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HomeMy WebLinkAbout038-1161-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 488158 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: Meyers, Doug Star Prairie, Town of 038 - 1161 -10 -000 CST BM Elev: Insp. BM Elev: BM Descriptio Section/Town /Range /Map No: ld - 6 IQU .0 P"_ 12.31.18.755 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. eptic Benchmark Dosing , ,, /� Alt. BM Z v{� w Aeration 6 t S _ Z � Bld . Sewer O' S�, quo Holding i t/ et TANK SETBACK INFORMATION S t /Ht O utlet TANK TO PIL V ent o r Intake n e e / Dt Bottom osing f � ea er an. A eration , & Pipe ipe o rng o . ys em _ v z f gD. ina ra e PUMP /SIPHON INFORMATION ..(I'. �J. 2 9 5 -9� anu ac urer 13emand SrUo GPM o e um er , / r I UN i n ion LOSS ys em mea orcemain 1 1-engin 'SOIL ABSORPTION SYSTEM Nu. ul Old Depin DIMENSIONS INFORMATION CHAMBER / I ffluuW 1141.1111v=11 i UNIT 1r n� ) �� �` ?0 7 p Q f r A JA I I- S Length Dias_ Length Di TV Spacing x Pressure Systems Only xx Mound Or At -Grade Systems Only 3 Bed/Trench Center` / Bed/Trench Edges Topsoil J � ] Yes] No Yes �] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 2221 135th Street �,New Richmond, WI 54017 (SW 1/4 SE 1/4 12 T31 R1 8W) Johnson &Assoc 1s dition Parcel No: 12.31.18.755 1.) Alt BM Description = eev 2.) Bldg sewer length = 36 vVW - amount of cover = Plan revision Required? Yes � No Use other side for additional information. �O " Stgrta are - - —J - SBD -6710 (R.3/97) Aivisi;hington Buildings Don County ` 20 Ave., P.O. Box 7162 � 00 .S C n unitary Permit Number (to be fil / led in by Co.) 8)26 GV 1 4 $B'l - - 2 Department of Commerce tate Plan I.D. Number Sanitary Permiti 0 1 2006 In accord with Comm 83.21, Wis. Adm. Cod pe o ation you provide ro ect Add re of different than mailing address) may be used for secondary Purposes ri sl .04(lxm) J T. CROIX COUNTY C;L hN I. Application Information - Please Print All Information i � a - I �S j .. Parcel # Lot # Block # Property Owner's Name Property Location Property wne s ailing Address 3S (� /., L ' /,, Section �� rty State' Zip Code Phone Number I r `� S 3 C( T3 N; RE o W� II. Type of Building (check all that apply) . .t�^'` Subdivision Name CSMNum Ior2 Family Dwelling - Number ofBedrooms (�' 1,/7 yjsAT6c, ls� - Ad d . ❑ Public/Commercial - Describe Use � ' T- r ❑City_ ❑Village 4ownship of S l K r ✓°c: t P, .� ❑ State Owned - Desc Use O r III. Type of Pc it: (Check only one box on din A. C mpiete line B if applicable) A * 101 New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Issued B. [I Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New 3 - 2 (p p 7 Before Expiration Plumber Owner 02" - 7 Q 1V, Type of POWTS S stem: Check all that a f Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < in. of suitable soil ❑ At -Grade ❑ Single Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Lin ravel -less Pipe ❑ Other (explain) Yo V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System EI t , ion 9d Pa VI. Tank Info Capacity in Total Number Manufacturer Concrrete Constructed Glass S _ r Plastic Gallons Gallons of Units New Existing Tanks Tanks SepticorHoldingTank 050 r W ` _S Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement - I, the undersigned, assume responsibility for in of the POWTS shown on the attached plans Blu mber's Name (Pr' `r5 P� bur's Sum' RS tuber Business Phone Number s S s Plumber's Address (Street, City, State, Zip Code) n C� t q VIll. C un /De artment Use Onl Sanitary Permit Fee (includes Groundwater L., ssu suing Ag nt Si ant o tamps ) proved 1 ❑ Disapproved Surcharge Feew, 11 Owner Given Reason for Denial o 0� IX. Conditions of Approval/ReasonsforDisapproval 3 /1 / _ / I 1j / TEM OWNER v `�C�LL �t 1 a tic tank, effluent filt and '33 C 3 SyS t'h dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. s Attach complete plum (to the Coun only) for the syste on paper not s than Sl/2 x I I inches in size a e SBD -6398 (R. 01/03) I [� rc 1 1 LO OAL , I I - -- - - -- - I { , IIII b -- I- I I ` ' I � I , I I I ! I _ i 1 i I I , - . 1 ' ; I I r 1 I { I ' I I , A 15 - ¢`tt I - - , f C 1 I _ i I I II I ! t I i , j F , I l I I I' , I - f _ I I I , 1 � J i I : I , i I flo 1w�. le ic Ls vo (0 Ef l ?