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HomeMy WebLinkAbout038-1059-30-100 -0 0 I o I a I c I N I O~ o I ~ I 'b I ry I I I a) I ` z° lL C o I 3 I I M (D w E v Cl) a m o I o z c Z 2 c o V1 F- ~ Z c E ~ ~+J Q1 a cc 1~1 t c Q z co z 7--r z is ~ c ~ I N a) N ca Y rn ~ m - d I a c°' O) y of 41 C O c ° G G a t~ N Z M> E U O o I Z •N ~aaa y ~v a CD ~i z N C-4 fn J U V rn rn Q'V o 0 M°o ^I ° ° - z3 E ° C m y C CL N U (n a) O 9 O d Q Y In co 0 Lo 0 0 w c (p 6 00 cc 4)0 l C? LO 0 E o l ~ v c E O f~ 0 d> rn N o a o E R I M ns ID • I.~ co in s o z `n Z= cO) I a m .2 `m IL r`N a o c`o 3 c r A uIL m !oU)u ;y DEPARTMENT OF REPORT ON SOIL BORING' AND SAFETY & BUILDINGS INDUtfRY, DIVISION I-ABOR AN P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (11 11 x) MADISON, W1 3707 (H63.09(1) & Chapter 145.045) 3 LOCATION: SECT( N: TOWNSHIP /M ITY: LOT NO.:BLK. SUBDIVISION NAME: /Tv COON Y: OWNER'S/BUYER'S NAME: MAILING ADDRESS J=ice.'' vim. ~~';i USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERC L DESCRIPTION: r~ (PROFILE DESCRIPTIONS: PERCOLATION TESTS: ®Residence MNew ❑Replace Il RATING: S= Site suitable for system U= Site unsuitable for system r[N--5 T: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED YSTE .(optional) ®S ❑U [ES ❑U ❑ S®U ❑ S ®U r - ~ If Percolation Tests are NOT re uired DESIG RATE: ~ If any portion of the tested area is in the under s.H63.09(5)(b), indicate: n ,S Floodplain, indicate Floodplain elevation: Z PROFILE DESCRIPTIONS , / i 3G,c ~L ~SI:IA'~/~'11~~^l~' Ilt~di' ✓ BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND EP1 H NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- I 9A > ' /I - _ 9'y Z 5 Ir - , _s - > 91 B- Q B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL INCHES HATE MINUT ES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- ~S~vZ / s P :>Z 1Z S~ P- 3 - P_ I P_ 2- 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. Sam/ SYSTEM ELEVATION 9 >lo"'o of ~xf slo~/iS Y.Y f i CJ~ .l 3 1~ ICI = ~ _ t i i tH 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 TESTS WERE COMPLETED ON: ADORE CEF6IFICATlO NUMBER: PHONE NUMB R(optional): JT CST SI: NAT RE: DISTRIBUTION: Original and one copy to Local Autlinrity, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02!82) - OVER _4~ AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP /~f'zez,6" l yR,P~i ~ 1,6zsoAl SECTIONT -~f N-R__,Zj W ADDRESS X IOASC.o Q~k "Ci ST. CROIX COUNTY, WISCONSIN SUBDIVISION - 1ZJz i;y i - LOT__LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM y ` ~6 t /J t 1~I~7 /GD /uSE y(' h' 41- G' ~a INDICATE NORTH ARROW BENCHMARK: Elevation and description:-, ev ~t,x~ s~-/tea h Alternate benchmark SEPTIC TANK: Manufacturer: Liquid Cap. Rings used: l Manhole cover elev:Final grade elev: /cog" D Tank inlet elev.:/~ 7/rz" Tank outlet elev.: /4X'.Y No. of feet from nearest road:Front , Side, Rear Ft_j~~ From nearest prop. line:Fro t Side , Rear Ft. No. of feet from: Well Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE 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: Trench: Seepage Pit: Width:- Z-)_Length- ld Number of Lines:-,-2__Area Built Exist. Grade Elev. ,AD9, i/ Proposed Final Grade Elev. ,h,2 ij Fill depth to top of pipe: No. feet from nearest rop. line:Front Side, Rear Ft.f~ No. feet from well: No. feet from building 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: PLUMBER ON JOB: - 2L LICENSE NUMBER: 6/90:cj c~rIngNrtSTndFu)~AIRIE 14.31.18. SW SEA CO. RD. C County: Labor and Human Relations PRIVATE SWAGE SYSTEM ' Safety and Buildings Division INSPECTION REPORT (ATTACH TO PERMIT) SanitarygnmitlOIX GENERAL INFORMATION Permit Holder's N "e: ❑ City ❑ Village ❑ Town o : State PlaT+PN.4,7 PM' SONvf3M Elev.: r BM DescriptionSTAR ~e64~ I I Parcel Tax No.: CS 11-0 1 (0 TANK INFORMATION ELEVATION DATA D~~ L TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ,,0' Idd, c 0. Aeration Bldg. Sewer Holding St/jf inlet $3Z~ /02, TANK SETBACK INFORMATION St/Koutlet 3r Vent irIto ntake ROAD TANKTO P/L WELL BLDG. A Air Septic © Z/ NA Dt Bottora►._..._. NA HeaderlUa+a. 9si ~d r Aeration NA Dist. Pipe Holding Bot. System q~ , lQla PUMP/ SIPHON