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FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
ti
TOWNSHIP C
OWNER_
SECTION TT.~ 1._N-RLH1
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I~S
f
1
90,
• y`I
e
r
INDICATE NORTH ARROW
DENCHMARK:Elevation and description: /,j 6,eAzeA
Alternate benchmark /
~ Liquid Cap.
SEPTIC TANK:Manufacturer: .
Rings used:- Manhole cover elev:~Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front_, Side, Rear-9-Ft.
From nearest prop. line:Front__, SideRear____Ft.
No@ of feet lroms Weli , Duiidings ors
(Include this information in the above plot plan) to se (2 reference dimensions REVERStic tank)
t
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.:
Pump size
Elevation of inlet: Bottom of tank elevation
Pump on elev.:_,__Pump off elev.:
Gallons/cycle:
Alarm: Kan.: Switch
Type Location
Distance from nearest prop. line: Front-,, Side-,, Rear Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: Trench:
Seepage Pit:
Width:
-4--2L_Length Number of Lines:-Area Built-Le-12
Exist. Grade Elev. Proposed Final Grade Elev. -4c ~ Fill depth to top of pipe:
No. feet from nearest prop. line:Front
Side, Rear _Ft.9 ~
No. feint from well:-A~No. feet from building HOLDING TANK
Manufacturer:
Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front___, Side--,, Rear _Ft.~
No. feet from: Wellbuilding
nearest road
Alarm Manufacturer:
INSPECTOR:
DATE :
PLUMBER ON JOB: _
LICENSE NUMBER:_
6/90:cj
4qooo&[~
' DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
DIVISION
LABOR & HUMAN RELATIONS ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
P.O. BOX 7969
State Plan I.D. Number:
MADISON, WI 53707 (It assigned)
NE 4f SE 4, Sec . 23 , T31-R19 CONVENTIONAL ❑ ALTERATIVE
Town of Somerset ❑ Ho ding Tank ❑ In-Ground Pressure ❑ Mound
2 iT ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
F HOLDER:
Tom & Lisa Swanson RR. Somerset, WI 54025 /
REF. PT. EL S R F. PT. ELEV.:
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN:
Z &Z
MP/MPRSW No.: County: Sanitary Permit Number:
Name of Plumber:
Calvin Powers 1563 St. Croix 128725
i
SEPTIC TANK/ K 01C cco_k = '
MANUFACTURER: LIQUID CAPACITY: pTANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVE
) c~ / PROVIDED: PROVDED:
00i,o~V~ ~C,- ! '/o J • %S YES ❑NO ❑YES NO
BEDDING: DIA.: V&4+-MAT1_.: HIGH WATER UMBER OF ROAD: PROPERTY WELL: BUILDING: VENT T FRESH
~J, ALARM: FEET FROM LINE: 1 AIR INLET:.
r"--
❑ YES NO L ❑ YES NO NEAREST --0i`
MANUFACTURER: BEDDIN Y: PUMP MODEL: PUMP/SIPHON MANUFACTURER: PRWAR OVIDEDLABEL PLOCKING ROVIDED:OVER
❑ YES ❑ NO ❑ YES ❑ NO S ❑ NO
PUMP AND CONTROLS OPERATION R OF PROPERTY W~F DING: VENT TO FRESH
GALLONS PER CYCLE: AIR INLET:
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF ❑ YES ❑ NO NEAREST
LENGTH: DIAMETER: MATERIAL AND MARKING:
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.) r
CONVENTIONAL SYSTEM: S -J-e~Yf M6V INSIDEDIA.: #PITS: LIQUID
WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: MCOVER ATERIAL: TH.
BED/TRENCH TRENCHES:
DIMENSIONS 41 67
PROPERTY WELL: BUILDING: VENT TO FRESH
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PE DISTR. PIPE MA,JERIAL: I R. NUMBER OF LINE: r i AIR INLET: /
BELOW PIPES: ABOVE COVER: ELEV. IN ETt ELEV. END:, y ~D )Wj-C PIPES: FEET FROM
ry a n r f 5 ~ NEAREST Irk
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.
