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Parcel 040-1061-30-000 03/21/2006 09:19 AM
PAGE 1 OF 1
Alt. Parcel 15.28.19.231 B 040 - TOWN OF TROY
Current X, ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - MOELTER, LYLE W & ILENE FAM TRUST
LYLE W & ILENE FAM TRUST MOELTER
634 GLOVER RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 634 GLOVER RD
SC 4893 SCH D OF RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 10.910 Plat: N/A-NOT AVAILABLE
SEC 15 T28N R19W PT SE NW BEING LOT 1 OF Block/Condo Bldg:
CSM 9/2510 10.91AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
15-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
01/10/2000 616726 1483/208 QC
07/23/1997 914/295
07/23/1997 914/293
07/23/1997 456/319
2005 SUMMARY Bill Fair Market Value: Assessed with:
102502 Use Value Assessment
Valuations: Last Changed: 07/19/2004
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 9.910 1,900 0 1,900 NO
OTHER G7 1.000 10,000 90,900 100,900 NO
Totals for 2005:
General Property 10.910 11,900 90,900 102,800
Woodland 0.000 0 0
Totals for 2004:
General Property 10.910 11,900 90,900 102,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 316
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76
HUMAN RELATIONS
N WI 3707
(ILHR 83.090) & Chapter 145)
LOCATION: SECTION: OWNSH I P/Za.UW CIPALITY: LOT NO. BLK. NO.: DIVISION NAM
S it 1/ NL.)% >S /T n N/R/9 E (ar) WT /ROY aPosE s
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
5-rr-k4 G~ ~0 - T R
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCR P IONS: ER OLATION TESTS:
Ig'Residence UIq KNew ❑Replace lu,4tA /99Z
ICS 321 SjLs_ I
RATING: S= Site suitable for system U= Site unsuitable for system
C NTI . MQ N~. IN-GRO S E1URE: SY LLIHOLDI T K: RECQAQMNENDED
~ 1 Ibu~~p pM
` l~
S ❑u (]Lw1J S U S U EIS S U (/rC_) f-
,jv[Gy
If Percolation Tests are NOT required DE,%LGN RATE: If an
` ! any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: L.4-t-5 I Floodplain, indicate Floodplain elevation: '/!"I
1VT PROFILE DESCRIPTIONS
BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH MV ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B 5,25 1~. 1~ ~(~D /S.ZS /O^LTS /Q A~PuaL9r BQa~G~ 7F ~CT$Qu !►'1`J
B-~ /d,33 96,A 33 //"Bcz~s22''eaa 9~ rB~,.,►t- ~/n e8e~~►
r2"6LLTs B'8eNL 16"Rd62A, MS-47Le
B-~ ~oTS T7.Za ~~105 ~}.v$ A9' $ej►l►SIfGi-
B-Q /7'IkLTS eNC c#_ /Q'Be"SLiZa
Voq , 71 ~74"ge*jMS f40-
B 9 ,44 40ME >'925- `rot&R /hs a~L Yee,~S,C
B- 6 9. Z 9~ nbN- > 9,9~Z ~"eLC.TS 2~~8a„>'S~L z~"t'~BeNMs~c,15c~"$a~►/~15~C~
ba,TT PERCOLATION TESTS
TEST EPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH
P_ 9641 97.06 3 > 2 > L > <
P_ -Z otS >
P- 3 s .bo oN 670 > 2_ > 'Z_ > •C
P- ~.Zp >Jt 6. O ? > <
P- LE.V AT tC
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil arewcA Ii ate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot p}an. S tPSe surOc'e elevatio'Mat all borings and the direction and percent
of land slope.
/Ep
SYSTEM ELEVATION ,Zv p-A
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I, the undersigned, hereby certify that the soil tests reported on this form were made- by me in ac rd with the rocedures nd me s specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the b st of y knowegge and belief.
NAME print): TESTS WERE COMPLE ED ON:
J6 44u5c►J O~1 rJSQyJ `tk'1/4 /^1G .
