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040-1041-20-100
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENE.RAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: &16 Col 1ptpy viow R ve,1 A'V R4QW;Aett4; Town of 09a__t296_Q8_QQ0 CST BM Elev: Insp. BM Elev: BM Description: �� Section /Town /Range /Map No: 1 TANK INFORMATION ELEVATION DATA Z$. /7. / 7 4 2 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic t Benchmark ion -6e W. c.. Z : b W - 7 AgX�r Alt� IS Aeration Bldg. Sewer Pa rbk F,`� s: Holding j St/Ht Inlet t = TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt le Septic _ Header /Man. ?s � /a5 — - , rd 5 Aeration Dist. Pipe ✓P jb �� z Holding Bot. System i0 �, • 43' S. 3 Final Grade PUMP /SIPHON INFORMATION U - Manufacturer Demand St Cove GPM i j�, -7. .� altti j 11 . a 2 '14, 7 Model Numbe 7T Friction Loss System Head TDH Ft 1 r �•7 Forcemain ngth Dia. to well tell $ 7.� 7 SOIL ABSORPTION SYSTEM BED /TRENCH Width i Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: 1 INFORMATION CHAMBER OR UNIT Model Number Type Of System /V/ ! 9� Q A 44 G6,.ve 18 - Q� V GJ � Ja G DISTRIBUTION SYSTEM J l e ,� I lod 13 Header /Manifold �� Distribution x Hole Size I x Hole Spacing Vent to In —7 / �) Pipes) � 7( Mrt Length / Dia ' Length Dia Spacing Vt 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 42 Bed /Trench Edges Topsoil Yes No Yes No COMMENTS: (Include co // de discrepencies persons present, etc.) Inspection #1: / / Inspection #2: Location: 972 165th Avenue New Richmond, WI 54 7 (NW 1/4 SE 1/4 7 T30N t3,18W) Country View Ridge Lot 8 Parcel No: 07.31.81.539 1.) Alt BM Description - J 2 Bldg t sewer length - - amount of cover = ���✓� ` Plan revision Required? Yes >j ZL Use other side for additional information, s J 6S� Date j ignature Cert. No. SBD -6710 (R.3/97) ' 4 Safety and Buildi Division County S t commerce.wii.gav Y 8 a 201 W. Washington Ave., P.O. Box 7162 / s C4 n n Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) t D i epartmen t o of Comet, 514 76 State. Tra Sanitary Permit Applieat' --- - ---- action Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form le a ental �� unit is required prior to obtaining a sanitary permit. Note: Application form r state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be t ary - ( p urposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. ••+� � >� 1. Application Information - Please Print All Information 6&- Property Own 's Name �SV4/0 arcel # Property ner's Mailing Address APpe pert Location 3 Lot `� (. 43 7 J City, fate Zip Code Ph ne NumllrrtN Y., Sk ] Y., Section 2 �1/ / 'E �-�j J � U 00 c N; R circle one) �Eor II. Type of Building (check all that apply) Lot (. G 0 F I or FantilYDwelling- 1�lumberofBedroom �� SU1y�SiQn _._._ F a,cyv'M Block C1 Public/Commercial - Describe Use ❑ City of ❑State Owned - Describe Use CSM Number ❑ Village of �;�� r �Townof 111. Type of Permit- (Check only one box on line A. Complete line B It applicable) A. Y p Y 8 P Y g Y ( ❑ New S Re lacement S El Tank Re O Other Modification to Ex istin g S ex lain ) B. C1 Permit Renewal ❑Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that app I )t Pressurized In -Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Devi (explain) V. Dis ersaVrreatment Area Information: Design Flow (gpd) sign Soil Application Rat e(g f) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevatio 45IZ2 o7 3 � �ti�I z 9-K •L V1. Tan Info Capacity in Total # of Manufacturer Gallons Gallons Units w , a E o o U _ ti New Tanks Existing Tanks � ' � � � u� yr v as � rA w'C7 a Septic or Holding Tank a VII. Responsibility Statement- I, the undersigned, assume respons for installation of the POWTS shown on the attached plans. Plumber' Name (Print) Plumber's Signature MP /Mi�RSNumber Business Phone Number 7/ © z2b P 7 X7. Plumber's A06ress (Street, City, State, Zip Code) VIII. ount /De artment Use Onl Approved Permit Fee Date Is Issuing A e t Signature w iven Reason for enial IX. ConditI15UTEAJ)9bVNMeasons for Disapproval 1. Septic tank, effluent finer and dispersal cell must all bbg services' / maintained as per management plan provided by plumber. 2 AN setback requirements must be maintained ails per appicable eaN I ardlinvilu es. Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 Inches in size SBD -6398 (R. 01/07) Valid thru 01/09 .