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HomeMy WebLinkAbout006-1043-70-000 Q o � ' 3 0 o > rn 0. 0 �. o � � o � N N U N O c N Q O y. 3 U, �J Y L- p !�. 0 0 v 0 G n p U 3 M Q ' O po �- m p ,wad. f C z N v- v LL r 0 N _ f� _O O U C Q Q 3 Q v Cl) rn Z o a E o z ) y co" z a m o I c C7 O z v r � w °' z v N z fq F- r O i c � � -0 _� Cl) ca a� w O Y N N � C. �l cn L 0 0 z 00 z w N O z I A � N N � R L d C (n a N 10 y T d N L O U C G d al 0] I _E '_ WSJ c} p 7 OD 000 N fA U o- rn rn } > N n O O N C pO w- O M O E O CQ O '.. N O N (0 + C C c C U O M cN0 30 O I C N — O. 4 N 00 Z .M -00 � izN •�i o i c - E � L- O O 0 . � cn m L. U Q O R L •C d E m a 0 #ti a • a d ;_� y a r� E i E C w 3 �! A vat 0 f � Parcel #: 006-1043-70-000 03/22/2007 10:31 AM PAGE IOF1 Alt. Parcel#: 20.31.16.299 006-TOWN OF CYLON 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 JOHN F& ELOISE M ANTON O-ANTON, JOHN F& ELOISE M 2103 210TH AVE DEER PARK WI 54007 Districts: SC= School SP=Special Property Address(es): `=Primary. Type Dist# Description '2103 210TH AVE SC 3962 NEW RICHMOND /) SP 8020 UPPER WILLOW REHAB DIST �n " � � /a l SP 1700 WITC V `,(�Vim- (lam 1 51 4e- ", 1 F CS Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 20 T31 N R1 6W 40A NW NW Block/Condo Bldg: S Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 20-31N-16W Notes: Parcel History: Date Doc# e Type 07/23/1997 758/256 07/23/1997 706/261 2007 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 09/08/2004 Description Class Acres Land Improve Total State Reason PRODUCTIVE FORST LANDS G6 36.000 108,000 0 108,000 NO OTHER G7 4.000 20,000 265,000 285,000 NO Totals for 2007: General Property 40.000 128,000 265,000 393,000 Woodland 0.000 0 0 Totals for 2006: General Property 40.000 128,000 265,000 393,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch M 512 Specials: Use Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 f Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER JO TOWNSHIP 16,,liI, SEC. ( T _LN-RIC W ADDRESS ,Z2.24) WSJ` ST. CROIX COUNTY, WISCONSIN SUBDIVISION - LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 e� 3 ice' r /o � p I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used _ Elevation of vertic4, reference point: / Proposed � �t ` p /d Proposed slope at site: 2 SEPTIC TANK: Manufacturer: Liquid Capacity: zzi,_� Number of rings used: �_ Tank manhole cover elevation: , 9 { + Tank Inlet Elevation:,,�� Tank Outlet Elevation: ,9� � 4 Number of feet from nearest Road: Fron't.0 Side, Rear, O -sue feet m nearest property line Front.0Side,0Rear,0 /� feet Number of feet from: well building: (Include this information of t e above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE 'DEPARTMENT OF INDUSTRY, IIVJrCIi.,I IVIY nr-r-un I rvn DIVISION LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O.BOX 7969 MADISON,WI 53707 NW1,4,NW1,4,S20,T31N-R16W ),CONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number Town of Cylon ❑Holding Tank ❑In-Ground Pressure ❑Mound Highway 46 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DA John Anton 222 West First Street New Richmond 1 54017 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: 11;1,1 REF,PT.ELEV.. Name of Plumber. MP/MPRSW No.: County Sanitary Permit Number: Byron Bird Jr. 3318 St. Croix 102818 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: EAN�K UTLET ELEV.. WARNING LABEL LOCKING COVER II PROVI ED: PROVIDED l O O O � •7 $ y S b I YES ❑NO DYES NO BEDDING. VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD. PROPERTY WELL. BUILDING. FRESH ALARM. 