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042-1082-70-100
N R~ O N O I y p 3 0 0 6-P o ~ ~ I a o ~ I m O O° i v O c T oC o o c c 3 rn m y 2 Q co 0 4) r c~> 1 00ZOco 'NZ c4 ~ U M ~ O O C x 4k y N 000 N O C O~ 3 C tl 4) UUO O N (D c N C' U U O• C Y 'O L' O l4 Y _O -u N N m L :4 ~ O O l4 Q p ET~ 1 o° E 0 N\.03 y4k 0 m ~Z v z 3 p I c 102 Ew c Z c_ av LL C - m 08 LL C (n .O„ m O 3 w cn ° N O N 3 N~o~~° 3 cx v L p o a a O Q 1- a m u°i Q H a of N 0 0) v z y Z a3o z E E o I o I Z € co o a m a co c t7 I ° z a 0 z a o v) i- a`Ei I ~ E I N N 3 N y IL N N N ~ N ~ I y y ~ I a a ~ L O C 'o z m z z m z O N E w L d N N E fVO 10 E N m > d C 1 Y LO a M o a a E 3 0 o a a z r N 1 U N N f/) o rr °v 3 a~n rrrr X 0 0 0 I o O O O a ii aaa I~aCL a a ° ui o o > N J Q ~ ~i a rn rn } L o ° 00 ;5 M Z Q N N •3 Q O - 0 L m y C co c c co m , Q (n 2 .o d cn Q Z ~ V1 vl I U ° ~ O p Q o 'a t o o (D U) 0 V L N H a ° C C. m S co o o co c m N 0 ~O O M> O r O z U U v 0 Z N 2 Z d a ° a a CL (D CL a. rr`hwwl w+ E c c a; c w c _1 A C) a1. o U) u p 2 o U) L) p N O N O M N o ° v> 03 ~ ~ Do y o c T 0 O (D C O m y O O O.: t0~ o f y ~O N a 05 N d )ri N~QV a) a t: c ti coo - cpM oQa) p O a) 01 a m U a) > M L -t; mn•w Q2a mm 0 D)~ y 7 L V O c .a a Q M O y ° co m O O a0r-~' X 0 O O c O L O Y N -O O p 'a a 4) p r-O N f>0 N MV( Do M .C ~.L a 4) O In L N .m-. 'O y m N to TON 3 a O V) CY a m~ N m0) 3 4)-o f0 o cm~~EEv 3A °~ri3~a co -0 Z aEim3 d- ° c Z y > Q0T?BOO LL o > o f0 00 O°) Li R N~ aUi•~ m 0L6 N L O) a d E a) a) > ya), O) V N 7 O m- L 3 a L OOaLL. v co > Ep NO NANO Q I- U) and 3 3 Q H nLL.a o 3 Cl) Z y 3 W E z y 1 z E v € 0 1 = °o Z a m ` ° a m r°> FN- m I I c C7 I I o z v a ai Z O r/) fn H r rn c 1 ` c C E E ° L N i m 7 a) N U) a 7 a a) N •IV t N N V N O c opp O 0- C, C -O 0 C 'p Q O U O O N zca z°mz w oN °Z`o E z E c CN ch aci m N O C14 E L m > m ~j rn LO m-` m pp12~. m CL (D O 01 N v W H d a) O I A. ° ~rcrrca , t3) E :3 lz > )33 F LU - 0 alit 0000 to 000 a, it a a a a a a CL > di i m' J U L 00 co a N°° U 0) 0) V CO } a rn _rn } C-4 0 (D CD CD C, ti~ 0) LO LO 0 a 0) o c, "0 > O r a) E m a L 'j y m N c a n o o m Q~ o m Q w a) U) 0 (D 0 co 0 H C OOi U' C ~i C U U) 3 O O Q c .n O c c E CD (D V 3 ti o o CD 0 (D > •E m N U) N O d 0 C> 4o N ao O c m y a 0 E E m y o N ° N d a) aNi a) o Z a°OO 'a Q n o 0-4 co E m a (D c a) co r-l 3. U r`5 o • O' o c°n Z N S H O CD Z N g !n m 0 CL • ee a m .v L: a L: a tt`wN E c c c _1 A U( ML 0 (n o 0.90 U) r."ll/07"E' 74-ST CO.1wPl7loeus /r fiPo x7 - 'OEPA INDUST MENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS ~ MADI y') VI 53706 (ILHR 83.0911) & Chapter 145) vim ,LOCATION: SECTION: TOWNSHIP/ OT NO.. BLK. NO.: SUB 1 ION NAME: NC sEV 3d /T29 N/R!aO E (or) W /-v~"ZFA-j IAI_t~ of moo f .f ace s COUNTY: MAILING ADDRESS: D, s_~ C1'a•X 'flR ChI~~I ~Csi3U/~i,~> 16'31'0 132 r,0 S']-. c -34ife J?",e Ljt:-. ~fi;uv, SS USE LL/Z^ t/ Z -GQ 7 DATES OBSERVATIONS MADE NO. BEDRMS.: COMMER IAL DESCRIPTION: PROFILE DESIONS: TS: 4Residence fZ New ❑Replace /.10t9 • I- 1 0 v NOV.fS-106 ixv 0-1$-I FOR, 0-F 7C_¢ / T iA~) Sy`Ef`L PO (E 13 L-fiYr • P'W'%J RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MEND: IN-GROUND-PRESSURE:SYSTEM-IN-FILL OLDINGTANK:N!, MMENNDEDSI5SST~3(opt nn~alu~UTrdunL s ou ❑ s ❑u ©s ❑u a s ou o s ❑u FPLAAfk_-* 411,15 7- A ,yalvv - If Percolation Tests are NOT required DERATE: S S If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS sC S Cal S~ CZ S,} BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIG E T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) /Z O OD- ~Z ' - _ _ ? 12 O 8,v , S/ 108 „ TAN CS ~r R . /SCv 03. 7G ~ tea- lS<v 9'aN.s/ f- es/ 2y /8t. Sf - - •1~ //y ~,v cs ' _.3 /ZU oz,p(~ r 120 "au.s/ /Z"W N•S/ IS"-BAI- / 'sQ•S. ~„Tdv CS'~i?_ /t L O Y. ,Y by( L S " F~ r Zq t3~. S/, A ~SiaaKy i• w/ ~a~4 I6. DrSAbJe7- B- C9a (s7 L Oe- 6y ~o7'~ v A, „ / - cep,,rog cr /y" sva-~f., sky. S.Y~ B_ 62 7L 105.36 c,_y si/. 'v //A ,r,.,,fA$y 13^ asr o10 -0, "ioTs, .e►ot ~fo yy.. Srlyo c. ,P s ti ~«.f~r .oiSP• i B- oeQ-6r. Ae aTs • °o B- 7 -7 2' /D D. S( ra~A~ ~ c~ c TO f3 oR (a $UAyy}!F /~/~7/'~S of ~1IC `PER OLATIONTESTS 1N CS I 5R. $Tic~1-7)f- EST DEPTH. WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLIN INTERVAL-MIN. PERIOD 1 P R D2 PERI PER INCH P. Z " Are- lOG. d Z (r d za it Z P i 1,93. 61 P o P- M P- .n 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. ~y0 ~ F~~,¢~pc~~ ~I~~z ~3 seE ~c.oT .~~yw- sE'PE+e~tTE ~ Pei 1 m e - - -r I t I f cS'4604'4~ 4Z? 0 *,VP6* 9 r f-vim 7Ke /w BUG ScGr ,30 o ___s~ ¢ o s ti t F iv V iL , "'9fi.Zfvf &e' 7 ? i ;'06- 4 00 cry ~4 D v , 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. NAME (print): TESTS WERE COMPLETED ON: C HOMESITE SEPTIC PLUMBING CO. 16 l /q e7 O ADDRESS: -655 O'NE11L RD., liUDSON WIS. 64016- CERTIFICATION NUMBER: PHONE NUMBE (optional): ROBERT ULBRIGHT Z Yf ?2 3aNE& f 14?s NATURE- MINN. INSTALLER & DESIGNER LIC. NO. 00663 CST SIG 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 fs - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand - Less Than 'I - Loam Bn - Brown 'sit - Silt Loam BI - Black Si - Slit Gy - Gray cl - Clay Loam Y - Yellow SO - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - 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. N -tp oc o two z_ ^y) m3=zW z J z J - WOW ^ 3~ 17c gv 77 w ¢ j ~(J M O F-- J 0. J J Uz V u ~O 0 ~ CL H: z v it Ih .l aC M V 0 9 a ~ 6~ d 7 ~ (L o `O o O ti . w PA o C~a r Xl 0 o ~ R 2 Itz W ~1 0 00 Ilk -T T` aL s wi - ! ~ O~ C i 3~ y'~'~ ~ e~ ~ ~ ~ ~ d ~ ~S`d3 yw a~d ' G 1 5' g~ ? f ~ g~ N qb b ~ ;l/ 5 ~ ~ ~ ~ Atio W u ~ ti~ a ~ 160 ~ h ~ r3G a' c _ Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 02 ng TOWNSHIP / ,sw,~,✓ SEC. T _j2f N-RIrW ADDRESS ST. CROIX COUNTY, WISCONSIN Cs yv~ ~-zs-5 SUBDIVISION l(~"6 -r aa~~s LOT / LOdSIZE C~ PLAN VIEW Distances and dimensions to meet requirements of I•T.HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM E t' d .Z JOG f INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used as 166- Elevation of vertical reference point: 16 Proposed slope at site: SEPTIC TANK: Manufacturer : )47 Ad 2,, Liquid Capacity: ~rJ e~ Number of rings used: G) Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: i Number of feet from nearest Road.: Front 10 Side,O Rear, O f2 fh,~.~.. feet ..From nearest' property line . Front 10 Side 10Rear,0 7 feet Number of feet from: well,!) C)C1 building: IS- (Include this information of the above plot plan)( 2 reference dimensions to septic tank) 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 Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side. O Rear, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed:' Trench: Width:_ f Length: G Number of Lines: 2 _ Area Built: X32 Fill depth to top of pipe: 4/12 " Number of feet from nearest property line: Front, O Side,, Rear, .-Eat, Number of feet from well: O O Number of feet from building:;- EQ? (Include distances 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 sytems? (Check 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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: /6 Cl Plumber on job: License Number : _ Al'o' .K3r2- 3/84:mj • DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING ,LABOR & HUMAN RELATIONS P.d. BOX 7969 ON-SITE SEWAGE SYSTEMS DIVISION NN, Mst INI 5 07 OFFICE OF DIVISION CODES & APPLICATION ~~4--, ec•30,T29-R18 (If atsigneel).Number: Town of Warren CONVENTIONAL ❑ ALTERATIVE dla ds Rd . ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: :[ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Dr. Phillip 0 burn 6310 132nd St. N White Bear Lake MN BENCH MARK (Permanen reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. ELEV., Name of Plum er: MP/MPRSW No.: County: Sanitary Permit Number: v Wm. Schumaker 6382 St 'x 128868 SEPTIC TANK/ MANUFACTURER: LIQUID CAPACITY: TANK INL E TANK OUTL ELEV.: WARNING LABEL LOCKING COV R A / i pQ PROVIDED: PROVIDED:, j/ YES NO ❑ YES NO BEDDING: Vc!•4F171A.: MEH} MATL.: HIGH MATE NUMBER OF ROAD: PROPERTY WELL. BUILDING: VENT TO RESH !lL •JO ALARM- FEET FROM LINE: y~ AIR INLET ❑ YES NO e C ~4~.C.- ❑ YES NO NEAREST'~r ~/G~ r ~/(/V /S ~ MANUFACTURER: BEDDING: ACITY: PUMP MODEL: P/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ NO ❑ YES ❑ O ❑ YES ❑ NO GALLON CYCLE: PUMP AND CONTROLS OPERATIONAL: UMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFF NCE BETWEEN ROM LINE: AIR INLET: PU P ON AND OFF ❑ YES ❑ NO NEARE SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: D ATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until the soil is dry enough to continue. MAIN CONVENTIONAL SYSTE / S teI.)_ O BED/TRENCH WIDTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: ID DIMENSIONS /02 J / TRENCHES: / MA ERIAL: ?So DEP t GRAVEL _DEPTH FILL DEPTH DISTR. PIPE DIST PIPE DISTR. PIP MATERIAL: NO. STR. NUMBER OF PROPERTY WEL :1 BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV I ET: ELEV. END: AIR INLET: i 1 V / PIPES: FEET FROM LINE: - - a NEAREST ~~/GY~ MOUND SYSTEM: J Mound site plowed perpen ular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope-_._.., and systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES O meets.t a criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER T URE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OV RENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL:';, SODDED: SEEDED: CENTER: EDGES: MULCHED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO OF LATERAL SPACING: G VEL DEPTH BELOW PIPE: FILL DEPTH ABOVE OVER: DIMENSIONS TRENCHES: MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERI NO. DISTR. DISTR. PIPE DISTRIBUTION E MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: ES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: INFORMATION OVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑ YES E:1 NO COVER [__1 YES ❑ NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY FWE_LL: BUILDING: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) ~ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUN -Attach t/k•'i~MI -Attach complete plane (to the county copy only) for the system, on paper not less than ❑ STATE/~; PE 8% x 11 inches in size. Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER R.. ERTY LOCATI N .fT , N, R r E (or PROPER OWNER'S AILING A DRESS BLOCK # CITY, STATE ZIP CODE PHONE NUMBER BDIVISION NAME OR CSM NUMBER Gut ` tl~ l6 II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE ' NEAREST D -2y NgW OF: ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms L PARUtL AX M ) III. BUILDING USE: (If building type is public, check all that apply) G I~ 1 El Apt/Condo Q 4 tV 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 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in fine A. Check line B if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 511 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 300 Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 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 VII. TANK CAPACITY l O o 3 A / ® Feet 7 S Feet in allons Total # of Site INFORMATION New Existing Gallons Tanks Manufacturer's Name Prefaboncret. Con- Steel Fiber- Plastic Exper. Tanks Tanks structed glass App. Septic Tank or Holdin Tank Lift Pump Tank/Siphon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system sho on the attached plans. Pllu/mber's Name (Print): Plumber's Signature: (No Stamps) PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPAR ENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date issued Issui g gent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) / Adverse D rmin tin A15 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398 (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, purnp/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'h 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 owner(s) of the property being developed. Any Inadequacies will Only result In delays of the patalt Issuance. -Should this development be intended for resale by ownet/contractot,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the apptoptlate deed recording. (h ner of property h i ~-~-14> C 4 C):5 NC -P NW I L-) Location of property1* ti'.1 1/4 1/4, Section _ 130 j T 2'q_.P-R_LtL_V Township Wai-re V Malling address Address of site subdivision name --r7ut c~ Lot number Previous owner of property a-vI Total else of parcel S C Date parcel was created a Acs all corners and lot lines 1 =Yas No Is this property being developed tot resale (spec house)? as xo Volume g 7 7and Page Number :fLZ..an recorded with the Register of Deeds. ------------------------------ft"..--------- INCLUDE WITH THIS APPLICATION TITS FOLLOWING: A WARRANTY DECD which Includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE RRGIBTER 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 teterencas to a Ceitllled survey map, the certified survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) eertlfy that all statements on this form are true to the best of my (our) knowledge that I (we) am (ate) the owner(s) of the property described In this Intotrmtlon form, by virtue of a warranty deed recorded In the Office of the County Register of Deeds as Document Ho. S~(o //l 3• A and that t (We) presently own the proposed alto lot the sewage disposal system tot 2 (we) have obtained an easement, to tun with the above described property, tot the construction of sold system, and the same has been duly recorded In the office of the county no Is or of Deeds, as Document No. / signature t Owner Signs u of co `Owner (11 Applicable) 64te of i n tore 9 Date of Signature Z. _7 DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED ►OR REGORGING DATA ~j i i STATE BAR OF WISCONSIN FORM 2-190 I 461113 - - _ REGISTER'S OFFICE I~ T• C OIX CO-, WI David D. Coyer and Carol J. Coyer, as his wife and in R C'd " her own ri ht . • ~I for Record If r hi it U 3 1990 1 Dt i 12:10 P. f 11i 0 conveys and warrants to Phi burn and Pe w P.... N:._.. 8 88y......._ Ogb. urn husband and wife, as•-survivorship marital property....... Re9rsterof-Deeds Ii RETURN TO _ . . L - 11 the following described real estate in .......St.--Croix .......................County, State of Wisconsin: Tax Parcel No: A parcel of land located in part of the NEk of the NWk and the NWk of the NEk of j Section 30, T29N, R18W, described as follows; Commencing at the Nk corner of said sectio 30; thence S31°15'00"W 469.17 feet; thence S2203710011W 19.60 feet to the point of I beginning of this description; thence S79051152"E 697.95 feet; thence S10 08108"W j' 512.56 feet; thence N79°51'52"W 743.80 feet; thence N6702310011W 66.00 feet; thence ' I N22°37'00"E 510.35 feet to the point of beginning. Also a 66 foot wide parcel located jl in part of the SW; of the SEk of Section 19 and in part of the NWZ of the NEk and the NE4l1 of the NWk of Section 30, all in T29N, R18W and described as follows; Commencing at the one-quarter corner common to said Sections 19 and 30, also being the point of i beginning of this description; thence N00003'26"W 425.04 feet along the west line II ~i of said SW; of the SE4; thence N18°09'19"E 406.14 feet; thence N64009'1111E 286.37 feet; ° thence N26 57141"E 113.96 feet to the southerly right-of-way of the town road; thence ° S80 13102"E 69.08 feet along said right-of-way; thence S26°57'41"W 156.57 feet; i thence S64009'11"W 280.56 feet; thence S18°09'19"W 367.55 feet; thence S00°03'26"E 432.95 j I feet; thence S31°15'00"W 482.68 feet; thence S22°37'00"W 524.96 feet; thence N67°23'00"W 66.00 feet= thence N22°37'00"E 529.95 feet; thence N31015100"E 469.17 feet to the point of-beginning. r This .......is homestead property. its-MY i (is) (kXWXX •25 i Exception to warranties: Existing highways, easements and rights of way of record. Ij Dated this day of , 19..9..... . (SEAL) (SEAL) I' D avid D. Co r I 6 (SEAL) f - • ......~t Ij AUTHENTICATION ACKNOWLEDGMENT i II Signature(s) STATE OF WISCONSIN ST. CROIX -----------------•..County. ( authenticated this I day of........................... 19...--- p ona y came before me this : ~a..:... day of J t!_. d C _ - - 19..90.. the abov~natifedj Da _ over and Gtarol ...oyez husband and wife . ' TITLE: MEMBER STATE BAR OF WISCONSIN • (If not, ..,..x.11.. authorized by 1706.06, Wis. State.) j to me known to be the person who executed the forego mstr~nt _d acknoC the same. j i' THIS INSTRUMENT WAS DRAFTED BY n ` f Attorney David J. Estreen it 62? 52sL'5fiH'_SEYd1st _ r~ hI/Z.SO iV Wz ..~.4l21b. ..-.1..!.. `........L_....._•--••---•-•-_. I~ Hudson..... i Notary Public County Wis. (Signatures may be authenticated or acknowledged. Both My Commission is perms nt. (If not, state exp' aY n are not necessary.) I date: 19 -Names of persons signing in any capacity should be typed or printed below their signatures. Rdrto STATE BAR OF WISCONSIN FORM A88 No. o. I 1982 Stock No. 13002 DOCUMENT NO. DATA II WARRANTY DEED - II THIS SFACE RESERVED FOR RECORDING I STATE BAR OF WISCONSIN FORM 2 -1988 I j , +I 461.14 REGISTER'S OFFICE l ST. CROIX CO., WI ! David D. Coyer and Carol J. Recd for Record Coyer, as his Wife and i .......in- her..own r 'ht at UV 0 3 1990 l! 2:10 P. M II . .b..... conveys and warrants to P...h....il...li.P....._....$.._..._......-----...,gY._..:....$.. N 0 burn and Pe S 0 urn ----...husband.-and--wift: 8 - ' Regtsferofp .,..as..suzxa.~tnzshz msz~t~~•..RZ4R~?G.~Y..... ! I i ! RETURN TO I 'i the following described real estate in - St. Croix i .County, I! State of Wisconsin: I I I Tax Parcel No: ! ii That part of the SW4 SE; Sec. 19-T29N-1118W lying South of Badlands Road ex _%Vt_ I the East 610 feet thereof, NW4, W, NE4, Sec. 30-T2911-1118W, excepting therefrom the following described parcel; A I i and the NWk , parcel of land located in part of the NE4 of the NW4 a of the NEk of. Section 30, T29N, R18W described as follows; Commencing ii at the N4 corner of said Section 30; thence S31°15'00"W 469.17 feet; thence S22°37'00"W I 19.60 feet to the point of beginning of this description; thence S79°51'52"E 697.95 feet; thence S10008108"W 512.56 feet; thence N79051152"W 743.80 feet; thence I jj N67023100"W 66.00 feet; thence N22037100"E 510.35 feet to the point of beginning. ~i Also except a 66 foot wide parcel located in part of the SW4 of the SE4 of Section 19 and in part of the NW4 of the NE4 and the NE4 of the NW4 of Section 30, all in T29N, I R18W, and described as follows; Commencing at the one-quarter corner common to said Sections 19 and 30, also being the point of beginning of this description; thence I N00°03'26"W 425.04 feet along the west line of said SW4 of the SE4; thence N18°09'19"E i 406.14 feet; thence N64009'11"E 286.37 feet; thence N26057'41"E 113.96 feet to the southerly right-of-way of the town road; thence S80°13'02"E 69.08 feet along said i right-of-way; thence S26°57'41"W 156.57 feet; thence S64°09'11"W 280.56 feet; thence S18°09'19"W 367.55 feet; thence S00°03'26"E 432.95 feet; thence S31015100"W 482.68 feet; thence S22037'0011W 524.96 feet; thence N67°23'00"W 66.00 feet; thence N22°37'00"E 529.95 feet; thence N31°15'00"E 469.17 feet to the point of beginning. This is homestead property. I (is) Pt~ast9 I I I, Exception to warranties: Existing highways, easements and rights of way of record. ~I I I Dated this day of I 19..0-. 9 I f TNNA~FAA 0 (SEAL) r (SEAL) 4 D vid D yer ° .(SEAL) . 1(SE")'. • . Carol J. er • y....---...................-....0.. rJ AUTB$NTICATION I ACHNOWLLDCiDIRNt;,' Signature(s) STATE OF WISCONSIN ST. CROIX as. authenticated this day of......_. ...............County. ..................119 P songlly came before me this II ij ................day of the above named Dav d over an Carol J. Coyerl_-•----••• - TITLE: MEMBER STATE BAR OF WISCONSINu$-"'d1`~ - I i !I ' (If not , by $ T06.06, Wis. Stars.) ~ authorized to me known to be the person who executed the for ' g instrument nd acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY l Attorney David J. Estreen ..c~... ,I ' 21 S 6 econd.'Street - ~~t~,oEGLSo Hudson f--W-l 5406---------------------------------------- Notary Public (Signatures may be authenticated or acknowledged. Both My Commission is " state Wis. are not necessary.) pe anent~. If not state expiration ~ I date: i.••••.C..........-----+ 19..~d) I .Names of tenons signing in any capacity should be typed or Printed below their signatures. I- I. SEPTIC TANK MAINTENANCE AGREVIENT St. Croix County r+ OWNER/BUYER ~ti-ti~~ e c cS . b ;r w 0 ROUTE/BOX NUMBER Fire Number 0 CITY/STATE ZIP HF_ of NN PROPERTY LOCATION: `f•N(,VSection jo T .2R N, R 1P W, Town of l3erT-s 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 licens'ed' 'sept'ic tank pumper. What you put into the system can a ect t e unct on o. the-septic tank as a treat- ment*stage in the waste disposal system. St. Croix Countyy 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 s'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. I/WE, the undersigned have read the above requirements and agree 00 to maintain the private sewage disposal system in accordance with the standards set forth, herein, asset by the Wisconsin Depart- o- ment of Natural Resources. Certification form must be completed .b and returned to the St. Croix County Zoning Office within 30 days of the three year expiration.date.