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HomeMy WebLinkAbout030-1014-60-300 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Building Division St. Croix INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) Loc~~tlTy/ 208 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Shimon, Eric & Heidi St. Joseph, Town of 030-1014-60-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 121~0. 04.29.19.61 TANK INFORMATION ELEVATION DATA OJ 64S7- J/Pt TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic L- Benchmark Dosing L• y` ~l lDD- fi Alt. BM Aeration - Bldg. Sewer./ Holding a s St/ nlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Y/5 2 Header/Man. Aeration Dist. Pipe Holding Bot. System PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM Model Number g s. y- TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dist. to Well SOIL ABSORPTION SYSTEM S)1't t BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of System: CHAMBER OR UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing pe(s) Vent to Air Intake Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded BedlTrench Center Bedlrrench Edges Topsoil xx Mulched 7 0 Yes 0 No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 57- Inspection #2: Location: 574 River Road Hudson, WI 54016 (SE 1/4 NE 1/4 4 T29N R1 9W) 40 acres Lot Parcel No: 04.29.19.61 1.) Alt BM Description = *5 L 1 6 bGG pkJ C G VC Lp C mss/ 2.) Bldg sewer length --41 36, amount of cover = ,M Z Z 44, toa45' h )G n, T7dd N Plan revision Required? Yes No ~r z Use other side for additional information. Q 7 S BD-6710 (R.3/97) Date Insepctors Signature Cert. No. Rio ~,JGZLt.(/u /l •vo7" ,j.~~ /,{q Q ~'D ,qT Y,!/S 77^46;_ wa~rJ 7' ge oc/ Fr~TZ~ Rb; _10-. ounty Sanitary Permit AppI" C ST. CROIX COUNTY WISCONSIN f In accord with Chapert 12 St. Croix County Sanit~'VG PLANNING & ZONING DEPARTMENT >i Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1)(m)] q 1101 Carmichael Road FEB 06 20! IJ Hudson, WI 54016-7710 (715)386-4680 Fax(715)386-4686 Attach complete plans for the system on p r i ches in size. County Sanitary Permit # ❑ Check if rev sion o previous app is ~I ~v 1. Application Information - Please Print all Information Location: Property Owner Name Sk- 1 /4 L. 1/4, Sec A)J KV 0, e) N, R 19, Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Numer Subdivision Name or CSM Number 1 Type o Building: (check one) tRK c r n C amVillage own of 19 ~or 2 Family Dwelling - No. of Bedrooms: ❑ Public/Commercial (describe use): ~ /"_I ❑ State-owned t oad G II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) J Number(s) A) 1.❑ Repair Its Reconnection ❑Non-plumbing 4. ❑ Rejuvenation^b~ Sanitation B) Permit Number q~ Date Issuefir State Sanitary Permit was previously issued G " ( J~ 1/:;12;10 419 IV. Type of POWT System: (Check all that apply) ff--Non-pressurized In-ground ❑ Mound t 24 in. suitable soil ❑ Mound s 24 in. suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) p ~ , ~ Elevation ~S L/ 9 d'IS~ 3 / - 99-9 1. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks aQb Gov Gc~c ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ II. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of on-plumbing sanitation system. Plumbers Name (print) PI m Sign stamp MP/MPRS No. Business PhoANu2ber Plumber's Address (Street, City, e, ip Code) VIII. County Use Only isa roved Sanitary Permit Fee Date Issued isnApproved wner Given 4hiti dverse G -7 Det nation - rnd f Ap royal/Reasons for Disapproval: ' .G-LL Nt"7~' a C~ J Rev: 8/05 i a sh, ~o SeG'p S _ v O~0 o I' z u~ ALL IIl/ ~Dn~ 5e1~el-- Tz~ KNU®TSON PLUWMiNG 21 CONTRACTING, LLC 927150TH ST. 648447MPRS R , ERTS, Wt 23-8526 CELL 51 1737 1~ d c~ g9~~C0 P'% 1 sh,°~o /00 a'te' '`eS pa~o~~ 5- X77, _s 1 _ v O1.D / N Ge°Q! ,12 a v ~oy,5e w~~~S 5e KNUDTSON PLUMSiNG CONTRACTING, LLC 927150TH ST. 648447MPRS R ER TS, WI 23-8526 CELL 51 -1737 s~ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND l OWNERSHIP CERTIFICATION FORM Owner/Buyer E L s h~ eviv 1 Mailing Address