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County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holders Name: ❑ City ❑ Village ❑.Town of: State Plan ID No.: TM 'PHFCjDQRF, F SPRINGFIELD lev.: Insp BM Elev.: BM Description: Parcel Tax No.. /Z"d , "'0 034-1017-10-000 TANK INFORMATION ELEVATION DATA A9200380 ~o/Zy~yz /~1 TYPE MANUFACTURER CAPACITY STATION BS HI FS EjLE V. Septic l i;° /GC~„ 1M Benchmark /C Dosing Aera ' Bldg. Sewer Holding St/ Inlet TANK SETBACK INFORMATION St/ Outlet 3'Z '%7 TANK TO P/ L WELL BLDG. VAerit Intake ROAD Dt Inlet Septic /(jj NA Dt Bottom ZZ ~ Dosing r ` ? L) NA odor-1 Man. O - ~ 2' / Aer Ion NA Dist. Pipe F_ Z 4 10d Holding Bot. System L ~LL - - PUMP/ SV INFORMATION Final Grade Demand' 5 z,~d i Manufacturer Model Number "GPM ~r r J TDH Lift t4 Lriction apI System - TDH~ ,4uft oss ad Forcemain Length 1dZ Dia. I, Dist. To WeII f SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length I No. Of Trenches PIT - No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N LEACHING facturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type Of CHAMBER Model Nu r: System: r f i OR UNIT DISTRIBUTION SYSTEM r / Manifol Distribution Pipe(s 1, x Hole Size x Hole Spacing Vent To Air Intake G, r2 ength Di Length Dia. Spacing ~a SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of 1 xx Seeded / xx Mulched Bed/Tm=rt rCenter Bed/Em ehrEdges / Topsoil ! es ❑ No ❑ No COMMENTS:. (Include code discrepancies, persons present, etc.) LOCATION: SPRINGFIELD 1p.29.15.250A,NW,SW, 290TH ST. ry j ni , d,~2 % 5;ar (2~ e Aw Plan revision required? C] Yes Al Use other side for additional information. Zel 1,9 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: REPT131 SPRINGFIELD ST. CROIX COUNTY ZONING PAGE 1 10/29/92 17:28 REQUESTS FOR INSPECTION WORK SHEETS FOR: 10/30/92 AREA: JT Activity: A9200380 10/30/92 Type: MOUND Status: PENDING Constr: Address: SPRINGFIELD 16.29.15.250A,NW,SW, 290TH ST. Patcel: 034-1037-30-000 Occ: Use: Despription: 180298 Applicant: BERGUM, THEODORE E Phone: Owner: BERGUM, THEODORE E Phone: Contractor: SCHUMACHER WILLIAM C. Phone: 386-3121 Inspection Request Information..... Requestor: SCHUMAKER, WM. Phone: Req Time: 09:10 Comments: Qt3C) Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Y ~~Ro STATE SANITAR? PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ch ~ es o 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 ,f, XW14'/a,S 14 TagN,R S E(o W PROPERTY OWNE1 'S MMAAILI ADDRESS LOT # BLOCK # G Q`- CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER mot/ CL 41f/41tey os- II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLL.AGE ' ' 9 14 t e NEAREST ROAD lej ❑Public 91 or 2 Fam. Dwelling-# of bedrooms3 PAR ELTAXNU BE ) ?~L~•Odd 111. BUILDING USE: (If building type is public, check all that apply) a 3 !1.3`-1 lei ale'- O6O 1 El 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 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.4 New 2. ❑ Replacement 3. ❑ Replacement of 4-E:1 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 A9 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) F, ; ELEVATION Feet /40?r 7Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank 604 / _4_~l ga Lift Pump TanWSi hon Chamber Q ,c t-° Vlll. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP PRSW No.: Business Phone Number: .s' ~3 3 ~'c S~ 2r Plumber's Address (Street, City, State, Zip Code): 0 7 4 -<'C e eL IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date issued Iss ' Agent Si re (No Stamps) Approved ❑ Owner Given initial ~ Surcharge Fee) Adverse Determination tJ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. y A•sanitary •Permit is valid for two (2) years.: j 2. Ybur1s1anitary 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. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water 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. LSBD-6398(R.11/88) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGb INDOSTRY, DIVISION LAQOR HUMAN PERCOLATION TESTS (115) P.O. BOX 7969 3707 HU AN RELATIONS \ / MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: e _JITOWNSH UN ICI PALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: N►~3~/ sub ~6 /TZ`1 N/R 1 SE (o S,Przijij G - -1 - COUNTY: MAILING ADDRESS: Z(.33 DIL11S/w Sr PPT- # (o sue. elzoUc ~GUt~ KVo ST: HN SS109 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: RON LE DESCRIPTIONS: PERCOLATION TESTS: ,Residence Z olZ 3 N , A XNew ❑ Replace - p _ 913 Qi - ZY-4 0 8 171 RATING: S= Site suitable for system U= Site unsuitable for system _71M 'T})t) WI ~SQ1V 0Aj ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) ❑S " ®S DU OS ®U DS ®U ros CCU I~)o~►ti~- I ~r awn If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: M. N' I Floodplain, indicate Floodplain elevation: Iv. A PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO ROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 Z ti 0 0.8 6 3 Z-9 s G Z o F Z B- Z3 y B- 3 6 a 1 o 3.3 3 2-, 9 11 ~ 6- or.+ 43_Z3- qo PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER L VEL-INC RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PER INCH Zo 3kl~ 3! 13/!6 3/ O P- P_ Z 2u F.11~ 3O 3/ i/~/b ills P_ 3 zo 1~-0 3~J 3/ 3/ 13!/6 37 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. S~OTZbI~t Q1 13km _e. 10L).9 Qf'~6~ S nP,GIJ- 917JT?6(.1 $ SYSTEM ELEVATION CnIN 1 j1.1 _`i~ S6 Pct t_ 'Sr Z S ~ F~P4 F'1 Y-7 Z Q A _ S C CA b 1 Q 4 ~ ~y ` . O ~ ~ C-a W ~L~ Ir y j •.i .r ~Or ( t~ ~r 1~1=~"~~ S(l./ 4V11~ ~ ~f' t - SW 1/y I - tTL • Wf'4.9~ 3v ......i I. i _ }7 W IIJ L. if Z em.. .p .e..e. t.,..~.. 144- 3 ~iT} t ' ~~I F E E Tol E zoo ~ _ - 3 `~c~1+a~-tr _gi 4- , r E 16 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. WEGERER SOIL TESTING NAME print : AND TESTS WERE COMPLETED ON: DESIGN SERVICE _ 8 - ZV_ gO ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): P.O. BOX 74 421 N, MAIN ST. Q% ST 0M S-) b ~ l S- L{ 2S- 0 /6 S RIVER FALLS. W1 54022 CST SIGNAT RE: 715-425-0165 • ~Y~ DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. F Z DILHR-SBD-6395 (R. 10/83) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well fs - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'st - Loamy Sand 'c - Less Than '1 - Loam Bn - Brown 