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020-1188-60-000
Wisconsin. Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538729 0 GENERAL INFORMATION ( ATTACH TO PERMIT State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'Permit Holder's Name: City Village X Township Parcel Tax No: Bevers, Anthony Hudson, Town of 020 - 1188 -60 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: ■ /60 16 a\ l l CST' 28.29.19.1183 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 4) � /1 f ,'V, Benchmark z 7Z- /62,12 /60 mT' �/'� GY �( z Alt. B LA./ z ( 5 z� t irFc�. 64J.e--....- 3 • Z4 9 I mo, c' ML n / Bldg. Sewer -- Holding U St/Ht Inlet ,e(.".‘"' TANK SETBACK INFORMATION St/Ht Outlet y iz cig- 3 TANK TO P/L WELL BLDG. Vent t Air I �ntµ / k ` e ROAD ^ ^� � � � 9 � S tic / / L ! . G �W .3(0 W 24 2 /6h 7 ( !o lS 9G q7 D2iill �� / / 7 f / � i � / Header /Man. 7 �S i 5 57 Aeration LJ Dist. Pipe , , 7, / S 95, Holding Bot. System -7. 7 J,, vz___ k Final Grade PUMP /SIPHON INFORMATION 3./ 7 7 Manufacturer GP St Cove C ave 3 zz( T s - Model er T `-_ TDH Lift Friction Loss System Head TB Ft (-----. Forcema • Length Dia. Dist. to Well "� SOIL ABSORPTION SYSTEM BED/TRENCH Width / 'Length / t No. Of Trenches / ,� PIT DIMENSIONS No. Of Pits Inside Dia. ' Liquid Depth DIMENSIONS 3 V/ E z Tie __ SETBACK SYSTEM TO P/L BLDG WELL , LEACHING Manufacturer: ....--- I r INFORMATION 51 � CHAMBER OR - • Il + (�' - � ct, p Type J o n 6 4vt✓e SL / ✓ 1 1 w 1 4- UNIT Model Number: d g DISTRIBUTION SYSTEM z z,+-Z Z = 44 11.6-1Z., Header /Manifold i n Distribution x Hole Size x Hole Spacing Vent to Air take /- � ,. S 4.1 Pipe(s) \ `_ �� �� C • ..xf- _ Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Vede'J dtC / c-C Depth Over Depth Over xx Depth of xx Seeded/ dded xx Mulched Bed/Trench Center j4 1 Bed/Trench Edges Topsoil f Yes 0 No Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 794 Harlar CircleH dson, WI 54016 (NW 1/4 NE 1/4 28 T29N R19W) Cedar Hills Estates III Lot 55 Parcel No: 28.29.19.1183 ` 1.) Alt BM Description = ' 4 (--(1J4../\__ 2.) Bldg sewer length = r 11 - amount of cover = {rI " Plan revision Required? 0 Yes :' No 1 Use other side for additional information. , �' , r II J co SBD -6710 (R.3/97) Date In...ctor's • gnature Cert. No. /Lik. \)))/ C V L , \ ( 7/ 9 A, 1 �•C r • comrnerce.wi.gov Safety and Buildings Division County fi Clt i 201 W. Washington Ave., P.O. Box 7162 S 1 o I x s eo n s 1 n Madison, WI 53707 - 7162 Sanitary Permit Number (to filled in by Co.) Department of Commerce — Sanitary Permit Application /� P I1 S 7z 7 U rite Transaction Numbe r , In accordance with s. Comm. 53.21(2), Wis. Adm. Code, submission of this form to the appropriate govcinmemal N unit is required prior to obtaining a sanitary permit. Note'. Application forms for state ownett I' - S are Project Address (if different thanmailing address) submitted to the Department of Commerce. Personal inlitrmatio r. • , • G� or sec Mary in accordance with the Privac Law, s. 15.04 1 (in , Slats. C / ` _ I I. Application Information - Please Print All tor _cation --774 / 4` / ! l a G� Property Owner's Name - — Parcel p 4 i .'rftac v-eit © Nov 1 72010 oa0- 1188-11/0-000 Property Owner's/Mailing Address ST. CROIX COUNTY Property Location 7 7 y _ n 1 AK PLANNING &ZONING OFFICE Govt. Lor __.__ _ ( 1/ ? 3) City. Sttatte Zip Code Pho Number r NW 4, N) 4, Section 28 !`t u () .S(J � �1 i S C- S 7 6/ /'Zj " 3 O t`03 J (circle one) T W 4 N: R _L E of W I1. Type of Building (check all that apply) Lot # � lytr 2 (artily Dwelling • Number of Berlmom Subdivision Nance ]],�r t;.Ip� Q. Silo • (ka t A11S' tl 111 ❑ Public/Commercial Describe Use Iry _ _. -.. ...._— .._... —. —._� ❑ Slate Owned - Describe f t Llsc �T CSM Number U Village of u _ G � • C.lL ll 'S 1' z �-NG s (� Si Town of — _ r-r�lb(110 III. Type of Permit: (Check onl one box on line A. Complete line 13 if applicable) A. __ ❑ New System lteplacentent Syslcm ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision El Change of Plumber ❑ Permit Transfer to New Before Expiration Owner g/../ r(al�_ IV. Type of POWTS System /Component/Device: (Check all that apply) — (f i ;C.-/Z- CL T ,iq.4. ion- Pressurized In- Ground 0 Pressurized In- firound ❑ At - Grade 0 Mound > 24 in. of suitable soil 0 Mound < 24 in of suitable soil U Holding -, Tank 0 Other Dispersal Component (explain) P )-- - -. __ —_ t ❑ Pretreatment Device (explain)_ --- ex lain V. DispersallTrea ennt Area information: , _ r Design Flow (gpd) Design Soil Application Rat pdst) Dispersal Area Required (st Dispersal Area Proposed (51) System Elevation / Co 0 b ✓ • r i _ � 5s -rota! - -_. -. 6 *if Z 1S • S t) ✓ VI. 'lank Info Capacity in tal Not �Nfanuf�ulcr era Gallons Gallons Units / / '/ c. I a g o 1 New Tanks Existing Tanks y - fig ° U y c 4' os at•( gel IAel: .10 01)i) WeS'eitg a , to w v - Septic or Holding Tank 1� I - 11/41(4 a _ r 'e. � t Dosing Chamber r W J VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation (gibe POWTS shown on the attached plans. Plumber's Name (Print) II P1 er'. ' u ' MP /MPRS Number Ilusiness Phone Number � N. 1 tmi� n l_ a aag � 11 - 3 (6 Vi �a -o Plumber's Address (Street, City. Stale, Zip Code) ) 7b Uw 3 N W1InsD� W ° rsc. 5 4b�� V ll1. County /De 'ailment � se Uri 1 r Approved P • ermit Fee 1 Date Issued Issuing int Signature /1 l / ICJ .�1. ,, - -_ nReason o nisi S 1 47 5 : �• a />� /!� IX. Conditim'enimagasons for Disapproval / 7 1. - Septic tank effluent filter and d / ispersal cell must all be services / maintaine4 as per management plan provided by plumber, Z.' An 5QQback :requirements must be maintained ._ st• - — mss- • tisc r n complete p ans or ,t. itan and submit to ter County only on paper not less than 8 112 s 1 I inches in size S130 -6398 (R 01/1)7) Valid that 01/09 • P io Z M A4 ip 01e 1°N) ♦TieP, e � �v�QS 37For‘ E • /on Cieoo ,� �S seti. 11) G,Ce4$e ' r\J . -*'00,4, 1' p o a xqu • 3 \ ,lea' '''. t ` f yyy� 1 �y uL` � ~ 1`� 9 R clime � 6 ,1 0Y-- Q ..66 }� f A. 1 0\44 — 413 UN ° ? S X04 \A Val; ROVY's 1 u CY��SW` " 4 Si I I 1cJccpy, CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Owner's Name: -Tr) AI" 1;-e V ks RS ' Owner's Address: ilAre._11;12, Legal Description: Nikk) tiV cla Ta9 g.)1 Township. 14 (ADS (.10 County: 5 Subdivision Name: C-tAPC, ) )I s 'Est-,S J 1 Lot Number: SS Parcel ID Number: GD, 1 ( gg (90 - 00 0 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Forrn Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: .0'1\ BoMPAtigt-Pit License Number: ODd 909 Date: ii ) )5)10 Phone Number lc • 01) 7 Signature _ 4111 1110-...■ Designed pursuant to t e In-Ground Soil Absorption Component Manual for POWTS Version 2_0 SBD-10705-P (N.01/01) Page 1 , ...I) A41ne --ron,) 4.1-g4;ce , 3 1?