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HomeMy WebLinkAbout020-1263-30-000 g o I' ~ ° I ~v o°ic m 0 h I o ~ I ~ I I I r I I m I o z c ti c I 3 ~ I Q I M ~ Z y O v °'w am N F- Z 0 O 2 c It w N H 'D N Cl) N •C Of y O. N ~ y C a O g C O CD C ZGo D o I c z N c - c Vi E a. N lp > d ` p e a ~g c v L d e ° °O cca ~N CL M 0 T w o hw O0 O a~ Z~ CL •N C N c o 0 tq J U rn rn y (n o 'D --t Lo w ' E N c co (D a I 0 a r v~ co y H O O co H = O~ N N U a :3 04 LO p p O C C O Q1 n c: 0 US FE • ~ N O O O co O a L O N 2 fn O Z fq r b U o co~ d ~ ~ d 0 a L: a • id a m 2 m rw r A ciao aic~ Parcel 020-1263-30-000 01/10/2005 05:03 PAGE 1 OF 1 F 1 Alt. Parcel 20.29.19.1279 020 - TOWN OF HUDSON Current 0 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * HEINECKE, THOMAS L & LINDA J THOMAS L & LINDA J HEINECKE 866 DORWIN RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 866 DORWIN RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.810 Plat: 2319-PINE GROVE HEIGHTS 2ND SEC 20 T29N R1 9W 2.81 AC PT SE NE LOT 34 Block/Condo Bldg: LOT 34 PINE GROVE HEIGHTS 2ND ADD Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 877/178 2004 SUMMARY Bill M Fair Market Value: Assessed with: 49319 246,400 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.810 34,100 156,500 190,600 NO Totals for 2004: General Property 2.810 34,100 156,500 190,600 Woodland 0.000 0 0 Totals for 2003: General Property 2.810 34,100 156,500 190,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 139 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 r 04 1 Form - ..S T C - AS BUILT SANITARY SYSTEM REPORT r OWNW"1 rt ' TOWNSHIP TEIG1 t1(/~ SEC. ~ Zv T C 9 N-R ! W CROIR COUNTY,' WISCONSIN. y4 C~ ADDRESS 7353> -0 4A111 ST Dti Q~, LOT ±,-:,4 LOT SIZE ~`a!Y_ I y' ckcg e. SUBDIOIB;ON~18'=t3a ~f , a } PLAN VIEW Distsnces and dimensions to tweet requirements of JILHRr83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM c 'J/i1;. ;t t is - : 'r r,'. ; N (~K S li~ ~'~*t1-~~ ~ ~ Ar~ •#,t~~ _ P~*~~,+-tii =1 Zip Y. ...f '.f - y, . „ ~ tB ~vbl8 INDICATE NORTH ARROW BENCHMARK: Describe the vet reference point used Elevation of vertical reference point: Proposed slope at site: ' quid Capacity: Ota;~ e SEPTIC-TANK: Manufacturer: Li ,,rr 044. tf 21 UaAA4N"ber of rings used.C,"' Tank manhole cover elevation: SO-P- i...- .__----Tank Inlet Elevations Tank Outlet Elevation: Number of feet from nearest Road: Front,( Side0 Rear, O /576' feet , feet. From nearest-property line Front,OSide,@Rear,O Number of feet from:' well building: (Include this information of ..the above plot plan)( 2 referenSeEEdiimenEssio SIto septic tank) PUMP CHAMBER Manufacturer: Liquid Capacity: ::Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: -Number of feet frpom•nearest property line:-. Front, O Side, O Rear, © Ft. 'Number of feet from well: Number of feet from building:_ • (Include distances on plot plan). SOIL ABSORPTION/SYSTEM _ Bddr V Trench: Width: LenBjEh: 5 Number of Lines: Z Area Built: (Zq Fill depth to top of pipe:~ Number of feet f am nearest property line: Front, O Side, Rear,0 Ft,Z 7 #Number of feet from well: /DD r N ber of feet from building: 07 (Include di tances on plot plan). ,SEEPAGE PIT i Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 01, or distribution box O been used on any of the above soil absorbtion sytems3 (C eck one). HOLDING TANK j ps Manufacturer: Capacity: Number of'rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from.well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: < Plumber on job: Dated License Number : 1v eg S * 3 nz j_ 3/84:m' j DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: N04-, N04-, 20, 29, 19W CONVENTIONAL ❑ ALTERATIVE (If assigned) Town U6 Hudtson Q Holding Tank ❑ In-Ground Pressure ❑ Mound .4 -7 O MI ADDRESS OF PERMIT HOLDER: INSPECTION DATE: R%chand C. Stout 1353 Awatukee Tka.%2 Hud6on w1 54016 ::5//? BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: C T REF. T. ELEV Nam of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: John P. S kola 111 3212 St. C oix. 135456 SEPTIC TANK/ t Car~'y = 94~ ~3 MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELE~ WARNING LABEL LOCKING COVER 7 /i PROVIDED: PROVIDED: jj~ 31 ES E;LVO ❑ YES NO 47 `f~- 7 BEDDING: VEW DIA.: VE#T-MATL.: HIGH WATER UMBER OF ROAD: PROPERTY WELL: UILDING: VENT TO FRESH Q CJ. RM: LINE:~ AIR IN T FEET FROM ❑ YES NO Gay's ❑ YES NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) I ❑ YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL 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: BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS a' `j GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. IPE MA G ERI i7tz ER OF PROPERTY WELL, UILDING: VENT TO FRESH BELOW PIPES: ABOVECOV ER: ELEV. INLET. ELEV~END: ~LINE: AIR INLET: FROM i s -"40 5 ST 1 MOUND SYSTEM: 1 " 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 ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: % FEET FROM LINE: COMMENTS: 5 1 ~i a-ne ~ZIA ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Retain in county file for audit. Sketch System on Reverse Side. SIGNAT RE: TITLE` b.