HomeMy WebLinkAbout040-1145-20-200 o (D °o,
v O
d
a °
C
O 2
C
OI
N I �
a U
ti
ti� III �
O
X
N
[r O
C
I
i N �
O N
z 3
a _
LL C f0
O Q7
3 0 °0
o
3 Cl)
(D
Z Yl
O N C
J
C III a m
0 ->
0
cu
O Z�y d c
Z O V-
d :!t
w °
fA H a- O N Z
c E -a
rn r�
4 a
N (n (If
•� d C:
Mob .0
c
o Q zF- z
N
w
Z
wQ 4 _ E c�
aLO a ? c
° _ C G a .� o
bip z N >° i'' 3 az
•'y ") aaa Z
CL = N
�1 p N 11 to 0) 0 y
U 0)
> O N N
O` —O O
(7 'p 7
m
I � y d
4 Q 0
O
l!00 O 1_w C
cl
Q N u p y W d = O
� aO
lfS 0 3 III Y C N
40 N F_ ) n -4)j N 7 co
O N O
N >�
Cl)
N
• o O C LO p c N t6 °
R1
.fir i i_
T
V
v� `m a
.. a d �,
• a a m .0 0 0 CL
m c
w
rrww to
_1 A V a g O tin V
h
•
Parcel #: 040-1145-20-200 07/19/2005 10:39 AM
PAGE 1 OF 1
Alt. Parcel M 12.28.20.575F-10 040-TOWN OF TROY
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
*
GEORGE K&MARY TR LINDEBERG LINDEBERG, GEORGE K&MARY TR
276 W GROVE RD
HUDSON WI 54016
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *276 W GROVE RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 12 T28N R20W SE 1/4 G.L.2 LOT 2 CSM Block/Condo Bldg:
7/2023 15 ACRES EZ-IE-1403/461 EXC AS
DESC 1403/455 EXC AS DESC 1755/240(ROAD) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
12-28N-20W
Notes: Parcel History:
Date Doc# Vol/Page Type
11/05/2001 661194 1755/240 WD
01/27/2000 617509 1486/458 WD
02/15/1999 597784 1403/455 WD
2005 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 96,000 309,500 405,500 NO
ENTERED BEFORE'05 CLO W8 13.000 68,300 0 68,300 NO
Totals for 2005:
General Property 0.000 96,000 309,500 405,500
Woodland 13.000 68,300 68,300
Totals for 2004:
General Property 0.000 96,000 309,500 405,500
Woodland 13.000 68,300 68,300
Lottery Credit: Claim Count: 0 Certification Date: 12/04/1998 Batch M PRGRM
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
a
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER / w TOWNSHIP _ 7 SEC. / T ALN-R 2 W
ADDRESS 2 7Ld a .rr. Jf CROIX COUNTY, WISCONSIN
Sd�
7/a 093
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
it
F
f
-A,! � r
7 %
01
i
cA°
---- -- - --- --INDICATE NORTH ARROW
/l
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point:i p Z6600,1) Proposed slope at site:
SEPTIC TANK:TANK: Manufacturer: 1, aj(' �k,-jLiquid Capacity:
Number of rings used: Tank manhole cover elevation: 29, 7
Tank Inlet Elevation: Tank Outlet Elevation: 9 z, `
Number of feet from nearest Road: Front 10 Side 0 Rear, " feet
- From nearest- property line : . Front 10 Side 10 Rear,0 �� -�,�/ feet
Number of feet from: well/ , building: ���C
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
r
s
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,Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
0 16 0
SOIL ABSORPTION SYSTEM
Bed: Trench: g /6
Width: Length: Number of mess Area Built:
Fill depth to top of pipe: y�
Number of feet from nearest property line: Front, O Side, O Rear,ort .
