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020-1084-90-100
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and,Building Division INSPECTION REPORT sanitary Permit No: 538734 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: Ste'skal, James I Hudson, Town of 020 - 1084 -90 -100 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: /!xj G 5 29.29.19.3390 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic // � (n , / / � e -2 ` lJ /l� Benchmark 5 /4:3 G>�5 Alt. BM , r d /� / L Bldg. Sewer Holding V St/Ht Inlet _ TANK SETBACK INFORMATION St/Ht outlet 97. li S TANK TO P/L WELL BLDG. intake AD lit- Fr�let� �c� sue. Vent to Air Itk ROAD '77- � S Septic / Dt ieltom Dosing / -2 �b7 i b / Header /Man. 2 9 ✓ g. Aeration Dist. Pipe Q f � a�Obd�. pi •h, Holding Bot. System PUMP /SIPHON INFORMATION Final Grade 7. S 96, Manufacturer Demand St Cover GPM F; t �-�- Co '�� Z .77 /Q!- Z9 er ` 161 (al 93. S TDH Lift Friction Loss System H fH Ft Forcemain eng ia. Dist. to Well �--� ti r� og g 5. 7 SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Inside Dia. Liquid Depth DIMENSIONS 3 1# E _\ SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Lv� Type Of System: i / Gs„ %) / 0 /� � �S UNIT Model Number: ✓, , DISTRIBUTION SYSTEM Aj -- Header /Manifold, // Dip t ` ` I x Hole Size x Hole Spa_ c V2 t�Ajr Intake Q Length Dia Length Dia Spacing A j SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only 34 Depth Over Depth Over xx Depth of xx Seeded /S dded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil \ Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 719 Country Vj (t � ,� wC�rl cle Hudson, W54016 (SW 1/4 NE 1/4 29 T29N R� Lot�3 � � � Parcel No: 29.29.19.3390 1.) Alt BM Description = &`— G ( J /l �` 2.) Bldg sewer length = - amount of cover Plan revision Required? F Yes No Use other side for additional informati n. (U SBD -6710 (R.3/97) Date Insepctor's ' natur Cert. No. commerce.vvi Safety Buildings Division County 201 W. W o e., P.O. Box 7162 JX ` 1 S Madt 53 -7162 Sanitary Permit Number (to e filled in b Co.) cons�n 538 73 y Departmerrt of Commerce Sanitary Permit Application State Transactipn N umber In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this fo � a governmental A 14 - unit is required prior to obtaining a sanitary permit. Note: Application fib s for d POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you pr ide in ondary ur oses in accordance with the Privacy Law, s. 15.04 1 m , Stats. I. Application Information - Please Print All Informat' 7 / l G ✓j t Property Owner's Name / o A 1 Parcel # i1 V 7 U Property Owner's Mailing Address � G ;X G'C1 Property Location 0 7Z �� ?.Y d d(D 21 aal `w &ZON / ��� Govt. Lot q City, State Zip Code Phone Number 9 `• 3 �� /a, � /<, Section n - (circle one II. Type of B ilding (check all that apply) Lot # T A N; R -- 1 or 2 Family Dwelling - Number of Bedrooms c - Subdivision Name Block # Vb / OD El Public /Commercial - Describe Use 114 V-4e i ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of b t. j l l t - It 5d Town of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System y ®Replacement System ❑ TreatmenUHolding Tank Replacement Only El Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision Change of Plumber El Transfer to New List Previous Permit Number and Date Issued ❑ Before Expiration Owner ' I r IV. Type of POWTS System/Component/Device: Check all that appl ® Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(g f) Dispersal Ar Required (sf) Dispersal Area Proposed (s System Elevation i � 6 yoC� �6 6� Yr7 Ti = 9v.. T,J= O 9 s ' VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks Existing Tanks 1V16Sf/t /'r. rr/t Cq1vS f>rR y A Septic or Holding Tank Dosing Chamber j VII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Sig re MP/MPRS Number Business Phone Number - Plumbe ' Address (Street, City, State, Zip Code) VIII. C unt /De artment Use Onl pproved Sapp �nRes,,fb, Permit Fee Date ssued IssZ=u re ia l $ r ///2- � l IX. Conditi$"Afff�#Nkl�easons for Disapproval t .0*p0c tank, ef,lue ^r lit qnd dispetsal poo must all De services ' �� +a •, as per managefr►erit plan provided by plurnoer. 2. Ab ack requirements must be> ned Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD -6398 (R. 02/09) Valid thru 02/11 EXr��>rr�C �raa!t c%d. /1 7i9 Coc�nfiy t 3, Cs.K ✓a /. S � . /SGT, EXis#i 1 swr,� SEys; 5tC.2y, 7's�,91a(,r 4.aw /9u> T . o�rS/udSorl, Pro postal d ;spt rj&f et - n"4 C b..rarri�g3.o�4cres 64 aked C Atvper&tw4 •r re adA 61 6C Asa CAW44 7 O ft eR+eEir EJ4'Sfi.t s> Shed loot 97e' S. d• A ssc...ntd e � =,d0 � �� /off /.�1� /ec�ft� -d EJ�•Sta� oOscTK` led is ju•Owrlef, � A:Rb' =�3 �"3 3 OsrJK` EXiS�s' /0'36 'a4 . 4 tr q p � e�cv 2 9� mo t . P,- �,ese�✓ wresei co, -,c. �': /E�' cam, ��� �c t��° -� � - f4o&e- cbsp etr&l ea // con *v v u-oo- E 5zh o /li. 4 , l CO 04; C'UI -dQ - Sac, Conventional POWTS Index & Tilte Sheet Project Name: Stejskal 3 bedroom Replacement Conventional POWTS Owners Name: James & Bonnie Stejskal Owner's adress: 719 Country View Circle, Hudson, WI 54 016 Site address: Same Project Location: Subdivision: Lot 3, CSM Vol. 5, Pg. 1500 Legal Description: SW1 /4 SE1 /4, Sec. 29, T.29N., R. 19W., Town of Hudson, St. Croix Co., WI Parcel ID #: 020 - 1085 -00 -300 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions Page 4 System Cross Section Page 5 System Management Plan Page 6 Filter Specifications Page 7 Treatment & /or Filter Tank Cross Section Page 8 Parcel map Page 9 Septic Tank Maintenance Agreement Page 10 Certification for Utilization of existing septic tank Page 11 Waranty Deed Attachments: Soil Evaluaiton Report Mater Plumber Restricted Service: Gary Zappa, Dep't. of Comm. Credential #222373 Signature: Date: e OF _ Page 1 Of 11 Design pursuant to 1n- Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD- 10705 -P (N.01 /01) `Ejri�fsnq �rao�t elld. �e�j a., ed 4f Zoo " e3te'spa/ 7/9 Co cas d/c� C�:rcle �/ac dq, "'m Svc) /(e CsnT ✓s/. S . /S Aa, EXisfi Swy {SEYs+ Sec, zf;`,z9-Y, a.