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HomeMy WebLinkAbout038-1103-80-000 p 0 ch ch 2 p t 2! c w p _ 1 C to x O c A 3 Z T . F Z ? W S S to Z (T N� CD CD O N C_ A m N (D d n C y O j ►p'q o c 0 m c a m N n m rn° O I $ $ y O o OD o ( N rr. O 51 C O I 51 C O R gL w co Z D eo F' u� D W co C p N m s (o y N a I rn (D W y m W :r I N 3 n0 = c (°o -Cy) O C e m ho CD z N N �1 p N N A p N N N K Z 000 I 0 Y � � c cc < C w z 1.5 3 0 Ch � 7 N 0� D p p O_ Ul ? l la ' (� Eli 7. N 4 ! N Qj OD z r w `� =-E D CD c D W 0 O r �i O @ O i tv o CD M y y � I c >. m (p m C N d 7 3 7 Z (D (b m tb N I y c y a A I a a G) � (p N w w T mC4 a a A z I °o o z cA m� I 'A I I o w � (� n c �.v a o 3 CC C N 7 p' N� N C C I cum o a ��, a a 0 o N I ° fD I �• •� a n ' I a,7 I (D p p (D I Cp I ms i `e CD a 3 3s a I `° ti n � o I y I o o N b I m I fD � I i XY \ � v) n qB 0 l - I _ STATE 126. - m � N _ � Q 179 0D W 11 787 f ,D - P c) o D o 0) 1 , rn CA W .N ,r OD �cn I 659.3 — m m n 00 N 0 I a zi m-�� W 1 y.� i �- � .4 j ro Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. C r o ix Safety and Buil. ing Division INSPECTION REPORT Sanitary Permit No: 49 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Briese, David I Star Prairie Township 038- 1103 -80 -000 CST BM Elev: T717M Elev: BM Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. I Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) 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 j No COMMENTS: (Incl de code discrepelicies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 190 hway 65 New Richmond, WI 54017 (SE 1/4 SE 1/4 25 T31N R18W) NA Lot 3 Parcel No: 25.31.18.436B 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes) No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. I ou�ty ani ry tit application In accord with 15.01 St. Croix Coun ST. CROIX COUNTY Vasco NSIN Paraonal iMpmation tY Sanitary Ordinance ZONING OFFICE YOU Provide may be used for secondary purposes ST. CROIX COUN7y G O VE R NME NT CPrivacy law. S. 15.04(1 el Road CENTER �/ 9 � �O 1101 Carmichael Road �/2 s— O Hudson. WI 54016.7710 Attach cornplet2lWan. for the. stem 0n r not less than 8.1/2 x 11 ' ( Fax 15 -4686 sanitar y Pe ❑ Chadt a revltion ro etches In size. 0 _ tNevioub application 900" Information - Please punt all information y Owner Name Ion: 4 2002 1 r 1/4. Sec oPaRy Owners MaNing Address T N. R E (Or W �, Lot Number ock Number ity, $tali r� zip Code Phone Numer Subdivision Name or CSM Number � c _ � YPe it try: cheek 1 or 2 Family Dwailing - No. of gedrooms, (amity ❑vili C Pu"WCOmmerciat (describe use); own of ❑ State-owned / Ir Type of ParrrtfR: (Chock only one boor en title A. Nearest Road x on line !3 if applitableJ �' /� Al t.p Repair ❑ RecOnnectl0n . ❑Non- Piumbi R arcs ax s ) ng • � e)uvenation um er sanitation g) Permit IWrmber ❑ State Sanitary Permit was Previously issued Date issued N. Type of POWT System: (Cheek an that apply( Non.pressurlted In ro nd ❑ Presaurited In-ground Q Mound 13 Sand Filter ❑ At -grade ❑ Holdin Tank D Single Pass ❑ Constructed Wetland ❑ ❑ Aerobic Treatment Unh ❑ ReGrcula ' Drip title i P O Other t • Design Flow (90) 2. Dispersal Area 8. Dispersal Area 4. sat 3DO Required Proposed App Rate 5. Pe 7. Final e (Min rcdation Rate 6. System Elevation (Gals. /day /aq.ft,J . /inch) EAvation . Tank IMormallon Cepaicty in t3euons p� of � Now Manufacturer Prefab to - Steel Existing G allow Tanks Concrete strucled F iber.- PlatdlC Tanks Tanks glass C❑ t. Responsibility Statement q� ❑ ❑ ❑ ❑ the undersigned, assume responsibility for repair/ ❑ r kense is not required for terrati(t re air or the ins AwOnadon/installation of non - plumbing for the POWTS shown on the attached I P a Name Ion non ►umbing sanitation stem. Pens. A {print) PI 9 najrire no stamps): 2� CU MP /MPRS No. Business P hone Number Plumbers Address (Street. City, State, c 11. County Use Only G Disapproved Sanitary Permit Fee Approved Owner Given Initial Adverse Date Issued Issui Agent Signature (No stamps) Determination X. Conditions of APprovat/Reason for Dis Z ` /h'`✓_ approval: t .a`��ilt t air aQ A %XV S S A& Sy54eA� � ``- ' '�` "s /gyp lt�.t /,,_ Pe Tooe 011INO2 OD XUD ZS 9996 991; SIL Xdd 6T:S1 NON ZO/61/90 RE CEIVED tit!(; Wisconsin Department of Commerce SOIL EVALUATION REPOR image Of Division of Safety and Buildings ST.CRo in accordance with Comm 85, Wis. Adm. Code OFFI County GE Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 6 3 8 —/)O O Please print all information. a awed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). , Z Z- Property Owner Property Location �j Govt. Lot SE 1/4 SE 1/4 S as T 3 1 N R1 7 E Prope Owner's Mailing Address Lot # I Block # Subd. Name or CSM# cit State I Zip Code Phone Number ❑ city ❑ Village ®.Town Nearest Road ,clno'P w2 Yd (t5 0%, 084 : +4 `P ' r. � S ❑ New Construction Use: ® Residential / Number of bedrooms _; k, Code derived design flow rate 3 O GPD ��u�e.utl; ►'© Public or commercial - Describe: Parent material J o t:55 0%) o -s't w A- t - , Flood Plain elevation if applicable R General comments "S g on c. For Pr,S rc't ove&i L4ja oF - *,S4;.. and recommendations: PALS t v 4 p `� r-- -` & e I e-v _,{ or r .' S.3 f ' . �a , ^� ,-4 18 'vt zy' 6e_ 61 *eA-<, zt9+ y o�49- • (o" I... .. `� -1 c9t, ,��„ c.oucr -t- t�bSo -�-: o h 5.� r sr e,. y„ , '["1� S S•iS'1'` ..r. w t l be v. ; �;'� w- a ring 9 7 9 o re- o e •• 'i L. L o f G$ Boring # . ❑ Pit Ground surface elev. ft. Depth to limiting factor 7 0 in. Sal 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 6- IayR 42 L IS a l'SYR.y / -- s �k6 -7 7r6 y0li k F-1 Boring # Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Sal 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 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD < 30 mg/L and TSS 1 30 mg/L CST Name (Please Print) `' Sig .. nature CST Number � L.f- Ic d a 7 s 1 .,. Address h S � Date Evaluation Conducted Telephone Number al 16 a 0 �.; a a 1. g - 1 y- o 71S �Y� - 1 . n f i Properly Owner Parcel ID # Page of F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to liming factor in. Sal 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 F-1 Boring # E] Boring - ❑ pit Ground surface elev. ft. Depth to limiting factor in. Sal 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 •Eft#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOD, < 30 mg/L 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. SBD -8330 (R.07 /00) p P�� IL ����0� �r►t$t r SE.h� Sec, a!5 O%w /9AAa,S - �aLr� Sce,1c . = �v . 33 ac r IL p d'�r «� e- , �,o S S�0 t u NOS. p�a o . W. ro s } � C „0- v-, -I f Pte I Cep D k &'4- - b.pr,; r O M j D o (r'G fl.�elnc -te . 1 f � A ` ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the ;���`r;r�_t. residence located at: Sec . a j T R Town of ��� !,�; �- St . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Q�- Did flow back occur from absorption system? Yes No I (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer if known): ( Age of Tank (if known) : (Signature) (Name) Please Pfint zj Z�- M (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle) . Name � .l,I� Signature MP /MPRS� ST CROIX COUNTY • SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM owner/Buyer haijid � r► es e— Mailing Address /QOQ Property Address (Verification required from Planning Department for new construction) City /State Ttk, /06bVe:;ood L✓` Parcel Identification Number 4Q E8 — //03 800 C706 LEGAL DESCRIPTION Property Location 'b E, V4, af_ V4, Sec. ,3'�; T N -R—L —W, Town of 7 ! Subdivision . Lot # S Certified Survey Map # ZIN5 Volume --... . . Page # ,ra 83 Warranty Deed # "��Kp 1 . Volume - , Page # e,, /-I Spec house ❑ yesA no Lot lines identifiable ❑ 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 affW 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, restrictedplumber or a licensedpumper 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 of year expiration date. Q.