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N e-~ 21 > EP N O> N OJ o r Q Z a LLJ 4) 4} a M U) U) C14 O H C O O LO 3 N N C C Cl) o 0 o E o c c rrO O' p~ N 0- 00 1 N N N " U N .e C 0 N a CL N N c: Co Q) E E LO o o C: N O O N C co Cl aci rn c Z 0 co N 'n `m H F cv N C o u) m Eo cLi a~ o o E E 2 2 'P't- 10 2: F- z r r xx E N d 5 a a> a w • :C O. 01 .V N y C ~ d C G w 0 E c c 10 o C- % 3° o a m o v~ 0 0 rn U wistorts;LQA)paf*mentofIndustry, PRIVATE SEWAGE SYSTEM County: `Lab-or and Human Relations INSPECTION REPORT St. Croix Safety and Buildings Division ATTACH TO PERMIT/Z-9~ Sanitary Permit No.: GENERAL INFORMATION SE 4j NF%, Sec. 27,T28 -R18, vergreeno 149153 Permit Holder's Name: ❑ City ❑ Village [jt Town of: State Plan ID No.: Merle Nielson Kinnickinnic CST BM Elev.: Insp. BM Elev.: BM Description: C LC- Parcel Tax No.: 410A TANK INFORMATION ELEVATION DATA 91o TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 0; e~r C,_C , coat" ~ Benchmark /o/ , d I ng Aeration Bldg. Sewer Holding St/ Inlet TANK SETBACK INFORMATION St/ I$ Outlet TANK TO P/ L WELL BLDG. ventAir Ito ntake ROAD Dt Inlet Septic } NA Dt Bottom NA Header i Man Aeration NA Dist. Pipe J~ 95~ r Holding Bot. Systems 9-~ PUMP/ SIPHON INFORMATION Final Grade ICL Manuf Demand Model Number GPM TDH Lift Friction SY TDH Ft Forcemain Length Dia. H Dist. To 7- SOIL ABSORPTION SYSTEM BED/TRENCH Width_ I Length 60 1 No. Of Tr nches No. Of Pits Inside Dia. Liquid Depth DIMENSION 5 60 DIMEN I N SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACH[ Manufacturer: SETBACK INFORMATION Type of 4~,A1 f-, CHAMBER Moe ber: System: :b '>1G 9 /,~,U ~1&6 OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Length ~ Dia. Spacing r r' - 7T71: SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over 6-_ 110 Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges y 1 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No iscrepancies, persons present, etc.) 3 , COMMENTS: (Include code d J-C _t4-~i 45~y,i CL111,_'-/ G~1k) CC~ t_ t d j Vo'.: Plan revision required? ❑ Yes p'IGo Use other side for additional information. C)lra SBD-6710 (R 05/91) ^ ( Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH . Y ' 41 SANITARY PERMIT NUMBER: { i8 tip' ~a cr o' e i • 4 ' 7D' SANITARY PERMIT APPLICATION - LHR In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than El # 8% x 11 inches in size. C 4k re ision to p lous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER WNE PROPERTY LOCATION V` -le t'e)o n ~;'E'/a S T,2?-, N, R I~ E (or lo PROPER OYVNER'S MAILING ADDRESS LOT # BLOCK rr e) CITY, STATE. ZIP CODE 1 PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER w r l- ~ , d rX 6 NEAFST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE: / LYl°j' 1 ❑ Public N 1 or 2 Fam. Dwelling-# of bedrooms PAR LTAX NUMBER(S) 4a~-1o7~~ad III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 9 ❑ Off ice/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 ❑ Seepage Bed 1 r 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ® Seepage Trench 5 X100 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. tt.) (Gals/day/sq. ft.) (Min./inch) ELEVATION vz~D 11515 B SJO Feet , d 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 strutted Septic Tank or Holdin Tank br) ct'S Lift Pump Tank/Si hon Chamber El I L] F-1 I El I El El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumb s gnature: No Stamp ^ M PRS Business Phone Number: 7Z A a S x 1'..1 V7 todl Ai Plumber's A~ess (Street, City, State Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee (includes Groundwater a e Issued ssuing A ent Signature (No Stam Approved ❑ Owner Given Initial Surcharge Fee) / 2al~l Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPRQVAL: cctv((' a~~-, ~r.