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HomeMy WebLinkAbout038-1063-10-000 v o p N 0 oc o a Q °o N N III', co y a~ ~ I J C" N I J B j N y N N_ O co ~ (n lf) o N U) O 7 Z 9 7 (6 E LL CO Co. O Q) 2? 3 Q a m I 0 vI, y I z y z a m c 0 c C7 -O co o z d c O z c ~ -o I N N O _~V O O 7 Q. n N c N d O U) O 0 o a a w Z m m z z c N _ N a m c I C a to b o c cD y m a~ g o ° o a m E m N a~ o co m m ~ o N ~ H H H 0 0 0 0 o m Z o •►NV ~ zaaa ~i a U I ~ o N o } I fq J V I' 6i ~ O O N N T N U O O j N C O O C T O N C N O C O bi O I- U N 0. ? If OO I N N Y O_ .O 'Z 04 E co O co O N C c y O :3 N ~Or M d y 00 0 N co L6 N L y N E U • O fn U O O - U) E 4) v w at a d a • c~ a m .tj d y c ~`F►.l + + E c c oj Co FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER L C~~~y~/✓~~l_SC~ TOWNSHIP ~'e~ SECTION-7 T N-R,L(W ADDRESS &5 4~94,X C i~" ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT ` -LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r by INDICATE NORTH ARROW BENC : Elevation and description: - lrjflo-t(° f Alternate benchmark SEPTIC TANK:Manufacturer: Gtr Liquid Cap. Rings used:S-Manhole cover elev: y nal grade elev: 2 .1 Tank inlet elev.: 5q- Tank outlet elev.:7~ 3 y l No. of feet from nearest road:Front Side Rear Ft. From nearest prop. line:Front , Side, Rear Ft. ~i 6 ~G //Building: ~2 cgc-,~`~ t No. of feet from: Well 14 1 (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE J r 1d r ' PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front_, Side, Rear-Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: -Trench: Seepage Pit: Width: Length 1 7 -Number of Lines: Area Built Exist. Grade Elev. b Proposed Final Grade Elev. Fill depth to top of pipe: -42!5~- No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from well: 1>4 No. feet from building- /b/.~~ / HOLDING TANK f'7 eo f 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: DATE:- PLUMBER ON JOB • 2 s" r` lS h LICENSE NUMBER: 6/90:cj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON WI 53707 Ei,SW;,SE4,Sec .15,T31-RI 8❑CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number Town of Star Prairie ❑Holding Tank ❑In-Ground Pressure ❑Mound (ff assigned) Co. Rd. C NAME OF PERMIT HOLDER: DRESS OF PERMIT HOLDER: INSPECTION DATE: Gerald Christensen ADRt.S Box 110 New Richmond, WI B CH MARK (Permanent reference Point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. EL FEE PT. ELEV. Name of Plumber MP/MPRSW No. Cnuoty. Sanitary Permit Number: ~j 1gyron Bird Jr. 3318 St. Croi 49062 SEPTIC TANK/ 3,G0 a "W 5T Coie(- .7 MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. UT LET ELEV.. CKING COVER IPROVIDED Y❑NO ❑YES BEDDING: aENi-OIA.: Vi~FT^MnTI HIGH WAT f NUMBEROF ROAD: PROPERTY WELL P'LDING IVENT'10 SH ~CtOr'1 I~ G`t71 ALARM LINE i I AIR IN ET FEET ❑YES LfdNO 'T ❑YES NEARESTOM ~-l DOSING CHAMBER: MANUFACTURER PUMP MUDt L PUMP. SIPHON MANUf ACTUREH WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL F PHOPEHTV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FRO I"E AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST --3 SOIL ABSORPTION SYSTEM. Check thesoil moistureat the depth of plowing N(VTTI JOIAMF TER INIATfRIAL ANOMARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to conti MAIN CONVENTIONAL SYSTE . WIDTH LENGTH jN..1 IDIST11 PIPE SPAIAN(, COVER JIN11111 DIA -PITS LIQUID BED/TRENCH THPNCHFS / i MATERIAL: PIT DEPTH DIMENSIONS RAVEL DEPTH FILL DEPTH I>ISllt PII'F UISTR PIPE DISTR. PIPE MATERIAL NO U.1H NUMBER OF PROPERTY WELL TFC~EDING V NT TO FRESH BELOW PIPES ABOVE COVER EIEV INIFI ELEV END t PIPES LINE / RINLET N . 