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Parcel 042-1062-20-000 06/16/2005 03:25 PM
. PAGE 1OF 1
Alt. Parcel 22.29.18.343B 042 - TOWN OF WARREN
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
• TUZINSKI, WALTER T
WALTER T TUZINSKI
863 HWY 65
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 863 HWY 65
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
I
Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE
SEC 22 T29N R18W 5A PRT SW NW COM 20 RDS Block/Condo Bldg:
N & 2 RDS E OF SW COR SW NW, N 40 RDS, E
24 RDS, S 40 RDS, W24 RDS TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
22-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1093/338 WD
07/23/1997 834/163
07/23/1997 439/75
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/22/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.000 48,500 125,700 174,200 NO
Totals for 2005:
General Property 5.000 48,500 125,700 174,200
Woodland 0.000 0 0
Totals for 2004:
General Property 5.000 48,500 125,700 174,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 217
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
FORM - STC - 104
v A
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP ~j1,~;~~✓
SECTIONT,2 ~_N-R_4,~_W
ADDRESS ST. CROIX COUNTI, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN-VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~J
~ 6 cc
=
l
~l r
BO
t' 7e
~y
INDICATE NORTH ARROW
e/_r~f~~ .~.~r j~E~~
BENCHMARK: Elevation and description:
Alternate benchmark
SEPTIC TANK:Manufacturer: J ;Liquid Cap.
Rings used:-2-Manhole cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet from nearest road:Front-)( , Side , Rear Ft.
From nearest prop. line:Front , Side, Rear Ft. ,11~
No. of feet from: Well , Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
T
• • 4
PUMP CHAFER
Manufacturer: s LLiquid Capacity: Z' . &742,
Pump Model: Pump/Siphon Manufact.: J Pump size Elevation of inlet: Bottom of tank elevation
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.• ~ • Switch Type: 14,wt,,~4Location
Distance from nearest prop. line: Front-, Side, Rear_Ft.,44a/
Distance from: Well y&-72Q Building
SOIL ABSORPTION SYSTEM
Bed: Trench: Seepage Pit:
-Q Width: Length_ Number of Lines:,.~_Area Built ,
Exist. Grade Elev. Proposed Final Grade Elev.,~~_
Fill depth to top of pipe:
No. feet from nearest prop. line:Front , Side,, Rear Ft..,,?
No. feet from well:-t--2_No. feet from building
HOLDING TANK
Manufacturer: Capacity:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side , Rear Ft.
No. feet from: Well , building , nearest road
Alarm Manufacturer:
INSPECTOR: DATE: PLUMBER ON JOB :
LICENSE NUMBER: ds'~
6/90:cj
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 ~DS¢. State Plan I.D. Number:
Sw 4 i TdW1, Sec . 22 , T29-R180CONVENTIONAL El ALTERATIVE (If assigned)
Town o Warren
Hw 65 El Holding Tank ❑ In-Ground Pressure ❑ Mound Ckl
. 811.2
NAM OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: 1NSPECT10 DATE:
Nancy Worrell 863 Hw . 65 Roberts WI /
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. V.: CST F. T. ELEV .
