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Parcel #: 020-1262-40-000 01/07/2005 04:15
PAGE 1 OF F 1 1
Alt.Parcel#: 20.29.19.1271 020-TOWN OF HUDSON
Current ❑X
ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): *=Current Owner
*STELTER, PAUL G&CYNTHIA A
PAUL G&CYNTHIA A STELTER
859 LASSIE LA
HUDSON WI 54016
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *859 LASSIE LN
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.000 Plat: 2319-PINE GROVE HEIGHTS 2ND
SEC 20 T29N R19W 2 AC PT SE NE LOT 26 Block/Condo Bldg: LOT 26
PINE GROVE HEIGHTS 2ND ADD
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-29N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
12127/1999 615963 1480/009 WD
07/23/1997 1135/329 WD
07/23/1997 850/143
2004 SUMMARY Bill#: Fair Market Value: Assessed with:
49311 215,600
Valuations: Last Changed: 10/29/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 30,000 136,800 166,800 NO
Totals for 2004:
General Property 2.000 30,000 136,800 166,800
Woodland 0.000 0 0
Totals for 2003:
General Property 2.000 30,000 136,800 166,8000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 216
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ��� TOWNSHIP J4, 5,,gA SEC. <'_>6 T 27 N-R I_LW
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION R & LOT 0L LOT SIZE 8'7 41 C>rI I
PLAN VIEW QZ 0-t Z_ qO
Distances and dimensions to meet requirements of I1HR 83
b
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
�l3 j
4r
ID
iZ
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used-116-14 Q& lttbr NLI� �J' d'
Elevation of vertical reference point: Js-�-'�-� Proposed slope at site:
SEPTIC TANK: Manufacturer:- Liquid Capacity:
Number of rings used: Tank manhole cover elevation: See )L, 1reP'&
Tank Inlet Elevation: ut1et Elevation:
Number of feet from nearest Road: Front Side y
'� 'o Rear, O C �b feet
From nearest property line Front Side, Rear,
0 O
"7`
�- D feet
6LA S+ ! 1/
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
IL SEE REVERSE SIDE
PUMP CHAMBER t
Manufacturer. Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
i
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: 1Z Length: '7 , Number of Lines: 2- Area Built:
Fill depth to top of pipe: le
Number of feet from nearest property line: Front, O Side, Rear,0 Ft .�Q,
Number of feet from well: 1 _ LS p,(�
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT �
Size: 1"(
/k 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: 91A-
Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, 0 Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector: A`a e:!5,- S.
Dated: �� �L �`I Plumber on job:71r
License Number: P.f>RS sZ to
3/84:mj
•
DEPARTMENT OF,INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING
LABOR HUMAN RELATIONS DIVISION
P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION
MADISON WI 53707 State Plan I.D.Number:
SE,NEE,20'"29,_-; 0W'- (If assigned)
Town of Hudson 22 CONVENTIONAL ❑ ALTERATIVE fQ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF P RMIT�,D_E'R_
ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Richard tout R.2, Box 340, Hudson, WI 54016
ENC JMARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: f��} REF.PT.ELEV.: CST REF.PT.ELEV.:
F Q� 1V V
Name of lumbe _ MP/MPRSW No.: County: Sanitary Permit Number:
John P. Sykora t 3212 ST. Croix 119486
SEPTIC TANK/HOLDING TANK: WARN
MANUFACTURER: LIQ1UID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: ROVIIN D ABEL LOCKING OVER
O U 2- to YES NO ❑YES .i NO
BEDDING: VENT IA.: VENT M .. HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH
ALARM: FEET F OM LI E AIR INLET:
❑YES NO �,•` ❑YES 0 EARE T---► 8 d ® (' I ba
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: P MP/SIPHON MANUFACTURER: ROVIDEDLABEL LOCKING C
❑YES ❑NO FO-01 YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND ONTRO OPERAT NAL: J¢UM6ER OF PROPERTY WELL: BUILDING AER NLET:RESH
(DIFFERENCE BETWEEN j FEET FROM LINE:
PUMP ON AND OFF) Y ❑N EAREST--�
SOIL ABSORPTION SYSTEM. Check the soil moisture at t ept of plowing FORCE ENGTH: DIAMETER: MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,constructi n s al cease until M/�IN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEIDISTR.
WIDTH: : ! NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID
BED/TRENCH TREN S: / tv►AYEF�IpL' PIT DEPT DIMENSIONS GRAVEL DEPTH FIL'DEPTH IPE DISTR.PIPE DISTR PIPE MATERIAL: NO.DIIS NUMBER OF PROPERTY WEL BUILDING: VENT TO FRESH
ES: ABO VE COVER: LET: ELEV.END' PIPES: NE:0 ` , �— NEARESTO—♦
MOUND SYSTEM.
