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Parcel #: 012-2002-80-000 09/19/2006 03:46 PM
PAGE 1 OF 1
Alt. Parcel#: 04.30.17.570C 012-TOWN OF ERIN PRAIRIE
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-HAGEN, STEVEN J&LINDA R
STEVEN J&LINDA R HAGEN
1771 178TH AVE
NEW RICHMOND WI 54017
Districts: SC=School SP=Special Property Address(es): '=Primary
Type Dist# Description 1771 178TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 1.290 Plat: N/A-NOT AVAILABLE
SEC 04 T30N R17W LOTS 14 THRU 25 BLK 78 Block/Condo Bldg:
VIL OF JEWETT MILLS
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
04-30N-17W
Notes: Parcel History:
Date Doc# Vol/Page Type
05/24/2002 679970 1898/63 QC
10/29/2001 660331 1747/560 WD
07/23/1997 704/577
2006 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/07/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.290 19,400 336,300 355,700 NO
Totals for 2006:
General Property 1.290 19,400 336,300 355,700
Woodland 0.000 0 0
Totals for 2005:
General Property 1.290 19,400 336,300 355,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 137
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER f �yC1L12 TOWNSHIP SEC. T _N-R W
ADDRESS,2-2Z S"t� ST. CROIX COUNTY, WISCONSIN
SUBDIVISION �1 `'� LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
)SO 7
- r _ i
s
41 8 '
4
0
INDICATE NORTH AR OW
BENCHMARK: Describe the vertical reference point used 41"
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer:�7i;=,(� � �,� ./'Liquid Capacity:
i
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: / Tank Outlet Elevation: � 7_j'
Number of feet from nearest Road: Front,O Side, Rear, O J feet
From neare8t, property line Front,O Side, Rear,O ��� feet
Number of feet from: well building:
(Include this information of the above plot plan) ( 2 reference dimensions to septic tank)"
SEE REVERSE SIDE
J 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: X Trench:
1
Width: Length: Number of Lines:. Area Built: _
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft ., L
Number of feet from well:
Number of feet from building:
v
(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, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: 5��"�� Plumber on job:
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.'BOX 7969 BUREAU OF PLUMBING
M*DISON,WI 53707
NW' ,NE%,S4,T30N-R17W IN CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: r
I f assignee)
Town of Erin Prairie El Holding Tank ED In-Ground Pressure 1:1 Mound
Wards Addition CTY K
NAME OF PERMIT HOLDER: DRESS OF PERMIT HOLDER: INSPECTION DATE:
7224 Tim Emholtz West 5th, New Richmond, WI 54017 -7'
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:
Cal Powers Jr. I1563 St. Croix 92511
SEPTIC HOLDING TANK:
MAN ACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
^ y �7 PROVIDED PROVIDED:
LIA)c / Ufa t97 /p .76 &WES ❑NO ❑YES O
BEDDING: VENT DIA.: VENT MATL.: HIGH WA ER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
/1 ALARM FEET FROM LINE: 1 / AIR INLET.
OYES �O Cz ❑YES ®'NO NEAREST 6
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO ❑YES 0 OYES ONO
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) ❑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 1 INO.OF DISTR.PIPE SPACING. COVER INSIDE DIA. &PITS LIQUID
BED/TRENCH TRENCHES / MATERIAL: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH jDISTR.,PIP' DSTRPIPE DISTR.PIPE MATERIAL: NO. STR. NUMBER OF PROPERTY WELL. BUILDING. V NT TO FRESH
BELOW PIPES: ABOVE COVER ELEV. NLET.ELEV.END. r�^ PIPE FEET FROM LINE 1 ^ AIR INLET.
ri . ga 4lp 3 d /o+ 5 NEAREST-1 V ~J t`►
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 NO
OIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED
CENTER. EDGES.
DYES El NO 1:1 YES 1:1 NO 1-1 YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE IMANIFOLDMATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
ELEV.. ELEV.: DIA.: ELEV.: PIPES
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ONO ED YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
3 FEET FROM LINE:
D YES ONO DYES ❑NO NEAREST
►� l Ho
Sketch System on Retain in county file for audit.
Reverse Side.
SIG TURF. TITLE.
DILHR SBD 6710(R.01/82) Zoning Administrator
{� DILH SANITARY PERMIT APPLICATION COON / X
u R In accord with ILHR 83.05,Wis.Adm.Code D
STAT 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. FFORI TION
I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. VARI ANCE ❑YES ❑ NO
PROPERTY OWNER PROPERTY LOCATION
Aj'/a '/4, S , N, R E (or+LV
PROPERTY W ER'S k3AILING ADDRESS LOT NUMBER BLOC UMBER SUBDI ISION NAME
CITY,STAT ZIP CODE PHONE NUMBER CITY EAREST R AD,LA OR LANDMARK
jj VILLAGE
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. X 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. 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. 9 seepage Bed b. ❑seepage Trench c. ❑ SeeDacie Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Squire Feet): �7I
•-� Feet 9 Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in aa 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 -- ❑ ❑
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.
