HomeMy WebLinkAbout038-1112-20-110 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 574383 0
GENERAL INFORMATION 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: Village X Township Parcel Tax No:
City
Cain, Shawn Star Prairie, Town of 038-1112-20-110
CST BM Elev: Insp.B Elev/: BM Description: Section/Town/Range/Map No:
q`1 t l0 Ex; f-�` �11a,w�.�.�. 28.31.18.475C
TANK INFORMATION a E EVATION DATA
TYPE MANUFACTURER i CAPACITY STATION BS HI FS ELEV.
Septic A Benchmark / •c •L 97,
Dosing Z �,s Alt. BM Z O� / J -1 7 /' �• Q
ty O l� o
Aeration Bldg.Sewer
.a
Holding St/Ht Inlet 1 _
SVHt Outlet C •a c7c, 5
TANK SETBACK INFORMATION 7
TANK TO P WELL BLDG. a to A' Intake ROAD 9114rrlet^ 00, Z ,� •Z
Septic 7a/ / Dt Bottom6 J L LC .
Dosing , J 1 ` Header/Man.
7�aa
Aeration i Dist. Pipe e►. / 9 Z
D• •
Holding Bot. System /6,7— 9 I' 3
Final Grade .7.10 -, Y- 5
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover '--7 17•
GPM 7-96
J
Model Number
TDH Lift Friction Loss System Hea TDH Ft , e
Forcemain Length Dia. Dist.to Well �/
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length r No.Of Trench s PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHING Manufacture•jar`
INFORMATION CHAMBER OR r! T
Type Of Sys��,a 7 16 UNIT Model Number: _r
DISTRIBUTION SYSTEM ( �K] /(o f-Up = 3Z., uS
Header/Manifo� / Distribution x Hole Size x Hole Spacing Vent to Air Inta e
sl Pipe(s) �_ •�� �_ �1°.6
Length_Dia /' Length Dia pacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Dept of xx Seeded/S ded xx Mu e
Bed/Trench Center r •7 . Bed/Trench Edge Topsoil s No s ( No
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2:
Location: 1040 192nd Ave. New Richmond,WI 54017(NE 1/4 SW 1/4 28 T31 R1 8W) NA Lot 2 Parcel No: 8.31.18.475C
1.)Alt BM Description= Z v v 6o j'�'« G�Q 'n t� /6G C' 6/1,
��
2.)Bldg sewer length= 1- 1 LIB
-amount of cover= r �A)L U� 90 it Pbr
TTT 1l
Plan revision Required? ❑ Yes o C+ 23 �11
Use other side for additional information.
Date Insepctor's Sign re Cert.No.
SBD-6710(R.3/97)
C=15 `
Safety and Buildings Division
x, a 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.)
Madison,WI 53707-7162
Store Transaction Numbyr�
Sanitary Permit Application /,,NVII
in accordance with SPS 38321(2),Wis.Ad-Code,submission of this fom to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if ddacm than mailing address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
purposes in accordance with the Privacy Law,s.15. 1 m Stets. -9
L A heation Information-Please nt All rmatloAf
Owner's .� Parcel#
Property O
Property Owner's Mailing Address Property Location
Govt.Lot 4 75
city,State Zip Code Phone Number At V4 61fi. z 3
le
2s-sJ L T N; R F16r W 1
IL Type of Building(check all that apply � Lot
Family Dwelling-Number of IieirN Subdivision Name
R� C.C.0 rhG�' Block#
❑Public/Commercial-Describe Use ❑City of
❑State Owned-Describe Use CS/M Number 11 b 7733 ❑Village of _
P.l.✓ �J V O Town of
/ f S S� / retJ
III.Type of Permit: (Check 71i one box on line A. Complete line B if appy ble)
A. ❑New System System ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain)
B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New
List Previous Permit Number and ZDIssued
Before Expiration O%Mw `�j 2
�. 1�
IV. of POW'fS S stem/Com nent/Device: Check all that apply) i '
on-Pressurized In-Ground ❑Pressurized in-Ground ❑At-Grade ❑Mound 2:24 in.of suitable soil ❑Mound<24 in.of suitable soil 5d k Pks
El Holding Tank Other Dispersal Component(explain) ❑Pretres unc rt Device(explain) `1 Lr5
V.DisversaLffreakment Area Information:
Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sV Drs'persal Area Proposed(st) evation I
Tank Info Capacity Gallons Units Manufacturer
NOW Tanks Existing Tanks � •• q
8
� a. 1� rn iz c7 w
Septic or Holding Tank ,
Dosing Chamber (�
VII.Responsibility Statement-I,the undersigned,assume rA for installation of the POWTS shown on the attached plans.
