Loading...
HomeMy WebLinkAbout038-1163-40-000 0eq, } @ @ A ] 0 § � � t o E _ . c CL (D ) k f ]k z ƒk Z \ / , �� % a 0 7 2 \ C r ■ � � � � } - } � _ o 0 ¢ R/\ 2 m a 2 � @ � 0z 2 2 \ Wz . J 3 Jf $ z U) I-- _ ƒ 2 A 2 a ® ) ® N 5 \ c / \ . ` $ I U) ' § -� ƒ $ / ƒ G \ § k < k { < . z = z z _ z .. .. \ k § m .. § oil � m ■ > © e \� 0 R o a a ( 7 0 a \& k 2 � �� �g & ƒ $ . 4) E a � E / / I § a a a / a a a 7 i CL U) r CY k \ § \ 0) / ° } \ \ 2 z (D N @ 2 _ ® iz z k o t \ § g \ ) / § o / ' ° / / ° 2 / k / � \ � $ # $ ƒ ) � ¢ c 7; 2 M k$ . °° K I f 2 I cl - E o I 2 @ En \/\ 2 \ j §�§� G )R 2{ \� a. @ 2 2 Q 2 E /*_ { o« - w k\\ 0 > i o 2/ k ] f o 2 f} §\ 7 2 G 0 a § £ # I " IL » �) f k a§ k a§ k 3IL 2 0 3 v 0 3 2 Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count INSPECTION REPORT, CIrb1 GENERAL INFORMATION (ATTACH TO PERMIT) ' Sanitary Permit Noo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. � I — 1 q - ( T Pe mit H Ider's Name• ❑ City ❑ Village Town of: State Plan ID No.: ph N CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: I " tae CD 3, TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV, Septic 4, Benchmark ?, `{o i02.qa �� •� Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet (0 -30 0 14 , 1 0 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet �- Air intake Septic } tno r yQ 6 r NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe •r . i ; Holdi Bot. System PUMP / SIPHON INFORMA — Final Grade pp U,c.IL 0'L r anu a Demand Model Number GPM TDH Lift Friction stem TDH Ft F emain Length D +a. Dist. SOIL ABSORPTION SYSTEM k , S Qz TRENCH Width , Length / 7 No. f Trenches PIT No. Of Pits Inside Dia. Liquid Depth D IMEN / DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING � {� fa SETBACK ur CHAMBER S � INFORMATION Type Of , r M e Numb System: � (eo - 1- - 3 OR UNIT DISTRIBUTION SYSTEM Header/Ma ifold 4 Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Int Length C -Dia. Length ia. pacing ake 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 El No E] Yes ❑ No COMMENTS (Include code discrepancies, ?ersons present, etc.) ' ,,,,04&4 � �, 2 ��� (arc- R.a-�^ ea-�' 2 1 'j � � Ian revi req t red? P Yes ❑ No r Use other side for additip al i formation. SBD -6710 R.3197 /)' Da Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: d 6 � iE w SCALE s ff E w. g ti ro Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 lV Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned. Attach complete plans to the county copy only) for the system, on paper not less than 8 -1/2 x l 1 inches in size. County State Sani errnit umber ❑ Check if revision to previous application State Plan I. D. Number sr ,- I. Application Information - Please Print all Information Location: Property Owner Name Property Location & 41 44 &L✓AS4�:_l/4,S -7QT- ,N,R/BE o Property Owner's Mailing Address Lot Number Block Number �J v /1� ✓ev 6 mac✓ 1 �..� City, State Zip Code Phone Number Subdivision Name or CSM Number II. Type of Building: (check one) , °' t.�__`_ ❑ City ge I or 2 Family Dwelling - No. of Bedrooms 7_ F,� y, r \\ ❑ own of • Public /Commercial (describe use):_ 1!. • State -Owned � l i �''r' 1 "'r' �� r Nearest Rk ad _ I •f'+�p.