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I Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division CROIX (ATTACH TO PERMIT) Sanitary Permit -11 . GEI~'ERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village)p Town of: -State Plan ID No.: CARLSON GARY L & ELIZABETH ST . JOSEPH Parcel Tax No.: CST BM Elev.: Insp. BM Elev.: BM Description: 030108870110 TANK INFORMATION ELEVATION DATA A9200196 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air intake Septic NA Dt Bottom Dosing NA Header / Man. 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. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manu acturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type O CHAMBER Moe Number: OR UNIT System DISTRIBUTION SYSTEM Header! Manifold Distribution Pipe(s) =xHole x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed !Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) acre ~ ,u,y,,~r gyp''' Plan revision required? ❑ Yes ❑ No Use other side for additional information. FT I J F_ SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t SANITARY PERMIT APPLICATION COUNTY Ea713ILHR 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 El 8'!z X 11 inches In SIZ@. C eck.f revision to previ us ap lication -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER WNER PROP RTY LOCATION ( - miu 6W SO Y7 S O T.~ , N, R 1 4) (or) W 10 PROPERTY OWNER'S AILING ADDRF.AS LOT # F LOCK # _741 6y-& 1 S A i 21P CODE PHONE NUMBER SUBDIVISION AME OR CSM NUMBER J• ~Z II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned VILLAGE : ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms i PARCEL TN M E ) 111. BUILDING USE: (If building type is public, check all that apply) / 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ 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. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. Reconnection of 5. ❑ Repair of an System System Tank Only xisting 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 El Seepage Bed 21 El Mound 300 Specify Type 41 El Holding Tank 12 MSeepage Trench 22 El In-Ground 42 ❑ Pit Privy 13 LJ 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. $gYSTEY E 1 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) ('n./Inch) 9&..L ELEVATION O kd ..S , Feet ~~"Fe~ co fe (9 VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete strutted Con- Steel glass Plastic App Tanks Tanks Septic Tank or Holdin Tank I " Lift Pump Tank/Si hon Chamber r VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati n of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber' ature: (No mp MPRSW No.: Business Phone Number: ti,. S' / Z 1:5 Zt-(O- P um er's A dress (Street, City, State, Jrs V` IX. COON (DEPARTMENT USE ONLY ❑ Disapproved Sani ry Permit Fee (inciudes Groundwater Date ssue Issuing gent Sig lure (No tamps V worcharge Fee) *Approved ❑ Owner Given Initial ~ 5 Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber INSTRUCTIONS A. 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 (§BD 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 jicehsed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code adrninirstrator,or the State of Wisconsin, Safety & Buildings Division, 608-266-3815- To be,complete and accurate. this sanitary.Prmit 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. Indic & prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only f 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. SBD-6398 (R.11/88) • FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SECTION T •N-R_L/W ST. CROIX COUNTY, WISCONSIN ADDRESS 1 SUBDIVISION _2___LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Sr > ~b0 O / f 0 \ ~ W INDICATE NORTH ARROW BENCHMARK:Elevation and description: Ofd , 'Irse Alternate benchmark SEPTIC TANK: Manufacturer: 1Z Liquid Cap. Rings used: 0 Manhole cover elev: ® 0 ,--Final grade elev: Tank inlet elev.: qZ'R .,.Tank