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Home My WebLink About020-1031-10-000 o° o° o CD 4 I d I h in N X p z � o E I I p i f v I O y N C � L it CM 0 0� o CL - o a Z n,•°' o z C N O C LL O C w LL O O L 3 ¢ Qn E U 3 M a `� V Z I N LU E E o) z = $ LL L V Z v m d m �C14 am am I o o z a c v � , w = 2 w v�H I rn rnC Z E m E e D U Cl) N N = N m cl C L f y _ N d N •� D N N ` O N EL O d O @ Q z m z z = z w Z d .. c CD E N Lo CL o m E a� O L m °' Y 4 Op v �'ooa E a coca Er @N �N z r 2 a N T$ d !A c c Z o •ti ;� Jaaa. Jaaa N IL '..� � U) 4) Q) 0) 0) } � rn 0) } r N N p 0 = O I N r r - O N p fV 'p fn N O1 f0 m �} m Q} p �Y i+ ° O L f��/! c L N c r O O p m C - U U ] t0 03 G d 0 CD 25 0 1v1 O M oi c v m O p p O H 4. p N y O O O y _ LO • N h 7 3 co V) O C O I O O C@ U O O r= e r r Z_ 2 (7 c) 0 Z � r 2 (A IL � T C� «'#t a € _ L: CL ::ate • a t� t A 0 C o �v i AS BUILT SANITARY SYSTEM REPORT OWNER ,504/ TOWNSHIP 7VVo D/L/. SEC. -R.& ADDRESS �So /l' C�s�.S , S'o /, ST. CROIX COUNTY, WISCONSIN. SUBDIVISION &t< �l1:5t) c5'1 AT S LOT S / LOT SIZE PLAN VIEW Distances' and dimensions to meet requirements of H63 QW-EVERY WITHIN 100 FEET OF SYSTEM IN v. c N r I di ale No thj Arrow SC L': C BEN C RK: Q (Permanent reference Point) Describe: � /AOA )61� AT i( W).(oC Elevation of vertical reference point: Slope at site: SEPTIC TANK: Manufacturer: 6 1 '�'SJ S Liquid Capacity : JQcc, 6449 Number of rings on cover 23 Tank manhole cover elevation: Tank Inlet Elevation:. Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal pump set for a cyc e gallons; total capacity distribution lines gallon: size o7 pump head; gallon per minute horsepower brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons -Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: Number ot pits feet diameter feet liquid depth seepage pit in e� ipe- elevation bottom of seepage pit elevation feet. 4 1 SEEPAGE BED SIZE: number of lines � wi th O leagth tilt SEEPAGE TRENCH: width length PERCOLATION RATE d A REQUIRED (aC� A AS BUILT_? INSPECTOR DATED •- 3 I PLUMBER ON _ j B_ LICENSE NUMBER REPORT OF INSPECTION - INDIVIDUAL SEWAGE Sy3IOM ~ Sanitary Permit/1.4%_ � State Septic_ NAME A TOWNS1iIP __. 3t. Croix County /OC&�T0 Sectiou Lot � 3ubdiviaioo ^ - ^��«� KP7IC TANK 3iz, �ollmoa N�mber� of comRartmeuta _��_'____�� ~ oiotaooe from: Well 'Building 12% alope ___ BlQhwuter___` 1 CHAMBER ----------'----- Siue_________ gallons pomp Mauufacturer___ 0 omber_________ |mL|)lNG TANK � S|ue --_____-__. 8alIouo Number of Compaztmeota__________ __________ Pumper Alarm System___ �,ipcmnre from: Wall 8uildiog_________ l2% alope_________________ Blgbwater_ �D�()KPTI0N SITE - -_ � 1 Bed � Ireocb______________ ''iston,c from: gell____ 8ulldiu8___ 12% el"ye ______ Bighwater AIISORPTION SIT Width of trench f t Required drea Length of each line ft Depth of rock below tile il Number of lines Depth of rock over t� ~J 8 ________ Total length of lines ft Depth of tile below grade i"' �� y/$��uiy��u�e ��eeo lineu f� Slope of trench «-~�u. per I00 ft' Total . -____ Jp tpttou area ft Type of Cover: Number of pits _ Gravel around yita____yes ...... oo Oucoi6a diameter f Depth below inlet �t Total absorption area f t Area required ft INSPECTED TITLE kpPKUVED D&I� --------- ----------- REJECTED DATE, l KD&SUN FOR REJECTION --' ` ' I - State and County State Permit # f PLB 6 Permit Permit # hermit Application Y for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: 7 DSO yi�i . U63 d�V l�lS syo & B. LOC A f 10 : -SI_ / dJ Z %, Section 7, TZ.�? N, R_/�?E (or) W Lot# _L City Subdivision Name, nearest road, lake or landmark Blk# Village P A r 0 L� r ,l < f s I' ll -C-5 Towns SO C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance Single family r,-'4_ Duplex No. of Bedrooms _� No. of Persons D. SEPTIC TANK CAPACITY / rT\0 Total gallons No. of tanks r HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete �� Poured -in -Place Steel Fiberglass Other (specify) New Installation r7C Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) E, EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New Replacement Alternate (Specify) . Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top)_ No. of Trenches Seepage Bed: � Depth Tile depth (top Q� No. of Lines BE Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land • & 7O Distance from critical slope WATER SUPPLY: Private tK Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other th pre owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certified Soil Tester, // NAME L5 U C.S.T. # � b ? and other information obtained from 0 Ao ( owner /builder) �� ryry Plumber's Signature MP /MPRSW# / Phone # ,3�6p ,-p � p S Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. Sto A do a 4 a ; r 3 a i 1 a a i E n w. f T E a a Do Not Write in S ace Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application — Fees Paid: Stat County. 4 `r` Date Permit Issued/ (date) �y/ Issuing Agent Name Inspection Yes No State Valid# Date Recd 1. county (whit copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 TEST tZ € F E WIZ Rev. 9/78 Co u ou - r y C.S. A441 1�B VIEVI./. /\ d PAQ a f �F L REPORT ON SOIL BORINGS AND PERCOLATION TESTS J+OUSC (>L,f_,US EK/ S WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES �UZ 7 f f S Lo7 P.O. BOX 309, MADISON, WISCONSIN 53701 4 5 LOCATION: '/4 „ /4, Section ,T�N,R�F�s� W, Township D Lot No. Z- , Block No. v 2�/� Y �r4� County A, Subdivision Name Owner's /UUyeF5- Name: Mailing Address: TYPE OF OCCUPANCY: Residence — � No. of Bedrooms COMMERCIAL— EFFLUENT DISPOSAL SYSTEM: NEW -REPLACEMENT —ALTERNATE SYSTEM DATES OBSERVATIONS MADE: SOIL BORINGS 4 L 1 9 J�6( PERCOLATION TESTS Z & L SOIL MAP SHEET S8 NAME OF SOIL MAP UNIT n� aTw, P L__C) Sef]R_.1 PERCOLATION TESTS TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHE I NUM- DEPTH CHARACTER SOIL SINCE HOLE HOLE AFTE INTERVAL RATE I BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /M P ) G - IF Ys- d — 3 3' S 51 6 1 1 4 1 P- .Z- 67 1 1 � NE 3 �v y4- 3 G P- ' P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- /0 0 av� > /za BL I_ TS l o- 75,.r5� L /3• L5 S L B - 7 o• z.4 41• KQ RAJ G M A z L o' Atcj L z' o a 572 IL ' PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the foratinn and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy ,Indicate scale or distances. Give horizontal and vertical reference. points. Indicate slope. r$ E A1 G+1 C>0• g Ef3 F�t AT _ ..f/— �Q�'1 . I �1= o �_ / -r- �,d pe c L.A�TI"A4 w -MS : .m._. w �, ..•_..PSENckt - ,..locy:o_ s- I tO cn1 a _ of S, s t s s _G E I .t c » I sit » r 1 5 5 H� i h of .+ I i M �v L I/ I, the undersigend, hereby certify that the soil tests reported on this form were i sip accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded an ation of test holes are correct to the best of my knowledge and belief. a Name (print) J A M — Q u SC,44 Certification t4 Address / Af k N vEk Z .Name of installer if known Copy A —Local Authority CST Signature - 1 H 5 Rev. 9 /78 pf REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION:` %. /4, Section / Z ,T 4 �N,R22E (arj*, Township or Munieipslit J V DSO AJ Lot No. , Block No. County 'S7- GR_44X � /� S ubdivision Name wner' yers Name: !% Mailing Address: TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS SOIL MAP SHEET NAME OF SOIL MAP UNIT PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTEP INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P— P— P— P— P _ P— SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B— d L T S L G' L – g� 8' B- a a3 ,. PJ B– 40 11 Z UaAla //Z L it L Y L 14-.8 Al S e G G S o ct PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) ndicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. ..3 a... 17 1 Or 7_0 a E .. `�. �.._.:�w__.,�A� art -a!r� f_ ��.r�`/t✓1.___ ' u .�...,G�,�.- lic%r� ,,��u.�._r3� tk � N / . �m � t Cif E 1, the undersigend, 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 location of test holes are correct to the. best of my knowledge and belief. Name (print) 4M MTS E . ZU S G/ Certification No. Address .Name of installer if known Copy A —Local Authority CST Signature � R / ' ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner P?lc NA,Pp rL�.tRoe !sa1 - FS0.4 Address 6 9.