HomeMy WebLinkAbout042-1004-60-000 Department of Commerce
PRIVATE SEWAGE SYSTEM County: St. Croix
'iuilding Division
INSPECTION REPORT Sanitary Permit No: 483977 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Krear, Robert & Diane I Warren, Town of 042 - 1004 -60 -000
CST BM Elev: Insp, BM Elev: BM Description: Section/Town /Range/Map No:
3 03.29.18.37B
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER ,`rV7� CAPACITY STATION BS HI I FS ELEV.
Septic , Benchmark
Dosing- Alt. BM
F`� P 1 a ��S r 3 • /o
Aeration Q Bldg. Sewer ,
K + �
Holding St/Ht Inlet
St/Fit Outlet !�
TANK SETBACK INFORMATION ,
TANK TO /L WELL BLDG. Veto AirIntake ROAD Dt Inlet
Septic 33 3'C Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe /P
Holding Bot. System
Final Grade C �
PUMP /SIPHON INFORMATION �•?/ 91: 3
Manufacturer De nand St Coved 3, (P 1,65.
Model N r
TD Lift Friction Loss System T Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length I - No. Of Tre nches � PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS � (,�, E � � �
SETBACK SYSTEM TO T P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer: — �•' f
INFORMATION Type Of System: CHAMBER OR
�
�,�Je , �✓«O' 23 �� // UNIT Model Number. �.
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Si e x Hole Sp c Vent to Air Intake
Pipe
1 1-ength 7 Z Dia Lang th Dia acin
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only a
Depth Over it Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center t Bedrrrench Edges Topsoil
5a es No es No
J
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /
Location: 1249 County Road E�New Richmond, WI 54017 (NE 1/4 NW _1/4 3 T29N R18W) NA Lot 1 Parcel No: 03.29.18.37B
1.) Alt BM Description= � -,. C j T"� '� �'�- `-"'� %' 1 f -- II � s `� •sh ' 1 ,- 2.) Bldg sewer length = 6'�lt,6A1�. k_bc.7 6 -, V .r-.__ ►
- amount of cover = r g , �/ d� /� s�-c.ej
aC �OJE,�I
Plan revision Required? ❑Yes i F16T y�
Use other side for additional information. iV
SBD -6710 (R.3/97) Date Insepctor's g lure Cart . No
��
commerce .Wl.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 v�`TGj/d i
i sco ns;; n Madison, WI 53707-2162 Sanitary Permit to I in by Co.)
Department of t,ommerce "' ►
Sanitary Permit Application We
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental
unit is required prior to obtaining a sanitary permit. Note; Application forms for state -owned POWTS are Project Address (if different than mailing address)
submitted to the Department of Commerce. Personal information you provide may be used for secondary
p urposes in accordance with the Privacy Law, s. 15.04 1 m , Slats.
I. ARplication Information - 'Please Print All Information IV hu
Property Owner's Name Parcel #
o e- .�- e cc Ql�/�Z� l0 a y-- Via- do�J
Property Owner's Mailing Address Property Location
l.2 y9, ST. G ROIX COUNTY Govt. Lot
City, State Zip Code LF*W1►A Ale—'L y, .� 1
GJ / <, Section
-. hLO G! -7 (circle one
4
Q cD T R V�
II. Type of Building (check all that apply) Lot #
9 1 or 2 Family Dwelling - Number of Bedrooms / Subdivision Name
Block #
❑ Public /Commercial - Describe Use
❑ City of
❑ State Owned - Describe Use CSM Number VO I ❑ Village of
32-& W, Z� JWTown of
ill. Type of Permit; (Check only one box on line A. Complete line B if applicable)
A ' If New System Re lacementS stem
y p y ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber fransfer to New List Previous Permit Number atsd Date Issued
❑ Permit'
Before Expiration Owner 30 ! - ! — 9 1'Z 171r
IV. Type of POWTS S stetn /Com onent/Device: Check all that appl
XNon- Pressurized In -Gro nd El Pressurized In- Ground El At-Grade Ell Mound ,> 24 in. o fstable s ik ❑ ound << 224 in. of spitable soil
❑ Holding Tank they Dispersal Component (explain) ( /YIGY /'L� �`2TPrnt evil explafi - 2Q.f.
V. Dis ersalrfreatmentArea Information:
Design Flow (gpd) Design Soil Application Rate {gpdsfj Dispersal Area Required (sf) Dispersal Area P oposed (sf} System Elevation
_ O
.'7 9 4
Vi. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units c
New Tanks Existing Tanks o y a a
a U in
Septic or Holding Tank
Dosing Chmnber Jr� ! Y f_�71
VII, Responsibility Statement 1, the undersigned, assume responsibility for installation of the P0 6Mwn on the attached plans.
Plumber's Name (Print) Plumber's Signature PRS Number Business Phone Number
eke l,J ' - -��—
Plumber's Address (Street, City, State, Zip Code)
VIII, ount /De artment tfqe Onl
Approved ❑Disapproved Permit Fee 'f1 Date Issued suing A e ignat `
�/ vv
Q Owner Given Reason for Denial $ / �' f - / 7 1 n ��
,�C�tt�ylroval/Reasons for Disapproval
41
1 Septic tank, effluent filter and -p
dispersal cell must all be serviced / maintained a 3 "33.
as per management plan provided by plumber.
2. All setback requirements must be maintained
as o lump e e pans for the system d submit io the County only n paper Aot less than 81/2 x I I inch in size �Gf�
SBD -6398 (R. 02/09) Valid thru 02/11
j CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:
Owner's Name: A
Owner's Address: �_q 44
Legal Description: �j1d ti
Township:
County: 5'�cyno r`
Subdivision Name: •--
Lot Number:
Parcel ID Number: Q y�? - -1,W y"l�d�- Q d d
Page 1 Index and title
,/Page 2 Plot Plan
/Page 3 System Sizing & Cross - Section
Page 4 Filter Specs f - CCCfjV,n �Drrrn�Cf i1 -y�2�
Page 5 Maintenance Information
,/Page 6 Management Plan
/Page 7 St. Croix Cty Septic Tank Maintenanc Form
.- 8 _ Warranty Deed
✓ Page 9 CSM or Plat
Attachments: Soil Test & House Plans
Designer /Plumber: Id , 1 1,10
S" ,�',ry� License Number:
Date: q /1$ //O Phone Number R��s_ �g4� Y
Signature
Designed pursuant to the In- Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (N.01/01).
