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HomeMy WebLinkAbout042-1058-20-100 n cn O 3 -0 n ° -1 ' v 7 CD o (1) '0 -a - c CD d CD K l u z z ° co A ° °C • (,D (D (D SD co o (J)0)~ o V N Q N O o w Oo o to (D ~ m 90 D y ~ °o O U) U) (a A v Z (n Q m ~ o (n a W CD c (D 0) ti rn Q O co C N O c z 41 -P, a- 6 Q r! "WA < , z M~ 0 ai cn Cl) o D n' ~ Z -0ooT o o (D N N = N O rd+ 2 O W Q o N O z zz co 0z O > CD a _O CL ' Z o h • CD CD N CD O C (D C (D N. O W O d n 3 7 z (D N O _ p, Z (D c M ' A Z O o Z N 03 " g N) CL z A 00 z Qp H M (D O w 0 x 0 D CD En Q CD a 0 CD < CD (nm30 ° T c Q CL -O (D ) n - CD <(D z a 3 o' x. c o~M c ~ (nn> CL 3 Q - < t 0 0 ° d c C) cn (o O) O 4 CD CD' 0 v 00 S O C n' 0 ti ' N O (n O O A O CD ' 2. W ,Gq O O ~ N °O L ti Parcel 042-1058-20-100 06/16/2005 05:02 PM PAGE 1 OF 1 Alt. Parcel 21.29.18.322A 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): = Current Owner * ERICKSON, SCOTT J & MARYANN B SCOTT J & MARYANN B ERICKSON 1171 HWY 12 ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 1171 HWY 12 SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 5.354 Plat: N/A-NOT AVAILABLE SEC 21 T29N R18W PT NW1/4 NE1/4 LOT 1 Block/Condo Bldg: C.S.M. 7/2086 INCLUDES P322A-10 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 21-29N-18W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 838/455 2004 SUMMARY Bill Fair Market Value: Assessed with: 38316 Use Value Assessment Valuations: Last Changed: 07/11/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 37,500 92,500 130,000 NO AGRICULTURAL G4 8.700 1,200 0 1,200 NO Totals for 2004: General Property 10.700 38,700 92,500 131,200 Woodland 0.000 0 0 Totals for 2003: General Property 10.700 38,700 92,500 131,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 211 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 15.00 Special Assessments Special Charges Delinquent Charges Total 15.00 0.00 0.00 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 ---------yyyyyy ® CONVENTIONAL ❑ ALTERNATIVE (State Ptan I D. If a rred Number (f assigned i ❑ Holding Tank ❑ In-Ground Pressure D Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Roy & Margaret Rode R. R. 1, Hwy 12, Roberts, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. NW NE, Section 21, T29N-R18W, Town of Warren Name of Plumber. MP/MPRSW No.. Cou nl y. Sanitary Permit Number. Henry Nechville 3258 St. Croix 58911 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. EYES LINO EYES LINO BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD. fOPERTY WELL. BUILDING. VENT TO FRESH ALARM FEET FROM NE AIR INLET EYES LINO EYES LINO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING: JLIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES LINO EYES LINO OYES LINO GALLONS PER CYCLE: FMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING (VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES LINO NEAREST 30 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing 1 FN(,TII 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 NO. OF DISTR. PIPE SPACING. COVER JINSIDE DIA. SPITS LIQUID BED/TRENCH TRENCHES. MATERIAL: PIT DEPTH. DIMENSIONS GRAVEL DEPTH FI(.L DEPTH J UISTR PIPE DISTR PIPE DISTR. PIPE MATERIAL. NO. DIS7H NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER. ELEV. INLFT ELEV. END PIPES. FEET FROM LINE. AIR INLET. NEAREST 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- meets the criteria for medium sand. TIONS MEASURED. EYES NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS EYES LINO OYES LINO DEPTH OVER TRENCH; BED DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES DYES LINO EYES LINO EYES LINO 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. IN0 DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.. ELEV. CIA.. ELEV, PIPES. DIA.'. ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS EYES LINO OYES LINO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LROEERTV WELL: BUILDING: FEET FIR EYES LINO EYES LINO NEARESOM Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE. DILHR SBD 6710 (R. 01182) n to O 3 -u n C7 -1 o c m o m iD CD c -0 a gt 3 m 3 w l Z 15 O n v O O O 00 O N -i A • [D 3 CD jCD N - fD p (NO L Q t^l N N O CO cn Q C:5 0 CO 1 00000 Ory g°. N° O cn = D 7 N ~ ~ O Q N N CO ~ C D) (V (D Cf) z l> a m ~c o N a o W V Q CD rn rn CD 0 co co X r c w a 3 W C d -0 _0 m n m rtjr z O O O c z o o z ID ti g < z , C 0 h fn fn fn o D rt H ° < 0 o O = (D K <D N O lI7 (D D N !V 00 CD - CJ (a LO _ N r N 3 > 000 j 0 o z co z O D n m tr v O t~l cD CD Q O m O N (n N (1 C (D CD CL `I✓ W D C)" I Q 00 z m N 4 H y ` o N n / Z 7-i N a 3 I L~J FD' O Z -I N N S Q~ ~ co -0 x n a ;i z R\ Z rt rr Q O z ro n H U) m (D 0 s H Na w O 0 ~ ~G _ N (D N D O C:) U5- 3 O - 0 CD :3 O CD C1 -p CD v C S d N Q O < CD Z O 3 0" x o C N CD S O ( O CD (D O C N CD OJ n 3 CCD `GS p S '-'1 O D1 N A N Co a) CD O Z CD O) CD "CDO O ~ nO x O S CD O O ~ ~ N Cn O A O ~ CG ~ O o e» O o C) a Wisconsin Department Industry, Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page of Z DiAsion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but Ste' ` X not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance ~raarVst road. Z- L O Sg - Z0-100 APPLICANT INFORMATION-PLEASE P T, L INFO`RMAT'ION R -D BY DATE PROPERTY OWNER: PROPERTY LOCATION S C~YT iE Iz Ch-,SO fV -GQV .Q9 - NW 1/4 NF- 1/4,S I T Z-9 N,R 1 ~ E tor~ PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # \ 111 Z~w`'l \2 si V - cs "I Vo L_ -2-~Z a b CITY STATE ZIP COPE PHONE NUMBER ❑CITY ❑VILLAGE 29FOWN NEAREST ROAD ~~DB~-TS, w 1 s ~-t o z3 nos) ~ ~9-. 3y 3a !.v~~,~ Irv v s ~t ~ ~Z" [ ] New Construction Use [4 Residential /Number of bedrooms [ ] Addition to existing building ] j [ ] xibe Replacement Public or commeci6t* Code derived daily flow 'A S O gpd Recommended design loading rate "A bed, gpd/ft2 Q trench, gpd/ft2 Absorption area required rv R bed, ft2 _ trench, ft2 Maximum design loading rate N bed, gpd/ft2 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations s to - 13 Parent material t cti e) v ka S ir~~:f wTwt~ Std Flood plain elevation, if applicable K~ . P , ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U =Unsuitable fors stem ®S ❑ U (ZS El U [RS El U ® S ❑ U ❑ S [aU ❑ S Z u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence BotYtdary Roots Bed Trerrh Z ~Z39 1o`1tz3IL Ground 3 3' _-lqu `)-S`1R-Y/L - SSG} O Sg rvl - -1 elev. 3ft. t~U 3 1_Zi1tLU ~S DOr U x-12 [ ot~ COt~I 1 U S 1: Depth to limiting ` 5T 3 3 1 S~ri `ova factor 4 > ~i W kEt L U\ fC S o" 1= tN rti I`j r 1s • C S SS U F-ts` r I S A B 6 Remarks: Boring # ~uU~v~ vR ~`CZkp~ v tT ~oU ~_D B ` A D w T-1 vS_'', Ground elev. ft. t~S 1~ ~O 8~ Sal mus-r g Depth to L^~&Ts') t'j t_ 1 Cott N S, limiting factor Remarks: CST Name:-Please Print Phone: Arthur L. We erer 715-425-0165 dress: egerer Soil Testing & Design Service-P.O. Box 74 River Fal1S,WI 54022 Signature: Date: - L CST Number: C 5 - / r - M00576 PLOT PLAN Page Z of Z , SCALE 1"= 3 Q ' yi _2! J 3 I k BoT- ~ ci o _ 0 k C "k 3~"oF Vz~,tMI OF SSE D 2 J Is N 6qI cG Qo ~L 8 b yC S tF'71 ~ 1tiQ,L a J i L Z.It, t l~~ x~ ' l~ (715 ) 425-0-165 _ MOO576 CST Signature Date Signed Telephone No. CST # I Wisconsin Department Relations Industry, Labor and Human Relati SOIL AND SITE EVALUATION REPORT Page of Z • Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but Ste' X not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road L! L O Sg - ?A-100 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R yVE BY DATE PROPERTY