��Name(Print) Plumber's MP/1vIPR8 Number Business Phone Number
�Z
PI/,/ty��`»,/�s�/A��d-�ddres^s`�(Stred, 7,W, P `'
/ / .,/"-; /V
VIIIxonniv/Depotment Use Onl
m-.d sermit Fee Date sued Issuing Signature
❑ ea Reason
IX Contli �1A1�lEasons for Disapproval
I.,`9epClc'tank'effluent 88er and .
dispersal cell must all be servtces f maintained
as per management plan provided by plumber.
Z: AtvqMWwkTq 40M,ents must W,malmathid
as code"/wd rnince:t
Attach to compku plans for the system and submit to the County only oa papa not kss than g W x I inches in size
SBD-6398(R.11/11)
PLOT PLAN
PROJECT Shawn Cain ADDRESS 1040 192nd Ave New Richmond Wi 54017
NE 1/4 SW 1/4S 28 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST.CROIX
SYSTEM ELEVATION 92.6/92.0 3' below grade DATE 9/17/14 BEDROOM 3
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32
Ilk BENCHMARK V.R.P. Top of septic tank cover
Filter BEAR Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
Town Road
All piping shall be SDR 30/34, within 10' Scale _ 1 /4" = 10
of tank,piping shall be Schedule 40.
Vent
>6" Quick4 Standard
of Cover Leaching Chamber
with 20.0 ft2 of Area
5.6ft^2/pair of end caps
4' Long I
Grade at System Elevation
34"
B-4 B-1
2-3' X66' cells with>3' spacing
0'
B-5 Garage
40' B-�0'
7% Slope B.M.*
ST 7� 3
Vents ST Bedroom
Valve 10 House
,
30'
B-6 20' 20 50,B-3 65' 10'
Well
95'
96'
148'
192nd Ave
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 9/17/14
Owner: Shawn Cain
Location: NW 1/4 SW 1/4 S28 T31 N,R18W1040 192nd Ave Star Prairie
In-ground absorbtion system(conventional)
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4-6. Maintanance and Contingency Plan
7. Filter Specifications Shee
8-10. Soil test
Signature
License number#2 0
PLOT PLAN
PROJECT Shawn Cain ADDRESS 1040 192nd Ave New Richmond Wi 54017
NE 1/4 SW 1/4S 28 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST.CROIX
SYSTEM ELEVATION 92.6/92.0 3' below grade DATE 9/17/14 BEDROOM 3
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32
hk BENCHMARK V.R.P. Top of septic tank cover Filter BEAR Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
Town Road
All piping shall be SDR 30/34, within 10' Scale = 1 /4" = 10'
of tank,piping shall be Schedule 40.
Vent
ji Quick4 Standard
Leaching Chamber
with 20.0 ft2 of Area
5.6ft^2/pair of end caps
2"
3T I Grad e at System Elevation
B-4 40, B-1
2-3' X66' cells with>3' spacing
0'
B-5 Garage
40' B-;0'
7% Slope B.M.*
ST 17� 3
Vents ST Bedroom
Valve 10, House
30'
10'
B-6 20' 20' 01B-3 65
Well
95'
96'
148'
192nd Ave
Cross Section of Infiltrator Quick 4 Leaching Chamber
Typical cross section for 2 of 2 cells
Quick 4 Standard Leaching Chamber
with 20.0 ft2 of Area per Chamber
5.6ft^2 pair of end plates To be >1' above grade
Finish grade elevation
Typical Installation 95'
Vent All Grade Vent
3' 4"
X30/34 Septic Tank 3
5' Long i 5' S' Long 1
36" Grade at System Elevation Grade at System Elevation
�I
Spacing 5'
2-3' X 66 ' Cells
Same on other end Observation tubeNent
At end of cell
A
16 chambers per cell B
System elevations:
A_92.6'
B 92.0'
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyerry^/
Mailing Address
Property Address
(Verification required from Planning&Zoning Depaitinent for new construction.)
City/State Parcel Identification Number®31?_ 111C9 _d6_110
LEGAL DESCRIPTION
Property Location r/4 ,5 LJ '/4 , Sec.Z , T N R W, Town of r
Subdivision , Lot# =�-
Certified Survey Map#_ 17 _ , VcIlume ,Page#! 61->
Warranty Deed# 9,-2 —7 -7 , Volume ` - , Page# L / -7
Spec house yes Lot lines identifiable yes o
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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 puff into
the system can affect the function of the septic tank as a treatment stage in the wasit disposal system Owner maintenance
responsibilities are specified in§Comm. 83.52(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.
1/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 Commerce 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 ear expiration date.
l/we certify that all statements on s form are true to the best of my/our k:¢owledge. 1/we am/are the owner(s)of the
property described above,by virtue of a wa anty deed recorded in Register of Deeds Office.
Nu r of edrooms
rG-
SIG ATURE 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.08/05)
POWTS OWNER'S MANUAL $ MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Tank Manufacturer:/f).� A/ ❑ NA
Perrhit# epb ❑ Dose ❑ Holding Volume: (gal)
DESIGN PARAMETERS Tank Manufacturer: ❑ NA
Number of Bedrooms: ❑ NA Septic ❑Dose ❑ Holding Volume: (gal)
Number of Public Facility Units: NA Vertical Distance Tank Bottom(s)to Service Pad: (ft)
Estimated(average)Flow: (gauday) Horizontal Distance Tank(s)to Service Pad:
�^� Specific servicing mechanics must be provided If vertical is>15 feet or
Design(peak)Flow=(estimated x 1.5): �JTv (gal/day) if horizontal is>150 feet. Specific instructlons to be provided on back.
In Situ Soil Application Rate: (gaUdaylftZ) Effluent Filter Manufacturer. �',4 12— ❑ NA
Standard(Domestic)Influent/Effluent Monthly average.. Effluent Filter Model:
Fats,Oil&Grease (FOG) s30.mg/L Pump Manufacturer:
Biochemical Oxygen Demand (BODs) s220 mg/L OJNA A
Total suspended Solids SS 6150 mg/L JJ�V�� Pump Model: .
High Strength Influent/Effluent Monthly average Pretreatment Unit
(FOG) >30 mg/L Manufacturer.
(BODs) >220 mg/L ❑Mechanical Aeration [I Peat Filter '+ -I
SS) >150 mg/L
Pretreated Effluent Month/ averse ❑Sand Gray ❑wetland
Y g ❑Sand/Gravel Filter ❑Other.
(BOD5) 530 mg/L Soil Absorption System
(TSS) s30 mg/L dA
Fecal Coliform(geometric mean) s10`" _ _around(gravity) ❑In-Ground(pressure) ❑ NA
Maximum Effluent Particle Size 3ti in dia. ❑ NA ❑At-Grade ❑Mound
❑Drip-Line ❑Other:
Other: A Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s) hen combined sludge and scum equals one-third(33)of tank volume
❑When the high water alarm is activated
Inspect condition of tank(s) At least once every: ❑month(s) (Maximum 3 years) [I NA
ar(s)
Inspect dispersal cell(s) At least once every: - [I month(s) (Maximum 3 years) ❑ NA
years)
Clean effluent filter At least once every: t! Q months) ❑ NA
Inspect pump,pump controls&alarm At least once every: ❑month(s) NA
❑'years)
Flush laterals and pressure test 'At least once every:. ❑month(s) NA
❑years)
Oti'or' At least once every: ❑month(s) NA
❑years)
Other:
NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper).
Tank inspections must include a visual inspection of the tank(s)to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil
absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent
on the ground surface. The ponding of effluent on,the ground surface may indicate a failing condition and requires the immediate
notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any treatment tank equals one-third(3s)or more of the tank volume,the entire
contents of the tank shall be removed by a Septage Servicing Operator (pumper)and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters,mechanical or pressurized components, pretreatment units,
and any servicing at intervals of 5512 months,shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
GMW-005(02/05)
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process'and/or damage-the soil absorption system. If high concentrations are
detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)prior to use
Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is not recommended, as the excess wastewater will be=discharged to the soil absorption system in one large dose causing an
overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the
contents of the pump tank removed by a Septage Servicing Operator(pumper)prior to restoring power to-the pump or contact a Plumber
or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the
area within 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the treatment
tanks and soil absorption system: acids, antibiotics, baby wipes,-cigarettWbutts, condoms, cotton swabs, degreasers, dental floss,
diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat
scraps,medications,oils,painting products,pesticides,san"V napkins,solvents,tampons;'and water softener brine discharge.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is property
and safely abandoned in compliance with s. Comm 83.33,Wisconsin Administrative Code`.
• All piping to tanks,pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator(pumper).
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil,
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by required
setbacks from existing and proposed structure,lot lines and wells. Failure to protect the replacement area will result in the need
for a new soil and site evaluation to establish a suitable replacement area. 'Replacement systems must comply with the rules in
/ effect at the time of their permit issuance.
% A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
re abilitated and barring advances in POWTS technology,a holding tank may be installed as a last resorL
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a
last resort to replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
LJ SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY
RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POWTS MAINTAINER.
Nam Name
Phone _ �/, r Phone .,f�C —
SEPTAGE SERVICING OPERATOR MPER LOCAL REGULAT RYA THORITY
Name Nam Y
Phone ._ v�7 Phone ���— 86
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections
Comm 83.22(2)(b)(1)(d)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code.
