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PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon nufact rer: Pump Size
Elevation of inlet: cttom o tan el v tion:
Pump off switch elevation: G llon p c cle:
Alarm Manufacturer: larm Sw tc ype:
Number of feet from nearest p operty lin F ont, Side,Q Rear,0 Ft.
Number of f t from... w 1:
Number of feet from bull ing:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: /��s Trench: A 2
Width: �J Length: j 7 / Number of Lines: 3 Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, `O Side, O Rear,(-\,/)Ft . 7(1
Number of feet from well:
Number of feet from building: 95� ~�
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pit8: Dia r:
Liquid depth: Botto f seep ge pit a eva on:
Area Built:
Has either a drop box O or distr- uti n bo O been sed n any of the above ,soil
absorbtion sytems? (Check one).
HOLDING TANK'
Manufacturer: Capac ty.
Number of rings used: Elevation of botto of tank:
Elevation of inlet:
Number of feet from nearest pr e V Fr Xt Side, O Rear, Ft.
O
'I O
Number of f et :
Number of fee from g:
Number of feet fr near :
Alarm Manufacturer:
Inspector:
Dated: 7-2747 Plumber on job: 422"�,r,, �.
License Number: IV/
3/84:mj
L
* Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
// SEC. T �9N-R �� W
OWNER L/l��P// h'��.roJ� TOWNSHIP �i,��o�l/ O
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION /( LOT / LOT SIZE �C✓'e S
PLAN VIEW j.7. 1
Distances and dimensions to meet requirements of I1HR. 83 9G
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ,cc
q0' E4
cPi
1/ent
15��1de
V B.M.
T ,
�'a�Qge 21
c,�all
zoo Gal . 15 38'
� Sc�f1G• � I
27 I
I
Not
�X,sf
�t /base
o Q�
n
INDICATE NORTH ARROW
J`l
cry <7-
r � 1 f
BENCHMARK: Describe the vertical reference point used ���dP_ Q7 5•�. C'o.✓��r oT
'
Elevation of vertical reference point: /ov ,O PropOosed slope at site:
SEPTIC TANK: Manufacturer: ee75S Liquid Capacity: I.Zee
jNumber of rings used: Qhc Tank manhole cover elevation:
Tank Inlet Elevation: 7,3&1, � Tank Outlet Elevation:
Number of feet from nearest- Road: Front,Side,O Rear, O
/�.�"y feet.
From 'nearest• property. line Ercnt,O Side XTN: 'r,O '
145 feet
Number of feet from: well _Rf _,building:
(Include this information of the above plot plan) ( 2 reference dimensions to septic tank)
x SEE REVERSE SIDE.
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
,LABOR 8j HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
NW4jNW4,S28,T29N-R17W 10 CONVENTIONAL ED ALTERNATIVE Stat PgnnIiD.Number:
Tdwn of Hammond ❑Holding Tank El In-Ground Pressure El Mound
0
•
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION TE:
Annabelle Hanson Route 1 Hammond WI 1 ✓�
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: 11:5T REF,PT,ELEV.:
1 f
I 7 M— � t v�•I )I J
ame of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Dale E. Hudson 6629 St. Croix 92555
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PR V ED: PROVIDED:
YES ❑NO 10YES ANO
BEDDING: VEN DIA.: VENT MAT HIGH WATER NUMB R OF ROAD: PROPERTY WELL: BUILDING
IV TO FRESH
ALARM: FEET FROM �j LI A R INLET
❑YES NO U - ❑YES NO NEAREST '✓ � � ��
DOSING AMBER:
MANUFACT RER: BEDDING: LIQUID PA ITV. PU MODEL: PUMP/SIPHON MANUFACTIIRER. RES NG LABEL LOCKING COVER
DED: PROVIDED:
DYES ONO ❑NO
[—]YES ❑NO
GALLONS PER CYCLE: VI CONTROLS OPERATIONAL: NUMBER OF PROPER TV WELL BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET.