ADDRE~ S~al~ CERTIFL~/~TIOIV NUMBE PH_ ONE Nl,1MBER~(optional):
)Cr~C dl•7e0~• ^AtOtTlr
CST SIGN URE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 ( .10/83) - OVER -
INSTRUCTIONS FOR `-71"' 'I_ETINC FORM 1 - S - 6395
To be a complete and accurate soil test, )Ort n-,:
1 . Complete legal description;
2. The use section rrrust clearly indicate whether this is snce or' corms
3, MAXIMUM number of bedioorna :)r cornmercial a ad;
4. Is this a new, or ~ it rat sys°r
5, Complete the ,1 rating l,, A SITE 13 SU, . 'ABLE FOR A SING TANK ONLY IF ALL
OTHER SYS -1 l- RULED OJT BASED ON SOIL CONDITIONS;
6. PLEASE use the s evictions shown here for t.'ritir : le descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagrarn accurately locating y< 'oCations, Drawing to scale is preferred. A
separate sheet may be used if desired;
8. Make sure your benchroatk and vertical elevation r(, i ace point are clearly shown, and are permanent;
9. Complete all appropriate boxes as to dates, names, resses, flood plain data, percolation test exemp-
tion, if appropriate;
10, If the iof )rraaation (such as flood pf-in, e=levation) does not apply, v)lace N.A. in the appropr ate box;
11, Sian the form and place your cur ~%h ;s and your certification number;
12. Make legibly copies and distribute as reclr.amd. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL RIT`r' WITHIN 30 DAB'S OF C'OMPLE:T1ON,
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
So tes and Textures Oilier Symbols
st we (over 10") BR Bedrock
col) - Cobble (3 - 10") SS Sandstone
gr Grav='+. (under 3") t_' - Limestone
~s =+4i Groundwater
cs - C"- Pcrcolati )r, Rate
is - p:,
t:- _ 1. ,ratY _ ~t1
si ~iE• f`
Y _
cct Lo=3rn
sic;l S, U irr, mot - Mottles
Sc c y J with
sic- Silty Clay fff - few, fine, faint
-Ac Clay cc: cornmon, coarse
pt - Peat n)rn Many, medium
in - 'Muck d distinct:
p prominent
l-kVIL High wate ievel,.
Six general sok`: surface, ,vater
for hquid vvasre: r _ mal BN1 Bench Mark
V RP Vertical Reference Point
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 bcsubmitted to the appropriate local authority in order to
obtain a permit. The sanitai y permit must be obtained and posted prior to the start of any construction.
K :;w/
4 85736
C ER T .Z- F I ED S UR V E Y MAP
Located intthe SE 1 /4 of the NW 1/4 of Section 15, T28N, R19W, Town
of Troy, St. Croix County, Wisconsin.
Surveyed for:
Greg Moelter Lyle & Ilene Moelter Family
634 Glover Road 'rust. E1/4 Cor.
Hudson, W i . 54016 W Sec. 15
"tN T28N,R 19W
.c, -01 co
mo'`
N CDo
Nj
N
Z
UNPLATTED LANDS
- - W sl 6'I
(SOUTH 825.00') 3
S 01`3 '33"E 829.30'
)0 00 352.33' 4''31I7.29'~j'476/~.97' 39.68'- I
N r ll~ ® I I G
95, 393 Sq. c co 11
r I
W V ~ Includin OW• ? o v
,333 Sq.Ft.(2,00 Ac.)N
I a) MI N ao Excluding ROW
ZI - - IV 0
437.31'
Z
a I N(M O N 00' 36' 1B"W 476.64' 39.33' I
A I w co m L07 I ~ a
NI ao 475,172 Sq. Ft. (10.91 Ac.)
E
PI Z Including ROW
,al 445,743 Sq. Ft. (10.23 Ac.)
Excluding ROW t- z 0
D I t9 5 • 07I
rn Qn
m:
1 p1992~' 4 W iv
Rget9, :C~t1o6% j I L I ti
m
Bearings referenced rr
Ln CID
to the East-West 1/4 N ti r I
quarter section line, 11 3 f+ f~ l U
~
assumed S88°49'42 "W 'y340
c~9, J wl
DUAL ~eF O BS• WZ .4 az I I V EE'l
/0~ 4 ..1 re LU W >
~ oa am N ui a I
.10 OB. I 2
LEGEND ds 1~.
-Section Corner monument I ~OI
Berntsen cap. I ~I
0 1'x24" Iron pipe weighing 1.68 lbs/lin, ft. set.