FILTER CARTRIDGE INSTRUCTIONS
Installation
STEP 2 Dry flt the Weir case onto the and of the outlet pipe to ensure it is
centered under the access opening. It not,then either Insert more pipe into the
tank through the outlet or solvent weld(glue)additional pipe onto the outlet
PIP*.
8.EP 2 While the case Is still dry fitted on the outlet pipe,measure the length
of vii-inch pipe needed to brace the filter to the tank and wall If utiftng the
optional suppiemerdal side support.If side support method.is not utilized,
proceed to stop four
5 ET+3 For instalatlons utilizing the optional supplemental side support:
solvent weld the%-inch pipe onto the frier case. If side support method is not
utilized,proceed to step four.
Solvent weld the filter case onto the
cartridge into the case, g outlet pipe. Insert a fitter
9 Pressing down until the finer ticks into the bottom of
the case.
If a VRS switch is utilized:insert into the filter and lock by turning n�
clockwise 900.
Maintenance
1. The effluent filter should be cleaned every time the septic tank is
serviced.
2. Open the outlet access opening to Inspect the tank and!liter. `
3. Pump the septic tank completely,making sure to remove the sludge "
layer on the bottom of the tank and not just the scum and effluent.
4. Once the effluent level has been lowered below the invert of the
outlet pipe,firmly pull up on the filter handle to dislodge the
cartridge from the case.
S. Slide the cartridge up and out of the case far cleaning.
6. If a VRS switch connected to an alarm is present,the switch
should be removed by turning counterclockwise 90*and cleaned
with water only. �I_ % r..
7. While holding the cartridge on its side(large fiat surface facing
down)over the access opening rinse off the cartridge with water
only,making sure all sq,tage material Is rinsed back into the tank.
il_ If VRS switch is utilized,replace by inserting into filter and
turning dodcwtse 90`. ,
9. Insert the filter cartridge
the fi d9e bade iota the case,pressing down until •' ,•r � a �
Itor locks into the bottom at the case.
10.Replace and secure the access opening on the tank.
«z tr..:nom^:".lc"•�C:4R'R:JM.� -1�-4-•'t r..:iY•et':.�`v�Y.xf.�.k••.
WWW beW6nsitiexG= 877-MI.PMRS(6S3-4S83)
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
is to certify that I have inspected the septic
--erving the tank preserlt.aY
N _=, Section (5M—, T residence locate<] < t: :
N, R-L W, Town >t:
--__. Upon inspection, I certify that I have fr,ii;;cj
the tank and baffles to be in good condition, and it appears to be
functioning properly.
`&I!�;t time serviced:
flow back occur from absorption system?
------------ Yes �--- NO (If , no, skip next line)
����pr_oximate volume or length of time: — '`
gallons
Construction: Prefab Concrete
Steel Other
t,111nufacturer: (If known)- -------
A/ture) (If known) .:/, e
(Name) Please print —___-_-_--_--
�76Z')
(License Number) --
l)ri to
COY-"' to be completed by licensed plumber (s. 145. 06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
_ –
– -- – – - - – – – – – – – – – – – – – – – – – – – -_
Plumber (applying for sanitary permit) Certification:
lit accepting the above statement regarding e isting septic tank
condition, I certify that the tank to the be f my knowledge will
conform to the requirements of ILHR 83 , Wis,' dm. Code (except f_or.
inspection opening o r outlet baffle) .
Name / Signature yz�
MP/MPRS` _
�• DC3�.0 Ai EtL: �U �I
'
WARRANTY ( `E ,
�� ! (l�r� STATE BAIL OF WISCONSIN FORM 2-2962
I If
VOL Il-=--- - -- -- - - _- CtEG1S"T��S O�cE
ji RICHARD J. WIE'R AND DIANE M. WZ8R, husband fi Ra¢'dtorRer-r:i a {�
11 a.na...wi e............................ i
li :.......... . ... .... ... . ........ ..: II APR 1 3 1995 I�
ij conveys and warrants•.. . a`IiAW14 L. CAIN a/k a SH__AWN •CA___ ;4 at 9:30 A. ril
and KATHY__ CAIN "
AIN a K a KATHERINE CAIN, 4
/.•• 7 ii...................._........... .........-....-...._ Vii.
,I TiLi5i3aFtc anc�..wife . . ........................ Re�Iateratn�:;
.-... ...............,a ii .... ..... ....
i --
�I
I� . .........---•--... ....----•---- .. .... -
.' _. ............................................. ......._........... ..............::.: . .:
_.. .... ...............•-•....................._•-• ... ..................... ...... .......
i L
•................. .
the ioilowing descriUed real oatate in ...... _.St...._�XO.i-X-................County, �� ------ ---°---
f State or Wisconsin: II
ii Tax Parcel No: ......... .............. i!
