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HomeMy WebLinkAbout016-1078-10-000 2 , 2 \ 0 2 \ r � . « 0 / � 0 ke � C4 , \o - \ \0 \ � \c '2 2 §G 0 z @8a ® E/LL k » � 7� ek»3 7 )°% � « § a LU E � \ � • & Z . « m n e m ; E . o z 2 } .o k / :!t / CD k £ ( 7 ] 7 V { ƒ -� K3 k § 6 1 Q ) ) k 0 .. } / _ E \ � _ , e e o § : E # § L o a a = OD / k CL 0 0 0 0 k E ° U) \ § } � � 2 m \ \ e 2 � = 0 k � ' r = ) � 2 $ 2 Lo 2 ] k m 3 § o \ : 2 $ / 8 ¥ ; _ & = Egg k § R ) § r- 0 . @ [ - ` © @ . % a \ S / G 0) CD Ed ® � , § = 7 © / m d \ } o z $ z / \ a « k $ k { C - C _ , .. 4 0-] k a § � k J J , . e Parcel #: 016-1078-10-000 03/22/2006 05:00 PM PAGE 1 OF 1 Alt. Parcel#: 35.30.15.536 016-TOWN OF GLENWOOD Current _K 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 VELMA R CROSBY O-CROSBY,VELMA R 1225 RUSTIC RD R4 GLENWOOD CITY WI 54013 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description * 1225 RUSTIC RD R4 SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 35 T30N R15 SW SE Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 35-30N-15W Notes: Parcel History: Date Doc# Vol/Page Type 07/13/2000 626381 1526/345 PR 07/23/1997 367/357 2005 SUMMARY Bill#: Fair Market Value: Assessed with: 89700 Use Value Assessment Valuations: Last Changed: 10/06/2003 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 35.000 4,400 0 4,400 NO UNDEVELOPED G5 2.000 200 0 200 NO OTHER G7 3.000 13,500 163,500 177,000 NO Totals for 2005: General Property 40.000 18,100 163,500 181,600 Woodland 0.000 0 0 Totals for 2004: General Property 40.000 18,100 163,500 181,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 208 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form — STC — 104 AS BUILT SANITARY SYSTEM REPORT Cl'OWNER Q ° TOWNSHIP >�;= 1 SEC. T3-c'-') N-R W ADDRESS A6 X /`7'� ST. CROIX COUNTY, WISCONSIN Ot �j SUBDIVISION /U�Aq LOT r�` LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM z 1 I 1 Ito r 5� 6 -Y)L /drly /ins i 1 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point usedrr� Elevation of vertical reference point: Zr*)/, 9 Proposed slope at site: SEPTIC TANK: Manufacturer: 'CJG ,�S Liquid Capacity: o Number of rings used: Tank manhole cover elevation: _/0 Tank Inlet Elevation/: L5 Tank Outlet Elevation: Number of feet from `nearest Road: Front Side Rear, O 1Z ? feet From nearest property line Front 10 Side,ORear,O /Y7 feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE I PUMP CHAMBER Manufacturer: y Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of Xrom Bottom of tank elevation: Pump off swition: Gallons per cycle: Alarm Manufa Alarm Switch Type: Number of feearest property line: Front, O Sid e, O Rear, Ft.er of feet from well: f feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: X Width: � r Length: / Number of Lines: 04J Area Built:Vz Fill depth to top of pipe: h 3(9 " Number of feet from nearest property line: Front, Side, Rear, Ft 0 0 Ai— Number of feet from well: Number of feet from building: 26 �Z�'� (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid de th. Bottom of seepage pit elevation: Area B ilt: 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 Xsuoed: Elevation of bottom of tank: Elevation Number of ne arest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: �J Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 3/84:mj E DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS O. DIVISION P. BO&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 State Plan I.D.Number: SW'a/,SE14,/ S35,T30N-R15W CONVENTIONAL ❑ALTERNATIVE (11 assigned) Town of Glenwood ❑Holding Tank ❑In-Ground Pressure ❑Mound stic Road NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DA Bob Crosby Route 1, Box 177, Glenwood City, WI 54013 ( 0- 16— BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN'. REF.PT.ELEV.: CST REF.PT.ELEV.. EPlumber MP/MPRSW No.: County Sanitary Permit Numberyle J. Myers 6219 St. Croix 112665 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.'. ITANKOUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. DYES ONO ❑YES ❑NO BEDDING. VENT DIA.. VENT MATL.. HIGH WATER NUMBER OF ROAD'. PROPERTY WELL: BUILDING VENT TO FRESH ALARM FEET FROM LINE Z AIR INLET OYES ❑NO ❑YES ONO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOC KING COVER PROVIDED'. PROVIDED'. DYES ❑NO ❑YES ❑NO DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PR OPE R TV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH NO.OF D COVER INSIDE DIA tPITS LIQUID BED/TRENCH TRENCHES MATERIAL PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH UISTH.PIPF DISTR,PIPE DISTR.PIPE MATERIAL. IN DISTR. NUMBER OF PROPE RTV WELL BUILDING VENT LE FRESH BELOW PIPES ABOVE COVER ELEV.INLET ELEV.END. PIPES. LINE AIR INLET FEET FROM NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM 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 ONO SOIL COVER TEXTURE PERMANENT MARKERS JOIIIEHVATIIIN WE 11 ❑YES 1:1 NO 1:1 YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =PSOIL SODDED SEEDED MULCHED CENTER EDGES DYES ❑NO OYES ONO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKIN(, ELEV.. ELEV.. DIA. ELEV.. PIPES DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS LIFT CORRESPONDS TO APPROVED ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS'. NUMBER OF PROPE PITY WELL: BUILDING. FEET FROM LINE ❑YES El NO OYES ❑NO INEAREST- q) 0 \ �.03 Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE DILHR SBD 6710(R.01/82) Zoning Administrator DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code �v f STATE SANITARY 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. PETITION [� I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES L�SI NO PROPE OWNER PROP jRTY LOCATION SLU'/a5L'/4, S 1:5 T N, R � E (or(W PROPERTY OWNER'S MAILI ADDR SS LOT NUMBER BLOCK NUMBER SUBDIVISI0 NAME / ,�>`t tea` CI Y,STATE 4AJ +S ZIP CODE3 PHONE NUMBER 7n CILLAGE N S n c- &/4 LANDMARK ITY II. TYPE OF BUILDING OR USE SERVED: • kjQ-7,V © —`A Number of Bedrooms if 1 or 2 Family e-� &A29"O/" OR ❑ Public(Specify): C�v III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a.>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. ,Conventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tan k V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b. ee a e Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABS RPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch)- REQUIRED(Square Feet): PROPOSED(Square Fe t): 9�` � r �--' -, Feet Private Joint ❑ Public VI. TANK CAPACITY Site in gallons Total #of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks ��''"" strutted Septic Tank or Holding Tank 60D06 — .0(0,9 L,yvL El 1:1 Lift Pump Tank/Siphon Chamber ❑ ❑ I ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system h2WLon the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/ PRSW No.: Business Phone Number:19 Z IS Plum is Address(Street,City,Alate,Zi od Name off Desig er: xe 'r C c cs' ) Z v� �c� VIII. SOIL TEST INFORMATION Certifie Soil Tester(CST)Name CST# CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Saar(Permit Fee Groundwater ate Is ing Agent Signature(No Stamps) Approved F-1 Owner Given Initial 11//e`�.(�V^` �hArge Fee Adverse Determination co 1W! L X. COMMENTS/REASONS FOR DISAPPROVAL: V SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber i 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 permit must be approved by the permit issuing authority. A new permit may be needed 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. Changes in 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 licensed 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 owner's 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 DILHR; 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 81,2 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; 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 form. 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 bill Ground included the creation of surcharges (fees) for a number of regulated practices which Wiscor4irt'S ° can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasrie 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 --f�'-eat 4 Location of Property e� �4� ' Section 3J , T ) N-R�— W Township 4_z Mailing Address J Address of Site Subdivision Name Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes X— No Volume 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 pagje number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) ce&a6y that att statements on this 6onm ane tAue to the best ob my (out) knowledge; that I (we) am (ate) the ownet(,$) o6 the pnopenty du ni.bed in th.ivs in6onmation botm, by viAtue o6 a wa�ftanty deed tecotded in the 066ice ob the County Reg.ustet o5 Deeds as Document No. `: (,� l�-:I - , and that I (we) pnesent.2y own the ptoposed site Got the 6ewage duspo�sat s y (ot I (we) have obtained an easement, to nun with the above deg n bed ptopenty, bon the cowsttcuction o6 said bydtem, and the same has been duty teco&ded in the 046ice o6 the County Register o6 Deeds, as Document/No. �) . SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) . _ l� L )AT! SIGNED DATE SIGNED '' III lra.8.2. Warranty Deed—.Common Form (STATE OF WISCONSIN) h4111shed by tail 01alin 8"k a ita$ooerr Go. —By Corporation. (Sea 286.16,Wis.Statutes) Form It 2 I' 75 ' sou FNcE. - C�t�t� ]dPitfurP, Made this 26th day of April ,A.D„19 60 , between BERNARD-WISCONSIN FARM DEVELOPMENT CORPORATION- - - a Corporation duly organized"and existing under and by virtue of the laws of the State of Wisconsin, located at Eau Claire , Wisconsin,party of the first part, and • ROBERT D. CROSBY and CARL J. CROSBY- - - parties of the secon:l part. tl itntoilttb: That the said party of the first part, for and in consideration of the sum of One Dollar ($1 .00) to it paid by the said part ieg of the second part,the receipt whereof is hereby confessed and acknowl- edged, has given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by ii these presents does give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said ! part ies of the second part, their heirs and assigns forever, the following described real estate, I' situated in the Count of i Y St . Croix and State of Wisconsin, to-wit: South One-Half of South East One-Quarter (S' of SEu ) jig' of Section Thirty-five (35) , and the North West �, ; ,�F' One-Quarter of South West One-Quarter (NW4 of SWu) Section Thirty-six (36) , all in Township Thirty North (30 N) Range Fifteen West (15 W) . � I IYY:iI 11, — -- � This deed is given in fulfillment of a certain r( � land contract recorded in Volume 348 of Deeds, _ page 469 - - oSetE}C> with all and singular the hereditaments anti `urn �rtenances thereunto belonging or in anywise ,II appertaining; and all the estate,right, title,interest,claim or demand whatsoever, of the said party of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained ICI premises, and their hereditaments and appurtenances. ii ZU 11abt anb to POO the said premises as above described with the hereditaments and appurtenances, unto the said part ies of the second part, and to their heirs and assigns FOREVER. aiibt�ft %aib Bernard-Wisconsin Farm Development Corporation- - Ij party of the first part,for itself and its successors,does covenant,grant, bargain and agree to and with the said parties of the second part, their heirs and assigns, that at the time of the ensealing and 'I delivery of these presents it is well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law,in fee simple,and that the same are free and clear I from all encumbrances whatever, I ' II and that the above bargained premises in the quiet and peaceable possession of the said part ies of the second part, their heirs and assigns,against all and every person or persons lawfully claiming the whole or any part thereof, it will forever WARRANT and DEFEND. lIn Uiitntoo Wbertot, the said Bernard-Wisconsin Farm Development Corporation party of the first part,has caused these presents to be signed by Eugene B. Casey its President, and countersigned by Dorothy H. Roos , its;$ecretary, at Eau Claire , Wisconsin, and its corporate seal to be hereunto affixed, this 2 �, it day of April ,A. D., 19 60. t. BERNARD-WISCONSIN,. FARk,�bEVELOPMEk!�• ,Sip-ned and Sealevii Presence of CIORFOTM'I"T 7 """"- »»"-""`- -' i� CO orate Narhe xI ............ - ..»............... ... ».». ................-.........................».. < President, .V Geo. Y. King Eugene B. C-a eV Countersigned: « �. Secretary __ Ione Bruss Dorothy H. Roos Drafted by Geo. Y. King i) (N-13--Ch.69 Wis.State.provides that all Instruments to be recorded shall have plainly printed or typewrittau tharaoa tAa rimer of the`ntiltbrs rrantees,witnesses and notary.) I!� Watt of Mt0Conotn' EAU CLAIRE ss. County. Personally came before me, this 4th day of May ,A.D., 19 60 , Eugene B. Casey ,President,and Dorothy H . Roos ,Secretary of the above named Corporation, to me known to be the persons who executed the foregoing instrument, and to me known to be such President and Secretary of sai Corporation, and acknowledged that they executed the foregoing instrument as such officers as the d e. of said Corr aon,by its authority. Ii • ..«..........� .. ...w........ ..................L.......`, /..................................................... r. �ze.R.......X.......King............6...........6............ �.... Notary Public, Eau Claire County, Wis. My commission jg7�y� AJC�XJC�C 110 is Permanent . CU Od III I � O �ch fZ: EE Ov -Cj .� 'ti q O U, U � h tit Q ' O i °o CU w dl W W $4 w � o • z cn H a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT H 0 St . Croix County z d a OWNER/BUYER U M ROUTE/BOX NUMBER e-/C- # — 13, 7 Z Fire Number � J CITY/STATE ZIP 3 f PROPERTY LOCATION: ,L�;4 SE 14, Section , T U N , R _W, Town of L"✓t St . Croix County, Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists of pumping out the septic tank every three years or sooner , if needed , by a licensed septic tank pumper . What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix. County residents m_ y be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1 , 1978 . St . Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained . The property owner agrees to submit to St . Croix County Zoning a certification form, signed by the owner and by a master plumber , journeyman plumber , restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary) , the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- "u ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Office within 0 days of the three year expiration date . /J SIGNED 4'�� ) DATE 0 St . Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address . DEPOTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, 1 C DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTIPN: T_OWNSHIPtff L O.:BLK.N .: SUBDIVIS O ME: Ld/ 1/ _ .`a /T31)N/R 155E (o ►W Al LINT o OWNER' E: ILING DDR SS: USE DATES_OBSERVATIONS MADE NO.BEDRMS.: COMMER l/D CRIPTION: PROFI E DES �'PT ONS: ERC L 10 S3S: esidence New ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system CONV�YtTIOaNAL: MOU S.OY IN-GR❑OUNDPR�iRE: SYEI S IN- yL H �G TA� : R�� { `�/� L(optional) a _ u JJ DESIGN RATE: uu J�`i < If Percolation Tests are NOT required I If any portion of the tested area is in the !) under s. ILHR 83:09(5)(b),indicate: It Floodplain,indicate Floodplain elevation: ,u( PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) f✓�I C7�J<< �� �J S A2 �.S r B_ a 2e lu_ a �� s .r� 0 n s r /v � Si � r�s B > r / d/ eC/S �9 r S) , 13 8"45 /z4/ 1251 B- 76 �'3 I� > 7 �r9 e d s d B- 7 K n 'S/ 6- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PE I D 1 PE I D 2 PER D PER INCH P-C92 P 3d `i ,33r6 r P_ P_ 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 theetoA pla . Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 3a� �_E p_ -5 / P-3 0-3 AL janmethods 7?I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord ith the proce ures s ecified in the Wisconsin Administrative Code,and that the data recor d and the location the ests are co rect to the best of my knowledge and belief. 9L �I _ NAME (print)� n� J TESTS C�OMPL TED ON: �4/ /z— ADDRESS: CERTIFICATION NUMBER: NUMBER(optional): F 0-1- a c2 CST G ATUR e DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR SBD 6395 (R. 10/83) —OVER — ' . ' . � ' INSTRUCTIONS FOR COMPLETING FORM 115 ' S0D ' 6395 ,T� b*� unm��oanda�umtomi| ��'your ,:�� mu� include: ��~ legal � .� ��m��� �p description; 2. The use section must clearly indioAt vihethor this ism residence nroommexio| pnjoct� 3, MAXIMUM number oY bedrooms orcommnrcia| Lisp piannvd; 4, |o this m new or replacement system; 5. Comp|etmtMeo"itubi|itvmdnoboxeu.AS|TEISSU|TABLE FOR /\HOLD|NB TANK QNLY /FALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6, PLEASE use theabhrPviations shown here for writing, pro,"ile clescriptionsand, completing the plot plan; 7 MAKE A LEGIBLE diagram aoou,mt*|y {oondnn your test \ooazim`v. Qmvvin8 to 000ic is preferred. 4 separate sheet mmy be used if desired; 8, Make sure your benchmark and vertical elevation reference point are clearly shvvn'and ate permanent; 8, Complete all appropriate boxes as zod/ueo'names'aUdromnas'flood plain data,percolation test o^emp' lion' if appropriate; 10, If the information (such as flood n|»in'elevation)does not apply, place N�A. in the mppropriate box; 11. Sign the form and place your ourert address and your certification numbe,; 12. Make legible copies and distribute as requimd, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OFCOMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols m — Stone (over 10") 8R — Bedrock cob — Cobble (3 lO^) SS — Sandstone g, — G,uvv| (Linde/3^) LS — Limestone °o — Sand HGVV — High Groundwater co — CuumoSand Pnm — P*mo|adunRuta nnwdv — Medium sand VV — Well fo — Fine Sand 8N8 — Building |o — Loamy Sand — Greater Than 'd _ &mdy bmm ( _ Less Than � ~| — Loam Bm — Brown °si\ — Sill: Loam, 8| — Black si — Si|z Gy — Gray °cl — QayLoam Y — YoUos sc Sandy Clay vv/ vvith sic Silty Clay fff few, fine, faint � ~ °.~ (11 C common, ~...~~ � � '^ _ . ~.^ r^.. ..., medium — ---' - --'— � ~ ~....`.` ''",L — High water level, Six peneral soil tex';ures surface Water fov liquid vvaste disposal BM Bench Maik VRP Vertical Reference Point TO THE OWNER: This soil test'report is in(,,first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local,authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction, ° 5(,j '1e sc ��� 2 6ox t Y 0-777 o A) ci cgo Z) Q,-r- 6it's A)lp- 1 :5- (-Ij . �o 13 `l ?(tug dC� tl Z zo y ac-(-)t LLCM, W r S ZV72 S- P�cs 0 63.4 alz-cs Ll v Om A It f�ous r q wz o rr-o �Z ado Q �1 C i