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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDI�STR�Y, DIVISION
t7'80 R ANA CC P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (��J, MADISON, WI 53707
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: T0WNSHIP /kjU"tQe)=3TY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
SE 1� NE !/ 6 /T31 H/1t9xf (or) W1 Somerset 1 17 n/a I Grace Development
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
St. Croix Don Andersi 8632 Hamlet Ave. S. Cottage Grove, Mn. 55016
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 3 n/a ®New ❑Replace 3 -25 -91 3 -25 -91
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND-PR ROI ESSURE: SYSTEM- IN- FILLHOLDING T TANK: RECOMMENDED SYSTEM: (optional)
[aS ❑U DS ❑U CAS ❑U ❑ S ®U ❑ S t
�U conventional
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 1 OnD2
BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ft ELEVATION OBSERVED EST. HIGHES T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B -1 6:84. 101.94 none >6.84 .67bl.1. 1.17bn.sil. 1.50bn.s.l. 3.50bn.c.s.
B - 2 7.00 102.02 none >7.00 .67bl.1. .58bn.sil. 1.17bn.s.l. 4.58bn.c.s.
B - 3 6.91 101.44 none >6.91 .83bl.1. .50bn.sil. .83bn.l.s. 4.75bn.c.s.
B 4 7.25 100.29 none >7.25 .58bl.1. 1.25bn.sil. .92bn.l.s. 2.00bn.c.s. &gr. 2.50
B -5 6.50 100.59 none >6.50 .67bl.1. .75bn.sil. .75bn.l.s. 4.33bn.c.s.
6-
decimal ' PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES
NUMBER XZXWS AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P _ 1 3.50 none 3 6 6 6 <3
p- 2 3.58 none 3 6 6 6 <3
P _ 3 3.00 none 3 6 6 6 &
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 location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 98.44 �a
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ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT * EIVEO t
Owner -,
Address s7 +
'�� , ST CROIX '
City /State $o,e�ce�'sz` i GAS COUNTY
ZON
Legal Description:
Lot 0 Block Subdivision/CSM # SG
' /•%. Sec. �, T / N -RLW, Town of _ 0 ?- PIN # 2 z io /G - eo
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer ALI T7 Size ST/PC /'/ - Setback from: House /Y Well - P/L 7 Jr
Pump manufacturer Model
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: .f5 c fJ Width > P' _ I�gth 3 Number of Trenches
Setback from: House 3 Well ncw.� P/I, . 9 ' Vent to fresh air intake
ELEVATIONS
Description of benchmark Ta/ I/
Description of alternate benchmark � Elevation X
Elevation
Building Sewer ,� ST/HT Inlet �/ 3 ST Outlet , a3 PC Inlet '
PC Bottom Header/Manifold y6 Top of ST/PC Manhole Cover
Distribution Lines ( ) ( ) ( )
Bottom of System ( ) 2j� _ ( ) ( )
Final Grade O , /5__ ( ) ( )
Date of installation / / 4i Permit number _ 3,0 26 State plan number
Plumber's ssiignature License number 'J�S Datet
Inspector If "�PA_
V AC
Complete plot plan *
Wiscoiasin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division yST . CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar3Vt.:
Personal information you provice may be used for secondary purposes [Privacy Lbw, s.15.04 (1)(m)).
96096* rs NIMN `�17M�M� i ❑ Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TY32=1016-80-000
l 6T ' SrO 47, 2, c- i
TANK INFORMATION U ELEVATION DATA A9800055
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
eptic ev f� Bench r 1 07-2- . /per
Dosing f .�7/ �7� D I.
Aeratio Bldg. Sewer �`3 �p
G• / 79"
Holding St/ Ht Inlet 6.77 l0 V-3
TANK SETBACK INFORMATION St/ Ht Outlet (�. 106.g j
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
irl
e tic �- ti NA Dt Bottom
Dosing NA Header/ Man.
9.7�` � yL
Aeration Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model N
TDH Li Friction S st TDH Ft
Forcemain Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
RENCH Width ) Q ' Length��, No. Of Trenches PIT No. Of Pits Inside Dia. liquid pth
DIMENSIONS G� DIMENSION
SETBACK
SYSTEM TO P/ L BLDG I WELL LAKE/STREAM LEA G Manufacturer:
INFORMATION Type O Z AMBER um er:
Syste • h, � J �' /QV
DISTRIBUTION SYSTEM
Header /manifold y Distribution Pipe(s) N x Hole Size x Hole Spacing Vent To Air I r take
Length Dia. Length Dia. Spacing � 7
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx
Bed /Trench Center r , _ � l ` j P Bed / Trench Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET 6.31.19.85H,SE,NE 2367 DELONG ROAD
" 0 -k - 4vvk
(�) A � ltslf�' 7n.
