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" .DEPARTAAENT OF INDUSTRY, INSPECTION REPORT FOR sAF Y & BUILDING
DIVISION
•L-ABOR & HUMAN RELATIONS
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
State Plan I.D. Number:
SE,,, ~ _K4, ec. 6 , T28-R17 L,~JC/ONVENTIONAL El ALTERATIVE (If assigned)
~N ~WI~
Town of PLeasant Vr,~ley El Mound
R J Ho ding Tank ❑ In-Ground Pressure
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
c+ b n Roberts, T R . EL CST REF. PT. EL '
BENCH M RKS(Pe manent refe enc point) DESCRIBE IF D FERENT ROM PLAN: 1 54091 ~,72
o/
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Dal E Hudson 2 S
SEPTIC TANK/ 5. ~wtw C 4111l ' G 6-~
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: NK OUTLET V' NING LABEL LOCKING COVER
PROVIDED: PROVIDED:
W~C~J CB F-R-V'ES ❑ NO ❑ YES Ea~
BEDDING: VEfdo'DIA.: /f MATL.: HIGH WATE FEET FRAM ROAD: PROPERTY WELL: BUILDING: AER NTET RESH
ALARM: LINE: ❑ YES Dw~O L l~ ❑ YES NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: ARVIN OVIDED:G LOCKING COVER
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: AER NLOTRESH
(DIFFERENCE BETWEEN FEET FROM LINE:
PUMP ON AND OFF ❑ YES El NO NEAREST
LENGTH: AMETER: MATERIAL AND MARKING:
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE DI
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.) 72
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH / p~ / TRENCHES: IAL: PIT
DIMENSIONS `p2 O`-~ (D
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. FE DI Tfi PI M TERIAI,: N ISTR. NUMBER OF PROPERT WELL: BUILDING' VENT TO FRESH
r AIR LET:
(lg LINE:
BELOW PIPES: ABOVE COVER: EV. INLET: ELEy,END:~~/ PIPES: FEET FROM
r l u ~/P p7 NEAREST b
19 1 61
MOUND SYSTEM: 91,60'
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 El NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
El YES ❑ NO ❑ YES NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: TNO.OF RENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
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:
COMMENTS: FEET FROM LINE:
❑ YES NO ❑ YES ❑ NO NEAREST 10
OA~//,, y',+ C/
o 4"1
eta' in county file for audit.
Sketch System on
Reverse Side. SIGNAT E: TITLE:
SBD-6710 (R. 06/88)
SANITARY PERMIT APPLICATION IRQ G-
lJ DR In accord with ILHR 83.05, Wis. Adm. Code COUNTY 1
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. Cn isi o pr sous 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 S _:S-e G/ S,E % NWIK, S T Z,?, N, R / 9 (or
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
, f
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
CITY /~ps~ F NEAREST ROAD
II. TYPE O~
BUILDING: (Check one) ❑ State Owned VILLAGE
a 404(N .11,e
TAX . NUMBER( ` e _ 1 0Q _ j- 006
❑ Public J 1 or 2 Fam. Dwelling-# of bedrooms PARCEL
111. BUILDING USE: ( If building type is public, check all that aPPI y) 6Z01-7 'Z/U
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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2.O Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System o/ 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
112K 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) ELEVATION
~t / 9[ o ' y 7 *J Feet 9-3 '-3 Feet
VII. TANK CAPACITY Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete glass App.
Tanks Tanks structed
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.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
.T_->a/e_ , du~✓snYt /t~a,.,4 Z 7/ -6" G~ -337
Plumber's Address (Street, City State, Zip Code):
C~.Z~ CIi~ CT W~~'1 ~i 7'00
IX. C LINTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuin Agent Signature (No Stam )
ehQ'Approved El Owner Given Initial Surcharge Fee)
/ r
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-8398 (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% 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; wa er 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 informations.
- - - - - - - - - - - - - - - - - - - - - - - - - -
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 ~clr/i C-
Location of property S 1/9 II ✓ 1/9, Section , T 3 N-R-.17 W
Township 1&1',
Mailing address 2L /if L- S , l-1",
Address of site e--
e--
Subdivision /~~rYt
Subdivision name ~X
Lot number
Previous owner of property V 6)r e C Za
Total size of parcel
Date parcel was created ////Z/ Are all corners and lot lines identifiable? -_Yes No
Is this property being developed for resale (spec house)? Yes 0
Volume '726-2 and Page Number J/ 7 q 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.
