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HomeMy WebLinkAbout032-1057-70-000 0 rt (D ° (D p, 0 . C ((D qz�, tj N m O Si c O ID W) Z ct O - 0 d k (D O 3 °' Nr. HO ( , (n 3 z Z o ri !, 0 °w • p� n y O m 0 -I (D ^� l,Jl O 01 O d N n H co 'ii m Nhp 000a23 ° pp 'i m N -4 N 0 0 0 a o 0 m C a 3 4 j O C O r\rQ o_ rn CD 3 n CD W a°o °w p CTl, o m o o a ! � O r V \'' w -. 'D — �C O o 00o 000 0 % y o e ri 0 0 3 1 3 Q O n CD 1 H z OOOco Y NU o W —° < z vy r~{ ~ 0 a c (/) y CO) a D (D � v P, w w W CD w � I:,' �� = ; Ct 3 � N N ° ~ 0 H -i D n 3 �r O l�l CD CD c D m Z CD a ii: z y X Q A G 7 (p � N eWD eTD m CL z I � � � O -co y z m fD A W f M Q d n CD r. — z a N (D fp ai a CD 7 O O a � 0) � S O �i N O O t0 _M Ii ti I 0 �I b N CD do w oO c �. o m III b o a i 1 � Form - S T C 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP ������� SEC. T,?ZN-R' W ADDRESS � �� D�C �`j ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE_ PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM �r L UST i V/ 3 at �o Sr 3� INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used r�Ale 1*�- 6qeS C`'0f / r Elevation of vertical reference point: /b © Proposed slope at site: SEPTIC TANK: Manufacturer: f,�,< <,/IotS Liquid Capacity: yx� �s�Z � Number of rings used: --���-= Tank manhole cover elevation: 7�p Tank Inlet Elevation: .p2 Tank Outlet Elevation: �z Number of feet from nearest Road: Front,Side,O Rear, O feet From nearest property line ront,O Side,0 Rear,O � feet Me Number of feet from: well building: (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE S.T.DF _ __ —,i-- r f 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 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan)'. SOIL ABSORPTION SYSTEM Bed• t� Trench: l� Width: Length: ,j Number of Lines: Area Built: 6o:?5r Fill depth to top of pipe: p �� Number of feet from nearest property line: Front Side, Rear,Olrt . o Number of feet from well: Number of feet from building: (Include distances on plot plan). // �- SEEPAGE PIT 1 alev— � Size: Ntim1)F-r of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or (.11-stribution 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 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: ✓ Plumber on job: , License Number: 3/34:mj • DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABOR&HUMAN RELATIONS DIVISION �PM.O.BOX 779�t6/9 7� ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION S L,�i�O L^l 1,�1, 19W State Plan I.D.Number: Town of N. Somerset CONVENTIONAL ❑ ALTERATIVE (It assigned) Co. I ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: Vt .DDRESS OF PERMIT HOLDER: INSP TION E: Brad Belisle 2 Box 450 Somerset 4JI 54025 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.P-.ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: B ron Bird, Jr. 3318 St . Croix 1128592 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER r� p Q� p� PROVID PROVIDED: Q�V 1 &dt ES ❑NO ❑YES O BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WE BUILDING: VENT TO FRESH ALARM: FEET FROM 5d v LINE: O/ N,/ ^ AIR INLET, ❑YES ❑NO E:1 YES ❑NO N EST—No H DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PU MODEL: M HON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ' ❑YES ❑NO ❑YES ❑NO I ❑YES ❑NO GALLONS PER CYCLE: UMP AN CONTROLS ERAT AL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑YES NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil mdkt he depth of p wing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, ons ion shall ceas ntil MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: BED/TRENCH LIQUID / n 5 3 TRENC�S: / MATERIAL: ` PIT DEPTH: DIMENSIONS Ol / (P V �' i GRAVEL DEPTH FILL DEP H DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: N ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE C VER: ELEV.INL ELEVEN PI S: FEET FROM LIN !