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HomeMy WebLinkAbout042-1057-60-000 "' '' � oo I � °o• I a o 3 0 3 60.* I H p U y c � I I o I I N I I I I � I I t I I cc •� I I °' I 4) w C Z o Z LL c LL o I o m I I (D Z Z E co w p o w app am I N H U O I O Z :t c c I j o Q c Z c E I 0 �w c o o = o o I CL CL fn N • aN N O O cn U L a L Q Z m z p Z m Z U o N Z Y I c C m I i O N O E �v CL CL 6 IL m �w Q o totroto �� tm0)otro � o I Z � > I Cl) 3 ° Z CD ° �` Z I 000 00 IL CL IL CL IL �w a 3 m3v � o CD rnrn z ° I i' r Z d r a- _ co m = p d c c = O = I > o m c Q l �, c a L d QI Z cn o d ¢ } (n m co a p I _ nt o r` a c ° y c U o �o ` � o o o U o A p o c c o TV•O`�AO C,4 tO� aCi Y O wr y a ON O N @ 0 p pp F- ` N N Z Z a LO 0) _v t N 2 Z y H FOy O N O 2 Z O 7 I I I I r \ € a € a I a � AIL • ° u c c c c r I 3 o r , A uo a 2 ! o ai u O to V Parcel #: 042-1057-60-000 01/16/2007 05:11 PM PAGE 1 OF 1 Alt.Parcel#: 20.29.18.320C 042-TOWN OF WARREN 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-KELLER, DAVID E DAVID E KELLER 1074 80TH AVE ROBERTS WI 54023 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description * 1074 80TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 1.750 Plat: N/A-NOT AVAILABLE SEC 20 T29N R18W 1.750 A IN SE SE LOT 1 Block/Condo Bldg: CSM V 4/1077 AS 632/148 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-18W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 927/148 07/23/1997 842/544 07/23/1997 632/148 2006 SUMMARY Bill#: Fair Market Value: Assessed with: 149468 169,100 Valuations: Last Changed: 10/22/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.750 34,500 88,900 123,400 NO Totals for 2006: General Property 1.750 34,500 88,900 123,400 Woodland 0.000 0 0 Totals for 2005: General Property 1.750 34,500 88,900 123,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 223 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 15.00 Special Assessments Special Charges Delinquent Charges Total 15.00 0.00 0.00 Parcel #: 042-1057-50-000 01/16/2007 05:10 Ply PAGE 1OF1 Alt. Parcel#: 20.29.18.320B 042-TOWN OF WARREN 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 THOMAS W ANNUNZIATA O-ANNUNZIATA,THOMAS W 444 CHESTNUT DR NEW RICHMOND WI 54017 Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description * 1078 80TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 18.253 Plat: N/A-NOT AVAILABLE SEC 20 T29N R18W 18.253A S1/2 SE SE EXC Block/Condo Bldg: LOT 1 OF CSM VOL 4/1077 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-18W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 1106/21 QC 07/23/1997 1052/259 WD 07/23/1997 755/467 2006 SUMMARY Bill M Fair Market Value: Assessed with: 149467 177,500 Valuations: Last Changed: 10/22/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 18.250 88,300 41,200 129,500 NO Totals for 2006: General Property 18.250 88,300 41,200 129,500 Woodland 0.000 0 0 Totals for 2005: General Property 18.250 88,300 41,200 129,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: 09129/2005 Batch#: 05-25 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 15.00 Special Assessments Special Charges Delinquent Charges Total 15.00 0.00 0.00 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.B&X"7969 BUREAU OF PLUMBING MADISON,WI 53707 CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Numbef: IIf assigned) ❑Holding Tank ❑ In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Ted Smith 77Coulee Rd. , Hudson , WI BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: SE SE , Sec . 20 ,T29N—R18W, Town of Warren—Elmer J . Smith S b . Name of Plumber: MP/MPRSW No County.. Sanitary Permit Number: Walter Nechville 3253 St . Croix 38495 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER JPF[O VIDEDPROVIDED: YES El NO DYES ONO BEDDING: VENT DIA.: VENT MATL: HIGH WATER IdUMBEii' ( ROAD: P VENT TO FRESH ALARM: M INE: AIR INLET: ❑YES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH LINE. AIR INLET: (DIFFERENCE BETWEEN FEET FROM ❑YES PUMP ON AND OFF) ❑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 FARCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING COVER INSIDE DIA.. #PITS: LIQUID (�{0,. TRENCHES. MATERIAL' PIT DEPTH. 4I1 � GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER,.OF PROPE RTV WELL BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER. ELEV.INLET ELEV.END. PIPES. FEET FROM .LINE: AIR INLET: NE.CARESI'—­*- 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 1:1 NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ONO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. JMULCMIU CENTER. EDGES. El YES 1:1 NO 1:1 YES ONO Ell YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER. BE OtrRy��yO TRENCHES: MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV.: ELEV.. DIA.-. ELE V.. PIPES: LE3fA"�'4�3(�AN CXISTf�I�TlI :HOLE SIZE HOLE SPACING DRILLED CORRECTLY �f COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED e �h. PLANS: ❑YES El NO El ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMB R,O'F PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES No ❑YES ❑NO WEAKEST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710(R.01/82) APPLICATION SAFETY&BUILDINGS DEPARTMENT OF FOR SANITARY INDUSTRY, DIVISION ,.-LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON,WI 53707 Attach plans for the system on paper not less than 8%x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed,sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: TM ailing Address: 4. X 102 5,wt� _ Property Location: City,Village or Township: County: a ,S �► '/a$ t/aS;Z0 /T .Q NCR / E (or GJ 4MPM. cv-, Lot Number: Blk No:: Subdivision Name: Nearest Road,Lake or Landmark: State Plan I.D.Number:• _ (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: ®„1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY ®®0 a NA 00 K A� HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED(Square feet): New ❑ Replacement ❑ Experimental I`�, Seepage Bed ❑ Seepage Pit Y4, L g, ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): CK Private 1:1 Joint El Public I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signature: MP/MPRSW No.: Phone Number: Plumber's Address: Name of Designer: q 1 Z. fl D . COUNTY/DEPARTMENT USE ONLY Signat re of Issuing Agent: Fee: Date: APPROVED Sanitary Permit Number: _gL .V. f✓ �� rp�g7��� ❑ DISAPPROVED Reason for Disapproval: Alternate course(s)of Action Available: Change of ownership, building use or plumber requires gSanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County,Canary-Bureau of Plumbing, Pink-Owner,Goldenrod-Plumber DI LHR-SBD-6398(R.07/81) } i _ Form - S T C 100 Owner of Property .Location of Property ;4 Section o?O ,T ,Z7 N R W Township Mailing Address Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel 7 Z/-7 Date Parcel was Created Are all corners identifiable? _ Yes No Include with this application one of the following: . Certified Survey Map .Deed . Land Contract , or . Other Legal Document which describes the property PROPERTY OWNER CERTIFICATION 1 (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. .-3 72'9 Z4—,and that I (we) presently own the proposed site for the sewage disposal system (or 1 (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. 