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476129 JUN ~ ~r
MR11FIED
F04ALDAP13 HELEN HALOS p $~REC4RD
Part of the Southeast 114 of the Northeast 1/4 of Section 11, Township ?8 North, Range
19 West, Town of Troy, St. Croix County, Wisconsin.
0 Indicates 1" x ?4" iron pipe
NE COR. SEC. lI, r2BN, R/9 W, weighing 1.13 lbs./lin. Ft.
I COUNTY SURVEYOR'S NON.) set.
UNPL A r rED LANDS
N
S 68 42' 52"E 646.001
587.79'
h 3
SEPr/C O VI ~ ,
OI C. DRIVEWAY a 4' N Ij h Q
ku Q)
0 W 3 r O ku
v WO WEL IN 0 OI I 4+ ~
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p Q
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00 POLE SHED lz~ ? W h N W m
p 8.282 ACRES Z MO 55' 10 ~
2I e L O r/ 360, 765 so. Fr. o v 3
O O 7. 440 ACRES EXC. ROAD R.O.W.? i ~I h V
b
FENCE 324, 107 S0. fT. O\ ` jI 2 y „
4664.59 646.00' I Z Q C N
I 57.7.20' 65.8 12 m W •
N 88 • 42'52"W 53/0.59 J'? m
R I N 90. 00'00 "W/ 3' W v + Z
L_O_r / I E/W 114 L /NE L_O_r 2
( E114 COR.SEC. r28N,R/9W,
C. S. M.' VOL. 2, PAGE 412 /COUNrY SURVEYOR'S NON.I
SCALE a 200'
O 50' /00' 200' 300' 400' 500' 600'
Oated: November 25, 1991
Owner's Address:
565 C.T.H. "U"
Hudson, WI 54016
-~C Note: This , lot is only to be. 4;pedL_far mortraP e ourpos=s: o o 4
N ~
e bacominq a sa3eable lot it must he re?:gned and f1\s..... 0i,
s ; .
'WWO d~ y Troy Township and the St. Croix County Rio
Zoning Committee as such. LAUR N
S` M W MPI~X o
S y13 3.
tl~ RIVER FALLS,:* :t' 10
mss` .F W►SC. JQ .M,r
Val. 9 Page 2427 •,~~~~~t~~'~~ t
Certified Survey Maps Laurence W. Murphy
St. Croix County, Wisconsin c9 47 Registered Land Surveyor
s FILED Go
Re
JAr o+OD69ft L
St Crdx Co., W, ~
'v SHEEr / OF 2
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION
LJBGR P.O. BOX 7969
HUMANN AND RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707
HUMAN
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: OWNSHI UNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME:
ss 1/ ►JE V /T zb N/R )9 E (or - - -
COUNTY: MAILING ADDRESS: S 6S c-,TT V
si - c~utx R.o>J RiJULUS N--)lk-1C>3oAv, w I S(4w1
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: I'E059-MERCIAL DESCRIPTION: I PERCOLATION ROFILE DESCRIPTIONS TESTS:
RResidence , A &New ❑ Replace Il Z - ZC1- G?) 2 - Z) , C?'
RATING: S= Site suitable for system U= Site unsuitable for system
rNS1:1U10S1__U1 ONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDINGTANK: RECOMMENDED SYSTEM: (optional)
[9S EA ®S ❑U ❑ S ~1U z TIZEUCHL`$_ L 4 S ~X !pp rLU+u6
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the N `
under s. ILHR 83.09(5) (b), indicate: M. t\. Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST-M HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-\ q-1.5 ~o>JC ~g seTZ p~~E Z OF Z
B- Z `7D qS--S 77 c7
B- 3 80 otV. 0 v ? F o
B- S 1~0• Z ? 5 /r
7 3
B- S `J3 q-~. $ h -7
B_
PERCOLATION TESTS
} TEST DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
f NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ 1 7- tip 3 3! 3/y /11. 4/ y
P_ 7- zy NQ 3o S/ .5J 510 4/8 -
P- - 7-V Iv O 3 0 7/ 3/ 3/ q U
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. taJtT I Pt L- X-Z ' uhL /erv T" ~{~G 4/ ~1 l l Q S 1
C7 q6•a C~) qs.Y
SYSTEM ELEVATION v Q6-1 M 9y.