'� Il
�i Part of the NEI/4 of SW1/4 of Section 28, Township 31 North, Range
18 West, St. Croix County, Wisconsin described as follows:
ii
�i Lot 1 of Certified Survey Map filed December 11 , 1985 in Vol. 116, ° „
l "age 1515; root No. 407739 EXCEPT the West 156 feet thereof.
�7�
This Deems d is given in fulfillment of that certain Land Contract
dated 30 June, 1989 , recorded 5 July 1989 in the office of
the Register of Deeds for St. Croix County in Vol. 845 Page 132
Doc. No. 449409.
Illli ��,y
I:
This ... ...LS..SlOt....... homestead properf•y.
(is) (is riot) �I
Exception to warranties: easements, restrictions and rights-of-way of I
ii record, if any.
�I t �i
�i Dated . .. ...... .. ... ........ .........2k �?.... day of ........... July 1�. 93 Ii
,
(SEAL) .�1%w.°`r . .. . /G��'G�� II
Richard J. Wier lane M. Wier
... .. ...... . . . . ............. .
(SEAL.) (Sr. T.i
. . .. ................................................ . it
r
i� AUTHENTICATION ACKNOWLEDGMENT j
MINNESOTA "
i II MSp � FSignature(a) ---°•--•-•...........................•• ................... STATE Ot
1,
1� ••---•� .�''�-vi�-•-- -.County.
' authenticated t h i s day of 1 1 9 19._.... Personally ca a beforo me this ......day at
i 11
........`.lI`iY.......................... 19--93-- the above name,,
....................•..........
l� • .. Richard J X.,...127 x1�_.1"L_.••..........
.. .••-
�! TITLE: MEMDER STATE BAR OF WISCONSIN WTr•................................................... ..........
it (if not, .............................................. l
9 1 authorized by § 706.06, Wis. Stats.)
II to me known to be the person,,d........... who executed the •,
foregoing instrument and acknowledge the same.
1-+ THIS INSTRUMENT WAS DRAFTED BY
Kristina Ogland ,_y. . .....
Attorney at Law '
MAl
....................... ...... ot,iry P bile .._ �_ ilt sue+://�. Count.•ASS
C•_'om fission is per nnrnt. ii-/not, state rspi
(Signatures may be authenticated or acknowledged. Beth � J ( V ation
are not necessary.)
date. _.. .. rwwwkwoee+srrN
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_ FORM No 2— [—'2 SI�^NM�IO
407739
CERTIFIED SURVEY MAP -
LOCATED IN PART OF THE HE 1/4 OF THE SW 114 OF SECTION 28, T31N, R18W,
- TOKEN OF STAR PRAIRIE, ST. CROIX COUNTY, WISCONSIN.
_ I
• APf�,'O W E:D
N `I E! d OWNER U-0 !l 4 1925
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a+; a 11i�A'�► ; RICHARD WIER COQ PaE"s:y Vc ?1ANtm#7
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a N 1/4 CORNER
SECTION 28
CO. MONUMENT
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PRI'lATE
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H 589052140 11W ROAD 1315.88'
$ 345.42' fASENENT 345.42' ;
;a 312.52' 312.42 9 6 6' 312.42' 312.52'
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oo a oa o
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$ $ Y
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CEHTERL-TNE TOWN ROAD U89046114 11E
SOUTH LINE OF THE NE 1/4 o N
OF THE SW 1/4.
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�_<'•_ =_e' v c S 1/4 CORNER
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' IY'l'ifa f-V 3" x 6' high
IS-14-37 1ROH PIPE
c'�•�',1 f
this instrument drafted by Douglas Zahler job no. 85-13
Vol. 6 Page 1615
Parcel #: 038-1112-20-110 11/30/2006 09:18 AM
PAGE 1OF1
Alt. Parcel#: 28.31.18.475C 038-TOWN OF STAR PRAIRIE
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
SHAWN L&KATHERINE A CAIN O-CAIN,SHAWN L&KATHERINE A
1040 192ND AVE
NEW RICHMOND WI 54017
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description * 1040 192ND AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 2.220 Plat: N/A-NOT AVAILABLE
SEC 28 T31 N R1 8W LOT 2 OF CSM 6/1615 Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-31 N-1 8W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 1117/417 WD
07/23/1997 794/618
07/23/1997 785/385
2006 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/14/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.220 33,100 133,300 166,400 NO
Totals for 2006:
General Property 2.220 33,100 133,300 166,400
Woodland 0.000 0 0
Totals for 2005:
General Property 2.220 33,100 133,300 166,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 220
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
' I
I
00
40773
CERTIFIED SURVEY MAP
LOCATED IN PART OF THE NE 1/4 OF THE SW 1/4 OF SECTION 28, T31N, R18W,
TOWN OF STAR PRAIRIE, ST. CROIX COUNTY, WISCONSIN.
