Loading...
HomeMy WebLinkAbout042-1104-20-000 m ° o o 0 °� �n a 0. o � p = N � N H 01 L ,� • 3 I ts D m i •� d I > A y a U O N N @ Z C Z • C z 7 f6 p 7 76 LL p '0 - LL p o = 3 rL 0 Q U O. m Q I m M > M 3 I Z Yl N Z r w am am N F Z c O o z :i v r > > = c cA H r rn � °�� N N N N N °• o CL •'� d N L CL - _r_ C O 1 63 O Cl) O N Q O N O `y Q O :w O Z m Z O Z H Z _� z • TV A O y J y N C d w N O w N d d x N N C`7 a N d d N C O C', i, El '2 > a > 3 3 CL a 0 z • t_aaa ¢ caaa �i a O1 c oo 7 p N O) M N O O O U) -j U o rn } o rn rn Z r r r _ E @ o o �a Cc o o � g m c m c o o p as Q} to co N Q � •p — Q Z (n i6 H N 7 N O O O .a Y! C 'oO y C O o 3` w LLI ( a o 0 T G CV j O y O Y Vl € C 'O N N V O _O -~ j� O N >` � . C 7 C-4 (v 4 C I U Z N sO►1 U N d 'O f` 1` Oi O f6 O y N E Y Y Q) �_ C N N N o m ao o N o m o o R L • O N A O z c 1- 2 co O Z c Z U) in L: d ` d `Iw E 3 0 3 o A L) IL �Om0 0 mcj I Parcel #: 042 - 1104 -20 -000 06/27/2005 09:36 AM PAGE 1 OF 1 Alt. Parcel #: 20.29.18.574 042 - TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): " = Current Owner " MATACZYNSKI, EDMUND G & MARY EDMUND G & MARY MATACZYNSKI 1098 89TH AVE ROBERTS WI 54023 Districts: SC = School SP = Special Pr ss(e ' = Primary Type Dist # Description * 1098 89TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 1.330 Plat: 2334- PLEASANT ACRES SEC 20 T29N R18W 1.33A PLAT OF PLEASANT Block/Condo Bldg: LOT 02 ACRES LOT 2 EXC E 20 FT EZ -HWY- 1182/534 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 20- 29N -18W Notes: Parcel History: Date Doc # Vol /Page Type 2005 SUMMARY Bill #: l=air Market Value: Assessed with: 0 Valuations: Last Changed: 07/19/2002 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.330 29,300 160,300 189,600 NO Totals for 2005: General Property 1.330 29,300 160,300 189,600 Woodland 0.000 0 0 Totals for 2004: General Property 1.330 29,300 160,300 189,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 104 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 i Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: IX Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)), 344549 Per 1WVX t � §kI , EDMUND & MARY ❑ Cit vill c e Town of: State Plan ID No.: CST BM Elev. Insp. BM Elev.: BM Description: Parcel Tax No.: 042- 1104 -20 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi ng Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction Syesatem TDH Ft L oss Forcemain Length Dia. FFii Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/ Manifold . Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: WARREN 20.29.18.574,NE,NE 1098 89TH AVEN Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (8.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division SANI TARY PERMIT APPLICATION 201 E. Washington Ave. Wis P.O. Box 7969 In accord with tLHR 83.05, Wis. Adm. Code Department of Commerce ,. Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. T G QO J^ • See reverse side for instructions for completing this application State Sanitary Permit mber The information you provide may be used by other government agency programs ❑ Check if revision to previous pptication (Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number L APPLI ATI N INFORMATION -PLEASE PRINT ALL INF RMATION Pro p erty Owner Name Property Location C� �.. �. �- MCAT 30 4`nc.taC. Z � 6 )" N 41/4 /./ Ell /4, S 70 T Zc/ , N, R E (or ID Property Owner's Mailin Addres Lot Number Block Number QVI S ate Zip Cod Phone Number Subdivision me or CS Number ve•e.,fis W .. 5 2Lz3 Z715' V4t•3G7�, 1 •cas�,,.,+ Vi ti GPcS II. TYPE BUILDING: (check one) ❑ State Owned a Cit Nearest Road /1 Public or 2 Family Dwelling - No. of bedrooms _ Town OF �t�,}C,,,I �e ,.i 6 A v t' III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) - 2z . 2I ` 19.51 1 ❑ Apartment/ Condo 6 `) Z - /) V q - Zv - 0 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2, ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ of an _____System ________ System _____________ Tank Onl�f______________ Existing System ________ ExlSttnq System B) WA Sanitary Permit was previously issued. Permit Number 3 c+ f6 y © Date Issued 4 -18 V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 E] Mound 30 E] Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 []Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation �1 �U G 3 ' 4­7 40 , Z Feet 9 3 , / Feet VII. TANK in Capacity llon Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanksl Tanks Septic ' k /000 W -c ckS ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber. ❑ I ❑ ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. ** wtber's Name: (Print) 's Signature: (No Stamps) o.: Business Phone Number: .PfQt1'rti't?f's Address (St-Met, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Signature (No Stamps) Approved []Owner Given Initial y G surcharge Fee) ' ff Adverse Determination • X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: St1D -SM (R I JANQ DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber ST. CROIX COUNTY WISCONSIN - - - -_`` ZONING OFFICE ■ •••� ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 - (715) 386 -4680 AFFIDAVIT OF SYSTEM REJUVENATION Property owner: E a mLA �� �, � Address: 10 b P-- IZ�b -u4s, W-,_ s 4 z3 Day time phone: (7/ S) "7 4 S - 34 74 Parcel I . D. # 6i4 2 - 11 o 4 • 2 o _O Legal Description of property: NE Sec. zy , T. 1C4 N. , R. I�W. , Tn. of St. Croix County, WI As owner of the above described property, I kn � wledge that the septic system serving this residence (is/ s no undersized by current code standards. I understand that a issuance of a sanitary permit to allow the attempted rejuvenation of the septic system does not imply that the system meets current code sizing requirements, nor does it imply that the proposed procedure will be successful. I also acknowledge that I will make this information available to any future parties interested in purchasing this property. signature: Date: — — 9 C' 5/97 wisconsin Department of commerce SOIL AND SITE EVALUATION Page 1 of 2 Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code A.C.E. Soil &Site Evaluations Attach complete site plan on paper not less than 8' /s x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.# O L- F APPLICANT IN FORMATION - PIease print all information. R Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). j i Property Owner Property Location Edmund & M Jo Matac ski Govt Lot NE 1/4 NE 1/4 S 20 T 29 Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1098 89th Ave. 2 1 Pleasant View Acres City State Zip Code PhoneNumber City Village ], Town Nearest Road Roberts WI 54023 715- 749 -3676 Warren 89Th Avenue New Construction Use: Residential / Number of bedrooms 3 ❑Addition to existing building Z Replacement [] Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpo1ft .8 trench, gpolftZ Absorption area required 643 bed, ft 0 trench, ft Maximum design loading rate .7 bed, gpolft •8 trench, gpd/ft Recommended infiltration surface elevation(s) Existing system elevation = 90.54' ft (as referred to site plan benchmark) Additional design I site consideration Soil evaluation conducted for Terra lift rejuvination of existing hydrolicaUy failed system. Parent material Outwash s & gr. Flood plai n elevation, if app NA ft S= Suitable for system Conventional Mound In Ground Pressure AT - Grade System in Fill Holding Tank U= Unsuitable for system ®S 11 U ® S❑ U N S U ® S U Z S❑ U ❑ S Z U SOIL DESCRI PTION REPORT Depth Dominant Color Mottles Structure GPDIft Boring# Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ;Trench 1 1 0 -9 10yr3/2 None sl 2fsbk mvfr as 2f 0.5 i 0.6 2 9 -21 10yr4/4 None sl 2msbk mfr cs if 0.5 0.6 Ground 3 21 -52 7.5yr4/6 None s 0 sg ml gs - 0.7 0.8 elev 93.14' ft 4 52 -88 1 Oyr4 /6 None s 0 sg ml - - 0.7 0.8 Depth to limiting factor >88" Remarks: CST Name (Please Print) Signatu / Telephone No. James K. Thompson s� 715 -248 -7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, Wl 54020 6/12/99 3602 1046 icr i ?,� T TM Y zofz w e J w CA N to CA CA A p � r d 0. �► W .� �� r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM °0w uyer Mailing Address b ti - 0. Property Address (Verification. required from Planning Departmeat for new construction) Cit #State _ �c,� v �s, l,J _ Parcel Identification Number co Ll 2 - I t a 4 - Z 0 - o LEGAL DESCMITON Property Location r l E r /., _ N /, Sec, _ - Z- 6 . 1 11 - 9 N R Town. of 1til a,r r c,� Subdivision l ��. 5� ,� �- \) ; ,� ,(� ,nos Lot Certified SmTey Map # Volume . Page # Warranty Deed # 3 b L� , a 3 Volume _ G .Page 9 Z of Spec House ❑ yes ❑ no Lot lines identifiable .