outlet elev.: _ ~10 No . of feet from nearest road:Front SideRear From nearest prop. line:Front(1, Side , Rear ~Ft. Noe of feet from: Well , Building: 251 mw~ (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE l PUMP CHAMBER - Manufacturer: qu id Capacity: Pump Model._pump/Sip n Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.:_p p off elev.:Gallons/cycle: Alarm: Man.: switch Type: Location Distance from arest prop. line: Front Side-, Rear_Ft._ Distance f : Well Building SOIL ABSORPTION SYSTElK ✓ I Bed:Trench: Seepage Pit: Width: ~ Len th ' g Number of Lines:=Area Built Exist. Grade ElevV ,2,- /74.e7proposed Final Grade Elev. Z 9? Fill depth to top of pipe: No. feet from nearest prop. line:Front/ Side Rear Ft._ No. feat from well:_1'=po, feet from building Z-1 " HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of i et: No. feet fr nearest prop. line:Front Side Rear_Ft._ No fee from: Wellbuilding_____`, nearest road Alarm Manufacturer: INSPECTOR: DATE : l 70 PLUMBER ON JOB : LICENSE NUM dl- 6/90:cj QEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION ADISON WI 53707 State Plan I.D. Number: i~TW, SE- , Sec. 30,T30-R19 CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of St. Joseph 1.R ri -F. 1A_r ❑ Hol ling Tank ❑ In-Ground Pressure ❑ Mound CO NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: B D rjp s.. Houlton, W1 2 ` a?' 1 BENCH MYAR (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. T. ELE ST REF. PT. EL C" o ~eC us - o s3 Y ~L8 n Zcn-, Name of Plumber: M PRSW No.: County: Sanitary Permit Number: Gary Steel 3254 St. Croix -,128727 SEPTIC TANK/HALO 0' & Ly- - 99.4 -7• 5 MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLE WARNING LABEL LOCKING COVF~(2~ p PROVIDED: PROVIDED: ~iJJ S / COU C-r Q r 9G • 9c~ YES ❑ NO ❑ YES NO BEDDING: VEAJT DIA.: ~fEN~ MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT, O RESH C r & C .D, ALARM: FEET FROM LINE: I ! AIR IN T ❑ YES NO ❑ YES NO NEAREST > ~12) DOS' Ve"AVrBleR: MANUFACTURER: BEDDING A ODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATION NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH WEA (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF El YES ❑ NO REST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENG DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) r CONVENTIONAL SYSTEM: S~e_ -~vr Sim QLed i aw'rS. WIDTH: LEN NO. OF DIST . PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH / TRENCHES: t IA PIT DEPTH: DIMENSIONS S 2 ~a GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE 'DISTR. PIPE MATERIAL: NO. S R. NUMBER OF PROPERTY WELL: ILDING: VENT TO FRESH BELOW PIPE ABOVE COVV: ELEV ET: EL q'" r}4 C C rfs 6'L PIPES: FEET FROM LINE: / / AIR tNbET: r~ 3 ~c NEAREST -4- of I ,-lN' MOdft SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrow un pos e~~' mo stems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the crl for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; NO 12MES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS' FEET FROM LINE: 4 AS LXll R ne ❑ YES ❑ NO ❑ YES ❑ NO NEAREST --11111" - ~ 0 - ~ I _ w --,d TC~C l (e o ~E_ Z. < L. c {fr, r t< ` wrr> //tzar) 1 all P 0 .7 9 Cq. :A-c- 9a, In 41 7 9, /o' _ ~is,7f~r Q. a ,3~ , ' . 9~~7 o~c e,GQ G✓ CicL~ Ica q3, 0/2. ~;2 L' 3 ,T.~Gt ,?'t'~;.e.~ (.l~G'<- ~P-G't`1 d-•-,~_~~....':~~c..rs C.Ryt ~[.~Cllf~'7~~slp/~~ EY Sketch System on R In county file for audit. Reverse Side. SIGNATU TITLE: SBD-6710 (R. 06/88) =0000000mmo~ LHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY St. Croix STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than b~ 8% x 11 inches in size. ch11 eck if revision/jto prey 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 Gary Carlson t/4 SE S 30 T 30 , N, R 19 AR (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 361 Co Rd. #E 3 CITY, STATE ZIP CODE PHONE NUMBER S41ke66W OR CSM NUMBER Houlton, Wi. 54082 612 720-8825 Vol. 8 . 