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HomeMy WebLinkAbout038-1089-30-130 c 3 00 p E» a N ~4 N 0. 0 C. I O O N p I i Z i N o z c LL c c ~ L. U Q ~ M 7 II' ~ z jry co E 0 z `m co w a co N H U) c O C z C U O 2 a c O fA F- r O U z c E -a .6 ~ M I _~V N wpm co N C •N~ a U) L 0 0 m O 0 N ¢ w z co z Q N z Cl) W c d. N c N N 'j O7 N - d CL C w w V c fD O N N d i vi 2 O O O O G a a - C4 < 0 LO U) U) U) Z N > ! F I- 0- N 3333 CL CL Zo O O O a a a FL E m o N 0 rn m N 05 w ~2 } Q) i o o 3 O n Q] U N d Q Q O O r+ 0 O O 3 N tlyj C r.+ r M 0 C c E lA m G U O O ss O O L" O O M M N N O. U) O 000 00 c O O c N O M H M d ~p N 0 H H .c CD T M't L M O N E E n7 U 0 04 U) C> z cO ~ _ r w - E E - v~ d ~ at a a w • ACC C. d .U d c r~ u E i c c d+ r A v a O m 0 FORM - STC - 104 • AS BUILT SANITARY SYSTEM REPORT OWNER $ rTOWNSHIP Q- r SECTION -~-T_ -RAJ& W. 3(oc1.4- 3o ADDRESS • 0-4 ,16D ST. CROIX COUNTY, WISCONSIN ~~2 P ~Ch Mo-nc) LAT-.5 x6l 7 6zK f~ ^A~ SUBDIVISION LOT„Q~)LOT SIZE U PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM a . INDICATE NORTH ARROW BENCHMARK: Elevation and description: Alternate benchmark SEPTIC TANK:Manufacturer:&,~,!v Liquid cap. 16a- 1XI Rings used: -,_Manhole cover elev:/Wi Final grade elev:/0/ Tank inlet elev.: Sa Tank outlet elev.: 9'7"d)n No. of feet from nearest road:Front//,5Side ~ , Rear Ft. //5 From nearest prop. line:Front , Side-L~, Rear Ft. 3 j No. of feet from: Well-It 69 Building: : a7 ' (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE y 1 ..ul A_ t . 1 rj 4- 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 T ype: -Location Distance from nearest prop. line: Front-, Side, Rear Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: -Trench: Seepage Pit: Width: /._Length _Number of Lines: _Area Built226-,w Exist. Grade Elev. /40•' proposed Final Grade Elev._ Fill depth to top of pipe: 31o ' 9 No. feet from nearest prop* line:Front Side Rear _Ft..3d No. feet from well: 79 No. feet from building 3S HOLDING TANK . Manufacturer: Capacity: No. of rings used: .....Elevation of bottom tank: Elevation of inlet: No. feet from nearest -prop. line:Front ,r, Side, Rear.-Ft. ~ No. feet from: Well , building nearest road Alarm Manufacturer: i I INSPECTOR: DATE : --L-30 PLUMBER ON JOB : LICENSE NUMBER: ) S 6/90 : a j t LOCATION: STAR PRARIE 21.31.18.364A-30,SE,NW,21,CO.RD.C, LOT 2 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 149260 Permit Holder's Name: ❑ City ❑ Village )F] Town of: State Plan ID No.: BRAYALL GEORGE STAR PRAIRIE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: IJ ,G- 6i6 S-OjI c'~.r' 038108930130 TANK INFORMATION ELEVATION DATA A9200104 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. r Benchmark Septic f 7' C bra<-` i Aeration Bldg. Sewer Holding St/ t Inlet 97 E.3~ TANK SETBACK INFORMATION St/ Outlet Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic NA Dt Bottom NA Headers 7,p , 02/ Aeration NA Dist. Pipe 9 7, 6_0 r Holding Bot. System + > r ' 9~, Q( PUMP/ SIPHON