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HomeMy WebLinkAbout040-1160-10-002 OLT > >. s 1 0 $ 2 OZ ° • k-N .. H ? d. A Z d CD W AL r _ Cp V N r G 3 N on rnrnw o ° C 100 ID own co A co � y W ° r a Irt' a°oa°o `D � i 0 :z :o v 1V rly o 0 ° a < � �`� w w o o ago OD y M c N SZ 7dZ < 3 c �4F � Z 000 °—' �• v. CS $� CO) fY Im c o O S CA M = w 3 .. a N N a Q ,r Z O D c o I t�l N 0�1 C rjA 7 r/ 0 CD C N ( w CAD G Z _ p Z c ca CL i' G (A —I N W MPaM m 00 CL z $ rr z � M CD g3i z CD CA) CL I I w a 1 (] II 3 m c p 0 a CD CD CA I a y II I t' Q '7 O I ti 0 0 v I a 0 N CD O ~ o b Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER y✓.v.✓ ��vifn7J'oiv TOWNSHIP SEC. T _W ADDRESS (�rL� o}� ,���� ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM lV 01?TA PROPEjPTY � I I EA17- ADPEATY ZJWE ' JAL we ti �3 1 PRope�SLO AeaPoSGP Aro ve ot- SAY �6ST i `/95 7o .fOWT;q Pa0Fra7Y �Rolot)(T y L=.� LiAve INDICATE NORTH ARROW /do ScktF BENCHMARK: Describe the vertical reference point used T� &k/ ,Z--r Elevation of vertical reference point: 100,6 0 Proposed slope at site: SEPTIC TANK: Manufacturer: (t-Jjetejr Liquid Capacity: J0009f Ai_, Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: ,�� Tank Outlet Elevation: Z& Number of feet from nearest Road: Front,OSide,(DRear, V / 33 feet From nearest property line Front,0Side,aRear,0 113t feet Number of feet from: well 5P , building: (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: 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: AFT Trench: Width: /,? ' Length: S.?' Number of Lines: Area Built:'t�-N--.1.0. Fill depth to top of pipe: y,?" Number of feet from nearest property line: Front, O Side, O Rear, t . Number of feet from well: 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, OFt. 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: ^,eVy, P �Z ?QO 3/84:mj a IIDEPAR eMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS ON I LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMB DIVISING P.O.BOX 7969 MADISON,WI 53707 $0i,NW( 4,S2S,T28N-R20w ,CONVENTIONAL ❑ALTERNATIVE stafa Plan l.D.Number Town a6 Tnoy El Holding Tank El In-Ground Pressure ❑Mound if assigned) De&nden Road NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DA Dan Knudt6 on 132 w # 9- 13" u ,30 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: MP/MPRSW No.: County. Sanitary Permit Number: Gij)ta 7appa i 3300 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV..V.: TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. OYES ONO OYES ONO BEDDING. VENT CIA.. VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. VENT 70 FRESH ALARM. FEET FROM LINE. AIR INLET DYES ONO OYES ONO NEAREST DOSING CHAMBER: MANUFACTURER JBIDDING LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO r_]YES ONO [—]YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONA L. NUMBER OF PROPERTY WELL BUILDING VENT TEFRESH (DIFFERENCE BETWEEN FEET FROM `I"E AIR INLET PUMP ON AND OFF) OYES ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH IDIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING COVER JINSIDE DIA rTS LIQUID BED/TRENCH TRENCHES. MATERIAL•. PIT DEPT" DIMENSIONS GRAVEL DEPTH FILL DEPTH IDISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR. NUMBER OF PROPERTY WELL. BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER. ELEV.INLET ELEV.END'. PIPES FEET FROM LINE AIR INLET NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES El NO SOIL COVER TEXTURE PERMANENT MARKERS OHSEH VA TION WELLS OYES ❑NO 1:1 YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MU CENTER EDGES 1:1 YES 1:1 NO ❑YES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING. GRAVEL D PTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: - DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEVATION AND ELEV.. ELEV.. CIA. ELEV.. PIPES ID IA.. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PVL ARTIICAL LIFT CORRESPONDS TO APPROVED ❑YES ONO OYES ONO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPER TV WELL. BUILDING. FEET FROM LINE ❑YES ❑NO OYES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE. DILHR SBD 6710(R.01/82) Zoning Adm ftiAth.atoft I I� - I SANITARY PERMIT APPLICATION COUNTY �MiLHR In accord with ILHR 83.05,Wis.Adm.Code C 1Q01 STATE SANITARY PERMIT# /a ys3 -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 FV_V I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES LEI,NO PROPERTY OWNER PROPERTY LOCATION 17 N f 61 v bTS0/L) S�!: % &)t %, S 25 T , N, R ;Lo E(oro PROPERTY OWNER'S MAILING ADDRESS„ LOT NUMBER BLOCK NUMBER SUBDIVISION NAME Z W 50AG50&) Z CITY,,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK �kULr�Q 4�411$ Sq027 ( - _7 II ❑ VILLAGE; TRO ��AIV bSA I`D Tnwpj 61:,II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. S 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. SConventional 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.-9 Seepage 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( quare Feet): 5 G 6 (p2 IcO 00 Feet `O Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank (oob 1_ K'r-'s ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plu er's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: 6dO ZAPM 5 3300 _Zy 1d Plumb's Address(Street,City,State,Zip Code): Name of Designer: 7 15 — G TA S-( - >v U f4 u©so curs 214f')VIV VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)N me CST## -)� �S c-/-/. 3 CST's ADDRESS(Street,City,State,Zip Code) , Phone Number: d, r S G o A- � CA,'I S s�U/ 7/� b — O IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Try Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) Sur harge Fee lApproved ❑ Owner Given Initial t �� i Adverse Determination 1 �U'� i y� 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'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 included the creation of surcharges (fees) for a number of regulated practices which Wisco n 1. a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried resuXe. is used in your building is returned to the groundwater through your soil absorption 0 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) 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 Location of property st- 1/4 N t=. 1/9, Section �� , T 1-y N-R 0 W Township. _T('o-,/ Mailing address 3 W CONNI-)e)N Address of site __t>GLAN t>- �j Subdivision name NOME L—At J'\AL-yI Lot number Previous owner of property Ah L LF1 T14 �,c7 i--LL1�('�L Total size of parcel C' P,F- Date parcel was created -�-K - Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes ✓ No Volume I and Page Number iqq-Z as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ----------------------------------------7-------------------------------------- PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. '-}r]_; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been/-duly recorded in the Office of the County Register of Deeds, as Documen N _ Signature of Owne --s natu of Co Owner (If Applicable) Date of Signature Date of Signature a L 00(WMEN� NO �I WXY r.as s►wca sesswveo row wseowotwe verve AIV VATS MR OF W1ISMNSIN hORK s—an K6 ?A:.1446 MrA M offia Sr. aersian.D...Gall�ds�..s�id 1tlil�abatbi..�w.. G91 ledge :. ... . am 13 e1 2:00 pM asNwy ad Warren% �pVIRl1a.-b1A t o ..>.MydOt..aAlas n...and .voso ........ A surt $ ... ......... ... . .... .................. j tlta mewing dsseribod road sets% in ...... .....St...� X....... .. .. County. eta% Of Wi$=MWN: Lot 2 of that certified Survey Map recorded in the St. Croix Register a of Deeds edds Office#4389311 7 Certified Survey MaF Page Being part of the SEC Of the ME% of Section 25, Township 28 North Range 20 West, Town Of Troy. fkA sm f1m This . �I& ..Att...... homestead property. (is not) Exception to Warranties: sasements, restrictions and rights of way of record Dated this 30th. day of June (SEAL) (SEAL) . Adrian D. Golled g , !' .. ... ... _.. . .... . . (SEAL) Elizabeth B. Golledge, -} - • .. ....... A die_D._"LLedger-he>c�Att4s11eg� ire—P►+'rt` - AUTUNUTICATION ACKNOWLSDOURNT owisli i s(s) Adtlan.