INFORMATION Final Grade 70 M-a u acturer Demand Model Number GPM TDH Lift Friction S stem TDH Ft Loss I ead Forcemain Length Dia. Dist.Towell SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length r No. Of Trenches PI No. Of Pits Inside Dia. Liquid Depth DIMENSION o2 , DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA NG Manufacturer: SETBACK INFORMATION Type Of ,n CHAMB , e Number: System: y~ y5 2 OR UNIT DISTRIBUTION SYSTEM Header -ARertifofd- Distribution Pipe(s) l x Hole Size x Hole Spacing Vent To Air Intake Length ~ Dia. Length 57 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 Zq -3 Bed/ Trench Edges Z - Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) ✓J'2e~ ~Tj G Plan revision required? ❑ Yes 046 pr / Use other side for additional information. 9 d SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ` 7 - 0 SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CouNTY ' Q4edk~4_ .a.,. ,,..v,...., ..,~,.,e. STATE SANITY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 17 qrv 8% x 11 inches in size. neck if revision 4o evious application -See reverse side for instructions for completing this application. STATE PLAN I.O. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION '/4, S T3 , N, R f (or PROP TY OWNER'S MAILING ADDRESS LOT # BLOCK # CI Z STATII~ ) ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ,CAI "I"Q IJA -7 7A- 91 II. TYPE OF BUILDING: (Check one) L1 State Owned 0 VILLLLAGE NEAREST ROAD ❑ Public 17 1 or 2 Fam. Dwelling- # of bedrooms 3 PAR L N B 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 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. ® 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 Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-in-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. 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 Feet Feet 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 strutted Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber El El I El El I Ll E2__ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installat' n of the onsite sewage system shown on the attached plans. Plumb is Name (Print): Plumber' Si ature: (No S MP/MPRSW No.: Business Phone Number: Plumber' Address (S reet, City, fate, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater a e ssue is ing Agent Signet Stamps) Surcharge Fee) tv Approved ❑ Owner Given Initial 4-/ Adverse Determination 6 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary per7ni' ,)ay be renewed before the expiration date, and at the time of renewi:l any new criteria in the Wisconsin Administrative Code will be applicable. 3- All revision, to this perinit must be appioved by the permit issuing authority. 4 Changes in ownership or plumber requires a Sanilary Permit Transfer/Renewal Form (SSD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pur.ped 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 admiiistrator 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. ll. 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 s 1e constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental prodict 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 ti- rough these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) STC-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 deer' recording. Owner of property Location of property 22. 1/4 Z E 1/4, Section 4_ T~N-R_Z LW Township c,54-atz P2 t ire, e Mailing address Address of site 11 Subdivision name Lot no. Other homes on property? yes l/' No Previous owner of property S c r)4 Q ZA a n L -r c~ Total size of parcel `t, Y(e Ac ee. S Date parcel was created /0-7 - / 9 7 / Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No volume J' o and Page Number 414-t-_ 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 Deed as Document No.~3, and that I (we) own the proposed site for the sewage disposal system orr I e(we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document No. _ c Signatu a of applicant Co-appl cant • Date of signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED . 48323 70 p 11 950PAGr 281 This Deed, made between ...