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Form - S T C - 104
AS BUILT SANIT,.AY SYSTEM REPORT
OWNER C�`y �eaS /n TOWNSHIP Qy SEC. T 3l N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
5zla/
SUBDIVISION - LOT i---" LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILRR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
64,v
yt �
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: -46a, `P Proposed slope at site:
SEPTIC TANK: Manufacturer: l , zS Liquid Capacity: %QG
Number of rings used: CJ' Tank manhole cover elevation: --
Tank Inlet Elevation: Tank Outlet Elevation: ---°
Number of feet from nearest Road.. Front en Rear,
. �Or Sid �J ,jo lam feet
- From nearest- property line . ' Front,C Side,0 Rear,0 4PO.W /SG/ feet
Number of feet from: well �dD f- , building': Z f
(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:
Number of feet from nearest property line: Front, O Side, O Rear,p Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: 'IF Length: Number of Lines: Area Built:
Fill depth to top of pipe: 4 71p7`
Number of feet from nearest property line: Front, O Side, O Rear,G Pt .
Number of feet from well:
Number of feet from building: q '
(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, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
. Inspector•
Dated 1 .2 Plumber on job:
License Number: !
3/84:mj
i � "
DEPARTMENT OF, INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISOf1I,WI 53707 XXI$ A SOr# S28 T31N-R18G! CONVENTIONAL 1:1 ALTERNATIVE swesPlanLD.Nurnber:
Town G� StaA PAAi)Lie ❑Holding Tank ❑ In Ground Pressure ❑Mound
NAME OF PERMIT HOLDER: JADORESS OF PERMIT HOLDER: INSPECTIO DATE:
Chuck Bong�stAom 510 Bait Sixth. S tAee � New Richmond, CV 54017
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELE V..
Name of Plumber: MP/MPRSW No Cnu nty.. Sanitary Permit Number:
GIi 2%am S chumakeA G 3 8 2 St. aoix 112829
SEPTIC TANK/HOLDING TANK:
MANUFACTURER'. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER
�I q� Iq PRAYED: PROVIDED.
q?�� YES ❑NO ❑YES NO
BEDDING'. VENT DIA.'. VENT MAT[ HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT FRESH
/\ ALARM 1 LI'NE'. I� I� (� I AIR 1=-LET.
I/`/.L FEET'FROM
ED YES NO ❑YES ONO NEAREST en
DOSING CHAMBER:
MANUFACTURER BEDDING'. LIQUID CAPACITY PUMP MODE =NUF A(:T UHEH WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES
NO ❑YES NO ❑YES ONO
PUMP AND CONTROLS OPERATIONAL NUMBER OF PHOPERT WELL BUILDING VENT TO FRESH
GALLONS PER CYCLE: LINE AIR INLET.
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing IN(,TH FMFTIIJ V"'IT AHKwa
or excavation. (If soil can be rolled into a wire,construction shall cease until FORGE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TFtENCH WIDTH LENGTH NO.OF UISTH PIPE.sPACIN(. COV H INSIDE DIA SPITS LIQUID
THE NC HES n1A iIAL PIT. DEPTH.to DIMENSIONS
GRAVEL DEPTH / FILL DEPTH UISTR PIPE DISTH PIPE DISTR.PIPE MATERIAL NO [ It Nk111I1 R,(�IF PROPERTY WELL. wa RESH
BELOW PI S J / ABOV COVER EIEV.INLEI ELE V�yE N`U PIPS{ •�.•,FROM b „ LINE I� I�t� T
�a.rl • l �� ✓ 'NEAR-EST'--^,^— Irv'//,
MOUND SYSTEM:
Mound site plow ed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES ONO
SOIL COVER TEXTURE PFRMnN1NrMAHKEfvs oRSEHVanoNwEUs
[--]YES ❑NO OYES ONO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH RED IDIPT1101 TOPSOIL SODDFI) SD MULCHED
CENTER EDGES
❑YES. El NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH NO.OF LATE HA SPACING (iHAVEL DEPTH HE LOWPIP E FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL Nn DISTH DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
I.ELEV.. ELEV. DIA ELEV. PIPES DIA.:
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS
OYES NO ❑YES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. 0E.R 0F. PROPERTY WELL: BUILDING:
r FROM LINE:
❑YES 0 N ❑YES ❑NO ..
�. � Z1
�.9 f
a
o SS
Sketch System on I t Retain in county file for audit.
Reverse Side. ATURE: TITLE
, Zow%ng Admin-i�sttca�on
DILHR SBD 6710 (R.01/82)
Q RQ
U .--
SANITARY PERMIT APPLICATION COUNTY
'ZI DILHR In accord with ILHR 83.05,Wis.Adm. Code 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 LM NO
PROPERTY OWNER PROPERTY LOCATION
4e� % /4, S ,2 T N, R E (or)
PROPERTY OWNER'S MAILING AbDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
S" c T e
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
VILLAGE: .lam„ r�
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family Iq OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a.Z 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. XLconventional 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. [ ,See a e 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 per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): d d gyp(
3 is Feet APrivate El joint ❑ Public
VI. TANK CAPACITY 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
Se tic Tank or Holdina Tank l
L
El L F�
ift Pump Tank/Siphon Chamber ❑ E]
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) P PRSW No.: Business Phone Number:
(�!/l�'4H'► 5'c�l`Hi sc�(i°y ..mod" �3 3 3l 02 /'
Plumber's Address(Street,City,State,Zip Code): Name of y ner:
e•
VIII. SOIL EST INFORMATION
Certified Soil Tester(CST)Name CST#
a s .S'
CST's ADDRE Street,City,State,Zip Code) Phone Number:
^4A
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
®Approved F-1 Owner Given Initial urcharge(�F(e)e jo
Adverse Determination S1 c,cyL
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'f 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 Ater—
included the creation of surcharges (fees) for a number of regulated practices which Wisco !r`S
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Teitt#i a
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)
I
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 Y ec"
Location of Property , Section _� ".�, T_2j N-R8 W
Township S�a P( &r;e-
Mailing r Address
aim
-4 k
C-Z ��^J( 1 • S-10 I-I
Address of Site d,-:S-0 A
Subdivision Name /), ti
. Lot Number p Ae.
Previous Owner of Property r
Total Size of Parcel o2a , �,3 AcPares
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 ,P and Page Numbez5o�- 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 Map, the Certified Survey Nap shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) cehtti.6y that att 6tatement6 on th.iJs mm ane tkue to the beat o6 my (ouk)
hnowt.edge; that. I (we) am (ake) the ownek(A o6 the pkopen ty des cni.bed in thiA
.i.n6o4mati.on 6okm, by viAtue o6 a waAAanty deed neconded in the 066ice o6 the
County Reg4A tek o6 Deeds ad Document No. and that I (We) pked en tty
own the pkoposed .bite 6ok the sewage didpo6 by em (ok I (we) have obtained an
easement, to nun with the above dedcAibed pkopekty, bon the cond'thucti.on o6 said
dydtem, and the same had been duty neconded in the 066.tce 06 the County Regi6teh o6
Veedd, Document No. ) .
t
SIGNATURE Olt OWNER SIG URE OF C -OWNER F APPLICABLE)
DATE SIGNED DATE SIGNED
A '
I
DOCUINENT NO. =l+tip, ;li,�t i THIS SPACE RESERVED roN RECORDING DATA �•
ff WARRANTY DEED
STATE BAR OF WISCONSIN FORM 2•-19U
i 432135
REGISTER'S OFFICE
v�. 9f PASE ST. CM Co.,W1
Reed for R-RRrA
Richard J. Wier and Diane. M. Wier,..hust�and and wifer. as.. Nov. 13, 1987
......
joint..tenants
. ...................................
. ............................. ............................................ at 10:55 A M
....... .............. .......................... ......... ...
convey%, and warrants to .0 .m.%..WM4.4?►...4.nd
r'9tx' ,..#�>1s1, ►c1.. fe,.. ma .t�1..PY. ?......
rights of suryivorshiP .............
. ....... ...... . .....................................
.__. .. ............................................................................ ....... ....... ..........
it ......... .. ..................................................... .... RETURN TO
.. ... ........... .................................. .......... .........................
i ...... ...... ............................................................ .... .
the following described real estate in ......Ste---CXC?7iX........................County,
State of Wisconsin:
Tax Parcel No: ..............................
A parcel of land located in part A the Northeast Quarter of the Southwest Quarter (NE}
of SW}) and part of the South Half of the Northwest Quarter (Sj of NW}) , ALL in Section
TW my-eight (28) , Township Thirty-one (31) North, Range Eighteen (18) West, further
described as follows: Commencing at the South quarter corner of said Section Twenty-
eight (28); thence North 000 39' 14" West, along the North-South quarter line, 2450.81
feet to the Point- of Beginning of this description; thence continuing North 000 39' 14"
West, along said line, 735.24 feet; thence South 880 47' 00" West, 1317.13 feet; thence
South 000 41' 58" East, 735.24 feet; thence North 880 47' 00" East, 1316.54 feet to the
Point of Beginning. MGETHER WITH and SUBJECT TO a 66 foot wide Private Road Easement
located in part of the Northeast Quarter of the Southwest Quarter (NE} of SW}) and part
of the South Half of the Northwest Quarter (Sj of NWT) of said Section Twenty-eight (28)
to be described by centerline, the sidelines of which lie 33 feet distant as measured at
right angles on each side of the following described centerline: Commencing at the South
quarter corner of said Section TWenty-eight (28) ; thence North 000 39' 14" West, along
the North-South quarter line, 1314.70 feet to the Northerly right-of-way of the Town Road
as shown on Certified Survey Map recorded in Volume "6" of Certified Survey Maps, page
1615, as recorded in the St. Croix County Register of Deeds; thence South 890 46' 14"
West along said right-of-way, 657.83 feet to the Point of Beginning of this centerline
CONTINUED ON REVERSE SIDE
This , -!<a*...... homestead property.
(is) (is not) t
r
Exception to warranties:
EBB
r
Dated this . . ..... .. 7.��C ..._......... day of NON.. . _ _. ... _.., 19.87
(SEAL) _. _.. _ .......(SEAL)
__. ..... . .. ..._...... ..... ................... • .Ri t.. J, W
...................(SEAL)
• .. . . ............................. ............ • .Diane..M.. Wien. ... .
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN
Signature(s) ............................................................
... sa.
..............••..............................----............... .............. St Croix
......................................County-
authenticated this ........day of........................... 19...... Personally came before me this .....7......day of
November ................... 19.87... the above named
...........................•-•-•-•------•-•----.....................••-•--..---• Richard J. Wier and Diane M. Wier
-•...............••----------------...------.....----•----•-•----........------.
•
.............. .....................................................TOUNB.N[A.. SM
TITLE: MEMBER STATE BAR OF WISCONSIN _________________________ NOTARY-PUBI,IC_
(If not........................ S PATE OF�tiISCONSIN
............. . ........... .... . .... .. ....... ... ....... . ............
authorized by 4 706.06, Wis. Stats.) I: '-1%1lAI%:ast
to me known to be the person ...... .... wRg WO{�1 the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Beinstr,4..Van..Dyk.b..Needb=4..S..C...............
Atto ys at� Law *_John R,-..H,�s�5ch..... __.. ........... ._... . ..
New-Ricc hnic�rmu,.-WI....5. 017-D127........................ Notary Public .... ..St,, Croix _____County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration
are not necessary.) date: .10-02-88....... _ ..._....1 19 ... )
eNanw of persons signing in any capacity should be typed or printed below their Pignature,
RGNWNwEaIOS�M® STATE BAR OF WISCONSIN
FORM No. 2— I102 SfOCI( NO. 13002
h '
P6)W raw
vk 111e)&
+
COUTINUED FMM REVERSE SIDE
n `
00° 40' 36" West, 263.85 feet to the point of curvature of a
dpsaxipon;% thence North
1900.22 foot radius curve concave Easterly whose central angle measures 08- 9rtYterly along
whOSe chord bears North 030 39' 10" East and measures 286.90 thence North 07° 58' 56"
the arc•of sai&-,tJrve, 287.17 feet to the point of t.angencY%
East; x.24.10 feet to t?* Point of curvature of a 646.54 foot radius curve concave Easterly
whose ceritraJ ang'lt`tftasures 240 00' 20" and whose chord bears North 19-59fe06 Easthe�
measures 268.91 feet; Ithence Northerly along the arc of said curve, 2
point of tangency; thence North 31° 59' 16" East, 302.49 feet to the Point of curvature
of a 242.74 foot radius curve concave Westerly whose central 26 gle eas;rt1 661 Northerly
and whose chord bears North 010 24' 09.5" West arid measures 267.1 thence North o 47'
along the arc of said curve, 282.92 feet- to the point
35" West, 127.46 feet to the point of curvature of a 286.64 foot radius curve concave
Southerly whose central angle measures 72° 27' 18" and whose chord bears North 7362048
14" West and measures 338.80 feet; thence Westerly along the arc of said curve,
Feet to the point of tangency; thence South 720 45' 07" West, 9.23 feet to the point of
curvature of a 355.28 foot radius curve concavP Northerly whose central angle measures
430 00' 52" and WY.,ase chord bears North 850 44' 27" West and measures 26C.50 feet; thence
Westerly along the arc of said curve, 266.72 feet to the point of tangency: thence North
640 14' 01" West, 120.86 feet to the Point of curvature of a 550.01 foot radius curve
concave Northeasterly whose central angle measures 12° 27' 05" and whose chord bears
North 580 00' 28.5" West and measures 119.29 teet;�th thence North 51st461y561 est,e99.84 f
said curve, 119.53 feet to the point of tangency;
j feet to the center of an 80.00 foot radius cul-de-sac, said center is the end of this
centerline description. The sidelines of this Private Road Easement shall be shortened
centerline
lengthened terminate at the Northerly right-of-way of said Town Road. Above
described parcel is SUBJECT to all other Easements of record.
ALSO SUBJECT TO THE FOLLC7WING RESTRICTION:
That Grantees shall not house, nor permit to be located on the above described PrOPerty►
any pigs, cows, beef cattle or other. farm type
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
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OWNER/BUYER
ROUTE/BOX NUMBER n ¢ oYD _Fire Number
CITY/STATE ttw � C.kp.n,1 INI 1 ZIP \S__ o1'7
PROPERTY LOCATION : _3L, Section _, T_ _ N , R/r-W,
Town of .S;La tle St . Croix County ,
Subdivision __— Lot number#e-.
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
0
E
I/WE, the undersigned , have read the above requirements and agree
to maintain the private sewage disposal system in accordance with H
the standards set forth , herein, as set by the Wisconsin Depart- ro
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
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
IpIDUSTf�Y, DIVISION
LABOR AND P.O.BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON,WI 53707
(H63,09(1)b Chapter 146.045)
'LOCATION:IV, TOW S i NI IPALITY: V NAME:
COUNTY: I QWN Y? NAME:
L) f2S u R1 G,N MONA
USE11 (IDATES OBSERVATIONS MADE Cc
1,UFlesidencs (L tv�, CO € TI New ❑Replace l L 23, /9 80 se I1- 24 f/9 O 9
t4 -llllEMlYlaQT-
RATING:S-Site suitable for system U-Site unsuitable for system D - r
ICOSOVJ�I ❑�. M,QfI�.�� i � a� � D�L �DI_G 7 NK:RECQMMENDED SYSTEM (opFnal)
(trk��i S
If Percolation Tests are NOT required DESIGGN RATE: if any portion of the tested area is in the
under s-H63.0915)(b),indicate: (.(./4� t Floodplain,indicate Floodpiain elevation: ►Y
PROFILE DESCRIPTIONS
BORING AL ATE -IN H -CHARACTER IL L�FfjEXUR,AND DEPTH
NUMBER DEpMjW, ELEVATION OB RVEQ TO BEDROCK IF OBSERVED(SEE ABSRV.ON BACK.)
B- I 19-1-z MS > 7.9 44''13p►�►�1 a' C 6n �N 11'I
B- 'z it .0% 97.54 r43 P4 .08 2e 8QW I,\S Q4'' /6" csi6 R 66-6 M-5
S. > 116 9z O.U6 r > 8,9�
q p �SCT{ i9"BQN►"►� s'GR cs 4 " R O'iej
B-
B-
B-
PERCOLATION TESTS
DEEPT WATER N HOLE TEST TIME RATE MINUTES
NUMBER IR]CN AFTERS WELLING INTERVAL-MIN. PERIOD I OD 2 PER105 3 PER INCH
P. r 39 ct > <
P. 7 Z.SU r4cwt 9 7 > >2
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 9,5
_ �► hla►n't -To fair
OD i.Itgoo'�
�Eric►tMa�K- NA%L ttq. 11" !C�
PINL I4i`"f tu.144T14N- W Uoj j
4 as TN
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A1LPLAccmtn/T ditsr�s,. Ta►s
I�h1E TO GET sysT6M CWSt� To
I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specifiers in the Wisconsin
Administrative Code,and that the data recorded and the location of the tens are correct to the best of my knowledge and belief.
NAM grant : T S WERE COMPLETED ON:
�-14P_ -1vR1 'L �y 14 "f .��f >' wC, IN<. 2 i9,1%
AD(7n� . , CERTIFICq/ATIO NUMBER: PHONE/NUIV(BER(optional):
6-7 CST SIG URE: f
DISTRIBUTION:06tional and one copy to Local Authority,Piaperty Owner and Soil Tester.
DILHR-SBD-6395(R.02/62) —OVER —
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