OWNER: PROPERTY LOCATION S coTT 1Z tC1-c Sly 1V 6911 9 NW 1/4 MIE 1/4,S 11 T -Z-°) N,R I ~ E (or~W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR GSM # W) l lAl j-l ~2 t - csr.l UOL. '1. I P5 b CITY STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®iOWN NEAREST ROAD 0$ TS, wi SLtoZ3 hLS)-)y9-:-3938 US1i ' VZ" New Construction Use [x] Residential / Number of bedrooms 3 [ ] AdditiQn to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 'A S O gpd Recommended design loading rate ►~A bed, gpd/ft2 ~4 trench, gpd/ft2 Absorption area required N bed, ft2 "A trench, ft2 Mabmum design loading rate bed, gpd/ft2 - S trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations S L:5_~ r~J VParent material s t (v L-R S ~ti ov a , N Flood plain elevation, if applicable ty - P , ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ®S ❑ U 1Z S ❑ U QS ❑ U RIS ❑ U ❑ S Lau ❑ S Z U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure 9 Texture Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr- Sz. Sh. Bed Tmnch lo4tZ3lL - - slI ? S~~k wt`t} CS S Ground 3 3°f _IL10 `~-S'I V-- V/L - S G>, b S g - elev. - Q6'_2 ft. K) 3 ZiS~IU \S Dbr Co L U S Depth to S _ limiting - T 3 ~3 ~S~rJ 1? -ZL_S_ ov}=rt~~f \s -Z) C S SS L) H ~'t- I S A J wiz L ~r B h1 G 6 Remarks: Boring # D 7Z _P0,,j v~T • o~~ t Sc~ U Ground S~`i1e ~'f~>ulrz IU1 ST ]=c~U L~ ltv elev. ft, o f~S P~2 ~0 3 0~ St g Cs"i Depth to L-D ~1"1>>Ly wL ) ^otJ E= s, limiting factor Remarks: CST Name:--Please Print Phone: Arthur L. We erer 715-425-0165 Mress: gerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: Date.- CST Number: M00576 Z of Z - Page PLAN SCALE 1"= 3 Q 2 J k BoT-~L QO3 s~~lLe G x ~ e.o C k ~a6"oF ~~lTU~1 OF D R,~ W mil, J. S A O ~-7 rJ G DoT. ~L, 8$0 ~C S ~P71 C ~C WQ.L ni J (715 ) 425-n-I c,5 1400576 CST Signature Date Signed Telephone No. CST 4 wisconsin APPLICATION FOR SANITARY PERMIT DILHR COUNTY - OEPRg77nEnTOF (PLB 67) - In ."U--TRV,LR60RSHUMRnRELRTIOns UNIFORM SANITARY PERMIT # • s5 -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. r -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER, MAIfZG A~RESS r, r I 4 Le t PROPER* LOCATION _L CITY: (1 VILLAGE: cal 1/4 1/4, S ~ - T'~_` /N, R /0 E TOWN OF: L C ' LOT N MBER BLOCK UMBER SUBDIVISION NAME 'k- NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I. . NUMBER TYPE OF BUILDING OR USE SERVED or 2 Family Number of Bedrooms:. ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ~ie~ air ❑ Replacement Soil Absorption System p Revision ❑ Privy Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ❑ Seepage Bed ❑ Seepage Trench ❑ See a e Pit System-In-Fill p y ❑ Holding Tank ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # ~1 An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions, issued Total # of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: F-1 Mound [1 In-Ground Pressure T~/aI #of Prefab. Site Ga ns Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY: r Lt -rr~ ISF'rivate ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name f Plumber (Print): / Signature: & J~ MP S Phone Number: Plum ber'Kddr ss: i Name f Designer: COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved L~ Owner Given Initial Reason for Disapproval: Approved Adverse Determination 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. ---gym T $C mot. ~ E ILA I i x~ FX 1, l o00 ~ ~ { e • APPLICATION FOR SANITARY PERMIT S T C - 100 This application turn: 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 it;nuance. 