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DEPAFtTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, 1 DIVISION
P.O. BOX 76
LABOR AND PERCOLATION TESTS (115) MADISO
N WI 53707
HUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: TOWNSHIP LOTNO.:BLK. Nfi.: SUBDIVI IO NAME:
/Sw1/4 3.5-/T_?oN/R/9 &or --5r/- Z 4
OOUNTY: OWN
160-M a 1) ER'S BUYER'S NAME: MAILING ADDRESS:
A> I
S~ ..J! GG.. SS
AL /JyJ-doij Or Ab
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMM R I L DESCRIPTION: PROFI ES PTIONS: ER ION ESTS:
Residence 'jew ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: REC~OMM~ENDJED SYSTEM: (optional)
S ❑U OS ❑U OS ❑U ❑ S &U ❑ S RJU /
C 1!/u/✓!
If Percolation Tests are NOT required DESIGN RATE: 1 G A, o If any portion of the tested area is in the
under s. ILHR 83.09(5)Ibl, indicate: r 9ji Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH A. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK F OBSERVED (SEE ABBRV. ON BACK.)
B-
'
75' 75'
x,25'"lyre, ~'~3hs
7B- 17` ?2,,Y "
B-3 7.0° e?,/ >70` s;, , .ss"~~,~,. rj.~ ~sy, y,•7~s
, 7!5" 6r,, 4 /7 ;JA x 2, 9 2 /3°~ s
B- y O, yo2~ , l ~r 4/
Y -W.7 V1__1
-3 3 j%,
FB-
TESTS
TEST DEPTH -WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 14C.14tS AFTERSW LLING INTERVAL-MIN. PERIOD t PERIOD2 PERIOD PERIN H
P- Z 7 3 G y~y 7'"~
P_ O J 3 Zay
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 0 l
F
46y 76,
gs
3 ,
M
r
+6i
H
oz,
_11:117
E ~
3 ,
i
.f• r C ~
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedure ethocified in th nsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and bell yC~ CV
10
NAM rint : TE T W E CO LETED
ADDRESS: C TIF ,CcATION NUMBER: IRHONE NUMBER (optional):
r
CST S l T
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
J
INSTRUCTION FOR COMPLETING FORM 115 - BD - 639E
To be a cc m~ cl accurate soil test, your, rep€ i't must include-
1- complete le(: `ion;
2. The use sectic ether- this is a residence n.m, Cial project;
3,MAXI;' UNI n rrnmercial use planned;
4. Is this , t- r
S. cornpl SITE IS SUITABLE FOR A HOLDING TANK ONLY I ALL
OTHER SYS [ t BASED ON SOIL CONDITIONS;
. PLEASE use ``ie a, f'2r Writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE d •i ;rcu€ I ;cating your test locations. Drawing to scale is preferred. A
separate shoes may br.
8. M ' sure your benchr,2 -k end verti vat :ion reference point are clearly shown, and are permanent;
R C- fete all appropriate boxes as to names, addresses, flood plain data, percolation test exemp-
tion, J appropriate;
10. If me information tsuch as flood plain, (levatior) 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 required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN:''- . F° COMPLETION..
..--...E' IATIONB FOR CERTIf ,COIL TESTERS
Soil i Tt, ~ ?r Symbols
st: 3edrock
cob c 't 10") Sandstone
gr Gravel (under 3") LS Limestone
Is - Sand IIGW High Groundvvater
cs coarse Sand Perc - Percolation Rate
rne:d s - M,-diursa Sand W Well
fs - F"n '7 Bidor - Buil('in ,
l I Rn - BrC7v° i
BI - Black
si Gy Gr,
scl Loirn R
s€cl m mot )ttles
a c VV
sic- I f f f fine, fai ,t
*c .C C,-Onion, co
pt ' mni Many, medium
nt d - distinct
p prominent
fIV,!' High water level,
six oil texture".. surface water
dispr~;a! E Bench Mark
V1 Vert,.:' cc Point
`i
f 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 constrciction.
I~
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP_.,
SECTION fsJT_E N-RW
ADDRESS c' ST. CROIX COUNTY WISCONSIN
SUBDIVISION 'o LOT_Z_LOT SIZE-
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
G6 .
IND CATE NORTH ARROW
75*
BENCHMARK: Elevation a S p~tion:Z1s461162Lgr - F/fD~l D ~Alternate benchmark
i
R5`7
7
SEPTIC TANK:Manufacturer: ~I,"E,_k~ Liquid Cap.
Rings used: ;;ZManho1e cover elev:_-~ Final grade elev:
Tank inlet elev.: Tank outlet elev.: '?9
No. of feet from nearest road:Front , Side, Rear Ft.
