HomeMy WebLinkAbout022-1075-60-100
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER (/U`d rr
ADDRESS ~`j 4
SUBDIVISION / . CSM LOT f
SECTION
N-RIF W, Town of_!/l/1lC~c!`11~11(►
ST. CROIX COUNTY, WISCONSIN
PLAN._VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~6at0 ~n,, ToP 3~" Posf
r
1
3,40
la&01AJ s~p~-►~
fb ~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
. 'pENCHMARR: y' G O s~L°P / S
ALTERNATE BM: i
EPTIC TAN PUMP CHAMBER /HOLDING TANK INFORMATION
Manufacturer: 6d~es t-Liquid Capacity: 0)14.6
Setback from: Well ~>5t~ House ~Q t Other
Pump: Manufacturer .Model# Size
Float seperation` Gallons/cycle:
Alarm Location
1 SOIL ABSORPTION SYSTEM
Width: Length INumberof trenches
Distance & Direction to nearest prop. line: b
Setback from: well: ~,/)D L
House c250 Other -ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: P7
PLUMBER ON JOB: Q
LICENSE NUMBER: 303
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 284275
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
FRIESEN KERRY AND ELISABETH KINNICKINNIC
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/GIJ.6j, /C ,GO, Q5 022-1075-60-100
TANK INFORMATION ELEVATION DATA 7 09 7
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
i
_ f } Benchmark A?Q 16d, 6c,
Septic 'CYGc1E',Ee/'h T,_
Dosing
Aeration Bldg. Sewer
i
Holdi St/ Inlet 3,38 (JZ)d. /
TANK SETBACK INFORMATION St/) ft Outlet 3, ~S 975~~
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic >Szi, 2,7 NA Dt Bottom
Dosing NA Header: SGn Y.p j~.~
Aeration NA Dist. Pipe s /3 s,~y'S,i 9/.30
Bot. System
Hol~in"g s:~ s
PUMP/ SIPHON INFORM Final Grade
Manufacturer Dema
odel Num GPM
TDH Friction t
Loss ead
Forcemain Length Did. Dist. To Well I F
SOIL ABSORPTION SYSTEM
BED /TRENCH width 5 % Length No. OfJTrenches PIT _ No. Of Pits Inside Dia. Li Depth
DIMENSIONS
CHING Manu rer.
SETBACK SYSTEM TO P / L BLDG WELL LAKE/ STREAM
INFORMATION Type O ~v, z CHA
r OR UNIT
System: --F F, l_>' -GS I~ >Sb
11f 7~_
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pi e(s x Hole Size x Hole Spacing 4 Vent To Air Intake
Length Dia. Length r!o Dia. L, Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade ms Only
Depth Over Depth Over xx Depth Of xx Seeded / So d xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ,No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: yK-INNICK NNIC"y.2/7.2 1 SE NE 1299 ,EVERGREEN D ~V_E^ L/OOT1
, =40110,
4,Q n
an revision requir ❑ Yes 9-%b
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
vp`ri SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County I ~~lX
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number -
The information you provide may be used by other government agency programs eck if revision previoapplication
(Privacy Law, s. 15.040)(m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Propert Owner Name ropert Location
V rhZ- & ese 1/4 t/4,s a7 T ,N,RlE(o W
Property Owne 's M41 ng Address Lot Number Block Number
Ci y 5 eSO Zip Code (h~opne/;urr~i„~~D SubdivisionN~crC~^ Num~b~a~ n 1.
II. TYPE F BUILDING: (check one) E] State Owned El cit~ Nearest Road
C] VII age cr
F1 Public fg- 1 or 2 Family Dwellin - No. of bedrooms Town OF c
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
oar-/075- 0 -/0d1 E] 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. Ci~ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
_____System System- ____________TankOnly______________ Existing System Exl-----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 [K Seepage Trench X6'7 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
Re ~~d ~Sq. ft.) Pro~~ (sq. ft.) (Gals/d y/sq. ft.) (Min./i ch) p~ El {ation
S 5 7 + Feet %Q 116 Feet
VII. TANK Capacity site
in gallons Total # of r Prefab. Fiber- Plastic Exper
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App_
New Existing strutted
Tanks Tanks rye
Septic Tank or Holding Tank ( S ® ❑ El ❑ E]
Lift Pump Tank /Siphon Chamber ~~A n I ❑ El
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans.
