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SAFETY & BUILDIN
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR DIVISION
LABOR & HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
P.O. BOX 7969
MADISON, WI 53707 State Plan I.D. Number:
NW 4 , W,, Sec. 28 ; T28-Rl (If assigned)
CONVENTIONAL ❑ ALTERATIVE
Town of Hudson, LotE ~OldingTank ❑ In-Ground Pressure ❑ Mound
INSPECTION DATE:
A F HOLDER ADDRESS OF PERMIT HOLDER
'O I
Wm. Harwell Co. Rd. UU Hudson WI T d U
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. EV.:
e . , . , . r / ~ ~ . , /Q 02-7 ~,:/'>r),~,'0 /
ame of Plumber MP/MPRSW No. County: Sanitary Permit Number:
Wm. Schumaker 6382 St. Cr 2
SEPTIC TANK/HOLDING T K 4_60 Cove = 6Z • i3/
MANUFACTURER: LIQUID CAPACITY: TANK INLET EL OUTL ARMING LABEL LOCKING COVE
PROVIDED PROVIDED:
0') / G( L1, f..a , Y 2 9 , (P YES ❑ NO ❑ YES NO
: T MATL.. HIGH WAT NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT T ESH
ALARM: FE
BEDDING: rT
ET FROM LINE:_ AIR IN T❑ YES NO C( ' ❑ YES ❑ NO NEAREST DGALLO OSING CH R A CYCLE: MMANUFACTURER: BEDDING: UID CAPACITY: PUMP MOD PUMP/SIPHON
MANUFACTURER: PRWARNING OVIDEDLABEL pROVIDED:OVER
YES ❑ NO ❑ YES ❑ NO , ❑ YES 0
PUMP AND CONTROLS OPERATIONAL: BER OF PROPERTY WELL: BUILDING: VENT RESH (DIF ENCE BETWEEN FEE LINE: A LET:
P P ON AND OFF ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETE D MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.
CONVENTIONAL SYSTE : S Si wm 4-6pa. _ .U
WIDTH: L NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH t TRENCHES: MATERIAL: DEPTH:
DIMENSIONS I . , I . '1i'-,
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N0. D NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOV~ COVER: EL V INLET- E EV. EN PIPES: FR LINE: / / AIR INLE
~ . , c Q e) FEET OM , .
MOUND SYSTEM: //%y\ 2 1 ( 5 b o(e u~ {-~ndec~J
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown un''s``ope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTf-i OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TO IL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAV EPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: N ISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MAR G:
ELEV.: ELEV.: DIA.: ELEV.: PIPE DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPOND O
INFORMATION APPROVED PLANS
❑ YES ❑ NO NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
A6 n ❑ YES ❑ NO ❑ YES ❑ NO NEAREST
In in county file for audit.
Sketch System on
Reverse Side. sIGNAT E: TITLE:
SBD-6710 (R. 06/88) ` /
SANITARY PERMIT APPLICATION
ILHR In accord with ILHR 83.05, Wis. Adm. Code CO-7 ed~~4
STATE SANITAR PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than [I
8% x 11 inches in size. neck If Zision 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
4LI i' //149L A01 IV'gp Y-tAlt/( % j' '/a, S T;24I', N, R & E (O
PROPERTY OWNER'S MAILING ADDRESS r LOT # BLOCK #
GO C~ GG i-r✓ ;2a 1
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
soy , 17 SYoI,c 1 _S
II. TYPE OF BUILDING: (Check one) L1 State Owned ❑ VI LL AGE NEAREST ROAD
❑ Public 911 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL TAX N u
6a - ~I7k-a
111. BUILDING USE: (If building type is public, check T11 apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYpPPEE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. t-%j New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.E] 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
11 171% 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) IT t ELEVATION
q/610 iaw f% ~ jor / a 7T/ G Feet rT~• SdFeet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New P-xisting Gallons Tanks Manufacturer's Name Concrete structed Con- Steel glass Plastic App
Tanks Tanks
Se tic Tank orHoldin Tank 6~ ~r
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) /MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater [Date Issued Issuin A ent Signature (No Stamps)
/ Surcharge Fee)
pproved ❑ Owner Given Initial 1 6 _
Adverse D t rmin i n J
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
i
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.
