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HomeMy WebLinkAbout040-1115-80-000 O �. 0 c C� O O N N N C i ,q I � I I i s I w I 0 z c LL LL c C O Q � i Z y E rn u = o Z 00 r a m M F- Z c O c v O z Z d' � U r O N O to h r rn Z c -o M co C�7�lVl = n N c O Z m Z NZ N c O R O d i E O. M w O co d L O ~ O o O O a n c w m E LL H H H o 3 3 Z � O O O �. a �y g �i m O N r n N 00 rn � v O 1!�l o o , o m d N ) N N � M Q E fA O ° m �n c o 4. O W = U N zp 0 0 Q CL co 0 W ,, c Y O c CV L' In 3 N y C N a N M r..i .- N T ''. m M 7 Z' E .0 D • 7a ° O O p C2 y f6 O m - y O M I- U p O z v 0� cc d a a ++ E ca C c 7 3 :a o A 0 a 2 0 v> 0 Parcel #: 040-1115-80-000 02/22/2007 01:15 PM PAGE 1 OF 1 Alt. Parcel#: 30.28.19.473E 040-TOWN OF TROY Current X 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 0-WOSKIE, MICHAEL MICHAEL WOSKIE 300 GLENMONT RD RIVER FALLS WI 54022 Districts: SC= School SP=Special Property Address(es): '=Primary Type Dist# Description '300 GLENMONT RD SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 5.320 Plat: N/A-NOT AVAILABLE SEC 30 T28N R19W NW SW EXC E 1008 FT Block/Condo Bldg: EZ-UT-1499/346 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 30-28N-19W Notes: Parcel History: Date Doc# Vol/Page Type 09/19/2001 656979 1721/378 WD 07/23/1997 1200/401 WD 07/23/1997 784/459 07/23/1997 705/316 2007 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.320 73,000 171,100 244,100 NO Totals for 2007: General Property 5.320 73,000 171,100 244,100 Woodland 0.000 0 0 Totals for 2006: General Property 5.320 73,000 171,100 244,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 121 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 PUMP CHAMBER r 1 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: X Trench: Width: Length: L? r Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear,0 Ft . Number of feet from well: �� Number of feet from building: o4o � (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, O 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 Form - S T C - 104 r t AS BUILT SANITARY SYSTEM REPORT OWNER 1Q� l�°s �/ C TOWNSHIP L SEC. Tom'° N-R,� W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE eT PLAN VIEW Distances and dimensions to meet requirements of ILHR, 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM p�y i ��K�0' ��1A�►E, f3 Q &5 (�req CJ_ p!.. 0 INDICATE NORTH ARROW �VI BENCHMARK: Describe the vertical reference point used r wret- �4s �h S'fhP Elevation of vertical reference point: 160 Proposed slope at site: 16196 SEPTIC TANK: Manufacturer: f 5' Number of rings used: T Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side,0 Rear, O feet From nearest property line Front 10 Side,( Rear,0 1�,� feet 1 t Number of feet from: well ;;>:!;/j9 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 R.O.HOX.7969 BUREAU OF PLUMBING MADISON,WI 53707 �ry SW�,. NW,,` S30,T28N—R19W ??CONVENTIONAL 1:1 ALTERNATIVE State Plan LID,Number Town of Troy ❑Holding Tank ❑ In-Ground Pressure ❑Mound (If assigned) Glenmont Road /> NAME OF PERMIT HOLDER: ! J ADDRESS OF PERMIT HOLDER' INSPECTION DATE: � William R. Cosgrove 1346 7th Ave. South, South St. Paul, 111 55075 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: rl`.PT ELEV.: Name of Plumber. MP/MPRSW No. County: Sanitary Permit Number Thomas A. Wang 3231 St. Croix 96036 SEPTIC TANK/HOLDING TANK: MANUFACTURER, LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED. PROVIDED'. /000) IUa C 3 I�Q TES ONO DYES LINO BEDDING: VENT DIA.. VENT MAT L: NIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH /� �, ALARM LINE: AIR INLET DYES ®NO l.L OYES 10 NEAREST \50 DOSING CHAMBER: MANUFACTURER. T71 LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑NO DYES ❑NO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL. BUILDING.JVENTTOFRE