HomeMy WebLinkAbout040-1190-50-000
a o ' 3 o I
O
h
o tl I c I
~ I
a ~
o ~ I
0
N y
O N
N C
O U
O
O O
y
O O
H
d a`) 3
O
I N U ~
c Z cO N
7 m 2
LL o o co I
a N x
Q IL- CC)
rn U) o
0
z
00
v z a co
o I
c U
o z
N Z O c o
N F ~ E v
v r)
N E c
a w 0 =
o 4) c O
y z m D Z
rn c c
(D E N
2 y
N C - EO
CL c
co 0
y I o G O (L n CM
0
a ~ o I
000 ~w I z
F CL CL CL
R
CL iN
7 O fA O M M y
V) J U 0 rn rn } M
Q n s o
o
U O :
C co c a
y d w
LL. d Q } (n N
C7 0 U .14
O o y C
y ~V!
9 4) :3
y U Y C 0. N N rn
O l~
Ln :z I CO a 0 O C C N d. t` h
V O
W Oj I M n ' n r a
0-4 o N O O~ N m r- L
O O H 2 0 z c fn
O ~
d C d 4
• eeS a m .q 0 c
`1v E ` c 3 0
A C) a o in 0
ST. CROIX COUNTY
. WISCONSIN
ZONING OFFICE
rrrrrr ....i
ST. CROIX COUNTY GOVERNMENT CENTER
. 1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
March 24, 1994
Mr. Chris Haroldson
538 Frances Avenue
Hudson, Wisconsin 54016
RE: Septic Inspection
Dear Mr. Haroldson:
An inspection of the septic system for the above address, further
known as Parcel No. 040-1190-50-000, was conducted on December 7,
1993. This property is located in the NE', of the SE; of Section 4,
T28N-R19W, Town of Troy, St. Croix County, Wisconsin. At the time
of the inspection, this septic system was found to be code
compliant for a three (3) bedroom home. Should you have any
questions, please feel free to contact this office.
Sincerely,
L4a c2~
4L,
Mary J. Jenkins
Assistant Zoning Administrator
mz
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER__t
ADDRESS Pi G') P (?60 f
s3q Fruyus Ave- - th-,L4svN,
SUBDIVISION / CSM# U L1 ltd ~~Z'/1 S LOT
SECTION- T 9Q N-R ~~W , Town o f7n
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~e11 rlol- Qe; lle~
9,Q°U~~I fig' ~
S~~fie C
a~
I
IS -O
` 1 II ,p
gbh, 10~J II~D~ ~~yrofN ~ hbf `pvAer S P,~. INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
r e
BENCHMARK: p_ Tmjl~
ALTERNATE BM:
SEPTIC TANK 11/ PUMP CHAMBER / HOLDING-TANK INFORMATION
Manufacturer: Liquid Capacity: 1,60b
Setback from: Wel l C~ G~ House Other
Pump: Manufacturer Modell Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Ic
Width: Length L 6r Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House r Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
~~artPhitiTRdf must .19.843
J1'r PRIVATE SEWAGE SYSTEM County:
L rand Human Relations INSPECTION REPORT
' 5'fety and Buildings Division ST- CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village 9 Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
. 50 L a=
TANK INFORMATION ELEVATION DATA A9300326 i d) to j q3
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / r t 1 t1if l~ Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet /-4 tj' /DI,5
TANK SETBACK INFORMATION St/ Ht Outlet S,at3;"
Vent
TANKTO P/L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Septic / y NA Dt Bottom
Dosing NA Header/ Man. 73 loo, 7X
Aeration NA Dist. Pipe b /0~1~5
Holding Bot. System (7a 9 7, 7S
PUMP/ SIPHON INFORMATION Final Grade ~°f lb d ,5(,
Manufacturer Demand a f / L
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width0 Length/_ & No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ! / DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION TypeO fU4,0 CHAMBER Model Number:
System: dry t'o 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 I, Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges f Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
„ COMMENTS: (Include code discrepancies, persons present, etc.)
