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Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER JP���e��pOY/Ji�/) TOWNSHIP 4G/CyG? L' SEC. �_ T .�cP N-R l� W
ADDRESS �/> / ST. CROIX COUNTY, WISCONSIN
SUBDIVISION L_L_l/ LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/1
12'
II
53
aI
4-4
/0,
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fix;sf 'n9 �
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Ile uSe- o
INDICATE NORTH ARROW
Y
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: /do,p ' Proposed slope at site: ..3 /O
SEPTIC TANK: Manufacturer: GUG YS Liquid Capacity: /ZDD A ')
Number of rings used: 617F_ Tank manhole cover elevation:
Tank Inlet1_Elevatt�ion: Tank Outlet Elevation:
Number of feet from ndarest• Road: Front Side, Rear D
O , O Zi feet
='•From nearest-property line : Front
,O Side,eRear,O �S feet
j Number of feet from: well
(Include this information of the above plot plan) ( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
t
' � t
PUMP CHAMBER
Manufacturer: Aae ty.
Pump Model: Pump/S r Pump Size
Elevation of inlet: k ele ation:
Pump off switch elevation: s p r c cle:
Alarm Manufacturer: wit h ype:
Number of feet from neare property ront, Side, O Rear,0 Ft.
Number f feet f
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION/ SYSTEM
Bed: yeS Trench:
/ D
Width: Length: �Z Number of Lines: Area Built: 6;ZY
Fill depth to top of pipe: le0
Number of feet from nearest property line: Front, O Side,Rear,
O Ft ._
Number of feet from well: 9
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits- Di er:
Liquid depth: Bottom f, seepa a pit, le ation:
Area Built:
Has either a drop box O or distr do box be n us on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: C yoo
Number of rings used: ' levat n t m of tank:
Elevation of inlet:
Number of feet from nearest ro er li t, O Side, O Rear, OFt.
Number o fee from well
Number of feet from buildin -:
A
Number of feet from nearest road:
Alarm Manufacturer:
Inspector: �✓
Dated: Z-Z-0 O /rs Plumber on job:
License Number:
3/84:mj
1
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.Bp�9gg.a, BUREAU OF PLUMBING
MADISON,WI 53707
SW1,4,SW1,4,S1 ,T28N—R16W E$CONVENTIONAL ❑ALTERNATIVE D.Number:
Ilf assigned)
Town of Eau Calle ❑Holding Tank ❑In-Ground Pressure ❑Mound
50th Avenue
NAME OF PERMIT HOLDER: FDDRESSOF PERMIT HOLDER:euben Doornink ute 1 , Baldwin, WI 54002
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Dale E. Hudson i6629 St, Croix , 92533
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
DYES ONO ❑YES ONO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET
DYES ❑NO
—]YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY. JPUMP MODEL. JPUMP/SIPHON MA NUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO ❑YES ENO : YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL- BUILDING'. VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) 1:1 YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO OF DISTR.PIPE SPACING COVER JINSIDE DIA. *PITS LIQUID
BED/TRENCH (1 rs TRENCHES MATERIAL: PIT DEPTH
DIMENSIONS d/'— .!/�
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL'. BUILDING'. V NT TO FRESH
BELOW PIPES'. ABOVE COVER. ELEV.INLET.ELEV.END: PIPES: FEET FROM LINE: AIR INLET.
NEAREST--w
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.
❑YES El NO
OIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ONO 1DYES 1:1 NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED
CENTER: EDGES'.
❑YES ❑NO DYES ONO DYES 1:1 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 DISTRIBUTION PIPE MATERIAL&MARKING
ELEVATION AND ELEV.'. ELEV.: DIA.. ELEV.: PIPES
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED LANS
El YES ❑NO ❑YES 1:1 NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
El YES 1:1 NO ❑YES F-1 NO NEAREST
em on Retain in county file for audit.