Page 1
/9 G .�l e �� f5 r/' B. C� ! i' �� � .l� c � jJ28.rJ � '/ D LCJ ✓U ®/'� ��c P'7` �.n/
®dam r
Pi
O, eh
J\
G y �
Q
1
.. A
A a
/6 0, o
J � r Se�
�o� r
.0 (h
Lip
�G
.p
' Q
L ,- ke ri ea
P
Soil Absorption SXstem Cross Section
r Cf� - ft
4" 3ch�lule 40 Final Grade
PVC Vent Pipe
With Vent Capes_ ft
Leaching ..� w. 7
Chamber fir ft
f--- System Elevation
ft - Z LL ft
Soil Absomtloo_Svstem f!I jIn Vlew
ft
cy ft
� " � Trench 1
ft Leaching Vent Or Observation Pipe Chambers
4" Dia.
Trench 2 Header
Leaching Ghalober Specifications
Manufacturer And Model
EISA Rating 04 sq ft per chamber Soil Application Rate . ? gpd/sq ft
yid gpd Design Flow + • 7 Soil Application Rate ,. eOT EISA = I�A Chambers
2 rows of chambers each.
Page y of
SEPTIC TANK � PUMP CHAMBER CROSS S�C.!C?N AN
4" CI' VENT PIPE ' 12" RfN. `ABOVE GRADE W EATHERPR OOF NCTI H APPROVED
> 25 FROM DOOR, WINDOW OR WITH CONDUIT MANHOLE COVER
FRESH AIR INTAKE W/ PADLOCK &
FINISHED GRADE WARNING LABEL
b" CI RISER �.�.. - 4" MIN.
IN. 6 MAX.
'NL£T
WATER TIGHT SEALS GAS•
TIGHT i �' PPROVED
A SEAL JOINTS WITH
ALM APPROVED PIPE
PPROVED B ON 3' ONTO
IPE 3' - T — SOLID SOIL
NTO SOLID C i + ** RISER EXIT
OIL PUMP OFF ELEV . FT. V IA MOFr PERMITTED ONLY
D IF TANK
MANUFACTURER
HAS APPROVAL
3" APPROVED_ BEDDING UNDER TANK
CONCRETE PAD
SPECIFICATIONS
SEPTIC / DOSE NUMBER DOSES PER DAY:
TANK MANUFACTURER:
TANK SIZES; SEPTIC 1 ._.__ GAL. DOSE VOLUME INCLUDING /i?•?_„__„�, GAL.
DOSE �e.S�4 _ GAL
ALARM MANUFACTURER: /_ � U a64An H __
CAPACITIES: A = ' 4 INCHES = 3� GAL
MODEL NUMBER: 'rte B 2 INCHES 2 5+2 GAL.
SWITCH TYPE: �i�r�_____.
PUMP MANUFACTURER:
C = $ INCHES = GAL.
!' MODEL NUMBER: e D = INCHES = _ GAL.
SWITCH TYPE: rrree^c
REQUIRED DISCHARGE RATE 3� GPM PUMP E ALARM WIRING AS PER ILHR 16.23 WAC
GE BETWEEN
PUMP OFF AND DISTRIBUTION PIPE . ! „ FEET
VERTICAL DIFFERENCE 4off FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . • • ' • . . ' . . . FEET
+ FEET FORCEMAIN X ,;q.,4 FT1100 FT. FR
DYNAMIC
TAL HEAD FEET
TO
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH DIAMETER ; ... -----
LIQUID BED '• �4°,��,��,� ,
SxGNED: J - ` � LICENSE NUMBER. :I,2 7!
fd DATE.
1/88
[qGOULDS PUMPS Submersible
At Effluent Pump
3871 EP0
EP05
. 3 -
APPLICATIONS • Fully submerged in high ■ EPOS Impeller: Thermoplas- ■ Bearings: Upper and lower
Specifically designed for the grade turbine oil for tic enclosed design for heavy duty ball bearing
S
P Y 9 lubrication and efficient improved performance. construction.
following uses: heat transfer. ■ Casing and Base: Rugged
• Effluent systems thermoplastic design provides AGENCY LISTING
• Homes Available for automatic and superior strength and corrosion
• Farms manual operation. Auto- resistance. a Canadian s tandards Assadation
• Heavy duty sump matic models include M Motor Housing: Cast iron (CSA listed model numbers end
• Water transfer Mechanical Float Switch in "F" or "C ".)
• Dewatering assembled and preset at the for efficient heat transfer,
factory. strength, and durability.
SP ECIFICATIONS ■ Motor Cover: Thermoplastic Goulds Pumps is ISO soot Registered.
FEATURES cover with integral handle and
• Solids handling capability: float switch attachment points.
; /4" maximum. ■ EPO4 Impeller: Thermoplas- N Power Cable: Severe duty
• Capacities: up to 60 GPM. tic Semi -open design with rated oil and water resistant.
• Total heads: up to 31 feet. pump out vanes for mechanical
• Discharge size: 1 NPT. seal protection.
• Mechanical seal: carbon -
rotary/ceramic- stationary,
BUNA -N elastomers.
• Temperature:
104°F (4000) continuous METERS FEET ..
- -... _._.._ T ,. _...
140OF (60 intermittent to i '
• Fasteners: 300 series
stainless steel 9 30 .I -5GPM :.
• Capable of running
dry without damage to $ z s FT
...- .. 1.. _ ;.. -.... ....d........ _ .
components. zs� - ... _, ..... �.
,
C i .... r .... ... ...... �, . _�.. _. 1 ... -..... ...
Motor: YV f) 201 .
• EPO4 Single phase: 0.4 HP,
115 or 230 V, 60 Hz,1550 a _
RPM, built in overload with o s 15
automatic reset.
a 4 EPOS
• EP05 Single phase: 0.5 HP, o
115 V, 60 Hz, 1550 RPM, ~ 3 10
built in overload with !.... _. EPO4
automatic reset. 2
• Power cord: 10 foot s
standard length, 16/3 ;.