�W ')` Pre posed d,•s�e rsaPec //. 71"c (4) l6re,rAe at 35r O'. "I2 ;r41 b�i� 3. o74cres -j S,6^. d &A .. t/ rr*4,144a i, 64.veato�c 7 en c�+.�i•� EXi'SEin s6ar'ta�cSl�cd . 9Zo' � Si c�iilq. A ss wned cow A .,1 L � ' EY %Sb%n� DtciK' r cts�orr• o�v�cr; ! 11:.Xi' � ,. 3bcd�ao�►. t � • : IQ4S.d4weC t r r FAIP �,Yisf�'n /,c+'b�Q, ccJYtkr C %; •� Q s�t �JE; to le /iC�t3tc�� °�' y� o!:spersa/C'L /! con aec 6roo. Eje . - /0236;' Veto cr P, _ L j t Il - S 9. u DISPERSAL CELL SIZING CALCULATIONS 1. (3 bedrooms)(100 gallons estimated flow)(1.5 design factor) = 450.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.7 gpd/sq. ft. 3. Absorption area required: 642.86 sq. ft. 4. Absorption area as proposed: 677.40 sq. ft. (33 chambers total) Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end cap (pair) = 5.80 sq.ft, EISA 642.86 sq. ft. — (3 pair endcaps)(5.80) = 625.46 sq. ft. 625.46 sq. ft. /20.00 = 31.28 chambers required Number of trenches: 3@ 11 chambers per trench Trench width: 2.83' Trench length: 46.00' Trench spacing: 7.00' on center Total system area w/ 5' trench spacing: 17.00'x 46.00' I I Pg. 3 of 11 Soil Absorption System Cross Section 94r 0 . �_ 9L,o ft lo 98.0 98,3s ft 4" Schedule 40 Final Grade PVC Vent Pipe 9� �, With Vent Cap ft Leaching Chamber A. o ; ft System Elevation Z. S3 ft 0 ft /o ft Soil Absorption System Plan View ft .Z. S3 ft { i ft Leaching Trench 1 Chambers 4" Dia. Trench 2 Header Vent Or Observation Pipe I Iii 110 11111 II Trench 3 Leaching Chamber Specifications Manufacturer And Model EISA Rating Z0.0 sq ft per chamber Soil Application Rate - 0.7 gpd /sq ft 1 15 19-0 gpd Design Flow 0 .7 Soil Application Rate 20.0 EISA = z. / 3 rows of ---Lt chambers each. I Page_ of ___[� i Conventional Septic System Management Plan tc P Y g Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD- 10705 -P (N.01 /01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be <_ 15' below service pad elevation. The operating condition of the septic tank shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The operating condition of the outlet filter shall be assessed every six months for the first two years of system operation and once every two years or as needed after that. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is not recommended. Soil compaction may hinder aeration of the infiltrative surface within the system and will promote frost penetration during cold weather months. Cold weather installations (October- February) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation i es within h dispersal cell shall be checked for effluent ondin . Pondin levels shall be reported to the pp the e s a c ed o p g g p owner. Levels above 4 inches indicate an impending additional, more fre uent monitoring. endin hydraulic failure requiring P g Y q g q g Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions relating to the operation or maintenance of the system should be directed to the installing plumber, Gary Zappa, at (715) 386 -2850, or the St. Croix County Zoning Department. Pg.5 of 11 EFFLUENT FILTERS PULYMOX "The PL -525 has 525 linear feet of 1/16" slots. It has an automatic shut off ball. When the ball will Alarm the filter is removed for cleaning, ccepts PVC aceesslDiliry �- - - - - -„ g 1 � extension handle float up and temporarily shut off the system so the effluent won't leave the tank. No other 525 line., feet filter on the market can make that claim!" o sl l" ts Illtration slu -- Rated for ova —� 10.000 GPD Accepts a" & 6" $ CHO 40 Pipe x J x Gas deflector C Automstic anur.off -• ball when filter 19 relnOVed "The PL -122 has over 122 linear feet of 1/16" slots. Rated for 1500 gallons per day, and < Han 1 '2` PVC can be manifolded together with other PL- Alarm Switch 122's to double or triple the GPD. It has an 122 linear h. — ell ,6 automatic shut off ball that stops flow when F u slm. i nc h w the filter cartridge is removed for cleaning. Comes complete with it's own housing, no . Filler Housing gluing of tee or pipe and no extra parts to with de Pipe A buy. 4' t, -. G.. Dulleclar Automatic Shut-off • Bell When Filter is Removed From Tank Order # Model # Description List Price PK -525 PL -525 Effluent Filter System 203.50 PK -122 PL -122 Effluent Filter System 6250 6 -10 432 D m '0 m� m�N oO m I-+ ter* D 0 - 1 ZD Nf Z I DAN r -Z r m D on 2, rn�r Dr N - �Co 37" 2 ., Z Cl) 6 „ � a � nm � A rn D= --I D m_ O Z . C� o o \ F71 18 MIN. m N m D r O m LX r z 37 I 2 on c-) I (A n, x m O m O 0 N m n4 D ' D D N TI Z (A — r D N N � m 1n W m rl D r n CA �U 0 Z D r Z _ o ic) ---ir m C r m D D 7 (n � m ��D D Dz r r � c (A - O� Z FVLTER CANISTER DETAIL SCALE:3 /4" = 1' REV N0. DATE: ° MIESER GURGRETE DRAWN BY:SWT m J \ z SEPTIC MANUAL W3716 US HWY10. MAIDEN ROCK, WI 54750 DATE: JANUARY 2008 ° REV. JAN. 2008 800- 325 -8456 FILE: SHEET 13 P�. Bahl CERTIFIED SURVEY MAP LOCATED IN PART OF THE SW 1/4 OF THE SE 1/4 AND PART OF THE NW 1/4 OF THE SE 1/4 ALL IN SECTION 29, T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN. CENTER SECTION 29 2 IRON PIPE N89 0 06'51 "E 522.00' SOUTH LINE NW1 /4 - SE1 /4 9 °06'51 "E 133,732 sq.ft. s 3.07 acres { 'l _ = r� LOT 3 q �' N CD CO ry (71 LAJ I _'y ♦ Z V" ♦OO ♦ �) ~ Q p0� la N I m � ° `� � g • 3 co LOT 4 �' 0 W o �t v `� 4-LOT 2 N = o o v = m " 90,930 sq.ft. `�° o � U_ N �i a' 132,481 sq.ft. ° �t s Q E-t x 2.09 acres cnl H 3.04 acres zf1 z < 438. m zi v 241�0% O� S87 58"W w C4 A i o o S61 2 Cal 0 W 1 3 0 ai 88,832 sq.ft. 66' o 0 2.04 acres A N c 9 C> w a r^ O O SCALE IN FEET N - N 66' ROAD 2 100 0 200 DEDICATED TO 1 - - - -�7 S87 °46' 58 "W OWNER THE PUBLIC. - 23.00' " SAM MILLER 8 TROUT BROOK ROAD unplatted - lands owned by _ platter HUDSON, WI. 54016 3 H v LEGEND N N • 1 IRON PIPE FOUND. o 1 x 24" IRON PIPE z C WEIGHING 1.68 LBS/ LIN.FT. S 1/4 CORNER SET. SECTION 29 COUNTY MONUMENT sun CURVE LOT CENTRAL RADIUS CURVE CHORD CHORD � °• ��� 'O wx •' \ { N0. N0. ANGLE LENGTH LENGTH LENGTH BEARING `'�. ALLEN C. NYHAGEN ` 1 -2 1 22 0 21 1 13" 929.13' 362.49' 360.20' N73 0 57 1 12.5 "E ! 