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HomeMy WebLinkAbout020-1281-50-000 C) r s o o ac o ~ a o a I Y O C cz, N ct _ co co 0) N O 4z N C O (6 - a O c a.' c N 1 C ~ 06 N N i~: Z N C X O O. O C Z (0 w a) c) to I' 3 LL O N U N N . Q ~ C M I 3 ~ v o Z yj U) C O Z y y w a co c~ H Z O Z ? c V ~ ~ O N d Z c to I- ~ I I c a~ v a) o a) co y _ N O U_~lVl Q) O W ol C) • m•V O L .L~ ._I O a C QI Uj O o Q N O Z H Z o a z o N N o w I N is ~ a III o. ~ I ~ ~ N m~ n a I 0 o D O d E L • m a a a $ O N N °N' °N' N U Z rn rn LID 73 C N ~ - O' O O O O > > N O CO 33 rn ~ o rn ~j Z o Q m C W N N a C O O O I ' U O C C E lA co C4 c U-) ® o in 3 (D o o N 0) o -.M o E a n o a) o :z Q S" ~ m N E E QJ W N co C UJ CM 1 0 0 N 7~ N G r O 0 N (lii H F n ~ oN E E UI • ii. O co 2 O r \ w - 41 r 10 a O Q ti a • CL .V 0) ~ £ L C C w 0 'o U d 'rL O N U AS BUILT SANITARY SYSTEM REPORT OWNER -S,,-, lh Acr- TOWNSHIP o rt SECTION T Z-1 N-R ADDRESS Pox " z6-Z ST. CROIX COUNTY, WISCONSIN I-E $s o ~ w s sy o I t~ ~ s C SUBDIVISION C off' LOT17LOT SIZE 2, PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 7s" Tit Mal O)e w a ~ L2 a I\I - ICI i T, 9 7 (N wcj .ys'Y SO s aJ'xzy~ ELI( INDICATEINORTH ARROW BENCHMARK: Elevation and description • Ie:O -I, = 100,60'=- y' 90 Alternate benchmark Inn aFnze (L1 O~ BG ~6~I7S 1/OQ r SEPTIC TANK: Manuf acturer : _W Liquid Cap. O j b~ 3 3 Rings used:b Manhole cover elev: 4, `f 7 Final grade elev: o, o0 Tank inlet elev.:-Tank outlet elev.: a`3 No. of feet from nearest road : Front , Side, Rear Ft. Z SO From nearest prop. line:Front , Side RearK Ft. No. of feet from: Well fo- Building: Z7 (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: d1 Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front, Side_, Rear-Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: ` Width: S r Length L / Number of Lines: Area Built 40 V s.~ V'sS Z Z•v~ 4.~ s Exist. Grade Elev.3tc.u3 Proposed Final Grade Elev.2- Fill depth to top of pipe:yz- No. feet from nearest prop. line:Front , Side , Rear,2~__Ft.7 5 No. feet from well: No. feet from building Z HOLDING TANK Manufacturer:'ItIA Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side Rear Ft. No. feet from: Well building , nearest road Alarm Manufacturer: G INSPECTOR: ~Q DATE : 7 PLUMBER ON JOB: ~ LICENSE NUMBER: r 3 6/90:cj l TION: HUDSON 34.29.19.1352,34,NE,SW, CHERRY WOOD LANE visrso'nsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety Ad Buildings Division ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 149273 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: MILLER, SAM HUDSON CST BM Elev.: Insp. BM Elev.: B escription: Parcel Tax No.: 020128150000 TANK INFORMATION ELEVATION DATA A9200119 TYPE MANUFACTURER PACT STATION BS HI FS ELEV. Septic Benchmark 3. Ss' Aeration Bldg. Sewer Holding St/H Inlet 8 Z. TANK SETBACK INFORMATION St/ Outlet Z.23 112.67 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 5' NA Dt Bottom :A 7 Vol, V Do ' NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade acturer Demand S. 80~ 0, 7 33' Model Number GPM TDH Lift `riction Syst TDH Ft Forcemain Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS w0 3 DIMENSIONS SYSTEM TO P/ L BLDG WELL 'LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O n CHAMBER Model Number: System: •Crt tt01& ^'7s (0 2' AA OR UNIT DISTRIBUTION SYSTEM Header/Manifold 9 Distribution Pipe(s) 0, x Hole size x Hole Spacing Vent To Air Intake Length p Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over '/q Depth Over rr a xx Depth Of xx Seeded/ Sodded xx Mulched Bed/Tr nchCenter 3T qi, Bed / Trench Edges BF~ ~111Z Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) e 5.Of Of, AA-T&T- ~dE / Q 2K p~ 6o,6~ . 9, f~8 9,7/ 10,78 7.09 3 3. 