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Parcel #: 182-1026-40-100 05/10/2006 08:11 AM
PAGE 1 OF 1
Alt. Parcel#: 311812-24-03-00-00-000 182-VILLAGE OF STAR PRAIRIE
Current LX; 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
O-NELSON, RICKIE&KRISTINA A
RICKIE&KRISTINA A NELSON
551 HILL AVE
STAR PRAIRIE WI 54026
Districts: SC=School SP=Special Property Address(es): *=Primary
Type Dist# Description *551 HILL AVE
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 10.000 Plat: N/A-NOT AVAILABLE
SEC 12 T31 N R18W VIL STAR PRAIRIE 10AC Block/Condo Bldg:
E1/2 NW1/4 COM W1/4 COR SEC 12, S 89 DEG
E 1705.86'-POB CONT S 89 DEG E 350.70'N Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
1361.91'TO S R/W HWY H, S 57 DEG W 12-31N-18W
135.98'S 54 DEG W 268',S 55 DEG W
22.40'S 1116.71'-POB FKA PARCEL 220E
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 732/267
2006 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 09/08/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 20,000 179,100 199,100 NO
PRODUCTIVE FORST LANDS G6 7.000 28,000 0 28,000 NO
I
Totals for 2006:
General Property 10.000 48,000 179,100 227,100
Woodland 0.000 0 0
Totals for 2005:
General Property 10.000 48,000 179,100 227,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 125
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
PUMP CHAMBER
� r
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:
Width: Length: ��3 Number of Lines: Area Built:_'
Fill depth to top of pipe: O
Number of feet from nearest property line: Front,P Side,(D Rear,0 Ft
Number of feet from well: j �`
Number of feet from building:
-r
(Include distances on plot plan).
SEEPAGE PIT 93 p
93. 0
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, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
�j Inspector:
Dated: Plumber on job:
License Number: ��%
3/84:mj
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER �� /� j �2 ,� TOWNSHIP SEC. T � N-RW
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE --
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
\1
&r `{('
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used p � X70 /1J; �icle
e-7
Elevation of vertical reference point: /e ` Proposed slope at s te: O
SEPTIC TANK: Manufacturer: Liquid Capacity: 6 3
Number of rings used: Tank manhole cover elevation: !6
Tank Inlet Elevation: Tank Outlet Elevation: t7 fr" L�
Number of feet from nearest Road: Front,0 Side,Q Rear, O feet
From nearest propert line Front, Side Side,O Rear,O 7J ✓ feet
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.ROX 79'69 BUREAU OF PLUMBING
MADISO WI 53707
S01 —R18W UCONVENTIONAL 1:1 ALTERNATIVE State Plan l.D.Number:
Town of'Star Prairie Of.-gned)
❑Holding Tank ❑ In-Ground Pressure El
CTY$ROAD H
NAME OF PERMIT HOLDER: A PERMIT HOLDER: INSPECTION DATE.
Rickie Nelson 332 North 4th Street, New Richmond, WI 4017
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:
Byron Bird Jr. 3318 St. Croix 96007
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV: TANK OUTLET ELEV.: IWARNING LABEL LOCKING COVER
'
1000 �I P PROVIDED:
W 9�i s� �"� ' YES ❑NO ❑YES WN6
BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER QF ROAD: PROPERTY W BUILDING: VENT TO FRESH
• ALARM: FEET FR
�7 - 1 LINE ! AIR INLET❑YES L�NO ❑YES 0 NEAREST L (�11 Jl
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO EYES ONO I OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUAABER OF PROPERTY IWELL. BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES 1:1 NO AIktEST'
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING FOftt
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONALSYSTEM:
�k,� WIDTH. LENGTH: JNOIO F DISTR.PIPE SPACING: COVER INSIDE DIA.-. #PITS: LIQUID
�. w TRENCHES- MA RIAL: PIT DEPTH:
�b1R1114I,INS
GRAVEL DEPTH FI L DEP H DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DIS EA OF PROPERTY WELL: BUILDI VENT TO FRESH
BELOW PIPES. ABOVE COVER. ELEV.INLET.ELEV.END PIPES: LINE. /, ` /I.� AIR INLET
.�
Cat 2v �I,ys 11'10 2- 2 9 k E i� w {U•(
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-
meets the criteria for medium sand. TIONS MEASURED.
❑YES NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS.
El YES 1:1 NO ❑YES 1:1 NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED =TOPSOIL. SODDED. SEEDED. MULCHED.
