HomeMy WebLinkAbout012-1007-40-100
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER M d/oo C '2a ADDRESS
W `r IV / ~ SUBDIVISION / CSM# LOT
SECTION T N-R W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIER
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICA E NOR H ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
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BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: „lam ~ye~a.oT-- Liquid Capacity:1~Gd
Setback from: Well &V z- House W' Other
Pump: Manufacturer Model #~gr Size
Float seperation Gallons/cycle:/./Z
Alarm Location A~Q ,g g
SOIL ABSORPTION SYSTEM
Width: Length ~d Number of trenches 3
Distance & Direction to nearest prop. line: ;O s
Setback from: well: /1&4-~ House~2 Other
ELEVATIONS
Building Sewer ST Inlet; ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATIO'~N/~/~ Q
PLUMBER ON JOB:L
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LICENSE NUMBER:
INSPECTOR:
3/93:jt
r~s'i~~ artr tT ln~i s IRIE 1. 30 PRI-VRTIr 96VM S+STENIOTH County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) sanitary ermit o.:
1 Q-4-19A
Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan D No.:
CST BM Elev.: Insp. BM Elev.: BM Description:0 X Parcel Tax No.:
n19_1oo:z_4u_jlnu
TANK INFORMATION EL ATION DATA A9300056
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmarko
f . rF old U. / /~~,Gd
Dosing
Aeration Bldg. Sewer
Holding t/ Inlet
/J,/,57 9e.76
TA SETBACK INFORMATION St/, d Outlet 9p,
TANKTO P/L WELL BLDG. Aierlntake ROAD Dt Inlet *,~/W/ 1-1
Septic- NA Dt Bottom CBS 7,C~~
Dosing NA Header kt
Aerati NA Dist. Pipe Z7 i r
3~ G. Z6 9s~ ,3
Holding__ _ Bot. System - 3/
j~ PUMAI INFORMATION Final Grade
VV'' T
Manufacturer Demand ~ o , -_1 11 `l Cr Jfi
Model Number GPM '
r'l. .1, s 0 eaL- S• 5~ S.
TDH Lift Loss System TDH Ft
Forcemain Length -70 Dia. 52 Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PI--- _ No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S ~ 3 DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHI Manufacturer:
SETBACK
INFORMATION Type Of &,.l CRAM Mode Num er:
System: .E-,.-rte<.ZVs O IT
DISTRIBUTION SYSTEM
Header fT Mjt , ' / Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
r
Length ~ f f 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 /TLePc*Center Z - Bed /T_rekeh Edges / - Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) ? yl
L.
LOCATION: IN PRAIRIE 1.30.17 SE SW-LOT 1 70TH
Plan ren regtjired? es ❑ No
Use other side for additional information. l a-~
SBD-6710 (R 05/91) at
;?,/,p Inspectorp's Swig-nature Cert. No.
L rt~° a u ~C1 Y
1
ADDITIONAL COMMENTS AND SKETCH-
SANITARY PERMIT NUMBER:
(2)
J
DILHR SANITARY PERMIT APPLICATION couNTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT 11
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 1
8% x 11 inches in size. h k i v Vno wapplication
-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
S'7&A- ,F '/4S"L✓'/4,S e T N,R 12E(or)W
PROPERTY OWNER'S AILING ADDRESS LOT # BLOCK #
w yth yy
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: Check one CITY : NEAREST ROAD
( ) 11StateOwned ❑ VILLAGE :
❑ Public V11 or 2 Fam. Dwelling-## of bedrooms PARCEL TAX . NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) l007_4141 _0 A'
10 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
50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. K New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 1;9-seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 430 Vault Privy
140 System-In-Fill
VII. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. 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) ~.S ELEVATION
d~B aG ~°Z`O 0 O~ a 3 f rr Feet 4Dl, rf5 Feet
VII. TANK CAPACITY Site
in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xistin Gallons Tanks Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank dd . ~d G✓eS7Jl~ r -0 [71 1 171 1 F1
ift Pump Tank/Si hon Chamber
LEj 0 1 0 0 F1 I F1
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) P PRSW No.: Business Phone Number:
it JieL AO
~ I (
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved SInitary Permit Fee (includes Groundwater Pa ssue Iss ' Agent Signature No Stamps)
Approved El Owner Given Initial Surcharge Fee)
Adverse Determination
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 (SBID 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 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 mainsiwater 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; (Jose 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.
