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Parcel #: 038 - 1013 -30 -000 10/12/2006 02:56 PM
PAGE 1 OF 1
Alt. Parcel M 3.31.18.34A 038 - TOWN OF STAR PRAIRIE
Current X'i ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
LAWRENCE L CARSON O - LARSON, LAWRENCE L
12972 FRENCH WAY
APPLE VALLEY MN 55124
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description " 2383 CARDINAL DR
SC 3962 NEW RICHMOND
SP 1700 WITC
SP 8055 CEDAR LAKE /N R
Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE
SEC 3 T31 N R1 8W PT GL 1 COM W SHORE Block/Condo Bldg:
CEDAR LAKE 882' SLY OF N LN, TH W 300'
SLY 250'E 300' TO LAKE, N ON LAKE 250' Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
TO POB EXC P34B 03-31N-18W
Notes: Parcel History:
Date Doc # Vol /Page Type
04/0112004 758320 2539/64 EZ -U
991/301 QC
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/27/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 185,600 335,600 521,200 NO 10
Totals for 2006:
General Property 0.000 185,600 335,600 521,200
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 185,600 369,000 554,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Wisconsin Department of Health and Social Services
Plb. #67 Division of Health
PERMIT APPLICATION
for
PRIVATE DCMESTIC SEWAGE SYSTEMS
A. OWNER OF PROPERTY TYPE OR USE BLACK INK
Name Address (Street, City, Zip Code)
A 4A1-12-e---- - \-
County
B. LOCATION OF PROPERTY WH FRE SYSTEM WILL BE CONSTRUCTED AL TERED C EXTENDED /
Check Ones _ `yi n -
CITY VILLAGE GA DESCRIPTIONt� Aa r /
TOWNSHIP 4, � �" 3 iA" /�
C. IS LOCAL PERMIT REQUIRED FO RK? //' YES NO ° O ^bar / 4.
D. SEPTIC TANK CAPACITY (C Gallons NEW INSTALLATION / ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUMBER OF TANKS TO BE INSTALLED:
E• TYPE OF OCCUPANCY
Check One: One or Two Family Residence �' / Commercial Industrial Other
Specify
' Number of Persons to be Acoommodated
F. APPLIANCES, ETCS Food Waste Grinder YES t� NO Automatic Clothes Washer YES 1-- -- N O _
Dishwasher YES NO Automatic Potato Peeler YES - LINO
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW G EXTENSION ADDITION REPLACEMENT
Tile Size No.Lin.Feet Trench .Width Depth Number of Lines
Seepage Beds Length Width Depth Tilo Size No. Lines
: Seepage Pitt Inside diameter _ Liquid Depth
P E R C O L A T I O N T E S T
Test Depth Character of Soil Hours Water Test flime Drop in Water Level Inches I;inutes
Number Inches Thickness in Inches Since Hole in Hole Internal Second to I Next to Last "o Fall
____ lst Wetted Overni ht in Mi:artes Last Periodi Last Period Period Une Inch
Example
P- 0 36" Top Soil 10" Cla y 26 25 yes or no 30 1/2 1/2 1/2 60
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in acoora with H 62.20 Wis. Administrative Code.
S 0 I L B 0 R I N G S- Minimum 36" Below Prop osod Absorption S stem
oring Total Depth Depth to Ground Water Depth to Bedrock
umber Inches Observed Estimated Observed Estimated C haracter of Soil with Thickness in Inches
xample
n
0 72" 72" Black Top Soil 12 "• Cla_y 18"; Sand 18 Gravel 24"
r
.
O r
�w
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
COMPLETE OTHER SIDE
1, 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.
n
NAME !�l l �, C - '(J i h S TITLE
Type or Print)
REGISTRATION N0. �� S % or MASTER PLUMBER LICENSE No.
ADDRESS } /(
/ 4
i�
DATE 7� . - 1 . � � � C' SIGNATU:� " 7 c L� _ � ._ .l �r y - 1
i
MASTER PLUMBER MAKING APPLICATION
> >� MP
Signatures J- ' '� LL . _ License Numbers
MP RSW
(To be Completed by Issuing Agent)
Date of Application �+ % __ Fee Paid
Permit Issued (date) Permit Number
Agent (name) i r ���� � '��� _ For: �'
__,
Town, Village, City, ounty, 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 IN- — U ACCEPTED BY �. RETURNED
111
(Initials) r CC�� (Date) See Corres, r
FEE RECEIVED '.. VALID. N0. / 7 S U PERMIT N0. 7
1 7 TI - I or No) .
REVIEWED BY APPROVED DATE
(Initials) Yes or No)
COMMENTSs
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Parcel #: 038 - 1013 -30 -000 09/13/2005 10:20 AM
PAGE 1 OF 1
Alt. Parcel #: 3.31.18.34A 038 - TOWN OF STAR PRAIRIE
Current �X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co -Owner
LAWRENCE L CARSON O - LARSON, LAWRENCE L
12972 FRENCH WAY
APPLE VALLEY MN 55124
Districts: SC = School SP = Special Property Address(es): " = Primary
Type Dist # Description ` 2383 CARDINAL DR
SC 3962 NEW RICHMOND
SP 1700 WITC
SP 8055 CEDAR LAKE /N R
Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE
SEC 3 T31 N R1 8W PT GL 1 COM W SHORE Block/Condo Bldg:
CEDAR LAKE 882' SLY OF N LN, TH W 300'
SLY 250' 1 N ON LAKE 250' Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
TO P XC P34B 03 -31 N-1 8W
Notes: Parcel History:
Date Doc # Vol /Page Type
04/01/2004 758320 2539/64 EZ -U
991/301 QC
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations Last Changed: 10/12/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 185,600 1,200 186,800 NO
Totals for 2005:
General Property 0.000 185,600 1,200 186,800
Woodland 0.000 0 0
Totals for 2004:
General Property 0.000 185,600 1,200 186,800
Woodland 0.000 0 0
Lottery Credit Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
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Wisconsin Depw1ment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 430446 0
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J.
