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HomeMy WebLinkAbout040-1128-50-000 ca O � m o '0 CD o - � p N 7 a) U a) U (n C : �c m (n M o (v Eom coa) �.E p 0 m � a a� f0 N m 3 m y . C> N m Z C :� a) d w U) O _ O y U L m m o c N N c c o ' E O c m M o co N c O O C cu t a) ? O N .O 3 0 U N O O 0 s r `���a� O U c N O O y ! C O O N> W m O w LL U E :p r O7 «. _N y� N N 7 'p O 2.O N C a) O Cd O a) }`� C Z m — �O m N C Z O f0 3 m N m m c a) 7 m > E> y O U. ul LL c m O m c - CD a� -w m o - o m - - 0 - � ' o o c - a _ o c — c o . _ ' N . N ' m �n o o c ac o— Q a r U n U° E a rn a c m n a C U O m d C N N 1/1 in E E O w O V E `O p 00 N d d 0) 00 w am am M Z (A C o 0 c z � o z d w 121 (Df ZI N E =I �I c v � m m � N a � N • N m o 0 N 7 7 0 cc N O a a O O C ) Z Z Z Z a cli N " O c O y L C 7 _ E LO t0 E N O m L .. L .. m LL c5 a Y a co �e a� c N j d U C N O O O a a a .0 L N O E ' H H H 3 a) LL F- F- F- E 0 0 0 0 d Z '- 0 0 0 d Z Z o • c a n. a a a a o -0 N O o o X co rn ur to J 0 °o z o rn 0) } y Z _0 O O w M-. N N O C N O 0 �� O N �' E N N EO `3 N m d O �y (0 { ' m O N c N C +.r O U N m a U U O O O ° C, c a o c E m o 0 0 Y N C N co 00 - h C N N O G 04 '* 3 E N ►.� O ' 00 >, N O � E O CO w 7 W E L .4 0 m .N- G U m O m N O N O O U • y am „' O co _ N d Z I M O z Tl Z X (n O w r.+ CL a eat eIL `IV ° d 'o °' " c m c t c c .. c c � A v v 0 in 0 W e County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN `OG In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road Hudson, WI 54016 -7710 (715J386-4680 Fax (715)386 -4686 Attach complete plans for the system on paper not less than 8 -1/2 x 11 inches in si P County Sanitary rmit # Cl Check if revision to previous application D 2 U I. Application Information - Please Print all Information Location: Property O ner Name 1/4 (itil /4, Sec , (�L'� /�� / ECEI VE N, R Of E(or Property Owner's Mailing Address Lot Nfrmber Block Number T 2007 --- ity, State Zip Code Phone Nu er ST. CROIX COUNT Sub vision Name or CSM Number II Type of Building: (check one) ti— 03ity ❑ Village Town of 1 1;K or 2 Family Dwelling - No. of Bedrooms: C ❑ Public /Commercial (describe use),: s GC ❑ State -owned v Nearest Road 11. Type of Permit: (Check only one box on line A. Check box on line B if applicable) U)t pV 6,q X y It " Parcel Tax Numbers) A) I t.[:] Repair 1 2.At Reconnection 3. ❑Non-plumbing 4. E] Rejuvenation Sanitation B) Permit Number Date Issued ��11 .State Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ❑ Non - pressurized In- ground ML Mound ? 24 in. suitable soil ❑ Mounds 24 in. suitable soil ❑ Mound A +0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating . Dispersal/Treatment Area Information: l $ t-v 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil pplication Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposedb. (Gals. /day /sq.ft.) (Min.Cnch) J Elevation O � V1. 'rank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks Z , Z z 10 ter �-' ❑ ❑ ❑ ❑ lh �� ❑ ❑ ❑ 13 II. Responsibility Statement I, the undersigned, assume responsibility for repair / reconnenction /rejuvenation/installation of non - plumbing for the POWTS shown on the attached plans. A icense is not required for terralift repair or the installation of non - plumbing panitation system. Plumb Name (print) m lumber's Signat (n o stamps):/ MP/�MPR�N� Business Pzn� If #I vZ�— NS zZ y Plumber's Address (Street, City, State, Zip Code) (_ L f uJ III. co u Use Onl Disapproved Sanitary Permit Fee Date Issued uing Ag t Signature stamps) Approved Owner Given Initial Adverse /D /J Determination J IX. Conditions of Approval /Reasons for Disapproval: Juv 47 - c— r1-j h d zC� ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM / Owner/Buyer PAa -�– 5 L L 1, 1 Mailing Address C� - z S ( S 4 Property Address (Verification required from Planning & Zoning Department for new construction.) City /State lP V k ��S Parcel Identification Number Q LEGAL DESCRIPTION Property Location /h� /4 , 2' /a , Sec. 7 )�l T 5�N R /�'W, Town of Subdivision —" , Lot # Certified Survey Map # , Volume / , Page # Warranty Deed # �j �� ©C� , Volume 1j g �, Page # 2 7 2 Spec house yes ® Lot lines identifiable es no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/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 Planning & Zoning Department within 30 days of the three year expiration date. I /we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 0010� �o"' I l 0 ? SIGNATURE OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 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 Alt, a- 5F}-(L of I)A residence located at: y 1 /4, fu-,A/4, Section _�_ Town Z N, Range / I W, Town of —f —/Zo y , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service /0 — "d 7 Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons_ minutes Capacity: j 2 0 - 0 54 - 75 PG 1 Z f Construction: Prefab Concrete Steel Other Manufacturer (if known): iyI /P W6/ 5 Age of Tank (if known): (Lic used Plumber Signature) (Print N e) L 49"7 zz� (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) z D ` m z z 00 m D O m ,— x O rV m O Cn o Cl) m m 0 < 0 i 0 0 X r _. C 0 rTh O o c f7 r- -� D G) m Z o`' m C7 (] m :LJ Q 00 C m U) -i cn Q7 . ;U - n U) c (/ < � �-1 z -i z0 m o C/) C7 ZZ m � p J c� m o I --� m v �m 5a 3 3v 5 Q Q) m n, w w m v CD n n a c" Q m m o �� �� �� ?