Loading...
HomeMy WebLinkAbout040-1212-10-000 v � I V C h III d h O N ~ C L ° <o ° ° ch E 80 w II � ° sue Y oo� a c C c v, E" � t > Z m ° I c a a� a o Om)o 0.0 I � o E o O 9 0 I � o I Q w °F- ( M v � a3i I Z Li I rn E co = °o q. V I o I O z �+ c w, w ° N H r c o d co N c 0 cc C 0 •� III D o o Q O (1) 0 Z m Z o � Z ! fd C '2 i 41 N W W E (mil > .. V li it mym � o oca �lJ o 0 3 o U I a = o z •� aaa IL _ }� 7 O N N aD M ° U) J U 2 Z rn rn o N N N w 0 0 0 m .0 E CL N N N 2 N .� N Q } CA CO 1� Li O N fyA C 0 ° oo ° d c CL g l r \ c E o c IF lrx') N 7 M N Z C N ~ O N O p O N p v •O o O F— O Z R III !T v� 1 4) a I EL 4, • e""e o- m .2 m a c `Iv y E t c [� —1 A U CL N V t Parcel #: 040-1212-10-000 07/15/2005 03:13 PM PAGE 1 OF 1 Alt. Parcel#: 07.28.19.1009 040-TOWN OF TROY Current X ST.CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner SUSAN M SYFKO "SYFKO,SUSAN M 312 W GROVE RD HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *312 W GROVE RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.034 Plat: 2597-WEST GROVE ESTATES SEC 7 T28N R1 9W LOT 10 WEST GROVE Block/Condo Bldg: LOT 10 ESTATES Tract(s): (Sec-Twn-Rng 401/4 1601/4) 07-28N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/08/1999 606521 1440/448 QC 07/23/1997 820/454 07/23/1997 811/169 07/23/1997 784/400 2005 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/22/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.034 87,800 266,400 354,200 NO Totals for 2005: General Property 2.034 87,800 266,400 354,200 Woodland 0.000 0 0 Totals for 2004: General Property 2.034 87,800 266,400 354,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 116 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 I ' QU� _K J Vr)gZ _S TOWNSHIP Ik 0 SEC. 7 T �JN-RAW ADDRESS a 13 locust ST. CROIX COUNTY, WISCONSIN kLA 4 S otj U 5(. � SUBDIVISION W'P_ -.L- GKCUQ LOT /0 LOT SIZE PLAN VIEW aya-iaja / /00 Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I &D �- — — — — — — I � 3a' W ! 0 13, I op 3 BcDoom, RotrtF INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 5 `EF_I FE N(, Q �- ��`` o Elevation of vertical reference point: V .nn V� Proposed slope at site: _ SEPTIC TANK: Manufacturer: W E z kS Liquid Capacity: 000 C Number of rings used: 3 Tank manhole cover elevation: II �, J Tank Inlet Elevation: ��,�$ Tank Outlet Elevation: Number of feet from nearest Road: Front,©Side, Rear, O Q10 feet From nearest property line Front 10 Side,®Rear,O �J feet Number of feet from: well J , building: 3 (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 Ft. ,. Number of feet from well: Number of feet from building: (Include distances on plot plan). Shut100-46 Hep (*3 ' �0S-R: �s• f*O 1 I q.(03 �ND l0S SU " 10S..:S V SOIL ABSORPTION SYSTEM IU .$ 10 . Bed: V Trench: Do tm lh Q¢b Width: O Length: 3�e Number of Lines: 3 Area Built:_ Fill depth to top of pipe: l )11 Number of feet from nearest property line: Fronts ,O Side, O Rear, Pt . p�S Number of feet from well: la o Number of feet from building: 30 (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: i I Area Built: Has either a drop box or distribution box been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector• Dated: Plumber on job: License Number: 'TTR503"163 3/84:mj I ' DEPARJ�UNT OF.INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LXBOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 SW%,SW%,S7,T28N—R19W aCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: (If assigned) Town of Troy ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 10 Westgove Estates NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Moser Homes 213 Locust Street Hudson WI 1 —d- `30 BENCH MARK(Permanent reference Pomtl DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber MP/MPRSW No.: County: Sanitary Permit Number: Richard Hopkins 1059 St. Croix 106132 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET j?, j B L LOCKING COVER PROVIDED ❑NO ❑YES ®NO eEDDING-. VENT DIA.. VENT MATL.: HIGH WA ER NUMBER OF ROAD, P . BUILDING. VENT TO FRESALARM AIR INLET❑YES ANO �� ❑YES NO NEARESTM 1Q 0. 1 .3 DOSING CHAMBER: `7 MANUFACTURER IBEIYES EDDING'. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTLIRER WARNING LABEL LOCKING COVER OVIDE PROVIDED: ❑NO Y ❑NO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPE Y W L BUILOING VENT TO FRESH (DIFFERENCE BETWEEN LINE AIR I"LET FEET FROM PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETE TE IAL ND 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 TRENCHES. ' M TERIAL. PIT DEPTH DIMENSIONS ..� GRAVEL DEPTH FILL D P UISTR.PI PF DISTR.PIPE DISTR.PIPE MATERIAL. NO DI R. NUMBER OF PROPERTY WELL BUILDING V NT TOTE HE511 BELOW PIPES ABOVE COVER. ELEV.INLET ELEV.END PIPF, FEET FROM LINE �O ALE NEAREST 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. OYES ONO SOIL COVER TEXTURE PERMANENT MARKERS 014SEHVATION WELLS OYES ❑NO ❑YES NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. DYES ONO El YES ONO ❑YES El 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 DISTR DISTR.PIPE DISTHIBUTION PIPE MATERIAL&MAHKINI; ELEV.. ELEV.. DIA.. ELEV.. PIPES DIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED OHRECTLY COVER MATERIAL PLANS LIFT CORRESPONDS TO APPROVED ❑YES 0 N OYES 1:1 NO C MENTS: PERMANENT MARKERS: OBSERVATION WELLS'. NUMBER OF PR OPERTV WELL: BUILDING: FEET FROM LINE C ❑YES ❑NO El YES 0 N NEAREST q Q Sketch System on / '' `' Retain in county file for audit. i Reverse Side. SIGNAT URE. TITLE. Zoning Administrator DILHR sBD 6710(R.01/82) I DILHR SANITARY PERMIT APPLICATION COUNT In accord with ILHR 83.05,Wis.Adm.Code ^��• �- STATE SANITARY PERMIT# /v Co 13 a —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 L'J No PROPERTY OWNER PROPERTY LOCATION 6 S� '/a W 1/4, S T.� N, R � E (or)W PROP TY OWNER'S MAI ING A RESS LOT NUMBER BOCK NUMBER U DIVI ION NAME NA f­�t Groy -EAQ 5 CITY, TATE ZIP ODE PHONE NUMBER CITY RES ROPED,LAKE OR L DMAR ( 0 VILLAGE: Q (� U a L5 L CRI TOWN F II. TYPE O BUILDING OR USE SERVED: v Number of Bedrooms if 1 or 2 Family. OR ❑ Public(Specify): COMqt M60 Be d- 111111. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. XNew 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. aX'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. MSee a e Bed b. ❑Seepage 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): (015 (p V .J Feet Private ❑Joint ❑ Public CAPACITY VI. TANK in allons Total #of Prefab. Site Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank l000 I we" 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' Name(Print): Plu er's Si nature:(N Stamps) MP/MPRSW No.: Business Phone Number: N to Plumber's Ad r ss(Street, ity, t e Zip ode): N e of�esigner- -ew C. N I�S C. d C, 111) 0 VIII. SOIL TEST INFORMATION Certified Soil Tester( ST)Name CST#G03 CST's ADDRESS(Str et,Cit fate,ZMi od ) Phone Number: gd b L- IX. COUNTY/DEPARTM NT USE ONLY ❑ Disapproved anitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) $.Approved ❑ Owner Given Initial S rcharge Fee Q¢ Adverse Determination 126`06 K..v 1,1c,-D `n Rzy h, X. CO MENTS/REASONS FOR DISAPPR V d^-) 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'h 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 .fir included the creation of surcharges (fees) for a number of regulated practices which Wisco th t can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasur @'€ is used in your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. 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- 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/contractgr, ("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 Propertyp �iwjJ . Location of Property LJ_ CL,-,' 34, Section , T N - R Jq W Township Mailing Address Subdivision Name ,�%r (� (r� t L) Lot Number d — Previous Owner of Property /410 'i l Z j 'fk? Total Size of Parcel CAL,✓ 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 1 _ and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) eeAti.6y tAat aeQ 6tatement6 on .th,ia 6onm ane tAue to the but 06 my (ouh) knowledge; What I (we) am (one,) the owrien(4) o6 the pn.opehty descAi.bed in th,ia in6aunation i6onm, by vi tue o4 a waAAanty deed &ecoaded in the 066ice o6 the County Regiz ten o 6 Deedb ah Document No. ; and that 1 (we) pneeent.2y oun the phopobed .6 to bon the aewage Y—Upa6dt aystem (on I Iwe) have obtained an ea.e ement, to tun with the above des e&i.bed pnopen ty, bon the conhtn.uctiov, o6 ba, d dybtem, and .the aame ha6 been duty %eco4ded in the 066ice o6 the County RegizteA o6 Deeda, as Document No. 1 . SIGN Un OF OWNER SIGNATURE CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED it I i) DOCUMENT No. I STATE BAR OF WISCONSIN FORM 1-19821 THIS SPACE RESERVED FOR RECORDING DATA it II WARRANTY DEED + �I ': 8 Boon REGISTER'S OFFICE II This Deed, made between ..Rue__R.