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040-1185-50-000
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Permit Holder's Name: City Village X Township Parcel Tax No: Jenkins, Ann I Troy, Town of 040 - 1185 -50 -000 CST BM Elev: Insp. BM Elev: BM Description: �c�,,,�, Section/Town /Range /Map No: in,- b Q� y U ,Q/ht rn Iv7 V 36.28.19.761 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 577 /tom D Benchmark O 2, p O r Dosing Alt. BM r�Z��XX v tiYU r Aeration / Bldg. Sewer Holding � St/Ht Inlet -� TANK SETBACK INFORMATION OU ` s h 12' 2 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet - /^ 'w ` L g Septic �!y n Dt Bottom s- pi � � c` I ` Header/ an. `Js q IS �Ti" r 1p Aeration Q rl� Dis�Pipe v Z Holding B ot. System L g v F I G r PU /SI PHON INFORMATION J V� �'�� �� WA l7?•Z gg �S Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss m Head TDH Ft Forcemain Le Dia. Dist. to SOIL ABSORPTION SYSTEM P-cr ( y` _ 2Z -10/ BEDITRENCH Width Length No. Of Trenches PIT IONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 11 5 SETBACK SYSTEM TO P/L VV JBLDG WEL LAKE /STREAM Manuf INFORMATION C ER O Ty Of S stem t / UNIT Model Nu er: �YCAj > $ ? S IBUTION SYSTEM S Header/ anifoY Distribution x Hole Size x Hol�ng ent t Air Intake b� - Ipe(s) > Length Dia Length Dia Spacing / SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Al l L'1�6 Depth Over t Depth Over xx Depth of xx Seeded /Sodded xx Mulched V / (,� Q s To soil Bed/Trench Center � ��. Bed /Trench Edge P sz� Yes :��1 No ' a] Yes � No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / U Inspection #2: / / ' Location: 63 E. Woodrid e Drive Riv r Falls, WI 54022 (SE 1/4 NW 1/4 36 T28N R19W) Oa k Ridge Acres Lot 8 Parcel No: 36.28.19.761 1.) Alt BM Description I � U 2.) Bldg sewer length = r �J f / N (r - amount of cover Plan revision Required? l Yes ' o r S S Use other side for additional information. ! 6 Date LQ �e, Sign ure Cert. No. SBD -6710 (R.3/97) r Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. I Sco nSII � Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 J Z 53 Sanitary Permit Application A EN .D. Numbe In accord with Comm 83.21, Wis. Adm. Code, personal information you provide / V may be used for secondary purposes Privacy Law, s ^ ro)ect ress (if different than mailing address) I. Application Information - Please Print All Inform L ation 3 Property Owner's Na me Parcel # 10r. Block # A vian TenKinS $ \-,,. Property Owner's M ailing Address Property Location fo3 E. w0cdrict �l° City, State Zip Code Phone Number ' 'A, N W '/s,Section 3l0 'R\vey FcL [lS, L01— 54oz2 p (circle one H. Type of Building (check all that apply) T .Z. $ N; R l� - Ti." W aK 0 ,1 or 2 Family Dwelling - Number of Bedrooms(z) Subdivision Name CSM Number ❑ Public /Commercial - Describe Use OU rta 9c A uts ❑ State Owned - Describe Use _b t.J �I • 5 �- �� % S )c2- (:�ID ❑City_❑VillagegTownship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Re lacement S stem Y p y ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System B. I ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner Q ! 2 / IV. ype of POWTS System: (Check all that apply) Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ A•_robic Treatment Unit ❑ Recirculating Sand Filter El Recirculating Synthetic Media Filter El Leaching Chamber El Drip Line ❑ Gravel -less Pipe El Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proed (sf) System Elevation 8� 30 50 ✓ . fj/ ✓ /.ZS /.ZS� / JIGJ� !Mort T "e . 4, 711. 711.`/D VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Filer Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic oaadekk**;tadE. J _ 6&_ `Coe 1 e � � Q �l Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, asstnne responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) MP/ is Si gnatu a MP /fir Business Phone Number P AUL C.S S�.e�ne+r ��C ZZS� S 1 1 , 71s- q zs- 5544 Plumber's Addre ss (Street, City, State, Zip Code) 8d3v 91-4s`+f St. �),\yar Falls tul 54oZZ. VIII. County Department Use Onl X Approved ❑ isapprove Sanitary Permit Fee (includes Groundwater Date 7 sue Issuing A Signatur (N tantps3 Surcharge Fee) � 7v� .,7 �• O � ❑ Given Reason or Denial ` v IX. Conditions of Approval /Reasons for Disapproval SYSTEM OWNER: 1. Septic tank, effluent filter and dispersal cell must all / as per management plan provided by pkffnlW- 2..All setbeok requirements must be maintained n per appWc" Code 10*dn". Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) p lof l plan �a Bore holes A _ e-,n,k Mar k BA )1 , a f S�cQ,nc� f le v =16d Am 1 Y'cnc4cs //r Lcn� �Cse EZ - rlow I 8s Dr►ve ! cy 4y j�1t« �, fXisfiny o r loo��gl�Se�yir� 3 Bed Dent ( � Nome xa fin y J• �,{ a5 � � N �. �d� /lS � L ang New ]�YPrc�ies � pu` r I B3 plof n Sea l c j yap A 8 e,tck Mar k BAPA 8 'f $rct'rKg Flea =lod /Vew EZ - Flow /It f il ier 14eld45 d ust A �Yev o 41 L o f f l jittc� (ja,o5. �well 5 fYirfi�y loo0 4l S�i,� o Tin n 3 3 8edmaxt yome 'V A l3M i �F Trtr ` �p f �1<'� Fe l i \ �8y Cam` Wisconsin Department of Commerce SOIL EVALU Of Page j— of Division of Safety and-Buildings in accordance with Comm 85, Wis. A Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must ro 1 include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. � w / /g � percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 0q0 500W Please print all information. Reviewe by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Q Property Owner RECEIVE Prop irly Location S Govt. Lot 1/4 1/4 S T N R E (or) W Property Owner's Mailing Address JUL 0 5 2007 Lot Block# Subd. Name orC # City State Zip Code one 1;�01X COUNT $'dttfage ,Town Nearest Road ' r wl Syo ( a ❑ New Construction Use: ❑ Residential / Number of bedroom Code derived design flow rate GPD Repl ac_ement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments and recommendations: Boring # Boring t1 Pit Ground surface elev. . ';/ ft. Depth to limiting factor Q14-P in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 /bY 5 a A a 6k 1K fr C w • 8 .2 - /oY m V fr r to 3 6 YA d / L a R 3 Yr I C, . G . 8 •92 )OLL Boring # � Boring Q ® Pit Ground surface elev. ®� • 3 ft. Depth to limiting factor EKG in. oil Application Rate S Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz, Cont. Color Gr. Sz. Sh. *Eff#1 *Eff #2 -1 16 l AAPlQ 3 lih f C W • g ) 2q ip si CZ M bh M 1 G 1 9 a4 - 3o &Y y v M r s w y - s t1 y r ,I ' 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 e (Please Print) Signature CST Number . rp&L e •3.54etncx' a 22s zff Address Date Eva ation Conducted Telephone Number ►J �� 3 0 Cl 5�' 1��vcr �v��15, 514o '716 - 4 Z S - S541f Property Owner A/ l jq �eh kit S Parcel ID # Page OZ of .3 Boring # El Boring F -3 -1 Pit Ground surface elev. � . o 7 ft. Depth to limiting factor ,.G in. Soil Ap lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 8 A k i CA4 6 8' t1 FY-1 Boring # F] Boring / Pit Ground surface elev. Depth to limiting factor o _ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 I `Eff#2 0- °2 1 s it V e ►4►t1 • (� r s - #0 1) YR 3 Z- ht ,4 C w 8 to • a 54,,�� ? 5' r r' NP N Oc' Boring # Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I - Eff#2 i * 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) I B �orc Woks .A ` Sere. M' ,rr k BOHOX, 8 f vwll l Flev =100' f �e,tv Teencke5 /8'ZOX kite EZ -I -loin /U$w Fi'f t er 4 ,4dd d u f A � er ref , Tom Q 41 Zoe �►I �r p 8s Dr►'ne �ioff" A well y, fX /t���j/g , VI 3 3 rte► -pe� (� Nome -v 8 Aam , Its eUr ws'h, y T rer e l a5 0 �O� !tS' Long. New Tr erc�iES So`�� �3 \ ®8y 40 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buye Mailing Address 3 . UVOUdri d e Property Address (Verification required from Planning & Zoning Department for new construction.) � 'dr City /State A ' I ye y L IS , U�► --� Parcel Identification Number © q 6 - l 1 `a5 - 50 - Q00 LEGAL DESCRIPTION Property Location � � '/ , 1 % , Sec. 3 (� , T 2$ N R 1 W, Town of Subdivision uQ K �� d�� CeS , Lot # D I Certified Survey Map # , Volume , Page # Warranty eed # 3 & Volume Pa e # VJ d ty � � g Spec house ❑ yes ao6 Lot lines identifiable Eyes 0 no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Dep artment i g ep wi thin 30 days of the three year expiration date. I /we certify that all statements on this form are true to the best of my /our knowledge. I /we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATUR F APP DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the R n S e�K I r - 4 6 3 C. h d 5 residence located at: 1 /4, N W 1 /4, Section alp , Town 2 RN ange Town of �rut�I , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Lo T 9' 04 t-ld r Most recent date of service Did flow back occur from absorption system? Iles No (if no, skip next line.) Approximate volume or length of time: gallons minutes Capacity: 0 Construction: Prefab Concrete Steel Other Manufacturer (if known): Age of of Tank (if known): a TAW- (Licensed Tomber Signature) (Print Name) Yw- stj -e rt cQRSgSj (Title) (License Number) MP/ -S (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner '— � K) %� S Septic Tank Capacity CO a l ❑ NA � Permit # Septic Tank Manufacturer W S -tr ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms 3 ❑ NA Effluent Filter Model Z ❑ NA Number of Public Facility Units jsi NA Pump Tank Capacity / gal 0<A Estimated flow (average) o al /day Pump Tank Manufacturer Design flow (peak), (Estimated x 1.5) 4 1 D a gal /day Pump Manufacturer NA Soil Application Rate 6. gal /day /ftz Pump Model dA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit 0 Fats, Oil & Grease (FOG) :530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODO 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) _ <150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand _ <30 m /L In- Ground oc yg d (BOO 9 � (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) :530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank At least once every: :-month (Maximum 3 years) ❑ NA p ( s ► ry � year(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: month(s) (Maximum 3 years) ❑ NA ❑ year(s) Clean effluent filter At least once every: ❑ on ❑ NA � I �year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) t4!rNA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) 21"NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) II - Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. • Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name { - e iY,oy Name ' -TTC - 4 V Phone Phone L{ ZS- S- 4 �F SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Q !re o u #4114 Name n o � >l CI O, ✓�, Phone � - Phone 715 - 3 V, - `Al 3 This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER t 1 POWTS MAINTAINER Name k _{"el ►''OY Name � u Phone L4 2S- S Phone C( SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Drtfr w Name S V' a , X o v ✓t. Phone .7. — Phone V15 - 31N — W3 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ® r SfioCit No. 1 3001 NGrw.Ca.eorti OOCtJWtt7 }}p, STATE BAR OF MISCONSIlt -RORY 1 VOL 664 �� 468 WAARA14TY DeED THIS SO-ACE RESERVED FOR RECORDING OAT^ 1 THIS DEED, made between —Rol 3 j ng Eli I IS - -- r ` �_____IIeu ^r ccar�;_a inn, a Wisconsin 16th —_ c — May 83 grantor ` L� and _____.