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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR HUMAN RELATIONS DIVISION
P.O. BOX X 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
~A44f~ISOAt,~VI'5~,7eC 21,T28-R18 ~j IDaSe (If assigned) Number:
11 Town JIJw CONVENTIONAL ❑ ALTERATIVE
22nd Ave. L~ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Tim Trollan Rt.2, River Falls, WI 54022 9oS t
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: / REF. PT. E / CST REF. PT. EL
_j Z~
8.
Name of Plumber: MP/ PRSW No.: unty: Sanitary Permit Number:
Tom Wan 3231 St. ix 128693
SEPTIC TANK/HOLBM~d#K: T O r O`
MANUFACTURER: LIQUID CAPACI"FROM TANK OUTLET ELEV.: WARNING LABEL LOCKING COVE
PROVIDED: PROVDED:
~Yl 'dweS~ (~-e l C/~v 93..ZO YES ❑ NO ❑YES NO
BEDDING: V"I DIA.: WEId7 MATL.: HIGH WATER ROAD: PROPERTY WELL: BUILDING: VENT T RESH CO)
C.O • ALARM: LINE: AIR IN T:
❑YES NO CapNO >a ®
DOSING CHAMBER: p" &V C 6 1. 5.~)= 90. 0
MANUFACTURER: BEDDING: LIQUID CAPACITY: LIMP MODEL: PUMP/91 AJM MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PR VIDED:
YA (A P YES ❑ NO 7SC7 YES ❑ NO YES ❑ NO
GALLONS PER CYCLE: UMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FR.SU
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:/( )
PUMP ON AND OFF ❑ YES ❑ NO NEAREST >.Z ~.3
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
-7f / TRENCHES: ♦ MATERIAL:
DIMENSIONS
~ / 6
PROPERTY WELL: BUILDING: VENT TO FRESH
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DISTR. PI E MA ERIAL' ISTR. NUMBER OF
/
BELOW PIPES. ABOVE COVER: ELEV INLET: ELEV. END:. y . (41 .1{Qp PIPES: FEET FROM LINE: AIR INLE-f
a 3Q~f- -a17 0~ ASEK-D NEAREST
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
❑ 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:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
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:
OMMENTS' FEET FROM LINE:
f~~n ❑ YES ❑ NO ❑ YES ❑ NO NEAREST
® PT ct,=W a--d +-,o Sys ~rrt. craa 4=/ (COLO S tna'~ P6s5i614 tae e r!e4 4C--l +Bcv~~h1
tar, P-r
k4w
21. • 11. Q32 T8 113c~ rL t'V-w 1~>y
022. I c3 to 0 _ "10 -ooo (Z . F- S4- oZ-Z.
Sketch System on a in in county file for audit.
Reverse Side. SIGNA RE: TITLE-
S B Dm671 0 (R. 06/88) `
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTfRY, DIVISION
P.O. BOX 769
LABOR AND PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: *TtW N UNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME:
Us 1/ sw 1/ /T28 N/RVe E (or trv~lc~l)v~ Lc -
COUNTY: cx.)wep_ MAILING ADDRESS: 60 wzS-T ST~Nej ST• {f- ►
ST" L-N-4_U ',-A -7,L 'l -T I-ZLN L-1. & N ST- ? 1*cu % In N S S t 17.~1
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: 1COMMERCIAL DESCRIPTION: I ROFILE A TESTS:
Residence 3 N • N- ®New ❑Replace It \ I_ Z_ 9 q 1`,3, A.
RATING: S= Site suitable for system U= Site unsuitable for system / 2J ' ~'3 - U
rONVIENTIONAL: ~M®f J: ❑U JIN-GROUND-PRESSUR-c- ~ SY~ I❑~ rEIS G®NK: RECOMMENDED SYSTEM: (optional)
ZS DU S ,((I~d~JJJ~ U \Z' 7«9'
DE
equired If any portion of the tested area is in the
If Percolation Tests are NOT r SIGN RATE:
under s. ILHR 83.09(5)(b), indicate: G` 1~S S Z Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 95 Ct S ~ ~ > R_S S~ ~GC= Z o F -2-
B- Z ct a
B- 3 q4 a 6.~ >
B- 4 q_1I q~. z. > q~ L,
B- 1, > 4 ,
B-
PERCOLATION TESTS
DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RAPER INCHES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. -PERIOD 1 PERT D 2 P
P_ .
P-
P_ V-71 tV_ LP7UM o (4Z" B- U ov s1 1 ` t
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
1~ DEC ~3 3 ~~h~a~q LU1\r''I
of land slope. Z1~~1 0~ Q~~
SYSTEM ELEVATION
- - S®i kUwt S\ S~~`? a 1~ W00..`llu¢ P~S4
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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 pri : rE'- SOIL TESTING TESTS WERE COMPLETED ON:
AND ~\-Z-s4?
ADDRESS: DESIGN SERVIeE CERTIFICATION NUMBER: PHONE NUMBER (optional):
~1S-yZS-ol 6 S
O_ ST 000 C. (0
P.O, BOX ?4 421 N, MAIN . CST SIGNAT RE:
RIVER FALLS. WI 54022
715-425-0165
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. OF Z
DILHRSBD-6395 (R, 10/83) - OVER - f
INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 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
fs - Fine Sand Bldg - Building
Is- Loamy Sand > - Greater Than
'sl - Loamy Sand 'c - 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.
SOIL DESCRIPTION FORM
Attach Soil Prof Ic Location Ma On • So orate Sheet)
CL E `~-N LINEAR LOADING RATE:
2b pU So1L e~3SORPl~ou SL1STEXIsloP : l 01~ Z''!o
PURPOSE;
DE~t_R1PilON BY ~1 rlV~ L wE,G ASPECT
Icy Z9 CURRENT LANG USE:
onrr.:
COUNTY/STATE ST C~V ZK C'Wu 1 l.~J VEGETATIVE COVER ~IiItSS -BR~.+Sti-Z~-ES.
LOT DESCRIPTION:' PT. O F TliE NEll -skj ! $*0,C, Z I t Tz-8 N, C J&4 bRAINAGE CLASS: IA-) M-L- 17 P•{IItil %F
SLG)J L3D o ' ~ ~
LOCATION. "rkZ, "Q (Z tC k jkj W l 11 t-LJ A.)A, l C GALLONS-PER S . FT. PER DAY s
PARENT MATERIAL s / PTH: _ SOIL SERIES: U~F~ ~~Tft ~-~Vh~
- !Z
)KXTIION OEPIII MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS PH -BOUNDARY REMARKS
Gr. St. Sh . COAT NGS
in. (moist)
o_tz V4v1cz-t/2
2 -3 \ r,"R 314
- S I O S c,S1, 5w 1b°1a GRRv~t
31-46 ~.S`'1I2.y/(
S v1o . ,
Lit - q 5 No-% a 3 I6 - rrI a~ S O S9 -Y,
o_~ toH2ZI - L 1'F ~ ~'g ms's
~Z_33 ~o-jv_ - L 1 s~ M'V►. gIAJ
33-qS -),s61 R y A. - s 1 o s ci s ti c S S °10
o t1
rna~ S O S w/ rt ` s Pu 1 S Id
145_98 60 31(a
3o yv 6 3
c s
o_ ~z lo~tz Z! - L 1 as
~Z ~ ioy~z 3151
223S-).5ltzYl6 - S1 O S C9s_ w 5~1b
S SZ lb cTa_ 3/6 mas cn~ S ~V% w s po cw s
5 1 _6L \0 tlZ ! - S I 1 S~ Yn "
66 - 9 4 tio-l~ 3!~ -Fs o s +~,1
o NG
e- ~o tu~rt~ 2-lZ - L 1 c~S s
%_-Z6 to~R31 - L 1 ~sb ►til r c
Z6-46 s l t~ s 1-0- s1. w is ~o N
-7 10-t ",L 31 6 rnla~ S S yn w! Ib` 1 11. S c! 0 L,
QC~ n.►6 5
0_ 10 lo`~tC 21x L
lb-3o in~f R 3t - L 5~k rn a w
30.4 ~_stir~vl6 - SI Q S dLsti cs s°1o
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OTHER SITE FEATURES/NOTES:
(//~7~N~^'L 1`- Z -8 9 0 0 0 S-7 6 T~/1 G~ Z of Z
LIMITING FACIORS/DEPTH: Signature Date CST M
I~
SANITARY PERMIT APPLICATION
~ILHR 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 ❑
8% x 11 inches in size. chec f revis n 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 OVILER PROPERTY LOCATION
I I, /y, I f-0 '/a '/4, S p~ T p,~; N, R E (0(0
PROPERTY W R'S MAILING ADDRESS T # BLOCK #
i
CITY, STAT ZIP CODE PHONE NUMBER SUBDIV
1 a2
IL TYPE OF BUILDING: (Check one CITY NEAREST R Qn
) ❑ State Owned VILLAGE : % O~l ,lJ:
❑ Public Q 1 or 2 Fam. Dwelling-## of bedroo s - PARCEL TAX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) n a ~ - /Q (Q b Zd ~V V
1 ❑ Apt/Condo V 6
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ERNew 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 511 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 G l ` ! ` 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.) PROPOSE D (sq. ft.) (Gals/day/sq. ft.) (Min./inch) p e~ ELEVATION
3. / Feet r Feet
CAPACITY
VII. TANK Site
in ailons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank ~C b G' Lu /
Lift Pump Tank/Si hon Chamber El 0 El 1-1 n
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber' ame (Print): Plumb ignature: (No Sta ps) r/MPRSW No.: Business Phone Number:
2
Plumber's AQc~ress (StreCity, State, Zi Code).
loo
IX. O NTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing gent Signature (No Sta p
elAApproved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of 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'/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement :system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 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 ornltz(s) of
the property being developed. Any inadequacies will only result In delays of
the petmit issuance. Should this development be intended lot tesale by
ownet/contcactoc,(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
Location of pcopetty 114 l/41 Section 1 T-22j-it-s-Y
Township . "thI, I(`k:14In !
Melling address
el'.) ey Ls~ (.ur
Address of site V
subdivision name w
Lot numbet
previous owner of property 4 If- 6
Total also of parcel 96K
,
Data parcel was created S
Are all cornets and lot lines Identifiable? ._-Yes 0
mac. No
is this property being developed for resale (spec house)? as
Vale" and Page Number ~ as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION TI(E FOLLOWING:
A WARRANTY DIRD which Includes a DOCUMENT NUMBER, VOLUME AND PAC: NUNatR, and
the ORAL OF TH! REGISTER OF NODS. In addition, a certified survey, it
avallable, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Cestlfled survey Map, the Cectifled Survey
Map shall also be required.
T
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (out)
knowledge= that I (we) am (ate) the owner(s) of the property described In
this Intotmation form, by virtue of a warranty ae ,R,e tded In the Office of
the County Register of Deeds as Document No. and that t (we)
presently own the proposed site for the sewage laposal system (Or t (we) have
obtained an easement, to tun with the above described property, tot the
construction of said system, and the same has been 1 recorded In the Office
1 /5
of the y R r of Deeds, as Document No.
algnatuce f nec Slgnatu a f Co-Ownet (If Applicable)
Date of algnatut• Date of signature
fl ~1
I,
OCCIlMENT No. I19TATe. JAR of WISCONSIN FORM 1-1982 t NJ SPACE R[9lRY[D FOIL 1%19OORDIN0 DATA
W~p Dyl i~
, 4)TTY
451410
- - - REGISTER'S OFFICE
This 7 e c1, made. 17et,y 4ty Ct~~ara I ar l eton, _
CO., WI
a si:.c3lty '
5T. Recd fIXor Record
?e_ ..rs...u.l: . R eC
a` , Grantor, S E $1 341989
at M
3.mathF M...'Trol
-
r~T~nteP, Reglsle of Deeds
;tI-1P:•*<_eth. That the -,ka!:i I;rai tor..for a va'u.able
. reazl~nN . T ,11'4Yfr1r, 11 PANK
conveys 4, t ghrtgE thg following de {real estate in St
Pl) k i,wA
j County. of Aisconsin: !?iUER FALLS, 11S!'OMIN 54022 if
I
t~Cn 29$0/89-102$'
Tax Parcel No:
i.
The West Half' of Northwest Quarter of Southeast Quarter (WJNWJSEA) of
Section 2i, Township 28 North, Range 18 West, a]td ai piece of land
corlu-nencir:q at the center of Section 21, thence North 534.8 feet, thence
East 660 feet., thence S 534.8 feet to East and West Quarter line, thence
West to point: of beginning.
All that 11a.rt, of Se(;tion 21, Township 28 North, Range 18 West. des~Yribed
as follows, to-wit: NEI of SW# except the South 365.6 feet of the 'apt
671 feet; anc(' all that part of EEi of NWI lying south of "h(:~ follo,., ing
descrtbFd line, to-wit; Beginning at a point in the west- line thereof,
;id Point: being 208 feet north of the SW corner thereof, and rung rg
iort:hE:astes'ly by a deflection angle of 8 1' 81 45 t_.
reflection anglw of 2211 f,' 636.2 feet; then::: i H~lw .1 :j
; ° g~_e o± 300 I I 199.1 feet to an Y pipe
<a t 1,a feeL, rro..rO or less to an iron pipe non11111ent I:Lrle
a zx r, G ,ice moo-iuirelo bei.ncl 784.8 feet t:ort:h of L, e _ 7 ..`.r1-Qof
tx~: c f°:ink to -he +_o,,7 .rnment. Survey thereof.
l 1c, no t.. holrastead property.
:3 (15 nCi '.i
wit':-t all a°- Q ,,Ka ar the heredowni its and app',irt='rta-nce :ydsTtl I1t4 .r I E'a'
Grantor
',;Y° * a` ;.ta titia i8 KnA, •n ;r•4 FsAii,,R ir. fee Stn;l,le ani frig and of 0ni:jMbra11tc? "
co'•-er^ ants, restrict'_":T11=s, conditions or easements of recc-- any,
to the rig its of tenants, it any.
day of SPptefI?e - - - ~a.
Charles W. Carleton
AUTHEI'd T ICATION .ACKNO W LEDGmUNT
CONNECTICUT
Signatiire(9) STATE 0F>WM6 A yyyy /f ~JJ
authenticated thili ........clay of 1D...... Personally came before me this .....s~~.-:' day Of l
.Se.p.. e.mb_ex the above named
Grantort Charles W. Carleton
.
- - - - . = .
TITLE: MEMBER STATE BAR OF tr6'I'3CONSfN
` .
to _ ma know t..--~
E (If n state.
fore et owiV to ba
authorized by ti 706,06, wig,
tho person who executed tho
$t 364 acknowledge the Canna.
Ift
I~I THIS IWITR41MENT WAS t7RAFTEra RY Y
Ri er )9enne.t,. Egan & Arundel .Q r, • g•
- r
. 5 h,a- Zo 2' q U L,-- lco rh Genf re Nn M1.n e.a .li s MN 5 4 p ..Ut hl,/..Lunty,
M%+ nIS Ion iff ' nt, if of state ex irat~ionn
aro not trticcessn y jc at.lthenticatc~l or ncl<nowled 'cll. Both
data: , 19 fg,.)
i►
. 4
*Names of perae,rra 8iplnins In any eapaetty ahni0d ba tyved u: ,.7c'nttd be1.,w %1101r w.i•'t'1!i-Cfi!:1if it
WARRANTY ]PEE]) ST:+7h 1SAR OF WISCOZ49IN Wimtonala Legal Blank Co. Inc..
E{IR~1 No. I 19S2 Milwauicea. Wit,.
Z0,d X00' ON 2Z~ti U6''~<' j_T -Ir ~Zsi Z "?"d~~1 s J panI~ ~±`I,dt4 &'J :
t mil' r III 1
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT w
St. Croix County
w
rt
OWNER/BUYER f
IL6
0
ROUTE/BOX NUMBER Fire Number :J
ZIP ~G d r
CITY/ STATE lP(U l `Y
M
PROPERTY LOCATION: k, S ~j4, Section I T_j2LN, RrW,
Town of ltfoo~l G1/I`1 ~C St. Croix County,
Subdivision Lot number.
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 p__umper. What you put into
the system can affect the function of tie-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,
whic_ 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 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
d
to maintain the private sewage disposal system in accordance with. N
the standards set forth, herein, as set by the Wisconsin Depart- z
ment of Natural Resources, Certification form must be completed .b
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
DIVISION
04DUSTRY, P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707
HUMAN RELATIONS (ILHR 83.090) & Chapter 145)
IPALITY: OT NO.:BLK. NO.: SUIVISION NAME:
UNIC
LO ATION: SECTION: *TtWJN~
T~ (or ,v1c~l,v,~, ~c -
COUNTY: p(,Jwer z MAILING AD DR SS: 6C) WET HT-e-\jena ST•
ST.C A-Q-c~ \~X L~1 'r-tzUL-L-NN Sr ~fN~~ PIN SSIQ'-j
USE DATES OBSERVATIONS MADE
I
NO. BEDRMS.: CO M AL DESCRIPTION: PROFILE DE M-LATION TES
Residence ZNe=w[03 Replace 1 ` Z_ 9 q t j- A,
RATING: S- Site suitable for system U- Site unsuitable for system
r OZNVgSNTEJI NAU . M®SJOU IN, 21 ROUND-PRESSUR S [1U E. SIRS I[:JN-FIUL a SG®1 .RECOMMENDED SYSTEM: (optional)
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
C_%.- S S Flood lain cate Floodplain elevation:
under s. ILHR 83.09(5)(b), indicate: hC 2. P
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGP"rST_ TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 015 CL-). S 'NC_~~ 1;a > R S SEE- fi-GL z o F 2
z C1 8
B
B- 3 q y Ot LI > q ti
> q b 'I
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN W V H RAT MINUTES
NUMBER INCHES' AFTER SWELLING INTERVAL-MIN. -pEplop P PER INCH
P_ .
P-_C~ IS P_ L1"!UK OF c~ U km: OU l •
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. "B;:4-mom s z, N~AC~11s Ll»\r'I
SYSTEM ELEVATION a s • -L
WGr T L ST Z _._o
C T -
I
00
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, ! \ Oda _ 2 UN
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d -
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C7 000"
R` ~ t
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T a
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seK~~ ~`t ~ 4 0'
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 (priWEGEFIER SOIL TESTING TESTS WERE COMPLETED ON:
AND 1\-Z-8q
ADDRESS: DESIGN SERVIeE CERTIFICATION NUMBER: PHONE NUMBER(optional):
cST 000 S~6 ')1S-U (S-o16 S
P^ BOX ?4 421 Ni, MAIN 8 • CST SIGNAT RE:
RIVER FALLS. WI 54022 y
715-425-0165
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. 11~ f! of= Z
DILHRSBD8395 (R. 10/83) - OVER -
SOIL DESCRIPTION FORM
(Attach Sod u Location Ma On • Su orate Sheol) -PrOf CL E ~hN LINEAR LOADI G RATE:
>_vRt_v p►J SoIL I~c8S0 P}701J SYSTER1sLDP :
POSE:
OESCR PT [ON BY F' xz -lUR L- WIEG~~ ASPECT SOQ-,T CSTK?.L_%t
Nov • 2 , 1 Cl 58 Cl CURRENT A A US : ODQ S
DATE:
ST Cp-QAk -OVA~I~t I VEGETATIVE COVER CS~Z.ftSS-eR~ST1-TR s
fAIINTY/STATE
1 ~C' ZI,V-BU,Rl(~J WTNAGECLASS: tv _L_ ~?4OP-,~
LOT DESCRIPTION:' PS• OF -NE N~ ~
LOCATION: _rt," Q OF \r_l MU•1•i L C hj AJ A,I t C GALLONS-PER S FT. PER DAY: p~,sLGQ LD . ?,M- o 14%
SOIL SERIES;
PARENT MATERIAL s PTI•
Q
HORIZON DEPTH MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS PH .BOUNDARY REMARKS.
moist Gr Ss. Shp -COATINGS
0-tz yr3 -1 -a 0s
't.-31 n~►R 3J.N - L J~S~ w1 Lam.!
5 1.0 °la G~'.RU E.R.
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u6 - 9 5 ~o~-L 3 J6 rn a~ S O s
p _ t l O`•~i R Z ~ 1, . ~ `F` c~ g ~ S
33-~1S ~,5-[, O S c~ s.1~ C S S °~o `1
M. w/ m S pu lS °1d l
y5_98 Lo-lit 316 rna~ S O sq.
30 >u 6 3
~ S
I as
~Z-~ loy~z 31 L 1~ Stk. Y4
s1 O s ~s~, w S. 1o ,
22 3s ~.S `1te- V/6
S-57- 1D-tt2 3/6 - mwat S S Zvi w 5 L cw S
66 y 1.t R 3/` O S - ,
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lb--z6 lb~tz 31 - L I ~sb ave'~L- C w
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26-516 -~.s~ttz ~flb - Sn~ b S 51• is
-9'7 1 -gL 3) b h7o S O s m) w1 Tb~t ! s ~o°! 0
Qv S
o_ to i~'~t~ Z.lZ L"F
14-3o ibL-i R. 31 L, ~bk Y►'t-' .
30.4 2_ S'l % y/& _ s l o s dZ. s~ c s s.°lo
sLa~S O S
q2.94 t . Q.31 - >71
OTHER SITE FEATURES/NOTES:
C%~ 11-Z -9 q o o a Sr? 6 nn 6~ of Z
LIMITING FACTORS/DEPTH: Signature Date CST N
i
WEC-yEFCEFC Sq 11_ TEST I P4 (3
AND
• DES I Sh! E3 ICE
F.O. LOX 14 421 N. MAIN ST.
RIVER FALLS, NI 54022
715-425-0165
ATTN: T)~ `l Ol-l, N DATE gR
CC:
SUBJECT:
L"~Z~5T
WE ARE ENCLOSING THE FOLLOWING ITEMS:
N0. OF
COPIES DESCRIPTION
1 IU v C_; Z J U C 5
SENT TO YOU FOR THE FOLLOWING REASONS:
❑ FOR APPROVAL ❑ APPROVED AS SUBMITTED ❑ INFORMATION DESIRED
❑-FOR YOUR USE ❑ APPROVED AS NOTED ❑ RETURN COPIES
❑ NOT APPROVED ❑ FOR REVIEW AND COMMENT F1
WEGERER SOIL TESTING
AND
DESIGN SERVICE
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