Loading...
HomeMy WebLinkAbout020-1036-70-100 CD o 03 I o Z o o o o qt, v N c O c O y R I i I a C I E O co C N O U a~ Z m C LL C O Z I O U C'. 3 :o a o I a c y M w z E rn z °o z ~ I `m m 00 ~ Z a 00 I o o z m z ~ ° ~ o (1) F- v v 12 Cl) N ca m ~ [0 CL N N ~ N C a` v o O z°m~ t/J Z c0 ~ y m c C) m N m E QO N V _ m a C. r C nO d a O c o a Z co > f0 if fn o °aaa y a _ rn rn iJU crnrn z O C) 0 N E o ~p a cn N m w CL y d Q to co U O p VJ U) ~O U) C om 3 c`) va° Lo O c o 40. V M ~ f0 m N L C U) O C 7 r N 'ONO N C C N L C- 2- O z c z cn E . I y a • a d 2 c r A c°~0 omci 1 z FILED z: - 111w ~1---" DEC 091988 3 r_ 9 JAMrSO'COMELL o R°gisiar of Dauds P~ ~ ~ ~ a,••, St. Croix Co., W, _T w 443732 P16 b.5 Is7 ~,o/ad M rt N .t / Li / 'l / " /q z w O o ~ vv Y n C W r• n rr n 0. to o w 0 /0 1-5 e u, to m CO :3 (D rr rt N 7' N O S /11 l • l~ 'fir r/ s fr N r-+ ' I• h% . 07J ;J • fp V • •p t ••f C C N r'• O C7 CO T T O O 01 O / F aL C1 rt s O B O O O O O p r o a z w I t° V' Cr N -n 7 W _0 m Q N M W N y = shall tract- 1IV 0 CD rt 00 7 C1 N N- CD w Ir 'D -S, W) 0 C- u r ° -j S000 1 7 1 1 211E 0- (D r(D N - 239.371 I~ 7/ 0 s 3 C7 w +~i-• fr o r = 238.11 m 1a l0 f' O 7 N Z Co SO X OD / jj ^ 'I~ 9'~'~Nca i✓6~, ~!i --1 ° .Fd7fi F C) w C> ` I 1 Certified Survey PJap vol. 7 2010 - pg. 1-2 a_ t n ' m 66 o Ca ~(os3 654.22 / -7/ F ° S01040111 lJ I - ~ N 11 .O 7 1 31 10 i 620.72' CO O C, i. 33.50 240.33' - ' s i - -east line of the PJVJ1 00°04'30"W G6 rt • i~ °o - east line - SW I a tw J IT O 66 z ° - N 1 ('r1 r Z I m 1 O ca 4_; .O rl- I rl- C) O Mr O I ~ t0 1 O ~ O -l rn ° 33.391 cn N i s I s m 'rt I N 585.271 M 1 rn I CO -0 - 0 O N10021121111 618.661 13- n C7 f N 1 I w D l N r- I I G. n fo 1 C-73 M lJ ' I S C. W fJ D ~o N00028120"E 683.03' - ' Cl) I r I rn ca < 0..~~ /bt T f` 648.82' 10 1~ J. N 0, el - 34.21' o I rt •:r C_ (~r'< r Kam? n z I PQ 91- O of :V . ic: 1 • m. v -n O l0 ~ F 13 33, D~wOj•w.... Qti I r, fit.,,! p' \ 675.82' N r-~' ~J~;~y„,rr N00028'20"E 720.41' m f rl O Q5 • r ► 0 • +~F\ small tract CO r y- C-) w w w r co ~n O o W p°° 7 0 \ \ \ \ ; m O C+l O F C N CD F F - ' C.) y CD P- X 7 - - - - -f , m O CO T r N N N C f••. p... N. h.. O Z F t n -1 7 M O O O O - rry nt N N O 0 7 0 r r- t- r 1•- W. 0 O O O O 7 rt •O 7 Cr •O 'a tO y '--t -y O r• O W CD a F W N r ~ N N '1f - •v -ti -n o F W f•- w m C7 ~*t o o c C o' o o c c o v r W V w CO CO .--•71 •O Q,° M D A N M 7 4 0. = C1 ~ O D Ln N O w v C n = N d L1 0 N N N ut tD U. ~ V1 L7 O tD ~ ~ C VI _q N .r7 N A N A ~ ~ 7 C ~ DEC 08 1988 rt rt rt rt m rt CPON 0001,4l`f CO C/) fV:X -NSIVE PARKS 1'Ui\Nfqu,4c ° yr c •t 7! )rJlfvG Cc:rnivtltlFi= ° N Cl ~ F W y. F rti F W t0 N O F C7 , x LP v c W V N Ul w F n F fl pt n C]1 1-. > C N VI N N N N G=7 N tY VJ ~ N L Vt 1] ' •C n• rt rt o rt N N Vol. 7 Page 2053 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER S Q ^ TOWNSHIP SEC. T°;~9' N-R, ADDRESS ~Z. ST. CROIX COUNTY, WISCONSIN SUBDIVISION C- 91'/ I~LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~.S.Ch~vir~ I N ~0, 1 j 3 SAS C (C) . 1o~,fn = ~OS.o i zo to" s f-- z ~y ~ f f G r a 1 3 ~ oV~ i 4 v T f N ~r INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 4, U Elevation of vertical reference point:.~ - ~l~ Proposed slope at site: -g% Sow T_fil = ~ SEPTIC TANK: Manufacturer: Wa ; Liquid Capacity: 166 Q '0 aj Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation:,LI : 0-00Tank Outlet Elevation: l.,ze~'~ a<" Number of feet from nearest Road.: Front 10 Side, Rear, O ~35 feet .From nearest property line Front,OSide,ORear,® feet i Number of feet from: well building: 2cl (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE i i 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, 0 Ft. Number of feet from well: Number of fees from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Cave Trench: Width: l~ Length: 3 Number of Lines: 3 Area Built: G s T`- Fill depth to top of pipe: i Number of feet from nearest property line: Front, O Side, Rear,O Ft &2-_ Number of feet from well: 9~ / Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: X*7 Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box 0 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 nearQ5-t property line: Front, O Side, O Rear, 0Ft. Number (Tf feet from well: Number of Fcet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector• OCT) Dated: Plumber on job: License Number: w 3/84:mj DEPAAAENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 p State Plan I.D. Number: N~Y y, NE' 4y S 18 , T29N-Rl9W (If assigned) Ed Lot 3 Casperson Driv CONVENTIONAL ❑ ALTERATIVE Holding Tank ❑ In-Ground Pressure ❑ Mound ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam Miller Box 282, Hudson, WI 54016 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: Do Strohbeen 5432 St. Croix 119471 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT CIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST--- DOSING CHAMBER: 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 OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST 111110- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: 4AREST- Sketch MBER OF PROPERTY WCOMMENTS: ET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) Zoning Administrator SANITARY PERMIT APPLICATION _©ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY s/, D X STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than / / 9 C/ 71 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 PROPERTY LOCATION Sah7 iIle Y VY./VE%a,S / V T ,N,R /q E(o d iv PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # /&m 70& Z q Z_ CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 17'9.4✓$6 w $Y,61 Off- )274017 II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD State Owned ❑ VILLAGE / K a 0 S Serer r~tJ~. ❑ Public N 1 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUIV15EK(5) III. BUILDING USE: (If building type is public, check all that apply) ZO _ - to 1 El Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. lol New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 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/da /sq. ft.) (Min./inch) ELEVATION (10401 p. < 3 /10,7-9 Feet Feet VII. TANK CAPACITY Site INFORMATION in allons Total of Manufacturer's Prefab. Fiber- Exper. New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank X / (rt7 3 a.✓ Lift Pump Tank/Si hon Chamber El 1 1:1 1:1 1 0 El Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Pl(umbbjer's Signature: (No Stamps) M~P~/MPRSW ~No.: Business Phone Number: bow Strok be-q-v, /'l/ J 3 y (Z'17 77-33 Plumbs 's Address (Street, City, State, Zip Code): 2,~? 41.w d.rM .C QT- y0/ 7 IX. COUNTY/DEPARTMENT USE ONLY I F-1 Disapproved Sanitary Permit Fee (include Groun Water pate ssue ssuing Agent Signature (No tamps) Approved ❑ Owner Given Initial Surcharge Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: i I SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8, Buildings Division, Owner, Plumber r v INSTRUCTIONS ' i 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-?66-3815. 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 or% 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-6M (R.11/88) r 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 SQ," Location of property Zvi 1/9 -1/4, Section 1:~K , TAN-R / f W Township f~k is o h Mailing address .o~oX aD'' 2 Y~ ~~sor 41-1-12:- .f S/d/L Address of site Subdivision name G. Lot number # 3 Previous owner of property V,'rf/*/ ~{/cu 6~.4Qr Total size of parcel 3.7 S X c a r S Date parcel was created i0~z7 17 k Are all corners and lot lines identifiable? e-y-Yes No Is this property being developed for resale (spec house)?