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HomeMy WebLinkAbout040-1166-95-000 h ~ 0 I d a w ~ I e °o I N d I ^r ti I I O I I T O 'O N z 0 C LL C EO O ~ N ~ I E d v U f0 M a I ° Z LLJ E 0 "0 v _ v f0 co LV m N F- Z o O Z a c tii lZ o (D Z c a 0 0 2 Cl) N a ~ .C ~ N I i co v, C a L r o r C o Q °2 z z N Z (v~ 0C14 y y C Y7 Fr, O R L N ~`y* 4.-1 24 00 o O. C cD cD I N V y N y d L O O ° c, I H .ra o O G 0. E C "4 (a 0 U) a N L a N N N 000 EL ~ UpP~ ~D ~i X000 = 0't C) •N a a a v, NH 4J ~a a LL 4-4 0 oN o ,\-t o N M J U rn rn Z CJ C5 v _ 0 0 N 0 E N N.\-' OC7 QN, C O O N N O 0] y c d a- O i W H (v O E CD O r ~z CD 4) C14 r-4 y C O E I ' O CA ~l O°_ C C E N In r- O Q m 0 4) 0 y y C d 0 0 r--A Tl , ~ O C J D. D. -D N N N LPG to a C O O H d 0 y L L Y 'O t` b H aj rl M co CD 0 *.i N > .0 0 :3 F- H c Qi •rl It .O O N H 2 O Z N M9 .rt U) I M r+ ~ t~ r••I N a I cd Z m #6 a N O I ~ I ~ a~ C C y C ~ •rl J-I bD y E > 0 N .U cd Q) cli P4 u S-I ra rl > 0. cn FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER LF~ 9' e ~ / 4 L Sz_A6__ TOWNSHIP lw~o/ SECTION L~ T 22N-R L 0 W ADDRESS 16 / 7` ST. CROIX COUNTY, WISCONSIN 71U-<2- ",//S' syQ 2Z LOT_ LOT SIZE ~ s SUBi6N PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Pt- ©T- sue- sue- _ a INDICATE NORTH ARROW -ro of g~q ~if, c D, Mavvy ~-vT BENCHMARK:Elevation and description: /D ~•o -Top ©F ,H-0-41'Va-A 0004 S/// 47- 57,E7, 5 Alternate benchmark MOO 9?__ /a© , (3 ' tU~f_k'S /000 dk_e . SEPTIC TANK: Manufacturer: C o.u c,~ f Liquid Cap 9,0, 6 Rings used: a Manhole cover elev:_Final grade elev: I~G 3 j~ Tank outlet elev.: Tank inlet elev.: No. of feet from nearest road: Front x , Side , Rear Ft. 75 / co t4- From nearest prop. line:Front K , Side , Rear Ft. No. of feet from: Well Building:r (Include this information in the above plot plan) (2 reference dimensions to septic ) tank) SEE REVERSE SIDE i ~ J PULP CHAMBER I Manufacturer: uid capacity: Pump Model: Pump/Sipho Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: P p off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance fr nearest prop. line: Front-, Side-, Rear Ft. Distanc from: Well Building z 7X6--3ve-4rS' S r )(57 ' SOIL ABSORPTION SYSTEM J-7 SAX S Bed: Trench: Seepage Pit: a~ gi R3 Width: Length Number of Lines: 2 Area Built Exist. Grade Elev. 7e. Y60 Proposed Final Grade Elev. rr rr Fill depth to top of pipe: 3 6 2 No. feet from nearest prop. line:Front X , Side , Rear Ft. No. feeet from well: 72- / No. feet from building 2- C,, /9-TT~A 54XO4 6••t HOLDING TANK Manufacturer: Cap Y: No. of rings used: Elevation ttom tank: Elevation of inlet: No. feet from neare prop. line:Front , Side , Rear Ft. No. feet from* ell , building , nearest road Alarm Manufacturer: r, INSPECTOR: ~`l0~/" SoN DATE:- 7 ~d f f O PLUMBER ON JOB : LICENSE NUMBER: 6/90:cj HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRIGHT WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. MINN. INSTALLER & DESIGNER LIC. NO. 00W i 'g- coo J ZE-0 j: ci zS2 z~ ~ 3- § S-2j S2 m cc LLJ r ¢ a CD kl) 20 2 y CL- j ~o SO W ~ 3 l ~ryJ O C ` ZL / o o o- - o Vj Ln 1 .9 i r_- ` t" i lo ti / M C„{! of • is ~ ~ / / / ~ ( ~ 61 i 4L C~ 3 . 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 7M DISON WI x53707 n State Plan I.D. Number: NE , NE , Ue~' . 