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HomeMy WebLinkAbout014-1061-80-100 s -0 C) N o fin, M o N O w O h ~I O N f', h O ^y I C 'O i I i'. i c o cu z t0 LL c ~p O U o c I 3 Cl) vl o z iii LO w E v c z `m y N FM- U) a co 0 c co_ O z :!t C> Z d c Z N E- m o c -2 o m ` _ N N O C w N N O ca Cl) 0 z m z _ z N ° a _0 O N N t6 E C i N c a i d N C a 2 c °M co ooa` a z °v • 4i ~aaa CL o (0 (0 I'' 12 0) 0) c" U z U E 00 rn o w _ O M y O O Q L co N U) W r _y Q } N 7 ~ Q O Q N c 45 O O 1 O E O 7 00 (D M 3 o a~i c c a o 11 00 N c N N U 3 M O o ut z z O c `n Q _c N • ~a O N LL CO O m O O L. O U O F- F- U') c CC L d „ a 0 Q CL >1 y c w L S A u m 0 vn UO h6L ce hN DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTR)%. DIVISION LABOt P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (ILHR 83.0911) & Chapter 145) LOCATION: SECTION:T N H UNICI_A~ITY: rOT NO.:BLK. NO.: SUBDIVISION NAME: COUNTY: MAILING ADDRESS: 6)'"a r L~ ,.17 6121 x gg!'~ rE r W-7 USE DATES OBSERVATIONS MADE ,r" 7 NO. BEDRMS.: 1COMMERCIAL DESCRIPTION: R A I TESTS: Residence tKNew ❑Replace ?^Cgo-OF RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) DqSDU SS DU MS [_]U OS®U ❑SC'll 6 If 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 BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST-M HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 96. 7 AO m-t_ 5 4eXs S 1"' Sl B- 3 7 a ^S~ls s= °2 X55. a y s B S~ ti/ o J 40/_; Jr-- 3.2 B~ 3a1-' 5J'" B- PERCOLATION TESTS } EST DEPTH WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES f NUMBER CMIIIIIIIIe5 AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- t © -E' G P- 0" G P- o ^-L- P_ PLOT - PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 9~. s f ~Z15- E a 3 s~ o 3y P e 0 ma F ( E a r~\ 411, - - j ! 3 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: Al~ d rl A, ` `v?- 7 - $ ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): z6/c CST SIGNATURE: r-f 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 is - Fine Sand Bldg - Building Is- Loamy Sand - Greater Than 'sl - Loamy Sand - Less Than '1 - Loam Bn - Brown 'sil - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay 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. Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC T,'N-R 1 -44f L ADDRESS o ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM s l ~ bra INDICATE NORTH ARROW BENCHMARK: Describe the Bert al refer nce point used o-zzxt r Elevation of vertical reference point: %~~V / Proposed slope at site: ro G SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: 3 Tank manhole cover elevation: l © Tank Inlet Elevation: 121~. y5 Tank Outlet Elevation: ' Number of feet from nearest Road: Front,( Side0 Rear, O "Z/feet From nearest property line : Front, 0Side 10Rear, 0 e? feet Number of feet from: well d ~'C~/building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) err ARVFRCV QTTV A PUMP CHAMBER 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: k Trench: Width: Length: Number of Lines: Area Built: Fill depth to top of pipe: Gfs2 Number of feet from nearest property line: Front, O'Side, O Rear,OVt. dZ Z Number of feet from well: ® _low Number of feet from building: (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 box0 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, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: 7, Plumber on job: License Number : a 3/84:mj-, DEPARTMENT 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,SE4,S29,T31N-R1V ktCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number ❑ Holdin (lf assigned) Town of Forest g Tank ❑ In-Ground Pressure ❑ Mound Hi wa 64 NANIT OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INS EC I N DATE: r Bensen Route 1, Box 64, Emerald, WI 54012 117.31- 99 A BENCH MA K (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.. Name of Plumber: T P/MPRSW No. IC,,n,y: Sanitary Permit Number: Byron Bird Jr. 3318 St. C mix 119504 SEPTIC TANK/HOLDING TANK: MANUFACTURER. / r! LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV. WARNING LABEL LOCKING COVER IL PROVIDED: PROVIDED f /03 YES ❑NO ❑YES BEDDING: VENT DIA.: VENT MAT L: HIGH WATER NM BER OF ROADPROPERTY WELL: BUILDING: I VENT TO FRESH G T ALARM EET FROM LINE ~ AIR INLET: ❑YES VIVO - ❑YES O NEAREST ISM (t~~ 55 DOSING CHAMBER: MANUFACTURER. BEDDING'. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑ND ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTRO LS OPERAT IONAL. NUMBER OF PROPERTY WELL BU ILDING. VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing JLEN~, T H 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/TRENCH WIDTH LENGTH NO OF DISTR. PIPE SPACING COVER SIDE CIA#PITS LIQUID 1-2 13b TRENCHESMATERIAL: ]ET DEPTH: DIMENSIONS `J4 GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DI TR. PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COVER: ELEV. INLET ELEV. END PIPES FEE BFROM LINE: f y~ ^ Q AIR INLET: II _4D ~S, "1 t O~~ NEAREST I J~~ 1 co UZ11 v 1~ tl' 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- ❑YES ❑ NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS: OBSERVATION WELLS ❑YES [:]NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED. CENTER. EDGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.. CIA.. ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES ❑NO ❑YES ❑NO COMMENTS: n PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: ( FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST ~o J ~ t~d o- 6 d Sketch System on Retain in county file for audit. Reverse Side. - SI ~ TITLE: DILHR SBD 6710 (R. 01/82) Zoning Administrator l T DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY IT STATE SANITARY S5D -Attach complete plans (to the county copy only) for the system, on paper not less than 9 9 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 OW PROPERTY LOCATION •G h $ /'1 /a C/4, S T , N, R =E (o PROPERTY O NE MAILING ADDRESS LOT# BLOCK # O 411 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned VILLAGE r,G ❑ Public D~ 1 or 2 Fam. Dwelling- # of bedrooms A ELTAX N MB ) G~ _ L du III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo v 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. [New 2.E] Replacement 3. ❑ Replacement of 4.E] Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 130 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 1-15-0 l6 l 5- 0 ✓ 171 74-12 Feet - Feet CAPACITY VII. TANK Site in allons Total of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank +C C Lift Pump Tank/Siphon Chamber. VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plum s Address (Street, City tats, Zip Code): zf~L IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued issuing Agent Signature (No Sta s) rv Approved El Owner Given Initial I Surcharge Fee) Ica- Adv rs a ermin i n J S gJ~C`/ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS . 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to,be submitted to the county prior to installation.' 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every ,2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner`s name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. 111. 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) APPLICATION FOR SANITARY PERMIT STC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property ~ air ,r n Location of property =GrJ 1/9 /9, Section _ ,~;L , T_1-N-R1-5-W Township Mailing address XT f /~oX 1,7 Holz Address of site , Subdivision name Lot number Previous owner of property Total size of parcel ~i k'e 5 Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes X_No Volume F'412 and Page Number .5-7 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, deed recorded in the Office of the County Register of Deeds as Document No. Y Y ~?-9 c13 ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. 3 Z - 10-4' 4 - ~ ~ Sign ure of Owner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature DOCUMENT NO. WARRANTY DEED THIS s►Aea assaevw FOR AiCOODWO "TA STATE BAR OF WISCONSIN FORM Z-OU 448293 c G Jr7 REGISTER'S OFFICE ST. CROIX CO., Wt Law.rence.... , Meyer. 4n,d_J44.1*' M.....M.ey.e.