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Parcel W: 030-1029-50-000 02/15/2006 03:25 PM
PAGE 1 OF 1
Alt. Parcel#: 07.29.19.108F 030-TOWN OF SAINT JOSEPH
Current LX ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner
O- HALL, GRETCHEN A
GRETCHEN A HALL C-VOORHEES ANDREW J
VOORHEES ANDREW J
1096 GOLDEN OAKS LA
HUDSON WI 54016
Districts: SC=School SP=Special Property Address(es): '=Primary
Type Dist# Description " 1096 GOLDEN OAKS LN
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 5.050 Plat: N/A-NOT AVAILABLE
SEC 7 T29N R19W N 1/2 NE PARCEL AS DESC Block/Condo Bldg:
IN 496/303 ALSO REFERRED TO AS LOT 12
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-29N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/02/1998 582194 1336/556 WD
07/02/1998 582193 1336/554 WD
07/23/1997 1025/189 QC
07/23/1997 1003/518 mo e..v
.
2005 SUMMARY Bill#: Fair Market Value: Assessed with:
83362 366,000
Valuations: Last Changed: 07/07/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.050 129,900 203,000 332,900 NO
i
Totals for 2005:
General Property 5.050 129,900 203,000 332,900
Woodland 0.000 0 0
� Totals for 2004:
General Property 5.050 129,900 203,000 332,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 212
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Form — S T C — 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP / SEC. T N-R W
ADDRESS : - ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT / LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Pro�Ea. �4 we 11
j
7 Z 5 3
43 rn L,Y;.,
��
c.kci vt f
\ V
1
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used �� c, �,_ �✓r �y� ,. � ,
O, r
Elevation of vertical reference point: / 'j Proposed slope at site:
SEPTIC TANK: Manufacturer: " 4S Liquid Capacity:
Number of rings used: O Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,O Rear, O /UQ /r- feet
From nearest property line Front 10 Side,O Rear,0 /v0 /t feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
PUMP CHAMBER •
Manufacturer: ALM
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, Side, O Rear,0 Ft. `
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width:_ 5 Length: 26 Number of Lines: Z Area Built: /QUO
Fill depth to top of pipe: a"y
Number of feet from nearest property line: Front, 9 Side, O Rear,(Dirt . 15
Number of feet from y
m well: S
Number of feet from building:' a '
(Include distances on plot plan).
SEEPAGE PIT
Size: /v Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box Q or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
VIII
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: 7-c:>-- Y' Plumber on job: iC�J' , Q/.r..�
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING
LABOR&HUYAN RELATIONS DIVISION
P.OABOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION
MADISON,WI 53707
State Plan I.D.Number:
N01-4,NW4-,S'7,T29N-R19W ® CONVENTIONAL ❑ ALTERATIVE (it assigned)
Town o6 St. Joseph Holding Tank ❑ In-Ground Pressure ❑ Mound
E 9 4 E E c ADDRESS OF PERMIT HOLDER: IN PECTION T
Gan Petet�son Route 5 Hudhon, All 54016 'a1 -$°f �;
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV:
Name of Plumber: MP/MPRSW No.: County: ary Permit Number:
Ra etc Timm 3224 St. Ctcoix T anit 119378
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑YES ❑NO ❑YES ❑NO NEAREST—►
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ❑YES ❑NO NEAREST---*
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS �
GRAVEL DEPTH FILL DEPTH DISTR.PIPE I DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF IPROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV.INLET:I ELEV.END: PIPES: FEET FROM LINE: AIR INLET:
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑YES ❑NO ❑YES ❑NO [--]YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING:
ELEV: ELEV.: DIA.: ELEV: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑YES ❑NO ❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
S 3 ❑YES ❑NO ❑YES ❑NO NEAREST----10-
s IGIA
4 00 y /�
f a.
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE: TITLE:
Zoning AdmintistAa; tc
SBD-6710(R.06/88)
�-° SANITARY PERMIT APPLICATION COU n
{� DILH e ,
LJ In accord with ILHR 83.05,Wis.Adm.Cod
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
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES X NO
PROPERTY OWNER PROPERTY LOCATION
f C�✓. Ae—leV —CX YA gli % n{,. %, S T Z-', N, R / (or),®
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION INAME
/ /2- r1ou'l-I&MIZ /// /
CITY,STAT ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
❑ VILLAGE
II. TYPE OF BUILDING OR USE SERVED: 036, X.A —SY0—O0
Number of Bedrooms if 1 or 2 Family - OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. IL'i 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.Y1 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. Z seepage Trench c. ❑ See a e 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): r# cr 3
30 56n CTU 7 2 415 Feet Private ❑Joint K_/1 E-1 Public
VI. TANK CAPACITY Site
in ga ons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks I structed
Septic Tank or Holding Tank IDCJ� �S LJ ❑
Lift Pump Tank/Siphon Chamber, ❑ ❑ ❑ ❑ ❑
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 St mps) MP/MPRSW No.: Business Phone Number:
3z G7
Plumber ddress(Street,City,State,Zip Code): Name of Desig r:
icy 44-1111.1 / 2
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
CST's ADDRESS Preet,City,State, ip Code Phone Number:
_tf dts 7 o d 11 icy
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved S Hilary Permit Fee Groundwater ate I uing Agent Signature(No Stamps)
urcharge Fee
Approved ❑ Owner Given Initial '� �Y • rr , M
Adverse Determination �� VC.J CJ� 1 ` C 1 1 W
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
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 when ever''pecessary, 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;
11. 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 8'/z 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 at�r-=
included the creation of surcharges (fees)for a number of regulated practices which Wiscor sin`s
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.
a
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
his application form is to be completed in full and signdd by the owner(s) of the
roperty being developed. Any inadequacies will only result in delays of the permit
ssuance. Should this development be intended for resale by owner/contractor, ("spec
ouse"), 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 l.. A-' Y AWt, j.;:�>p t�� —s ,:1
Location of Property `1t, Section , T j c/ N-R Icl W
(!Township T r1_�
'Mailing Address ,q y,r,
Address of Site
l es,izk H e) 1nv►A
Subdivision Name i kxnv.'L
Lot dumber
Previous Amer of Property Gk 441P J
Total Size of Parcel :{ p
Date Parcel was Created
Are all corners and lot lines identifiable? .� Yes No
Is this property being developed for resale (spec house) ? Yes _ _. No
volume 41 I - and Page Number Q O-7 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 refer-
ences to a Certified Survey Hap, the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
T W I cv_A_U6y that af.0 Atatement�s on tlu�s ohm cute thus to the bets t 06 my (owL)
hncwtedge; U,at T (we) am (she) U:e owneh.(.61 o6 the phopehty deAcAi.bed in tit"
.in6olma.LEon 6ohm, by viAtue 06 a waAAanty deed hecoh.ded in the 066ice 06 the
Countyy Regvsteh o6 Ueeda a�5 Document No. and that I (We) pheeentfy
c.un the phoposed site 6ok the zewage diA75 d ys tem (oh. I (we) have obtained an
easement, to Run with the above d6cAi.bed p&opehty, Ko& the conbthucti.on o6 aa,i.d
sys.t", and the same ha.s been duty Aecohded Xn the 066tee o6 the County RegiAteh o6
Deeds, as Document No. ) ,
SIGNAT& 0I1 OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNBD DATE SIGNED .
odcWL&T No. T8VAT'Z SAKI OF WISCONSIN FORM 1—!Mt' '"N sacs ��
WARRANTY DEED
' . 44iPM X15���t �.
e o� 823
This Deed.
made between .. .. ... �
..........jac . A.f. Tyacke. and_Gayle..L. Tyacke,. husband
l . .
...... nd-wife .as. joint .tenants _ _. �• M " `
a
Grantor. ��#W�
{ and_ -Gary AL..Peterson.and Lisa..N.. Peterson, . . •
r 1 .........husband and.wife. as survivorship marital .... . 9x20 $'
- .property.
y.
............ .......... .. ....... _.
_ Grantee.
� .
i s
W1tI1 @88 @t1. That the said Grantor, for a valuable consideration
1 ..Tack..and..Gayl.e..Tyacke.. .
li conveys to Grantee the following described real estate in .St...Croix.
County, State of Wisconsin:
4
;i
.. , E,n:
w.
Part of the North Half O of the
Tat .._ �
Parcel No: ..............
Northeast Quarter (}) of Section 7. Township 29 North, Range 1 '
West described as follows: A parcel of land known as Parcel
#12 located in the North j of the Northeast Quarter of Section 7, ; 4 . ,
Township 29 North, Range 19 West. Town of St. Joseph, described '
as follows Commencing at the Northeast corner of said Section
71 thence South 3039•'50" West (true bearing) 330.46 feet; thence
South 88'55'30" West 1029.78 feet to the Point of Beginning; . t :
thence South 23.23 20 West 634.53 feet; thence Westerly along t?le � .
Northerly right of way line of a proposed town road 42.44 feet , If
on an 85.00 foot radius curve concave Southerly whose chord bears
North 80'54'50" West 42.00 feet; thence South 84'47' West
132.95 feet along said Northerly right of way line; thence North
74'4140" West 30.00 feet along said right of way line; thenceI
Westerly along said right of way line 59.12 feet on a 211.83
foot radius curve doncave Southerly whose chord bears North
82'40'40" West 58.93 feet; thence North 0'46' East 562.97 feet;
thence North 88'55'30" East 505.71 feet to the Point of Beginning. - ,,
46' t
This ._.- 18 not homestead property. LNG 4
(is) (is not) -�
Together with all and singular the hereditament s and zrpurten:,nces thereunto Lel�n�inp: FM "
I
And........Jack...a2'ld..C.ayle- Tyacke-
i warrants that the title is
good, indefeasible in fee simple and free and char of er.cumhran,es except .�
easements, restrictions and rights-of-way of record, if any.
and will warrant and defend the same.
k
Dated this __ _. l 3 day September 1,,88
y
.�sl� F::>,LJ D� (t�'`"� (SEAL; •
$lack D. Tyracke/t_ Gayle L. TyTcke
4_
15F:A 1.r (SEAL).
ti
AUTHENTICATION ACKNOWLEDGMENT
Signaturt(s) _-_ �:TATI'. OF WI:4C1_1NSiN
^, gc•
authenticated this .. ,n, of I? i•,r<• ,,'1. ,:,me Ill ' Il• . . t _--day of > a
E.m T tie rixn'C naMed
• y-�cr: .l r I-:. 'Cyacte
TITLE: XI I:N*IItER STAI F: 11A1, �,r , .
1
I"not.
autfinrized o' ;u,'„4, \' f, �•r'ttrd the =
Pip
hristina Ct-land ,,n,; •�_,•
Attorney at Law )
•..�
(Signal rn•k may hr
„r r" a
are not nee"!-ary.)
•t111M nt r••`fMt,.f ±'.f t:,^4 fn r! ., - L 54' •'
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STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT Ho
St . Croix County z
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OWNER/BUYER
P9
ROUTE/BOX NUMBER �-� x7 �p�, ,,�.� .Cluj° /ID _Fire Number
CITY/STATE � � jY!° ,�..�,,f� ZIP :5-4--4,4
PROPERTY LOCATION :T I/� �, �L, Section '7 TAN , R L5__W,
Town of St . Croix County ,
Subdivision2Z=__4_3&12t d II.S ' 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 may 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 b the owner and by a master plumber ,
y
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 z„
to maintain the private sewage disposal system in accordance with x
H
the standards set forth , herein , as set by the Wisconsin Depart- v
ment 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 .
S I G N E D
DATE
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 .
DEPARTMENT OF . REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON W1 53 07
HUMAN RELATIONS
(H63.090)&Chapter 145.045)
LOCATION: SECTION: OWNSHIP UNICIPALITY: OFOILK NO.: SUBDIVISI AM N�. �� ZY N/R/9�(o W 5r Jos
COUNTY: W £R' NAME:
Sr Ce,0 $A Z,AR FT£ieso T I //LjAIERMA MAI SS39F
E DATES OBSERVATIONS MADE
DESCRIPTION] I PROFILE DESCRIPTIONS:IFE .
Residence WN K New
❑Replace 1 �UL� ZCi �� U4 1 /1 IT
41 SnoLS ' SANT144iJ
RATING:S-Site suitable for system U-Site urouite a for system
rAj
N ei ❑� MOUND:
' U ❑� IN S ❑U S ❑UL
-IS Gyt to :RECC..nMNVI�N�O►J Al.tional) 4 4 ORAL`
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the ��
under s.1-163.09116)1b),indicate: C)LA SS Floodplain,indicate Floodplain elevation:
FN c F1. PROFILE DESCRIPTIONS
BORING TAL P R U D ATER-INCHE CHARACTER OF SOIL WITH THI KN S,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH to ELEVATION OB ERV TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
> 7.S@i /3'Inc r5 2��� a L s3"�o$a,�,r►► s�.C,�e �o� ear
>/O-so
B- y 9.i1 9'7. 1 o Nomir 9 l -2 kktqL 7l RA8ktiM SL.& 4jA
B- ,6 90,06 v Lf > $.67 19"kLLTS 27" 8,kiv L4 31 N81tN MS AL '411 eon•
J
B- C' 9,5� g�,q< fttc C �co" fA"6d 1e+A
B- b 1-7 to il,00 n/o Ir 17 /brE«r5 3o'G e S L 'S - s VG
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES A MINUTES
NUMBER 1S AFTER SWELLING INTERVAL-MIN. IQp O PER INCH
P. I 4a
le- %.4 30
P- Z S00 oo Do so 7 YZ ' z _ /' 2 0
P- S 9D otitz 11001U to YA
P
PLOT PLAN: Show locations of percolation tests, soil borings anif the dimension f-jbi%b� soil as. Indicate scale or distances. Describe what are the hori-
zontal and vertices elevation reference points and show their-f"ocat on on the plot pla ho ,"vurfa levation at all borings and the direction and percent
of land slope. LkPPSCTQidro<4 - yOO� I �b-4
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SYSTEM ELE ATIONLa--s ly _ oo '�r.Pa-1 ` z6'
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661.t t&r,J UA45 L4r&
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.
NAME(print): TESTS WE E COMPLETED ON:
hl4 pN IQusc_14 '�u(2 E rvC ic 40s-r /
ADDRESS: CERTIFICAT ON NUMBER: IPHONE NUMBER(optional):
a7 SEconi�0 /�IU �So ti ) <;4o It r., I iu- %�
3 CST SIC TURE:
h c v l sP_h Nov. 11 19"aa _---
DISTRIBUTION: Oj i(mal and onv em)v to Local Aulhnrily,Ptnpeily Owner and Soil Tnstel.
nil.HR-SBD-6395 (R.02/8?) -OVER ..-
MPRS 3224 WI
MPCA 696 MN Joe rT Pe ter Sc)i7
1 1 11 1 1 SHEET NO. OF Z
CALCULATED BY DATE 9/ �6
Excavatin 9 Co. i CHECKED BY DATE
I� 1, Box 192, Wilson, WI 54027 SCALE
715-3864443
tOGFR TIMM 716-772-3214 t
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Tit�,m SHEET NO. OF
CALCULATED BY A+f7 Ate-.
- 6f�r �✓ DATE
Excavatin 9 Co. CHECKED BY DATE
R I, Box 192, Wilson, WI 54027 SCALE
715-386-5443 i
R TIMM 715-772-3214
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