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COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715 - 962 - 3121
800 - 962 - 5227
ST. CROIX ZONING REPORT NO.: 25641/01 PAGE 1
ST. CROIX COUNTY REPORT DATE. 7/13/92
COURTHOUSE DATE RECEIVED: 7/09/92
HUDSON, WI 54016
ATTN: THOMAS C. NELSON
9 ef//
OWNER: Mason Moyers � ���
LOCATION: 1010 Spring St., Somerset, WI
III COLLECTOR: Mary Jenkins
DATE COLLECTED: 7-08-92
TIME COLLECTED: 2:00pm
SOURCE OF SAMPLE: Outside Faucet
DATE ANALYZED: 7-09-92
TIME ANALYZED: 2:00pm
COLIFORt: 0 /100 mi
INTERPRETATION: Bacteriologically SAFE
NITRATE-N: 5 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard,
Coliform Bacteria/100 ml. -
Nitrate-Nitrogen, mg/L
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LAB TECHNICIAN: Pam Gane
°FAtiDEPE/4o
WI Approved Lab No. 19
Means "LESS THAN" Detectable Level Approved by:
® PROFESSIONAL LABORATORY SERVICES SINCE 1952
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�'� jJ CROIX COUNTY ZONING--AFF,I.CB_
' St. Croix County Courthouse
�1 911 4th Street
Hudson, WI 54016
Telephone - (715)386-4680
he St. Croix County Zoning Office off era the service of septic
nd water inspections to Lending Institutions, Realty Firms, and
rivate individuals.
Completion gL this for is essential z_Q that ±1= property can kg
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail ,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received.
WATER TESTING--- ---------------FEE• $ 35.00
(For nitrates and coliform bacteria)
WATER TESTING FEE: $185.00
(For VOC'S) 074 SEPTIC SYSTEM INSPECTION-----------------FEE: . $25.00 2iJ�
(Determines if system is properly functioning at .*time of
inspection) PA t r
PROPERTY OWNERS NAME:_ Irr� y
PROP. ADDRESS:- C) 1.0 t2 K trd b CITY
Legal Des i ption 1/4 f the u ,-1/4 of Section '35- , T--31
N-R/4_
Town of Lot Number 0 04,&3Subdivi s ion:
FIRE NUMBER LOCK Dox NUMBER 1qP A
Color of house Realty sign by house? If so, list fir
m•
PLEASE INCLUDE, IF AT ALL POSSIBLE, k HAP,i.e,COPY OF PLAT BOOK, vwt�lGL.
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained. � W p
Firm or individual re nesting ervices: G &rpn�u,*(..
Telephone Number F ,V 0 2 - Sl
REPORT TO BE SENT TO* A^j +C.- 04-- Z�>01-"ev ,0 , ar 7-7-0
d►-. Q.r&cl- W Sao t f 7710.1j:
U3v
CLOSING DATE:— 2-
signature
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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
z Y,, .:! ' ST. CROIX COUNTY COURTHOUSE
" ` 911 FOURTH STREET • HUDSON,WI 54016
- (715) 386-4680
July 1, 1992
Tom Strandberg
Bank of Somerset
P.O. Box 220
Somerset, WI 54025
Dear Mr. Strandberg:
An inspection of the septic system on the property of Mason Myers,
located at 1010 Spring St. , Somerset, WI was conducted on July 1 ,
1992 . At the same time a water sample was obtained for testing.
The results of that testing will be sent to you as soon as we
receive them back from the laboratory.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and did
not involve any excavating or chemical analysis. Accordingly,
there is the possibility of hidden defects in the system not
discoverable by this inspection. This does not in any way warrant
or guarantee the continued proper functioning or operation of this
system. It is recommended that the system should be pumped once
every three years. Therefore, the prolonged life of this system
may be dependent upon proper maintenance of the system.
Sinc rely,
Mar _J- a ki
Assistant Zoning Administrator
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POLK CO. LAND SURVEYING COMPANY
RT. 2, Box 157A, St. Croix Falls, W1. (715) 483.9484
WAYNE SWENSON CARL HETFELD
DATE: December 1, 1992
CU ENT: Mason C. Myers LEGEND
e DENOTES I°IRON PIPE FOUND
O DENOTES 314"X 24"IRON PIPE SET
• DENOTES I"X 30" SOLID IRON BAR SET
cry 0 M
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GAR.
