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HomeMy WebLinkAbout038-1021-30-050 ~ I I a. o I ~ o 06 a 0 h N 0 o ti ~ I E ~ E I o c y O h 0 L U ~U .m o m o d. I a Z 3'c c o 3 °2 Q M CL Z y ` p ~ (n = O z N_ 9 d ~ vl"- s i am 0 o z a r Cf) 01 z o U) F- r N Z c E '2 N d ( co • N Q7 ~ IV a U L o w Q Z H Z o N Z C 0 n Y d ~ otf O H d L C E N N N E v CL O ° 2 E ~ N EL o ai N J U 3 rn rn _ i ~ 04 Z - N z O - 0 co 00 0 N w O O a ° E O O m c d r-_ I M 7 w O O c N y C O C0 O F°- N E N LO I T !C+ O Q C U CL O O V M co 7 c ~ N N N O O f0 O c C _O C ° T d n(0 It w c n jx~ 1~1 OD M E 00 O N L •O O O D U O Z c Z In V O ~ w I I J ~ m R I € a I a m (L • ~ ad:~ ~ 1 A 0 a (O u • Parcel 038-1021-30-050 05/10/2005 03:57 PM PAGE 1 OF 1 Alt. Parcel M 4.31.18.89 038 - TOWN OF STAR PRAIRIE Current [X! ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner ALLEN G & CYNTHIA CAMPEAU CAMPEAU, ALLEN G & CYNTHIA 2311 100TH ST NEW RICHMOND WI 54017 Districts: SC = School SP = Special roperty Addr s(es * = Primary Type Dist # Description * 2311 100TH ST SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres. 35.050 Pat: N/A-NOT AVAILABLE SEC 4 T31 N RI 8W SW SW NW SW PT OF THE lock/Condo Bldg: W1/2 SW1/4 DESC AS COM SW COR SEC 4;TH 01 DEG E 390.50'POB;TH S 89 DEG E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 1324.09';TH N 01 DEG E 1154.44';TH N 89 04-31N-18W SW DEG W 1321.51';TH S 01 DEG W 1154.49'POB Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 901/110 07/23/1997 603/583 2005 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 10/13/2004 Description Class Acres Land Improv Total State Reason AGRICULTURAL G4 30.050 4,200 , 0 4,200 NO UNDEVELOPED G5 1.000 100 0 100 NO OTHER G7 4.000 35,000 125,100 160,100 NO Totals for 2005: General Property 35.050 39,300 125,100 164,400 Woodland 0.000 0 0 Totals for 2004: General Property 35.050 39,300 125,100 164,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 516 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 lee '70 11`/ -14 /OU ~ l I L 'A BENCHKARK: Elevation and description: 0 Alternate benchmark SEPTIC TANK:Manufacturer:--,-//~P_ Liquid Cap. Rings used:- Manhole cover elev:i4` `Final grade elev: Tank inlet elev.: Tank outlet elev.:- No. of feet from nearest road:Front , Side C, Rear Ft._ From nearest prop. line:Front , Side Rear Ft._ ~rg No. of feet from: Well Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: L, "=y dquid Capaci*" Pump Model: ?umpJSip4 Man, Pump Size -7 ofact. : Elevation of isle Bottom cad.ior °f tank eleva- Pump on elev.:Pump off elev.:- cycle: Gallons/ Switch Tr- Alarm: Man.: -Location ype: Distance from nearest prop. line: Rear Ft. • ront_, Side • ' Distance from: Well , ~luilding SOIL ABSORPTION SYSTEM Bed: Trench: Seepacle Pi Width:_„~_Length--S- _Number of Linet l Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to ton-4c pipe: No. feet If"rom' nearest prop. line:Front-,,Y, Side , Rear Ft i -No. feet from building No. feet from well: -7 6 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: Well , building , nearest road Alarm Manufacturer: INSPECTOR: DATE: PLUMBER ON JOB: LICENSE NUMBER: 6/90 : c j~ aim . t. f DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS 537 7 OFFICE OF DIVISION CODES & APPLICATION MS ~ ,ON Spa WI 4 i Spec . 4 , M-R18 Stassignel.D. Number CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Star Prai e loot S Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DA : Allen Cmau 21h St- New Richmand. WT BENCH MARK (Permanen reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. E i 5 L Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Kim A 0'Connell 3325 St- Croix ,-h 198745 SEPTIC TANK/"^' ^''r,..