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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP hu~sa 1~
SECTION T.2q N-R /9 ^~1
ADDRESSo~r ' Z Z ST. CROIX COUNTY, WISCONSIN
flu Asor►
SUBDIVISION Rns!5i+ LOT ~-2.S LOT SIZE a • 3C ,4C .
PI AN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
S
1
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g~ y
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r= 36 -s~`-III ?I
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jy17 i l,5, LoT Z6
zsxSo' ~ Z~"xa`l' ~ ±
bz, ~ well
i
I
$.M. Ilot P,
IJ~ aI S_E. Ccrn~r E1. =IQO.a>~,~
pis INDICATE--NORTH ARROW
/ dG
BENCHMARK: Elevation and description: 1„/°-~ P',o- at sFCoda., E -106,0'
Alternate benchmark
SEPTIC TANK:Manufacturer: w.,, adf Liquid Cap. l ood gQ-~
~ Final grade e1ev:
Rings used: z Manhole cover elevs
Tank outlet elev.:
Tank inlet elev.:
No. of feet from nearest road:Front_, Side XRear_Ft.14- 5*_
From nearest prop. line:Front, Side, Rear____Ft. 13 S
No* of feet from: Well 6,2- , Buildings /7
(Include this information in the above plot plan)
nk)
(2 reference dimensions
SEE REVERSE iSIDE
I
PUMP CHAMBER
Manufacturer: -Afzf11 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: Manz Switch
Type Location _
Distance from nearest prop. line: Front Side-,, Rear-Ft. Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: 6„v.,,i; 6hQi Trench: Seepage Pit:
Width: Length 3a' Number of Lines: _3 __Area Built 4yss4:97
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe: 41z No. feet from nearest prop. line:Front
Side,_, Rear Y Ft./,O'
No. fes+t from well: G s '
No. feet from building 3 T 0
HOLDING TANK
Manufacturer:,J//f
---.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: Wellbuilding_., nearest road
Alarm Manufacturer:
INSPECTOR:
DATE :
PLUMBER ON JOB.-
LICENSE NUMBER:
S
6/90:cj
A9lioo > 4/j°
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-:
GENERAL INFORMATION _ 149067
Permit Holder's Name: ❑ City -Village 4 Town of: State Plan ID No.:
Sam Miller Hudson,
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA 1//P F
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark ~5 I~G
Septic
Gi
_23 0 92
Bldg. Sewer
St/ Ht Inlet n
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet
Ar
Septic I ( NA Dt Bottom
NA Headers
Aeration NA Dist. Pipe
sot. System , zf 99 ,
Holding
PUMP AWOO INFORMATION Final Grade
Manuf er Demand G 1_7 /
Model Number GPM i2 ' 0. /
TDH Lift Friction stem TDH Ft
Forcemain Length Dia. Dis . well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING nu acturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type o _ CHAMBER Mode Num er.
System: V' 161E CoS OR UNIT
.1
DISTRIBUTION SYSTEM
Leng er tl Distribution Pipe(s) i x Hole size x Hole Spacing vent To Air Intake
th Dia. Length -2a- Dia. Spacing _L I
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over 1 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.)
~g~y, l'✓l, /C j fG , , r e t'>' } poi 7rL
f
Plan revision required? ❑ Yes Vo
Use other side for additional information. 1-7 1/2
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
SANITARY PERMIT APPLICATION
:EDILHR In accord with ILHR 83.05, Wis. Adm. Code CouN
~a
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑QG
8% x 11 inches in size. ec if revisI. to evious 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
S~ I! 5 ~t14AIE t/4, S 2-T_D1 , N, R ~ej E (o
PROPERTY OWNERS MAILING ADDRESS LOT #a BLOCK #
jbo 4F Z~d Z S_ I
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
S o ~ vJ~ S 0 3g(o ~7 Co~1' ~ ass i ~ rd V ; ac..~7
II. TYPE OF BUILDING: (Check one) L1 State Owned V CITY ILL ILLAGE NEAREST ROAD
Otl~
El Public [K1 or 2 Fam. Dwelling--# of bedrooms Q__ PAR EL X N M ER( a 0-
III. BUILDING USE: (If building type is public, check all that apply) j •2
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. ❑ 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 ZI Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
130 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
c REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Q9 ELEVATION
/ 5o (.,1 s 8 C7- 4 1.06 Feet /10 3, `/19 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
Ta s Tanks strutted
Septic Tank or Holdin Tank 00 f lJa ~S~c y
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): Plu er's Signature: (No Stamps MP/MPRSW No.: Business Phone Number:
S ~o►. ~a Z 47 3 U
Plumber's Address (Street, City, State, Zip Code
IX. C LINTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a to Issue Issuing ent Signa re (No Sta )
rcharge Fee)
AApproved ❑ Owner Given Initial 9
Adverse De erminati n
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
.
