HomeMy WebLinkAbout020-1166-40-600
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DPAR MT ENT 7F REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 3707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
I OCATI N- SECT OON N/D r (o TOWNS HIP/M04W~At1 : LOT NO.:BLK. NO.: SU DIVISION NAME:
11 C 'ecd
COUNT OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE ` ~ S '
ATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
LPResidence 3 EPIew ❑ Replace 5,1"1 Are
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: IMOUND: PS IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
RS ❑U ❑U V 0U DS [~T 19-S ❑I p ene 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), indicates LFloodplain, indicate Floodplain elevation: w
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, OBSERVED EST, IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- / S 63 AJMc- a FY r5'' / Q
B- 9tl of r ? f .'2 Br rs , 2&(A' tY6 r
B- 3 1er 1 ?~/r 3, r k- IN 5
B- !o3 v!r> 03 rt' w ;t♦ ' rGhs
gave 13-5-
f490 r~ s7 10 ♦ C rJ 404 It '
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD I PERIOD 2 PERIOD 3 PER INCH
P- 5-D c
P- 6
P-
3
P--
P- 3
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 pl S ow jhe face elevation at all borings and the~lireption anc~ percent
of land slope. /q`P/~C C p < Z elGl~l ndX t' ~tT QGt~II' f !"t^
r irQ~
SYSTEM ELEVATION p6rs H,.54 ~ f r ~ AIM,/ Aw We
e ,
€ Ura'ue i I ~ e4 le
411 - F
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F. ~aS~ ®f vsr'reYrts.
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- 4.
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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.
NAME (print : TESTS WERE COMPLETED ON:
Licensed Perk Tester & Plumber
ADDRESS: Fpgarty Ha 0320 !i ht! (00ad CERTIFI ATI UMBER: PHONE NUMBER (optional):
ltOBEFtTS WISfN iN
OM 14903056 CST SIGNATURE:
31STRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
)I LHR-SBD-6395 (R. 02/82) - OVER -
1
4
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;
1 MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. Complete the --it rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTE" RULED OUT BASEL} ON SOIL CONDITIONS;
6. PLEASE use the < eviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
s-,)ara iy be used if desired;
S ,.;re your -enchniark and vertical elevation reference point are clearly shown, and are permanent;
.-:lete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
n, if appropriate;
10. information (such as flood plan,, ';an) does not apply, place N.A. in the appropriate box;
11. Siyr1 the ~orrn and place your current au,.., =aid your certification number;
12- Mate legible copies and distribute as re ;aired. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION,
ABBREVIATIONS FOR CERTIFIED SOIL, TESTERS
Soil Separates and Textures Other Symbols
st - Stone! (over 10'") BR - Bedrock
cob Cobble (3 - 10") SS - Sandstone
gr Gravel (under 3") LS - Limestone
Xs - Sat, ' HGW - Nigh Groundwater
cs Sand Perc - Percolation Rate
med s - :I Sand W - Well
I's I nd Bldg Building
Is - Loarny Sand > Greater Than
'sl - ` idy Loam < - Less Than
*I ~•r Bit - Brown
*5i' am BI - Black
si - S Gy Gray
"cl - Cl oam Y Yellovv
sci - C: y Loam R - Red
sicl - I y Loam mot - Mottles
SC W with
sic ;lay fff few, fine, faint
"c cc - cornmon, coarse
p _ mm Many, medium
r'n d - distinct
p - prominent
HWL - High water level,
soil .:xtures surface water
e disposal BM - Bench Mark
VRP - Vertical Reference Point
TO TFIL iE ;
T; s I n moit. T ;J, r tt= may r :west
="LIInce A e, I
t ;t z ~ i 'C `e .Iz s
.f+e~fa~riC t~•th~:Sf<irt~of~ah4~.:[>rts;r
d
s '.V V
' Form -3TC-106 .