Number of feet from well:
i
Number of feet from building: 3
(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 O been used on any of the above soil
I
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, 0 Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: ? !U Plumber on job:
License Number: -.3
3/84:mj
PARfiMENiOF INDUSTRY, INSPECTION REPORT FOR SAFETY BI BUILDINGS
ABOO& 900 ' RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. ISO 7®B9 ' BUREAU OF PLUMBING
MADISON,WI 63707
Gov' t Lot 2 ,See. 12 ,1`28-RHO CONVENTIONAL ❑ALTERNATIVE IStot@ Plan I.D.Numbers
(lf a�el®ne61
Town of Troy ❑Holding Tank ❑ In-Ground Pressure ❑Mound
Ct . Rd. F
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER IINSPECTION DATE
George Lindeberg 1276 Westgrove RT.Hudson, WI 54016 4' &—Q ; (�
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF,PT.ELEV.: CST REF,PT.ELE V.
Name of Plumber MP/MPRSW No County Sanitary Permit Number:
Henr Nechville 3258 St. Croix 135397
SEPTIC TANK/HOLDING TANK:
MANUFACT FIER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV_ WARNING LABEL LOCKING COVER
V PROVIDED; PROVIDED: ��
S �i /� YES ❑NO OYES ENO
BEDD N : VENT DIA.: VENT MATE JHIGH WATER NUMBER OF ROAD: P OPERTV WELL. BUILDING: VENT TO FRESH
���y% ALARM FEET FROM / LINE AIR INLET:
❑YES �L!J NO ,L I/ YES ,? NO NEAREST ��� s a5
DOSING CHAMBER:
MANUFACTURER'. BEDDING'. LIQUID(' PACIT PIMP MODEL 1PUMP,SIPL11 MANUE ACTIIHEH WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES NO ❑YES ONO I DYES ONO
GALLONS PER CYCLE: PUPA07CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING JVENTTOFRESH
(DIFFERENCE BETWEEN LINE AIR INLET
F.EET'FR()Atl° F
PUMP ON AND OFF) YES ONO NEAREST'---��r.
SOIL ABSORPTION SYSTEM.Check the o'1- ,,,Xerat t de th of lowln uc, , JDIA n+ATERInL AND MARKwG
or excavation. (If soil can be rolled into a co uction s all cease until FC?'RGE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
'WIDTH LENGTH NO.OF OISTH PIPE SPACING, COVER INSIDL DIA &PITS LIQUID
BED/TRRENCH'` t� NI TRENCHF� 7ERIAU PIT DEPT
DIMENSIONS �
L FILL DEPTH DISTI{ PIPE UISTH PIPE DISTR.PIPE MATERIAL NO D' TN NF .. RO E TV WELL. BUILDING: VENT TO FRESH
BELOW PIPES ABOV VER ELEV INLE t EL V.ENU PIPfS a* ':'LINE IR INLET.
FEES' OM �;p� 7 9 3 3
q51 ,3 0 �- I'NEARE T - .
M OUND 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-
❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS
_ ❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED ID1 PTH OE T11PS()1L Sf)UUE I) [...ELY E S MULCHED
CENTER EDGES
OYES. ONO ❑NO OYES ONC,
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO OF LATERAL SPACING IGHAVE1 DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED?TREN�C�i TRENCHES
m,DIMENSiIpI
' M % MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL IND DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
ELEV.. ELEV. CIA. ELEV. PIPES DI A.:
°�LEi1t�E'139C311�fS;
DIST,
RIUTION HOLE SIZE HOLE SPACING DRILLED COHHECILV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
fiNFb fit
11�ATl�l t
PLANS
DYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. ;- PROPERTY WELL: BUILDING:
NU81rRs° LINE:
FEETRC?
1:1 YES ❑NO DYES ❑NO P,tlwASi�ST . ,"
\U
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. , TITL
DILHR SBD 6710(R.01/82)
l
°. �ILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05,Wis.Adm.Code c
STATE SANITARY PERMIT#
-Attach complete plans(to the county copy only)for the system,on paper not less than ❑ C 2
8%x 11 inches in size. ch k f r�Jvlsld` to re ous application
—See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER
I. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION.