APPLICATION FOR SANITARY PERMIT
9TC-100
This applicatlon form Is to be conpintad in full and algned by the ayntr(s) et
the property being developed. Any lnadoquaclea will only result in delays of
the p:rmit Issuance. -should thls development be Intended for resell by
owner/contractot,(spec houoe), thon a socond torn should be retained 'and
coxpleted when the property is sold and submitted to thla otllee with the
approptlate deed recording.
----------------rr-rr---r-------r-------------------------
OYnir ot propetty 1/we-
Location at property 1/4, Sectlon y _ `a T•R~
T o vn s h l p Ak t-5en
Halllnq address <~ox #zl?z
Address of site _Co~„fi~ Uur ~q011,
subdlvlslon naa►e ~Q~~fiy y,~, '
Lot number
Previous owner of property r%
Total slit of parcel z 3o fl~~,r~ J
Date parcel was created 7
Art all corners and lot lines ldentIflablet `_Yes o .
Is this property being developed tot resale (spec house)TX _Yes NO
Volar.e _ and page Number as recorded with the Register of Deeds.
---------------------------------------------a---------------------------------
INCLUDE WITH THIS APPLICATION T11¢ FOLLOWINCI
A vAARXXTr DRID which Includes a DOCUHIIHT NVH81R, VOLUMt AHD PAOt NtlltatR, and
the 81Al, OT T1tt RHOISTBR OF DHBDS. In addition, a certilled survey, It
available, would be helpful so as to avoid delays of the reviewing Oracles. It
the deed description references to a Ceitltled survey map, the Cattltled Survey
Hap shall also be required.
q
PROPERTY OWNER CERTIFICATIOH
I(V4) certify that all statements on this form are true to the best of my jour)
knovltdgel that I (we) am (eta) the owner(s) of the property dtscrlbtd In
this Information form, by virtue of a warranty deed recorded in the office of
the County Register of Deeds as Document No. zZa.i., 1 and that i (ve)
PftstntlY own the proposed alts for the
obtained newage disposal system (or I tve) have
an eaetment, to tun with the above described property, tot the
construction of sr Id nyatems and the same has basr!}},~duly recorded in the office
at,-4a Caynty Reglatayl Deeds, as Document Hog
y~Za3C~
slgnatute of owner 8l9natura of Co-ovnec (11 Applicable)
Date of slgnatur Data of Blgnatuce
f
71,91"wL 49 DOCUMENT NO. STATE BAR OF WISCONSIN FORM 11-191 X-`~'s s►Aee Rrsrsvro VON R[CORa1N0 DATA
LAND CONTRACT REG•=TER'S Ut-~ICE
r 1041.1,11121 and ('e.eerat.
eiA11V's~V ITO BY IIRF.D FOR ALL TRANRArTIONR WNERE OVER ST
Vl ."t MI0 la FINANCED AND IN OTHER NON.CONSUMER • mix CO., W'
ACT TIIANSACTIONRI i Intl p:'!COrd
RC.C ,
Contract, b1 and between }?uXZ£f1t..~.a...~QI}!9.(lab.~n~ M
'~••.K0Y..Rn~~.yr.. a sin&le woman at 1:25 P
( ( ("Vendor",
R whether one or more) and..Sanh.E....I AA1.C.r Register of Deods
? ~l~snsiR
c: ("Purchaser", whether one or more).
