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HomeMy WebLinkAbout040-1209-50-000 \ y 7 C) } ~ ° K (D 7 ( 0 $ 0 I ƒ/ i /\ � §f I Ea f § I 2 ' > m #) � } J/ LL ;5 E I 2 )} � � ? $ Cl) � \ k g \ § IL % I ( B 2 / $k k } CD � § \ � \ 2 0 ) i } ; I -� I & \ 8 ) CL I k 0 i . a I \ .. § a ] I k ) E a \ k § k § I 2 \ a a) , & S I / 0 2 o a � & # _� « r p ( 2 G 4 § § § • m / a a a R 2 ) \ § \ \ k I } \ \ \ ° & I C) § a . ° 0 @ E 2 ± % ( # \ ■ U, a I 2 S 2 m b E g = o 9 0 ± ) I $ \ § % % \ k k \ \ / ( / E / c 5 a Q / z , ■ _ / C') $ m 2 c o \ § / / \ Cl 2 p / / \ � ® I \ m k CL . — 5 2- L a » I w E ) § © § & 3 a 2 3 k j . . � 1 PUMP CHAMBER b 4 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: C - Z 3ZSL f�eE�uce� Width: 5'-0'4' Length: Io!!!�-a'` Number of Lines:469aorea Fill depth to top of pipe: 34'� Number of feet from nearest property line: Front, ©Side, O Rear, Ft . �5�-O" Number of feet from well: 94 W, Number of feet from building: 4��-7_1% (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, 0 Rear, Q Ft. 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 �,l r Fo rm - S T C - 104 • AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP ;2-IoS; SEC. T N-R W ADDRESS ST. CROIX COUNTY, WISCONSIN (►2 1� 6-m' ]Z S4UZr-1 SUBDIVISION LOT S LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Ell - O ToP _ INDICATE NtRTH ARROW BENCHMARK: Describe the vertical reference point used -1yea [ fit , I E 2, &WxjEt, Elevation of vertical reference point: 160-00 Proposed slope at site: 414121 SEPTIC TANK: Manufacturer: Liquid Capacity: to 6*oL0VJ Number of rings used: Tank manhole cover elevation: %A0 Tank Inlet Elevation: 9S," Tank Outlet Elevation: QS_35 Number of feet from aearest Road: Front,O Side,Q Rear, O d, /���j' feet From nearest property line Front,0 Side 10 Rear,© �g-/ feet Number of feet from: well `� building: (Include this informatioi 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?#16L9 BUREAU OF PLUMBING VTask]E�%'% 'Y HN—R20W CONVENTIONAL ❑ALTERNATIVE sratePlanLD.Number: Town zf Troy (If assigned) ❑Holding Tank ❑ In-Ground Pressure El Mound Lot 5 St. Croix Highlands NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DTrE: Steve & Janet Talafous C/O Jeff Swenson, Route 3, Box 188A, Hudson 11-3-87 /0:3 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: Thomas H. Cody 6593 St. Croix 96023 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: IWA.NINGLABEL LOCKING COVER ^ ' PR DED: PROVIDED: YES ONO EYES NO BEDDING: VENT DIA.: VENT MATL: HIGH WATER NUMBER OF ,ROAD: PROPERTY WELL: BUILDING: IVENT TO FRESH f ALARM: FEEL,FROM LINE: AIR INLET: OYES ONO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTUREF, BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO DYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF" PROPERTY WELL BUILDING:I 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 FORE LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until MA#N the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.. #PITS. LIQUID / TRENCHES. MATERIAL: PIT DEPTH. GRAVEL DEPTH FILL DEPTH DISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COVER. ELEV.INLET ELEV.END PIPES. FEET 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- ❑YES ❑ meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER TEXTURE PERMANENT MARKERS: JOBSERVATION WELLS. ❑YES ENO OYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED. CENTER. EDGES. ❑YES ❑NO El YES ONO ❑YES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: ap WIDTH: LENGTH: NO.OF LATERAL SPACING:JGRAVEI_DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER TRENCHES: °„e ' MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. JNCLDISTR. DISTR-PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEV.: ELEV.: DIA.. ELEV.: PIPES. D A,: IRE �► O�i Nti °tJl "�t1�UT�QN. HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED �+ U PLANS: ❑YES 1:1 NO ❑YES ONO COMMENTS: p—/ PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING y S J FEE^I FI IM LINE: l/`///) ❑YES ❑NO ❑YES NO NEB E'S'A Sketch System on Retain in county file for audit. Reverse Side. . TIT LEDILHR SBD 6710(R.01/82) [7ATURE Zoning INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION • TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private'sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed 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 owners name and mailing address. Provide the legal description where the system is to tie installed; 1!. 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 vkith 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'/z 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. -------------------------------------------------------------------------------------------------------------------------------------------------------------- i I 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 Grouncywater included the creation of surcharges (tees) for a number of regulated practices which Wiscorr itrfs a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that, buried frea5ur'B 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. a The monies .collected through these surcharges are credited to the groundwater fund adrninis- )ered by the Department of Natural R-sources. These funds are used for monitoring ground- t vaate!, groundwater contamination investigations and establishment of standards Grounr,Mat-:r, ''s Alcrtt: protecting. 3D-6398 fR.03/86) SANITARY PERMIT APPLICATION COUNTYY ����++IJ////��,�� ^/� j2ILHR In accord with ILHR 83.05,Wis.Adm. Code STATE ANITARY6ERMIT# —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 NO PROPERTY OWNER P %S,- %a,S Td� , N, R old E(or)t0 PROPERTY OWNER'S MAILING ADDRESS LOT MBER BLOCK NUMBER $SDIVISION NAM Cre ," is CITY,STATE ZIP CODE PHONE NUMBER Cl Y NEAREST ROAD,LAK OR LANDMARK 6Y40 1/' VI LAGS: h:9 (e-L II. TYPE OF BUILDING OR USE SERVED: ' Number of Bedrooms if 1 or 2 Family OR EPublic(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or, ,if applicable) 1. a. [Y New b.❑ Replacement c. ❑ Replacement o d. ❑ Reconnection of e.❑ Repair of an System System Septic Tank On y an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil condition meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. A ttach 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. ❑ Exp Brimental 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. ❑ Seepage Bed b. X Seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTIOt I AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Sq are Feet): IN 6 5v 7 3' � Feet Private [:]Joint ❑ Public VI. TANK CAPACITY in allons Total #of Prefab. Site Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufact rer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank r f.J21 Lift Pump Tank/Siphon Chamber I ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT 1,the undersigned,assume responsibility for installation of the private sewa ge system shown on the attached plans. Plumber's Name(Print): Plum er Signature: o Stam P/ PRSW No.: Business Phone Number: �C� a.