---------------------------------------------------------7---------------------
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 (are) 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. _410 7/ 6 1? ; 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
of the County Regi ter of Deeds, as Document o. c!0 l& ' )
gith-a-ture of Owner Signature of o-Owner (If Applicable)
Date of Signature Date of Signature
i
_ /mar .-y"/.~ Two MACS I019ge"D Von RIO~~'
WAVIIIANFY
STAT=. BAS OF Wl MN" "211 1- is" ~
mss ~?~~47~
- REGISTERS Cff"
'
George T. McLaughlin and Ethel McLaughlin, : i. M1X CO.* W*
wife .3:; iax~fd
-
Nov A.U.'
9.
K
conveys and warrants to ._4urta--•.----Schu• •bel•- xnd • Laut:e_le- K. :00 A
$chuebe.l...b"ba.nd -_and--+eci£_t;.>.-.a
RETURN TO
Menomonie FAraeTS Cs•edt
-
Box 126 B+Rda 3iL: '
5t. Croix ...County,
the following described real estate in
State of Wisoonsia:
Tax Parcel No:..._.... •.-.r*~:
in volume 5, Cet`tl<ff
# ? Lot 1, certified Survey !Map f led July 6, 1983,
Page 1303, as Do ument No. 3h592, being located in the
Survey Map:
SEI of the NW} of Section 6/2 /17-
x
Subject to recorded easements, reservations, and rights of way.
This deed is given in satisfaction of that certain land contract
between the parties dated August 1, 1983, and recorded in the Office
of the Register of Deeds for. St. Croix County, h'i,-~consin, bn August 11`
1983, in Volume 669 Of Recor' s, at Page 609, as Document No. 386598.
41 . r -
is not
h This . homestead property.
706k (is not)
E:eeption to Wasroatisa Except any liens or, encumbrances created or at>t~~~
r to be created by the acts or. defaults of the grantees, their success ro
or assigns.
4 Dated this day of
' .(SEAL) rL..
Geol-ge ''I McI aughI in
(SEAL),L k
. i the l Mc Laugh 1 in c
Q iY
! r bye
AUTRZINTI,CATIOII ACHAIOWLEDti1t
~ .
STATE OF WISCONSIN
gigaatnrr(s) ss.
St,. CI-orx County.
>k,
authenticated this dray of , 19 Personally came before me this C '1 ~ e htwr mb...
9
1 the above so"
Gt oi.1T_ I Mcl tulh1 in and Eethe :
Mcl tight in > E
- .
'I'1=- MEMBER STATE BAR OF WISCONSIN
; - .
(If not .
authorized by 4 706.06, Wis. Stats.) to me known to be the er who tbY
fore g instru t a~ ack Ke
THIS INSTRUMENT WAS DRAT TED SY 'ever-, ♦♦ryry
~F
Thomas A. McCormack
Balliwit►, wl i4002
Notary Public .:Sl 1<~I. Corot
Mrsatures. may be authenticated or acknowledged. Both M Y Commission is permanent. (If . ~ .
not`necassary.) date: hAM-,
are
40"M at pnimans drains i4 a" "aWelV +huuld be tTW os WiAt" below their sisnatu- r •'w -
. >
>
low
H
H'
9
ST C- 105 r
r
9
H
SEPTIC TANK MAINTENANCE AGREEMENT H
St. Croix County z
d
a
OWNER/BUYER ~ r ~G~Isf'~F M
ROUTE/BOX NUMBER Fire Number
CITY/STATEnr~,,/~~ ZIP
PROPERTY LOCATION: Sf_ 14, 14, Section l T2Z N, R.. /7 W,
Town of St. Croix County,
Subdivision AI Lot number //X
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 pum er. What you put into i
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of'the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their 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 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
0
I/WE, the undersigned, have read the above requirements and agree z
cn
to maintain the. Private sewage disposal system in accordance with x
the standards set forth herein,
as set b the Wisconsin Depart-
b
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SICNED_
III 1) ATE_ <0 2 CJ
St. Croix County Zoning Office
P.O. Box.. 98•
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign,.date and return to above address.
