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HomeMy WebLinkAbout032-1039-60-000 I oo, 1 (D 0 1 h. 6 p p p c c c ti 4 0 0 om O- N 0 0 CD a o Za vi 3 C C u 0 4 Ci I 7 to .D + L,., N c rc� ° NMN� ��� �. p L r- j. 0 co O r U E N I d OIC C. Z N LOY U le r z z N c �w Z ch °C°,) c -- — > > c N- tt� I - m m m L o - O O O C y 3 LL a 0 O a 3 v 3 v o (D 'a a 'a rn E E Q u,co m m m N - �t CL 3 a I I I v N N N of z E E E rn z c :: c = c z v o z r a m a m �V)U) am 0 0 0 z a c v I c c H y N Z '� O O O` 'U O Z m Z v) F -� E'� E '2 E' E c m E v N E 3 N N •L 'C L N C N N C= N 7 7 U � n C N • N N N N N N O N a 0 a s a 0 *a c O z J z Z m z z G Z w N Z I z w� rn m a E a c E E N cc E t ea E E N LO R LO d U') O. .0 r O 1 N d W ate. 1 N a w - f0 CD N d d. 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FE O C m p L N C •C N C C :: (� L j N N m c c c °° € N ayi d v z € 0) a CD v c c_ a°i 0 , o l • ~ M O' m O T N .N U N N N C y O O N n O N O N .m U ���111 O r fq -V O Z- d' Y U) C� r N Z N z I- U' M O Z N z Y fn I I 1 y A €a €a 4)a E c c = c go r� c Wisconsin Depar�ment of Commerce PRIVATE SEWAGE SYSTEM County SL Croix Safety'and Building Division INSPECTION REPORT Sanitary Permit No'. 499119 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Maier, Thomas I Somerset, Town of 032 - 1039 -60 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: ,Q f (� & P TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benc mark t �3 �� �� .4- Wax I' L L O S O Alt. BM Aeration Bldg. Sewer ,V %W Holding St/Ht Inlet p7, 3 0 f p-� TANK SETBACK INFORMATION St/Ht Outlet IO • �7' TANK TO P/L WELL BLDG. I Vent to Air Intake ROAD Dt Inlet %eptir �5, 33' Z 3 Dt Bottom t' f Header /Man. �, >�� —42- t Aeration Dist. Pipe Holdi Bot. System Final Grade PUMP /SIPHON INFORMATION Manu cturer St Cover GPM Model — F T ` 1 8 s- C75- TDH Lift Friction System Head TDH Ft ? Forcemain g Dia. Dist. to Well SOIL SORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No Of Pits In�Dia Depth DIMENSIONS SETBACK SYSTEM TO P/L G WELL LAKE /STREAM L ACH Manufacturer: INFORMATION CHA R OR Type Of System: l Model Number: I ( DISTRIBUTION SYSTE Header /Manifold Distrib ion x ze x Hole Spacing Intake Di e s Length Dia Length Dia S SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded j xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes No Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: 2-9/ #2 Location: 688 215th Avenue Somerset, WI 54025 (SE 1/4 NE 1/4 14 T31 R1 9W) NA Lot 5 Parcel No: 14.31 19 195G 1.) Alt BM Description = 2.) Bldg sewer length= 23� - amount of cover p - Zp � ��,� �i t VLb L,/ Z Ptak. Plan revision Required? Yes No Use other side for additional informa lfon.' _ Date I Signature Cert No SBD -6710 (R.3/97) Safety and Buildings Division County M 201 W. Washington Ave., P.O. Box 7162 St. Croix N visconsin Madison, WI 53707 — 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 Z/ 17? // Sanitary ermit Application State Plan I.D. Number rY PP Na In ccord wi m a th Com 83.21, Wis. Adm. Code, personal information you p N project Address (if different than mailing address) may be used for secondary purposes Privacy Law, s IS. 04(1)(m) I. Application Information — Please Print All Information 'v ED Same Y" Property Owner's Name / azce1 #: Pending Block # Thomas E. &Debra J. Maier G 5 2006 032 - 1039 -60 -000 Na Property Owner's Mailing Address Property Location th ST CRO1X COUNTY 688 215 Ave. SE '' /4, NE '/4, Section City, State Zip Co one Number T 31 N; R 19 W Somerset, WI 54025 715) 247 -3026 II. Type of Building (check all that apply) X 1 or 2 Family Dwelling — Number of Bedrooms 5N� Subdivision Name CSM Number CSM Vol. 1, Pg. 109 ❑ Public /Commercial — Describe Use ❑ State Owned — Describe Use ❑City ❑Village XTownship: Somerset I11. Type of Permit: (Check only one box on line