Plum is Name: (Print) PI r' Signature: (N S amps) PRSW N Business Phone Number:
-TAoho,S 3-31 a - 5~
Plumber's Addr ss ( treet, City, Wp C de): , 1 0
t _5
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Age Signat No Stam
pproved ❑ Owner Given Initial Surcharge Fee)
7d~~
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
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, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. 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.
VIII. 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 8 112 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.
SANITARY PERMIT _'~4.. cra i~C COUNTY
EL. OILHR TRANSFER/RENEWAL UNIFORM PERMIT #
(PLB 67-T) 8 S/.;) 7s
PERMIT RENEWAL ATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSU NCE DATE: STATE PLAN I.D. NUMBER:
'7 7/0 3 /9 7 3///9-7 /4-
PROPERTY LOCATION: CITY:
S 07,T d(~ N,R ft E (or W TOWN OF 1-119
LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: ST ROAD, LAKE OR LA DMARK:
/ S r 1 s5~ao3 Uo f`/ r
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: SIGNATURE: NAME: PHONE NUMBER:
ADDRESS: PHONE NUMBER: ADDRESS:
I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
p p rty.
P ER'S SIGNAT/OR PREVIOUS PLUMBER'S NAME ( HANGED): Po BEAT
PLUM ER' A DRESS: A0 PREVIOUS PLU~BER/AgDRES%:
NU&tBfR PHONE NUMBER: //MPRSW NUMBER: PHONE NUMBER:
IDIP
3 a 1 (YaS'► Q5 3 3 0-7 (-715) M6 - PAU
SIGNATURE OF ISSUING AGENT: DATE APPROVED: DISTRIBUTION: Original - County
Copy - Bureau of Plumbing
Copy - Owner
DILHR-SBD-6399 (R. 5/82) Copy - Plumber
v Sa etyety angs Division
SANITARY PERMIT APPLICATION Bureau of Building Water System:
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 81/2 x 11 inches in size. 5T' 6iel,x
• See reverse side for instructions for completing this application State Sanitary tPermit Number
c~ it 7 Q -7 5--
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION f~
Pro" Vy Ov_yn~er Name j &/,Z & Property Location ` e/R,~^, '~~.~Ofcf- ~C /Es~' 51 /4 Vg,1/4, S L T o N R E (or) W
Propert Owner's Mailing Address D Lot Number Block Number
Cit , Staoe,.__o.o~ Zip_Codee / Phon umber Subdivision Ngne or CSM Number
II. TYPE OF BUILD NG: (check one) E] State Owned 0 !t Nearest ~Road
Public [TI or 2 Family Dwelling - No. of bedrooms Vllw9 ofi~ti~ Ale
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
D2~ - to O
1 ❑ Apartment/ Condo 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 Flew 2. ❑ Replacement 3. E] Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
wr► ------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
110 Seepage Bed 210 Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 R'Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit s 1 7 a (2, l s 43 ❑ Vault Privy
14 ❑ System-In-Fill X
VI. ABSORPTION SYSTEM INFORMATION: If S: 5'6 Z.. `3 •O
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
f✓o Required (sq. ft.) Proposed ft.) (Galway/sq. ft.) (Min./i ) 475, 50 Feet Elevation
4~J Feet
VII. TANK Ca
in galloacitns Total # of Prefab. Site Fiber- Plastic Exper
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App.
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank /Ofi7 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber 'e ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) /MPRSW NO.: Business Phone Number:
F,05.a7- Z~l 6 ~~GLc 33 0 71S• 30VI ~f8
5
Plumber's Address (Street, City, State, Zip Code : 9 O `~D~
4f 5 S p .v u cG /W - S v J
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
O(Approved ❑ Surcharge Fee)
Owner Given Initial
Adverse Determination 0 j9
X. CONDITIONS OF APPROVAL / REAS NS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be 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 BuHtlings Di-vision, 608-266,,3815.