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11) ti w 4•i:• .», a!a r:
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TANK
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N.88°S328'W.
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33.01, 33.01'
a / SW COR. NE-NW
(` NW-NW __ — A y tORAV EL��
NW "' ORIV E!V �., FENCE 90.00 L/NE
O
9�y' .•/ SBB°22%2"E,
SOUTH LINE NE-NW
g,76°O�I8' /327.68
CULVERT �.`■■rrrr�
rz�
CARL W.
f HETFELD
S-1544
,�.SST. CROIX FALLS„ ry
wIS. .a?
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24"C111 VERT +errm�ars
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SCALE: / = 50
I SURVEYOR'S CERTIFICATE
I, Carl W. Hetfeld, Registered Land Surveyor, do
\ hereby certify that this map is a true representation
o; nl of the lands surveyed and is correct to the best
Y of m knowledge and belief.
g
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n Carl W. Hetfeld, L.S. No. 1544
i t
1� I
I l MAP OF SUR VEY �
/ LOCATED IN THE
y NW //4 OF SEC. 35, 7_3 1N, R 19W
VILLAGE OF SOMERSET, ST. CRO/X CO., r n
\ W/SC.
92-159 C
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER V �L H+P SEC. T N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION _1�/� LOT LOT SIZE 7 ,AGJ?LsS
PLAN VIEW
Distances and dimensions to meet requirements of IIHR, 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
NL
PM,4YWI`
I Y X 53 s CEPA64
wimi_ l� 0
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used f �S j r-L 191P ZE
Elevation of vertical reference point: �'L�ta, r Proposed slope at site: �d
SEPTIC TANK: Manufacturer: C-,4;; Capacity: j.,t)0
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation: 61-
Number of feet from nearest Road: Front,w Side, Rear, 0 y Qc> feet
From nearest property line Front,OSide,�Rear,0 !7oa feet
Number of feet from: well �5� building: _
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
1
PUMP CHAMBER rs, ��9 �'— J^•�
Manu turer: Liquid Capac y: �"�S
Pump Model: Pump/Siphon Manufacturer: Pu ze
Elevation of inlet: Bottom of tank elevation•
Pump off switch elevation: Gallons cycle:
Alarm Manufacturer: a witch Type:
Number of feet from nearest pr rty line: Front, e, O Rear,0 Ft.
Numbe feet from well:
er of feet from building:
( ude distances on plot plan) .
SOIL ABSORPTION SYSTEM
Bed: k Trench:
Width: 2 Length: Number of Lines: Built: 12 22
Fill depth to top of pipe: 7&Q er ALE&4 G`Z
Number of feet from nearest property line: Front, O Side, ( Rear,0 Vt .
Number of feet from well:
Number of feet from building: G r
(Include distances on plot plan).
EPAGE PIT
ze: Number of pits: Diameter:
Liqu depth: Bottom of seepage pit elevation:
Area Buil
Has either a drop b or distribution box O been used on any the above soil
absorbtion sytems? (Chec one) .
HOLDING TANK
Manufacturer: Cap ity:
Number of rings used: Ele on of bottom of tank:
Elevation of inlet:
>umber from neare property line: ont, O Side, O Rear, OFt.
N er of feet from well:
of feet from building:
of feet from nearest road:
rer:
Inspector:
Dated: —�e� Plumber on job:
License Number: 51�
3/84:mj
bEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING
LABOR&HUMAN RELATIONS DIVISION
P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION
ADISOy WI 53707 _p State Plan I.D.Number:Re S5'NW, i5 ' 31' 1W C CON EN t El ALTERATIVE
(It assigned)
Town of Somerset ❑ Mound
CTY I ❑ Holding Tank El in-Ground Pressure
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSIDE TION DATE:
Mason, Myers 2009 W. Hilloway Rd Minnetonka MN
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: 55343 REF.PT.ELEV.: CST REF.PT.ELEV:
Name of Plumber: MP/MPRSW No.: rs1t ,nty: Sanitary Permit Number:
Donavin Schmitt 3205 C
S EPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
❑YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: I 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: PROVDED:
❑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�
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
�I
E:1 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 I ❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE.