If. 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
STC - 100
This application form is to be completed to full and signed by the owner(s) of the
property being developed. Any Inadequacies will only result in delays of the permit
i6suance. Should this developaeat be intended for resale by owner/contracCQr.("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 Al, yf/,a yc1v
Location of Property fit, Section ~ ~ . T .z f N - R W
Township
Ma i. I ing Address i 7` a
Subdivision Name
1-ot Number
Previous Owner of Property
Total. Size of Parcel
UaLe Parcel was Created
Are all corners and lot lines identifiable? you No
IS Ellis property being developed for resale (apse house) ? Yes _ No
Volume 7 and Page Number ' ga.recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION•ONE OF THE FOLLOWING.
1. Warranty Deed
2. Land Contract
3. Other recordings filed with the Register of Deeds Office
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 the Certified Survey Map shall also be squired.
PROPERTY aMER CERTIFICATION
I (We) eVL y that a t atatemente on A" a w au true to the beat o6 ay/ (oux)
knowledge: that 1 (we) am (au) the auw&46 of the pU 44 dwAaed 4! th.ia
.i.n6oAmation 6oA m, by vi tue o6 a w Aa*4 eked UGOA&d dot the 064ae 04 the
Cuwt4 RegialteA of Deed6 ab DoewmAt No. t : and that 1 (wt)
piesentCy own the pn•opoeed 6itg `oft the ♦~poa'Z'"byetem (ax 1 iwe) have
obtx,Lned an easement, to sun wI A the above dockibed pnopeA4* bon the
eon.e,thuction o6 maid b~/atem. a,Ad the dame. hoe been duty heeonded in the 066.~ee
) .
o6 late County Reg" Itch of Deeds, as Document No.
SIGNATURE; OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
~YG1,, 4tex o on.~
• (Dr.4uMENT NO. f l1T dP''WISOOMBIhb b}. ~ Tttu s►Aes asssavas aaeOeetM
LAND CON'i#ACT:,.:
►nsu ota w s over ~ QfFI•._~t
t~~ t a
XA! a n~c~ uiui>< ST. cam Co., WI&
ft_jIth
- Rec'd for, Roaord
b between Harry J. Stewart as 86•
Contract, by and Psraonai day of June 19 ;
.
Represeatative_of the Estate _of•Aldro,Larsen•aLkja,john pt
("Vendor", James,-O'Connell
whether one or-, more) and.. . RUIN...Q# ...T.KgI,L
s inn le .imam • ("Pnrdtaia", .whether one or sore) • 7t, A
Vendor sells •and•sgrees to convey •to Purchaser, upon the prompt and full per- deputy
formance of this eontract by Purchaser, the following property, toaetber with the
rents, profits fixtures and other appurtenant iateswta (all called the "Propsrb").
in .............t n.•Croix.................................... _ County, State of Wisconeh4: naTYON TO
See legal Description on Addendum
Tax Parcel No.
,386 - Q~73 "
WS
This 19--Mt.......... homestead property.
04 (is not)
Purchaser agrees to purchase the Property and to pay to Vendor at • such..place as.. he 8ha11,•Aame••
the sum of $.A.R.L500.00 In the following manner: (a) $...60A.09..QQ......................
at the execution of this Contract;' and (b) the balance of 0N.JQQ•49 together with interest from date
hereof on the balance outstanding from time to time at the rate of LOA-11U)•••,.••-••• per cent pis annum
until paid in full, as follows:
See Payment Terms on Addendum
' l lth
Provided, however, the entire outstanding balance shall be paid in full on or before the day of
aUlm .......................0 171.. 4Q. ( the maturity date).
Following any default in payment, interest shall accrue at the rate of ...~,Q.... % per annum on the entire amount
in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire
principal balance).
Purchaser, unless excused by Vendor, agrees to pay monthly to Vendor amounts sufficient to pay reasonably enaci-
pated annual taxes, special assessments, fire and required insurance premiums when due. To the extent received by Vendor.
Vendor agrees to apply payments to then obligations when due. Bach amounts received by the Vendor for payment of
taxes, "assaments and insurance will be deposited into an escrow land or trustee account, but shall not bear interest
unless otherwise required by law.
