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HomeMy WebLinkAbout020-1231-10-000 ti 3 0 N C O �} O h N n O i -o kr i C Z 7 c6 U. C O 3 Q 3 Cl) v m rn W Z E N z ( a m J ° I o z v N O) CL C @ N N • a = GO O O N Q O U N ZmZ 0 E 0 N CL W d N O G d o • � aaa C CL O a 'a rn O �' f) J C) > N �y 2 rn rn } N 0 0 0 E � N N U) N 0 ° 0 3 v _ o M C V O O Y O N M O M @ C O � C U1 N FH C N V N r. N � O N O O — O O to f6 I U •Q O N 2 O Z C (n v� m m a CL 0 r`ly E c c 10 � r A dIL o rnci Parcel #: 020-1231-10-000 02/07/2005 04:21 PM PAGE 7 OF 1 Alt.Parcel#: 29.29.19.1238 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 * DUANE T&NANCY R FIER FIER, DUANE T&NANCY R 490 COUNTRY VIEW RD HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *490 COUNTRY VIEW RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.000 Plat: 2421-ROSSING'S COUNTRY VIEW SEC 29 T29N R19W LOT 10 ROSSING'S Block/Condo Bldg: LOT 10 COUNTRY VIEW ADDITION Tract(s): (Sec-Twn-Rng 401/4 1601/4) 29-29N-19W I Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 879/534 07/23/1997 834/41 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 49278 230,900 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 30,000 148,600 178,600 NO Totals for 2004: General Property 2.000 30,000 148,600 178,600 Woodland 0.000 0 0 Totals for 2003: General Property 2.000 30,000 148,600 178,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 153 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 - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER &W a TOWNSHIP A�k :F,&A SEC. —27 T 21 N-R L S ADDRESS /�,�y2 $ Z� ST. CROIX COUNTY, WISCONSIN /4 ASSN �5- SUBDIVISION_ ,' , /,iul LOT f4 j LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM a U) A wm ? r s ('toN SL ?8'xto 120 79• Ar C I 1 E i. ' 1 O • b INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used / i1o� /Q i xoi mf 44 Elevation of vertical reference point: LCbd,O 7- S Proposed slope at site: :t S o $.W, SEPTIC TANK: Manufacturer: Lk)m('s c V- Liquid Capacity: hnoc) Number of rings used: Z Tank manhole cover elevation: �• Tank Inlet Elevation: �AO! Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side,©Rear, O / 7 S feet From nearest property line Front,OSide,O Rear,� / 5'0 feet i Number of feet from: well building: (Include this information of th above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE r � PUMP CHAMBER Manufacturer: ��j� Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,© Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM/ Bed: (vn Trench: Width: /9' Length: 3 Number of Lines: Area Built:G�/ _ Fill depth to top of pipe; Number of feet from nearest property line: Front, O Side, ©Rear,0 it .ho Number of feet from well: Number of feet from building: SG , (Include distances on plot plan). SEEPAGE PIT } Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box©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, OFt. .Number of feet from well: Number o feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: � � Plumber on job: License Number: A 7 3/84:mj ' drPARTMETIT 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: NGIj,SE%, S29,T29N-R19W CONVENTIONAL ❑ ALTERATIVE (If assigned) Town o4 Huct6 o n aping Tank ❑ In-Ground Pressure ❑ Mound WA ME OF PERMIT A L ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam MiUen Box 282, Hud6on, W1 54016 �` - () - BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT ROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV: �*� t / ,r 6 Name of Plumber: MP/MPRSW No.: County. Sanitary Permit Number: Doug Stuhbeen 5432 St. cuix 119410 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: , TANK OUTLET ELEV: WARNING LABEL LOCKING COVER _ / PRO ED: PROVIDED: � 01.O� I o YES ❑NO ❑YES�J NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH ALARM: FEET FROM LII,Er, C� AIR INLET: ❑YES O �'� (&� ❑YES NO NEAREST / * DOSING CHAMBER: } t- l MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: P/SIPHON MANUFACTURER: WARNING LABEL L KING COVER PROVIDED: PROVIDED: DYES ❑NO E]YES E]NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AN CONTRO OP ATIO AL NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET PUMP ON AND OFF ❑ S N NEAREST—� SOIL ABSORPTION SYSTEM. Check the soil moisture at/h d th of 4w g FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,con stru to all cea u it 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: RIAL� PIT .