SITOW with three prong
grounding plug. Optional 20 0 0 0 1 0 2 0 30 40 50 GPM
foot length, 16/3 S1TW with
three prong grounding plug 0 2 4 6 a 10 12 m)/h
(standard on EP05). CAPACITY
G P umps
® 2000 Goulds Pumps < �/ ITT Industries
Effective February, 2000 �
03871
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYST SPECIFICATIONS
Owner o Y �- � Y tic Tank Capacity g al ❑ NA
Permit # C Septic Tank Manufacturer ,re�e ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer rpm % 1/ It, ems•/ ❑ NA
Number of Bedrooms 3 ❑ NA Effluent Filter Model ?� ,�,$� ❑ NA
Number of Public Facility Units A Pump Tank Capacity D al ❑ NA
Estimated flow (average) gallday Pump Tank Manufacturer ' s,0 ❑ NA
Design flow (peak), (Estimated x 1.5) +� Q gal /da Pump Manufacturer r�dA ❑ NA
Soil Application Rate gal/day/ft' Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average" Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cells} ❑ NA
Biochemical Oxygen Demand (BOD <_30 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized}
Total Suspended Solids (TSS) 530 mg /L NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in di . ❑ NA
Other: ❑ NA
Other: ❑ NA Other: ❑ NA
13 NA
"Values typical for domestic wastewater and septic tank effluent. Other:
MAINTENANCE SCHEDULE
Service Event Service Frequency
month(s) (Maximum 3 years) ❑ NA
Inspect condition of tankis) fAt least once every: earls)
Pump out contents of tanks) hen combined sludge and scum equals one (Y of tank volume ❑ NA
❑ month(s) (Maximum 3 years) ❑ NA
Inspect dispersal cell(s) At least once every: 3 Wyear(s)
— month(s) E3 NA
Clean effluent filter At least once every: years)
❑ month(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: ❑ year(s)
❑ month(s) O NA
Flush laterals and pressure test At least once every: ❑ yea1
❑ monthis) ❑ NA
Other: At least once every: ❑ year(s)
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector, POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tankis) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any p
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y3) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized gomponents, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by E certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
I
page of
products or other chemicals
START UP AND OPERATION
p ersal cell(s). If high concentrations are detected h
For new construction, prior to use o f the POWTS check treatment tanklst for the presenc of painting ave the contents
that may impede the treatment process and /or damage the dis
of the tank(s) removed by a septsge servicing operator prior to use.
S start up shall not occur when soil conditions are frozen at the infiltrative surface s restored the excess wastewater wiil be
By fill above
During power outages pump tanks m normal highwater levels. When power
ischar ed to the dispersal cail(s) in one large dose overloading to k re ll rr ( ' s o ) aenddby ay di scharge Septage Servicing ng Operator
effluent. To avoid this_,situation have the contents of the �umN p r controls to
d ! operating the Pump
power to the effluent pump or contactta Plumber or POWTS 'Maintainer to assist in manually o p
restore normal levels within the pump ta nk .
over tanks and dispersal cells. Da nat drive ar par
n slope k over, or otherwise disturb or compact, the area
Do not drive or park slope of any mound or at -g les rade soil absorption area• the life of the
within 15 feet dow rove the performance and prolong
Reduction or elimination of the following from the wastewater stream may rdepgreasers;
dental floss; diapers; disinfectants; fat;
s; cigarette butts; condoms; cotton swabs;
water; fruit and vegetable peelings; gasoline; grease; he
foundation drain (sump pumP) rbicides; meat scraps; medications; oil;
POWTS: antibiotics; baby wipe
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
When the POWTS fails and /or is permanently taken out of service the foll ionsin A dmin i stra tive Code:
msure that the system is
ABANDONMENT
properly and safely abandoned in compliance with chapter Comm 83.33,
' shall be disconnected abandoned pipe opening s sealed
• All piping to tanks and pits and th a S age Servicing Operator.
• The contents of all tanks and pits shall be removed and properly disposed of by
in ,all tanks and pits shall be excavated and removed or their covers removed and the void space
After Pump filled with
• p 9
soil, gravel or another inert solid material.
must b4
CONTINGENCY PLAN taken, to provide a code compliant
if the POWTS fails and cannot be repaired the following measures have been, or. acement soil absorption
replace suitable replacement area has been nt system; for the location of a repl n b
p be utilized
evaluated and may prot the replaceme
system. The replacement area should be protected from disturbance and compaction to � s houl d not be infring nt area will
led upon Y
required setbacks from existing,. and proposed structure, lot line's and wells. systems must
result in the need for a new soil. and site evaluation to establish a suitable replacemen t area. Replacement
comply with the rules in effect at that time•
ant area is not available due to setback e �the faledtPOWTSs Siring advances in POWTE
❑ A suitable reptacem sitE
technology a holding tank maybe installed as a last resort to replace tanl
441 ❑ T
e
.f de soil absorption systems may be reconstructed in place following removal of the biomat at th
❑ Mound and at -gra with the rules in affect the ttme.
infiltrative surface. Reconstructions of such systems must comply
< <WARNING> > EATMENT TANKS MAY CONTAIN LETHAL` GASSES ES. D iNSUFFICIENY OXYGEN. DU NO
SEPTIC, PUMP AND OTHER TR
ENTER A SEPTIC, PUMP O
R OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE O
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSI
ADDITIONAL COMMENTS
POWTS MAINTAINER
POWTS INSTALLER
/� /} Name
Name �i✓ a • L !r Gt e,,-a yy..�G 1^
Phone
Phone
SEPTAGE SERVICING OPERATOR (PUMPER) L OCAL REGULATORY AUTHOR
Name #m e
a .s:
Phone i�lOne
This document was drafted in compliance with chapter Comm 83.22121(b)f f)(d) &if► and 83.64(1). (2) & (3). Wisconsin Administrative Code.