❑YES ❑NO ❑YES ❑NO NEAREST—i
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE: TITLE:
SBD-6710(R.06/88)
Zoning Administrator
omas a son
ILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05,Wis.Adm.Code couNT
STATE SANITARY PERMIT#
–Attach complete plaris(to the county copy only)for the system,on paper not less than /�8s 9!L
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 OWNER PROPERTY LOCATION
%4 44A,S T - , N, R E(or W
PROPERTY OWNER'S MAILING ADRARESS LOT# BLOCK#
r
CITY,STATE IZIPCODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
I. TYPE OF BUILDING: (Check one) F-1 CITY NEAREST ROAD
I State Owned VILLAGE� �_
❑ Public 1 or 2 Fam. Dwelling–##of bedrooms__y_ -PARCEL TAX NUMBER(
III. BUILDING USE: (If building type is public,check all that apply) O
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. ❑ New 2. W 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 N 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/day/sq.ft.) (Min./inch) ELEVATION
G 6 1,2-,7�2 a 27 DES" "" Feet Feet
VII. TANK CAPACITY Site
in aallons Total #of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdina Tank
Lift Pump Tank/Siphon Chamber FTS1 _L� FF El Ej I El
VIII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name(Print): Plumb /ignature:(No Sta s) NfRkUea§W No.' Business Phone Number:
a sy9-�
Plumber's Address(Street,City,State,Zip Code):
i
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa ' ry Per it Fee(Includes Groundwater a e ssue Issu' g ent Signature(No Stamps)
PSurcharge Fee) n Approved ❑ Owner Given Initial Q 3J(Adverse Determination ! v ate/
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years. c
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any ndw
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.
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 on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398(R.11/88)
APPLICATION FOR SANITARY PERMIT
S T C - 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 1/9 _QLG(�1/9, Sections , T LN-R _W
Township
Mailing address l Zoo 9'' A74fz o W'd,/ 4AP
tai 640- Zuu 5'-S 3
e
Address of site �Mt�iAS�?'T /IZ&
Subdivision name
Lot number Q1/ S LAS'
1
Previous owner of property NvPig-wQ 4
Total size of parcel _ 1:2 ,9CPIE-S
Date parcel was created
Are all corners and lot lines identifiable? _ , Yes No
Is this property being developed for resale (spec house)? Yes No
Volume 4014,_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. �. �,iB �/N• ; 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.
Signature of Owner Signature of Co-Owner (If Applicable)
-- ?1 4 / F
DjXe of Signature Date of Signature
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i0►_1 .. Y�a Revocable Trust Dated
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-- -- . Minnesota - ---- '
of_-;a Pin _._.-County.�i,hereby quit claims dety t
Mason,.C.. Mers
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t. all a is
11lt>lusepi3>' _County,tt Tsum of
..:Wllar and other Good.-..and Valuable --
mewing vast aiisad in St.- Croix- —County,State of Wmiconsin. `
g4divided one-half interest in
� v',011#tist 03" of Assessor's Plat of
Village of Somerset. �,}t e
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Womall(W.tie and granu r he_
s_-_ berooato set -his __�.,_,_ �
da7►d�DeCSaber .A.,D.,19 79.
'SIGPM AND BRAM IN OF -
BTATt OF 111mmumm
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i Penooay cone beters tae.thin_._ .14th - der of Decenber
the above uamed Mason C. Myers
to me a ox to be the peon . who executed the foregoing Instrument and tl eaeae.
:►� JOHN A. BURTON,JR.
NOTAP`/PUP..+_IC-MINHASOT
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HENW"i'N COUNTY ,
�" -instrumted +Cu�
_John A. Burton, Jr.. M�i�fM�
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SEPTIC TANK MAINTENANCE AGREEMENT . o
St . Croix County z
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OWNER/BUYER b,1�2.504
ROUTE/BOX NUMBER Fire Number / yt3
CITY/ST ATE��� �� Z/V ZIP ��3Z
PROPERTY LOCATION : , 114, Section, T3_N , R _W,
Town of '5cNS .qE St . Croix County ,
Subdivision �/ _ Lot number_.
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. Ho
I/WE, the undersigned,, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with 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 ✓
DA•rE �-
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 .
