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HomeMy WebLinkAbout042-1051-30-000 \ ` \ / $ % o a 0 \ ) ' 2 ] f7 � , 2 #o / � x 4 k\ � cc 0 / \) § z +/ § m L ee &c \ "D EBB < R�= « / \ % Cl) E ® Lu z' o � § a m . / \ z � 2 co § « J 3 \ 2 7 \ c § z 2 Cl) j { ? } � § ° { - o ) ) CU ) k .. ) { � k k C 2 k ) ` v E / * r 5 F, / \ .. / -� � ) a a a E ® j \ \ § § z f § 5 = _ �_ a): 2 \ / � \ a) £ # / k k 8 %k � £ ELF 2 6 # ^ f a J E 2 f o G = �§ c o % k 5 @ 7 \ a \ $ a s g \ z 3 '0 R - k § k \ § c z ƒ j / \ � , m k } _ EL L / m ' � � Q 00 a 2 to & u Parcel #: 042-1051-30-000 06/17/2005 09:22 AM PAGE 1 OF 1 Alt. Parcel#: 19.29.18.290B 042-TOWN OF WARREN 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 "JOHNSON,JEFFREY S&MICHELLE L JEFFREY S&MICHELLE L JOHNSON 945 HWY 12 ROBERTS WI 54023 Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description *945 HWY 12 SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 8.550 Plat: N/A-NOT AVAILABLE SEC 19 T29N R18W IN N1/2 NE1/4 COM 33 FT Block/Condo Bldg: S& 1286 FT W OF NE COR SEC 19,TH W 761 FT, S TO RR R/W, ELY ALG R/W TO PT 1125 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) FT S OF POB TH N TO POB EXC P290C AS 19-29N-18W DESC IN VOL 760/315 Notes: Parcel History: Date Doc# Vol/Page Type 10/22/1999 612524 1465 WD 07/2311997 01/253 2005 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/19/2002 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 8.550 59,000 207,200 266,200 NO Totals for 2005: General Property 8.550 59,000 207,200 266,200 Woodland 0.000 0 0 Totals for 2004: General Property 8.550 59,000 207,200 266,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 516 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 OWNERS -,//t TOWNSHIP SEC. W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW Q RYTHING WITHIN 100 FEET OF SYSTEM well S p S i I l 16 a !._► - -- s ---- o i �Ht /rri O i i INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: lean//" ' Proposed slope at site: --- SEPTIC TANK: Manufacturer: ! ; Liquid Capacity: Number of rings used: r Tank manhole cover elevation: Tank Inlet Elevation: "z Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,O Rear, O /S feet From nearest property line Front 10 Side 10 Rear,0 t� feet Number of feet from: well -7 S'a building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE a 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: ✓ Trench: Width: 18 Length: Number of Lines: 3 Area Built: Pd Fill depth to top of pipe: /a- Number of feet from nearest property line: Front, 0 Side, O Rear,0 P't . Number of feet from well: > �� Number of feet from building: 3e (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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector• ����'S Dated: 71 6 /L� Plumber on job: -+---�— License Number: �! 3/84:m3 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS I 'LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS ON BUREAU OF PLUMB DIVISING P.O.BOX 7969 i MADISON,WI 53707 NW1,4,NEk,S19,T29N-R18W $CONVENTIONAL 1:1 ALTERNATIVE State PlanI.D Number . I It assigned) Town of Warren ❑Holding Tank ❑In-Ground Pressure ❑Mound HWY 12 NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Dennis Smith 1818 Fargo Lane Mendota Heights, MN 5 118 °)/ BENCH MARK(Permanent reference pomtl DESCRIBE IF DIFFERENT FROM PLAN: - REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber MPlMPRSW No.: County: Samtary Permit Number: St. Croix 112697 David B. Fo ert'. 3289 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY'. TANK INLET E LEV.. TANK OUT LET ELEV.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. �t�.. q; DYES ❑NO ]YES NO BE DOING. VENT CIA.. VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING. IVENTTOFRESH ALARM. LINE. AIR INLET I, FEET FROM I .