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Parcel #: 020-1011-10-100 02/16/2007 03:59 PM
PAGE 1 OF 1
Alt. Parcel#: 10.29.19.47A-10 020-TOWN OF HUDSON
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-LARSEN, ROBERT E&BEVERLY J
ROBERT E&BEVERLY J LARSEN
1021 SCOTT RD
HUDSON WI 54016
Districts: SC= School SP= Special Property Address(es): =Primary
Type Dist# Description ' 1021 SCOTT RD
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 20.270 Plat: 3046-CSM 11/3046
SEC 10 T29N R1 9N PT SW SW&SE SW BEING Block/Condo Bldg: LOT 2
LOT 2 CSM 11/3046 18.00AC& INC PARC COM
NE COR CSM 11/3046 LOT 2;TH CONT N 02'W Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
66.08FT TO N LN; TH 89'W 179.28FT TO NE 10-29N-19W
COR SE SE SEC 10;TH N 89'W 1318.24FT TO
E LN SE SE; TH S 00'W 66FT; TH S 89' E
more
Notes: Parcel History:
Date Doc# Vol/Page Type
10/30/1997 567644 1273/292 QC
07/23/1997 1195/424 WD
2007 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/30/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 20.270 153,800 274,800 428,600 NO
Totals for 2007:
General Property 20.270 153,800 274,800 428,600
Woodland 0.000 0 0
Totals for 2006:
General Property 20.270 153,800 274,800 428,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 112
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
PUMP CHAMBER ,
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
` I
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,Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Z( Trench:
t
Width: 1e;_p'' Length: S: C'," Number of Lines: Z� Area Built: 224
Fill depth to top of pipe: 2
1
Number of feet from nearest property line: Front, O Side, ® Rear,0irt .6teltO
Number of feet from well: 76-''A
Number of feet from building: S11- 2%
(Include distances on plot plan).
SEEPAGE PIT
Size: I BCO GALL-A Number of pits: Diameter:
Liquid depth: 46" 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). /v/1!} -
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
l Alarm Manufacturer:
i
Inspector:
Dated: Plumber on job:
License Number:
i
3/84:mj
Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER �2 At J \J20-=X-C-.. TOWNSHIP SEC. IU T 2.`t N-R (9 W
ADDRESS ST. CROIX COUNTY, WISCONSIN
kj
�J
SUBDIVISION LOT f Cw _ LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
if
0 4.
} T
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I 6 �
A
n
o 0
N
INDICATE IRTH ARROW
i
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i
BENCHMARK: Describe the vertical reference point used Fora -Lnw_ GC ME-rm_ .`jZtT.rv"
Elevation of vertical reference point: Proposed slope at site: 411/
SEPTIC TANK: Manufacturer: �,+ ZC-SSE , Liquid Capacity•
Number of rings used: Tank manhole cover elevation: gq,42-
Tank Inlet Elevation: Tank Outlet Elevation: 0, silo
Number of feet from nearest Road: Front 10 Side,0 Rear, O :M', 1r,. Ali:', feet
From nearest property line Front 10 Side 10 Rear,O feet
Number of feet from: well to-l-O` building: Z_1l-O"
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
VOkRTMENTOF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
OR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.bOX,4969 BUREAU OF PLUMBING
MADISON,WI 53707
%,SE.,S10,T29N-R19W [CONVENTIONAL ❑ALTERNATIVE State
Town of Hudson ❑Holding Tank ❑ In-Ground Pressure ❑Mound (lf assigned)
Scott Road
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE:
Ron Willie Route 5, Hudson, WI 54016
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:
Thomas H. Cody 6593 St. Croix 96009
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
OYES ONO DYES ❑NO
BEDDING: VENT DIA.: I VENT MATL.. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM. FEET FROM LINE: AIR INLET.
DYES ❑NO I ❑YES 1:1 NO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY JPUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO I DYES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL-. BUILDING.JVENTTOFRESH
(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:
r�pprr ` WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA.. #PITS. LIQUID
TRENCHES. MATERIAL: FIT DEPTH.
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR MER Q1= . PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPES. ABOVE COVER. ELEV.INLET.ELEV.END: PIPES. FEET FROM 7. LINE. AIR INLET:
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
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO 1:1 YES El NO
DEPTH OVER TRENCH/BEO DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED:
CENTER EDGES.
❑YES ONO OYES El NO DYES 1:1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
iii'Y WIDTH. LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
bit IUOt*I TRENCHES:
��3dMElIp1US
MANIFOLD PUMP MANIFOLD DISTR,PIPE MANIFOLD MATERIAL IND.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
��
ELEV.. ELEV.. DIA.. ELEV. PIPES: DI A.:
N
aEVATq�ylb�l�l A
HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
El YES El No ED NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: MtInt� DER° F PROPERTY WELL: BUILDING:
IFR LINE:
L1 YES E:1 NO DYES 1-1 NO [ EAA
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE.