(D W D o o a (D CD O O CD O 0 3 r' m -i =_ _ 0 O -n m 3 (D a m? c 0 CD ID m (D o �, c fn. ' 4, o Q o� � :3 ° cn n W o m C7� '° CD _ m< ? ' w y - ,. m = w =r a m 3 0 N o a 3 3 0 3 CD - D fD to °,_ - a (D CD N CD co w m 3 w > (D v g 3 0 0 y v m ? = m v m 3 e 3 3 0 Cfl a 0 0 ° .(I Z � c = �� �� �' o �;� vv m O m � m - o C- C7 CD w o m Z r Z o :3 @ Cl CD ° _ o o ° m o D D n m a m CD CD m 70 CD vN m O O Z p D_ n�i vm0 0 �o Z ZG) Z z7 m a a 0 a w o m = El 11 � El CD m Q 7 (D o m . o� NOTICE: Please provide the following: A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. LAN VIE 0.0 t E j i l 1 ec Cj i 7 '51; ",Z IA eo _ I F i 35` if ''r INDICATE NORTH ARROW h • Department of Commerce Buildings Division PRIVATE SEWAGE SYSTEM CountyT. C�20IX INSPECTION REPORT _NERAL INFORMATION (ATTACH TO PERMIT) SanitartB�it.: arsonal information you provice may be used for secondary purposes [Privacy Ljw, s.15 04 (1)(m)) Permit Holders Name. flLity_[ I Village ❑ Town of: State Plan ID No.: HASKINS, LYDA I +fi )P CST BM Elev.: Insp. BM Elev.: BM Description: Parcel 1 00 1 00 C> 1001- 1128 - 8-4D00 TANK INFORMATION ELEVATION DATA A9800508 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchrr )�/`i8 Y ULiw`� "O �[.tryv irtC ( ?PA l0 2v �«e er Holding (�)40 Inlet TANK SETBACK INFORMATION Outlet TANKTO P/L WELL BLDG. Pj e ROAD Dt Inlet /�. 0 S �j NA Dt Bottom � o NA Header/ Man. X�� as 7 Z7 9� 3 NA Di st. Pipe -7 Holding Bot. System $• o ; PUMP/ SIPHON INFORMATION Final Grade 5 - r►t a Manufacturer j' Demand �L(�� -750 4, lu• Model Number GPM �w TDH Lift L ridion. S1rstem s TDH t ZIn I�-� '1 SV - 7 o 7 Forcemain Length 3 Dia. '/ Dist_ To Well SOIL ABSORPTION SYSTEM Im TRENCH Width D i Length 0 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth D IMENSION S �$` DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING facturer: INFORMATION Type O q n um er: System:�otA ��� / S� 1 - 7 DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x x Hole Size Hole Spacing Vent To Air Intake �� Spacing �. Length � Dia. � — Length � - 6 Dia. _ S f g of SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only j fro t�rh Depth Over :::: Ed:/ h /07 Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Trench Edges Topsoil ❑ Yes ❑ No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 4 -1'10 I6 sr LOCATION: TROY 34.28.19,NE,SW 642 SWEDISH MISS ON ROAD h3�. 3 ftowIy j to a3Ob - 7 -S5-- g7 - lo CoYr�vr w-- sa n" �s- F'-vri Wthfi L� „ c Z• - -6 lac S>' b 18 4” b P k `� Gfuctno , iK s� Iw v c r; d �Cev► s { -1 -}�+�� P" � p �cwl.be.� -- Plan revision required? El Yes [1j/No Use other side for additional information. I T SBD -6710 (R.3197) Date = Inspe . No. SANITARY PERMIT APPLICATION 201 E . a t o nAv ivision n sin 201 E. Washington Ave. of Commerce In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 ' complete plans (to the county copy only) for the system, on paper not less County 8 112 x 11 inches in size. 5 • cro e reverse side for instructions for completing this application State Sanitary Permit Number k information you provide may be used by other government agency programs E] Check it rebrs�on to'previdCs plication privacy Law, s. 15.04 (1) (m)]. State Plan I.D. N tuber 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property O er ame Property Location t SCR' 1 /4, S T 17 - , N. R j E Property wn is Mai ►in ddress Lot Number I r Y 2 9 « Bock Number City, St e Zip Code Phone Number Subdivision Name or CS N ber II. TYPEOF BUIL DING: (check one) ❑ State Owned E] i Ne est Road Public 1 or 2 Family Dwelling - No. of bedrooms 17 V own of III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers) 1 ❑ Apartment/ Condo © � a l I .-z 9- � r 0610 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 my one box on line A. Check box on line B, if applicable) A) 1. E] New 2. eplacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an _____System ________ System _____________ Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressuri d Distribution Experimental Other 11 Q Seepage Bed 21 found 30 ❑ Specify Type 41 Q Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13E] Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTIO SY STEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5_ Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed sq. ft.) (Gals/day /sq. ft_) (Min. /inch) rT Elevation �Q El? _- — ls •�� Feet bf 1� Feet Cap acit y VII TANK in Ca gallo s Total # of Prefab. Site fiber- Exper._ INFORMATION Gallons Tanks Manufacturers Name Concrete con Steel glass Plastic App New Exist in structed Tanks Tanks SepE..pT..k ) olding Tank L phon Chamber `�t9D f ��, VIII. RESPONSIBILITY STATEMENT r 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PI u ber's Name: (Print) + Plumber's ignature: (No amp MP /MPRSW No.. Business Phone Number: X )Vk- Z)7 W cl.vt