A. Complete line B if applicable) A ' ❑ New System ❑ Replacement System X Treatmen i g Tank Replacement Only ❑ Other Modification to Existing System B. 11 Permit Renewal ❑Permit Revision El change of 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner / �7 t/ T '� •Q IV. Type of POWTS System: Check all that apply) O X Non — Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe V6ther (explain) V. Dispersal/Treatment Area Information: See inspection report for previously installed 2000 dispersal cell Design Flow (gpd) Design Soil Application Rate (gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks T s Septic or Holding Tank SO s 1 Wieser Concrete X Aerobic Treatment Unit Dosing Chamber VII. Responsibility State ent- I, the u dersigned, assume res sibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe s Signal MP/MPRS Number Business Phone Number James K. Thompson - MPRS #30021 (715) 248 -7767 Plumber's Address (Street, City, !0e, Zip Code) 340 Paulson Lake Lane, Osceola, W1 54020 VIII. Coun /Department Use Onl ,Approved ❑ Sanitary Permit Fee (includes Date Iss ed Issuin gent Signatu tamps) Groundwater Surch ge Fee) I � ( ❑ en Reas or Denial IX. Conditions of Approval/Reasons for Disapproval 3) 6� n L 4 SYSTEM OWNER: c� Q n �1an 1. Septic tank, effluent filter and dispersal cell must all be services / maintained G0� as per management plan provided by plumber. 2. Ail seRlack requirements must be maintained u per sppka6lfe code / ordinencss. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) i bf'S,yxrsa.�, 5� .Crock � Pte(. o32 ilSPe - e /ffo,.4 �ssrLv Gri.siSfiJ of `t -l��ec -E�snc.�s 2� 3 X G2•S, • 1�n ��: �/o o`'Gt�C./�C°Q.S:�Iy'. E.ri:Sa�i' tcJci,,f's Cor�crt� ansokx! To 6.ea6a.,dor��/ �iopo 3e as / Code s�. P c. 6u;/d✓. `lfi�� G'ne Proud t c9. yci wa760'r►1Q SiF►E•C EXr3/s`n9 (cJPJ/ EXi Sz�ir�9 S/cSd�jy/. ga �a�e �e S • a(t..,� e CI A dc�u e T4 cos Sec, /5; 7731,l f4J, Tq. Pte. X032 X039- Go - i�S�e� ee< / a'a Cow ss octh,-cc -fr,nc.lu-s a� 3re2.5.' r/ EXlS�i' cc.�,cf's Cogcrc� - ,i3 1de e 6 -- e 4 1 6,6 out /� E an5okcx✓ To 6ea6a daY,cJ �3 vz Av c. 6u :�✓� a s/u Code �j2w¢i - 6v reel. ce �Ci fi, Lir/C' Popoaed c 4). csx-- �' ncrc t �J wa 96o *bf 54pt EXi S��+y �6d�M, l�a raft' Ae S, c Q to ? /5"" ,4W IA 4 ^V ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner Q•S 6. Oe - &,�ra 4a i Gl Mailing Address 669245 - 9 ,' �. Property Address 6aeoe (Verification required from Planning & Zoning Department for new construction.) a o3 - c� el -�-� � sy zf o3z -� 9 6 o City/State /State S� cc� Parcel Identification Number Y LEGAL DESCRIPTION Property Location SE 1/ , /)E 1 /a , Sec. IV , T _ N R—/LW, Town of Subdivision — , Lot # S . Certified Survey Map # , Volume Z , Page # 14F Warranty Deed # , Volume , Page # Spec house ?ycus no Lot lines identifiable es X SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic sy stem could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of m /our knowledge. Uwe am/are the owner(s) of the Y g property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms :Z:z� . ;A2 SIGNA - U A OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) U 1 8 7 0 P 6 1 `f 27600'3 STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between Ronald J. Germain and Carol Ann G_ ermain, husband and wife, 04 -11 -2002 9:35 AN WARRANTY DEED EXEMPT k 3 Grantor, and _ Thomas E. Maier and Debra J. Maier, husband and REC FEE: 11.00 wi — TRANS FEE: - COPY FEE: - — CERT COPY FEE: PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Part of S 1 /2 of NE 1 /4 of Section 14 - 31 - 19 described as follows: Lots 5 and Name and Return Address 5A of Certified Survey Map filed April 18, 1975. in Vol. "I". page 109 (No. !1@ILltli ppaMoMllk (, 116), St. Croix County, Wisconsin. AM /101 Cr This deed is given to correct the legal description in that Warranty Deed 91, miN 65114 �Jo7d dated September 27, 2000, recorded October 20, 2000, in Vol. 1552, Page 341, as Doc. No. 632125. 