PERMANENT MARKERS: OBSERVATION WELLS;
SOIL COVER TEXTURE:
❑ YES ❑ NO ❑ YES NO
SEEDED: MULC ED:
DEPTH OVER TRENCH/BE DEPTH OVER TRENCH/BED DEPTHS OF TO OIL: SODDED:
CENTER: EDGES:
❑YES ❑ NO ❑YES ❑ NO ES NO
PRESSURI D DISTRIBUTION SYSTEM:
BED/TRE H WIDTH: LENGTH: TNO.OF RENCHES: LATERAL SPACING: GR L DEPTH BELOW PIPE: FILL DEPTH ABOVE VER:
DIMENS NS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. PIPE DI TION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: PIPES:
ELEVATION AND
DISTRIBUTION COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
HOLE SIZE HOLE SPACING: DRILLED CORRECTLY: gPPROVED PLANS
INFORMATION
❑YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST-110-
FD11
in county file for audit.
Sketch System on SIGNATU TITLE: /
Reverse Side.
SBD-6710 (R. 06/88)
v' IMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
ST. CROIX ZONING REPORT NO*** 17431/01 PAGE I
ST. CROIX CMTY REPORT DATES 1/30/92
COURTHOUSE RATE RECEIVEDS 1/29/92 I
WDSOI, WI 54016
ATTNS THOMAS C. NELSON
i
OWNERS Th s & Lisa Swanson
LOCATIONS 679-205th Ave., Somerset
COLLECTOR: M. Jenkins
DATE COLLECTEDS 1-28-92
TIME COLLECTEDS 2S150m
SOURCE OF SAMPLES Outside faucet
DATE ANALYZED401-29-92
TIME ANALYZEDS24'00pm
COLIFORMS 0 /100 mt.
INTERPRETATIONS Bacteriologically SAFE
NITRATE-NS 2 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 ml
Nitrate-Nitrogen, mg/L
LAB TECHNICIANS Pam Gane S~Q
NpfN
f DOPE
WI Approved Lab No. 19 _
Z ( Means "LESS THAN" Detectable Level Approved byS
® PROFESSIONAL LABORATORY SERVICES SINCE 1952
ST. CROIX COUNTY ZONING OFFICE
G
~p St. Croix County Courthouse
911 4th Street
Ap~` Hudson, WI 54016
l~
Telephone - (715)386-4680
The St. Croix County Zoning office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
Completion of this form is essential so that the property can be
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received.
WATER TESTING----------------------------FEE: $ 25.00 XXX
(For nitrates and coliform bacteria)
WATER TESTING FEE: $127.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00
(Determines if system is properly functioning at time of
inspection)
Property owner's name Thomas B. and Lisa A. Swanson
Property owner's address 679 - 205th Avenue, Somerset, WI 54025
Legal Description NE 1/4 of the SE 1/4 of Section 23 , T_:Ll_N-R 19
Town of ~pPhE%YSe~ Lot Number Subdivision Name
FIRE NUMBER 679 LOCK BOX NUMBER
Color of house Realty sign by house? If so, list firm:
-PLEASE CALL LISA FOR AN APPOINTMEN'T' AT WORK— TELEPHONE # (612) 439-3021_1
PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with' this
office to ensure time when entry may be gained.
Firm or individual requesting services: Bank of Somerset
Telephone Number (715) 247-3348
REPORT TO BE SENT TO: Bank of Somerset, ATTN: Kristen Dixon, P.O. Box 220, Somerset, WI
_ 54025
closing date ASAP
Signature ,
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code
E7DILHR COU
STATE SANITARY PERMI!