__ ElstOn__and___________ __ ST• CROIX CO., WI I Cara._L.__Elston,__-husband__and _wife.................................... Rec'd for Re?cord -------------------- ---------------...------------------------------------•----••---- •---- --- . MAY 19 1988 I ...........................................................-.........-............................, Grantor, .., - and._____Wayne_ F. Moser and Murray. A, Knecht, as at 11:00 A. tenants.. in common:....................... ....... M I, ... ....---• -• ................ ----•--•-----------------• •-•-------••----••--••---•-•--------..._.........--------•--••----_..... Grantee, R Of Deeds Witnesseth, That the said Grantor, for a valuable consideration_0ne'i ($1_._QO)__Do11ar__and_•other __-good_.and••valuable-_consdleration - • j RETURN TO conveys to Grantee the following described real estate in ........8 ,... Q .? .... I! County, State of Wisconsin: II Lot Ten (10) , Plat of West Grove Estates in Tax Parcel No: ................................... the Town of Troy. Together with and subject to easements , covenants , reservations and I{ restrictions of record. FIEa EXEMU it I This ...--?S.-_l]_Qt--------- homestead property. Together with all and singular the hereditaments and appurtenances thereunto belonging; And...... �baz�d..and..Wai.fe.............. ......... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except!. g � P P easements , covenants , reservations and restrictions of record; . and will warrant and defend the same. Dated this -------__18th 1988 -------------------------- day of •--•---•----•••-••••----Ma y------•--•-•----•---••--............ . .... ---.•--------•----•---------------•---•-•---•••--••- ................ . ........ .....•-............ .......(. (SEAL) I� ---------•------------------------------------------•---- ------- Rue R. Elston �) -- .......................(SEAL) ---(SEAL) * ----------------- ---•-•--•-•-•-•---•--•---------••-•-...... * •--C1ara..L....Elston........................... �i ALTTHENTICATION ACKNOWLEDGMENT Signature(s) ------_------------ STATE OF WISCONSIN � i --------------------------------------------- Pierce ss. ----------------------- --------------County. authenticated this ._..••..day of--------------------------- 19------ Personally came before me this ---I-ath---day of it ¢,i.......................May---------_-, 19._a$-. the above named -----Rlue._R --1.1ston...and... J a.ra..L,.___E1.s.ton;i *---------- ------------------------------------------------------------------- .....husb_and_.and_.ia-i.fe,----------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN - - ---- --------------- (If not- ------------- ----------------------------------------------- authorized by § 706.06, Wis. Stats.) to me known to be the person$........... who executed the fore oing instrument and acknowledge the same. �� _ �zv THIS INSTRUMENT WAS DRAFTED BY 1 Charles...E_....White,...Attorney-_at._Law *---Mary--.E. ...Caha].an-------------------------------------- ._ y_er__Falls.,. WI 54.022 Notary Public .. e ge My Commission I (Signatures may be authenticated or acknowledged. Both are not necessary.) i XX--expLres •September---29L ., 19-19-1—) "Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 1-1982 Milwaukee, Wis. 'L N y, STC - 105 y SEPTIC 'TANK MAIN'T'ENANCE AGREEMENT o St . Croix County o ' y H ,OWNER/BUYER ROUTE/BOX NUMBER Fire Number CITY/STATE ,/d,ju,3 w/ _ZIP PROPER'L'Y LOCATION : � .J jLL, t/ Sec t ion '1' tl , R/C� 'W Town of St . Croix County , Subdivision ��(� re0UK_ Lot number. Improper use and maintenance of your septLe system could result in its premature failure to teandle wastes . Pruper maintenance can sists of pumping out the septic tank every three years or sooner , if needed , by a licensed septic tank L mLr. 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 nsa� be eligible `Lu receive a brunt for. a maximum of 60% of the cost of replacement 'of . a failing system, which was in operatinn prior to ,luly 1 , .1y7f3 :` St . ..,. roix County accepted this program in August -.01.1980P. with` the - requirement that uwners of all new systems agree to- keeli their systems properly maintained , The pr.uperty 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 ur 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 bf sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. Ho I/WE, the undersigned , have read the above requirements and agree E to maintain the . private sewage disposal system in accordance with rx, the. standards set forth , herein, as- set by the Wisconsin Depart- ^d went- 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 may. DATE OL St . Croix C:)unty Zoning Office P. O. f-ox 98 Nammoid, WI 54015 115-756-223 or 715-425-8363 Sign, date and return to above address . DEPARTMENT OF IL BORINGS AND !A SAFETY& BUILDINGS INDUSTRY, REPORT ON SO DIVISION ND •� P.O. BOX 7969 LABOR A HUMAN NDATIQNS PERCOLATION TESTS (115) MADISON,WI 53707 (1,163.090)&Chapter 145.045) OWNSHIP/h1I C :_OCATION: SECTION: O O UBDIVIS NAME: s W '/,00/ ' 7 /T 7_s N/R ry E lorW s ttk5��ff s—AS-A COUNTY: OWNE 'S BUYER'S NAME: A I Got SS 5,4/MD-W, 213 lK,,s 7't soy w'' Syv�c USE DATES OBSERVATIONS MADE F_ NO.BEDRMS.: COMM R DESCRIPTION E TS: �Residence 3 NIA New ❑Replace L7 �'7 RATING:S=Site suitable for system U_=Site unsuitable for system C NV� fl❑�. M�.�� IN-G � ❑�R : SQ M-IN-FILL a1NG TANK:RECOM SYSTEM: Pt' nal) S S J�OGj}�V� IF Percolation Tests are NOT required DESIGN RATE: rN If any portion of the tested area is in the X/C=9(5)(b),indicate: �� Floodplain,indicate Floodplain elevation:- J I PROFILE DESCRIPTIONS iBORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH ELEVATION OBSERVED MUffFST TO BEDROCK IF OBSERVED SEE ABBRV.ON BACK.) EST. �s�d✓s!/.c�'�3,�lfs,. s•By�s,>�,,.�3'B�n�s, y,�2athcs r'd s/ 1,/7 2.51' 33164/1 /off n s� , n .5 y� '15-V tS Bn LS El- 3 OY.S� 1 �, p 3 ' 'or s •7 S'Bn�c Sd�r,,Z�Y'c S 9 /,,yL, B 70 5' '75 _ O s ! ,92'b s f Z.S�'on/ s� • Q/�n.s =r >r qi►c s��r Z.�7 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-iNCHES RATE MINUTES ('NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD PER INCH P- S a P. 3 6 < 3 P- A P- P- P- 'LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- ontal 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 )f land slope. SYSTEM ELEVATION xo S-Z r A A, �Da pal i s /Q-s Ad 6,43 p ` G i /0 : the undersigned, hereby certify that the soil tests reported on this form were made b in acd"with the procedures and methods specified in the Wisconsin 4dtninistrative 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 W RE COMPLETED ON: �_ ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): CST SIG T DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. �It.HR-SBD-6395 fR.02/82) —OVER -- ;.. . Q... .. _6 7 . P OT A H 1 , � .' 1-1 0 S IS 5 E NAMEs.).E K N .A M E — - _ c ,t - - - C • AT I 0 , 4 s x � � i_ I C E N S E _�__.... �.-- - -- P T L 0 �� NofiE �kRfi � �'1��►� loo T k � � L to(��:��.��►+Id � \ � � s O'�'fi F20M �P� l`S A loo.4 SIET. 1 fc4ce Past on ZrAs . ApPrzox ��o�fi � 9�a N lie s T GA01) FRESH ATI'. TNLI:'.CS-AND OBSERVAT1ON I'T.2E C1 03S SECTION Approved Vent Cap Minimum 12" Above Final Grad0.___.-`(-- ��t1N ! :SRI.JA 4" Cast Iron Above Pipe Vent Pipe To Final Grad*- - Marsh Itay Or Synthetic Covering Min. 2" Aggreg'.11 _ Over Pipe DistribtiL-i124>. �-- Tee Pipe _..._....__ I Aggregate lD Per-forated Pipe Below Beneath Pipe <- CoLipJi.ng Terminating At J. "'"`� �/ BoL- L-om of System q. . k. 1 � GIs _ Av, �a" I lilt ,9 � � a�B•�' fie" � y' �_ �,_ a ? yy ,� 1 ; i ` � 3 J �t �+ 'Y yg�3y��r,M s A �k