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026-1069-10-000
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O � ti •i OOO L'l ID CD CL N C =n C k � c = aa� "NI w CD .w.,, o fli C) m CL W _ o a �� a w o O i o 0 0 rD o 0 m .,. ° 0 C 7 � J Jr, .`: O l!> CD r VII to N. 01 rn m L V Z Z 0 c N ;n N H W _ CD N 0_ N —. O 10 7 O %0 F rn au 0C .4 o �. o D_ p m co ° co � c O ,t (D p 3 0 rj .. rn Qo 0 0 0 C D l Ln LA rn o T N f X a: C fD (D (D fl d ai rD 0 H W 0 (D m n, CL CL R V) Ln (D (D D r, p N N J '- 10 (C t11 4t 0 DDO.. CL rc-N; �ICj County Sanitary P 1q�-` ST. CROIX COUNTY WISCONSIN Gp In accord with Chapert 12 St. Cro Co u �vrm& PLANNING & ZONING DEPARTMENT �p1fb In information you provide ma be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER $� [Privacy Law. S. 5.04(i)i 0 1 7 2006 Hudson, 7710 F1 I1"" 1�(( (715)386 -4680 Fax 715)386 -4686 Attach complete plans for the s tem c;AT &0W I8 - 1/2 1 11 inches in size. C ty Sanitary ermit # ❑ vision to previous applica ion o r oo9g I. Application Information - lease Print all Info do Location: Propert Owner Name L V UJ 1/4 5 (J1 /4, Sec 3 1 C I� A0 N, R r) W Property Owner's Mailing Address / Lot Number Block Number 14 00 , 0 0 " (D — City, State ip Code Phone Numer Subdivision Name or CSM Number 39 6 Q.c II TypeLof Building: (check one) ` 03ity ❑ Village OTown of A S,& 2 Family Dwelling - No. of Bedrooms: J ❑ Public /Commercial (describe use): ❑ State -owned Nearest Road C II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel Tax Numbe s) A) 1 Repair 2 3. ❑Non- plumbing 4. El Rejuvenation Sanitation 1 O 2 0 — 100 — 10 — cub 35 3 B) t 711 Q� r p G Permit Number � r �� Date Issued q `S ate Sanitary V Permit was preva us5V i ued O . J ( O j / l IV. T e of POWT System: (Check all that ply) Non- pressurized In- ground ❑ Mound >_ 24 in. suitable soil ❑ Mound :5 24 in. suitable soil ❑ Mound A +0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade _ 5fo Required Proposed (Gals. /day /sq.ft.) (Min. /inch) f Elevation 9 VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existin g Gallons Tanks Concrete structed glass Tanks Tanks O r ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repair /recon ction /rejuvenation /installation of non plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non- mbing sanitation system. Plum er's a (print) P ber's ignatur n ps): MP /MPRS No. Business Phone Number ut wc. 1 �o 5 7 3 7)5 /�S lumber's Address (Street City, State, Zip C de) r III. County Use Onl Disap roved Sanitary Pe it Fee Date Issued Issuin Agent Si Joslamps, Approved O er Give itia vers Determination IX. Conditions Appro /R ' SYSTE R: 3) `�nk $ 1 Septic tank, and dis ersal cell must all be serviced / maintained - p c � as per management plan provided by plumber 2. All setback requirements must be maintained --"� as per applicable code /ordinances. �i9�e Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit NO: 99 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: Ohifs, Rick I Richmond, Town of 026- 1069 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 23.20.18.353 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration B dg. ewer o ing t t n et S UM Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Dt I S eptic Dt Bottom using Header/Man. era ion Mist. Pipe o. Sy H olding F inal ra e PUMP /SIPHON INFORMATION m anufacturer uernencl St Cover GPM Knodel Nurnffe I UN ILI me io LOSS system a 1 717 FT orc m i ng I . SOIL ABSOKPI ION SYSTEM DIMENSIONS INFORMATION CHAMBER OR UNIT DTSTRTBUYIUN 5Y5 17M Pdullly 1"MUIUM] 11 Pipe(s) Length Dia Length Dia Spacing x Pressure Systems Only xx Mound Or At -Grade Systems Only P "' J AA Urptil Or q I .., , . xx-Muldied Bed /Trench Center Bed/Trench Edges Topsoil - Yes 7[]N, Yes ;.