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HomeMy WebLinkAbout276-1043-35-112 > 0 LL Cl) U)(D 0 CD r M E$ U. 0 -6 cn E 0 0 z ■ C, co co LUU) i IL i E 0 z E(D CIA tm (D V m CL in CD .0 0 0 m 0) z z L; 1 E C14 c Its :3 i 04 CN 0 .0 1 0 0 E CL ma .0 CL 0) b E CD U) U) U) E 1L 0 00 m LL- CL IL IL EL Z 0) 0) 0 U) 00 00 ■ "*mob a) E E 0 M uj C,4 Cj C) to (A W, 0 c LL 0 C? 04 W Cl) 0 0 -0 oi y A 2 (5 F Z Z E C-0: -6 1 �; cn 0* 6 04 2 S E E co o m 0 Cl) Cl) z 22 m CL 0 M CL r r CL Q v £ 2 0 U) 00 Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP `6d SEC. T N-R W �7q � ADDRESS (MJ.t,?/1c�1 ST. CROIX COUNTY, WISCONSIN WA SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM w 00 V 1-3 e ft-;C- tic lee.0 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: i? str,'► squid Capacity: / 6� Number of rings used: Q Tank manhole cover elevation: � J Tank Inlet Elevation: ' Tank Outlet Elevation: / l/C7 Number of feet from nearest Road: Front 10 Side,@ Rear, O �© feet f From nearest property line Front 10 Side,O Rear,0 �o feet Number of feet from: well >� , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE • PUMP CHAMBER Manufacturer: �Y;ji. ����� rPl�Liquid Capacity: Pump Model: t6 Pump/Siphon Manufacturer: Pump Size Elevation of inlet: 1 Bottom of tank elevation: Pump off switch elevation: ✓ 7 J Gallons per cycle: C/ Alarm Manufacturer: 4e Drl,!�trA Alarm Switch Type: Pat 1'(m Number of feet from nearest property line: Front, O Side, ©Rear,Q Ft. � i Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: 2 Width: Length: 3 , Number of Lines: ✓ Area Built: O Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, ®Rear,O Pt. Number of feet from well: S� Number of feet from building: a4 (Include distances on plot. plan). Jk I" SEEPAGE PIT Size: Number of pits: Diameter: r , 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 absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: _Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 3/84:mj I DEPARTMIENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABOR&HUMAN RELATIONS DIVISION P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION SgkD,II��I 4W I S e 0 . 3 6 ,T 2 8-Rl 9 State Plan I.D.Number: El CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Troy HW . 35 ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: 7892 RESS OF PERMIT HOLDER: INSPECTION DATE: arl Wichman Pomer Rd. River Falls WI 54 16 m- 1 _ .�1v BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Thomas A. Wan 2860 St . Croix 1135381 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: la ES ❑NO ❑YES NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER I NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALA M: I FEET FROM LINT ^� AIR INL ❑YES W NO YES ❑NO I NEAREST ♦ DOSING CHAMBER: MANUFACTUR : BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP//SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER ��/ ❑YES NO / j �✓�O j l�d Z l/ PRO DED: PgOYES � l(!! YES E:1 NO LrtXYYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE— C� AIRR)L � PUMP ON AND OFF YES ❑NO NEAREST J ,J °C SOIL ABSORPTION SYSTEM. Check the soil moisture at the de th 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: WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID BED/TRENCH / TRENCHES: / ( TRIAL: PIT DEPTH: DIMENSIONS (O GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO. TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW P 0� ABOVE: WER: ELEV.INLFL: ELE .�jNBC PIPES: FEET FROM FROMT�♦ LINSy , AIR I T:<1 MOUND SYSTEM: L) �✓ Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑YES ❑NO ❑YES ❑NO ❑YES ❑N 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 ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: 2 1 ❑YES ❑NO ❑YES El NO NEAREST- 0 a y I ) Sketch System on i Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: A SBD-6710(R.06/88) I -- 7701L' HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm.Code COUNTY –Attach'complete plans(to the county c0 PY only)for the system,on paper not less than STATE SANITARY PERMIT# 8%x 11 inches in size. 1:1 /01VI&P111vious application -.See reverse Side for instructions for completing