-tV egg , Z C42 37111‘ ...86%MeeSsier DOxl.t)Is stliite j 11) 4. sc, e .01'.1 Ase 0 _ . , „ s - 7 ... ,, • .9" -c VAS T 3 -13k) , $ IIA . '1 IL cljuAit-V1/414,..--,17, $ 'a,(91 (itA VtOlt-4,,, l'PO/IL 19\414.- (e) 1\tiN14.' VkiN LV IL f \ \ ii •Ci , WON . . ..,- -,.. . . 7 l'io Ott Ci a Li,.q • / . / I - Soil Absorption System Cross Section �.f- -_ r b°•Sa ft X9.50 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Cap I ill et (,,S Leaching Chamber t` 3• S 4 _ ��•S U ft • System Elevation fl _ • ft ft Soil Absorption System Plan View 40. ft 3 ft { M1111I1111111Il,hI1nII 1,i1u iu1 uu11Iu1E1I 3 -5 ft Leaching 1 Trench Chambers 1111111IIi111111IIIIIIIIIIII1111II1111111I1IIIIIIIIli11I11i 11111 E \ 4" Dia. Trench 2 Header - • • • • ervation Pipe 11M111111111 iiii111111111111111111iiiiD1111 :111 rTrench` Leaching Chamber Specifications Manufacturer And Model _ j.► ! is-tows vlla "l a y EISA Rating . a U sq ft per chamber Soil Application Rate . 1, gpd /sq ft Co U 0 gpd Design Flow* . Soil Application Rate ÷ 07 0 EISA = _7 1► Chambers '® rows of a). chambers each. Page of PL7525 Effluent Filter - Fffluent Filters .: Polylok Inc. Page 1 of 2 i lazt ,e!,ir r'tik te , ;5 ;, ; ; ; i `` ;! ! . =`: Polylok inc. 3 Fairfield Blvd Wallingford, CT 06492 Call Toll Free: - a com You are Mere: Horne > Product Details "i + hl "ill ■ i',1 tU i, Y ;ll� i t 1 , ,i', Ig„ ,�, � r l +�, l P. ;, ` ,ai li g; •1, i t s,1 ;I r ,i i i f i;l l 4 , , 1 � � lie 91,' 1 i� , f irl,i l �ti1 �i� � , �f i } t i4 lI Rill i EFFLUENT FILTER ;;; ' 4 i � : 1 1., ,1 i, „ F , A i i lip, {t l i'oti!, „ 1 I •! �� ,, l o,, l l 1l l i I, il,i i'rl { ;,, � ill, " I1 ;1 I ,1 ; i ri,lli,� + [11; Raising the bar in filter technola • ' i hi ;���( ii ll il w olli ii �1 1,��i 4� ie�l,I,+f, kilo l+,ld dlli,rt ,ul1, :;, ,,! .. About P9 4,31 N+f^.w Pron New PrOakgct Rer,T,04 -c.:" ;£r ckIiiin Contas:1: Us , ,-4 t4i , ..ti :., r c fc;, .. , : i 4.44; Ci66t9 it: ip':Ix 1. • PL-625 Filter :LA Description Effluent Filters Polylok„ Inc is pleased to add its new commercial filter to its existing line of quality effluent Extend & Lak filters, The PL -525 is rated for over 10,000 GPD (Gallons Per Day) making it one of the """•”" — largest commercial filters in its class, It has 525 linear feet of 1116" filtration slats. Like the !Risers &R Lavers Polylok PL - 122, the new Polylok PL - 525 has an automatic shut off ball installed with every `' "'" "�" "'"� "" "' filter. When the filter is removed for cleaning, the bail will float up and temporarily shut off i Distribution Boxes an • l )rl (r {I1,�i the System so the effluent won't leave the tank. No other filter on the market can make that I Accessories ::, claim! " Pumps, Basins, Pump e ., I ,awya, , ,1t�; • and Step Systems i Ordering information Request a Quote Related Products , •"--------- .--- -.-_._ """°�"""" ' i Seals / Gaskets II , 1 Features „ I? 1 Baffles, Sanitary Tees Deflectors i • Rated for 10,000 GPD (Gallons Per bay) j . • •. .. ... • 525 linear feet of 1/16" filtration j Reber Spacers Enlarge for details • Accepts 4" and 6" SCHD, 40 pipe • ..- -•• • -- • Built in Gas Deflector Handles and Receiver§ • Automatic shut-off ball when filter is removed • Alarm accessibility I Signs • Accepts PVC extension handle . , i Landscape / Drainage The PL - 525 Effluent Filter should operate efficiently for several years under normal ; Forms S. Clamps . conditions before requiring cleaning. it is recommended that the filter be cleaned every I .•....,,..,,,....,.. "_,,__ • time the tank is pumped or at least every three years. If the installed filter contains an i I utyl Sealants optional alarm, the owner will be notified by an alarm when the filter, needs servicing, { • Servicing should be done by a certified septic tank pumper or installer. Concrete Accessories Maintenance Instructions: , Pressure Filters • I Odor Crontrol Product 1. Locate the outlet of the septic tank. �.•.- 2. Remove tank cover and pump tank if necessary. i Rebar-Lok and CMU 3. Do not use plumbing when filter is removed, I Accessories 4. Pull PL out of the housing. 5• Hose off filter over the septic tank. Make sure all solids fall back into septic tank. Reber Safety and ID C; 6, Insert the filter cartridge back into the housing making sure the filter is properly r • aligned and Completely inserted. I Landscape 7. Replace septic tank cover. PL -525 Installation; Ideal for residential and commercial r .... ""'""' waste flows up to 10,000 Gallons Per Day (GPD). 1 Technical Specif(catio! Installation Instructions: Related PrpdUCt~ tic tank_ Pump, Filter and Sun 1. Locate the outlet of the septic ` 24" x 12" Riser 2. Remove tank cover and pump tank if necessary, 1 Filter Alarm Panel an 3. Glue the filter housing to tha 4" or 6" outlet pipe, If the filter is not centered under SmartFi terrm Control the access opening use a Polylok Extend & LokTm or piece of pipe to center filter. 4. Insert the PL -525 filter into its housing. httn'Il�uww 1' I' � ,9 9 0, O I V I �,cvtc riptgilc stcr Pr rl„nt Tl —� Wd :6 01.0Z V °Or inns n k \I'11-711' nS i 'u p l dipliiil III 1 Ilii "1 i ,I I� 1 -1111 `li{ I I li �I � Ir/ �: �� � • � , p1 1 ll Ip� I ! h� Pl il, IU1 I Io1 {11�u � milli ' + 19111��1�1111 , 1Plllhl6l,Il�JfdNill IIIIII�II IIII'111111,illl�l�11 illl f IIIIIII X11.1 III,1111111►�Illull(,I... ,,,I�'1i116111'I'I ,. !1111 ►I 111,1..- ,..�1., II[ iltoliiitittrNt flim.[IIiiimilI�Ilillll_�lii{II 014 €N111111 11111111�Plllll0 imil IIIllilllllill'i ills 0Ili --4 I'llllli! 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W 2 ., df tocn • , . , � 1 ,, -x 1 uL m � j� C, 2 j: . ; ,. . : . ,,, H. . : t ) 1 0 i 3 IA/ "� _, if Lti < Oct. 14. 2010 9 :12AM r No. 3066 P. 3 • M — 10 7/ / ' ' /I 1 Al 11_,_ _ ___,..49 i /11:0 Ir .1 1 , p ... tj r ..l. 1 vo� ij C, d!iP -.— ca ..,.. ..; 0, m = 0 rn ay v rn rn / , i 7 4 . 1 r11 ' II i Ai4im k 1 1 ' 1( « « �� 1111 IN 1 I, a \ t , ,,9, \ 77 — i' V. , 1 riliviv,....„—___,,,==lkil 1 I ! allik E ,i k". ..' ..'%..4.4'',011111Lj / 0.. - L f.f: .-..... LID (-4 a ami lltio J.I. ,.......,..,....., , 1,., ,, , ,..,„ od uaTii . net ....„ Imi ,...... E........ . \ i . i 1 il p ill 4 :: 1 • a) Nov -11 -2010 10:45 AM St. Croix County Plan /Zoning 715 - 386 -4686 1/2 . POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _ of _ FILE INFORMATION SYSTEM SPECIFICATIONS P J d 1 N) ),(0 Owner -t� �� p c v f Septio Tank Capacity J a o C; 0 10 NA Permit # 100 Septa Tank Manufacturer 14, s d. ( Lc 0 NA DESIGN PARAMETERS Effluent Filter Manufaoturer 'poly (.0 D NA Number of 13edroams y 0 NA Effluent Filter Model Pt_ 5 5 Q NA Number of Pubiio Facility Units DMA Pump Tank Capacity as! — 11.NA Estimated flow (average) y 0 0 pal /day Pump Tank Manufaoturer NA Design flow (peak), (Estimated x 1.5) o u al /g d Pump Manufacturer NA Soil Application Rate • '7 gal /day /ft2 Pump Model A Standard Influent /Effluent Quality Monthly average* Pretreatment Unit 0 A Fats, 011 & Grease (FOCI 530 mg /L 0 Sand /Gravel Filter 0 Peat Filter Biochemioal Oxygen Demand (BOD 5220 mgiL Ci 0 Mechanical Aeration 0 Wetland Total Suspended Salida (TSS) 5160 mg /L 0 Disinfection 0 Other: _ Pretreated Effluent Quality Monthly average Dispersal Cell(s) 0 NA Bloahemioal Oxygen Demand (BOD,) 530 mg /L Ain - Ground (gravity) 0 In -Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L NA 0 At -Grade 0 Mound Fecal Coliform (geometric mean) 610 cfu /100m1 _ 0 Drip -Line 0 Other: Maximum Effluent Particle Size y in dia. NA Other: 0 NA Other: AZNA other: 0 NA *Values typioal for domestic wastewater and septic tank effluent. Other: 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s) At Least once every: A lnanth(e) a year(s) (Maximum 3 years) 0 NA Pump out contents of tackle) When combined sludge and scum equals one -third (3) of tank volume 0 NA Inspect dispersal cell(s) At least once every: 0 manthls) (Maximum 3 years) 0 NA � saris Clean effluent filter At least once every: 0 month(s) 0 NA !ik earls) Inspect pump, pump controls & alarm At least once every: 0 y NA Flush laterals and pressure test At least onoe every: 0 month(e) NA 0 ysaris) Other: 0 month(s) At least once every: 0 year(S) NA . Other: NA MAINTENANCE INSTRUCTIONS Inspections of tanka and dispersal cella shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspeottons must include a visual inspection of the tankis) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal oell(s) she(( be visually Inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface, The ponding of effluent on the ground surface may Indicate a failing condition and requires the Immediate notifioation of the local regulatory authority. When the combined accumulation of sludge and scum In any tank equals one -third (y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of In accordance with chapter NR 113, Wisconsin Administrative Code. All other services, Including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any aervice event. GMW (4/01) Nov -11 -2010 10 45 AM St. Croix County Plan /Zoning 715 -386 -4686 2/2 Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentretlona are detected have the contents of the tank(s) removed by a septege servicing operator prior to use. System start up shall not occur when soil conditions are frozen et the Infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the exoeaa wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or perk over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at - grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; ootton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peefinge; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS falls and /or fs permanently taken out of service the following steps shall be taken to insure that the system le properly and safely abandoned In compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and plts shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fella and cannot be repaired the following meaeures have been, or must be taken, to provide a code compliant replacement system; A suitable replacement area has been evaluated and may be utilized for the location of a replacement soli absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setbaok and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to Identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. if no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the blomat at the infiltrative surface. Reconstructions of such systems must comply with the rules In effect at that time. «C WARNING.? > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC. PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name -3I rv■ k, f') -ere. Name Phone 1 S -'7 110 U j) 7 - Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name 1)p t ) S Name 51'. C.KOIk c% Phone '1 I S — i. e ).S 16 S Phone ` 1 I yt.g'6 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(t) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY • SEPTIC TANK MAINTENANCE AGREEMENT AND • OWNERSHIP CERTIFICATION FORM Owner/Buyer y lofvy + TRx,4c.tx rtS Mailing Address 79\ IAA& Property Address \\ (Verification required from Planning & Zoning Department for new construction.) City /State ADS 014 . W S C,- Parcel Identification Number LEGAL DESCRIPTION Property Location N W 'Ae % Sec. ,S . , T O)4 NR19 W, Town of Subdivision Cecb Pet I• i 111 4 es 11) , Lot # 5S . Certified Survey Map # , Volume , Page # Warranty Deed # , Volume , Page # Spec house yes ._nQ Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. t 83.52 and in Chapter 12 - Croix () ap St. roux Coun t3' Sanitary Sari Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe the undersigned have read tog ` gn s is and agree to maintain the private sewage tem:with the standards set forth, herein, as set by the ' ■ ce and the Department of Natural Resources, StateeofWisconsin. Certification stating that your septic system has • 4 ' • must be completed and returned to the St. Croix County Planning & Zoning'Department within 30 days of the three ;on date. Uwe certify that all statements on this OrUL ate to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deolpeorded in Register of Deeds Office. Number of bedrooms / I s / GNATURE OF APPLICANT(S). DATE ** *Any information that is misrepresented may sanitary permit being revoked by the Planning & Zolking Department. * ** Include with this application a recorded warranty 4e4tfonl the Register of Deeds Office and a copy of the ceriled survey map if reference is made in the warranty deed. (REV. 08/05) �s; DOCUMENT NO WARRANTY DEED i THIS SPACE RESERVED FOR RECORDING DATA ;[ . STATE BAR OF ViTICONS1.1■1 FORM 2-1982", _ 484245 yoi 453PAGE 555 REGISTER'S OFFICE Cedar Hills Development, Inc. ST. CROIX CO., WI . . Rec'd for Record . . JUN 0 3 1992 conveys and !xi:mums co _ _Anthony R .aever.a. and Tracy Cit 10:45 A. A.. Bev.ers, husband .and wife. 11/41 . 144, Register of Deeds • • • ---- - ... - - ... • . ....... CiIJPli Tr) d THE FIRST NATIONAL BANK OF HUDSON . . Croix 307 Second Street • t ix the following described real estate in S . County, Hudson, WI. 54016 state of %Wisconsin: 'Tax Parcel No: • Lot 55, Cedar Hills Estates III in the Town of Hudson, Ct. Croix County, Wisconsin. egAIT FEE in not. 0:4) and rir;hts -of -way or record, if' any. 1s June 92 ou, t 11111s De elopment by • •(,-EAL. . N. bar:-.on, P-c;Ident A U T it NTICATION A C N %A. E 1.) N T ;.! , ; • I ) ii.t. s L •11.1! ttl.• , e.■lo • I • ' 7..- • , '.:1 11.1 S " N11- N. I I-. 1. 1; I , T •••• t. . ee . a • r .10 F16ev S. •-. - 4 Id 0 - - 1 a x a . P1 * ° O Pi ▪ O = c 2 2 A x 4 o Y. 2 z 0 * 6> _ . - is al o 0 .. 