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07 03:41 P
Parcel #: 014-1012-50-110 02/16/20 PAGE 1 OF11
Alt. Parcel#: 6.31.15.85C 014-TOWN OF FORES
Current X ST. CROIX COUNTY, WISCONSIM
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-AYER, BRADLEY B&JANE M
BRADLEY B&JANE M AYER
2348 265TH ST
CLEAR LAKE WI 54005
I I
Districts: SC =School SP=Special Property Address(es): '=Primary
Type Dist# Description *2348 265TH ST
SC 1127 CLEAR LAKE
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 3.030 Plat: N/A-NOT AVAILABLE
SEC 6 T31N R15W NE NW 3.03AC THE S 100' Block/Condo Bldg: j
OF NE NW
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
06-31N-15W
Notes: Parcel History:
Date Doc# Vol/Page Typo
07/23/1997 788/50
2007 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/17/200
Description Class Acres Land Improve Total State Reason)
RESIDENTIAL G1 3.030 20,000 145,200 165,200 NO
�I
i
Totals for 2007:
General Property 3.030 20,000 145,200 165,200
Woodland 0.000 0 0
Totals for 2006:
General Property 3.030 20,000 145,200 165,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 312
Specials:
User Special Code Category Amount
III
Special Assessments Special Charges Delinquent Charge$
Total 0.00 0.00 0.00
I
Form - S T C - 104
• . AS BUILT SANITARY SYSTEM REPORT
1
/
OWNER "c/ ,��o/� TOWNSHIP SEC. �_ T _N-R 3`W
ADDRESS P,20 ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
I
PLAN VIEW
Distances and dimensions to meet requirements of I•I,HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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4 � V)
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INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used a '0
/ C a W_
Elevation of vertical reference point: Zee Proposed slope at site:
SEPTIC TANK: Manufacturer.: `A/L,e�� Liquid Capacity: `j-a�
Number of rings used: !/dfx,-"ank manhole cover elevation: 5
Tank Inlet Elevation: U� J� Tank Outlet Elevation: qj 3
Number of feet from nearest Road:
, Side Rear, O ,�� feet
Front
i
. From nearest- property line /Front,O Side, Rear,O 72 feet
Number of feet from: well 1;1'9 4c;/uilding: Ag'
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
I
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: /oZ Length: A0 Number of Lines: Area Built: �a5�
Fill depth to top of pipe: y
Number of feet from nearest property line: Front, , Side, &Rear,0 Ft .
Number of feet from well: �CYY
Number of feet from building:
(Include distances on plot plan). / J�
ear .e �n'N .3 l/o"+ o�
SEEPAGE PIT Z-7
Size: Number of pits: Diameter: f'
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: y 3 ' Plumber on job: 4 J r�
License Number: /1?d'a— 5 3 31
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
.MADISIGN,WI 53707
SE=4jNW1-4;S6,T31N–R15W RRCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number:
11 If assigned)
Town of Forst ❑Holding Tank El In-Ground Pressure El Mound
70 54..7`Lr..,,. ,.,s
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Brad Ayers 220 South Avenue, Clear Lake, WI 54005
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No.: Coumy: Sanitary Permit Number:
Byron Bird Jr. 3318 St. Croix 99069
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
J P O IDED: PROVIDED:
✓ / v �� �� q 3 YES 1:1 NO ❑YES O
BEDDING: VENT TL. IGH WATER NUMBER OF ROAD: ILIU:ROPERT WELL: BUILDING: VENT O FRESH
JAI LARM. FEE,I,FROM �/10 AIR INLET:
❑YES :A07ENTDIA..
�" ❑YES O NEAREST . � I 1 a
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES FIND I I DYES FIND OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBEROF. `.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 She depth Of plowing C LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORGE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA.. *PITS. LIQUID
BED/TRENCH /f TREN=HES `1 MATERIAL: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH 1.11TR. I F DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR NUMBER OF FROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES- ABOVE CLOVER ELEV.INLET.ELEV.END PIPEESS INE, AIR INLET,
(.D It f–�— aA I �� 8� o;k 01-1 cn NEAREST M � �[)
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.
DYES ONO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS.
OYES ONO DYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED. SEEDED. IM111YES ULCHED.
CENTER EDGES.
