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HomeMy WebLinkAbout038-1060-80-000 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ! d d y+ TOWNSHIP ~~it°~ ~'rl ; rr c SEC. T,7/ N-R /"_W T ADDRESS iL/,/'o?G ST. CROIX COUNTY, WISCONSIN r ~y /'arhr ~ SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~p U `L- 6r Ai s ~ INDICATE NORTH ARROW c ~ BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: /dO Proposed slope at site: SEPTIC TANK: Manufacturer: ~e.e /I S Liquid Capacity: ~z9o_ Number of rings used: Tank manhole cover elevation: '7 Tank Inlet Elevation:&Nl3-Tank Outlet Elevation: J;G- "",5 Number of feet from nearest Road: Front, Side, Rear, O e--v feet From nearest-property line Front .0 Side,(DRear, 0 feet Number of feet from: well, building: do? (Include this information of the 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 Manufacturers Alarm Switch Type: eNumber of feet from-nearest property line:'. Front, OSide, ORear,© Ft._.,_,_ 'Number of feet from well: Number of feet from building:_ (Include distances on plot plan). SOIL ABSORPTION~SYSTEM - Bed: Trench: Width: f < _ Len$th:_-,-/-5Z .-Number of Lines: Area Built: ~s Fill depth to top of pipe: 24 .S- Number of feet f m nearest property line: Front,f O Side, 0 Rear,O It {Number of feet from well: 4; l N111 ber of feet from building: (Include di Lances 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 sytems4 (C eck 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 : Inspector:.. Dated: Plumber on job: License Number: / 3/84:mj 1; . H ~ I o c ~ I Q) I ~ I co N i N 1 'n aa) m 0 0 c Z c ci c o 0 3 ¢ -0v I M aa) Z yj co E Z v ? I Z ~ y y I CL o o z -V c v w. fY r ~ v ° c o N z z c ~ -o I Cl) f0 N I N N CD NQ N •WAWA (D 0O a L I o 4) ¢ O N zco z z I C12 E N c a r C a C o c LO .9 w ¢ Z - O frn fA fA w WSJ O U33 Z 2 CL CL IL a N a g Z o o N V rn rn Z i 6i a N 4-- 00 Y M M = 0 E co O O N a (n m N c N N N p o c9 7 O W U> O CO Fem. N o N C) IT V N N O co w 'm 1 0) ° c a~ o c r. 5! CL Q) y n v H r- CD ~ 00 M lf> 0 Lo O E RS C y~ra O f/~ U) .M-- O Z N Z: (n Q co r V~ Y .a a `IV +r a 4) m a rw a~ = Y t A c0 ~ IL 0 V) V Parcel 038-1060-80-000 02/17/2006 11:02 AM PAGE 1 OF 1 Alt. Parcel 15.31.18.264B 038 - TOWN OF STAR PRAIRIE Current X I 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 0 - STACKEN, JOSEPH M & CHERYL M JOSEPH M & CHERYL M STACKEN 2196 GOOSE LAKE RD NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 2196 GOOSE LAKE RD SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 3.830 Plat: N/A-NOT AVAILABLE SEC 15 T31 N R1 8W 3.83AC NE NW LOT 1 OF Block/Condo Bldg: CSM 5/1290 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 15-31N-18W Notes: ' 12 Parcel History: Date Doc # Vol/Page Type Z 07/23/1997 1180/224 WD 07/23/1997 842/12 07/23/1997 799/25 07/23/1997 T~ 1757 sed`with: 2005 SUMMARY Bill Fair Market Value: Asses 119055 225,600 Valuations: Last Changed: 10/13/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.830 41,200 180,500 221,700 NO Totals for 2005: General Property 3.830 41,200 180,500 221,700 Woodland 0.000 0 0 Totals for 2004: General Property 3.830 41,200 180,500 221,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 136 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 t 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 MADISON, WI 53707 1 State LIE 4, _~t4 4, Sec • 15 , T31-R18 (Ifa sP Number: gned) & NVENTIONAL El ALTERATIVE Town of Star Prairie oft CO ~O Hol Ing Tank ❑ In-Ground Pressure ❑ Mound A E H [A;_DDRESS OF PERMIT HOLDER: INSPECTION DATE: Jody Speer t.1, Box 265, Star Prairie, WI o~ BENCH MARK (Permanent r ere rev point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PZL4 CST RREE 916, /'0' Cl i F. PST.. N~i Name of Plumber MP/MPRSW No.: !county- - Sanitary Permit Number: Bvron i.rd Jr. 3318 St. Croix 135449 SEPTIC TANK/ 8/ to a eo = 97, 7. MANUFACTURER: LIQUID CAPACITY: TANK INLET E TANK OUTLET WARNING LABEL LOCKING CC&F. PROVIDED: PROVIDED: LL77 LCD -C 95, S.SI