SIGNATURE'. TITLE
710 IR.01/82) Zoning Administrator
'
DILH1� SANITARY PERMIT APPLICATION COUNTY
s`t '
In accord with ILHR 83.05,Wis.Adm. Code r'o
STA 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 2;1
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES In NO
PROPERTY OWNER PROPERTY LOCATION /
oFeu/ _Dooe— �i9 S�'/a„S'&)'/4, S / T�a, N, R 1� 16(Or W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
IV All AM
CITY,ST TE ZIP CODE PHONE NUMBER CITY NEAREST ROAD LAKE OR LANDMARK
VILLAGE:
D , u� S�ooZ 7�5 67
-RD
II. TYPE OF BUILDING OR USE SERVED: l
Number of Bedrooms if 1 or 2 Family -3 OR ❑ Public(Specify): Al/,
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. ❑ New b.0 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.JoConventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a-9 seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): fit
to 15 GZ 7 Feet O Private ❑Joint ❑ Public
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 /OD DOO ❑ ❑
Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
1,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:
.tea/ So 7/S Gem 337
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
ZD /Y .� O Sorry
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
Dole �� ��sor� 3�/.3
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
L�Approved ❑ Owner Given Initial Su harge Fee
Adverse Determination /��'w "•v Q
X. COMM ENTSIREASONS 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 j
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 necessaey, 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 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 8'A 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 deoate. The groundwater bill Groundy aver
included the creation of surcharges (fees) for a number of regulated practices which Wisco tr1S
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reSSl2ft3
is used in your building is returned to the groundwater through your soil absorption o ,
system or the disposal site used by your holding tank pumper.
a
The monies colle:;tee thruug these surcharges are credited to the groundwater fund adminis--
terer. by the Department cf Natural Resources. These funds are used for monitoring ground-- t
orate;, groundwater contamination investigations and establishment of standards. Groundwater,
e''s worth protecting.
30-ri98 f9.03%86i
APPLICATION FOR SANITARY PERMIT
• ST C - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
Owner of Property
Location of Property s� �� , Section —, T 00 N - R A�,' W
Township ,cdU 4�;70 jfc°
Mailing Address ICI-41
Subdivision Name
Lot Number
Previous Owner of Property L saws o�v��
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3. • Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
of the reviewing .process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (we) ceAt16y that att 6tatemen-4 on th.ia 6onm ane true to the beat o6 my (oun)
knowledge; that I (we) am (aAe) the owneh(a) o6 the pnopeAty deacAi.bed in this
.in6onmati,on 6oAm, by viAtue o6 a waV.anty deed Jeconded in the 066.ice o6 the
.,County RegiAten o6 Deeda as Document No. d-7,? ; and that I (we)
pneaentty own the pn.opoaed site bon the sewage pos syatem (on I (we) have
obtained an easement, to .nun with the above deaeh,i.bed pnopenty, bon the
conatnucti.on o6 said ayatem, and the same has been duty neconded in the 066.iee
06 the County Reg.ia.ten o6 Deeds, as Document No. ) .
-7e
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
I wQllr�.'eEM.w•�
DOCUMENT NO. aw STATE BAR OF 111I9COMBIN–IrOft 2
L�A /h NAn 1NTr DOD
O i
Vol `} 'A. '614 THIS SPACE RESERVED FOR atco EO1N0 DATA
RECASMS OFFICE
3T. MIX CO.,
RIVER FALLS FEDERAL--SAVINGS--.fi_.LOIAbi.ASSN. _. R«'d. for RrMOrd Mda 26th
a U.S. Corporation_-- _. --- --- of Jan
_ r A.D. 19 82
at 10:00 A Ak
ronvc•;s and warrants to_. __—
_James O'Connell
i
aETUAFE TO
the following described real estate St . Cr01X _ County, l +
State of Wisconsin.
k µ .
Fast 6 1/4 rods of West 18 3/4 rods of South
12 112 rods of Southwest 1/4 of Southwest Tax Key No. __.___.
1/4 of Section 1- 28- 16.
i
FF1'
f
This ___-- homestead property.
(is) (is not) It -
Exceptiontowarranties: municipal and zoning ordinances , casements for public
utilities, and building restrictions, if any.
Dated this
_- - -= . _ 'davot January . L9 82.
RIVER FALLS FEDERAL SAVfNGS F, LOAN ASSN.
(SEAL)BY:
4_�
R. Stokkc, Presidcfit ,
(SEAL.)AT'IL• /�o'�cv (SEAL.)
Roger Engebrethi__-V_ice President
/ AUTHENTICATION ACKNOWLEDGMENT
Signatures authenticated this play of STATE OF WISCONSIN
Pierce County.
F ersonally came before me, this _ _ _ day of
.Jan, , 1982 the above named
TITLE MF.MIIF.R STATE BAR OF WISCONSIN Paul R. Stokke Ft Roger Engebreth
(If not,
authorized by 5 706.06. Wis. Slats.)
This instrument was drafted by
Stuart J. Krueger, Atty. to me known to he the person S who executed the fore-
BYE, KRUEGER F, COFF, S.C. going instrument kno le grd the same.