S- 7 Property Address 3 (Verification required from Planning & Zoning Department for new construction.) City/State ~~5.0 f, W Parcel Identification Number /C Al _ &0 O CC) LEGAL DESCRIPTION Property Location '/4 , 1/4 , Sec. 4 , T Z'I N R 1 `1 W, Town of A Subdivision Plat:' Lot # Certified Survey Map # , Volume Page # Warranty Deed # L 7 Z (before 2007)Volume , Page # Spec house Elyes;*o Lot lines identifiablejjfyesOno SYSTEM MAINTENANCE AND OWNER CERTIFICATION ll Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warroty deed recorded in Register of Deeds Office. v' Number 9MdXooms 3 lop ~i~ iii 1r- SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) 8 2 8 1 4 2 4 Document Number Document Title Tx :4230699 1007328 St. Croix County BETH TH PABST Affidavit for a single POWTS REGISTER OF DEEDS ST. CROIX CO., WI servicing Two Structures via Private Interceptor Main RECEIVED FOR RECORD 02/02/2015 10:02 AM 51-i'_ L~~ 1 /rLror► EXEMPT V : Name - (Owner) Typed or printed REC FEE: 30.00 being duly sworn , states, under oath, that: PAGES: 1 He/she is the owner/co-owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Document Number 1002727 St. Croix County Register of Deeds Office: Recordin Area A parcel of land located in the 5E '/e of the l• C- of Section T29N Name and Return Address - R 19W, Town of 64% Jo , St. Croix County, Wisconsin, being duly Cci ` 6k)M4qn described as follows (include number and subdivision/CSM or detailed SAY amaA legal description: ~!D Aare 5 SE AJE 5CG 1 -7-Z97 A) 2 ! / ~ 0 3e , 101AI `o - 006 Parcel Identification Number (PIN) As owner of the above described property, I acknowledge that a Private On-site Wastewater Treatment System (POWTS) serving the primary residence is sized for _3- bedroom(s) with a design wastewater flow of 45 gallons/day (DWF is based on 150 gpd /bedroom @ 2 persons per bedroom). A maximum of 6 occupants are permitted; if the number of occupants exceeds the maximum for POWTS design, the system will be undersized to accommodate increased wastewater flows and/or contaminant loads and may be subject to premature failure. An accessory structure will be used as the primary residence due to the poor condition of the house and connected to the POWTS via Private Interceptor Main Sewer (PIMS) in compliance wiih SPS 382.30(12). Two dwellings are not allowed on the parcel and I understand that disclosure of this information will be made to any parties interested in purchasing this property in the future. Dated this day of T-e 6 , art` Skl.Np~ AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. St. Croix County. ) h~Q Personally came before me this c9 day of authenticated this day of ~ L 1 (year) (year) the above named .QVj°L(,tltJl,t. ~ ~ TITLE: MEMBER STATE BAR OF WISCONSIN i to me known (If not, to be the person(s) who executed the foregoing instrument and acknowledge the same. Authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY H eXFt'u,,,q-` 'ctce,te Co y- Ryan t Land Use Specialist x 0 U Community Development Dept. Nota Publ~~ateof Zcon Q (Signatures may be authenticated or acknowledged. My Commissj irl p'ennanentsif6st, state expiration Both are not necessary.) date: 1 Date: ~~CC-'I~vvf~.~c'✓. 1 O I g "THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE" This information must be completed by submitter: document title. name & return address and PIN (if required). Other itlformalion such as the granting clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. Note: Use of this cover page adds one page to your document and $2.00 to the recording fee Wisconsin Statutes. 59.43. St. Croix County 1007328 Page 1 of 1 • II I III II ~ IIIII I 8261835 STATE BAR OF WISCONSIN FORM 2 - 2000 Tx:4213982 Document Number WARRANTY DEED 1002727 BETH PABST THIS DEED, made between Violet G. Peters and Russell G. REGISTER OF DEEDS Peters, Wife and Husband, Grantor, and Eric Shimon and Heidi ST. CROIX CO., wi Shimon, as survivorship marital property Grantee. 