{~ ,n SIGNED- DATE QQ J ~,ti,~ _ l 15 / 9 0 St. Croix County Zoning Office 911 4th St. Hudson, WI 54b16 386-4680 Sign, date and return to the above address. INDUSTRY," w, KtF'UK 1 UN 5 DIVISION LABOR AND P.O. BOX 7969 HlhI REE~ATIONS PERCOLATION TESTS (115) MADISON, WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/ OT NO. LK NO.: SUBDIVISION NAME: A - 4 30 /T29 N/R/,?E (or)W ui~ti°,PEti A_-toe of --,no * Mertes COUNTY: MAILINGADDRESS: act,x R 111 06r- Uu ~3/o tai 9~v/ ,lo C.t. pvas D./~ oB eTS N O S ( ) ~t I f e ~t7 IiaEZ USE 012-- L/ Z 7 DATES OBSERVATIONS MADE NO.BEDRMS.: COMM R IALDES RIPTION: TESTS: PROFILE D1 ERCOLATION Residence New ❑Replace moo I ^ l O NO(~ • (S - 1 ~f ~l D .y0 t) • I S' 1 C7 Fop, Of i C k / 7- /n) S-, e6e- PO (E I3 LLYr R9t~PN RATING: S= Site suitable for system U= Site unsuitable for system OQ STI . MOUND: Q S [:]U IN-G ©S E: SYSTEM-IL G TANK:IRECO 9 T SYTiS 3 loptcauuE~T/~u~L SS QU Q S DU y E PLAWle j7• iko -ivsr d3 E /'/Glvv - 8 I13e 7 f 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 SG S ~u7 Sl, CL S~f 77;AC- 104 BORING TOTAL ELEVATION DEPTH TO GR UNDWATER•INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. OBSERVED HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) _ I Z o /i gN . s/ 1081 Ti1.u cs y G t~ z /S(, 03.7G' fie- ISM 9`aN:s/.yAae S/ _ -j /Z v o -.0 6 S/ a " U _ N • s/ ISO B. yriBo-C~f. _9N fo Si•L)y >f~ CDS~ oroe oE.vfF-- t s/~ b/o~,~y r 'vlAta.p;t 1C. 491srw~T 6 y .r•0 n / Co ' Off. Q,.s. e~uM~ (r % f /yir .J. SuQ"Jf~I l~ Sid h B- 7Z /aS.3 G 2c~ z y sy. 13/OC, ,r r%/. M4APY if. asp 04 -61 14ex. ,pro>/cfo c Ly., ajJup t"p 'Sk. B- oR - 6,v o 7--T . ' o B- 7 -7 z~ /DD. S& 7'z,v Z~ Z 0f_'0 i CA C To i3 oR£ - co SU,~• Aee_ F/C/11T/&j r of ~ C PER OLATION TESTS IN C S 3 S~. $Tify-7Y~ c EST DEPTH WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLIN INTERVAL-MIN. / Z" PERIOD t PER INCH P. r /OG, Q s Z c P-3 702.0.~ Z = P- o P. M P- - v~ 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. ~y!O / Fob ~Rt~ ~,_(~,-~3 see- Pc oT P~~w - sC•tTE s~/447- i 4741 . -F _ i 3 p4 1 y" ~ ll Rt ~ S ~ E 7 s%r 1 GT Ti. Go-v T_ i 47 N Qlrivc°S ,SvcpCSG Z//v 1r-9 _ S -v17 i L 40 _ SSG 3of o~ _ sod • / s 172 yep ,3 f! Li'-S><UC~ --QQ ~,s s c r 79) C,rPo S.r.c~~... /3r G. l cv c ~I~ T,~~~i",• r _ 44 W/-V 00 w 1 l r.. t 1, 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. NAME (print): TESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. 16 ^ l' f'Q ADDRESS: 655 - - CERTIFICATION NUMBER: PHONE NUMB(optional): ROBERT ULBRIGHT Z f ? 2 3J?6 -.0 LA IdINN. INSTALLER 6 DESIGNER LIC. NO. 00663 CST DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD•6395 IR. 10/83) - OVER - S C~ • - i ~ ,rp ~ ~M,o r v o. N 04 0 cA J b e° o c i~ ~i ~ Ov 0~ O O • Y O ~ 'U N i r ~ W o ~ a ~o r a - i rp-~~Ltl~? Z . M~ccn ~ V1 mZ? "I b w y ~ C1 C ~'O ~WO ]7 N N N DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, , DIVISION A AND PERCOLATION TESTS (115) MADISON WI 3707 P.O. BOX 76 HUMAN RELATIONS (H63.090) & Chapter 145.045) LOCATION: SECTION: OWNSHI MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: SW 1/ SW 19 /T 29 N R 18 E (or) W WARREN XXX XXX COUNTY: OWNER' BUYER'S NAM MAILING ADDRESS: ST. CROIX PHILLIP OGBURN 6310 132nd St. N., WHITE BEAR LAKE, MN 55110 USE - - DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLATION TESTS: Residence 4 k]New ❑Replace 6/21/90 6/21/90 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U ®S ❑U x0 S ❑U ❑ S [:]U 0 S ❑U 12' x 68' field If Percolation Tests are NOT required DESIGN RATE---------] [Ffiloodplain, any portion of the tested area is in the under s.H63.09(5)(b), indicate: n/a I indicate Floodplain elevation: n/a PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 1 77 97.1 none 77 .6' bkts 2,5' rdls w/gr. 3.3' bnms. B- 2 54 92.2 none 54 1' bkts w/gr,cob 1.8' bncs w/gr;cob 1.7'bncs w/g COO 4.15' . B- 3 .120 97.6 none 120 .4' bits w/gr 1.9' bums w/gr,cob 2.9' bncs w/gr, B- 4 86 96.8 none 86 .7' bkts 1.9' hnl .8' rdls w/gr 3.8' bums. B- 5 106 9529 none 106 1' bkts w/gr 7.8' bncs w/gr,cob,rock. B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R D PER INCH P- 2 18 none 3 .5 P- P- 83 none 3 } 6" drop in 3 min. period P- P- 3 .5 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. SYST ELEVATION Qn- 7 I E . JJ4_ oo s potwing area private drive' F- .5 cut i der 3 t ~i~4r1r waterway e ~ o4ae ` Cowin TiilT s sip - - __11+ I t 7~ . ale, 1° Bp , assume lo+o.o tb of Ana 1. /j7 v ""T-0c L_ a _ p boring., i I tperk. ~~..r,.--~s I, the undersigned, hereby certify that the soil tests reported on this form were made r> i~ ,t4brit vJft4feWOCC~UT~s and methods specified in th VVy1~~js onsin Administrative Code, and that the data recorded and the location of the tests an * unacceptable bo'ringp - CL layer w~Ch~n filtration area. NAME (print): DAVE FOO&WTV TESTS WERE COMPLETED ON: Wensed Perk Tester & Plumber 6-21-90 ADDRESS: Fo#3233 08289 gerty Heights Rood CERTIFICATION NUMBER: PHONE NUMBER( optional): RnSERTS, WISCON IN 54023 Phone 749-3656 CST SI ATURE~ P c DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DI LHR-SBD-6395 (R. 02/82) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To b Pte and accurate soil test, your report must include: 1. Compl description; 2. The use must clearly indscate whether this isa residence or commercial project" 1 MAXIMU!` umber of bedrooms or commercial use plann6d; 4. Is this a ne or replacement system; 5, Compl~" -j tabilkV rating boxes. A SITE IS SUITABLE FOUR A 14OLD.ING TANK ONLY IF ALL 0711 HE F EMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLE, -.he abbreviations shown here for writing profile descriptions and co ,1 _ plot plan; 7. . , t GIBLE diagram accurately locating your test locations. Drawing to preferred. A may be used it desired; B, jr benchmark and vertical elevation reference point are clearly shown, d are permanent; 9. A appropriate boxes as to elates, names, addresses, flood plain data, percolation test exemp- tir "propriate; 10. If information (such as flood plain, elevation) does not apply, place N~A. in the appropriate box; 11. ~ the form and place your current address and your certification number; 12 legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil and Textures Oxber Symbols si.._ Stoila (over; 10") BR Bedrock cob - Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone s -Saari HGW - High Groundwater cs Coe 3=rd Pare - Percolation Rate reed s - i~. n 4anci W - Vvc11 is ( iy - Sar{ fI Bide - Building is Loamy Sand > Greater Than sl Sandy Loam < - Less Than r., `I Loam Bn Bro~,vri sil Silt Loarn BI - Blank 51 Sil! G, v cl Clay Loam y scl Sandy ";i~.y Loam R - E r sicl - SCI- C L,>sim mot - Mc ss Sa (ly wl - wit, sic - Silty C' fff - fete, r Sint c _ Clay CC - Corr )arse nt - Peat MITI - Many., , um m - 1`0uck d - distinc! p - promirt. HWL - High Jet, also x. sue r I' Iuid vvasl~ . BM Ben-' VRP Ver erence Point A c -'y the t " _ A le 1 i posted pl,ior t} °e start 1'.at y:cesngixuGt c~ 1: Form-8TC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP /J ,~,cc..✓ SEC. /y T ~1,- N-R /Y-W ADDRESS ~,r,~~1.,, . ST. CROIX COUNTY, WISCONSIN SUBDIVISION % LOT C5 LOT SIZE d_ ~e y- e- PLAN VIEW Distances and dimensions to meet requirements of ItiRR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 '`6 r i 2 s r' = b js . a INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Sta c a s / i Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: 14,6,;d 4l,G,ot` Liquid Capacity: j;C-r_1 Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: ' Number of feet from nearest Road.: Front, Side Rear, 0,16 OJL feet • From nearest-property line Front,OSide10Rear, O 4/21A feet Number of feet from: well , building: ye` (Include this information of the above plot plan)( 2 reference dimensions to septic tank) PUMP CHAMBER s Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: J Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft, Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: Number of Lines:_ 'j _ Area Built: Fill depth to top of pipe: "/.;z Number of feet from nearest property line: Front, O Side,. Rear, Pt. Number of feet from well: O O Number of feet from building: (Include distances on plot plan). t 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 sytems? (Check one). HOLDING TANK F' 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, Ft. 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 DEPARTMENT OF INDUSTRY, I,AIROR & HUMAN RELATIONS INSPECTION REPORT FOR SAFETY & BUILDING P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS DIVISION OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 5)3p707 p SW, SE , 19 ,28, 18W 1=T`CONVENTIONAL ALTERATIVE State Plan 1.D. Number: ❑ (If assigned) Town of Warren Ba dlnndQ ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION D TE Phillip Ogburn 6310 132 St. North, White Bear MN X02 /D- 91J BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REFC3 3 . PT. EL Name of Plumber: MP/MPRSW No.: ounty: Sanitary Permit Number: William Schumaker 6382 ST. Cr ' 128788 SEPTIC TANK a ts , MANUFACTURER: LIQUID CAPACITY: TANK INL TANK OUTLE EV.: WARNING LABEL LOCKING COVER r / , PROVIDED: PROVIDED: I3.( Y r t ?6. 9`S gc~ • ° ~ YES ❑ NO ❑ YES IVO BEDDING: le DIA.: u6h JITMATL.: HIGH WATE NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT O FRESH it t) ALARM: FEET FROM LINE: JAIRI E ❑ YES NO 'Ci ❑ YES NO NEAREST ~s S t MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIQNA NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN ❑ YES ❑ NO NEARFROM LINE: AIR INLET: WiQ PUMP ON AND OFF J ~1 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: D7"~ IAL AN or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue. CONVENTIONAL SYSTE r BED/TRENCH WIDTH: LENSTIT O. F DISTR. PIPE SPACING: COVER INSIDEDIA.: # PITS: LIQUID r TRENCHES: MATERIAL: DIMENSIONS DEPTH GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIP MATERIAL: NO.~JDIIS TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW IPES: ABOVE COVEI1: ELEV. INLET: ELEV. END: ,ryv,, / ~L 40 PIPES: FEET FROM LINE: AIR INLET: L e Lin NEAREST -75 -.A:56 > a2S MOUND SYSTEM: /D Db' Mound site plowed perpendicu ar 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. 