[9 yes ❑. no SYSTElVi�4IAlNANCE Im p� no p au � emd �yooQldtmrtspnuratuti� +eto handlewast6L Pznper . consists of pampiag oat the septic task every throe yesns or somcr if aoodedby a yuoeasedpun4i= What you put.mGo &c system ism affect ire frmctioa of tine septi c taaTcss.a ti�catmart ttsgC m the �asted"i_sposdxystcmL PL'oP Y owner agrocs submit to St CEoac Zug Department it oatific a ion. foam. signed by flue 4nn= and by a • IPdplcnmbaoriliaascdpampaves3 fyimgfirat (Ijdueoa�aiteR�duposalsystc� is m proper opotating condition and/or (2) after won and pm %ag.gf necessary). the mcptic taak less than w fa of sledge. Ywc. dw tmdctxM=d4ave read fire above mquircments and agree to maiat:ia &c private sewage disposal system wi& tine stmdaids set folk herck vs: set by the Depa bmW of Commerce and the DcPatM d of Natural Resources State of Wiscons:m. Cectmadoa 91 ting that Y= septic system has be= zngntahwd must be complded and tchun.ed to the St. Croix. i Oiix wbhia 30 days• of the throe year expiration date, �Y � F .aPpra / of r DATE Oymm. CERTIPTC VITON I (we) ccr fy that all statemcats on this form arc true to the best of my (our) knowledge. I (we) am (are) the owacc(s) of the property above, by virtue of a warranty deed roeorded in ltegistec of Deeds Office. C � : cl% - I Cri`lA DATE « « « « «« Any infoamation that is tuis-rcpreseatodmay tesntt in the sanitary permit being revoked by the Zoning Department. « « « « ` 0 «« Include with this application: a stamped wammty deed from the Register of Dads office a copy of the certifrod survey map if rcferenee is trade in the warranty deed K ' , �, - •.....••w+_ Two ePacZ at""as "0 secoaoHle "TA NTATN D" OF WUMNSIN FORM t —190 VOL QQ PAGE Qu c7 RECD STARS OFFKE z Gerald Louis .. Ka�dea�t .......................... ........ ST. CitOiX CO., MIl6► ..... ........ ........, . ....... ............I.•................ .................... Wei. for Record IMt 10th ..,. " ' ............... .... ........................... day Of xty A. D. 1 992 .._, ............... ..... 4t+yR and wasranta to .Admund..Qi.... Max .ate!;yrA8ki..and ............. 01 11:0 A Me ,aDA.Mb K..Jo ll atacaynskf,-- .husband..and-- w1fa..&a...... . a3. at.. x�eaan. ts ................................................ ............................... ...................... ........................................... ...._.......................... i ......... ......................................................................... ............................... "Tun" TO ........... .............. . ......................................... ......................................... .. tie felbewing described real state In... St.-•- ;* ......................County, — — State of Wuoonata: � Tax Par-al No: ................. . ........... i Lot Two (2), Ple sent Acres in the Town of Warren, EXCEPT the East Twenty (20) feet Thereof, SUBJECT to easements, restrictions and reservations of record. Tp . , ....v•� ;seas $-M - r This 4-4 - 11Q - ..... --- --- homestead property. (is) (is not) Exception to warranties: i Dated this 21st .... s ..... day of sees Aprai.l . 1� . .. .......... ....... ........... - - (SEAL) - - ... __.,. sees.. ...... - - - ....._......._._ ............. Gerald Louis Nadeau. - . ,[SEAL) ........ _ ................. .... .•-•---- •- •- •-- --•---• -•• -- - - -- ..(SEAL) .. - sees.- sees---- - .. ---- _... -- ---- • . - - - -. - (SEAL) ... e ' - ......... ............ •- •---..._...--- --. • . ..... .. -sees. -•--- - - --sees. ..... ... .... .... ..........._ f t AUTHENTICATION ACKNOWLEDGMENT it 1 {i Signature(a) ----------------------------- ------------- ------------ - - - --- STATE OF Wt9e *N3tN Oklaho as ............. ._..--••-----•-------...--•--•------ •----------- ----- •- - - - - -- sees.. Jackson • ........ ..................... ...County. authenticated this ........day of ........................... 19...... Personally came before me this ... 21St ----- day of A il- , 18_$3__ the above named ................ ---............................................................ rald /�L� N_ ddec�- - -•- L - ••-- • - - - -- _. TITLE: MEMBER STATE BAR OF WISCONSIN tathoriud by � ?06.06. Wise Stets.) ..............•- •- --- •• - -• - -- s .................... .---••- -- -- -• - -- --- - -•- --- to na known to be the person ._. ...... 1 ,;'w�o elierufed the foregoing instrument and acitnowle4e 1h0.z Mir: •. TMIS INSTRUMENT WAS DRAFTED BY J ` •.. Reinstra, Van Dyk & Needham, S.C. - - - . • -- a. Attr�' rneyl3•• xt•• L�iv--------- •-- •------- • - - - -.. ._ � Jac � ----- - - - - -- :see - - - - -- IQEW_. 