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HomeMy WebLinkAbout040-1261-90-000 r 4 County: Wisconsin Department of Commerce 'PRIVATE SEWAGE SYSTEM St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 82 (ATTACH TO PERMIT) GENERAL INFORMATION v 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: Hedin, Scott I Troy Township 040 - 1261 -90 -000 CST BM Elev: Insp. BM Elev: T Description: Section/Town /Range/Map No: CST BM Elev: Insp. BM Elev: 18.28.19.1408 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 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 113LDG IWELL 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 [N No [U Yes �]o COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / ! Location: 379 Cty. Rd. F (Namdre Drive) Hudson, WI 54016 (NW 1/4 1/ 18 T28N R1 9W) Deer Valley Lot 29 Parcel No: 18.28.19.1408 1.) Alt BM Description = 1 2.) Bldg sewer length - amount of cover Plan revision Required? [] Yes 0 No Ll Use other side for additional information. — Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) Coun Sanita ermit Ap ica� ST. CROIX COUNTY WISCONSIN In accord with 15.04 ty Ordi ZONING OFFICE Personal information you f s ry purposes T. C OIX COUNTY GOVERNMENT CENTER (Privacy Law. S. C' f 1101 Carmichael Road 1 Hudson, WI 54016 -7710 Hudson, (715)386 -4680 Fax (715)386 -4686 Attach complete plans for the system on x 11 Ind4s in size. County Sanitary Permit # ❑ Check rf revision to pr Application Information • Please Print all Information Location: Property Owner Name 1 V 114 /(� 114, Sec C- =-A r r'1 T 9- '�khl , `9 R E (or) Property Owner's Mailing Address Lot Number Block Number 3 '1 '1 ci, Ve--& P rJve.) g q ty, State i Zip Code one Numer Subdivision Name or CSM Number 44L-c s �ti, t,� ► 5� 1) l q II T of Building: (check one) 7'r ity ❑ Village Town of or 2 Family Dwelling - No. of Bedrooms: 3 S O PubIWCommercal (describe use): ❑ State-owned rynAw C rest R n ,� 1. Type of Permit: (Check only one box on line A. ChAck box on line B if applicable) (�(' Parcel W Number(s) U c' A) 1 1.0 Repair 2. Reconnection 13.ONon-plumbing ❑Rejuvenation T Sanitation 04 b° 13 0- D rnJ Permit Number c,f1 Date Issued State Sanitary Permit was previously issued (q 3 I �'" �j 9 3 . Type of POWT System: (Check all that apply) p�,, ' 2 / k G-/7 Non-pressurized In-ground S- "` - Mound `t ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ AtIpade ❑ Aerobic Treatment Unit 0 ❑ Recirculating ❑ Other . Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. Sy to Elevati 7. mat Grade Required �{ . Proposed (�.yr (GaisJda /sq.ft.) (Min. ��C.��� Elevation (Q'S `'F ` n v ( i . Tank Information Capaicty in Gallons Total # of Manuffacturer refab Site Con- Steel Fiber- Plastic New isting Gallons Tanks oncrete structed glass Tanks Tanks .� 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1. Responsibility Statement 1, the undersigned, assume responsibility for repair/ reconnenction /rejuvenationrnstallation of non - plumbing for the POWTS shown on the attached plans. A !cerise is not required for teralift repair or the installation of non - plumbing sanitation system. PMrdW Name (print) Plumber's Signature (no stamps): MP/ PR o. Business Phone Number L- 2S Plumbees Address (Street, City, State, Zi Code) IqU (.� C 11. Coun se Only Disapproved Sanitary Permit Fee ate Issued I 5Agen Signature tamps) 9 / Approved Owner Given Initial Adverse / r ✓ - (0 q / Determination f IX. Conditions of ApprovattReasons for Disapproval: SYSTEM OWNER: �' e'S pfic tank, effluent filter and dispe sa ce mus a e service aintained (�"� as per manaaementplan orovide�d by_nlumhar �/'d �f' � ���YI,S -�� .� ��- ?