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HomeMy WebLinkAbout040-1199-95-000 @ a 0 \ � b � 2 � k � 2 � 2 = � ? Z k 2 2 E 0 k e a 2 2 � � » � � i w B z & m § $ I § § ) «_ 2 k « 0 z � � 2 . { -� § J / c g \ ) z co .. . z ! � - R E a � f g c � 0 0 C 2 2 ) .0 4) ° ` k k ¥ \ - E m $ � - \ 2 2 2 « FL ) 00 m � / \_ \ B o 0 � ® _ ° E : o o / U) c I � � £ 4 (D rn � 5 ° Cl) . . LO $ Ec cl 2 co 6 - § I ? § § k \ j § $ ) , - o a , E E � � k K / � ƒ / o z ) 2 k L � E ) $ c & 0 £ z U-1 00 h l - Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT 5CA&I 'A 0 W fl;11 s OWNER �'�e.:r `�.� ,;z TOWNSHIP , SEC. T N-R W ADDRESS 2__ ST. CROIX COUNTY, WISCONSIN L(Is SUBDIVISION _ nK���. �, 1'f l LOT # / LOT SIZE 1pocc�n, �yz Rcre, PLAN VIEW Distances and dimensions to meet requirements of I•ZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM * G iod r 1 1� 6,0 ( f + 72"f V e /I C4 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used nay lJ/u�WLy ,k Elevation of vertical reference oint: �� P fUC� [� Proposed slope at site: SEPTIC TANK: Manufacturer: C'u�e _ Liquid Capacity: 16 L) C46L Number of rings used: / Tank manhole cover elevation: Tank Inlet .Elevation: 4?1. Tank Outlet Elevation: Number of feet from nearest Road.: Front, feet Sid ar, O `� ��-' From nearest property line . Front,OSide,®Rear,O S feet Number of feet from: well ��kl kk building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE I PUMP CHAMBER ��)J Manufacturer: _ f A Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: r 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). SOIL ABSORPTION SYSTEM Bed: �)( Trench: Width: / Leng, h: �J� � Number of Lines: Area Built: /f7b 2 Fill depth to top of pipe: J Ic Number of feet from nearest property line: Front, O Side, ®Rear,O Pt . Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT : Size. Number of P its: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 0 or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: kVIZ 14 Capacity: zE 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: �I�/U f�f�C� Plumber on job: License Number: m ��F' 3/84:mj r + DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 Sei Nei 4�S28 T28N-R19W .CONVENTIONAL El ALTERNATIVE State Plan I.D.Number: >, (If assigned) Town ob Tnoy ❑Holding Tank ❑ In-Ground Pressure ❑Mound Lot 11 Sundown HiUz NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Peter. Sykora Rowe 3, Riven Faets, (UT 54022 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.' 7F,PT.ELEV. Name of Plumber: MNa.. Cnumy. Sanitary Permit Number:John P. S Fiona ITI 212 St. Croix 112801 SEPTIC TANK/HOLDING TANK: MANUFACTURER'. LIOUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER /^, QPROVIDED: PROVIDED: \�1C) Z) J SYES ONO DYES KNO BEDDING: VENT DIA.. VENT MATT HIGH WATER NUMBER OF �RFOA; IP R OPERTV WELL. BUILDING: VENT TO FRESH 11 ALARM LINE. C� AIR INLET'.FEET❑YES �<NO 4✓ L ❑YES ❑NO NEAREST—­3 M � 1 DOSING CHAMBER: MANUFACTURER BE7YES LIQUID CAPACITY nCRV PUMP MODEL JIUMPSIPHON. MnNUi ACTUHEH WARNING LABEL LOCKING COVER PROVIDE PROVIDED: ❑NO Y S ❑NO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF -PRO HTV LL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. PUMP ON AND OFF) ❑YES ❑NO NEAREST i► SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing I I N(,Tll D TIATI�I A L ND MAHKwG FORCE or excavation. (If soil can be rolled into a wire,construction shall cease until the soil is dry enough to continue.) MAIN; CONVENTIONAL SYSTEM: WITH LE 7H NO.OF JOISTH PIPE SPACIN(, COVER INSIDE )IA -PITS LIOUID BED/TRENCH THF.NCHES ` MATE'I AL PIT DEPTH. DIMENSIONS, Z PAVEL DE TH FILL DEPTH DISI l PIPE UISTH PIPE DISTR.PIPE MATERIAL NO DI H NUMBER;OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER EI EV.INLE 1 ELEV IN PIPFS LINE ^ I AIR INLET r� FEET