�l •1 V ' z, • Parcel Tax Number(s) l i. III. T ype of Permit: Check only one box on line A. Che bat on lin licable A) 1. ❑ New 2. placement 3. ❑ Replac a of Z'�fI v ; S. 6. ❑ Addition to System System Tank Only k Existing System Permit ` b ee- , Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) Y vl ,Alen pressurized In ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland • Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line • At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (GalsJday /sq. ft.) (MinJinch) Elevation eKJ`7i � Y3 -'K r 0. t 53. Z 1 5 ds VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks J� ❑ ❑ ❑ ❑ ❑ ❑ T15 ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume res onsibili for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): RS No. Business Phone Number C-, 6_"' Z G,i zZr 7if- LG�= B Plumbers Address (Street, City, State, Zip Code) �e J cry / IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse Suffharge Fee) Determination a : M X. Conditions of Approval /Reasons for Disapproval: va t s iar� Pis Cal - r�J c�� 1 ;-,M /oaG L . Hoof SyYkr• , � J.. - -�', C TtS- xr- ----yo yg L L T i i Wisconsin Department of commence SOIL EVALUATION REPORT Page - —of Division of Safety and Buildings In accordance with Comm 85, Wis. Adm. Code County .� Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Include, but 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. Please print all Information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Z5 Property Owner Property Location Govt. Lot 114 1/4 S T N R X(orl7 Property Owner's Mai ng Address Lot # Block Subd. Name or CSWI# 1 ' e City ^ Sta a Zip Phone Number ❑City ❑ lage Town Nearest Road ❑ New Construction Use: Residential / Number of bedrooms Code derived design flow rate _ GPD Replacement ❑ Public or commercial - Describe: Parent material �n/l Flood Plain elevation If applicable ft. General comments and recommendations: .5 fr "A' Boring # ❑ Boring JZ Pit Ground surface elev. ft. Depth to limiting factor Z&4 in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD In, Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 "Eff#2 I I j 3• zo a Boring # Boring .® Pit Ground surface elev. �_ ,QS ft. Depth to limiting factor ? //l in. Soli ication 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 � G - 3 • E;M uei #1 = SOD > 30 < 220 mg/L and TSS >30 _< 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS 130 mg/L C3T N Signature Number Address ✓ Date Evaluation Conducted Telephone Number �" - - - �S Property Owner l s>• Parcel ID # Page of Boring # ❑Boring .� Pit Ground surface elev. ft. Depth to limiting factor } /D in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 _ 1 a Boring # ❑Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil lication 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 a Boring # ❑ Boring Ground surface elev. ft. Depth to limiting factor in. 11 Pit Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff In. Munsell Qu. Sz. Cont. Color Or. 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. SOD•8330 (R.6100) AJ/y%sf1 / s c rfiAd i I CA'WL ' Ili law �1fi l i �j o Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number c ? Number of Bedrooms Design Flow - Peak (gpd) S^b Estimated Flow - Average (gpd) Septic Tank Capacity (gal) _ Soil Absorption Component Size (W) z C•�'""' Type of Wastewater D mestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) 6 S Z Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 Aug 1,8 00 03:29p Marissa Van Meier 715 - 247 -2074 p.1 ST CROIX COUNTY BANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerMtiyer c� o Mailing Address U� � 1 uC r \il Property Address 0 �D \ 61_j oI(�J Loa (Verification required from Planning Department for new construction) City /State _ � , � Pzircel Identification Number ll't0 LrG AI, DESCRIPTION Property Location 'A, sE ' /A, Sec. 3a , T 3 f N - R /P W, Town of Subdivision C+^er lu�'�.. ___ Lot # 1 / Certified Survey Map # , Volume , Page # Warranty Deed # 62 003> 6 Volume ` Page # Spec house D yes K no Lot lines identifiable ®- yes O no SYSTEM MAINTENANCi; Improper use and maintenanceul'>(iin 