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038-1093-20-000
o N 0 o W 0 n CO) 0 z n ° m f o d f ° w f c d o � (D CD 3 m M v Z T n ,< v 7! 'o ' o xt 3 3 - 3 n CD O N 0 O V N `` N z O A N O D) vi Cd p A N N w `C = < O C 3 N yr• O 01 m O O °. CD #D N _4 @ M N C 3 p m O C p , y 1 °- m m N y_ =r ` n oo D Z a p OD D N N O CD n CD CD ° ° O m m O OI 1 N n) Q 6 3 rn .0 m 7 PO o d N ° w ^ � Cj CD O w tp C n O ° en w CD ° 0 O 7 Q CD 00 O n O D� O 3 Q o _ _ > > o _ _ ! _ _ ° o 7 y 7 4f ' 7 O O�{ d O 0> O d C° v v D m a s l I, Z D m¢ ID D m a •� p Q7 CD m Z N O CD N N CD ? CO m ° N F W F w o o m A y m 000 N o c 0 0 N N ? N N 3 3 K S c 3 1 3 3 p Z 0 0 0 ° 0 0 0 ° 0 0 0 -°- < Z N a 3 to N N a fn f/1 Ul N N (A CA D C) ° CO �� O C o l m C o y m m m ° p CA 3 _ _ cn 7 CD - CD 1D - M (D CD D1 fu (7 D1 m m m a m � Q r Nz �- z z z --q Z z co o O 0 ' D ° D a D a p . m 0 fn H CD o N h N N m CD m = m m a) c (° N 'O N f° N n a I �" fo a m °- a 3 v 3 CD o 3 7 z m m <° m � m (6 Z m O O 7 O Cn C Vi C N C A =ry G CL a Q �' C 0. N) CD W CD C CD m 0 3 0 3 0 3 a l -m ° n f A W U W O N 0 j a 9 o a m a 1 Q v c 3 0 3 0 c 3 � v t o _ m _ o a CD (D o a H CD o a CD Z T o* m m S N ° 7 y a N F CD CD m 0 c 3 3 m m O C- CU - o a ° -� CD Q 3a CD a I Q � am 3 a 3 ° o N o A O C CD C N 69 0 69 0 69 Q L O (D O CD O a r * .- WisconsinD`epartmeptofCommerce ' Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count St. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary7e0225No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 3 Permit Holder's Name: ❑ City ❑ Village r6wn of: State Plan ID No.: Lau, Allen Star Prairie Township CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: c7t� a f .— L 5f4 C 038- 1093 -20 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic pap Benchmark Oz OI.O wo • O Dosing Alt. BM Aeration Bldg. Sewer - #2 Holding St / Ht Inlet 90 rz TANK SETBACK INFORMATION St/ Ht Outlet (0 ZZ. 90 . 16 0" TANKTO P/L WELL BLDG. Aenttake ROAD Dt Inlet ------------ Septic >: �� I NA Dt Bottom Dosing NA Header/ Man. &.00 0.02 o. Aeration NA Dist. Pipe /t. Vs Holding Bot. System ►2. 2 0 00 8t3 . o Z PUMP/ SIPHON INFORMATION Final Grade -� Manua Demand St cover $, Qa. 38 Model Number GPM TDH Lift L oss riction System TD = Ft ead For main Length Dia. H Dist. To well SOIL SYSTEM O ENCH Width Len th No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth 1 EN 1 3 Z DIMEN t N SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING Man t rer: A SETBACK CHAMBER INFORMATION Type of r M el Number: System: �� ` /05 /pD OR UNIT c DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Dia. 7 I QO SOIL COVER Sc4 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 E] Yes Q No COMMENTS: (Include code discrepancies, pers p L, nspec ion : ©ro iZ 90 1Mil2C;L;L1U11 IT/— Location: 2001 110th Street, New Richmond M W 1/4 SW 1/4 22731N R18W) - 22.31.18.383C -Lot 1 1.) Alt BM Description= N/A _ 2.) Bldg sewer length= — e t, 5" /CA.-e_j c.+ - amount of cover — Plan revision required? ❑ Yes [@ No _ Jc 1 2— (O Use other side for additional information. 22 2�aa SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ` SANITARY PERMIT NUMBER: e 1 i , —4— _ s ®� e� - - - -------- i 6 1 E � E �- i i E 3 � s ? a I a I 6 i --_ Safety and Buildings Division Vi sc ' ons i n S ANITARY PERMIT APPLICATION 2 01 W. Washington Avenue P O Box 7302 Department of Commerce In accord with Comm 83.05, Wis mgCpd Madison, WI 53707 -7302 Je • Attach complete plans (to the county copy only) for the Sys pape�not less�� unty than 8 112 x 11 inches in size. �l `' • See reverse side for instructions for completing this appli 2iti n tat Sanitary Permit Numb - ., r F r_ Personal information ou rovide ma be used for.seconda u oses'! �-i 3 Y P Y ry p rP - i k if revisi 3n to previous action [Privacy Law, s. 15.04 (1) (m)). ST CA40I X $ta; Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL l R `' — Property Owner Name / tu roperty Locatf c�c-- is _ _ iK4;� T N, R or Property Owner's Mailin Address b rbl Block Number C' y , tate < / Zip Code Phone umber vision me r CSM Number f:I / / — Q :! TYPE F ILDIN : (check one) ❑ S ate Owned � r Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms own oI`` ��'��fr��C" III. BUILDING U E: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 [] Medical Facility/ Nursing Home 10 [] Outdoor Recreational Facility 3 E] Campground 7 E] Merchandise: Sales/ Repairs 11 C] Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 E] Mobile Home Park 12 E] Service Station / Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: 'Check ox on line A. Check box on line B, if applicable) A) 1. 