11 r' FEET FROM / i Z _3 NEAR EST--► S© o Tfi' MOUND SYSTEM: Z$r Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑ meets the criteria for medium sand. TIONS MEASURED. YES ❑NO SOIL COVER TEXTURE 1,11 H4IANINIMAHKFHs OBSERVATION WELLS _ ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED ID EPTHOVFH TRENCH BED IDIP11101 TOPSOIL SOI)Uf 1) ISE F Of I) MULCHED CENTER EDGES ❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: _ BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING JGRAVEL DEPTH BE LOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MA EHIAL NO OISTH DISTR. PIP UISTHIBUI ION PIPE MATERIAL & MARKING ELEV. ELEV. DIA ELEV. PIPES DIA ELEVATION AND DISTRIBUTION INFORMATION `HOLE SIZE HOLE SPACING UNiILLLO CORRECT LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST F ~.r ( fi Sketch System on Retain 'n county file for audit. Reverse Side. SIGNATU E: TITLE I DILHR SBD 6710 (R. 01/82) E7ffILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El ,L fip , o? 8% X 11 inches in size. Check i 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. lJo2 PROPERTY OWN PROPERTY LOCATION e ~j^ p`J 1.taYa/a, S -T , N, R `EE (o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # / - CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ILLLL.AGE ' d~ ~O `I t NEAREST ROAD G II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ V 41014 OF: & Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - A RHCEI TAX NUMBER(S) ~O 111. BUILDING USE: (If building type is public, check all that apply) 3 -.7f 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 90 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 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 420 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 ft.) PRO ED (sq. ft.) (Gal ay/sq. ft.) (Mi n./inch) f;~~' ELEVATION 1(1 .ip:Feet • Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 411~ D I L1 p F-1 Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber' ame (Print): Plumb; ' ignature: (No Stamps) MP/MPRSW No.: Business Phone Number: y Plumb; Address (Street, City, State, Zip Code): e' x -er GCJ o co, / IX. CO NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Agent Si na re (No Stamps) Approved El Owner Given Initial /of- Surcharge Fee) 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 sanitary permit may be renewed before the expiration date, and at the time of r~~nowal 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: 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 131/2 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 41 0 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) PLOT PLAN PROJECT_ ~4- r a l G4rj fdr5Grn ADDRESS f ~v "r l e .S017 ~LJ1 /4 1/4/S/:~-/T,7/ N/R f g'W TOWN ar r C4 f -e COUNTY MPRS Byron Bird Jr. 3318 DATE - - BEDROOM CLASS PERC__,,_ CONVENTIONAL XIN-G UND PRESSURE CONVENTI NAL LIFT MOUND_ HOLDING TANK SEPTIC TANK SIZE ogt& LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA 'i)-& PERC RATE L ABED SIZE Benchmark V.R.P. Assume Elevation loo' Location of Benchmark 4~ks ~ ~,:e * H. R. P. a Borehole Q Well Scale Feet O Perc Hole System Elevation Uent Grndp + Fz 1, ✓ TYP AR COVERING w . 2 y- 12 3' 4 6' O 3• 3r Q 1 6" Sewer Rock 12' E Ct ; RESPONDENCE ero -0 , 30 \ p o, ~5 d~ L 91 20 217 a - \W~ 09 ~ 16 i's h LU i s Ud I Q ~t: + V JL ~ o rN, Indicate whether the following facilities are present. ; Floor drain yes no. Number of drains Food waste grinder yes no Dishwasher yes no Automatic clothes washer yes no Number of clothes washers ^r., Septic tank capacity f I/0 Holding tank capacity Septic or holding tank manufacturer SEEPAGE TRENCHES: total square feet width of trenches length of trenches depth number of trenches SEEPAGE BEDS: total square feet width / depth length of bed outside diameter SEEPAGE PITS: total square feet depth below inlet total depth from top to bottom of pit Signature of person completing form:, FOR DEPARTMENTAL USE ONLY Address Zip r~•„P o 0 Telephone Nu er 20 2 Date ' G ~r+-/1 Qr~~ Ova/ L i r~-~ ~ ~ • ~ _ SAO C itso-n .3X l• 5 5 t 75~° - .4 70S I P1 b. _ 60 1/18 f PROJECT. DETAIL DATA SHEET NAME-OF BUSINESS rp~ LEGAL DESCRIPTION'.''