FROM _ – (+- )R_,5 U ��r v5 9�,Qa a� �.G d 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. ❑YES NO SOIL COVER TEXTURE jPIIIMANINT%1A HKI'S 85 E'VATICIN WELLS _ ❑YES ❑NO 1:1 YES ONO DEPTH OVER TRENCH BED DEPTH OVFH THE NCEi BED OfPiH OF TOPSOIL. S(1DOED SEE UFO MULCHED CENTER EDGES ❑YES. ❑NO ❑YES ONO 1:1 YES E:1 NO PRESSURIZED r DISTRIBUTION SYSTEM: BECI/TR"N4r.H W G IDTH LENTH TRENCHES. LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER I DIMENSIONS, � A 1,11 '<MANIFOLD PUMP MANIFOLD DISTR.PIPE M A UIST DIST IPE DISTRIBUTION PIPE MATERIAL&MARKING .ELEV. ELEV. DIA. ELEV. PI A.: r EL�YATION,ANp. DISTRIBUTION, IIVIFORMATION HOLE SIZE HOLE SPACING CHILLED COHHECI LV COVER M EHIAL PLANS VERTICAL LIFT CORRESPONDS TO APPROVED DYES 0 N ❑YES ❑NO COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS: NUMBER OF LINE ERTV WELL: BUILDING:FEET F14 r L1 YES ❑NO ❑YES NEAR ESL L-L 'v t3 Sketch System on Retain in county file for audit. Reverse Side. UR E. 7�;ng DI LHR SBD 6710 (R.01/82) -�cGr.o i •,(J Admin.0 to ton a ILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code - STATE S^ ITANITARY PERMIT# //o) o o/ —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 [9 NO PROPERTY OWNER PROPERTY LOCATION r S" '/a NL '/a, S �b T 1 N, R l% E(o W PROPERTY OWNER'S ING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER 7n CITY � NEAREST ROAD,LAKE OR LANDMARK / '7(c'`" {p Li ❑ VILLAGE: /`'4� y i �COUYt �L1�n Q t . II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): 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. X Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tan k V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. See 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): [A'Private [:1 Joint ❑ Public VI. TANK CAPACITY Site in ga ons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank w lon6 ❑ ❑ ❑ 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(Prin/t): Plumber's Signature:(No Stamps) M MPR W No. Business Phone Nurt►ber: Plumber's Address Street,City,State,Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# 'yZt'k ' r �c�u eZ 73r ?_- 3Z_ CST's ADDRESS(Street, ity,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) pproved ❑ Owner Given Initial [10 ,00 S harge Fee Adverse Determination �� X. CAkMMENTSIREASONS 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; ll. 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'/2 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 ICItS can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried re0st: is used in your building is returned to the groundwater through your soil absorption e system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) L 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 /- Te v- -D , Cc Location of Property t 1% 1V1.'. It, Section , T ; N - R W Township -ro bi Mailing Address " ao Subdivision Name l5 Lot Number C L Previous Owner of Property 4 2 Total Size of Parcel -' Date Parcel was Created � � Are all corners and lot lines identifiable? I/ Yes 5 Is this property being developed for resale (spec house) i G •J Volume J I- and Page Number 1_1_-; as recorded wd INCLUDE WITH THIS APPLICATION ONE OF THE 1. Warranty Deed 2. Land Contract 3. • Other recordings filed with the Register of Deeds In addition, a certified survey, if available, would be he of the reviewing process. If the deed description referee Map, the the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTV OWNER CERTIFICATION I (We) eenti6y that att 6tatement6 on phis 6o4m ane tAu.e .t knowte.dge; that I (we) am (are) the owner(s) o6 the pho peA .in6onmati,on 6o4m, by viAtue o6 a waAAanty deed neeonded in County Re9iAteh o6 Deeds a6 Document No. ; pnesentty own the proposed A to box the sewage posaT-ey obtained an easement, to h.un with the above desehibed phop%.,&", Din �e co ctio o6 said b y,6 tem, and the same has been duty teco4ded in the 06jiee o the C 9AAten o6 Deeds, as Document No. -7, IGNA OF OWNER SIGNATURE SIGNATURE OF CO-OWNER (IF APPLICABLE) �� DA E S Me.ED DATE SIGNED DOCUMENT NO. S1'ATE BAR OF WISCONSIN-FORM 1 i .