~.tiu.e.kl~ind....... Recd for Record and. wif.e..as... f oint...ttenantIg it A)i 1989 , 01 11-45 A. M o vvys and ..•arrants to R.QBe.r A Bepson...and Mar.ily.11.,K. fenson, Husband and. w .f fe ag...eurx.i xo.rs.ktxp..la.ar..it#1 Raglsterot0ee& pro.per.ty. Rivard Law Office P. 0. Bout 9 Glmrrwlood city, wt %M3 the following described real estate in S t . C r o i x County, State of Wisconsin. Tax Parcel No: Part of the Southwest one-quarter (SW 1/4) of the Southeast one quarter (SE 1/4) of Section Twenty-nine (29), Township Thirty-one (31) N, Range Fifteen (15) W, more particularly described as: Lot One (1) of Certified Survey Map No. 2101, in Volume 8, page 2101. EXEMPT This - is, not homestead property. 0Z)K (is not) r +3i Exception to warranties: Subject to easements and rights-of-way of record, if any. Dated this Z 7rt day o ° { 19 99 . (SEAL) Lawrence R. Meyer (SEAL) (SEAL1 • Janis M. Meyer AUTHENTICATION ACHNO W LEDOMENT Signature (s) ..Law-r.ence. R. _Mf.;yar STATE OF WISCONSI.% ' and Janis M. Meyer sy ('ounty. n ' this .26. day f.. '.M'S.Y authe 19 Personally came before me th:s day of 19 the Above named r cis X. i drd . TITLE: . ER STATE BAR OF WISCONSIN (I rat, _ authorised by § 706.06, Wis. Stats to me known 41 be the person µf„ executed the foregoing instrument and acknow1c,1K • the Same. TH:S INSTRUMENT WAS DRAFTED BY Francis X. N.iv=>_r•d Glenwo~;ii City, ota-v 1,001t' 1 ountc, Wis (Signatures may be authenticated or acknowledged Both %I,, Coniwi<Qinn is ;;rr:i:ar, •i' • If +,ot -tatc expiration are not necessary.) date, 18 + -Nome[ of D.Mn. -igning in •ny '*P&r y 1,. tyt,..t rant. ~t I,.+ ,r ..[~,rt.. r.•. 4w~ srwrvoaii OF a- 1#h2 WISCONRIN Stock No. 13002 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER lpiri ~l~Y' ROUTE/BOX NUMBER FIRE NO. CITY/STATE Z4 L (~f✓ ZIP _5~_L/O12 PROPERTY LOCATION: 544 1/4 ! ~ 1/4, Section T~N, R~W, Town of o .5; 7'L- , St. Croix County, Subdivision , Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. S I GNED DATE e!/_ 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 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDI)STRY,, DIVISION LABOR , P.O. BOX 7969 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 3707 RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: N MUNICIPALITY: OT NO.: BLK NO.: SUBDIVISION NAME: ),/S~,/ /T N/R) (or OY-e~ T 4..-m COUNTY: MAILING ADDRESS: 51 6ro)-A, Roger 46`e..,75j2j Al ggn~6 V 0 1' 5'a W-7, USE -j I DATES OBSERVATIONS MADE 7 NO. BEDRMS : COMMERCIAL D S RIPTION: E : Residence .New ❑Replace / L -1.2 RA.TIN6: S= Site suitable for system U- Site unsuitable for system ONVENTI NAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:(optional) 1 S ❑U SS ❑u 2 ❑ S ®U ❑ ou DESIGN RATE: If Percolation Tests are NOT required If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: ~Q< PROFILE DESCRIPTIONS BORING TOTAL P H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. H TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- L4- 5 -5 7,1 -c`401~'t G PERCOLATION TESTS DEPTH . WATER IN HOLE TEST TIME D I WATER L V L-IN HE RATE MINUTES TEST NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 -PERIOD PERIOD PER INCH P- Z'00'& "e dif e- ;3 p. p..,c G P- o •^t_ G 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. e -:1W_ SYSTEM ELEVATION _ y '00 PZ> v• 1~ I AL 4 _ I T._ L - - _ • I ; 1 ry ~•y . 1-1000 ~ I 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: AVO-41pil d' I 1 '7 ADDRESS: - CERTIFICATION NUMBER: PHONE NUM/ ~rl: Im toe f T CST SIGNATU E: i '00- 1-ir I DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. I OVER DILHR-580~6 (R. 1QLl%3)_ - - PLOT PLAN PROJECT z~n ADDRESS ~ !5{ 1/4 ~E- 1/4/S ;71 N/R13 W TOWN COUNTY MPRS Byron Bird Jr. 3318 DATE _ BEDROOM CLASS PERC__~Z7 CONVENTIONAL, I -GRO RESSURE CONVENTIONAL LIFT_ MOUND_ HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA 4: PERC RATE BED SIZE /~Z 1116 Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H.R.P. O Borehole 4Weld Scale = Feet Ue O Perc Hole /2'f System Elevation TYPAR COVERING 2» 4 4 4 12 g g © 3 3 © 3, ' 1 6 Sewer Rock 18 12' 0 ~ I b a ~ ~ I b Fa. Y 4 I a d .,1 ~i