this application. STATE PLAN I.D.NUMBER 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. PROP TY gWNE� t` PROPERTY LOCATION QA rf wle Q!'1 SE %IVE Y.,S 3o T Pt/ -, N, R E(or CQ PROPERTY OW R'S MAILING A LOT# BLOCK#�—r a 0 KRJSS . ITY,STAA, ZIP CODE PHONE NUMBER SUBDIVISION NAME OR C SM NUMBER � � �• as �16(J 11. TYPE OF BUILDING: (Check one) ❑State Owned ❑ vILNLAGE r— NEAREST ROAD ❑ Public ®1 or 2 Fam.Dwelling,#of bedrooms PAR EL I Ax N MI III. BUILDING USE: (If building type is public,check all that apply) 1 ❑ Apt/Condo l 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 ❑ Specity Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure f / 43 ❑ Vault Privy 14 El 11FX 3� VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 1 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE �U REOU R7(sq.ft.) PROP SED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION (,D! ! 6�< 3 P,� Feet QQ Feet VII. TANK CAPACITY Site in alions Total Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank pdp I Lift Purno Tank/Siphon Chamber Vlll. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name(Print): P is Signature: MP/MPRSW No.: Business Phone Number: s �4 as QP� Plu er's aciaress Street,City,State,Z Code): 313 I IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved tary Permit Fee(includes Groundwater Date issued Issuing Agent Signatur (No Stamps) 0 Approved ❑ Owner Given Initial Surcharge Fee) _per Adverse De ermin lion p 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 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: 1. 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. Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398(R.11/88) i APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------- ---------------------------------------------------------------- Owner of property �V'/ �i�l �I) Location of property IL 1/4 /�F 1/4, Section , T 2L N-Rff__V Township 7AI'o Mailing address �! Address of site S a"U C Subdivision name Lot number Previous owner of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? as No Is this property being developed for resale (spec house)? Yes No Volume 3V 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(Ve) 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. a67 05 6 . ; 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 hhe construction of said system, and the same has been . my ;ecorded in the Office of the County Register of Deeds, as Document No. 96 Signature of Owner Signature of Co-Owner (If Applicable) r F Date of gnature Date of Signature ' STATE OF WISCONSIN—FORM NO.27(Rev.1956) I a� MORTGAGE—INDIVIDUAL AND CORPORATE 2 67 0 5 6 DOCUMENT NOL r� Mortgagor KNOW ALL MEN,that......Carl_L.t__Wichman..and••Eva-J. Wichman "_husband-"and-•wife, - River Falls ................... :. Of_ ............................................................................................................. Wisconsin , .............................. .......................... ...............•--•-•-----•--.................._, Mortgagee herein called the mortgagor,whether one or more,hereby mortgages to...Lu-dwiig..W-�CI}m"fin"•an"�1"__..prAi.K>a""""• Wichman? .his wife, as ,joint tenants, of Algoma, Wisconsin ----.....n......_......-"............................ ' .....................................................herein called mortgagee,whether one or more,in consideration of Consideration ' --_ Five Thousand and no 100 - the sum of..............'.'.'....................... -- . .............•-•---.........L..........----...._-..-*.-.-.-..-.-.-.-.-.-.-.-Dollars($5000. 00 ) in hand paid the receipt of which is hereby acknowledged,and conveys and warrants to the mortgagee,the following described ' real estate in-...............��1..._�e.I l)lx. County,State of Wisconsin: ascription Part of the East Half of the Southeast Quarter of the Northeast Quarter (E 1/2 SE 1/4 NE 1/4) of Section 36, Township 28 North, Range 19 West, � g described Ibe d as follows:o s. Commencing on the south line of said Northeast Quarter 608. 