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Parcel #: 026-1051-70-100 02/20/2007 03:21 PM
PAGE 1 OF 1
Alt. Parcel#: 18.30.18.2670 026-TOWN OF RICHMOND
Current X ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): 0=Current Owner, C=Current Co-Owner
0- DUBOIS,JERRY R&MARY
JERRY R&MARY DUBOIS
1584 95TH ST
NEW RICHMOND WI 54017
Districts: SC =School SP= Special Property Address(es): "=Primary
Type Dist# Description * 1584 95TH ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 10.240 Plat: N/A-NOT AVAILABLE
SEC 18 T3ON R18W 10.24AC LOT 1 OF CSM Block/Condo Bldg:
6/1505 ALSO LOT 1 OF CSM 6/1787
Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
18-30N-18W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 711/165
2007 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 04/22/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 10.240 68,000 196,100 264,100 NO
Totals for 2007:
General Property 10.240 68,000 196,100 264,100
Woodland 0.000 0 0
Totals for 2006:
General Property 10.240 68,000 196,100 264,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 109
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
PUMP CHAMBER `
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
•
Pump off switch eelevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of f,,0.- from nPnre7. r err-' line: Front
�../(Thqide, O , Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORBTION SYSTEM
Bed: Trench: •
C�(�/
Width: Length: / l Number of Lines: Area Built:
Fill depth to top of pipe: S('(!
Number of feet from nearest property line: Front, O Side, O Rear,( Ft
Number of feet from well: C/5^- ICJ/
Number of feet from building: 51,2 - •
(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() or distribution box() been used on any of the above soil
absorbtion sytems? (Check one) .
HOLDING TANK
Manufacturer: _ Capacity:
Number of 'rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, ()Rear, QFt.
_
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
'
Dated: k` ��— !� Plumber on job: /
License Number: L j `
3/84:mj
r
Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
c� TOWNSHIP Loc2,4_____/ .. '' ? SE C. 1)� T kj N-R/9 W
OWNER ����1 �t� �J.a
f
ADDRESS kill 2.t<' ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
iki/
^ 1 �
P
)
sr
Ali
> 0
/7/.
_ 4
2`jLV,N L'
NDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 44-,,; 41
Elevation of vertical reference point: /(4/,,e) Proposed slope at site: 7 �f
SEPTIC TLNK: Manufacturer: iti 't Liquid. Capacity: ftr'7O { Li
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Numbt.r of feet from nearest Road: Front,O Side Rear, O 1/‘I.) feet
From dearest property line : Front,QSide,ORear,O t /L() feet
I)
Number of feet from: well Y(% , building: .
(Include this information of the above plot plan) ( 2 reference dimensions to septic tanld
SEA REVERSE SIDE
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
I„,ABOA&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 7969 BUREAU OF PLUMBING
• MADISON,WI 53707 y�
)>•JCONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number:
(lf assigned)
❑Holding Tank El In-Ground Pressure ❑Mound
/4�7oaO,„/8'
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Jetty Du Bois 704 E. 2nd, New Richmond, WI 54017 �''') -2 1 �� . (-)0
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
NE NW, Section 18, T3ON-R18W, Lot #1, Town ob Richmond .
Name of Plumber: 7MP/MPRSW No.: County: Sanitary Permit Number:
K.Lm O'Connae 3259 St. Cnoix. 88466
SEPTIC TANK/HOLDING TANK: _
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
(y PROVIDED PROVIDED.
0 00 7. S0 % 7. 5 3 YVES ONO OYES„--FINO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
/ ALARM FEET FROM /� h LINE _/ 0 O 3 j AIR�rNLET:
OYES NO 1 OYES NO NEAREST-0.- Y V L
DOSING C /AMBER: If
MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL: PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER .
PROVIDED: PROVIDED:
OYES ONO OYES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH.
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) OYES ONO 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: NO.OF DISTR PIPE SPACING. COVER INSIDE DIA. *PITS LIQUID •
BED/TRENCH /2_ / TRENCHES: M TERg au PIT DEPTH
DIMENSIONS /!/" r �,r
GRAVEL DEPTH FILL DEPTH DISTR.PIPE (DISTR.PIPE 1DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES. ABOVE COVER ELEVQI�NJLEeT'.fELpE,V.END: PIPES-- FEET FROM LI 60 _� I S S2. 2 TT
l//p_ 3 -/,1.4 /3.!1 9 2.. 72-.c"/ NEAREST--0-
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.
OYES ONO
OIL COVER JTExTURE: PERMANENT MARKERS OBSERVATION WE LLS
OYES ONO OYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL'. SODDED SEEDED MULCHED
CENTER: EDGES.
DYES El NO OYES ONO OYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. rNO.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
INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
OYES ONO ❑YES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY 'WELL: BUILDING:
FEET FROM LINE:
❑YES ONO OYES ONO NEAREST >
. •-) (2 '7 i
.,.1.
_ /02., . _ (-) .
I:-
-------
Sketch System on " ' ..• y file for audit.
Reverse Side. -age-Aar
SIGNATURE. T
DILHR SBD 6710(R.01/82) ,
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:
! 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, .ndicate 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;
ill. 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 avid/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 81/2 x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss;•pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection !aw. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Ground'. ater---
included the creation of surcharges (tees) for a number cf regulated practices which Wisco
can effect grnundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure 4
is used it your building is returned to the groundwater through your soil absorption
system or the disposal site used by your holding tank pumper.
The monies collected through these surcharges are cred ted to the groundwater fund adminis wr ® ;
terec by the Department of Natural Resources. These funds are used for monitoriu:g ground-
,.ate', groundwater contamination iricestigations and establishment of standards Groundwater,
r.'s worth protecting.
SBD-6398(R.03/86)
d SANITARY PERMIT APPLICATION COUNTY
DILHR In accord with ILHR 83.05,Wis.Adm.Code s ATE t SANITA6 IT#
—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
I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑NO
PROP RTY OWNER PROPERTY LOCATION
�j��y �iu JS z %Ad Y4, S /O T3 , N, R 4 E(ord
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOC UMBER SUBDIVISION NAME
1 70,/‘ c=i21Vo0 0,-,0,,,,A)
1
CI Y,STA ZIP CODE PHONE NUMBER CITY NEAREST ROAD, KE OR LANDMARK
I� ❑ VILLAGE:
�€GI ihmA/n J4 I S-549/7 (Y/c 1.,24-4,25-3? ® TOWN_OF 43'd/1) /,Jdr14) /KI)Ar,D
II. TYPE OF BUILDING OR USE SERVED: /W - /24 — 1051-76/d0
Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): o,
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 art 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. gi Seepage Bed b. ❑Seepage Trench c. ❑Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(S ure Feet): PROPOSED(Square Feet):
3 /4S 1/--25—a? 27 9 Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total #of Prefab. Fiber- Ever.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks �/ strutted
Septic Tank or Holding Tank O1 - up / jA/z"Z.,l s• 0 ❑ ❑ ❑ ❑ ❑
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.
Plumb-is Name(Print): Plumbe 's Signature: No Stag ps) MP/MPRSW No.: Business Phone Number:
/ .1 /,'
f ,,, AP, - A_ ,.,... _•lu ber's •ddrres ( treet,Ci , tate,Zip Code-: Name of Designer:
/T.� /Yih) J&Mif//') /4)Z ,�'S/I/ 7 /)/A
VIII. SOIL TEST INFO MATION
Certified it Tester(CST)Nlame CST#
i P7 CSTs DDRESS S eet City, to Zip Code) Phone Number:
' ( tY. P )
�� �sd //2/4,20/A(.0 1/J,- .i /7 (7/.S"' ) '-/QQI
IX. COUNT /DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
r 1 Approved ❑ Owner Given Initial /�/� Surcharge Fee ,Q� kat!� � � �)Adverse Determination 4°/0 41 S / 5— " 9 c�Cei"t-✓
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
S T C - 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 ,12 ,,i
Location of Property ,4J,4" 21/A) 1, Section 'le' , T,2/9 N-R jg W
Township ,e,%14/ 6a/0
Mailing Address 7f ,,,-;?i °
kJ ,/ //l�,a 4)z 7
Address of Site
2jiW-e!61
Subdivision Name aAP /414„/
Lot Number /
Previous Owner of Property 0,9-007<4/ J r 744jly.4,/,/
Total Size of Parcel 4`/c2 /94 `i
Date Parcel was Created -
Are all corners and lot lines identifiable? Y Yes No
Is this property being developed for resale (spec house) ? Yes >(- No
Volume % and Page Number 45- 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 (We) ce. t,LSy that a.€2 statements on this bonm cute true to the beat ob my (out)
fznow eLedg e; that I (we) am (ate) the awnen(.$) o b the pna pent y de4 ct Lb ed in this
Lnbonmation bonm, by virtue ob a wantanvy deed necotded in the Obbice ob the
County Reg.csaten ob Veeda ass Document No. -=.7 ; and that I (We) pnesen y
awn the pnopased site bat the sewage di�spos 4y� (an I (we) have ob.taLned an
easement, to an with the above de.4cA bed pnapenty, bon the cansttuctLon ob said
system, and the same has been duty necotded in the ()Wee ob the County Regtisten ob
Deeds, as Document No. ) .
SIGH T' F OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
4-m4- r r /9 2
DATE ED DATE SIGNED `�
• DOCUMENT NO. 1* —_--
WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2—1982;;
401593 1
VOL. 711 PAGE j_65
i , --
REGISTERS OFFICE
11 11 Martin J. Germain a/k/a Martin Germain, ' ST. CROIX CO.
a single man, ' WISE
H Recd for Record this 30th
H day of A_ F. r_
A.D19
��11 at 8:30 A
conveys and warrants to Jerry R. DuBois
■
MoNur
RETURN TO
the following described real estate in S.t.._..C:r:.o.j,x. County, i'
State of Wisconsin: ('
Tax Parcel No:
Lot One (1) of the Certified Survey Map filed
on February 12, 1985, in Volume 6 of Certified
Survey Maps on Page 1505, being a part of the
Northeast quarter of the Northwest quarter (NE4 of NW4)
i,, of Section Eighteen (18) , Township Thirty (30) North, Range
i Eighteen (18) West.
;!
$ ' �
9.S.5FE0,
FEE
I
ij
1;
I This 1S not homestead property.
(is) (is not)
Exception to warranties: II
(i
R
1!
Dated this 26th day of April , 19..8.5...
(SEAL) (SEAL)
.. Martin J. G main
(SEAL) - -•a iZ ,./..44/Y1-42-44./- (SEAL)
AUTHENTICATION ACKNOWLEDGMENT I ,
Signature(s) of Martin J. Germain STATE OF WISCONSIN
ss. j
County.
r authenticate this 2 6 thjay of App i.i , 19..8.5 Personally came before me this day of , +
-�" - , 19 the above named
* G. E. Norman
TITLE: MEMBER STATE BAR OF WISCONSIN
fIfnot,- -- - - -- - - - - - - --- - -- - --- ---
authorized-by § '19606,-Wis.-Stats.4 to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
DOAR, DRILL & SKOW,..•5, C,
New Richmond, Wisconsin 54017 * I�
■ Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration �I
are not necessary.) 19 )
{' date:
�∎ *Names of persons signing in any capacity should be typed or printed below their signatures. 11
— —Jj
HGMNIiwCoerKwy STATE BAR OF WISCONSIN t
d FORM No. 2— 1982 Stock No. �3002
�' L,c,.�1�- 1 APRr 19851 .
• 399709
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Vol. 6 Page 1505
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STC - 105 9
H
SEPTIC TANK MAINTENANCE AGREEMENT
St . Croix County
a
�
OWNER/BUYER ^f�j� Y / ,gols
ROUTE/BOX NUMBER JlF AA Fire Number
CITY/STATE 44 ) 4?i/ J/ A/4 ZIP
PROPERTY LOCATION: , ,V 14, Section J,� , T , N, R / W,
Town of i( /11440 , St . Croix County ,
Subdivision ac,(4,9,j41 , 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
I/WE, the undersigned , have read the above requirements and agree
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as set by the Wisconsin Depart-
ment 'v
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 .
P
SIGNED :
DATE / 9r7
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;
?3, 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;
S-. 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. Dr awinrg to scale is preferred. A
. separate sheet may be used it desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
Ii, Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemtr
burr, if appropriate;
10. If the information t:?on (such its flood plain, elevation) does not apply, place NA.in the appropriate box;
11. Sign the form and place your current address and your certification number;
12, Make leyihic copies arid 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
-- Stone (over 10") BR — Bedrock
cob — Cobble (3 - 10") SS -- Sandstone
qr _ Gravel (under 3") LS -- Limestone
s — Sand HEM — High Groundwater
ca -- Coarse Sand Pere - Percolation! Rate
reed .s --- Modium Sand W -- Well
Fine Sand Bldg — Building _—
Is — Loamy Seed ; --- Greaser Thorn
i's! Sandy Loam < — Less Thar,
-- Loan) Bo --- Brown
Sti -- Silt Lorin BI Black
si Sib: (.ty -- Gray
— Clay Loam Y — Yellow
-- Sanity On Loam R --- Had
sick — Silty Clay Loam mat — Met lea
Sandy
-- Silty Clay Of - few, liee, i<unt
e; Clay Ce; ._ common, !.Dense
nt Peer rem — Many, medium
in -- Muck d — distinct
p -- prom me!it
HWL -- High water level,
Six ger:@ nal soil textures San"fa+ce water
liqu id waste disposal BM Bench Mark
VRP -- Verne::l Reference Point
TO THE O W 1i E f
ollers is tee brat step in securing s; r sanitary perm=-t.The county or the Department may request
..,+ -d;la, .i r ref this soil test in the field !anal no permit issuance, A complete set tit plans for the private
c„ieo: rant in permit! atlr,.!Ica_,o.. must be sf, mutted to the appropriate local authority in order to
xposien x permit, The SCrnnt i `f Deifies miter, be rrfr wiled and posted or to the start of any construction.
r
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
F{UMAN RELATIONS
(H63.09(1)& Chapter 145.045)
IT ATION: / SECTION:T� u / r ill IP/M�fVf£tPRtITY: LOT NO.:B�L/K.O. SUBDIVISION NAME:
�//YY)� R Rl�L MAIGADDRESS:• N OWN, / NAME:
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCI L DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence N [ New ❑Replace /„, p 8,7 / Q_A17
RATING:S=Site suitable for system U=Site unsuitable for system g£ Lc tN�� 0,046,p -d4/TZ, ( #'i,a r,)/
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional)
ES ❑U EIS DU ZS DU OS MU EIS DJ .0 df,{)�o��/
If Percolation Tests are NOT require DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate:A/ al9 5 `� Floodplain,indicate Floodplain elevation: A,/,,,...51
d�fr PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTH MI. OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B. ♦ > /- 'i - .'.. :- i' - r - i _ -
i or
011111111111 Al. > r . :_ S .__ /
B-
PERCOLATION TESTS
,oE/'FT
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 1446-1-1-ES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIO 3 PER INCH
P- l -2'1 ��n/2 o / 14 i a
P-.3 ,---,2.-9 Alon/L: 3e9 / // /
P- .s 3- N44/L 3a / '/ 78 .*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. 90'747 �Y. i.Z,(2c
SYSTEM ELEVATION V9
4-4,-dre-ilt / " ---it-Aid' - rzi-4-.e, r2 [ 1 , ,
1
I
1 [
-x�ye�L� R e _ I 6
( 3
°
E � �
/ {
3
{
}
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 (p int): ' , TESTS WERE COMPLETED ON:
i i/ - _40. . ,4- — • - •
Al i•�SS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
•
CST Stir- i „Aim.
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
i 1 DILHR-SBD-6395 (R.02/82) -OVER -
e° ?Ow)80/.5
• 7O I,E,��,�a /W*.A if/�/esee /8; T30A/X2/8 iJ
/YEW 7S/ /7/aNO id"- /1 ia,v/7,a✓,o
s3/oar
)2/77 ai-i.ir
.9.".,,J/e 7_,,,,,,,e_ /000v/
,Z7,47l . /-. 1-S7 ,g-',-sI)O ?S9
/
. _ ------
--,,,__,_
901 06i
-LT-
Vt
90' 4111.424)4L- • 41- 94 3
i
4o/10 )
,G/7 of 90,),,.) /0/
' PAGE OF
CrUSS I�C1iO11 Ot a \ ec) SySl'r'0-1
ifi,,.._ 764&.5
/° 1 /c ,) fresh Air Inlets And Observation Pipe
/ N ^ Approved Vent Cap
41.0 r 704)2 A)).-
///e Minimum 12"Above T
Final Grade
. 20-42"Above Pipe _4"Cod Iron
To Find Grads
Vent Pipe
Marsh Hoy Or Synthetic Covering
win 2"Aggregate
Over Pipe ,
Distribution Itr
`
Distribution t l— —Tee
Pipe
L__1
6"Aggregate o Porto/44J Pipe 131;w
Beneath Pipe
4.....o Cooping Terminating Al
bottom 01 $ystem
-
NO poseD Ina.1 9rhC1� '
1 -- .
•
SOIL FILL
DISTRIBUTION PIPE
APPROVED SI NTHETIC COVER
•
`7 `i':2_. --aMM .'i "----MATER%^I- OR 9" OF STRAW
2"OF AGGREGATE ---------°- 111114) 4) 4) // OR MARSH HAy
MI L.O F!'2-21 2 ...e 8a-
tLEV. OF EET_..
�F
._ fir---. -�
DISTRIBUTIO1J PIPE TO BE AT LEAST _50 INCHES BELOW ORICIIJAL GRADE
AtJU AT LEAST 2.0 INCHES BUT MO MORE THALI H2 IMJCHES BELOW FINAL GRADE
MAXIMUM DEPT H OF E%tAVATIDO FRaii OFlIGWAL 6R'ADE WILL BE 'W FICHES
MIMPWM MEP f$ OF E$CAVATIoIJ fPO! ol'G1aAL GRAPE WILL BE -?() INCHES
9,2-- 1 / /
SIGIJEO: .,..2.., „„,,,,_
,..1-i f ,....! 6
Lac EUSE 1JUMBER: � Z.-%
' DATE: � ,Y g> J
110 .