INFORMATION rade r Demand j2,X , e) 166, 6.V Model Number GPM I Loss Friction SYs TDH Ft TDH Lift Forcemain Length Dia. M Dist. To We- u-"--SOIL ABSORPTION SYSTEM BED/TRENCH Width Length ( No. Of Trenches No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~a DIMEN I N ` SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAC Manufacturer: SETBACK ~ INFORMATION Type Of (2 C,,, V-, , CHAMBER Mo tuber: System: r' cj, =cQ dA OR UNIT DISTRIBUTION SYSTEM Header4AAaa4&H ii Distribution Pipe(s) , r x Hole Size x Hole Spacing Vent To Air Intake / Length At- Dia. Length Dia. Spacing _LZ ~ 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 U Bed /Trench Edges Topsoil [I Yes ❑ No E] Yes ❑ No COMMENTS (Include code discrepancies, perso present, etc.) C F1, Plan revision required? ❑ Yes 2 <0 I A Use other side for additional information. ku Al :1 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ' SANITARY PERMIT APPLICATION 7DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT-#~r -Attach complete plans (to the county copy only) for the system, on paper not less than / 9~(~U 8% x 11 inches in size. ❑ Checkevision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION rs. 5'/a I,J%, S TAI , N, R or) W PROPERTY W _ 5-S MAIILIINNG /ADD E - LOT # BLOCK # W-X- CI1Y, ATE C,{ ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY - NEAREST ROAD ❑ State Owned .VILLAGE : f ~y ~Sff law w. X4 ❑ Public '[~A1 or 2 Fam. Dwelling-# of bedrooms, 'PARCEL TAX U R b 3 S jd g 3r cq a, O III. BUILDING USE: (If building type is public, check all that apply) r 3 4iJ) ^ 3c~ 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. IC) New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 511 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.) (G /day/sq. ft.) (Min./inch) / it ELEVATION & f -3-7 (G C leSS 96 Feet ODD 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 structed Septic Tank or Holdin Tank Oµ' Q"' Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name rint): Plumber's Signatur Stamps) MP/MPRSW No.: Business Phone Number: V L-1-I V` S l J f'o 3 t 01 c> -5 t13-5 Plumber's Address (Street, City, Statq, Zip Code): IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved itary Permit Fee (includes Groundwater a e Issued Issuin Agent S' N ps) Approved El Owner Given Initial I~ Surcharge Fee) Adverse Determination Val= X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your ganitary 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 (SEID 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'-9 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 cn 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. Vlll. 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 3% 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 sizi69 information. - - - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SIB D-6398 (R.11/88) APPLICATION FOR SANITARY PERMIT S T C 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. 