H (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. PUMP ON AND OFF) ❑YES 1:1 NO NEAREST= SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LE vGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH. NO,OF DISTR PIPE SPACING. COVER JINSIDE DIA. 1t PITS LIQUID .BO � TRENCHES. I / MATERIAL: PIT DEPTH: €IM#N #ON GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO R NUMBER OF IN WELL BUILDING. VENT TO FRESH BELO PIPE$ ABOV COVER. ELEV.INLET ELEV.END PIPES'!) FEET FROM "LIN�E7 r� A�I�T- // / py NEAREST /5 U d8 7'L 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 YES ❑NO DYES ❑NO DEPTH OVER TRENCH/BED 7PT H OVER TRENCH/BED DEPTH OF TOPSOIL. SO DDED. SEEDED. MU MULCHED CENTER GES. ❑YES ❑NO EYES ONO DYES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: 1p1 C1 1� WIDTH: LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. ,IEdRNH TRENCHES: !J}bII�N$FONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. ELEV.: ELEV: DIA.. ELEV.. PIPES: DIA.: ak Pt i#2l Ttoil Fda p. IX,, HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED T�} .. PLANS: DYES ❑NO ❑YES —]NO COMMENT PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER O PROPERTY WELL: BUILDING: FEET FRO LINE: ❑YES ❑NO ❑YES 1:1 NO INEARJEST_.!__� 1 D 7 Sketch System on rl (Retain in county file for audit. Reverse Side. S SIGNAT- TITLE: DILHR SBD 6710(R.01/82) Zoning Administrator i f _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 pei`mit 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 OF 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; 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; lll. 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'h x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scare 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 alter included the creation of surcharges (fees) for a number of regulated practices which Wisco in'S 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 fhe 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 ILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code ,, ,.e,..,..�,,o� STATE SANITARY PERMIT#91e&3& 17 —Attabh 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 X NO PROPERTY WNER PROPERTY LOCATION S I^DU� '/a 0%, S 36 Te)d, N, R E (o W PR 3ERTY OW ER' MAI NG ADESS LOT TBER B SUBDIVISION NAME e-_� CITY,PTATE ZIP C DE PHONE NUMBER CITY EST ROA LAKE OR DMARK 5�0 7 VILLAGE: IV— rot 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. �ew 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. RSee a e Bed b. ❑seepage Trench c. ❑ Seepage Pit Idex Fo 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): aj �� Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons I Total ##of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks nks Ta structed Septic Tank or Holdina Tank d0 WC° ❑ ❑ ❑ ❑ 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. Plumb is Name(Print): Plum r ignature:(No S mps) MP/MPRSW No.: Business Phone Number: /�-� lumber's Address(Street,City,Statef,Zip Code): Name igner: VIII. SOIL TEST INFORMATION Certified Soil TTeZer(CST)Name CST# / Q / (�� CST's ADD ESS treet,City, tate,Zip ode) A /� }♦ Phone Number: D 9 v G/ IX. COUNTYIDEPARTMENIr USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) rvr `{tDt' S harge Fee LJN Approved ❑ Owner Given Initial ! Adverse Determination X. C,QMMENTSiREASONS FOR DISAPPROVAL: .� SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber • r 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 iG i Oosckroyf,., Location of Property _ � , Section , T Z_$ N-R W Townshi EXeeft F_aSfecty 1008Fee7 Hailing Address ���7 LCI CJ �l SCo 75 Address of Site R�Verl�sr �!sc• z Subdivision Name . Lot Number Previous Amer of Property t Total Site of Parcel 5,,�� . Date Parcel was Created ar y m S" Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number y5� 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) ceAti.6y that au Atatements on th,iz akm arse t�cue to the best o6 my (ours) hnowtedge; that 1 (we) am (aAe) the owners �s ( � 06 the pnopenty descAi,bed in this .i.n6o4mation 6onm, by Vi tue o6 a waAAant deed Aecoaded in the 066ice o6 .the 2,7868 County Regust¢h o6 Deeds a�5 Document No. ; and that I (We) pneaen�y awn the phopoded site 6oh the Sewage pas 6u em (on I (we) have obtained an easement, to nun with the above de, ch ibed pxopeh ty, bon the cond.thuc ti.on o6 said system, and the dame had been duty keeakded in the 066tee o6 the County Reg.i,a.teh o6 Veedd, ad Vocipen t ) . M, rnra , , — SIGNATURRE 1Olt OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) 7- ,7- -� DATE SIGNED DATE SIGNED • IIC.MNIerCompoW DOCUMENT NO. STATE BAR OF WISCONSIN-FORM I !�• WARRANTY DEED �y�( (� 'VOL p (� THIS SPACE RESERVED FOR RECORDING DATA U786S g4PAGF. 45g rcLItxlSTERS OFFICE THI� DF�ED ade between C.J. Skyline, formerly •T. Cmix CO., WIS: Clancy Jue1�s, a single person by Roca. f i ftncord this 7th Rona ue s, ttorney-in-Fact day of July A.D. 1987 Grantor i 1: 00 R M4 and William R. Cosgrove and Megan M. Cosgrove .. RpYlr N Daad� Grantee, W i t n e s s e t h, That the said Grantor, for a valuable consideration RETURN TO conveys to Grantee the following described real estate in St- Cm]X County, State of Wisconsin: The NW 1/4 of the SW 1/4 of Section 30, Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin, EXCEPT. etCey No. Easterly 1008 feet thereof. FED This is riot homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; AndC•J• Skyline, formerly Clancy A. Juelfs a gjagle Berson by Ron ald .T1iP1fa' warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except NONE *Attorney-in-Fact and will warrant and defend the same. Dated this 29th day of June , 19 87 (SEAL) (SEAL) * *C.J. SjoylineVformgrly Clancy A. Juelfs, (SEAL) a single person by Ronald Juelfs, (SEAL) * R.Attorney-in-Fact AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this day of STATE OF KKXX)Q= Minnesota l , 19 tss. Ramsay County. . Personally came before me, this 29th day of * June 1987 the above named TITLE: MEMBER STATE BAR OF WISCONSIN [ _ T- v no�o 2l=-via"vSzrdii-r8,(If not, authorized by §706.06, Wis. Slats.) a single person by Ronald Juelfs, Attorn ey-ii- Fact This instrument was drafted by Charles Hoyum (law) to me known to be the person—who executed the. fore- 46 East 4th Street #224 going instrument and acknowledged the same. St. Paul, MN 5510 (Signatures may be authenticate or acknowledged. Both are not necessary.) Notary Public Washiri n County,Wkpmv My Commission is permanent. (If not, state expiration date: Nove nber 11 , 19 2.) "Names of persons signing in any capacity must be typed or printed below their signature fVVVVVkV%%AA^AA,*v%^AA/viv~ REBECCA L KORKOh KI NOTARY PUBLIC- 'L_ II WARRANTY DEED—STATE DAR OF WISCONSIN, FORM NO. I-1977 mvrnmmieein..ICy.....,, !I 'An 2 I /BM � f ICITE r ide 4 Ol v v vv 1 = l�/ N � O � N ,B C D C F G S. g7A S. 024 5. 09A 5. 09A 5.09A -5"09A 5.09A -K:c" tiiA a Z 0 s S. o9A / 5 I a 1 4 D 66 s � —W- O" -•-....,.-8 SS Old ! 8SS 176 i- i o �P -tz) o If • 856 Bb. � � Cenl-e) •of Sec. 3o, Jrz8 N, 2 /9 W , 1 r he,-eby cc�rfff'y -fhc�-� -��j;s n-�ap /.s 4 f'rU� c/ryd Gor/-ecf repre.ser/�- n, �,i 4 q-/i'on of the G. J. Sky/i'ne /nna�s �i 1 � qs fagsea� oYj records o f' ,Surveys �h my of'f'ice. S. �z e9 /3, /975. t i i IV- ; ME5 R. GRU 38 t t �eyi s fered L.ghd Sc.�rvec 1 i �q //5, w/ s . ,ZGO VIzIo It t i REVISIONS No. DATE •Y I Y ' Sic. 34.E T,28 /V, /Z /9 Troy 7"./p., S74, Croix Lo.� [ DRAWN [Y j K^c •CALF r3zoO MATERIAL ` CHK'O OAT[ ",7S DRAWING NO s TRACED A►r'D J ti H z H 9 r ST C - 105 r" 9 H SEPTIC TANK MAINTENANCE AGREEMENT o St. . Croix County z d a H OWNER/BUYER `rck ROUTE/BOX NUMBER P.nb11�t<1 Fire Number CITY/STATE ICi . I.JrS. ZIP CC)2- PROPERTY LOCATION : _, 5 c't/ �4, Section, T Zg N , R W, �KeQ'f �asfer 1008 Feed Town of� �f t . Croix County, Subdivision , Lot number I 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 !I 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 agree: to submit to St . Croix County Zoning a certification form, signetd 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 ti three year expiration . o E z I/WE, the undersigned , have read the above requirements and agree x 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 "witin 0 days of the three year expiration date . SIGNED DATE ���-8 St . Croix County Zoning Office P .O . Box 98- Hammond , WI 54015 715-796-2239 or 715-425-9363 Sign, date and return to above address . INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 5395 To be a complete and accurate soil test,your report roust include- - 1. Complete legal description; 2. The use section must clearly indicate whether fliis is a residence or commercial 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; 6. 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; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete 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 riot apply, place N.A.in the appropriate box; 1 1. Sign the form and place your current address and your certification number; 12. i`~llake 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 HGbV - High Groundwater cs - Coarse Sand Pere - Percolation-Rate med s - Medium Sand W - Well .,fs Fine Sand Bldg - Building Is - Loamy Sand > - Greater Thai) 4sl Sandy Loam < - Less Than 'I Loam Bn -- Brown sit - Silt Loarn BI - Black si - Sift. Gy - Gray cl - Clay Loarn Y - Yellow scl - Sandy Clay Loam R - Red sici - Silty Clay Loam mot - Mottles SIC - Sandy Clay wi with sic - Silty Clay fit few, fine,faint 'c Clay cc; -._ common, coarse pt - Peat mm - Many, medium m - Muck d - distinct p - prominent HWL - High 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 permit, The county or the Department may request verification of this soil test ill the field prior to perrrri( 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 perrnit. -The sanitary permit must be obtained and posted prior to the start of any construction. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS IVDUS TRYY,, INDUS GG DIVISION HUMAN LABORAND PERCOLATION TESTS (11J) MADISON WI 53707 09(1)&Chapter 145.045) LOCATION: SECTION: MUNICIPALITY: LOT NO.:BILK.NO.: SUBDIVISION NAME: 7'' -a"//V� _76 /k`�b'H 9E (o W �� 161 - 1 COU 6^ , OWN,ER'�UYER —F Ca�� AILING ADDRE S: �� Q USE^(! ((//�� `' A�c DATES OBSERVATIONS MADE NO.ND BMS : COMMERCIAL DESCRIPTION: PRO IL DESCR PTIONS: PER)O T107TESTS: Residence 5j�qew ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) NS ❑U ES ❑U S ❑U ❑S U ❑S RUA nca. :ago' 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: r I Floodplain,indicate Floodplain elevation: _J 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 BACKJ B- f �,©o bb.50 one B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 PERIOD 3 PER INCH P- l 7510 0 k P- P- ..0 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 Aa 2 O b _ _ _ 3 3 N � E Y` ...(?I .. Ta. P a A8 _ u�� Q E --- - - __, . - - - - -- — -- - _ 16 4) od,e I E E fly o' 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): I TESTS WERE O PLETED ON: ADDRESS: , nn CERTIFI ATI N NUMBER: PHONE NUMBER(o tonal): C S d CST SIG R L DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. D I LH R-S B D-6395 (R.02/82) —OVER— r . � f �3 I � � i � ao. ��,yck� C Ilacc • i