26 , T2 -R29 El CONVENTIONAL El ALTERATIVE (If assigned) Town of Troy El G nmon Rd Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.. Lee Halber 161 C1 nmont Rd. River Falls -JI 4022 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: ~4 REF. PT. ELEV.: CSTEF. PT. ELEV.: . -~o of ~UDr 5 eaz>& SidC o'r kouSG ✓IQa!' /YL Cam, /Gd,/o~7 I~•~~ Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Robert Ulbricht 3307 St. 'x - 135416 SEPTIC TANK/ : M hd ¢ cooci-, MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET WARNING LABEL LOCKING COVE PROVIDED: PROVIDED: G. WQ QS UT/c~ 9 Cv, 114 YES ❑ NO ❑ YES NO BEDDING: L`5m, DIA.: V MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH 4 ~ -78 AIR INLjj ❑ YES Nri ALARM: ❑ YES 0 NEARES1 LINE: DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑ 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 wiAq,construction shall cease until MAIN the soil is dry enough to continue.) - CONVENTIONAL SYSTEM: v5~ T l~ G. 3 i~ !Q o/ dr ^ J BED/TRENCH WIDTH: LENGTH: N OF ISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: / MATERIAL: PIT DEPTH: DIMENSIONS S I-~ GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTji PIRF,FjTERI ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT T FRESH BELOW PIPES: ABOVE COVER: ELEV. I T: ELEV D: {/'/~Q~~ • 1 VC S C~Q IPES: FEET FROM LINE: AIR INLET: ` _Z NEAREST----* 3 i 7e? a3SS ~as -CaD MOUND SYSTEM: X96' 9, d" Mound site plowed perpendicul Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: n FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST C _G a s 9s', 06 N, 9,5 99 9/ ' Sketch System on Re ain in county file for audit. Reverse Side. SIGNA RE: TITLE: SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION ` ®ILHR In accord with ILHR 83.05, Wis. Adm. Code 5 coUNTY~~©i x STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ' 8% x 11 inches in size. ❑ cheif r`vislo too pievlous application -See reverse side for instructions for completing this application. STATE PLA I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION (Vr y4AI97 Y4, S ~ T Zk, N, R G' E (o 6W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 161 G- IC j A4 0 u T- GP . CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER W? L) & FA 115 601.157 *0 2,2- IL12-52 V5 31 14&e 1-1 11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State owned VILLAGE ; "-F' % O ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms R EL X NUMBER(S) - / S III. BUILDING USE: (If building type is public, check all that apply) L , l ej ,S J i 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 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/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. El Reconnection of 5. ❑ Repair of an System /W 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 220 In-Ground 42 ❑ Pit Privy 3 1 Seepage Pit r Pressure 43 ❑Vault Privy 14 El System-In-Fill l..__..y J k' S VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM EL . 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION d 3 Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank ' Lift Pump Tank/Si hon Chamber. ' Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Sign turn: (No Stamps) MP/MPRSW No.: Business Phone Number: t fl-, fZ _33o 7 - (?1,5 Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) Approved El Owner Given Initial 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 & Buildingi; Divisi wrier, P try f ? t 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; repiacement system areas; and the location of the building served; B) hcrizontal and vertical elevation reference points; C) complete specifications for pumps and controls; (Jose 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 owner(s) of' the property 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 Location of property N 1/4 N C 1/4, Section L , T 2-JO N-R W Township T R 6 Y Mailing address ( G-1Etimacoa 7- L)fL-1 Furs s y~ Address of site Subdivision name Lot number Previous owner of property N o E N i-B Total size of parcel 4!