CENTER: EDGES. ❑ ❑ 1:1 YES ONO
YES ❑NO YES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER
TRENCHES:
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING:
'- ELEV.- ELEV.. DIA.. ELEV: PIPES. CIA,:
�3�; F �1`�i10 ml HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
� t "i@{fIV PLANS:
DYES
NO
DYES NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: AtUSIER _ LINE:
ERTV WELL: BUILDING:
❑YES E-1 NO ❑YES ❑NO
10 7. Z
5.76
Sketch System on S Retain in county file for audit.
Reverse Side.
SIGNATURE: ]TITLE:
Zoning Administrator
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 os 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:
I. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
ll. 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'/i 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; re lacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form.
------------------------------------------------------------------------------------------------------------------------------------------- ---------------
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more-
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater-bill Ground 8t F=
included the creation of surcharges (fees) for a number of regulated practices which Wisco 16
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried a
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- 1
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
' COUNTY
=701LHFi SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm.Code / Gro 1"
STATE—SANITARY^^PP�ERMIT
0V
—gttach.camplete 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 D� NO
PROPERTY OWNER PROPERTY LOCATION
r G ' '/4/�/d!J'/4, S T , N, R E (or)
PROPERTY WNER'S MAILING A DRESS _ LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
m? c / ,�Z
CITY,STATE ZIP CODE PHONE NUMBER CITY NEA REST ROA ,LAKE OR LANDMARK
f a VILLAGE: �r It TOWN OF7
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. e1 New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.El 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.Xconventional 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. 9seeDaae 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(Square Feet):
L
615— 4 -17- 4g" Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in aa ons Total ##of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank �{
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): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number:
ra
Plu is Address TStreet,City,State,Zip Code): Name of Designer:
c t
VIII. SOIL TEST INFORMATION
Certified ' Tester(CST)Name CST O 7
CST's RESS(Street,City,State,Zip Code) Phone Number:
IX. COON Y/DEPARTMENT USE ONLY
❑ Disapproved Saary Permit Fee Groundwater ate Issuin Agent Signature(No Stamps)
Approved F-1 Owner Given Initial \\ S harge F,^e\\e
ermination ��• W "
Adverse Det `
X. COMMENTS/ ASONS FOR DISA PROVAL:
`q� -e�tr2 r.t�Qo)( � o - lam✓
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 . 9( LLP aviJ Ni n, n A.
Location of Property �yg__OLk — �- , Section /,2 , T_,3 / N-R _Ly W
Township
Mailing Address Al, q�& app.
Alp.J�Mc),j r L,T ,S7 q6)1-1 .
Address of Site � � •
si'l rr Prar r-i e- 5,yo_ {o
Subdivision Name fj �-
Lot Number
Previous Owner of Property _� Uy,yj ��r Q y�arw AJPO r'P
Total Size of Parcel 1C)
Date Parcel was Created 01-
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes V No
Volume ' a- and Page Number A(° -] 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) ee ti.6y that att statements on th,i�s bon.m ah.e true to the best o6 my (ouA) •
hnowtedge; that I (we) am (arr.e) the ownen(.6 06 the phopenty deAcAi.bed in this
i
in6o4mdton 6o4m, by viAtue 06 a wa Aanty deed kecokded in the 066.iee 06 the
Count RegiAten o6 Veed�sas Document No. �.Q and that I (we) pneaentty
own .the pnopoaed a-ite bon the sewage di�spoa dya em• (on I (we) have obtained an
eaaemen.t, to nun with the above de cAi.bed pnopehty, bon the eonstAucti.on o6 said
ayatem, and the dame has been duty keeakded in the 066.ice o6 the County Regi6ten o6
DeC&, ab Document No.
SIGNATURE Op OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
1IGNED DATE SIGNED
jo ,V06 �32FAGz268 �
TOGETHER WITH an Easement for ingress and egress over all that part of the
Southeast Quarter of the Northwest Quarter (SE4 of NW4) of said Section
Twelve (12) South of the Apple River and North of County Trunk Highway
"H" to provide access to the Apple River.
W
i
. I
r- .... -_ ....... - _.... ..... ...__ _ .. ...._ -_ _... _ .-.. ...__. _ ...-.