5 feet west of southeast corner thereof; thence north on east right of way line of State Trunk Highway 113511, 541 feet to place of beginning; thence north on said east right of way line 150 feet; thence east parallel with south line of said northeast quarter 150 feet; thence south parallel with said east right of way line 150 feet; thence west parallel with south line of said Northeast Quarter 150 feet to place of beginning. Together with easement for access road over a strip of land 66 feet wide adjacent to and south of above described parcel extending west to Mate Trunk Highway 1135". I ~ I Fixtures together with all the hereditaments,privileges,and appurtenances to the same belonging,and all the rents,issues,and profits Included which may arise or be had therefrom,including screen and storm doors and windows,attached mirrors,fixtures,shades,at- tached floor covering,hot water heater,furnace,oil tank,and light fixtures............................................... __ which shall be a part of the real estate for the purposes of this mortgage, TO HAVE AND TO HOLD the same to the mortgagee. Covenants of And the mortgagor hereby covenants that the mortgagor is seined of a good title to the real estate in fee simple, free and Title clear of all incumbrances,except as follows: no exceptions. and the mortgagor will forever warrant and defend the same to the mortgagee against all claims whatsoever. Provision for PROVIDED ALWAYS,and these presents are upon this express condition, that if the mortgagor shall pay or cause Defeasance to be paid to the mortgagee the sutra of money as expressed in the note or notes secured hereby bearing even date herewith, and in the amount of the above consideration,according to the terms thereof,and shall make all other payments and perform all other terms,conditions,covenants,warranties and promises herein contained,then these presents shall cease and the note or notes be void. Tax Clause The mortgagor covenants with the mortgagee that the interests of the mortgagor and of the mortgagee in such real estate shall be assessed for taxation and taxed together,without separate valuation,and to pay before they become delinquent all taxes and assessments,now or hereafter assessed or levied against this mortgage or the note or notes secured hereby and on the real estate described in this mortgage, including every mortgage interest which this mortgagee may have or be deemed to have in such real estate by reason of this mortgage,and to deliver to the mortgagee or the mortgagee's representative on demand receipts shoving due payment thereof,hereby waiving and releasing all rights of offsets or deductions against the Insura nCe indebtedness secured by this mortgage because of the payment of such taxes or assessments. Clause The mortgagor further covenants with the mortgagee to keep the mortgaged premises insured for fire and extended coverage for at least the sum of#"full insurable value .""" to pay the premiums thereon when due, and to comply with coinsurance provisions, if any, in inuurance companies approved by the mortgagee with loss payable to the mortgagee as interest may appear and all policies covering the mortgaged premises shall be deposited with and held by the mortgagee. Additional The mortgagor further covenants with the mortgagee: I Covenants 1. To pay the indebtedness hereby secured, 2. To keep the mortgaged premises in good tenantable condition and repair, 3. To keep the mortgaged premises free from liens superior to the lien of this mortgage, 4. Not to commit waste nor suffer waste to be committed, 5. Not to do any act which shall impair the value thereof. u Mortgagee may In case anv such taxes or assessments remain unpaid after they become delinquent,or in case of failure to keep the mort- cure Defaults gaged premises so insured,the approved policies deposited,or the insurance premiums paid,or to keep the same in good con- Disbursements dition and repair, free from liens and waste, the mortgagee may on its part cure such defaults,and all sums so paid shall by Mortgagee immediately be repaid to the mortgagee and shall,unless so repaid,be added to and deemed part of the indebtedness secured Capitalized hereby,and bear interest at the rate of.....5..._.