Plu ber' Name int): Plumber's Signat e: Stamps) MP/MPRSW No.: Business Phone Number:
Plum Street
,bgr's Add re? ty,State,Zip Code): Name of Designer
J
VIII. SOIL TEST INFORMATION
Certified Soil ester(C )Name CST##
.". I k_
J
CST' D RESS treat,City tats, ip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved jSnitary Permit Fee Groundwater ate Is ing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial S charge Fee
Adverse Determination
X. CO ENTS/REASON//SFOR DISAPPROVAL:
e(Jl !S Ord
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 locetion, 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 mast 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 41. 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 8f`Br
included the creation of surcharges (fees) for number of regulated practices which Wisco irl=!
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried re.4611 a'
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 collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house"), then a second form should 'be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
Owner of Property L 4,1/a,taz-
Location of Property '� /, ' , Section T: jQ N-R ,/7 w
Township.
Mailing Address
� I
Address of Site
&;,4&VA40 rat Z L7
Subdivision Name
Lot Number
Previous Owner of Property ��p/�Aj-�
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 )J"7 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) ceka6y that a t statements on this 6onm cAe tAue to the but o5 my (oun)
knowtedg e; that I (we) am (are) the owneA(s) o6 the pro penty des crib ed in this
.in6onmation bonm, by viAtue o5 a wa4Aanty deed Aeconded in the 066ice o6 the
County Regasten o6 Deeds as Document No. ,3 and that I (we) pnes entCy
own the proposed .bite bon the sewage d.izpos sys em (on I (we) have obtained an
ea3ement, to nu.n with the above deschibed pnopenty, bon the constn.uction o6 .said
6y6tem, and the came has been duty teco&ded in the 046.ice o6 the County Regi.6ten o6
Deede, as Document No. ) .
SIGNATURE 09 SIGNATURE OF CO-OWNER (IF AP LICABLE)
DATE SIGNED DATE SIGNED
DOCUMENT NQ. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA _
STATE BAR OF WISCONSIN FORM 2-1982
199 X90 i V0� J 04 PAGE 577
MGM ER5 OffiCE
Margaret Moore and Patrick Moore wife and ST. CRCHX CO., WIS.
..............................................................j..- --------------------d 28th
husband as oint tenants .aka..Margaret.--Aran-..... Recd for Record thIa
�. . .
......MQQre...and.-Patrick__J.....Mo.ore---...------•------••--•-------------------- day of Jan A.D. 1985
...•. -• . ----=•..... •---- -- •. ....•------ -• - .. .......... ---------
conveys and warrants to _.Timothy_ J..-Emholtz_._and
Katherine__K.__.Emk;<Q�.t --.husband..axed---wife---as..._..--.
......joint-_tenants................ boMta d SIN&
•--•-------•...................•-------........................---.........................---...................
—�// 7 �A V
.............
RETURN TO • �H+�T
_ ---------=--- -------- ---------------------------------------------------------- --- • �7 the
following described real estate in .........$.ts.._�xQi3s;.................County,
State of Wisconsin:
Tax Parcel No: .............................. I
i
I
Lots 14 , 15, 16 , 17, 18, 19 , 20, 21, 22 , 23 , 24 and 25 of
; Block "78" , together with Lots 1, 2, 3 , 4 , 5, 6 , 7, 8 , 9 ,
10, 11 and 12 of Block "8711 , all being in the Plat of
Jewett Mills.
TOGETHER WITH all vacated streets and the park lying
South of Lots 19 and 20 of Block "78" and North of
Lots 1 through 12 of Block "87" , and alley lying East
of Lots 20 through 25 of Block "78" , all being in the
Plat of Jewett Mills , St. Croix County, Wisconsin.
TRANSFER
This ----i 5...nQt.......... homestead property.
(is) (is not)
Exception to warranties:
Dated this ------------------------------- day of ..........De.Qembex....................................... 19..84...
,-dvr��'. �-��:------- ---------(SEAL) Y_ -`. T ✓�(\
* ............:.... . - Margar t Moore, aka Marga_ ret Ann Mo re
Rp g. M�RRa
..R.C.H� acrE--�,I IesotA . (SEAL)
�Y�IIr C0� 7--•------ ---- ¢SEAL)
RAMSEY 1g
M cwtlf"Of �Ire'i°iY�u.�9 ra:tck--Moore,- aka,-Patrick•- J. Moore
AUTHENTICATIO ACKNOWLEDGMENT
Signature(s) Minnesota
STATE OF ftQXSdX<
ss.