-Attach complete plans (to the county copy only) for the system, on paper not less than / aZ 7a
8% x 11 inches in size. ❑ Check if rev sion 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
~(or
%_!5;' '/a, S T , N, R
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVI NAME OR CSM NUMBER
SprsYl -e r' S~ 0.25
NEAREST ROA
11. TYPE OF BUILDING: (Check one) ❑ State owned O VILLAGE
❑ Public 01 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NU E ( 03a -16103- ~/~g6
III. BUILDING USE: (If building type is public, check all that apply) -3/5 G esI
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
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Off ice/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ® New 2.E] Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/ ay/sq. ft.) (Min./inch) ELEVATION 11 Feet Feet
VII. TANK CAPACITY Prefab. Site Fiber- Exper.
in allons Total # of Manufacturer's Name Concrete Con- Steel glace Plastic App
INFORMATION New tin Gallons Tanks strutted
Tanks Taisnks 19
Septic Tank or Holdin Tank - A
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' Name (Print): PI bar's Sig atur :(No S mps) MP/MPRSW No.: Business Phone Number:
Plum is Ad cdf rasa treat, Cityfate, Zip Code
3
IX. C N /DEPARTMENT USE ONLY
Disapproved Sanitaryermit Fee Includes Groundwater a e slue Issuing Agent Signature (No Stamps)
rApproved ❑ Owner Given Initial Surcharge Fee)
Adverse Determination
ONDITIONS 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% 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; (lose 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 forpl; and F) all sizing information.
- - - - - - - - - - - - - - - - -
GRIOUNDWATER 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 BANITARY PERMIT
9TC-100
This application form is to be Completed in full and signed by the owntz(s) of
the property being developed. Any Inadequacies will only result In delays of
the permit issuance. -Should this development be intended got 94561• by
owner/contcactatt(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 ITIc MQ5 L~ /J
Location of property _&L-114 ~_145 1/4, Section , 3 ~•11LL-Y
Township S61- e►^s.' -
Ma i l l nq address
• Address of site 5y0
Subdivlston name. •
Lot number -
Previous owner of property
Total size of parcel 0
Date patcal vas created - Q~ 7 p-~ xx
Ate all co:nets and lot lines identifiable? an __J10
Is this property being developed tot resale Capec house)?as e
Volume-and Page Number 1~1& as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWINGS
A WARRANTY DRID which Includes a DOCUMENT NUMBYR, VOLUKE AND PAGE NVMSRR, and
the BEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, it
available, would be helpful so as to avoid delays of the tevlewinq pprocess. It
the deed description references to a Ceitlfled survey Map, the Certified Survey
lisp shall also be requited.
---------------------------------------------------------7---------------------
PROPERTY OWNER CERTIFICATION
I(ve) rectify that all statements on this form are true to the best of my (ouc)
knowledge= that I (we) am (are) the ownst(s) of the ptopetty described In
this lntotmation tocm, by virtue of a wartanty,d ~d~ ee tdad In the Office of
the county Reglstac of Deeds as Document No. zf e I and that I (wet
ptesantly own the ptoposed site for the sewage disposal system (at I (we) have
obtained an easement, to run with the above described property, tot the
conatcuctlon of said pystem, and the same has been duly record d in the o[flee
et t County Register of Deeds, as Document No
_77- - 5 nature of 0 nee Si' nature o! Co-Owner (I! Applicable)
Date of signature Data of Signature
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA li
STATE BAR OF WISCONSIN FORM 2-1982
466968 %1.-, S t7PAU2S i
- - REGISTER'S OFFICE
- - - g - - - . , ST. CROIX CO., WI I,
R y
husbandaBdlwife asnjoiat---------------------------------------
tenants Baillar-geon Recd for Record
~ li
- - -
at 1210 ~~~P M
conveys and warrants to -Thomas--B.--- Swanson---and.- Lisa__ A /'D Ci6y'^^
------_-Smansoxl_, _.husb-and__and--.wa._fe---a-s marl--t---al V
-.---.__S-u viVor-Ship--_pro_pe-rty------------------------------------------- RegIsterof Deeds
RETURN TO
the following described real estate in S.t - .--.CrOlX ......................County,
State of Wisconsin:
Tax Parcel No:
Lot 3, Certified Survey Map filed December 7, 1981 in Volume 4,
Page 1135, Document No. 374789.
3
This i-S.-110t.......... homestead property.