3 -4 1 27 0 48 1 34" 137.00' 66.50' 65.84' N16 007119 11W 5-1407 4 -5 310 °01'31" 80.00' 432.88' 67.59' N44 °41'09.5 "E HUDSON, a ( � 1 87 0 33 1 40" 122.26' 110.70' N66 0 26 1 46 11 0 % W WIS• 2 82 °33'39" 115.28' 105.56' N18 0 36 1 53.5 "E �r<'9 NO 3 52 73.79' 71.20' N86 °19' 12.5 "E 4 46 0 08 1 26" 64.42' 62.70' S03 6 16 1 18 11 E 4 -5 cul -de -sac 40 0 54 1 47" 57.13' 55.92' S46 0 47 1 54.5 11 E �I 5 -6 32 0 48 1 48" 203.00' 116.26' 114.68' S18 0 37 1 26 11 E 4 15 0 23 1 06" 54.51' 54.35' S27 0 20 1 17 11 E road 17 0 25 1 42" 61.75' 61.51' S10 0 55 1 53 11 E lk 1 -8 27 0 14 1 38" 863.13' 410.41' 406.56' S74 0 09 1 39 11 W (� PHIS INSTRUMENT DRAFTED BY DOUGLAS ZAHLER JOB NO. 84 -12 U� B a ll ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ownerl'c®r —J GLiy1�.S �L.b nrl i e. SAC j - I Mailing Address 6440e i eu-) rcle. Property Address Saoc"e_ (Verification required from Planning & Zoning Department for new construction.) City /State 9kWSgn. tADt Parcel Identification Number 0.2.0 -/08s LEGAL DESCRIPTION Property Location 5k) 1 /a , SE 1 /a , Sec. � , T _.�gtN R—Zg--W, Town of ,Hacic�✓SO•-� Subdivision �- , Lot # ,3 Certified Survey Map # , Volume S , Page # /. 5 - Warranty Deed # 5 7897 , Volume 1 3 , Page # �s 5� Spec house no Lot lines identifiable es 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. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and b a master lumber, journeyman lumber, restricted lumber or a licensed pumper verifying that (1) the on -site Y P �J Y P P P P Y 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms I I& AAAA rrY% SIG ATURE bt APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) T11is is to certify that I have inspected the existing se tic and/or dose tank - � presently serving the following residence es¢onn:e 660 -%ea/ (Street address) 1/y Coat -. J; ew C f— r/e, 1�as ft W located at: 5cJ '' /4, 6 '/4, Section � , Town Range W, Town of ) 44Gc(scr, , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No � - (if no, skip next line.) Approximate volume or length of time: --d,4-- gallons minutes Tank Capacity; /, izo Construction: Prefab Concrete !/ Steel Other Manufacturer (if known): 4cL2 (�O,ct -ZA Age of Tank (if known): .9S veov -s Permit number (if known) ( - r (Lic ( jr l Kr Signature) (PrintTlame) 2 ,Z,;3 Title) (License Number) MP /MPRS z a (Date) Form to be completed by'licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposef (NR 113 Wisconsin Administrative Code) Rev 9/2008 y r� "c 1 1'9t' k' ?54 STATIE € AR OF t41sCONSiN FORM ? - 2'4£•2 WARILANTV DEED i Allan K Wa a singjte tea- — �� ST. C OI ft CO- W1 .on. - eye and a��rraretu t.j wvrg ames F. &gzkal and Bortr,.ie isband a nd wife . APR 3 P the foltmving described mal -slate in _ �. S- Croix Ccamay. ERT 2 _29590 5ratc eS t \'w 20-1 0£14 - 90 -.100 +IiKFlF1 a,�,TaA�r9Cars�uo 3.'YtD.fBE3i – Part of VPA of SEI /a of Semicm 29 -29 -19 described as fcsUows: Lot 3 of CAmrified Survey L%Aap filed 1/17/85 m Vol_ 15 Page 1500. '1' VirM 66 fort road ant- as shown on said Cenafiad Survey Map. St- Croix County, 'Wisconsin - AN T"nis is _ horrtestcad proper[): Exception to %v- arramur4: Ea.senum s. restrictions and righm -of -way of recatd_ Dated this clay of : AtxTii _A D_ 0 , 98 -- (SEAL) (SEAL. Allan H. Waldorf -- (SEAT.) — — (SEAL.) AUTHENTICATION ACKNOWL.EDGN[rNT Signature(s) 54ate of Wisconsin, ss auth_- micated this dap of _ _ ..19— Personally came before me this dap of _ Allan H. Wa ldorf. a single pers a TITLE M.E.MBER STATE BAR Of WISCONSIN (If not. aulhori_ed by §706.05. Wis. Stars.) Brenda Poulin t me kn v n to be the rsan who executed the foregoing publi instrun nt anJ rein[ -led the same. THIS INSTRUMENT WAS DRAFTED BY State o f Wisconsin f Attorney Kristina 0gl _ Hudson. WI 54016 Notary Public, t — County: Wis. (Signatures may be zuthenrcated or acknowledged. Both are not My commission is permanent. (If /Got, Cate exptrauon dare: necessary.) ° X�!acs nr -r::m . � •ng m an, raeauty �' n AA Fir ! Wd .,r ; rcacC [x'ou :fror .vgnaimes. 5t'A RR43Tl" M'l-D STATE BAR OF WISCONSIN L09ME— e'%= Form No. 2 – 19A2 LALUK"4t"RT D 2232 Wisconsin Department of Commerce SOIL E Page 1 of 3 Division of Safety and Buildings in accordance with Corn A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8'% x 11 inches in size. St. Croix include, but not limited to: vertical and horizontal reference poi WO wean percent slope, scale or dimensions, north arrow, and location e t6 Marro Parcel I.D. 0 -10 5-00 -300 Please print all information. Revi ed By D Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location James & Bonnie Stejskal Govt. Lot SW 114 S /4 $ 29 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Nfne or CSM# 719 Country View Circle 3 na CSM Vol. 5, Pg. 1500 City State Zip Code Phone Number City J Village J Town Nearest Road Hudson WI 54016 1 715 - 381 -8418 Hudson I Country View Circle J New Construction Use: 0 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD f!f 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. Trench elevs to be 93.5, 92.0'& 90.0'. Existing system stem elev. = 96.00'. Boring # J Boring 0 Pit Ground Surface elev. 96.80 ft. Depth to limiting factor >136" 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 -5 10yr3/2 & 4/4 none sl fill na na ci 2f na na 2 5 -13 10yr3/2 none I 2fgr mvfr cw 1fm 0.6 0.8 3 13 -24 10yr4/4 none sl 2msbk mfr gs 1vf,f 0.6 1.0 4 24 -28 10yr4/6 none Is Osg ml cs - 0.7 1.6 5 28 -40 10yr4/6 none it I s Osg dl aw - 0.7 1.6 C6 k 6 40 -136 10yr4/6 none s & gr I Osg dl - - 0.7 1.6 Horizon #5 contains approx 40% gravel and cobble. Boring # -j Boring 0 Pit Ground Surface elev. 92.78 ft. Depth to limiting factor >88" 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 I 1 0 -14 10 r3/2 none I 2f r mvfr cs 2vf,f 0.6 0.8 Y 9 2 14 -34 10yr3/4 none sit 2fsbk mvfr gs 1 vf,f 0.6 0.8 3 34 -39 10yr3/6 none Is Osg ml cs - 0.7 1.6 4 39 -62 10yr4/4 none D Osg ml cs - 0.7 1.6 5 62 -70 5yr4/6 none a s & gr Osg dl aw - 0.7 1.6 6 70-88 10yr4/6 one s & gr Osg di - - 0.7 1.6 Horiz I s # 5 & 6 contain approx 40% gravel and cobble. * Effluent #1 = BOD 30 < 220 mg and TSS >30A 150 mg /L * Effluent #2 = BOD <30 mg /L and TSS < 30 mg/L CST Name (Please Print) Sign ure: CST Number James K. Thompson 3.. 