~,e JC Date parcel was created AML Are all corners and lot lines identifiable? _2!~_Yes No Is this property being developed for resale (spec house)? Yes No Volume and Page Number 3 P(Pas 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 references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) 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. 2j21 CP 5 S ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of th C ity~ ~2 Register of Deeds, as Document No. ignature of Owner Signatu of Co-Owner (I icable) Date of Signature Dat Signature `r' a $ { ''1poitk- "-WARRANTY DgtD-TO Joiti ti""IVAI i, ` ~1} t ~d NE t ''Y t w. e: wi~uo eo., ~f~M~ucn 321655 -~oo~ pa^~► rw This, Indenture' -Made this........... 266 day f..ti April , A. D,, between. .die 1.0.11.. fftlhe.r8 : ........part...Y.:.....of the first part, and. LeeRoy P Halberg and Kathleen Ann Halberd: hu5barid a nd wife, as joint tenants, parties of the second 'part. Witnesseth,., That the said party............of the first part, for and in consideration of the sum of One Do114X and Other Valuable Consideration to...... heT. ...........in hand paid by the said parties of the second part, the receipt whereof is hereby confessed and acknowledged, ha. s........given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by II these presents do............ give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of ~i the second part, in joint tenancy, their heirs and assigns forever, the following described real estate, situated in the 1 County of .._S,t.,.... CTO.ix........ .and State of Wisconsin, to-wit: II I Part of Government Lot "Z" in Section 2628.-20 lying W of P centerline of Town Road and N of following described line: Commencing at SE corner of said Government Lot 112", W on S line of said Government Lot "211, 623.0 feet; thence N30010'W 378.5 feet; thence N21034' on centerline of Town Road 977.3 feet; thence S880561W 421.0 feet to top of bluff above Lake j St. Croix; thence S880561W 125.0 feet, more or less to Lake_ and place of beginning; thence N700E 72.0 feet to a point 60.00 ~i feet S of N line of said Government Lot 1.12"; thence E parallel with said N line 86.0 feet; thence NEly 140.0 feet, more or less, to N line of said Government Lot "211. 11 Part of Government Lot 113" of Section 26-28-20 described as follows: Commencing on N line of said Section 26, 15.12 feet W of NE corner of said Government Lot 113"; thence Sly on My ii Ii line of road 805.0 feet to place of beginning; thence 967x3 'W on line passing 7 feet N of foundation of garage, 312 feed Lake St. Croix; thence Sly on Lake to S line of said Government li Lot 113"; thence E on said S line to Wly line of"road; ihence`Nly i on said Wly line to place of beginning EXCEPT Commencing on I centerline of said road and S line of.said Government Lot"3'1.; - thence W on said S line 280 feet, more or less, to fence; i thence NEly on fence line to centerline of said.road; thence Sly on said centerline to place of beginning i TRANSFER ~ •QO ,DFEEQ-~ Q. FEE `.APR' o EXEMPT i I I Togetheir,' with all and singular the hereditaments