PUMP ON AND OFF) YES ONO NEAREST
SOIL ABSORPTION SYSTEM.Check the s of to a the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a 'I ire ons u tion shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH: LENGTH NO.OF DISTR.PIPE SPACING. CO ER JINSIDE DIA *PITS LIQUID
BED/TRENCH I /r ' TRENCR / I M RI L: _ _ / PIT / /� DEPT
DIMENSIONS / +T1 &
RAVEL DEPTH FILL DE H ST FT.PIPE DISTR.PIPE DISTR PIPE MATE NO D IT NUMBER OF PROPERTY WELL. BUILDING. V NT TO FRESH
BELOW IPES: ABOVE VEj� ELEV.INLET ELEV.END: �.y�Q PIPES FEET FROM LI / I J r AIR r/
!� � _ 3 NEAREST=�
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 ITEXTURE JPFRMANENT MARKERS OBSERVATION WELLS
1:1 YES 1:1 NO ❑YES 1:1 NO
DEPTH OVER TRENCHIBED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED
CENTER. EDGES.
1-1 YES El NO 1:1 YES ❑NO DYES El 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
ELEV.. ELEV.. DIA.: ELEV.: PIPES DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL PLANSCAL LIFT CORRESPONDS TO APPROVED
1-1 YES NO El YES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
j ❑YES ONO ❑YES ❑NO NEAREST
L
Sketch System on Retain in county file for audit.
Reverse Side. +
.� SI UR ITLE.
DILHR SBD 6710(R.01/82) 7 Oning Administrator
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION t
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:
1. Property owners name and mailing address. Provide the legal description where the system is to be
installed;
11 Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if buildirg 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'/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 ears of stead ne otation and public debate. The groundwater bill
Y Y 9 P 9 Ground, —
included the creation of surcharges (fees) for a number of regulated practices which Wiscorfsin's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure
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.
i,
The r�-,onies collec;ted through these surcharges are credif:ed to the groundwater fund adminis- °
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, gr*-lundwater contamination, investigations and establishment of standards. Grounclv,ater,
it's worth protecting.
SBD-6398(R03/86)
i
COUNTY
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05,Wis.Adm. Code 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 PROPERTY LOCATION /lam
�/a '/q, g 7 T, 7 N, R / rz (or "W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISIONPAME
CITY,STATE ZIP CODE PHONE NUMBER ❑ CITY / NEAREST ROAD,LAKE OR LANDMARK
J y'
F-1 VILLAGE i /
/
Vii:a> �.�'y �j,,, :� -M(, / /; �Y�� ,��� /./ f it 124:" r� �
II. TYPE OF BUILDING OR USE SERVED: )w 0l0— j00_&0
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. LE 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:.0ounty Copy.
IV. TYPE OF SYSTEM; (Cheek only one in#1 and only one in#2)
1. a. I 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 1NF0RlMPeTKM. (Check one)
1. a. Seepage Bed b. ❑See a e Trench c. ❑Seepage Pit
2. PERCOLATION RATE & ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVA-RON 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
Feet OPrivate ❑Joint ❑ Public
CAPACITY
VI. TANK ##of Prefab. Site Fiber- Exper.
in lions Total Manufacturer's Name Cost- Steel Plastic
INFORMATKN New xisting Gallons Tanks Concrete strueted glass App.
Tanks Tanks
Septic Tank or Holder Tank j f
El El
Lift Pump Tank/Siphon Chamber El / El El
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:
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
Vlll. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
CST's ADDRESS(Street,City,State,Zip Code) / Phone Number:
s _,
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee
Adverse Determination
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
APPLICATION FOR SANITARY PERMIT
S T C - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequaoies 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 Annabelle D . Hanson
Location of Property NW 14 NW 14, Section 28 , T 29 N - R 17 W
Township Hammond
Mailing Address Rh 1 Hammond , WI 54015
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel / y ,Qc•�C-S
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 6 and Page Number �7rf as recorded with the Register of Deeds
vz� 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
Hap, the the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - - - -
PROPERTy OWNER CERTIFICATION
I (We) eenti.6y that ate 6tatement6 on th,iz 6onm ane tkue to the but o6 my (oun)
knowledge; that I (we) am (aAe) the ownen(6) o6 the pnopenty dacx bed in thiA
in6onmati,on 60nm, by viAtue o6 a wannanty deed neconded in the 066ice o6 the
.County Reg"ten 06 Deed6 a6 Document No. 3�� ; and that I (we)
pnea entCy own the pnopo6 ed 6.cte bon the 6 ewage po6aZ_6 y6tem (o& I (we) have
obtained an ea6ement, to nun with the above ducxi.bed pnopenty, bon the
con6.t4ucti.on o6 6atd 6yztem, and the Game ha6 been duty neeonded in the 066ice
06 the County Reg•i.6.ten 06 Deed6, a6 Document No. ) .