. A8... BUILT SANITARY SYSTEN REPORT
TOWNSHIP 1 I7ti SEC. / 7. T y N-RZW
i ADDRESS ST. CROIX COUNTY, WISCONSIN
4-~
d IOW o o~
2) yz
SUBDIVIEICII R-eJ LOn t.13 LOT SIZE
_ _ ~j• - ' -PLAN VIEW
Distance and
dimensions to meet requirements of IS/HR 83
SHOW EVERYTHING WITHIN'100 FEET OF SYSTEM '
w...,• . . ji.•I • • • 1 , ~tlpt1r1r~ ~ /I ~ •j ••,a • ''i' •
~..,t~'••:: .t• Ids. ,
, •:to• t, j3
• a f: ~y.•L1((..yy~~~~ s, ~
Jff
' INDICATE NORTH ARROW
• BENCIWAMt Describe the vertical reference point used
•
Elevation of vertical reforefice points_ 41gl_ip ' Proposed slopi/at sites
• SEPTIC TANKS Manufacturers- .5 Liquid Capacitys LV6
'•'••+•Numbet of rin s useds
6 • Tank manhole cover elevations _ !o /
• Tank Inlet Elevations
Tank Outlet Elevations q7. 9s
Number of feat from nearest Roads Front to SideJo Rear. feet
• From nearest-property line i • Front,Oside 0 Rear, O > so ; feet
Number of feat irons. V ell _Lz`~ j:
, buildings l
(Include this information of.the above plot plan)(y reference dimensions to septic r>
SEE tic? r
PUMP CHAMBER
• N
Manufacturers Liquid Capacity:
pump Model: p /Siphon Manufactu s pump •81se
Elevation of inlets Bot _ of tank elevation:
pump off switch elevations Gallons per cycle:
Alarm Manufacturers Alarm Switch Types
-Number of feet from;ne eat property 1 a:~'• Fronts OSLdeg O Rears O R
bar of feat from wells
mbar of feet from building:
• (Inc a distances on plot plan).
SOIL ABSORPTION • SYSTEtf f, c
Bddr• ✓ST Trenchs
Width: /•32-- • Lendtht~_,.-.Number 'of Lines:_Area Builtt
i
Fill depth to to cif pipes
Number of feet f~om nearest property lines Frpnt, C)'81des O Rur,O 1t. _
Number of feet from wells
• N 'bar of feet from buildings _ .2 7
(include di lances on plot plan). '
SEEPAGE PIT '
Site: Number f pits ametert
Liquid depths Bo om of spage pit elevations
Area Builtt '
Has either a drop box O o istribution x O been used on any of the above soil
absorbtion sytems? (C~ one).
HOLDING TANK
Manufacturers Capacity:
Number Wirings load:. _ Elevation bottom of tanks
Elevation of inlets
Number of feet from.nearest pr a ty lines Front, O Side. O Rear, OFt.~_
Number feet fr m wells
Numbe of feet from bu ding:
Numbs of feet from.neareat oads '
Alarm Manufacturers '
i~ Inspectors AL4
Dated: / Aa Plumber on Jobs
s License Numbers
•
3/84:nij
' DEPARTMENT OF INDUSTRY, SAFETY & BUILDING
INSPECTION REPORT FOR
LABOR & ITUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MO §V R 7 , T29-R19 Sf at signed) Number:
Town of Hudson 1 13 CONVENTIONAL El ALTERATIVE
Brookwood Dr. Ho X ank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTI N TE:
Kent Fliziak 551 Helen St. Hudson WI 54016 03
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. P1. ELEV.: CST REF. PT. E /
/
6~ e- 14a
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
David B. Fogerty 3287 .-,7 1 A o_'X 13552
• d
SEPTIC TANK/ '-~'cF ~ , y ll~ • 19 115
MANUFACTURER: LIQUID CAPACITY: K INLET ELE ANK OU WARNING LABEL LOCKING COVE
~S /(z 98. 5sB 519163 / PROVIDED
YES ❑ NO P❑ YES NO
BEDDING: DIA.: V ItT MATL.: HIGH WATE NUMBER OF ROAD: PROPERT WELL: BUILDING: VENT 1110 FRESH
0
AIR ?q
d-19 ' .0, ALARM: FEET FROM LINE
❑ YES NO ❑ YES NO NEAREST --1111111
DOSING HAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: POMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FRO LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST -I►
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: M MARKING:
or excavation. (If soil can be rolled into ire, construction shall cease until MAIN
the soil is dry enough to continue.
CONVENTIONAL SYSTE 5 = 2 O/
BED/TRENCH WIDTH: L NO. OF DISTR. PIPE SPACING: OVER INSIDE DIA.: PITS: LIQUID
n t z TRENCHES: / M-ATEPIAL: PIT
DIMENSIONS o` a GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE M E IAL: NO. D TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET) ELEV. END: / y 1'k; S . a~t0 PIPES: FEET FROM LINE: s AIR INLET: /
~o?S
Y 38-~ I (t t}Z 2 NEAREST ~ S ~ *7
MOUND SYSTEM: $ /
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
NO meets the criteria for medium sand. ELEVATIONS MEASURED.
BSERVATION WELLS;
SOIL COVER TEXTURE: PERMANENT MARKERS: O
❑ YES ❑ NO ❑ YES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SEEDED: MULCHED:
CENTER: EDGES: SODDED:ES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BEL IPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LI 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
Sketch System on Retain in county file for audit.