7OVERTRENCH/BED Co PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED THS OF TOPSOIL: SODDED: SEEDED: MULCHED: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO YES ❑ NO STRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: AVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: DIMENSIONS TRENCHES: MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. D ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE ❑ YES ❑ NO ❑ YES ❑ NO INEAREST-~ 7-1 nn4 a Sketch System on in in county file for audit. Reverse Side. SIGNAT RE: TITLE: SBD-6710 (R. 06/88) Zoning Administrator ~~LHR SANITARY PERMIT APPLICATION _ In accord with ILHR 83.05, Wis. Adm. Code COU STATE SANIT Y ER # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ L7 8'f X 11 inches in size. if revisio rto evious 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 /1, -to -Al <Z-a '/a S j T ,p 4, N, R /f'E (or) PROPERTY OWNER'S MAILI ADDRESS LOT # BLOCK # ~.3! O T ,j.~ t CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned ❑ VILLAGE . e.✓ all OT3 ❑ Public 241 or 2 Fam. Dwelling- # of bedrooms i PAR L TAX NUMBER ) l`! J III. BUILDING USE: (If building type is public, check all that apply) O _l 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. TYPPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.S New 2. ❑ Replacement 3.E1 Replacement of 4. ❑ 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 6seepage eepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12.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) ~/s~ELEVATION O FA a a r 3 ~~r Feet 7' 7~~' -;Z d Feet CAPACITY VII. TANK Site in allons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete structed glass App' Tanks Tanks Septic Tank or Hold in Tank z(JD Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans. Pllumber's Name (Print): l Plumber's Signature: (No Stamps) P PRSW No.: Business Phone Number: (J( I/►4 AOL S c~l 441 041C ~Gl fr 3 v~ Plumber's Address (Street, City, State, Zip Code): 4C 9-5- GG~G 7 e, et s IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing A ent signatur No Stam Approved ❑ Owner Given Initial C~ Surcharge Fee) Adverse Determination ` a© 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 pumpod 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; 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'SUACHARGE 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 conplatod in full and signed by the owner(s) of the ptoperty being developed. Any inadequacies will only result In delays of the pstm1t issuance. -Should this development be intended for resale 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 appgopciate deed recording. _ Owner of property "'PhtL_L_t4> 04k 001 1 - N B of /U W of - Location of property*'_LW_1/4 _.,c- /4,, Section T i P R V Township (~Glrreyy Mailing address Address of site Subdivision nave -Y7 ut ~ ,1-- Lot number Previous owner of property ~av~d C e Total size of parcel g' $ Ac. Date parcel was created /lam Age all cognacs and lot lines Identifiable? No is this property being developed lot resale Caper house)? No Volume g 7 and Page Number 7(Z as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION T116 FOLLOWINCt A WARRANTY DE><D which Includes a DOCUMINT NUMBQR, VOLUMR AND PACs NuMasn' and the 82AL OF THR R9018TSR OF DBBDS. In addition, a certified survey, it avallable, would be helpful so as to avoid delays of the reviewing process. it the deed description references to a Ceitilled Survey Map, the Cactifle0 survey Map shall also be required. PROPERTY OWNER CERTIFICATION i(we) certify that all statements on this form era true to the best of my (ouc) knowledge) that t (we) am (ate) the ownerts) 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.o //_l 3• j and that i (Ye) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, tot the construction of ssld system, and the same has been duly recorded In the office of the County Re is ac of Deeds, as Document No. elgnatuce t Owner BignatUW of Co wnec (it Applicable) 15 q0 L31__;70_ I. ■ . • 1., ..I. ~ .1- Date offs ign tuts Date at 91 natuce I' DOCUMENT NO. i I~ WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2 -1M ~I Ujun _ REGISTER'S OFFI CE !I I co, 1 I. David D. Coyer and Carol J. Coyer, as his wife and in STR. ~C'd Mf or ix . (I own right Record her I' 03 1990 I 1210 P. conveys and warrants to ....Phillip. N._ Ogburn and Peggy S: Ogburn /i1 . husband and. wife,. as survivorship. marital property. V Register of Dee* Ii li RETURN TO the following described real estate in St-Croix .......................County, I I I State of Wisconsin: Tax Parcel No : ..............7said A parcel of land located in part of the NE4 of the NWk and the NWk of the NEk li Section 30, T29N, R18W, described as follows; Commencing at the Nk corner of sectio I~ 30; thence S31015100"W 469.17 feet; thence S22o37'00"W 19.60 feet to the point beginning of th is description; thence S79o51'52"E 697.95 feet; thence S10608'08W li 512.56 feet; thence N7905115211W 743.80 feet; thence N67023100"W 66.00 feet; thence N22037'00"E 510.35 feet to the point of beginning. Also a 66 foot wide parcel located ~i in part of the SWa of the SE'k of Section 19 and in part of the NWk of the NEk and the NEk ~I of the NWk of Section 30, all in T29N, R18W and described as follows; Commencing at the one-quarter corner common to said Sections 19 and 30, also being the point of II . beginning of this description; thence NOO00312611W 425.04 fee t along the west line II of said SW'' of the SE'k; thence N18009119"E 406.14 feet; thence N64009111"E 286.37 feet; thence N26 57141"E 113.96 feet to the southerly right-of-way of the town road; thence ~I S80o13102"E 69.08 feet along said right-of-way; thence S26057141 "W 156.57 feet- I! thence S64009' 11"W 280.56 feet; thence S180091 19"W 367.55 feet; thence S000031 26111 432.95 feet; thence S31015'00"W 482.68 feet; thence S22037'00"W 524.96 feet; thence N67023'00"W 66.00 feet= thence N22037'00"E 529.95 feet; thence N31015'00"E 469.17 feet to the point of-beginning. ; i I This lS homestead property. $ - (is) O mom • ES I Exception to warranties: Existing highways, easements and rights of way of record. i i i Dated this day of 19..90 (SEAL) 4 _....---•-.(SEAL) . . David D. Co r - - (SEAL) a (SEAL) ' • ......Cs .....coyer I Signature (s) AUTHENTICATION ACKNOWLEDGMENT - STATE OF WISCONSIN l - ST. CROIX 11 authenticated this day ot___________________________ 19 County. P on y came before me this . ~ J I $sy of • - -------19_.90. the aboVe`naaied~ Coyer and _-Gtarol J. Coyer _ I ban _ hus d and wife - - - - TITLE: MEMBER STATE BAR OF WISCONSIN ---I ~ • I (If not, Ii prA1. by 1 706.06, Wis. State.) - - - 1113 to me known to be the person who execuQithe fore7n~ insnt~ nowled the same. THIS INSTRUMENT WAS DRAFTED BY(( Attorney David J. Estreen lt" • --~v------ s2r-"sz=~ui~a'-srr~z=t------------------------------------•-•-------- • ~ ~ f~ rZS o Notary Public .......Count, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permsvenn .t-.- ~..If.. n n .o state ex at' n II are not necessary.) date: = 19 a1 l ) I 'Names of persons signing in any eapaeity should be typed or printed below their signatures. II Q"s-MIN- sTwr FORM M No. . gwt- 1 1982 98E rl Stock No. 13002. ii DOCUMENT NO. WARRANTY DEED - THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-19a 461114 L~ - c REGISTERS OFFICE - ST. CROIx co., WI Recd for Record ~j David D. Coyer and Carol J. Coyer, as his wife and n her ` i own right l AUG 0 31990 12:10 P. Mn~ - - li conveys and warrants to ...Phillip_ N. Ogburn and_ Pe~~y S.__O~burn, Register of Deeds husband. _and..wife3..as..suer.rxlzQxshxp._tu,3x~ta~..Rx48~r_ : I I - - _ - f RETURN TO j the following described real estate in Cro St. ix I ...........................County, - State of Wisconsin: I Tax Parcel NO: That part of the SW4 SE4 Sec. 19-T29N-R18W lying South of Badlands Road, except the East 610 feet thereof, NW4, W2 NE4, Sec. 30-T29N-R18W, excepting therefrom the I; following described parcel; A parcel of land located in part of the NE4 of the NW4 and the NW4 of the NE4 at of Section 30, T29N, R18W described as follows; Commencing the N4 corner of said Section 30; thence S31°15'00"W 469.17 feet; thence S22°37'00 "W Ii 19.60 feet to the point of beginning of this description; thence S79°51152.1E Ij 697.95 feet' thence S10008'08"W 512.56 feet; thence N79°51'52"W 743.80 feet; thence fI j N67°23'00"W~66.00 feet; thence N22037'00"E 510.35 feet to the point of be innin . I Also except a 66 foot wide g g i parcel located in part of the SW4 of the SE4 of Section ~ 19 and in part of the NW-4 of the NE, and the NE4 of the NW4 of Section 30, i ~ all in T29N, R18W, and described as follows; Commencing at the one-quarter corner common to ! said Sections 19 and 30, also being the point of beginning of this description; thence N00°03'26"W 425.04 feet along the west line of said SA of the SEk• thence 406.14 feet; thence N64°09'11"E 286.37 feet; thence N26°57'41"E 113.96feet Ntootthel9"E i southerly right-of-way of the town road; thence S80°13'02"E 69.08 feet along said right-of-way; thence S26057'4111W 156.57 feet; thence S64°09'11"W 280.56 feet; thence I S18°09'19"W 367.55 feet; thence SO0°03'26"E 432.95 feet; thence S31°15'00"W 482.68 f feet; thence S220 3710011W 524.96 feet; thence N67°23'00"W 66.00 feet; thence I ! N22°37'00"E 529.95 feet; thence N31°15'00"E 469.17 feet to the point of beginning. I This ........ls homestead property. (is) "100*9 Exception to warranties: Existing highways, easements and rights of way of record. ! I ! Dated this daY of • 19.- 90 I ' 4~.................. (SEAL) (SEAL) 5 D vid D. • (SEAL) l_ 1(SE.t) _ ' Carol J. yer 0 J AUTHENTICATION T~~ ~ . , Signature(s) ACHNOWLEDtiM$Nfi~' STATE OF WISCONSIN ST. CROIX as. -y authenticated this day of 19 -------------------County. Personally came before me this J~ day of - - - - - - 19.--90. the above named ! Dav d Co er and Carol J Co er - - - - • - - P----------------------------------•----------- i TITLE: MEMBER STATE BAR OF WISCONSIN _ hus----------------bamd -Auld .---W---- i (If not - • i l authorized by $ 706.06, Wis. State.) f i to me known to be the person who executed the fog instrumencknowledge the acme. THIS INSTRUMENT WAS DRAFTED BY j ! Attorney David J. Estreen 62Y • - - I Second Street ~ o ~ • r~~ eD f1 A GL_s u son,__W.j 54046................................................ Notary Public _Commission County, Wis. (Signatures may be authenticated or acknowledged. are not necessary.) Both MY is pe anent. If not state expiration I~I date: .