and appurtenances thereunto belonging or in any wise I appertaining; and all the estate, right, title,; interest; claim or, demand whatsoever, of the said. 0art...Y-......of the first part, either in law or +equity; either in possession•or expectancy of in and to the;above bargained premises, and their 1 hereditaments, and appurtenih6iir , i " Td have and, do hiold~ the said' premises, as above described K°+th `the he'reditamenta aril appd"rtenances, unto _ I the'saidpartie$ of the'seeond pert, in jointtenancy, and'not as tenatlks in common, and-to their respective heirs and i assigns FOREVtR. i ,i And the said ...............:...HelenHalbe g.....:.:............. . for......the'11Ise:1VQs,..and..the1T...... heirs, executors and administrators, do__....... covenant, grant, bargain and agree to and with the said parties of the second part, and their respective heirs and assigns, that at the time of the ensealin and delivery of these ~ g presents he.y....1x'e......well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and f clear from all incumbrances whatever i j and that the above bargained premises in the quiet and peaceable possession of the said parties of the second part, as joint tenants, and their respective heirs and assigns, against all and every person or persons lawfully claiming the i whole or any part thereof, she will forever WARRANT AND DEFEND. In Witness Whereof, the said part..y....... of the first part ha_. S_....hereunto set.. .her .hand . I I' and seal this.........2.6.th..... _ day of......_...........April..-....-.....--...., A. D., 19.7.4 SIGNED AND SEALED IN PRESENCE OF elen Halberg a~-~ „ J ar(SPAL) ' N yi~•,u••••C ~ r.-R.1.Q n -(SEAL STATE OF WISCONSIN, ss. Pierce.. . County. II Personally came before me, this 26th. __._...day of...... .._.._...April A. D., 19.7.4.._, the above named He l_e.n.. H.a erg i to me known to be the person...... who executed the foregoing instrument and acknowledged the same. 'I 3tokke Notary Public,_.........P1_e-rCe - . .-__County, Wis. My Commission expires ....12 11. A. D., 19._T (Drafted by C. M. Bye, Attorney. River Falls, Wisconsin. I of 79 ; y a t!7 W to w Cb W t- z GA v (3 C r" 0 X, I W o In m o a ` `y CO Z w w! C) o Q I 0 ' o ~ ~ w x ~ o !I 0 C7 F+ a; BOOK STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER 161 &1Eti,4eti7' FIRE NO. CITY/STATE 121, yxt, F /f A-If ~ S " ZIP Syd 12-- PROPERTY LOCATION: bl~- 1/9 1/9, Section T 2-If N, R W, Town of T Pp 1 , St. Croix County, Subdivision , Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists 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 treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix Coun Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 (715) 796-2239 or (715) 925-8363 Sign, Date, and Return to above address i INDUSTRY, SAFETY &BUILDING$"' HUMAN RELATIONS P.O. 60X 777 LAQ9R AND PERCOLATION TESTS (115} MADISOND1V1769 Q OLHR 83.0911) & Chapter 145) , WI53707 LOCATION: SECTION: OWNSHIP/ LOT NO.: BLK. NO. SUBDIVISION NAME: AlE NE / 2-1- /T 2? NCR zo E (o W -TROY `ar't R 1 0 F ce 14Ci s COUNTY: OWNS 'S S NAME: MAILIN ADDRESS y~.C,PD/X Lee 4A14ffg&- IllI 6-16AJM6:4 T W. ~OiuER Nils (UfS 5402 USE NO. BEDRMS : COMMERCIAL DESCRIPTION: DATES OBSERVATIONS MADE . Residence 2 PR (Ili FI17 NS: F~C~Y N lye? 3 • , ❑ New Replace AP,Q% / 47 C OR RATING: S= Site suitable for system U_= Site unsuitable for system ✓ C 6 AA y S4,0 Q rO V ENTI NAL: MOUND: IN-GROUND-PRESE: §KSTEM-INFILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) f S ❑U EIS ❑u QS ❑U ❑S QU ❑S ®U CtlNv~NTioN~k ( - TIeE4d-k¢ Q It Percolation Tests are NOT required DESIGN RATE: G~ S' S Z~ If any portion of the tested area is the under s. ILHR 83.091511b1, indicate: Floodplain, indicate Floodplain elevation: NoT /QC'G7/J/,Q~v PROFILE DESCRIPTIONS BORING TOTAL PTH TO GROUNDWATER-INCH S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED ES HES TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) B- i ,p 17, yyr >1?,o - .'716 ' '1>1l IS1I,s • ~a s, s.1 s' lee- e- B-2- O,✓ ge7z A > Q~C /,O, 'Dr-a, IS'.7.0' X111(, O~ ~til• ~OC9Qje S I Q K+ a-~ v' a ~2 G S B- ~ - 9,00- y, S' TAti ~s Q I. B-3 ~8• g(o > o' ~JK. 3a S, 1.33 ' 3ra Coo R S& S B- B- PERCOLATION TESTS TEST TH NUMBER INCHES FTER SWELLING INTERVAL-MIN. - DROP IN WATER LEVEL-INCHES RATE MINUTES lop I p I 2 PERIOUT PER INCH P- P f~4 A-k .t) ~U / N(Y S C A AS_ LiP' T O IQ 'T' j S P r9 t ~ 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 hors { zontal and vertical elevation reference points and show their location on the lot plan. Show the surface elevation at all borings and the direction and G' of land slope. ' Dwe TR~~ persxnt; SYSTEM ELEVATION u ham- TAN - 5. so 10 1AAJ 1 • .~TN 'P&UEP-SE_ 51•PE_ r 1, the undersigned, hereby certify that the soil tests reported on this form were made by n in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. Y NAME (print): HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED ON: ADDRESS: ROBERT ULBRIGHT CE TIFICATION NUMBER: PHONE NUMBER(optionaq; WIS. MASTER k4maEalill 7 M.P.R.S. y p2-- 3 d ~O " dle S` MINN. INSTALLER & DESIGNER LIC. NO. OM C SIGNAT RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil T er. DILHR-SBD-6395 (R, 10/83) - OVER - L PLOT PLAJ f I ,f • ~c,~ ~F : =30 13ACk'MOE- 130,e406-s HOMESITE SEPTIC PLUMBI gG CO- 656 0-NEIL RD., FMOO , CS' ROBERT ULBRIGHT T WIS. MASTER PLUMBER LIC. NO.3307 M.P.R.S. O EQT• RE F, ~T MINN. INSTALLER & DESIGNER LIC- NO.00663 SETA y1,~ pi pc Nix T f To 54 all ~ ~ ~8 F dos T. E~C-VAT►ov l O I/ • D f .°l~ ~9 Iq. 77 ' -~0 J ^5 _ ,f 1 CSYSTEM> Stp'lIL ~ ~ 95 .tip. \ 1 t. 1 • 7& / Ae_1 , L , Cfo 30 Ex is rw6-- ~i9ili~lr %ti S/o pe ~ PLOT ~L4 = Bhcell0E-- ;Yo,e.;06-,5* F~, IO~.t`t~lp "'PWMEOrM SEPTIC PLUMBING CO. O'NEIL RD.. HOSON WIS. 54016 W ULBRKGHT ST ~y~Z WIS.` R PLUi11WR VC. NO. 33D? M.P.R.S. ' NI STAt, ER d DESIGNER UC. NO.00663 ~ Qr• R~ F. Ser k,,* p~ pif_ NExT 14, To S4 t~ E~EVkT~Oy /00, p' a ~a aNES RE REStaT h~ ~ASIFE{~ ~Oklt t 04F .IAE+IIa P120POSEv ~,~rsTw(r K. Ge v th>-" Lo-. RE"' q h Rf . fig. 1 1 1 1 a ' pl s; ' SI~STfh 77f. fA0J E 9y 1 ~ 1 1 AA-%D IT, ' r s ~ _ New ,OOO Sn-Q A~.. C~ ~aP Se p i i c T. vRop, 30 C o~ p t-1 Fx ~'S rlAu G- - OU£kfla r, Fresh Air Inlets And Observation Pipe 1 upp~K rtQEA.) GG` Approved Vent Cap i / Minimum 12".Above Final Grade 7 4" Cost Iron 02 7 Above Pipe r Vent Pipe 1o Final Grade Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Tee Pipe 0 0 0 0 ' Aggregate o Perforated Pipe Below V. Beneath Pipe 0 • Coupling Terminating At i Bottom Of System 9~s~o sys~~M V) cr `i std V v • L o c~E r2 T Rt k) u Fresh Air Inlets And Observation Pipe J 0 Approved Vent Cap Minimum 12" Above Final Grade Above Pipe 4" Cast Iron • z - Vent Pipe' 'To Final Grade lei Synthetic Covering min. 2" Aggregate Over Pipe Distribution-,' Tee pipe 0 0 0 0 0 , co " Aggregate o Perforated Pips Below ' Beneath Pipe 0 Coupling Terminating At Bottom Of System s y 5' 7-f:Al 9y o'