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HomeMy WebLinkAbout020-1056-00-500 � = o \ / ƒ / % t e � I ) m � m � i E � § o � j � $ 8 it ] 2 ) � % Z ƒ , m 2 \ a 2 2m � � \ § } C, \ p a i R m C :t \ 7 K z t z 2 7 � _ ■ � � ) ƒ k § $ \ � z m \ f ; z _ 't .. Ni ] 2 2 § 0 Cvo R ƒ CL ( - _ • 2 & o / E m \ . / \ 2 U \_ \_ j 7 > 2 2 K k ® - .. z o � k a a a � CL m & � 0 \ v \ \ f O ) \ / § f » o o = _ > / . 0 2 1 . & § 2 4 ƒ f I % » ° 2 § / / § 2 7 k » @ 2 � / / 2 > n / / t ] f § f � , t 3 a = ® ® m § m - § \ } \ / o z 2 2 / � 2 k \ D IL , 2 k % / 0 § e c c § k 00 a 2 3 § J , 12/20/2004 03:59 PM Parcel #: 020-1056-00-500 PAGE 1 OF 1 Alt.Parcel#: 21.29.19.208G 020-TOWN OF HUDSON ST. CROIX COUNTY,WISCONSIN Current 1K Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): "=Current Owner * ROENFANZ, ROGER&JANE H ROGER&JANE H ROENFANZ 811 HARBOR VIEW RD HUDSON WI 54016 Districts: SC= School SP=Special Property Address(es): '=Primary Type Dist# Description *811 HARBOR VIEW RD SC 2611 SCH D OF HUDSON SP 1700 W ITC Legal Description: Acres: 2.444 Plat: 0359-CSM 06/1747 SEC 21 T29N R1 9W SW SW LOT 7 CSM 6/1747 Block/Condo Bldg: LOT 7 EXC TO CTY HWY PROJ 1312/585 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 21-29N-19W SW SW Notes: Parcel History: Date Doc# Vol/Page Type 04/07/1998 576672 1312/585 WD 07/23/1997 1048/278 WD 07/23/1997 791/462 07/23/1997 785/568 more 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 48046 277,000 Last Changed: 10/29/2001 Valuations: Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.444 32,200 182,100 214,300 NO Totals for 2004: 2.444 32,200 182,100 214,300 General Property Woodland 0.000 0 0 Totals for 2003: General Property 2.444 32,2000 182,100 214,3000 Woodland 0.000 Lotte ry Credit: Batch#: 301 Claim Count: 1 Certification Date: Specials: Category Amount User Special Code 27.00 018-RECYCLING SPECIAL ASSESSMENT 0.00 001-WATER SPECIAL ASSESSMENT Special Assessments Special Charges 0 Delinquent Chaes 0.0 00 Total 27.00 P PUMP CHAMBER !R Manufacturer: Liquid Capacity: . 1 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 Bed: Cou �/a,,,L"f oyq Gt,� Trench: Width: Length: 3 to Number of Lines: 3 Area Built: 8 �� Fill depth to top of pipe: ?� Number of feet from nearest property line: Front, O Side, Rear,01ft . �5 11 Number of feet from well: _�/� Number of feet from building: ' (Include distances on plot plan). i_ _ qz.'7 S 1 ► SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK / Manufacturer: ,/Jv 4 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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: r^� Inspector: Dated: O Plumber on job: License Number: Iq 3/84:mj t Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP RI;0 yj SEC. o"Z T _!R_JN-R/c ADDRESS 2_ ST. CROIX COUNTY, WISCONSIN SUBDIVISION c LGA6 r y. LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM SC6L (4C 147r =-/p' f ayX2 I1 s I N a — ` INDWATR NORTH ARROW pp BENCHMARK: Describe the vertical reference point used J i n FFh�d Te,s-r 4-7• - AM.0 Elevation of vertical reference point: W p / ��/� Proposed slope at site: ��% SEPTIC TANK: Manufacturer: /-4/l / Liquid Capacity• X10©y Number of rings used: Z Tank manhole cover elevation: Tank Inlet Elevation: 9q. 2-=< Tank Outlet Elevation: `7�7 -$S i . Number of feet from nearest Road: Front,O Side,Q)Rear, O C' feet From nearest property line Front,0 Side 10 Rear,0 (9Q feet r Number of feet from: well 95 building: d- _j�-//�io S•�•CorNd✓ o� No Sc- (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.BdX 7969 BUREAU OF PLUMBING M7aDISON,'WI 53707 � SW-14,SW,'4,S21,T29N—R19W XXCONVENTIONAL ❑ALTERNATIVE State Plln�iD.Number: Lot X67 Jacobs Landing ❑Holding Tank F-1 In-Ground Pressure ❑Mound (It assig Town of Hudson NAME OF PERMIT HOLDER: DRESS OF PERMIT HOLDER: INSPECTION DATE: 7Route Sam Miller 1, Box 292, Hudson, WI 54016 9� Q/_ 7 13, ac)BE MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: Name of PI ber, MP/MPRSW No.: County: Sanitary Permit Number: 5472 St. Croix 92552 Douglas Strohbeen SEPTIC TANK/HOLDING TANK: MANU ACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV,: WARNING LAB L LOCKING COVER 9 I � o o` N �I �� P O IDED: PROVIDED: U (/li (� YES El OYES ONO BEbDING. VENT DI A.: VENT MAT ALARMATER FEET WATER ROAL/\I L�QO W�L. BUILDING: AIR INLET FRESH - YES ONO \l ❑YES NO NEAREST OSINGCHAMBER: l/—S (2?