HomeMy WebLinkAbout012-1011-60-000
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Parcel 012-1011-60-000 09/14/2006 03:34 PM
PAGE 1 OF 1
Alt. Parcel 03.30.17.47C 012 - TOWN OF ERIN PRAIRIE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - THIELKE, DOMINICK & JACLYN
DOMINICK & JACLYN THIELKE
1860 170TH AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1860 170TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 1.880 Plat: N/A-NOT AVAILABLE /
SEC 03 T30N R1 7W 1.88A IN SW SE LOT 2 OF Block/Condo Bldg:
CERT SURVEY MAP IN VOL IV PG 948 ORD
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
03-30N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
09/19/2002 691015 1983/38 WD
07/23/1997 1039/607 WD
07/23/1997 997/250 QC
07/23/1997 682/539
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 11/07/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.800 28,200 169,200 197,400 NO
Totals for 2006:
General Property 1.800 28,200 169,200 197,400
Woodland 0.000 0 0
Totals for 2005:
General Property 1.800 28,200 169,200 197,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 119
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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Parcel 012-1011-60-000 02/22/2006 04:36 PM
PAGE 1 OF 1
Alt. Parcel 03.30.17.47C 012 - TOWN OF ERIN PRAIRIE
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - THIELKE, DOMINICK & JACLYN
DOMINICK & JACLYN THIELKE
1860 170TH AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 1860 170TH AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 1.880 Plat: N/A-NOT AVAILABLE
SEC 03 T30N R17W 1.88A IN SW SE LOT 2 OF Block/Condo Bldg:
CERT SURVEY MAP IN VOL IV PG 948 ORD
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
03-30N-17W
Notes: Parcel History:
Date Doc # Vol/Page Type
09/19/2002 691015 1983/38 WD
07/23/1997 1039/607 WD
07/23/1997 997/250 QC
07/23/1997 682/539
2005 SUMMARY Bill Fair Market Value: Assessed with:
104579 190,900
Valuations: Last Changed: 11/07/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.800 28,200 169,200 197,400 NO
Totals for 2005:
General Property 1.800 28,200 169,200 197,400
Woodland 0.000 0 0
Totals for 2004:
General Property 1.880 7,900 131,100 139,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 119
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP r•,,aSEC. T % N, R~ j W
P.O. ~ADDS' 4,f J,r,,. • , , ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION 4-""/ LOT LOT SIZE
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
t
SEPTIC TANK(S) MFGR. / CONCRETE STEEL
NO. of rings on cover Depth DRY WELL
TRENCHES NO. of width length area
BED no. of lines width length__', 4_ area
depth to top of pipe
AGGREGATE
PERK RATE AREA REQUIRED/-' AREA AS BUILT
Disciaimer: The inspection of this system by St. Croix County does not imply complete
compliance with State Administrative Codes. There are other areas that it is not possible
to inspect at this point of construction. St. Croix County assumes no liability for
system operation. However, if failure is noted the County will make every effort to
determine cause of failure.
GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM.
N
INSPEZTOR__.__--
DATED PLUMBER ON JOB
LICENSE NUMBER
i
f
R
I
Li
s
P_P,PORT OF I11SPrCTIO?I--I,~,')I JIDIJAL SE?IAGE DISPOSAI, SYS'T'E1.1
Sanitary Permit_
State Septic /
t TOWNSHIP _ j
• t CCro" County
SIRPTIC T!C K.
Sze gallons. `lumber of Compartments
Distance Front: fell s ft, 12% or greater slope i1.
Building ft. Wetlands
Highwater ft.
DISPOSAL •SYSTE:-I Tile field or Seepage Pit(s)
Distance From: Tlell
ft. 12°lv or greater slope ft
Building,~ft, Wetlands f~.
C~ ~n
FIELD ~ i;ighwater /\J J ft
Total length of lines ~5 ft. Number of lines - Length of
each line Ft. Distance between lines
' ft. Width of file
trench / ft, Total absorption area sq• ft. Depth
of rock below the in. Dr-pth of rock over the in. Cover
over. rock , % % Depth of tile below grade in. Slope of
trench "in per 10ft. Depth to Bedrocks , ft. Depth to
ground water ft.
'lumber of pits %out~ide diameter ft. Depth below inlet
ft. Gravel-r~und Tiit: `_yes no. Total absorption area
sq, ft.
Square feet of seepage tench'bottom area required
,quays feet of seepaj.,e nit are required _
Inspected Title'
Approved Date 197.