Permit Holder's Name: City Village X Township Parcel Tax No:
Larson, Larry Star Prairie Township 038 - 1013 -30 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
/ 0 at D Z)D. a W �� 03.31.18.34A
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic / 6 Benchmark 00• D 4 b
,, S / l
Dosing b0 / qO Alt. BM,-- .0 0 tJ /
I o, �� 3 i
Aeration Bldg. Sewe
L-1 s
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION ..�'
TANK TO P/L WELL BLDG. Vent to Air Int ROAD Dt Inlet l
-50 Q Z, 4-(� --
Septic 1, a Z Dt B tto I
Dosing (/ e
ea a r an. •0
Aeration D ist. Pipe y 10. 5
V • 1 zg-
Holding Bo System Z ?S-
It%lc 2 `Z • Z4 4. q S �
PUMP /SIPHON INFORMATION NOT Final Grade ,
few st �. s - - a `f S • rte"
Manufacturer Demand St Cover
GPM 1D 3.1
Model Number Dr n Yex_" , Z Q
TDH Lift � Frictio� LASS System Head T1, i0 Ft 1' T-
3 1
la"6 teT6�
Forcemain Lengt Dia. Dist. to ell
SOIL A PTI N SYSTEM 2
BED /TRENCH Width / Length i No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS -7 Y
SETBACK SYSTEM TO / 7 P/Lls JBLIDG IWE LL LAKE /STREAM LEACHING Manuf re
INFORMATION Ty e Of System: CHAMBER OR t6 {()S -� s
�7 _7�' I UNIT Model Number:
DISTRIBUTION SYSTEM
Header/ ni old x Hole Size x ng Vent to Air Intake
Pipe(s) If 11 r t ! / > 4fJ
L th Di Length Dia Spacin
SOIL OVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over t Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil �� J
U Yes No Yes
No
COMMENTS: (Include code discrepencies persons present, et ) Inspection #1: / / U 3 Inspection #2: / t 1,4 /0
Location: 2383 Cardinal Drive New Richmond, WI 54017 (�nknVM 3 T31N R18W) NA Lot GL 1 9 Q —fwvt Parcel No: 03.31.18.34A
1.) Alt BM Description by 0 � k O tAJ 5t S. ''
2.) Bldg sewer length = / mid /VD -{� (ot 01 S �
- amount of cover = l
Plan revision Re uired? Yes "� No
Use other side for additional information. 1 ___lS
Date 0 � pc SigJla re � dJY�f� %L��f/Carl N�:.a
SBD -6710 (R.3/97)
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
;a ST. CfOIX COUNTY GOVERNMENT CENTER
- -� 1101 Carmichael Road
Hudson, WI 54016 -7710
(7,15) 386 -4680 • Fax (715) 386 -4686
EROSION CONTROL PLAN __rcel #03.31.18.34A &4� "(3d
Part of Gov't. Lot 1.2383 Cardinal Dr. (Star Prairie ) — Owner(s) Lawrence Larson
Under St. Croix County Zoning Code 17.70(3)(b) 5: "The (Zoning) Administrator may attach reasonable erosion
prevention conditions to a permit approved for issuance." Wisconsin Admin. Code Comm. 21.125 requires the
building permit applicant and/or landowner to follow erosion control procedures and maintain them until the site
has been stabilized.
The Owner is responsible for notifying all contractors performing construction on this site that an
Erosion & Sediment Control Plan (ESC Plan) is in effect and the following activities will be required
in order to maintain compliance with the plan:
1. The primary source for construction site runoff will be the house foundation excavation, driveway, and any
soil stockpiled until final grading and stabilization is complete. Septic system excavation/installation adds
to temporary disturbance, but establishing cover on exposed soils will prevent erosion. Plan to apply seed
and mulch as recommended in #5 below. Maintain existing vegetation wherever possible to minimize
sediment movement. Plans submitted indicate house construction and the proposed septic system are >100
ft. from the shore of Cedar Lake.
2. Route contaminated runoff into stabilized vegetated buffer areas by creating temporary diversions graded
ALONG CONTOUR between excavated areas and any drainage ditches or waterways (see attached detail
for construction of temporary diversions). Make sure no concentrated flow of construction runoff is
directed toward the lakeshore.
3. If builder /excavator grades the site to create temporary diversions (see #2) to contain sediment and leaves
adequate vegetative cover to protect areas of concern, installation of silt fence MAY not be necessary. Silt
fence or other approved sediment control products will be required if sediment cannot be contained on
owner's property with the diversions and vegetative buffers. The Building Inspector or POWTS
Inspector will evaluate ESC plan effectiveness and make recommendations to owner for any action required
to comply with applicable regulations.
4. Construction equipment and vehicles must utilize a stabilized driveway access off public road for heavy
equipment; this includes cement trucks, well drillers, and other contractor's vehicles that access the property
during construction. This helps avoid muddy, rutted conditions that may allow contaminated runoff to reach
waterways and/or drainage ditches. Property owner must repair damage to ditches resulting from multiple
access points and sediment tracked on public roadways must be removed at the end of each workday.
5. Stabilize all disturbed areas with topsoil cover, seed and mulch immediately after final grading. If weather
does not permit seed germination, a heavy straw mulch cover will prevent erosion until grass /vegetation can
get established. On steep slopes or areas with little topsoil cover, erosion control matting can be applied any
time of year and if installed properly, will provide protection even if seed germination is delayed.