Reverse Side. SIGLTURE: TITLE
SBD-6710 (R. 06/88) /
T IMLHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUN
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~'E-a.
8% x 11 inches in size. check f 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.
PROPERTY OWNER PROPERTY LOCATION
.,to , C IVI~el Y4 5 Y4, S 17 T 2?, N, R E (or
PROPERTY OWNER'S MAIL G ADDRESS LOT # BLOCK #
S 3
CITY, STATE ZIP CODE PHONE NUMBER SU IVISI N NAME OR CSM NUMBER
p c
II. TYPE OF BUILDING: Check one) CITY NEAREST ROAD
( ❑ State Owned ❑ LAGE :
❑ Public [q1 or 2 Fam. Dwelling-# of bedrooms ~ PA EL A Nu B R() ~
III. BUILDING USE: (If building type is public, check all that apply)
po
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
12 ❑ Service Station/Car Wash
4 ❑ Church/School 8 ❑ Moblle Home Park
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. l!g New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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-Pres urized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 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) El(/ATLON
S f - 5S
Feet Feet
VII. TANK CAPACITY Site '
in allons Total # of Prefab. Fiber- Exper.
INFORMATION Manufacturer's Name Con- Steel Plastic
New istin Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holdin Tank
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.
Plu is Name (Print): Plum is Signature: (No 7mps) r /MPRSW No.: Business Phone Number:
r / 3i L3)9'
PI 's Addr (Street, ity, tate, Zi Code):
3
IX. COU N /DEPA TMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing A pent Signat
Approved El Owner Given Initial Surcharge Fee)
Adverse Determination 14e~_ e Q7
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
I
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 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. dnsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a'licensed
pumper whenever necessary, usually every 2 to years. _r
6. If you have questions concerning your onsite sewage system, contact your local 688 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'h 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) hc)rizontal 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-8398 (R.11/88)
. APPLICATION FOR SANITARY PERMIT
8TC-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 petmit issuance$ Should this development be intended lot resale by
owner/contractot,(spec house), then a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property 'f
F- Sru)
Location of property X1/4 -Set/4• Section 7 Tom.-
Township y & s z. n -
Hailing address
S`tol~
Address of site
Subdivision nasr„ Pusr~Cv~ eu-► 5 e5
Lot number
1
Previous owner of property D0"rre1
Total size of parcel CP- cue S
Date parcel was created
Ate all corners and lot lines identifiable? ✓ Yei o
I$ this property being developed for resale (spec house)? Yes 0
nd Page Number 3 as recorded with the Register of Deeds.
7L 3
Volu"
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which Includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed descclption references to a Certified Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
t(we) cattily that all statements on this form are true to the best of any (out)
knowledge] that I (we) am (ace) the owner(s) of the property described In
this Information form, by vlrtue of a warrant ged(r~ corded In the Office of
the County Register of Deeds as Document No. y d j and that t (we)
Presently own the proposed alto for the sewage disposal system (or t (we) have
obtained an easement, to tun with the above 'described property, for the
construction of said system, and the same has be t) ly r ord;d In the office
Of the County Registog of Deeds, as Document No. 5 c~
(A - -1 A
Signature of Owner Signature of Co-Owner (If Applicable)
5 /31 /qG
Date of Signature Date of Signature
t i
THIS SPACE RESERVED FOR RECORDING DATA ,I
DOCUMENT No. WARRANTY DEED
I
STATE 1„)rAR 0 ;,72PAGE W CONSIN-FARM 2-1982
4
55048 33 REGISTER'S OFFICE
- ST. CROIX CO., WI
Recd for Record
-•..••..•plrrel E. Wert. and Bever•ly...A.....Wert! husband
and •wife, ind viddal:ly and each in their MAY 3 01990
at 11:20 A. M
Qwn...r, I.sht
.
_...---r....'•------
Ke.. nt M. Fili iak, a sin le Re isterofDeeds
conveys and warrants to ................................P.-............ 9
man
i
RETURN TO -
the following described real estate in t...... SQl,:K............ County,
- -
State of Wisconsin:
Tax Parcel No: ..020-1166-40.=600 i
1
I
Lot 113, Parkview Estates, Fourth Addition to the Town I
of Hudson.
rR NS 0
-0
FEE
i
i
i
i
This is_.not homestead property.
(is) (is not)
Exception to warranties: TOGETHER WITH AND SUBJECT TO any other easements, coveants,
reservations or restrictions of recrod, if any, but this shall not be deemed to extend
any such other recorded encumbrances beyond the term established by law therefor.
Dated this 25.th...................... day of May....................................... , 19.90...