'sit - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point r 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. OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IN c DIVISION LAWN PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969 HUMAN, RKLATIONS (H63.090) & Chapter 145.045) LOGA ON: SECTION: O TOWNSHIP/ LOT NO.: BLK. NO.: SUBDIVISION NAME: / ~ /T N/ E (o COUNTY- WNEIiS/BUYER'S NAME: MAILING AD RESS: -5-1 USE ` DATES OBSERVATIO S MADE Vesidence NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILED SCRIPTIONS: ER O ATION TESTS: uUR New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system , CONVENTAl MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILLHOLDINGTANK:RECOMMENDED SYSTEM: (optional) ❑ S CAS ❑U ❑ S CCU J❑ S Cat! gS ❑U If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 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- I O.0 0a. I/ A/ / Y B- B- y e, 0 B- B- ^ w 3 5 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P_ 13 3 S l P- P- 13 O P-_ P- 3 Al 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 41114 s E ~ t E E 4 't r i !Y//J7` v~r ( 1 ~ 3 t r i ~ ~ 7 1 : L 1 [ lJ [ 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): DAv! roomy TESTS WERE COMPLETED ON: won"d Perk Tester & Plumber q ADDRESS: Fo 111110400 O&OW ~ Road 5023 CERTIFIC N NUMBER: PHONE NUMBER (optional): MRS: W0 I NSIN Phone 749-3656 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - -mm. II `"WCTIONS FOR COMPLETING; FORM 115 - SRD - 6395 ~ To be a cf e I accurate soil test, your report must include: 1. Complete ption; 2. The use = clearly indicate whether this is a residence or commercial project; 1 MAXIML' per of bedrooms or commercial use planned; 4. Is this a n lacement system; 5. Comple x, l3ility rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER ~Y ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE iations sV in here for writing profile descriptions and completing the plot plan; 7. MA A V_ diagram ately loc. I ~ .~.ir test locations. Drawing to scale is preferred. A r=sed lI `F imark a 7d t i it elev~ cIl point are clearly s',nwn, and are permanent; d. ~ all date boxes to dates, n-r 'resses, flood plain rcolation test exemp- f aFpropr 101 m< s flood plain, elevat: es riot apply, place N.A. in the appro{~~riate box; 11. or m your current address ,r, certification n- 1' 12. ...le(; ble cot id distribute as require ALL SOIL TES` )S. BE FILED WITH THE L(- °,L AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS p and Textures Other Symbols G""', 10") BFI Bedrock (3- 10") SS - Sandstone (under 3") LS Limestone d HGW - ; i GrounW Sand Perc 'n r iGm Sand W - F; Sand Bldg L,.'Iding Is L my Sand - Greater Than "sl Loam < I Than 11 Bn B w~ri `sil Loam Bi t si v - - - Clay Loam Y y : "'v Sandy C' R Silty Cl_/ t mot . - Sandy Clay v - L, °y Clay fff - IF v, it cc CI I n t rnm - N iunl ck d - d li I-) l )IT HVVL High el Si s~ ii ' sur' ; ft, l '_e dis' Burl B VRP V nctr Point T TI' a TI c u. L ;t i:'ILk, i. ~..0 ~j„ `~~'a t;,.: .f y _ ,_f.. i i i .rv ~t i B. SOIL DESCRIPTION FORM Attach SolI Prof Ile Location Ma On a Su