s
a C; l h ,
11A2'-4~' 0►,> > oF^ - - -
f I
p~ )QI'DHL 17,lw , F
5 Y) 9~ c'Y SIB, ~ ~a
zii.1~w,)
8 5
48-
i E
L 7 t
x
A
IL4
I Mid ~ I"'3
sc-Nu~~ Y'= Lto' At
I, the undersigned, hereby certify that the soil tests reported on this form were made b in%arcnrd with ttie` r dures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to th-rrr~y ie and belief.
WEGERER SOIL TESTING
NAME print): AND TESTS WERE COMPLETED ON:Z
DESIGN SERVICE
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
P.O, BOX 74 421 No MAIN ST, GST 0(30 S_ 6 ~ ) S- S/ZS- 0/ 6 5
RIVER FALLS; WI 54022 CST SIGNAT RE:
715-425-0165
°11- 0 6
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
1PPrf= Lot= ?
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
cl - 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.
r
SOIL DESCRIPTION FORM
Attach Soil Pr Ills Location Me On a Su orate Sheet)
LINEAR LOADING RATE: 2- Z S
PURPOSE CUNLUPM FUR 1--,ssA3 SSAYaR, sLfs'rCY/ SLOPE: 6 0A.
srrcr : S ~o ~ w
R W EG -
O,~CRTrf[0N BY: L GZ ,
~s~ , Zt) Q 9
DATC: CURRENT LAND USE: F~ 'b
COUNTY/STATE: ST• C1eZ01X Wv~ VEGETATIVE COVER' GR 1~SS
LOT DESCRIPTION:' PT OT= Stii 'IV- titE S'EC I tT-8Nt R 19t.UDRAINAGE CLASS: w F-7L "L" R.AIAJ G"D
LOCATION: -rUwN O F T'Ra GALLONS PER So. FT. PER DAYS "4 S
SOIL SERtESt ~1 LW T 5 I
PARENT MATERIAL S /DEP111:
so I Mum-,
HORIZON DEPT11 MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS P11 •BOUNDARY REMARKS
in, moist G Sz. Shp. COATINGS
80 N G
1 0-13 \Z)4?- 7112 - SI) l ~Shct Yn ~r- 3`'~-'
Z ~3-~lS loyR316 - SO Z4) sbk wl"ql- C
3 45-~8 IotiR 3Jt, 1 s 1 ~s~k k1 v -~V-,
3oi?1NG Z
l o-z Io~m zlz - si 1 1fsb1~ m gc."
?0-S-7 VotiR 3/6 - s i I z AV-
Z
4 I-
3 5)-70 3A ~'-s
(.-3\rj NG 3
1 0-19 tz)Ll R Z.[ z - S I l S bk 1►h c S
2 19- bo Irs~-!R 316 Si I zm91~h 5S
Leo Iv c,
a-1) IOmR zlz- 1`~Sbk 1~`~h cS
_Z_ ll-3Z 1OYR 3/& - S1 I ZMSl it Vn'F►. cw
3 3z_s► ~~~ti31 - s I ~`FSb~ My ~ cS
9 S1-7S 10`'12316 - 51 V~ sbk yYl'FH J Ftsk I" (.A LS ~t~cs
owl N G 5 -
Z 1 -~l3 1D R alb - s '1 Z>r,sb1~ rn'F~ c s
3 y3-6 ~t!,-qz 3)b - s 1 5,bk yv ' 9 s
_1~ bo-~3 ~o~-t23 /6 - S 1 1..`FSb1rc miL- w/i=~w ~o,-i tt LA LS Pik `S
OTHER SITE FEATURES/NOTES:
/~.TlI►w.~re pi.'~~!W~'~ Z-ZI-91 00057 nNC~~ Z oP ~
LIMITING FACTORS/DEPTH: Signature Date CST S
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNERD TOWNSHIP- 77
SECTION T N-R_W
ADDRESS C6 yK ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT1LOT SIZE
i
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM y SrO _ / V
•
~o e £xrs ~ ~ kx
K,6 0\ q
0,5
l/c t vxk 9
~i.^rt
A T-61) ',j
INDICATE NORTH ARROW
Jj {l Y /~t< 1su ~I
To
BENCHMARK:Elevation and description:
Alternate benchmark
SEPTIC TANK:Manufacturer: kj P, Liquid Cap. ~pv~s
Rings used:-fZManhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road : Front, Side , Rear Ft. /G{3
From nearest prop. line:Front_,, Side , Rear Ft. ,/L'a
No. of feet from: Well y , Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
.