8' 8Z $3 ~17 7w/ 7,/1 4~3 7. / ~P Phan r vision required? ❑ Yes ❑ No Use other side for additional information. P~ I SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. a ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i I i SANITARY PERMIT APPLICATION Z 13ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNT( STATE SANITARY PERMIT # -7 -Attach complete plans (to the county copy only) for the system, on paper not less than / (7) 010, 1/") a1 8% x 11 inches in size. N Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION Sctr M, 1111!,- AIC- t/a e41%, S j T 2F , N, R / E (ordp PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Z ?Z ~ -7 1 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME O CSM NUMBER ~~se wZ S-Yoi 3g¢ 37 0,Cltr-er #1 II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ Stat@ OWned ❑ VILLAGE N~ ~ ems., wood ❑ Public Ylvj PARCEL 1 or 2 Fam. Dwelling~# of bedrooms [4 4OWN OF: AX Nu B III. BUILDING USE: (If building type is public, check all that apply) D ZD - $ 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Off ice/Factory 1130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. © New 2.E] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 N Seepage Trench 220 In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 430 Vault Privy 140 System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 3 1 D 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) #I 10 L)•n ELEVATION d z /p 1,49 -0) 107.6 SO `7 g4 1700 D . SD C V 10 .e, Feet z AFeet VII. TANK CAPACITY Site in alIons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holding Tank z SU 3 e r Ix LJ 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: ~v7 32 3 3 Do st. 6aR.., Plum is Address (Street, City, State, Zip Code): Z Z cw P.ck, IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue issuing em: Sign lure (No S Surcharge Fee) Approved ❑ Owner Given Initial ~l Adverse Determination s~ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 101 SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber i 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 r ew 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 (SBE 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'f x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. - - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of :standards. SBD-6398 (R.11/88) ~o D a r Nw ~ _ ~ A l~ ' ~ lc S n F •1 s r1 4~ s7/ e r ~ ~ ~ 4r un 1 V I' 1' S 2go CG ; ~ l C O L t ~ g go v i s i c X S N t ~ ~ ~ uo rt N p r I r N 41 J d i P fS l 6 ` j ; ~ t V~ _ _ ~ 4l ul ; r s 1 c } ~N rt I o R U N O ~ c ~ a P t P ~ F r 9~ v i i 1~ + C /i¢ /may 4/DO~/ i 1 P ~ I ~J P Z A P A ~ a w ` 4% -41 V enn.`b P o- S I P j ~ t a c ! i ! r i I 1 I a P A) I I ~ P P I I ~ i o I 5 ~ I ~ c I I I 'b j i by ~ ' r i 1 . ro w G F ! a I I w G GJ 10 e { ~ E ! , o a.o `r i ` j k ~ v t II ~ -o I f Gl k ~-F r - - -I a ~ g $ A 'b O 0 P S IQ COQ ~A ~SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code 7NTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ , V C? a 6 8% X 11 inches in size. Check if revision to pre us application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION /yip U'd 01/41 %4, S T.~9 , N, R / rf E (oryfD PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 8m 'F .;2 $ Z-- /7 - CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER !/l r~ S`~a/G S8' i k-L-ee 14;11 II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned ❑ VILLAGE ; 4l e woo 1 ❑ Public IX 1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL ~ TAX NUM ERO 111. BUILDING USE: (If building type is public, check all that apply) O O - 'sue 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. DuNew 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 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)/ / p oa ' r,~~Ve JION 01 eet Arr- Feet LSD SSf s's~ ~t Co o o F r p. 7 S < $ z. /a z. pOF VII. TANK CAPACITY Site INFORMATION in allons Total #of Manufacturer's Prefab. Fiber- Exper. New istin Gallons Tanks Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank O DO (,t f a.~ ft r Lift Pump Tank/Si hon Chamber F1 I [I I F-1 I El I El El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: d u /0s S fro 6 t Ati fps ~**~r /I'I I' - y y 3 z 9 7 3 2 3 7 Plumber's Address (Street, City, State, Zip Code): 4f -f !j/,, e 4 o d d W,-5, 7 IX. CO NTY/DEPARTMENT USE ONLY ❑ Disapproved ISa itary Permit Fee (Includes Groundwater a Is Issued issuing gent Sig Approved El Owner Given Initial urcharge Fee) Adverse Determination X. o? X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety A Buildings Division, Owner, Plumber I INSTRUCTIONS .ti 1. A sanitary permit is valid for two (2) years. 