-- _Mike_A__Jp i ns and Ann - M_ T n i nG ._— 8:30 A _- -- -- Grantee, 1 Wt t ne s s e t h , That the said Grantor, for a valuable consideration _ - - - - -- RETURN TO _ conveys to Grantee the following described real estate in 4t Croix P11K J k I 1 County, State of Wisconsin: Tax Key No. ��p - its 500 Lot 8, Oak Ridge Acres, Town of Troy This i c not- _homestead property. ) (A) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging, And Rol - lino Hills Development Corpo L ion warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements and restrictions of record and will warrant and defend the same. Dated this day of __— _—.— M?Y - - - -- - - - -, 1983 ROLLING HILLS DEVELOPMENT CORP: (SEAT,) � f/ !� � (SEAL) _____ - - - -_ -- --- _ - -� -- fBk ^_Richar N, Fix, Presiden (SEAL) �� � t'- (SEAL) �_ __ •� J. Fra nces Fox, Secretar AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this_ -_ -_- ____day o f STATE OF WISCONSIN _-- - - - -.. 19_� PIER County. Personally came before me, this _ day of s __MAY _19_8a _ the above named __ -- -_ TITLE MEMBER STATE BAR OF WISCONSIN _ Blchar d-N._- Fox. &..I. Franc -PS Fox _. (if not, authorized by 706 06, Wis. Stats.) This Insttument was drafted by Jaseph, D- Lol es, - Attorney to me known to be the person who executed the fore- going Instrument and ackwi-wil dget�the game r River Falls, t�isconsi,n Charles F. P gX n (S ;natures may be authenticated or acknowitdped. 4wh - are not necessary.) Nostar Public ST - C19O1X _ _ County, Wls. 11t ( o:nmisslon is peraiAnrno,. Ai not, state expiration d:ece b1ARt`'1i 4 19 •Vaa!s, -,f pera ,n :r gn:nI, rn arty aeo a. - r Iv ,u. be !Y P e:.1 ,.r pnn''t r ,,. t., Y ANk A�4TY i7F: F.rr .Tarr. BAR OP W:i-UYSi!r' rrl;i ti:. - a Form -STC- 104 AS BUILT SANITARY SYSTEM REPORT f f ,� OWNER �l e K i N 5 TOWNSHIP U SEC . T N -R jg W ADDRESS S 'S'' .7 Y ST. CROIX COUNTY, WISCONSIN SUBDIVISION <:2� kR t�Cc? `LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 11/l l v�o� d�0i e Ur l et e rTM IM may' ut �► . l� � cT , ;rv' Ve INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: loo ,421 Proposed slope at site: �f SEPTIC TANK: Manufacturer: (fj/��� �� Liquid Capacity: /coo t Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: !7 Number of feet from nearest Road: Front,O Side, Rear, feet From nearest property line Front,�Side,ORear, _ a r feet Number of feet from: well building: ; tf (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE * j 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: — Ff Length: . 6 — . Number of Lines _ Area Built: s� Fill depth to top of pipe: ,3$ ' Z $' 1 ✓lG�' - -5. Number of feet from nearest property line: Front, 0 Side, O Rear, Opt. 7 Number of feet from well: 0 L J^ J a y Number of feet from building: _� f (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom p.£.seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: r Alarm Manufacturer: Inspector: Dated: �/�'`�� Plumber o j ob : License Number. ., 3/84:mj i DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUll RELAT &ONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, W+ 53707 MCC ONVENTIONAL E] ALTERNATIVE State Plan I.D. Number: El Holding Tank ❑ In- Ground Pressure El Mound 111 assigned) NAME OF PERMIT HOLDER: J AODRESS OF PERMIT HOLDER: INSPECTI N DAT Mike A. Jenkins R. R. 5, River FAlls , WI �r(, BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: IREFfPT. EL V.: CST REF. PT. ELEV.: SE NW Section 36, T28N —R1 T own of Troy, Lot#8, Oak Ridge Acres �)C Name of Plumber: MP /MPRSW No County Sanitary Permit Number: Paul Cudd r 2739 St. Croix 64893 SEPTIC 2 TANK /HOLDING TANK: // ' MANUFACTURER: _ LIQUID CAPACITY: TANK l LET ELEV: JT��K OUTLET ELEV WARNING LABEL LOCKING COVER 5 7 PROVIDED: PROVIDED. YES E NO ❑YES ❑NO BEDDING: VENT DIA.: VENT MATLL: HIGH WATER NUMBER ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM. s, � LINE: �• ,j AIR L DYES ❑NO DYES LINO NEAIREST '/ DOSING CHAMBER: MANUFACTURER - . [ 71 LIQUID CAPACITY PUMP MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑NO ❑YES ❑NO DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. N OF PROPERTY WELL BUILDING: VENTTO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until F the soil is dry enough to continue.) MAIN CONVENTIONAL SYS ey WI — LENGTH. NO. OF DISTR. PIPE SPACING. COVER INSIDE DIA. - . *PITS. LIQUID oga/TREN&H J� { — TREN ES (J� (• RIAL: P IT DEPTH: 011ME1IhStONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE JOISTFI. PI //P` MATERIAL: NO, R NUMBER O F PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIP ra ABOVE COVER. ELEV. INLET. ELEV END J ? PIP FEET