` OWNER •,e ica~ MAILING ADDRESS 1 ✓ Gi`l~ o: ZIP J o / . fill<5L- , ARCHITECT, ENGINEER, ror,~q ADDRESS PLUMBER OR DESIGNER,, _ ZIP S` o 10 LEPHONE NUMBER ' • _ X26 ~ 7 6l ,1.. Check appropriate building usage(s) and fill in'the information requested opposite each usage.,listed. Please consult Section,H 62.20. . -,~Extsting - bui-lding--•- - --New building Addition Apartments`-and condominiums Number of bedrooms Assembly hall . . . . . . . . . . Seating capacity ( ) Bar Seating cap4city of meals served, )-Bowling alley : Number of lanes ( } With bar Campground.and camping resorts . . . Number of sewereT-sites., _ Number of unsewered 's i tes Total number. of sites ( Camps ( )bay use only Number of persons ( ) Day and night Number of persons ( ) Catchbasin Number ( )Church No kitchen Number. of persons ( ) With kitchen Number of persons ( ) Dance hall . . . . .Number of persons ) Dining hall . . . . . . . . . Number of meals served daily Doq kennels . . . . . . . Number of enclosures ( Drive-in restaurant . Inside seating capacity Car-service --..Number of car spaces bump station . Number of dump stations mployees ( total.of all shifts) Number of employees Hotel ( ) Motel:( ),Cottages Number of units with l?persons per unit Number of units with 4 persons per unit Medical and dental office bldgs. Number of doctors,-nurses,.medical staff Number of office personnel Number of patients ( )'Mobile home parks Number of sites O Nursing homes . . . . . Number of beds Parks Number of persons ( )Toilets ( )Showers Restaurant Seating capacity ( ) Dishwasher and/or disposal? ( ) 24-Hour service ( ) Retail, store Total number of customers ) Schools Number 'of classrooms 77 Meals' ( ) Showers ( )Self service laundry . . Total numbe'r of machines Service station . . . . . . . . . Number of cars serft ~ daiTy Swimming.pool bathhouse- . . . . Number of persons OOTHER (Specify) V ; 'T ww COMPLETE OTHER-SIDE ii NO I SP fi. SAFETY & BUILDINGS DIVISION Tommy G. Thompson Governor Gerald Whitburn Secretary State of Wisconsin Department of Industry, Labor and Human Relations PRIVATE SEWAGE PLAN APPROVAL Northwest Regional Office 209 West First Street P.O. Box 754 Hayward, Wisconsin 54843 BYRON BIRD, JR. Owner: GERALD CHRISTENSEN ROUTE 4 BOX 6 ROUTE 5 BOX 110 AMERY WI 54001 NEW RICHMOND WI 54017 RE: Plan Number: S91-20217 Date Approved: May 21, 1991 Gallons Per Day: 550 Date Received: May 21, 1991 Project Name: CHRISTENSEN COUNSELING Location: E,SW,SE,15,31,18W Town of STAR PRAIRIE County: ST CROIX The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved'. This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. This approval will expire two years from the date approved or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Section of Private Sewage has reviewed these plans for private sewage system code requirements only. These plans have not been reviewed for the code requirements set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: - NEW CONVENTIONAL Inquiries concerning this approval may be made by calling (715) 634-4804. Sincerely, JOE MCGAVER Section of Private Sewage Division of Safety and Buildings cc: GERALD CHRISTENSEN X Private Sewage Consultant SBD-6123 (R. 07/80) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,. DIVISION LABOR AND PERCOLATION TESTS (115 P.O. BOX 7969 HUMAN RELATIONS \ MADISON, WI 53707 x (ILHR 83.0911) & Chapter 145) LOCATION: SECT!,QN: T WNSHI /MUNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: '/4 ~/4 /T N/R E (o - r,OUNTY?' Loll MAILING ADDRESS: Yo G earr~ USE DATES OBSERVATIONS