PROPER OWNER PROPERTY LOCATION
.7. t/4, S j T. , N, R E(o
PROPERTY O ER'S MAIL ADDRESS Ir, LOT# BLOCK#
�7( W ;2,
CITY, TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (C,jteck one) ❑State Owned ❑ CITY LGE: NEAREST ROAD
�,_,/
❑ Public 1 or 2 Fam.Dwelling-#of bedrooms 3 PARCEL TAX NU ER(S)
III. BUILDING USE: If building a 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. TYPPE/O'F PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. U TNew 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 El eepage Bed 21 F-1 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(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION
/15-0 419.5-
_<0Q r o. Feet 9'$.lo Feet
VII. TANK CAPACITY Site
INFORMATION in ga ons Total #of Prefab. Fiber- Exper.
New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdino Tank V Oil 1000 /ti0
Lift Pump Tank/Siphon Chamber
Vill. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name(Print): Plumbel Signature:(No Stamps) MP/MPRSW No.: Biness Phone Number:
tt�Nr �6� V/� 3�-s8
Plumber's Address(Street,City,State,Zip Code):
lt1 67,�O" LC/ .. o.i2
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps)
rrvq
/El a 6 Surcharge Fee) //
Approved Owner Given Initial (/� ![ /5=1
Adverse Determination 'L I 1&�., —
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.
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 tp installations
5. 'Onsite sewage systems muse 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 admini'trator or the
State of Wisconsin, Safety& Buildings Division, 608-2W3$15.
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 th8 eountyi E}soil test.-da ta on a 115 foam; and F) all`siing information. `
GRbUNDWATER 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�suftharges are,-used for monitoring groundwater, ground- r 4
water contamination investigations and establishment of standards.
SBD-6398(R.11/88)
+ APPLICATION FOR SANITARY PERMIT
ETC - 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 6—•J--,a 1/9 1/9, Section G2 , T N-R ��
Township
Hailing address a6ej�
Address of site
Subdivision name
Lot number
Previous owner of property
Total size of parcel
Date parcel was created 9��
Are all corners and lot lines identifiable? _ Yes No
Is this property being developed for resale (spec house)? Yes � No
Volume V3 ! —and Page Number 49049� 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. -2 $ 2 5`6 S� ; 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 y tem, and the same has been duly recorded in the Office
of ounty e r e s, as Document No. ) .
3 gnature of Owner Signature of Co-Owner (If Applicable)
Date o Si nat re Date of Signature
REG18TER111 OFFIct
ST.CROIX CCII W 1s,
r
+ Reed for Record this,_?st
600 t,1 . P�1,E day of eEtember A�D.19. 67
• p e WARRANTY DEED �.,t,t.13avid Hope
THIS INDENTURE, Made by bon A. Chandler and First Guft
Beach Bank & Trust Co. , 'a Corporation, as co-trustees for Don A.
Chandler, grantors, hereby convey and warrant to George K. .Linde-
erg and Mary Jo Lindeberg, husband and wife as joint tenants,,
grantees of St. Croix County, Wisconsin, for the sum of Twenty-two
Thousand Five Hundred ($22,500.00) Dollars, the following tract of
land in St. Croix County, State of Wisconsin:
That part of Government Lot One (1) , Section
Thirteen (13) and that part of Government Lot
Two (2) , Section Twelve (12) , all in Township
Twenty-eight (28) North, Range Twenty (20) West;
together with reservations and easements des-
cribed in that certain land contract dated
July 16, 1957 between Don A. Chandler and Marie
A. Chandler, his wife, as parties`of the first
part, and George K. Lindeberg and Mary Jo Linde-
berg, husband and wife, as parties of the second
part, recorded in the office of the Register of
Deeds for St. Croix County, Wisconsin, on July
18, 1957, in Vol. 339 of Deeds, on pages 613
through 616, index #251270.
