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r r SURVEYOR'S RECORD
NW CORNER N 1/4 CORNER
SECTION 24 SECTION 24
T30N , R20W 2601. 12 MEASURED T30N , R20W
S 89°24�E (2606.50' RECORDED)
CNORTH LINE OF NW 1/4
POINT OF BEGINNING 1300.56 _
S 89°24'E 1267. 56 r 1300.56
6, 617. 28 : F-
650.28'
3-� 33'
Q oo
1900 °° a / o VAL
2 � 03 M� I
M �. ,..3,;.-4 4 AC ES 09 _M" ICARLSON
N POND a M RIVARD i II
U) � OF 6�N FO
PRIVATE ROAD 8 UTILITIE '� 3
.
Z 11 ui �—'�p„M q �b 00 �Z �ro 'It
(0I
lL
O cD - 9.T RES o 68,9 may.- vi
cD � RIVARD ° NTQo LOT LINE a(p
Rs
Z W N z 01 M 0 OM 6 6 00
-j � M HOUSE S _ 24� �� ro 26X 48' �,,, =a
I- -;45105.5 GARAGE � o M M BASEMENT W 0 (D I {-
cn O � Ro 2 3 9, 3 � �LJ 3 Z 36.5' d 5. 90 ACRES pp QD
NW- NW K UKLIS 30 3
215.5 314.4'
635.40' 629. 34'
PON D WEST 1264.74' 1
LEGEND
O SECTION CORNER MONUMENT 2"x36" PIPE WITH BERNSTEN CAP
• 2" PIPE
O MEANDER CORNER 1"x36" PIPE
SCALE IN FEET
O 1"x24' PIPE
'A FENCE 0 200' 400'
CURVE DATA TABLE
CHORD CHORD CENTRAL TANGENT
CURVE LINE RADIUS LENGTH BEARING ANGLE BEARING
1-2 North Side 375.64' 181.75' S77 000'30"W 280 S63 000'30"W
Centerline 342.64' 165. 78' S77 000130 11W 280 S63 000130 11W
South Side 309.64' 149. 82' S77 000130 11W 280 S63 000130"W
3-4 North Side 167.00' 121. 24' S84 017130 11W 42 034' N74 025130"W
Centerline 200.00' 145.19' S84 017130 11W 42 034' N74 025130 1W
South Side 233. 00' 169. 15' S84 017130 11W 42 034' N74 025' 3011V
5-6 North Side 241.40' 139.83' S88 044120 11W 33 040120" S71°54'10"W *1
Centerline 208.40' 132. 38' S87 003120"W 37 002120" S68°32'10"W 'v
South Side 175.40' 125.2 0' S84039'5 S "W 41° 49 ' 10" S63°45'2 0"W
APPROVAL OF THIS MINOR SUBDfVISION t
A NF",+40VE D DOES NOT MEAN APPROVAL FOR SEPTIC
GT. CF:_.I: •".:.�, � SYSTEM. REFER TO H62.20
cow, ��:. ,'A:'';i I'Lr,iQt'oI:V� 1yI iK" 1 9 1y16 v, O
AtZ LCNING COMMITTEE
Volume 1 Page 217
Parcel #: 030-2034-95-000 01/30/2007 02:43 PM
PAGE 1 OF 1
Alt. Parcel#: 24.30.20.466D 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): O=Current Owner, C=Current Co-Owner
TODD V&TAMI L CHAVEZ O-CHAVEZ,TODD V&TAMI L
1492 23RD ST
HOULTON WI 54082
Districts: SC=School SP=Special Property Address(es): '=Primary
Type Dist# Description * 1492 23RD ST
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 5.900 Plat: N/A-NOT AVAILABLE
SEC 24 T30N R20W NW NW LOT 3 OF CSM Block/Condo Bldg:
1/247
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
24-30N-20W
Notes: Parcel History:
Date Doc# Vol/Page Type
04/29/1998 578067 1318/518 WD
07/23/1997 907/632
07/23/1997 587/152
2006 SUMMARY Bill#: Fair Market Value: Assessed with:
169768 295,900
Valuations: Last Changed: 07/09/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.900 108,200 148,500 256,700 NO
I
I
Totals for 2006:
General Property 5.900 108,200 148,500 256,700
Woodland 0.000 0 0
Totals for 2005:
General Property 5.900 108,200 148,500 256,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 118
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
PUMP CHAMBER
i
Manufacturer: Liquid Capacity:
Pump o Pump/Siphon Manufacturer: P Size
Elevation of inlet. Bottom of tank elevat
Pump off switch elevation: Gallo per cycle: `
Alarm Manufacturer: larm Switch Type:
Number of feet from neares roperty line: Fr O Side, O Rear,0 Ft.