10/09/2014 2:36 PM Grantor for a valuable consideration, conveys and warrants to EXEMPT#: NA Grantee the following described real estate in St. Croix County, REC FEE: 30.00 Wisconsin: TRANS FEE: 1123.80 PAGES: 3 SEE EXHIBIT "A" ATTACHED HERETO AND MADE A PART HEREOF Recording Area Name and Return Address: 3 Edina Realty Title, Inc. 400 South Second Street, Suite 115 Hudson, WI 54016 1136916 Exceptions to warranties: 030-1014-60-000 Easements, restrictions and rights-of-way of record, if any. Parcel Identification Number (PIN) This is homestead property. Dated this October 3, 2014 Violet G. Peters Russell G. Peters WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2-2000 St. Croix County 1002727 Page 1 of 3 AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF ~>ur S~h~'j.h I/WIA COUNTY OF authenticated this October 3, 2014 ~ p/3r'(~ i Personally came before me t (is ` 1 * the above Violet G. Peters and Russell G. Peters, TITLE: MEMBER STATE BAR OF WISCONSIN Wife and Husband to me known to be the person or (If not, persons who executed the foregoing instrument and authorized by §706.06, Wis. Stats.) acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY I Martin D. Henschel 6800 France Avenue South, Suite 410 Cheri Brown i Edina, MN 55435 Notary Public, State of Wisconsin (Signatures may be authenticated or acknowledged. My commission is permanent. (If not, state the Both are not necessary.) expiration date: 03/01/2015) *Names of persons signing in any capacity must be typed or printed below their signature. CHERI SR=N I40TARY PUSLIO STATE OF WISCONSIN i WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2-2000 St. Croix County 1002727 Page 2 of 3 Exhibit A Legal Description The Southeast Quarter of the Northeast Quarter (SE 1/4 of NE 1/4) of Section 4, Township 29, Range 19 West, Town of Saint Joseph, St. Croix County, Wisconsin. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2.2000 St. Croix County 1002727 Page 3 of 3 Fora - S T C - 106 AS BUILT SANITARY SYSTEM REPORT ?I. "T£P., s ~oS q OWNER EBQE TOWNSHIP SEC. T N-B- 17 ii ADDRESS I~~X 2 yV ST. CROIX COUNTY, WISCONSIN ~UvsaJ. SUBDIVISION LOT LOT SIZE a D PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 i SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I 4-W -fee h j 1 1 2b~ , s3 • ' w to (e0 OF /O(e r f y D~+ae7~•F I. y t. ~C", d woo sin nr-Roy„ fr fax p Lo OUR tat )j s INDICATE NORTH ARROW 1 00 .0 i Fok St p4;, lXv,- % yo~ft N•E. Fq&c o wooD Dce~C # BENCHMARK: Describe the vertical reference point used i /DO.O 7 Pte-- Elevation of vertical reference point: Proposed elope at site: SEPTIC TANK: 'Manufacturer: w4k*t'S *AY-' Liquid Capacity: Number of rings used: Tank manhole cover elevation: f 7e J7 Q p~ 0 Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front A61 Side 0Rear, O feet ..From nearest-property line Front,( Side,ORear, O ~Q Q feet p / , Number of feet from: well / s building: 2 3 ' (Include this information of the above plot plan)( 2 reference dimensions to septic tank): _ SEE REVERSE SIDE ~ o a~i o° I a~i °o I N ti p p N ono 0 O h c c Y m c N w LO o a ( x I y I ~ I o m m I I n N M O p U 7 O C ~ O « -2 M C N N 3 N T N YN O'D Z m0 Z LL c N D LL m O U - O 3 N> 3 O_• 0.4) c i v o m~ Q CD Q E '-x m m m c) a I a I cc w y 0 00 O> Z « 0 _ € V C V Z G 4 U) dm 0..m I I 0 Z :t c I r 7 N v1 d Z ° c ° c to F- r m 0 c 0 E 0 1 -0 0) a) m N CL O N O. O N a) N a) .0 N N U) C? C 2 .2 .2 ai N N C C O C C O V S O O O a) O N Z 1- Z Z H Z Z Z o N Imo.. d r I R E (_D ) 4) m m e L• d O y m c. O `c LO) w (D MA G G IL G O a a U) E r co) U) 0) 4i r 000 000 ~y m a. 'a co 4) N J U m o o m co rn } 0 IT 00 It r- LO 4) C) 0 o CD > 07 O O C, N N N N I 0 o v ,n o o v E r n v m' c m m y c a o o rn CD rn rn ~Q z to m y ¢ (n as C~ O J N 06 y H Q0 3 c c o 2 H c Q O H cc o rn rn 0 v y a 0) c v l V m ` ` a) c c rnoooo T fp L O j- C -p N N N N p `t Oi m as c or m t c 0) E- m CD c ~n N n v l W p 17 N :s F- Z 2 '00 N r N a) a) IN N' N y N c c d 0 d ~ C a) 0 06 c7 _ L 00 O f0 f0 .O O S O L • C) L O O w T T O 0 O m m Cl) ~ U) W 0) 0 Z N d' Q' L W O Q1 O Z H H~ ~ to O O V~ ik = E da ~a CL 0, c 4) c 0 to a t O ai v 3 U p O v) U , t A v Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 198 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Ebbe, Valerie St. Joseph, Town of 030-1014-60-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 04.29.19.61 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration I er Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding F Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of System: CHAMBER OR Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bedrrrench Center Bed/Trench Edges Topsoil Yes I` No F : Yes ! No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 574 River Road Hudson, WI 54016 (SE NE 1/4 4 T29N R1 9W) 40 acres Lot n T' PMeI N • 04r2eJf2.~ 1.) Alt BM Description = ! i gel e 6 yet 2. Bldg sewer length = ~ GL~ ` ca~e~ - amount of cover = n, ~ ~5~~.. C. revision Required? 0 Yes No ! - -1 j- /-d?s Use other side for additional information. Plan (R.3/97) Date Insepctor's Si ature Cert. No. County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN ~ r1v~ In',accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT e7+~ REF P information you prov*e#n, b~~!!s r secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER G ~ [Privacy L W. ~ `15•tt~(.. 1101 Carmichael Road $ n j Hudson, WI 54016-7710 ` W (715)386-4680 Fax (715)386-4686 r,\ Atta6h plete plans for the system on paper not less than 8-1/2 x 11 inches in size. purity # ❑ Check if revision to previous application r` 1. ApplicationirS~ jars`, lease Print all Infor on Location: Property Owner / / 1 /4 1/4, Sec V CC,4- r e 913t' T 2 N, R 11 E (or) Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Numer Subdivision Name or CSM Number t4,j5on W i 5 _~Wl 6 11 Type o Building: (check one j~ ❑City ❑Village COT-own of 030~_1 or 2 Family Dwelling - No. of Bedrooms: 3 Jack J fJ` " L ❑ Public/Commercial (describe use): D r 51- ~OSef ❑ State-owned Ne4rest Road Ii. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 73, tiz CY Parcel Tax Number(s) ylepair 2.0 Reconnection 3.❑Non-plumbing 4. ❑ Rejuvenation A) 1. Sanitation ~~D -000 B) Permit Number Vl ~ Date Iss 4 j<-7 ❑ State Sanitary Permit was previously issued U 11 IV. Type of POWT System: (Check all that apply) P"Non-pressurized In-ground ❑ Mound z 24 in. suitable soil ❑ Mound 5 24 in. suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation S't7 VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks 1000 LA)e¢. ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) PSignatur o p MP/MPRS No. Business Phone Number Rl l 14uh G? v?-1630 Plumber'ss Address Street, City, State, Zip Code) 7,q ~ l '1~h ~/Y'/Y ~zr l l S IN ' S1C 0z~ III. County Use Only ssuing t Signatu (No s ps) d Sanitary Permit Fee 7;71 I Approved Owner Give i dverse 7 ~ q De 'n ✓ / IX. Conditions of Approval/Reasons for Disapproval: SX St~~ h w~ 6 eeM fDAev-_OvS LY 5A? C ~'e Q( O'fA"f . rfie /4/e! Gh LY Gk4,e WA,s' T--q- ."nom GFpl-cell hJ 1 L.e nl~ cacti S UvP/!~ -VL L 17L L, VVW P,j° ~ -r- t-Le~,r" C) 61 7-wi n Rev: 8/05 Q o I' ° I H ~ o N ~ c I 4 p zo c ~ ~ m I O N Q t i y (n O U ~ II N N N LO p 'd F. T y y ~ I m z ~ c LL O 01 C o L I N 'O O O E Q x co N I N E Z 0 z rn N wn a co v F- t i I I E Z c r r O U) N Z _v 2 N ul - r?) E ~~V N N W • L L 0 O O D td N O N M O f g z F- Z O `7 N ZZo d U) 42) 4) o o N N N a • 3 a a a IL O co co 0) - N J U rn _ } v o o n N o o 0 O O E N N a' O O 'B p ~ O N a N ~ V (D A p L 7 U 'ir 30 ~'I O O 7° n d o a°i c c a rn o 0 0 CD co 0 0 CL II r N c m N Lo N V a cy; '0 C3 a C N pNj w 3 E O m l0 16 • O O fn W a) O Z N to v~ d m € a S a L CL c - c °.3 `Iv •c ~ Parcel 030-1014-60-000 09/04/2014 11:43 AM PAGE 1 OF 1 Alt. Parcel M 04.29.19.61 030 - TOWN OF SAINT JOSEPH Current IN] ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner 0 - EBBE, VALERIE P (LE) VALERIE P (LE) EBBE C - PETERS, VIOLET G VIOLET G PETERS 574 RIVER RD HUDSON WI 54016 Property Address(es): * = Primary " 574 RIVER RD Districts: SC = School SP = Special Type Dist # Description