� DYES NO � � ❑YES [:J NQ NEAREST V5c) DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY::=.I/SIP.ON MANUF ACTIIRER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. ❑YES ❑NO DYES ONO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERAT IONAL. NUMBER OF PR ER LL BUILDING VENT TO FHE SH LI AIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) ❑YES —]NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing I LENGTH D III!AM T MA F L 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 INSIDE DIA tt PITS LIQUID BED/TRENCH 0 TRENCHES ( l rorERIAL:� PIT DEPTH DIMENSIONS 'T GRAVEL DEPTH FILL DEPTH DISTR.PIPF ISTR.PIPE DISTR.PIPE MATERIAL. NO.D TR. NUMBER OF PROPERTY WELL BUILDING V NI TO F HESH BELOW PIPES ABOVE COVER. ELEV INLET PIPE FEET FROM LINE �y ^ AIR INLET f� g tC l NEAREST 4 k �.✓ �� 'I� 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 OBSERVATION WELLS ❑YES NO El YES 1:1 NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODUFD IbEEDED MULCHED CENTER EDGES. OYES ❑NO DYES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKIN(, ELEV.. ELEV.. DIA, ELEV.' PIPES DIA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING GRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES. El NO OYES ONO PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING - COMMENTS: , LINE S FEET FROM / ❑YES ❑NO ❑YES N0 NEAREST 1 � Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE. DILHR SBD 6710(R.01/82) Zoning Administrator I z:DAL SANITARY PERMIT APPLICATION COUNTY /t/� In accord with ILHR 83.05,Wis.Adm. Code L/ 44s,,,, STATE SANITARY PERMIT# A)- 64 —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 %NO PROPERTY OWNER PROPERTY LOCATION '/a '/a, S T 29 , N, R 1 R E (or) Dennis Smith NW PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME --------- ---------- ----------------------- CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, Mendota Hei hts 5118 5 VILLAGE: WARREN Hy 12 II. TYPE OF BUILDING OR USE SERVED: ©[10� _/05-1 _ Number of Bedrooms if 1 or 2 Family '3 OR ❑ Public(Specify): // �u _ III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. U 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. DConventional 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. 119 seepage Bed b. ❑seepage Trench c. ❑seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): 30 1125 1125 91.5 Feet ®Private ❑Joint ❑ Public VI. TANK CAPACITY Site in aIIons 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 1000 -- 1000 1 weeks concrete � ❑ ❑El 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): umber's S' nature:(No Stamps) MP/MPRSW No.: Business Phone Number: David B. Fogert Plumber's Address(Stree,City,State,Zip Code: Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# 11ar-yey Johnson '14114 CST's ADDRESS(Street,City,State,Zip Code) Phone Number: RE 1 )4080 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stam ) XApproved ❑ Owner Given Initial S charrg^Fee Adverse Determination 2 -;?v '00 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. ,AII 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 maintaine8. 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: 1. Property owner's name and mailing address. Provide the legal description where the system is to be installed; Il. 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; 1 11 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 i result of over 2 vears of steady negotiation and public det.ate. The groundwater bill Grourtd�8#eC- included the creation of surcharges (fees) for a number of regulated practices which Wiscort�sin'S a „an effect groundwater. The surchargq took effect on July 1, 1984. All of the water that buried r asc�re` is used in your building is returned * • the groundwat�=r through your soil absorption system or the disposal site used by yr)ur holding tank purrper. � t :;1; Ae 11'r g- 'hf 3e ,rcharges are ct'edi 2d to th-.' groundwater f;_,rd aclrn;nis re: tbk yep ftrn"n' P;-so> ?rcc These fures are Used for rionitori'i g tr OUC'6- t3tf at' n af1 S t s •rd£t`ds rc,-n d 1NaIe s worm. protecting. .:` t�-F.X96 R.03!336) SANITARY PERMIT APPLICATION COUNTY �^ ,Q DILHR In accord with ILHR 83.05,Wis.Adm. Code / U�X .....