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 Location of Property Section __::21, TO N - R Township Mailing Address Subdivision Name Lot Number - Previous Owner of Property Total Size of Parcel X Date. Parcel was Created Arm all corners and lot lines identifiable? ~~Yes No is this property being developed for resale (spec house) ? Yes 4-~N o Volume :R!Z 'V and Page Number A17 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 c,1 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.) eeAti6y that akl statements on this ~mm ane VLue to the beat o4 my (ouA) know.eedge; that I (we) am (ane) the owner(s) o6 the pnopetty desnibed in thin 4n6onmati,on 6oAm, by ~,;htije- 04 n r/ond hecwLdgj in the 044ice o6 the i_ounty Regis teA o6 Deeds as Document No. and that 1 (we) pne,~ent y own the proposed site ion the sewage di.apol~a _ system (on I (we) have obtained an easement, to nun with the above de otibed pnopeAty, ion the constAuc ion` o{ said system, and the, same has been duly neconded in the 066.tce o4 the County Reg-us.ten o6 Deedss, as Document No. ) . SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H S T C - 105 r r y 'T'ANK MAINTENANCE AGREENIK'N'T 0 St. i:roi_x County 0 :j OWNER/BUYER I,(IU'Crs/11OX NUMBBI: Hire Number CITY/STATE Y 11, PRt)PEkT'Y 1,0CATI(IN:~ , =4i Section T N, R W,' Town St. l:roix C' 0 till I, Y, SubdivLsi n~~ Lot cumber I Ltill) roper use'alid Ill it Ltttenit nce of your septic system coit ld resit _LC in itr~ premature failure to handle waste:s. Proper ilia ill tertauW Li con- ~ists of pumping out Che septic tank every three years ur suouer, fl need(-- d, by a licensed sc.1)Lic tank. puIli ler. What you put into tine system can affect ttte function of these--ptic tank a5 a treat - went stage in the waste disposal system. St. Croix County residents may be eligible to receive it grant 101 a Ili axLIli uIli of 60% of the cost of replacement of it fit i_Iiit g system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the r-equLreuterrt that owners of al-L new ystcrns itgree to keep their systems properly Ili aLntained '1'lte property owner agrees to submit to St. Croix County Xorr:iul; it certification form, signed by the owner and by a master pluIli be.r, Journeyman plit Ili ber, restricted plumber or a licensed pumper verI fying that (1) ttte on-site wastewater disposal system is in propcr- operating condition and (2) after :inspection and pumping (if ne('- essary), the septic 'Cank is less than 1/3 full of sludge aid scum. Certification Eorut will be sent approximately 30 days prior to three year expiration. ~r 0 1/WE, the undersigned, have read Cite above requirements and agree to maintain thc private sewrige disposal. system in accordance with the standards set forth, Iacrein, as set by the Wisconsin Depart- v ment of Natural Resources. Certification form must br, completed and returned to Lite St. Croix County Zoning Office Within 30 days of the three year expiration date. 1) A'I St. Croix County Zoning Office. P.0. Box 96 Hammond, WL 54015 715-796-22'19 or 715-425-8363 Sign, ditC(' and return to Ltbovc address. Form - S T C - 102 ONE ANT) TWO FAMILY The existing system must be inspected for compliance to bedrock and high groundwater requirements of the code. This, in many instances, will require a soil_ test to be conducted by a Certified Soil- 'T'ester 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 ,-.in 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 sewa~~;e system. AIV ' A 6~F l4 c. T_v1_s?..on ,ot # Sections? y Township Gt1~ p~~,~ Xl/ A~r~ Rural Route # Address Post Office Zip Code (I) (We) plan to (build an addition to, remodel) the bu ldin.g at the above named location. The present private sewage system has been working satisfactorily as far as disposing of wastes. T! the present private sewage system does fail, it will be replaced with one that is code. compl_yl_ni}. (1) (2) i r Cc' rte' (Owner's Signature) Date Subscribed and sworn to before me this