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HomeMy WebLinkAbout182-1022-90-100 N 0 N y © 0. O C N E N CL I' C � I C � C � I [: a a> c 0 0 z @ C O LL C O 0 Q > M Z �I O Q £ O Z Cl), a m ° ►- Z c E t7 6 v o Z c m Z C o fq F- Z O c E -o M N N O C O n N � � O • II'. d .c O O N Q w Z c0 Z o N C N > 06 L a cc b U c y y a to o O E l s x 0 0 0 z N _@ a a a N a g ;' U) �vj to U Q _rn rn Z @ N 'O ca m d I U) 'o m ai cs� .2 a� L N y Q } p �w _ O @ O N C ++ o CL r `o E o w O U 68 5 Cl '..I O c c CJ p L N c u, y y m `" C N W —O 4-� p ED Z ` 'o n co.�, N M N o N E E s yam' o o > rn o Z N H v� .Q ' as L IL 0 CL y V y Y C o t A L) IL 3:0 (j)- s ' Parcel #: 182-1022-90-100 02/22/2007 10:56 AM PAGE 1 OF 1 Alt. Parcel#: 311706-32-03-00-00-000 182-VILLAGE OF STAR PRAIRIE 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 O-BERGER, ROBERT R&PATRICIA M ROBERT R&PATRICIA M BERGER 124 SARATOGA AVE BOX STAR PRAIRIE WI 54026 Districts: SC= School SP=Special Property Address(es): '=Primary Type Dist# Description " 124 SARATOGA AVE SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 4.300 Plat: N/A-NOT AVAILABLE SEC 6 T31 N R1 7W COM E LN NW SW WHERE E Block/Condo Bldg: LN INTERSECTS NTHLY BOUNDARY STAR PRAIRIE&DEER PARK HWY, N TO NE COR NW Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) SW,W 275', S TO NTHLY BOUNDARY STAR 06-31 N-1 7W PRAIRIE& DEER PARK HWY NELY ALG HWY TO-POB FKA PARCEL 204E Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 1077/45 WD 07/23/1997 778/82 2007 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/18/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.300 25,900 120,700 146,600 NO Totals for 2007: General Property 4.300 25,900 120,700 146,600 Woodland 0.000 0 0 Totals for 2006: General Property 4.300 25,900 120,700 146,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 133 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 w PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: i Width: Len$th: Number of Lines:_ Area Built Fill depth to top of pipe: Number of feet from nearest property line: Front 0 Side, gRear,0 ift . Number of feet from well: Number of feet from building: t (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK 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, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector• Dated: Plumber on Job License Number: 3/84:mj Form - S T C - 104 • r AS BUILT SANITARY SYSTEM REPORT OWNER TQR9:�_HIP s ,� SEC. G T�N-R�W ADDRESS l ((J ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM j:1 : r 3�' J I .... ,. i,: a _, ,-.: ,.±.' .. - ::. t r- �: ar _4_` L_'='.i'f 1. iF'rr A r _ •.r:;. "INDIC9TE NORTH NRROW / 1 j BENCHMARK: . Describe the vertical reference point used 1041 Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: LI iquid Capacity: n Number of rings used: Tank manhole cover elevation: ��j ZJ/ Tank Inlet Elevation: 7 Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side, Rear, O >'- feet From nearest property line Front 10 Side,®Rear,O feet r Number of feet from: well ,building: (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 M ADISON,..'NI 53707 NW',,, SW,, S6,T31N-R17W MUONVENTIONAL ❑ALTERNATIVE (if. gned(D.Number ,—TQ&m of Star Prairie ❑Holding Tank ❑ In-Ground Pressure ❑Mound NAME PF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Michael McMartin 120 Hill Avenue, Star Prairie, WI 54026 9- ?- 0 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. I96031 St. Croix 96031 SEPTIC TANK/HOLDING TANK: M N pACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WAR IN LABEL LOCKING COVER l) ) P O DED. PROVIDED: ° YES ONO DYES ❑NO BEDDING: VENT DIA.: VENTMATL.-. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: IVENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: DYES ❑NO DYES 1-1 NO NEAREST DOSING CHAMBER: MANUFACTURER. JBIEDDING 11-10111D CAPACITY PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO OYES ONO I [—]YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL. BUILDING.I VENT INLLEE ENT FRESH (DIFFERENCE BETWEEN FEET FROM LINE T PUMP ON AND OFF) EYES ❑NO NEAREST" SOIL ABSORPTION SYSTEM.Check thesoil moistureat thede th of plowing f LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORGE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH. N DISTR.PIPE SPACING. COVER INSIDE DIA. #PITS. LIQUID BEDfTN3ENCH TRENCHES MgkTERIAL PIT DEPTH: .N,�#M•EN�I.ONS ,. t� GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DI R NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES- ABOVE COVER. ELEV.INLET ELEV.END. PIPES:,. FEE•P FROM LINE: AIR INLET. NEAREST 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. El YES NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ENO DYES 1:1 NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED ISEILIED M ULCHEDCENTER EDGES. ❑YES ❑NO ❑YES ❑NO IOYES ENO PRESSURIZED DISTRIBUTION SYSTEM: i.WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. 