S8 D-6398 (R.11/88)
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AN P.O. BOX 76
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/IITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
SE 1/4 91/ 1 /T30 N/R 17kr) W Erin Prarie n/a n/a n/a
COUNTY: CNNEWESUYER'S NAME: MAILING ADDRESS:
St. Croix R. Doornink & H. Hielkema 841 220th. St. Bal_dwi.n, Wi. 54002
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL D RIPTIO IPR F N PERCOLATION TESTS:
Residence 3 n/a 2&New ❑Replace 5-18-92 5-19-92
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND•PRESSURE: S STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
EaS ❑U BS ❑U EiS ❑U ❑ S ®U ❑ S RU conventional- trench
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5) (b), indicate: Tl/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS page 30 JeA
BORING TOTAL DEPTH O GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTI-M, ELEVATION OBSERVED ES GHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
1.00,10yr3 3,L.; .75, 0yr+ , si_.; ,-_.s.&
B-1 6.00 100.45 5.00' 5.00' gr., 1.92,10yrz,/4, co. S.
Wyr414
, si_. ; , - 4-1.25,ioyrM, L.; 1.00, B-2 6,25 100.85 5.4?_ 5.42 l.s., .83,7 .5yr4/4, s.1.,; 1.50,10yr4/4, S.,
yr.
3 6.58 100.+5 5.33 5.33 - , L. ; • , 3. 501 TOyL-47 4, -
B- l.s.,; 1.25, 10yr4/4, l.s.
4 6.16 100.55 5.16 5.16 3, - , L•; 1.33, 10yr4/4 st-.-•; ,
B- +/4, l.s.; 1.00, 10yr4/4, ls.
B-5 5.17 100.35 A.83 4.83 1.00,10yr3/3, 10y r4/4, s' . ; - . yr
4/4 1.s.
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD3 PER INCH
P_ 1 24 none 30 1if 124
P-2 24 none .1 1 7/8 7/8 34
P- 24 none 30 1 1 30
P-.
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 98.45
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1, the undersigned, hereby certify that the soil to ted on this form re de by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded n e Iocatigp.of the fists a ct to the best of my knowledge and belief.
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NAME (print : 1~ TESTS WERE COMPLETED ON:
Gary L. Steel 5-19-92
ADDRESS: ; CERTIFICATION NUMBER: PHONE NUMBER( optional):
1554 200L-h. Ave., New Richm 54 2298 715-24,5-6200
CST SIGNATU
DISTRIBUTION: Original and one copy xo Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
0 ,
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and'accurate soil test, your report must include:
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial, project;
1 MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing.;the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
suparate sheet: may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation testexemp-
tion, if appropriate;
10. If the information (such as tlood plain, elevation) does not apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL_ TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 10") BR - Bedrock
cob - Cobble, (3 - 10") SS.- Sandstone
gr - Gravel (under 3") LS - Limestone
`s - Sand HGW - High Groundwater
cs Coarse Sand Perc - Percolation Rate
reed s - Medium Sand W - Well
fs - Fine Sand Bldg - Building
Is - Loamy Sand > - Greater Than
sl Sandy Loam < - Less Than
*I - Loam Bn - Brown
*sil - Silt Loam BI - Black
si - Silt Gy - Gray
*cl - Clay Loam Y Yellow
scl - Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot - Mottles j
sc: Sandy Clay w/ - with
sic, - Silty Clay fff - few, fine, faint
c _7 Clay cc - common, coarse _t
pt.' I Peat mm - Many, medium
ni -Muck 1 d - distinct
p prominent
` HWL - High water level,
Six general soil textures surface water
for liquid uvaste disposal BM - Bench Mark
r VRP Vertical Reference Point
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TO THE OWNER: _
This soil test report is the first step in securing a sanitary permit. The:county)or,the Department may request
ve,ification of this soil test in the field prior tq permit. issuance. 'A complete"set,of plans for the private
sevvage system and a permit application must be submitted to the appropriate local authority ire order to
obtain a permit" The sanitary permit must be obtained and-posted prior to the start r')f any construction,
485376
CERTIFIED SLFTVEY MAP
LARRIE QUAM
Part of the Southeast 1/4 of the Southwest 1/4 of Section 1, Township 30 North, Range
17 West, Town of Erin Prairie, St. Croix County, Wisconsin.
0 Indicates P x 24" iron pipe weighing 1.13 lbs./lin. ft. set.
- -c Indicates watercourse.