- �c WARRANTY DEED 32245 BOOK 512 PAGE►.334 T SPACE RESERVED FOR RECORDING DATA TMS DEED, made between Richard F. Lewinski and Ruth B. REGISTERS OFFI@.'E, Lewinski husband and wife ST. CROIX CO., WIS. Reo'd for Record this__ALto Sykora Inc. a Wisconsin Corporation Grantor and YR ra Laced Company, day of---Jq1B_-___A.D.19_?ll t------8 Q Grantee, W i It n e s s e t h, That the said Grantor for a valuable consideration $17,070.00 conveys to Grantee the following described real estate inSt. Grout County, RETURN TO State of Wisconsin: A parcel of land located in the SW� of the NW* of Section 27, T28N, R19W, Town of Troy, St., Croix County, Wisconsin Tax Key a _ Described as follows: Commencing at the A corner of said This is homestead property. Section 27; thence N001714011B (True bearing) 26.00 feet along the West line of said ]Wk to the point of beginning; thence N001714011E 1289.37 feet along said West line; thence N8901812011E 769.62 feet along the North line of said SWt of the NWJ; thence SO°1714011W 775.61 feet to the centerline of an existing town road; thence Southwesterly along said centerline of town road to a point which is N89020130"E 23.45 feet, of the point of beginning; thence S89 020130"W 23.45 feet to the point of beginning; subject to a town road easement across all of the above described parcel lying radially ar1c i at right angles 331 Northwesterly of the above described centerline of town road; and subject to a Wisconsin - Minnesota Power and Light Company easement across all of the above described parcel lying within the Southerly 33 feet of said SW4 of the NW4 ii TRANSFER Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertainingH And Richard F. Lewinski and Ruth B. Lewinski, husband and wife {,,,, warrantcthat the title is good, indefeasible in fee simple and free and clear of encumbrances except existing easements and will warrant and defend the same. Executed at River Falls, Wisconsin this 10th day of June , 19 74; SIGNED AND SEALED IN PRESENCE OF (SEAL) Richard F. Lewinski (SEAL) (SEAL) Ruth B. Lewinski (SEAL) Signatures of Richard F. Lewinski and Ruth B. Lewinski z� authenticated this 10th day of June , 19 74 � 1 fl Ralph E. Senn j Title: Member State Bar of Wisconsin (� i! STATE OF WISCONSIN f ss. j County. Personally came before me, this day of 19--1 the above named ( f to me known to be the person_ who executed the foregoing instrument and acknowledged the same. i This instrument was drafted by i Ralph E• Senn, Attorney Notary Public County, Wis. it River Falls, Wisconsin IF (Expires)Ex The use of witnesses is optional. MY C ( P ) (Is ) I: Names of persons signing in any capacity should be typed or printed below their signatures. M Ye, HC.Mi1laComprry M WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 1 - 1971 L- - DOCUMENT NO. I STATE BAR OF WISCONSIN-FORM 1 WARRANTY DEED 080 HIS SPACE RESERVED FOR RECORDING DATA TIIIS DEED, made between __ F+aY'�- CiernO�'iou8, Bernard ri @1"nOhOUS, REGISTERS OFFICE Rosella Cernohous Hendrickson, Margaret Cernohous Ahrens, ST. CROIX CO„ WIS., Lilliam Cernohous Blake Reed for Record this___Z$ h and _ Sykora Land Company, Inc. a Wisconsin Grantor day of__ -------A.D.197L Corporation at____$330-__ A:, M. Grantee, ' W i t n e s a e t h, That the said Grantor for a valuable considerationsgnty Rig star pf Dee s One Thousand and No/100__($21,000.00)-- —Dollars conveys to Grantee the following described real estate in St. Croix County, RETURN TO State of Wisconsin: The Southeast