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HomeMy WebLinkAbout032-2008-90-010 � I a o I 4 � I > o2 c N o °a0 N o > oa�3 a a`� N o� �' aa> c� me c o O g N Z 80 ao Eo pp m Z ° LO c .?� 6a) N p O U 'O—n N y N y+ Z'O11 O) N ac )L N N N N f0- .(D N N C y O 4= a) O.- C a m N L LL O ,Q O,q O f` > C O y m Q '> N jU')c >.N Q N cM m D N z E 1 °o z M cn c,, �- z a m � I o z a r � r 2 N N H w (D N N (D U > E a c � U) E m > a� 0 a Z d Z O N L N 4.;C) `6 I c, N n N m N otS y ` m `° 'o o a E h� Nt) N •V mi�'i l' O� fO°q' J� U~y aa°0 on CL m N (D ON N o 0) 0 cli E ° 0 m m Q s O Z°�n ii o 0 m 0 C O ° W W O CD C i I ~ N M E °' M N d N • ' o o c°n Q M O Z '? Y Y Aj 0 s� = E V ` V1 d € o°' = it a L: a CL m .Y m c `N E c`o 3 o A UaZD ocnU o p cn 0 `fl m > y Mi 4 0 o �fe o .o :° `o O N c a•'i iu3c �N c_ a0 00 E_ aL � •N .N f0 O O lC Q L .. y N 7 U rq � w N w a t� o d E ca ? c w � N N� O•D�� � O N Q L 0 CL o cNNn.OMc3 ° w o v '> Q o y. 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CL `y Y O O O - E Q' ` O O d' N N d 7 w N 0) W O M N L L N z .✓ '0 M N o a o v+ E E n CL o 0 0 • o o U Q o z !n Q ao o Z 2 2 H U co I V € a € CL •� L: 0. L: CL CL r`1v o i`a 3 0 3 '+g 0 r A Uaa 0V) u 0 vnv a ao 0 a 4 0 o �� •p er x w E a Rio ry y N O N O N O O $ N C = N Im N •'V fn D � -d .y � V CL CD 4r- Q °Oa, p Eo ND N a N O Op O C o ° y O o t? N x Z . N �a oa2a) Q M V = I N` h O O O O I N z N O) c O Z N O N C U' N O Z a O 0`z�* Co i-- N 0 PD E ° QQ `o m a N O O O • c 0 v V N O 0 2 z z p o Z N .: E z I E = I �� o e ..� -� Its � !, CL � w § 4) CL �� 0333 CL U) T) 000 •ti oo.ao. CL n g � o N N J V y rn rn s p E � o m ° C > W N O ° O U O O Q� a 0 0 O M ° i O Q Q C O O 'O •p N N O O e N 0 0 C N° 7 N ~ m N E o co O fA E E 0 0 • O O O O fn m N O 2 N= 3 -i � (n Vl r m N d � •� a rr`I���i rte+ E ` ' c �1 A c 0(a0 t DECISION OF ZONING BOARD OF ADJUSTMENT ST. CROIX COUNTY, WISCONSIN Case No: 5 -91 Filing Date: 2 -1 -91 Notice Dates: Weeks of Apr. 8 & 15, 1991 (C(Dpy Hearing Date: Apr. 25, 1991 FINDINGS OF FACT Having heard the testimony and considered the evidence presented, the Board find the following facts: 1. The applicant or appellant is: Steve Montbriand Rt. 2 Somerset, WI 54025 2. The applicant or appellant is the owner of the following described property which is the subject of the application or appeal: SW 1/4 of the SW 1/4 of Sec. 2, Town of Somerset, St. Croix Co. 3. The property is presently used for: 4. The applicant or appellant proposes: Re petition for a special exception permit (original permit was rescinded at a special revocation hearing in Dec. of 1990). The request is for tubing on the river, camping and 2 (two) outdoor open air concerts. 5. The applicant or appellant requests: Special exception a. An appeal of the Zoning Administrator's determination. * b. A special exception permit. c. A variance Under section 17.15(6)(m) of the ordinance. 6. The features of the proposed construction and property which relate to the grant or denial of the application or appeal are: The property is located in the close proximity of other recreation commercial tubing operations. It is also located 1 adjacent to properties of residential uses. CONCLUSION OF LAW Based on the above finding of fact the Board concludes that: SPECIAL EXCEPTION - The application for a special exception use permit does qualify under the criteria of Section 17.15(6)(m) of the ordinance because the proposed uses are considered commercial recreation. ORDER AND DETERMINATION The basis of the above finding of fact, conclusions of law and the record in this matter the board orders: VARIANCE /SPECIAL EXCEPTION - The requested special exception is granted subject to the following conditions: 1) Tubing be permitted as a recreation activity. 2) Camping be permitted provided applicant develop a campground plan as per .H78, obtain state approvals, and furnish the County Zoning office a copy of the state approved plans. 3) The campground have a "quiet time" between 10:00 P.M. and 8:00 A.M. where gates are closed for admission. 4) Concerts be allowed 2 (two) times per year provided speakers are turned toward the east toward trees and attendance to restricted to less than 1000 people. Concert hours be permitted between the hours of 10:00 A.M. and 11:00 P.M. 5) The County Zoning office and the town board have access to the property at any time for inspection purposes. 6) Violation of any part of this special exception permit will result in the right to hold a revocation hearing. Motion to by Stephens, seconded by Menter. Motion carried. Vote: Stephens, yes; Menter, yes; Sinclear, abstained; Kinney, yes and Bradley, yes. The Zoning Administrator is directed to issue a zoning permit incorporating these conditions. Any privilege granted by this decision must be exercised within 12 months of the date of this decision by obtaining the necessary building, zoning and other permits for the proposed construction. This period will be extended if this decision is stayed by the order of any court or operation of law. This order may be revoked by the Board after notice and opportunity to be heard for violation of any of the conditions imposed. This decision may be appealed by filing an action in certiori in 2 4 . N the circuit court for this county within 30 days after the date of filing of the decision. The municipality assumes no liability for and make no warranty as to the reliance on this decision if construction is commenced prior to expiration of this 30 day period. ZONING BOARD OF APPEALS/ADJUSTMENT Date • Signed 1 Filed: 5-22-91 Chairpe n cc: Town Clerk and file 3 Y 7 Wisconsin Department of Commerce EM Count AG PRIVATE SEW SYST ? Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 363897 Permit Holder's Name: ❑ City [ ❑ Rown of: State Plan ID No.: ontbriand Steven I Somerset Township CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 032- 2008 -90 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. is M t j , A 1 5- 4,, Benchmark S r6s"D AW4 - 6 ", Alt. BM n Zeoa Bldg. Sewer Holding C° St/ Ht Inlet SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to ir I ntake ROAD Dt Inlet A Septic NA Dt Bottom Dosing NA Header/ Man. n �w ��' �y op `-- NA Dist. Pipe Holdin Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover Model Number GPM TDH Lift Friction Syestem TDH Ft oss Forcemain Length Dia. FFii Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N SETBACK SYSTEM TO P/ L I BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER Model Number: System: 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 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) Inspection #1:0(- /02 / Inspection #2: Location: 710 170th Avenue, Somerset, WI 54025 (NE 1/4 SW 1 4 2 T30N R19W) - 02.30.19.498 1.) Alt BM Description = toy z o - 1�,...QS� T''/' 2.) Bldg sewer length = 9 t�1 Id-- - amount of cover — _ �'�, Z. Plan revision required? ❑ Yes ❑ No Use other side for additional information. OZ Da SBD -6710 (R.3/97) Date Inspector's Signature Cert- No. i ` 0 Safety and Buildings Division Vis cons in SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue P 0 Box 7162 ` Department of Commerce In accord with Comm 83.05, Wis. Adm. Code- Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) for thesystem, on pa per not les§ County than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this applicatidn�.; * �C% tats Sanitary Permit Number �� Personal information you provide may be used for secondary purposes t '! ;_ Chec�reDislon to previods application I [Privacy Law, s- 15.04 (1) (m)). CX1 /'` tat, Plan Review Transaction Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF R N /`` Property Owner Name operty I, t n :5 tie e , - Ft /4 /a, S T jj , N, R If' E (or) Property Owner's Mailing Address '.. LotNurgtier` Block Number 76 f O ___. ' __ r City, State c Zip Code Phone Number Subdivision Name or CSM Number w Q� S ( > — S��n c ,S � S crt II. P BUILDING: (check one) ❑ State Owned ity Nearest Road Ig Public 1 or 2 Family Dwelling - No. of bedrooms W Towge Ill. BUILDING USE (If building type is public, check all that apply) ar Tax Number(s) 30. 1 ❑ Apartment/ Condo Q 2 [ Hall 6 E] Medical Facility/ Nursing H 10 oor Re nal 3 ❑ Campground 7 ❑Merchandise: Sales /Repairs ❑Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. S New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an ______System - _______System __ _____ ____ __ Tank Only_____ ____ - - __ Existing System ___ -____ ExistiggSy tem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 []Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ,Vault Pr'v 14 [] System -In -Fill .mac 0e .dam/ �,.k pt r ,�� . ,�,�, tPr4�►es -to Ioe_' n •S " VI. ABSORPTION SYSTEM INFORMATION: cts �.,,� /. �� 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. erc. R e 6: Sysrrt� v.N"fa Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation Feet Feet Ca acit VII. TANK in allon Total # of Prefab. Site Fiber Exper- INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete strutted Steel glass Plastic App Tanks Tank Septic Tank or Holding Tank Md 4d �. ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) /MPRSW No.: Business Phone Number: c Le O V 7 f Plumber's Address (Street, City, State, Zip Co ): O G k IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued ssuin A nt gna ure (No Stamps) Approved ❑ Surcharge Fee) Owner Given Initial �C /� �� J Adverse Determination J J X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROV iprf i M Vi f W40 -Ki . no- (Z,,( -, S • X'rom a• tZ,�O aol• Ir_ ke SBD -6398 (RA 2/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber l INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a 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 and Buildings Division, 608 - 266 -3151. 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 oe installed. II. type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on 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 for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /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. 4ouoty/ Department Use Only. :K. County /.Department,Use ` Only. - . Complete plans and specifications not smaller than 8 112 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 testdata 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 contamination investigations and establishment of standards. d � \YC' IQT CPO \ � j S� s Q t �I d 7 I Y ��J qa o a J C 7 \\ ISN l.l. MAY -17 -00 WED 01:26 PM NELSEN WEBER SURVEYING,M 1 718 423 6864 P.01 1-= _+.::�, v[�sx/ir�uWaw 11- �S`T�.I.L. U ►`RF1 u.J�" 'l'1"tou1 =� lhaS��.Y t�t�uUF"' R. (e i I Jf 1 iiu DIET 'a �.hN'r�„ f- �A► JVf' � tficE� .:,,,�1�� cc�?- .�:..�_._... I 1 I ' r a { v I r V j sG`l� �,G Svc /(c►p� G�DC„!� dY $fiu7 v q P 7152326601 Apr. 27 2000 W : 34AM P2 4,A7 To et 6 t.�11S 'N ' 36 min �? V 1 � 1 _ c �n 1 Moor Now 1 I 56min 59 ' rnin A. HEALTH RECORD MANAGEMENT SERVICES IMMANUEL -ST. JOSEPH'S HOSPITAL 325 GARDEN BOULEVARD • P.O. BOX 8673 MANKATO, MINNESOTA 56002 • (507) 345 -2697 t, I3op, 14 / >r q Y / __.... ----- I X q v Ll Gr y a )c L, X - << x s l "' s x � X % -' l r . , }t boa F W'� #8 ors a x g x S S x iZ �o► xi.�. �o td Sf �tr si«[ L l s G t It oo ' $crews �, ah� l .s ;,� - DIVISION OF PUBLIC HEALTH 1 WEST WILSON STREET P 0 BOX 2859 Tommy G. Thompson MADISON WI 53701 -2859 Governor State of Wisconsin (808) 288.1251 Joe Leean FAX: (808) 287 -2832 Secretary Department of Health and Family Services www.dhfs.state.wi.us October 4, 1999 Apple River Hideaway Steve Montbriand 712 170TH Ave. SOMERSET WI 54025 Campground Plan Approval - CPG9909 Dear Mr. Montbriand: The Department of Health and Family Services received your application and plans on May 14, 1999 for Apple River Hideaway campground, 712 170th Ave., Somerset, WI. The plans show a campground modification of 175 additional sites. The plans were reviewed for compliance with the requirements of HFS 178, Campgrounds. The department has reviewed the plans and hereby approves those plans with the following conditions: 1. Only 117 of the 175 are approved. 100 sites downstream and farthest from the already developed campground are approved. 17 sites upstream and closest to the dining facility are approved. The 58 sites in and around the developed campground are NOT approved. If in the future you desire to have the 58 sites approved, Department of Commerce will need to give approval to utilize the dump station mound system for additional toilet facilities. A request for a waiver from the dump station will have to be approved from this department. 2. The field sanitarian shall verify that sites are clearly marked, numbered and properly spaced. 3. The field sanitarian shall verify that a water outlet is within 400 feet of all campsites. 4. The field sanitarian shall verify that the toilet facilities are within 400 feet of all campsites. When the campground expansion is completed, contact Walt Burcaw for inspection and increase in sites. This approval does not supercede any town or county requirements. If you have any questions, please feel free to contact me at (608) 266 -9443. Sincer , Douglas Voegeli Evaluation and Training Officer Environmental Sanitation Section Bureau of Environmental Health cc: Walt Burcaw, Western Regional Office, (715) 836 -3944 HOLDING TANK SERVICING CONTRACT Contract Date _ f / 0 This contract is made between the --------- - - --- ----------------------------- / Holding Tank Owner(s) Name(s) and I Pumpers Name i / l ��C �✓ �S� �-h � I We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal descriptions) N.2- w ------------------------------------------ - - - - -- ------------------- 1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement required in Ch. ILHR 83.18(4) (b), Wis. Adm. Code and with the County of _ .57 C e— a lZ 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local governmental unit which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; C. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local govemmental unit and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) I Owners Signature(s) Subscribed and swom to me on this date: 4P /? (i '0, /9 - &/,a �Ta a" t 1-:n C. ,a ` 9ys a ' � �3'a ays Date m e ' � ©����/♦CY/ I✓ /�L��i[�'" /97 �i a� � SrceA ° s I � r Pumper's Name (Print) I Pumper's Signature Pjblic nature Pumper's Registration Number Commission Expiration G Drafted by G y r aq /O Qv �. 5614-G3 VOL 3 Document No. WARRANTY DEED SST. CHOix CTY Frances Hinz, 'JUN 25. 1991, t 9:30 A M convey(s) and warrant(s) to Steven S. H eyste.JNeds r Mont briand and Jo Ann K. Mont briand, , and wife as Ol nt te nants Recording Area Name and Paturn Address David J. Estreen the following described real estate in 304 Locust Street Hudson, WI 54016 St. Croix _ County, State of 032 - 2009 -30;_ 032 - ?09.1 Wisconsin. _ 032-2009 4� Parcel Identification No. (PIN) , a An undivided one -half interest in: That part of the Southwest Quarter (SWIA) of Section 2, Township 30, Range 19, lying Southerly of the Apple River, subject to flowage rights, lying and being in St. Croix County, Wisconsin. Y 1 j This is homestead property. (ie /is not) °tom iZ y da y of y l&n -ems 1997. Dated this Y * * Frances Hinz c. . 4 , AIITHENTICATION ACKNOWLEDGMENT'' .' STATE OF Gliscorisin Si nature (s) S `� _ C authenticated this day of 199 Personally came before me this 2411'1 day_of OF WISCnNSIN .tune 997, the above named -- Frances Hinz s� le erson ? Signature -_ Type or punt name to me knc+/ to the person(s) who executed TITLE: ME1 STATE BAP. the for ing ` umeat- aid- acknowle3ge the cif not, _ S "' David J. Estreen authorized by §5706.06, Wis. Stats.) Type or rint ame: County, WI THIS IN;;RUMENT WAS DRAFTED BY: "nary Public: St. Croix. _ My commission is permanent. (if not, state Same F. Lammers 1835 Northwes Pv °nue expiration date: Stillwater, ,4 55062 _ k s STATE BAR OF WISCON +IN FORM 3 - 1982 561464 U>, D cc 1 DOCUMENT NO. Y�` QA�C1 F 'TERS O; n "F 3 �5� S CRONCTY,V4 Firstar Bank of Minnesota, N.A. f /k /a w. First National Bank of Stillwater i _ 1991, sl quit- claims to _51 -yen S Montbriand and s JoAnn Mo husband and wife _ _ 9:30 A r Fiuyiste. wt Dead9 the following described teal estate in St. Croix County. State of Wisconsin: `.• THIS SPACE RESERVED FOR RECORDING DATA Property Address 710 — 170th Avenue NAME AND RETURN aJDRESS 2 Somerset, HI 54025 4 David J. Estreen Legal Description: Hudson, WI 54016 54016 It That part of the SW1 /4 Sec. 2— T30N —R19W lying ,-, SouthErly of the Apple River to P CEL IDE 1 NTTIYFICAT ON NUMBER 032- 2009 -10 y. 032- 2009 -40 032- 2008 -90 ,a FEE EXE Fs t o A 1 This is not homestead property. )OSX (is not) i.; Dated this 24th day of June 19 97 _ r" " Firsta>� k f Minnesota,'N.A. H (SEAL) (SEAL) _ � s .. dentT t (SEAL) (SEAL) P ' AUTHENTICATION ACKNOWLEDGMENT ` State of Wisconsin, se't Signature(s) "y St. Croix �%X count 'Jrb fi --c- authenticated this day of — 19_ Personally cam_ before me phis � >^� � " y of June 19 trle above ri ed — J ason S. el emoe *Assistant u'de` j ' Pie d t for Firsta'r MAW* TITLE: E'. TITLE: MEMBER STATE BAR OF WISCONSIN �— (If not, -- — authorized by §706.06, Wis. Stats) to n µ to be the person who executed the foregoing ins n an same. , THIS INSTTRRUMENT 'NAS DRAFTED BY 4 Fi t r tra j .r rs a e n o of Minnesota, N.A. David J Fez Lowry Avenue N.E. , Minneapolis, MN 55418 Nc.ary Public, St Croix County, Wis. y (Signatures may be authenticated or acknowle-Jged. Both are not My commission is permanent. (1f not, state expiration date necessary) ' Name> of persons stgni •g in any capacity sh, ld by typed v pnnted below the signatures. STATE BAR OF WISCONSIN Wsconsln Legal Blank Co.. Inc QUIT CLAIM DEED Ferm No. 3 - 1982 Milwaukee. Wis. 10 � 1 S tate of Wisconsin AR ME HEALTH AND SOCIAL SERVICES F tJ DIVISION OF HEALTH c ✓�. Fiji MAIL ADDRESS: July 12, 1991 �` �O 1 WEST WILSON STREET P. <b Cn �� 1 99! ~ MADISON, WI 53701-0309 0 S? 41 Steven & JoAnn Montbriand 5 inr 712 170th Avenue ONAA/Di SOMERSET WI 54025 COQ Dear Operators: P = The Environmental Sanitation and Milk Certification Section of the Bureau of Environmental Health has examined the submitted plans and specifications for the proposed campground to be called Apple River Hide Away, located at Somerset, St. Croix County, Wisconsin. The submitted plans show 100 sites located on an area of approximately 35 acres. The sites are intended for tent camping only. T:. ��U a� gd- for -dent The toilet requirements are complied with by means of 3 privies located within $00 feet of camp sites. Water is supplied by means of a single galvanized riser pipe located between the concession stand and the stage. The flush toilets, lavatories and showers are intended to serve the tube ride operation which is separate form the camping operation. If over 30 RV units with holding tanks are accommodated, a sanitary dumping station would be required. The examination of the submitted plans and documentation indicate that the applicable requirements of Chapter HSS 178, Wisconsin Administrative Code, will be complied with. Therefore, the plans are approved as submitted. When the proposed campground is completed, a sanitarian from the department, or its agent, will inspect it to determine if the installation complies with Chapter HSS 178, Wisconsin Administrative Code, before it can be licensed. Sincerely, Charles A. Boettcher, R.S. Evaluation Officer �� cc: Western Regional Office i PFROVEP - 7 1z�gj p t PP (tarp r 2, o^ a 'r •- i A'AIK o a , Vi F-5 D ° Y' o? r A �i _ W o . �a a z < t O 'ti 1 • �Yl a O - OP+'� a T a� A \ - a V - r . JJ . - # ,�" < E' � '�' i .y �'� _' � �i'r fi r S �`. x T� � ^ x- x V -4`JRm .j���X i'�S� ;�fe ;T ,. Y -�• s i '. '�, ;. - ♦ ..f ' � } \.�' '� ',I' r j �.? > " �f a Pit w ol Wi a CAMPGROUND PLAN APPROVAL APPLICATION (See Chapter HSS 178, Campgrounds) Submit plans to: Bureau of Environmental Health, P. 0. Box 309, Madison, WI 53701 Owner's Name: Address: �� �- / �� - , yylpVS�� �� Zip Code: / (City) (State) Name of Campground: l`f- ���.a- (I(�1JzV r'cif. -e -W,C) Location of Campground and Mailing Address: - Vp X C() u. -- (County) Zip Code: New installation 1 4 Modification only[ --- 1 Utilities: Public= Private Q Number of acres occupied by camp sites: S ;k. Total number of camp sites (including tents): Number of sites with sewerage connections: Number of sites designated for R.V. units with holding tanks: hnita- Number of toilet facilities (total): For Males Stools Urinals Lavatories Showers For Females Stools _ Lavatories Showers Number of privies Number of flush toilets Sanitary dumping station ❑Yes PRO Number of Locate the following on the submitted drawing - Garbage and refuse containers - fire extinguishers - toilet stru'c-tu�res._ - Internal streets with dimensions - sanitary dumping stations - Wells - water outlets - water piping - sewage disposal field - Sewerage system(s) Show the following on the submitted drawing - Designated sites - distance between recreational units - aetbackfrom, streets, highways or parking areas - surface water - slopes and runoff areas - � Department of Industry, Labor & Human Relations (DILHR) c. l cs S -c Submit documented proof of DILHR approval for the sewerage system(s) and the water distribution system(s). Department of Natural Resources (DNR) Name of Wisconsin registered well driller and pump installer. �..� w; ►� �c,.f Sfo f i WL Submit a campy of the last laboratory analysis of the water supply. Y O / `J Signed: 0� Date: l6 - 0 0 1 t � � a v J.. - ` U C _ S � l �� MiLK O C£ TNSECTION cl cz� ! 1 ���tJ r k a v �i, Y r • Ji 4(- C 5? �c �S1 ✓vim �14.� �Cl�� cc����S l a, 3 . — rL I r c V • 6 - arc. 6 C / ��� S oG� WL S -3 D L ct G l Z -e 1�4- G L(V j c« s /I/ d c� ct v 4 le cl 6 i (mot/ V C71LHR SANITARY PERMIT APPLICATION COUNTY, In accord with ILHR 83.05, Wis. Adm. Code ; v STATE SANITARY PERMIT # –Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ check it revision top vious application —S reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION – PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION t ' /4`,;_c�l /a, S T =r N, R yl for) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF UILDING: Check one CITY NEAREST ROAD ( ) State Owned ❑ VJLLAGE :�- r!_ Public ❑ 1 or 2 Fam. Dwelling —# Of bedrooms PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line 8 if applicable) A) 1. 2New 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 Distributio t1 o `� Other 11 ❑ Seepage Bed 21 El Mound u FC 11 Specify T e `1 41 F Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground – 19Y 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 Vault Privy 14 ❑ System -In -Fill ROR�AENTAL SAM & VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 14AOADINGRATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION --- Fee -Feet VII. TANK CAPACIT Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New istin Gallons Tanks Concrete glass App. /;: . Tanks I Tanks structed S nk i ? -- Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: /" Plumber's Address (Street, City, State, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination 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 OF INDUSTRY SAFETY & D F _PARTM�NT B UILDING INSPECTION REPORT FOR P. LAB B OX 7969 DIVISION HUMAN RELATIONS ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION P.O. B MADISON, WI 53707 State Plan I.D. Number: SW4, SW Sec . 2 , T30 -R19 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Somerset ❑ Holding Tank ❑ In- Ground Pressure ❑Mou 17nth Ave. NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV: Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: N/A I N/A Croix 14Q0S8 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: j0F INLET ELEV: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: IDYES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER ROAD: PROPE RTY WELL: BUILDING: VENTTO FRESH ALARM: FEET FR LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEARES# DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: P PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑ NO 1 ❑ YES ❑ NO I ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST --- 1► SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N0. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST �► MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO 1 ❑ YES ❑ NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO j ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: I GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL:j NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST --► 2 � Lev d",c4_j:! . Re in in county file for audit. Sketch System on Reverse Side. \ ATURE: TITLE: SBD -6710 (R. 06/88) S -� SANITARY PERMIT APPLICATION - aDtLHR In accord with ILHR 83.05, Wis. Adm. Code c::;� u . STATE SANITARY PERMIT # –Attach complete plans (to the county copy only) for the system, on paper not less than / <-,( ga2k 8% x 11 inches in size. co if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION – PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION - ev - r :!�, (j Y. SLc)' /4, S a T N, R Q ;for) W PROPERTY OWNER'S MAILLNG ADDRESS LOT # BLOCK 1 - 710 7 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF ILDING: Check one) CITY NEAREST ROAD „c0 A P ( State Owned GE � 56r �1lLVti Public 1 or 2 Fam. Dwelling -# of bedrooms _ PARCE TAX NUMBER Ill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo o e- 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 E5 Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF RMIT: (Check only one in line A. Check line B if applicable) A) 1. 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Privy 13 ❑ Seepage Pit Pressure 43 Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ASSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 1 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION --f eet VII. TANK CAPACITY Site in o allons Total ## of Prefab. Fiber- Exper. INFORMAT New Existing Gallons Tanks Manufacturer's Name C on cret Con- Steel glass Plastic App Tanks Tanks structed ,ZfA Lift Pump Tank/Siphon Chamber El 1 0 El Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): l �sSlgnature: (No Stamps) MP /MPRSW N .: Business Phone Number: Plumber's Address (Street, City, State, Z p Code): 71 0 IX. COUNTY /DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing A nt Signature No Stam Approved El owner Fee) owner Given Initial Adverse Determinat X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: i SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber I INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608- 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number w ;th 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'h 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; «ater 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 eleva icn reference points; C) complete specifications for pumps and controls; dose volume; elevation differ>nces; 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 , I APPLICATION FOR GANI PERMIT • 9TC -100 This oppllcstlon form Is to bt conpintod In full and tlgned by thtt ovnet(s) of the prop being developed luny lnndoquaclea will only result In delays of the p:lmlt Issuance. •Should thus development be Intended for reealt by ovner /contractor,(spec houoe), thou s second form should be tetalned and completed vhan t1)a property is mold and submitted to thIa office vIth the appropriate deed recotdlnq. Ownsr at property _.. - LeJ/" 6, ?Mon - jyt`4, c Location o[ property - ,—_ 1/4 "5w 1 /I Sectlon 1'V T o vn s h l p I e r T Hall)nq addremrt d / 7 6 tL v SeAar CAD/. 5W.23'" r Address of site 5oz ,e. lubdlvlston no" Lot number A A ,,/I Ptarlour ovnar of pcopttty _Era, 1C fi; n� •• Total slse of peccel --LO'S' A. '/ r Date parcel vas created - 0,001_„ _19g"'t — Ara all corners and lot llnea ldentlflablal „_______,Yea ✓ N o Is this pro petty belnq developed for remala (spec house)? an ✓ xo Yoinr.r 7 and Page Humber � as recotdod with the 114912ter of Deeds. -- - - - - -- --------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION Tiffs FOLLOWIHCt A vAARXXTI DVID which Includes a DOCUMSHT HUHnIR, VOLUHtt XXD PA02 yumlIR, 4n4 the SVKL Or TIM 1190I0TER Of DBRD5. In addition, a certified survey, If available, would be helpful so an to avold delays of the tovievinq process. if the deed description tolerances to a Cattlfltd Survey Nap, the Cattlflad Survey Hap shall alto be required. -------------------------------------------- PROPERTY 01RIER CERTIFICATION t(ve) cettlty that all statements on this form ate true to the best of my (out) anovledgcl that I (we) am (are) the owner(s) of the property deacrlbtd thIa In tot mat 10n form, by virtue of a Warrant decd re the County Reglster of Deeds 'Re Document NO, � In A 01 10 PtesentIy own the co r corded In the Offic of 1 and that I (v,) p posed alto for tho sewage disposal system (or I (we) have obtelntd an easement to tun with the above daacrIbad property, for th conettuctlon of Held nyatem, and the same time been duly recorded In the Otllce of he Caynty Aeglatec of Daadm as Document Ho. r )• al9nstuts o Ownoc slgnatuta of Co -owner (If Applicable) Date of slynatute Date of signature `' `` ' � �. ,.::, � 'r � ,, � � ,� � k �: �_ �,: �r '�` �, w� � ,� .. �. � � ,� .. .. ... ;:1, ,,�,.. q ;�°' �f #? �" �A�i'S' � 3 �' \' +. ~ k � t 4 N:` -------- .... � C V u d a � a a v z - O m C �° � 3 2 vl d f• O G 'E u > > o o z c c 3 d O o 3 > v m V n v o o A A a fl. C C 'b L C Cc U t O C d C N , /� Z p U 2 a u Q � ^°' o c t � F 3 r c J w X b 0 c w o h O Q. 0 S LL. f 3 s E Z I °> W ; 3 o Y A ♦ � a Z = a = a f V O} W 7 O Q 0 J z y c O C h 7 z o a �� 3 3 3 Z x 0 0 O: a u, ° / r 1— W¢ cc co ( 7` d J o E c ' > m } m It E H v z x W o ul F- O c u o i E a v¢ z Q � a ° C y1 W L. z O I S m a 0 O O Y O 0 ° ° 3 ° o > v U 1�-` c v c v a lu ° c r E c n c � Z Z, .3 � 'ie v w �° y d •• G L p N O D C 1 O .ry C V v C ^ N e� " 00 � Z d m Z \ c o Z O 2 3 c D O _ M a N a O c o 3 aCi y cn h0 N It LL tr O o OJ 3 7' s H H° H 5 H H Q J 6' 6' + ORAB BAR TORST PAPER D O O' Y 000R woe — oaoR o TOILET STOOL (3 THUS) ' I r/ Q EANOUT r• CLEANOUT S'6 VENT 5'0 VENT �. r O' W Y —r H m W DOOR AND CENTER W WALL 2' -4 WIDE MEN >; O D WOMEN 4' CONCRETE SLAB W/ 4 CONCRETE SLAG W/ 6x6— W1.4011.4 W.W.F. 6a6— WIA.M.4 W.W.F. These buildings are handicap accessable and can meet DNR specifications. With no wood floors or walls to rot, this building is a maintainence mans dreams. If cleaning is required, the building can be hosed down with water or disinfectant. The buildings are very resistant to vandalism. The stools are made of durable plastic and will not dent. The door and frame are constructed of steel. After completion the building is painted inside and outside. 11 µ i aP 4 i i i • Bug screens are installed and • The inside of the building is • This unit can be done as a then the roof is constructed of finished off which includes in- two seat or one seat unit. A 2 "x6' lumber. A ventilator stallation of grab bars, stools, concrete roof can be added draws air from both pits. and stalls. also. When looking at the long -term maintainence cost of this building, you can see what a value it would be. We can also manufacture a secure utility /storage structure. This building would be ideal for storage of flamable or hazardous liquids and materials. For more information contact: XL 2 � P V ,, HUFFCUT CONCRETE 0 0 737 Herbert Street Z0 Chippewa Falls, Wisconsin 54729 �TF ASS (715) 723 -7446 Huffcutt Concrete is a member of the National Precast Concrete Association and Wisconsin Precast Concrete Association. John Olson, President - Steve Olson, Plant Manager ' i �1 O i �s� � i Form - S T C - 104 x AS BUILT SANITARY SYSTEM REPORT OWNER o�7 fl��n �'1�'Ipr TOWNSHI g SEC. °? T 3 O N -R L S W ADDRESS �,'� eA� Z ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT �1�- LOT SIZE So PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM `v v e 0 17-00 I�0 1 1 �a`IC 4 G b INDICATE NOR'SH ARROW BENCHMARK: Describe the vertical reference point used 4212 Elevation of vertical reference point: 10 Proposed slope at site: O - 2 SEPTIC TANK: Manufacturer: �� S Liquid Capacity: Zo e Number of rings used: o Tank manhole cover elevation: O �( r Tank Inlet Elevation: Tank Outlet Elevation: f� 3 Number of feet from nearest Road: Front,0 Side, Rear, O 1900 feet t From nearest property line Front 1 0 Side, Rear, 0 ` feet Number of feet from: well 0 , building: (Include this information of the above plot plan)( 2 refe ence dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: JA Liquid Capacity: 80c %V I Pump Model: A.. Pump /Siphon Manufacturer: A)6 4, Pump SizeI �0 Elevation of inlet: cc f ' 3 ` G � r Bottom of tank elevation:_ f� — Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: 1 1A� 4t E4 Alarm Switch Type: Number of feet from nearest property line: Front, O Side, Rear, 0 Ft, i Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: '�� Trench: Width: ` Length: ^ ye Number of Lines: 2 Area Built: 200 en Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear,0 Ft, Number of feet from well: Number of feet from building: A)IA-- (Include distances on plot plan). w SEEPAGE PIT Size: umber of pits: Diameter: L7drop Bottom of seepage pit elevation: A Has eior distribution box O been used on any o f the above soil absorb ck one). HOLDING TANK Manufacturer: Capacity: Number of ring used: Elevation of bottom of tank: Elevation inlet: Number f feet from nearest property line: Front, O 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: _1 • p��- (o Plumber on jo License Number: 3/84:mj DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7"t69 BUREAU OF PLUMBING MADISON,�111 53707 ❑CONVENTIONAL 0ALTERNATIVE [ronSSW7 tate Plan I.D. Number: El Holding Tank ❑ In- Ground Pressure RPMouncl 0 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INS CTION DATE: Steven Montbriand Rt. 2, Somerset, WI 54025 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CEV.: NE SW Section 2 T30N -R19W Town of Somerset Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: l Gary Steel 3254 St. Croix 884 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LA L LOCKING COVER 9Q 3 PROVIDED: PROVIDED: Upon 17-. 0 () qq $ I 9 9 S WYES ❑NO ❑YES ENNO BEDDING: VENT DIA.: VENT MATL.: HIGH WA R NUMBER OF ROAD: ] PROPERTY WELL: BUILDING: VENT TO FRESH ALARM. O Ni OM AIR 1_N_LET: FEET FR OYES MNO DYES NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER Q, PROVIDED: PROVIDED: �"�QiO ❑YES ®NO v 0O3 L) L 1-10 'J YES ONO YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING NT TO FRESH © LINE AIR IN ET (DIFFERENCE BETWEEN I :� S FEET FROM Z Z PUMP ON AND OFF) I 1p YES NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING FORC or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN O �v the soil is dry enough to continue.) CONVENTIONAL SYSTEM: LIQUI BED /TRENCH WIDTH LENGTH TRENCHES: DISTR. PIPE SPACING MATERIAL: PIT NSIUE DIA SPITS \ DEPTH DIMENSIONS - GRAVEL DEPTH FILL DEPTH UISTR. PIPE DISTR. PIPE DISTR. PJP� MATERIAL: NO. DISTR PR . NUMBER OF OPERTY WELL BUI LDING. I V NT TO FRESH BELOW PIPES: ABOVE CO VER. ELE V. INLET ELE V. END: _ PIPES. FEET FROM LINE AIR INLET. NEAREST - -► MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ONO SOIL COVER TEXTURE: PERMANENT MARKERS OBSERVATION WELLS l�./✓p� YES ONO LJY ONO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED SEEDED I MULCHED ILC CENTER: / EDGES. LEI YES NO /' .5 •• a 15 DYES MNO � YE$ ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH. LATERAL SPACING GRAVEL DEP7H BELOW PIPE. FILL DEPTH ABOVE COVER TRENC . BED /TRENCH / , + TRENCHES: DIMENSIONS MANIFOLD PUM MANIFOLD DISTR. PIP ;MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING E LEY.. EL IA.'