� .., ..i „� - ..,,,. .. .; ., i .. + j A l t X x 6 co Fcopy I � P(lw�5- r—Ez� Lr-/ ( LY C � _ o K w ic l �Q Co . d Wisconsin Department of Commerce SOIL EVALUATION REPOR+- '"""""'� Page of - Division of Safety and Buildings in accordance G Code County G S'„ �'�, • Attach co mpletes�e_ol an cjrrp��pp n t less than 8112 F s in size. Plan must incl e, b S�CCI(�� to: veal an horizontal refere BM), dire d Parcel I.O. per nt slA"SC`dl�or dimensions, n rth arrow, and to giltat�st roa A' Please pr t all inform �Jty tn1�+Yy ��(JT Reviewed by Date Per�onal inf0or0i ob provide may be u ed for secondary rivQQ0, 'Li&1) (m)). wner roperty Location ST OI / ff p r d .et N W 1/4 S W 1/4 S ! T26 N R Property Owner's Mailing Address Lot # Block # Subd. Name CSM# 6- �� S 6 Al � ����� � cU City State Zip Code Phone Number ❑ City ❑ Village JS Town Nearest Road Hc a , - 57�� 71j b - s T Ra SFrl, GtaYE� R ❑ New Construction Use Residential / Number of bedrooms Code derived design flow rate GPD Replacement ❑ Public or commercial - Describe: IVW -- Parent material 6 �� /� Flood Plain elevation if applicable / " 24 ft• General comments /i ^�< s �X Errs r EF+ C pr ( ra ? , rt h / ' T e. Q( F y 5 �Cf f'�L Co o�GS Q and recommendations: S a4 oC �a e ccs, chi d e - s`. 9 e-r � s'�°s zrl /� A, �^c s � -Z - 07 1 0 "/ L .:� �'' 1_. 7" r � }� p .. C.u`.*rr.+ a Boring # Boring C� } 9 a Pit Ground surface elev. "eft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 5 1 1 Boring # Boring ® pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 0, 7 /.6 F 4 C3, % �- i * Effluent #1 = BOD > 30:5 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Address Date Evaluation Conducted Telephone Number Property Owner �7 `O� �, ale FQ, Parcel ID # 0 4 1(;4 Q ° j ®O Page of ✓ Boring # ❑ Boring U Pit Ground surface elev. g 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 I *Eff#2 z �-� 7Si+�°5 /b O -7 �- F-1 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/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring # Boring El 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 * 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) - A) ALI - -- am 0 0 s 3 v -u _ `•.� ..� J t k ',®� 1� LN oj oj p lO 3 k p i0 1 - � � IN �dL C Criz-,"3� Aso 9 P'0 , 7 6 3 I = �? 9 �° �" k4 Go rj Mu 2 D STANDARD CHAMBER 52" Quick4 Standard Chamber 48" (EFFECTIVE LENGTH) e B B B 12" 8" 34" SIDE VIEW SECTION VIEW Multiftrt End Cap R i6 ". 12" 1� 34" SIDE VIEW TOP VIEW FRONT VIEW INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY (a) The structural Integrity of each chamber, and plate. wedge and other moseeary manufactured by Infiltrator ( "l1Mtal, when installed end operated In a leachfield of an onsite septic system in accordance with Innitratoes Instructions, is warranted to the oripFatl purchaser ( Hailer") against defective materials and workmanship for one year from the fate ghat the septic permit is issued for the septic system containing the Units; provided, however, that N e septic permit is not reryuaired by aPPlceble law. the warranty period will begin upon tlhe date tat Installation of the septic system commences. To exercise its warranty at hidden Drat racily lldllralor In writing at its Corporate hlBadQUBdate In Old Saybrook, Camectk;ut within fifteen (15) / • Ifitt o f attor's� a leged speGAcally ewAdes the i < o ar Units �llaW determined of the Units Infiltrator to be covered by this Limited Warranty. 0 To TTM}1E LIMITED I C� NG Np AND ARRAMIEES OF MERCHANTABILITY !T ARE O FITNESS FOR A � y � � SYSTEMS INC (c) This Umited Warranty shall be void If any part of the chamber system Is manufactured by anyone other than Mratm.. The Limited Warranty does not extend ro laldenfd, consecsrenttlel, avaciel or Indkecl damages. Infiltrator shell not be I" for penelges or 44dated damages, Inc hand loss of Envlronmental Onslte Wastewater Solutions production end proms, Ietar and materiels, overihead coats, or Daher losses or expenses Incurred by the Holier or any cold party. SpedAcaly excluded horn Lkn tad Warranty coverage are daanege to the Units due to ordinary wear all tear, alteration, accident, miaase, abuse or neglect of the units; the Units being subjected to vehicle traftio «other conditions which are rat permitted by the IrWaletlan Instructions, faYlure to rtelCaIn