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HomeMy WebLinkAbout038-1120-20-120 ~ o ~33i o I ~ d I O I N ~ i a~ I o a o I ~ I ~ I I 0 N I M ii I ~ i, I 0 e I ti I c I 3 P I ayi ~ I z° I LL c E I o w 3 ~ ~ I Q ~ I I M I v ~ ~ I 3 W ! Z E I o Z I m N H a 0 I o z c I m z E o v) I- 4' N Z c v I - E ~ M ~ w ~ G1 7 I ~"~J I C ~ I u=i a y 1 a d fn d O i L I ' o Q z° m z N ° c c I O N V N O LA R 01 - d C t~ d •a a 9 c ~ N Q O C h N M ~ E r r r O Z N > - O al m tOOO z~ I~ a o N d o 0 NJV li 0 z I I ' c O N O I Q O O .0 I = O C m N C a p OI ON1 N N N w d - p ~i LO 7 a~ I C E fC h H ..r O O i 0 H c m 92 Lm C C = N OD F- Yi O O ~ O Q o rn ) a~ a$ o I r a U p N N V o C W N N 7 W y N 0 0 d~ I M a 0i ~ ~ c W o f • rabi of CO O~ Z y E E O N fA fn O -7 I O sk a € CL I eat, • a _ 0 ~r`wiv a E ° c " I _1 A 0 IL o3 vi ci Parcel 038-1120-20-120 01/31/2007 10:23 AM PAGE 1 OF 1 Alt. Parcel 29.31.18.497B20 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): O = Current Owner, C = Current Co-owner O - DILTS, TODD D TODD D DILTS 965 192ND AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 965 192ND AVE SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 2.001 Plat: N/A-NOT AVAILABLE SEC 29 T31 N R1 8W PT SW SE LOT 2 CSM Block/Condo Bldg: 8/2191 2.001AC Tract(s): (Sec-Twn-Rng 401/4 1601/4) 29-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1128/370 WD 07/23/1997 865/114 2006 SUMMARY Bill Fair Market Value: Assessed with: 175722 175,000 Valuations: Last Changed: 10/15/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.001 32,000 122,700 154,700 NO Totals for 2006: General Property 2.001 32,000 122,700 154,700 Woodland 0.000 0 0 Totals for 2005: ~ General Property 2.001 32,000 122,700 154,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 133 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 038-1120-20-000 01/31/2007 10:20 AM PAGE 1 OF 1 Alt. Parcel M 29.31.18.497 038 - 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): O = Current Owner, C = Current Co-Owner O - DILTS, TODD D TODD D DILTS 965 192ND AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description ' 963 192ND AVE SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 1.410 Plat: N/A-NOT AVAILABLE SEC 29 T31N R1 8W PT SW SE BEING LOT 3 Block/Condo Bldg: CSM 11/3203 1.41 AC Tract(s): (Sec-Twn-Rng 401/4 1601/4) 29-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 07/16/2002 684282 1928/118 WD 03/16/2000 619696 1495/606 QC 07/23/1997 1234/14 WD 07/23/1997 1128/477 LC more 2006 SUMMARY Bill Fair Market Value: Assessed with: 175718 31,600 Valuations: Last Changed: 10/15/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.410 27,900 0 27,900 NO Totals for 2006: General Property 1.410 27,900 0 27,900 Woodland 0.000 0 0 Totals for 2005: General Property 1.410 27,900 0 27,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form -3TC- 106 AS BUILT SANITARY SYSTEM REPORT "OHNER'r ' (q In a. L9 P TOWNSHIP • fr~ SEC. T f N-R W . ADDRESS _17~ ~~y A1tw ST. CROIX COUNTY, WISCONSIN SUBDIVISION - LOT LOT SIZE _ PLAN VIEW Distances and dimensions to meet requirements of t'!HF. 83• SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ,0` i 1 , • . , gyp. ~D Ks 11 ;Xsh Lr • r r INDICATE NORTH ARROW ' BENCMUM: Describe the vertical reference point used O • ..r... , _~~J4 t, Elevation of vertical reference points /f D Proposed slope at site: SEPTIC TANKS Manufacturers tt _ Liquid Capacity: l ea Qa I"Numbee of rings useds hb&4Tank manhole cover elevation: Tank Inlet Ele6apions Tank Outlet Elevation: Number of feet from nearest Road: Front QSide~ Rear, Ofeet • From nearest-property line : ront,OSide, Rear, 0 feet AA Number of feet fromi well D~~'; building: " (Include this information of ..the above plot plan)( 2 reference dimensions to septic tank) I 4• SEE, REVERSE SIDE PUMP CHAMBER Manufacturer:_ Liquid Capacity: -'.Pump Model: Pump/Siphon Manufacturer: Pump Sise Elevation of inlet: Bottom of tank elevations Pump off switch elevation: Gallons per cycle: Alarm Manufacturers Alarm Switch Types •Number of feet from:nearest property lineif Front► O Side► O Rear, O Ft. `Number of feet from well: Number of feet from building: (Include diatances.on plot plan). SOIL ABSORPTION•SYSTEH: Bdd:-• Trench: n Width: ~•r~! • • Length: • ~ 3. .