Quarter of the Northeast Quarter of Section 28, Township 28 North, Range Nineteen Wealt. Tax Key # This is nOt homestead property. TRANSFER FEE Together with all and singular the hereditaments and appurtenances:, thereunto belonging or in any wise appertaining; t And said five grantors and each of them warrantSthat the title is good, indefeasible in fee simple and free and clear of encumbrances except easomonta of record and will warrant and defend the same. Executed at fiver Falls, Wisconsin and rra�2nd day of 19 74 St. Paul, Minnesota (SEAL) SIGNED AND SEALED IN PRESENCE OF -v -r 4c r, Zvi u ,L9 ern0 O Hwr cKs DA i (SEAL) �1151ernard Cernohous Lillian az, 4c Certgohous Blake $aret Cernohous Ahrens r - Signatures of &W1 Cernohous, and Rosella Cernomous Hendrickson aujhegtiC'afed this A,10 day of May 19 '14 046 X. :Bauta Title: Other Part Authorized under Sec. " • Minnesota Y 706.06 � STATE OF 1100000M Viz. Notary Public , State of Wisconsin Ramey County. ss• My comisslon expires: 6/6/76 Personally came before me, this 3th day of 197 , � the above named er Bnard Cernohous, Lillian Cernohous Blake, and lFaigaret Cernobous Ahrens I timeLknewn to be the person s who executed the foregoing instrument and acknowleEdged the same. trumgnt was drafted by Earl H. Plante ftlp4j. Senn Notary Public Ramey County,As. Rive 'Falls, Wisconsin Pas H. pl_ANTE The use of witnesses is optional. My Commission(Expires}'(ls). rJ1i,'f Ir r cc ki tl i�t Notary Nuf li,- aus• T-„ rgiffif�ilSSiof, t.+�Vu ds AW t•• . Names of persons signing in any capacity should be typed or printed below their 1gotTes. y CC liGMil,.rCanpry WARRANTY DEED—STATE BAR OF WISCONSIN, FORM NO. 1 — 1971 800n DI PK D ® 1 H z H a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d a OWNE /BUYER �� �, H ROUTE/BOX NUMBER ►l # Fire Number rlbig ' CITY/STATE ZIP PROPERTY LOCATION :_5f_ 14, /1 1Z 1, Section ?2 �) , T G N, R %(/ W, Town of 1-cl t-1 , St . Croix County, Subdivision Lot number_. 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 I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources . Certification fo us a ompleted and returned to the St . Croix County Zoni g Of ice it in 30 days of the three year expiration date . SIGNED DATE St . Croix County Zoning Office P .O. Box 984 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 DIVISION INDUSTRY, G LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.0911)& Chapter 145.045) LOCATION: SECTION: - TOWNSHIP UNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: S //V�4/ Ti23N/R 1-7 E ( r, -T,,� COUNTY: OWNE UYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMER AL DESCRIPTION: PROFILE DES IP IONS: R A I N TESTS: R //� KNew ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system r ONVE TIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMEND D SYSTEM:(optional) rVI lini S ❑U S ❑U ®S ❑U ❑S ®U ❑S NU Coll✓0 wr11.116 / QP�I If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the , I qI / f under s.H63.09(5)(b),indicate: A I vIl� Floodplain,indicate Floodplain elevation: �// PROFILE DESCRIPTIONS BORING TOTAL P H TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) � p'!�'� �N s;l'7'y, �„- 4��°��, �•`l / l,°_ , // �..�C_ ,./ TSB (� 3 Z V"—fa �k'�5, 7F, N /i 'Y C/(_') �<a' �N._ 32" 63—, Si/-I 2 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. —PERIOD 1 PERIOD2 --PERIOD PER INCH P_ =/ s P- I,i 04 c. P- � i` PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil ar ndicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show th urface elevation Iiat all b irec on and percent i' of land slope. (731 ,011 .IF,,7' SYSTEM ELEVATION al� y~Z r - I E i ' E Tao► �-i.41� _ D�L� '�s��-� � _ ; _4...... E � 1 7 � ,: _ _ gy<m. �3 I � I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: ADDRESS: e CERTIFICATION NUMBER: PHONE NUMBER(optional): p 7'i <> ` �? t�5� CST SIG ATE: I DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 , To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4, Is this a new or replacement systern; a. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A FOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 0. PLEASE use the abbreviations showy: here for writing profile descriptions and completing the plot plan; 7. N1AKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; S. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9_ Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain,elevation) does riot apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL. TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3- 10") SS - Sandstone gr, - Gravel (under 3") LS - Limestone s - Sand HGW - High Groundwater cs Coarse Sand Perc - Percolation Rate rimed s - Medium Sans W - Well r fs .._ Fine Sand Bldg Building 1s - Loamy Sand > - Greater Than sl -- Sandy Loam < -- Less Than 'I - Loam Bn - Brown *sit - Silt Lo«rn BI - Black si - Silt Gy - Gray cl Clay Loam Y -- YeIIow scl - Sandy Clay Loam R - Red sicl -. Silty Clay Loam mot - Mottles sc - Sandy Clay wI - with sic - Silty Clay fff few, fine, faint `c Clay cc -- cornrnon,(:curse pt Pcar mm Many, medium M - Mrack; d -- € istinct p __ prominent HWL - High water level, Six general soil textures surfacc water for liquid waste disposal BM Bench Mark VRP --- Vertical Reference Poirot 'rO TIME OWNER: Thi. soil test reporr is the first step in securincy a sanitary permit. The county or the Department may request vcr lication of this soil test it-, the field prior tca permit issrrarce. A complete set of plans for the private sev'Jage system and a permit application must he suhrnitt(td 11) €fie ;ww'opriaw loyal authority it) order to r r,tt�irt a The sanitary f-;>rmit muse be ohlained and pest cd t�,,for to thy-start of ar v tc,nso'uction. + fe, &* n To-v C'I^t-1 I X -ZV, t-no"j"`"e o [e- zl�<11 IF x fq-OC44 C� '72, NCC—lt o Step MOUND LENGTH A) End slope (K) _ (D + El+ F + H x 3 = ft. B) tal mound length (L) = B + 2(K) ft. Step 5. MOUND WI TH Al) Upslope correction factor = A2) Upslope w th (J) _ (D + F + G)(3) actor) _ ft. 81) Downslope co ction factor = 62) Downslope widt (I) _ (E + F + G)(3)(factor) = ft. C1) Total mound width W) fo bed = J + A + I ft. C2) Total mound width ) r trenches = J + 2 + (no. t nches - (c) + A + I _ ft. 2 Step 6. BASAL AREA A) Infiltr tive capacity of natural it = 2 f _ g al./ t /day B) Ba 1 area required = wastewater flo = n ural soil infiltrative capacity = s .__ q ft. C Basal area available for bed for slopin sites = Bx (A + 1) = sq. ft. C2) Basal area available for trench for. sloping ites = (B)[(W)V—<J + A-1 • sq. ft. C3) Basal area available for trench or bed for level sites B x W = sq. ft. i < s' Parcel #: 040-1199-95-000 ozro7i2oo7 02:59 PM PAGE 1 OF 1 Alt.Parcel M 28.28.19.918 040-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): O=Current Owner, C=Current Co-Owner O-DUBOIS, DAVID R&JANELLE L DAVID R&JANELLE L DUBOIS 593 SYKORA LA RIVER FALLS WI 54022 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *593 SYKORA LA SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 2.000 Plat: 2522-SUNDOWN HILLS SEC 28 T28N R1 9W SUNDOWN HILLS LOT 11 Block/Condo Bldg: LOT 11 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 28-28N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 875/449 2007 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 60,500 384,500 445,000 NO Totals for 2007: General Property 2.000 60,500 384,500 445,000 Woodland 0.000 0 0 Totals for 2006: General Property 2.000 60,500 384,500 445,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 140 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00