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HOMESIT.E SANITATION CO.
SEPTIC CLEANING - SEWER SERVICE.
ROUTE 3, O'NEIL ROAD
HUDSON, WISCONSIN 54016 4
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Parcel 040-1156-50-000 12/14/2005 03:05
PAGE 1 OF 2
F 2
Alt. Parcel 24.28.20.612A 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 - SOBOTTKA, FRED H & SANDRA F
FRED H & SANDRA F SOBOTTKA
263 COVE RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ' 263 COVE RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.800 Plat: N/A-NOT AVAILABLE
SEC 24 T28N R20W PART OF SE 1/4 OF NW Block/Condo Bldg:
1/4 SEC 24 DESC AS: COM SE COR LOT 27 ST
CROIX COVE SUB: TH S 38 DEG E 66.13 FT Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
TH N 47 DEG E ON SLY LN COVE RD 278 FT 24-28N-20W
TO POB;TH N 47 DEG E ON SLY LN 130 FT TH
N63DEG EONSLYLN 70FTTHS22 DEG E
more
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 895/462
2005 SUMMARY Bill Fair Market Value: Assessed with:
103237 559,800
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.800 101,200 437,600 538,800 NO
Totals for 2005:
General Property 2.800 101,200 437,600 538,800
Woodland 0.000 0 0
Totals for 2004:
General Property 2.800 101,200 437,600 538,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 214
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER- rl ral TOWNSHIP i D
SECTION- i~T N-R6 W
ADDRESS- ST. CROIX COUNTY, WISCONSIN
SUBDIVISION -LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
COA
t
(oil
t r
r
INDICATE NIDkH ARROW
BENCHMARK: Elevation\and description:`''
. CL 1 b0
Alternate benchmark
SEPTIC TANK:Manufacturer:_ jjp, Liquid cap._ (Drop
Rings used:_12_Manhole cover elev:_Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road: Front , Side,, Rear Ft.- I=
From nearest prop. line:Front____, Side , Rear( Ft.-
No. of feet from: Well__ ~o Z! , Building:: /V
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
f .
•
PUMP CHAMBER
Manufacturer:
Li
quid 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 t X seepage Pit:
Width: Length__ L o Number of Lfnes:__Area Built Gores
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: 47 N 4
No. feet from nearest prop. line:Front_, Side-, Rear_ Ft. /a'
No. feet from well: -7 No. feet from building Z (11
HOLDING TANK
Manufacturer: ________.Capacity:
No. of rings used: _Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest .prop. line:FrontSide
Rear Ft._
No. feet from: Well , building
nearest road
Alarm Manufacturer:
INSPECTOR:
DATE: PLUMBER ON JOB:;.:- y
LICENSE NUMBER:.
6/90:cj
4
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
INSPECTION REPORT St. Croix
Safety and.Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GtNERAL INFORMATION Se, NW, Sec. 24, T28-R29, Cover 149259
Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.:
Fred Sobottka Troy
CST BM Elev.': Insp. BM Elev. BM Description: / / n Parcel Tax No.: reAll- Ila, 64D, ~ '60 _ ~ C6.~~-C+ E. Jlo~ a-,e~ 612A
TANK INFORMATION ELEVATION DATA p A
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 14,E
.
S r~ , ~9
Dosi
Au-
Aeration Bldg. Sewer 3'
Holding St/)A Inlet 1-7 % 9170
TANK SETBACK INFORMATION St/ bK Outlet 97
Vent
ir Ito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Air
Septic ` NA Dt Bottom
osin NA Header/-Men. 91~
Aeration NA Dist. Pipe " 7
9/O
. RS
Holding Bot. System qua r f
PUMP / SIPHON INFORMATION Final Grade
'C
c u Demand , ,
Model Number GPM V
TDH Lift Friction
Forcemain Length Dia. Dist. To we
SOIL ABSORPTION SYSTEM
BED/TRENCH Width I Length r No.O Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS Jr
SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING ufaaurer:
SETBACK CHAMBER
INFORMATION Type O ~ n/ Z Model Nu r:
System: /o ,L, OR UNIT
DISTRIBUTION SYSTEM
Header h+#slEl 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 it xx Depth Of xx Seeded / Sodded xx Mulched
Bed /Trench Center Bed / Trench Edges , F-(/0 ' Topsoil E] Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
4~c LCJ~;7C
Plan revision required? ❑ Yes a-K
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector s Signature Cert. No.