Plumber's Ac 8ress (Street, City, State, Zip Code - IX. COUNTY/ DEVARTMEN T USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate I ssued Issuin nt Signature (No Stamps) Approved ❑Owner Given Initial Surcharge Fee) pp Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR ISAPPROVAL: 580.6398 (R t f/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber VOL 10ST DOCUMENT NO. WARRANTY DEED S 9 2 6 0 0 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI Lyda B. Haskins, a widow, Grantor, conveys and warrants to Paul S. RECEIVED FOR RECORD Haskins, Jr. and Sally J Haskins, husband and wife as survivorship marital property, Grantee, the following described real estate in St. 11-30 -1998 9:30 AM Croix County, State of Wisconsin: wWHTY aEED EXEMPT 8 A PARCEL OF LAND CONTAINING 14 ACRES LOCATED IN THE NORTHEAST QUARTER CERT COPY FEE: OF THE SOUTHWEST QUARTER (NEW OF SWU) OF SECTION THIRTY -FOUR (34) COPY FEE: TOWNSHIP TWENTY-EIGHT (28) NORTH, RANGE NINETEEN (19) WEST, BEING THE TRANSFER FEE: 750.00 EAST 586 FEET OF SAID NEIA OF SW',( LYING NORTH OF THE TOWN ROAD, FURTHER RECORDING FEE: 10.00 DESCRIBED AS FOLLOWS: PAGES: 1 Beginning at the Northeast corner of said SW4 of Section 34- 28 -19; thence west along the North line of said SWIX a distance of 586 feet; thence South parallel with the East line of said SWU a distance of 901.5 feet to the centerline of the Town Road; thence Southeasterly along said Town Road to the East line of said SWX a distance of 643 feet; thence North along the East line of said SWg a distance of 1175 feet to place of beginning. . . . . . . . . . . . . . . . . . . . . . . NAME AND RBT ap Mo s rtgage Dept. First A N 1 at � i l o V na ll Bank of River Falls PO Box 166 River Falls, WI 54022 040 - 1128 -50 This is homestead property. Parcel Identification Number (PIN) Exception to warranties: All easements, restrictions and rights -of -way of record, if any. H Dated this J J r day of November, 1998. (SEAL) (SEAL) Lyd4B.k*lns (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. E , COUNTY ) authenticated this day of 19 Personally came before me this 05 day of lf�lp o ff , 1 9L_ the a4ove named Lyda B. Haskins to me known to be the person(s) who execu�E t8e' 'y foregoing i ment Uanowledqe the r • ,/ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, 5 LJeca� authorized by 5706.06, Wis. Stats.) ` .4,. Q. ,f •......... THIS INSTRUMENT WAS DRAFTED BY: Notary Public e j x •�Wis. My commission is perm�anen . (If not, eXj' date: Leo A. Beskar _ ) v P.O. r. ) Rodli, Beskar, Boles & Krueger, S.C. P.O. Box 138 River Falls, WI 54022 111111 {1111 Ifllf lilll If{II 11{i1 1111111{I 1111 IIII Document Number Document Title 861394 KATHLEEN H. WALSH St. Croix County REGISTER OF DEEDS ST. CROIX CO., W1 Occupancy Affidavit for a single POWTS 09/28/20Q7 FOR 01 20PM servicing Two Dwellings via PIMS AFFIDAVIT EXEMPT e REC FEE: 13.00 Name — (Owner) Typed or printed PAGES: 2 being duly sworn, states, under oath, that: 1. He /she is the owner /co -owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume i:39I Page __ Document Numbers St. Croix County Register of Deeds Office: Recor ,grey A parcel of land located in the A/6 '/ of the'*%/ '/4 of Section 3y N„ Retu Address T � N — R _ 19 W, Town of Z?fg / 6 � �y� S a+ y s�e+elr r[D St. Croix County, Wisconsin, being duly described as follows E,�r s � - 5 - 3 604 (include lot number and subdivision/CSM or detailed legal description): Parcel Identification Number (PIN) As owner of the above described property, I acknowledge that a Private On -site Wastewater Treatment System ( POWTS) serving the primary residence is sized for - bedroom(s) with a design wastewater flow of gallons /day. (DWF calculation based on 150 gpd /bedroom @ 2 personsibedroom). Two dwellings will be connected to the POWTS via Private Interceptor Main Sewer (PIMS) in compliance with Comm 82.30(12). A maximum of-0— occupants are permitted. There are currently a total of .5 — occupants in these residences, therefore the POWTS can be considered code - compliant at this time. However, I understand that if the number of occupants exceeds the maximum for POWTS design, the system will be undersized to accommodate any increased wastewater flows and /or contaminant loads and may be subject to premature failure. I also acknowledge that I will disclose this information to any parties interested in purchasing this property in the fixture. Dated this 22_3 day of AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. St. Croix County. ) authenticated this day of Personally came before me thisd.9 day of S2 0 01 the above named !x! as Lt _5 • - .,��s71[�o TITLE: MEMBER STATE BAR OF WISCONSIN to me known (If not, to be the person(s) who executed the foregoing instrument and acknowledge the same. authorized by § 706.06, Wis. Stats,),._ THIS INSTRUMENT WAS DRAFFI /s LC �• Notary Public, State of Wisconsin (Signatures may be authenticated or a f t My Commission is permanent. If not, state expiration Both are not necessary.) �d� • ' date: T ^. Date: /oJ_!;l Dl� "THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT REMOVE This information must be completed by submitter document title . name & return address. and L'LAt (if required). Other ittformation such as the granting t of glauses, legal description, etc, may be placed on this first page ofthe document or may he placed on additional pages of the document. Note Use ofthis cover page adds one page to your document and E2.W to the recording fee. Wisconsin Statutes. 