IN
• 1" Iron pipe found v APPRoVED
'-A Fenceline 16 g'I
I J
( R) Previoubly recorded information. 10.'92. N
iA o
S. T. CROIX C4ut4TV U
SCALE IN FEET I = 150 yomprehensive planning z
0 100 200 300 450 Zoning and W 1/4 C o r
parks 00mtnittcte Sec. 15
if not recorded
This instrument drafted byIPA wtithin30d0sOf 4922039
approval date
VOLUME 9 2510 approval shAb•
null & void
Parcel 040-1061-30-100 07/23/2007 09:27 AM
PAGE 1OF1
Alt. Parcel 15.28.19.231 B-10 040 - TOWN OF TROY
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - MOELTER, GREGORY J
GREGO J MOELTE
0 GLOVER RD
HUDSON W154016
stricts: SC = School SP = Special Property Address(es): Primary
Type Description " 650 GLOVER RD
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 2.190 Plat: N/A-NOT AVAILABLE
SEC 15 T28N R19W PT SE NW BEING LOT 2 OF Block/Condo Bldg:
CSM 9/2510 2.19AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
15-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
01/10/2000 616726 1483/208 QC
07/23/1997 967/248
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/19/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.190 48,000 182,700 230,700 NO
Totals for 2007:
General Property 2.190 48,000 182,700 230,700
Woodland 0.000 0 0
Totals for 2006:
General Property 2.190 48,000 182,700 230,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 131
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Y
AS BUILT SANITARY SYSTEM REPORT
OWNER jel Ay TOWNSHIP
SECTION T 2-y' N-R--ZJ-W
ADDRESS GyfT 4;101,lel ST. CROIX COUNTY, WISCONSIN
/a
SUBDIVISION A/4 LOT Z LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
o p t EL '7/,7-0
L
I } A
l F
I B~ A
I i rt
D
~vkSR ~~c
8 rV
fl y R IND E NORTH ARROW
io~~ ~w° tee
BENCHMARK: Elevation and description:
Alternate benchmark
SEPTIC TANK:Manufacturer: 1)<eks G 19. Liquid Cap. 1}4W
Rings used:__L_Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest .road:Front x , Side , Rear Ft.
From nearest prop. line:Front , Side, Rear Ft.~
No. of feet from: Well S q~ , Building: /(o
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
I
PUMP CHAMBER
Manufacturer: 11~4 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
I
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
Width: S~ Length Zd' ~ Number of Lines:---L-Area Built
Exist. Grade Elev. 96.2 Proposed Final Grade Elev. 96.4'
Fill depth to top of pipe: y~
No. feet from nearest prop. line:Front , Side_,_S._, Rear Ft._
No. feet from well: E± No. feet from building 9d
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: a, a'~A~
DATE : PLUMBER ON JOB : Zc 7/ Hiw"
LICENSE NUMBER: /Y 01e.S 37-2y
6/90:cj
.28.19,SE NW LOT 2 WAGE RD. County:
-Wis`con~iIn partmeRntOo l(~d,15ry,
L'aborand Human Relations ~'RI~ATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 180270
-Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
OELTER GREG TROY
CST BM Elev./: Insp. BM Elev.: BM Description: Parcel Tax No.:
~(~,d'K CQ S 7pi AW
160 , V oaky~t ao C S t 1 -C
TANK INFORMATION ELEVATION DATA A9200349
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic p o Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet q q3 ~j7
TANK SETBACK INFORMATION St/ Ht outlet Vent P/L WELL BLDG. AirIto ntake ROAD 1911 Inlet ~ (o~ 9a,,c(b
Air
V%togAw
Septic ~(o NA
Dosing NA Header / Man. 9,73 Cfa, -15
Aeration NA Dist. Pipe `l ,Ct q q a, (,q
Holding Bot. System 11 al 01 -Pci
PUMP/ SIPHON INFORMATION Final Grade b, 0
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~J- DO 0- DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type O> Model Number:
System: yu,., `l J~7 30 c/ 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 Txx Mulched
Bed /Trench Center dy'Z/`L Bed /Trench Edges ~`1 7 Topsoil El Yes ❑ No El Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
y'(I f 1
L CATION : TROY, 15.2 8.19 , SE N ; LOT 2 : GLOI RD
~
a~..: g(.~.,....~
t
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
, I
I
DILHR SANITARY PERMIT APPLICATION COt,NTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE S IT Y PER IT #
-Attach complete plans (to the county copy only) for the system, on paper not less than T
6% x 11 inches in size. ❑ CF 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.