M
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
t
1
LOCATION: TROY 24.28.20.612A,SE,NW,SEC.24, COVER
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 149259
Permit Holder's Name: [I City ❑ Village X] Town of: State Plan ID No.:
SOBOTTKA FRED H & SANDRA F TROY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
040115650000
TANK INFORMATION ELEVATION DATA A9200110
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet
rl
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
I
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
I
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
a ~
3
SANITARY PERMIT APPLICATION
HR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
„~.,e.
T0=41
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 ~ ,rQ
8% X 11 inches in size. Check if reVslto prevlo s 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
P-yya a6-bz)-4ko, 5E t/4 rVOY4, S zlf T N, R Z.G (or W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
Cue ezL AA114 1 1444
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
(Check one) ❑ Stat@ Owned ed ❑
1771 TOWN VILLAGE :
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms 3 -PARCEL AX NUMBER(S) 60-000 ILIIN III. BUILDING USE: (If building type is public, check all that apply) j 2- 14
1 ❑ Apt/Condo C.
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
50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPPEE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. C 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 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 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SY5TEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ?-t ,_c ELEVATION
C.`' Feet KCC Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
M F] F1 [I
Septic Tank or Holdin Tank ! G
Lift Pump Tank/Si hon Chamber
Vill. 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 S mps) MP/MPRSW 1.: Business Phone Number:
/y; L 3ZIY~
Plumber _ dress (Street, City, State, Zip Cole):
/Ci//> r G ,
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes roue Water Date Issued issuing em Sign a (No S mps
XApproved ❑ Owner Given Initial ~ 1`7
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2: Your sanitafy 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:
I . 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 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; close 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)
f
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 b~! intended for resale by owner/contractgv,("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
Location of Property- c/i.) k, Section T N - R Z W
Township
Mailing Address
Subdivision Name jl
Lot. Number
PruVious Owner of Property -4E
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
is this property being developed for resale (spec house) ? Yes _e- No
Volume and Page Number ? as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3. 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
Mai), the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) eeAti.6y that at .btatementb on th.ib 6ohm are true to the but ob my (our)
knowledge; that I (we) am (ane) the owner (a) o6 the pnopen ty deb cA bed in thi.6
insonmati.on Soam, by vi tue o6 a wahAanty deed teco&d d in the 066iee o{ the
County RegiAften o6 Deed6 ab Document No. - _ S ; and that 1 (we)
pnebentty own the pnopo.tic.rl s4te 6o.4. the aewage poa by_,-frn (on I (we) have
obtained an eaeemeni, to n.urt w.Uh the above debc_Aibed p&ope/L y, Do)t. the
eonbt&uct(.on ob said eybtem, and the bame hab been duty keco&ded in the O~6ice
o6 .the County RegiAten ob Deeds, ab Document No. J
IGNATURE OF OWNER IGNATURE OF CO-0 R (IF APPLICABLE)
L) X11
V - f - - L
DATE SIGNED DAT S GNED
,t fJCt>wAE14S iVfi. n0191 W* A* Aleppo" R~ M>t
A P~Cf, n t
Richard-G-Ste--Marie. and Margaret M. Ste Marie
MAR
a 1
.
11:30 A:
.
con eys and warrants to ..-!?Y'ed-.H Sob - ----ottkd-. Sandra F. Sflbott . y
hus !r►d mod.-wife . ag.. t.jvQ "h.-i~p- ~ ...PAY
3
.
. - . . . .
R QN
~I - - . ETU TO
-
. II
the following described real estate in ...SC-.GlCQ:LX............. ,--County,
State of Wisconsin:'
Ta: Pared No:................. t
1
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Part of the SE% of NW4 of Section 24, Township 28 North, Range 20 1a
West, St. Croix County, Wisconsin described as follows: Commencing
at the SE corner of Loc 27, dSt. Croix Cove Subdivision; thence
S38°30'E 66.13 feet; thence N47 50'E on Sly ~ine of Cove Road, 278.0
feet to the point of beooinning; thence N47 50'E on said Sly line,
13060 feet; thence N63 14'E on said Sly line 70.0 feet; thence 4
S22 35'E 680.0 feet; thence S86°45'W 203.8 feet; thence N22 351W
563.9 feet to the point of beginning.
sr
Together With a non-exclusive easement and rights in and over the !
private roadway, private walkway and beach areas as described in a F
Warranty Deed recorded in Vol. "344", Page 425, Doc. No. 252015, and
membership in the Winford Lands Home Association, Inc. with all of fE
the rights, benefits and obligations of the same.