~o t,~fey,~,a~a.~.,~..,.►-~ . ~ ,cam. SBD-6398 (formerly Plb-67) (R. 11/86) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber 1 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT n FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify //thatt' II have inspected the septic tank presently serving the residence located at: c 1/4, 1/4, Sec. 07 P , Tf N, R IT W, Town of rCk~&I tec Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. / Last time serviced / Did flow back occur from absorption system? Yes No if no, skip , next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete _>(_Steel Other Manufacurer (if known): Age of Tank (if known): f Ys -iLL 4 S (Signature) (Name) Please Print ~V17 503 (Title) (License Number) 92Z (Date) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-8 , Wis. Adm. Code (except for inspection opening over outlet baffle). Name Signature P/MPRS ,723/ 5/88 505 1 doer t\) pay r~ mlyl Foe V, "eve 0r, 1 Sciv, ~e oe Ve to ~ c re ~ Ike J QQ Qb' Atoll NAK VkJOP 1~000 a ~ se polpgen litmf ~ xlvU ~u'en,~Ul • H N ' H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County cy a OWNER/BUYER M ROUTE/BOX NUMBER C Fire Number i I T .CITY/STATE l~ < ZIP PROPERTY LOCATION: _j Ek, AIE&b, Section / , T, 7k 3N, R W, 741 Town of r:!y 1 , St. Croix County, Subdivision Lot number 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 pumper. What you put into 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-eite 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. 0 I/WE, the undersigned, have read the above requirements and agree z to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- Iv ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Offkre within 30 days of the three year expiration date. SIGNED DATE / 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. l • a ~ APPLICATION FOR SANITARY PERMIT 8TC-100 This application form is to be completed In full and signed by the owners) of the property being developed. Any inadequacies will only result In delays of the permit Issuance. -Should this development be Intended got tesale by owner/contcactot,(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 tecocding. - - ,Owner of property Location of pcopertY. -3-f-1/4 1/41 Section T-IIY Township 1 Malling address < ' Address of alto f~ subdivision name- • Lot number Previous owner of property Total also of parcel 0 2 Date parcel was created kiii Ace all corners and lot lines identifiable? Yes 0 is this property being developed tog resale (,apee house)?Yes 0 Volume and Page Number as recorded with the Register of Deeds. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - INCLUDE WITH THIS APPLICATION TITS FOLLOWING: A WARRANTY DEED which Includes a DOCUMENT NUM62R, VOLUME AND PAG2 NVMaSR, and the BRAL OF THE R2QI8TKR OF DREDS. In addition, a cettifled survey, it available, would be helpful so as to avoid delays of the reviewing process. It the deed descrlptlon references to a Ceitifled survey Nap, the Cectlflad survey Map shall also be required. 