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Parcel 040-1217-60-000 02/01/2007 09:16 AM
PAGE 1 OF 1
Alt. Parcel 7.28.19.1048 040 - TOWN OF TROY
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - BRANSHAW, ROBERT JAMES
ROBERT JAMES BRANSHAW
419 S FORK CIR
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 419 S FORK CIR
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 2.000 Plat: 2478-SOUTH FORK ADDITION
SEC 7 T28N R19W SE SE LOT 11 SOUTH FORK Block/Condo Bldg: LOT 11
ADDITION 2AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 952/52
07/23/1997 896/27,
07/23/1997 788/464
2006 SUMMARY Bill Fair Market Value: Assessed with:
159418 265,500
Valuations: Last Changed: 07/22/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 48,400 193,800 242,200 NO
Totals for 2006:
General Property 2.000 48,400 193,800 242,200
Woodland 0.000 0 0
Totals for 2005:
General Property 2.000 48,400 193,800 242,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 127
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
LDINGS
USTM OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707
HUMAN RELATIONS
IILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: T IP/MUNICIPALITLOT N0.:BLK. NO.: SIVISION NAME:
'/a5 C '/a -1 /TAN/R/9 E(or)rMAIULMINZ POP
CO NT : OWNER'S BUYER'RAME: ADDRESS:
~T QL~) x eof LS AA flS) l iA vJ
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIALDESCRIPTION: PROFI D RIPTIONS: PER OL TI TESTS:
Residence New ❑Replace is r1Z J6 9Z
I~ LAN
k
o1L5 V, 4 73 Z_ Q L' e~Y
RATING: S= Site suitable for system U= Site unsuitable for system 4)u A I ALL er-
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: lop ' nal) El U
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)N indicate: CGd~ Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
L
rB TOTAL DEPTH TO GROUNDWATER INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
DEPTH I& ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
p.OD /0.43 lo,ob Z i 9" 2
> !0,65 ; 34 8 LL75 2D t) * RN MS¢Glr2
.Og /69A
146 Al E
B- S 92 ///.74 1\6 ? -t 9Z 9,. &1--M 98'9 RA) 0,
hxC PERCOLATION TESTS
TEST DEPTH ATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER FTER SWELLING NTERVAL-MIN. PERIOD 1 PERIOD 2 PERT D 3 PER INCH
q.D o /ID 9 > > >z t3
P-
P- Z -3.7-C, tewE I./69.-Ldl > > >
P-
P A-r
P-
lLf OT PLAN: Show to tions of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hon-
11 and vertical ele tion reference point and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
land slope. O' y 112
SYSTEM ELEVATION AD-
CF1~
ca 1
i-fio% I,
C
.b I
l ~CA2G _
~Z, tN
z
La-r C 0'Z_Q M
e z /bD.c '
Zq ~ ~ _ C~...EYa ~ cN
...Stn a~ ~
I, the un ersigned, hereby certify hat th oil to ported on this form were made b e in accord with the procedures and methods specified in the Wisconsin
Admini rative Code, and that th data record nd the n, of the tests are corr to the best of my knowledge and belief.
NAM (print): TESTS WERE COMPLETED ON:
I A
Jo trn/~o ,O 14 4s6 N _!~J P, , MA
ADD SS: CERTIFICATION NUMBER: IP ONE NUMBER (optional):
CST SIG URE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
4 _
INSTRUCTIONS FOR COMPLETING; FORM 115, . 35D - 6395
To be ar,=:~rnr)<:pie artd accurate S'Oil t3~,st, your report must include:
1. Complete I=,oal description-
2: The use section must clearly indicate whether this is a residence Or Commercial J-moject;
1 MAXIMUM riUmber, of bedroorns or cornrr7 e1-cial use rilartnedl;
4, is this a nevv or reulacement System;
5. Complete the suitability ratting boxes. A SITE IS SUIT ABLE FOR A HOLDING -TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6, PLEASE use the abbreviations shown here fotvtti-iting profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagrartt accurately locating your test locations. Dr,-w ng to scale is preferred. A
separate sheet may be used if desired;
8. Make sure y£tfur benchmark and vertical elevation reference point are £:dearly shown, and are permanent;
9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation te. t exemp-
tion, if appropriate;
z
10. If the ime) rata°ion ,caet, as fIood plain, elevation) does not apply, plar:r i,3 tile rtpProoriaie box,-
11 . Sign the for4i) and ;)la»e your current address and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS `vlUST BE FILED ?'~,FI (II THE
LOCAL AU T! i01,1TY WITHIN 30 DAYS X11=: C 0,N1Pt..E_:T10N,
e
ABBREVIATIONS FOR CERTIFIED SOIL, TESTERS
Soil Separates and Textures Other Symbols
tip. Stone Inver 10") 61:3 Bedrock
u0b - i_,obble (3 - 10") SS Sandstone
,
iit,p .,rave? (under" 3 J LS Li; stonc
s Sand I-1GAl 1-ligh C.irovm ivate r
cs C--, Sang P£~~rc - Percoladon gate
med, s I Nand i;u" :II
fs F.
L, all)
sc,= t L R Reif
l~-1 ...=y i-., Mot !es
.I.
e v, C" II"y vv i
sic; Silty Clay fff - few, fate, faint
..lay cc £;orn4 for , coarse
!>i. 1'eaf n~ rt - Many, rneriiJrYt
n zvk)ck d distinct.
P prornine nt
H W L High vv ir ,)r
SIX ge } raI :c} €eXtuF,s suri~4 c o
`O, .'tt£.4!C `vi%%ist:£' USpo53. B 1`0 Bench RA,,
VRf Vettica Hi ce Po ni
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private
sewage system and a permit application must be submitted to the appropriate local authority in order to
obtain a peniiit. The sanitary permit must be obtained and posted prior to the start of any construction.
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER &b f' ? si'G1~,°L ar
ADDRESS S-xedr-
Pik c(sa t, L) 9 6-10 d
SUBDIVISION / CSM# o w-t:. It LOT #
SECTION_TN-R W, Town of 1?U
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OFtfYSTEM
4
v '
r
i
c
fv
v
i
INDfiCATE NORTH AR W
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
r
t
BENCHMARK. U~ U ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: mid k e S ZGrn Liquid Capacity: A4)0
Setback from: Well House 7 Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: SJ Length 3 k" Number of trenches
i
Distance & Direction to nearest prop. line: r o
Setback from: well: 5 House r2 Other
/ ELEVATIONS
Building Sewer ST Inlet ST outlet
c~
PC inlet PC bottom Pump Off
i
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATIOP: S - ) I- 9 S;_
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Safgty Lafr and ~ Buildings Relations Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI
BRANSHAW, ROBERT X
T BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
1451. TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 1Z Benchmark 3 -13' Dosi n
Aeration Bldg. Sewer
olding St/ Inlet ~S6/~
TANK SETBACK INFORMATION St//Hf Outlet g 9s1
TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt inlet
Air
Septic L~ ya5 31' NA Dt Bottom
Dosing NA Header-13.63 90, PO
Aeration NA Dist. Pipe 113, 0 ~i' 3el
Holding _ Bot. System
,✓~f 40 g'
PUM / SIPHON INFORMATION Final Grade /x.65 a rJ~'
Manufacturer s
and
/
96, 7--,-?-
Model Number GPM
TDH Lift ~Lri,ction System TDH Ft
emain Length Dia. mead
Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 51:;2 Dliifi
LEACHING Manufacturer:
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM
INFORMATION Type o ,w, l j CHAMBER M um r~__
System: --re.^C4 5l~So, ~7S - OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s ~ x Hole ize x Hole Spacing Vent To Air Intake
Length Dia. Length 60 Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syst On
Depth Over F h Over ,r trio xx Depth Of eeded / Sodded xx Mulched 'A *
Bed'/Trench Center ~p - Trench Edges :2~ ' 3d Topsoil C] Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: J TROY.7.28~.p19E, SE SE ~S~OUTHF(p~iu7~`
Plan revision required? ❑ Yes No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
t
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
t SANITARY PERMIT APPLICATION
COUNTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than A.2.3 V4
8% x 11 inches in size. ❑ Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
Robert Bra haw SE % SE S 7 T 28 , N, R 19 E (or) *
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
502 Stageline Road Apt. 6 11
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Hudson, WI 54016 Southfork
II. TYPE OF BUILDING: (Check one) -1 State Owned VILLAGE NEAREST ROAD
:Tro Southfork
❑ Public ❑ 1 or 2 Fam. Dwelling-#~ of bedrooms 4 PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) O -7-26-1:7-16 i
- - D
1 ❑ Apt/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 in line A. Check line B if applicable)