DOCUMENT NO. WARRANTY DEED �� THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-19821
1092 `7 �y
�t, REGISTERS OFFICE
t 26 f icy
132
_ _ �i
i • � • •
14th
Steven Alencich and Mary L. Alencich, husband '1 day of Feb A. - 19 86
...................... --•----------•---•......--•-----------------
and _wife as _i_oint tenants at at 4:00 P ma
-- -------- -----------•--•-
i
- -----•... ...........•--..... --------•-•---•-----------------•--•----....----------------•----.---•-
_•,%.Names O'Connell
I
-------- ----- -• ----- -•-•---•----....-•--•------•-•------••--•-•---.................-----•------..........
convey and warrants to ...Riekie_.Nelson_.and. Kristina__A,____
Nelson, husband and -wife,_._as__martal..property,
------ ---------_-- ---•--.
with rights of survivorship
I Deputy 1'
---- -------
�- -
;; ... .... ........ .........._...._...._..._.......-----.........__--........_.........--....._............_- .__ li RETURN TO
,! ...... ....... ............................................................... ................................ ..... -. -. .-_.. :..:...:. :......
the following described real estate in .......St_.__.GXolX...................County,
State of Wisconsin: j
Tax Parcel No:
A parcel of land located in the East Half of the Northwest Quarter (E' of
NW4) of Section Twelve (12) , Township Thirty-one (31) North, of Range
Eighteen (18) West, further described as follows : Commencing at the West
1/4 corner of said Section 12; thence South 891 03 ' 15" East along the South
line of the Northwest Quarter (NW4) of Section 12 , 1705. 83 feet to the point
of beginning of this description; thence continuing South 891 03 ' 15" East, i
350. 70 feet; thence North 001 41 ' 56" East, 1361. 91 feet to the South right)
of way line of C.T.H. "H" and a point of curvature of a curve concaved to
the Southeast and having a central angle of 061 09 ' 24" and a radius of
1266. 07 feet; thence Southwesterly, 136. 04 feet along the arc of the curve,;
the chord of which bears South 571 57 ' 49" West, 135. 98 feet; thence South
541 53' 07" West, 268. 80 feet to a point of curvature of a curve concaved
to the Southeast and having a central angle of 011 31 ' 12" and having a
radius of 844. 32 feet; thence Southwesterly 22 . 40 feet along the arc of the
curve, the chord of which bears South 551 38 ' 37" West, 22. 40 feet; thence
South 001 41' 56" West, 1116. 71 feet to the point of beginning of this j1
description. Said parcel contains 10. 00 acres and is subject to easements
of record. ---continued on reverse This deed is executed solely for the purl
This --is not homestead property. pose of fulfilling an unrecorded land con—
(is) (is not) tract between the parties hereof dated
July 12, 1983. --
Exception to warranties:
Easements and restrictions of record.
Dated this 4th da y of Fed ruar_ ---------------_--FEE............ 19---8b.
•----------- ----_----------(SEAL) � . -------- -----•---- . --..'.'-"..(SEAL)
!' . . Steven Alenc ' c
-------------------------------------------- ----------- -••-•-• --- ---------- -----• ------- -------------
/�) qq ,
(SEAL) ` ..��? (SEAL)
• ..-M1a y L. Alencich
AUTHENTICATION ACKNOWLEDGMENT
I�
Signature(,) _Steven Alencich and_____________ STATE OF WISCONSIN .!
Mary Alencich as.
......... . ..............................................................
--------------------------------------County.
uthen thi 4th
day of February 19.86 Personally came before me this ................day of
-------- -- ---
, :� ----------------------------------------- r
19........ the above named
,'. cott Needham
-------------- ----------•-------------------------------------•------------- -----------•---•-•-------•-•-------------•------•----
TITLE: M BER STATE BAR OF WISCONSIN
(�fno ,:--------_------------------------- ..............................................................................•.
atlbllexaee��Y-� �A6,A6'�Kls`-State'1`-- to me known to be the person ------------ who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Reinstra, Van D k & Needham S.C. i!
New Richmond, WI 54017
------------------------------- Notary Public ..........................................County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration
are not necessary.)
date- ........................................................, 19-•------•)
*Names of persons signing in any capacity should be typed or printed below their signatures.
__.._ . ..._...._.. — ...-- --
®® STATE BAR OF WISCONSIN
KC.Millercomperw FORM No. 2— 1982 __ Stock No. 13002
N
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ST C - 105 r
a
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
a
_o ,J H
OWNER/BUYER 9�p CZ✓IO[ KYislira A. "0/-7
ROUTE/BOX NUMBER �� Fire Number
CITY/STATE ,PrarriP ZIP y� (o
PROPERTY LOCATION: NI Section 1 a ., T 31 N , R 1,' W,
Town of St . Croix County,
Subdivision 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 m_ y 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
E
I/WE, the undersigned , have read the above requirements and agree En
to maintain the private sewage disposal system in accordance with H
the standards set forth , herein , as set by the Wisconsin Depart- b
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 A�►ati
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 .