_ All setback requirements must be maintained �,�r✓ � G �� a� I � _ I I _ _ I I 1 i I r , 1� I i t r : I ( I I I I I f r I I I r r , I ; - r I I 1 r I I I 1 I r i , f T r _ { f I I I ' i I -- L r l r r I{+ Y I I I I r I I r i _ I r i I ` r I ' I r I I I 1 I I I I i I r IA ic r Safety and Buildings Division Cou 201 W. Washington Ave. O. Box 7162 ` Madison, WI 53 IW n Permit Number (to WN W in by Co.) De artment Of Commerce OWNS) 266- 31 Sanitary Permit Applieatia aft Plan I. D. Number In accord with Comm 83.21. Wis. Aden. Cod-, personal ' you P may be used for secondary ptupos -s Privacy Law. s15. Xm) Pro (if dificrent than mailing address) I. Apphadian lbt&Dvt t - please print AU tnfo oo R C!L' , Property Owner's Na we N XC OIV / !CF of Lot �� Block A Property Owner's M ailing Add `-/ _ � lS `�• - ,�.Sectiott City. State Zip Code Plum Number -So IN (cirri Building (+�k aH th" may) T (9 N: RCIE or(w I or 2 Family Dwelling - Number of Bedroom Subdivision Nance CSM Number ❑ Public/Commercial - Describe Use �• C?2� �9q l ❑ State Owned - Describe Use (_iCity Yownuhip of p Ili T YPe of Petrmk -- (Check onlY am boat an lone A. Compkte kue B if ap tbk) A. ❑ New System ❑ Rq0acemert System ❑ Treatm- ttdHalding Tank Replacement Only U Otiur Modification to Existing System B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New list Previous Permit Number and Date Issued Before Expiration Plumber Owner — IV. Type or POWYS : ((,heck all that a ) _ _ Z C Non -Pressurized Lt- Grvurd El Mound > 24 in, of suitable soil (.l Mound < 24 in. of suitable soil IJ At -Grade ❑ Single Pass Sand Filter onsinuted Wetland ❑ Pressurized In -Gwund ❑ Holding Tank I I Peat Fitter U Aerobic Treatment umt ❑ Recirculanng Sand Filter � f ❑ Re circulating Synthetic Maria Filter ❑ Leaching Chamber ❑ Drip Litre [] Gravel -las Pipe ❑ Otiter (explain) V. Alva Infartattadion: _� Design Flaw {gpd} Design Sal Applitnaian Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System evation 6 7c ?V// 7 VI. Tank Info Capuity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Foisting T.W. Tacks ' Septic or Bolding Tank Aerobic Treatmerx Unit Dosing Chamber Vu- Statement 1, the mod, responsibility for ingalkiil4v of the POWTS shown an the attacbed plans. $ Na me ( .m Plumber's Si tune umber Business Phone Number t v1 ©Ly 53 - its s a ac) Phtmber's Addre ss (Stmf-tt, City, State zip Code) �+ J t VIM use Onh ❑ Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Hate Issued Isssting Agent Signature (No Stamps) Surcharge Fee) 11 Owner Given Reason far D-+tial IX. Coaditians of AI►provaatl/Rewom for Disal r viol i i wtmch t> fa+ tae ecwpy a�bt ter ttte syeean on papas wst Issa ehao alll x 11 hKlin k" size O y0 onE 1 O o1 w N N O w 3 a y N 7 Q d lA> (A\ p ? N O <0 (n f0 O p p x O N � a -4 co O O W ° N N C I N W 0 ° a �? cn Z D � 0 �n m rn d c`0 D 4 0, co M y W o o a l n. T -n I 0 � 0 0 N I N 3 N W W N I p A rr Q • pl 3 v Z 000 � I 000= °Y ID 0 CA a l o o m 00 0 1 2 3 v v o Q v v m - I n cn K CD rr rn I m o M m o O o m? 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IQ �N -RR -4W, Town of o Subdivision tC'' ,Lot #_. Certified Survey Map # Volume Page # I 1p L/ Warranty Deed # '7 Volume Page # J 3 . Spec house 0 yes no Lot lines identifiable *y es D 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 task 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 plumber or a licensed pumper verifying that (l) the on -site wastewater disposal 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 44 days three exp` n ; t , 4 e _ . 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 d, eri Aabvirtue of a warranty deed recorded in Register of Deeds Office. SI ATUIt$ OF APPL 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 r �k ST. CROIX COUNTY;; ZONING ,\ CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the _� �C1`� r� residence located at: - • - i V - 114 Sec. T_aLaN R 1 W, Town of r0 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 Did flow back occur.from absorption system? Yes N04x— (if no, skip Approximate volume or length of -time: next line) gallons --minutes. Capacity: Construction: Prefab Concrete rete Other Manufacurer (if known): Age of an if known): f/ Uj - oslCSI gnature (Name) Please Print Mars abs3�7 (Title); (License Number) (Date Form to be completed by licensed plumber (x.