PROPERTY OWNER PROPERTY, OCATION
S ICJ TS,N,R ~(or
PROPERTY OWNER'S MAILING ADDRE LOT # BLOCK #
(03q C: La:Jer 2
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
II~~ ( ) ❑ State Owned r~ O, VILLAGE I~ 1 bL' N t
r
JQU F:
❑ Public JL~J 1 or 2 Fam. Dwelling of bedrooms ! PARCEL T NUMBER
Ill. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo 36/4)6
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 80 Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ~ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only 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 JZ 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.) PROP/rOSED~ (sq. ft.) (Gals/day/sq. ft.) (Min./inch) c~ELEVATION
oU !
3 Feet 76' 64eet
CAPACITY
VII. TANK . Site
in allons Total # of Manufacturer's Name Prefab Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks oncret strutted glass App.
Tanks
Septic Tank or Holdin Tank Tanks I __M 1 El 1-1
- -,&-H =:F=
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 (Print): Plumber's Signature: (No Sta ps) MP/MPRSW No.: Business Phone Number:
v r'ti ` 7 /t!~ M Z ZI y
Plumb is Address (Street, City, State, Zip Code):
'o C; b, h
IX. COUNTY/DEPARTMENT USE ONLY
q Issuing A pent Si ature (N to s)
❑ Disapproved Sanitary Permit Fee (lSurchargGe Feej water Date Issued
Approved ❑ Owner Given Initial
9 0?3 i
Adverse Determination
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
;4. INSTRUCTIONS
1. A~sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new r
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 installatiop,.
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.
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.
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
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 got tesale by
ownet/contractot,(spee 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.
- - rr rr ---r r------- r
Ownet ,ot property
Location of ptopazty /4 _ _1/4, Section 1, T= •R Y
Township /
Maliing address
Address of site TA-~
subdivision name S
Lot number
Previous owner of property
Total else of pstcel 7 L4 I„ to 14 4Z
Date parcel was created
Are all cotners and lot lines identifiable? as o
is this property being developed for resale tepee house)? as 0
Volum y~Zand Page Number ,-2VY_ as recorded with the Register of Deeds.
----------r----r--r----•------- •rr•------
INCLUDE WITH THIS APPLICATION THE FOLLOWINCs
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAOE NUMBER, and
the SEAL or THE REGISTER OP DEEDS. In addition, a cartifled survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Cartilled survey Map, the Cettlfled Survey
Map shall also be required.
PROPERTY OWNER CIRTItICATION
I(We) cettlty 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 totm, by virtue of a wsrtanty `d~ t corded In the Office of
the County Register of Deeds as Document No. 7y rj_I and that i (we)
ptesently own the proposed site lot the savage disposal system (or i (vs) have
obtained an easement, to con with the above described property, lot the
construction of sold system, and the same has been duly recorded In the office
of the ounty Register of Deedso as Document No.
