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HomeMy WebLinkAbout020-1210-60-000 M ~ O 69 o� a a 0 w � � I °o I N � I o I Y � � I i I CL CL I .'j � � I N a) C z V7 7 to p� LL o Q c I I M � � I w z •' rn z :_ c Ix Z m mci IL o o z c u 95 — 'o - W H �= c Z S E .O 0 ` N N 7 a7 y CD U) a) y C •taw d _ Q z m z N 0 Z w E p° N m CL 'R .mob a) ,n 3 y m ) 4 °O c c a N a H H N = 2 o I m O O a in o z IL IL IL FL LO 7 p N °° co (N J V rn rn Z ti o o v c = a0 0 d m N C) E N O N y C p y 0 O �+ N 7 r O ° o LL w c co 0 Oo 0 3 m d m o cfl � a) — c v d {, O Cnl O C N O O C U) C, C O C O N I t"i r O y d a) V C = co It • � O CN r = O Z z H (n \ it m v C/� y t6 i d ~ +' # G of .� CL IL o ST. CROIX COUNTY WISCONSIN �' '�"`�` ~-t - 4• mi''`l ZONING OFFICE I�Bgllllllr■ rrrr6 ST. CROIX COUNTY GOVERNMENT CENTER �,;,• 1101 Carmichael Road f --_ Hudson, WI 54016-7710 - (715) 386-4680 V- - /?Ff July 17 , 1995 0 2 2,16-6& — Q� Sam Miller P.O. Box 282 Hudson WI, 54016 RE: Water Test Results - Address: 988 Fern Road, Hudson, WI Lot 6, Parkway Addition, Town of Hudson Dear Sam: Enclosed is a copy of the water test results for the above described property. If we can be of further assistance, please do not hesitate in contacting our office. Since ly, S— es K. T ompsbn Assistant Zoning Administrator St. Croix County, Wisconsin db Enclosures COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715 - 962 - 3121 'f 800 - 962 - 5227 FAX - 715 - 962 - 4030 8 9 ST. CROIX COUNTY ZONING OFFICE REPORT NO.: 87714/ 40`` �� PAGE 1 ST.CROIX CTY GOV.CTR REPORT DATE: 7/1 �� 1101 CARM{ICHAEL ROAD DATE RECEIVER: 7/0 /Ln HUDSON, WI 54016 ATTN: THOMAS C. NELSON &�, OWNER: Sam Miller LOCATION. 986 Fern Rd., Hudson COLLECTOR: Jim Thompson DATE COLLECTED: 7—O�.r-95 TIME COLLECTED: 11:OOam SOURCE OF SAMPLE: Outside tap 'k DATE ANALYZEU: ST. CROIX COUNTY WISCONSIN ZONING OFFICE 1 N M N 11 M r r�rri ST. CROIX COUNTY GOV ENT CENTER 1101 Car I ;. Hudso (7 6-4680 SEPTIC INSPECTION / WATER TEST REQUE .7 VR , :" 00 O Please specify desired test(s) & remit appr"-k,i w' application. Outside water lines are often t offO'du winter months, making access to the home necessa ' lea e arrangements with this office to insure that entry d. ❑ Water VOC's ( ) $185. 00 ❑ Se P tic $50. 00 Water (Nitrate & Bacteria) 45. 00 0 Nitrate & Bacteria retest $15. 00 Owner: M /lli�le'r Requested by: M iAA me c-, ri� / Son ail Address: 0. 6 0 X Ta Address: &00 -;? 5f 0/1 ZIP 510/ dS o✓1 u-)-r- ZIP 570/(v Telephone N°: ( ) Telephone N4: ((-7(5 Property address (Fire N° & Street) : 5'�16- n l�� • ` OA WI 5y0/b Location: ;, � , Sec. , T N, R W, Town of 50011 L6f(o, P�iuc�y dd�i�pn Ir, dson Realty firm: Lo VLO - ✓l..o Lock Box Combo: Closing Date: z / TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Water sample tap location: 00-�s i 0(k Is the dwelling currently occupied? ��-R Yes ❑ No If vacant, date last occupied: auf�' ena,,,U C re 0n) IwAa o-Kzdt a Age of septic system: Septic tank last pumped by: Date: Previous Owner's Name(s) : Have any of the following been observed? ❑Y ON Slow drainage from house. ❑Y ON Sewage Back-up into dwelling. ❑Y ON Sewage discharge to ground surface or road ditch. ❑Y ON Foul odors. Other comments relative to system operation: Y I certify that the above information is complete and true to the best of my knowledge. OWNERS SIGNATURE: DATE: 1/94 i OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION 1N TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? ❑Yes ❑No Soil series per SCS Soil Survey: sheet # Type of soil absorption system: ❑Below grd ❑At-Grd Mound Approx. size $ X ❑Gravity ❑Dose ❑Pressurized Ft. z ❑Bed OTrench ODry Well Molding Tank OOutfall pipe OBSERVED DEFICIENCIES ❑Other ❑Unknown Septic tank Setbacks: OHouse OWell ❑Prop. line ❑Other Dose tank Setbacks: OHouse OWe11 ❑Prop. line ❑other ❑Locking cover OWarning label OPump/Floats OAlarm OElec. wiring Soil Absorption System Setbacks: OHouse ❑Well ❑Prop. line ❑Other ❑Ponding: ODischarge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title I Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER �j a W� ° � TOWNSHIP; SEC. 1(� T. ?c:LN-R. ADDRESS B oXZ Z ST. CROIX COUNTY, WISCONSIN SUBDIVISION rC ��y LOTS LOT SIZE Z-�/2 /�c¢K PLAN VIEW 9 Distances and dimensions to meet requirements of I•ZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM " /O L.2t -P:p c. S to vKUr t- = IOO.Q S Nou 5c y2y 43 rod / INDICATE NORTH ARROW i BENCHMARK: Describe the vertical reference point used / Elevation of vertical reference point: 166.0 Proposed slope at site: s-, vi, SEPTIC TANK: Manufacturer: _a1'-8tk Liquid Capacity: 1-ma 64.x. Number of rings used: Tank manhole cover elevation: .Os= ZQ Tank Inlet Elevation: -7.295 Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side Rear, O feet g� From nearest property line : Front 10 Side,0Rear,0 7z "" feet Number of feet from: well (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE j ~ L PUMP CHAMBER Manufacturer: .� Liquid Capacity: A 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 liner Front, OSide, ORear,© Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: / Lendth: g_e Number of Lines:_y Area Built: 4VfSf97' Fill depth to top of pipe: I/.>- —'-T'- Number of feet from nearest property line: Front, Side, 0 Rear,0Ft •219_ i Number of feet from well: Number of feet from building yZ (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 0 or distribution box 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: Dated: Plumber on job: License Number: - 3/84:mj f i 1 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS DIVISION LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O.BOX 7969 MADISON,WI 53707 NW,14 NE'4, S16,T29N-R19U1 CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number'. (If assigned) Town of Hudtson ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 6 PqAkwatf NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam MiUeA RrJwte 1 Box 282 Hudson W1 54016 BENCH MARK(Permanent reference pomq DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT:ELEV. Name of Plumber: MP/MPRSW No.: Coumy: Sanitary Permit Number'. Dou &6 Stuhken 54a 119740 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY'. TANK INLET ELEV.: ]TANK OUTLET ELEV.. FROVIDEDLABEL PROVIDED OVER DYES ❑NO DYES ❑NO BEDDING'. VENT CIA.. VENT MAIL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING. VENT TO FRESH AIR INLEE ALARM LINE: T FEET FROM DYES ❑NO DYES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER JBIDDING LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL ILOCKING ROVIDED OVER DYES ❑NO ❑YES ON O DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING JVENTTOIHLS" LINE AIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH JIAMETER MATERIAL AND MARKwc, 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 DISTR.PIPE SPACING COVER INSIDE DIA 'PITS LIQUID BED/TRENCH TRENCHES MATERIAL PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FHES/1 BELOW PIPES. ABOVE COVER ELEV.INLET ELEV.END. PIPES FEET FROM LINE. AIR INLET 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 ❑NO PERMANENT MARKERS OBSE RVAT SOIL COVER TEx7URE ❑YES ❑NO : YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. ❑YES El DYES 11 NO ❑YES ❑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 INO DISTR DISTR PIPE DISTRIBUTION PIPE MATERIAL&MAHKINI; ELEV.' ELEV.. DIA.. ELEV.. PIPES DIA.. ELEVATION AND DISTRIBUTION INFORMATION MOLE SIZE HOLE SPACING. GRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ONO DYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS'. NUMBER OF LINE.ERTV IWELL: BUILDING. FEET FROM ❑YES ❑NO DYES El NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE. i DILHRSBD67101R.01/821 Zoning Admin.tAixton I DILHR SANITARY PERMIT APPLICATION COUNTY ���� In accord with ILHR 83.05,Wis.Adm.Code ° STATEJrSANITARY_PEFj�IT# -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PPLANN I.D.N7��7`// 8%x 11 inches in size. -See reverse side for instructions for completing this application. TiTION 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE 1:1 YES 1 9 NO PROPERTY OWNER PROPERTY LOCATION S, �q,e Al W A E '/4, S 1(0 TQ7 , N, R 11 E(orp PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME tL* I L 0 K"# z.1 Z Ife 1 ar wQ CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,4.AKE OR LANDMARK USX- ` ��10 ���� VILLAGE: is H -A 6v�. TOWN OFm is C� /C II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): t; HI. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) _. ri 1. a. New b. ❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of as System System Septic Tank Only an Existing System Existing SyslgT-- 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. c 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) j 1. a. Conventional 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. seepage 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): c �g 7 7. Feet 14 Private ❑Joint ❑ Public CAPACITY Site VI. TANK in allons Total #of Prefab. Fiber- Exper. Manufacturer's Name Con- Steel Plastic INFORMATION New xisting Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holding Tank ©� Wn�S ❑ ❑ I El Lift Pump Tank/Siphon Chamber ❑ El 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). MP/MPRSW No.: Business Phone Number: Plumber's Address(Street,City,State,Zip Code): Name of Designer: V-Rst.3 kf`o.AZ V,at-ml,,e',2. VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name ` CST¢# t) R- C\,k-a CST's ADDRESS(Street,City,State,Zip Co ) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee #A5,(fk)undwater ate Issuing Agent Signature(No Stamps) charge Fee XApproved ❑ Owner Given Initial ( ' �a ���� �} ,Adverse Determination ( // , X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber i I 1 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 thq.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 ro er1 maintained:The septic tanks should be um ed b licensed' , 9 Y P p Y P O {1 a P Y 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 .: tr included the creation of surcharges (fees) for a number of regulated practices which Wisco ilW. can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure is used in your building is returned to the groundwater through your soil absorption o 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) n T APPLICATION FOR SANITARY PERMI 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 Icy"�OX Location of' property N UJ 1/4 k 1/4, Section �� , T Township 4 &•S0V%_ Mailing address -KZ--0- I cMo)( -*- Z 1KZ Address of site sfca,,,,, 11k..-- G:/c-/ Subdivision name—ar- k I AJQ- Lot number Previous owner of property khc s Fern Total size of parcel 246 14 FMS Date parcel was created 14' Are all corners and lot lines identifiable? —Yes No Is this property being developed for resale (spec house)? Yes-**� No Volume TD,and Page Number-�:��as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ---------------------------------------------------------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. .S--$ 5t_Z ; 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 r c rded in the Office of the eCCounty Register of Deeds, as Document No. ) . Signature of Owner Signature of Co-Owner (If Applicable) !E -A ` b Date of Signature Date of Signature I ;fin. a C .««»..w......•...... .. aad waeeaale M »lea.,lllll�a>e,.+a..ainSLa,.p�t�o..»....»... � , 145. �4► .., »...............wNt•. .»....».»...........•..�....•.......... ».» .•••..+M»»w..w•.w..........................•s.ww•.....«... .......... r...•..........«•. •.•.••........ ...................... .......................... ..»ww ........ ,.6 1 «• •. w....w....••••h...•.•.•• •... » ........................ .......... M it of dneelled y 1w sftb h« �Lw»l ip.... •••••.••.t.'OrOgr• ! . 'Tm Ta ld Ifni ' Of, ebe NOrtlMaat 8t. 9NMOr of S MU M 169 loMn aip`2eg*' OMtl; MiaoaaNa QCZn LOW,l tMro"A ♦e n iabfr _iw ` 23 498 `to Vol "S , ��t3ed�Julp , "� PoM 14�7e Ooo. No. �Mt io`.dls D #� of ftftsQts r COMeOaata dated tebroary 13."1m;& Doff ��' OKiaees of Oohs vo Iabsoary 18, 1985 in Va., 7068_tap ; .1',. ''" �aat`to nowsalwiw oaoOMMsto of record for tine of the 66 toot road Mal the above aantiomm Cartitl+�d SU Mar Map• '0 A" tbr'tartition. Tnn k=opt batwaa the State of Miaconain 1:Nao�tsoa mad Ms3W Tiro dated September 13. 1979. seoosdad . P Me;2i; 197!'!a'Vol. "601" Pap 639. Does No. 360128 for the maintomroe of; betwaM str 8M k of on k of seatioa 9-29-19 emd M k of a k Of 1i-69-19• ,- .;� � q l AfI M ..♦ ..... �1 �Nba N raenbbet : FEE 7 r .............• of ...•. . ' N rim ...... ........f 11 f t"h ......................... (aSAL) ' ,AdOiE11L� t .(SEAL) ..l..Ati .. .(S!�►L) e ` «».. .............. t ............ . ....... ......... 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Roth )Kr G+mndewk►n b L� expire�jlee �• date: .................... 1 '1••1 ewe/ at eew.er f�ere M eer fee.ew fhwq M � M _ ____ _.... • 4fM.l M Aria.d lnr.tlrfr flf..Wns. ��" +. NTAti DA%Or W;LjW fdtlr $ tF ::, • ^$ �, irON1�N� e.I.q Mrd wive least C. � • STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER �c L - ROUTE/BOX NUMBER __ 2 I `6 Z- FIRE NO. CITY/STATE Ck y-I So yt- liV= ZIP PROPERTY LOCATION: A1014 i 1/4, Section , T : c N, R W. Town of �JUA.Sa v'-_ Wes- , St. Croix County, Subdivision�a V- (.osc=V , Lot No. <P 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. SI 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 = 1 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS INDUSTRY, C DIVISION ' LABOR AWD PERCOLATION TESTS (115) MADISON WI 53707 ! HUN(AM RELATIONS < (1-163.090)&Chapter 145.045)TOWNSHIP OT NO.:B .NO SUBDIVISIO N AM t 1/ �/ to /U N/R1 Ito 6 U1.4 i�- us LINTY: W E 'S BUY R'S NAME: MA A O IL ` /tft.•c vI`p /� f0 t S 4 _ DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DE 'ERCOLATION TESTS: �Rasldence New ❑Replace _ y rJ 6- �, 1 SaD r'/MAC' S/Q v � ;i RATING:S-Site suitable for system U-Site unsuitable for system (, S S 111'e .0 j i [ONVENTIONAL:� �� IMOUND:� Q� IN G�� ❑� D� -1 -FILL �ING TANK:RECOMMENDED SYSTEM;(optional) ' � • If Percolation Tests era NOT required DESIGN RATE: If any portion of the tested ar he 4q,(§)p t antler s.H63.09(5)(b),indicate: Floodplain,indicate Floodplefn elevation: PR FI E DESCRIPTIONS r � a BORING TOTALf 3U1 D ATE ARACT O IL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER SLEVATION OBSERVED TO/BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B /. 3 B� /, . Y 8.� /s, /•T Bh wed s, 1 /. 9'0,v i, ,3 /s, .2..3 ah � S, is'0/1, 40AU1 An S' •7 B//, /• On /, • a��n /t� /•9 Ba M aC,/S, &J ?. � O •0' orue 7 �•s o Y PERCOLATION TESTS T%A D PTH� WATER IN HOLE TEST TIME I H RA MINUTES �N 'M&S� AFTER SWELLING INTERVAL-MIN. PER INCH P 6 III a P. "k` PL 0,T 0:4w'Show Ioca`tlons of,percolation tests, soil borings and the dimensions of Suitable soil areas. Indicate scale or distances. Describe what are the hori- to vertical elevation reference points and show their location on the plot plain. Show the surface elevation at all borings and the direction and percent of lagdsippe.': I SYSTEM ELEVATION - ,L `IS� oZ ,S l.• - r .. r � I � Nt j , --�- i .... .�.*' Ass Q� .E��I_-/alaad W ♦ �/� _ tH ,r\\r \�O I S Y f r t{ / r i 7 1 9 S � L i �._ 1,the undersigned,hereby certify that the soil tests reported on this form were made by me In accord with the procedures and methods 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, k NAME(print): , TESTS WERE COMP LETEp ON: ". � ^ dye i e r ,� 4 s l Q lie ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional). J r lie SO S. -CY0/ao /S-? 7/S- � us CS ATURE: ,•i Jriginasf and one copy to Local Authority,Property Owner and Soil Testae. r5(R.02/82) —OVER— ; - j 5 1-z kv,, i. 2 VcVT + N 4r Pa;4 ��� s E ff--f11�0 1 C_O J Y.a✓ �f.� \ O UO a Q 'r/ 1 a A S .S t,,,h1 4-K PE 1. /0©. / - _ s�ff� 16 td fJCJ b 0 v tf a n h r h �1 Ali r" fbatrajt f{ay�sa �fl1f-18��1� r t a5/KLy a[Y'/'Y © /O Its B3 Soart l dt 1 i w� S.4 s $taw Q v1 v I a6 0. 4. Aa- -� 6 • M µ q � �t � � d .. d N c9 o- c .00 H r