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Wisconsin Department of Commerce t PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division- INSPECTION REPORT sanitary Permit No: 399568 13 ,f ERAL 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)). I -� Permit Holder's Name: City Village X Township Parcel Tax No: Johnson, Dennis I Star Prairie Township 038 - 10$7 -80 -000 CST BM Elev: Insp. BM Elev: I BM Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (,�tJ ^ e :2 oD Benchmar Z • w v 6 , L Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet r-S &I r 9z .o TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic I 7 1 Dt Bottom Dosing Header /Man. Aeration Dist. Pipe n Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer emand St Cover G M Model Num TDH Lift on Loss System Head T Ft For ain Length Dia. ist. SOIL ABSORPTION SYSTEM v� SFOT RENCO Widt Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Dept . DIM 3 I I s 3 SETBACK SYSTEM TO /L JBLDG WELL LAKE /STREAM LEACHING Maw r r. INFORMATION CHAMBER OR 4Fti t pC Type Of System: I a / UNIT Mo I Number. -� DISTRIBUTION SYSTEM Header /Manifold � Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe 1 1-eng t h �' Dia L is Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes Fig] No [] Yes [] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection # L / ' / `JL (nspectiio #2: / Location: 2073 Cty Rd C Somerset, WI 54025 (NW 1/4 SW 114 31 T31N R18W N Pal °cel � � (\ .3-, 31.18.360D t f f "' 1.) Alt BM Description = S r • Z Q • st 2.) Bldg sewer length 9I r r �• f� • y'p 3� - amouryl of ver = i ..� � �,� e -�°� ; - 71 0 . 'R`(. 0 3 ` Q ► 2„ t 8 • �. 4. � kS �+. / � PI s4o e a Yes UU o er side or addi final ipform ( �)raa,_c.�ag ���� Data Insepctor's Signature Cert. No. U710 R 9 Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 1*6cons Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x I 1 inches in size. Coun State Sanitary Permit Number ❑ Check if revision to previous application State Plan I. D. Number l� 399-5(0 I. Application Information - Please Print all Information _ - - -. -- Location: Property Owner Name l Property Location ? /W \ �J7 5 �,� 1/ 1/4, SAI T3 / >N,►Z -�(, W Property. Owner's Mailing Address ,, •. ECEhIEO X umber Block Number Ll. 1 U City, State Zip Code Ph mbe , 7 " r, �qq S m ivision Name or CSM Number d Eji1 t -�- II. Type of Building: (check one); �� °Q ity ; ZON1NG0FFIC✓ 1 or 2 Family Dwelling - No. of Bedrooms: , . ; ` „ C Village of llage o ❑Public /Commercial (describe use):_ �� t,.� '' -. ; �; 167 ❑ State -Owned Nearest Road / -2 /xE_ l l / rr L �� t '' �`^ 5 ) arcel Tax Number(s) l0 T K III. Type of Per (Che only one box on line A. Check box on line B if applicable) . 3 ir .. A) 1. ❑ New 2. VcMeplacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System $) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) C% - ji�Non- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland Q, ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatme Area Inf ormation: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Ara 4. Soil Application 5. Percolation Rate 6. Sy m Elevation 7. Final Grade Required Proposed Rate,(Gals. /day /sq. ft.) (Min. /inch) _ Elevation C VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks, Con- Con- glass New Existing crete structed Tanks Tanks i }} 1 'i � ❑ ❑ ❑ E) 7/ ❑ ❑ ❑ ❑ ❑ I VIII. Responsibility Statement 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): MP/MPRS No. Business Phone Number Pl is Address (Street, City, State, Zip Co e y �-r IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse Surch a Fee) dD Determination �S• / //O T/., X. Conditions of Approval /Reasons for Disa proval• II 't � �-- �� fie. � c,�•✓', (,>-t�1�. �. ( 5 S-(e -'�„� ed �8 �a Qo�s 4aA& - `CPA. t s L, - V J JtAur - tie. (our s s� - S 6�RN,, �w-t Hn rtC� PLOT PLAN PROJECT Dennis Johnson ADDRESS 2073 Co. Rd C NewRichmond Wi. 0 /64017 NW 114 SW 1 14S 21 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX At t2ade CONVENTIONAL 10 -25 -01 4 MPRS Byron Bird Jr . 2205 DATE BEDROOM CONVENTIONAL XXX LIFT HOLDING TANK I MOUND SEPTIC TANK SIZE 1260 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 0 LOAD RATE 1.2 ABSORPTION AREA 500 # of chambers 30 IL BENCHMARK V.R.P base of sideing ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. same as BM k699 SYSTEM ELEVATION T- 1= 90AT- 2 =89.6T -3 =89.1 T-4=88.6 f idewinder High Of apacity Leaching # Alt BM Elv 97.6 base of deck post C ove hamber with 17.2 t ^2 per chamber Long 34" Elevation PL75' 93' 30' i Ob pipe 20' _ 4 5 , 0' 20' 65 62:5 PL Apple ver 3 ' existing drain field 12`X54' st 125' septic to be 5 — new - 1 I removed st adition 22' ence #a!tB � 15' deck 4 bed house 46' 40' 3g'�ge driveway 36' PLOT PLAN PROJECT Dennis Johnson ADDRESS 2073 Co. Rd C NewRichmond Wi. 0 /64017 NW 1/4 SW 1 /4S 21 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX 4M-Grade 10 -25 -01 4 MPRS Byron Bird Jr. 2205 DATE BEDROOM CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 0 LOAD RATE 1.2 ABSORPTION AREA 500 # of chambers 30 BENCHMARK V.R.P. base of sideing ASSUME ELEVATION 100' ❑ BOREHOLE O WELL 1H.R.P. same as BM Vent SYSTEM ELEVATION T -1 =90.1 T- 2= 89.6T -3 =89.1 T -4 =88.6 AT' Sidewinder High Capacity Leaching # Alt BM Elv 97.6 base of deck post Chamber with 17.2 6 99 t ^2 per chamber lop Grade at System Long 34" Elevation PL75' 93' 30' Ob pipe 20' 4 30' 20' 65' 62.5 PL Apple ver 3 existing drain field 12`X54' st 125' septic to be 5 — new 7 ence removed st adition 22' #altB 15' 1 deck 4 bed house 46' garage 20' N "- 40' 38' driveway 36' Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County S . G� o �� X Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. — !� 5 print all information e ' wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner ,r? / Property Location Govt. Lot (J 1/4 /4 Sa( T N R l E (o WV Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 0 7 -5 G� City State Zip Code Phone Number City ❑ Village XTown Nearest Road ❑ New Construction Use: Residential / Number of bedrooms Code derived design flow rate 455�2d GPD [ J Replacement ❑l Public or c mmercial -Describe: Parent material Flood Plain elevation if ap c General comments and recommendations: RCCEI` EO F_/1 Borin Boring # ❑ g A� �' �i �GOFFICE ,� Pit Ground surface elev. / ft. Depth to limiting factor -- I? oil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence oy/ndary r?n GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 a� s 7 D Boring # �- q� � Boring 1Q Pit Ground surface elev. ft. Depth to limiting facto in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 7 * 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 (Please Print) , Sign re CST Number Address Date Evaluation Conducted Telephone Number ,V7 le SBD -8330 (R07/00) Property Owner JN ;', t- Te-xg Parcel ID # Page of ❑ Boring # Boring / Pit Ground surface elev. 9l � ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft f in. Munsell Qu. Sz. Cont. Color L / Gr. Sz. Sh. / *Eff#1 'Eff#2 ► ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 E] Boring Boring # Ground surface elev. ft. Depth to limiting factor in. F D Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R.07 /00) Soil Test Plot Plan Project Name Dennis Johnson Byro ird Jr. Address 2073 Co. Rd. C NewRichmond Wi. 54 CST #220527 Lot Subdivision Date 10125/2001 County CROIX NW 1 /4 SW 1/4S21 T 3 1 N /R W Townshi Sta rPrairie FI Boring Q Well PL Property Line# Alt. BM base of deck post Elv 97.6 ,BM or VRP Assume Elevation 100 ft.base of sideing System Ely. T- 1= 901T -2 =89.6 H.R.P. T-3=89. 1 T-4=88.6 Same as BM PL 5' 93' 30' y 92' 20' 0' 60' 20' PL Apple ver 65 existing drain field 12`X54' 125' septic to be removed st adition ence 2J # 15' BM� deck 4 bed house 46' gage 20' well 40� 38' driveway T POWTS OWNER'S MANUAL ez MANAGEMEN PLAN ra of FILE INFORMATION Septic SPECIFICATIONS ..Owner � - . �`Jn Septic Tank Capacity 2.�f al ❑ NA Permit # Septic Tank Manufacturer c� [3 NA Effluent Filter Manufacturer ❑ NA DESIGN PARAMETERS �� ❑ NA Number of Bedrooms ❑ NA. Effluent Filter Model Number of Commercial Units ❑ NA Pump Tank Capacity gal L9�NA Estimated flow (average) gal /day Pump Tank Manufacturer m NA I Design flow (peak), (Estimated X 1.5) 6 aV gal /day Pump Manufacturer IS NA Soil Application Rate p. 7 gal/day/ft' Pump Model IS * Pretreatment Unit Monthly average* Quality ❑ Sand /Gravel Filter ❑ Peat Filter Fats, Oil a Grease (FOG) s30 mg/L ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODs) 5220 mg /L ❑ Disinfection ❑ Other: Total Suspended Solids ( TSS) 5_ 150 mg /L Manufacturer Pretreated Effluent Quality ' ❑ NA