/ A Alf$em -T6 51 " 03. ' Vi 9a' 3 OLI rkp, - f ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer D „o„ P V -,s Mailing Address I _: ' Property Address J cr (Verification required from Planning & Zoning Department for construction.) City /State VQ it/ � Parcel Identification Number 0 3 9 Ma ( I D 00 � LEGAL DESCRIPTION n Property Location S '/4 , _S Z - ' /4 , Sec. / X, T .3 1 NR / S W, Town of Src i r^ r 11 C1 ; r, If Subdivision J 0h "so 4— (m 3 - N�k AW W -, , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # �4 I 09): , Volume — 15 9 , Page # Spec house yes no Lot lines identifiable OS no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. 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 my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms S l 41� SI NAT F 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) i POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page --/— of O NiFt?lRMATION SYSTfSIi! ATM Owner Permit # Septic Tank Capacity I If 0 al ❑ NA Septic Tank Manufacturer f s O NA D1;Sit3N PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms o D NA Effluent Filter Model �j DNA Estimated flaw (average) Number of Public Facility units DNA Pump Tank Capacity D NA D o Pump Tank Manufacturer DNA Design flow (peak). (Estimated x 1.5) allda Pump Manufacturer Q NA Soil Application Rate g al/day/W' Pump Mode! 0 NA Standard Influent/Effluent Quality Monthly average * Pretreatment Unit NA Fats, Oil & Grease (FOG) 5330 m /L 8 D Sand/Gravel Faker ❑ Peat Filter Biochemical Oxygen demand (BOD 5220 mg/L 0 NA D Mechanical Aeration D Weiland Total Suspended Solids 1TSS) 5150 mgfl D Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal "lei ❑ NA Biochemical Oxygen Demand {BOO s30 mgiL B(in-Ground (gravity) 0 In- Ground (pressurized) Total Suspended Solids (TSS) 530 mgfL XNA � ` At -Grade E3 Mound Fecal Conform (geometric. mean) 510' 100ml D Drip -Line p Other Maximum Effluent Particle Size Y in dia. ❑ NA Other. Other: E3 NA ❑ NA Other: © NA * Values typical for domestic wastewater and septic tank effluent. Other Q NA MAMITENANGE SC#*MLE S"vke . invent Service F requency Inspect condition of tank(s) At least once every: ❑ man a) ear ls) (M 3 yam! DNA PUMP out contents of tank(s) When combined sludge and scum equals one -third (Y) of tank volume p NA Inspect dispersal cell(s) At least once every: D JR month(s) will u n 3 read ❑ NA y ear(s) Clean effluent filter At least once every: D month(s) CI NA years) inspect pump, pump controls & alarm At least once every: ❑ montfits) p NA D Flush laterals and pressure test At least once every: D month(s! ❑ NA ❑ year(s) At best once ev I morlth(s) b I�Ih" Other: '' ' Cl yearfs) ❑ NA MAINTENANCE INSTRUCTiONs Inspections of tanks and dispersal cells shall be made by an individual carrying one of the fallowing licenses or certifications: Master Plumber; Master Plumber Restricted Sewer, POWTS inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware; identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for an i ces t of effluent on the ground surface. The he ponding of effluent on the ground surface. may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one - third %) or more of the tank volume, the entire contents of the tank shall be removed b a W to p M 113, AN other services, incfud"mg but not.limited to the servicing of sf j �?�ec ed con s, and any servicing ai intervals of 512 months, shelf be pertormed by a certified POWTS Maintainer. ponents, Pretreatment A service regulatory authority, w f service event. START UP AND OPERATION page �of For new construction, prior to use of the POWTS Check treatment tank(s) for the presence of Painting products or other chemicals that may impede the treatment process and /or damage the dispersal ceWs). If high concentrations are detected have the contents of the tank(s) removed by a Septage servicing operator prior to use. System stet up shall not occur when soil conditions are from at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. Whan power is restored the excess wastewater will be discharged to the dispersal caft(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effiuett. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring Power to the effluent pump or contact a Pkr vdw or POWTS Maintainer to assist in manually operating the -pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within IS feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss, diapers; disinfectants; fat, foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides. meat scraps; medications; oil; painting inducts; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is . Properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: e All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. e After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by nxiuked setbacks from existing and proposed structure, lot aloes and wells. Failure to protect the: replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply ,with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. e site h been ev to id suitable rep t area. Upon failur�ol e P alu I tion st perf a suit r ar If piac s availebte tank may be aged a 1 rssort.to rWiac:e the fat WTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WAR1111M> > $B "W- PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL. BASSES ANDJOR INSUFFICIENT OXYGEN. DO NOT ENTER A sEPTiC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE .INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS Pt?11ltTS INSTALLER POVYTS MA WTA Name Cs W eN C j S Name Phone Phone BUTAGE SERVICING OPERATOR UVMM LOCAL REGULATORY AUTHORITY Name Nine " / '. Phone phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(7 NOW) and 83.54(11, (21 A (3). Wisconsin Administrative Code. Mmunion o °ip" Tw �d SOIL EVALUATION REPORT „, / d 3 �� tugs r. aaapi.b of owaa on paper no x t 1 neM�da .OntwaRRliairrtbcv�fo�iand a�rar�pa and i'a 10_ Pomsat privet ON Do* D v `'L rnv r s iioiR. tuft w 'CE—t% 8 v N R J tat# l ftft* l &AdNmw or C9 pp E oufte Wrom Nwood ftm d 1�tt,�►te�n�j, o f � /S K— 3 c c 'f"h S r l ' t "Cbvbuoson tta io F*& low OPi1 Rio' 0 Q l'aitiaaraetaarMaM - plrtitaaatwY --p fiooaFIMM .i.►xappf�. e � J ct 9oi llvitoe OaMa Danirtnt IN Ion tconcooft taaArw tim Maws/ QA 8t OWL Calm QL 8L W - /v r3 2 IS th , k mJ�r D r 51 r Xp /_- lz 2 — 4r 2” s Q0 9 OWauadantao.aan► 2_ R 1i lath iaNpr // i r. aew.ea oaplA Dbw t:., gadaicfaa.ofpMen Ti aar allol000s tiotafalass.9oaaain„ NaaUt op w h t/rrrn! QIL &L Gant COW Or. SL OL 'fit 'BlN2 8� s 3 I/z vm I 1. L r mo th . 301 Tas P l W OOL " TA rD �ew6wwon" ir l 9�9 lt7s'' — /a s(6- _5/ _5-5 ■ r tu A4# t s /a6 r--1 /D" n t I c? i F EZ1 203H vsovovv r- 19 V V V w v V W ••ma ( t .• h •• , h .• O O W W W O O V POw000v VVVOwvv �� vvv L 4 " VV• tl Vvvw , t '' ' vvwT. 24 „ vvv O V Pev vvP vv♦ PWO 4.625" V V V wwv v w o vvv '1 1/2 Circ. = 18.84" wwIV wvw. WVw ovv w VWwOVV VV VWwV VWO'0 WW WV v w .O WwOOw.♦ ♦w7PV VWVOVOw vvvvvvv VVwwvwO WVWWOVOV.VOVVWV WwWOVVP ♦VVVVWO: ♦ VVPW WWOw O.v WVww ♦WV VOwV 2411 _ A Bottom 36 Void Volume Soil Interface Area .in. Ig�4: Void Coefficient in Aggregate given at 57.484. Sidewall (2 Sidewalls) 2 18.84in _ 1241 - 3.14 O.D. of 4" pipe = 4,625 inches _ IR Void volume per linear ft 2.3125in 12inlfl 3.14 • t 11 —1.117 ft' Bottom 2.00 ` O.D. of center cylinder =172,5 inches 11 Total Soil Interface Area 5.14 SQ.FT Void volume in aggregate of center cylinder - 3.14 • 6.25in 3.14 . ( 2.3125f. 1 .,574 -.422 ft' 12ur 1 ft, — 12in J fr �= O.D. of outside cylinders =l2 inches Projected Trench Area Void volume in outside cylinders - 2.3.14( clot .. 574-.901 Sidewall Height = 12 in. "2 = 2.00 Sq.FI. 12in / ft 901 ft Bottom = 36 in. = 3.00 Sq.Ft. Void volume at bottom between cylinders - ( 24in • 6m b m 12in/ft 12in /ft) (3'14(12inift) )] =0.215 ft' Projected Trench Area = 5.00 Sia.Ft. Void volume at outside bottom corners (1/2 of void volume between cylinders) 0.215 12 - 0.log ft' Total void volume — 0.1 17 + 0.422 + 0901 + 0.215 + 0.108 = 1.763 cubic ft / ft Gallons per ft - 1.763 X 7 -48 — 13.2 eallons ner linear ft It 1' X f t) EPS Aggregate Trench System EZ1203H EZ,,flow Ring - industrial Group 65 Industrial Park Rd. Oakland, TM .18060 SCALE nLE NAAdt?: EZ1203H —vsl SHEEr. 1 of 1 11 -27 -01 -�s DEICA MINT MO. WAF RAMY OM Me SF"x ataiRYto Von "VA iTATit "I Of WIBMNSIN Faint : � Uft { 7 _ • 1 �yrr� / James H. Johnson and Glen E. Johnson, aka Glen %e4L for %mwd ob 7th 'd'?i1fL'ittf8ii� 'iii "�et�iiifiti• 'iii . ............... � - •'"*"'� .................. .................. ............ Nov ................... .................................................................................. ............................... 8s90 A ... Douglas rB and ......Re... Ye ew"ye and warrants x> ,... v� b ► .. xad..yrlfe�..... as.. maxi .till...Rr "zt�t1.. Vi tt .. rights --- Q9 .. SUrVIVQ 4ahipR............................................. r .................................................... ............................... ........................... RsTUnM ♦e ................................................. ...... the following described real estate in ........St..-. "Croix ......... . . . . .. ...County, state of Wisconsin: Ta: Parcel No: .............................. Lot. One (1), Johnson & Associate's First Addition to the Tbwn of Star Prairie, AND � ca mxdng at the South querter corner of Section Twelve (12), Township Thirty -cue (3f) North, Range Eighteen (18) West; thence Plorth 00 Al' 56 East (assured bearing) along the West line of the Southeast Quarter (SEW of said Section Twelve (12), 979 feet; thence South 89 07' 38 East, 497.00 feet to the Point of Beginning; thence xxmtinuing South 89" 07' 38 East, 333.00 feet; thence South 00° 41' 56' West, 66.00 feet; thence North 89 07" 38 West, 333.00 feet; thence North 00° 41' 56 East, 66.00 feet to the Point of Beginning, TOGMUM WrrH an Easement for ingress and efress over a private street, designated as Outlot One (1), private street, in Johnson & Associate's First Addition to the Toni of Star Prairie, and SMMM to ail.- de-sac easement at the North end of outlot One, private street, as shown on map of said Johnson & Associate's First Addition. This deed is executed solely for the purpose of fulfilling that certain Ladd contract between the parties hereof dated May 17, 1986, recorded May 29, 1986, in Volume - 741 - , page 390, as Document No. 412604, and for correcting the description contained therein. This A s ... not •......_...._ homestead property. FE tai iu ) 't� � ,- � , � p Exception to warranties: v11y+1�B<" i this ............ t --- -- - _--•• - -_ ......... day of - - - - - -- October - - -- ------------ ------- - - - - -- ............. 19.8b... l y . ....... ..- -•---. ......(SEAL) / ........(SEAL) James H. Jo on Glen E. Johnson .. ... .. ....................................... .__ .---- ...... - - - - -- ........... II ...---.(SEAL) ......._ ........ .. .. ................ .........................(SEAL) • I i i AUTHBNTICATION ACENOWLBDGMZNT If !lignatare(s) - - -- STATE OF WISCONSIN l! ------------------------- • - - - -- - - - - -- --------------------------------------- St. Croix County. ss. audwa eaWl this -------- day of------------------- ------ -- 19 ------ Personally came before me this ..ls ...... of October . ... .... ...... 19_$k-.. the above namc-d ............ _ ................................... ..... ......... •---- ............ James H. Johnson and Glen E. Johnson e TITLE: YBYBER STATE BAR OF WISCONSIN °• ... .. ...............,,r.'_'�AlE7SI ' mo�ett,,, - .- • ----- aothoriasd by 1 706.06, Wig Stata) to me known to be the person -- S __i, the • foreqing instrument d poknowledgif rNla INSTRUMENT WAS DRAFTED aY � • �D�J : - s Reinstra, Van Dyk & Needham, S.C. ` ... -- r 1 J v ✓. �. ' E AttBf`li' 4sj� 'fit " "I�31' ....... .. ...... ...... .�_. .Tan a L Glaser._... •-- - - -... :.,..'. �...... New.. Richmond....lili.acon ain. ....5�4t)1? Not, Pnblie ._ St_. Cro . ix roanc� W • ?. (signatures may be authenticated or acknowledged. Both My Commission u permanent. (If not, state ez rdtion an act necessary.) 4- .°i 87 date: .-- -- ••------ ...•--- -- - ••- - - - -........................... 19---.. -...) { i at ..tom .r'abes In sal ester - sbould be {ypod or printed below Ukjr tigAi Wrm. .. WATU U." OW WISCONSM ` P J 0 H N S O W 0 C ATE FIR Low co nw U Ur_ r 0 � rt ' S r '` V *�� • • �Q � . ., 8 10 K A09 a t) - - I� ltia +U S 89'- 07138' E 830.00' OUTLOT ? -- FUTURE PRIVATE 1 37 ET , 1.258 - } Y -s'� • nos Ss E as..00 - • - -a000 -r- �\ a . x �t 1 - C BD'LO't• -3f E 70000' . ' {. r' + ,.s i S 6aW9= '�T•E\ , ti - L TEM PORARY -- - - o ; CUL ..._r f wI .p .:, k • 'V ;' �` , 33• 1 % TO BE REMOVEDUPOK - Q THE E+TENBW Of ,� ME FUTURE STREET 10 9 ' + Lt�# r �` a lat A. = L • I .377 A. LVl A.' c' p 1 c- ' J S P•--�• 1 1 . l. 21a.D--------- I L ---- _----- 2SO. OO' 1 �..1 3r _..______.__3�:OD._ -___ - r 'f•iK0T -3S "X44:00 a ..k . S ( • N I. a12 A. H O '�.il.���• �,� $-•fit W161aAia llETMIWI _ • 1 T ; _ s• � - y 1..,� :.303 A. 1 " ` ~t• 4'- -" - f_Q9!.OY.. Sb - E_ _ a - �. Jr a 77r _ ����..�� ., 1 C $ 4ti'• - -- •SOO.OD------ n < t�• / , r Q 1.543 A. q , • c 1•ii7 • .� 5 ,,at Iw�af••oo• - ... C x. „ I r_______ S.6L i O. ­1F ' - '7' ; l� K � -' .i • d t a � - Ita:lO• � - -- - -_ -- -- 22b- 60' -__' �' ��E. � ^ ,� ' _ S_sfSo7 sf _c _ _ -- _- / • •% a. ''—• 6• QvP. .-� �.. / /,, . c � '. `• M .y''. - '1444 _ ` 1»�sf •p� (D !3 STL I`O�u'•a0'• u99 A = 1.263 A ~ �,; •�� 1 -_: '; •. r •.. ».. w K' 2aa.00 a' 22000 -- pY'Lp7:3a - E. 300.00'n i6.00 fD3F07: SC 1/a St -E a6a.00' « ........... LEOICATED TO r � SOUi LI � » THE- PUBLIC N 89*-OT -'38 W . 830.00'..... R084.. ... ". .....3 .................�.... .