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 he requirements of ILHR -83, W Adm., Code (except for inspection a 'ng over outlet baffle). Nam Signature MP /MPRS 5/88 ~ SR t Ma i N at,— �. ►. .. L ._ s •� _ _ _ IIMMLIAL M77M Parcel #: 040 - 1261 -90 -000 10/19/2004 10:08 AM PAGE 1 OF 1 Alt. Parcel M 18.28.19.1408 040 - TOWN OF TROY Current 1K ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): * = Current Owner SCOTT & JENIFER HEDIN * HEDIN, SCOTT & JENIFER 379 NAMDRE DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 379 CTY RD F SC 2611 SCH D OF HUDSON — SP 1700 W ITC Legal Description: Acres: 6.925 Plat: 1899 -DEER VALLEY SEC 18 T28N R19W NW NE /SW NE LOT 29 DEER Block/Condo Bldg: LOT 29 VALLEY Tract(s): (Sec- Twn -Rng 401/4 1601/4) 18- 28N -19W NE Notes: Parcel History: Date Doc # Vol /Page Type 1 2 703675 2091/533 01/1 2 1483/535 W D 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 400,000 Valuations: Last Changed: 07/23/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.925 106,000 307,600 413,600 NO Totals for 2004: General Property 6.925 106,000 307,600 413,600 Woodland 0.000 0 0 All 6.925 106,000 307,600 413,600 Totals for 2003: General Property 6.925 99,000 286,000 385,000 Woodland 0.000 0 0 Total 6.925 99,000 286,000 385,000 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 STATE BAR OF WISCONSIN FORM 1 - 1998 �, 16842 WARRANTY DEED KATHLEEN H. WALSH 1483PA OF DEEDS Y . I_ ST. CROI Document Number ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between JUNE M. ERDMAN, a single person 01- 12-2000 10:00 AM WARRANTY DEED Grantor, CERT FEE- and SCOTT�HEDIN and JENIFER ERDMAN,_ single persons as COPY FEE: ioint tenants TRANSFER FEE: 600.00 RECORDING FEES 10.00 PAGES: 1 —_— Grantee. Grantor, for a valuable consideration. conveys to Grantee the following described real estate in St. Croix County. State of Wisconsin (the "Property "): Recording Area Name and Return Address Lot 29, Plat of Deer Valley in the Town of Troy, 1 St. Croix County, Wisconsin. J �a 040 - 1071 -20 Parcel Identification Number (PIN) This is not homestead property. j (is) (is not) �Q �/� 1 1�• Together with all appurtenant rights, title and interests. Grantor warrants that the tide to the Property is good, indefeasible in fee simple and free and clear of encumbrances except — none. Dated this -day of January 2000 (SEAL)- . / � - "' (SEAL) * . NE M. ERDMAN (SEAL) (SEAL) i AUTHENTICATION ACKNOWLEDGMENT Signature (s) State of Wisconsin, ss. St. Croix County. authenticated this day of Personally came before me this �'S r day of January 2000 , the above named June M. Erdman TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, me known to be the erson who executed the foregoing authorized by §706.06, Wis. Scats.) m eWW"men a o dg the same. THIS INSTRUMENT WAS DRAFTED BY Atto Barry C. Lundeen MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. Notary Public, State of Wisconsin 110 Second Street Hudson Wisconsin 5401 mis son is rmanent. (If not, state ex pi ton e: (Signatures may be authenticated or acknowledged. Both are not �` necessary.) Names of persons signing in any capacity must be typed or printed below their signature. WARRANTY DEED STAT WI N Wisconsin Legal a FORM No. I - 19 ml uke . Wis. U 2091f 533 STATE BAR O CONSIN FOR 3- 96 KATHLEEN H. MALSH • IT CLAIM DEED REGISTER OF DEEDS ST. CROIX Co., WI Document Number RECEIVED FOR RECORD _:.. 