'Any inadequacies will only result in delays of the permit issuapce. Should this development be intended for resale by owner/contractor,("'spec house"), then a second 'form should be retained and completed•when the propertyfis sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Property 'k LW_34, Section T 3_,,_ N - R W fewnship . ' -9 4tfF Mailing Addtess woo h LOT Subdivision Name Lot Number • 1 Previous Owner of Property ~n 4 v - Total Size of Parcel ! "e Date Parcel was Created Are all corners and lot lines identifiable? )C Yes No Is this property being developed for resale (spec house) ? Yes_ No 7 Volume ~ and Page Number 21-13q as-recorded with the Register of Deeds INCLUDE WITH THIS APLICATION ONE OF THE FOLLOWING: 1. Warranty Deed < eeo, /,Of/) 2. Land Contract / ,q S! ` d ~l o~✓•~ 1. Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTV OWNER CERTIFICATION I (We) cvLtZ6y that a.U atatement6 on this 6oAm ane tkue to the beat o6 my (owL) knowledge; that 1 (we) am (axe) the owner (s ) o6 the pnopenty de c ibed in th A .in6o,mati,on 6onm, by v.lhtue 06 a waAAanty deed neconded in the 06jice o6 the County Register o6 Deeds as Document No. 911 1 and that I (we) pneaentZy own the proposed .6 to 6on the a age polo. syd#em (on I (we) have obtained an ea a-ment, to hun a;ith the above des en ibed property, bon the. eon tAucti"on o6. said system, and the dame hab been duly neconded in the 066.ice o6 the County Reg.izten 06 Deeds, a6 Document No. ) SIGNA URE OF OWNER SIGNAT E F CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED • j i DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1]982 _ . 477421 Vol 'A-i REGISTER'S OFFICE Rob .o int..tenantska&-.ta..anenthi.rd~anterest~aand..ThendoreA.... ST. CROW CO., WI Recd for Rec Coo-k. . Z . _Su-a .-D.- . Coak, _4usa.nd --and. wif e ..as ..to, t.--&.-Gary. 1_. Caak..as to.-one-thi.r-d..interest__one-third.',-. i n y JAN 02 1992 M; conveys and warrants to GeOra@ L. .QY'sya]-].-.and..Tammy of lal • 55 A. L-;_Le.i tner...as..Joint..Tenants..With. the-. rights...of........... . (M~, survivorship-----• . .._._.F of Regrster _ - - - . _ _ RETURN TO I. the following described real estate to St. Croix . . ' _ . . . . . ..County, L - State of Wisconsin: Tax Parcel No. i ~ II A parcel of land located in the Southeast Quarter f the Northwest Quarter (SE1 of NWT) of Section Twenty-One (21), Township Thi -One (31) North, Range !I Eighteen (18) West, further described as Lot 2, C ified Survey Map as recorded in Volume "9", page 2434. i I OANS I. I i ji This --i---- Kl(1t-.:-------- homestead property. (is) (is not) l Exception to warranties: I ~ i I Dated this . 31 st December j 1x..91 _ . day of - - i 00 (SEAL) (SEAL) Robert--J....Cook........................ Theodor -..,---Cook - (SEAL) c-~ L4-- (SEAL) * Ma rjo...e..E. Cook------ µ an D Cook..._ (SEAL) * AUTHENTICATION G L OWLEDGMENT Signature (aSTATE OF I CONSIN ss. St. Croix ---------------County. 31 St authenticated this ........day of 19...... Personal came before me this ................day of ...