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j,WPVMONRartOwlft,inU 30.29.16W,PFU$AT:64EVIAliE4(SlWle Stre unty: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division Sanitar rsnit _ (ATTACH TO PERMIT) GENERAL INFORMATION ❑ City ❑ Village ❑ Town of: State PI Permit Holder's Name: X Parcel Tax No.: Elev.: BM Descriptio . TANK INFORMATION ELEVATION DATA A9400116 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent to ROAD Dt Inlet TANK TO P / L I WELL BLDG. Air Intake Septic NA Dt Bottom NA Header / Man. Dosing Aeration NA Dist. Pipe [Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM No. Of Pits Inside Dia. Liquid Depth BED /TRENCH Width Length No. Of Trenches PIT DIMEN I N DI EN I N Manufacturer: SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING SETBACK CHAMBER Mo a Number: INFORMATION vs e OR UNIT Sys Stem m: DISTRIBUTION SYSTEM X Hole Size x Hole Spacing Vent To Air Intake der/Manifold Distribution Pipe(s) Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Dep:hO ver I xxDepth Of xx Seeded /Sodxx Mulched Depth Over YeS ❑ No ❑ Yes ❑ No Bed / Trench Center Bed ench Edges Topsoil ❑ COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Baldwin.30.29.16W, SE, SW, Lot 22, Maple Street Plan revision required? ❑ Yes ❑ No Use other side for additional information. Inspector's Signature Cert. No. SBD-6710 (R 05/91) Date ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e t r ~DILHR 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 Ot 0%995 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.= - i~00 G PROPERTY OWNER PROPERTY LOCATION T~ N, R /H (or W 'a ^ e C-' a t v , 51-7 t/4 5LUl t/4, S 3 0 PROPERTY OWNER' AILING AD RESS LOT # BLOCK # ,f CITY, ST~jTE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER : Ei_a ~~+c >,r LCD. j Z- /X P"ia r II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE NEAREST ROAD l =N OF: Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - PARCEL TAX N MBER ) III. BUILDING USE: (If building type is public, check all that apply) 106 - 1050 - v 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 40 Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash 50 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. 0 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 Othrrerr 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 M 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/day/sq. ft.) (Min./inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank M F] 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) MP/MPRSW No.: Business Phone Number: 1, 7-' , _57 a~ r l 715 %T Plumber's Address (Street, City, State, Zip Code): 4 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanity Permit Fee (Includes Groundwater ate Issued Issuing Agent Sign %Do / pproved ❑ OwnerGivenlnitial Surcharge Fee) Adverse Determ nation X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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 prioto 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. If. 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 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. I SBD-6398 (R.11/88) SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations April 12, 1994 2226 Rose Street La Crosse WI 54603 BOLDTS PLUMBING 820 MAIN ST BALDWIN WI 54002 RE: PLAN S94-40126 FEE RECEIVED: 60.00 BALDWIN SPORTS PARK SW,SE,30,29,16W VILLAGE OF BALDWIN COUNTY OF ST CROIX HOLDING TANK The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sin erely, 6*erard Swim Plan Reviewer Section of Private Sewage (608) 785-9348 3108R/ 1 SBD•6423 (e. ui/su Oct 0 rG~ C S J Abonvione-of ioPC'r i `~11 Cr Access o a f _~p6ois 211, 4 DtV1S1 c°C of ,V C SSE ~ c X20 ~ I I ~ Pro 3At -7 I •5 a aid , I. f ! al S, f "W ONt I I Score ti 133 / Boar C/ /oo,0 Pole 95, Z`I az- qq ,off' 133- d c I ~ (1` I I IT A 8t 4 R,M, /6P a I+ Corner post SlJ% SL- ~ ~ y Owner : Sec . -30 e 01 130 lowi'n 9 N 1 W F_ f1 },~a:o m p GG Z9 ~4/G✓tvi r.., Lv; . ~'yoaZ , C M 3 3y/ l" _ ~,lo Sc4Ie s T" 3_11-9-' '~Gi"G~ ~ i C1 Yv C.1 / / G /N ~y"i~'1~~1•o Y~- ~ r /Are. / " "7~/ ~ ILC n ' f ' ~c~ ,n.. ~ ~c r'G~ ~'O~ sW ~ yam, ~ ~ c c s s p,~s• .'v e ~.v a ~o G a~ o ri. y e r ~ /7 e S' a~' p o R.tl leopd rac~'i Alanalor.C~ y P,f 7:i/alai ~r l~ in z- 1300.1, e X.