arate Sheet) (3 GU LINEAR LOADING RATE: CL T• PURPOSE CC~~'S7QC.T20" SLOPE- L/ 0/,, 2ESr.Il1PTION BY ~R~ H-AJR w L~ZL~ ASPECT: SOLa`T1~C` 5j'atTRL~I' DATE: CURRENT LAND USE: S'r~ L° ~~Q K L° V V N VEGETAT V COVER: Gs S ' r LL wb S COUNTY/STATE: LOT DESCRIPT ION:pT' 0F QkJ-5to -5L3- (Z IL,TZ.9k)lRISWDRAINAGE CLASS: LOCATION, _M- TM Qt= SpRJN G Ft GALLONS PER S Q. FT. PER DAYi b~S~ GI`1 1-1T Q • yU PARENT MATERIAL s /DEPTH: SOIL SERIES: SOIL L HORIZON DEPTII MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS PII -BOUNDARY REMARKS jn, (Rio ist Gr. Si. Shp COATINGS o tio~-c;L 31 s i 2 m s lb ►n'Ft^ a s h S S la 51?J1 ut=L Z 1OyiZ y/y - Sil 2i Al Y-1 g_39 LO~cR 316 ~Z~ S I ~-f►•►Sb w1~Y- 9t.~, ~.syp-sJa lno'I' S 3q-6 10 2 31b ~Z9 s)-sal 1 sbk yn`~i bo G ~ 0= l lug Cz 3 2 3 s l Z hti M ~l- c S _Z 7-1 b 1V `i2 y!y - Sl~ P M ~h eS 3 16, 3 1WlZ 316 S Zm3~k M'1 `S _Z _3°! 10 Tz 3! z~ 5 Z 1113bk m't~ gw S 39_~Z lo-tTZ .31. Zo~ s)- sc.l ~.S7RS B M0`)' 8o1z1 6 3 s1•( Zw,sblt m~C~- cs ~ 0-£3 ►o`Itz313 - Z. lS 1p'-c12 Y! S ~'~P1 CS S°lo rs ULL 3 S _ Zvi l 6LI R- 3 /6 S) Z >n S b~ m 'F~ GS q Z9AQ) l~`tTz 316 ZGk S 1 _,n,S~k wtih ~syR s/s bxu-T S i) 16K23A, sl-Jcl 1 Zbh 07'x^-4n '\QJ Ql. IAL PI !.v vr. c Mo T1 S W' S 1 1 L V` Ee-J F-20 T-3 ~'v Kh Y SMyjl_) T //V a SE wct LCt~ avo~~p t~RO Hl `r~t~ uus`i~tLl r~PuAJ all p uv ~t S MWJLA~ S4S w TIV Lp / c TzAk of o.y0 i LLp)v A SQ • FT, 1 S RECD M-1E~vD _ /S S17L~. OTHER SITE FEATURES/NOTES: cz, ooS`7 G nn6t? of Z LIMITING FACTORS/DEPTH: Signature Date CST N TIOR120N DEP111 MATRLX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CIAYSKINS/ PORES ROOTS PII BOUNDARY REMARKS in. 010 1st Gr. Sz. Sh COATINGS i IiE i I OTHER SITE FEATURES/NOTES: Qn 6e- of _ Signature Date CST M LIMITING FACTORS/DEPTH: DEP•ARTMSNT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR•AND PERCOLATION TESTS (115) MADISOP.O. BOX N W1 7969 HUMAN RELATIONS 53707 (ILHR 83.090) & Chapter 145) LOCATION: SECTION: TOWNSHIP UNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: NA3% svSV ~6 /Tz9 N/R tsE (o sn~ijG Pie_ b - - COUNTY: MAILING ADDRESS: -Z,(=133 DIU1310A) S')' . ffPT # <22M V -Tlzn~ LAG tir tz ST-. F'PrJ L 1-1)Q -S)09 USE DATES OBSERVATIONS MADE k NO. BEDRMS.: 1COMMERCIAL DE R PT ON: I TESTS: ROFILE DESCRIPTIONS: PERCOLATION Residence lZa 3 N• L$New ❑ Replace 8_ t p_ 913 S_ zy_q 0 RATING: S= Site suitable for system U- Site unsuitable for system <DAJ S M S1M ~j }}fJV~I ~S01J O+~~ g- 3. q ri CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S TEM-IN-FILL r!jS IN G TANK: RECOMMENDED SYSTEM:(optional) ❑ S IU ® S DU D S ®U ❑ S ®U CCU 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: N' N. Floodplain, indicate Floodplain elevation: I v' - PROFILE DESCRIPTIONS BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGPrSf- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) s- 1 7Z 10 0.8 6 3 Z~ s )Pt'V ('SE Z OF B- Z 6 g Cl a 7Z8 41 B- 3 6 a 1~u.3 C~3 Z9 'i oe s~z1,I~ B- ci. `a-Z3- 40 B- B- PERCOLATION TESTS } TEST DEPTH WATER IN HOLE TEST TIME DROP 1 WATER LEVEL-INCHES RATE MINUTES t NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D PERIOD PER INCH P- T o IJO 3Q, 3/ 13/16 0 P_ 2 2u 1.11 3 Q;i 3/ t//16 i/l/ P_ 3 zp 1~ 30 3/ 3/ 13!