1
N FILED DEC 04 iCO"►
N 4 DEC111985 OWNER
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3 M 1A W of IM HU L6 RICHARD WIER 8T.CR^;X C JUNT`!
° N bvidW of a� 3077 LYDIA CT, co�sraeFteN;,re NnR,•: Ptsr�Ntittl�
`� �� ZOA NG COMMCf7�
C1 C Wes+ , ROSEVILLE, MN. 55113
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= N 1/4 CORNER
SECTION 28
= CO. MONUMENT
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y S89 052140"W ROAD 1315.88' i°
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IE
10 312.(52' 312.421 6 61 312.42' 312.52'
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75*177! 200 300 700 ` �^. A'LFN C. .k ro SECTION 28
NY6161CW ' 3" x 6' high
S-14107 IRON PIPE
HUU50N1,
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this instrument drafted by Douglas Zahler job no. 85-13
Vol. 6 Page 1615
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10 IL ll0 U0
PUMP ifancturer:R
Liquid Capacity:
Pump Model: .Pump/Siphon Manufacturer: Pump Size ,
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
r
f
Bed: Trench:
Width: Length: Number of Lines: Area Built
Fill depth to top of pipe: ry
Number of feet from nearest property line: Front, 0 Side, O Rear,0 Ft 4�
II Number of feet from well: /DS
Number of feet from building: '
(Include distances on plot plan).
SEEPA PIT
ize: 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).
HOLDI ANK
an acturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, 0Ft.
s
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
c
Inspector•
Dated: / Plumber on job:
License Number: 22Zf l�07�9
3/84:mj
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
� Sms W OWNER SEC. T �N-R_L
7
ADDRESS , /�` !C-1�7'+5�4n)TsT, ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE Q< f}
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r r�
ii,
top
R--L g. m
j;1-3 17
c3 -3
U�
f8�/
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used /-;7 d
j-3
Elevation of vertical reference point: , - Proposed slope at site: -1 �-
I I
SEPTIC TANK: Manufacturer: Pxzlr4sx-Liquid Capacity:
sed.
�,, �� �3
Number of rings _� ��' ._
g ��?� Tank manhole cover elevation:
� 38
Tank Inlet Elevation: 90211y✓__ Tank Outlet Elevation:
Number of feet from nearest Road: Front 10 Side,6A Rear, l i �„ feet
From nearest property line Front 1/0 Side 1 Rear,O feet
Number of feet from: well �� f buildiJ11JJ 7n"````'''"'������g"''''": JJJJ����
(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&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
MADISON,WI 53707
�NE�, SW14, S28,T31N—R18W CONVENTIONAL 1:1 ALTERNATIVE IState Plan l.D.Number
Lot 2, Town of Star Prairie❑Holding Tank ❑ In-Ground Pressure ❑Mound (If as signed)
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Calvin Burton 314 Pleasant Street, Roberts, WI 54023
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FR PLAN. REF.PT.ELEV.: CST REF.PT.ELEV.:
\ h f., J
Name ot Plumber: M /MPRSW N. County Sanitary Permit Number
Lyle J. Myers 6219 St. Croix 96067
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TANK INLET E V.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PHOVIDED: PROVIDED:
. o ./ ,� . YES 1:1 NO ❑YES NO
BEDDING: VENT DI VENT L HIGH WATER NUMBEROF ROAD PROPERTY WELL: BUILDING: IVENTTFRESH
ALARM. FEET FR OM ,' LINE / AIR I1T.
DYES NO DYES StNO N \�X
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAP AC ITV PUMP MODFI_ PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
OYES ❑NO OYES ❑NO DYES ONO
GALLONS PER CYCLE: UMP TR OLS 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 m ist at th depth of plowing LENGTH JDIAVITIR MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, onstructi n shall cease until FORGE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LE NGTH NO.OF JDISTR PIPE SPACING. COVER JINSIDE DIA. #PITS ILIQUIQ-
_ffEO/TRVN1Cf4 ` TRENCHES MAT71AL: PIT DEPTH:
DIMENSIONS /
GRAVEL DEPTH FILL nPTH UISTH.PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO DISTR NUMBER OF I I PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPES ABOVE COVER. ELEV INLET ELE ENDS f1 PIPES. LINE L. AIR INLE
�' V l '�" � NEAREST / G
MOUND SYSTEM: d D
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
❑YES NO
meets the criteria for medium sand. TIONS MEASURED.
❑
SOIL COVER ITEXTURE PERMANENT MARKERS JOBSERVATION WELLS
El YES ❑NO El YES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED.
CENTER EDGES.
