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HomeMy WebLinkAbout020-1056-00-600 § � Q _ k � k 2 « � m � ( E � A 3 J j � � 2 � � � f 2 3 \ \ ; � 7 3 � Cl) \ w E � { t & � Q / \ # � 0 z § 9 J } k § ƒ_ b � } m \ / ., k 0 2 D k 2 ) » 2 / ~ ca ƒ a % £ / 0 E o k 2 ) 2 / 8 m � � / \ \ 77 a a a z ° E a k \0 § § § ƒ § \ ® 2 @ § a . \ b . ] m .0 k $ ƒ f ) ■ 8 « 3 ° § � ' - z _o 2 £ b k ( 8 § o E . c $ § \ f LO , % f / / 2 k q / } § a I'D' / ± -� ) Q 2 § $ o ] / ] / 2 I 4j \ � 2 2 2 B C k CL E / ƒ J a o & k � Parcel #: 0 -1056-00-600 12/20/2004 04:01 PM PAGE 1 OF 1 Alt. Parcel 21.29.19.208H 020-TOWN OF HUDSON Current ST. CROIX COUNTY,WISCONSIN Creation Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner *KRAUTBAUER, KENNETH J &DORIS O KENNETH J&DORIS O KRAUTBAUER 518 JACOBS LA HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *518 JACOBS LA SC 2611 SCH D OF HUDSON SP 1700 W ITC Legal Description: Acres: 5.490 Plat: N/A-NOT AVAILABLE SEC 21 T29N R1 9W SW SW 5.490 ACRES LOT 8 Block/Condo Bldg: CSM 6/1747 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 21-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 795/537 07/23/1997 784/568 07/23/1997 770/632 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 48047 271,600 Valuations: Last Changed: 10129/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.490 47,500 162,600 210,100 NO Totals for 2004: General Property 5.490 47,500 162,600 210,100 Woodland 0.000 0 0 Totals for 2003: General Property 5.490 47,500 162,600 210,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 137 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 27.00 001-WATER SPECIAL ASSESSMENT 0.00 Special Assessments Special Charges Delinquent Cha 0 00 Total 27.00 0.00 f PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, oRear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench Width: l� Length: Number of Lines: 3 Area Built: �y� �` Fill depth to top of pipe: 4 Number of feet from nearest property line: Front, O Side, ( Rear,O Ft . /V0 Number of feet from well: 13-l' �J Number of feet from building: 'KO (Include distances on plot plan). SEEPAGE PIT Size: �(/� Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil" absorbtion sytems? (Check one) . HOLDING TANK All 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: Inspector: Dated: �DIJ � Plumber on job: License Number. 1 �~ 3/84:mj y Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT ow TOWNSHIP SEC. �C N-R c/ OWNER ADDRESS . I C»X �-�' Z ST. CROIX COUNTY, WISCONSIN SUBDIVISION , %,'� LOT a LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM SysT`4► V _ lDl. ► � A A 3 %M. I �loT Nc� Cof „wr �1V. = lao.o' �2Kc ctrr O 3 y�' p m + - - o 0 4,s o u o 21 �� r i i gs % Spa INDICATE NORTH ARROW d 3'4� L 2 /o'No sc,�a BENCHMARK: Describe the vertical reference point used W Co. ,,Q.V' Elevation of vertical reference point: �bn.Q Proposed slope at site: 3 SEPTIC TANK: Manufacturer: ZW Liquid Capacity: 1 000 qg - Number of rings used: Tank manhole cover elevation: ��(o• 3 S Tank Inlet Elevation: /Q Tank Outlet Elevation: /® 3. 70 Number of feet from nearest Road: Front, Side,O Rear, O 2©� feet From neare8t property line Front,O Side,nRear,0 (p S , feet Number of feet from: well S , building: 3l lyvic 3T N caiNa✓ oft House. (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 DIVISION LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O.BOX,7969 PJIADISON„WI 53707 State Plan 1.D.Number: SWa, SW�,S21;T29N—R19W )XI CONVENTIONAL ❑ALTERNATIVE (If assigned) Town of Hudson ❑Holding Tank ❑ In-Ground Pressure ❑Mound Lot 8 Jacobs Landing INSPECTION DATE: NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: Sam Miller Route 1, Box 282, Hudson, WI 54016 - ij 47 j'.50 REF.PT.ELEV.: CST REF.PT.ELEV.: BENCH MARK(Permanent reference point)DESCRIBFa IF DIFFERENT FROM PLAN: I P p 0 C°>DR, u'E - SRm b s CST (� U MP/MPRSW No County: Sanitary Permit Number: Name°'Plumber: 99075 Douglas Strohbeen 5432 St. Croix SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK C)+.INLET ELEV: TANK OUTLET r�E LE V.: WARNING gROOVVIDED`ABEL PROVIDED COVER S Z..