59.517. n �0 o ■ ƒ 0 � c § § 0" B ° I J §q $ \\ % � , E � k_ C:) / ± ® k 2 Q �. $ƒ f F/ F e e Cl .a m �� \} 2¥ 7 E %} w\ j k \ � 2 \ � \ § � / 2 7 a- m L c\ e O C o a m o © g - 12 CD / / > C i ) a co \ / » CL ` f \ f ® _ = 8 g $ 2 + 0 r CL z z k k k/ �. �2{ § / D §} s\ E [ / G� f i g D a ± I ( / 7 - § [ z ~ i > > o _. ° O I � [ z J -4 cn o $ / + § % � 2 . z w m > � � f } f z ) \ D « w / > ) CL 0 § / % . �. ƒ � ) v 2 � � » — � \ 0 w * § \ o ® k I \ i � 7 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT „• Owner rz Property Address ( -�� /t'.,( City /State t �� 1 Legal Description: Lot Block Subdivision/CSM # / '/4 01' '/4, Sec. TZLN -R� , Town of u�_ PIN # l - O —000 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION 7 7 SL Tank manufacturer tozZf - ' Size ST/PC 1 - 2eK�1 lace Setback from: House /S?/ Well 13 P/L Pump manufacturer ?e /fi- Model y K��A /i Alarm location (HOLD WTAN ONLY) Setbac road Vent to fresh air intake l b Water Line > Meter Alarm SOIL ABSORPTION SYSTEM c- Number of Trenches Type of system: i/� Width � Length `�C; Setback from: House /5,S" Well 00 P/L Vent to fresh air, intake /z -:L� ELEVATIONS �.J G Description of benchmark # / �� /�• > �'" .- -F" 17 / i h�`� f /�� Elevation Description of alternate benchmark _- `C �-�7` �� = Elevation ?-?-16 r w Inle � S � O utlet y �;`�c =� �- PC Inlet Building Se er ST/HT t / �- ST Ou � PC Bottom . Header/Manifold f • 3 Top of ST/PC Manhole Cover e Distribution Lines ( ) ? S v ( ) ( ) Bottom of System( ) ` G` V ( ) ( ) Final Grade ( Date of installation U /- Permit number �� State plan number i '3 Plumber's signature Y" � t, License number < S f T K Date /U' Pzz/ ' / Inspector Complete plot plan � 1 NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. S� LAN VIE i i0)� 75 1 V i 3-1 w ' A u � o0 INDICATE NORTH ARROW VA I ` Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and-Buildings Division Count y ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitartN% ".: Pe information you provice may be used for secondary purposes (Privacy L r, s.15.04 (1)(m)]. Permit Holder's Name: flLity_fl Village Town of: State Plan ID No.: HASKINS, LYDA p 2fi )p CST BM Elev.: Insp. BM Elev.: BM Description: Parcel X91128- 8-4D00 t UO I 10 TANK INFORMATION ELEVATION DATA A9800508 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ,,tt e 1 GC �L7 Benchn )� sl�i8 'I /9� BOG / ltd 106.1 (00 r) 1_44 0 r er I (o b Holding (�)40 Inlet ).0.1 6 y TANK SETBACK INFORMATION IIDV Outlet TANK TO P/ L WELL BLDG. t Ve ntto ROAD Dt Inlet /p NA Dt Bottom �� NA Header/ Man. -7. Z7 9 �j Aeration NA Dist. Pipe - 717 Holding Bot. System g a PUMP/ SIPHON INFORMATION a Final Grade too. Manufacturer Q , Demand r� �l `^ r� - 750 V, to. Model Number g JD GPM b �� TDH Lift Lriction Systerrr�s TDH �, t �N ��T 151 •7p� '7q= oss Forcemain Length ' Dia. F If Dist. To Well Ov l e - 71Y Y SOIL ABSORPTION SYSTEM TRENCH Width i Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIM NI N S DIM SETBACK SYSTEM TO P / L BLDG I WELL LAKE/STREAM LEACHING acturer: INFORMATION Type O ^ lszr 1 q �' 17 0 umber: System: Oa 1 "I *�--'' OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length _4_� Dia. a — Length _U Dia. 2 n SpSpacing J I , i ,v ng � SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only / 'D 7 "{rowt / wr 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.) 4-1.1c, LOCATION: TROY 34.28.19,NE,SW 642 SWEDISH MISS ON ROAD Z-- -* 0i t, i 10 1 9` 5 k1S • '7 S- q ? •ID C oy►lavr ��8�� b(d5 Se�xc.- �r5-��O �l _.5, 75-x' �rvw. wit L�„c tom' S 5� � mat" ,P e- w f � 3 wo P Glct,PLO S, 1yt5,,l fc v��Cc(v��cc _18 ice, -� bd.v► s ���,�. �4:".. -l�� p�� p b�-- Plan revision required? ❑ Yes GJ/No Use other side for additional information. a SBD -6710 (R.3/97) Date Inspe 's Signature . No. a � ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ( �L c (-� •__Srn t M r� „wS rq VAN 175D SANITARY PERMIT APPLICATION 2 01 E w shn Wisconsin P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 12 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check if re Ion to'previdds plication (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. N mber 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property0 er ame L Property Location c� l ,1, 4'1 /4 SCU 1/4, S I T e a. N, R l9 E(0,( Property Own r s ailing ddress , Lot Number Block Number Y City, St a Zip Code Phone Number Subdivision Name or CS N ber II. Y F B IL ING: (check one) E] State Owned � o v ita e N est Road n Public 1 or 2 Family Dwelling -No. of bedrooms own OF 1Yc� 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑Apartment/ Condo O 11;2 g - � 40 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 (CWepiacement my one box on line A. Check box online B, if applicable) A) 1. ❑ New 2. 