12/26/2002 03:05P?l This Deed made between S r o it {�-� otey a - 4-v- EXE►PT * 1 REC FEE: I1. 00 Grantor TRANS FEE: and _ COPY FEE: CERT ���1 1 t n ^$ tt•t, tr, f r �g y �� jer �� COPY FEE: PAGES: 1 Grantee. Grantor quit claims to Grantee the following described real estate in I' County, State of Wisconsin: �f Re:corc q Trott Name and Return Address Z �' 0 sy '4o -oco T I N 2 } 4i i W w N (5 Sw / Par ei tdeni4itoaiion Number (PIN) T is --- homestead property. �o L (� •c Jcti (( — ` `A � (is) (is not) i lJ W ti i -z - 7 1 Deer' V�ti� Qz f�cr lg �ti Rr�w�` S�n• �+ lie C- v v e -rte t`s 0. ✓l a vl ! cr t" y 0 v.1 y Cc t� c Cc . v-t`k n c /! t ✓ S 7 7. Z (t', Together with all appurtenant rights. title and interests. / / rj^r �r S Dated this '^ day of u / i tr zoo Z— (SEAL) ---- - - - - -- - -- — -------------------- - - (SEAL) n e vt ' v{ i ✓1_ den i Tom!' (SEAL (SEAL) tIT IvNTICA'TION ACKNOWLEDGMENT Signature(s State of Wisconsin. J ss. _ S t< _ _,- County. authenticated this day of _ -_ Personally came before me this 226th ___ day of _ `"a` IIecember 2002 the above named Iiedia rind 3e*ti f er R- rc]mnn TITLE: MEMBER STATE BAR OF WISCONSIN = r '; _ _ to (If not, : C' : i me known to be the person A who executed the foregoing authorized by §706.06, Wis. Stats.) t ; y 0 ,' instrument and acknowledge the same. r r O THIS INSTRUMENT WAS DRAFTED By �iy '• '1 �[Y_.d.� �� ' r-p S � /Af �'U f Paulette Orf Notary Public, State of Wisconsin My commission is permanent. (If not, state expiration date: (Signatures may be authenticated orkacknowledged. Both are not necessary.) • Names of ranns signing pe g g m any capacity must tx typed or printed below their slgnawre. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. QUIT CLAIM DEED FORM No. 3 - 1998 MINSH 1,89. W- Parcel #: 040 - 1071 -20 -000 10/19/2004 10:48 AM PAGE 1 OF 1 Alt. Parcel #: 18.28.19.273A 040 - TOWN OF TROY Current ❑ ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): ` = Current Owner * ERDMAN, RETIRED RETIRED ERDMAN NKA DEER VALLEY NKA DEER VALLEY Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 260 COVE RD SC 2611 SCH D OF HUDSON SP 1700 W ITC Legal Description: Acres: 12.000 Plat: NIA -NOT AVAILABLE SEC 18 T28N R19W 12AC NW NE EXC N 935 FT Block/Condo Bldg: NKA PT DEER VALLEY Tract(s): (Sec- Twn -Rng 401/4 1601/4) 18- 28N -19W NE NW Notes: Parcel History: Date Doc # Vol /Page Type 11/22/1999 614326 1473/104 TI 07/23/1997 1090/102 QC 2004 SUMMARY This parcel will not get taxed. It exists soley Assessed with: for parcel history tracking purposes. Valuations: Last Changed: 01/25/2000 Description Class Acres Land Improve Total State Reason Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 All 0.000 0 0 0 Totals for 2003: General Property 0.000 0 0 0 Woodland 0.000 0 0 Total 0.000 0 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS Z�C 600e R-0 Q05b W( SUBDIVISION / CSM# LOT # SECTION T N -R W, Town of TL 3q- ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM lei' to C 5 Z Y, J6 � ° INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. f i i j BENCHMARK: c j� / �. �� y kJ ( "' 4 1 ( 6f1 -'/y s ALTERNATE BM: i s, SEPTIC..TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well A j House /� Other Pump: Manufacturer Model# Size -- Float seperation Gallons /cycle: -- _ _ . _ Alarm Location { SOIL ABSORPTION SYSTEM Width: Length Number of trenches 9c Distance & Direction to nearest prop. line: J Setback from: well: /JA House - Other i 1 9 { ELEVATIONS i Building Sewer 7 ST Inlet; T ST outlet 7 PC inlet PC bottom Pump Off ` Header /Manifold 457 Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: AX(- LICENSE NUMBER: INSPECTOR• 3/93:jt I II W's ,28.19.2 E SYS M County: Labor and Hu ildinRelations INSPECTION REPORT Safety and Buildings Division ST. CROIX y (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 