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HomeMy WebLinkAbout040-1194-90-000 Qo (D O aa) O o 0 O 6% c a a o � I a 00 M w N U a) _ a) w C i C `O O �C O _ O'y CD a) O C M O tl O 2�Cc N a) L � M V1 'y N C ?i f0 O CD CL N C O Z N X000 a� E o r' o a- O z EL z co �T c LL O C 3 LL O O O C as E <1 9 cc m E M O M 3 I a I m w p z e v v z a m a m I o I o z S c m $ 2 2 o (a Z z r c rn C z c E c E ' Cl) N m t� o cc y o. r O Al cn L7 _ d Q O @ Q z m z z m z N z d c T N L D O G a m C G a .n CD a rn y N W a fA N y j a ^' W aN z •N _ � aac. � a. an. �l M +0 U) O 00 rn O f-- f-- 'D M a) N Cl aD 00 � > O N C a0 .... •C .. 0 0 'O O N = (D d N m N 'O m O LO N H if to H 00 w N O N O N t0 Q o 00 o C9 0) 2 c C9 (D c U a °o c) rv\ p aTi c aa)i a) v o l 40. F- E o y � 'a Z E N y z N °: ° E U iO :: -41' E c c o O O U N co 0 N m U O (n 'af • ' O O F- Z N S H m 0 Z 0 Ic z c CQ O � Y U #s E E E E a m a CL C at a .. CL CL c c > > � I is I rrww 0 3 3 � 0 3 0 _1 A 0 IL ', 0 ) U 0U) 0 i � � _.�_�.� �\ \ \ 6~ r�� SS -_ i • AS BUILT SANITARY SYSTEM REPORT ER �C IU , TOWNSHI SEC aN, R W 0, ADDRESS C) rU (�,' , ST. CROIX COUN Y, WISC NSI '3DIVISION In LOTALOT SIZE PLAN VIEW Distances b dimensions to 'meet requirements of H62.20 SHOW E RYTHING WITHIN 100 FEET OF SYSTEM i i I f j � I 9 ! BSI i I di ate No:�thi Arro{ ! S CAL PTIC TANK(S) MFGR. � _ CONCRETEX STEEL N0. of rings on. cover / Depth DRY WELL tT.NCHES NO. of 1W width length area D no. of lines width length / area deptfi to t?p of pipe 3�t� ,GREGATE ��.�c ` r(L I CK• RATE p AREA REQUIRED AREA AS BUILT_ isciaimer: The inspection of this system by St. Croix County does not imply complete o�,Pliance with State Administrative Codes. There are other areas that it is not possible o inspect at this point of construction. St. Croix County assumes no liability for Stem operation. However, if failure is noted the County will make every effort to etermine cause of failure. GASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. `INSPE DATED PL R ON JOB LICENSE NUMBER \ o a ) o � jk � � k § 2 0 §2 k \/ C nr/ / 0EI £ 5 � 0 $ ) 0 \ f\) & f L= E ; k Zcc �� 0 = 0) ma %£ C - 3 e _ IL § 7 /) E2 \ n � - = w E z \ k --t § I CL m q � 0 § k 2 } U) k k k § 2 % 7 D ? - § E I } k § ) ) 0 � \ j .. } 0 2 \ m § ^ z ƒ m f 0 a a k a k M I / U) E / } I « / 000 ~ 0 k R a a a \ 0 B 0 r- ® ■ o = E § 0 § k % / \ \ § § # ° \ I £ @ a. § § f 4) � � LO& 0 » ° 0) 0 \ 8 a E 0 k N o 0 / 2 2 0 0 0 = _ @ g a 8 7 2 0 / & @ I y \ R , 2 \ § / ) / 2 7 ! f I ® / / f 3 3 e I § o ] / ) ) ) % « + E E g l 0 J — � EL L: . t k(In Q / co ) k U) , " Parcel #: 040-1194-90-000 11/03/2004 10:54 AM PAGE 1 OF 1 Alt. Parcel#: 4.28.19.880 040-TOWN OF TROY Current ❑ ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units 00 0 i Tax Address: Owner(s): *=Current Owner * GREGORY J&MARY MCCARNEY MCCARNEY, GREGORY J &MARY 579 OAK DR HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *579 OAK DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.160 Plat: 2080-HIGH RIDGE COURT SEC 4 T28N R19W 2.16A HIGH RIDGE COURT Block/Condo Bldg: LOT 09 LOT 9 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 04-28N-19W Notes: Parcel History: Date Doc# Vol/Page Type 2004 SUMMARY Bill M Fair Market Value: Assessed with: 224,900 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.100 60,500 174,600 235,100 NO Totals for 2004: General Property 2.100 60,500 174,600 235,100 Woodland 0.000 0 0 Totals for 2003: General Property 2.100 55,000 161,400 216,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 140 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 s 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: Width: /g Length: Number of Lines: 3 Area Built: VVs, Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear,0 Pt ./`7�� Number of feet from well: Number of feet from building: (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, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: G� Inspector• Dated: oC Plumber on job: License Number: ®C7 3/84:mj i Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ,, - TOWNSHIP SEC. T aC� N-RW ADDRESS /y� ST. CROIX COUNTY, WISCONSIN —,,—// — LY/�rn,jyti SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•I.HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM t /Vo Sca�g yy, d4 � 3 q w `!607ZC TArj)L �� _ _ _ _ - ---" �_ - -- - - -INDICATE NORTH ARROW \ �FiorL Eo .�xsS r2..,cs D�tYti..ELL BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: � c?p Proposed slope at site: 9 SEPTIC TANK: Manufacturer: Aj zr7- Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,o Rear, 0 feet From nearest property line Front,0 Side,0 Rear,O 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 FOft SAFETY& BUILDINGS BO X 7969& HUMAN RELATIONS P.O..O.BO PRIVATE SEWAGE SYSTEMS DIVISION MADISON,WI 53707 BUREAU OF PLUMBING NP, , NE4j S4,T28N-R19W 123CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number : (If.s gned) Lot 9 High Ridge Court ❑Holding Tank ❑ In-Ground Pressure ❑Mound Town of Troy NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPF_CTl N DATE Greg McCarney 1453 Oak Drive, Hudson, WI 54016 -p1a -87 BENCH MARK(Permanent referencepomt)DFSCRISF IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP;MPRSW No.. Sanitary Permit Number Gary Zappa 3300 96052 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY'. TANK INLET ELEV.: ]TANK OUTLET ELEV.: IWARNING LABEL LOCKING COVER PROVIDED: PROVIDED.JI_ ❑YES ❑NO ❑YES ON BEDDING: VENT DIA.: VENT MATH HIGH WATER NUMBER OF :ROAD: PROPERTY WELL BUILDING: VENT TO FRESH ALARM'. FEET FROM LINE: AIR INLET: ❑YES ENO DYES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING'. LIQUID CAPACITY. PUMP MODFI_ JPUMPISIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED ❑YES ONO ❑YES 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) _ YES ❑NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BEO�,hRENCiI'I ,WIDTH'. LENG TH NO.OF DISTR.PIPE SPACING. COVER [=INSIDE DIA. #PITS. LIQUID TRENCHES. MATERIAL: DEPTH'. atIME(stONS '�' GRAVEL DEPTH FILL DEPTH DISTR.PIPF DISTR PIPE DISTR.PIPE MATERIAL: NO.DISTR WUMBER OF %PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER ELE V.INLF.i ELE V.END. PIPES. FEET FRAM. LINE: AIR INLET'. NEAR EST.. 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- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS 1:1 YES 1:1 NO DYES ONO DEPTH OVER TRENCH;'BED �DEPTH ENCH'BED DEPTH OF TOPSOIL. ISODDED. SEEDED. IMULCHED CENTER DYES ONO DYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER. QED/TiNCH TRENCHES: ` t)fMENSION3 MANIFOLD PUMP MANIFOLD DISTR.PIPE JMANIIOLD MATERIAL'. NO.DISTR.TO .PIPE DISTRIBUTION PIPE MATERIAL&MARKING. "ELEV.. ELEV.'. DIA.. ELEV.: PIPES. ELE1l ATIClN AND L3lSTRtBfJt101xi HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED 1Nft�7�tI1RATION. PLANS ❑YES 0 N ❑YES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBI.+R OF PROPERTY WELL: BUILDING: FEET'-FROM LINE: DYES ❑NO EYES 0 N INEAREST- Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710 (R.01/82) Zoning Administrator 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.frow (number of bC�d- 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 iieensed - 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; Il. 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'/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and-pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test_data on a 115 form. ----------------------------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection 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 in`;; 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 o 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) E:::c—� —a SANITARY PERMIT APPLICATION COUNTY ILHR In accord with ILHR 83.05,Wis.Adm.Code d l X '" STATE ANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. PETITION I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES EC/;Al NO PROPERTY OWNER PROPERTY LOCATION '/a '/a, S ' P T oL�', N, R/,9 E (oryQ PROPERTY WNER'S MAILING ADDRESS I>e LOT NUMBER TILOCKNUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER C Y NEAREST ROAD,LAKE OR LANDMARK 6 ❑ VILLAGE : II. TYPE OF BUILDING OR USE SERVED: /� . %o• -��QV QO_00 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.® 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. ®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. R 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(Square Feet): .S Feet X Private ❑Joint ❑- Public VI. TANK CAPACITY Site in oallo ns Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xistin Gallons Tanks Concrete structed glass App. Tanks I Tanks 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: A- d o J� .2ee_ S-0 Plumbe Address( t et,City,State,Zip Code: Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST) ame CST# ST's ADDRE (Stree,City,State,Zip Code) Phone Number: p r/ Z VT 4111, IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial �Q� ,q �'y� rcharge Fee Adverse Determination 4 fu�' 92.6b /VJv� '/�t�'7�✓ o" X. COMMENTS/REASONS FOR DISAPPROVAL: �e('rY;t�- �I e�e-e ckd h y �' teary �'; .T��, �;•-Ls 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. r. �w — r r — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 00ner of Property re r J. G, � a w c Ca V ` Location df Pibperty � ' Section Dl�l2 , T p�0 N-R�� W Mailing Address t- I Address of Site► r U arm t Subdivision Ngme ( �{ ntiLot'Number .'Previous Owner!of property O `Motal Size of :parcel C Q � „Oate,Parcel,wim'„Created Are all cornetd and lot lines identifiable? Yes No Ia this property being developed for resale (spec house) ? Yes No E Volueate and Page Number aLi5as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warrant_v .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 T (We) eeAti.by that att .atatement6 on this bokm ane tAue to the best ob my (own) knowP.edge; that I (we) am (ahe) the owner(b) o6 the pnopen ty de6 cA bed in th.i a .cnboAmation bonm, by vi tue ob a wa4 ant deed neconded in the Obb.iee ob the . County RegiAta ob Veedbab Document No. and that I (We) puzenttCy Quin the p�iopoded b.c to bon the a swage di a Po b y6 (on I (we) have obtained an easement, to nun with the above de c4 bed pnopehty, bon the eon,6tAucti.on ob said *AbybZ¢m, and the dame has been duty neconded in the 046ice ob the County Reg-iaten ob fle�da, 44 Document No. ) . 'r r OWNER SIGNATURE F CO-OWNER (IF APPLI LE) 5 3 / 7-S-] y DATE SIGN i:)M1 State of Wisconsin County of St. Croix I hereby certify that this instrument Is a fuW, true and corred copy of the docM W-f an file and of record in my office and has been compared by me. Attest July 14 . 19 87 .Tames O'Connell James C+'Conner Register of D"* deputy ,��'_; j , :�` Y �,�,.�� .� .. ti r �, .. •. _ �h, ' s.{ r ., t. �' �+ � �,�,. s � ' � �, sr�-. ,.� �• �i�. r �:`} :Y+�t � � Sas e ;�'. 5. � ... 4, 5. -'��1 '. 1 " ka f�� � . f t�: „�.,,;.. �� ,� w „� . ,�. �. u ,-4 z En H • a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT 0 St . Croix County z r� a OWNER/BUYER OAC� ROUTS/BOX NUMBER P16Fire Number S� .CITY/STATE f D-Z-;n­�J Lbs ZIP !�7:' VO PROPERTY LOCATION: �6, N C— 14, Section, T�N , R W, Town of ( t (_ �/ , St . Croix County, Subdivision ki-(01 7'r 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 pdt 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 I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x 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 Offk< :e within 30 days of the three year expiration date. SIGNED 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 . J` DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY m BUILDINGS INDUSTRY, DIYiS101V LABOR AND P.O.BOX 790 HUMAN RELATIONS PERCOLATION TESTS (1151 MADISON,W153707 (H83.09(1)6 Chapter 145.045) UNICIPALITY: OT NO.. LK "11416.M: S DIV I : N �/�E'/ Z8 MIR/9�Ior _ %Po `1 tD�, Coukr COUNTY. ___._._ _N ER A • 4s3 OA k he J s S 4U/ USE DATES OdSERVAT10Ni MADE _ NOS COMMERCIAL DESCRIPTION: \ �KR sidan » Nk ❑NswReplacs .)(.)N& ZS O►CS 44�' 6 Z - 8u4r &.0 RATING:S-Site suitable for system U•Site unsuftalsie for system CW.C - b rk r S l__Ju. MQ S.Q� I Q ��L IQ�G T� . ECOMMENDED SYSTEM:(op iboE- _ _ j! CoNvcNr10 A p E� if Percolation Tests era NOT required DESIGN RATE: If any portion of the tested area is in the under s.N83.(39(5)(b!,indicate: IC[-ASS / lFloodplain,indicate Floodplain elevation: ��� �. PROFILE DESCRIPTIONS' BQfi1NU 1,1-0TAt. ~� QEPTH TO AT NC CHARACTER IL WITH THICKNESS, R, TEXTURE,AND DEPTH NUMBER ;PTH lei ELEVATION O – V TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) II. cS /Og,26 7 P.So t *&crS /Z~ BC�iY SL I� LT&RM ZAk, B- �cal,�, .t$ $RN MS fC,>e B- /Z.G7 //4.27 40NE > 12.67 a'' rs-^i�"G csC 7A$ S, 7S MS I B- MS t G� 5/ALT M s ON C 19Ems 1 e /hS </ -- -~ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST ME DROP IN WATER LEVEL-INEHES RATE MINUTES NUMBER IlsgWeS AFTER SWELLING INTERVAL-MIN. PER INCH P z iS.�Z �PT OT PLAN: Show locations o Percolation tests, soil boric a7td 11M AL. Tsitsble soil area. Indicate scale or distances.Describe what are the hori zontal and vertical elevation reference points and show their location on the plot plats. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVAT 107 3 Lor /o l4k4AQK.- C*A,4C I SCOOL iA /`6 � P� Alty� vN G�►JCRETk Aaa a �3 '24 ' D 4T AtW aX/MAT-t Lor Coto. • • . C�.C-v 2 /00-fib ., g•z N L e'T. 9 suoLC ...:..:::::. son .... .. . . ...::::. lGa::• 11 �.. .fe /bar//',Ba•'ni '9arhva Lac4-nor-/ o b:y as ..l • ff ,, I efrs Z1evt �` `�.reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin A' 'QOM" Fran(/�Q7wf�i the location of the tests are correct to the best of my knowledge and belief. NAM print TESTS WERE COMPLETED ON: —�✓ 144 +�NN50 SGN SUAVE iN I 3oNg. 27 /9'k 7 AQi�Z CERTIFICATION NUMBER: PHONE NUMBER(optional): 4o-7 'SF-coNN ST aubsoN 540)6 34 5.4 3%6. 46rso j;"ZkATUR E OISTPISUTION:Otujina(and one ropy to Local Authority.Property Owner and Seil Tester. L t)I1 6 ara ',J!,'-4 ,41r. +td .:'._1?) • OVER .�E CTSDiv Pilo rVS 1S Cor"CILETE PA40 OF C-LeCT'1%ZCAL- PAO /i '-r F) otiroN&E EL E V._ /OD.ou oAx Dn r vE i'zo 63• VEivT -mau< —Nv/LTj+ L Asr /°ZO�fZtY 1 7F \,. nE PLAC4M E.,/T SYS7-,-M /8 T Vu"/ OF T oY NOTE=P/lopoSED i✓iLaSvFiElb �- `� S7 C/zo=,x CD'/N1 Y Ss o�E2 /30' Frtvr� wFST IOAD PFn.7Y Ls v E �\ � '36 /�f0 1\133 �'�XYST2NG /�itxvE�.iOY / /V /f'Lo�/A'"'r\ s, � �_E/aST /�iio�tnTY ExrsrY,�G // W000EO AAEA Axle by ELL / nVoTe= PIto10o.rEo � Xl�tcx,.�F.�L D SS kXrsTSivv /YEW / �FFL�tFn f Soa-mj !o/toPEATY 1��\ /aoo GroL .S6/�TlC � L._TtiE L.=rvE T.nNI� /VO .SCI's L E Ewsrs /=XZS72n/G\ 60 Z I- - GAM6E — - - - - ' DES GE /_XZC7TN� NOTE= L-XxSTSN6 ,0AkAL-ovF=EL.0 I 71)l3E AtCDw£D TD /ZEST �oti O D/tRZNF2El n of cvty oar) L`xrsT='-'& ,O/tASsvF2ELYJ �" — — — — — —' Tip C�< Q.ZCCONNFGTI=/1 Ini�V/OL✓F FRESH AIR INLET AND OBSERVATION PIPE APPROVED VENT CAP ABOVE FINAL GRADE 4" CAST IRON VENT PIPE Mi AXIK4JM OF 42"ABOVE P I PE TO FINAL GRADE SIGNED: MARSH HAY OR SYNTHETIC COVERING LICENSE: MINIMUM 2"AGGREGATE DATE: OYER PIPE DISTRIBUTION PIPE � o TEE ;OIL TESTING BY: r- - / � ELEVATION BED 6"AGGREGATE • d BOTTOM PER SOIL,-, BENEATH PIPE PERFORATED PIPE BELOW TEST IS ` i COUPLING TERMINATING /O 2_? FT. A AT BOTTOM OF SYSTEM REPORT OF IITSPECTIO?J--I:JDIJIDiJAL SMIAGE llIS OS Sy. TF.Ii . Sanitary Permit • - C r/ State Septic TOWNSHIP • t. Crok. ounty SEPTIC TAUS: Size J412M gallons . `lumber of Compartments . Distance From: *Jell ft. 12% or greater slope ^' ft Building '_�,�ft. /8 Wetlands ^�. f Highwater ft, DISPOSAL SYSTL:1 Tile Field or Seepage Pit(s) Distance From: Well. ` ft. 