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Parcel 030-2068-70-000 01/13/2006 09:12 AM
PAGE 1 OF 1
Alt. Parcel 35.30.20.609V 030 - TOWN OF SAINT JOSEPH
Current XST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - SCHMIDT, ROBERT H
ROBERT H SCHMIDT C - ZEDELL REGINA A
ZEDELL REGINA A
192 RIVERVIEW ACRES RD
HUDSON WI 54016-6751
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 192 RIVERVIEW ACRS RD
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 1.320 Plat: N/A-NOT AVAILABLE
SEC 35 T30N R20W PT GL 4 LOT 16 OF CSM Block/Condo Bldg:
IN 1/57
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
35-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
03/02/2001 639568 1594/302 WD
07/23/1997 941/528
2005 SUMMARY Bill M Fair Market Value: Assessed with:
84683 315,800
Valuations: Last Changed: 07/09/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.320 87,700 199,500 287,200 NO
Totals for 2005:
General Property 1.320 87,700 199,500 287,200
Woodland 0.000 0 0
Totals for 2004:
General Property 1.320 87,700 199,500 287,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 10/19/2005 Batch M 05-37
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
gOMNERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227 W ,
ST. CROIX ZONING REPORT MO.t 17755/01 PANE 1
ST. CROIX CM1NTY REPORT DATU 2/06/92
COURTHOUSE DATE RECEIVED2 2/05/92
HUDSON, WI 54016
ATTNS THOMAS C. NELSON
y J
. ?fib 3
OWNER. (Zio 6 Roberta Gray
LOCATIOW 192 Riverview Acres Rd., Hudson
COLLECTORS M. Jenkins
DATE COLLECTED# 2-04-92
TIME COLLECTED: 2S00pm
SOURCE OF SAMPLES Kitchen faucet
DATE ANALYZED: 2-05-92
TIME ANALYZED: 2200pm
COLIFORMS 0 /100 mt
INTERPRETATION'# Bacteriologically SAFE
NITRATE-N*# 2 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 ml
Nitrate-Nitrogent-*g/L
~ 9 ~D
A% OVA j
V".
CTo~ o
LAB TECHNICIAN: Pam Gane ) C)
24
d,NOeor"oE~, WI Approved Lab No. 19 S~ .
'/3 ( Means "LESS THAN" Detectable Level Approved by.
A
PROFESSIONAL LABORATORY SERVICES SINCE 1952
oZ ?,;I, q~
ST. CROIX COUNTY ZONING OFFICE
911 4th Street
Hudson, WI 54016
~r Telephone - (715)386-4680
The St. Croix Co. Zoning Office offers the service of septic and
water inspection to Lending Institution, Realty Firms, and
private individuals.
COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE
LOCATED.
Please provide the following information, enclose appropriate fee
made payable to ST. CROIX CO. ZONING, and mail, along with form
to the above address. Testing will be done as soon as possible
after fee and form are received.
WATER TESTING FEE:$ 25.00 v~
(For nitrates and coliform bacteria)
WATER TESTING FEE:$175.00
(VOC'S)
SEPTIC SYSTEM INSPECTION FEE:$- 25.00 -Al""
PROPERTY OWNERS NAME: 114e l~ /~c8'F'?X7 (5 ",}'9/9,1 471V iE eQEs
PROPERTY OWNERS ADDRESS : Xaff.D CITY: Legal Description 1/4, .1/4, Sec. .35' , T _3o N-R.2D W,
Town of, T cis p><1 , Lot: No. Subd`i~vision ~vE,t►~«,g~arJ
FIRE NO._ A91 LOCK BOX NO. D
Color of house .,&®&_p Realty sign? cs Firm:
PLEASE INCLUDE, IF AT XLL POSSIBLE, A MAP, i.e., COPY OF PLAT
BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained. /y
Firm or individual requesting services: % R
Telephone No. -
REPORT TO BE SENT O: a i9
~ fOL~P Y14!t~ ,r F S O I
CLOSING DATE: 4 p
Signature:
Ile-
ST. CROIX COUNTY
tC'`t
WISCONSIN
I'M
ZONING OFFICE
3 ~
ST. CROIX COUNTY COURTHOUSE
` - { - 911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
Feb. 5, 1992
Milo Gray
192 Riverview Acres
Hudson, WI ;54016
Dear Mr. Gray:
An inspection of the septic system on the property of Milo &
Roberta Gray, located at 192 Riverview Acres, Hudson, WI was
conducted on Feb. 4, 1992. At the same time a water sample was
obtained for testing. The results of that test will be sent to
you as soon as we receive them back from the laboratory.
At the time of inspection, the sanitary system appeared to be
functioning properly. The inspection of this sewage disposal
system was based upon a surface inspection of said system, and
did not involve any excavating or chemical analysis.
Accordingly, there is the possibility of hidden defects in the
system not discoverable by this inspection. This does not in
any way warrant or guarantee the continued proper functioning or
operation of this system. It is recommended that the system
should be pumped once every three years. Therefore, the
prolonged life of this system may be dependent upon proper
maintenance of the system.
,5'n erely,
`
Mar'y-J Jenkins
Assistant Zoning Administrator
cj
,q
j Form -STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP ~T „14"s~-=- SEC. TN-_W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of 11HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
f Q,fq,fGE
o25-'
,6~a S
AA9ad /ell
is NOS o / ~h`~a fQ
lD~~ I NORTH ARROW y
BENCHMARK: Describe the vertical reference point used
1~n
Elevation of vertical reference point: Zm.(L Proposed slope at site:
SEPTIC TANK: Manufacturer: &062e4i07 -~iquid Capacity:
Number of rings used: Tank manhole cover elevation: -Z1L-Q f2
Tank Inlet..Elevation: Tank Outlet Elevation: ye
Number of feet from nearest- Road.: Front,O Sde,O Rear, Z7 feet
=.`From,nearest- property line Front,O Side,n Rear, O ;5~ 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: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: Number of Lines: _ Area Built: ~5/
Fill depth to top of pipe: !
Number of feet from nearest property line: Front, Side, O Rear,0 Ft. Sf
Number of feet from well:
Number of feet from building:
e
(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 0 or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: 7---,-, 2: Plumber on job: m.~
License Number:
3/84:mj
PPP'
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & H JMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON`, WI 53707
k5d CONVENTIONAL ❑ALTERNATIVE IStfateaPlandl).D.Numbe,
f
E:1 Holding Tank El In-Ground Pressure El Mound if ssigne
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPFCTi N DA.
Milo Gray Rt. 2, Box 253 N, Somerset, WI 54025
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT, @I__V. CST REF. PT. ELEV..
s
SE SE, Section 35, T30N-R20W, Town of St. Joseph,Lot#16,Riverview Acre
Name of Plumber: MP/MPRSW No. County: Sanitary Permit Number:
Cal Powers 1563 St. Croix 75031
SEPTIC TANK/ DING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: (WARNING LABEL LOCKING COVER
< / C P OVIPED PROVIDED:
f 9S- Y~ 9S YES ❑NO uYES O
BEDDING: VENT DIA.. VENT MATL. JHIGH WAT R NUMBER OF ROAD: JPROPER Y WELL BUILDING: IVEN TO RESH
ALARM FEET FROM 7 LI IN (°t r AIR INLET
❑YES NO ❑YES ❑1N0 NEAREST Gl.+ j
DOSING CHAMBER:
MANUFACTURER. BEDDING: 11-tOUID CAPACITY. PUMP MODFI_ JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMPANDCONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) iJIYES ❑NO NEAREST 30 1
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I,r,TN „,'METER 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 ND. OF DISTR. PIPE SPACING: CO ER JINSIDE DI A S
PITS. LIQUID
BED/TRENCH TRENCH MTRIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTE PIP DISTR. PIPE DISTR. PIPE MATERIAL. NO. DIST ' NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH
BELOW PIP SABOVE COyEFi ELEV. INLET ELF„V E - ? PIPES: FEET FROM LIN AIR INLET:f
I f L ~ NEAREST 5 T4/ L
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-
❑YES NO meets the criteria for medium sand. TIONS MEASURED.
❑
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH;BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL. SODDED. SEEDED: MULCHED.
CENTER EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH. NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: JNO. DISTR. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.. DIA. ELEV.. PIPES: DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDfNG:
FEET FROM LINE:
l ❑ YES ❑ NO ❑ YES ❑ NO NEAREST
o ~ vl \ I t
Sketch System on\ tain in county file for audit.
Reverse Side.
TITL '
r. y.
DILHR SBD 6710 (R. 01/82)
1
wlsconsln APPLICATION FOR SANITARY PERMIT
i
'Z~ DILHR COUNTY
(PLB 67) UNIFORM SANITARY PERMIT #
~ DEPFIRTTEnT OF
InOUSTRV, LR90R 6 HUMR RELRTIOnS Ise-9Z
t
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
PROPERTY LOCATION G4T-*:
1 /4 /4, S , Ted, NR 2.Q & (or) W TOWN OF: %in 5(f
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR ANDMARK STA~ PLAN I.D. NUMBER
pla 1 Fve U 1 t&j C$ u/15 Gf 5 1
Y~
TYPE OF BUILDING OR USE SERVED 3CJ -0706- Y--
X v~
N
1 or 2 Family Number of Bedrooms: ❑ Public (Specify:
THIS PERMIT IS FOR A:
,k] New System ❑ Tank Replacement ❑ Repair
I Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
N 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 /OQ / X
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of refab. Site Steel Fiberglass Plastic
Gallons Tanks CPoncrete 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):
Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): at /MPRSW No.: Phone Number:
aw e.- ! (t, 12152
Plumber's Address: Name of Designer:
r
J r ~ c,+ n. Cti ~ 5 Sal q P '1 t~
193
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
❑ Owner Given Initial
as' 3 a41- 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
a. {
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
r
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from 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.
i
t~i4E / e~ .Z . A14 G
DEPARINIENT 0" REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDU6TRY, ~ DIVISION
LABOR AND PERCOLATION TESTS (115) 0MADISP.O. BOX 769
ON w 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: OT NO.:BLK NO.: SUBDIVISION NAME:
rv~'11~r~ •9 ~~ES
SE 1/ 3S- /T 30 N/R Z°E (o S/ • TO J*ICP - 16
COU Tom: OWNER'S BUYER'S NAME: MAILING ADDRESS:
(r' i2)r- Z 136X 7-9'3 A/
USE DATES OBSERVATIONS MADE
N17` COMMERCIAL DESCRIPTION: PROFILE D S R IONS: A I N EST.:
(Residence ^/1L XNew ❑Replace 2 fJ
Y7L G+s J-*e ivs /N ewe,s)7~cvr AS N i i~-Sic T L -
134PT /5 C 70/1 GG uh4! .LS .
RATING: S= Site suitable for system U= Site unsuitable for system s x/
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE; SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
® S au ® S ❑U 1- 14 S IDU a S U 0 S U sEf- tide If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area
is in the 2
under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORINGI TOTAL DEPTH TO GROt1I1DWATER•INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH I
,~cotr~wr+ ELEVATION l;. nn:/ : c ~~^V. O": °A~
Iw+ =~w.+ .:a •^y OBSERVED S.. TG BEDRO.L1. 1F OBSERI,ED iS EE r•.
g. 170 ` 144SOA14 y ' rl 7' 131j-6X 45, 7•13,v.G f 3cr- Es 4,e .414...1
Iq M w f> WSTWer moTs eta:, s
2.6 7 7(-o
d-
B ~jc°/sa~o u r !d
/J, ~GN S+F~sasJ~f~y CLr 4v,6t f f F"
- 2 13.3
_f ,.^4 s_ " 3P z4M S,
B- t 'r ` s ' ` ~.U "l~'f t • S'~` E3A'• 1-7 1 '1 .;R rr3~t1. C L cuf 0~,.
g.3 S 97,~~._ S~r?SaU/4/W ~~ST CE~(yy.~a_~C?N._45 la•~ 1
~r PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN tNATER LLEVEL:INCHES RATE KM U'TE:S.W_W
NUMBER ES AFTER SWELLING INTERVAL-MIN. p RIO(~9 _ _PERIOD - R /NCH
P_ 5- All
P_ ••77 - J~
:f y -7 p.
P. 3 i .12.
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions Of suitable soil areas. Indicate scale or distay?ees;. Describe what are the hori-
zontal and vertical elevation refdrence points and show their location or, the plot plan, Show the surface elevation at ail borers-and the direction: and per:-ent
of land slope.
SEA ~~E
SYSTEM ELEVATION /•u~~~~~
i
S~Ec
1177
l
:
I
v rv, ,
Dom'/M -7
v ~v- I I i• I ~ t
I G
Q"/U~~L
r ~
1, the undersigned, hereby certify that the soil tests reported On this form were made by me in ac: rd 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 if my knowledge and belief.
(NAME (print : TESTS WERE COMPLE E
TD N.
6ERr ZIG/3R i c ti T- ~q3
A0
CATION ~ y~ PMBER: Pjj fy~NUEP.IoPtionaU:
ADDR SS: &)/-f ~RT~In
RY O',VEt L Ad - HUDSOAJ V J(OV vI/
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER - ,
DUS.TR cNT•OF. AND SAFETY & BUILDINGS
IN '
NDUSTRY, REPORT ON SOIL BORINGS DIVISION
LABOR AND PERCOLATION TESTS (115) MADISP.O. BOX 7969
ON W1 3747
HUMAN RELATIONS (H63.090) & Chapter 145.045)
~C
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: OT NO.: BLK. NO.: SUBDIVISION NAME:
~Sr 35- /T3QN/R201 (o W Y71• U6s h` /Co ~v ir~Ew ~c,PEs
COUNTY: OWNER'S BUY R'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO.BEDRMS : r OMMER IAL DESCRIPTION: PROFIL D S RIP IONS: PERCOLATION TESTS:
1/-QRpsidince N dom. New ❑Rep}ace ~3 Z
~P3 I
T o
RATI":G: S= sits suit bta for systam U= Site unsuitable for system
ONVENTIONAL: MOUND: -FIN-GROUND-PRESSUR, E rEJS.DU STEM-IN-FILLHOLDING TANK: RECOMMEN D SYSTEM:(optional)
r 1_
]S C]U EIS ❑U ❑S ❑U ❑S ❑U
,If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the 2 - _
`Lunder s.1-163.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
F PROFILE DESCRIPTIONS
}c,ORING ALI GVATION• DEPTH T GROUNDWATER-tN ES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
~ T = ScAVE r EILT. HIGHEST TO nEDROCK IF OBSERVED ISEE ABBR .ON BACK.)
' t r > i 7 w(yy- L_S, 6,(J. t 1 , 5 r /ff %X O~ AI. 45
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PERCOLATION TESTS
'EST DEPTH WATER IN HOLE TEST TIME DROP I N WATER LEVEL-INCHES RATE MINUTES
na".3ER iNCHcS AFT>:RSWELLING INTERVAL-MIN. PERIOD I PER'O0 - ~Q -R795-T PER INCH
ei.OT PLAN: Show locations of percolation tests, soil burings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hon
nta; and vertical elevation reference points and show their location on the plot plan. Show tho surface elevation at all borings and the direction and percent
o' fan;: slope.
aTEM ELEVATION
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with t: 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 kr. ,ledge and belief.
PJAME (print : TES i WERE COMPLETED ON:
ADDR SS: _ R IFICATION NUMBER: PHONE NUMBER (optional):
l 3 D;yE~L ~vOsov f s:s =a1-~~Z 3~~•-~t~
CST SIGNATUR :
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
`DILHR-SBD-6395 (R. 02182) OVER -
R€PO!T ON SOIL 13oRINGS PERCOLATION TEST5 IIS
kUlf w ~ ~~'ES
pt-vT pl.~1N PROTECT r• O. /&)p "J 6&0)1
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HOMIESITE TESTING CO.
A ► . 3, O'N EIL ROAD BOB UL,8H1 Gi.s
allo3oNr WIS.- 54016 e57- .SS- 02 Y-f2-
pRoposED Noose mosT i-ie 2s' Fr. opt Mo,?E "oM. ALi- Trsr ^ee.45.
pizo posE D I.UE LL m vs i Lie 0 -AfOff- F&Al ALI- TEST A."45.
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!1 Uenc //7~¢~K °'(C~P t~~/'ee.n pl.o~+~ 5 7'' J oSeIo4 how' /C Y '
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Fresh Air Ini•/e And Observation Pipe '
(=-,)-Approved Vent Cap
• Minimum 12" Above{ L, 57
" final Grade
20- 42" Above Pipe _ 4" Cost Iron
To Final Grade F Vent Pipe
Marsh Hay Or synlhelk Covering
Mtn. 2" Aggregate
Over Plp$
Olalribullon - Tee
Pipe 0 0 0 0 0
6" Aggregate o Perforated Pipe Below
Bsneolh Plpe 0 -Coupling Terminating At
Bottom Of Sy6lem
P~p~n1eIDt~kl grHc~~
SOIL FILL
DISTRIBUTIOIl.1 PIPE APPROVED S40P F-TIC COVER
1-JUTERIA11- OR 9~'OF STRAW
OF706REGAZE c' OR MAXSU HAy
°+v r(B OF -2112 AGGREGATE
t.LEV.OF EEZ - r
DISrRigUTIOU PIPE TO BE AT LEAST IIJCHES BELOW ORIGIAJAL GRADE
ALJU AT LEASTZO IIJCHES BUT KIO MORE TRAM H2. IkICHES BELOW FIAIAL GRADE
MAXIMUM ®EQrH OF EXCAVATImw, FKOM OKIGWAL 6KAoF- WILL BE IIJCHES
M1I4IMUM 9r-f" OF EXCAVATI(W fR01i0%.'0i1i(IG1WAlL GRAPE WILL BE INCHES
LICEUSE AJUMBER:
DATE :tf (J-~~
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT Ho
St. Croix County z
d
a
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OWNER/ BUYER m,/6 f~. fIL,7Yt_ Q!, ('-e e
~
ROUTE/BOX NUMBER Fire Number
.CITY/STATE ZIP
PROPERTY LOCATION:~S Section T? Z) N, R 2-j W,
Town of _5T, ` JSc,Q St. Croix County,
r
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
0
E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- Fd
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. t~
SIGNED
DATE C9
St. Croix County Zoning Office
P.O. Box 9&
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
i
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor, ("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property , (d J, (Lena y
Location of Property S C ;4, Section 3 5 , T _,2c N-R 2- d W
r
Township
~ cam. c3d
Mailing Address R-r
S~h7 C.^ a (J Lc
Address of Site
Subdivision Name / v C"',
Lot Number
Previous Owner of Property JOS&Q tz S
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume 6 and Page Number ko L2- 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 Rester 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) ceAti6y that a t statements on thi-6 4onm ahe tAue to the but o6 my (out)
knowledge; that I (we) am (ahe) the owneA(.s) a ehty de~schibed in this
i
n6oAmation 6atun, by viAtue ob a wal[A eed tc tided in the 066ice a the
County Registers o6 Deedd a3 Document Na. ! a that I (We) pt uentty -nd awn the puposed site 6o& the sewage pas ~yA o& I (we) have obtained
an
eatsement, to tun with the above duc4 be 0ity, 6o,% the consttcuction og said
.6ydtem, and the same has been duty uco&ded in the 046ice a6 the County Regi6teA o6
Deeds, as Document No. 395 y jl ) .
SI ATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
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