-1"h1,Z-..h�� MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL: PUMP/SIPHON MANUFACTURER. WARNING LABEL 1 LOCKING COVER PROVIDED: PROVIDED: DYES ONO i [!]YES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTR SD[ERAT NUMBER OF PROPERTY WELL BUILDING. VENT TO FR ESH (DIFFERENCE BETWEEN FEET FROM LINE AIR wLEr PUMP ON AND OFF) ❑YE NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moistureat the depth of Owin LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shal cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH JLING H: JNO.OF DISTR.PIPE SPACING: COVER INSIDE DIA. &PITS LIQUID BED/TRENCH TRENCHES: MATER PIT DEPTH DIMENSIONS GRAVEL DEPTH FIL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WEio. BUILDING: VENT TO FRESH iii BELOW PIP` ABO Co��R: ELEV INLET.ELEV.END �,/ PIPES. LINE �j ( AIR INLET C C 1 �::� 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. DYES ❑NO OIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS 1:1 YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =0P SOIL. SODDED SEEDED MULCHED CENTER: EDGES: 1:1 YES El NO DYES 1:1 NO DYES ONO 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 MANIFOLD MATERIAL'. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.: ELEV.: DIA.. ELEV.: PIPES DI A.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES NO DYES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST t r,, AA�JJII 1t n, t j �. Sketch System on Retain in county file for audit. Reverse Side. i/ - SIGNATLTE. TITLE Zoning Administrator DILHRSE3D6710(A.01/E2) i INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems'must be properly�maintai nod.The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/z x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. ------------------------------------------------------------------------------------------------------------------------------------------------------------ GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground included the the creation of surcharges (fees) for a number of regulated practices which Wisco in' can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Teas. q. is used in your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. 0 The monies collected through these surcharges are credited to the groundwater fund adminis- ° tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) -- SANITARY PERMIT APPLICATION COUNTY AIL' HR In accord with ILHR 83.05,Wis.Adm.Code v� ""°"` STATE SANITARY PERMIT## -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 3 / 101/ 4.✓• SV'/4 k/'/4, S -J L T N, E (or PROPER OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME oleo / M( 112— -0 �---- /4'A CITY,ST TE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR L DMARK Q ' ;?A ❑ VILLAGE: 0 6 C t ek /-L14 �.- 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): 111. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable) 1. a. New b.El Replacement c. El 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. ❑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. X Seepage Bed b. ❑Seepage Trench c. ❑ Seepacie Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square�F^eet): 3 IS ?r ��O S 7 r �/� Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total ##of Prefab. structed Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic A pp' Tanks I Tanks Septic Tank or Holdin Tank 00c) (,th r ❑ ❑ El Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW N Business Phone Number: ro Plu er' Address(Street,City,State Zip Code. Name of Designer: Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST## C-0. p LIJ Q 41 S T CST's AD D SS( treet,City,State,Zip Code) Phone Number: 4 .3 ma,W PI h W 0, , k of l IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater T�ate Issuing Agent Signature(No Stamps) Approved El Owner Given Initial � a Fee loo. S�charge g-f Adverse Determination ! X. COMMENTS/REASONS FOR DISAPPROVAL: _ SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber e . 