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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER +"'Gt~r•Y.~~ SEC i Q-4::5-45,
ADDRESS b ro x
Mew a2 ► f two, to
SUBDIVISION / CSM# r- LOT #
SECTION--,2_T 3j N-R__/ J_W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4Ue 3 beet 4,,,
> - let l/ of '757
` z 4 *N
c►. / i
P.~
INDICATE NORTH ARROW
I
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
T~ *Z(, Q✓ /fe, Xkjs^,t-
ALTERNATE BM: Aw ~ 6 Ae-
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Wella4aC House Other "
Pump: Manufacturer Model# Size "
Float seperation 0_ Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: /Z Length -Number of trenches /A ed
Distance & Direction to nearest prop. line:
u.
.01
Setback from: well: ad, 2e House_ g,7 Other
ELEVATIONS
Building Sewer ST Inlet : ST outlet ~ s~
PC inlet PC bottom Pump Off
Header/Manifold ~3 y Bottom of system
Existing Grade b- Final grade .J
r
'00a iG
DATE OF INSTALLATION:
PLUMBER ON JOB: /r~
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and H-urnan Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
Perrmi l g', N ►lg , O ❑ City ❑ Village Town of: State Plan ID No.:
CST BMiiEElevv.: tSKA Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ' Benchmark /po,6 /00-
Dosing
Aeration Bldg. Sewer .S g R 2. a 6
Holding St/ Ht Inlet 3 Cr 4 r
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic >as //1,+ NA Dt Bottom
Dosing NA Header / Man. rj a } ,
Aeration NA Dist. Pipe L/ ~S-j 3
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade (o,~S
Manufacturer Demand ~~n) qO J~/'
Model Number GPM
TDH Lift Friction Syestem TDH Ft
Forcemain Length Dia. FFii Dist. To Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 1--- DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK _
INFORMATION Type of iy(,eAcJ"' l
System: 7 / _A/ /¢vl CHAMBER Model Number:
OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold I Distribution Pipe(s) I x Hole Size I x Hole Spacing I Vent To Air Intake
Length Dia Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
4.3
LOCATION: SOmerset.2.31.19.ht>1~ Lot 2, Polk-St. Croix Road
U
SI~z~
Plan revision required? ❑ Yes ❑ No r
Use other side for additional information.'
SBD-6710 (R 05/91) Date 1; Inspector's Signature Cert. No.
SANITARY PERMIT APPLICATION
COUNTY
ILHR In accord with ILHR 83.05, Wis. Adm. Code &0;
~,.,..e ...,..,~.,e. STATE SAT Y RMI
-Attach complete plans (to the county copy only) for the system, on paper not less than
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 OWNE PR PERTY ATION p
~'/a '/4, S T N, R 1 E (or)
,Rd,CL,Qk 13 PROPERTY OWNER'S AILINGAD&hEM
p LOT # ^ BLOCK #
O hli S 4. C r o ;,PC )C Gam[-.
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CS NUMB
~i ,rri Y,~ Q L~ 'b (c
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
) State Owned VILLAGE
❑ Public $1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL TAX NUMBER(5)
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. X New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
120 Seepage Trench 22 ❑ In-Ground 420 Pit Privy
1130 Seepage Pit Pressure 43 ❑ Vault Privy
140 System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
~ REQUIRED l~~ sq. ft.) PROPO$ED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) LEVATION
7 ICY 81 `93•1 Feet 779 Feet
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank /QQO A+ Ej F-I F] I Ej Fj
Lift Pump Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for install ion of the onsite sew We system shown on the attached plans.
Plumber's Name (Print): Plumbe ' nature: (N m MP/MPRSW No.: Business Phone Number:
311.01-0y- 13~'djy ~ 1 3:3
Plu ber's Address (Street, City, State, Zip Code):
t~j~ S
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sancta a it Fee (includes Groundwater a e s Issuing Agent Signatur (No Stamps)
Approved ❑ Owner Given Initial Surchar e'Fee'
V Advers
e Determination
1
X. CONDITIONS OF APPROVAL/REASO OR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety S 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.
