam, Bl — Black
Sill �, ,` � Gy — Gray
� °d'- QaVLomnv ` Y — YcUmw
ol _Sandy-Clay Lomm R — Rom
—
.sid — SUty nnnt — Mottles
� '— — Sandy Clay ith
�*ty�| | �� — fmw fine �inT
� ~ — ' '
G�av-. nc — ovnmon.com�o
mm — manv
m48' Muck ` d — distino|
HVVL — High |ove|
° Sixgnoe,n| soil tckf� sw��vA"at��,
fo�|iquidwamodioposa| BM — Bench K8oA'
vRP — VerUom| Refm,oncn Point
TO THE OWNER: '
This soil test mport is the fli'st step in securinc
q a sanitary permit, The county or the Departmomt rnay rp(jUeSt
vet /f of this soil cw# io the flnN pri»rIo rermh isouanca� Acomp|mte set of o|anm for the p,/vmte
ucv, p/otom and u no/mll application mu,z be, submitted to 1he oppropriule (orm| autbo,ity in order to
ob:ein a pn/mit. Thexamtmry pmrmk mus� bembtained and po!�Iod p,ierto "hl starr ofony oonqruCtion�
|
. ���
INDUS T TR Y, OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS
INDUSY, DIVISION;
LABOR AND PERCOLATION TESTS ( 115 1 P. °. BOX 1 069,
HUMAN RELATIONS \ / MADISON, WI 5J7
(1-163.090) & Chapter 145.045)
OCAT O S CT O • TOWNS HIP /19[p[ft {XrY: LOT NO.:BLK. NO.: SUBDIVISION NAME: �!
NU 1/4 Set/4 34 /T 30 N/R19fior1 W St. Joseph 11 n/a j Deerfield
COUNTY: OWNERS NAME: MAILING ADDRESS:
St, Croix S. Henning & D. Norell 665 Walsh Rd., Hudson, Wi. 54016
USE DATES OBSERVATIONS MADE
N0. BEDRMS.: COMMERCIAL DES R TIO : � P OF DESCRIPTIONS: S
esidence Ulew ❑Replace ?:
3 n/a 7-10 - n/a
l N,
RATING: S- Site suitable for system U- Site unsuitable for system
I C ' ONVEN i5 MOUND: IN- GROUND RESSURE: S STEM- N -FILL HOLDING T T A U N u '� K: RECOMMENDED SYSTEM: (optional)
BS ❑U U s ❑t ®S ❑U ❑ S 9U EIS Li conventio
If Percolation Tests are NOT required re DESIGN RATE:
q I If any portion of the tested area is in the a
under s.H63.09(5)(b), indicate: class 2 Floodplain, indicate F l oodp lain elevation: n /
t PROFILE DESCRIPTIONS p age 42 JSB
BORINGI TOTAL DEPTH T R UNDWATER INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED HE T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
, IUyr , .; 9-19, l0yr5fl s .; 19
B- 1 89 102.10 none >89 7,5 r4 /4,sl.• 27 -89, 7.5yr4/4, Is.
7,5 sl.; 50- 8012109r4/lyrCo., S. .;
B _ 2 80 101.20 none >80
y y �
yr , L.; - yr+ , si .; - ,-�
101.18
B. 3 80 none >80 7,5yrii /6, S.
4 74 101.18 none >74 0 -6, 10yr 3, L.; 6-24, 7.5yr4/4, si .; Z4
B- 7.5 r4 4 Is.
B- 5 80 99.40 none >80 - 2, 0yr 2, L.; - yr , s1 .; 33-8(4-
7.5yr4/4, Is.
6 76 100.00 none >76 yr+ I, L.; - yr , si
B- 29 -76, 7.5yr4/4, sl.
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATE LEVEL - INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERT D t PERIOD 2 PER INCH
P-
P-
P- see J esiRn rate
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 lyorl-
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 98.01
U.
1 4 , 1
,
i
g
p
I� 1.
! �Q
V
t•
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 Wisc
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 7 -10 -9 2 7 a
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optio. , (:
1554 200th. AVe., Nela Richmond, T;i. 54017 2298 715-24g-620 ;
CST SIGNAT E:a
;s
,
i�t9.
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
fall fill- "11)r;"105 Ili 0 ?Ifi ?) (tVFR —
J
f -
STC -105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix un
Co ty
OWNER/BUYER _ _I o, .o_ �
I
MAILING ADDRESS �tlVQ uk s moo
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY /STATE _ (� -, , w L
PROPERTY LOCATION - A(0) 1/4, `,. _ 1/4, Section 3S/ , T _,3n N -R 2 W
'SOWN OF -'54 7 s Q Q ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP — ,VOLUME - , PAGE _ 19a , LOT NUMBER
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may 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 system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on -site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED: �r�rup�nf St4'
DATE: `-f/ /6 /y�
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
i .