IN WITNESS WHEREOF, the said grantor, Don A. Chandler,
has hereunto set his hand and ,sea�l the 21• day o 1967;
v
and IN WITNESS WHEREOF, the said grantor, First Gulf Beach Bank &
Trust Co. , has caused these presents to be signed by Frank P. Clackin Jr.
its Vice President, and countersigned by Roy K. Graesser
St. Petersburg Beach,
its Cashior at Florida , and its
corporate seal to be hereunto affixed this 7th day of July ,
1967.
Signed and Sealed in Presence of:
- (SEAL)
Ro e t R. Larson Don—T. Mandler g
Frank P. Morrissey FIR F B & RU. Cc.
-rCC'C c�iG'< /�-�c -�i�-C • f
L' ian DeRoche Frank Gla.
••President
t
Lauretta Lard oy, . raesser
Cashier
OMN 8Y PKTZNER
ATTORNKY•AT LAW 1 .
NUOwN
TBG.6uPONT*."i• -
Mt
S
f!
STATE OF
ss
COUNTY OF )
Personally came before me this j,a( day of , 1967,
the above named Don-A. Chandler, to me known to be the person who
executed the foregoing instrument and acknowledged the same.
a�
Notary Publi
My comm. NG ,Y P4b11y,Ramsey County Mlhn.
1�
STATE OF FLORIDA
ss
COUNTY OF PTPTELT.A.>
Personally came before me, this 7th day of Jules ,
19671 Frank P. Glackin. Jr. a Vice President and Roy K. Graesser
Cashier of the above named Corporation, to me known' to be
the persons who executed the foregoing instrument, and to me known
to be such Vice President and Cashier I . of said Corporatio
and acknowledged that they executed the foregoing instrument as
such officers as the deed of said Corporation, by its authority.
Lillian D. Dlqq, e
Notary Public, ,e.,L,C,eetir,? Count ,
Not po a
My COMM. My Commi'si"n E; of Elprida at Lnrgs
o Y American SurQty Go.or N:Y,
THIS INSTRUMENT DRAFTED BY
_A
HUGH F. GWIN
rt4 •U 1
li
GWIN Or FCTZN[W
ATTORN[T•AT MW
NuasoN �
W18CONUN
TLS.OUPONT 4/o1a, -
i
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
ROUTE/BOX NUMBER 27 6 U/nJ /7 iT. FIRE NO.
CITY/STATE t�t�st, ZIP CVO r�
PROPERTY LOCATION: 64/4 1/4, Section T,2S N, R / W
Town of St. Croix County,
Subdivision C-ldh -VzurP_ , 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.
� MAY be eligible to receive a grant for a MAXIMUM of
St. Croix County Residents M g Q
$3000 of the cost of replacement of a failing system, which was in operation
prior to July 1, 1978. St. Croix County accepte d this program in August of
1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman plumber,
restricted P lumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must be completed and returned -4to• the St.Croix County Zonin ffice within
30 days of the three year expiration date.
S I GNED '
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
11-163.0')(1) & Chapter 145.045)
TO_YYLQLW/MUNICIPAL11'Y:
L ?r!4 acE I. U&L V. s
.T•:,OUNT-Y: `+ j"F' ' WWtMYE��SMIA
C,
DATES OBSERVATIONS MADE
fit 10fli-q
nee co
L-DReside D4New PLI
RATING:S-Site sua!ehla for system U-Site unsuitable for system
-Y -WTI _f�ib 1 TANK:'fil E C6 '—)E-L*')-S-Y_ (up,...b;('—jt 1-9-1)-
,OtNIVENTIONAt.. Iv.0r," .
W
FYI S ❑U I L"I S OU Cl$ ❑U
Ej F_vj S U ';�U
]S L
I Peel-olation Testt d•e required DESIGN IIATE:
if.ny port ion Of the
Indef S.63.09(5)01).indic ze -A Florcplin,inicaw Floo.fillain elevation:
LLLLL -T PROFILE DESCRIPTIONS
iii,.MING TOTAL
uPOHER DEPT►4 i-N.. ELEVATION COLOB, (i.XTtj!(E,AND DEPTH
OBSERVED ro BEDROCK IF OBSERVED ISFF AIMPIV.ON EACK.)