SC 2611 SCH DIST OF HUDSON SP 1700 WITC Notes: Legal Description: Acres: 40.000 SEC 4 T29N R1 9W SE NE Parcel History: Date Doc # Vol/Page Type 04/15/2011 935019 QC 03/26/2010 913752 QC 03/24/2010 913631 QC 05/12/2003 721112 2238/360 QC more... Plat: * = Primary Tract: (S-T-R 40% 160% GQ Block/Condo Bldg: * N/A-NOT AVAILABLE 04-29N-19W SE NE 2014 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/11/2011 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.000 68,400 70,000 138,400 NO MFL BEFORE '05 CLOSED W8 37.000 126,600 0 126,600 NO Totals for 2014: General Property 3.000 68,400 70,000 138,400 Woodland 37.000 126,600 126,600 Totals for 2013: General Property 3.000 68,400 70,000 138,400 Woodland 37.000 126,600 126,600 Lottery Credit: Claim Count: 1 Certification Date: Batch M 117 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 Manufactur Pump Size ~......aY Elevation of inlet: Bot of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet fro earest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). 2 %~FS 5 X S y SOIL ABSORPTION SYSTEM S X s 3 Bed : Trench: ^ 17 Z s. Width: 5 Length: Number of Lines.: Area Built: Fill depth to top of pipe: .r w ~ Number of feet from nearest property line: Front, © Side, O Rear, O Pt ---T--;' Number of feet from well: 2-00 Number of feet from building: (Include distances on plot plan). SEEPAGE PIT* Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit ele ion: Area Built: Has either a drop box O or distribution b been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings u d-:. Elevation of bottom of tank: j Elevation o nlet: s Number 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: y Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: nl w owN It SEPTIC PLUMON D0. RT. 3 O'NEIL RD., HUD90N, 41M& 51016 ROBERT ULBRICHT WIS MASTER PLUMBER LIC. N0.3307 M.P.R.S. 3/84:mj MINN. (NSTALLER i DESIGNER LIC. NO. 00663 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT :t "T,E1'" s~- dos Z~ OWNER E1313 45- TOWNSHIP SEC. T N_R, ADDRESS ^f'~" ~aX ZYv ST. CROIX COUNTY, WISCONSIN i SUBDIVISION LOT LOT SIZE , PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 i I SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I 9130 SYSTEM = 8y:do . I &At O ; , PIPE PIPE g 910 wed. OF -io E 0.0 96 7^aK -roe ~P93 1p x ~1 9To r 2-6 ' E,ist io Io• (gyp ` of /oG ( 9' I ~ L'~✓~" IuSJLATt~ ~ cawc,,~~.4 i sox 4,- 7Rc~ - ~(evhta 0 Nr SET to of 9Z.3~ !sr 0/ sox Cob ir' s y y zP I UF,Q7' ~ f ~ p,S 4• I • , D olt Q WO. Rof OF s~tr ' G Rv 0 600 01, f INDICATE NORTH ARROW J00•0 Fok SL-P4; e -',4,v& % re/ N-F 4C,4*4- QA', BENCHMARK: Describe the vertical 'reference point used w00D DEG/~' 'r Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: 6046-i4t'S *V6 Liquid Capacity: Number of rings used: 141 e Tank manhole cover elevation: 7 Tank Inlet Elevation: 72.1'0 Tank Outlet Elevation: ptwj2 /ep Number of feet from nearest Road: Front (V Side ,ORear, O feet From nearest-property line Front ,©Side 0Rear,0 feet Number of feet from: well 95 building: 23 (Include this information of the above plot plan)( 2 reference dimensions to septic tank), SEE REVERSE SIDE DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR &4-1UMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION 1P'O. BOY 7969 BUREAU OF PLUMBING r MADLsiciN, WI 53707 S',,NE!4,S4,T29N-R19W Ip KpXCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Numb er IIf assigned) Town of St. Joseph El Holding Tank El In-Ground Pressure El Mound River Road NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTIO A E: Ted Ebbe Route 2, Box 240, Hudson, WI 54016 ~~-~S S -7 fill /.t,30 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: Robert Ulbric 3307 St. Croix 99092 SEPTIC TANK/HOLDING TANK: MANUFACTUj2 ER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV~ P R IDEDLA B E L PLOCKING ROVIDED OVER r\ ? YES ❑NO ❑YES ❑NO BEDDING: VENT DIA., IVENTM TL. HIGH WA ERL NUMBER OF ROAD; 1PINE ROPERTY WELL BUILDING: VENT TO FRESH r ALARM ffr~ I: y'/ l AIR INLET FEET FR 1 ❑YES NO ❑YES O NEARESTOM VV ~ S5 Z3 DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑ND ❑YES ❑NO ❑YES ❑NO FRESH GALLONS PER CYCLE: JuMj A DCO R LS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING VENT LET (DIFFERENCE BETWEEN FEET FROM LINE AIR IN. PUMP ON AND OFF) S ❑NO NEAREST 10 SOIL ABSORPTION SYSTEM. Check the soil moi ur th de th of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (if soil can be rolled into a wire, c nst ction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. L GTH4 NO. OF DISTR. PIPE SPACING. COV TER INSIDE DIR.. #PITS: LIQUID BED/TRENCH ^ THE CH ES ' ERIAL PIT DEPTH. DIMENSIONS 4f GRAVEL DEPTH FILL DEPTH DI DISTR. PIPE DISTR. PIPE MATERIA ; NO. D R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELO IP€€S. ABOVE COVERI ELEV3 . , INLET. EL V Er PIPE FEET FROM LINE: AIR INLET: ~1 x_28 0 2 4J 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 TEXTURE PERMANENT MARKERS JOBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/RED DEPTH OF TOPSOIL SODDED. SEEDED. IMULCHED. CENTER. - EDGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑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 IM ANIFOLD 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 VERTICAL LIFT CORRESPONDS TO APPROVED ❑YES ❑NO ❑YES ❑ND COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: TNEAREST--~ MBER OF PROPERTY WELL: BUILDING: ET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO i C, ~ f , ;r t: 1 t L~ _ b LJ, ! (Y~ Sketch System on Retain in county file for audit. ~Yt Reverse Side. C,\ SIG AT RE. TITLE: Zoning Administrator D I L H R SBD 6710 (R. 01/82)/'w~`~ 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 (SBb 6399) to be submitted to the county prior Jo installation; 5. Private sewage systems must be properly maintainecr." The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 t6,3 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. Prcperty 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 CILHR; 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 sgction of the soil absorption system if required by. the county; E) soil test data on a 115 form:, . r GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more l_ commonly known as the groundwater protection law..This change ira,sfatu€es was the r` result of over 2 years of steady negotiation and' public debate. The groundwater bill Groundwater included the creation of surcharges (fees) for a number of regulated practices which wiscort~in's a 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 o system or the disposal site used by your holding tank purnper. 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) SANITARY PERMIT APPLICATION ~ . c RO ILHR In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARYPER# ~qk -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. N• A , -See reverse side for instructions for completing this application. PETITION 1. 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES IZ NO PROPE lev RTY OWNER PROPERTY LOCATION q me,- S T Lf , N, R E (or P OPERTY OWNER'S MAILING ADDRESS LOT NUMBER B /C~K~NUMBER SUBDIVISION NAME 94. L X z7 0 7//" r- o go s CITY, STATE ZIP CODE PHONE NUMBER ❑ VILLAGE: NEAREST ROAD, RK v S o,✓ W/ S SP LW TOWN . S- as !imix 11. TYPE OF BUILDING OR USE SERVED: #44,C- ^ T 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. KReplacement 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. )M Conventional b. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f.. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) y L~tiES ,F~( SO 1. a. ❑ Seepage Bed b.& Seepage Trench c. ❑ 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): 89, a Y3 6 T J 42, Feet Private ❑ Joint ❑ Public VI. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xisting Gallons Tanks Concrete glass App. Tanks Tanks strutted Septic Tank or Holdin Tank Qsf~ ❑ ❑ ❑ 1:1 0 Lift Pump Tank/Si hon Chamber ❑ E1 ❑ ❑ 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 Sig ature: (No Stamp,) *lP/MPRSW No.: Business Phone Number: ROWT u LSOCA r- 3,30 7 '71. 7 X ^8~~'f Plumber's Address (Street, City, State, Zip Code): Name of Designer: t ' Ol oelL P%X - 0 0,SD~ 5~-- VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST # RT. 3 O'NEIL RD.: HUDSON: VWS. 54016 2, Z.. CST's ADDRESS (Street, City, State, Zip Code) ►,4sT€R PLUMBER UC. NO. 3307 M.P.R.& Phone Number: 'NSTALLER & DESIGNER LIC. NO. 00663 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S$nitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Su h~arrg'e Fee Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: lah SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber / 65/,l 115 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. r r yrr r r r:. r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 00ner of Property Location of Property S Ale 14, Section , T a'LN-R W Township j ' c7o-rho"- Mkiiing Address his s-~c~~ ~ 'Address of Site Subdivision ' Dame Lot Number Previous Owner of Property :Total Size of Parcel Irae Date Parcel was „Created Are all cornerd,and lot lines identifiable? Yes No r Is thispropertp being developed for resale (spec house) ? Yes 1>< No Volude.J and Page Number, 90 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - r r - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) ceA i.by that att .statements on thin bonm ane t1Cue to the but ob my (oun) knoweedg e; that I (we) am (are) the owner (b) o6 the pnopeht y deb cA ib ed in Chia in4ohmati.on boAm, by vixtue ob a warranty deed teco&ded in the Obb.ice ob the County Regihten ob Deedaas Document No. 33; and that I (We) pneaentty own the pnopoa ed .6 to bon the sewage d A pos .s ya em (oh I (we) have obtained an easement, to nun with the above ductibed pnopenty, bon the conatnuction ob baid eye#em, and the same has been duty tec ded.in the Obbice ob the County Register ob needs, as Document No. g~ g ~iF 33) . 4ASIGNATM OP OWNER SIGNAT OF CO-OWNE F APPLICABLE) DAftti,SIMD DATE S I D e 'i .,cIVT NO. STATE BAR OF WISCONSIN-FORM ~If QUIT CLAIM DEED VOL 573 ~t ^C ~~~J THIS SPACE RESERVED FOR RECORDING DATA J 34843 N,:: Valerie Peterson Ebbe and REGISTERS OFHICE BY THIS D ED, _ Theodore ames e, er us an ST. CROIX M, WI& Grantor _ , Recd. far Record Ibis 9th quit-claims Theodore James Ebbe anff_Va Brie day of V" A. D. 19,38 ---T--~- Petertoson Ebbe, hus and an wide- as point tenants, °t io'oo Grantee-- , for a valuable consideration Rapbfa► of DNds the following described real estate in St. Croix County, State of Wisconsin: RETURN TO The South Half of the Northeast Quarter of ~~0 a4a L~ztri Section 4, Township 29 North, Range 19 West. { Tax Key # This is homestead property. as to part. I ~j i, Exempt Under Section 77.25 (8) TR I XE r II ii i Hudson, [Wisconsin 8th May 78 this day of 19 Executed at SIGNED AND SEALED IN PRESENCE OF (SEAL) I Valerie Peterson Ebbe (SEAL) Theodore James Ebbe ±i (SEAL) ,j - (SEAL) ii ~F I! Valerie Peterson Ebbe and Theodore James Ebbe, her husband Signatures of j XLY 1 authenticated this day of 19 In l ohn D . Heyw od Title: Member State Bar of Wisconsin gC)CMXRR[>i4X 1 y Authorized under Sec. 706.06 viz. II STATE OF WISCONSIN l t; County. 1 ss. i ~i Personally came before me, this day of 19 . t the above named 4 l to me known to be the person- who executed the foregoing instrument and acknowledged the same. This instr ment was drafte by ` John . Heywoodd, Attorney Hudson, W1SCOriSlri Notary Public County, Wis. The use of witnesses is optional. My Commission (Expires) (Is) ` Names of persons signing in any capacity should be typed or printed below their signatures. KGMdI9'Convuv QUIT CLAIM DEED-STATE BAR OF WISCONSIN, FORM NO. 3 - 1971 e Cn ` STC - 105 H t~ i SEPTIC TANK MAINTENANCE AGREEMENT ~o St. Croix County z "9 H OWNER/°".r fi~ V~ cd ROUTE/BOX NUMBER /~•~aX Fire Number CITY/STATE ZIP 41 PROPERTY LOCATION: Section , T~N, R _W, Town of S7` , St. Croix County, Subd { 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 pdt into the system can affect the function of the septic tank as a treat- j ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximym of 60% of the cost of replacement of a failing system, j 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. y I/WE, the undersigned; have read the above requirements and'''agree ti to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- IV ment of Natural Resources. Certification form must be ompleted and returned to the St. Croix Count Zoni Off Y lpe wiC"h. ys of the three year expiration date.; "r SIGNED r lrfC !f~ 1 /3~! i • DATE St. Croix County Zoning Office P. 0. Box 98.E Hammond, WI 54015 j 715-796-2239 or 715-425-8363 Sign, date and return to above address. j DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION ! LABOR AND PERCOLATION TESTS (115) MADISON ° 53707 HUMAN (i~LATIONS j (1-163.090) & Chapter 145.045) I i LOCATION: SECTION: TOWNSHIP/ : E'~S1' OT NO.:BLK NO.: SUBDIVISION NAME: s=a 1/ 4 /T29 N/R 19 E (o W 5T- s osE P PrtRr ,t c o s t COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: Ss Lloi V4I ? TED L l3f3E ~T 2 Qa X 240 flupSa,v . W .'(s USE 2 Z DATES OBSERVATIONS MADE G NO.BEDRMS.: COMMERCIAL DESCRIPTION: Residence 3 iJ~ . d ❑New Replace I 3 I_ ~7 9_ / _ i v /T v T~ RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND•PRESSUR S STEM-IN-FILL OLDING TANK: RECOMMENDED $YSTEM:(optional) ?IEE.V t.~.c S ❑ U ®S DU 2S ❑U ❑ S QU ❑ S Ell C Of L) EA-) T/ o,v rt pie-or w~ K . I i If Percolation Tests are NOT required DESIGN RATE: i If any portion of the tested area is in the under s.H63.0915)(b1, indicate: C I1f S S Z' Floodplain, indicate Floodplain elevation:. i PROFILE DESCRIPTIONS BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. I HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 9 5 ~ IG 36 > - s' ~ s• ~Ni , ) /.o ` a,p. S B- S 5 'BN .'u c S 3 9 ' 9(o v CS -rjA-, ut-p- cs GR B-,3 S9.S 9 3-FD A- > 00. o' T3a e- G 2 . B- B- PERCOLATION TESTS ~;u V r e-5 R. Sfi #7~f ' TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PER INCH P L Z P- P- P-_ P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori• zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. 1 1 r V ~_s ~2 . 3 6 1~ N eo SYSTEM ELEVATION 1 _ } 1 t } I 7 7_7 I . 1 1 . _ III ) Fi 1 ~ I t 1 15f ICe 1 { t 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 HOMESITE SEPTIC PLUMBRiG CO. C/' _ 1P 2 ADDRESS: R T. CERTIFICATION NUMBER: PHONE NUMBER (optional): ROB IM PR LIC, NO. ERT ULBRICHT 3307 M.P.R.S. CST SIGNATURE: U0bbJ ;NSTALLER & DESIGNER LIC. N0. DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - REPORT ON SOIL BORINGS ~ PERCOLATION TESTS IIS s P oT P4AN PROTECT . D. VA I ' -TED E: I& A ff- r DArr sue. q- 12P? HOMESITE TESTING CO. RT. 3, O'NEIL ROAD BOB ULBR1C.14 AU SON, WIS.,-- 5,4016 CST SS- 02 yez PROPOSED moose mosr l.IF 2,5' Fr• o f MODE F~POM X411. rrsr 4,ec. 5. PRo Qo5E D WE'LL M V5r we ,So Fp dt mews, F-fem Atz. TEST ^0z. f S, • = eAce* O ;r$ O = EXISAIA1 !r WELL _ i( ` ~EQG /OG,¢~~GN/f f/AAJ~ Ad ycew ow 54WI-1. DES • !lo,~iz . BMA VFRric,►t ,PEFERle"r Pour - ,x f~~cE IWE- ToA °f coR4e 2 cc~ coD ~~NC£ ~oS T LE GE N D e&Vl r10A1 of y~tr ~PEi. Pr i o o • o ' 1~~=3o -~rPEa~^' J^Tf''~ (I~ 1 f ~r /Co L l-y x J OoM_.e_ f A I. o~ i,, o tR o F sloe ' L P°rt~~ floes"~~ sf'WAo s4#0~ 0 3y' ~ ;ate willow a(r 7- VrA) ~ y /'Alit 1 Wit'64.) iVLk a r--- ~ ~ ~ ~Vry~ + I Y`7l✓, i ~i [[[x~ dgk ~ 1 r !9 ~ r`. ~ r, / t e~ ~ . ; l R 30S 33~ ~4, I-) - I ~r To~ 5' &t- C 40 O SCh ATOP iN s pRioE ~o \ r \ 61 ki) 2' 10 2 \ .r . c" c~ gED~ _ 170- V 5, To c~ t\~ r G ~ f 1~0r1 ~ \ \ ~ ~tl J STgTE' ~ S • 3y ~ p Cox . 1 Vaces <oA)c, ffxL- N~,v /00 Seprlc • • ~qa K fe yo' c~7£~KS Cv~ _ v Fresh Air Inlets And Observation Pipe h Ty P CA L Fd (L 307 Gam, 7"12 e&) C" S 00 Approved Vent Cap Minimum 12° Above Final Grade PeR Soi L 1t4/fX1-M0M TES Tv I OJT _ 4° Cast Iron vele r- Fr. ff Ro Above Pipe Vent Pipe' o Final Grade Marsh Ho Or Synthetic Covering ST Y Min. 2" Aggregate ,l p,3 Over Pipe Distribution Tee Pipe 0 0 0 0 0 , r!i " Aggregate o Perforated Pipe Below `0w 9 Beneath Pipe 0 Coupling Terminating At 7xor g~,g~ Bottom Of System