Owner's Address: Phone No. 1-612-890-7676.
712 Thorbeau Drive
Burnsvi l lp . MMN =553:7 SCALE I • = 200'
20• UNPL A TIED LANDS 050, /001 200• 300• 400' 500• cool
y S88-47-08--C 2J6.88'
NL/NE SE//
S{Y S OJ • 18' 25 "E 20. J/
FILED
J'°~ W 9 ~
o 3 JUL 0
11992A1-
POND AND JAMES n'rn 2
~ ~ 5 NNELL
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MA R S N O Z vy1SI8r C1 Doed9
\ N Z\ ~ ~ '0 St Croix Co., WI
W /8 " CULVERT W N
N ~ ~ •
W LOT /
- 14.047ACR£S Ct k^
3 6//, 874 SO. FT. N O h
1 /J. 714 ACRES EXC. ROAD R.O.W = 0
597, 40/ SO. Fr. Z
• Q 3
O
BARN 0h W tu
.
FENCE N i h
b BARN y
Q O Q
~I I J o° Dated: April 10, 199?
4
2 b WELL o Revised: Ju 1992
OI O SILO SILO y~ y \Soo~S/
,i
LAU EN
Q SHED a s` r W UR HY . o
Qj.l ) o 4, 1 1713
J" RIVER FALLS •
/ 111 ~
M Q WISC.
C DRIVEWAY Q I4 ~A v
LAND h J 6~~~/Iit~~
° Laurence W. Murphy
ROAD SET BACK LINE
_ _ _ _ _ . _ _ _ _ _ s /r , E Registered Land Surveyor
y0.4y
pp N 146.p8.
Z, N88-5,--59 4J5,26'
/J/J. 40• 6- - _ i. 871. SO'
N 88'.57'39 "W uN 2626.80' t«,' " N n r 4
66' /TO TN 4!y , W3' N o Q 4
UNPLA TTEO LANDS S L/NE SW //4 q? e. < O ~ H
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S1Y CDR. SEC. TJON, R/7W, S114 CDR. SEC. TJON, R17W~ a w. A '0
I/ IRON PIPE FOUNO/ IRON PIPE FOUND/
This instrument drafted by Laurence W. Murphy g o Q
Vol. 9 Page 2500
Certified Survey Maps
St. Croix County, Wisconsin
SHEET 1 OF 2
MEN I IFIEO SURVEY MAP
LARRIE QUAM
Part of the Southeast 1/4 of the Southwest 114 of Section 1, Township 30 North, Range
17 West, Town of Erin Prairie, St. Croix County, Wisconsin.
Description:
That certain parcel of land located in the Southeast 1/4 of the Southwest 1/4 of
Section 1, Township 30 North, Range 17 West, Town of Erin Prairie, St. Croix County,
Wisconsin, more Fully described as Follows; Commencing at the Southwest corner of said
Section 1, thence S 88057'59"E (assumed bearing on the South line of the Southwest
114 of said Section 1) a distance of 1313.40' to the POINT OF BEGINNING, of the parcel
to be herein described; thence N 00011'46"W 1304.63' on the West line of the
Southeast 114 of the Southwest 1/4 of said Section 1; thence S 88047'08"E ?36.88' on
the North line of the Southeast 1/4 of the Southwest 1/4 of said Section 1; thence
S 03018'25"E 20.311• thence S 52048'25"E 348.791; thence S 26017'29"E ?71.4S'; thence
S 32001'00"W 373.831; thence S 03008'13"W 373.45';'thence S 11020'49"E 146.08'; thence
N 88057'59"W 441.80' on the South line of the Southwest 114 of said Section 1, to the
POINT OF BEGINNING, containing 14.047 acres, being subject to easement over the
Southerly 33.00' thereoF For town road purposes and also being subject to easements of
record.
Each parcel shown on this map is subject to State and County 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 For advice.
Dated: April 10, 1992
Revised: June 29, 1992
State of Wisconsin)
County of Pierce)
I, Laurence W. Murphy, Registered Land Surveyor, do hereby certiFy that by direction
of the Owner, Larrie Quam, I have surveyed and divided those lands as shown on this
map according to oFFicial records, Chapter 36.34 of the Wisconsin-Statutes and the
Ordinances of St. Croix County and that this map and description are a true and
correct representation thereoF.