2. IS Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an *et.e Syrstem__ _____Tank Only______________ Existing System ________ Existing System B) E] 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 12KSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 Seepage Pit 43 ❑ Vault Privy 14 ❑System -In -Fill VI. ABSORP SYST1 INFORMATIOW 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. SySte! Rv. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /s . ft.) (Min. /inch) �Y /s�f�S Elevation L 751 _2= P et i Feet VII. TANK apacit in gallons Total # of Prefab. Site Fiber- Exper. New Existi INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App n Tanks Tanks strutted Septic Tank or Holding Tank Q��j ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I ❑ I ❑ ❑ 1 ❑ 1 ❑ I ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb "Name: (Print f Plumb ignature: No MP /MPRSW No.: Business Phone Number: /mod �1 Plu bysAcjIdr ess (Street, City, State, Zip Code): M ` 9 Z Z4f22� IH IX. COUNTY /DEPARTMENT USt ONLY ❑ Disapproved anitary Permit Fee (Includes Groundwater D ate Issued Issuing AgentSigna ure (No Stamps) Surcharge Fee) t / Approved ❑ Owner Given Initial s— � 1 6-s - — LBd� K—� Adverse Determination ' X. CONDITT y OF APPROVAL / REASONS FOR DISAPPROVAL s� S Y ar PA.- G� -e tIt e4s C 2S SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber 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. Onste 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 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 is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must incfiude the following: A) plot plan, drawn to scale or with complete diriiensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. I r S�- ��`'` Plot Plan PROJECT , �� ADDRESS 1/4 /�f 1/4S, /T e) N/R /�/ W TOWN " Byron Bird Jr . 220527 _ �'�� BEDROOM CONVENTIONAL IN -GR ND PRESSURE C NVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE�ABSORPTION AREA -# of chambers IL jJ BENCHMARK V.R.P. 6���/ ASSUME ELEVATION 100' ❑ BOREHOLE O WELL //// *H.R.P. !"` �4 SYSTEM ELEVATION L >12" Sidewinder High of Cover Capacity Leaching Chamber with 31.8 ft/12 6 91 per chamber 6' Long 34 Grade at System Elevation E a � V J� t I Wisconsin Department of Commerce Division of Safety and Buildings SOIL AND SITE EVALUATION Page of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and !jt CjyYj x percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 3 0 73 APPLICANT INFORMATION - Please print all information. Revi wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ° _ Property Owner Property Location act Govt. Lot 114 114,Sa T ;' N,R E (o Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 69 e 4 /� � 5� '-- G � /.;2>o Ci to Zip Code Ph Number f �I' Nearest Road 1 ` ( one um !� city u Village Town ❑ New Construction Use: CWResidential / Number of bedrooms - 3 Addition to existing building Y Replacement ❑ Public or commercial - Describe: p^ Code derived daily flow ed, gpd /f1 • gpd Recommended design loading rate � b ^Q_ trench, gpd /ft Absorption area required bed, ft 2 6a"t�? trench, ft Maximum design loading rate " 7 bed, gpd /ft < Q: trench, gpd /ft Recommended infiltration surface elevation(s) �i^ 1 6C is o� 1515' �� ft (as referred to site plan benchmark) Additional design /site considerations Parent material (�r� c Q Gcc rCya"i -"X Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank e' U = Unsuitable for system S ❑ u '? ❑ U J&S ❑ U _5rS ❑ u ❑ S ,® U ❑ S .9 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench / b 3 Ground �f b � -2 - d -� 74' / ev ' ft. Depth to limiting factor --- y in. Remarks: Boring # S ` Ground elev.� ft. Depth to limiting Z 8 � f r in. Remarks: CST Name jp3pase Print) S' re h Telephone No. / a Address Date CST Number i SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boren # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench Aq Ground DG elev. e �ft. ' Depth to , limiting *2 factor �in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; i .,......