er of feet from well:
Number of feet from building:
(Include distances on plot plan) .
SOIL ABSORPTION SYSTEM
Bed: y L S Trench:
Width: _U Length: Number of Lines: Area Built:-
Fill depth to top of pipe:
a
Number of feet from nearest property line: Front, O Side, O Rear,Pt .
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
EEPAGE PIT
e: Number of pits: Diameter:
Liquid the Bottom of seepage pit elevation:
Area Built:
Has either a drop box O distribution box O been used on any of a above soil
absorbtion sytems? (Check one
HOLDING TANK
Manufacturer: Cap ty:
Number of rings used: Elev on o bottom of tank:
Elevation of inlet:
Number of feet from ne est property line: Front, Side, O Rear, 0Ft.
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:
3/84:mj
Form - STC - 104
Y .
AS BUILT SANITARY SYSTEM REPORT
/J tj T 1f TOWNSHIP v 'J
OWNER ��,�/"�}%1% , � SEC. T31 N-R W
ADDRESS i� ST. CROIX COUNTY, WISCONSIN
I
T
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
6o'
izk/ Xis .� 7% J
j ltN/� ` �� C: f S'&EP.4 C c 13'E0 c
P c
is Y 1
-J
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: �C �, ;t Proposed slope at site:_
S Manufacturer: Liquid Capacity:
Number of rings use -. Tank manhole cover elevation:
Tank Inlet Elevation: Tank Out ion:
Number of feet from neares Front,O Side, O feet
From rest property line Front,O Side,O Rear,O feet
Number of feet from: well , building:
(Include this information of the above plot plan) ( 2 reference dimensions to septic tank)
II SEE REVERSE SIDE
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BOX 1969 BUREAU OF PLUMBING
MADISON,WI 53707 g-g
NW4, W.4,S24, T30N-R20W {CONVENTIONAL El ALTERNATIVE State Pll^nIiD.Number:
Town of St. Joseph ❑Holding Tank El In-Ground Pressure ❑Mound
23rd Street
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Brian Smyth Route 1, Box 422, St. Joseph, WI 54082 lG'15_y �,GCO
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELE V.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Donavin Schmitt i3205 St. Croix 92567
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIOUID CAPACITY TANK INLET ELEV.: ITANKOUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
DYES ONO DYES ❑NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUM OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM'. ROM LINE: AIR INLET:
1:1 YES ONO REST Ille
DOSING CHAMBER:
MANUFACTURER. BEDDING: jLIQUIDCAPAC%jiilFPUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO
OYES ONO DYES 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) 1-1 YES 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
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDT,,, . NO.OF DISTR.PIPE SPACING: COVER INSIDE CIA. *PITS LIQUID
BED/TRENCH TREN S ( I M.JERIAL: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH 1§P IPE DISTR.PIP DISTR.PIPE MATERIAL. NO.D R. NUMBER OF PROPERTY WELL. BU DI G. V NT TO FRE H
SELO�IPfj ABO GQVER. ET ELEV E �� ^ PIP FEET FROM LI � AI♦ LF
,]YIr 4- NEAREST—► M
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
OIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS
El YES 1:1 NO ❑YES 1:1 NO
DEPTH OVER TRENCH111 DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. ISE"U"UOYES MULCHED
CENTER. EDGES:
DYES 1:1 NO 1:1 NO OYES ON 1
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
ELEVATION AND
DISTRIBUTION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION PLANS
❑YES 0 N I I OYES ED NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: INUMBER FEET OF PROPERTY WELL: BUILDING:FROM LINE:
DYES ONO YES NO NEAREST
VAJ
111 r C 2� ❑ ❑
�-
r�
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE TITLE
DILHR SBD 6710(R.01/82) Zoning Administrator I
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT °
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to.this permit.must be approved,by the permit issuing authority. A npw.permit may be needed