Mound site plowed perpendicular to nCheck ture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: ms to make certain that it ON REVERSE SIDE. SHOW
❑YES ❑NO teria 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 QFTOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑YES ❑NO ❑YES ❑NO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
BED/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
INFORMATION APPROVED PLANS
❑YES ❑NO ❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
D YES ❑NO EYES ❑N NEAREST—�
`.Q U
Retain in county file for audit.
Sketch System on -
-i TITLE:
Reverse Side. SIGNATUBLE:-
tiJ'&/" Zoning Administrator
SBD-6710(R.06/88)
CILHR SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05,Wis.Adm.Code s i � CRO l}C
STATE SANITARY PERMIT#
–Attach complete plans(to the county copy only)for the system,on paper not less than �8%x 11 inches in size. revision to previous application
—See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER
I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
, N, R E(or W
PROPERTY OWNER'S MAILING ADDRESS LOT# .� BLOCK# y—
AT1Y ZIP CODE PHONE NUMBER KSBDIVISION NAME OR CSM MBER �77$! ,,2 rte
NEAREST ROAD
. O4FB IL DIIN//��G: (Check one) ❑State Owned VILLLLAGE: �A g StQ ,t'a �._
❑ Public 54 1 or 2 Fam.Dwelling-#of bedrooms -PARCEL TAX NU B R(b)
111. BUILDING USE: (If building type is public,check all that apply)
1 ❑ Apt/Condo
2 [] Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 [:1 Outdoor Recreational Facility
3 El campground 7 ❑ Merchandise: Sales/Repairs 11 El 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. , l 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 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 El Seepage Pit Pressure 43 El 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. 17. E FINAL EVATION GRADE
REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch)
VII. TANK CAPACITY Site Fiber- Exper.
in allons Total #Of Manufacturer's Name Prefab. Con- Steel lass Plastic App
INFORMATION New istin Gallons Tanks Concrete structed g
Tanks I Tanks
Septic Tank or Hold!no Tank ` a� 7- Wp�-s _F
Lift Pump Tank/Siphon Chamber jVZA
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 Signature*.(No Stamps) M MPR .: Business Phone Number:
(� P�
Plumber's Addre treet,City,State,Zip Code).
-,;g^ I a)c
IX. COUNTY/DEPARTMENT USE ONLY Issuing Agent Signature(No Stamps)
Disapproved Sa nary Permit Fee(Includes Groundwater a ssue
❑ 3� Surcharge Fee) / r A Approved ❑ Owner Given Initial y�(,F+/ .1/ft/,f
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber
S
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 61'199) 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 numbers) 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 i
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to file 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; (lose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
»..-r 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 caR 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)
5 DOCUMENT NO. "STATE BAR OF WISCONSIN FORM 1-1982 �I' THIS SPACE RESERVED FOR RECORDING DATA
• WARRANTY DEED I,I
Nil
1E 604 ~152tAGE' it
RE!lISTERS OFRCE-
George J. H. Gies and ��
This peed, maiie betwe --- -------------------------------------------- ST. CROM 00., WI&I
Jean Dorwin es, nis wie ReC d for Record M�is 29th
.....................
- - ... - Grantor, day of_Aua.• ,aa 19,_86
------------------------------------------------------------------------
and_.__._1�iCtiard_0,__Stout_and_Janet_P, Stoutx_husband_____________ 9:30 A. IL
and_wife__as__joint__tenants__as-_to__a... 0%_ interest_; and_ ►
..Maud..H.&..SLQUt._a.9..sQ1e... wnex_•of_.a.. 01. V@Ww of Owde
'Li $�;
-------------------------------•-----------------• -------- -------------------------------•- ., Grantee >
Witnesseth, That the said Grantor, for a valuable consideration......
-
............_----------------------------------------------------------------------------------------------------
RETURN TO - -
conveys to Grantee the following described real estate in .51-t..Croix______________ lI
County, State of Wisconsin:
All that
part of_ the NEB of the NEB lying Southerly of
the railroad right of way; Tax Parcel No:
The SFh of the NE14;
The NE14 of the SEk;
All in Section 20, T29N, R19W;
SUBJECT TO all existing highways, platted roads and easements of record.
EXCEPTED FROM THIS DEED are all parcels of land previously conveyed in part performance
of the land contract referred to below by deeds of record.
