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HomeMy WebLinkAbout002-1057-10-000 \ '4"'t . 0 w 0 2 1 en % & . / k 1' E• 1 2 I / . L. A I § $ I ( 7 ! %1 2 I ; § ?k k 2 7 § a, \ \ E < _ $ n f ! E 5 1 E E I / / I 2 z I § 2 I Q § J a ■ I E 1 ) z C \ • C4 = 5 7 k k 7 / E 2 I CD 2 r •C / j � kf \ • \ c 0 \ Q ) / k .. k , co LN .. E \ i § I m 2 § w tit 06 \ 2 b § ttio E o o a co .Q ¢ \ • \ k E 2 . 9 0 0 0 z 1 . . a a a 7 I \ o2 ' � Q : o § § ) §I � k 2 10 § § _ 0 § r , , k $ } ƒ f s M = 1 / § a ° I 4 o : � 6 E o cm) • 6 � g 12 a) § § e \ \ • / ) ¥ ! ƒ o / 2 $ 2 / • ■ « , \ c ) A § ) , \ § 0 2 2 1- k ) \ © I 4. % ii I zk 2 k I § ° E $ $ I k a g k J a 2 1 0 , . . Parcel #: 002-1057-10-000 12/18/2006 09:22 AM PAGE 1 OF 1 Alt.Parcel#: 23.29.16.351B 002-TOWN OF BALDWIN Current X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): 0=Current Owner, C=Current Co-Owner O-MOMCHILOVICH, PAUL&ANNETTE PAUL&ANNETTE MOMCHILOVICH 2596 CTY RD D WOODVILLE WI 54028 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *2596 CTY RD D SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 0.710 Plat: N/A-NOT AVAILABLE SEC 23 T29N R16W PT SE SE E 23 RDS OF S Block/Condo Bldg: 7 RDS EXC PT TO HWY DESC 1012/612 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 23-29N-16W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 1012/612 WD 07/23/1997 851/2t--) 07/23/1997 07/23/1997 826/107 2006 SUMMARY Bill#: Fair Market Value: As . 153772 121,300 Valuations: Last Changed: 10/25/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.710 11,900 112,100 124,000 NO 00 Totals for 2006: General Property 0.710 11,900 112,100 124,000 Woodland 0.000 0 0 Totals for 2005: General Property 0.710 4,300 63,500 67,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch#: 510 Specials: User Special Code Category Amount 010-GARBAGE SPECIAL ASSESSMENT 45.00 Special Assessments Special Charges Delinquent Charges Total 45.00 0.00 0.00 r I Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER L /2 „h,,J,e TOWNSHIP �A7_�D � SEC.-?___ ___ T N-RI W ADDRESS ST. CROIX COUNTY, WISCONSIN 19l/- a /-S' ,, j ,,l� LOT SIZE 2 , - SUBDIVISION /�`�- ...._ LOT ov PLAN VIEW Distances and dimensions to meet requirements of ILRR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i 10 / r La-61` /y� s 7o ' - /0,v611--t_ Vl G CI i-3-3 k . a a �/D 2. jj i (40 �'` '1 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used /a.,/abgetkv., o f l%'i�,C,Ffg� Elevation of vertical reference point: /e 't Proposed slope at site: SEPTIC TANK: Manufacturer: A.-)(", r(; ,gs;L1.,,uid Capacity: /OVO Number of rings used: ----- Tank manhole cover elevation: 99: ,� Tank Inlet Elevation: ?21.? Tank Outlet Elevation: 5-711' i,.c-Zg Number of feet from nearest Road: Front,O Side,O Rear, O /33 / feet From nearest properrty, Line : Front,OSide,ORear, : 9 / feet � / 7-=Da2 1 LL B p /' Number of feet from: well , building: . (Include this information of the above plot plan)( 2 reference dimensions to septic tank) , PUMP HAMBER Manufacturer: Liquid Capacity: 1 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,Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: x Width: Length: /C C) r Number of Lines: (lc1G` Area Built: 76%),,c,' Fill depth to top of pipe: c>2 / " Number of feet from nearest property line: Front, O Side,Rear,O Pt .1 9 Number of feet from well: `% -P/t/Get; ' r Number of feet from building: c.21 f' (Include distances on plot plan). SEEP E 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). HOLDI TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: . Number of feet from nearest road: Alarm Manufacturer: Inspector: •i■ Dated: Plumber on job: �4 dye License Number: /43 e2 /5' /5 3/84:mj 1 EPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 SW4,SE47Sec. 23 ,T29-R16 ii CONVENTIONAL Li ALTERNATIVE State Plan I.D.Number. Town of Baldwin O Holding Tank O In-Ground Pressure O Mound C.H. D NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE Paul Momchilovich 845 Charolett St . Hammond,WI 54015 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF PT.ELEV Name of Plumber. MP/MPRSW No County. Sanitary Permit Number: Lyle J. Myers 6219 St . Croix 128670 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV. 