1�i11iLQnf1P.. JATi3Cf] 113jI1 ......................... Notary tic .. kson - s .? ".._.County, Ri's Okla] (signatures may be authenticated or adkaowledged. Both MY Commiasic is permanent. (It ;not,'•state expir$tion t are not necessary.) date : A @�u $. • =�., s - 19- 8-6- • '>Ii 7 of se"KW..ianine in any eapaeft should be ty or printed bdow their ■;Sox :«s, f �� .�_____. _�._-' -- - ped RC srw FOAM No. a tsC ei y Stodt No. 13003 r - AS BUILT SANITARY SYSTEM i(EPUK1 UWNJrk( /� �� A(i�Y�. f�' _ — "1'UWN•iHll' _ 5lrl:oZo '1�7�jly Itfgw (1-3 r . ST. LRU 1X LUUNTY , W I S 1N subDIVISIUti U6 ad l.U'1 _? 1.U'1' S iL1~ P LAN VIEW Dlatancae �lnd 4jadnaion CO weeL r•eyuirell►enLb ut 116J ... 1LI'+�YTHING WITHIN IUU 11::1::'1' 01" SYSTQ VaJ1 -.1_ I di Le N Lot� Arrow SC 1iENCHMA1tK: (Pdrawnent reference PUil►t) UCbLf ibc . ! iml Opt f:levacion of vsrti c a;l,, retarnnce p o1nL : fi - � 5 1upu aL a1Lc: SEPTIC TANK: Manufacturer: ,o 1.1yu1.J CapuctLy: /00 t dumber of rings on cover _Tank luu►it t)IC Cover cicv /O/ 19 p Tank Inlet Elevation: �%rL _ l a1►k UuL1C li1cVc► 11u1 1.' 0 PUMP CHAMBER Manufacturer: NuutUcL , ,i r;ullunt, _ Number of p utup adt �Or �► �ycl�:, ballutld, Lul�il �:aNu� ily �,E diatribu on linau _bu11011 aizr ur pump 11u1J, gallon or lninuLo , _ , hurue..puwtl brand name ul pump and dal nuulbur _ Ty of W4rning ev C0 HOLUING T Manufacturer_ NuwbL:I ut ba11011s Elev On of u"mhule. euvor l' e tit w ruing ddvice -- _ _. !iLEPA E P SIZE: _ `►4umiuur of i I_:> t'cct di�lwut uc fee iyuld cseepaLrC pll. iLdCl pipe - CleVaLL011 tow N t of Uda a e iL d�yvuLiull 1�`1 _ Sl- .*L'AI:E 1:G SIZ4: n umbar ut 11w;a __ 1 �� E, 11 L 1 IL: J 1,L 11 SEA,FACL TRENCH: width 1u111;L1► PLkGULATIUN, RAU � 4 AItLA �t1:QUTRI D �,��,�G ARL•'A AS BUlL'1' 1N51'l:l:Tuh UA'1'1:u_ 8 _, cQ , - - -- - r l.umw-.lt uN I Oli LiLL IISL NUMbl::lt � J- i DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR &_HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BLX 9969 BUREAU OF PLUMBING MADISON, WI 53707 CONVENTIONAL ❑ALTERNATIVE M. an CO. Number: ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DyfE: Edmund Matacz nski RR #3, Spooner, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELE V,� NE NE Section 20, T29N —R18W, Warren Township Name of Plumber: /MPRSW No.: County: niary rmit Number: Gary Steel 3254 St. Croix 34800 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNI G LA LOCKING VE OV ED: PRI ES ❑ NO BEDDING: VENT 01 .: VENT MATL.: HI HWA NUMBER OF G ROAD: ROPERTY ELL: UILE TTO ESH ALARM: //�� FEET FROM IR INLET: ❑YES NO ❑Yes N NEAREST DOSING/CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: U MODEL: P P /SI ON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO 1 0YES ❑NO DYES ❑NO. GALLONS PER CYCLE: D C N R L A ZONAL: PROPERTY WELL: B ILOING: V NT O FR H (DIFFERENCE BETWEEN u MP EET FROM LINE: AIR INLET: PUMP ON AND OFF) ❑YE ❑ Y NEAREST SOIL ABSORPTION SYSTEM. Check the soil q4bKure at the depth of plowin FORC LENGTH: DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a w' ,construction shall cease III Al M the soil is dry enough to continue.) C NVENTIONAL SYSTEM: WIN: LENGTH: O. DISTR. PIPE SPACING: INSID DIA. *PITS. LIQUID BED/TRENCH /' TRENCHES MATERIAL: PIT DEPTH DIMENSIONS r `— L H FILL DEPTH UISTH 1 F DISTR. PIPE IST I MATERIAL: NO. DISTR. MBER OF WELL: BUILDING: VENT TO FRESH BELOW IPE ABQVE COVER: ELEV. INLE7- EV.END: PIP LIN j AIR INLET: FEET FR �_ z 7 NEAREST IUC� MOUND SYSTEM: Mound site plowed perpendicular to slope Check rthext re of the fill mate a� for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown u mound to make certai th t it ON REVERSE SIDE. SHOW ELEVA- meets for medium sa TIONS MEASURED. DYES ❑NO IL COVER TEXTURE: P RMANE T MARKERS: OBSERVATION WELL S YES ONO DYES ❑NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH TOPSOIL SODDED DED� MULCHED: CENTER: EDGES: YES O ❑YES ❑NO ❑YES :10: PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH. TRENCHE . LATERAL SPACI (i G H BEL PIPE, F LL OE TH A 13OVE COVER: DIMENSIONS MANIFOLD PUM MANIF DISTR. PIPE I MANIF LD MATERIAL I NI ! ,Dl STR DI R. 1 DI THIBUIION I E MATERIAL 8 MARKING ELEV. ELEV. DIA. ELEV.. P S DIA .: ELEVATION AND DISTRIBUTION 1 INFORMATION HOLE SIZE HOLE SPACING DHIL D COHHECILY COVER MATE IAL VERTICA L LIFT CORRESPONDS TO APPROVED PLAN i ❑Y N ❑YES ❑NO COMMENTS: [EMANENT R A a RVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES L..INO I OYES ONO NEAREST 51 JA.3 49 �98 g � q';•ia Sketch System on d �unty file for audit. Reverse Side. S1(.NA TUNE � I DILHR SBD 6710 (R. 01/82) �� TMENT OF APPLICATION