NSA
QQ.lt s
This - 18 -AOt:_- homestead property. Q
(is) (is not)
Exception to warranties: Easements of Record I
hated this day of Y, it C~ 19,11
p
(SEAL) (SEAL►
Richard G. Ste Marie_ • Margaret M Ste Marie 'h
'ra
a
(SEAL) ISEAL!
~..e-c ~►i~ ~k -tom
i• ti
AUTHENTICATION ACHNOWLEDGMANT J`
_ ~~>t4~s) ~•hOt1.l~-- _~r_..S'j ~.~1R~L'1~ STATE OF WISCONSIN E
I C..•. ` ss. i
/~•-~"'i-• -T------------ - ✓T l ✓t. - X !
County. LL
atlthentj&ated tlris 4-~ day of IGi? 19_A'. Personally came before me this t;Pkday of
t
- _A-4 et x-.C_ ~t 19.1--- the above nauleti a
' L
' My Commission Expires August 1. 1993 - i~
s,-- d1Nn ran re
TiT1 1C1~ STATE BAR OF WISCO N~Iti _ a
authorized by § 706.06, Nis. Stats.)
to me known to he the person who executed the I
I °
SW ;4oiA instrument and . phpo_wird/ge theJ me. y
T -4'S INSTRUMENT WAS DRAFTED nV 6DII 1J4
I.~ C?~. ~Ci!i`'~•-•
fill tl
CI-ex r
~
- -r-r--- ~r Notw-r Public . 5f. r~ tX County. Wi4.
(Signatures may he authenticated or acknowle&red.4-I .-M`- rpnimissi-n is permanent. (If not, state expiration
• are not necessary.)
• : ~I Names of parsons aiming in any capacity should he typ"I .•r pI-int'4
N~ :a
r
WAARAW" DUM STAT1< eAti OT R ~YIlCONSt!! ~1►eo4HR t
YQR~ SM. ~YNi
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STC - 105 r'
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SEPTIC TANK MAINTENANCE AGREEMENT '-o
St. Croix County
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OWN ER/BUYI:It
! ;r
ROUTE'/BOX NUMBER Fire Number
CITY/STATE ~!~1 Jj• 'ir -.__k?..-_ _
11It(Jl'IiRTY LOCATION: y>= I~~c_> !r., Section _t N, ft--~~ W' .
'Down of St Croix County,
Subdivision Lot number ~V.
I
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank p.LLu 1) e r. What you piit into
the systellk can affect the function of the septic stank as a treat-
meat stage 1n the waste disposal system.
St.-Croix County residents muY be eligible to receive a I,raiit 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 s sytems agree to keep their systems properly
maintained.u _ "
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 (it 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. o
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with H
the standards set forth, he•rei.n, as set by the Wisconsin Depart- 'd
ment 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. i
• SIGNED
DATE IV
St. C,,oix County Zon Lng 'Office
P.O. itox 95.
Hanuno'pd , WI 51,015
715-7 16-2239 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 (1 5) MADISON, BOX 707
HUMAN RELATIONS , WI 533707
(ILHR 83.09(1) & Chapter 145
L
,Sc OCATION: SECTION: TOWNSHIP/ LOT NO.:BLK. NO.: SUB IVI ION NAM~1 Nw 1/ Z.¢ /TZ~ N/Ran E (o C,r2i4 - ~Teeb lX (-_bVC
C NTY: OWNER'S/BUYER'S NAME AILING ADDRESS:
T_4&A 4 / T"rr 4A'Mcl Q CAGE MA) ss/Zi
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: IPROFILE D CRIPTIONS: PER OLATION TESTS:
Residence New ❑Replace Q 1992 ~AN -7 i9
yes 1 aGs - ~Z - $t~ V_iq.4 A
RATING: S= Site suitable for system U= Site unsuitable for system
E~CNc,
CO ENTIO❑NAL: MOUND: IN-GROU P RE: S 1LHOLDINGJJ((''~~~/'TA~VK: RECQMMENDED SYSTEM: (optional)
S,
S U ,FfZJf S EA ~((J]~JIJ'S ❑u ID OS ❑u DS ~JJ(UU f~.,.~ KA
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s. ILHR 83.09(5) (b), indicate: ~JQ Floodplain, indicate Floodplain elevation: A/ A
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH 1d ELEVATION OBSERVED EST.. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- f Do 4`6 ? '1".00 ",~5c s "Se")SL 46 10 4D"AR1, C Sk4
B-
B- ~.Z< ~9.C►Z a1,rF 16.Z5 13'$z L-S r'61R~► 4~'~k~ n'1S CCS~~geaC'5t 4A
B- -
I A
B- U./ /7 c3 > 9J7 ►Z"6L-S4 1S iY&..St. 4 '&oj :S 41 B&CSi6Z
B-
PERCOLATION TESTS
Nacv.r TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER J~RPQPY6t~ AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ 12.0011%is
P-'Z C ~b > >Z >Z
P_ lti ~O` >2 >
P-
P_ I-Lc A 110,. km 0Q<_
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. Sh the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION ik~acH A QS.CA o
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rative Code, and that the data recorded and the location of the tests are correct to the best o my knowledge and belief.