l day of Notary Puhlic County, Wisconsin My Commission Expires % ST. CROIX COUNTY (County Authority) Plot plan attached (show location of building addition to drainfield and septic tank). Include soil testers report form. I c o L o ` z >o ~c cn' o c m-0 co d o ° c° o m . U = ctS s Z7 O 4) (D c 9 m N F' O)o c Ov YYY m o C IM ` U m 0 O N T m = C CD NLw ca vi (73,~ o~ W 0 010 r4) 3 ov ~3r.2 vEc Q cm~- >N o o = mm~ cN m4) oti cocriyN Om W ~ c m U m a ....t CL m m3 coN ac W of pt ~w. c c~v cr. c m 3L o m? m Q ~f m N fA ` U m 3 m L U-~ m N C Z m= N Q " Z m 0- m m N vi O V> > y- cv a t c CD m O co c o o 4) 0) a o d m L- o~X T- CD Q N N O N V 7 m '7 N M C Q O.a~Oo m ` r- 0 - W -ca a C m C o•- O = j 0 o 3 c.0T ` ~ m _c >.M rn z S yc0 »a =r E io c t coo C°ocoo0'acio C6 IM o, o v E U M co 0 m o m L m~ o, u ,..c L)mmc Co `1) -X m 3 a~i c c m °i coo m 3m ''3mm0 ~o-mm'o a 4) 0C). N rnrn~ E o t 5 .0 ° a L: O am cc c c`o 0) E .o a cow>jmc L~Cc N m = cc m c = ♦ y J O i T` DEPA NF JT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDU~STrsY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS J MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/N44444 XtttTY: LOT NO.:BLK. NO.: SUBDIVISION NAME: A'Al Y 4/ 2 / /T zy N/RISE E (o 4/711"E,v ~ ~ Awe F~te~ COU{vTy: OWNER'S/Bld'rE,`'AFi'SAN NAME: MAILING ADDRESS: ,.5 ~//~Zeq eo 1-21-- CCJ/ s. USE DATES OBSERVATIONS MADE NO. B EDRMS.: COMMERCIAL DESCRIPTIONPROFILE DES RIPTIONS: PERCOLATION TESTS: Residence ❑New O a !`7 Ix ~E~°iFic~Tio J o~ Sai/S rfD,T~scG~-@~ Al ~,rr RATING: S= Site suitable for system U= Site unsuitable for system f' CONVENTIONAL: MOUND: IN-GROUND PRESSURE:'SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) RI S ❑U 01 S ❑U ©S ❑U ❑ S [iU ❑ S ©U If Percolation Tests are NOT required DESIGN RATE: FF an y portion of the tested area is in the under s.H63.09(5)(b), indicae: oodplain, indicate Floodplain elevation: C PROFILE DESCRIPTIONS y BORING TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 1 __41 B 130. S B- o B sOi~ ~D 7/0 4 X,9,14, ~ UE e y New I'~/S~~'!>o,c7El~ B- B- o /foo,~Ep 2~-yi S~S G S ~1ov~p o v O B- 6 f D~c,~-ti fM St_, OR 16s71Zt-, S IV45 /V07~,a PERCOLATION TESTS (mil TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH R P- 1~VVV1 P- P- h P- P Vol) 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 CL P-D- 3,0_ Tom/ j~ lox 0 b a F~~ v rio~ Top 0 f a0v - o r Fitikw 13 IjE _y Io N~ 3 16 care D , Irk, I 13, . APPROVED' This hest site for a conventional septic system. CSC 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. ),41r ADDRESS: ROBERT ULBRICHT CERTIFICATION NUM R: PHO //NUMB (optional): Z--- 3cp "-1~ C' WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S SS - a L L-Kf MINN. INSTALLER & DESIGNER LIC. NO. 00663 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - 1 r, „sc mplete and acc: ; irtp!ew legal descriptio The tr~r~ section must clea° _ MAXi~: NJM number of bedresor< of c0n)111r:rcial , k , 1~rtitr_ is rirr: E~ =evv or replacement sys1=- Fri; Comp ore the suitability ratk-,,; hoxes. A SITE IS SLII"_ABLi _ OT HE SYSTEMS ARE RU .)LIT BASED O £ " OlL CONDITICY P EAYE: use the abbreviation, shouvri here for writinc, pvc'ile, desct ip'O- MAKE A LEGIBLE £aiac, . r? ;Ccurately locating y©rr .~~st IoCations. Is,.ayu s= at,e ;d?eet may be used r< ta;ited; SUl' y10t_l" b£.ltT,l'Stiz~ w...t vertical clevatron wfi.,vr ce point, as ciE3arly shown, and ate ;der $?t',t£.' 'a(l al:)pltapi 5 X`S .9s to dales, 'iif.7L1 E .?Ia[Ct Caata, perco(;lon te i~llch "a, d :aiev rtrcw} iro, also'+l, N . p o l a`ii8 ~ icic °y ,Fw C.,tr e ,E =.tz~tatC <tr}(s P4t~€i ~ I Cc Sa.I I tr H;oh Gr a r, s r~ r_. G _ r l3: ~r nor, `~__esa,jl - - Silt C Loan, 'r, yc r F4 , Siliv Clay I - `,,=sip t, sli-C Y PF MITt" e~