/- a AIR INLE I / NEAREST—mow / 3 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; El YES El NO [__1 YES 0 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: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: iAREST- ------------------------------------ MBER OF PROOPERTY WELL: BUILDING: ET FROM ❑YES ❑NO ❑YES ❑NO�M LJV 3 - St Sketch System on Retain in county file for audit. Reverse Side. SIGN TITLE: SBD-6710(R.06/88) hl� 5� Zoning Alministrator K� � City, i j SANITARY PERMIT APPLICATION =Zah LHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY f STATE SANITARY PERMIT# -Attach complete plans(to the county copy only)for the system,on paper not less than Aq ��-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 I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. PROPERTY WNER PROPERTY LOCATION x �'/e . %, S T_ , N, R E(O PROPE OWNER'S MAILING ADDRESS LOT# BLOCK# CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD State Owned VILLAGE; iy ,Y r�. y ❑ Public 1 or 2 Fam.Dwelling-#of bedrooms, PAR EL AX NUMB R( ) 70-0C/0 111111. BUILDING USE: (If building type is public,check all that apply) 1 ❑ 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.X 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 1. Seepage Bed 21 El Mound 30 El SpecifyType 41 El HoldingTank 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(�ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch ELEVATION ,ee5 ,-'i `7 y fr �. /v/.�� IC,_ _,meet Vll. TANK CAPACITY Site in ga llons Total #of Prefab. Fiber- Exper. INFORMATION New rExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks I Tanks structed Septic Tank or Holdina Tank 5K I 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. Plumber's Name(Print): Plumber's ' nature:(No Stamp r MP/MPRSW No.: Business Phone Number: iii ,�7e P s A dress(Street,Ci State,Zip Code): oel IX.—C U / EPARTMENT USE ONLY ❑ Disapproved itary P rmit Fee(Includes Groundwater D e Issued Iss ' g ent Signature No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination r X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(formerly 13115-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete## of bedrooms if 1 or 2 Family Dwelling. Ill. 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) 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/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 Location of property C 5 � 1/9 1/4, Section _, T�_N-R a_W Township as roe�a�- c)rneRStA- �Z Mailing address Address of site (2 C-,unL-'4 fYh.l I�e-S r�0(z�1� a'f so meveS(�� s on name Previous owner of propertye�mAN Total size of parcel Date parcel was created Are all corners and lot Ines identifiable? _Yes No Is this property being developed affor. resale (spec house)? Yes _N0 VolumeS-q-1 and Page Number SS ) 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. ; 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. ) . a6j�L�-rK',—� Signature caner Signature of Co-Owner (If Applicable) Date�t Si nature Date of Signature DOCUMENT NO. �STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED. 450159 Ok 84 7PAGE 285____ REGISTER'S OFFICE This Deed, made between -----------------------------*--------------*------- -- _-- ST. CROIX CO., WI ..•._-----.Sherman__J_..._anslDs�nnaNl._._ ei.s�. Y�usnd_..._. Recd for Record ..........and..wife.............. ------------------------------------------------ JUL 2 81989 -------------------•------------------•--------------------------------------•-•-- ... Grantor, at 10:15 A�: and_______________Bradley- ..._._Bel.isle_.-._a___married__man._,_-..-__-_'- d �.e 9 �. --------------------------------------------------------Grant•-- Re isterof D --------------------•-----••---------------------•----•-----•----•----------------------•-------- Grantee, Witnesseth That the said Grantor, for a valuable consideration..