_...... Ground elev. ft. Depth to limiting factor in. Remarks: Boring # I Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) Soil Test Plot Plan Project Name Allen Lau Byro ird Jr. Address 2001 110th st. lAe zzer, New Richmand Wi. 54017 CS M #220527 Lot 1 Subdivision csm 5/1270 Date 5/30/067 SW 1/4 SW 1/4 S 2 2 T 3 1 N /R W Township PRAIRIE E] Boring Q Well PL Property Line County S T. C R O IX BM or VRP f la Assume Elevation 100 ft.top o slab System Elevation t -1 =88 t -2 =88.6 H.R.P. same as BM Alternate B.M. base of sideing fail a � drained t � � 10' 1 0th st. 30' 3 bed hod e 15, NB. 30' B� Alt. 30' NB.M. DRIVEWAY I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer n 6-1 cs - Mailing Address no 1 D t� S Property Address X00 / /�� V (Verification required from Planning Department for new construction) f c .r� & Parcel Identification Number D City /State ,Q��n . —� LEGAL DESCRIPTION 1 _ J Property Locations ' /., V., Sec.O . T�N -R�W, Town of Subdivision ,O Lot # Certified Survey Map # Volume ` Page # /�70 Warranty Deed # . V o l ume , Page # Spec house ❑ yes 0 no Lot lines identifi614 yes ❑ 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 masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. �s 13a l�?ctT SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 6715 /3d lo?a' S A TURE 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 BAR OF W IM"WIN YUMA I— a" twie• o s>�isav2� rca iwa DATA k WARRANTir =tj 1 VOL i E, An L., Heinecke and TES O FFIRE ThIs Avalon 3.nec iI 1 1f� artrl ea�h •iii their ; . S7: 7IX co, cn�rn xiEht. .............l._......._...................... ._.................._......._.. R for R&MM�ft 12th sirai� y Aril ............... ................. ................ d of P sr A.D 19 83 1_.ard.,.A..l era- .1 ...Lau.__ her.__hushand. �_ i :3o p aa..J oAint... tersarata _with.ar_i.�hts-- of.. v.or.sh� F, _... kl. ............................ ............................... . ........... ............. .... , Grr.xtwi, W jtn '64eth, That the ash'. Grantor, for a valr,able conaldkr ati .. . .. ar.. an - - ..One... Dolld.. o .thex._�aiva.tl.e,_.cor�s.idf > °< io - . .... ...... b,U TO wwways to Grantee the following daaeribed real estate in ...... jSt.....CrU�:C...,.. i County, State of W iseonsin: A parcel of land located in the Sltl• of the S4-, of Section 22, T 31N, R 1$ Town of Star Tax Pareel No -- -------- - ---------- _------------- Prairie, St.. Croix County, Wisconsin, described as follows: Beginning at the S,'rl corner of said Section 22; thence N 0 E 290.4 along the West line of said Section 22; thence S89 "L 375.00'; thence SO 02 "W 290-42 thence N 89 22 " 375. along the South line of said S'iii t6 the point of beginning. SUBJECT to an easement for existing town road right - -way. This parcel contains 2.50 acres,being 10$,900 square feet, more or less, including existing town road or 2.27 acres, being 98,861 square feet, more or less, excluding existing town road. i FEE C S This .. _.._Z_5 _ NOT ---- _- hotre=tead property. (is) (is not) TogeCiar with all and sing the hereditantents and appurtenances thereunto belonging; And. ....... A..._H.eir1ac. {e- ,_..his - -w -e------------------------- warrants that the title is good, indefYasible in fee simple and free and clee.r of encumbrances except easements of recoi and will warrantt any defend the siur.e. D this ... ... ----------- day of - -•-• - -- - - - - A --- --- -- - - - - -- , 19- 83.._, - - -- (SEAL) Erwin L. Heinecke Avalon A. Heinecke ----• -. - - -- -(SF,AL) - --- -- --- - - ---- - -- ---- -- - -- •(SEAL) AUTHIgNTICATION AC1i:IV OWL'_RT%GMSNT ,atury s r ��r?Xl_ Si .Z s.__H °inE C kE' Ztl`�_ - - - - -- STATE of WBCO"SIN O Avalon A. Heinecke his ,rife an- -------- •------ ----- - - -• ---------- -------- t-- --- - - - - - - -- - - - - -- Sr. QP0 I x autheatiested this -------- day of___Apr_ 1- _______- Personally cave before me thiq _ _______________day of - -_ +�_- , 19___ the above named Y" - -- --- --- •- ------ --- - -- --- --- (If not, . - IQt.ar.y_..�;�r.l _cSt Cr Co. 4 - -- -- --- - -- --- -- ----- - ° ------------------- ---- -- - - -- -- --- --•--- ----- - -- - autborb*d by 1 706 -M, Wis. Scats.) t me, known to be the i;rr:.on s --------- who exe-cut- the tre =dma, foregoingtnatz9inlant nn• ! acknowledge , HIS INSTRUMENT WAS DRAFTED BY f �-. / `- ° ---- -- - --- -- - --- - -- --- --- -- --• Notary Public ------- P ! Cou ^.ty,'•�Yis. (Sigl.atures may be au+'•e;tticat�d or ack�uhle <h� - R =,rh •ic C�innils? ion is peg ;ao^ +.. (� r�Y� st ti! expiration /; are not . � f ,:ecrs tzy.) lJ � � , .jeianw o4 1+eex,n. aigaai»g in sr,y e&P4';t' ei !Ad be v;1 — crinted Minor their ai$�:atur+ic. {'tl (tAt^".