UCATION: TROY 4.28.19.843~i
V( J+ -
L-y
Plan revision required? ❑ Yes ❑ No °
Use other side for additional information. /7 93 (o ~o
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH ,
SANITARY PERMIT NUMBER:
LOCATED IN THE NORT'HEAST 1/4'
SECTION 4, TOWNSHIP 28 N
TOWN OF TROY, ST- CROIX
s600 UNPLATTED
e4
sa' ss' . st•
I -
I g _ S 85.3 '00"E 396.7g~
.I
r_ a k YO""►t. 16p:p.
I s ~4G~ u g g~ ~O•
I ~ p o o
s' c 5
oe.
I 1s2•Y6•
S 85
I Y00.00,
UNPLATTED s es• sr oo•t
N
LANDS i o
o UNPLATTED LANDS
I
I °
. I A
o
I O
I w
I 2
I
I o v'
• °o CURVE LOT RADIUS C
NO. NO. LENGTH L
A 2- 1 550.17 2
I o 4
I o
= 3. 550.17 1
3- 4 270.13 1
I zoo•oo• 5- 6 336.13 1
I s or 56' 00.E 7- 8 1490-71
I T STREET
7 1490.71
I
I
I
c I
I
I ~ N N
I u u
I a 1 0
1
• I
i
I ~
I
OF THE SOUTHEAST 1/4 OF E1/4 COR• SEC•4
RTH, RANGE 19 WEST, T28N, R19w.
COUNTY, WISCONSIN
N
O p
~ m
LANDS : U S
loo
- e MONUMENTS
O fsX 30" IRON PIPE,
- - , . P.O.B 3/4" X 3e ROUND ARC
e ~
AT ALL 01
31.32 ~ m lb
00, o~ 3w
UNPI.ATTED NOTE, ALL IMTAN=
s, c OF A FOOT.
ALL ANGULAR
a ° f, a w p LANDS NEAREST SECC
r m As
o« r c g s
0
o c
!
p w ~ r O
g ~ o g 8
C C t
ti p ~ss •6
LOCA
'fs• ''ba~ j ~
'b. d,• s~j
~s0•sscc.zo• zz9.e4s2z•s~30'00"E 863.87+
VAL
CURVE DATA TABLE CENTRAL TANGENT
0RO ARC CHORD ANGLE BEARING
NGTH LENGTH BEARING " 24-37'00' N 85-30'00-0"W
4.56 236.38 N 73' 11' 30.0 W
06 ZS
62.22 N 82,15137.0"W + 46"
69057'07.0"W 18008,1411 5 00' 04' 00.0"W
2.18
174.16 S 12.29' 12.5nW 240 50' 25"
73.43 117-11 n 20-42,24" N 20,46'24-0"E
16.20 N 10• ZS' 1 Z• O E On 5 85030'00-0"E
0
20.82 121-48 N 86#47150.0"E 1502412
400.82 "
99.61 S 87035142-5"E 04 l 1 25
09.00 109.02 02,32114"
66.01 66.01 N .83.26' 00.5"E 08040'41"
25.57 225.78 N
®IL R SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
Iwo -S
~wnwu~swwr~w„v~ Teel V
STATE SA A RMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
0% x 11 inches in size. ~ ❑ Check r is s appl
ication
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PRO RTY OWNER PROPERTY LOCATION
S~ t/L_ , S T N, R E (o W
PROP R W S M LIN ADDRESS 4 LOT # BLOCK #
L n
I TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME O
SM NUMBER
pt,
160
u P C'~S/
III. TYPE OF BUILDING: (Check one) Stat@OWn@d VITM NEAR T ROAD
5 11
❑ VILLAGE ~ ❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL Ax
NUMBER(Fy
III. BUILDING USE: (If building type is public, check all that apply) /60
1 ❑ Apt/Condo U 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. [9 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 j~"'X S'9 f 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
d 3 Y / Feet 1. / Feet
VII. TANK CAPACITY Site
in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New lExisting Gallons Tanks Concrete structed glass App'
Tanks Tanks
Septic Tank or Holdin Tank es ' ( $
Lift Pump Tank/Si hon Chamber F1 ED Ej F-1 F] I F-1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumbs 's Name (Print): Plu r ignature: (No to ps) WID- PRSW No. Business Phone Number:
n
Plumber's Address (Street, City, State, 'Zip Code):
'/~v e sJ a
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
El Owner Given Initial Surcharge Fee)
Approved
Adverse Determination
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
r
INSTRUCTIONS
I
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 purri'ped by a ;icgnsed
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.
