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Parcel 042-1104-60-000 09/30/2005 08:22 AM
PAGE 1 OF 1
Alt. Parcel 20.29.18.577A 042 - TOWN OF WARREN
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
MARK J & CECILIA V BLANSKI O - BLANSKI, MARK J & CECILIA V
1084 89TH AVE
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 1084 89TH AVE
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 1.010 Plat: 2334-PLEASANT ACRES
SEC 20 T29N R1 8W 1.01A PLAT OF PLEASANT Block/Condo Bldg: LOT 05
ACRES LOT 5 EXC W 20 FT INCLUDES
042-1104-50 Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
11/05/1997 567976 1274/518 WD
07/23/1997 938/610
07/23/1997 929/570
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/23/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.010 26,900 116,000 142,900 NO
Totals for 2005:
General Property 1.010 26,900 116,000 142,900
Woodland 0.000 0 0
Totals for 2004:
General Property 1.010 26,900 116,000 142,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel 042-1104-50-000 09/30/2005 08:23 AM
PAGE 1 OF 1
Alt. Parcel 20.29.18.576B 042 - TOWN OF WARREN
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
MARK J & CECILIA V BLANSKI O - BLANSKI, MARK J & CECILIA V
1084 89TH AVE
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 0.140 Plat: 2334-PLEASANT ACRES
SEC 20 T29N R18W.14 A PLAT OF PLEASANT Block/Condo Bldg:
ACRES W 20 FT OF LOT 4 & EXC AS DESC IN
WD- 1061/93 ASSESSED W/042-1104-60 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
20-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
11/05/1997 567976 1274/518 WD
07/23/1997 1061/93 WD
07/23/1997 938/610
07/23/1997 929/570
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed:
Description Class Acres Land Improve Total State Reason
Totals for 2005:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2004:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
v,
1
AS BUILT StVNITARY SYSTEM REPORT
TOVITS11IP SEC. TT tt, R ~ W
A DRESS-~ S CF,Ct:i COUNTY,
WISCONSIN.
a_V-SION LOT LOT SIZE .
FLAN VI EW
Distances & dimensions to meet requirements of H62.20
SHOD EVERYTHING WITHIN 100 FEET OF SYSTEM
I i-
I— J-
( 11 , I
- - i -~--1- L L---,;
l i ; I 1~ i I ~ I ( ( j
- - - : I ( - 14
T
1 All
1 _ - Indicate North Arrow
- - --j
a~
- ~ -1---_
SCALE:
"?'IC TAh'KiiFC:R. rL`' :<< ~ee~r J CONCRETE_d STEEL
NO. of rings on cover--.,_ Depth T DRY WELL
'?G? ES NO. of width length area
no. Of lines_ ^ width- 4 length T a r e a Z -Z~
de th to top of pipe---22
-FGATE AREA REQUIRED 1,1S ~ AREA AS BUILT r
°_~.aimer: The insp`ction of this system by St. Croix County does not imply complete
?liance with State Administrative Codes. There are otz:er areas that it is not possible
inspect at this point of zonstzuction. St. Croix County assumes no liability for
:.e r operation. However, if failure is noted the County will make every effort to
_.}rmdi:e cause of failure.
-:%SES AYD OILS SHOULD NOT BE DISPOSED THROUG: THIS SYSThM.
a .
~ZNSPEC. '
DATED PLU111BER ON JOB_
LICENSE NU;tliER .~W f ~
I
PLB67 State and County State Permit #
Permit Application County Perm' #
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 Mailing Address:
B. LOCATION: Y4 '/4, Section C, T ~ N, R /-S' E (or) W Lot# --City
Subdivision Name, nearest road, lake or landmark Blk#_ Village
Township Liflxyv~~r
- - -
C-. TYPE OF OCCUPANCY: *Commercial _ *fndustrial *Other (specify) *Variance
Single family' Duplex No. of Bedrooms -3 No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste GrinderYES- NO # of Bathrooms-%
Automatic Washer ,X YES NO Other (specify)
E. SEPTIC TANK CAPACITY Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation J( Addition Replacement Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 3 2)_',-) 3) 3 Total Absorb Area sq. ft.