127, ,or greater slope' e" ft Building - ft. Wetlands �` f FIELD Highwater ft. Total length of lines 7 ft. Humber of lines Length of each line wCft, Distance between lines ft. Width of the trench ft. Total absorPt�on area sq. ft. Depth of rock below tile din. Depth of rock over tile _in. Cover _ nver.rock,, . Depth of tide below grade in. Slope of trench -L-in ner 100 ft. Depth to Bedrock ft. Depth to ground water . PITS Number of pits Outsi a er ft. Depth below inlet ft. Gravel around �' `y no. Total absorption area sq. ft. - Square feet of seepage trench bottom area required Square feet of se �e nit ar uired Inspected �1e': . . App ed Date 197 Rejected Date 197 1 _ —.� ..: _ ., " r� , �,�� r d . � _ _ _ - � � __ __._— . _ 11 i � .__ r ..�' _, ,.�.,r _. _ ___ �__.. � �� .. , � ", � . f .:. �_. � � I . ' � __� �,__ ,� � �� EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON,WISCONSIN 53701 �/y �`� REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: 0/4,C&/a,Section � ,TAl, R 4.!%(or)�fownship or Municipality �©y + Lot No. —T—, Block No. , a A �e ��u s^ County Sub ivision Name Owner's Name: t/ A �^ Q Mailing Address: �� 50 . R 1 jD C ju !mil P 1 ��0 y J �Ac� L Ad A7>1] SSII q TYPE OF OCCUPANCY: Residence No.of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW X. ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS 17-77 PERCOLATION TESTS -5 7 7 SOIL MAP SHEET �r 1 SOIL TYPE 4 3 7'1�1'Z- CAI',6-1 "nl iA 14°13 l-, PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE NUM INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P_ re" ;2'y X2_ IZ, 2 0 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) t' �' �,� _ �6•� �� 3!A/ S�,a, SAC, ei S I7 PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. In t n ber of sq are feet of absorption area needed for building type and occupancy. ar ndpZe -1 or distances. Give horizontal and vertical reference/poi'n'ts. Indicate slope. >r Sys Qs.,. . � ....rte" y a MA 0 • v 0-40 AW o o � / � s r It 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 dataxecorded and location of test holes are correct to the best of my k wledge and belief. Name (print) Certification No. Address 4 Alp Name of installer if known 'CST Signature. COPY A—LOCAL AUTHORITY P L B 6 7 State and County State Permit # Permit Application County Pernfitj# for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: ell . &ellv)y B. LOCATION: �'%4 AIE'/4, Section T N, R '1& (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village cou I Township C. TYPE OF OCCUPANCY: Commercial Industrial Other (specify) Variance Single family _ Duplex No. of Bedrooms A� No. of Persons Z D. TYPE OF APPLIANCES: Dishwasher C YES NO Food Waste Grinder YESX-NO "# of Bathrooms_; Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY J nC)n_Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement_ Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2)_,?.a3) Total Absorb Area qS sq. ft. New Addition Replacement *Fill System Seepage Trench: No Lin Feet Width Depth Tile Depth No. of Trenches . Seepage Bed: Length Width Depth Tile Depth__ 36�, No. of Lines 3_ Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope_:�r) _ I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil resters, p NAME tj (,S 1 i� ( �-rQ_P4 FN50pj C.S.T. # `� j - 1S0 land other information obtained from Iven Ade 0 AK A/C (owner/builder). .q Plumber's Signature MP/MPRSW# Phone #h%- 29Yd Plumber's Address 2 # & /�;* . 00 c% ffv n W., - o / PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). 4/05 L �I m ISO' ti0U5e p PRID �„�.�eeD _ Do Not Write in Space B low FOR DEPARTMENT USE ONLY a p� Date of Application 70 Fees Paid: State�D , Od Count�- -f-�--Date Permit IssuedA d (date) v2 Issuing Agent Name Inspection Yes-,A5 o Valid# Date Rec'd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON,WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date