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Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~eo k7i ~ (moo r TOWNSHIP SEC. T N-RIT W
Y '0"' ST. CROIX COUNTY, WISCONSIN
ADDRESS fSr Q 6 UX 9Y'0"'
SUBDIVISION ~J1 LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Af"'N~ J
31
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INDICATE NORTH ARROW
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BENCHMARK: Describe the verb..--al reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: r 4ke Liquid Capacity: 16)01r'
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Read: Front ,0Side 10 Rear, O feet
.From nearest-property line Front,OSideQRear,O I S~, feet
Number of feet from: well. building:
(Include this information of. Ite above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
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 from nearest property line: Front, O Side, O Rear, Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: GI S Trench:
Width: Length: Number of Lines: o` Area Built: 7&0
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,O Pt.
Number of feet from well: N
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area: Built :
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
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:
[f Inspector:
Dated: Plumber on job:
License Number:
3/84:mj
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
SW A~ , ec.14 T31-R19 Lob4 Stassign l.D.Number:
CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Somerset
HWY ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
. 35
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Thomas Moore 2 Bo548 Somerset 141 54025 /y-9d 'Old
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Calvin Powers r. 156 St. Croix 135420
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PO"end 1 0 0 0 PROVIDED: PROVIDED:
YES ❑ NO ❑ YES NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
J N a Z AIR INLET:
' t ALARM: FEET FROM g LINN
NO "1 C- I ❑ YES NO NEAREST
❑ YES
31
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
1:1 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 ❑ YES ❑ NO NEAREST 00-
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:
WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH Q TRENCHES: M ERIAL: C PIT DEPTH:
DIMENSIONS 2 - G
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIP S: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: LINE: AIR INLET: FEET /1 l1 ~
3 61 / D I '4m / ol'9D 2 7 L -j NEAREST O- / So N 3 l .3lf
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:
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:
S J ❑ YES ❑ NO ❑ YES ❑ NO NEAREST
711
7 ~
Sketch System on /Retain in county file for audit.
Reverse Side. SIGNATURE: TITLE: i7
SBD-6710 (R. 06/88) f//~~
uw- R SANITARY PERMIT APPLICATION COON
:EO& In accord with ILHR 83.05, Wis. Adm. Code
I ZA -
mommons
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than J,5- 8'f1 x
11 inches in size. f revisibn 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
O n7 d no v -,e S kA, S /el L ON R /9 40(or) W/
PROPERTY OWNER'S MAILING ADDRESS LOT # K #
)?R,2 e;,e% sy /v
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUM BPR
me r . 5
L_j
II. TYPE OF WILDING: Check one CITY NEAREST ROAD
( ) State Owned VILLAGE : S~
❑ Public L',X1 or2 Fam. Dwelling-# of bedrooms3 PAR LTAXNU ER( )
III. BUILDING USE: (If building type is public, check all that apply) _ AOn2 _
-Sri no In
1 El Apt/Condo 2 ❑ Assembly Hall 60 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 1120 Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYP OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an
P 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 El Specify Type 41 El Holding Tank
12 Seepage Trench 220 In-Ground 42 ❑ Pit Privy
130 Seepage Pit Pressure 43 ❑ Vault Privy
140 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
97S CO ej&AA /OO;ByFeet ®3,aveet
VII. TANK CAPACITY Site
in allons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete structed glass App'
Tanks Tanks
Septic Tank or Holdin Tank O L'a
Lift Pump Tank/Si hon Chamber R F]
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Pr t): Plumber's Signatur : (No tamps) /MPRSW No.: Business Phone Number:
Lccalw war h /~6 7/S 316
tuber's Address (Street, City, State, Zip Code):
3 Ovy q i
IX. COUNTY/DEPARTMENT USE ONLY
,~y~ ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature No Stamps)
Approved ❑ Owner Given Initial surcharge Fee) _QA
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Adversi D t rmin tin
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X. CONDITIONS OF APPROVAUREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
r
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.
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 it
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
f S T C - 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
issuapce. 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/. D I'I'1 ct S r'-~
Location of Property S ;4 Section, T N - R ..G.- W
fAmship
Mailing Address
Subdivision Name
Lot Number _ T
Previous Owner of Property
Total Size of Parcel Date Parcel was Created p
Are all corners and lot lines identifiable? 7 Yes No
Yes No
Is this property being developed for resale (spec house) ?