.
Vendor sells and agrees to convey to Purchaser, upon the prompt and full per-
formance of this contract by Purchaser, the following property, together with the
rents. profits, fixtures and other appurtenant Interests (all called the "Property"),
in......St....GXQi County. State of Wisconsin: R[TURN To
West one-half of Northeast Quarter (WiNVO
except the east 8 rods, and the Northwest
Quarter of Southeast Quarter (NW!LSE't), except Tax Parcel No
the south 6 rods, all in Section 29, T29N, 19W.
FEE
R
This . is .not,. - homestead property.
( (is not)
Purchaser agrees to purchase the Property and to pay to Vendor at 208 8th St., Hudson, WI....................................
the sum of i.756,.1.~.Qr~O............... in the following manner: (a) =.Qe.QQOr.QQ
236 150 00
at the execution of this Contract; and (b) the balance of E-•-••~-•••• • together with Interest from a
hereof on the balance outstanding from time to time at the rate of.nine..497 per cent per annum
until paid in full, as follows: Interest to January 11, 1988 shall be limited to $1,320.29.
$80,000.00 plus interest on the unpaid balance on January 11, 1988.
$50,000.00 plus interest on the unpskid balance on January 11, 1989.
$50,000.00 plus interest on the unpaid balance on January 11, 1990.
$56,150.00 plus interest on the unpaid balance on January 11, 1991.
The above payments shall be made in addition to any payments made for the conveyance of
lots until the total price is paid in full.
All payments shall be by 2 checks, one to each Vendor for 4 of the full amount.
en shi lEd ot~.tgla dateb 11th
A l~,ot.rove ~tedl~ase Ag eemnt h adl ng so or
v , ow'erer, Ie (•tI Ire ousRII I bnce a e pat to u on or efore the day of
....Luxuaty 19..91.. ( the maturity date).
Following any default in payment, interest shall accrue of the rate of . 4....... % per annum on the entire amount
in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire
principal balance).
PorebRSerr ualese excused by Vendor, ogre" to pay monthly to Vendor amounts sufficient to pity rrnaonably antici-
Pated aanuRl taxer`, apvetal a-a.wrmenta, fire anti required imurance premiums when (live. To the extent received by Vendor.
Vendor agrom to apfAy paynwnta to these oWiltations when due. Such amounts receivwi by the Vendor for payment of
taxes, arAr.ASments and insurance will be deposited into an •scrour fund or trustee account, but shall not bear interest
anteee 6therwise required by law. Any amount may be prepaid on principal at any time.
Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. Any
.amount may be prepaid without premium or fee upon principal at nny time after 19....... (OR)
n n
there -nnaw be no prepayment of principal without permission of Vendor.'° ,A
In :he event of any prepayment. this contract shall not be treated aq in default with respect to payment so long -
as the unpaid balance of principal, and interest (and in such rnse accruing interest from month to month shall he treated I
as unpaid principal) is less than Vic, amount thnt said indebtedness would have been had the monthly payments been
made as first specified above; provided that monthly payments shall be continued in the event of credit of any proceeds
of insurance or condemnation, thr condemned premisei being thereafter excluded herefrom.
Purchaser states that Purchaser Ia satisfied with the title as shown by the title evidence submitted to Purchaser
for examination except:
Purchaser Rerees to pax the en-%t of future title evidenct.. If title evidence is in the form of an abstract, it shall
be retained by Verdor until th-- full purchase price is paid.
Purchaser shall beent''dedto take possession of the Property on the date boreal IQ .
~ •cr,,., n,: nu
LAND CONTRACT -Indiv0dual and ST\ll' I1\1t (1t' WISCIINMN t1'+•r.• n 1!v.l wank ro. Inc
Corporate fUxN Xn. 11 IYbt }Iur nu,.., w,e.