+ 103 �l O 1�YES ONO DYES O NUMBER OF 'ROAD: PROPERTY WELL BUILDING: VENT C'FRESH BEDDING: 400W DIA.: +FGLii MATL HIGH WATER AU LINE: AIR IN(L/EET. `I ALARM: FEET FRUM W DO I I �S/ I / / DYES IXNO DYES �NO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY PUMPMODE L. PUMP/SIPHON MANUF ACTURER. WARNING ELABEL LOCKING COVER DYES 1:1 NO DYES ONO DYES ONO PUMP AND CONTROLS OPERATION A L NUMBER OF LINE ERTY WELL. BUILDING: AIR INLET.RESH GALLONS PER CYCLE: FEET FROM (DIFFERENCE BETWEEN DYES ❑NO NEAREST PUMP ON AND OFF) .LENGTH. DIAM ETER. MATERIAL AND MARKING SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing DFORCE or excavation. (If soil can be rolled into a wire,construction shall cease until the soil Is dry enough to continue.) CONVENTIONAL SYSTEM: S S, o •la INSIDE DIA. *PITS LI( WIDTH: LENGTH: NO.OF ! DISTR.PIPE SPACING COVER DEPTH B0bITRENCId I ' TRENCHES / MATERIAL: PIT' DIMENSIONS, I N MBER OF PROPERTY WELL BUILOING: VENT TO FRESH GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR AIR INLET: BELO PIPES ABOVE COVER: ELEV.INLET ELEV.END. PIPES FEE FROM LINE: II 11 Q 01. 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. DYES ONO P ERMANENT MARKERS: OBSERVATION WELLS. SOIL COVER ITEXTURE DYES 0 N DYES ONO SODDED. SEEDED. MULCHED. DEPTH OVER TRENCH/BE DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. CENTER. EDGES: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER: WIDTH: LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE BEOITRETMCFI- TRENCHES: EIIMENS4ONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL PIPESISTR. pOISATR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ;.ELEV.. ELEV.: DIA.: ELEV.. EI.I=VATION ANt� DISITRIOUTION COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED INFEIRMIATIfIN, HOLE SIZE HOLE SPACING DRILLED CORK ECTLV: PLANS ❑YES ❑NO ❑YES ❑NO NUMBER CIF LRNEERTY WELL: BUILDING: COMMENTS: PERMANENT M7A ERS: OBSERVATION WELLS: FEIrT FROAA YES ❑NO ❑YES ❑NO NEAREST .�� 'A ul 0- 4 Sketch System on Ly Retain in county file for audit. Reverse Side. TI LE SIGNATURE: � Zoning Administrator DILHR SBD6710(R.01/82) r INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system; contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owners 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-'or 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 �I�Br— included the creation of surcharges (fees) for a number of regulated practices which Wisco in 'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasUre! e is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. 0 The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) i SANITARY PERMIT APPLICATION COUNTY J� �/ � DILHR In accord with ILHR 83.05,Wis.Adm.Code ' ' y'v STA SANITARY PERMIT# v7 –Attach c®mplete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches Ili 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 \Qr Z" SU.Y4, S at Tag , N, R l ;(Or W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME � Z Fe Z S S0..t6 r4 " V\5 V\ CITY,STATE ZIP CODE PHONE NUMBER 7n CITY NEAREST ROAD,LAKE OR LA MARK So & _ sqo� 3Y`a 09 VILLAGE: O 5� a 11. 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. El Replacement c. El Replacement of d.El Reconnection of e.1-1 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. gConventional 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. ❑ 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): C 3 (p 15--S T (p 4l'g S r Feet �Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Fiber- Expp. INFORMATION New xisting Gallons Tanks Concrete strructed Steel glass Plastic App Tanks Tanks Septic Tank or Holdin Tank � ❑ 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 No.: Business Phone Number: a Str o h bps,, -�J l P- S`f ,3 Z Zy 7 Z 3 3 Plumber's—Address(Street,City,State,Zip Code): �� l T Name of Designer: t VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST#/S9 At- GA o g! W CST's ADDRESS(Street,City,State,Zip Code) Phone Number: / a. 4 4.5 0 4o) o Irs 291 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S nitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial ry� S harge Feet) 9 7 Adverse Determination I�-)-m `��,ov ��/ � 72) . 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 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 _S � �p/• /�Q/'1 Location of Property S w k h;, Section 2 / , T a S N-R��� Township Y4 GY S ea �l Nailing Address 2 ©fi 2 ?