� N In #2: ! ! COMMENTS: ( p Include code discre encies, persons present, etc.) Inspection #1: / ! Ins p Location: 250 North Starr Avenue New Richmond, WI 54017 (NW 1/4 SW 1/4 23 T30N R18W) NA Lot Parcel No: 23.20.18.353 1.) Alt BM Description = 2.) Bldg sewer length = amount of cover = I Plan revision Required? Yes L� No F Use other side for additional information. — rrrsepc s9nature - -- – -- SBD -6710 (R.3/97) I _ LO { • r _ p! 4 'aaoP - _ - _�} S Q 92 50 N _57q rr Awc» _ �Ct D l d' Al k► o � a ---- -- _ t aoo 33 2 - � r r , } R t , ��_ ` + S-•f' �i a � I k4_ - � R � rt f. lo , _ S _ s c.'__ Arlbb , , y , - WisconsM oqm m m of Industry, Labor aQ,Wvp Re GENERAL PLUMBING Sat* and Btcj"s j sbn � 'Water 1 PLAN APPROVAL APPLICATION P.0.8ox7f M Msdl=%W153MY -7969 NOTE: Appointments for pert review should be made � osez Prior to submitat by calling any one of the oftloes shown at the bottom of oft form. INSTRUCTIONS: This form is required with each general phtrrtbtng plan staf. Please complete bath sides. this form. must accompany submittal, Data recItiired in submittal Is described on the reverse side of font. 1. PROJECT INFORMATION (type or print dearly) Plan Review Appokmnenf otm p Plan Menefiaefion t4tat�.r N of 8 JOrNttktg Parry . (P b same) ~ S I l Qfe "' 0 413 Prefect CRY zo 4� 6 .! Protect L 3stion - Sued a No, �. r �► •- clancly • CCl,�lly p `" � � stare ilk R t%cl W � S O - Y 7 ❑ OF: p t Tatepbona Nb. (ir>ciude area ), Town+ l� i a r� / ° c T.lepbona Na. (uda aro, code) 2. PLANS FOR: 7t s Sl L 5 J Name Tdewtone NO. (Include area code) street a No. tcunent address) ❑ Revision to plu eft plan No. ST4.VM v- 401 1 }4,. 28. Fee For Pavisiorts -580.00 city ZiP al Foos are ptmuarn to Wis. Adrtttn. so` Coda. Chapter ILHR 2. and may be sntfm to c h o annually. 3. THIS APPLICATION FOR: FEE COMPUTATIONS Chill Appropriate " 4. FEE tree Reverse Side for Add liortNRemodefirg Fees) SUBMITTED ❑ Saof 9 Setnrer Only (no dram and ve" »»--» . of ❑ `., drain and Veld b�rstem St " Of BsvMef ......». _— kx9tea X $20.00 �vf ILY vate UNercell Matt Sewer ....» ....... 61d1es x 535 00 Sanitary Pri » » .... -» «..» .... Som of Largest Diameters . ,, ,• inches x $20.00 = ' 0 Bu(drtg water service. aY 1 only (no water diem ) . ..»» µ.. Sum of Warm Service Diameters » .. _. tnchee x 120A0 ❑ &AdbV Water Distft ion x $36.60 p »..... ... _ . „„ . „ •»» »� .. »Sum of water Servbe Diameters tehes ❑ Private Water Mein „.,.,,„,, „,,,,,,,,,,,,,,,,,,»•„ ».,��. -» ..».. Stxm of water Main Diameters ..»»».»»» btdres x $2000 = I ❑ ❑ Building Storm and Claw Water Drain system »«. Sum of stone Sewer Dbnetws � Storm Private interce�r fit Sewer» »..,,.......»:...»»».•,_,,,,,,, gums of Largest t)laertetere ,• , .•» . btdtes x S 8.00 = ❑ Conlydbd Roof Drainage syatern (Does Not htckrde ktdtse x $ am j ❑ Reduced Pressure Pr MOS Beddlow Prevwt er.»......». Storrs ) S80.00 Required = i » .............»..._ Number of Vahres »»..»........»» »............. _- ❑ ❑ stxf sprkdder systsrm ..».........»...... » ..... _...... »» Number o1 Tud 8p*dd&r ...._... _ _ Grease � * (See Note Baton).... »»... ......» .............».......... Nwobarof Grasse 6 terospiore x sec ao ......»»._ ..»».».... _ x 560.00........».... _ Chmil waste System * (See Note Befawj, .� Ned Waft ❑ Garage Catch Basin * (See NOW _Below) . », ... Systems »» x $80A0 ❑ Ofi intereer "»«... ” »».» » • .`» N=W of Garage C Baatns ... »... x $60 , 00 .»..»...,.: * (See Noe ee>orv) ... ..••••» ».•» .-» ......... »» » Number of OR hues ».....»...» ... _ x $80.00 ❑ Car 14uh hfterceptor * See Note t Belovr) .. .......... ».. . ».....» Nkxrtber of Car wash »„, x ❑ Sanitary dump Station ,tr tree Note Bebw) ...... .»_... »..... »„».. Number of Sanitary Dump Sm ns....».. _ _ x $80.00........» 