/6 37 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. %twmm OF 13 in -tL. 100.9 &Nkml~G0- ' wil scl $ SYSTEM ELEVATION c ynit a . 1 , 2- CA z sL w 3 2-_ l0 ".yr i 7 i r ILL - N r ; ~ o .,~I car} { 3 r , SLL llt_ SO` SEC. 16 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. WEGERER SOIL TESTING, NAME print : AND TESTS WERE COMPLETED ON: DESIGN SERVICE ADDRESS: CERTIFICATION NUMBER: PHONE NUMBERIoptional►: P.O. BOX 74 421 N• MAIN ST. C. ST 000 S7 1o 1 S- L12S- 0/6 S RIVER FALLS; WI 54022 CST SIGNATURE: 715-425-0165 , DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. L DILHR•SBD-6395 (R. 10/83) - OVER - i ' SOIL DESCRIPTION FORM A tat SOiI r0 II OCati Ne On . Su orate Sheet) T LOA ING RATE: MEN Qk ' PURPOSE : S S 3''f>~"I ~w CON U C ON SLOPE, • T 0 V L w ~ 6 ~Zc~ nsrrcT• SoL~•~-'~~-sT~TRL-Y _ - QESCRIPTION BY 1~v G • 10 1 9 REN LANO US OATI:: CJ3 Vwr4 LL//. VEG TVE VE G2ASS I-IN LL WL'7 bS COUNTY/STATE: LOT OESCRIPTION:'E' ew 1J w/!yshi!/ ,5E*c li- 241JtRISWDRATNA CLASS,- wL~-` ~`2fltAJ~T~ LOCATION: (73F Sp W G PI GALLONS PER SO. FT. PER DAYt ~yCS 61`1 l~T n Yu ~ '1"1 6Ct- I I~+T)C,O f9ND ~T IL r/-GR11Y1WL~L1. SERIES. ARENT MATERIAL s / P ! SO TL HORIZON DEPTII MATRIX COLORS MOTTLES TEXTURE GSTRUCTURE CONSISTENCE CCL YSKINS/ PORES ROOTS PH -BOUNDARY REMARKS in, moi t --COAT IkGS ~ >v 6 1 a S 0- ~1 ~oK ~ j 1 s i. l 2 m s bk tn'F~. - s l Zi Pd yI'Fh -s sVt, 6RA VEL Z• 7 _ i / 10 `7 R y /Y 3 1y-z.$ 10Kt~ 31(. s I Z>n gbh m~ c s s I M s )Z, wt ~r 9 L., yp- s/a ~T o-r x_39' to ~•rR 3/6 ~ Z~• S 39- 6 ti~~R 31 b Z~ S)-Scl 1`F S bk In I 8o G ~ ~ - s, l Z n1 c s O , 1u`•t [z 3 13 Z -1 lt~`12 y/S/ - S1~ P M I 'f*, 3 J-6-28 lo4Q 316 S Zm3 k VA G S Lw L4 z_ 3q Io ( 2 31 Z wI 3 bk rI'f~ 3 7•S7Rsys mo S 3g_~Z 1o4cz. J1~ ~Z~ sl-scl ~ gblc h>.~'►--ln~ 30 6 .3 ~ 0-8 ►~`ITL313 - si'I Z►+,sb1t _m'f'~ cs Z lS 1p~-tR y! S 1 ~ ~'~P~ y''I'~~ cS 5°!o ctLRv~L 3 S- Zq l by ii 3 - s 1 Z m S bk m'Fh cS - n 5~ ~.SyR s/>j ~uT q Z9_40 !0`tR 316 TZr S ~h~Sbk `n1'Fh S D_ba lb'-12 3/6 ~Z~ sl,~cl 1`E'Sbrc wT`~-h'i`Fi' tSJP AL t w, 1z, c rlo u S l i L I r3 t'v 1'9 Y JAJ SE wct'tC;t4 bVov Lb 1'~Ru H't 'n e j/V S -M L L IOT oti T -to ki p NV~hh~ L. L'1 S Mov1.~ S`ts w Lp r Tt T OF d•y a~~ow S~ • o w1~,p r S17a I OTHER SITE FEATURES/NOTES: azzdw T ~ g-Zy-40 L~oos'7 G t'n6~? of Z Signature Date CST M LIMITING FACTORS/DEPTH: 1 SAFETY & BUILDINGS DIVISION i State of Wisconsin I Department of Industry, and Human Relations i PRIVATE SEWAGE PLAN APPROVAL Western Regional Office 2226 Rose Street LaCrosse, Wisconsin 54603 i WEGERER SOIL TESTING & DESIGN Owner: TED BERGUM PO BOX 74 2633 DIVISION ST. APT. #6 RIVER FALLS WI 54022 NORTH ST PAUL MN 55109 RE: Plan Number: S92-40395 Date Approved: June 8, 1992 Gallons Per Day: 450 Date Received: June 8, 1992 Project Name: BERGUM, TED Location: NW,SW,16,29,15W Town of SPRINGFIELD County: ST CROIX The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved'. This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. This approval will exp-Ire two years from the date