This deed is given in final performance of the land contract originally made by
George J. H. Gies and Jean Dorwin Gies, his wife, as ve s and Robert L. VerDugt
and Betty Jane VerDugt as purchasers, the purchasers interest in said contract
having been assigned to Richard 0. Stout, Janet P. Stout and Maud H. Stout.
The original land contract was recorded in the office of the Register of Deeds for St. k
Croix County, Wisconsin August 18, 1975 in Volume 52't, Page 271, Document #328700.
The assignment was recorded in the same office on September 30, 1982 in Volume 652,
Page 447, Document 4380015.
T�,.NSF� __
This ._:.......iSis n C___._.. homestead property. *.---, Aa j6
(� (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging; FEE
And...........GeorgeJ_tH4Gies__and__Jean_ -orwin_Gies_t__his__g: fe,__________________"•--"""-"".................
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements and protective covenants or restrictions of record, if any; conveyances,
liens or interest created by the act or default, if any, of the grantees,
and will warrant and defend the same.
1st Agtat 86
Datedthis -"•"""---- ..................................... day of ----------------------------------------------------- - 1 1 9------------ 19....-••..
� 7
/ff. c ,t,� .................(SEAL)
.(SEAL) /C�(,"`�.__1�-__�-�--�. � �
f * George J. Gies
...... -- -------
-"--"---""""-•""""-"""""""-•--""(SEAL) / � ......` .... " �•--- "".".(SEAL)
* Jean Dorwin Gies
...-•----•--• --"--------"--"-------
AUTHENTICATION ACKNOWLEDGMENT
" George J. H, Gies and Jean
Signature(s) STATE OF WISCONSIN
Dorwin Gies, his wife ss.
----------•- -----•-- - -- --- ---- - g - County.
authen ' ated this .-��day of-•._Au ust , 19.86 Personally came before me this ----------------day of
�' ------------------------------------------- 19..--.... the above named
_...... --•...--
------------•------------------"---•-----------------------------------_-_-••--
* ohn D. Heywood
--- -•------------------•----------------------------------------------------- --------------------------------------------------------------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
i
(If not- ------------------------------ ----------------------------- --------------------------------------------------------------------------------
authorized by § 706.06, Wis. Stata.) to me known to be the person ------------ who executed;the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
i He yw_ cod _•Cai, Murray_& Sherburne
P. 0. Box 229, Hudson, WI 54016 *------------------------------------------------------------------------------
JohYr"D 'tiey vuad----------------"------------------------------------- Notary Public ."..------------------------ ------County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration
are not necessary.) date:_ .... ........ ................... ....... . ... ,
19---- ---
ids )
*Names of persona signing in any capacity should be typed or printed below their signatures.
WARRANTY s)RF—In__ __ STATE BAR OF WISCONSIN Wisconsin Leral Blank Ca Ins
i •
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/contractpr, ("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 j ,- 0
Location of Property 5E-1i �� it, Section 2O , T 29N - R W
Township
Mailing Address 9*7- -x :340
Subdivision Name d-e ✓e- <<„�
Lot Number Z-7 `
Previous Owner of Property C e-lbr�� �, s
Total Size of Parcel ab j<.
Date Parcel was Createdf[T f 97
Are all corners and lot lines identifiable? �_ Yes No
Is this property being developed for resale (spec house) ? _ Yes No
Volume 7SZ- and Page Number 16-0 as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3. • Other recordings filed with the Register of Deeds Office
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 the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) eehtt.6y that att statemewte on thiA 6oAm ane tn.u.e to the beat o6 my (oun)
knowte.dge; that I (we) am (ore) the owner(d) o6 the pnopeh ty des eh i.bed in this
in6oAmati.on 6onm, by vi tue o6 a wamanty deed neeonded in the 066ice o6 the
County Reg•ceten o6 Deeds ae Document No. A.41 G ; and that I (we)
pneeentty own the pn.opoeed a•c to bon the eewage poe aydtem (on I (we) have
obtained an eabement, to )tun with the above de wtibed ptopenty, bon the
constA.ucti.on o6 eaid eybtem, and the same has been y n carded in the 066iee
o6 the County Reg.i.6ten o6 Deeds, ad Document No. 1 .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
5,& s/89
DATE SIGNED DATE SIGNED
J
H
z
En
' H
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
9
H
OWNER/BUYER f111 CL"
ROUTE/BOX NUMBER Z .98-pz 3Y0
Fire Number Ou-
.CITY/STATE{ G �r S ZIP ,S4�6((o
PROPERTY LOCATION: 14, ..A)F _'-L, Section 2L Taq N, R__,L'? _W,
Town of ibW6_CkC4 9 St . Croix County,
I
Subdivision , Lot number 27
OgA 6 c-f
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
0
E
I/WE, the undersigned , have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
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 Office within 30 days
of the three year expiration date .