� 8 ,�.�/ qSIA 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 I e pro rty described above, by virtue of a warranty deed recorded in Register of Deeds Office. Q SIGNATURE OF APP ICANT 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 AI NT NO. WARRA V DUD �- y` � TMI. W"C IK{CIWC* Pon DATA STATE BAR OF WISCONSIN FORK 2 —1rY I ,' 3801os ZL 652 FA U 6 I REGISTERS OFACE Rus ell G.- Kteeow arnd Sy J. Kzasow .................. ST. CROIX CO., WIL hv! #rAt�d..�4?�t ., wi fq_, as join ., tenants .............. - _ Rsc'd. for Record 8i h ......... ..........+.'..._...... ..................... ...... ...................... .......... __ d of` 2S AA I9„ ! eoatreya tad warrants to .. Aax�. d.kl....A]Ciszte...a1)d..I`iQJC 4:I1..K. at 8:30 A ja:tl�f:... tanan ta ............ .... ............................................... .............................._ e'sY'" °"'ts ....................................................................... ............................... _.._ '814*?K °C• .T ,_.`IR LAKE - Box t the following described real estate in ........ St,...CrO1X .County, Stott of i;lireoruia: Tax Parcel No: .............................. Part of the Southeast Quarter of Southeast Quarter (SERE of SE of Section Twenty -five (25) , Township Thirty -one (31) North, of Range Eighteen (18) West described as follows: Commencing 404.81 feet West and 191.20 feet South of the Northeast corner of the South Half of Southeast Quarter of Southeast Quarter (Sh of SEit of SEit) ; thence SM North 81 41' West, 113.00 feet to the Easterly 'A A line of Highway e65e; thence Southwesterly on said Easterly line, 120.20 feet; tlhenge South 81 41' East, 120.00 feet; thence North 8 °•18' 'East, 120.00 feet to place of beginning. t This is .... .... homestead property. (is) (is not) Exception to warranties: Dated this / ........ ......... day of October- -- . - - -•- -- .....-- .- ........, 19..82... .. ..... .................... ...... (SEAL) ......(SEAL) F -- .Russell G. Kiesow ............. .................................................... ----------- f� -- -- - -- --- •-- ...... .. (SEAL) !. \. ��� �...... ......(SEAL) t ........ .................................. .. °_........ ......... • S.y.lvi.a - -J -• -- Kie.soyr._... ......... AUTBSNTICA ?ION ACSNOWLSDGMZNT (s� ------------------------ -- -- ---- ---- --- ------ -- -- ------ STATE OF WISCONSIN - sa. .....__._.. -------•---- -------- •-------------- •- - - - - -- St. Croix N -------- - - - - -- -County. t swunedicaW ti b ...._.day at - __— ______________ _ - - -_- it ..... PersosaBy tame before me this -• --- -- -day a .._._._..ctCtQfoeX_.____._ -_ --- 19.12.. the above named - -- J�usse�, ._an_d._Syl- via..J....... ------ ---------------------------------- 'ts: Icas[ss>tisTA�s sAle or rvlscoxslx •--- - - - - -- --------------- - - - - -- ------------------------ -------• - -• -• - - -• -- .. -• - - - ..�._... - ntisr�sd h ! 706.�I Wis. Stats.) ---------------- .._-_--------------------------------------- to ate known to be the person ---Z- - -_.__ who executed the foregoing instrument and acknowledge the same. .' 1"10 trievo unswr wws oRarrm sr SO it � NA A:S i._ 1 __54Q�.. ____._.. . .._.--.-. Notary Pntd�ie _ St. .Croix T ty O111►i1r1 k be aadsa�i W aaknow%dgad. Yy Commi *= Is permanent (If nota DUt j b Gate:.. - -.... 