. ! . .
et.cx) _T
0 VLA'irsi I!
IS- 7, 1
'C
t 4- I> . m , C_"G. L T, BN V ,, 6A -Lt.-" - 3,j —le,R_
GO' i't- L-; 1,40' 01'-P_6-J r C 5:)' rS,j S Y.oin* Sj v f SC14A*-I
9's-d
I•O.-J-' P>L L t— I.:;-Z-) 1 L_ W_-�o :J C1, 3,j C S
/0 15� e"--) N C) 'j —7/0- 5 r,
I t3 10.&0 /•00' 1.,601 P", P,;4 Vt'S; tl a-4 77
_ S_040'.
'
L- �'A LA-!. *- 1% 0.30' _i -r.R>
t3")Cs
113-
PERCOLATION TESTS NOTE '7p vrit_%z.a� :SI"rE% rHF_ M0771-i
t'&O V E-1�0
DEP'Tt-i WATFR IN MOLE TEST TIME DROP IN 01AT-61 L9!VaE_1i•t_FNCHFS ITNTE MINUTES
NUU8ER INCHES Ai•TERSVitELLING INTEFIVAL-MIN. I'kR INCH
P. I
P 7 Pi .)_^J 5-
I
V
T•LOT PLAN: Show locations of percolation tests• soil borings and the dimensions of suitable soil areas. Indicate sate or distances. Descitze What are the hori-
.rontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and th-d;,rection and paictnt
of land slope.
SYSTEM .ELEVATION_—_ ':),4-,-60
f�
q-,
-7-
IL
4A
jj
7
I _LJ
3
I
�d �
� ya P
U *.. C,v
o k°6
�n
B 6
w• � �.o o yam` dr
1f c-
a t3
Cj
/ •,
5P k a
0,k m I p
Sow \_ jvvc� �cr-a,gc
3
B,-Al
13� �/�L�Vii �F ITFNG-y
358
h
fi
F•
y .
1�7
IT?
51-
ar -t;
4 kill
Y��c
�4h
Owl,
�iR
T7
OR
4fi
"A
Ail ......
v �
1 �
V
r
I
i
l
I
I
i
t
d
y
� w
-.00op
-7y
J
fir,i TME N SAFETY & iUIL01
%f s oTPry,, BORINGS D DIVISION
ION 4 PCi i:�i7� 7969 6 R� � LATIO � MADISON,W153707
:1JMA RFLATIQNS - : 7 �
W-U.09(1)& Chapter 145.045)
OCATION: �r SEC7�'� J TO+NNSI-IlyiMUNICIPAL.ITY: LOT PJO. SE_K.NO. �UEIDIVISION NAfAE:
�-
13VJNF.H'9in1_)YE:Ft'S NAME: MAIL ING ADDHF55: I
5° GR.o �-7 ��._.�— ''`►a G ---- f
Co,Tk r-. 4 wY... .._'I F_„ t4 U t7SON lti 1
E O_AT ES OBSERVATIONS MADE
+ MO PEDi'r+5 iOMMERC'IALDESCFitfTl(1N: ----� F'HOFILEUE>CF11PiI�PJC�: irEfll A-r1 NTES75:
r, {
+rl Ne r�Replac � V/
Residence 7/1
RATING:SR Site suitable for systam U='Site unsuitable for system
,rNJ cNTI(3N�1L "c10UiJr,. IN-GFtOUNDPRESiURF TIOS STEh1•IN-FILL_ RELQPd vt JDEC3 SYSTEGt:loptirnat)
L M o����� c���1 S 0�� a� �s �v���,�����
'it Percolation Tests are NOT re wired DESIGN RATE -- --�- -
-4 —' It any portion of to tester)area l w..the
+ +d>_r i.H63.09(5)(b),inriic.r:z. ..-�-� Flootlplain, indicate Floo•Ip!arn a+rv,tron:
pie. ---C.. -7 ON It, -- PROFILE DESCRIPTIONS
S?iitNG
TOTAL DEPTH TO GROUNDWATER INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
;i..+".iHER 0EPEI4+00, ELEVATION _ OHSERVED -EST.HIGHEST TO BEDROCK IF OBSERVED (SEE AUSFIV.ON BACK.)