5' C c CEDAR RILLS E STATES is • p y O 0 OUTL07 4.. PRIVATE PARK s t- --- - '— r X r 01 J OF a• x0 s r X 21 0 ri CP I. 1' 7 i etv / i M. o l e sd g r ~ ~, \ f• S OW Mr 1S " (.14 w • „-_ 0 . 7:3z2 i re d N IN i'l ti. ,p$•- N Q Ar •• Z n a \ / i ..� a N 1 • 0 0 4! 0 N 6� O. 0 a c 4 ,, I N # O \Et. v • I N rn 0 • t ° 1 01 ” ° `i w r 1 td x o a fJ� a A re i Fe 711 I'Ll- m , a Q f C! V 1 ° 'a , o #. tA + a o " QC 0 Al -11. I O N N m '' L r ++QO N � , o +� ' . 6 0 � . • 1+ 134+ • ! s•1 ... .: e 0 N • H �° . ca m i ,;,"---{ cs,, S 82 ' Og • OO•c N 59 N 600 'IVA3 a,LIS '8 1IOS a 3 V b9LL 9TZ STL XVd 20 :6T OTOZ /5T /TT ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the 'ONUS 'i Trtb“, v$CS residence located at: NW N Sec. �$ , Tx:). N, R 19 W, Town of \-\ s St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced IV Q \J, ( a O I 0 • Did flow back occur from absorption system? Yes__ No (if no, skip next line — __ Approximate volume or length of time: ---"-_ minutes Capacity: - -. / __ Construction: Prefab Concrete \/ Steel Other Manufacturer (if known): Age of Tank (if known):) ° - �'� -- - -- rib (Signature) 1 36v, Yh . s t-ni (Name) Please Print in Prl,s _ aa.9U (Title) _ (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name - ∎ri\ .%ktkri.41-g 5 ., Signature • MP /MPRS ___ -- aka U4 • r ' 2236 Wisconsin Department of Commer SOIL EVALUATION REPORT Page 1 of 3 Y Buildings Division of Safety and Buildin � ' in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations County Attach complete site plan on paper not l:., han 8% x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and h. o ,h rence point (BM), direction and percent slope, scale or dimemsions, no arrow , w4• •: ' and distance to nearest road. Parcel I.D. 020 - 11:8 -60 -000 Please pri all informili Review By Date seco Personal information you provide may • used forndary purposes (Priv s. 5.04 (1) (m)). �� /� �7 �b n � b Property Owner ] b ' P roperty Location Anthony & Tracey Bevers Pt / > . • t,,, ` u /0 Govt. Lot NW 1/4 NE 1/4 . 28 T 29 N R 19 W Property 794 Harlar Circle ailing Address N N C Z o� Lot # Block # Subd. 55 Cedar Hills Estates !II Ci State Zip Code Phone Nu • . J City J Village e Town Nearest Road Hudson 1 WI 1 540161 715 - 222 - 7665 Hudson I Harlar Circle New Construction Use: j Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD » Replacement J Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.7 gpd/sq.ft./day loading rate. Prop se :6 ..x., system elevation to be 95.50'. Existing system elev. = 96.25'. w ,�, 1! / / { ,.. n 1 Boring # _ Boring i'S 10�� Jefr,t'� tom. -:mA. 6( e Pit Ground Surface elev. 98.94 ft. Depth to limiting factor > 91„ m• Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 AAA. 1 0 - 10yr3/2 none sil 2fgr mvfr cs 2vf,f 0.6 0.8 2 6 -12 10yr4/4 none sI 2fsbk mvfr gs 2vf,f 0.6 1.0 3 12 -18 10yr5/4 none sicl 2msbk mfr cs 2vf,f 0.4 0.6 4 18 -24 10yr4/4 none 1 fsl lmsbk mfr cs 1vf 0.2 0.6 5 24 -30 7.5yr4/6 none qr J l f s Osg ml aw 1vf 0.7 1.6 6 30 -91 10yr5/6 none 'strat. s Osg d - 0.7 1.6 Horizon45 contains approx 20% gravel and cobble. 2 Boring # J Boring ✓J Pit Ground Surface elev. 98.62 ft. Depth to limiting factor >90„ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -6 10yr3/2 none sil 2fgr mvfr cs 2vf,f 0.6 0.8 2 6 -10 10yr4/4 none sl 2fsbk mvfr gs 1vf,f 0.6 1.0 3 10 -19 10yr4/6 none i fs! lmsbk mfr cs - 0.2 0.6 4 19 -23 10yr4/6 none 60 I Osg ml cs - 0.7 1.6 5 23 -61 10yr5/4 none , 0 i s Osg ml aw - 0.7 1.6 6 61 -90 10yr5/6 none p strat. s '' Osg dl - - 0.7 1.6 n #5 contains approx 20% gravel and cobble. * Effluent #1 = BOD 30 < 220 mg /L a TSS >30 < 0 mg /L "fluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) Sianatu CST Number James K. Thompson 7 e7‘,......--- 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 11/15/2010 715 -248 -7767 Property Owner Anthony & Tracey Bevers Parcel ID # 020 - 1188 -60 -000 Page 2 of 3 3 Boring # 1 Boring J Pit Ground Surface elev. 99.69 ft. Depth to limiting factor >102" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 - 10yr3/2 none sil 2fgr mvfr cs 2vf,f 0.6 0.8 2 8 -12 10yr4/4 none cosl 2fsbk mvfr gs 2vf,f 0.6 1.0 3 12 -18 10yr4/6 none Is Osg ml cs 2vf 0.4 0.6 4 18 -29 10yr5/6 none cos &gr Osg ml cs 1vf 0.2 0.6 5 29 -66 10yr5/4 none co ti • I Osg ml aw - 0.7 1.6 6 66 -102 10yr6/4 none (� - �� trat. s Osg dl - - 0.7 1.6 T Horizon tains approx 40% gravel andcobble. Boring # J Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff #1 *Eff#2 Boring # J Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD 5 <30 mg/L and TSS <30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R.07 /00) A.C.E. Soil & Site Evaluatlgns :/_ 1d' Propose_cf d ;Spusal //. $ icy?'eda/u�ACorrpl6 /D0.0 6,,,6,ul Tivo Cs) frcrlaws a - 6 ♦ E /edaLeh \ 3'x 90: \ • .Coca c d perya. S 9739' \ ■ 99. N • 8 o Aetkony4 in :Icy dedprs ° T'Iaos -6 on \ ��f�at� h 7911 /arG:,.c% /0e C:ne. �.' 01 \ Q f/“c dso., i.' /. s-09/6 ', Lo 6 ss,, P4=< ocCcda.r �'�3��5�5``�� Ih/ /scrstatcs$ r1a��/JEf'y \ 4:1-15- \ Sec ..28, T. .29i1 /9�, ril • :51:19 �3 . / ce!/at /2;t 69 ?' T. of /ludso�, St. '�',e eo,, <.:(. r;+f% a cor74tGe .ele4. z %.2.S' / oc% : 2°1/ -100 -V \ 1 � � \ ,6e� #0 . S4ees \ \ z , \ \ t \ N, II \ E,C'si ocle.esi`ern ,4ec S t- el / 2ce 9,, ,e ,14,06t, fo.. ' e1C ,r' ='S9' \ of tap owE/i = 942 ' \ \ Ex.3vny gr'wzle = 99 sus'' r ,aeri Il'� i. epe: G, Q. 0�' ` \ • A 11. R. w1_ ■ : T /° °c ft/ 6;c4 a 6 s6 = t ` � t , 54:45"c + vita/it/tote Cn i aa.b'E6 dwr. ,4ssu n • ■ o eke. a99.6b N 1 ' . C` / f I 1:31 • l \l's Lex n \t u.'eq i ` Vara hiee,/ /ate G'rc%. 3 0{',3 r 1 ' „<, vi, b c-a-e— , 4 AS BUILT SANITARY SYSTEM REPORT OWNER /? /l1 �l s�,..e.G7 TOWNSHIP /V- d d.. SECTION T N -R W ADDRESS /164 ed. 4a,.t--- 1 Z e ' ST. CROIX COUNTY, WISCONSIN IS SIN N SUBDIVISION �.° c Z6-.K. ' e l' 1 4' LOT S LOT SIZE 2'- a PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET / OF SYSTEM r'S"_ .-- ___ 3 91 a ,/ cti,, lY ®GS -L . tt,' , ' , , It/ s',,G /5' cr 1:!11 � NI INDICATE NORTH ARROW BENCHMARK:Elevation and description: 5'a he 4!S /l Alternate benchmark ��a/ c SEPTIC TANK:Manufacturer: h?l,0111) 7` Liquid Cap. /26 8 Rings used: (9 Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear Ft. From nearest prop. line:Front , SideJ, Rear Ft. ` 7' No. of feet from: Well 4 43 - , Building: /3( (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons /cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front Side Rear Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed; _Trench: Seepage Pit: Width: /.