SAFETY & BUILDINGS STRY FOR SANITARY DIVISION B!: A AND PERMIT P.O. BOX 7969 U M RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: u nd Property Location: City, Village or wnship: County: ft tN E %a So?0 /Tc N /R /� W or) W W � ��� mber: Blk No:: Sub vision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: �S � J I / - C I (if assigned) TYPE OF BUILDING Public* ❑ � Number of Variance ❑Other (specify) * /� — QQ� Bedrooms: 1 or 2 Family *State Approval Required. —3 i TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER RGLASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 000 HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: W s e K S EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit l /3 ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): L MA Pk Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation 9 p y Ion of he private sewage system shown on the attached plans. Nam Plumber: Signature: MP PRSW .: Phone Number: ( / S 5 Plumber's Address: Name of Designer: 8 20 v9 � COUNTY /DEPARTMENT USE ONLY Si na ure of Issuing Agent: Fee: Date: Q APPROVED Sanitary Permit Number: ©� O ❑ DISAPPROVED Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White - County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod- Plumber DILHR -SBD -6398 (R.07/81) L 0 cn =,00' l I I '30` r �d uFir,ny � 1 ►20GK cQEt� 3' ) 44) go c�s� � PP I )"Yl � As �6 Form - S 'r c loo i Owner of Property A 02ak � G A - 7 Location of Property � �t��, Section ° ,T R /b' W Township it, ja, rY uLY s Mailing Address R61 Subdivision Name Acres Lot Number o Previous Owner of Property Total Size of Parcel 170 X ' 2 V3 Date Parcel was Created Are all corners identifiable? Yes X 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 (We) 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 ' 3 // 5 �9 ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. ). c� SIGNATURE OF OWNER SIGN TUBE F -0 N R IF AP I BLE) DATIE SIANEAf OAT SIGN " DEPA OF REPORT ON SOIL BORINGS AND SAFETY & BUILD DIVISION • INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MApI P.O. BOX SON, WI 533707 707 HIiMAM RELATIONS ( ' r q p H63.0941) & Chapter 145.045) L I~ ,� , s ,� a O /Y� / N /R /('Yq (or) w TOWNSHIP = — LO�NO.:BLK. NO.: SUB VISION NAME: /, CO BUYEfl'S NAME: MAILING DDR SS: T USE DATES OBSERVATIONS MADE NO. BEDR ERCIAL E f PTIO : IPR. F NS: PERCOLATION TESTS: Residence ❑ ' N WNew Replace RATING: S° Site suitable for system Ua Site unsuitable for system _°/� 5 9 _ y b ONVE NAL: MOUN': ,,tt IN-GROUNDpPR )RE-.SYSTEM-IN-FILL OLOIING TANK: RECOMMENDED SYSTEM: (optional) � o ®J �Y S �� � J EIS SU It Percolation Tests are NOT required DESIGN HATE; If any poruon of the tested area is in the �J under s.H63.0915)(h indicate: , Floodplam, indicate Floodplai elev Qts,.rnf►) PROFILE DESCRIPTIONS BORING TOTAL P R U ATER INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DePT"fN, ELEVATION O BSERVED TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) fo/ ` /)Oat, > 08 O 58131.l.,-, B- z zs /o/ -- " / V v d 8� �'I. �,.- •�o s ue.. S. ,[.. .3 S B - 6 oo /00 _ 100 ? m° 0 $8 61 -L, 6/)•oSi. _ "S'[ 3 a.rn, S. L. le 0- 83 ✓ /. L _A9 ,n S B- S 4 z3 IVQ AJ 6 >'=� Z - 6- . 25 61.4 , - 1 � n � S i , _ � i �� fin . S, 4, e'',L, P_ 2 i/off 2' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINU NUMBER -OJQ"" AFTER SWELLING INTERVAL -MIN. PER INCH P _ '/ 3 3 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation reference points and show their locption on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 98 03 ;, N, �P � 6 ; i Fo w�; Polk. p 13 '1 J. - v t Z � pjo,A• Zp /' � ' 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 ,C , J he L - CERTIFICATION NUMBER: PHONE NUMBER (optional): 8 AJ, ,mod �;. zz �1 z - 440 CST SIGNATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR- SBO- 6395(R.02/82) OVER - �4, J f f '�'/ caw Erw Of we 9 0"" ST. CROIX co, WOO a i L c t t 3 �w nG A: G�peENH111� �dE SIR • NIIN nlpGT1 1. eK! 33l PUASANT ACRES o � O,M :. Itl9, t3t.= ON] 36.11lllwldClJ.W4.SWU..sMM,33«d 9S of !M Wls AdNIG► Ei0! M M�•Id•4 b 31E. 331.13 /Gl, ; s �1�1N � I `Ifw 14 tfi�i.�s..,,QGraeft.IS.d IN THE LOCATED _ t�.1►' .A,: sFwfG! MME w.wM ♦ CGIM AwIMA!! `' AVON"" ImAlls A a t/•E E 112 O F THE N E 1/4 O F SECTION 2 0 T 29 N , R 18 W, ST. CROIX COUNTY, WISCONSII1h�,y� _. Nf coRNE0 or i UNPLATTEQ HANGS SECTION to,TtsN,� 4' _NV~ CORNER 00, R lew 9[CT10N {O,tNti, N�f �t(27!7Y - - - --„ _-- _� 1n - - --• --- J ^ N H )7 • E 9 {O lti wlr LINE ryp 190.02 l $6' 7f1'( I\ ... _ 190.02 p t oo _ le o0' $ b� %v' •�d! b• •A a b. 0 N99•to »E _ u )x' 9EfN ............... 