approved or if a sanitary permit is obtained, i~ will expire the day the initial sanitary permit expires. The Section of Private Sewage has reviewed these plans for private sewage system code requirements only. These plans have not been reviewed for the code requirements set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: % 9 - NEW MOUND ~D Inquiries concerning this approval may be made by call (608)cJ-85i048. Sincerely, GERARD M. SWIM Section of Private Sewage E Division of Safety and Buildings PPP039/0009n/43 cc: TED BERGUM X Private Sewage Consultant SBD 6423 i R. 01/811 Page 1 of MOUNFORD SYSTEM A ~s BEDROOM RESIDENCE LOCATED IN THE N\k) 1/4 OF THE SW 1/4 OF SECTION 16 T Zg N, R 15 W, TOWN OF Sp\2ltiG Ft(5-b , ST'• CR01X COUNTY, WISCONSIN. INDEX PAGE 1 of 6 TITLE SHEET PAGE 2 of 6 PLOT PLAN PAGE 3 of 6 PLAN VIEW-CROSS SECTION PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT PAGE 5 of 6 PUMPING CHAMBER PA GE 6 of 6 PUMP PERFORMANCE CURVE PREPARED FOR 2633 ~1ulSl0~ ST• R-PT" 6 1vo1cm ST. FOUL, IN sS1o9 -PREPARED BY W E G E F;t E FZ E; Q I tL -T E E3 T I N G oec'~~®ef aogt iy AND oft, fe SER'J I CE re°°~1~"••«•d ~~'i I7EE3I GP4 l P.O. HOC 74 421 N. MAIN ST. _ WECEPER L. t5 RIVER FALLS. NI 54022 r 0.9"(5,PTH, wr, _ % s 715-425-0165 r••.N.M•rr' A. hNN~sN~ ~P~-~ ? Z~ L4 g Z JOB NO. 07'Z-18 ' PLOT PLAN Page Z- of Scale 1 ~LZ-LUkWK`'f Q 1~u1~ = i X1,1 ~0 b E RT LE)N Y'r Q ~ 50~QAI"I YIOU,vp }~n.,D Wr LL" ST Z 5 FiCp1~1 TPti h S. S ti,Z Q V1 ! ti \ O of ~l" PV C ~ S 0 ° N 4 Yrj 1 Env' 3S' of PUC i v ONSITE SEWAGE S itio ~ a 3 Cod Ono L-L to I n RELA`~i~NS LA80R AND 5 o S' O F 2"PV e Of INUTRY,F BU r-9~cE ~-,~,ti ~Cppz, LN Vl510N OF E E aA SEE UQRRES gh * z aolo 13.1 ~ s ~ ~o n~oT C.urlPrlcT oR IN TrA\S 1%VVt_ a '13.2 NOTES: 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install permanent markers at end of each lateral. required) 3. Install 4" observation pipes with approved caps. ( Z required) 4. Septic tank to be loo O gallon capacity manufactured by Y---~ \ Zwes N PA<C^3 r 5. Bench Mark c 1 - tL too.(), o," I V?czu wooil Sr*ke w1 LAT)4 ttZ - eL. kQV-W 6. Divert surface water around mound to prevent ponding at the-uphill side. Page 3 Of b Approved Synthetic Covering Distribution Pipe Medium Sand - H - JG Topsail _ J F Elev. X00. _ D E' „ b y % Slope - Bed Of '2'-'2 %2 (Force Main Plowed ON 1TE SEWAGE SYST£gregate'` From Pump Layer ist rbed D 1.0 Ft. S LLE92f E 1•i Ft. ROV ion Of A Mound System Using F (.)-S Ft. For The Absorption Area G 1.~ Ft. A P"P DEPARTMCN O.= itvDU5"'Y, LAM' .APB A 5 Ft. H S Ft. VISION OF B S Ft. SEE I IS Ft. Linear Loading a e= 6.0 GPD/LN FT J S Ft. Design Loading Rate= o- 1 GPD/SQ FT K ~O Ft. L °15 Ft. Position of Force Main W 7- ES Ft. L B K tafanr- A 7L W Distribution Trench Of 2~ - Z 2Y Pipe Aggregate Observation Permanent 1 Markers Pipes (Anchor securely) Mound Using I Trench For Absorption Area 1vo "OVKjt, \g cow ct~v~~ vpsu~p~ s p!: . SCE' 11-~-oT l~l.R►`► ~f16~ Z OF (6) Page '4 Of 6 Perforated Pipe Detail 0 J""' End View )Perforated End Cop" PVC Pipe Jo~~o o~~c AGE SYS~~N, E SSW o ONS~1 f Install permanent-marker IA