7 PROPERTY OWNER CERTIFICATION I(Ye) certlty that all statements on this form are true to the best of my (out) knowledge; that I (we) am (ate) the ownects) of the pcopetty described In this Intormation torm, by virtue of a warranty deed recorded In the Office of the County Register of Deeds as Document No. ?)730& • l and that I (we) presently own the proposed alto for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of sold system, and the same has been duly recorded In the office of the Coun :Register of Deeds, as Document No. f" /Ax Horace E wn~c signature of Co-owner (If Applicable) Date s na ure Date of signature BORINGS AND SAFETY & BUILDINGS DEPU TQQ~ REPORT ON SOIL DIVISION C IN D U LABOR STRY, AND- P.O. BOX 7969 PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (1-163.090) & Chapter 145.045) LOCATION: SECTION: Q u (y OWN UNI 1PALIT-Y LOT NO.:BLK. NO.. SUBDIVISION NAME: L'1 /I T ~U N/ 0 E (or t7l % - COUNTY: W Re-de 1) BUYER'S NAME: MAILINU ADD SS: / S ~rCd ~a 'veK~~5 SSva~ USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE ES RI TONS: PER OL ION TESTS: Residence ❑ New ''Replace C / RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) S ❑U QS DU IS ❑U ❑S [RU ❑S AU &nfu, sr ~oQ' ran If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV, ON BACK.) 2 No -Al F, ",6 l s i Ir7 "b, y5'©131? pte ds L B- 6.6d S B- ,l3~ 9 7 , d B- ,fin , D ;Ia'` B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERS/W~ELLING INTERVAL-MIN. PERIOD PERT D2 P R PERINCH P_ 40- P- 2 - p 6 P- o l i 6 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 r ~ Old 17 A_ I'a~'~_~~s~ec~~o _ie_fe - 1--v flf=~ . .__rej~ tai A mm E E t AMA r E € r ti t a - t t E I I E b3 ~ I I ( 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 COMP LET 0 ADDRES : 1 r CERTIFICATION ER PHONE NUMBER(o tional): a ruC' S a g~ CST SIG RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. D I LH R-SB D-6395 (R. 02/82) -OVER - VOL 18 P 4752 BATHLE&R H GE APR 2 7 ST. CROIX CO. MI 2005 RECEIVED FORDEEDS ECORD 05/20/2004 02:30P?1 sr - , _ CE TFEESD 13R00Y MAP COPY FEE : r~ PAGES : 2 CERTIFIED SUR Y MAP Merle Nielson Located in the Southeast 1/4 of the Northeast 1/4 and the Southwest '/4 of the Northeast 1/4 of Section 27, T 28 N, R 18 W, Town of Kinnici innic, St. Croix County, Wisconsin APPROVED ST. CROIX COUNTY I Planning Zoning and Parks CommRae © # e o MAY 2 0 2004 U_ 1 1vQs n $ _ 2d ana void N 30,58" E 393.34199iY act y P~7 Tv _ - '-N O6~Q;5 .391-.94' - - - o • = - a- 0% it it' l noy yk Q lr,~ a f ~S'i atrirnge'11%y JT~+ i'+ s. i s~V r~tar _3i S S N yooo~ Q0000 000, ~n/fa °D 4s 0 2 ~ a 5' ns ° ° . TTU►~1 O% ~oooooo N 0164.70' « o,, , c l rr~_ M L~ 2. o- x _ a. d i a 27'2.52 V ~O s~~s 3T . s - Z u to o ' = 1 o 9 1% a z p > 348.70' >g 501°29'01" W 309.61, 14.1: s' s Pei.'° ° : CtgIT z 9 8 :e 580.52' O Y~ Ct'i7F_ ~15 N 01°?01" E U w Q 501-29-01- W 350.0 ' l~ - - -N- M°LA 3 E~sT LINNE 1/4 SECTIO 2 - N 01°29'01" E 26472'_ - - fit N This Instnanent Drafted by Mark W. Peavey \ vol 18 Page 4752 SHEET 1 OF 2 Parcel 022-1075-60-030 02/10/2006 03:39 PM PAGE 1 OF 1 Alt. Parcel 27.28.18.420A-05 022 - TOWN OF KINNICKINNIC Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 05/20/2004 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - NIELSON, MERLE C MERLE C NIELSON 145 CTY RD JJ RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 1291 EVERGREEN DR SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH { Legal Description: Acres: 7.859 Plat: 4752-CSM 18-4752 022-04 SEC 27 T28N R18W PT SE NE & PT SW NE CSM Block/Condo Bldg: LOT 4 18-4752 LOT 4 ( 7.859 AC) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 27-28N-18W NE Notes: Parcel History: Date Doc # Vol/Page Type 05/20/2004 763246 2576/548 AFF 2005 SUMMARY Bill Fair Market Value: Assessed with: 143781 219,200 Valuations: Last Changed: 08/11/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 7.859 80,000 141,600 221,600 NO I ~I I Totals for 2005: General Property 7.859 80,000 141,600 221,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 • AS BUILT SANITARY SYSTEM REPORT TOWNSHIP EC. TVN, R~W 0. ADDRESS , ST. CROIX COUNTY, WISCONSIN. .