the 6 Business Park Road • P.O. Box 768 mhlnxam ground covers sat form In she Instmatbn instructions; the placement of improper materiels Into she aystam camaInhp the Wits; fakae of exc Old Saybrook, CT 06475 any other the Units or the septic system due to lnpmper siting or improper siring, m" water usage, hmpopar prase, disposal. or Improper operation; or ry event riot cm,sea by InAitratar. Tee Limited warrant shell be volt a as holder rue �v to co with as d to tee set forth In ale L 860- 577 -7000 •FAX 860 - 577 -7001 «tea my produc In l cl ins of responsible For � Ll� t to ap Units must l «�' 800 - 221 -4436 wah al site conditions required by state and local codes; al other applicable laws; and InRtrator's Installation Ine6mx sons. (d) representative epreaeruative d Infikrator has she authority to charge or extend Ws Limited Warranty. No warranty apples to any perry omen than the oriel- net No Holder. The above represents the Standard United Warranty offered by Infiltrator. A fimited number of states and wxitee have different warranty re%ka. meras. Any purchaser of Units should contact Infiitrator's Corporate Headquarters In Old Saybrook, Connecticut, prior to such purchase, to obtain a copy d the applicable warranty, and should carefully read that warranty prior to the gxdnase of umib. U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending. Oak Infiltrator, Equalizer and Sidewinder are registered trademarks of Infiltrator Systems Inc. Infiltrator Is a registered trademark In France. Infiltrator Systems Inc. is a registered trademark in Mexico. Contour, Contour Swivel Connection, Mkrol- eeching, PdyTuff, SnapLock, ChamberSpacer, Posit -ock, OuickCut, QuIckPlay, RecycLE0 PAR and Quick4 are trademarks of Infiltrator Systems Inc. 0 2003 Infiltrator Systems Inc. Printed In U.S.A. Q011203HP -0 •s (A-N 6- F�� Private Onsite Wastewater Treatment System Management Plan r Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number Numb of Bedrooms Design Flow - Peak (gpd) So Estimated Flow - Average (gpd) 3 rfb Septic Tank Capacity (gal) Z - 0 - 711D Soil Absorption Component Size (ft Z Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) Sb Maximum Influent Particle Size (in) 1/8 Maximum BOD (m /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the 'a • Management ement Plan for a Septic Tank and Soil Abs Component 9 Absorption Com p p p filter is equipped with an alarm the filter shall be serviced if the alarm i s activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined r space. The atmosphere within the septic or other e p P treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. I pLO- — i gCC sa /J PI- 9 6 7/� �Y" C O i 3 111'21,'98 WED 07:25 FAX 715 386 4686 ST CRX CO ZONING iCitr2 ST. CRO,IX COUNTY 'ZONING OFFICE CERTIFICATION S'TAT'EMENT FOR UTILIZATION OF AN EXISTING SEPTIC 'TANK. This is to certify that I have inspected the septic tan presently serving the 2.� _ G�3 residence located at.: N w , Section T Z 8 N W- , R--f- w, Tocan of y Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears i:.o be functioning properly. Last time serviced: C2,( L Z C- 0 g Did flow knack occur from absorption system? Yes _� No (If no, skip next, line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other .Manufacturer (If known): — Age of Tank (If known): 11 gn e} � � - /yC Ls O ) Please ri IL nt (Title) Q (License Number) �O ;date Form to be Completed by licensed plumber (v,145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Cede) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge Will 170nform to the requirements of ILHR 83, Wis. Adm. Cade (except for inspection opening over outlet baffle). )Name S M ` C SAFETY AND BUILDINGS DIVISION Plumbing Product Review commerce.wi.gov P.O. Box 2658 Madison, Wisconsin 53701 -2658 isconsin Department of Commerce Jim Doyle, Governor Mary P. Burke, Secretary July 22, 2005 POLYLOK, INC PATRICK MULHALL 4003 CAPITAL DR WALLINGFORD CT 06492 Re: Description: SEWAGE TANKS, POLYETHYLENE Manufacturer: POLYLOK, INC Product Name: PUMP OR EFFLUENT FILTER BASIN Model Number(s): 24" BASIN (1.95 GAL PER INCH, 38" THROUGH 62" HIEGHT IN 6" INCREMENTS) Product File No: 20050596 The specifications and /or plans for this plumbing product have been reviewed and determined to be in compliance with chapters Comm 82 through 