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HomeMy WebLinkAbout030-1017-70-300 � o oH � M c c 4 0 L c .3 o v c io m M +_ x a L' � � c i 0 w.p o U 'o m U N ° L o Z c o 7 N 0 � i U. 01 t O Q LL M Z jry z w O` Z .- N w a m U.) z o I c o z 0 Z V o y Z m Z o cn (D m cm 7 n d p O Z m z w N p Z N d = c 00 'R E y N r G ; f0 �' 0 IL O O. •' L C n N @ O :A L) U) NJ 55 z Q N o o oaaa CL m in J V ono ono y y rn rn � N r d E d 7 C m N _O co d Q O o 00 a H V! LO O C3 O W C C V a 0 0 o CD -O N N v p n rn H O y c 4 N O N C 00 N U Z n 00 Hi N 0 y LO .�.. 4) E L M � Cl c O U O O (n Co 0 0 Z � rL' Cn Ca 4j r+ a 3 #6 a L:CL .. •2 c �1 A 0CL2 Omci Parcel #: 030-1017-70-300 02/18/2005 10:37 AM PAGE 1 OF 1 Alt.Parcel#: 05.29.19.74J 030-TOWN OF SAINT JOSEPH Current X, ST.CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): "=Current Owner BLIVEN,TEDDY R&JANET A TEDDY R&JANET A BLIVEN 487 BLUEBIRD DR HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description "487 BLUEBIRD DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.510 Plat: N/A-NOT AVAILABLE SEC 5 T29N R19W NE NE 3.51AC THAT PART Block/Condo Bldg: OF LOT 2 CSM 6/1773 NOW KNOWN AS LOT 1 CSM 7/1812 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 05-29N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 779/630 2004 SUMMARY Bill M Fair Market Value: Assessed with: 4841 234,900 Valuations: Last Changed: 07/07/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.510 81,700 149,400 231,100 NO Totals for 2004: General Property 3.510 81,700 149,400 231,100 Woodland 0.000 0 0 Totals for 2003: General Property 3.510 47,900 121,400 169,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 127 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 } I � r PUMP CHAMBER y � Manufacturer: Liquid Capacity: R 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,Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL .ABSORPTION SYSTEM Bed: X Trench: Width: 15-0 Length: -0:' Number of Lines: 3 Area Built: bZ Fill depth to top of pipe: ++ Number of feet from nearest property line: Front- ,I_C�O. Side, O Rear, .9�-' 6 Number of feet from well: No i i Number of feet from building: 54 'a" (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). r 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, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: / Inspector: Dated: �l �b �� Plumber on job: License Number: 0? s X13 5 yv2 3/84:mj f r Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP. Jo SEC. .j T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN c2 SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I CLUE � ' Nf EQ N INDICAT NORTH ARROW BENCHMARK: Describe the vertical reference point used j",T w �;Iw_ Elevation of vertical reference point: fG .CC? Proposed slope at site: ' SEPTIC TANK: Manufacturer: Liquid Capacity: /Wb Number of rings used: �_ Tank manhole cover elevation: 910- 17 Tank Inlet Elevation: 23J4 Tank Outlet Elevation: 93-85 Number of feet from nearest Road: Front,0Side10 Rear, © ov£Ie107� feet From nearest property line Front,0 Side,0 Rear,0 ©Q&IL /X r feet Number of feet from: well Ajb W6y, , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE I DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION MADISON,,W WI 537,07 P.O.BOX BUREAU OF PLUMBING NEB-;If'Ek,S5,T29N-R19W CONVENTIONAL ❑ALTERNATIVE I State 118a umber • ♦ Ilf a..ilI dl Town of St. Joseph ❑Holding Tank ❑ In-Ground Pressure ❑Mound Blud Bird Drive NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Teddry R. Bliven 208 Wisconsin Street North, Hudson, WI 4016 BENCH MARK(Permanent reference Point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: imp/MPRSW No. Coumy: Sanitary Permit Number: Thomas H. Cody 6593 St. Croix 99058 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: 1 ?5 . 