~~ Y vcr - 4, /0' . MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLETELEV.: / WARNING LABEL LOCKING COVER i PROVIDED: PROVIDED: ro 1/~~C' C((f / ~c 96 YES ❑NO ❑YES NO BEDDING: rNT'DIA.:, •V£fd'f-MATL.: HIGH WATER NUMBER O ROAD: PROPERTY WELL: PI LDING: VENT T FRESH C ALARM: FEET FROM LINE: / r JAIR IN E : YES NO ❑YES NO NEAREST >/GD o' MANUFACTURER: BEDDING: MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: YES [__1 NO ❑YES ❑ NO ❑YES ❑ NO 7' r I GAL S PER CYCLE: PUMP AND CONTROLS OPERA AL: NUMBER OF PROPERTY WELL: BUILDING: I VENT TO FRESH (DIFFERENCE BETWEEN T FROM LINE: AIR INLET: PUMP ON AND OFF E] YES ❑ NO NEAR 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~y CONVENTIONAL SYSTE 5 ~.~e th 92,8 BED/TRENCH WIDTH: L TH: 1140. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DIMENSIONS d GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DIST PIP M/YERIAL: NO. ISTR. NUMBER OF PROPERTY WELL: Z LDING: VENT TO FRESH BELO PIPES: ABOVE COVER: ELE INLET. EL ND: i PIPES: LINE: i r V FEET FROM t / AIR INLE ~g•_a~„ ~ ~~-~-a-a~a~ NEAREST-► >lU~ 35 ti MOUND SYSTEM: -r -7' s~ 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 ES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL CO R TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ N ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERALS CING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH AB VE COVER: DIMENSIONS TRENCHES: MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFO TERIAL: NO. DIST~JDISTR. PIPE DISTRIBUT N PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: MAN ELEV.: PIPES: : DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM 1-1 YES F-1 NO ❑YES F-1 NO LINE. NEAREST / N' Se.a~ ,c r~.C~-can r f c y 1 Grp a r,/ ' r E ~c r C c, e-~' ~yt/Yy1 /9C 1 K I . / c c o ....c, ° ~c}}Ge 7L~-&- KLd ~J C`~"C~) rG7Q ar7 ,G to / 'Lk C.~ Gr_L , - y) Lac '15 Sketch System ofi fn in county file for audit. Reverse Side. SIGNAT E: TITLE: / SBD-6710 (R. 06/88) ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CouN STATE SANITARY PERM -Attach complete plans (to the county copy only) for the system, on paper not less than /~j~Q~7C'"/ 8% x 11 inches in size. ❑ Chad c if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP OWNE PROPERTY LOCATION ~/a, S , N, R Q(o -AWAW PRO ERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Cl . ST E ZIP CODE PHONE NUMBER SUBDIVISIO NAME OR SM NUMBER JL 11. TYPE OF BUILDING: (Check one) ❑ State Owned O VILLAGE : NEAREST ROACy ❑ Public 1 or 2 Fam. Dwelling~# of bedrooms PAR EL TAX NUMBER() ^ fy5 III. BUILDING USE: (If building type is public, check all that apply) 0"3a b I -3 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 120 Service Station/Car Wash 5 ❑ Hotel/Motel 90 Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. W New 2.E] Replacement 3.E1 Replacement of 4.E1 Reconnection of 5.0 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 2. ABSORP. AREA 3. ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet 7, Feet VIi. TANK CAPACITY INFORMATION in allons Total of Manufacturer' Prefab. Site Fiber- Exper. L1 I ED] El New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the o site swage sys m shown on the attached plans. Plumb is Name (Print): Plu er' 16S ture: MP/MPRSW No.: Business Phone Number: 0 00, umb is Address (Street, City, State, Zip Code): IX. C /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue issuSta ) Approved El Owner Given initial surcharge Fee) Adverse Determination /%.f 0 v, 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. 