- Length C f Number of Lines: Area Built FP' Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side AL, Rear Ft. No. feet from well: 9 No. feet from building 39 HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: 3 7/ 4.r pSa-l../ DATE: Y/ lC)/,..P PLUMBER ON JOB: LICENSE NUMBER : J 1-96P 7 6 /90:cj r : LOCATION: HUDSON 28.29.19.1183, NW, NE, 28, CO. RD. UU Wiscon "sin Department of Industry, PRIVATE SEWAGE SYSTEM County: - Labor and Human Relations t I NSPECTION REPORT ,,Safety and Buildings Division ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 149274 Permit Holder's Name: ❑ City ❑ Village)] Town of: State Plan ID No.: CEDAR HILLS DEV INC ( HUDSON CST BM Elev.: , Insp. BM Elev.: BM Description: Parcel Tax No.: /O e /ce. d' cirptc. az Qsij 020118860000 TANK INFORMATION ELEVATION DATA A9200120 34 0 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. i Septic /77' ' A 1 Benchmark /C.d ,O0 Do ing i Aeration 1111111111111111111111111111Tbi Bldg. Sewer t.Ar--- Holdi�i St /,H Inlet TANK SETBACK INFORMATION St/ I*(Outlet TANK TO P/ L WELL BLDG. vAirentto lntake ROAD Dt Inlet )4 ' Septic >sd > ) ' , 14 , _ NA Dt Bottom Dosing �—IIIIIIJ Heade Aeration P---- NA --.144 0 Dist. Pipe Holdin• �_` Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand --.4111111111111 Model Number GPM TDH Lift riction , -m TD Ft Loss ea • For ain Length Dia. Dist. To Well w— SOIL ABSORPTION SYSTEM BED / TRENCH Width / Length No. Of Trenches PIT No. Of Pits Inside Dia iqui. • - : DIMENSIONS 42 / DIME IIT` SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHL�. ►' anufacturer: SETBACK L A + BER INFORMATION Type Of✓te.�.' -C.. ( r ModefNumber: System: �a if - 4 4- , OR UNIT DISTRIBUTION SYSTEM Header / Manifold r• Distribution Pipe(s) ,,,-(/ / I x Hole Size I x Hole Spacing ,rrTo it ke Length 6 Dia. Length lli ' Dia. Spacing G ��,/ SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only ,-LL Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COM MENTS: (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes o ,/ / n Use other side for additional information. S /, \ r- ,, " 7 �— ?` //( J SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 1 I 2.JI4.I. I".IR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COON ‘ � STATE SANITARY PERMIT — Attach complete plans (to the county copy only) for the system, on paper not less than / I? 27 8% x 11 inches in size. ❑ Check if revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION C-edn. r /4/;'/(s. l7c .atL6i✓T , ah4,i/6 %, S o r T , N, R /7 E (or& PROPERTY OWNER'S WAILING ADDRESS LOT # BLOCK # rtk 7 '/ SS CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER • 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned m VILLAGE • • ,, • O ❑ Public LJ 1 or 2 Fam. Dwelling — # of bedrooms PAR E TAX NI MB R( III. BUILDING USE: (If building type is public, check all that apply) iJ A O -- // re - C d ti a / / g.7 p 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel/Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. EL New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 M Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min. /inch) ELEVATION 40 d / a d 7' o r G.� 3 O o� /. � /d 4 Feet /a f r Feet VII. TANK CAPACITY Site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New Existing Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank x / 2 Gd l yh , r1 eves I �y ❑ ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber In ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) I iP APRSW No.: Business Phone Number: a s ! 3j•� I ( .3 ) — 3 /z/ /✓� l/ ._._ ch 4..�..�t - sew G�/ Plumber's Address (Street, City, State, Zip Code): • O Allk I . COUNTY /DEP RTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee (Includes Groundwater Date Issued Issuin • A, = nt Signat = o Sta • rcharge Fee) Approved El Owner Given Initial /� e)419 ' 0 1 �' i • =�j "— ,p- Adverse Determination / ®� I. ,,.. -� ` —'a•• X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly PIb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS • 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 814 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) C' •e ;L4't✓ f( . lIS / Q - ;se T r J~.J ec c - r / LC) ,i/t S'taal'iilo Al - "9 4/rf Y tind ( 1. 1 tiX k r de 00 e ‘ a4. K 57C ' 4' 0/ 1 i/K SP A j49" u STeck� i 4 % °. w p S �` 7` � 1 i0( /... .!/ e. 0 • o f C'' arso -C ''IP A 197 /oP yr w /e` 'P ,vg 0' a de d r e. Si i 1 : --- e r va '' - ::(?' ,;:- f‘407,t;:tdit) I DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS -INDUSTRY, C DIVISION BOX 7 LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 H RELATIONS (ILHR 83.09(1) & Chapter 145) LPCATION: SECTION: TOWNSHIP Y: 'LOT NO.: BLK. NO.: S DIVISION NAVE: i W /4! T 2` /T2, /R /1E(or)W c1 <c.)AI >; �4 J�ri S C NT : OW ' ER'S /BUYS NAM • MAILING ADDRESS: , Sic i) CeMe, / LLS E: v& 01'r i T e (4t-t. 1.10 � oK) ^fit 461 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: ,_ DE CRIPTIONS: PERCOLATION TESTS: WResidence C4 +e —R New ❑ Replace Ft $ ) /1/z- M4 r /9 • RATING: S= Site suitable for system U CON r•, NTIONAL . M f S LiU IN -GRO P ❑ � RE:'SY EM -IN LL HOLDING TANK: RECOI�Q rd o..,JAL /`, hgt LIED If Percolation Tests are NOT required DESIj1 RATE: If any portion of the tested atK,,j,. ,in the under s. ILHR 83.09(5)(b), indicate: L r ,4' 1 Floodplain, indicate Floodplain elevation: bc-Ci2r PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH Of ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 In 9' i\ur,i > /Q,o% "2( tii.crs /1, litioL i kie n^s Ko' ° geL c&i t,v2. B- 2 /6.7- 9437 riL)Kl > "P: /b37- is C S 2 4 i i 9 "'R&E.Q nisf;- e 7 fris siCe. B- j0,s 903 _ r4oN 5 '' /o.'? J'a 1 /rlie.sL Ca�►i' r 4 gb.l 5i � • 74/314v �si(; B ill ,tx 9/,61 „.. /, 61 ` r i ,�I`j I o, os ie &L i5 fink)i.'zKK `'Rhige:3rTs 6 . ge„J' "� r B- < 9, i ; 7 ( )2, - *- P4 O N if > c . C7 Ins `L. L'r5 /T E.eN i_ . c:” - Ct k /)')S7gta#,) n,S (: � B- LECC PERCOLATION TESTS TEST DEP WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER AFTERS'NELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- 1 k.zD rJ: 9 3 >z_ > , - Z •G, P- . i �,,S° t O ►= 94 9( > 2 3 >2 > <3 P- 3 3. Z.a /loo 92-.& 3 > 7. >2. ›`2„. 4..3 P- P- . FL :V4,' AT f4C 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. I SYSTEM ELEVATION 8 j I J P t i ., i P l I r i _ + € L E; � i 1 ... ........ .. _._.. ._ _. -�_. _ .. ... ., a ,_„ _ E ,.,... _ .,, . 1 . N i / _ 3 ,fi 3 Z l� 1 I r ILLY ? i 60 ■ 60 (t 0 •jC . 40.)C� f 1 . 1, the undersigne bereby certify that the soil tests reported on this form were made a in accord with the proce ures an methods specified in the Wisconsin Administrative C..e that the data recorded and the location of the tests are correct t e best of my knowledge and belief. sl • I 1 r NAM Et(print): / `�—� TESTS WERE COMPLETED ON: : Mkvii, Sc)) J64..) ' - \ ,. - 01 . 