if there is a change in your building plans, 10sternib6ation, estimated wastewater flow Inurrlber of beta_'
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 colunty prior to installation;
-
5. Private sews s items must, properly maintained.'•The se tic tanks sk�ould be• m ed b a licensed-
pumper - -• -
9e Y P oP Y P ( ) Pa P Y
whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description where the systenh is to be
installed;
It. 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 81,12 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 groundwateC bill Ground M176
included the creation of surcharges (fees) for a number of regulated practices which Wisco ir1w °
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried TeSSt1tB'
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)
SANITARY PERMIT APPLICATION COUNTY CC -
D�LHR In accord with ILHR 83.05,Wis.Adm.Code srA�ITAR �MIT#
�aCgo
—Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION �
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES N NO
PROPERTY OWNER PROPERTY LOCATION
'/4 '/4, S T.30 N, R t6 E (or
PROPERTY OWNER'S MAILING Ab ESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
IFTI O
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
... ❑ VILLAGE
II. 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.lit 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.
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.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. Xseepage 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(Square Feet): PROPOSED(Square Feet):
17416r 7 X5 9,_3 Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank El ❑ 1 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.
Plumber's Name(Print): Plumb Signature:(No Stamps) SW NoNo• Business Phone Number:
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
D �d
Vlll. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST##
1
CST's ADD E �SS(Street,City,State,Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved I Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
r_1 ��
%Approved Owner Given Initial rcha�r^ge Fee
Adverse Determination Q
X. C MENTS/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
i
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, ("sped
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 i f3- jAi I
Location of Property r Section Oy , TAN-R W
Township 5 - Zu S�=l�l IV
Mailing Address
Address of Site
Subdivision Name
. Lot Number
Previous Owner of Property DAA(YrI ��l�i liLj
Total Size of Parcel t"',
Date Parcel was Created j• 9 Z
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number --,t5:Z as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warrantq 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
1 (We) eentti.6y that aU statements on thi.6 for are true to the best o6 my (ouh)
know.tedge; that I (we) am (ahe) the owner(s the pnopeh ty dens cAi.bed in this
in 6o tmation 6ofim, by viAtue o6 a waAAan ty deed neconded in the O g 6ice o6 the
County Regcs#en ob Veeds as Document Na. _; and that I (We) p4aentty
own the proposed A to bon the sewage d"pos s ys em (on I (we) have obtained an
easement, to nun with the above de cAi,bed pnopeAty, bon the eondtnucti.on o6 said
byb#em, and the same had been dut nec
Veede, ad Voe ment No. onded in the 066�.ce 06 the County Regcdteh o6
/� ) ,
SIGNATURE 476WNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
a:
: ,t V V VQL THIS tirw�E rtEIED FOR
r _
DANIEL D. KJKLIS and CYNTHIA REGISTERS OFD
, ._. 1►. XUKLIS, his wife �__- I ST.CROIX CO., WJS.
_ Rr!c,j. for Record 0....... �>
e1La•�ar e • w.n�s tq £RIAN J. $MYTH and CHERYL_L.-_ - day A.D.Of�""�"" iq Y y
iiMYZ H, h b rla 1 g:r
us a an w e as pint ter.ants 1� of ' A .N� V '
--- - -- . Grantee_
tar•valuable cossideratioa ------_----- -- _-- _-•- aETIM To ��O.�Y•.-j
the following described real estate in__ —County,State of Wisconsin: 'ti�, r M! 1 Se 9-3
Tax Key r ---_-.
s.' This is homestoad property.