ST. CROLK COUNTY
SEPTIC TANK 'MA.INTRNANCF AGREEMENT
AND
OWNERSHIP
CERT1FiCATT ON FORM
lei
Owi er/Duyer
Mttiling Address - — � T
Pto crt Acldtcsa - -.- - -- - _ De partment for new cc�netrocnion.)
p y frrnm plannin & Zoning a
P
(V cri�fication required B
(:it /state Gd t22�C -s��
Parcel ldentificaiion Numb er
Y
T �4 N R
. _ l? W, Town of
property location v a , t t /a ,Sec . 3 _..�
Subdivision
Volume page #
C:eirtlQed Sut"veY Map #
, 3n
Volume
Walrrataty Deed # _3�6 ...— �..� ----- -- -� -
Lot lines ide»tiftable es no
Spec house yes
SYST1�lV� _IN' N ANCE AND OWN " , R , ""'Wo FIGAT_�ON
Improper ase an d mmutenance of Your septic system could result in its lxematwe faihac to taed der § P' put into
saaintenance consists of putnpiatg out the ar
Septic tank cvWy dive yes or sooner, if needed, by
e in the waste disposal systorn. Owner maintcxlarsoe
th avotnrn (Mn a ffect i
ct the function of the septic tack as a troatalotlt drag
1,e,..' �............ _ __ _ - . 0. P`...:+ r..,, nsv Ranitnry Ordinance.
responsibilities are specitacd i-0. §Comm. ti _j,5Z(l) and itt (.t►aperr 14 - a1. w,.w
Planning & Zoning Departlim t a certification form, signed by the
'The property owner agrees to submit u b". rexqW� lunber or a licettsed pumper vcrifyita$ that (1) the on -site
owner and by a magtet plumber, jowrneYanatt P (it nece9"ary), the sevt+v hank. is
wastewater disposal sy ttem is in proper operating condition atndlot (2) after inspection and pumping
3 1W1 of stlul e.
less than 1/. 8 StP1n with the
9
1/we, the undersigned have read the above reyuirernottta wad. agree to WfAintstn the private Rewvage dixpt:sal Y esm
stariderdR set forth, herein, as set by the D of C add the UePat °t cif. e u n d to the St. Gro C'Omtty Pla s on'" &.
Cerfir e ltion stating tit your septic system has been maintaxt>ed rrr�st be completed and returned
w di y§ aL.„ �L,.ou {MA P7f1)lrAt1011 da
Zoning Depart within 3u QAys Ul wa = > t,• t - Lra
I/we certify that all statemeitts on this .form are Me tti tho best of my /owe knowledge. Uwe atr>lare the oancr(s} of rite
pro pe r ty dcsc dbed above, by virtWs of a warr'3ft deed recorded an Register of Deeds Office.
Number of bedtruoxnS . 3
n
...-- DATE
SIGNA A;�PLICAN'T(S)
permit l-evoked by the Planning & Zoning Aepari""t. * *"
*"'"'Any information that is m'isrepn*scnted rxta)'rc9ult in the seu�itar Y rm�it
include with I.Mq applicarirrn a rrs.orde� wnnarftY deed from the Reg
IAter of De
eds Office send a copy of the certifled earvey mall if
reference is made in the wurranty deed,
(RaF.V. 0$ 105)
. -' D9.n�7.Sti!l fi Sgi1•. .. _.,�... r7 SLATE RAR OF "WISCONSW PORN 3
,_. = axaaHrrr of
,s9¢ _ g 2la i� S¢'-zC'E RESEAVXo tall RiCogDr•' GAYS
3 5- 1-t3_nd and ri_G,'S,.le`J OFFICE _
_ -- _ - _.__._ . .p __.... _._..�... _- -.- �. y , C � -. : off •LS 1
' 3_.1�.x " - On� 3"
}
eEivav To
ate 8w98,nacw:? �. =s. - 7a�_ r�°sA : - axle ao. _._- -- -_ °- - - -- _ ° - - __. __ __ Q_•.�,n�.
St :s c f Fs ¢_cc stn
='�si L^'`L' the `+1- r,r tten1 , i 1/ :b v` th4 Narthr^^t 3arll �D:` -,ems _ion -
, knZ
Ct*,1e € s •_i: tat _ rt? @t i t cs - . - t+arset mLGr *er :x :.Sectis:n ', Tax Keg No..^
^a,aimshdp 2, ernnorr :1, Woo,= =w; tiv� pcivnr .t— h -e inning of the ogee? -herein described;
".ence s a rY , > c sl „•i cif ,aue Scoutn, a1long ',hu: Mrr%.h- .ScutR V4 line of sold Seetion
. p x� ?fitsm 0.; %n irory ::+i. t en° c* :i -zLv h .69 ; West, 150.00 ?eet: t* an iron pipe;
tle,e"Zo due '74 rth ;mot -,asp x - _ ai'd 1:'? %.ir>r. ?9C".5% Feet to the Worth line ei Section 3;
t:'ftence Mirm"t {ro ka!A =id N.rArth of Section 3, 150.00 Feet to the oolnt
c•r 4e"�itt<'t vtt nib 'a 2 _ the rt4att< - "y tea: Cownty Trunut Hirl'way . "AA" .alorts the North
TAde .•9' th'a aE ew- ��;� Tf19srt3 'arr:� b. (.antninir -. 3.00 acren.
ho srrarat:Lc•'� ctre the prt%rwrty pax coy encinf TAeitlh tie-z dale of JanaST7 tat"
1973-
FTEM
r5"a_ _z -mot _ t'o.:,t�xa
ry Z
Dul"v' thisi
(SEAL) .� -1 �1 //� �lC �'�i r �" (SEAL)
Go - rald N. Hopk ins
(SEAL) ' -� (SEAL)
AUTHENTICATION - ..rf ACKNOWLEDGMENT
Sigaat¢trers a¢ enticated thi •t ay of STATE OF WISCONSIN l
Auoustc_ e� '( ss.
County.
^ Personaliy came before me, this __ _ _ day of
t — F-bn 'a _i-le s =i oaen _ the above named
TITLE: i lEtl STATE BAR OF DiI5CONSI.N _ —
(lf Trot, -
authorized by ; 706.05, Wis. Stat3.)