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, 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 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 systElm. 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% 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 tarks; building sewers; wells; water mains/waterservice;
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; (lose 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)
< PLOT PLAN
PROJECT. Brad Briggs ADDRESS 689 Polk St. Croix Road New Richmond Wi 54017
NE 1 / 4 NE 1/4S 2 /T 31 N/R 19 W TOWN N. Somerset COUNTY ST. CROIX
5/21/94 BEDROOM 3
MPRS BYRON BIRD JR. 3318 DATE
CONVENTIONAL X)« IN-GRO D PRESSURE ONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 Galls LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 648' BED SIZE 12'X54'
BENCHMARK V.R.P. Top of Corner Post ASSUME ELEVATION 100'
❑ BOREHOLE (DWELL *H.R.P. Same as Benchark
vENr SYSTEM ELEVATION 93.9
12" GRADE
qTYPAR COVERING
12;' 3'
K
300' Property Line
bB.M.
105'
b
B-510, B4
Pro 3 Bed
U
' House ri
Rep A 0
a
25'
10'
5' -3
12'X 54' Bed
0'
ent
15'
B-2 B-1
5'
I Property Line
sin MIdi oflndustry,°i
SOIL AND SITE EVALUATION REPORT Pa a of
La nd tions g
Div of s
r'g+ in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paRer nofless than 8 1/2 x 11 inches in size. Plan must include, but t f L",
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 REVIEWED BY DATE
PROPERTY OWN : PROPERTY LOCATION
GOVT. LOT 1/'" 1/4 T N,R E (oK,2
PROPERTY 0 ER':b MAILING ADDRE I OT # BLOCK # SUBD. NAME OR CSM #
CITY,STATE , ZIP CODE PHONE NUMBER LICIT ❑VILLAGE ]MOWN NEAREST ROAD
/
i jav/~ Lf'hs ra '~cf/~✓ ' c'-wbl r'.
b(] New Construction Use Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 415-0 gpd Recommended design loading rate =imbed, gpd/ft2 -1trench, gpd/ft2
Absorption area required ga~u bed, ft2 j X 4 trench, ft2 Maximum design loading rate gibed, gpd/ft2_ , V trench, gpd/ft2
Recommended infiltration surface elevation(s) y - ` It (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable It
r S = Suitable for system COJVVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for system t3 S ❑ U CAS El U (RS ❑ U 5? S El U 1:1 S 15 ❑ S ICU
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
Trench
AA f. P40 V s'
r1
Ground _ c
elev.
ft.
Depth to
limiting
factor~
Remarks:
Boring #
o- _
~t
Ground l... 100,
elev.
a ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print r o n r Phone:
Address: ,
~ ^S
Signature: r Date: CST Number:
i
PROPERTY OWNER / SOIL DESCRIPTION REPORT Page o U ,
PARCEL I.D. # ,
Depth Dominant Color Mottles Texture Structure Consistence Bour>dary Roots Bed Trench
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
Ground
elev. .
ft.
Depth to
limiting
factor
/ Remarks:
Boring #
lj~j-Mr 1'Z
/w
Ground
elev.
~f
Depth to
limiting
factor
Remarks:
Boring #
G
0Z A4 OZE
I A t/1 -A& -d
Ground
ev.
~t.
Depth to
limiting
factor
1-3
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Soil Test Plot Plan
Byron Bird Jr. c ~ Z`e~'roperty Owner `
896 68th Ave. Address
Amery Wi 54001 1 /4/~1 /4/S.2/TAN/R/,W
CST #3479 Township
Date_ 4~ -i 3 -y County
C Boreing ► Benchmark - H.R.P. System Elevation
ap
A, r
i
lyti ,~o
'SGT ~ ~
7v 'y
i
r
516 94
CERTIFIED SURVEY MAP
Located in part of the Northeast Quarter of the Northeast Quarter of Section 2,
Township 31 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin.
Surveyed for and at the request of: LEGEND
Brad Briggs Q Aluminum Monument found
689 Polk-St. Croix Road
New Richmond, WI 54017 • Found 1" Iron Pipe
William Briggs - Owner o Set 1" x 24" Iron Pipe weighing
1.68 pounds per linear foot
+I--• Fence
UNPLATTEDLANDS
N 1/4 CORNER
ZON NORTH LINE OF THE NE 1/4 NE CORNER
- - - - - - N89°36'22"E 2614,04' REC.AS 2613.76' - - - SECTION 2
- - N890 36'22"E 994.02' - -
.02 231 .03 - - - - 62.99 J~ 313.00'
"2 31.00 t 7f 3.03 ti M 1
S89059 59"E 994.03' - - ' rv 8 n
.
A P.. CA A.HOUSE 6 v OD LOT I
- - - -
a O F HIGHWAY SETBACK 6 rn
oweLL u o C. S. M.
LOT 2 SEPTIC SHED OD_
81
PPRO3 m $ v. 6
OI 1 % OyK;~tn v =BARN n A u 1
to
N
o PG. 1633
MAY2255'"! S Ln
8 4'
Z LOT 3 N890 36 22 E I
S". CROIX COUN'~Y,c o 1,386,664 sq. ft.] 313.00' g
0
C prehensive PlaflriiriZ 31.833 acres ]Total Area
Zoning and -'arks CoEnrt>itt~e i 1 231.00' 365,131 sq. ft.) W ,
Excluding R/W -1
o m N89059'59 W 31.339 acres ] r-
N Z IC
rn N
Z
If riot r"dcorded In I
It* W `ravS')6f 10 to m AREA OF LOT 2 ~ p i>
Ipr3(/al'~ICe I~ 136,458 sq. ft.] ioo co i-1
1v r Total Area m07 0 1m
a;VF6` I 'ha" bo = 3.133 acres ] z.-4 Ie
-4 X
ni'M'Z Vold rn 130; 728 sq. ft.] is
(X Excluding R/W iy
c0 3.001 acres ]
Lo m y '
= z Q
a
a
Z
m
~ N
A Oo'
SOUTH LINE OF THE NE 1/4 OF THE NE 1/4 13'
N89015 36 W 1312.66' 1
Bearings are referenced a' I
to the north line of the UNPLATTED LANDS _
NE; assumed to bear W'
N89°36' 22"E. SCALE I" = 250'
m
200 100 O 250 1
Drafted by D.J.Z. E I/4 CORNER
SECTION 2
COUNTY GENERAL NOTICE
Note: The 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.
C
d
Z MAY 2 1994.. 8
' J ~ F$ C'CONN
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Bradley N & Amy T- 'Briggs
MAILING ADDRESS 689 Polk-St-Croix Rd. New Richmond. Wi. 54017
PROPERTY ADDRESS 685 Polk-St-Croix Rd. New Richmond, Wi. 54017
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE Ntmw gi r-rmnnr1 Jai- - 5403:7
PROPERTY LOCATION N-1/4, NF. 1/4, Section 9 T i N-R i ct W
TOWN OF Somerset ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP 516 9 9 4 , VOLUME_Q_, PAGE 2760 , LOT NUMBER 2
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)
2
the on-site wastewater disposal system is in proper operating condition and O after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I
I
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 xpiration date..
SIGNED:
~~-O C
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
i 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 Bradley & Amy Briggs
Location of property NE 1/4 NE 1/4, Section 2 T 31 N-R 19 W
Township Somerset Mailing address 689 Polk-St.Croix Rd.
New Richmond, Wi. 54017
Addresso site 685 Polk-St-Croix Rd. New Richmond, Wi. 54017
SubdI -1-76 Lot no. 2.
Other homes on property? Yes X No
Previous owner of property witliam N. & Shirley M. Briggs
Total size of property 37 Acres
Total size of parcel 3 Acres
Date parcel was created- May 25,1994
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for (spec house)? X Yes No
Volume 1D79 and Page Numbers 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. 517036 , 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.
517036
Signature f App is Co-Appli t
Date of Signature Date of Signature
DOCUMENT N0. STATE BAR OF WISCONSIN FORM 3-1982 THIS SPACE RESERVED FOR RECORDING DATA
a
5IL 7036 (QUIT CLAIM DEED
YQL 1079PAGE 495
C..1.1 C111.1t.
