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S&,, SW 4, Sectlo o f3Richmon
WAYNE T30N-R18W, Town
COLEMAN, y~TY Road
Route 4 ~
i W, 04-
New Richmond, WI 5[017 ` ~~k
r'W
i
a' ~ 5
address of sit same
027 Ypowers5 Jr.
8-5-87 Calvin
Permit No. 9027
C Re acement
8-7-87 Q S (y
INSTALLED'
. 1
PUMP CHAMBER
f ,
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, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: X Trench:
Width: ~2 / Lenth: Number of Lines: Area"Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, ®1Ft._
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size:- Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
i`
Has either a drop box O or distribution box / been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: pacifv:
Number of rings used: Elevation of bottuin of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O S3,de, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
~f
Alarm Manufacturer:
r-
Inspector:
~1J.=~r OS"
Dated: - 1-1a - Plumber on j b:
License Number:
3/84:mj
r
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP ZI o4w-.,O SEC. T .9 N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
1
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
7 9
i) //.1.2 - 9 ~
rip,
d:~S _ g.73
r
INDICATE NORTH ARROW
BENC Describe the vertical reference point used
Elevation of vertical reference point: ZX -2 Proposed slope at site:
SEPTIC TANK: Manufacturer:/L c• z/ iquid Capacity: /
IL2d ,o-
Number of rings used: Tank manhole cover elevation: 99 ~,2
Tank Inlet Elevation: ?7-/ Tank Outlet Elevation: y, 00
Number of feet from nearest Road: Front ,Q Side0 Rear, O ~L feet
From nearest property line Front,OSide,ORear,~ feet
Number of feet from: welly, building: X2
(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, W''I 53707
SE4,'SW4, S3,T30N-R18W JACONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number:
(1f assigned)
Town of Richmond ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
CTY Road A
NAME OF PERMIT HOLDER: 7ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Wayne Coleman Route 4, New Richmond,WI 54017 T 9 7 ,J v
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV..
Name of Plumber: MP/MPRSW No.. County Sanitary Permit Number:
Calvin Powers Jr. 1563 St. Croix 99027
SEPTIC TANK/HOLDING TANK:
ELE V.TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
ET
MANUFACTURER: UQU ID CAPACITY. 141(~L
PROV DED: PROVIDED:
76 YES ❑NO ❑YES NO
BEDDING: VENT DIA.: VEN MATE. : IH113HVVATEFI NUMBER OF ROAD: PROPERTY WELL: BUILDING: IVENT TO FRESH
ALARM' FEET FROM / LINE AIR INLET
❑YES NNO ❑YES ❑NO NEAREST
DOSING CAMBER:
MANUFACTURER. BEDDING. LIQUID APACITV PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
[::]YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING. VENTTOFR ESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET.
PUMP ON AND OFF) ❑YES ❑NO NEAREST III,
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing uTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE JLF the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH: LENGTH NO. OF DISTR. PIPE SPACING. COVER INSIDE DIA #PITS: LIQUID
BED/TRENCH TRENCHES M EE IT DEPTH:
DIMENSIONS ERIA
I _L,
GRAVEL DEPTH / FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DI RR OF PROPERTY WELL BUILDINGI VENTTO FR H 1j 1 BELOW PIPES REqVINLE
ELEV. END~ PIPES ROM LINE: AIR 'Id
T-i► I g o 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.
❑YES ❑NO
SOIL COVER TEXTURE 4SODDED ANENT MARKERS OBSERVATION WELLS.
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SEEDEDM ULCHEDCENTEREDGES❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER:
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.. ELEV.. DIA.. ELEV.. PIPES. DIA.:
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY JCOVER MATERIAL PLANS.
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑YES ❑NO ❑YES ❑NO NEAREST
Sketch System on twin-in county file for audit.
Reverse Side.
SIGNATUR ~ TITLE:
DILHR SBD 6710 (R.01/82) ZOniri Arimj
strator
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 b the permit issuing
authority. Anew permit m
by ay 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
I
State of Wisconsin Bureau of Plumbin9608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property 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 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'h 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 Groundwater =
included the creation of surcharges (fees) for a number of regulated practices which VViscor#vsin's a
can effect groundwater. The surcharg+- took effect on July 1, 1984. All of the water that buried 'reasure i
is used in your building is returned to the groundwater through your soil absorption
system or the disposal site used by your holding tank purnper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- f
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
Si3D-6398 (R.93%86)
D'LH~ SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code 5 / • C ,4~v/ X'
s.. STATE ANITARY PERMIT #
9va >
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
'
8z 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
PROPE TY OWNER PROPERTY LOCATION
Z, 6j
'/4 czij '/4, S S U , N, R E (or)(9
A,4V419 4M _510F PRO OWNER'S MAILING ADDRESS LOT N BER BLOCK N BER SUBDIVI ON NAME
CIT , STAT ZIP CODE PHONE NUMB R CITY NEAREST ROAD, L KE OR ~AN Nu1RK
El VILLAGE :
.0 h 2Z "T ~(7/s,13L,2L4d( ITOWWOR 1- 4112
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. 0 Replacement c. ❑ Replacement of d. ❑ Reconnection of e. E1 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. X Conventional b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. E1 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. 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:
(Min tes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
r o7 r
/ Feet L9 Private ❑ Joint Public
VI. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank S
Lift Pump Tank/Si hon Chamber El Li ❑
VII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plum er's ame (Pr'nt), Plu Pr's 'gnat Sta ps) MP/MPRSW No.: Business Phone Number:
f
um is Add ess ( treet, Cit State, Zip Code): Name of Designer:
VIII. SOIL TEST INFORMATION
Certifi Soi Tester (C ) Name / CST #
i
CS D RESS (S eet, ity, St e, ip Code) Phone Number:
Aay (7Z
ilk)
IX. COUNTY/DEPART ENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
Approved F-1 Owner Given initial S rcha ge Fee/ ~fy)
Adverse Determination
~ M I ' ,Cr ~ F7 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
I
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 MA!
Location of Property Section T- 32 N-RW
Township
Mailing Address
9-hl 7
Address of Site T_r
Subdivision Name
.Lot Number
Previous Owner of Property ;UZZ
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume ,Z' 8 and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWIMG:
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 ((ve) eeAti.6y that att statements on this o/un are true to the beet o6 my (ouh)
.knowledge; that 1 (we) am (are) the owners o the pto
6 pen.ty deseA,i.bed in this
.in6okmati.on 6onm, by viAtue o6 a waAAant deed neeond d '
6 y e in the 066.ice o6 the
ountyy Reg* eh o6 Deeds as Document No. ; and that 1 (We) pheeently
own the pnopoaed site bon the sewage di~spo.a aye em (on I (we) have obtained an
eaaefflent, to nun with the above de cAibed pnopehty, bon the eonatnuetion o6 said
system, and the same has been duly neeohded in the 06 'ee o6 the County Register o6
Veedd, ae Document No.
I
SIGNATURE Op OWNER SI URE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
I
DOCUMENT NO. WARRANTY DEED
STATE OF WISCONSIN-FORM 1
THIS SPACE RESERVED FOR RECORDING DATA
286496
1.4EG15TERS OFFICE
THIS I DENTURE, Made this 29.th..... .day of.-O.C.tO.b.e.r ST. CROIX CO., WIS.
A. D., IEI....b., betweet,A.rth-ur..... J....... Pe.t.er.s-on.. a.nd....Na.rz.ay...G.....................
Pet.erson,--.. h.i , wife • James_ A . Gretz and. Marly I,• Recd for Record this__3191
G.ret-z.,...his...wife;..,E....... H.ol?l ins....a_nd._.M r.en.._T....... day of__ Octobe1966
H.opkns.,....his...wife., at-- -9:-----Ati M.
f u Vg t part and
..................part ie Vf
Wayne._-G...._C-olanan-..and... Erma...J_,..,,C-oleman-,.. anc v~...e.,...a.s..
r.........._ -ei «r I)ePds
part ._.j Q-3-of the second part, RETURN TO
W I t n e s s e t h, That the said part.:i.f'S...of the first part, for and in consideration
of the sum of---Qne.... and..-no/100 1 00
....(..~._...........)....I?o.?..la.x'_..a.nd....o th.e.r......
.._..valuab.le.._cons.ide.1_.a.do_n.:.................. s
to theM........in hand paid by the said parti.e.,cl_of the second part, the receipt whereof is hereby
confessed and acknowledged, ha...V.C.. given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents
(to... give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said partl.e.P...of the second part,th.e JA7rs and assigns
forever, the following described real estate situated in the County of....... S ti....Ci.X.'.alx............. and State of Wisconsin, to-wit:
A parcel of land located in the South one-half' (S,'7) of the Southwest one-
quarter (SW,i-, of Section Three (3), Township Thirty (30) North, Range
Eighteen (18~ West, more fully described as follows: Commencing at the
Northwest corner of the Southwestone-quarter (SWu) of the Southwest one-
quarter (SW-41) of said Section Three (3), said point being in the center of
C.T.H. "A"; thence East along the North line of the South one-half (S2)
Of the Southwest one-quarter (SW,-~~) a distance of 1814 feet to point of
beginning; thence continuing vast along said line a distance of 360 feet
to an iron pipe; thence South at right angles a distance of 660 feet to an
iron pipe; thence West at right angles a distance of 360 feet to an iron
pipe; thence North at right angle;, to point of beginning.
(Revenue St2MPS on reverse side)
(Il NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE)
Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate
right, title, interest, claim or demand whatsoever, of the said part-1.Q. 5)f the first part, either in law or equity, either in possession or expectancy
of, in and to the above bargained premises, and their hereditaments and appurtenances.
To Have and To Hold the said premises as above described with the hereditaments and appurtenances, unto the said part.._the
second part, and to. their heirs and assigns FOItEV1.R.
And the said..A is thui, J...__fe.teraQn, Naricy._G... _ Pe.te.rso.n....... Jatne.s..A.._..Gnetz ,.._Ea.r.ly.s....
E.....Gratz.._E.u;ex:e_.F_...Hopklns_and Marion T . Hopkina.,.....
for.... t}7e)71SC.l.VC 0._.a.Cl .the,1r___heirs, executors and administrators, (to... covenant, grant, bargain, and agree to and
with the said part i.e,)f the second part,.__their. heirs and assigns, that at the time of the unsealing and delivery of these presents
they..... ax'P__.._....w•c•11 seized of the premises above described, as of it good, sure, perfect, absolute and indefeasible estate of inheritance
in the law, in fee simple, and that the same arc free and clear from all incumbrances whatever_._..............
r
Ij
and that the above bargained premises in the quiet and peaceable possession of the said parti.e.S.of the second part,.th_e.deVs and assigns,
against all and every person or pcrsous lawfully claiming the whole or any part thereof,...tb.Q.y_..will forever WARRANT AND DEFEND.
In Witness Whereof, the said p:artiezof the first part ha..1lL'••.hcr nto et.. h.~'.i.X'.hand... and seal_.a__.this_29.th....
day of Octo.be.r_ A. D., 19 ..66_.
4 (2FALI
SIC AND SEALED IN PRESENCE OF 6ASEAL)
_`.....a....c.y...~........et rson........_.
(SEAL)
.._.E.. Nor 7 n.. J.am .i3....A. z..._
(SEAL)
M..._. l,ys....
Mzu een_.Ho?'hbo~tel .
Eugene F,.... iopkins
STATE OF WISCONSIN,
Ss. SEAL
S Count
t-•~
y. Marlon Ohopkin
Personally came before me, this........... ,9.th ............................day of..O.G.rinhex'.................. , A. D„ 19....66.
the above named ...A.r th u.r-„J . ----Peters-on,~,--•Na n.c y....G.E.....Pet.e.rs.an.,....Name.s....A......Gre.tz.,....Ma.rlys....E....
re.tz.,"_APgene...F.~....Hopkins.......and...J4a,r.XAn...T......Hapkina
to me known to be the person.... .....who executed the fore ding instrument and acknowledged the same.
G. E. Norman
NOTARY
• SEAL
This instrument drafted by Notary ..........................County, Wis.
OAaE.. A...KNOWLEt5 My Commission (fd*k9( Is) . Parl:ia rlt
(Beaton 59.51 (1) of the Wisconsin Statutes provides that Nil ins ruments to be recorded shell have plainly printed or typewritten thereon the n
.of the grantors, grNntees, witnesses and notary).
WARRANTY DEED-STATE OF WISCONSIN, FORMWFI PAUE343 H. C• MILLER CO., Ma
z
H
r
S T C - 105 r
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
~ a
H
OWNER/BUYER
ROUTE/BOX NUMBER_ T Fire Number
CITY / S T A T E.J r('r✓JJR9.~.o Gt/ Z I P z/'Jj; ~7
PROPERTY LOCATION: ~ ~4,FLJ_14, Section, T5!0_N, R W,
Town of , St. Croix County,
Subdivision r , Lot number_,V~
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 (I
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
to maintain the private sewage disposal system in accordance with H
the standards set forth, herein, as set by the Wisconsin Depart- 110
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
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.
-tXTIONS FOR COMPLETING FORM 115 - SRC3 - 63
To be a coin and accurate soil test, your must include:
1. complete` Short;
2. The uses dearly indicate whether thi a residence or r _ project;
3. MAXINIUI` er of bedrooms or commert ` planned;
4. Is tht, a cement sy-,, r;
I 5. Co_ , i ratin- A SITE IS:".=_IITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER ARE RULED _.T BASED ON SOIL CONE 14 IONS;
0. r aviations shown here for writing profile dit= is and comt.' the plot plan;
21, diagram accurately locating your test loca Sobs. Drawing to : preferred. A
,:_l it desired;
nark and vertical elevation i, point are cl: permanent;
< riate boxes as to dates, narrtes, ad Messes, flood plain on test exemp-
ch as flood plain, el-, ion) does not apply, place J,A, in the ~,,iopriate box;
~r la, -e your current your certification IlUrnber;
diAtitwte r ired. ALL SOIL TESTS MUST BE FILED WITH THE
WITHIN 3„ COMPLETION.
EVIATIC" ERTIFIED SOIL TESTERS
Ind Textures Other Symbols
S r," {over 10'") BR - Bit~)ck
cobble (3 - 10' , ) SS - ure
er 3LS - L
HGt,/V
Pert;
_ Bloc, J
S - C -
Brtt~
BI
;I! Gy -
- o : R
n~c
Ana. - _ ~
fff
rn m -
n1 - k d - (I it, `
p _ pr :IT
HVVL -..H 'i
~I s sur
r+i BM - B. u'
VRP ~.ce Point
T THE R:
0 to is the first step in secs-h-- permit. The county or Department may request
il test in the field ~ 'rr. t: issuance. A + of plans for the private
-r ap, licat ~n Cted to the I :a1 authority in order to
-r a mit r n, ~1 1, t of any construction.
j
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
dNUUSTRY, DIVISION
LABOR P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: u (.*T OW HIP/Mlf tPALITY: LOT O.:BLK. O.: SUED ISION NAME:
I
COUNTY: OWNE 'S B Y R' ME: MAI G A RESS
i
szaew - I ~z 4, ~ Si6Z; 2
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: ICOMMERAL DESCRIPTION: I PROFI LE DESCRIPTIONS: PERCOLATION TESTS:
Residence ❑ New Replace Il - f -dz
RATING: S= Site suitable for system U= Site unsuitable for system
r ONVEQcNTIO 'AI1L: MOUND: IN-GROUNNcD-PRESSUR_E: SYSTEMc -I -FILLI ULDMcc ANK: RECOMMENDED SYSTEM: optional)
ov ElV ®J ®J OU IDS U 0J ®U
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the 71
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: '44~
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED EST- H GHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 7
age
>S ~00 ;
B gel r
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERT 1 PER10 2 PER PER INCH
P- I MM&
P
P- 3
P-_
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale ou distances: Describe what are the hori
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elev io at all borings and the direction and percent
of land slope. Zza SYSTEM ELEVATION
l `
I '
(
i
I
t 1 t€ 3 ~ 1
t ~
I, the undersigned, hereby certify that the soil tests reported on this form were made by rhe accor wj h the rocedures and ethods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to estof my ge and belief.
NAM pri TESTS WERE COMPLETED ON:
_,9
A[TD E CER IFICAT ON NUMBER: PHONE NUMBER (optional):
CS 1GNA RE:
~V
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) OVER
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Ise
64
pis
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Jlfjdvj ✓e~ ?S ~~P
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PAGE OF
C.rc~SS Szc~l~n o~ t~ ~ei7 Sys~«-~
Fresh Air Inlelc And Observation Pipe
Approved Vent Cap
Mlnlmwn 12 Above
n / Final Grade
20- 42" Above Pipe _ 4" Cad Iron
To Final Grade Vent Pipe
Marsh Hay Or Synthetic Covering
Mln. 2" Aggregate
01stribu Over Pipe Tee
Pip*
pipe - 0 0 0 0 0 -
6" Aggreaote
o Prtoralee Pipe Below
Beneath Pip e
o -C:gIng Terminating At
Bottom Of System
Pir0~~s~t~ r~l~~_I ``gr~.cl<
711
~~eJ•.T tor? ~ '
SOIL FILL
DISTRIBUTI0" PIPE APPROVED S4pltPETIC COVER
MATEIZI^I OR 9" OF STRAW
Z" OF R6GR EtO ATE OR MARSH HAy
o
ELEV, OF26EIET (o~OF%2-Z'/2 AGGREGATE
_
i
DIS-rRIAJTIOIJ PIPE TO BE AT LEAST J~Q WCHES BELOW ORIGIOAL GRADE
AtJU AT LEAST?-0 INCHES BUT AIO MORE THAM 42 IKICNES BELOW FINAL GRADE
MAXIMUM DEPTH OF EXCAVATIOW, FROM OW WAL 6KADF. WILL BE LL_ INCHES
M1141MUM DEPTH OF E'XCAVATjoW fP,0^ O*tGINAL GRAPE WILL BE -Ttle INCHES
SIGUED:
LICEUSE DUMBER:
i
DATE:
110