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HomeMy WebLinkAbout038-1015-40-000 f / { R ) ; o= � 7ƒ) &c o , woe % 2/¥¥§ / 4) a) � Eg»£ a 0 » =° 00 k CL cc �� k-0� � t/§\ G4K)I$ ) ] \`§ q cc E ) 7fE Je (D \ �\\ �1 E o a m kB « � t § I a m e 2 � § � 2 � { � \ � < < u E % j � CL % cl, a a ■ / L E § / V) � ' k j c a IL a E E \ d k k-i °§ { � ° \ f D < y % � / � _ � . � ■ ■ W �) � Lo � 2 \ / ) . m ) 2 a z $ § $ \ § CD \ f o 2 z / 2 � 2 « k § I CL E c ka / k L) a 2 I 3 ) Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Rag" :1 L' Mter TOWNSHIP �' Ct�Z e, SEC. _ T k f N-R /�&W ADDRESS )Jler S$T. CROIX COUNTY, WISCONSIN 44 1 SUBDIVISION $ (WT Q4'r� � LOT SIZE �2 aCr2r PLAN VIEW Distances and dimensions to meet requirements of I•1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM CEIAV ACC i N 33` Q 6`z BM i 2-3' INDICATE NORTH ARROW i i BENCHMARK: Describe the vertical reference point used gQ? w, OS 5�� ► Elevation of vertical reference point: Proposed slope at site: ©-Z SEPTIC TANK: Manufacturer: O)tekSS C..dkW14C Liquid Capacity: 1, Number of rings used: __hf),jP__ Tank manhole cover elevation: 9 Tank Inlet Elevation:NA Tank Outlet Elevation: Number of feet from nearest Road: Front,Side ,Q Rear, O feet- 1 From nearest property line : ' Front 10 Side 10 Rear,0 `7 feet Number of feet from:- well /A , building: 0, �// (Include this information of the above plot plan)( 2 reference dimensions to septic tank) - SEE REVERSE SIDE i PUMP CHAMBER / Manufacturer: - Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of le in t. Bottom of tank elevation.. Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, 0Side, 0 Rear,Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: o�114 Trench: Width: Len$th: Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,0Vt . Number of feet from well: Number of feet from building: (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) Manufacturer: �� Cr pi Capacity: Boo (0 ,, Number of rings used: t)bu-'� Elevation of bottom of tank: / 3 Elevation of inlet i IA- Number of feet from nearest property line: Front, O Side, Rear, OFt. _ Number of feet from well: uJql/i Au _L Number of feet from building: Z Number of feet from nearest road: Alarm Manufacturer: � ZoAr Inspector: �� �l S�✓� Dated: V1 / Plumber on job: License Number: A4 r 9 5 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 Gov't Lot 4, S3,T3LrI-P18W MCONVENTIONAL 1:1 ALTERNATIVE State Plan I.D.Number Town of Star Prairie (If assigned) ❑Holding Tank ❑ In-Ground Pressure ❑Mound County Road H NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER INSPECTION A . Randall J. L'Allier 6838 Nicollet Ave. South, Richfield, M 55423 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: MP/MPRSW No.. Coumy: Sanitary Permit Number: John P. Sykora III 3212 St. Croix 119506 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO DYES ❑NO BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM. FEET FRAM LINE: AIR INLET: ❑YES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER. 7ING: LIQUID CAPACITY. JPUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: S 1:1 NO ❑YES ONO DYES ❑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 1:1 NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH NO.OF DISTR.PIPE SPACING. COVER :INSIDE DIA.. #PITS. LIQUID BEtf/TRENCH TRENCHES MATERIAL: PIT DEPTH: DIMENRIolo's GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR,PIPE DISTR.PIPE MATERIAL: NO.DISTR NUMBER OF I 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 slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES E NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED-. MULCHED: CENTER. EDGES. ❑YES ❑NO ❑YES ❑NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: ,��y, F WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: 5i'IF TIICiH ,! TRENCHES: MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEV.: ELEV: DIA.. ELEV.. PIPES: DIA.: ELEVATION AND �®IR�BE.I' IN": HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED FTIMA fiEKN PLANS: DYES 1:1 NO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBEF �RIOEPERTV WELL: BUILDING: FE FR -.. ❑YES El NO DYES 1-1 NO INEAR,ST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: Zoning Administrator DI LHR SBD 6710(R.01/82) D�ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm.Code COUNTY : 6)('01 (, STATE SANITARY PERMIT# –Attach complete plans(to the county copy only)for the system,on paper not less than 119(56 (,0 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 LOCAT N qa 4'Q,S 3 T3I , N, R 1?5 E(o W PROPERTY OWNER'S MAILING ADDRESS LOT# 9/A— BLOCK# I/ 6838 r cb I e–f '�✓Q, S - l y CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME O SM NUMBE +'1C }� z 48 (Check one) CITY NEAREST ROAD II. TYPE OF BUILDING: h II �� ( ) ❑Stat@ OWn@d ❑ VILLAGE: f�. � �,i cr ,n• B?4OWN❑ Public ®1 or 2 Fam.Dwelling–#of bedrooms/ PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public,check all that 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. ❑ 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 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 13.ABSORP.AREA 14. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE / REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION ` �o I I I Feet Feet VII. TANK CAPACITY Site INFORMATION in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Exper. New istin Gallons Tanks oncrete glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank 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): t Plu tier's Signatur (No Stamps) M SW No. Business Phone Number: �J d�.. k6u� - '��6�— S 5�–�� Plumber's Address(St et,City,State,Zip Code) Z &DL 75' B tabs IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Sta ps) Approved ❑ Owner Given Initial c Surcharge Fee) (gyp Q� 'IV�,' Adverse Determination ` S Coo —/— � U X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(formerly Pib-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 prdperly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questionstconcerning 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. Vlll. 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-63M(R.11/88) APPLICATION FOR SANITARY PERMIT i STC - 1Q0 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 fAA04Z_1_ J. L `�LGifj� Location of Property .Se 14 �_'�, Section �3 , T_ N-R W Township Er,4 R P2,41,e ie- Mailing Address (�93S- N 1 eD��t' �¢v� • S. AIAJR Address of Site NCB 1P�c�rr►o,u ro W� c �' s�O/ �, N Subdivision Name .1", ��3y Lot Number /✓14 Previous Owner of Property 1,4c.k &11A,)Aj6-A Total Size of Parcel GZ Date Parcel was Created 1^ �e�6 p�` -Q. Ali Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes _� No Volume $© `a and Page Numbers as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) ee ti6y that att statements on baicm ane true to the best o6 (awc) now edge; tha (we) (cute) the awn s) o 6 the ptopwy des cAibed �� thus .in6onmation Joiun, by vi) tue o6 a wa4Ac pity deed keco&ded in the 066.iee of the County Reg.caten o6 Deeds as Document No. 56 3 andthat� (We) pnesent2y own the ptopoaed site ban the sewage dispos s� (on I (we have obtained an easement, to nun with the above deisen,ibed pnapehty, bon the constnucti.on o6 said .system, and the .same has been duty neconded in the 04j.iee o6 the County Reg.i,sten o6 Deeds, as Document No. ) . ` R Z A KGNATURE OF MAR SIGNATURE,r0; CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED R A DOCUMENT NO. _ STATE BAR OF WISCONSIN-I . t �("y°�('�(((��yyy ►w+ �y�}�'•'yyy WARRANTY DEED �r],,•$'iy L'UVf� V1l� PAGE'526 THIS $PACK RKSKRVCO FOR RKCOROINO [1• II This Deed, made between JACK M. WINGER and REGISTER'S OFFICE ad.azzd.zerife. $T. CROIX CO., WI II . . . ... ..... ............ Rec'd for Record _....... ........ ...................................... .........Grantor 1988 RANDALL J. L'ALLIER •.............I.........--.........._ ._................. and........................ R ..............................................................................--•---••••--................_...... qt 9:45 A M Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... Repisfer of Deems ...................................................................................•---.......................... conveys to Grantee the following described real estate in ..- ,... 72C............. RKTURN TO County, State of Wisconsin: ITax Key No. ...................................... !i I A parcel of land located in Government Lot 4, Section 3, Township 31 North, Range j! 18 West, Town of Star Prairie, St. Croix County, Wisconsin more fully described !i as follows:i C r encing at the intersection of the Center line of Highway "H" as presently laid and travelled with the West line of said Government Lot 4, which point is also 2086' North of the Southwest corner of the Southeast quarter of the Southwest quarter '! (SE1/4 of SW114) Section 3, Township 31 North, Range 18 West, thence North 59°23' East along the center line of said'Highway H a distance of 643.45' to the point of j beginning, thence North 21042' West 213.70' more or less to the shore of Cedar Lake, thence South 68 1112' West along th Ghor o Ga;t3 Cedar Lake 75' thence South 21°42' East 225.34' more or less to the center line of id Hi. hwa H,�thence North 59 023' East along the center line of said Highway H a distance of 75.921 to the point of beginning. Above bearings based on West line of Gov't Lot 4 being due North and i South, and includes part of R/W Highway "H". 