~• I sy1•s' s.i f m elda• ~ ~ a ~I Bail s...~ ~i... ea po,o' 0 e~• ~ 0 Jlk At- 952'1' o~• 9k,27' v 2 ~-<rd A I p _ I a' ~r •P C.Mi fas l ~ ✓,'//o~e o•~ BolO~win ,(7a.1~ C, j./wele+„ MPiGtq r,/, Z, csrm SOIL AND SITE EVALUATION REPORT L D.I :L H ~...~R in accord with ILHR 83.05, Ns. Adm. Code COUNTY Attach complete site plan on paper not less than 8 112 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 REVIEWED BY DATE PROPERTY OWNE % PROPERTY LOCATION ' C5 ~ l~ 1 y s GOVT. LOT S t 114 5W 114,S30 T .2 9 AR 14 If (orl PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBO. NAME OR CSM # /o o zoo ~''ye_.. IV.4 AI 14/14 CITY, STATE , ZIP CODE PHONE NUMBER []CITY RVILLAGE []TOWN NEAR~EST ROAD 19 New Construction Use ( ) Residential / Number of bedrooms -,Pe 4 e.:1i 1V(-4~ Pj Replacement c~ P< Public or commercial describe Seaso n~ use yes ,moo,-,~ c?~a~ S~Q, Code derived daily flow 700 gpd Recommended design loading rate *VA bed, gpde /1&99 bench, gpd/n2 Absorption area required /1/A bed, n2 NR bench, 112 Maximum design loading rate bed, gpd1ft2 /✓A trench, gpde Recommended infiltration surface elevation(s) AIA It (as referred to site an benchmark) Additional design /site considerations e m n res 0' A S Parent material plain elevation. If applicable n S - Suitable for system CONVENTIONAL MOUND "ROUNDPRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable forsystem ❑ S W U ❑ S D au ❑ S U ❑ S AU ❑ S A U j2d S11 U SOIL DESCRIPTION REPORT Depth Dominant Color Modfes Structure Consistence Baidary GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Roots Bed Trend / o -Z4 /o Y)f Z Z/ s-R r, ci S 413 i~ / /Vs 7,5 Y9-56 e~ /Vt r Ground elev. 95~C n. Depth to limiting factor Remarks: Boring # -YR Zk IA S14~ ---n ir.'- Lq 5 Jv~l •q Ali /0 Y9 C6J /VA N Pit 5G C ► /'r A Ground :3 O m3 76 elev. 9y od n. Depth to - - limiting factor - Remarks: # Z sari Z6 4 B es -7t .6e -E; 11 CST Name:-Please Print' 16 Phone: Address: '7ZO Sy4e9 Z Sgnature: Date: CST Number: 7n~-~ io - Z 9,- 9.3 3Z-/ / 3 Boring # Horizo Depth Dominant Color Mottles v v - in. Munsell Texture Structure Consistence • GPD/P Qu. Sz. Cont. Color Gr. Sz. Sli. ' Y Roots Bed :Trend a ,Z / QS /1M - Ground ~ . 25;3 r» S6 r elev. 151YR S G r° 9y70 rt. Depth to limiting factor Remark's: y0r'1OY1. Q ~ r E #3 Boring # {gR~ f Ground elev. Depth to limiting factor Remark's: Boring # Ground elev. Depth to limiting factor Remarks: Boring # r` f Ground elev. fl. Depth to limiting t facto Remarks: NLHF~ J" `"r'4" X11 r_ CVALUAI ION HE:POH I LJ in accord with ILHR 83.05. Wis. Adm. Cade .,.....M.,.,,,.r COUNTY nn • Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but riot limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D.1 dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFO RMATION-PLEASE PRINT ALL INFORMATION REVIEWEOBY DATE PROPERTY 0 NE / PROPERTY LOCATION ~ C l5 7l1 v, j') GOVT. LOT 5,C 1/4 501/4.S30 T ,29 N,R ~G ►(or~ PROPERTY (7/VNER'S MAID G ADDRESS LEA BLOCK N SUBD. NAME OR CSM I AM 1 14/14 CITY, STATE 21P CODE PHONE NUMBER ❑CN]VIL LAGE QTOWN NEAREST ROAD New Construction Use ( ] Residential / Number of bedrooms ess~ m fr- f Replacement v Public or commercial describe Se'?X nQ usL ,~e~ / ,•~~~r,, ~~~,1 y fQ„ q/ Code derived dally flow O ©O 9pd Recommended design loading rate /Vf] bed, 9WI? trench. gpolit2 Absorption area required IVA bed. 112 NA trench,, ft2 Maximum design loading rate IVA d, gpolft2 /✓~►i