1 93412 Permit Holder's Name: ❑ City ❑ Village ❑ of: State Plan ID No.: JA 11 TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 166)6 oo, 6 "1`k 7 /y to �,� 040- 1071 -20 -000 TANK INFORMATION ELEVATION DATA A9300072 :Z TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing &,) x•06 /J� j�JU Aeration Bldg. Sewer Holding St /Ht Inlet 3 27 TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air ir l to ntake ROAD Dt Inlet Septic j /L// /UI NA Dt Bottom Dosing NA Header / Man. b , 6. Aeration NA Dist. Pipe q(- Holding Bot. System 15 q.5 , 1 PUMP/ SIPHON INFORMATION Final Grade 4, V6 q�, Manufacturer Demand 9 Model Number GPM TDH Lift Friction Syestem TDH Ft cl Forcemain Length Dia. H Dist. To Well 7 F SOIL ABSORPTION SYSTEM BED/TRENCH Width Length , j No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / 1 DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O Model Number: System: O� CHAMBER OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length ' Dia. 6f Spacing LL— 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 discrepancies, persons present, etc.) f L- L 4' x fv "' LOCATION: TROY 18.28.19.273A,NW,NE, CO. RD. F `'' " 4 I t Plan revision required? Yes C1 No Use other side for additional information. SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e I I I I SANITARY PERMIT APPLICATION LI 0ILH couNTV In accord with ILHR 83.05, Wis. Adm. Code STATE /41 SANITARY �4 I - Attach complete plans (to the county copy only) for the system, on paper not less than 0� 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWN ^ f PFI;OPE TY LOTION _ n ) ° C 7 `✓ N /a u S T 7 v(JY N, R E (or PROPERTY OWNER'S MAILING ADDRESS �� LOT # BLOCK # 2 (J& ,J— C ZIP CODE PHONE NUMB SUBDIVISION NAME OR CSM NUMBER ubt W( II. TYPE OF BUILDING (Check one) ❑ State Owned VILLLLAGE O NEAREST R0� a ❑ Public &or 2 Fam. Dwelling-# of bedrooms PA L A N NUMBER(S) 1 III. BUILDING USE: (If building type is public, check all that apply) r 0 1 `� o 1 El Apt/Condo 1 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. New 2. ❑ Replacement 3. ❑ Replacement of 4. El 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 El Mound 30 El SpecifyType 41 ❑ Holding Tank Seepage 1:1 12 Trench 22 In- Ground 42 ❑ Pit Privy � 13 [j Seepage Pit Pressure 43 ❑ Vault Privy i 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INF MATION: 1. GALL NS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQU RED sq. ft.) PRO OSED (sq. ft.) as ft.) (Min. /inch) G� / - 1 b.OFeet Feet VII. TA K CA A ITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank _ C Lift Chamber I F j VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum err lame (Print): Plumber's 'nature: VS MPIAAAR&Mf:No.: Business Phone Number: �? Plumbe s ress (Street, ity, State, Zip ode): C_ c > 4 il IX. COUNTY /DEPARTMENT USE ONLY %, Disapproved Seotary P rmit Fee (includes Groundwater site e s e I uing Agent Si a (No Stamps) Approved El Owner Given Initial Cj �1 Ad a ete ination ✓ 6 X. CONDITIONS OF APPROVALIREASO&IS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS t • 4 1. A sanitary permit is valid for two (2) years. 2. Yodr 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 questions 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: 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 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 systern 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% 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 through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) r a 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 e rmit issuance. Y p ,Should this development be intended for resale by owner /contractor,(spec house), thenta second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. -------------------- ..-- ..