❑YES ONO ❑YES 1:1 NO ONO
PRESSURIZED DISTRIBUTION SYSTEM:
Eb1tRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER:
1'M'EIN019INS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. JNO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
ELEV.: ELEV.. DIA.. ELEV.. PIPES:
ELIEVATION'AND
®iSt'RfBt1 i ION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
"�NFORtVIATiON PLANS:
❑YES NO DYES _ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUINBER C}F! PROPERTY WELL: BUILDING:
FEET FROM LINE:
DYES 1:1 NO DYES El NO NEAREST
2 5-
Sketch System on ` Retain in jjnffile for audit.
Reverse Side.
ATURE: TITLE: Zoning' minsltrator
DILHR SBD 6710 (R.01/82)
SANITARY PERMIT APPLICATION COUNTY
DILHR In accord with ILHR 83.05,Wis.Adm.Code � (,6 1
�. .��,...�.,� STAT SpANITAlR-YPERMIT#
7 (�
-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 j &-r-4:5 S�= '/a /a, S T3 , N, R/SE(o W
PROPE TY OV&f-R'S7MATLING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY,STATE ZIP CODE PHONE NUMBER CITY NEA EST ROA AKE OR LANDMARK
VILLAGE: ve
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family ❑ 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.X�onventional 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. Y seepage Bed b. ❑seepage Trench c. ❑seepage Pit
2. PE COLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
92 Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank ❑ 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.
Plum is Name(Print): Plumber's ature:(No Sta MP/MPRSW No.: Business Phone Number:
!.
Plrl5er's.Addreiss atreet,City,State Zip Code): Name o esigner,
II. SOIL TEST 11INIFORMATION
Certifie it Tester(CST);GZ"_,- C ST#
a 3
CST's. D SS(Street,Ci ,State,Zip Code) Phone Number:
IX. COUNTY/IJEPARTMENT USE NLY
❑ Disapproved nitary ermit Fee Groundwater ate Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial a r�11 S chhaarge Fee (, ?',t,7
Adverse Determination v�7 ds•C V
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 PERM_ IT
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 8% 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 Atielr--'
included the creation of surcharges (fees) for a number of regulated practices which Wisco in s a
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reas.re
is used in your building is returned to the groundwater through your soil absorption u
system or the disposal site used by your holding tank pumper.
ro
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 s oz,
c7 17
Location of Property""y_ , Section _, T N - Rte_ W
Township
Nailing Address
Subdivision Name
Lot Number ,
Previous Owner of Property
Total Size of Parcel 43 a&VA.)
Date Parcel was Created (�GG� 7 190
Are all corners and lot lines identifiable? �_ Yes No
Is this property being developed for resale (spec house) ? Yes _ No
Volume 7$$ and Page Number 5 09 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
Nap, the the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - - - -
PROPERTY OWNER CERTIFICATION
I (We) cvLti6y that ate d•tatementa on thin 6oam ase t ue to the beet o6 my (oun)
knowledge; that 1 (we) am (ane) the ownea(d) o6 the paopea.ty de cAi.bed in thi4
in6oamatLi.on 6oam, by viAtue o6 a wama.nty deed %ecoaded in the 066ice o6 the
County RegiAtea o6 Deedd ad Document No. Y d q 3 01 q ; and that I (we)
paeeentty own the pnopoded Aite bon the sewage pos dyd.tem (oa I (we) have
obtained an easement, to aun with the above de cAi.bed paopen.ty, boa the
conet.ueti.on o6 said d ydtem, and the dame had been duty aecoaded in the 064ce
o6 the C unty Reg.cstea o6 Deeda, ad Document No. ) .
SIGNATURE OWNER ' jNATURIE OOF7CO-O R (IF APPLICABLE)
__V-�20 A 7 2
DATE SIGNED DATE SIGNED
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
a STATE BAR OF WISCONSIN FORM 2-1982
423323 ), FiCE
o
ST. Cpolx CO., WIS.
LaMo ne C Emerson, as to an undivided "c:. fw Re�=rd ihis 19th
2/3rds interest, and LaMoxne D_ Emerson,__.-- �;�y of Aug. a,D. 1987
----------------------------- --- /.. . as 1:00 P
as to an undivided_ 1 3rd interest
tenants in common
conveys and warrants to ______________B radle
Tang--- A.yexy..hus.band_.and._-wife.>.--cm- ----------------- I Iwbiv of u..&
....5urvi.uorship._mari.tal..property...................... ------
--------......................................................................................................... RETURN o. Keller
---------------________________....._.._.__._.._....______.._._._.._
--------------------------------------------- Arne Mn 4001 �
r'7h -
' 715-268.636
St . Croix _ _ _ _ __ _ — --
the following described real estate in ........______________________ ....County, --__' ---
State of Wisconsin: Tax Parcel No: .............................. I,
SE 4 of M 4 and the South 100 feet of the NE-,,, of NW4,
Section 6-31-15, St . Croix County, Wisconsin.