. ELEy� PIPES/ DIA./ ELEVATION AND C ( ' ' J � l \ DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED /1 C PLANS 3 YES ONO I YES 0 N COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY W + �� ,t �� EET FROM LINE L�K Y ES ❑NO YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE DILHR SBD 6710 (R. 01/82) ��/ DIL R SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code 4. STATE SANITARY PERMIT 9 .9 —Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. 6 Q s S --See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION FOR VARIANCE ❑ YES ® NO PROPE TY OWNER PROPERTY LOCATION e n IV if 1 /6 U) '/d, S� T 3D, N, R � j )I ,(or) W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER B SUBDIVISI N NAME , z. ! 94Y, STATE ZIP CODE PHONE NUMBER CITY : NEAREST ROAD, LAKE OR LANDMARK 25 5 _3 ❑ VILLAGE : . La TOWN e4— 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR 29- Public (Specify): 111. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. 6 I *Iew b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit ## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner /building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in ##1 and only one in #2) 1. a. ❑Conventional b.'4 ? Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. K Mound I. ❑ IGP In -Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. 64 Bed b. ❑ seepage Trench c. ❑ seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): -3A 2198 Z e� `06 Feet L.Private ❑ Joint ❑ Public VI. TANK CAPACITY Site in aal lons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank ✓ ZDO 1 $ Lift Pump Tank/Siphon Chamber VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. PI ber's Name (Print): i Plum s gnature: ( o St ps) /MPRSW No.: Business Phone Number: 3 S 4-6— 4- 24 v Plumber's A dress (Street, City, St ,Zip Name of Designer: tY Vlll. SOIL TEST INFORMATION Certifi oil Tester (CST) Name CST # Imo.. ( enk C 's ADDRESS (Strebt, City, State, Zi qllsf de) (� Phone Number: IX. COUNTYIDEPARTMENT USE ONL ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signatu (No Stamps) Approved ❑ Owner Given Initial rcharge Fee Adverse Determination ; o Y X. COMMENTS /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber I INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed . if there is a change in your building plans, system location, estimated wastewater flow (number` of bed- rooms ' etc.), depth of system, or type of system;, 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licens - od ` { pumper whenever necessary, usually every 2 to 3 years; 6. if you have questions concerning your privat_ sewage systern, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description where the system is to be installed; 11 Type of building or use served: If public is checked, indicate type of use 'i.e 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; HI. Purpose of application: Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in #1 -6; Vl. Tank information: Fill in the capacity of every new and /or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate refab or site constructed n p a d tank material. Complete for all septic, lift /siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number address, a nd p hone number. IX. County /Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. 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; dosing or pumping chambers; 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. ----------------------------------------------------------------------------------------------------------- ------------------------------------------------ GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is mere " commonly known as the groundwater protection law. This change in statutes was :! -e result of over-2 years of steady negotiation and public debate. The groundwater bii Ground Ater -- included the creation of surcharges (fees) for a number of regulated practices which Wiseor'jsih can effect groundwater. The surcharge took effect on July 1, 1984 Ali of the water °hat buried tr a 't1CB' a is used in your building is returned tc the groundwater through your soiI �abso.rpt or; a system or the disposal site used by your holding tank pumper. 0 `he rrror,ies {collected through these surcharges are credited to the groundwater �ur adminis- tereO. by :fie Department of Natural Resources. These funds are used for monitor ':c ground- t ,I groundwater contamination investigations and establishment of standards. - !oindwater, ?'s worth protecting. :SD -6398 (R.03/86) I cb I f id I � G V r ` i B � AG ol 19 0 N� t ` ENS o s�o�' • aF eo N °E� do' 1 1 $ OD pix V% h Ay^b Gyp 60 /. �a S p-� ►e id pips- x+3 �, 90060.1. 1 60 A erF-s � � �' J r � �s �. T� r4-P `�4"Y` s � ri vs PA-ei j s s4i n ereral c not Orlude Plans for the B Iding r al dc�� Ft , Yi�ing to the sePtic " lane rs rpp ur e`r Those P elk. tmusi he sr;hr;.."< -r.� and ePP Page _ Of Straw, Marsh Hay, Or Synthetic 'Covering Distribution Pipe Medium Sand G Topsoil F 3 J 1 E C P� ^� pe n, (9 �' , ed Of N 2 %2 Force Main Plowed lip'''" " -_ _ , ��►�.��ote Layer V11) D � _ Ft. �NO SPF�� 0t ?N o % l \ON �� ESection Of A Mound System Usin E .�� Ft G 0FtR A Bed For The Absorption Area F , 7$ Ft. u'" SEE G / Ft. A o , Ft. H 1, S Ft. Signed: B Ft. a License Number: VN w 3a K _ l o Ft. Date: i-1 g ro L (D B Ft. j ._ Ft. I, Ft. W,;M Ft ., . L Observation Pipe g K �•- -- --------------- +--------------- - - - - -- 1 Force Main Distribution Bed Of Pipe Aggregate RECEIVED. • i Observation Pipe Permanent Markers SEP l PLUMBING BU 9� 1053W Pion View Of Mound Using A Bed For The Absorption Area Page _ Of Perforated Pipe Detail �0 End View )Perforated End Cop PVC Pipe � e Holes Located On Bottom, M 1! c e Eauo y foo ed PLUMB pptjove � i e i 4 RELATION LABOR AND JAUMI OF INDUS TRY BUI LDING k'- DEPARSMENT 1VISION OF SAf TY AND CE Loa Hobe should Be CORRESPO Nest To End Cop Distribution Pipe Layout P . Ft. s .3 X 3<o Inches Y -3 (�- Inches ✓ Sign �d — Hole Diameter ( Inch � Lateral Ya Inch(es) License Number: l 0 ?� /2.S��asf Manifold _ , Inches Date: „j -�/ D r 8 Force Main a Inches # of holes /pi pe, _ Invert Elevation of Laterals Ft. S�Q 1 wR�P�1 Ci 1 9 q7 Q PAC.,* OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VEAIT CAP 4 VEMT PIPC WEATHER PROOF APPROVED LOCKING JUAIGTIOAI SOX MAWHOLE COVER ?' L5' FROM DOOR. LD1'{"H W�rlts I.Mbil a WIIJOOW OR rRC3H AIR IA m iTAKE � D Sdfe d �t�� GRADE 4 MIN. i I MIN. COWDUIT - 10'I'11A1. � ---- - - - = -- IAILET 4 \� ROV ( - - -- W APPROVED JOINT A °'� ��� ( I I APPROVED JOINTS W /C.t. PIPE p �0���0 ( II W�C.I. PIPE EXTEWDIIJG 3' 4 0 0 I I I ALARM ON OUI S � P� ( ONTO SOLID S OIL OWTO SOLID SOIL, S 04 fJF Q p� p I I O LZ. C F GO��� ELEV. FT. OF,e I/' S �� PUMP -� - -� OF► CONCRETE BLOCK 4 1 9 yl • RISER EXIT PERMITTED OULU IF TAUK MAIJUPACTURER HAS SUCH APPROVAL ' AU 2 SEPTIC SPECIFI'CAT 3 KS MAUUFACTURER: (.4��E 4�� 1 -,rt e IJUMBER OF DOSES: TANK SIZE: AO GALLOIJS DOSE VOLUME p� ZS A LARM MAWJFACTURER: ��'� r� �^�` IMCLUOIMCP 6ACKFLOW: 7 &ASLONS MODEL UWAliCR: CAPACITIES: A= d � Imc!019116R Cats OR ' 7 GALLOIJS SWITCH TIJPE: ' d s GALLOLIS PUMP MAIJUFACTURCR: ���'�"� ` G �,k.tIJCNEi OR CALLOUS MODEL HUMMER: D. _)2- - INCHES OR -2 A 7 • GALLOUG SWITCH T>rP[S rn� `� COTE; PUMP AWD ALARM ARE TO BE MIIJIMUM DISCHARGE RATE - a�GPlr1 //IUS��TALLED OW SEPARATE CIRCUITS DIFFE&CUCi OETWEEU PUMP OFF AIJO 013TRIbUTIOIJ PIPE. FEET ♦ MIIJIMUM METWOKK SUPPL Z- •5 FEET ♦ S ; ?, P X FEET O F iORCC MAIM X , n FIRI CTIOU PAC►OR. .j4$12- IsEET P X R I x 0 s 1c�� FEET .?3 1 '' I TOTAL Dy1JAMIC HEAD : INTERAJAL OIMEW IOW! Of TANK: LEkJ&TH ;WIDTH ...•. ;LIQUID DEPTH 8161�iE0 L E LWMdERt 12 DATE: 7/ PRIVATE SEWAGE SYSTEMS W ATN DIL.HR itiWtEAtJQIfrpLtJMl/Nia . , • so+ L wsn Awnu.. �w u11 PLAN APPROVAL APPLICATION P.O. ftfet », M.dtsoe, tin Gres so0406-MO INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are receive. 1'he back side of this form describes required plan Information. Plumbing codes can be purchased from the Department of Adntlnk*atlan, Document Sales, 202 South Thomton Ave., P.O. Box 7840, Madison, Wisconsin 53707, Telephone (608) 286.3358. 1. PROJECT DFORMATION (f W* or pint dearly) Rev ision To Plan Number. fN e= 5 Name of Submitting Party (Plans return to same) Jett Nams fro WAd No. or R No. or Legal De Route Project Location - Street & scription & W h apf 6Y W y t3o C!ty o► !lags Sta Zip city County ,j I;� Village OF:. / w -• (i W i S f 7 Town S� 17� ri `M' • Telephone No. (Mdude area code) Designer Telephone No. (Include area code) Owners Name Telephone No, (Include am cods) Street & No. Street & No. rliege State Zip ity o Vfllaga Stab ZIP M r , 2. APPLICATION FOR: ew Mound System (3a) Groundwater Monitorinig (7) Conventional SystemwPublic Building (1) U Replacement Mound (4a) Holding Tank (2) Replacement Pressurized System (4b) System in fill (1) Petition For Variance (6) ❑ New Pressurized System (3b) System in Flood Fringe (1) Other Alternatives (5) 3. FEE COMPUTATIONS (Include existing tanksj 4. FEE SUBMITTED FOR OFFICE USE MAKE ALL CHECKS PAYABLE TO DILHR .. 3a. 750- 1,500 gallon septic tank - 50.00 4a. •S D• a e 3b. 1,501- 2,500 gallon septic tank - 60.00 4b. 3c. 2,501. 5,000 gallon septic tank - 80.00 4c. 3d. 5,001- 9,000 gallon septic tank - 100.00 4d. 3e- 0,001.15,00.0,gallon septic tank - 150.00 4e. 3f. Over 15,000 gallon septic tank -250.00 4f. 39 500- 1,000 gallon dose chamber - 30.00 4g. 3h. 1,001, -, 2,000 gallop dose chamber - 50.00 4h. 31. 2,001- 4,000 gallon dose chamber - 70.00 41. 31. 4,001- 8,000 gallon dose chamber - 90.00 4j. 3k.' 8,001= 12,000'galion dose chamber - 110.00 4k. 31. Over 12,000 gallon dose chamber - 150.00 41. 3m. 500 - 5,004gailon holding tank - 30.00 4m. _ 3n. 5,001 - 10,000 gallon holding tank - 55.00 4n. 3o. Over 10,000 gallon holding tank - 100.00 4o. 3p, Revisions - 20.00 4p. - -- 3q Groundwater Monitoring Per Lot - 32.00 4q. , OO (other than a proposed subdivision) Subtotal 3r. Priority plan review: walk through 4r. Submittal of plans In person, + b y appointment, with double-fee 3s. Petition for variance Setback - 25.00 4s. - Site evaluation - 50.00 Total Fee An, fib i" i l , s r MM- pow ptrsuaM b Wis. Adm. Code. Chaplsr VA et shay be sweat b ahanee OwA ty -OVER SOD41740 (R. evaa) OWN" Jaly 1.1lM tn - STATE OF WISCONSIN - DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING P.O. BOX 7969 - MADISON, WI, 53707 APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM Location: Township/it I 1 3!C}L7C NE h I SW 'k S 2 IT 30 N/R 19 10 Somerset St. Croix Street Add ress: Subdivision: County: Landowners Name:, Mailing Address: Steven Montbriand Rt. 2, Somerset, WI 54025 I (We), the undersigned, hereby make application for an alternative system on = e abaYe�tte�scribed- premises. -1 i ecognize•--that the above promises e'Tnot suited for o''conventional private sewage system. If approval ` is granted, I Fr` rr agree to have the system installed in conformance with the BurAn plans and specifications. rr further understand that an alternative system is more complex in nature .than: a' conventional private sewage system and as such will require detailed Inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged with administering county sanitary ordinances and Bureau employes or other authorized persons to have access to the above described premises at any reasonable time for the purpose of inspection the construction of or monitoring of the system. I further agree - to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system. I understand that this application does not permit me (the applicant) or my r r; agent (the contractor) to begin installation. If the system is approved. the Bureau will send the applicant a letter of approval which authorizes construction of the alternative system after all necessary permits have-been obtained. I agree to give notice to any subsequent buyer that an application for an alternative system has been made and if installed, that the premises are served by an and- further - agree to give- - the buyer a copy of this application. The Bur *suaoeepts this application subject to this understanding and subject to all the , conditions and obligations s -get out in this application. ignature of Applicant , Dat pe - STAT&OF WISCONSIN` � .����. Subscribed and ;sworn tq "'aefore me Coati OP f1S a1 t E This day-of - No ry Public,: tate .6f v1sconsin My Commission Expires: DILRR -SBD -6413 (N. 05/81) ST. CROIX COUNTY , WISCONSIN 4. ZOW0 OFFM 798-2230 O AMMOND) 426-8363 M ER FALLS) HAMMOND WI 54016 July 18 '1986 Divislon of •Safety and Building �"'�r Bureau of, Plumbing. i+ 0 Box 7969 Madison', WX 53787 4 9 Dear Sits An on site investigation for the Steven Hontbriand property, located at the NE1 14 of the SW1 /4 of Section 2, T30N -R19W, Town of Somerset, St. Croix County, revealed suitable soils at a depth of 2.58 feet, below which seasonable high ground water was noted•. This site should be suitable for a mound system. Should you have any questions, please feel free to contact this office. Sincerely, Thomas C. Nelson t,:•Zoning. Administrator . _ w...... TCN /mj _ x h. t x a w °' i WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS DIVISION OF SAFETY b BUILDINGS, BUREAU OF PLUMBING P.O. BOX 7969, MADISON, WISCONSIN 53707 Verification of Exception Status for an Alternative Private Sewage System In the County of St Croix Location NE 1/4, sw 1/4, Sec. 2 T 3o N, R 19 x i<xW) W Town G0dkXA0iP614AW Somerset Street Address Lot No. , Block , Subdivision Landowner's Name Steven Montbriand The application for this site is for: new construction use. ❑ replacement system use. 50 4 If this is NEW CONSTRUCTION USE, the alternative private sewage system is: �.1to have one of the first five approvals guaranteed for this year. This is number - - of those applications. (Use one of the first five quota num ers — issue T6 - you.) W one of the applications needing a quota number. The quota number assigned to this application is 59 09 - 7 ❑ for one additional homesite on a farm to be occupied by a parent, child, grandchild, sibling, niece, nephew, or first cousin. [for an individual lot for which a sanitary permit was issued but was later ruled unsuitable due to new or changed soil criteria established by the department. [.A for an application on file prior to February 1, 1980. (a for a lot that meets the criteria for a conventional private sewage system. If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is replacing: ❑ a failing conventional soil absorption system. ❑ a holding tank that was installed and in use prior to February 1, 1980. O a privy that was installed and in use prior to February 1 1980. 1�J - ❑ p Y . P y w rt�x 19 If this is a REPLACEMENT SYSTEM USE and the Jot meets the criteria for a conventional private sewage system, check here. ❑ r '' J ScC: "n� I certify that'the above information is true and accurate to the best of my knowledge. Name Thomas C. Nelson Si re (C ounty Officia Title Assistant Zoning Administrator Date July 18, 1986 DILHR -SBD -6158 (R 12/82) (� PI b. # 60 1/78. PROJECT DETAIL DATA SHEET NAME OF BUSINESS z4au E. n MOrifiby-1 A-V% LEGAL DESCRIPTION N 4 C, uJ k/4 S . 2. + D n7 P. 1 G InI OWNER �.Ft• oA+6t _ MAILING ADDRESS (2r*!2, Se m0.0 Le ZIP .5 4.6ZS ARCHIYECT, ENGINEER, t 4 fty 4a ADDRESS �� e� �1. S �► e�,r E,' bY. PLUMBER OR DESIGNER TELEPHONE NUMBER 1. Check appropriate building usage(s) and fill in the information requested opposite each usage listed. Please consult Section H 62.20. Existing building New building ✓ Addition (j Apartments and condominiums . . . . Number of bedrooms 6 a 4 4 (} Assemblyy h 11. Seating capacity Bar•fr.� . ak.1mi . 0g Seating capacity „Z # of meals served Q_ Bowling alley . . . . . . . . . Number of lanes ( ) With bar Campground and camping resorts . . . Number of sewered s tes Number of unsewered sites Total number of sites ( ) Camps . . . . . . . . . . . . . Day use only Number of persons Day and night Number of persons ( ) Catchbasin . . . . . . . . . . . . . Number ( j Church . . . . . . . . ( ) No ci_tchen Number of persons ( ) With kitchen Number of parsons Dance hall . . . . . . . . . . . . . Number of persons Dining hall ... . . . . . . . . . . Number of meals served daily Dog kennels . . . . . . . . . . Number of enclosures Drive -in restaurant•. . . . . . . . Inside seating capacity I Car - service -- Number of car spaces Dump station . . . . . . . . Number of dump stations Employees ( total of all shifts) . . Number of employees: Hotel ( ) Motel ( ) Cottages . . . Number of units with 2 persons per unit Number of units with 4 persons per unit ( ) Medical and dental office bldgs. Number of doctors, nurses, medigaj,staff 4 _ Number of office personnel .. Number of patients Mobile home parks . . . . . . . .,, 3,. 9 . Number of sites �;1�� 43 l 2 ;; 1 _ 9 1 , , F Nursing homes . . . . . . . . . . . Number of beds Parks . . . . . . . . . . Number of persons ( ) Toff ts1 ( ;) tiShowrers Restaurant . . . . . . . . . . . . . Seating capacity ( ) Dishwasher an or disposal? ( ) 24 -Hour service Retail store . . . ... . . . . . . . Total number of customers _ Schools . . . . . . . . . . . . Number of classrooms T7 Meals ( ) Showers Self service laundry . . . . . . . . Total number of machines Service station . . . . . . . . . . Number of cars served daily Swimming pool bathhouse . , . . . . Number of persons ( ) OTHER . . (Specify) . . . . . . . COMPLETE OTHER SIDE I 2.1 Indicate whether the following facilities are present. Floor drain yes _�C no Number of drains ?