-7 Do
From nearest prop. line:Front Side , Rear_,X_Ft., t7s"
No. of feet from: Well- Building:_ .~f11
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
I
M'
{
PUMP CHAMBER
Manufacturer: 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: 14 Trench: Seepage Pit:
Width: Z._ Length /_f> Number of Lines: -,L2--Area Built LX 2
Exist. Grade Elev.E"?Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line:Front Side , Rear( Ft.L20p
No. feet from well: a3, No. feet from building ll~
i
HOLDING TANK
Manufacturer: 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:
INSPECTOR:
DATE : 2-,-:>2o0- 9,2 PLUMBER ON JOB :
I
LICENSE NUMBER:- > 9
6/90:cj
ry, PH 35.30 .19 . 398 SW SW LOT1 CO. RD. E Count
`Wi;-con ail 9451 It incQ,s E
Labor andflumanR2lations PRIVATE'SEVIIAG~E SYSTEM Y
Safety and Buildings Division INSPECTION REPORT ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 171466
Permit Holder's Name: ❑ City ❑ Village EkTown of: State Plan ID No.:
EESE NATHAN ST. JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
r' ,d
030-2012-20-000
TANK INFORMATION ELEVATION DATA A9200231
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark W, 17 /00
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Air
Septic 7 Sr G ;1' 3, 91 y ° NA Dt Bottom
Dosing _ NA Header / Man. q6jf 87,09
Aeration NA Dist. Pipe l -ds 2
Holding Bot. System /0U9 9 v CV
PUMP / SIPH N INFORMATION Final Grade 6,0 92,1-7
Manufacturer Demand „2, F'~.,z,_.k_ 5• '57
Model Number GPM
TDH Lift Logs ion System TDH Ft
Forcemain Leng Dia. I f Dist. To W-II
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length , No. Of enches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS / I DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type Of f.ZLj Mode Number:
System: ~cd3 f` g OR UNIT
DISTRIBUTION SYSTEM
Header/ Manifold Distribution Pipe(s) x Hole Size 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 Edc -P Topsoil ° 1 + Yes ❑ No ❑ Yes ❑ No
1A
i
~
COMMENTS: (Inclu a code discrepancies, persons present, etc.))
j
°S
~vIOT t°
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. D i> r t(C s~+ wok SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: ~
a e.
{
r
79I&MR SANITARY PERMIT APPLICATION Cou `
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 17 V6
8% x 11 inches in size. 1:1 Check if revision t previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP TY OWNER PROPERTY LOCATION
S , N, R 19, E (01 W
PR PERTY OWNER'S MAILING ADDRE LOT # BLOCK #
CITY, TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
_Z4, /-j T Is, 9qtl-
II. TYPE OF BUILDING: (Check one) CITY J NEAR ROD
❑ State Owned VILLAGE : _
IXI
❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms P
ARCEL TAX NUMBER(S)
III. 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 7 ❑ 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 130 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 4.0 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 N Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 El 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 (s q. ft.) (Gals/day/sq. ft.) (Min./ inch) ELEVATION
7 Feet 17 Feet
VII. TANK in allons CAPACITY Total 10 of Manufacturer's Name Prefab. ConSite- Steel Fiber- Plastic Exper.
.
INFORMATION New istin Gallons Tanks Concrete structed glass App.
Septic Tank or Holdin Tank Tanks Tanks - 1"r t 77-F F1 I
Lift Pump Tank/Si hon Chamber El El 0 1 L1 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for install ion of the onsite se age syst shown on the attached plans.
7PIumber' Name (Print : Plumb 's gnat e: ( ) MP/MPRSW No.: Business Phone Number:
P umber' Address (Street, City, Stale, Zip Code : r
IX. COUNTY/DEPARTMENT USE ONLY
X ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ing Agent Signature (N Stamps)
Approved ❑ 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 k
w y
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 mainfained. The septic tank(s) must be pumpe'd_bya 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.
Vill. 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. .
GROUNDWAYEA 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)
SANITARY PERMIT APPLICATION
T-OILHA In accord with ILHR 83.05, Wis. Adm. Code COUNTY
• STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ Check If revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PRO RTY OWNER PROPERTY LOCATION
'/4 t/a, SSS-_ , N, R Elord
hhAld A~Lr SL PROPERTY OWNER'S MAILING ADD ESS LOT # / BLOCK #
CITY TATE IP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
I
11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ PARCEL VILLAGE NEAREST ROAD Public ~ 1 or 2 Fam. Dwelling of bedrooms -1- TAX N UM
F7 =N OF ~Z~A ~Kl
III. BUILDING USE: (if building type is public, check all that apply)
1 ❑ Apt/Condd
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 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. PA 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 ❑ 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
19.1-2 / Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank d Q d
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installat' of the onsite sewage system shown on the attached plans.