' S T C - 100 i
. This application form is to be completed in full and signed by the
owner(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 owner /contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
--------------- - - - - -• r------------ •- - - - - -- -----------
Owner of property ' 2 b-&"-+ '&-'¢.LS,r�,
Location of property NWW_ /4 1/4, Section 3u ,T_J _N - R . /2! W
Townshi c nsepA' Mailing address Vy Q "7
I gl
Address of site
Subdivision name �.e_g -- F14Z [ Lot no. l
other homes on property? Yes _ No
Previous owner of property Q
Total size of property 1 Ac"
Total size of parcel
Date parcel was created
Are.all corners and lot lines identifiable? r/ Yes No
Is this property being developed for (spec house)? Yes No
Volume - 7 and Page Number IM 9 as recorded with the Register
of Deeds.
-------------------------------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
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 Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Signature of Applic nt Co - Applicant
rata ref Sinnaifii - C% 1)Atp nf 91(1nat11rP
PLAT DE FI� {" LD CTION 34,
SIN• INCLUDING PART OF LOTS '- /• s OF E� DOCU
I OF ST. JOSEPH;. ST. CROIX COUN MENT
• ALL, IN S
LOCATED IN'.THE NWI /4 OF THE SEI /4 AND IN PART
OF THE' SWI /4 OF THE R OF GEED
„ . . , AT THE ST. CROIX COUNTY
MAP. RECORDED IN VOLUME 7, PAGE 1989 ' REGIST
CURVE D ATA CN06D • AR laxcnl tAiu +l
- CNOIID
CYOK lOf %AOitlf CI616AC ;. , IC�+4 Il !GIN ICa�I Ni
eu�uc NSO•u'27•E
1 , No y
M. [a_�x • ' AaG__[ � 707.00• !13.13 NOO.2:•:o•E
' . � ,
• 1 - 2 7.7.00' S0'2Po7• 1IS 7V 57.3•[ ASO•u•37•c i0o•12'io•[
Nv, [ORNTq O< 744.OJ• 371.)+`
SCCTIOH N 1- a 710.00• SO.2S'0)• pYNIS1. S•E .
"S•a2.03 -p 5s.0f ' MIT, .. to 310.0 0 10.10'44• I
f 3- 17NOI'01•[ I1S.00 ULO + 0.
.. ,.t 11000• 1S•OIVO• SLDI +1.11' I QI
/ )10.00'. • 11.05113- 10)•S6'S/ S•[ sso•aT23-Y
244.0 �
0•'. ' 30.25'07• 9211-34-S3.1-11 707.11' 116.)1• 300.27.20•Y
• 3-0, 3 - 6 • 261.22' 271.31' 330'G7'2) "Y fyyii•!0•Y >-I Dp1
201.00' SO 71.01•
h - 12.21.2,.' yff.yLl.S•M. 66.32 ' N�
.44.64'
�i
y ]o %.00
g n y !09.00' , 19.01'�0�,..- SIf•2a'10•M 201.!1 20% 4 7 � uil
.
l 0 OI al 'OI
UNPLATTED' LANDS I �. .SS.I w, 1 N I
I Ell 101
NORTH EIRE Of THE SEI /, Cr S[CTION Sa . I •' 7�1'
. 1321.14• ».eo' 1 3-i CSI 1'�ll
589.27'3TE ,ca.00' I ao. ¢I v1
66.00' WI' IEII '
192. at' ; . TEM►ORART t0 FOOT RADIUS V, �I Q1
NS.CO' 719.46' f ^ 0 '4.I n • , I CuL -DE -SAC. _ �1 LI
SCALE
N . ,� ( = g ; A LOT 8
4 $0. °1 ?; '�.°
i
.. \ ] • 171.2,7 FT. --
. a � • T• ' � •CEnTCR � 3.01' ACRES
LO 8
LOT 6 1 Eu�-0 SAC
150.677 f0. 7 6' I ~
1)! IT. 20 50.. FT. 3.00 ACRES \ I I
I.Iz ACRES
J•
Sf9•ti'7T' ' r� + • j •
320.11'
LOT, 9.
\ y� �i 4• a5 75
1... 604 so. FT. w
3.46 ACRES
•
40i•t 2 � '7`'1
•'a°,_.�\'^/3 /�' 136.237 f0..FT. LOT 10 n IF I
, 3.13 ACRCS , •••� 111.290 SO.. FT. 190 I p 07 ]
3.01
ACRES o O , .n
lM a.
A
1 n
21 ' Ia. \ ` / /ter( '..•��,�f.'D6• . 1s.00• .`. _
4.•131.6 .0 . _Sal
!� J ... -27'. 7.E i Y I JI SI
r 1 e oe
' ! .
1
;.' 396.34 411.41r
100' 106' 411.4[' ; ~I
,b :N o�I zj21
o1 i r
7 0 I LOT 14 - 1
.I in. �1 71
a l c LOT 4 a i - D 6 - '
0
,tl _ LOT I _ �� a e1
s o. FT
. 0
o 130.67% -SO. 1T, A 1.00. A
�- @ Y- 136.241 s0. fT. •� \. i CRES YYY I O
'GI 0 .00 ACRES
e •�
'WI ),IS ACRES
1 \ x•..1 . .
dl 2 44 � 8 ' B • � y •�i �� y O
N ,•� i
/y � BO6.03'�
i L7 �ssf•f7'f7•L )N. • ) 1_ I
O OBY 77'77 - C O
O 396.34' ♦11.,2'
R R s•37 r 1
Q ~ 17.00'
13 ....1 I R
OR
..... I I LOT 12 r 1 « R C....
130 :
LOT 3 -erg - -- - 40 A RES FT.• ......... f I i
J 130.679 so. •fi. S,o A CRES ��. s3' ,
• , 130.679 S0. FT. 1 3.00 ACRES
-• I
3.00 ACRES 'g
i 1 8
• . $ -- .� -_ . . y a . c sue. - 8 . vl QI u�i
a
6a1J4 a n.[ iC J� 131.Y 1 vl
623.00 n 8 ' O;
'
�1 -1
396.34 -- 4469'2117 -v3-
• R69 - ROAD - -� wl
8 .= WAl SH 4409.27 37•w I:nsr •23.00' I
8. >i a
55 49'
46 s6.00
. ' .34' 4489 2T MI �
'
. _ 1 ' 1 ao' I �� OI' w
uj
II i y I f•�1,'t Sl(!�C71��17� lil Oi
^ rQN N N I Vi ZI
LOT 2
N
' 131.207 S0. F
3.01 ACRES R O
a �
g -r r V Y MAP, IN VOLUME 7 , PAGE • 1989
St✓R E _ _ _ - , - - -
I IFIC __ -
CER -- - -_ -.
-
33.0i- -33.00' 5139.27.37.E 90' -�-
' )96.51' 569.27•)7.1 e •
54g•41' 33' W 431'.52' QDC . NO. 438728
.O O N
N •
1
N
SP_lALL TRACT' ry m r�..J
..4. 54, FT, n
R b N S.0 - f•. U
1 ., 1 U n1 .. • ` N ..
$ /z
����� State Bar of Wisconsia Form 2 1982
% WARRANTY DEED
C'JCUF.IENr NO. 11 76Pa'a� J�1�
Richard w. LaCasse
JAN 3 1996
8:00 A.
iuu�cys :u,d wawa qs [ , Robert D. Rriesemeister, Jr., aM
v Janis �3riesemeister, husband and wife,
.,.;'N" A'A r
- -- - - - - , /AVF ANr) HF :IWN APr,W'i
_ •/ `
the fullo. iu St Croix
g described real estate in . U 47
Countv, State of Wisconsin.
303- 2089 -20
TR c;. (Parcel ldentifikation Number)
$ 077 E
Lot 11, Plat of Deerfield in ''own of St. Joseph, St. Croix County, Wisconsin.
This is ______ -_ ____ not _ homestead property.
w tis not)
Exception to warranties: Easements, restrictions and rights -of -way of record, if any.
20th
Dated this day of Cece tlber lal 95
- - - -- — - (SEAL) c�� -tl_ �'�
Richard W. LaCtlsse
— -- - -- - - - -- — - -- - -_ tSEAL) - - - -- - -- - - - - -- - - - _ ISFALI
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) - -- . -_ STATE OF WISCONSIN
,`,` t t uatUtgi ss.
— -- - - --
lx
County. �
authenticated this .. - _ day of , 19 �1� ame before me this a'. of
19 95 the abose named
i - - -- -- - -- - LaCasse
TITLE: MEMBER STATE BAR OF WISCONSIN J, _
(If not, _._ .. - -- - - - -- - ----- f +fs�....�•• �g��� _ _
authorized by §706.06, Wis. Stats.) by to be the person who executed the
arre "Ind r3�I(U 111 1 tan acknowledge th same.
INSTRUMENT INSTUMENT WAS DRAFTED BY
Kristina Ogland
Attorney at Law 5f- N "U_ �2
Notan Puctiic (2K 0;x County. Wis.
(Signatures may he authenticated or acknowledged. Both are not %1v com#si..ion is permanent. (If nut, state expiration dlte:
necessarv.'
19
\,nna ur lw..on. acnm� m :m� capaan .hould ,¢h 1,r d or pnmrd h•lo•.. ,hcv ....utura•..
N% %RRA A. r, UEFI) S F % T F. RAR OF wISCO \>I♦ YSNISCCn- Sin LNgal 9'ana C I 'nc
FORM No. 2 — 19x2 .1',v,r,••� :'!s