4s . NYES ONO ❑YES nNO BEDDING: VENT DIA.: VENT MAT L: HIGH WATER NUMBER CIF ROAD PROPERTY .. WELL: BUILDING: VENT TO FRESH / ALARM_ LI ` r AIR INLET: FEET FROM OYES NO L1 C f ❑YES NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO 10YES ONO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER I OF !PROPERTY WELL. BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. PUMP ON AND OFF) ❑YES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BE01T EWCF1 WIDTH � ILENGTHL N ]IIITR CING COVER UE DIA #PITS LIQUID Q a 3 TRENCMATERIAL: DEPTH: gggEEE GRAVEL DEPTH FILL DEPTH DISTR,PIPE DISTR.PIPE DISTR.PIPE MATERIAL NO.DI R NUMBER'OF PROPERTY WELL �11UILD G: VENT TSH BELOW PIPES / (� ABOVE COVER. ELEV.INLET E END, PIP LI FEET FROM �) L / 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- ❑YES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER ITEXTU RE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED SEEDED. MULCHED.. CENTER. EDGES. [:]YES ONO ❑YES ONO IOYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BECREIVCFF` WIDTH: LENGTH TRENCHES: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: J MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. JDISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV.: ELEV.: DIA.: ELEV. PIPES. DIA.: �35 'FFfB�iT1�N �1FM4QN HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED TT of 11 PLANS. OYES ❑NO ❑YES ONO COMMENTS: I C Qi PERMANENT MARKERS: OBSERVATION WELLS: N 3MBE CfF PR OPERTY WELL: BUILDING:0 9S f""E"ER�F F#?E)I4I i LINE: ❑YE NO DYE S ❑NO tIA R ' B' S� O JJ 4 , Sketch System on in in county file for audit. Reverse Side. SIGNAT TITLE: Zoning Administrator DILHR SBD 6710 (R.01/82) T 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 pLmper'-whenever necessary, usually every"2t6.3 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: 1. 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; I X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'%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. ' ' s ♦ a ------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 atef included the creation of surcharges (fees) for a number of regulated practices which Wisco iCl'S o can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasutt3 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. 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) N COUNTY SANITARY PERMIT APPLICATION TDILHR In accord with ILHR 83.05,Wis.Adm.Code x STATE SANITARY PERMIT# ' 0 Attagfi complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER ` 8%x 11 inchbs 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 -e U-ah (1 '/4 �'/a, S T o� , N, R ( 9Y E (or) PRO PERTY OW ER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER 71 CITY fi NEni ST RO LAKE OR NDMARK O VILLAGE: sl- ('� f,(�4 �f r . 11. TYPE OF BUILDING OR USE SERVED: '/&` 0�-- /0/7- 76-200 Number of Bedrooms if 1 or 2 Family 3 OR Public S ecif : y (Specify): Y) III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable) 1. a. [:�New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. i 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. ❑ See a e Pit 2. PER OLATION RATE -3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minute2s per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): ?� Feet Private ❑Joint Public VI. TANK CAPACITY Site in gallons Total ##of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank Q-� � e/' ❑ ❑ 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): Plum s Signal ur :(No St mp PRSW No.: Business Phone Number: I s Address(Street,City,S te, C de): Name of Designer: Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# elnvlas A CG�� o � � 151q CS s ADDRESS(Street,City,State,Zip Cod Phone Number: 111(, f-4(4 ,a, (,,fit . 5uo�,� '2 IX. COUNTY/DEPARTMENT USE ONLY �j Disapproved Sanitary Permit Fee Groundwater ate FeAay.,,,j uing Agent Signature(No Stamps) VJ Approved ❑ Owner Given Initial ja'^, ^ S rcharge�F�ee Q �/y] Adverse Determination I C�v`0V . � _g ° r 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 Location of Property (JE _�L /�) , Section , TAN-R l 7 W Township S-- Z S-.2 _. nh Mailing Address zr a J*Jo W' S c- r c SC, lU:�,, Address of Site R z Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created OR , Are all corners and lot lines identifiable? Y, Yes No Is this property being developed for resale (spec house) ? Yes No Volume -7 and Page Number 1St-_> as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and pa&e 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) ceAti6y that a t atatement/s on this bofcm cute ttcue to the best of my (oun) knowtedg e; that 1 (we) am (aAe) the owneA(.