G
7 9 71 PA,r r 50
J 1'or, I,% t r pr•,min• Y Ur p:,) when due all taxes and a--sn., rt•I levied on the 1'ruperty' or upon hdor's interest
rrS :r I •I to if- 1,:••r to \'/•ndor „rt de nla I, (I r(•r•el pt.; sIt, V: I hg sur 11 I,a)tit rr n I.
-r;r rl ad kw p tf ^ ool-roV.-M.•nt" nn the Prol'i it I 111 •-r••J a/aiurt b,.v (ir damage occasif,ned L~ fire, acx,
pproved
I -tr.w-- I••rtts mud suet: oU.r•r i,:rza.rdx ay Vendor maI r••,iu,n, without co-iwurance, through insurers ai'i
# ut \'cr,•lur I all not require coverage in an aTno'lot more
-,n ter ti.;s I ontract. Purc)ctser ni,al! ,,:,y tLe .a±nrance prrnuunrs when due. Tne pol.cn•s shall
ul. t , -t.r •Lud , L,u•,• In III%.,It 'If tl- 1',111101'+ If tt,INt :tnd, untrss Vendor of„erwlsr agrees in writing, tire original
WI I:n' •'•0'rln~ the 1'roP,•rt% =gall he del •I: itld w•Itl \'I ndor. 1'urcLaser shall promptly give notl;e of loss to
nr,d Ct•ndor. hdv4s 1'urcwt9er WA \'1•ndtrr •,therwn.e alfree in wrtttntt, tmuranco proc0•eds .hall
1.• r+rr,a:,tlou or repair of tl,e Propertc darraged, provided tLe Vendor terms the rest.oratlnn or repair to Ire
nn t . , riot !!:,:t wa-lt• n,,r a to t., •1 r- tl.e Property, to keep the 1'n,{,c:t
' . • - : . , 1 Contract. and
:o r,w h: •r.rtu.u,n :rtd~ r -;tit lift , keep the 1'IU;,t.rt. '1,•c 'rnm h11., > iperior to the lien of thin
, Ith all larva, ^nllna nc,, :it,(; rcrulations sJiecun;; t!•e 1'roprrt}.
\or:d,•: avlr,•r t`.al Ill rase the purebwe price with Int, •-est and otl,~r tuone)s shall be fully paid and all eon(;Itions
r•).:t,i he fully pl rt, rn:ed at v.c ,.I :•^d In the nlanner aboct• speedod, r on dt•mam'. eflocute and deliver to
tl.e I•urri:• ,•r, a arrant) held, in lei Ample. of the Prolwrt%, Irt•e al:d cienr of all Lena and encumbrances, except
exist Ing highway. If. East
ul,y h,•n, , L, .r•n6raneea created Ly tf,e act ur defnllt of I':lr,':a r•r, a!:r, l'xc' {
or West fences encroach till this. or. adjoining land, warranty will not aPPlY to land...
between such fences and Lrue description lines.
P it i:r:,•r a; I,•es that ht W is of till' e•.eIll e :I it IaI in tlr , t ^f a der: in till' i'llini"It of ao;. prr,rlpal or
.I ..t, Iii:ue,t rr,r it ri"d If GU da,s f. Ilov ;rig I,,, w.1 a;v „r 160 in the t•crnt of a defu•rlt In
1 . day ~ .`r,llnwrn~ A r It, rI r ogre
•.t.• • „ll.t r ohli~ati„n of I'urt h:,a•r tcl.e i, (,,tit r • :,•r t' r•' r _ . .;:tr'tct
• 1. ~ I,t ••01.11 pt r.,rtrrll: ,.r mailed 1,:. c,•rt;!:rd Ina':,. 1 (1I't c:.
„l,r .11-,,•t•n„tier- SwiICh 1'urrl.a•rr F,reLy
;I!I • n, latclc 1111• u•Id pa'.nhle in f•.III, :,t \-,•.,I„r'
' rein; r G 1. i r. t t•, Inn1!;,t: pr, tlJrd Ir.' I;,'•, 1 in
I1 :rl- L:r,l ti. : : „ 1. an,i 1'ur'ra••r'~
1, ,f L} L,u ,r in , ,nt•, 1 i I } r I . _ a t 1 r
1 'r -,,,,t r . .II ♦'h unc r,l-ut}r of
n tl.
I'I•,1 tt I r,' 1 r Ir..,,. 00,1
1 t', •ri •.1. r r. r I I ,a r. • I 1 , ,1•pl,l
r r ta,l t 1,10+0:11. ,r I.I \ ~
n.•rA ,ftlr•t 'Ir, t ! t
u I'r :,!..I 1'nrf;,••r
1 1 , t .u, ,cnr rl le hl•I,,tn,!,•r, : • „ t
i,r,rtmn
I'irionr) : „r 1 Ili) \ t :I?.: . .
;vl, t title
t rt ! In a
•.r 1 ,uc ,I„!: n. r, 1 r.• :Ir , ~ 1 ~ „ rr.rtr t. 'vn
1 I ae, a I t„ :e, 1 apt„ , 1 .I t,.: :u,
IT \ , I • . r r ::ne
nn,!, 1 t I I ,i'.1 d c:.\,•t•, tl•t l„ .r't,, • ,1 r
, eP, S;.re
and
, t'. it u
1 h• la,c ,r 1 rsP, tl' !I f i i 1 ? l':l'0 a• r. in-
n„ i. ru ,1 . li 6l'• inr!ad,+1 it,, ary iu•icn • r,t.
re „f tla= Clintart. !'urO a°er consents
l'o,~n tee ,nn:mencer~ent nr dur.np t, c :~•n11er.r; n,r un;. :.,t:,~r, • ` ~ of
t„ t t 0• an; • 'rar•, rlt a tt•t•cicer of file fit, I:l l' mc;u,l:r.`• a.! I u,•wi,rt en • : r^ikoe i ska'l I,e profits
f.eld and
the I'n,Prtt d•Inc.! ^ Of- plndenc}' of such art ,.:u:d -'IC:: .,r.••.
f' nc! •er -t :,!I ! tr:!r.,f,r. -I I? .r ,,,nc, I '1:• rut i1.. tie 1'r, p,rt th;' :r- tnn;l• of ann
r
v::r, 1 c thr.•:! •!:e pr- ,r
of I'll rcl::t- rje•It un„ter ti: i. . !I::ct n r 1 > 't -1. 1^ct -t, rr❑ 1, *-ntr:rr t
0^1_,•0;1 ..1„r u•Ily- e`tl-r it 1 ,:v, 111, tract 1- flr~ rrt .•:li „r if. r.... IFt
r :r it 1 ,,It of
1'o10f nr :1 -1 lle!tt 0,l' 1''a o .I r •,'t r• l nt n!.tar. Ili. l•
' . nt r tn•, • ttal' f, t •.1 r r•., r , r'. „rit!.... t
01 a-, r t•
I,alartr• Tilt. .1.1, .r:,!, r II. r ..:ItI art all L, ,:n, ,r , I c! .1,! I m .':11. al' \ I r t- „S ! , it tc t r+ lo'.: e
\•,•1••I I1,1 m:J:r all t` n•rnte %%I • t'• it • , .,,r1 t • ':t :uuG it •t' t t' •.l'1• rte . n tFe dale of
r, e • tit ',,r :i!.% m„rt: a> r .:ranted fly )'urcltncrr 1 I r :1, It 1 Pro Cld,'d
n t c P:: ❑,•,tt n' },r i1)" nt. •n 1. r •n..}, ,',.r t a ,!1•r't~> t^
i• t t 1, 1 • , 1 ( nt::,.l n!:
-
r • • ?f 1,110 1:615 to ,I„ :v 1 .I!I rill tt<
\',:r,!• • :,e wake ane drfaolt v:aln:tlt v: i• c :.c1. ••t?. I ir•., r t:, :'t ,:f i' !l'!.:1-• r
All •,...na or thin fontrmt shall he F,in,:?nc crnn and in:irr to the f,-!e''i:s of the rcir!, lecal repre-entat;r",
sqc- a :,nd a=+irrts of Vendor and 1 •Ir^hnrer. (lf not at. owrer or the Prwpertc the vrru.e ••r Vendor for a raNah!e
r•n~id^rt•:^•, mina her0'in to rr•len~r Itrm,•-tend rirl-•ts in the rlbjec+. Property and screw to :oir in the execution of the
deed t., I,. rrnrlc in fulfillment her-o".)