3r ❑ Mobile Home Parks and Vehicle Parks. 1-25 81" $250-00 2830 Spa 5300.00 ..... 51 -125 Silas 535000 Over 125 Sba $400.00..«....._. : P 9 "Intintsn SY1 "-C&b* is Fee In Atoord with REM 8 - See Reverse Side of this Form) 3L O Petition for Variance (must be atdrmilled on form S83) 3u. ❑ Pdo ty Review- _. .. .. _. ».. _ . •.... ..... . �....� ..... . »�....�»....... T�Ta. = f Enter Sams Amount as Su6tdal w * NOTE * No Additional Fee Required N Submitted witt Drain and fit► vent system TpTAt, FEE (fiA&tkmurt S80A0) _ NOTE: Appointments �� should be made prior to Submittal. You may contact one of ttte offk;es Noted bebwr. "aro Office Crosse Office Shawano OMcle West First street. t M y 63 2226 Rose Street Mailsort Office Wauicedm OMM S. Box 8072 LaCr0851e. YVI 5460d' 201 E. W9ashi gton Ave. 1053A M Green Bay Street 401 Plot Col SuMe C ward. W154843 Phone (600) 785.9382 P.O. Box 7869 P.O. Box 434 WatAosetls. WI 53iB8 no (715) 634 FAX (808) 785 - 9330 Madsen. Wi tiM 7M Shawano. WI 54188 434 Phone (414 848-aft pis) 634 -5150 FAX ( 08) 2 2137-3506 Phone (M) 5243627 ) FAX (608}767-0592 FAX (414j 548.9514 FAX (715) 524 • CONTINUED ON REVERSE SIDE - ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer S Mailing Address J-4 .A C1 S .�, {� , tas Property Address S 0. vvj - (Verification required from Planning & Zoning Department for new construction.) City /State hi 1 1 Lol peel Identification Number LEGAL DESCRIPTION Property Location N W l4 , S t - J '/4 , Sec. T _r_N R_ 1,2� W, Town of t C m o Subdivision , Lot # Certified Survey Map # $0 a-0- '` e , , Volume , Page # Warranty Deed # S/ 9 l , Volume 6 �� , Page # 6 Spec house yes 60 Lot lines identifiabl yes o 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(l) 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 by a master phunber, 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. 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. Uwe certify that all statements on this form are true to the best of my /our knowledge. I/we 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 A IP SIGNATURE OF LICANT(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) i 5 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Address 3 91 City /State Legal Description: Lot — Block Subdivision/CSM # ' /4 &W V 4 �, Sec. 0A3, T.3VN -R_,jj V, Town of PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size Svw / _I � Setback from: House , Well P/L Akr Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road. rj Vent to fresh air intake ,� Water Line Meter location / Alarm location SOIL ABSORPTION SYSTEM Type of system: Width /., Length 7S Number of A 55 Setback from: House _v Well ,� , _ PAL V0 Vent to fresh air intake _ ja S ELEVATIONS / ' Description of benchmark r a Elevation �. Description of alternate benchmark W --_=1 — b�.�.t� E.t ! 0 8 , _ r Elevation 10 Building Sewer STIW- Inlet ST Outlet ` f PC Bottom Header/Manifold C ZY , $ Top of ST/PC Manhole Cover 9. Distribution Lin-- I Bottom of System Final Grade Date of installation /b /�Wer 't number /� poY3 �_ � k'S State plan number � 9�" Plumber's signature License number 36 76 gs Date 1 4/ Inspector Complete plot plan or NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. MA PLAN VIEW _ S� , INDICATE NORTH ARROW WisconsimDepartment of Commerce PRIVATE SEWAGE SYSTEM Y' Safety and Buildings Division Count ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar�P�urLit,lup.: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. bbtt5i�� P @lpiit o'de slV�p�ie: fJTLg_G1a(il a Town of: State Plan ID No.: CST BM Elev.: 1Ca( Insp. BM Elev.: BM Description ` : I{l(,tfl°ivivl7 Parcel l ft o_:1069 -10 -000 TANK INFORMATION EL VATION DATA A9800074 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic j h r- Benchmark Dosing Aeration Bldg. Sewer Holding St/*Ft Inlet 9/3 � y , a 9 TANK SETBACK INFORMATION St !A Outlet TANKTO P/L WELL BLDG. Air to i ntake ROAD Dt Inlet Air Septic i i NA Dt Bottom Dosing NA Header / Man. $ ,�c� ' 23 -5 Aeration NA Dist. Pipe 9,03 7 Holding Bot. System a 0 ' Old - y ' PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand r _f 'iP_- ii S� r J.r'o 5 Model Number GPM TDH Lift Fri on System TDH Ft ss H ead Forcemain Le th Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS — I rr DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION TypeO Model Number: System: " _ d 1 ff VIA, OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center $ `' Bed/ Trench Edges z/ a % iJ Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 23.10.18.353,NW,SW 1439 S.T.H. "65" 13 127 at Ix, 3 Plan revision required? ❑ Yes eNo Use other side for additional information. / a I I'YWAJ SBD -6710 (R.3/97) Date ns is Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH r r SANITARY PERMIT NUMBER: oI DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # –Attach complete plans (to the county copy only for�he sys 9m, on paper not less than 307 8% x 11 inches in size. !�. � 4 �j/� 1 n ❑ Check if revision to previous application -See reverse side for instructions for completing this applicatioX � STATE PLAN NU BER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. t5 Z2 3 PROP TY OWNER l PROPERTY LOCATION 1C h NW % S4! %4, o?3 T30,N,R 4 r)W PROPERTY B O NER'S MAILING ApDRESS � � LOT # � BLOCK # "!�" r r w CITY, S ZIP CODE PHONE NUMBER SUBDIVISION AME OR CSM NUMBER Ki n I,tj S Yoi7 7/S yd ayM 6;0 44A-. � II. TYPE OF BUILDI : (Check one CITY NEAREST ROAD ) ❑State Owned VILLAGE � G ❑ Public 1 or 2 Fam. Dwelling #� of bedrooms AR L N III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 93. 090- /8 353 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/ a` Was h t 5 ❑ Hotel /Motel 9 El Off ice/Factory 13.R Other: Specify f j IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.1K 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 X Seepage Bed 21 El Mound 30 El SpecifyType 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 1 7, IL 1 S 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.) (Mi//' ch) LEVATION 9� i , � W Feet y Feet VII. TANK CAPACITY Site in aallons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glace Plastic App Tanks Tanks structed Septic Tank Lift Pump TanldSi hon Chamber F1 El I F1 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 Signatur : (N S mps) lMPRSW No.: Business Phone Number: a V�A 1 S 6 - 5 7 7 /S" Pee. Plumber's Address (Street, City, State, Zip Code): ,ex I IX. COUNTY /DEPARTMENT USE ONLY Lj Disapproved Sanitary Permit Fee (Includes Groundwater a e slue I gyj�g Agent Signature (No Stamps) Su rcharge Fee) i Approved El owner Given Initial !' 1 Adverse Det rmination X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber .z p 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. 11. 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 8% 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) r r ! 1 l ` i SAFETY AND BUILDINGS DIVISION 2226 Rose Street N Visconsin La Crosse, WI 54603 Department of Commerce �' Tommy G. Thompson, Governor 23-Mar-98 William J. McCoshen, Secretary POWERS EXCAVATING RICK OHLFS CAL POWERS 1969 185TH AVE NEW RICHMON WI 54017 RICK OHLFS Plan ID 9820434 1439 HWY 65 Municipality of Richmond Inspector: Ken Pertzbom County of St Croix (715) 234 -8074 General Plumbing plans including the following element(s): PIMS The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for compliance with all code requirements. This plan action is subject to no additional conditions. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department. All permits required by the state or local municipality shall be obtained prior to commencement of construction /installation /operation. This project is under the supervision of a state inspector. As inspection concerns arise feel free to contact the state inspector at the number listed. The inspector for this project is listed above. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when making an inquiry or submitting additional information. Sincerely, cl t�_ Herman J. Delfosse Plumbing Plan Reviewer (608) 789 -5535 Wisconsin Depar,.AmenWf Industry, Bureau of Building Water Systems Labor and Hur6an Re0ions GENERAL PLUMBING 201 E. Washington Avenue, Rm 141 Safety and Bu,dirgs D+ ;Sion PLAN APPROVAL APPLICATION P.O. Box 7969, Madison, WI 53707 -7969 608- 266 -3815 FAX 608.267 -0592 NOTE: Appointments for plan review should be made prior to submittal by calling any one of the offices shown at the bottom of this form. INSTRUCTIONS: This form is required with each general plumbing plan submittal. Please complete both sides. E i !on f de ed�n this form, must accompany submittal. Data required in submittal is described on the reverse side of form. W9 V I Plan Review Appointment Date Plan Identification Number ,,II 1. PROJECT INFORMATION (type or print clearly) rL� a S 1 W a � of Submitting Party (PI turned to same) Project Na a •? ' � Oh Na E � r Street & No. Project Location - Street & No. M T& H39 T. H (PS _ City State �r Zip City County lC��tM W Z 5yo 17 Village ❑ OF: 1 To 'l I GhW% C V- O %)IL Telephone No. (include area code) Designer (Plumbing) Telephone No. (Include area code) Q irte �5 /mss � 71 S- :1 y G S ! 2. PLANS FOR: Own Name Telephone No. (Include area code) � %Ck o M4 ,;) New Building ❑ Addition /Remodel Street & No. (current address) ❑ Revision to plumbing plan No. a N S't 4'~ r tom• City 'kale Zip 2a. Fee For Revisions - $60.00 (f106 Fees are pursuant to Wis. Admin. Code, Chapter ILHR 2, and may be subject to change annually. Usk 3. THIS APPLICATION FOR: FEE COMPUTATIONS 4. FEE 1y, ti Check Appropriate Box(es) (See Reverse Side for Additions/Remodeling Fees) SUBMITTED ev ' 3a. ❑ Sanitary Building Sewer Only (no drain and vent) . ............................... Sum of Sanitary Sewer Diameters ......... _ Inches X $20.00 = 4 ❑Sanitary Drain and Vent System ............................ ............................... Sum of Sanitary Sewer Diameters ......... Inches x $35.00 = 4 3c. Sanitary Private Interceptor Main Sewer ................ ............................... Sum of Largest Diameters ..................... Inches x $20.00 = 0 x ;? 3d. ❑ Building Water Service Only (no water distribution system) ................. Sum of Water Service Diameters ........... Inches x $20.00 24 3e. ❑ Building Water Distribution System ........................ ............................... Sum of Water Service Diameters........... _ Inches x $35.00 = 3f_❑ Private Water Main ............................................ ............................... Sum of Water Main Diameters ............... _ Inches x $20.00 = 3Q_ ❑ Building Storm and Clear Water Drain System ...... ............................... Sum of Storm Sewer Diameters............. - Inches x $ 8.00 - 4n. ,ur 3h. ❑ Storm Private Interceptor Main Sewer .................... ............................... Sum of Largest Diameters ..................... _ Inches x $ 8.00 = 4h 3i. ❑ Controlled Roof Drainage System (Does Not Include Conve I uildin Storm Piping) .... ............................... .. ... $60.00 Required = ❑ Reduced Pressure Principle Backflow Preventer ........................ .! �� lumberB Walves ........ ........................... x$11000 - ............. 4. � `• � � ' ... ......... 