111110ifTRENCH TRENCHES: [DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. '.!ELEV.. ELEV.. DIA.. ELEV: PI PES. DIA.: 4 EVATTON AND ESNNiTRNBUTION HOLE S12E HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED N M° I PLANS: DYES ❑NO ❑YES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF.. PROPERTY WELL: BUILDING: FEE€FROM LINE: ❑YES ONO DYES ❑NO NEAREST I r Sketch System on Retain in county file for audit. Reverse Side. TITLE SIGNATURE: Zoning Administrator DI LHR 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 pKoperly maintained. The septic tank(s) should be pumped by,a-licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Prcperty 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; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not.smaller than 8% 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 0the soil absorption system if required by the county; E) soil test data on a 115 form. ------------------------------------------------------------------------------------------------------------------------------------------------------------ GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground ater-- included the creation of surcharges (fees) for a number of regulated practices which Wisco Wt e can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure' 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. a 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) o°� DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm. Code °�:,. .o.�.,.. �..o. STAT SANITARYPERMIT# • 6 el j / —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 �j 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES LQJ NO PROPERTY OWNER PROPERTY LOCATION '/a %, S T,3 , N, R E (or PROPERTY OWNER'S MAILING ADDRESS LOT NU BER BLOCK UMBER SUBDIVI ON NAME ZOL CIT ,STATE ZIP CODE PHONE NUMBER Y NE ST RDA LAKE OR LANDMARK VILLAGE : , 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. ❑ 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. L& seepage Bed b. ❑Seepage Trench c. ❑See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(aquare Feet): Feet N Private ❑Joint ❑ Public VI. TANK CAPACITY Site in alIons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank ❑ ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of he rivate sewage system shown on the attached plans. Plumber's Name(Print): Plwfter' Signatu :(N tam ) MP/MPRSW No.: Business Phone Number: Plumb is Address treet,City, tate,Zip Code): Name of De gner: VIII. SOIL TEST INFORMATION Cert'' d S it Tester( )Name CST# CST' DDRESS( reet,City,S te,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S Hilary Permit Fee Groundwater rate Issuing Agent Signature(No Stamps) ® F-1 Approved Owner Given Initial Surcharge Fee �^ Adverse Determination /� �` � 4%0 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 Ml kqP I }T. AAO- /- a4,lh ani &nnie Location of Property J�J y� 5W , Section 6 1 , T 3 jN-R )�] W Township Mailing Address �;-. �;APTk)R�t a Address of Site Subdivision Name . Lot Number Previous Owner of Property IJ ' S Total Size of Parcel Date Parcel was Created L Qatj 7 1G rj Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes V/ No Volume and Page Number rp, 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 ti.6y that a t statements on thi.6 6o,%m ahe true to the but o6 my (ouh) know.tedge; that I (we) am (ane) the owneh(s) o6 the pnopenty dens c A ibed in this .in6oAmat.ion 6onm, by vi tue o6 a waAAanty • eed %econ in n the 066ice o6 the County RegihteA o 6 Deeds as Document No. 44 S 51,37 ; and that I (We) paces entty own the phoposed 64te bon the sewage dizpoiat system (on I (we) have obtained an easement, to kun with the above dedeAibed phopeJrty, bon the construction o6 said system, and the same has been duty recorded in the 066.ice o6 the County Re9i,6ten o6 Deedb, ae Voeument No. ) . SIGNATURE Oi