❑YES 1:1 NO ❑YES ONO OYES 1:1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
#E.tF.3(TiRENCIi WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
? "13F.�,RI�y IQNS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. fSTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKINGELEV.: ELEV.. DIA.. ELEV.: PIPES: A.
-EL ",AyT
�B�RTON P HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
IfVFf1RIWTIgN
PLANS:
❑YES NO ❑YES NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER 01:PROPERTY WELL: BUILDING:
FEIET'FR#}M ! LINE:
DYES 1:1 NO 1:1 YES 1:1 No INEAR1_$T
Sketch System on / \ ) Retain in county file for audit.
Reverse Side. ✓`/
G TURE: E
444—.
DILHR SBD 6710 (R.01/82) 1s ( 1La Zoning Administrator
I
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 yeiars;
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;
Il. 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 dependimg on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
------------------------------------------------------------------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Grounater—
included the creation of surcharges (+ees) for a number of regulated practices which Wisco iws
can effect groundwater. The surcharce 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 pumper.
o ,
The micinies coile,�te c thr }ugh these surcharges are cred red to the groundwater f;And adminis-
tered by the Department 2f Natural R.�source,. These funa's are used for monitoring ground- t
Vk,ater, grour'.dwa"er coati°mination in '9stigat'nns -and est�bliSh n(;,-1t Of standards. GroundwatF'
`'s wcrth: prc'ecting.
c 33-6398 i 9 031 36)
4 A SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05,Wis.Adm.Code , &x
.. �..o� STAT SANITARY PERMIT#
S
y
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES bZ NO
PROP TY OWNER PROPERTY LOCATION
� � AC'/as fib %, SAS T 3 1 N, R I Y E (or(@
P•RROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK N JEER SUBDIVISION NAME
.off ?J /U( r/-� AJA
CITY,STATE ZIP CODE PHONE NUMBER 0 CITY NEAREST ROAD,LAKE OR LANDMARK
/ .� �n ❑ VILLAGE:s'� /TOWNOF7
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family 62 ?9D&(2Mn93OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. 9New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2)
1. a.Xconventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ❑seepage Bed b. See a e Trench c. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feenet): PROPOSED(Square Feet):
�,3 S f-'7'" 41 Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks I Tanks structed
Septic Tank or Holding Tank 5D 04e r Lift Pump Tank/Siphon Chamber ❑ 1:1 ❑ ❑El 0 1 El
❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print): Plumber's ignatur (No St ps) P/ PRSW No.: Business Phone Number:F rMVEY" I �l 1 -� 2
Plu is Address(Street,City,State,Zip Cod Name of Designe
23dZ Z 2 ' L
Vill. SOIL TEST INFOR TION
Certified Soil Tester(CST)Name CST#
2, s
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
2 _ �" Z�-
IX. COUNTY/DEPARTMENT USE ONL
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
®Approved ❑ Owner Given Initial /1 Surcharge Fee p
Adverse Determinationj�U 06 `w �s• ����o/ ��
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03186) 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 Cam. 1 V I_Cl �U`�( 'O r\
Location of Property � !��r, Section Z , T Z g N-R I ? W
Township
?tailing Address
Address of Site \C� nd cJ�ce T
Subdivision Name
Lot Number -�
KD
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created O, UCLA
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? !1Z Yes No
Volume and Page Number �? 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.
PROPERTY OWNER CERTIFICATION
1 (We) ee ti.by that att statements on this bonm ane true to the but o5 my (out)
hnowtedge; that I (we) am (aAe) the owners) o6 the pxopeAty denscAi.bed in this
.in6onmation bonm, by viAtue o6 a waAAanty deed recorded in the 066.iee o6 the
County Reg.esten o 6 Deeds as Voeument No. 6 73 i ; and that I (We) pnea ente
own the proposed 6i.te bon the sewage diapNFE 6ys e►n (on I (we) have obtained an
easement, to )um with the above desc4i.bed pnopeJtty, bon the eonstnuCtion o6 said
system, and the same has been duty recorded in the 066ice o6 the County Reg.csten o6
Heeds, as Vocament No. yb ) -7 q ) .