trench, gpde Recommended infiltration surface elevation(s) N17 It (as referred to site plan benchmark) Additional design / site considerations x> re, ~f ,p,' 7L Se - Parent material FVW plain elevation, d applicable It S = Suitable for system o~N1r UL Q 0 U O NGROLN0 U SSURE A❑TGS DI U ❑ St3t N F1LL FIOIDNG TANK U= Unsuitable for s tem ❑ S U S ❑ U SOIL DESCRIPTION REPORT Boring # Horizo Depth Dominant Color Mottles Texture Structure GPD1ft in. Munsell Qu. Sz. Conn Color Consistence ear>ciary Roots Gr. Sz. Sh. C Bed Tr1~1ct s/ 7,5YRS6 CL 'M7Cr * Ground elev. 95~ ft. Depth to limiting (actor Remark's: Boring # 4\R 7-11 / OJT /VF I I. : Z 4A rn3 75 5 S C m S b /~~r CW NA G round j /O / m 3 76 r I VA 9y o6 ft. Depth to limiing (actor _ Re Zorl- eg epr 6e CST Nara Please tialr Phone: --3'3 7 $ Address r^ ?A S~nalure Date: ~ - CST Numbei: 1i Boring # Horizo Depth Dominant Color Mottles Texture Structure Consistence Ba.nlary Roots IIGPD/Its - - in. Munsell C;u. Sz. Cont. Color Gr. Sz. Sh. Bed . 7w, / o- o ,Z l .y, s6 a 5 , 3 `Z -z.5 /o / m 3 -s' K614 c / M-15r C1,0 IAIX - Ground 5YR -1/4 S G 1° /Y7 5 Y A i elev. 9914-70 It. Depth to limiting factor Remarks: Boring # Ground elev. fG Depth to limiting factor Remark's: Boring # ~Z Ground elev. ft. Depth to limiting factor Remarks: Boring # <A j ~ Ground elev. fL Depth to Gmi6ng factor Remarks: Q~ s Page Of E S 9 4 40126 E E E c p -Ril •r ~ ~ 1d VT• _ W C 1) r 4- O i y G > C~ C~ •r -Al U 41 O c p Fes' S Q1 U ~ tIl N r to V a x p Y O i-3 > Q W u C Q L cQ L- -C V O•- C L'_ ro 0. M-0 S- 0 v = t. v u 0) ~ o vw > 3 , t4 ~ O t~ c 1n 'Ilk - CL 4-) E Q 3 E ~\\ASa r N Ilk! \ N c OF \ ®F •r r Z\~ A W LN 41 to Go N \ L4- N u w Q W ro L C] C] N O N 4-r- U W _ : Y C:3 CU 4-3 of -0 • r m W N p (U U N rt7 lu to 0 3: CL g L") O "o E-• N b LL U L W O Z C7 7 V U Y ) d' m ad < ea W V) F- _ Z ~ c a a ¢ z c~ z t/ o J O i L r~ W 4- v 8m 3N C "1 L (tC~ a 0 rn i co - aLi c •r ro ~ C 1' t ~ .r s ~ rl Ci V~ W u o ¢ a ~o c Ck U 41 0 c i vw a a o d b U Z i r W 1 d •r ~ E ~ •i ~ E r z o d N N D •r OC 7 N > U L N r N y~i W N co to C C 4J O ac ~ 3v w o o J M.~~ rd CLN yr 04J1-U C N Jp y ro v a, LU o~ o U N m ~J aar LL 11 cor) r. 514470 1 DoyumentNo. This space reserved for recording data HOLDING TANK AGREEMENT Agreement Date March 21, 1994 This agreement is made between the : County or Local Governmental Unit kEGJS r t: S OFFICE I Holding Tank(s) Owner(s) ! ST. RC/~ VVI Village of Baldwin I Village of Baldwin R 'd cr R~ .,d (Called Municipality below) I MAR 2 3 1994 We acknowledge that application is being made for the installation of (a) holding - tank(s) on the following property, (Provide legal land description:) ~ 3:00 p , ZVI Return To or that continued use of the existing premises requires that a holding tank be installed on the property for the purprose of-proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats. As an inducement to the County of St, Croix to issue a sanita we agree to the following: ry permit for the above described property, 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and 146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered, The charges will be assessed as prescribed by s. 66.60, Stats. 2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be collected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with s. ILHR 83,18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain In effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) (Print) I Owner(s) Signature( r _ Vi 11 age of Bat i n _1_.. Cal vi_n_ Ho.~„_ erk.7Trea_ . Subscribed and sworn to NpI?~s date: 1n90 i nth AvP ~ee.••.. Baldvin, I WI 54002 1~ i Municipal Official Name (Print) I Municipal Official Signature I ! ~ ~ Notary ®u ~ _ Cl erk--Treds . My commission expiics: P U B • I • Municipal Official Title'(Print) I e0. P . • y I *,r. S5D-6123 (R. 10/85) This Instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. 