The owner of record during site construction will be responsible for compliance with the ESC Plan.
Please feel free to contact me with questions regarding eros* n & se 'm ontrol installation.
Prepared by: Pa m Quinn, Soil Erosion Ins ector #6650 4
Owner acknowledgement of ESC Plan re uirements �/,Z /2003
Safety and Buildings Division County
201 W. Washingt Ave..
P.O. Box 7082
Madiso n, WI 53707 — 7082 Sanitary Permit Ntunber (to be filled in by Co.)
NVisconsin O 3 0 608 261 -6546
Department of Commerce
State Plan D. Number �
Sanitary Permit Application. , z-f� l v
in accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide L Pte�
may be used for secondary purposes Privet Project Address (if different than mailing address)
I. Application Information — Please Print All Informatic n r �,
Property Owner's Name 1 F7007
_ 0 Q Parcel # Lot # Block #
lQ r
Pt Owner's M ' ' g Address ,"I `' Property Loc Lion
operty
y ZONING OFFICE / /L'��I'I / �-M- //��
T I'd — VV V V4, /4� Section
V
City, State Zip Code Phone Number
va-& A/ I /' / circO
J J! T L N; >1� E
e of Building (check all 410 apply) '
Subdivision Name CSM Number
or 2 Family Dwelling - Number of Bedrooms
❑ Public/Commercial — Describe Use
❑ State Owned — Describe Use ❑City ❑Village owtuhip of
IIL Type of Permit: (Cher on line only one box A. Complete line B If applicable)
A. New System 1 1 - Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
. Tyne of POWTS System. Check all that a 1
on — Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
Constructed Wetland ❑ Pressurizod round ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter, p ❑
Recirculating Synthetic Media Filter ding QLknber ip Line ❑ Gravel -less Pipe ❑ Other (explain C,
V. Dis ersaVrreatment Area I ormation:
Desip Flow (gpd) I Design Soil Application Ra gpds tspetsaI Area Required (st) Area Pro posed (sf) S t EleviLtio
VI. Tank Info Capacity in Total Number anufacturer Prefab Site teel F i&-r 'Plaitic
Gallons Gallons of Units _ Concrete Constuuted lass
New Tank Tanks l
Septic or Holding Tanis
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement - 1, the underd assume responsibility for installation of the POWTS shown on the attached plans.
Plum 's Name (Print) PSign MP/MPRS Number Business Phone Number
(d pan - Z
— V 0
Plumber's Address treet, City, State,
I. our /De artment se Onl
Sanitary Permit Fee (i cludes Groundwater Da Issued uing Age t Signature s�
IP( Pproved ❑ Disapproved j�
Surcharge Fee) QI (f1�
❑ Owner Given Reason for Denial w � D
IX. Conditions of Approval/Reasons for Disapproval_
STEM OWNER:
f: , SL ���
1� Septic tankk, , effluent filter an �Q.t,ryyl
dispersal cell must all be serviced / maintained T_!^ -�
as per management plan provided by plumber. &
All setback requirements must be maintained /_� pt Q/� d �9
• 33
as per applica a code /ordinances. — t4
3. » r r s
Attach complete plans (to tW County only) for the system on paper sot less than 81/2 s 1 lathes is size
SBD -6398 (R. 08/02)
PL T PLAN
PROJECT Lanv Larson ZDDR 12 972 French Wav Aoole Vallev Mn 55124
1 / 4 1 / 4 S 3 /T 31 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 10/8/03 BEDROOM 4
CONVENTIONAL IN- GROUND ! S JRE CONVENTIONAL LIFT )00( HOLDING TANK
0
MOUND SEPTIC TANK SIZE gallons LIFT TANK SIZE -AW I gLTO DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 9A�#'1 y of chambers
IL BENCHMARK V.R.P. Top of Power Box ASSUME ELEVATION 100 Filter Zabel A -100
❑ BOREHOLE O WELL «H. R. P Same as Benchmark
SYSTEM ELEVATION 95.7/94.9/95.3 3.5' below grade
Alt. BM Top of Slab @ 97.5'
Cedar Lake
ent
>6 » Standard Biodiffuser
of Cover Leaching Chamber
with 3 1. 1 ft2 of Area
11 " sig Using
' 6' Long Grade at System Convention owts
34" Manual Ver ' n 2.0
c Proo 15'" 150
N Bedroom , Com Tank
Well House
rV
20
a 4 ra
40' 8% , 10'
Slope B -2 25'
10 ,
10' 8' 35' 30' 40'
1
V B -3 Vents hed
3 -3 X.49
Cells with >3'
S acing
ed must be
removed
inorder to ,/ ¢
To Cardinal
install system°
Drive o
N
135 Property Line
ST. CROIX COUNTY
, WISCONSIN
ZONING OFFICE
ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016 -7710
EROSION CONTROL PLAN fFJ&e1 63T.1W3 4A 7 15) 386 -4686
Part of Gov't. Lot 1, 2383 Cardinal Dr. (Star Prairie ) — Owner(s) Lawrence Larson
Under St. Croix County Zoning Code 17.70(3)(b) 5: "The (Zoning) Administrator may attach reasonable erosion
prevention conditions to a permit approved for issuance." Wisconsin Admin. Code Comm. 21.125 requires the
building permit applicant and /or landowner to follow erosion control procedures and maintain them until the site
has been stabilized.