DILHR SBD 6710(R.01/82) Zoning Administrator
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT +
APPLICATION
r
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:
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;
Ili. 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 'aw. This legislation is more
commoniy known as the groundwater protection law. This change in statutes was the
result of over 2 ears of stead negotiation and public debate. The groundwater bill l
Y Y 9 P 9 Ground}slater.— -
inciuded the creation of surcharges (fees) for a number of regulated practices which Wisco ' Ill`s e
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasare
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.
c
Thr monies collected through these surcharges are credi ed to the groundwater fund adminis-
tered by the Department of Natural Resources These funt:is are used for monitoring ground-- f
Water, q<'r:undwater contamination irwestigations and estt blishment of standards Groundwats:!-, _
it's �.,vcrth Protecting.
58D-f;398 ;8.03/36)
D'LHg SANITARY PERMIT APPLICATION COUNT) .
In accord with ILHR 83.05,Wis.Adm. Code `
STATE SANITARY PERMIT#
9/,o q
` —Attachh 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
I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ONO
PROPER OWNER � PROPERTY LOCATION 0 � ��Oh [` % /, S p 5E s� E Or)y
PROFS 10 OWNER'S�LING14�DDDR S ®� �-- L LOT NUMBER BLOCK NUMBER SUBDIVISI ME
CITY,STATE a ZIP CODE PHONE NUMBER CITY NEAREST ROAD LAKE OR LANDMARK
W\l SKvI(o 3 a nnVIL��L,,A''GE
TOWN OR
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.
4 New b. El Replacement c. ❑ Replacement of d. El Reconnection of e.El 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.
Lr
Conventional b. El Alternative C. El Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. X Seepage Bed b. ❑See a e Trench c. X 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):
"1 13"' 9'7 4( • Feet Private —]Joint El Public
VI. TANK CAPACITY V 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 � ❑ ❑ ❑ ❑
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 er's Name(Print): Plum a 's Signature:(No Sta D MP/ PRSW No.: Business Phone Number:
G5 i3 or
a S' R- 33
Plum be 's Address(S reet,City,State, ip Co e): Name of Designer:
V I. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
CST's ADDRESS(Street,City,State,Zip de) Phone Number:
KA (sw oc 15 eta
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
Approved ❑ Owner Given Initial S ccharrge Fee I /a �y�
Adverse Determination )DD-0O H`- §, �� � �1�� �1���h� /J/ .cad
X. COMMENTS/REAS NS 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
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 t4&LLi> °P- A&y , 9!
Location of Property Section d , T_N-R� W
Township � ��
Mailing Address F 6 5-4101,
Address of Site 0 Al Z1_U ]
Subdivision Name IV4
Lot Number N-
Previous Owner of Property L tr-r��-� y- Rd:61
Total Size of Parcel ^^��
Date Parcel was Created 9
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume_ and Page Number 5y6 a as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Deed which includes a Document number, volume and Eat 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) cv.a6y that aU statements on this banm atce t ue to the best ob my (ou&)
knowledge; that 1 (we) am (ate) the owners) o6 the pu pen ty dens ch ibed in this
inbatmazton bon.m, by virtue ob a wantcanty deed neconded in the Obbice ab the
County Register ob Deedsas Document No. Lj,9.? ) , and that I (We) pnezentty
own the pupased s-cte ban the sewage di�sposat yst (oh I (we) have obtained an
easement, to nun with the above desn bed pnapenty, ban the constAuction ob said
system, and the same has been duty neconded in the Obbice ob the County Register ob
Deeds, as Document No.
- i T•
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
PZ
DATE SIGNED DATE SIGNED
JI
1
`�'ow DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 . THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED p
• �r`�`�Sx 9UOK 733 YA�i��L:
KG45"R5 OFFICE
_. $i. CRt�rlC 00., WlS.
This Deed, made between Ronald L. Willie and Naomi R. 4th
Willie, husband and wife; and Bonnie Grass, a married Wd. for Record
------------------------------- ----------------- ------------------- -
_person_, as individually owned -property .......- Y of Feb A.D. ��7
----
- - - - -------- ----------- Grantor, 3:50 P
and____-Ronald-_L.__Willie.-and_-Naomi_R. Willie-,_.husband__--.------ !'
_.--and__wife-,- as survivorship marital--propert ------------------------ w
- . .. ! R "
--------------------------- Grantee,
Witnesseth, That the said Grantor, for a valuable consideration.._---
------------------------------------------- ------------------- --------------------------------------
RETURN To
conveys to Grantee the following described real estate in ----St... Croix------------
County, State of Wisconsin:
The SE-'k of SE-k of Section 10 and the SZ of SA of
Section 11, all in Township 29 North, Range 19 West.
EXCEPT the following described parcels previously Tag Parcel No- -----------------------------------
conveyed to Grantees: (1) A parcel of 1.16 acres
located in the SE-3-4 of SE4 of Sec. 10-29-19, further described as follows: Beginning
at a point on the W line of said SE-14 of SE-34' a distance of 177.3 feet N of the S line of
said Section 10, thence N a distance of 208.7 feet, thence E parallel with said S
line a distance of 241.7 feet, thence S a distance cf 208.7 feet, thence W a
distance of 241.7 feet to the point of beginning, the W 33 feet thereof being used
for town road. ALSO (2) a parcel of 25.54 acres located in the SE4 of SE4 of
Section 10 and in the SA of SW4 of Section 11, all in 29-19, further described as
follows : beginning at the SE corner of said Section 10, thence W along said S line
of Section 10 a distance of 1322 feet to centerline of town road, thence N along
said centerline a distance of 716 feet, thence E parallel with said S line a distance
of 1539 feet, thence S a distance of 716 feet to said S line, thence W along the S
line 6f the SA of SA a distance of 247 feet to the point of beginning ; excepting
therefrom a parcel of 1.16 acres as recorded in Register of Deeds office in 1147311,
page 245. The above described premises contains 95 acres, more or less.
(This d'e'ed is given in fulfillment of a Land Contract dated July 20, 1979, recorded
July 20 1979, in Vol. 597, page 562, as Doc. No. 358477. )
This _19............._---___- homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging; t
Ronald L. Willie,.-Naomi R. Willie,__and-_Bonn-ie_Grass_--___-__-__-----_..-------lLed S
And - - ------ ------
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
,��La o0,
;z
STC - 105 r
9
SEPTIC TANK MAINTENANCE AGREEMENT 0
c�
St . Croix County z
t7
y
OWNER/BUYER 400 e 1-1 'W A1,090 In / L.G.
ROLiTE/BOX NUMBER � IVOSeA r�f�/ Fire Number_
�/ s
CITY/STATE 81) Qso V W) 7.IP_ z;�01
PROPERTY LOCATION : '-4;2� 14, Sec t ion 0 , T N , R W ,
Town of 5 0 St . Croix County ,
Subdivision N Lot number.
Improper use and maintenance of your septic_ system could result in 1
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 rank 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 . o
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 .
SIGNED
JA)AIL
DATE__ _��—`7
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 .
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To be a complete and accurate soil test,your report must include:
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
1 MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. 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;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
separate sheet may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
9. Complete all appropriate boxes as to dates,names,addresses, flood plain data, percolation test exemp-
tion, if appropriate;
10. If the information (such as flood plain,elevation) does not apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st — Stone (over 10") BR — Bedrock
cob — Cobble {3- 10") SS — Sandstone
gr — Gravel (under 3") LS — Limestone
Xs — Sand HGW — High Groundwater
cs Coarse Sand Perc — Percolation Rate
coed s — Medium Sand W — Well
fs — Fine Sand Bldg — Building
Is — Loarny Sand > -- Greater Than
`sl -- Sanely Loam < -- Less Than
*I -- Loam Bn -- Brown
*sil Silt Loarn BI -- Black
si — Sint Gy — Gray
*cl — Clay Loam Y ._ Yellow
scl — Sandy Clay Loarn R — Red
sicl — Silty Clay Loarn mot — Mottles
sc — Sandy Clay w% — with
sic — Silty Clay fff -.. few,fine, faint
x-C ...-.. Clay cc -- common,coarse
pt — Peat mm — Many, meediurn
rn — Muck d -- distinct
p — prominent
HWL — 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 th first>tep in securing a sanitary permit. The county or the Department may request
VCIrific:ation of this soil test io the field prior to permit issuance. A complete set of plans for the private
sevvage system and a permit application rust be submitted to the appropriate local authority in order to
obtain a permit. The sanitary permit mars! be obtainers and posted prior to the start of any construction.
I
FDEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS
DIVISION
INDUSTRY, c
LAIBOR AND PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIONS (H63.090)&Chapter 145.045)
LOCATION: SECTION: �TOWNSHI UNIC IPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
1/4 1/ do Tz9N/R 19 E (o �so,.� —
COUNTY: OWNER'S UYER'S NAME: MAILING ADDRESS: ' Z2 Q-N.IEZ-7 S 3 4-7
&,T.(!'zo�X RO1J W l t_l_t E S I
USE DATES OBSERVATIONS MADE
NO,BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: ER ATION TESTS:
Residence 3 �\ ew ❑Replace
RATING:S=Site suitable for system U=Site unsuitable for system
CONVENTIONAL: MOUND: IN-G ROUND•PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional)
ZS ❑U ZS ❑U IS ❑U ❑S ®U ❑S ®U �Q�'x S3 ' cu>vUeJ-D011kL_ eb
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: \_�-S Z Floodplain,indicate Floodplain elevation: , v
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INe$*ES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH tSk ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
q. S ' 1.0 n-3 i 1 TSB`Z.1 C3M �5.� �h ►»ec� S 6
B- Z 6-S ' 01S-S' 6 S . p.�' �l ; 2 .0 '
B- %J4 a-1•S ' 1 -7 g .y'
B- '-[ �•9 r Cj 6" ` 9 7 6.9 ' O-1' '� j Z•O ' �[ y-Z ` 'I
1
B- ry -7 Q l l Z ' �c
f
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P-
P-
P- - N S L M'►M4 IM UX-1 0Y V Z CIIOU 8Q 1
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. PcL- - c Z t l�PVa E S O fp,I I-I-0T-
SYSTEM ELEVATION `� `-"`��'' `�z•�
d {
! '� i
3 I
2
t
All,
4 I
_ N
_ - --_
i
Q Z.
Wit-
_1 -_
I ,
1
` e L
E
I,the undersigned, hereby certify that the soil tests reported on this form were made by m cord wi the proce and methods specified in the Wisconsin
Administrative Code,and that the data recorded and the location of the tests are correct to the e y knowle elief,
I
NAME(print): RE COMPLETED ON:
ADDRESS: «�V1� l dox ZZ (o CERTIFICATION NUMBER: PHONE NUMBER optional):
� s Sou 1 s�6 �IS_4zs_o16
CST SIGN TURE
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) -OVER-
'W_k� ,3 LA-3 l San. Permit No.
OWder's name
H63.05 PLOT PLAN
Show:
ET NA Dosing 'chamber
Location of building served
Septic tank Vertical horizontal reference, point
UD Q � System elevation is
Building sewer
EJEffluent system Well
EJ Replacement system area
Property lines w/in 50' of system
11 =
Q Distribution boxes R Scale = 15� or dimensioned
,
N pi Pump and controls:
Mfr. & Model No. Vertical Lift Size Force Main
.
Friction Loss T. D. H. Vol. Dist. Pipe Gal Pe r Min. Gal. per Cycle
Place check mark in appropriate box, indicating item is shown on plot plan,below:
5T pCwP. �1Nt
_D
Co
Fi L d co �Ns�r S�oc�E
5Z
3 E c.tS1»G '0+?8.) . 7 1/a a• 8 33
42`9 w ttl_S- \D �S IaS`�TCI I. 1000 ! ! =�
�oOF4 Io C?prJC. S 1lC -rnAj*
�S M
IOoG4kGI
��p0 uR L. -Z)"W 41.L
LB\ �vG 'M Wit. 88.0 i i
III
i
0 W�l
By the granting or approving of the above plan, or upon the event of a subsequedoent
permit being issued,St.CroixCounty and theSt.CroixCounty Zoning Administrator,
not assume or hold itself liable for any defects in plans or specifications, Plan n
omiss , examination oversight, construction or an damage that may or
after i stallati
-- 7– t _
__ i ens o. ace
- —,---
YI'_��!;r�r S sign ure
a
CROSS SECTIDU OF A BED SYSTEM
T�rVElJT 17iPE.-.\Z�� arC30V�`
�II.l�3H�o SIZADa
�X f SAN o �m-p,z C-
�l�U
a- SOIL FILL N ?-" OF AGGREGATE
DISTR BUTIOk3 PIPE S APPROVED 5y1,ITHETIC COVER
_ ( -MATERIAL OR 9"
OF STRAW
OR MARSH NAB -
!e OF%t-ZI/2 AGGRF-GATE
a-Z--7 FEET
ELEV. of ,.
DISTRIBUTIOiJ PIPE TO BE A7 LEAST
INCHES BELOW ORIGIIJAL GRADE
AUD AT LEASTZO WCHES BUT AIO MORE THA)�1 42. IUCHES B-LOW FIT�IAL GRADE
S� WCHES
MAXIMUM DEP H OF LXCAVATIOI.] FROM ORIGIQAL GRADE LJILL BE -
-
MINIMUM DEPTH OF EXCAVATIOU FROM ORIGIUAL GRADE WILL BE 3 INCHES
SIGLlED:
ICEi.1SE AJUMBER= ' " "W�'�—�--