1 LIN� 1 I IVENTTO AIR INLET FEET FROM DYES . NO 1:1 YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING'. JLIQUIDCAIACITY PUMP MODEL PUMP/SIPHON MANUFACTURER TMATERIAL LOCKING COVER PROVIDED. DYES ❑NO OYES No DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTBUILDING VENT TO FRESH LINE 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 LENGTH DIAMETER 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 &PITS LIQUID BED/TRENCH TRENCHES I MATERIAL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH "ST" DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR. NUMBER OF PR OPE RTV WELL BUILDING VENT TO.FHESH BELOW PIPE/S ABD E CnOVER. ELpEV.INLET ELEV.END' PIPES FEET FROM LINE O AIR INLET f01� 4d "1�,SS SS-44 Z7 2 NEAREST �U 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 PERMANENT MARKERS OBSERVATION WE LLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEUED MULCHED CENTER. EDGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTH IBUT ION PIPE MATERIAL&MARKING ELEV.' ELEV.. DIA.. ELEV.. PIPES DIA.'. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANSC AL LIFT CORRESPONDS TO APPROVED /") ❑YES ❑YES ❑NO ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING. t FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST I' t Sketch System on / ,L t, eta' in county file for audit. Reverse Side. i� j l"" IGNATUR E' ITLE T Zoning Administrator i DILHR SBD 6710(R.01/82) PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size , Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,© Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width: Len$th: Number of Lines: Area Built: E � 3 Fill depth to top of pipe: Number of feet from nearest property line: Front,! O Side, Rear,0 Pt ./->"8 Number of feet from well: &0 Number of feet from building: y (Include distances o 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: 1/ '�7' D Plumber on job: f�U License Number: i SANITARY PERMIT APPLICATION COUNTY =Zal. In ac cord with ILHR 83.05,Wis.Adm.Codes CPO 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 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO PROPERTY OWNER 1 PROPERTY LOCATION '� R t2 n D Gt % 11( %, So20 T , N, R E(or PROPERTY OWNER'S MAILING ADDRESS / LOT NUMBER BLOCK NUMBER SUBDIVISION NAME A/C lcmw CITY,STATE ZIP CODE PHONE NUMBER CITY REST RO AKE OR LANDMARK �►- VILLAGE: II. TYPE OF BUILDING OR USE SERVED: IM, 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.,KReplacement 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. X Seepage Bed b. ❑Seepage Trench c. ❑ See a e 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): �r �_/rj d J© /7 Feet 4�Private ❑Joint El Public VI. TANK CAPACITY Site in gallons 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 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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: �PlumbepXA54ess(Street,City,State,Zip Code): Name of esigner: M G �/' ✓tom rah �'� VIII. SOIL TEST INFORMATION Certified SZ1,0,ter(CST)Name CST#, ism �.0- . C 0 3 CST's AD S(Street,Cit ,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate issuing Agent Signature(No Stamps) I%Approved F-1 Owner Given Initial Surchharge Fee / p Adverse Determination r_'C?n g6• X. COMMENTS/REASONS FOR DISAPPROVAL: Pan O #A � mar 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 81/ 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 ater —> included the creation of surcharges (fees) for a number of regulated practices which Wiscofr0n'S can effect groundwater. The Surcharge took effect on July 1, 1984 All of the water that buried reasuro'. is used in your building is returned to the groundwater through your s it absorption � o 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- f 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 ' r � Location of Property �� 4A2-:j , Section , T `I� N-R� W Township 0 S �LV . Nailing Address , Address of SitaP S Subdivision llama . Lot !lumber Previous Amer of Property 7 Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? y { Yes No Is this property being developed for resale (spec house) ? Yeso Volume .