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HomeMy WebLinkAbout034-1025-20-000 Q o @ O o @ p I/ h op b4 N ! N @ M O C O O 1 �S `3 L O7 C N O '3 w - 0 N ON .- T N i = L � O � N N c U w 0 0 O@ t` I a o � o LL I rn I > I c I O> c > I et' � '= pop =o Ct E I 0:5 I ai I @ U C CL c L co �� om� ' o a @_� oa O N O 0 (,04 O � z O p Z E C w L _• @ \�X , Q CU LL C C U LL C @@ w LL C - O c N 7 N C :p 15 Q °E a mE °c 1 a) Q Sa I o . o 0 0 Q I Z Em Z f L L O i L 4 O m a m d m N z I I o z :!t c U tY o r� w et � I E E E ` N 3 C O 3 m CD a� I N 4 a f- I N O N N N I •� d @ L I � •° L C L I Q i O -O Q M Z (n Z Z Z c S Z Z N O c e 3 d — LO .. iv E m > EE c v @ 0 U i .. @ N > R T >@ co 4t CL M U N d N q •O N 61 N C V d i N N a o 0 0 a N O -o G a 1 ' c h Q p to f/� f� E ) 'O (n (A U) �) O 0 (/� (n N W� Z Q n 0 0 0 a �' O O O = 0 0 3,2" a J ' • Ai ,� C9 aaa I a a a � C7 a a a I co 7 O N O N N J V o a) a) 0 o 0 0 0 o o rn rn °) N N Z �- F \V U O_ O E O M Z V N w m m LO in o c n 00 m CO i1 °� rn �0 CT) N VI LL N N O N N � � ±:+ O O `p C p w p } ma y ° N ° n ~ a o m a�i FI .� O u4 N c c0 m x c N N N c CO cD 04 O N C 00 2 3 O O U� Cl) W > C V O O L. o (n ! U Z? 2 2 Cn Cl) o Z `1 `L � Z 2 2 .. I ✓� d M d a d a d a o .e 1 c a w L: (L L: a • a ar a w c a m c an d ; 3 o c 0 O A U D. o v) U O - ) U O v) U a i �. ry ) o p vy 0o ao a� M � ti c I � i 1 N c I N ' I � E I c 0 � L N O M I O E C Z C N LL C N `O p U N a� E Q ° m U I O O N r N a m .- h Z o I o z d I CD 2 Z fn F- p E M `> LO o T 3 cu O N Z Z : o z I N m Si a r w c L N d O O m C G a a y N 0 0 0 n 2 Z �aaa n 0) o N ° rn rn to D U I .. rn rn z c CL o o o m o I v N U) o ca C °—' d > l io o m CL C fl> C O °o o ff c ° v , o cis o f O ^ o N C N a LL O N '. ' Y E G 'D N N Q N LO N ,X C C E N co O c,. o o t L Cl) O ,�- (n co O .z N cmµ U) rr eC ✓a, a a 00 0 `1 A 0 a j' O h ti r r �-d boo REPORT OF INSP71TICN--- INDIVUAL Si ,JAGE- DISPOSAL SYSTM i PRIMACY TIMMITMENT consists of Septic Tank% Other (Describe) SEPTIC TANK: Distance from: WellL<aft., Lot Line ft. Buildin ft. High watermark ft. 12% or greater slope ft. Wetland ft. Cistern ft. No. compartments 2 i Liquid capacity ;, gal. EFFLUENT DISPOSAL SYST'_M consists of Tilefield. pit (s). Seepage Pit or Tle Field Distance from:! Well ft. Building ft. Lot Line ft. ftstern ft. High Watermark of water course ft. Slope 12 or greats -,x ft. Wetland ft. Total length of tile lines ft. Number of lines Length of each line ft. Distance between lines ft. Width of trench in. Total effective absorption area of trench bottom Sr. ft. Depth of filter material below tile in. Depth of filter material over tile in. Cover over filter material Depth of tile below finished grade in. Slope of trench bottom in. per 100 ft. Depth of bedrock ft. Depth to ground water ft. Number of Pits. Cutside diameter ft. Depth below inlet - .5 -- ft. Lining material Gravel around pit: - , Yes. No. Total sbsorption area . sa. ft. Square feet of seepage trench bottom area required o�le Square feet of seepage pit area required //y Inspected by: �G'- 6 t X i / f Title: T ` Approved Date 92Z, Rejected Date County, Town of ' Owner Sanitary Permit No L P r o - o e r t Address Septic Tank Permit No. .//V.Z/4 Subdivision I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. NAME A S f KT 3 /7 N 0_a i4 5 r , .v TITLE Type or Print) REGISTRATION NO. f4it AS. �X- 9 a Y or MASTER PLUMBER LICENSE No. ADDRESS DATE f3 AR:.1 3 c / / SIGNATURE MASTER PLUM E R MAKING A PLICATION MP Signatures License Numbers MPS y I (To be Completed by Issuing Agent) Date of Application Fee Paid $ Permit Issued (date) `r y / Permit Number Agent (name) For: 7 Town, Village, City, SvOI ty, etc. (Specify) Notes The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the Permit (yellow copy) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below • FOR DEPARTMENT USE ONLY DATE RECEIVED ACCEPTED BY RETURNED (Initials) (Date) See Corres.T FEE RECEIVED _ VALID. NO. PERMIT NO. Yes or No) REVIEWED BY APPROVED DATE (Initials) (Yes or No) COMMENTS: i III f Wisconsin Department of Health and Soclal- Servioes' Plb. #67 10/69 Division of Health ` PERMIT APPLICATION for PRIVATE DOMESTIC SEWAGE SYSTEMS A. %MR OF PROP FRTY TYPE OR USE BLACK INK Address (Street, City Zip Code) County B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED Check Ones - ..Y*�(� CITY VILLAGE LEGAL DESCRIPTIONS TOWNSHIP ,- , .. .{ } /Ye 4710 —'"j �. C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO _ /n 7 PEWIT NUMBER 'l' D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT — ADDITION MATERIALS: Prefab Concrete 'N Poured in Place Steel Other NUMBER OF TANKS TO BE INSTALLEDs E. TYPE OF OCCUPANCY Check Ones One or Two Family Residence Commercial �_ Industrial Other Specify Number of Persons to be Accommodated _ Number of Bedrooms F. APPLIANCES, ETCs Food Waste Grinder YES _ k NO Automatic Clothes Washer YES NO Dishwasher YES —; NO Automatio Potato Peeler YES _ NO Other (Specify) G. EFFLUENT DISPOSAL SYSTEM NEW X EXTENSION ADDITION REPLACEMENT Tile Size No.Lin.Feet 9DO ench Width _?6 Depth LIV Number of Lines Seepage Beds Length Width Depth Tile Size No. Lines Seepage Pits Inside diameter 5f „ Liquid Depth P B R C 0 L A T I 0 N T E S T Test Depth Character of Soil Hours Watsr Test Time Drop in Water Level Inches Minutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall lst Wetted Overnight in Minutes Last Periodl Last Period Period One Inch Example P- 0 36" Top Soil 10" CLU 26" 25 yes or no 30 1 2 1/2 _ X/2 60 RECORD DATA FROM MINIMUM OF 3 TEST HOLES ompute •ize of absorption area in accord with H 62.20 Wis. Administrative Code. S O I L B 0 R I N G S - Minimum 36" Bel ow Prop osad Absorption System oring Total Depth Depth to Ground Water Depth to Bedrock —� umber Inches Observed Estimated Obs erved Estimat Character of Soil with Thickness in Inches xample 0 72" 72" Black ToR Soil 12" Cla 18 "• Sand 18" Gravel 24" t v r •, RECORD DATA FROM MINIMUM OF 3 BORE HOLES COMPLETE OTHER SIDS Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety aid Buildings Division INSPECTION REPORT St. Croix R 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)). 383982 Permit Holder's Name: ❑ City ❑ Village Town of: S r43 (191 o Plan ID No.: S t. Croix County Parks Department, Springfield Townshi : -F^tims. Ip.* CST BM Elev.: Insp. BM E ev.: BM Description: � e Parcel Tax No.: tro . or 614 S T. 034- 1325 -20 -000 TANK INFORMATION ELEVATION DATA I ` z 9. 1 —, 06 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aft. BM Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht outlet 8, 9(: • 30 TANK TO P/ L WELL BLDG. Air i to ntake ROAD Dt Inlet Air I Septic ? Qp I (0� 2 Z I NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holdin Bot. System PUMP/ SIPHON INFORMATION Final Grade �.,� Ma ufacture Demand over M 0 Mod Number GPM 10046 L , TDH ift Frictio S stem TDH Ft F I Dia. To well b SOII,,AAS ION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT NO. Of Pits Inside Dia. Liq Depth I E ION I N SETBACK STEM TO P / L BLDG LAKE / STREAM G LEACHIN Manu acturer: INFORMATION Type CHAMBER model Number: 01 System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distrib n Pipe(s) x Hole Size x Hole Spacing Vent To Air Intak Length Dia. Length Dia. Spacing r t / SOIL COVER x Pressure Sy ms Only xx Mound Or At -Grade Systems Only \� Depth Over Depth Over xx Depth Of L x:x Seeded /Sodded =Xxed Bed /Trench Edges soil ❑Yes ❑ No Q No COMMENTS: (Include code discrepancies, persons present, et . nspection #2: I Location: 1049 Rustic Road, Glenwood City, WI 54013 (NW 1/4 SW 1/4 11 T29N R15W) - 112915170 1.) Alt BM Description = 2.) Bldg sewer length= n R - amount of cover= �� Vj . �s,�r. - t�.,.erur �e C. 4v Plan revision required? ❑ Yes Pa No S� Use other side for additional information. SBD -6710 (R.3197) Date Inspector Signature Cert No Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application t' . PO Box 7302 Madison, WI 53707 -7302 Personal information you provide may be used for secondary purposes t]eparttnent of Commrcee [Privacy Law, s. 15.04(1 xm)) (Submit completed form to county if not state owned. Attach complete plans to the coup only) for the stem, on a r not less than S -l/2 x I 1 inches in size Late P it Number O Chock if revision to previous application Man I. . Numb county �`. Cro i Y Stat '8 - Z I. Apolication Information - Please Print all Information Location: Property Owner Nam/e� /� Property I oeation v Cr 0% C O ♦ P r � , S T ,N, o W Propaty Owner's Mailing Address Lot Number Block /0 5 �'C- oaor .3 City, State Zip Code Phone Numbs Subdivrsro Name or CSM Number ❑city II. Type of Buildin check one) p Yiliage ❑ 1 or 2 Family Dwelling - No. of Bedrooms : own of �' C I _I 0 0P �Public/Commercial (describe use):_ � �/ r , r, 4; `Qf L State -Owned a /1 N V Parcel Taxxumber(s) III. T e of Permit: Check only one box on line A. Check box on line B if a livable A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. Addition t Existing S steo m System System Tank Only B) '� Permit Number Date issued VA Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) • Non - pressurized In-ground ❑ Mound r ❑ Sand Filter ❑ Constructed Welland • Pressurized In- ground g ❑ Holding Tank ❑ Single Pass 13 Drip Liter • At de ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other. V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Ekwdtion 7. Final Grade Required Proposed Rate (Galslda /sq. R) (Min�nch) ,� Q Elevwtion VIL Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con - Con- glass New Existing Crete structed Tanks Tanks n ,d � �OV Pi b sB �'.S V ❑ ❑ ❑ O U 1 -0 t�, aD 0 VIII: Responsibility Statement I, the undersigned, assume ibility for installation of the POWTS shown on the attached laps. Busimss phone Number Piumbees Name (print) ®® Plumber's Signature (no stamps): MP/MPRS No. Plumbers Address (Stroet, City, State, Zip Code) IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ing Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse ge Fee) OD Determination X. Conditions of Approvals eons fo Disap o 16 i I 41— �� f� oo nn� � � t 4Q= �li� LS J rr �- _ s 1 0- 1 J i w i3 S T vWX Q'°At 41 VW� Safety and Buildings PO BOX 7162 MADISON WI 53707 -7162 _ � TDD #: (608) 264 -8777 �sconsin www.commerce.sta Department of Commerce Tommy G Thompson, Governor Brenda J. Blanchard, Secretary September 06, 2000 CUST ID No.827623 ATTN.• POWTS INSPECTOR v M ZONING OFFICE MIKE MCDONELL >���`, $ ST CROIX COUNTY SPIA 340 PAULSON LAKE LN r l r`JD U , 101 CARMICHAEL RD OSCEOLA WI 54020 SON WI 54016 RE: CONDITIONAL APPRO ' �" _ sr cau�x PLAN APPROVAL EXPIRES: %0 0002 r our Itleijtifi a*v �'• Transaction ID No. 431191 •' 'a IJM1lNG0 E C �. Site ID No. 198009 SITE: ` �� l r ° ',� �� k'lease refer to both i enttid b,. Site ID: 198009, JOE GRANT abo,�inall`Qttes ST CROIX County, Town of SPRINGFIELD; LOT 1 CO HWY E SWIA, SETA, S7, T29N, R15W FOR: Description: NEW DWELLING MOUND 450 GPD Object Type: POWT System Regulated Object ID No.: 759041 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(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: • A State approved filter capable of reducing the wastewater particle size discharged to the drainfield to a maximum diam. of 1/8 inch is required to be installed • Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the State approved filter will be required. • A User's Manual shall be provided to the POWTS owner as per Comm 83 Wis. •Adm. Code. 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, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. I Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 08/23/2000 FEE REQUIRED $ 175.00 FEE RECEIVED $ 175.00 ROBERT KANTER , POWTS PLAN REVIEWER BALANCE DUE $ 0.00 Integrated Services (608)261-7735, 8:OOAM - 4:30PM, MON -FRI I RKANTER @COMMERCE.STATE.WI.US i cc: JOE GRANT ST CROIX COUNTY • SEPTIC TANK MAINTENANCE AGREEMENT AND • OWNERSHIP CERTIFICATION FORM Owner/Buyer C r, Marling Address /o - Q �' G Ao� D S• f4/3 Property Address Sam f, (Verification required from Planning Department for new construction) City /State d e A 00 1 C► ►" , pal Identification Number LEGAL DESCRIPTION Property Location %, '/4, Sec. . T Z7 N R W. Town of r, y 'C Subdivision /✓� Lot # Certified Survey Map # Volume , Page # Warranty Deed # Volume _ . Page # Spec house 0 yes 2/no Lot fines identifiable 9'y ❑ no SYSTEM-MA MENANCE Improper use and maintenanceof your septic systemcould result is its Fnmat=failune to handle wastes. Prupermaintenance consists of pcMping oat the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can aff nt.the function of the septic tank a treatmcut stage is the waste Tie ProP«tY ownex agrees to submit to St Crone Zoning Department a certification form, signed by the - owner. and by a 1 nW=P 11 =bcrJOUmcymanplumbcr, restricted a Ho=sed pampervrrifying drat (1) the on-site wastewaterdisposal system is m proper operating condition andlor (2) after inspectica and pumping (if nec=uy). the septic-tank is less than 1l3 h1l of sludge. Ywr, the undersigned have read tic above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by die 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 retar=d to the St Cro ix.County Zo ning Office within 30 days of the &= year expiration date. ,3a o 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 described above, by virtue of a warranty deed recorded in .Register of Deeds Office. M OF °j DAT * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department « * «s «* ** 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 r - i a ku i f v o z i w _ QQ J � o Jw sQ w Ne U O o s d� x U i £ O w I v) Q v o�F�cC REST Roots - - - - - -- Sloop x 10` i i C D r I GLEN HILLS P RRK FQU ipmcN?" S-roRA4C 36 X �}-g - A g SToo P FoR Qooe 4N4 Wi�VOo W ScyE�utF SEE 5 Pt 7 C /F/CAr/ON ZZ. I I v .----------- -- - - - - -- - -- - - -- -- � 1 I oc oc \f ! 1 1 1 1 I j '/7 1 E / " ( ■J o r Y -- ----- - - - - - , o LLJ 1 LU A W I oQc - - - - -- Cb 1 1 Y ` m 1 A V J m 1 u ; W v i H m 1 � CY. WO 1 0 LL- i I - -- • `�� - - - - -d Y (D C Jf C _ a A A C O. a W E r s c V W J o a) on W, Q s 3 U C d Y o W �•; U ta��` O 8 E vim �a . 3 M o o v w v U 00 L iE E o off= L- C14 o OL 14 01 C Q W I v v JO C) V v 3s3o N a t Z o ° 3 % k § @ � z E z \ w e C o f , 0 o a - \ / \� D \ k tI n` «�/ § @ k} § 0 o t Q EE «§ 8 « § M / >� E' _ §jai k k ] 3 CD / \ \ § E r % s " Z 0 o o a F' E . .. CL { § 3 § / > Oro $ 7 -0 v v E E $Em5 § # :3 \ § § \ $ CD _ cn ° N a \ E w CD � c6 '$z CD E R . ■ � 2 E § 9 k F e & ° / 0 k ` + § / � a £ c $ f % m / � ( CL d 2 m 0 @ ° § / . . _o �§ \ i 7 : � Wisconsin Department of Commerce SOIL AND SITE EVALUATION 3 Division of Safety and Buildings Page of BureAu of Integrated Services in accordance w' 83.09, Wis. Adm. Code p r� !/ County Attach complete site plan on paper not less than 8 1/2 x 11 in &i ize. Pla�gmust' : .?1 include, but not limited to: vertical and horizontal reference t M), ��;�t;IE''RT °and percent slope, scale or dimensions, north arrow, and locati `BOO distan IOy� road; Parcel I.D. # J (� APPLICANT INFORMATION - Please print afl anforma[ on! , � Rev' wed b Date Personal information you provide may be used for secondary purpo' ��{krivacy La ST � ?W (m)). ` , � Property Owner /� '/� (, t�lr; rty, > n S /, �/� U�/� C ; a - p4h Its Go 4(, 1/4 1 /4,S (r T_ ! �N,R /S E (or Property Owners Mailing Address Block # Subd. Name or CSM# �ayy 4,5/1 leodc7ll =� City State Zip Code Phone Number ❑ City ❑ villa e © -Town Nearest Road 6 1eil u> C�'� I SY0!3 MS') —Zs 5"6Z3 New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building ❑ Replacement ©1 -umic or commercial - Describe: Code derived daily flow 6 . 5 gpd 7 Recommended design loading rate 1 410 bed, gpd/ft gpd/ft Absorption area required _ bed, ft � trench, ft Maximum design loading rate -0 bed, gpd/ft gpd/ft Recommended infiltration surface elevation(s) /t ft (as referred to site plan benchmark) Additional design/site considerations 11f 114 �>> Parent material � eokse �// __ Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [3 S � El 03 El 0-d' El ETU ❑ S D ❑ S SOIL DESCRIPTION REPORT Boring # HodZon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 ` in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench o-11 I C) P_ `3�- 's � L 13 r Ground _ 1�-3y 5 �` Sc c. �, elev. Depth to limiting factor, r 9 in. Remarks: Boring # 3 V 3 `/ L) 9 ,shit - . S P) M b Q-.) I v � •� Ground - S y2 y k 5C ? C Sk n' elev. Depth to limiting factor u2— Remarks: CS7Nne (Please Print) Signature Te ephone No. Address r Date CST Number 2 4 0 1 s o �� �����P�'• -�� y� a day PROPERTY OWNER P SOIL DESCRIPTION REPORT u � Page 3 of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench �i, r r j o � ` � 5 (� L SL 14 If 0111 -2 LL) Ground elgy. - I�� .5 — ft Depth to limiting f a cl<or 88 in. Borin Remarks: (- 4 pr(�0�� 5 F II CDC ca �c f= ta�rmP�f �d �rcc.y�_� 9 # C,3 Ground elev. ft. i Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # E3 Ground elev. ft. Depth to limiting factor in ' Remarks: Boring # L3 Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) a � � f � c n I a a G ' oil I r STC - 104 AS BUILT SANITARY SYSTEM REPORT r OWNER C c�k e 6� ADDRESS b �� SUBDIVISION / CSM# SECTION _/ LOT # -- T �j N_R IN { ,� W, Town of \ ST. CROIX COUNTY, WISCONSIN SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 -�A T6e 5 1 ' t 0 Y;V u Tb� o� _ ^ l i INDICATE NORTH ARROW Provide setback and elevation information on reverse Provide 2 of this form. dimensions to center of septic tank manhole cover. t BENCHMARK: [ g, c L% ALTERNATE BM: -T-'o rp S 11y Cyr r e� �av� rr e� S�cx (n l��s W Od SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: 1 "(Jc�Ue,.� Liquid Capacity: /r Setback from: Wel 3 Other Pump: Manufacturer ��, � Model# Size , �/o x � Float seperation S,-;� � Gallons /cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: & 3 Length ( ,�) 3. 6cy Number of trenches Distance & Direction to nearest prop. line: Setback from: well : House 3 � Other ELEVATIONS Building Sewer ST Inlet: 4 ST outlet: PC inlet 7 PC bottom Pump Off Header /Manifold l Dye S Bottom of system Existing Grade Final grade ( DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER• ,� ho INSPECTOR: 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Permit y 1893 9 Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)J. Permit C C�!'Y PARK — GLEN HILL � f r�;'r j] Town of: State Plan ID N o.: CST BM Elev.: Insp. BM Elev.: 7 BM Description: Parcel IM-4025 -20 -000 TANK INFORMATION ELEVATION DATA A9700192 7/09'97 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �,e,�n / J r j Benchmark Dosing u� px -zmt , /�l , e?. ��� a� /o(v ,O K Aerati Bldg. Sewer Holding St /hd Inlet TANK SETBACK INFORMATION St/ 0 Outlet g 39' 9 TANK TO P / L WELL BLDG. Ae Intake ROAD Dt Inlet �, y3 9, Septic NA Dt Bottom / ?,15 Dosing NA "I`eaSk / Man. Aeration NA Dist. Pipe Holding Bot. System � 93� PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand � ° rte` , J�' 103, 70 Model Number GPM ' i TDH I Lift Friction I System TDH Ft Loss m ead Forcemain Length d' Dia., '' Dist. To Well "o, SOIL ABSORPTION SYSTEM V , BED/TRENCH Width Length No. Of Tr nches No. Of Pits Inside Dia. Liquid Depth ° DIMENSIONS IMEN SYSTEM TO P / L BLDG WELL LAKE / STREAM LEAC nufa SETBACK CHAMB .., INFORMATION Type 0 Mod Number: a System: t< �- OR IT o DISTRIBUTION SYSTEM I oWer -/ Manifold Distribution Pipe(s) �� x Hole Size x Hole Spacing Vent To Air Intake Length Dij Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only . g Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed / Trench Center Bed /Trench Edges Topsoil [I Yes No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) 6- LOCATION: SPRINGFIELD 11.29 15.170 1049 RUSTIC R AD #3 /p �3 P , ``' "r✓a�i- r r v 'r? �c- ' "� � AD'ta a �„= '�: /s� ✓.�:G4�_�"> jr " Plan revision requ ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3197) Date s rec3 Cert. No. / In Signatur inspector's Si ADDITIONAL COMMENTS AND SKETCH ` SANITARY PERMIT NUMBER: L i i I Safety and ofBuil Bui W a te r D iv i s io n SANITARY PERMIT APPLICATION Bureau of Buildin Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. ST CROIX • See reverse side for instructions for completing this application State Sanitary Permit Number 99 31 The information you provide may be used by other government agency programs ❑ Check it revision to drevious application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION S97 -40226 Property Owner Name Property Location ST CROIX COUNTY PARK GLEN HILLS NW 1/4 SW 1/4, S 11 T29 • N, R 15 ) W Property Owner's Mailing Address Lot Number Block Number 1049 RUSTIC ROAD # 3 City, State Zip Code Phone Number Subdivision Name or CSM Number GLENWOOD CITY WI 1 54013 1 (715)265-4613 II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ cit Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Tow OF SPRINGFIELD RUSTIC ROAD #3 Ill. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 034 - 1025 -20 2 ❑ Assembly Hail 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 box on line A. Check box on line B, if applicable) A) 1 ❑ New 2. [3 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 Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 [X Mound 30 ❑ Specify Type 41 []Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 600 2000 2000 .3 N/A 103.83 Feet 106.17 Feet Capacit VII. TANK in Ca allo s Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank 1200 1200 1 JMIDWESTERN PRECAST ❑ ❑ ❑ ❑ 1 ❑ Lift Pump Tank /Siphon Chamber 1200 1200 1 MIDWESTERN PRECAS ® ❑ I [] ❑ I ❑ 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: ( Stamps) r220292 MPRSW No.: Business Phone Number: BENNIE HELGESON 715/265 -4613 Plumber's Address (Street, City, State, Zip Code): W1229 770TH AVENUE, SPRING VALLEY WI 54767 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issuing Agent Signature (No Stamp Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination c�0 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: I t S80-6398 (R. 05/94) DISTRIBUTION: Original to County, One ci)py To: Safety & Ruildings Divi ion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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 -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 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 isto 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 1/2 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 j 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. i -- ----- ----- ----- ----- - ----- ---------- ------------- ---- ------ ---- ---- -- -------------------------- ---- 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. I r - SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Commerce April 21, 1997 2226 Rose Street La Crosse WI 54603 HELGESON EXCAVATING W1229 770 AVE SPRING VALLEY WI 54767 RE: PLAN S97 -40226 FEE RECEIVED: 220.00 ST CROIX CTY PARK /GLEN HILLS REFUND DUE: 30.00 NW,SW,11,29,15W TOWN OF SPRINGFIELD COUNTY OF ST CROIX MOUND SYSTEM The Department has reviewed the above- referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters Comm 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter Comm 82 or in chapters ILHR 50 -64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. An overpayment was made in the required fees and you will receive the refund noted above in six to eight weeks. ks . Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, 6 er rd M. Sw m P an Reviewer Section of Private Sewage (608) 785 -9348 SOD -7997 (8.11/96) �.. .:. Fc Private Sewage System Plan Index/Checklist Op s ot t> & 9 9? All plan sets should be legible and permanent copies, organized into sets, bound with staples and covered B( p� by an index sheet such as this sample. No other pages need be signed as long as the index sheet for each 0/V set is signed. Your cooperation expedites your plan review and shortens plan entry time. Plan ID # Owner's Name S97 -40226 ST CROIX COUNTY PARK GLEN HILLS Le al Descri tion Address g NW4 f S�Wj, S 11 T 29 N R 15W W1229 770TH AVE CityNillagefrown County SPRINGFIELD TOWNSHIP IST CROIX Contents Comments /Special instructions Page # Included Two copies needed for all plans 1 X Plot Plan 2 X Plan View/Lateral Return by Mai 3 X Cross Section 4 Tank & Pump/ Q FakL,etterto (County)!(Submitter) X Siphon Information Circle One and Provide Fax #: ( ) 5 X System Sizing (Public) 6 Q Calf for Pick -Up: (, 7 Other. I, the undersigned, hereby certify that the Seal (if applicable) plans and specifications submitted herewith were prepared under my direction and control. Plumber/Designer License/Registration # BENNIE HELGESON 220292 Address City State W1229 770TH AVENUE SPRING VALLEX WT 54767 Signa ure _ For Office Use O ySySTEh1 Attachments: F : o3'vr vl SEV4AG - Application jli Soil & site evaluation / g L iy Fee Needed for Holding Tank Submittal: '. �' a One copy of notarized holding tank. Gt � agreement. (Originals to County) R HAN OF 1WS my, L,BB hD BUILDINGS Needed for At -Grade Submittal: otVIS10% OF Skf Original signed and notarized Application for "Use of an At- Grade" pC Np�hICE SEE C County on -site One additional set of plans SBD -10268 (N.01/96) -vv S9 3�, P" A F of cn TT oA F v cr' A l o _ � R R m r IA EJ � o b v `1� "d X s Page Of Cross Section Of A Mound Using A Trench For The Absorption Area Tito o�- i rvi L 3� H Medium Sand Fill � 1 F — 6 T o p soi 3 E D Trench O -.2h" Aggregate, Plowed Layer 6" Below Pipe, Covered. With D / -33 Ft. Straw, Marsh Hay Or Synthetic Fabric E i Ft. G / • Ft. F S ao. = Ft. H 1� 5 Ft. Plan View Of Mound Using A Trench For The Absorption Area L .... Distribution Pipe Permanent Observation Pipe ti W r B K I \Trench Of" - 2�2 Aggregate 1- f A �" _ "t. I Ft. K Ft. W Ft. B ZM Ft. J 7 2 Ft. L Ft. License Signed- — Number: ��C:��� _ Date: _ T� ±x r ��s Page_ Of Distribution ` Pipe Detail For Lateral Network PVC Force Main Holes Located On Bottom Are Equally Spaced End Cap 7 F ( X 1 PVC Distribution Pipe P a.S A bm& ole Should Be Next To End Cap ! First hole to be It from manifold end of bed p q 76- Ft. Hole Diameter Inch X ( C) Inches Lateral Diameter Inch(es) Y 3 0 Inches Force Main Diameter _ Inches # Of Holes /Pipe( Invert Elevation Of Laterals jog_ 3 Ft. • 'k CnLx^b -S4 r-(s-w;lv L ) PUt CHAMBER CROSS AMC/ 5PEwjF . /IIU�!`: VENT CAP 4 "C.I. vEtiT PIPE WEATHERPROOF APFROVED LOC.:'.: %;(, Z5' =RO•^1 DOOR, JUNCTION BOX MANHOLE COVEF. WINDOW OR FRESH 12 "MIU. AIR INTAKE GRADE 4" MIN. ` -- 18 /`CI U. CONDUIT _ __ --- ' - - - - -- INLET PROVIDE I - - - -- � T AIRTIGHT SEAL I III V APPROVED JOIIJT A I III APPROVED JOIUTS W/C.=. PIPE I I W /C.I. PIPE EXTENDING 3' I I ALARM EXTEUDIUG 3 01JTO SOLID SOIL B ( II ONTO SOLID SOIL I I / c 1 I o LLEV. C G•- 3 FT. i PUMP - -� ,� OFF D CONCRETE BLOCK RISER EXIT PERMITi'ED OIJL'J IF TANK MANU ACTURE.R HAS SUCH APPROVAL l & /SEPTIC E , SPECIFI•CATIOUS DOSE TANKS MANUFACTURER /"I : JU �'rh � Agf NUMBER OF DOSES: 31 75 PER DAy KS-- SIZE: GALLONS DOSE VOLUME ALARM MANUFACTURER: :� • �Iec � 4,f INCLUDING 6ACKFLOW: l� sy GALLONS MODEL NUMBER: J CAPACITIES: A =2_LINCHES OR 7 S � /l � l gGALLOUS SWITCH TYPE: B = / _� — IUCHES OR 6_ GALLOW _PUMP MANUFACTURER: C = �P- IUCHES OR J I ALLOIJS - 71 MODEL NUMBER: -39 (� D =.r2'>y_INCHES OR �S GALLOWS SWITCH T`JPE: I-e MerL LktI 4 PC K� -I NOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE 1 GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. 9, Q FEET + MINIMUM NETWORK SUPPLY PKE , • • • .. • • , , 2.5 FEET + lg F OF FOR M AIN X +'J F/oa rT.F KIC TION FACTOR.. FEET TOTAL OJIJAMIC. HEAD = ) , as _ FEET INTERNAL. DIMEWSIOWS OF TANK: °j.LE ".,C;TH _ ;WIDTH —. 5 " 9 11 ,; LIQUID DEPTH 51GIJE LICEIJ�F UUMQER: Q 1 _ DATE: • N;I�S � �� 11&e- 3871 MODEL: S(„� meC$� SIZE: 3/4" SOLIDS RPM: 1550 Effluent Pum p HP: 0.4 METERS FEET • � I 25 Q 7 - w g 20 I n 5 z 15 z I ~O 3 10 2 5 1 . -.. 0 0 1 1-- 1 . .......... . . ...... -1 0 10 20 30 40 50 GPM 0 2 4 6 g 10 12 m' /h CAPACITY NGOULDS PUMPS, INC. cSe CA FAILS f NCW 13148 I Effective October, 198E O 1988 Goulds Pumps, Inc. SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE PRINTED IN U.S.A. i r^ r •. 6' 9 1 jgeo':r j O7w9 a, 3 6 ze S .. � 1 r 1 - 1 _ o p r _. ,.. j Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page J__ of i Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 'Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but '�L ' �'/ not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 0:3 /0-2. �O APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION M �� ' �S GOVT. LOT �/ 1/4 Sk/ 1 /4,S T ,N,R J 5 aW W ax - 11 PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # I SUBD. NAME OR CSM # o / os r e- CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OW NEAREST ROAD i S'yvl3 (7l) (j New Construes oo p Use [ ] Residential / Number of bedrooms N bg (] Addition to existing building Replacementc *ger�k +M Public or commercial describe �> e r r 662k GmT C e roc s xromn t minis r Code derived daily flow 6 00 gpd 050-3 Recommended design loading rate . 3 bed, gpd/ t trench, gpd/ft � Absorption area required QOO bed, ft 15W trench, ft Maximum design loading rate . 5 bed, gpd/ft _trench, gpd/ft Recommended infiltration surface elevation(s) 103,6 It (as referred to site plan benchmark) Additional design/ site considerations b `� Z Wei '� rd Parent material r ja 0 t Cf 4 1 Flood plain elevation, if applicable IV Aq It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT-GRADE SYSTEM IN RLL HOLDING TANK U= Unsuitable fors stem [Is O U ®S ❑ U ❑ S S U [Is ®U [Is Z U CI S ® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmr& Ina C M Ft? L" S 3 G'o 5" 2 M 5'bk fYl Fe 6 3 M .5 Ground 3 6 � S% Sil 2 M sbk � F� Cs • zrr ,s l eft. Q .Z ;Z (VA Sbk M Fe 1 4s -Z- 6116 r Depth to ,� J el L �jo ` & limiting factor fr Remarks:) S(+ A s oh Boring # 1 0_6 l o Q 3 I 1 S"/ 2 -rr s'6 Fie .� 3 ,-0 1 w: z ; r^ 5 rn'Fie 6 S Zeo ss } Ground SQL- 1 rn+ S6 k M F2 C S Zr►1 , elev7 � 7-3 6",R y� 5.4- l m 56 k f'+T F/Z /45 Depth to . limiting factor � \ � ccc� l'�►(r+1 tt � 5«vC�i �t�5 +r►-� _ 1 S� J Remarks: s 0 // p P D�S rrl� A w CST Name. Please Print <S E Phone: Signature- K. Date: CST Number: �/ JlO a yes PROPERTY OWNER 54, VARX5 SOIL DESCRIPTION REPORT Page .of } PARCELI.D.# cl :Rq — /o -- ac) ! Depth Dominant Color Mottles Structure GPD /ff . Boring Horizon -Texture Consistence Bourrl3y Roots in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Tn 4A : a 10 _1 o E .5 /3 s t I z m sbk m -F2 as s Ground 3 19 - '33 to we 6 8 k Pq fl` 14S $ 5 elev. l o- , 5. ft. 33- �5'q C6 sCl z r» Sb rn ,' - if OR 1.Z Depth to limiting factor Remarks. n �A lv `. o? r, �r ka Boring # lQry• n`. .. Ground elev. ft Depth to limiting factor Remarks: Boring # M IMIC S , Ground eleV. ft Depth to limiting factor Remarks: Boring # Ground elev. ft . Depth to limiting factor Remarks SBD- 8330(R.05/92) Z/ 9 t y �• n f ' lo ci / (a / I df -,� Zl ool y _ c _..rte � •`�� - � � � � I • o '( o {, CIO N c • ot n r rt tp (X- rl CA 0 m o r �p 1 XAS U1 In n I R Ob i n r� .f- s' �tz � i I r i i STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OVVNER/BUYER S CROIX C PARK (GLEN HILLS) MAILING ADDRESS 1049 RUSTIC ROAD #3, GLENWOOD CITY WI 54013 PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY /STATE PROPERTY LOCATION NW 1/4, SW 1/4, Section 11 T 29 N -R 15 W TOWN OF SPRINGFIELD ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: 6L?i2 DATE: Z S"J 7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - loo This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------- owner of property St Croix County Parks ( Glen Hills Park Location of property NW 1/4 SW 1/4, Section 11 ,T -R 15 W Township SPRINGFIELD Mailing address 1049 RUSTIC ROAD #3, GLENWOOD CITY, WI 54013 Address of site Subdivision name Lot no. Other homes on property? Yes X No Previous owner of property Allen L. & Delores E. McClelland Total size of property 696 Acres Total size of parcel _ 696 Acres Date parcel was created April 26, 1966 Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? Yes X No Volume 422 and Page Number 510 as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. 284125 , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. gn ture of Applicant Co- Applicant 4 -25 -97 Date of Signature Date of Sianatura DOCUMENT NO. .� WARRANTY OLEO vot_ 4 PVEe510 STATE OF WISOONSIN —FORM 9 2 84125 , THIS SPAM iEIIBIM POR 10MODIC DATA THIS DWENTM Made by Al 1 Pn L. _ mt,01p1 l�Tld_a11d�_ f2etG13TldR8 OFFICE T1r�l nraS F_ MnC'l r�l l anrl' finch . ..and aid --;4 Q aS ST. CROIX CO., WIS. rm nt tenants Recd for Record this__?.?_th grantor - -of - qt. f'roix County. Wisconsin, hereby conveys and warrants day of --- AP.ril____A,D.19_ to qt- rroi Zr rni Sni l —A hl a +n T' Vnn -P On 2t_ :00 - -- 1111. , Regt �of 4 .4' Of grantee RETURN TO G# .- _�'poi X County. Wiscoasin, for the sum of `l'hi rt3t —OnP Thntrsand (S 0011 - 0O) _ Richard P'. Rivard I)01_1 ors Sils�uii2c2si_ CiL1. ,i:�. the following tract of land in — St- Cyojx County, State of Wisconsin; South Half (S 1/2), of the Tlorth vest f ltd trlc "ISo �n F f - (IJ, „1/2Y �{ of the South West Quarter (SW 1%4), Section' 11, Township'29 North, Ranpe`15:West. t I,: t I 4 ' ` I � 1 1 4't VW 1V'Y 1 r r "f' IN WITNESS WHEREOF, the said grantor C L ham_ ere hunto ' s ' et 'tlli�i— hand P. and seal g_ this day of -- April , A. D., 19 s 't • SIGNED AND / SEALED hN PRESENCE OF ( (SEAL) I P l la _ -;u: �— �+`.a�+'t' --•ew '+r4 a �.'• -..” ';r � _"i °i�a".`c' ,"r�z .' . -A.,, , Y tam) , is Richard P.'- Rivard (SEAL) STATE OF WISCONSIN. St Grnix County. } as. Personally came before me, this ^ .._ - day of Apri , A. D., 19-" the above named —Al l eh I, i•iccl Pl l and and Del nres E McClelland, his wife 1 to me known to be the person d''t who executehe foregoing Instrument and acknowledg Velme T t a NOTARY Richard P. Rivard 47 This instrument drafted by Notary Public St. roiX county.Wis. Richard P. Rivard ,5 I myCommre>rlon4Qije4kfs) Permanent (Saeon 69.51 (1) of the w at lecanp &at "providas that ati nts Instrume to he recorded ehaH have vtainly printed or typwKnea thereon the ` i3emes o[ rho grantors, grantees. witnesses notary)., ^M WARRANTY DEED —STATE OF WISCONSIHV FORM NO. 9 ,. .L M C NILUA CO.. UILVAUKU s alg _per da � are Scosc 'I r=? 2 ! _ Ge-ol,S O7?� 9 re 7`G veer js l(f 7ye 5 y_Y_Am � a O 4 � �q w x U � Z Q � x Z N o � � a H z .fi F <►- J D a 0 IL Z Q O V) ` oc ? o J z O O Q4 ''� W o° o'r T o N �Y W w o� CX 0 k � N J o0 C1 0 O LL z i