----•--•--•------✓6Jw ! 19_.~) ~Nasss of Persons siEnins in any eavacity should be tyyed or printed below their sicnatures. N SEPTIC TANK MAINTENANCE AGREEMENT 03 St. Croix County 03 OWNER/ BUYER r f? w 0 ROUTE/BOX NUMBER Fire Number d CITY/STATE ZIP tjF_ of NW PROPERTY LOCATION:r!'NbJSection ja T 2R N, R IF W, Town of AO bf,'r S 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 licens'ed' 's'ept'ic tank pumper. What you put into the system can a ect the unct on o, t e•septic.tank as a treat- ment'stage in the waste disposal system. St. Croix County residents-mom be eligible to recieve a grant for a maximum of 607. of the cost-of replacement of a failing system, wh c'N 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 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. ,n SIGNED, DATE_ 15 /go St. Croix County Zoning Office 911 4th St. Hudson, WI 5016 386-4680 Sign, date and return to the above address. y DEPARTMENT OF REPORT ON SOIL BORINGS A ND SAFETY & BUILDINGS INDUSTRY,' M DIVISION LABOR AND P.O. HUMAN RELATIONS PERCOLATION TESTS (115) MADISON BOX 7969 (1-163-090) & Chapter 145.045) LO ATION; - OWNSHI MUNICIPALITY: OT NO.: BILK. NO.: SUBDi V1S1p V~ NAME: Sw 1/ s4/4 19 %T 29N 18E (or) w WARREN xn in COUNTY: WNEA' MAILING AUUH Su: ST. CROIX PHILLIP OGBURN 6310 132nd St. N., WHITE BEAR LAKE, 14N 55110 USE DATES OBSERVATIONS MADE NOL BEDRMS : 1COMMERCIA1 U R TION: PROFILE DE5 RIPTiONS: ER OLATION TESTS: f~esiacnte 4 ~ k]New :DRep)ace i 6/21/90 6J21/90 RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: W-GROUNDPRUMURE: 15 STEM•IN,FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) C~7 S ❑U ®S DU D S DU RS ❑U 5]S IU 12' x 68' field If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area i3 in the undtvr s.H63,09(5)(b), indleate: n/a I FToodplein, indicate Floodplain elevation: n/a PROFILE DESCRIPT;ONS BOfi1NG TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION pgSERVED ES , HEST TO REDROCK IF OBSERVED (SEE ABBRV. ON BACK,} 1 77 97.1 none 77 .6' bkta 2 5' rdls w/gr. 3.3' bnals. B- 2 54 92.2 Rolle 54 1' bkta w/gr,cob 1.8' bncs w/gr;cob 1.7'bacs w/F co B- 3 120 97.6 stone 120 .4' bkte w/gr 1.9' bnms w/gr,cob 2.9' bncs w/gr, B- 4 86 96.8 none 86 .7' bkts 1.9' bal .8' rdle w/gr 3.8' bnals. 8. 5 1,26 95.9 none 106 1' bkts v/gr 7.8' bncs Wgr,cob,rcck. B- IOi7L= i _95.7 (Vatenw) PERCOLATION TESTS 1 T=1 DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. p RI D 2 PFR D PER INCH 2 __18 .-none 3 .5 p P- P 8 none 3 a 6" drop in 3 man. period . -4 P_- 5 _A2 3 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. corrtai and vertical elevation reference points and shove their location on the plot plan, Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION gn at 7-T 7 K 71, 7,77 D7, - - r i woods • o>srl ...area---- p drive - . _t 5' T Cel ~N rLLy~l waterway, { - - proposed ftse dafaR Fi37S y a.• _ I . - * 3' I 3 le- ftala - 1` -501 w,..__.,C! A...B loo to of na>ilr bpriag woo" _a.-Ve-rk. I, the undersigned, hereby certify that the soil tests reported on this form were made At ibrlfbrif ' pMocRTM, And meth s sPgcif)ed in thq yi(~s~onsin Administrative Code, and that the data recorded and the location of the tests arc ? 1fYfaCt:eQtatrle ,b~r£ngs - layer tiilCDln filtration area. (NAME print ; L TESTS WERE COMPLETED ON: Limed Dark Tester & P)Umbar 6-21-Y90 ADDRESS; ROW CERTIFICATION NUMBER: PHONE NVMSER(optional): NSIN 54023 Phone CST SI ATURE i . { !DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tnstr r, 0I1-HR•600-6395 (R. 02/82) - OVER - II as vk6 o J a y~ 3` 3 Ya CERTIFIED SURVEY MAP Located in part of the SWJ of the SE} of Section 19, and in part of the NWJ of the NE} and the NE} of the NWj of Section 30, all in T29N, R18W, Town of Warren, St. Croix County, Wisconsin. NJ corner Section 19 _ 80th Ave T29N, R18W 6 °57i 41 -?--'r7 S80°1- . N2 . _ . 69.081 , T F0 . 113.96 E 66,1 IN ~'*r / • S28°57141,, c j M 1 i 156.57, W or ,y.. 041 i H ta6~~ .11 lo, 6p' ~6 N :~0Q9,~,"w 2 OWNER =M a1 00 - o 56 Phillip Ogburn 6310 32nd St. N. N o° White Bear Lake, Mn. 55110 13 -3 1~ z m /Z O -3 PQ O~ / /Cp 0 o m M LEGEND N off fD / Cu / /01i St. Croix County Section Corner Monument- ' Aluminum Cap in Concrete found. I w. rr c c Set 111 x 2411 iron pipe weighing 1.68 pounds tD D per linear foot. d D ~ IC T I i d--„-- existing fenceline et 4! I I d O O N I C S I7 7 ~ I IN SCALE r 1 200 100 0 200 N} corner Section 30 point falls on top of culvert- unable to monument Sk corner F with a stake. -unr Lline of the NW}-qf nnr+h section 30-29-18 Section 19 lice of the NEB of Sggtion 39v._ 661 PRIVATE ROAD EASEMENT ib / / wO north E south J line of Section 30 o ti S?WW un 67,60, I __Plafted lends CLE S79051,5?ItE 1 y 697.9 5 630.35 a: ~~5 0 i o / I 3 ':6: HUDSON, /a oo /v I Wis. r' Q' I, ° % 'Q ~NM 0 b LOT 1 d a~No SUR~a~ , 386, 344 sq. ft.) ".i$ 4 INCLUDING ROAD R/W o fb y / 8.87 acres ) o o ~ co ~I- ~ EXCLUDING ROAD R/W is 85081acres. ft.) rt ti Cn this instrument was N6)o _ ?,7,00"Ir N790511 211W 7 drafted by 43.80r Douglas J. Zahler 1 #90-43 °nPlatted lands ~~~~~OOgg~O ~ boo ~r~ ns pNb,~Ap aM '!NOSGOM • am,es buzddgui pug buTAan.ans 'uT aisuoos S STntpgn$ pugZ atgq Pup s94ngpgS Tf4 ;o Aqunoo aqq ;o aouguTPzO uoT aqg V£'9£Z aagdggo ;o suoTSTnoad 4uaaano aq4 qqz.M PaTtdouioao ~ttn; AT og a aosep pug P9Aanzns Aavpunoq aoTxagxa aqg ; angq T gggq 'P q.T TsTgg I"ti, jTaaaO OStg I uoTgggu9s9ad9a go9aloo g st dpw T_. S Pv-..; ('M,l9Z,£Oo00N zgaq og pauinssp 6t uoTgoas ;o auTT q/t ggnos-ggaou aqq 04 paouaaa;aa . aae sbuTages) •paooaa ;o sguauiasee tTp 04 go-aCqn.s ostg Taaag'3 'dgui uMOgs sr 'uTsuoosTM 'Aqunoo xToao •qS 'uaaavm ;o um0l 'M8TU 'N6Zs o zgd tg4 uo s UT ttp '0£ uoTgo.aS.;o hmN aqg h3N aqgpu~ H apagpo TMquauiasgg Ppou uT pug 6t uoT409$ ;o hZS aqg CMS qq q •buTUUTbaq ;0 4utod aggnT.zd apTM ~.oo; 99 p Oq 4oaCgns pug ggTM zaggaboS, aqg o4 499; SCOTS. ZL.OO.L£oZZN aouag4 1499; 00'99 M,.00,£Z°L9N a°ugg aousg4 .1488; 99'ZTS M118018000TS soueg4 :499; :49 08'£fi~L M.~ 6LN to°t4dTa°sap stg4 ;o butuuTbaq ;o 4uTOd 9q4 S6' L693 .►ZSJ t9o6o6LS LS 9ou9g4 ~ zn; oq 489; 09'61 MilOO,L£oZZS 80u994 1488; LT0696 M°61OO06SToT£S pagTSosap 9au894 zag4 ~0£ G g buTouaMmOD . sMOtt ; uoT4oas pips zauaoo N :uTSUOOSTM ~T4unoo xTOZ3 qS quaaapM uMOy 'M8t2i 'N.6Zs '0£ uoTgoas ;ozN ' aqg VAR aqq pug NMN aqg ;o N3N aqg ;o gagd uT p94900f pugt ;o taoagd V :sMOtto; sr pagTao gd pugt aqg ;o Aavpunoq aotaagxe aqq gpgq -sap ST paddvm pup paAanzns taoz aguasazdaz sT goTgM taozgd pugt aqg paddgm : dgya AananS paT;zgaao sTgg q p , uangbo d-c ' uoTgoaaTp aqq ~Cq gpgq pug pagTaosep 'paAan.ans anugg IuTSUOOSTM pTlTq ;o 'uabgq~CN uattEl I A;Tgaao ~Cga.zaq op .zo~Can.znS p Z 91VOlallUai S ► HOAMAuns O ■'L AUG 17 199010, JAMES O'CONNELL Register of Deeds 461509 f#L Groh CO., VVI CERTIFIED SURVEY MAP m Located in part of the SW} of the SE} of Section 19, and in part of the NW{ of the NE} and the NE{ of the NW} of Section 30, all in T29N, R18W, Town of Warren, St. Croix County, Wisconsin. N{ corner `o _ 80th' Ave Section 19 = S800 131 110 2 _ E R18W o 6 9.08, N26 - 9.081 0 1 5714111E 3 1:3 3.96' / 66~/ rt 1-0 S i a 5260 1 rt 57 411fW 1 / m 66 i 1 156.571 s i 1ko09i ' SCO 11 OWNER 9 o 7 h N o a /g6u Phillip Ogburn o co 6310 32nd St. N. N ° ~o / o White Bear Lake, Mn. 55110 CD o o area Low o m rn o / /`O C~ (D LEGEND Pa 0, St. Croix County Section Corner Monument- Aluminum Cap in Concrete found. 0 0 r 0- w 0 oF / 0 0 '9 Set 1" x 2411 iron pipe weighing 1.68 pounds T ~o °n 1 o per linear foot. 0 ( is a o 1 0 -3 1 10 Iv N d fl--- existing fenceline C er ~ ,t . a I ° I Cr a C i co 1 _ i0 a rt o ~ ~ ~ 0 0 i y c P rt SCALE •a I N 200 100 0 200 N{ corner Section 30 I point falls on top of culvert- unable to monument S{ corner ( with a stake. north line of the NW}-Qf_ Section 19 north Jirle of the NEI of SpCtion 30 section 30-29-18 / / 66' PRIVATE ROAD EASEMENT / / as described In Vol. 877, Page 578 V11 'K 114 ~ i llG 1 1990 ,T, i l:u X CJUNiY : cm mica, .V:PAfr/sP11',f`LNIN , north C south } line of Section 30 o Ora +y!~~1 AND 70,Nj," ~ cQItivArim oy(0 67.60f I unplatted lands S __~/r Z > rr ' i 790511 52 p. z I 697.95,630-35, of mnon, o t ; •n~ IS V ~ 1~iS. f *s a ~ O /v ' ~qf .:..awe'' ~ •'i ty' ' LOT 1 su , Q o ' ys r:~.a'v~." ~ 386,344 sq. ft.) 1 INCLUDING ROAD R/W tia ;o / 8.87 acres ) o` ; i~ 352,175 sq. ft.) 8.08 acres E ' XCLUDING ROAD R/W a / • 1 N 7 this instrument was drafted by Ns'70 100"4' N7go51f52'fN , 743.801 Douglas J. Zahler H90-43 nn_platted lands n - cn J t n ra/ r URVEYOR'S CERTIFICATE do hereby certify Allen C. Nyhagen, registered Wisburnconsin ILhaveSsurveyed, described and hat by the direction of Phillip epresented by this Certified Survey Map; apped the land parcel whichof~theland parcel surveyed and mapped is des- hat the exterior boundary -ribed as followsi' Gated in part of the NE4 of the CNW4 roixndothe NWWi fthen; A parcel of land to Town of Warren, St. NE4 of section 30, T29N, R18Wr Commencing at the Nh corner of said section o further described as followsi thence S22 37100"W 19:60 feet to 30; thence S31°15'00"W 469.17 feet; thence S79°51'52"E 697.95 the point of beginning of this description; "W 512.56 feet; thence.N79°51'52"W 743.80 fee ; feet; thence S10°08'08 N22°37'00"E 510.35 feet to the in Together with and subject to a 606 foot wide Private thence. N67°23' 00"W 66:00 feet; thence of Section 19 and in point of be g art of the SA of the SE k all in Road Easement nt located in p as Section sh30, own on this part of the NWT of the NE4 and tC~oiNEx ~e of County, the NA of *.Section T29N, R18W,.Town of Warren, St. map,. and described in Vol. 877, Page 578. Parcel also subject to all easements of record. rve Ma is a correct representat I also certify that this boundary dsurveyed and described; to scale of the exterior oundarrovisions of Chapter 236.34 of the. fully complied with the currant p ion Statutes and the 'Land Subdivision Ordinance of the County 0 Wisconsin St. Croix in surveying and mapping same. ~'~~,~~9aeoa aao !o STMT. , 3 WJDSON;, off' a Vol. 8 Page 2259' `SU5,4 O 9- + 2 N I d O 4 O 3 ~ O ti h c C 1 ~ 'I ~ T c o a o N O 1 7 a CV N L 0-0 a a ~ ~ cam vas a d w a s Lobo c~c o Irv c x0 Q w O O rn (V y OO y c0 N a It= m O .X W e 0 O Y C u M Y G O M.0 c MOIL 3Q N O N N 3 L 0-0- 0 ^ 3 N C Z N C V- T~ 7 c6 U).O TOrn co LL o d w 0) C N 4) 0 04 7.