FROM : LINE / AIR INLET az j���, NEAREST 7 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- El meets the criteria for medium sand. TIONS MEASURED. � NO SOIL COVER I TEXTURE PERMANENT MARKERS OBSERVATION WELLS. DYES 1:1 NO ❑YES ❑N DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED SEEDED - . MULCHED: CENTER. EDGES. DYES [:1 NO I DYES 1:1 NO ❑YES ED NO PRESSURIZED DISTRIBUTION SYSTEM: I3ECl1TRENCI I WIDTH: LENGTH LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: TRENCHES `;ME�IOINS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO DISTR. I D ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.: ELEV.: CIA. : ELEV.: PIPES: DIA.: ELEVATION A Il ISTR M'A TIClN TION I FORA HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: DYES ONO 1:1 YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMB OF LR ERTV WETC7 7DIN G: DYES 1 NO ❑YES ❑NO I NJEAREST � Sketch System on Retain in county file for audit. Reverse Side. 7 TITLE: DILHR SBD 6710 (R. 01/82) �c &_ i .wlsconsln -' APPLICATION FOR SANITARY PERMIT D ILHR (PLB 67) St . C r oix C OUNTY OEPRRTRIEnT OF UNIFORM SANITARY PERMIT # IrIOUSTRV, LRBOR& mumRn RELRTIOnS V 93 — 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 OWNER MAILING ADDRESS Mike A. Jenkins Rt. 5, River Falls, WI 54022 PROPERTY LOCATION JIXXX SE 1/4 NW /4, S 36 , TL8, N, R19 KXNXW X Troy LOT NUMBER I BLOCKNUMBEF DIVISION SUB NAME I NEAREST S ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER 8 - - -- Oak Ride Acres oodrid a Drive TYPE OF BUILDING OR USE SERVED r,► _ _!� ._f 2J 1 or 2 Family Number of Bedrooms: ❑ Pu i�fy THIS PERMIT IS FOR A: ® New System ❑ Tank Replacement ❑ Repair 7 Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepaye 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 1000 1 Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: Wieser Concrete Products IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed 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): Class 2 750 750 ® Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for in lation of the private sewage system shown on the attached plans. Name of Plumber (Print): Si wratury. I MP/MPRSW No.: Phone Number: Paul R. Cudd MPRSW2739 (715) 425-2049 Plumber's Address: Name of Designer: Rt. 5, Box 364 River Falls, WI 54022 Arthur Wegerer (576) COUNTY /DEPARTMENT USE ONLY Signatur201 Issuing Agent: Fee: Date: El Disapproved / � El Owner Given Initial L41 I J ' Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber 6� a 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 upit, (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 questioconcerning your system contact your local code administrator or the Bureau of Plumbing, DII-HR, State of Wisconsin. Owner's name San. Permit No. H63.05 PLOT PLAN r S how: Location of building served NA Dosing chamber Ca Septic tank Vertical/horizontal reference point uPr1i�� - rRCMVCH- C� 9�. ) Building sewer System elevation isb cwlI',,uL 4 -c _.9�• Pj Effluent system Well Replacement system area Property lines w /in 50' of system Distribution boxes j ,j} Scale = \� , or dimensioned 1�1} Pump and controls: t � _ Mfr. & Model No. Vertical Lift Size Force Main Friction Loss T. D. H. Vol. Dist. Pipe Gal. per thin. Gal. per Cycle Place check mark in appropriate box, indicating item is shown on plot plan 1CZoN PIPE �t�P -Loo l,eT UA.IC J J i � \ouo GAS- wtiESC� r' 1I1 .A 1 Cor�C. S�PTC Z'Pw\r \'TC H' .0�• O I / ex�'RL'T �`L. = l o 1 . 1 J I =' S S a �� f FiL LZn 1 G3 'F'1 - ZL'J 10Q0� BS a� ToP oF7aEe .b y "pvc G CE Bux. pp LATeRr, t, Z 'PIPE. 89 v I s / By the granting or approving of the above plan, or upon the event of a subsequent permit being issued,St.Croix County and the St.CroixCounty Zoning Administrator, does not assume or hold itself liable for any defects in plans or specifications, plan omission, examination oversight, construction, or any damage that may result in or e installation. P umber s sign a ure Licens — e N. -- �aCe _ Art DEPARTMENT OF REPORT ON SOIL BORINGS TY & BUILDINGS INDUSTRY, �,� � �! DIVISION LABOR AND PERCOLATION TESTS (11 j ��lj M� SON WI 370 t HUMAN RELATIONS (H63.090) & Chapter 145.045) Oy LOCATION: SECTION: r UNICIPALITY: LOT NN: K. N I N E: SE+mj /a 1 /a 3� T N/R 19E c ► � g t2. COUNTY: OWNERS ' UYER'S NAME: MAILING ADDRESS: S� , �.ZUtX S`'11 �� !ti Z2 S dux `�y Ai��v SVu�,�, USE DATES OBSERVATIONS MADE + NO. BEDRMS: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS: L aResidence 3 N /1" New ❑Replace 5 — RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN -G IOUND•PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional) ZS au ❑S ®u �S ❑u oS �.0 EIS ®u z�c�S H 5 t ><�s If Percolation Tests are NOT required DESIGN RATE: Q If any portion of the tested area is in the under s.H63.09(5)(b), indicate: N Floodplain, indicate Fl elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER -I CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHM ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- S 9.� 1oZ.5 I�o�,F 7 9.6' �.3` - o�Y-Bn L s ; �.�' "!6h LAS ; o. S'13h IS ; B- 'V-S L 8 r\ ' T s w I L S Pt e'-e S B- 9 �o•yI l(�.p IUVyJ" > 6. V (-TS 1 , L/ I 8n •3.1 ' 8K UJAS B - S , o. 6' k - A1 - re Ts CA+uB(3'.tb ft-ft a B- B- PERCOLAT40N TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P- P- P- ° CL = S T+ VL6 119 (1.t bF 11 R V2 b 15N I C) 19 8 Z. 