--...De. - tuber......____, 19.91... the above named i, . . Robert--J_ -Cook TITLE: MEMBER STATE BAR OF WISCONSIN ,..Ma 7jpy:ie..E __Cook...... ...Theodore. ....Cook, Susan D. Cook (If not, authorized by § 706.06, Wis. Stats.) y to me known a the person w ex cuted the foregom nstr ent and acknowledge th"WN THIS INSTRUMENT WAS DRAFTED BY ~7y -1 N107 REINSTRA VAN DYK & NEEDHAM S.C New Richmond, Wisconsin 34U77 . ~~1Ln►.n.-- avv... a Notary Public . - ...-$t'---..r0.--.......-----.County, Wis. (Signatures may be authenticated or acknowledged. Both My Commissio is permanent. (If not, state expiration are not necessary.) date: . 19.1. 'Names of persons signing in any capacity should be typed or printed below their signatures. i 0i DF'o oe'0 37991,1., 4 Sr, clq~FlC 477:107 Ni Corner of CERTIFIED SURVEY MAP Located in part of the SE4 of the NWh of Section 21, T31N, Section 21 R18W, Town of Star Prairie, St. Croix County, Wisconsin. an AT w N89Q 1715211W N N 1r O M O C /I N a -0 834.001 to o ZNorth line of the SE} of the NWJ of Section 21 d v s " 26LL I96CI b U, OWNERS YQL , 538, 2Q , 5QQ Cook Construction W " N co c N ~ N 1558 Hw 64 C. C y y• - - ~ New Richmond, WI 54017 C. U V N ro o 0171 11 a v, N89 52 W c_#- 391.651 y s c .r m d+ N nl c 0 l01 w N~ LOT 2 87,324 Sq. Ft. -1+ tai M 2.00 Acres z C] 1 Co s I Aj. 0q] C/ i 4- __N ' ~~h 1 l1N2LATT~~ L~N~~ >i H ro ~ e W • Ln to N M .t . LEGEND -1 Roadway Setback- Line AL, C• County Section Monument - Aluminum NV14 Cap Found o'~-1~IQ7 a`~,p~0 111 x 2411 Iron Pipe Set, weighing 0 HUDSQNI, d 1.68 lbs. per linear foot. rwjs •f~ e 111 Iron Pie Found 118t Q'" ^I1 CURVE (D - Q UNEL[ II D LANN APPROVED Radius Length- 378.001 DEC 1 3 1991 Central Angle= 1904211811 51. CInI ~.IJUNiY Chord Bearing- S5205511011E ~.C;MPREHENSIV(` PARKS F~lA(!1',tf.+ Chord Length. 129.361 A • r~ ~ Arc Length. 130.001 C'~NINf--. . ttiAiwl ~ F. AND 2_ Tangent Bearing- S6204611911E. SCAL]k TN FEET Tangent Bearing S43°0410111E 5 SEEN 0 100 200 300 This instrument drafted By Brennan J. Cox Proj. No. 81-21-291 Center of Section 21 VOLUME 9 PAGE 2434 i - hEhZ 3Odd 6 EWfMA •aOTApt? 70; aot;jC) 611tuoZ AqunoZ) xTO.z- -IS aq4 gosquoo sTao-sd us buidOTan thus ap aO 6uissyoand aao;ag ( •ole 'Too.aed oq ssaoos 'azTS DoT unwiuiw 'spusT49m •a•i) suOTIPTnBea pus saTn.i 'GmPT Aqunoo pus agsS of joaCgns eT (4sTa) dsw STgj uO UMOys Tao.7sd yosS n a T J ' T 5 a;aa a ~eq~N • 0 ua T Tit A Y-fL l \ D•awns butddaw pua buZdaAIns ut xto-10 •qS ;o d;unoo aq; ;o aouauTpIO uOTSTAtpgn$ pueq aq; pus sa;n;s;S utsuoastM aq; ;o V£'9£Z 194HagO ;o suoTsTAOid ;uaaano ag; g;tM paTTdwoo ATTn; aABq I ;ag; :pagTiosap Pug p8AGAins Aaepunoq aoTaegxa aq; ;o 81208 o; not;a;uasaadea ;oaaaoo a sT daw A.ahanS pat;T-4;190 G'M ;gq; 4TI:190 091v 'I •butuutbeq ;o ;uTod eq; o; ;aa; 990T6£ 'aot;;o ptas IS 90S abed '8£S awnJOA ut pegTaosep punt ;o laoaud a ;o euTT q;nos aq; buoTa M„Z$,LTo68N aauaq; :;aa; ZV LS4 „~T 05oS£AT aouaq; :;aa; 00'0£1`"'P d,3 UMO; aq; ;o