_Z-~-Yes No SS- Volume (_and Page Number 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. eI V,3 r 9 ( ; 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 a County Regis of Deeds, as Document No. g Signature of Own Signature of Co-Owner (If Applicable) '5 - It, -q - Date of Signature Date of Signature [COQ 30 rAh"t 55 I 1 DOCUMENT NO. WARRANTY DEED i THIS s►ACC Rncevco FOR *CORDING DATA STATE BAR OF WISCONSIN FORM 2-1082 j I REGISTER'S OFFICE it Virgil. L.. Neubauer & Linda M.. Neubauer.,.. husband. and . Sr. CROIX CO., {M wife _ Rec'd for Record DEC211M conveys and warrants to Sarn..~-Miller,, a...single. per$gn........ at 10:50 AM . r waft, aw of 0006 _ _ _ _ . RETURN 3 the following described real estate in Si;.••Lroi.x .........................county, State of Wisconsin: Tax Parcel No: Part of the NE } of the NW I and Part of NW I of the NE I of Section 18, Township 29 North, Range 19 West, St. Croix County, Wisconsin described as follows: Lots is 2, 3 and 4 of Certified Survey Map filed December 9, 198' in Vol. "7", Page 2053, Doc. Nc. 443732. TOGETHER WITH AND SUBJECT TO a 66 foot wide Private Road Easement as described in ;I Warranty Deed in Vol. "656", Page 544, Doc. No. 381696. 'rRp,NSf'~R FEE ~I Taus . homestead property. (is) (is not) Exception to warranties; Easements and restrictions of record, if any. bated this day of December , 1983 _ (SEAL) V.~^tj1,~~• Il._7.~~~Cta-~ (SEALI • Virgil L. Neubauer . . . . . ASFAI.) 6l17l« eZ ' (SEal.l • Linda M. Neubauer AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ` 1 ss. St.. . Croi.x ......County. authenticated this ........day of 19...... Personally came before me this !1(-._ day of December , 19 88 . the shove nnmerl Vi . . rgi 1.. L.. Neubauer and Linda I';. Neubauer, • husband.. and. wife TITLE: MEMBER STATE BAR OF WISCONSIN (If not . authori ted by 1 706.06. Wis. Stats.) ....xg, me known to he the per on s who executed the i fumn!irw instruni and acknowletll:e the Sate:.. THIS INSTRUMENT WAS DRAFTED BY ,~iJ.l.i.a~►..J... R,~d4sey.i.cha..Atto.r.n~;~:4:~`~aw ~ .502.Second..St. Hudson WI....5A01'-~...... - 11- 1 nta'~ I'uhlic St. Croix County, Wis. (Signatures may he authenticated or acknowledged'•Botts ~?Iy 1 "emission is permanent. (If not, state expiration are not necehaary.) 3 date: 2 7 19~~f iii t` •Namea or persons ahrnins in any capacity xh-bl I,c 1>P,.1 . r print.d h.•low th• it .iKt. t. WARRANIT DEiD STATE HAR OP p~'15CONSIti N:.,.n+:n L.xwl Itl:.•.. t'.. L~, • H • z 94 a 9TC- 105 rr- a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a OWNER/BUYER S4,rr M ROUTE/BOX NUMBER ~v y- Z g Z Fire Number .CITY/STATE x/4!1 IVA- le-47: ZIP Syy/~ PROPERTY LOCATION:-&,~) It, , Section T.21I N, R Town of A44"On , St. Croix County, Subdivision e-5-101 , Lot number 3 G%r91#1 Alt v6.v~r Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their 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 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. 0 ' E I/WE, the undersigned, have read the above requirements and agree y to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- ro ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning OffkVe with n 30 days of the three year expiration date. O CA SIG DATE St. Croix County Zoning Office P.O. Box 98, Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. DEPARTM66NT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISO N WI 53707 HUMAN RELATIONS (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/"^"^"' [OTNO.:1BLK. NO.: SUBDIVISION NAME:~rs*. W 1/4e'4 J2 /TAIN/R171(o sc COUNTY: O NER'S BUYER'S NAME: MAILING ADDRESS: 14 ni 5 row ok No,/ d'jo., Wt/ $110 11160 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 1,4 xNew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system G. S fA,LS AQ CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDEDSYSTEM:(optional ~L•x f-2• ®s ❑u Lids ❑u s ❑u os ©u ❑s au 'o.9w "A az. If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation: PR FFI E DESCRIPTIONS BORING TOTALJ1 DEPTH TO GROUNDWATER.W+@WC-t CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHw. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) /07.7' 116te- 7 if, 0 B/S/ n as, S /S %3 0n hS B- Z .S_' /106,'7' v 7 7• ~r' /s/ 4 Z, 7 6 /r S rs S 3 & S B- 3 0 /10 7. ' /1JOAAe 7 e~• .~'1 s/ . 0',Ast get, s . o s .,~~e 7 7•' . Y 8 / s/ s'/ 7.S' a 7.,z' B-~ .S' 0~~,~' S-r S/ . 3 s/ ,~/S 3 7 $n S B- 6 . o s : S' Norve ? .S' 1 s/ .Z. 3 e /s 3. o AV r s B' 7 ~.5~ ~C9 5, 8' ~clv,v e. 7 7,S' PERCOLATION TESTS s/,2,C$^ /s 3.0 AUt 94- S TEST DEPTH,1 WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER OW44 8 AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERI002 PERI D PER INCH P_ l ell 00 1 o 3 4 6 ---3 P_ v .o' 0 6 3 P- -3 of P- P- P- =T-= 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 boa, 9 F4S'~,/e i 1 410 -tJ F.'_ 0.u! rd € _ _W S - _ r~~- ,tee ( r IT; ? f. rf~i 711 1 -re x . i E ya m 1 ^ . #ate: smon e" A-3 T-6. i~i,►.5~.~`,+<.,~► ✓A t-,' a/ ^OtA If4Qucre-0at.-is~ 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: .^s r,f s s,- w r/- /e ~'8 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): '1116 / S-? 97 CST ATURE: , DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - i INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be ,:I accurate soil test, your report mast include: 1. Cc legal description; 2. The u =ction must clearly indicate whether this is a residence or cornmercial project; 1 MAXh ,'M number of bedrooms or commercia; use planned; 4. th' -,iv or r,- - _-rnent systern; 5. the sr., bilit:y rating boxes, A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL IYSTEIV 7 RULED OUT BASED. ON SOIL CONDITIONS; 6 r a rse the ab' 4rtions sh i here for writing profile descriptions and completing the plot plan; 7. LEGIBLE d::rgr.,m act y locating your test locations. Drawing to scale is preferred. A rm=y be used I benchmark -levation reference point are clearly shown, and are permanent; ropriate box( tes, names, addresses, flood plain data, percolation test exemp- ' I Qri (such as flood elevation) does r Daly, place N.A. in the appropriate box; 1 1 I place your cur ?::lress and your c. tion number; ;)ies and distrib rs r(21tluired. ALL _ -'1' TESTS MUST BE FILED WITH THE L' _ RITY WITHIN : 1AYS OF COMPLET11 E REVI ATIM.0 . ri ,,.,ERTIFIED SOIL TESTERS Textures _ Symbols aver 1b") BR E- -hl (3 - 10") SS - ~a gr - vel (unclOr 3") LS L ~.ne ~s - Sand HGW Grounr'.Wat?r cs - s_ Pe"rc nation F med s tin, vv fs Bldg Is lySand C . rThart sl _ Lorin Less Than II - Bn - Brown ~sil Irn BI Black si - Cy ( *cl 1 y Le am Y Y. '")"v - Sandy C° y ' R - Red I -,Silty Clay L ^ not - Mot Sandy Clay vvr' - vntl~ sic - Slh'~y Clay fff - f, it c y cc - coma r ; rnin - Many, ' d -~istin, P Promlr HWI - F r rr< soil textures ssrtac~ „ . u ...!aste distiasal BM Bench N/J.- VRP Verticai Refel 1 l 1 I c a cnur; y a f Ja s~ r'f i ~~QV L.S. /y. V.'r 6; l N-,4, a~ Leff # 3 L1 ~.(1►►. ~s.,rth~ V~~* f Hot~Z P~. C 0- m~-t.f of C- 101- ~:r ZT tk4. s.w, Al 3 2 Y M /4s-5 w.+~ E I. ~oo.o' 41 vhstc' S Al.."rX /off ~.'1t4__v u Z II J o - ~E-- 110, --~i a4'X3~/' ee 'X :;-p 20 0 h a 3 a Zl ( t~/l~t ~ ~ ~ i 21~ I i ~ /4I'fav/rw 7"t 30 110 I { x { d✓' sa 1 -16- ~ vb T L4) tA Y., 4 N ' r- N . P ~ r c ~ P ¢ H t~ p I GCE d ~••P d ` P •1Lr i J i T o- -d P x` ~1D• ;W w S 0 -f