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042-1012-70-000
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Parcel M 05.29.18.76B 042-TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O-BLAISDELL,TIMOTHY A TIMOTHY A BLAISDELL 1116 105TH ST ROBERTS WI 54023 Districts: SC =School SP= Special Property Address(es): *=Primary Type Dist# Description * 1116 105TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE SEC 5 T29N R1 8W PT SE SW LOT 1 CSM Block/Condo Bldg: 5/1285 TOGETHER WITH 66' PRIVATE RD EASEMENT FOR INGRESS AND EGRESS MORE Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) PARTICULARLY DESC ON SD CSM 05-29N-18W Notes: Parcel History: Date Doc# of/Page Type 07/23/1997 872/626 2007 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/19/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 25,000 83,300 108,300 NO Totals for 2007: General Property 1.000 25,000 83,300 108,300 Woodland 0.000 0 0 Totals for 2006: General Property 1.000 25,000 83,300 108,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 156 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 i J r 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: Length: Number of Lines: 2. Area Built: 7.2p Fill depth to top of pipe: '& Number of feet from nearest property line: Front, O Side, O Rear,(�rFt . Number of feet from well: Number of feet from building: > /Vg r (Include distances on plot plan). SEEPAGE PIT vo,.f i 90• yG Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 0 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: Inspector• 0 � Dated: l Plumber on job: License Number: 3/84:mj z Form - STC - 104 AS BL 1T SANITARY SYSTEM REPORT OWNER / � ��,� TOWNSHIP � SEC. - T,2'? N-R/,-9 W ADDRESS /m S" s� ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE �— PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM fx,s�H9 Qri/K wov ArrJr+/ 6d 0 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used L Elevation of vertical reference point: /Va a Proposed slope at site: ,Z 2 SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: " �- Tank Inlet Elevation: -- Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side 0 Rear, O 7 so feet . . From nearest- property line Front,0 Side,O Rear,O 'O feet Number of feet from: well ? S� , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR&HUMAN RELATIONS SAFETY&BUILDINGS P.o.Box,7sss PRIVATE SEWAGE SYSTEMS DIVISION MADISON,WI 53707 BUREAU OF PLUMBING NE4, SW4, S5,T29N—R18W MCONVENTIONAL ❑ALTERNATIVE Stale Plan I.D.Number: Town of Warren ❑Holding Tank ❑ In-Ground Pressure ❑Mound (I(assigned) 105th Street NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Todd Packer 105th Street, Roberts, WI 54023 f0-a0�7 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: 3`06 REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: MP/MPRSW No County: Sanitary Permit Number: David B. Fogerty 3289 St. Croix 99118 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: IWARNINGFLAB�NO LOCKING COVER PROVIDED: PROVIDED: BEDDING: VENTDIA.: VENTMATL. HIGH WATER ❑YES ❑YES ❑NQ ALARM. NUM OF ROAD: Pq OPERTV WELL: BUILDING: I VENT TO FRESH DYES ❑NO FEET FROM LINE HAIR INLET: ❑YES ONO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER ❑YES ❑NO PROVIDED: PROVIDED NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL ❑YES ❑NO ❑YES ❑ (DIFFERENCE BETWEEN N PROPERTY WELL BUILDING VENT TO FRESH 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.) L MAIN CONVENTIONAL SYSTEM: B1=.wI �•f•RENril"I WIDTH. LENGTH- NO.OF DISTR.PIPE SPACING. COVER 4 / TRENCHES NSIDE CIA #PITS LIQUID 01MENWONS /Z MATERIAL: PIT DEPTH: GRAVEL DEPTH FILL DEPTH DISTR.PI PF DISTR.PIPE DISTR.PIPE MATERIAL NO.DISTR BELOW PIPES- ABOVE COVER ELEV.INLET ELEV.END. NUMBER©F PROPERTY WELL: BUILDING VENT TO FRESH PIPES :FEET FROM 'LINE: AIR INLET: MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for FERS E A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ERSE SIDE.SHOW ELEVA- ❑YES meets the criteria for medium sand. EASURED. ONO SOIL COVER rexruRE PERMANENT MARK : OBSERVATION WELLS. DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DYES —]NO DYE S ONO CENTER. EDGES. DEPTH OF TOPSOIL. SODDED. r ED- MULCHED: DYES ONO ❑YES ❑NO ❑YES ONO PRESSUURIZED DISTRIBUTION SYSTEM: •BEtiTRENCH. WIDTH: LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. TRENCHES: FILL DEPTH ABOVE COVER: `0IINtC1NS ' MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL &MARKING: �s, '.ELEV.: ELEV.. DIA.: ELEV.: PIPES. DIA.: ;EL„E�tATI€3N AND 131STRIBUTION' CNEC1RI41ATION'' HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED '. PLANS: ❑YES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM '.LINE: / ❑YES NO ❑YES ❑NO NEAREST I l0 .�/a f /o ioA Sketch System on Reverse Side. Retain in county file for audit. 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 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, 608-266-381:5. To be complete and accurate this sanitary permit application must include: 1. Property owners name and mailing address. Provide the legal description where the system is to be installed; 11. 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-for►n. t ------------------------------------------------------------------------------•-------------------------------- 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 (tees) for a number of regulated practices which Wiscori irt`s can effect groundwater The surcharge took effect on July 1, 1984. All of the water that burie, treasure 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. through these surcharges are credited to thi group(+water f_nd adrn;rtiis 0 e, by E Depdrtrnent r)f Natural P sources. These fund's are used for monitoring guru•{ - f -u-11water contaminatio.i Ire`,estlgationS and establ€shm,_nt o f standards �arCJrlrt ti CIF �' 1 's v,,cr1U,, protecting. :_;iu-Ease rn.03!86) .4 ®ILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code O/x WMNWM" STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than / 8%X 11 inches in size. STAT PLAN I.D.NUMBER —See reverse side for instructions for completing this application. 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. PETITION FOR VARIANCE DYES ❑ NO PROPERTY OWNER PROPERTY LOCATION Packer ne %4 sw %, S 5 T 29 N, R 18 E (or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME 105thSi__ -------- ---------- ------------------------ CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, Roberts WI 154023 246 5271 O VILLAGE : WARREN 105th St. 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 3 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. seepage Bed b. ❑seepage Trench c. ❑seepage 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): 15 615 Feet O Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank -11000 000 Unknown Lift Pump Tank/Siphon Chamber ❑ ❑El VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plum ture: No Stamps) MP/MPRSW No.: Business Phone Number: David F ert 3289 49 3656 Plumber's Address( treet,City,State,Zip Code): Name of Designer: Roberts, WI 54023 D. B. Fogerty Vlll. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# CST's ADDRESS(Street,City,State,Zip C 3233 ode) Phone Number: RnC;Prf.�L TjrTt.,q Rd Roberts, WI 54023 49 _ IX. OUNTY/DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee Groundwater Date Iss ng Agent Signature(No Stamps) Approved ❑ Owner Given initial y / x rc rg9_"ee Adverse Determination 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 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 )cdc� Location of Property S k �L)\Pj__Jx, Section , T_ a9 N-R�� W Township ,►. c rrf n Hailing Address New l RVC-6n0n it Address of Site Q-} l{ RA(oa e uo k ck rn 6 5 0 Subdivision Name . Lot Number Previous Owner of Property pc( nn li rye C!U le rv-ta''1 . Total Size of Parcel Q` P Date Parcel was Created _ Jc -� Are all corners and lot lines identifiable? _Yes No Is this property being developed for resale (spec house) ? Yes Volume and PaLob ge Number 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) cehti6y that att Statements on this 604m ane tAue to the but o 6 m knowledge; that 1 (we) am (cute) the ownen(b) 06 the pnopeAty de�scAi.bed iny ) this .in6o4mati,on 604m, by viAtue o6 a wwvcanty deed neconded in the 066.ice o6 the Co Regi4ten 06 Deeds as Vocument No. ; and that I (We) pAuentty own the pnopoded b cte bon the aewage di6po.b d yb em (on I (we) have obtained an easement, to nun with the above d6cnibed prope74 bon the cond.thcuction o6 said system, and the name has been duty neconded in the 066.ice o6 the County Reg.ia.teh o6 Veed6, ae Document No. 3 y 5-_y ey- ) . _ A SIGNATURE Op OWNER SIGNAT OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED A e F- P , w ow NOW f Alk a. �',�,, 1t_, � '�,� .c e ',•rte � e .�..�,W r 4�: ��47• .} �-`- fr' � xY �. �! s Z rr }3, a A R y P� ,1 i gig• ,_ ,� tAir '5th AMA/ {5 JaTME QpNNMf ;:# " P�l Ai r » w : a H«a� b t� M►com�gilnioe Esow. —/ r, s�nrn�ntand. ,tome w1ow soi'T zailt H , z rn y a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT Ho St . Croix County z t� AA D 1, a OWNER/BUYER TOd6 M . $ Nnr1nP N- `Gc�i�e✓" ROUTE/BOX NUMBER Fire Number 1591 .CITY/STATE New R1C11r)Ipr,d ' W ZIP 15 L4 PROPERTY LOCATION: 5E W 'k, Section T 09 N , RJ_W, Town of W(a r y-p n St . Croix County , Subdivision Lot number_. Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists of pumping out the septic tank every three years or sooner , if needed , by a licensed septic tank pumper . What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix. County residents m_y be eligible to receive a' grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior - to July 1 , 1978 . St . Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained . The property owner agrees to submit to St . Croix County Zoning a certification form, signed by the owner and by a master plumber , journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary) , the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration . 0 E I/WE, the undersigned, have read the above requirements and agree En 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 . 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 . r r INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test,your report must include; 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or 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; 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 may be used it desired; 8. Mal<e 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 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 — Stone (over 10") BR — Bedrock cob — Cobble {3- 10") SS — Sandstone gr gravel (under 3") LS --- Limestone *s — Sand HGVV — High Groundwater cs — Coarse Sand Pere - Percolation Rate med s — Medium Sand W - Well fs Fine Sand Bldg — Building Is — Loarny Sand > - Greater Than �sl - _Sandy Loam < - Less Than *l — Loam Bn Brown 'Asil — Silt Loam Bi — Black si — Silt Gy -- Gray �cl — Clay Loam Y - Yellow scl --- Sandy Clay Loam R — Red sicl -- Silty Clay Loam mot — Mottles sc -. Sandy Clay wl -- with sic — Silty Clay fff few, fine,faint 1 c Clay cc - corrmmon, coarse p# — Peat corn — Many, medium M Murk 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 vorific.ation of this soil test in the field prior to permit issuance- A complete set of places for the private w4rcie, system and a permit: ar)[lication rnust he SA:mrittecl �:'W.:�Jrr. t. �'rdor o oblai„a permit. The sanitary hermit must be obtained arld posted;,J.-J ij:rrot'o thy;stare 01af,ly construatio n> k _J DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS ' INDUSTRY, DIVISION LABOR / ND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS 1 / MADISON,WI 53707 (H63.09(1)& Chapter 145.045) LOCATION: SECTION: TOWNSHIP ET O.:BLK.NO.: SUBDIVISION NAME: NE 1/SW1/a 5 /T 29 N/R 18 E(o ) WARREN COUNTY: OWNER'S MAILING ADDRESS: St. Croix Todd Packer Roberts, WI 54023 USE Phone - 246- 5271 DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILEDESCRIPTIONS:IPERCOLATION TESTS: Residence 3 n d New ❑Replace 8-17-87 8-18-87 RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) Q S ❑U Qx S ❑U ®S ]U x❑S []U x❑S ❑U 1gravity 12 X 52 bed 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: n/a class I Floodplain,indicate Floodplain elevation: none PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- / > y c B / S / > /erp B- > B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH P_ /S is 7 P P- t o 1 P-_ P- 'y y > > — 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 € - �- I € I1 € 2 --- E E j � � J € a 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 k'howledge and belief. NAME(print): FOGEM PLUMBING TESTS WERE COMPLETED ON: Licensed Perk Tester & Plumber 8-18-87 ADDRESS: #3233 13299 CERTIFICATION NUMBER: PHONE NUMBER(optional): Fogerty Mel is Road Phone 746.3686 DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — � � o J u M I�zl n n n� I i i t V w a sm� l � IN �y h � O ca l p C p� W h � f (� �1 ~�� �CD R _X IL � g , 1 I � u � a < < • pvy ^ (D h c 3 I H Y) I O -6 c a N a E� cc M U O .p 04 O m L.o c N O r0 y Co U L a dH E N C N w o'€ O U a a Z OO N 1L o cm r- °O f�6 N,O Q co O N N v a3i I Z y I a E go C z o o z v (D z v a o to F- N z co N o W N NCL •t�v n o 'a a 15, I � � �� I Q z° mz N z:: co _ d N r.. ca E co I . w L {p _U a N $' w ° ° c c a ° > 35 � z z � > � I •N � aaa ti a tv B m O co co Lo ° ° O E ^ 00 c a' m Q cn m O O N C a r� n o w ° c 40 c m ° N tt E Z rn • 0 0 Lo 7 0 N 0 Z C 0 (n O Cd Cd w E v e a d c I �1 A ciao Oa0 t Parcel #: 042-1012-70-000 10/04/2005 04:36 PM PAGE 1 OF 1 Alt. Parcel M 05.29.18.76B 042-TOWN OF WARREN Current LX1 ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner TIMOTHY A BLAISDELL O-BLAISDELL,TIMOTHY A 1116 105TH ST ROBERTS WI 54023 Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description * 1116 105TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE SEC 5 T29N R18W PT SE SW LOT 1 CSM Block/Condo Bldg: 5/1285 TOGETHER WITH 66'PRIVATE RD EASEMENT FOR INGRESS AND EGRESS MORE Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) PARTICULARLY DESC ON SD CSM 05-29N-18W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 872/626 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/19/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 25,000 83,300 108,300 NO Totals for 2005: General Property 1.000 25,000 83,300 108,300 Woodland 0.000 0 0 Totals for 2004: General Property 1.000 25,000 83,300 108,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 156 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 � o � ci °o I a�i o°°• I 4 0 0 O U y .a 0 C 0 C 3 � p.o > N � c� �'p� I Q,•� 1 D)o r °tM-r � I y � I � V�� c'�i ti y C C r= y O O L M `-'HO OY N Nye O o.'o 0 (D Cr' ai�N 1 L o CL o —cn z d c m (D -0� x o o o z C aLL o E o - C cao aX� y Vl C 0 3 = o�m Q Co 0i:� $.- Q c0 CD v CS M N zt a3i r z y fl! a3o E E Cl)Ix y °o 4s 0 1 rn m m € d �n � vi ! am am _o o z g c c Z o r o w uCi ` C z 5 E c E GO) v m M Im CL cx •� 2 C c 0 �- 0 Q z m z z m z `= N 1 z I n aCi n 0 041 E N 42 3 m a� C7 a m m _o o O ov 1 0 N AM ID C N N r Nr � 0 E t 3 2 Z cr5000 .2 00 0 • � aaa 1aaa V; a 0 U) CD 0) a3i Z co Go w N J V rn rn } rn rn z 2 LO N M (A N N 0 a) O C G L �n �n E N m y C O m C d o d Q fn y Q z cn O O w O O f6 N C _O f0 N O •O E O a' U -� - N O O O UN N N w N C m C m m N _C 0) G � r aj N E tC1 M -D � E p W • N IS � N N � N N O O -so 7 O O N � � _ � C C � � � O • "� � o O r O v1 t0 m 1 0 O 0 O o R U it O CJ h Z y m S (J M O z z Z .�' fn d a6 a i L: CL € a i :r E E c :: C c �1 A ciao ° 0U) 00 39 O N V -� FILED l MAY101983 / ��3 i •7 1"m 01 CONNELL �J v ROOM&M Mood's SA aNs qty, cD 1Ai1b�e�Y i / ST. CRO/X COUNTY CERTIFIED SURVEY MAP LOCATED ART OF THE SE 1/4 OF THE SW 1/4 OF SECTION 5, T 29 N, R 18 W, TOWN OF WARREN, ST. CROIX COUNTY, WISCONSIN. Zoo• s � ° 4 2 3 2 RO" T PLATER_ _UNPLATTED LANDS OWNED �Y �,• ss' F• 3 . 3 � 3> g0° 38' 27" o O�ha O v Q' 76.05 2 p1 \(0 R ?20 �ASC�i11 Zoo is K �� f� EXl3T/NG `S2' s8 °O 3. 23' (D 0 CO HOUSE 2 99, ail 2. ZI F 5' C 30S Ow 43,665 SQ. FT. ( 1.002 ACRES) SO' o) �1 LOT / v N KI IT 362.27 �i z S• 79° 31' LANDS OWNED BY PLATTER J� UNPLATO 1 � • w N O O q fL co o E0 tt Z N. 890 53' 18" W. 718.21' S 114 CORNER THE SOUTH LINE OF THE SW //4 OF SECT/ON 5 SECT/ON 5 -/B /' /RON PIPE SW CORNER `SECT/ON 5-29-18 COUNTY MONUMENT W E S OWNER & PLATTER L EGEND RONALD M. 8 DELORES COLEMAN 0 I"X 24" IRON PIPE SET WEIGHING 1.68 CBS./LIN. FT. .RURAL ROUTE 4, BOX 62 THE SOUTH LINE OF THE SOUTHWEST QUARTER OF NEW RICHMOND, WISCONSIN 54017 SECTION 5, T 29 N, R 18 W, IS ASSUMED TO BEAR N. 890 53' 18" W. cis +°•��� r1�, SCALE. ONE INCH EQUALS ONE HUNDRED FEET • AE' = 100' 0 100' 200' 300' lV A EN !� .S 7 < APPROVED -WAY 41983 •- ST. CmIX COUNTY COMPREKENSIVE PARKS PLAH"O SIGNED�� DATED 4 AND ZONING COMMITTEE U ALLEN C. NY GE R.L.S. 1407 VOLUME 5 , PAGE 1285 CERTIFIED SURVEY MAPS 1 ,t r r �• � s .,_ � ' +fir �. „ 1 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRE*ON / TOWNSHI rx SEC..S N, Rg W ST. CROIX COUNTY WISCONSIN. SUBDI ' r LOT LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62. 20 -SHOW MAYTHING WITHIN 100 FEET OF SYSTEM *7- l ' iz TI di a e o 'th Arrow - SCkLt : SEPTIC TANKS) MFGR �, /'f'] , CONCRETE STEEL y N0. o ri s on cover Depth — PUMPING CHAMBER SI PUMP MFGR. -MOIL NO . GA LOINS Per Cycle TRENCHES NO. of width — length area BED NO. of lines 2_ width Va length 3R area tr� depth to top 07 pipe NUMBER OF SEEPAGE„PITS Out a met er total pit area AGGREGATE ” PERK RATE ,S AREA REQUIRED ,S 1J n a' AREA AS BUILT Disclaimer : The inspection of this system by St. Croix County does not imply complete compliance with State Administrative .-Codes . There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is ted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED ,THROUGH ,I'HIS SYTEM. INSPECTOR DATED (� PLUMBER ON JOB LICENSE NUMBER s . : xt ope-� 4 REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM Sanitary Permit 1700 State Sep,ti IV PE;Kgwc- NAME Town4h�p St. Caoix County Location,V16 SV Section fat # Subdivi4ion. SEPTIC TANK Size gatZona Numbers o6 compan,tment,,a Diz Lance 6'nom: We.Z.0 �." B44,44'n9 - 12% 4.Cape Highwaten PUMPING CHAMBER J Size ga4,eab4"__f/ ,amp Manujac.tui.et Mode.E Numbers HOLDING TANK Size ga.C.Zo mEf n as Compan.tme.nfia Pumpers f I ,At nm S y4 xem Di4 Lance Eno•m: We.C.Z I uiZding 12% 6 tope_ Hi. hwaten ABSORPTION SITE Bed s- -'— Tnenc,h Die.tance 6 om: We.CC Bu ,Cd ,ngT _12% a.Cape Highwaten ABSORPTION SITE DIMENSIONS Width o6 -trench 'Req ui,%ed area �/�% 6•t L'e ng-th o6 each tine <5 _� Jx 'c- 'Depxh 06 no ck b etow tile in Numbers o6 tin e,6 Depth o6 rack oven .tile in TotaF tengzh a6 Cine4 f� 6.t Depth o6 -tiZe below grade / in Di4.tance be.t�veen tine4 6•t S.Cope o6 trench — tin. pen 100 6t T u4.u,. ab,5 u)cp:t-i.on area 6 6.t Type o6 Coven: %en on 6 thaw ti PIT DIMENSIONS Numbers o6 pits �� Gnave.0 around pit,4 ye.a no Out.6ide diameze4 epth betow in.Ce.t 6t i ToaC ab4 onp ti an area 6t Area %equited -_ ---5t INSPECTED BY TITLE APPROVED A, DATE 19 REJECTED DATE 198 REASON FOR REJECTION i 1 : 459 REPORT ON INSPECTION OF SANITARY PERMIT # 9�6 (1) me and A re s of Permit Holder Person/Persons at Site (2)Date of Inspection ame, ress, License No. of ns ing Plumber Time of Inspection I (3)INSTALLATION CONSISTS OF: [-] Septic Tank ❑ Seepage Trench ❑Dosing Chamber ❑Seepage Pit ❑ Seepage Bed ❑ Holding Tank ❑Fill System N ermanen reference Point) escri e: Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well M DOSING TANK: Manufacturer: # of gallons : # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number Is the warning device installed? ❑YES ❑NO Wired? []YES ❑NO 8 HOLDING TANK: Manufacturer of gallons ; construction depth to the cover ft; If septic tank is being used are baffles removed? YES ❑ N0; ft from residence; ft from well ; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑NO; Wired? ❑YES []NO; Locking device on cover? []YES ❑ NO; Diameter of vent and material ; Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well ; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe-elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; lineal feet tile; ft to residence; ft to well ; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; tile depth ft; ft to well ; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? ❑YES [:] NO (13) Has system been installed in floodway? ❑YES []NO Floodplain? ❑YES [] NO DILHR-SBD-6095 N.05/80 Signature of Inspector: Q State and County State Permit # PLt 6 7 Permit Application County Perm!;# 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: B. LOCATION: ,SE '/4 ,!5U '/4, Section , T,;2-7 N, R /9 q (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township Q I•/e .` C. TYPE OF OCCUPANfZY: Commercial *Industrial *Other (specify) *Variance Single family �/ Duplex No. of Bedrooms Z No. of Persons D. SEPTIC TANK CAPACITY 422Y-157 Total gallons No. of tanks G-� HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation L/ Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT ISPOSAL SYSTEM: Percolation Rate •S Total Absorb Area 112 - sq.ft. New (/ Replacement Alternate (Specify) Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top) No.of Trenches Seepage Bed: 6!5 L Length_1 IK idth /:,t-I Depth 3-1 z�Tile depth (top) mgz�> No.of Lines �- Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits Percent slope of land- D ' `� %, Distance from critical slope WATER SUPPLY: Private ❑ Joint-5i Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information 1 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 Cert,lied Soil Tester NAME 41 C, 6 rZ c� 1AZ /-At- el/Z- C.S.T. # / L/ / 3 and other information obtained from 7T (owner/builder). Plumber's Signature y`_S y MP/MPRSW g Phone #Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. E I 7 � r E 3 � E w.. _ _.... 3 a 3 4, i y t � ` _ _. � .. , e t i r 1 3 3 � t E d g i Do Not Write in Space Below - FOR COUNTY AND STATE DEPARTMENT USE ONLY p Date of Application g- ; �/�J Fees Paid: State,,S, County Date Permit Issued/Re}ee4ed (date) 0 Issuing Agent Name Inspection Yes No State Valid# Date Recd 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 7/11/78 EH ,U5,Rev.9/78 ' REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309,MADISON,WISCONSIN 53701 LOCATIONSE %, W/a,Section_&L (dr)W,Township or Municipality Lot No. , Block No. County u division Name Owner's/Buyers Name: �ti l- �a P& a 'fi& Mailing Address: � P� c� J-11 oft ft cz TYPE OF OCCUPANCY: Residence N of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS �'2- :5 PERCOLATION TESTS �^ S 2 b SOIL MAP SHEET S� NAME OF SOIL MAP UNIT- PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME 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— 1 -e—-e L P— .2. / N 5,-- P— t l r I J CO S P— P— P— SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B– J B- PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the locatioi d squae felt f�s stable areas. Indicate number of square feet of absorption area needed for building type and occupancy ,I dlf( cafe sc�, 1�r distances. Give horizontal and vertical reference points. Indicate slope. It E p , } E _. . 7 a 0 �ILI �___ _m.. _� _ C I,the undersigend,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 location of test holes are correct to the best of my knowledge and belief. J / Name (print) ,W �� 9 t ,Certification No. �� 3 Address ,y �p..y !�i CI. ,4L'a'b .Name of installer if known Copy A—Local Authority CST Signature _ i , + i i , F S IJ , , { • s , • l , , i , i 1 , , • - 7:,.,. iokl a zn DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR&HUMAN RELATIONS , SAFETY&BUILDINGS P.O.BOX 7f?69 a PRIVATE SEWAGE SYSTEMS DIVISION MADISON,WI 53707 BUREAU OF PLUMBING bUCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number RECONNECTION El Holding Tank 1:1 In-Ground Pressure ❑Mound of assigned) NAME OF PERMIT HOLDER: A PERMIT HOLDER: INSPECTION DATERonald M. & Delores Coleman . R. 4, Box 62, New Richmond, WI BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN REF.PT.ELEV.: CS7 REF.PT.ELEV.. SE SW, Section 5, T29N-R18W, Town of Warren Name of Plumber: MP/MPRSW No.: County Sanitary Permit Number Henry Nechville 3258 St. Croix 64926 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: IWARNING LABEL LOCKING COVER PROVIDED: PROVIDED: BEDDING: VENTDIA.: VENTMATL. HIGH WATER ❑YES ONO ❑YES ONO ALAR M OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH FEET FROM LINE: AIR INLET: DYES ONO ❑YES ONO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: YES ONO DYES NO -]YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL (UMBER 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=F61NC LENGTH DIAMETER MATERIAL AND MARKING or excavation. (if soil can be rolled into a wire,construction shall cease unti the soil is dry enough to continue.) CONVENTIONAL SYSTEM: .BEDITRENCH WIDTH LENGTH TRENCHES DISTR PIPE SPACING COVER INSIDE DIA #PITS LIQUID TRENCHES. MATERIAL_ PIT DEPTH: GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR NUMBER OF P PROPERTY WELL BUILDING: V NT 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 NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER ITEXTURE PERMANENT MARKERS: [EISERVATIONWELLS DEPTH OVER TRENCHREO OYES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SEEDED. CENTER. EDGES: SODDED MULCHED. EYES ONO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: w" EOlTI 11 6. ENCH, WIDTH: LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. TRENCHES: MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING_: ELEV.. ELEV.. DIA._ ELEV.. PIPES: DIA_: l ATF11 A 7l. ORM4T� N 'r HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. DYES ONO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ONO NEIET Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710(R.01/82) INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city,village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report,the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system,circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed,and at the time of renewal any new criteria in the Wis.Adm.Code will be applicable. 10. A new permit will be needed if there is a change in,estimated wastewater flow, (number of bedrooms,etc.), location of the system, depth of the system,type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan,drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances,distances between beds if appropriate,tank locations,effluent line from ta&(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit.Private sewage systems must be properly maintained.Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years.If you have questions concerning your system,contact your local code administrator or the Bureau of Plumbing,DILHR,State of Wisconsin. � 0 Wit°"5'" APPLICATION FOR SANITARY PERMIT ®ILHR OUNTY (PLB 67) DEPggTTEI-IT F UNIFORM SANITARY PERMIT�# O InDU5TRY,LRBOg6MUTg1-IgELfiT10n5 J —Attach complete plans in accord with s. H 63.05,Wis.Adm. Code for the system, on paper not less than 8'/2x 11/!inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT P PERTY OWNER / MAILING ADDRESS �o e X a 2 �7 PROPERTY LOCATION CITY: CuP 1/4SllJ1/4, S S , T-29, N, R E (o W VI WN OF: 4/Vl_ LOT N BER BOCY,NUMBER SUBDIVISI0 AME NEAREST ROAD, LAKE OR LANDMARK STAT P I.D. NUMBER TYPE O�,BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: p�,' ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ revision El Privy El Alternate System Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy L❑ %nisting, For Which A Previous Permit Is On File, Permit # issued — A Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Sip n khamber Holding Tank capacity Manufacturer: IF THIS IS ANA TER ATIVE Sf STEM COMPLET IS BLOC ❑ Mound ❑ In-Ground Pressure tal Prefab. Site Steel Fiberglass Plastic allons T#aniv Concrete Constructed Septic Tank Capaci Lift Pump/$iphon hamber Manufacturer: PERCOLATION RATE ABSORPTION A EA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED ( quare Feet): 04 /T /1 A1 Private ❑ Joint ❑ Public I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatur ' MP PRSW N Phone Number: 1 Plu a 's A ress: Name of esigner: COUNTY/DEPARTMENT USE ONLY Sign ur of Issuing Agent: /�� � J��! �Ree: �` Date: p' ❑ Disapproved �+ 6lti(Hw �/ OJ �6� ❑ Owner Given Initial Approved Adverse Determination Reason for Disapproval: Alternate course(s)of Action Available: DILHR-SBD-6398 (R.5/82) 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/contractgr, ("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 7�Z� Location of Property _ , 0 3�� Section oS , T 2 N - R 18 W Township 'IcZ-� / Mailing Address �R il- Subdivision Name Lot Number , Previous Owner of Property Total Size of ParcelC Date Parcel was Created Are all corners and lot lines identifiable? v Yes No Is this property being developed for resale (spec house) ? Yes 1--- No Volume . and Page Number ird obi as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. • Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION 1 (We) cuLtt.6 y that att statements on fih i s 6oAm ane t ua.e to the but o 6 my (oun) knoweedge; that I (we) am (cute) the owneh.(6) o6 the pnopen ty des en i.bed in .this .in6o4mati.on 6onm, by viA tue o6 a wauanty deed neeonded in the 066.ice o6 the County Reg.c6tea o6 Deed6 as Document No. 33? 0 2 ,Z , and that I (we) pees entfy own the p!co po6 ed 6.ete bon .the 6 ewage diApo.6at system (on i (we) have obtained an ea6ement, to hun with the above de6c i.bed phopenty, bon the con6thucti.on o6 said 6y4tem, and the same has been duty seconded in the 066.iee o6 the County RegiAten o6 Deed6, ab Document No. ) . 9 SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED yy t � NMne•seth, TDat.t6e grid Grantor for a vsl# 11e catmidaretrw► Conveys t j Grantee.the following dwsaibed real***me in__.�t�_ C *So of Wisconsin: of Sits, Sec. S Tai R1AN" eohiistW 0 86 acres r ? sole or less. - (This deed is given in sittisfaction of a land eantjraC d�it+e St thw.St. Croix County Register of ;Deeds office c t"3ts _ 3 $nSS4-S55, as Dac. No. 323046.) ' fi '0 lifer with all and sitip{ar W hereditsaieata and appurtenances tboteunto belonging ar in any�► Ftt►lda T_ Anl} ,T�� F itrrrr�t- ► c "OaXtba.title is good, ind*t"*Able in fen simple and hee and cleat of eacypnhrances wxvj�pt . dahad the 4 t wt.e at mss, WiscAnsf�►__ _ —day of_this i. _ # 9 lam` ;. t R,=.Ai11R Ai.Ta� flt 1�RrSME OF P F Lotus T. Rolf €f ' 1 qIr `a; axles E. jr: b Ks,_ M C. PC . f Title:' Member $t Ott*ber al•Niti "gr * Authorised under See. 706.04.tflt+. y 01► WISCO14ffUt x. w as. ;: :.. .. M0 before me. this _ --- day of ^ r d - - e , bR INOV4I ba the person who ox6cuted the foregoing instrument and acknowledged the same fit+ .�, f t itllgant Irma drafted by w 1t. r Notary Public ' `btiktiaes its optional. MY Commission(B:DrraA fh)'. / .�. raiMi ; '9 64pins n any capac*Sb*Ad �t ped opri►tfd.Qelow4u (put � a� �� •��� `>�OI .MfSCt►Ngeff, FORI�7�(0. t .«'�f1i>.'-:. �; »?.� 1 1 16 go / 129 MAYJO 1983 -j r, .� ✓ lMIS O'CONNELL V�L�'�Ir.�•! SR CA* ioratp, � I ST. CROIX COUNTY CERTIFIED SURVEY MAP LOCATED ART OF THE SE 1/4 OF THE SW 1/4 OF SECTION 5, T 29 N, R IS W, TOWN OF WARREN, ST. CROIX COUNTY, WISCONSIN. o°• s. T2 0 ti 32, 20" PLATTER_ � _UNPLATTED LANDS OWNED QY 66• F. — Q DL WI 8' 27„ R 330 3? o h N. 80° '' 0 040 coq : 3 a176.05 Dt 2 6 �a ry �2°32 2 S�4,, Nr t' `S90 �a p'� O IV of ro 01 K EX/STING S2' 68 9 .0 3/2 23 m (\i O HOUSE O WI N F 31 3p O S 4/O• �: y1 w 43, 665 SO. FT. ( 1.002 ACRES) SO' Q' LOT l . N ° R w' 1 z S 79° 3L' 40', OWNED BY pLArrER C2 Jf U,VPLArT-Ep aT I r.. N O O o co Z N. 890 53 18' W. 718.21 S I14 CORNER SECT/ON 5-29-/8 THE SOU TH L INE OF THE SW 114 OF SECT/ON 5 /" IRON PIPE' SW CORNER 'SECTION 5-29-/8 COUNTY MONUMENT W t E S OWNER 8 PLATTER LEGEND RONALD M. 8 DELORES COLEMAN O 1"X 24" IRON PIPE SET WEIGHING 1.68 LBS./LIN. FT. RURAL ROUTE 4, BOX 62 THE SOUTH LINE OF THE SOUTHWEST QUARTER OF NEW RICHMOND, WISCONSIN 54017 SECTION 5, T 29 N, R 18 W, IS ASSUMED TO BEAR N. 890 53' 18" W. SCALE: ONE INCH EQUALS ONE HUNDRED FEET s.4;r .'»''"""'"'�. r• , 100' o loo' 200' 300' *� �a ALLEN' Ct a. I .. •..rr aN �;�Yr APPRO\ t� ; 00 .4. NO t ST. C?OI•X COUh:TY COMPnCNENSJVL- PARES PLAt4NU40 �}�� AND ZO,�ING GOM�.�IITEE SIGNED��-uw� lU DATED � O S ALLEN C. NY&GEPf R.L.S. 1407 VOLUME 5 . PAGE 1285 CERTIFIED SURVEY MAPS Ihle Inortimr,ni was rlrnfi(,d by kon hnrlLi�1'11c7. JOR NQ nT r:pow rOlIrlITY, �A'1''rorAlc'lrl L z • y 9 STC - 105 r' r a SEPTIC TANK MAINTENANCE AGREEMENT ►y� St . Croix County z d OWNER/BUYER ROUTE/BOX NUMBER Fire Number CITY/STATE 77x� - �U� ZIP 11e /7 PROPERTY LOCATION :$ k, $60 k, Section T P9 N , R IB W, Town of St . Croix County , Subdivision NP Lot number Nk Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists of pumping out the septic tank every three years or sooner , if needed , by a licensed septic tank pumper . What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix. County residents 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. y 0 I/WE, the undersigned , have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- ro 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 . 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 . ` 111VP111 1 Vi LC1G1 G111C �ll�y 1 , CERTIFIED SURVEY MAP z m O , C O z O n CENTER OF SEC 5, Z' c RR SPIKE m -4 WEST t/4 , SEC 5, EAST -WEST 1/4 TOWN ROAD = EAST 1/4, SEC 5, T29N, R18W SECTION LINE T29N R18W S89 2 3 W W '- - -Q r - -- - 75-4'-2- .,r _- \ S89 5423' W 510.00' N 8 9 3E + 2097.32' __w°' �'' - ZA. 0 • 2609.63 477.00' _ - ^ r - R/W LINE --- - Oc (c I w` I I • � APPROVED ti Nom= APPROXIMATE 1 HOUSE LOCATION ' I `.r J MAY 7 1979 I i ST. CROIX C:-)U. i r COMP.,IEHENSIV: PARKS FLANiANG I 1 AND ZONING COMW EE I 1. I APPROVAL OF THIS Ml,NO,, I DOES NO, 1'SUB,DIVISION 1 MEAN APPROVAL FOR O BUILDING SITE OR SEPTIC Sy„jEM. N N 15.00 ACRES N I I REFER 70 H62.20. (.A TO (L- - (L) ( z� Cu _ OI U N I N nj 1 SCALE IN FEET u'- L°—° cn� IN —� 100 0 100 200 300 rn I 13.67 ACRES i I �N ( TO R/W LINES) N l C11 I 1 0 = Il"X 24" IRON PIPE I � WEIGHING 1.13/LINEAL FOOT SET I I 3 0 1 X 24" IRON PIPE FOUND I IL El) � (0 $o i I _ �Ivf�gy S 1979 0 1 — �s tit N Rap1,1 oo CCNKBIr CD or w' c� I CAS f 0•od, r' CP 477.00' ' 3 I V� ty4�aC°"°h, V N 89 054'23"E 510.00' 133 331 616, 1 1 I R/W LINE —►I I N0021'51"E I 1332.27' I i i Z i �"SOUTH 1/4, SEC 51 Volure 3 page 801A T29N, R18W e 79 29 THIS jPttcroi,*!r,,r n4ACTFr1 Ar 44 w,.*. 129 Continued. SURVEYORS CERTIFICATE: �~ hereby certify that by I, Allen C. Nyhagen, a registered Land Surveyor, the direction of Mr. & Mrs. Coleman; owners of said land, I have surveyed b this described and mapped the a d the parce parcel Certified Survey Map; that survyed and mapped is described as follows: A parcel of land located in part of CroixECo/untyf Wisconsin4 further 5, T 29 N, R 18 W, Town of Warren, St. described as follows: 18'� W Commencing at the S 1/4 corner of said Section 5; thence N 890-531- along the South line of the SW 1 /4t ing 71of21 feet; th point of beginning description; thence E, 587.00 feet to the continuing N 4°-41 '-29" E, 207.51 feet; thence N 80°-38'-27" E, 76.05 feet; thence S 59°-52'-26" E, 305.50 feet; thence S 79°-31 '-40" W, 362. 27 fe.et to the point of beginning. sured"Togather with a 66 foot road ewnement, aocated alongtthegEastn line, ofor ingress and egress from the To the SW 1 /4 of Section 5, to the no rt of the eSEy1/4nofothehSWa1/4eo described parcel, said easement being a part St. Croix County, Wisconsin, further 5, T 29 No R 18 W, Town of Warren, described as follows: I I 18" W,ion Commencing at the S 1/4 corner 1f4said8S21tfeet5� thenceeNN48 9415329" E, along the South line of the / _ 794. 51 feet; thence N 80°-38'-27" 76-05 of thiseeasementedescription2611 E, 102.41 feet to the point of beginning thence N 47 o_03 -54" E, 200.67 feet; thence S 720-32'-20" E, 330.37 feet .� ' W along 2 to the westerly R/W line of a Town Road_ thence S 031232335 W thence said road R/W,W6914 feefeethethence7N 59°-520-26" W, 68.99 feet to +1 S 470-031-54" the point of beginning. that this Certified Survey Map is a correct representation of the exterior boundary surveyed and described; that I have fully complied with the current provisions of Chapter 236.34 Wisconsin Revised Statutes in surveying and mapping same: vol. 5 Page 1285 .�.. ♦ws.a„ ,f.. N, ALL 14 5-1•:�7 ! G► n ` P..lUC:.0 iq, t 1:14. •,d�j''Qi��. r. 117 continued 1 �I 1 I, Bradley J. Canaday, registered land surveyor, hereby certify: That in full compliance with the provisions of C apterC 36.34Sof th sion Wisconsin -Statutes and the provisions of the St. Ordinance and under the direction ofd ondldaColeman, lownerthat said �hland, I have surveyed, divided, and mappe P plat correctly-.-represents all exterior boisdlocatednintthesNE1 of the of the land surveyed; and that this SW� of Section 5, T29N, R18W, Town of Warren, St. Croix County, Wisconsin, to-wit: Commencing at the St corner of said section; thence NO°21' 51"E along 271 to the point of beginning; thence the N-S Quarter section line 1332• 251 to the E-W Quarter continuing along said line N0021151"E 1281• r • thence SO°21151"W section line; thenceo$925iE2510.00°ntosthe point 5o�f•begi-nning. 12$1.25' ; thence N$9 54 3 Said parcel contains 15.00 acres andis subject to existing Town Road f right-of-way over the Easterly and Northerly 331 thereof. °i BRADLEY J. to CANADAY a S-1462 FALLS RIVER �J .J W IS. f! < ..........• J d �`prq N �Sf/� day of ���/� 1979• Dated this Brad J. an Wis. R.L.S. N S-1462 Dittloff Engineering Co. River Falls, Wis. 54022 !; been paid. And the joint tenancy of Nancy Rolf in the property was Iteriniriated as of the date of death, and Louis T. Rolf is the survivin joint tenant. 108 Ronald M. Coleman and Mortgage. Delores Coleman, Con. $20,000. husband and wife Dated May 8, 1979. as joint tenants, Ack. May 8, 1979. Rec. May 10, 1979 @8:30 AM. -to- In "593", page 416 #3567+3. The State Bank of Roberts, la Corporation. '! SEI of SW1 and NE1 of SW of Section 4 u r 5-29-18, Town of Warren, ; except the following described parcel: Commencing at the S' corner !! of said section; thence N0 021151"E along the N—S 1/4 section line , 1332.271 to the point of beginning; thence continuing along said line N0021'51"E 1281.251 to the E-W 1/4 section line; thence 589054123"W !! along said line 510.001 ; thence S0021151% 1281.251 ; thence N89054123"E ;. 510.001 to the point of beginning. it Recites : Subject to existing Town road rights-of-way. o 101)) . (Partially Released, See No. 123) . iI E'/Z of SW'/4 of Section 5-29-18 Except Lot 1 of Certified Survey Map filed May 18, 1979 in Vol. 11311, page 801A(No.117) Also Except Lot 1 of Certified Survey Map filed May 10, 1983 in Vol. 11511, page 1285(No.129 ). i 123 Durand Federal Savings and ; Loan Association, by Pres. , Partial Release of Mtg.(No. 1(8) . Con. $1 .00 OVC. Secy. , and Corp. Seal , Dated May 16, 1981 . Ack. May 16, 1981. -to- Rec. May 19, 1981 . ., Ronald M. Col In "629", page 382, #370926. Coleman and Delores � ; Coleman, husband and wife as Releases from mortgage recorded ! joint tenants. in 1159311, page 416 described as follows: .Part of the E'/2 o SW% of Section 5-29-18, Town of Warren, St. Croix County, Wisconsin, described as follows: Commencing at the S quarter- corner of said Section 5; thence N 00 021151" E along the N-S quarter-section line 2613.52 to the center of said Section 5; thence S 89 053100" W along the E-W quarter-section line 510.00 feet to the Point of Beginning of the parcel herein described; thence continuing S 89°53'00" W along said E-W quarter-section line 787.00 feet to the west line of said E'W of SW%; thence S 00°21151" W along said west line of said E''/Z of SW'/4 1304.75 feet; thence N 89 054123" E 787.00 feet to a point on a southerly extension of the west line of Lot 1 of a Certified Survey Map filed May 18, 1979, in Vol . 113 : of CSM, page 801A, Doc. No. ,356934(No. 117) , in the office of the Register of Deeds ; 'for St. Croix County, Wisconsin, which point is 23.00 feet southerly of the SW corner ,' of said Lot 1 of said CSM; thence N 00 021151" E along said west line of said CSM 1305.07 ! feet to the Point of Beginning. Subject to town road right-of-way over the northerly 133.00 feet thereof. 124 jJeannine M. Murphy, Affidavit,of Jeannine M. Murph . y I, -to- Ack. May 5, 1981 . r Rec, May 19, 1981 . The Public. In 1162911, page 383, #370927. Jeannine M. Murphy, being duly sworn, says: 1 . She is the wife of James ,E. Murphy, Jr. 2. James E. Murphy Jr. is the same and was known sometimes as James E. Murphy named in the following documents recorded in the office of the Register of "Deeds, St. Croix County, Wisconsin: Vol . "366", page 323, Document #261344(No. 79) ; !'.Vol. "483", page 171 , Document #309803(No. 87) ; Vol . 1151211, page 87, Document #32229!1 li 11(No_ 91) ; Vol . "512", page 93, Document #322292(Nn an) • v„� ray CA/1- v _ = o � m w co 0 c 3 c 0 M w � `" ID C fD CIO ° ' O (D ° O (� = R1 cD cD CD OL N A _ W A3a o -000coo In 3 w O O 0 0 y O C- c CA m? 0 < co a c ..• Co o CD O t O 1u O O O O O ?. CA NCO -way CD �d a ppO N NA O A cr A fD C p ._cO N O o c c .O A•p.. 0 = 0 0 (D aO ;k O CO W O n .� v fD N �D fD .-► -' O D g = a ° r 0M y d 3 � 0 ayo 0 ti ' a cpc ju � -i C m O N O O O• lD S o a(a a 5 r n ' y `< (A C Q CL0 M aaaa � Z c o N Q f �.o 0 0 3' --k ma oCoa o � � � M0 ` A CL C mow;; : p c a O -• � W A S Z o0 o 3 MR #»n�� • y. � � a \ � \Q � « v ,�/) .