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038-1084-95-002
o y O n 0 0:1 3 m c d o m m a m 0 v .. o c ID 1 CD z w o ul CD o o 0 0 0 0 o w C C) m o u, o I o v I � N) c O m w 0 m m v w O 1 fD N C N (A C) O. 0 CS K O_ O_ O fD cn o� No 1 a w cn m v ° A O O O 0 0 n (� � O. N O N N n y C O ►� �1�� O m N O �1 Sll U z D D e cn cn c\ n o O N O ,`.,, O N fl. !may 0- ;""' O N 3 .. C7 N 0 CD C 0 O OD OD O C A A .. Q N u eZ z 000 000- z 0o o N Z pp T 0 0 Wcr O O p o O .L CAD CD 7 A (D N z zo_oz z CC) z p N O O D o :3 O D o. 0 m O_ 0 -b CL cn - - 3 CO to CD Ch m m c c CD c m CD w n n CD CD cn o y D o N n z 3 o. z No co M co m m CL a '�° � z 0 3 0 3 A zl � .. o m 1 3 m 00 f/1 fll N A - N C I CD Xy Q CD CD a C CD CO 0 :3 .+ a G '! CD Z CD y O d d 0 C y CD C CD E3 u y CD 0 o ? z o C CD a m a � E N I rn � pr CO cr ( N O I d II O V ti O O CD CD H ' � O o 0 O (co O a I 0 0• I o a �, C) Fd w cn w a � coo z c (D n F) o rt rj) CO (D x z Fi) (D a H rt E o 0, n U) H r � H - rt ul (D o v (D 4- (D z O rt Ln N In F- 0 I N v 0o bHz v K W Lxi P) r• z K I r• � rn Cd (D r t=] K 00 v et+ o t p O :n rt H (D Cd O 0 r• N rt n r• n n O O O :3 C-4 N • rt an o �C rt w ;d K O W a n Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Buildirgg Division INSPECTION REPORT Sanitary Permit No: 453193 0 GENERAL INFORMATION (Ai'TACH T'J 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: Perry, Guy Star Prairie Township 038 - 1084 -95 -002 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 00 10 6u..Ja ' z ct:T % AA / 20.31.18.353D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark r r Beg Alt. BM S Aeration Bldg. Sewer i Holdi ng St/Ht Inlet ll l 1 St/Ht Outlet TANK SETBACK INFORMATION Z.�Z jol.$Z' TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 2 + 2S 2- I , Dt Bottom i Dosing Z� �} .� Header /Man. • JJ Z 1 , Aeration Dist. Pipe ;. 1Z. 1 67 Holding Bot. System set: PUMP /SIPHON INFORMATION Final Gra %f Manufacturer Manufacturer Demand St Cover•* I M Model Numb S-V-44"Z 95 i it 6 , TDH Lift Fric ' n Loss System Head T Ft V t Forcemain gth D ia. Dist. t - rZ11404 2 -0 2 ' 9 b 8' SOI SORPTION SYSTEM c+n& . r. Oftk ILENC Width , Length No. Of renches PIT DIMENSIONS No. Of Pits Inside Liquid Depth DIMENSIONS 3' -P !� •� , SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manuf ture nr INFORMATION CHAMBER OR i0 �Gr Type ystem: I t �t UNIT Model Numb f • 0 /1 DISTRIBUTION SYSTEM 1 ad / Distribution x Hole Size x Hole Spacing Vent to Air Intake It Pipe (s L Leng Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded 1 xx Mulched Bed/Trench Center Bed(rrench Edges Topsoil Yes i', No 'Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: kk /ZJO Inspection #2: Location: 2042 Cty. R . C Soiaerset, WI P4025 (NE 1/4 SE 1/4 20 T31 N R1 8W) NA Lot 2 P rcel o: 20. 1,18 353D 1.) Alt BM Description - 2) Bldg sewer length = Z 1 / I 1 2•as = 9 2 •�' - amount of cover = �' ' '� nn `i = ��• S 3. 3 -- -- -- ' revision Required? Yes y�No r side for additional informati6n. - - -- - — - R.3/97) Date Insepctors Signature \\ Cert. No. s���► �� Pte' .�„- 2'� �,�,,.'�� .Q.�2s • �� � � �J Safety and Buildings Division ' � ' t nb 201 W. Washington A vc.. P.O. Box 7162 �seons�n Madison, WI 53707 - 7162 antary Permit N umber (to be filled in by Co.) (608) 266 -3151 S 3 ` 1 3 Department of Commerce Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.2 1, Wis. Adm. Code, perso ,aJ infnrmar�_ P E ." d. - •. r _ ) r:25D may be used for secondary purposes Privac Law, s t Project Address (if different than ailing address) r ���°°� L� t� �� t „^ 1. ton Information —Please Print All Information Property Owner's Name Parcel # Block # Property Owner's Mailing Ad v( C)rF��C't Property Location Ad dress , o S • 3s3 City, State Zip Code Phone Number e r✓► 8 !` �� f l/� /` a� �/� Y 6 77/ T.�/ N R E o e o II. Type of Building (check all that apply) �— 11. + r S SM Number �7q I or 2 Family Dwelling - Number of Bedrooms ✓❑ Public /Commercial -Describe Use T ❑ State Owned - Describe Use C ❑City_ ❑Village ownship of 111. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System r Replacement System El Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Issu d B. ❑ Permit Renewal ❑ Permit Revision ; ❑ Change of ❑ Permit Transfer to New J / p Before Expiration t Plumber Owner Un,�n4l)n_ 2 6 1N'. T ' e of POWTS Sys . t m: (Check all that apply) y Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructe Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Leaching Chamber El Drip Line L1 Gravel-less Pipe ❑Other (explain) V. Dispersal/Treat ent Area Inf rtttation: D Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) i stem lev Lion 933 !-- VI. Tank Info Capacity in Total Number Manufacturer Prefab Site [eel Fiber Plas iC Gallons Gallons of Units /J C Crete Constructed Glass New Existing�.!�f( Tanks Tanks e'T ep or olding lank r Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Sign e r ^MP /MPRS Number Business Phone Numb/ -err Address (Street, City, State, tp Code) Vill. .ount /De artment Use Onl Sanitary Pe nit Fee (includes Groundwa Date sued / Issuin Age t Sigi t ( amps) pproved El Disapproved Surcharge Fee) � �� • i �j l � � El Owner Given Reason for Denial IX. Conditions of Approval /Reasons for Disapproval SYSTEM OWNER: 3. —3 j 1 Septic tank, effluent filter and ed dispersal cell must all be serviced / maintain as per management plan provided by plumber 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on palter not less than 81/2 x t I inches in size SBD -6398 (R. 0 /03) PLOT PLAN PROJECT Guv Perry ADDRESS 2042 Ctv Rd C Somerset Wi. 54025 NE 1/4 SE 1/4s 20 iT 31 N/R 18 Y W TOWN Star Prairie COUNTY ST. CROIX 5 -03 -04 BEDROOM 4 MPRS Byron Bird Jr. 2205 —DATE CONVENTIONAL XXXX A rade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 EX 800gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE [3 LOAD RATE .7 ABSORPTION AREA 900 # of chambers 30 BENCHMARK V.R.P. Top of basement apron ASSUME ELEVAT 100' ❑ BOREHOLE O WELL *H.R.P. Sameas BM Vent SYSTEM ELEVATION T- 1= 90.4T -2 =90.3 T -3 =90.1 >12 Of Bio Diffuser with Cove 31.1 ft A2 per chamber 6 " 34" Elevation 20' PL 4 bed house ex ex drainfeild s 10' Alt BM BN 18' 80' 45' st 60' Wel 1 O ob pipe 30' v Garage 0' Driveway B2 40' 20 95 B 1 B3 70' 5' 94' 125' V CoRdC PLOT PLAN PROJECT Guv Perry ADDRESS 2042 Ctv Rd C Somerset W. 54025 NE 1/4 SE 1 /4s 20 /T 31 N/R 18 w TOWN Star Prairie COUNTY ST. CROIX 5 -03 -04 BEDROOM 4 MPRS Byron Bird Jr. 220529 DATE CONVENTIONAL XXXX A rade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 EX 800gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE a LOAD RATE .7 ABSORPTION AREA 900 # of chambers 30 kk BENCHMARK V.R.P Top of basement apron ASSUME E 100' ❑ BOREHOLE O WELL *H.R.P. Sameas BM Vent SYSTEM ELEVATION T- 1= 90.4T -2 =90.3 T -3 =90.1 >12 Of Bio Diffuser with Cove 3 1. 1 ft ^2 per chamber 6 " Lor4 34" Elevation 20' PL 4 bed house ex ex drainfeild s 10' Alt BM B 18' 80' 45' A 60' Wel O ob pipe 30' Garage 50� Driveway 60' B2 Li , 20 95' B 1 B3 70' 5' 94' 125' Co Rd C PAID Vttoonsin Department of Commerce QIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. + I percent slope, scale or dimensions, north arro and l ocatio n an d distance to nearest road. 4g `1 �j l ` O Please Pr nt a /t4WbW@V*W Revie b Date Personal information you provide may be t red for secondary purposes (Privacy L w, s. 15.04 (1) (m)). � 1 b el Property Owner MAY i � 7 2004 Property Location � 'LA r �� �' Govt. Lot 1/4� 114 S Q T 3 N R ( E Property Owner's Mailifig Address. Lot # I Block # Subd. Name or CSW City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road i�� .� V,67711 ❑ New Construction Use: [2 / Number of bedrooms -�4'5— Code derived design flow rate e, , :: 7 � GPD eplacement ❑ Public or commercial - Describe: Parent material ��� i elood Plain elevation if applicable R General comments and recommendations: — Q Boring # Boring Pit Ground surface elev. 46? Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Descripticn Texture Structure Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 -�32 o = Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 loo -� �' y `' g. 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 Name Print) ignature CST Number Address to Evaluation Conducted Telephone Number i <���1 Property Owner c� �r� ` Parcel ID # Page of D Boring # oring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal 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► F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Appl ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W 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 1 30 mg& and TSS _5 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608- 2648777. SBD -8330 (R.07 /00) 1 Soil Test Plot Plan Profect Name 'Guy Perry Byron Bird-Jr. Address 2042 Co Rd C Somerset Wi. 54025 \ CSTM #60527 Lot Subdivision csm5/1413 Date /3 / 2004 County CROIX N E 1/4 1/4S T 3 1 N /F W Townshi Sta Pr Boring Q Well PL Property Line # Alt. BM top of sidewalk ,BM or VRP Assume Elevation 100 ft doo rway apron to basement System Elv T- 1 =90.4T-2=90.3T-3=90.1 H.R.P Same as BM 20' PL 4 bed house ex ex drainfeild s 10' Alt BM B 18' 80' 60' WeI Garage 50' Driveway B2 40' 20 95' BI B3 70' 5' 94' 125' CoRdC POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page / o FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity 6� ff ❑ NA l�1C �0 al Permit # /1 / Septic Tank Manufacturer /r> ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model d ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity al k V Estimated flow (average) al /day Pump Tank Manufacturer E Design flow (peak), (Estimated x 1.51 l kw al /day Pump Manufacturer NA Soil Application Rate * - al /day /ft2 Pump Model A 17 Standard Influent /Effluent Quality Monthly average* Pretreatment Unit A ats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD :_220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L � O- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 m L � A ❑ At -Grade ❑ Mound 1 ° Fecal Coliform (geometric mean) 5 fu /1 ✓ V m ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: 103 NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ earl 1(s) imu NA Pump out contents of tank(s) When combined sludge and scum equals one -t ' 3 t o ume ❑ NA Inspect dispersal cell(s) At least once every: ❑ onth(s (Maximum 3 years) ❑ NA yearls) Clean effluent filter At least once every: ❑ month(s) ❑ NA Rr - year(s) Inspect pump, pump controls &alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once eve ❑ mo year(s) ❑ NA P every: ❑ years) Other: At least once ever: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following 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 any ponding of effluent on the ground surface. The 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 (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page of C/ START UP AND OPERATION " For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. 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 Plumber 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 15 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 products; 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: • 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. • 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 re aired the following measures have been, or must be taken, to provide a code compliant r lace ent s stem: :-� P Y A lacement area has been evaluate nd may be utilized for the location of a replacement soil absorption system. The replacement areas ou a protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines 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. tThe si not been ev o identify a suitable �ee ment area. Upon failur POWTS a soil and site eva ation m st be rmed to loc e a suitable a ement area is avails a tank y be installs s a last resort to repace ai ed PO ❑ 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. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR 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 POWTS INSTALLER POWTS MAINTAINER Name rpm r y , Name Phone , Phone 71 SEPTAGE SERVICING OPERATOR (PUMPER LOCAL REGULATORY AUTHORITY Name yi �i y Name G!^o ♦ �� Phone l g Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. I ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the CA- �`� • ^ ` residence located at: Sec. T N, R_2 W, Town of St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes _,< No (if no, skip next line. Approximate volume or length of time: gallons Z ( !5) minutes Capacity: Construction: Prefab Concrete I> Steel Other Manufacturer (if known) : .e 2 Age of Tank (if known) : (Signat e) (Name )-' Please Print ' (Title)� -- (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - r (applying for sanitary permit) Plumbe (a ) Certification: PP Y g Y P In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle) . r Name Signature 4 � %/^b ^e'�� MP /MPRS s-� 2 � � ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer r u- l/ Y r^ Mailing Addres Tfi 1�el r , Property Address G� r Jam (Verification required frc tr Planning Department for new construction.) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location '/, ,Sec. T _:�IN R,W, Town of Subdivision / 3 , Lot # . Certified Survey Map # 3 �o , Volume 5 , Page # 3y/ Warranty Deed # Volume O Page # Spec house yes Lot lines identifiable es no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. 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 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 b the Department of Commerce and the Department of Natural Resources, State of Wisconsin. p P Y . Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Department within 30 ys of the thfr year expiration date. r/ / DATE / SIGNATURE O LICANT � OWNER CERTIFICATION Uwe certify tha I stater ne on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the property descri e, by v` of a warranty deed recorded in Register of Deeds Office SIGNAXGRE OF ICANT DATE * * * * ** Any information that is misrepresented 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 and a copy of the certified survey map if reference is made in the warranty deed. DOCUMENT NO. WARRANTY DEED ,N19 %PA..E RE cnvco FOR RE•_o RUING DATA STATE BAR OF WISCONSIN F04H 2 -1982 521964 v�� y�_- u-r =sL + , ii5i� i�,�::i $ - 51 a SIX Co., Yti1 Gordon E. Borawski and Margaret J. Borawski, j P=dPorRecord husbari'd'•arid...wife-.... _._ . - ._ -- _ .................... .• -- -- - -.... .. OCT 3 1994 ........ .. . ....... . . • .... ...... .. .................................._ ,.. ...... ........... - - - -- . 3t A s • oo a. M conveys and warrants to ...... Guy..J ....Pe.rr.y. .. and- MicheIle..?► .►ti ��f�+R.�GQ, ....._.Par.r.y,... husband.- and... wif. e ......... .......... .................. ............. a doaft - ................ ............ .......................... .. .... . ............................. ..... ..... .......... ............................... .......... ..... .......................... I........-- - - - - -- -- - - - -- --- ....... - - -- - -• -- - - -• v .. .. ....... . ................................... -...... .... ..................... __ ...... .. ........ ...... RETURN To ....................... ....... ...................................................... .:� ... - ............. A - ... ..... the following described real estate in ...... .! t . C Cr.. X ... Count State of Wisconsin: i Tax Parcel No: ..................... Part of the NE 1/4 of SE 1/4 of Section 20, Township 31 North, Range lF West, St. Croix County, Wisconsin, described as follows: j Lot 2 of Certified Survey Map filed April 17, 1984, in Vol. 11 page 1413, Doc. No. 392579. ' a j i This ...ls ..... ....... ..... ... homestead property. (is) UXANX Exception to warranties: E restrictions and rights -of -way of record, if any. , �I Dated this ........... ��Q .. ................_... day of ........ ..._. Sept mbe ... �....... er .. ----- ... - -- ... -_.. 19. 94 f ... . ....