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030-2040-50-000
Wisconsin Department of commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578914 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Kearns, Max St. Joseph, Town of 030-2040-50-000 CST BM Elev: sp.BM Elev: BM Description: Section/Town/Range/Map No: l GS"� 25.30.20.489E T TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER .s CAPACITY STATION BS HI FS ELEV. Benchmark 4.a4 16q,d Septic I 1 f�� -I Eli'3�i rat. l.✓ , Alt.BM � z � y,i5 �7.y ,,,j 3 Aprativ Bldg.Sewer ,n. Holding St/Ht Inlet V St/Ht Outlet 7, 3{p goo + TANK SETBACK INFORMATION _ TANK TO P/L WELL BLDG. ent t Air Intake ROAD At-Inlet �� "�. 37 y(� -4o J ✓� Septic I Jed Z7 �J�[' 7.47 -• - S Header/Man. /D 6c� /DU `73 Dosing / /J , 27 , /Da 1 Aeration Dist. Pipe fa,X09 415 . 3 Holding Bot.System //.5v -7Z - Final Grade q-,d qi -a PUMPISIPHON INFORMATION i Manufacturer Demand St Coverer 4.57 c/c?,A4 GPM �- Model N er TDH Lift Friction Loss System Head T Ft Forcemain Length Dia. Dist.to well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length �C No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth th DIMENSIONS 3 6 3 6� --_ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactured Z its/o�J CHAMBER OR G INFORMATION Type Of System: t UNIT Model Number: Z7 3Z '7 X56 DISTRIBUTION SYSTEM tEi., - [D �-Lo 4--ko x Hole Size x Hole Spggu�g Vent Air n a HeaderMlanifol� 1 DisVibution \\ Pipes) Length Dia Length ` Dia _ Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ,a Mulched Depth Over Depth Over xx Depth of xx Seeded/Sodded Bed/Trench Center 5� Bed/Trench Edges �� Topsoil �� No Yes No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: / / Location: 1335 27th Street Hud on,WI 54016(NE 1/4 SE 1/4 25 T30N R20W) NA Lot 4 Parcel No: 25.30.20.489E 1.)Alt BM Description= , ' ' 2.)Bldg sewer length 6 -amount of cover Plan revision Required? Z Yes �o U q=,;,- se other side for additional information. Date Insepctor Signat Cert.No. SBD-6710(R.3/97) PLOT PLAN N Project Name: Kearns Replacement Septic System Legal Description: NE1/4,SE114,S25,T30N,R20W P.I.D: 030-2040-50-000 Subdivision Name: NA Lot#: 4 SCALE:7"=40' Township: St.Joseph Parcel Size: 3.021 Acres County: St.Croix System Elevation: T1=92.48'Proposed 60'EZ Flow Trench Slope: 5% T2=92.48'Proposed 60'EZ Flow Trench BM1 Elevation: 100.00' Top of existing tank inspection pipe T3=92.48'Proposed 60'EZ Flow Trench BM2 Elevation: 99.61' Top of existing drainfield vent pipe Backhoe Pits: 4 inch Sch 40-ASTM D2665 NOTE:See page 12 for a complete plot of the parcel. 14 inch 3034 - ASTM D3o34 -,3 11\1 N s� ` . ® 67 4c \ °� C7 1° \ 3 0 hpui�L Pr -67>- FIS'TJNC Tz b�lV r fl i2o©h� 3$^ t Page 2 LL- 0 WELD County r0� I us rvices Division St.Croix i� (1$0 "�'i� 0 E.1L"shington Ave Sanitary Permit Number(to be filled in by Co.) S P 3 ,�6 -_ P.O. Box 7162 $ 1 �, 1.�. _ --1df8Bi"son',WI 53707-7162 alJl.i` f �d14+a.tits �a 4 State Transaction Number, Sanitary Permit Application In accordance with SPS 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to project Address(if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary Same yE I G h C17- purposes in accordance with the Privacy Law,s.15.04 1)(m),Stats. �-J J JI ef I. Application Information—Please Print All Information Parcel# Property Owner's Name Kearns,Max&Marlene 030-2040-50-000 Property Owner's Mailing Address Property Location Q 9 r 1335 27s'Street C. C� Govt.Lot L4 v City,State Zip Code Phone Number NE 1/4,SE 1/4, Section 25 Hudson,WI 54016 rcle one) T30N R20Eor�W II.Type of Building(check all that apply) � of# ® 1 or 2 Family Dwelling—Number of Bedrooms 4 Subdivision Name NA ❑Public/Commercial—Describe Use Block# !' [1 City of ❑State Owned—Describe Use El of CSM Number 0 b e 2 r f1 CJ 3 ® Town of St.Joseph Z III.T e of Permit: Check o one bo on line A. Com lete line B if a licable) O A. ❑New System ® Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System(explain) F1 Permit Renewal ❑ Permit Revision E]Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued B. Before Expiration Plumber Owner I of POWTS S stem/Component/Device:onent/Device: (Check all that apply) Non-Pressurized In-Groun ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound>24 in.of suitable soil ❑ Mound<24 in.o sortable s '' II Holding Tank Other Dispersal Component(explain) ❑Pretreatment Device(explain) [„ z 1263 14 — 10 , V.Dis ersaUTreatment Area Information: b Design FI (gpd) Design Soil Application Dispersal Ar Required(sfj Dispersal a Proposed(sf) S9y to Elev on 450 Rate(gpd f) 900 900 0.5 VI.Tank Info Capacity in e Gallons Total #of 2 U° anufacturer w Gallons Units ' QL New Tanks Existing Tanks t„/ a U Septic or Holding Tank 320 ✓ 1000 El 1320 2 v ieser&Week's ® ❑ ❑ ❑ Dosing Chamber ❑ ❑ ❑ ❑ ❑ VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plu er Si lure MP/MPRS Number Business Phone Number John Schmitt zw 223760 715-760-0486 Plumber's Address(Street,City,State,Zip Code) 616 15Wh Ave.Somerset,WI 54025 VIII.County/De artment Use Only Approved &71 ap Permit Fee Date sued Issuing Agent Signature ry s L175'° IX.Conditions moo/ ""s for Disapproval rX l s �y Sys ,M he e,,bG nd A,_.k 1.Septic tank,effluent filter and G dispersal cell must be serviced/-maintained �e L ode. � as per management plan provided by plumber. 2.All setback requirements must be maintained pef R&1 t@6ystem and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398(R03/14) , CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Kearns Conventional In Ground Owners Name: Max& Marlene Kearns Owner's Address 1335 27th Street Hudson, WI 54016 Legal Description: NE1/4, SE1/4, S25, T30N, R20W Township St. Joseph County: St. Croix Subdivision Name: NA Lot Number: 4 Block Number Parcel I.D. Number 030-2040-50-000 Plan Transaction No. Page 1 Index and title Page 2 Plot Plan Page 3 Septic Tank Specifications Page 4 Filter Information Page 5 System Sizing &Cross Section Page 6 EZ Flow Instructions Page 7&8 Management and contingency plan Page 9 Existing Septic Tank Certification Page 10 Septic Tank Maintenance Agreement Page 11 Warranty Deed Page 12 CSM or Plat Attachment Soil Evaluation Report Designer: John Schmitt Licnese Number: MPRS 223760 Date: 4/10/2015 Phone Number: 715-760-0486 Signature: It -7 1Z�� In- round Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01) Page 1 a PLOT PLAN N Project Name: Kearns Replacement Septic System Legal Description: NE114,SE114,S25,T30N,R20W P.I.D: 030-2040-50-000 Subdivision Name: NA Lot#: 4 SCALE:V=40' Township: St.Joseph Parcel Size: 3.021 Acres County: St.Croix System Elevation: T1=92.48'Proposed 60'EZ Flow Trench Slope: 5% T2=92.48'Proposed 60'EZ Flow Trench BM1 Elevation: 100.00' Top of existing tank inspection pipe T3=92.48'Proposed 60'EZ Flow Trench A BM2 Elevation: 99.61' Top of existing drainfield vent pipe Backhoe Pits: 4 inch Sch 40-ASTM D2665 NOTE:See page 12 for a complete plot of the parcel. 4 inch 3034 - ARTM D3034 A. 30e Nv2ri t PL p \ 011 k s� ` ® $7 \ h � 133 d�1 N \ IoQC� G41- ScP,'�c � rkA fj K T3 POOY�� \ 3$t0 QthS G Page 2 LL- 0 WcL- NO-MA :311A 9518-5Z2-008 ZLOZ 'Ndf 43SVA38 o \ z r- :8nod-1SOd Zl oZ £ ':31VO ZIoz kNvnNvr :31VO 09LtiS IM 'N008 N3aIVw of AMH sn 9LL£M -ldnNVN 3I1d3S £ 'ON 'A38 w O :8nod-3Nd „0-,l= b L :31VOS 3WS :AA NMVmQ 3130 logo 13131M NW-=m (n �- 0 W J w ui HQ a z m O z 0 :D w V2 J W —0 0 .� N d 0 ¢M N (L w w d. m z :D o WW °ow v) m V) LA Q o Ln 0 WH J F- J i m FW w Z �� C—iOF- O Q r Z c c z Q O O m O�kQ a. U H O > .n U O HJ aJ2 Z Q m� F 3 V' Q CL OW JWW Q Z lL �O U ¢ nw O CL m(n � \ O U a cc U c (n J I °fn O c Z z V) N f� Q a G �QO -'* NI mWN O O Q 0 � z V dog OH�cop H I Q 1-tn< o0 a0 W 0 r �< z 0, W oo WQU W } cV L1J c M �w�U, o_3W i �� 0-0 F- D \ 0 Z Z O M .. J .. .. J .. =(n H" Ozx U N W U W(/1 QH � ui ..O ==zF "30= OUY 0vW a o m a o0 0�V) 0 0Q0 �QWZOWO� Qd � Q30 0 U Q N �x �O zZ3m UMx��m�w3 f- f- o oU- z ? J J F- 0< U J Q W Q Imo' z W U 5 s D W cc W N 0 91, I V) — Sdo ,� 3 0 II II s i „ts .8ti do 5 0 II ` I„s W W LO II ` II o -n st sdo ut, ° o IL _� � ~ „ st do W L- W Li Q m m � w o O � _ Q W z w N F .A9 _ U a a032� „85 a Sb 2 W Q N Y z Q F- Page 3 1 %lyi i o Filters PL-525 EFFLUENT FILTER (COMMERCIAL) Polylok, Inc is pleased to add its new commercial filter to its existing line of quality effluent filters.The PL-525 is rated for over 10,000 GPD Alarm Accepts PVC (gallons per day) making it one of accessibility extension handle the largest commercial filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the new Polylok PL-525 has an automatic shut off ball installed 525 linear feet with every filter. When the filter is of 1/16" removed for cleaning, the ball will filtration slots _ Rated for over ---� 10,000 GPD float up and temporarily shut off the system so the effluent won't leave the tank. No other filter on � the market can make that claim! Accepts 4"& 6" SCHD.40 Pipe .� PL-525 Maintenance. The PL-525 Effluent Filter should operate efficiently for several years under normal conditions before requiring cleaning. It is recom- mended that the filter be cleaned " every time the tank is pumped or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs Gas deflector servicing. Servicing should be done by a certified septic tank i Automatic shut-off pumper or installer. ball when fitter is removed 1. Locate the outlet of the U.S.Patent No#6,015,488 septic tank. 5,871,640 2. Remove tank cover and pump tank if necessary. PL-525 Installation: 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover and 4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the P 4" or 6" outlet pipe. If the tank. Make sure all solids fall filter is not centered under the back into septic tank. access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL-525 filter into completely inserted. its housing. 7. Replace septic tank cover. 5. Replace the septic tank cover. Page 4 SOIL ABSORPTION SYSTEM DETAIL/ GRAVELLESS LEACHING UNIT Project Name: Max& Marlene Kearns Gravelless Leaching Unit Specifications Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 System Sizing EISA Rating per Foot of EZ Flow F-5- ft2 Soil Application Rate 0.5 gpd/ft2 450.0 gpd Design Flow_ 0.5 1 Soil Application Rate_ F-5� EISA= 180.0 Feet of EZ Flow trenches 60 I feet long each t 3 No. of Cells 6 Per Cell 'I �,b 3 ft Cell Width 18 Total No of 1203H 60 ft Cell Length 300 sq ft EISA Per Cell 3 ft Cell Spacing 900 sq ft Total EISA Typical Cross Section Finished Grade 96 ft Observation Pipe with approved cap or vent Soil Backfill _. _.____._ __.._..y_ _.._.._._�._.__,�_ .. �_._...___. . ._ ._ _. ._..._. ■ _.._..._ _ . ._,..., tom___��� 36 Inch Geotextile Fabric ■ ■ . ■ ■ ■ 12 inc �I II O I Slotted and Anchored VentlObservation Pipe h \ with Cap 92.48 ft Infiltrative Surface >36 inch 89.47ft ■■■■■r■■■■■rrr■■r■■■■■rrr■■■■■re■a■■■■r■rr■r■■■■■r■■■■■■■■■■■■■■ Plumber/Designer Signature: License#: MPRS 223760 Date: September 12, 2014 Wisconsin Department of Commerce,Safety and Buildings Division, 5. The Absorption area (SF) necessary for a given site shall be has reviewed the specifications and/or plans for this product and sized based on maximum daily sewage flow(GPD) and the determined it to be in compliance with chapters Comm 82 through Permeability for the site. If certain criteria is met, the EISA 84,Wisconsin Admin.Code,and Chapters 145 and 160,Wisconsin sizing can be used in Wisconsin, resulting in a 40%smaller Statutes. All sites must meet the Site&Soil Conditions&Locations drainfield. &Isolation distances as noted in local regulations. The approved products are 1203H(3-12" bundles with pipe in cen- 6. Place EZflow bundle(s)in the EZflow configuration approved ter bundle in 5'or 10'lengths)and 1203HP(3-12"bundles with pipe by system design permit specified for the particular site.The in each bundle in 5'or 10'lengths. top or center-most bundles containing pipe are joined end to end with an internal pipe coupler.Any additional aggregate A single pipe bundle contains a four inch perforated pipe surround- only bundles that be required,should be butted against ed by EPS aggregate and is held together with polyehtylene net- y may q ting.A single aggregate bundle contains aggregate only and is held the other aggregate-only bundles and do not require any together with polyethylene netting. type of connection. Materials and Equipment Needed 7. The top of each GEO cylinder contains a filter fabric pre-manu- • EZflow® Bundles factured in between the netting and aggregate. The fabric • EZflow Geotextile Fabric is inserted to prevent soil intrusion. The installer shall make • EZflow Internal Pipe Couplers sure the the GEO is positiioned upward and is in contact with • Pipe for Header and Inlet the fabric contained in the adjacent cylinder before backfill- • Backhoe/Excavator ing. Installation Instructions 8. The EZflow Drainfield Systems should be installed in a level The instructions for installation of EZflow®products are given be- trench in all directions (both across and along the trench low. This product must be installed in accordance with state rules bottom)and should follow the contour of the ground surface defined in chapters Comm 82 through 84,Wisconsin Administrative elevation (uniform depth), with all continuous adjoining Code,and Chapters 145 and 160,Wisconsin Statutes,as well as the 10-foot cylindrical bundles placed end to end, with central local health department's current design manual. bundle distribution pipe interconnected, without any dams, stepdowns or other water stops. 1. After the local health department has determined sizing,con- figuration,and layout for the EZflow systems,stake or mark 9.The trench top shall be graded such that water will not pond. with paint the location of trenches and lines. Be careful to set Backfill should be seeded or sodded immediately after correct tank, invert pipe, header line or distribution box and completion to reduce erosion. trench bottom elevations before installation of pipe bundles. 10.EZflow EPS bundles are flexible and can fit in curved trenches 2. Remove plastic EZflow shipping bags prior to placing bundles as may be necessary to avoid trees, boulders, or other in the trench(es). Remove any plastic bags in the trench be- obstacles. fore system is covered. 11. EPS aggregate is lighter than water, therefore, it might be 3. This product must have geotextile fabric that meets require- expected that natural buoyancy forces would tend to cause ments of s. Comm 84.30 (6) (g), Wis. Adm. Code, installed Wow assemblies to float out of ground when ponding oc- directly on top of the product and extending down along the curs. Field experience has shown, however,that this is not a sides of the product to a point at least six inches from the problem when systems have a minimum of 6"of soil cover as bottom of product. recommended by manufacturer. 4. When installed in a trench, the trench should be dug to a 1203H-GEO width of 36 inches. This not only saves labor in excavation, Geatextile Barrier Material but also provides better load-bearing capacity after backfill- ing is complete. +r iow cEr.rexot>i�1.PS wrni wivwnl PwECWPLWG �� 36- np New Ring Industrial Group P: 1-800-649-0253 30 Industrial Park PERFORMANCE. QDOES IT., I F: 1-866-279-9203 Oakland,TN 38060 Ringlndustrial.com 1044-101008 ©2006 Ring Industrial Group,LP Page 6 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page—of FILE INFORMATION SYSTEM SPECIFICATIONS Owner: Max&Marlene Kearns Tank Manufacturer: Week's C. P.oncrete NA Permit# j tw Septic E Dose E Holding Volume: 1000 gal DESIGN PARAMETERS Tank Manufacturer: NA Number of Bedrooms: 3 NA E Septic Dose E Holding Volume: 320 gal Number of Public Facility Units: NA Vertical Distance Tank Bottom (s)to Service Pad: ft Estimated(average) Flow: 300 al/day Horizontal Distance Tank(s)to Serivice Pad: ft Design(peak) Flow=estimated x 1.5: 450 gal/day Specific servicing mechanics must be provide if vertical is>15 feet or if In Situ Soil Application Rate: 0.5 gal/day/ft2 horizontal is>150 feet.Specific instructions to be provided on back. Standard Domestic Influent/Effluent Monthly average Effluent Filter Manufacturer: Polylok NA Fats,Oils&Grease(FOG) 530 mg/L Effluent Filter Model: 525 Biochemical Oxygen Demand(BOD5) 5220mg/L F NA Pump Manufacturer: 7NA Total Suspended Solids(TSS) 5150mg/L IPump Model: High Strength Influent/Effluent Monthly average Petreatment Unit Fats,Oils&Grease(FOG) :530 mg/L Manufacturer: Biochemical Oxygen Demand(BOD5) 5220mg/L V NA r Mechanical Aeration r Peat Filter h NA Total Suspended Solids(TSS) 5150mg/L Disinfection r wetland Petreated Effluent Monthly average r Sand/Gravel Filter r Other: Biochemical Oxygen Demand(BOD5) 530mg/L Soil Absorption System Total Suspended Solids(TSS) 530mg/L R"NA In-Ground(gravity) I" In-Ground(pressure) r NA Fecal Coliform(geometric mean) 5104cfu/100m1 At-Grade r Mound Maximum Effluent Particle Size: Ye in dia. NJ Drip-Line r Other: Other: X111 Other: NA MAINTENANCE SCHEDULE Service Event Service Frequency When combined with sludge and scum equals one-third('/3)of tank volume Pump out contents of tank(s) When the high water alarm is activated month(s) Inspect condition of tank(s) At least once every: 3 fd year(.) (Maximum 3 ears) NA months) Inspect dispersal cell(s) At least once every: 1.5 Wr year(s) (Maximum 3 years) NA month(s) Clean effluent filter At least once every: 1.5 Ip", year(s) NA month(s) NA Inspect pump, pump controls&alarm At least once every: I-- year(s) t" F mont s Flush laterals and pressure test At least once every: I— year(.) W, month(s) i'°". Other: year(.) 1 N Other: MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:Master Plumber;Master Plumber Restricted Sewer; POWTS Insepector;POWTS Maintainer;Septage Servicing Operator(pumper).Tank inspections must include a visual inspeciton of the tank(s)to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on ground surface.The dispersal cell(s)shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface.The ponding of effluent on the ground surface may indicated a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumualtion of sludge and scum in any treatment tank equals one-third(%)or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,Wisconsin Admininistrative Code. All other services, including but not limited to the servicing of effluent filters,mechanical or pressurized components,petreatment units, and any servicing at intervals of 512 months,shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. (Rev.2/05) Page 7 Page of START UP AND OPERATION For new construction,prior to use of the POWTS check treatment tank(s)for the presence of painting products,solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are detected have the contents of the tank(s)removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above normal highwater levels.When power is restored the excess wastewater will be discharged to the dispersal cell(s)in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over,or otherwise disturb or compact,the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics;baby wipes;cigarette butts;condoms;cotton swabs;degreasers;dental floss;diapers;disinfectants;fat;foundation drain (sump pump)discharge;fruit and vegetable peelings;gasoline;grease;herbicides;meat scraps;medications;oil;painting products; pesticides;sanitary napkins;tampons;and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33,Wisconsin Administrative Code: •All piping to tanks,pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. •The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. •After pumping,all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been,or must be taken,to provide the opportunity to obtain a sanitary permit for a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure,lot lines and wells.Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology,a holding tank may be installed as a last resort. ►[� The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area.If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT OXYGEN TO SUPPORT LIFE.NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY CIRCUMSTANCE.DEATH MAY RESULT.ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT. ADDITIONAL INFORMATION: POWTS INSTALLER POWTS MAINTAINER Name:John Schmitt Name:John Schmitt Phone:715-760-0486 Phone:715-760-0486 SEPTAGE SERVICING OPERATOR(PUMPER) LOCAL REGULATORY AUTHORITY Name:Owners Choice Name:St.Croix County Zoning Phone: Phone:715-386-4680 This document is intended to meet minimum requirements of Ch.Comm 83.22(2)(b)(1)(d)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. Palms.005) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 1335 27th Street located at: NE 1/4, SE '/4, Section 25 , Town 30 N, Range 20 W, Town of St. Joseph , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service April 10, 2015 Did flow back occur from absorption system? Yes No X (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: 1000 / Construction: Prefab Concrete X Steel Other Manufacturer (if known): Week's Concrete products Age of Tank (if known): 30 Permit number (if known) ,. John Schmitt ( ensed Plumber Signature) (Print Name) MPRS 223760 (Title) (License Number) MP/MPRS April 10, 2014 (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 Page 9 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND Max Marlene CERTIFICATION FORM Owner/Buyer M & Marlene Kearns Mailing Addrds's l 335 27th Street Property Address Same (.Verification required from Planning&"Zoning Department for new construction.) City/State -luds®n, wl Parcel Identification Number 03Q 2044-5®-0®0 LEGAL DESCRIPTION Property location NE �� '/+ , Sec. 25 ,T 30 N R2® W,Town of St. Joseph Subdivision Plat: �Lot# Certified Survey Map# Volume , Page# Warranty Deed # (before 2007)Volume , Page# Spec house❑yesOno Lot lines identifiable ByesElno SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed,by a licensed pumper. What you put into the system can affect the function of'the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in§SPS, 383.52(t)and in Chapter 12- St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning&Zoning Department a certification form,signed by the owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper vcrilymg that(1)the on-site wastewater disposal system is in proper operating condition and/or(2)after inspection and pumping(if necessary),the septic tank is less than 1/3 full of sludge. 1/we,the undersigned have read the above requirements and acree to maintain the private sewage disposal system with the standards set forth, herein,as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning&Zoning Department within 30 days of the three year expiration date. 1/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s)of the property described aboveLby ' a warranty deed recorded in Register of Deeds Off ice. Numlbe I cdrom r 0�/s VOIIFN�E OF Ai'I'i ICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&"Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV.04/12) TO d JHjd 0 41 GNy dOHS lzdiiva SA9.00tH :uotasaS xe3 ET:6T ST/80A,0 :xl?3 pantaoag #1772 ,,SOIL EVALUATION REPORT $�, = Saf y and r n�L�r In accordan th o is.Adm.Code Page 1 of 6 Professional ��'+l' C.� t Schmitt Soil Testing,Inc. Attach complete site plan on p per(n®��a?i 8Y2 x 11 inches-in County St.Croix include,but not limited to:verticcaal�<a'nnd ontal reference point(BM),direction and percent slope,scale or dimen north arrow,and location and distance to nearest road. Parcel I.D. pe p' 030-2040-50-000 Please print all information. Reviewed By Date Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). Property Owner Property Location Kearns,Max J&Marlene M Govt.Lot NE1/4, SE1/4, S25,T30N, R20W Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# 1335 27th St. 4 1 CSM 3/853 City State Zip Code Phone Number City 0 Village ❑ Town Nearest Road Houlton WI 1 54082 1 715-549-6905 St.Joseph I 27Th St. []New Construction Use: Z Residential/Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement ❑ Public or commercial-Describe: Parent material Outwash (Chetek-Onamia Series) Flood plain elevation,if applicable na ft. General comments Replacement area is suitable for a conventional system with a 0.5 gpd/sgft rating. Fossible system elevation for area is 92.48'. and recommendations: /� 1 62 �. �� /,J ?� 5 -M bf Ins*4 f U / F-11 Boring# [I Boring L]pit Ground surface elev. 95.15 ft. Depth to limiting factor 68 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-18 10yr3/2 none sl 2mgr mvfr cs 2vf 0.6 1.0 2 18-27 10yr4/3 none sl 2msbk mfr gw ivf 0.6 1.0 3 27-68 10yr6/4 none fs Osg ml rs ------ 0.5 1.0 4 68-83 10yr5/6 c2 Vr6/3 6 1 0r6/3 fs Osg ml as ------ 0.5 1.0 5 83-92 10yr5/3 m3d 1 r 6/�8 sil Om mfi ---- ------ 0.0 0.2 1,• b a a Boring# ❑Boring Pit Ground surface elev. 96.95 ft. Depth to limiting factor 112+ in. Soil Application Rate FHodzon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 0-19 10yr3/3 none sl 2mgr mvfr gw 2vf 0.6 1.0 19-38 10yr4/6 none grsl 2msbk mfr gw 1vf 0.6 1.0 3 38-54 10yr6/4 none fs Osg ml cs ------ 0.5 1.0 4 54-68 10yr5/4 none vgrcos Osg ml a ------ 0.7 1.6 5 68-112 10yr6/4 non s Osg ml ---- ------ 0.7 1 1.6 *Effluent#1 =BOD5>30< 0 mg/L and TSS>30<150 mg/L *Effluent#2=BODS<_30 mg/L and TSS<_30 mg/L CST Name(Please Print) Signature: CST Number Thomas J. Schmitt 227429 Address Schmitt Soil Testing,Inc. Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond,WI 54017 1/2/2015 715-760-1978 SBD-8330(R07/00) Property Owner Kearns, Max 7&Marlene M Parcel ID# 030-2040-50-000 Page 2 of 6 [� 3 F Boring# Boring Pit Ground surface elev. 95.05 ft. Depth to limiting factor 67 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-16 10yr3/2 none si 2fsbk mfr gw 2vf 0.6 1.0 2 16-28 10yr4/6 none sl 2msbk mvfr gw lvf 0.6 1.0 3 28-67 10yr6/4 none fs Osg ml as ------ 0.5 1.0 4 67-84 10yr5/3 m2d /3/6 sil lmsbk mfr ---- - 0.4 0.6 p_ F [�]Boring 4 Boring# N Pit Ground surface elev. 98.15 ft. Depth to limiting factor 45 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-16 10yr3/3 none sl 2mgr mvfr cs 2vf 0.6 1.0 2 16-30 10yr4/3 none sl 2msbk mvfr gw 2vf 0.6 1.0 3 30-45 10yr6/4 none scl 2msbk mfr gw lvf 0.4 0.6 4 45-51 10yr6/4 c2d 10yr6/6 sicl 2msbk mfr gw ------ 0.4 0.6 10yr6/3 5 51-77 10yr5/3 c3i 1 y 2 8 sil lmsbk mfr ---- - 0.4 0.6 Boring F51 Boring# Z Pit Ground surface elev. 98.15 ft. Depth to limiting factor 49 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-14 10yr3/2 none sl 2mgr mvfr cs 1vf 0.6 1.0 2 14-22 10yr4/3 none sl 2msbk mvfr gw 1vf 0.6 1.0 3 22-31 10yr4/4 none sl 2msbk mvfr gw ------ 0.6 1.0 4 31-49 10yr5/6 none fs Osg ml gw ------ 0.5 1.0 5 49-76 10yr5/3 m3p 10yr6/8 SO OM mf ---- ------ 0.0 0.2 7.5 r5 2 *Effluent#1=BOD5>30<220 mg/L and TSS>30 a150 mg/L *Effluent#2=BODS<30 mg/L and TSS<30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format,please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330(R.07/00) SChmltt 5011 TeStNtg,Int. Property Owner Keams, Max J&Marlene M Parcel ID# 030-2040-50-000 Page 3 of 6 Boring F 6 Boring# Pit Ground surface elev. 97.47 ft. Depth to limiting factor 45 in. ISoil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *E11412 1 0-15 10yr3/2 none sl 2mgr mvfr gw 2vf 0.6 1.0 2 15-31 10yr4/3 none sl 2msbk mvfr gw lvf 0.6 1.0 3 31-45 10yr6/4 none Ifs lcsbk mvfr gw ------ 0.5 1.0 45-72 10yr5/6 c2d 10yr6/6 sl Om mfr ---- ------ 0.2 0.6 4 10yr6/2 F ❑Boring 7 Boring# E pit Ground surface elev. 97.24 ft. Depth to limiting factor 50 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-13 10yr3/3 none sl 2mgr mvfr gw ivf 0.6 1.0 2 13-26 10yr4/3 none sl 2msbk mvfr gw ivf 0.6 1.0 3 26-50 10yr6/4 none Ifs lcsbk mvfr gw 1vf 0.5 1.0 4 50-65 10yr6/4 c2d 10yr6/6 Is Osg ml gw ------ 0.7 1.6 10yr6/3 5 65-78 10yr5/3 mad 7.5yr6/8 sil Om mfr ---- ------ 0.0 0.2 7.5 r6 2 Boring 8] Boring# 0 Pit Ground surface elev. 95.35 ft. Depth to limiting factor 34 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#t *Eff#2 1 0-15 10yr3/2 none sl 2mgr mvfr cs 2vf 0.6 1.0 2 15-24 10yr3/4 none sl 2fsbk mvfr gw 1vf 0.6 1.0 3 24-34 10yr3/4 none Ifs lcsbk mvfr gw ------ 0.5 1.0 4 34-58 10yr4/4 c2d 10yr6/6 scl 2fsbk mfr gw ------ 0.4 0.6 5 58-78 10yr5/3 mad 10yr6/8 scl lmsbk mfr ---- - 0.2 0.3 1 r6 2 *Effluent#1 =BODS>30<220 mg/L and TSS>30<150 mg/L *Effluent#2=BOD5<30 mg/L and TSS<_30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format,please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330(R.07/00) Schmitt Soil Testlng,Inc. Property Owner Kearns, Max 3&Marlene M Parcel ID# 030-2040-50-000 Page 4 of 6 ❑Boring F91 Boring# ❑Pit Ground surface elev. 95.55 ft. Depth to Limiting factor 50 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munseli Qu.Sz.Cont.Color Gr.Sz.Sh. `Eff#1 'Eff#2 1 0-27 10yr3/3 none sl 2fsbk mvfr gw 2vf 0.6 1.0 2 27-44 10yr4/3 none sl 2csbk mvfr gw 1vf 0.6 1.0 3 44-50 10yr6/4 none Is lcsbk mvfr cw ------ 0.7 1.6 4 50-84 10yr5/3 c2d 10yr6/8 sil imsbk mfr ---- ------ 0.4 0.6 10yr6/3 ❑Boring Boring# pit Ground surface elev. ft. Depth to limiting factor in, ❑ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munseli Qu.Sz.Cont.Color Gr.Sz.Sh. 'Eff#t •Eff#2 F-1 ❑Boring Boring# Pit Ground surface elev. ft. Depth to limiting factor in, Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDt t2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. `01#1 'Eff#2 �I I "Effluent#1 =BODS>30<220 mg/L and TSS>30<150 mg/L 'Effluent#2=BODS<30 mg/L and TSS<30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format,please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330(R.07/00) Schmitt SoN Testing,Inc. Page 5 of 6 -ConductedTry:_ _ _ __._ -_--_- __Conducted For: Schmitt SoUesting,Inc___<_ --Name: __ -- -------Max&Mariene:Kearns __---- ------ __--- Thomas J. Schmitt, CST 227429 Address: 1335 27th St. - -- `595 72nd St._ . -_ -_. _City, State,Zip: Houlton WI 54082 Phone: 715-7r-0-1978 CSM No: 3/853 sigu Lot No. . 4 - -- - - - — ,� 1 - - �e�ai Description: -NEI/4 SE1/ X25 T30N 8291 -- ------ !Backhoe Pit! Township, County_ St Joseph Township,St ,Croix County _ - - ,Bench Mark 1 El. 100.00'Top of Existing septic Tank insection pipe. --A Bench-iWark-2-Ei:-W64'-Top ofExistftDrain-fietd-vent-pipe --- - -- -------------- --___ ;Slope=_ 5% - Scale V=40'--_ _ ------ - 0 Q � -_ - ------ -- - - - ��'` `� - 3 - -- - - -- � uIQe � ��LL 4LL LO T S/2C � p�3 F � w T^Sryy t k3 a ! IF T CD iF l AU V 6. Ar ,a5 , # u. _PARTMENT OF REPORT ON SOIL 130hiNGS AND SAFETY & BUILDINGS ,NDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNS HIWM4N4Q}P LITY: LOT NO.:BLK.NO.: SUBDIVF I N NAME: 5 T,� N RzaE (or)W OU T : OWNER'S/ N3S NAM • VA; AILING ADDRESS. USE DATES OBS TIONS MADE NO.BEDRMS.: COMMERCIAL D SCRIPTIO PROFILE DESCRIPTIONS: PER OLATION TESTS: Residence , w ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system CG CONVENTIONAL: MOUN�+D: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHO❑LDING�NK: RECOM����SYSTEM:(optional) ❑ S ❑U (��]�S UU SS,YS]L'l��- S U If Percolation Tests are NOT required DESIGN R If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: � PROFILE DESCRIPTIONS Ap- / W BORIM15 TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER BEFR44N, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) 1 I`1 K) CYO 5° B-0 17 Lk 7116n of 01 41 co B 171J iVT l�� G 1 , PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER S AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER JNCH P_ c L:b ap 13 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 I - t I 41 6 1 P TN { I , I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ADDRE CERTIFICATION NUMBER: IPHONE NUMBER(optional): CST SIGNA U DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — 0 O 3 m c d �1 (: 1 3 � 3 F. _ 0 2 to Z � m (D � Cn w `C �• = y O N a O O �1 -� CD O CD OD 3 W co N ~ ` q! Z! O7 C1 N O. \ 0 v N IV A M C A Cl D- OD CD x co 0 W N N CO Cn O y W T p0 (r ef (` 3 H W O (vcpr GT 7 0 Cl) D tO—p7 O' CA m co' � I O S (D W 3 2 c cn CO W � 0 0 0 0 0 O CO O O CL W Q � _ r!, I to cn CCn CT O 7 3 T lV 0 0 0 °~ ��yy���r C 3 Co Ca c A D `�V Im ° ° w WW ° m Z OD Cl) W `v�` LO C, p 0 Z Z O No D 0 > 0 0 N N ,C7.,, 5 s l�l O 7 co c /�/� W 7 CD CD - �f CD 0 c N N N C1 CD N (D (p a A C I I Z N W m w0 cn eo CD o Z I g A 0 X CA N m C, N Z Cp A w � 0 a a t N O C W c 0 O CD I 3 y r. I C ro I y 'o a I ►. N O Cn FA 0 Cb CD b ft EA 0 V OWo Oo CD Parcel #: 030-2040-50-000 04/20/2005 03:55 PM PAGE 1OF1 Alt. Parcel M 25.30.20.489F 030-TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner * MAX J&MARLENE M KEARNS KEARNS, MAX J&MARLENE M 1335 27TH ST HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description * 1335 27TH ST SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.021 Plat: N/A-NOT AVAILABLE SEC 25 T30N R20W NE SE LOT 4 OF CSM Block/Condo Bldg: 3/853 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 25-30N-20W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 720/181 2004 SUMMARY Bill M Fair Market Value: Assessed with: 6060 285,400 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.020 91,600 189,200 280,800 NO Totals for 2004: General Property 3.020 91,600 189,200 280,800 Woodland 0.000 0 0 Totals for 2003: General Property 3.020 53,500 151,300 204,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 129 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 Manufactu r: Alarm Switch Type: Number of f et from nearest property line: Front, O Side, O Rear,0 F't. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM A ,--1 �, 7 5 �7�/ �7 Bed: Trench: Width: C Length: 6 Number of Lines: Area Built: 500 f Fill depth to top of pipe: '30 , Number of feet from nearest property line: Front, O Side, Rear,0 Pt Number of feet from well: IJ14 Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth- Bottom of seepage pit elevation: Area Bu t: Has eit a drop box O or distribution box O been used on any of the above soil abso tion 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: Dated: " —15 Plumber on job: 474 7 License Number: 3/84:mj • Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Z'` TOWNSHIP � �cz,� �7 SEC. r T 3c� N-R 20 W ADDRESS �� ,�L), ` ST. CROIX COUNTY, WISCONSIN SUBDIVISION C J l" ° � LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of 11HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Lora' ay L 1 � INDICATE NORTH ARROW I BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: J 46 � Proposed slope at site: SEPTIC TANK: Manufacturer: A) E s iquid Capacity: /J J d 2j!! � Number of rings used: C9 Tank manhole cover elevation: �Z oy Tank Inlet Elevation: lP y Tank Outlet Elevation: X9 Number of feet from nearest Road: Front,O Side Rear, 1G � feet From nearest property line .: Front,O Side 10 Rear,O �.3Q feet Number of feet from: well /)xe _ , building: sZS � (Include this information of th T`ab'ov�e plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE 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 Manufactu e`r: Alarm Switch Type: Number of f et from nearest property line: Front, O Side, O Rear Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM J � Bed: Trench: Width: Length: Zo 6 t Number of Lines: Area Built: <00�t a Fill depth to top of pipe: ;�y Number of feet from nearest property line: Front, O Side, Rear, Pt l Number of feet from well: IJ14 Number of feet from building:l (Include distances on plot plan) . SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth- Bottom of seepage pit elevation: Area Bu t: Has eit a drop box 0 or distribution box O been used on any of the above soil abso tion 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: Dated: '° , � "� Plumber on fob: License Number: 3/84:mj h DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,011 53707 CONVENTIONAL 1:1 ALTERNATIVE State assignn I.D.Numbers (if assigned) ❑Holding Tank ❑ In-Ground Pressure ❑Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE'. Max Kearns Trout Brook Hills, Hudson, WI 0 9��o BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV: CST REF.PT.ELEV.'. NE SE, Section 25, T30N—R20W, Town of St. Joseph, Lot## Name of Plumber: MP/MPRSW No.'. County: Sanitary Permit Number: Gary L. Steel 3254 St. Croix 69787 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET EL V WARNING LABEL LOCKING COV R + �y PROVIDED: PROVIDE L/z(/1 v-r' / / J �7P YES ONO ❑ ❑NO BEDDING: JVENTDIA.'. VENT MATL: HIGH WATER N ROAD: PROPERTY WELL: BUILDING'. VENT TO FRESH f• ALARM- �- LINE AIR INLET: V DYES NO �'" �` � ❑YES NO DOSING CHAMBER: MANUFACTURER BEDDING-. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO DYES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: ..PROPERTY WELL BUILDING'. VENT TO FRESH b LINE. AIR INLET: (DIFFERENCE BETWEEN PUMP ON AND OFF) 1:1 YES El NO SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing ¢ LENCrH DIaMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until the soil is dry enough to continue.) CONVENTIONAL SYSTEM: QWIDTH- LENGTH NO.OF D ISTR.PIPE SPACING. COVER ; "INSIDE DIA.: #PITS'. LIQUID L� TRENCHES M RIAL' DEPTH: GRAVEL DEPTH FILL DEPTH JDISTR.PIPE IDISTR.PIPE IDISTR.PIPE MATERIAL. NO. STR ^ .q.PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPE ABOVE COVER. ELEV.IN�3 ELEV.END. PIPES: F L LIN AIR IN ET: J 97 v `7 '� ... S MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ❑NO SOIL COVER. TEXTURE. PERMANENT MARKERS: JOBSERVATION WELLS: DYES 1:1 NO DYES ONO DEPTH OVER TRENCH;BED DEPTH OVER TRENCH/BED =.PSOIL'. SODDED. SEEDED: MULCHED'. CENTER EDGES. 1-1 YES ONO DYES El NO ❑YES El NO PRESSURIZED DISTRIBUTION SYSTEM: JUHOLE LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE'. FILL DEPTH ABOVE COVERTRENCHES:PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEV. DIA. ELEV. PIPES. DI A.: HOLE SPACING'. DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES E NO DYES El NO COMMENTS: PERMANENT MARKERS: - OBSERVATION WELLS: PROPERTY WELL: BUILDING: O LINE: ❑YES ❑NO ❑YES ❑NO LJ __ _ d Sketch System on Retain in county file for audit. L S Reverse Side. SIGNATURE _ TITLE: DILHR SBD 6710(R.01/82) 1 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 perm it; 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 tank(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. Ewlsconsln APPLICATION FOR SANITARY PERMIT �/ DILHR 5j. ✓ Z`7 OUNTY LJ (PLB 67) -OEPRRTR1EnT OF UNIFORM SANITARY PERMIT# 1nA3USTRV,LRBOR 6 HumRn RELRT10nS —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.7 —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNS / M (LING A R SS �l Ott "Od ati,5" //� PFfOPERTY LOCATION C TY: / 061/4 P,-1/4, S �, Teo, N, R QOE.(or) W TOOW o: LOT NUMBER BLOC N MBER SUBDIVISIO NAME NEAREST ROAD, LA E OR ANDMARK STATE P A I.D. NUMBER Ad a Yvgt 6tJoa�ls�r�7%� TYPE OF BUILDING OR USE SERVED C3 IK 1 or 2 Family Number of Bedrooms: El Public (Specify): THIS PERMIT IS FOR A: 5New System El Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ 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 ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An 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/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Gs �Ja6 WPrivate ❑ Joint ❑ Public 1,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name Plumber (Print): Signatur hIP/MPRSW No.: 113hone Number: Y Z 3>jr -71,S )Z��ha Plumber's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ,� Ga ❑ 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 S 'P C - 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 �$ Location of Property T4 — , Sectioni , T N - R W Township Ph Mailing Address v::I:i &0 /nrA4 lls Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel -3, 0Z aGs Date Parcel was Created , 1:5 1i Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes �- No Volume O and Page Number 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. - - — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — PROPERT V OWNER CERTIFICATION I (We) eehti.6y that aka statements on this 6otm ane t&ue to the best o6 my (ouA) knowledge; that I (we) am (ane) the owneA(.6) o4 the ptopenty de,schi.bed in this in6oAmation� joAm, by vi tue o{ a waAAanty deed Aeconded in the Oj6ice o6 the County RegiAteA oA Deeds as Vvcwrnent No. r .5,19 [ ,,tu xhut I (we) pn.esent.2y own the proposed site 4o4 the sewage d sposai system (oA I (we) have obtained an easement, to Aun with the above descA bed pnopeA-ty, jo)L the eon6tAucti.on,,o6 said .syatem, and the tame has been duty Aeconded in the 066ice of the County RegisteA o� Deeds, as Document No. J . SI AT 01' OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGN ' DATE SIGNED �I! DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED f � K rr�� —. — =- - — � 1 -- _— REGISTERS OFFICE � I �PAG. This Deed ma ST. CROIX CO. WIS. de between erne Anderson_and________________ Elizabeth_Anderson,__husband_and-wife _and__each__in_______-____ Ivs�d• � Record bus 5th .....their__awn_•segarate--right............................................................ &y of Sept. A.D. 19_85 - ---------------------------------------------------------------------------------------------- Grantor, CS$ 8:30 A Ma and-----Max--,.1.--Kea rns_and_Iiarlene_M._-KeL&mS..__huaband-_and___-__ .._wife_as-}Dint--tenants 8sg er of vial,% ----------------•---•---------------------------------•----------•--------•--------._..._..._---_., Grantee, Witnesset , That the said Grantor, for a valuable consideration______ ; + i+: .. y. 1St•.•.�xA1X 1 conve iAo' ; t oll -• -- - •- - RETURN TO Marlene Kearns eys•'�o,6rantee the following described real estate m ' II Count State of Wisconsin: � y, Trout Brook Hills Part of Northeast Quarter of Southeast Quarter ofU —Y,�T 141 j Q Q Seetion 25-30-20 described as follows: Lot 4 of Tax.Parcel No_ ___________________________________ Certified Survey Map filed August 22, 1979 in Vol. "3", page 853-in the office of the Register of Deeds for St. Croix County, Wisconsin. it II 1 I � i Fes' i I ,I This ......is_-nct.......... homestead property. (ta) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And------grantQrsx--LaVerne••Anderacaa-.and._Elizabeth-_Ande son-----------------------------------••---------•--- j warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except I I' easements, covenants and restrictions of record, if any, I i iand will warrant and defend the same. Dated this ------------------------------------------------ day of --------August-----------------• -•-----•--••••-••--•--•----•, 1985-._•. ------------------------•-------------_(SEAL) �C�---'LL-f....IIJ--. `! '--�.._ (SEAL) II * * LAVERNE ANDERSON •-----------.....!'rr(i��•- ---------------•---------------------(SEAL) ...............................(SEAL) :I -- ' ELIZABETH ANDERSON - ----------------------------------------------------------------- I �I AUTHENTICATION ACKNOWLEDGMENT Signature(s) ------------------------------------------------------------ STATE OF WISCONSIN ss. I II -------------------------------------------------------------------------------- St—Grnix....................County. j authenticated this ........day of........................... 19...... Personally came before me is ................day of ............. gu........................ 19........ the above named LaVerne._Ansi�x a Blj7gbg�ft_Anderson ----------------------------------------------- -------------------------------------------------------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN authorized by § 706.06, Wis. Stats.) to me known to be the person s_________ who executed the foregoing instrument and acknowledge the same. II THIS INSTRUMENT WAS DRAFTED BY HEYWOOD, CARI & MURRAY by Samuel R. Cari -- P.O. Box 229 *• �`. ---------- s-a>t; W -------- 4 01 6 Notary Public --- -- - --- - ----------- county, Wis. j I (Signatures may be authenticated or acknowledged. Both My Commission is permanent. If not state ex iratY i\n` r are not necessary.) date: ""- ------ --- ---- - -- a NOTARY PUBLIC—MINNESOTA •Names of persons signing in any capacity should be typed or printed below their sil e9�� WASHINGTON CCl1NTY I STATE BAR OF WISCON y' commission expires Nov. 18 1987 WARRANTY DEED �I \l�iscansisl al Blank Co. Inc. _t.n 11 l.T- . .nnn _ .�.-.�.._..- _ H z En H a ST C - 105 r r a . H SEPTIC TANK MAINTENANCE AGREEMENT H" St . Croix County z ry a OWNER/BUYER -x ROUTE/BOX NUMBER 94ylat'"/L0r)"/ ,5 Fire Number . w CITY/STATE / dSr9-,-I 1AJ / ZIP _j4-0/ PROPERTY LOCATION : e 14,.5 , Section T 76 N , R =';Z) W, Town of 5IA'_GPA7 St . Croix County , Subdivision Lot number A 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. H 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 H the standards set forth, herein, as set by the Wisconsin Depart- �u 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 Q 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 . "p > o c N .• C O c 4) :6 .6 ca . d O O .. N O t E C Lk C N ~ � N V O C ' U mh � Eyor � rn � � c0 ov, � w yt •- 3 ca o i C73 �' o cc c ao v o -0 W E o h C'3 cc Q U) :3 w o` .U)N m . mom > N O- v . . °O C V U) ca W ~ m3QNN ° � � oov a. U) c3ac� � U) (DN CC c « Q W O cow 3 c � :. cc cc Q N3 � CCO ; ai co a e 2 �" °� d y 0 3 N — ca ac of y O 30 °' mo � ca & �� C7 � marnQw j5 > c a� � O 'p o o ca C13 0 0 3 cm >. S �Z .E NC � � -', � ooE � ca _ � ° oca � cc CM C6 (D►. V p O V � .. y �0) Baca " .c t5 cd cc_ M C � '� ca i U C3 'p O a 3 v� •- o C� m O a o, li �c>+cY 00 w LcO i �y w o° 0O�c. FLLc-- ::S' 30 c H Q Z� E 0 O n E ° (ai 0c cc to p O E cv Um) 2 Ira .a o. 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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 15 SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; B. PLEASE use the abbreviations showy} 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 he. used if desired; S. Make sure your benchmark and vertical elevation reference point are clearly shown,and area permanent; 9. Complete all appropriate boxes as to dates,names,addresses,flood plain data, percolation test exernp- 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 Scan Separates and Textures Other Symbols st Shone (osier 10") BR - Bedrock coo Gobble (3- 10") SS - Sandstone ter Gravel iunder 3"1 LS - Limestone 5 - Sand HGW High Groundwater cs __ Coarse Sand Perc Percolatiorl Rate roK! s -- Medium Sand W - We 11 fs Fine Sand Bldg --. Building Is - Loamy Sand > __ Greater That) sl Sandy Loam < Less Than �I - Loarn Bn Drown �sil - Silt Loam BI -- Black Silt: f:7y Gra', cl Clad' Loarri y Yellow scl -- Sandy Clay Loam R -- shed sicl - Silty Clay Loam, mot - Mottles s,c: - Sandy Clay w - with s;c - Silty Clay fff -- fevv, fine, faint c - Clay cr: - common,coarse pt: -- Peat mm -- Many, medium rin - Muck d - distinct p - prominent � H W L High wester level, Six general wail textures surface water for liquid vaste disposal BM - Bench Mark VRP - Verticai Referenec Point TC THE OWNER: This soil tast report is thL first stop in securing a sanitary permit. The county or the Department may request v„ t=catiorl of this sod tent in the, field pi for °o Inermi'l issuanc,i. A cm-ni"flea; set of olans, for fhlprlvato �,.,•;1� -y:>ta'"Ts rind a permit application must be submitted to the appiopri23te focal juthoriry fri order ('} ol,.ain .# pc(.r'i w he winit,11 y p(crrnit toast Le oblli"d itA am.i posted pl for to',he,start of ,,ny clonstrtiction. ARTMENT OF REPORT ON SOIL ( KINGS AND SAFETY& BUILDINGS DUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS _. \ / MADISON,WI 53707 • (H63.090) &Chapter 145.045) r LOCATION: SECTION: c TOWNSHIP4A46L4W7HA*LITY: LOT NO.:BLK. O.: SUBDIV I N NAME: OT OWNER'S NAM AILING ADDRESS. S 64-11 9 J/ USE DATES ORS TIONS MADE NO.BEDRMS.: COMMERCIAL D SCRIPTION: PROFILE DESCRIPTIONS:1PERCOLATION TESTS: Residence �ew Replace /j( 7 9�� -� RATING:S=Site suitable for system U=Site unsuitable for system CCl6%f ('/ CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMME D D SYSTEM:(optional) KS ❑u S ❑u ❑u a S [:]S 4u) If Percolation Tests are NOT required DESIGN R (If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation:: PROFILE DESCRIPTIONS / 16 BORINIt TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER N, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) Iq 00 08 J06 io B- �b 0�3� D NG �- / 6l � n•�. •S 7 BS, 0 �� / �, DD ..5 �''" ,�.. too / PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER S AFTERSWELLING INTERVAL-MIN. PERIOD PERIOD2 PERIOD3 PER NCH P- P- �, >U .3 G� �p to �3 P- s2 PS- P__ iy -2 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 114 ✓ c�� r 1 t �. , r i i 3 i •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 knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: ADORE CERTIFICATION NUMBER: PHONE NUMBER(optional): CST SIGNA U IIDISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. 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