�.o. STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8'%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION {� I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE F-1 YES l_/11 NO PROPERTY OWNER PROPERTY LOCATION '/4 '/4, S T , N, R log E(or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME l �.fs-,C CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,1!*KF!OR LANOMA W ❑ VILLAGE : f 1- 111. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. LJ New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an �-,� System System Septic Tank Only an Existing System Existing System 2. Lam"A Sanitary Permit was previously issued. Permit#,/�4 Z© Z Date Issued �—�f�—py 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. [J 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. LJ 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): ��/ D LJ Private ❑Joint ❑ Public J,� �� Feet VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank S ❑ ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber ❑ 1 Ll ❑ ❑ ❑ ❑ 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) 46P/MPRSW No.: Business Phone Number: 9 S� P umber's Addr ss(Stree,City,Stat ,Zip Code): Name of Designer: r ©i VII. 901L T ST I ORMATIO Cer'' Soil TeAt"+-OST)Na a CST# Q T's ADDRE85S eet, ity tate,Zip Code) Phone Number: � 7 IX. C LINTY/ Fn A-TRMWT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) charge Fee Approved ❑ owner Given Initial ] Adverse Determination G`C r`^' 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 t INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT. ' 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; 11. 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 repai r; 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 a//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 81/2 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 ove: 2 years of steady negotiation and public; debate. The groundwater bill Ground} 2tter included the creation of surcharges (fees) for a number of regulated practices which WiSCO tnrS can effect groundwater. The surchare�, took effect or) Jul} 1, 1984. All of the water tha buried �i�aso�le is used in yolrr building is returned t., the groundwater through your soil absorption o ' system or the disposal site used by y::ur holding tank purnper �szcn s ,:ok _.te_ throi4 the sze (,,edi'ed to tha groundwater fond adm,inis ° ,e Iep art[ ont )f Tl�esv funds are Used for Ior, t(7ri tg g o � rti; protecting. 3D-r,398 G3'86) �/���/✓�J'�=^,t� ,er_1�0�%` -�,�¢TTi�e1r�,�rJ .1-s o��,c�..:=rTr,�G dEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION ,LABOR AND PERCOLATION TESTS (115) MADISON W 53707 HUMAN RELATIONS (H63.090)& Chapter 145.045) LOCATION:,v SECTION: �Q}/� TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: w 1/ —1/ /T,� N/'Y� E (or 1� �I1/ — COUNTY- OWNER'S MAILING ADDRESS: / l USE 2_ 'r (A" 'BATES OBSERVATI NS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence � lew ❑Replace. 7 RATING:S=Site suitable for system U=Site unsuitable for system r ON_VENTIO�NAL: MOUND:�� IN-GR�Pa URE: SYSaTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional) If Percolation Tests are NOT re wired DESIGN RATE: �u DS q I If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH 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.) B- 7 Nlwe ? 9 T s sue ' N z / . B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD I PERIOD 2 PERIOD 3 PER INCH P- 7 30 3 3 3 O P- P- 3 3 6 / P-_ 2 Z P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 1 ) l 1 ..,....J a E t _ } i 3 I __.,,.,,_ .., _ _ _ ...... i E ' .�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): DAVE FOGERTY PLUMBING TESTS WERE COMPLETED ON: A G ( --I rr1.& Plf�lU ber 7 8 ADDRESS: 3233 #i32 CERTIF CA ION NUMBER: PHONE NUMBER(optional): F rty Heights Road '&,Qlhl R4022 Phone 749.3656 MI GNAT E: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — INSTRUCTIONS OR COMPLETING FORM 115 - SBD - 63 "4 To be a complete and accurate soil test,your report must include: 1 1. Complete legal description; 2. The use section rnust clearly indicate whether this is a residence or commercial project; 1 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 tot,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; B. Make sutc your benchniark in(] 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, it appropriate; 10. If tl�,e nforrnation (such as flood plain,elevation) does not apply, place N.A,in the appropriate box; 11, Sign the form and place your current address and your certification number; 12= Maker legible copies and disnibute as required, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Sail Separates and TextMeS Other Symbols st - Stone (ovc,r 10„) BR Bedrock cob - Cobble (3- 10") SS - Sandstone gr Gravel (under 3") LS Limestone s -- sand HGW High Groundwate cs Coarse Sand Perc Percolation Rate rra€'t, s - MWclruro Sand W Vv=11 fs - Fine Stand Bldg _ Building Ls - Loamy Sand ,_ -- Greater Titan si Sandy Loam < - Less Than 'I - Loarn Cars - B;ovvn `ssI Silt Leman BI - Black S l I cl --- Clay Loarn Y _._ Yellow sc,s - Sandy clay Loam R Red sicrl - Silty Clay Loam mot - Mottles sc Sandy clay wf - w1tl) sic - Silty C I'ly f€f few, Fine,faint _ c Clay cc rts3-rsmon,coarse w Peat rn - Many, medium nn - 111r)c;k d - distinct p - parorninent H''VVL -- High water level, Six general soil textures surface vvatet mt liquid ,,vaste€ isp o�al 8IiJ Bench Mark VRP - Vertical Reference Pont TO THE OWNER: Soil to s" re no- is dw first Step in srec w ii ns}<, sanitary permit. Tire county or the Department may request �at.c}rs c;fi hi so°1 test it the- fi.ad prigs tea raarrnit iss�.i<ance. A cornplevi sat of plans for the private «c,P "Md a r :r r,it aop)laoar; ,n must rre sui r, rated do the apj-.) >o rrt ate lot Q1 authce ily-in.nrdw to ri a n ,,,n; n,rrst"be o h,til e,l iV 9d r'los t e d p)rror,Lo 'rite stdrt 0 f �� �, r .-� _, G n t V a Q e :J 4 N � , r! ' e _._ S • Fr i ` r li 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 roperty �' 34, Section Tzo�_s_N-R�- W Township 1Z,2ats Mailing Address �-b 1 ,n _ \ w.a Address of Site Subdivision Name -Lot Number Previous Owner of Property Total Size of parcel �(�C Date Parcel was Created 1� Are all corners and lot lines identifiable? !4C->_"� Yes No Is this property being developed for resale (spec house) ? Yes _ No Volume(I and Page Number G�_C,� as recorded with the, Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) ceAti6y that att statements on thivs 60nm ake true to the best ob my (oun) knowledge; that I (we) am (are) the owner(s) o6 the pro peh ty des cA bed in thin insonma Lion 6onm, by viA tue o6 a wa4Aanty deed neconded in the 064ice o j the County Reg"ten o6 Deeds ass Document No , and that I (We) pnesentty own the pnopos ed s.cte bon the sewage dins pas system. (on I (we) have obtained an easement, to nun with the above desn bed pnopeAty, bon the construction ob said s stem, and the same has been duty neconded in the 046ice o4 the County Reg.usten o6 e , as Document-4o. ) , SIGNATURE OF 0 E SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED At took 4g �^ am ttI ��ii Mt �� �� avll7lWr of x. c woo #3s. twtim strocom. f • fift to the (W i 41 r 7 o.