OWNEi SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE S GNED DATE S GNED ° ' a•' "Y THIS SFACE RESERVED FOR RECORDING DATA DOCUMENT NO. WARRANTY DEED STATE BAR OF WISCONSIN FORM 2-1888 REGISTERS OFFICL '7`78wt _ ST. CROIX Co., wis, Recd. for Record this 11th Bernard M. Matthys, aka Bernard_ ' Matthys, and Ma_ Y ....................................... .........._... day A.Da t ;Irene M Matth s -aka. Irene H. Mat£hXs, Yiiisbarid at 4.00 P and wife as. .7°joint tenants.!............. .......... :.: . ...... .:..... James .0 onne , ,,,� .... .. .. :. ....:.:. ---- :... , conveys and warrants toMichael ......... McMartin and' $onnle "L. McMartin._. husband .and.wife,_..as..marital pro�erti, Kathleen H. Walsh; ........ with rights of survivoi zvvi ................................................ deputy .................................. ..................... RETURN TO the.following described.real estate in ...:S ....Cxai G.....................County State of Wisconsin: Tax Parcel No Part of the Northwest Quarter -of the Southwest Quarter (NWj of Sw�D Section Six (6), ' Township Thirty-one (31) North, Range Seventeen (17) West, described as follows:': Cam encing on the East line of said Northwest•Quarter of Southwest Quarter (NWJ of SWD where said East line intersects with the Northerly boundary of the Star Prairie and Deer '' Park Highway as now located and situated; thence North along the Section line to the Northeast corner of said Quarter.Section; thence Westerly along the North line of said Quarter Section, 275 feet; thence South, parallel with said East line of•said Quarter ..Section to the Northerly boundary of said Star Prairie and Deer Park Highway; 'thence Northeasterly' along the North line of said Highway to the Point of Beginning. Now within the„corporate limits of the Village of Star Prairie. This ....is...not---------- homestead property. (is) (is not) x Exception to warranties: lst May .' 19 Datedthis ................................................ day of ............. ... ...... _..... .......... ...... ........ ... ....... ..........• . ----- (SEAL) '... .... (SEAL) �� EA Irene M. Matthxs - * .Bernard M. MatthY.s.._...... ....... ............. ..:: ... . ..... .(SEAL) .............................................................. ............: . ... ..........:................... ............................................... ..:(SEAL) . e .............7---------7... ....... ........................ .. AUTHENTICATION ACKNOWLEDGMENT ",,-”, Signature(s) •........................................................... as STATE OF WISCONSIN . . ................................................................ County II St. Croix ... .. ....:.. authenticated this ....:...day of.... ...:. ... :.......:., 19....._ Personally canna before me this �:St .. day of ..:MaY.. 19 -8 the above named �f ............................................................... .Bernard M. Matthys -and IrenezM: �� .. . . TITLE: MEMBER STATE BAR OF WISCONSIN ........ •w .. • ............... r �._ _ I (If not, .... authorized by § 706.06, Wis. State.) to me known to be the person _S. .....: who•executed the foregoi instrument a �wled the same: THIS INSTRUMENT WAS DRAFTED BY Reinstra, Van Dyk & Needham, S. C. I' ............................................................. ................... T a L. Glaser Attorneys at Law *..•-•-•- •- ... ........... t St Croix i New.-R-ic and.,--•Wisconsin.....54A1.7.-D.127 Notary Public .t................................. Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration i are not necessary.) date: .. 3-31-91 ......... .,` *Names of persons signing in any capacity should be types or printed below their signatures. '. STATE BAR OF WISCONSIN Stock No. 13002 'f KC.iller 1 FORM No. 2—• 1 982 P%' M gr t'1, z H 9 ST C - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT 00 rM- St . Croix County z d / n / 3 ` '� jc H OWNER/BUYER 1�;dl2Ac'./ � 'Alja ROUTE/BOX NUMBER `%7�YL- Fire Number CITY/STATE _PieRl,C c � lx)z--5 °c7,n,5 ZIP PROPERTY LOCATION : A/14.f k, _5jV 14, Section Cp T % N , R/7W, l Town of �7-AR PR_,z41R1E , St . Croix County , Subdivision -- Lot number Improper use and maintenance of your septic system could result in I jits premature failure to handle wastes . Proper maintenance con- If, 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, t_ which was in operation prior to July 1 , 1978 . St . Croix County i ` 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 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 x/L W_ 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 - SBO - 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 cornmercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4, Is this a new or replacement system; 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; 5. 