Tb•'be complete arid'accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
Ill. 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. ..r
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.
VIII. 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. • t
X., County / Departmen-t Use Only.
Complete plans and specifications not smaller than 8 112 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 "w'hich can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
p~ J2~
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9
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A57 ~o
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
Final Grade i
~i•ll/~~wdC fit~~~ y~ ~
Above Pipe -4" Cast Iron
Vent Pipe'
-to Final Grade
Synthetic Covering
min. 2" Aggregate
Over Pipe
Distribution--,- Tee
Pipe + 0 0 0 0 0
(o Aggregate o Perfbraled Pipe Below
Beneath Pipe
0 Coupling Terminating At
Bottom Of System
Sy5%
Std
Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum t2" Above
Final Grade
a.0
All n
FILED
6 FEB 2 5 1997 ► 3
KATHLEEN H.WALSH
Register Of Deeds
SLCroixCO,Wl
556003 IV
% CERTIFIED SURVEY MAP
OMERLE NIELSEN
Part of the Southeast 1/4 of the Northeast 1/4 of Section 27,Township 28 North, Range 18 West, Town of
Kinnickinnic, St. Croix County, Wisconsin.
Owner's Address:
N F COR. SEC. 27, r 28 N, R /B W, ~_Ti• 1295 Evergreen Drive
/COUNTY SURVEYOR'S MON.!
UN PL A TIED LANDS m River Falls, WI 54022
E~_~1V OR/ VE
S 89. 38'27"F 250.0/'
r~
N LINE SE 114 N b O
F 114 b ~ 1~p ~ W
r tk zt
N89.28'51"W O
240.00, W q h
o /3' 2 t
M
3
Jl~
WATER COURSE
h ~
to Q
Q I b CI) tu
Q " ROAD SETBACK LINE ~I ~ 0
V N
Z-OT
W
p 0 - O 0; I % tu ku
q a q t
Q h 'n 2.238 ACRES ~ Z Q p
~J 0 97, 476 q ~I O
8 O r .'FT. N Q 114 t N
2. 00/ ACRES EXC. ROAD R.O.W.
87, 163 SO. FT. O 0
J z~ Q2i
JI,
/0'
N 89 • 28 5/ "W 250.00' SCALE /00'
0 25' 50' /00' 150' 200' 250
UNPLA TTED LANDS h 2.
W
E 11E COR. SEC. 27 J
1881
fCOUNrY SURV T28N, R/BW,~ W ,~~`CJVONS 2IE'
EYOR'S MON.!
41 A0,
Dated: January 2, 1997 `~LAUR NC
indicates 1" x 24" iron pipe weighing m W M R15HY.'s °C
1.13 lbs./lin. ft. set. 13
APPROVED , • _ R FALLS. ~ ~AW
CERTIFIED SURVEY MAP
MERLE NIELSEN
Part of the Southeast 114 of the Northeast 1/4 of Section 27, Township 28 North, Range 18 West Town
Kinnickinnic, St. Croix County, Wisconsin. of
Description:
That certain parcel of land located in the Southeast 1/4 of the Northeast 1/4 of Section 27, Township 28
North, Range 18 West, Town of Kinnickinnic, St. Croix County, Wisconsin, more fully described as follows;
Commencing at the East 1/4 corner of said Section 27, thence N 01`29'01 "E (assumed bearing on the East
line of the Northeast 1/4 of said Section 27) a distance of 930.55' to the POINT OF BEGINNING, of the
parcel to be herein described; thence N 89°28'51 "W 250.00'; thence N 01°29'01 "E 389.61; thence S 89 °
38'27"E 250.01; on the North line of the Southeast 1/4 of the Northeast 1/4 of said Section 27; thence S 01
29'01 "W 390.31' on the East line of the Northeast 1/4 of said Section 27, to the POINT OF BEGINNING,
containing 2.238 acres or 97,476 sq. ft. being subject to town road easement over Northerly portions of said
parcel as shown on this map and also being subject to easements of record.
