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ST. CROIX COUNTY
WISCONSIN
ryY ~y ~,a°
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
4 r 911 FOURTH STREET a HUDSON, WI 54016
(715) 386-4680
~w
SEPTIC INSPECTION / WATER TEST REQUEST FORM
Specify desired test(s) & remit appropriate fee with application.
Outside water lines are often turned off during winter months,
making access to the home necessary. Please make arrangements with
this office to insure a time when entry can be gained.
❑ Water (VOC's) $185.00 ~yl Septic $25.00
Water Nitrate & Bacteria
( ) $35.00 (Visual inspection)
Owner:__~;r e5~ - Requested by:
Address:` 4l ~~,a Address:
City & State: F,41s ~l City & St.thwgjw@,L~) ,
Zip Code:_ ce--z z Zip Code:
Telephone N°: ( ) Q-? -j _ /cjq Telephone N°: ( )
Property address (Fire N° & Street) :
Location: Sec. , T N, R W, Town of i
St. Croix Co., WI. Tax ID N° Parcel ID W
House color C'%_' Realty firm: (_0WV Lock Box Combo: -
Water sampl ap location: C(;
TO BE COMPLETED BY PROPERTY OWNER
*PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Is the dwelling currently occupied? Yes ❑ No Ir
If vacant, date last occupied:
Septic system installed by: •`z Yokr:
Septic tank last serviced by: Date. ' ; ; .
Previous Owner's Name(s): Have any of the following been observed?
1--
❑Y ~N Slow drainage from house. (c ; E4L.U
❑Y Sewage Back-up into dwelling. G 3
❑Y Sewage discharge to ground surface 93
road ditch or body of water.
~«~ko~x
❑Y Slow drainage from the dwelling.
4`. uQr~~GE \
❑Y Foul odors.
Other comments relative to system operation:
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE. ` G5 mar DATE
i ~
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
IN
a ~ 1
yN y
TO BE COMPLETED BY INSPECTIO~N~ENCY
System design &/or permit on file? []Yes G~No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: low grd ❑At-Grd []Mound
Approx. size 'X W-favity []Dosed []Pressurized
Ft.2 []Bed []Trench ; ry well
[]Holding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES []Other []Unknown
Septic tank
Setbacks: ❑Houseo-K []Well []Prop. line []Other
peDoet n k
etbacks: []House []Well []Prop. line []Other
[]Locking cover []Warning label []Pump/Floats-
❑Alarm []Elec. wiring
Soil Absorption System
Setbacks: OHouse G~ []Well []Prop. line []Other
❑Ponding: []Discharge:
General comm ts: 4•~ ~n cl
INSPECTORS SKETCH OF-SYSTEM LOCATION
Inspector
1 e
o~
September 2, 1993
Mr. Jim Helgeson
154 Co. Hwy. F
River Falls, WI 54022
Dear Mr. Helgeson:
An inspection of the septic system serving your home located at the
above address was conducted on August 30, 1993. This inspection
was based upon a surface inspection of said system and did not
involve any excavating_ or chemical analysis. Accordingly there may
be hidden defects in the system not discoverable by this
inspection.
A water sample was also taken at the same time. We will forward
the results to you as soon as we receive them from the lab.
Most septic systems consist of a septic tank which traps the solids
and greases from the sewage stream and then allows the remaining
liquid to seep into a subsurface drainage area. once the liquid
reaches this point it. seeps away by percolating through the soil
surrounding the system. Failure is caused by the soil surrounding
the system becoming plugged with microscopic bacteria and sludge,
among other things, which form a clogging mat. As time goes on,
this clogging mat becomes progressively thicker, allowing less and
less liquid to drain away from the system. When this clogging
becomes severe enough, liquid becomes trapped in the drainage area
resulting in a condition known as ponding.
At the time of inspection, your system appeared to be functioning,
but not at full capacity. I noted that there was sewage effluent
ponded within the first drywell. Because this is a progressive
process, I cannot predict how long this system will continue to
properly dispose of sewage effluent nor how soon the system will
reach complete failure. With proper care, this system could
concievably last for :several years. However, I cannot guarantee or
warrant that this system will continue to function properly in the
future.
In an effort to prolong the system's life, I recommend that steps
be taken to minimize the wastewater flow from the house which
enters the system. For example, repair any leaking water fixtures
and/or replace them with water conserving fixtures, reduce time
spent in the shower, wash clothes and dishes only when there is a
full load, use a washing machine with a suds saver feature, etc.
I would also recommend that you have the septic tank pumped at a
minimum of once every three years.
Should have any questions or concerns that I can clarify, I can be
reached at this office between 8: 00 am. - 5: 00 pm. , Monday - Friday.
C' Sincerely,
Yames~ K. Thompson
Assistant Zoning Administrator
cc: file
CAMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121 Agw
800- 962- 5227 cz: w
FAX - 715 - 962 - 4030
I~
;c~ tlt REPORT DATEY 9/0719:
01 CARMILCHAEL ROAD
,~SON, WT
Rd
i1i..LLl i C ;I
COLLECTED#* 3200, -
OF SAMiPLE2
ATIOMl2 Bacter i o logical.[- SAFI'6 PFsi;
J F,\NDEPENOFN~"' V.-
J.