3602 Address A.C.E. Soil & Site Evaluations f Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osc6ola, WI 54020 10/15/2010 715 - 248 -7767 Property Owner James & Bonnie Stejskai Parcel ID # 020- 1084 -90 -100 Page 2 of 3 3] Boring # I Boring Y'l Pit Ground Surface elev. 98.25 ft. Depth to limiting factor >116" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-9 10yr3/2 none I 2fgr mvfr cs 2vf,f 0.6 0.8 2 9 -26 10yr3/4 none sil 2fsbk mvfr gs 1vf,f 0.6 0.8 3 26 -36 10yr3 /6 none Is Osg ml cs - 0.7 1.6 4 36 -60 10yr4/4 none s Osg ml cs - 0.7 1.6 5 60 -69 5yr4/6 none ,l s & gr Osg dl aw - 0.7 1.6 6 69 -116 10yr4/6 none h� & gr Osg dl - - 0.7 1.6 Horizons # 5 & 6 contain approx 40% gravel and cobble. Horizon # 6 evaluation completed by use of hand auger from a depth of 94" - 116 ". a Boring # I Boring J 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 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # J Boring _f Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM 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 < 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. SDD -8330 (R.07 /00) A.C.E. Soil & Sfb6 Evaluations .Sa{/eA/cca6 - ,vi • Ear /7b`r� �radc t1ed. 404 - 714 Coc� %cam Cede f/k ds d q, l vt 3, Cs,� ✓o � S P99,1SUD, EXi.Sfi P. /9c.cJ., T�. o�NccdSoil, /085 - - 3.o74cres oL E�r.�SE:.�q s6ora9e S/�cd a.v �oos� Qaa' Con �ec✓ 9i S, d: A d EX Gt�!'Qd X11 ` UG[�c asPu-ocv�lc� 5'90' 3b !� �3 // LOnN¢Cf%drJ. iE 416. Act s��t�e�vpofirj..+h. /eCo✓c+ E /eJ : ro.z.3S, �F E5 Maw d c lei �oP e � s r. owE�{ ° 9775' Cu,L - de - y ✓; c � Cam. Parcel #: 020 - 1084 -90 -100 02/04/2005 07:46 AM PAGE 1 OF 1 { Alt. Parcel #: 29.29.19.339C 020 - TOWN OF HUDSON 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 * STEJSKAL, JAMES F & BONNIE M JAMES F & BONNIE M STEJSKAL 719 COUNTRY VIEW CIR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): • = Primary Type Dist # Description * 719 COUNTRY VIEW CIR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE SEC 29 T29N R19W W1/2 SE1 /4 PART OF LOT Block/Condo Bldg: 3 C.S.M. 5/1500 ASSESSED WITH P340D Tract(s): (Sec- Twn -Rng 401/4 1601/4) 29- 29N -19W Notes: Parcel History: Date Doc # Vol /Page Type 04/30/1998 578197 1319/254 WD 04/30/1998 578196 1319/252 TI 07/23/1997 724/359 i 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 48306 212,400 Valuations: Last Changed: 11/27/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.070 35,400 128,900 164,300 NO Totals for 2004: General Property 3.070 35,400 128,900 164,300 Woodland 0.000 0 0 Totals for 2003: General Property 3.070 35,400 128,900 164,300 Woodland 0.000 0 0 Lottery Credit: 1 O tery Claim Count: 1 Certification Date: Batch #: 05 Specials: User Special Code Category Amount 018 - RECYCLING SPECIAL ASSESSMENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00 SECTION 29 UNPL A7TED LANDS OWNED 91 N89 320.63 s \ a a \ 9 \ THE SW 1/4 OF T NORTH . HE SE 1/4 r LINE O 00 6 h 121,493 SQ. FT. 2.79 ACRES CV w �a \ PPS V, = 40 54 47" V R = 80.00' , j 0 C8 = S 46 47 54.5 E 00� N C = 55.92' V �G 1 = L = 57.13 R r v IST TO = N26020'31'W 2 ND T8 = N67 " W . 0� C ° 4 0 10 UTILITY (D Q \ �EAS EMENT i ? ' 43 2 � N 8 r�0 35 45' 2 1 R = 203-00' W / \ CB =S08 °05' "E 66 L- 41 65' W IST TO = N 2 13' 02" W 2N TO = N 13 58'V _ I _ ..r p o 87,660 SQ. FT. } 2,01 ACRES LL O Z I I __--- ---- -- 420. Z5' 87046 58 E o � W / �, 40 4 �' M N 87 46' 58" � ui V� \ G � _ 317. 44 53' 40 340.40' I . S� 10' UTILITY EASEMENT ui 56 40 10 ' 39 ti GG 1 Q o 09 ' o / w o = 27 14' 38" 152,14 147 SQ, FT. Z '( ; R 863 3.49 ACRES ... ....... • • ' • L = 410.41 ISTTB = N60032 E " CK ' 2NOT8, N8�° 46.��.�. • 5 0 BUILDING SETBACK 3 I m► Q� , i N 729. T2' 1 5 �� S .7 46 MI e4_0 CERTIFIED SURVEY MAP LOCATED IN PART OF THE SW 1/4 OF THE SE 1/4 AND PART OF THE NW 1/4 OF THE SE 1/4 ALL IN SECTION 29, T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN. CENTER SECTION 29 2 IRON PIPE N89 0 06 1 51 11 E 522.00' SOUTH LINE NW1 /4 - SE1 /4 9o06'51IE '- 133,732 sq.ft. 0j °= s 3.07 acres rol 3 LOT 3 . :� /� Z o z v N G o�� - 9 o 0 L" a N 5 N N O -0714% C - ; v 0 % % Ni Nr �; SLOT 2 LOT 4 0 r- .01 C3 04i 90,930 sq.ft. 132,481 sq.ft. o H d E •1 x 2.09 acres u?I Ey � acres En 'o ; x a i c°n 3 'o \ 1 i 2 2` ` 438.61 ro m H i � -� 4� • ��w -4 �' zI N z 2��Ow S87 58 A i o o S61 W! z z LOT 1 3 6 0 ai 88,832 sq.ft. D w 66' o c 2.04 acres A N o ~ W _ SCALE IN FEET o ^� O 0 c _ N mmmw 66' ROAD 2 N M 100 0 200 DEDICATED TO ' "7 04615 THE PUBLIC. 1 .� - ' S87 OWNER 23.00 - SAM MILLER 8 TROUT BROOK ROAD unplatted lands_owned_by_ platter HUDSON, WI. 54016 3 4 14 LEGEND N N 0 1 IRON PIPE FOUND. 0 0 1 x 24" IRON PIPE z o WEIGHING 1.68 LBS/ LIN.FT. z S 1/4 CORNER fo SET. SECTION 29 COUNTY MONUMENT CURVE LOT CENTRAL RADIUS CURVE CHORD CHORD N0. NO. ANGLE LENGTH LENGTH LENGTH BEARING ALLEN C. NYHAGEN ` 1 -2 1 22 0 21 1 13" 929.13' 362.49' 360.20' N73 0 57 1 12.5 "E 3 -4 1 27 ° 48'34" 137.00' 66.50' 65.84' N16 °07'19 "W S-140T 4 -5 310 °01'31" 80.00' 432.88' 61.59' N44 047109.5 11 HUDSON, !► t �J 1 87 0 33 1 40" 122.26' 110.70' N66 0 26 1 46 11 W WI 2 82 0 33 1 39" 115.28' 105.56' N18 0 36 1 53.5 11 E 3 52 73.79' 71.20' N86 0 19 1 12.5 11 E 4 46 0 08 1 26" 64.42' 62.70' S03 616118 11 66aW E m 4 -5 cul -de -sac 40 ° 54'47" 57.13' 55.92' S46 °47'54.5 "E rt0 5 -6 32 0 48 1 48" 203.00' 116.26' 114.66' S18 0 37 1 26 11 E 4 15 0 23 1 06" 54.51' 54.35' S27 0 20 1 17 11 E road 17 0 25 1 42" 61.75' 61.51' S10 0 55 1 53 11 E c 7 -8 27 0 14 1 38" 863.13' 410.41' 406.56' S74 0 09 1 39 11 W '" J THIS INSTRUMENT DRAFTED BY DOUGLAS ZAHLER JOB NO. 84 -12 ... , t .. .nw+wyy n o•.... . =,rty+.w 'u•rnw...uws#+viY.YKRS;. _ . t ,'d.'1NM'�'e"ne" +fk+NR'w.. _ ` 1 Form -STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER / /// �; J i j ' f . j I F t r. T OWNSHIP SEC. _`^ T >:�' N- R 1 ��. � W ADDRESS L ;, / :.�f ST. CROIX COUNTY, WISCONSIN /�c� (_5 o �► Gam`' <',, SUBDIVISIONI' . , / i, LOT LOT SIZE ,, ' l �� r PLAN VIEW `� V1�& K Distances and dimensions to meet requirements of H 63 M SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM CIA CR C _7 l4•o �o fi CoI - -4- i INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used w , Elevation of vertical reference point: /;. Proposed slope at site:; SEPTIC TANK: Manufacturer: �z; .,r Liquid Capacity: Number of rings used: $ Tank manhole cover elevation: �' J Tank Inlet Elevation: �cj . �, j7 Tank Outlet Elevation: Number of feet from nearest Road: Front, Side,0 Rear, 0 feet From nearest property line Front, OSide ,fNear,O , feet Number of feet from: well building: 1 1 ' ` ' ? , (Include this information of the ab. r.. plan)( 2 reference dimensions to septic tank) 141-11: ti 101., PUMP CHAMBER Manufacturer: ' ° Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: i Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: � �. ✓ • v 'T ( Trench: Width: / Length: C- Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear, O Ft. Number of feet from well: 1 'de) Number of feet from building: '� r (Include distances on plot plan). SEEPAGE PIT Size: " Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: r 7 Capacity: lumber of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, 01 Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector• ¢� Dated: .� Plumber on . job: License Number: 3/84:mj 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 IRONVENTIONAL 1:1 ALTERNATIVE State Plan l.D.Number: (11 assigned) ❑ Holding Tank ❑ In- Ground Pressure El mound N ME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPEC ION DATE: Sam Miller RR #I, Box 282, Hudson, WI 54016 �0 q y--; BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: RE . PT. ELEV. CST REF. PT. ELEV.: SW SE, Section 29, T19N -R19W, Town of Hudson, Lot #3, Country View Name of Plumber: MP /MPRSW No.. County Sanitary Permit Number: Douglas Strohbeen 5432 St. Croix C' 69615 SEPTIC TANK /HOLDING TANK: , ! MANUFACTURER: jLICrUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER "' V ��C/ PROVIDED. PROVIDED: YES LINO ❑YES ONO BEDDING: VENT DI .: VENT MAT[ JHIGH WATER NUMBE F ROAD: PROPERTY WELL: BUILDING: TO FRESH ALARM FEET FROM n _lS LINE � IA VENT IR- I V YES ❑NO DYES ❑NO NEAREST �( D ING CHAMBER: MANUFACTURER. J BIEDDING LIQUID CAPACI TV PUMP WIDE J PUMP,SIPIIIIN MANUF Al TITHE H WAR N ING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO ❑YES ❑NO 1 1 [- ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF' ; PHOPEHTV WELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET•FROM LINE AIR INLET PUMP ON AND OFF) OYES ❑NO NEAREST —� SOIL ABSORPTION SYSTEM. Check thesoil moistureat thedepth of plowing I II (,Tt+ J DIAMITIH IND ntATFRInL A MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FOR the soil is dry enough to continue.) MAIN' CONVENTIONAL SYSTEM: p WIDTH LENGTH NO. OF DISTH PIPE SPn'IN(� COVER INSIDE UTA -PITS LIQUID BED /TRENCH TREN S / M E IAL' PIT DEPTH DIMENSIONS AVEL DE T H ' FILL DEPTH DISTH PIPE DISTR. PIPE MATERIAL NO DISTIL NUMBER 1 PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIPES ABOVE OVER EV H INE�I ELEV E PIPE' LINE AIR LET. FEET FROM G �U EARE'ST --- 0 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. ❑YES ONO SOIL COVER TEXTURE PE HMANI NI MAHKF HS OHSEHVATION WELLS _ ❑YES ❑NO 1:1 YES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENCH HEU DEPTH OF TOPSOII D SEE UFU MULCHED CENTER EDGES SODUF DYES. 1:1 NO ❑YES 1:1 NO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO.OF LATERAL SPACING IGHAVIL DEPTH HE LOW PIPE FILL DEPTH ABOVE COVER SED /TRENCH TRENCHES. °CIIME111�aDNS. : '. MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NC7 UISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING e ELE V.. ELEV. DIA. ELEV. J PIPES DIA.: ELEVAT1l t&I �4ND' tSISTkiBtT�pN HOLE SIZE HOLE SPACING L'HILLED CORRECT LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFt7RMATICHV, .. PLANS ❑YES ❑NO ❑Y ES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBR DF PROPERTY WELL: BUILDING: FEET.RCtM' °" LINE: ❑YES 1:1 NO ❑YES ❑NO N.EARST` `' Sketch System on Retain in county file for audit. Reverse Side. SIGNATUF TITLE. DILHR SBD 6710 (R. 01/82) l mmumino wlsconsln APPLICATION FOR SANITARY PERMIT �`DILHFA (PLB 67) UNIFORM SANITARY PERMIT # - inDUS InIXJ5TRVLR LRBOR6MUTRnRELRTIOns ( 9 l / e�I [> .S _ — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. —See reverse side for instructions for completing this application, PLEASE PRINT PROPERTY OWNER MAILING ADDRESS PROPERTY LOCATION CITY: 14sa L S6 h SW1 145E 1/4, SZ7 , T21, N, R I (or LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER 3 Co „ .� © t2 /1//y ---------- TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: I ❑ Public (Specify): THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. VT ❑ Seepage Bed El Seepage Trench U Seepage Pit El Holding Tank System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity O40 Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: 4r, ,i �T IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Pr ivate ❑ Join ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: MP /MPRSW No.: Phone Number: D at*_< 1 0_5 o b @a 0 0 I MP-Sq 32- 1 ( 2 #7 )32- 3 Plumber's-Address: Name of Designer: ��W t G �� S� O / �- 4 017 CI I COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved v s El Owner Given Initial Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber L .. 