2. Your sanitary'permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection,.or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if :ranks received experimental product approval from DILHR. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate pref x (e.g. ASP, 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./grater 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. SIB D-6398 (R.11/88) l S T C - loo 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 Location of property /VE 1/4 S /x/1/4 , section .3"7', T w2f N-R /,9 Township ~40 So H Mailing address _~c y ' Z g Z Address of site r'/7 Subdivision name Lot no.--/ 7. Other homes on property? yes_No Previous owner of property lSf of N B~„~ ~ I(fcc ~so Total size of parcel y~ /~G Date parcel was created Are all corners and lot lines identifiable? ___X__Yes No Is this property being developed for (spec house)? Yes No Volume 131 . and Page Number 3 2- 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 & 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. 4V790 .0 , and that I (we) r own the proposed site for he sewage disposal system or I e(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. X1.7 BOC. r Signature of Plicant Co-applicant Date of Signature Date of signature I p(N .1 II,II ,tJ I t II ; WARRAN fY DEED IIIH; SPACE I+rsr6VED MIT RECORDING DAIA STATE BAR 010 WISCONSIN hU1tM 2-1982 L / (p First National Bank of IIudson_ a United States Bank in Cor oration . . p l 619-2- . Z conveys and warrants to Sam. E. Mille., S-• sin le pers4l? ;o o 4 Al RETURN TO st G. the following described real estate in I'OlX _ _ . County, . State of Wisconsin: Tax Parcel No- Lots 4, 12, 13, 14, 15, 16, and 17, Plat of Cherry Hill in the Town of Hudson, St. Croix County, Wisconsin. Part of the SW'4 of NWk of Section 34, Township 29 North, Range 19 West, St. Croix County, Wisconsin described as follows: Lots 2 and 3 of Certified Survey Map filed June 27, 1989 in Vol. "8", Page 2117, Doc. No. 449209, i Outlots 1 and 2, Plat of Cherry Hill in the Town of Hudson, St. Croix County, Wisconsin. L l_ a Y--.. j 'Phis homestead property. II (is) (is not) Exception to warranties: easements, restrictions and rights-of-way ~ of record, if any. 1Jated this 11:t................... day of Jax>Uary........ 199 F s Natio B k of Hudson, by) _ (SEAL) (SEAL) (SEAL) _(SEAL) AUTHENTICATION ACKNOWLEDGMENT I Signature(s) STATE OF WISCONSIN I II St. Croix ss. I i authenticated this ........day of .......•----••----.........County. 119 ersonally came before me t rs ..........day of fanuary , 199... the above named TITLE: MEMBER STATE BAIL OF WISCONSIN (If not. 1 authorized b ' y § 706.06, Wis. Stats.) 8 to me known to be the person who executed the j folrego pg instrunpin nd ackno a ge the same. THIS INSTRUMENT WAS DRAFTED BY I Kristina 0 land Lundeen --.g Alice Jo y Co&esloy Connors I! Attorney at Law - St . t. - Notary Public A~ral'y P4. 1 (Signatures may be authenticated or acknowledged. Both My Commission is perman { ~~~$Nt.I I ' ~1t7 QfV o prration are not necessary.) date: July 12 93 I! I II II *Names of persons signing in any capacity should be typed or printed below their signatures, I. { WARRANTY I)EPD STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. FORM No. 2 - 1982 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER .5a.m Mi IIC4" ADDRESS: ~p x Z~ 2_ P o.., -so &A FIRE NO: LOCATION: 1/4, SW 1/4, SEC._344 T_Z y N-R TOWN OF: n ST. • CROIX COUNTY SUBDIVISION: _,/AZk1t LOT NO._ 1 7 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 to help with the cost of the 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 the 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 from 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 DNR. Certification form must be completed and returned to the St. Croix county Zoning officer within 30 days of the three year expiration date. SIGNED: I DATE: St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 ` DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, _ DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISO N WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP PAWK URA1 'T . LOT NO.: BLK. NO,: SUBDIVISION ~rME: 1/asw 1/a 34 /Tz9 N/R/9 E (or) W TOWNSHIP n Cjlt ICY N~« CC UNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: 7r~r2b►x SOM ►LLM USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: JKResidence //rj~ X New ❑Replace ~eS /3 /99Z Fig ,4'/99` V` `~a`u.