9o prr: e,4 _ 19
~ D
G i : \ Oy
~-3p.s "I ESS THAN" Detectable Level. Approver
PROFESSIONAL LABORATORY SERVICES SINCE 1952
Parcel 040-1114-80-000 06/04/2007 01:35 PM
PAGE IOF1
Alt. Parcel 30.28.19.472B 040 - TOWN OF TROY
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 - SMITH, CHARLES S & SUSAN M
CHARLES S & SUSAN M SMITH
154 CTY RD F
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 154 CTY RD F
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 2.098 Plat: N/A-NOT AVAILABLE
SEC 30 T28N R1 9W PT NE SW THE E 554' OF Block/Condo Bldg:
THE N 165' OF THE NE SW INCL WELL SITE N
OF LN BEG 165 FT S OF CEN S SEC 30 W Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
151.7 FT S 10 FT W 10 FT N 10 FT W TO W 30-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
11/10/2000 633361 1558/170 WD
09/01/1998 586195 1353/295 WD
07/23/1997 1034/415 WD
07/23/1997 999/57 WD
more...
2007 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.098 50,800 152,000 202,800 NO
Totals for 2007:
General Property 2.098 50,800 152,000 202,800
Woodland 0.000 0 0
Totals for 2006:
General Property 2.098 50,800 152,000 202,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 134
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Wizoonoin Department of Health and Sooirtl Scrxicec
Plb. k67 3/70 Division of Health
SEPTIC TANK PERMIT APPLICATION y y y -lo
v
TYPE or USE BLACK INK ~
A. OWNER OF PROPERTY
Name Address (Street, City, Zip Codo)
~J i ,ic!"t'i iii ~ ~ / I. ..J /F (i.l jt_ 1.1,x' r,---'~~' 1..
Be LOCATION OF PROPERTY Wf wRF.' SYSTE14 WILL BE CONSTRUCTED. ALTERED OR EXTENDED COUNTY_ t
Check One:
CITY VILLAGE LEGAL DESCRIPTION
V TOW,S HIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? V ~ YES NO \ IT NUMBER
D. SEPTIC TANK CAPACITY _ Gallons NEW INSTALLATION REPLACEME?T it ADDITION
,MATERIALS: Prefab Concrete Poured in Place Sterl Other
NTIDER OF TI"ZKS PO BE INSTALLED:
E. TYPE OF OCCUPANCY J
:Check Ones One or Two Family Residence / Cormercial Industrial Other
Specify)
Number of Persons to be Accommodated` Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES l NO Automatic Clothes Washer YES NO
Dislaasher YES NO Automatio Potato Peeler YES NO
Other (Specify)
G. MASTER PD,&3ER MAKING INSTALLATION
Name: Address: Lioonse Numbers
f J
Signature of Applicants 1 L L r_ / ~ ~ 3 c l MP Rte,; J
Address:
H. > (To be Completed by Issuing Agent)
Date of Application Fee Paid j
Permit Issued (date) Permit Number y
Agent (Name) Fo.•: ! I r
Town, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above E;:estions are answered and the
fee paid. Agents w il; ferµ and appiicr~ticn, the fee of ;1.00 or each septic tenr and thr3 third oopy
of the permit (cana.ry) to the Division of Health. Checks and money orders should be made payable to
the Division of Health.
Do not wa•ite in space below - FOR DEPARTMENT USE ONLY
r-1- DATE RECEIVED 6r - ~ ACCEPTED BY RETURNED
j (Initials) (Date) See G~rres.)
FEE RECEIVED d VALID. No. PERMIT NO.
kyes or No
REVIEWED BY APPROVER DATE
(Initials) (Yes or No
COMPLETE OTHER SIDE
SEPTIC TkRK PERMIT NO. ;
R E P O R T 0 V S O I L P E R C O L A T I O N T E S T
A H D 5 O 1 L B O R I N G S
TO
DIVIS1CII OV KLALTII - PLU?BJJTG SYCTIel,
P.O.Box 309, I.idison, Wis. 53701
Pur$Llvnt to H 62.20, Wis. Administrative: Code
P E R C O L A T I O N T E S T
rest Depth Cnracter of Soil Hous Water Test -71-110 Drop in Y-ter Level_Inahes .inutss
Numb or Inohos Thioimoss in Inchos Sind Holo in 11010 Interval Second to Noxt to Last JITo Fali
1st Wlatte 1 vei aight in Minutes Last Period Last Period Period :io: Inch
Examplo
P 0 3611 To Soil 101° 01a 2611 25, Yes or No 30 1 2 2 2 1 2 60
~ 1 fix'/, ~ if JT~7 ~-//,~i
4-
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Mir_izam 3611 Below Pro osed Absorption Sy9tt.-3
Boring Total Depth Depth to Groard Wator Dzth to Be rack
Number Inohas 0':)served rati %ttod Observed Estirc:ated Character of Soil with Th1o':~ness in Inches
Example
B - 0 7211 7211 Black To Soil 12" Clay 1817 Sand 18"; Gravel 2411
RMRD DATA FROM MINIMUM OF 3 BORE HOLES
TYPE OF OCCUPANCY:
RESIDMACEs Nu:eber of Bodroores `J OTHER: (Specify) Number of Persons
OD WASTE GRINDFR3 Yes No V Dis1riashers Yes No but..atic Clothes Washer: Yes " No
FFUJENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLAC2" F.NT ~
Tile Size NO.Lin.Feet Trench Width Depth Number of Lines
Seepaga Bed: Length _ Width Depth Tile Size No. Lines
' Seepage Pits Inside Dianeter Liquid Depth 1
I, the undersigned, hereby eerti'y that the percolation tests reported c-i this fora here mada by me or under M, super-
vision in accord with the procedures and method specified in Chapter H 02.20 (13), Wisconsin Administrative Coda, and
that the data recorded and location of test holes are correct to the best of cry knowledge and belief.
NAME /1 / i/ : i TITLE f
(Type or Print
REGISTRATION NO. or MASTER PLUti3ER LICENSE NO.
ADDRESS
71
DA E % SIGNATURE
11
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