-BDIVISION (OT T SIZE 5 2 PLAN VIEW IVK LoT-`7 W r" I f $7 -Distances b dimensions-to meet requirements of H62.20 . SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM L2 /14 `i J ee ti ~ I I di~cate ozth Arota -y--~ { SCAL . 1 i i OPTIC TALK (S) 00 MFGR. `AJ~tA.Q,~Q/u CONCRETE STEEL / NO. of rings on cover Depth DRY WELL v _ `M INCHES NO. of width length area • no. of line width= length area 5. _ d p to top of pipe 3 Q f AGREGATE + h~ ea- 3'K RATE Q AREA REQUIRED AREA AS BUILT # / 0 &&It I 44-1 i lisclaimer: The inspection of this system by St. Croix County does not imply complete :opliance with State'Administrative Codes. There are other areas that it is not possible ,o inspect at this point of construction. St.-Croix County assumes no liability for ystem operation. However, if failure is noted the County will make every effort to itermine cause of failure. . ASASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. `INSPECTOR DATED 6 - PLUMBER ON JOB LICENSE NUMBER .3 Wisconsin Department of Industry, P B_1 INSPECTION REPORT Labor & Human Relations Safety & Buildings Division Bureau of Plumbing, Platting & Fire Protection ' 'Name o remises Date an o. Street i y County ry Permit 0:,. I I N' 4_11 ~ 0 Ut' Master 6" er irm ame Address f y U,1,~ f'7 L.~,eS A) - r T a Z Journeyman PIUMDer -Address owner / ress /),x s f ti R-{ Z. &KATt -4 FALc.5 WL 5 CfO ZZ 6u v 7 N loop L f t Z,c_ . Discussed with nature ( )See Attached. DIUR-M-6192(N.09/80) Sfigna n i s e "ecial9t White-Inspector Yellow-Local Inspector Pink-Plumber or Responsible.Party Green-(Twner REPORT Of INSPECTION - INDIVIDUAL SLWAGE SYSTEM Sant t wi r l P v li rri t~ p S t a t Sep.tA"c~~!`~ / - NA~1f Township. St. Cno.ix Counts I oca tion S _Secti.an_~ZLot ~ubdEviAtian S.i c - gaffonA Numbe.n o6 eornpa~itrne.nt.5 tense 6nom: Weff Bu..c.tding Z.~ 120 ~kape - H, ghwa ten PUMVING CHAMBER Si;c gaffonS Pump Manu6ac.tune.n. Modek Numbers 1101 DING TANK gaffoVA Numben~ r,6 CampantrnentA I' i, rn F' ~,r A Q-a. A rn S y A t e. rn II, tt4kic v. "w al: Wee(' Buieding-_ 12o ekape_---- - Highwate n AhSORPTION SITE Bed Thench 1) Lance Pt m: Weef 8ui.f(14.ng A? 4!~, r2s Akope___ _ fl,i uhwate/( 0i►,il11ON SITE DIMENSIONS W<dth o6 tneneh-,-- ht Requi.ne.d area t. Lcnyth o6 each fine . 1?1, - 1L 6t Depth o6 hock bekow tif.e. <n Nu.rnben o6 E'.i:ne's Depth o6 4oeh oven t<ke I r. t ri t'' Length o6 P-i.n.e.A 6t Depth o6 tite be ('ow gii.ade •i n Ur A tance between ei.nes 6t Snare. o6 t4ench in. pefr 100 At fotae abAanption area 6t Type oh Coven: Pape.n an 6.Vlaw I'I T DIMENSIONS t 11 Numbers o itb `2 c h p ti GnaveP anaund pate yeA --no G~ Ou tA.i de: di.ame-te.n (fit Depth bekow ,i-nfet t To tak abAOnpt.4on aA.ea 6t Arcca nequt.ne.d 6t INSPECTED 8V TITLE . APPROVED DATE 198 Rf JECTED DATE 19 x I:I A S 0 N FOR REJ(: CT1ON ~V, C\ 10 Z PState B 6 7 and County State Permit # x, Permit Application County Per 't # for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: lM eks~f Nlvtoke'n 1(-/ e a 'e" Per filh B. LOCATION: :Sk Y4 Section , T , R R (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village tr Township ?rt%~n/1JC C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance Single family Duplex No. of Bedrooms No. of Persons 3 D. SEPTIC TANK CAPACITY U Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement ✓ ~'litJlit~- 0-d~fZc")'j Sc41/1-Va4--~- Lift ump ank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New-X' Replacement