2196 171 CITY NEAREST ROAD I1. TYPE OF BUILDING: (Check one) ❑StateOwned VILLAGE St. Jose h Co. Rd. #E 40W . L X NU e ) ❑ Public R1 or 2 Fam. Dwelling-# of bedrooms 3 III. BUILDING USE: (If building type is public, check all that apply) a / ) 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 12 ❑ Service Station/Car Wash 80 Mobile Home Park 4 ❑ Church/School 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE I OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. R New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill Vl. 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) 96.22, 94.32 ELEVATION 450 900 900 .50 37 Feet 104.2-94:9Q7 VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank X 1000 1 Weeks Concrete 4R] I E] Lift Pump Tank/Si hon Cham er Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber' ignature` (N tam/MPRSW No.: T ess Phone Number: _ 15& Gary L. Steel 3254 5 246-6200 Plumber's Address (Street, City, State, Zip Co e )ice 1554 200th. Ave., New Ri hmond, Wi. id 54017 IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater a e ssue Issuing A em Signatu o to Approved ❑ Owner Given Initial Surcharge Fee) Ad Det r i tin lq D 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 7 INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. 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 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) APPLICATION FOR SANITARY 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 6 T S Location of prope'rt'y 1/9^1/9, Section --?6, T_a.-~) N-R~ W Township Mailing address "f~(~(~~ Address of site 3 ~Z Subdivision name Lot number Previous owner of property 112 0~~ Total size of parcel r4' Date parcel was created- Z f Are all corners and lot lines identifiable? Yes No Tom/ Is this property being developed for resale (spec house)? Yes No Volume 9-7&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. ---------------------------------------------------------7--------------------- 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 warrant deed recorded in the Office of the County Register of Deeds as Document No. a 4 8 6 ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) 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 Regis er of Deeds, as Document No. )010 A ~ kh a,, ~ ' Signature o Owner Sign re of Co-Owner (If Applicable) Date of Signature Date of Signature . I WARRANTY DEED I DOCUMENT NO. ~i - THIS SPACE RESERVED FOR RECORDING DATA j I I STATE BAR OF WISCONSIN FORM 2-1982 460486 ( ~ PAGE O it REGISTER'S OFFICE ST. CROIX CO., WI Jr...... nd...Shi rizy.........--••...__. ReC'd for Record nd wife .................F JUL 161990 at M '3o conveys and warrants to ....GSS ElIzabeth••.A•.••-C >i•1•so ,.--husband.-arid...wi.e_.... RaglsterofD j~ i ' RETURN TO _ the following described real estate in ...,St.....~X:A I X .......................County-, ~I State of Wisconsin: Tax Parcel No: I i. I . .Pact of the NW1/4SE1/4 of Sec. 30-T30N-R19W, Town of St. Joseph, described as follows: Lot 3, Certified Survey Map, recorded April 20, 1990 in Vol. 8, page 2196 as Doc. No. 457750. I • ~,1'";,,MIS-+~ s~1_L.oo. I I I I~ This is riot homestead property. (is) (is not) ~i I I' Exception to warranties: ~f I I ' Dated this .4t..h day of J1]ITIe.............................................. , 19..9_0... 7 . (SEAL) i 1Z, (SEAL) i' . ~?os~h.. (SEAL)' ; Shird,.d. i AUTHENTICATION ' ACKNOWLEDGMENT 1I11~~~~ QQ STATE OF ~OYMARX I' Signature(s) as. Wash -iigtan..•.._..__...County. I authenticated this ........day of 19...... Personally came before me this of il-ule 19...9.0. the above named _..aloaeph..A__.No ].dam,....Ix.....a.nd------------------- EILLrley..B.._..I~ralde., husbar~d..and:..wife j . TITLE: MEMBER STATE BAR OF WISCONSIN ~y I (If not, .;,_....~T.l[~ItQTHY.~ fJl.t?`---••- I I~ authorized by § 706.06. Wis. Stats.) ' t 64 '~At1ieF'}~'eYdnh.It~~v,.