HomeMy WebLinkAbout040-1213-40-000 ti 0 °fin,
� I
a
d
C O Or-
Ile r
N OF
i C r N O N to
N E N W N
s cr am 3 Z3
> j
=
CD rn rn
� 3
U L O 'mc,
° o
N CO N
3 7 w
O N C N
+L-L!_
U) N @ C1 O C
C Z C,L M 7 7 Q O
m 2
ao ca
(D x c ca ca_Cpp
Q C.mw 3 U
i
� N Cl)
� Z y
0) 3: ; E
Z O
z :';z:
oF- Uw am
a
o z
C
0
o z
.� m �
d Z � w
0
o c z
U) I- F O
c E '2
o M
d o �
rn
m v
m �
•N Cn
d 0 O L_
(,l i � fp N
1� O N Q O U O
0 Z m Z o
N ! z o I
d
_` t• N
O
U O. '0 w
24 m
o a
r0 rrr
0 3 3 3 D o
CL co T-
0 0
m z
•N oaa
o N c
rn rn
N J C V
0 O CV � N DOi W O
M CO .. 0 N
Z O O
O 7 N •- N
^ O m y C a O (O 00
�i,• �I 2 'O y 2
Q cn m
O O O w CO
N Cl) W d O to O 0 o CA
C
Lw O O C U A O O O CA
>.r M O 3 E C
O Cl) LO M N
O O N N N Cp
cli co � .NO. C N M CO W
• � co OO o
cli
O N R U
O lo o F- ! W o Z 2 U)i
C�
� •L Lai
E
_,1 A c0 Ii 2 O U) u b-
Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ,JIr"N 10.5'1 r�-O,t TOWNSHIP -ff,> SEC. T N-R n_C�
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION Re n �(''d r-K A& LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of II,HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3 a•�pR��c�r��
110m c.
j �
1 d
Oaf/
171
0
ILI
/r � IC►'
k �
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used ( y�t�'� Ivek� �U Sl�l1►01', SIK
Elevation of vertical reference point: 100-0, Proposed slope at site: _
SEPTIC TANK: Manufacturer: WIC k Liquid Capacity: jOOC�C�r.� �
Number of rings used: �" � Tank manhole cover elevation: �0j.Tank Inlet Elevation: 'OO. r Tank Outlet Elevation: q / Tl
Number of feet from nearest Road: Front,O Side,( Rear, O ,��Q feet
From nearest property line Front,0 Side,0 Rear,IVY
feet
Number of feet from: well building: u
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
RRR RR.VRRSR 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,Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances o lot plan). e
shoi r. � 10176 P eR a8 97 �
SOIL ABSORPTION SYSTEM �00:0 0 8 6 U END %35 94a. lS
Bed: ✓ Trench• �ottor►Rod
Width: ' 0 Length: 3�p Number of Lines:� Area Built
Fill depth to top of pipe: yak
Number of feet from nearest property line: Front, O Side, ( Rear,O Ft .�
t Jam/
Number of feet from well: I�V
Number of feet from building: L
(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:
i
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:
d
Inspector•4 //
Dp
Dated: �p' $ Plumber on job: D
License Number: ,SP95 0374.E
3/84:mj
i
i
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT c
OWNER J1 I�'� �' �05'1t EkKLt TOWNSHIP d SEC. T a 0 N-R�
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION I?xb BfZJ C,k �4�'_ LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•IHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
3 �eDRc>o/''1
HoM P,
loa
�000Ii a
XT
/ 1
i
Ids
b'
'T
1�x3� Bed N
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used UUI.I e '�" W CNN.Q �l
GR �1 k � S
�, K
Elevation of vertical reference P oint: b�-Q Proposed slope at site: u
SEPTIC TANK: Manufacturer: WCCkS Liquid Capacity: 00 6 b
Number of rings used: �` I Tank manhole cover elevation: I0J.4d s
Tank Inlet Elevation: 100- Q8 Tank Outlet Elevation: 9 9.97
Number of feet from nearest Road: Front,O Side,Rear, O l feet
From nearest property line Front feet, � 3
Number of feet from: well ��, building:
(Include this information of the above plot plan) ( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
s
� T
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&rHUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707 State Plan I.D.Numbec
SE�,NW%, S8,T18N—R19W ��ONVENTIONAL El ALTERNATIVE❑ El IHasst,anedl
Town of Troy Holding Tank In-Ground Pressure Mound
Lot 8 R
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTIO A E:
Jim & Josie Ehert 409 Helen Street N. Hudson WI 54016 �! � $� -XJ0
BENCH MEA K(Perm,ane�ntt eference point)DESCRIBE IF DIFFERENT AFROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV..