11ULU1NU 1 ANK S1-_HV1UNU GUN I MAL; Contract Date March 21 1994 This contract is made between the - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Holding Tank Owner(s) Name(s) and I Pump er's Name Village of Baldwin I Village of Baldwin We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) s - % _57w% s~ C, , <30 2 z 9 Af 1~'l4 6J. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1. The owner agrees to file a copy orthis contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of St Crni x 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the -all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit ntimber issued for the holding tank; e. The dates on which the holding tank was serviced; I. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract. the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) i OW .s ignature(o-}) Village of Baldwin I Calvin Hop'l erk-Trea. Subscri '~X ~QyQ 1090 10th Ave. I 1090 10th Ave. _ e i'cR, P bed and sworn to befor 1his datZ!. su. Baldwin, WI 54002 I Baldwin, WI 54002 s i1 rN I/ ' . i 3-aa 9~ ,qf:} 'w Pumper's Name (Print) I Pumper's Signature WIS. Nola ►~l~ Village of Baldwin My commission expires: '4,,s~r; Wl c~~ 'rasaeo~oeo~eN g eL I -11 Pumper's Registration Number 1 N/A SBD-7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County -r OWNER/BUYER 7 ROUTE/BOX NUMBER FIRE NO. CITY/STATE ~a/(? ZIP PROPERTY LOCATION: / X1/4 ~ 1/4, Section 3 N, R A,/ W of St. Croix County, Subdivision Millpond Park,, , Lot No. 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 $3000 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site 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. Certification form will be sent approximately 30 days prior to three year expiration. 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. i~ SIGNED Calvin Hop Clerk-Treas. DATE_ March 21, 1994 St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address APPLICATION FOR $.ANITARY PERMIT S T C - 100 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 i Location of property 1/4 1/4, Section 0 , T N-R Mailing address zoo?o 'Address of site 410 Maol st Subdivision name Miil and Park Lot number Previous owner of property - 7L" r Total size of parcel Date parcel was created Are all corners and lot lines identifiable? 1./Yes _ No Is this property being developed for resale (spec house)? Yes / V 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 Zn~, the County Register of Deeds as Document No. presently own the proposed site for the sewage disposal system ~(ordIt(we)I have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Reglctcr.of Deeds, as Document No. f if Signature o 0 ner Signature of Co-Owner (If Applicable) bate of Signature Date of Signature • •Na 5-11. golteW Dead-Common Form (STATE OF WUMNWN) PUNT "6W am CMM Hoot i SMUMM 00. (Sea 436.16, Wie6 ststntea) Form Na 11 304725 This Indenture, made this 22 day of 4pril , A. D.,19 71 , between • . First National Bank of Baldwin, a Wisconsin banking corporation part y of the first part and • Village of Baldwin. a Wisconsin municipal corporation • part Y of the second part. iViQttn OMD, That the said part y of the first part, for and in consideration of the sum' of . One and no/100 ($1.00) Dollars and other valuable consideration Dollars, to it in hand paid by the said part y of the second part, the receipt whereof is hereby confessed and acknowledged, ha s given, granted, bargained, sold, remised, released and quitclaimed, and by these presents does give, grant, bargain, sell, remise, release and quitclaim unto the said part ' Y of. the second part, and to its heirs and assigns forever, the following deseribed•real estate, situated in the County of St. Croix , State of Wisconsin, to-wit: Outlots 19 and 22 of the Village of Baldwin REGISTERS