at end of each lateral ID PVT nc1 n` ~N F ¢o a 4 Holes Located On Bottom, Are Equally Spaced Q End Cop * ti PVC Force Moin 4 Distrloutlon Pipe Lost Hole Should Be Next To End Cop Distribution Pipe Layout P 3y. S Ft. X 3 Inches Y 36 Inches Hole Diameter JA( Inch Lateral v Ily Inch(es) Manifold Inches Force Main 2 Inches # of holes/pipe 1Z Invert Elevation of Laterals 101.E Ft. Place lst hole %b" from tee with succeeding holes at 710 intervals Last hole to be next to the end cap. PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS ' PAGE S OF - VEiJT CAP 4" C.I. VENT PIPC WEATHER PROOF APPROVED LOCKING MANHOLE: JUMCTION BOX COVER WITH WARNING LABEL 25' FROM DOOR, 12"MIU. WINDOW OR FRESH I AIR INTAKE I GRADE I `I0 MIIJ. t~1- t~ l e I CONDUIT 18"MIN. I III = _ _ _ IAI I_E r BITE SEW A`' aRRT _mT SEAL- pN I III APPROVED JOINT APPROVED JOINTS ~r;••:, ~®~~y ~ I III Y I III ALARM e ~ ~ v BOR A~lD ;iJ I My' BUI ► GS I I ON c mrplo.i t~tC~ ;OF ; ' i I CLEV. c16.33 FT -SEE UMP OFF r D I;TL gS.OO COMCKETE BLOCK 3" APPRwt RISER EXIT PERMITTED OKILy JF TAWK MANUFACTURER HAS SUCH APPROVAL. gEppING 5PEC.IFICAT10MS DOSE F'il )GllM_ J 1-RECAS'T TAWK MANUFACTURER: WUMBER OF DOSES: 3.8 PER DA4 TANK SIZE. GALLONS DOSE VOLUME S•Z• O SYSTS'I5 INCLUDING OACKFLOW. 1 b'S GALLONS ALARM MANUFACTURER: MODEL NUMBER: IS3 CAPACITIES: A= S11ZINCHE5 OR 321.3 GALLONS SWITCH TUPC: L Z~12 L( B = Z INCHES OR 39-2 C. ►LLOUS PUMP MANUFACTURER: _7_O ELLS C01" I}11N Jai' C = -7 IMC14ES OR ~16* S GALLONS MODEL MUMBER: 17 D- 16 INCHES OR 312.0 GALLONS SWITCH TYPE' " ZckjNZ'y MOTE: PUMP AMD ALARM ARE TO BE MIMIMUM DISCHARGE RATE .28'08 GPM INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFERENCE DETWEEM PUMP OFF AUD..DISTRIBUTIOAI PIPE.. S'O, FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . 2.50 FEET ♦ FEET OF FORCE MAIM X A-132-IFY0 FEFKICTIOU FACTOR.. x'44 FEET TOTAL DyWAMIC HEAD = 2-2" ~ -FEET DIAMETER - L40 ' ILITERLIAL. DIMEWSIOMJ OF TAWK: LENGTH WIDTH - ;LIQUID DEPTH _ 17, BOTTOM AREA _ 231= - GAL/INCH AS PER MANUFACTURER GAL/INCH W LU 6 0~ 6 U. HEAD/CAPACITY CURVE 46 30 MODEL 97 4% - ►-I m s 4% 25' o - 1'6 - 11'6 NPT Q 20' 43/16 W 6 S m U_ z 15' G 4- 10- 2- O q,OI I 5 2.8.08 r 0 US 10 20 30 40 50 60 70 GALLONS LITERS 0 80 160 240 1011/,6 FLOW PER MINUTE TOTAL DYNAMIC HEAD/FLOW PER MINUTE EFFLUENT AND DEWATERING CAPACITY HEAD UNITS/MIN 315/16 FEET METERS GAL LTRS 5 1.52 56 212 _ 10 3.05 46 174 15 4.57 35 133 20 6.10 15 57 Lock Valve 23.75' CONSULT FACTORY FOR SPECIAL APPLICATIONS a Electrical alternators, for duplex systems, are available a Mercury float switches are available for controlling and supplied with an alarm. single and three phase systems. a Mechanical alternators, for duplex systems, are avail- a Double piggyback mercury float switches are available able with or without alarm switches. for variable level long cycle controls. SELECTION GUIDE 1. Integral float operated 2 pole mechanical switch, no external control required. Standard All Models - Weight 33 lbs. -1/2 HP 2. Single piggyback wide angle mercury float switch or double piggyback mercury float switch. Refer to FM0477. 