Alternate (Specify) Seepage Trench: No. of Lineal ft. Width Depth Tile depth (top No. of Tre hes Seepage Bed: _Length~Width~_Depth ► Tile depth (top) No. of Line Seepage Pit: Inside dis,meter Liquid Depth No. of Seepage Pits Percent slope of land- 3 Distance from critical slope WATER SUPPLY: Private" Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the C d Soil Test, P6U NAME Q !Z C.S.T. # and other information obtained from (owner/builder). q -Po V, Plumber's Signature P/MPR W# 31231 Phone Plumber's Address /O& . d PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. 3 Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY / Date of Application - Fees Paid: State Co my Da ~o Permit Issued/Rejceted (date) j~o Issuing Agent Name Inspection Yes No State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 v► Ar,~K10 4 Se.:C3 e Ir`fine irre erg V it ~X` J f WINS 1 o v EIS. 115 y e > Rev. $/78 ' • REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES C e P.O. BOX 309, MADISON, WISCONSIN 53701 co Z C7 0 I"n M ~ Z G~<G LOCATION:'/a„ Section ~,T2tN,Rff_E (or&ownship or Municipality Lot No. , Block No. County J u vision Name ~ Owner's/Buyers Name: welse'a -Ale V- Ic Mailing Address: *9 fi F4,§s TYPE OF OCCUPANCY: Residence No. of Bedrooms 5 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW _REPLACEMENT -ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS Q PERCOLATION TESTS SOIL MAP SHEET J 01 AME OF SOIL MAP UNIT Pla;~► e PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- SINCE HOLE HOLE AFTE INTERVAL MIN/IN BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 46 P- a s`' I av°' B,, s s''Bx o o MO4 P_ 0 a? " " f o" r L P- 114 P- P_ tee~ n04 o-<& SOIL BORING TESTS _ TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF R, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B_ / ,r Q c L / N t• 8- .1116 1/r 9.0 1/' lip PA61,5 111YA S B- 112, 11 s A0 r a. S B- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plar~th joc do and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy 6 ?ea Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. d c Liver reen Dr; vp a 4 • 0 , • , E e i ` ~0 i E N ~!•teo~il gt a xx E R I- 95 B = 9y 8 ~3 - 9 5 9`6 .4_ y - ) 6 sf _ 3 L AI noY br AlleJ 3 I~'~bbAv_ 4sea~Chele I, the undersigend, hereby certify that the soil tests reported on this form made by me in acxord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) t h1 Certification No. S J .S Address ® )Ujer Name of installer if known CST Signature Copy A -Local Authority L 10/ FILED 6 F E B 2 5 1997 ► 3 MAR - 3 1997 KATHLEEN H.wa segister of g St. clohCO.. VWAI ST. CROIX COUNTY 556003 s SURVEYOR'S RECORD CERTIFIED SURVEY MAP MERLE NIELSEN Part of the Southeast 1/4 of the Northeast 1/4 of Section 27,Township 28 North, Range 18 West, Town of Kinnickinnic, St. Croix County, Wisconsin. Owner's Address: N E COR. SEC. 27, r 28 N, R /8 W, 1295 Evergreen Drive /COUNTY SURVEYOR'S MON.1 River Falls, WI 54022 UNPLATT£D LANDS 0 Er&GREL l OR/ V£ S 89' 38'27"E 250.01' M W p N LINE SE 114 NE 114 J ~ y N 89 • 28 'S/ "W 250.00 /3• 2 Q O J ~ 0 WATER COURSE /00' Q r,, b " 1 4i Z 2 q -w-~-~ N Q I ~ b N ROAD SETBACK L/NF t ~ ~ N b LOT / a W W yh%4 ~ o a - ~ a r ~ a M M o o 0 Q H M 2-.238 ACRES a N ~ • 97, 476 sOi.'rT. N Q W \ 4 O 2.00/ ACRES EXC. ROAD R.O.W. v z 2 87, 163 S0. fr. Q 2 Z ~y J ' /0' a SCALE 100' N 89 • 28'51 "W 250. 