r r L SL , I,3't t�rr �(_� 0.7s p�NL,Sw�Cr�.�
' a v^�_�3 �1 c�r a ?' a- c:��' 1.Z. 6,.j M S 1) v., C-t r_ �,+z �" 3 N M ey 5
lU,�j1 3?,40 ��qr)e: 7;' J0 7.&7 ?
- 0.75 13L S(-, I.Z S' 13N L.S •z.G-.ANrG w a�'rTL1Z�
'•r.', .3 c3.`�z: c -� ¢Co �11.0�1C > :�.�? �.`�a� .3 of/%rt;/.i>o'g� S,`t05 X65
�� ^•75' 6G SL; 0.t53' &L SLwf�� � o•SO' ���z.S ��/6,�e;�
U 6r33, `%%•L! jUJ1.1c 7 .3 ^j .,,%rw� '? v �; r?SAtt�� _
a sc.lrw�c PERCOLATION TESTS
TEST DEPTH LIATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES' RATEM1l�JUTES
tar MRER "ONeWS AFTER SOJELLING INTERVAL-MIN. PF- LQp-1 PEF1100 22 -` PEC(INCH
P.
PLOT PLAN: Show lor•ations of percolation tests, soil borings and the dimensions of suitable soil areas. lndicat? scale or uti�Fr3nces. Describe what are the hori-
+:r,tal and vertical e!evation reference points and show their location on the plot plan. Show the surface elevation at all fla%ri ngs and the direction and percent
C11 00d slope.
'7STEM ILE s IOC
r
t T
1
( IE
F - -- - -
-r r
Y
r- L
5 t
t I +
j
f ` I
1,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods spad&d 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.
SAME(print)-. TEST WERE COMPI,E FED ON-
iADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
4;;-4ca v 16 -408C
�—
CS GNATURE:
JrS7RISt7T10N Orrginat a�n.+ npy to 1 r>eyaY4}Authoary P nper ty Owner Jn(t Soil Tester
•Y N !'.' S ,tj 'r •7JR.,;+zb.c;"' `A+ _.• L rcw
•�it_Nri; eR (e21H?t:: tz e r+t` "` OVE 41,
`r •r":
C)o
U
o i
cr.
C3
Or
IL
r 40
j
1.11 ,la i �` `� a) —d
w
It.