LDISTRIBUTION: dersigned, hereby certify that the soil tests reported on this form were made by me in ac tbr-prQcec6esind ethods specified in the Wisconsin
print): TESTS WERE COMPLETED N:'
S CERTIFICATION NUMBER: PHONE NUMBER(optional):
10 r-,
CST SIG RE:
Original and one copy to Local Authority, Property Owner and Soil Tester.
BD-6395 (R. 10/83) OVER -
1
INSTRUCTIONS FOR COMPLETING FORM 115- ` - 6396
To be a complete acid curate soil test:, your report rriust it ciurie:
1_ Complete legal desc
2. The use sect=ion must ` arly indicate i its is a rasiderice or comirielcial project;
3. MAXIMUM number of bedroorras or t °<~ial use plarimed;
4. is this a I-- or retalzlc'-rlent sys^eni;
S. Complete the suitabi' vratirg t --E IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHE'' v TT . - RULES.) OUT BASED ON SO t_ CON tITIONS;
.PLEASE a the a bb. is shown here for v,~ritiiag ;;s descriptions and cram. ;ing the plot plan,
7. MAKE A LEGIBLE c i - : clr ~tely locating your to locations, F . ;1 to , is preferred. A
separate sheet may bu us ,f
Make sure your benclinta , ar ical elevation reference point are cl -,rl, shown, and are permanent;
9. Complete all appropriate boxes as to dates, names, addresses, flood pla l percolation test exemp-
tion, if appropriate;
10. If the information (suc=h as flood plain'', r at:--I) does not apply, place N.B-~. all the appiropriate box;
11. Sign the form and place your curl ent s and your certification number;
12 Make legible copies and dist=ribute as rc dined. 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 - Sandstone
gr Gravel (under 3") LS Limestone
Ks Sand f 1 CaHigh G, cw ?dwater
cs - C<aarse Saud -rc - PPP-colat:ion Rate
rn,ed s - Medium &md W Well
Is - Fine Sa-Id Mori i cling
s Loamy Sand > l nan
1 :irii - 3
t 1
~ -t1 Y t [ i7 ui'
SO - x C; Reza
sicl C L runt - rvlottles
sc - `sandy Clay v' with
sic; - Silty clay fff - few, fine, °-=int
c --Clay Cc - comt"rv~"n, €;caar-"a
pt Peat III r41 - Many, ri
ill Muck d dist ;.,1.
Ia prorylin~,nt
HWL High vdater level,
Six genes"al sot( -textclres surfac=e water
for t;'quid .vas? e r1isposal BM - Bench Mark.
VRP Vertical Reference, Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county orthe 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 applic=ation 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.