Plan revision required? ❑ Yes TjrNo
Use other side for additional informatl n. P 3 �8 v
SBD -6710 (R.3/97) Date Inspe is Signature
Vi sconsin SANITARY PERMIT APPLICATION 2 01eE. WshingongAve sion
P.O. Box 7969
Department of Commerce accord with ILHR 83.05, Wis. Adm. Code
P Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. STS Ci.
• See reverse side for instructions for completing this application State Sanitary Permit Number
30766 (,c.,
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)). �� /„ -7- 710 //7V�C'' X10/ State Plan I.D. Number
I. APPLICATION INF RMAT N - (,( �PLEASE . � J P I R / IN v T L A 4 \! L L INF RMATI N
Prope cation
p y O ner Nam Property Loca
V a A d �i So �1 /a fqE t /a, S T 3 I , N, R E (or)1 )
Property Owner's Mailing Address r Lot Number Block Number
pq rc I 7
Ci State Zip Code Phone Number Subdivision Name or CS
t er F,i�wa7" -to- M �( ss o p z, GiT ),?si , 5PvC
II. TYPE F BUILDING: (check one) ❑ State Owned [] Cit ar Road
Public 1 or 2 Family Dwelling - No_ of bedrooms 3 [] Towa � �� r S n OF
III. BUILDING USE (If building typ it s public, check all that a pply) Parcel Tax Number(s)
1 [] Apartment/ Condo " li /' / / �� '? 2 y >0 O �
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 ff New 2. ❑ Replacement 3, ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
- _____Syrstem -------- 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 o 42 ❑ Pit Privy
13 ❑ Seepage Pit /5a�' 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
Req//u��ired (sq_ ft.) Prop seed q. ft.) (Gals/day /sq. ft.) (Min. /inch) C/ Elevation
�� cvy y �� 1 Feet Feet
Cap acit y
VII. TANK in Ca ga llon s Total # Of Prefab. Site Fiber- Exper-
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks
Septic Tank �(9v J /pa o ® ❑ ❑ ❑ ❑ ❑
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.
Plumber's Name: (Print) Plum is nature: tam ) MP /MPRSW No.: Business Phone Number:
' D U -IqA, V,
Plumber' ddress (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent ignature (No Stamps)
® Approved ❑ Owner Given Initial � Surcharge Fee) 2 r
Adverse Determination / l U
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
(FL 1 tom) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
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Wisconsin Department of Commerce SOIL AND SITE EVALUATION
11vision Uf Safety and Buildings Page of
Bureau of Integrated Services in accordance with. s. ILHR $$.09, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1/2 x 1 finches in -ctx&,IafWst
include, but not limited to: vertical and horizontal referenie;pgint (BM)! eeetio�rand
percent slope, scale or dimensions, north arrow, and loc4tion and distance to nearest road Parcel I.D. #
Z — /C) �(� - ��
APPLICANT INFORMATION - Please print atl reformat` %�� R','`'' 1 Re iewe by Date
Personal information you provide may be used for secondary purpo s (P6vacy,
Property n �. ` Propertylracation C �
w t ,
` y i + ovttiLdt S'� 1/4 A'G i 1/4,S T ,3 J ,N,R E (or)V
Prope wner's Mailing ress Lot # Block# Subd. Name or CSM#
J , B� S ST J
C' State Zip Code Phone Number ❑ City ❑ Vill ge io Town are t Road
New Construction Use: ® Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe: Q
Code derived daily flow gpd // Recommended design loading rate 7 � bed, gpd/ft a Q _
trench, gpd /ft
Absorption area required _ bed, ft %563 trench, ft Maximum design loading rate t' / bed, gpd /ft 0 trench, gpd /ft
Recommended infiltration surface elevation(s) / �- 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- Ground Pressure I AT -Grade System in Fill Holding Tank
U = Unsuitable for system g S ❑ U 49 S ❑ U @� S ❑ U ❑ s .® u ❑ s [au ❑ s 0 u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
ii Bed ,Trench
l .. s )S"YRZ.S'1/
Ground -3 - lo l S�� $Y Y/ ` h1 L i f '7 i d
ley
/ L_La
ft.
Depth to
limiting
factor
? 1D� in.
Remarks:
Boring #
I AR 313
Sip 7
Ground
elev
Depth to
limiting
factor
71q in. Remarks:
CST Name (Please Print) nature Telephone No.