��Z��G. r--•- --•--(SEAL) ... . (SEAL) Gordon -. E ._..Borawski ................... . - Margaret J ,._,Bprawski I.......... .. ................. ............................... ........(SEAL) -- - ------ -- ---- - -- --- --- ................... . -- _(SEAL) �i 1 G A nQ*rnW T.tenQMSMT Z 396'U, jo r 3:32575 : o w° 'C N 0 8 00 1 O O Q Q r�0 �„ AP N ekC R1� N8 'tales coo 0 00 s o N8 OO° �w. % f u V c� ae s ok ° 2 v° o Irk o �r N � D O 0 3 No i � 2 Qtr O m a C n m to - v 2 N ;�o r i Form -STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP _ , y' % �Z I `'l c:_ SEC . � T N -R �S W ADDRESS L r E °�{,� r�_ , � ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT - LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of II-HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I � i d r v / INDICATE NORTH ARROW I J , 4• , L i 1_7 / r BENCHMARK: Describe the vertical reference point used .y! 4 Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: 4✓ e �` T! Liquid Capacity: /'� -& .% Number of rings used: Tank manhole cover elevation: 1�3 Tank Inlet Elevation: ` 4 Tank Outlet Elevation: 0 Number of feet from nearest Road: Front, Side,Q Rear, O Tr, feet From nearest-property line Front 1 0 Side 0Rear,O feet Number of feet from: well building: X 77 ' (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE RE VERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: /` Trench: Width: Length: Number of Lines: Area Built: :t Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, © Rear, Pt. /D Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT , o� 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, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: �� " Plumber on job: L , � License Number: 3/84:mj r DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS ON P.O. BOX & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMB DIVIS P.O. BOX 7969 MADISON, WI 53707 State Plan I.O. Number: NE�,SE %,S20,T31N -R18W CONVENTIONAL ALTERNATIVE ❑Hldi Tank Illassigned Town of Star Prairie Holding an ED Pressure ❑ Mound Lot 2 Coun INSPECTION DATE. NAME OF PERMIT HOLD R: 74 ESS OF PERMIT HOLDER: Gordon Boroski Cedar Street, Somerset, WI 54025 1)-&-2 )r ,3(? BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: j C5T REF. PT. ELEV. Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number. Byron Bird J.r I 3318 St. Croix SEPTIC TANK /HOLDING TANK: MANUFACTURER LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LAB L LOCKING COVER PROVIDED - . PROVIDED. w ` V too� ®YES ONO ❑YES WNO BEDDING. VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY W BUILDING. (VENT TO FRESH AL ARM FEET FROM LI O 4rtlC ( AIR INLET DYES KNO C C ^ OYES VNO NEAREST C' DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL. PUMP /SIPHON MANUFACTIRER WARNING LABEL J LOCK:NGCOVER PROVIDED. PROVDED. DYES ON [ ONO [ ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH LINE AIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) ❑YES ❑NO 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 the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. I LE G . NO. OF DISTR. PIPE SPACING COVER INSIDE DIA #PITS LIOUID BED /TRENCH TRENCHES / MA RIAL: j IT DEPTH DIMENSIONS �/ CO"` r GRAVEL DEPTH FILL DEPTH DISTR PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH BELOW P PE .. AB VE OV R ELEV INLET ELEV. END'. PIPES FEET FROM LINE y�/I AIR INLET 3 NEAREST IU ' N .4C) MOUND SYSTEM: Mound site plowed perp ndicular 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. DYES ❑NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES ONO DEPTH OVER TRENCH /BED 11111TH OVER TRENCH /BED =PSOIL I SODDID S EEDED MULCHED CENTER EDGES. ❑YES ❑NO I OYES ONO OYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING JGRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED /TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKIN6 ELEV.. ELEV. DIA. ELEV.' PIPES DIA.. ELEVATION AND DISTRIBUTION IN ION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED ❑YES NO J DYES ❑NO OMMENT