Dated: January 2, 1997
Note: Each parcel shown on this map is subject to State, County and Township laws, rules and regulations
(i.e., wetlands, minimum lot size, access to parcel, etc.). Before purchasing or developing any parcel contact
the St. Croix County Zoning Office and the appropriate Town Board for advice.
This instrument drafted by Laurence W. Murphy
State of Wisconsin)
County of Pierce)
I, Laurence W. Murphy, Registered Land Surveyor, do hereby certify that by direction of the Owner, Merle
Nielsen, I have surveyed and divided the lands shown hereon in accordance with official records, Chapter
236.34 of the Wisconsin Statutes and the Ordinances of St. Croix County and that this map and descrition
are a true and correct representation thereof. P
,``,t~~11! I t ! I f fl~h'h,
'
LAUR CE•;
=m W HY1 act
WI?
c S 1713
N : RIVER FALLS,/
WISC
D LANs)
Wm4tnsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations -
Division of Safety 8 Builclings
in accord with ILHR 83.05, Wis. Adm. Code
^
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but n
ot limited to vertical and horizontal reference point (BR, direction and % of slope, scale or L I.D. dimensioned, north arrow, and location and distance to nearest road. APPLICANT
INFORMATION-PLEASE PRINT ALL INFORMATION S j96 DAJE_
WIEV
PROPERTY OWNER: ~ LQ ►v l ~t S ~ PROPERTY LOCATION
BU~-t ~1'_ ~C~TZC~- ~Z~C STN ~Z-IE S ~N 66 @T S 1/4 W tr w
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBD. NA
`0,o\ 1fv~Ug'C~ t_ sT-. # L \ \PlRa7MMAD
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE BLOWN - l~soNN 11)1 S~.OL(a (7l S) 3a)- 6o Ir~lQ1Q\1~Jij 1C 7ot62t?a)
[ New Construction Use [4 Residential 1 Number of bedrooms Addition to existing building
j ] Replacement [ j Public or commercial describe
Code derived daily flow S gpd Recommended design loading rate bed, gW 5 trer>ch, 9P
Absorption area required 9 0 0 bed, 112 -Ic0 trench, P- Maximum design loading rate S bed, gpd$ • L trench, gpo1ft2
Recommended infiltration surface elevation(s) 01 S, S ft (as referred to site plan benchmark)
Additional design / site considerati onsl~M r'1 ~D 'J `RtQ~ C E~{'cz ~4 S~ X E, 0 Lo~y G q t) t7 S 1. 'F=t.1
j
Parent material S M /.JO y ovl~/t~ S t Flood plain elevation, if applicable t-3 • N, It
I
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for Sys tem S❑ U ®S ❑ U Ems ❑ U S❑ U J OS ❑ U ❑ S UU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bouncby
Bed Trench
-a m
~ [ a_t0 lb`1~Z3l3 S~~ Zwt MU V- Cw !
Ground 3 3$ >o S y 2 YA - T s t) S 1 -
elev.
tOb-O it 3 core W S Pr s Iz 171 Yn v s B f A S
Depth to
limiting
factor
-2
Remarks:
Boring # p _ l 8
m s ~V` `n v i _ n'j - • S i
) 1~~~-~13 s~ \
a mw~lm
Ground
elev.
qct -1 ft
Depth tD
limiting
factor
>7Y'
Remarks:
CST Name:-Please Print Phone' 715-425-0165
Arthur L. We erer
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Si nature_ Date: CST Number:
fQ900576
PROPERTY OMER_ 1"~-IBS J SOIL DESCRIPTION REPORT Page of
"
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
o-~s ~o~~ 313 I mv~. ~w - •S
Z 15 -3'7 3 J 6 ~ S ~ °~S b1z Y>7 U A. C • 'Z ~ $
Ground 3 3)=."-3 14`tR S 4 33 1~ _ S
elev.
ft.