D%PARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
P.O. BOX 7969
LABOR AND PERCOLATION TESTS (115) MADISON,WI 53707
HUMAN RELATIONS
+ (H63.09(1)&Chapter 745.045)
LOCATION:. ► SECTION: TOWNSHIP/MUY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
�
SE %W/4 35 /T 31 N/R19�(or)W Somerset a n n
COUNTY: OWNER'S B1jMfiff66&ME: MAILING ADDRESS:
Mason Myers 12009 W. Hilloway Rd. , Minnetonka, Mn. 55343
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: S(PROFILE D RI TIONS: PERCOLATION TESTS:
esidence 3 n/a ❑New place 6-21_88 n/a
RATING:S=Site suitable for system U=Site unsuitable for system
r ONNVVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)
cis ❑U :61S ❑U S ❑U ❑S 9U ❑S EJU I conventional
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: class 2 Floodplain,indicate Floodplain elevation: n/a
desimal' PROFILE DESCRIPTIONS a e 18 BrB
BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTHXX ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B-1 16.91 96.99 none >6.91 .58bl.1. 2.00bn.sil. gr. 4.33bn.dirty cob. gr.
B-2 7.58 97.99 none >7.58 .42bl.1. 1.33bn.s.l. 5.83bn.c.s.&gr.
3 6.92 97,17 none 22 00 1.00bl.l. 1.00bn.s.l. .67bn.sil. w occ.f.f.f.
B- Iess than 1 .00 mot. 4.25bn.dirty cob. gr.
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD( PERIOD 2. PERIOD PERINCH
P-
P-
P-
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 93.99
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I,the undersigned, hereby certify that the ests d4r9d?brjahjgW wer"- de by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data reco nd the Irtjpgt�o�1d eas f the tests ar rect to the best of my knowledge and belief.
. P 1.: n
NAME(print): l �� TESTS WERE COMPLETED ON:
Gary L. Steel 6-21-89
ADDRESS: ��4 a CERTIFICATION NUMBER: PHONE NUMBER(optional):
8 N Shore dr. , CST SIGNAT - -
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and accurate, sail test,yratsr report roust include-
1, Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
1 MAXIMUM number of bedrooms or commercial use planner];
4. Is this a new or renlacernent 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;
O. PLEASE use the abbreviations shover) Piero for writin} profile descriptions and completing the plot plan;
7, MAKE A LEGIBLE diagrarn accurately I«cating your test locations, Drawing to scale is preferred. A
se;)arate sheet may be used if desired;
S, FI9aEce sure your henchmark and vertical elevation reference point are clearly shown,and are permanent;
d. Ccaaraplele all appropriate boxes as to dates, name's,addresses, flood plain data, percolation test exemp-
tion,if appropriale;
30. If*he information (such as flood plain,elevation) does not apply, place N,k in the appropriate box;
11, Siv; the form and 13lace your current address and your certifi€ation number;
122 Make legible, copies and distribvate as required. AL,L.. SOIL TESTS MUST BE FILED kNITH THE
LOCAL AUTHORITY WITHIN 30 GAYS OF CONIPLETION.
ABBREVIATIONS OR CERTIFIED SOIL TESTERS
wail Separates and Textures Other Symbols
St Stone (over 101 BR - Bed,o-k
cola Cobble (3- 10„) SS - Sandstone
gr - C1r.wel (under 3") LS - Limestone
s - Saud HGW - Nigh Gacaundwater
Pi."rct P c.)lation Bate
me d M=tutor=; Sand Vv well
fs - Fine Saran' Bldq Building
k Loamy Sand > - Cheater Thran
sl .... Sandy Loam < Les Thwn
I __. Loam Bn Brov,m
ml silt Loam BI - Black
si - Silt G - Gray
cl - Clay Loam Y - Yr�llovir
scl -- Sandy Clay Loam R Red
sicl - Silty Clay Loam mist Mottles
w - Sandy Clay wl` - vv t
sic - Silty Clay fff - fev.r, fine,faint
X
e, - Clay cc - caMrnon, coarse
Pal_ _ Peat rnm Ma=Iy, rYle€}irrm
M _. Muck d distinf f
p - prominent
HWL - Nigh water level,
Six genereai sail textures surface water
foa liquid r-vaaste disposal BM - Bench (Mark
VRP, - Vertical Reference Point
TO THE OWNER:
This soil fast report is th e first steps in securing a sanitary permit. The county or the Depawrnerat may request
ve a ific.at on of this soil test in the field prior to [)e!rrnit iss,€ancc,, A comply tta set of plans fear the private
vvrage system and a permit applicalion rnust be subr,titted tca tha appropriate local authority in order to
oh';ti n a p;ef m'i, The sanitary Para=wait narasc (s?ohs ira ra ";1d Posted r)rioi to than Start of any c.c',>nstruc;ti€nr
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AS BUILT SANITARY SYSTEM REPORT
-a SEC. T No R -_ W
i
p; ADDRESS , ST. CROI COUNTY, WISCONSIN.