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 master plumber, Journeyman plumber, restricted plunihcr or n licensed pumper verifying that (1) the on-site wastewaierdisposal system is in proper operating condition anchor (2) afirr inspection and pumping (if necessary), the septic tank is less than I/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standar ds set forth, herein, as set by the Depanmen( ul' C onimerce and the Department of Natural Resources, State of Wisconsin. Certnfical!un stating that your septic system has been mauttomcd trust he completed and returned to the St. Croix County Zoning Office wi'i,!n : r) days if the thre car expiration date. / / Q ,116NIATURE OF APPLICANT DATE _ OWNER CERTIFICATION I (we) certify that all statements on this form are tic to the best of my (our) knowledge. I (we) am (are) the owners; of (lie perry s ribc above, by virtue of %kjrranty deed recorded in Register of Deeds Office. 3 / IL Lo SIGNATURE OF APPLICANT DATE "• " Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. ••• "' '• Include %vith this application: a sianipcd warranty deed from the Register of Deeds offcc a copy of the certified survey map if reference is made to the warranty deed Aug 18 00 03:30p Marissa Van Meier 715 -247 -2074 p.2 08/15/00 `TLTE 08:26 FAX 715 986 4687 REGISTER OF DEEDS 0 002 VOL U97pw3f16 SGCr[ PAR VP WISCONSIN 90Aa,1- 199A DoeuaatNt..uaar WAIUUM'T DEIiU KATMLEEN H. WALSH REGISTER OF DEEDS 'I his lO d, made between Lowdl I., dohs a d Noncj K, ,lohsuan, S . CROI X CO., U1 huaba and wife MMUED FOR f1E= Graaaor, eanvcyw and 0343 -2000 1e30 RA warraob to -- Alp _ ' Vnn Moles (iARApI�(TY� No Crnnlec. ' 07p6PY FFE: Gnrmr, for a vowible ronsidermion, costvcys and warmaa in Gcw%tcc the COPY FEE; following dcacsibed teal ewlaie is St- Crohx _ County, State of Witcoasin (The TRAMSFER FEE= 525.00 . moely . ) , RECORDING FEE: 10.00 Rwmd% Ana Nam and Rca.m AWMW River Valley Abstract & Zitio, Mac. P.O.BozUe vo -tola13 Hadscis WY 5019 O xt- tlCtla Pascal Ideallnu0nn Numaar (PW) mi. — sm"Coand P.vpanr, Lot 4, Creatview Addition in the Town of Star Prairie, St. Cmix County, WiscOl>sin. 6xceptivm to wwmnusw Fyaomeau, restrkdoss and lights uGway of record, if arty. Dated AAa 2Zud day of March, 2000. tNxl m n ACKNOWL STATE OF w13CONSIN ) AtrrjUUVT1CAT10N ) IN' S Croix County ) Sianenre(a) Paso —llj same befeee ma Nir2 day of Match. �_� dlLt day of Fobruary, 20DO, ' 2000, the phnve lamed I dwell L klllr4ot> nnJ N trtov K FakpW hw hand and Wife - lu mt: known to be the " Rri,tt+ra Ott•nd porson(1) who excoxco uu ta En foregoln0 inssrwned Acknowlodae she ns c T1TLM MEMBER NTATE BAR OP WISCONSIN Qtnac + c 1n a Cartaan authorised W ii Notary Public, sine of wtu"Wift `nil$JwS1'AvJMWr- AS59AFTEOaY My Comm ll,ion is pemancm. (if not, iuu expiation dal, AtWrneyKrfaWsaORland Jq,uar 2QA$�•) Hudson, W154010 (7ipmmn..I.ar Dr aultl■dllealed or.eanowladaal . Rnfi tie nut IMeawary.) ii Yi A� .e•N� n •Names of p�raoas dwntae In any galleMy aluUld fir ypat aR M� �1�'' the4 siyelurN WAax*%'rV INMP aTAia INaZ WOCON"d FOaa1 Ie•. N�OI.w110N /nOaT ,ONAU• CDIanANY FMO DU LAQ. TA 0045*7wb Flug.1 -8 00 03:30p Marissa Van Meier 715 -247 -2074 p.3 i c"r- M / I U Llr) N � / a, b� e 69 � � / S 4 / O QF (� . 1`N 'Z N; VAL \ F'6 S ` 'L �► Y . s .n F N � CU a Co �L� a '� a 2 s 2 cb0 F �N 6 CA 1 o z f ti nN 41 „ f7 0 p�o91 fy Li F W -, ' A O h ti w 0 Cl 3 Z N • 'pj• . N Ti r �e r ` � d ti z •r ,p u f/l W O o� Am — ---4% i 00'S9b oo'o£b rnnrn, anaan .4n N1.7.RTFla3i LRAb QQr. QTL VVA L7.:Rn an.r. nn /gT /Rn rnu) 74 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 !'�DrrSSc Uo� r-►�,.,� residence located at: k/�j %, s %, Sec. D, , T D r N, R _Zf- W, Town of Siu - /�. , r.' 