FEE
i
I �
This ------ --not homestead property.
(is) (is not)
i Exception to warranties: Municipal and zoning ordinances of record and
i
recorded easements and restrictions .
Dated this 6th ...
---_ $�
)SEAL
.........._..-•------------•---•--------------------•---------_._..._( ` C6C�1' (SEAL)
•��
LaMoyne E son
----- -- - -------------------
---------------------------------------------------------------------(SEAL) i/J-:�. �y ��3V� 7----_---.(SEAL)
'a�e D. Emerson
------- -----------------------------•-•---..._....------------.
j
YES' I ACKNOWLEDGMENT
I
-- STATE OF WISCONSIN
ss.
-------------------------------------------------------------------------------
----------P-- -o-l•--•k
-------------------County.
XN0["M XXBC_-_.___y��� , y came before me this .__6th-----day of
fe Wl+��-------------------------- �...--- -----fa t-------- 19-AL�__ the above named
-------------------------------------------------------------------------------- LaMo ne C Emerson and LaMo -ne
---------y----------------------------------------------------- - --•---
D. Emerson
----------- - ------------------------------------------------------------------
------------------------------------------------------------ •-----------------• ............................................... •--•---•----
I� �X to me known to be the person _S--------- who executed the
foregoing instrttl nt and acknlbwl2daibee.
THIS INSTRUMENT WAS DRAFTED BY J JI y
.. ..... ......•... •. -------------------------
Bert D. Petersen Atty. at Law -
Bet'Ll D.JPit(rsen
------------- Z------ --- ---------------------------------
Clear Lake, raI 54005 �olk�-_ _-_-........
- - e ------ •- 0 Notary Public'il_,-- ----- - County, Wis.
(Signatures may be authenticated or acknowledged. Both My CommissiorS'"�sper�anekt.(If not, state expiration
are not necessary.) Sl
f3 �t
date: '�+ ----•---------------------- 19 )
ii Names of persona signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc.
FORM No. 2— 1982 liiilwaukee. Wis.
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STC - 105 r
9
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
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OWNER/BUYER `C�
ROUTE/BOX NUMBER Fire Number
CITY/STATE C 6rs- 1. /¢ w ZIP UU
PROPERTY LOCATION: 'S 14, AjKlk, Section lQ T -31 N, RJEW,
lvn �y��G- 09 AJ-)y
Town of S 7— St . Croix County ,
Subdivision Lot number
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. H
0
E
z
I/WE, the undersigned, have read the above requirements and agree c,
to maintain the private sewage disposal system in accordance with H
the standards set forth, herein, as set by the Wisconsin Depart- b
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
DATE -0?_a O
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 .
IL
DEPARTMENT OF
REPORT ON SOIL BORINGS AND SAFETY& B D VIS
INDUSTRY, • 1 1 P.O. BOX 7969
LABCTR AND PERCOLATION TESTS (115) MADISON,WI 53707
HUMAN RELATIONS (ILHR 83.090) & Chapter 145)
LOT NO.:BLK.NO.: SUBDIVISION NAME:
LO ATI N: SE TION: p, O SH MUNICIPALLY: _
,�'�/ /T3 H/NiSA to p rC S
COUNTY: OWNER'S BUYER'S AME: MAILING ADDRESS:
Lo • �� S ��al� �� Wr� r
DATES OBSERVATIONS MADE
USE a A T
NO.BEDRMS.: COMM R IALDESCRIPTION:
Residence RNew =E]Replace -7 �
RATING:S=Site suitable for system U=Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUNDPRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)EA
IWU If Percolation Tests are NOT required
]DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.091511b1,indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH IN. OBSERVED HEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) K
40 0
B- S tic
04 AV/B•. ;!5/L
B- s `�
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER L V L-IN HES RAPER INCH ES
NUMBER AFTERS ELLING INTERVAL-MIN. PERIOD 1 PERIOD P
P. .6
t�
P_ a �
P-
P-
p-
P-
of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal PLAN: Show elevation p at all borings and the direction and percent
reference points and show their location on the plot plan. Show the surface elevation 9
zontal and vertical elevation re p
of land slope. i
a �
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 tt a Wisnsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME(print): TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
CST SIGNATU E:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHRSBD-6395(R. 10/83) -OVER -
DEPARTMENT OF SAFETY& BUIL
INDUSTRY, REPORT ON SOIL BORINGS AND DIVIS
LABOR AND P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON,WI 53707
(ILHR 83.09(1)& Chapter 145)
LOCATION: SECTION: OW SH MUNICIPALITY: LOT NO.:BLK.NO.: SUBDI VISION NAME:
COUNTY: OWNER'S BUYER'S AME: MAILING ADDRESS: /
o �® II I �t nn 5-
USE 411, DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DES R PTIONS:1PERCOLATION TESTS:
Residence - 5<New ❑Replace _
RATING:S=Site suitable for system U=Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional)
❑U S ❑U S ❑U ❑S U ❑S YU
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: Floodplain,indicate Floodplain elevation: �D
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERV D (SEE ABBRV.ON BACK.)
