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-Parcel'#: 020-1028-10-004 02/16/2006 02:50 PM
PAGE 1 OF 1
Alt. Pare I#: 16.29.19.124E 020-TOWN OF HUDSON
Current FX_I, ST. CROIX COUNTY,WISCONSIN
Creatiom Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Add'ess: Owner(s): O=Current Owner, C=Current Co-Owner
O- KOSCINSKI, MICHAEL R&KATHLEEN M
MICHAE R&KATHLEEN M KOSCINSKI
980 FERN RD
HUDSO WI 54016
Districts SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *980 FERN RD
SC 2' 11 SCH D OF HUDSON
SP 1'700 WITC
I
Legal D scription: Acres: 3.069 Plat: N/A-NOT AVAILABLE
SEC 1629N R19W NW NE LOT 4 OF CSM Block/Condo Bldg:
5/1447
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
16-29N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/29/2002 685259 1935/271 WD
03/20/2002 673963 1856/530 QC
05/18/1999 603355 1427/277 WD
07/23/1997 796/514
more
200531UMMARY Bill#: Fair Market Value: Assessed with:
91579 250,000
Valua ions: Last Changed: 10/25/2005
Descrip ion Class Acres Land Improve Total State Reason
RESIDE qTIAL G1 3.069 73,300 181,700 255,000 NO 05
I
Totals for 2005:
General Property 3.069 73,300 181,700 255,000
Woodland 0.000 0 0
Totals for 2004: II
General Property 3.069 50,700 135,900 186,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M
Speci Is:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 27.00
Special Assessments Special Charges Delinquent Charges
Total 27.00 0.00 0.00
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,Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: i Trench:
Width: /,;L Length: 5��. Number of Lines: 2 Area Built: G �.5^
Fill depth to top of pipe: 1I-1-4
Number of feet from nearest property line: Front, O Side, O Rear,Opt
.
Number of feet from well:
Number of feet from building: 6.7 '
(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, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector• ',�
Dated: �� . ' Cp ? Plumber on job: Z4,j /LL--- .
a
License Number:
3/84:mj
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 'Pr s > TOWNSHIP Snr1 SEC. _ T N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distance and dimensions to meet requirements of ILIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
! l
n`IIII
-1 J
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: 1zs/3,.`r Proposed slope at site:
SEPTIC TANK: Manufacturer: �,� _ Liquid Capacity:
Nu ber of rings used: - Tank manhole cover elevation:
Ta k Inlet Elevation: Tank Outlet Elevation:
Nu ber of feet from nearest Road: Front 10 Side,O Rear, O e feet
From nearest property line Front,O Side 10 Rear,0 1.3e' feet
Ntmber of feet from: well 3 5 building: a �2 `
(Inclu( a this information of the above plot plan)( 2 reference dimensions to septic tank)
SFF pEVERSE SIDE
DEPARTMENT OF I DUSTRY, INSPECTION REPORT FOR SAFETY& BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
M4DIS6`N"WI 53707
NW-4, N04, 'S16,T29N—R19W CONVENTIONAL E:1 ALTERNATIVE State Plan I.D.Number:
Town of Hudso (Ifassigned)
❑Holding Tank 1:1 In-Ground Pressure ❑Mound
Lot 4
NAME OF PERMIT HOLDEF ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Hupp Enterprises Inc. Route 1 Ellsworth, WI 54011 10_9b_9 7 �Q
BENCH MARK(Permanent r(fe ence point)DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.: CST REF,PT,ELEV.:
Name of Plumber: MP/MPRSW No,. County Sanitary Permit Number:
William Sch aker 6382 S t. Croix 99072
SEPTIC TANK/HOLE ING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED: �yf
R VYES ONO ❑YES INO
BEDDING: ENT D A. VENT MAT L.. HIGH WATER NUMBEFI ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
� (( I ALARM FEET FROM LIE / ^ r� JAIR INLET:
DYES
NO `4 DYES NO NEAREST'. ' 7v III
3� V` `—G/_.
DOSING CHAMBER:
MANUFACTURER JREDDING. LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
YES ❑NO DYES: ❑NO ❑YES 0 N
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONA OF PROPERTY WELL BUILDING JVENTTOFRESH'(DIFFERENCE BET EEN jjjjjIM8f4ER
ROM LINE' AIR INLETPUMP ON AND OFF ❑YES NO EIEST
SOIL ABSORPTION YSTEM.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 SN STEM:
i�
au�. IDTH. LENGTH NO.OF DISTR.PIPE SPACING. COVER JINSIDE DIA.. #PITS. LIQUID
BEI3(TFRENCH TRENCHES MAT RIAL: PIT DEPTH.
DIMENSIONS ��' Z
GRAVEL DEPTH F LL DEPTH JDISTR,PIPE DISTR.PIPE JDISTR.PIPE MATERIAL: NO.DI R NUMBER OF I PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES.(r A OVE COVER. ELEV.I LET.ELEV.END. ^ PIPES. LINE: AIR INLET j
//N71J�� L FEET FRt7lIA
NEAREST laa
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
and furrows thr wn upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
,, meets the criteria for medium sand. TIONS MEASURED.
1:1 YES ONO
SOIL COVER ITEXTUF E PERMANENT MARKERS JOBSERVATION WELLS.
1:1 YES NO ❑YES F-1 NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED:
CENTER. EDGES
DYES ❑NO 1:1 YES ONO ❑YES 1:1 NO
PRESSURIZED DIST IBUTION SYSTEM:
W DTH: LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER
Si :
.I O/T EN.O.tj ". TRENCHES:
NIFOLD PUMP MANIFOLD Of PIPE MANIFOLD MATERIAL: NO.DISTR. ID ISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
E EV.: ELEV.. DIA.. ELEV.: PIPES. DT:
LEVATION ANQ
f)ISI FIIt3I°IOI�f
.tN�Iy I I'ry
A+Llel N,.-, H LE SIZE HOLE SPACING: DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS:
OYES ONO ❑YES ONO
COMMENTS: 4 PERMANENT MARKERS: OBSERVATION WELLS: I—Nf BER� ; PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑YES ❑NO DYES ❑NO NEA€:EST,
u'SS
r
8.71
0, s
Sketch System on ain in county file for audit.
Reverse Side.
SIGNATURE. TITLE:
Zoning Administrator
DILHR SBD 6710(R.01/82)
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 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 biter-
included the creation of surcharges (fees) for a number of regulated practices which Wisco irt'S
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasurB 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.
0
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)
Y
SANITARY PERMIT APPLICATION COUNTY
(ZI DIL R In accord with ILHR 83.05,Wis.Adm.Code
STATE SANITARY PERMIT##
9�j 7 z
—Attach complete 1 lans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in ize.
—See reverse side or instructions for completing this application. PETITION
1. APPLICANT INF RMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO
PROPERTY OWNER PROPERTY LOCATION
��'r• :`� .[/G/ '/a Wlf '44, S /G T a2 AR/�' E (or
PRO R OWNER'S I AAILING ADIVRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LAN MARK
d� / +� VILLAGE TOWN OR
76 sl
II. TYPE OF BUILE ING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family _ OR ❑ Public(Specify):
III. PURPOSE OF A I,PPLICATION: (Check only one in##1. Check;!#2,3 or 4,if applicable)
1. a. ® New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an
Syste m System Septic Tank Only an Existing System Existing System
2. ❑ A sanitary Permit was previously issued. Permit# Date Issued
3. ❑ An Exist ng System has been inspected and soil conditions meet minimum requirements.
4. ❑ The Sys em is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYS EM: (Check only one in##1 and only one in##2)
1. a.V Conv ntional b. ❑Alternative c. El Experimental
2. a. ❑Syste - b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ® seepage Bed b. ❑See a e Trench c. ❑ Seepage Pit
2. PERCOLATIO1 I RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per rich): REQUIRED(Square Feet): PROPOSED(Square Feet): ,r+
S 7u r s Feet 9rivate [I Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total ##of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank 13 Ps 0
Lift Pump Tank/Siphon Chamber L1 1:1 ❑
VII. RESPONSIBI ITY STATEMENT
I,the undersigned, issume responsibility for installation of the private sewage system show on the attached plans.
Plumber's Name(Prin Plumber's Signature:(No t ps) P/ PRSW No.: Business Phone Number:
/ . ��
Plumber's Address(S -eet,City,State,Zip Code): Name of D igner:
T �!a�' ,fps �✓_•
VIII. SOIL TEST It ATION
Certified Soil Tester( T) a CST##
CST's ADDRES re , ity,State,Zip Code) Phone Number:
r
IX. COUNTY/DEP RTMENT USE ONLY
❑ isapproved Sanitary Permit Fee Groundwater [7Date Issuing Agent Signature(No Stamps)
S rcharge Fee
Approved ❑ wrier Given Initial a6 � �� /^
d verse Determination
X. COMMENTS/R ASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb 7)(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 Properly _ � �AW %A/
Location of Prol erty Z14J ,t% Section /� , T b19 N-R l W
Township
Mailing Address 7` �-��L �W e111?`% if
Address of Site
Subdivision None
42
. Lot Number
Previous Owner of Property
Total Size of . arcel V -_. �
Date Parcel wee 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 i2 as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Deel. 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 o avoid delays of the reviewing process. If the deed description refer-
ences to a Cer ified Survey Map, the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) ceJt_Li6y that aQC ztatementz on tW onm cute true to the but 06 my IOUA)
hnowtedge; that I (we) am (ahe) the owneA(,s� 06 the pnopenty de�scAi.bed in thiA
.in6o4mati.on 6otm, by v.iAtue 06 a waAAanty deed necon.ded in the 066.ice 06 the
Count Regist o6 Veedh a�5 Document No. 1 q �� ; and that I (We) pne�sentty
own -the p1topod d .bite bon the sewage dizpos Sya em (on I (we) have obtained an
eaa eme-nt, to Am with the above deis cA bed pnopen ty, bon the conAtnucttion 06 Said
�yStem# and the Same haS been d4y keeokded t.n the 066.ice 06 the County Reg•idten o6
reds, a�
VoCanent No. 4,f y115 ) .
1IRE 0 E SIGNATURE OF CO-OWNER (IF APPLICABLE)
..D DATE SIGNED i
rpq.•a.r-nr ..... .. ., .one. ., ,:...,.: .....,. . ...r... - -. :. . ..mr•,Y.w •"�?•"ra.. ... ., ..
M.CICUMENT NO. I WARRANTY DEED n«a MACS assavee sat aSeeRStMe a"&
,.
STATE BAR OF WISCONSIN FORT[ 1—na
429415
K I t_
Marjorie Elaine Fern, a/k/a Marjorie E. Fern, and I . CR `RS CO.,WIS.
ST. CROU( ..WIS.
We ley Ferny a/k/a Wesley W. Fern: her husband__. . �, Reed for Record iIb 21st
. ....
_._. _....._ .._ . ......... ......... ... .. .. .. ... .._....... ......... ...................... !i Aug• A.0. 19Z
. . ........... .. ... ........I.........._..
i 1:00
conveym and warrants to . Hupp..F•nterp,ris.e$,, •�n�,....
,
_ ........ ..
... ,. ... .......................
. ...... ..... . ..... .... .....
...
j
the foil wing described real estate in ..._ Str.-Croix ..County,
State o Wisconsin:
i
I'I Par of the Northwest Quarter of the Northeast Quarter Tax Parcel No: .......................
of ection 16, Township 29 North, Range 19 West, described as Lot 4 of the '
Cer iiied Survey Map filed in the Office of the Register of Deeds for St. Croix j
County, Wisconsin, in Volume 5, C.S.M., Page 1447, Document #395024.
Together with a non-exclusive easement to use as an access road to and from Lot 4,
the 66 foot road-day easterly of said Lot 4 as shown on the above mentioned Certified
Sur ey Map.
i
Sub ect to easements for public utilities to be located between the lot lines and
the dashed lines parallel to and 10 feet from such lot lines. �I
ti
i
i
$
FEB
,
his ......... n
is ot homestead property.
is) (is not)
xception to warranties: Protective covenants of record and easements for public
utilities, if any.
Dated ti isl-t... �:. c7..G. _... day of _ ._.... ii
__. ........_............ .. 87. .. I
... . .(SEAL) E`Z�'.. s.a .. . -
• OR 1GA>tN�..FF.T;N.
(SEAL) .. ... .. . �{
(SEAL)
• ......... . WESLEY F RN
L
AUTHENTICATION ACKNOWLEDGMENT
......
of..Marjorie Elaine Fern and STATE OF WISCONSIN
S (s) _ .................................••••.......
ey.Fzrn• .................................................
• EL- .............County. yi
an tad this ........day of..................... 87 Perwnally came before me .�D..a ..day of I-
• JO D. .HEYWOOD
i f .. ................. ...... I..........................
...................••---.................. .% I, .......... , ,,�,, .��
TITLE: EMBER STATE BAR OF WISCONSIN
.... .... .......... .. ..........
...............
( ed by . ) to me known b.. ..............................
an f
I not,............................................................ r
s rued b 706 is Wis. State.
he person ...... who executed the
fgr�roinR instru ent and adtnol►kdae the Satin,
THIS INSTRUMENT WAS DRAFTED BY (\ \1(� �--
Joh D. Heywood, HEYWOOD, CARI & MURRAY ,)�1,-.-
Ij
............ ..................................•-••............................_ , ,,. .._.... ....
.0. Box 229, Hudson, WI 54016 .'
.. ......... .......................................... . . . .. . Notary Public .... ..................
_. ........... County, Wis.
l i iSignn a may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration
'i date: . s'C!"..�......z3••�...... rE� )
I� 81�� 1AI1 f_-
•iYaN aT ea eiaalna to am eaDacit7 should be b'MA or printrd 6eloo thrtr•knature•.
1,
DxzD STATZ BAR 07I WISCONSiN �lbren�fa L.fal Blank C.. lar
V0k&1 No. 11— IV92
H
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ST C - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
t7
OWNE /BUYER ��J, ��Y/' M
ROUT /BOX NUMBER 11,, Fire Number
CITY STATE ZIP
PROPERTY LOCATION : ,64J �(/� Section i T o2?N , R W,
Town of St . Croix County ,
Subdivision 3 ,� �� Lot number_.
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 reeded , 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,
whTch 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
cer ification form, signed by the owner and by a master plumber ,
jou neyman plumber , restricted plumber or a licensed pumper veri-
fyi g that (1) the on-site wastewater disposal system is in proper
ope ating condition and (2) after inspection and pumping (if nec-
ess ry) , the septic 'tank is less than 1/3 full of sludge and scum.
Cer ification form will be sent approximately 30 days prior to
thr a year expiration . H
0
z
I/W , the undersigned , have read the above requirements and agree
to naintain the private sewage disposal system in accordance with H
the standards set forth, herein, as set by the Wisconsin Depart-
menL 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
DATET
St . Croix County Zoning Office
P . O . Box 98-
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sig , date and return to above address .
'
INDUSTRY, REPORT ON SOIL BORINGS AND DIVISION
LABOR AND P.O. BOX 19G9
IL PERCOLATION TESTS (115)
COUN-1 Y: - MAIL ING ADDRESS: 7-7
DATES OBSERVATIONS MADE
4�r.E3'1EUAZ P_ F__1ON.j___
RATING: S=Site suilablelor system U=Site unsuitable for system
If aiiy pot tion ut the tesudat ea is it)the
If Percolation Tvst ,,?NT F required
PROFILE DESCRIPTIONS
SORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL. WITH THICKNESS. COLOR, _1EXTURE, ;AND Duril
NUMBERIDEF-T-H It+. ELEVATI EST. TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL.-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD PE R_1_0CTT___Pff_A_F5D_3 PER INCH
PLOT PLAN: Shoov locati ns of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Ditcribe what are the hori-
zontal and vertical eleva i reference points and show their location on the plot plan. Show the surface elevation at all borings and Via 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 tliat the data recorded and the location of the tests are correct to the best of m L knovvle�?e and belief.
NAME(print): TESTS WERE COMPLETED ON:
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
DISTRIBUTION:Original nd one copy to Local Authority,Property Owner and Soil Tester.
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