M FILED
JUL ~ 19
1983
NNELR
o°°ds
CERTIFIED SURVEY MAP R°9~''°' of
S6 c olx CorefY, LOCATED IN THE SE 114 - NW 114 OF SECTION 6, T 28 N.,
wlx°~~I~
R 17 W, TOWN OF PLEASANT VALLEY, ST. CROIX CO. `rr (IT E,
OWNED BY: GEORGE MC LAUGHLIN
12 75 2ND ST. , HAMMOND, WI 54015
I, Arthur L. Wegerer, registered land surveyor, hereby certify:
That in full compliance with the provisions of Chapter 236.34 of the
Wisconsin Statutes and the provisions of the St. Croix County
Subdivision Ordinance and under the direction of George McLaughlin,
owner of said land, I have surveyed, divided, and mapped said parcel
of land, that such plat correctly represents all exterior boundaries
and the subdivision of land is located in the SEk-NW4 of Section 6
T28N, R17W, Town of Pleasant Valley, St. Croix County, Wisconsin,
to-wit:
Commencing at the S4 corner of Section 6; thence North along the l
N-S 4 section line a distance of 2638.77'; thence N87°30'11"W 74.80'
to the Northerly right-of-way line of Interstate Highway "94" also
being the point of beginning; thence N87°30'11"W along said right-
of-way line 696.521; thence NO®09'11"W 475.801; thence N89°50'49"E
730.77' to the Westerly right-of-way line of C.T.H. "J"; thence
SO°0911111E along said line 195.00'; thence S89®50'49"W along said
line 35.0011; thence SO°09' 11"E alon said line 313.00' to the point
of beginning. Contains 8.01 Acres 349,075 sq.ft.)
N I/4 CORNER
SEC. 6,T28N, R 17 W
Dated this day of Q0 , 1983. CA~m ZeA-1 (CO. SURVEY MON. FD
Arthur L. We rer
`yGpN Wis. R.L.S. No. S-9631
.RER UNPLATTED LANDS
I
NAMOM
Pj
Q1
Z
--N-890 50 491 E 730.77. r4 ;n
0
° SHED :G"
Z EXISTING
~~F I " I
I" HOUSE 88901
504
Sr
,•z D ( LOT 1 35.00'
.D
8.01 ACRES rn I
w
rn (349,075 SO. FT.) BARN
M
0
° APPROVED W °
o~
JUL 61983 M.
I
ST. CROIX COUNTY 80' 80'
COMPREHENSIVE PARKS PLANNING 1 Z
AND ZONING COMMITTEE '
of
E N 8 7° 30 11 W 6 9 6.52 7a.8O' ~a I
87°3O' -
$ ZI n
o ~
SCALE I"=150' INTERSTATE HIGHWAY .94. a m
0' 75 150' 300'
~I
NOTE: BEARINGS REFERENCED TO THE 0= SET I"X24" IRON PIPE WEIGHING 1.13 LBS/LINEAL FOOT.
N- S 1 /4 SECTION LINE OF SEC. V S V4 CORNER
6,T28N,R17W(ASSUMED NORTH) SEC. 6,T28N,R1
(00. SURVEY MON.I
Volume 5 Page 1303:
THIS INSTRUMENT DRAFTED BY
i
DEPARTKENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IIVDUST'RY, DIVISION
7969
LABOR AND PERCOLATION TESTS (115) P.O. BOX MADISON, WI 53707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATI SECTION: TOWNSHIP/MUNICIP LI Y: LOT NO.:BLK. NO.: SUBDIVIS ON NAME:
SE u~~/a M NA 178 cor 1•~s,~
COUNTY: OWNER'S B YER'S NAME: / IMAILING ADDRESS
USE 13TES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PR FI NS: TS:
Residence 3 ❑New Replace
RATING: S- Site suitable for system U- Site unsuitable for system
CONVENTIONAL: MOUND: EMS ROUND-PRESSUR- : S STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: ptional)
LAS ❑U S ❑U ❑U ❑S .2'U ❑S 2U
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation:
)C541 PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH 139, ELEVATION OBSERVED E T. 1 HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
/
B- 7.03 9s''-~3 > Q~f . 61,7
B- Z ~•`~9 one
B--3 5+y9~ Z Mond Z/9 .P3
s' • / ~'B~r z•Z-.:r r~
13-
13-
13-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER +Ne4IE6 AFTER SWELLING INTERVAL-MIN. -PERIOD 1 P RI D PER INCH
P- I q-11 AAne- SO 3 z
P. ,72: Ald /2 e 30 'Ll P /
P__3 '9101, Alo,? e, 30
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
L4 .................._..y......-._..-_L......_..........