-SCOtt__4T_,___~OLlIlt~r__c1Il-d______ REGISTER'S OFFICE St-eue._E,_--Pet_ex_sQn,---a ---te-n ail ts...in__-ommon,---------------- ST.CROIXCo.,VW Recd for Record - - Grantor, MAY 141992 and........ Qary__W.__Peterson__and_•Diana M------------------------ terson.,. usba~?-d__and__wfe.,___as._survivorship_ marital...... 8.15 A. M grap.exty, f Grantee, (1 Witnesseth, That the said Grantor, for a valuable consideration...... Register of D" - • RETURN TO conveys to Grantee the following described real estate in Crq County, State of Wisconsin: Lot 3 of the Certified Survey Map recorded in Volume "9" of Certified Survey Maps on Page Tax Parcel No: 2411 as Document No. 474491, being a part of the Southwest 1/4 of the Southeast 1/4 of Section 1'd Township 31 North, Range 18 West, including anc~ subject to the joint driveway easement appurtenant to Lot'h' 2 and 3 as shown on said Certified Survey Map. it i p i g r b- ..JIB E 00 F z. This i is n t homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And........... C'.r ant O r warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except municipal zoning ordinances and easements of record, and will warrant and defend the same. Dated t ' -41 - - day of MAY------------------------------------------, 19.9 2... ---(SEAL) (SEAL) * Scott J. Counter 9711-- 7, 1 EAL) (SEAL) * Steve F. Peterson AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WISCONSIN SS. County. _ authenticated this ----....day of 19 Personally came before me this ......6-day of M4y........... 19.a2 the above named ..SGOtt--=T..... ounter__ and----------------------•------- _.St.eYe F,.-.Peterson------------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN (If not . by § 706.06, Wis. Stats.) to me known to be the person 5....-_..-. who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY y(/~ji,~•: + Ay, BAKKE NORMAN, S.C. 7- 12' MCI_l.R~ us- P"me Ot b~ New Richmond, WI 54017? New Notary Public St.__ CTOlX ------------------County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration are not necessary.) date: ° --------------------19.) ~I Names of persons signing in any capacity should be typed or printed below their signatures. ` I WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FARM No i ~.7gA8 F p ~)199~ This instrument drafted by Fran Bleskacek Proj. No. 91-08 pC~ ~.!l~FLt 47a14~.~,, Re4ti~"' y WS Sti Cso~ ERTIFIED-•SllRVEY SAP.. Located in the SA of the SEh,of section 14, T31N, R18W, Town of Star Prairie, St. Croix County, Wisconsin. LEGEND L B y 9 Aluminum County.'Secti•on Monument Found a ro v O 1'1 x 2411 Iron s - Pipe Set, weighing 1.68 lbs, per linear foot ° Existing Fenceline ~ o a +Building Setback Line 0PROVED d u u N C t~ L W ^ N 4- OCT091991 0 L W y' "y (n o L')I*. CPON COUNTY L a, ~ c, C.Q{v!F'f~EH~fSIVE PRRK.S NLUUnFVc ; t co o -4 z 0 - AND 2014 Wn C(.Xr?t!- ° M z y OWNER M a Allen Peterson ° -4 ° UNPLATTED LANDS 411 W. 4th Street SCALE IN FEET New Richmond, WI 54016 0 0 100 200 ,7. North line„ of the SW of the SE} M N89032138!1W 1323.71' 14' Joint Dr . I ACA ive Easemer.,. De-tail ' ~ %~Y 1 - `~~.f~,.' 40' LOT 4 L T 3, LIT 2 r < q4 t, ; aw 2og 20' 91.3,305 Sq. Ft. Inc. R/W'9~'vrj ~U'•:, o Acres 20.97 Ln I~ 910,588 'Sq. Ft. Exc. R/W y C.T.H. "C" 20.90 Acres co d U)I ni OD ZI v Q_ ° z1 QI, 1-14 -1 Mal rl N ~ -1 C]l ' Ga 151°' N8905412711 597.081- N8905412711E 661.83' 4 LLJi ~ 298.531 298.53' i ° ° ° v CO f-1 Q1 _ f-- I CL ° QI 0 C) I OO N N O -JI Z1 ~I `n LOT I W z z 431,179 Sq. Ft. inc. R/W ~i LOT 3 LOT 2 ao Go co so 9. so Acres 0 40 C) c Inc. R/W: o o Inc. R/W: 400,761 Sq. Ft Exc. R/W co Cn co 194,310 Sq. Ft.= ~ 194,310 Sq. Ft: -4 9.20'Acres o s = o ; to {O 4.46 Acres eo iO 4.46 Acres to 0 0 to o Exc. R/W: c Exc. R/W: 91 183,880 Sq. Ft.°oo 182,728 Sq. Ft.' o° ° OQ 4.22 Acres 4.19 Acres x z Buildings u;~Sept•ie• ,t 1,..WeII.. ° o .4 o M $ - 8900915111E 1326.18' - $ 29 561 r T 1 298. 5L1 .6.3.03' I 4' _ 298.53' 863.06' - rof N89 54' 27"E•-1326.12' South line of the SE} N89°5412711E Si Cornier of C. T . H . CT 1 Section 14 UNPLATTED LANDS 1326.12 SE Corner VOLUME 9 PARE 2411 Section 14 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER a(-~ L 1 ~QnC~p~ r~ ROUTE/BOX•NUMBER K. FIRE NO. CITY/STATE_ )-a. K c_1~Y~~nc~ .7 ZIP /Vo 7 PROPERTY LOCATION: S-w 1/9 Sa 1/9, Section T 3 / N, R ~ 8 W, Town of S t A (Z hra t St. Croix County, Subdivision 41 e. CA A; ~yyy9/ , Lot No. 