Name of Plumber: IMPIMPRSW No.. County Sanitary Permit Number:
Richard Hopkins 1059 St. Croix 102868
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
a PROVIDED PROVIDED.
r !' Q /Do' 7-8 YES ONO ❑YES NO
BEDDING. VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD PROPERTY WELL: BUILDING. VENT TO FRESH
ALARM /' LINE ,1 hh �. j AIR INLET
❑YES NO ❑YES NO NEARESTM �UU / 3�l �V
DOSING CHAMBER:
MANUFACTURER BEDDING'. LIQUID CAPACITY AP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
OYES ONO ❑YES ❑NO DYES ONO
GALLONS PER CYCLE: P AND ROLSOPERATIONAL NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) Y S E:1 NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil m ist eat th depth of plowing LENGTH IDIA111TER MATERIAL AND MARKING
or excavation. (if soil can be rolled into a wire co structi shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH
WIDTH / ILENGTHTRENCH DISTR PIPE SPACING COVER 1 TERIA L: PIT JINSIDE DI j tt PITS D PTIf j
36 DIMENSIONS
GRAVEL DEPTH ILL DEPTH fILISIVI PIPF DISTR.PIPE DISTR.PIPE MATER( NO R NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
BELOW VER. E INLET ELEV END. G]' PIPE�j LINE —7 AIR INLf.T
17' 1 7 s00 / v NEARESTO--► 5 wO 7
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.
DYES 1:1 NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSEHVATION WELLS
YES ❑NO ❑YES ONO
DEPTH OVER TRENC H!BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
DYES ❑NO DYES ONO 1:1 YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM: NO.OF BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MAHKIN6
ELEV.'. ELEV.. CIA ELEV. PIPES DIA:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES NO 1:1 YES NO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE
DYES 1:1 NO ❑YES 1:1 NO NEAREST
l* 1
I '
-3.Ij
Sketch System on Retain In county file for audit.
Reverse Side.
SIGNA RE'. TITLE
DILHR SBD 6710(R.01/82)
/I,tJo oning Administrator
SANITARY PERMIT APPLICATION COUNT
DILHR In accord with ILHR 83.05,Wis.Adm.Code • CK
.....�. STATE SANITARY PERMIT#
—/j 9
—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 ® NO
PRO TY OWNER PROPERTY LOCATION
M
QSI E .5C %N 0%, S T , N, R1 E (or)W IVA PROPERTY OWNER'S MAILING AD RES LOT N MBER BL C NUMBER BDIVISI NAME cl)LICR
CJTY,STATE zIQ C DE PHO E BER CITY N EST R AD, KE OR L NDMARK S(S ILA Q 0 VILLAGE:
II. TYPE OF BUILDING OR USE SERVED: oc o— la
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): aNVeNkfujAl 15eG(
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
1. a. � 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. ,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. K Seepage Bed b. ❑Seepage Trench c. ❑SeeDacie 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): / �l