MADE 46-5 NO. BEDRMS.: COMMERCIAL DESCRIPTION: DESCRIPTIONS PhHUJILATION TS: Residence ,New ❑Replace 94 D RATING: S= Site suitable for system U= Site unsuitable for system 2 C> CONVENTIONAL: MOUND: IN-GROUND•PRESSURE: SYSTEM-IN-FILL OLDINGTTAAN~K: ECOMMENDEDSYSTEM:(optional) ❑U S ❑U S DU EIS U O SgV DESIGN RATE: If Percolation Tests are NOT required If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: !25 i I Floodplain, indicate Floodplain elevation: i'y O PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED T. HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- o*V Zg4 25- '0_ le V5 776- B- _ PERCOLATION TESTS TEST 15EPTH . WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES NUMBER AMMWPS AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH P_ P- G P- P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION. S7- 3 S b rt I° r 3 N Y- ~j _ r 4_ I 1 i -A I&I 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. NAME (print): TESTS WERE COMPLETED ON: Szr-rgo 1) - ff / _ I # -1112 2~__~4c_7 ADDRESS: CERTIFIC,ITION NUMBER: PHONE NUMBER (optional): 7 d/ Z /J o?6 7~1~ -gel CST SIG T E: c DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. 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 - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well is - Fine Sand Bldg - Building Is- Loamy Sand - Greater Than 'sl - Loamy Sand - Less Than '1 - Loam Bn - Brown 'sit - Silt Loam BI - Black si - Slit Gy - Gray ct - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - 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 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. t n `SEPTIC TANK MAINTENANCE AGREEIIENT St. Croix County 014NER/BUYER LaLa:~i o ZNumberf-------- ROUTE/Box NUMBER Fire n CITY/STATE IP _ Section PROPERTY LOCATION C-SU, , • Town of ~T~k ~_411,rl&._.• St. Croix County, Subdivision ~✓~R , Lot number- improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Prover maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licens'ed' 's'e t'ie tank um er. What you the system can affect the .unction o. t e•aeptic tank as a treat- ment-stage in the waste disposal system. St. Croix Count 71 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 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 nec- operating condition and .(2).after inspection and pumping less than 1/3 essary), ,-he sepc~~ilkbe is Certification form three year-expiration. y 0 I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- ment Natural he Resoures. tion form completed V and returned to the of the three year expiration.date. SIGNE DATE J c7 I St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. • APPLICATION FOR BAHITAAY PERMIT • 9TC-100 This appllcatlon form In to be eonplntad In full and signed by the owner(s) of the property being developed, luny Inadequacies will only result In delays of the pit rett Issuance. -Should this development be Intended for resale by ovnec/contractot,(spac house), thon a second Lorm should be tetalned and completed when the property is sold and submitted to this office with the appropriate deed recording. ---------------------------------------------------------------m--------------- 1 Owntt •of property GERAId Location of property 5-W 114 5 ~ 1/4, Bactlon T ~ r-R-j!Q-V Township •J~ ` K4111nq address t Address of site Bubdlvlolon naa►a__ Lot number Ptevlous ovner of property _15k.aG r1gAVea Total Bile of parcel _ 5S &re:5 Data parcel was created ~/T,~•~ ~9D Are all corners and lot lines ldentlflable? - 2_ -Yes _ 110 Is this property being developed for resale (spec house)?