> o >.O.N wO Q w &LLD U)- i 3 ~ v a~ uJ II Z E a~0 Z = o v € ` Z m N a CO M P c w O Z $ c U c z f~A F W O M N N 7 7 f0 _O Q C4 O. d t o CL 0 v Z Z Z 0 o m E '0 C'4 E V N N L L..I CL Y c cca E j Q C M N U1 U) Z > p S a Z aaa N a 7 o N l V ~i 00) N U) J V l a Y N O y 0 N Q O a > 0 11) d L m N m N V U) I~I O ,O M Q Y Cn co CO 0 ~ 7 N o o II a c E o o c 3 0 Q c l a N u LL o o o la co °O N O S I O O d~ N o d i E C ai WE I d c c~ a ~a i..i N >>N I O) co O c E r2 (n O M 9 i O C) Z V~ d C d z a6 a € ! U IL 0 C rrww• a ` m ~ c°~a~ ,vic0 "~1 A a N a O N Co O a0 nr 3 C N O m p~ 0E09 c c 2 O N Oh c 0 -0 Cu O N ~ ~ t N 7 C co O0 U 1 x m'a y~ 0t Of 2 f0 a C g Ma <S2 OLE NM m (a 7= -00) .T -0 NO N 7 c ;j LO y -0 y M p~ N v o`er x~ 0.0 a 0~ c > CL 0) f0 co i ~t L o 3m~ 1 2 ~mcy°EErn z y`m v z u0 c E~ m ymYyy ~m 3 O k N LL C T O N p y 5 o ~ c c d 3 0 ~ ~ < t0 mQ o m o maLL Q F a y Q F- y (a (L 3 a 3 M r~ ~ z z 3 ~ Z E E O N> I L co d ~ CL m c') F- f4 I O Z a c c Q 'o W H Cl c E c N ~ N N N U) C C. N y N C of N d `i y c O z z z 0 1 z co z N 1 I « « d d ~1 N N > I m £ O l0 /L! > 0 a IL It j N H W 3 o 0 N N N ,I ) I CI) 0 0 ~ 1 ag R,CL CL CL IL CL CL a g M 3 0 U) 00 0 00 00 o N ° o o ~o ~°oo _ O ) c > m L ~a z U) L71 < L m ¢~rto N O oc o H c 0 C r Q c rn rn 4) 0) c V N * H f>6 f> O o p p y 1 O co ao 0 p C, 4) n y a 0 r N N ~p C E L O M U v 0 Z c z Ui 0 Z c H «'ik a ! €IL 1 €a L: CL C d c 1 d m c _1 A 0 L2 0 viCi 0 -2,111 c 3 1 ' t j= y FILED AUG 171990+- JAMES O'CONNELL Q 461.509 §L~IC°.,wi ,ten CERTIFIED SURVEY MAP Located in part of the SWi of the SQ of Section 19, and in part of the NWi of the NEJ and the NE} of the NWJ• of Section 30, all in T29N, R18W, Town of Warren, St. Croix County, Wisconsin. NJ corner '-80th'A - v e ection 19 T29N, R18W o S80o13'02rrE- ° i~ 1N26 57,41nE 69.08, o 13.96,. S260 57r41nW a ,Lg6.i 156.57, °c 9 011 OWNER 0 CD o o / S61`o~9 Phillip Ogburn N 0 CD /C13 6310 32nd St. N. o / /o ^ White Bear Lake, Mn. 55110 o . ~Low area CD - LEGEND o> _r"°/ St. Croix County Section Corner Monument- _ N f1 I C Aluminum Capin Concrete found. rt W / rt I N / 0 0 / Set 111 x 2411 iron pipe weighing 1.68 pounds i* 1 m rn O 1--. S per linear foot. d 7 Id 'A o 1 = Iv rt IW is existing fenceline ~ s rt rn I j a o o 1,. flo SCALE I 200 100 0 200 NJ corner Section 30 I point falls on top of culvert- unable to monument SJ corner ( with a stake. north line of the NW}_Qf_ north -1irle of the NEI of SvGtion 30 section 30-29-18 Section 19/ / 66' PRIVATE ROAD EASEMENT M,., as described In Vol. 877, Page 578 AU G 17 1990 8T. C1iGIX COUN1Y ` OMi'REH34+W'PAWAPLA1`LNINC; north E south J. line of Section 30 AND70Nfl*_' C"_ ,A1,Jiif(pC oti/ /h 67.601 I -platted lands . LLr / 79051, 52"E 1)y z ,L s: 697.95, 630. 51 r'..C~ r D S. 0 IN 41 :i j h. O ~4 S u LOT 1 01 Ito, Ja+ cn 386,344 sq. ft.) ; 8.87 acres )INCLUDING ROAD R/W co ro c„ C3 lv 352,175 sq. ft.) ;r 8.08 acres )EXCLUDING ROAD R/W g a N ry / U1 this instrument was N62o23i N790511drafted by 00„W 52„W 743.80, Douglas J. Zahler I #90-43 unplatted lands 'I` Vol. 8 Page 2259 AS BUILT 'JANITAKY SYSTLM 10-VURT ~ •l'uWNUtll' UWNL K-~~ ` - ST, CKU 1X CUUNTY, W 1S1:UN5 IN AUUItLSS LU'1' S 1'LL - - - SUUULVLSIUN LU'1 PLAN V 1 LW ULdCUnead and diuandione t0 u►eet. reyulri:u►etutb ut Hb3 .1LUyTHING WITHIN 1UU h_'L.LT UI' SYS'1'1•:M _ j y3 ' - - I dil a e o th Arrow w~ - Sc .LE ►tK: (Peruwn~tnt rntarrdnce Pu1ut) LICULL lbu . 5, k ,r w-0oo ANIC 1lk:NCHMA " ~~~►t--_Lf1_o.0 ~ t ~1t s-G f:levacion of vsrtlerit~ .retarance N lug.: d G G l.tyuld LapaCll.y . Oroa-z ..►►►I►ulu c►►vcr ul.•vut iu►► SEA'1'IC TANK; MJ►nufwcCUrer:~ ---Tank u► Dl wub e r o f r in d o n cover T a r►k U uL.. 1 • I c lwf it t- 1 u 1 i. -Y~ Tank Inlet Eldvation: - - PUMP CHAMBER Nuu~U~ i 1 t a l l u~t~ _ M,imufacturer. Nuaber of gal. _-r►a_t_-fur u cycle_„t,~ tut,►l .,I~.►, v puutP l did tribuCiun liana bu l lui► a i Gcs jr j) Limp I, _ _ brut►.~ ttuu►u c. hurd4Puwer gU1lon per ►,ul and uwdal nuuttbnr Type of warning Nutul,~, ul b~.tllu►►:. HULUING TANK: Manutaccurer Elevacion of "nhule euvor_---_ - •1'y ul WaruinK Nutuber uC i .l i,u►„ ► :il:l:l'AL PL'P SIZK . - - et:Pa6e p i t L111 c, ► 1'• i.:vu► , tees liquid dbpth r ~ but t utu of datlpYKn_ r~ At e7-Mvul Lut► .'A- VAUL BLU SIZE. numbiar ut~_c, 3_ 1 kil t It X3.9 :t.►•:1'A~:L• 't'ltl;NCH . w1SC -AREA 'A1:QUIRIU i►t►_.'n:- 1•~►i I l ►•L.K~:uI.A'1'LUN ~r ,0, ; 1 i~ izt DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR Q SAFETY & BUILDINGS LABOR & HLMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION BUREAU OF PLUMBING P.O.r8QX 7968 + O~ Ppj lulAO1SON, WI 63707 E3CONVENTIONAL DALTERNATIVE Sta+ Plan ,D. Nun,4 (If semnodl ❑ Holding Tank Q In-Ground Pressure Q Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: ^ Dave Coyer 361 Brookview Rd.,Woodbury, MN J BENCH MARK (P+rmamnt r+l+r+"e poml) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.' CST R . PT. ELEV. SW SE, Section 19, T29N-R18W, Warren Township 1478-me of Plumber. r /MPRSW No.; County: Sammy Permit Number: t David. B. Fogarty 3561 St. Croix 34813 SEPTIC TANK/HOLDING TANK: JLOCKINGC MANU ACTUPER: II ~ LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: PWRARV III EDLA PROVIDED VE 4.94 lam/ (;t)?,O 01T -o 9 S. X 9 YES Q N0 Q Y S LJMO eEDOING: VENT DIA.: VENT MATL.: HI ALAR NUMBER OF ROAD: OPERTY WELL: [UILDING; VAENT T ET FRESH L~ M. FEET FROM fLIINE : DYES NO QY O NEAREST / !]E}SING CHAMBER: LOCKING : ;MANUFACTURER. 6EDDIN L UI APACITV PUMP MODE I: PUMP/SIPHON MANUFACTURER: pgpV10 OLABEL P OVIDED COVER OYES 04, DYES ONO AYES ONO GALLONS PER CYCLE 1PUMP AN CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL IBUILDING. VEINT TO FRESH INLET: FEET FROM LINE. (DIFFERENCE BETWEEN PUMP ON AND OFF) QYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH: IAMETEH r AT& RIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shell cease until FORCE 'the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: COVER IA / ITS 1I0U1D GTH: No DIS R. PIPCSPACING . I WIO H: L N U DEPTH IT BED/TRENCH 3 6 TRENCHES (11 MkTAMAL: DIMENSIONS / ILL TH UISTR 1 DI R. PIPE UMBER OF WE BUILDING: VENT TO FRESH ,'GRAVEL DEPTH '(BELOW PIPES. ROVE COVER ELEV. 1 LET ELEV. END PIPE FEET FROM - LINE: ✓ s~ AIR INLET, -r 9 . o7 93.9 7,~ / q 4=7_7 NEAREST S MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture' f he fill ateri or PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems o eke rtai hat ON REVERSE SIDE. SHOW ELEVA- meets the 01 te 'a f me um s d. TIONS MEASURED. DYES QNO TE KTURE / fER A S. OBSERVATION WE LLS . - YES DNO ❑YES ❑NO HOV RTRENCH/BED OE►THOV R TRENCHISED ]=01L~_/ DED SMULCHED CENTER EDGES S QY S ONO QN QYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHESNO.OF A HAL SPACING AVEL UEPTyt'WEl PIPF FILL DEPTH ABOVE COVER: DIMENSIONS r MANIFOLD U MANI L DISTR. PIPE I L A HIAL PAM H UI 1 1 THIBUI ION PIPE MATERIAL & MARKING ELEV ELEV. DIA. ELEV. IPES DIA.: ELEVATION AND Ae Z-1 I DISTRIBUTION HOLE SIlF /0lE SPACING Dr I UILEU ONHE LY C Vf MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS O OYES QNO PROPERTY WELL: BUILDING: COMMENTS: 1PRIPMANINTMAKERS, as VA IONw I.S. NUMBER OF LINE: _ j (.~NO O QNO NE FEET FROM _YES _ES O AREST i r Sketch System on Retain in county file for audit. Reverse Side. sl 31LHR SOD 6710 (R. 01/82) _ DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An. index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A Jegible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: I/E 3V Cl~ kgw/ d, 1-.0604ceC J Property Location: City, Village or Township: Cou ty: w '/a-fe '/aS iT N/R It E (or) v Lot Number: Blk No:: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: (If assigned) TYPE OF BUILDING Number of ❑,~Public* • ❑ Variance* ❑ Other (specify)* Bedrooms: LiQ 1 or 2 Family *State Approval Required. 3 TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHEGALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: Ao&/e e EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): Bo'New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit ❑ Alternative (specify) ❑ Seepage Trench Ap 21 Ash ;c:v F- y 3.2 . Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): R ?'Private El Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: re: MP/MPRSW No.. Phone Number: rG (7?at ►--365 Plumber's Address: Name of Desi• z COUNTY/DEPARTMENT USE ONLY Signat a of Issuing Agent- Fee Q 0 Date: ~i APPROVED Sanitary Permit Number: [ 2A2AA&/7' ~~~v ❑ DISAPPROVED Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DI LHR-SBD-6398 (R.07/81) i i if) it u~lli'•a~ i ,Jiu r4 ►1 is i± ~ t, I y ,k , f; r' Xi: ali i►' , i{• •3, bsf 6: i iJl c:f+~i.',~b:_.;k: Strr'~ ~ x.` ~i x . w- j+E ~{p } 4 1 ii~' f)f`ti. s a. a. 3?$a"ii ~t~ iii? e4 43ti1 ai Y. , NUTS.-+ rstaYi.: It, i:n.st l c: 'Wil leoi out <+:ul rot. meter !;c fury Form - S T C 100 of : IB -,67 to coun-.y zc:n:: i;LnL office. Owner of Property Cs 7)"d~,~~ f.ocation of Property, Section T N R W Township (tld11e- v Mailing Address Subdivision Name_ Lot Number_ Previous Owner of Property_ vezs pezw Total Size of Parcel Date Parcel Was Created g Are all corners identifiable? _ Yes No Include with this application one of the following: certified Survey Map Deed .Land Contract, or Other gal Document which describes the property 155-75Z 16- roAi PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that* (we) qp (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recor ed in the Office of the County Register of Deeds as Document No. Sz'ld ; and that it(we) presently own the proposed site for the sewage disposal systen,{eN-bave_ en , o ru n pr e SIGNATURE OF OWNER SIGNATURE OF CO ER (IF APPLI OLE) DATE SIGNED DATE SIGNED r ' ~ `s, . , . ! . I. it is ~ I{ ! ; .i';... IJ ~ ~ di( . ..:i r., I { I ' t . I . . q i. . ~ ~ i i , ' it i ~i ri il'., - ii ~ I-,7 ?1ri ~ ~ , r ; i I a' .i. i.. , . . ~ L, 1 I. ~ J I 1 ' I i. ~q c' !