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HomeMy WebLinkAbout020-1190-50-000 c Nt 0. O 0 o vo I N "' mo O 2 Mn CD v w« I d o y q v (D 6 a) a r a u � o I f0 y '—J U c Z O E L LL CO (6 �p 3 = M=—O -o ° E c O°' I ¢ 3►- in I CD Z W c" z a m 0 o z v w N Z c Z Cl) I � N .r- :3 u1 C d L O c O o ¢ c z z D o Y m z O) QCl 3I N C {a E O c N �' J 6 w N C N N d N N O_ O C d a L @ co N N N � o O if In OOO Z IL n. a 00 00 I •� V� J U rn rn Z v 0 2 ao rn O N _ 0 0 — v E � m � a I 9 y a - v °—' a) z cn m c m — a � � .9 I uyi c w O t N — — E O O to Fy O O to L� O � 3 C U a Qj p r G o E o c � N `° o c FN N N N E C L T O (=xi N O •� O N = Co z C C� � I h a ` d • a m ;2 m E c r- 0 rrww _1 A cao o (a0 Parcel #: 020-1190-550-000 12/20/2004 03:53 PM PAGE 1 OF 1 Alt. Parcel M 21.29.19.1196 020-TOWN OF HUDSON Current ❑X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner * DAVID E&COLLEEN A KROMER KROMER, DAVID E&COLLEEN A 512 LANDING CIR HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *512 LANDING CIR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.004 Plat: 2133-JACOBS LANDING 1ST ADDITION SEC 21 T29N R19W SW 1/4 LOT 13 JACOBS Block/Condo Bldg: LOT 13 LANDING 1ST ADDITION 2.004 ACRES Tract(s): (Sec-Twn-Rng 401/4 1601/4) 21-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 952/77 2004 SUMMARY Bill M Fair Market Value: Assessed with: 49236 196,000 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.004 30,000 121,600 151,600 NO Totals for 2004: General Property 2.004 30,000 121,600 151,600 Woodland 0.000 0 0 Totals for 2003: General Property 2.004 30,000 121,600 151,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 112 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 Form - S T C ... 104 AS BUILT SANITARY SYSTEM REPORT OWNER i 116Y TOWNSHIP SEC. Tla-1 N-R±-7 OW ADDRESS �� z�Z, ST. CROIX COUNTY, WISCONSIN SUBDIVISION acn� I LOT l 3 LOT SIZE a S PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM W*4 F ' w —1- i a O l3 -Iff X S lV L I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Z"%ate S,(,j�j�`� Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: ^JJ) %S4- ' Liquid Capacity: Number of rings used: Z Tank manhole cover elevation: r Tank Inlet Elevation: 7 Z Z Tank Outlet Elevation: � , g Number of feet from nearest Road: Front,0 Side, Rear, O feet From nearest property line Front 10 Side,//////��O' Rear,0 feet Number of feet from: well S3 , building: ) •� `g �f/o r., 94)oaf n— (Include this information of the above plot plan)( 2 reference dimensions to septic tank)' , L SEE REVERSE SIDE I PUMP CHAMBER Manufacturer: Tl" 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,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: ?3 Trench: Width: �� Length: 2 Number of Lines: Z. Area Built:�a S% Fill depth to top of pipe: L/ 2 i Number of feet from nearest property line: F�nt, O Side,Rear,O Pt .S Number of feet from well: `7k i 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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: dk4r7 p p License Number: I 3/84:mj • DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 NW,, SW4-, 21, 29, 19W CONVENTIONAL 1:1 ALTERNATIVE IS,,,,Pam il,D.Number Town o6 Hudson ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 13 Hanbetc View Road NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER. INSPECTION DATE: Sam MUen Route 1, Box 282 Hudsson, WT 54016 � 9-�� i 3°O 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: Doug Stnohbeen 5432 St. Cnoix 112691 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV_ WARNING LAB L LOCKING COVER PROVIDED: PROVIDED. ��,� _7 YES ❑NO ❑YES NO BEDDING .. VENT DIA.. VENT MATIL HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING 11INTTOFRESH ,y ALARM LINE AIR INLET - JJ FEET FROM (` � C" t_ ❑YES NO �.r.L ❑YES ONO NEAREST I�. �J DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY JPUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO OYES ONO DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMB R O LfIN RTV WELL JBUILDIN(, AIR NLOTHESH (DIFFERENCE BETWEEN FEET O / PUMP ON AND OFF) DYES 1-1 NO NEAR T SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DI 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 DISTR PIPE SPACING COVER INSIDE DIA 'PITS LIQUID BED/TRENCH TRENCHES MATERIAL: PIT DEPT DIMENSIONS l 5S E"' 0' GRAVEL DEPTH FILL DEPTH [Q!TV P IPF DISTR.PIPE DISTR.PIPE',MATERIAL. NO.DI TR. NUMBER OF PROPE RTV WELL BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER. .INLfET� E� E D I� PIP FEET FROM LINE AIR INLET l( 1 ..� NEAREST 1U �5 �S T 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 ANENT MARKERS OBSERVATION WELLS PERM OYES ONO 1:1 YES El NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. . DYES ❑NO ❑YES ❑NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. No.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTHIBU T ION PIPE MATERIAL&MAHKING ELEV.. ELEV,. DIA.. ELEV.. PIPES In IA.'. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS —]YES LIFT CORRESPONDS TO APPROVED 1:1 YES ONO ❑YES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING. ^ ET FROLINE t+t` ❑YES 1:1 NO ❑YES ❑ F NO OD I /p a� Sketch System on Retain in county file for audit. Reverse Side. SI URE TITLE � Zavi ing Admiwusc DILHR SBD 6710(R.01/82) crtan i ILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code St. cu ix STATE SANITARY PERMIT# 112691 -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 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES © NO PROPERTY OWNER PROPERTY LOCATION Sa_10% M; It c.✓ A /tij X., S T..'2 , N, R E(o W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NArME e dL- CITY,STAT ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK w ,.}. ❑ VILLAGE : ..S bar •�j R—e II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family _3 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. X 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.Pyconventional b. ❑Alternative c. ❑ Experimental 2. a. ❑S Y stem- b. El Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. El IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. W Seepage Bed b. El seepage Trench c. ❑ See age 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): G 3 G / C -�7 (o �- �s } /c� J•0/Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App T ks Tanks strutted Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber ❑ ❑ 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) MP/MPRSW No.: ' � 3 Business Phone Number: � 7 3 � 3 lumb 's Address(Street,City,State,Zip Code): Name of Designer: GZ l� l tvl - 7 Oeu St4e, ��- VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name -�1- CST# Q i 5 10. C AL 02 t-C v CST's ADDRESS(Street,City,State,Zip Code) Phone Number: /0 412.4.e V 41 ( .3 8'4 ) IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved anitary Permit Fee Groundwater ate Issuing Agent Sign ur o Stamps), 0 Approved ❑ Owner Given Initial 12 .00 Surcharge Fee Adverse Determination $25.0 r7-8-88 X. COMMENTS/REASONS FOR DISAPPROVAL: Han appnaved by Many J. Jenkims 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 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; 111. 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 experjmental 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 applicablq; VIII. Soil test information: Certified soil tester's name, certification number, address, and P hone number. IX. n / Cou ty 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% 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 star: included the creation of surcharges (fees) for a number of regulated practices which Wisco in t e can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reSre,! 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. o 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 / APPLICATION FOR SANITARY PERMIT S T C - 100 I 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 ili; /It-4/ Location of property 1/9 s W 1/9, Section _, W Township -A(Ic is d yl Mailing address Z-- /tY2e 45 On ly S�O/ Address of site �,!? l-/ c., /70" L-0.� Subdivision name Lot number / 3 Previous owner of property y .� � �'n , *1 /ar�oAll Total size of parcel Z- 0c5 #"'�-S Date parcel was created L - 2 - 8 -I Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes No Volume Sd 5 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. 0"If 5-c/ 1-7 ; 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 Registe off Deeds, as Document No. S/2,5-c//7 ) . 4Vt— . Signature of Owner Signature of Co-Owner (If Applicable) -7 t-S r-7 6 ,Date of Signature Date of Signature " DOCUMENT NO. WARRANTY DEED rNI. of AC[ a[e[RYtD 1011 scCORDINO DAM D 1 STATE BAR OF WISCONSIN FORM 2-1910 IRsS OFFICE 1 35417 ti:. . i►�c 2 ST. CWX co., vv� fted fa Record Virgfai.a.M.. Hanson. a single woman. . . .. ..... ........... . . ........ .... ......... ........ ... ..... . ... . ... . ... .. ............. ............ . ..... .. . . ......... . ..I.. .. .... .......I .. .... 48 8:00 A AA . .. .._. ...... . ..... . ...................... oe conveys and warrants to . S.am..E. Millera..a..single titan... ........... . 0 &�/K . . ... ...... ... ......... ..... . ...................... ftow of D" .. . .. . .... ... ....... ......... . ..... ! .... ....... ... . .... .... . .... ..... .. .. ............. .. ........ ... .. .. .... Rt TURN +O .. ...... ........... . ... the following described real estate in ......St..,Crolx ..County, .................. Stste of Wisconsin: TaxParcel No: .............................. West Half (W11) of the Southwest Quarter (SWtt) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin except that part South of the public highway and except Lots 5, 6, 7, and 8 of Certified Survey Map in Vol. 6, Page 1747, Doc4 No. 419479. That part of the West Half (Wil) of the Northwest Quarter (NWIt) of Section Twenty-one (21), Township Twenty-nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin lying South of the right of way of the Chicago, St. Paul, Minneapolis and Omaha Railway Company. 'I'IiANSFUi 0 EEE This . ..is not.. ....... homestead property. >bkk (is not) Exception to warranties: easements of record and protective covenants and restrictions of record, if any. S� Dated this . ) ... ... .. .. day of . . IA r c L, , 19.88 . .... .(SEAL) .t �CjilJ�//J��l.[r��w..ISEAL) . . ........ ..... ......... .......... ................... . . ... • .Virginia.M...Hanson .... ...... ... . .. ....... . .... . .(SEAL) .(SEAL( • AUTURNTICATION ACKNOW LEDGKIIINT si`nature(@) ..•......... STATE OF WISCONSIN ..............................................•• as. ................................................................................ ....... .r tru.yc.............County. authenticated this ........day of........................... 19...... Personally came before me this ..°1.I........day of lhri.r t l- ................ 19.88... the above named ................................................................................ Virginia M. Hanson . '..................................................... ................................................................................ TITLE: MEMBER STATE BAR OF WISCONSIN .._._...._•..•...... ........................................ .... (If not. ............................:............................... ..... .. ................ ... ..................I ... ....... . . . .. .. . authorized by I 708.08. Wis. State.) to me known to he the perfon ....... .... who executed the foregoin r trument nn, acknowledge the same. THIS INSTRUMENT WAS ORAFTED BY til •'• ...... .. �. ... .. .. .... ltP.),a..11,...R(W x FaY.a..�!eywood,..Ca r i..b..Mur r ay.... . P..O....Box..229,..HadaQnA..}I ....�401Et.................. Notary uM'tc p (Signatures may be authenticated or acknowledged. Both My Co mi.��Ih gltkt�ld{tcnt.(If not. elate expiration are not necessary.) date: .4y. ) ....,.. .. . ............ . 19. .. . .. 'I, .. ' •Names of persona alaeine In any capacity.hould be ty'De•1 or prinvA M•Inw•Ih•ir riannlarr.. WARRANTT DEED STATE BAR OF WISCONS14 WI.r..n.ln 1..*al nln'A C... Ine FORM Ne a— 1742 �I.I..•�e. tt h. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _ �//?� /�!, I/d✓_ ROUTE/BOX NUMBER &j(_7 2-Q' Zr FIRE NO. CITY/STATE �44)�So y. W - ZIP .S d/*(- PROPERTY LOCATION: 1/4 S W 1/4, Section a , T o1'FN, R l 9 20 Town of #a olze' , St. Croix County, Subdivision cob S Lot No. /_. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, - DIVISION LABOR AND PERCOLATION TESTS (115) MADISON,W 5370 HUMAN RELATIONS (1-163.090)&Chapter 145.045) LOCATION. — N• TOWNSHIP/A4WAW64P*t_-try: OT NO.:BLK.NO.: SUBDIVISION NAME: Nut �1 w'/ -Z /T-2?N/RJ9e( ► / ua►lso,�.. /.3 s� COUNT) WNr S AM 14M M USE DATES OBSERVATIONS MADE Na B DR : COMMERCIAL DESCRIPTION: PROFILE DESCRiPTIONS: PERMLATION TESTS JJQResidence —3 1-11,4 J?rNew ❑Replace SO'/AW 19x llll13 RATING:S-Site suitable for system U-Site unsuitable for system Ar -51- ONVEN 1 N L: MOUND: IN-GROUN ESS : S -E N-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) if Percolation Testa are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: �Floodplain,indicate Floodplain elevation: PROFI E DESCRIPTIONS BORING TOTALS KVA P H GROUP DWATE A AC SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH.LIi OBSERVED E TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) i B- / Qr ./ � . ./B- Z .� due 7 v .D B- A 6•-•1, • Y en ��-/CS, Al. / d� B- y pal 60.41 /elf 7 .d r /-91 , b 6 7 -s 3. PERCOLATION TESTS TEST i DEPTH ATER IN HOLE TEST TIME O 1 LEVEL-INCHES RATE MINUTES NUMBER 1#16+}#£8 AFTER SWELLING INTERVAL-MIN. p PER INCH P• 31 d 3 16 6 3 P- 2 0 3 r.91 A10 P. P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 9S _51-OC4 1016 F 6 � Jll i t i 1 _ o 1, I , I . _. CBS � r1 /8. B � SAc ` 1/ � 04 1, ' J �w A"w.✓h >oYa- were ade.-�q/ 4���u.�ew , I,the undersigned,hereby certify that he soil tests reported on this form were made by ma in acco d wi h e procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests ore correct to the best of my knowledge and belief. NAME(print): / TESTS WERE COMPLETED ON: A S: CERTIFICATION NUMBER: HONE NUMBER(optional): S S s /s 'i CST E: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR•SBD-6395(R,02/82) —OVER --• .1, rj 1 V QN� w d , i I • I ' - i 1 16 K--:�+V U-3 � A ( y ID � � 3 p s Vi >- VI " 8 u —o-Svnd r O � v, a ` , a 1 M d �• ��• Nil a �- .� Q V/ o o d s �I + i I' a ' i J I 0 CZ ? II v N I As � s q N � o a o. 1 r M-t