0 y
r7. 00
oz~ d.2,aZ lGY)-
ALL, r &IL 6,E c i-ru 0 ~tct,-5,- = 92,
AwKi
' ber:
Name of Plumber: MP/MPRS County: Sanitary Permit
Calvin Powers Jr. 1563 St. Croix 128746
SEPTIC TANK/O2Gt5 1fihT#MK: t tr- / I r
MANUFACTURER: LIQUID CAPACITY: TANK INLET EL TANK OUTLET ELEV.: WARNING LABEL LOCKING COV R
{ , PRO IDED: PROVIDED:
{ Cam, P Q~+, 5Q 7 ~ZJ 2 f YES ❑ NO ❑ YES NO
BEDDING: VEMT DIA.: IVE+K-MATL.: HIGH WATER MBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: r / AIR INLET:
❑ YES O S t~ ❑ YES NO NEAREST
DOSING CHAMBER: ( qF P.T. -
MANUFACTURER: BEDDIN LIQUID CAPACITY: PUMP MODEL: PUMP/SIAH6f4 MANUFACTURER: WARNING LABEL LOCKING COVER
PROVI ED: PROVDED:
~c P ❑ YES NOS YES ❑ NO YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUIL NG: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:,
PUMP ON AND OFF YES [11 NO INEAREST-11111~1 .50 (Y
9 FORCE LENGTH: DIAMETER: MATERIAL AN MgRK)NG:
SOIL ABSORPTION SYSTEM. Check the soil moisture at the 'depth of Plowin
i f~jrf`c,{~ ~Jc
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continu y'
CONVENTIONAL SYSTE 5 S~~yn ~e✓- gS-S Vii.. ~IS,.•,
WIDTH: NO. F DISTR; PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH TRENCHES: ~W~t1.~rVR.c~S MAT RIAL: TN
DIMENSIONS ' 49 a bef~acu~btr~ G+/'
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. 151STR-1 NUMBER OF PROPERTY, WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET ELEV. END: ••~1,r y3~,i(p(,,,,. PIPES' 4 1 FEET FROM LINE: 4 E: AIR INLET: /
NEAREST U > Z~ 2,70 3 C.()
MOU D SYSTEM: 3 9f - }~cff IGi ~ ,~5 :cXkt i _-E.,, ,F 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
❑ YE 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 TREN /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. MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUT 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
4. C/
in in county file for audit.
Sketch System on
Reverse Side. SIGN RE: TITLE:
0
SBD-6710 (R. 06/88) f 0!0
PP_
SANITARY PERMIT APPLICATION couN
ILHR In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑
8'fz x 11 inches in size. C eck if 'vision to pievious application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PRO TY OWNER PROPERTY LOCATION
'/a '/a, , N, R (or
k h ~ A-e0_01 5W PROPER WNE 'S MAIL NG ADDRESS LOT # BLOCK #
r
CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME R CSM NUMBER
111. TYPE OF BUILDING: (Check one) CITY NEAREST R AD
❑ State Owned O VILLAGE
❑ Public 1 or 2 Fam. Dwelling- # of bedrooms J/- P EL TA NU ER( )
111. BUILDING USE: (If building type is public, check all that apply)
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 80 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. X Replacement 3. ❑ Replacement of 4.E] 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 M Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 420 Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
Feet Feet
VII. TANK CAPACITY Site Fiber-
in allons Total # of Prefab. .
INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic ExperApp
Tanks Tanks structed
Se tic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber -
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsits sewage system shown on the attached plans.
Plumber' Name (Print): Plu is ignat e: S ps) MP/MPRSW No.: Business Phone Number:
Plum 's Address (Street, Cl , State, Zip e):
IX. C LINTY/DEPARTMENT USE ONLY 1-17
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing gent Signa re (No Sta ) D 4k_ I Surcharge Fee)
*/Approved ❑ Owner Given Initial P
o
Adve Determination
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.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; close 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 for(n; 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)
A ~/9~7f~+
d
A/Z
6
1
i
i
is ~
PAGE OF
` Pomp CHAMBER CROSS SECTIOU AMD SPECIFICATIOUS
VENT CAP
4"c.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
25' FROM DOOR, JUNCTION BOX MANHOLE COVER
WINDOW OR FRESH I2"MIU.
AIR INTAKE I
GRADE I
I `I" MIN.
I
co►JDUIT
18"MIN.