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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:
,.ri_./ GT /
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 2~i 571' 1-31161,1
CST NATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
IR-SBD-6395 (R. 02/82) -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 to scale is preferred. 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 appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
tion, 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 your 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 - Sandstone
gr - Gravel (under 3") LS - Limestone
*s - Sand HGW - High Groundwater w
cs Coarse Sand Perc Percolation Rate
med s - Medium Sand W - Well
fs - Fine Sand Bldg Building
Is - Loamy Sand > - Greater Than
*sl - Sandy Loam < - Less Than
*I - Loarn Bn - Brown
*sil - Silt Loam BI - Black
si - Silt 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, rnedium
rn Muck d - distinct
p - prominent
HWL - High water level,
Six general soil textures surface water
for liquid waste disposal Blyl - Bench Mark
VRP - Vertical Reference Point
TO THE OWNER,
This soil test report is the first ste) in seCOnn l ? sariitary pernrlt. The county or the Department may request
vr.rifi:,<,;ion of this soil test it) the Held prior to permit iss;.rance. A complete set of plans for the private
sovvaga s',stern and a perr-nit: application ; rust I;- to the appropriate focal authority in order to
! it,,,ifl it aGrrnlt- The init.2ii y Dorn it niul,,t .)e o "fined acd pC) tErJ 0i io . ci the Start of any construction.
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• DOCUMENT NO.
STATE BAR OF WISCONSIN-FORM 2~ j
WARRANTY DEED t
w ~~Q~"• 1Q THIS SPACE RESERVED FOR RECORDING DATA
L} Q Not ~Jcr~ ME M i
_ Charles W Fedi Sr ..~/k/a 1 A- edle,
REGISTERS OFFICE
and Emma J. F di P-4-/k/a Emma Fed i ~ u ba d-~nd_ ST. CRO IX CO.~ WI q
wife as joint- t enan+-c Reed/ aQeOrd
j
conveys and warrants to_ David Tee and Mi r_hal 1 P Lee, 'VJv 0 1990
hltshand anra~„-•-s -yuYv1v-Qr-B ~P 41 11:05 A. -'AM
ro err y, said na-Mi d TPA -ma a1
and said Michelle Lee, a k a michele K. Lee V
f~ ~n ~,2 a1 Lp_ Register of Deeds
RETURN TO
the following described real estate in St. Croix County,
State of Wisconsin:
Part of the Northeast Quarter (NEJ) of
Northwest Quarter (NWJ) of Section 36-29-17 Tax Key No.
described as follows: Commencing on N line of said
Northwest Quarter (NWJ) 163 feet W of NE corner thereof
thence W on said N line 117 feet; thence S parallel with E line
of said Northwest Quarter (NWJ) 350 feet; thence Southeasterly on
Northerly bank of Creek to point 360 feet South of Place of
Beginning; thence North 360 feet to Place of Be
ginning.
I
MANSE,
o O I'j
• M
I1
I"
This is homestead property.
(is) (kxlxt)
Exception. to warranties:
~i
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LEJ
Dated this p day of 192_.
i
j
(SEAL) (SEAL)
(SEAL)
(SEAL)
r
i1
r
AUTHENTICATION ACKNOWLEDGMENT
Signatures authenticated this day of STATE OF WISCONSIN
1
ss.
County. / i
P rso ally came before me, this /tO day of
* r
the above named
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.) Gmn'jG ~i This instrument was drafted by
Donald J. Fast
it~'Ito'Fne,)fnown to be the persons who executed the fore-
Of fis e Park , Box 5 4 6 I t,Tument and a k owledged the same.
Baldwin, Wi srnnsi 54Q02
. ;.110
(Signatures may be authenticated or acknowledged. 138fh; me
are not necessary.) Notary P~Sb_
t i V/
11 County, Wis.
his% n i permanent. (If not, state expirati
191/
WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 2-1977
+ Wisconsin Department of Health and Social Services
j
pib. #b7 370 Division of Health
A10 2ECbkb OF SEPTIC TANK PERMIT APPLICATION rf
IN A? 74 FOB ~~rCt✓ r r GK (V Shy,
TIDE or USE BLACK INK
A. OWNER OF PROPERTY
Name Zvi Fd2 ow /V t- A dress (Street, City, Zip Code)
r~ ~
B. LOCATION OF PROPERTY W-&RE SYSTEM WILL BE CONSTRUCTED ALTEREL OR EXTENDED COUN/~Y
Check One:
CITY VILLAGE LEGAL DESCRIPTION
% TOWNS HIP
C.' IS LOCAL PERMIT REQUIRED FOR THIS WORK? V % /YES NO .:1 PERMIT NUMBER
D. SEPTIC TANK CAPACITY f i Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALSt Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
r
E. TYPE OF OCCUPANCY
Cheok One: One or Two Family Residence U~ Commercial Industrial Other
_ (Specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES l/ NO _ Automatic Clothes Washer BYES NO
Dishwasher, YES v N0" Automatic Potato Peeler YES i/NO
Other (Specify)
G. MASTER PLUMBER MAKING INSTALLATION
iJ , •f'' h /
Name: %/,rl~-"G~LC~G~c/ Zl-~ <<-.:C- 1~,.✓J Addresst 'License Numbers
ter
,i
Signature of Applicants MP RSW
Address:
H. (a be C pleted by Issuing Agent)
i /
Date of Application Fee Paid
Permit Issued (datey "i Permit Number Ll
rl.' Ii-1==i~
Agent (Name) l r~•' { / _ i L~- ' Torn Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above G:Pstions are answered and the
fee paid. Agents wil' forward application, the fee of $1.00 "or each septic tarot and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Health.
Do not write in space below - F,0_f DEPARTMENT USE ONLY
~v
I. DATE RECEIVED ` -10 ACCEPTED BY RETURNED
(Initials) (Date) Se ^,r=rs.)
FEE RECEIVED v VALID. No. 0 ~O PERMIT NO.
es or No
REVIEWED BY APPROVED DATE
(Initials).. Yes or No
COMPLETE OTHER SIDE
SEPTIC TANK PERMIT N0. 7L
R Z P 0 R? O N S O I L P Z R C 0 L A? Ij0 N ? E S T
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLUMBING SECT1611
P.O.Box 309, Medison, Wis. 53701
Purse mt to H 62.20, Wis. Administrative Code
P Z R C 0 L A T I 0 N T Z S?
Test Depth Character of Soil Hojrx Water Test Time Dr mop or Level Inches 'Minutes
Number Inches Thickness in Inches Since Hole in Hol Interval Second to Next to Last To Fall
lot Wetted Overnight in Minutes Last Period Last Period Period Ono Inch
Example
P - 0 36" To Soil 10" Cla 26" 25 Yes or No 30 1 2 1 2 1 2 60
2
J
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62020 Wis. Administrative Code.
S O I L B O R I N G S- Minimum 36" Below Pro osed Abso tion system
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches
Example
B - 0 721f• 72" Black To Soil 12" C1 18111 Sand 18111 Gravel 241'
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
TYPE OF OCCUPANCYs
RESIDENCE: Number of Bedroxas OTHER: (Specify) Number of Persons
D WASTE GRINDERS Yes Na 6 Dishwashers Yea No I---- Automatic Clothes Washers Yes Z . Ne*
FFWENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT
~j ~k
Tile Size No.Lin.Feet Trench Width Depth Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth _
Is the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location/,of test holes are correct to the best of my knowledge and belief.
NAME TITLE
(Type or Print)'
REGISTRATION NO. or MASTER PLUMBER LICENSE NO. ADDRESS
r;,
DATE SIGNATURE
TT"~ ✓
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CL,c~ CS
57 ( ~,,C3
W'7 Lf 3 3
Parcel 024-1007-80-000 05/04/2007 12:55 PM
PAGE 1 OF 1
Alt. Parcel 6.28.17.40C 024 - TOWN OF PLEASANT VALLEY
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - SCHUEBEL, LAURELE K
LAURELE K SCHUEBEL
554 CTY RD J
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 554 CTY RD J
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 8.010 Plat: N/A-NOT AVAILABLE
SEC 6 T28N R1 7W SE NW LOT 1 CSM 5/1303, Block/Condo Bldg:
TOWNSHIP PLEASANT VALLEY.
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
06-28N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
08/08/2005 802734 2861/221 TI
07/23/1997 726/479
07/23/1997 669/608
11/19/1985 407168 726/479 WD
more...
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 04/10/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.000 42,600 76,900 119,500 NO
AGRICULTURAL G4 3.000 300 0 300 NO
Totals for 2007:
General Property 8.000 42,900 76,900 119,800
Woodland 0.000 0 0
Totals for 2006:
General Property 8.000 42,900 76,900 119,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 306
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
-C 0
Q. O O O
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IL ED
JUL 1983
v o ~ _ S-
Register D~.ds
CERTIFIED SURVEY MAP aNKE"
St. Croix etCornly, Co
LOCATED 1 N THE SE 114 - NW 114 OF SECTION 6, T 28 N, Wixon.,ln
R 17 W, TOWN OF PLEASANT VALLEY, ST. CROIX CO.-
OWNED BY: GEORGE MC LAUGHLIN
1275 2ND ST, HAMMOND, WI 54015
I, Arthur L. Wegerer, registered land surveyor, hereby certify:
That in full compliance with the provisions of Chapter 236.34 of the
Wisconsin Statutes and the provisions of the St. Croix County
Subdivision Ordinance and under the direction of George McLaughlin,
owner of said land, I have surveyed, divided, and mapped said parcel
of land, that such plat correctly represents all exterior boundaries
and the subdivision of land is located in the SE4-NW4 of Section 6
T25N, R17W, Town of Pleasant Valley, St. Croix County, Wisconsin,
to-wit:
Commencing at the S4 corner of Section 6; thence North along the
N-S 4 section line a distance of 2638-771; thence N870301 111tW 74.50'
to the Northerly right-of-way line of Interstate Highway 119411 also
being the point of beginning; thence N87°3011111W along said right-'
of-way line 696-52t; thence N00091 11"W 475.801; thence N89°50149"E
730.771 to the Westerly right-of-way line of C.T.H. "J11; thence
S000911111E along said line 195.00?; thence S89°5014911W along said
line 35.001; thence SO°0911111E along said line 313.001 to the point
of beginning. Contains 8.01 Acres (349,075 sq.ft.)
NI/4 CORNER
SEC. 6,T28N, R 17 W
Dated this 7 9 day of QQ , 1983. (CO. SURVEY MON. F
note.` Arthur L. We rer
Wis. R.L.S. No. S-9631
;_ER UNPLATTED LANDS
O s e~m N 89°50'49"E 730.77' ;n
z coo ,
0 10 .
O° SHED 8 M ;C-
;z EXISTINS,,-,D 1 ;
r ; HOUSE S
.z D LOT I
-i 8.01 ACRES rn t
M (349,075 $0. FT.) BARN W
0 Z .Ia
ID,
w APPROVED W Z
JUL 61983 M
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go'
ST. C~OIX COUNTY
COMPCEHENSIVE PARKS PUNNING Z
AND ZONING COMMITTEE cn
E N87°3011 W 696.52 74.80' a
B7°30'11 N
I M
S
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0
SCALE ►"=150' INTERSTATE HIGHWAY " g4 = M
0 75' 150' 300'
U f
NOTE: BEARINGS REFERENCED TO THE 0= SET I"X24" IRON PIPE WEIGHING 1.13. LBS/LINEAL FOOT.
N - S 114 SECTION.LINE OF SEC. v S 1/4 CORN R
6, T28 No R 17 W (.ASSUMED NORTH) SEC. 6, 728N, F
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