84, Wisconsin Administrative Code, and Chapters 145 and 160, Wisconsin Statutes. The Department hereby issues an approval based on the Wisconsin Statutes and the Wisconsin Administrative Code. This approval is valid until the end of July 2010. This approval is contingent upon compliance with the following stipulation(s): • This tank must be designed to withstand the pressures to which it will be subjected. • The manufacturer must keep at the manufacturing plant a set of plans and specifications bearing the department's stamp of approval. The plans and specifications must be open to inspection by an authorized representative of the department. A copy of the approved plans and /or specifications is enclosed. The department is in no way endorsing this product or any advertising, and is not responsible for any situation which may result from its use. Sincerely, Michael J. Beckwith, CIPE Plumbing Product Reviewer phone: 608 - 266 -6742 fax: 608 - 267 -9566 e -mail: mbeckwith @commerce.state.wi.us SBD- 10564 -E (N.10/97) File Ref: 05059601.DOC 08/29/2005 10:50 FAX 715 273 0444 NELSON - PLUMBING 001/001 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer T/ / d Z `� �/ l ✓V __ Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City /State A- Lnl aj Parcel Identification Number © iLO --10el �7110 -- / - PIP LEGAL DESCRIP � Property Location / V k /4 , s /< , Sec. T � N R W, Town of '� 1 Subdivision ' , Loc # Certified Survey Map # , Volume , Page # 1,5 Warranty Deed # , Volume , Page # Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment srage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the o C ommerce and the De ent of Natural Resources, State of Wisconsin - herein as set b the D e p artment f C eP at standards set fo y P Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I /wc certify that all statements on this form are true to the best of my /our knowledge. I /wc am/are the ov CT(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATU F APPLICA�A DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey reap if reference is made in the warranty deed. (REV. 08105) � T1e3 •. f ; � $'I'A'i`L BA32 'OIl` �PTBbCII�$dN �'l��t i z'"�e *lsaa eruim.eo how w�ze�xo��o ewYw _ , f > W- A1%R/ANT1?- DEEk3 ' y' rt l bz r t P J ti al ► s c}n i�E + 00"Ml: iSTERS 711 Dea mttae bet�reen CO T a /k /a A $serf HansAn and ;Myrtle A Hanson, Ti2xsbarid.. iid._ iff,i, -•- ,.- f£ .. Rse'�, fc+c R®aoi*d #tiffs 20th= and N1&rQld J 4 Fe11?e> $ aRSI D>�a[)� �4�t1 @z� s �: 9:35 A Nlt h and _wife,,. - _ -• - - - - - . - - - _ - - • =--=------ ------ - - - - -• - - • - - - - - - - - - - -...- - - - = - . - - - -. .. - - .. - - - - I I ...... Grantee, of 1 sM- '211 @SS @, That the said Grantor for a valuabloconsir3eraton !� .I - - -- - - - --- -° -- - ..... ...... L t - - f ro �i RF7VRN .TG - - - -- -- —__ - conveys to Grantee the following described real estate in lx, . County, ,State of Wisconsin: - {I l - Part .of .%.Ik of S I. and SWk of NWk of Section 9, Township 28 North, Range 19 We s t , Tax Parcel NO_ __ ____ _ ____ __ . -.. described as follows: Lot Two (2) of Certified Survey Map filed October 17, 1985, in Vol. "6 ", page 1593. l r -e �i j� i' is not 'M This ------------ homestead Property. ----- ----- - - - - -- (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; N And.... 1.>�e.0 .. p....- J.,... Iians4n.. a. /. k1_a- -Albent.- P.__..Hanson.,. ..and- .-Myx.tl -e -.A- .._Hanson ,l warrants that the title is good, indefeasible in fee simple acid free and clear of encumbrances except easements and rights of way of record ii I� and will warrant and defend the same. }' Dated this ................. t.t1... ........ . -.. --- day of ............ ......... .J - anuary. . - ....................... 19_86... f' (SEAL) / /1�i�W ° irk 7�7.. ---- � - -- -- (SEAL) .... ..... .. ..... ............... . .. . . .... f- Albert P.`J. Hanson, a /k /a . •. - - - --- - --- a -- - i ` -- -- A , H t� s � o ..� n a -y ...... ............... .................... ........ (SEAL) / -// C �i l �- - �5 ✓�,< >� � . eta...... (SEAL) tle A. Hanson t ...... ....... ....... .. ..... ... .. .. . . . . .. AUTHENTICATION ACKNOWLEDGMENT Signature(s) Albert P_ J. - __Hanson aka STATE OF WISCONSIN Albert P. a _ _Hns _on - and__M tle A. Hanson � sg ' l r Y . -. 