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 2/ zzz Did flow back occur from absorption system? Yes No (if no, skip next line. Approximate volume or length of time: a i /C . � gallons C l�, /cti minutes ; Capacity: S_T- Construction: Pr Concrete Steel Other Manufacturer (if known) : Age of Tank (if known) 7�,sT CC �<L o-. �`- /5 -�23'y (Signature) (Name) Please Print r" L es (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� L.�li'�� L c✓, c-r,, Signature 5YMPRS w� 2 O "l I - Form - S V - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 104'k TOWNSHIP 1 � SEC . �� T ' N -R W ADDRESS yX ST. CROIX COUNTY, WISCONSIN SUBDIVISION �L��� LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM t , i INDICATE NORTH ARROW = S'f BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TA4dK: Manufacturer; r"t .'� Capacity Al a'A T Number of rings used: Tank manhole cover elevation: ti Tank :inlet Elevation: �/( Tank Outlet Elevation: r � , Number of feet from nearest Road: Front, 0 Side, Rear, O �"� feet From nearest property line Front,O Side,0 Rear, O Z2' feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) 1 SEE REVE RSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORBTION SYSTEM Bed. 1l Trench: Width: 1 Length:, Number of Lines: _�_ Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, � Side, O Rear, O Ft.7 Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 0 or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest_ road: Alarm Manufacturer: x Inspector Dated: - �j` Plumber on job: License Number: 3/84:mj DEPARTMENT OF IfEPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, � c DIVISION BOX I_ABQR AND HUMAN RFNATIONS PERCOLATION TESTS (115) MADISON WI 79 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP /h 4N4C1P�: LOT NO.: BLK. NO.: SUBDIVISION NAME: 1 / 4 , 2 5 1 / 4 .3 o /Ta/ N/R /Awo W - COUNTY: OVtlt EfPS BUYER'S NAME: MAILING ADDRESS: 4 - ar 13 LCOLO I USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: P R LATI TESTS: Residence New ❑ Replace _7 7 -8 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN- GROUND PRESSURE:SYSTEM- IN- FILLHOLDING TANK :RECOMM ENDED SYSTEM: (optional) ®,S DU 9S ❑U C�,S ❑U OS�U I ❑S [SU If Percolation Tests are NOT required DESIGN RATE: if any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: 09S)PIA11 PROFILE DESCRIPTIONS 1 !5�� _ /� A)c ?_ BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WI THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEpy"4;J, ELEVATION OBSERVED EST. HI HEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) °O -8 COn.C,S. ZS 81 y 2.$ 15 z5 So Ad R? B- 3 - °c� �l( o A) �-'7 �� S . . B- Z S r1'� (9 A) I-, 7 � (. �� , G-. 5. / �7zd Ran . S, Z LIS o A) �� zs '� B- logs 1m41 � PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL- INCHES RATE MINUTES NUMBER HdCME-S AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD PERIOD PER INCH P_ I 3 _ Z v l0 `/z , ti z. 3 Z P_ 2 2 ° ec /0 3 `/Z - VA Z o P_ /Vo 1 P -_ P_ PLOT PLAN: 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 slope. SYSTEM ELEVATION 93 5 ta ; z F- I t ��►-K ►> rS r r1A i __.. i l ' N - 3 _ E C� 3 i I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print) TESTS WERE COMPLETED ON: f♦7^ Z_ �� l - Z 7 DDRESS. CERTIFICATION NUMBER: PHONE NUMBER (optional): a . CST SIGN U IBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester, BD -6395 (R. 02/82) — OVER — J INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 • To be a comp''ete and accurate soil test, your report must include: 9. Corplete legal description; 2. The use section must clearly indicate whether this is a residence or cornrnercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. is this a nevtr or replacement systern; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7, MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Male sure your benchmark and vertical elevation reference point are clearly shown, acrd are permanent; 0. Complete ail appropriate boxes as to dates, narrres, addresses, Flood plain data, percolation test exemp- tion, if appropriate; 10, If the information (such as flood plain, elevation) does riot apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. i ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols I st - Stone (over 10 ") BR Bedrock col:) _ Cobble (3 - 10 ") SS - Sandstone gr Gravel (under 3 ") LS Limestone s - Sand HGW - High Groundwater cs Coarse Sand Perc - Percolation Rate rued s - Medium Sand W - Well i Fine Sand Bldg - Building Is Loamy Sand > - Greater Than *sl -- Sandy Loarn < - Less Than *1 Loam Bn - Brown sit Siit Loam? BI - Black si - Sill. Gy Cray cl Clay Loam Y Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay wi - rnJith sic - Silty Clay fff - few, tine, faint c - Clay cc - cornrnon, coarse pt -- Peat rzarn - Many, medium r - Muck d - distinct p - prominent HWL - High water level, Six general soil textures surface water for liquid waste disposal BM - Bench 1` ail< VRP - Vertical Reference Point TO THE OWNER: i h' :? f rr t r !art in; t rt hi'st Step in sec" 'F m) a safatca y perrnit The county or the Departrner4t may reCluest of tins so.l test in the,= fay id pi for to herrr)it. A co,ra 31 tt, set o "' plane for the private s" >tew alit] a pwrnil. applicarluon IY"U"t lie sUhnlitted to the ,i(­.l =r0f)6ate local <; tl5oriiy in order to r .. J a pet nil , 'The .rtW y pe.rrnit tn.r„t bf a ?,<'riIve(J d'."'rd post ior tot sta of anv co I)jt"rucl,4o?1. o sT o, tiR DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING i MADISON,'WI X3707 ®.CONVENTIONAL ❑ALTERNATIVE State Plan 1.0. Number. IIf assigned) El Holding Tank ❑ In- Ground Pressure El Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION DA LoweZZ Johnson Sax 223, New Richmond (UI 10,3 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. CST REF. PT. ELEV.. NW SE, Section 30, T31N- R18W,Lot #4,C&estview, Town of Sxatc Pna Aie Name of Plumber: MP /MPRSW No.. Coumy: Sanitary Permit Number: Cat Poweu 1563 St. Croix 49458 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV. TANK OUTLET ELEV.: WARNING LABEL LOCKING C VER �,�/J 7 q PROVIDED: PROVIDEP: � " ^� /" V y � . 91. / YES ❑NO ❑YE ❑NO BEDDING: VENT DIA. VENT MATL.. HIGH WATER NUMBER aF ROAD: PROPERT ELL BUILDING: VENT TO FRESH ALARM: FEET FROM LINES AIR INLET: ❑ YES O 1:1 YES ❑ NO NEARES / &C / T DOSING CH BER: MANUFACTURER: BEDDING: LIQUID CAPACITY PU P MODEL. J PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PuMPA C NT LS OPERATIONAL NUMBER PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN 1` FEET FROM LI AIR I "LET PUMP ON AND OFF) ES ❑NO NEAREST_'_ SOIL ABSORPTION SYSTEM. Check the soil moisture A the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORGE the soil is dry enough to continue.) MAIA1' CONVENTIONAL SYSTEM: WIDTH: LENGTH. NO. OF DISTR. PIPE SPACING. COVER INSIDE DIA.. #PITS: LIQUID TRENCHES: N1 7 1AL: ��, DEPTH: 2 GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. TR NL4N(BER (F PROPERTY WELL: BUILDING. VENT TO FRESH BELOW PI (� ABOVE COVER. ELEV. INLET E V END. PIP LINE. AIR INLET: FEET FROM MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE. PERMANENT MARKERS. OBSERVATION WELLS. ❑YES ❑NO YES ❑NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL: SODDED. EDED MULCHED: CENTER. EDGES. E NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: �y Lf `WIDTH: LENGTH: NO. OF LATERAL SPACING. GRAY DEP LOW PIPE. FILL DEPTH ABOVE COVER: TRENCHES: MANIFOLD PUMP MANIFOLD DISTR. PIPE MA OLD MATERIAL NO. ISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: �a a� ELEV . ELEV.: DIA.. ELEV.: PI S. DIA.: "' .. HOLE SIZE HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF ',� : PROPERTY WELL: BUILDING: FEET FROM LINE. • 2 El YES ❑ NO ❑ YES ❑ NO NEAREST z' �i�, 45 s /D.0 — G I 1 1 �� ✓�' `�a� IJ .