The Owner is responsible for notifying all contractors performing construction on this site that an
Erosion & Sediment Control Plan (ESC Plan) is in effect and the following activities will be required
in order to maintain compliance with the plan:
1. The primary source for construction site runoff will be the house foundation excavation, driveway, and any
soil stockpiled until final grading and stabilization is complete. Septic system excavation/installation adds
to temporary disturbance, but establishing cover on exposed soils will prevent erosion. Plan to apply seed
and mulch as recommended in #5 below. Maintain existing vegetation wherever possible to minimize
sediment movement. Plans submitted indicate house construction and the proposed septic system are >100
ft. from the shore of Cedar Lake.
2. Route contaminated runoff into stabilized vegetated buffer areas by creating temporary diversions graded
ALONG CONTOUR between excavated areas and any drainage ditches or waterways (see attached detail
for construction of temporary diversions). Make sure no concentrated flow of construction runoff is
directed toward the lakeshore.
3. If builder /excavator grades the site to create temporary diversions (see #2) to contain sediment and leaves
adequate vegetative cover to protect areas of concern, installation of silt fence MAY not be necessary. Silt
fence or other approved sediment control products will be required if sediment cannot be contained on
owner's property with the diversions and vegetative buffers. The Building Inspector or POWTS
Inspector will evaluate ESC plan effectiveness and make recommendations to owner for any action required
to comply with applicable regulations.
4. Construction equipment and vehicles must utilize a stabilized driveway access off public road for heavy
equipment; this includes cement trucks, well drillers, and other contractor's vehicles that access the property
during construction. This helps avoid muddy, rutted conditions that may allow contaminated runoff to reach
waterways and/or drainage ditches. Property owner must repair damage to ditches resulting from multiple
access points and sediment tracked on public roadways must be removed at the end of each workday.
5. Stabilize all disturbed areas with topsoil cover, seed and mulch immediately after final grading. If weather
does not permit seed germination, a heavy straw mulch cover will prevent erosion until grass /vegetation can
get established. On steep slopes or areas with little topsoil cover, erosion control matting can be applied any
time of year and if installed properly, will provide protection even if seed germination is delayed.
The owner of record during site construction will be responsible for compliance with the ESC Plan.
Please feel free to contact me with questions regarding erosion & sediment control installation.
Prepared by: Pam Quinn, Soil Erosion Inspector #665054
Owner acknowledgement of ESC Plan requirements: / /2003
10/09/03 THU 15:51 FAX IM 002
MA �RVI N
Warroad. MN 56763 Windows and Doors
1- 800 -346 -5044
www.marvin.com Maq le for you
TAM we ! ' i
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OSCEM& In
(115J 116 • FAX
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Indicate management strategy by checking (/) the appropriate box:
Qom _� Management Strategies 05 C,Ullf
D 21" stabilization of disturbed areas. P
Note: It is recommended that disturbed areas and soil piles left inactive for extended peril ids of time be stabilizWd
—/ by seeding (between April 1st and September 15th), or by other cover, such as tarp ing or mulching.
l2 Permanent stabilization of site by re- vegetation or other means as soon as possible (lawn establishment).
Indicate re- vegetation method: Seed Sod[] Other ❑
Expected date of permanent re- vegetation: S Rit.+Llf. �a0y
Re- vegetation responsibility of: Builder D Owner /Buyer ❑
Is temporary seeding or mulching planned if site is not seeded by Sept. 15 or sodded by lk ov. 15? Yes D No O
D I" Use of downspout and /or sump pump outlet extensions.
Note_ It is recommended that flow from downspouts and sump pump outlets be routed thrn nigh plastic drainage
pipe to stable areas sudh as established sod or pavement.
❑ Trapping sediment during de watering operations.
Note: Sediment-laden discharge water from pumping operations should be ponded behinc a sediment barrier until
most of the sediment settles out.
Proper disposal of building material waste so that pollutants and debris are not carried off - by wind or water.
Maintenance of erosion control practices.
• Sediment will be removed from behind sediment fences and barriers before it reaches a depth that is equal to
half the barrier's height.
• Breaks and gaps in sediment fences and barriers will be repaired immediately Decompc sing straw bales will be
replaced (typical bale life is three months).
• All sediment that moves off -site due to construction activity will be cleaned up before the a id of the same workday.
• All sediment that moves off - site due to storm events will be cleaned u before the end o
1 . the next workd
y
• Access drives will be maintained throughout construction.
• All installed erosion control practices will be maintained until the disturbed areas they prc tect are stabilized.
For more assistance on plan preparation, refer to Chapters ILHR 20 & 21 of the Wisconsin Uniform Dwelling Code,
the DNR Wisconsin Construction Site Rest Managemenr Handbook, and UW— Extension publicatior Erosion Control for
Home Builders.
The Wisconsin Uniform Dwelling Code and the Wisconsin Construction Site Best Management Har dbook are available
through State of Wisconsin Document Sales, 608/266 - 3558.
Erosion Conrrol for Home Bw/dels (GWa001) can be ordered through Extension Publications, 601: /262 -3346 or the
Department of Commerce, 6081267 - 4405.
10/09/03 nM 15:51 FAX 0 003
EROSION CONTROL PLAN CHECKLIST
Check (/) appropriate boxes below, and complete the site diagram with nec issary Information.
/ Site Characteristics
Cd North arrow, scale, and site boundary. Indicate and name adjacent streets or roadways
Z ❑ Location of existing drainageways, streams, rivers, lakes, wetlands or wells.
O Location of storm sewer inlets.
Location of existing and proposed buildings and paved areas.
j� The disturbed area on the lot.
l/ Approximate gradient and direction of slopes before radio operations,
P grading P
2t Approximate gradient and direction of slopes after final grading operations.
O ZOvedand runoff (sheet flow) coming onto the site from adjacent areas,
Erosion Control Practices
21 -100, 13 Location of temporary soil storage piles.
Note: Soil storage piles should be placed behind a sediment fence, a 10 That wide vege Wive strip, or should be
/ covered with a tarp or more than 25 feet from any downslope road or drainagewa y.
g Location of access drive(s).
Note: Access drive should have 2 to 3 inch aggregate stone laid at least 7 feet wide at d 6 inches thick.
Drives should extend from the roadway 50 feet or to the house foundation (whit ►ever Is less).
PI ❑ Location of sediment controls (filter fabric fence, straw bale fence or 10 -foot wide veget: five strips) that will pre-
vent eroded soil from leaving the site.
.Zo Location of sediment barriers around on -site storm sewer inlets.
g ❑ Location of diversions.
Note: Although not specifically required by code, it is recommended that concentrated f, aw (drainageways) be
diverted (re- directed) around disturbed areas. Overland runoff (sheet flow) from a ijacent areas greater than
/ 10, 000 sq. ft. should also be diverted around disturbed areas.
❑ H' Locatlan of practices that will be applied to control erosion on steep slopes (greater thar 12 grade).
Note: Such practices include maintaining existing vegetation, placement of additional se diment fences, diversions,
and re- vegetation by sodding or by seeding with use of erosion control mats.
❑ Location of practices that will control erosion In areas of concentrated runoff flow.
Note: Unstabilized drainageways, ditches, diversions, and inlets should be protected fm n erosion through use of
such practices as ir►- channel fabric or straw bale barriers, erosion control mats, si eked sod, and rock rip -rap.
When used, a given In- channel barrier should not receive drainage from more the►► two acres of unpaved
area, or one acre of paved area. In- channel practices should be installed in pi irennial streams (streams
with year -round flow.)
❑ 21 Location of other planned practices not already noted.
PL QT PLAN
PROJECT Larry Larson DDRE 12972 French Wav Aoole Vallev Mn 55124
1/4 1 /4S 3 /T 31 1 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 10/8/03 BEDROOM 4
CONVENTIONAL IN- GROUND i 'a� RE CONVENTIONAL LIFT XXX HOLDING TANK
MOUND SEPTIC TANK SIZE gallons LIFT TANK SIZE74W , ( T o DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA $InLr of chamber
,BENCHMARK V.R.P. Top Of Power Box ASSUME ELEVATION 100 Filter Zabel A -100
❑ BOREHOLE O WELL :H Same as Benchmark
SYSTEM ELEVATION 95.7/94.9/95.3 3.5' below grade
Alt. BM Top of Slab @ 97.5'
Cedar Lake
ent
>6 " Standard Biodiffuser
of Cover Leaching Chamber
.a with 31.1 ft2 of Area
1 1 " Plans Designed Using
' 6' Long Conventional Powts
34" Grade at System Manual Version 2.0
o ProA*��' 150
N Well Bedroom 25' Combo Tank
House
�k
40 ' S2' 8% 40' 10'
Slope 10 B -2 25'
10' 8' ' 35' 30' 40'
10B_ ,
0
3
> 0'
Vents Vents hed
Shed B -3
3 -3' X-Q'
Cells with >3'
Spacing
shed must be i
removed >
inorderto t
To Cardinal install system
Drive c
v7
N
135' Property Line
SEPTIC TANK € FUMP CiiAMBER CROSS SECTION AND SPE CIFICATI ONS
_ ABOVE GRADE E W£ATHERPRWF
C l VENT PIPE 12„ MIN. � APPROVED
r�cT�
�H BOX
AFP
> �5+ FROM DOOR, WINDOW OR WI MANHOLE COVER
FRESH AIR INTAKE WITH CONDUIT Wl PADLOCK &
FINISHED fI , ,-WARNING LABEL
.yt. ..,4, MTN.
� S.L7�
28" IN. N C.Z. E1b%R� u
: � t$ MfN•
! x
T k
INLET € `.
6
GAS- t
WATER TIGHT SEALS "��'" TIGHT t .f N APPROVED
F$LTLR ^---w— A SEAL JOINTS WITH
_i f ALM APPROY£D PIPE
APPROVED L _j ON 3' ONTO
PIPE 3' — _ ! SOLID SOIL
ONTO C ; OFF
SOI i
SOLID ONTO
PUMP OF EL £V . � / FT _ '
D
3" APPROVED BEDDING UNDER TANK C TE PAD
SP ECIFICATIONS
DAY: S
SEPTIC / DOSE
NUMBER DOSES PER - /
TANK MANUFACTURER
IU
G DOSE V£ILUi'fE FLa AC�
SEPTIC .
GAL - .
ANK SIZES:
T DOSE GAL.
f C' CAPACITIES: A
/ i�GFiES
ALARM MANUFAC'URER: 2 INCHES 2
GAL MODEL NUMBER = � � SWITCH TYPE - � _ _ _-C --- AL,
K ;�HES ____ _.
puMP MANUFACTURE D = INCHES =� �� �� GAL -
MODEL NUtiBER � 1 .23 y1AC
SWITCH TYPE: �'/
D ptll'�P � ALARM L,tIRIiSG AS PER ILfiR
�� GPYI tle}T FEET
REQUIRED DISCHARGE RATE _— 4FEET
BETW EEN PUMP OFF AND DIST ` f T-014 PIPE • ET
VEgTICA3. NETWORK SUPPLY PRESSURE - • - - -FRICTION FEET
NETWORK Q -FT. £Id23 I'ACTOR . _ . ���....— F£
+ MINIMUM N T/ ltd MEAD
+ �v F'££T FORCEMA. TOTAL DYNAMIC
- ---- -- - D I AM ET£R
L£1�GTHD= S'j pT
INTERNAL DIMENSIONS
n{ PLtMP TANK: LIQUI
I,fCEidS Y-
NUMBER
/ i
SIGNED:
HEAD/CAPACITY CURVE
EFFLUENT and DEWATERING
WARNING: Model 18514185 should not be subjected to less than 30 feet TDH.
TOTAL DYNAMIC HEAD /CAPACITY PER MINUTE
N sl ss
x
ERIE 4 3731 fl 137139 t10N1 /0 161/II61 16]7116) 165N 165 11LHU 166tH 16 1W1161 11U+11f
UL FT. ill Gal. Lera;;' G+1. La ,: Gil. to Gil. Ctrl Gil `;Ctrs G+1 i1.h1 Gil, ltrs GAL LUS: ;? Gil Les:: GAL ales;' G+1 llrt Gil LOS;, G+I. LOS WI. ': Les
14 f 1 ST'i 1N t2 21 109: 'i U 163 4 72 1T3 fl :352 K 1736 106' 101 61 271 tt flf SI Me, 1SS 561 US Se7 1! ' t)l i
42 10 7Aa 131 f0 'I 27 17 34 119 ' 11 371 79 300 90 311' 100 776 61 1711 N 271
;
s1 aa: lu Sae u1 IT2 /s ne
1S If IS 70. 64 > 1 17 i' f1 1p 60 727 - i 60 S1i: SI <- tU 1 : 1+f IS 17
1 3 M CSI': St? is Il 76 'ISU 73 VA.:: IZ 310 sf 22].;! 10 lzTi 31 73e;: 131 5/S 110 Sm 4S 1111
40 23 `7A2: t `30 bl 175 N 200 57 bL` St 133:1 SI 121:: 11t 441 w S07 AS ?
:
l
1 3 30 ,1.1[: ` 63 701 ' SS iti SS 20! Se 720:j >a 3165 St Ile 1N '416 !: 127 Idt l5 :170
/0 :1111. 70 (S1, /i 11t /6 113` 15 Ter: rs 1175 N 220 :i 10! 317 ? 111 q1 If 171.:
3 8 - 125 5 5 - - s0 .1521 21 10 33 12s; !1 tfl! SI 21f> fl 229? to 711; 1D0 171, Is ire;
/S tlt!i 7t 176:1 f! 220> 71 IS 72 ;: 43 171
so us9;
ro `21 x l0 1u: to u. 7 f1 ft7 70 316 a ne
12 u . nl tt :104 s1 to+ a ue ".
i
! U;,
36 191 3: Itt'' s S 37 a
115— 21 40
34
110 120 31 >-
130 : Al
32 105 Lod W". 214' 21• ills• 2r M' a6' S6• bb' or L T7
100
30
95
28
90-1 186,
4186
26 85
165,
24 80 4165
75
0 22
s g 70
x
2 20
� 65
18 60 14163 189,
4189
f 55
16
50
14 45
12 40 188,
140, 88
4140
35 41
10
30 185,
8 25 137, 4185
6 20
15
4
10=
2
5 43 4 57,59 98 4661
0
U.S. GALLONS 10 2 30 40 50 601 70 80 90 100 110 120. 0 140 150 160
LITERS 80 160 240 320 400 480 560 640
0 FLOW PER MINUTE 009922
Not For Head Capacity on Model 112, industrial column - explosion pr000f pump, see FMO219.
W isconsin Department of Commerce SOIL EVALUATION REPORT Page Z of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County e �
Attach complete site plan on paper not less than 81/2 x 11 irx*ies in size. Plan must
include, but not lirrrited to: vertical and horizontal reference point (BM), direction and Peel I.D.
percent slope. scale or dimensions, north arrow, and location and distance to nearest road. 9 - M - 3 - 3o — WO
Please print all Information. R y D
Personal brformlion You provide may be used for secondary purposes (Privacy Law. s. 15.04 (1) (m)). �iy h v w o
Property Owrter Property Locat'
GGr Govt. Lot _d__ 1/4 114 S 3 T3/ N R E (Or)
Property Owners Mail Address Lot # Block # Subd. Name or CSMII
City / State Zip Code Phone NunjW O City ❑ Village own N arest d
❑ NewConsbuct&w Use Residential / Number of bedrooms Code derived design flow rate 1<0 0 GPD
❑ Public or commercial - Describe: —
Parent material ® Flood Plain elevation if applicable r
�eirliegicigktiom -e 5' 3,
and
JUL 0 1 2002
ST. CROIX COUNTY
1 Borirlp# � �! ZONING OFFICE
A Pit Ground surface elev ft Depth to fruiting factor -,�= in.
Sol Application Rate
HAM Depth Dominant Color Redwc Desa"on Textue Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
2
3
Co o
VV �V-,
M Boring Boring
Pit Ground surface elev.�ft. Depth ib Limiting factor ��ls in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsefl Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
®— ~�� eta/ r '
2 — O -1 ---- -, , S
3 2 i 1
•
Effluent #1 = BOD > 30 1 220 ffxA and TSS >30 < 1 ' Effluent #2 = BOD < 30 mg& and TSS < 30 mg/L
csT (Please 2 ture CST xnber
Address Date Evaluation Conducted Telephone Number
r
Property Owner Parcel ID # Page of
❑ Boring # ❑ Boring
. Pit Ground surface elev. ft. Depth to limiting factor /a� in.
SoN Application Rate
Morimn Depth Dominant Color Redox Description Texture SMxbxe Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Etf#2
2 12-30
F-1 Boring # E] Boring
❑ Pit Ground surface elev. ft. Depth to Wilting factor in.
Solt Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz Cont Color Gr. Sz- Sh. 'Eff#1 'Eff#2
wing # ❑ Borin
❑ Pit Ground surface elev, ft. Depth to Wilting factor in.