This instrument was drafted by
John C . f1e ti ngen Attgt to me known to be the person_ who executed the fore-
Baldwin, fizca:nsin 54402 going instrument and acknowledged the same.
(Signatures may be authenticated or acknowl- riged. Both
are not necessary.) Notary Public County, Wis.
My Commission is permanent. (If not, state expiration
date: 19_.)
SAAR A:rTY OF:ED -SATE BAR OF 9-'SeGNSS`:, FORM NO, 2 -1672
Wisconsin Department of Co p A j OIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildin accordance with Comm 85, Wis. Adm. Code
_ County
Attach complete site plan on paper not less than 8 x 11 inches in size tt KK)' St. CTO1X
'h
Include but not limited to: vertical and horizontal reference point (BM), ire �� *l>rr^i Parcel I.D. 042 - 1004 -60 -000
Percent slope, scale or dimensions, north arrow, and BM referenced to
Date
Please print all information eviewed Da e
Personal information you urposes (Privacy Law, s. 15.04 (1) (m)) d
P M 1 0 wne* PropertyLocat krear Govt. Lot NE 'i< NW '/4 s 3_ T 29 N R 18 w/ 3 - 7 -6
Property Owner's Mailing Add n 1 Q Lot # lock # Subd. Name r CSM#
1249 County Rd. E AUG s 0 plc, ��- J, l / 2/ - see !q 7f
r State IN & M ING OFFICE ❑City p Road
age 0 Town Nearer Richmond - 46 -5275 Warren Co Rd E
O New Construction Use: 0 Residential / Number of Bedrooms Code derived design flow rate 450 GPD
0 Replacement 0 Public or Commercial — Describe:
Parent Material Loess over Till Flood Plain elevation if applicable N/A ft.
General comments and recommendations: Install system at 56" below surface to stay below the compacted sands observed in
horizon 5 of B -3. This allows 38 inches of separation from redox observed in B -2 at 94" below surface.
Vd
Boring
ETBo ring # 0 Pit Ground Surface Elevation 100.0 ft. Depth to Limiting factor >95 in.
Soil Awlication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eti#1 *EtT42
1 0 -10 10YR3/3 - SIL 2 -m -gr mfr gs 3f 0.6 0.8
2 10 -18 10YR3/3 - SIL 2 -m -bk mfr Cw 1f 0.6 0.8
3 18 -28 10YR4/4 - CL 2 -m -bk mfr Cw 1f 0.4 0.6
4 28-42 7.5YR4/4 - GRS 0 -sg ml Cw 1f 0.7 1.6
5 42 -95+ 10YR5/6 S -y2` GRS 0 -sg ml - if 0.7 1.6
5A 42 -95+ 10YR4/4 - S 0 -sg ml ab - 0.7 1.6
5A bands are not continuous
21 Boring # Boring
OPit Ground Surface Elevation 100.3 ft. Depth to Limiting factor 94" in.
Soil Oplication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft�
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'EtT#2
1 0 -8 10YR3/2 - SIL 2 -f -bk mfr gs 3f 0.6 0.8
2 8 -14 10YR3/2 - SIL 2 -f -pl mfr gw 1f 0.0 0.2
3 14-44 10YR4 /4 j(p Z CL 2 -m -bk mfr gw 1f 0.4 0.6
4 44-R4 - 7.5YR4/4 - GRS 0 -sg ml gw - 0.7 1.6
5 94 -100+ 10YR5/4 10YR416 f -1 -f S 0 -sg ml - - 0.7 1.6
' Effluent # I = BOD5 > 30!5 220 mg/L. and TSS > 30:5 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS _< 30 mg/L
CST Name (Please Print) S' CST Number
Mark Iverson 46672
Address Date Evaluation Conducted Telephone Number
P.O. Box 155 Hammond, WI 54015 August 5, 2010 715- 796 -5664
Property Owner R obert Krear Parcel lD# 042- 1004 -60 -000 page A of 3
0 Boring
Boring # ppit Ground Surface Elevation 99.0 ft. Depth to Limiting factor >98" in.
Soil ADDlication R ate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GpUffe
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 `Eff#2
1 0 -10 10YR3/2 - SIL 2 -f-gr mfr gs 3f 0.6 0.8
2 10 -17 10YR3/2 - SIL 1 -f -bk mfr gs 2f 0.4 0.6
3 17 -30 10YR3/3 - SIL 2 -co -bk mfr cs 1f 0.6 0.8
4 30-46 10YR4/4 - CL 2 -m -bk mfr cs if 0.4 0.6
R 0 -m mfr as - 0.7 1.6
5 46 50 7.5YR4/4 G S
6 50 -98+ 10YR4/4 - GRS 0 -sg MI - - 0.7 1.6
a Boring # 13 Boring
OPit Ground Surface Elevation ft. Depth to Limiting factor in.
Soil A ligtion Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
0 Boring
Boring #
EIPit Ground Surface Elevation ft. Depth to Limiting factor in.
S oil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 *EfW
' Effluent #1 = BOD > 30:5 220 mg/L and TSS > 30:5 150 mg/L " Effluent #2 = B013 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.
Page 3 of 3 0 ft. =fc. 40 ft. 80 ft.
I
Well
O
Clean out
House
BM#2 - Door plate
103.1'
Garage
C ollapsed septic tan_ k
c O
J
0 Existing vent pipe
0
a
BM#1 - Top of 3/4" PVC Pi B -1
100.0' 100.0
0
M
B-2 101'
100.3
100'
No sand in
boring. 4' of B-3
topsoil ove 99.0
clay loam
'�"-' U r nmX
Edge o f R 0
Ind E I'S on no r441 s .j-
BM# & Descrip = Bench Mark B -1
Elevation 100
Owner: Robert Krear Site Information:
1249 County Rd. E NE1 /4, NW1 /4, S3, T29N, R1f
New Richmond, WI 54017 Town of Warren
St. Croix County
Phone: 715 -246 -5245 �a 4vv
1h
0 CO) p 11 3 M c d �1
c c 3 r;
'I o eo C
4b ...
c \ 1
I c ,.-' p
cn 2 Z m z w 8 A O O l�1.