Plumb 's Name (Print: Plumber' Si at : ( m MP/MPRSW No.: Business Phone Number:
Plum is Address (Street, City, State, Zi C)de): le;~ //r,57 ,q - _ Z~, P.,- j . r
IX. COUNTY/ EP ENT USE ONLY
Di roved Sanitary Permit Fee (Includes Groundwater 7Datelue issuing Agent Signature (No Stamps)
Surcharge Fee)
❑ Approved wrier Given Initial
Advers Determination
X. CO ITIONS OF APPROV /REA NS FOR DIS P OVAL:
SBD4;398 (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 expiraticn date, and at the time of rener,r I ary new
criteria in the Wisconsin Administrative Code will be applicable.
3. A'I revisions to this permit must be approved by the permit issuing authority.
4. Changes in cwne-ship or plumber requires a Sanitary Permit Transfer/Renewal Form (SBC 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 t y 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 admi listrai:or 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 C!welling.
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, r(,connection, 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 t~:nks 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)
APPLICATION FOR SANITARY PERMIT
~ S T C - 100
This application form Is to be complatod in full and signed by the owner(s) of
the property being developed. Any Inadequacies will only result In delays of
the pztmlt issuance. -Should this development be intended for resale by
ownet/contractot,(spoc houcel, then a second form should be retained and
completed when tha property Is sold and submitted to this office with the
aPProPrlate deed recording.
_ _ -
---(-o-p-~-------
Owno[ of property NQ r'`Q~
Location of property k) 1/4 t~) Me, Section 3 T~"R~y
Tovnshlp S , _
Mailing address
s Z
Address of alto i
Subdivision nows IVblti~ -
Lot number n
2
Previous owner of property aC, KO►\ I 'Cj
Total also of parcel `1~ e C
Date parcel was created
Ate 411 cutnets and lot lines identifiable? _Ye■ .moo
Is this property being developed for resale ('spec house)? Yes No
Volume 9SS 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 PAOR XU1XBER, and
the 92XL 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 reLerenees to a Certified Survey Nap, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(Ve) certify that all statements on this form are true to the best of my (our)
knowledge that I (we) am (ate) the owner(s) of the property described In
this Intotmation form, by virtue of a warranty eed recorded In the Office of
the County Register of Deeds as Document Ho.~ yS~ I and that I (We)
pftse y own the proposed site for the sewage disposal system (or I (we) have
obt me an ore! ent, to tun with the above escrl d property, for the
eo etc etln f s d system, and the same has b duly recorded In the Office
o thT n star of Deeds, as Document No. 1.
s 9 a u e o I 'vats r S ura t Co- er (It Applicable)
Date at signature Date o Signature
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SEPTIC TANK MAINTENANCE AGREEMENT w
St. Croix County
OWNER/BUYER •C%L H.
7w °
ROUTE f,9OX NUMBER ' 755- 2 Fire Number o
d
CITY/STATE ZIP
/9~ o
PROPERTY LOCATION: '.SzJ Section s' T G// N, R_/2_W,
Town of D S St. Croix County,
Subdivision ,vLot 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 1'ic~enbed' 's'e'ptip,.t.ank pumper. What you put into
the system can aFEect the, .unctlo-n of the 's-ep;tic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents*'mqLay eligible to recieve 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 'sys't'ems 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 rivate sewage disposal system in accordance with
the standards set forth, herein, as..set bthe Wisconsin Depart- a'
ment of Natural Resources. Certi£icatio must be completed .U'
and returned to the St. Croix County Z g c ithin 30 days
of the three year expiration date.
SIGNED
DATE ~Z-
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
P.^,RTM,EN= oF REPORT ON SOIL BORINGS AND SAFETY & BUILD"'°:., i
C:,STF Y, DIVi510N
>BOR AND PERCOLATION TESTS (115) P.O. BOX 7<
;IAN RELATIONS \ / MADISON, VVI :-.'.7C
:
(ILHR 83.09(1) & Chapter 145)
DCATION :SECTION:T g TOWNSHIP LOT NO.:BLK.