032 - 1039 -60 -000 Parcel Identification Number (PIN) This is not homestead property. 01) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of Janua 2002 V *onald J. GeraVain • Ca rol Ann Germain AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN ) Signaturc(s) --- - -- -. - - ) ss. St. C roix _ -_ County ) authenticated this day of Personally came before me this _01. day of January 2002 the above named - Ron J. Germain and Carol Ann Germain, husband and wife, TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (If not, instrument and acknowledged the same. authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY + — Attorney Kristina Ogland _ Notary Public, State of Wisconsin Hudson, WI 54016 My Commission is permanent. (If not, state expiration date: J (Signatures may be authenticated or acknowledged. Both are not necessary.) ' • Names of rsons signing in an capacity must be typed or printed below their signature. lrf r Pion r� fessionsl: Comp —v. Fond e, LK. VIA Pe g g Y P tY YP P g 900855 -2021 STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2- 1999 Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD- 10705 -P (N.01 /01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be <_ 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October - February) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two -year schedule by use of a diversion valve. Valve to be switched diverting effluent from dispersal cell currently in use to resting cell on a two -year cycle coinciding with septic tank inspection and maintenance. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248 -7767 or the St Croix County Zoning Department at (715) 386 -4680. . 0 �� / R ; § V / f z \/ C' f§ 2 - E , E \ J m ` ( @ � g % � §72 c § § °3 ■A 0 § Q § § e 2 ' o \ c t � K E e � \ § C ° k / B m� 8 °° ©Ec $ ° o $ 47 �- 0 0 0 § CD .. Oro o E I I BE o § ■ CO) ■ _ ( J 0 2 E J e £ g i § 2 E CL \ ' c / 0 .. 5 m 0 g o 7 = S o n E , % k £ ; C E a FL 3 0 kk0 0 � CL a: § \ ■ T q 2 « 0 § 2 z 8 m j 7 m � � �$ ^ . � £ > § to CL m iƒ :E R. � %{ ƒ \ z A §� 0 � 3 � § � 3z � 2 � � k o » (D 1 0 9 i @ o � ; ■ I AisconsinpepartmentofCommerce I PRIVATE SEWAGE SYSTEM Count y Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy L aw, s.15.04 (1)( m)]. 374981 Permit Holder's Name: ❑ City ❑ Village ❑ j[own of: State Plan ID No.: ermain Ronald I Somerset Township CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: CrO.0' OD 032- 1039 -60 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. i Septic Benchmark 2.9b 1o2.9b C>fl D Dosing Alt. BM Aeration Bldg. Sewer Amer—)) Holding St /Ht Inlet I � TANK SETBACK INFORMATION St/ Ht Outlet 61 q5-11 TANK TO P/L WELL BLDG. Ai Intake ROAD In et 3.9 9, -.04 Septic >SD` - qZ' 5g`+ NA R of om 9 01 .64 Dosing NA Header/ Man. Aeration NA 8 Holding Bot. System" 3• PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover ModeTN GPM TDH Lift Friction Syestem T, H Ft L oss FFii Forcemai n Len gt Dia. st. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width r Len th r No O Trench No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 1 J DIMEN I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK -(;lk—� - 5_1"� INFORMATION Type Of I r _ CHAMBER Model Number: System: b "o i D + 5 B — OR UNIT _ a te, DISTRIBUTION SYSTEM Header/Manifold , J Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Q L Dia 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 COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: oq /M / o Inspection #2: Location: 688 215th Avenue, Somerset, WI 54025 (SE 1/4 NE 1/4 14 T31N R19W) - 143119195G -Lot 5 1.) Alt BM Description= N/A 2.) Bldg sewer length= y? - amount of cover = �5 14Yan revision