1#p. �? - •---- ...... .. ~ 1 .) ' y v . / 1wsRR ftmk it nor wse+A rwM be "VW or amts 'w tuar arss5w.. t I stm a" or wuooaraK , start 1006 s — INS S" NO. i �OOZ i V 1967P 167 XAATHHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., MI Document Number Document Title RECEIVED FOR RECORD 09 - 04 -2002 9 :30 AN St. Croix County AFFIDAVIT Affidavit of System Rejuvenation EXEMPT # REC FEE: 11.00 TRANS FEE: J, Cu) .d �� COPY FEE: 2.00 CERT COPY FEE: Name — (Owner) Typed or printed PAGES 1 being duly sworn, states, under oath, that: I. He /she is th owner art owner of the following parcel of land located in St. Croix County, Wisc , recorded in Volume r Page G /3 Document Number St. Croix County Register of Deeds Office: Records Area Name and Retu Address 1 A parcel of land located in theS�' /, of the-'5C '/. of Section o?S L AVi T N — R IS W, Town of —<qnr �, jam_ St. Croix T . County, Wisconsin, being duly described as follows (include lot no. and e l(f Q4 , Q •� subdivision/CSM or detailed legal description): Loft 3 of C5m V 5 page, o5 3s�y Parcel Identification Number (PIN) As owner of the above described property, I acknowledge that the septic system serving this residence (isrs not) undersized by current code standards. I understand that the issuance of a sanitary permit to allow the attempted rejuvenation of the septic system does not imply that the system meets current code sizing requirements, nor does it imply that the proposed procedure will be successful. 1 also acknowledge that I will make this information available to any future parties interested in pruchasing this property. Dated this day of v% �riCSG r,e, AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) authenticated this day of St. Croix County. Personally came before me this day of Ps7 �� the above named * r / TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the per ecuted the f authorized by § 706.06, Wis. State.) Instrument and acknowledge t ARY • THIS INSTRUMENT WAS DRAFTED BY PUBLIC 2 /na,,-u 0 S Ad q Notary Pu i fate of Wisconsin (Signatures may be authenticated or acknowledged. Both are not My Commissior ,is rent. if not, s e: n Date: L C 1 "THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT REMOVE" This Information must be completed by submifter document we name 8 return address. and PIN (if required). Other information such as the granting clauses, leagal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document Note: Use of this cover page adds one pace to your document and 32.00 to the recordina fee. Wisconsin Statutes. 59.517. nO'COMMU ��� Ir7 ST. CROIX COUNTY CERTIFIED SURVEY MAP 8 y LOCATED IN PART OF THE S 1/2 OF THE SE 1/4 OF THE SE 1/4 OF SECTION 25, T 31 N, R 18 W, TOWN OF STAR PRAIRIE, ST. CROIX W I/4 CORNER SECT /ON 25-31-18 COUNTY, WISCONSIN. COUNTY MONUMENT N yGONi��ti LEGEND �+�� /� O I "X 24" IRON PIPE SET DUANE a MARY JOHNSON ALLEN C. WEIGHING 1.68 LBS. /LIN. FT. ROUTE 3 NYHAGEN • 3/4" IRON PIPE FOUND NEW RICHMOND, WISCONSIN )t • I IRON PIPE FOUND 54017 co S - 1407 — �- -M--K- -CHAIN - LINK FENCE 3 (N. so° oo' e.) DATA OF RECORD HUDS ON, � _ QD THE EAST LINE OF THE SE to WiS. .� 1/4 OF SECTION 25-31 -18 IS ® ` ASSUMED TO BEAR < ` N. O° 18' 44" W. �1�� O Sli eo® • o W E TI N Z O S — UNPL AT T�F L ANDS OWNED BY OTHERS THE NORTH LINE OF THE S I12 - SE I/4 - I14 OF SECT /ON 25 y N. 89 38' 54" W. 520.76' "v I N I L I II / NE CORNER OF y I THE S I/2 - SE I/4 - SE I/4 ( u � l � w 1 — I - o N S- — M Z 15" / ^ 120.20' / co w a) v ti NOTE: _ N Q r- LOT-3 IS SHOWN ONLY TO hI d ro ' REPRESENT A DESCRIPTION M �0 d "� Q o _ CORRECTION, AND NOT TO CREATE aj — A NEW PARCEL. \ Q S. 9 45" E. Z 127.38' 3 0) LOT / Z h�' LOT 2 ^ 276,351 SO. FT. I OD t q, �,�` (6.344 ACRES) O 25,973 SQ. FT. o � �► . (0.566 ACRES) W EXCLUDING RIGHT -OF -WAY O V� 3 IT z IR 7r) N ' ��J,� N 292,555 SQ. FT. �1 c\j N A (6.716 ACRES) N JI 60' N o goo 16� \.Y. O INCLUDING RIGHT -OF -WAY N � N 7 48-54 „ E I vi N 62. 