+.M ° {'� `ygi.}id1 a1A r; B. % OF WNC0ti'31:4 Wi c n�: 'i.3 £ilY4 C.. S Te. FORA 1 4 1 —MI. M; r akta, wi%. t3 'k =`. #�t w :.r . ..:. # u..,. .'m -�.- + FORM NO. 985•A M.4M`II.rCprp.ny� Y N O - 383628 Ri CERTIFIED SURVEY MAP Mies o ,3 how. w NW CORNER so Groh SECTION 22 W T31N, R18W 6 $ SCALE IN FEET 0' 100' 200' U N P L A T T E D L A N D S rq cn I N I 01 z I 1 1 �I zl 133' 33'1 SW -SW 01 QI w I I S89 0 57'22 "E 375.00' ZI I .J) L I Q I 4Z ))� 332.2 3' Q I 0 1 O of w1 I I M -_ 1 N cn LOT 1 N DI F-I :51 3:: 1 o ;° 1 08, 900 Sq. Ft. or 2.50 Acres wl E �� N O � including town road ° LU N 98, 861 Sq. Ft. or 2.27 Acres N A SSUMED NORTH QI �I w U excluding town road 3 ~I - iI to zl o QI z 1 c �1 0 144 c al �I z w � � zI / V� SW CORNER / � SECTION 22 j 41 � T31N, R18W 5.66' j 369.34' N89 0 57 1 22 11 W 375.00' S1 /4 CORNER 6 LINE OF THE SW1 /4 SECTION 22 U N PLAT T31N, R18W � T E D LAN D S POINT OF /� - - - - - -- - - - -- BEGINNING / i CURVE DATA TABLE CURVE RADIUS ARC CHORD CHORD CENTRAL 1ST TANGENT 2ND TANGENT NO. LENGTH LENGTH LENGTH BEARING ANGLE BEARING BEARING 1 -2 466.00' 179.35' 178.24' N12 0 23'10 "E 22 0 03'04" N23 0 24'42 "E N1 0 21'38 "E LEGEND APPROVE' 0 COUNTY SECTION CORNER MONUMENT, FOUND. 0 1 "x24" IRON PIPE, SET, WEIGHING 1.68 # /LINEAL FT APR 061983 EXISTING A "ODiLE HOME ST. CROIX COUNT - -- EXISTING FENCE COMPR[HENUVE PARKS PW- AND ZOMNG r.0W iii i:: This instrument drafted by James T. Swanson. Volume 5 Page 1270 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP 2 SECTIO14 T —ILN -R _W ADDRESS �� //644 CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1� L i3 INDICATE NORTH ARROW BENCHMARK:Elevation and description: Alternate benchmark X A SEPTI,iTANK:Manufacturer: S. S` Liquid a /00 Rings used: Manhole cover elev: J " FinaYg g gr ade elev. Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front_, Side , Rear Ft. 3 From nearest prop. line:Front , Side ^ Y, Rear Ft. r No. of feet from: Well °�z , Building: " S (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE 1 PUMP CHMMER Manufacturer: Liquid Capacity: p y. Pump Model: _Pump/Siphon Manufact..: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons /cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front_, Side_,, Rear —Ft. Distance from: Well Building SOIL ABSORPTION SYSTEK Bed: `` Trench: Seepage Pit: Width: /Ot- Length °Z Number of Lines:-A_Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front Side Rear Ft. 7 No. feet from well: No. feet from building HOLDING TANK Manufacturer: Capacity: No. of rings used:_ Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from: Well , building_, nearest road Alarm Manufacturer: INSPECTOR: DATE: PLUMBER ON JOB: LICENSE NUMBER: 6 /90:cj r - ,Wisconsin Department of Industry PRIVATE SEWAGE SYSTEM County: ` Labor and Human Relations INSPECTION REPORT Cra; x Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No -: GENERAL INFORMATION d Permit Holder's Name: ❑ City Villag n of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 8 -� S 6 Dosing Aeration Bldg. Sewer A gv gs 7. D Holding St / Inlet 9$, 8 0? TANK SETBACK INFORMATION St /yf Outlet TANK TO P / L WELL BLDG. Air I to ntake ROAD Dt Inlet Air Septic X1401 7S/ NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Fiction System TDH Ft Forcemain Length Dia. H Dist. To Well 7 SOIL ABSORPTION SYSTEM -- --` —"' BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION S� DIMENSI SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O ecn if �� ti gS /(fL� OR UNIT CHAMBER Moe Number: System: DISTRIBUTION SYSTE C Header/Manifold Distribution Pip (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 discrepanc persons present, etc.) C1 <s?+` f / / /�� /{ ��' � .