(t.. ~ . _ - , DOCUMENT NO, STATE IIAIt o 15 ltM ]1 1982 lti~8 `PACE RESERVED FOR RECORDING DATA LAND CONTRACT Individual and Carporatu . ' - , ~ ` r ('ro nx USED FOR ALL TRANSACTIONS WHERR OVER ~ x26,0(1(1 IS FINANCE'l, AND IN O'riWR NON-CONSUMl61t ACT TRANSAOT)ONs) REGIISTfaRS OFFICE Ciontra,ct, by and between NELSON POLCN and Rdc'd. for Record this 2nd ~ ('Vendor", ~ whether one or more) and.... 1XV,-.J~,_.CQ R. i ~,t~I2Q~_, ~QYLR, day Of Feb A.D. 19 83 husband.. and. wi.fe..aa. jni nt..tex t ' " - ("Purchaser", whether one or more). Vendor sells and agrees to convey to Purchaser, upon the prompt and full per- formance of this contract by Purchaser, the following property, together with the tpM M rents, profits, fixtures and other appurtenant interests (all culled the "Property"), irk XQAX............................... County, State of Wisconsin: RE7UflN TO That part of the Southwest Quarter of the Southeast Quarter of Section 19, ^bwnship 29 North, Range 18 West, "lying r'south of . Badlands' Road, except the East 610 feet thereof; and the Northwest Quarter aril the Tux Parcel No West Half of the Northeast Quarter of Section Townsiltp 29 North T~znge 18 West (approximately 256 acres).. and Vendor further agrees to release from this contract and convey by warranty deed 1 free of all liens and encumbrances, except any liens or encumbrances created by the act or default of Purchaser, a parcel of the above-described land, about five acres in size, 330 feet east and west and about 660 feet north and south on the west side of the Southwest Quarter of Southeast Quarter of Section 19, south of and abutting Badlands fbad, upon payment of a lump sum payment of $10,000, which shall reduce the tQtal debt, but which payment will not change the requirement to make the monthly payment of $1,00G. i This ...._.:*".I$ homestead property. (is) (is not) Purchaser agrees to urchaso the Property and to pay to Vendor at their house or wherever they desicjpat the aura of y..._........135 &100. 00 15 00000 - in the following manner: (a) $--,...1..........: at the execution of this Contract; and (b) the balance of .•i4100-00 $ * together with int4rs t freiu dote hereof on the balance outstanding from time to time at the rate of Ik.i G-..(.9%) until paid in full, as follows: per cent per annum Monthly payments of one Thousand and nc/100 ($1,000.00) Dollars per month on the first day of each month beginning March 1, 1983, and continuing until March 1, 1993. ~I 4 Proy~dcd,hhowever, the eutjr outstanding balance shall be paid in full on or before the........lst 19_.._.... ( the maturity date). day of Following any default in payment, interest shall accrue at the rate of i% per on the e unt n default (which shall include, without limitation, delinquent intorest and, upon accel rationnor~matu ity,tltheaentire principal balance). Purchaser, unless excused by Vendor, agrees to pay monthly to Vendor amounts sufficient to pay reasonably antici- pated annual tuxes, special assessments, fire and required insurance premiums when due. To the extent received by Vendor, Vendor agrees to apply payments to these obligations when due. Such amounts received by the Vendor for tuxes, sasessments and insurance will be payment st deposited into an escrow fund or trustee account but steal unless otherwise a ul 1 not boar interest r re q d by law. Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. Any amount may be prepaid without premium or fee upon principal at any time after... N1arCh 1 83 18.----... (Q In the event of any prepayment, this contract shall not be treated as in default with respect to payment so long us the unpaid balance of principal, and interest (arid in such case accruing interest from month to rnunth shall be treated as unpaid principal) is less than the amount that said indebtedness would have been had the monthly payments been made as first specified above; provided that monthly payments shall be continued in the event of credit of any proceeds of insurance or condemnation, the condemned premises being thereafter excluded herefrom, except that * Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser for examination except: *the $10,000 luny sum paynent above referred to shall not be considered in determining whether off' not the contr ct is i d Yurl:il efc-t lt. seer A t'0U K s to pay tho coat of Future title evidence. It title eVidui be retained by Vendor until the fu co is in the form of an abstract, it shall 11 purchase price is paid. Purchaser shall be entitle to take possession of the Property on ......Pebrua.....] .-1 . •cro.a Out ono. 1e.83 LAND CONTRACT - Individual ant, ST A1 ,v,vC(1VSIN ._l Wi! u•o. l-au 1 rrul Ipr nl ('a 1 1 A : ,rt lr'. •.t r;tlS t." tlir ' u I'- 1I 1.;I'I ! •I. !r! Il r .,~r(. I 11.1,. i. , ;14 u • f ltt ,1 L'~ ) ill' ~ , ,r, ~h Ir I li .li i r ~ ~ r i , J 56 ~ voL 6 58 Purchaser promises to pay when due all taxes and assessments levied on the Property or upon Vendor's interest in It and to deliver to Vendor on demand receipts showing such payment. Purchaser shnll keep the int} rovements on the Property insured against loss or damakre occasioned by fire, ex- tondod coverage porils and such oChor hazards as Vendor may require, without co-insurance, through insurers approved by Vendor, In the sum of .__..N/A........................... but Vendor shall not require coverage in an amount more - than the balance owed under this Contract. Purchaser shall pay the insurance premiums when due. 1he policies shall contain the standard clause in favor of the Vendor's interest and, unless Vendor otherwise agrees in writing, the original of all policies covering the Property shall be deposited with Vendor. Purchaser shall promptly give notice of loss to insurance companies and Vendor. Unless Purchaser and Vendor otherwise ngree in writing, insurance proceeds :hall be applied to restoration or repair of the Property damaged, provided the Vendor deems the restoration or repair to be economically feasible. Purchaser covenants not to commit waste nor allow waste to be committed on the Property, to keep the Property in good tenantable condition and repair, to keep the Property free from liens superior to the lien of this Contract, and to comply with all laws, ordinances and regulations affecting the Property. Vendor agrees that in case the purchase price with interest and other moneys shall be fully paid and all conditions shall be fully performed at the times and in the manner above specified, Vendor will on demand, execute and deliver to the Purchaser, a Warranty Deed, in fee simple, of the Property, free and clear of all liens and encumbrances, except any liens or encumbrances created by the act or default of Purchaser. w : . . Purchaser agrees that time is of the essence and (a) in the event of a default in the payment of any principal or interest which continues for a period of .45..... days following the specified due date or (b) in the event of a default in performance of any other obligation of Purchaser which continues for a period of 5._. days following written notice thereof by Vendor (delivered personally or mailed by certified mail), then the entire outstanding balance under, this contract shall become immediately due and payable in full, at Vendor's option and without, notice (which Purchaser hereby wnives), and Vendor shall niso have the following rights and remedies (subject to any limitations provided by law) in addition to those provided by law or in equity: (i) Vendor may, at his option, terminate this Contract and Purchaser's rights, title and interest in the Property and recover the Property bnck through strict foreclosure with any equity of redemption to be conditioned upon Purchaser's full payment of Clio entire outstanding balance, with interest, thereon from the date of default at the rate in effect on such date and other amounts due hereunder (in which event nil amounts previously paid by Purchaser shall be forefeited as liquidated damages for failure to fulfill this Contract And As rental for the Property if purchaser fails to redeem); or (ii) Vendor may sue for specific performance of this Contract to compel immediate find full payment of the entire outstanding balance, with interest thereon at the rate in effect on the (late of default and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser shall be liable for any deficiency; or (iii) Vendor cony sue at, law for the entire unpaid purchase price or any portion thereof; or (iv) Vendor may declare this Contrnct at an end and remove this Contrnctasacloud on title in a quiet-title action if the equitable interest of Purchaser is insignificant; and (v) Vendor may have Purchaser ejected from possession of the Property and have a receiver appointed to collect any rents, issues or profits during the pendency of any action under (i), (ii) or (iv) above. Notwithstanding any oral or written statements or actions of Vendor, an election of any of the foregoing remedies shall only be binding upon Vendor if and when pursued in litigation and all costs and expenses including reasonable attorneys fees of Vendor incurred to enforce-any remedy hereunder (whether abated or not) to the extent not prohibited by law and expenses of title evidence shall be added to principal and paid by Purchaser, as in- curred, and shall be included' in any judgment. Upon the commencement or during the pendency of any action of foreclosure of this Contract, Purchaser consents to Clio appointment of it receiver of the Property, including homestead interest, to collect the rents, issues, and profits of the Property during the pendency of such action, and such rents, issues, and profits when so collected shall be held and applied as the court shall direct. Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property (by assignment of any of Purchaser's rights under this Contract or by option, long-term lease or in any other way) without the prior written consent of Vendor unless either the outstanding balance payable under this Contract is first paid in full or the interest conveyed is a pledge or assignment of Purchaser's interest under this Contract solely as security for an indebtedness of Purchaser. In the event of any such transfer, sale or conveyance without Vendor's written consent, the entire outstanding balance payable under this Contract shall become immediatly due and paynble in full, at Vendor's option without notice. Vendor shall make all payments when due tinder any mortgage outstanding against the Property on the date of this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaser makes timely pnyment of the amounts then due under this Contract. Purchaser may make any such payments directly to the Mortgagee if Vendor fails to do so and all payments so made by Purchaser shall be considered payments made on this Contract. Vendor mny waive any default without waiving any other subsequent or prior default of Purchaser. All terms of this Contract shall he binding upon and inure to the benefits of the heirs, legal representatives, successors and assigns of Vendor and Purchaser. (If not an owner of the Property the spouse of Vendor for a valuable ennsiderntion joins herein to release homestead rights in the subject Property and agrees to join in the execution of the deed to be made In fulfillment hereof.) Dated this 1st--• day of .