YES ❑ NO ❑ YES 21 NO BEDDING: VENT- DIA.: VEF}T MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY' WELL: BUILDING: VENT TO FRESH r-, O, n. ALARM: FEET FROM LINE: I AIR INLET: ❑ YES NO - ❑ YES NO NEAREST-► S6 IL, (03 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: JPUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ 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 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue. CONVENTIONAL SYSTEM BED/TRENCH WIDTH: LE NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID DIMENSIONS /!l S Z TRENCHES: / MATERIaA~ PIT DEPTH: GRAVEL DEPTH FILL DEPTH DISTR' PJIPE DISTR. PIPE DISTR. PIPE MATERIAL: DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW/ PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: , 6a , 6000.. PIPES: LINE: AIR INLET: & t .30„ 35 it Q y i FEET FROM 3 NEAREST ~ 51 I1n, ~O~ 3(1'1 >-V)5' MOUND SYSTEM: r x z Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST ain in county file for audit. Sketch System on Reverse Side. aSIGNAT TITLE: SBD-6710 (R. 06/88) d' Y7 5 SANITARY PERMIT APPLICATION ILHR In accord with ILHR 83.05, Wis. Adm. Code couNTY STA SANITARY PERMIT#1 -Attach complete plans (to the county copy only) for the system, on paper not less than E] ~ 8'f1 x 11 inches in size. ch k re ion to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER OWNE PROPERTY LOCATION p c '/4 %4, S T , N, R E (or PROPERTY OWNE S MAILI ADDRESS . OT # BLOCK zy- CI STA E ZIP CODE PHONE NUMBER SUBDIVISION AME OR CSM NUMBER ) State Owned VILLAGE CITY ArG NEAREST ROAD II. TYPE OF BUILDING: (Check one ❑ Public [&or 2 Fam. Dwelling- # of bedrooms A LTAX NUMBER( ) III. BUILDING USE: (If building type is public, check all that apply) t 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash 50 Hotel/Motel 9 ❑ Off ice/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 B 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 140 System-.In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6IWFeet EV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION --Q I q14117_ Feet VII. TANK CAPACITY Prefab. Site in allons Total # of Manufacturer's Name Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks oncret structed glass App' Tanks Tanks Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber' Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plum s Address (Street, City, State, Zip Code): f!7 ''CY' o Z,7- f;z IX. COON /DEPAR MENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes G oundwater Date Issued Issuing Agent Signature (No Stamps) Approved El owner Given initial surcharge Fee) Adverse Determination / ~ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber C 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. 111. 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 This application form is to be completed in full and signed by the ownet(s) of the property being developed. Any Inadequacies will only result In delays of the permit issuance. Should this development be intended got resale by owner/contcactoc,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Ownet of property JoD\~ K- Location of property t=1/4 /4, Section 1 T-211-11-RIC?-Y Township 57'Pr✓L P Ai (Z i 'r- -"ailing address Oft *wtw O W g32 yam" -~>a _p 1_%Cx_\ vC0g, W 5g01:j Address of site 0116 6ao!56, aim N6W ACAMoO W1 5gol7 Subdivision name C5M 5 - 1250 Lot number _ Previous owner of property - tit &",L, U-jt, ( tom Total size of parcel 3.831° Date parcel was coated Ace all corners and lot lines identifiable? )e ON 0 Is this property being developed for resale fapec house)? as Y Ko Volume 54 'L- and Page Number as recorded with the Register of Deeds. a----------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DIED which Includes a DOCUMENT NUMBRR, VOLUME AND PACE NVMaER, and the ORAL OF THE RRGIBTRR OF DREDS. 