1 ._......� {IALaNa aTt IS e �H00 w 1,4tACIIEf w LG9ACRE( 1.40AtlK5' -n \4 I.A'ACRES �.a b LgAC11[{ b 1 0 , y 1.44 AG1Et n w. i b x n n b w as � �o �,� { ab. •� b: ' 1 � it 'N n7 10 w GS( TG' CQiJ ; yg� _ e,�7 3 _ •p 119 ACRES t b.�"E • n N lt.99'xs_ "w - 694 _Sb - -__ 2 a 1 N o, 9456 ,y 19000 HO 00 ' n' 4 ✓y0 11700 ] 0 . 1 37.00 _ �. • 1 e �• 12 13 11 l 3. ° 9 10 g 11 g S 2.12 ACRE{ t.39 ACRES 1.li ACHES n 1,56 ACRES g ._ HAS ACRES - Z -,' N 2 n , 1.04 ACRES 3CA'�lOp\ o ^' w m. 1 = r .. c W '+ 0.b ► b- w N •'� a 11000' 19000' I.O.. •, , 1)700 _ 1' G• c Io -- • t 2 M o 77700 m i N. a a i 0 N09- 5925 "W a s F-N •� i. . I• - ea Gil � � n 99 V4 LS 1S tt40' . 'k th ® 14 $74.12w S S9 ACRES •. 1 AC: In p 77.00 N X1 1 n -co A M 1 4. App `--- --- - b .�,J �0 �NOR TNCRIT RICMT•OF - INAT LINE 2 CONTOUR A90v YtALE 1M FEE t 1 "14N ORO< wn tR f �\ ti P- b3 33.) rill EST f Oo• *'s a 34 4S'- • A NOS _ • Eap , .� 1 CURVE DATA TABLE ~ " N4� `g „ 1 ;Irve stir - MENN C/WNO LNOND Ct11TNA. TANGENT I.E.StC ~ • . ..... �4D N9, Mf:.. L{11GTN LttGTN 1tAtINt AMGII tEAA1NG CJYNTT ![CTION G1M1N[N tIpNVM[NT = "A!G "1NON At►t" �� WEIGHING 1•MLGtnN1lAL100T MITN tl S THEN CAI 1•L p.00' Ifl. N' No•00'!i`t.' tN' EO'OO NH•t0'!Yt M i0' IRON Ilte. WENNINt i1G L1t /LING AI f00T. �•�� M.10 •0/•If'tt -!" !110000' rip 1 " ALL O►NEN LOTCONNEN4 STA 1119A WITH 1 . 1 11 �� 1 / �..,.�._..� E. 01R1{NIN9L LM 490. /u NEAI ►SOT. / /7u• tso•4o'u•lr so•odoo y Go.00• s111/'tG•. tfi•bo•ad NOTE 1 ; 1 RtP1YtPt GD•00'00' A'L 91*1ANCEG, LIMEYNt AMO WIOTNt ANl MtA ALL ( • 1t.1G' N/4.00 GG"t tG•t0'oo- To Tilt NEANttT ow NYNONEOTN Oft t00Y. EEEN MA All ./ ANOYIAN Nt A1YNEM[NTl NAVE Ot TO 1, GTTt.ff' M /.OV N7A•G/'i0'M �•l1'b' MT /•t1 GO•r NEAtEGT TMENTT tECONOt ANO CON IYTte TO Mt (I/4 CORNER 01 • • 1N.1/ NTt•i4'tIr I- So' rA{.VE GMOMN. SECTION SO. T ttNt ' 194.9 NTf•t4'Of'I! t it' 10 ALL /LAMING 406 TRY[ F/0M iOLAt OGtA`MT10M fl It W ON live. I r ./ .. I Ak AS BUILT SANITARY SYSTEM KEPURT UWNLK .,(.y,,��.,� A�z Y�ISff' �._ 1'UWNSHII' S L C 1 ; 2 0 ' Q7i l s<1gw T ST . L•KU1X CUUNTY , W1SCUNS IN subDIVISI0N A ( IIP"to-) LUT 'Z LOT SiL� --- - - - -.- PLAN VIL:W piNCanegg lied OUND610no CO WeeL reyuiruutL:nLb ut H63 . UUW ;1L YTHING WLTHW JUU FE'Ll' U1� SYSTEM , 1 i 0 ` a I d1 a e o th Arrow 1iENCHMA1tK: (pdruwndnt rafarance P UiLIL) U edcr'ib e: i Its d'i Oiw',t III' 9Levacion of varticaj.,rafarance NuinL : �? ' - -- �S1uPC a l yiLe SEP•1'IC TANK: Manufacturer; �� Liquid (:apa� 1 L y /6'df✓ Number of rings on cover : L _Tank a cover clevaLiut► /p/ .VLF Tank Inlet Elevation: 'latt Uu L1CL L1eVaL1ut PUMP CHAMBER Manufacturer __ _ _ Nuu lbcL -A ryl lulu utp _ Wusabar of pu edt Eor a CYC IU ballunb, LuLA _:apu,'ity Of dia Lribu on linam _bu l luu . — d i ze ur pump hu,ld , gallon fi minute _, huruopuwri brand rwu►u of pump and diel number Ty of warn ing dev eb — — HOLUING T Manufacturer _ Nwtibci ut balluitt. Elev on of amanhole cover 'r a of W rnirig davice SELtiPA E tW SIZE: _ - -_- Number of pit bee d i.au►ui ut fec lyuid de �_ - - -- tst e(�ugu Nll lulus `,ll,u elcva llun LLULU of eaapa kka p� C �� *vat lust i 1 � l � i. t t� L t SEt:1 Al.)r 1�U SIZ utl, nu.ir of 1 lnu u w 1 d i I� F, �3 d.. N L h 51::�1CGL '1'Ki:NCN width _.`�.. lua.6ll► � PL ACUL.AT IW4 kgrT AREA TtI:QUYRI A_11:7 AkL'A AS BUILT LN:iI'I - -C "FUR UA'rLU _ J PLUMBF.K ON loll LICLNIiE NUMBER I DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR,& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION NO. BM t969 BUREAU OF PLUMBING MADISON, WI 53707 jkCONVENTIONAL ID ALTERNATIVE St ate Plan I.D. Number. ❑ Holding lank ❑ In-Ground Pressure ❑Mound ta NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECT ON D�yrE: Edmund Matacz nski RR#3, Spooner, WI G 4, BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. NE- NE4, Section 20, T29N —R18W, Warren Township Name of Plumber: /MPRSW No.: County: nitery ermit Number: Gary Steel 3254 St. Croix 34800 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARN( LOCKING VE Z� re v � OV EgOVI !