••Number of Lines: X`Built:~~_ Fill depth to top of pipes Number of feet f fm nearest property line: Front, O Side, Rear,O Ft.~_ Number of feat from wells q e-- N or of feat from building: (Include di lances on loot la-nI. SEEPAGE PIT Size: Number of pits: Diameters 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 (deck one). HOLDING TANK Manufacturers Capacity: Number of'.rings used:. Elevation of bottom of tank: • Elevation of inlet: Number of feet from.neareat property lines Front, O Side, O Rear, Opt. ..Number of feet from well: Number of feet from building: Number of feet from.nearest road: Alarm Manufacturer: X~ • ~a Inspector Dated: G o?6 - 9p Plumber •on Jobs License Number: 3/84:nij as a 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 State Plan I.D. Number: SW 4i SE 4, Sec. 29,T31-R18 El CONVENTIONAL ❑ ALTERATIVE (It assigned) Town of Star Prai-qlp 1 Q9 Ave. I~I Holding Tank ❑ In-Ground Pressure El mound -NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTI N A : Craig Schauer 198A Rt.4, New Richmond, Wi 6-)6-90 11s36 BENCH MARK (Permanent reference point){ DESCRIBE IF7DIFFERENT yFROM PLA 1 y / REF. PT. ELEV.: CST REF. PT. ELEV.: 9 Name of lumber: MP/MPRR SWgo.: C nty: Sanitary Permit 135492ber: Byron Bird Jr. 31 Croix SEPTIC TANK/HOLDING TANK: MANUFACTURE LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER a p PROVIDD: PROVDED: e S 16 d ES ❑ NO ❑ YES 2-60 BEDDING: VENT DIA: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH . ALARM: FEET FROM ~J c LINE: !l AIR INLET: ❑ YES E140 / l/L ❑ YES 0 NEAREST / ✓ V DOSING CHAMBER: EL: ,4MP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP OD PROVIDED: PROV DIED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: CONTR LS ERA IONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF 7v/E] E ❑ NO NEAREST ~ I SOIL ABSORPTION SYSTEM. Check the soil , ure 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 TRENCHES: MATERIAEFEETFROM DEPTH: DIMENSIONS ~z S 3 / GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. TRPROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: EV. END: PIPES: LINE: A NL, s I S Z -,>,3E 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; E:1 YES ❑ NO [__1 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---- t D,~ K (r Retain in county file for audit. Sketch System on Reverse Side. SIGNATUR TITLE: SBD-6710 (R. 06/88) DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY w STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ! o~ C~(~~ 8% x 11 inches in size. ❑ Check if revision u 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 cjl~ f k V_ &A/4 W%4, S T ; N, R (Or PROPERTY OWNER AILING ADDRESS LOT # BLOCK # CITY, STATE// 9 , ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER lkJ IQ G/IiKO Gl/ - a ~ -s~L II. TYPE OF BUILDING: (Check one) ❑ State Owned VI AGE ; 510,c NEAREST ROAD IXIIQWN W: 44 5;,.7 ❑ Public -#~ofbedrooms PARCEL A NUMBER(S) 11.1 or 2 Fam. Dwelling 'rr`- f~aCJ~aO- v III. BUILDING USE: (If building type is public, check all that apply) 10 Apt/Condo 2 ❑ Assembly Hall 60 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 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 9 New 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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 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 (s q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION ,j 0 ig~ l 7 6 0'17 f ~ Feet ZOO Feet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istIn Gallons Tanks Concrete glass App. Tanks Tanks structed Se tic Tank or Holdin Tank GC> - s Lift