��-1 �C1 �E -5 Plan revision required? ❑ Yes No I id 61t I Use other side for additional information. _ SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 9 I I� SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY DILHR ` GYM i STATE SANITARY PERMI -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 1qq 8% X 11 I n che3 In SIZ @. Check if revis on fl application -See reverse side for instructions for Completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPE TY OV PROPERTY LOCATION •ch ,�� '/a /a, T ,N,R E(or PRO ® I NER'S MAIL P E LOT # BLOCK # Cl STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) CITY � NE /,/ ROAD N1 or 2 Fam. Dwelling -# of bedrooms TIRCELT R( ) 111. BUILDING USE: (If building type is public, check all that apply) 1 F-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 B if applicable) A) 1. El New 2. El Replacement 3. El 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 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING E 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day/ q. ft.) (Min. /inch) / ELEVATION / j c 7 ./Fe 4et . Feet VII. TANK CAPACITY Site in a allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 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 nature: (No Stamps MP /MPRSW No.: Business Phone Number: t7 % ♦h� �� 5 J It / o `is .6 l Plu s Ad Tess (St City, State f , Zip Code): IX. COUNTYIDEPARTUFNT USE ONLY ❑ Disapproved Sa itary Per it Fee (Includes Groundwater a e Issued suing gent Sign A epproved ❑ Owner Given Initial ���,�; Su rcharge Fee) Adverse D t rmination �GiVV X. CO ITIONS OF APPROVAL /REASONS FOR DISAPPRO AL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber 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 questiors 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: 1. 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. 111. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'f x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected throe gh these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) STC - loo This application form is to be completed in full and signed by the owners) of the property being developed, Any inadequacies will only result in delays of the development be intended for resale p ermi t this e byowner /contractor,l(spec Douse), then a second form should be retained and completed when the property is sold and submitted to this office with the a ppropriate - deed - recording -------------------------------------------------- Owner of property Location of property �J� l/4, Section Pzz..� Township Mailing address Address of site Subdivision name Lot no. 1 , Other homes on property? es Previous owner of property Irl t f ei Total size of parcel p?. 6' Date parcel was created /713 Are all corners and lot lines identifiable? ,}_ Yes No In this property being developed for (spec house)? Yes No Volume "� �d page number of Deeds. L Y— �/ as recorded. with the Register INCLUDE WITIi THIS APPLICATION THE FOLLOWING: A WAItIWITY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE. NUMBER & THE SEAL Or TILE 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 Nap 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 the property described in this information form b e owner of warranty deed recorded in the office of the County Registerfof Deeds as Document tto, ?� �Y own t and that I we he proposed site for the sewa a disposal system or I obtained an easement, to run the above described rt, for the construction of said system, recorde he office of and the same hae been duly d County Register No. of deeds as Document �-- Signature of ap�licant Co -al pl cant % r Date of Signature Date of signature DOCUMENT N o. 1 STATE BAR OF WISCONSIN FORM 1 -1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED VOL 662 PAV 4 383 his a made betwe Erwin L. Heinecke a nd REGiSTIMS 0FrjCE I 2 Avalon A. N his wi�'e and . eabh in hei "r ST. Gi�'OIX CO., �11'�: -• ................................................................................ ............................... n?rrn..right ................. Recd. for Record Hs 12th .......... ......................................................................................... Grantor, dpy of Apr 83 00 A p r i l and .....lammy..Dee. -. Lau -- and ... A�.J.en..L...l,au + ..har...husb -and. A D �,� as..doi.nt ... tenant.s.. with ..r.ightaxaf ... aurvim.or.ahi p........ at 1:30 P 3olit�e ... 2.,-.. Box.. 242R.,.. .New..Ri.chlnand.,...Wiacons1r1 _54017 • .........................................•------•---......--------. .......--- •-- ................., Grantee, ', Witnesseth That the said Grantor, for a valuable consideration...... �� °' ..