OFFICE, FEE ST. CROIX CO.,~ WIS. Rec'd for Record this- 30th-day of-- P-r-U-----A.D.19 Zl at-- --$=30 At Reg}st of a -s-- Ca gabt anb to DOW, the same together with all and singular the appurtenances and privileges thereunto belonging or in anywise thereunto appertaining, and all the estate, right, title, interest and claim whatsoever of the said part y of the first part, either in law or equity, either in possession or expectancy of, to the only proper use, benefit and behoof of the said part Y of the second part, its heirs and assigns forever. U MftntoO tlti bMot, the said part y of the first part ha s hereunto set its hand and seal this 22 day of April AA. D199 NZ BANN .1 11- i d and Sealed in Presence 0e9d) lpf: i' williniF siaeryz BYs Dale e . J. inneyanhns ~ L O r t Shirley A. Rademaker ,m doe do~`l %tatt of MUOconofn, ss. ' , St. Croix county. N p~ . Personally came before me, this 22 day of April ,'A. D., 19 71 , theabovenamed A. A. 1,=11.1ink, President, and Dale Fern, Cashier, to me known to be the person s who executed the foregoing ' went and acknowledge he same. L /J. Snoe enbos Notary Public, St. Cry-~tyf W~J f My commission expires November 1 : ,19 7 co, t alp' N $ Gaiic, Richardson & Skow, Spring Valley, Wisconsin 54767 ''•.,`~~C~~~~~~` Drafted by n DiLHR SBD-6698 (Plb.89) APPLICATION FOR DEVELOPNENT OF FLOOD PLAIN DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS When the installation of a new, replacement or expanded eds~rivate sewage disposal be completed and system is proposed for a flood plain area, this6 Human Relations along with plans submitted to the Department of Industry, Labo and other necessary data. OWNER'S NAME V i l a fG o ~ SCIA G) W ► r" , tWq 1 5 G ov15.► h DATE 1J, 0(4... ADDRESS k ocl O t p Q U } a~ a~w w (SL vY1 g1 'f L [u, ~ ADDRESS OF BUILDING OR LOCATION OF PROPERTY Z-L t Z V o~~~~aW.~ Ma M~ Ll PO C~ V& . LEGAL DESCRIPTION Z"L C) 16, ~~td w1 1 TOWNSAIP'~t_ ga-1dVV t COUNTY Cv'o I,-,- Is this system new 'X replacement expanded Is area: In regional floodway? yes no ✓ not determined v' _ In regional fringe flood area? yes no not determined Contiguous to ground higher than any of the above? yes ✓ no What is the established regional flood elevation? It a ( N G v _D Are flood plain maps published and available or determined by the Department of Natural Resources? Has or will permission be granted for the following: Fill required for building? yes ✓ no Building permit? yes ✓ no / Sewage disposal system (sanitary permit)? yes ✓ no Action taken locally by V1_=a' % Comments regarding development (zoning administrator, board of appeals, etc.): Favorable Unfavorable Special Recommendations: Signatures ~t County Representative Department of Natural Resources (A) c o Department of Industry, Labor & Human R ation DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 1p SW-14, St4,S30,T29N-R16W ❑CONVENTIONAL EXALTERNATIVE State Plan l.D.Number. (II assigned) Town of Baldwin XX Holding Tank ❑ In-Ground Pressure ❑ Mound 87-07402 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Village of Baldwin 1090 10th Avenue, Baldwin, WI 54002 / J .1_57 - I? ~-~.3(I BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. Name of Plumber. MP/MPRSW No.: County: Sanitary Permit Number: 6 St. Croix 102826 664 Joe Stan SEPTIC TANK/HOLDING TANK: MANUFACTURER. ILIOUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED'. PROVIDED ❑YES ❑NO ❑YES ❑NO BEDDING. VENT CIA VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. IVEN, TO FRESH ALARM FEET FROLINE AIR INLET ❑YES ❑NO ❑YES ❑NO NDOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY JPUMP MODEL JPUMPISIPHONMA NUFACTLIRER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY J WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LI"E AIR INLET PUMP ON AND OFF) PU ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH'. LENGTH. NO. OF