Rejected Date -197-.
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
. DIVISIOI~COF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
f/ P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATION: S Cj'/4, Section a, T.30N, R ~E (or W, ownship or Municipality aAl ~/eC
~T
Lot No. Block No. County ~ •
ubdivision Name
Owner's Name: V457,eAe, /4-0
Mailing Address:-
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW - ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: OIL BORINGS PERCOLATION TESTS
SOIL MAP SHEET - SOILTYPE l y~ -47"e -S C5,1e7
PERCOLATION TESTS
TEST DEPTHT CHARACTER OF SOIL HOURS WATER IN TESTTIME 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
I,,--
'J& 5 G K I f'"'
lp- 3lI L16
30
SOIL BORING TESTS
r TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
i NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
7 6
41 _11/0 51L SL
2 96' 56 4 f 5
B_ d s. - Q6 s
I 8 T 5 r SjL 5; 6
C ! 0- 5Z T- L- C) I ,
5~ 647-5 ' 90 Sie- 'i'G SL-
AN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.)
Aicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area
11eeded for building type and occupancy. Z-~ JD6 Indicate scale
or distances. Give horizontal and vertical reference points. In icate slope. 4JC 9-1 t ) V 10 0 1
♦ _
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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) in Certification No. ~ 5 5 32
Addressi c -l ca t
Name of installer if known
r
CST Signature -
COPY A - LOCAL AUTHORITY
State and County State Permit #
PLB67 Permit Application County Per #
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 l Mailing Addres
/ - ltJ r1 C~ ~l
B. LOCATION: S Y4 !j rc. Y4, Section, T_3_(DN, R t-7 E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township ~~ll~1 I J¢/n~ F
C TYPE OF OCCUPANCY: *Commercial ~L *1drooms ustrial *Other (specify) *Variance _
Single family Duplex No. of B No. of Persons Z
D. TYPE OF APPLIANCES: Dishwasher )!r YES NO Food Waste Grinder YE NO # of Bathrooms_
Automatic Washer YES NO Other (specify)
E. SEPTIC TANK CAPACITY /000 Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation -Addition- Replacement _ Prefab Concrete 4-
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2)LQ3) QTotal Absorb Area 1/Z,e sq. ft.
Newk Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length 9 V Width I L' Depth C-/9" Tile Depth 32No. of Lines 2
ii
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land 2- 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 C/4 U i ivW2rS C.S # S S'31 and other information
obtained from ) wr? PH wrier b ' er).
Plumber's Signature MP RSW.. IS-6.3 Phone #2.`/6- -k2 ZA Plumber's Address ",o< a C2~tD
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
ck 110 0
6 n®°
9 y/ ;AlG l o l
TiL g ' C IL L, O Z
C
rV
e. / L ~ tl cy d
Do Not Write in Space Below F R DEPARTMENT USE ONLY
Date of Application Fees Paid: State County ~v Da
Permit Issued/ est d ( ate) -Issuing Agent Name
Inspection Yes~4!No Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707 ,-~y
[~&ONVENTIONAL ❑ ALTERNATIVE IS,,,, Plan I D Number
Ilf assigned)
❑ Holding Tank ❑ In-Ground Pressure D Mound
NAME OF PERMIT HOLDER. :JDRESS OF PERMIT HOLDER INSPECTION DATE.
CPi64 Wit,Son . R. 1, New Richmond, DUI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.'. CST REF. PT. ELEV
SW% SE%, Section 3, T30N-R17W, Town o4 Etin Pnaiitie
Name of Plumber. IMP/MPRSW No. JCO~lySanitary Perm ~t NumberCad. Powetcz 1563 t. Cttoix 41
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED. PROVDED:
DYES ENO DYES ENO
BEDDING: VENT CIA VENT MAT L. HIGH WATER NUMBER OF ROAD: PROPERTY WELL'. BUILDING: JVENTTOFRESH
ALARM FEET FROM LINE AIR INLET.