1 T tp V Feet Private Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper.
INFORMATION New xisting Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holding Tank 10GO ��FE�Lift Pump Tank/Si hon Chamber ❑ 1 ❑ ❑
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:
Ic ra a0
Plumber's Address(Street)ICit yI(_hM9/\Ja tate, ip Code): Name of D signer:
t . r/ IL goj2KI N
VIII. SOIL TEST INFORMATION
Certified SCo,�Teste`er(CST)N me � t , CST#
W tu 0
CST's ADDRESS(Street,City,State,Zip de) Phone Number:
1301 10"j, S p(AASGit4l U s C S y01� S 38(o- 31
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuin Agent Signature(No Stamps)
L,N FA Approved ❑ Owner Given Initial / Surcharge Fee
r�.�\ 2
Adverse Determination t/ 2�'a c&,(. )
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
Ir_
i
WNW --
i
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
um er whenever necessary, usuall, ever 2 to 3 ears;
P P Y� Y Y Y
6. It you have questions concerning you r private sewage system, contact your local code administrator or the
State of Wisconsin,Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. Property owners name and mailing address. Provide the legal description where the system is to be
installed;
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'/z x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
--------------------------------------------------------------------------------------------------------------------------------------------------r---------
GROUNDWATER. SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection This change in statutes was the
result ci over 2 years of steady negotiation and public debate. The groundwater bill Ground L��r
included the creation of surcharges (fees) for a number of regulated practices which Wisco iCtrS a
can effect groundwater. The surcharge took eff ect on July 1, 1984. All o` the A ater that buried I 5t2rE3
is used in your building is returned to the groundwater through your soil ab:.,.:rpti;,n e
system or the disposal site used by your holding tank pumper.
0
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
ka«ter, groundwater contamination im,estigations and establishment of standards. Groundwat=::r,
s worth prctecting.
53D-F398(R.03/36)
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 'rj kr-
Location of Property _J��k NIA , Section ^, T 0 N - R �° _ W
Township _ -ULU/�) y-fir
Mailing Address C,/jrpi.l
Subdivision Name
I.ot Number
Previous Owner of Property
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 t � 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
T (we) ceAt46y that all a.ta.tementa on thi. 6onm ahe tAue to the but 06 my (ouA)
knowledge; �ha.t I (we) am (anel the owrieh(b ) o6 the pnopenty ducAi.bed in the
in6ouiati.on j6onm, by vO, e ob a wmAan.ty deed aecoaded in the 066,i.ce o6 the
County Regis to o6 Deedb a,5 Document No. -4� L�; and that T (we)
pheaentty oun the pnopoeed b.cte Got the eewage �cap'�oaat ayatem (on 1 (we) have
obtained an eab emen.t, to nun with the above des eAibed pnopehty, 6o,% the
con,6tAucti.or, o6 aa, d ays.tem, and the .6a►ne haz been duty seconded in the 066ice
o6 the County Reg ' .ten o6 Deeda, a4 Doement No. 431141 1 .
SIGNATURE OW OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNET) DATE SIGNED
L ._....
_ i WAHHAN I Y LJtt:U I' - -111 —.— —1- - -
STATE BAR OF WISCONSIN FORM 2- 1982 :
434924 1 7* 804PArE
REGISTER'S OFFICE
ST. CROIX CO., WI
Rec1d for Record
. .......Glen...M—Xieae.............................................................................
..................................................................... .......................................... MAR
. ...............................................................................................................
a1l 11:00 A M
............................................Jalff�8--',TO'8'(!YPh...EhINYt...8Tfd'--,76 8e-] hlhe
convms re aR�,%vaVan%A0Sbd!Yd-6:M... ffid-r-f t di...:�-Iyrvlvbivs I-.rLp q..". CA
...................
............................. ............................................................................
............ ....................................................................................................
... .............................................................................................................
..... ................................................................................................. ....
... .. ............................................................................................. .........
. ............................................................... ..... ............... ........
the followin- described real estate in ........ St.........*
0 ...... ........................Count y,
State of Wisconsin:
Tax Parcel No: ..............................
Lot 8, Red Brick Addition to the Town of Troy St . Croix County,
Wisconsin.
FED
This .......i-s...not-------- homestead property.