� �R`E,�,,•, �c c L� City /State A4 -j w, y viG Legal Description: Lot / Block — Subdivision/CSM # V0 y Pte. '/, SE '/. iy ,C ,. Sec. _Ll, T,JN - RAW, Town of 4 o^j PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer wiE so Size ST/PC Ooa/ GAL Setback from: House 20' Well 4-S P/L 34/ ' m Pump manufacture_ r. *– Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Q :: J ri L- -f A-r.,p S�oE w i,v pE/t �I ��L�G� irtf�IT Type of system: e: rowy Tr Width 3' Lengths ..?s' Number of Trenches x Setback from: Mouse 5-_ Well i o ' P/L yam' Vent to fresh air intake / /3' ELEVATIONS Description of benchmark _Soy r� ,w G "AsH T�tr Elevation /do' Description of alternate benchmark Elevation Building Sewer ST/HT Inlet – ST Outlet PC Inlet PC Bottom Header/Manifold 69. Top of ST/PC Manhole Cover Distribution Lines ( A) 88 . ?,7' (g) 88, .*' ( ) Bottom of System (A-) 88. ca 88, oo ' ( ) Final Grade (A ) r 'q. 33' (p) 5'4/. 33 Date of installation /n_ / Permit number 31 sg Yo State plan number Plumber's signature License number .22 W7 –<7 Date 4/10/ 9f Inspector - / Complete plot plan ar '7 f NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW N OQrH PQ ap��?Ty ,L /Nf r � OJT? boo' To c.`ks7 r d V I - /� i i � Cifitwr8E2 T ?��H R/�s e�rio,� r Sri.vf. 1 gLPT�( ?I'tiJK r �okQ1G£ ®uW 1 R E5',0"CS y "G✓c 3 � fFUICNT LiivS INDICATE NORTH ARROW T Wiwconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count bT. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) San itall jEn%1'd_: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. �sJ am kI CHARD & CAROL �� S ®g illage E] Town of: State Plan ID No.: CST BMAEtIev.:. 1V Insp. BM Elev.: BM Description: Parcel ftbq,,,:1031-10 -000 �) I d O V 4/� ..,1.. S :)'R`.v: «"1....,1 / .!� k G:rfr",4:ai'L/" TANK INFORMATION ELEVATION DATA A9800227 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 6 a ? ��-0 c A� Benchmark / /oo -� /`a .1 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to i ntake ROAD Dt Inlet ir Septic ` r > r 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 L rictigw Syestem TDH Ft Forcemain L th Dia. FFii Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH width r Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 g_.r i DIMENSION SETBACK SYSTEM TO P/L I BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type O 2,L,. _ CHAMBER Model Number: System: v^ C4 '// �) ' f) /`� 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 r' Bed /Trench Edges c G' " Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 17 492 GREEN MILL g LANE �/ �;�ud.,, t✓�/ c t��/:rk.c,.l�. , e_. ,,C,,C,c,; lD rr �{:�L. -lt, �ilcC.t.� s� � •�, + ;�°t�r'tr,!«.I. . .� . ;�i•�,•C�C.- +� ".f.�`y d fL. - �; `jx'C .} �t °..: r Plan revision required? ❑ Yes No Use other side for additional information. 1 41 f ;t.,; n /'J SBD -6710 (R.3/97) Date dn�pector's Signature Cert. No y r Safety and Buildings Division Vi s ciliin s i n SANITARY PERMIT APPLICATION 2 01 E. Washington Ave. In accor d with ILHR 63 .05 Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County � //►►� t than 81/2 x 11 inches in size. , • See reverse side for instructions for completing this application State Sanitary 1 Permit Num er y ou p rovide may be used b other g overnment agency p rograms `� e vio y p y y g g y p g ❑Check if - revision to preus application The information [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location Ff fl i 4- ifoc �u5ri4- St�cl S€ 1/4 /QE 1/4, S / 1 7 T .?9 , N, R /4 E (or)o Property Owner's ailing Address Lot Number Block Number 4/49 Cit , State Zip Code Phone Number Subdivision Name or CSM Number )0s oti) w/ II. TYPE OF B ILDING: (check one) ❑ State Owned ❑ Cit Nearest Road J� Public 1 or 2 Family Dwelling ❑ Village - No. of bedrooms 3 Town OFlTrR Sow NM ALL 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 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. E] Replacementof 4. E] Reconnection of 5_ E] Repair of an System_ System Tank Only _ Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure 1 42 ❑ Pit Privy 13 ❑Seepage Pit �� E� _ k �6 43 ❑ Vault Privy 14❑System -In -Fill � "F /LTiQAToe - 5;,0_rWj,.110j - R 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 yea 1 57� .?, S S�?