==am%�ammoom 4w m ., *k imam^ �• :.. ��>r.aMr �� � +F• ag ^i. krill ik�t' b �l. �I r a ,memo aft co+wM.it• /n1.R �s ss iNiaauti4t a> to at khmimm is do hW4 is as .mrk md 1 bow f,T qwd w 4 k at and ! eLe ow paA 2 7" y s m" or Maas ice►da+�r�MMR wr at WANk"m AM TS IwMt �alit..3/s.!iE tle flrt Met faun,.... set *r�y�.....L1tr+� ... ,..., -L ' '�� � �� • yam..-.�� _. +. 'i_x u. k . - � • T7 v y , '74 &L IL Wig ftOdUber, a tog* W= Age 31ftlk -y Dwaidr A.D., -1987 a'rad&ft Ct XWMC06, to me kno to,be t* &dmmlsdPd the ZU rY ftblic 040400.� 71;4 raw"- l6g 41 md its cotpo*ft I* A. PBMMNNM or .-CASO&j- ol, ED ................................. $T4T%,AwAwmwm EYE= C aL away. 2", day ou.......... At and.­­- abow ftfthdlCft� 10 0*b5o" w b,ae p"Som wi_ kd.560"qj*d CoCrantioa. ftecjftd the &rwing instnunele. AM *W Kbw*WSW dw they 10 me V the f Noft" Kw Comm* 77T .. H Z • r � H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z C1 9 H OWNER/BUYER �C-�r'(��s-, ROUTE/BOX NUMBER ('aC`O Fire Number - .CITY/STATE�P`( ArA � 'n ZIPL�gwzzs PROPERTY LOCATION: _ , 34, Section _, T N, R _W, Town of �A�Sa�`C�'(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. Ho I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- v ment of Natural Resources . Certification form must be completed and returned to the St . Croix County ing Office within 30 days of the three year expiration date . SIGNE L DATE ` __ I R INDUS T TR Y Y,,DEPAFNT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS INDUS DIVISION LABOR AND P.O. BOX 7969 ~ULAN RELATIONS PERCOLATION TESTS (115) MADISON,WI 53707 (H63.090)&Chapter 145.045) LOCATION! SECTION: OWNS IP UNICIPALITY: OT NO.:BLK.NO.: SUBDIVISION NAME: N W '/4 E:'/4 ji jT 2i N/Rils'a(or dIe>er _ COUNTY: NER' R S NAME: MAILING ADDRESS: 75--Cpo LL e-NN I S S N USE DATES OBSERVATIONS MADE NO.BEDR COMM CR TIO E S: Residence New ❑Replace j%_7 IbfX-8 19 S7 MILS A6 . ` Cj SoICS SIA- 5ATT*C �1 '�, RATING:S'Site suitable for system- U'Site unsuitable for syst m ' rC�U�Ca.►S ou IN GYMS �� SCUS IDOL r0s G j _K:RECOMMENDED NVENTwAL SYSTEM:(optional) If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the I under s.H63.09(5)(b),indicate: C.Lr4SS Floodplain, indicate Floodplain elevation: N LAC. AA ,:,.t i PROFILE DESCRIPTIONS BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH M ELEVATION OgSERV D TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- ( x.67 93 q3 rIoNt 7 67 zo" r= 3G"Be.,L. RP,4 MSJ;'�,R < SI 84,LLS GT y B Z 7.7� ? t ©N 7 7 5 /> Bu 2" N S,L � Qte /y-s J'c <I'S I IR41L s ^' B- '� 0$, 96 06 y9,o �3., `L ?�' Q sty �t; Q,�r►SdC,,e <�'' s s B- 4 /0,56 q% pr`/L >/d S6 IZ" LLT 5 3o k'r �9��$R MS-�lsR raw Rh B' `� 8.67 7.3c� > 67 l2" LLr� ?7�t3aN' ' ,L SS"gQ rwtS-�6R �rto<j4�� B- � 5. b+►ct.S PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP N WATER LEVEL-INCHES RATE MINUTES NUMBER TIII=S AFTERSWELLING INTERVAL-MIN. PERIOD 1 p PER PER INCH P. 7 A.66 t U 36 ; ' / Z P- P- 'l-E I AT I O N T PLkL 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 locatiog on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. ll I i j'c)N 1 c t W'V4 AldRrw OP 41&404Y SYSTEM ELEVATION en C:thlrCtyl-1 N� 'A i -go, 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: 1jAeve'1 Jou < i ter~., ��, �CL rE Q S /9i�7 ADDRESS: r`� A r CERTIFICATION NUMBER: PHONE NUMBER(optional): �FC- CST SIG URE: DISTRIBUTION: O,ritual and onu copy to Local Authority,('lope,ty Owrner aria Soil Testcl. DILHR SRI 6395(R.02/82) "O'.r..R - ST C D 5T brt 7�'un�k I-�?c�Nwn r / Z 1 � 26f3 I 1 � 1 4N QnSLONC 20't FQC)M 1 1 Ct . FL. \ /oo.00 1 NEAP �' ECM `f- I ' •,1 5,-rE Locn�-►o nt y\o /,%/% 115 y� g• t: Yell dN ItIA !/a,.l�// 04,•...-•J vv N:.wr•// Cja!>��:>cvw ,s-r» OBE TS f lei, st C tl et.h P.lrre O a s kJsw�>r : ede. Ihh u ,, •'J,���r. �IuQensc,/J rr�w F':'. I 6S .. t S c / o ---- o - 6 � fi V) m �' � r 1 0 0 A y ZZ• �T a � Q n 3 p N N m y Sa 3 M a n n