I
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
-M i g i
DATE SIGNED V DATE SIGNED
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4.
*q�Of the No$of UM*wdmc
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�N 11111! dMdr t N pNtonM p opwty in joint»nancy a at forth M thw Mw vla g A fft >
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'ter (S;i 1/4) of Seetian twenty-one (21) r
Mouth, Range Seventeen (17) West, EXCEPT: S
Mdll,30D fleet thereof and EXCEPT certified sueay so � .
22P IMP In vol. 2, page 353 and EXCEPT certified swvw +
* F 1979 in vol• 3, Page 629 and EXCE PT part to , t
t311'istLu C. Md R0bbye S. Hanson in vol. 501, page 268. 3152
,090.00
NorthMt Quarter (Nil 1/4) of Section Twenty-eight, Township
lti�dty-niffe (29) North, Range Seventeen (17) West, EXCEPT R/W of
L 0 P St- Paul, MinneMpolis and Omaha Railroad ComparW and
Pert of the Village of Hammond in Vol. #661, Page #103. 192 660.00 '
C - Pars PM
ert ,
ote r amount of $3,600.00 computed at all times
eo 00 unpaid balance of pr,.ncipal at the rate of 10% per annum.
Ha
new Farm maker, by Chris Hanson and Evan Hanson. Interest
Said throw December 31, 1983. 3,600.00
1983 Oldesobile, Royal, 4-dr. 3D#1G3AN69YMM786498, Title
. M DETERMINED AND ADJUDGED THAT 9,575.00
r4_vrr � uav�
died Ug"W
an—June 3ZT' 3 and ft foilowim vim to hero of tM d t
IRrb►to how to H**#W: ,
Annabelle D. Hanson - wife =,
Evan Hanson, son
Christian Hanson, son
Joel Harmon, son
Barbara Schrank, daughter
4,
I Usaw
I rO.0' ArmmbeU*1� HOOMI, aU ln accatwim with Me
Ot, dM*V4W4��t WUI and Testiimwit.
71
4.
51�11
TInifts-ft of ftelsoodent a joint lanant in real wW personal propwW wnwkmmdatdo&dL
1 qPw
By On Court
�ve OE
State at Wb"
VLAIV county ot SL Crem
Attorney I hereby
true and
Ill W- Walrait St- and of
A
River Fall-R, WT 56CI22
Addmu
*Striko as appropriate.
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SEPTIC TANK MAINTENANCE AGREEMENT
St . Croix County z
a
a
OWNER/BUYER H
Annabelle D . Hanson �
ROUTE/BOX NUMBER RR1 Fire Number
CITY/STATE Hammond , WI ZIP 54015
PROPERTY LOCATION: NW NW �4, Section 28 T 29 N , R 17 W,
Town of Hammond 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 eligib.1 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
I/WE, the undersigned , have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- o
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 ~ /
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 .