William N & Shirley M Briaas rm-r'dear R;e.x.aa
M AY 2 5 1994
quit-claims to Rrarll p3A DT~i~Amy! .1 Briggs ....___25. P•~~~
the following described real estate in Si- _ rn i w County.
State of Wisconsin:
RETURN TO
Located in part of the Northeast Quarter
of the Northeast Quarter of Section 2,
Township 31 North, Range 19 West, Town
of Somerset, St. Croix County, Wisconsin. Tax Parcel No:
Lot 2 Vol. 10 Page 2760 of Certified Survey
Maps, Document #516994.
}
This is not homestead property.
(is) (is not)
Dated this 25th day of May , 1994_•
(SEAL) (SEAL)
William N. Briaas
AL~L dz_~~ (SEAL) (SEAL)
Shirley M. Rricicjs
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
SS.
ST. C.0-ox,1( County.
authenticated this day of 19 Personally came before me this taS7)4 day of
M/yY , 19?Y-the above named
=C,
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person 5 who executed the
authorized by § 706.06, Wis. Stats.) fore oing nstrument and acknowledge the same.
THI INSTRUME WA DRAFTED BYy I rn (Xny\
Notary Public `S'• C_A=X -County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date: 7 -191) -9 9
1g )
Names of persons signing in any Capacity should be typed or printed below their signatures. S83 NTF 1023
QUITCLAIM DEED STATE BAR OF WISCONSIN
FORM No. 3-1982 Neico Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208
'Wisconsin Department of Indus*, : SOIL AND SITE EVALUATION REPORT Page _ of
kpbor and Human Relations
Divis'tdY oPSafety & Buildings W in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
ess than 8 1/2 x 11 inches in size. Plan must include, but f G~°
Attach complete site plan on pap
04
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location dnd distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWN : PROPERTY LOCATION
Q GOVT. LOT 1/4 1/4,S T N,R / E (o~
PROPERTY 0 ER':b MAILING ADgRE A / I OT # BLOCK # SUBD. NAME OR CSM #
CITY, TATE%' / ZIP CODE PHONE NUMBER LICIT ❑VILLAGE MOWN NEAREST ROAD
y
l u~/ 4[ GIB .b9c 6Y f d -C 0-
r 4
New Construction Use Residential / Number of bedrooms [ ] Addition to existing building
Replacement [ ] Public or commercial describe
Code derived daily flow 415'0 gpd Recommended design loading rate = bed, gpd$ -trench, gpd/ft2
Absorption area required w1y 3 bed, ft2 trench, ft2 Maximum design loading rate gibed, gpd/ft2, V trench, gpd/ft2
Recommended infiltration surface elevation(s) y - ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material 10-2'- Flood plain elevation, if applicable ft
S Suitable for system ,CO`~VENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U:= Unsuitable fors stem Dg S ❑ U 5!~S ❑ U [as ❑ U 5? S ❑ U ❑ S I ❑ S [?U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bcund3y Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground y4 7
elev. ~r5
ft.~
Depth to
limiting
factor i ?a ' v }t
A _i
Remarks: `~J,,~'-'mac ! :T r
Boring #
00
Ground
elev.
Depth to
limiting
factor
i
Remarks:
CST Name:-Please Print Al o r Phone: ,000"
Address:
Signature: r Date: CST Number:
jp-
y-~ 3
1
PROPERTY OWNER in! / i 1PTfSOIL 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
4: .
n...::.
. ,
"
Ground o~ ff a
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring # /
ti:•<::..::. O / r~ / n i" is
d/-
LS
Ground w
elev.
~j
ge ft.
Depth to
limiting
factor
Remarks:
Boring #
/0 Sow
Ground!
~t.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
i~ SBD-8330(8.05/92)
Soil Test Plot Plan
C
Byron Bird Jr. rope rty Owner &n4~'ef
896 68th Ave. A d d r e s s.%~' rox
Amery Wi 54001 ~1 /4 1 /4/S Z,_/TAN/R/1N
CST #3479 Township
Date County
C? Boreing k Benchmark H.R.P. System Elevation
o / ~G e 02,
,l
LP ~
tea` ~
o