_ on _)4- _No volursr "DA,and Page Number -a273 as recorded with the Reglstet of Deeds. INCLUDK VITII THIS APPLICATION TIIFI POLLOVINCI A VARRXXTr D¢SD which Includes a DOCU)iZHT NUMBER, VOL"K AND PAOR YvXj[R, and the 01IkL OF THE A9018TRR Of DSKDB. In addition, a certified survey, it available, would be helpful so an to avoid delays of the reviewing ptocees. it the deed description references to a Ceitifled survey Hap, the Cattitled Survey Hap shall also be required, PROPBRTY OVNER CBRTIPICATION live) certl(y that all statements on this form are true to the best of my (out) f;novledgel that I (we) am (ate) the owner(s) of the property described In this Intotmatlon form, by virtue of at warranty deed recorded In the office of the County Register of Deeds as Document No. _ .Sr~4I 3 I and that t lvel presently own the proposed site for tha oewage disposal system (or 1 (vs) have obteln on easement, to run with the above described property, for t.h. cons! at ion of sold system, and the same has been duly tecotdad In the office of t e VayntY q glatet of Deeds, as Document No. 1. r al ure of Owner Signature o! Co-Owner (11 Applicable) Date of 819 a to Date of Blgnaturs DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2 -1982 459913 vc*~ PACE - - - - REGISTERS OFFICE ST. CROIX CO. WI Gregory J,_Gartner and Pamela Jo Gartner, , - - - Recd for Record ;hlusband_ -and wife~___as---marital__property- with rights-•Of---survivorship-..----- - JUN 2 s 199O of 10:00 A. M _ ~a ` conveys and warrants to _._GQ;4c1ld- T1_l~l_i~eXlSen--_aTx d------------- .Carol..J-._.Chr.istensent-.husband... and_wife_,_.a~._ V marital ---property ---with-.rights..of...survi-vo-rship Register of Deed" it HLIUNN ~I . I the following described real estate in ..--.$t-.-„CYQ1X...................... County, II State of Wisconsin: ~I Tax Parcel No: I I The Southwest Quarter of the Southeast Quarter (SW4 of SE4) of I Section Fifteen (15), Township Thirty-one (31) North, of Range Eighteen (18) West, EXCEPT Lot "1" of Certified Survey Map, filed June 21, 1990 in Volume "8" of Certified Survey Maps, page 2227, as Document No. 459765. TOGETHER WITH a non- exclusive easement for ingress and egress in, to, upon and over the Easterly 20 feet of the Northwest Quarter of the Northeast Quarter (NW4 of NE4) of Section Twenty-two (22), Township Thirty-one (31) North, of•Ran`.e Eighteen (18) Vilest, specifically excluding any part of sai Northwest Quarter of Northeast Quarter (NW4 of NE4) lying South of County Highway 11 c it j TRAM SMR SUBJECT TO RESTRICTIVE COVENANTS OF RECORD. SD This 1s--not.------ homestead property. (is) (is not) Exception to warranties: I I I I I~ Dated this 22nd----------------- day of June.---- , 19...9.0.. --------•-----------------(SEAL) . ..(SEAL) Gr or.. J Gartner. ------------------------------------------••----------••----•------(SEAL) - - (SEAL) * * _Pamela..Jo_Gartner-. - - AUTHENTICATION ACKNOWLEDGMENT I) Signature(s) STATE OF WISCONSIN ss. S t ....CY O1X County. authenticated this day of--------------------------- 19 Personally came before me this _.22,nd___._day of June 19---90 the above named _Gregory-_-J_,___Gartner__and_ Pamela-__Jo_ tner Gar - - - TITLE: MEMBER STATE BAR OF WISCONSIN (If not, :;.,1.....: authorized by § 706.06, Wis. Stats.) to me known to' 1 ehd"Fri S wh executed the fore bo' ins at .3 owledg be same. THIS INSTRUMENT WAS DRAFTED BY Rein_stra, Van Dy) & Needham, S.C. 201 South Knowles Avenue, Box 127 He r L3yk . New---Ric•hmondy- W1---- 540.1-7-------------------------- Notary Pub)lc E''xOYX County, Wis. (Signatures may be authenticated or acknowledged. Both My Conunissio~f. 1s .prmhnent, ('lt not, state expiration are not necessary.) ~F' date: n•,-~-:-•----~•-=---=-------------------• 19--------•) *Names of persons signing in any capacity should be typed or printed below their ,ignatures. WARRANTY DEED STATE BAR OP WISCONSIN wisconsin T.e$fll 111ank Inc FORM No. 2-- 1932 ~I r~u!: r•. lV;F.