--..-._...FE'bru 19...$x.. .....__r. .:.........................(SEAL) Nelson Polen David .,_Oo r - ................(SEAL) ' (SEAL) Florence Polen Carol _J.. ..Coy . . . . AUTHENTICATION ACKNOWLEDGMENT Signature(s) .Qf_the._at?ove._£our..personS........ STATE OF WISCONSIN es. ................•-•----•----...County. authenticated this a.St_day of .._FebXl11ry 19-__83 Personally came before me this ________________day of t U 1 19-------- the above named Hugh .'...Qw~ n TITLE: MEMBER STATE BAR OF WISCONSIN authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. ! THIS INSTIi 11MEN7 WAS DRAFTED BY Hugh F. Cowin, Attorney Hudson, Wisconsin 54016 ' Notary Public - ---------------•----------County, Wis. (Mirnntures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state., expiration are not necessary.) ) date: - 19--------- DE,,.*TCMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HLtMAN RELATIONS (H63.0911) & Chapter 145.045) LOCATIONS SECTION: TO LOT NO. BLK. NO.: SUBDIVISION NAME: A N/RIVE (o w COUNTY: OWNER'S/BUYER'S NAME: MAIL NG ADDRESS: Co zr USE 11 m v'u.J r - DATES OBSERVATIONS MAbt Ir~ NO. BEDRMS.: rMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: jPE7;0LATION nce w ❑ Replace =RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLOING TANK: RECOMMENDED SYSTEM: (optional) IVI S ❑u 1 sou s ou To s gu o s ~u a a In 1 r - It Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS Y &Aa '4 rc S^f BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 4N, ELEVATION OBSERVED ES . HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.( B- B Z ,a ~•G > . o sue„ .tip ~e~ B- B- t/ B- 6- B- 7. /,v a .7 xt z,&m ~f c a Z 3-? ~ Bn c -c d- PERCOLATION TESTS Gt .3( "d-1 t. r ETEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES R INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 _PERIOD2 PERIOD _ PER INCH P- P- 1 tAA ' 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 y3. TN SE t grT~~~D .s;~',ET 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specifie in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the~_~~ cnowle~{ d belief. MME (printl: TESTS WE ETE 11 ON: 3 3 0 --Y3 )RESS CERTIFICATION NUMRE13: PRONE NOMRFR(optinn.il): - 14 ST SIGNATURE: e Y v a I ' a ~-.r _ r i ..1 ~ s a_.... . _ _ 'E,,... s 6.. i k' 3 1 ~ ~ { r r i i ' ~ ~ ~ ~ a C y' t ~ - I ' Y i a i j i 1 - - DIP w e m _ M c h~ I ~ APPLICATION SAFETY & BUILDING DEPARTMENT OF FOR SANITARY DIVISION INDUSTRY, . LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8'/s x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: Dave Coyer Roberts WI 54023 Property Location: City, Village o ownship County: sw • t/a se %4S 19 iT 29 N/R18 E (or) Warren St. Croix Lot Number: Blk No.:-- Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: --..w....'...-.w„---- Badlands Rd. (if assigned) . TYPE OF BUILDING Number of ❑ Public* E:1 Variance* E:1 Other (specify)* Bedrooms: 3 ® 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 1000 HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: weeks EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ® New ❑ Replacement ❑ Experimental ® Seepage Bed ❑ Seepage Pit 18-35 (615) Alternative (specify) ❑ Seepage Trench ❑ 1 Water Supply: rnes Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: at re: MP/MPRSW.No.: Phone Number: Dave Fogerty 3289 (749-13656 Plumber's Address: Name of Designer. Fogerty Hgts. Rd., Roberts, WI 54023 D. B. Fogerty COUNTY/DEPARTMENT USE ONLY Sign ture of. Issuing gent: Fe -v Date: APPROVED Sanitary Permit Number: CA I)Ajee') e DISAPPROVED / 3 ~a 3 Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber 'ILHR-SBD-6398 (R.07/81) VO . DEPARTMENT OF APPLICATION -SAFE'TY 1!i W LI)IN INDUSTRY ~ FAW SANIT ARY DIVISION LABOR, AND PERMIT P.D. <BUX 7989 HUMA!!1-RELATIONS (PLO 67) (MiAI?i WI 53707 Attach plans for Ole &ys on paper not less than 8% x 11: inches in, size. Include a plot plan that is dimensioned er dr 3p_=di +kwiatmtal and vertical elevation referenm points mustbe shown. All appropriate separating distances and physical character-sties UANX iced io,d ter' H-$3, Wis. Adm.. Code, must be-shown: An index,page or each page-must: be. signed, sealed and dated by the designer. If elt ignod.by a Master Plumber, the date, -signature and license number must be shown: A legible reproduction, of tha,soil test report or the "s ce, pV'irnust'be included. roper#y ner; Mailing Address: Dave Co r Roberts, W1 5423 roperty location: City, Village o owrMip County: aw '/ase 14S 19 J29 N/R18 E (or Warren St. Croix of Number: ik No Subdivision Name: Nearest Road, Lake or Landmark: Ilimi FG-1A. Number. d.lands Rd. (if assigned) " TYPE OF B4ALOIht(a - of Public* ❑ Variance's ❑ Other (specify)* 1 or 3 Family . *State Approval Required. 3 GA4 TOTAL OF TANKS CONCRETE POLAC,EIN STEEL FIBERGLASS INSTALNew LATION MENTE_ p(Specify-PL SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER y' `MANUFACTURER: "ekA r' LUENT DISPOSAL SYSTEM ' TEACOLATION A E A I AREA (Minutes pen incM): PROPOSED (Square feet): F91 New ❑ Replacement ❑ Experimental ® Seepage- Bed ❑ Seepage Pit 1 I8-35 (61S) Alternative (specify) ❑ Seepage Trench Water 'Supply; Owner's Name as Listed on Soil Test Report (If other than present owner): 6 Private ❑ Joint ❑ Public I, the undersigned, hereby -essumesponsibility for installation of the private sewage system shown on the attached plans. - Name of Plumber: Siwval rei MP/MPRSW No.: Phone Mtmbdr: Dave Fogerty 3289 (749-13656 Plumber's Address: Name of Designer. Fogerty Hgts, Rd., Roberts, WI 54023 D. S. Fogarty COUNTY/DEPARTMENT USE ONLY Si n ture of Issuing gent: Fgg• Date APPROVED Sani y h Number' +A • ! f~' V . a , , -7e(~;~ - ❑ 3 DISAPPROVED Reason for Disapproval. Attiernate course(s) of Action Avaitable: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-WD-6398 (R.07/81) MEW T p 4 . { - ' fig` ° Ifim 5i. ot ,~f t t4dFa,) E} 4?f 3t in,.!fn} b ti i{'" f t41 eve^fli "'i x sI,,`R ,3i ~c`fl ra Z lak F ivT ty6 ~ } r - 3 Ps1 r ,.r. b s >se sill dt44gb I#, r++, 0 s~ = b si ~ ►T r Sd, i e J, i i0 3* ~ t lis3 ~kft' t3 ~8{ ,'!E'd+~~r fji `per oCf, 'y' w - . ygargr+-.r: 4n lpi!1 , r s C~3 f i ~i F . 1 N17MW- j_4^~ Cl V~t },y ~r1 v r _`i e•fS 1 Tt. { JI {,[stl ^CwIAi ,k. +nu~AY•.1 w° ~r ! X4;3,- "t IU r ".j~:'. ~t ;i. 4.!t1` 1 "Y ~lJ ..1a1]i'Na i { [}iv~!e •L I ~L JxIL1eTLlf1 r{`~ Y1lOPi -1$ t4 :!J, W 1ii; 0 tit) ).yr._.+«-..._ .-...w. a _-r• ww~.nY~rr~-...._..... .1ir_. F 1- ~ ~'~'H o _ 9 i*NUv^ FrMr94QiiB1~f Ygfitr t1tlei 1~? ~C ➢ 1 zr SA r i:..5e}t ~a ~rf~k est inn c{; ~sfbi►ti z r ?t, ri21#~Bfliriari r c a y r;r1 j s -ilk J1$(a^Xi3. ji~'oY~~L~I~r_':i~~ :Y° ~ ~ ! - _ _ 4 YJ°S ~Y".v R4 li: '...4a'S,• iLR Y!a :0~/ ~,~a'„1 ae~ L 7 tx~awq .'T+~3ES%y 'i1 ern" 'a 7 V {r 4qA i 913yKl Jib! '+t 6i,Ml t3.. IiiiR4w,44 jf: 't r.r4# t~t5 7<~,al:~ .:ti_ r• t?T ~l°t ,Y°'1 ~ ~',~,~:ae^+r ~}'f tF~. ,.?Y$"1!~` .`(4'i8~► "'t'7'F r .iC Nt 'l'Y !'.9[?il,~' '-~a~ ~ii, -ji Y~.~ n ! 001, n list he fi2iu! out ~in([ ru. i letcQ bE. Port: Form - S T C 100 . IB 67 to 'county office. Owner of Property 19.66ei i-e e~u Location of Property~_k_.12 ;4, Section ,T_.tf_N R a Township Mailing Address Subdivision Name Lot Number Previous Owner of Property) - ,8-G Total Size of Parcel Date Parcel Was Created .2 Z Y S- Are all corners identifiable? Yes No Include with this application one of the following: J'Certified Survey Map r .Dee d Land Contract, or Other Legal Document which describes the property 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. 3 f A YG / ; 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 aid system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. _X82 yb/ SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED QWA r, i i ~pe so 4s • i L 4 ol- v• 7 to-I a`'rr y o ' 7-1 irr ~ r , SM J ~ ,c M ~ s F 3t' r + • r • ,gyp/ R k . f 3 I I I ~ I Ir 1 i 4. I've DIP A \ jx 9~ w t t7l 'Al • I P D v r IV e-7 rift P, F~ I 1' 00, 4-P ri / I / i" I ~i - i Q i ,d o ~ t p►S~ ` it i pee' I ~ l I 1=21 A- or. A SL, a, i -1 T-7 i t 1 4ro ~ r 0 ~ to ~1 t F 4v~, A„ . 1 ~ 14 A y'~, 1G y ,1f i zo a i , O D V O Z O ~ U) o C z COO* co -o z rn rn a m O orno -10 N C= ::i r v rn C002 x < _ ~ n r . rn a 0 p r C O r ~ :30 D C) Z = r C~ CT1 0 00 ■ rN u7 Z p c x Uo U) Z z U) 0 < n O rn °o v' C') Cl) n zz O z~ m ~ C m 6f G. w Q F ~o 7 d a n o m D O .Oi N 7 d S 7 7 N T rn fTl N K Q NS S 7 .0 H W 7 N j W D O m m n c . m o 8 s 3L 2 v D m e S 7 ~.d mO m- »-K mOO O•~ O 0 » O 7 C Q 1 w d m N W ° m3 ad H °°a 'm3 ~i m cF c- N.~' f 3 m ~ cn S~ C- .C + O K 7 p d . K S W O d m ay C D O C O u~i ? 7 m X71 C D C N tp 3- y K C :r m O m 3 3 3. a C v° a3 O N 13 rnrn <3 ~Q =r ~ d. co Z 0 ~ C N N » ~ N N D `dam d 2ao ~0 2 'n z J f o, m a 3 ° 3 N C 13 m m "m m Q 7 3 -c' 3 o D 7' m En 4:~A- n Kd 3D 0 W D O v 3° 0 n a O ° N D H F O tD N O o 7 O- 3 0 N (D =0 7 m W s;"W~. _ Y . .i. _ ~ _ n_ _ ~ ~ , . _ ~ LL _ . a , r . ~ i'...~ ui f . DEPARTMENT OF REPORT ON SOIL WRINGS AND SA INDUSTRY, DIVISION LABOR AND u • PERCOLATION TESTS (115) MADISOP.O. BOX 7969 N WI 3 07 HUMAN RELATIONS (H63.090) & Chapter 145.046) LOCATIO OWNSHIP/MUNICIPALITY: OT NO. LK. NQ: SUBDIVISION NAME: /T N/Rir E I ICOUNTY: OWNERSIBUYER'S A T ti e-~3 USE DATES OBSERVATIONS MADE N06 BEDRML: MNIERCIAL DESCRIPTION: OFILADESCRIPTIONS PERCOLATION TESTS: oiesidence 'Flew ❑Replace / -11 RATING; S- Site suitable for system U- Site unsuitable for system ~S C7U • IND: C~U ~ S ❑U Ti S YSTEM-IN-FI LL aS rOLDiNGTANKIRECOMMENDEOSYSTEM:(optional) NU If Percolation Tests are NOT required DESIGN RATE: [Floodplain, ny portion of the tested area is in the under s.H63.0916)(b)• indicate: indicate Floodplain elevation: PROFILE DESCRIPTIONS _S 9 BORING TOTAL AT INCH A TER OF SOIL 1 CULOR, TEXTURE. AND DEPTH NUMBER DEFM IN. ELEVATION OBSERVED ST. HIGHEST TO BEDROCK IF OBSERVED EE ABBRV. ON BACK.) B- > s -a - /Vo -e B- 2 v. > _ _ > ' .9. A7;gJ d4 QC x B- L IP.6 r. ' x pt*' drmeA /Ns~lr PERCOLATION TESTS DEPTH WATER IN HOLE TEST TIME -DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLIN INTERVAL-MIN. PER INCH p- i P- P- P_ P_ 3 Zr, P_ PLOT PLAN: Show locations of percolation tests, ail 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 9p. r 4-4 1'N 64 t - - --i _ T- 1, 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. NAME print : TESTS WERE COMPLETED ON: DORESS: CERTIFICATION NUMBER: PHONE NUMBERloptional): N w S e2 CST SIGNAT E: