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' Parcel #: 040-1188-30-000 01/1412005 04:26 PM
PAGE 1 OF 1
Alt.Parcel M 36.28.19.806 040-TOWN OF TROY
Current I X'
ST.CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): '=Current Owner
*FENZEL, RAYMOND L
RAYMOND L FENZEL
57 W WOODRIDGE DR
RIVER FALLS WI 54022
Districts: SC=School SP=Special Property Address(es): '=Primary
Type Dist# Description '57 W WOODRIDGE DR
SC 4893 SCH D OF RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 0.445 Plat: 2237-OAK RIDGE ACRES
SEC 36 T28N R19W LOT 53 OAK RIDGE ACRES Block/Condo Bldg: LOT 53
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
36-28N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
01/22/2002 668990 1820/222 WD
07/23/1997 790/66
2004 SUMMARY Bill M Fair Market Value: Assessed with:
27598 207,600
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.445 35,000 173,000 208,000 NO
Totals for 2004:
General Property 0.445 35,000 173,000 208,000
Woodland 0.000 0 0
Totals for 2003:
General Property 0.445 25,300 159,900 185,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 102
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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,Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
,5 7
SOIL ABSORPTION SYSTEM "-2
Bed: y Trench:
r
Width: f 2 Leng't'h: Z Z Number of Lines:— Area Built: 6 y
i
Fill depth to top of pipe:
Number of feet- from nearest property line: Front, 0ide, O Rear,0 Ft .
Number of feet from well: / 7/
Number of feet from building: S—/
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job:
License Number:
3/84:mj
k�
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER U _ p��,LQ, TOWNSHIP SEC. T .2LN-R�Q
ADDRESS / -PG E;4-*t4 �-kZ�ST. CROIX COUNTY, WISCONSIN
SUBDIVISION Ax&4-LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•ZHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
w
� I
s-s
0
INDICATE NORTH AR OW
- v
BENCHMARK: Describe the vertical reference point used _�Z.Cet�( �, c�dl.►glLl
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TANK: Manufacturer: d) CA J k� Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elev tion:
Number of feet from nearest Road: Front, Side o Rear, O feet
From nearest-property line Front, Side, Rear,O feet
Number of feet from: well irO r building: Z-3
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
'L
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.BO)e 7969 BUREAU OF PLUMBING
MADISON,WI 53707
S.W4, NW14, S36,T28N—R19W XM CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number:
Town of Troy El Holding Tank ❑ In-Ground Pressure ❑Mound (lf assigned)
Lot 53 Oak Ridge Acres
NAME OF PERMIT HOLDER: AF PERMIT HOLDER: INSPECTION ATE:
Ray Fenzel 128 Emory Drive Apt. 2, River Falls, WI 54022 16-1S1-9 '7 3 W
BENCH MARK(Permanent refe,i a point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.:
Name of Plumber: MP/MPRSW No County Sanitary Permit Number:
Henry Nechvill 3258 St. Croix 99089
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WRVIIES NG LABEL LOCKING COVER
P ED: PROVIDED:
ONO [:]YES O
BEDDING: VENT DIA.: [VENT MATL'. HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH
ALARM: FEET FROM LIN AIR INLET.
❑YES O ❑YES NO NEAREST
DOSING C AMBER:
MANUFACTUR R. BEDDING. LIQUID CAPACITY PUMP MODEL JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ONO ❑YES ONO OYES 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 ONO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until MAIM
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
` WIDTH ^ LENGTH- 11\0�01` DISTR.PIPE SPACING. COVER JINSIDE DIA.. #PITS. LIQUID
BED/TRENCH / TRNCHES MATERIAL: PIT DEPTH
DIMENSIONS [7
GRAVEL DEPTH FILL DEPTH IDISTR,PI E 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 ONO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE JPERMANFNT MARKERS OBSERVATION WELLS
1:1 YES 1:1 NO DYES 0 N
DEPTH OVER TRENCH'BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. MULCHED:
CENTER. EDGES:
YES ❑NO ❑YES El IOYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
ry WIDTH: LENGTH. NO.OF LATERAL SPACING E.. GRAVEL DEPTH BELOW PIP FILL DEPTH ABOVE COVER.
0EDfTRENCH " TRENCHES:
011MIENSIONS
f MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
E' UATION ANI3 ELEV. ELEV. DIA.. ELEV.. PIPES: DIA.:
1'=TION V TION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
E1 YES ONO ❑YES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY I WELL: BUILDING:FEET
I ❑YES ❑NO ❑YES ❑NO NEAREST LI
l
� `71
Sketch System on 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 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 priv=tt<, 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:
1. Property owner's narne and mailing address. Provide the legal description where the system is to tie
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 dweliing;
111. 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 81/2 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 Groundwatbe--
included the creation of surcharges (fees) for a number of regulated practices which Wisconsin,S a
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that curied �tdsilP !
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.
0
The monies collectec-. through these surcharges are credi,:ed to the groundwater fund admirlis
tered by the Department of Natural Resources. These funds are used for monitoring grou-d- t
v�ater, groundwater contamination investigations and establishment of standards. Ground vatf_r,
it's worth protecting.
56D-6398(R.03/86)
DIL R SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05,Wis.Adm.Code
•a. ..a.�.�..�..� STATE SANITARY 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
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES E NO
PROPERTY OWNER PROPERTY LOCATION
Q. . � _5MP14 ,!/!1 %, S 3 GT , N, RXWE (or
PROPERTY OWNER'S MAILING AD TRESS LOT NUMBER BLOCK YBER SUBDIVISION NAME ,,• -
CITY,STATE ZIP CODE PHONE NUMBER 7n CITY NEARE T ROADOK-An OR LA_ NDMARK
Ill. 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. ['d 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)
P,TI
1. a. See a e 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):
Feet rivate ❑Joint ❑ Public
VI. TANK CAPACITY Site
Nn alIons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks I Tanks tructed
Septic Tank or Holding Tank ` BOO
Lift Pump Tank/Siphon Chamber IYA
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 St am MP/MPRSW No.: Business Phone Number:
/Vh /vtir �/ ��s8 7y9-33-F
Plumber'd Address(Street,City,State,Zip Code): Name of Designer:
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
l-A car G Gl�"/)'J L h - f Y-S-
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
i S'-gd3
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved I S nitary Permit Fee Groundwater ate Issuing gent Signature(No Stamps)
Approved ❑ Owner Given Initial
urcharge Fee
Adverse Determination � �r
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
APPLICATION FOR SANITARY PERMIT
STC - 100
his application form is to be completed in full and signed by the owner(s) of the
roperty 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 9ct.
Location of Property u) �� Section - f� , T �' N-R�
Township
Mailing Address ? M�
Address of Site
Subdivision llama
Lot Number �
Previous Owner of Property
Total Size of Parcel r9d' ,`�(, Q�
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 and Page Number Lw".. as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WarrantyDeed which includes a Document number, volume and page number, and the
Seal of the Register of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) ce-A-ti,6y that ate Atatement6 on thi,6 onm aAe true to the best o6 my (oun)
hnaotedge; that I (we) am (cute) -the owneh(.s 06 the phopeAty deAcAi.bed to thiA
i"4v ►mat ion 6o4m, by viAtue o6 a waAAanty deed kecokded in the 06 ice o6 the
Cowtty RegiAten o6 Deeds aus Document No. e;20-796, ; and that I (we) pne�sentty
avn .the pnopoded elite 6oh the -sewage di/spo's aye em (on I (we) have obtained an
eaeemen.t, to 'tun with the above deischi.bed pnoperrty, bon the condtnuction o6 said
eydtemp and the dame hae been duty n•ecohded in the O66tce
Detdb, ae Doemen t No. 06 the County Reg idteh o6
)
SIGNATURE Of OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
FUCHI - 5 T C 1U0
4
Owner of Property a �/ 7 �
.Location of Property .dal 14 A)V ection -3 ,T_�_$N R_�
Tawnehip__ ��
Mailing Address A Q r
Subdivision Name C'.
Lot Number_ ,L
Previous Owner of Property A
r �
Total Size of Parcel X
Date Parcel Was Created
Are all corners identifiable? 6' Yes No
Include with this application one of the following :
. Certified Survey Map
. Deed,
. Land Contract , or
. Other Vagal Document which describes the property
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that 1 (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No. 60-V�! 78G, ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
Of the County Register of Deeds, as Document No. ).
SIGN TORE Of WNV8 SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIQNEQ DATE SIGNED
-- ---: __.___—_. - THIS $FACE RESERVED ►OR RLCORDINO DATA TF
DOCUMENT NO. I STATE BAR OF WISCONSIN FORM 1-1988
WARRANTY DEED i
' NOOK 790
j
97$6 - REGISTERS OFFICE
This Deed, made between ._Rapia--- _.-.Niemi.•and.............
ST. CROIX CO., WIS,
....Mar-jor_ie...Ii....Niemi.,/_.husb and-_and-.wiLe•••as...3raint-•• l Qec'd. for Record this 1st
l.�l.kl�_. axjax .. �lit� •--•............... ii
tenants• day of Sept. A.D. 198
......--•-_..., Grantor,
............ •---•• 3S 30 P1
�• aymond:::�� T`enzel and Jennifer E. t M4
antF'enzeY, husband and wife as survivorship marital ,
..........................................
;----- •--••---
--.-•--•-•---
----------•-•--- �gMer s! DOWN
Grantee, 1 I
1t11et3 (pth That the said Grantor, fo a valuable consideration_.on
dol'Iar and other good and valuable considerati -- ------ _=-
....... .. . ..........._.........----------- .............................................................
--•------•--------------•. ••-------••---•:--...._..._
_...__. i RETURN TO
St. Croix
conveys to Grantee the following described real estate in ................
County, State of Wisconsin:
Tax Parcel No: ...................................
Lot 53 , Oak Ridge Acres, Town of Troy.
n i
SOW
TES
I.
�IThis ........is TlOt..... homestead property.
(pf) (is not)
liTogether with all and singular the hereditaments and appurtenances thereunto belonging;
I; And. Rayno..D. Niemi and Marjorie H. Niemi..................
if
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except y
easements, restrictions and reservations, if any, of record.
and will warrant and defend the same. //�� Q�'+
(9. day of ..._.*7U. ------ ---------•---.--.--.--------•-----...._, 19�?.. ..
Dated this ........PA
........................................:.............................(SEAL) _... .
�. ._.... ... .. . . ............(SEAL)
R no D. Niemi
+ ---• -----.... e
(SEAL) _........ ....................................(SEAL)
-•-----••..........................................-•-•-••......._
_ _..Ma._.�orie H. Niemi ..alkla.....
Marjorie Niemi
AUTHENTICATION ACBNOWLEDOMENT
Signature(a) ............................................................. STATE OF 'P XXVIO MK
NEW YORK sa.
................................................................................ ......................................MONROECounty.
authenticated this ........day of........................... 19...... Personally came before me this ..,2.QTJi....day of
AUGUa T................._.., 19. .Z... the above named
.............•-.............................._...............------•---•----•-.
............... - --------------
............................................ ...• ---......----.......... _._...
TITLE: MEMBER STATE BAR OF WISCONSIN
r'!ar3orie 1?�:-• Niemi
(If not. ............................................................ --..... -•------------ •----___---•-......_...••---••---............
authorized by 4 706.08, Wis. State.) to me known to be the person 5.......... who executed the
fo o instru en an cknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
................
Russell E. Berg, Attorney at Law '
Dou las Bantle , Es
1 5 N� Main S£ree£ - -- --5. ............................• -........ �.. ..........
i Ri�xer-..Falls. W1...._54.•22_---•___________________ Notary ?ublic ............."MR0 1 ...............County,)m N.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(if not, state expiration
j! are not necessary.) date: -Regis . X4793739-April 34 1989.---,)
I.
*Names of persons signing in any capacity should be typed or printed below their signatures.
1 �1
[TTI"1 HTATR n8ft OF WISCONSIN
.. J
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STC - 105 9
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
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OWNER/BUYER /{ CL V M
ROUTE/BOX NUMBER /;,-9 �,ry�.�., liJ1 Q& �D 2 Fire Number
.CITY/STATE /Q,.� //J.1,( ZIP
PROPERTY LOCATION: .SCV 14, /VU/'16, Section 6 , T 2�Z N , R /2
Town of aw , St . Croix County,
Subdivision C0_A )94_:, 41 Q.eAA,,j_, 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
r+
the standards set forth, herein, as set by the Wisconsin Depart- ►v
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED i 'yam
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 .
ti yf
d
w
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 5395
To be a complete and accurate soil test,your report must include:
1. Complete legal description;
2. The use'section €must clearly inditate vZhether this is a residence or commercial prdject;
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;
0. 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 rnay be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
d. 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 not apply, place N.A.in the appropriate box;
11. Sign the form and place your current address and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION,
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st Stome (over 10") BR Bedrock
cob Cobble (3- 10") SS — Sandstone
qr — Gravel ('under 3") LS - Limestone
s — Sand HGVV -- High Groundwater
cs — Coarse Sand Perc - Percolation Rate
med s — Medium Sand IN — Well
I's — Fir're Sand Bldq — Building
Is Loamy Sand > -- Greater Than
'sl - Sandy Loam < — Less Than
i — Loam Bn — Brovvn
'sil — Silt Loam BI -- Black
si - Silt. Gy — Gray
'cl — Clay Loam Y — Yaliow
sill _. Sandy Clay Loam R — Red
sicl — Silty Clay Loam mot Mottles
se — Sandy Clay vv,` with
sic — Silly Clay fit — few, s"ine, fant
'c Clay cc - common, coax>e �
pt Peat rYrm — Many, medium
m — Muck d -- distinct
p — pron-)inert
HVVL — High vvatcr level,
Six general so;i textures surface water
for liquid waste dispersal BM — Bench Mark
VRP — Vertical Reter€ince Poin'r
TO THE OWNER:
This soil test report is the first step in securing a sanitary permit. The county orthe Department may reoUest
rifit,at;on of this soil test in the field prior to permit issuance, A complete, set of olans for the private
evvagn system and a permit application must be submitted to the appropriate local awhority in order to
o stain a Perrnit. .fhe sanitary perm it muse. be iabtaiired and p<:}steci prior to the start of ar3y construction..
1
OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
rQEP,�WTMENT
INDUSTRY, DIVISION
rL'ABQRa4ND PERCOLATION TESTS (115) MADISON WI 969
HUMAN RELATIONS
(H63.09(1)&Chapter 145.045)
L CA ION: SECTION: TOWNSHIP MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
SW �4 NW'/4 36 /T28.N/R/9 E (or TROY 53 N. A. OAK RIDGE ACRES
COUNTY: OWNER'S DYER' NAME: MAILING ADDRESS:
ST. CROIX RAY FENNEL 126,1M0R,Y, DRIVE APT; 2, RIVER S- W/y _54022
USE DATES OBSERVATIONS MADE
NO.BEDRMS,: COMMERCIAL DESCRIP77,,--//,, PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence , 3 N A IJNew ❑Replace 6 - 26 - 87 6 - 30 - 67
I
RATING:S=Site suitable for system U=Site unsuitable for system
CONN/V�ENTIONIAIIL: MOUND: IN-GA�R—O}}U�ND-PRESSURE: SYSTEM-IN-FILLHOLDING�TA{�NK:RECOMMENDED SYSTEM:(optional)
US EIV OS I US ❑U EIS DU EIS I U CONVENT/ONAL /2X 32 BED
If Percolation Tests are NOT required DESIGN RATE: y �I V LJ
4 I If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: CLASS / Floodplain,indicate Floodplain elevation: N.A.
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK) 1
B- / 7.8' /.00.4 NONE 7.8' OnI12.3 ') en IrI1.2'/ On r 14.3 '1
B_ 2 7. 51 99.8 7.5 Bn I (2.399n I r (0.7') On r a n o pr f4.59
B-
3 8.3 ` 99.7 iI y 8.3' Bh,:/ f 2. /9 On ii f/. 3 '1 8n Is f0.5'1 On s /4.4'I
B-
4 7. 7 ' /00. / ' Ir y7. 7' BnI12. 6'1 BnIr(0. 69pnt 14.59
B- 5 8. 51 /00. 01 /i 5 8.5' Bn / 1 2.6'1 On r/ (0.7'1 On /s (0.4) 8n r (4.6')
B-
S OIL SHEET 91 P /L LOT S1 PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ I 4 . 1 ' 5 4 112 " 4 //4 4 I/4 !
P-
p- 2 3.81 S 5 3 718 " 3 7/8" 3 112 " 2
P U
P- 3 3.5' S 5 4 " 3 718 " 4 1116" /
Lp-
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 96.3'
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I,the undersigned, hereby certify that the s sts re� &n this for ere made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code,and that the data recor d ` d the to n of the.f are correct to the best of my knowledge and belief.
NAME(print): ^ TESTS WERE COMPLETED ON:
LAURENCE W. MURPHY 6- 30- 87
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
R/ BOX 36 A RIVER FALLS W/ 54022 55 - 2443 425 - 9032
CST SIGNATURE:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
D I LH R-SB D-6395 (R.02/82) —OVER—
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