A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit 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 B Seepage Trench 220 In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
600 780 780 .78 0 106 Feet 102 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed _7F F1 El
Septic Tank or Holdin Tank 1 1200 1 Midwestern
Lift Pump Tank/Si hon 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): Plumber's Signature: (No Stamps) r P/MPRSW No.: Business Phone Number:
Joe Stang MP 6646 715 698-2266
Plumber's Address (Street, City, State, Zi Code
506 Willow Drive WoodpvilTer WI. 54028
IX. LINTY/DEPARTMENT USE ONLY
X❑ Disapproved San) 'Pry Permit Fee (Includes Groundwater Date Issued Issuing Age ignat r o Sta S)
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination 3
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS t
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the 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 r
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 & Buildings Division, 6013-266-3815.
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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/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 iin 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% 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
j Robert Bradshaw
502 Stageline Rd. Apt. 6
Hudson, WI. 54016
SE! SE! S7T28R 19W
Township of Troy
j Subdivision Southfork
Lot 11
System el. 89.5
B M 100 on door sill
Drawn by Joe Stang
MP 6646
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E"levs, 5 ~ 5 S ,
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L-111i [_,iJ
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of
Pabor and Human Relations
N1;ion of Safety Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION r~VIEWEDBY DATE
PROPERTY OWNER: PROPERTY LOCATION
GeVF.±eT S Ir 1/4 S C 1/4,S -7 T Z N,R 19 E (orQ)
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK it SUED. NAME OR CSM #
So t EL_W Q bZt~ T\ - Sk)u"N- #'FDw-L ""fQp 1,0 W%,)
CITY, STATE ZIP CODE PHONE NUMBER CITY []VILLAGE ®fOWN NEAREST ROAD
N}voSt WI S4p16 01S) S°v' Foci OR•
[JQ New Construction Use [JC] Residential / Number of bedrooms 3 AdditiRn to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daffy flow q3 O gpd Recommended design loading rate o-1 bed, gpolft2 0 - trench, gpd*
Absorption area required b\ 1.3 bed, ft2 S b 3 trench, 1`12 Mabmum design loading rate o . bed, gpd/it2 0 - 6 trench, gpolft2
Recommended infiltration surface elevation(s) 8 9. 5 ' ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material csv y~ fv,%to Flood plain elevation, if applicable N : A _ ft
S = suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for tern QS ❑ U ®S ❑ U ®S O u ®s o u ®s o u O S R3 U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ranch
0.1 lb-tQ Z17- Z'Fs~k Yvv-fl,_ q, - 0.S o.b
~t
3llr f s.1,s\ o ss -
-7-s_L SytLy/6 - gS r-~.%. Cl
Ground 3 5Z-161 izt- l - $ O Sg M\ c. .-I
o.ta,
elev.
Depth to
limiting
factor
Remarks:
Boring # ;
1 0-9 ~o~ ~lZ - ail z~sd~ ►~~Fa- 0.S - a_so
2 °I-q,0 I \AV_ul6 - S ~G~ Ogg wt l ct~, - o.l :Ia.
Ground
elev.
0 ft
Depth to
limiting
factor
Remarks:
TName:-Please Print Arthur L. We erer Phone:
715-425-0165
ergerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: Date: CST Number:
9 3 -Sf1c, 3,2 1 -9,S M00576
of _
PROPERTYOWNER ~3~-fYDS`Ct~ SOIL DESCRIPTION REPORT Page" 'Z,
PARCEL I.D. 0
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourx:13y Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends
\ 6-to 1k's'tR 3 [Z Z Su v'% o.S It,
3
Z ~~.y S X,7~ Utz y/6 S AGM o S9 cw d,~► c,
Ground 3 uS 78 "Z) 4 R Y / _ S O s9 }vt - 0.7 0•
elev.