111. 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 81h 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; frict;on 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 rnoni€a co!'Ioced through these :surcharges are used for rrioniloring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (8.11/88)
r
5E 5YV~05AJ
~srtal~e ~a9~
Se~~►c
S . vu,.~ 9, 7
.11~ W
f Ml < O A
I~ x W
a M O .
ZO z
it C C
I~i 3 f
01 Q! Z: [
' QC O 000
_ o ovo
` z
O O N O
\ N r,
W 486 • 45'; 11 0: o c (D O
Z Z M O v M
5 0110)414 ~"E 1 5 01.041 48"E 254.77' ~2 :1 o o in
=1 •r a~ z a 00 o N 00
~1 i y.y ~ti r m Z Ln z N
*00 1 I ~r e`
1 2, e e c 1 1.1 1: 1
I 1 ° (DC(n.rou1c-»
1 J O Q:- N N NN.-• Q
1 • 0cW n;3 Go ONQ -•NO
1 ° 1-J MNOInQ N.-•In tf
1 °
1 W2 V tDOQOlnQNO~
1 1 U< NO. NN X000
I 1
1
I 1 a~ 3333WWWWW
Coul
' t. e. e. . i e~. ooov7oou7 C
C
0 1 1 r
O
1 1 x10•!0' O(- I~NNON4;,
Q l 1 I Q f 04. 00-W MMO--V4NO
.°r Z In N N'7 M O N
ORSPqd
V) Z. I I W v _ •
F-W 1 I C{ J ~D: MNm 0w (D - Tin
J Ul 1 3 00 01.00.4 O < n CO (D 00 00 CO IQOO ( i a:•r0/,.. :pi•to• a um zzzcnzzcnzz
s.
I 1 co = 00 N (D CO N N OD
OW I 1 a' „ 1a
O C9 N.+•-VoocO r
3 M 1 1 ~t 4 in
tnz I I ea - f0 OQ UZ (D NQI-r.O; (D In
< I `•ti cr w Mto OO(DN
_a: H fQA: i 187-44-10. j Q J N
~ N
1- Z 2: 1 Q 200.60• IY
S O ,J: -I 300'01•00•V ~O U Op.. In.Go 1-1 C~ CI
-•.lNO(DOOM
LL. I.- 1
1 nM 0z cNM(D 0 Q) 07(D V1
OX 2W 1n (D 1r- mO(DN
J Z I s 00 U J N M. N
O ~ ^Q 1 Q w In
co):
Q
V) Cl- (n 2 f~ r•. M••. M r.
en LD
49: 1 ..r i 25"
• ;m (/7 I .4 !0.07• Rt~~ 0: J 1n 1n N M 17 .17
»
1-- z z . 1 W _
30 cr 3 o I j 00.04•00w Wi
ooO I I~ 1 F-:
z 1- I I S -=v R a: M (D cr-
LLJ
I-
W i o 3 00.06• pOw a
O O
Z: Ln
C) U,
Z
1 % : a•
zOZ I J1 , \ti W QtDm
f- 3
O 1 • 1 I I I
J LLILW I n° Uz N MV7
1- N j Q N
< I q
O I!x• 1!' 30• -
JC3 1
J I
1 I rr.
J f 204.13. 5 00104100"W 646.71'
I
! 00.04• Mw x79.1!• x!S•00' 2BS•6t'
1 I
/ I Y
I
/ / O g g c
I M 8 0 w s
I M
SO•
41)p \!1.1 !0.00.00•
j h`dD'L•.0• 350-00. x!!•00• 245.66'
ti.