4 &J SO►■.d >kk P7 N ! / 99? A RESS: CERTIFICATION NUMBER: PHONE (optional): 6 c ct / f ijF, 'c ‹ K/ 1^�i \41'(�� �, ,+ u " oi o / CST SI . RE: ` DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 10/83) —OVER — L 1 INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section roust clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bndr•oorns or commercial use planned; 4. is this a new or replacement system; 5, Complete the suitability rating boxes. A SITE IS SUiTAC3LE FOR A HOLDING TANK ONLY IF ALL • OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for .•Zriting profile descriptions and completing the plot plan; 7. MAKE A L•EGIBLL diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 1€0. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST SE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st: Stone (over 10 ") t3R Bedrock cob — Cobble (3 - 10 ") SS - - Sandstone •gr — Gravel (under 3 ") LS — Limestone • s Sand High Groundwater cs -- Coarse Sand Pe c — Percolation Rate reed s - -- Medium Sand 4hr -- 'JVeH f4 -_ Fine Sand Bldg - -- i r;,l,;irrfl • is Loamy Sand > -- Greater Than • 's! -._ Sandy Loam Less Than 4 11 ...... Loam Bn _.._ E3rov,'rl • -- a =rt Loam Br ..._ E3s`at;i< Si • • Silt r,,, -- Gray cI -- Clay Loam y __ Yellow . sci --- Sandy Clay Loam R - -- Red • sic! Silty Clay Loam snot — Mottles sc -- Sandy Clay -'- with sic - -- Silty Clay fff -- few, fine, faint — Clay ac common, coarse pt Peat ram Many, medium nr -- Mock d - distinct: p prominent HWL -- High water level, • r Six general soil textures suraCe wa ter for liquid WaStO disposal BM -- Bench filark • VEP .. Vertical Reference Point • • • TO THE OWNER: • This soil test report is the first step in securing a sanitary permit. The county or the Department may request • verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to • obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. • • _-----N3 o sF F ,,,,,t„ 131247 SQ. FT . 6:94 y o i .,, x ; (3.013 AC.) a. • op. ..: . \ C, 0 . W 4 �. ti r �IICl ,-L OF : NE - NE z 3r �)� � ��f r was 4 Aiw ��`; � , I --i — � ' '• .. °�7. � � ' � �ZQ� B � 310 i ', a i' \ / or 43 184.00' '. W >`� N 0 2'04'47 "E !I F- 0 1 0 1 .�. -, . 93498 SQ. FT. (2.146 AC.) • a A ; •s 9 . Ia vi e, tta LY y , 2 . 09 ' 42i. 3 N t2 27'2%1 2* s eo < w \ s gl f, 5 4 • • 89262 SQ. FT., C) 41 • • (2.049 AC.) it Z oo' p • SOO° 41' 04" E 53 Sr ;r I� • 89262 S Q W -► • • c (2.049 A( e0 li f: :4 0. . � • DRAINAGE PIE FOUND , EASEMENT P � - � 1 q, (1 PE POUM 4 L f16.04 ' __- _ — - --_ ' Ie a9' N ii'4S'E --- *---1- 1 1 -, f N P Pt wtI�NINi r 117.39 15 ', " 'a NO f r. 99T t Ili. 'OTNER. I , E $TAKEO ITN 1" X 2 2 2 3 —? SHINS 1. 01.1111. / L IN. FT. / J TILT T Y RA *IIVIT. WIDTH 1 r Yy , i l — CEDAR HILLS ESTATES MONUNENTi NNNT$CN CAP � �vOL. 5 PAGE 35 n OP EASEMENT Note :. All linear meas have been made to the nearest hundredth , of ,a foot. All angular measurements have bee made to the nearest six seconds and have bee n POINT (20' ON EACH LOT computed to the values shown. 10 COMMON LOT LINE .) • 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 -ee/G>' 4',' 1(3 Pe Location of Property ,414 14, Section 2 , T N -R / 9 W Township 14(6._ d _i • Mailing Address G.G 774 At/ >V 41,c7./-4/ -5-,f-- av 6 • Address of Site Subdivision Name . 7/ Lot Number .� s Previous Owner of Property a Total Size of Parcel a -7 a �Q, Date Parcel was Created Are all corners and lot lines identifiable? K Yes No • Is this property being developed for resale (spec house) ? 2( Yes No Volume and Page Number //1 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 Register 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) centt6y that ate btatementa on this 6onm are true to the bet o6 my (owt) hnowtedge; that 1 (we) am (aAe) the owner(4) o6 the propetity denscni.bed in th 4 in6onmatLon 6onun, by vi tue 426 a waAAanty deed neconded in the (Mice o6 the County Reg oten o 6 Deeds ai Document No. 11/ ; and that I (We) pAu entey own the pnopoaed .44 to bon the sewage di.apo4 4y4 em (on I (we) have obtained an easement, to nun with the above deck Lbed pnopehty, Got the conbtthucti.on o6 aid dydtem, and the dame has been duty neconded in the (Wee o6 the County Reg.Lsten o6 Veedd, ae Vocument No. ). ' S IGNATURE OF OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED L F r ----- WK. :14Jri« 7y s ' ?cx;UMENT No: s TAT$ , o f WI F 1444 THISIPACI asasWVM IWO 1111000011110- DATA LAND CONTMCT • • - 413.:11.7 ' MO rnt iauan� wa'fRi ovne REQ13T'ER.$ C?f'f ri. . a 1,u. t i rl Moxs) $T. CROIX CO., viis. Recd for Record (Iris pith COlitritot, by and between Harry J. Stewart as PeFsonal day of June A.D. 19 8 Representative of the Estate of Aldro LarsenLa John at 1 :4S 1 M. A1410? LIIKASD..4i1S1 .�4 ]0.. X4..15Y.T.02../tati9e.9....a. ( "Vendor ", James O ; whether one or. more) and.,. ILitii$at..�,...4fi(€li& " "' s r01 *single man ( whether one or more). QV' L e � 4410144"— Vendor sells and agrees to convey to Purchaser, upon the prompt and trail per deputy formance of this contract by Purchaser, the following property, together with the rents, profits, fixtures and other appurtenant interests (all called the "Property"), , ..- -:- ht. St, Croix . County, State of Wisconsin: IltTuim To ,, See legal Description on Addendum • • Tax Parcel No. • S FEE This ifl..AQI homestead property. ' Xis* (is not) Purchaser agrees to purchase the Property and to pay to Vendor at such place as he shall name , the sum of $ 192 in the following manner: (a) I. .§4.,Q!)9.49 at the execution of this Contract;' and (b) the balance of $.13,44544.194 , together with interest from date ' hereof on the balance outstanding from time to time at the rate of MU per cent per annum until paid in full, as follows: See Payment Terms on Addendum • Provided, however, the entire outstanding balance shall be paid in fuU on or before the 11th day of • June , 19..9O.. ( the maturity date). Following any default in payment, interest shall accrue at the rate of ...IQ.... % per annum on the entire amount in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire principal balance) . • Purchaser, unless excused by Vendor, agrees to pay monthly to Vendor amounts sufficient to pay reasonably antici- pated annual taxes, special assessments, fire and required insurance premiums when due. To the extent received by Vendor, Vendor agrees to apply payments to these obligations when due. Such amounts received by the Vendor for payment of taxes, assessments and insurance wUl be deposited into an escrow fund or trustee account, but shall not bear interest unless otherwise required by law. Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. Any amount may be prepaid without premium or fee upon principal at any time► payment yes i i In the event of any prepayment, this contract shall not be treated as in default with pset, paym so long g as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shall be treated i as unpaid principal) is less than the amount that said indebtedness would have been had the imehlikkpsymenta been made u first specified above; provided that monthly payments shall be continued in the event of credit of any proceeds of insurance• or condemnation, the condemned premises being thereafter excluded herefrom. Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser for examination except: Purchaser -agree to pay the cost of future title evidence. If title evidence is in the form of an abstract, it shall be retained by Vendor until the fall purchase pries is paid. Purchaser shall beentitled to take possession of the Prapert/ ew ••.••.ihe..daxfi..hf < x!iP. / , \ •Cro.. Out Ono I - .... • n . av op wsar4NAIN Wisconsin Legs! Blank Co. Inc. . _ --- - - — [ SVC ft 4 14 PAGE 160 79 --- /er . . .. ,. Purchaser promises to pay when due an taus and assounn•nts levied on the Property er upon Vendor's inreit 1 . , iit, it end to deliver to Vendor on demand receipts showing such payment. • „„ • Purchaser shall keep the improvements on the Property insured against loss or damage occasioned by fire, ex- , .... t-erded coverage perils and such other hazards as Vendor may require, without co-insurance, through insurers approved by Vendor, in the sum of $. .fl/.a , but Vendor shell not require coverage in SR amount more than the balance owed under this Contract. Purchaser shall pay the insurance premiums When due. The policies shall confetti the standard dense in favor of the Vendor's interest and, unless Vendor otherwise agrees in writ4ng, the original or MI policies covering the Property shall be deposited with Vendor. Purchaser shall promptly give notice of loss to in:gtrutice companies and Vendor. Unless Purchaser and Vendor otherwise agree in writing, insurance proceeds shall he applied to restoration or repair of the Property damaged, provided the Vendor deems the restoration or repair to be , mu:ideally feasible. Purchaser covenants not to commit waste nor allow waste to be committed on the Property, to keep the Properte in good tenantable condition and repair, to keep the Property free from liens superior to the lien of this Contract, and to comply with all laws, ordinances and regulations affecting the Property. Vendor agrees that in case the purchase price with Interest and other moneys shall be fully paid and all conditions shall be fully performed at the times and in the manner above specified, Vendor will on demand, execute and deliver to the gergr R lifi net) any 4 n s or encumnrance npea crea ton i of the Property, free and clear of all liens and encumbrances, except al s thd by ad or default of Purchaser, and except: ....easements...protective.. .. • Purchaser agrees that time is of the essence and (a) in the event of a default in the payment of any principal or interest which continues for a period of ...60... days following the specified due date or (b) in the event of a default in performance of any other obligation of Purchaser which continues for a period of AO.— days following written notice thereof by Vendor (delivered personally or mailed by certified mail), then the entire outstanding balance under this contract shall become immediately due and payable in full, at Vendor's option and without notice (which Purchaser hereby waives), and Vendor shall also have the following rights and remedies (subject to any limitations provided by law) in addition to those provided by law or in equity: (i) Vendor may, at his option, terminate this Contract and Purchaser's rights. title and interest in the Property and recover the Property hack through strict foreclosure with any equity of redemption to be conditioned upon Purchaser's full payment of the entire outstanding balance, with interest thereon from the date of default at the rate in effect on such date and other amountsdue hereunder (in which event all amounts previously paid by Purchaser shall be forefeited as liquidated damages for failure to fulfill this Contract and as rental for the Property if purchaser fails to redeem); or (ii) Vendor may sue for specific performance of this Contract to compel immediate and full payment of the entire outstanding balance, with interest thereon at the rate in effect on the date of defamt and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser shall he liable for any deficiency; or (Hi) Vendor may sue at law fer the entire unpaid purchase price or any portion tbere•f: or (iv) Vendor may declare this Contract at an end and remove this Contractas acioud on title in a quiet-title action if the equitable interest of Purchaser is insignificant; and (v) Vendor may have Purchaser ejected from possession of the Property and have a receiver appointed to collect any rents, issues or profits during the pendency of any action under (1). (ii) or (iv) abaee.Notwithstnnding any oral or written statements or actions of Vendor, an election of any of the foregoing remedies shall only be binding upon Vendor if and when pursued in litigation and all costa and expenses including reasonable attorneys fees of Vendor incurred to enforce any remedy hereunder (whether abutted or not) to the extent not prohibited by law and expenses of title evidence shall be added to principal and paid by Purchaser, as in- eurred, and shall be included in any judgment. Upon the commencement or during the pendency of any action of foreclosure of this Contract, Purchaser consents • to the appointment of a receiver of the Property, including homestead interest, to collect the rents, issues, and profits of the Property during the pendency of such action, and such rents, issues, and profits when so collected shall be held and applied as the court shall direct. Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property (by assignment of any cf Purchaser's rights under this Contract or by option, long-term lease or in any other way) . vithout the prior written consent of Vendor unless either the outstanding balance payable under this Contract is first paid in full or the interest conveyed is a pledge or assignment of Purchaser's interest under this Contract solely as security for an indebtedness of Purchaser. In the event of any such transfer, sale or conveyance without Vendor's written consent, the entire outstanding balance payable under this Contract shall become immediately due and payable in full, at Vendor's option without notice. Vendor shall make all payments when due under any mortgage outstanding against the Property on the date of this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaser makes timely payment of the amounts then due under this Contract. Purchaser may make any such payments directly to the Mortgagee if Vendor fails to do so and all payments so made by Purchaser shall be considered payments made on this Contract. Vendor may waive any default without waiving any other subsequent or prior default of Purchaser. Al) terms of this Contract shall be binding upon and inure to the benefits of the heirs. legal representatives, !successors and assigns of Vendor and Purchaser. (If not an owner of the Property the spouse of Vendor for a valuable consideration joins herein to release homestead rights in the subject Property and agrees to join in the execution of the deed to be made in fulfillment hereof.) Dated this llth day of June 19 86 (SEAL) Ihkl\i'l) t kt 5 -§AAJ•CO•ki 4,1 A e . .. ' • _Harry .J....Steeratt : ,, ■ . • / % en•.. • • . ,;. •-k. (SEAL) .411,.