__.. -------------------------------------------------------------------------------------------------------- — conveys to Grantee the following described real estate in -_--__St. CrOlx RETURN To County, State of Wisconsin: 1 Tag Parcel No: ----------------------------------- j I Lot 1 of Certified Survey Map recorded on November 28, 1988, at the Register of Deeds - St. Croix County in Volume 7 of Certified Survey Maps at page 2048 as Document No. 443446. i ry IT j This .........1S.............. homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And.........Sherman J. Belisle --------------------------------------- ------------------------------------------ -----_------------- ............... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except municipal and zoning ordinances, easements and restrictions of record. and will warrant and defend the same. l Dated this --•--•-- Y 8 9 3 ' ------ day of ---------•----- Jul i ---•----•-- ----------------- --•---------------- _-------(SEAL) -----Sherman•-- - .......................(SEAL) * --------------•-.•_.____--• - * Belisle I; ----------------------------------- - --- ................................ ............. ----•-•-- ............................................................(SEAL) --- ------------1-:..a....... -------(SEAL) Donna M. Belisle l --------------------------- ------- -----------------------------• * ---------------------------------------------------•-------------- i AUTHENTICATION ACKNOWLEDGMENT Signature(s) ------------------------------------------------------------ STATE OF WISCONSIN -------------------------------------------------------------------------------- St. Croix SS. ----------------- --------------County. authenticated this --------day of--------------------------- 19------ Personally came before me this _._0 Y{ .day of July------------------------- 19---89- the above named Sherman J. Belisle and ------------------------------ --•-----•---------------------------------------------- * ------------------------------------------------ Donna M. Belisle, husband and_. TITLE: MEMBER STATE BAR OF WISCONSIN wife s -------------------------------------------------------------------------------- (If not, j authorized by § 706.06, Wis. Stats.) ----------------------------------------------------------------------------•-- to me known to be the person -----5----- who executed the i foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY �! Judith A. Remington ---'`J'�•f REMINGTON LAW Opryy m8.......................... --------------------•---------------------•-•--•----------....---••-••-•--. -- iIa_.Richmond WI 54017 Notary Public _..._St-,.-_Croix County, Wis. (Signatures may be authenticated or acknowledged. Both MY Commission is permanent. (If not, state expiration are not necessary.) /��- n) ��// ((�� � FFd��ate: 1..� mot'--•------..--, *Names of persons signing in any capacity shou d be type �x'inL blld�KMr signatures. f�otary Public-State of Wisconsin ry M STATE BAR OF WISCONSIN H.GMiIlerCompsr ^ w„F i ® FORM No 1 1982 S#� 0.,. 300' "y NOV 2819 $ WES O�CONNELL '4 44344 a S CERTIFIED SURVEY . , MAP s Located in the SE 1/4 of the SE 1/4 of Section 21 , T3 IN,R 19W , Town of Somerset, St. Croix County, Wisconsin. Surveyed for:Sherman Belisle Rt. 2 Box 450 . �� � Somerset , Wi. 54025 NOV 2 8 1888 SCALE IN FEET 1"=200 SECOWCOMY 0 50 100 200 400 E 1/4 COR. M; COWAM SEC. 21 T31N.R19W co co ti�• �f---EAST LINE OF THE 4E 1/4 N I UNPLATTED LANDS 1 s a'I I ^ — — 33.00' � , Bearings referenced i N 89°31'35"W 668:35' 1 I pl to the South line of WI - 635. 35 al the SE1/4 of Section 3 w hi' JI 21 . Assumed N89° a� o LOT 1 ;o- �,) I 31135"" . 0 179279 SO. FT. (4.116 AC.) 'n0 0 to 'w� al _ =I c INCLUDING RIGHT-OF-WAY c0� �ipl F- N 170435 SQ. FT.