�.. Form - S T C - 102 ONE AND TWO FAMILY The existing system must be inspected for compliance to bedrock and high groundwater requirements of the code. This, in many instances, will require a soil test to be conducted by a Certified Soil Tester or an on site by this office. If the existing system does meet minimum requirements for groundwater and bedrock depths and if it is functioning, an addition can be added in most instances without updating the existing system. If the existing system is utilized for the addition, every attempt should be made to locate and reserve an area which is suitable for a code complying replacement system for when the system fails. If the addition will substantially increase the wastewater discharge, the existing system shall be replaced with a code complying private sewage system. 1/4 1/4 (Subdivision & //Lot 0 Se-ction Township Rural Route # Address Post Office Zip Code (I) (We) Dr��� /yf C' a�Cyjab plan to (build an addition to remodel) the building at the above named location. The present private sewage / system has been working satisfactorily as far as disposing of wastes. e If the present private sewage system does fail, it will be replaced with one ���GGG•^^"" that is code complying. 'ri Pc*eGin9 d /yx ?a Mal./e fioa�e (1) 8 A a X 34 1/ Ito cG5 c 77fa f •s (2) - ��/ �• sL 64,7' ",eveee oil On it 74// ,6a$r_dP; a (Owners Signature) CcVrC Sc!/107? 7A "dielc Aomc, 12 2 Da Subscribed and sworn to before me this day of 'li/V'6- 19 & Notary Fublic WYOM ATE OF NR9COi51F} County, Wisconsin My Commission Expires ST. CROIX COUNTY (County Authority) Plot plan attached (show location of building addition to drainfield and septic tank) . Include soil testers report form. .�r INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test,your report must include: 1. Complete logal description; 2. The use,section must clearly indicate whether this i-s a residence or wri-irnercial project; S, MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement:system; 5, Complete the suitability ruing 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 abbreviation shown here for writing profile descriptions and completing tire plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale, is-preferred. A separate sheet may be•usect if desired; 8, Niakc sore your benchmark and vertical elevation reference point are clearly shown,and are perman�nt; d. Co nplete all appropriate boxes as to dates, names,addresses, flood plain data, pert.olation test exe;mta flan, if appropriate; 10. If ilre nforrnation (such as flood plain,elevation)does riot apply, place N,A,in the�ipprol_ariate box; I 1. Sian the form and place your current address and your certification number; . 12, Make legible copies and distribute as requires, ALL SOIL_ TESTS MUST BE FILED WITH THF. '.,J`C;AL AUTHORITY y1}ITHIN *DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Seta=at-ates and Textures Other Syanbols st Storw (over 10") BR — Bedrock co I) Cob3are {S.. 10") SS — Sandstone tr kGravel (undue:3") LS Lirnestone _. Sand 1-IC°W - Hicih Gt0LradVVa101 cs - C`a sa Sancd Pr:rc _ P rcolrati 1, Rate r;at;rt riu diem sand W Va,€i 4 r,r.c Sava E kill L t trim(l s c o flny Sand ; Greater Thwi �s1 - Sandy Loam Less Thars; l uanl inn Brown t si( S,It: Loam bi Black si &1t G - G ray 0 - C°lay Loam Y __ l`,IIo>,u wl ._ Sanciy Clay Loam R - !-led sic, - Silty Clay Loam mot - Mott=es • sf; Safac y lay v,,r %V rni Silty Clay fff — f-vv -fire, faint €,hay ;t: - tcarrrr?°;r,r i <ria r� P u;a tanin — Marty, nia,i,,urll tri _ <f.aiucik rd __ (I istirlc P — wominoIt 11 kit- — Hialh wri er level, Sex cennral sol textures surfarv� 'n;ater for {iqui d waste disposal BWl _ -Bench I Mark VRP - Vertical-L;rsfierei c °oirfi TO THE OWNER: I hw;st _ [e5t tel>ort is'rile first step in securing a sar°.itary palmit. The county or the DPpartrnem ralay r{acauest � v"'-!,r;c.al,t w, of this snail test in the fief prioa to permit issuance. A c;otnple,te. set of plaaa:> for the privste :d-, erstaar. railed a ls;r t,is_ _faplicaii ra must he submittetd to the applopriall" local -aulhoaity ill or er to ,-, < Deft rid" I Ilv amtary fie.rnlit rtY4'=4€.he e`f 3isl i rie;d and posted pt im to fhe start rt of a€7y oil{ t#'uel.[t3 Ca. _J INDUSTp?MENT of REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND„ PERCOLATION TESTS (115) MADISON WI 53707 HUMAN Fi�ELATIONS (H63.090)& Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: 5 F— a/4$0/ 9 /TAI N/R 18 1(or)�l 0 AIR � COUNTY: OWNER'S/_Blii i#*ME: MAILING ADDRESS: 0. , cJ syo 17 USE DATES OBSERVATION MADE LIX N O.BEDRMS.: COMMERCIAL DESCRIPTION: p/4 PROFIL D RIP IONS: E AT N T SResidence �/Q LIJ'h]ew Replace / / _ Q 6' ,t/Q RATING:S=Site suitable for system U=Site unsuitable for system rD (� D f�" CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:S STEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optio all ZS ❑U MS U ®S ❑U ❑S ®U ❑S ®U r ' 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 Floodplain,indicate Floodplain elevation: NR PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HEST TO BEDROCK IF C SERVED (SEE ABBRV.ON BACK.) B-AIR B- R B- B-4 PERCOLATION TESTS TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD PERIOD PER INCH P_AtA P- 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 NR lot 7 1\ ..p .._ t y s I � i , 44 E boo t e- a ga _. u E E _ . f : 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 I(print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER:- HONE NUMBER(optional): 94. 1 Bo o279 go 6 r—►- f s o;, d ;? - X 37 3 1 3 3 ,2 CST SIGNATURE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — LO S�Q � y V fip 00 lQo.6�-r fs, N® - L/ (,(�a w j,� O� i N Sfcx��� rt/c� -a- /V F G✓ SZ 4).JZ k L%�llL :�.A aYA ©c�5 SS�p'l"c- 7 A Zk h o � ;20;z — ----- Ny f E7 0 —� 1 i —row Iti ��