B-
B-
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��6 � 6'-'�9' � .5�' tea-�Y•�r
B- . Ste' p•�.�.
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER f/ AFTERS WELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
jP- .(O OZ
P-
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 q.2. c2 4. y 'IF/V` --- '-
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3
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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 t e is onsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME(print): TESTS WERE COMPLETED ON:
ADDRESS: a: r CERTIFICATION NUMBER: PHONE NUMBER(optional):
O� e!50 G 6
CST SIGNATURE:
+a
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHRSBD-6395(R. 10/83) —OVER —
w
INSTRUCTIONS DNS F 1R COMPLETING FORM 115 - SRI - 6335
To t>e a complete and a€;curate soil test:,your report must include.
1. Compiete legal description;
2. The use section must clearly indicate whether this is residence or commercial 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 SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
PS. PLEASE use the abbe evictions 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;
B. Mal<e sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
B. Complete all appropriates boxes as to dates, names,addresses,flood plain data,percolation test exemp-
tion,if appropriate;
10 if the information (such as flood plain,elevation)sloes not apply, place N.A. in the appropriate box;
11_ Sian the form and place your current address and your certification number;
12. Make legible copies and distribrite as iecluired. ALL SOIL TESTS MAST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
I
st Stone (over 117"l BR -- Bedrock
cob Cobble (3- 1(7") SS Sandstone
gr - Gravel (under 3") LS - Limestone
S Sancti HGW ...- High Groundwater
€.s - Coarse Sand Perc - Percolation Rate
med s Medium Sand IN Well
I's - Fine Sand Bldg - Building
Is - Loamy Sand > - Greaten Than
sl Sandy Loam Less Thera
"I Loam Bn - Brown
�sd Silt Loam BI - Black
Silt Gy .. Gray
cl - Clay Loam Y - Yellow
sal - Sandy Clay Loarn R - Red
sicl - Silty Clay Loam snot - IVlottles
so - Sandy Clay w.l -.. with
sir; - Silty Clay f f - few, fine,faint
*c _..._ Clay cc common,coarse
pt - feat min - Many, medium
rn Muck d - distinct
p ...... prominent
HWL - High water le=vel,
Six general soil textures surface water
`€?r lictiiid wasto disposal BM Bench Mai k �
VRP _._ Vertical Reference Point
I
i
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.
PLOT PLAN
PROJECT ADDRESS ,S_
Uc.
TOWN r��,�COUNTY,SJI Gr�.1r L`'
PRS Byron Bird Jr. 3318 DATE — —
BEDROOM CLASS PERC_��CONVENTIONA ZIN-GROUND P SURE
CONVENTIONAL LIFT MOUND_HOLDI G TANK
SEPTIC TANK SIZE ,� _ LIFT TANK SIZE
DOSE TANK SIZE , `/ HOLDING TANK SIZE
ABSORPTION AREA _y�,d`T PERC RATE BED SIZE
Benchmark V.R.P. A's'sume 'Elevation 100'
Location of Benchmark
* H.R.P. err'
0 Borehole Q Well Scale Feet
O Perc Hole System Elevation
TYPAR COVE
2'
12' 3' 0 6' 0 3'
1 64 Sewer Rock
12' /
20
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