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Parcel 030-1053-40-000 02/18/2005 05:12
PAGE 1 OF 1
F 1
Alt. Parcel M 23.30.19.197U2 030 - TOWN OF SAINT JOSEPH
Current ik' ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): * = Current Owner
* SMITH, EDWARD E & ELLEN
EDWARD E & ELLEN SMITH
1414 RIDGE RUN
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1414 RIDGE RUN
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 198 Plat: N/A-NOT AVAILABLE
SEC 23 T30N R1 9W GL 1 OT 2 OF CSM 1/2 Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
23-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 541/375
2004 SUMMARY Bill M Fair Market Value: Assessed with:
5171 216,600
Valuations: Last Changed: 07/08/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.200 60,700 152,400 213,100 NO
Totals for 2004:
General Property 2.200 60,700 152,400 213,100
Woodland 0.000 0 0
Totals for 2003:
General Property 2.200 35,600 124,400 160,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 217
Specials:
User Special Code Category Amount
I
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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"r 'ER TOWNSHIP 4 SEC.c T N, R W
!0. ADDRESS ST. CROIX COUNT I, WISCONSIN.
3DIVISION LOT - LOT SIZE
PLAN VIEWC 1
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
•Ci GG SF~. '
.
e
t
"TIC TANK(S) MFGR. j CONCRETE 2--_"STEEL
N0. of rings on cover Depth- 24 DRY WELL
'NCHES NO. of width length area
7 no. of lineswidth length, 6,-:) area
dto to of ipe .gyp
3REGATE XL-Z7)-71' /
_!K RATE t AREA REQUIRED a~ AREA' AS BUILT C ~
:claimer: The inspection of this system by St. Croix County does not imply complete j
•.pliance with State Administrative Codes. There are other areas that it is not possible/
inspect at this point of construction. St. Croix County assumes no liability for
_tem operation. However, if failure is noted the County will make eve ort to
-ermine cause of failure.
:ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM,
t 'INSPECTOR
~J DATED z PLUMBER ON JOB
LICENSE NUMBER 17 2~7
17
I
REPORT OF IMSPECTI011--INDIVIDUAL SEMAGE DISPOSAL, SYSTEM
Sanitary Permit J
• • r State Seotic i~2
' .,.A:1Fi
T&I-111SHIP
t: Croix County
SEPTIC TANK G' .ooe
Size
•,Ze gallons. 'lumber of Compartments
Distance From: Well l~0 ft. 12% or greater slope - ft
Buildingft. Wetlands ft
Highwater ft.
DISPOSAL SYSTL:2 Tile Field or Seepage Pit(s)
Distance From: i1ell l ft. 12%.or greater slope' ft
Building; -j ft. Wetlands - f
V
FIELD ` D ( r ighwat er ft.
Total len• t oi lines r
g C ft. Humber o~ lines 2 Length of
each lineft• Distance between lines G ft. Width of the
trench Zft. Total absorption area sq. ft. Depth'
of rock belvw tile Dp-pth of rock over the 2- in.. Cover
_ over.rock., Depth of tile below grade ~
0in. S=' lope of
trench 'in per 100 ft. Depth to Bedrock Depth to
?,round water -
PITS
:lumber of pits Outside d Xame '_!~ft- Depth below inlet
ft. Gravel around pit .Total absorption area
-___•____sq. ft.
.Square feet of seepage tr ottom area required
::quarts feet of seep e nit a required
Inspected byTitle:.
Approved .Date
X1979.
Rejected Date 197
.I
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
' P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: - -CII.,rIL4'/4, Section-?2, N, R/_? Ef (or) W, Township or Municipality _5T ,j f, S "e A
Lot No. , Block No. S/ §il j-~sion Name County
Owner's Name: -S ✓ t Y
Subdivi ..r~
e
Mailing Address: G-
TYPE OF OCCUPANCY: Residence No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW / ADDITION REPLACEMENT
DATES OBSERVATIONS ADE: S91 L BORINGS 7 ! PERCOLATION TESTS i:;~
SOIL MAP SHEET SOIL TYPE
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P- , 3 G
e 41
P- 01
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B- 9/,e 7 7~ I 5
-S
72 owQ Il 5 _5
B -7 ke
S 7'=5
A/ t Ale :
13 A2
PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. ndicate numbeZf sgLare feet of absorpp area
needed for building type and occupancy. d-~e e -zytTdfa,a e
or distances. Give horizontal and vertical reference poi s. ndicate slope.
3
tN
Q ~
c
_F C
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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) If Gt el VV A/17 A2 /j Z h t' Certification No.
Address
Name of installer if known
bIIIIIIIIL40PY A - LOCAL AUTHORITY CST Signature
I
I
` State and County State Permit #
PLB67 Permit Application County Permit #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY j Mailing Address:
JYl- / 2~
/17 Ll
B. LOCATION: % Section ;7j, T3PZ7 N, RZ,7- E (or) W Lot# -City_
Subdivision Name, nearest road, lake or landmark Blk#~L Village
Township
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family /,-I- Duplex No. of Bedrooms 3 No. of Persons
D. TYPE OF APPLIANCES: Dishwasher LOPES NO Food Waste Grinder YES c- tr # of Bathrooms)
Automatic Washer L-YIE`~- NO Other (specify)
E. SEPTIC TANK CAPACITY Z,--Z-V Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation L/' Addition- Replacement- Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) __L_ 2) i S 3) _J Total Absorb Area sq. ft.
New t--~Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth _ No. of Trenches
Seepage Bed: Length S.;) ' Width /.2 , Depth _ Tile Depth --i- y No. of Lines -2-
Seepage Pit: Inside diameter Liquid Depth Tile Size el It
Percent slope of land Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Tester,
NAME K 1 get>s_( l k C.S.T. # / f and other information
obtained from
(owner/builder).
Plumber's Signature P/MPRSW# Z92 2 -Phone #-;1-y6_ S
Plumber's Address
. Q~a.c.l ~ vs ic~~J
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
1"(
E-71
t? G 3
~f
i
Do Not Write in Space Below DEPARTMENT U DEPARTMENT ON Y
Date of Application Fees Pa d: State Of
Co nt Da
Permit Issue (date) Issuing Agent Name
Inspection Yes No Valid# Date
1. county (w it copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/1 /76
` Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 1~a - .esp. TOWNSHIP ~~z CL SEC. ~ T ~N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION l J o~~j~ LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IZHR, 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
h
g~
r
A
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point:
Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity.
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,Q Rear, O feet
From nearest property line : Front 10 Side,0 Rear, O feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
gPP RRURRgR gTT)P
a `
PUMP CHAMBER
Manufacturer: Liquid Capacity: `
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. _
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: 42 Length: Number of Lines: Area Built
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, ( Rear, 0irt _
Number of feet from well:
Number of feet from building: ~f
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, OFt.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job: License Number :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7959 BUREAU OF PLUMBING
MA[)ISON, WI 53707 r~
9YCONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number.
• (lf assigned)
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Ed Smith Rt. 4, Box 106B, New Richmond, WI 54017 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT.
ELEV..
SE SE, Section 23, T30N-R19W, Town of St. Koseph
Name of Plumber: MPIMPRSW No.: County: Sanitary Permit Number:
Cal Powers 1563 St. Croix 88426
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIOUI ACI TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO DYES ONO
BEDDING: VENT DIA.: VENT MATL.: HIGH IN N MBER OF ROAD: [ROPERTY WELL: BUILDING: VENT TO FRESH
AL M F ET FROM INE: AIR INLET.
DYES ONO S ONO AREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
OYES ONO DYES ONO OYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES ONO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH: DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH. INOEOF COVER INSIUE DIA*PITS LIQUID
BED/TRENCH TRNCHES / MA AL: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH UISTR. PI DISTR. PIPE DISTR. PIPE MATE
FIF- NO. DI R. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIPE ABOVE COVER ELE~V1. INLET. ELEEV. END. n PIPES. LINEn- AIR NLET
1
a 7a! NEARESTO--► dJ /T 7 2.Z
3.87
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-
D meets the criteria for medium sand. TIONS MEASURED.
YES ONO
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
DYES ONO OYES ONO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED. SEEDED MULCHED
CENTER. EDGES.
DYES ONO OYES ONO OYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.. ELEV.: DIA.: ELEV.: PIPES DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL BUILDING.
FEET FROM LINE:
3 DYES ONO OYES ONO NEAREST
l WS
G _7
Sketch System on
lain in county file for audit.
Reverse Side.
SIGNATURE: TITLE. _
DI LHR SBD 6710 (R. 01 /82)
T DILHR SANITARY PERMIT APPLICATION COUNT CM44
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
017 Al ap
-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
'/4 - '/4, S , N, R / E (or
S,E PRO ERTY OWNER'S MAILING ADDRESS LOT NU ER BLOCK MBER SUBDIVISI N NAME
.4 4f-
CIT STATE ZIP CODE PHONE NUMBER C NEAREST ROAD LAKE OR LANDMARK
O VILLAGE
11;1A 7 (1/s [A TOWN OF7
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable)
1. a. E1 New b. Z Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit Date Issued
3.E1 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. E] Pit Privy d. E1 Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. 0 Seepage Bed b. ❑ Seepage Trench c. ❑ seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
Feet Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic A
Tanks Tanks structed pp'
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber'§ Name (Print): / Plumber's Sign re: o Stamps) MP/MPRyS93 Business Phone Number:
JAA
Ituer"'s Addres (Street, City tate, Zip Code): Name of Designe .
Ill. SOIL TEST INFORMATION
Certifi Soi Tester (CS lame r CST #
CST's RESS (S eet, City, te, Zip Code) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
yN Approved El Owner Given Initial D Surghar~ e~e
Adverse Determination
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable;
3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation;
5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your privat:, sewage syster1, 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 the system is to be
installed;
ll. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
Vi. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/2 X 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement
system areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 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 negotlation and public debate. The groundwater bi l Groundwater
included the creation of surcharges (lees) for a number of regulated practices which "1iSCon i°s
can effect groundwater. The surcharge took effect on July 1, 1984. All -)f the waster that bue _ d t; easLire
is used in your building is returned t< the groundwater through your soil absorption
o
system or the disposal site used by your holding tank pumper.
The monies r:ollected througF.. these surcharges are credited to the giount'svvalar'-, nd ~cr,,-nis-
terec by the Department of •,Natur I R sor:rces. These funds are used of o~ X o x
water, gr'~)undwater contamination investigations and establishmcrit of standa 'al
it's worth protecting.
SBD-6398 (8.03/86)
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969
HUMAN RELATIONS
(H63.090) & Chapter 145.045)
LOCATION: SECTION: pp OT21NSHIP/MUNIC PALITY: LOT NO.: BILK. NO. SUBDIVISION NAME:
1,/ / 1Itt E (or
COUNTY: OW ER' BUYER'S NAME: MAI I AD ESS: 7
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMMERCI L DESCRIPTION: IPROFILE DESCRIPTIONS: PERCOLATION TESTS:
I Residence 1:1 New ®Replace It i7~, g j ` ~~y
RATING: S= Site suitable for system U= Site unsuitable for system
r ONVENTIONAL: MOUND: IN-GROUNcD-PRESSURE: SYSTEcM-IN-FILL LDI(N~G TANK: RECOMMENDED SYSTEM: (optional)
S ~U J ®J ~UJ ZU J ®U
If Percolation Tests are NOT require DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 1,
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH M. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- ? - - k
B-
B- ,3 -
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. PERIO 1 PERIOD 2 PERI D 3 PER NCH
P-
P- /
?
P-
P__
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION g~ 9
r
3
I
E
E
~ _
~.~DC9Tic_o{s.~f
3
TM.
-
30
iE
E E r
90
3
Ilk
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a
E
1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures ethods 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.
TESTS WERE COMPLETED ON:
NAM rint):
! r
pluo -
AD CERTIFICATION NUMBER: PHONE NUMBER (optional):
r CST §~§NATURK 72-5 -,29 ZIZ~
F
ri "naI and one copy to Local Authority, Prot' and Soil Tester.
L,.
.OVER
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INSTRUCTIONS FOR COMPLETING FORM 115
TO or-npletr I curate soil test, your report Must include;
I d
ly indicate whether this is a residence ; aject;
3 commercial use planned;
A SITE 1S SU[TAM_ F n1J\J TANK ONLY IF ALL
DO _ W CC
6 l _ at completing the plot plan;
7, scale is preferred. A
8. i, and are permanent;
s 'D . flood pl, I rcolation test exe p-
1~. ,n}xr
12 THE
Ls Y` 1[ 30 D A)t ~
to 9 IONS FOR EFL, , SOIL TESTERS
c to res
:3") L
1s - 3
Y AV
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mot .