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 i, Number of Lines: Z
Area Built le~~zC9
Exist. Grade Elev.
Proposed Final Grade Elev. 5~
Fill depth to top of pipe: /V
No. feet from nearest prop. line:Front f
Side , Rear'2' Ft.l~L
No. feet from well: ~No. feet from buildin
HOLDING TANK ~j
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:
q INSPECTOR:
DATE: _''7
PLUMBER ON JOB: A~
/ LICENSE NUMBER:
3 zZy
6/90:cj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR X Hl,6MAN RELATIONS DIVISION
P.O. BOX 79969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707 State Plan I.D. Number:
SF4,NF.4,Sec.11, 28-R19 (If assigned)
CONVENTIONAL ❑ ALTERATIVE
Town of Tro ❑ Holding Tank El In-Ground Pressure ❑ Mound -7 All 0 It-,
z'rf t
LDER: ADDRES
S OF PER INSPECTION ATE: Ronald Handlos S6S Co. Rd. U, Hudson, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF.
PT. ELEV .
iAj
~ '/zo, S EF. PT. ELE
GV /
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Roger Timm 3224 St. Croix 128885
SEPTIC TANK/ s• , er = l y, . 3 3/ /
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV. TANK OUTLET ELEV.: I WARNING LABEL LOCKING COVER
IPR~OVIDEED PROVIDED:
G(/P~~.~^d~, a~- o?S, 0/ /o?.~ 7 LI~YES ❑NO ❑YES O
]oil
BEDDING: yDIA.: +tE#PMATL.: HIGH WATER NUMBEROF ROAD: PROPERTY WELL- ILDING: VENTTOFRESH
- q J~ "9. ALARM: FEET FROM LINE ~T / N 9 / / AIR INL T:
IG~I /
DYES ❑ NO ❑ YES 4&0 NEAREST---*
DOSING CHAMBER:
M EDDING: LIQUID CAPACITY: PUMP MODEL: /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUM F PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FRO LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: TERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH TRENCHES / MATERIAL: P} DEPTH:
DIMENSIONS -7 01
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N ISTR. NUMBER OF PROPERTY WELL: IBUILDING: VENT TO FRESH
/
LOW PIP ABOVE COVE ELEV. INLET: EV. END ✓ PIPES: LINE: AIR INLET:
/
BE F~. G FEET FROM 6~o
-~y Se Z W ?nl- lp` NEAREST~~ ~c~U
MOUND SYSTEM:
Mound- site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrow lope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO is the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
FTH R TRENCH/BED D EPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SO SEEDED: MULCHED:
EDGES:
F-1 YE NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PI FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. P DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL L RESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
71
e-, c!
1-(i-[~.Clczr.,_r"
Y ~
99 1
r 6
6, 6
tRet n in county file for audit.