I
Volume 6 and Page Number S__i>_~~`s-recorded with the Register of Deeds
i
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
{ 1. Warranty Deed
2. Land Contract
1. Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if avacri,would
tosa CertifiediSurveydelays
referenceshelpful
of the reviewing process. If the deed des ption
Map, the the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - -r - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) ce that aU Statements on this jojun ahe tnu.e to the beat o6 my (ou1L)
fznow.~edge; tithy at 1 (we) am (cute) the owneh. (.a) 06 the ptopenty deschibed in this
.injonmat.ion ~onm, by viAtue o6 a wWLAanty deed neconded in the 06jice of the
County RegiAten o j Deeds as Document No. a? / ; and that 1 (we.)
pnedentty own the pnopo.aed .6 to bon the Sewage poa bydtem (on 1 (we) have
obtained an easement, to hun with the above dedcA bed pnopen ty, jox the.
con6tkuction o6 said ayatem, and the same had been du,2y xecohded in the 06jice
og the County Reg"id"ten o4 Deeds, ab Document No.
SIGNATURE OF 0 ER SIGNATURE OF CO-OWNER (IF APPLICABLE) 91 DATE SIGNED DATE SIGNED
THIS NO. STATE BAR OF WISCONSIN FORM 1-1982 SPACE RESdRVED FOR RECORDING DATA
' WARRANTY DEED
' 455231 ~61PArE522
REGISTER'S OFFICE
Edward E. Germain and $T. CROIX CO,, WI
This Deed, made between
Recd for Record
' Ann Marie Germa>.n- husband and wife
JAN 1J;
• Grantor, Gt M
Th 11:45 A.jj
,d omas P. Moore a d__yick?4.+,..dI44,._k~u~ka>~d end I~e. a CAti""~tJt'.J.
urvivo=ship Irlarital ~roperty
Register of Deeds
Grantee,
WitnesSeth, That the said Grantor, for a valuable consideration......
conveys to Grantee the following described real estate in ....St.-.Crolc.._•__•__-_- Thomas P. Moore and Vicki L.
County, State of Wisconsin: I Woo5e Box
548, Somerset, WI
I
Tax Parcel No-
Part of the Southwest Quarter of Southwest Quarter (SW 1/4 of SW 1/4) of
Section 14-31-19 described as follows: Lot 4 of Certified Survey Map filed December
8, 1978 in Volume "3", Page 746.
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This is not
homestead property.
I; (is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And.... Edward__E. •Germain _-and Ann• Marie -Germain,__ husband_ and-wife•
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
i
and will warrant and defend the same.
Dated this 18th----_-----------_---------- day of . January 19- 90
(SEAL) Cf?~..L---•--(SEAL)
- (
I
* * Edward E. Germain
- C
• (SEAL) C1_~LCh.~._.525~ ,
c- (SEAL)
* * Ann Marie Germain
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
SS.
St Cro:
- ]x----------------- County.
authenticated this day of___________________________ 19 Personally came before me this __180day of
January----------------------- 19_9Q--- the above named
Edward E. Germain- and Ann _ Marie .Germain,
-
usband..and- if
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not-
III authorized by § 706.06, Wis. Stats.) to a kno n o be the person S who executed the
regoi in trument and ackn 1 age t e sam
THIS INSTRUMENT WAS DRAFTED.HY e First. Security Title .
te Bear-Lake-------------- iT
~faplt~wood~• Al---- 551-I1V------ W0250----------------------- Notary Public --------.-County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) - p
date: __19..2/- )
-a -
' *Names of persona signing in any capacity should be typed or printed below their signatures. ij
WARRANTY DEED STATE. BAR OF WISCONSIN Wisconsin Leeal Blank Co. Inc.
ROIL".f NA i - IeR2
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STC - 105 r"
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
ty
OWNER/BUYER
S/C.~rn
ROUTE/BOX NUMBER_ _10 fay Fire Number
CITY/STATE _906fiaiw zip
PROPERTY LOCATION: S(,lJ !y, S•`'Jk, Sect onT- 3Z N, R ~.G=W,
Town of 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 pumper. What you put into
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. Cr'bix 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.
0
E
I/WE, the undersigned, have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- v
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 7P 1~4n
DATE
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.
f.