--- DEPTH: DIMENSIONS l r GRAVEL DEPTH FILL DEPTH DISTR.PIPE I DISTR.PIPE DISTR.PIPE MATERIAL: NO.PISTR-j NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW IPES: ABOVE COVER: ELEV.IN}Ejoj ELEV.EN PIP Ste- FEET FROM LI ,r'� ,,.. AI INLET: O a(o 6)01 NEAREST----� C✓ � E 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 PTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: DE ❑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: I ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDSTO INFORMATION APPROVED PLANS ❑YES ❑NO [:]YES ❑NO PERMANENT MARKERS: OBSERVATION WELLS: iAREST MBER OF PROPERTY WELL: BUILDING: COMMENTS: ET FROM LINE: E]YES I--]NO [--]YES ❑NO —� t( f Retain in county file fo a It. Sketch System on Reverse Side. TORE: IT SBD-6710(R.06/88) +" '= one( Adn. n i`ztAaton L Z(�t=DaIlLn SANITARY PERMIT APPLICATION COU C � In accord with ILHR 83.05,Wis.Adm.Code STATE SAANNITIARRY/PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES TM NO PROPERTY OWNER PROPERTY LOCATION G '/4 Y4,S T , N, R E(Or W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME - & '— CITY, T TE ZIP CODE PHONE NUMBER CITY : NEAREST ROAD, LANDMARK / ❑ VILLAGE: �* W 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family. � OR ❑ Public(Specify): 111. PURPOSE OF APPLICATION: Check only one in#1. Check#2,3 or 4,if applicable) ( Y 1. a.XNew b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) 1. aX Conventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d.❑ Vault Privy e.❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. W Seepage Bed b. ❑seepage Trench c. ❑ seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): 4� y e Feet X Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Expp. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks ` •`�Q structed Se tic Tank or Holding Tank ®D / ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: um er s Address(Street,City,State,Zip Code): Name of Designer: O III. SOIL TEST INFORMATION Certified Soil TesteST)Name CST# ` CSTs ADDRESS(Street,City,State,Zip ode) Phone Number: .� V fS/ -71S_ 396 IX. COUNTY/DEPARTMENT USE ONLY ❑ sapproved S Rary Permit Fee Groundwater ate Iss mg Agent Signature(No S psApproved Owner Given Initial a � /��� W/v) Adverse Determination " pIC7 O X. COMMENTS/REASONS FOR DISAPPROVAL: _ SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s)should-'be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a//septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/z 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground At r, included the creation of surcharges (fees) for a number of regulated practices which Wisco in: ° can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Maw�B< " is used in your building is returned to the groundwater through your soil absorption c system or the disposal site used by your holding tank pumper. _ The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03186) 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 t appropriate deed recording. ------------------------------------------------------------------------------- Owner of property jZ A', I Location of property &1/4 �j1/4, Section N-R T --� Township nn Mailing address ` s Address of site Subdivision name Apel Lot number 4g) Previous owner of property Total size of parcel 2 •DC) Date parcel was created //- / —�S Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)?, Yes No Volume 29 7 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. ---------------------------------------------------------7--------------------- PROPERTY OWNER CERTIFICATION 1(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. 9 1-Z-X 3 67 ; 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 R ter of Deeds, as Document No. 434,2.:310 ) . �A Signature of Owner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature ry 1 PA.t DOCUMENT NO. STATE BAR OF WISCONSIN FORM 11-198a TNIa 1►ACtn R[aiRV[D IOR R[COROINa DATA t LAND CONTRACT REGizTER'S Uf-►=10E IMhWu1 and l'erpnb e 43230 V1% 00 IS FINANCED IAND R IN OTHER NON-CONSUMER ST. Ck�ilX Co., W� J ACT TRANSACTIONSI COrd RLC:.i h/r p;a ea�g�.1T, t o T Contract, b) and between . l QXXlt&x..�.....RR$ .iBS.and............. Nov-._ AukX..P.:}ijqyz.a single woman at 1525 P M ..................................................._............................................ ("Vendor", whether one or more) and..Sai>1.T....Mil1.g.T.............................................. R991ster of Deods ............................. ........................................... ....................................... ............................... ("Purchaser", whether one or more). Vendor sells and agrees to convey to Purchaser, upon the prompt and full per- formance of this contract by Purchaser,the following property,together with the rents,profits,fixtures and other appurtenant interests (all called the"Property"), in......,5t.,..GKQAX............................................ County, State of Wisconsin: MltuRN.o West one-half of Northeast Quarter (1-11404) except the east 8 rods, and the Northwest Quarter of Southeast Quarter (NW!ZSE'y), except Tax Parcel No. .................................. the south 6 rods, all in Section 29, T29N, 19W. TRANS�A $ FEE This .,is...n-.o.,t-.. _ homestead property. ( (is not) 208 8th St., Hudson, WI Purchaser agrees to purchase the Property and to pay to Vendor at ............................................................I the sum of$..2.5_6.._1.5.0...0.0.................................... in the following manner: (a) $2 QAQQ!M............................. at the execution of this Contract; and (b) the balance of $z3fi,,150.QQ_.......•..__.....together with interest from date hereof on the balance outstanding from time to time at the rate of.nine..49x1l ..................... per cent per annum until paid in full, as follows: Interest to January 11, 1988 shall be limited to $1,320.29. $80,000.00 plus interest on the unpaid balance on January 11, 1988. $50,000.00 plus interest on the unpaid balance on January 11, 1989. $50,000.00 plus interest on the unpaid balance on January 11, 1990. $56,150.00 plus interest on the unpaid balance on January 11, 1991. The above payments shall be made in addition to any payments made for the conveyance of lots until the total price is paid in full. All payments shall be by 2 checks, one to each Vendor for � of the full amount. A )pot.�tedlwe Aggemelnt h�i al been shietgdpo j .tg1ff dateb 11th rovi c owever, a en ire ou s ant In balance s e al in u on or @fore the...................... ... day of ....,7,2UUuary.....................9 19.11.. ( the maturity date). Following any default in payment, interest shall accrue at the rate of 10.......% per annum on the entire amount in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire principal balance). Purebeeerr,unless excused by Venderr agrees to pay monthly to Vendor amount@ sufficient to pay rensonably antici- pated annual taws*,s:peeial usscwements,lire and regaised-insurance premiums when due.To the extent received by Vendor, Vander-agrees,-to-s.pply pa ioente to the"oblifrattons when due.- Such amounts receivwi by the Vendor for payment of taxes, at ss,lcarnents and insurance will be deposited into an escrow fund or trustee account, but shall not bear interest unless ethet wise required by law.Any amount may be prepaid on principal at any time. Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. Any amount may be prepaid without premium or fee upon principal at any time after........ .. ............. 19....... (OR)11 there-may--tie no prepayment of principal without permission of Vendor. 91411 rtiptsvdipp fire R In '.he event of any prepayment, this contract shall not be treated as in default with respect to payment so long as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shall he treated as unpaid principal) is less than t),e amount that said indebtedness would have been had the monthly payments been made as first specified above; provided that monthly payments shall be continued in the event of credit of any proceeds of insurance or condemnation, the condemned premises being thereafter excluded herefrom. Purchaser states that Purchaser is sutisfied with the title as shown by the title evidence submitted to Purchaser for examination except: I Purchaser agrees to pay the cost of future title evidence. If title evidence is in the form of an abstract, it shall be retained by Verdor until thr full purchase price is paid. Purchaser shall beentitledto take vosse.,sion of the Property on the date hereof to LAND CONTRACT—Indir,dual and 9T%117 LAR nr' WISCONSIN Wi­•- n I,r.l Hlank C.+. inr. I Corporate PORN N". II•–IYtl: flu°":^•, tti,�. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S4v�n ROUTE/BOX NUMBER FIRE NO.c CITY/STATE I+CtLo �� UJ ZIP PROPERTY LOCATION: 4-z-1/4 : 1/4, Section �, To1 N, R� Town of d�,ti , St. Croix County, Subdivision��c�,� (O �f 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 $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNE DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address 1 INbUS T OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INbUS TR Y, � 11 cc DIVISION LABOR HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707 (H63.090)&Chapter 145.045) LOCATION:S SECTION: OWNS OT NO.:BLK.NO.: SU DIVISION NAME: vv '/E'/a d2 /Ta2yN/R/��(or 1/o — Ott. 4f g',e&J /sr COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATI NS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS:IPERrOLATION TESTS: 1'xResidence 3 111114 New ❑Replace 1 9,2d—�p '7-2 d-,PP l 4 �{ 4 RATING:S=Site suitable for system U=Site unsuitable for system 6 f� By,C Z �, ` ,tglAe Co1+K lG rKsONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) ❑U ®$ ❑U CAS ❑U ❑S ZV ❑S ®U CO ve,ri>�d` 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: P e FI E DESCRIPTIONS t BORING TOTAL( ELEVATION DEPTH TO GROUNDWATERIPW4+E•3' CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH+Pt OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- (31 0L/. > .0 ae S S S 3./Ans B- Z .0' jj61 .r/ . J .2. AA, S B- ,3 ,r" 10,2.0' dwell 7 7•�� S 4 70A pr CS S h S B- PERCOLATION TESTS TEST DEPTH( WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PE R D PER INCH P- t a a L G P- A10 6 6 4•3 P- 0 2 3 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. SYSTEM ELEVATION �`j• 9' _ S� -/� �,,.._yd• w. ,Ge �_ _�.___ � _� __, .__ _ ---- � _ t _ c .[- L� e (mot± . _. �3 41b 1 l r� € t t 7 t r—Jr- yu,7 e IV- � } I 't-A&f e : s��</ cu.f �yr�-d �P% �-�� 7O � 4e► . *A, v� l O�of� fe '" AA I,the undersigned,hereby certify that the spit tests reported on this form were made y me in ac h the procedures and methods specified in the Wisconsin Ndministrative Code,and that the data recorded and the location of the tests are correMQ best o owledge and belief. (print): T w WERE COMPLETED ON: G C ICATION NUMBER: PHONE NUMBER(optional): TUBE: .ial and one copy to Local Authority,Property Owner and Soil Tester. (R.02/82) —OVER — 1 , 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; 0. 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 it desire(!; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; (J. 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,elevation)does riot apply, place N.R.in the appropriate box; 11. Sian 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 - Sandstone gr -. Gravel (under 3") LS - Limestone *S - Sand HGW - High Groundwater cs - Coarse Sand Pere - Percolation Rate rued s - Medium Sand W - Well I's Fine Sand Bldg - Building Is - Loamy Sand - Greater Than sl Sandy Loam - Less Than l - Loam Bn - Brown sil - Silt Loarn BI Black si Silt Gy Gray cl - Clay Loam Y Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loarn mot - Mottles sc Sandy Clay w/ with sic - Silty Clay fff - few,fine,faint e - Clay cc -- c(arnnnon,coarse pt - Peat mm - Many, medium rn - Muck d - distinct � p - prominent HWL - High water lever, Six general soil textures surface water for liquid waste disposal BM Bench Mark VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sarsitary permit- The county or the,Department may request verificafiott of this soil test in the field prior to perrnit issuance, A €:ompiete sot of plans for the private sewage system and a permit application must be suhrrritted to the appropriate 10Cal authffily in order to oblaw a perrnit. 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