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ----- System________ System ------------- Tank Only___________ Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressuri d Distribution Experimental Other 11 E] Seepage Bed 21 found 30 ❑ Specify Type 41 ❑ Holding Tank 12 E] Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -f=ill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Propoked sq. ft.) (Gals/ /sq. ft.) (Min. /inch) / Elevation �Q �r�2 . , !v Feet bl Feet Capacit VII. FORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New Existin Gallons Tanks Concrete strutted glass App. T nks Tanks 5 ptic C Tank ) ! wa s FkA rs L umpTank phonChamber I tEp VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu ber's Name: (Print) f Plumber's ignature: (No amp MP /MPRSW No.: Business Phone Number: X. "ckvW ®g `715 - ? P lumber's Ac Bress City, State, Zip Code IX. COUNTY / DEPPTkRTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued lssuin nt Signature (No Stamps) surcharge Fee) - yApproved [] Given Initial ���k� Adverse Determination 0 X. CONDITIONS OF APPROVAL/ REASONS FO ISAPPROVAL: SBD42198 (R ttom) DISTRIBUTION: Original to County. One copy To: safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation S. 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 and Buildings Division, 608 - 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 "1/2 x 11 inches must be submitted to the county. The plans must 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; Q. soil test data on a 115 form; and F)..,all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can: effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Safety and Buildings Visconsin PO BOX 7162 MADISON WI 53707 -7162 Tommy G. Thompson, Governor Philip Edw. Albert, Acting Secretary Department of Commerce October 19, 1998 CUST ID No.226375 ATTN: POWTS INSPECTOR ZONING OFFICE ROBERT W ULBRICHT ST CROIX COUNTY 655 O'NEIL RD 1101 CARMICHAEL RD HUDSON WI 54016 HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 10/19/2000 Identification Numbers Transaction ID No. 181682 Site ID No. 157943 SITE: Please refer to both identification numbers, ST CROIX County, Town of TROY above, in all correspondence with the agency. -- NEI/4, SWI /4, S34, T28N, R19W PAUL HASKINS FOR: Description: MOUND SYSTEM / REVISION TO TIN 136808 Object Type: POWT System Regulated Object ID No.: 418033 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. S iDATE RECEIVED 10/07/1998 FEE REQUIRED $ 60.00 P G L O S PLAN REVIEWER II FEE RECEIVED $ 60.00 Ivic BALANCE DUE $ 0.00 (608)266-2F89, M - F, 0745 - 1630 HRS PEPAGEL @COMMERCE.STATE. WI.US ORICINAL Safety and Buildings PO BOX 716: MADISON WI 53707 -716' '%nsi n Tommy G. Thompson, Governor ,ommerce William J. McCoshen, Secretary 1998 CST ID No.226375 ROBERT W ULBRICHT 655 O'NEIL RD HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 09/06/2000 TdentrficafdonNumbers Transaction ID No. 136808 SITE• Site ID No. 157943 ST CROIX County, Town of TROY Please refer to both identification mumbers, NEIA, SW1 /4, S34, T28N, R19W above, in all correspondence with the agency. PAUL HASKINS FOR: Description: MOUND SYSTEM Object Type: POWT System Regulated Object ID No.: 418033 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: 4 On page 3, Y = 48 inches. There are 20 holes in each distribution pipe. The distribution pipe discharge rate is 23.3gpm. The network distribution rate is 46.6gpm. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincere y, DATE RECEIVED 09/02/1998 li � FEE REQUIRED $ 200.00 PETER E PAGEW POW TS PLAN REVIEWER II FEE RECEIVED $ 200.00 Integrated Services BALANCE DUE $ 0.00 (608)266-2889, M - F, 0745 - 1630 HRS PEPAGEL @COMMERCE. STATE. WI.US I P f UL,•BRICHT & ASSOCIATES CO.�� 655 O'Neil Road • Hudson, WI 54016 o signers of Engineering Systems 715- 386 -8185 C j �) �'rivate Sewage Consultants ' 19s* PROJECT INDEX A REVISION, TO DILHR Plan I.D. # 136808 Date Owner P aul Haskins Phone 715- 425 -9093 Address 642 Swedish Mission Rd. River Falls, Wis. 54022 Legal Description 14 Acres approx. PIN 1128 -30 -100. NE, SW, Sect.34, T28M, R19W Town of TROY County ST. CROIX C.S.T. Robert Ulbricht 226375 Installer Local Authority/ Supervision ST. Croix Cty. Zoning Dept. PROJECT DESCRIPTION Replacement system, for an existing 4 bedroom home (600 GPD) with a failing inground drainfield. Soils are permiable (.5/.6 GPD /ft) but seasonally saturated at 28" as evidenced by mottling. The owners wife proposes to build'•-a small (garage type) building, free standing, to serve as her own office and artist studio. It will have a bath and clean up sink. THIS STRUCTURE, PER LOCAL ZONING, SHALL NOT BE USED AS A STRUCTURE FOR HUMAN DWELLING. IT SHALL NOT BE INTENDED AS AN APARTMENT OR SECOND HOME. NOR IS IT INTENDED TO BE A COMMERCIAL STRUCTURE REQUIRING LOCAL SPECIAL EXCEPTION ZONING USE APPROVAL. IT IS ONLY INTENDED AS A PERSONAL OWNER -USED STRUCTURE. Highly recommended: for ultimate pretreatment, equip both + new septic tanks with Zabel filters and approved above ground locking covers for servicing. P.0 APp condit - r Di DE EP TMENr, p VD E F C F S MMtRC ET Y. D @U NGS 1 g . 