1. A20 212�, SIGNATURE Of OWNER SIGNAT0RE OF CO-OWNER (IF AP (CABLE) zo. 9 6.3 0 8_ DAW SIGNED �- GATE GNE0 T y �1 � _ -., ,. ,. ! .. .' - � .. .. Parcel #: 042-1057-60-000 10/12/2006 10:11 PAGE10F I Alt. Parcel#: 20.29.18.320C 042-TOWN OF WARREN 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-KELLER, DAVID E DAVID E KELLER 1074 80TH AVE ROBERTS WI 54023 Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description ` 1074 80TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 1.750 Plat: N/A-NOT AVAILABLE SEC 20 T29N R1 8W 1.750 A IN SE SE LOT 1 Block/Condo Bldg: CSM V 4/1077 AS 632/148 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-18W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 927/148 07/23/1997 842/544 07/23/1997 632/148 2006 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/22/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.750 34,500 88,900 123,400 NO Totals for 2006: General Property 1.750 34,500 88,900 123,4000 Woodland 0.000 0 Totals for 2005: General Property 1.750 34,500 88,900 123,4000 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 223 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form C 10+ AS BUILT SANITARY SYSTEM REPORT OWNER Q�t-d -P�J TOWNSHIP �.ri!/�!?� SEC. ?CP T N-R W ADDRESS �,� / ST. CROIX COUNTY, WISCONSIN - f I SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 6' INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used e ��`` Elevation of vertical reference point: 190,D r Proposed slope at s3te: � SEPTIC TANK: Manufacturer: ,/.G,IC,s Liquid Capacity: 1!'dL/ Number of rings used: 0 _ Tank manhole cover elevation: Tank Inlet Elevation:�J -, Tank Outlet Elevation: 6 1-og Number of feet from nearest Road: Front,Q Side,0 Rear, 0 ��Ap � feet From nearest property line Front 10 Side,O Rear,O G� feet Number of feet from: well , building: AND A D (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE a � PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gail-ons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: ✓ Trench: Width: /s' Length: 3S' Number of Lines:J_ Area Built: ,/,/J''^ Fill depth to top of pipe: 12Z & Number of feet from nearest property line: Front, O Side, O Rear,0 Pt .�r Number of feet from well: > 70 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 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, 0 Rear, O Ft. Number of feet from well: , Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: r� Inspector: Dated: Plumber on,'job: , License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABOR&HUMAN RELATIONS DIVISION P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION MADISON,WI 53707 State Plan I.D.Number: SE4,SE4,S20,T29N-Rla-J FN4 CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Warren ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound R iOLDER: ADDRESS OF PERMIT HOLDER: INSPECTIO D Dave Keller 108 River Street, Roberts, WI 54023 (0 —N -Scl P100 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: David B. Fogerty 3289 St. Croix 119511 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER ID/ 3' (h/ ' 1? PROVIDED: PROVIDED lsJ l.�a 'DYES ❑NO ❑YES -&NO BEDDING: VENT DI .: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY W VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑YES SNO �� ❑YES ,KNO NEAREST---* �o DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIP* N eta:-ANUFACTU ER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO I ❑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) ❑VES ❑NO NEAREST---111" SOIL ABSORPTION SYSTEM. Check the soil moisture at the dppth;of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,constructioA SIXIall 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 DIMENSIONS Q® _�55 GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: N0. ISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET, ELEV.END: PI S: FEET FROM LINE: AIR INLET: ll 9 % a D Y" 1 1 NEAREST----11111" YC� � � r+ MOUND SYSTEM: ,W Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM;!F SYSTEM slope and furrows thrown unsiope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER I TEXTURE: =[--]YES KERS: OBSERVATION WELLS; ❑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: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS [::]YES ❑NO ❑YES ❑NO `R PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST `1 --- o_ 3 Z Retain in county file for audit. tch k� tem on 69verse Side. TITLE: SBDr6710(R.06/88) c�-r+ Zoning Administrator SANITARY PERMIT APPLICATION El 0ILHR In accord with ILHR 83.05,Wis.Adm.Code COON /( ko I X STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than 119611 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 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. PROP RTY OWNER PROPERTY LOCATION { '/4 ,s�'/4, S T , N, R /F E(or)W PROPERTY OWNER'S MAILING LOT# BLOCK# la J9 S CITY,aTAT ZIP CODE PHONE NUMBER SUBDIVISIO NAME OR CSM NUMBER 3 Z4, .7w 7� N NEAREST ROAD II. TYPE OF BUILDIINNG:: (Check one) ❑State Owned ILLAGE r719 T(❑ Public L1?1 or 2 Fam. Dwelling-#of bedrooms- PAR ELTAX NUMB R( ) III. BUILDING USE: (If building type is public,check all that apply) Z a 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 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,--P,reessurized Distribution Pressurized Distribution Experimental Other 11 LJ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 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 b .'7'3 3 /D/,2— Feet 17.3 Feet VII. TANK CAPACITY Prefab. Site Fiber- Exper. in allons Total #Of Manufacturer's Name Concrete Con- Steel glass Plastic App INFORMATION New istin Gallons Tanks structed Tanks Tanks Se tic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) /MPRSW No.: Business Phone Number: r Plu ff rs A ress(Stree,City),State,Zip ode):14Z V, Za4,4. LAIr 1pfle IX. toUliTYIDEPAATMENT USE ONLY Lj Disapproved Sanitary Permit Fee(Includes Groundwater ate Issued Issuing Agent Signature(No Sta s) TV Surcharge Fee) L(N Approved ❑ Owner Given Initial I q UO Adve a Det rmin on / 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: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete ##of bedrooms if 1 or 2 Family Dwelling. 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'f 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. GROUNDWA ER 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. SBD4398(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 UAJipQk'4Aic1 &4)s-),0A M 469!E l . Location of property S,6- 1/4 SC 1/4, Section 6 , T AN-R IPW Township / P YL x) Mailing address /b &4e S1 e, i S SV6 ,� Address of siteF Subdivision name Lot number Previous owner of property /�� Sr✓� c t �1 Total size of parcel Date parcel was created 'u i Are all corners and lot lines identifiable? _Yes No Is this property being developed for resale (spec house)? Yes Xc No Volume and Page Number M 71 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. ;77115 F7* ; 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. 3 7 kS 9 -7 ) . Signature of Owner Signature of Co-Owner (If Applicable) C 'P 4Zf"Ir v Date f Signature 46ffe of Signature I •DOCUMENT NO. STATE BAR.OF WISCONSIN FORM 1—1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 1448565 Ink. 842PAGE 54 4 _ REGISTER S OFFICE This Deed, made between -.T-heodo-re. S-.-_Smi.t.h ._._..__._... ST. CROIX CO., Wi and .-Loretta_ M. Smith, - husband and -wi-fe.--- --- Recd for Record _.. _. - - - - -- - ------ - - - - -- .. .__ --- - ---- -- -- Grantor, AM li JUN 1989 David I Gt 11 .15 itnd -husbnd E .and1wife, asLsurvivorshipem.ari_ta.l- --- property - ----- _ Register of Deeds �' Grantee, Witnesseth, That the said Grantor, for a valuable consideration.. - - l(ey Tip`' I conveys to Grantee the following described real estate in St. Cro1 x.. x Ua � �e it �eru+�es t�C . ii County, State Of Wisconsin:i5CO8111 i : � Certified Survey Map in Volume 4 of Certified9j v I Survey Maps , Page 1077, as document number 371597, filed in St. Croix County Register Tag Parcel No: ................................... of Deeds office on June 22, 1981, being located in the SE4 of SE-4 of Section 20, Township 29 North, Range 18 West, Township of Warren. j ii u T- RxsFFZ .1 jr FEE i This _..._l.s_not_._.----- homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And.__Th.e.od.or-e..S_._.Smi.th...apd_-Loretta M. _Smith. ._ . --- -- --- -----..... .................. warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except �! ii easements and rights of way of record, if any, and will warrant and defend the same. i I)aced this _.. . ... -------- --- day of . ... ...June ..--- -- -- ----- ------------ - 19. 8.9.. �,\// I - - - - (SEAL) --l ..XJ.- ---- ------(SEAL) . - ---------- --------------- * - The.od.ore...S.. ..S.mi.th----- -------------- _... _._. . - - (SEAL) / J�- J. (SEAL) ..... ... * Loretta M. Smith �! - .. _.. . . _-- -------- -- -- _ --- _ . -------- --------------- I AUTHENTICATION ACKNOWLEDGMENT ' Signature(s) --------------- -------------------------------------------- STATE OF WISCONSIN ss. I ------ St. Croix ------------------------------------- County. authenticated this -_-_-_.day of---------_-------------._., 19------ Personally came before me this ... ._.._...__day of ................ .....June--------- I 19.89. the above named !' -------------------------------------------------------------------------------- Theod° e $A...51n th-_and-------------------- i * Loretta M----$mi-_tit-------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN ii ---------------•------------------- -------------------------------------------- (If not, -- --------------------------•- authorized by § 706.06, Wis. Stats.) to me known to be the person ------------ who executed the foregoing Ltrument and ack /`, \ "' sarge. THIS INSTRUMENT WAS DRAFTED BY C. .•.•L- Gaylord, Attorney---- ------. a .. ................. -------- iii.. , Ric_hard F. Prokash River Falls, WI 54022 -- - ------- ------------------ -------------------- °" r okar:Y Public ------ St. CroiX County, Wis. �I (Signatures may be authenticated or acknowledged oirlJ 1 NI'y, Cpnmiission is permanent. (If not, state expiration are not necessary.) ,-a �, -c 1-17 93--• ate 19 ) C� '.y'ti7 r t - ------ ---------- ---- --- it *Names of persons signing in any capacity should be typal o�pLintlkd bLloihitm<ir s•grvauucs. j N. MF4Crr11Ma, STA•rF. iiARiQ�, ,IhS{CiQiNSIN + FORM No. 1—1982 Stock NO. 3 W STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 0, 0i' ROUTE/BOX NUMBER FIRE NO. CITY/STATE �i) � S C•y t. ZIP PROPERTY LOCATION: _1/4 � 1/4, Section )6 , T�N, R W, Town of a°L,) , St. Croix County, Subdivision 1��14 , Lot No. G - 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 —,..�-L. 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 DEPARTNFENT OF' REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS tNDUSTt?Y, DIVISION LABOR HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090) &Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MQ#+I2f Y: LOT NO.:BLK.NO.: SUBDIVISION NAME: f— �/a ,2 /T� N/R E (ar — ------ SOU T O ER'S MAILING ADDRESS: USE 7 DATES OBSERVATIONS MADE NO.BEDRMS.: COMMER IAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: P�esidence ��-- 92'New El Replace S p RATING:S=Site suitable for system U=Site unsuitable for system 7 CONVENTIONAL: MOOUUN(D: IN-G�R,O]U,N�DPRESSURE: SYSTEM-INN--F,I'LLHOLDIIN`G TA'NIK:RECOMMENDED SYSTEM:(option�U U J E� LJ V �U DS DU ©J OY If Percolation Tests are NOT required DESIGN R 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 GROUNDWATER-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- 2- 1 9,, /0 7.1 f, ' ' s .> B-3 w B- 3 ' L,. B- o u l "ezal PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- P- P- 24 G 4 r P P- MA 3 c6 L6 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 1 • �1 Stu �-_ { T- ..__ tH , 1V E ! 3 � t ----_---- .�._. r _. -_ —1 i µ 33 t 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 COMPLETED ON: s 9 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): Licensed Perk Tester && Plumber Fogge�_rty Heights 0 I G N A ROBERTS, WISCONSIN 54023 Phone 749.3656 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 - 6595 To be a complete and accurate soil test,your report must include: 1. Complete legal description; 2. The use section rnust 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 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; 0. 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 if desired; S. Male scare your benchmark and vertical elevation reference point are clearly shown,and are permanent; 0. Complete ail appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If tiro information (such as flood plain, elevation)does not apply, place N.A.in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE FOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols i st Stone (over 10") BR — Bedrock co 1) — Cobble (3- 10") SS Sandstone gr - Gravel (under 3") LS — Limestone *s — Sand HGW — High Groundwater cs Coarse Sand Perc -- Percolation Rate mod s — Medium Sand W — yvlell fs Fine Sand Bldg _- Buiiding is Loamy Sand ; -- Greater Than +a - Sandy Cc> rn < Less Than L€yarn Bn — Bs sil — Silt Loam, BI — Black si Sill 02 — Gra% %1 Clay Loarn Y — Yellow sci — Sanrfy Clay Loam R — Red sicl — Silty Clay Loarn mot Mottles sc — Sandy Clay wl — with sic — Silty Clay fff -- fevv, fine, faint c -_ Clay cc — common,soar.>€: pt Peat nrm — fJ;any, medium rr -- Muck d — distinct P -- prominent HWL — Hiah vvatw level, Six geneial soil textures surface water for liquid ?&,aste disposal BM Bench Marl. VRP Vertical Reference Point TO THE OWNER: T, rs soil test report is the first stap in s'e'Curinq a sanitary per nit,The county or he Department rn ay request r 0 Caton ± ,rs sod est rya ,Ile field t`rr"rc;V" In per,rit raS�r<a,; :�. A corrrplr tr, vE>l: of plans for the private t� syst�rr= r:°rf a pefr1i1 almflicat,""n nnusi >)e suhnait l! tea par= appropiate local aulh city ill order to x9t'W-!- . f"0 SalOia v of.r.=6 1 rr,tea. :7f'L�c bT'al E2d an(i pos 'd of iot 'i.Q &e.start of an_y.1� )S,U.LJ ?r ,r�ra.t l _�, a ,� rYw:i`'. � , ��. �� r �� S� � - .. ':3 Per c Ak_ v � I �o U� r T3 iki ° V o o I i 1� i in on l 0 `ANA 0 8 N* �Nif _ I\ WZ �14 r �- w 92 �. . .� � + . ' .` !' � � _,. t� r '� y `�`C 0 �� � 4� a v �� � i `��'�' �,. i� , `, � i. . � M � : �� �� ,,. . , v � , . � ,. „ , �; +, �, ; � -� �., I �. • • y � ` r_._..___._ .. is • � ` ± � � ' '� �,�, � ,,. "1' ' a„I . F DOCUMENAID. STATE BAR OF WISCONSIN — FORM 2 VOL 632 PA�E��B WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA 3'719'�S REGISTERS OFFICE ELMER J. SMITH and BLANCHE SMITH, ST. CROIX CO., Wis. indiVi3ually and as husbaEd and wi e, Rec'd, for Record this_ 8th day of July A.D. 1981 conveys and warrants to THEODORE S. SMITH and ct LORETTA M. SMITH, husband and wife, as � joint tenants, 1w4tw of ONds RETURN TO M/M T. S. Smith the following described real estate In St. Croix County, 77 Coulee Road, Apt State of Wisconsin: 77 Hudson, WI. 54016 Tax Key No. The parcel described and easement included in the Certified Survey Map filed June 22, 1981, in the Register of Deeds office for St. Croix County, which is the part of the SE4 of SE4 of Section 20, Township 29 North, Range 18 West, filed as Document No. 371597. EEA EXEMP''�� ( TAX EXEMPT: 77. 25 (8) Thisis no homestead property. (is)(is not) Exception to warranties: Dated this 7-th- day of July _ 19 81 (SEAL) (SEAL) • . Elmer J. Sm/ith (SEAL) (SEAL) • . Blanche Smith 0 AUTHENTICATION ACKNOWLEDGEMENT Signatures authenticated this 7th- day of STATE OF WISCONSIN July r 19 I ss. r � - N/A County. Personally came before me, this day of Hugh F. Gwin 1s TITLE: MEMBER STATE BAR OF WISCONSIN the above named authorized by§706.06,Wis. Stalls.) N/A This Instrument was drafted by Hugh F. Gwin, Attorney Gwin, Gilbert, Gwin & Mudge 430 Second Street Hudson, Wisconsin 54 016 to me known to be the person_who executed the foregoing in- strument and acknowledged the same. i (Signatures may be authenticated or acknowledged. Both are not r necessary.) 'Names Notary Public County,Wis. of persons signing In any capacity must be t yped or printed below their Signatures. ' , My Commission is permanent. (If not, state expiration date: :'A IUPAN TY DI FD STATE BAR Or V I,CONSIN FPO6 NO - 1077-- - Stock No. 13002 OMPT )OA G�5 Rev.9/78 ` REPORT ON SOIL BORINGS AND PERCOLATION TES! ZM S WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERICEP.O. BOX 309,MADISON,WISCONSIN 53701 LOCATION: s�� %, '/a,Section ZD ,TAN,R/,kE (or) 1�1 Township or Municipality Lot No. , Block No. �iPT 0 A' f1R � County �9 ~ Owner's/Buyers Name: S'_ u ivis on Name s7 Ir titi Mailing Address: a,010-J 4J/S. i TYPE OF OCCUPANCY: Residence No.of Bedrooms - COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SCAL BORINGS NDU. 7 Z M0 PERCOLATION TESTS /J' l' PO SOIL MAP SHEET C NAME OF SOIL MAP UNIT 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 AFTEF INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- LIP , 1, 13 710 y06'oO P_ P-2, 60 13"k.Si/, "/3,v.S;/ 9"G/450. S > to � (P > P— /Z ''G . i/ 2 "13N. Si/ 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— . 76 NONE > p!o /O'%�v.L� 17"41•11,041 , B- L l0f -vorJL- ? /off z/"A/-A, Z- /p"6 Y, S,Y " 5� 62 .ez aN CS R. B- .3 If AI&K e_ ? "11A). L 5".fd "SG / "a/P, CS " -,RV C S B- N&ra- ,.G c //"G y. sv, i0" 0'e. es B- 5- „�� t /�.,off,. S� , 20" Of Cs ) 7 B- _ "" d" .L . Si/ 3 " , w o?, ka is Z Y S PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the play the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy &/.5­51. F/• FolP Indicate scale or distances. Give horizontal and vertical reference points Indicate slope. 3 13---Ae00M /1a y.6- N H . � } § , } , A- A/0i ems N J�; E. 3 F , ° fi 4R_ � 1 - - / 3 6toPSoi[ o cve.� 4-- 7�0 s BFI m -.. 3 ,�cam T�1T .PEA I,the undersigend,hereby certify that the soil tests reported on this form were made by me in accord with the proceciutes°ad 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) ARb Aggr 4 1?1•e Certification No. �Lf)ZT 2� Address .Name of installer if known Copy A—Local Authority CST Signature 1P1 15Rev.9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS C WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309,MADISON,WISCONSIN 53701 LOCATION: %;SS %,Section Zy J4 N,R 9E (or)&ownship or Municipality Lot No. , Block No. p/9'xr Of AC60-9- County 57J- � _ n �.�i� Subdivision Owner's/Buyers Name: �c Mailing Address: TYPE OF OCCUPANCY: Residence_ N No.of Bedrooms __COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEM ENT G D ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS A.,00• �`a U PERCOLATION TESTS SOIL MAP SHEET NAME OF SOIL MAP UNIT PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN ;INMINUT]ES T TIDROP IN WATER LEVEL,INCHES NUM- SINCE HOLE HOLE AFTE ERV RATE BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING PERIOD 1 PE RIOD 2 PERIOD 3 MIN/IN P— P— P— 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- 4 UD B- dam_ /'.f S ;So -)h[,G v/2 TED B— w i Ol,.uV B- 4 o 5/cr B- i 5 Al O 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 .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. I L g Z , _ m�,o , _ m_ . ._ _ � ms .e. N 3 .. 4_1 _ a 3 / t @ k PPP2P o I,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 beliefp �� Name (print Aor6e^ _" +/C 17 -Certification No. bL y� Z"__ Address &T• -3 d'J )El l_ P&O _d U P.SoA_) CCU/S - .Name of installer if known /VECI? 9/CA Ut t/,V-&- --- h"&E Copy A—Local Authority CST Signature ��i�' Z�: tiU TE-d. l A3i 17 4 ���.._.. /IFr � o ` L 3 — L Heft�—� b e•D e:� t• r �� i a�a , n 1 M