Depth to
limiting
factor i
Remarks:
Boring #
I 6-l~ 1o`1~Z3[3 S~ ~wtsb h'IV`~1~ Cw • Ll ;S
4 Z 1o`1~S1(, p S m S i
•
Ground
elev
q~ 6 ft.
Depth to
limiting
factor
i
r
j Remarks:
f Boring #
Ground
elev. I '
a ft.
Depth to
limiting
factor
i
Remarks:
Boring #
i
13
Ground
elev.
ft. '
I Depth to
limiting
factor
Remarks:
cnn n^ontn ncin-
• of
PLOT PLAN Page 3 3
SCALE 1"= y0'
~ . Z 1vL ~ ~1
~ Q \1 Nom( ~ S' Z H
eY') - fit. 100.0 c~ Z'Ol~- cifi' 3q t-}1 Q
`-\VNPn_ Fe ,-Cc V-03-r, w/ Lf-rY1 }
fit, 0.1 6
~3• s -0-
10
\ ps 5
0 b V~ "j
S X
60, s b i
C2 3 gL °1'16 c~
B• I
LL
a.Z
--w~-L 4 •a
q. LitvS5 '1v B fer T'..5' k k -
a 6-311
(715 425-O165FBI00576
CST Signature Date Signed Telephone No. CST #
I
I
Lavora a Hew Rata f r 'SOIL AND SITE EVALUATION REPORT Page of 3
Division of Safety 8 Bufldrgs in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S-'•
not limited to vertical and horizontal reference point (BM), erection and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. -
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
G9VF4 T S l~- 1/4 IJE 1/4,S Z7T ZS N,R 115 E KW3
PROPERTY AWNEFV S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
`°LtJk %JZUS'fjPfL sZ-. 4 L/ 1 - ~R0P(X3 is-",
CITY, STATE ZIP CODE PHONE NUMBER OCITY []VILLAGE RrOWN NEAREST ROAD
1~QbsorNX >1J1 S4- O1 (2 01 S) 381~~~60 lyvlvlC ,11UI ~Uta-It 6iLOEJ bR.
New Construction Use [!d Residential / Number of bedrooms AddWkn to existing building
j) Replacement ( ) Public or commercial describe
Code derived dally flow S O gpd Recommended design loading rate - bed. gpolft2 , S trench, gpolft2
Absorption t eti ~h~►^ -ISO trench,ft2 NNax6mumdesign loading rate • S bed,gpd/ftAbsorption area required 9~O bed,ft2 trencft, gpd/ft2
Recommended ifiltration surface elevation(s) S . S ft (as referred to site plan benchmark)
Additional design / site wr~siderations ~M Nt J `~R C1t~~ f? 2 H S' )z L o L owl C b o S Q. Pr.) ,
Parent material S R,+O ovT~/t~S l~ Flood plain elevation, if applicable 1-j • R. ft j
i
S = Suitable for System CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM IN F~L HOLDING TANK
U= Unsuitable for fain 19 S O U ®S O U [I S❑ U ®S ❑ U S O U O S IffU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Baxxt3y Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rench
a-LO 1b`1\Z-313 S~ Zwt >nU CW ,5
Z Zo-3F3 -1 S-1R- 14 ~ S ~ Cs~k rnU cw ~ •`3 ~
Ground 3 3$ b S-1 2 Y/( _ ~S 0 s cs r.,
elev.
tp0.O ft 3 ^ar~ S Dr S C--1 tL / l ic/ t lu I / i w, v S 1 tLf~ ? S
Depth to
limiting
factor
I
Remarks:
Boring # q € • S
~0~~~13 sl ~msb1-~
Z Z 1~-y O `1 R_34 S
L
~S~,l •5
Ground 3 y 7 1 R S /6 -
elev.
qq , ft
Depth to
limiting
factor
Remarks:
CST Name:-release Print Phone: 715-425-0165
Arthur L. We erer
egerer Soil Testing & Design Service-P.O. Box 74 River.Falls,Wl 54022
Date: CST Number:
900516 -
PROPERTY OWNER V~tZSIN SOIL DESCRIPTION REPORT Page 2--of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Boundary Roots
Bed Trend
o-~S X0`12 3!3 I w1v Cw , _S
Z 15 -3'7 `'t 316 S ~o S b
Ground 3 3)=n3 v;~,,TR S '~S O 9g
elev.