-z— Address of Site S Lo SV0I � Subdivision Name ,j�c d b s I cc,� �3 Lot Number # $ Previous Owner of Property Y_r 9 i V� Total Size of Parcel '-{5(0 c q-lS Date Parcel was Created 3 S'-- S>'7 Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house) ? Yes No Volume -7 0 and Page Number (p 12- 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 I (tie) wtti.6y that aQ,e. statements on zhih �onm aloe thue to the best o6 my (oun) hnowt.edge; that I (we) am (cute) .the owneA(s o6 the ptopehty deAcAibed in this .in6okmation 6o4m, by vi tue o6 a wa Aanty deed neconded in the 066.ice o6 the Count Register o6 Veedhas Document No. 363 ; and that I (We) pneaentCy own the proposed site bon the sewage dihpo4at s ys tem (on I (we) have obtained an easement, to nun with the above debchi.bed pnopehty,. bon the constAuction 06 said system, and the same has been duty neconded in the 066.ice 06 the County Reg-is.ten o6 Veeds, as Vocument No. 2 30. 3 ) . SIGNATURE Olt OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED G-2-S C DATE SIGNED DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982. THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED REGISTERS OFFICE �it�3�.3ta @OOK .�"E d)t) ST. CROIX CO.. WI& 7 0 PA Recd. for Record INs . 5th This Deed, made between ....Virginia M. Hanson-...a day of �( ch A.D. 1987 .........single woman ............ ......• -•......... .... of 11:45 A a NL ................................................................................................................ ........, Grantor, + James O'Connell and....................SM.Mil:ler,---ddb/aL-Sam.Mill,er--Conmtruction_-•, 1• W. DOW ......................... ................................... ..... ..... ..... ..... ....- .-•- . '' deputy ......................... Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... �! .........................One...C1011 4.r..and..Qt)i.er._vai al? 8_.con ideration.. ;i RETURN TO conveys to Grantee the following described real estate in ......... County, State of Wisconsin: Tax Parcel No: ................................... Part of the SW+ of the SWJ of Section 21-29-19, described as follows: Lots 5, 6, 7, and 8, Certified Survey Map filed November 19, 1986, in Volume 116t1, Certified Survey Maps, page 1747, as Document #419479. Subject to recorded easements, reservations, and rights of way. � Zi Ov , es This .........its..not....... 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....7... ..................................................................... SEAL }y� SEAL) f rginia M. Hanson I .................................................................. ............................................................. I, ..(SEAL) ......(SEAL) • M i I AUTHENTICATION ACKNOWLEDGMENT ' Signature(s) ......virgins#..M,..HA.Il•nQn.................. STATE OF WISCONSIN ........................................................•-................._.... _ St. Croix . . .March......................County. authenticated this Ath.day of.....March ., 19 87. Personally came before me this ._ th.......day of ..........................................1 19....7. the above named ........................•------..............-------••---........---------...--- Virginia M Hanson • Eric J. Lundell ...........-.1�.._......•......................................................••. ........................................................••...........---...... ---•--............................---........................................... TITLE: MEMBER STATE BAR OF WISCONSIN ..................................................... .... . ..n- ......-----... (If not. ............................................................ authorized by $ 706.06, Wis. Stats.) ................................................. ���(� ,....:........ to me known to be the person ...:.�,y... who a xecuted�the foregoing instrument nn ckn0: ),edge t)ro•same. THIS INSTRUMENT WAS DRAFTED BY v �. Eric J. Lundell * nn . New Richmond,..WL.S.�!0� �.._.... - Notary .............. Public ....... t.l...Groix',;:G/ Conntyl'Wis. (Sigrintures may be authenticated or acknowledged. Both My Commission is permanent.(if'npE���ttMte expiration are not necessary.) date: 1 y\ _::,'19.� .) •Names of persons signing in any capacity should be typed or printed below their signatures. d STATE. RAR OF WISCONSIN H.CMMIh.Canparry FORhl No. 1-1982 Stock No. 13001 H z rn H 9 r ST C - 105 r" 9 H SEPTIC TANK MAINTENANCE AGREEMENT p y St . Croix County z * d 9 H OWNER/BUYER SG7-✓n ROUTE/BOX NUMBER (� zoX �8'^Z Fire Number CITY/STATE 14"LScnn (-"JT-o ZIP PROPERTY LOCATION : S4/�, s� > Section OL / T_1N , R/<- Town of St . Croix County , Subdivisions pips GLA Lot number-'g I 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 H three year expiration . 0 E z I/WE, the undersigned , have read the above requirements and agree v, x to maintain the private sewage disposal system in accordance with H the standards set forth, herein, as set by the Wisconsin Depart- 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 . SIGNE DATE 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- SBA - 6395 To a,co'ti fete and accu ate soil test, our re ort p f Y P Must it-4oi.ude: 1. Complete legal description; 2. The use section must.clearl*�indicate vvh th(,r'th, .fs�"residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement systern; 5."Complete e str tabitly rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE R�,61L;ED OUT BAS ED.ON SOIL CONDITIONS; r s. PLEA$E.userthe abbreviations shown here four writing Vrofile descriptions and completing the plot plan; p y. MAKE A LEGIBLE cliagrrn accurately locating your test locations. Drawing to scale is preferred. A 0T)arate sheet may be u4d if'desiree)`, . B. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 0. 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 oil�ejaarates',and Textures # Other•Symbols 3, t p st — Stone (over 10") BR — Bedrock cob -- Cobble (3- 10") SS — Sandstone gr --. Gravel (under 3") LS -- Limestone *s — Sand HGW — High Groundwater . cs - Coarse Sand Pprc - Percolation Rate med s Medium Sand W — Well fs Fine Sand Bldg — Building is Loamy Sand j ._ Greater Than sl -- Sandy Loam < -.- Less Thai) "I Loam Bn — Brawn psi! — Silt Loam BI .- Blank si — Silt Gy Gray *cl -- Clay Loam Y -- Yellovv scl — Sandy Clay Loarn R -_ Red sic( Silty Clay Loam mot — Mottles sc - Sandy Clay w1 - with sic — Silty Clay fff few,fine, faint F c Olay ce common, coarse t f�C — Peat mm — Many, medium ". ey rn Muck d — distinct p — prominent HWL — Hi0h water level, Six general soil textures st*face water for liquid waste disposal M• BM — Bench Mark , VRP -- Vertical Reference Point ` a Y'y TO,TH OWN 'Fi. : This soil test report is the first step in securing a sanitary permit. The county or the Department may rectuest verification of this soil test in tine field prior to permit issuance. A complete set of plans for the }private sevvace system and a permit applicat:iDn must: be submitted to the appropriate local authority in order, to obtain a perni,t.''The stnitary perrnii mast be cbtar+re.j and posted p for to ttne start of arry construction. SAFETY& BUILDINGS DEPARTMENT OF REPORT ON SOIL BORINGS AND DIVISION INDUSTRY, P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON,WI 53707 HUMAN RELATIONS (H63.09(1)&Chapter 145.045) LOCATION:, SECTION: TOWNSHIP LOT NO.:BLK.NO.: SUBDIVISION N/AME: � Su! 11 w'14 a� I /Tay N/R 1?,(or)W S 0AJ F Gd f COU TY: OWNER'S BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL SCRIPTION: PROFILED SCRIPTIONS: ER O ATIONTESTS: A.Residence / New ❑Replace d/� Q i f RATING:S=Site suitable for system U=Site unsuitable for system �Q�j- �� �/ & !4� r',,-*,J',SONVENTIONAL: MOUN�.❑� IN G®� P��RE: SYSTEM-I L H DING TANK:RECOio�a N S,dµa(optional) • IILL��} DESIGN RATE:. If an oorrL��tionn of the tested area is in the u Percolation Tests are NOT required Y P A under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: /Y P FI E DESCRIPTIONS RING TOTALO G PTH TO NOUM ER DEPTH.AW ELEVATION D O SERVED GROU EST. IGHEST TO BEDROCK IF OBSERVED I H(S(SEE ABBRV.ON BACK.)EXTURE,AND DEPTH B- .�' d •l� awe 7 ��' l� 811 . Y S;i .; B- Y 9.of /oY.V 7 d,4� AW&L .s' s-/ s a.3 B-_�r •O r /0.r,41 deje, 7 9. 01 ) S r B- PERCOLATION TESTS TEST DE WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE ER INCH ES NUMBER +h19tFEB AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R P_ <? S,o' 0 3 6 c 3 P_ 1 /CIO 10_ o 3 �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. Sho rface elevation at all borings and the direction and percent of land slope. 1 SYSTEM ELEVATION__.____._.. tN . w _.m 77 i i- m� w 1 I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the proce ur 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: P6-PC ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 0 / 7/f-316- d' CST S TUBE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER— SQvn Wlller jczC-© b 's 10AA , ng IO-r # S "mss v s�'a rm . uC J GrL Il , N 40, -C 6 s � r + 4 r rr Ad I o r r P -• -v w JA Pp � P O P P I 0 ins-- r 2s. .. ` 5a ,M W, o- r i Jc�cob5. Ic,V\atVNJ tI ' Sys ta.� �' r L2G2hc� 22zz - e•Yn- ; ,,,,ey c� 1' lot 'P i P d ..17QZ 2s' E/ VZ- 4-,r e- s C firms t la o ito 00 ON NAd-; -s m a ll C L.t o r% Lip S), p d- Siena_ to b ll, �a1 ut�amanl s. d X LLA 3 d J s