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030-2032-30-000
o N O l o (A O 0 N O CD 0 r9 1 A � y 3 " 1 3�- g co 3 z z �, z o w D l � z �, z O D z 2 N z � � to N o � 0 3 y ? o o o a l o o o r a I o m o w OD CD m a m m N CD p CD m fb m a° CCDD m O p O Iv v , Q , a CD m� fn w( z m 00 rn m a fn o 0 fn N o 3 m 5 °D o m m 5 OD o m W o D o w O N) co N N N a Lf N ? I N Cn ? I d Cn 7 s O O O OOD w O o m o o n m m' ` ° o n o 3 �o N f ' fD N y N-4 •► C - C C O `.7 z D " cn c D !n z D CD fn D (A cam' y �' a c= o a m c m co CD W CL W N n = rn rn z n I» A o z N N O r« rn O m O 0 0o m CID °° I °' I oG �r (� cn o z o o < CD co co ) z o o A r cn O O O 2 y co co 2 O co h c j C) „p c Q I c l 5 .0 0 o z 0 0 0- 0 0 0- O O O . c c 0 N , (a fJf CO) „ 3 to N y 00 D Oro 0 0 0 D m tD O O m Cp O 7 C Cp O N O O> :r - Cp Ul N N co N (d Cp �. N n I CD I a M I! M -"+ D 0 1 D m 0 D m 0 L - O O o o O a o Z o” =r ? w h o m m m m m m m �• co m ;o (n N .Z) v CD m m C CD D N m •C N m O :3. _ c a co a m a o CD 1 3 m 3 3 z m m o CD 6 o rn c 1 v a I a I n A 0 z -I N m CD m CD CD CD a 3 a a A z 0 !T 0 0 cn � ¢ 0 U) y z y z < A Ca m w f w f m ao a 1 �3o a n CL 01 can o 0 k o o D a y Sy C D (9. v C m N C 38 z CL m°-' a 0 a I 3 o a 0) CD u a o v; N z m o m CD o C m N m Lo N f0 CD Q (D V 3 ft a rm m a M c m CD a o g m A n �• S O < 0 CD u0i m N sM 3 CD °: w �• oN Zb c� CD v a CD o i o b m m CD o A 0 0 Q 0 I o 0 Parcel #: 030 - 2032 -30 -000 03/22/2006 10:37 AM PAGE 1 OF 1 Alt. Parcel M 23.30.20.453C 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner BARRY W & JODI A ANDERSON O - ANDERSON, BARRY W & JODI A 1447 SETTLER'S WAY HOULTON WI 54082 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 1447 SETTLER'S WAY SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.000 Plat: N/A -NOT AVAILABLE SEC 23 T30N R20W NE SW LOT A OF CSM Block/Condo Bldg: 4/944 BEING A DIVI- SION OF LOT 1 OF CSM 3/711 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 23- 30N -20W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 802/220 07/23/1997 751/415 2005 SUMMARY Bill M Fair Market Value: Assessed with: 84380 306,300 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.000 91,200 187,400 278,600 NO Totals for 2005: General Property 3.000 91,200 187,400 278,600 Woodland 0.000 0 0 Totals for 2004: General Property 3.000 91,200 187,400 278,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 218 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 RRPORT Or IPISPECTIO ? l -- INDIVIDUAL SEWAGE DISPOSiv. SYSTEM . Sanitary Permit •• State Septic CL . - - TOUNSHIP zz (2, Croix County SEPTIC TA' ?I: Size gallons. dumber of Conoartments v Distance From: ! -jell _ ft. 12% or greater slope ft. Building' ft. Wetlands f Pighwater ft. DISPOSAL SYSTMI Tile Field or Seepage Pit(s) Distance From: i1ell. ft, 12 %.or greater slope ft Building; �ft. Wetlands — f FIELD HiFhwater ft. Total length of lines - ft. plumber ' o z lines Length of each line ft. Distance between lines ft. Width of the trench �ft. Total absorption area sq. ft. Depth of rock below tile in. Dp-pth of rock over the in.. Cover -over .rock,, Depth of tide below grade in. S of trench in per 100 ft. Depth to Bedrock ft. Depth to ground water ,�f t. PITS Number of pits Outside diameter ft. Depth below inlet d ft. Gravel around pit: ` yes no. . Total absorption area sq. ft. .Square feet of seepage trench bottom area required Square feet of seepage nit area required Inspected by: Title': Approved •• Date 197 Rejected Date 197 '.115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES o DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION:/v_R %- '/4, Section, T.3/N, R(W-9(or) W, Township or &4zy '�� �^ f 10h Lot No. Block No. County _75V Subdivision Name Owner's Name: '.•4'.a icy �l`l (° f / / Mailing Address: /�A /? • »� � �, %rL' '5'S TYPE OF OCCUPANCY: Residence y No. of Bedrooms -� Other EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOILBORINGS Z-3 1971' PERCOLATION TEST Z.3, / 9 7� SOIL MAP SHEET SOIL TYPE PERCOLATION TESTS TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE CHARACTER OF SOIL SINCE HOLE HOLE AFTER INTERVAL NUM- INCHES BER THICKNESS IN INCHES 7ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) Z 7Z v l/ 7 Z # 77,7'( PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy. �S �Z 3 ,o ' /49 x' IlAsv� Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. I lien y �t ' 4 L ► _ �► N �7 V rT 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 location of test holes are correct to the best of my knowledge and belief. Name (print) —,✓ ' •� ifica ion No. Z Address / Name of installer if known l CST Signature COPT' A —LOCAL AUTHORITY State and County State Permit PL867 # Permit Application County Permit # i for Private Domestic Sewage Systems County 151/ *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: � 0 A C — 14, r�� C� t� l 17 - �'�C ;L� 4 , 4a 0 B. LOCATION: l� '/ 0 Y4, Section ,�� T 3c N, (or) W Lot# City Subdivision Name nearest road, lake or landmark k# Village Township _ �Z � � Z .z c. -c_ t ,.+ C. TYPE OF CCUPANCY Commercia *Industrial *Other (specify) *Variance Single family !/ Duplex No. of Bedrooms No. of Persons Z_ D. TYPE OF APPLIANCES: Dishwasher c-i YES NO Food Waste Grinder '-- �0 # of Bathrooms_/— Automatic Washer - NO Other (specify) E. SEPTIC TANK CAPACITY Z&ar --J Total gallons No. of tanks / *Holding tank capacity Total gallons No. of tanks New Installation �� Addition Replacement _ Prefab Concrete -� I *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) / 2) / 3) / Total Absorb Area 61-5 sq. ft. New ti --- Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length Sz' Width JZ Depth __36, Tile Depth Z AA 1 1 No. of Lines Z Seepage Pit: Inside diameter Liquid Depth Tile Size 'S'G Percent slope of land Al % Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certified Soil Tester, NAME C ya-,,. y k �Jr- / C.S.T. # 7 z- 9c3'' and other information obtained from .I A I A_ i C (ownerfbaiA&4. _ Plumber's Signature MP /MPRSW# j /.� S Phone Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). lvq i e J11 e Do Not Write in Space Below— FOR DEPARTMENT USE ONLY Date of Application Fees, a' : State Count Date p Permit Issued /Rj B (date) d Issuing Agent Name L Inspection Yes No Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 Parcel #: 030 - 2032 -30 -000 02125/2005 08:47 AM PAGE 1 OF 1 Alt. Parcel M 23.30.20.453C 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * ANDERSON, BARRY W & JODI A BARRY W & JODI A ANDERSON 1447 SETTLER'S WAY HOULTON WI 54082 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1447 SETTLER'S WAY SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.000 Plat: N/A -NOT AVAILABLE SEC 23 T30N R20W NE SW LOT A OF CSM Block/Condo Bldg: 4/944 BEING A DIVI- SION OF LOT 1 OF CSM 3/711 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 23- 30N -20W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 802/220 07/23/1997 751/415 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 5982 283,200 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.000 91,200 187,400 278,600 NO Totals for 2004: General Property 3.000 91,200 187,400 278,600 Woodland 0.000 0 0 Totals for 2003: General Property 3.000 53,500 140,800 194,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 218 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 370238 Permit Holder's Name: ❑ City ❑ Village ❑ T n of: State Plan ID No.: Anderson, Barry St. Joseph Township CST BM Elev.:- Insp- BM Elev.: BM Description: Parcel Tax No.: 030 - 2032 -30 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing AIt. BM Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to i ntake ROAD Dt Inlet ir Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover Model Number GPM TDH Lift `riction System TDH Ft H ead Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING manufacturer: INFORMATION Type Of CHAMBER model Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No /I COMMENTS: (Include coded' screpancies persons present etc. Inspection #1: / / Inspection #2: Location: 135 St. Rd. 35/64, E ton, WY 54082 (NE 1/4 SW 1/4 23 T30N R20W) - 23.30.20.453( 1.) Alt BM Description= 2.) Bldg sewer length= - amount of cover = Plan revision required? ❑ Yes ❑ No Use other side for additional information. 1 F1 I I SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ° a ' }s ,v �. H4- — H 6 � S q g e _ _ a I F � d e e E 3 E � F 1 Vi scon s i Safety and Buildings Division SANITARY PERMIT �Ol ti 2201 B 0 Wa Avenue n Department of Commerce In accord with Comm 8 .0`St Adm. Qgda Madison, WI 53707 -7302 • Attach complete plans (to the county copy'only) for the 1 , o aper s [au ,ty than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this appl n Sr $tatesanitary Permit umber te -A Personal information you provide may be used for secondary purposes J ]'Oheck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. ' t`ate Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL IN Property Owner Name ation 11j i1 /4 va,S a, T ,N,R,20 E(or Property Own is Mailin Address Lot Number Block Number — Cit , State Ip Code Phone Number Subdivision Name or CSM Number t , � z 1 (?1<)57yq , - 6 S y 5 - 3 21 II. TYPE F ILDI G: (check one) E] State Owned It� Nearest Road ❑ Vil age Public 1 or 2 Famil Dwe ►lin - No. of bedrooms Town of � III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 23. 30. q5 1 ❑ Apartment/ Condo nom) .._ �� — 2 " 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) —Li F=17 A) 1. ❑New 2. ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of ;�ep ir of an ______System System Tank Only Existing System x stngSystem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) 'f' zl>mYzIV y- _5 -6 3 Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 QrSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORP SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. S stem Elev. 7. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) % - y..3y Elevation `V � d . - Z Feet Feet Ca acit VII. TANK in allon Total # of r Prefab. ^ Site Fiber- INFORMATION Ex per. g fb Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic A p p New Existing structed Tanks Tank Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility fc installation of the onsite sewage system shown on the attached plans. (Print) �t : (No Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Address (Str4ek, City, State, Zip Code): ( (' ((1 "r Au IX. COUNTY/ DEPARTMENT USE ONLY =Owner oved S nitary Permit Fee (includes Groundwater ate slue Issuing Agent Signa re (No Stamps) Surcharge Fee) Approveiven Initial Determination 6'g �XJAAA X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (R. 4199) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber 1. 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. 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 -3151. - 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 lank(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 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. S Q.. l� � � nr•� — sS og Oi CPO N V � J A) e) sG� �_ s y s�t ca/e vc-4% 0A 93.59 L/ Y p 4 2 zit, t3 Sax to 6 �3 s'� T OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS OMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION _ 7969 BUREAU OF PLUMBING 07 eNAME SW14,S23,T30N- CONVENTIONAL ❑ALTERNATIVE SllassgncdlD.Numbe St. Joseph ❑ Holding Tank 1:1 In- Ground Pressure El Mound wa 64 OF PERMIT HOLDER: J ADDRESS OF PERMIT HOLDER: INSPECTION D T Barry Anderson 1104 S IN outh 1st Street Stillwater MN ,9082 _) BENCH MARK IPermanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF, PT. ELEV. Name of Number: MP /MPRSW No.: County Sanitary Permit Number. William Pfannes 6222 St. Croix 102858 SEPTIC TANK /HOLDING TANK: MANUFACTURER. LIQUID CAPACITY'. TANK INLET ELEV.: TO UTLET ELEV.. WARNING LABEL LOCKING COVER /y!) � Z n R PROVIDED ax) Q /e�i rq� AYES ONO ❑YES SLNO BEDDING: VENT DIA.. VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING VENT TO FRESH ALARM � / LIN�k' AIR INLET FEET FROM ❑YES SNO I DYES SiNO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING: JLIOUiD CAPACITY PUMP MODEL PUMP /SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DI AMETEH MATERIAL AND MARKING 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 NO. OF DISTR. PIPE SPACING COVER INSIDE DIA - PITS LIQUID BED /TRENCH / THENCRES MATERIAL: PIT DEPTH DIMENSIONS S GRAVEL DEPTH FILL DEPTH I DISTRPIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. TR. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH SEL / O _ W I PIPES ABOVE COVER ELEV INL ELEV. END: PIPES FEET FROM LINE. .t AIR INLET IP + Qq t J / 3 - (P a o NEAREST - --► a/ MOUND SYSTE Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES El NO OIL COVER I TEXTURE PERMANENT MARKERS OBSERVATION WE LLS DYES ❑NO DYES C - 1 NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BEO DEPTH OF TOPSOIL SODDED I SEEDED MULCHED CENTER EDGES. DYES ONO OYES ONO DYES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF. FILL DEPTH ABOVE COVER BED /TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE J MANIF MATERIAL NO DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & NIAHKIN(i ELEVATION AND ELEV. ELEV.. DIA. ELEV. PIPES DIA • DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑Y ES ❑NO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY J WELL: BUILDING FEET FROM LINE: 3a5- 7 [11 YES El NO DYES 1:1 NO NEAREST g$ Sketch System on Retain Q, coun ile for udi Reverse Side. SI ATU TITLE Zoi yng Administrator DILHR SBD 6710 (R. 01/82) • cd i ' Form -STC- 104 v L rMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUIL B R &HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DI ` 4' JIIS X 7 "- W07 BUREAU OF PLU E -R20W CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: (11 assiynrld) Town of St. Joseph ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound Hi hwa 64 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION D T Barry Anderson 1104 South 1st Street Stillwater MN 082 _ A/ BENCH MAgK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: q PT. ELEV.: CST REF, PT. ELEV Name of Plumber MP /MPRSW No.: County: Sanitary Permit Number: Distan William Pfannes b222 St. Croix 102858 SEPTIC TANK /HOLDING TANK: V MANUFACTURER. 1 q LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV: WARNING LAB LOCKING COVER �1 /� ^ R 1 PRO PROVIDED: 7 /t DI �(, 1`7 9YES ONO DYES REDOING: VENT DIA. VENT MATL. HIGH Wq NUMBER OF ROAD: PROPERTY WELL: BUILDING. I VENTTO C ALARM FEET FROM L'"��� CT AIR INLE —� OYES SNO '� ❑YES S NEAREST `W`� UV P Y ✓ ( DOSING CHAMBER: / MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL. PUMPISIPHON MANUF ACTLIRER WARNING LABEL LOCKING COVER PROVIOED: PROVIDED: ❑YES ❑NO YES ONO ❑YES ❑I GALLONS PER CYCLE: PUMP ANDC CON TROLS OPERATIONAL: NUMBER OF PROPERTY WELL ] BUILDING — TV - ENT TO (DIFFERENCE BETWEEN FEET FROM LINE AIR INLE PUMP ON AND OFF) ❑YES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED /TRENCH WIDTH LENGTH N0 F DISTR PIPE SPACING C V J INSIUE DIA SPITS LI EP71{ OUIU DIMENSIONS ` TRENCHES MATERIAL: IT o GRAVEL DEPTH FILL DEPTH DISTR PIPF DISTR. PIPE DISTR. PIPE MA ERIAL: NO. TR. NUMBER OF I PROPS LINE TV WELL BUILDING V NT TO BELOW PIPES ABOVE COVER ELEV INLET ELEV. END: PIPES AIR INLE �' r �, G FEET FROM ^ �qL 3 , & °� v� NEAREST --► d3� 5 V �� MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- OYES ONO - � meets the criteria for medium sand. TIONS MEASURED, ' OIL COVER TEXTURE PERMANENT MARKERS Otl NO St VA TIO DYES ONO DYES ONO DEPTH OVER TRENCH /BED TEDGES H OVER TRENCH /BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER DYES ONO DYES ❑ ❑YES El PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER TRENCHES: DIMENSIONS MANIFOLD PUM MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO OISTH 1 1):STR I UISTHIBUiION PIVE MATE HIAL &A7AHKINC; ELEV. ELEV.DIA. ELEV PIPES DA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVE PLANS ❑YES ONO ❑YES ONO COM MENTS: PERMANENT MARKS S: OBSERVATION WELLS: NUMBER OF PROPERTY WELL BUILD( N FEET FROM LINE: 3 ❑YES 1:1 NO DYES ❑NO NEAREST 10 BENCI,' Sketch System on Retains co Reverse Side. un ile for udi . C� SI ATU Elev, T Zo 'ng Administrator DILHR SBD 6710 (R. 01/82) SEPT i �--� Ce lint a .in tnr: yy e9�ten 06 Deeds ah Document Noe VA ice ob L►le avn the pROpoded 4ite bon .tile Sewage CUA v a ,� eme and .that 1 ?We) pheaentty "AC to Run with .the above deach,ibed no � I )we) have obtained an s ya.tem and ,the name has been duty Aeconded Xn the 066tee o p pe&t bon the con tAuct 06 Said attdd, ate DOCrrallen.t No. a 6 .the County Reg.caten 0 6 CtiA OIl' OWNER p NATURE OF Co -OWNER (IF APPLICABLE) (Inc g o DATE SIGNED _ `S DATE SIGNED Form - S T C - 104 �n AS BUILT SANITARY SYSTEM REPORT OWNER Y' t^,t JA ,N,CL t - l TOWNSHIP -_ ;� ��� 1 SEC. T N -R ADDRESS s - - _.(..- ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•ZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM y J 4 f � i 4i INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: l t� Number of rings used: Tank manhole cover elevation: 10t Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front, Side Rear, O feet From nearest property line Front .0 Side I@ Rear, 0 feet Number of feet from: well ° , building: (Include this information of the ' b ve plot plan)( 2 reference dimensions to septic tank) S EE REVERSE SIDE Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. IL HR 8U9; WIs. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size I'd�rnust 5-T, �� include, but not limited to: vertical and horizontal reference point (BM), rK n and 1�� �r percent slope, scale or dimensions, north arrow, and location and dist nearest Foeq �Sf0 parcel I.N. # APPLICANT INFORMATION - Please print all informalttbslrl. D 6',: : eviewed Date Personal information you provide may be used for secondary purposes (Privacy Law, s.' 15.04 (1) �cvx Property Owner Pt Govt. Lot 1te:_41/ A01 /4,S a 3 T 3 ,N,R a O E (ore) Property Owner's Mailing Address +"� /■` L Lot # Bfock 5ubd. or CSM# P 4Y ❑ City State Zip Code Phone Number city El Village S4 Town Nearest Road - .ju -j ew%.. +oov, o F f f . $ r 7ro+ 0Rj4i n j E 1 New Construction Use: LJ Residential / Number of bedroom Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow y5 D gpd Recommended design loading rate bed, gpd /fi °" trench, gpd/ft Allsorption area required _ bed, ft trench, ft2 Maximum design loading rate bed, gpd /ft trench, gpd/ft Reee� 6 d n ed t infiltration surface elevation w (s (,Y I. 3y ( T. 2)1 013 ?2-- (as referred to site plan benchmark) Additional design /site considerations Parent material nv 0, Flood plain elevation, if applicable ft FU= Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank Unsuitable for system (� S U bg S El 9S ❑ U 52 s U ❑ s 5� U ❑ S [kU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 0' („ 10 FS L -- --» .A ` Z - 7, SIRS FS !. ----- --. — --� Ground a 5 - 31 7.61 Q y / PS L Depth to limiting 39'1` 7.S ......•�*r., factor T iv r ' � 11 Remarks: Boring # M �`+ 4 Ground elev. ft. r ; Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. 3s - aNg - 3s88 Ad ress + p U. Date CST Number 5 a a. to SOIL DESCRIPTION REPORT PROPERTY OWNER Page of. PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ; Trench Ground elev. ft. Depth to limiting factor in. Remarks: Boring # .._.. ... Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # Ground elev. tt. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) f � d I 1 , s- I I } i J _ L I 1 I y : 0� : 1 I . ' � I � ti (0 44 I � ' i I { I f I ! :• 1 I : c � 1 r I i 1 y ' 1 I i I i I I 1 ' l'1 , : • , �... —. �.._. _., i. .. _..�_..... Y. ..;. ;..... :. __ .. ..-_. 7. _.. _.. «_ . -�. -.. _.._.� - . :._... _.. t._ _� ._1_. ._.... ---.. .. .µ__.'1•—.._,r ......__..t.___.ti_� .._. _f.. .... _ —. -.� I I , ' , : tt ti �_— : c ; I I r ! i I I I 1 : j , I J t , I ! : : I 1 , I : 1 i : 1 , i I , i I � , ; r it , _ . - i i : ? .{.. } - } _1 .. _- - -.' }.. - _ .... � _.. � _. -_• ___ .... _ I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer y' Mailing Address f Property Address (Verification required from Planning Department for new construction) City/State- b ,AV-► Parcel Identification Number _ ®2 21!5C5 Z- — 30 npr LEGAL DESCRIPTION Property Location ��� 1 /4, 5 l� 1/4, Sec. . T_2a_N_R W, Town of C . Subdivision Lot # Certified Survey Map # v�C2�;L -7 , Volume - , . Page # Warranty Deed # Volume 0, , Page # (Z - Spec house ❑ yes q no Lot lines identifiable 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. 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 three year expiration date. J c ns � /moo ATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the property descr above, by virtue of a warranty deed recorded in Register of Deeds Office. C6 - ?cry TURE OF APPLICANT DATE * * ** ** permit be' revoked b Department. * * * * ** . Any information that is mis- represented may result in the sanitary p being Y the Zoning Departm ** 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 i 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 ��rti ��- �c�� -, residence located at: Section 3 T ;; � N, R Z - W, Town of 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: file ales na Did flow back occur from absorption system? _ Yes No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: �( Construction: Prefab Concrete X Steel Other Manufacturer: (If known): Age of Tank (If known): (Signature) (Name) Please rint (Title) I (License Number) 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, W' Adm. Code (except for inspection opening over outlet baffl Name A /Y � e S ignatur MP /MPRS v rfG' DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1 -1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED REGISTER'S OFFICE 434145 BOOK $02 wt:1224 ST. CROIX CO., W1 Recd for Record This Deed made between Donal A. Rice and Pauline A. Ric Feb 2, 1988 husband and wife, as Joint tenants of at 11:00 A. M Washington County, Minnesota Grantor, and F�Arry w. Anderson and 'Jodi A. Register of Deeds Anderson h,aahand and wife as joint tenants of B'gnhi ngtnn rnunty, Minnesota Grantee, Witness That the said Grantor, for a valuable consideration Of S 6 . 800 . 00 RETURN TO conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin: Tax Parcel No: Lot A, being patft of NEB o f Slim of Section 23, T3ON R20W, described as lot 1 of Certified Survey Map filed October 24, 1978 in Vol. "3 ", page 711, replatted as Lots A and B of Certified Survey Map filed May 21, 1980 in Vol. "4 ", page 944, document no. 36 fiRANSF FEE This is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And Gr an i Q in A warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except No exceptions and will warrant and defend the same. pp� Dated this day of 19 (SEAL) (SEAL) • � D /1/29r �,, � �, � I c L (SEAL) `f� �• 2� J��c_ -� —y (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN St Croix SS. County. authenticated this day of , 19 Personally came before me this 2nd day of February , 19 the above named Donald AL. Rice and Pauline A.� Rice TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to m known to be the person 8 who excuted the authorized by § 706.06, Wis. Stats.) fore of g instrument and ack ledge the same. THIS INSTRUMENT WAS DRAFTED BY 0 Al L. O 'Connell � o �,L� •/ C- �' Notary ublic St Croix County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: April 30, 1989 1g .) 'Names of persons signing in any capacity should be typed or printed below their signatures. NF 3573 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Forms, P.O. Box 10208, Green Bay, WI 54307 -0208 FORM No. 1 -1982 NMA41 /� 4 . 0 0 11 11 If 11 ' 0 0 co r G� G �A I < A G O a • 4' rr n 0 NORTH 376.5 �+3 9 0 o 0 4 y c> 3 ro .. m 0 ti ° cn G R 0 I 'y . '•� M 1 N I � •l < 1 co U.''� I m s O Gy o ? < 1 fD ` OVA Q O m ` N 9 w - CIS 1 - to i3 U _ C) 5 c 1 I w — n v o tO m I nD N ORTH 1 Cn n f71 1 573.0 9 ' I t/1 C7 10 < I z • i to I N �- Ca1 � O W ` W O m Z r > �J rO OD In f�1 c ;n � •w . o 1 # W � N N 1 m Q� (D N N • _ N - U_ CD CA rn e 9 0 O • 372.77 SOQTH '4 O i „ 0< L �•; BEARING ARE- REFERENCED TO LO I OF C S. M VOL 3 PAGE 711 > L : :5 r ve hcre certi T Aiir��n C. E'yhagen. a registeref land ",)r T have sur d- of Donra A- U_ n eed I t Ch is rcpr0sC" p -.,. r C e I— exterior bc of the l end parce- ,. U , -: , s follO' S TI - Vol Cn, L tif4ed e _' CerLI_ j- o o f 1 of slarvey ne 0 - JC E _J c e o If A ReEister of Deeds, Sl. r1roix County. . ...... + 1 , /L of - he S 1 A of Section 2 V urther described s ' C_ D ix C 0 uxlt y . f , X. C o mencing a V the \7 corner of said Lot I o WC_ - of '-eginning 0 being e 'h -joi of " 7.n r S. 80 B alon6 the Southerly RA 0+ ja Southerly S 11ce N; 8 -25" 3 along sa 7 0 - -.29, feet; thence South, - feet; tI to the poin Of ',-egJmnir_,_c%-. 01 ' 'n U U 3 feet V I - �0 - .:hove descri parcel contains 6.0 acres and m;b t C 'z� that this Certified Survey Map' is a correct re-presle.ntu^.. boundary surveyed and described; plied with the current prov-*-sionc 0 - a p t 2 h t have fully Com _L - surveying- and U U ,;isconsin Revised Statutes C-Ir.-fied this74-kday 19709, Z; ne6i: Allen C. Nyhagen, R.L.S. NO. 1407 A iJ CC 7', T. S urvey dudson, 'yo-i. AULEN C.. Y , n OF THE T0't_-"N OF S ^ V -DA i do hereby certify that this r or ". f__fL Survey Map has been approved by the To of St. Joseph this day of 1 9 Town Clerk of St. Joseph Form - S T C - 104 F � 1 AS BUILT SANITARY SYSTEM REPORT OWNER �(lti''r� f' lUC J TOWNSHIP SEC. T 3a_N -R.2 ADDRESS `ft t -F-� ST. CROIX COUNTY, WISCONSIN SUBDIVISION ' LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM { �Y� P S I ti 1 � INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used - / ;� '. k •g . Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: 4 1 C j Q Number of rings used: 0 Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,0 Side 0 Rear, O E feet From nearest property line Front,0 Side, Rear, O P feet Number of feet from: well ° , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: 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, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: a � Width: Length: Number of Lines: Area Built Fill depth to top of pipe: Number of feet from nearest property line: Front, © Side, O Rear,0 Ft Number of feet from well: •4 i Number of feet from building: 1 (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: 1 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 sytems? (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, O Rear, 0Ft. Number of feet from well: Number of feet from building: i Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: tf (' Plumber on job: r w License Number: 3/84:mj T DEPAPTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS ON I r LABOR & HUM'AN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMB DIVIS P.O. BOX 7969 MADISCthl, Will W07 State Plan I.D. Number: 14E�,SW4iS23,T30N —R20W CONVENTIONAL ❑ALTERNATIVE fit aeslgned) Town of St. Joseph ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound Highway 64 NAME OF PERMIT HOLDER: J ADDRESS OF PERMIT HOLDER: INSPECTION D T Barry Anderson 1104 South 1st Street Stillwater MN 6 082 ������ �"C'd BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. Name of Plumber MP /MPRSW No.'. Coumy: Sanitary Permit Number: William Pfannes 6222 St. Croix 102858 SEPTIC TANK /HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. 9YES ONO OYES AND BEDDING'. VENT DIA. VENT MAT L.: HIGH WATER NUMBER OF ROAD'. PROPERTY WELL'. BUILDING. VENT TO FRESH FEET ALARM. AIR INLET /� . LIN `� DYES SNO Cz OYES A�I NEAREST ��/ / 5 � DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL. PUMP /SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: E] YES ONO ❑YES ❑NO [:]YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL'. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) 1 OYES 0 N NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth ofplowIng DIAMETER MATERIAL AND MARKING LENGTH Or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH. LNO. OF DISTR. PIPE SPACING COVER J INSIDE DIA -PITS LIQUID BED /TRENCH l rRE =GRES MATERIAL PI T DEPT" DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. TR NUMBER OF PROPERTY WELL BUILDING VENT TO FHESEI BELOW PIPES ABOVE COVER. ELE V. INCE ELE V. END: n PIPES FEET FROM LINE AIR INLET 9"+ 4q I% P / NEAREST � .6'8/ 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- meets the criteria for medium sand. TIONS MEASURED. ❑YES 1:1 NO SOIL COVER I TEXTURE PERMANENT MARKERS 1 011SIERVATION WE LLS ❑YES — ]NO OYES ❑NO DEPTH OVER TRENCH /BED D ED EPTH OVER TRENCH /B DEPTH OF TOPSOIL SODDED SEEDE MULCHED CENTER E [:]YES DGES. ❑YES ❑NO YES El NO I O ' YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED /TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE M MATERIAL NO DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & AIAHKIN(i ELEVATION AND ELE V.. ELEV.. DIA. ELEV. PIPES DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANSCAL LIFT CORRESPONDS TO APPROVED OYES E] NO ❑YES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS'. NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE. 3a 5 7 ❑YES 1:1 NO DYES El NO NEAREST ------------ �*/' J e � �$ s�ra Sketch System on Retain�Q coun ile for udi Reverse Side. SI n7u TITLE Zo 'ng Administrator DILHR SBD 6710 (R. 01/82) �O SANITARY PERMIT APPLICATION COUNTY 701LHR In accord with ILHR 83.05, Wis. Adm. Code � � v ....� � STATE SANITARY PERMIT # /D� 8So —Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8 x 11 inches in size. See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION FOR VARIANCE ❑ YES 19NO P OPERTY OWNER PROPERTY LOCATION C- %S 1 /a, S 9Z &O , N, R,,'10 E (orAD PROPERTY O NER'S MAILING ADDRESS LOT NU BER BLOCK NUMBER SUBDIVISI N NAME o s o ►� S't' ti CITY, STAT ZIP CODE PHONE NUMBER 71 CITY N E T ROAD, LAKE OR LANDMARK VILLAGE / II. TYPE OF BUILDING OR USE SERVED: 0.� �Z Xz . Q 30 — � t �® Number of Bedrooms if 1 or 2 Family _i? OR ❑ Public (Specify): 111. PURPOSE OF APPLICATION (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. XNew b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner /building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in ##2) 1. a. KPonventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In -Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b. A Seepage Trench c. ❑ See age Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYS TEM EL 6. WATER SUPPLY: � inutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): - — 4 ,,5 &Feet Private ❑ Joint ❑ Public VI. TANK CAPACITY Site INFORMATION in aa ons Total #of Prefab. Fiber- Exper. Manufacturer's Name Con- Steel Plastic New xistin Gallons Tanks Concrete structed glass App. Tanks I Tanks Se tic Tank orHoldin Tank ivp ❑ 1 0 Dod Lift Pump Tank/Siphon Chamber ❑ LJ I ❑ ❑ El VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MPMIPR6W Ne.: Business Phone Number: I 1 ` 2-,2 Z � c g P ber's Address (Street, City, State, Zip Cod ): Name of Designer: VIII. SOIL TEST INFORMATION Certifi oiI T ster (CS ) Name CST # CS 's ADDRESS Street, City, State, Zip ode) Phone Number: �'- o C_ c V ► IX. COUNTY/DEPAVITMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) Po� Approved El Given Initial �QLfD rcharge Fee Adverse Determination X. COMMENTS /REASONS FOR DISAPPROVAL: Ems 1 cu 042 p rots -ed b� kohl auo L - hJ-e is SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber I INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT t APPLICATION TO THE APPLICANT: t 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the exliiration 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 by the pmit issuing authority. A new permit may be needed if there is a change in your building plans, system loo tion, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment; 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1 -6; VI. Tank information: Fill in the capacity of every new and /or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift /siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County /Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8' /s 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; tr 'n r chambers; i s earns and lakes dose o pumping c amb boxes so I absor tion s stems replacement re 9 P P 9 P Y P 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. ------------------------------------------------------------------------------------------------------------------------------------------------------------ GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground included the creation of surcharges (fees) for a number of regulated practices which Wisco iniS 7. can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried ree xUre' a is used in your building is returned to the groundwater through your soil absorption, o system or the disposal site used by your holding tank pumper. a The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD -6398 (8.03/86) APPLICATION FOR SANITARY PERMIT STC - 100 this application form is to be completed in full and signdd 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Z Ar G.) �y� �, A'Z ole r5 o n r Location of Property 1 0 f LJ k, Section o? , T So N -R Q Za . W Township ° ' 7 3 oS -e-TA Mailing Address O Q 34 r S J— c , Address of Site Subdivision pass &Ix Lot Humber Previous Owner of Property Total Size of Parcel aC re Date Parcel was Created MaM Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes .. _ No Voluse - F- -• and Page Number � 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 refer - ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATIO i WO ev�t A6y that att etatement�s oil (ws dorm ape t�eue to the b est o m ( 6 y (ouA) hncwtedge; that 1 (w am (ape) .the owneA(s o6 the phopeAty deacAibed in this .in6oima,tion 6ohm, by vi&tue o6 a waAAan.ty deed neconded in the 06 ice o6 the Count Regaten o6 Deeds ass Document No. ! ;� and that (We) pheaentfy "On .tl:e p4oposed site bon .the sewage digs o 6 st em (on I (we) have obtained an fdAtmen.t, to Run w.i.th .the above deAmc bed pkopeAty, bon the eon&thuction o6 said syst", and the same has been duty hecohded .tn the 066tee o6 the County Reg•ieteA o6 Deeds, ab Doemen.t No. ) . GNA OIL OWNER NATURE OF CO -OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED -- DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1 --1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED REGISTER'S OFFICE ��434145• BOO w . �o o� 8U2 Iart2zQ sr. caoix co., Hn '. Recd for Record This Deed made between Donald A. Rice and Pauline A. Ric e, Feb. 2, 1988' htasthand and *rife, as joint tenants of cd 11 A. M Dint Washington Co unty. Minnesota •rvtr..: •••. ,: _: - •� �. •� • , Grantor, Of Deed8 1AarYr.^ i - Anderst " " on l and JodlA. �Anaerson and /J jf h14a1•,and And wife as�,ioir►t tenants of wa °},ingtntn Petsn .x, Minnesota Grantee, Witnesseth That the said Grantor, for a valuable consideratio Of RETURN TO conveys to Grantee the following described real estate In St. Croix County, State of Wisconsin: Tax Parcel No Lot A being patbt of NEJ o f SWJ of Section'23 T3ON, R20R, described as lot 1 of Certified Survey Map filed October 24, 1978 in Vol. 113 ", page 711, replatted as Lots A and B of Certified Survey Map filed: May 21 1980 in V01. 11 4 11 , page 944, doeument no. 364329. =TRANS FEE Thi ifs Mod h omestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And 6i=ante ^° warrants that the title Is good, indefeasible to fee simple and free and clear of encumbrances except No exceptions and will warrant and defend the same. Dated this day of 19. (SEAL) (SEAL) • • �ea��� A� Rtc� (SEAL) (SEAL) . AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN St: Croix County. as. authenticated this day of , 19 Personally came before me this 2nd day of February , 19 88 t he bove amed i Donald A Rice and Pauline -� R ce TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to rn known to be the person who excuted the authorized by § 706.06, Wis. State.) fore of g Instrument and ack ledge the same. THIS INSTRUMENT WAS DRAFTED BY Wamas �r O To o A/& T �r �' '6 Notary ubllc St� Croix County, Wis. S atures may be a he ica f 9 Y ut nt ted or acknowledged. Both My Commission Is ermanent. If not, expiration P ( P are not necessary.) date April 30, 1989 19 ) 'Names of persons signing In any capacity should be typed or printed below their signatures. NF 3573 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Forms, P.O. Box 10209, Green Bay, WI 54307 -0208 FORM No. 1 -1982 G, s PLC r N ORTH • o W� r (5 7 6. 0' "T ral o �D .00 � ' ,�, cu O 0 Cl) ° Z 0 0. �e m c c — 0 0 ,, I =j x a °z CA --t ° cn > O W -0 co 40 1 y m us i' r .` N J o`°i 0) - i a 4 ' O D -n rn I rn - -i a, 0 0 �o 180 -10 ( Z t ! ✓O C L Z—r n } N — z . N (D Q 1 l i n I' 1 NORTH wcoo i I ° s cn :'a 372.77' ivN " it. r-3 m Q •G Z Q I * f o < I Q • m ` to ' w i ( `• m o 0 ° c w o •. � N lo 4r) rn CA rtl `' �� t.• - � k� .� : `f 16. �.• ; ,' SOUTH op b C� ! O O to N OD W_ c -. �:.,'cT 17 l T Q.URV Y hjAL p$ m �_ BEARING ARE ASSUMED ;;�.. C ROIX COUNTY, ii N00 -07 -06 E ALONG THE ca _ EAST LINE OF THE S.E. I/• in , OF SEC. 23 r A O o z N 00 -07 -06 E fn 1' O M R m Z N , i SURt,3YO� CERTIFICATE: I, Allen C. Nyhagen, Registered hand Surveyor, hereby certify that in °: l compliance with the Provisions of :Chapter 236.34 of the 'riisconsLn Stat »te^ and Section 5.4.2 of the St. Croix County Zoning Ordinance and unaler the direction of Henry Lentz owner of said land, I have surveyed, divided, and sapped said parcel of land, that such'survey correctly represents exterior boundaries and the subdivision of the land su=••vcycd and t ^� t ±: land is located in the NE of the S��� and the Ire; ' of tre SET of Section 23 , T -30 -N, R -20 -W, Town of St. Joseph, St. Croix County, Si sc ^ns-�.. further described as follows: Commencing at the.East 1/4 corner of said Sec. 23; thence S 89 58' - 25" 2431.67 feet to the centerline of S.T.H. "35 "; thence South, 50.0 fcot to the South R /W line of said. S.T.H. "35 ", also being the point of ':n- ginning of this description; thence continuing South, 381.18 feet; -n — West, 1 049.50 feet; thence North, 376.50 feet to the South R /:.' ine c said S.T.H. "35 "; thence S. 89 26' -25" E along said 7 1.1 line, 395.37 thence N 89 58' -25" E along said R /1; line, 635.22 feet; thence X 00°- 01' -35" Y;, 8.25 feet; thence N 89 58' -25" E along said South► line, 17.91 feet to the point of beginning. Above described parce? con- tains 9.0 acres and subject to easements of record. �tl w s • G' 'tL.E`1 • � '� �tYi��G�19 i; ' . 3-1407 ��::_. t; ,•... HUDSON, v SU i CERTIFICATE OF TOWN OF ST. JOSEPH I Carlo n Barrette f• - y , being the duly elected, qualified and acting Town Clerk of the Town of St. Joseph, do hereby certify that this Certified Survey Map has been apprvoed by the gown Board of St. Joseph this day of 1 978- Carloyn Barrette, T own Clerk Ilc�o.w,® o U O 0 X 11— � r �N v _ ,n ° O _ • v ° i t'R 9,% x r` ! 