001�tS S .: g E v RESp `� s Pg .1 PLOT PLAN VIEWS �( O2 ONCE CBWVL (1 D11d9n mum" IT"A Pg.2 SYSTEM CROSS SECTIONS &SYSTEM PLAN VIEWS � D Pg . 3 PIPE LATERAL LAYOUT Pg.4 DOSING CHAMBER CROSS SECTION Pg.5 PUMP PERFORMANCE SPECS Thi design for installation is based entirely on measurements, elevatio landscape onditions (Slopes etc.) and soi The accura� 1 s uitability ns, of it provid . Y his Y p ided �. specs, b C of the CSTM, p s, as reported, shall remain the sole res Y ibi , j ponsibility Any use of this POWTS design by any licensed plumber, or any related unlicensed parties or persons (excavaters, laborers) shall not be construed as an assumption of responsibility by the designer for the workmanship, construction, placement, substitution or selection of any components not specified, or any assumptions by the plumber that any unspecified components are state approved or proper, or the effects of poor judgement if working under adverse damaging weather conditions (wet /frozen %soils) by any such parties or persons. - ` N d w d i m a c I A N I � aim W M y x w I I I W y I I I I I r `.� � Z�z I Z w CD 0 rn O w , ---- - -- • w0D � z z - n y w oc�o 10 CO) w -c a P5 2 o 5 - CROSS SECT10k) of MOUAJD wi rti BBD Bev -0 F % " ro DI STRi(3uT�o� 1 1� AilecSATE' Gs• Tkt G 0 E'S 9 pi f1J Cr oF,To sysrEM P soiL E'IEvhrioo UuiFORM To 99.10 qr r� N u I- E L h. ( RRT � iO MEIN, • 8 9 1 ,t' SAup , • . pIowrO TopSo�' �t UL) i F'O RM % 510PE F ORCE EIr-VATtoa UOVER MAW BEV e l �.� FT . -- ELEVA S �r F /. 3 F INVERT' OF 2 1AT£ -5 G /, D Fr. • T o f R o c J P �f• �y /f 7g 78 H /S F T. • �' °P OF IATERAIS PLAN VIEW v F M OUAJD Wi r tN 13 t✓a� Fopuz MAW A 8 F I F r Fr I a L `0 r FT W _ _ k Fr � w � -° w 3 Z FT - BBP OF PVC- cgpPEp To 1 d(3sp-RVArlo,u A 99RE5hTE pf pE5 i ` PERMAAjtJT M ARkERS RE (QViRep BASAL hReA - T AI'�y SCIL rai�ITl?�T»E l B ( PRopoSEe BASM AReA = A t z C s a2 , F T, 3 o - f 5 DISTRIf3urlok3 PIPE OarwoRK LAyov'r P R 0 ,\ E aE�T f _ Fr o' R 1 7 1 - Fr X yf 1N�NE FoRce MA 5 F r• of Z Pvc y - �,uCNIF VARi A(3l.EE TOTAL Vo l[) U010A ' 2- GAIS , V I TJ),3cft H o l E D' . A M e TE R y� N� 1♦ �S A - 1 Z. �L 1 0C li MAWFvLD 2 ►,� c f} � s IN�F{�S 4P OF H /ei PE 70 Z , uVERT EI�VAT1orJ or- L ATE RM 5 D " pipe - DETAi L EuD CAP PE R Fo R hTE C r • Re MauE - All 3)RM Bmz(:z5 Y NeIES 1 dCATEb o,3 BOTTOM UgUA11y SPACED �I.PTRi BurI0" DISChARCrE RATE P°R E�RC-h LA'rERq L P c)-r ( - -S 23.3 R G A 1 - TOTAL 17( SMBOTIoO 'Di5CH RATE r qot r w OR K &Af- M 1'A� . ;Z..5 ' M I i M () okA PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS P,41E -VENT CAP 4 "C.I. VEIJT PIPE WEATHER PROOF APPROVED LOCKING ?: z5' FROM DOOR, JUNCTION BOX MANHOLE COVER WIIJDOW OR FRESH 12 "MIU. AIR INTAKE r A�Epi1T /On/ GRADE l/' I `__ ' CONDUIT _ 3,p - INLE T P ROW DE I - --►- —- - - - - -- AIRTIGHT SEAL 4 APPROVED JOIIJT A y, K I I APPROVED JOIWTS 1J /C.2. PIPE IN 'I p1� I I I W /C.I. PIPE ' EXTEIJDIAIG 3' C),p1� i II EXTENDIAIG 3' 1J O ALARM ONTO SOLID SOIL ONTO SOLID SOIL B 10 I I I I /- 3.3 I 1 9 /.?o ELEV. FT. __� 2 PUMP 3 -�, OFF ZISE O�Q t E p pl,J lr o � • � � �10�PE e� , f N k l� ItJ 1 BLOCK �IE G�iv RISER EXIT PERMITTED OIJLy IF TANK MAIJUFACTURER HAS SUCH APPROVAL SEPTIC E ry" SPE DOSE A / f^MOMI/y /� �/f •S 7 3 TAIJKS MAtJUFACTURER: IJUMBER O 2;O�ES: PER DAH TAWK SIZE: / z GALLOMS DOSE VOLUME �p ALARM MANUFACTURER: 1-09a INCLUDIMG BACKFLOW: Z�d GALLONS MODEL MUMBEP v ( L - CAPACITIES: A = `' 7 IAICNESOR GALLONS SWITCH TYPE: 1- • ,/ 4 ! g � T„ ,Q C' + 7 8= Q IIJCHES OR � GALLONS PUMP MANUFACTURER: C OR GALLOMS MODEL NUMBER: �Z- `CS D= /2 .& INCHES OR 37 8 GALLONS SWITCH T9PE *lp_Myl6d10t y aC 104_ NOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL. DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. `� � FEET - rAA)k ! PCCS ' 4- MINIMUM NETWORK SUPPLY PRESSURE , . , , , - . 2 . 5 FEET E/IIC.Gt r I Al- FEET O FOR MAIN X �' F oFT FACT OR..''? FEET t4o.A1s 36 TOTAL DYNAMIC HEAD = FEET 9 t . 4 , INTERNAL DIME."SIONS OF TANK: LF-KI&TH / ;WIDTH / ;LIQUID DEPTH k ALL NON-CONFORIAIA Q TREATMENT TANKS PER PLUMBING PRODUCT APPROVAL gg ABAW011 ROpERLY (CODES, ALL ABOVE - GROUND PVC FOA jLHR 83 .03(2)- PIPING (FROM TANKS & SYSTEM AREAS) MUST BE SCH.40 PVC MEETING ASTM D1785 OR D2665 STANDARDS. Y I • f r HEAD CAPACITY CURVE 30 MODEL'6ey- 1/4 e s/a zs ' S ( 3 S/8 18 N O 4 10 6 1 3/1e s— 1 1/2 -I1 1/2 NPT 0 • U.S. CALIONS UWAS 10 20 10 50 80 )0 80 801 160 0 FLOW PER MINUTE 210 TOTAL OTNAYxs MuMtow p1li u.,+ure 1 EII IUENTAN00tWATENNe NttAO CAIACIIY 12 YNITa/M1N . FEET MET[R• OALa lrtt• It I.bZ it M 10 3.00 at R]1 1E �.ar IE I 4 20 a 10 26 oe lockvatw «�' 3 5/1 Ele CONSULT FACTORY FOR SPECIAL APPLICAT! ctrical atterrlalors, for duplex systems, ere available and ONS supplied with an alarm. • Mercury float swllChes are available for conlrollin #..Mechanical alternators for duplex g Single and w , p systems, are available with or • Double syslems. 