(is) (is not)
Exception to warranties: easements restrictions and rights-of-way of
record, if any.
Dated this .............. ........::77=.......... day of ............February.._.................................... 198
li
...................................................*..................(SEAL) .................... (SEAL)
.......................
Glen M. Wiese
.................................................................. .................. ............ ..............
.....................................................................(SEAL) ..... ...................... .......I.... ........... .... .......(SEAL)
• .................................................................. • . ..... ..... ..... . . .. . ......
jj AUTHENTICATION ACKNOWLEDGMENT
Signature(s) ............................................................ STATE OF WISCONSIN
SS.
................................................................................
...St.......Croix...............County.
authenticated this ___.__..day of........................... 19..___. Personally came before me this _ ....day of
February
................... ......................I 19 the the above named
................................................................................
................................................................................
Glen M. Wiese
.............................................................................. ................................................................................
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, ............................................................ ..................................*-------------------"----------*..............
authorized by § 706.06, Wis. Stats.)
to me known to be the person ............ who executed the
f going instrument and pch I I the same.
0)1�49 To� et 9X
THIS INSTRUMENT WAS DRAFTED BY
.......................
Kristina Ogland Lundeen
..............................iiYTZ'�.....................................
Attorney ...Alice... . 'lachauer.............................
i —Fl I
. ................................................................................ Notary Public .....S.t......C-r.o i x................County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is pe 3tg
L!6.?&d he expiration
are not necessary.) Am i
date:June...11.............-i;i;r-PUbft---------
•Narnes of persons owning in any capacity should be typed or printed below their signatures.
�'.t � r..t�* " t- • .. >� tp„ ti�i 7r + f A,°� i '�' � •Ji"'� "�- ��K � g*r
dtr � } � S , }' J ' ° (a 6 1 + • �ri S,'!' k r •• r•�' p �{sy,4P 7
' 1 • �.•' • / "� '" 1t; rt �
4'. f•'•' $rK
i'
4 t „ ! ? ! t. r t r^!: 2 ' f''•t t `i
� +`
t k"r 1 r., i •" F 1.•a a. t+ t J, 4 .1 ♦ r i Fr Fit
� '.•` t♦ `; � t r•' p F i e ,.^,* ? �tuy} ., � f "kt ,y}„ 4� 1'�•';' ; 1r � t�1 '���
y'1 ks` A '1 � • r `7iij �'1.:' �r !:' ,•� 1 C rt .' .°r 1•$: �! ti y-.�Y4 r, :'� `. t' a..
r fr •d 4•,, ':t"`` 'r t'1 :t'r A'J J- •t 1 r 4..1. t:,^I t�t' z t '''r�Jrj { i,LS!
♦n •4 1 f. P �. "'""SST.. .x..
f
7 i
73 '� q�9 f• V �f
�sl v :q �.,�•,, � f.. . . , � r. { - l� a�j X .1#ti� p'. i' � `r. *T r i4f � '�? r '�' E i� S;.,i r
�r iq t't�� ; •,t" N., t rn: #�'s i`;�r �fi'' RI' ;^ w�f'6 ! :ay. ` 4a''d� !�'?!� 5�'�, t�Ya'` ��n��j� � �'
rr ,V t r 1 w f :ir, , `"�� ' ,. r . ::J! i r !4 ,a •,'s ,;a'�a /,,,. +�, r +k�� •;'i
y 9' .rr 'r 1 K i. ♦may 1 (.E.M.' t4 w•• r '.r, lhrr j.. "4Ya '"t KW�'11 rj PsX �'
�N f� / ' r. .+ ��r � ♦ 1 /��, #i Y. y, �}1 M yr i' 7• •` �Y•� t. I!y#
� �'f (a t r Y
�y,.l� t ��' •� i �' $ �:."• >f ra�` 1# _ y r� .: S r.SX. �� '�1S'�?' l .y r �yZy #•�'' � .#
`�4,"t y .`'♦���, ''��ff •!- �' ��'�_;� �4._�'#}♦,r�r'ytr'fr�t< � . xt+•`•'=ii`G eil*.t f�7��� •r"��. �k�y��' ( �'��j �s� •'���,�� ° p' '��r •�3���f'
i ,_t%F gt 1. .S,y ..i'.. ;►+1+' •.,��.�L `�',. T�• :i di rpl ;e. ry .;Y�.. r }r.(. ,f+
a • a - ! r r�fi.Y•C'.� N .�- ! + �+1.' Y f� ka..r+� 1 ��� '} t i � �, ',�
�-t4+ .,r '-7 r.4 r ll., ,r*_.f !<i•. ! y, 44f. .! 3334��i
� .fr. '!''�� ��.. y i ;!� ti!:,r� r •fjFl r. �f aj;. ��..%.t lf.r• i 1 Tr 1 t.?ak ! ! � ra r• 1 •'� ti��y�y•. `'
? ,r- n t,A a t 2 . • frr r 'n7 '.