ID, STR. PIPE SPACING COVER JINSIDE DIA ITS LIQUID BED/TRENCH TRENCHES MATERIAL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH UISTR PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PROPERTY WELL BUILDING VENT TO FHE SH BELOW PIPES ABOVE COVER. ELEV. INLET ELEV. END'. PIPES FEET FROM LINE AIR INLET NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES FIND SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES FIND ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER. EDGES. [:]YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL IND DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & TV HKINI, ELEV.' ELEV.. DIA. ELEV.. PIPES DIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING FEET FROM LINE. ❑YES ❑NO ❑YES FIND NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE DILHR SBD 6710 (R. 01/82) Zoning Administrator DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code 7,-, ( ~ x mans STATE SANITARY PERMIT # a Fa (10 -Attach complete plans (to the county copy only) for the system, on paper not less than 8% X 11 inches in size. STATE PLAN I.D. NUMBER 7-07L/O -See reverse side for instructions for completing this application. 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PETITION FOR VARIANCE ❑ YES U(~ Lb NO PROPERTY OWNER CATION L~ROELR V' 14 a off' F/4, S T N, R 1G E (or) W PROPERTY OW E R'S MAILING ADDRESS BLOCK NUMBER SUBDIVISION NAME VI-t a t341L1„.• of& /rid V CITY, SAT ZIP CODE PHONE NUMBER NEAREST ROAD, LAKE OR LANDMARK 0Gdw ,K II. TYPE OF BUILDING Oft USE SERVED: Number of Bedrooms if 1 or 2 Family N - .4 OR 0 Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b. W Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. ❑ Conventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. 1,9 Holding c. E:1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b. ❑ seepage Trench c. ❑ seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Feet ❑ Private ❑ Joint ❑ Public VI. TANK CAPACITY Site INFORMATION in allons Total # of Prefab. Fiber- Exper. New xistin Gallons Tanks Manufacturer's Name Concrete structed Con- Steel glass Plastic App Septic Tank or Holdin Tank Tanks Tanks Lift Pump Tank/Si hon Chamber ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plum is Signature: (No tamps) AAPMPRSW No. Business Phone Number: ~o St A G G ~L 71s b9fr-2t.~ Plumber's Address (Street, Cit , State, Zip Code Name of Designer: VIII. SOIL TEST INFORMATION Certified ~Soil Tester (CST) Name CST # O CST's ADDRESSS treet, city, Statg, Zip Code.) '1 I Phone Number: 1 S,, - IL J.V1 Q t A J 1 I L W I- t5~ O -,E~ 8 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee Groundwater a e Iss ' g Agent Signature ( Stamps) Approved El Owner Given initial lJ 7~ surcharge Fee Adverse Determination p 5 XA- gdz~ . COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; Il. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more , commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Groundwater included the creation of surcharges (fees) for a number of regulated practices which Wiscori,~;in's can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Treasure is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398 (R.03/86) APPLICATION FOR SANITARY PERMIT STC - 100 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. - - - - - - - - - - - - - - - - - - - t - - - - - - - - - - - - - - - - - - - - - - Owner of Property O 7 /9Q Id L</ JIr7 Location of Property S G/ k S~ , Section U , T N-R W Township J/ (!G a at f.3a ~a(w• 01 Mailing Address /0 4v Address of Site Subdivision Name N A Lot Number Previous Amer of Property _Nl Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? x Yes No Is this property being developed for resale (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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY O(VNER