11:i East Elm-Street �� .�
River Falls , Wisconsin
(Signatures may be authenticated o1 acknowledged. Hoth F.J. italada
are not necessary.) NV tary'publlc !'fierce County, Wis.
M% C..-,mme+sem o, permanent. ILf nol, state explralro
date
WARRANTY 119KV -MATE PAR OF WISCONSIN FORM NO 2 10'7 _
z
cn
H
9
ST C ' 105 r
r
9
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
0
9
H
OWNER/BUYER )ee L{L ey? 1D ooY-121i7 r�
ROUTE/BOX NUMBER 15-T Fire Number
CITY/STATE 30/ Y GcJ I..IP :/UQZ_
PROPERTY LOCATION :5/0 14, _5W !4, Section T 2F N , R 1Z W,
Town of 14124.4 (;Ol �° St . Croix County ,
Subdivision Lot number //j1
I
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.
C
E
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- 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 .
SICNED ::::�? __D
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, c DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(H63.09(1)&Chapter 145.045)
LOCATION:5 SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
SW � �/ /T,29N/R/0(o Za-a �'a / NA
COUNTY:"; OWNER'S BUYER'S NAME: MAILING ADDRESS: /
S , ,X r- i I t i� i Q
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL�IDESCRIPTION: ❑New PROFILE DESCRIPTIONS: R A ION TESTS:
Residence /, Replace I � Fl s —�?
RATING:S=Site suitable for system U=Site unsuitable for system l
CONVENTIONAL: MOUND
�S.a� IN-GROUND-P�URE: SYSTEM-I�LHO�LDING WANK:RECOMMENDED SYSTEM: optional)
SS JncLl S U S EIS MI D Ala
If Percolation Tests,are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: N� I Floodplain,indicate Floodplain elevation: N�
F7 PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTH CPF. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- 2 .Q" W,67 /UofiP. 7- 'G Si 30'e" >'
B- 3 7,33 99'QO '7�3.5 00`�B�si/• s�` / 13 P r• O S
B-
B-
B-
�, PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER ING1 66 AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD z PER D PER INCH
P_ `7-3 O .%"' '7
P- ,2 3,9y', Z„ �,
P- ,
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
T
:
._. _ _ ; .._ _ _ _ __. .........._ _ --
tN
__j
I +
- - a - � --
+
I
-- -_ —
i
i
tee__
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:
-Dale
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
CST SIGQ(A R
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 - SB[} ' 6395
To be complete and accurate soil test,your ,°pot't m"st inc|odp: �
1 Complete legal description;
2. The use section must clearly indicate whotho,thio is residence orcommo,cia| project;
3, MAXIMUM number of bedrooms o,pomnnvrdo| use r|annwd;
4. Is this a now or mp|onomenr system:
5� Cnmcdmn the Suitability mhnu boxes. A SITE IS SU|7AULE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
G. PLEASE use the abbreviations shown here fnrvv,iting nn�h|e descriptions and oomrd«.ting the plot plan;
7. MAKE A LEGIBLE diagram accurately |umadnq your test locations. Drawing to mm|n is pnfo/md. A
separate sheet may be used if desired;
8. Make su,e your he^rhma,k and vo/uov| p|mv/.m .e|,.ence noinI.a,a clearly shown,and nre permanent;
9. Cump|o/o all appropriate boxes as to dates, namvs.addresses,flood plain data, percolation test exemp-
tion, if appropriate;
10. if the information (such as ood plain,elevation)doo riot apply, place N.4. in the apvmn,late box;