(3.913 AC. ) NW �N EXCLUDING RIGHT-OF-WAY oCy 10 CL S 89031'35"E a a 2008.69' N t Z I —"—S-89°31 '�b"E 669.56 ' SE COR. S I/4 COR. SOUTH LINE OF THE SE I/4 I SEC• 21 � HARVEY SEC. 21 5• 33.00 G s S, _ JOHNSOry UNPLATTED LANDS 8°1899 HUDSON LEGEND Sj ? -�- SECTION CORNER MONUMENT �,�Iy® SURJ � 0 I"X 24" ROUND IRON PIPE WEIGHING 1.68 LBS./LIN. FT . SET, x----*E FENCE LINE . A parcel of land located in the 5E1/4 of the SE 1/4 of Section 21, T31N,R 19W Town of Somerset, St, Croix County, Wisconsin, described as follows: Beginning at the SE Corner of Section 21; thence N 0°26155"E ( bearings referenced to the South line of the SE1/4 of Section 21, assumed S89°31135"E) 268.00' along the East line of the SE1/4 ; thence N89°31155"W 668.351; thence S0°42129 11W 268.00' to the South line of the SE1/4 ; thence S89°31'35"E 669.56' along said South line to the point of beginning containing 179,279 sq. ft. (4. 116 Ac.) more or less, and being subject to all easements, restrictions and covenants of record. I, Harvey G. Johnson, registered Wisconsin Land Surveyor, hereby certify to the best of my professional knowledge, understanding and belief, that I have surveyed and mapped the above described property; that such plat is a true: and correct representation of the exterior boundaries of the land surveyed; and that I have fully complied with the provisions of Section 236 , 34 of the Wisconsin Statutes, the St. Croix County Subdivision Ordinance and the Town of Somerset Subdivision Ordinance. Vol. 7 Page 2048 j Harvey G. Johnson S-1899 Rusch Surveying, Inc. This map is hereby approved by the 407 Second Street Town Board of the Town of Somerset. Hudson, Wisconsin 54016 L I Date _ To W4, be pg�a�R t . STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER.Z?2.�--2� �j� FIRE NO. CITY/STATE_n2�(nef'-J2V W,- ZIP S 0 d PROPERTY LOCATION: 5_E1/4 SE /4, Section 1 _, TZ_N, R1_W, Town of s0n1QR"S(z-V , 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. SIGNED DAT 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 BORING AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR RE PERCOLATION TESTS (115) MADISON WI 53 07 P.O. BOX 7969 HUMAN RELATIONS (ILHR 83.09(1)& Chapter 145) LOCATION: SECTION— UNICIPALITY: OT NO.:BLK.NO.: SUBDIVISION NAME: �21 /Uj N/R/!�f"(olv& r COUNTY: � MAILING ADDRESS: 'Crd� u �/I Sfe G •T o irr C�^ "r. 7� s'/; ,�`r<C� USE DATES OBSERVATIONS M DE,4 41 7 NO.BEDRIMS,:ICOMMERCIAL DESCRIPTION: A TESTS: Residence New ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system rogENTIONAL: IM O NcD: 11'' Ic 10SEU SYSTE -1N-FILL OLDING TANK:RECOMMENDED SYSTEM:( ptional) S ou S �V J o� os 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 T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED TO BEDROCK IF OBSERVED(SEE ABBRV.ON BA .) B- 1 9 -5 �c%� 5 �C ��w 3i �s u — y� ass s - �� B- B- B-,5- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES T NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH 6 L P- .2 P Z-t– 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 / a s- lee�° ys1L��. �-Z 1 z s- : t i i >_. �Jr> F/-" fob Cj O _ 4 o ; o Ifro Al'j .- F t 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 prin / TESTS WERE COMPLETED ON: f ADDRESS CERTIFICATION NUMBER: PHONE NUMBER(optional): -'7�/ 7"-49' 1 1 e-r CST SIG TUBE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SepA3gii IR in/wil L �. PLOT AN PSOJECT ADDRESS A�tPRS1/Byron Bird Jr. 3318 N DA�E W TOWN ^ � - COON Y �c BEDROOM.--�- CLASS PERC_7Z_CONVENTIONAL_,?(I -GRO ESSURE CONVENTIONAL LIFT MOUND HOLDING TANK SEPTIC TANK SIZE IFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA . -tf PERC RATE A,3 /,7-BED SIZE / 16 Benchmark V.R.P. Assume Elevation 100' Location of Benchmark lior� cr � * H.R.P. C3 Borehole Q Well Scale Feet 0 Perc Hole System Elevation 5"- Uent 2 Grade 12" TYPAR COVERING 2" 12" 3- 4 g' O 3- 1 60 Sewer Rock 12' NL Ea °_ l 0 G /