—C1 `� - f C E P ❑ NO BEDDING: VENT DI .: VENT MATL.: HIGH A NUMBER OF ROAD: ROPERTV ELL: BUILDING: V T TO ESH ALARM: FEET FROM LIB AIR INLET: ❑YES NO ❑YE6 N NEAREST 2 DOSIN CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: 7 MODEL: P : 7P/91 ON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO � ❑YES ONO OYES ❑NO. GALLONS PER CYCLE: LIMP DCONTROLS 0 A ZONAL: -- PROPERTY WELL: BUILDING: VENT FRES (DIFFERENCE BETWEEN o f EET FROM LINE AIR INLET PUMP ON AND OFF) ❑Y J NEAREST SOIL ABSORPTION SYSTEM. Check the soil ryibofure at the depth of plowine FORC LENGTH: DIAMETER MATERIAL AND MARKING Or excavation. (If soil can be rolled into a w' , construction shall cease unAl MAI the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WID H: L NGTH: NO. STR. DI PIPE SPACING: INSIDE DIA. #PITS. LIQUID BED /TRENCH �� ) / I TRENCHES MATERIAL: PIT DEPTH DIMENSIONS S C V L DEPTH FILL DEPTH I DIST11 PIPE JOISTR, PIPE inift PIP IkTERIAL: NO. DISTR. BE OF WELL: BUILDING: V NT TO FRESH BELOW PIPE r AB¢VE COVER: ELEV. INLF7 EV. END. L1N IR INLET: Z 7 2 PI % FEET FROM IG'� �G�O NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check rstems re of the fill mate a, for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound to make certai thpt it ON REVERSE SIDE. SHOW ELEVA- DYES ONO meets a for medium sat TIONS MEASURED. OIL MOVER TEXTURE: RMANE T MARKE S OBSERVATION WELLS. YES ONO ID YES 1:1 NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH/BED DEPTH TOPSOIL: SODDED r EQED: MULCHED: CENTER: EDGES: YES O ❑YES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH LENGTH. TRENCHE LATERAL SPACI G GRAY H BELO PIPE FILL DEPTH A COVER: DIMENSIONS MANIFOLD PUMP MANIF DISTR. PIPE MA I LD MA EHIAL N .DISTR. DISTR. 1 DISTHIBU/ION IP MATERIAL &MARKING ELEVATION AND ELEV. ELEV.. DIA. ELEV ' .. PI ES DIA.: DISTRIBUTION 1 INFORMATION HOLE SIZE HOLE SPACING DHIL U COHHECI LV COVER MATE IAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑Y � N / OY ES El NO COMMENTS: ..MAN N A B RVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑ YES L I NO ❑ YES C7 NO I NEAFEST 618 9t) Sketch System on �) n unty file for audit. Reverse Side. SIGNA UHE I TLE --t DILHR SBD 6710 (R. 01/82) i DEPARTMENT OF APPLICATION S AFETY & BUILDINGS INDUSTRY FOR SANITARY DIVISION LABOR AN5 PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: Property Location: City, Village or wnship: County: E t /a C Y4S o7 P7 /To7 N/R IK(or) W l t,a oy4- Lot Number: Blk No:: I Sub vision Name: Nearest Road, Lake or Landmark: tta lan I.D. Number: Z - 6 65n,,4 J I �, C 1 Z igned ) / TYPE OF BUILDING ^` Number of El Public* ❑ Variance* El Other (specify)* ` /�� C %2 "ad -- 0o o [ Bedrooms: 1 or 2 Family *State Approval Required. —3 TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER LASS GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY DdC9 HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: Q �$ EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA st, (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit O 1 El Alternative (specify) El Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): NA Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of he private sewage system shown on the attached plans. Nam Plumber: Signature: MP PRSW .: Phone Number: ,9r V 3 ��5 ( /SL7 -roa[b Plumber's Address: Name of Designer: o RD COUNTY /DEPARTMENT USE ONLY Si na ure of Issuing Agent: Fee: Date: APPROVED Sanitary jPeerr�mit Number: .. ©� 1:1 DISAPPROVED �/ Alf OC) Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink- Owner, Goldenrod - Plumber DILHRSBD -6398 (R.07/81) - Form - S T C 100 G Owner of Property lT �GtG ,Location of Property It Section d0 ,T R 1,P W Township 1& 10, r>` Q,Y� + Mailing Address Subdivision Name ��`§ S & �� CI"¢ S Lot Number / o4- /� Previous Owner of Property lTcr1f.J A4 e Total Size of Parcel / ?Q JC 2 f� Date Parcel was Created Lj� � ,,,� � / 7A Are all corners identifiable? Yes 7< No Include with this auplication one of the following .Certified Survey Map .Deed .Land Contract, or .Other Legal Document which describes the property PROPERTY OWNER CERTIFICATION I 1 (We) 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. -?-? /is9 ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. ), -- "&i JLa SIGNATURE OF OWNER SIGN TURF F -0 N R IF Appoll OLE) DATE SI NE OAT SIGN I1 5-A �. ®m =loo' 33' f t 1 "05� e of g. -25, o S p-�� (J �3 12o�K � u�Etl I A-5 s b u e-F DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, DIVISION LABOA L`ABOFi AND C P.O. BOX 7969 RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707 /-p (H63.090) & Chapter 145.045) I /V L L /4 N /4 S cab OIO/ 1 � / u /p/�jr tor) TOWNSHIP _ T O�T�NO.: BLK. NO.: rSrUrBVISION NA Z1j J4 k- NTY IN BUYERS NAME: M 1 DDR SS �✓' d 'c� �i97C' z h ." 