--------"_--"-----------------------•-----------------------------•--- _Croix
-------' - --------------------------County.
authenticated this --------day of___________________________ 19_ . - Personally came before me this . 8._.--_.day of
___._-.-_...n..... r -- , 19.8 4-- the above named
" ". • --- ""'"'"""""'""" •-' Mar aret P•400re and Patrick Moore
g ---------------------------------------------------------------
TITLE: MEMBER STATE BAR OF WISCONSIN
--- --- ---------------------------------------------------------------------
(If not,
---- -- ---------------------------------•---------------------------------
-- ---------
authorized by § 706.06, Wis. Staty.) -------------•-------------------•---------------•------------...-------•----•-•
to me known to be the persons----------- who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Re
--------------------------------------------------------------------------------� Va Needham,--- -- --------------------------- -------------
-
New Richmond WI -
54017 '-------------------------------------- -----------------------------------••--
.c..... . . Notary Public ------------------------------------------County,�i+ yMiri
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration
are not necessary.)
date- ......................................................... 19.........
*Names of persons signing in any capacity should be typed or printed below their signatures.
W
FLGMIIIsrComparry STATE BAR OF WISCONSIN
FORM No. 2— 1992 CMS Nn 11 1%nn7_
• H
z
N
H
' a
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT Ho
St . Croix County z
tv
a
H
OWNER/BUYER ':� h jy"� t`'
ROUTE/BOX NUMBER ���"t� Fire Number
.CITY/STATE ziLz �/Lly�y�_�/ ZIP��0/7
PROPERTY LOCATION:' , , Section , T10N , R-2-7—W,
Town of St . Croix County ,
Subdivision h�42& ja , Lot number
• I I�
Improper use and maintenance of Y o ur
septic system stem 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 .
0
E
I/WE, the undersigned , have read the above requirements and agree Cn
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ►d
ment of Natural Resources. Certification form must be completed
and returned to the St . Croix County Zoning Off a within 30 days
of the three year expiration date .
SIG
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 OFD REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS
HUMAN RE4_ TIQNS ( � P.O. BOX 7969
A 115
MADISON,WI 53707
(H63.090)& Chapter 145.045)
L ION- ;' E TI N: ITOWNSHIPIMUNI IPA4ATY: OT NO.:BLK. O.: SUBDI ISION NAM
'/ /TON/R (or)W
C NTY OWNER'S BUYER'S NAME: MAI G ADDRESS:
1 ��'
USE DAT S OBSERVATIONS MADE
NO.BEDRMS,: C 0 M M E R C I A ESCRIPT10N: ROF DNS:IPERCOLATION TESTS:
Residence oNew ❑Replace '
RATING:Sm Site suitable for system U.Site unsuitable for system 7 g
CONVENTI NAL: MOU D: IN-GROUND PRESSURE: S STEM-IN-FIL HO DING TANK: RECOMMENDED SYSTjEM:(Optional)
: sou s ❑u Us ❑u os ®u El U -
If Percolation Tests are NOT required DESIGN RATE: If an
; y portion of the tested area is in the
under s.H63.09(5)(b),indicate: loodplain, cate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL PTH T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH K ELEVATION OBSERVED E . I HE TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- , / 17.9.14 7 - 1 /-7
Al
B- AhA6E _ Z&-
B- - _
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER L40PMS AFTERSWELLING INTERVAL-MIN. PERTO 1 PERIQP PERIOD PER INCH
P / -
P- s 9i 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
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1,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.
NAME4print : TESTS WERE COMPLETED ON:
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ADD SS: CERTIFICATION NUMBER. PHONE NUMYER(optional):
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CST 'N7TURE:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) -OVER -
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PAGE OF
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rvSS SILC ' It) 1-1 Or /� Zco S SIe"•l
C y r
� Fresh Air It►lot• And Observation Pipe
fnJ �1/Li/r�afl�
Approved Vent Cap
7 Minimum 12*Above
Final Grade
20-4 2'Above Pipe _♦"Cost Iron
To Final erode Vent Pipe
Harsh Hey Or Synthetic Covering
Min 2"Aggregate
Over Pipe
Distribution —Too
Pipe o 0
V Aggregate o Perforate0 Pipe 8 .w
Beneath Plp•
p Coupling Tnmineling At
Bottom Of System
P/tp�01�D T 1r1a' 9raClt
SOIL FILL
DISTRIBUTIO1.1 PIPE APPROVED S41M ACTIC COVER
"'MAT�IiU�I OR 9" OF STRAW
Z"OF N�iGREGATE —��
OR MARSH HA`J
Je OF 12-21/2 AGGREGATE
DIS'rRIF3UTI0W PIPE TO BE AT LEAST -52 INCHES BELOW ORIGIMAL GRADE
AIJU AT LEASTLO IAICHES BUT AIO MORE THAM H2. 11,104ES BELOW FINAL GRADE
/''WwwA ®EQTN OF EXe-/1VAT1613 FRONT OKIGYJgL 6KNoF- WILL BE INCHES
PUMMUM Wrr of EXCAVATIOW fR0M'I*t(.1WAL GRAPE WILL BE sue_ INCHES
SIGMEO:
LICEWSE DUMBER:
DATE : r J