Signature [ Owner Signature of Co-owner (it Applicable)
Data of Signature Data of Signature
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STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT ~
St. Croix County
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OWNER/BUYER
® /i o
ROUTE/BOX NUMBER ire Number :J
t7
~✓S ZIP
CITY/STATE
PROPERTY LOCATION: '.'S ~E rUC Section j, T 2,fN, R_/LW,
Town of TY~,u St. Croix County,
Subdivision Lot numberoZ
Improper use and maintenance of vour 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 licensed se tic tank RL= ear. What you put into
the system can aTTect ttie function of.the septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents may be eligible to recieve a. grant for
a maximum of 60% of the cost.of replacement of a failing system,
whi.c 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 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 private sewage disposal system in accordance with
the standards set forth, herein,.as set by the Wisconsin Depart- ::r
ment of Natural Resources. Certification form must be completed .d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED
DATE c~' _ ! y a-
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
P.O. BOX 76
LABOR AND - PERCOLATION TESTS (115) MADISO
N WI 3707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/Z.UWCIPALITY: LOT NO.: BLK. NO.: DIVISION NAM
1/a 1~~1/a /S /T 6 N/R/9 E (or) W I leo Y Z teaPps&t. ~~Jr l
COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILED RIP ONS: ` PERCOLATION TESTS:
*IJL~~ 2New ❑Replace~`~ I l J*;l+J$~ /9gZ
< )L5 k ~Z S61C S - RA-
4 ) ~Lo 1
RATING: S- Site suitable for system U= Site unsuitable for system
C NTIONAL: IM_QUPD: IN-GROUNDS Pa~ RE: SYM-IN-FILLHOLDING T K: RECf)AIJMEND-ED SYSTEM:(optjgnal`
❑ U /L-~+_yN
S U rJ~1y~S ff] S K 0U S
4.3 Zr ELL-
If Percolation Tests are NOT required DEGN RATE: I If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: [~5 Il Floodplain, indicate Floodplain elevation: ~Q
~T PROFILE DESCRIPTIONS
BORING TOTAL 7 PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHffSf- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- S>2s 6.9~ .rJ > i~>Z5 to"<S 16A9Q oL 89` gea ois 7$~LT$Qy r►~5
I/'BOLTS 2-Z "$PaSL il' 3QN5, C. 3/" d8e:►m
B- 'Z Id>33 4~.?`~ > 33 X19 *'BQ,j P7s 44 e
WISLCM i$'9e jL /Q'RA&ju '!S47&e
B-3 R7.Za ~r(E g.c18- L< 9' 8e,3P15 4Ge-
J~ 1'7'BLLYS iC' e& C Ge /Q"8e~5L~~Q
B_A %,L6 oq'- > 9-r5 7-4 49P-..jMS fc,L
B- q,-' 9~,g /d4&_LTS t3' $~L i6 YBr~~S,C
ONE >'9.7~
B- 9.
h VT PERCOLATION TESTS
TEST EPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PER D PER INCH
P_ o 97,oI5 yZ > Z > t
P_Z ,ors lijn'j r_ '7.2-o .S >Z >Z . <
P_'3 5.40 o 76 > Z > Z >2_ .C
P_ ~.zo 1J 96,46 > > 3 <
P_ REV AT RC.
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil area icate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot p}an. S w-tne sur'f~ce'elevatio"it~at all borings and the direction and percent
of land slope. L
SYSTEM ELEVATION 4 1
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I, the undersigned, hereby certify that the soil tests reported on this form werremacre by me in ac rd with the rocedures nd me s specified in the Wisconsin
Administrative Code, and that the data recorded and the location' of the tests are correct to thest ov ylknowOge and belief.
NAME print : TESTS WERE COMPLE ED ON:
Jb 44 >JSd N p U o'Sa-0 _!5ok /nit / /J C . I
ADDRESS- CERTIF- AT'I,O,NUMBE PHONE N MBER(optional):
t~ Tj ~jI S~1a1 3^~- ado
CST SIGN URE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHRSBD-6395 (R. 10/83) - OVER -
ros G P~ /"vee /"i'
TIMM EXCAVATING
' Route 1 BOX 192 SHEET NO. ~ OF Z
• WILSON, WISCONSIN 54027 CALCULATED BY 1Af 4) DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT205-1 ~ Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE I-BDD-225-M -
roe 6re!~ Aloe lirr
TIMM EXCAVATING SHEET NO. z OF Z
Route 1 Box 192 ~rZ
WILSON, WISCONSIN 54027 CALCULATED BY DATE ~w
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE I-800.225-M
REPT131 TROY ST. CROIX COUNTY ZONING PAGE 1
11/05/92.11:44 REQUESTS FOR INSPECTION WORK SHEETS FOR: 11/ 5/92 AREA: MJ
Activity: A9200349 11/ 5/92 Type: CONVSEPT Status: PENDING Constr:
Address: TROY, 15.28.19,SE,NW,LOT 2, GLOVER RD.
Parcel: - - - Occ: Use:
Description: 180270
Applicant: MOELTER, GREG Phone:
Owner: MOELTER, GREG Phone:
Contractor: TIMM, ROGER Phone: 772-3214
Inspection Request Information.....
Requestor: TIMM, ROGER, Phone:
Req Time: 14:11 Comments:
Items requested to be Inspected... Action Comments O Time Exp
00012 FINAL INSPECTION
Inspection History.....
Item: 00012 FINAL INSPECTION