j tr•k.: v v
}4 S:. ' 1 ' t'•rC 6)� . '.• Rey ,w er 4rt}r;ST ;
1s d
IF ,s .� wy� t! ••,' ��^'� ; i!,�..'., s, ��� r�71 # r'P � `,i ►'�)i.'! 3. •t�$� r�r..•
). �? .n '1Y•a' t. t ,. '![I • ,•ti,n :.L ,sr }.`� Mt .r n f •• t•G �- 4 1(" � .i'"��• t
.•'�� +«.Tr, } '),•. t i. . 1 r I J,: t t d .��, L�•f 1 M �� r } )�r. F:M,�"na �'6 W� Y��
Y �. .i. -.! � • r' r".tT� � - v '� •.. 1" rr TF,' � �fi
tiFr• $r",` t ?. ( X11`'�` , .Sik i , « l.. ♦ t ;/ •.a ! PPS !x fi�pi+ . II
A"
1 ► 1 ( r l 1 1[.� i%-:l " ,•f`.I' + 'r •1 ♦Ps R r `y (_r ., �rsf° , "r fL• �y,t
y ,�- t ,; -r +(J'•#.,, >rS :t,•,.#' ai. '7 a lV r t ;� !4y
-t .- 'i "�M.l3e ,�a r �'+ � a i ti•.? t.•,t 1 ° #,•.� •� N '.�:. 4 :TF� e;i�T ':.�yy�,r' Ys.ir
�P • * r .,'1 t. 1: a + ..., is "�r a ���fr 9 �, 'E"
(:"• ! r.. Y• .•^• {d} f ,i tP i;'� f �... i ) �.:
Afth
� { 1
J .1 � til l 8 _"�' 'j,.t ,i �. 7 {� tt 71�� �,1 �F .:.r} �°�: �rr•�x! a•S •
t.ii 4! �=...� ' k l i 1 � � • �•. t+� ,�"' ,., t i . �„Xqi a.
1 'v. r. 4 R, 1 � f .}n. � +� i t rY # [s. 1 �•�+'r: f''a
u'�'4""!`���� 8� :7 + 1 1 a ltt7r � ).' � J: {� / �r♦ �a 1� a - �
r
As�' �,,- r t�! t. 1 g0 t.� ;+ } .r;p¢. � r ti, >a r°.')„��� a� ,� t •• f•i t
ri r •.�1 r.rt 1 �l - .��'�dy � _� ,,��: z it '�rte ...�w�
����� tf ,'�'••tl,s ... � "r j.'J'•' i`tt�� �� f �t f�A�1�'�' K�+ r •: +�!� r��'+d r,�ll - p f
�Tf `� F 1 J t �• ti } ) t.. k � ��'^,� r'�rrz P* ,.