�5 Sketch System on Ret ' in county file for au J G Reverse Side. SIGNA7URE. /rte TITLE. DILHR SBD 6710 (R. 01/82) UUU i Lpisco APPLICATION FOR SANITARY PERMIT DIL.HR r. OU, � OEPRRTR.1EnT OF (PLB 67) UNIFORM SANITARY PERMIT - InbuSTR4, LRBOR 6 MUMRn RELRTI0 f15 — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /2x 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS t / PROPERTY LOCATION �I V I10 -AGE : 1/ 1/4, S = r� N, R • k (D TOWN OF: LOT NUWER BLOCK NUMBER SUBDIVISION NAM NEAREST OAD, L/ KE OR LANDMARK STATE PLAN I.D. NUMBER f, TYPE OF BUILDING OR USE SERVED " //, 1Z 1 or 2 Family Number of Bedrooms: Public (Specify): THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System-In-Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity ' Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: - fS IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): C;2 7 � Private ❑ Joint ❑ Public 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Na of Plumber (Pri Si MP /MPRSW No.: Phone Number• _ re: — ( — - Plumb s Address: Na of Designer: ;f COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: ^ ;� Date: El Disapproved 0" r �J k El Owner Given Initial pproved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR - SBO -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber 1 f , INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6318 ' To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.) ; 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. 19,114 "All is in41,14w4f osold ana operated 7 7 0 � / 0( xe / i !�j llc /7� lti' T O We're Here For You. ,� Litho in U.S.A. S T C - 105 SEPTIC TANK MAINTENANCE ACREKMEN'l.- 0 St. . Croix County OWN E It /I U y I.' R 1 ROUTE/ BOX NUMQER Fire Number z I I C IT Y / STATE '&J - _71 PROPERTY LOCATIONJI,j,' " 5 t - N , R I_S W, 17 T o 1 21, St. Croix County, Subdivision 1, 0 L number Improper use .. and Maintenance of your septic system could result in its premature failure LU handle wastes. Proper maintenance con sists o f p out the septic tank every three years or sooner, it needed, by a Qqqu_jq;f lupLky jig! pumper. What you put into the system can affect the luneLion of the septic Lank as a treat- ment stage in the Waste dispusaL system. Sr: Croix County residents may l eligible to receive a grant for a M a x i mum of 6U% of the cost of replacement: of a failing system, whAWKS in operatiun prior to July 1, 1918. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new jy1tyTY agree to keep their systems properly ma L n t a i n e d The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (L) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and'pumWK (if nec- essary), the septic tank is less than 1/3 f of sludge and scum. Certification form will be sent approximately 30 days prior to H three year expi.ratioa. 0 I/WE, the undersigned, have read the above requirements and agree to maintain Chu private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- wont of Natural, Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration dare. S I G N E 1) DATE St. 1roix County Zoning Office P'0. Box 98 Hamm )ad, W1 54015 7.1.5- 196-2239 or 715-425-8363 Sign, date and return to above address. APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - -/ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property /J t / - &/, L,2 Location of Property4, Section Q T N - R W Township ` j}"� Mailing Address i Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Q�j Date Parcel was Created 4 Are all corners and lot lines identifiable? -- -I1 Yes No Is this property being developed for resale .(spec house) ? Yes No Volume Page Number a as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING -4-% Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION 1 (we) eeAti_6y that aU statements on .thin 6o&m are tAue to the best o6 my (outs knowxedg e; that I (we) am (aAe) the owner Gs ) o j the pro pen t y dea etubed in this in6o 6o4m, by viAtue o6 a wa4Aanty deed ne i the 066ice o6 the Coun Reg vsaten o Deeds ah Document No . �y a d c b � and t hat I (we) p4menay own the proposed .stite bon the aewage poaaf- system (on I (we) have obtained an easement, to nun with the above duct bed pnope ty, Aon the con6tAucti.on o6 baid system, and ,the .same has been duty recorded in the 066ice o� the County, Register o6 'Deed/s, Document No. ) . al" " SIGNATU / .0014 / w, ER SIGNATURE OF CO -OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED DOCUMENT NO. . ' STATE BAR OF WISCONSIN FORM 2 -1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED Lester H. Martell I conveys and warrants to Lowell L. Johnson RETURN TO the following described real estate in St. Croix County, State of Wisconsin: Tax Parcel No: Lot Four (4), Crestview Addition, located in SW; of the SE *, the NWJ of the SEI, and the NE} of the SEJ of Section Thirty. (3), Township Thirty -one (31) North, Range Eighteen (18) West J This i S n o t homestead property. (is) (is not) Exception to Warranties: Dated this 13th day of April '19 84 (SEAL) (SEAL) Lester H. Martell (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. St. Croix County. � authenticated this day of , 19 Personally came before me this 13 day of April _19 the above named Lester H. Martell TITLE: MEMBER STATE BAR OF WISCONSIN i (If not, to me known to be the person who executed the authorized by § 706.06, Wis. Stets.) foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY ` NNIS FIEI4C; ?1.U� Acorn Realty i lr=: de _ TIaue Route 2, Box 241Aoctir�,�C�,. Somerset, Wi 54025 Notary Public • Croix County Wis. (Signatures may be authenticated or acknowledged. Both My Commission is per anent. (If not, state expiration are not necessary.) date: 5 'Names of persons signing in any capacity should be typed or printed below their signatures. NTF 2280 WARRANTY DFFO STATE BAR OF WISCONSIN NPIrn FrIt o n Box 1075 Green Rav, WI 54305 -1075 - J PAGE OF C.rc) S zc�lon Fr*611 Air InI916 And Oburvatlon Pipe Cam- Approved Vent Cop Minimum 12" Above Final Grade 20- 42" Above Pipe _ 4" Cost Iron To Final Grad• Vent pi pe Marsh May Or Synthetic Covering Yin. 2" Aggregate Over Pipe Oi elt ibullon Pipe o o o — Tee 6" Aggregots ° orated PI Perf a Belor Beneath lots p o — Coepling Terminating At Bolcom Of Sy6lem P r p n o � e D T' I n �.) {{ C� ro% cl -c l ip SOIL FILL DISTRIBUT101.1 PIPE AP $`�KTH PROVED ETIC COVER n, >c 0 ° " ^t- OR 9" OF STRAW 2"OFl*6GREWE � � OR t4ARSN HAy 9 �f OF 1z- z GRI- GATE. 08 E L EV. OF �' F E ET, -- DI5TRIf5 PIPE TO BE AT LEAST INCHES BELOW ORIGIWAL GRADE AUL) AT LEAST? INCHES SUT 1,10 MORE THAN HZ IIJCNES BELOW FINAL GRADE MOVIU ®6 P rH ^= c,-*X nenwrl "'Q104JAL WK. WILL R; 7 � iMCHES ruKI ®F-Prili OF EXCAVATi FKOM. off► (.IMAL GA/4VjL WILL 6E 1171 INCHES SIGUED t LIGE0SE. DUMBER: - 1 S6 3 !,( DATE: / / 7 / - -- -- -- _._ _ . _ . __ i i o - - -- - - - - -- - -- I - -- I d i i I i � i ACA I � r I I I L-J+ TT 1