,This instrument draFted by Laurence W. Murphy
%
'LAUREN E'
M W MUR °C
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3 WISC. 4rt.
'D F•• .....-••''SJ
y N f~ LAND 0~•.
Ca Q
< •r►
O 'C L ur nce W. Murphy
p' y: N M: Registe ed Land Surveyor
v 0)
o:
Vol. 9 Page 2500 Cy
CertiFied Survey Maps SHEET 2 Z
St. Croix County, Wisconsin
l
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St
. Croix County
OWNER/BUYER fl ~~i N~ Lrc1'~~t~~r r {r;~ - )4 L_h1"r;~ Nt t~- 1
~h
ADDRESS FIRE NUMBER
CITY/STATE RJti:G h~5>>Gti>> ,c-~ ZIP
PROPERTY LOCATION:) 1/4, 1/4, SECTION , T 3 0 N-R L7 W
TOWN OF St. Croix Count
i
Y.
SUBDIVISION 1211,-l C-69f 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 a licensed septic tank pumper. What
you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system. :
St. Croix County residents may be eligible to receive a grant
for a maximum of 60% of the cost of replacement of a failing
system, which was in operation prior to July 1, 1978. St. Croix
County accepted this program in August of 1980, with the
requirement that owners of all new systems agree to keep their
system properly maintained.
The property owner agrees to submit to St. Croix Zoning a
certification
'form
signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or a licensed pumper
I
verifying that the on-site (1). wastewater disposal system is in
proper operating condition and (2) after inspection and pumping (if
necessary), the septic tank is less than 1/3 full of sludge and
scum.
I/We, the undersigned have read the above requirements and
agree to maintain the private sewage disposal system in accordance
with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be
completed and returned to the St. Croix Co. Zoning officer within
30 days of the three year expiration date.
SIGNED: 44,4' 1rr~
DATE : ~ ./719 3
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
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 pormit issuance. ,Should this
development be intended for resale by owner/contractor,(spec
house), thenla 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 Ae~ S i_
Location of propertycf 1/4 ~1/4, Section i
T~_N-R j 7 W
Township- t~~`~►
Mailing address 3e, ' r
Address of site i i s
~C
Subdivision name_ - L5Y, (/W p 'Q3. 0'2t5Lot no. /
Other homes on property? yes =No
Previous owner of property
Total size of parcel / el~ Llc F1 -s
Date parcel -was created 7//2
'Are all corners and lot lines identifiable? m~ Yes _No
is this property being developed for (spec house)? Yes ~No
0,5KVolume and. Page Number as recorded with the Register
of Deeds.
L eed ~2Q Ce l~
~o-P_ 9 ? .as,
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I(we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner (s) of
the property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in the office of County Register of deeds as Document
No.
Signa re of applicant Co-app scant'
Date of Signature Date of Signature
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DtPARTkENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 539069
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/M0NC ITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
SE 1/4 9t/ 1 /T30 N/R 17E4,)r) w Erin Prarie n/a n/a n/a
COUNTY: OUMMEMBUYER'S NAME: MAILING ADDRESS:
St. Croix R. Doornink & II. Hielkema S41 220th. St. Baldwin, Ili. 54002
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: IPERCOLATION TESTS:
Residence 3 n/a New ❑ Replace I 5-15-92 5-19-92
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
®CS ❑U BS ❑U CAS ❑U S ®U ❑ S EU conventional trench
If Percolation Tests are NOT required DESIGN RATE:
If any portion of the tested area is in the /a
under s.H63.09(5) (b), indicate: n/a Floodplain, indicate Floodplain elevation: n
decimal' PROFILE DESCRIPTIONS page 30 JeA
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH5011, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B-1 6.00 100.E+5 S.OQ' S.QO' 1.00,10yr3 l,L.; .75,10yr a , si__.; I ,-_.s.&
br., 1.:2, 0yr /4, co. S.
2 5.25 100.55 5.42 5.42 3, J.. , sz_.; . rd 4-
g - 1-.s., .53,7 .5yr4/ , s.l.,; 1.50,10yr4/4, S.,
100.45 5 yr3 I, 4,-
B 3 6.53 .33 5.33 l.s.,; 1.25, 10yr4/4, l.s.