requlr'ed? ❑ Yes No Use other side for additional information. D3 f S o I S SBD- 6710(R.3/97) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: F k E ° 1 3 i d 3 3 y S r 3 e i ° t C E E e a (mil x x 3 3 < s E � u ° I 3 E ° a 1 ° � k ° e s. _. ._ . Y ° k � = x p x x t 3 ° I S Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 `�s eon s i n Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(I)(m)] (Submit completed form to county if not state owned. Attach com fete plans (to the county copy onl 11 s p i m pn paper not less than 8 -1/2 x 1 I inches in size. County State Sanitary Permit Number CIL i.l.reSigiun t' previous application Stale Plan I. D. Number 1. Application Information - Please Print all Inform ti'W 1 Location: Property er N m ; `�' \ Property Location ► --' t. 1/4 1/4, S T N, or Property Owner's Mailing Address Lot Number Block N tuber ST Cs_C?rx i ! OGL':"Y' e l City, State Zip Code I t ter `..� a Subdivision Name or CSM Number s j II Type of Building: (check one) ❑ Ciry O 1 or 2 Family Dwelling – No. of Bedrooms; Cl village O Public /Commercial (describe use): _VTownof 0 State -owned III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road A) 1. ❑ New System 2. OReplacement 3, O Replacement of 4. ❑ Addition to Parcel Tax Number s ° System Tank Onl Existing System 1 (? — B) Permit Number a Date Issued 0 A Sanitary Permit was previously issued e22 � � !. � IV. Type of POWT System: (Check all that apply) j$ Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V Dispersal/Treatment Area Information: I. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. P rcolation R to 6. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (MinJinch Elevation / ,� ✓ C ✓ VI Tank Capacity in Total 4 of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks �� ❑ ❑ ❑ ❑ e ✓ ' VII Responsibility Statement I, the undersigned, assume responsibility for install ion of the PO TS shown on the attached plans. Plumbe's e ( tut Plumb 's Si MP /MPRS No. Business Phone Number P u er's ddress (Street, City, State, ip de) VIII County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fe e) - Determination Z Jam, f�0 Z ZOUO IX . (1 Conditions of Approval /Reasons for Disapproval: (` / 1 \ )1;4fr 4 � ►Ma;c.�Ct�v.C'd�SCrv�CeCt Per w,0_K1A_ ctGtL'relS re'Gou,rn °,ti4�efi�jk5- Z C�rGV q k is !c �i Z, 1 9 C / 0 �li rn �¢ °- tv; �� fo v i CAle Q, ew �/– a S ee �/ "O SBD -6398 (R. 07/00) SIA 4/ r! .�IAIIII e 90") 3 _ �wgoo q / ,36 /1 �N s�sic f Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Z �V Property er Property Location Govt. Lot 1/4 1/4 S T N R E (orlff Property Owner's Mailing Address Lot # I Block # Subd. a or CSM# a City S to Zip Code Phone Number ❑ City ❑Village W To n Nearest Road ❑ New Construction User Residential ! Number of bedrooms Code derived design flow rate GPD Replacement ❑ Public or commercial - Describe: Parent material ,L;�� Flood Plain elevation if applicable ° ft• General comments and recommendations: n Boring # Boring 1 / I Pit Ground surface elev. ,97 / ft. Depth to limiting factor },(gam in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 9./ 3 q 3 1i y 2 ee ® Boring # Boring Pit Ground surface elev. , /_ 7 ft. Depth to limiting factor in. n Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 - Eff#2 1 1 SZ Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Nam P- ase Pri i Sig natu CST Number j •. 4 Address Date Evaluation Conducted Telephone Number i Property Owner i --1,46 Parcel ID # Page of � ? _ Boring # ❑ Boring ❑ ® Pit Ground surface elev. 7 ft. Depth to limiting factor 7 i?�S in. -- § - o — ilApplication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 3 3 g" , ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 F-1 Boring # F] Boring F] Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an altemate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R.6 /00) 1 4 ZIPS 4 /OpD�sl T,�G �1 1/ouSE G'.�,GF6� ,OPr ✓►��r� ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERS141P CERTIFICATION FORM Owner/Buyer ' t Mailing Address 4ff •Ct" Property Address y (Verification required from Planning Department for new construction) City /State Parcel Identification Numbe / LEGAL DESCRIPTION Property Locatio ' / <,_ ' / <, Sec., TN -R W, Town of Subdivision ,�,� ,Zi� /� , Lot . # Certified Survey Map # m �71 37 , Volume , Page Warranty Deed # , Volume _ , Page # S� Spec house O yes T no. Lot lines identifiable a yes O no SYSTEM 1V7[AINTENANCE 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 wastewaterdisposal 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 stem has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days het yea piration date. &- - �1 � A/ Ind SI NA OF APPLICANT DATE OWN ER CERTI TION I (we) certi that 11 statements on this form are true to the best of my (our) knowledge. I (we) ant (are) the owner(s) of thappg a ve, by virtue of a warranty deed recorded in Register of Deeds Office. S NATLICANT D ATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed i I r r M- MINT G.wp�ry® DOCUMENT NO. I f� (j y STATE BAR Of WISCOtISIN —FORM 2 C ( WARRANTY OECD .if, 5PACIE RESERVED 11R RE10N0IN6 DATA Edward E Germain and Ann Marie 3ermain, husban3_ and wife, as _joint tenants ____ f '•'fr conveys and warrants to _ Ronald - __J Ge rmain -- Carol Ann Germain, husband and wife as terant RETURN TO the following described real estate in St �r01_� -_ County, State of Wisconsin: Lot Five (5)of the Certified Survey Map filed in the St. Croix County Register Tax KeyNo._— of Deeds office on April 18, 1975, in Volume 1 of Certified Survey Maps on Page 109, being a part of the South ene -half of the Northeast quarter (S' of NE;) of Sect -ion Fourteen (14), Township Thirty -one (31) North, Range Nineceen (19) West, including the access easement contained in said Certified Survey Map and designated as Proposed Town Road. I +SF ui s !� FEU This __is not homestead property XN (is not) Exoeption to warranties. Dated this -- 28th - day of _February- 19 80 _ (SEAL) ! �'[ It L� C 2�t<<tt-v (SEAL) • Edward E. Germ _ _ _ - -- - - - -- — -- (SEAL) �E lc r. t zyl I, ,�y' 2 frLr ­' (SEAL) A nn Marie Germain AUTHENTICATION ACKNOWLEDGEMENT Signatures authenticated this _ -- day of STATE OF WISCONSIN __- _February -_ ___ - - - -_ 19 80 _. ss. - -- N/A County. Personally came before me, this N/A day of G. E. Norman 19 TITLE: MEMBER STATE BAR -F WISCONSIN NLA the above named This r.strument was drafted by - - - " -- DOAR, DRILL,_ NORMAN_ t.. - BAKKE, BELL & SKOW New Richmond, WI 54 . to me known to be the person who executed the foregoing in• strurnent and ac %nowledged the same. iSlgnatures ma; ,e authenticated or acknowledged. Both are not n ;eSS3fif Notary Public _- County. Wis. My Commission is permanent. (If not, state expiration date: h A{+BAN' O ,:EPL. iTATC BAR [,W l.'. Sr:C�15'N f?QM ". J 2 — 1977 i ,w L.lJiat. Ut s!,. s `R19W., Town as oT ows : Conunencing at the NE corner of es o thence S1 (assumed bearing) 1860.88' along the centerline to Trim Highway 11 35" and the Northerly extension thereof; thence N87 ° 31 1 W 1334.72' e'point of beginning; thence S87 ° 31 1 E 647.37'; thence S1 ° 28'W 712.00'; thence N87 6.00' along the Northerly right -of -way line of an existing town road; thence N1 ° 28 1 E 307.50 thence N87 °31'W 675.00 thence N14 0 32 1 50 11 E 413.59' to the point of beginning. v I certify that the above description and map are correct and that I have fully complied with 'the provisions of -Sec. 236.34 of the Wisconsin Statut DATE: April 3, 1975 FRANCIS H. OGDEN -882 Map No. 75 -434 LEGEND ® SECTION CORNER MONUMENT NOTE: ASSUMED BEARING REFERENCED TO CENTERLINE OF STATE TRUNK HIGHWAY 11 35 ". WEST, 1 X 24" IRON PIPE 4.30 O 1b1IG71ING 1.68 # /LINEAL FOOT. S 1 60. CENTERLINE b S E TRUNK IGHWAY 35 SW 1/4- POINT OF BEGINNING TAT H NEI /4 � N 87 31' W 1334.72 6 6.0 S 87 E 647,37' 9� NE CORNE 0 SECTION I 03, a7 T31N,R19\ f W 5 5.83 ACRES 3 _ 4 nM w ° 0 0 1 z SE I/4 - N E 1/4 6 - - - 0 5A o 1.08 ACRE a am r' Sri tn N 2 °5 675.00' 3 N 87 31' W -� a 58I. a 83.8 0 ± 20 r 5� 43 3 X 1 01 " C,0N ` N POND I �,���.�' ~ter.......,,. � 3 V 1 ► 9 -- : FRANCIS H. OGDEN FILED is S -882 RIVER FALLS, APR 181575 - wIS, C JAMES O' CONNELL N ,�, d Register of Deeds / 'V '!+ St, Croix County, ,';� ®o��e� S U ��'��, Z M t 1r Wisconsin �, tp�� t r� SCALE I ASSUMED 100 O 100 t BEARING , NORTHERLY RIGHT OF WAY o�� D LINE 9` - -- - - - - -- - 66.00. - - -- '` ' _E XJ�TJIYQ_ — IQYKN E?Q AD- W N 87 0 31 W N M Volume 1 Page 109 s� .. Voles 1 Page - - AS BUILT SANITARY SYSTEM REPORT ' a OWNER �K�A �crpy�,A „� TOWN SHIP,5�tt) � ± SEC./,Z T N, R /7 W ADDRESS ST. CROIX COUNTY WISCONSIN. m 3 ,S� -f SUBDIVISION Cpl /A LOT LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM #1 I . i I I I di.cat North; Arrow SCALD . i!�t. -- � :- --•- -i I --_ I I SEPTIC TANK(S) _ MFGR. - �� , CONCRETE STEEL NO. of rings 6n cover Depth /g ,, PUMPING CHAMBER SIZE PUMP MFGR. MODEL NO. GALLONS Per Cycle TRENCHES NO width length area BED NO. of lines width length area r «j�q' depth to top of pipe NUMBER OF SEEPAGE PITS Outside diameter total pit area AGGREGATE PERK RATE ” AREA REQUIRED ��5 xt AREA AS BUILT 60 4CaJ Disclaimer: The inspection of this system by St. Croix County does not imply complete compliance with State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability or system operation. However, if failure is noted the y y P , County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM. /1 INSPECTOR_ DATED �, _ G PLUMBER ON JOB ATED �,��1�,� �� LICENSE NUMBER +, jZS" , State and County State Permit PLB" 67. rr tb Permit Application County Permit # m for Private Domestic Sewage Systems County 'DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Q a ') 9 0, ,, q , � , 0 Yn 1 V) I S B. LOCATION: cS0 _ '/ 4 ►�1�� ' /4, Section/ , Tom_ N, RI�4&- (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village IBC 0 �A t Y g fn (0 Q Township a sg C. TYPE OF OCCUPANCY: Commercial "Industrial "Other (specify) Variance Single family `� Duplex No. of Bedrooms Z No. of Person D. SEPTIC TANK CAPACITY 6&0 Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel Fiberglass Other (specify) New Installation t_/ Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) E. EFFLUENDISPOSAL SYSTEM: Percolation Rate Total Absorb Area 6.1-16 sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width_--��,�D,epth Tile depth (top) No. of Trenches Seepage Bed: ` — Length S2 ` Width 1 Depth�_Tile depth (top �' No. of Line �— Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land ,h Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ O name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certifj d oil Tester, NAME /� . i ^�,� � r,7 i 5 C.S.T. # t/ / and other information obtained from (owner /builder►, Plumber's Signature A yaz / Mr /MPRSW# / 4 •5 l Phone # V/ •� L/ �- j Plumber's Addr PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. if i 3.m , t i € 1 . A ,. z , ' W i E i t t { k i Do Not Write in Spac Below - F COUNTY AND STATE DEPARTMENT USE ONLY Date of Application — _ Fees Paid: Stat Co n DD Date< - — �— Permit Issued /R ' (date) < < Issuing Agent Name Inspection Yes No State Valid# Date Recd 1. county (wtrt copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4, plumber (canary copy) Revised Date 7/1/78 P State and County State Permit # Permit Application County Permit # for Private Domestic Sewage Systems County "DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Q a ') (�,, ,�, , q , � I a ely,_s 6- ; 0 1 -S a, B. LOCATION: S_ ' / VUL ' /o, Section/ , Tom_ N, R_Lj4&- (or) W Lot# _ City 1 � ► y� Subdivision Name, � nearest road, lake or landmark Blk# Village 1� © �\ i o c, tao (0!1 Township C. TYPE OF OCCUPANCY: Commercial "Industrial "Other (specify) Variance Single family `� Duplex No. of Bedrooms Z No. of Person D. SEPTIC TANK CAPACITY 611 D Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel Fiberglass Other (specify) New Installation ✓ Replacement Lift Pump Tank or Sip Cham ber Total gallons Prefab concrete Poured -in -Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area — sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top No. of Trenches Seepage Bed: '--- Length Sz ' Width 1 Depth ' Tile depth (top) L ' No. of Line Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land I Y L Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name a s li o E H 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certifi d Soil Tester, NAME /c •� c,, s ^r, _ 4 f S C.S.T. # yam_ and other information obtained from (owner /builder). Plumber's Signature / M(' /MPRSW# / I Phone Plumber's Addr PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. y ! .i.-.« ,e. ew ...... ........ ..� ��. ».. .. °..,.. W...M.d. __,.._......_tm ,. . _ 3 ,,,...... — ..s�... ,.. .. we, 3 «. ......„.ti...wk, .......�._! I #-. �.... , I I y ! I ! 3 I I I 4 r t I } C I c i i � t I y E I F 3 )o Not Write in Spac Below F COUNTY AND STATE DEPARTMENT USE ONLY n )ate of Application — _ Fee J � Paid: State Co n Date — �— Permit Issued ' (date) C / J Issuing Agent Name nspection Yes No State Valid# Date Recd I. county (wht copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 ?. state (pink copy) 4, plumber (canary copy) Revised Date 7/11/78 J n cn O C) cn O 3 v 0 b v1 d f ° o o d ° F � '+ h, 3 m m a m(D m y • m -Z -a n oo — a m 3 m � Z N Z O W - Z (n Z N _' 0 0 A W • 3 m < C A O li 3° C O N CD (D 3 ; CO a CD m Z m m - 4 0 m o ►�.., /� N ? N (D (D N 1 N 'D CL 0 N >' (D 0 1 > > (D a p CT C) O O C (D C (D (7 7 (D N 0 M CL O 3 3 N d a 0 (%1 a � O � 0 C, C 0) 41 N N O I CD (a ? � Q O ca m (A p ' Z3 a m _ � CD C Q. ° C O O S 0- C 0 0 3 (D Z N ( 0 l S ` � f ! N N °° a O (D CO CD cn CO) j 3 0 c c 3 3 0 cr CL 0 M CD O 0 O O O O O (o ° a o p p 2 �L < o+ Z _o Ci ai ai ai - N co ti o D v Q 7 (D W A C, O= ^�' N 'a ° N N m M N �1 m N (D (O (V N n N y N 3 3 d w 3 (O a `� - N Z °_ ZD . o D co o O w O a �. o @ N "*A � (n (D N N ? � I, N w � C C N a W (D o a N _ Q 3 a 3 Z m n 0 O j A Z N p N 0 A Z O a a L 7 oo v oo v m A (D (D ( Z (D 3 a 3 a A a - o° - Z 0 0 m (O N m m A a N g ED N o a CD �3 o a w ° � CD a. 'C)m 2' CC � a 3 D) C CD a w C w < 0 7 O (D Z G N N Z Q n N O (D 0 0 O ° O m o c �3 -o �� (D n O N (D (D n� 3x m cn w o N a m y 3 CD Q N c A x x CD CD _ CD CD> N G7n >c ' N 0 , CL FA, 3 C) > CD CD 00 CD CD 0 fp 0 (D O O . O w 7 O N O w. CD CD O (0 69 EA p r °CD °CD a C) � 0 CL 1 AS BUILT SANITARY SYSTEM REPORT OWNER , �,, TOWNSHIP. /t SEC . T om/ N, R ✓� W ADDRESS t"- ST. CROIX COUNTY WISCONSIN. SUBDIVISION �Jlii , r_ 1r LOT �`� LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM (� 4 J : 2 , U I � I i / m I I dicat North; S CALF : SEPTIC TANK(S) MFGR. , CONCRETE STEEL N0. o rings 6n cover Depth � PUMPING CHAMBER SIZE PUMP MFGR. / MODEL NO. GALLONS Per Cycle TRENCHES NO. of width length area BED NO. of lines 62 width 1_:2 length area depth to top of pipe ` NUMBER OF SEEPAGE PITS Outside diameter total pit area AGGREGATE 1 - a rt a� PERK RATE AREA REQUIRED Al AREA AS BUILT Cd 56 aJ' Disclaimer: The inspection of this system by St. Croix County does not imply complete compliance with State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYTEM. INSPECTOR , DATED /��T,jy� PLUMBER ON JOB �y - LICENSE NUMBER � P�./Zs ,y/ z REPOR1"•OF INSPECTION INDIVIDUAL SEWAGE SYSTEM San.itany Pehm.it 2 z 2 • - State Septic 1 z11 NAME I _�' � rownehi S;C. Cno.ix County ' S .ion - Location /L G ect / SEPTIC TANK Size/' gattona. Number 06 Compn At men ts Distance FAom: Well ' 9 �� �. 