$) o6 the pno pent y des cA bed in this .i,ngoAmati,on 4onm, by vZLtue o5 a waAAanty deed neconded in the 044.ice o6 the County Reg.usten o6 Deeds as Document No. Zoo ; and that I (We) pnesenty own the ptopos ed site jo,% the sewage d.Ls poz at system (o L I (we) have obtained an easement, to nun with the above desni.bed pnope%ty, bon the constcucti.on ob said zyhtem, and the same has been duty Aeconded in the O{yb.ice o4 the County Register ob Deeds, as Document No. 4 Z G 2 c,c-, ) . SIGNATURE OF OWNER �GNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED + 3 Pa • -DOCUMeN-r NO. STATE BAR OF WISCONSIN'FORM 1-19M THIS OFACR R"19"'m an RECORD'He OATH /� n(�} WARRANTY DEED �• 42C201 GC 6,7 ��PA�.6tj REGSTERS OFFICE Dean K. Lindstrcan and_ ST.CROIX CO. W I T� - --------•---•-•----• -----------• S. I�ndal�D nan��lwus�aiLd•-avid-wife; -•----...... Rec'd.for Record this 28th .............-............................................................................................•..... day of rtay A.D. 19s7 -•-- •--------•--•••••-------------------------•-------.......------ Grantor, and Y-R.•-B11 VeIl_atld-JaTbet-A.--B11vP11r 1?�]sba[1d alld_._.•. ; � wife-as-survivorship marital..prgperty= l ....-•-•--------•------------------•----••----•-•-••---.....-•--•-------.._.._........._•-•••••-•----••-•--_----- � s .............•---•--................................----......-•--•-••-------•-•-----•-•-----••...I Grantee, Witnesseth,That the said Grantor,for a valuable consideration..._.. of one collar and other valuable consideration -----•------•------......•....................•-----•-•---•-------•--...............-------•-•--....---------_.. St ---•••---•••-- RETURN TO conveys to Grantee the following described real estate in ... •..C1X County, State of Wisconsin: Tax Parcel No:_._•-•-•.............•••°--.--...- Part of the NE 1/4 of NE 1/4 of Section 5, Township 29 North, Range 19 West described as follows: Lot 1 of Certified Survey Map filed May 12, 1987 in Volume "7" of C.S.M., Page 1812. This -----ls_. t...._..... homestead property. (is) (ie not) Together with all anA tOhd ere � apd n Onnces thereunto belonging; And....- K... LC ...... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and covenants of record, if any, and will warrant and defend the same. Datedthis ............26th........................... day of ......_�y.....-----------....................................... 19.87... .....................................................................(SEAL) '.. .....__............. SEAL) r r Dean K. Llrfdstroall .................................................................. - ......(SEAL) .....................................................................(SEAL) _ �-�4�63.r__`.__. . C:(�x4�•�S.-i?:f'►�/ ♦ r Linda C. Lindstrom _....__...._....._.-°---.....----•-•............................. .-°---------.........°--••-----.............................._.. AUTHENTICATION ACKNOWLEE16MXN1T Signature(a) ............................................................ STATE OF WISCONSIN q, V -----------------•---------•--------•--.-...-.._..........._•••••-••--....._..._ St. ...............-C---•---•--roix............count . d o`#.. authenticated this .-......day of........................... 19....-. Personally came before mew .,;.day of .......... DSF,n STATE BAS OF WISCONSIN z y ST C - 105 r r ;v H SEPTIC TANK MAINTENANCE AGREEMENT H 0 St . Croix County z d OWNER/BUXER ! i�s__ J o Rai _ ___�` _,i.�� �P►.oH.�' 3$�-1Zl / ROUTE/BOX NUMBER�o_gi �o�y Rai �Q Fire Number _ • CITY/STATE �(�,� gC,N W= ZIP PROPERTY LOCATION : Section S T_21 N , Rtq__W, Town of `�a�;c St . Croix County , Subdivision � h s cd Lot number 1_. 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. 0 E I/WE, the undersigned , have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth , herein , as set by the Wisconsin Depart- v 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 . SIGNED », DATE_f 12-, �_Z : 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 . INDUS DEPARTMENTOF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS INDUSTRY, DIVISION LABOR AN P.O.BOX 769 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON,WI 537907 (1-163.090)&Chapter 145.045) LOCATION, SECTION: E / S �1 OWNSHIPAMW OT NO BLK.NQ:SUBDI Yy j? NA��,�y/ID?N/R -A T&S lt/ it COUNTY: WNER' 8U ER'S NAME: MAILING / IX WaA A dsafn r ll/is .J 1/4,0 USE DATES OBSERVAIfIONS MADE COMM DESCRIPTION] {TION T€S : esidence New ❑Replac R p NO.BE RATING:S-Site suitable for system U-Sit...itable for system (r ,s0 ,_c S-� /d-01.1 ONVENTI NAL: MOUND: IN GROUN -IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(oprio I) ®$ ❑U ©$ ❑U ®$ ❑U 705 NQ I [IS ®U II Pamela ion T.us ara NOT rayuired DESIGN RATE: If any portion of the tested area is in the under 0463.091511W,indicate: �/� Floodplain,indicate Floodplain elevation: PR IL DESCRIPTIONS 80HING TOTAL.ELEVATION R A I R- CHARACTER F SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH l NUMBER DEPIIi Q/ p g V H TO BEDROCK IF OBSERVED SEE ABBRV.ON BACK.1 B- / ra' 7 8�i rPB//, /./ 6.r/, /C �rr Si/f, /•y�r t, B_ / I/• t Qn• ' �n Sr.tij B- y 8•�' 96.9' d4Q a .o' �6//• �i �s 'y sad ., ro Ar 90- f, B'S r0' 9Cr �d�� o' •8 X08,./, •s�•/.r, s.� Alsip-/i s• PERCOLATION TESTS TEST DEPTH/ WATER IN HOLE TEST TIME DROP IN WA TER LEVEL-INCHES RATE MINUTES NUMBER iOiCiifiB AFTERSWELLING INTERVAL-MIN. PER INCH P 3' 0 6 G P- P• 3 P` o G3 P_ P_ - ._... ... _ P__ i 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 plpn.Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION S' V¢'r I_ Rcoqs 4) NV i IF i 1. iV[f-{.real A �^ 1,the undersigned,hereby certify that the soil tests reported on this form were made by me Ina oord wil h the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME print : / TESTS WERE-9MPLETEO ON: e r �/l s Y-.2 7- Jo? ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER Ioptionall: CST TUBE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBO 6395 JR.02182) -OVER- I INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 a To he 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; . Is this a new or replacement systerrr; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; S. Make wire your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete all appropriate boxes as to dates, names,addresses,flood plain data, percolation test exemp- tion, i;appropriate; 10. If the information (such as flood plain,elevation)does not amply, place N,A, in the appropriate box; 11. Sign the form and Place your current address and your certification number; 12. ilflake legible copies and distribute as rerluired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Scan Separates and Textures tuber Symbols St Stone {over 10") BR - Bedrock cot) Cobble (3- 10") SS -- Sandstone gr - Gravel (under 3") LS - Limestone *s - Sand H G W - High Groundwater cs Coarse Sand Perc ._. Percolations Rate rned s - Medium Sand W - VIVell f File Sand Bldg - Building Is Loamy Sand � --- Greater Than sl Sandy Loarn --- Less Than 'I Loam Bn - Brown sil - Silt Loanr E31 - Black si Sill Gy° - Gras cl - Clay Loam YellotV scl - Sandy Clay Loam R _ Red sicl - Silty Clay Loam plot - Mottles' sc Sarrdy Clay w/ ... ;rr+tla sic - Silty Clay fff --. fow,fine, faint C -- Clay cc -- common,coarse Nt _ Peat ruin - .Many, rnediu€n rn Muck d distinct �q p - p ominent HWL High water level, Six general soil textures surface water for liquid waste,disposal BM Bench Mark VRP ._ Vertical Reference Point TO THE: OWNER: so'! rest report is the first SLE'pa in securing a sanitary permit. The county or the Department may request this sail test in lhrr field prig w tiernrt issuance, A eomplE t+,, sei of plans for the private r'3 njicitl`.?#1 musi' ,")E $UI}r7ietl:ed LG the e9p3i3IL,?prtitE? lt)Cal 8L1t.liQ1"ity in Ordt:',r to3 l " s-ar)Oary p t r snit rr"ust bre and pzrSteri f.riE,; 0 the start of any c.ai=st ructirrra. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS DIVISION INDUSTRY, C LABOR AND PERCOLATION TESTS (115) MADISON WI 3707 HUMAN F(ELATION`S a (H63.0911) &Chapter 145.045) LOCATION. vSECTION: TOWNSHIP/AA LOT NO.:BLK.NO.: Sl1�BBDDVIS�O0�N„AN N� '/4 1/ � — s..•,�C sra� !/lw�B�d o.. COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: // 5)6 Cvt,� 434n0 L��1 s �o�t / al '7 A Gvts USE DATES OBSERVA IONS MADE NO,BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLATION TESTS: Residence t' New ❑Replace I j/) y_,y_� S/9 �/ J RATING:S=Site suitable for system U=Site unsuitable for system !G ,s0 l/PC i•I;,L CO®ENTIO1U. M©S.aU IN G®� ❑U RE: SYSETEM-1®ILL H❑SGC U RECOMMENDED vsTEM:(option�l) / •x36' If Percolation Tests are NOT required DESIGN RAT I If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: PRO,IV DESCRIPTIONS BORING TOTAL/ DEPTH TO GROUNDWATER- CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER jDEPTHoIPK7 ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) . 6 8 /� // 601/, /, O 017 Aej5 s /.3 B.z /� / B- 7.S' 96 d, ld 7 S S!o Bn r S •(0 8//, Br, 1, .3 Bn V f-/s, Y.2 Bn 0 I ?6, 7 , /lil dill 7 �.0 �9 8//, /• l Bn/ • �/ 6� /s .f v Bti I /si B- Y g, ` B s too Ix B- PERCOLATION TESTS TEST DEPTHS WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER LWG " AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 FER1003 PER INCH P_ / y 3' 0 a 16 G 3 P- 3 ,S' Ala 1 ( � P- I f PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or dist+eefi. Descril?,yvhat a harj_,� zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the •�iurtctip"'n an percent of land slope. V t� VAT E SYSTEM ELEVATION_ _ T-1 -I-- F 3_ F 1 r ._ _../� F! _ > tut t N a 30 1 Sf �t i V,4 4`e.4/.`eA/ Ao J'n 1,the undersigned,hereby certify that the soil tests reported on this form were made by me in abcord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): // TESTS WERE�C�ppMPLETED ON: 4;:, Y=.2 7- J' ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): vc, .s'% CST TUBE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395`R.02/82) ! — OVER ` 1 i � f — San. Permit No. i Owner's name H63.05 PLOT PLAN • Stow: `- 1 ✓!� Location of building served NN Dosing chamber Vertical/horizontal reference point Septic tank Z.S 9� Building sewer ✓ System elevation is q Effluent system Well rt lines w/in 50' of system IF Replacement system area N A Pro Pe y - L40 or dimensioned Scale - 1JA Distribution boxes ✓ ----- NA Pump and controls: -- Size Force Main Mfr. & Model No. Vertical Lift Friction Loss T, D. H. Vol. Dist. Pipe Gal. per Min. Gal. per Cycle Place check mark in appropriate box, indicating item is shown on plot plan Ibelow: $LVEB 1R,p 70Y,L V C L.aT L,J N E �$M- EL,10o.00�ON 1�� B� BS NV-LNr.1 IP!t-E i hC.EF16vT PtR� .D �m L viZNT 3 I6 1 b 3' y''PEA�otZAZE� J I O1STi2aev�ory P��S a a21 i � N �t_L SE('$itC`+�S 1�RE 617 �R 6 �ttc� 83. 1 C �� gT Cpirx��zS w�7u_Zb LiE P\T L-L ST S6' FFI3 1 pQ A IN F�E1 p Pic,JD ^Ir t�'R Sl" �{5r of y`PVC Sou DiuR�-t- P)PE 1Doo GAL w��Se;R S "'�� GOa�CCZETE SEp�C �TCN\C lo�OF4leax „ �ovs` r �n By the granting or approving of the above plan, or upon the event of a subsequent permit being issued,St.Croix County and the St.CTOix�County Zoning Administrator, lans or specifications, plan not assume or hold itself liable for any defects in p om.iss'on, examination oversight, construction, or any damage that may result in or a-f to 'nstalla ion. �l ' 2 -- ----- - ----- LIc r it - - CROSS SECTIDU OF A BED SYSTEM �11J�Sl1C"b G�„yoE r—lAJ I S H-6b G ODE r a— SOIL FILL OF AGGREGATE yet-�C DISTRI6UTIOA3 PIPE ApPRovED 5`D/JTHETIC COVE o✓ so �;?� MATERIAL OR 9 OF STRAW OR MARSH ti4Ay ' ° 1 OF%L-ZI/2 AGGREGATE ELEV. OF9esoFEE.T , -�DT'T"OI"� OF eED G -. DISTRIBUTIOIJ PIPE TO BE AT LE0.ST 3 IMCHES BELOW✓ ORIGII.IAI- RADE AIJD AT LEASTLO WCHES BUT AIO MORE THAKI 42- IMC14CS B=LOW FIAIAL GRADE I MAXIMUt% DEP:"H OF EXCAVATIOU FROM ORIGIQAL GRADE VJILL BE :5 1Qc-HES ` MINIMUM DEPTH OF EXCAVATIOU FROM ORIGIUAL GRADE WILL. BE Y� INCH1=5 SIGL.]ED: LICIUSC ►DUMBER: