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HomeMy WebLinkAbout004-1029-95-000 Form-STC- 104 • AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP G~GJG)'Y SEC. L T ZeN-R W ADDRESS ST. CROIX COUNTY, WISCONSIN qq// _T SUBDIVISION 1y~ LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM tie n Selo 01 Na _ a ~ooo a/ o ~aulG INDICATE NORTH ARROW Well 7 BENCHMARK: Describe the vertical reference point used Itla / 112 37s%Jc° /,-c~e /JOr!/~ i west ~ ~v~~ house "o~ 9 Elevation of vertical reference point: 1100,0 Proposed s ope at site: SEPTIC TANK: Manufacturer: Zdee,;r Liquid Capacity: AVO0 q~ Number of rings used: Ooe, Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: 0/" Number of feet from nearest Road: Front 10 Side, Rear, V -.?(00 14, feet i From nearest property line Front,OSide,©Rear,O feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liq id apacity: Pump Model: Pump/ hon nu a turer: Pump Size Elevation of inlet: otto f tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: J.arm Switch Type: Number of feet from near st p erty ine: 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: -5- Trench: .17 Width: Length: o Number of Lines: Z Area Built: ~0 Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear, Number of feet from well: 300 -f' Number of feet from building: Z~d (Include distances on plot plan). SEEPAGE PIT Size: Number :Ott f pi s: Diameter: Liquid depth: of eepa pit elevation: Area Built: Has either a drop box O or distr ut b 4 en used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elev on of ttom of tank: Elevation of inlet: Number of feet from nearest prope i ront, O Side, O Rear, 0Ft. Number of feet rom w Number of feet f m bui in Number of feet from earest road: Alarm Manufacturer: / Inspector: Dated: la-2'1 Plumber on job: License Number : ~olo 3/84:mJ i DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR III HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 79e9 BUREAU OF PLUMBING MADISON, WI 63707 CONVENTIONAL El ALTERNATIVE State Plan I.D. Number: Ilf assigned) ❑ Holding Tank D In-Ground Pressure D Mound NAME OF PERMIT HOLDER: DDRESS OF PERMIT HOLDER: INSPECTION A E: ekstra A2517 80th St. E. Inver Grove, MN Aq-a ~lo lall( v BENCH MARK IPermenem reference pomtl DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV. SE NW. Section 13, T28N-R15W Town of Cady Name of Plumber: MP/MPRSW No Cnunty. Sanitary Permit Number 4489 St. Croix 83861 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY TANK INLET ELEV. TANK~UTLET E LEV.. WARNING LA LOCKING COVER / PRO IDEO: PROVIDED: 100 O S~~ ` ~ YES DNO DYES 1 0 BEDDING: :~VENT DIR.: VENT MATT 1HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING. V NT TO FRE H ALARM FE L INE / IN AIR INLET. ST FROM DYES DYES NO NEAREST ~vof ~V DOSING CHAMBER: MANUFACTURER BEDDING. ILIQUIOCAPACITY PUMP MOUE( IPL)MP,SIPHON MANUf ACTUHER WARNING LABEL. LOCKING COVER PROVIDED. PROVIDED. DYES DNO DYES DNO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF. PHOPE HTy WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE 41R INLET PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1 I Nt'1H FAMI TE if IIIAIIIIIAI AND MAHKINI. or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: HIA SPITS ILIOUID WIDTH LENGTH IND OF I]ISTH PIPE SPACINt, COVER =1111 /sas BED/TRENCH H NG O rHENy,HFS f C EHIAL DEPTH DIMENSIONS V : GRAVEL DEPTH FILL OEPTH UISTH PIP' UISTH PIPE DISTR. PIP MATERIAL N"I N UMBER OF PROPERTY NT TO FRESH BELOWPIPES ABUVE COVER EIEV IN(1I ELEV E S LIN AIR INLETi ~.f At 2 1-14015, 70 y Z 7 Z-9 NFEET FRM EAREST---► X2070L 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- meets the criteria for medium sand. TIONS MEASURED. DYES DNO IL COVER TEXTURE JPINMANINIM1(ARKkHS =ATIONWELLS DYES ONO YES ONO DEPTH OVER TRENCH BED DEP TH OVFR THENCI/FED OF VTII OF T111'S!)IL SODDED 5F1 OFH MULCHED CENTER EDGES DYES. ONO OYES ONO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO. OF LATERAL SPACING [HAVILDEPTHBELOWPIPt FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATFHIAL INO UISTH DISTH PIPE UISTHIBU I ION PIPE MATERIAL & MARKING ELEVATION A ELEV. ELEV' DIA ELEV. PIPES DIA DISTRIBUTION INFORMATION HOLE SIIE ROLE SPACING U111LIEU CO/1RFCIIY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED DYES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE b OYES ONO DYES ❑NO _ NEAREST 9,74 7.57 ({1 Z $ ti 0 7'. 9 S G9.~ Sketch System on etain in county file for audit. Reverse Side. SIGNATUR I L - 11 DILHR SBD 6710 (R. 01/82) DILHR SANITARY PERMIT APPLICATION Coo ~X In accord with ILHR 83.05, WIS. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ No PROPERTY OWNER PROPERTY LOCATION 5,C A ld%, S 12 T,Z , N, R (or W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISIONAME CITY, STATE ~/'//fJ ,GZIP CODE PHONE NUMBER CITY / NEAREST ROAD, LAKE OR LANDMARK ✓G+~ roV xy, VILLAGE: per,/ Ie~- _ 604= II. TYPE OF BUILDING OR USE SERVED: fix' /T u da - Number of Bedrooms if 1 or 2 Family ORE] 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. E1 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. E1 Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. seepage Bed b. ❑ seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Q ~S ° ~D L9'a~ Feet Private El Joint El Public VI. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holding Tank 006 Lift Pump Tank/Si hon Chamber -A+- I I ❑ ❑ FIT 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 i ature: (No Stamp MP/MPRSW No.: Business Phone Number: ✓e,e e i R~ejl k ~ k:~; ~ m A J/ 41r 7i s-- 6,? V -S3 Plumber's Address (Street, City, State, Zip Code ' Name of Designer: oc 9.,tJ 5t. L. w /,J LAX 540a 6;4m e VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST # OOS.s vez~f /do L f CST's ADDRESS (Street, City, State, Zip Cod Phone Number: IX. COUNTY/DEPARTMENT USE ONLY X❑ Disapproved Sanit ry Permit Fee Groundwater ate Issuing Agent Signature No Stamps) D 'A Approved ❑ Owner Given Initial Sur harge Fee at ` Adverse Determination /v0 ~ V ?S 1 47 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 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 Fora! (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,t6l:9'1y~ars; 6. If you have questions concerning yoiir private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description where 'he system is to be installed; 11. Type of building or use served: If pubic 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; M. 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'/z x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. 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 Groundwater included the creation of surcharges (lees) for a number of regulated practices which vviscois in`s a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that tUriedraasure is used in your building is returned to the groundwater.through your soil absorption system or the disposal site used by your holding tank pumper. U The monies collected through these surcharges are credited to the groundwater fund adrrinis- tered by the Department of Natural Resources. These funds are used for rnonitori ~-,g ground- 1 vv,ater, groundwater contamination investigations and establishment of standards. Groundwater, tit's worth .protecting: SBD-6398 (R.03/66) 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 i- A R E--~ hi k S i 219 Location of Property Section 3 , T 9'g N - R W Township 4 1~ V ~ b Mailing Address 1?-~ S 0X PP s 5 C7 1/ 9 Subdivision Name Lot Number Previous Owner of Property /4 K L /7L/ L/0 K Kk Total Size of Parcel 0 A E S a. Date Parcel was Created 1900 Are all corners and lot lines identifiable? Yea No Is this property being developed for resale (spec house) ? Yes No Volume `7M and Page NumberA1 2 --3 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 I (We) cehti.6Y that at atatemienta on thiA 6orur, alLe ttu.e to the beat o6 my (our,.) knowledge; that 1 (we) am (ane) the ownen(a) o6 the pnopenty ducxbed in thiA .in6onmation 6onm, by vi tue o6 a warranty deed neeonded in the 066.iee 06 the County RegiAten o6 Deeda a.e Document No. 0 ( 4 4/ and that I (we) pneaentty own the pnopoaed 4 to bon the sewage poa ayatem (on I (we) have obtained an easement, to nun with the above de cAibed pnopenty, bon the constnucti.on o6 aai.d ayatem, and the dame has been duty neconded in the 066.iee o6 the County Reg.ieten o6 Deeds, as Document No. ) . SIGNATURE OF OWNER SIGNATURE OF -OWNER (IF APPLICABLE) B-d~ - 86 DATE SIGNED DATE SIGNED property takes liave been prorated and Purc2 s`e`"r4q'pro e"Ay bility commences with date of 1-1-1985 Purchaser promises to pay when due all taxes and assessments levied on the Property) Ven ter", in it and to deliver to Vendor on demand receipts showing such payment, t i 7TTPV,,.tv M 10 Purchaser shall keep the improvements on the Property insured against loss or damage occasionee, ex 5`s{ tended coverage perils and such other hazards as Vendor may require, without co-insurance, through insurers approved s by Vendor, in the sum of Vlt• 1~I~UAE3J~ka._VAT~Cjl'but Vendor shall not require coverage in an amount more than the balance owed under this Contract. Purchaser shall pay the insurance premiums when due. The policies shall=<, contain the standard clause in favor of the Vendor's interest and, unless Vendor otherwise agrees in writing, the original of all policies covering the Property shall be deposited with Vendor. Purchaser shall promptly give notice of loss to insurance companies and Vendor, Unless Purchaser and Vendor otherwise agree in writing, insurance proceeds shall be applied to restoration or repair of the Property damaged, provided the Vendor deems the restoration or repair • he economically feasible. Purchaser covenants not to commit waste nor allow waste to be committed on the Property, to kee the Property in good tenantable condition and repair, to keep the Property free from liens superior to the lien of this Jontract, and to comply with all laws, ordinances and regulations affecting the Property. Vendor agrees that in case the purchase price with interest and other moneys shall be fully paid and all conditions shall be fully performed at the times and in the manner above specified, Vendor will on demand, execute and deliver to the Purchaser, a Warranty Deed, in fee simple, of the Property, free and clear of all liens and encumbrances, except any liens or encumbrances created by the act or default of Purchaser,, and except: .p.........._.__........_..___.___......................__......._.....__.___................................................. h5i.. Purchaser agrees that time is of the essence and (a) in the event of a default in the payment of any principal or interest which continues for a period of ...IQ... days following the specified due date or (b) in the event of a default W"t performance of any other obligation of Purchaser which co times for a period of ....1Q.. days followinyt written aajew thereof by Vendor (delivered personally or mailed by certifipo -fail), then the entire outstanding balance under this eontract shall become immediately due and payable in full, at Venoor's option and without notice (which Purchaser herebv. ~ waives), and Vendor shall also have the following rights and remedies (subject to any limitations ppavided by law) in addition to those provided by law or in equity: (i) Vendor may, at his option, terminate this Conti-1 and Pt, :haser's rights, title and interest in the Property and recover the Property back through strict foreclosure th any equity of redemption to be conditioned upon Purchaser's full payment of the entire outstanding balance, with ,.:cerestthereonfrom the date of default at the rate in effect on such date and other amounts due hereunder (in which event all amounts previously paid by Purchaser shall be forefeited as liquidated damages for failure to fulfill this Contract and as rental for the Property if purchaser fails to redeem) ; or (ii) Vendor may sue for specific performance of this Contract to compel immediate and full payment of the entire outstanding balance, with interest thereon at the rate in effect on the date of default and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser shall be liable for any deficiency; or (iii) Vendor may sue at law for the entire unpaid purchase price or any portion thereof; or (iv) Vendor may declare this Contract at an end and remove this Contract as a cloud on title in a quiet-titl: action if the equtiable interest of Purchaser is insignificant; and (v) Vendor may have Purchaser ejected from possessio of the Property and have a receiver appointed to collect any rents, issues or profits during the pendency of any actin under (i), (ii) or (iv) above. Notwithstanding any oral or written statements or actions of Vendor, an election of any of the foregoing remedies shall only be binding upon Vendor if and when pursued in litigation and all costs and expenses including reasonable attorneys fees of Vendor incurred to enforce any remedy hereunder (whether abated or not) to the extent not prohibited by law and expenses of title evidence shall be added to principal and paid by Purchaser, as in. curred, and shall be included in any judgment. Upon the commencement or during the pendency of any action of foreclosure of this Contract, Purchaser eonsentai to the appointment of a receiver of the Property, including homestead interest, to collect the rents, issues, and profits of the Property during the pendency of such action, and such rents, issues, and profits when so collected shall be held and applied as the court shall direct. Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property (by assianrnent of any of Purchaser's rights under this Contract or by option, long-term lease or in any other way) without th 3rior written consent of Vendor unless either the outstanding balance payable under, th>s ;,.~.gtltr$ct,_ a_„f fat paid, in._full .r the- iaterssl<-- conveye473s-4e*dge or assig ent''of Pitfchasees interest d&- -Contract sotey as security for an debtedness of Purchaser. In the event of any such transfer, sale or conveyance without Vendor's written consent, the entire outstanding balance payable under this Contract shall become immediatly due and payable in full, at Vendor's option without notice. Vendor shall make all payments when due under any mortgage outstanding against the Property on the date of this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaset. ; makes timely payment of the amounts then due under this Contract. Purchaser may make any such payments directly b the Mortgagee if Vendor fails to do so and all payments so made by Purchaser shall be considered payments made oil id this Contract. Vendor may waive any default without waiving any other subsequent or prior default of Purchaser. All terms of this Contract shall be binding upon and inure to the benefits of the heirs, legal representatives, successors and assigns of Vendor and Purchaser. (If not an owner of the Property the spouse of Vendor for a valuable consideration joins herein to release homestead rights in the subject Property and agrees to join in the execution of the deed to be made in fulfillment hereof.) Dated this 29 day of Apr.il..................... , 19.85.-.. Gi: IL l o-Z~t'.t yl~ ......-(SEAL) L. (SEAL) • C r 1_.J~..... .ke (SEAL) (SEAL) AUTSE'N'71CATION ACSNOWLEDLiMBNT ignature (a) as. St. Croix _ County. authenticated this day of 19 Personally came before me this 29..... day of Apr i 1.........., 19._s.. the above named ` Carl JNokken and Clarenv~Z;i- ....A TITLE: MEMBER STATE BAR OF WISCONSIN Hoeksix-a r (If not, authorized by § 706.06, Wis. Stats.) to me kn be the peso e><eCd foregoi g ins u nt and aVwl flthe e. THIS INSTRUMENT WAS DRAFTED BY v~ G,...Nestingen~.. Atty.!. V3 AldWin, W...sconsin...54002 Notary Public ............5 ......ti (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If+t,s~te~exp~~'a4t4 ; l b n're not necessary.) *Names of persons aigning in any capacity should be typed or printed date' ••••'-•'-"'••""Jla'y"317"'•'-: 19 below their signatures. H z H a ST C'-105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z t7 a OWNER/BUYER I,. 19 D E KS 779A ROUTE/BOX NUMBER Fire Number CITY/STATE ZIP y7'7 JC•v A P P PROPERTY LOCATION: 4 IVW &4, Section r?j T g N, R ~.S W, Town of C 'i L) Y St. Croix County, Subdivision - Lot number I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into 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 z to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- w ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office with In 30 days of the three year expiration date. SIGNED DATE S ' 8 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. T OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) Box 707 HU.M/~N'REtATIONS MADISON, WI 5337Q7 (H63.0911) &'Chapter 145.045) _LOCATII S 0 TOWNSHIEWftWW ?Pp'4': LOT NO.:BLK. NO.: SUBDIVISION NAME'. 56 1/4 1/4 /3 / T"4*NfR~ ftor) Ad /r,/A NA IVA COUNTY: OWNER'S BUYS S AME: MAIL N ADDRE S: .S C1.Rali L AA CAP C a sf~R' 8my*A( XA 6,arf .Tvre'e 4*6ve mfr. hi E DATES OBSERVATIONS MADE NOB R OM R ESCRIPT ON: PR FI S IONS; IRA 10 TESTS: Residence► New QRe lace RATING: S= Site suitable for system U- Site u~n+suitable DU for [IS system LJU TANK:IRENDED SYSTEM: ECO 0STC~U MC7S NGCJJ E: ~ SYSTEM-IN-FILL-FO-LDING If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the tender s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION PT GR UN WAT R INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 49 OBSERVED H - T TO BEDROCK IF OBSERVED ISEE Aj3BRV. ON BACK.) V.os tAloAlC } G . 4 47 t 4.4*2 ~19 sg-il > 02, o ' 4 94, r,* r i 10 ps ' a R S'.G, /.92' & 4. B_ ,g Ale 4 7' Cw. S, L kw '7c' 642 SA. Co. 7-2•y! 4/ e > G .67 tT4s •C r AV ' s.L (0,0' 7-7-90 /V t) W e' P'3 e 4., r" L .a /11 a q/ Sd PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP i WATER LEVEL-INCHES RATE! MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. R PERIOD ' PER1NCH P_ jG e n a y P- ` e P- 6 P - Fez.- A_ 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 69. a 5 f i S4:t C 4 #9 C_ kilt C/ e d TN k , --i l t 1, 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: ADDAFSS: CERTIFICATION NUMBER: PHONE NUMB''ER(optional). /4 c~ W I ,11 ~ ll 4/ ° - T!! - 3-37 TUBE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester: DILHR-SBD-6395 (R. 02/82) - OVER - j 46 t' rOrn 4 ~ ° ~ ! w V ,.Q Q IQ 13 +O ~ 1 Q ter. i 4 +1' to C~z Dais kv- all w' 2 zv a A.. LV !