--- J- ----------------- - - - - -- Owner of property �� Location of property � 1/4 N C 1 /4,ection, TN -R W Township Mailing address f - C ' & Address of site CD_ RD J I Subdivision name - Lot no. Other homes on property? yes No Previous owner of property _ Total size of parcel _ ?57 A Date parcel was created & Are all corners and lot lines identifiable? Yes ,� No Is this property 30eing developed for (spec house ? Yes No Volume.3kand Page Number as recorded with the Register of Deeds. ------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. ,In addition, a certified survey, if available, would be helpful'so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. 13 , and that I own the proposed site fo he sewage disposal system or I e (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document No. Sigp of applicant Co- applicant Date of Signature Date of Signature WARRANTY DEED (Former 'Statutory Porm). STOE OF WfSCCNSIN Miller-Davis Co., Minneapolis, Kinn. - - t Perm No. Y W. _ [ 259154 IR *Ub>ettfltrV, Afadeby Archie J. Waxon and Lois Waxon, his wife, grantors , of $t. Croix County, i[''iseonain, hereby convey and warrant to' r Jack J. Erdman and June M. Erdman, husband and wife as ,joint tenants j grantees , of St. Croix County, i Wisconsin, for the sum, of One dollar and other good and valuable consideration the following tract of land in St. Croix County, State of Wisconsin: Northeast quarter of Section Eighteen (18), Township Twenty-eight (28) North, Range Nineteen (19) West, (NEJ 18- 28 -19) . I REGI%TLRS OFFICE ST. CROIX CO., W16. Rec'd for R4cord this 17th day of___Aut',a$L. A.;) 1 59 David Hope Rdglster Cf Deputy fn Witneao W4rreaf, The said grantor S havehereu.nto set their hard saml S thi, 14th day of August — .1. 1). I9 59 SIGNED AND SEALED IN PRESENCE OF ^y e A - - - - -- - -- r - _11ugh F ,Gwin —_ — Lo ■ Otate of Wisronsin, S.S. St. Croix C,ottnty Personally cattle before nie., this 14th day of August .g. D..19 59 , the above named Archie J. Waxon and Lois Waxon, his wife, to me known to be the person. who exceit ted the foregoing instrument and cuknowledged the saitic. i v 4..; ) t +H11f7h & 1n -- - — - - -- — — Notary Publio, St Croix_'' - County, Wis. - diy comrrbission expires Sept. 12 r1. I). 1.9 6 0 t *Typewrite N u nder each e S � gnature ' BDOK J�L► F "'�E� J1 . S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER G'G f� ADDRESS ,— j C�' r. % -- FIRE NUMBE �(o CITY /STATE �'t �� t---L ZIP -- PROPERTY LOCATION:�1 /4, E . SECTION , T � O N -REZ�W TOWN of 1 1�-��i St. Croix County, SUBDIVISION - -- , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by 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 for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)• the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and SCUM. I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix.- o. Zoning icer within 30 days of the three year expiration date. SIGNED._._ DATE: St. Croix co. Zoning Office / 911 4th St. Hudson, WI 54016 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3 Later and Human Relations �. Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ST �l k not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. O - It) I - APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT 1\3W I/4 ►JE 1l4,S �� T zg ,N,R V) E (oo PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # Z b(3 cov 1�7 T2.