INL.F T PROVIDE
AIRTIGHT SEAL
APPROVED JOINT A I I i ( APPROVED JOINTS
W/C.I. PIPE. I I W/C.I. PIPE
EXTENDIAI& 3' I III EXTENDIUG 3'
ONTO SOI.ID SC:;. ALARM
B I I ONTO SOLID SOIL
i I
4~ ON
C I I
I I
!1 PUMP -1
~ OFF
D
CONCRETE BLOCK
RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL
SPECIFICATIOUS
frEPT-+C AND ! ,~J
DOSE TANKS MANUFACTURER:, ~.n"'J` / D!~ NUMBER OF DOSES: PER I~Ay
TANK SIZE:ALLONS DOSE VOLUME~/Yl.w F Ccw
ALARM MANUFACTURER: INCLUL'!~!C ZAC!;FLOW: ' GALLONS
MODEL LUMBER: o/ h/h, CAPACITIES: A-INCHES OR GALLONS
SWITCH TYPE: - /,~i~a• .t1,o.✓ ~'l J 8 -INCHES OR GALLONS
PUMP MANUFACTURER: C:INCHES OR.-_~,y~ GALLOWS
' MODEL NUMBER:
DINCHES OR __.!_Z- GALLONS
SWITCH TYPE: NOTE: PUMP AND ALARM ARE TO BE
PUMP DISCHAR`E RATE _GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE Bjo'l?WCrU PUMP OFF AND 015TRIBUTION PIPE.. FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . FEET
♦ FEET OF FORCE MAIN X -=--FYooFT.FRICTION FACTOR.. FEET
TOTAL DYNAMIC. HEAD = FEET
IMTERNAL RIMEWSION OF TANK: LENGTH
---;WIDTH ;LIQUID DEPTH
SIGNE D: LICENSE NUMBER: ~n DATE:
-117-
y
• PAGE OF
Cro S S I tt, 1 1.1 o~ A 3 e 1-3 S. S Tenn
,,nk/ fifth All InI:IS And OD►arvallon pipe
i
APDrovid V:M Cop
~flna Grod~ova
20• ♦2' Above Plpr 4• Cosl Iron
To final Orodo Vanl Pip:
M&%h Nor Or 5rnlM01C Covailna
sun 2• AapiepolS
Oval PIPS
016lrlb lion .
1'IpS o 0 0 Toe s
6• AIaooleo
S
Bansalk PIP: ° Perlorel:d PIP: below
o '-CovPllea Ternlnollnp Al
Ballow Of Sraleam
Pro o)ep ~In C~rac~t / _
SOIL FILL
DISTRIBUTIOM PIPE
APPROVED SyMpETIC COVC0.
2"OF hGGR GAiE ~'-PIATERIM- OR 9" OF STRAW
~sy ' OR MARSH HAy
O
F~y~FEI;T_~ (.~F:rL-21/2 AGGRCGATC,
ELEV. o S
~~t r
DiST'RIbUTIOW PIPE TU BC AT LEAsT(;>2- INCHES BELOW ORIGINAL GRADE
AQU AT LEAST tO INCHES BUT 1,10 MORE THAI) 41 ILIC►tES BELOW FINAL GRADE
MAXIMUM MN OF FXCAVATIOP )ZKOM OR16 NAL 6R)\DF- WILL BF- INCHES
11lNmtj OEPrti OF EXCAVATION rAOM 0~14IWAL rjRgD€ WILL 6C --7 7- INCHCS
StGIJCO:
LIGC►JSC LJUMBER:
+ DATE: ~C = 7O
Ila
LI It ck ~ Ale
-All
i k`~~ GQtlLDS :SUBNIERSIB~.
x
G &
SEVIIAGE'~AHD EFFLUENT LIMPS n
{
}
Ilea 6R, A
EP!0311
Lwr DISC.
2 EP011 115 V Effluent Rim 1/2" solids `256.60 172.10 `
s~~h - tl. a 000PFP0311 14 1/3 HP :
STti cowl
,:Submersible
p k
Effluent MODEL EP0311
4 Pump
r
SIZE 3/e" SOLIDS
METERS FEET
2s .
fV 5
d v? k
4
A
10
2 -
f
3
xt
0 00 4 0 12 IB 20 24 28 32 36 40
t GPM
0 2.5 5.0 7.5 m'!h
CAPACITY
t Performance
3885
Curve
9D MODEL 3885
s, SIZE 3/4" Solid
a,
I IA
70
20.
r
X
WE07H-
16 50
E06M
.r 40
i` to z WE
10 WEM
s 0 0
{ 0 f0 20 30 49 'EO EO 70 8D 00 100 110 120 OEM
'
100 20
CAPACITY
r LISP DISC.
r 7, CtOUFWE03111, 142 WE0311L 1/3 HP 115 V Laa H 3/4' solids 491.55 329.35
{ r GOUPWE0311M 142 WE0311M 1/3 HP 115 V Mod H 3/4" solids 491.55 329.35
QO(>PWi051 1H 142 wE0511H 1/2 HP 115 V High H 3/4" solids 704.25 9.1.85
t
S GXpwE0712H 142 WE07121i 3/4 HP 230 V High H3. 3/4" solids 843.65 565.25
*p-*s='F0Lj cwiNG PAGE FM PERKRKA= MID SPWIFICA170Ns.