4 --------------------- ----------------- County. "I � Jsnu3r $6 _ _ _ the a ove ut nticat this _.- __!d y of_._._... .._.. a Y. 19._.-_.. Personally came before me this ____ __ __________day of � f 29 b ramp �, 1 r �. -� - C. -I" Gay -- ---- - -- ------- - - -- - --- ------- -- --- - -- - -- •-- -- ---------- --- - --- - - --- TITLE: MEMBER STATE BAR OF WISCONSI:v ------------------------ - ----------- .--..-- ----- --------•.---------•_-_----- (If not. ------------------------------------------------------------ ------------------------------------ - ----- -- --•--- -- - -- - -• -- ------ authorized by s 706.06, Wis. Stats.1 to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY ---------------------------------- - ------- -------------------------------------- C' -..L_- ...Gaylord: A - -- - -- `------------•-------------- •- •------ •----- - - -... --........................... River Falls Wl 5 +022 - ------ - - -- -- Notar Public __----- - - - -._ ..County, Reis. (Signatures may be authenticated or ac: nowledged. Both My Commission is permanent. (if not, state expiration are not necessary) date: ---------- ---------------- --- -- ------ --- - - - - - - 19 ------ ) •Names of persons signing in any esp &city should be typed or printed below their eignatu —s. STATE BAR OF WISCONSIN IiGMiIlerConparry� FORM ho_ 1 — 1982 - Stock No. 13001 Ik g 0 3 0 2 T } ki / & _ m s ¥_- z o w e o n, o M; o m _ - a ha @ Q f 2 } E % o / § / \ / I ; ; I' § § E 2 g' A 0 % %\ O e ( E E ® o - E � _ & §i� © � c E E o o{ O - ,e «� CL ® § k k I g E c g s Z o: ( "a V "a f 0 0 0 - » % § < © z / } § co (A in 2 E > ; _ D G E 5 m -3 « CL / { z B 3 z co z \ 0 �f� / m ƒ @ 2 r OIQ } D = � ; \ 2 z 7 06 z R / co E . k / § z r § \ 2 z $ i $ � o ± E § E z % � E o ƒ 3 ? qb � t a � a � � $ 4 % ; f � K ƒ \ CD § � ƒ? «� Form -STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP 7�/n SEC. T N -R W ADDRESS 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 `V I � 1 ;2 6 e 15 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: G/_:_ Liquid Capacity: ld0 O Number of rings used: IF Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side o Rear, O feet From nearest property line Front 1 0 Side, Rear, O _ feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE -REVERSE J 1 - PUMP CHAMBER � r 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, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: x Trench: Width: Length: S2 Number of Lines: Area Built: 'L lS Fill depth to top of pipe: �O Number of feet from nearest property line: Front, O Side, 0 Rear,0 Bt. 7d Number of feet from well: 7 S Number of feet from building: 3 (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: _ 21&F A F1, Plumber on job: License Number: 3/84:mj DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 XXX ONVENTIONAL 1:1 ALTERNATIVE State Plan l.D. Number: Ilf El Holding Tank El In-Ground Pressure ❑ Mound assigned) NAME OF PERMIT HOLDERI ADDRESS OF PERMIT HOLDER: INSPECTION DATE Harold Fel 1367 E. 7th St. St. Paul, MN 55106 — O� BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST F. P . ELEV. NW SW, Section 9, T28N —R19W, Town of Troy �C� U Name of Plumber: MP /MPRSW No Cnurnv: Sanitary Permit Number: William Schumaker 6382 St. Croix 79201 SEPTIC TANK /HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COV ER •� C' PROVIDED: PROVIDED: DYES ONO ❑YES ❑NO BEDDING. VENT DIA.. VENT MAT NIGH WATER NUMBER OF a ROAD PROPERTY WELL: BUILDING. (VENT TO FRESH ALARM LINE-, AIR INLET: FEET FROM _ L� ❑YES NO ❑YES ONO NEAREST r „ / / DOSING CHAMBER: MANUFACTURER: 1 71 LIQUID CA P ACI TV PUMP MODEL 1 PUMP,SIPHON MANUf ACTIIHEH WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ONO ❑YES ONO OYES ONO GALLONS PER CYCLE: =No CONTROLS OPERATIONAL NUMBER OF 1 PHOPEHTY WELL I BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEEL' FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ONO NEAREST —�}► SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I f ral,u+ uiAVIF TER+ I NIATI RIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH N TH PIPf SPACI NtI COVER ..INSIDE UTA -P17S LIQUID BED /TRENCH - TR Mn�scHlAC PIT: DEPTHDIMENSIONS GRAVEL DEPTH FILL DEPTH 11THPIE UISTH PI PIPE MATERIAL NO DIS�t Ra NUMBER {3F "- PROPERTY WELL: BUILDING. VENT LE FRESH .,L PIPES, ABOVE COVER ELEV INLf f ELEV END ` PIPES" LINE: ..._., _ AIR INLET. / N . .«I FEET FROM j Z. N EAREST --- —t y f MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- OYES FIND meets the criteria for medium hand. TIONS MEASURED. SOIL COVER TEXTURE PFHMANI NO MARKFHS OBSERVATION WENS ❑YES ❑NO OYES 1:1 NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH 11111 J OE PTO OF TOPSOIL SODDF II [11 OFD MULCHED CENTER EDGES ❑YES. 1:1 NO 1:1 YES El NO OYES El NO PRESSURIZED DISTRIBUTION SYSTEM: NO BED /TRENCH WIDTH LENGTH TRENCH ES LATERAL SPACING GRAVEL DEPTH HE LOW PIPf FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO UISTH JD�STR PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. CIA ELEV. PIPES D A.'. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING CHILLED CORRECT LV COVER MATE HIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS EYES ❑NO OY ES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMB ER O F !. +PROPERTY WELL: BUILDING. _ FEET FRO LINE F-1 YES El NO ❑ YES El r, NEAREST t' to 4 f ti ' Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. , TITLE i � DI LHR SBD 6710 (R. 01 /82) i M uJiscons,n APPLIC DILHR ATION FOR SANITARY PERMIT W1 AA&k � COUNTY - OEPRRTmEr1TOF (PCB 67) UNIFORM SANITARY PERMIT # - InDUSTRV,LRBOR&HUfnRn RELRT10rIS �dla Y/ — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWN R MAILING ADDRESS 2 13C C-- . T PROPERTY LOCATION CITY: VILL E: AW 1/4S'W1/4, S �/ , TN, R E (or) wN o ►r LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROA , LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms. 3 Public (Specify): THIS PERMIT IS FOR A: 0 New System ❑ Tank Replacement ❑ Repair 1 Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 0 -3 /3 6/ . ® Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: /MPRSW No.: None Number: j u m �✓ y-- 27,3) .5"� Plumber's Address: Name of Designer: IQ2 lrJo?�' fX PY COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved � El Owner Given Initial o(J Approved Adverse Determination Reason for D' ppr al: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber - 1 INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. . APPLICATION FOR SANITARY P RMIT 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 onl result in delays of the permit issuance. Should this development be intended for r sale by owner /contractAx,( "spec house "), then a second form should be retained and co pleted when the property is sold and submitted to this office with the appropriate deed recording.. - - - - - - - - - - - - - - - -, - -. - - - - - - - - - T - - - - - - - - - - (honer of Property Location of Property k Section , T _2S N - R W 'n *VA Township Milling Address ed � � Subdi ision a Na a 0/ `V `oAL� Lot Number Previous Owner of Property ZZ LCf�_ Total Size of Parcel puce Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec hou e) ? Yes No u V a Page Number as recorded with the Volume - 7 nd a of Deeds 8 INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract . 3. Other recordings filed with the Register of eeds Office in addition, a certified survey, if available, would a helpful so as to avoid delays of the reviewing process. If the deed description re erences to a Certified Survey Map, the the Certified Survey Map shall also be requi ed. ------------ - - - - -' - -,.. ------------------------ PROPERTY.OWNER CERTIFICAT ON 1 (We) cati.6y that aU aatatementa on thiA 6onm one t u to the beat 06 my (sun) k nowt a dg e; .dust 1 (we am ( ace) the owner (,d) o the p , . opeAty des cA bed in t;U4 016ulunat on 6onm, by viAtue o a wavcanty deed %eco&d7A in the 066.ice o6 .the Cuun t y RegiAten o6 D eeds ad Document No. 4 0 and that i (we) ph ee e.na y own the, pro poe ed z.;; to bon the d ewage po AIX s ya tem (toot I (we) havtr— obtaiji� , Ai em, an 1 neeon. ice U 6 .the o y e94A SIGNATURE OF OWNER SIGNATURE OF CO -OWNER (IF PLICABLE) DATE SIGNED DATE SIGNI a irt�1 .y i I k +a 4W fi I it b was i y v' ` 3 .R Yr` syihi�g d , �. F W :"� TM �' • , S`- F f �, +1 X. R� - � 3 t 8 i s. ryFC gate of Mimnsin Co y of 9. Croix hereby certify that this instrw w* is a fug, true and =Ted copy of the docwnw* co file and of record in my office and has bs�n compared by me. Atte,t June 11 19 86 1amPe O'Connel James v C,omeq + ReVW* d � Deputy CERTIFIED SURVEY MAP ._OCATED IN THE NW1 /4 OF THE SW1 /4 AND THE SW1 /4 OF I HE NW1 /4 OF SECTION 9; T28N, R1 9W, TOWN OF TROY, ° �o� SO ° SO'Syu E 3T. CROIX COUNTY, WISCONSIN. h h 6 0o W 150.3" �.. OWNER AND SUBDIVIDER o' THE S�INF O v'\ ALBERT P.J. HANSON S MYRTLE HANSON WI /y 'P R.R. #1, HUDSON, WISCONSIN 54016 T ROF m o -•1 N " e � A RINC z ,z -i-p a z on I X Z p /• / o m � 1 G o Tj w /mil h � r 1 ,a n a' n "' �' 1 R► kp 177 p c -ry / b ti z -n coo 1 CD r17 00 01 Tj v, I I Ln m APPROVED o 'o OCT 0 31984 _ o ' •� � O 1 - 6 , `°� y , ST. CRCNK COUNTY co n COMPREHENSIVE PAW P6AN"Od Cn O -s N AND Z0"Q GC1MM►1tEE - 7 1 77 O N �G�N c co, CURVE 3 -4 [� In CD �y / ZS = 19"27'46" R = 40 3' w c„;0 y L= 136.89' c 1 2 1ST TAN. =S16 °48'58 "E 0 O v 2ND TAN. =S36 0 16 1 44 "E ' lu 13 6.24' 3 ._ 4 I � 0 19.1 �i 2 5 v 'G N ,W P 1 O $ _ 133 co s g2 ,1 � 525 5 3 1 �� �C9 hp 5 � 391'6 565.6 � 685•$2` ` '' J CURVE 1 -2 6 _20 0 44'32" R =370' G O E� p — L = 133.95' 1ST "tan. =S15 0 32 1 12 "E 2ND TAN. =S36 0 16'44 "E GEN � uNP' s Drafted By: Walter J. 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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 o"f the septic tank as a•treat- ment stage in the waste disposal system... St. Croix.County residents m ay be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation pry St..-,Croix County accepted this program in August of 1980, with the requirement that owners of all new sy stems 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. o E I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with H 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 Offkre within 30 days of the three year expiration date. SIGNED DATE v St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 715- 796 -2239 or 715- 425 -8363 Sign, date and return to above address. k 0 � $ $ ] 2 o m 2 _ ■ o c o a# s § J a $ ■ 2 ! © \ t k (D � A U k ? D \ i � , D 7 7727% j J\ 7 a to t o % ° - § \ 9 � \ 2 0 �c_a SD o 7 o c ] o a o � ��7wtƒ �k� k�a � _ o � ®\ O k�R� � CD ƒ��0 §� �kk \t C U) . �� �2G S' (n o m$ 2' O f z f ��� \ /���� I k\\ �����k CD &¢ao \ 0 k D \ - , o D c 7 0 m t Z CD =r �� CD ) � 2 IR o$s \ \ \ 3 CL $ § 0. t 0 rn �*��7� Ake �to(D �.c CA 0 Q 2§ o n$\ g _ CL r wCC, 2 0 BCD CL �0K \7ko �o \ mac] g R - 7 z «% CL CL) < % x f o DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, . G DIVISION LABOR A N D LA TIONS PERCOLATION TESTS (115) MADISON WI 53 07 (H63.0911) &Chapter 145.045) LN �1 :' t ' SECTION:T Rj E (o TOWNSHIP /JAU IRALITY: � SUBDIVISION NAME: /a / 9 / W / T� y �r -99 COUNTY: O BUYER'S NAME: MAILING ADDRESS: S f CiPoi' X t/rf;Po /O �"E /�(3ER G /36 7 E. Y S� • 1�10� 'hu�w.. �SS /o G USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFI E DESCRIPTIONS: 1PERCOLATION TESTS: Residence 3 XNew ❑Replace �pC�I; 2 i v y 4 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional KIS ❑U ES DU ©S ❑U ❑S DU C)S Ej U / � If Percolation Tests are NOT required DESIGN RATE: i Q If any portion of the tested area is in the under s.1463.09(5)(b), indicate: �'Gi¢SS S_ Floodplain, indicate Floodpfain elevation: --+ PROFILE DESCRIPTIONS IN 'J)EClyA1 f BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. H CHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) . s B- 7 ' - d • , �1 •Sa / > �� 1.0 B- .u, S •o �,. T�,►•V eS , B - 42 •d f l /. 16 ,- > i1.6 �' 1 S ti � r r B- 7 > 11S • 7S . S --W Cs' B_ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD2 PERIOD3 PERIOD PER INCH P_ - 7 OS,t s P - - / .:Z i E P- L P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distanc e w r horn zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borin s the direp } 1n and ent of land slope. 1X SYSTEM ELEVATION 13 ,070M .�t db ./i,�'1FCv p o tN t E E 111 j $ j 77 33 � e J 1 � t ` . I . , z � f 1 !1/D � I TO , G'I .� ' Y�ifU/ Fit .. �0�•t �'r ''� c 'o l _ _ -_.. �. s 3 j 171�ij //t/ r . /7iO4 5� e4? a _ I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): E SE PTIC PLU418ING CO. TESTS WERE COMPLETED ON- DC �� RT. R O'NEIL RD., HUf)SON M& 54016 0e ? • .? 1 " a J ADDRESS: WS. MASTER PLUMBER LIC. N0. 3307 M.P.R.S CE $ TIFICATION NUMBER: PHONE NUMBER (optional): NJNN. INSTALLER 3,5 CST tGNATURE DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) — OVER — I INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 sv. To be a compine amJ accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether 00s is a residence or c;oritmercial project; 1 MAXIMUM number of bedrooms or commercial use planned; 4. 