11. Sign the form and place your current address and YOLIV 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.
�
ABBREVIATION'S ERT!F|ED "0L TESTERS
Soil Separates and Textures Other Symbols
� u — Slow, lover 10^) DR — Bed.ock
cob — Cobble (3 lO^) 3S — Sandstone
gr — Gravel (under 3') L — Limoctono
� °» — Sand HGW — High Groundwater
uo — Coarse Sand Pc,c — Percolation Rate
mmfs — Medium Sand VV — Well
fs — Fin: Sand 8|d0 — Building
is — Loamy Sand > — GrcaterThmn
°d — Sandy Loam ( — Less Than
°| — Loam Bo — Brown
°,i| — 8|tLvpm 8| — Black
si — 3i!/ 6v — Gray
°d — Clay Loam Y — Yellow
uJ — Sandy Clay Loam R — Red
sid — Silty Clay Lvom mot — Mottles
sc, — Sandy Clay VV/ — with
sic — Silty Clay hf — few, fine, faint
� °r — Qnv cc — vpmmon' roano
� p t — Peat mm — Manv' m,dium
m — Mock d — distin/t
p — prominent
HVVL — High water |ovo|'
° Six general soil texture's surface water
for liquid waste disposal BM — Bench Mark
VRP — Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in SeCl.irill(
verification of this soil test in the field prior to pen-nit ISSLianc.e, A cornpipte set of plans for the private
sewage system and a Permit applica!k-)n n:rsl he shrmlllod io l""W local arlthotoy in ordcl to
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Request fo As-Built ---��
Requester's name: one#:
Original owners name: ' ( Q 1apr
Address: ��CJ k., 5 b �--- �-'`�
Subdivision: c �"— Lot#
Township:
Plumber: Year Installed: 0
Legal Description:
�/� —
SL
Kevin Grabau
From: Rod Eslinger
Sent: Tuesday, July 11, 2000 4:44 PM
To: Jon Sonnetag; Kevin Grabau; Mary Jenkins; Steven Fisher
Subject: FW: Comm 83.O3(c)
-----Original Message----- tiAl
From: Jansky, Leroy [mailto:ljansky@commerce.state.wi.us]
Sent: Tuesday, July 11, 2000 4:38 PM
To: Barron County; Eslinger, Rod; Farmer, Darryll; Helgeson, Mike;
Herrick, Cleo; Jain, Kenneth; Koehler, Jim; Peterson, Dan; Peterson, �) G
Larry; Shambeau, Jay; Spanel, Gary; Tesky, CeCe 1 M�
Subject: Comm 83.03 (c)
Here's yet another question from the field: 31 1 1' LJ
Q: We have a question on 83 .03 (c) . Can a homeowner add on 2-bedrooms
to
an existing 3-bedroom mound system, original installed in 1990, (thus S
the
resulting construction would undersize the system) without enlarging the
system? Wr s �
As I understand the paragraph, in this case the POWTS needs to be
modified
to conform to the rules of the new code. We no longer have the option
to
allow an affidavit to be recorded for the parcel to inform future owners t0
of
the parcel that the system is undersized, right? What about the 25
rule,
that seems to be missing as well? I`
A: There's not a lot of wiggle room in 83.03 (c when loads and/or flows (�w;ty
However, there could be situa ions where the addition (even a
increase- ,
bedroom) doesn't add additional loads or flows to the existing system.
For
example, four persons living in a 2-bedroom home and they want to add a
third bedroom but there is no immediate increase in flow or load. Yous
could
issue conditional use permit for the addition that spells out the use nn
of
the structure such as you might for a commercial use. In addition, it
is
advisable to get a writ en statement from the owner as to the occu anc
and (re
use f the structure. Furthermore, you can have a document recorded
ith
the deed that indicates occupancy limits for the stir
ucture based on
POWTS size limitations. Lastly, you may want to ih-soect the system to make
sure
it's not failing (no t ondin ) by surface discharge, etc.
�- d 14 Wilk.btj jer&-
,
As far as the 25% increase in floor space rule to be used as a trigger
for
POWTS inspection or as an increase in flow, that would have to be in
your
sanitary ordinance. However, before you equate a 25g or more increase
in
literature that
.floor space to an increase in flow I'd try to find some
backs up �_, ,
what the additional flow is for incremental increases in floor space. l - p.RV's
I'm - (l 2'1C S2.' ` (02� � l SaJr evv%
2 oS �ge 1 / .ems•
S\A S a t�i
w
Y
Parcel #: 008-1002-20-000 osils/loos 11:05 AM
PAGE t OF 1
Alt.Parcel#: 1.28.16.11 B 008-TOWN OF EAU GALLE
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-KUTZLER,SHERYL J
SHERYL J KUTZLER
2606 50TH AVE
WOODVILLE WI 54028
Districts: SC=School SP=Special Property Address(es): "=Primary
Type Dist# Description "2606 50TH AVE
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 0.630 Plat: N/A-NOT AVAILABLE
SEC 1 T28N R16W.63A IN SW SW BEGIN Block/Condo Bldg:
206.25'E OF SW COR TH E 133.12';TH N
12 1/2 RD W 133.12';TH S 12 1/2 RDS TO Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
POB 01-28N-16W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 971/44
07/23/1997 785/205
07/23/1997 640/614 Y n ' h l L�
2006 SUMMARY Bill#: Fair Market Value: Assesse .
0
Valuations: Last Changed: 05/12/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.630 11,300 72,200 83,500 NO
Totals for 2006:
General Property 0.630 11,300 72,200 83,500
Woodland 0.000 0 0
Totals for 2005:
General Property 0.630 11,300 72,200 83,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch#: 513
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00