i 5 00104100"W 930.66'
/
--------------------------r--
ZE
Z I Jc
Z:
Sst+t
. ~
t TX REPORT >
No. OTHER FACSIMILE MODE START TIME USAGE TIME PAGES RESULT
01 3865804 TX(G3) Sep.27 12:30PM 01'06 02 OK
89!271993 19151 FROM F49er0 pT. .Inc. 154258355 P.81
INDUS QF REPORT ON SOIL BORINGS AND $AFl:rY & BUiLDiN
INDUSTRY, DIVISION
LABOR A PERCOLATION TESTS (115) MADISON, 63 o9
HUMAN RELATIONS (ILHR 83.090) & Chapter 145)
LOCATION: ECTiBN: O'oWNSHIP~ I Y: t7i' Nu.. 1-K. Nu.: $U b V SI N NAME-.
j COUNT/Y~ /NEB's/ l YFR R F ~S r G• 130H :
S{ G~~,p ex c~I rsf'' ~l fff G f. r
$E 1.7Y DATES 08SERVATIONS MADE
ITTIMA". f".n M Ai ni-A .niierin . 1 ION T i
Vnaiidenes i;Nrw nRnrtl,~rn
/ r
RATING! S= Site suitable for system . U= Site unsuitable for system
Qr1z VENTI NAL: MOUN IN~ROUND•PRESSURE SYSTEM-IN-FILL. OLDiOMM NDEq SYSTEM:(optional)
s u n s nu I" I n s au [Is u 11: if ercoiation Tests are NOT re uirod DDS ATE:
9 If any portion, of the tested area is in the
u r s. ILHR 83.09(5)(b), indicate Floodplain, indicate Floodplain elevation'
PROFILE DESCRIPTIONS
DOnINC TOTAL D PTI i To Gn0 l` DWATCn-tNCI ICr CHARACTER or SOIL WITH TI II0KNCGG, 00L0K, l hA I VKt, ND DEPTH
NUM6ER DEPTH IN, ELEVATION OBSERVE EST. =HE TO BEDROCK IF OBSERVED (SEE A SRV, ON BACK.)
j
El- 7Ya / 3 ' S . n,s ' Isis 3.3
B- 2 s"D /0 . / /V 7 ,f0 S . F n waf
Al NA -r- P0 0 A LZ
B• 7 /P/.~ Af .Y ~ ' ~ i1 r ~ r r rtr~ r
B' S /Uei'rlr 47 , s'2?1s~'l
r f nv f t' ~ r" r Jr rrr f'••br% r rrr ' ~'rt I ~crrr r f-. ,l ti'r • k r • 4kd. ! ~iap/r
PERCOLATION TESTS
TEST DEPTH- WATER IN HALE f S TIME DROP N WATER LEV t S HATE MINUTES
niumpCn PNOIitO ArTCnOWCLLINO INTCnVAL-MIN, rcni u' u PER INCH
P-
P-- G ~5 y
P-
P. -h 7
P-
s PLOT PLAN! Show locations of percolation tests, coil 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 a 17ercent
of land stove.
~~+c.er tr
SYSTEM ELEVATIONS
pip
1
_4? ir
MI
r r :
.
-
•
I
I Ar-
t-7
• I I I i i ri ~ ,
9 k)' . 4,y~~ i I r i
..ice... _ q_ _.1... .1.. O r , I
r T'
y r, rlr/(~• - !t'I ds±i )aeft2f r, . I
I
11
a
N
SEPTIC TANK MAINTENANCE AGREEMENT CT
St. Croix County 1-4
OWNER/ BUYER V3 (9 )-1 w
o
ROUTE/BOX NUMBER ~O f1 /i1 Fire Number, 0
d
03
CITY/STATE ~°aC~1!1 wl t ZIP AZ Ct
PROPERTY LOCATION:- Section , T N, RZW,
Town of t. Croix County,
Subdivision Gt Ile 4 /J; C Lli/Aot 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,
if needed, by a licensed •s'e t'ic tank um er. What you put into
the system can a ect t e function o the septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents may be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
whit 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 County Zoning a
certification form, signed by the owner and by a mater 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.