� Food waste grinder yes no -A_ Dishwasher yes no p, Automatic clothes washer yes no Number of clothes washers 3. Septic tank capacity 200 �g t, C o 5 2�"� •� E d Holding tank capacity 7 . Septic or holding tank manu acturer 4. SEEPAGE TRENCHES: total square feet width of trenches length of trenches depth number of trenches SEEPAGE BEDS: total square feet _ —�88 width G �oU,,v% d length of bed depth —" " • SEEPAGE PITS. total square feet outside diameter depth below inlet total depth from top to bottom of pit Signatu f person completing form: FOR DEPARTMENTAL USE ONLY Address ., lU. Ao : W cl ex. z 9 '7 Tel ephone Number 7/ S" • 2 V-w — Date IEPARTiIAENT OF REPORT ON SOIL BORINGS AND SAFETY & BUI LDINGS I VISION NOUSTRY, P.O. BOX 7969 .ABOR AND PERCOLATION TESTS (115) MADISON, WI 53707 IUMAN RELATIONS (1-163.090) & Chapter 145.045) TO WNSHIPMAHNICftRLi'P NO.: UBD • / h.� /R w E xi is DATES OBSERVATIONS MADE ❑Residence ow ❑Replace �� a �v G IATiNO: go Ske sultowe for system Ue Ske unsuitable for system 0S M 0 NK: RECOMM ED SYSTEM:1 Tonal) mom a� ❑S �S - f Percolation Tests are NOT required D IGN E If any portion of the tested area is in the :nder s.H63.09(8)lbl, indicate: Floodplain, indiu Floodplsin elevation: AZ& PROFILE DESCRIPTIONS a e, ORiNG ELEVATION TEXTURE A DEPTH ER AT N H T 8 R K F ERVED EE A BRV.ON BACK.) s 3. 7 3.?. . �. /1 .� v 3 PERCOLATION TESTS MBER AFTER RATE D EPTH- . A ROLE TE TI P IN H NIL LLIN INTERVAL-MIN. P• 2. P. L ' P• 3 P_ P_ P. .OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. lhdleate scale or distances. Describe what an the horl- ntal and vertical elevation reference points and show their location on the plot plan. Show the su elevation at an borings and the direction and per t Irnd slope. /� ` ��1v .00 ;YSTEM ELEVATION t � i i d r r.. ...... - - - moo! i the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and rrnetharl speoified.inthe Wisconsin dministntive Code, and that the data recorded and the location of the tests an correct to the best of my knowledge and belief. COMPLETE ON: C ERTIFICATION NUMBER: PHONE NUMBER optional B ey 7 s z • 2,0 .0 CST SIGN ►ISTRIWTIION% Original and one copy to Local Authority, Property Owner and Soil Tester. NLMR4504396 1& 021421 — OVER OPTIQNAL WORKSHEET 1. MOUNQ SYSTEM �,�/� 11. IN-GROUND PRESSURE SYSTEM-,Continwd- i. Wastewater Load, Total Dally Flow • '. '= gal. 10. Force Main: 17i Use s. ILHR 83.15 (3) (c) Minimum Dosing Rate ■ . Adm. Code and PROVIDE A DETAILED Diameter ■ - -- LIST OF SIZING ON PLANS. 11. Total Dynamic Head: 23 ft 2. Depth to Limiting Fstdor • ?` ft. System Head ■ 3. Landsiope • � % Venial Lift = %- 4. Distance from Dose Chamber to Friction Lose • Distribution System = iL TDH ■ n' S. Elevation Difference Between / me 12. Pump Selection: -7, Pump and Distribution System • ..Y� ft. Pump ww* dlschar/r at Mast spin 6. Absorpti" Area Sking: � at -=A-IM ft. total dynamk head. Area Required • .�5�. 20. h • („ n u 1 A Manufactur d I 1 Bed or Trench Length (B) ■ _� fL Bed or Trench Width (A) h 13. Dose Volume: pacing (C) • h• 10 Times VOW Volume of Trench Distribution Lines ■ - 'L 7. Mound Height: Spa Fill Depth (0) • fL Dally Wastewater Volume + 2f Fill Depth Downsiope (E) • /L 4 Dom In 24 hn. • W Bed or Trench Depth (F) • IL Backflow = Cap and Topsoil Depth (G) • rL Minimum Dow • gin• Cap and Topsoil Depth (N) ■ fL 14. Dose Chamber: p,,,,,,, �• t. Mound Length: Volume ■ End Slope (K) ■ h� Total Mound Length (L) ■ ft. 111. CONVENTIONAL PRIVATE SEWAGE SYSTEM !. Mound Width: 1. Wastewater Load, Total Da11Y Flow • �.� Upslope Correction factor • Use B. ILHR 83.15 (3) (c), Nis. Upslope Width (!) ■ iL Adm. Code and PROVIDE DETAILED Factor LIST OF SIZING ON PLANS. S. DownslopeComctbn ac ,. pownslope Width (1) • 2. Required Sepik Tank Capacity • W Total Mound Width (W) • fL 3. Percolation Rate • MbLlb • 10. Basal Ana: 4. Absorption Area Sisins: Infiltrative Capacity of Refer to Table Z in ch. LHR 83 Natural Soil = 511IJ9 .it./day and PROVIDE A DETAILED L OF Basal Area Required ■ 14. R SIZING ON PLANS. Basal Area Avallable = Z i $4. fL Required Area ■ p• ft 11. Of Standard Tables from Chapter ILHR 83 Length ■ �--� -� ft. --� �-�= h• ale, Width ■ 'used, indicate Table N Number of IL For the Distribution Network, Use Numbers S -14 In Section 11. • Trench Spacing �••� 11. ON-GROUND PRESSURE SYSTEM 2 S6 S. Distribution f t. lo 1. Depth to Limiting Factor ■ rt. 2. Lsndsbpe ■ % Numb* f Laterals • ��- 3. Percolation Rate • min./in. Lots Spacing ■ •�-� -� io• 4. Proposed System Elevation ■ ft. D anco from SWswall to Pipe lo• S. Wastewater Load, Total Dal l Flow: gal. stem Elevation • �� n• Use s. ILHR 83.15 (3) (c) , 58. Adm. Code and PROVIDE A DETAILED IV. SYSTEM4N -FILL LIST OF SIZING ONTLANS. FNI in All Items from Sect) t 4 9 Required Sepik Tank Capacity ■ .Zo gal. 6. Abption Area Sitkg: V. SEPTIC TANK aw 2 Percolation Rate • min./lo, i. Capacity ■ 01!f V S Lp 0v% S&L Area Requited = 14. It. 2. Manufacturer. System Length • ft. 3. Show Site Constructed Tank Detalle on Plan System Width • R• 7. Distribution pipe Stains: VI. DOSING TANK - gal. Hole Sire • M. 1. Capacity = e- Hole Spacing ■ ft. 2. Manufacturer Lateral Lenath . ft. 3. Pump Manufacturer: Lateral Sire • • In. 4. Pump M414101: I.Meal Spacing ft. S. Operating Head= ft. t)hct.an;v (noon Sklewa114o Pqm in. G. Flow Rate= SPIN. A. Ubtribution Plise DINAW tr R.ntr: 7. Show Site Constructed Tank Details OR Plans Number of I loin Per Pier - 1 low Per Pq+e : spin. VII. IIOLUING TANK 0. Manifold Shins: 1. Capacity = Type (center or end) . F r, d 2. Manufacturer: ` Length = ..�� ft. onstructed Tank ,O�taUs Diameter • ..s'� .� in, - � SL -SHOW ALL INFORMATION ON PLANS- IMLMR 1 1111 " MI 40) _. • � , � • • � �. ,:1 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■ �� �►"�� ■ ■�� \iO� \ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■ ' ■ ■ ■ ■ ■1.1 ■ ■�� ■ ■P� ■ ► \ ■ ■ ■ ■ ■ ■■ ■ ■ ■ ■ ■ ■ ■fli ■I■ ■ ■ ■I■ ■ ■ ■ ■ ■� ■ ■ ■ ■ ■■ ., ., ., �, ., 0 ■■1 ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ® ■ ■■ � � :: � ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■ e \ \ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■�i:'ri'� � ■ ■ ■ ■� ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■rVLJ � . ■�� ■ ■ ■ ■ ■■ ■fir ■ ■ ■ ■ ■ ■ ■ ■ ■ ■! ■ ■■ �.� . �■ ■ ■ ■ ■ ■ ■ ■ \ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ . � ■�� ■ ■ ■ ■ ■ ■ ■ ►� ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■�! ■ ■s ■ ■►■■■■■a�� ■ ■■■■■■■■ ■�� .. ■ ■■■■■►■■■■■■P� ■■■■■■■■■■.■�■ ■■ ■■■�■■►•■■■■■■:�■■■■■■■■■�aa ' ■■■■■■■■►�■■■■■n�■■■■■■ ■ ■ ■■ . ■■■■■■■ ■ ■��■■■e��■■■■■se■■ ■■■■■■■w■■��■■■� ■►�■■■■■�■■■■ ■■i■i■■ ■■■■■■�■■w■�■■■■■ ■ ■■■ .• I r tI b�,�,��� N� `/ Sw`sA� o 1acl U) � S / 'us5 S5 1 i7 Ot P Lr4yOa -7/ 8605449 /1 0 os o h s 0 h r9rrr� 6 r 1.2. 01 Pei k) 3.4 6-v DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS � • INDUSTRY, DIVISION LAB AND PERCOLATION TESTS ( 115 P.O. BOX 7969 HUMAN RELATIONS 1 MADISON, WI 53707 (H63.0911) & Chapter 145.045) L ATION:S SECTION: TOWNSHIP /4Mbfdt£tPXt'CTf LOTNO.:BLK NO.: SUBDIV1 10 NAME: 1 / / /T�a /R )99 (or) WI �S s COUNTY: OWNE 'S BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMM RCIAL DESCRIP ON: PROFILE DESCRIPTIONS: E LA ION TESTS: ❑Residence New ❑Replace _eq J / �Z` — Ac RATING: S= Site suitable for system U= Site unsuitable for system O NVEN MOUND: ❑� IN- GROUND P RE: SYSTEM -IN -FILL HO�LDINGNK: RECOM SYSTEM( � G :op Tonal) OU If Percolation Tests are NOT required DESIGN A E: If any portion of the tested � / ar � rea is in the under s.H63.09(5) (b), indicate: Floodplain, indica Floodplain elevation: S / PROFILE DESCRIPTIONS a lam/ BORING TOTAL D PTH TO GR UNDWATER- INCHES CHARACTER OF SOIL WITH THICKNES , COLOR, TEXTURE, AND DEPTH NUMBER ELEVATION OBSERVED EST. HIGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 2M Afr, . Ldt o l.s•�� ray- .�5. 4 133— 00, B- B- B- -yy�� / PERCOLATION TESTS �J TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER WG44ES AFTERSWELLING INTERVAL -MIN. PERIO 1 P RIOD2 PERIOD PER INCH P- 1 z- - 2-- 3 P - Z -eDl 0 3 61 & 4- 3 P_ Z -W 10 P -_ P P- PLOT PLAN: Show locations of percolation tests, soil borings and the dime i of S.. cafe scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plan ti irfac "� ation at all borings and the direction and per ent of land slo � � ® I i Q � � �+ SYSTEM ELEVATION 106 �'� � � � _ __ - I ig e _-- � ? I ,w f � e 01 • I E ..'