�: LOCATION SKETCH CURVE DATA TAO LE CURVE LOT RAOB CNORO CHORD CENTRAL TlNG L1.7 W » NO I NO LENGTH LENGTH HEARING I ANGLE BEARING C) 1 c 0 0 / � 0 f 2[ 0 ° 2 E� \ ro S = - , 3 . & + _ e » } ° 2 k ) \ / 2 k k \ l ƒ \ -4 S E E 2 g '\ 6 m/ 2 40 to g c a © 2 @ * ƒ 2 E C . CD � " a 7 7 CD ® \ 2 ? §, \ i mp � \ e - : S� z ; 2 7 2 1§ E r E 2 ƒ k k k \ ¥ . 7 ! CA ■ CA �: 2 & § m v @ -, . ' n \ ^ k / z R z z § co o 2 / 0 2 % § . & 7 , a ! . . ` 2 f c { ./ O t cl) \ \ , § k 2 / _ C _ � � ■ � / E : R � [ . 2 ¥ . I £ } ~ CA) # . § /E± ® f /} � \\\\ , - ;oz A r . . / @m EqEL C D a { = I ƒ CL 2 Vm j % 03 A §CD aZ & \ CQ � / � § - o § ! \ CL \ � Form- S T C 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP S`f4"r V` SEC. �.�, T _&N -R /,PW ADDRESS Or> J ST. CROIX COUNTY, WISCONSIN LL) ,yC SUBDIVISION J6 h MW LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 0 3 e J3 � Apo INDICATE NORTH ARROW l�Yk /SD BENCHMARK: Describe the vertical reference point used s15' C0rYN4r S7o,k Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: P Pp iquid Capacity: 04 M R Number of rings used:_ Tank manhole cover elevation: ZiQ /, 7 Tank Inlet Elevation:- Tank Outlet Elevation: Number of feet from nearest Road: Front,RSideoRear, O feet From nearest property line Front, 0 Side, 0Rear, O Ido feet Numbed` of feet from: well ,,T , building: - 3( y (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE i 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, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width: L a Length: S z Number of Lines: OZ Area Built:' Fill depth to to of pipe: z P P Number of feet from nearest property line: Front, © Side, O Rear,0 Ft. _ Number of feet from well: _NgLi Number of feet from building: �3 , (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion 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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: I Alarm Manufacturer: Inspector: Dated: .. a Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 SW,SE, S12, T31NOR18W )M CONVENTIONAL 1:1 ALTERNATIVE State Plan I.D. Number: (lf assigned) Town of Star Prairie ❑ Holding Tank El in-Ground Pressure El Mound Lot 1 Johnson NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: D oug Meyers Route 5, New Richmond, WI 54017 —! I — V BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV: CST REF. PT. ELEV.: Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: Calvin Powers, Jr. 1563 St. Croix 92477 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: [11 YES ONO DYES ❑NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET OYES ONO ❑YES ED NO NEAREST DOSING CHAMBER: MANUFACTURER'. BEDDING: I LIQUIDCAPACITY. PUMP MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ONO ❑YES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. V N LE FRESH (DIFFERENCE BETWEEN FEET FRO AIR I NLET PUMP ON AND OFF) DYES 0 N NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING 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: LENGTH: NO. F DISTR. PIPE SPACING. COVER INSIDE DIA. SPITS LIQUID BED /TRENCH TRENCHES MATERIAL• PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL. TING . V NT TO FRESH BELOW PIPES. ABOVE COVER: ELEV. INLET. ELEV, END. PIPES: FEET FROM LINE. AIR INLET. NEAREST- 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. 1:1 YES El NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS El YES 1:1 NO 1:1 YES ONO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CENTER. EDGES: DYES ❑NO 1 ❑YES ❑NO DYES ONO 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 MANIFOLD MATERIAL. NO. DI STH DISTR. PIPE DISTHIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV.. ELEV.: DIA.: ELEV.. PIPES DIA.. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS CAL LIFT CORRESPONDS TO APPROVED OYES ONO 1 1:1 YES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY W FEET FROM LINE: _� OYES ❑NO ❑YES NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. TITLE DILHR SBD 6710 (R. 01/82) SIGNATURE: Zoning Administrator Thomas C. Nelson SANITARY PERMIT APPLICATION COUNTY I�I DILHR In accord with ILHR 83.05, Wis. Adm. Code STAT ANITARY PERMIT # �• ya y > —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 )X NO PROPERTY OWNER PROPERTY LOCATION '/4 % 4, S T , N, R lit (or)� 3az PROP f RTY OWN R'S MATILING ADDRESS LOT NUMBER BLOCK MBER SUBDI IS ION NAME Cl Y, STA ZIP CODE PHONE NUMBER EJ CITY NEAREST ROAD, LAK R LANDMARK / VILLAGE : / TOWN OF II. TYPE OF BUILDING OR USE SERVED: /M O "lllQ/ /&1 0 0 a Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check ## 2,3 or 4, if applicable) 1. a. 0 New 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. ® Conventional 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. V seepage Bed b. ❑ seepage Trench c. ❑ seepage Pit 2, PERCOLATION RATE 3, ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): °? °� Feet Private ❑Joint []Public ,8.9 zytz VI. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New xisting Gallons ## Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank zoo Lift Pump Tank/Siphon Chamber VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of tqgprivate sewage system shown on the attached plans. P 7 Name (P ' ty P= (No amps) MP /MPRSW No.: Business Phone Number: S um is Address ( treet, Ci , S te, Zip Code): Name of Desi ner: VIII. SOIL TEST INFORMATION Cert 'ed it Tester T) Name t CST # C ADDRESS ( treet, City, S te, Zip Code) Phone Number: 3 I X. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) ® Approved ❑Owner Given Initial IU C J i c) S h�a Fee 1 _ 7�6i /,,'r,,, U V O�' �) 7 7� � ✓�'�"�'I Adverse Determination rrytC� X. COMMENTS /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, 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. The septic tank(s) should be pumped by a licensed pumper whenever necessary usually every 2 to 3 years; 61 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; 11 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'h x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; dosing or pumping chambers; 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. ----------------------------------------------------------------------------------------------------------- - - - - -- 11 ------------------------ — ----------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commoniy known as the groundwater protection law. This change in statutes was hE. ^" result of ever 2 years of steady negwi ation and public debate. The groundwater b'll Wound ter included the creation of surcharges (tees] for a number o? regulated practices which 1Nisco in'S e an effeci groundwater. The surcharc° took effect on July 1, 1984 All o€ the water ha buried fe35►IrB -, used iri your building is returned t. the groundwate, th oug`) your soil a_bsorp ic.n to s,;rstern or the disposal site used by your holding tank pur,7per. ion:es tt,=_ th� Se ­irC.arges are credited t-, th g,ounc'water f_;nd adminis PIe bN: Ie epartnien if Nc3tur , Fs 1so. rce.. These fun•ls a =e a ed fo r mare *rr t u F lw_31er contarninatlG. i ir'. est gat.7ns and establi5llmr ; ,1 i ii t;4 .dat rls .,s v.�__rt1 pro tecting. D -E , 9,? i D° 36) APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, ( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property Location of Property Section , T _,Zj_ N -R W Township l "�,� ?�Ss`•4iaP >� s Mailing Address Address of Site _ Subdivision Name Lot Number / Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume .>" Li 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 (We) centi.6y that att. Atatements on this ohm aAe tAue to the best o6 my (o knowledge; that I (we) am (ane) the owneA (,s o 6 the pnopen ty du n i.bed in .th,i,a .en6o4mati.on 6onm, by vi tue o6 a waAAanty eed neconded in the 066ice o6 the County RegisteA o6 Deeds ass Uoeument No. ; and that I (We) pneaentey own th p1topo&ed 6 to bon the bewage di6po6 byes em (on I (we) have obtained an easement, to nun with the above deAcAi..bed ptopwq, bon the eon6tAucti.on 06 eai.d &y &tem, and the dame hae been duty neconded in the 066ice o6 the County Regi6teA o6 Deed& , a§ voeamen t No. ) , SIGMA 0 ER SIGNATURE OF CO -OWNER (IF APPLICABLE) 3 DATE SIGN DATE SIGNED L ' DOCUMENT NO.. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 - - -_. ' 9c�82 .. -_ .- .. B I 5 �PAGE V1 _ RFMS S OF HCE ST. CROIX CO., WI& James H. Johnson and Glen E. Johnson, aka Glen Recd. for Record this 7th -------------- •- •-- ••-- •- •......- •- - - -... " "teriaii "ts - - - iri "- common day of Nov gyp 1986 --------"-.....-"-"---------------------------"-------"--------- • "--- •-------- ••---- ••..... ............. t 8 : 30 A ------------------ - " - - -- -"------"------"------------"--"------------•"•---.....-••---......-•-•--•-••••••-- convey and warrants to .... R . Meyers___ and _ C L indy__._ Mey_ers.,___ husband _ and__ wife ,_ -. as -- marital- ..proPerty,___ V with - ..rights_ of. "- survivor$ hip ................................................ .................................__........._..._ .-- ............._..-- ....... - -_ ....... RETURN TO -1 - - - -- ---------"•------•--" " ".