00' O 25' 50' /00' 150' 200' 230' W UNPLA TIED LANDS h W z ,~~1tfu~l~hr~~i 1111 E 4 COR. SEC. 27, r 28 ON, R 18 W, ly ,,►~"I SvOltrs~ 1 /COUNTY SURVEYOR'S MON.1 •a►..,. ILAUR NC Dated: January 2, 199x7 ~ • W M RPHY•' °C O Indicates 1" x 24" iron pipe weighing = 0 13 + 1.13 lbs. /lin. ft. set. N R : !44 APPROVED FALLS, ~ ~ WISC. Q ~ E a '97f~FO LAND SJ.'. This instrument drafted by Laurence W. urphy !i~ae11~~a~a~ ST. CROIX COUuTY Comprehensive Planning Laurence W. Murphy Zoning and Registered Land Surveyor ' Parks Comrnittee Vol. 11, Page .3215 Certified Survey Maps If not recorded St. Croix County, Wisconsin. within 30 days of SHEET 1 OF 2 approval date ` • approval shall be null and void 1 CERTIFIED SURVEY MAP LOCATED IN THE NE1/4 OF THE SE1/4 OF SECTION 27, T28N, R18W, TOWN OF KINNICKINNIC, ST. CO. OWNED BYs Merle Nielson, Rt. 2, River Falls, WI 54022 I, Arthur L. Wegerer, regstered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions of the St.. Croix County Subdivision Ordinance and under the direction of Merle Nielson, owner of said land, I have surveyed, divided, anri mapped said parcel of land, that such plat correctly represents all exterior boundaries and the subdivision of the land surveyed; and tnat this land is located in the 'NE1,/4 of the SE1/4 of Section 27, T28N, R18K, Town of Kinnickinnic, St. Croix County, Wisconsin, to-wits Commencing at the SE corner of section 271 thence NO°36'27"W (Recorded as NO°00'00"E) along the east line of the SE1/4 of section 27 a distance of 1317.80' (Recorded as 1320.60') to the point of beginning; thence S89°18'35"W along the south line of the N112 of the SE1/4 of section 27 a distance of 569.65'; thence N4°41'56"E 410.35' to the southerly line of a 66' wide roadway easement; thence S87°49'16"E along said line 532.33' to a point on the east line of the SE1/4 of section 27; thence SO 36'2?"E along said line '81.89' to the point of beginning. Contains 5.00 acres ( 217,887 SQ. FT.) of land subject to any and all easements , rights of ways, and conveyances of record. Including a 66.00' wide roadway easement for ingress and egress purposes, as recorded in volume 5, page 135' of Certified Survey Maps and a 66.00' wide roadway easement for ingress and egress purposes as shown on this map. 0""11111~,ote%~ S iy .•'''•~sC ON Dated this 31 day of M~4Y , 1984. C.v ARTHUR L Arthur L. Wegerer WEGFRER Wis. R.L.S. No. S-963 ~ S-963 ELLSWORTH ; WIS. ; #ORO 91 O I'll", NO~SURq E 1/4 CORNER SEC. 27, T28N,R18 (00. SURVEY MON. FD. NOTEr THE ROADWAY SHOWN ON THIS MAP IS A PRIVATE ROADWAY. ANY MAINTENANCE ma COSTS OF THE PRIVATE ROADWAY, AFTER ITS APPROVAL BY THE ZONING stn ADMINISTRATOR AS A STANDARD ROAD, SHALL BE SHARED PRO- RATA BY m N'I THE ADJOINING PROPERTY OWNERS. SHOULD THE PRIVATE ROADWAY BE d1 yr TAKEN OVER BY A MUNICIPALITY AS A PUBLIC ROAD, MAINTENANCE COSTS THEREAFTER WOULD BE A PUBLIC EXPENSE. m M z0 • S 9749'16" E 526.2_1 M -4 XISTING 66'WIDE~p, _ .0 R9AowAY_ EsAEf WI DE ROADWAY EASEMENT J ~ y -t Yb NT1 o O •O IT ~-S.PI 53., gfo! o rn S 87 49'16 E 532.33' bl ~I to -I r ao M A . 0 1 Wza o z C Z - 2rnA y .n O Z O N AT6 n f D~ O A N r A - y v m 1" 0 b. ~ o ~y~ ~ 1lJ\' A w N .~I O z a m m CI cn L O T I rn V -i v,-•z :0 rn m C4.4 M '0 rn zoo .p "n 5.00 ACRES o o ns (217, 8 87 SQ. FT.) n, O Ono - .m A N ,f to to LVI 0 z = W CD 2 V _ O NY rn O • W to V a O = t0 W !e (A A ' N _ 35. A S 89 0' 234.17' ^I S 89 18 35 W 569.65 r SOUTH LINE OF THE N I/2 OF THE SE I/4, SEC. 27 I Q) z AS ESTABLISHED BY C.S.M.-VOL.1 PAGE 206. AND z A PARCEL REC. IN VOL. 534, PAGE 116 UN PL ATTEO 0 r C. S. M. RECORDED IN VOL. Ia PAGE 206 LANDS , c N a V Z I E ro O O O JOB NO. 83-155 SE CORNER O 01 C SEC.27, T2 8N, R 18 W FD.) rn THIS INSTRUMENT DRAFTED BY (CO. SURVEY MON. /CLrryy~