dgM-;o-;g5T.1 dT-301829q42ou sq; pug aAano pTas ;o 012 aq; buoTg 'ATie4aseq4nos aouau4 :;aa; 9£'6ZT seanseaw pus S„OT,SSoZSS sagaq paogo asogm '„8T,Zto6T saansvew aTbua T214u90 asogM 'ATaa;saMq;nos anaouoo 'aAano sntpga 100; 00'8L£ a uO ;uzod a o; ;aa; 3£'86Z 'T 101 pzas_;'o auTT Alxa;saa aq; buoTa 'z„9£,LSo£OS aoueq; 'uoT;dT:tosap stq; ;o buTuutbaq ;o ;utod aq;,o; ;aa; 09'80Z 'OOT;;o spaaQ 3o 29ISrbag 4unoo xtoao •;S aq; ;a 95£Z abaa g awntop uT pap.zoaaa daw, AOAanS pai;t;aaO ;o T ;oq ;o auTl Ajaa;saa aq; buoTa 'M,,8g,.VZoTOS aauag; :;aa; 00'V£8 'uOT;aas pTgs ;o V/TMN 9q4 go V/TSS aqj ;o auTI q;aOu aq; buOTs 'M„7.S,LTo68N 90ueg4 :499; Sb'SZ£T 'uot;oas piss 3o t,/TMN aq4 3o auTT ;sae eq; buoTa 'M„8GJZoTOS aouag; ;TZ uOt;oaS pass ;o aauloo V/TN eq; IV buiouawwoo :sMOTTo; sa pagT1098p aaq;an; utsuoastM 'd;unoo xtoao •;S 'aiaTaaa 294S 3o uMO.L 'M8TH 'NT£s 'TZ uOi;oas go b/TMN aq4 go V/TSS ago ;o ;aad uT pa;eool puaT ;o jaoaad v :sMollo; sg pegTAosap st paddaw pus POAGAZns loosed pugl aq; ;o Aiepunoq aoT39;xe aq; ;aq; :daw AOAanS paT;TIIaD sTg3 dq pa;uaseadea ST gOTgM Taoied puaT aq; pegTIosap pug peddew 'paAeAans anag I 'uOT;ona;suoo %ooo ;o uOT;oaITp sq; dq ;aq; A;i4190 Ageaeq 'IOdaAanS puaI uTsuoosTM paaa;sTbea 'uobggAN •o ually 'I S,LKOIJUHSO S , HOASAHnS J • r. N H • a ST C- 105 r r a SEi-rIc TANK MAINTENANCE ACREEMEN'r 0 St. Croix County z d a OWNER/ BUYER r_ 1-14 ROUTE/BOX NUMBER!/ Fire Number CITY/STATE k ZIP PROPERTY LOCATION: Z, 14, Section 1 TN, R W, Town of_ S4$4., ILIlALP'C_ St. Croix County, Subdivision Lot number' Improper use and maintenance of your septic system could result in its premature failure,to handle wastes. Proper maintenance cori- I sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into i the system can affect the function of the septic tank as a treat- ment 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 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 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 wil•1 be sent approximately 30 days prior to three year expiration. H 0 I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- u ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Offi.ce within 30 days of the three year expiration date. S I G N E D T E 1 I lay DA St. Croix County Zoning Office P.O. Box 98- Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, _ DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969 HUMAN RELATIONS IILHR 83.09(1) & Chapter 145) LOCATION: SECTION: p TOWNSHIP/M LITY: LOT N .:BLK. O.: SUBDI ISION NAME: S, , '1 N/R i (or COUNTY: OWNE 'S/ UYE 'S NAME: MAILING ADDRESS: 1,-4, Sr USE DATES OBSERVATIONS MADE NO. BEDRMS.: ICOMMER AL DESCRIPTION: W New DESCRIPTIONS: PER ATION TESTS: ®Residence 4gaNew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE, 1,YSTEM-1 N-F I L[HOLDING TANK: RECOMMENDEDSYSTE :(optional) I 'I S ❑U DDS ❑U DS ❑U ❑S EZU ❑S ©U or,e 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: Floodplain, indicate Floodplain elevation: 4Z~ PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AN DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 6o ? B--2 ~3 ZX AZ T 3 6? B-I - B- 7 C S B- - e B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- P- 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. SYSTEM ELEVATION ,'t . E E E nE 3 3 E . , > 3 E E r a1 E a 3 E E E E ~ E I, the undersigned, hereby certify that the soil tests reported on this form were made,by a in accord with the procedures 2,r 'd methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct`6p t best of my knowledge and b~elfief. NAME ( int): TESTS WERE COMPLETED ON: k" /1 AD R S: CER IFICATI N UMBER: PHONE NUMBER optional): At x- I CS SIGN U E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER - t' a l `A T 1, co, 2. 1 he ors 3_ N1AX1„ 4, is t i' IF , L'__ 6, : n . BE t-1L>u =atzff THE .~~13~ =size ~T ex, fls &x TO THE w, This soil test report is q t may request verification of this soil t :t 'he private sewage system and a per to obtain a permit. The sanit oi>' of c _1 1 L ( _I 1 _ ~ i ' i I i OLI~~I 00 I O I ~ I ! ~ I ~ 1 I I I Y I ~ i ' I I I , I i ! ~ ! I I! ~ I! ~ f ~ I I C ~ ~ ! ~ ~ I I I 1 I-. i ! ~ I I + I I r'Cfi , ' ~ i ~ I l j , ; ! I I ~ I I ' I i i i I , I I ; 1 I I I i i I I J I I 1 E ~ I I i ' i I+I I- I ' r I R I ~ I I 112 I I I I I I I i t I I I I I ICI I I I i I ' ~ ~ i i j I i I I I t I I _ I I , i l l l I~ I I I ~ I I I I I I I I I I ~ I I I j ~ I I~ I~ I r I ! I I i ~ I ! I ' I I ~ ~ i I ' ' 1 I j I ~ I ! I i ' ! I I I I ~ I I i i I ! I I , ! i } I I L I I I f l l I . i I ~ 1 r I ' II I - 1 I I ~ , I ~ I I I I I i i I I I ~ I I i I I I ~ i I I 1 , I 1 r 1 I t fi- I I ~ i i I I I ~ i ! I! I I T r i i I I I I I I i I f I - I ~ I I I I ' ~ - I I . i - I I i~ ~ l~ I I ~ -It , i I ' T ' , i ' I ! I I 1 I ' t I I I I C I' - I ~ - f , I ' i _ ~ ~ ~ I i I I ~ i I l i l CrUSS~c~IOr~ o~ rtcl~ SYSten-~ two FfdaA Alf In1816 And ObLervallon pipe S~ ✓ ~'j -~~5 ^-►~_APprorid Vent Cap ►Ilnlmurn 12•Abov4 Flnel Grad. Sfi~~ rem 20-.2' Above Plpr _ 1• Carl Iran To final areas Venl Pipe ►tar rn Noy Or Sfnl Mlk Covering wm 2' Aggreoalo Over Plpe Olrul°r1lon Pips 0 0 0 Tao Aggragall Beneath Pipe ° Porlorarod Pipe baler o --C0,01Ag Terminating Al flollomm Of System t C) PruP SOIL FILL DISTRIBUTIOM PIPE APPROVED S49TMETIC COVCR o '---/1ATF-Ri - OR 9" OF STRAW 2" of AGGREGATE OR MARSH H&J ~r lb~b OPAG 6RCGATE vP~v„ ELEV. of /E~FEET DIS-rRIFjUTIOU PIPE TU BE AT LEAST IUCHES BCLOW ORIGIUAL GRADE AI,IU AT LEASTtO IUCHE$ BUT 1.10 MORC THA1.1 tit INCHES 6ELOW FlUAL GRADE MIMUM DaPrH OF EXCAVATIOP FKOM oWWA>L 6RADR WILL BE yO _ IUCHES 711fOMV11 ©Kp rVi OF FACAVATIDFJ r-POM CA~1( NAL, CRnvf- WILL BE MCHE 5 SIGAICO: LICEUSC UUMBER: DATE. _ I~ REPT131 ST. CROIX COUNTY ZONING PAGE 1 02/04/92 11:18 REQUESTS FOR INSPECTION WORK SHEETS FOR: 2/ 4/92 AREA: JT * * * * INSPECTION REQUEST SUMMARY Address Time Activity Type STAR PRARIE 21.31.18.364A-30,SE,NW,21,CO.RD.C, LOT 2 09:02 A9200104 CONVSEP Item: 00012 FINAL INSPECTION