'TANK OUTLET ELEV.-. WARNING LABEL LOCKING COVER PROVIDED PROVIDED' OYES ONO OYES ONO BEDDING VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING. 'VENT TO FRESH. ALARM. FEET FROM LINE AIR INLET. YES ONO (�( OYES NO NEAREST- C CHAMBER: (v MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED PROVIDED: OYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY 'WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES ONO NEAREST )' SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TfIENCH WIDTH LENGTH NO DISTR PIPE SPACING COVER ATERIAL: PIT INSIDE DIA SPITS DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTH.PIPF IOISTR.PIPE IOISTR.PIPE MATERIAL. NO DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER ELEV.INLF I ELEV.END PIPES FEET FROM LINE AIR INLET. I NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: '\ mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- TIONS the criteria for medium sand. TIONS MEASURED. OVES ONO SOIL COVER'TEXTURE PERMANENT MARKERS OBSERVATION WELLS OYES ONO OYES ONO DEPTH OVER TRENCH'BED DEPTH OVER TRENCH/BED DEP TH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. OYES ONO OYES ONO _ ❑YES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING.'GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER ABED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV. ELEV. DIA ELEV.' PIPES DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED I INFORMATION PLANS OYES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF LINE PROPERTY WELL: BUILDING: FEET FROM IIOYES ONO OYES ONO NEAREST j_ ..�� Sketch System on Retain in county file for audit. Reverse Side. . SIGNATURE: TITLE DILHR SBD 6710 IR.01/82) w,; ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm.Code Cou STATE SANITARY PER f# –Attach complete plans(to the county copy only)for the system,on paper not less than ❑ � 8%x 11 inches in size. cn C r iis n to previous application –See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. PROPgSTY OWNER P OP RTY OC9TION -'f'i P.i.L /1�k0;-)40 /.Ca d< C/4 a /a3L:/a,s1,23 T�'i, N, R /6' E(o� PROPERTY OWNER'S MA LING ADDRESS LOT# BLOCK# CITY STATE /- yy1,,notd ZIP CODE PHONE NUMBER SUBDIVISIQ AME OR CSM NUMBER L.e 1 s.s�/e/5 ( ) /i` II. TYPE OF BUILDIN (Check one) ❑ C NEAREST ROAD /r_ ) ❑State Owned ❑ ILLAGE �a /,Y/ / N_ • I ∎ • d LJ ❑ Public IK1 or 2 Fam.Dwelling–#of bedrooms - • - ELT• N MB R( ) III. BUILDING USE: (If building type is public,check all that apply) 3 • -2 9` // . 3 57.13 1 ❑ Apt/Condo p� Co 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. 'Replacement 3. ❑Replacement of 4. ❑ Reconnection of 5.❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit# — Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 i Seepage Bed 21 CI Mound 30 CI Specify Type 41 CI 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 cs O, n Q L! 9s'--v .5796 fU f-�5� - e y 5 n.m,Ai // Feet frec 3 Feet t VII. TANK CAPACKY in gallons Total #of Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks y,/t �{ structed Septic Tank or Holding Tank /(96C /e$C)(i l�,0 )� 1 �; .P/? 'i- Ln ❑ ❑ _ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber I ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signatu e:(No Stamps) /MPRSW No.: Business Phone Number: X2 /9 ( `2/5 V3 ~1;�� Plum is Address(Street,alatecj,Zi Code _ 2 14 Z 'r-, )- ''/c<>� I f� , / 2- C IX. COUNTY/DEPARTMENT USE ONLY t r 0 ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial O Surcharge Fee) Adverse Determination /� /Date ('! h/g.4%. X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(formerly PIb-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: I. 