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; B. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete ail appropriate boxes as to dates,names,addresses,flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain,elevation)does not app) t y, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL. TESTERS Soil Separates and Textures Other Symbols St — Stone (over 10") BR Bedrock cob Cobble (3- 10") SS Sandstone gr — Gravel (under 3") LS - Limestone *s — Sand HGW — High Groundwater cs Coarse Sand Pere — Percolation Rate med s Medium Sand W — Well fs Fine Sand Bldg Building Is Loarny Sand > — Greater Than sl — Sandy Loam < — Less Than 'I — Loam tan Brown #sil - Silt Loam BI Black Si — Silt Gy — Gray cl — Clay Loam Y _ Yellow set — Sandy Clay Loam R Red sicl — Silty Clay Loam mot — Mot ties se — Sandy Clay w! — with sic — Silty Clay fff -- few, Fine, faint "c — Clay cc common,coarse Pt - Peat corn — Many, rnedium ray — Muck d — distinct p — prominent HWL — Nigh water level, Six general soil textures surface water for liquid waste disposal BM — Bench Mark VRP -- Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary perrrait. The county or the Department may request verification of this soil test in the fi(>.l€l prior to pert-nit issuance. A complete set caf plans; for the private se�v=age system and a permit application rrusi be submitted to the appropriate local authority it) order to obtain a Permit, The sanitary permit must he obtained and posted prior to the start of any corastr'U(30011. • lie DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, c DIVISION LABOR ANDS PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.0911)&Chapter 145.045) LOCATION: SECTION: TOW146fifP/MUNI IPALITY: LOT NO.:BLK.�JO.: SUBDIVISI N NAME: ,�/ /L N/R (or)W r COUNTY: OWNER'S BUYER'S NAME. MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIA DESCRIPTION: (PROFILE DESCRIPTIONS: EFICOLATION TESTS: ®Residence 1ZNew ❑Replace RATING S=Site suitable for system U=Site unsuitable for system 1 1 CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:rYSTEM-1 N-FILLHOLDING TANK:RECOMMENDED SYSTE :(optional) DS ❑U OS DS U OS CZU s If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b),indicate: / r Floodplain,indicate Floodplain elevation: J �7 �_ fr PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH M, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- c B- > -2 0, - - B- ., } ­ B PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER P�E� AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 -PERIOD PER INCH P 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 poins and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION ,- _ _ t p i 1U I i i ,. ..�., - f �W I d m ----- _ ._ I � l , • T r SrJ9r•� I,the undersigned, hereby certify that the soil tests reported on this 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 prin ): TESTS WERE COMPLETED ON: j - —P AD R S: CERTIFICATION N01MB R: PHONE NUMBER(optional): CS GN URE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — 14W"I,v -Am 7 36 x; it/ Jy e��.fr—�u��� y7a e -'44%4- ;Ny off • PAGE OF Cr c) 0n ef3 S Y 5 �en-� Fresh Air Inietc And Opcervation Pipe rADProved Vent Cap Minimum 12"Above Final Grade 20-42"Above Pipe _4"Cast Iron To Final Grad• Vent Pipe Mash Hoy Or Synthetic Covering Min. 2"Aggregate Over Pipe I Olstributlon IIII Pipe 0 0 0 0 0 —Tee Beneath Plpe Aggregate o Perforated Pipe Below Be o —Coupling Terminating At Bottom Of System P���nsel� i''I�wl gr�.Cl< SOIL FILL DISTRIBUTIOt.1 PIPE APPROVED g40PETIC COVER ° OR 9" OF STRAW Its OFg6GREGAlE �� OR MARSH HAy ° to'0F12-a/2 AGGREGATE M[V, OF FEET, DIS-r'RIIjUTI0A1 PIPE TD BE AT LEAST IIJCHES BELOW ORIGIMAL GRADE AQU AT LEASTZO iUCHES BUT 1.10 MORE THAU H2 IMCHES BELOW FIAIAL GRADE MAXIMUM DEPTH OF EXe-AVATiowi F014 b ttwju 6RAoF. WILL BE 2:22" INCHES M114IMUM ®rP1"H OF EACAVATIOW FROM; 01KI61WINL 6RA.OE WILL BE INCHES SIGAIED. � . LICEUSE DUMBER: DATE : 4/.,-�— : 110