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, ti I'NI'M Pr<l, Z EZ-LRCpy(5vT �At- ti-►t.L - X2.38•) � - fit. 96.9 ' SYSTEM ELEVATION -- r _r - - r _ 1 _ ( I f I �Pto��1- y,a Zu E 15IS I I WN w E E . 1 3 3 I _- -- (--- - I , I I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: '�-t'cz_ Z L. w�c> S- I b - 8 S ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): • l2-T t3 o X Z� I- wo RT» w 1 S v o! S �: �ls jZ�U \SII IVt �U� `pVS� 'gff)ti16 CST SIGNATUR "Toa c.� `tn s�rs'� s'�2�1a oZl6!!�►rcl -ley �t� -oPos� �"+� ��� '1v C=r�C. Y C�L/��iJ IN �2151�v1t1, P� - C � DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) — OVER — INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 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; 3. MAXIMUM number of bedrooms or commercial use manned; 4. Is this a nevv 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 abbreviations 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; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complele all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. I. the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 1 1. Sian the form and place your casr rent address and your certification number; 12. Make legible copies and distribute as reatuired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10 ") BR - Bedrock cob Cobble {3 - 10 ") SS - Sandstone gr - Gravel (under 3 ") LS - Limestone s - Sand HGW -- Nigh Groundwater s:s Coarse Saiid Pere Percolation Rate rned s - ta. odium Snmi W VVeli Is - Fine Sand Bldg - Building Is - Loamy Sam! �> Greater Than 'sl -- Sandy Loam -- Less Than i - Loan) Bn - Ba'ov 'sil Silt Loana BI Black si - Sill Gy -- Gray cl - Clay Loam Y - Yellow sci - Sandy Clay Loam R - Red sic( -- Silty Clay Loam mot - Mottles sc - Sandy Clay w/ -- pith sic - Silty Clay fff - fevv, fine, faint c Clay cc- commas, cr�aarsi I }t - Peat rnm - Many, roedium m Muck d -- distinct p - prominent HWL - Hirsh water level, Six general soil textures surface mater for liquid vvaste disposal BM - Bench Mark. VRP -- Vertical Reference Point TO THE O ' his soil test report is Ilse first step Ira scacuril)e a sanitary permit. The county or the Department may rertuest r fication of this sagal test 'sat the fi: prior 1�o peirni issuance. A complete; set of plans for the private <ge sysiern and a p - rni` application. must: he sub,ttitted to the appropriate local authority in order to owa!n <a l,ermit. The sanrtai }y peirnit mmst he ohtadwd' and posted prior to the start Of any ceraastruction. _ I NA)-IE CROSS S= �7I3 �'�1 �uSH���t f�PARUU� 54/.7Z?IETIC �L \oZ•$ ,RTN1�';�CST ��ctS7N�6 pu:r�r, Covju` of 9'' Sa "hflxlhun u DF ZoFAG�r�EGA7E RF3oUe PIPE � v�7 n ni= w/ \Z FruISH� - Sort, C'2Anl: GrLI� lo��oF EL Ar.GRE66TE 8S �9 - J L ` f�ERF�AA•TLD Pt aE lU P�"T�H or DISTRIBU710M PIPE TO BC AT LEAST .INCHES BELOW ORIGIUAL GRADE AIJD AT LEASTEO IAICHES BUT IJO MORE THAM 42- MCHES BELOW FINAL GRADE MAXIMUM DEPT H DF LXCAVATIO►J FROM ORIGIIJAL GRADC VJILL BE 5� IUCHE5 MINIMUM DEPTH OF EXCAVATIOU FROM ORIGIUAL GRADE WILL BC Z'� INCHES I 7 S1Gl.]ED_ LICEIJ5C UVMBER: 7 DAT t v y r x x <o� m o m 2 m _ cc z ' �o ?m v m m° o c 7R c �p �-00 1 113 o w m to O a0 . 0O N co _ cor m = CD'C acn- i w v m � g� .AyyD C . / . N ► CL O (D C O w 0 7 r t0 O = O � ? w .... �w w w N v, w m C am I M n CO D < c�D O 20, ? wN� oDc � BOA =w wciw ��aw�w O = m Q �, C �m NON cn CD 0��� D M M �w J --I Z s aym 3wMM n -1 �_ U) CA Co v N ? — n > > w wN =aQ V) V CL v 3C �m�w�-� M oa o��v = i = i n 0 (COL M o EE Et 2. v � , c 9 ! '9 R N y � ID v w L) C m CL o ao f in c aw o wow ao.o.M cn v ao v-, * a ?vi Q fn �; cD ao5 ova c� -im(AM CL C o w = W? w w A w a CD o 3 z I Y ST. CROI X COUNTY AM�K, S Y WI SC0 NSI N ZONING OFFICE x; . 796 -2239 (HAMMOND) 425 -8363 (RIVER FALLS) HAMMOND, WI 54015 May 20, 1985 State of Wisconsin, DILHR Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Attn: Carolyn Haag Dear Carolyn: Permit #58946 is being rescinded, and replaced with permit#64893 due to the difference in the system location. Should you have any questions regarding this, please feel free to contact this office. Sincerely, Mary J. Jenkins, Secretary St. Croix County Zoning Office z O r o * K z M O z X :30 :o O rn M rn � � C O 2 x cn M m 00 r m rn 0 O ! o0 C K O Z = i C7 r O rn 4p o D n n :a M • O O o► m C o cn 0 � co 5z � C 9 _� W z M W 00 0 m o z n O '�z M C z 3 = fD c �m = m D �_ d� � �.�� o "' Q � " - _ ° "d 7 ' 7 �S M C m d< �m ; 7 " z m e ° m c v f) of a' ym 0a �d3? dD Nc 2 sc O »� 3 c Q < �w m » Q o v :Ew --- - o 3o m m ( s Z mf do 3��o c° a 7� '�co m fN 7 m N^� M c ° y'd f 3 g m cd c31 O m 0 m m c 'O O C O m 7 7 m �CCJ1 7'N C N S� SN.0 o p m � m _• 3 -• Q C7 m c��o d� � 0 3 f7 M m 0 �N 3 MN y T D am d C S N m m a m N N r N 7 tG N 7 S - y D o < m� ° a d3 j 'O m d o j 3 u7i• (D CD N 1 1 ti 0 3D 7' m c D 3 • 0• a < i DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7669 BUREAU OF PLUMBING MADJSON, WI 5378 El CONVENTIONAL ❑ALTERNATIVE I State Plan I.D. Number: 11f assigned) El Holding Tank ❑ In- Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: J ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Mike A. Jenkins R. R. 5 River Falls WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: SE NW, Sec.36,T28N —R19W, Town of Troy,Lot #8, Oak Ridge Acres Name of Plumber: MP /MPRSW Na: County - . Sanitary Permit Num er: Paul Cudd 2739 St. Croix 58946 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ❑NO DYES ONO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER N�IUI�IBER ON gOAD: PROPERTY WELL BUILDING: VENT TO FRESH ALARM. LINE: AIR INLET: FEET FROM ". ❑YES ONO OYES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL I LOCKING COVER PROVIDED: PROVDED: ❑YE S ONO ❑YES ❑NO DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH J OIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until MANN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH. I N OF DISTR. PIPE SPACING. COVER J INSIDE DIA. *PITS: IL IQUID fi�NtFENH TRENCHES MATERIAL: FIT DEPTH: ki'itNtEtt�l5{S GRAVEL DEPTH FILL DEPTH . PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER JE . INL ET. ELEV. END. PIPES. FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE, SHOW ELEVA- OYES NO meets the criteria for medium sand. T'IONS MEASURED. ❑ SOIL .`OVER TEXTURE. PERMANENT MARKERS. OBSERVATION WELLS. OYES ❑NO DYES ❑NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL: SODDED. SEEDED. MULCHED CENTER. EDGES: OYES ONO I DYES ONO ❑YES El NO PRESSURIZED DISTRIBUTION SYSTEM: { WIDTH. LENGTH. TRENCHES: LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER: 0601 rAtNICH . 'N�)ENC3NstS F' MANIFOLD I PUMP MANIFOLD DISTR, PIPE MANIFOLD MATERIAL- NO. DISTR. I DIA. ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: : E: : E: . : LE VAT1N 0 AN[ ELEV. LEV DIA. LEV. PIPES N I&7FN #BUTto HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED 1tC1RMATNON PLANS. OYES ONO ❑YES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS NUMBER OF' L IERTY WELL: BUI LOING. OYES ONO DYES 0 N NEAREST M Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE: DILHR SBD 6710 (R. 01/82) Wisconsin APPLICATION FOR SANITARY PERMIT 1DILHR (PLB 67) St • 1 Cr0X C OUNTY `DEPggTmEn,TOF (FORM SAN ITAR MIT # InDU5Tg4,LRBOq 6HUTgn gELFiT10n5 — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the s tem, on paper not less than 2x inc —See reverse side for instructions for completing this application. PLEASE RINT PROPERTY OWNER MAILING ADDRESS Mike A. Jenkins Rt. 5, River Falls, WI 54 022 PROPERTY LOCATION MNK SE 1/4 NW 1/4, S 36 , T 2 8 N, R � IMN W TOWN OF: Troy LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER 8 - - - -- Oak Ridge Acres Woodridge Drive TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify): THIS PERMIT IS FOR A: IN New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. , Seepage Bed Q 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 1000 1 Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: Wieser IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed 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): Class 2 / JJ 750 [6 Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): ure: P /MPRSW No.: Phone Number: Paul R. Cudd PRSW2739 (715 425-20 Plumber's Address: Name df Designer: Rt. 5, Box 364, River Falls, WI 54022 Arthur Wegerer (576) COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ❑ Owner Given Initial Approved Adverse Determination Reason for Disapproval:• Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber 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, (whother 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. Form - S T C 100 Owner of Property M, ` A A !% ink k,S Location of Property st� �4 NN Section ` R_L�_W Township ' Mailing Address w �� Subdivision Name Lot Number Previous Owner of Property ,•c,�eY� �f�rg i}"`C �( Total Size of Parcel k Date Parcel was Created Are all corners identifiable? Yes No Include with this application one of the following .Certified Survey Map .Deed .Land Contract, or .Other I:egal Document which describes the property PROPERTY OWNER CERTIFICATION I Me) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. 3 6V$ - ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an .oasement, to run with the above described property, for the construction of said system, and the same has been duly re orded in the Office of the County Register of Deeds, as Document No. ), SIGNATURE OF Ow SIGNATURE OF CO-0 R OF APPLICABLE) DATE SIGNED DATE SIGNED " ^ 'P71 ER RETtit�: GO MM: x °' e' TIP {$� trers�+r r,{ ," :xf�rd! r Jaw faheied andllddriss towrhiafl frlirrrNigli, blood rristiYe, Par tertnwaer, ter: r �5 or, • Y t CNarfter ( _ T QlAAtb6� n O 41 Q�lty��.i/illlpa Y i' fie, .A "• �},tr( 4 t Y:. 4 c. rte. A� #lIlt itl boe►A � tt .2 f . f, g' �' +�� t, wY�•VR end 4 ; };•_- r i Town rtf}i _ i ..rss.ii...a 7,g; .�iii+,...�. .. ..i. ..a..a...�r rti• ' .._. d`�iL �!`s >, �t+�. `'� �ftk 0 � r'� 7 ,, t 'a. c O tt i, a � #%Mfu OF Fyap4rtY fl eektanOei Units, If � Z ''Prim!' lnterac r! !JM �" t Dnh k [ 9'Fnily i #. t RNidstak c1 tiri ' "a" ss.r� 1 i -E6 4'unit8 b.: rZ {� Prat►1!!bd �� cKrs units c. '0 Mdastrii# "* Othsr „ Solar Dbsian c; ('�°, Rental m ; r Earth Sh iorad kf mf d r a .�f�v1 k Me 4. ❑ De* �i#in of land t b ect WhA was thaderw WU _ �5t. 8 t3W�iNi ►nterast.t !!lrsd Pint O #3etowl 7. YYheR is r ge 77 x ' 'faflow , o " `° ilrar►eaie ;d oes the grantor rstan any of e � to: # fl l.if# estate ' � h d � 1 L EST�4 r . ' w ao price .etc rWnds6 text even hundred. Do not include pNrson pls Vafri prop btr3 from lil►e 1 erty !$ `r k value of u* X31! WWI wk►d, waste trestmeut,.mfg MOE, other) inck0ed ►n Nne l x f TRANSRER EXEMPTION NUMBER if exempt for R 113 Ine jostructiori); Sec. 77.25. !l. corm: per bna ir la of glue (tine t times .003) !Make check payable to Register of A t own b t►Iport l lerOm of the Grantor's state Rf residence. Information orl i aurA wMl lee user eo' L : osof tlnteQbilklaearity mmnber.is voluntary: Ow daelare Oft pow4v that thie return (Including arhi yIng schedule► has been examined by us and `RY� o� �hldi t Signature Grantor or Agent - Date Print or Type open #iue' HERE, X fintor +_ �i Vol. Reel Image Date Recorded' 04" OMIK&d THIS •... ca! 1Hurrtbsr A yy p r w► SANK° A = 8 C x41 r . s DaUiCtt46., PRQPERTY �C10 NIP tS' _� . 4 Owner ft"M If 44" Payable to of Dn *jq$trvmer A- = -1 if. Pf gy-UM 'AIIIAMR:V". v ft� do bn& of the p (the T A 040100 �,i lesse#4*-400000K� C OW UIX 0 :and the m W=nyj" 1110M Enter ...... ....... 0 or is I no VI WW 117 an am k *#to t4 humber 0 thisform. Abo, PP IN 01 21 PA RT It' ORYSICAIL 11 1 �� 1. -� Item le: Check all beies -di ox muwu, sdt favIAW. in, � U 0*,' :'t F jUm, Check IV one ,4,-�-, Th.- on Chec Item I C: k if pre party is to �Aiitod. if non-reftw4osuiMMIL. - hem 2: Ch ,ad only one box w4ick bW describes iftlendetipt If 4"t" li�� Enter tot size. If unkn BMW estimated size MW iback nouw�mtw maked tow gVew Ul. 3b: EnWtotd acres. If til Itm,31;1: Enter nundw of I tom 3bV -- f- -ftewlibt Enter wA** of ac - P M win 3c. law nuinliff of fost **K* 400010. enter K , At�w: Owners of fetest 46�qp land A� nWitedby law to o"WOW Row Of-&Alf* of 10�4� Me oil" date must rer� ***V be (F&ff i0d ARM h rty ash Whold hullc caft of 41"AlikoP, entwv "at value 4ft A* could irdinarl Wymer 4 W, 10 00d N in,� I but iiampf" pig, T i 00juaAanter-Tooler. XWOW 0.43L'If -transfer is, this is pioi 41 an line 1. Alse" 66109 1 "WE10114W, Wb. saw 6A '%Ufn Is boselt I n 0.0 Apply to the trwift" 6f 31W par $190 an US161 Prior 41 to PW ioUd ti lo"Willi Mt of n Dec. 1811 ft too Sept 1. Int 90 osivow�,' too �-W 4 A Akio V - Ctirrintmov �Mnsfaf MM i*rW mllardless of thr#*Wlsti Wiftidenc4. Information M — IM - 5 !W10 is volluntary� 4 ql% SECTION 77.26 - EXEMMONS FROM FEE The fees imposed by this sullichapter do not apply to, a conveyance: (1) ftior to the effective date ofthis *46opter (Octo* 1, 1969). (2) To the Ur4ftd States or to this state 4to any iratn#entdity, apncy or, subdivisim to either. Weration confirms, corre a Which, executed f4w nominal, inso"te, or-no, TP (41 On sale for delinquent taxes'or i6iji (6) Oil po"MOK.. 4. A) hrsuantu merva of corporations. '(7) subsidiary zinporiql* to its parent for no "nsidoration kW nom consideration or in sole consideration or caocalkition,' M& bW*vwj4" ond 116001" bu$mnd, or parent and child for nominal or no -consideration. - '(9) aeuva" bsne&WV without actual consideratio Silent Sold 41010 tion u b L 77. 2(2 b). uteptatreq ired y 2 orioles securityforadebtaroM 6soMrA orig�lp�� l 112)'Nisuant to or in IOU condamnation.--� T • Stoc No. 13001 "":'."� DOCUMENT NO. " �� Q STATE BAR OF WISCONSIN —FORM 1 VOL 6 64 PbcEV WARRANTY DEED r ���• 1dv^ �� THIS SPACE RESERVED FOR RECORDING DATA eXEGI � �R a OFFICE THIS DEED, made between Rnl 1_ i ng_-ii 1 1 c St'. C !X CO., WIG. Development n orporati on, a Wisconsin Rec' i, R„eord this 16th nnrpnrati r Grantor OD'd Via_ May -- A.D , -1 �,, 83 and Mike A_ Jenkins and Ann M_ .Tenkins Gt 8:30 A M. Grantee, 1pMIK of Doha W i t n e s s e t h, That the said Grantor, for a valuable consideration RETURN TO _ conveys to Grantee the following described real estate in St _ ('rni x /►')iKe J C�� County, State of Wisconsin: Tax Key No. Lot 8, Oak Ridge Acres, Town of Troy 'F c S1 �SFER t xI D This i G not homestead property. *i (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And Rolling Hills Development Corporation warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements and restrictions of record and will warrant and defend the same. Dated this day of May , 19 83 . ROLLING HILLS DEVELOPMENT ORP: (SEAL) — (SE * * By: Richard N. Fox Presiden (SEAL) (SEAL) * *B J. Frances Fox Secretary AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this d ay of STATE OF WISCONSIN 1 , 19 > SS. h PIERCE County. Personally came before me, this 12TH day of * MAY 1983 the above named TITLE: MEMBER STATE BAR OF WISCONSIN Richard N ox Franc -e, Fnx (If not, authorized by § 706.06, Wis. Stats.) This instrument was drafted by , TnA e -nh n _ Rn1eG, Attr)rn to me known to be the person_ who executed the. fore- going instrument and acklml id. ge the same. }liver Falls., Wisconsin Charles P c� (Signatures may be authenticated or acknowledged. Both *• are not necessary.) Notary Public Si' !