� � - �3 �r�' 9 Y� 3 3Sy P mber's Address(Street,City,S t ip Co e): Name of Designer: to,VIII. SOIL TEST INFORMATION CeMieq Soil Tester(C;T�Name CST# CST's ADDRESS(Street, ity,State, e) Phone Number: E IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved F-1 Owner Given Initial Surcharge Fee Adverse Determination /od_U(3 CAzS:Cov X. COMMENTSIREAAONS 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 �%t.,J tA A,%0 3A,4* 1`. "iA�.AAO j Location of Property NA 1 1%, Section T _2_8 N-R 2,(:) W Township Q-�� eoQJ614c Mailing Address 12-76 UJtLSp,J AVibizE, Z 0 to Address of Site �j o i jog] ekj2g. DVI Subdivision Name Lot Number Previous Owner of Property ptiL H. \.1%LuA-h 4.h4,4§161 , s%_1ef2&1N A Total Size of Parcel . ACPC-> 2 PcnA%ej t:!0 Q&,L T. FAiELLM+A Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume 62-7 and Page Number 3-20 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPFRTy OWNER CERTIFICATION 1 (We) eent%6 y that ate statements on this 6otm ate tAue to the best o6 my (out) knowledge; that I (we) am (ate) the ownet(s) o6 the property de.6cAibed in this insotmation 6otm, by viA tue ob a waAAanty deed tecotded in the 044ice os the County RegisteA o6 Deed s as Document No. 3c)G-10 S and that I (We) ptes entty own the ptoposed site 4ot the sewage divspos system (ot I (we) have obtained an easement, to tun with the above d6cAi,bed ptopehty, 4ot the eonsttucti.on ob said system, and the same has been duty tecotded in the 044ice o4 the County Reg.ustet of Deeds, as Document No. SIGNATURE OF OWNER SIGNATURE OF CO-OWNER ( APPLICABLE) 6ZI7 J�U 17 S 7 DATE SIGNED DATE SIGNED I, 'DOCUMENT NO. S^ E BAR. OF' ;VISCONSIN .FORM 1-1982 1 T.11, IrAUk. hESERYF.D FOR RECOROINO DATA ryCC�� ri WATANIY DE��D. .!'• 396 I Q� I VQ: (1�,� jPAc,�, ,�0 t This Deed, made. between Del H. Einess., _ ST. CROIX CO., WIS. Lance A. Norderhus-, ._William -S S . _Myers, __. Rec'd. for Record this 1st Clifford A. Peterson and Paul T. Fjellma�lautor,s day of Oct. AD. 198Zi .... ..... -. .. . _ ` Ot 1:00 P and .... ...,Steven- M...-and_ Janet_L... Talafous, As .j.oint...tjBnants_ _.. I Grantee, 1 Witnesseth, That the said Grantor, for a valuable consideration. ... . --- .. . ------' . .. .. . ..._ . ..__ . conveys to Grantee the following described real estate in .. St-. CrolX. I RETURN 10 County, State of Wisconsin: rte_ Tax Parcel No- -----------------......_.....----•- Lot Five (5) , St. Croix Highland, in the Town of Troy, according to the plat thereof on file and of record in the office of the Register of Deeds, St. Croix County, Wisconsin I ITANSFF_ This, ..,1 S not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And----- --- --- -----Granto.r.s..._ warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except NONE and will warrant and defend the same. I. 1�f _ day of ._......,. I.i.� �l. j;..It . (:............... _... , 19..__... Dated this _..._ . - _..... y t�.r.. _-.. .._ _ (SEAL) � f. 4? EAL) Del H. Einess Clifford A. Pederson (SEAL) I �G2GG(� S ,FAI, • Lance-.A...Norderhus..,._ -... . Paul T. Fje n ,*William . AUTHEN ICATION ACKNOWLEDGMENT Myers STATE OF WdAN s 1 Signature(s) .................................------------------------- . -------------- ss. ...................................................-.........................._ County. 7f I ................. 19-.8 4. the above named authenticated this ........day of................ ...__...., 19...... P Bona y came before me this ...... ... .... ay of •-•-•-•--•--.. ...................................................... --•--•--- -....Del.. _..Eilaess,.--- �.................... •..... ..... •---- ..Norderhus.,--.hTi,lliaxn.. ...M_y_exs,........ TITLE: MEMBER STATE BAR OF WISCONSIN � eat1',� ,P xd ---•-••-•------ I (If not, ------------ --. a.Llj..' authorized by § 706.06, Wis. Stats.) ` too�tt� know to lt(Cl,tl'ik I(ld"bn'a�Ji;i01A wl0 executed the f gwng ini;tr4,m n l a1; cl e`same. �P f5 THIS INSTRUMENT WAS DRAFTED BY '•� V '" vVv�' ---- -------- - Del...H.....Niness... .1. ............... -•--- . ... 5100 Edina Industrial Blvd. *. r / Ed-inak---MN---5543'5-------6.12-83-5-68,66 --- Notary Public .�E.X�!�d��? _. ____.County, VVis.lil,.. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 09u4;r4 3 Z ----- --------.- •Names of persons signing in any capacity should be typed or printrd below their signatures. i WARRANTY DEED STATE BAR OF WISCONSIN wi�emnMn Les-ml Blank Co. Inc. FOR%I No. 1—1982 Milwaukee, Win. C� -< � cn Noun rn .... Wo ft lu e � � .. �-' '' y•-= a v. +� vl r fn � �C t- O %, .t� i; - .. to c� <) n ( (.,) �• •U •_" .t� �t ') rn iJ !t' v N ,� J' r7 ... !r 'rs C` ,n ..) '\ !'�, .. ` �.:: r• `,1 "' '~.rte,. - ! w Of rho �j tv v ra rL r,- Q p, r Z tt, ro ry .., 1 1 m rn Cr 'rJ CJ G .•, O . �., •., F `�{ —•n "E� " t1. 't ,; tJ 0 FA ZCL ri if W U !' ,1., r� n .t rJ n C1 A U M 1.•, ,-•• 0 m ju r ,. Lt r 3 ., r• L1. b1 t•J (,, ;. . 7. is ... C/` f? •n r• ,{ :' lJ T] z .. � I c AS, boom. 0 m 17 z' z z I� 1. 3.1Z.OVON / t pl N urL N'r U� OI N $ ql oow . 2 � k A z I v N r 3..CC.69 OS W n N d ZS,4£G,S i W a� I N 9 i \ N 67 to 44 m \ M � � t o H� \\ N t rn W ci 0 N O \� vy 9Zy 4 p�, m ip co Ak /�. 7 \ � t� 0 + IL I M..00.00 08 nLn --..... .. 't t a �co :J ✓. r•.. N r, r► u O N O 1 I �7 A r � G /y MA&.90 0$ r w t � ra ti IC �! of ti V) ST C - 105 r a SEPTIC TANK MAINTENANCE AGREEMENT 0 St . Croix County z a rj OWNER/BUYER '5I1N(,.3"� ��� �- _VNL.R�O`A5 rra ROUTE/BOX NUMBER Q . 'Q . •j , OQ4 mQq Fire Number • J CITY/STATE RAJ- � uS } � ZIP j4Q2Z PROPERTY LOCATION : _ / 14, Section_ , T Z,S_N , R 2-C) W, Town of TRC)q St . Croix County , Subdivision. CP,01J OiC—AkAi `p Lot number '5 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 se p tic 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 . a I/WE, the undersigned , have read the above requirements and agree Cn to maintain the private sewage disposal system in accordance with x 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 . SIGNE4 6 ��i8? 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 1Y5 - SBD ' 6395 ^ . To be complete and accurate soil test,your report Must include: 1. Complete legal description; 3. The use section must clearly indicate whether this is residence or*ommamim| project; 1 MAXIMUM number of bedrooms or uommcpoia| use planned; 4. Is this new or replacement system; 5. Complete the suitability rating boxes. AS|TE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; S. PLEASE use the abbreviations shown here for writing profile descriptions arid completing the plot plan; 7� MAKE /\ LEGIBLE diagram accurately locating Your test |000dnnc Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make Sure your benchmark and vertical elevation reference point are o|omdy shown,and are permanent; B. Comr|'u* all 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 apply, place N.A.in the appropriate box; 11. Sign the form arid 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 nob — Cobble (3 lO'') 3S — Sandstone gr — Gravel (under 3") L8 — Limestone °s — Sand HGVV — High Groundwater os — Coarse Sand Pu/c — Percolation Rate m,0o — Medium Sand VV — Well fo — Fine Sand Bldg — Building Is — Loamy Sand > — Greater Than °o| — Sandy Loam ( — Less Than °| Loam 8n — Brown °si| — Silt Loam 8\ — Black d — Silt Gy — Gray °d — Clay Loam Y — Yellow sc| — Sandy Clay Loam R — Rod sin| — Silty Clay Loam mot — Mnu|pa sc — Sandy Clay m/ — with sic — Silty Clay M7 — fmm. fine,faint °n — Clay wn — common,coarse pt — Peat mm — Many, medium m — Muck d — distinct p — prominent HVYL — High water level, ° Six non,m| soil textures Surface water for |iquid waste disposal BM — Bench Mark VRP — Vc,doa| Reference Point TD THE OWNER: Thiu m`i} rest mpow is the first Step in securing a uanicery permh, The county or the Bepartmcm nmye4uo# veri4i0o1ion of U`is »oi| tez in the field prior to permit issuance. A complete s+u of plans for the private aewaUe oyotnmanJ a pmrmir application must beoubmiuud /n ,hempp,op,iate local outbo,kv in o,deru/ ubrain n Thnsxnitury permit muu be obtained and posted prio,to the meuotanv construction, TMEN70F REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUS INDUSTRY, C DIVISION BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090)&Chapter 145.045) NCgTION: SECTION: TOWNSHIP/ LOT NO.:BLK.NO.: SUBDIVISION NAME: 1/ 1/ �S /T4 N/RIOE(o ►W TRoy s s,- Qo��c �4 �c LANos COUNTY: &WWE-R'S/BUYER'S NAME: MAILING ADDRESS: P V GAJ Sf•CeO(K S+r=uE 3 TAA3mT 'rA(Af OJs e/a T--ff StaWWO.A), T4 3, 130A 188-4 47I S . s yo/ - USE DATES OBSERVATIONS MADE NO.BE MS.: 3 / COM ERCIAL DESCRIPTION: I PROFILE `a DESCRIPTIONS: PERCOLATION TESTS: Residence /y,h gNew ❑Replace 0 • / _IG / i RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND- IN-IN-FILLHOLDINGTANK:RECOMMENDED SYSTEM:(optional)®S ❑U ®S ❑U OS ❑U ❑S CCU ❑S AN TAE s o.��r . `l HijI'A OTQEv«,e Do Z LiL1ES Z If Percolation Tests are NOT required DESIGN RATE:=_ If any portion of the tested area is in the under s.H63.09(5)(b),indicate: CIA 5 S Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS IA1 '_DECIMAL ` + BORING TOTAL" DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH 3- NUMBER DEPTH IN. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) vc r B- 0' 97• �6 1 S ' D1F�1334 S i , S ' B►t . $ �.<07 ' O c o v Scr > O S/ T�eu .4n, TIAJ e S • � 33 0 rooks.*-5"1, /G7 fr.Le S ) . G G B-2- 9�,oi , �. � a 4,ey C , 47 n�X.of TAN f.s.t cs. = T y 5 ':D-. IZO. s%l, . s ' 73a . �y. s��, l.s` ore . c ovlp� xy B- 3 z - �o , 1,33 • T4 K) O� �S �7' �� f,•N� s - i 75,E ��' Ra Si I I. ZS' BN-yy Si/� ,43' 010-IW - B- I, 5 TAN) VERY cs A N NA- s . N B� �f l 7 0' ytQ- > �, y 7S' Pk EA3- S%/, 1.a P I?u .s I h p ' oR• c s, .W7-- ev five I T,4 A+ u cS �. ' �� B- '17r1 rJ f 1, S p—j r PERCOLATION TESTS C$' S7�6}7-*_ o TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES 09 f- NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 P RI D 2 PERIOD PER INCH y0 P- -3' oZ y 7b-4 P x P- Z I P i fr ,ro P- 3 d c P I PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent =s of land slope. 93- �7 ' 'RFLCj imEA>,0A rfo,J ; Z1SE POOP 13ox — i SYSTEM ELEVATION / �J !� ovE12 s►ZE TIeGNG�QS . _ _ I(+ [E 1 7 (�...y: ......._,..._l l ...§§§ ."rr .�. .� r„_,. .,�,. .......... -...� ..... ., �y...."._.m.y......-_ `#'� . __j` 0 >' N kw E I ' � E *4- ( 'l SSA El _ N � �-4 _._ _ 3 _ This te onve 3 i 1 E � f i } i 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. Bt NAME(print): TESTS WERE COMPLETED ON: RE 3 CIVIL RD NIIMN WIS 501A HOMESITE SEPTIC PLUML C0. /F ADDRESS: ROBERT ULEIRICHT QERTIrICATION NUMBER:: PHONE NUMBER(optional): MS.MASTER PLUMBER LIC.NO. 3307 M.P. fJ q; `Yb(J 3 .NO OD6J`11` /YC dad STS ATUR onA -1 OFF/�F DISTRIBUTION: Original and one copy to Local Authority,Property Ow DILHR-SBD-6395 (R.02/82) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND BOX 7969 HUMAN RELATIONS PERCOLATION TESTS (115) P.O.MADISON,WI 53707 (H63.090)&Chapter 145.045) LOC N SECO K NO S . sr. .: SUBDLVISION NAME:'/ '/4 �S /T4 N/RZOE(o W T2o y COUNTY: 9WNER'S BUYER'SNAME.:� MAILIN ADDR HUO 40AJ -54 'C pl K StE(7E � 3l�A-lET II�IAf ou_5 19'b' off St9,r,vro d jpq 3, (3DX l8��1 W I S • S V0 x USE DATES OBSERVATIONS MADE NO.BE MS.: COM R IAL DESCRIPTIO I S: ,Residence 3 1 �• ZNew ❑Replace L/1 _ D / ��GD / _ ', / "' v jQ �O � RATING:S=Site suitable for system U=Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE:S STEM-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) v os ❑u ®s ❑u as au as au ❑s au TQ�� s 0,0 4r . TPEiuC6..tS O►�t �. Link;• �NI'M uM Z If Percolation Tests are NOT required . DESIGN RATE: any portion of the tested area is in the �J under s.H63.09(5)(b),indicate: C1_4 5 S Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS 14 3�EGiAol3kL If+ BORING TOTAL DEPTH TO GROUP DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION BS RVED EST.HIGR—EST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) yr r B- / �'0 9�• l� ? - . 5 ' A4- 13 a - S , . 6" ' BA). s , /.Io-2 ' O SI I.83`T*�► ut R c s X V -b-Aix S Al sj / a quy c 40 7 McX•of ?gym f.s.� CS. _ O ' l � Zz > q .S 'Dt- (3,x. 5:/, . S ' 13a . J�/. Stl,�2.,5 OR . cOuk4{ by B- .3 — / 0 1,33 ' T44 VER C S 7 ,EA.) ff'a.c S - i o L Q . 95 ", 'r Ra• Si I , I. 15 B"-yy. s'd .83' Op-W . s� B- / L l ��l /`Q` / I, Ti a r-R CS N N; N b - la B� Cf 00 - > 4', 5/ .'7S' ��' Qa. S�/, !•o?' 130 .51� /,p ' oR Csl N -b-Air Taw uagv CS ,v B- Tr►N f Nit Jr . *1 r PERCOLATION TESTS -0 /N 06e y CS SY�pi 7-4— p TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RA E MINUTES r NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD I PER INCH 0, P- 3• Y -� P- P- P_ r Z P- ,d 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- S 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. �J2, 2- 'RELOHrrEUDAT%O.J USE- v OP 13ox — i SYSTEM ELEVATION / „•J oVE/2 Si2E rjeeuci hs , r 3 � _ is x _._.�� .a__ �..t._.� ._foR.__ _.,r.,- _._ - ._ _- � — } --; Al I NN. u _� - rt - ; isite r _ h I .qn i 40 P , I j 1 I 5 or i E 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: HOMESITE SEPTIC PLUMOM CO. b a 7 ADDRESS: R06ERT ULBRICHT CERTI ICATION NUMBER: PH3h-ONE NUMBER(optional): WIS.MASTER PLUMBER LIC.N0. 3307 MARS ;Y y CST S ATUR DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02182) —OVER— Permit No. Owner 's, name H63.05 PLOT PLAN Show: Location of building served NR Dosing chamber Septic tank Vertical/horizontal reference point cj oT*1 QBuilding sewer System elevation is T Effluent system Q well Replacement system area Property lines w/in 50' of system Distribution boxes Scale = � =3�� , or dimensioned i P Pum and controls: -- 1J A — Mfr. & Model No. Vertical Lift Size Force Main i Friction Loss T. D. H. Vol, Dist. Pipe Gal. per Min. Gal. per Cycle Place check mark in appropriate box, indicating item is shown on plot plan ,below: i i t — pl c�,..� -Sy�P17c TEt�..►k NI 7-s'oP%4 PV S 8oX I � f � B3I II y„CI ? I y< 1°Ib X131 tT — C � AC'�lx1MAZE w�tc ( p_ ParJ +Iv 5T S& FZoM S,fSTEM> Uj J � I i ,� I✓Z I L,�T � 1 � , �. �t S;Rl$u�0►J �-�i PL-60�lA►J 6 P2 LoT_S B� $y BYRE GPE`R '� _ rIBM-e- Itzo-b'oN-w-oP 57Fe- t-UC Po-571 r�s REDvl R>� &y 2r� lj�:-ia- LOT CO�=k)Gr\� ►>.�t2 83. 0 � i� C— L Iv C- C La By the granting or approving of the above plan, or upon the event of a subsequent permit being issued,St.Croixcounty and theSt.CroixCounty Zoning Administrator, does not assume or hold itself liable for any defects in plans or specifications, plan omission, examination oversight, construction, or any damage that may result in or after stallation. aa - (o5S3 - P ei:'s signa ure — icense o. a e T�.•+ 3l S-�IL ;4' Pv nE,, Z6 of � -2"/a -PIE 9 -3 SE A-r- 3y C>TZIGJ�J)Qt:L _Z—_7-Ta P' f—=Y,CA J 3 OZ YSI A.3�L L L _1EL 6513 q q_r)