Lot 3 of that Certified Survey Map filed in the
office of the Register of Deeds for St. Croix.
County on May 26, 1976 ir-. Vcl. 1, at page 247 , as TRANSFER
Document No. 333150, the same being a part of the
M.4 of the N of Section 24-30-20. 7��
WT ;
TOGETHER WITH and SUBJECT to the road and utilit,•
FEE
easements therein noted, the said eas<-!ments to be
non-exclusive roadway and utility line easements for use by the
Grantors and Grantees, and their heirs, successors or assions.
Repairs, maintenance and snow removal costs on saic: private
roadway shall be prc-rated among the users of the roadway.
SUBJECT to easements, restrictions, reservations an:3
covenants of record.
ssprition to. arrestisa:
. 1
Esecawd at his -_ S day �f. December r 1978
UCNED Atsi. !RAI=D IN PRESENCE OF _(SEAL)
N/A -DANIEL D. _K1 KLIS -
to - ►� (SEAL)
— — — -- 1 CYNTHIA A. KUKLIS
N/A ( (SEAL)
(SEAL)
Signatures of. -----_-------__N/A_
a
z audwaticated this — day or-
Title: Member State Bar of Wis...nsin er othvr Party
Authorized under Sec. 706 06 vit.
•
' lTATE OF ft ¢
W_ Q s..
Personally.Cae before als,this _ 18 ' _ ear or DecembC r
ta Iq 713
ttsaso.eMw.a Daniel D. Kuklis and Cynthia A. Kuklis , his wife �f '
w
to as knows to be the person_. S who ett«ytod-tbe foregoing inatq►tnent wW ack edged the same•. � ,sx��s
- SC<,-T F C-Gn1f=5
a s 7• �" NotsrT Public K
ft»we of witnesses is opl{tiiralz ' My Commission (F�pirr:)(is)
s signing in any capacity should t• below thoir signatures. u
aka or wwotaat, roan *6! . *671
H
y
9
STC - 105 r
, r
• y
SEPTIC TANK MAINTENANCE AGREEMENT
0
St . Croix County z
a
9
OWNER/BUYER
ROUTE/BOX NUMBER RLJ, / Fire Number
CITY/STATE /, 90 � ZIP ,�ws I
PROPERTY LOCATION : A10;4, 1�i Section , T N , R [ W,
Town of St . Croix County ,
Subdivision Lot number 3
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes . Proper maintenance con-
sists of pumping out the septic tank every three years or sooner ,
if needed , by a licensed septic tank pumper . What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St . Croix . County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1 , 1978 . St . Croix County
accepted this . program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained .
The property owner agrees to submit to St . Croix County Zoning a
certification form, signed by the owner and by a master plumber ,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping ( if nec-
essary) , the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. H
0
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- u
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 r
r
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 - SBD - 6395
To be a complete and accurate soil test,your ref)ort must include:
1. Complete legal description,
2. The use section must clearly indicate whether this is a residence or commercial project;
S. MAXIMUM number of bedrooms or commercial use planned;
4, Is this a new or replacement systern;
E. Complete the suitability rating boxes.A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEUIS ARE RULED OUT BASED ON SOIL CONDITIONS;
(3. PLEASE use the abbreviations shown here for writing Profile descriptions and completing the plot plan;
r. MAKE A LEGIBLE diagram accurately ICtcatinlj your test locations. Drawing to scale is preferred, A
s.el)<ar<ata�sheet may be riled if desited;
S. L'ial<e sure your be€ichmark and vertical elevat ion reference point are clearly shown,and are permanent;
S. Co €Lalete all appropriate boxes as to dates, narnes,addressers, flood plain data, percolation test exemp-
tion, ifappromiaie;
fd. If t=ie infotnnation (such as flood plain, elevation)does neat apply, Place N,A,in the appropriate box;
11. Siltn the form and place your,current address and your certification nurnber;
rc kV,'ke legible cops es anti distribute as required, ALL SOIL TESTS MUST RE FILED WITH THE
LOCAL_ AUTHORITY WITHIN Sd DAYS OF COMPLETION.