Monthly average* * Dispersal Cell(s) Biochemical Oxygen Demand (BODs) :530 mg/L „min- ground (gravity) ❑ In- ground (pressurized) Total Suspended Solids (TSS) s30 mg/L ❑ At -grade ❑ Mound Fecal Coliform (geometric mean) s10 cfu /100m1 ❑ Drip -line ❑Other: Maximum Effluent Particle Size A inch diameter * Values typical for domestic (non-commercial) wastewater and septic tank effluent * * Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Frequency Service Event inspect condition of tank(s) At least once every 3 ❑ months ❑ year(s) (Maxima S.) Pump out contents of tank(s) When combined sludge and scum equals one -third (Ys) of tank volume inspect dispersal cell(s) At least once every 73 E3 months ❑ year(s) (Maximum Clean effluent filter At least once every ) — ❑ months ' A year(s) Inspect pump, pump controls 8t:alarm At least once every ❑ months ❑ year(s) hkNA At least once every ❑ months ❑ year(s) )Q_NA Flush laterals and pressure test NA Other: At least once every ❑ months ❑ year(s) Other: At least once every ❑ months ❑ year(s) hNA MAINTENANCE iNSTRUCTIONS Mast inspections of tanks and dispersal cells shall be made b�aeodlviPdOuaas Maintalne� Septage Servi ing Operator. i Ta k inspection Plumber; Master Plumber Restricted Sewer, POWTS p must inducts a visual Inspection of the tank(s) to identify any m issi n g or onding of effluent on the ground surface dispersal i volume of combined sludge and scum and to check for any back up p cefl(s) shall be visuaily inspected to check the effluent l evels In the observation p i e failing t condition and requires immediate the ground surface. The ponding of effluent on the gr ound surface may indicate a notification of the local regulatory authority. entire When the combined accumulation of sludge and scum in any tank equ i and dispo of in accordance h vo NR 113, Vd scons contents of the tank shall be removed by a Septage Servicing Op Administrative Code. The servicing of effluent Biters, mechanical or pressurized zeds OhWTII be performed by a certified POWTS Maintainer.ny other maintenance or monitoring at intervals of 12 mon A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION • For new construction, prior to use of the POWTS check treatm r c Il o If high concent detect d have the con e ng products or oher that may impede the treatment process and/or damage the dispersal Ar rls ranlria ramovPd by a sentage servicIng operator prior to use, I I e z 7 70 aweN 11INOH1nV Abolv11M3b w3ol a 3dwnd) bol ado C)NDIAb3S 37YId3S auoyd au04d b3Nldl.Nlvw 51MOd. 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Jo) paau a41 ul IIns10 111M ca,it uiatu»tldaa mp imoud of ajnllrsl •s11am put .scull iol'asrronAt pasodoid put aululxa woa) r4)egix pallnbai AQ uodn pa2ujju1 aq iou pings put uopedujo.) put a�urg1mslp uw.g pavaiold aq pin04s tar tuawaxlda,i a41 waists uopdjosgt llos luawoMdaa t )o uopM) atp )o) p20211pn M Atw put pawnlena uaaq st4 race ivawa)t{dai a14mjm Y 0 :waists wawaxldai mIldwo) apo) a aplAojd oi'uaIM aq iSnw .ro'uaaq ane4 Wnsiaw 3u1µ0110) a43 pailedai aq louut) pul . slle) simod a43 )I NV'1d A:)N37Nl.LN07 •lehaipw pllos iaaul aa43oue )01ane.13 'ilos 41!M paliU ands D1oA An put panowaJ s.:an05 a1443 ao panowaJ pur pal AMa a411r4s n1d put quM Ile 1 3uldwnd ,atiy a •aotejado luIIW&S astldaS t dq )o posodslp J4 adoid put panowa i oq 11t4s slid put sJuei lie )o nualuo) 441 a •palms ssuluado adld pauopurgt ayi put paixuuomip aq 11c4s n1d put sNun of 3uldid Ilb' • MM OAPerWIWPV uISUOMM '££•£8 wuJO'J •40 431M aouellduao) ul pauopuegt Ala)es put Apadold si waists #411" WWI of U04µ aq 11e4s $dais 3u)µop0) atp a .)lA.ias)o ino uajri AiSuaurtwad sl ro/pur sl1eJ S.LMOd 041 u04M IN3w3rtoaNrrs�r •wNq aauayos Jabµ Puy !suoawn =140eu Auetlues :sapi.)l1saa :s•ionPola buliulyd sp lo :suolit.*)lpaw :sdtim %taw isappWa4 lastayl laugow ls2u1laad algriOm put i►ni) :1aieM (dwnd dwns) uleap uol3epuno) !lei 'numnump (s f tip . Irluap !timas3ap lsgems uonoa tswopuo) lsiin4 aiiairSID (sadint Ageq 'sopojgjwe :SIMOd ap )o a)!1 otp 1Uolold put axrcuuo)sad alp smoadum Am wt it Jolrµa IIIA Ali Uaoa) 3ulm*IM atp )o uopeulw1la Jo uop"pad •eut uopdiosgr pos spr•ul•ie jo punotu Aue )o adols uMop iaa) S 1 u1431µ ran a4t 'i5edtuo) jo cpMgP MIAW43e JO'Jano need jo aApp lou 04 •1114� jewdslp put %NUn Kano s313146A jod 10 aAllp Sou oa •jum dwnd a43 u1411µ slanal itLUJOU aJotsaJ m clomo.) dwnd go 3upetado Allenuew u1 islste of Jauiriuiew SIMOd JO Jagwnld a p ei um ao dwnd ivanli)a a4i of aaMod auijoisaj of aopd•imado suPntaS aatldaS t Aq pinouiw jun dwnd atii )o nU8gUO3 84) uo(ienils sltli plonr. 