Sketch System on
Reverse Side. SIGNAT RE: TITLE:
G'
SBD-6710 (R. 06/88)
5 C71 SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code CouN
STATE SANITARY PF;R
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 f~
8%x 11 inches in size. cd i rewsiontopreviousapplication
-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
t/4 kU<t %a S E T 2S , N, R (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
~ /1, /V I /i
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISIQN AME OR CSM NUMBER
i 4 c1 ~/Z - S63~
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
❑ State owned VILLAGE T~6 1
❑ Public ®1 or 2 Fam. Dwelling- of bedrooms PA 7EL A IJIMBFR(st
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
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.9 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 430 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. ft.) (Gals/day/sq. ft.) (Min./inch) / E ~EVATION
J6C> /f~Ob r y y~ L Feet ! Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank oOr~n fs
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's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW N__w Business Phone Number:
Plumbe 's Address (Street, City, State, Zip Code):
IX. LINTY/DEPARTMENT USE ONLY
4❑ Disapproved S ry Permit Fee (Includes groundwater [at ssue ssuingnature (No Sla' m urcharge Fee)
Approved Owner Given Initial C~ O~ /1
Adverse Determin tin 7
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Pib-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 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:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes, pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
- - - - - - - - - - - - - - - - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
. APPLICATION FOR SANITARY PERMIT
ETC - 100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. -Should this development be intended tot tesals by
owner/conttactotgJapec
sold and second submitted r to should this office retained
property Is then a
completed when th
appropriate deed recording.
---------j-------]------•------------
Ownec of property o 0_ ~ Y11 , n 1Ct ~ l a
Location of property if4 x_1/4• Section
Township
Mailing address 574! 'ez~-
9 K J_ s0.V_., W
• Address of alts
subdivision name
Lot number
Previous owner of property
Total also of parcel 0, 0 S c ~ .
Date parcel was created
Ats all cornets and lot lines identifiable? )Yes o
is this property being developed for resale (spec house)? as 0
Volvos 41-and Page Number as sacorded with the Register of Deeds.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
INCLUDE
WITH THIS APPLICATION T119 FOLLOWINCs
A WARRANTY DRID which Includes a DOCUNSNT NVM6aR, VOLUM2 AND PAOX NUMBRIt, and
the SRAL OF THR RROISTRR OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. it
the deed description references to a Ceitifled survey Map, the Cettifled Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(ve) certify that all statements on this form are true to the best of my (out)
knowledge= that I ~am t4RRA the owner(s) of the property described in
thin lntotmation Eorm, by vls of a warrant d t eptded in the office of
the County Register of Deeds as Document No. ) and that I (we!
Presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, lot the
construction of said system, and the same has been yl otd d In the Office
of t unly Register of Deeds, as Document No4 X/ g
occ
gnstute of Owner signature of co-Owner (If Applicable)
Oats of signature Date of signature
Ari,
• TMw etret e~esswra ,tea
alp 0"64M No. WArAMWIT
F' UqD~,
AMM"
St. COM Mo 1
we'd fW
~nce J. Handlos and Gertrude Handlos, ~No~~lB, 19Sf °
sfi>Id aMfr 8:30
?
"owes asdr le to . AaA41.4 .14• [Mr.k 4iioo.. and Helen. G,_. Kei
#1 1d 09&..Awband ..lad . wife, aw-survixorshiD
T
ldNr hum"W daerlhw no etitats in . St... CK044 Counq,
stem of Wisasasia:
Tax Pared Me:
~x
Ali,
.
it. Croix County, State of Wisconsin, to-wit:
t 1lo>rthwost Quarter (NWJ) of the Northwest Quarter (NW) t the SOUth a
11+► f so of the Northwest Quarter (NWJ) of Section One (l)t Township',*.'
;t Twenty-eight (28) North, Range Nineteen (19) West, except a parcel
sWOVL"s ly deeded to Wayne Handlos and Diane Handlos, husband and wife u.
~ fOleTt: t+snaltsi the east Half (Ei) of the Northeast Quarter (NEB) of
.;e/ed~e~m.on Bleven'(11) Township Twenty-eight (28) North, Range Nineteen
This deed.is given in satisfaction of the land contract between the
pltrtibh dated December 17, 1969, recorded December 30, 1969 at 8:30a.m.
in Volume 658 of Records, Pages 95-96 as Document Number 299106. .
r°
This i .fit. :homestead yroperty. ::i!
(is net) j6
Xseptim to wiarrs*ties :
"40Ments,t/restrictions and rights of :gay of record, if any.
Dsted:,this day of November 87.
_eelf-a -AL) (SEAL)
(SEAL) (SEAL)
AVTXSWTIO,T1011 ACKNOWLZDGKX14T
1 . 1►f -1,t,,~G¢...7. H3t}d}~08...... STATE OF WISCONSIN '
V'l
A*rtrw
< County.
Illrtl8 ....»elobar 19 Personally eame before x;
me this dad of ~ .
r 19..,.::.. the a6y Nt,A0M*
X STATE 1!f/ XA* WIBCONSIN
r
. n to btthe p*raoL . ,1ikj y
to me kDow
foregulme lwftun ent sad &&nowkd=e the aams ,s
~r *rg 04ftoavow w~y1OMAOTMsy
Y s g*& Fetk MY CWMvWiion il permanent. (It
r1d1 is .r .ir N+rw MW~i► eNIK.r~lw~ + _
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT w
St. Croix County "J
r
1-Y► /bs
OWNER/BUYER o
ROUTE /BOX NUMBER Fire Number o
t7
M
CITY/ STATE 1": ZIP rt
PROPERTY LOCATION:'. S4- k, Section ( T a~ N, R I
Town of o St. Croix County,
Subdivision Lot number Ai
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 of ect the function of the septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County, residents may be eligible to recieve a grant for
a maximum of 60% of the cost-of replacement of a failing system,
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 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 disposal system is in proper
fying that (1) the on-site wastewater
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 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, asset by the Wisconsin Depart-
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.
SIGNED
DATE
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
,11`40USTRrY,. DIVISION
HUMA AND PERCOLATION TESTS 115) MADISON WI 53 07
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
L A 1 SE TION: OWNSHI UNICIPALITY: OT NO.:BLK NO.: SUBDIVISION NAME:
Se 1/ tJE 1/ /T z'6 N/R )a E (or -T"R-Q `-r - - -
000NTY: MAILIN ADDRESS: S6S c-`T~ V 11
ST. .c.~~x R.o>J ~'~PtIJ~~-OS ~~~~so~v, w I su~l6
USE DATES OBSERVATIONS MADE
NO. B DR COM R A DES R TON:
~Ftesidence , A New ❑ Replace ( Z _ Z~ _ 9 I Z _ Z ! , 4
RATING: S- Site suitable for system U= Site unsuitable for system
CONVENTI NAL: MOUND: IN-GROUND UR : S TE -IN-FILL OLDING TANK: RECOMMENDED SYSTEM:(optional)
®S DU ®S DU ~S DU ®S ❑U ❑S .®U Z'nz ct+~`~_ etcH S'x J'aQ uyu
DESIGN RATE:
If Percolation Tests are NOT required r I If any portion of the tested area is in the N , A -
under s. ILHR 83.09(5)(b), indicate: N- Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL P R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OB ERVED TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- \ -7 8 Q-1. S N Ui'J C ? 7 8 S Pc G E Z O F Z
B- Z `7D qS•3 7 ?0
B- 3 So R~,O I, > 80
B- •15 VMS • Z # 7 S a
B- S `7 3 °17 8 4 -7 7 3
B-
PERCOLATION TESTS
DEPTH , WATER IN HOLE TEST TIME I WA R L V -IN H S RATE MINUT S
NUMBER INCHES AFTERSWELLING INTERVAL-MIN, p I D 1 p RI D P PER INCH
P- 1 7- lip 3~ 3/ 3/ tit/!{. k/V
P- Z Zy No 3o 5/ sJ 5/9 ~
P- 3 ZV NO 30 3/ 3/ yo
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. f t 9 I $ z q t T- Qf~ G E' ~7 L/ l~ L p r S l I
SYSTEM ELEVATION v g 6. i R, 9 y.
- -
Po r. T I- o - c
~
1 w' )1~ PI g F I TIE j
o g•I
9 , _ _ _ ~DL IO .4
~ i ~ _ ~ it 1J S C II
I
Sch~-~ 1"= 40~ EXCEPT hS sNuwN
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.
WEGERER SOIL TESTING
NAME print : AN~ TESTS WERE COMPLETED ON:
DESIGN SERVICE z - z~ - 4
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
P.O, BOX 74 421 N• MAIN STe GST 6ta0 S, 6 S- V1.5- 0/ 6 5
RIVER FULLS. WI 54022 CST SIGNAT RE:
715-425-0165
°I 1- 0 6
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. _
DILHR-SBD-6395 (R, 10/83) - OVER - OF ?
SO1~ DESCRIPTION FORM
AftaCh Soil Profile oeation Ma Oo a Su orate Shoe I
~0~ }~1.~~ LDS LINEAR LOADING RATE: 2. Z S
PURPOSE EUNLU KM FOR 1J~~ SEW~Z S Y SKH SLOPE: old
DDEESCCRuION BY: ~ R--n'}UR L W EG ~ZC--R ASPECT: -
DATI,; F~S~ , Zo I CT 9 1 CURB N AND US : F/ ~Lb
COUNTY/STATE ST. C1~A 1X C wU ,Jl t , Lki 1 VEGETATIVE COVER; G R KS S
LOT DESCRIPTION:' pS OI= SE -1J~ ~I S ~ 1 I.TlbN, R 19LU DRAINAG CLASS: w ~I- O R.AIAj e D
LO TON ~~(~IJ of ~~Q~-( GALLONS PER Sp. FT. PER DAYt O'LlS
PARE MATERIAL s / PTI : SOIL SERIES: 7i LL_Q, T S I I
FIORIION DEPTH MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS PH -BOUNDARY REMARKS
in nnisL Gr. Ss. Sh COAT NGS
8o N G l
1 O-l3 ~0`tCz z/Z r - si) 1'Fsblz Y~l 9w
Z ~3-pis ~oHR -3A - s I• I Z rn sb}~ kn,~k c
3 4S-~8 10`-tR3Jt, 1 S 1 `~S~1z. ~1U`Fh
BoRI l~ G 2
l o -2.o I o4 R Z! z - s i t ) f s dk m 'Fc g c,"
Z 20 S7 ~0~9 R 3) 6 - S i l Z yh Ak `f=h 9 S
3 57-70 ~o`1R 3l6 - s I l~s~>t M'F1~
30 NG 3
1 0-tq l0`i R zl i - S f l S bk 1►ti 'f4- s
Z 19- 60 1tW-fP.3l6 - S1 ZM31~h h1'~l~ 9S
3 6o-Bo ~otiR X 16 - sl 1 ~sb1~ W,'o F
o-ll 10`i►Z z!2 - s i 1~Sblt Yn `F, CS
Z ll-3z IoYR 3J6 - s i l Zm Soh 1ryI~~. cw
3 32 _ S I R- 31 S I `FS 1z M U 1., C S
y S1_7S m l` z 316 - 5) l`~Sbk h~'~4. Ib'l f-A LS c-l~csS
3bPJ. n1 5
~ v-►8 11~~ltZ Z!Z - S i ~ l~ S~12 hn'Ft,.
Z 1 -~13 10`iR 3Ib - s '1 ZTmSbI~ rn'F~ c s
3 43-6 ZotiR 316 - s I 1`~Sbk vr~V+i,, 9 s
Y l6--73 ~o-t(Z~ l6 - S) 1.`FSblrc M ~ Loo ►0,fP_ 6/6 LS P~ S
OTHER SITE FEATURES/NOTES: , j~~
~Gf.L~i.+~r. o~syr,G~_~-~»-~. Z-z.~-9I 00057 z
Signature Date CST k ~~6H of
LIMITING FACTORS/DEPTH;
7~an~/~ 7Yi.ncl~aS
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TIMM EXCAVATING z
• ~ SHEET NO. OF
Route 1 Box 192 ~J
WILSON, WISCONSIN 54027 CALCULATED BY rCd DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 A sp Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-8OR2254380
JOB 6y/Cc~1 T' /os
J . , TIMM EXCAVATING SHEET NO. Z OF 2
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED BY 6Gre r7-/ M DATE 3
(715) 772-3214 (715) 386-5443
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