%per annum and form a lien upon the reaf estate described herein. Option Clause In case of default in the payment of any principal or interest when the same shall become due,or in the performance of any of the terms,conditions,covenants,warranties,or promises by the mortgagor herein or in said note or notes to be kept or performed,and such default shall continue for a period of sixty(60)days,then the whole amount of unpaid principal shall, at the option of the mortgagee,be deemed to have become due and payable without notice,notice being hereby expressly waived. IIRemedies Incase the option herein shall be exercised,the unpaid principal and interest,together with all sums which may be or have been paid by the mortgagee as herein authorized with interest on such disbursements at the rate aforesaid shall be collectible in a suit at law,or by foreclosure of this mortgage by action or advertisement in the same manner as if the whole of said unpaid principal had been due at the time when any such default occurred;and the indebtedness shall embrace,with said unpaid principal and interest all the sums so disbursed with interest as aforesaid. Power of Sale And it shall be lawful for the mortgagee to sell the said real estate with appurtenances thereunto belonging at public sale, and thereupon to make and execute to the purchasers deeds of conveyance pursuant to the statutes. itForeclosure In case of foreclosure proceedings, whether abated or not, all foreclosure expenses,including reasonable attorney's Expense fees,shall be added to the principal,become due as incurred,and in case of judgment,shall be included therein. Receivership Upon the commencement or during the pendency of any action to foreclose this mortgage,the court may appoint a receiver of the mortgaged premises,including homestead interest,and may empower the receiver to collect the rents,issues, and profits of said premises during the pendency of such action and until the confirmation of sale,and may order such rents, II issues,and profits when so collected,to be held and applied as the court shall,from time to time,direct. Heirs,t.cgat All terms,conditions,covenants,warranties and promises herein shall be binding upon the heirs,legal representatives, Representatives, successors,and assigns of the mortgagor and shall inure to the benefit of the mortgagee,the mortgagee's heirs, legal repre- Successors, Assigns sentatives,successors,and assigns. �I STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ( QfT V_ 1dA a n ROUTE/BOX NUMBER d119 / FIRE NO. CITY/STATE G(J ZIP PROPERTY LOCATION: SF 1/41/4, Section 3 P , T2LN, RW, Town of , St. Croix County, Subdivision , Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after Inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED + DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address QPP MENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS v RY, DIVISION Ogg R Al�fl" PERCOLATION TESTS (115) P.O. BOX 7969 P',�iIAPC RELATIONS 1 / MADISON,WI 53707 - . (H63.090)&Chapter 145.045) LOCI N: SECTION:���N/R E (or r� /MUNICIPALITY: OT NO.:BLK.NO.: SUBDIVISION NAME- 5 --. COUNT OWNE BU ER'S NAME: MAILING ADDRESS: rX Qrl OCYP d I - --- I USE DATES OBSERVATIONS MADE NO.BED COMMERCIAL ON PROFILE DESCRIPTIONS: E A N TE TQS�: Residence ❑New ®Replace 1 4 l7 1 RATING:S=Site suitable for system U=Site unsuitable for system R]STIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDING TANK:RECOMM NDED SYSTEM:(optional) ©$ ❑U $ ❑U D S ❑U ❑S ®U ❑S CS Pe . 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: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B- J 6.66 D4.5 D oh e ?b,00 9 ,� t d S 5'! ,S aA S �r B- 6.Dti 6D.Sr0 B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PFRIC111 t PERT D P R PER INCH P- A6 AF U P- ? �� P- to 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 ELEVATIONl� c ^ , 6 1 _ Ai I F ; E M 0i 0 o e tN 3 R 1,the undersigned, hereby certify that the soil sts 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 WE COMPLETED ON: om iq 4 va . 