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. H i z cn ' H 9 STC - 105 r H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d OWNER /BUYER ROUTE /BOX NUMBER - $ e Fire Number CITY /STATE / Jt�'t ~� `, ZIP :5 PROPERTY LOCATION: S V - 1, Section ��' T �9 N, R Town of '�-j_� �i%J _ _ , St. Croix County, Subdivisior ecuyyfj�,�&,uJ Lot number �3 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 m 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. Ho E I /WE, the undersigned, have read the above requirements and agree z „ to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro 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 date. 1 � SIGN 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. i 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 /contractgr,( "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 tiv`r Location of Property S r , Section, T N - R W Township s e 1 Mailing Address _-K 3 d - / L ) X Subdivision Name _['�. w:t Lot Number z;W , 4 Previous Owner of Property Total Size of Parcel Date Parcel was Created 7 g Are ail corners and lot lines identifiable ? Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume iz and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING 1. Warranty Deed �—� � .Land Contract 3.• Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. -------------------------------------------- PROPERTV OWNER CERTIFICATION 1 (We) cma6 y that att a.ta temente on th,iA 6oAm cute tkue to the best o6 my (oun ) know•ee.dge; that I (we) am (cute) the ownen(a) o6 the pnopehty dedcAibed in xhiA in or+mati.an oAm b v c A tue c a w No. ` deed d A " e core ed in th a 0 .tee o th � County Re9i4 teA o 6 by ad Doeumer tt 3a z-, ; and I (we pnee en tey own the pn.opoa ed a.c,te 6oA the sewage di6 po.6WFAyatem (oA I (we) have obtained an easeme to Aun with the above dea m i.bed pupm ty, 6o& the eon,6tkuctlon o6 said system, and the same has been duty tecoiLded in the 066.iee o6 the County Regi,steA o6 Deede, as Document No. 3-7 SIGNATURE OF OiMER SIGNATURE OF C OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED ' 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 Al Wo I Location of Property 7 f�/', Section j N- R g W Township Shy 1 Mailing Address d(p ��� Subdivision Name e, V - 0; <I Lot Number Previous Owner of Property 'ANAi���s� Total Size of Parcel - 7S Ac s Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes Volume (_02f`) and Page Numbe as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING 1. Warranty Deed �.La�ontra_ ct 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. -------------------------------------------- PROPERTY OWNER CERTIFICATION I (We) ce4ti6y that att statements on this 6onm aAe .true to the but o6 my (ouA) knowledge; that I (we) am (are) the owner o6 the paopenty desn bed in thi.6 in6o4mat%on 6onm, by viAtue o6 a waNAanty deed neconded in the 066ice o6 the County Register o4 Deeds as Document No. `7 Z ; and that I (we) pnes entty own the pnopos ed site bon the s ewage di4 pozat s ystem (o t I (we) have obtained an easement, to nun with the above deschi.bed pnopeAty, bon the construction o6 said s ystem, and the same has been duty neconded in the 066ice o6 the County Regi6te4 o6 Deeds, as Document No. 3'73a 7 z- ) . r1.J SIGNATURE OF OWN SIGNATURE OF CO OWNER (I PLICABLE) DATE IGNED DATE SIGNED I I 1 # VOL I^ I PAGE p OOC�jtiMiNT NC, ITATS "R OF WIi=NsiN Foix 11• ! TMw f!og7 LAND CONTRACT twe&a s cwswasa yl tTO 7l� USX0 lOR ALL TRAKSACMONa WHIMN OVZR 1 R�.M� O PM"CMD AND tK OTHUR �.._.' FIFA .4fYQV1'iQDlIINo* •CWIRpItRR � i Aw"Tuts OFFICE S, t f fr'-- LUW)t, by and'Mtwestl garbaX Am i a .A- i�ctli.... (� as 'd. r Ft � 1�itiiPd Alf: $T. CIMM Co., Tom (' ........$. •i18 A +� ........:.................. .......... R 7th .......... ..... ...�........ Wbad rr one ore cater.) d+ay of May. A.D. 19,Q -4 1 ........................... .,.................._......... ct 8 :30 A b »....... � - ....... ("Asrehet se. whether one os more)• a i` Vendor sells awl -awes to Convey to Pureharer, upon the prompt and full per- '` �Mer flsds foemsaoe of Sala eootsaat by Purobwr, the Wowing pr togetbee %sith the pals. ;Tote M Is" other apparteeao iatarests tall Called the "Property"), l tt.............. .................._...........» . County. 8tato of Wisoou►sia: MIXTURN TO +'f as Quartos of the Southeast Quarter and (l���*'+o 949,1. 949,1. 4t tbr ( 3brast «v �.a•+r�.y. ) acres off the South side of the Northwest o#' the So ,,' . Qtwsrtsx utheast Quarter all in section Q� t 49 PorO,, ?ct "bip 29 North. Range 19 west. Fes Pared No6 t r t� i S TbU ....... is )..... homestead property. 5709 Hyland Court Drive. Bloomington. ` !Pwtb&w C a r g � r r e w to purchase the Property and to pay w Vendor atMinnesota. p � i ^ dM =a of R�fi. 5 nD. AD........ . .............................. in the following manner: (a) $ � QQ. .B�.Oit+a2ArXe11 ......................... ♦t the execution of this contract; and (b) the balance of 69• i . 5QQ.00 .................... together with interest from date bersof oa the balance outstanding from ti •ntil paid in fall. as folloTrs; mo to tim at the rate of ........ 13X ........................... pox, coa per annum s° Payments of principal: 6/6/84 $5.000 3/6/86 $5,562.50 In addition, the purchaser will on December 6th 9/6/84 $10,000 6/6/86 $5,562.50 of each year during the term of this contract pay x12/6/84 $10,000 9/6/86 $5.562.50 interest at the above specified rate on the balance 3/6/85 $5,562.50 12/6/86 $5.562.50 of principal from time to time outstanding. If 6/6/85 $5.562.50 the purchaser makes his final payment before the 9/6/85 $5,562.50 required date all interest accrued to the date on 12/6/85 $5.562.50 which payment is made will be paid on that date. Provided, however, the entire outstanding balance shall be paid in full on or before the... 6th ............... day of .«,...,.. eL........... 19 ...$fx t the maturity date). Following any default in payment, interest shall accrue at the rate of ........ % per annum on the entire amount In default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire D No amount of principal or interest may be prepaid except as stn ted C lo w. i FM �ndsr.- agteesis P ay M-10111 to dov wne ."fri sisal -ttr-pxr- v R*jy-snttei► 100464 0 - awLaeyuis�inr�+s�u►cs► psrmiuwa wltira►iire..T�si+r 3�ndsC- a�i�eea- te- sl.yi�ia +>tr•ie.i4rre .iw+eir+ww» sate+ see` aeJ -1%6- She- ltenrieriea- y�lt++reasot A jMee++edi ate• rla- awww.iwwi- era�wiw.aueewM�lwi eila8- set- 4eseJwieseet. ed.1►yt,iats, Payments shall be applies se. e M e . pr -11 »teals- 9peoifie+*"+ h" 60 - odpail Any amount may be prepaid without premium or fee upon principal at any t ime after__.. January tllese.a�w •puww+wat.•s. p y i � ...l......., 1saQ6.... ttiit) ..tae• •f.i4wtdw. In the event of my prepayment, this contract shall not be treated as in default with respect to payment so long ae the unpaid balance of principal, and interest (and in such ease accruing interest from month to month shall be treated as unpaid principal) is less than the amount that said indebtedness would have been had the monthly payments been made as first specified aLGvs; provided that monthly payments shall be continued in the event of credit of any proceeds of insurmwe or condemnation, the cundemned premises being thereafter excluded herefruu►. Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser for examination except: i none. In the event of partial condemnation, the inability of the Vendor to convey full title shall not constitute a default on tae part of the Vendor; but the Purchaser shall be entitled to the entire amount of the condemnation award. Purchaser agrees 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 full purchase price is p aid. Purchaser shall beentitled to take possession of the Property on.. ._. 1`la}• r 84 ocr"s Out om. _.,. �..... -.. .., 1D_.... I LAND CONTMACT.— tad►rleus► see $TATE RAN ON w1K4,u \ -41N L• r +I (11•n4 Co. Ins. Corpuq.M EUNN S.. 11 -- 1%04. fi •TATX a" OF W11300NAIN PDXV 11 -am � T,us a►aea as"wevo Tae aseeaatws DATA - " LAND CONTRACT I" M ttaED fin1A31� A 1036 ALL nWSACTIONS wusxte o vim . •..: .'_° alir1i11 � ND A�!lT1IQ>Ma )t034COtiaQlstt � 49"Tm$ OFMCE tract. as and tl.rwa :.�. .+l.xldtlllc.,. S $T. CnO Go.,1 a (. � 1�.' BOA ......................».».. ,.......,...............»...... !! A*c'43. k r Rww Adt 7th i' 11 et4w OW 3aorsl aatl.: ....5�.. .. 21BZ. » ..... ........ _ d'3y of May A. D. I9A4 • --»..- ....» ................ ....._.. (:t 8:30 A • I Voider • •..•.•.. «..• d .•... .....' ........ ( "Purebaur", whether one or more). seas Da aprees eon so stiy Purcbawe i . uDo+e the prompt and full per- r of t lee+ WN" Of 11" goesteaet, fir Purchaser. the " See" followin 1t�►lPes4Y. with the M%6 per• ftIU as and otYa apporkaga i,ttrwte . lW called the "Pro,), Cans 4 of Wiseotlsia ...........» .. w. Sta te 1 'ssnunn To Southwest Quarter of the Southeast Quarter and { � , die i 4.w4w'o j. r three (3) acres off the South side of the Northwest 4w&rtss.af the Southeast Quarter. all in .Section l Tawmshll 29 North, lunge 19 West. Tax Parcel 1 Na ..................... 1 } This ..........iB nc C ..... homestead property. Oti�gptlGirit) p + 5709 Hyland Court Drive. Bloomington. ^ .SQD.DiD purchase • the Property a Ito pay w Vendor atMinnesota.55632 .aJa.Bonnrg,�+',�ejI Pam as the following manner: (a) i. 5�► AQQ.. QO ............................ at tba execution of this Contract; and (b) the balance of =.69#500.00.................... together with interest from date bereof on the balance outstanding from time to time at the rate of ......... 13X ........................... per teat per annum r Ono >O In,tnll, as follows: Payments of principal: 6/6/84 $5.000 3/6/86 $5.562.50 In addition, the purchaser will on December 6th 9/6/$4 $10.000 6/6/86 $5.562.50 of each year during the terns of this contract pay x12/6/84 $10.000 9/6/86 $5,562.50 interest at the above specified rate on the balance 316/85 $5.562.50 12!6/86 $5.562.50 of principal from time to time outstanding. If 6/6/85 $5.562.50 the purchaser makes his final payment before the 9/6/85 $5.562.50 required date all interest accrued to the date on 12/6/85 $5,562.50 which payment is made will be paid on that date. Provided, however, the entire outstanding balance shall be paid in full on or before the.. fish ............... day of .- .........CL........... 19...$bt ( the maturity date). Following any default in payment, interest shall accrue at the rate of ..1..... % per annum on the entire amount in dafault (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire ' Inca)• No amount of rinci al or interest ma be P P y prepaid except as stated a w. Mesa- aeneeir�eetdar,'x'reeele Pep' mntttMrte -�l enders- �tteuttersn!'tirisnrttrpsr �. sad- sey�isallanrusat +cw.�iunta#al�� • YatWK- tttfsdes- ie- +il�- �1•ser il>ero sires.. ii�e1►+ww+►as..+�sewweJ- bi'-We - uendes sea- p.ysa.rsoi - isew►rAaee..viiL.h► l ed . iAto sleep- net- Ma►3Diewst. payments shall be applies iwbU e- e d ir i=ie� pri.l�a} riser- H- ii►e- ewsa- spesifieeF *n+rbes je priocip" Any amount may be prepaid without premium or fee upon principal at any time after.....laauary...1....... 193(1.... &0 (91t) r - - ga.ps4psy+atwi.a(. oLa4kW. , In the *went of Any prepayment, this contract shall not be treated as in default with respect to payment so long as the unpaid balance of principal, and interest (and in such case accruinic interest from month to month shall be treated as unpaid principal) is leas than the amount that said indebtedness would have been had the monthly payments been made as 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 excludes hereirum. p Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser for eseaninatfon except: none. In the event of partial condemnation, the inability of the Vendor to convey full title shall not constitute a aefauit on the part of the Vendor; but the Purchaser shall be entitled to the entire amount of the condemnation award. PurchasO agrees 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 full purchase price is paid. Purchaser shall beentitled to take possession of the Property on.. his Ocnwa out One �...�........ 19 - .84 LAND CBNTILACT —. tad/rldual sad ATATt. nAa or WISCONSIN Gamum" FUK►t \u. 11 — 9s1 W %r ' I.rytal Hunk Co. Ibe. z r � H y STC - 105 r SEPTIC TANK MAINTENANCE AGREEMENT 0 St. Croix County z d OWNER /BUYER 111'a ER (0 1[' Fire Number CITY/STATE 4 ,Sc�'a W: S. `LIP PROPERTY LOCATION: W �, Z E �4, Section Z / T 2- ? N, R Town of 5prX St. Croix County, Subdivision &Uccz'V ilia -w Lot number -� 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 se ptic tank p 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 m_. 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. o I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage u:'•nos syc,�_tt i, accordance with x H the standards set forth, herein, as sec by the Wisconsin Depart- ro ment of Natural Resources. Certification form must be completed and returned to the St. Croix County `honing Office within 30 days of the three year expiration date. I rx SIGNED DATE St. Croix County Zoning Office P.O. Box 911 Hammond, W] 54015 715 -7;16 -2239 or 715 -425 -8363 Sign, date and return t.o above address. _v N r n x , �o n N 10 v uJ w cD p 0 O O O 7C n n m 7 �cDa o�QO c 0w w�,�w .. cp w'fl m CD (n < mww s� =.. = ?� " 3 a o w rowo -,� 3'Z� c -1 3: c� v� : m 1 30 ° �o a� m w oo�vv 00 CD w N �� Qo (D (h p Dc A Adco wmw °aw a :3 m C w =r ID 9) Z aCD0 3 MCD a wa° cw u CA v;wa ac.Mm� C m 1 0 C = D N C U ° , ° CD Vi" n o m c� N W O CD 'o W C_ C o o c Q° c F 0? w m & , j m CL a a ao Q - E acv; r� N�c `<cc?:��3 a n m _ m mc -te 0N� ° No g O < CD z ON to . f DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR*AND PERCOLATION TESTS ( P.O. BOX 7969 ' "HUMAN' RELATIONS \ / MADISON, WI 53707 • (H63.09(1) &Chapter 145.045) LOCATION: ` SECTION: TOWNSHIP Y: LOT NO.:BLK. NO.: SUBDIVISION NAME: e. . Sj) 1 / 1 / o 2 /V?N /R,7#(0 soN -3 j gm,• / COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: . 9 Al, USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: I PROFILE DES I T ONS. ERCOLATION TESTS: )�Resid Ib. ence +a New El Replace I 0_3o_r� &,� RATING: S= Site suitable for system U= Site unsuitable for system it CONVENTIONAL: MOUND: OUND - PRESSURE: SYSTEM- IN-FILL HOLDING TA K: RECOMMENDED SYSTEM:(optional) QS EA .® flu IN- GR ❑ u El S Xu 0 S 1 lU a e0ketics 9 If Percolation Tests are NOT required re DESIGN RATE: q I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicat Floo dplain elevation: PR FI E DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 4*. ELEVATION OBSERVED EST. HIff TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / 7.3' D• �' �,cCe 7 7.,�' /. o e s /, • g s , • h s , R e si- r d- 4, S` a S B - a 2, 7• S' /..'l k n S A SA cs� / 7 R 8n s �9► Co B- y if, 0' . c f A o j o A A a B- s o t S c©6 o n s B- PERCOLATION TESTS TEST DEPTH/ WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER AFTER SWELLING INTERVAL -MIN. PE RIOD 1 PERIOD 2 PERI0133 PER INCH P- 3, ol A1 ,3 3 P -3 2 r. �3 P -_ P- 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 tP Z d, T I j 3 Pi,_ �OiF I .. s ia I--- � �� rte � ---��� - -°� f , b► �` IT� z i J_ 1, 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 cor est of my knowledge and belief. 6 NAME (print): // / 1 S WERE COMPLETED ON: ADDRESS: /� TIFICATION NUMBER: PHONE NUMBER (optional): / Z &, fi Ae sa w G am" /S / r/ ATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner S i- DILHR -SBD -6395 (R. 02/82) — OVER — INSTRUCTIONS FOR COMPLETING FORM 115 - S C} - 6395 To be a cot .Vpiete and acetate sail test, YOLK report must,inclucle: , 1. Complete legal description; 2. The use section must clearly m4r -at0 vvhether lNis is a rvskkince or commercial project"" 3, MAXIMUM number of bedrooms or commercial use planned; 4, Is this a new or replacernent system, Complev'' the stritabdi rating boxes. A SITE IS SUITABLE FOR A RO_L DMG TANK ONLY' IF ALL OTHER SYSTEMS ARE.RVL,ED OUT iMSED`CN SOIL, CONDITIONS; 6 use the abbrev shown here)(ar U3rritinv profile descriptions and completing the plot plan; 7, MAKE A LEGIBLE diagram accurately locating ycFcrr test locations. Drawing to scale is preferred. A sopar'at , shoet [nay be use4 if desired; £f. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9 Conrplete all appropriate boxes as to dates, narnes, addresses, flood plain clata, percolation test eXernp- '' tio , if appropriate; . 1 10, if t;aE-'.'Inforrmation (such as flood plain, elevation) does not apply, place N,A, in the apprvpr'iate box; € Sir;iE the form grad place your current address and your certi.f- icaiion number; 12, °daxa legible copied and distribute as regcrired. ALL SOIL. TESTS MUST BE FILED WITH THE LOCAL AL AUTHOR litrl i }-!IN 30 CLAY 0- � 60MPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS i Soil 1 3 1 j and Textures _. t�filt.qr yiarbols st — Stone {outer '0 "} BR Bedrock cc - Cobble 1:3 - 10 SS — Sandstone c ;r -- Gravid {undei 3"1 t_S — L.irn::stone x. s — Saari HCVV — F-iigh G;'c>krrrdtwater a: Co@F <,e Sand rNrrc . _ as , relation Rate era,. €F "Madium Starrd 3r Orr' '1 F Sand „ [3tdct Btr,irli?'rb} Is — I -cminy San, - ! C reat£rr Th,'M sl `aar,cf,; Loam {' Less — Loi3ni Bn -- L t ow;r Silt Locrnt L31 _. Blacv, Silr G, �cl - (flaw Loam `r - ` ell v ,c:' -- S gray Clay Loam R arr .- Silt Clay Loon meat fto1e,s C Sandy Clay V vvlt i S,l'ty clay f f I Fc f4 <', faint { t >l a y. � 4 , CC distinct p .._. p.,ern!raent, HWL — High rt' r 1 Ile Six r onerai sod textures surface v ate. ' wf Irr;rlur 0sposa3 ` BM Bend; Fvlark VRP - V£ rt;£tai R ferenrr Pw`nT . s t TO THE OWNER, t= soil t st rea,rart is 01 t64t 00p fry s ,errt;rar,l a sanitary perr - r , The only £ r i e: Departrxtent may request flak, s test in :'re field prigr tca pe ; - mit A con +, t of plans for the private must he Sl, ;hrriitted 'o !ho ajah #r',tj)i'i<ItC local i1ut�lC}n<tif.i #1 order to - i'n I F,..,, , =t -f 1r ;'nif Wars' be rlf wlllBA and poseed jrrr m tc;r t�tn of any.:collt ru aon. t `. , I .rte i v Iwo ' ,K `� C� �a { V I i 1 I t \ 7 l vn i I i 0 N i y o� U Q e P -4 LA A "F C A M rs �O � � ♦II#,, ti 41 IC 0 b o p I J m S k� n► ti < Q -p O ru