Depth to
limiting
factor
Remarks:
Boring #
~ lp`CR 3f2 S1.j Z`~ S~1rt a, s - 0.5 u.~
s
o s 1 cw - o~ d$
y Z I$-~L8 ~tR ~l{, S 14
3 ~ -9L to-~Z ! M 1 _ o.~ m•43
Ground
elev.
ft.
Depth to
limiting
factor
7 °lZ`r
Remarks:
Boring # o` 9 N, `tR 3 1 Z.
S t Z`F Sb12 `F1,. S _ S o
1
5 <h 2 9-29 tp~t~ v 8~G► ~9 m~ c o.~ ~.8
Yt - S 3q ~ - n•l ~8
3 Z9-8S L~`t2 ►ti1
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Yr*lz V s
o si wrt- -
rww"'11'111' 16
~ b Z-(1 Z `7 L U1L 0 ~-3 . '
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
PLOT PLAN Page 3 of 3
SCALE 1"= ►4p '
l -w tD-i W-(_ -
~ovsF
U
J
et, 84 9
13.
•o` ~j' oto - too o'
g .3 CIS{ g
I:r. Ito 6 1 ~~c q ~LNvs. = 8 9. g
tt, qa ,
tv ~ ~ L4T _
U ~E
w ~L 1v @~ ~Y L~ ST Sp 1=tzq y, `1 TZ~w e.~ s ,
~p ~►S-S.~
off. 3 zz_g5 (715 42-5-0165 M00576
CST Signature Date Signed Telephone No. CST #
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
/
OWNERBUYER -7 A6 AQ r1 S40 ktl
MAILING ADDRESS SD Z S r G e 49
PROPERTY ADDRESS 1'50 ,V /moo, k Kd Za 70- '111Z (location of septic system) Please obtain from the Planning Dept.
CITY/STATE
y~r-,
PROPERTY LOCATIONS E7 1/4, 1/4, Section, T z~N-R ~T W
TOWN OF -f e Off/ ST. CROIX COUNTY, WI
SUBDIVISION So v~~i moo/ K LOT NUMBER
CERTIFIED SURVEY MAP , VOLUMEI'AGE_ ~ , LOT NUMBER -
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 returne to the St. Croix
County Zoning Officer within 30 days of the three y e irati n date
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1 101 Carmichael Road
Hudson, WI 54016 11/93
SC--100
This application form is to be completed in full and signed by
the ot:!ner (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.
y Owner of property P S ~1•
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Location of property _$e 1/4 SE 1/4, section' -7 , T ZEN-R~W ,
Township 4"')Ov
Mailing address _ 5-0 2 S Tom(,- ~,~•1 j` d p/1 f 4~L S'yQ/~
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j Address of sAit1
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Subdivision name_ _ 49vf1i EgrK Lot no.
other homes on property? yes No
Previous owner of property _ --onc Zm"01
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Total size of parcel _ Z•O .4C/.e S
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Date parcel was created
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Are all cornars and lot lines identifiable? _ Yes No
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Is thin property-being developed for (sped house)? Yes 4No
Volume Find Page Number _ 5_ Z as recorded, with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
E A I9AIZit1UUY DLED which includes a DOCUHENT NUILDER, VOLUME AND PAGP,
HUMBE11 It THE SELL or THE ItEGISTLR 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 Nap
shall also be required.
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PROPERTY OWNER CERTIFICATION
I(we) certify that all statements on this form are true to the
best of n y (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. '4e3 7&-G , and that I (we)
own the proposed site for the sewage disposal system oresen
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 County Register of deeds as Document
j No•_~~ff ~'IS'rL
S gn to f appllca tCo-applicant
Date of Signature Date of 8
t gnature
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II OCCUMENT NO. ! WARRANTY DEED
TIII;. SPA:.E~ RE:•r,RVED FOR RCCOROIND- DATA
STATE BAR OF WISCONSIN FORM 2-1982
4 83' 36 v~t . y02PAGE 52
- ~I REGISTER'S OFFICE
ZAPPA..