INDUS I'$/I OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, , DIVISION
t;AND P.O. BOX 7969
E4 PERCOLATION TESTS (115) MADISON WI 3707
AN Fr ATIONS (H63.090) & Chapter 145.045)
DIVISION NAME:
LOCA I SECTION: ITOWNSHIP/MN30CKDOOCTY: LOT N=n/a
SW 1/40/ 14 /T 31 N/R 19fNor) W Somerset 4 COUNTY: OWNER'S AME: MAILING ADDRESS:
St. Croix Ed Germain Box 120 C, Somerset, Wi. 54025
USE DATES OBSERVATIONS MADE
NO. BEDR COMM R A E CRIPTtON: PR N OLATION ESTS:
(iesidence 3 n/a New ❑Replace I 9_21-89 n/a
RATING: Ss Site suitable for system Ua Site unsuitable for system
CONVEN I L: MOUND: IN- ROUND N-FILLHOLDIN(i TANK RECOMMENDED SYSTEM: (optional)
gS ❑U g S ❑U ®S ❑U ❑S 91U ❑ S )ElU : conventional
If Percolation Tests are NOT required DESIGN RAiE:
class If any portion of the tested area is in the n/a
under s.H63.09(5)(b), indicate: I Floodplain indicate Floodplain elevation:
decimal' PROFILE DESCRIPTIONS page 10 GOC
BORING TOTAL DEPTH TO GR UNDWATER•INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED ES HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B. 1 7.17 104.84 none >7.17 1.08bl.1. .92bn.sil. 5.17bn.l.s.
B 2 7.42 104.72 none >7.42 1.08bl.1. 1.42bn.sil. 4.92bn.l.s.
B 3 7.17 103.84 none >7.17 .92bl.1. 1.25bn.sil. 5.00bn.l.s.
4 6.58 102.32 none >6.58 1.58bl.1. 2.00bn.s.sil. 3.00bn.l.s.
B. 5 6.84 101.43 none >6.84 1.50bl.1. .92bn.l.s. 4.92bn.m.s.
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCH ES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN., PERIOD 1 PERIOD 3 P
P-
P- se desi rate
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.
100.84
SYSTEM ELEVATION
- T l I ► - -i 1
4,E... I _
lilt
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1![he 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:
Gary L. Steel 9-21-89
ADDRESS: CERTIFICATION NUMBER: PHONE N M ER optional):
988 N. Shore Dr., New Richmond, Wi. 54017 229 171-A ~20b
CST SIGN E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
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• ' rn A.,-S Moo rte. PAGE OF
CroS Sltr~lo,, A Ztro -Sys[en-)
-.2,;x I' ) Frd►b Air Inlat► And Ob►arvallon pipe
1~ Approv►d vent Cop
Minimum 12" Abor•
Flnel Grade
20. 42" Above Pip' _ 4" Cost Iron
To Final Grade Vent Pips
Mash Hal Or SlniMtk Coverlny
MIn 2" Aareale
Owe( Pips
OIelrlOullon '
Pipe - Tea
V Apprepole
Beneath Pipe ° perloraled Pipe below,
o I-CoWing TaminallnS AS
Bottom Of Slslem
III
~.Icve.~ 1 on Fma2m,
SOIL FILL
OISTKIBLITIOVI PIPE
APPROVED ,SJU -HETIC COVER
r ~-P1 AT~It1A1 OR 'I" OF STRAW
2" OF /fi rj 9 EWE MARSH H A'j
~yy a~ fm OF 12 -21/Z AGGREGATE
ELEV. OF /fJb. rEE7
DIS-1-1115JTIOM PIPE TU BE AT LEAST IIJCHES BELOW ORIGIMAL GRADE
A►JU AT LEASTLO IAICHES BUT AIO MORE THAI) 42 INCHES BELOW FINAL GRADE
MAXIMUM WN OF EXCAVATH)MI FKom OKIGrJAL 6KAK WILL BE IMCHES
PUI41MUM ®EPrtt OF EXCAVATION FROM. OIKI41WAL CAW- WILL BE ~ INCHES
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51GAIED:
L I G E 1J S C AJ U M B E li : ~L~c~
DATE: 'Z
ST. C\ OIX COUNTY
WISCONSIN
PLANNING & DEVELOPMENT
PLANNING SOLID WASTE REAL PROPERTY ZONING
715-386-4674 715-386-4623 715-386-4677 715-386-4680
October 8, 1993
To Whom it May Concern:
An inspection of the septic system for the Thomas Moore property,
located in the SW -h of the SW h of Section 14, T31N-R19W, Town of
Somerset, was conducted on February 14, 1990.
At the time of the inspection this septic system was found to be
code compliant for a three bedroom home.
Should you have any questions, please feel free to contact this
office.
Sincerely,
Thomas Nelson
Zoning Administrator
mij
ST. CROIX COUNTY GOVERNMENT CENTER • 1 101 CARMICHAEL ROAD 0 HUDSON, WI 54016