Pum Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): / Plumber' Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Az4_ Plum er' dress (Street, City, State, Zip Code): /J't QT !N / O IX. COUNTY/DEP RTME USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing Agent Signature (No Stamps) ~ Approved ❑ Owner Given Initial - Surcharge Fee) Adverse /V rmin lion 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 ran Y P Y e o ewal 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 lumber requires a Sanitary Permit Transfer/ Renewal Form SBD 6399) t P P Y ( 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. Vlll. 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'f 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. s, The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) i r . APPLICATION FOR SANITARY PERMIT 3TC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit Issuance. -Should this development be intended tot tessle by owner/contcactot,(spee 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. Ownac of property S~C ELK Location of property Lsa_ /4 _SE /4, section Township S~G~,- Mailing address t--) Address of site r P BUMIvlslon name Lot number Previous owner of property ~Q4. 6 V Total else of parcel Date parcel was created - Are all cornets and lot lines identifiable? /.Z-Yes = o is this peopetty being developed for resale ('spec house)? as P0 Volewe ~~_~and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION TITS FOLLOWINCt A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAC! NVMsZR, and the REAL OF THR RECI8TER OF DEEDS. In addltlon, a certl1led survey, If available, would be helpful so as to avoid delays of the reviewing process. it the deed description references to a Cet:tlfled Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION 1(ve) certlfy that all statements on this form are true to the best of my (out) knowledge; that I (we) am (ate) the owner(s) of the property described In this Information form, by virtue of a warranty _deed recorded In the Office of the County Register of Deeds as Document No. lfS'Gy6?, • i and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to tun with the above described property, got the consttuctlon of sold system, and the same has be n y recorded In the Office of the County lReglatet of Deeds, as Document a 6 No* ! gnat a of owner signature of co-owner (If Applicable) 422"_ Date Ignatute D Date of Signature _ _ - - - = WARRANTY DEED THIS SPACE Rfs[RVttO FOR RECORDING DATA DOCUMENT NO. 11 STATE BAR OF WISCONSIN FORM 2 -1982 4,56463 v r,,. 865 PASE REGISTER'S OFFICE ST. CROIX 00., WI j o d u nd ..Ra7.ph..B.x... WadOlt...slld..MaXY...~:...~`.?..)?...4~:.~_..~...~~~........... Reed for ReC01'+d ...and...wife-•-as...jair t..t,enants at MAR 07 190 M 11' 15 A~ ..............................................................................._.................rt. ~Orof conveys and warrants to ..Craig.. chauer and. Mary__ A..__•___ • ~Arr''+sU~JC I ...S ~chaues t..hllsband...and.. ~rt~~e.,...as...max.~.tal..1?x9P. ~ ....Y p~ ii - ...with..r_ hts...ol..surva.varsh RETURN TO ,I the following described real estate in 5t-....CrolX ....................County, State of Wisconsin: i i Tax Parcel No: I I Lot Two (2) of Certified Survey Map, filed February 27, 1990 in Volume "8" of Certified Survey Maps, page 2191, as Document jl ii No. 456198, being a part of the Southwest Quarter of the South- east Quarter (SW4 of SEk) of Section Twenty-nine (29), Township I Thirty-one (31) North, of Range Eighteen (18) Jest. I. l SAL I I i This not homestead property. i (is) (is not) ~i I, Exception to warranties: j March Dated this 6th day of 19...90.. QQ ..yyam], 5 /J~ (SEAL) sU~../_l? 6t ..............(SEAL) i • _kZa].ph.. /4 (SEAL) X'; z_on BZ ..............(SEAL) II Mary IC. Mondor I AUTHENTICATION ACKNOWLEDGMENT I! I; ~I Signature(s) STATE OF WISCONSIN i 1 as. I! i . YOi County. authenticated this day of 19...... Personally came before me this ...6t! day of ! March 19. 