-- ... --... One ... Dollar.. and..othex..valuab ).e..conai.dere RSTU TO conveys to Grantee the following described real estate in ...... .at.....Croi ...... County, State of Wisconsin: A parcel of land located in the SW4 of1the SWg of Section 22, T 31N, R 1$W, Town of Star Tax Parcel No: ................................... Prairie, St. Croix County, Wisconssn, described as follows: Beginning at the SW corner of said Section 22; thence N 0 E 290.4 2 1, along the West line of said Section 22; thence S89 11 E 375.00'; thence SO 02 11 W 290.42 thence N 89 "W 375.00'jalong the South line of said SW bb the point of beginning. SUBJECT to an easement for existing town � road right -of -way. This parcel contains 2.50 acres,being 10$,900 square feet, more or less, including existing town road or 2.27 acres, being 98,861 square feet, more or less, excluding existing town road. FEE Thin ___.__ ..... homestead p roperty. I 1S..n?QT.. p. � � y (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And ........ Er-win ... ... wif -e .......................... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements of record and will warrant and defend the same. .............. Dated this 12th ........................ day of .................. April....... ._._...._...........__........, 18.$3.... (SEAL) .... a UL2... .G�!..`�»t<l!2G.Z!!C....(SEAL) Erwin L. Heinecke Avalon A. Heinecke ........................ .........................•..... . .......................... . . ... (SEAL) ............. ...................................................... (SEAL) I i AUTHENTICATION ACHNOWLEDGM —ANT -Signature(s) ....... STATE OF WISCONSIN - Avalon A.. - . - Heinecke, his .. Sr. QR� ee. I .... .. ...... authenticated this ........day ol ... .Q;?X 1.1......_..., 19. County. Personally came before me this ................day of 4 -------- --------- •-- .......- -• - - -, 19. .. the above named .. - -• • ........................................... ............................... s ..... ... ..............•......._..... TITLE: li� ��' ---- - --•• - - U _. - - - -- .... XJ ........ ..------------------------------- • ---------------- • ------ •------- - - - - - -- ��kX�X�� (If not, Cr01A C0.`;d_I_ __ _ . .... . ......... ............... ..... .. authorized by § 706.06, Wis, Stats.) . . - _.._ to me known to be the person .'�.�.......... who executed the foregoing instrument and acknowledge "tli'e "a the. HIS INSTRUMENT WAS DRAFT D BY • ....: ---••• ........................................... ..................... •--- -..... Notary Public ......0.A .•..... - .......... : ;... �.o untY, =Wis. (Signatures may be authenticated or acknowledged. Both My Commission is er ane t._9 noit� state.' expiration are not necessary.) �,o�. ",Q_ n r g date: . .._�.__..'.' ................... ..�� ;,... ?- �.....•., 18..�..) r *Names of persons signing in any capacity should ' typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leval Bl$n✓ '�, FORM No. 1 1982 Milwaukee, Wis. SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER ADDRESS: j , ,� ��� G/1✓YIOr.� F RE NO: LOCATION: l /4, 1/4, SEC. TOWN OF : ��j t p "�'et !r� ST. • CROIX COUNT SUBDIVISION: LOT NO. 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 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 to help with the cost of the 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 the St. Croix County Zoning a certification form, signed by the owner and by a master 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. Certification from will be sent approximately 30 days prior to three year expiration. 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 form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office 911 4th St. - Hudson, WI 54016 i IND USTRY , NT o f REPORT ON SOIL BORINGS AND �,� D ISION LABOR AND P �, HUMAN RELATIONS PE RCOLATION TESTS (115) 1 j � NAV� D9 53707 LOC ATION: — SEC O( SECT N: R� , TOWN r O .:BLK. NO.: / ON VISI NAME 8 - COLI TY: OWNER'S BUYER'S NAME: MAILING ADDRESS: .5 o e / ,Z eru j USE DATES OBSERVATIONS MADE g NO. BEDRMS : [OMMER DES R TION: S: ESTS: IMOFILE Residence New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system G L► �-7 i ®,? d,,, e Go ,7/J NV 11 11 MO D: IN -G O ND PR UR : S S E - N- I LL HOLDING TA K: RECOMMENDED SYSTEM:(optional) S ❑u S ❑u S ou [Is u as Icolation Tests are uired ]DESIGN RATE: If any portion of the lot is in the .09(5)(b), i Y Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H R _ Q _ DWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED S TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) � e- w Z 7-77 77 !3'/3/ Z_ .2 s- ,s B S 6 l o -� -7 7 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. I p t P ERIOD 2 PERIOD3 PER INCH i P- O _;; � P- f2w 2 i P- P- P- P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION : e f I Y (f j _._Insp111 et 11 _ _ I ep 1 I 1 jj ^.