97 Series Control Selection 3. Mechanical alternator 10-0072 or 10-0075. Model • Volts-Ph Mode Amps Simplex Duplex 4 See FM0712 for correct model of Electrical Alternator, "E-Pak". M97 115 1 Auto 12.0 1 or & 7 - 5. Mercury sensor float switch 10-0225 used as a control activator, specify duplex (3) N97 115 1 Non 12.0 2 or 2 & 6 3 or 4 & 5 or (4) float system. D97 230 1 Auto 6.0 1 ort&7 - 6. Four (4)hole "J-Pak", junction box, for watertight connectiowor wired-in simplex or E97 230 1 Non 6.0 2 or 2 & 6 3 or 4 & 5 2 pump operation. 10-0002. 7. Two (2) hole "J-Pak", for watertight connection or splice, 10-0003. CAUTION For information on additional Zoeller products refer to catalog on Combination All installation of controls, protection devices and wiring should be done by a Starter, FM0514; Piggyback Mercury Float Switches, FM0477; Electrical Alternator, qualified licensed electrician. All electrical and safety codes should be followed FM-0486; Mechanical Alternator, FM0495; Alarm Package. FM0513; and Sump/- including the most recent National Electric Code (NEC) and the Occupational Sewage Basins, FM0487. Safety and Health Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. 3280 Old Millers Lane Manufacturers of . OELLEf' 0~ P. 0. Box 16347 • Louisville, Kentucky 40216 (502) 778-2731 • FAX (502) 774-3624 u,4urr LIMPS lver Q P s /~93~9 ST. CROIX COUNTY T ty}~ WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 Feb. 11, 1992 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 To whom it may concern: An onsite investigation of the Ted Bergum property, located in the NW 1/4 of the SW 1/4 of Sec. 16, T29N-R15W, Town of Springfield, St. Croix County. This onsite revealed suitable soils at a depth of 28" requiring 12" of sand fill beneath the mound. Should you have any questions, please feel free to contact this office. gic erely, James K. Thompson Assistant Zoning Administrator cj S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER o a`o Y 'L_ ✓ ADDRESS FIRE NUMBER CITY/STATE ZIP PROPERTY LOCATION: -VAI 1/4, -f1V 1/4, SECTION, T N-R is W TOWN OF S r~'-~ , St. Croix County, SUBDIVISION p%-_ , LOT NUMBER.y. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper 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. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be 'completed and returned to the St. Croix Co. Zoning officer within 30 days of the three year expiration da ~f SIGNED: C DATE•_ 0 St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 l 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 'e'ev t e, 'ft Location of propertyA44/ 1/4 ~liJ 1/4, Section 4'!~ , T.2!? N-R /,g'W Township Mailing address 2 ' 3:3 ,Z~•`~ a `s°. s'T r Address of site Subdivision name Lot no. x_/eL_ Other homes on property? -yes No Previous owner of property Total size of parcel Date parcel was created ZZ Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume 7C-~ 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 & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document No.__~~~ o lS_ ignature of pplicant Co-applican Date of Signature Date of Signature !t r. 4