9 without . Alarm s�v,tchea. Piggyback mercury float switches are available for variable level long cycle controls. Standard all mod - Weight U Ibe - �i H.P. 1. fe1od2 eELECTIONOu10E earl•• N 2. 81n 14 I P In•OhaNcal switch no •xlelrlal wnYa laquk•d. M1od•I y he.ph Control Selacllon o P 99Yback mercury 110,W awkch a, double M 116 Mod �'" 61m lax D Switch. R u o f [ orer b FMO17r. PlaRyback mercury. eoy 1 ub a or J< 3. M•chudcd alt•rnalOf 10-0072 of 1 1 • ee0 FMo 712. for 001190 "WxW d Eleckkal Akeroalof. • • 230 1 A o T e• Mercury aeruwl heat ew11cA 10 too 230 1 Non T.5 1 or 1 A 7 duplex t or N) float syslem 5 ° e coned activator .peclll 2 Or. R I< t 3 or 1116 :. fa :F hPle • '.►Pak ". Iur"Oel bob lof : pl•x a duplex ope(a) 1% 10-0002, y atl collnecikart or wk•d,n slm 7. Two 't2) Wei "J•Pak ", rot walowatll oalrla.__.. spec•. fa kdor PWVb -kk Mmccwyad vAlh l . u seiii FLI0 11; f q lacer b oataloq an Caff"'Leon BLMN, FM0014; b1o1W; A" ► fkWl)T, Ekrc1,kM A[aroalor, Woe"; VuGlunky AE bslslhlloa of F sa�1r _CAPTION FMa133 Sd'SOS. fMObq; tumWliaua0s 1 FMOMT; ww aj Axs,nsbr, 1"ae'llo al Mad hl' • w Carwal IMd Eti ^Nd sMwrlol.n All • ee wkkp sAo�10 N 4 0 " by Jim* Ing aw aw.l raownl Ndloa.l El.arla C ` 111 so4'a C 90 4 "41 McluO. HOG" Ad (0[NA) °� (NEC) and M,a t ooupaYa^d E.Isb ana RESERVE POWFPED DESIGN For'unusual conditions a reserve safety factor )a d1`190eered into the design of agery Zoeller pump. MAN ra r .0. 009 16317 iaasyiff,'KY 40 ?56 -0311 Manulacluters 01... L [ E SNIP 10: 3 ?e0 04 AGllsfs lane loLl,r r; Ky 40,116 w lso 77e 2731.. fAr;soz� 771 ?� 441.4tirr ps .rrvcE /.9.�9" Wisconsin Department of Industry SOIL SITE EVALUATION Labor and Human Relations ; ,\ Page Division of Safety and Buildings in oe d�'aiiice' th *HR 83.09, Wis. Attach complete site plan on paper not less than 81/ nches �r�42 must - County < Include, but not limited to: vertical and horizontal ref mn point (� 'f �ibh� and percent slope, scale or dimensions, north arrow, an 16a tion istance to nearest road_4 Parcel I.D. If APPLICANT INFORMATION - Please prloit # infor�� Reviewed by Date Personal information you provide may be used for secondary p (� 1 4+"WlL� !?�61)). Property Owner p VvVt. Lot N� 1/4 SK/1 /4,S 3� T 2A ,N,R E (or) W Property Owner's Mailing Address n Lot # I Block# Subd. Name or CSM# City State Zip Code Phone Number 0 ci ty 0 V r„ -T / wn Nearest Road ,fQ��/ �� ��`lS GJl• S� (7l5 )�1.t.5' •f 3 o lb �f�•SS /Oa . ❑ Ne Construction Use: esidential / Number of bedrooms Addition to existing building _eplacement //-- El Public or commercial - Describe: // Code derived daily flow (00 god Recommended design loading rate ..S bed, gpd/ft — * ( 10 trench, gpd/11 Absorption area required _ bed, ft S4ro trench, ft 2 MEtxlmum design loading rate • .S bed, gpd /ft • (-y trench, gpd/ft Recommended infiltration surface elevation(s) S� � � �D ft (as referred to site plan benchmark) Additional design /site considerations 7 ~ 144,-6— A0,* 14fdv . 1 Parent material /04 � d 0 � •� Flood plain elevation, if applicable ft S = Suitable for system Conventional ,- M-,ound In Ground Pressure, AT Grade System in Fill Holding Tank U = Unsuitable for system ❑ S � s U U ❑ S 9 ❑ S U ❑ S S SOIL DESCRIPTION REPORT Boring Q # FHorizo Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench '/3 ioy 3/3 :571L 2fsGr� s� •31 lou % !L Z - Fsl7 - C-S 1 7 s' . Ground / 7 c L /M�t s s . Y• .S r elegy n. • (a /o yie C - 2-4 4 - 1101 S'GL '7 / ��• ' Z ' • 3 Depth to 91% IA limiting factor Remarks: Boring # y 3/3 r �o .� -3 7 S ffl e L 5 / ' r �' S e,5 ' Ground 3 •/ /o 51& t S V S 7. ele /o /D D . 7 2: .� �ft. Depth to limiting � factor in. Remarks: CST Name (Please Print) i �Signature Z `S T pe N S 1 Address Date CST Number Uibricht & Associates ivate Sswa a Consultants 13' �l ?.,-_ 665 O'Nai Hudson, Wis. 54010 ORIGIN � �ff /' <N S SOIL DESCRIPTION REPORT P e Z of ,� PROPERTY OWNER 9 PARCEL I.D.# 10 /l L � • / � D Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench lo (w 31t� RF m y y to v,e y` eZ- /07 . C(; ..S Ground ' 71 e L,S elev. ft �o y`, S /( C2 Apl 45 • - 7 s y Depth to Iva lol z limiting 7G factor � iri. s,s•S Remarks: Boring # Ground elev. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor In. .. r M s: SBDW -8330 (R. 081")WI J � J v C 1 Lr) it k C13 y QPJ Qi I \ _ T�A Y 1- o I - � w All 06 W Q ST CROIX COUNTY ' SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM ��wncr 7 n Mailing Address y Property Address (Val iicatioa required from Phnaiag Department for new construction) Cit3atate t �! ��' Parcel Identification Ntunbcr _ (n 'lO - 0 a T-EGAL DESCRIPTION Properly Location ,�- %, y, Sea T9N R Town of Subdivision Lot # Certified Stuvey Map # Volume 4qALZ page # _ Warranty Deed # J C " // 9 x aZ Volume In 5 6 Page # O Spec house o yes @rno Lot lines identifiable. Q yes ❑. no �XSTF�' - WAXJ'�'rR. i4NC9 j10 mud ofyomrqtcsysbaaoodldremkmitsp tohaadlcwast�es.Proper eaa isft o pc -fun.ctioa of the � � � y� oc want; if medcd by 9 N=sedp=pm What you pat.into do system scp6�ctaaTCSS.rhratmeatstage lathe �rastcd'r..