O W W A t,
O N
O
d d N (D
N f _ N N f�i = W C O
co
0 �• N (o
m cn D 0 o
(D (p y y a
� a 7 W 7
N N
rj 3 O
A C
� CL N a ! 1
co (D (o (D m li n r N
N m OD m 3 Q
000 C
N y ° o D
c m a
W
c
\o p CD 0
o a 7
I _0 m o
C/) N•
o ;
0 a 3 ,j
�• C (D (
13 5
O
_ (6 N
A Z n CD
(D (?
fu
m W o m °'
C A Z
0
w C ZZ co
(D y Z j <
(D A
I �
W
(D N a
°- (D n
C o.
C
n z CL
N �
N N
(D N
CD
CD
A �
77 1
o 7:
(O
0) ti
0 O
i
N
X o
N
0 b
CD ao
CD
di O
� N
b
° 0 i
n
c - /w
n N
R cu
o O
vN k
�3 n
mw
w O
CL C
7
7 O
O C s
0w `
o� ^
N Y7
F O
7 fD ic
N � �
N n
A
C s°
N
fD N
N -
OO
7
O
N
c
N
N
m '
0
V
n N
O N rF
O N
o O
O N x
N _
7 41
s o
7
' n C
La �
7 ^
y CCD Y
O V�
7 W ic
fD n
C
m
N N
O
7 �
N N
O"
W
C �+
y
' N
b
-71 •
'µ I 3
Part of the Northeast One Quarter (NE� of the Northwest One Quarter (NW- of
Section Three (3), Township Twenty -nine (29) North, Range Eighteen (18) West,
Warren Township, St. Croix County, Wisconsin, described in Volume 1
Certified Survey Maps on page 121 as Certified Survey No. 121 �^ i� q)
U
326685 e
SURVEYOR'S RECORD
State of Wisconsin) SS
St. Croix County ) ST. CROIX COUNTY
I, Lee F. Villeneuve, Registered Land Surveyor, hereby certify: that I have surveyed,
divided and mapped a part of the Northeast One Quarter (NE4) of the Northwest One
Quarter (NW4) of Section Three (3), Township Twenty-nine (29) North, Range Eighteen (18)
West described as follows:
Commencing at the North 1 corner of Section Three (3), Township Twenty -nine (29) North,
Range Eighteen (18) West for the point of beginning of the parcel here -in described;
thence on an assumed bearing of due South, along the North -South 1 line of said
Section Three (3) 290 .5 feet to an iron pipe;
thence South 89 29' West, 150.00 feet to an iron pipe;
thence due North, parallel to said 1/4 line, 290.5 feet to the North line of Section
Three (3);
thence North 89 29' East, along said North line of Section Three (3), 150.00 feet to
the point of beginning. r� o V .�6
Subject to the right -of -way of County Trunk Highwa "AA" along the North side of the
above described parcel. Containing 1.00 acres. Warren Township, St. Croix County,
Wisconsin.
N 1/4 COR.
SEC. 3
T 29N,R18W
NORTH LJNE - S.EC. 3 N 89 29'E
C.TT.H AA i _�0 150.00'
ti 8 \ P.O. B.
o d„ 'bq ,n
v
v
180000' 180000
PLAT BROS REF. TO THE
NORTH-SOUTH 1/4 LINE,SEC.3
T 29 N, R 18W, ASSM'D BRG. NORTH.
SCALE IN FEET
0
N N 60' 0 60
1.0 ACRES
UQ ui
O N D
Z 0
•- I" IRON PIPE
NORTH -SOUTH 1/4 LINE
SEC.3 �%% SGONS
32G688 y ft
0ti 4 1 , , i L E
0q 150.00' 8
S 89 29'W -
Q:1 F1 OV
LE D
A>R 3 1975 ♦ '•,� ' �'►
in 0. 'e,
C C Deada
Y,
Z [
Volume I Page 121 tumble
d
G. L. N. 4120175
326'685
I certify that I have made such survey, land division and plat by the direction of
Gerald Hopkins, that such plat is a correct representation of all exterior boundaries
of the land surveyed and the subdivision thereof maps, and that I have fully complied
with the provisions of Chapter 236 of the Wisconsin Statutes in surveying, dividing,
and mapping the same.
Surveyed November 15, 1972.
Certified Survey Map prepared April 20 ,' 1 975
r
Lee F. Villeneuve RLS 0984 g
Certified Survey No.
St. Croix County, Wisconsin `� �q6�', ro
LEE F. APR 301975
VILLENEUVE
In JAMES p, H
� CONMECC
.n
S•0984 ' RB9 ° � °f Oe
V MENOMONIE, :� `S�i Goix C oun t ),
• Wis Y
.� ;W I S. �� ti consin
n (A O 9 "a n r�
m 0 C7 `i1
C') v v N o O w w o
N O O C l O d N N *4 O
O C11 d 01 N O K'
CL cr
0 CD co
3 7 H N O C
c0 Z
CD N a F' 0
3 a
O o
CD �V
A
CD CO N O G
z 00
O 1�+1
m 3 N to o D
Q M v °
c cc
I r
m
CL Nz
°; DD O
O a
o m h•
� N
m co M
C m N
W C.
a 3
Z O
cc I —1 Co
w a Q
o
Z w
W M m N
a z
p » Z
m
I O A
m W D
as a
v o —
I
0 z a
N O
m m
N N
CD
f0
A vi
C
i O A
O
p N
N I O
O
X V
O
CD
7 A a Sn
M. CP .
ffm z pun %uprun)d .4wmJ aWll "'I
f
'Parcel #: 042 - 1004 -60 -000 01/02/2007 08:50 AM
PAGE 1 OF 1
Alt. Parcel #: 03.29.18.37B 042 - TOWN OF WARREN
Current ' X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
ROBERT &DIANE KREAR O - KREAR, ROBERT & DIANE
1249 HWY E
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description " 1249 CTY RD E
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 0.828 Plat: 0239 -CSM 01/121
SEC 3 T29N R18W IN NE NW COM N 1/4 COR, Block/Condo Bldg:
TH S 290.5 FT, W 150 FT, TH N 290.5 FT
TO N LN, TH E 150 FT TO POB BEING CSM Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
VOL 1/121 03- 29N -18W NE NW
Notes: Parcel History:
Date Doc # Vol /Page Type
07/23/1997 521/190
2006 SUMMARY Bill #: Fair Market Value: Assessed with:
148929 189,700
Valuations: Last Changed: 07/19/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.828 22,400 116,000 138,400 NO
Totals for 2006:
General Property 0.828 22,400 116,000 138,400
Woodland 0.000 0 0
Totals for 2005:
General Property 0.828 22,400 116,000 138,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 316
Specials:
User Special Code Category Amount
018 - RECYCLING SPECIAL ASSESSMENT 15.00
Special Assessments Special Charges Delinquent Charges
Total 15.00 0.00 0.00
AV
Windows 2000
Printer Test Page
Congratulations!