.
4 6.16 100.55 5.16 5.16 • 3,1(?yr3 3, L.; I. Si-IL.; ,
B- +/4, l.s.; 1.00, 10yr4/4, ls.
B-5 5.17 100.35 11•53 4.83 _ , L.; 1.17, r` , s?--.; . , yr
4/4 l.s.
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD3 PER INCH
P_ 1 24 none 30 24
P-2 24 none 3Q 1 7/8 7/8 34
P-3 24 none 30 1 1 30
P__
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION 98.45
= _
ct I ~I/ t
E
Ll-
J- TN
i
b
3
7-
, t
•
I, the undersigned, hereby certify that the soil to ted on this form re de by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded n e locatipp_f thgt~sts a ct to the best of my knowledge and belief.
c; /,w`9' i
NAME (print): 'rj lr TESTS WERE COMPLETED ON:
Gary L. Steel 04 5-19-92
ADDRESS: s CERTIFICATION NUMBER: PHONE NUMBER( optional
1554 200th. Ave., New Richm w 54 2295 715-24~ 1,6200
CST SIGNATU
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
i
1
y
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6385
To be a complete and accurate soil test, your report must include:
1. Compl scription;
2. The, use se °i(m most clearly Indic:-rte whether this is a residence or commercial project;
3, MAXIMUM number of bedrooms. or commercial use planned;
4. Is this a nevv or replacement s%1 ,
5. Complete the suitability rating b,.;.i;s. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
5. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. AKE A LEGIBLE diagram accurately locatil)g your test locations. C !ving to scale is preferred. A
°---'te sheet may be used if desired;
w sure your benchmark and vertical elevation reference point are ovum, and are permanent;
0. - rmplet:e all appropriate boxes as to dates, names, addresses, flood plair =lata, percolation test exemp-
tion, if ap)riate;
10, i ic. 7 (such as flood plain, elevation) do s )ply, place `i.~V in the apf x;
11. r -id place your current address and Your ~ Jeation our r r
12. copies and distribute as required. ALL E,Al- TESTS 1nT BE FILED ITH THE
LOCH L)THORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st Stone (over 10") BR - Bedrock
coke - Cobble (3 - 10") SS - Sandstone
gr - Gravel (under 3") LS Limestone
s r Id HGW - High Groundwater
cs ~ - ld Perc`, Perco'r~ on Rate
wed s' ~ nd W-W1Il
fs Bldg BL
Is - t l > - Grew, r
sl - F n < _ Less Thr
II - Lkill Bn Rrov n
sil - Silt 1 Im BI Black
si Silt Gy - Gray
cl - Clay Lc y - `t
- San r am R F
Silt,, CC .;.n mot
Sandy C y -
Sic - y Clay fff - f
"c CC cotrir u
t)t rnni r,,lany, rli
m - IV .::I< d distinct
p - prorninei,
W,/L - Nigh
c it textures
(;x v disposal BM - E„
VRP Vcrti=: c:e Point
TC -'.-."N
. ` .
tht first Ste In t y „ c quest
!I t-r + private
p °mit I l ~ler to
y it mu pr ;.i pt i r tart: of -rr.
r
Parcel 012-1007-40-000 04/04/2007 03:30
PAGE 10F 1
Alt. Parcel 01.30.17.12 012 - TOWN OF ERIN PRAIRIE
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 - QUAM, LARRIE
LARRIE QUAM
712 THOREAU DR
BURNSVILLE MN 55337
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST L/
SP 1700 WITC ( /
Legal Description: Acres: 25.953 Plat: N/A-NOT AVAILABLE
SEC 01 T30N R17W SE SW (91 CV 162) EXC Block/Condo Bldg:
PT TO CSM 9/2500 (RETAIN 790/15) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
01-30N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
12/11/1998 593643 1386/332 WD
07/23/1997 1
07/23/1997 937/30
07/23/1997 923/04 mo~
2007 SUMMARY Bill Fair Market Value: Asse Frith:
Use Value Assessment
Valuations: Last Changed: 06/22/2006
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 22.000 4,200 0 4,200 NO
UNDEVELOPED G5 4.000 1,300 0 1,300 NO
Totals for 2007:
General Property 26.000 5,500 0 5,500
Woodland 0.000 0 0
Totals for 2006:
General Property 26.000 5,500 0 5,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00