SIGNATURE OIL OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
ILA
DATE SIGN9@ DATE SIGNED
INSTRUCTIONS FOR COMPLETING FORM 115 a S D -6595
To be a complete and accurate soil test,your re;lort rni.rst_ sncluder
1, Complete legal description;
2. The use section must clearly indicate wi-iithter this is a residence or commercial project;
3. MAXIMUM number of bedrooms or comrnescial Lisp v)lanned;
4. Is this a new or replace€ll€ant asysten7;
E, Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY €F ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6 PLEASE use the Zlbbreviations shown here foe �"vnting profile descriptions and compiming the plot plan;
d_ MAKE A LEGIBLE diagram accurately locating your test locatio ns. Drawing to scale is preferred. A
separate,sheet may E:£ €ase d if desired;
83 Make sure your benchinark and vertical elevatio i reference point are clearly shoe n,and are permanent,
9. Complete all appropriate boxes as to dates, nar"aes,addresses,flood plain data,percolatio n test exemp-
tion, if appropriate;
10, If the informat ion (such as flood plain,elevation)does not apply, place N.A.in the appiop€-late box;
11. Sign the form and plane your current address and your certification number;
13. Make legible copies and distribute as require i- ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS O CE RTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st Stone (over 10") SR Bedrock
cob ...... Cobble (3- 10"), SSA — Sandstone .
gv — Gravel (under 3") LS Limestone
Is Sand HCaW — High Groundwater
cs - Coarse Sand P-; c — Percolation Rate
need s — Medium Sand W — Well
fs Fine Sand Bldg�— Building
Is Loamy Sand > - Greater Than
�sl - Sanely Loam < Less Than
Loam Ern - Brown
sil Silt: Loam BI Black
si — Silt Gy — Gray
�c;l Clay Loanl Y ...._ Yellow
scl Sandy Gray Loan) R — Red
si€<I S:Ity Clay Loam mot Mottles
sc Sandy Clay wl — with
sic — Silty Clay fff ... few,fine,faint
*c Clay ce - common, coarse
pt _ Peat mill -- Many, nee€_Burn
m -- . ;luck cl - distinct
p — pron anent
HWL — High water level,
Six tenerai soil textures surface,water
mi li€_laid?waste disposal BM Bench Mark
VIP — Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit.The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private
sewage system and a permit application must be submitted to the appropriate local authority in order to
obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction,
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, —_ -- a..�_�._ - - _ ___ DIVISION
P.O. BOX 7969
PERCOLATION TESTS (115)
LABOR AND
[+UMAN RELATIONS MADISON,WI 53707
' (ILHR 83.0911) &Chapter 145)
1L0 ATION-N-: SECTION: R Q� TOWNSHIP/MUNICI ALITY: LOTNO.:BLK.rNO SUBDIVISION NAME:
COUNT • OW R'S/BUYER'S NAME: MAILING ADDRESS:
— 1 J)
USE DATES OBSERVATIONS MADE
� NO.BEDRMS.: COMMERCIAL D�RIPTION: �PF7 / 16,FI DESCRIPTIONS: PER fITES:
L !Residence a A, New ❑Replace f? 771W,77
RATING:S=Site suitable for system U=Site unsuitable for system
rONV I�AL: M ❑� IIN-IROU�WRESSURE: SYSTEM-IN-F�LHOLDING TAN . ECOMMENDED SY 0EM:(Optional)MS El U
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the /n
under s. ILHR 83.09(5)(b),indicate: Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER IDEPTH IN. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
c
B- f (� s emcs+q� 16 6ncs
B-a t @111 DkISMSL 146niA 3& liencsfor to c
63 3,94,50 > "I a- nCs ! C
B- riof Q . > nf—st 316alif 19 A CPS
B-ter s,3 > 7 1�it
B- 7 QK C r /
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCH^^ AFTERSWELLING INTERVAL-MIN. PERIOD 1 P!�IOD2 OD PER INCH
P ^' O� 3 o"L
3
P-
p_ O
P-
P-
p_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION �I
✓ .[
B-413
/)k per,
$ fir;
W...
a
5 Un t/ a 30' TN
• y
� l
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 that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME(print): TESTS WER COMP ETED ON:E I'C.� k 9, e, 9 1(0
ADDRESS CERTIFICATION NUMBER: P ONE NUMBER(optional):
ta
/may
CST ATU
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) —OVER —
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the Qrtw of MU, Simptim-
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of pcdAod Survey ap iilad December 11, 1985, in volume "6w ct ;s
,N 1615, as Doc ram* no. 407739, SMIWT 20 an easrtt for �
s aht Ert 33 fast ttwoot, and KM as assommot for ink n-
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
\\ a
OWNER/BUYER �OL`� -��1u "Qr1
ROUTE/BOX NUMBER -F)C-)X �} 'ea j[X 5�, Fire Number
CITY/STATE k" \A1 ZIP _61 0?,3
PROPERTY LOCATION : , , Section Z T Z N , R _W,
Town of 'j�O 'r PrGC` St . Croix County ,
Subdivision 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 needed , by a licensed septic tank pumper . What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St . Croix . County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1 , 1978 . St . Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained .
The property owner agrees to submit to St . Croix County Zoning a
certification form, signed by the owner and by a master plumber ,
journeyman plumber , restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping ( if nec-
essary) , the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration . yo
E
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 ��
DATE I
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 .
1
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