~t It 4 IK6 14S xGz' BUR '~►1 RATING: S= Site suitable for system U= Site unsuitable for system Coli- C14M'itr, CO®~NTIOaNAL: MOU IDJ~VS. ❑A IN-G~ND-P URE: SYSTEM-IN❑-FILL TANK: RECOMME~~SYSTEM•op~onal) 1.~ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: CLASS I Floodplain, indicate Floodplain elevation: A/ PROFILE DESCRIPTIONS BORING TOTA DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) .p$ I1$Lc-r5 17'Bcs~ 32'$e,~ MS 6i~$ANrns,! c,A- a B- ~ jD.tJ& 14ONE p 10'ALcrS 17"BLSL /34LTIBRw AIS /3 ft8ft46 49 B- 1r77-S ~~7IS oMc > 4V9't j :S ZJ"$QNC.5 B- 3 9.33 /C)3 > 9.33 is BLL B 5 Sc. F'G+Ry55S 1. ;6 $R 'I S M S44#. 20 L.sLTS i3 GYS /4. o N FO- B- 4 -K 9917 No4E > 8.719 ~6',Rb$au 015.4 ~ Z ~a",RaN MS B- 15- 9.n 99.5$ l4o,,g > 2 rz`&-scm zeGQySc. 4601P &'S4./S,L 4s'S"rn B- G PERCOLATION TESTS TEST DEPT__FI~~ WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER JA1~19~ AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH P_ 1 216 nIE a.90 b >Z > > < < P_ b 116tSIG 7.10 > 2 > >A P- P_ E VAT161V AT Icy, . 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 q9'. m . `4_ 1 t A 14 6,66 I pax . 3 ..d t 3 o .oa . Lc - 0 -T J j , F 3 &A : : E t : I LANt I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin 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 WERE COMPLETED ON: 44ye-Y 'V~E& 14 /W ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): (n~ S~ro 1 b 34$4 35x6- 40io CST SIG TUBE: ;jp~ 31 ly T' DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - - TR CTIONS FOR OMPL.EPIV` FORM 115 - SBO - 6395 To be a A accurate soil test:, your rel)ort ude. 1. Comp legal description; 2. The cae s ion must clearly indicate wh< . this is a residence or commei vial project; 3. MAX!', rkrnfa; r o" bedrr orris or comrx~earcial useE ~larrra<:d; 4. Is this ,nlent system; b, Comply; I;ty rating bocce:;. A SITE IS SUITABLE FOR A MOLDING TANK ONLY IF ALL OTH R SY-1 ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown E=re for writing profile descriptions and completing the plat plan; i. MAKE A LEGIBLE dizaclram accur< .-i 1 ;'atirrg your t;eSt locations. Drawing to seat(, is preferred. A separate sheet may be used if desk , B. Make sure your benchmark and, elevation refeie';3 it are clearly shown, and are permanent; 9. Complete all appropriate boxes as to elates, names, art' flood pl< ',t cp rcolation ti.,st exemp- tion, If appropriate; 10. If the information (such as flood plain, e s iticn) does t place N.k. io the appropriate box; 11. Sign the form and place your current a('~ s ar)ri your c =aon number; 12. Make legibly: conies and distribute as re-iuiied. ALL ~ TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS CAF COMPLETION- ABBREVIATIf '_i r~-_)R CERTIFIED SOIL TESTERS Soil Separates and Textures father Symbols st - Stone (over 16") Bedrock cob Cobble 13 - 10") Sandstones cgr Gravel (under 31 LS Limestone s Sar~ I H ,ae ...,-;tr.r cs Coa;se Sand - F-Rate risen s kle>rdun-r Sand IF f ne: Sa.i a Is i Cai3i Brl ro`r; f., st S G-V G' r f y 1 Loam R col sicl Loam mOt r 1 sc Sandy Clay vv; - with sic Silty Clay fff - few, rint c - Clay cc - Gorn? C!' )a",~ pt beat n) In Many, rr I'+ rn - "10 rcr: cl distinct: s p prorninent: IV" High wa'?r ' Six ger Surfac 1A log L1 eenc' V. E' R :e 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 local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. r is i it J S TJ J I 0 N v ~ ? V o VI 1 LCJ W vt1 v f- 3 a ~k a ~ ~ t•►1 ~ ~ ~ ~✓I Ct-' i t 1 h O QQ ~J h ~ v I S I i O V) 1 1 may, ~L L 5 J XrD"'/ h \ aOPd- ~ I Vi - s o as z r d ~ o a o ~ a o L4 v Y i 4 ~ j I a ? j ' y i 3 i J i~ IN I .1119 I f t o d- i i S vo E1- y ~ d 'j n p ~ 1 o I tl I 3 o° u Q h -~E- 4~ ate ~ I Zr- s