Payments shall be applied Ant to interest on the unpaid balance at the rate specified and then to pdnclpOL Any VIEW
amount way be prepaid without premium or fee upon principal at any time.
tlmnaxetal7c~lexeot
In the event of any prepayment, this contract shall not be treated ae in default with respect, to payment so long
as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shall be treated
'I w unpaid principal) is less than the amount that said indebtedness would have been had the payments been
made as first specified abow; provided that monthly payments oball be continued in the event of credit of any proceeds
of insurance. or condemnation, the condemned premises being thereafter excluded herefrom.
Purchaser states that Purchaser is satisfied with the title es shown by the title evidence submitted to Purchaser
for examination except:
Purchaser agrees to pay the cost of future title evidence. If title evidence is in the form of an abstract, it shall
be retained by Vendor until the fall purchase pries l1 paid.
Purchaser shall be entitled to take possession of the Proposty as....... 1ihA•• AML.baxna 2.., UX......
~y •crou Out Oat,
oasp no wrIRM"atx Wisconsin y.Ed monk Co. Inc.
3
je Purchaser promises to
Pay when due all taws and &"%momenq levied on the Property or upon Vendor's in;•ar%t
e it it and to deliver to Vendor on demand receipts showing such payment. Purchaser shall keep the improvements on the Property insured ainst loss or "damage occasioned
by Are, ex-
terded coverage perils and such other hasards as Vendor may uir ag
e, without co-insurance,
by Vendor, in the sum of ~ through insurers approvesd Vend
not than the balance owed under this Contract. ,Purchaser shallbpay the lnsuraaneb premiums when sg due. In an The amount more
contain the standard clause in favor of the Vendor's.interest and, unless Vendor otherwise agrees In writing the original policies shall
of all policies covering the Property shall be deposited with Vendor. Purchaser shall ice of loss to
in:mrunre companies and Vendor. Unless Purchaser and Vendor otherwise agree in writing, tinsurance proceeds shall
he applied to restoration or repair of the Property damaged, provided the Vendor deems the restoration or repair to be
MuNfleally feasible.
Purchaser covenants not to commit waste nor allow waste to be committed on the Property, to keep the Propert.;-
in vood tenantable condition and repair to keep the Property free from liens superior to the lien of this Contract, and
to comply with all laws, ordinances and regulions affecting the Property.
Vendor agrees that in case the urchase
shall p pries with interest and tithe
be full r moneys shall be fully paid and all conditions
y performed at the lines and in the manner above specified, Vendor will on demand, execute and deliver to
tine urchoser a ghoet7t in i simple, of the Property, free and clear of all liens and encumbrances, except
arsonal K%resnPa V~
any ens or encum ones crea yhe act or default of Purchaser, and except: ...sat3eaeri S xAL~ciavr..
X • F
.tOV
*aanta.-af..recard
,._.if ..anx,..arid..raniag..axdi njtnca._xsquirsmants.
•
Purchaser agrees that time is of~the
essence and (a) in the event of a default in the payment of any principal or
interest which continues for a period of ...GLQ... days following the specified due date or (b) in the event of a default in
performance of any other obligation of Purchaser which continues for a period of AD.... days following written notice
thereof by Vendor (delivered personally or mailed by certified mail), then the entire outstanding balance under this contract
shall become immediately due and payable in full, at Vendor's option and without notice (which Purchaser hereby
waives), and Vendor shall also have the following rights and remedies (subject to any limitations provided by law) in
addition to those provided by law or in equity: (i) Vendor may, at his option, terminate thin Contract and Purchaser's
ri4*hta, title and interest in the Property and recover the Pro pert hack through
redemption to be coedit' y strict foreclosure with an uit of
toned upon Purchaser y re y
(IM C full ~
the d,lte of default at the rate in effect on such date sndother amounts duehereeunder(inbwhichev n~tlall amounts pretio sly
paid by Purchaser shall be forefeited as liquidated damauvii for failure to fulfill this Contract and as rental for the
Property if purchaser fails to redeem) ; or (ii) Vendor may sue for specific performance of this Contract to compel
immediate and full payment of the entire outstanding balance, with interest thereon at the rate in effect on the date of
defnnit and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser
shall he liable for any deficiency; or (iii) Vendor may sue at law ter the entire unpaid purchase price or any rtion
therr:of-, or (iv) Vendor may declare this Contract at ~
,,~tlu„ • • a an end and remove this
if the equitable interest of Contract ac o title in a pulse-title
Purchaser is insi niticant
of the Property and have a receiver g ,and (v) Vendor may y have Purchaser ejected from possession
under / i appointed to c lect any rents. issues. or profits during the pendency of any action
(it) or (!v) above.Notwithstandin any oral or written statements or actions of Vendor an election of any
of the foregoing remedies shall only be binding upon Vendor if and when pursued in litigation and alr costs and expenses reasonable attorneys fees of Vendor incurred to enforceany
remedy hereunder (whether ab)tted or not) to the
e
extent not prohibited by law and expenses of title evidence shall be added to principal and paid by Purchaser, as in-
eurred, and shall be included in any judgment.
Upon the commencement or during the pendency of any action of foreclosure of this contract Purchaser consents
to the appointment of a receiver of the Property, Including homestead interest, to collect the rents, issues, and profits of
the Property during the pendency of such action, and such rents. issues, and profits when so collected shall be bold and
applied as the court shall direct.
Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property b i
of Purchasers rights under this Contract or by option, long-term lease or in any other way) • thout the prior written
consent of Vendor unless either the outstanding balance under t
convene payable his Contr t '
d IS a led e o ac is first aid full or the interest
p g or assignment of Purchaser's interest nn der this Contract solely as security for an indebtedness of
Purchaser. In the event of any such transfer, sale or conveyance without Vendor's written consent, the entire outstanding
balance payable under this Contract shall become immediatelydne and payable in full, at Vendor's option without notice.
Vendor shall make all payments when due under anv mortgage outstanding against the Property on the date of
this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaser
makes timely payment of the amounts then due under this Contract. Purchaser may make any such payments directly to
the Mortgagee if Vendor fails to do so and all payments so made by Purchaser shall be considered payments made on
this Contract.
Vendor may waive any default without waiving any other Subsequent or prior default of Purchaser.
All terms of this Contract shall be binding upon legal representatives.
successors and assigns of Vendor and Purchaser. (If not an owner of the Property h the heirs, consideration joins herein to release homestead rights in the subject Property
a the spouse of Vendor fora valuable
deed to be made in fulfillment herwf.► agrees to join in the execution of the
Dated this .......11th
day of June
19..86...
(SEAL)... N ~3194AL)
• ..Harr .J....S.tewart........................ (SEAL) ...gi...CJ...!K.....
AL~
" William C. Harwell =
A-0-' `i
%
AUTHNNTIOATION ACKNOWLSDGIMBNT~'~~7~.'• `y
Signature(s) STATZ.OF~ WNCONSIN
F
authenticated this ........day of.......................... 19, figie...rt1~A,~?~ ...................County.
, Personally came before me this .11.0k...... day of
.4.VItR9....................., 19.$6. the above named
• HAFNA311
TITLE: MEMBER STATE BAR OF WISCONSIN
If not.
authorised by § 40ti.08, W**i S.•St>.ts.~.....................
to me known to be the person who executed the
forego~n netrument and acknowledge the. same.
THIS INSTRUMENT WAS DRAFTED By /y(/J
~oi$..A•..Mur>aY....HEYW001),, CAI .M,URRAY
& SHERBURNE, P.O. BOX 229 x. • r~!D RsO~
. .
.
utem...WI...540lfr Notary Public St Croix
County. Wis.
(Signatures may be authenticated or acknowledsed per " " of state '
are not necessary.) • Both My Commission is p/r~a nent. If no state expiration
des '1 a................... 19..
Names of pernom Illanins in any capacity should be ty rl or prlated W.
y
r.,
STC - 105 c~ ~ Y
r:
Sl.'P'f 1C TANK MA I NTENANCL A(;kEl-:MI.NT c
St. Croix County
d
y
y/ rl
uW FI:/liUYER t(~d Q _--fYaY l cn
Itil ITE/ BOX NUMBLAR Fire Nuillbvir
CITY/STATC Y. i1'-`~~lf~~j- ,
1110WERTY LUCATWN: Sect toll T.99- N, Ii I9 W, `
Town St. Croix Cuultty,
S 1:ot number
Subdivis 1.uLt
tmprope r use and lnalntenance of your Sep Lic systuw could result in
it'; preulature"Iallure to handle wasters. Vroper ma intellatlc:e cUil-
sists Of pumpiub out the septic tank every three years or sootier,
it needed, by a licensed 5 tic tank hutit i,er. What you put into
(lie syt;teut can all-ect the f uuctlon of the supLic tank as a treat-
went Stage in the waste disposal system.
tit. Croix County residents uw~+ be eligible Lo reevivu a granL 1'ur
ft maxin►utn of 607. of the cost of replacement of a failing System,
which was Lu operation prior to .luly 1, 1978. St. Croix County
JCC4lited this program lit Au~,ust of 1980, with the requirement that
owners of all new Stews agree to keep their Systems properly
w~tiutained. - The property owner agrees LU Submit to St. Croix County Zoning a
CL:rtificatluu turn, sighed by the owner and by a waster plumber,
journeyman plumber, resLriCLed plumber or it licensed pumper veri-
fyilll,' that (1) the on- Site wastewater disposal System'is in;prupur
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 farm will be Sent approximately 30 days prior to
three year expiration. 0
4
!./WE, the undersigned, have read the above requirements and agree c„
r-u maintain the private sewage disposal system in accordance with M
the standards set forth, herein, as scat by the Wisconsin Depart-
went of Natural Resources. Certlficatiuu 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. C.-oix County Zoning'Office
N . O lox 95,
Hammu'Od, WI 54015
715-7 +6-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUS RRY, DIVISION
P.O. BOX 769
LABOR AND PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: , SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISIO NAME:
ntw / N~ zg /Tz`~ N/R M E (or W Asv-'j zZ Cie ~~s
OWNER'S BkQ•&R:S~E: MAILING ADDRESS:
COUNTY:
C>>ZoIX DATES OBSERVATIONS MADE
USE
NO. BEDRMS.: ICOMMER IAL DES RIPTION: I PROFILE DESCRIPTIONS: E' R A QNQTESTS:
Residence UNY New p Replace Il AlOv AkV /9 /r r6
So~~-s &ov Ch 66 So~c.s ' llk$- $uRuwoQ~ i
RATING: S= Site suitable for system U= Site unsuitable for system
I ENTIO~NAL: IM C,Nj. ❑U JI__ i s RE: SYST s -I~u L HOaLDING TANK: RECOM NMENDED SYSTEM:( Q)WKL e naq
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: ct-Ass Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH=t. ELEVATION OBSERVED EST. HIGR-ESf- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 2 6 9 99.S2 > 6.9 -8,s, ij*BR.iCS4CA '&a )%?:r
B- 3 4, dZ 9-7 - pZ IV rs,,, r > (.gZ I F'" 1- /9' a / . 4
B- SSA >S.'SZ i6" ga,,cs,~4,e 'v ",BQ". ks
B- S S n ~i~ } S.7S L Z2" $R1i M.5'
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RAT ES
NUMBER 4;=FS AFTERSWELLING INTERVAL-MIN. P RI D1 -PERIOD PER INCH P R D
P- 1 1.90 r ' Ig7-so >Z > a x <
P_ 1-16 >
P. 10 Ir . c i9~s•l0 >2 > <3
P-
P_ rz"~1 `f 10U ar AL
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 QS•w
i
I I ~ i
f
j, N
INEZ
L T
31 r I I-SZ
-
I
P
ir
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 (printl: TESTS WERE COMPLETED ON:
14. Msu r, ~a N f 1"C ! /99-
0-ADDRESS: CERTI~j(CATION NUMBER: P ONE NUMBER (optional):
f5 N~ NUrv 1.J1 S~O J 6.40 6
CST SI TURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) -OVER -
•r a tot, ~W ~-c- v2 ~~[~y o f d. Sim D ~ ~o Aid.' /~s
lea' ' a , Fc,✓ i°
zu s,;2
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