11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'/ x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) APPLICATION FOR SANITARY PERMIT STC - 100 his application form is to be completed in full and signed by the owner(s) of the roperty 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 Akav 24 T4zf" Location of Property ~_k =Su> Section , T~N- R_ W Township Nailing Address -44 ,n Address of Site Subdivision Base Lot Number Previous Amer of Property / Yin j3 Total Size of Parcel Date Parcel was Created fun 9 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume- and Page Number 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (we) cer.UO that att Atatements on zhi-s oron aAe tAue to the best o6 my (oun) hnowtedge; that I (we) am (ane) .the owneh(,s 1 06 the phopehty deAci i.bed in •thiz in6olmati.on boron, by viAtue 06 a waAAanty d ed kecokded in the 06 ice o6 the Co mty RegiA teA o6 Deecti a~5 Document No. L) c and that I pAu en tty CRUn the pnopoaed b t to 6oh the sewage .digs o~5 a ye em (on I (we) have obtained an ea.aement, to /tun with the above deAcAibed paopenty, bon the eonetnucti.on o6 eai.d a y6 to m, and .the dame hae been duty keeo)tded .tn the 066ice o6 the County Reg,i.a.ten o6 Duda, Qa Doemen t No . ) SIGNATURE Op OWNER SIGNAT 0 CO-OWNER (IF PLICABLE) DATE SIGNED DATE SIGNED . 4 yJi s p_ ST. cO 4 t...- SRI rF D1 C ~X d 11 o., WI F i, at N 0 V 011989 12:30 PM LAND CONTRACT EXTENSION AGREEMENT C~n`C Register of Deeds Agreement made October 31, 1989, between Elaine Marilyn X rogstad, formerly Elaine Marilyn Lueck, also formerly Elaine Marilyn Johnson, individually and as the suviving joint tenant of Orville J. Lueck, deceased, of 8031 Neal Avenue North, City of Stillwater, County of Washington, State of Minnesota, herein referred to as Vendor, and Allen G. Campeau and Cynthia J. Campeau, husband and wife as martial survivorship property, of Route 2, Box 193, New Richmond, County of St. Croix, State of Wisconsin, herein referred to as Purchasers. The parties recite and declare that: a. Vendor is the owner of a certain Land Contract between Vendor and Purchaser dated November 1, 1979, and due on November 1, 1987• b. Such Land Contract was recorded on November 2, 1979, in the office of the Register of Deds of the County of St. Croix, in Vol. 603 at page 583, as Document No. 360916, and covers land in St. Croix County, Wisconsin, described as follows: The West one-half of the southwest Quarter of Section 4, Township 31 North, Range 18 West, except parcels heretofore sold for highway purposes, and subject to the easement to Northern Natural Gas Company recorded in Volume 385, page 468, Document No. 268874 in the Register of Deed's office for St. Croix County, Wisconsin. C. Said Land Contract was extended by a Land Contract Extension Agreement dated October 29, 1987 and recorded October 30, 1987, in Vol. 795, at Page 232, as Document no. 431624 in the Register of Deed's office for St. Croix County, Wisconsin. I d. On such Land Contract as extended there is owing the sum of Eighty-five thousand, three hundred fifty seven and 34/100 dollars ($85,357.34), with interest thereon at the rate of nine and one-half percent per annum from October 1, 1989. e. Vendor and Purchasers, for their mutual benefit, desire to extend the maturity date of said Land Contract until May 1, 1991. For the reasons set forth above and in consideration of the mutual convenants and promises of the parties hereto, Vendor and Purchasers convenant and agree as follows: 1. Extension of maturity date. In consideration of One and no/100 Dollars paid by Purchasers and other valuable consideration, the receipt of which is acknowledged, Vendor does hereby extend the time of payment of the principal indebtedness secured by such Land Contract to May 1, 1991, provided that Purchasers shall pay on the same payment schedule and at the same interest rate as set out in the original Land Contract. 