12% oA gneateA slope t Building (� 6t. Wettanda - " 6t. H.Lghwaten 6t. DISPOSAL SYSTEM Distance FAom: Well 12% oA gneateA ztope t. Building 6-6 6t. Wetlands � F t. • H.ighwateA FIELD DIMENSIONS: Width o6 trench /'2r 6t. Depth o6 Aock' below t.ite in. Length of each tine 6t. Depth ob Aock oven tite �i n. Numb et o6 .Linea 2, Depth ob t.ite below gAade Z .in. Total .length o6 tines 4 t. Slope o6 trench r"' in pen 100 6t. D.iA tance between .Linea Depth to b edno ck 6t. Total ab oAbt.ion area 2 t Depth to gnoundwateA fit. i .. Requited area 6t er o 2 Type o6 Covet: Pap Straw PIT DIMENSIONS: NumbeA o6 pity GA et a� and :ita yea no Outside d.iameteA � ep ow .inlet 6t. Total aba oAbt.ion are t 2 Z A AAea Aequ.i %ed 6t rn INSPECTED BY TITLE APPROVED , DATE 197 REJECTED ,DATE 197_ �i 1 1 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH • P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: L.�/4,�4, Section /Y-, TIN, R (or) W, Township or Municipality �� ! Lot N o. s5 Block No. County C r - 4 ) Subdivision Name Owner's Name: — e zg gr z -t Mailing Address: TYPE OF OCCUPANCY: Residence L'' No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW Z ' ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS 7" Z - PERCOLATION TESTS �` 2 2 SOIL MAP SHEET Z SOIL TYPE r-Czn - L:!i -a 6"� 4r C1 PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P— t ,2 P— • ( / 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) r ? r r — 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 numbe f square feet of absor ion area needed for building type and occupancy. � scale or distances. Give horizontal and vertical reference lkints. Indicate slope. ri 0 tN A IS 4 TT_ I 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. �/ c- fj �- r- /r/ / X_ i h Certification No. 5 i Name {.print) ��- � T Address -y ,= � 4! --1 »s In .. 141 � Name of installer if known CST Signature 4&-46e Z��e" i -_77 COPY A —LOCAL AUTHORITY State and County State Permit # l r Permit Application County Permit # for Private Domestic Sewage Systems County A" of * DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Q 614) ac C1 �or� s t 0�sa'. B. LOCATION: S0 1 / . �� ' /4, SectioivVfi�, T,, N, Rl J—r W Lot# _City Subdivision Name, nearest road, lake or landmark Blk# Village 0 " t O q fn tao(D S Township F�c-p C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance Single family �� Duplex No. of Bedrooms - 2— No. of Person D. SEPTIC TANK CAPACITY PlfS'a Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel �� Fiberglass Other (specify) New Installation y' Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area 6 sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: `� Length S2 ' Width 1 Depth 4 Z' Tile depth (top) '' No. of Line Z Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land �7� �� Distance from critical slope WATER SUPPLY: Private Joint ❑ Community F-1 ❑ Owners name as listed on EH 115 if other than p owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Cert d Soil Tester, NAME �1 /c 1 cr -4Z 4 �Z +,>k�4 C.S.T. # 4 % / and other information obtained from (owner /builder). Plumber's Signature tc MP /MPRSW# I e 5_ l Phone # x/ Plumber's Addr _. , PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. .. s .._ . �5 t E �. ��. y a. .ax . 0 a ia- ��- IJ Al e . m i 3 3 F t i s E E Do Not Write in Spac Below F COUNTY AND STATE DEPARTMENT USE ONLY Date of Application _ Fees Paid: State C Con „CC Date Z� Permit Issued /Ra#gW4d (date) l - -9 1_ A/ Issuing Agent Name � Inspection Yes No State Valid# Date Recd 1. county (whit_ copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78