:BDIVISION , LOT LOT SIZE
PLAN VIEW
-Distances dimensions to meet requirements of H62.20 -
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
C
Ir di ate or'tly A ` oW I
SC L
;,tPTIC TANK(S) MFGR. r.l �= ,r '� CONCRETE Y STEEL
of rings on cover _ Depth C,* DRY WELL
A:NCHES NO. of width length area
no. of lines ,3 width_ length area
depth to top of pipe ;l
' GREGATE
RATE AREA REQUIRED AREA AS BUILT Y 5
hSciaimer: The inspection of this system by St. Croix County does not imply complete
;e#pliance with State Administrative Codes. There are other areas that it is not possible
to inspect at this point of construction. St. Croix County assumes no liability for
►stem operation. However, if failure is noted the County will make every effort to
ikermine cause of failure.
.1EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST
`INSPECTOR Aln
DATED '` 'l�' PLU;iBER ON JOB >
LICENSE NUMBER ;�� 5
REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM
Sanitahy Pehmi ,
State Sept
NAME Township- St. CAatiX County
Location Sec f.anJS�77Lat # Subdivision
SEPTIC TANK /
Size �16o gatto n.5 NumbeA o b co mpaAtmentz / -
Di6Lance beam: Wett d Building 1,2% stope
HighwateA
PUMPING CHAMBER
Size gatto nh __ .Pump Manu bactuneA Mo det NumbeA
HOLDING TANK
Size gatton.5 NumbeA ob CompaAtments
PumpeA AtaAm S y,6 Lem
Dti.6tance bAam: Wett Buitding 12% .stape_
HighwateA
ABSORPTION SITE
Bed TAench
DiAtance 6Aom: Wet 4 ()d4-� Buitd.i.ng ��`J 12% .6.2ape �--�
HighwateA
ABSORPTION SITE DIMENSIONS
Width ab ttench bt Requited aAea �7 6
Length ob each tine bt Depth ob tock be.2ow Cite _ � _ tin
NumbeA ab ti-ne.a 3 Depth ab tack oven tite '� in
S4'4 oxat .length ob Zinea/S� bt -Depth ab t�..E'e betow gAade in
� ' / Sto a trench v gin. en 100 -t z
I ti� once between .E'tine�5 l0 b� pe b p b
T at ab�saApian aAea _b Type ab Coven: (DeA n 6Aaw
;, MENSIONS
Numbers ob pits GAave.E around pit,6 yes no
Out.6ide diameteA bt Depth betow inter bt
Totat ab.6 oAption aAea bt
AAea Aeq uike A bt
INSPECTED BY TITLE
APPROVED DATE 19
REJECTED DATE 198
REASON FOR REJECTION
1 444
REPORT ON INSPECTION OF SANITARY PERMIT # �
1) Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection
Time of Inspection
ame, Adaress, License NO. OT Instaning Plumber
l 21C r
(3)INSTALLATION CO SISTS OF: Ej Septic Tank ❑ Seepage Trench ❑Dosing Chamber
❑Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑ Fill System
BEN ermanen reference Point) Describe:
Elevation of vertical reference point: Slope at site:
(5)MATERIAL AND DEPTH OF SEWER:
(6)SEPTIC TANK: Manufacturer: Liquid Capacity:
Tank Inlet Elevation: Tank Outlet Elev:
# ft to lot or property line: # ft to well
(7)DOSING TANK: Manufacturer: # of gallons :
# of gallon pump set for a cycle gallons; total capactiy of distribution
lines gallon; size of pump head; gallon per minute ;
horsepower ; brand name of pump and model number
Is the warning device installed? [--]YES ❑NO Wired? ❑YES ❑NO
8 HOLDING TANK: Manufacturer # of gallons
construction depth to the cover ft; If septic tank is
being used are baffles removed? YES [] NO; ft from residence;
ft from well ; ft from property line. Type of warning device
Is the warning device installed? ❑ YES [-]NO; Wired? []YES ❑NO;
Locking device on cover? []YES ❑ NO; Diameter of vent and material
Distance from building to vent
(9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth;
ft to residence; ft to well ; ft to property line;
ft to ordinary high water mark of lake or stream; ft to edge of slopes
greater than seepage pit inlet pipe-elevation ft; bottom of
seepage pit elevation ft.