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 fr , A OC Location of Property � 5�,/ It, Section / , Tr N-R. Township }fl.� 44 01�,•1 Mailing Address _jt"�",�'°-Po eC7 , 4,e r�,t d- „1 ela 4 Address of Site -Alt i .� �.r •�,, 6 s ,�„� Subdivision Name _ ..TG G, o s /,4 . Lot Number Previous Owner of Property V j r q j e�� �Jl� ¢�� S C, Total Size of Parcel a.�y / j�E r • Date Parcel was Created A-1 L7 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? /r Yes No Volume /_?__ and Page Number 4c 3 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warrant q Deed which includes a Document number, volume and pie number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) eentti.6y that atC statements on th.i6 6orcm ate tltue to the but o6 my (out) knowledge; that 1 (we) am (ate) the ownen(d) o6 the p4opehty de cA bed in this .in6o4mation 6onm, by vi tue o6 a waAAanty deed seconded in the 066.ice o6 the County Register o6 Veed6as Voeument No. #Z a�, and that I (We) pneaentey own the proposed h to bon the .sewage diapoa .6ya em (on I (we) have obtained an easement, to nun with the above d6n bed pa.openty, bon the constnucti.on o6 said ,6y46te n, and the tame ha6 been duty neconded in the 066.ice o6 the County Regiaten o6 Veeda, ae Voeument No. 0 SIGNATURE OP,OWIER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED REGISTERS OFFICE � •�� BOOK 770 P eAR ST. CROIX CO., WI& Recd. for Record thin . 5th This Deed, made between ginia._M._.Hanson __a............ day of single woman , Maek AD 1987 --------- -------------------------------------•-------•------...------••. at 11:45 A I i, ................................. ---------------- .......................................................... ......._, Grantor, James O'Connell and......-......-.....Sam'-Millerd/b/a/--Sam--Miller--Construction---- i• � ---------------------------------------------------------------------------------------------------------------- '' deputy ......................... •-•--•................................•--......._...........•-----_...., Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... Q1le__d011ar__and..other•-valuable__consideration•- . RETURN TO conveys to Grantee the following described real estate in ......>5. ...-.Cx0.1zC......... County, State of Wisconsin: Tax Parcel No: ................................... Part of the SW+ of the SW4 of Section 21-29-19, described as follows: Lots 5, 6, 7, and 8, Certified Survey Map filed November 19, 1986, in Volume t1611, Certified Survey Maps, page 1747, as Document #419479. Subject to recorded easements, reservations, and rights of way. This .........1,9..RQt........homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And----------Virginia.M,..Hanson.....---- -- ----- --­---------------------- -- --•---. . . ---•------........--•-••-•...... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except no exceptions and will warrant and defend the same. Dated this 4th . day of --------------.....March---------------------._............... 19..87... ...............(SEAL) .... SEAL) ginia M.. G r l anson p f ------------------•------•----(SEAL) -------•-----......---------------....---•--------------. ------..(SEAL) AUTHENTICATION ACKNOWLEDGMENT �I Signature(s) ......ViFg1I1J 4_-Ms. _LT 11AnA2Qn.......-•------... STATE OF WISCONSIN SS. -------------------------------------------..................................... St. Croix -----• ........---•----•--.........County. authenticated this �th.day of.....March........... 19.87. Personally came before me this .. th.......day of _ March ..........I 19.. 7. the above named .....-•-•••••--•-•-•-•-•-••••••-•••-••-••-•-•-•--•--•-•----•-•---••--••-•-••-••. Vir inia M Hanson ........................................................ Eric J. Lundell ----•-- ------------------- TITLE: MEMBER STATE BAR OF WISCONSIN ................. (If not, ---•----••--••--••--------------••-•..................•..... ------......--•••-.............•-• ...A...:..._...- authorized by § 706.06, Wis. Stats.) to me known to be the person .-.__S,., who exc�uted the foregoing instrument and aekno r g g . .],edge tro•same. THIS INSTRUMENT WAS DRAFTED BY /'�' A O'A Eric J. Lundell U ��-'--.•.----.. nn� I LL .........................New..Richm,_ond,-•WI_5.4.017....... ._. Notary Public ...---.St CT'O1X..I.;ii. ......_Co�.ntyt':Vis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If'not/,'11t...Ae .ckpiration are not necessary.) M date: ._.1_!... ....................................... *Names of persons signing in any capacity should be typed or printed below their signatures. J STATE BAR OF WISCONSIN H.C_MiIlelCarnparryrlr�rtl FORM No. 1-1982 Stock No. 1 3001 H 9 r STC - 105 a H ' SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d 9 H OWNER/BUYER p1,1 cn ROUTE/BOX NUMBER Ede( W Fire Number — f7 4 � I.I P � )�6 CITY/STATE G. „dIn - PROPERTY LOCATION :.5 k) 1&, rJ (.). 4, Section .� � T�N , R C W Town of�,.!/�o.. , St . Croix County , Subdivision, aacai� r�► e�ces'4 , 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 . H 0 F L I/WE, the undersigned,, have read the above requirements and agree L, to maintain the private sewage disposal system in accordance with H the standards set forth , herein, as set by the Wisconsin Depart- 'b 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 . SICN Bza. yy�� DATE J 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 . DEPARTMENT NDUST Y, OF REPORT ON SOIL BORINGS AND SAFETY BUILDINGS INDUSTRY, DIVISION LABOR`AND P.O. BOX 7969 HUMAN RET_"JIONS PERCOLATION TESTS {115) MADISON,WI 53707 (1-163.090)&Chapter 145.045) TIO�T� ION: OWNHIP/MA PALITY: OT NO. LK. O]SUBDIVISION NA E:: j�?911/R/9 f(o& COUNTY: WNER'S BUYER'S AM h: MAILING ADDRESS vas USE DATES OBSERVA11ONS MADE NO.BEDR : OMMERC DESCRIPTION: PROFILE DESCRIPTIONS: ERGOLATIONTES Residence New ❑Replace I A— RATING:S-Site suitable for system U-Site unsuitable for system ONVEN A MOUND: IN- -i - ILL 'OLDI G TANK:RECOMMENDED SYSTEM:(optional) Es au ®s ou 0S ❑u [is Zu a s au If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodpiain,indicate Fioodplain elevation: PROFILE DESCRiPTIONS BORING TOTAL P H To GROU ND ATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, EX uR AND DEPTH NUMBER DEPTH M. ELEVATION OBSERVED EST.HIGHEST TO E,EDROCK IF OBSERVED ISEE ABBRV.ON BACK.) B- C 7 I-CA 41A 6'a-.l,.S!/.r,Ait-s .TS Aw,r sd roll B- c` 7 O tob ILL- Z ss-7 s c 4 B- y :,/ B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER ING14ft AFTERSWELLING INTERVAL-MIN. PERIOD I PER INCH 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. � � r ! q i r„� SYSTEM ELEVATION 2Z2 X IT Nu_ i r r ® I I r TH f _ I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with a procedu an thods soicified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of m kknow dge and beii f, NAM (print): TESTS WERE COMPLETED ON: ... r ADDRESS- CERTIFICATION NUMBER: PHONE NUMBEI ;optionaq: CST SPATURE DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) -OVER — r • T 9a A P J r A Alt/;"fl Ni r � ; `rem 1 5- -.0 to TV -u u aJ A j T • � r S--4. 6 1! w Q Z 0 JV1d �`gyv1� . O � ` v r d i CS 4Xz L, L 711 I .wr..w- +1 mv or Ir 'I v 6 ' 4ks • 14 qz- j r I � f Of x 7 # I t1 /, � ti �� lot 4 J 1 IV 6 J to 11- k r I al ri---It- V' ; 1 I I 11A Y 9