2. Principal and interest payments. Purchasers, in consideration of the above extension and other valuable consideration, the receipt of which is acknowledged, shall continue to pay the principal sum and interest as set forth on or before the maturity thereof as hereby extended, and shall comply with the other terms of the Land Contract, except as modified herein. 3. Purchasers shall not transfer, sell or convey any legal or equitable interest in the property (by assignment of any of Purchaser's rights under this Contract or by option, long-term lease or in any other way) without the prior written consent of Vendor unless either the t 9VC! SJr5ParE 414 outstanding balance payable under this Contract is first paid in full or the interest conveyed is a pledge or assignment of Purchaser's interest under this Contract solely as security for an indebtedness of Purchaser. In the event of any such transfer, sale or conveyance without 'v'endors written consent, the entire outstanding balance payable under this Contract shall become immediately due and payable in full, at Vendor's option without notice. 4. Default period. The time period of default -hall remain at fifteen (15) days. 5. Prepayments. Prepayments will be accepted by Vendor after January 1, 1991. 6. Conflict of terms. When the terms and provisions contained in the Land Contract in any way conflict with the terms and provisions contained in the prior extension agreement or in this extension agreement, the terms and provisions contained in the prior extension agreement and in this extension agreement shall prevail, and as modified by the two extension agreements, the Land Contract is hereby ratified and confirmed. The failure or omission of either party to exercise, in one or more instances, any option given in either extension agreement or in the Land Contract, shall not be construed as a waiver or relinquishment of a right to such option in the case of any other default, but the right to such further option shall remain in full force and effect. 7. Binding effect of agreement. This agreement shall be binding on the heirs, executors, administrators, successors, and assigns of the respective parties. 855PAGE 4'75 IN WITNESS WHEREOF, the parties have executed this agreement at Hudson, Wisconsin the day and year first above written. Elaine Marilyn Krogstad Vendor - U~ - . . )A, O&A~ -0-" - - Allen G. Campeau, Fur aser y thin J Campea , Purchaser STATE OF WISCONSIN ) ss ST. CROIX COUNT ) Personally came before me this 31st day of October, 1989, the above named Allen G. Campeau and Cynthia J. Campeau, his wife, and Elaine Marilyn Krogstad to me known otdib EC t e persons who executed the foregoing instrument and J :'adkftov~ d d he same. • TA \o' ' r win, Notary Public 9l tat .....1o ,.Isconsin, St. Croix County F~Ipyw'g~on is permanent This instrument drafted by: Hugh H. Gwin, Attorney at Law Gwin & Gwin 430 Second Street Hudson, Wisconsin 54016 . z • cn H a ST C- 105 r" r a H SEPTIC TANK MAINTENANCE AGREEMENT ~_4 St. Croix County z a a OWNER/BUYER ROUTE/BOX NUMBER_~Z': 2Q~ Fire Number CITY/STATE Zal~ It t z I P 7 PROPERTY LOCATION:^S& 'j ;4, _<7jd_1k, Section , T N, RW, Town of St. Croix County, Subdivision 4~Z 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. 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. Ho I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- ro 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. SIGNED DATE to 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. DEPARTMENT 'V: OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS lN'DUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 HUMAN RELATIONS N WI 53707 (H63.090) & Chapter 145.045) LOCATION: SEC ON: u r TOWNSHIP/ LOT 0.:BLK. O.: SUBDIV SIGN NAME: -Std )/4 ' T /TS N/ g E (or COUNTY: OW ER'S BU ER'S NAME: MAI ING ADDRESS: '4 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMER IAL DESCRIPTION: PROFI E D RIP IONS: E LATION TESTS: Residence ,New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system r ONVENTIONAL: MOUND: IN-GROUNDPRESSURE: S STEM-IN-FILL HOLDING TANK: RECOMMENDE SYSTEM: (optional) S DU ®S DU S ❑U ❑S ®U ❑S [ZU If Percolation Tests are NOT required DESIG RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: nee 10i;r PROFILE DESCRIPTIONS BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF IL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 1gJ, ELEVATION OBSERVED EST- GHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B--fKl -41 4 -?Z 3 B- 70 7 ? B- _ ? k;7 B_ B- ,'o 9x -IVA B- / PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER WR}124 AFTERSWELLING INTERVAL-MIN. PERT 1 PER 2 PIER 100 3 PER INCH P-_?9 A1,9A1Z 142 P- 9 1119 '4 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. SYSTEM ELEVATION ( J'V" i I i t----_.. - 1 _T I ` J I, th undersigne ereby ce ify that the soil tests reported on this form were made b me in accord with t e roced es and methods specified in the Wisconsin A he data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (prin TESTS WERE COMPLETED ON: f~ )A" Z/ AD - CERTIFICATIOAI NUMBER: IPHONE NUMBER (optional): his CS N URE: I/ 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 complete and accurate soil test, your report must inclUd'e: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 1 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; 0. 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; S. 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- th if )propriate; 10. 'r -mation (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. S, )rm and place your current address and your certification number; 12. M I, ible 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 cs Coarse Sand Pere - Percolation Rate med s - Medium Sand W - Well fs Fine Sand Bldg - Building Is Loamy Sand > - Greater Than sl - Sandy Loam < - Less Than *I - Loam 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 wr - with sic - Silty Clay fff few, fine, faint c Clay cc; - common, coarse pt Peat mrn -(Many, roedium ~m - Muck d - distinct p - prominent HWL - High water level, Six general soil textures surface water for liquid waste disposal BM Bench Mark VRP - Vertical Reference Point TO TIC' Thy ` in scf- r --nitary permit. The county or the Department may request v -"I ;.i the field to permit issuance. A complete set of plans for the private ~rmit application n- submitted to the appropriate local authority in order to sanitary permit: must I ` and posted prior to the start of any construction. • , ~~l ~.tl ~~i/J/ ,~i9t~ ~.S'k~ ~S,r..G ~j ~~//1l j ~~1~ l/ OD t ~f 5~~~ ~'ir" Ilk Jt- S) - i~~ ~~a f PAGE OF C.ro Szc~1011 0~ Sys e0 fmh Alf Willi, And OD6hfvollon Plpo Ark Approria Vsnl top Illnlmum 12' Above i final Good. Al, 20- 4 2' Above Pip' 4" Cast lion To final Orada Vent Pipe Maim hot 01 SymAeik Cove'iny win 2' Ayy#oyol6 ' Ore( Pipe Dlell lDullan - Tao 0 0 0 Appiopalo o Beneath Plpo Perlosolea Plya below o -CorplIng Tewminollny Al Bottom Of system 5-1400A ion + SOIL FILL DISTRIBUT101.1 PIPE APPROVED $y►,ITI{ETIC COVER ` "MATER14 OR 4" OF STRAW 2- OF AGGREGATE OR MARSH "A,-J Ie0F. Z/2 AGGREGATE ~p IFP ELEV. OFl a~.s FEES'-.. 00 DIS-1"RBg1JT10M PIPE TO BE AT LEAST 'Mr-HE5 BELOW ORIGILIAL GRADE AQU AT LEAST t0 IUCHE.r, BUT 1.10 MORE THA, J tit IAICHES OELOW FINAL GRADE MAXIMUM ©EPrM OF F-1KAVAT100 FK011 OK16VJAL 69AK WILL BE MCHES MKIMUM MPT)i OF EACAVAT100 r-ROM CA~164JAL. C3RADE WILL BE It`]cHEs SIGI.ICD: LICEQSC I.JUMBER: - DATE: 110