0 ,,p ;a c z ?� r -0 -^ m ' m o NORTH c r=: ''u. •i 376.50 W n 9 p. o - 6 0 4 '00 C bb ° p 0' CL ( Gy 0 00 4� v ^' . < I m �yG F� coo �A / a< w r N ( y 9 9� w o cn _ ca CA IOD � Z rn D. m c wo C11 m - n W ca 7t o I r to cm W ± ' N ORTH 1 (n n Rl 1 1 N n 373.09 I o • 01 W rn _ I W Z �N CD W r m o :n W �o, C D , W Nl . rn P4 "•' ::s N mco o o y i .•` . a p 0 I 7 . 372.77 I SOUTH .. ` •. 0,�, BEARING, ARE REFERENCED TO . .._.._ 1 ..: �v ?� �..�` '_'_+'� .• •• � • � ?� ,CU. ZrI ' c�ln LOT 1 OF C S M. VOL 3 .PAS 711 , •, .. y , •'_ ,e' :* .. . r+.f fi-0 i 4 •A IM 3,y 4��'t J y. �d�YGRS C:.RT Land Allen C K a registered y r 'r_erer3• cer :ify t'.? ^'; 1p yhageregistered .,carve o '�� - - ._ , r, �a? '1n std ::L:�� `� . c t e di r ectio:� of Donald A. Rice, I have surveyed, dc,. c_ _ ... e . _ nd' parcel :.h; ch is represented by t:113 CE�r N 1 _ :.., • , exterior of the �.� d parcel . � � c; ec .. .:'� ^c_•i�+ed r:.s fello:<.s s , A r a t r 1 of Certified Survey Map, viol. 3; . ,- i , - �. oil. Lot ' _ epl . the Office of the Register of Deeds, St. Crory: Court;�> .:i• 1 "'' " 1/4 of the S'.; 1 1 /4 of Bection 23, T T , -,.r_ o� C t. Croix County, ::'i. , further described as foil oYs: C, mer_cing at the �'; corner of said Lot 1 Of Cc- li:"I Sk- ' ='ve;r - -;e 711, also being the point of begin nG cif -"is r:cscr_rt_ ^n; .. t.. -7 S Southerly �. ` 89°- 26' -25" E along the therly R/„ line of S.`.�•. ,� .. 3: , ,9, . . _ thence `T 890- 58' -25„ 3 .along said Sou S.T.__. "35" p / ..._. r . -� S ou t' r -L feet t".6- ence Vest COQ 66 ,03.29 feet; thence South, 372.77 :':ortn, 376.50 feet to the point of begiir nir_t;. ribove described parcel contains 6.0 acres and sub4s.ct t o easer-on�r, ow`` t '- s �h Certified Survey Map' is a correct represent ^tion cf ti1 "� n1_''c- ' = =o-' that boLmdcry surveyed and described; ,hat I have fully complied with the current provision of C- .wpter 2;6.3A '.;'isconsin Revised Statutes in surveying and Lapp.i.n_;; cvtame rQ ; ed thisday of ale c -_� 1979 d ^ct:, c �s.. *.�.. rtif_ Allen C. N agen, R.L.S. No. 1 407 S cc r: Lad Surveying Hudson, ;i. _ n,R�•, OWN }J'� �•4V �� �.. C i c v : • aka7 w i ea � 'K .. ". - �i�J9�ncia, ri r CIT_ 1 ^FICATy OF THE TO" OF ST. JOSI'z'I? ' i4; `` `'t , , rr�'• • *_'c that this I, do hereby certify •�:- -:° Certified Survey PIap has been approved by the Town of St. Joseph this .,day of 19 , Town Clerk of St. Joseph 1 . H z • y a ' S T C- 105 r � a y SEPTIC TANK MAINTENANCE AGREEMENT o • St. Croix County z d a OWNER /BUYER Akml U)• c .Tbct; 4 , A t4e S o n ROUTE /BOX NUMBER Fire Number CITY /STATE �_46Sf Qk %(.t) . SC nr->S- r1 ZIP PROPERTY LOCATION: n),E 5 CJ 1 4, Section , T 211_ R _QeQ_ W, Town of , St. Croix County, Subdivision 3% Lot numbe 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 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 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 E I /WE, the undersigned, have read the above requirements and agree z „ to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart - u 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 t rlt Z -�� j�.�e:�Ly✓��� ,i DATE 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. PARTMENT OF REp ON �� ,u � ^ 1 � • V P.O. BOX 7969 INDUSTRY, PERCOLATION TESTS (115) MADISON, W1 53707 LABOR AND 4 } �' HUMAN RELATIONS •! = ..'� (ILHR 83.09(1) &Chapter 145) • • '� Yl'�. HIP/ Y LOT W.: BL]C.��: SUBDlVIS10 N ME: LO AT ION: 1 SE TION: N/Ra?CE (. OOJJ�III�� �� /4,SW /4 / AILIN ADDRESS: VNTY: O ER'S BUY R' NA nk U SO , (� ' DATES OBSERVATIONS MADE( A N / TESTS: USE NO,BEDRMS.: COMMER IALpES RIPTION: A L1 New ❑Replace 3 L�!IResidence Site unsuitable for system RATING: S= Site suitable for system U= RATING: MOUN IIV- GROUIVUPRESS E: SYSTEM IN FI HOLDING TA RECOMMENDED SY �tional) 41 El S DESIGN RATE: L ny portion of the tested area is in the If Percolation Tests are NOT required odplain, indicate Floodplain elevation: under s. ILHR 83.09(5)lb), indicate: PROFILE DESCRIPTIONS PTH TO GROUNDWATER-INCHES TO BED ROCK I OBSERVED (SEE I ABBRV. ON BACK.IEXTURE, AND DEPTF BORING TOTAL ELEVATION BSERVED ES - IGHES NUPABER 0EPTH_IN B- �' 7 z 7 9, 41 OX 8 I j 7 1 13 a{�r •� / 8 R;-3 Q G r y a r C:. ►� � � � I I � s B- n' �A� D 5� Y g t3 �: �k 40 '13 s �B� Y f > K n -S l l r15 a r �'� PERCOLATION TESTS CROP WATER PER INCH L VEL- INCHES ROP I AT ES TEST DEPTH WATER IN HOLE TEST TIME RI D NUMBER INCHES AFTERSWE� >LLING INTERVAL-MIN. P III /D ` P- 3 _ I P, P 3 1 P P- P- their location on the plot plan. Show the surfacs elevation at all borings and the direction and p PLOT PLAN: Show locations of percolation tests, ho�livbh d the dimensions of suitable soil areas. Indicate scale or distances. Describe what are t e inns an zontal and vertical elevation reference points and s of land slope. SYSTEM ELEVATION 6y � i r, w �. f B-A 641 06-1 j ' a a - a rn • A ijui Q U 3 6� 6 A 1, the the undersigned, hereby certify that the soil tests reported on.this form a a 0 r ee bt mhe b of with wledge andrbelie{ metho specified in the N e in accord Administrative Code, and that the data recorded and the location of the tests i TESTS WERE ,COMP ETED ON: NAME (Print): LhQ 1 — ' CERTIFICATI N N MBER: PHONE NUMBER 11 ADDRESS: (� i t r, tifrl�L '� er end qil Te§� OVER f ) b tl 5 2 DISTRIBUTION: Original and one copy to Local Authority, Property Own 1� I : �s Ln /J — n� L" DILHR•SBD -6395 (R. 10183) I ,€'Vt�ily sL a3 13O le CPO 6 v z Z �c 4 Z ! { �L Ol