` , 9 gf. OO Feet T Feet Ca acct VII. TANK in altos Total # of Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con Steel glass Plastic App New Existing structed Tanks Tanks Sep IcTank /ow /0,00 > 4J1E56 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb Si atu t p MP /MPRSW No Business Phone Number: � 1 O/15 3� =111V7 1 1 7( S 3 W: ^ 8 So Plumber's Address (Street, City, State, Zip y ode): - Y 1� � V r o�.S CYt1 C•�� J��{U! IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued ISSLKg pgent Si nature (No Stamps) X Approved []Owner Given Initial r+� &-)/ Surcharge Fee) Adverse Determination (f X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: (R.11/96) DISTRIBUTION: Origiral to County. One can To. Sa" i Widings Divisim. Owner, Mrw&& INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. If. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ili. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section_ of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all-sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. 5/3 'PLOT 14 1 0 ' SECTION PLANO IAPPA 81100. EKCAVAWA VC W KUMINO UNIT ... ' VEA/TS " PIIQIECT 1 Q � PAC#& 1 oc IOkS? i50 j B� > 8q 442 19 t-jcrW. , hPK - �'o�Xr i� G "' � Sr C,pv1 x Gnu,.JT 1 -1' ENV. - /oo . 00' �J r - .�/r It- 57ZAl 1 1/i, A, E X lSii \ L- x�Sri�l c 5�. LAI LN AAS oPPT WJ L'rFr�rri �S� 'fR i1yQe4(i E , 'rrteJ K kiA X r S 'TiN L. A l e _ ) y " PV( 502 35 EFFjAL&rQT L INE Ex t5 -ri jr, 3 Rio 450 E. . � /• (i ! Q'l �ZS� SI �GGJIN N�'( f7R � �R��tI CS .� y CALK • � ��N •rlttL ��iuc y �7 V" T, slor�D: - A,�v�o„£Q VENT cxo uceNae:Pl'f DATE: FN esH �n.Q.a�E I S, m yo V-- P. PE ; BaLTEO�INq ev: ( Ae CCr Jotw-sd"o ?o � N t 5 H GQ ekpE Side View EavATioA 1�snlc H Sono., -. Af End View �i fC4 15° Id 34' S,pEC..��.J��.�Q NeGN �AP Ac�r�/ /vIvOEL ' lsconsin Department of Industry, It onsin'HumanRelations SOIL AND SITE EVALUATION REPORT Page Oivisi n of Sale & Buildi s 9 �/ n9 in accord with ILHR 83.05, Wis. Adm. Code CO Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ST CIP.- 0, I not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PAR dimensioned, north arrow, and location and distance to nearest road. r7a0 ID APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION /; P PERTY OWNER: PROPERTY LOCATION GOVT. LOT SE 1/4 1/4,S 1 '7 T Q ,N,R /g E (or) W 1 �NOQ Cd �eot C� U ST/J�Sca n!� Z P OPERTY9WNER':S MAILING AD PRESS LOT # BLOCK # } �UBD. NAME OR CSM # n /6 � � 9Z C�,er M MILL - ,4 I L SM V 4 CIT S TATE ZIP CODE P ONE NUMBER [:]CITY C3VIL GE OWN I & A REST ROAD M So19 t- Sqo/(- f /S� 38' -- 3/3V dSc�N EE� A -LL tA'4C [ J New Construction Use Residential / Number of bedroo s 3 � (J Addition to existing building kf Replacement Public or commercial descr ibe Code derived daily Recommended design loading rate 0.7 bed, gpd/ft 6.? trench, gpd/ft Absorption area to ;; 2 Maximum design loading rate D.7 bed, gpd /ft Yench, gpd/ft infil urace elevation(s) �� ft ReComme n ded Nation s ( as referred to site plan benchmark) Additional design / site consideratio ! N LO Parent material Flood plain elevation, if applicabl S - Suitable for system CONVENTIONAL MOUND IN• ROUND PRESSURE AT-GRADS IN SYSTEM FILL HOLDING TA U - Unsuitable fors stem 1$) S ❑ U W S ❑ U 1S ❑ U S ❑ U IXS ❑ U r S I� U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Botri Roots Bed ITrench A , sz. s b m fr -F' 4.4 a.S -1 1 /6Y+24 A - yhY C5 14 6.4 O.f Ground {�, 17- ) — qS S G n1 C S o• S a 6 elev. 9 �.0 I t. $ /- P S 3 CZo( o sr S r r! in b,x Mfr GS N p NP Depth to 1� Z ` f'�Yf2 4 M 5 S6 M limiting factor 2 -f I Yk 4 3 MS (,, r►� f3.7 �.$ Remarks: Boring # �- �' A 6 -8 /dyR z -5L M S bx r►� Tr' S QA 1 0 1 z A -zz /bYA4 z s� 1 c s Ground �� O ,s a, elev. g2 S" f ,Q S 3 C z of �r-usr 5 SL M 5� IL M44; CS — N P N 9�. ft. $s iv- .e 4 -- A S s G ,-►, � 6 s — 0.7 ors Depth to limiting —• � S 0. O. factor g , L $g 7, S � /h S G rif _ a. S SG 7 D /b 4 3 >� 1 R emarks: CST Name: — Please Print M EY Phone: /- Q aO ress: Q r 'g p dS(w )5 d5 -6, 9r Signature: Date: pp CST Number: C L— ii6Lif2�0� 0/7 PROPERTY OWNER &Ube 16JSTAMA) SOIL DESCRIPTION REPORT Page z of PARCEL I.D. # Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon i Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bo�rriary Roots Bed rend 3 6-10 6 Z 5 t j ,, sb14 rh r 5 14 b, a.5 z 6- Z/ ,`,.4 - — SC I Sb9 !'hd�r C5 0. 