ST MIX , VM
.
.
. BROTHERS EXCAVATING INC.-, a. Wisrons~in_..... - ! bc'd6Rec r
ao.rpoxation,-Grantor...... OOOfd •I
. MAY 26 1992
conveys and warrants to ROiFRT JAMES. BRAN$HAW, a dingle- I of 9:30 A. M
I psxson, .Grantee
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the following described real estate in . St... Croix County, r
-
Mate of Wisconsin:
Tax Parcel No:
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Lot 11, South Fork Addition in the Town of Troy.
tie
FEE
TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and
rights-of-way of record, if any.
This is not ho nlestead t.rvpert.
(a) (is not)
F:xcc(ttion to warranties:
Dated this day May 19 92
ZAPPA BROTHERS EXCAVATING, INC.
BY: Gary Zappa
LA L)
AUTHENTICATION .1CKN0WLEDGMENT
Signature(s)
St. Crisis
authenticated this - day of 1P
.lay; of
- - -
?lay' t r 1,)2 - the ai ce mum,,i
Girt' •Zappa
TITLE: \tF:.liL'P:R SIATE BAP OF W1- 4'UN.SI - -
ut not.. r) ~ i1C 0
authorized by 1 iU,i.lll;, iViZ5. tat.:.) ~1~, .
o!; i'!.c t!IC , uLo .:Xecu4t~,l the
- _ ~ r... !t',::r~.;:~:~. .~a;?I.. ~i~t r: R,,~,r 4:7O.va4t•-. .
' -3 'N.irRUt.'rN; WAS CRAFT[--D NY - j ~ !
:ltturnev Barrv C. Lundeen 1
~lllul ..l~!~"I1:( ~ LC:~lll.l\, y t ~ '`'%'t+10tt .
I1(1 `sUCOMl Strtct, Hudson, 1~itiinnsitl 541)1(,
SC . ,C '0
(Sign ttt rl: may he a,lthentiattul I.r arl:nrnc!I' ,I, ("m!! u 41W]
rll r:,l . ••r
are not nevess:
try.) 1
•Namrs ur prrv, n,,. .sicninr; In fins -;"-ty i-'A Lr
WARRANTY DEED S'rAli; BAIT OF \t t.,, uN5iN
FPli ~t Nn. - hL: v, d,..kce. 'rVisC,-n•an
I . ILt U rtWXkW *Just • 1.9, SE, AiftEi AGE'SVfi5hl Vk_ Road. county:
Laboranfd Human Relations
'Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary era, it 0.914
.)n a QA 3
Permit Holder's Name: ❑ City ❑ Vil e Town of: State Plan D o.:
Elev.: nsp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATI TA A9400106
TYPE MANUFACTURER CITY STATI BS HI FS ELEV.
Septic ark try
Dosi ng
Aeration Bldg. Sewer
Holding St/ Ht Inlet •
TANK SETBAC N MATION St/ t t w pot
't 0
TANK TO P/ L WELL BL nnt
ake ROAD t
Septic NA t ottom
Dosing Header
Aeration A Dist i r
Holding k fdlI"""I1i1 yst
PUMP/ SIPHON INFORMATION final G
40
Manufacturer D
Model Number • GPM
TDH Lift Friction System • H t
oss Forcemain Length Dia. Fi t. To II .
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length f Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS DIMEN I N
SYSTEM TO P/L BL G WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type 0 CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. I Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Troy.7.2$..19, SE, SE, Lot 11, Southfork Road
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. I F
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No
1
ADDITIONAL COMMENTS AND SKETCH '
SANITARY PERMIT NUMBER:
tea; `
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SANITARY PERMIT APPLICATION
cog.