�, ! E llliYij - t _ 1 I oQ dp _4 4 E t i 1 1, the undersigned, hereby certify that the soil tests reported on'this form were made'by me in accord with the pr ce urss m thods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief, NAME (print): TESTS WERE COMPLETED ON: ADDRESS. w _ CERTIFICATION NUMBER: PHONE NUMBER optional): IF / Y ay��SY E T SI Z4) . , 4 . DISTRIBUTION: Original -Local Authority, 2nd page- Bureau of Plumbing, 3rd page- Property Owner, 4th page -Soil Tester. DILHR -SBD -6395 (N. 03/81) 1 PROJECT ry,n Z�ti ADDRESS 1 /4 /Sa2,? /T; M /R l�1! TOWN st f ✓' 1 °/"C COUNTY, MFRS Byron Bird Jr. 3318 DATE BEDROOM CLASS PERC _ CONVENTIOI NAL N -GROU RESSURE CONVENTIONAL LIFT MOUND HOLDING TANK SEPTI TANK SIZE = .1�IFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA 6 PERC RATE ______ SIZE Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H.R.P. M Borehole Q Well Scale = Feet 0 Perc Hole ' System Elevation �y � i i I o ^v i loo, 1 3 I 6 �� . y • l f3 r AS BUILT SANITARY SYSTEM REPORT OWNER _ TOWNSHIP � AC OOi9� SI,C Z '131 N - I W ADDRESS •.z �!Zf.Lc9�YS CROIX COUNTY, W 1 - 5CONS LN . SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 HOW - VEBYTHING WITHIN 100 FEET OF SYSTE' M 444--- LALr rT a I L� S C _.�1, -�— 1 i BENCHMA (Permanent reference Point) Describe: ��% C Elevation of - vertical reference point : _ I c� - �1ope at si tc SEPTIC TANK: Manufacturer: l Capdc i.t y Number of rings on cover Tank manhole cover e.levat ton - -- zr Tank llevat i.ori - OuL1eL Tank Inlet Elevation: _ —` —_ PUMP CHAMBER Manufacturer: -Cy - _ Number of �;a 1 Lons Number of gal. pump set or a - gallons, t ota� capAc t t y e� distribution lines gallon: size of pump head, gallon per minute horsepower brand most OI pump and model number _. Type of warning ev ce HOLDING TANK: Manufacturer _ Number of ga -ton:-, Elevation of manhole gover Type of warning device - SEEPAGE PIT SIZE: - NumTer o� pits veer c�i�►me i er feet liquid d'ept�i - seepage pit inset pipe - elevation bottom of seepage pi e evasion feet. SEEPAGE BED SIZE: number. of lines Li l depth SEEPAGE TRENCH: width_ _lengtj► _ _ _ -____ PERCOLATION RAT : INSPE REA AS � DATED 13LR ON JOi3 r LICENSE NUMBER l g 3,0 0- 3. - 30 DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY &BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. 60X'7969 BUREAU OF PLUMBING MADISON, WI 53707 CONVENTIONAL ❑ALTERNATIVE State Plan LID, Number: (lf assigned) ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAM F PERMIT HOLDER: A H DER: ter: ELEV.: BENCH MARK (Perms rent r e,en a point) DESCRIB IF DIFFERENT FROM PLAN: , CST REF. PT. ELEV Name of lumber- MP /MPRSW No.County SEPTIC TANK/ LDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV. WARNING LABEL LOCKING VE 7 PROVI ED: PROVID It �� O .] YES ONO ❑ BEDDING: �VENTDIA.. VENT MATL. HIGH WA _ ggC ROAD: PRO TV WELL: BUILDI VE TTO RESH ALARM- - PE LIN AIR NL YES ❑NO ❑Y S D SING CHAMBER: MANUFACTURER BEDDING: L Y UM P MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES O NO ❑YES FIND ❑YES ONO GALLONS PER CYCLE: P AND CON TROLS OPERATIONAL: PROPERTY WELL BUILDING IVENTTOFRESH (DIFFERENCE BETWEEN u ! LINE AIR INLET. PUMP ON AND OFF) OYES ❑NO SOI L ABSORPTION SYSTEM. Check t s moistur at the depth of plowing s LENGTH I DIAMITER MATERIAL AND MARKING or excavation. (if soil can be rolled in a wire, con ruction shall cease until the soil is dry enough to continue.) �•_� „_ CONVENTIONAL SYSTEM: J NO.OF DISTR. PIPE SPACING. COVER s INSIUE DIA_ PIT LIQUID �+ 57 TRENCLi€S. WCiERr1Ct:1# DEPTH. RAV L E H FILL DEPT IDISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. - PROPER W LL: BUILDING: VENT TO FRESH BELOW PIP it ABO�/E C ER. ELEV_ INLET ELEV. END. PIPE - a14 aw IIM, y. �' LIN A AIR INLET: JX MOUND SYSTEM: Mound site plowed perpendicular to slo Check h texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mou d stems to make certain that it ON REVERSE SIDE. SHOW ELEVA- me s t e cr' eria for medium sand. TIONS MEASURED. DYES ONO SOIL .