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HomeMy WebLinkAbout042-1087-40-110 ~ -0 O a, o N 0 h M O N C O � � w O h � O � N a O x •O CV O � Q O i C .a N N W N � 7 C (0 LL O O7 3 � 3 Cl) v m z Li I w E o U) ;,; O z a m N 3 M I- Z O I O z a c w 4)i z 2 Z V) l -E V N M N co cx d o O O O N Z Z o� Z Z N d N co LO m E a� IA % > m m @ EL CL c M oca EI CL bip zM > aLL Z • 3aCL N lA J V rn 00 0)M 'o I r M � N Q O O w 'O E li 7 N M Q } (n m �1 7 0 o O O v N C E O 6d LO 3 N C Y O C � ° N C 00 N N ) — Z C L p N 0 Cl)\ Cd # w COL v ( d R € a � . is - ea • c� a 2 c � A o ° ' U) Parcel #: 042-1087-40-110 10/03/2005 10:27 AM PAGE 1 OF 1 Alt. Parcel#: 31.29.18.485H 042-TOWN OF WARREN Current 1X'I ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): 0=Current Owner, C=Current Co-Owner 0-SHIRMER, SCOTT A&DEINA S SCOTT A&DEINA S SHIRMER 918 64TH AVE ROBERTS WI 54023 Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description "918 64TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 1.800 Plat: N/A-NOT AVAILABLE SEC 31 T29N R18W 1.8AC NW SW LOT 3 OF Block/Condo Bldg: CSM 6/1580 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 31-29N-18W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 834/75 07/23/1997 824/415 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/22/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.800 35,100 114,600 149,700 NO Totals for 2005: General Property 1.800 35,100 114,600 149,700 Woodland 0.000 0 0 Totals for 2004: General Property 1.800 35,100 112,600 147,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 302 Specials: User Special Code Category Amount I 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 O-e , pc� TOWNSHIP G4�elo �1�i. SEC. / T _N-R�W ADDRESS / ST. CROIX COUNTY, WISCONSIN SUBDIVISION '�— LOT 3 LOT SIZE �— PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM II � I ; I 'y � 'Sao �z y .�_-� 3 -� �S,l• fi �b c �3' y��•�� — /d S z d INDICATE NORTH ARROW ~ 1 BENCHMARK: Describe the vertical reference P oint used Elevation of vertical reference point: /®O O Proposed slope at site: SEPTIC TANK: Manufacturer: /il/C S Liquid Capacity: / ep'y Number of rings used: O Tank manhole cover elevation: Tank Inlet Elevation:_/a)?, Tank Outlet Elevation: _le T,-S5/' ` Number of feet from nearest Road: Front 10 Side (D Rear O � $'0 feet — From nearest property line .° Front 10 Side,©'Rear,O 77 feet Number of feet from: well ?57;0 , building: 30 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE k: s PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: 5 Number of Lines: I/ Area Built: y� Fill depth to top of pipe: qZ Number of feet from nearest property line: Front, O Side, O Rear,®Pt . Number of feet from well: -257-0 r Number of feet from building: (Include distances on plot plan): SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector• 2;4:!Z�';?f Dated: t"'Q / lL Plumber on job: License Number: Z ! Z/- T 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.P.BOX 7869 BUREAU OF PLUMBING MADISON,WI 53707 Nw%,SU!%,S31,T29N—R18W XN CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: (N assigned) Town o6 ;Awften ❑Holding Tank ❑ In-Ground Pressure ❑Mound Cotbeth Road NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: GeAaP-d D. Viebnock P.O. Box 187, Osceota, W1 54020 0_314$ 4 r BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELE V.. Na I Plumber,, 7PIMPRSW Nn.. Cnu nty. Sanit arV Permit Number: David B. PogW y 3289 St. Ctr.oix 112 821 SEPTIC TANK/HOLDING TANK: MANUF ACTU ER: LIQUID CAPACITY TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER (�, p L,[ P IDED. PROVIDED: "G 4 � .,� G�a E } �D f S / O�l�� YES NO ❑YES NO BEDDING: VENT DIA. VEN MATT fGH WATER NUMBER OF ROAD: PROPERT WELL BUILDING. JVENTTOI-RESH LARM FEET FROM AIR INLET. !�. / LINE / 1:1 YES NO 1 � 1:1 YES O NEAREST �Q 7 7�� 7 / DOSING CH BER: MANUFACTUR R. BEDDING LIQUID CAPACI TV PUMP M(I)EL PUMP:SIPHON MANUF ACTUREH WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. ❑YES ❑NO [ YES ❑NO ❑YES ONO GALLONS PER CYCLE: PUMP ND NTRgASOPE RATIONAL NUMBER(j F- PH OPEHTV WELL BUILDING I VENT TO FRESH r,.� LINE AIR INLET . (DIFFERENCE BETWEEN F€ET FROM" PUMP ON AND OFF) Y NO NEAREST-- 0 SOIL ABSORPTION SYSTEM.Check the soi ist re at t e depth of plowing N( TI ulnnaE rE H atATE Hlnl AND MAHKwa or excavation. (If soil can be rolled into a w e, o structit4n shall cease until FORGE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH IN1,11H JOISTH PIPE SPA(.IN(, COV�FI INSIDE f)IA =PITS LIOU10 r� THNCFS A AL t PIT / DEPTM" DIMENSIONS I J' •" GRAVEL DEPTH FILL DEPTH STH PIPE DISTH PIPE - DISTR.PIPE MATERIAL NO DISTI NUMBER OF "PROPERTY WELL. BUILDING. VENT TO FRESH BELOW PIPES ABO COVER [E)L'EV.INLE i ELEV .NU( PIPE FEET FROM :LINE Sa / AIR INLET: NEAR EST''«—^-- 5 �3 J 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. OYES ❑NO SOIL COVER TEXTURE _ PE HMANINTMAHKEHS oHSEHVAI NwELLS : YES ❑NO DY ES 0 N DEPTH OVER TRENCH BED DEPTH OVER TRENCH HEU DEPTH OF TOPSOIL ISODIAD SEEDED MULCHED CENTER EDGES ❑ ❑YES. ❑NO YES NO OYES 0 N PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BE LOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE UISTHIBUTION PIPE MATERIAL&MARKING ELEV.. ELEV. DIA. ELEV. PIPES DIAJ ELEVATION-AND DISTRIBUTION-, HOLE SIZE HOLE SPACING DRILLED COHHECI I COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLnnls EYES ❑NO ❑YES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER Oi PROPERTY WELL BUILDING: FEET FROM LINE: OYES ❑NO ❑YES ❑NO NEAREST. ", V" 104 ( 0 , ,. t% Sketch System on (,, Retain in county file for audit. Reverse Side. °" r1rLe SIG TD B Zoning Admin"t ratotc DILHR SBD 6710 (R.01/82) A- SANITARY PERMIT APPLICATION COUNT DILHR In accord with ILHR 83.05,Wis.Adm. Code �C STATE)AID I PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. [FOR TION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. VARIANCE ❑YES ❑ NO PROPERTY OWNER PROPERTY LOCATION l', p % %, S T , N, R /f E(or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIQD?0 PHONE NUMBER O CITY : NEAREST ROAD, II. TYPE OF 6UILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family -3 OR ❑ Public(Specify): Ill. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. [9 New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in##2) 1. a. Lonventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding C.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. VSeepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): ® Feet rivate ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete stC n- Steel glass Plastic App Tanks Tanks Se tic Tank or Holding Tank Lift Pump Tank/Siphon Chamber ❑ ❑ I ❑ I ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) #P/MPRSW No.: Business Phone Number: Plum 3 er's Address(Street,City,Stifte,Zi C e): Name of De V 11. SOIL TES11 TES INFORMATION Certified Soil Tester(CST)Name CST# r-- as v rL CS 's ADDR S (Street,City,Sae,Zip Code) Phone Number: j IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S tary Permit Fee Groundwater ate Is 'ng Agent Signature(No Stamps) Approved ❑ Owner Given Initial / S��uyrcharge Fee 1 Adverse Determination /� �LD,7-5. X. CO ENTS/REASONS FOR DISAPPROVAL: _ r 11 6AaJjjJ I-)JL j.j-ell,4 SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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 per-mit must be approved by the permit issuing authority. A new permit may be need&d', if there is a change in your' building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system,.-or type of system; 4. Changesin ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained- The septic tank(s) should be pumped by a-h6nsi�d pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owners name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from CILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8''/z x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawrii,to scale or With con Rlete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; W01s; water mains/water service; streams and lakes; dosing or pumping chambers; 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 forma --------------------------------------------------------------------------------------------- ------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more- commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater:biII Ground included the creation of surcharges (fees) for a number of regulated practices which Wisco in: can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried TfasutB ° is used in your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- .. t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) 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 G E-,< A L » t7, y iL_- r3 Z n c_ K Location of property hy1/4 S w 1/4, Section -3 / , T_Zj _N-R_ZL_W Township wig /Z F n/ Mailing address ; �. o�Y S Address of site Subdivision name yv iLe- 1,9AI�J C 6 o K Lot number Previous owner of property tiny /L e- /A IVI .►_ A Al fiG-r T.E G o o Total size of parcel 4 F--5 Date parcel was created Are all corners and lot lines identifiable? Yes 1,---No Is this property being developed for resale (spec house)? Yes 2—� No Volume and Page Number J3-5 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. ---------------------------------------------------------7--------------------- 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. r 4�% o//• ; 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 7- 2L;, Signature of Owner t,7 Signature of Co-Owner (If Applicable) Dat4 of Signature Date of Signature DOCUMENT NO. I STATE BAR OF WISCONSIN FORM 1—x98211 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 240 REGISTER'S 0RICE 445 BOOK 89,: rA„i 415 II ST. CROIX CO., WI Recd for Record ____William G. Cook and j C This Deed, made between ---- •-------•--•---- ------ ------------ D�iT V t+7RU;, I' Annette Cook, husband and wife as point at 3.00 P, -----------tenants------- ---------------- "A'. ---------------- -------------------------------------------------------------------------------- Grantor, and----- der-ald__D.,..V ebrock----------------------------------------------------- Re$ist6rofDeeds ------------------------------------------------------------------ ----------- -------------------------------- ------------------------------------------------------------------ ---------------------- .........................................---------------------------------------------------------, Grantee, j Witnesseth, That the said Grantor, for a valuable consideration___--_ i • RETURN TO -_ i conveys to Grantee the following described real estate in -5t_,...Cr-Q1x_.--- .-_- County, State of Wisconsin: i it �j Part of NW k of SW �4- of Section 31, Township 29 Tax Parcel No: ___________________________________ I North Range 18 West, St. Croix Count y, Wisconsin described as follows : Lot 3 of Certified Survey Map filed !I !+ September 6, 1985 in Vol. 6, page 1580, Doc. No. 405011. I I' Together with and subject to a 66 foot private road as shown on said Certified Survey Map. i s 'PEE is not This --------------------------- homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And----Wi11 Lam__G_.---Cook-_.and_.Annette...CoQk----------------- -------------------------- ------------------------ -- -- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except I 11 the easterly 33 feet of the premises lying within the limits of the town road and those easements executed to St. Croix County Electric Cooperative recorded in the da office��o of the Register of Deeds f�o$r St. Cro Count a-$ Documents #328527 and 328083 , and will warrant and defend the same. , Dated this __._-_._.___ 3rd y , -------------------------------------(SEAL) ---bj_z! - -----A---•ok-----------------(SEAL) * William G. Cook _-- ------ --- (SEAL) (SEAL). ' * * Annette Cook ------------------------------------------------------------------ ------------------------------------------ ----------------- AUTHENTICATION ACKNOWLEDGMENT Signature(s) ------------------------------------------------------------ STATE OF WISCONSIN SS. -----------------•-------------------------------------------------------------- St. Croix -- --------- ------------- County. authenticated this --------day of--------------------------- 19------ Personally came before me this ------3rd ___day of _ October_-___, 19.88__ the above named -------------------------------------------------------•------------------------ William G. Cook and - ---- ------- __ ----------------------------------------------------- * Annette- - Cook TITLE: MEMBER STATE BAR OF WISCONSIN -------------------------------------------------- ----------------------------- (If not- ------------------------------------------------------------ authorized by § 706.06, Wis. Stats.) to me known to be the person 4---------- who executed the %'w r,"foregoi instrument and ackno edge the same. THIS INSTRUMENT WAS DRAFTED BY - �� Charles B. Harris ,�.. ----- .... j ! - - = ,may-�” d". �! RrCHAl2L5S; 67ALII & HARt�I \� * -------- 1 Hudson WI 54016 t : = 5t. Croix -------- ------------------------------------------------- - ,v.Pub11c- County, Wis. --- •----------------- ---------- ', (Signatures may be authenticated or acknowledged. I,ioth. P1 v t�lxfm}l lon s jermanent. (If not, state expi tion are not necessary.) �4• ,C ti -------------------------------------- .�C 19 -� *Names of persons signing in any capacity should be typed or printei�llthr`styt3es. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 1-1982 Milwaukee, Wis. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER e� f 2 AG 4-2 J V/ _ f?'Cd C 1C ROUTE/BOX NUMBER FIRE NO. CITY/STATE 96, r-,,a,T 5 ZIP S¢ o 2, S PROPERTY LOCATION: AI Vi _1/4 5 W 1/4, Section �, TAN, R _W, Town of W A .t� n/ , St. Croix County, Subdivision VU-,,4 e , 14& r c? c K , 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. x SIGNED„�i�� x 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 SAFETY & BUILDINGS ,EPA; ENT OF REPORT ON SOIL 130r\,, . .r; AND DIVISION JOUSI ABOR AN, PERCOLATION TESTS (115) MADISON WI 53707 UMA14 RELATIONS (H63.0911) & Chapter 145.045) OCA� SECTION: TOWNSHIP/1ttt7NtCTl`At44Y: LOT NO.. NO.: SUBDIVISION NAME: #&J 1/ 1/a 31 /T4 N/R /q (o ) WA/P, 6_.v cs 4a- . Z P. 1/170) OU TY: WNER'SPBtiYt'R`S-NAME: MAILING ADDRESS: dov / o 2 co/f Ede �� , iPo,aE�rf cis . ST_ DATES OBSERVATIONS MADE NO•/BEDRMS.: COMMER IAL DESCRIPTION: _ PROFILE D-- E�T(I1ONS: R OLATIOQN..TEESTS: OResidence 31 ? � �• , New ❑Replace ��_U S i ll-- = n uitable for stem /3_ Site suitable for stem U Site u s Y — tATING.S S _ Y _ _-- _ _--- :ONVEN110NAL: MOUND: IN-GROUN -PRESSURE: SYSTEM-IN-FIIL IiOL TTY TANI RECOMMENDED SYS1 EN1 (optional) t ®sou� �sou ( ©souIosauI SKu D !t Percolation Tests are NOT required ESIGN RAl-E:�--- II any portion of the tested arc,i is in lhr. - Jndert.H63.09(5)(b),indicate: C L�s S Floodplain, indicate Floodplvn elevation PROFILE DESCRIPTIONS iN '1)ACi/11/ L- Fr. 30RING TOTAL PTH TO GROUNDWATER•Ir\. CEIAFIACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHESI TO BEDROCK IF OBS-RVF.D ISFE ABL311V.ON BACK.) B- S /03. 15 -- > 7 s s ' r�,o 11"Y ' 7 CS G '1?� . , .7S��Qa. S S P' �'• 'P- Co .6 7 ill/ veti,, CS • so' 3 / - 7• S 7 7,fN v cS B- / 9. J1-q ' i�ti v c s G S RN , S ' a. s ; �.i� 0s, B• /O0 . /oy / 7to— >/Q '0 ' 74,4) v cS Ge B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WA1 EH LEVEL-INCITES RAI E MINUTES NUMBER IN AFT ER SWELLING INTERVAL-MIN. PERIOD-t-__ PE_rti.0o 2 P R -_ PER INCH P. .L < I P- P- P. _ P. P. — OLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil arras. Indicate scalp, or distances. Describe what are the hurl ,ontal and vertical elevation reference points and show their location o the plot plan. Show the surface elevation at all borings and the direction and percent of land tloDe• p prl 0-F °/� .)o ;_ 3 � Q ,SYSTEM ELEVATION � ae o /3 o /3 xc FS �` CJ <34 v tS 5 3,5 (3 3s' �, • a t i V . � a TN h � 3 5s 63y 3 SS �j Vin o I '� ibis test site A t s stem. : 10' WT �---,• 7o for a conventional Sept coR�+�P 3y. �r z /00.0 /0,(�o/�oS�v NEW i S�E'c• oc L� I,the undersigned, hereby certify that the soil tests reported.on this form were made by me in accord vrith the procedures and methods specified in the isconsin Administrative Code,and that the data recorded and the location of-the-tests-are correct-to-the best of my-knowledge and belief. NAM print): TESTS WERE COMMPLEI ED ON: ADDRESS: ""` "t" CL �TIFICIiTION N MBER: PHONE NUMBER(optionoll: liUliEl{I U,dlill• it SS- O Z � 2---- 3?60 —Qp/ I C' SIGNATURE: !rt;i N. IPIII%'!i.'.It..{:C=:aG?:r p;Il ?:�i 1}t)r:•i'1 "�-�_ DISTRIBUTION.Otigrnal and one copy to Local L, -a,ity,r poverty O.•:ner and Soil Tester. -OVER -- <- _x - � ;. yi V STMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS STRXDIVISION TRND P.O. BOX 7969 R'RELATIONS PERCOLATION TESTS (115) MADISON,WI 53707 t - 3.09(1)&Chap ter'145.045) LOCATION SECTION:�n�N/R �(or) TOWNSH OT N`.:BLK.NO.: SUBDIVISION N E 5� / S COUNTY: /~ OW ER'S BUYER'S N E: IMAILINU Q_SS: 1 �, t ,Q• USE DATES OBSEfIVATIONS MADE NO.BEDRMS.: COMM R RIPTIO R F N : T STS: esidence ew ❑Replace RATING:S-Site suitable for system U-Site unsuitable for system NV rtosTIa�. ��.�� IN �� Q� . S��YSTEM-1 N-F�L D SG TANK:RECOMMENDED SYSTEM:(o�pt�n��� i If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the P under s.H63.09(5)I b),indicate: Q Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTA DEPTH T 0 GR UNDWA ER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH." ELEVATION OBSERVED H TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) > .']� � ,'t12 BJ/ 1,09 Bns:� �.31 B.►S�gr, ��C3��h(S�Sr, 3� j c� / s;, .33l3.,sf"� S F3 b,n Is A­ y//3 0� an s, , ?.0 4 .A4'6.r s jF, B- 3 1. > S i 1 .1 3WT, ,3 A s. Y2 n5 % 3-0'4n 5-V v PERCOLATION TESTS _ TEST DEPT ATER IN HOLE TEST TIME DROP I WATER L V L-IN HES RATE MINUTES NUMBER AFTER SWELLING INTERVAL-MIN;. I R D PER INCH P- Aof- ,. P III. P- s' t P k P- P 4 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 9S S 3 Lo.'_ 1 11 f I I lo t- � i f 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 i 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 OWERY CO PLETED ON: L 1 V1G-e. CJ/ AD R S: CERTIFI ATI N NUMBER: PHONE NUMBER(optionalF I %b !LAO, �" w W� �✓ l �?J CST S G DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) -OVER-