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Parcel #: 032-1020-10-000 05/25/2007 03:42 PM
PAGE 1 OF 1
Alt. Parcel#: 8.31.19.96A 032-TOWN OF SOMERSET
Current X 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
f,.
O-JOHNSON, VINCENT J
/VINCENT J JOHNSON
2286 40TH ST
SOMERSET WI 54025
SC = School SP=Special Property Address(es): '=Primary
Type Dist# Description "2286 40TH ST
SC 4165 OSCEOLA
SP 1700 WITC
Legal Description: Acres: 20.000 Plat: N/A-NOT AVAILABLE
SEC 8 T31 N R1 9W NE NE EXC P96B AS DESC Block/Condo Bldg:
795/214
Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
08-31N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 939/217
07/23/1997 820/63
07/23/1997 795/214
2007 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: - - - L t Changed: 07/12/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 48,000 111,600 59,600 NO
UNDEVELOPED G5 17.000 34,000 0 34,000 NO
Totals for 2007:
General Property 20.000 82,000 111,600 193,600
Woodland 0.000 0 0
Totals for 2006:
General Property 20.000 82,000 111,600 193,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 204
Specials:
User Special Code Category Amount
II
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
RECEIVED 1 111111 IIII''""' 111 IIIII IIIII Iili illlll If II IIII
858407
SEP 5 2W KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
ST.CROW COUN N RECEIVED FOR RECORD
SURVEYOR'S RECORD 08/22/2007 09:OOAM
CERTIFIED SURVEY MAP
VUL: 22 PAGE: 5438 13
CERTIFIED SURVEY MAP REC FEE: 13.00 3
LOCATED IN THE NEY OF THE NE)/4 OF SECTION 8,T31N,R19W TOWN COPY FEE: 3.00
OF SOMERSET,ST.CROIX COUNTY,WISCONSIN. PAGES: 2
OWNER/SU801VIDER
�S aZ'j N01E. LOT 5 HAS A C.B.A.OF 9.04 ACRES AID VINCENT JOHNSON
•'� % LOT 6 HAS A C.BA.OF 8.48 ACRES. BOTH LOTS X88 40TH STREET
SOM
f� ARE SUBJECT TO THOSE SETBACKS ASS 'W.54025
* ? GRA RG * REQUIRED BY THE TOWN OF SOIaERSET.
NEW RICHMOND =
WI
`1y•'-w.....,,•-job O
°
3 u f
LOT 3 OF C.S.P . VOL 11,PO 3248. LOY 9_OE_C.S.k�
VOL.11,PQ.324& VOL.11,tom.3246. LOT 2 OF C.S.ML
— I NORTH LINE OF THE NE1/4� I VOL 13,VGL 3677.
(RSI�'3850VN 662.68) L
S89'201121E 652.48'
SOV20'02'E 1957.4:' _230TH AVENUE _
ao SW41-46'E 619.59' CORNER,SECTIONS
Q — 50'SETBACK LINE FROM RIGFiT-0F-WAY ————— (ESTA
TIES BLISHED FROM RECORD
w LL I {CL
w
{ 13' 33'II�'
Sox.°
I o LOT 5 L0Cdtjjj0NC3 2
m 437.649 SQUARE FEET 2 o B
{ I 399 W SQUARE FEET Y //
EXCLUDING RIGHT-OF-WAY SOIL I I 1111.�C�
J_
LOCAn o�^� �
' 620.98 Z7777N 4.00' rEcEND
p ig —'— -INDICATES SECTION CORNER
�I s (AS NOTED)
9L. LOT 6 ' 17(ISTINC� I DRIVEWAY -INDICATES 1.25'DIAMETER IRON
v 438.039 SQUARE FEET / •I I • -PIPE FOUND'DIAMETER IRON
p (10.06 MMES) - / W I ts
INCLUDING RIGHT-OF-WA- s` "v3 I bo I ® PIPE FOUND.
415,998 SQUARE FEET I oyM.) Q -INDICATES 1'X 18'IRON PIPE
(9.55 ACRES) DWELLINNG g 1 I `�I a° �1 WEIGHING 1.13 LBS.!LINEAR
®�dl EXCLUDING RIGHT-CF-W,-CF-W,Y I �I FOOT SET.
CL
(R) INDICATES PREVIOUSLY
���'I Q7 • 3 I I �+ . RECORDED INFORMATION
(�+ EPTIC• I 1NDICATES AREAS OF20%AND
VENTS 181^- GREATER SLOPES
O==r -INDICATES DISTANCE BETWEEN
I°•+ EXISTING OR PROPOSED
DRIVEWAYS
el 1
w 1 I I D -INDICATES PROPOSED
DRIVEWAY LOCATION
Y ———-INDICATES 50'SETBACK FROM
1
RIGHT-OF-WAY
-INDICATES AREAS BElWffl4
j I 12%AND 20%SLOPES
SOUTH Ll NE Ys N
511 00
N89 "M 656.50 I PREPARED BY.
GRAMERG SW?VEYff^MfC.
L01T 3 OF C.S pA 1235 C.T.H..'E' ^�
®��-�F®'6®3:4. I NEW RICHMOND,VA.54D17
0' 200' 400' 600' PHONE(715)246.7529
iiiiii ,
$ JOB NO.07-019
SCALE IN FEET T.200' E)S CORNER,SECTION B
THIS INSTRUMENT DRAFTED BY JOSEPH W.GRANBERG S-2295 (ALUMINUM CAP FOUND) SHEET 1 OF 2
1 of 2 IJ
Vol. 22 Page 5438
• Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER -� } ��h // !� f� TOWNSHIP f SEC. T f / N-R_Z
ADDRESS j ESC % / / ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE ----__
PLAN VIEW
Distances and dimensions to meet requirements of II,HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
:'W
5T ,
_'?c c
7 1
)7N 13
1
.z
� C INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
0 1
Elevation of vertical reference :oint c c /
P � Proposed slope at site:
7c, -�--r/`
SEPTIC TANK: Manufacturer: J� Liquid G�apacity:
Number of rings used: / F147- Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,O Rear, O 2 -s oz feet
From nearest property line Front,O Side,O Rear,O —2 5 -2 feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER •
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type: `t{
Number of feet from nearest property line: Front, O Side, O Rear, Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: / -? Length: Number of �L' Area Built: `
Fill depth to top of pipe:
Number of feet from nearest property line: Front,/ O Side, Q Rear,O Ft "?e r
Number of feet from well: ,>'c"
Number of feet from building: f'
(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, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated• 75 —1-,2 � < Plumber on job:
License Number:
3/84:mj
a
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
NEB NEi SS Samet�e�
T31N—R19w CONVENTIONAL El ALTERNATIVE ISI,I,Pl,"I.D-Number
4j ❑Holding Tank F-1 In-Ground Pressure ❑Mound IIf assigned)
Town v6
h S;fteet
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Ftcank LindeU _ Rowe 1, Box 92B, Sometct e t, W1 54025 _/ r) - ?k
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV..
Name o1 Plumber: MPlMPRSW No.: County. Sanitary Permit Number:
By,ton &Ad Jn. 3318 St. Ctc.oix 112138
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIOUID CAP ITV. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
DYES ENO DYES ❑NO
BEDDING. VENT DIA.. VENT MA TL: H WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH
ALARM FEET FROM LINE AIR INLET
EYES ONO YES ❑ O NEAREST
DOSING CHAMBER:
MANUFACTURER BE DDING. LIQUID CAP V ]PUMP MODE PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO DYES ONO ❑YES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ❑NO 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 DISTR.PIPE SPACING COVER INSIDE DIA SPITS LIQUID
BED/TRENCH BENCHES ERIAL: PIT DEPTH
DIMENSIONS
GRAVEL OE
FT FILL DEPTH DIST H.PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH BELOW PIP ( ABOVE COV R ELE V.INLET ELE V.END S FEET FROM LINE,.�y� (� 9/, AI T
NEAREST-----m- 30-0 �j'o vv 9�4-
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-
❑YES ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER ITE%TURE PERMANENT MARKERS JOBSIRVATIONVIII-LI
❑YES ION YES ❑NO
DEPTH OVER TRENCH/BED ,DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER. EDGES
DYES - NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE JMANIIOLD MATERIAL NO DISTR DISTR.PIPE DISTHIBUTION PIPE MATERIAL&MAHKIN6
ELEVATION AND ELEV.. ELEV.. DIA. ELEV, PIPES DIA
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES 1:1 NO DYES 1-1 No
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL. JBUILDINC
FEET FROM LINE
❑YES ❑NO ❑YES ❑NO NEAREST
/0�
Sketch System on eta in county file for audit.
Reverse Side.
SI NATO TITLE
DILHR SBD 6710(R.01/82) / Zonting ,4dmLVUiSt&dtotl.
{ SANITARY PERMIT APPLICATION COUNTY
Ll DILHR In accord with ILHR 83.05,Wis.Adm.Code . G
STAT SANITARYPERMIT#
7,ia y3.'
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%2 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 i r rN0
PROPERTY OWNER / PROPERTY LOCATION
_Y,, S -` T , N, Rl E (or&7
PROPERTY OWNER'S MAILING ADDRESS..� L NUMBER B SUBDIVISION NAME
.(7 r/1J�YL �- ��-
CITY,STATE ZIP CODE PHONE NUMBER ROAD)LAKE OR LANDMARK
a VILLAGE :
11. TYPE OF BUILDING OR USE SERVED:
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. ❑ New b.X.Replacement c. El 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. tgLConventional 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. 14 Seepage Bed b. ❑See a e 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):
G
l J Z. Feet XPrivate ❑Joint ❑ Public
VI. TANK CAPACITY IF Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank 5e p(,J-e �
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 Stamps) MP/MPRSW No.: Business Phone Number:
!"d i► 49r wj^ � ( l� �616
Plumber;Plumber;9 Address(Street,City State,Zip Code): Name of Designer: / �^
VIII. SOIL TEST INFORMATION
Certified Soil Test r(CST)Name CST#
r8 e fir. -�?V -_
CST's ADDR S treet,City,State,Zip Code) /� Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
C9Approved ❑ Owner Given Initial S rchharge Fee
� Q
Adverse Determine ion � '��' � pt�•�LJ
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 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 8'/s 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 Wisco
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried >'tfrBS
is used rn your building is returned to the groundwater through your soil absorption
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)
w
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.
--- 1---- ---- ------—---------------------------
Owner of property ��
Location of property/S GZ_ 1/9 � � 1/4, Section � T L N-R W
Township _ cF2z
Mailing address
GC= y o
Address of site
Subdivision name
Lot number ^� _
Previous owner of property 4v." 1�f 1a-,
Total size of parcels o
Date parcel was created 6
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)? Yes No
Volume 53q and Page Number 941 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.
--------------------------------------------------------------------
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 warrant die r Corded in the Office of
the County Register of Deeds as Document No. 3 7 J ; 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 County Registe of Deeds, as Document No. ) .
Signature of Owner Signature of Co-Owner (If Applicable)
Date of Signature Date of Signature
d.
` iaStra
Tax Key S y
'fr
'roMnShip,'31,
the A�olloi+ina Tract: r `
} Y Ida V ode the SE Jcorner of the SE 1/4 `' M
A
Section 01 thence if 208 feet; 44- < .
- bAmnoe a 208 leett thence E
t containing one acre.
MI
/ `T da, Feb
Of PRSSSNCS or
x
$" Frank J..Lindal l r
�s F
l
y �~
.Y4
. Frank J. Lindell 1
do a ruary , l
Ilia. W. ward >,
:a
Title; Member State aer of Rbcosldua0♦ .
9TATS OF WECONSDI
PMwsily Come before W. We__ day of ' 19-9
the abets wed
M W knows M M IM versos_ wio executed the forelping Instrument and seisowledSed tit some.
Y
This Mdb meet we**sited by
IBMT_M A VAN DYK Notary Public c..ay,ei.
New Richmond, par 54
il
Tb use of witnesses is option". my Commission(styires)(ts) `i
Rams of perms sysYK to any capacity should be typed or printed below their sysatntes. ;
wdR"W f MM-WA" MIR or WnCOMggt, TORY no.2 - 1911 a
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
0 WNER/Wj4ft Aewli Z/'&�'
ROUTE/BOX NUMBER /r// `�� �� FIRE N0. 72 i�/
CITY/STATE '�l•Cd / zl)l ZIP S_Y62
PROPERTY LOCATION: 1/4 L %Z 1/4, Section J , T_N, R f -/ W,
Town of � e-c�e�Ii , St. Croix County,
Subdivision , 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 GS AND SAFETY& BUILDINGS
HUMANfCND PERCOLATION TESTS (115) DIVISION
HUMAN RE ATIONS P.O. BOX 7969
(ILHR 83.09(1) & Chapter 145) MADISON,WI 53707
LOCATION: SECTION: O SHIP/ UNICIPA LOT NO.:BLK.NO. UBDIVISION NAME:��/ / N/ E (or)
COUNT : OWNER'S BU ER'S NAME: MAILING ADDRESS:
f-`Gro ` e r
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
iesidence 3 ❑New y413 Iace _ , 4
RATING:S=Site suitable for system U-Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
MS ❑U S ❑U (-S 11U ❑S 11 U I ❑S U �
If Percolation Tests are NOT required DESIGN RATE: If an
y portion of the tested area is in the
under s. ILHR 83.09(5)(b),indicate: . Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- A0 dro
1/ .2`f��
B- 44 :> 3c f �al/f (I
B-
B-
B-
�L� PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER lihl€S AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER O PER INCH
P- °2 L
P
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Descri a 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
Pr
f ��g
4191 Ae
y -
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8 4 l c-
Alt
I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in"the Wisconsin
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 WERE COMPLETED ON:
0 17 f7
A D D R _ CERTIFICATION NUMBER: PHONE NUMBER(optional):
CST SIGNATURE: t
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
---- - -—------------- _-
DILHR-SBD-6395 (R. 10/83) OVER -
• i�
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 R
To be a complete and accurate soil test,your report must: include:
1, Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY '•F ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
b. PLEASE use the abbreviations shogun here for writing profile=descriptions and completing the plot plan;
? MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
separate sheet may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
9, Complete all appropriate €oxes as to dates,names,addresses,flood plain data,percolation test exemp-
tion,if appropriate;
10. If the information (such as flood plain,elevation)does not apply, place N.A.in the appropriate box;
11. Sign the form and place your Current address and your certification number;
12, Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 10") BR Bedrock
cob - Cobble (3- 10") SS - Sandstone
gr - Gravel (bander 3") LS - Limestone
"s Sand HGW - High Groundwater
cs - Coarse Sand Perc - Percolation Rate
med s - Medium Sand W - Well
fs - Fine Sand Bldg - Building
Is -- Loarny Sand > Greater Than
sl -- Sandy Loam f _ Less Than
*l - Loam Bn - Brown
*sil Silt Loam BI -. Black
si - Silt Gy - Gray
XcI - Clay Loam Y Yellow
scl Sandy Clay Loam R - Red
sic! Silty Clay Loam mot Mottles
sc Sandy Clay wl - with
Sic - Silty Clay fff - few, fine, faint
*c Clay cc - common,coarse
pt - Peat rnm -- Many, medium
m - Muck d - distinct
p — prominent
HWL - High water level,
Six general soil textures surface water
for liquid waste disposal BM Bench Mark
VRP - Vertical Reference Point
TO THE OWNER:
This soil test report is the 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.
PLOT PLAN
PR JECT_
ADDRESS
1/4 1/4/S /T oix c.•5 '71�`S f��
�� `� 3� N/R/JW TOWN /1/ COUNTY _ Gro '
MPRS Byron Bird Jr. 3318 DATE
BEDROOM CLASS PERC � ^�S
�_CONVENTIONAL IN-GROUND PRESSURE
CONVENTIONAL LIFT_ MOUND HOLDI G TANK
SEPTIC TANK SIZE via LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE I'
ABSORPTION AREA —�=f— PERC RATE G
L Benchmark V.R.P. Assume Elevation 100' —BED slzE
Location of Benchmark s e a
* H.R.P.
C] Borehole Q Well Scale Feet
O Perc Hole System Elevation �' _
Uent
12"
* TYPAR COVERING
1 2"
12" 3' 4 6' 40 31
6" Sewer Rock
71 ,L_
12'
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