1145 41 ~/~/1 ~OH/I~9 vfor ~OSQ SUBDIVI IO NAME
V
JUNTY CWtNE~Rh'S~/~B~UYER'S NAME: MAILING ADDRESS:
;E DATES OBS RVATIONS MADE
NO. BEDRMS.: ICOMM R L DESCRIPTION: PROFI IPTIONS: r ION tSl 5.: I
~JResidence 3 /1 ~ew ❑Replace )
ATING: S= Site suitable for system U= Site unsuitable for system
)NVENTIOONNAL M ND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
\l/JC j SS UU S -i - S ❑ U ❑ S t1 ❑ S U>b~~
Percolation Tests are NOT required DESIGN RATE: {S
pp y~rs CIA If any portion of the tested area is in the ,
d,+r s. ILHR 83 09(5)(b), indicate: 10 plain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
)RING TOTALeP' ' DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXT!)FiE ANU UEPfFt I
r,IgSc? IDE~H ypd, ELEVATION OBSERVED ES HE TO BEDROCK F OBSERVED (SEE ABBRV. ON BACK.) _
3,? Jh /D n S 3"9!' 75' k/Ul
__A
- -
7' jj > 717'
- 9/ 1 „ > O / 9s / s~ vii L s G r' y 7rJ r.
i- I
5,17- 2"9
1,2
'SOY 7~5 > /.'o ~3. lf~ 3 Q.,
PERCOLATION TESTS -
77= DEPTH' ATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTE i
aEEf?rt 1r5 AFTER SW LLING INTERVAL-MIN.
- P I Q1 P 819132 P R PER I~1 H
7t' 3 y 3/y
OT PLAN: Shov, locations of percolation tests, soil borings and the dimension-, of suitable soil areas. Indicate scale or distances. Describe what are •',e or,
a' nd vertical e!evation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and ;e!,xr;t
i
YSTEM ELEVATION 0 1)
--r 17
r V
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1 V
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v 77
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A:.G. S11-01/3
P~P~~ a 3
0'~P
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H(41 _
the undersigned, nereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wrscr.r:sio
im-nistrative Code, and that the data recorded and the location of the teas are correct to the best of my knowledge and belief,
IT E T W E CO L~ ETEO ON: -
.11o~~ --L-- -
)DRES'S C TIF CATION NUMBER: PhICtN[ NUMBER(n c r ij }
c f
~r(__~ !'__._L~~~~ si^--- G5 00~~%~ 7~ mac'<d
CST SI T - - . ___...------~I
'VTION: U"U!nal ar.d one copy to Local Author!ty,Property Owner and Soil Tester,
G-6:95 ir" 10%83! - OVER -
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PAGE OF
vS `
Cf S S~.c~lol~ p~ la ~~A: .~Ys
j feeth Ali IINeI• AAO 00ill(vollon Pipe
I ~ ! ~SS~ S',yovtaau~~~i'
' i A/Ptevil VtAI Cap
i UosO.,l ,~y 1G /lnel G....
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20- y2' Above PIP' _ C.vl lion r
' To floe) Goode Vvnl Pipe
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SOIL FILL
OISTKIBUTIOki PIPE '
APPP O'/r p S•II,/1'IIETIC COVE
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/"1ATEIZIAI OK 9MOF STitA~.
2"OFhGGRE4A1E OR MAKs1- PlAy
to n(:o-Elie F.-,G KCGATE
EL E V OF.&L-YFEIT---..
OISTRIBUTIOU PIPE TO BE AT LEAffi'Y INCHES BELOW ORiGIMAI, •;,;~,OC
ASJU AT LEASTLO INCHES BUT LIO MORE, THAN 42. IMCHES OELOW FINAL. 41iAOC
MNcIMUr► DEPTH OF EXCAVATIO0 FXOM OWWAL 6R)\DF. WILL BE IIJCHES
tVNIMVM OEP711 OF EXCAVATION r'AOM 00d,144JAL c RAPF- wit.L. 6C ~ INCHC S
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LIGCUSC LJUMBCIS: 1-2,S-
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110 _
REPT131 ST. JOSEPH ST. CROIX COUNTY ZONING PAGE 1
08/28/92 08:55 REQUESTS FOR INSPECTION WORK SHEETS FOR: 8/28/92 AREA: MJ
Activity: A9200231 8/28/92 Type: CONVSEPT Status: PENDING Constr:
Address: ST. JOSEPH 35.30.19.398,SW,SW,LOT1, CO.RD.E
Parcel: 030-2012-20-000 Occ: Use:
Description: 171466
Applicant: REESE, NATHAN Phone:
Owner: REESE, NATHAN Phone:
Contractor: O'CONNELL, KIM A. Phone:
Inspection Request Information.....
Requestor: O'CONNELL, KIM Phone:
Req Time: 14:08 Comments:
Items requested to be Inspected... Action Comments Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION
II
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