V
INSTRUCTIONS E R COMPLETING FORM 115 - SRC -6395
r
To be a ccarnPlete 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 usi; 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;
Fi. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MADE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
separate sheet may be used if desired;
B, Mahe sure your be rich marl<and vertical elevation reference point are clearly shown,and are permanent;
9. Cornplet(, all appropriate boxes as to dates, names,addresses,flood plain data,percolation test exernp-
tion, if appropriate;
10. If the information (such as flood plain,elevation)does not apply, place I ,A.in the appropriate box;
11. Sign the form and Place your current address and your certification number;
12. Make legible conies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS NS C R CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st -- Saone (aver 10") Bid - Bedrock
cob Cobble (3- 10") S - Sandstone
gr - Gravel (under 3") LS Limestone
*s Sand HGW High Groundwater
cs -- Course Sand Perc Percolation Rate
med s - Medium Sand W - Well
fs - Fine Sand Bldg -- Building
Is Loamy Sand > Greater Than
sl Sandy Loam < Less Than
"l - Loam Bn Brown
s i I Silt Loam BI Black
si - Silt Gy Gray
cl Clay Loam Y - Yellow
sci - Sandy Clay Loarn R Stec!
sicl - Silty Clay Loam ra-ot - Mottles
sc Sandy Clay w,! with
sir✓ Silty Clay fff - few, fine,faint
*c - Clay cc common,coarse
pt - Peat min Many, med°sum
M - Muck d distinct
p prominent
HWL High water level,
#.
Six general sail 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 permit.The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private
sewage system and a permit application must be submitted to the appropriate local authority in order to
obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction,
`9
'DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR AND HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707
(ILHR 83.09(1) &Chapter 145)
LOCATIONr SECTION: OWNSHI MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
�/ /,J�/a /T, H/IP E co a AG'r��i.►.'G -- —
COyU�NTY: OWNER'S B YER'S NAME MAILING ADDRESS:
JJ Kf
USE DATES OBSERVATIONS MADE S 97
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS:1PERCOLATION TESTS:
Residence New ❑Replace / 1
RATING:S=Site suitable for system U=Site unsuitable for system 3
rivZisou O ENTIONAL: MOUND:oY IN-GROUND PQ URE: SYSTEM-IN-FILLHOLILDING TANK:RECOMM ENDED SYSTEM:(optional)LOU
If Percolation Tests are NOT required DESIGN TE: C7
Q If any portion of the tested area is in the
under s. ILHR 83.09(5)(b),indicate: Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS -
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
C>-//G/ 5// y a�-� ��B- f / 41B /
2 404e— >qel
� /f�Q•L�C. �,g D—>'
B-
p ���� may_a Y /S r�y-85! *
B- mot 7� r�
B- Jr ot.y- /�jis
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMB R k%WMWr6 AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH
P- 4. 6 ll;;�
P- 2 0?• G
P L.
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.
SYSTEM ELEVATION
3
a
E
a 7`
tk-
6 � F
O
�('
E 3
L t E
t
3
3
`
_ ��: .- z_ ..._ . _f �J.
I .
as eZ
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 Wisco sin
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:
ADDRES CERTIFICATION NUMBER: PHONE NUMBER(optional):
•� �� v1 c S�/�o/ a i ° sue
CST SIGNATURE-:
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DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHRSBD-6395(R. 10/83) —OVER —
y Y
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I
. 1 A
E e e
PLOT PLAN
PROJECT AgAb,�3 ADDRESS 99,2,& ` 1% 101e d
' 1 14JY1.J. 1/4/St:-IT,71 N/R ,/-�W TOWN,,� 4cZlw" .1 OUNTY
.M.PRS Byron Bird Jr. 3318 DATE 6 --
BEDR M
00 CLASS PERC_,,,/_CONVENTIONAL_,�IN-GRO D PRESSURE
CONVENTI NAL LIFT MOUND_HOLDING TANK
SEPTIC TANK SIZE /' g=2!!f LIFT TANK SIZE
DOSE TANK SIZE HOLDING TANK SIZE
ABSORPTION AREA g;� ERC RATE BED SIZE
Benchmark V.R.P. Assum levation 100' �
Location of Benchmark - ''� �° �, Cor11.er o� �i'�'a_ �. � �
D Borehole Q Well Scale = Feet
O Perc Hole System Elevation
TYPAR COVF--Rlma- - - - - ---
2"
121' 3- Q 6' 0 3- j
6 Sewer Rock
12' A
fro
i
I
�p
t7 �
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