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HomeMy WebLinkAbout020-1183-60-000 (2) I tr 0. �n 'a 00 � I CD O c C I Q V T 0 Ct N D. C N O c L O " 0 O > m y y Z y 0 LL C O O O d 3 v E E Q H v I � Cl) rn E Cf) w 0 d 0 Z r °' w am Co FN- Z l 0 o z c N Z T Z N H c E v a� :3 N m O co a vii y � c a` O = °- III C C O f6 O N C 4U—_- Z m D o y 4i Z aci c c (D M E m N _ R 0 'o 2 o d N C G d E c ° ° v) mv) aU) a r a ' 000 a CL a I • m U c y 00 00 O (V O O Z 7 M O � (D C C N N M O N N U O 7 3 U m y c 'o y � ILL Q to 0 a co � .. ° O O N C O O O d 1 N O CD O O (6 c U 0. O O O O O O O O O W iw M 0 _U t0/1 N � 00 C 0 0 c 7 � M G r 6 t0i1 � � N N Z C N ^ O H O O O N N E t4 O N 2 U) O Z E F0— to = E I C� E 6 a ` a 2 r A U d l O o Parcel #: 020-1183-60-000 01/07/2005 04:28 PM PAGE 1 OF 1 Alt.Parcel M 20.29.19.1156 020-TOWN OF HUDSON Current IX ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner *NISTLER, RONALD A&KATHY J RONALD A&KATHY J NISTLER 486 FOX CIR HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *486 FOX CIR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.120 Plat: 2328-PINEGROVE HEIGHTS 1ST ADDITION SEC 20 T29N R19W NE SE LOT 16 PINEGROVE Block/Condo Bldg: LOT 16 HEIGHTS 1ST ADDITION TOWN HUDSON Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/15/1998 583008 1340/246 WD 07/23/1997 1170/51 QC 07/23/1997 817/423 2004 SUMMARY Bill M Fair Market Value: Assessed with: 49196 176,600 Valuations: Last Changed: 10/29/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.120 21,200 115,400 136,600 NO Totals for 2004: General Property 1.120 21,200 115,400 136,600 Woodland 0.000 0 0 Totals for 2003: General Property 1.120 21,200 115,400 136,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 103 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 PUMP CHAMBER Ma ufacturer: Liquid Capacity: Pump Mo Pump/Siphon Manufacture Pump Size Elevation of inlet: Bot of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Switch Type: Number of feet fr nearest property line: Front, de, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Lenith: Number of Lines: Area Built: ,1 y Fill depth to top of pipe: y� T Number of feet from nearest property line: Front, O Side, Rear,O Ft . -7A If Number of feet from well: Number of feet from building: 7 7 (Include distances on plot plan). EPAGE PIT S Number of pits: Diameter: Liquid the Bottom of seepage pit elevation: Area Built: Has either a drop box r distribution box O been used any of the above soil absorbtion sytems? (Check one HOLDING TANK Manufacturer: apacity: r Number of rings used: E vation o bottom of tank: Elevation of inlet: Number of feet from ne est property line: Front, Side, O Rear, OFt. umber of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: F Dated: (%-' Plumber on job: ` License Number: 3/84:mj 1 Lai A (f6W Form - S T C - 104 ow, AS BUILT SANITARY SYSTEM REPORT SEC. T N-R W OWNER 1L' Irk2/7 ✓/IuT TOWNSHIP CliJSQ� -.. ADDRESS Ti Z ST. CROIX COUNTY, WISCONSIN Gl I-TD" / SUBDIVISION pJ�(/G [y�OU� LOT (j LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I-LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 4, G� N 4i r N7 , go 53 lD00 S.T� INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 57r rL n/per Elevation of vertical reference point: Proposed slope at site: _ SEPTIC TANK: Manufacturer: uj6t� Liquid' Capacity• Awo Number of rings used: NN&' Tank manhole cover elevation: j Tank Inlet Elevation: Tank Outlet Elevation: ! Q 6o y 7 Number of feet from nearest Road: Front,w Side,0 Rear, O / (f / feet From nearest property line Front,OSide,�Rear,0 `�S3 J feet Number of feet from: well , building: 2- (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE I DEPARTVENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS `LA8( R&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 79696 BUREAU OF PLUMBING MA ISON WI 53707 NE4,SW-4,S20,T29N-R19W )M CONVENTIONAL El ALTERNATIVE IState Plan I.D.Number: Town of Hudson El Tank El In-Ground Pressure ❑Mound Lot 16 Pine Grove Heights NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Richard Stout Route 1, St. Joseph, WI 54082 / j` 3v BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN'. REF.PT.ELEV.: 11;51 REF.PT.ELEV.. Name of Plumber MP No.: County: Sanitary Permit Number: Donavin Schmitt I3205 St. Croix 102792 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. ❑YES ❑NO DYES ONO BEDDING. VENT DIA.. VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL'. BUILDING. (VENT TO FRESH ALARM FEET FROM LINE AIR INLET ❑YES ❑NO ❑YES ONO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING'. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: DYES ❑NO ❑YES ONO [--]YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING V (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) 1:1 YES ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH IN 0 or UDISTR.PIPE SPACING COVER JIN!;ID1 CIA -PITS LIQUID BED/TRENCH TRENCH MATERIAL: PIT DEPTII DIMENSIONS GRAVEL DEPTH FILL DEPTH UIS7H PIPF DISTR.PIPE .PIPE MA TERIAL'. NO.DISTR NUMBER OF PROPERTY WELL BUILDING VENT TO FHES BELOW PIPES ABOVE COVER ELEV.INLET ELEV.END. PIPES FEET FROM LINE AIR INLET NEAR.ST MOUND SYSTEM: 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- meets the criteria for medium sand. TIONS MEASURED. 1:1 YES El NO SOIL COVER TEXTURE JPIRMANIENT MARKERS OBSERVATION WELLS 1:1 YES NO 1:1 YES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEELED] MULCHED CENTER EDGES. ❑YES ❑NO YES El NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATEHIAL&MARKING ELEV.. ELEV.. DIA. ELEV. PIPES DIA.'. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLARtTSCAL LIFT CORRESPONDS TO APPROVED ❑YES El NO El YES ONO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS'. NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE ❑YES 1:1 NO 1:1 YES ONO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE. DILHR SBD 6710(R.01/62) Zoning Administrator 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,,, ❑errmit may be-,n, l-- ' if1here 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 p'roperiy maintaineEO The septic tank(s) should 6e pumped by-a-licen&d, = pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Prcaerty owner's name and mailing address. Provide the legal description where the system is to be installed; 11. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if 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 anti/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 a//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, cert'fication number, address, and phone number. IX. County/Department Use Only; , X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following;A) plot plan,drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model ,- 1pump manufacturer; D) cross section-pf the soil absorption system if required by the county; E) soil test data on all-15 form ------------------ ----------------------------------------------------------------------i---------- GROUNDWATER SURCHARGE On May 4, 1984, 1981i,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 dedate'. The groundwater bill Ground fikrll included the creation of surcharges (fees) for a number of regulated practices which Wisco Ctt'S can effect groundwater. The surcharge took effect on July 'I, 1984. All of the water that buried re asurB' 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. 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 COUNTY, C �� DILHR In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT## 92 —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES NO PROPERTY OWNER PROPERTY LOCATION IQ �/4 '/4, S 10 T , N, R E(or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME C O s CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK i d8 VILLAGE: 4 TOWN OFN IV"TOM II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. �New 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. Conventional b. El Alternative c. El Experimental 2. a. ❑System- b. ❑ Holding C.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. CK seepage Bed b. ❑Seepage Trench c. ❑See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): �1 02' eet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons I Total #of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber ❑ 1 ❑ 1 ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plum s Signature:(No Stamps) /MPRSW No. Business Phone Number//: 5 Plumber's Address(Street,City,State,Zip Code): Name of Designer: ® S /V T Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST## -- CST's ADD SS(Street,City,State,Zip Code) Phone Number: 68 N. Sllooeg / CEO IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee Groundwater ate Issuin Agent Signature(No Stamps) Approved F-1 Owner Given Initial /d,v� S charge Feel1 Adverse Determination X. C MMENTS/REASONS FOR DISAPPROVAL: loa, a#mj-ad io( c - nle Is vv SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property 0BE/?T c�WAA,11�Z — �ICh�-„(2I� 2-1OGI t Location of Property �14, Section 20 , T N-R W Township Mailing Address QT 4 7-1 © Address of Site RT Subdivision Name Lot Number G Previous Owner of Property Ae-.