_ _ -` tN _._ �_- i J j _A__ 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 correct to the best of my knowledge and belief. NAME (prix TESTS WERE COMPLETED ON: cc ADDRESS J CERTIFICATION NUMBER: PHONE NUMBER (optional): ��� CST SIGN E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 02/82) —OVER — ` INSTRUCTIONS FOR COMPLETING FORM 115 - 0BD - 6395 ' To bemcomplete and accurate soil test, your report Must include: ' 1. Complete legal description; 2. The use section must clearly indicate whmherdhio is n residence v,commercial project; 1 MAXIMUM number of bedrooms o/nommmmio( use planned; 4. |, this a new or ,co|eo*ment system; 5. Complete the suitability rating boxes, A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED 0N SOIL CONDITIONS; 8. PLEASE use the abbreviations shown here for writing pn,(i|p descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. [vawinsto scale is preferred. A separate sheet may be used if desired; 8. Make Sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, vdd,eoos.flood plain dam' percolation test exemp- tion, if appropt rate; 10. If the information (such as flood plain, elevation) doe-, riot apply, place N,A. it) the appropriate box; 11. Sign the form and place you, oormn^ address and Your certification number; 12� KXnkn |*Aib|v copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS BFCOMPLETION. � ` ` � ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols m — Stone (over lU'') 8R — Bedrock cob — Cobble (3 10'') 3S — Sandstone gr — Gnxvr| (under 3^) LS — Limcutonc °a — Sand HGVV — HighUrnondeater ca — Coarse Sand Pero — Percolation Rare mmiv — Medium Sand VV — Well I's — Fine Sand B|dO — Bui|dinU Is — LoamvSand > — G*ate,Than °d — Sandy Loom < — Less Than ° — Loam Bn — 8rmvn °xU — Silt Loam B| — B}xok ` vi —Silt G — Gray °d — Clay Loam Y — YoHowv z| — Sandy Clay Loam R — Red oid — Silty Clay Loano mot — K8nNes sc — Sandy Clay w/ — �'vith ' sin — Silty Clay ff| — fo�"" � ~c — Clay cc — rpmmon.oeoe pt — Peat mm — Many � m — K8ud, ` d — diSinc; � p — pnzminnrn HWL — High level, ° Sixqemrm| soil textures sudanewater � for liquid Waste disposal BM — Bench Mark VRP — Vertica| Reference Point ` TO THE OWNER. This soil rest report is t first stop In securing a sarlitary peltnit. county or the DeV.)a�rnerlttTiaymciu(,'St ,e,ificahon of this soil test in the fie|d prior to pwrmit issuance, A comv!eyu a`/ of plans for the private sewage system and a permit application muSI bo oubm�M�d on the apnropriate local authority in order to obtain a permit. The sanitary perrnit must be, otnoinndand pos-L*t',l p'iorzo,hnstart of art nunStruotion, - , � I • ST. CROIX COUNTY ' WISCONSIN ZONING OFFICE 796 -2239 (HAMMOND) 1. YSV 4 425 -8363 (RIVER FALLS) _ HAMMOND, WI 54015 I July 18, 1986 Division of Safety and Building Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation for the Steven Montbriand property, located at the NE1 /4 of the SW1 /4 of Section 2, T30N -R19W, Town of Somerset, St. Croix County, revealed suitable soils at a depth of 2.58 feet, below which seasonable high ground water was noted. This site should be suitable for a mound system. Should you have any questions, please feel free to contact this office. Sincerely, U y��r f Thomas C. Nelson Assistant Zoning Administrator TCN /mj i STATE OF WISCONSIN- DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS ` DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING P.O. BOX 7969 - MADISON, WI, 53707 APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM Location: Township /&MJoLkWJ= NE i Z SW S 2 IT 30 N/R 19 XWOU Somerset St. Croix Street Address: Subdivision: County: Landowners Name: Mailing Address: Steven Montbriand Rt. 2, Somerset, WI 54025 I (We), the undersigned, hereby make application for an alternative system on the above - described premises. I recognize that the above premises are not suited for a conventional private sewage system. If approval is granted. I agree to have the system installed in conformance with the Bureau's approval of plans and specifications. I further understand that an alternative system is more complex in nature than a conventional private sewage system and as such will require detailed inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged with administering county sanitary ordinances and Bureau employes or other authorized persons to have access to the above described premises at any reasonable time for the purpose of inspection the construction of or monitoring of the system. I further agree to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system. I understand that this application does not permit me (the applicant) or my agent (the contractor) to begin installation. If the system is approved, the Bureau will send the applicant a letter of approval which authorizes construction of the alternative system after all necessary permits have been obtained. I agree to give notice to any subsequent buyer that an application for an alternative system has been made and if installed, that the premises are served by an alternative system and further agree to give the buyer a copy of this application. The Bureau accepts this application subject to this understanding and subject to all the conditions and obligations set out in this application. Signature of Applicant Date STATE OF WISCONSIN Subscribed and sworn to before me SS. COUNTY OF This day of 19_ Notary Public, State of Wisconsin DILHR -SBD -6413 (N. 05/81) My Commission Expires: r � . _ WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING P.O. BOX 7969, MADISON, WISCONSIN 53707 Verification of Exception Status for an Alternative Private Sewage System In the County of St. Croix Location NE 1/4, sw 1/4, Sec. 2 T 30 N, R 19 W Town auuMunlotpoIN4K Somerset Street Address Lot No. Block +, Subdivision Landowner's Name Steven Montbriand The application for this site is for: E new construction use. ❑ replacement system use. If this is NEW CONSTRUCTION USE, the alternative private sewage system is: �.1to have one of the first five approvals guaranteed for this year. This is number - - of those applications. (Use one of the first five quota num ers ssueTTo you.) M one of the applications needing a quota number. The quota number assigned to this application is 59 - 09 - 7 ❑ for one additional homesite on a farm to be occupied by a parent, child, grandchild, sibling, niece, nephew, or first cousin. D for an individual lot for which a sanitary permit was issued but was later ruled unsuitable due to new or changed soil criteria established by the department. (._.]for an application on file prior to February 1, 1980. (_]for a lot that meets the criteria for a conventional private sewage system. If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is replacing: Fla failing conventional soil absorption system. a holding tank that was installed and in use prior to February 1, 1980. ❑ a privy that was installed and in use prior to February 1, 1980. If this is a REPLACEMENT SYSTEM USE and the Jot meets the criteria for a conventional private sewage system, check here.0 I certify that the above information is true and accurate to the best of my knowledge. Name Thomas C. Nelson County Official Title Assistant Zoning Administrator Date J uly 18, 1986 DILHR -SBD -6158 (R 12/82) r+ . z CA H ' 9 STC - 105 r 9 H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a OWNER /BUYER ROUTE /BOX NUMBER (L. Fire Number .CITY/ STATE S 0 TYti &iy S F CA3 Z IP $ t- v z - S PROPERTY LOCATION :_ &4, Lj Section Z- T 3e7 N, R l9 W, Town of St. Croix County, Subdivision oil Lot numbe 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 pdt into the system can affect the function of the septic tank as a treat- , ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 i E I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart - �v ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Offkce within 30 days of the three year expiration date. S IGNED -.+ r DATE za lo 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. 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 /contractpr,( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Property A)G 1 4 A% 0 1 4, Section Z , T 3 N - R 1`� W Township Mailing Address rL , 2 S, �✓S Subdivision Name }. Lot Number /v y 4- , Previous Owner of Property 0- (-S Z.. Total Size of Parce p Date Parcel was Created /l 7 9 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes � o Volume and Page Number - Z 1 7 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING 1. Warranty Deed ` 2) Land Contract 3.• Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to.avoid delays 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) eeAti jy that aft statements on this ,6onm are tAu.e to the best of my (our) , knowledge; that I (we) am (cute) the owneA (s) o 6 the p %o peh ty de, cA bed in this in6onmafii,on 6onm, by vi tue o6 a wakAa.nty deed neeonded in the 066ice oS the County RegiAteA o6 Deeds as Document No. 7G V3 ; and that I (we) pees entey own the proposed A to jon the aewage dizpozaZ system (on I (we) have obtained an easement, to nun with the above desehi,bed ptopenty, bon the eonstau.cti.on o6 sa.id system, and the same has been duty neeonded in the 066iee of the County RegiAteA o6 Deeds, as Document No. ) . SIGNATURE OF OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE) A/) �G DATE SIGN DATE SIGNED a r F t�' . +. � �` ,:. y �.ujy.: .. ,g ' �r�} !. _ i`- Ag'•.� ?d4., � .s".,. t � # �r.,.:a„ � *, 'gam OA It AZ ka 5 + t f t 9 � � c , 1 r O F �D°i ,mss � } •., t : NY ow too �11111111 doo boo }~ M *Pow 00001606 too boo .. 10 0 4 M . { St :" l ".• tit; t ®.�}�.. a ?'a`rt a. J r x K Gh - _ �• •'' °- +w.d...r °��, it I �.. e G rt le e � { 1 '� .� f �+J,,/''„� ✓r yr. r�� f • • �, „ � L -- r � � mac; -°�� } Q O C �-.,� �S I • � � tt � � �. n o O ID Y A LO Alk- i v -� • i 3 �i r 1 -- }-- F' As 0 i' r f 1 • • • / �' • • l U • r