~'~L■7~1 In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than Ooz i&5
8% x 11 inches in size. El Check if revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY,QWNER / PROPERTY LOCATION
/lo6titt )3)e4& h qW Se '/4SCY4,S T2p,N,R E(or)W
PROPERTY `OWNER' ~ SLING A'~DDFjE ~ ~ /0 LOT # BLOCK #
JJ' I-11 1
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
d is, So IPre A
II. TYPE OF WILDINheck one CITY : NEAREST ROAD
El State Owned 0 VILLAGE : L
I*Q l. ~Ga C ~i c
LW TOWN OF:
L~
❑ Public 1 or2Fam. Dwelling-#ofbedrooms ! PARCEL TAX NUMBER( 040-191-7-60 _6 U 0
III. BUILDING USE: (If building type is public, check all that apply) 7 _ 2 _ _ 1 u
1 ❑ Apt/Condo l
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 ERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 F-1 [page Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/da[y/'sq. ft.) (Min./inch) ELEVATION
406 4? ~b ? 7 T 1 G ( Feet ~ Z Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks I Tanks strutted
Septic Tank or Holdin Tank /160 ^t +
Lift Pump Tank/Si hon Chamber -.001 El 1 1:1 El
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 's Signature: (Ko Stamps) .16N Pl" No.: Business Phone Number:
Plumber's Address (Street, City, te, Zip Code)•
s"GG w,I t.,, LrJa. c/4 if f t t✓s' S^k~ ~
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate s e Issuing Agent Signatur No Stamps)
Owner ~/7> Surcharge Fee)
F Approved ❑ Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) 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 the 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.
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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 & Buildings Division, 60B-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.
ll. 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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/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% 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 i1'
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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
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DEPARTMENT OF REPORT N SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, P.O. BOX 7969
LABOR AND
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707
0&R $13.09(1) & Chaptef 145)
LOCATION: ' SE TION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUB IVISION NAME:
~ /45C /4 -1 /TnN/R E (or) W ~o / I c, ►a ¢o>Q
CO NT OWNNER'S BUYER'S AAM~E:: MAILIN ADDRESS:
Hurts ~T ~V A'el -6 O/1
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMM R AL DESCRIPTION: ~PROFI 10 TESTS:
LA Nk LVVNew ❑Replace L is qZ J6 9~
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Residence
01L5 Y1 G 7~ USN e~
RATING: S= Site suitable for system U= Site unsuitable for system r I L dT
CONVENT ZONAL: MOUND: IN-GROUND-PRESSURE: EM-IN-FILL HOLDING TANK: RECOMMEND~TEM:( op nal)
' v~ ac. -T>\1c~ a
S O u ®S OU ®S O U MS O U EIS
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: CL/! Floodplain, indicate Floodplain elevation: AIA
PROFILE DESCRIPTIONS
G
BORING TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. I HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- t p.Ol7 /10.43 > 1 D .D~ 2 i -s Q'
B- -Z 9.'~3 y LLB 231 `Jr 1hS
LC?~ 20 ~•J R~ 119$`¢~i~
B 3 .Og /61./ 1 /0.6F 34 IV
B-4 %i< / s.3S d6?j E:
B-5 •IZ /11.74 1\16 Ili E .C q ig~CTS 9~~~R~v 1n'IS~G~
Nxt V PERCOLATION TESTS
TEST DEPTH ATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCH ES
~
NUMBER FTERSWELLING NTERVAL-MIN. PERT D 1 PERIOD 2 PER
P_ A• D o 11 a 9 ?
P- Z 3.7-0 .Z > > > <
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PLAN: Show to tions of percolation tests, soil borings and the dimensions of suitabl s it reas. In to ale or stance Describe what are the hori-
z ntal and vertical elevation reference point and show their location on the plot plan. Sho t e s fa evati at a borin n he direction and percent
f land slope.
SYSTEM ELEVATION
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$b / = 3a t N
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L67T C094
66,
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I, the un ersigned, hereby certify hat th oil to ported on this form were made b e in accord with the procedures and methods specified in the Wisconsin
Admini rative Code, and that th data record nd the n of the tests are corr to the best of my knowledge and belief.
NAZOV int : l TESTS WERE COMPLETED ON:
Jd 1I N-54)1j -~o 14-56 Io -!~j MAY / ~ 14
ADD SS: CERTIFICATION NUMBER: IP ONE NUMBER(optional):
CST SIG RE:
60
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
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