6 M ADD E$I; CERZI ATION NUMBE PHONE NUMBER(optional): 0.6 iL)a `S ; 0 �(lf CST S U R E: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — r INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test,your report most 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 planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE FOULED 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 used it desired; S. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Coo-riplete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10 if the information (such as flood plain,elevation) does not apply, place N.A. in the appropriate box; 11. Sian the form and place your CLment address and your Certification number; 1 . Make legil:rle copies and distribute as recfuired. ALL SOIL TEST'S MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF CW0PLETION. ABBREVIATIONS FOR CERTIFIES} SOIL. TESTERS Soil Separates and Textures Other Symbols s Stolle (over 10") BR - Bedrock cols — cobb!(" (3- 10") SS — Sandstone gr — Gravel it rldol 3") LS - Limestone M.s Sand HGW — High Giouradwatei cs _ Co arse Satan I=erc Percolation Rite ud _ M rdiuln k<Istd Vvell Loamy >aild � _ G l a r. tie n F - l_r',ar3? car; - Br >.rrra it L{.alt;,, Iii la .;ck s= S;It (sy - C <ay C1,y l_c.'ar;"3 or _- Yt E`rC)'t= &r ldy C r aye t...oa lrn R Reo {cl — S,It%, Cl ay° f O,sin tilol - lMi'-)t9ris ,t: S3r;f1'v Clay pt -- I i<ai i33Er+ ..... l" 4ri:yti rr d r) .._.. I'vi isck High Six uenei> s' soillext -"+s suriuco vai'kn fo? liquid ivast 'dispot "al BI�1 - BE ncli t`;ai,�K Oi RP -- Vertical R lerr na r Point TO THE OWNER: This sod reef report is the first step in securing a sa,wary permit.The county or the Department may request verificition of this soil test it) the field prior CO Permit. issuance. A complete set of plans for the private sa wvagt� system and a permit appliC«t;on must bE' subrTtitted 10 the appropriate local authority in order to f.±,i,.;=r;a per'llit. The san il at permit, must be obta fined and posted pt"If)r to ftae Sti;rt cf ittn Y C€llStt"laCti0o. 3031 Q K I � `n3b ► �tc� i r -: Parcel #: 276-1043-35-112 01/22/2007 10:56 AM PAGE 1 OF 1 Alt.Parcel#: 36.28.19.322G-12 276-CITY OF RIVER FALLS Current X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O-S&CBANK S&CBANK 355 S KNOWLES PO BOX 475 NEW RICHMOND WI 54017 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description " 143 E POMEROY ST SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 0.570 Plat: N/A-NOT AVAILABLE SEC 36 T28N R19W PT E1/2 SE NE COM S LN Block/Condo Bldg: NE1/4 608.5'W OF SE COR,TH N ON E R/O/W HWY 35 541'POB,TH N 150',TH E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 150',TH S 150'TH W 150'POB FORMERLY 36-28N-19W 040-1139-10(563F) Notes: Parcel History: Date Doc# Vol/Page Type 09/08/2003 739171 2403/17 EZ-U 04/02/2003 715603 2191/488 QC 01/21/2003 706627 2116/613 WD 07/28/1999 607581 1444/638 mo C2..0 . 2006 SUMMARY Bill#: Fair Market Value: Assessed with: 179981 1,148,200 Valuations: Last Changed: 09/19/2006 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 0.000 164,900 1,028,000 1,192,900 NO Totals for 2006: General Property 0.000 164,900 1,028,000 1,192,900 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 32,300 980,000 1,012,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch#: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 040-1139-10-000 01/22/2007 10:52 AM PAGE 1 OF 1 Alt.Parcel M 36.28.19.563F 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): O=Current Owner, C=Current Co-Owner CARL L FAM TR WICHMAN O-WICHMAN,CARL L FAM TR ANNEXED Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 0.570 Plat: N/A-NOT AVAILABLE SEC 36 T28N R19W PRT E1/2 SE NE COM ON S Block/Condo Bldg: LINE OF NE1/4 6081/2 FT W OF SE COR,TH N ON E R/O/W HWY 35 541 FT THE POB,TH N Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 150 FT,TH E 150 FT,TH S 150 FT TH W 36-28N-19W 150 FT-POB ANNEXED RF'95#526829 Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 952/521 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 04/07/1995 Description Class Acres Land Improve Total State Reason Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount I Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00