-D..--•Goll.edge-....... •••-•• STATE OF WISCONSIN Zlisabeth S. Golledge, blr'l�drtait�'. "• s .... . .County. tiffs .30..day d......JUM........... 19.$8 Personally came before me this ................day of K.. . �. �.�, . 19........ the above named .r....... ...................................................... 7 ........ ...... ......_ ................ e.....s.1eMAA Wha var.................................. ..... ........ .. ..... ..... .. .......... ...... Tr=:KZ=Z1R ITATZ BAR OF WISCONSIN ..I....................... ... ......... r ............... .... . ................... . awgleeIsed by I MOS.- Wis. Stab) to me known to M the person . who executed the foregoing instrument and acknowledep the same. THIS INSTRUMENT WAS DRAFTED Sy 4lG..lcuhsyar,� _ .............t Law • RODLI, BESKAR i BOLES, S.C. ..--Z3r9••�iv•••MAiA--S�..••-Ri-V4C. Fil•�.S-,...IIlI- lots-� Punlic county,. expi Lion (signatures stay be authenticated or acknowledged. Both v1F (ommisai.m it pt rmunt nt.(I f not, wtate expiration are not Necessary.) date: 19 ) •Sr...d s+sees slselsf is"y capacity.Mould be tyr,#A pnnt�d I l.,w th.Ir -Iffnw wAma&m I=I STATS SAa DIP WISCONSIN P i• •.twin I..ytel roam No. e— ivs! �t ..•.. 1Cu. i CERTIFIED SURVEY MAP • Located in the SE1/4 of the NE1/4 of Section 25, T28N, R20WW , Town of Troy, St. ,Croix County, Wisconsin slimtlj� �� h I � `yGONS�� Surveyed for :,Adrian Golledge P.O. Box-,307: River Falls,. W. x,4022 UNPLATTED LANDS t O f8441 ark � c P. cu a • N 10 37'07"E 667.47'. ( n N -4 0 N'0 y cD D K P1`H N l �p (D.0 N 0 `C N P. W o r G-4 z � K � �x'Z' o HO K3 P. p, kx Z CA D O 01 t, h *• fD e-r ''' O Al er O _r P1 P1 a (� D o 'd o Iy,o o Q' (is ZA * �,r r d° y O Q. a. (A 'p 41 1 �'�+ �ay ►'"m 111 n 1 {� Z �o Irn Iz c N 4 41'45"E'/ ,_ •163.00' pER_oslvE 01 t :1 �� S 1041 ��W '.662.00''. �` w .35 ' 10 N 1 041'45"E W N N (D p N W CI 1 ' y , .i / <71 w ar ° rn m 1 X71' j IWO r O' 01 O I(n ;D, (D "1 t f U)Z vu z ' ra CD ITS A O n. f�1 z 0. ZS .f ,. . • . . . __1976:75_ N Fn S., I04145"W 660.00 0 • •_ 25 Q m a UNPLATTED 'LANDS t N Z Z� o O,O � s h QA G c � o Z C (x m ASSUMED BEARINGS : REFERENCED TO THE mZ m EAST LINE OF THE N.E. 1/4 m° o o �0ZZ o rz Tro AN 29 In � ° m SE CROIX00ulQY �IRMPMIA�FlA�f AA1�IP r! yyjj` .11A',"o DESCRIPTION A parcel of land located in the SE 1/4 of the NE 1/4 of Section 25, T28N" R20W,. a.w Towri of Troy, St. Croix County,',Wisconsin, described as follows: ' Beginning,' . at:the E1/4 corner of said Section 25, thence N87027106"W (assumed bearing . referenced to the monumented E W 1/4 Section line 1324 3' E / . ) .3 along the W;X/4 Section line; thence N1037'07 11E 667.47' along the West line of said SEl/4 of the NE1/4; thence' S87°07'46"E 903.53' along the South line, and the Westerly exten Sion thereof, of the South.line of Lot-5 of. Plainview Acres; thenceNlo41'45"E':, 163.001.:along the East'line of said Lot 5; thence Easterly 68.03' along the arc;of an .$0' radius curve concave Northerly, whose chord bears S8801'8104"E (recorded as S88018114"E) 66.001; thence S1 041145"W 164.35' along the West line of Lot 4 `' of said Plainview Acres; thence S87 007146"E 355.82' along the South line of said,-,-_ o �� Lot 4; thence S1 41 45 W 660.00 1 along he East line' of said NE1 4 to the oint-'" g / P., .. of`be innin containing 889 681 square feet 20.4243 acres more or less nd g g g � ( ), � a q ` being subject to all easements, restrictions and covenants of record. _ I, James E. Rusch, registered Wisconsin Land Surveyor, .do hereby certify. that L have surveyed and mapped the`above..described property;,that. such plat is-a true and correct representation of the exterior boundaries `of the land - surveyed; and that I have fully complied with the provisions of Section 236.34 of',the Wisconsin Statutes, the St. Croix County Subdivision Ordinance, and the Town of .Ttoy Subdivision Ordinance to the best of my professional knowledge',` understanding and belief. e s E. Rusch Professional Surveyor ' Rusch Surveying, Inc. • DAMES E. RUSCH 407 Second Street �.�( 6.1376 _ �. Hudson, WI 54016 VAL o Dated this 1st day of May", 1986. ��������� This map is hereby approved by the Town Board of the Town of Troy. D to Ma a Schiltgen, Town Clerk ail" 1 � r,n .d,•.MY , 1 i STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County i OWNER/BUYER L)A N L L-t c-,c_ iJC��T �� N ROUTE/BOX NUMBER 3J� 1�/ 1C It1``��GtU FIRE NO. CITY/STATE 1'\1C_0_ i_� { VI-) ZIP PROPERTY LOCATION: ff 1/4 IN 1/4, Section , T )--YN, R 7-0 W, Town of �—► iJ�i , St. Croix County, NoNc - CAM Subdivision Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE 7 ' Cj 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 INDUSTRY, DIVISION P.O.BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON WI 53 07 HUMAN RELATIO (1-163.0901 & Chapter 146.046) LOCATION7 SECTION: OWNSHIP "Y: OT N0.• LK.NO.: SUBDIVISION NAME: sc '/n1 `i ,,,7-5 . Tz.�N/R z�E rl_ ' l-T- ©.. --- PfZO Pow GD COUNTY: UWNE S NAME: _I ) -a• , -:r.r: := 'r"1 `' .t,.' c7Y i vain-�� .A 5_40 I 2.Z_ r USE DATES OBSERVATIOfft MADE NO.B rOMMERCIAL 1 -r R , ,. �i dance ___._, I WNew ❑Replace 41 8 /U G G F=O lt. G. S M, 4-1!P 9-0 a A_L_— RATINO:S-Site sultabta for system U_-Site unsuitable for system J,ti ♦+�i t�': N1.a /-► ` �' f L ENTIO S Q�. Q� �� IN(ai ❑� •Q�L OaLDIN TA►VK:�Ct�MENDED SYSTEM:(optional)E)S roln MOUND: tl�] S U If Percolation Tests are NOT required DESIGN RATE: 1 If any portion of the tested area is in the under s.H63.09(511b),indicate: I �, I A Floodplain,indicate Floodplain elevation: /V •� r PROFILE DESCRIPTIONS BORING TOTAL DEP R-1 CH HA A R SOIL WITH THICKNESS.COLOR,TEXTURE.AND DEPTH NUMBER WTH IN, ELEVATION TO D OCK IF OBSERVED ISEE ABBRV.ON BACK.) no r.. / /• ' lr ,,J,/� I % C.cj2•' C � � /•5�' Gfl ;,i:� G+IC j � ' rl�nl &0 10 Ps_ 9, J L L; 1.w' 314 L W04 0-7-J 3�� .. B- '✓ !.7•..,� ! ,;'!' I/'. �/ �.�i� TO 1"-�i' .,',•J' �,•I it� '�rG • ".dJ'✓Al 1014E�D'— �•(+(/'a`.F/ �"'� B- e,4 Moo S; 2•vZ.0, ~E.r Z5 B---- ,',570 11 l•?':' ?1 .i:'.:._ j '. �1 G.::"; 6L t.; 0-(-7' P'j L5 u .r r:o 5 ri ro PERCOLATION TESTS TEST DEPTH WATER IN HOLE. TEST TIME RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PER INCH P, P- P- l E�/MTrO, 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• sontal and vertical elevation reference points and show their location on the plot plan. Show surface elevation at all bar ln s and the direction and per.011111t of land slope. N C H M k I`.. (" 1 P-0;U P f Pe r� i w SYSTEM ELEVATION r r •1 0V1 : 3`� LF_Ge n, P4' tl' ' e! Noe.T H l.oT Q X L,N E .0 SEE-COI-4T14,J �-`.T E�.1 r t r -t>_�'• i 11 W. LOT' <<..,�►, ' i ... 1 S IT o 144 Ps 6y- tN 11 A CIA- Ike,f IL 2 f I f • 8 Z ty �.•: rev tc�' ��'� 5, 1,the undersignea,no y certify that the soil tests reported on this form were made by me in accord with tWo procedures and 3 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. 1NAME print): [� TESTS WERE COMPLETED ON: ADDRESS: CE14TIFICATION NUMBER. PHONE NUMBER(optional): ^ r CST StGNATU /Z, /.j 7 Z/PON /SP1_ Sn/ NoirrN /noAE2TY L2ivE v F„Ltv. _loo.ao=/00,001, `10 Lai / L0T ^"10 /2<9,U SL C710N ��/or✓�' /30� /� 9/3/TU ZIST /�/LOp.E2T� LANE Q�S ,D ld ��7 / /2as�cT SLOPE J 7X' O�i 6 s 98 /�/,�I„/ SY.f T5r1 !� y"Er f[uenn LANE T�o U.c /lz U Y C/2 oxiY CO LW vTY yo/ J /.Z-IOW CAI. SEPrtc TANX sV O �-Y"6LO6 WEST P/toPfJt7Y �<-,p/ZOPb..Eo ULL LSNs :Z,O� P/2oF»aSEO /ZESSO�ivG t /�iw/�aSfO LOWE2 L�v�L G�oitAGE Y9 tTY /srE ,pnoPosFo DELANob =vFv Ay 2 Ai Druv� �D I L L� FRF l-1 AR INLIFT AND OB.firiERMTIOW PIPIF ell All APPROVED VENT SCAF ABOVE Firi.".L P',Pf- TO FINAL GRADE MARSH I'la.`v OR `t''rt'a13"II-TKs Lr.;'Y'El elltl%� S_. ! _ — Li�sEij:C. J, OYER PIPE DI Tyr iBUTI;>N PIPE .... FSTING BY: .. R-'ENEATH PIPE r._OUPLING TE1iC,#it'ATIN a wry® AT BOTT�.��t;4 OF s STBA