�posalsysbcm, .. - - The Pi'oP ' owner agrees to to St. Oro& Zoaiag Department x ccrffication farm, signed by the: owner and by a p (Ij tt�coaaitcaraisraterdisposalsysGcm is P evadrtian aadlor (2) a&r iuspcctioa and P -fief n cccssar3r), See scptictaak is less Bran In fan of sludge. Ywe„ the tinder kwdhm Vead tie above rugrricmmats sad agree to maitmttia &c pdvak savage disposal system with rho standards Set foci, beveia. xs set by the Depatment of C mm= and the Deprtmeat of N' dz l Resoareer, Statc of Wimoo=m - (edification statulg YOur ups systcmbasbaamaintaiaedsmartbe conyletedadreftmaed. to the St. Cmix.County Zoning Officewidda 30 days-of the dwee year erpiratioa date. Si d Z 1m OF APPLICANT DAZE OWNER. - C MEBIiCA.TXON I (we) certify that all statements on this form am tare to the best of my (our) lmowlcdec. I (we) am (are) the owners) of the Prommity dcscn'bod above. by *bte of a mmaty deod cecordkd in Register of Dads Offi, S1044ftlkll OF APPLICANT � T 3 / 9 S DA s « « « «« Any information that is tniz'rePre=WmaY riesilt in dx sanitary permit being revoked by the Zoning Department. 400000 s« Iadude: With this application: a cumpod warranty deed from the Register of Dodds oilier I Copy of the certified eurvcy map if reference is made in the warranty deed _ e 'wt s ., n* .•�., , �( t ±� .y.. � ��QQ .: A '.f,. ,. .� .mac w,4�axss- a�wsy*•. TERMINATION OF DECEDENTS PROPERTY INTEREST • Joint Tenancy or life Estate Termination (s. 867.0451 or • Summary Confirmation of Interest in Property (s. 867.0461 edenM NWW Paul S. Haskins Addre of Doosdor t at Des of Deal h fly S tate ap REGISTER'S 0 642 Swedish Mission Roadr Rive Falls* WI 54 022 ST cm= Data r1 Deeeh $Od" Seamy msrbs ReO�d I1D► IAecofd 2 -2 -93 390 -22 -7179 DEC 21 1993 Pr of Dealt CwtlNcaM - i i have vfOwad a d the death ca<oflcate. at -- Q �• A • M �ht�onae Deeds signetae This lrtteree! in r" eetaM b terrranated under (dhedc oft): Record Me d invent W*h Me Aagisfer of Deli!! Xs. ti67.oas which pertains to real property in which the decedent was a joint tenant,' in the county where the real esWe is boated . had a vendors or mortgagee's 'sterest, or had a He estate. *(You must provvis a copy d Recording Am is $25 as per s. SP 04 867.046 the deed estaelishinq joint tenancy) Return to: G. E. Norman s. 867.046 which pertains to (1) real property of a decedent specified in a marital Bakke Norman r ' S . C . property agreement, and also to (2) survivorship marital property. (You rrArA provide a P. 0. !lox 50 copy of the deed establishing survivorship marital property.) New Richmond r NI 5401 Presentation of real property tax bill. Present with fts docurrrent a copy of the real property tax bill for each parcel for the year wirriedlarely prece*V decedents d&O, - Presentation of deed esWAs" joint tenancy or survivorship madMI property. This deed is found in volumehed 355 pagelwnage 169 of (check one) Records X Deeds . #256929 Description of the real estate. Include only the extent of ownership (or vendor or mortgagee's interest) in land at the time of the decedents death. N ft extent of tend is exactly ft same as on the deed, a ccpy of the deed may be attached to describe ft real estate. The legal description of the property is as follows: (N more space is needed, attach pages.) See attached DECLARATION: 1. we deda- that this docur.renc is : 'he best of my ( our) knowledge and befhef, true, correct and compiste and is in conformity with the provisions and limitations of L' 3 Wisconsin Statutes. N more a is needed, attach PRgetiJ Name and Address of Person Pecemng Property Relationship to Decedent (Notarized) bete Lyda B. Haskins Surviving f L t2 642 Swedish Mission Road Spouse Rivev W 54012 AUTHENTICATION or ACKNOWLEDGEMENT The above named person(s) was swom to bebre me on (dabl Rot -/ 7 -9 a - `.'hs document was drafted by (print or type name below) Signature of notary or other persona G. E. Norman aoixtedto a noeM BAKKE NORM AN r S.C. (as s>C s. 7 os.oR. 7os.o>) KA I I I. � New R ichmond, Pmtartypena.e t�OTORY rt�f' -6 1,41 State Of Wisconsin, coixxy, of St. C roix 2 -12 -95 WMCOns- Realer ot Oeeds Assoc~ Form HT -110 (1192) Tdb Dale Camm sw 3xpirts SCHWUM A A parcel of land containing 14 awes located in the Northeast Quarter of the Southwest i Quarter of Section 34, Township 25 North, Range 19 West, being the East SM feet of said ; Northeast Quarter of Southwest Quarter lying North of the Town Road; further described as follows: Be;innin= at the Northeast corner of said Southwest Quarter of Section 34-25- 19; the= West along the North line of said Southwest Quarter a distance of 386 feet; � thence South parallel with the East line of said Southwest Quarter a distance of 901.3 feet to the centerline of the Town Road; thence Southeasterly along said Town Road to the East line of said Southwest Quarter a distance of 643 feet; them a North along the East line of said Southwest Quarter a distance of 1,173 feet to place of beginning. St. Croix County, W1 � a a a 1 4- a ` ., � —� �� ��� � l� �, s . i S �� � V