5 5 5 � b K rh��' CS b Ground $ Z / - 1;t 1Q 4 S _ t g - ft - C 6 , r25 J' C-2.(>, rc, S,L S c j rh bK �1, CS P Depth to 4-in >DY+, 4 3 MS SG n, j b,7 D. lim / 6,7 Remarks: Boring # g JjA 16AI14� r n, rf� c' Ground 6A, +/4 3 7 ft. g k - -60 I tvk4 Depth to � limiting factor . Remarks: Boring # T �' I s L, JC��€ I �g LCLJ e pan aC v Rk "A I A A tN i N� Z a 13 Ground M CMG R� 5 r S IM i' 19 c�c� Cr P k k elev. -1 - ft. Depth to limiting factor s Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Ol% CA n rl � B ro F d Z S o i i - � o I O N /U / � I r r r7l Ul _______--- - ---- gip i w � � �I c o W � ° Z ,Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations Division of Safety t{ Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ' l Attach complete site plan on paper not less than 8 1/2 x 11 inches in size Plan must utCftyd @ ' Cie 0.1 not limited to vertical and horizontal reference point (BM), direction and % of slope, sc2te'ar` PARCEL I.D. # " '�' dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION, ' VEWEDBY DATE P PERTY OWNER: ( %OPEf1jy qN; , p I NQ+e C4 R67- � C) ST��So Goo. Le 1 %4A .t ".,S 17 T Z Q N,R / ! E (or) W P OPERTY 9 WNER':S MAILING AD RIESS LTA ' ; jBirf3Clf' y t3 .NAME OR CSM 9Z G RFC �.► >M�LL .. ?: # y l oc. 4 P4 1666 CITY STATE ZIP CODE PHONE NUMBER (]CITY []VILLAGE OWN I N i AREST ROAD My Sow ( ) &S reEEAJ NLL LAS [ j New Construction Use [(x( Residential / Number of bedrooms (J Addition to existing building Replacement (J Public or commercial describe Code derived daily flow 1S0 gpd Recommended design loading rate O.7 bed, gpd /ft 6.'g trench, gpd/tt Absorption area required bed, ft trench, ft Maximum design loading rate 0.? bed, gpd /ft trench, gpd/ft Recommended infiltration surface elevation _d ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN- ROUND PRESSURE AT -GRADE SY TEM IN FILL HOLDING T K U = Unsuitable fors stem WS ❑ U INS ❑ U 14S ❑ U S ❑ U 2S ❑ U ❑ S SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Botxrdary Roots Bed lTrendn c - /0 R477 sl_ /F D.4 ®.S -1 15YP,4 SL bK Av�r C5 1.7 7 6 A O.f Ground �, 17-4d �Q s� VS SG M C S — elev. 9 5.0 ft. $ !- Q 3 clpf us 5r l nn SU \t Cs — Np :NP Depth to 63 14%9m z b - /P"+/ A /MI 5 M C5 0 6.$ limiting _ factor , 2- f7b I YQ 41 3 MS C »'► a.7 61 ? IO , � Remarks: Boring # 6 - 3 & 4/z 1 /6VA4/ 0A 0"s $, -39 It) P'4/ FS osi a, 4 Ground � elev 44 . $ _ S 1 y,e 5 3 C z t rus-r S, C S "L /n S b K M ; C S N P" N1"' 8 ,3 /-�q e 4 te .— A 5 S rv C S — 6.7 6S Depth to limiting {� $g 1 A 3 —' /h 5 S G M/ CS 67 az factor > lb.3 gs - /o yre 4 3 `_ M SG A / . � 6.7 0,8 Remarks: CST Name: — Please Print dARVEY up /Sa�j Phone: ddrass: o / &< O Signature: Date: 5 (]p CST Number: ,.4 70 PROP8RTYOWNER RICUMA 46iSTAlMd SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourrary Roots G P D /ft AA in. l� Mu Qu. Sz. Cont. Color Gr. Sz. Sh. Bed W& ` /6 e Z 5 t ) r ., S b K rn r 5 6.4 16- 5' �3 z (� Qz 4 &144 —" 5C / SL 1hv7r CS 1 6 .4 0.5 Ground R 4 5 c_ 0 , 3 b K A;- e-.5 6 o S e e v — q V- it eT -C6 /6y +e 5 C o� c f n, b l� Jh r C S Depth to MIS limiting ? f tl. Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # '�Wi'•`rnir8. i �:iii�',Q�1 Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) � L f� (r'�t CA ON xd L �1 Q n D _ N J.yn J, L n o w r j P .� ti ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer , ,,,,,,,) 6u .r T--9 f ro/1J Mailing Address y9� �i1 �E�� Lz� . L i9iv� Property Address ,,, Z ,v� (Verification required from Planning Department for new construction) City/State /y , ],,,4_ Parcel Identification Number o ,i (-) 1 3 1 -/O LEGAL DESCRIPTION Property Location J_ %4, �i '/4, Sec. , T_2LN -R /9 W, Town of Subdivision h /fit i , Lot # � . Certified Survey Map # , Volume , Page # Warranty Deed # -S"f . Volume Page # Spec house ❑ yes ❑ no Lot lines identifiable N yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLIC DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPL ANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed DUCUOKNT NO. STAT1i 8 ":.