7 -X Z ZS�� MkNSFES ,I This ?u?t........... homestead property. �'��,1 (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto beiOrigi,.g; And......Jack..M..:..Winger And.Rhyllis Y.P..W � .......................................... ............................ i warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except any liens or encumbrances created on or after July 27,1981. and will warrant and defend the a l 1 e a me. �(� ,Q jDated this ...............�a.�...................... day of ........Z.(.k)!.. , I: .Y .. .......(SEAL) ................ . ... ......... ......(SEAL)7 J ick qer ..., ... .. .. .` ,(SEAL) (SEAL) ) ........................... + .._.............................................................. . ,I AZJTIIENTIOATION AOKNOWLEDObIENT f i Signatures authenticated this .................. day of STATE OF WISCONSIN TaxKey No. ...................................... A parcel of land located in Government Teat 4, Section 3, Township 31 North, Range 18 West, Town of Star Prairie, St. Croix County, Wisconsin more fully described as follows: I' Camiencing at the intersection of the Center line of Highway "H" as presently laid �I and travelled with the West line of said Government Lot 4, which point is also 2086' North of the Southwest corner of the Southeast quarter of the Southwest quarter (SE1/4 of SW1 14) Section 3, Township 31 North, Range 18 West, thence North 59°23' it East along the center line of said Highway H a distance of 643.45' to the point of beginning, thence North 21042' West 213.70' mare or less to the shore of Cedar Lake, ' thence South 68°12' West along the shore of said ,Cedar Lake 751 , thence South 21°42' East 225.34' Mare or less to the center line of said Highway H, thence North 59°23' East along the center line of said Highway H a distance of 75.92' to the point of beginning. Above bearings based on West line of Gov't Lot 4 being due North and South, and includes part of R/W Highway "H". ANSFER ;i This ....is not..._....._. homestead property. FEE (is) (ia not) Together with all and singular the hereditaments and appurtenances thereunto belonging; iAnd . Jack Mt Winger and Phyll�; P..: .Wj.-�qX..... ...... .........................I............................... Ij warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except any liens or encumbrances created on or after July 27, 1981. I and will warrant and defend the same. j Dated this ..............2Q.. . ...................... day of / 18.4 ...... , j .. ... .......(SEAL) ....... ... .................(SEAL) « J ck M. Winger ..... * .......... .................................................... ! �.�... .. .. (SEAL) .......................................................(SEAL) Wei........................... * .............................................. ................... j AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this ... day of STATE OF WISCONSIN ...................... .. 18............ as. f = ..._. ....County, i ..................... . ..................... Peregnally came!!More mv,this ....,�Q.:-....day of I « .V....P Ae above named ........................ .........................................................C.0- ..- J ck.Mt..YAA9 x.slAd.2b,Y...Ura.D,..tcllingsx..... TITI+E: MEMBER STATE BAR OF WISCONSIN f (If not, ............................................................ ?�7�4�. 4�.YS�� �...... .. .................................. authorized y 706. 6, Wis. State.) .................................. ................................................................................ THIS INSTRUMENT WAS DRAFTED BY to me known to be on 5.......... who executed the foregoing ins andltnowledge the same. Forrest..M:.. qs4r.1. HARPER & ANDERSON, cHART'ERl ................... Qp�© � , "TS01 iUtYi'Sfix'e�ir ' �,AN ......... I t��-�� a Grov 01 (612 45q P$ y y '' ignatugrea may �e�au en cal or 8412)ledgea. a 1.-..G.? c!'....County, are not necessary.)are permanent. (If not, state expiration i a .........................�..'.r��l�........ ., •Namos of persons signing in any capacity should be typed or prin ow their signatures. ! WARRANTT DBRD BTATR BAR QH WISCON8iN Wieennein T.wal Wank fn 1ne. H z v� 9 u ST C - 105 r 9 H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z ty . a OWNERIBUYER , 9� 1-3 a ROUTE/BOX NUMBER AU 'k�e .2 Fire Number- — CITY/STATE / ALW ,eke4 tr»1W b)Uc ZIP ,¢ PROPERTY LOCATION: Ste Section 3 T 3/ N , R W, Town of S*,4A° Px,41,ete , St . Croix County, Subdivision Lot number 4 ' I 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 i the system can affect the function of the septic tank as a treat- went 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. H 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 St . Croix County Zoning Office P.O. Box 9&=' Hammond, WI 54015 715-796-2239 or 715-425-8363 _Sign, date and return to above address . i - - 1 DE`PARTM'ENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, REPORT DIVISION HUMAN tABOR,AND PERCOLATION TESTS (11J) MADISON WI 53707 (H63.090)&Chapter 145.045) LOCATION:,/ 1/ SECTION: ��/�'� (o � TOWNSrP/MUNICIPARLITY:' I N/N�O.:BLK.NO.: SUBDIVISION NAME: COUN`TTY: OWNER'S BUYER'S NAME: MAILINGG_ADDRESS.- N IC aLLE AV T C OIX R IC 44 FILL MAIL C54?_3 USE DATES OBSERVATIONS MADE SE 5VAMLINO.BEDRMS.: COMMERCIAL DESCRIPTION: IPROFIL S71PTIONS:1PERCOLATION TESTS: Residence I ❑New X Replace Il 3 '!/ Q� 11 RATING:S=Site suitable for system U=Site unsuitable for system �/ rV / r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional) oS ®u oS �u ❑SOU EIS 2111 RIS ❑u VALTFn PRIVY If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the x� under s.H63.09(5)(b),indicate: N I Floodplain,indicate Floodplain elevation: AWE off-KOP. PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL W H THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATIO OBSERVED EST.HIGHEST TO EDR K IF OBSERVED (SEE BRV.ON BACK.) B- 1 73:' q�� ��� NDNE. 211 �s �-2�+ v k�,t" s w"c w��2�ygl 3g D 12 186% Cap S me M0+ B- B_ 8- B_ I B- I I PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PERIOD 3 PER INCH 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. SYST EM ELEVATION NIr I 1 � � I 0,S7L _ ' N 7 011 At E £0q DI�J6i 5 N E o A t3 E � I i I � , �C I i 5, � 1 • � I i � � � i 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): TESTS WERE COM'L TED ON: H N P. S Y ORA �C 5 / $I so K � ,� ADDRESS: S47,1941 CE F TON NUMBER: PH NUMBER�(optional): LOOM ER w)S S47 CS SIG ,TGU•R. T DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) OVER — I INSTRUCTIONS FOR COMPLETING FORM 115- SB - 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 systern; 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 to scale is preferred. A separate sheet may be rise(] if desired; S. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 0. Complete all appropriate boxes as to dates,names,addresses, flood plain data, percokition test exemp- tion, it 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 glace your current address and your certification number; 12. Make legible copies and distribute as recguired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Sail Separates and Textures Other Symbols st _. Slone {over 10`:) BR — Bedrock coh Cobble (3 - 10") SS Sandstone cqr Gravel (under 3") LS Lirnestone *s Sand HGirtf — High Groundwater cs - Coax°se Saar# Pere Percolation Rate med s -- 'Mcilium Sand `N - lrt't�li fs Fine Sand Bldg _- Birildincg Is — Loarny Sand > ._ Greater Than 'sl Sandy Loam < - Less Than 'I — Loana Sn - Brovvr) sil Silt Loam BI - Black si — Silt Gy — Gray cl Clay Loam Y Yel OVY scl -- Sandy Clay Loam R — Red sicl — Silty Clay Loarn mot — Mo1,1les se Sandy Clay ,are with sic Silty Clay fff few, ;dire,faint c - Clay c;€, - common,coarse pl - Peat near - Many, medium n - Muck cl distinct. p — prominent HWL High vvatcer level, Six general sail textures surface water for liquid waste disposal BM Bench Mark VRP Vertical Reference Point TO THE OWNER; This soil test report is the first s'10p in seCUrinq a sanitary perrnit. The county or the Department may request volificalion of this sail test ir. the field prior io Perin;, issuance, A cornplete set of plans for the private Sr 4Vdoe sv<t rn an""I a pe,rrnit ar_rplicaiion mast be subnritt(,'d 10 the appropriate local authority in order to obulin a t elnnit. The sanitary rmi'mit rnust be obtained and poster! t 6of to the start of any con's€ructi€.an. of - 2 Y µ O vLL I W J 10 00 an ap o W� w r ..I y � Qe oe — 3 o S r ar �-C4 aA �1 ;a a Qj M u1 M i J