New X Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches----
Seepage Bed: Length > 1-.Width / Z. Depth IC
Tile Depth ;?,Y No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size 3'
Percent slope of land -5 ~ 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 and that I have sized the effluent disposal system from the EH-115 prepared
by the Certi ' Soil Teter,
NAME C.S.T. # S S - 5 and other information
obtained from
(owner/builder). -6 3 -
Plumber's Signature MP/MPRSW# S Phone #J,L ->13 S
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
1
1
r
5Y
E
E
o )0
r
Do Not Write in Space Below FOR DEPARTMENT USE ONLY Cam,
Date of Application S~ Fees Paid: State L' Cou ty Date - f 7
Permit Issued/ d (date) l ? Issuing Agent Name ( I
Inspection Yes No Valid* Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76
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:'/,, _;4 Section, T-~/N, R flo(or) W, Township or Municipality t w -r/4'4
Lot No.., Block No. County
Owner'sName: J yn / o Subdivision Name
w
Mailing Address: Rr I`~n [z/! 5
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW - ADDITION REPLACEMENT
DATES OBSERVATIONS MADE; SOIL BORINGS PERCOLATION TESTS
SOILMAPSHEET 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
i BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/L:`;
P_
P-
56 7~ -7
r ?
SOIL BORING TESTS
I TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
i ;
"LAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
,dicate on the plan the location and square feet of ,Kuitable areas. Indicate number of square feet of absorption area
- =eded for building type and occupancy. tJS- Indicate scale
c distances. Give horizontal and vertical reference points. Indicate slope.
1 .,7)
j k € I
i I -
I 1
,f(.
V, IA
1
{
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.
f
Name (print) - Certification No.
Address r f R
Name of installer if known { 1
CST Signature ^
RFPOP,T OF It1SPECTION--INDIVIDUAL SEWAGE DISPOSAL SYSTEM
. , r Sanitary Permit
7'
_ f State Septic .
..A! T&INSHIP
t. Croi;; County
Sr.PTIC TA'?Y C /V C- . C;~) 0
Size gallons. `umber of Compartments
Distance From: Well ft. 12% or greater slope
Building* ft. Wetlands f
Ili.ghwater ft.
DISPOSAL SYST2,I Tile Field or Seepage Pit(s)
Distance From: Well ft. 12% or greater slope - ft
Building `t £t. Wetlands _ f:.
T•
FIEMD 11ighwater ft - - -
Total length of lines
ft. Number of lines Length of
each line = ft. Distance between lines ft. Width of the
trench -,-f t. Total absorption area sq. ft. Dept::
4=1
of rock below file / in. Dp-pth of rock over the in. Cover
t>ver.-rock,,~^ Depth of tile belc<<i grade ~ `Jinz . Slope of
trench in per 100 ft. Depth to Bedrock ft. Depth to
ground water ft.
PITS
Number of pits Outsi' dia eter40. ft. Depth below inlet
ft . Gravel around p ' t :`yeS Total absorption area
sq. ft.
Square feet of seepage trench bottom area required
..Oquare feet of seep° g.e n4t area required.
Ins;)ecL-ed by: Title':
Approved Date 197
• ~ ~ ~ ~
Rejected Date 197.
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 1.7
'TOWNSHIP SEC. T _IWW
A')'. ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 03
SHOW EVERYTHING WITHIN 100 FEEL' OF SYSTEM
517
hurt ~CoV'/~l✓' y3
74 ~ l l 30
Bl~
J ' C.fGI
i~x'Y6
4/3
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used -Wg
101
Elevation of vertical reference point:
Prop Z
1 Q osed slope at site: ~
SEPTIC TANk.: Manufacturer: Z
_ Liquid Capacity: -----1/~~__
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,0 Side,0 Rear, CD feet
From nearest property line Front,0 Side,aear, o feet
Number of feet from: well D building: A
(Include this information of the above plot plan)( 2 reference dimensions to septic, tank)
SEI? RGV1~12S1? SII)1?
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: C~' ) Trench:
Width: 'TT Length: Number of Lines:~ Area Built:/'_~%
Fill depth to top of pipe:
Number of feet from nearest property line: Front, &ide, 0 Rear, 0 Ft .5_
Number of feet from well: -fA 4
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: V/~ Number of Pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box 0 or distribution box hru~~ w;" d oo- zany oY the above soil
absorbrion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
ElevaCton of inlet:
Number'of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm ianufacturer:
Inspector: _
Dated: Plumber on job:
License Number: 3 ? ~9
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
'P.O. BOX 7969-a PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
MADIS~,N, WI 53107
1CONVENTIONAL OALTERNATIVE State Pla
assignednL)D.Number
(lf
O Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER' INSPECTION DATE'.
Bill Cook Pleasant ACres, Roberts, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV
NE NE, Section 20, T29N-R18W, Pleasant Acres, Town of Warren
Name of Plumber_ MP/MPRSW N, Count
v Sanitary Permit Number_
David Fogerty 3289 St. Croix 49511
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.. TANK O E WARNING LABEL LOCKING COVER
tt~ a""/ PROVIDED PROVIDED
(W DYES ENO DYES ONO
BEDDING: VENT DIA.. IVINT MA HIGH WATER NUMBER OF D'. OPERTV WELL'. IBUIL71NG. VENT TO FRESH
ALARM. FEET FROM [ LINE: AIR INLET.
DYES ONO OYES ONO NEAREST 7
DOSING CHAMBER:
MANUFACTURER BEDDING. [1111111 CAPACI TY PUMP MODEL. PUMP; SiPH ON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
DYES LINO EYES ONO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY JWELL BUILDING VENT TO FR ESH
(DIFFERENCE BETWEEN FEET FROM LINE qI I INLET
PUMP ON AND OFF) DYES ONO NEAREST ill,
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing H IIIIAMITIR MATERIAL AND MARKING
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:
BED/TRENCH WIDTH'. JLENGTH NO. OF DISTR. PIPE SPACING LOVER INSII)E DIA =PITS
' TRENCHES. I157EHIAL: I,IT DEPTH
DIMENSIONS
GRAVEL DEPTH. FILL DEPTH DISTR. PI F DISTR. PIPE DISTR. PIPE MATERIAL NlO. STH NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH
BE LOW PIPES ABOVE COVER ELEV. INLET EV ENC,D~ Cn PIP j.-.. FEET FROM , LINE AIR INLET.
r C / L ` NEAREST -o-®vL
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 cer in that ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium nd. IONS MEASURED.
EYES ONO
SOIL COVER TEXTURE P MA KERS OBSERVATION WELLS
ES ONO EYES ONO
DEPTH OVER TRENCH 'BED DEPTH OVER THENCH,BED DEPTH OF TOPSOIL SOODE SEEDED MULCHED
CENTER EDGES.
DYES ENO DYES ONO EYES NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH 7LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVEN
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. ID ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. DIA. ELEV.. PIPES. DIA.:
ELEVATION AND
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ONO DYES ONO
COMMENTS: PERMANENT MARKERS: 777TION WELLS. NUMBER OF PROPERTY JWELL: BUILDING:
FEET FROM LINE'
DYES ONO OYES ONO NEAREST
i7 ) J
f
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURES. TITLE:
DILHR SBD 6710 (R. 01/82)
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOP►AND PERMIT P.O. BOX 7969
HUMAN RELATIONS (PLB 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Property Owner: Mailing Address:
BILL COOK Pleasant Acres, Roberts, WI 54023
Property Location: City, Village or Township: County: /IKN NE % N8 %4S 20 /T 29 N/R 18 E (or W Warren St Croix
Lot Number: Blk No:: Subdivision Name: NearestFWa,d, Lake or Landmark: State Plan I.D. Number:
(If assigned)
TYP=BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)*~~,~ Bedrooms:
~1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA r
(Minutes per inch►: PROPOSED (Square feet): ❑ New Replacement ❑ Experimental LYI Seepage Bed ❑ Seepage Pit
6 828 ❑ Alternative (specify) ❑ Seepage Trench
Water upply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public Bill Cook
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signature: MP/MPRSW No.: Phone Number:
David B. Fogerty 3289 1(749t3656
Plumber's Address: Name of Designer:
Fogerty Hgts. Rd., Roberts, WI 54023 Dave Fogerty
COUNTY/DEPARTMENT USE ONLY
Sig~nfature of Issuing Ageno F~e: D9-a e: Sanitary Permit Number:
y/ ~/u /lJ L I APPROVED
- G *ISAPPROVED I
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (R.07/81)
1 Form - S T C 100
Owner of Property 91Z 6211
Location of Property~~ Section T ~N R_ I'VW
Ong
Township_ ,kw,L-- /
Mailing Address TOa E /
koB ER T5, W.L vINQ
Subdivision Name 1 LE4519tir ACRES
Lot Number cJ
Previous Owner of Property- J perry
Total Size of Parcel !.a ~4C2E5
Date Parcel Was Created
Are all corners identifiable? Yes No
Include with this application one of the following:
.Certified Survey Map
.Deed
.Land Contract, or
.Other I:egal Document which describes the property
PROPERTY OWNER CERTIFICATION i
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that 1 (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed recorded in the Office of the
County Register of Deeds as Document No. -'WV & 6 ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
~ H
Ln
Y
S T C - -105 rr"
~ y
H
SEPTIC TANK MA1NTLNANCL ACk.1?LMLNT r+
G
St. Croix County
d
y
OWNER/BUYER
ROUTE/BOX NUMBER ROUT-E 1 Fire Numb, r I &OF
CITY /STATE Ra R E 2T S W,,L---_ - G 1 P S4-09,3
PROPERTY LOCA`1'ION: ~=4;, Socti.oll I N, R'Aff
Town of VVAppkV6A1 St. Croix Count
Subdivision ? a,54 / Lot llulllbur
Improper use aild maintenance of your septic system could result in
its premature failure to handle wastes. Pruner maintenance cull-
sists of pumping nut Like septic tank evtrry lilree years or suuuur,
if needed, by a licensed sc.1)tic tank J~uIII l,er. What you put into
the sysrelll aifT'_t + ,n of the sent to tank as a treat-
ment stage in the waste dispusul sys~"::
St. Croix County residents nlaI 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 ill August of 1980, with the requirement that
owners of all new s_tums agree ro keep their systems prupurly
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 ill proper
up era till g condition and (2) after inspection and 1luIll I) iub (il - 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
I/WE, the undersigned, have read the above requirements and agree a~i
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- ro
went of Natural Resources. Cer.tificatiun form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SICNLD
D A 'J 1.. `o
St. Cruix county Zuning Office
P.O. Yox 98
Ilammor d, W1 54015
715-7~ 6-2239 or 715-425-8363
Sign, date and return to above address.
6~wMCV- rw.s~- 'S tSn~Q
HUMAN RELATIONS f"`~~l' yL A i iuii I Lb 1,-) tll.J) MADISON, W1 53707
(H63.09(1) & Chapter 145.Q45)
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
COUNTY: OWNER'S BUYER'S NAME: MAILING AD RESS:
/7
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS:
rRgesidence ❑New ~eplace L
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMEND D SYSTEM: (optional)
~DS❑U r__14% ❑U C~S❑U ❑SCAU ❑S29 L_- 6
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: tvze, PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER O OIL WITH THICKNESS, COLOR, T TUBE, AN DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST_ 'TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B- L T S r
B- 2 p s~ 7
B- 5- tf/ r
B-
B-
B_
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PER( D 1 PERIOD 2 PERIOD PER INCH
P- 7 d 3 1 J
P-
P- 2-
P-
P_ 3 ritf Sr j I l
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
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I, the undersigned, hereby certify that the soil tests reported on this form were made by mein 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.
E (print : TESTS WERE COMPLETED ON:
f7i - 'S 1.
g; CERTIFICATION NUMBER: PHONE NUMBER (optional):
n1 f,T R I R1 i'rIC1N: ininri and one corny to Local Authority. Pr a;' '-nrner and Soil Tester.
lZ ,
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