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 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) r • APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property 2 1 4 i-U L //9/4 E;401, ) J/C:- Location of property-S W 1/4 Sc- 1/4, Section .2.3 , T .2c7 N-R /6 W Township < ,CA.J/ N Mailing address ,c7,7 J A' ,3 2 5`'- /-174v;-7,--77),,t/-7 ( (S Address of site £ il (,C16 e3-g)crf/L2 / ( f t Subdivision name /VA Lot number Al i4 Previous owner of property _ ,:vi.. lam_ A_/ _ -_ I L L__.. e Total size of parcel A- -c 12--C:te; , Date parcel was created c/ /.3/ 0 Are all corners and lot lines identifiable? XC Yes No Is this property being developed for resale (spec house)? Yes )( No Volume g / and Page Number ...23? as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty c]eed recorded in the Office of the County Register of Deeds as Document No. g-57'-;"--4,7 ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has bee�n^� duly recorded in the Office he County Register of Deeds, as Document No. 4Y•-/Ste/ ) . 63.421\N=S\mlfla9A I') n , i Signature of Owner Signature of Co-Owner (If Applicable) \4 \'1/4.1 \q1 , ( 6/ 1 1 gel Date of Signature Date of Signature ,..- . ■ . DOCUMENT NO. I I 1 '''-' - WARRANTY DEED II' mti-its SPACE RESERVED FOR RECORDING DATA il i' 11 STATE BAR OF WISCONSIN FORM 2-1982 451541 !I ..... , - orc,. 851 PAU 239 _ J REGISTER'S OFFICE •, ST. CROIX CO., WI ii Basil L. Traynor and Arlene Traynor, Rec'd for Record husband and wife, as joint tenants h II S EP 1 5 1989 at 11 :10 A. M . 1 II 11 conveys and warrants to Paul Momchilovich and Annette H 0 II i! i; Momchilovich, husband and wife, as joint : ■! 1 ". Register of Deeds 1 i tenants li 11 . , 11 11 , ! 11 0 RETURN TO ■ 0 Hammond State Bank ii 1:1 915 Davis St. , Box 28 the following described real estate in St . Croix County, 11 Hammond, W --5-40T5---- ,. State of Wisconsin: I Tax P rcel No: li — . 11! East Twenty-three ( 23 ) rods of South Seven ( 7) rods of :1 i Southeast Quarter of Southeast Quarter (SE,12-1 of SE ) of Section Twenty-three ( 23 ) , Township Twenty-nine North (T29N) , Range Sixteen West (R16W) , subject to easements Il i and right of ways of record . il rl Il This deed is given in fulfillment of that certain Land Contract ! II between the above parties dated June 28 , 1989 , and recorded June 30 , 1989, in the office of the Register of Deeds for H , St. Croix County, Wisconsin , in Volume 844 of Records , at Page 576, as Document No. 449308 . .. i 11.1fill i! 0 H EEE This is not homestead Property. , X(Z9X (is not) Exception to warranties: Easements and restrictions of record , and except any ;I liens or encumbrances created or suffered to be created by the acts and defaults of the grantees , their heirs, successors or assigns . Dated this 13th day of September , 19 89 ;1 laj.--tezd (SEAL) 4 (SEAL) ,..," L. Traynor • (SEAL) ze)Aaf-ozi (SEAL) * * Arlene Traynor AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN i ss. ST. CROIX County. authenticated this day of , 19.. Personally Caine before me this .1.3_th_day of September 19 89 the above named Basil L. Traynor and Arlene . , .. * Traynor TITLE: MEMBER STATE BAR OF WISCONSIN , . ,te , (If not, _____ ______ __ _ ___.,. ...... .. .............. .......... authorized § ii0-6.0-6-, Wis. S......) to me known to be the person S ,I. who evect4d ta foregoing instrument and.)acknowiecke the-saile.,-.) THIS INSTRUMENT WAS DRAFTED BY '---_— _,...-- ,' -'' /V Thomas A. McCormack _ (.. k9 ". . ,. ,,,,:,,it,.,.r .c. •,44, c Baldwin, WI 54003 Notary Public .'''''--,Ti' .,"'7-et-i Ct./•,1.c"' ..)• ' .- Coiniqty.,' 'Wiz. (Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration are not necessary.) date: , 19 ) *Names of persons signing in any capacity should be typed or printed below their sign%ture.. WARRANTY DEED STATE SAE OF WISCONSIN „.s s . . . FORM Jr* t,_ l STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER PigZ/2.