Sail ication Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Ou. Sz. Cont. Color Gr. Sz Sh. - 'Eff#1 •Eff#2
i
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD < 30 mg& and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777.
SBP4330(RA100)
Soil Test Plot Plan
Project Name Larry Larson Shaun r
Address 12972 Finch Way
AppleValley Mn 55124 C �, #226900
Lot ------ Subdivision - --- --- Date 6/29/02
1/4 1/4S 3 T 3 1 N /R W Township Star Prairie
Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Top of Power Box
System Elevation 94.9/95.3/95.7 *HRpSame as Benchmark
Alt. BM Top of Slab @ 97.5'
Cedar Lake
a�
a
Existing Cabin To
0 be torn down and
replaced with a 4 150
o bedroom house Alt.
N Well M.
T
5 '
52' 8% DW 10'
Slope B -2 25'
IF 10' :8 8' 35 30' 40'
10, B -1 0' 0'
3 99'
5' IL%.
100' Led
Shed B -3
a�
shed must be a
removed >
inorder to ¢,
To Cardinal
install system 0
Drive
0
N
135' Property Line
ST CROI K COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/l3uyer C `a �SUd "
Mailing Address
Property Address
(Verification required from Planning Department for new construction)
City /State 3
/State Parcel Identification Number OM - �0 /3 - 6-
LEGAL DESCRIPTION ��� o 3 yA _
Locatio P-11 3 ,� '
p� V4, Sec. . T .N -I W, Town of
PAY
Subdivision Lot #
Certified Survey Map # Volume
V T' C �eeedd # Q , Volume Page #
Spec house ❑ y no Lot lines identifiable, ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system,
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
mastorplumber, joumeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewaterdisposa . system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Itwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating t your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
da the year expiration date.
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
(we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
the p rty des above, by virtue of a warranty deed recorded in Register of Deeds Office.
/ /
SI OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.***
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
maintenance and Contingency Plan for a Septic System
Maintenance Plan pumped once ever 3 years.
1 Septic Tank is to be ..pump
Y
2. Effluent filter is to be
cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
, garbag
e and water conditioner discharge into the system.
4. owner agrees to limit greases, eases
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
Ifs stem fails, determine cause of failure, use alternate area and install new system or
1. Y
y
install
system at a lower
elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715- 246 -4516
St.
Croix County Zoning 715 - 386 -4680
Pumper Tom Mondor 715-246-5
Shaun Bird #226900
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3 - -19ft TI415 SPACE RESERVED FOR RECORDING DATA
9449'7 QUIT CLAIM DEED
VOL 991PAGE 3f11 REGIU I=FlCE
S !��r� �/�yy,y�/�s/�
. VftV1A W.
�--- —� —�- Reed for Record
r
-�— I t. 4 a / Qr L r� ,•sue,. M c _ L ! , JAN 2 9 1993
quitclaims to _ 4'dW d ent t L . L. vsa „. W b.a__L f 1014 AA
—I tad L er. AlMt.
f1110r Dub
the following described real estate In • C rs ix County,
State of Wisconsin:
RETURN TO
5. aoeicm unto the Mid part-14111.. of the rcond Patt ........ k!>s *� .__..__.. .......... -- - -• .
4wrsaad real estate, situated in the County of..._ .....St•..i:Ltl"._....._.._. ad stalls ON Wi essitiiii, WVitt
Coelooncing at a point on the North I'.ne of Goverment Lot i ftetion S ;I
Township 31 Range 18 which point is 711 feet East of liar• Ntlortbwes! corner !
of said Government Lot I and which said point is at the Interttwetion of said 1
North line of Goverrusent Lot 1 with the West shore of Cedar Lake= theme
Southerly along the West shore of Cedar Lakes 662 feet to %be, place of
beginnings thence West 300 feet, thence South 230 f"11 thence, fast 357 feet
more or less to the West short of Cedar Laket theme Northerly along said
West shore of Cedar Lake to place of beginning *Ace” that part described
as followsr A part. -1 of land Incated in Government Lot 1, Section 5,
Township 31, "ige 18, Town of Star Prairie, Wisleonsinp more fully described
as followst Counsince at an iron pipe which is set 950.47 feet South and
1826.82 feet least of the Northwest �:nrner of .aid Section 3 as the paint of
boo ming loft p arcel to tie describeds thence proceed South 89" 07' "11110 '
a distannce of 307.4 feet to an iron pipe tied on a meander line of Cedar Lake;
thence proceed South 10 55' !'sags along said meander line s distance of
112.11 feetj thence proceed North W) 'e' west a distant•. of 64.3: feet;
thence procaMSd North 90 07' West a distance of 2:9.73 feet; thence proceed
North 90 2 3 0 East a distance of 100.86 feet to the point of beginning.
X r
i
r•r.
3 ! Y� ''••
This �3 h 0 1 homeeteed property. �,•�� '••� ! : I
(is) (Is not) '. x• _• j .., :_ .i
Dated thi day of
n 19. �fi� •: ° .}
i A n 0 s• 4
~ , � • rrr,.:,r�.....r r �ucu�., n.Altr1� _�JL
(SEAL) (SEAL)
I
jj
4
j AUTHENTICATION ACKNOWLEDGMENT
Signature(s STATE OF WISCONSIN
as.
County.
authenticated thi day of 19— Personally came before me this day of
19 the above named
TITLE: MEMBERSTATE BAR OF WISCONSIN
(It not, to me known to be the perso who executed the
authorized by § 7Cb.06, Wis. Slats.) foregoing Instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
�.awYr,h l.ctat t7
Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date: t9 )
- Names of persons signing In any capaclfy sneuld be typed or pr lied below their signaturwr. S83 NTF oon r te'
{
Nt STAR PRAIRIE PLAT T -31 —N • R -18 —W
>
See Page 112 For Additional Names.