CERTIFICATION I Vve) ceAV6y that a,Ct' a.tatement's on .tluh fonm cute xicue to the be,5t 06 my , hncw.w,Cedge; .that I (we) am (ahe) the ownen(~s o6 the phopehty de~schi.bedin .thiA in4alma.tion 6o", by viAtue o6 a waAAanty deed kecoAded in the 066.ice 06 the Co„n.t RegcAteh o6 Deeda ah Vocumen,t No. ; and that i (we) p4aentty own t e p4opoded Aite bon the sewage digspos e h em (on i obtained y (we) have ob.ta.ied an f-dAt gent, to tun with the above deAchi.bed pnopeAty, OIL the eondthuct.ion 06 said a ystem, and the game has been duty heeohded .tn the 066.tee o6 the County Reg.eaten. o6 Veede, ae Doc meet No. ) SIGNATURE Olt OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H H a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z ty V,741 OWNER/BUYER O 14 1 ROUTE/BOX NUMBER Nl4- Fire Number Nl'~ CITY/ STATE_ X94 u . . ~ rt z i p 5-1-160 PROPERTY LOCATION: k, S-Lr it, Section , T 2 I N, R G W, T~tdi► of V" , 0 go Uwt,h St. Croix County, pv1 r4.0T Subdivision 12ostc/ , -hrezE= number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, I if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. y 0 I/WE, the undersigned, have read the above requirements and agree ~z„ to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. S ICNED_l~ DATE St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. EPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS iNUUSTRY, DIV!31ON LABOR AN° PERCOLATION TESTS (115) ~UAUISO ` 153; WMAN RELATIONS f°- (H63.09(1) & Chapter 145.045) 1 _ LOCATION: SECTION: TOWNSHIP/MUNICIPALITY - - OT NO:BLK.N,SUBDIVISION NAME. r titst '/4 '/4 SCE /TAq / H/R41(or V/ `6g ) COUNTY: OWNER'S BUYER'S NAME: MAILING DDRESS: T c V1 I L x t law ~ .~.1~ L c USE DATES OBSERVATIONS MADE - NO. BE[ RMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLAEION' TESTS: DResld e I[31New (]Replace r'" RATING: S= Site suitable for system U= Site unsuitable for system -7 CMOUNcD: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) XU XS EIU: [under lation Tests are NOT required DESIGN RATE: If any portion of the tested area is ut the r H63.09(5)(b), indicate: ~f j/ Floodp lain, inar.ate e Floodplain elevation y _ , - - ° -J PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, 4ND uEPTH 1 NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- i I B- B- B- B- - - - - - PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES -j NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH j P - - P- P - i P- r PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what ine th' t zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and ti?: dr rtion and pe cent of land slope. SYSTEM ELEVATION r,,p T". c~ l° ,l Q u s h f f: ~a use e,~ ~ ► ni T F-f ' I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methoas specified {n the Viascx,nsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): / TESTS VV RE COMPLETED ON. - - j #17 - -14 AF ADDRESS: CERTIFICATION NUMBER PFLONEV M B E M r ----C' - 1 CST SI NAJURf v - _ DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DIL.HR-SBD-6395 (R. 02/82) OVER _ 4 ~ { y y ~i ~ Y s ~ l~t b { W . C v Y I Y e at ,.~4rtti , r i7 , +.2 f 4°Ar}s f°k ~ t 3 .El{ J~+ dF 13 14~a 15;jE 17 is. 19 3 IC 5 d' 10t too H 1' 9 1wx 20 19 is 17 19 1s 14 NEWTON 1s G . r Gj 1 12 13 1 s 1s 17 1,$ z 4 3 t-2 1 20 1~ w irz 1A S t0 rM'. M'' H. 12 7 s \vv 17 S 7 O s AND OMAHA BAILEY - - RAIL WAY -PARK K K 1 4 3 2 1 MILLPONDtK 23 pr \ \tK s S s 7 s 22 16 I 4 3 2 24 25 19 s S 6 7 s , 2s 21 20 I 30 27 w 1 I 2 I 129 13 1 1 1 2 24 4 'ar ARK ?I\\ Dc 1 10 1 i 1 1 2 9 2. 2 C2 2 A 35- s 43 - 3 f53 63 Ix I 4 7 4 4 4 Dln J ADD 30 noN I s s y s a s lit LM • 1 , 2 2 2 __3. 3 I H I j ii I H I I ~ I Q ! I~ ' ~ l 4j ' I w 4.I j Cr' J!i ai -w4 OIL H O;, F~ i I a I ~ e sFk Y. I ~ i qqw h <I h i D 1 a a 2 ' • i -77 S I 0 ~ ~ 1 i F H \ 01 z 11 i m o o Y 3 yt o ' I /Y to i~ IL T I Yll tt.