`0, 6 ft.
Depth to
limiting '
factor
Z 3,~ .r
Remarks:
I Boring #
I 6-lt~ 1o1.~Z313 s~ Wish Y►'IV`FI~ C k,
~ os m1 ,s ?•b,
Ground r
elev.
ft.
6Depth to
limiting
factor
Remarks:
Boring #
I o_1 ti~~~ s I3 s ~w,sb~
Ground
elev.
ft.
Depth to
limiting
i factor
~3" j
' Remarks:
Boring #
Ground i
elev.
ft.
Depth to
limiting
factor
Remarks:
rnry n^n/Vn nr/M% -
3 3
Page of
PLOT PLAN
SCALE 1"= y0'
env r.►,"
V-%eN*n_ FV JM P03T. V-1/ Lft-Y)+
~-~►~fff `CRS C~$ ~
\ t*.L q1 6
B• y
tL a7 8 . ~ \
0:\
1N1T1f1L 'M~VC.W
9s ~ 0 e ~5 J
\o S S b b` S
3 6ss ~
0 b
5
C7 3 ZL On
tL
a.Z
L-L °l a
cl 6-3k 1
(715 425-0165 M00576
CST Signature Date Signed Telephone No. CST #
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWN ER BUYER 1C j V IV j
ADDRESS /yof -:z-WaS71f 1,4 L sr' FIRE NUMBER lZ /
CITY/STATE ;~~,Psa,() 4v ZIP
PROPERTY LOCXTIONs'sue 1/4, 1/4, SECTION 2-7 , T_ Z N-R /o W
TOWN OF/~/~V 3t. Croix County, '
• SUBDIVISION' ~ SSlpoO 3 v0~ LOT NUMBER / . 00 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 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 co. Zoning officer within
30 days of the three year expiration date.
SIGNED: /Oeo
DATE:_ ~44 7
St. Croix co. Zoning office
911 4th St.
Hudson, WI 54016
i
a STATE BAR OF WISCONSIN FORM 2 - 1982
556Q6 WARRANTY DEED
DOCUMENT V VOLMSPACEMn REGISTERS OFFICE
Sr. CROIX Ml WI
Merle C. Nielsen and Maxine P. Nielson,
husband and wife, MAR IT, 1997.
4:15 P
conveys and warrants to Kerry D. Friesen and "T~a S.tu+c -A 0,4k
Elisabeth Friesen, husband and wife, Ftegisterof Deeds
as survivorship marital property,
THIS SPACE RESERVED FOR RECORDING D TA
NAME AND RETURN ADDRESS /e0/ i1
the following described real estate in St. Croix County, 1 p "1
State of Wisconsin: /or~''
022-1075-60 400
PARCEL IDENTIFICATION NUMBER
Part of the SE 1/4 of NE 1/4 of Section 27,
Township 28 North, Range 18 West, St. Croix
County, Wisconsin described as follows: Lot 1
of Certified Survey Map filed February 25, 1997
in Volume "11", Page 3215, as Document Number
556003.
TJRAN~
$ ~o
FED
This is not homestead property.
(is) (is not)
Exception to warranties:
Subject to easements, reservations and restrictions of record.
Dated this 1171-t day of March A.D., 19 97
9
(SEAL) (SEAL)
* RLE C. NIELS~ENN
(SEAL)S /7 (SEAL)
* MAXINE P. NIELSEN
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) State of Wisconsin,
ss.
St. Croix County.
authenticated this day of , 19 Personally came before me this day of