DYES ENO DYES ENO NEAREST
DOSING CHAMBER:
MANUFACTURER =0 11-111111D CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED'. PROVIDED
NO DYES ENO DYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF ROPERTV 111111- BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM NE AIR INLET
PUMP ON AND OFF) DYES ENO NEAREST
SOIL ABSORPTION SYSTEM. Check thesoilmoisture at the depth ofplowing JLENGTH 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 N!E~O F DIS TRPIPE SPACING COVER DE DIA &PITS JLIQUID
BED/TRENCH TNCHES MATERIAL: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH IDISTH. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PR OPERTV WELL BUILDING'. VENT TO FRESH
LINE. AIR INLET
BELOWPIPES ABOVECOVER ELEV.INLET ELEV_END PIPES FEET FROM
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
DYES NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ENO DYES ENO
DEPTH OVER TRENCH BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
DYES ENO DYES ENO DYES ENO
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. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. CIA.. ELEV.'. PIPES. DIA.:
ELEVATION AND
DISTRIBUl ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
DYES ENO DYES ENO
COMMENTS: PERMANENT MARKERS : JOBSERVATION WELLS. NUMBER OF PR DIPERTV WELL'. BUILDING'.
FEET FROM LINE
DYES ENO EYES ENO NEAREST _
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE
DILHR SBD 6710 (R. 01/82)
wlsconsln APPLICATION FOR SANITARY PERMIT
COUNTY
~DILHR
(PCB 67)
o~:RRRTmenT of UNIFORM SANITARY PERMIT #
InOUSTRV,LRBOR6 HUR1Rn RELRTIOnS
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROP,E TY OWN R MA "ING ADDRESS
11 f~
PROPERTY LO ATION ~T CITY: /I
/ / VILLAGE-
1/4~, , 1/4, S T ~ , N, R / (or W/ TOWN taF:
LOTN/UMBER BLOCKrNUMBER SUBDIVISION NAME NEAREST POAD, L,AK O LANDMARK rATE,PLAN I.D. NUMBER
ti
TYPE OF BUILDING OR USE SERVED
yQ 1 or 2 Family Number of Bedrooms. ❑ Public (Specify):
zw
THIS PERMIT IS FOR A:
❑ New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System 9 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 ~r )
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):
0 Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Nance; of lumber (Pri t): Si"u re.: MP/MPRSW No.: Phone Number:
P umber.'s Address: / Name off D(~signer-
° ~_,z
, J
LL2 _j
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee:: Date: ❑ Disapproved
C ~i ~L V ~Q ~116 Approved Owner Given Initial
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
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from 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.
3
APPLICATION FOR SANITARY PERMIT
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/contractav,("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
U); /SC1 i 1
Location of Property ' Section, T N - R W
Township ~17j-~
Mailing Address )L~ulz
~,h~~~~~r~~ SLIyf7
Subdivision Name
Lot Number
Previous Owner of Property ~l YYu it l ~K6i 30me-5 Pen rc, 1)(11Cr/
Total Size of Parcel 1~C!re
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 and Page Numbers 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) eeh 6 y that a.U statements on this 6onm ane tAue to the bat o6 my (ouA)
knowledge; .that 1 (we) am (ahe) the owneA (s) o j the pnopenty dea ct bed in this
in~onmati.on ,~onm, by viAtue o6 a wa4Aanty deed neeonded in the 066ice o6 the
County Rego teA o A Deeds as Document No. > and that I (we)
pees entty ou ~n the p4o pos ed site ion the sewage pos ads ystem (off. I (we) have
obtained an eaaement, to nun with the above d"cA bed pnopehty, bon the
consthucti_or o6 said system, and the same has been duty neeonded in the 06~ice
o~ the Couna'y Regi,6ten o6 Deeds, " Document No. ) .
SIG ATURE (F OWNEb. SI ATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
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SEPTIC: 'T'ANK MAINTENANCE At;RELMV111'
St. Croix County
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OWN FR ~BU YEN Vv~`1-so) z~
ROU'T'E/BOX NUMfil:lt ~rD 14 F i r u Ncliuber
1 SyGI/7
C1IY/STATE ,Llyt_ . !r
PROPERTY LOCATION: fill 4, J~ 1 icrii ~ I' j~ N, It i7 4J,
Q/ I
Town of ~IiJ1 tSt CrolX County,
Suhdi-vin wn Lot uumher
I
imiicopei "n'' and maiuteualluc of your 5 PI K ,ySLem could rennll in
iin premature failure to handle wasion. Koper maintenance eon-
.ints of pumping out the septic tank evei three years or :soonct',
it needed, by a l Cen cd Sc pj- lc Lank li"mp , . What you Put into
the system Can affect- the f unct iota of the PI is tank an A ? real -
mw"L SLagv in the wasCe disposal System.
;t. Croix County rusident.s m Ay he eLLg,i'ul, l.r Icrolve a ti""L tot`
a maximum of t,U'Z. of the cost of replacement_ of a Jailing synCem,
which was in operation pries Lo July 1, IQ/H. St. Croix County
a, ceprvd this program Ln Aolr,usL of i9HU, with the voquiremenL that-
owners of all new systems nrec Lo keep Llceir systems properly
The piopwii .,""t1 .rgi -ahmit Lo St. CVO LX Co""Cy Zoning a
ert-il lCal tun lorw, niri cd by the owner and by a mawci plumber,
journeyman plumber, restricted plumber or a licensed pumper vuri-
f ying Chat (.l) the on--rsi_tc wastewa[cr disposal sysLom is in proper
opurat-i"g couch L ion and (2) ,al fur Uspoct ion and pumping, (if nec--
cAsary), the septic Lank i h less Lhan 1/3 1 ul L of sludge and scum.
Cortlti_ration form will he sort approximately 30 days prior co
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rliree year expiration.
l/WE, the under:si-M"ud, lava read Chu Above requirement:, and agree_ U)
lri maiutaiu Lhu pt ival-c scwagu disposal nysLem in accordance with r~
!he standards set iorLh, herein, an s-I by Lhe Wisconsin Ucpnrt- v
monL of NaLura i resources, Curt i l ic'aL ion i orm must be Completed
and reLUraed Lo Chu SL. Croix County Z."uing Ul l i_ce w1rhin 30 day:-
o) Chu three year cxpfrat gilt dale.
I s ~l ' f 1~: ~
SL. 1roix CounLy %onin, 01 I i-ee
P.U, Box 9&
Hamm ind, W1 14015
115-/` Ci-2239 or 715-425-8363
K Qn, data and return to :above address;.
Form - S T C - 102 1
ONE AND TWO FAMILY
The existing system must be inspected for compliance to bedrock and high
groundwater requirements ~ L«e Cuu-. in many will require
a soil test to be conducted by a Certified Soil cs per or an on site by this
office.
If the existing system does meet minimum requirements for groundwater and
bedrock depths and if it is functioning, an addition can be added in most
instances without updating the existing system. If the existing system is
utilized for the addition, every attempt should be made to locate and reserve
an area which is suitable for a code complying replacement system for when the
system fails. If the addition will substantially increase the wastewater
discharge, the existing system shall be replaced with a code complying private
sewage system.
1hd~~ I ~.r4y
1/4 1/4 (Subdivision & Lot Section Township
15UX 6,1017
Rural Route # Address Post Office Zip Code
(Q (We) / f l ,rte St plan to (build to r
Lauio4e4--) the building at the above named location. The present private sewage
system has been working satisfactorily as far as disposing of wastes.
If the present private sewage system does fail, it will be replaced with one
that is code complying.
(2)
I 1
(Owne 's Signature)
Date
Subscribed and sworn to before me
thisday of 19
Notary Public
ee'3 County Wisconsin
` 6OI.I.EEN ZIMMERMAN
N "lic - State of W is-:t.---11',
My Commission Expires Ay Apc. 2i. I56e
ST. CROIX COUNTY
(County Authority)
Plot plait attached (show location of building addition to drainfield and
septic tank). Include soil testers report form.
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
r DIVISIOIy OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
LOCATIONS -/4,~~'/4, Section . -j- R -"E (orIW 1-ownship or Municipality
Lot No. Block No.
-County - -~_L----
/ ubdivislon Name
Owner's Name:1/~__ -_011_ t2.t~ - - -
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms .__3____ Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION - -___REPLACEMENT
DATES OBSERVATIONS MADE: 'OIL BORINGS -PERCOLATION TESTS
SOIL MAP SHEET
SOIL TYPE 0~2--------
_ 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
P-Z y l r 1 a
P -3 6 13d
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)
c~,= 0 - 9,9
9 d- -
.4 co) Ly B- r6 } 4- - e s. 6 S
Ll. ^ 7T~~ 4 _ -r r S ^ L .r
o- Ts y a S ;e-
PLAN
VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area
needed fpi~ uilding type and occupancy. 6 e- ~ Indicate scale
T7_ - or distanceyy f.,ive horizontal and vertical reference points. Indicate slope.
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50-11
t IN
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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) C-'Iq ®w qct' C' Certification No. S S S^3/1
Address
Name of installer if known
CST Signature - -
COPY A -LOCAL AUTHORITY
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