E. •( r ;
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and accurate soil test, your retaort must include:
1. Complete legal description;
2: The use section must clearly indicate whether this is a residence or commercial project;
3. :MAXIMUM number of bedrooms or comn'101'cial use planned;
`4. `Is this a"new or replacement system;
6'. C6mplete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY'IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
completing the plot plan
i 7 M�AK�"A LEGIBLE diagram accurately locating our test locations. Drawing to scale is preferred,: A
6 "P_LEASE use the abbreviations shown here for Writing profile descriptions an
\ g g Y •
.separate sheet may used if desired,
_8. Make sure your benchmark and vertical elevation refereru:e 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, (levation) does not apply, place N.A.in the appropriate box;
11 , Sign the form and place your current address and your certification number;
_12. Make legible copies and distribmt wnt!iw(i. Al SOIL TESTS MUST BE FILED WITH THE
;,;LQCAL AUTHORITY WITHIN 30 DAYS OF CsO"+sIPLFT ION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st — Stone (over 10") BR — Bedrock
cob — Cobble (3- 10") SS — Sandstone
gr — Gravel (under 3") LS — Limestone
*s — Sand HGW — High Groundwater
r
_ cs''- Coarse Sand Perc Percolation Rate
\, med s`— Medium Sand Vi --- Well
fs. =.Fine Sand Bldg Building
Is — Loamy Sand j Greater Than
*sl — Sandy Loam < Less Than
*I Loam Bn Brown
*sil — Silt Loam BI Black
si Silt Gy — Gray
*cl — Clay Loam Y - Yellow
scl — Sandy Clay Loam R -- Red
sicl — Silty Clay Loam mot - Mottles
sc — Sandy Clay Wr - with
sic — Silty Clay fff --- few, fine,faint
*c Clay cc --- common, r.,oarse
pt — Peat r-nm — Many, medium
m — Muck d — distinct
p — prominent
HtIVL - High water level,
* Six general soil textures surface water
for liquid waste disposal BM — Bench Mark
VRP - Vertical Reference Point
TO THE OWNER:
This soil test report is the first step s :. J The county or the Department may request
verification of this soil test in the f., ar;. A complete set of plans for the private
sewage system and a permit applicrat.� ; ;;c the appropriate local auth0l'ity in order to
obtain a permit. The sanitary permit r E Df, and I ostod prior to the start of any construction.
INDU6ifit 1, 0 12�PORT ON SOIL BORINGS AND SAFETY& BUILDINGS
IIVUUS +� �, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: E TION: TOWN�HIP/MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
w 1/2d/a ,7P/T29N/R 172(or r�r
COUNTY: OWNER'S TB UYER'S NAME: MAILING ADDRESS:
.5f. CEO i A C7
USE DATES
I �O_BSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: ROFILE DESCRIPTIONS:
O A ION TESTS:
1P7 OffResidence (X ❑New Replace
—F7
RATING:S=Site suitable for system U=Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM�:( ptionall
S DU ®S DU ®S ❑U EIS 210 ❑S CCU �
If Percolation Tests are NOT DESIGN RATE
required : If an
q I y portion of the tested area is in the
under s.H63.09(5)(b),indicate: N� I Floodplain,indicate Floodplain elevation: 11(/W
PROFILE DESCRIPTIONS
BORING TOTAL" DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH It ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- ,33 991.9_ A I N2 f- 73.3 /v" �� � '' s; • , 33'�
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH• WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER !N–HE':E_' AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD PERIOD PER INCH
P-Z O / /" A9
P- r
P-- ICI
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
__.
I ;
i
r–
i
E
N
i ! i - ? - - - - --
I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
-:5'- �/ —F7
ADDRESS: / / � � '// /✓/ l CERTIFICATION NUMBER: PHONE NUMBER(optional):
–517113 1
CST S NATURE:
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) –OVER --
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Parcel #: 018-1063-60-100 09/18/2006 10:54 AM
PAGE 1 OF 1
Alt. Parcel#: 28.29.17.427B 018-TOWN OF HAMMOND
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-LIDDLE, JERRY M
JERRY M LIDDLE
1719 CTY RD TT
HAMMOND WI 54015
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description * 1719 CTY RD TT
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 7.144 Plat: N/A-NOT AVAILABLE
SEC 28 T29N R1 7W 7.144AC LOT 1 CSM 7/1827 Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-29N-17W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/07/1998 582478 1338/068 QC
07/23/1997 806/564
2006 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/14/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 26,000 89,200 115,200 NO
UNDEVELOPED G5 5.144 4,800 0 4,800 NO
Totals for 2006:
General Property 7.144 30,800 89,200 120,000
Woodland 0.000 0 0
Totals for 2005: i
General Property 7.144 30,800 89,200 120,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 214
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00