1 , �O
C,
\ I
Gn
�N ILL
ko
44) rQ
Ln
rd zv
>
15TV,
A(X
(,� Iql ocs >ty D3
lit
116
\I)
,.NN
I AY e6-
Q
OLV)
4j
G
�• R3 ro -0
Ai 41 MD
N J r d +J O • b U N U +J 21 G1 7) >i 1J ro N
� " � �� tiw 0C: crn vc � me OCKNO 'v � o c: N ) 0
C7 +1 N G G u i, n cn M u 1n -14 N N C: v `•+ C v G -- �C v w N ro a r: ro y h y O v
v m 0 c R cn u3 Cr ro ;) US .--1 ro v w = rJ -� U v N ►4 '-4 w
t 3 !w
•., rn n (0 OD•� n u U 4d N T (q C Iw > 1 p r-4 w O p c O c: � U) vro �^y J
� o�o ,J -+ wvv O
+ + ; mv > .- , . V0 0V, ro 0 u0 ur-4 u, � u y, Lr, gv, u +) 3r a, + �, , ,
� >ro rn
. :
- -
14 m w fd --4 4J Ito >, N 0 ro ro ,; �, +T r. o
+1 41 to G H N „ N r ra U J �+ a3 y to 3 N C ro N J (L R, ro N +�
w U .V 3 m cn ro iJ H O -•1 p y U) w ro
IJ n - F R, N •�
R E +, w u-1 O C 4J 4J m -4 O u +, n O [J J J u S4 41 N A U +N, b to ., �± - ---— --
U) +J v O b U C w !1 i o 0 .0 � O ro v n >, � m C7 K cn r
•� tv „� X b to N 'o f1.,C N o ul cv � � w ', N O � u w O :s � :� v �-+ v rt ,-i 3 C, v � o
U i ri 1 L7 •i +.� C to It w Q1 'O N G tP to a 1 f v N CT J LJ LJ M C � ?) !~ N rl ��i
--q 0 41 rd -'-1 ro .-4 C:U -4 ro N • 4J C 0
+ �+ G � mm00E-4o v(jj 4 R, 41ro3v � k" 4) vk . 404-1V -.grorovIn N4 Lo v
U ti N r: [ 14 w 0 4J U •�•, m U 0 -4 v m +1 rn .-1 v7 A ro i O +) +� a) r1
y 1) 44 3 a 1-r ro r i , r�
i N o v +� 0 w E+ +O� �y W r A v � m U W v 7) �i -� •� w N rn 1-1 m tr ►a a 4 :1 c' N
as �, >~ rJ 3t
u) u � 3 .WHO ` � y �, ' �' � J: �+ o +� NG � , + +� � Nrrmou o � � nN Wrl �+ v
G) ro +J O O J~ N rd ll r y rn ro •.� ro rd +� O tr ? ro c0
E+ o o v 0, +- p o y v � v 0 � W 1U 0,+j o o a� � y 3 + •., R. 1N +� v m -v N � +� � � R
L} 1 N r4 ., 4J IA aJ tT > W U a) 0 U S•+ U C +-3 N .-4 3 b N N b N G to 6>~ rl r ro d O
r~ w � -- ►1r ,, �, ro � o 44 4-4 m 0 0 0 �, m a3 � +� ro +) w p ro 1 .� ril ro 0 0
t3 o ro o v �- 3 +� Urou, y 0 [ ,� 0 +� N N J trc w o avr
W-••+ w a o •) -+ >,� - > c 4J c � c • ,~ r [ 0 V) V V � � ro -) -•-1 tr C ro ro > N > N .0 A U --I 0 ri Ix
+1 W ►, +j +) ,� +J o >~ +J v s: C ro r +) oo :, -0 v) v C N w 3 v = 0 c c •-� c v v +) o 1:; v v v +1
! J y 44 q ) c ) U, 0 :d � E r1 -'-1 -4 r N • 1 >y N +-) W y N 1l r0 J N ro Lf o !fl > ^eJ x .V
( 0 O 2) 'J) iL > V > 0 rT r!1 _ r1 •+1 3 r i 0 1 v 4 = C � 0 )4 >1 !v m 0 [ ro ••-'1 0 E 0 0 0 H C 4J 3
W 3 e' GS 3 '0 0 m )4 y i w - s! N 4 3 ro LO 0 -V .0 +J 4J .-+ 0
+ v + 0ro H •,..1v) - 4 C7 1) A v O -N . , , U � � +' :j G r y u N p .o m is
't! u f.1 4 .- - -4 ro 7; > 1 = = a 4J ,!J .ro7 u � r-, (d r- a) 0 0 0 = � av J � O Lo O v � C u y m Q C! � ro H >
t••4 q ro U 0 4.4 N to N N to .-r J) ;r, ;� r •1- N .] U) +-, N 1~ +J ,C O +-1 rA rn U U) m
r b m N rr J, o 4 o n+ 4 r U 0 ro vro -1 44 ---1 .-a rn In 4J .-4 -, n -0 +j o .~
i 14 V) UI ',> —44 (U k� ;�. v 0 1! ft o JJ N J-J W • U) a) R. S4 -A
orncrov u +Ja43 >4 1~ w4-1 +1w . � •, :504v Noro co lid m +�J w
r4� 0 >, N0 pQ� o J
O y - 41 4
ro No G .� rovo +) N _ 1) . 4 om .c0) trrri0 t, va v
nc 14 y to +.) 0 +J R, C V w (d r4 N N a +- C N 4 m ) c ,- - p �+ x C NuaJ C •
r 3 N •.•1 = N 'L3 N O N N ro 1.1 •••+
W I G1 fa r<, ✓ l - 1 X R 1 iJ +1 3 +i r, y a) CT N yi p Iw C ro ro 0 v rte, C rt N y
1 y +1 ro ro � -P row v + 3 �+ w u tr 1; A 41 n3 �, u 1� 13 u C4 s~ v
t ro
o >+ o [ o00 c . ,u :~ R >~ n ro ro o 4-1 a o w a
u �nyv ") cvr- V -; ayN -r-+ ro1oA0005crn prt ro or.