If you can read this information, you have correctly installed your HP Color LaserJet
8550 PCL 5C on STCRXGC.
The information below describes your printer driver and port settings.
Submitted Time: 2:52:26 PM 11/10/2006
Machine name: STCRXGC
Printer name: lj8550pl
Printer model: HP Color LaserJet 8550 PCL 5C
Color support: Yes
Port name(s): IP_172.17.129.153
Data format: RAW
Share name: lj8550pl
Location: P &Z
Comment: Color HP LJ 8550 PCL 5
Driver name: hpbf40lg.dll
Data file: hpbf40li.pmd
Config file: hpbf40le.dll
Help file: hpbf40le.hlp
Driver version: 0.24
Environment: Windows NT x86
Monitor: HP LaserJet 5 Language Monitor
Additional files used by this driver:
C: \WINNT \system32\ spool \DRIVERS \W32X86 \3 \hpbafd32.dl1 (4.8.0.4)
C: \WINNT \system32\ spool \DRIVERS \W32X86 \3 \hpbftm32.dll (0, 1, 0, 4)
C: \WINNT \system32\ spool \DRIVERS \W32X86 \3 \HPLJ8550.cfg
C: \WINNT \system32\ spool \DRIVERS \W32X86 \3 \hpcdmc32.dll (1, 0, 2, 29)
C: \WINNT \system32\ spool \DRIVERS \W32X86 \3 \hpbcfgre.dl1 (1, 0, 0, 36)
C: \WINNT \system32\ spool \DRIVERS \W32X86 \3 \hpdcmon.dll (04.20.00)
This is the end of the printer test page.
I
• AS BUILT SANIT SYSTEM REPORT
NER c6 4 y , TOWNSHIP ��,'fl 1 ^i SEC. - 72L N, R /(f W
.0. ADDRESS �1.G , ST. CROIX COUNTY, WISCONSIN. .
3DIVISION LOT LOT SIZE ,�jn %r
PLAN VIEW
Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
2L
3 '
• - f�L�•5 C-
'TIC TANK(S)_ _ MFGR. -�, /�, �� CONCRETE STEEt�
N0. of rings n cover / Depth r" 'l DRY WELL
NCHES NO. of width length area
D no. of lines -2 width length Ll area .
depth to top of Pipe 16`
3REGATE
tiK RATE 5 AREA REQUIRED /�� i7 ' AREA AS BUILT
I� claimer: The inspection of this system by St. Croix County does not imply complete
_ State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
,tem operation. However, if failure is noted the County will make every effort to
::ermine cause of failure.
"ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM°:
`'INSPECTOR
DATED ,�, ; / j J% PLUMBER ON 30B �S
LICENSE NUMBER - S
I
i
z
REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
San.itany Penm.it -
/ / State S ept.ic /�'QD 5
E
NAM <C �� Township l,c.lk�AA_ St. Croix County
Locaz.ion o6 Section_J_TZN,R W
SEPTIC TANK
Size gattonz. Number 15 Compartments
D.iztance From: Wett $t. 12% an greater ztope _ it
Building J 10 it. Wettandz
H.Lghwatea it.
DISPOSAL SYSTEM
t
Didance Fram: We2P �vl 12% an greater z 2ope b.
i Bu.itd.ing �- W ettandz Ft.
Highwater it.
FIELD DIMENSIONS:
W.i o6 tAench ; _ it. Dept aj Aock be.Cow t.ite ? — in.
ti Length of each tine it. Depth o6 rack oven t.ite i n.
Number, oS tinez Depth o6 tite below gnade n.
Totat tength ab tines /00 it. S.Lope o6 trench in pen 100 it.
Distance between tine.6 i t. Depth to bedrock it.
1 U Totat abd orbt,ion area Depth to groundwater
i_
y A Required area 5 it
2
PIT DIMENSIONS:
Numbers of p.it4 Gravet around p.itb yea no
t
Outzide d.iame� '% /6t. Depth betow .inlet
2
To tat yrbdonb �.c�n a4.lea it
z — I L f j v 2
Area ` cequ.ired it rn
INSPECTED BY -TITLE
APPROVED , = 19 7�.
REJECTED , DATE � 19 7
i
EH 115 .
! WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
P.O. BOX 309
MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
A
LOCATION: h�� %, P014, Section � , V*N, R Lf E (or) W, Township or Municipality V 14 i/" p h
Lot No. , Block No. W 4 // Z. 4 11 d!o k 1 4 County r�� �' \ x
Subdivision Name
Owner's Name: ifg h =
Mailing Address: G y 12:3
TYPE OF OCCUPANCY: Residence No. of Bedrooms Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS t RCOLATION TESTS L
SOIL MAP SHEET r �� /,� SOI L TYPE
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P-�
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST y (DEPTH TO BEDROCK IF OBSERVED)
B 72
— 6'
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suitable area . Indicate number ors– vare feet of abso area
needed for building type and occupancy. " �t-t a e ale
or distances. Give horizontal and vertical reference points. Indicate slope.
C
N
1
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 location of test holes are correct
to the best of my knowledge and belief.