(Aeret. e 41.4441/ '. MAW . . c r' . William C. Harwell r...c. , , - .1 — - 5–.4-.i••• i CU .. k • : • 0. .... . , ';.4 ...., ....., •• •44 1 I % #0 •■• e;04 g AUTHENTICATION ACKNOWLEDGMENT.. .... .1 .t, A /2 • • • • s Signature(s) STATE . Or WISCONSIN , ''''' ., h 1 st. figAAPAN County. authenticated this day of , 19 Personally came before me this ...1.1..th ..... day of • Ame , 19..0.6— the above named Altny : i t Stewart and William C, jiarwell • TITLE: MEMBER STATE BAR OP WISCONSIN (If not, authorized by § 706.06, Wis. State.) • to me known to be the person 8 who executed the , • • forego n nstrument and cknowledge the.same. THIS INSTRUMENT WAS DRAFTED BY c......d 4‘2.704;....o....■ jopilLA4 .. Mntm, HEYWOOD, CARI, MURRAY . & SHERBURNE, P.O. BOX 229, . iDip/i) t-- , wpfaso,a/ , • Hutison-i--WI-540-16 Notary Public St t Croix County. Wis. I (Signatures may be authenticated or acknowledged. Both My Commission is per anent. If noj, 19 state expiration • • are not necessary.) N• . .. datito • A 6 , fT7 ) • . • 'lams u penom, dining In /MY rooselty should b. tYR41 Or rplonad 1)0 - allow 2 y 9 STC - 105 9 SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z r7 a OWNER /BUYER CccaY 4(2/45 42.ea2lev4/•e.U ROUTE /BOX NUMBER Con" G'a. Fire Number CITY /STATE ;„d .'a.✓ 4 ZIP e PROPERTY LOCATION:/(/W 1, JJz Section :2r , T 29 N, R l9W, Town of /,4,. , St. Croix County, Subdivision c -Gdacr eK7/,5' , Lot number j.1 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 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- 'v 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 d "ate. S I C N E D /� L- Z��'ti►7"i/'r � Il DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715 - 796 -2239 or 715- 425 -8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS 1 INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP /MUNICIPALITY: LOT NO.: BLK. NO. SUBDIVISION ME: '/ /4 NW ' 2T /T79 N /R19 E (or) W Hut l SS Cee4& Cx COL' TV OWNER'S /BUYS 'S NA MAILING ADDRESS: r c� IIA eLL4 k. NILL1 EN ELOP a-6 U uL Notes w, '4o' USE DATES OBSERVATIONS MADE ��//(( NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFE /DESC IPTIONS: PERCO AT TESTS: d�1Residence / 1<ANA ..—. ;04` New ❑Replace G-/ Z QQII 9 l 9 e� \\ t .SCA ue-Pe,a „`'' - $ &B IcN �tT !/ RATING: S= Site suitable for system U= Site unsuitable for system CON ENTIONAL: MOUND: a IN-GROUND-PRESSURE: SYSTEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: loptio) s DU -:� S ❑U a ❑U DO'S ❑U EIS zu OdNysA il AL a If Percolation Tests are NOT required DESIGN RATE: 1 If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: el-AS ( Floodplain, indicate Floodplain elevation: M4 \\ CZ. PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IJlli, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 rD,c 9?. NJotJ iQ.o% 2d /6 ° ' 'n,NL i9''ig>eavnis fo E'Qio cS4-4k B- B- Z 03 94.97 1\16 > /6.91, I s ` &['rs Zs''$ aoL /9' gis4g Ri �s�40 ?2 4a e B- B- S i.C 92:; N e n ' € >9,67 AS IS SR,J L ib I Q lae&, rvis7o .,'I 'Gtt B- . PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER TNerYLPS AFTER SWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P_ 1 A7c, tdoile 93.66 3 ?Z > _ > <3 P- "1 " 4.C)0 Ne t C 94.90 3 >Z >2 > Z < P- 3 ' .7o uc, QZ.Go 3 •z >2_ > Z <? P- P- ::iJ L r id>J Ar - 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 percen of land slope. SYSTEM ELEVATION .9 ?=.--' 1 1� �1 TAIC 014if TWA. TO 1S 1 1 \` Lb .- To Lo r tv /o o f 1 E i \ - rN r &b ai Ibr~F Przyr 1 F , .__. r . , �� - 4 , ' -� i 4c iv I ' O 7 , 4. i R � _ �"" °..� _ -_-s Z.; _ _ . _. _.7 .._,..., __..mot.... .,.... y .. _...,_ , -.,_.. -4 _ _ .,. ._ .e, _ _, -., _ _ _ _.._... f Glrllh�.� m to.. 4L �. (t,1 i4r- C12'To , Akt> -C - 1:4, -Sr&c. I, the undersigne hereby certi y that the s it tests reported on this form were made y me in accord with the procedures and methods specified in the Wisconsin i Administrative Co e, $nd that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME print): — TESTS WERE COMPL ED N: U 't ' - \s /.( .o +►,sow , kr� vl„�_,, // 9z ADDRESS: � , )U Q)o W1 S'Ao CERT I� QN N MBE PHONE NU,V16 ` I , optional): CST SIG ''T'URE: SCDts° —/ J� tJ III illa r .: / 1►! ..il • 1 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR- BD -6395 R 10 83 S ( / ) -OVER- �1 • INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To, be a complete and accurate soil test :, your report must include_ f. Complete legal description; 2. The use section must clearly indicate wheatbei - this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replac,einent system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6, PLEASE use the ehbreviatioras shown here For writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram act;iirately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; B. flake sure your benchmark and vertical eievat.ion refer point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10- If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the loran and place your current addles& and your certification number; 12. Make legible copies and distribute as rer_luired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OE COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - -- Storrs (over 10 ") BR -- Bedrock cob — Cobble (3 - 10 ") SS - Sandstone gr Gravel (under 3 ") LS ._ Limestone -- Sand E Hi1gh Groundwater cs - -- Coarse Sand Pe c — Percolation Rate rued s .__ Medium Sand LV _. !well is Fine San [31dri t3a .Izaar�er Loamy Sand > __ Greater than — Sandy Loam < _...- ers Than - r' o it r t !: _an Bi ___ (31ack ci - -- Ciay Loam Y — Y flog :r SCr —. Sandy Clay !,_Can) R - Red sic( ..... Sky Liar; Laarr: mot .- I1 other sc — Sandy Clay _... with sic Silty Clay fff -- few, Inc i, taint --- Clay cc - -- common, coarse p t Peat ram _- Many, medium rrt -- Muck d .- distinct p - -- prominent. I - l et L High seater level, s SEX: tuna t'x?:L3rc.'S ,urlacf water for liquid waste ittisposai BM -- Bench Mark VRP Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request Verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must he obtained and posted prior to the start of any construction.