1s this a rye v or reniacernent system; 5. Complete the ukabiMy rating boxes. A SITE 1 SUI1 ABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 3. PLEASE use the abh evial ions shown here for vvkkg profile descriptions and completing the plot plan; 7, MAKE A LEGIBLE diagram accurately locating your test locations, Dravving to scale is pmferrecl. A sqnsrMa sheet may be used if desired; LS. €iklake scare your bmxhrnark and vei HEW elevation reference point my clearly shown, and are permanent; r, Complete all apps opi fate boxes as to dates, names, addresses, Hood plain data, percolation test exernp- don, if sapproprAte; 10, if the information to fah as flood retain, elevation) does not apply, place N,A. in the appropriate box; 1 1. Sign the f orni €a, €d faiaCe yrai.ir c.rariem ackkms and ymar ceirtitkation number, 12, ft'lake legible copies and distributes as reclUired. ALL SOIL. TESTS MUST BE FILED WITH THE LOCAL PUJTIKORITY y), 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st Stone {over 1w') BR — 1 Nkmk cob f ohble= (3 - 10 ") SS Saindstone gt -- Gravel (under 3 ") LS - Limestone s Sand 1-1GW - High Groi.inokfvater cs `- Go "� sand Pere -_ Prtrcoiatron R aie wed s - C0 idiw - n Sand tl' EN, i1 f F.ne Swwl £3ic ;g - Hwidiny Is -- Loaruy-Sand — Greater Than s! .. S <a! �dy Loarn <' — Los Than t — Loaarn Rn Smarr 'wl Silt Loam 131 Rlmk si — Sit' Gy — Grey low Q (T =y Lo nc R — Red sic! — Silty Clay Loam mot - Mottles SG -- SONY f,lz'ly trjti — i ^J?th c. g SMY Cloy ft' fevv �fine, faint X _.. cGlay' j.ks`a's2- PI -- Prat rnm — Many, medium m Muck d — distinct p -- prominent NWi- — High water lever, Sip g eneral soil textures surface water for lirp6d uk'astrw disposal £3M — Bench Mark `,/RP _ Vertical Reference Point TO TIRE OWNER: 1 h Thi w € , q relmrr is the first stop it securing a sanitary permit. The county or the Departnser,t may terj pest ca .`un o r Q thk no _ n W the Fuld grin to t,t tact _=s.ra�amce. A cc`rnp to skit of plans for the private .,d4e syMon ?'d a tr_ e: h apolfc2a wn „"Sun be s"tPliir7ahmd to ME! a pprLlprt'�lle local authority in order to _Slaw a wfpiL i lay sarioat v rwrrrait now & obtdowd and lwood prior to the mat of any cv?rrstruCf ou3 I� .. REPORT ON SOIL 13ORIN&S l PERCOLATION TESTS LIS IIA#g0 t0 fel d" (r- s� 2- ..PLbr PLAN PROTECT r. D. DATE ate' Zf - 3I fr' I f ff HOMESITE TESTING CO. RT. 3, O'NEIL ROAD BOB Uf BRjc;j., : AUDSON, WIS. ,..._. 54016 e57 SS"— 02 yet. seA% / y � PROPOSED m wse MosT LIE 2.5* FT at Mop r "oAf ALA TEST �9 ,PEAS. foo posE 0 WELL MVsT LIE 54 F a� fi D�PF F�Poti ,,tc TEST �.PE/1S, • = e #4F f iTs O = 4r1 ev- wELL �( ` �E.QG /pGq��p,Uf � _ /lqu� Rv9EQE0 o,Q S�iDI�JEt �tES • ` RZ A t RZAMr PO 110'e;z . B P� F rice l_ %a r T op � 1 y P �e s4 r ���/ VR So Vo"� SOT 10,V rfN /•'A!E � • /a *,�,�/VExT To w op -erct rewcej- LE GE N D elEVhrON Df tl r. &, P r /00. 1 . o r 3 •.- AR EA- Meier ` s�J! �r ♦ i LoT Z o f Cf r �k E 3 X £ VAT lD+v f ��s i5 �g. �/ E I �. d RYA • H �' TE E 0 � S h / bs )q i C3 c� s - - - -� b 3`I ov S aL SysTLwm TO iE rN VEST �P£R bL �1 �Ey4 ��' R PT ` So N d2 we o p fE'a�c /ppSTS '��/ ti 3,5-0 1 2 6 t-e „gyp Pro �,y , ,r- y Parcel #: 040 - 1041 -20 -100 02107/2007 10:09 AM PAGE 1 OF 1 Alt. Parcel #: 09.28.19.137G 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner HAROLD J & DIANE FELBERG O - FELBERG, HAROLD J & DIANE 446 N GLOVER RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description " 446 N GLOVER RD SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 5.160 Plat: N/A -NOT AVAILABLE SEC 9 T28N R19W NW SW LOT 2 OF C.S.M. Block/Condo Bldg: 6/1593 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 09- 28N -19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 730/525 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/19/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.160 71,500 179,300 250,800 NO Totals for 2007: General Property 5.160 71,500 179,300 250,800 Woodland 0.000 0 0 Totals for 2006: General Property 5.160 71,500 179,300 250,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 148 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I r cn En O w rt w m ON r C V G m ;J m �d rt G 47 r• � O r• V 0 rt rt x w v N r t 4 O '' ON � E o cn � H V � r'- 0 0. O W ON H 0 b z z �� ::E� (� cn rt o o x o (p rn K H ri -L