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. iz~j i~.r Q SIGNED -M ?0 DATE _61 St. Croix County Zoning Office St. Croix County Courthouse 911 9th Street Hudson, WI 59016 (715) 386-9680 Sign, Date, and Return to above address W~sr~et DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS \ / MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTI N: TOWNS IP/ ITY: LOT NO.:BLK. SUBDIVISION NAME: N/R gi (o -sul COUNTY: OWNER' BUYER'S NAME: AI G ADDRESS _ 1 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERC L DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: Residence ®New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system [OSE]NAL: MOUND: PRESSURE: SYSTEM-I®ILLHO~LDING®NK: RECOMMENDED YS~TENy.(optional) i If Percolation Tests are NOT required JDIf any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS ,6,,, BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. GHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 91~ 9,f s B;,2 qtl B- / - i B- 8 B- ° - s 9L2 Nlgd~ B_ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD I PERIOD 2 PERIOD PER INCH P- s~a AldAZ6 3 P_a s- P- 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. 3 SYSTEM ELEVATION 9,9' All l 1.1 _ [ t... --"-7.. _ 3 - ~--'-""'-TTY"" ~ .__.y....,, ~ ' ' - E _ - - - r 7- 3 r 3 r € i , tN ~ i ~ I . 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 ( ri TESTS WERE COMPLETED ON: ADORE CERTIFICATI NUMBER: PHONE NUMB R optional CST SI T E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. D I LH R-SB D-6395 (R. 02/82) - 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; 0. 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 to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation re, rence point are clearly shown, arid are permanent; 9. Complete all appropriate boxes as to dates, names, sses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does riot apply, place N.A. in the appropriate box; 1 1 . Sign the form and place your current address and your 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 col:} Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone *s - Sand HGW - High Groundwater cs (-)a,-- Sand Perc - Percolation Rate med s - n Sand W - Well fs - e Sand Bldg - Building Is - Loamy Sand > - Greater Than "sl - Sandy Loam < Less Than *I - Loam Bn - Brown *sil - Silt Loam BI Black si - Silt Gy Gray *cl - Clay Loam Y Yellow - Sandy Clay Loam R - Red s - Silty Clay Loam mot Mottles - Sandy Clay w/ - with sic - Silty Clay fff - few, fine- t *c - Clay ce - comma p t Peat inns - Mane, rn - Muck d - distinct p - prornine ~t HWL - High Six general soil - -es surfs for liquid waste c _ I BM - Bench N VRP - Vertical F" erence Point TO THE 1:+ first st,~ p in r[ -he county or the D# ~ r_, it may request test in ";le p<: r A complete_set c: , .-ns for the private a permit application msr~ the appropriate local rority in order to a it. The sanitary permit nlust be obtain 'zosted prior to the start of any construction. Sr T3in/, cif w' Sf~~ ~~r.'~rR°rr "7' 7~ SiyT'C /f /~~JG✓ 3 >!d /ef/iJa SO 'lei Y 0 R, k r • ' v ~ • PAC, c or • ~rOSS J~CC~1O1'1 coT Zito I ~ ~ r fl•+A Ak Inlele And obtalvollon Pipe t' ~ZGI/ ~ APp+•rid vM Cy I' MWnaw 12' Above Final Geode i~ 20. 12' Above Pip' 1' Coal pee Y) - T• /leel ofede ~ Vaal Pipe 1Nr.• 11.Y Of 6Re O• OLLDdIee i five --Tee IP.'laele• Pipe YNow ~CeVpllnq TMOieelleq Al i Y•uew 01 ST.leme I j ' Pt`u ~ o) t 0 t' •-1 g r~, c~ c /Gb2 ' ~W-*, it ! ~~cJ..~ Ioll ~Uw SOIL FILL OISTRIBUTIOM PIPC APPRO'•/ro S•jNTHETIC COVC 2"OF1~6GRCG1ITE-~ `'11AT~R1^~ OR VOF STAA%. OR MARai• +'Ay ELEV. OF-W1-='FEC•r t."OP:~L->=~~Z AGGRCGATE DISTRIBUTIO/J PIPE To BE AT LEAg'T -21,~ IIJCHES BELOW ORiGIWAI, •;,,;AOE AQU AT LCASTLO IIJCHES BUT kIO MOKC THAW 41 IMCKES DELOW FINAL. r.PkAOC NXIMUM Mfli OF EXCAVATIou ROM OWMAL 64ADF- WILL. BE _,75;=_ IucHCS rg?(IMVM OEP711 OF EXCAVATION r-&OP\ 04R,14INAL GRAPE WILL 5C ~ INCHCS SIGUCO: LICCUSC 11UM8Eli: i DATE: 110