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ff
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Mil
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is fi i in ar jest
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APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of PropertyC~~-c_) n Sr» . ALL F6y ! Srrs i
Location of Property ;4, Section T 30 N-R % s W
Township Za SG J/9144
Mailing Address x / o
a ti S .J 6-4za 7
Address of Site F2i3vu-c
Subdivision Name
Lot Number Tw
Previous Owner of Property 6f e esV,43 F .1J 45'c,,,j
Total Size of parcel 02 QF S f1~5
Date Parcel was Created
Are all corners and lot lines identifiable? , es No
Is, this property being developed for resale (spec house) ? Yes qNo
Volume 5111 and Page Number 3 7S as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Deed which includes a Document number, volume and page number, and the
Seal of the Register of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) eeAti6y that att statements on this bonm ahe tAue to the best o6 my (ours)
hnowtedge; that I (we) am (ake) the owneA(.s) o6 the pnope ty daelc,ibed in this
in6mmati,on 6onm, by vi)ttue o6 a wart arty deed necanded in the 066i.ce ob the
County Reg csten o Deem ass Document No. 3-?and that I (We) pnea enntQ.y
own the proposed site {fan the sewage di6poz system (on I (we) have obtained an
easement, to nun with the above de,6c& bed pnopenty, ban the covustnueti.on o6 said
system, and the same has been duP-y necanded in the 046iee o6 the County Reg-usten o6
Deeds, as Document No.
Y, ~Ilc,J ct~_ U
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
0 91
DATE SIGNED DATE SIGNED
Ln
S T C - 105 r
SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County
t~ ~I
9
OWNER/BUYER
d- X11
ROUTE/BOX NUMBER ]RW Q 1 to Fire Number
UL----
CITY/STATE
PROPERTY LOCATION: 4, _4, Section c),3 T ,70 N, R _W,
Town of sT I-cje 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 se)tic tank pumper. What you put into
the system can affect the function of t11e septic tank as a treat-
ment stage in the waste disposal system.
St_. Croix County residents may be eligible to receive a grant Ior
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained. -
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
0
I/WE, the undersigned, have read the above requirements and agree W
to maintain the private sewage disposal system in accordance with x
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.
SICNED_x
DATE X /0° 2 9
{
St. Croix County Zoning Office
P.O. Box 9.1
Nammotnd, W.. 54015
715-7:"46-22'19 or 715-425-8363
Sign, date and return to above address.
A9411.6
f~sE
ans
al`ot~~,,v.~ ~ 9~ q
PAGE OF
Cro5S Sec~1OrN O~ A ~en S s~e~
~f 7 ~or~D~
Fresh Air Inlets And Observation Pips
`*)i --Approved Vent Cap
~[J Minimum 12" Above
Final Grade
't
20- 42" Above Pipe _ 4" Cast Iron
To Final Grade Vent Pipe
Marsh May Or Synthetic Covering
Min. 2" Aggregate -
over pipe
Distribution
Pipe o 0 0 0 Tee
6' Aggrega
Beneath Pipe a Perforated Pipe Belay
j 11
o Coupling Terminating At
Bottom Of System
Proposer ~tnk~ 119nccl<
SOIL FILL
DISTRIBUTIOF.J PIPE
APPROVED S4kq1IETIC COVER
MATERIAI- OR 9" OF STRAW
OFh6GRUWE MARSH HAy
OF - 2i12 AGGREGATE °~8\~
a 16'
F4.
W-V. OF EE7_.-
DISTRIIjUTIOAI PIPE TO BE AT LEAST IUCHES BELOW ORIGIMAL GRADE
AQU AT LEAST20 IMCHES BUT 1.10 MORE THAN 41 INCHES BELOW FINAL GRADE
MAXIMUM DEPTIJ OF EXCAVATIOP FROM ORIGINAL 6RADF. WILL BE - MCHES
11114IMUM Off r" OF EXCAVATION FROM ORII(AWAL GRAPE WILL BE _3t! IINICHES
I
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f
I
I
SIGHED:
r t
LICEWSE kIUMBER:
DATE : , _ `0 Co