ABBREVIATIONS NS FOR CERTIFIED SOIL TESTERS
Sail Sepaiates and Textures Other Symbols
st — tone: (ovt>! 10-) BR — Bedrock
cob ._ Cfabbkt, (i- 10") SS Sandstone
gi, &lavCel (under 3") LS Lirnestonc
*s Send H G W -- Hiorl Gimmdwater
s C ,a'w Sar,rf Pc°a: P€ czalation Rate
rate d z' — ,06iiurn Sarad
Bid( Suildm,,q
li- — L f zmv "'aaii, > .._ Greater Than
Sandy Lmvn < Less,s Than
+ l_€.:giant Lie, Rt-ovvn
Sill fay ,rah;
C.av L a Y
,and", ti;I<y f.o.:ir€ R fit:o
k,,i Silty Clay L-oriin rnot .._ itt,, ties
atady Clay "v f
Clay IFi ..._ ieo", 'filw' faint
C lie=,' :a; - conina(sa7 .oarse
d __,. €:,istit ci
prominent
1-1W .. - High vv'atcer level,
€x qen rz'! `oil Iex"'llreS rifle"iaCt; 'crfsltE'f.
fo, {ic;m I vvaste disposal 6,M — Bench Mark
VRP - Vertical elerence, Point.
TO THE OWNER:
1 €: sc n [nst rc,p<rt is th= first sleep ill seCASrincl a sanitary Permit. The county or the Department may MCluest
L„[ s4C;Ei, ,tit C:3°f Pi,� test, in the field pnfir 't is perit Et: issuanco, A complet€? set (tf {Bans for the private
gaga sy'}crn and a ,�°:rt;ie,� acaplicat�:t masse he ;u m'Jtv�d to the appio riate local authority in order to
n v tiE.1,nI,t illiIS1 1"ic:obtsai? f'C1'1' t+rit. pc it pi i o r itb t he, ;tar-t o any cc)II tUCi3oII
J
ARTM�NT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ / MADISON,WI 53707
' ^ (H63.090) &Chapter 145.045)
LOCATION: SECTION: TOWNS Y: LOT NO.:BILK.NO.: SUBDIVISION NAME:
NW '/4 W/4 24 /to N/R 20i (or)W St. Joseph I n/a n/a n/a
TY: OWNER'S E: MAILING ADDRESS:
St. Croix Brian Smyth R.R.#l, St. Joseph, Wi. 54082
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCIAL DESCRIPTION: IIP OFILE DESCRIPTIONS: ER A ION TESTS:
EI Residence 3 n/a ❑New Replace t 4-28-87 n/a
RATING:S=Site suitable for system U=Site unsuitable for system tttt
CONVENTIONAL: MOUND: IN_ -GROUND•PRESSUR_E: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
®S ❑U [as ❑U ®S ❑U ❑S ❑U ❑s il U conventional
If Percolation Tests are NOT required DESIGN RATE:
Q I If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: class 2 Floodplain,indicate Floodplain elevation: n/a
decimal' PROFILE DESCRIPTIONS
page 33 OND2
BORINGI TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTHM. ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- 1 7.42 97.10 none >7.42 .67bl.1. 1.83 bn.sil. .50bn.l.s. 4.42 bn.c.s.
B- 2 8.09 97.40 none >8.09 .67bl.1. 1.92bn.sil. .67bn.l.s. 4.83bn.c.s.
B- 3 7.65 97.19 none >7.65 •92bl.1. 1.58bn.sil. .67bn.l.s.
m s.
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PERIOD2 PER1003 PER PERINCH
P-
P rate
P-
P-_
P-
P- _
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances'.rlhS"Pi$a dvR Y the hori
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borinpind,4 dir io?f�. ercent
of land slope. J 1• ¢¢ll \; >
SYSTEM ELEVATION 93.60
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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(print): TESTS WERE COMPLETED ON:
Gary L. Steel 4-28-87
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
988 N. Shore Dr. New Richmond, Wi. 54017 2298 71 246-6200
CST SIGNAT
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
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