01 •wanlilo to a2u4oslp ax).tns ,w dn)ptq No ul llnsaj Rrw put 4s)psa cep 3uipeoljan0 'atop a3aq auo U1 (s)1101 lesJadsip 043 of pa2Je4-tslp aq IpM meMaistM smxa No p+um"i si iaMod uatiM •gaA*j .airjA431q JKWOu Mcit Ills Aew sjuei dwnd togrino jaMod Sulin4 •aseyins aApt.npiul Kp it uasoj) alt suoMipuoa lbs ua4M M30 iou 11e4s do unt wal _ —pled . l - ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer l ea Z Mailing Address .-Zo ,,;;; 3 4 :::�;2 Property Address �5_, a, 5, 7—' '2-_5' (Verification required from Planning Department for new construction) City/State Parcel Identification Number LEGAL DESCRIPTION Property Location //W " ` /., Sec. T,_N -R f L W, Town of Subdivision , Lot # Certified Survey Map # , Volume — , Page # Warranty Deed # _5�—JN �� �� . Volume i 33 . Page # 6) Spec house ❑ yes (V no Lot lines identifiable a yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mamrplumber, joumeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of, the three expiration date. r SIGNATURROF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the property descigibpd above, by virtue of a warranty deed recorded in Register of Deeds Office. --�- -- DATE SIGNATURE OF APPLICANT « « « « «« A information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** *« Include with this application; a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed t /O vv ppp STATE ILAR OF WISCONSIN FOIIM 2 - 1982 WARRANTY DEED .- DOCUMENT NO ST. CROIX CO., WI Robert A. Simpsm and Marrie J. Simpson. husband and wi fe, ± SEP 10 1996 9 A conveys and warrants to Donni iA_ Tcibng= and Cvnthla J. � •a•► tA�. . ii TMrta m, 11 al -grid and W tw- t ;t f _ f THIS SPACE RESERVED FOR RECORDING DATA t NAME AND RETURN j the idlowing described teat estate in St. Croig County f, r1'/ d JJ 77 ( ,I Stated Wisconsin: G i� tFER s 038 - 1087 - 80-000 ` PARCEL IDENTIFICATION NUMBER Part of S 1/2 of NS 1/4 of Section 21- T31N -RlSW; described as Wlows: Cotmaencina at the Northwest corner of the SW 1/4 of the NE 1/4 of Section 21- 31 -18; thence East on the North line of the S 1/2 of the N34 1/4 of said Section 21 for 1071.4 feet to the East Right of Way of Connty.Trunk - C•. hereinafter known as the place of Beginning; thence South 36 degrees 50 minutes West for 24.94 feet; thence Past parallel with the North line of the S 1/2 of the Tats 114 of said Section 21 for 595.57 feet; thence youth for 115 feet; thence East to the ltpple River; thence Northeasterly on the shore of the jj Apple River to the North line of the S 1/2 of NR 1/4 of said section 211 thence best on said worth line to the Fast Right of Way of Co't}aty Trunk "CO. the Place of Beginning. St. Croix County, Wisconsia. it i' This is homestead Property. (is) 1QOM Exception to warranties: Easements, restrictions and rights -of -way of record, if any. Dat this day of August 98 tAA (SEAL) FAL) • Robert A Marrie J. C 3 (SEAT.) (SEAL) t AUTHENTICATION ACKNOWLEDGMENT. + SigtatuK(s) State of Wisconsin, SL St. Croix Cou authenticated this day of , 19 Personally came bdom tae this a. &,. ti f Audu9t 19 96. the above named �i Robert I.. Sinjum and MLiMle J. Simpson. husband quad wife. TITLE: MEMBER STATE BAR OF WISCONSIN 'l ( not, authorized by §706.06, Wis. Staw) Was" to instr to be the who aaecuted the forep tg Not"y PnbUc THIS INSTRUMENT WAS DRAFTED BY State Lt OIIS�A u and ac sarne. Attorney Ristinat Ogiand da Poulin Hudson, WI 59016 Notary Public, St. Croix C0=y. W �{ (Signatures may be autheenticated or an that My commission is petTttat►ent. (If not, sate expiration date n ecessary.) It / 19 20Qa } �! • Names of persons signing in any capacity should by typed or prmred below their aywures. - I� STATE BAR OF WISCONSIN 'Mo. Law 8IK*Ca M z. WARRANTY DEED Foes Nu. 2 — 1992 MRVSLII a, i n N 0 0 N p 3-V n d r� o 3 ? !, 3 �1 �1. v � • F n o m m m o 02 o coo c� v, o w o Cll R 0.0 m M am m LnN o y N a p to 0) 0 w m ' v o CD m. aD - p n A a 0 r v f� l w CD r- c y y j o o �, 0 I � a o 0 .' C N N C N N O O 5'j A ° O N (A VA N m a W G a w (D (O O. n (0 (D n a o IW ; a IW 3 a°D z! CD O o a O Z n O A V CT O y m ° ° ° °3 N a°oa(Ooo' Nrrn o c C . CD rn rn l; M ° z 000 0 0 0 �l O ' •'► 91 r • Q � I ` d y d !Y IQ CL a y ` o — z , z z W z I _� o 0 D I D O ul � I O � O = Co fD O (D lD (D � • CD y .Z) y m o y CD (O N m O N c =r O C (D fD w ( •' D n a N a (i 3 d 3 3 7 CD CD N I � �o I �, o rt D a p A o I W M I W � CL C C Z A ;p 3 " 3 cn I m m v I g A I A m I w� CD a m CD C m I a o = ' �. C° T n N C N 61 C Q 0 d y N D y 3 t m Er Er I � I ( 0 N I CD ° a I I = j b CD CD N 0 0 0 0 N I ° o n CD a f ( Q) � N ' Q$ (n Pa 4J O� 3 •rl �4 O ro Pa CA 00 U ;p p i W z z' O t 00 1 O U'1 Ci cq h A H H O Ln H O cn H GO r-1 0.i ` '� • '��. •' A r z x (n U ! Form -STC -104 AS BUILT SANITARY SYSTEM REPORT OWNER � -Z,,e TOWNSHI 0 _ j,,�j SEC. T �/ N -RW ADDRES ST. CROIX COUNTY, WISCONSIN SUBDIVISION � X) LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 78� Wx�L f3,S INDICATE NORTH ARROW _j BENCHMARK: Describe the vertical reference point used 1 1 9 13lee Azi Elevation of vertical reference point: �)M Proposed slope at site: SEPTIC TANK: Manufacturer iquid Capacity: o mac/ 1 Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation:_ 3 Tank Outlet Elevation: Z6�Z J Number of feet from nearest Road.: Front,m Side,Q Rear, 0 feet : ,From nearest property line Front,O Side,O Rear, feet Number of feet from: well f , building: r , lude this information of the above plot plan)( Z're erence dimensions to septic tank) SEE REVERSE SIDE �� PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 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:-6.24��_ Fill depth to top of pipe: 3© Number of feet from nearest property line: Front, O Side, © Rear, ' ��� Number of feet from well: Number of feet from building: (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 I Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of.feet from nearest road: Alarm Manufacturer: _ Inspector: Dated: — Plumber on job: �ju,�, �Cd:!S l License Number: 3/84:mj 'AAA .DEPART -MENT QF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 - BUREAU OF PLUMBING MADISON, WI 53707 E � I � 7XONVENTIONAL ❑ALTERNATIVE Sta l.D. Numbec 111 assi9neA) ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound I � NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPE 10 ATE. Scott Neudecker Rt. 1, Somerset, WI 5 4025 BENCH MARK (Permanent reference Pmntl DESCRIBE IF DIFFERENT FROM PLAN: F. ELEV.: CST FEI PT. ELT. V SE NE, Section 21, T31N —R18W, Town of Star Prairie Nainr. of P)umber. J MPIMPRSW No County Sanitary Permit Numbe . Cal Powers 1563 St. Croix 83792 SEPTIC TANK /HOLDING TANK: MANUFACTURE LIQUID CAPACITY TANK INLET ELEV ITANK OUTLET ELEV. WARNING LABEL LOCKING COVER A� ./ PROVIDED PROVIDED j j A YES ONO ❑YES ❑NO BEDDING. VENT DIA. VENT MATL_ HIGH W ER NUMBER OF ROAD. PROPERTY WELL BUILDING VENT TO FHFSH �� ALARh1 FEET FROM /J� LINE / AIR INLET YES ONO DYES ❑NO NEAREST�� DOSING CHAMBER: MANUFACTURER BEDDING LIQUID CAPACITY PUMP MODEL PUMP: SIPHON MANUE AC TUREH WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. ❑YES ❑NO OYES ON DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPFRTV J VVELL 18011-DING IVENTTOFFIESH (DIFFERENCE BETWEEN FEET FROM NE AIR INLET PUMP ON AND OFF) ❑YES ONCE NEAREST — 0 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of lowin LENGTH OIANIE TE I; 1 11ATI I+IAI AND MAIIKIN(, or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH NO. OF PI ESPA(.ING COVER INSI Hf. UTA sPIIS LIQUID BED /TRENCH rRENs f MA ERIAL PIT DEPTH DIMENSIONS (p ('AiAVEL DEPTH PILL DEPTH UISTH PIPE UISTR. PIPE DI$TR. PIPE MATERIAL NUMBER OF PROPERTY WELL BUILDING VE NT TO FRESH BELOwPI � ABDVECavER EI v iNIEE D. ( /J / 6 � STH FEET FROM ,uNE /10 If alRkvler NEAREST --► O MOUND SYST Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES NO SOIL COVER TFxTUHE P F I I M A N I N T M A H K E HS U I i.M I I V A t 10 N W I I I S __ DYES _ ❑NO ❑YES _ ONO DEPTH OVER TRENCH BFD DEPTH OVER TRENCH gED DEPTH OF TOPSO I M IL SODUEO YES ❑NO SEEDED ULCHI D CENTER EDGES � �� ONO DYES ❑ OYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH LENGTH NO. OF LATERAL SPACING GHAVLL DEPTH 11 LOW PIP1 _ FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLO DISTR, PIPE MANIFOLD MATERIAL NO DISTR 0: STR PIPE STHIH UI ON PIPI M TT A HIAI & NIAHKIN1. ELEV. ELEV. DIA ELEV. VIPES DI 1) A. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHECTLV COVER MATERIAL vEHTTCAI LIFT CORRESPONDS TO APPHI)VI D PLANS OYES ONO DY ES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL. BUILDING FEET FROM LI ❑YES 0 N ❑YES ❑NO _ NEAREST Sketch System on Retain in county file for audit. Reverse Side. s1GN , ��� TITLE DILHR SBD 6710 (R. 01/82) CX -- SANITARY PERMIT APPLICATION cou TY DILHR In accord with ILHR 83.05, Wis. Adm. Code � �• � TATE SANITARY PERMIT # �7 - Attach,,complete plans (to the county copy onlyj 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 ❑ NO PROPERTY OWNER PROPERTY LOCATION Lr /a %,S T J ,N,R (or PR ER TY OWNER'S MAILING ADDRESS LOT NU BER BLOCK UMBER SUBDIVISI N NAME CITY, STATE ZIP CODE PHONE NUMBER 11 ITY NEAREST ROAD LAKE OR LANDMARK VILLAGE II. TYPE OF BUILDING OR USE SERVED: /O ` f-0-0do 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 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. X seepage 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): 3 Feet ® Private ❑ Joint ❑ Public VI. TANK CAPACITY in allons Total ## of Prefab. Site Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New xisting Gallons Tanks Concrete structed glass App. Tanks 1 Tanks Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation 9MIW private sewage system shown on the attached plans. Plumber's Name (Print): PI er's Sign ure: Stam s) MP /MPRSW No.: Business Phone Number: mb 's Address Street, City State, Zip Co e): Name of Desi er: VIII. SOIL TEST INFORMATION Cert' ' d S '1 Tester (C T) Name CST # C s A DRES (treet, Ci State, 'Zip Code) Phone Number: IX. COUNTY /DEPARTMENT USE ONLY , ❑ Disapproved Sa i ary Permit Fee Groundwater Date Issuing Agent Signature Stamps) Approved F owner Given Initial �ry S�harge Fee �� Adverse Determination P i X. COMMENTS /REASONS FOR DISAPPROVAL: I 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' c 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; 6. 'f you have questions concerning your private sewage syste;,?, 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: Property owner's name and mailing address. Provide the legal description where the system is to be installed; ll. 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; fll. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; W. 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'/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; 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 IGtay 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 negotsation and public debate. The groundwater b :?l Ground ater included the creation of surcharges (fees) for a number of regulated practices which Wisco in s --an effect groundwater. The surchar+ � took effect on July 1, 1984. All of the water that buried r asu e is used ir; yo:.jr building is returned tt the groundwater through your soil absorptiom o 'R .yster i or the disposal site used by your holding tank pumper. 0 ;oliected through these surcharges are credited to the groundwater f,�nd adminis- t< re t:y `are Department of Natural R:- sources. These funds are used for rnon Lori rg ground- . t Ott r, gc ar _fwaier contamination ini.,estigatinns and .st_blis' rnn.t of standards. E3roundwa`e;, ^_ s worth protecting. ::;3D -6398 t3.03/86) 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 G, (� r\ Location of Property _ 2 4, Section _ , T - _' N -R W Township ' D+C�_(' CCLA c Tf — Mailing Address 2 p U�ra_ Address of Site ]�a� iz�. pt 5 Subdivision Name ;.'Lot Number Previous Owner of Property = ry L 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 and Page Number L((G 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) ceAt 6y that att Atatement6 on thi6 botm cute true to the beet ob my (out) knowledge; that I (we) am (ane) the owner (.$) o6 the pto pen ty de,6 car ibed in thi,6 in6oAmation 6o4m, by viAtue o6 a waAA nt deed econded in the 0 66ice ob the County Register ob Deeds Document No. 1 � ; and that I (We) ptesent.2y own the ptopobed .sd to Got the Sewage d.i� po-s �R em (ox I (we) have obtained an easement, to tun with the above deb ctibed pnopeh ty, 4ot the con6tnuc ti,on o6 .6atd by 6tem , and the dam hab been duty tecotded the 046.ice o6 the County Regi6tet o6 Dee as Document No. SIGNATURE OF OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED DOCUMENT N o. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA - STATE BAR OF WISCONSIN FORM 2-1982 il�:_. (4 RAGE � "srER5 OFFICE t : _�_ ST. cROix co., was. Dennis J. Brotzler a single person Read for Rqoord this 25th -------- • - ---- ----------------- --------- ••----- •-- •-- •••• - - -•- . day of une D. 19 u ---•--------•--------------------------------------------------------------------------------------••-•---- o . .9 45 H , M. conveys and warrants to ... SCOtt. ... tud.Q.ck 'X'-.•311.5 •-- jr3uKs� _.jt husband ... and. .wife,...as.. max ita1..proper - • ty Wi ... rights---of .. suxvivarshi. g ........ ..... ••-------- •- •--- •-- : ...... .................................................... ....................................................... TURN TO - - --•--- --- -•- •- - -- ollow -- -- ' ibed ' re " e e - i t •--••- - --•- St.- • •Cr'O1X....•--•---•------ ----- --- .._...._.. - -- - - - --- he fing described real estate in ................ ............................... .County, State of Wisconsin: i Tax Parcel No: .............................. Part of the South Half of the Northeast Quarter (Sh of NE4) of Section 7Um ale (21), Township Thirty-one (31) North, of Range Eighteen (18) West, described as follows: Cb m racing at the Northwest corner of the Southwest Quarter of the Northeast Quarter (SWA of NEa) of said Section Twenty—one (21); thence East on the North line of the South Half of the Northeast Quarter (Sh of NF%-) of said Section Twenty-one (21) for 1071.4 feet to the East right of way of County Trunk "C", hereinafter known as the Place of Beginning; thence South 36° 50' West for 24.98 feet; thence East parallel with the North line of the South Half of the Northeast Quarter (Sh of NF34) of said Section Twenty -one (21) for 595.57 feet; thence South for 115 feet; thence East to the Apple River; thence Northeasterly on the shore of the Apple River to the North line of the South Half of the Northeast Quarter (S� of NE4) of said Section Twenty - one (21); thence West on said North line to the East right of way of County Trunk "C ", the Place of Beginning. Containing .9345 acres. D. . This 1S not -_ - -- homestead property. '� .2 �• (is) (is not) EM Exception to warranties: j Datedthis .. ..... .... .........2 J:d - --------------- day of .......... ------- June .......................................... 19._$.6.. I (SEAL) 41A !!`d . .. . . .. . .......(SEAL) ---------- - - - - -- - - - - - -• (/ I * Denn.. s........ B...Q. r...... ................... .........................(SEAL) .. .............._ --------------- ......... .........................(SEAL) 1 AUTHENTICATION ACKNOWLEDGMENT Signature (s) Dennis J. Brotzler STATE OF WISCONSIN as. • ........................................... ............. •-- ....... - - -• -• • - - - - -. County. auth ated hi 2.3 _..day qf.... -Ju a 19___86 Personally came before me this .... ............day of 1V/ :......1a. . ------------ ••---------------------- • - - - - -- 19 ........ the above named ..... ............. Hendrik W. Van . ... ... ................ .... .......... ......-------- • -------- ... + Dyk_ TITLE: MEMBER STATE BAR OF WISCONSIN • ...........................•---•--•--...... ...-------------- .........• - - -. • -• -- (If not, ........................ -------- ------------ --- -------• - - -- •-- •••......- -- -••.... ..... authorized by § 706.06, Wis. State.) to me known to be the person ..._.. ..... who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY eis3 - -.- yon - _Dy_k & -- Needham, S - , C. i New - , • _WI. 54017 Notary Public ................. ........................County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: ............. 19 ......... i •Names of persons sianine in any capacity should be typed or printed below their sisnatures. STATE BAR OF WISCONSIN . HCMiII•rcorr%mmf ®® yti t:nn.:r rl,. I __ Ir !, StAtk NA 3002 H z ' H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County z d a OWNER/ BUYER fl r L CD. l 1 cn L._.. 