50' 36.00' 35.64' %Z `� : 42.84. (s2,S..62° 1864 APPROVED ►q J . S. 88 44' 11" E. E• (N. 88 42'w.) 1 ` - " (N. 82° 16' W. 71.4') W MAY 1983 z -M co3 — 3 0 o� ST. CROIX COUNTY PREHENSIYE PARKS S 5' 51" 89° 3 E. 144.68 d�tMliTEfr p .. 0 , O RIW L /NE O I — S. 89 35' 51" E. M S. 89 35' 51" E. 407.33' O 6 THE SOUTH LINE OF THE SE I/4 OF SECT /ON 25 SE CORNER STAGE TRUNK SECT /ON 25 -3/ -/8 RAILROAD SPIKE` SCALE= ONE INCH EQUALS NINETY FEET SEE COUNTY SURVE OR FOR TIES. 100' S0' O !00' 200' app' VOLUM PAGE 283 CERTIFIED SURVEY MAPS T " IL . APPLICATION SAFETY & BUILDINGS INDL FO SANITARY DIVISION LABO AND PERMIT P.O. BOX 7969 HUMAN RELA7 .*NS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. Property O. ner: Address: Mailin ' Lc lit/ C r J !v Property Location: or ip: County: '/a 5 /aS /T N/R / W r /r Lot Number: Blk No.: Subdivision Name: Near st Road, Lake or Landmark- S State 'Plan I.D. Number: �r C E (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance ❑ Other (specify)* Bedrooms: 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY /pC HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBE MANUFACTURER: V1/f C 'r, EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): ❑ New Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit 'f T-, ❑ Alternative (specify) ❑ Seepage Trench Water Supply: /I2 6P Aft V/ kft Owner's Name as Listed on Soil Test Report (if other than present owner): ❑ Private ❑ Joint ❑ Public ,$s I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signature: MP /M E JpLNo.: Phone Number: ✓� a �Y ! 1 C / a 1 ) 4 &j 1 / - I Plumber's Add; T Name of Designer: `7`A'' / / COUNTY /DEPARTMENT USE ONLY ignat a of Issuing Agent- Fee: Date: APPROVED Sanitary Permit Number: DISAPPROVED Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod - Plumber DILHR -SBD -6398 (N.03/81) I I - ENT OF IN , Y, INSPECTION REPORT FOR SAFETY & BUILDINGS LAEtu�: 'UMAN RE, aTIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O: BOX , 9 BUREAU OF PLUMBING MADISON, -NI 53707 CONVENTIONAL El ALTERNATIVE State Plan l.D.Number: (If assigned) ❑ Xlding Tank El In-Ground Pressure El Mound NAME PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE: � a B CH M ARK IPermanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: S LID Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number .Z 94, If SEPTIC TANK /HOLDING TANK: o`Z MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV. WARNING LABEL LOCKING CO ER 1"0 IDED: PROVID YES ONO NO BEDDING: VENT DIA.: VENT MATL. HIGH WATE= ROAD: PROPERTY WELL: BUILDING: I VEN O RE H A LAR v i LIN - � Y-0 AIR L YES ONO l c S " NO f OSING CHAMBER: MANUFACTURER r NG: LI I CAP ITV PUMP MODEL. PUMP /SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: S ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: MP ND OLS OPERATIONAL PROPERTY WELL BUILDING IVENTTOFRESH IDIFFERENCEBETWEEN LINE AIR INLET: PUMP ON AND OFF) ❑YES ❑NO SOIL ABSORPTION SYSTEM. Check the s mo ture t the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, cons uction shall cease until the soil is dry enough to continue.) CONVENTIONAL SYSTEM: �,, �" WIDTH: LENG TH. NO. OF DISTR. PIPE SP�4CING. COVER ` INSIUE DIA. LIQUID TRENZS. / M IAL: DEPTH: BELOW PIPES DEPTH _x A V ELEVH INLET 6LET/ END DISTR. PIPE MATERIAL: P OEDISTR �rrrlr' LINE ERTV WELL: BUILDING ' A V E NT R NLET FRESH ' Z C g o U f as S MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. EYES 1:1 NO SOIL COVER_ TEXTURE. J PERMANENT MARKERS. OBSERVATION WELLS. OYES ONO OYES ONO DEPTH OVER TRENCH BED DEPTH OVER TRENCH/BED JEPTH OF TOPSOIL: SODDED SEEDED. MULCHED: CENTER EDGES. DYES FIND DYES El NO DYES 1 NO PRESSURIZED DISTRIBUTION SYSTEM: 'WIDTH LENGTH . NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.. ELEV. DIA" ELEV. PIPES. DT: . HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. � ❑YES ONO ❑YES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS PROPERTY WELL: BUILDING: LINE: }�•� 1 ❑YES ONO ❑YES ❑NO I'c 4 `° o pots: 9, Jos :9 7 7.4,, .7Z. i Sketch System on Ret in in county file for audit. Reverse Side. GNAT TITLE: �� DILHRSBD6710 JR. 01 /82� , AS BUILT SANITARY SYSTEM REPORT TOWNSHIP ` J �' �.aVQ OWNER [j - / N -R" ADDRESS /d�iy 11 )U&cj wise ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE - /,?O PLAN VIEW Distan ;and dimensions to meet requirements of H63 THING WITHIN 100 FEET OF SYSTEM R Old P � I dii6a e o th A ro SC i.E BENCHMARK: (Permanent reference Point) Describe : &?--or C o rhCr 04: Gr r4 ce. Elevation of vertical reference point z&7t;- Slope at site: 3,�, SEPTIC TANK: Manufacturer: .Qr A 4 Liquid Capacity: _ Number of rings on cover : a Z.= anck manhole cover eleva' ion: Tank Inlet Elevation: 19 Tank Outlet Elevation: It A PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set for a cyc a gallons; total capacity of distribution lines gallon: size of' pump head; gallon per minute horsepower �; ran name of pump and model number Type of warning device HOLDING TANK: Manufacturer_ Number of gallons Elevation of manhole cover Ty pe I of warning device' SEEPAGE PIT SIZE: - N pits eet iameter feet liquid dept seepage pit in et pipe- elevation bottom of seepage�t e: evat on feet. SEEPAGE BED SIZE: number (if lines width y! length depth a EEPAGE TRENCH: width length ERCOLATION RATE �A U tE REA BUILT INSPECTOR TED PLUMBER ON JOB LICENSE NUMBER DE M ENT OF REPORT ON SOIL BORINGS AND DINGS II' LABOR AND PERCOLATION TESTS ( 115 ,j AF ' B 67 HUMAN StELATIG�NS \ � � /y J,�!I/�Cf�1�}l11 07 LOCATION: SECTION: TOWN H IP /h464+F13+"Ll I Y:, LOT NO.: BLK. NO.: S VISIO f /T/ N/R E (o S /•Q.c .<' i, C'�.� / r/,�z xJ4 COUNTY: OWNER'S BUYER'S NAME: / AILING ADDR SS: 0lL/ USE DATES OBSERVATIONS F NO. BEDRMS.: OMMERC AL DES RIPTION: A ESTS: Residence ❑New Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOU D: IN- GROUND - PRESSURE: S STEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional) S [:]U ❑U ,CIS ❑U S ❑U ❑ S zu If Percolation Tests are NOT required DESIGN RATE: SYSTEM EL ( If any portion of the lot is in the under s.H63.09(5)(b), indicate: ',4! 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 E _T H ­ EST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL- INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL -MIN. P RIO 1 PERIOD 2 p R PER INCH P- YZ Al a /0 .?— e P-S V P -- P- P_ PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil a eas. 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 su ce elevation at all borings and the direction and percent of land slop. 1 SYSTEM EL VATION t .r - `APPAc - n. r . VED m. .� L P opo e u+ tN ^. ._.. _. E � J 3 %f. C _az 0 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures 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 nt): TESTS WERE COMPLETED ON: r A DRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): CST SI NAT � R E: t DISTRIBUTION: Original -Local Authority, 2nd page - Bureau of Plumbing, 3rd page - Property Owner, 4th page-Soil Tester. DILHR -SBD -6395 (N. 03/81) r + ,! _s�£ _ t , kt Ilk r ST. CROI X COUNTY 3 } f� h� W I S C O N S I N ZONING OFFICE 796 -2239 - l HAMMOND, WI 54015 May 18, 1982 Robert J. McNeil Box 12 Webster, WI 54893 Dear Mr. McNeil: We received the amended percolation test for Russell Kiesow located in Star Prairie township. System elevation is still incorrect. According to your data bore and perc hole elevation that we arrive at is 96.5. Your bench mark location is too general for us to correctly identify. Should you have any questions, please contact our office. Yours truly, / Thomas C. Nelson Assistant Zoning Administrator TCN:sl Enclosure t l � r� [ V - E � � o � d � �d o� oel4j w F` a ! W i i I i � l \1 I e of 'n 1 .2f 1 O J f'L . M...�....u�:e.,