11 v t''�'' •� a. :'' r .fie ni
t 1 � s r 1 r v r t •t ,1s s... ti• r r
Ri� �y. .� ' � 1 fr y t `tl• y. 1• p
IN
V yj
t � 1 axr a! f. '1 i• A; t. 1 •1�
t I �r,.,�'�� + 3 �''*'�,""bj�'�i�it`.r• rr` ii
) r�
;STS r !° ; }` • t r
�t,,'`R ,a F•' '•' •'$'= a'��Y ) •��r �4 ti+ !j, +r .lr�"�e t ,
h ii � :. sk- � ''�.lt = 11. • !, ^S. t4 �e ' � y J
s' ry� r `T '•14•
r' r71 t .. i r ., { � «iri� ,. x . t p:t, 7�r� .yP :4 F, •: 3�
�# �1 a �• • +f S i�.
ru
7,71
! _ •y • • •: ,'�C, A{C's rr-' t v rµ § b i p
rz
" t aV�•�C�Y � i°r �• ' •
P 4' :•'� ''f' � L` ;' t � ,1 rr r?3Y t S ' f; .� { : s �,� 1J` .�jk �r y R i �: �k ,r� ,
�. . t ' • t h .1
�yi t 1• SS !
* 1 S !.1 , r, y', S; yR ,•�, �,` , }r r ��$'y��".�., '�t.+t� � �?,tel.. �!a
14 rtr''> k 5, it
i
4 r a
/t t*, ,.' a '•.� 1 .xr pi,..��. 't i n y" !� p.
Slug Z$1,• T' - '!: r ._. �.. �^ �', "VS y�„ r+Y y'}b•
y„f d} t '� � r •tt Tl 7 .$ �•�r± �Tt s s,_
#�� 1 " T 1 1 i � +• fY 1`a y 'j '? r `�'!� k # :.�"`�' P�'�{4����1:� � •"�
�r -i'i Y�'�_{ .�'r' 1. ,,� { •: � �.j ��ti� �� � + ;,,.� ,rte 'r Y'11 RY'j �i✓r
"A111• a•.• i��a'� .J' 1� !. ..k, _ , �' :» Q���,ip � ° (I X ° ty. �'�f.>�
r¢ 4� " - ( +. ! t r r •,TAR+{ n
�.�' .
t is 1 1 t a
t� � , r tr4�a :,r � r, 1 •,: _ ear 4Y„ �r ,� ' � 4t �' ��''IS
1 i 4h 3 �»1. • i t• � ,� � j ? � 11.: ��-11.#�r '^aA"r.- 4' �" it rrl}.. j �� �'��11* �+ "kP !>t•
y�:r x� t: t r• "•+ •. ! 1,.1 T " tlJS.l1., t). lt�W ��'t �a�.!':•. .�.t•,�'�'� ra _t, ar,lA�;:. � �1' ! '
4 'Ir� a ti nJ ° � � r� t'1J r: "#•. !Ia ',�. ( .r•r,J.v•�-i .f'<� - •';Fi F> !�"fl""r.�+�• ") .7i.t N�.' r'?' f{,- i �t
� "r1�P' �' ayq..) ,:tt� S 'r_a .r a.•'i t .,. Ir ,. r. � '•• r/ lT' � � E# fit,..�^ ! � Er; x qI f •
! 1''"t 1•' .p Yr t r`, ,. + .•t,, t t � t +••i " 4fi „ + •c� ��'1 �., �R, � !f k
t � } ,. v '� .� d,1 ar• 1 �- rJ � tN1�)� (lR lv:: i+ l 'i' .� r,SS {' �!'!f •g ;
,a 1` ,�: �Yr'/"�a Mja °, Y J•'�s•,t rt ` Y 7 1 r a .+` •n.,t J', r'ti:• fi•r •+ ` .'•i +1. � 6r'
d3
S'., K'.ti` •? tf I =. y a°t A yr t>Z+t .,1,_ rp +e, � � v %'
• r 3 .�l s r 1 ,fi rf4a. • '1• " nr ) 1. t tt�1 I `� h
" 1�+� ir` '•�.� ! a.• Y -t° t'�.f� i*++hip. •' rr'g F '!•. r r•' � a'f+r' '
�# t p• t:a � . � .f �, h,• ' P� >ff rl
,.� r fs< g .i ..t ' � :f }•_ 4 3r � r3 "i t 1 i S. � .�a•�r, ��" '�!