W v3 rt ra O Cr + , u +' fn r-1 it ro U ? N v ro ?; ro y r+ . a O a 1+ 41 +�
w C to J U Z C 11 '0 O $4 > N 4 y ro V U) 0
N
• Gro w O v cro 1)
v c vcv � a0M4J "0 (n
! +ro mvJ C G 1) ro c40 rn c r1 u C 111 oNo C:E v piJ t a r. a Rro +v.) �-!, C rn - > , > N G
-4N �, m y � u
a Nu3 -4 op Oro vC o ~ EE 11 ) 4J0 NN " r vroc +j 4 1) 110 v J 0) no a,
ro O ro A row ro U R, v ro C C G U, 1; -Li 0 1 1) v !n M L- F
', �r a n v.J ..N•O.i rN•1 y � •� t v +- •� � 3 N~ ro> R
S4N >,X: - W $-4 , � 0 v vu X: 4-0 0 4, (T) 'J 4J J 4J 'U ') ') S R� ro
v n ru
4.1 +J > 0 :1 1J J ^J , -t ro Ra N.
ro+�-) [>
,, n N > -Se ro > ? > 0 `AC' 0 'v ortN r 3 to 0 � +.) 0 v •- o000 41r� vro -, 0m ru1 u w 0 U1 r4 3 41 N �n w M O ^J +) ro 4, 01.+) U) n c O .Q ro
U +J .[ �, 3 w 0 w 0 R,L A N O ro .4.) 1-4
+J z [ >, U, yro W 1 A +1 0 U) 0 + N 4a W e c: rororov �+ w t*4 o v -Y 0 1 O � v ro + � p � p h U, v 4-j �
A 44 Q4 1) > ++ C O 0 ro oo N 4 C i v m N w ro
4) m 4J ,, -- � � � 0 ro C) 0 -J N v r +, +� U) n •-1 2� 'J " ' m J m ) C rn U) -, 0 O E
w � w ro 3 ! r ) T+ T > C O m N O N O
• X N 4 0 C N O ^J O O w '4 w
W cUW r�a l)�
J� � �+ U 1O w O , F w. 0 _ -+ +j U u O ,) a, 3 0 3 C U. ro w F O R. H ro O, [ co O fn
i
M
i � >
w j ,r
vi
a
o
V1
� 7-
oar
� 7
� 1
i T,
o .
Ika
_ . �' CO / /
14)
LL
vl) In
Co
3C
cn
w x') J
-' ' a— 4
Cl
`� qj t IL
IL
Z cn
40
ILI
LLI
; • 1 (n ui z
w Z cn
LLI Z
LLJ
z z 0
UJ
lip cn
di uj
0 f LLJ
C\j
>
0 LLJ
14 .4
Ld MIT pq by
In U)
CIO
C\j
j ' r,e.. _ .,..� r
0
t -Z z
Jx
3
13
'o
in OL
o 144
uj
IL
Lo
vi
Q) at