(Landowners)
POLK CO.
g00 900 POLK/ST CROIX RD 1000 1100 CARDINAL DR 1200 1300 1400
ear, tr 0
PC
w c 2 4 ^ Randall & = a ~ , ' C DAR zo t - W $ STAR
GwIs � � n � S a $ 2 tr CED 'S .�2ss PRAIRIE
Dreebwa m v 261 CEDAR TON DR 2 1
in,. -, G & Iop a� ^ ' 33 gI s
Ob-a 83 qg
-d 30 Nelson vZ $ 4 s
'a r c Ti
41 n rr4 _ � 8
r Wilson 0
g 126 m ss 40 0 95th 128 ails ]'�y_ �C'71�1'I tr r M
r i s--t- Z € EE I 1��ss S BB b SN 9
a sawn - R 20 TO
s$HH R a c ] x A Ab— Meeds A $I AI[ceda 38 H
O Al
& N 40 J2 6 i 60 bameoa 39 �r AW ae Ili P 4
Nelson o
JJ 9 g o DE e Norma� 8 t u Fu 1n c�1
6 240 A a T 1 * sl a
DB a o el uae V J a., o a - n 1 RD Daniel F a s alem
2 tc r• lax E1' 15 -.eo- dd as a m we u w
y w Sri C 24 O son • s.a tr
$�.[p 8YO iy tr FdiD 20 Ewer- w.
tr v ,.� 05cc 40
32 tr sia�a 4 n tr x^� ss f 1. 117 _40 LC }0 a ss
lU a R A N R 2221 st L Richard 7 g m cc dor & ° � r N 3 San S 4 Patricia Anderson
AVE Hansen o.""- '" 14 Ianet 1 !s cr 82 Farm ome
120 Norma■ $ �„ 8 s„ emetlt
77 33
LO m Eric p. s - 2 Scott Harlan
E Inc 6s
(, 1 nia m a-s 1a 40 tr
78 RV 13
109 X Ca mveins C 158
ber smm
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.RALEIGH RD WINDING TRAIL RD 180th AVE RICHMOND PAGE 448
SOMERSET'S' PAGE 62
FARMINGTON MUTUAL INSURANCE CO..
COUNTRYSIDE VETERINARY CLINIC, S.C.
DR. JOHN SWINGLE, DVM DR. LORI VON RLIDEN, DVM
j DR. BRIAN KELLER, DVM DR. KRISHAWN KAIBEL, DVM
i DR. MEREDITH SMITH, DVM
full Service Veterinary Clink * 24 How Emergency Service
Pro %ssianalPet Grooming * B"&W
i
715- 246 -5606 1231 N. KNOWLES AVE.
I 715- 248.7041 I-kW RXHMOND, WsCONSP4 54017
Fax 715.246 -9256 E -Mask cvckk0pressenter.com
�" 66
RECEIVED
7 Safety and Buildings Division County
5 T r 2 3 201 W. Washington Ave., P.O. Box 7082
Madison, WI 53707 - 7082 Sanitary Permit Ntunher (to b filled in by Co.)
jD etm (608) 261.6546 3 Q 2 7i d
am ary ermrt
• Application State Plan I.D. Number
� � �
In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, x15.04(1 xm) Project Add (if different than m address)
I. Application Information - Please Print All Information 4 17 (o 6 /d iny , • T.
Property Owner's Name Parcel # Lot # Block #
i D old -lv- &o - 50b
Property Owner's Mailing Address Property Location
City, S e / Zip Code Phone Number
r - �- �b,i., Section �_
t]1 - (circ le )
D S' !S" 760 /` a`�
�
II. Type of Building (char T N; RE all that apply)
❑ 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Nu mb e r
❑ PubiicJCommercial - Describe Use
❑ State Owned - Describe Use ❑City ❑Village owmship of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable) -
A. New System ❑ Rep wMC11t System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B • ❑ Permit Rea wrermit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date issued
Before Expiration Plumber Owner 1 '3 Z^7 / V(2 D3
IV. of POWTS System: Check all that a 1 1 �i I
Non - Pressurized In- Ground ❑ Mound > 24 is of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
CMsducted Wetland Pressurized in C hing nd ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter 11 Recirculating Synthetic Media
Filter Chamber ❑ Li Gra 1 -kas Pipe ❑ Other (explain)
V. Dis ersaUTreatment Area I rmation:
Design Flow (gpd) Design Soil Application Rat pdsf) Dispersal Area Required {sI) Dispersal Area Proposed (so System Eleva tion
VL Tank Info Capacity in Total Number Manufacturer Prefab Site Sfeel I Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tads
Aerobic Treatment Unit 7�
Dosing Chamber W d /
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) 1 Plumber's Si natu MP/MPRS Number Business Phone Number
NIt✓ Sa+� s-eC 22o Z1 Z 71 S- i-ni-- 327P
Plumber's Address (Street, City, State Zip Code)
VI .Conn /De artment Use Onl
Approved ❑ Disapproved Sanitary Permit Fee ijacludes Grouddwatei Uing t Si Stamps)
Surcharge Fee) son � 0 0 Owner Given Rea for Denial 6 3
IX. Conditions of Approval/Reasons for Disappro /vale', ` n
/ 1�
a 4
- e c
/ ryv" e4Ydtt4i 7KI
Attach avmpkte punt (to the Cassty a*) tar the sysas a as paper nut Was than 2112 x II taehes is sine
SBD -6398 (R. 08/02)
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