29. the above named i! . Ralph S. Mondor and Marv K Mondor I a TITLE: MEMBER STATE BAR OF WISCONSIN (If not- j authorized by $ 706.06. Wis. 3tata.) to me known to be the person 5.......... who executed the i fore g instrume and.lsclFn~wIedge the acme. ~I THIS INSTRUMENT WAS DRAFTED BY t ` +I Reinstra.s Van Dyk & Needham, S.C. " s - - - *Ruth A on j j 201 South Knowles Avenue, Box ..1:27 i N.ew--_Richmon.d-,...WZ..... r1-4A1.7 Notary Publi ~ St,....Craix. ......County, Wis. ij (Signatures may be authenticated or acknowledged. Both My Commiss 6t~rmanent. (If`~i state expiration I~ are not necessary.) 1 2' ~C date:.... 1.Z - 19......... ) l: = r f -Names of persons si[nine in any capacity should be typed or printed below their si[natures. - li J STATE BAR OF WISCONSIN i~lwcrnsier FORM No. 2 - 1982 Stock No. 13002 SEPTIC TANK MAINTENANCE AGREEMENT rt St. Croix County r-~ \ 1 w OWNER/ BUYER o ROUTE/BOX NUMBER Fire Number d CITY/ STATE ZIP 3 -y/ J rt PROPERTY LOCATION: JW k, Section,l T _N, R_ 9W, Town of N(~f 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 'se tic tank um er. What you put into the system can alTect tze function o 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 .s'ys'tems 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 9 the standards set forth, herein, as set by the Wisconsin Depart- ~r 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 /~i 5 ✓ ~`'G"~ DATE J y St. Croix County Zoning Office /J 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. DEPARTMENT OP REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISO N, WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: • SECTION: NSHI MUNICIPALITY: OT NO.: BLK. NO.: SUBDIVISION NAME: _f!! /T H/R~ (o OU T MAILING ADDRESS: ~CG~OC `1~.~'rp of reA /1u"e f USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: ST . Residence MNew ❑Replace 7-- RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) SS❑u ©S au OS EA EISOu oS®u If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. I LHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: /-~o PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. I HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- p --6 G n ~ o B- a 9or~` Ale, --p- 7 B- ~p Ale d 6 S, 6- 6 n - Ste-, B- ~ 7a? 0 --e_ ; dZ B- PERCOLATION TESTS TEST DEPTH . WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES } f NUMBER RJOWeS AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D P R PER INCH T-< G P- 4.1 P- a dk~ 07 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. ~ C ( ~ g SYSTEM ELE"TION. ~,2A,_ yip' l ~ ~ E 3 3 t 90 JIe' 'or _ N _ 1. ~ y F- . 3 i 3 ' t I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified i e isconsin 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): r TESTS WERE COMPLETED ON: ADDRESS: r CERTIFICATION NUMBE : PHONE NUMBER (optional): T ~n fir- 1z,/< S ~e 7 - CST SIG U E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. ,ILHR-SBD-6395 (R. 10183) - OVER - 1 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 fs - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand 'c - Less Than '1 - Loam Bn - Brown 'sil - 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. it 9 FLUt PLAN PRO JE C T ADDRESS f~4f G'f~/ 7 w 1/4~ 1 /4/ d2y/T 3j N/R l~W TOWNS f/,. COUNTY T: r cam. PRS Byron Bird Jr. 3318 DATE - BEDROOM- CLASS PERC CONVENTIONAL, IN-GROU PRESSURE CONVENTIQNAL LIFT MOUND_ HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE BED SIZE Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H. R. P. yam? F~v c _ /y~ _ Gorrr c, M Borehole Q Well Scale = Feet 0 Perc Hole System Elevation 7. z-- Uent 12" Grndp t TYPAR COVERING i 2" 12" 3' 4 6 ® 3' Sewer Rock c 16", 12'_ i i `4 L 30 r 30 1 L' 4- ~oKS~ i I 06 , *GS 4, 01~ 16 t ~ r rx IN, gar & N~ ~ ~ .+'~~°~'~~~4 ~ a f AMP ok, r. Idiv 7 3 i N. , Ve 54c \ '.7' S k. J 4' rfi vx T~ s V rr Fr,,'h. 1. 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