----------------- ........... .. -- . ---- ...--- •- •-- • - - - - -- ........... i ... _ ..... _ ---- _ the following described real estate in -------- St.-- X roix ..................County, State of Wisconsin: Tax Parcel No: ------------------------------ Lot One (1), Johnson & Associate's First Addition to the Town of Star Prairie, AND commencing at the South quarter corner of Section Twelve (12), Township Thirty (3f) j North, Range Eighteen (18) West; thence North 00 41' 56" East (assumed bearing) along the West line of the Southeast Quarter (SE4) of said Section Twelve (12), 979 feet; thence South 89° 07' 38" East,,497.00-feet to the Point of Beginning; thence.continuing j South 89 07' 38 East, 333.00 feet; thence South 00° 41' 56" West, 66.00 feet; thencd y North 89 07' 38" West, 333.00 feet; thence North 00 41' 56" East, 66.00 feet to the Point of Beginning, 'TOGETHER WITH an Easement for ingress and eEress over a private street, designated as Outlot One (1), private street, in Johnson & Associate's First I� Addition to the Town of Star Prairie, and SUBJECT to cul- de-sac easement at the North end of Outlot One, private street, as shown on map of said Johnson & Associate's First Addition. This deed is executed solely for the purpose of fulfilling that certain land contract between the parties hereof dated May 17, 1986, recorded May 29, 1986, in Volume "741 ", page 390, as Document No. 412604, and for correcting the description contained therein. This ls__ nOt_____________ homestead property. t 1� (is) (is not) ,y p Q�'� 10041 Exception to warranties: IRXE�' , ed this x S t day of Q CSabe Z 19.8 -6 ... --- - ----------- • -• - "- ............ ....................... (SEAL) -` -- ._ (SEAL) James H. Jo h on Glen E. Johnson ---•-•------------ --- ------ --- •-- -- •-- •--- ... - -- (SEAL) -------------- - --....... - - - - - -- ................................ -(SEAL) i �f AUTHENTICATION ACKNOWLEDGMENT Signature(s) _____________________________ ____________________ ___ __ _ _ _ _ __ STATE OF WISCONSIN - St. Croix ss. I .... ........................... County. 'j authenticated this -------- day of ............. ............ 19...... Personally came before me this .. 1St_ I �i y � y • - - - -- -day of October_________________ 19.86... the above named j ------• ------------------------------- - - - - -- James H. Johnson and Glen E. Johnson .............................•---------------"-----------------------....------ ------------------------------------------------------------------------------ TITLE: MEMBER STATE BAR OF WISCONSIN ............................................................... �t� l �' (If not, - -- - - -- - -- - --- --- authorized by § 706.06, Wis. Stats.) ' �'t ' "` Ii to me known to be the person -- ._._A. aEecu" the / foreg ing instrument d c nowledge Q � THIS INSTRUMENT WAS DRAFTED BY � einstra, Van Dyk & Needham, S.C. : -, s ,, L ttorifeys• at•- I;aw - - - -- ------------- •-------------------- - - - - -- Tan a - L. Glaser _ Croix Q 4 i w..Riphmond, _. Tdi scnns�i.n ___. 54D.11=012-7-- Notary Public --------- - St. Cro --- --------- ----- --- -- -- Wip. t Coant (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration re not necessary.) date- -------- - - - - -- 4-5- 18 ) l ea of persona signing in any capacity should be typed or printed below their signatures . STATE BAR OF WISCONSIN conlpnq� FORM No. 2 — 1982 Stock N o. 1 3002 H z H a ST C- 105 r H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z ty a H OWNER /BUYER ROUTE /BOX NUMBER Fire Number CITY /STATE �U,fi IaZi4aln h),t ZIP Z PROPERTY LOCATION: 'tf) 'k, 'k, Sectio , T / N, R Town of &he , St. Croix County, Subdivision 2 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. H 0 I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE "V 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. l DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS 19DUSTRY, DIVISION LA MADI BOR AND PERCOLATION TESTS ( P.O. BOX 7969 HUMAN.RELATIONS , \ / SON, WI 53707 (H63.090) & Chapter 145.045) LOCATION SECTION: � A �( TOWNSHIP /M TY: OUNTY: LOT NO.:BLK. O.: SUBDIVISION NAME: ZA) �'44 R'S BU ER'S NAME: AI ADORES S=ga.