(is) (is not) II
Exception to warranties: easements, restrictions and rights-of-way of
record, if any.
it
Dated is Z7 6•------------- day of ~Llly------ 1990
' ✓ (SEAL) G / - & - (SEAL)
Randy Baillargeon *Joan M. Baillargeon
STATE OF CALIFORNIA
COUNTY OF '57f9a )J96-0 SS.
On V Uri ?7, r 9 `vo before me, the undersigned, a Notary Public in and for said State, personally appeared
,~m~oy n,~,cc A; 47" ~zo to- 13,E-AI /lrtc e_eti
personally known to me or proved to me on the basis of satisfactory evid nce to be the person(s) whose name(s)
subscribed to the within Instrument and acknowledged that executed the same.
WITNESS my hand and official seal.
.•T,;;; OFFICIAL TEAL
HARRY C. SHANK
(Seal) NOTAriY PUOUC CALIFORNIA
Ir.,.. r SAN DIEGO COUNTY' ~i
fsY C'~NM EXP. OCT. 1 1993 (Notary Public's Signature)
023200 9-82* 25 PS Individual Notarial Acknowledgment
IHIS INSI HUMtNI WAS UHAF ItU UY it
Kristina O gland Lundeen
Attorney at Law Alic-e, J.Qy...C_ nmr.a.-------•------------------------
Notary Public ------.fit- -_Cr_0 .-x-------------County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date- ------------July_-12--------------------•----- 19.93._.)
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Cu. Inc.
FORM No. 2- 1982 WIilwattkcc. Wis.
co FILED
DEC 7 1981
j=r.S O' COWELL
Rephler of Geth
&4 Crolr Cocatr, ✓
v ;✓EiSaotl~ '~'~r
CERTIFIED SURVEY MAP
1/4 CORNER U N P L A T T E D L A N D S E1 /4 CORNER
ECTION 23 SECTION 23
31N, R19W Point of T31N R19W
_----Be~inni E_l'V - Section Line
-
N 870 36'35 "W 1156.76'
XISTING A 186.00' B TOWN ROAD
h Right-of-W _ N 87°45' 38"W
186.00'
w
ne
M o Victor Martinsen
w Z Vol.. 333, Pg. 53
Doc. No. 248832 I n
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z I NOTE; The true B Recorded as N 87° 41 "W N
QI - location of this corne- , N87°36'35"W B F- v=i %o
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is occupied by a wooden 264' c~ C)
= fence post, existing pipe J w
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- -TABLE Or ANGLES - - - -
A=05`''16'5!1
C=90-1 09'.
SC.-'.LE fill, FEET
e' 1o0' 2001 30c,
-='~':T)' SECTION CO.R'-ER f.'.ONU:.,ENT, FOUND.
EXISTING 1" PIPE . p,DFDOVED
x24" IRON PIPE, SET, I.EIGHING 1.6E=/LINEAL FOOT.
3
EXISTING FENCE r ~jot
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SEPTIC TANK MAI=NANCE AGREEMENT Ct
St. Croix County
r
v~
OWNER/ BUYER "j:~ a ~l `5=tecJ~ .t s a /J
0
`
ROUTE/BOX NUMBER Fire Number :3
W
CITY/STATE ZIP .SyQ 4t S Ct
PROPERTY LOCATION:'.' ' k, k, Section • T -N, R W,
Town of y °,1 St. Croix County,
Subdivision Lot number Improper use and maintenance of vour septic system could result in
its premature failure to handle wastes.- Prover maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed''s'e'ptic tank pumper. What you put into
the system can affect t e' .unct on ot the 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,
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 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 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart-
ment of Natural Resources. Certification form must be completed •d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED
DATE 2--d S- Qd
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
DEPS TMENT.OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
-INDUSTRY, DIVISION
*LA`BOR` P.O. BOX 76
HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.090) & Chapter 145.045)
LOCATION. SECT10%~ ~lor y1P/MHM+E+PAI=+;FF': LOT NO.: BLK. SUBDI ISION NAME:
h'Z COUNTY: R'S/BU' ER'S NA E: +f~ 17-AILIN'd ADDRESS:
A~_ S4-46
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMER IA DESCRIPTION: PROFILEDESCRIPTIONS: PERCOLATION TESTS:
Residence ®New ❑Replace 9,11
RATING: S= Site suitable for system U= Site unsuitable for system b
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTE :(optional)
Z s ou ®s au Sou o s ou o s ®u
If Percolation Tests are NOT require DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL D PTH T GROUNDWATER-INCHES CHARACTER O OIL WITH- THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTHM, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED SEE ABBRV. ON BACK.)