*A 12 s T Total Size of Parcel 1, Date Parcel was Created e3G T, /98 7 Are all corners and lot lines identifiable? k Yes No Is this property being developed for resale (spec house) ? X _ Yes No Volume 75;Z and Page Number /L,177) 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) cvW6y that att statements on this 6onm ane true to the best o6 my (oun) hnow.eedge; that I (we) am (ane) the owneA(s) o6 the pnopenty ducA bed in this in6o4mati,on 6onm, by vi tue o6 a waAAa.nty deed neeonded in the 066ice o6 the Cowry Reg.esten o6 Veedsas Document No. 41116'-3 4-" ; and that 1 (We) pnesentty own the pnopos ed site bon the sewage d i s pos s ys em (on I (we) have obtained an easement, to nun with the above dea cA bed pnopehty, bon the conatnuc Lion o6 said system, and the same has been duty %econded in the 066ice o6 the County Register o6 Heeds, as Voeament No. 17 ) SIGNATURE 01 OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED a. S t�ESK OE FR JAMES O'CONNELL Register of Deeds Box 226 Hudson, WI 54016 The Warranty Deed in volume 752 Page 150 Covers all of Pine Grove Heights and Pine Grove Heights first Addition. .:' ;.. ... . a Wisconsin De artment of Revenue otit I y DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 804; . 52PAGEi5 . S�ISTERSes. This Pe d, ma a betwe n George J. H. Gies and it CO.,�� 29th g d --------------•---•--•----------------------------------- Jean Dorwin Gies his wire - ------------ ------ Recd. for.Reaord ft ---------------------------------- ----------------------------- ---- Aug. 86 , Grantor, ! day 0 a a 19 and______I� Chard_0, Stout_and Janet_P. Stout, husband_---------_- # :30 A. pV --and_wife__as _1oint__tenants as_ to a 70� interest• and 9' ------ • ••--••......--- ........ ..Maud._H.._.Stsziitas•-soe_.4 ?er -ofa--30/_-interest------_---- L. --------- Grantee s i, � Dww -----------------------------------------------------------------------------------------•------' , , ..l - Witnesseth, That the said Grantor, for a valuable consideration___-__ ---------------------------------------------------_ _.__.________________.__:______.__!_.._______. .._...____.__. I RETURN TO conveys to Grantee the County, State of Wisconsin: following described real estate m St_ __Croix iI i I All that part of the NE-4 of the NE4 lying Southerly of the railroad right of way; Tax Parcel No_ -----------------------------------SE-14 of the NE4; The NE4 of the SE4; All in Section 20, T29N, R19W; SUBJECT TO all existing highways, platted roads and easements of record. EXCEPTED FROM THIS DEED are all parcels of land previously conveyed in part performance i of the land contract referred to .below by deeds of record. This deed is given in final performance of the land contract originally made by George J. H. Gies and Jean Dorwin Gies, his wife, as ve sand Robert L. VerDugt n and Betty Jane VerDugt as purchasers, the purchasers interest in said contract having been assigned to Richard 0. Stout, Janet P. Stout and Maud H. Stout. !i The original land contract was recorded in the office of the Register of Deeds for St. Croix County, Wisconsin August 18, 1975 in Volume 52T, Page 271, Document #328700. The assignment was recorded in the same office on September 30, 1982 in Volume 652, Page 447, Document ;'380015. TPANSFM This --------- J.191...... homestead property. � 1 (is not) Plftifr' +� F Together with all and singular the hereditaments and appurtenances thereunto belonging; FEE And...........GeorgeJ. H._ Gies_ and Jean_Dorwin-_Gies-!__his-_wife,_______-- - e warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements and protective covenants or restrictions of record, if any; conveyances, liens or interest created by the act or default, if any, of the grantees, and will warrant and defend the same. 1st August 86 Datedthis ......................................... ------ day of ................................................. ............ 19......... II - -----------------(SEAL) ...........................................................-...... ...(SEAL) . - -------- 't —George J. . Gies / ------------------------------ (SEAL) .- r (SEAL) Jean Dorwin Gies AUTHENTICATION ACKNOWLEDGMENT George J. H. Gies and Jean Signature(s) ------------------------------------------------------------ STATE OF WISCONSIN Dorwin Gies, his wife as. -------------------------------------------------------------------------------- �fAay of..... g --------------------------------------County. authe/ti Au 19 86 ...... ... . Personally came before me this ----------------day of ated this --7_ y ----------------------------------------- ' 19-------- the above named -----------/ =���--------!3-F'------------------------------ : ohn D. Heywood -------------------------------------------------------------------------------- -------------------------------------------------------------------- -------------------------------------------------------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN (If not- ---------------------------------- -----•------•----------- -----------—------------------- authorized by § 706.06, Wis. Stats.) to me known to be the person ------------ who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Heywood,_ Cari,._Murray_ & -Sherburne --------------------------------------------•---------------------------------- P. 0. Box 229, Hudson, WI 54016 *------------------------------------------------------------------------------ Joh'n D:--Hey waud----------------------------------------------------•- Notary Public ------------------------------------------County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration are not necessary.) pds date: ) -•---------------•-------------------------------------, 19---_..... z H a ST C - 105 r a SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d OWNER/BUYER 9Q/342T c�C,�JA-NSdN IC#'4/10 ROUTE/BOX NUMBER ' Fire Number CITY/STATE 7oS�eisf PROPERTY LOCATION : E' , 34, Section, T 7.17 N. R__L,9_W, Town of #a,0_ DA1 , St . Croix County, R Subdivision &Ata 62RQUS� /#AT, 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. Ho • E I/WE, the undersigned , have read the above requirements and agree Ln to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning 0 fice 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 . INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 � • To be a complete and accurate soil test,your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion,if appropriate; 10. If the information (such as flood plain,elevation)does not apply, place N.A.in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st — Stone (over 10") BR — Bedrock cot) — Cobble (3- 10") SS — Sandstone gr — Gravel (under 3") LS — Limestone *s — Sand HGW — High Groundwater cs - Coarse Sand Perc — Percolation Rate med s — Medium Sand W — Well fs - Fine Sand Bldg — Building Is — Loamy Sand > — Greater Than *sl — Sandy Loam < — Less Than *1 — Loam Bn - Brown sil - Silt Loam BI - Black Si — Silt Gy — Gray *cl — Clay Loam Y — Yellow scl — Sandy Clay Loam R — Red sicl — Silty Clay Loam mot — Mottles se - Sandy Clay wl - with sic = Silty Clay fff -- few, fine„faint *c Clay cc — common,coarse pt Peat mm — Many, medium m — Muck d — distinct p — prominent HWL — High water level, Six general soil texture' s surface water for liquid wasto disposal BM — Bench Mark VRP -- Vertical Reference Point TO THE OWNER: This soil test report is the first step in securincl a sanitary permit. The county or the Department may request velification of this soil test in the field prior to permit issuances, A complete set of plans for the private sev 'ge systern and a pern-tit application must be submitted to the appropriate local authority it) order to obtain a The sanitary permit must be obtained and posted prior to the start of any construction. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS 1 INDUSTRY, DIVISION LABOR AND P.O. BOX 7969 HUM,QI`�!RELATIONS PERCOLATION TESTS (115) MADISON,WI 53707 . , (H63.090)& Chapter 145.045) LOCATION: SECTION: TOWNSHIP/ Y: LOT NO.:BLK.NO.: SUBDIVISION NAME: NE �/4.SE/4 20 /T29 N/1119 L-41 Hudson 1 16 n/a jPine Grove Htgs. COUNTY: OWNER'S NAME: MAILING ADDRESS: St. Croix Richard Stout R.R.#2, Box 340, Hudson, Wi. 54016 USE DATES OBSERVATIONS MADE NO.BEORMS.: COMMERCIAL DESCRI PROFILE DESCRIPTIONS: PERCOLATION TESTS: PTION: Residence 3 n/a New ❑Replace 110-1-87 10-1-87 RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUNPRESSURE:S STEM-IN-FILL 11:1 HOLDING TANK:RECOMMENDED SYSTEM:(optional) ®S ❑U S U ]S O U 1:1 S EM S ®U conventional If Percolation Tests are NOT red re ui DESIGN RATE: Q I If any portion of the tested area is in the under s.H63.09(5)(b),indicate: n/a Floodplain,indicate Floodplain elevation: n/a decimal' PROFILE DESCRIPTIONS page 58 BRC2 BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH= ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- 1 6.92 106.16 none >6.92 .42 bl.l. .50bn.sil. 6.00bn.c.s.&gr. B- 2 6.91 106.11 none >6.91 .58bl.1. 1.33bn.sil. 5.00bn. c.s.&gr. B- 3 6.91 105.11 none >6.91 .58bl.1. 1.33bn.sil. 5.50bn.c.s.&gr. B 4 6.67 103.90 none >6.67 1.00bl.l. 1.00bn.sil. 4.67 bn.c.s.&gr. B_ 5 6.66 103.71 none >6.66 .83bl.1. 1.00bn.sil. 4.83bn.c.s.&gr. B- decimal' PERCOLATION TESTS TEST P WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH P- 1 3.80 none 3 6 6 6 <3 P- 2 3.75 none 3 6 P- 3 2.75 none 3 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 102.36 t ? i V_i ` ; lk t F c o ! y yt TH � r Y i I,the undersigned, hereby ,certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: Gary L. Steel 10-1-87 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): 988 N. Shore Dr. , New Rich mond, Wi. 54017 2298 715-246-620(0 CST SIGNAT DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — L gill I' ll � � fil �� � � III � Ililillll C _ Ir i1 i I I ' III j I i � I f I ' � II' IIII � I I � i L--j MOM Am low, RUN CN SIR E 0 OMNI ME I IIE 101 MIMI IS IS IN momommil 0 ENV