-7 and Page Number 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 (Wo_1 ceh.Li_6y that aft etatement6 on tIUA ohm ahe t ue to the best 06 my (ouh) hncwCethat dge; � at i (wel am (she) Uie owneh(A1 06 the phopenty deznibed in •thiA .in6offmaLion 6o4m, by VilQue 06 a wahhanty deed hecohded in the 066ice 06 the Coiin.tyy RegiA tePL o6 Veeds ass Document Na.L 6 ; and that I (We) pheaentty avn I phoposed bite 6oh the Sewage dapoe bye em (oh. I (we) have obtained an V-dAc +ent, to PLUM with the above dehc&ibed phopeh.ty, 6on. the cone.thuction 06 said eyetem, and the dame has been duty PLeco&ded to the 066tee o6 the County Reg•i.eteh o6 Veede, as Doeeaeent No. ) SIGNAi4M Of ER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNS DATE SIGNED 1 DOCUMENT NO. i I WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 .1.50 1J86 BOY PAGE ;<T3lWSTL+Z5 OFFICE IT. CROIX 00., WISa jBank of New--Richmond______________________________________________ ____ ,:"C,4!. frar It13a�rd Nds 28th !I - ----------- ----------------------------------- --- ---- - day of Oct A.D. 19_26 conveys and warrants to -----•---•------------------•--•--------------------•------- -•----------•- P 12:45 P Weal- ..... ... . ..._ -------------------- -------------------------- ------•-•---------•----•----•--- John F. An ....1ild._E�,ox;?.�.. I A1�.t9i1,..--------•--•------------ tso 1r of �.d• hus.band...and""wife,.__-as...surei vorship-----------_------------- .mar.ita7._.-prope_rty----------- ------------------------------------------ ---------- ji .... ...... .............."-__--__.--.._...__--.__._ -------------- ...................................... RETURN TO .. .... ...--------.--------------...-------------------------------------------------------------------------- . .. ....... ............ -..____---------_---- _. the following described real estate in ...... St. CrQiX County, State of Wisconsin: Tax Parcel No: .............................. ij I! North Half (N 1/2) of the Northwest Quarter (NW 1/4) and the Southeast Quarter (SE 1/4) of the Northwest Quarter (NW 1/4) of Section Twenty (20) , Township Thirty-one (31) North, Range Sixteen (16) West, Town of Cylon, St. Croix County, Wisconsin. ii S 1 O ;I FEE I I. ii I� This -------is._.nQt------- homestead property. (is) (is not) Exception to warranties: municipal and zoning ordinances, easements and restrictions of record. I i q I Dated this --►- --------- day of ...........0 tober -- 19.86. .. ANK OF NEW RI D ------------(SEAL) ------ -- --- ---�.-- ........(SEAL) B James A. Gre z * _.V.ice_Pr si en. ----------------------(SEAL) --. (SEAL) and by. Gary nuts n * * -I -s---Assi-stant-- V-ice-President AUTHENTICATI ACKNOWLEDGMENT Signatures) _"_______________________ __________________________________ STATE OF WISCONSIN ss. ------------------------------------- ---------------------------------•------ -ST.---------—-- ---------•--• County. authenticated this ____- _-day of--------------•_____---_--, 19._..._ Personally came before me this ... ...day of ______October------------------- 19 86.._ the above named ----------------•••••--- ------------------ ---------------------------- ...... James A. Gretz and...Gary * Knutson ------ -----------------------------------------------•-------------------------------- TITLE: MBER STATE BAR OF WISCONSIN as officers of Bank of,,,,,,,:,,�,: f not, --- -- --- --------------------------------------------------New Richmond ' �� ... --- ..r----- authorized by § 706.06, WIS. Stats.) to me known to be the person ._S_,.�__ whg executed the foregoing instrument and acknowledge the--same.V THIS INSTRUMENT WAS DRAFTED BY y ' Judith A. Remin ton "" d REMINGTON LAW OFFICES 4ota-= ---- .1--� ti'L'I=.'� :� St Cro x " ------Ne-w--�ic�Imond�T--�I-----SAD-].7------------------- Y Public ------••'----------- -_. --•-- ------.,-_�onnty, Wis. (Signatures may be authenticated or acknowledged. Both ommission is permanent.