*QIX County, Wis. My Commission i$ 1>?tnlienj 6 .not; state expiration date: *Names of persons signing in any capacity must be typed or printed below their signatures. ��, s" 4 •... i _____. WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 1 -1977 U, ;y S T C - 105 r� r H SEPTIC 'TANK MAINTLNANCE A( ,'ItF.EMEN'I' St. Croix County OWNER /BUYER t1i ke ROUTE /BOX NUMBER Rocs f &G. 7 Fire Number - CITY /STATE Rivc r PROPERTY LOCATION :��' %o, N _'4, Section 1 N, R W, Town of �/'c, St. Croix County, - a 6c R, eye S, Lot number a Subdivision y_ Improper use and maintenance of your sepc is 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 pu Ler What you put into l I the system can affect the function of the septic tank as a treat - ment stage in the waste disposal system. St. Croix County residents ma_y be eligible to receive a grant for a maximu of 607 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 re(1uiremeut that owners of all. new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County 'Zonini, 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 H three year expiration. O z I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- Ks ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED r DATE — -� St. Croix County Zon_ng Office P.O. I,ox 96 Hammord, WI 54015 715 - 7� 6 - 2239 or 715 - 425 - 8363 Sign, date and return to above address. i P O LA r m S M � m p f/f w m ci N j N m a co =r =r 1 to c Q3 c o�n �r� z � o �p a cD (D ? N a 0 �w0 = ���� S W mgOo mXCD w� ,< 10A ( M CD c�D =r cCD cu v, O ' W 0 n CO 0 3 a c tp co W o w o_ h o ,< c_ c N Zo c <QM :E S W =r 0 w m c o am � < 0 Q -(a co CD oDc -FD o =w w 0 'a w m� O � v C N oNCD cD�a'w 2 N��� D Z o �Nm tD 3 ?a -1 o a 0 3 �ai� v� 3 M, co a w �o �o R1 w r: �-y c Q a =r CL ( N = a co " M y o (D 1 w \/ a w M Q- M S t o �o o w =co a G, �3a cQ0c *w M _. ,. ao 0 ,3-* ° 3 w �• n c �O co n 0 O 7 ao o o a c - iN c o C CL 'pm =r 0) a <_ c M.cM! o �` €. w n• � a cD o w 'a o s DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY-7 ' DIVISION LABOR AIJp PERCOLATION TESTS (115 MADISON W 53 07 HUMAN RELA11ONS LOCATION: SECTION: OWNSHIP/ .: LOT NO BLK. NO.]SUBDIVISION NAME: w�/ �/ 3 L /T :N /R 19E (or T A� S o+�K DGG cr COUNTY: OWNER'S BUYER'S NAME: MAILIN ADDRESS: ST• e- \f- F- ax L S, ��, SVt�, Z_ USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMER : AL DESCRIPTION: �� ! PERCOL ATION TESTS: Residence 3 1^� New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system L: M CONVENTIONAL: IN-GROUND-PRESSURE SYSTEM- IN- FILOLDING TANK: RECOMMENDED SYSTEM: (optional) ®s ❑u ❑s ❑u ®s ❑u EIS COu LH EIS ®�i Z SlX�S' If Percolation Tests are NOT required DESIGN RATE: S S If any portion of the lot is in the under s.H63.09(5) (b), indicate: — I Floodplain, indicat Floodplain elevation: -� PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED ES CHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) s1Ts; z�C'� L���t L - 16`` 8h si B- �p �-1 _ t�orv� 7 Lo ' ( o Bh 5� S �� N. �S Z ) ' -- 17` B 1 4 14 I� Z \- 7 ` f � J J 1 311?_ A T- mi B- 3 6 8 ZOp B- � - 7 3 1 � S - lva iN �, > � 3 '� 1 `' LT b„ �v L s i �c8s B- 7 Z DYLQ,� l TSB Z4/gn S ZT l3n �S w,//-S Tv G "N� m IS ; 3&"LrBt'FS kVLS n ib )o" 14 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PE RIOD 1 PERIOD2 PE RIOD PER INCH P _ 1 z y h P_ Z - LV P- 3 �/ �� 10 �/$ -7 /g P -. P_ Stl c�`�ToM of t �S zy� DES P- PLAN VIEW: 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 slop, p- S \ Sol L S�Zv� SttcwS2TR1 S") . ��7 roYl OF �Pti I �L N - �L I oZ ° 1 L l't� oFr �L \S "L,T _N 1�1 c t 1_ oC= t� T L 7 Zoe i SYSTEM ELEVATION C ._ 1 ._. .9_.. .., _. is - N &?_fA/14.E =t 11 1P " 101V,_nff1L_11 i , 8 I . .. . C w . Ly v� to e. 1 qN btu' 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER optional): >CLLSL)CTL`T1-{ S �- 1 7)s- ��ZS -J3 CST GN TURE- nISTRIBUTION: Original -Local Authority, 2nd page - Bureau of Plumbing, 3rd page - Property Owner, 4th page -Soil Tester. BD-6395 (N. 03/81) v " 1 J �nrcoe =. GT f�PARouLp 54�7'1HFT1C i.- C.ov L`X'J tiJ G oR 9" u DP 51T2RW Z "OF AC�iZ6GA7E 1)aoUti PIPE L4 V EiaT Pi w/ �pP2ovEA CAP 1 ` Vz HBCQA �p _ -" . FI I s L•TU SO«, AIX. PILA- boF � AGGREGATE BE<owprP� L pL y � G u �'�FuR+iTL'D P t pE 'lu �u1 h or rrit cH DISTRIBUTIOM PIPE TO BE AT LEAST .INCHES BELpw ORIGIIJAL GRADE AUD AT LEASTZO WCHES BUT IJO MORE THAI.] 4? - MCHES BELOW FINAL GRADE MAXIMUM DEPTH pF LXCAVATIOIJ FROM ORIGIIJAL GRADE WILL BE 30 II,lCHES MINIMUM DEPTH OF EXCAVATIOIJ FROM ORIGIUAL GRADE WILL BE {NCHE5 SIG IJED: UA7C: l� Owner's name San. Permit No. ^• H63.05 PLOT PLAN SN -� E Location of building served N A Dosing chamber Septic tank Vertical/horizor,tal reference point % PIMI-U'r7 J°H - \0 -.o Building sewer Q System elevation is town - AM%- - \ S , ✓� Effluent system Q Well Replacement system area Q Property lines w /in 50' of system Q Distribution boxes Scale = 1 1 ='� 0 , , or dimensioned Up Pump and controls: _ Mfr. & Model No. Vertical Lift Size Force Main Friction Loss T. D. H. Vol. Dist. Pipe Gal. per Min. Gal. per Cycle Place check mark in appropriate box, indicating item is shown on plot plan \RoN PIPE �ttP Zob LoT LAIN-3E ',1 ORluEwh�( �S'eR9u�or., �f v I Imo1� GR% Wj%PSQR GAP- - �' 1 I 1 1 r 4,c O { Law �,ovSE 1 ,o ��8 0 t_C 10o.D 'oN \Sb 5 Y N 3 by of Nm TEE . cR� $Ox ,t vo{ v By the granting or approving of the above plan, or upon the event of a subsequent permit being issued,St.Croix County and the St.CroixCounty Zoning Administrator, does not assume or hold itself liable for any defects in plans or specifications, plan omission, examination - oversight, construction, or any damage that may result in or er installation. P r ssure icL� ense�o. um g