~ SBD-6710 (R. 06/88) Zoning Admin.i6 t axatc n 7j, DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code coin , C ~.e.;.M...e. STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than / 5-1-15& 8% x 11 inches in size. ❑ Check if 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 R i Q4 4~VN4 6. cJ Ow % IVE-7'/4, S 2Z) T,? N, R E (o W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # * < I 34 - Cl STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER l t) , 5~ta! co (71-57 q9-673I P; w e G, ve ep_ s dd 171 TY VILLAGE NEAREST ROAD ~,Qp 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ #1t ~Q t'I O J' btu t h 1~ ❑ Public 01 or 2 Fam. Dwelling- # of bedrooms - PARCEL TA NUMBER(S) Ill. BUILDING USE: (If building type is public, check all that apply) 2 _70 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 100 Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. New 2.0 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-Pressurized 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) per/ / ELEVATION 4 50 ~ /'i~ Cp Z4 X72 4 7 ? 5 0FA- Feet VII. TANK CAPACITY Site in allons Total if of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Hold in Tank C) Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, 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) M Rt0PF!1SW No Business Phone Number: _P SL4~6 4~" ?>-z I _Z1 Plumber's Address (St t, City, State, Zip Code): R* Z AS D K `75' 8l z>6a Z IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) XApproved ❑ owner Given Initial 4.1Surcharge Fee) Adverse Determination 0 q~ _ , ` X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R.11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 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: I. 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. 111. 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 Dn 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 hone number. Plumber must sign p application form. IX. Co u nty/ 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 STC-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 for resale by owner/contractor,(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 l G1 5~6 " Location of property 1/4 /4, Section 210 , T 7-9 N-R_/'~ W Township G Tj-X-%A Mailing address I Lp'-Z ~y`ac► Address of s ite u 41 ~.c`V ~n Subdivision name 24J A Lot number '3-4 Previous owner of property ~a~`a a C,: es Total size of parcel eo tLp4x 4,., Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? es No Volume and Page Number F60 as recorded with the Register of Deeds. 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 description references to a Certified Survey Map, the Certified Survey Map shall also be required. I PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (ate) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. ~"7 ; 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, for the construction of said system, and the same has been duly recorded in the Office not the County Register of Deeds, as Document No. ~f t Signature of Owner Signature of Co-Owner (If Applicable) Dat f Signature Date of Signature S DOCUMENT NO. ISTATE BAR OF WISCONSIN FORM 1-1985 11 THIS !PACE RESERVED FOR RECORDING DATA , i ' • WARRANTY DEED. , 1 ► 'f seaK _ 52 AGE RW REGISTERS ©FRCA T 131s ~e~~l~sma Cis wfr ..George............Gies..and ST. CROfX 4X0. WISP Jean orw n I 29th I` Re ..................................................................••-•...................--•---........Reed. for Reoord , r Granter, 'I day of~_A.Da 19 8 and .....lti.tk~axd. Q,...$144!ti .and. Janet„P, , Stout,,, husband. I~ 9:30 A. .-itDS~..I+li~~„5$,-jQ~nt„tenants-,as- Co,-a•,70~,_interest,;, and,;••,•„ li ..Maud..Ha..St:out:..as..sQl-e..Qwngx..Qf..a... 4LIxLtsxg$M..................... ;i 9111wel, of Oak j G:anteep, Witnesseth, That the said Grantor, for a valuable consideration...... conveys to Grantee the following described real.estate in $C e...~T4 RETYRN To County, State of Wisconsin: All that past of the NEk of the NEk lying Southerly of the railroad right of way; Tax Parcel No: The SEk of the NEk• ~ i The NEk of the SEk; All in Section 20, T29N, R19W; I SUBJECT TO all existing highways, platted roads and easements of record. EXCEPTED FROM THIS DEED are all parcels of land previously conveyed in part performance of the land contract referred to below by deeds of record. ` i~ This deed is given in final performance of the land contract originally made by I George J. H. Gies and Jean Dorwin Gies, his wife, as v s and Robert L. VerDugt and Betty Jane VerDugt as purchasers, the purchaser s interest in said contract j having been assigned to Richard 0. Stout, Janet P. Stout and Maud He Stouts ii The original land contract was recorded in the office of the Register of Deeds for St. 1! Croix County, Wisconsin August 18, 1975 in Volume 5231, Page 271, Document #328700. The assignment was recorded in the same office on September 30, 1982 in Volume 652, Page 447, Document #380015. or Al This AA.A 91...... homestead property. (is not) P17 I Together with all and singular the hereditaments and appurtenances thereunto belonging; FE And .QQaxs.~ 1 a..~.... ('rig$..nd..:Ien R4?Li?~. G~~.• if€ • warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except it easements and protective covenants or restrictions of record, if anyi conveyances, liens or interest created by the act or default, if any, of the grantees, and will warrant and defend the same. lot At:bl.at 86 , Dated this day of 19......... .....................................................................(SEAL) ...................(SEAL) ; . e George J. Gies .....................................................................(SEAL) SEAL) ...Jean Dorwin Gies AUTHENTICATION ACKNOWLEDGMENT " George J. H. Gies and Jean " 1; Signature(s) STATE OF WISCONSIN Dorwin Gies, his wife a• County. auth ated this TeAay of.... August 19.16 y came before me this day of , 19........ the above named •ohn- D. Heywood TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorised by 1 706.06, ~WinState.)~ to me known•to be-the person ..----...•.••-who-ezecubd the foregoing instrument and acknowledge the same , THIS INSTRUMENT WAS DRAFTED BY i Hey................................................................................ wgQ .Murray, j. Shgrburne.•_••.•..•-.-•-••• P. 0. Box 229, Hudson, WI 54016' ' Johu'?1:...l~leywoud County, Wis. Notary Public (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiation are not necessary.) pds . 19 ) date• ONamm of persons signing in any capacity ebould be typed or printed below their ehTnatures. STATE BAR OF WISCONSIN STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNS BUYER ~6eca ROUTE/BOX NUMBER 353 A cA6-t nL 1 FIRE NO. CITY/STATE ZIP zS,40 ((a PROPERTY LOCATION: _A2E_1/4 N- 1/4, Section, T Z9 N, R_L'I__W, Town of dIAILS61 , St. Croix County, Subdivision Q~ Lu" r , Lot No. Improper use and maintenance of your septic system co l) result in its premature failure to handle wastes. Proper maintenance consists 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 treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 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 verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), 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. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department 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. SIGNEDRA.&" VJ DATE tf 9 L St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address i DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUST ?Y, DIVISION LA50R AND PERCOLATION TESTS (115) MADISOP.O. BOX N W 5739069 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: OWNSHIP UNICIPALITY: OT NO.: BLK. NO.: SUBDIVISION NAME: N J 4 A) F_ zo /T2!9N/R /A 1 ) W ~ s lA th COUNTY: MAILING ADDRESS: t R! 0. t I -q-0 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: X 70rrn DESCRIPTIONS: New TS: Residence - ~XNew ❑Replace I AIIAt 170 ~ 14 ?e RATING: S= Site suitable for system U= Site unsuitable for system C x STlau ONAL: Mu4s. ❑u IN GZ S aU ROUND-PRESSUR SY OS LH a S G ~TANK: UC&A(J E©SYSTEM: (o (optional) f~~/Jl S ~ ,`,af If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the Iivl under s. ILHR 83.09(5) (b), indicate: N /Floodplain, indicate Floodplain elevation: Sa+,jLt_,* /.aa,IAA PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. 1 HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 7 4 Is B- /OO 99` Z i~ IOp I2`~ 51 7; It Z`= Z~` a` e6 too~~,CS 0, B- v 90 CIS""" ?I CID I/ d'P B- B0 97' > gp 00 /r t31 sf T ll Mats ~~-t3cj Gs'* B- ~0 sJ -rs Z3;~~B~, B- PERCOLATION TESTS } EST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES f NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P_ 51 7- P-'Jg~ 1.1-14 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. y ! 