�3kb - CITY STATE ZIP CODE PHONE NUMBER EICITY []VILLAGE MOWN NEAREST ROAD 1 (.v� S�4t(, rnS) 3 86 -S IF y (,1Q New Construction Use [Jd Residential / Number of bedrooms 3 [) Add4iQn to existing building j) Replacement f I Public or commercial describe Code derived daily flow LA S gpd Recommended design loading rate O bed, gpd /ft trench, gpd/ft Absorption area required b 1 13 bed, ft s 63 trench, ft Maximum design loading rate o •'1 bed, gpd/ft 0- trench, gpd/ft Recommended infiltration surface elevations) 5Qe uo1m oxi Prt6E 3 It (as referred to site plan benchmark) Additional design / site considerations S I Q ►Q I�RSE 3 Parent material S � ova S 4 G h Flood plain elevation, if applicable 1113 - ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ®S ❑U ®S OU 0S ❑U ®S ❑U ®S ❑U ❑S ®U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Baxtdary Roots Bed Trench Ground 3 31 -3'3 Ion•-! 2 3 C•-% O• S elev. q - 5 ft. 14 38 -Rb V/L S © S- ©.1 0• Depth to limiting factor X98 Remarks: Boring # - L m U f e S u• S o• Y/b �x Ground elev. 9 )-B ft. Depth to limiting factor � qs Remarks: CST Name:— Please Print Arthur L. W e e r e r Phone: 715-425-0165 egerer Soil Testing & Design Service -P.O. Box 74 River Fa11s,WI 54022 Signature: Date: CST Number: M00576 PROPERTY OWNER ItMIZ2.1" to* - SOIL DESCRIPTION REPORT Page?' of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Baydary Roots GPD /ft in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Trench :,•:.:...'S -l0 ti0"t 3I S Z `� C o•S Z Y S 21 G ► , 4 Sg c- o•l o• $ Ground 3 Z$ G>- ro Sy �^n o•l v elev. X0 -o ft. Depth to limiting factor � 7 r->>6 Remarks: Boring # ;;;<::•,..,:: o- t- 0 4Y :•. Ground O 0. S9 1 7 O• $ elev. q 0 ) . Z, ft. Depth to limiting factor > SS Remarks: Boring # 1 0 -1 Z O ye 3 / 3 v Yn c. S s '� Z u -z3 t 3 -- S o sg �1 � g o•`>' o. 3 23 -80 16'1 Y/6 — S O sg vrt Ground elev. Cl ft. Depth to limiting factor 7� Remarks: Boring # M.. �Y,Ch Ground elev. ft. Depth to limiting factor Remarks: SBO- 8330(R.05/92) PLOT PLAN Page 1 of 3 SCALE 1 "= 20 ' � }ousE 3� RT ��TRST ZS' p". S k4$ 3h S W v ✓4_ IL = � 1 M qe" Web lb�) S4 sTev 1 aL.gS� S �b ` S3 •Z dL • Q V1...tou.o or., 6M4"C24 A,4 IK.> 'N c3_S tWT� ♦ TD l to S`CPT t..L.�' . -- 3� pvC.1�1 A� A.��`cR lite _ Ubr-Oj t cat - T)tt _ 1A t TT7 L lqa.Vi� F- A ♦ d �j�♦ CJ ` '�-�J . A ")rV) HUH 1;��- Pcljul'Pc11v !M N X1 Mum q z" Co)kjzt OUP- `TM'L 1�15`i�- l�ta77 u�v 1��P�S peb 1s 'm e�-- ).YT C-Lev. qS -3' wr cam► '11` " \G 4t� 1F `T� pfT A VO 6t}L"R eI - , t ot (715 — 4 25 -01 h5 M 00 576 CST Signature Date Signed Telephone No. CST # _ G L M A �12V� ="Z 0' �o y � 63 2� �►T ��' B gM czX 8 57 PAGE OF t Crv Scc�lun o� en SY5t4arn Fresh Air Inlels And Observallon Pipe Approved Van# Cap Minimum 12" Above Final Grade 20 42' Above Pipe _ 4" Cast Iron To Final Grad• Vent Pipe Mush Hoy Or SyntM#k CorerMg Min 2' Aggregate - Over Pipe Olwlbutlaa — Teo Pipe o 0 0 0 ! 6" Aggi egol• o Perforated Pipe Below Beneath Plp• — Coupling Terminating At (101101" Of System �L1tJ•.T Ion SOIL FILL DISTRIBUTIOM PIPE APPROVED S4M"(7•IETIC COVER _- MATERIAL- OR 9" OF STRAW r OF AGGREGATE OR MARSU HAy (e OF l2 -2 / AGGREGATE F-LEV OF UT, J � (x-- �� -( -' � ----� DIST PIPE RIaUT101J PE TO BE AT LEAS7 ! L INCHES BELOW ORIGINAL GRADE AMU AT LEAST20 INCHES 13UT 1.10 MORE THAN 42 Mr BELOW FINAL GFtAOE I'WIMUM ®t N OF E FR oM M&wj L. Cvft & WILL BE � I NCHES PUMM1UM 9f-fTli OF EACAVATLoN FP011 0 GRAPE W ILL 43E 1L_ INCHES S164JE0: LICEUSE NUMBER: DATE: / i REPT131 TROY ST. CROIX COUNTY ZONING PAGE 1 05/11/93 11:08 REQUESTS FOR INSPECTION WORK SHEETS FOR: 5/12/93 AREA: MJ --------------------------------------------------------------------------------- ,-Acti+vity: A9300072 5/12/93 Type: CONV93 Status: PENDING Constr: Address: TROY 18.28.19.273A,NW,NE, CO. RD. F Parcel: 040 - 1071 -20 -000 Occ: Use: Description: 193412 Applicant: ERDMAN, JACK J Phone: Owner: ERDMAN, JACK J Phone: Contractor: NELSON, ROGER Phone: 273 -4444 -------------------------------------------------------------------------------- Inspection Request Information..... Requestor: NELSON, ROGER Phone: Req Time: 11: 05 Comments: 11:06 Items requested to be Inspected... 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