Name (print) Ae. /
Af �/ h S Certification No. � 3 l y
Address �Z. Al e , i I �
Name of installer if known
CST Signature
l
COPY A —LOCAL AUTHORITY
State and County State Permit # /
PLB67 Permit Application County Per i -
for Private Domestic Sewage Systems County
* DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY 1 Mailing Address:
/ e- .- P Z' VV /S
B. LOCATION: NF ' M tip /4, Section —, T_A2 N, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township Vleozr r �.
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms 3 No. of Persons
D. TYPE OF APPLIANCES: Dishwasher !/ Y - ES NO Food Waste Grinder YES I- N # of Bathrooms
Automatic Washer L-I NO Other (specify)
E. SEPTIC TANK CAPACITY 1pZ-V Total gallons No. of tanks t-►-�
*Holding tank capacity Total gallons No. of tanks
New Installation �� Addition Replacement _ Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) / �;-- 2) C 3) ? �; , _ Total Absorb Area sq. ft.
New t- Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length �;A.' Width /;L' Depth .,7G ^ Tile Depth 2 y No. of Lines "
Seepage Pit: Inside diameter Liquid Depth Tile Size y
Percent slope of land _4" 04 Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Certif* d Soil Tester, /
NAME / c, It 9 �z' D .�9� ih _S _ C.S.T. # / `l, / �/ and other information
obtained from (owner/builder).
Plumber's Sig nature y(f Rag IriA /IP /MPRSW# �P � 2 Phone # J-q 6 - �9
Plumber's Address
lG t lstp + f S
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
ell
�>
Do Not Write in Space Below FOR DEPARTMENT USE ONLY
Date of Application Fees Paid: State 10.00 ou Date
Permit Issued /Rejected (date) _ Issuing Agent Name
Inspection Yes No Valid# Date Recd
1. county (vpite copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/11/76
Part of the Northeast One Quarter (NEJ) of the Northwest One Quarter (NWJ) of
Section Three (3), Township Twenty -nine (29) North, Range Eighteen (18) West,
Warren Township, St. Croix County, Wisconsin, described in Volume I of
Certified Survey Maps on page 121 as Certified Survey No. 127
32GG8 1,.
I
State of Wisconsin SS
t r
St. Croix Coun � S . CROIX COUNTY
SURVEYORS RECORD
I, Lee F. Villeneuve, Registered Land Surveyor, hereby certify: that I have surveyed,
part of the Northeast One Quarter NEB
divided and mapped a r 4, ( 4) of the Northwest One
pp p _ n 18 )
North Range Eighteen Three Township Twenty-nine 29 , ng g (
Q uarter N4T-� of Section 3 � p Y ( )
Q ()
( 4)
West described as follows:
Commencing at the North 1/4 corner of Section Three (3), Township Twenty -nine (29) North,
Range Eighteen (18) West for the point of beginning of the parcel here -in described;
thence on an assumed bearing of due South, along the North -South 1/4 line of said
Section Three (3) 290.5 feet to an iron pipe;
thence South 89 29' West, 150.00 feet to an iron pipe;
thence due North, parallel to said 1/4 line, 290.5 feet to the North line of Section
Three (3);
thence North 89 29' East, along said North line of Section Three (3), 150.00 feet to
the point of beginning.
Subject to the right -of -way of County Trunk Highway "AA" along the North side of the
above described parcel. Containing 1.00 acres. Warren Township, St. Croix County,
Wisconsin.
N 1/4 COR.
SEC. 3
T 29N,RISW
NORTH LINE- SEC. 3 N 89 29'E
C.T.H. "AA" i A� 150.00' tiAg P.O.B.
d� a/' 40
180 180
t PLAT BRCS REF. TO THE
NORTH-SOUTH 1/4 LINE,SEC.3
T 29 N, R ISW, ASSM'D BRO. NORTH.
`.) ',� SCALE IN FEET
0
m o
N N
60' 0 60'
1.0 ACRES
_ tp
_ U ' v
Cr N
O
Z O
*-I" IRON PIPE
NORTH -SOUTH 1/4 LINE
SEC. 3 C
5
3 2 E f "'1
t
m� 150.00' N
S 89 29'W
co F1 FD �° ° ." ! e
.
♦� .' Qw
APR 301975 '�ti ..,,�•� y, �.
10 -IA& 0! CONNELt
holster of Dead, �Itf s ItR��
Sh Dots C I "
Wisconsi
� z
Volume I Page 121 tumble
Cb
G. L. N. 4120175
o ao c
�s n to °
L C X +E M
cc
O N N CL C O
N
L o -6 O Em
o (D a )
E
E c m E
c c
c
v(D u`) ° o
O
ctv c
3: 0 -
o - dm
Y 8tu a `o
N � to ti
U) N O O a
O O Y :3 0 0 V! T m
z iT C m y y Z V — V
"'
Y
LL c c LO 0- LL c N C) m
o v ce a) •N o m
3 coN oar
�o oU U) 4)
E a m :3 .0 co rn
CL
I I
M M
d N
fn Z N
E >
Z o :: o
v
v x € v
rn w a m c a m
M H z
0
c C7 —
O z
o w
N Z N c Co 2 c
E Lm c E
o N d m v d
' 0 0 l4 N m 7
Q' N .` ta ta
O
• O N C N N N N
O
O Z S Z Z m Z
LO
N
_ E _ Cl)
a E a q � I E a m
0 o a ` a a E `-' ro r o a` a
IIzOO� acn
I
•►v �aaa I�
�i a o Q o
(V 2' O y co 0) Q' N
1� 7 O V� I- n y 1
N J U C 0 2 Z w rn rn
C N 0 a .O p
O p Z 0 O g w. 0 N
U p U O N N
O •� °O 'iJ tT O O .� a N O
O O O N
m c N m N to co
� N � p
C d a A C m
d O Q Y' Cn
�j IA E M C �
IV + p O ad O 'O atS O E
O O m 3 y N c N O O O V a 0 0 0
' O O Q C 'e C Cc Co
V O p c6 ~ C 7 y O C m Co C a f� O
w ° n to C7 d ,O o `O ao
FBI N m 0 .d+ 7 E° m 0 2 7 § 0 C L
N m N M O to m 0 y 0 a O rn m m m U
• N ' o Cl) Y v o z �' a Z Y c r ° Cl) Z
U �
L L a L a
E ` 3� 3 .9 O 1 320
r A C)(L 0 0) 0 0 m U