3k. ❑ Turf Sprinkler System ............................................. ............................... Number of Turf Sprinkler Systems ......... _ x $60.00 .............. _ z 31 Chemical Waste System ( stem * See No Below . SAFt Numliee ofrease Interceptors ............. x $60.00 .............. = i m• ) ........... 1 t umber of Chemical Waste Systems .... _ x $60.00 .............. = 4 �l 3n. ❑Garage Catch Basin * (See Note Below) .............................. .......... �dt}mba3ttif•Gtrt��e Catch Basins ........... _ x $60.00 .............. = 4n # , 111 W` 3o. ❑Oil Interceptor * (See Note Below) ...................... ............................... Number of Oil Interceptors ..................... _ x $60.00 .............. 3D. ❑ Car Wash Interceptor * (See Note Below) ........... ............................... Number of Car Wash Interceptors ......... _ x $60.00 .............. = 4p. ❑ Sanitary Dump Station * (See Note Below) ......... ............................... Number of Sanitary Dump Stations........ _ x $60.00 .............. = 3r. .. ❑ Mobile Home Parks and Campground/Recreational Vehicle Parks ...... 1 -25 Sites $25000 26 -50 Sites $30000 51 -125 Sites $350.00 Over 125 Sites $400.00 3s. ❑ Engineered Plumbing System (Minimum $225.00 - Calculate Fee in Accord with ITEM 8 - See Reverse Side of this Form) ........................ = 4 3t. ❑ Petition for Variance (must be submitted on form SB -8) ....................... $225.00 ............................................................. ............................... = 4 ...................................................... ............................... ....................................................... ............................... SUBTOTAL= 3u. ❑ Priority Review ............................................................................................................... ............................... Enter Same Amount as Subtotal = 4u. * NOTE * No Additional Fee Required If Submitted With Sanitary Drain and Vent System TOTAL FEE (Minimum $60.00) = O D NOTE: Appointments view should be made prior to submittal. You may contact one of the offices listed below. `a Hayward Office LFAX(608) ice Madison Office Shawano Office Waukesha Office 209 West First Street, Hwy 63 treet 201 E. Washington Ave. 1053A E. Green Bay Street 401 Pilot Court, Suite C Rt. 8, Box 8072 I 54603 P.O. Box 7969 P.O. Box 434 Waukesha, Wl 53188 Hayward, WI 54843 785 -9352 Madison, WI 53707 -7969 Shawano, WI 54166.0434 Phone (414) 548 -8606 Phone (715) 634 -4804 5 -9330 Phone (608) 267 -3606 Phone (715) 524 -36 27 :- FAX (414) 548 -8614 F %X (715) 634 -5150 FAX (608) 267 -0592 FAX (715) 524 -3633 - CONTINUED ON REVERSE SIDE - ■■- ■ ' : ''i �■ mommommomm ■ _ - - MEMO w o o l rom : ■ • ; ME■A, �!� iii-I ■ mul ■ ■■ ■ M■ ME ■■■■■ ■ "■M ■ �,, !� ENE �i■ ■■ ■■ i�■■■�■■■i■■■■i■■■■■■ ■�■m■� M■ 1 ■■ ■■ -_ = '!�� • • ■ ■ ■■ ■AIM ■ ■ - r ■■ ■I ■1■■ M IN IN ■ / •. M ■ ■I ■M No IN I ■ ■ UPON ■�. ;■ I , ■ ■ - ME■ ■E■ ■ hilbbiwliiiiillii' " i ■I■ ■ M■ , MMMM ■ ■M ■ ■ ■ MEN 1111■■ III ■■ � � ■viii NOON ■ME■1 il■ M VALLM . �■ ■ ■■I i * ♦ • • ' • i • PAGE OF CrvSS St C. U o.� Z S, S .� f •` c� t�tA Alt Wall An0 ODt►rrollon plp� o^ as � til ►linlmun� Appvovll Vonl Cop t ck ff /lnol Oiid000ro ,t t_✓ ' '�O11C� ) �C . 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Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and C percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 0 at J0 169 -16 APPLICANT INFORMATION - Please print all Information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Pr arty Owner Property Location y © Govt. Lot Aj Uj 114,C&$ 1 /4,S a ' T 3 •r Q ,N,R 18 &o W Prop rty Owner's Mailing Address Lot # I Block# Subd. Name or CS M# ' 10113 N S'tirw N LA WA All City State Zip Code Phone Number Nearest Road R lam� W 5 oc� (� /S`)o�S/b-aY5 cit El 'Rage ,� Town w K New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building Replacement J$ P Describe: Pel M ha� w,�, t. ►Jj&t" e Code derived daily flow !