- /din C / 4 d ')/C H ROUTE/BOX NUMBER '4($ C l 4, 7.O 5 1 r— FIRE NO. CITY/STATE ,v7Dp(1) a), S ZIP PROPERTY LOCATION: 1/4 1/4, Section , T N, R W, Town of dgi9z.v uJi/tj , St. Croix County, Subdivision /ti A , Lot No. 0,/ A Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.,Croix County Zoning Office within 30 days of the three year expiration date. SIGNED J� k�` DATE ICI L (cc St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address r• 1 DEPARTMENT OF REPORT ON SOIL BORING S AND SAFETY& BUILDINGS _ DIVISION IfJDUSTRY, ABOR AND PERCOLATION TESTS (115) P BOX 7969 P.O.MADISON,WI 53707 HUMAN RELATIONS (I LHR 83.09(1) &Chapter 145) LOCATION:Sw'/4 SE'/4 SECTION:3 /1 CR/bE (o , [T`NSHIP/MUNICIPALITY: LOT NQ BLK._N SUBDIV SJON NAME: C UNTY: O' NER'S/BUYER'S NAME: /, 'w� i•Ln1 MAILING ADDRESS: �,rjJ�/ ,(//` �,/(J/,��Jj USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTrypNS: PERCOLATION LESTS: [ esidence 3 , v ❑New Replace 7-31- S 7 3-0=8Y RATING:S=Site suitable for system U=Site unsuitable for system CQNVENTI�AL: M�S:� IN-GROUND-PRESSURE: SYS❑TEM-I�ILLHOLDINGTANK: RECOMMENDEDSYSTEM:(optional) DESIGN AT o, / If Percolation Tests are NOT required If any portion of the tested area is in the /�i under s. ILHR 83.09(5)(b),indicate: r^`'�/ Floodplain,indicate Floodplain elevation: /' !/ x PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)II B- / 7 7 /o% l , ;y!fre 27,? o_ '� 134'/Y5 ae- 71Zr8,Y,tts B-a 7 to/. / ,,,,,i/0.4., 7Y 0-7E4 tat ,.41s B-3 S0 I0/. a 4/h 760 0-7?'LT,3,,US B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PER OD 1 PERIOD 2 PERIOD 3 PER INCH P- I A ,.. s , ,),/a 3/- P_ 2 , .r. 0 ,, A .E: .. F - P- .d ' I /,. . i MK7 Z P- P- P- , PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. £; 7 c SYSTEM ELEVATION 17 6 is c ter i4 R64 i 4� LcTL twt .. Cti_ v. _am/v __-_ _ _ _01%alM V aRcVIn., 1 flit i ,rVFE.05 AESL fi0__ . R, _ Ill.__ 4 ,-and ii/C./6 — —.A. ' , , a 570 ...)/c,05! TN 4 JJ v pt el f • 1 Tip w_F{! � ton,me- E 4' La.....00,_, , 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. NA 1 is!t): TESTS WERE OMPLE E ON: — 8 i �ov,4�� cR/y/C,4�t/ r` ADp S: CE TIFICA ION NU BER: PHONE NUMBER(optional): l7 a s«�i LA/VW/00D Crr/ 11% CST 6 '1 a 65- 7/6 CS NATURE• ef*ritif-ein 1 DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. iDILHR-SBD-6395(R. 10/83) —OVER — INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test,your report ru rst ,.rciu es. I, 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 rilarined; 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; P. 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 to scale is preferred. 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 appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. if the information (such as flood plain, elevatioa) does not apply, place N.R. in the appropriate box; 1 1_ Sign the form and place your current address and your 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 --- Sands•one - Gravel (under 3") LS - Limestone s -- Sand HOW . High Groundwater cs - Cea=se Sand Perc --- Percolation Rate mod s Medium Sand W Well rs -- Fine Serb Bldg --- Building is Loamy Sand > -- GreatelsThan 'sl Sandy Loam --- Less Than I -- Loam Fan --- Brown s i ._._ Sid: Loam Ri Black Silt Gy Gray Clay Loam Y -. 'YeloW _.... Sandy Clay Loam B Sod srci Siitty Clay Loam iTiot --- Mottles so --- Sandy Clay sic - Silty Clay fit - few, fine, faint c -- Clay cc - common, coarse pt -- Peat men _- Many, medium ell - •- distincI o •-- prominent I...1VVL --- High water level, Six general soil textures surface for liquid waste clispnsai BM - Bench Mark V RP 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. 1 i 1-- 0 1 ■ i'l ) 1 1 i c o .._- v), \ 0 � & �0 (., \ _, t 3 o ' (s‘:\,,. _ N 1- 1 1 Z N N CAI q* \ i 1 i '.-, r. k--i" \I\ - A T'''.4 `mac 4.- e h - Cl 1. '. I 1 N >c.. y n r �} 0 /1/4. ---\ (--- 'II i \ Ni n , -- e 1z 1 Z-- (i‘').., i r,. 4 \)."\ ... k.,,,, ii A -7 \ \l-,- \ ul > 0 c..., _.] , ,,, A 1 k ' .6 1 r -----c 7. C---____ C_ - '' )/ X' 1 'Zs 1 0 tA f\\ , 1 (V �s .._________ / o 1 ! -.5 . ‘ , ,,,0 , _____ , . N ,,,,, ,_ \\I 0,, ,5,,,, t i / ,\ ,._, , , , . ,,--- ,,