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Parcel #: 038-1044-40-100 12/14/2006 10:57 AM
PAGE 1 OF 1
Alt.Parcel#: 11.31.18.194C-10 038-TOWN OF STAR PRAIRIE
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
TODD A JODARSKI O-JODARSKI,TODD A
1294 CTY RD H
STAR PRAIRIE WI 54026
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description * 1294 CTY RD H
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE
SEC 11 T31 N R18W PT NE NE COM NW COR LOT Block/Condo Bldg:
9 BLK I VIL HUNTINGDON;TH N 195FT;TH E
219FT MOL TO E LINE OF NE NE;TH S TO N Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
LN CTY RD H;TH N ALNG E LN LOT 7 BLK I; 11-31N-18W
TH WLY ALG N LN OF LOTS 7,8, &9 BLK I
TO POB
Notes: Parcel History:
Date Doc# Vol/Page Type
01/30/2001 637681 1581/18 WD
07/20/1998 583249 134113.1 — QC
07/23/1997 1094/274 WD
C ---
2006 SUMMARY Bill#: Fair Market Value: Assessed with:
174941 287,800
Valuations: Last Changed: 06/27/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 54,900 199,500 254,400 NO 05
Totals for 2006:
General Property 0.000 54,900 199,500 254,400
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 54,900 192,200 247,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch#:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel #: 038-1045-20-000 12/15/2006 01:27 PM
PAGE 1 OF 1
Alt.Parcel#: 11.31.18.195H 038-TOWN OF STAR PRAIRIE
Current I 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
KATHLYN M BUKOVICH O-BUKOVICH, KATHLYN M
2301 HUNTINGTON DR
STAR PRAIRIE WI 54026
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *2301 HUNTINGTON DR
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 0.940 Plat: N/A-NOT AVAILABLE
SEC 11 T31 R18W PT NW NE COM NE COR W Block/Condo Bldg:
182 FT TO CL HWY SWLY ON HWY 194 FT E
275 FT N 175 FT TO POB Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
11-31N-18W
Notes: Parcel History:
Date Doc# Vol/Page Type
09/04/2003 738796 �W WD
07/23/1997 908/231
07/23/1997 8
2006 SUMMARY Bill M Fair Market Value: Assessed with:
174948 176,200
Valuations: Last Changed: 10/13/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.940 29,600 126,100 155,700 NO
Totals for 2006:
General Property 0.940 29,600 126,100 155,700
Woodland 0.000 0 0
Totals for 2005:
General Property 0.940 29,600 126,100 155,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 215
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
• Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ALb , .fE TOWNSHIP SEC. _ T N-R Zr? W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4-1o!
t/OUst
Q
ON
f�
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point:
p /��,� Proposed slope at site:
SEPTIC TANK: Manufacturer quid Capacity:
Number of rings used: Tank manhole cover elevation: .` 7�y
Tank Inlet Elevation: 2 9,1/ Tank Outlet Elevation: �� z�
--�
Number of feet from nearest Road: Front,o Side,o Rear
s—e feet
From nearest property line Front,0 Side,®Rear,o feet
Number of feet from: well building: 16 /
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
r
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
ih
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: Trench:
i
Width: Lenith:_-� — Number, of Lines: Area Built:
Fill depth to top of pipe: �l
Number of feet from nearest property line: Front, O Side, O Rear,O Pt .
i
Number of feet from well:
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, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector•
Dated: Jl - Plumber on job:
License Number: 1<<--/'�
3/84:mj
DEPARTMIEN't OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABQR&HUMAN RELATIONS DIVISION
PRIVATE SEWAGE SYSTEMS
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707 IS,,te Plan l.D.Number:
CONVENTIONAL ❑ALTERNATIVE
NF4-, NET, 11, T31 ❑Holding Tank ❑In-Ground Pressure ❑Mound (It a:signed)
Town StaA Pna yr ie
CTH "H"
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE
kilan R. 1, Statc Ptca, Aie, W1 54026 1 -�1'$� g��O
BENCH MARK(Permanent referenceoomt)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.
Name of Plumber: MP/MPRSW No.: Counry: Sanitary Permit Number:
Can n Pawe Jar. 1563 St. Croix 112771
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV_ WARNING LABEL LOCKING COVER
G ` �7 PROVIDED PROVIDED
��•G/ YES ❑NO OYES CNO
BEDDING. VENT DIA VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING. (VENT TO FRESH
C ALARM ,��// FEET FROM 5� a vg S QO /� AIH Ian,E_
❑YES O ❑YES YAO NEAREST �/ /
DOSING CHAMBER:
MANUFACTURER JBIDDING LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ONO ❑YES ❑NO DYES ❑ FR
GALLONS PER CYCLE: 70YES MP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING IVENTTO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) 1-1 NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth Of plowing LENGTH JDIAMITIH MATERIAL AND MARKING
Or excavation. (lf soil can be rolled into a wire,construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH LEN NO.OF DISTR.PIPE SPACING COVER JINIIDE DIA SPITS LIQUID
BED/TRENCH TRENCHES r MAT IA L: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH UIST .PIP DISTR.PIPE DISTR.PIPE MATERIAL. NO.OIS NUMBER OF PROPERTY WELL BUILDING IVENTTOFHESI4
BELOW P/P�ES ABOVE C/,HER. E V INLET ELEV. ND'. PIPES' LINE `J AIR INLET
l9 r r 5.� 2 ( NEAREST,--► /O ! J .2 {
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.
❑YES NO
SOIL COVER TEXTURE IPERMANENT MARKERS OBSEHVATIONWELLS
DYES ENO ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
❑YES ❑NO ❑YES ❑NO 1:1 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 NO DISTH DISTR.PIPE DISTRIBUTION PIPE MATERIAL.&MAHKIN(�
ELEV.' ELEV. DIA. ELEV. PIPES DIA
ELEVATION AND
DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS
DYES [11 NO 1-1 YES NO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE.
DYES El NO ❑YES ❑NO NEAREST
ti
Sketch System on UBnin in county file for audit.
Reverse Side.
SIGNATURE. TITLE
DILHR SBD 6710(R.01/82) �''G' Zoning Admini6ttaton
LJ'DIL R SANITARY PERMIT APPLICATION COUN Y
In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY RMIT#
IT
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION
I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ENO
PROP RTY OWNER PR PERTY LOCATION
106g:2 nqA '/a '/a, S T.3 , N, R E (or)
PROP Y OWNER'S MAILING ADDRESS OT NU ER BLOCK UMBER SUBDIVIS NNAME
I
Z2CITY,STATE ZIP C DE PHONE NUMBER CITY NEA T R AD LAKE OR LANDMARK
1,T011 7 It TOWN VILLAGE : s ►1 /i
II. TYPE OF BUILDING OR USE SERVED: /
Number of Bedrooms if 1 or 2 Family 2 OR 11 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. ❑ 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. M 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. ❑See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes er inch): REQUIRED(Squ4re Feet): PROPOSED(SWare Feet):
Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete glass App.
Tanks I Tanks structed
Septic Tank or Holding Tank ❑ I ❑ ❑ 1 ❑
Lift Pump Tank/Siphon Chamber ❑ 0 1 ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation th rivate sewage system shown on the attached plans.
Plur 7r's Name(P ' t): P er' Sign re:(N tamps) MP/MPRSW No.: Business Phone Number:
✓
Plu er's kddre s Street,ZState,Zip Code): Name of Designer•
dL-,� A150 '0 �o.,411,hVQ r),�/ '572/2,Y �4
VIII. SOIL TEST INFORMATION
Certifje{i Sail Tester(C Name CST#�
(/.�.' � J-1/Z CST' DDRESVZAA11 'eet,City, tate,Zip Code) Phone Number:
dr !
IX. COUN /DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signat (No Stamps)
Approved El Owner Given Initial y ( J n ! �f�ar`geFee 19—�I
ILI!hi Adverse Determination pS v / J
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% 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 Groundt8�--
included the creation of surcharges (fees) for a number of regulated practices which W/isco lClt
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Ir �sute
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)
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
Owner of Property jella.-VK9-�-
Location of Propert Iv ,14, Section , T N-RJS W
Township
Mailing Address
Address of Site
Subdivision Name
Lot Number
Previous Owner of Property uAS�O
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes _ No
Volume and Page Number -,(-,/,S—, as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Deed which includes a Document number, volume and pane number, and the
Seal of the Register of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPFRTy OWNER CERTIFICATION
I (We) centi.by that att .6zatement6 on this boAm ace tAue to the but ob my (ouA)
k.now.Cedge; that I (we) am (ane) the owneA(.$) ob the ptopetty de-scAibed in this
inboAmati.on boAm, by vi tue ob a waAnanty deed %eco&ded in the Obb.ice ob the
County Regibxen ob Deedaas Document Na. a ; and that I (We) ptuentty
awn the pAoposed site ban the sewage dizpos zyz em (oA I (we) have obtained an
eab ement, to nun with the above de s ch i.bed ptopeh ty, bon the constAuc tion ob said
.system, and the aame has been duty Aeeonded in the Obbi.ce ob the County Reg-i.ateA ob
Deeda, ab Document No. ) .
9 l 8g
SIGNATURE OF OWNER SI ATURE F CO-OWNER (IF APPLICAB
474 /
DATE SIGNED DA14 S GNED '�
1 DOCUMENT NO, WARRANTY REEK
STATE OF WISCONSIN—FORM 9
'
2'73012 THIS SPACE UMVED FOR RRCORDDIG DATA
e
THIS INDENTURZ,Made by 1'ritz N. Asplund and Violet P. REGISTERS OFFICE.
ST. CROIX CO., WIS.
Asnlund,_husba,nd And wife_
-- Recd for Record this 12th__
grantor 8of $t• CTo1X _County,Wisconsin,hereby conveys and warrants daYof--July-----A.D.196
to Sca-rset -- - — at--- .00__-- A M.
------- -- Regis_t D tls
_.-- —_ grantee--- RETURN TO --- —of_ S t. Croix_ —County,Wisconsin,for the sum of
Eleven hundred dollars
the following tract of land in___fit___C.r.oiX— ---___County,State of Wisconsin;
Commencing at the Northeast corner of the Northwest quarter of the Northeast ,
quarter (NW'-4NEI) of Section Number Eleven (11) , in Township Number Thirty-
One North of Range Number Eighteen (18) West; thence West to center of
Highway, One hundred eighty-two (182) feet• thence Southwesterly along
said highway, One hundred ninety-four (194j feet; thence East Two hundred
seventy-five (275) feet; thence North One hundred seventy-five (175) feet
to the place of beginning.
�I
IN WITNESS WHEREOF,the said grantor-S ha_Pee__hereunto set t h e i r- hand S__and seals this_._$
day of—------Ju ly------,A. D., 19 63_.
SIGNED AND OF CE SEAL DIN PRE
r � — (SEAL)
ritz N. Xsp]und
(SEAL)
---
(SEAL)
--L o-r a ne_ Johnson--------_ ------_-- (SEAL)
STATE OF WISCONSIN,
St. Croix 89'
x
.-- _ County.
Personally came before me, this_____8_ day or—__—_July__--------___—___--_ , A. D., 1963._
the above named.—_Fx—itz_K--As-plund_._and-Vi41_et_
to me known to be the person who executed the foregoing4nstruwent and acknowledged the same
T = Wm_ V YAXd_—
M� l
This instrument drafted by Wm. V. Wa' . I ��� ` ;tr Notary Public_a�t_�__�. _Q iX County,Wis.
•.,yll•. r '
My Commission(Expiree) (Is) Permanent
(Bectfoa 59.51 (1) of the Wisconsin Statutes provides that all Instruments to he rsoorded ship have plainly printed or typewritten thereon the
r,_of the arantore,pnnteee,witnesses tad notary): (]r
WARRANTY DEED—STATE OF WISCONSIN,FORM NU.N. ��JJ pA."E615 N.C.scare co.,suuucrs
H
� H
En
a
ST C - 105 r
, a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
a
OWNER/BUYER H
nn
ROUTE/BOX NUMBER Fire Number
.CITY/STATE ZIP S Ozr 2
Axi
PROPERTY LOCATION:A'r/'_ _k, NL k, Section_, T N , R _W,
Town ofs L?fJ��--Lrd�°/� St . Croix County,
Subdivision Lot number .4)1,
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 by the owner and by a master plumber ,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary) , the septic 'tank. is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. H
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- d
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 .
SIGNED C
DATE
St . Croix County Zoning Office
P.O. Box 9&
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• P.O. BOX 7969
HUMAN RELATIONS �� 1H ER CATION TESTS 115 MADISON,WI 53707
3 9 ) Chapter 145.045)
LOCATION: SECTION: TOW SHIP/ff0TdtB#iA�1�Y: LOT NO.:BLK.NO.: SUBDIVISION NAME:
'/4 E% /T N/Rt'y i (or)W :5T �0�rlrl -- w� �'� �
COUNTY: OWNER'S MAILING ADDRESS:
USE DATES O ERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence 1 ❑New Replace _
RATING:S=Site suitable for system U=Site unsuitable for system — a
C N ENTIONAL: M U D: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMM DED YSTEM:(o tional)
$ ❑U $ ❑U ❑U ❑S ❑S U ca
If Percolation Tests are NOT requAi,re DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: ►V � 2 Floodplain,indicate Floodplain elevation:
ET P MILE DESCRIPTIONS
BORING TOTAL D PTH TO GROUN ATER-W#@I+ES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER pSXR 141. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
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B- !V �c�a r L iR re
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- 1 o
P D 2—
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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 9V' L/
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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(21'In TESTS WERE COMPLETED ON:
,) 1^ —
A RESS: ^ CERTIFICATION 7R: PHONE NUMBER(optional):
2 V -S7
CST NATUR
DISTRIBUTION, Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395.(R.02/82) —OVER —
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 61395
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 IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
B. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. 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 boxes 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 {under 3„) LS Limestone
�s - Sand HGW - High Groundwater
cs - Coarse Sandi Perc - Percolation Rate
coed s - Medium Sand W - Well
fs - Fine Sand Bldg - Building
Is Loamy Sand > .- Greater Than
4 1 - Sandy Loam < - Less Than
'I Loanl Bra - Brown
.sil - Silt Loam Bl - Black
Si - Silt Gy Gray
*cI -- Clay Loarn Y Yellow
scl - Sandy Clay Loam, R Red
sicl - Silty Clay Loam mot -- Mottles
sc Sandy Clay W/ - with
sic .- Silty Clay fff few,fine,faint
Mc _.... Clay Cc -..- common, coarse
pt Peat mm - l'v iny, medium
rr! - Muck d - distinct
p - prominent
HWL - Nigh water level,
`
Six general s?i iI teXtUres surface water
for liquid vvaste 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
c ificatinn of this soil test in the field prior io permit issuance. A complete set of plans for the private
�r-gage system and a permit application must be subri'ritted to the appropriate local authority ira order to
obtain a penrlit. T'le sa r:tar� 'wrrnit mr.rst be obtained and posted prior to the start of an-
t
w;t
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PAGE OF
r o S S S z c I
Fresh Air InIels And Observation Pipe
^- Approved Vent Cap
Minimum 12"
Final Flna.� I�.+ Grate Zo
20-42"Above Pipe _4"Cost Iron
To Final Grade Vent Pipe
Marsh Hay Or Synthetic Covering
Min. 2"Aggregate
Over Pipe
Oletrlbution —Too
Pipe —~ 0 0 0 0
6"Aggregate 0 Perforated Pipe Below
h
Bonsai Plp• _
o Coupling Terminating At
Bottom 01 System
Prppoel� T't�kl 11grH���
tZJ2J..T
SOIL FILL
DISTRIBLITIOVI PIPE
APPROVED SIJNT}dETIC COVER
° ""`MATERIAL OR 9" OF STRAW
rOF&GOREGATE --� OR MARSH HAy
,�/',/� AGGREGATE
IELEV
CP / ti
DIS-rRiB'JTIOIJ PIPE TO BE AT LEAST iIJCHES BELOW ORIGIIJAL GRADE
AMU AT LEASTZO IAICHES BUT AIO MORE THAI) y2 RICHES BELOW FINAL GRADE
MAXIMUM DEPTH OF EXIC-AVAT100 FROM OKi&WAL 69AIDE WILL BE 1522 INCHES
PUNiMUM OEPtlt OF EXCAVATION FROM 0IIKk61WAL GRAPE WILL BE 3_ INCHES
SIGIJED
LICEIJSE DUMBER:
DATE :
1 1 0
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