�AHri SON -!FORM l TvtS SPACE RESERVED FOR �ECORgaG DATA 64 t 378:1.11 , n" .} 1 REGISTERS OFFICE THIS DEED, made between, Val G. S Dierks and ST. Cgo"X CO., WI& nice F, Di ,, i,abA and wi Rec'd. for R-scord th. 29th -' Grantor day of June A.D. 1982 � arrd Richard C Gus;.afson and Carol A Gustafson at 9:55 A i _ huchand and—wife fa acs nin Unan" Grantee, tai a witness t h hat the said Grantor, for a aiva o sid -tat ion On Dollar (1.b0� and other good anc valua�l"e c onsi Brat °n �T „To -,� conveys to Grantee the Following described real estate in St. Croix County, State of Wisconsin: Part of SEk of NE of Section 17 -29-19 described as i follows: Lot 1 of Certified Survey Map filed Tax Key No. F` May 20, 1981 in Vol. "4 ", page 1060 as Document No. 370960 l ract entered into between the parties This deed is given in fulfillment of a Land Cont on July 18, 1981 and recorded in Volume "63-1", page 17 as Document No. 372293 in the records of the Register of Deeds for St. Croix County, Wisconsin. This is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenan es thereunto belonging. And Val G. S. Dierks and J F. Dierks warrants that the title is good, indefeasible m fee simple and free and clear of encumbrances except easements and zoning ordinances and building restrictions of record, if any. and will warrant and defend the same. Dated this - -- -day of "Jane - - - -- -- - - - - -- . 19 82 (SEAL) (SEAL) Val G. S. Dierks r (SEAL) - (SEAL) * F._D - ier ks AUTHENTICATION t ACKNOWLEDGMENT Signa res entic red this 1 { tlt _ —day o f STATE OF WISCONSIN _ ' SS. County. r Personally came before me, ' this lay of the above named _ ou la s R. i1z _ _ __ - -- __ - -- TITLE: ENIBE" STATE BAR OF WISCONSIN (If not, -- authorized by ?706 06, Wis. Stars.) __ ____------- -- - - -- This instrument was drafted by J d' DOUGLAS R. ZI LZ to me known to be the person - who executed the fore Attorney at Law going instrument and acknowledged the same. H�idg�n_ 4lisconsin_.54016. __.. (Signatures may be authenticated or acknowledged. Both Notary Public County, Wis. are not necessary.) \R' Commission :s permanent. (If not, state expiration date._ —__ 19__•) •Yar.zs ut pe-s ons rqn inA M any capar.tty .mum t)e typed �r pr:ntrd Dei ,'._.r gIKn e'�ree •ARR -_NTY DEED -SrATE BAR OF Wi9COYSIN FORM %0 I - 19" . J..p. a�,nrB ®7A4riaiN r ItiAY� 'IFS 00 198 Shot oel p N afcc i Cb �- o U H � O w p � CERTIFIED SURVEY MAP �. • - ' , C '� � !0' �c � o r 0 n sy n n t''' a ny„ t� Cti 0 O - U) Pj r'� rtc� f�A a ~ O � In � a C z (D rt X O� VI ��j (D rt �-+ N 1✓ 0 (�D '� f7 ((DD O� n `- �� rh M = rN}. p Q p (j) • " v d w to (n (D �z" t ZS �C N o G r A � M ♦+ j " `i ''a ....�'� + ��° rt O (D (D O N (D (D C� V) (D Sj O `C rS O n ' r••r .. +`Vv v� o C1+ � ~ 6 m O Ul 4• fj O � ( n rt °� •.x..30. a �. o � Pi rr n h0 0 0 ( N H. rt n cn ri ¢ -+�� rt O_ 2�a — (n G7 (n ownrj WOy ( I N (D N F-- n I I m � rt .( 0 I , Sj O In m ° I NO 06'3 0 W _ ----- - - - - -- O ' r t z (n H. � p '17 ' Z ( 9 0 311.0 0 c O (D (D H. p- ri z O rt SZ (D to j (D b (n fTl - : : 5 " rt c a (2 - o n n H. 1 \ (n (n \ (D (D rn cn m m DN O `s] �.., n O • (D I8 rt (n o - �o O ) C : ) D I O m O m N oz 0 1:), � �� s� 0 ° & 0 Cl In -C 00 O (n (D Au L r f m N u > _ O �' (n SU SZ+ 0 tit (D rt o m p F I � lD 2 _n (A .� H ' , C O d C) O rt G) W m o �c\ F (D �c o ,n ��0 in Q z co m I W i ;; I \ F' 1'j f' rt 12 - _ c, C t n H . rt N• n 'i I co r z I rn (n r 0� (fit (D 04 tD Ln z I F U' m - m N �• O• M n fn ' CO 4 n a (D ; z ° w CT 1_ �-3 O G rj .7 O 1 H A I o r' 1 ^� ; O -r JG �j rt s?' (�v D NO°06'30 "W ice,- o N ri H .a i rt 0 L, m 311.00 N �r- I - APPROVED d rf ,j ro 0 y w M Fl• o (D O n t7 � rt ,(j o p O to rt rh Fr O fD Y207981 �:r - n 9- .