12, oo ncc r 0 i , Fko / USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DE New ❑Replace 1 R PTION: l R. FI N S: Residence � N �/ --4..— g 3 � o _ 8 RATING: S- Site suitable for system U- Site unsuitable for system g� 5 9 _ b ONVENTI NAL: MOUND: IN-dROUND-PRr : EM -IN -FILL OLDING TANK: RECOMMENDED SYST :(optional) S ❑U ®S S ❑U EIS U I EIS NU If Percolation Tests are NOT required I ESIGN RATE: If any portion of the tested area is in the �f under s.H63.0(5)(M, indicate: Flood lain, indicate Floodplai e le v at i on: / f ' PROFILE DESCRIPTIONS BORING TOTAL P TO GROUIS ATE - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER pCrThF1N, ELEVATION BSER TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B' O A) 08 O -. S8 K31.1.,' . �0 7 ,�n, vS S, ,L.. B- -1 1 147 IVO n) �. ( 0 -. 8. 191,1 ,.- •6 7 en.Si, en. 00 JS mo 08 3 3 B -3 1 11 0 0 -' /00 A) E. ? 6 0 - 5'8 61, / - 'Bn.�i, "� /�.13n, S. L. B - X 83 99 � d� � x.5 -1 - 3 C) -, D�,C. bn.5;, - 6 ? /?. 110 z-3 IVQ ou6 1 ",% gz, 6-.2561.,C, o' en, Si. " 7` � • L , 2 ��� ? PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINU NUMBER .IAiW" AFTER SWELLING INTERVAL-Ml PER1061 2 PERIOD 3 PER INCH P_ �, �' �3Yt 3/ P- P- 104S P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori• zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 98 i © ,. y, I t w 1,fhr/1 /�IAr fly,. oas f � i T ;s P- e N. vl, I 13_ i 1 , , S till 5q ZQ 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: - 6 - 3 ADDR SS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 8 A1, Z e- CST SIGNATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02182) — OVER -- REGISIES' S?. CROIX CO. e j,f`1` 1 A Pk * .N,ro3 336 IS, A P T ACRES o I t� cliff 0.>: '., 216 16, 236.20 Nrd l)6 21 111 OrNi (21. WI. Slats., and My i1 and . i s 1 ` c.lE�,w lu;.i�!`Eti..itl . ,Q.GroedX. ,9.r?r THE RemO d l- �'�a�E• LOCATED IN • �e MONISM n.R. 6! e.A A.IN.Iw l `i E 112 O THE NE 1 /4 O F SECTION 2 4 ��•- -- T 29 N , R 18 W, ST. CROIX COUNTY, WISCONSIN+�,� c SEy$i)i7T w OR& NEC O3 1 NI /4 C~* 09 UNPLATTED ,LANDS ucnoN 2o,taN, J Y I i R u w o�Pla "r" d 9[CT1pNt0,'T[9N,. ......p_aM23�0 ^ i t{23 - T - - - - - - - - - � -- - ^ - J F ° N s9•to 3a "[ 060 6111 w " .r L 4 1N[ - - Iso.oi ,1{�,�, 190.02' q p 190 02' S _ a 1 K' , 21x00 .ti .4° ro 0 $692' ,r� lb %' �� b• '�� b• 1. N o »[ d 3i 3 � 9[wNNINa 61 ..._.......!_.. 9111LO1NO3[TUA�' .... 90 1 ti 1 - 1 y R 144 ACRES w .CKS • 449 ACK$ L40ACR[S . 149A -.. III ACRES �a b 101 ACRES b I, Vc 4[.e[' � • b � A 1 7 V r ti1 1 c IP� •Ab t I O N"? r 6 g 94 76 • • 190 DO 19000 /D N 9/99 25 W 531 76 ' 1 2 7 ti w r v� ASANT ACRE S,._„ -- 44 j i 4' -0 419 ACRES ?• '^ y •� r N 89 iS_" W 6_91 SR I J. bN ��O S \4 44 8 94 ,{ 19000' ._ �' Ib� 177 ,� ; • W D W * o b ^ Q b�� • AO b• 9 1 0 $ � <• A tp - 35.00 .. 12 ' 8 13 / • op t.9 ACRES 2.)2ACRES RA9 ACRES O L$6 ACRES g Lab ACRES g 1.15 ACRES - 1 o' R N r. n Z I • b : o o; � - �r{.00A7101t 3KETtM o_ w ,ri, . x _ 1 ° y r br {fiN SIII4 8 ,3• rf }� 19J 00 i0.. ! 'trod _ -_ I ze . IG A N .� m 55700 00 4 :3 d al N n• _ N 69 25"W ID •• a ;. � T h• OCALA 1••f640' ,� 1 K 14 P - ® 559 ACRES 99 •:.1 I r ' 4 30 '. - .• N: 1 M � Q0 -" i1s•f9 1 / A 1 RIGHT-OF-100#1' LINE 1 - -i coNTOUR A9o� i S/ ALE IN 3'[E T NION ORO N�1 0 MA ``` e ya, fDO too 400 p! q . t TfD ` NO wE •oo„w -0530" a . 34 Aa.� . 1v 1 'CURVE OATH. TABLE 1 rANSaNr LfSt4� "� � 40 "g tuft, u7 �RlNM M a i 6o CtNTRAL M: UMOM R1M{ ANOLS SEARING e COUNTY SCCTION CORNGR 1y(IdW116 t.M LK /4M[K HOOT WIH AR t" N i0 IRON ►IRe W(16NIN0 !1•ON 6.06 LOS - /Li Nt AI 1007 0{ 't6 ala•to 00" N nto tft 6't6 " • !!•0000" O ALL OTNQ LOTCORNORS STAKED W /TN IR � pi /e. Wal{NINe LOS L•t. /LINEAL TOOT r16 0 6o•OW 00' 't6 67.0 60.00'00" NOT€ 1 6 f' S0M1•!6•t 00.00' 00• ALL S16TAMCtf, LSM6T NS AMO WIDTNI ARt N[Asu"o jk ♦ i • ,�� w { + fa.7S• N04•00'a06 ts-to' 0O" TO The M6ARt6T Ong NYNDR[OTN A 1007. ALL L, AMOULAR MWAfVfaMtNT6 NAVt 0(CM MAGI TO VMS ,a'�•�, 6776.6{ M6.00 N71.4O'60 6•fl'40' it 74-116 10•N N[ARl6T tNtM tRCON06 4010 COfl WTtO TO TNI [I /4 CORNER OF 77 ..,. • 174.17 NTM t4'If N 1•4f'60" ruyt 6NONN. SECTION E0. T29/1, ' �'.' • 1N•{I N.MG4'06 1• •f' 10 ALL 0fA•IMSe aRa TRYa /ROM GOLA6 O66pvA7N/M p low y 1' �'R"°""�' 'F-•T f 7:p1 t*+'." i . I • F'"" v ('( 1 :�''- }� v ,�.y L61 A + v `� . 4 a,.s .p.. \'' , , , ":, ., r ,•v .. , r ^' t`1'.:,Wry�^kt+S�e.il�i' 'R ;F '. wA�k a '�I. _