� Mae '��Vz'es USE DATES OBSER ATIONS MADE NO. BEDRMS.: COMMER IA DESCRIPTION: New (PROFILE DESCRIPTIONS: PERCOLATION TESTS: Za Residence ❑Replace ,� l l �r / � Co /�.2_ RATING: S= Site suitable for system U= Site unsuitable for system r ONVENTIONAL: MOUND: IN- GROUND - PRESSU SYSTE -IN -FILL OLDING TANK: RECOMMENDED SYSTEM: optional) ❑U ®S ❑U S DU RE: D S AU EIS U / DE If Percolation Tests are NOT re uire SIGN RATE Q I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, in Floodplain elevation: : PROFILE DESCRIPTIONS 555 BORING OT L DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IM, ELEVATION OBSERVED EST. GHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- Z Wk B- , B- - B- > - B- y FB- er PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL -MIN. PERIOD I PERIOD PERIOD3 PERIOD PER INCH P- s i P ? J *W16 4 P y� P- 4 P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are th hori- zontal and vertical elevation reference points and show their location on th , plot plan. Phow the surface elevation at all boring anon and t of land slope. SYS ELEVATION x _ 9 1 E - + 4 i �- tN 1 � r m.� �- - _ �. _. _ _ — - - -- -- - 8 _j 1 3 --.. E _ x I E € ....{�. � _ .. E... _ � ..... t _.„... _ � _ _ �,..._.._ ........., rte- }-"-..,.._, i ...... y........ v..e .�..�_.,._ I J _ F l f i E Q QQ I, the undersign d, hereby ertify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin dministrative Clode, and t at the data recorded and the location of the tests are correct to the best of my knowledge and belief. (pri t): TESTS WERE COMPLETED ON: SS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CS A URE: ION: Original and one copy to Local Authority, Property Owner and Soil Tester. 395 (R. 02/82) — OVER — i . INSTRUCTIONS FOR COMPLETING FORM 115 - S D - 61395 ' Y To be a complete and accurate sail test, your report must include: 1. Complete legal description; 2. The use section most clearly indicate whet her this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use falanned; 4, Is this a new or replacem snt system; S. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL. CONDITIONS; S. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; I. MAKE A LEGIBLE diagram accurately locating your test. locations. Drawing to scale is preferred- A separate sheet may be used if desired; 8. Make sm e your benchmark and vertical e+a nation wference point are clearly shown, and are permanent; 9- Cornplete all appropt"iate l:roxes as to dates, names, addresses, flood plain data, percolation test exemp- tion� ii appropttale; 10, If the information (such as flood plain, elevation) does not apply, place iN,A, in the appropriate box; 1 Sion the form and pidee your current address arYd your certification number; 12. Makes ieljih;e copi akld distribute as required- ALL SOIL TESTS 'N1UST BE FILED WITH THE LOCAL AUTHORITY kNITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st _. Slane (over 10") BR Bedrock cola ._ Co.3l'flo {3 10") SS Sawktomn gi" — Caravel (under 3 ") LS Liraesto€ o u s - -- S«r,d HGW - High `.3iwmdt ^.rater cs - C o. rse `sand Perc Pr r olati'O ; Rate E,, -_ l - ins; Sand Bldg .- B,jildinrt l> — I rar {Yy" Sand j ._ G €eater - l sl Sandy Loarn '; - Less Thar? « i — L.<sam - BEi -- i ;Io "rI 'sil Silt Loam BI ; "°Ia i Si11 Coy G; c; Cl ,, scl Sandy Clay Loat;a sic! S;!ty Clay Loam mot - !'v1 "!eti > :c - Srlty .,ray fff - fe�vv firic" faini i C _. Ci<;y t - €; -- C'i)raifYio1?, { ,ir:£; rI iEc,k d - d istinc t P - prominew HVk {L — High wit =:r Ifel, Six Iles ti.ra4 soil textcires surface iwater for lic,kiid evaste disposal BM Bench E../Jw o VRP — Vertical Reference Paint TO TFIF OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prioi Jo pe:rrnil issuance. A complete set of plans for the private sewage system and a ermit application must be su�Urnitted to the appiopriale local authority ti p p yin order to ohia €n a wn trait. The sanitary permit mk.Yst be obtained and posted prior to the start of any construction, yo k O AS T _ O /�ti9 6'eG O i t I its i i # Ad I A I PAGE OF SYS�en A(S Froth Air Inlets And Observation Pipe C�0-- Approved Vent Cop Mlnlmwn 12" ADOw �yo�7 Final Grade 20- 42" Above Pipe _ 4" Cost Iron To Final Grade Vent Pipe Mash May or Synthetic Covering win 2" AggregI Over PIP a –�' Distribution l °n — Tee Pipe 0 0 6" Aggregate Beneath Pipe Perforated Plpe Below Covpling Terminating At Bottom 01 System -- ��cJ..T SOIL FILL DISTRI13UTIOV.1 PIPE APPROVED $4WT4ETIC COVER ° ~— MATER OR 9" OF STRAW rCFh6GREGAlE OR MARSH Hky (o'OFJ2 -2 E G A T E ,, / ALE V. OF- �FE�T —.,. AGGR DIS rRIF�UTIOIJ PIPE TO BE AT LEAST 3(u INCHES BELOW ORIGIIJAL GRADE AMU AT LEASTZO INCHES BUT KIO MORE THA J 42 IUCHES BELOW FIAIAL GRADE MAXIMUM WrH OF EXcAVATIoo FRoM oRI &Way 6KA'DF- WILL BE IAI PuMmUM MET" OF EXCAVATIOW FRoM'CHl GRAPE WILL BE INCHES SIGIUED: Od" LICE►U5C Q0MBER: DATE: 110