PERMANENT MARKERS: J OBSERVATION WELLS. UMBER OF PROPERTY WELL: BUILDING'. FEET FROM LINE L1 YES [:]YES ❑NO NEA EST Cn VVI 1 r�� Sketch System on Retain in county file for audit. Reverse Side. DILHR SBD 6710 (R. 01/82) SIGNATURE TITLE Zoning Administrator I = Z a z ! sTATt SANITARY PERMIT APPLICATION COUNTY HR ' S In accord with ILHR 83.05, Wis. Adm. Code G SANI TARY PERMIT # . /off y gs —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 NJ NO PROPERTY OWNER , PROPERTY LOCATION C '/a — /a, S T , N, R E (or PROPERTY OWNER'S, AILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION AME Z-e_W41 1 :5 It C TY, STATE ZIP CODE PHONE NUMBER El CITY dqfAAEST ROW, LAKE OR LANDMARK 11--l- VILLAGE S7 If - t !! // II. TYPE OF BUILDING OR USE SERVED: 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. New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing Sys tem 2. ❑ A Sanitary Permit was previously issued. Permit ## Date Issued 3. ❑ An Existing Y P 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. ry Conventional b. El Alternative C. El 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. aSeepage Bed b. ❑ seepage Trench c. ❑ See a e 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): Q' P L- �✓ =A— Feet Private ❑Joint ❑ blic u VI. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank 10 - __�_ El El Lift Pump Tank/Siphon Chamber ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's S' nature: (No Stamps) �7 MP /MPRSW No.: Business Phone Number: PI s Address (Street, City, State, 1p Co ): Name of Designer: ! -e VIII. SOIL T ST INFO MATION Certified Soil Te er (CST) Name ` CST # CST's ADDR (Street, City, Sta e, ip Code) Phone Number: z sa-i .edd� Lc� ` UQ IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps) . �✓ v `� S rch a Fe Approved ❑Owner Given Initial )� 0 �} /7�� Adverse Determination tO C 7 � X. COMMENTS /REASONS FOR DISAPPROVAL: n h SBD- 63" .jfoE l9t)y 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. septic tank(s) should be pumped by a.licensed pumper whenever necessary, usually every2'to 3years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1 -6; VI. Tank information: Fill in the capacity of every new and /or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift /siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County /Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8' /z 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. --------------------------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984. 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bili -Groundia included the creation of surcharges (fees) for a number of regulated practices which Wiscon�irt'S a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. a The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD -6398 (R.03 /86) 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 _ a + IC Z � y Location of Property ��- - , Section 2-?1 , T -R W Township Mailing Address p Q C P A Ar Address of Site Subdivision Name .Lot Humber Previous Amer of Property � LC Total Size of Parcel Date Parcel was Created �, Z ) <} 7 a, Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes _ No Volum end Page Number �40 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 1 (Wel cmti.6y that dtt statementA on thin onm ane true to the best o6 my (oun) hnowtedge; that I (we) am (aloe) -the 0wnen(,sf 06 the pnopeJcty descAibed in thiA indohmation boron, by viAtue o6 a waAAan-ty 4 eed kecoAded in the 066.ice o6 the Count RegiAten o6 Deeds ass Document No. _; and that I (We) pheaentty own -the pnopoaed bite bon the sewage diLspoa aya em (0rc I (we) have obtained an Qd A"ent, to nun with the above dei chibed piopehty, don the conatnucti.on 06 aai eystem, and the same has been duty n.ecohded .tn .the 066.tce o6 the County Reg•caten o6 Veeda , ae Docment No. SIGNATURE OP OWNER SIGNATURE �OF CO -OWNER (IF APPLICABLE) 1o1a. IQ� DATE SIGNED I� DATE SIGNED I . `` DOCUMENT N o. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA I. STATE BAR OF WISCONSIN FORM 2-1982 i 431330 79.4 _- _ -- . __ - _ - va -- - - _: -- �_ __ RECASTERS OFFICE ! Urban Germain and Pauline Germain, husband and ST. Mix CO., wi& mod. Record thi 22nd - Wife - - - as �oirit tenants ------ • ---------------- • ------------ . ...... . -------- ..._...---------- ... I day q Oct ao . . 7 ......--- •••- •----- •- • - -•• -- : 8:30 A M jj conveys and warrants to _... 5? Q rdO II.. ,E.-... BO. ra3o1 .ski.._an.d ................... II .dames O I, Margaret. -J. Boxawski.,•-- husband .and ... wi- fe- ,--- as------------ mar i.tal..pxoperty., I ... ith. .rights-- of.•surv.ivor_ship•,..- •'t • --------------- •••--- ••••------ - - - - -- ------------- - -------- ••-• --------- ... ............ • ------ ••-•...... ._......--••-----...•••-••• ..............•••••--•-•--••-•-••-•----•.... ................- •- •--- •••••• -• .......... RETURN TO Ili ....................................... .. ........ . .... . ... ...- ............... .......... ... II ..... ........ . ............ .............................. ._.._ _ ! St. Croix the following described real . .. . .. estate ... .... ...... ....... ............ ........ ........................County, State of Wisconsin: II I' I� Tax Parcel No: .............................. !,l, �I i I, I !j Part of the Northeast Quarter of the Southeast Quarter (NEJ of SEA), Section Twenty (20), II Township Thirty -one (31) North, Range Eighteen (18) West described as follows: Lot Two (2) of Certified Survey Map filed April 17, 1984, in Volume "5" of Certified Survey Maps, �! I � page 1413, as Document No. 392579. !� ;� 41 •� 00 FT 'I I ! i I , ! This ..._ 1S not . homestead property. (is) (is not) I Exception to warranties: l I� Dated this ........... ......................... day of ......... QCtgber........................................... 19.. -87.. I ..__..._ (SEAL) (SEAL).. -.. I � Urban Germain Pauline Germain ............................... .................................. i _..-•-------•---•--•-•---••---••-•---•• .............••-----•..-•-- �I ......._.(SEAL) . . ... ............... ..._......._... .............................. (SEAL) I .....................--•-•--. ....- •--- -............-- •_....- I * . ............................... AUTHENTICATION ACKNOWLEDGMENT t I! STATE OF WISCONSIN ! Signature(s) ------------------------------------------------------------ as. I I j! ..---------•----- ---- --- ------ ------- - •-- -• -- -- -- ----- .._._-_..' 18...__. Personally came before _.._._._.. St.•_.`4r01-y•-- - -- --• -- County. 22 d- • - - -da II authenticated this .._.._._da y of ...................... . 19.. 8.Z. the above named me this . y of i October Ijrb�an ... Germain..and•._Pa uline - -. Germain ' ............................. ..................................... it TITLE: MEMBER STATE EAR OF WISCONSIN -•-•-----• ..............•-...---••--•-•-----••_.__ ...._.......__............_.... (If not. ............................................................ ----•---....•-••---••••••-•--•-----•........••••. .............._................ I authorized by § 706.06, Wis. Stats.) to me known to be the person S .......... who executed the. . foregoip instrument.9,4 acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY , I, f, I : .L�� Reinstra, Van Dyk & Needham, S.C. ' Att orneys at --- L aW ----------------------- •------------ - - - - -- * l 13uth..A.•-- J.Ohnssln_..... new .. Richmond .,...Wisconsin ----- 4- Q1.7-0127 Notary Public __ _..S_t_..._Croix-- ------------- County Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: .. - - -a 2 -/ 2 - 3 / • .. ......................... 19 ....... ) it i' *Names of persons sinning in any capacity should be typed or printed below their signntures. STATE SAR OF WISCONSIN Stack No. 13002 H z H a ST C- 105 r • a H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County z d a H OWNER /BUYER y- � P jiMc 4!s t NL!rCk Ck ROUTE /BOX NUMBER �l�Qj �2C1c�a/ Fire Number CITY/STATE � Sp�, c,r S� �- ��} j Z IP ;1 C) PROPERTY LOCATION: 14, SF k, Section 2 T �� N, R _ W, Town of �( , }��- �.