B- ~
r
B-
B-
9A dig 2, 4- 7,e~ogo-g 5
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER MIs;H'E5 AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIO 2 P R PER INCH
P-
P- 9 - y
P- S 17 A& Wp JA 3
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
-4
r ,
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t
1
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t j
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I the undersigned, hereby certify that the soil tests re ort d on this form were p w mad by me in accord with the procedures and methods specified in TtthhWisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME prin TESTS WERE COMPLETED ON:
A - CERTIFICATION N R: PHONE NUMBER (optional):
- ~S-_ S-
C NAT R
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
INSTRUCTIONS FOR COMPLETING; FORM 115 - SBD - 6395
To be a urate soil test, yorrr reKsort must ir)clude:
1. Complete le
2. The use secti, arly indicate %A, ~iis is a residence of c;csmmercial ; ~c
3, MAXIMUM c4 bedrooms or com use planned;
4. Is this a ne ,ment system;
5. Cornpl th rating boxes. A IS SUITABLI CR A HOLDING TANK ONLY IF ALL
OTHER SYSI RE RULED Ol T ? ON SOIL C TIONS;
6. PLEASE use tl- viations shown her ~ ~r writing profil scriptions and cr- the plot plan;
7. W A LEA", 'i:.jram accurately ating your test ` ations. Drawing t,, preferred. A
sheet r-,_ (I if desired:
;ur.~ your ;-k an(] vertical on referem _ iy shown, acrd are permanent;
all U, , axes as t( -„nes, address in data, percolation test exemp-
"o
flood plan ;n) does not appl~ N.A. in the appropriate hox;
11, 'our current "id your c" 'i" )or;
distribute as Jed. ALL SOIL MUST BE tNITH THE
I .'ITHIN 30 DAYS; OF COMPLETION,
AE- IATIONS FO; ITIFIED SOIL TESTERS
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PAGE OF
CrUSS SeC~IVl1 O~ A zeo
frsih Ali Inlal• And Obwwallon Plp•
~ p/►~ ~oS lS~ ~i~/~✓Iw<,S 0~
( Approvjd Vent Cop
MInIM.m 12' Above
Final Goods
20- 42' Above Plpp _ Coal loan
To final 01000 Vent Pipe
Ma.h Hal Of Slnlhalk Coveting
Wn 2' Aggeapole
Over Pipe
Olwlorllon
Plpa o 0 0 - Tao
d' Apa~apala o Pa(lorolad Pipe baler
Banaalk Pipe
o -Co.ipllnp Tavonlnollna At
Balloon OI Syalaln
P~p~o)eD PInal
Vc%JJion
SOIL FILL
DISTRIBLITIOM PIPE
APPROVED S4WPE.TIC COVER
2" OF AGGREGATE o-OR MARSH KAy9j1 OF STRAW
IoOF12-21/z AGGREGATE
F-LEV. OF p ~P
t _
DIS'rRIB'JTIUW PIPE TO BE AT LEAST _?eS' INCHES BELOW ORIGIIJAL GRADE
AWU AT LEAST LO INCHES BUT MO MORE THAI) 6Q IMCHES BELOW F11JAL GRADE
MAXIMUM Wi'N OF F-)(e/lVAT100 ROM OKIGWAL 6RADF- WILL BE IAICHES
roomUM pV-rr1i of EACA\/AT101J rAOM 04~16INAL GRAPIL WILL ac _ INCHES
SIGIJEO:
LICEWSE UUMBER:.-~ ~
DATE
110