~~Fa wh executed the f eg st~"h-VNf d1-b-kn pji he' ame. (I ' THIS INSTRUMENT My commission Expires mar, 1, 1goo 11A(S~ DRAFTED BY T/ WAS ._~........._._.',.'p.nat^w _ __..Tr.. II 311 S. Third St. Notary Public County, Wis. (Signatures Sa. may "l be authenticated 1v or a acknowledgeIN""cknowledged-. Both My Commission is permanent. (if not, state expiration I are not necessary.) date: 19_._.._._.) 1 I ~ I -Names of persons signing in any capacity should be typed or printed below their signatures. Ij STATE, DAn OF WISCONSIN Stock No. 13002 KGMillerconv"~ FORM No. 2- 1982 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER hr , C4 rk=' ~l ROUTE/BOX NUMBER FIRE NO. CITY/STATE ZIP PROPERTY LOCATION: /4 G 1/4 Section T N, R ) W, Town of AS h , St. Croix County, Subdivision , Lot No. 2 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by 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. ~j SIGNED DATE AD St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 r (715) 386-4680 Sign, Date, and Return.to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY`, DIVISION .LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNS SHIP/ LOT NO.: BLK. NO.: SUBDIVISION NAME: NW% ~ V4 3o r - S - C S M e P R/9'~ (o 3 ~ 2 r 9 3o IT N I o 8 !J or_ ~ COUNTY: -BUYER'S NAME: MAILING ADDRESS: S; C1eo~ x G.a~e Ga~LSO►J USE DATES OBSERVATIONS MADE TESTS: NO.BEDRMS.: COMMERCIAL DESCRIPTION: IPR FI PIPT ONS: PERCQLATIPN JV Residence 'A XNew ❑Replace I( S ~[~/qb S/ZCf+/Q~ SoIL~. c, 41 A,, D RATING: S= Site suitable for system U= Site unsuitable for system 2 - An~~Y -PRESSU C~ONVEN JSTI~U. I '1 (20 IT MWS.OU-INGrS aURE:SYSTEM-INQFILLHOaLDING20 TANK: RECOM NV VT/O0y14L.ptif~ftN~ 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: C"A-s:s Floodplain, indicate Floodplain elevation: fv~ IF PROFILE DESCRIPTIONS BORING TOTAL PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH-W. ELEVATION OBSERVED EST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) r B- ! y.33 (44.9z o C 7 9.33 LSLTS Sr✓ zs ~r,rls~c,~ o"~ ~►S B- Z .b? 13 Np K ' .6> 7,"9LM-LTS 21' ~e jSL 7S'•Rt. MS B- 7 Z~ gS, P 40NK > ZS r''$LSLTS 33"BaNSc. q3"~r,MS ~c,~ 26"geaSL?~'Kolrts~cob "2oMS~~~ B- 4.00 Ul. NE 9.00 %"&<_L-7S B- .~3 9 4 .111 7 8.33 %"&s'LTS /0"gesJSC -Z I "y P ` I tj! " &Ms."G 1R B- ~>v~ C PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 114M315S AFTERSWELLING INTERVAL-MIN. PERT D 1 PERIOD 2 P R D PER INCH P_ 1 '540 o.'X 9S'10 30 //8 I' 3 P- Z . 5,60 tjrt4C 0 3o I' I' /'/a 3 P_ 3 3•10 gs•ZO 30 '4 174 37 z hjQNr. P- P- C L~,V!/QT tT - 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. 'j1LS1VG~ ) -'SO _ r) SYSTEM ELEVATION 2 = 3 -ro CT la r+ ~ucNrh~O~ti- ~2"QSP~N -SP. K~ 3B' i A&VE 6kooN4 `'ELIFV 100 00 vI g _5C 4l r Zj, 65 1, 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. NAM (print TESTS WERE COMP LETED/ON: ~4Q~($Y JQ).Itn,~ ~uP~NSu ~(✓h'V INC. S ~4 ~O A DRESS: do CERTIFICATIO NUMBER: PtONE NU BER(optional): 0 SIScoN~ S i 6'sar~, ~A S4o 16 34R 'S8~- oS6 CST SIGN RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - V ' )b J '`'pro a CP ` 1 D Z z lp~z~ ~Z ~ 50 a _ z 1,00~vk STEEL'S SOIL SERVICE Gary L. Steel 988 N. Shore Drive C.S.T. 2298 Gard Carlson New Richm d, WI 54017 MPRSW-3254 NW4SE4 S30T30NR19W 15) 24 -6200 St. Joseph, twonship WG _ . Z I 30( 4r"mil y . Tl. l/ 2 03 • 10 X70 ~ w 3 e.A-4- - o~ ,CIL S7 Gary L. Steel 1554 200th. Ave. New Richond, Wi. 54017 MPRSW 3254 7-30-90 x U A zp I o OHa=+Fj J I co R P., m av f ~ w f ~J co ~ ~ H • e F S . 6 O F (O~\ Ha .-a ~~H~ A U H Fd AACL.]cI~FW m q(&, t3.rv(, 6 cc,-nct;%, STEEL'S SOIL SERVICE 'e(_... Pedi< E-LI CO,27' Gary L. Steel 988 N. Shore Drive C.S.T. 2298 Gar Carlson New Richmo d, WI 54017 MPRSW-3254 NW4SE4 S30T30NR19W (915) 24 -6200 St. Joseph, twon'ship I V g t ea;.c' -td n1 fib 4r I- / C; / u 4/0 . 0 6J, ~ ~ 04- 1 l ~ r1 dc.~C ' 1 f I Gary L. Steel 1554 200th. 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