`OVER. TEXTURE. _ PERMANENT MARKERS: OBSERVATION WELLS. ❑YES ❑NO ❑YES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENC / D aEPTH O TOPSOIL: SODDED SEEDED. MULCHED. CENTER EDGES. DYES ONO OYES ONO DYES E1 NO PRESSURIZED DISTRIBUTION SYSTEM: ¢ x WIDTH. LENGTH. NO. OF LAT L SPACING: GRAVEL DEPTH BELOW PIPF- FILL DEPTH ABOVE COVER. TRENCH a, n MANIFOLD PUMP MAN O IST P MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING'. ELEV.- ELEV. DIA. EL PIPES: DIA.: HOLE SIZE HOLE SPACING. 711 C ECTL COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑ ES 0 N DYES ONO COMMENTS: PERMANENT M 3K OBSERVATION WELLS: PROPERTY WELL: BUILDING: LINE: ❑ S 1:1 NO DYES ❑NO Sketch System on Retain in c my file for audit. Reverse Side. SIGNATURE. TI LE: DILHR SBD 6710 (R. 01/82) ���^ LB State and County State Permit # Permit Application County Permi for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: 4L /- eh /- /- 'n- z B. LOCATION: '/4 ' /4, Section o2� T N, R (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Towns C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family C/ Duplex No. of Bedrooms 2— No. of Persons �-- D• SEPTIC TANK CAPACITY /0-A-0 Total gallons No. of tanks L HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel L� — Fiberglass Other (specify) New Installation A,- Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) E. EFFLUE 1T DISPOSAL SYSTEM: Percolation Rate Total Absorb Area �- sq. ft. New �� Replacement Alternate (Specify) Seepage Trench: No. of Linea Ft. Width Depth Tile depth (top) —_ No. of Trenches Seepage Bed: 4 % Length S 2 Width % Depth 12 /+ZTile depth (top No. of Line 2— Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land & -- 40 % Distance from critical slope WATER SUPPLY: Private XJoint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present o wn e r: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certifio Soil Tester NAME / L � t C ��- -.—h —S C.S.T. # �� and other information obtained from (owner/builder). _ g Plumber's Signature MP /MPRSW# D Phone # Plumber's Address J- ` PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. s w _.W y E 3 E L = m .... t.. .... _ m e ar E a¢ z .m, .... m.. �.. ..... P W. ... ( i a . i E E 3 i � E � I �ry r � 1 3 �x I ..@ .. .. a , ..t... P e , t ... .. ... .... ... E c E c t 1 i 5 E e 3 3 Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE LY Date of Application �' / 9�, Fees Paid: State �� .6earity Date 5 Permit Issued)'RL d (date) �'�—� 9 �� Issuing Agent Name Inspection Yes State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 I v DEPARTMENT OF REPORT ON SOIL BORINGS ANDtro DINGS f 11�1DUSTRY, C Mqy ISION HUMAN RE DATIONS PERCOLATION TESTS (115) � I AN/ -9 139SN 53707 LOCATION: SECTION: ITOWN LOT 0.: BILK. NO.: VISION _5W 1 /�/ 1;_ /T N /It /ffift) . � COU TY: OWNER'S BUYER'S NAME: MAILING ADDRESS: 5 e h e�•u s USE DATES OBSERVATIONS MADE g NO. BEDRMS.: COMMERCIAL DESCRIPTION: S: A ESTS: Residence yNew ❑Replace — O ,,, RATING: S= Site suitable for system U= Site unsuitable for system G 4 -e-7" ©nr m m / e ca C NV NTIONAL: MOU RE: D: IN -G O ND- PRESSU SYSTEM ILOLDING TA K: MMENDED SYSTEM: (optional) s ❑u K S ou ❑u as -IN- u LH os RECO If Percolation Tests are NOT required re DESIGN RATE: SY 4 '7 � � I If any portion of the lot is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 72 7 7 / �-- r- S B 177 2 7 � k 6 A B-'- 7 t /��� 7 13 _ L %31_1 11 _ 5 , � r� L . f r -S B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PE RIOD 7 PERIOD 2 PE RIOD PER INCH P_ O rho 1 / P- 2- 3 i P- P-_ P- P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION X 1 ..._ .__ ., ���.� !.. �i _ _ .... E I F t . { I I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the pr ce ures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: r S_ _ 1 7 — 2- ADDRES CERTIFICATION NUMBER: PHONE NUMBER optional): L&2 gZ 4� 1_� __1_3 ;L L116 .167 y A41 I CST SI TU E: , DISTRIBUTION: Original -Local Authority, 2nd page- Bureau of Plumbing, 3rd page - Property Owner, 4th page -Soil Tester. DILHR -SBD -6395 (N. 03/81) t� r � rr s i� o r (3 Val -ell 1 L? tI .