SIGNED --�°�
DATE �z a
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 .
DEPARTMENT OF` REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY„ DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(ILHR 83.09(1)& Chapter 145)
OCATION: SECTION: OWNSHIP UNICIPALITY: OT NO.:BLK.NO.: S BDIVISION NAME: Z
1/ VLZI/ ao /TZ7N/WE Q-
COUNTY: MAILING ADDRESS:
.54cralK f � Z aec 3'4 0 SdN o f
USE DATES OBSERVAT ONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: A TS:
Residence d%+ New ❑Replace 15/ZZ s ZZ/9
RATING:S=Site suitable for system U=Site unsuitable for system
r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)
NS ❑u NS ❑u ®Sou aS Nu DS r<u4� K /z`xsZ
If Percolation Tests are NOT required DESIGN RATE: �/�
q I If any portion of the tested area is in the
under s. ILHR 83.09(5)(b),indicate: I/j� Il Floodplain,indicate Floodplain elevation:
S PROFILE DESCRIPTIONS fkq O__ //
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL H THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
01' 41'ig
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PERCOLATION TESTS
EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P_ a Z.
P-
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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. Ab
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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): ITESTS WERE COMPLETED ON:
b __ _ _
ADDRESS: CERTIFICATION NUMBER: IPHONE NUMBER(optional):
tZE
C SIG T tE:
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395(R. 10/83) —OVER —
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INSTRUCTIONS FOR COMPLETING FORM 115- SOD - 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
'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.
J
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS
DIVISION
INDUSTRY,
LABOR AND -PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIONS
(ILHR 83.09(1)&Chapter 145)
rL_CATIO SECTION: OWNSHIP UNICIPALITY: OT NO.:BLK NO.: S BDIVISION NAME: Z
kiciv 1 IJL' zo /Tz9N R/QE 1 ► N ZGa Q
NTY: MAILIN ADDR SS:
� R � .> ae. ��o safx A)4,%. o r
USE DATES OBSERVATIONS MADE
NO.BEDR : COMMERCIAL DESCRIPTION:
[�Irtesidence � 141;4— KNew ❑Replace
RATING:S-Site suitable for system U=Site unsuitable for system
ONVEN AL: MOUND: IN-GROUND ESSURE: S -IN-FILL OLDING TANK:RECOMMENDED SYSTEM:loptional) ��lx sZt
®S DU Q S Du ®S EA 0 S ®U a S Nu �44/�lo.� �
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.ILHR 83.09(5)1b),indicate: 9/k I I Floodplain,indicate Floodplain elevation:
S PROFILE DESCRIPTIONS
BORING TOTAL P H T R UNDWATER-INCHES CHARACTER OF SOIL H THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH IN, ELEVATION pgSERVED H TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
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PERCOLATION TESTS
TEST DEPTH , WATER IN HOLE TEST TIME O 1 WATER LEVEL-INCHES RAPER INCHES
i NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD t PE ,3
P_/Z Z h Q
p_
p_
P_
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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. /ae '-
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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): ITESTS WERE COMPLETED ON:
DRESS: CERTIFICATION NUMBER: PHONE NUMBERloptional):al 2-7
Mi K. 75 q WSI
T{�E:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DtLHR�BpLR395 IR. 10/831 — OVFR— _ J
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REPORTING LOCATION INFORMATION
1 . Plan view (plot plan) must be drawn to scale or dimensione .
2. Establish a perman nt, easily identifiable horizontal r erence point
(HRP) . Describe a d locate this point so that it can found at a later
date by someone oth r than yourself.
Examples of acceptab a horizontal reference point are: lot corners,
fence posts, building corners, wells, power pole , telephone junction
boxes, power transfor rs, etc.
3. All distances to soil b rings and percolati tests must be referenced to
the HRP. Therefore, it s necessary to es ablish a north, south, east or
west base line through th HRP. All mea rements to borings or peres are
to be made off of this ba line and at ight angles to it.
EXAMPLE:
base line -
45' �
. I o P-3
85, B-3
I �
2 '
65' - - - - - - AP-2 _
4/900
50
�—HRP
well
xisting 1
House
110'
County B
Indicate distance from nearest HWY intersection.
If p colation test holes are adjacent to the soil boring there is no
nee to duplicate horizontal location data. However, if the peres are
not closely associated to the soil borings, a separate location for the
perc must be shown.
4. All setback distances from the syste ' area to wells, buildings, critical
slopes, lot lines, water services, et ., must be shown. See section ILHR
83.10 (1), Wisconsin Administrative Code.
1
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