(If not, state)expiration are not necessary.) fJJ date- ----------------�-r-�-��---------•----------'::•_:_:; 19, __O..) -Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Ltygnl 111ank Co. Inc FORM No. 2— 1982 Nlihcsckec. Wis. ' H G En H ' a r STC - 105 r , a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z t7 a H OWNER/BUYER ROUTE/BOX NUMBER Ge) Fire Number I C! 41— CITY/STATE +-L � ¢ �zy� ZIP © � 7 PROPERTY LOCATION :, 1& > Section , T �N , RP-(4 � ""TT T W-f 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 E 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 Zoning Office within 30 days of the three year expiration date . SIGNED a �N7G DATE 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, CC DIVISION LABOR HUMAN RELATIONS PERCOLATION TESTS (11J) MADISON WI 53707 (ILHR 83.09(1) &Chapter 145) LOCATION: SECTION: OWNSHIP/M NICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: %/ O o /T3 N/R 6 E (o c o _ COUNTY: OWNER'S)BUYER'S AME: MAILING ADDRESS: / �• Gwa( j ob 1_4 yt W.. r -;, ¢.o vex cll m� d lrJ, �5 0 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLATION TESTS: N$esidence �� ❑New eplace /)� C/��I� //`/� ­� •7 RATING:S=Site suitable for system U=Site unsuitable for system / ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) rNs ❑U S ❑U S ❑U ❑S U ❑S [Y u 5c JIF If Percolation Tests are NOT required DESIGN RATE: 4 �� If any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate: � ' I Floodplain,indicate Floodplain elevation: )Yiv PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMB/ER DEPTH IN. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) y� B- l 9{O 7 Owl. G- 7 4f7 ,a? q7�S�/ B- B- B- tef' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER Lqj@M AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH P- Y,5 .zL o y 6 P- L 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. SYSTEM ELEVATION E 1 a 1 Ftw, E 3 � E E ° a e r E E F E ._ate P oi`3 I 3 E 611007 Aj 3 �v E a 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( ' t): TESTS WERE COMPLETED ON: ADDR S: CERTIFICATION NUMBER: PHONE NUMBER(optional): 91 1 /,5"2. 6 7G CST SI ATURE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R. 10/83) —OVER — INSTRUCTIONS FOR COMPLETING FORM 115 - S D - 5595 . To be a c omplete and accurate soil test,your report must includes 1. Complete,cgal description; 2. The use section must clearly indicate whether this is a residence or oornrnercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4, Is'this a new or replacement system€; b. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEivIS 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; €3, 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 not apply, place N.A.in the appropriate box; 11, Sign the form and place your current address ran€;I 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 Gobble d3- 10") SS Sandstone gr --- Gravel (under 3") LS -- Limestone "s Sand HGW High Groundwater €.s — Coarse Sand Perc Percolation Rate coed s Medium Sand W — Well fs Fine Sand Bldg -.... Building Is - Loamy Sand > — Greater Than sl - Sandy Loam < Less Than 'I Loam Bn -.. Brown sil Silt. Loam Bl — Black s( — Silt Gy Gray #cl Clay Loam Y — Yellow scl - Sandy Clay Loam R Red sicl - Silty Clay Loam} snot — Mottles sc -- Sandy Clay w,' with sic — Silty Clay fff — few, fine,faint *c Clay cc common,coarse pt Peat mm -- Many, medium m — Maack d — distinct p - prominent HWL - High water level, Six genera' soil texture's surface water for liquid waste disposa( BM — Bench Mark VRP Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit.The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. r PLOT PLAN PROJECT JD �`��, ADDRESS 114 1/4/S /T N/R � W TOWN 4v,o 6 COUNTY o1X C bYer'� MFRS Byro Bird Jr. 3318 DATE -� ®-- Jr BEDROOM CLASS PERC__/__CONVENTIONALXN-GROU PRESSURE CONVENTIONAL LIFT MOUND-HOLD NG TANK SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA gz,>— PERC RATE _BED SIZE Benchmark V.R.P. Assume Elevation 100' Location of Benchmark ,Aa//,-, oar * H.R.P. Sic 4_0 z h1 0 Borehole Well Scale Feet v c,. O Perc Hole ,a ,� System Elevation ��• 7 � f ,i1' TYPAR COVERING cta ~ 2" 12" 3' 4 6' 3' 3' Q 3' 1 6" Sewer Rock 1 12' 8' C14 I r �-s 01%4 fV r f Ue 9 F I