0 Qj_ cLo c kur- ROUTE /BOX NUMBER C, Fire Numbers�q .CITY/ STATE �C��1n�Cn ZIP (`� YYl Q {��C �� 1 <� L PROPERTY LOCATION: k, Section, T R Town of -St. Croix County, Subdivision Lot number 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 I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart - b 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. o SIGNED DATE St. Croix County Zoning Office P.O. Box 98; Hammond, WI 54015 715 -796 -2239 or 715 - 425 -8363 r - N f DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, ; DIVISION CABOR HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: OWNSHIP /MUPI�6FPfXCI - I Y: LOT NO.: BLK. O.: SUBDIVIS ON NAME: '/a '/a I N/R g f (or COUNTY: 5WWEFrS7Buy E 'S NAME: M L G ADDRESS: 7 '7 tZ USE DATES OBSERVATIONS MADE NO. BEDRMS.: I COMMERCI DESCRIPTION: PR nn��II OFILE DESCRIPTIONS: ER OLATION TESTS: Residence ❑New I,a7Replace I /` —' S RATING: S= Site suitable for system U= Site unsuitable for system ( IL'W� /O VS rONVENTIONAL: 'II MOUN II'' IN- GROUNQQDPRESSURE: SYSTE�c`M -(( rOL I IcNG ANK: RECO MENDED SYSTE :(optional) 1 v y If Percolation Tests are NOT require DESIGN RATE: If any portion of the tested area is in the / under s.H63.09(5)(b), indicate: Floodplain, indicat Floodplain elevation: PROFILE DESCRIPTIONS w'f BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH'W. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- ? B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER mem ES AFTERSWELLING INTERVAL -MIN. PERIOD PERI 2 PERI PER PER INCH P AQ 3 .3 AMe �P p_ ` 3 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. { 1 SYSTEM ELEVATION (r 7 / it I tN I � I f y s� < r i r 3 t i � I E 4 ", Lj i ' l e � i s I, the undersigned, hereby certify that the soil tests reported on this form were made by me in acc d with a procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best f my kn wledge and belief. NAM print): TESTS WERE COMPLETED ON: ADD CERTIFICATION NU P ONE NUMBER optional): 4�3 41 2a.. 42r S]��l 2 CST I URE 7 I DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. i DILHR -SBD -6395 (R. 02/82) —OVER — M 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 or commercial project; 1 MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbrevialJons shown here 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; S. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appr opriate 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 appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as re(Juired. 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 col) Cobble (3 - 10 ") SS - Sandstone gr - Gravel (under 3 ") LS - Limestone * s - Sand HGW - High Groundwater cs Coarse Sand Perc Percolation Rats; rned s Medium Sand W -. Well fs - Fine Sand Bldg - Building Is -- Loamy Sand > - Greater Than * sl - Sandy Loam < Less Than 'I - Loarn Bn - Brown * sil - Silt Loam BI Black si Silt: G - Gray *cl - Clay Lonna Y - Yellow sc:l -- Sandy Clay Loam R - Red sicl - Silty Clay Loam mot -- Mottles sc -- Sandy Clay iv/ - with sic Silty Clay fff few, line, faint Ic - Clay cc - common, coarse pt - Peat ITIM Many, raac�c9ium ni -- Muck. d - distinct p - prominent HWL - High watm level, Six general soil texturea surface water tot liquid waste disposal BM - Bench Mark VRP - Vertical Reference Point TO THE OWNER. This soli test report is the first step in securing a sanitary permit. The county t>r the Department may request v0"J "i .ation of this soil test in tfw frr ;,rl prior to Permit issuance. A complete set of plans for the private sc svaq�" system and a pe, rnit apphcatic;n must he sr.atanaitted to the apr wri ale local authority in order to obtain a potinit.. The sanitary permit n rasi be orrtainf"zd and posted prior to tho ; =art of anv construction, r' Iii' S�•�ri� 7.9NX- /��" /do0q.�/ -�7- 94' 7�5 A) n ,gym 6 -Y ?r PAGE OF l'ro A Vjcn SySt�n -� / Fresh Air Inlets And Observation Pipe .� ©I�14 $r / Y ✓� .� QO�� Q-- Approved Vent Cop Minimum 12" Avow Fln4 hods i i 20- 42' Above Pipe 4" Cost Iron To Final 6reds ` Vent Pipe Ieerah Illy Or Synthetic Covering Min. 2' Aggrey0te Over Plpe Distribution —Tea Pipe — ' 0 9 o 6" Aggregale O Perforated Pipe Below 1 Beneath Plpe Coupling Terminating At **Hoot Of System • Prwp oycD P Ina1 i SOIL FILL DISTRIQU E TIO!I PIPE S�'FIETIG COVER �`` I"1ATER1i1t- OR 4" OF 'STRAW OR nAKSM F AGGREGATE (o O /t - 2 /z A G G E ATE DIS'TRI5 PIPE TO DE AT LEAST _ INCHES BELOW ORIGIMAL GRADE AWL) AT LEAST20 IUCHES BUT AIO MORE THAU 42 IKIC14ES BELOW FILIAL C.RADE • M1IXINMIM OF-PTH OF EXe-/lVAT1 FXOA OW NAB 6RAoF- WILL BE IuC14ES PYKIMUM AEPrt+ of EXCAVATI fK0\ 0� I4I WAIL CMPE WILL BE INCHES r I GAlEO. LIGEMSE AJUMBER: DATE: 1i 7,--27 & _. _