.........................(SEAL) .../.G,e-~.~.j~....~------- (SEAL)
" * ...Darrel...E . Wert
(SEAL) E.lj~rG Q.... (SEAL)
* * ...Bev~rlY..A. ert
AUTHENTICATION ACKNOWLEDGMENT '
Signature(s) STATE OF WISCONSIN
ss.
........................•-....N1a---------••---------...-----•---.-----
........S:t.....Cx'QZz County.
authenticated this ........day of 19 Personally came before me this ...25:0 day of
Msy..................... 191L. the above named
•
Dazxea ..F~....W..Qrt..1nd...v~rlY.. A=
Wert, his wif---e
TITLE: MEMBER STATE BAR OF WISCONSIN
_
(If not, . r•
authorized by § 706.06, Wis. Stats.) S
to me kto•be-the; personS........... who executed the
foregoi ; if trument:and iii~lcnowledge the same.
THIS INSTRUMENT WAS DRAFTED BY ' h\ r,'~
A Y __)?~1Jh._H.....GW? n,_ GWIN &..GWIN..... Via;
t V .5w--------
F.
eod__St: , Hudson f ..016.....
Q--- $-...on WI Notar~ ' hlie 5 .t~.,ZC.rQ X
- - • y~ ~ ...County, Wis.
(Signatures may be authenticated or acknowledged. Both My Cq I`ssiAv.. is perrna-bent. (If not, state expiration
are not necessary.) . •f+' r
. date: 19 Y.2
*Names of persona sinning in any capacity should be typed or printed below their si¢natures.
WARRANTY DEED STATE 33An OF WISCONSIN
A'
FORM No. P - !-(2 isronsin I,r>ixl I31nuk Co. lur. . 11-
r STC-105
o
SEPTIC TANK MAINTENANCE AGREEMENT r
St. Croix County r-
w
OWNER/ BUYER ~e4\k.' 1 ` . \ rr
ROUTE/BOX NUMBER L1.71 ',rU®< uo ~ Y. Fire Number
d
CITY/ STATE ZIP 5 1 (a rt
N M
PROPERTY LOCATION: _ Section ~_7 T Z,,~ N, R~W,
Town of v~50-\. St. Croix County,
Gr t
Subdivision -Ak►-,k&k 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 licensed 'Septic tank um er. What you put into
the system can aTfect t e unction of'eptic 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,
whicTi 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 'sys'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 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart- ::r
went of Natural Resources, Certification form must be completed .d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date. 1 n
SIGNED ~S
DATE 5)3 1 Q~
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016.
386-4680
Sign, date and return to the above address.
DPNEPA'P,DUSTRY,TMENT OF REPOR 1 ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION NGS
LABOR AND PERCOLATION TESTS 115) P.O. BOX 7969
HUMAN RELATIONS J MADISON, WI 53,07
(HG3.09(1) & Chapter 145.045)
LOCATION: S CT ON: OWNS HIP/N*Wf6}PAjrI-TY: NO.: BLK. NO.: SU DIVISION NAME:
1 / R E (o T OT Gr/ t
(VW C07T OWNER'S BU E S A E: MAILING ADDRESS: ZZ"o
/
S G
USE ATES OBSERVATIONS MADE
ND.BEDRMS.: rOMMERCIAL - DE CRIPT ION: TFR~F _071 S: ~jAT ON ES1-S: I 0, I~Fiesidence 3 Ql~ew ❑Replace • 7 -1~7`~ /
RATING: S- Site suitable for system U° Site unsuitable for system ✓T
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STE -IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:loptional)
[OS 0U E S EA CAS ❑U ❑ S DT CAS ❑U c.,ow tzeAicl-e-na
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.091151(b), indicates Floodplain, Indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B' l 613 ,S'
B- 2- 0.2
> 'y la. S .7 w .f'
B- 3
13- _7 9/ ;M71I,117 '131., -s 1 49 401, 3, MI-C-1
B-
PERCbLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN, PERIOD p I D PER INCH
P. - 5-0 ^ Y e- P6V f-
p- q T -e, 5_
Y
P-
P. S- _T s-
P. to 3 „
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 pl n, Sow he ~rface elevation at =40 the direption anr( percent
of land slope. ~Pr,~ CCO/'~ g?-/ 2 ev Oo.yYr f rc-
SYSTEM ELEVATION
00 i4
i 6. t 1
N
,2-
I ~ I
I I I I J. i I ~
j -
s,
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 lprint : AVE~FOGER I Y-PLUMBING TESTS WERE COMPLETED ON:
Licensed Perk Tester & Plumber
ADDRESS: 0-3233-#3289
Fogerty Heights Road CERTIFI ATI UMBER: PHONE NUMBER (optional):
ROBERTS WISCONSIN W23
One CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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