ti d� #.• a '. � { 1 �J .• t• ft YIS�.. _.tf1 '7 �i S t �.� 1;� � i
t 7 x• ra! aµ o- a t r � t � �' '!.+ .( t ,. � t T� '#',`,�
1 i�'{�ltlk in .� •� - 1 :'s 1 t t -� i ._. � .�� ri ! } �-�� 1�"ts
i4
• cn
y
S T C - 10.5 y
SEPTIC 'TANK MAIN,rENANCE ACREI-MEN'T p
St . Croix County
. c
OWNER/BUYL'R_�/rr °"�
ROUTE/BOX NUMBER a- Gip _L Fire Number//
CITY/S1'ATEgU ZtP U� b
11It0PER'TY LOCATION : 14, Section�-!, '1'.
Town of St . Croix County ,
Subdivision ,P jL&— Lot number_.
Improper use and maintenance of your septLc system could result in
its premature failure to handle wastes . Proper maintenance cull-
sists of pumping, out the septic tank every three years or sooner ,
if needed by a licensed septic tank LmL0 i. What you put into
the system can affect the function of Chu ScIItic tank as a treat-
ment 'stage in the waste disposal system.
St . Croix County residents iiLa be eligible `tu receive u grunt fur.
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 iri :August ,,o.f. 1,980, with' the ' requ.irement that
owners of all new s stems agree to_ keeli thulr systems properly
ma intainud .
The pr.uperty owner agrees to submit to St . Croix County Zonin.g 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 'of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. o
I/WE, the undersigned, have read the above requirements and agree M
to maintain the private sewage disposal system in accordance with H
the- standards -set forth, herein, as- set by the Wisconsin Depart- •o
ment• of Natural Resources . Certification form must be completed
and returned to the St . Croix County. Zoning Offkee within 30 days
of the three year expiration date. .
S I C N E D
DATE
St . Croix C:,unty Zoning Office
P..O. I•ox 98
ktammor d, WI 54015 a
715-7S:6-2231 or 715-425-8363
Sign, date and return to above address .
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILbIN
INDUSTRY DIVISION N
LARO,,R AID' PERCOLATION TESTS (115) MADISON WI 53707
HUMAN,RELATIONS
(H63.09(1)&Chapter 145.045) _
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: OT NO.:BLK.NO.: SUAY S N N A/TiS N/ For to ��r
C U TY//: OWNER,S BUYER'S P AME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
pp�� I NO.BEDRMS.:jC0MMERC IjALDE CRIPTION: lt�t-ew Replace PROFIL D S RIPTIDNSI�Residence `� // l�L'N 9 2 g 8
RATING:S=Site suitable for system U=Site unsuitable for system
r QNVENTIO�NAL: M U �.❑� IN GFI � ❑�RE: YS�TEM-1��L ��G�K:RECO � STE :IoPti Hall
IfPPerrcolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the M-
under s.H63.09(5)(b),indicate: ` 3 Floodplain,indicate Floodplain elevation: /v
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH JAQ ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBR .ON BACK.)
"Is-1 ,338,s; 2,0`l3.rcS�+/ ash •,,v i%�+^
i '3�B/si �S�Sj�d�Bh es if>j /, 7 �� j C,�G Sy
B- 2 9,Z5 /oz,�s 9, ZS ,zs
of
r yL`B.,s �-, Brf, �3 8y c s 5,- �✓/1Ay
' X6,3 B $�r Bh �5 �r, L s► .5 2,0 M 3,, n<
B- 103, r7`
9, ZS a
B- ,t !0 7 > D•"�'s� ,(.'7 'Q�/�1,�`3 Bh S �9►^� 3.0 Bn C S�ej�" w ��yA►ot / 3.
J'-
/.®fs°!3I/�, s$Bh �s r�/,d Bh s, • 3 • 78nLSl9r v
A'lo �S 's
PERCOLATION TEST
e
EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER L VEL- H RATE MINUTES
NUMBER I+4Q"6S AFTER ELLING INTERVAL-MIN. PERIOD 1 PERT D 2 P E PER INCH
P_ ,1f 3 2
p_ 7 I C,0' i 6 (0 C 3
P- 3 1 q,Oq
P-_
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. C�/
SYSTEM ELEVATION, /6, 0 ��-
_
S
q � t
1
olopry�sS
�' _ w ,i . _ _, �.. � ..-4v-. .-
_ "
_ -V� i
f
L )d P-3 I ._ _ _ .
3
E
(
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.
NAM 'in%. Ua� TESTS WE E CO PLETED ON:
1. �l e
ADDRESS: I CERTIFI ATI N NUMB R PHONE NUMBER(optional):
oo 3 -30, (0 613 I
CST SI
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
INSTRUCTIONS FOR COMPLETING FORM 116 - SBD - 6395
To be a complete and accurate soil test, your report must include;
1. Complete legal description;
2. The use section rnust 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;
6. 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;
$. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
S. Cornpleie all appropriate boxes as to dates, names,addresses, flood Main data, percolation test exernp-
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 for 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 - Nigh Groundwater
cs - Coarse Sand Perc - Percolation Rate
coed s Medium Sand W - Well
fs Fine Sand Bldg - Building
Is - L(ar-ny Sand > -- Greater Than
sI -- Sandy Loam < .-- Less Than
"! - Loam Bn - Brown
psi I - Silt Loam BI - Black
si - Silt Gy - gray
cl - Clay Loam Y - Yellow
scl - Sarrdy Clay Loam R - Red
sic[ - Silty Clay Loam mot - Mottles
w - Sandy Clay w r' .- vvitlI
sic Silty Clay fff - few, Tine, faint
IX C _ Clay cc - common, coarse
pt f'ea't mm Many, medium
rra - 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 Secrsrin(l a sanitary permit, The county or the Departnvgit may request
verification of }his soil lout in the field prior to pern-rit. isstrance. A complete set of plans for the private
sr wane systern and a permit application must be sut)nritted to the appropriate local authority in order to
atrair a port7;it. The sanitary Tx,�rfnit must be ohtai;neci and posted prior to the start of acv cons ructi rt.
6 7 --' OSS SEC -1- InN
PLOT A m 1 )
OJ EC T PLUM
N E Jim
A M F- Lkfz?=t- E -K1
.-F—LOCATION L I C E N S E ,:-/t-i
K-Ril
A E -.3
P LO T
A P
10i -1)"t Lo U. -100.0
Bryl Gwk Next jo S CAWWkK (6t Sk A K e.
10MIYA S-Itts
Rust -8p
CLk 0 mt
-* Lots ON
SA-'s 0� th"S
t g1ZZ VjkC-F10t
DR. N�*IeA+ SkelL
13 'BF-DPoofY\
L4 Sol I Hofytz
80(o S I ape sa o By
"A Pa
qxvo
jf13 (316
63
i 6m
\11 S1110 ..........................
C&"K
FRESH A'111 INI,ETS AND OBSERVATION PIVE
Lj,e, 4 1"N E. Cj,1\0S,S—SECTION
Approved Vent Cap
EWA I
Minimum 12" Above f 3K AOP,-
Final Qr
q,� 4" Cast Iron
MAX
Above Pipe Vent Pipe
To Final Grader----...
Marsh Hay Or Synthetic Covering
Min. 2" Aggreg'vil. ,-
Over Pipe
Distribut i2-!;>- Tee
Pipe
Aggregate Perforated Pipe Below
Mop) Bey Beneath Pipe —CouplAng Terminating At
Bottom of System