� St. Croix County, Subdivision 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 m_ y be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 E 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 - u ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. c SIGNED DAT 97 St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 715- 796 -2239 or 715 -425 -8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: OWNSHIP /MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: /Y� 1 /4 5E 1 /4 azo /T N /P/f E (o �f�c�- COUNTY: OWNER'S /BUYER'S NAME: MAILING ADDRESS: SE DATES OBSERVATIONS MADE o2 q 7 36 d NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILED SCRIPTION PERCOLATION TESTS: Residence EXNew ❑Replace 7 � RATING: S= Site suitable for system U= Site unsuitable for system b CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) $ ❑U ❑$ � $ ❑� ❑$ 0 Z u / If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: G 3 Floodplain, indicate Floodplain elevation: 6 &-: / PROFILE DESCRIPTIONS BORING TOTAL LOEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 9 0�� � B- B- / - B- j�c PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER IMOW AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD P =R0 3 PER INCH P- P- K2 ¢� P- P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION V O N I o l J � a 1 - - - - _ _ E- E 3 o E Q f E m E o �� 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 Wis onsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (prin TESTS WERE COMPLETED ON: ADDRES : CERTIFICATION NUMBER: PHONE NUMBER (optional): t ZS d6 J �� CST SIGN TURE: Ao DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 10/83) — OVER — 1 INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 5395 . To be a complete and accurate soil test, your report must include, 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence of commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or repla€zement system; R. 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; FS. PLEASE use the alibicviations shown Mere for writing profile descriptions and completing the plot plan, 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; B. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; B. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10 If the information (such as flood plain, elevation) does not apply, place N.A. in the appiopi iat:e box; 11. Sian the form and place your current address and your cal tificat:ion number; 12. Make legible copies and distribute as required, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone. (over 10 ") BR - bedrock cob Cobble (3 - 10 ") SS Sandstone gr -- Gravel (under 3 ") LS - Limestone * s Sand HGW High Grouncivvater cs - Coarse Sand P €xrc - percolation Rata m€.>d s - Medium Sand W Well is - Fine Sand Bldg Building Is - Loamy Sand > - Greater Than *sl _. Sandy Loam < Less Than I - Loam Bn -._ Brawn siI _. Silt Loam BI - Black Silt Gy Gray cl Clay Loam Y - Yellow scl -- Sandy Clay Loam R Reef sicl - Silty Clay Loans rnot - Mottles sc -- Sandy Clay w." with sic - Silty Clay if - 'few, fins, faint * c Clay cc common, c7ai "s €', pt - Peat mrn - Many, medium rn - Muck d distinct p prominent HWL High water level, Six general sail textures surface water for liquid waste disposal BM - Bench Mark VRP Vertical Refe =rence Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. ' PLOT PLAN PR�pJECT C"� • "u�a�, rr �- �, - ADDRESS �+ 1/4 �1 /4 /S �r/T,�/ N /R/ W TOWN:�1�; - COUNTY MPRS Byron Bird Jr. 3318 DATE BEDROOM ';?- -CLASS PERC CONVENTIONAL,2 IN- GROUND PRE URE CONVENTIONAL LIFT_ MOUND_ HOLDING TANK SEPTIC TANK SIZE 1d- LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA _� PERC RATE BED SIZE IL Benchmark V.R.P. Assume Elev tion 100' � Location of Benchmark * H.R.P. r D c , l� Borehole Well Scale = Feet O Perc Hole bra S Elevation v TYPAR COV ERING 2» 12" 3' 4 g' Q 3' I 6„ Sewer a t 1�0 d, 1 3 g�e 4 -- - -- — - - _/ .a. V� 3 i