2 ~o T; _Z 1 3 10 ( I : _ r- ~oK i I t f _ off ' z 1 N N 711-1 -A I, t e un er Ligned, hereby certify that the soil tests reported on this form wen made by me in accord with the procedures and methods specified in the Wisconsin Ad i is at de, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. GW rd. NAME (print): c TES~TS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): R _75- P_ 3;- 2, -7 if 569-Ai-2#6 CS SIGNATU 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 mods - Medium Sand W - Well is - Fine Sand Bldg - Building Is- Loamy Sand - Greater Than 'sl - Loamy Sand - Less Than 'I - Loam Bn - Brown 'sil - 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. 0, P- A ' ~ l3t4 t4e- 8L t-s a" kJ-A. IN PPS S -IOZZ. ca P/O aH Sca BM~ Derw~,i Plo" B- 7P IDVd swept a ~ ~ ou.sQ 2o 7P our. prZrVIF- AD / sy~~e-m- wy o s s T ~'o ut 17-1 Plu) ~~G > F- C- Q ~ II a A rS (ppe / OdC~ ~Gt.l~ G V~ W c) 194Q--J, 7- fob ox sz' dw k e.Cd 0 ~v.r-~ , 't'e s la vu ~~h ca re~~a ~-s ~1 r -7 The follo ' g information is required for plan review. An index page or each page of the plans must be signed, seat and dated by the designer. 5. MOUNDS i ROUND PRESSURE DISTRISUTHM SYSTEMS 5a. Application for as of an Alternative System (DILHR-SBD-6413) signed by owner and notarized. 5b. County on-site. 5c. Verification form sig by county (DILHR-SBD-6158). 5d. 115 photocopy. 5e. Plot plan showing lot size d all lateral distances from the system to buildings, wells, we rcourses, etc. Show permanent reference points. Direction and percent of slope or two t contours must be included. Provide system slevatio or in-ground pressure, show area for replacement if for now construction. (TWO COPIES). 5f. Plan view of system with observe n pipes and permanent lateral markers (TWO C IES). 5g. System cross section (TWO COPIES). 5h. Pipe lateral layout (TWO COPIES). 5i. Construction detail of septic tank if site-co tructed, or manufacturer N prof ricated (TWO COPIES). 5j. Dosing Chamber cross section with construct n details if site-constr (TWO COPIES). 5k. Pump or siphon model, performance curve, total ynamic head calcul one and minimum dose volume (TWO COPIES). 51. If the site is suitable for a conventional private sew system, item from this section is not required. 6. CONVENTIONAL PRIVATE SEWAGE SYSTEMS ea. Photocopy of soil test (115) by CST, including data for rep ce t system, if new construction. 6b. Plot plan showing location of septic tank, soil absorption s m and replacement area. Indicate lateral distances to any buildings, well, watercourses, lot lines, etc. The plot plan must also show the location of r anent horizontal and vertical reference points (benchmark). Also indicate ground slope with 2 foot contours in entire area, extending 25 feet on a sides t initial and replacement systems. (TWO COPIES). 6c. Plan view of soil absorption system showing all di one, pipe le gths, spacing, etc. (TWO COPIES). Sd. Cross section of soil absorption system showing s elevation, agate, cover material, depths, aft. (TWO COPIES). Se. Construction detail of septic tank if site-construct , or manufacturer if p abricated (TWO COPIES). St. Detail of lift pump tank or automatic siphon, size, gpm, gallons per cycl vertical lift, friction loss, etc. (TWO COPIES). 7. HOLDING TANKS 7a. Photocopy of soil lest 015) by CST. A ful n must be made to eliminate possibility of any other eysNm being installed. 7b. Photocopy of agreement document n owner and local unit of government, rized and recorded in reference to the deed. This agreement must include a statement about the arlerly pumping report. 7c. Plot plan showing location of hot Ong tank with lateral distances to any buildings, wet water service piping, watercourses, lot lines, etc. Provide horizontal and vertical reference ints. Include all-weather service road within ton feet of service port. (TWO COPIES). 7d. Holding tank profile showing nt, manhole, alarm and manufacturer N prefabricated. plate construction details if site-constructed. (TWO COPIES). 7e. Pro'ect tail to roviding all sizing information (TWO COPIES). This is not requir for residential Installations where the number of bedrooms is indicated on plans. S. SYSTEMS N PILL 8e. Systems in fill must i lude an on-ails InveMigation form (DILM -SM-61f8), as well as all of to app items listed in sections 6. 9. OROUNMATER 9a. Mpholotopy 0 COPIES). 91)• Groundwater nitorin Report (DILM143ND4412) (TWO COPIES). 9c. Verification data and proosdww from county (TWO COPIES). 9d. Preci itat n data. 10. FOR VARIANCE 100. Privets Sewage Petition for Variance Form (DILH11-30-11). - EXAMPLE 23 - L ,