Address Date CST Number
?Z d s�" in lv «�� -9g" �s�tit 3q
M
S�"' NEYS '(o73 IH�19cv N87 3ly 7
mc tj VGMev'S� C 1 fs�D
gem / f a — — LQ 7' Z " o_ - e
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STC -105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS
PROPERTY ADDRESS 7
(location of septic system) Pl9dse obtain from the Planning Dept.
CITY /STATE SO T 4c-_1
PROPERTY LOCATION S_ 1/4, NF 1/4, Section 6 T N -R S W
TOWN OF 7 ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIEDSURVEY MAP W? S , VOLUME L;/, PAGE 2 - , LOT NUMBER 7
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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on -site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year it 'on dale.
SIGNED: z
DATE: c7a
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
J `
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner /contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
-------------------------------------------------------------------
Owner of property U ;/�� -
Location of property. 1/4 Z 1/4, Section , T 3 / N -R —
-- W
Township ' i3m f ✓ s 4 ( Mailing address f �8'� f S 1 3 - A/
Address of site C
Subdivision name Lot no.
Other homes on property? Yes PC No
Previous owner of property
Total size of property
Total size of parcel '24
Date parcel was created
Are all corners and lot lines identifiable? P� Yes No
Is this property being developed for ('spec house) ? Yes No
Volume and Page Number as recorded with the Register
of Deeds.
-------------------------------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY.:DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
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. , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run 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.
ign e of Applicant Co- Applicant
__ — q
Date of Signature Date of Signature
FEB-24-98 TUE 14:29 RIVER RIDGE REHAB INC FAX NO. 8127386905 P.02
VOL 1,271 FAC1112
BAR OF WISCON51N FORM 2 1982
STATE WARRANTY DEED
DOCUMENT NO
REG1
t r M ST C 0 " Co. W
hew R OCT 0 1997
EG I R
01 ,
P_ R
- Miche a M.V1 i 4 A9.Ltj 1 F0004
2
2 to _. md 12 OFFICE
Mal PM
Wnfty!t IrVa warrants .1_Jahl=TL 12�00
THIS SPACE RESERVED FOR FECan"(1 DATA
NAME AND FJkTURN ADDRESS
the furrowing deurib.d oral rslate in x - 5� 1 P4'
' Vo V 11,
Stoic of Wisconsin:
(_-) - 1G to
FAjZTL F01KA'r10_N
Part of Southeast 1/4 of Northeast 1/4 of Section 6, Township 31 North, Range 19 West,
described as follows: Commencing at the Northeast corner of Se ction 6; thence South
05 W a long the Section line 1715.52 feel. 10 the point of beginning; thence South
05 West 253.2 feet-, thence South 98*19'05" West 679.14 feet; thence North
77'32'50" East 166,17 feet; thence North 45 °31'35" hast 38.37 feet; thence North
24 East 159.69 feet; thence North 08u52'15" West 50.75 feet; thence North
88 °19'05" East 456,54 feet to the point of beginning, subject to road.
This deed is given in fulfillment of that certain land contract between the parties
hereto dated July 11 , 1996, recorded July 16 , 1996, in Vol. 00 , Page
C ro i x 1i r St. C
as Doc. in the of of Register. of Deeds E [
r.
Wisconsin.
This iS nOt-_ 110UMSECIRLI [MOPEr
CXL Easements, restrictions and rights-of-way of record, if aliY-
Dated this
(SEAL) apt
MaLtbezj"aron
a Carr
(SLAL) (SEAL)
AUTHLN] [CATION # r ACKNOWLEDGMENT
State or Wisconsin,
St. Croix
Own
stuthenticrudih6--doyor_ _19 lly L'Am hel, a-
Ne ahu AliA jta
-Mat t.hew-R—Caron and .P • IL
f Jk/&_ Michellr-111 . Ca= aqab w irr
T7TLE: MEMBER $TME BAR OF WIS CONSIN
(If nut, ._
21lLb0TiZVod by 9706 06, Wis. SWS.) to mv known W he the N11011 S.. [caller
1115111111TVIA and ncknuwtedge the
THIS NSTRUMEN [ WAS DRAFTED sy
_ALt.LtULeLni 0gland
- . )
Hudson W1 34016 Nato' P"Nic 47'r '�F �c
ih M Couluy W13.
((Signatures may be a i viii(aiA or ad4now1odgvel. Voth w riot y
L� trilanctil (If 1101, Sure trXpirkilpil iatt
PAULA J. RlXMANN
STATI• 118A OP WISCONSIN Notary Public-State of
WAILRAINVY DEED roan N. 2. 1482 My Commission Expires June 18, 200r`ft"'