I.. 1601 ! Nvvember o 87
orres; E. Kos sIn:,a• 'liller
_ I
Ruby Olley
AUTHENTICATION ACKNOt't'LEDG'\1ENt
all parties
ra .t0 r .
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SEPTIC TANK MAINTENANCE AGREEMENT ~
St. Croix County
w
n
014NER/BUYER o
ROUTE /BOX NUMBE Fire Number :J
CITY/STATE ZIP
' ' w•~ ~
PROPERTY LOCATION:' Section=,• TAN, R /f
Town of St. Croix County,
Subdivision CouO6,1 Pi et-tj Lot number? S
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 licens'ed' 's'ept'ic tank pumper. What you put into
the system can affect the .unct on of the septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix Count residents'-may be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
whic 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 s't'ems 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 9
the standards set forth, herein, as set by the Wisconsin Depart- Y
ment of Natural Resources. Certification form must be completed V
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration-date.
SIGNE
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016.
386-4680
Sign, date and return to the above address.
i
' QEPA~TMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
'INDUSTRY, CC DIVISION LABOR AND
P.O. BOX HUMAN RELATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSH LOT NO.:BLK. NO.: BDIVISION NAME:
hC NL )PiMU
Zq /TZ9 N/RM E w owl v6so 2S Aassi Y w
COUNTY: ER'S/94W#-I!R'8 Fil _11 _1E.
MAILING ADD$E~SS: A~
>T (9 L DUT' d f&4 C1~YJ+u j S'~U
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPT~QNS: P~~EyyR ATION TESTS:
06Residence ~~JeNew ❑Replace MA 2/ /97~ '`'A Z3 )9
'Sill - RATING: S= Site suitable for system U= Site unsuitable for system
6 «~C ]I ~S ~Af(q . €jrrj/1~
ONVENTIONAL MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (opti aq
S ❑U xS ❑U 0S ❑U ~S ❑U ❑S CCU Q#JVFN7/oNxL &I
If Percolation Tests are NOT re uired DESIGN RATE:
4 ' ~J ~ If any portion of the tested area is in the w,
under s. ILHR 83.09(5)(b), indicate: CLlZS Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHZX. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- ND N FS . SO t l n u5C a&,4MS i&k
B- Z p.VS /09.3C> dNjqg > /D. /6~ cc 23">ge,~,C N%y$ Sdgo mis 4
B- 3 0.41 64 .S 0 f4aige > 16-4Z 51 kTS / L 2.9 "$tNcS4(A 9 72"B ey MS46 0-
B- 11b,oo 01.48 14> 16-60 " taS 11" L A 6 91WSik MS44+
B-1~ .gZ 0216 = > Z 74~Bc(-T517I L17Gy Sit 1134CS469 4110N
B-~ 10.00 /v8.00 AI&NLr
} /0.~~ 2l" c~ 23$RNL 17g4+w5~/~'aGS~G~R ulh5
"hFcvy PERCOLATION TESTS
TEST EPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERS ELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P- o 140ME Palo 3 >'Z > > Z <
P- Z ao r4aja 1o4.z >'Z > <
P- -06 101.00 > > >
P-
P_
P- T10 T c
PLOT PLAN: Show locations of percolation tests, soil borings and the dimen ons 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 of plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION g9•UO Ar°'Pt°'`
r ~N~ 1
s VIOL
d
at
All
F {
SCALIF
yr
o'
Nat 0_ L
,p E
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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.
r V00019y (print): \ TESTS WERE COMPLETED ON:
So JpNIJS6 AA --:5A lifg'l 1W. 23
ONE NUMBER (optional):
Af-RESS: u CERTIFICATIO NUMBER: 516-461W
6• & S o,6 34g+ CST SIG URE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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