H
I/WE, the undersigned have read the above requirements and agree o
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart- "
ment of Natural Resources, Certification form must be completed .d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
4
SIGNED
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
STC-100
This application form is to be completed in full and signed by
the oc•;ner (s ) of the property being developed. Any inadequacies
will only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor,(spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property C r ~~SG
Location of property_&~1/4 SEl/4, Section T ~Q-N-R~W
Township(
Mailing address D
Address of site 64
subdivision name ~-e Lot no. .
other homes on property? es No % Previous owner of property CAa t'~ /J0~ &4
Total size of parcel r~
Date parcel was created
J
Are all corners and lot lines identifiable? --2L-)(es ---No
Is this property being developed for (spec house)? Yes LC No
Volume 36,and Page Number A// as recorded. with the Register
of Deeds-.-
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
HUHDER & THE SEAL OF TILE 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. _ i~1 < 9 , and that I (we)
own the proposed site for the sewage disposal system orrIe(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.
5 gnature of ap cant Co-applicant
Date of S ature Date of Signature
. Y ,..+~~i .a ft 'i[ t:;, {4~i' j` •"Y:. J..3' w 1.~. a(.1 ? i4,
Iwo s I
VOL 1036PaGE 141
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING OAT4
STATE BAR OF WISCONSIN FORM 2-1982
I
505969 _
Richard- D•. Maloney and Terri G. Maloney,. husband 'lec'Qr RtcorQ
. ry wife........... SEP 2 3 1993
8:30 A. ,
` it ~,P~Qq
conveys and warrants to _Ck)X.l.St9phe.;;..A,-•H~•;-gld~on•and------------------
J pP~ s~:r ,r c~~c9
y. ........Kathleen. A...Haroldson,..husb-and. and wife..........................
o: as..si=vivorshi-.marital.praperty........................................
RETURN TO
•
the following described real estate in ....St. -Croix .............County,
t State of Wisconsin:
Tax Parcel No:.... 040-1190-50.._
r
Lot 4, Valley View Heights in
the Town of Troy.
r ;r
R,
is nit
This homestead property.
(is) (is not)
Exception to warranties:
Subject to easements, reservations and restrictions of record.
Dated this 22nd day of September----------------------------- 19..93...
(SEAL) ~1-`-"'...cL1 1 L • (SEAL)
. RICHARD D..- MALONEY
• .....................•----•---••-•-•••---••--•-••••----.....---(SEAL) C ..........(SEAL)
9
.A
-
a G. MALONE
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
as.
• St. Croix
authenticated this day of 19...... Personally came before me this 2nd- day of
--septe1aDer....................... 19.93--- the above named
Richaxd_ `?a] oneX._and_.Tarzi.__~. --Maloney,
gi,
:f
TITLE: MEMBER STATE BAR OF WISCONSIN
(TI not _
aorized by § 706.06, Wis. Sta s.) to me known to be the person _P who executed the
foregoing instrument and acknowledge the same.
~a THIS INSTRUMENT WAS DRAFTED BY 1 xwii~f 2R o
STEPHEN J. DUNLAP Notaiji Public
F
Janet F. Roatch State-pf.yylicq Sin ,1 _
Hudson, Wisconsin Cnmmissl Ex ireS
. , Notary Public St....Cr ys-
` t (Signatures may be authenticated or acknowledged. Both My Commissicn is permanen . not, state expiration
are not necessary.) date: Mar-ch_17------------------ 199.(2....)
'Names of persom signing in any capacity should be typed or printed below their signatures.
STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
Q I WARRANTY DEED Milwaukee. Wisconsin
Y FORM No. 2 - 1982
r. R. ,p . Pt.,
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
MAQ
HUMAN RELATIONS 3707
VA ll IS 1 53707
(ILHR 83.0911) & Chapter 145) e(,tJ
LOCATION: SECTION: TOWNS HIP/NV.LN+e+P*t-iTY: LOT NO.: BLK. NO.: SUB IVIS[ON NAME:
COUNTY: OWNER'S BUYER'S NA AILING ADDRESS:
Zrs-tot) / 4 -
USE - I~ G DATES OBSERVATIONS MADE
NO.BEDRMS.: COMM RCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS:
(Residence New ❑Replace 93
RATING: S= Site suitable for system U= Site unsuitable for system
rZS ONNVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDE SYSTEM:(optional)
❑U ❑S ®U ❑S 0U ❑S U EIS U 4vta~i' ~e
DESIGN RATE:
If Percolation Tests are NOT required If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate/ Floodplain, indicate Floodplain elevation:
i
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / /~!►tc 3 r / t j.; ' n,S w 3.3' n..S 76 B 2 PD /D ~D S P~ n►+~t
gO~10wG /fii~ /Y/Af1'i ✓G ~
B- 3 7 /03.9 /l//>< i71_51 M r s / w -
'Ale
B- y 73 1,11 ,3 M 5 Z.? sc / c s w r caC VS2
B- S~ L o N t' ~--G7 s- 'Ysd . 'A, 5;,k c it/nrs rt r L
B- G 74 BPC aK liH/f (/I j / H As- ~i(IJQR
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 PER PER INCH
P-
P- Z 3
P-
P- 3 orrt
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 an percent
of land slope.
SYSTEM ELEVATION 99.7 '
11DI
3 E
< i
1
•i ~~tr 1
r ,
. ! ~ yo
4.3
E
E k 3
- `S'rirvC.Al $+A kCs - u
40
i
AE - 3' r
c+vvl'
P°
v
I ,
17-
the undersigned, hereby certi y that the soil tests repo a on is rm were mnae 5y me in accorcl i i s onsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
i DAVE FWFRU NAME (print): Wonsed Perk Tester & TESTS WERE COMPLETED ON:
#3233 #3289 ' 3
ADDRESS: CERT FICA ON NUMBER: PHONE NUMBER (o ti mal):
04%,S, WISCONSIN 5402:
CST SIG ATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6396
To be a Corr accurate soil test:, your report must include:
1. Complete legal !ption,
2. The use sectic i `?.irly indicate whether this is a residence or, commercial project;
3. MAXIMUM racy I E--droorns or commercial use planned;
4. Is this a new cr71ent syst:ern;
S. C(;,,7 -i, fl t`llity rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
Cl ARE RULED CUT BASED O SOIL CONDITIONS;
6. PL abbreviat ions sho n ' e for writing profile scriptions and completing the plot plan;
7, ILE diagram a€;( r 1cating your test ' 't ms. Drawing to scale is preferred. A
s~: s m ,y be used if des (
8, MI k sure _ it enchnrark and v .,I elevation reference p:.. int are clearly shown, and are permanent;
9. Complete ail appropriate boxes as to dates, names, addresses, flood plain data, percolation test exenip-
tion, if appr€:}pr :e;
10. If the intr. _ _ 'ch as flood plain, elevation) does not a, . }dace N.A. in the appropriate box;
11. Sian the f . ;)'-ce your current address and your cer J( 1 number;
12. Make legible Ties and (distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
3REVIATItNS FOR CERTIFIED SOIL TESTERS
, rtes and c 0 - /rnbols
st: Stone (over 10' _ BR - Bedrock
cob Cobble (3 - 10") SS - Sandstone
gi gavel (under 3`°) LS Lirnestorr:
s Sand I'C„ , High rr') .:iwater
cs Coarse Sand c - PercoL... Rate
Medium Sand Well
I =re Sand - 3uilriing
is I any Sand > t. aa`
Loam T"
Lo I
LI (r-,k
Loans Y - v
r Clay Loam R
"°.y Clay Loam
so Sandy Clay t
sic Silty Clay fff' - f fine, faint
c - cc cor€~ rnon, coarse
pt - €11m Many, MediUm
rn d - distinct:
p prominent
HWL High €vater level,
Six gene-. ttures surface, water
for hqk r:al BM - Bench Marls
VRP Vortical Deference Point
TO THE OWNER;
This soil test report is the first step in securing a sanitary permit. The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of. plans for the private
sewage system and a permit application must be submitted to the appropriate I661-authori6, i-order to
obtain a permit. The sanitary permit must be obtained and posted prior'td the start of any 6667ttuction.