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TIMM EXCAVATING
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Route 1 BOX 192 SHEET NO. OF
DATE 7
WILSON, WISCONSIN 54027 CALCULATED BY
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA 0696 MN CHECKED BY DATE
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TIMM EXCAVATING SHEET NO. 2 OF Z
' ' . Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY r DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM co nty,
Laboran4 Mum,an Relations INSPECTION REPORT St. Croix
Splety sn&Buildings Division
ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION Se%,NjN%, ec.24,T28-R20, Cove Rd. 149114
Permit Holder's Name: ❑ City ❑ Village aTown of: State Plan ID No.:
Fred Sobottka Troy
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
I Loss Friction System Head TDH Ft
TDH Lift
Forcemain Length [D ia. Dist.Towell
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS-
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O CHAMBER Model Number:
System: 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 T x Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes E] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
}
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. AH -H
SBD-6710(R 05/91) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: ' ,
SANITARY PERMIT APPLICATION
CHLHR couNTY
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than El 1~
8% x 11 inches in size. c eck i revis o to previ 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 n
V c- n /1 k~ -'S~' % 4/✓ '/4, S a~ T 7-W, N, R '-6 (Or)
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
/o-' 14
CITY, STATE ZIP CODE PHONE NUM SUBDIVISION NAME OR CSM NUMBER
CITY NEARE,fST ROAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE / j f~v~ v
_2 a
❑ Public N 1 or 2 Fam. Dwelling-# of bedrooms A
III. BUILDING USE: (If building type is public, check all that apply) J _ f z yi
1 1:1 Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ ln-Ground 420 Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
140 System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 7-! 7Y.;73 ELEVATION
eet Feet
VII. TANK CAPACITY Site
in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xistin Gallons Tanks Concrete strutted glass App.
Septic Tank or Holdin Tank Tanks Tanks de
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' ignature: (No S ps) MP/MPRSW N4.: Business Phone Number:
pp~ 1 % 2 /
Plumber' Address Street, City, State, Zip
Pods):
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (includes Groundwater Date Issued I ing Agent Signature (No Stivrips)
/ Surcharge Fee)
Approved C1 Owner Given Initial 7-91
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber
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
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. Onsitb sewage systems must be properly maintained. The septic tank(s) must be pumped by 'a licensed
pumper whenever necessary, usually every 2 to ;i 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 tYPa is Public, check all appropriate boxes that aPPIY.
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; (Jose 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)
IL
DEP,ARTM~NT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY,, 1 DIVISION
A .AND PERCOLATION TESTS (115) MADISOP.O. BOX 76
N WI 53707
HUMAN RELATIONS '
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: c TOWNSHIP LOT NO.:BLK. NO.: SUBDIVISION NAME:
SE t/4 NW 1/4 24 /T28 N/R201(or)W Troy n/a n/a n/a
COUNTY: BUYER'S NAME: MAILING ADDRESS:
St. Croix Fred & Sandra Sobottka 4872 Knottingham Cir., Ewen, Minn. 55122
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PR FI DESCRIPTIONS: PERCOLATION TESTS:
I~Residence 3 n/a New ❑Replace ( 2_1$_91 2-18_91
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
tren h
❑ S ❑U ®S ❑U~ LiiS ❑U ❑ S ®U ❑ S ®U conventional split level
D
If Percolation Tests are NOT :SIGN RATE: required If any portion of the tested area is in the /a
under s. ILHR 83.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n
decimal' PROFILE DESCRIPTIONS page 8BrC2
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTt-DM. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 6.00 102.93 none >6.00 .67bl.1. 1.58bn.s.1. 3.75bn.c.s.&gr.
B-2 6.00 102.93 none >6.00 .50bl.1. 2.33bn.s.1. 3.17bn.c.s.&gr.
113-3 6.00 101.58 none >6.00 .50bl.1. 2.00bn.s.1. 3.50bn.c.s.&gr.
B-4 6.00 100.38 none >6.00 .42bl.1. 2.33bn.s.1. 3.25bn.c..s&gr.
B-5 6.00 100.13 none >6.00 .50bl.1. 1.58bn.s.l. 3.92bn..c.s.&gr.
B-
decimal' PERCOLATION TESTS
TEST P H WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD PER1003 PER INCH
P_ 1 3.00 none 3 6 6 6 <3
P_ 2 3.00 none 3 6 6 6 <3
P- 3 3.00 none 3 6 6 6 <3
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. 99.93= upper trench
SYSTEM ELEVATION 98.58=lower trench
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1, 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): TESTS WERE COMPLETED ON:
Gary L. Steel 2-18-91
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. Ave., New Richmond, Wi. 54017 229 17A5-246-6200
CST SIG I)F RE: - 91/
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DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
JOB
TIMM EXCAVATING SHEET NO. OF Z
Route 1 Box 192<'~/'
E -
WILSON, WISCONSIN 54027 CALCULATED BY DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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TIMM EXCAVATING SHEET NO. L OF
Route 1 Box 192 {
WILSON, WISCONSIN 54027 CALCULATED BY / `7 / DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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