/50 gpd Recommended design loading rate i .S bed, gpd/ft _._ trench, gpd/ft Absorption area required 9'00 bed, ft 2 __7_5_1_) trench, ft Maximum design loading rate .5 bed, gpd/fi trench, gpd/11 Recommended infiltration surface elevation(s) 9 ft (as referred to site plan benchmark) Additional design/site considerations Parent material C - - �* La. UN Flood plain elevation, if applicable N / a ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ® S ❑ U WS ❑ U ®S El �❑ U ❑ S X U EIS g U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 13 / O.1� Io r► rveh k v 3 "• Z o rd o T*A. � -S m Ground �d r d h !, lit elev. ! ' �ft. q 1 Q . /6 Yk LIJ fU O rk-u Y M Depth to limiting factor >_%L Remarks: Boring # G �� r � O'riA.. Al .3 Ih►1 • 5 ' • a Z ,l•d p r � 1 S b r, t.J � rr. . S ; . �o .3 Wk D r It S e m Se. rA 0f' Ground �` ,s �/ s hi 4 Y' _ g eleev. � ; •c� Depth to limiting factor .22Lin. Remarks: CST Name (Please Signat Telephone No. `.513 —E Address nn Date CST Number 14 ( a C? W l-_ 5 -1 01 7 I -- S3/ Rick h1s SOIL DESCRIPTION REPORT PROFEIRTY OWNER Page a of 3 PARCEL I.D.# OA,42 - / o Boring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench a o•�� 51 Y"% t 40 1 rr Y Ground �.S o S Yh 5ft p elgv. Depth to S `� ti S M I r . • limiting factor Remarks: Boring # • 13 Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots P In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; E3 Ground elev. ft. Depth to limiting factor I "' Remarks: Boring # Ground elev. ft. Depth to limiting facgir Remarks: SBDW -8330 (R.,08/95) I / y LJ K _ L � 1 _. .e,�{�._. �i . 4 , OD ek efi 114 _► _ Jng LJ4 -Ahuz 16 1 - I - -- _ -;-_� - - -} -- ._ - _ - - --- 1 -- - WisWg94 Department of Industry SOIL AND SITE EVALUATION REPORT Page of .� labor and Human Relations Division of Safety & Buildings irf accord with ILHR 83.05, Wis. Adm. Code R COUNTY Attach complete site plan on paper not less than 8 1/ 1 6s in si I st include, but not limited to vertical and horizontal reference poin irectiorr and % o scale or PARCEL I.D. # dimensioned, north arrow, and location and dista earelst "{ APPLICANT INFORMATION PLEASE PRI LL INFORMATION. "$ REVIEWED BY DATE PROPERTY OWNER: C "' ` PRO . LOCATION GO 'T 1/4s I 1/4,S T AR e(or V� PROPEfITY OWNER':S MAILING ADDRESS ,r.� BLOC r# SUBD. N E OR CSM # 3 4 II CITY, STATV ZIP CODE PHONE MB R TY ❑ LLAGE ®TOWN NEARE T ROAD ( ) �(] New Construction Use pQ Residential / Number of bedrooms { ] Addition to existing building [ j Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate gpd /0 gpd /ft Absorption area required dD bed, ft trer�h, ft Maximum design loading rate _, gi bed, gpd /ft gpd/ft Recommended infiltration surface elevation(s) S ft (as referred to site plan benchmark) Additional design / site considerations Parent material - Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ®S ❑U W S ❑U ®S ❑U 0 S ❑U ❑S O U ❑S OU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 42 W_zz Ground r elev. ft. , Depth to S 9, limiting ' factor , Remarks: Boring # 2 IS Ground 3 elev. s �� ft. Depth to � limiting fact Remarks: CST Name: Please Print Phone: Address: 4 Signature: / Date: _ CST Number: PROPERTY OWNER , ��f 4 2 SOIL DESCRIPTION REPORT Paged lef PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITrer& z o. . . . . . . . . . ::... Ground , elev. ft. — Depth to limiting factor Remarks: Boring # Ground S elev. 5k1 14 Z/0 ft. Depth to limiting factor , Remarks: Boring # / Ground s elev. o _ 21 ft. Depth to ell limiting factor _ Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) X �oe�J�.0 u�s,�C ✓ i � rso I NIS i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer - RI t C- I © W r S Mailing Address 5 N S 't r r A y M Property Address 65 r o ((Verification required from Planning Department for new construction) City /State A" C cW& , LL) ., C Parcel Identification Number 0:1 (- LEGAL DESCRIPTION Property Location AM %a, W %a, Sec. ° , T 3 0 N -R_Z& W, Town of Subdivision N/LL �U may"'• Lot # WA- Certified Survey Map # _ , Volume . Page # Warranty Deed # 5 / 73 7Z Volume la . Page # �� Spec house O yes I,S( no Lot lines identifiable 11 yes 0 no SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman pl*nber, restrictedplumber 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 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 Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT �! DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. j//j/ S GNATURE OF APPLICANT P DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed - ,� � . 5, . i .b'• T^.. c - � ate.: fi' r - . � ? +�.� xY h � _�.: �.. � �. DOCUMENT NO. I; 1 WARRANTY D UD STAY TN I� s�ACt R( fOR R(COR I�� Y + FORM 2 — laei +<7 1 c _ JMJ Acres: Lnc .---- •-- - -• - -• - - - - -- U. C11� xco,, y 1 .... ..-- •• . ..................• - -... ------------------ ---• -. •.••... : d tlyr �+d _..... ••........_._ JUN 2_ 1994 conveys and warrants _.... RiCtlBra ... . .. ......... .. ................................... -------------- ........ rt 2:15 J """L+ 9 i - Iblydp�11M t ....................... .....- '....._..___.._...... -... __.. ... R[TURN TO .. ..... ........................ .. ............................_.._..................... ._. ..... .._- .......... --- ------- ---------------- ..... the following described real estate in St• CrO1Z County, - State of Wisconsin: MM Tax Parcel No: ................. North Half of Southwest Quarter of Section 23, Township 30 North, Range 18 West, Town Of Richmond, St. Croix County, Wisconsin. .y i! This ------- S - jR' ........ homestead property. (W(is not) Exception to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this ................. �l} ....... day of - --- - -- -M .JKJ Acr , Inc. 1 - -------- --- • --------------------------------- (SEAL) By - • -- -•- -• . ....................... ................ • - .... .. ......... .. --- ---------- (SEAL) By.:- __(SEAL) ' ... • - -.1111.1 7 -- -- ----- �*_ AUTHENTICATION ACSNOWLBDOMBNT Signature (s) .Ja .. ... ................ ..' Cv l k C C b'Y•�- tn L AX'V%7t !�. I........................... -_ STATE OF WISCONSIN --------- County. authenticated this �l t ,f 1�n i Persona3ly came before me this ._._.._ 1 - ' .day of �� -bov --••---------- - ----- --- ------•----..__...._..----•- ••----x.1 ._.. ---- 8 the above named ' a .....].S t7.4�..�$ZaTld... TITLE: MEMBER STATE BAR OF WISCONSIN I (If not, .--•-•--- -------------------- Wis. 3tata.) •...-----•---------• Y • ----- •---••--•-----•---- authorized b . .. . .. .. ................... ........................ -- -- -•-- - -. -. to me known to be the II person ------------ who executed the THIS INSTRUMENT WAS DRAFTED BY foregoing instrument and lcknowledge the same. ________ ______ .......... zs_ tans. Ogla�------------------ ---- - - -- -- -------- - - - - -- - Attorney at Law - .......... .. - --- Notary Public -- -- --- ------ -- ---- -- - -- ---- are not necessary.) County, Wis. (Signatures may be authenticated or acknowledged. Both Yy Commission is Iiermanent.(If not, state expiration j date: Noma o! �I veTaons aigning in any Capacity should be types or printed b.-'or th♦ it signatures. WARRA NTY D8ED STAIR BAR Or WISCONSIN Wisconsin legal Blank Co Ind. FORM No S— Ps82 Mi;*auke Wi , �, � _ e, stonsin