(10) SEEPAGE BED SIZE: ft width; ft length; tile depth;
lineal feet tile; ft to residence; ft to well ; ft to lot or
property line; ft to ordinary high water mark of lake or stream; ft to edge
of slopes greater than 20% falling away toward lakes, water courses or drainage ditches
Elevation of tank discharge line entering bed ft.
11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft;
tile depth ft; ft to well ; ft to ordinary high water mark of
lake or stream; ft to edge of slopes greater than 20% failing away toward lakes,
water courses or drainage ditches; elevation of tank discharge line entering seepage
trench ft.
(12) Has system been installed in area indicated on EH 115? ❑YES ❑ NO
(13) Has system been installed in floodway? ❑YES []NO Floodplain? [:]YES ❑ NO
DILHR-SBD-6095 N.0 /8
Signature of Inspector:
EH 115 Rev.9/78 ,
• REPORT ON SOIL BORINGS AND PERCOLATION TESTS /
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES f'
P.O. BOX 309,MADISON,WISCONSIN 53701
S
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,�/''/
LOCATION '/4/ '/4,SectionTN,R (or) o unicipali
Lot No. , Block No. County
Subdivision Name r .
Owner's/Buyers Name: S �/'•
Mailing Address:, Se,�,��"s�7�, �S� C)d
TYPE OF OCCUPANCY: Residence--No.of Bedrooms ?1 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT X ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS ��O PERCOLATION TESTS ,-
SOIL MAP SHEET / 9 NAME OF SOIL MAP UNIT p
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE
NUM INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P- ! 6'! sg� 3 0 3 021,-,- /2-
-
Ao.-e
P– `! O 30 ` Y9
ALO Y'
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,
TEXTURE,MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- I! N lx�S �� S s 2-
`/
B—
B—
B—
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy Oi A0 .Indicate scale or distances.
Give horizontal and vertical referenc points. Indicate slope. `` �e/o{'
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1,the undersigend,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 location of test holes are correct to the best of my
knowledge and belief.
Name..(print)
Certification No.
Address c
.Name of installer if known
Copy A—Local Authority
CST Signature- �
r
PLB State and County State Permit
Permit Application County Permit #
for Private Domestic Sewage Systems
County 6&
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: L'/4 NW'/a, Section =.) T i N, R / — E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village �r'�rJC�sCT
Township
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance
Single family A Duplex No. of Bedrooms -.Z No. of Persons
D. SEPTIC TANK CAPACITY /CIGCI Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1272 V — ' Total Absorb Area sq.ft.
New Replacement Alternate (Specify)
Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top)—No.of Trenches
Seepage Bed: _Length -Y_3 Width_ZZ Depth Tile depth (top No.of Lines
Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits
Percent slope of land ,Z
p —1 9Z, Distance from critical slope
WATER SUPPLY: Private ❑ Joint X Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester, _
NAME ��li/N�S C%�/�iS i Gk?if�`'/�lc-iV C.S.T. # 5r—/ f / and other information
obtained from wne wilder►.
Plumber's Signature MP/MPRSW# ,'�ZLr`,� Phone 143%
Plumber's Address S�a-adiFw I(�/1 6-�e4 :
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Below , FOR COUNTY AND STATE DEPARTMENT USE ONLY
Date of Application —�L' Fees Paid: Stated •CL County �5�. <<� to
Permit Issued/Rejected (date) Issuing Agent Name zZC t
Inspection Yes_�_No State..Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary=;'GApy) Revised Date 7/1/78
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