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 Certifled 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 (out) Rnowledgel that I (we) am (are) the owner(s) of the property described In this information lotm, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. jy 8 Zlo`t • f and that t (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above descrlbed property, for the construction of said system, and the same has been duly recorded In the office of the County giater of Deeds, as Document No. _gjfrU;7 >rlq at to o owner Signature of Co-owner (If Applicable) Date of signature Date of Signature 13140cat 448 1961 642PAGE 12 PW I of 2 269 LIMITED W J . A►RRANTY DEED THIS INDENTURE, made this day of 19 , between Farm Credit Bank of St . Paul; f /k/a The Federal Land Bank of St. Pau a federally chartered corporation, with a post office address of REGISTER'S OFFICE P.O. Box 136, Amery, WI 54001 ST. CROIX CO., WI party of the first part, and Jody K. Speer, a sin e Recd for Record -person MAY 3 01989 Gf 10 00 AM whose post office address is Route 1, BOX 2 5, Star Prairie WI 54026 Register of Dee6 party of the second part, (hereinafter referred to as party whether singular or plural), WITNESSETH, that the said party of the first part, for and in consideration of the sum of FOUr ThOusand Nine Hued red arrd no / 100 DOLLARS, (a 4,_00.00 to it paid by the said party of the second part, the receipt whereof is hereby acknowledged, does grant, bargain, sell, and convey unto the said party of the second part, his/her/their heirs, successors and assigns forever, the following described real estate, situated in the County of St. Croix Recording Information and State of Wisconsin ' to-wit: Part of the NE4 of the NW4 of Section 15, T31 N, R18W described as follows : Lot 1 of Certified Survey Map filed May 26, 1983 in Volume 5, page 1290 (no. 7) The above parcel contains 3.836 acres including road easement. This deed is given in fulfillment of a Land Contract by and between the parties hereto dated December 10, 1987. This conveyance is exempt from the state deed transfer tax pursuant to W.S.A. 77.25(2) of the Wisconsin Statutes. ALA- ~.I ~.1! ~I,! ,T 1 f subject to all existing easements and rights of way; also subjcct to all taxes on said premises for the year 19 88 and following years; also subject to all unpaid parts and installments of special assessments on said premises which have fallen due, or will fall due hereafter. EXCLUDING therefrom and excepting and reserving to said party T heretofore reserved or excepted of record by The Federal Land Bank of Sait first prior o' January 22,y1986, if any, with interests, such easements titles ingress, egress and use of surface as may be incidental or necessary to use of such rights. The foregoing exclusion, exception and reservation shall include, but not be limited to, all oil, gas, hydrocarbons, coal and other minerals of whatsoever nature lying in or under the above- described lands and all royalty interests as to oil, gas and other minerals produced and saved therefrom. It is expressly understood that the said party of the first part will make no warranty as to the extent of its ownership of minerals, or as to its title thereto. TOGETHER with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all estate, ' right, title, interest, claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. TO HAVE AND TO HOLD the said premises as above described, with the hereditamenis and appurtenances unto the said party of the ' second part, and to his/her/their heirs, successors and assigns FOREVER. AND THE SAID party of the first part, for itself and its successors, does covenant, grant, bargain and agree to and with the said party of the second part, his/her/their heirs, successors and assigns, against all and every person or persons lawfully claiming the whole or any part thereof, by, through or under said party of the first part, and none other, it will, forever WARRANT and DEFEND. J /;.sr. I, tl rST1' • e::•'.i.•? _ _ •apVe Y, • r. . Y~r.'-. ...d NS'~.5. th ..yt". i!1.i• ~~,.~F.ii,:•`'l Ne A 13140 (B) Svc! 842pasE 13 . hp2of2 IN WITNESS WHEREOF, the said party of the first part, has caused these presents to be executed in its corporate name the day and year first above written. WI TNESSESS: FARM CREDIT BANK OF ST. PAUL By: Melvin L. Pearson Regional Vice Pres. Mane) critic) of the Federal Land Bank Association of Northwest Wisconsin Acting as Attorney-in-fact for Farm Credit Bank of St. Paul. OR: PRODUCTION CREDIT ASSOCIATION OF By: (Name) (ride) STATE OF Wisconsin . COUNTY C ' Polk ss } Its W May 24, 1989 The foregoing instrument was acknowledged before me on (Due) Melvin L. Pearson Regional Vice President by of the Federal•'}.andi:B?nk Association (Nam) (Tide) of Northwest Wisconsin as Attorney-in-fact on behalf of'1irgr CrcdlCbank* or $t. Pau). JIlof, October 27, 1991 My commission expires NOTARY PUBLIC istine r''•j3reault Polk Wisconsin County State STATE OF 1 ss. COUNTY OF ) The foregoing instrument was acknowledged before the on (Date) By of the Production Credit Association of (Name) (rite) on behalf of said corporation. My commission expires NOTARY PUBLIC County State This instrument was drafted by: Farm Credit Services of NW WI (KB) S I P .O. Box 136 Amery, WI 54001 .v ) y STC - 105 c~ SEPTIC TANK MAINTENANCE AGREEMENT w St. Croix County w OWNER/BUYER ~Ob~ JQ iL n T p ROUTE/BOX NUMBER_' '~~'2 Np 5tbg5; LZ%ja Fire Number :J d CITY/ STATE OaJ f? e*82N {1 44\ ZIP Z. r PROPERTY LOCATION:'_ NW k, Section T__14_N, RJ.& W, Town of ~~*p_ p2j AiS St. Croix County, 9 0 , Lot number Subdivision CS^ 5 -12 Improper-use and maintenance of your 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 'septic tank pumper. What you put into the system can affect the unction of t e-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, whl- 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 'sys't'ems 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 o to maintain the private sewage disposal system in accordance with 9 the standards set forth, herein, as set by the Wisconsin Depart- W ment of Natural Resources, Certification form must be completed H' and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office 911 4th St. Hudson, WI 54016. 386-4680 Sign, date and return to the above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS 'INDUSTRY DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: OWNSHIP MUNICIPALITY: OT.NO.:BLK. NO.: SUBDIVISION NAME: 1/ 1/ /T N/R E (O -ir it COUNTY: MAILING ADDRESS: 5'1<G.~a See a~ ~a C_ -oaf USE ool DATES OBSERVATIONS MAD G -6 NO. BEDRMS.: COMMERCIAL DESCRIPTION: X New TESTS: $Residence te>1New ❑Replace 0;z Y: RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) 9S sau sou Os u 0 s50 If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- c 7 Y B- e B- p h ? 1Y B- 7 e~ ,..,r• 7 Q O ~S - l$'Gy.~ ACS JW ;,a '2 B- PERCOLATION TESTS } EST DEPTH , WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES f NUMBER WJOWC-S AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 PERIOD PER INCH P_ el 3 ~t P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at a l l 'bo~/rriinngs and the direction and percent of land slope. Gam. SYS EM ELEVATION 70 o Von , - I E I l TH E ~ E ,ao , i , i -C 0y i t i ~I r f ~ 3 a L___ a - L...- 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in..accord with the procedufs and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best af, my knowledggatid belief. NAME (print): TESTS WERE COMPLETED ON: ADDRESS'/ CERTIFICATION NUMBE PHONE NUMBER (optional): r / CF 7 ~ l CS SI AT E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - 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 scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well is - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand < - Less Than '1 - Loam Bn - Brown 'sit - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay Ill - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. II, s, 42- o 67 7-0 f I 1~ ~ I 45 1 1 otY r ~ 4 ~ r., `'U ~ V 0 rr~~0 V c~ ii bit b ~l 5 ~5