» 30 PAGE U
IKIZ 10/88
„y
DFPARTI'vI ENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(N63.09(1) & Chapter 145.045)
(COCA (10': SECTION: TOWNSHI=naO . NO.:jSUBDIVISION NAME:
1/ 1/ _22 /T N/R ort W Warren /a I n/a
sw '22 COUN TY: OWNER'S 'S NAME: MAILING ADDRESS:
St. Croix Nancy Worrell 863 Hy. #65, Roberts, Wi. 54023
USE`--`-- DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROF E DESCR TIONS: 1PERCOLA I ION TESTS:
li)dResidence 4 I n/a ❑New Replace 6-12-90 6-13=90
RATING: S= Site suitable for system U= Site unsuitable for system
rLIS ONVEN f101VL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMEional)
❑U 1 ®S ❑U ~ S ❑U ❑ S ®U ❑ S [41 conventional
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
n/a Floodplain indicate Floodplain elevation: n/a
under s.H63.09(5)(b), indicate:
decimal' PROFILE DESCRIPTIONS
BORING TOTAL P H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OgSERV D EST. HIGH-u- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 7.25 99.47 none >7.25 .00bl.l. 1.33bn. sil. 4.92bn. s.l.
F3_2 7.67 99.37 none >7.67 1.08bl.1. 1.17bn.sil. 4.50bn.s.1. .92bn.l.s.
B-3 7.42 98.60 none >7.42 .92bl.1. 1.25bn.sil. 5.25bn.s.l.
B-
B-
B-
decimal' PERCOLATION TESTS
TEST WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. IOD 1 PER INCH
p- 1 3.92 none 30 i
P 2 'J.82 none +
-3.05 none 30 - 1~1 „ 1~ 14 24
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 95.55
~rr, lt_~ I i \~C
\O Aowt h a,
'tip
e, t
ISI
ti _ _ s +
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 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,
Tf.FSTS WFRF COMPLETED ON
NAMF (Ixintl:
Gary .L. Steel - 6-1.3-90
ADDRESS J CERTIFICATION NUMBER: PHONE NUMBER (optional):
L90__N,_._Shore Dr., New-.Richmond, Wi. 54017 22~_ _ 7 5-246=6200
CST SIGNA?(J
7
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Snil Tester.
f:?il_; lFt SEC'-6305 Ifs, p2/87) - OVER
SEPTIC TANK MAINTENANCE AGREEMENT
w
St. Croix County
OWNER/BUYER (,J a r r--e. c
ROUTE /BOX NUMBER Fire Number
to
5 y o a
CITY/ STATE zip rt
D~,~ri~ W ~ 5 en
PROPERTY LOCATION:'.' Section , T22N, RAW,
Town of ( ct r r St. Croix County,
Subdivision A t0. 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 's'e tic tank pumper. What you put into
the system can aTTect t e .unct on o, the-septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents MZ be eligible to recieve a grant for
a maximum of 60% of the cost-of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their system properly
maintained.
The property owner agrees to submit to St.. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or.a licensed pumper veri-
fying that (1) the on-site.wastewater disposal system is in proper
operating condition and •(2)•after inspection and pumping (if nec-
essary), the septic-.tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year'expiration.
H
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart- w
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 Q ~l
DATE c
r~ St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
. APPLICATION FOR SANITARY PERMIT
9TC-100
This application form Is to be completed in full and signed by the owlet(s) of
the property being developed. Any inadequacies will only tesult In delays of
the permit Issuance. -Should this development be Intended got resale by
evnet/contract at,(spec house)- then a second form should be retained and
completed when the property Is sold and submitted to this allies with the
appropriate deed recording.
- - - - - - - -
Ovnec of property 1
Location of peoparty -C-W-1/4 ._A/iJ /4t section
Township 0.
Mailing address
Address of alto
~a - •
subdivision name_ rd
Lot number AV A
Previous owner of property
Total else of parcel i~ c {
Date patcal was created ,
Ace all cornets and lot lines Identifiable? =,_Yon
Is this property being developed lot2 resale tepee house)?__Yes )4_1 o
Volo" - =rind Page Number as recorded vfth the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWINGS
A WARRANTY DQED which Includes a DOCUMENT NUMBERp VOLUME AND PACE NVxAnt and
the SQAL OF THE REGISTRR OP DEEDS. In addition, a eertllled survey, if
available, would be helpful so as to avoid delays of the revleving process. tf
the deed description references to a Cettlfled Survey Map, the Cettilled Survey
Map shall also be required.
7
PROPERTY OWNER CERTIFICATION
1(Ye) certify that all statements on this form are true to the best of my (out)
knowledge; that I (we) am (ate) the ownet(s) of the ptopetty described In
this Infotmation form, by virtue of a warranty deed recorded In the Office of
the County Register of Deeds as Document No. : ~%u0 1 and that t (we)
Presently own the proposed alto for the sawaga disposal system lot i (we) have
obtained an easement, to run with the above described property, got the
construction of sold system, and the same has been duly recorded In the office
of the ounty Register If Deeds, as Document No.
! gna ute o Owner signature of Co-Owner (If Applicable)
Data of 049nature Data of Signature
P
• . DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OS3 ONS RM 2-19821i
445503
- - - ! REGISTER'S OFFICE ~
ST. CROIX CO., WI
Recd for Record
._LA- em.M..__- Wo rxe_1.1 ...and..Nancy.A....Woxxe.l_1.,..huebend..end-.~ai.fe,
~ 0 8.30 -AJIA
i
~I conveys and warrants to -Nancy-_A. Worrell.; .a married -woman
Registe
r of Deeds
.
RETURN TO
ii
_ jl
the following described real estate in St_ -_.Gr_GiX ......................County,
State of Wisconsin:
ji Tax Parcel No:._..-----•--------------------
i( A tract commencing at a point twenty (20) rods North
and two (2) rods East of the Southwest (SW) corner of the Southwest Quarter of the
Northwest Quarter (SWk of NW4); thence North forty (40) rods; thence East
~i Twenty-four (24) rods; thence South forty (40) rods; thence West Twenty-four (24)
rods to the place of beginning, in Section Twenty-two (22) Township Twenty-nine (29)
North, Range Eighteen (18) West, excepting therefrom conveyances heretofore made for
highway purposes.
I
EXE11~ '
~i
This ___...,ls bomestead property. ii
(is) 0(1.=49
i
Exception to warranties: easements and protective covenants or restrictions of
record, if any.
,5-~- 7). ..~9... it
Dated this 1..- day of . x iLcc...........
D'.... . . (SEAL)
I ....................................................................(SEA
Lavern M. Worrell
*
(SEAL) X ns' i. 4%ll ...............(SEAL) li
U
* * Nancy A. Worrell
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
ss.
St. Croix
.............•---..-•----....County.
authenticated this ........day of 19...... ersonally came before me this ........day of
sw---------------- 19.169--- the above named
Lavern M. Worrell and•_Nancy_ A_ ..W9KrP_11..
.
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
by § 706.06, Wis. Stats.) to me known to be the person s............ Who executed the
foregoing instrument and acknowledge the sainq,,,•,~
THIS INSTRUMENT WAS DRAFTED BY '
W ~.~-t M•-- , 'mac- f
Lois A. Murray, HEYWOOD, CARI & HURRAY
P.O. Box 3; I ud'son, WY.... 54t3Y6
* e4~.•-- aiN............
Notary Public . St... Croix
(Signatures may be authenticated or acknowledged. Both My Commission is permanent (If -slot, D t'
are not necessary.) 2 i _ q ( 1 v.
kn date. •IP~
- , I;
•Names of persons signing in any capacity should be typed or printed below their signatures. •.,~~flllf/0'I,,,,
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Cu. Inc..
FORM No. 2 1982 Mi:w•e.okcc. Wis.
DJDUST ' OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
If~DUSTRY: Y; C DIVISION
HLABOR UMAN NDLATIONS PERCOLATION TESTS (115) MADISON W 7969
(H63.090) & Chapter 145.045)
LOCATION: SECTION: ITOWNSHIP/P90302030213W: LOT NO.:BLK. NO.=SUBDIVISION NAME:
SW ,9 1/ t/ T N/R or) W Warren n n a
COUNTY: OWNER'S 'S NAME: MAILIN ADDRESS:
St. Croix Nancy Worrell 1863 Hy. X665, Roberts, Wi. 54023
USE DATES OBSERVATIONS MADE
NO.BEDRMS: r5vivER AL DESCRIPTION: PROFI D SCR P IONS: R ATIONTESTS:
Residence 4 n/a New Replace I 6-12-90 6-13=90
d~a
RATING: S= Site suitable for system U= Site unsuitable for system
r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
S ❑ U ®S ❑ U S ❑ U ❑ S ®U ❑ S Cpl conventional
If Percolation Tests are NOT required DESIGN RATE:
If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 7.25 99.47 none >7.25 .00bl.l. 1.33bn. sil. 4.92bn. s.l.
B-2 7.67 99.37` none >7.67 1.08bl.1. 1.17bn.sil. 4.50bn.s.l. .92bn.l.s.
B_3 7.42 98.60 none >7.42 .92bl.1. 1.25bn.sil. 5.25bn.s.l.
B-
B-
B-
decimal' PERCOLATION TESTS
TEST PTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. PE I0D1 PERIOD2 PER PERINCH
P_ 1 3.92 none 30 12 1 3G_
P_ none 30 178 118 34
P 3.05 none 30 12 1, 24
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 95.55
f
`nom
t
may,,
L - .I.
. YYYY 4YY/
,100' ~1a_ ► ► K~r, PA
TN
E
3
3
'Oro
E
1 f j
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the proce es nd met4err C"d in onsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge a dQb lief.
NAME (print : TESTS WERE VO LETED j
i
jyo,
Ga L. Steel 6-13-Jr~NU,
ADDRESS: CERTIFICATION j NUMB (o ional):
88 N. Shore Dr. New Richmond Wi. 54017 22 8 el`/CST SIGNA
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 - SID - 6396
To be a co. 'ete and accurate soil test, your report must include;
1. Compl, i'ascription;
2. Th ~ w must clearly indicate whether this is a resit' commercial project;
3, MA. 'nber of bedrot r rommerciw use planned;
4. Is ^ replacement s.
6. .iitabilit:y nr in . SITE IS SUITABLE FOR A HOLDING T,r_ Y IF ALL
EMS ARE f ;l IT BASED ON SOIL CONDITION;
6. the abbreviati here for writing profile descriptions and completing the plot plan;
7. "'d.. rf,IBLE diagram ~uraurly locating your test locations. C''--wing to scale is preferred. A
a used if rl-,:red;
k and vertical elevation reference pain it;
0. ;l api r riate boxes as to dates, names, addresses, flood , I. ;t emp-
appro~rriate;
rrrtation (suc°t as flood plain, elevation) does riot apply, pl A. in the appropriate box;
I f;)rm and o ace vour current address and your certification i
cop tribute as re<luired. ALL SOIL TES, JST BE FILED WITH THE
UTHORIT." IN 30 DAYS OF COMPLETION.
-VIATIONS FOR CERTIFIED SOIL TESTERS
Other Symbols
E' - Bedrock
coil (3 - 10") - Sandstone
gr I (under 3") I Lim{--stone
*s F Groundwater
cs C Sand P >lat'on Rate
rmr d s V I Send
Is - L > - Grea.,, Than
sl n Less if wn
'I - Bn - BrovNm
c, BI - Black
Si Silt Gy - Gray
Clay Loam Y - Yellow
S-idy Clay Loarn R Red
- Si,-_y Clay Loam mot Mottles
r , Iy Clay iw1, with
sic T Si;,, Clay f f f f ;,r , f i
C - Clay CC
pI Peat rnm
ni Muck d - ci inct
p - prominei,'
HWL - High vv ,t
Six general soil 'turns sur~ac~ r:r
for lipuid v 'j f :>o~ al BM - Beach M,. k
VRP - Vertical Reference Point;
e
TOT. l F
I. i-lq a Sant Tt,. t~)- Es,,.....
$ei
: l t i ;7Cs1?St'="t]Cn£in.
i