< _ (� rn r. ;a vi n t ST. CROIX COUNTY `' 8 rt COMPREHEVSJVE PARKS PLAt6 ;nG rt �3 O (a ' AND ZONING COMMITTE(0 o � O n0 ¢ n I Z LnDN 0 rnC �'o En (D 6 6 0 (n 0 0 '� ." N K� rt M r, CD O z i 33 33 O p N ° � '� On ¢ to O t' n W (D (D U Fl O c I Z N 0 cQ Aar" F c O �O G %J (CD (it E G w W G F� O ft 0, 0 O l H 7C' N I O ° I �_ WESTERLY RIGHT -OF -WAY LINE �cD�n 0 90 0 ^r n oR, - -- S 0 E X3 SO £ ( N m m w 311.00 ----- - - - - -- W O _Z �>__ w _ DAILY ROAD _ fD o w ; .01 z� °? NO 43� 30 W 2652.8 7 Z ► �A w Nmm o (' %o EAST LINE OF THE NE i/4 CENTERLINE �Z0 (D z z THIS INSTRUMENT DRAFTFn RY J. MCCANN Volume h Pare 1060 �� 4AI -9R7 , s r Ap AS BUILT SANITARY SYSTEM REPORT OWNER ! r/9�SC�4/ TOWNSHIP / OS 0/t/ SEC .ZZTVN -R ADDRESS UDSo /l' C -C /l, S o r 6 ST. CROIX COUNTY, WISCONSIN. SUBDIVISION 011 7%0 <5,7 S LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 — lERY THING WITHIN 100 FEET OF SYSTEM .� k All, .rarY►.. .wee. w:i wren., .. ,..i. ., a \�+ n u k law Y I di a rel!lo th Arrow �-- I S C L C I y BENCHMARK: (Permanent reference Point) Describe: r� IAOA) P/PC AT �w'Cof 9� or- 8/LI /QO" Elevation of vertical reference point: Slope at site: SEPTIC TANK: Manufacturer : _W e i,5 r or-� Liquid Capacity: / Cx::YG G AU K Number of rings on cover Tank manhole cover elevation:_ Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set for a cyc e gallons; total- ` capa___ city __ o� distribution lines gallon: size oT pump head; gallon per minute horsepower brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: Number ot pits feet diameter _ feet liquid depth seepage pit in et pipe - elevation bottom of seepage pit elevation feet. If ,, SEEPAGE BED SIZE: number of lines Olength depth 3�_ SEEPAGE TRENCH: width length PERCOLATION RATE / AR EA REQUIRED C�lS REA AS BUILT L2_ INSPECTOR DATED_ 3 j - 1 PLUMBER ON JOB _ LICENSE NUMBER / (n_ ___ REPORT OF LNSPCC?L0N - INDIVIDUAL SKuACB SYSTEM Sanitary Permit� � State Sept I(- �AMC ?0WNSHl� Sc' Crois Count-y S Ion � Subdivision Sect ou� o * _ ____________________ �[yT}C 1`ANK / -�� Sic,/ 0 gallons Number of compactmeote_ __ _ _ /`iycao,e [rum: Well 12% elope______�______._____ 8 ighwater__'_____ ,11MP1NC CHAMBER -'----' Size gallons pump Mauu[uccvrer___8odel Num �v`/'|`|Nr 7ANK '---' s(^, gallons Number of rr &1uzm System___ /yta".', from: �ell 8uildiog__________ 1.2% |0N SITE ----- n J / {� x" .1�� T b .' reuc / �/ /~ �/ /~� /s/a/`. .' from: gell/ 7 _ Bu1ldiu�_�7 ___ 12% olope_____________�__ BiAbwmter________________ lx�)'()x|`1'|0N SITE DIMENSIONS Width of trench �t Kequiced Lrn&ch of each lioe___ [c Depth of rock below tile--- Number of lines .1 Depth o� rock over �ile in. .J � ---------'-~-'------'------ ----- ----- Total length of lines f Depth of tile below grade.�� ' Z— in. between lines �~ f� Slope of tre"ch�- per LOO [t. . _ | abaortyttoo area �� ft Type of Cover: l'[ U[MO0SIONS / Number of pits Gravel around yits______yes_ _ no outside diameter Depth below iulet __ [ L Total absorption ft Area required / �SPKCTC Tl'[�F ^|'|^k0VED DATE DATE________________.__________ _ __ 198_ x|��SUN FOR BEJECII0N � __-___-___---_-_-_- � PLB 6 7 State and County State Permit # U Permit Application County Permit # for Private Domestic Sewage Systems County * DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: 5:F ' / /a, Section 1`7, TZ�N, RWE (or) W Lot# _ City Subdivision Name, nearest road, lake or landmark Blk# Village C A r I< , j l � C.�) S c 47 Towns SO C. TYPE OF OCCUPANCY: "Commercial "Industrial "Other (specify) Variance Single family 1 /-_ Duplex No. of Bedrooms _� No. of Persons D. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concret Poured -in -Place Steel Fiberglass Other (specify) New Installation , 7G Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate - - r Total Absorb Area ��' sq. ft. New Replacement Alternate (Specify) . Seepage Trench: No. of Lineal Ft. Width D%pth Tile depth (top) _ No. of Trenches Seepage Bed: _ Length - Width �_Depth '346 Tile depth (top) No. of Lines 3 Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land 16 %o Distance from critical slope WATER SUPPLY: Private X Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certified Soil Tester, // NAME �3 �J C.S.T. # SS .� �O and other information obtained from .r 1 ' - .(J 0 A./ ( owner /builder) Plumber's Signature MP /MPRSW# _ Phone # Plumber's Address Csv WfS a r PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. '(out, Vt 4. ute ale 33-- y j F F r tot A, 71 011 J Do Not Write in S ace Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application ,LT -�� Fees Paid: Stat County M ` Date _ Permit Issued/ (date) �y Issuing Agent Name Inspection Yes No State Valid# Date Recd 1. county (whit copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4, plumber (canary copy) Revised Date 7/1/78 E {.� M' n/ �✓N EST povE F 2- 1 -15 Rev. 9/78 Co(�.vTY C S . t 1 �LVlE1�.�. /V REPORT ON SOIL BORINGS AND PERCOLATION TESTS j+c.)uSG WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES r v( i T P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION: %,�'/,, Section 17 TZaN,R _LFzbnr4 W, Township Lot No. Z- Block No. fEil> M� County uuidiivision County Owner's /9>�s�Name: �� ter` I Mailing Address: t TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW � REPLAC / EMENT ALTERNATE SYSTEM / (F DATES OBSERVATIONS MADE: SOIL BORINGS 4 '` / &13t PERCOLATION TESTS 4 / l ?! Mr SOIL MAP SHEET i NAME OF SOIL MAP UNIT t''A -OrRg / `i_Q i S�-J PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL, INCHES RATE NUM INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /EN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- z 6,1 Y2 &t 5_ 3 3 i %4- 3% 1 P_ P_ P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- l l'-� /vrvF_ > �Zea $L L 'T; lo- M„r5, L i3 L5 S L jaw M B- o rar ✓� n z J4- L v L z , g o . g s PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the ocation and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. $ � AJ � M fib -I< - 1 L, / 00 • v 's /y " 5T E e r_ rsit R. �r !`•i lecl co ��-- ►10 9_'r - 4 I_ I N s L o O Lio QE t �� T � 7' S I T - t ( � i��i�.� c> I-- r'�Tlol� 'T - �.4.- i Sint• + i • Z aA tj M.AIEe_ El_ . / C30 . a MA-P-5 t-Z OF= V=_ -/ l S7 A Er �Le VA 0 AJ5 -- J I,'. Z 8 gG, o ��ai /, f3 -Z 97.E g -� �� EI �� gi p• ,L� 650 i 1 I V/ 9�� e eo 1/ I, the undersigend, hereby certify that the soil tests reported on this form were roade by me ip accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded an r=ation of test holes are correct to the best of my knowledge and belief. Name (print) A M T= J - u SC Certification o. Address / �- Name of installer if known Copy A — Local Authority CST Signature H — 115 Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION G ' /a, Section ,T�N,R /9E (ePOW, Township or M m i e*—_ . Iy U�SO Lot No. , Block No. County -� Subdivision Name �wvner' B(�yers Name: i— I �k� � ' Mailing Address: TYPE OF OCCUPANCY: Residence No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW _REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS PERCOLATION TESTS SOIL MAP SHEET `_SiFl NAME OF SOIL MAP UNIT PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P— P— P— P— P— P— l 1 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B ' fJ L T' L z G' L w oTw P - o g B- < a 43 _ It B- f Z_ AleuJt //� L ' Y R js, L as o rs PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) ndicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. f � rte- �- �� 3T�K S / �� =' 7n �► G'7- � �r4So�c.lA �-- S U /� --F�4 c� TO tZv A./ 0 / - / -' 7 Th - iS _ 5 /7 g.A-j D l� P 7c:> !'lol/E S a / L �" /Y! 777 P.80 Pose2D OP i�/ � P`r c.c�s Ta 7fr� 4E;4_,I ✓P q.T70A/ C?t A. c. T `)Z' Q l TA/ c.c/ •Q c /G 4—' 01' C-ol 7-7cY AJ 6- V S rc llc L-D i TttA /(/ '7a ?`�E�" Lo f/�/ �,�•9 7U 77i"E KI X= 7 . K I E L DS C� T I F I 2VC+Y rM f{-t I, the undersigend, 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 location of test holes are correct to the best of my knowledge and belief. Name (print) r4M E . A"_U s C- Certification No. S -S` Address Name of installer if known CST Signature Copy A —Local Authority L ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the ca"g w" residence located at: Section T N, R 1 W, Town of Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: ��„� /� /99�? Did flow back occur from absorption system? Yes )Z No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concret Steel Other Manufacturer: (If known) : `✓sr�r�2 Age of Tank (If known) : 1 mss (Signat (Nam Please print (Title) (License Number) es /i9 /9 Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83 Wis. Adm. Code (except for inspection opening over outlet baffle). Name - �/0✓z� o Signatur MP /MPRS