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HomeMy WebLinkAbout042-1058-80-000 o 3M0 d fD I c .. C 1 � ( D m ° m � CD •o � • v at c C' M \ 1 A W _ n D . ( O (A O O N O O x N O O� CO p l y I A `C • I C o m CD y ° Z a y �' m ! m co c ^ I N N CD m Dc ch I y v y CO 0° OD 0 Q = (D C CD f I 7 f�D C j O O K O O fn \ m D� aaa,'I CD m a W 1 = CL I ° m I a N N j co co C) 0 y W W I y CD 00 00 W W y w c !r -4 3 Q 1 000 I OOO Y �• o z O I o (D g Ch C4 CA CD CD cr ig I m I 2 m ! a CL o 1 D a l w 1 D CD 0 0 v O O o CD � � m @ • 1 CD y 1 1 a y v c '. V q C m c m CD a z m m Z w I y a n A O 7 0 1 Z N 1 m 0 1 0 m � m CL r g z ° o I ° o z OD y z m v I CD W I �000 n m I m »o a w CD CD a 3 am a a I ? o o $ o (p °� z a 1 �x ?ce. z n m ° o X X0, 0 a Cv y I v W- w ((D y 0 Qw ogm y m CLx WZv m m m'o N° om a 3 � 3 c �CD 5i ? Ca o o z X 0 .Z m I m CD o ' EL o I m CD o N I o'o I o y ° o 0 o a v I I y a I o o I o b I ( D I m o 0 I o 0 v Parcel #: 042 - 1058 -80 -000 01/19/2007 09:20 AM PAGE 1OF1 Alt. Parcel M 21.29.18.324C 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 RICHARD A & DEANNA C AHL O - AHL, RICHARD A & DEANNA C 1177 HWY 12 ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 1177 HWY 12 SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 38.000 Plat: N/A -NOT AVAILABLE SEC 21 T29N R18W PT OF THE E1/2 NE 1/4 Block/Condo Bldg: DESC AS COM N1/4 COR SEC 21; TH S 88 DEG E 1332.99' TO POB; TH CONT S 88 DEG E Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 634.56'; TH S 00 DEG E 1350.77'; TH N 89 21- 29N -18W DEG E 161.71'; TH S 01 DEG W 1033.61'; TH N 88 DEG W 756.89'; TH N 00 DEG W more... Notes: Parcel History: Date Doc # Vol /Page Type 07/03/2003 728848 2302/201 WD 1008/87 WD 485/623 2006 SUMMARY Bill M Fair Market Value: Assessed with: 149479 Use Value Assessment Valuations: Last Changed: 07/11/2003 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 14.000 112,000 138,600 250,600 NO AGRICULTURAL G4 24.000 3,400 0 3,400 NO Totals for 2006: General Property 38.000 115,400 138,600 254,000 Woodland 0.000 0 0 Totals for 2005: General Property 38.000 115,400 138,600 254,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: 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 ,--- _ AS BUILT SANITARY SYSTEM REPORT OWNER C/� �. `" TOWNSHIP SEC.-;?j T, -- ADDRESS f ; ST. CROIX COUNTY, WISCONSIN. SUBDIVISION /- -,--� -- -- L O T S TZ` -- PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I di at N r h krraw BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: Slope at site: %dam SEPTIC TANK: Manufacturer: &L 2 r4iquid Capacity:�� Number of rings on cover Al e - Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: A Number of gallons Number of gal. pump a fo cycle gallons; Total capacity of distribution lines g llon: size of pump head; gallon per minute horsepower ;brand name of pump and model number Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole co ; Type of warning device SEEPAGE PIT SIZE; Number of pits feet diameter feet liquid depth seepage pit inlet pipe - elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines width depth SEEPAGE TRENCH: width_ length PERCOLATION RAT , AREA REQUIRED AREA AS BUILT INSPECTOR DATED PLUMBER ON JOB LICENSE NUMBER 2 10EPART01ENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON; WI 53707 13 CONVENTIONAL ❑ALTERNATIVE I State Plan I.D. Number: Ilf ❑ Holding Tank El In-Ground Pressure ❑ Mound assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECT( N A E� 7 Douglas Rode Roberts, WI g �s 83 •— � BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. P . ELEV.: CST REF. PT. ELEV.: NE NE, Sec. 21, T29N —R18W, Town of Warren Name of Plumber: MP /MPRSW No. - . C: Sanitary Permit Number: Henry Nechville 3258 St. Croix 38464 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: l I t ANk ' OUTLETELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED v� 'v DYES ONO DYES ONO BEDDING: VENT J V TMA L: JHIGH WATER NUM PROPERTY WELL: BER OF ROAD: BUILDING: VENTT ESH ALARM: FEET FROM LINE 7 lAI ❑YES ❑NO ❑YES ❑NO NEAREST [// DOSING CHAMBER: MANUFACTURER: BEDDING: 11-1011111 C= MODEL. J PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ONO ❑YES ONO OYES ONO GALLONS PER CYCLE: uMPA CL: OPERATIONAL WUMBER OF PROPERTY WELL BUILDING: V NT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH . LENGTH: NO. OF DISTR. PIPE SPACING: COPE INSIDE DIA. -. #PITS. LIQUID SEO /TRENCH ) TRENCHES MA RIAL: PIT DEPTH — DIMENSIONS GRAVEL DEPT FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE ERIAL: NO. R NUMBER OF - PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABOV OVER: ELEV. INLET E PIP LINE: AIR INLET: FEET FROM NEAREST' --- �--sl• MOUNDS Mound site plowed perpendicular to slope Check the text of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound sys make certain that it ON REVERSE SIDE. SHOW ELEVA- meets th c eri for rw4ium sand. TIONS MEASURED. DYES ONO SOIL COVER TEXTURE AMAN ARKERS: 08SERVATION WELLS ❑NO OYES NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED J OE O TOP D SEEDED MULCHED: CENTER: EDGES: ❑YES ONO I DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: elsfx� RENII WIDTH LENGTH: TRENCHES LATERAL SPACI G G NRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER #�14frcNS #DNS MANIFOLD PUMP MANIFOLD DISTR. PIPE M IFOLD M RIAL: N0. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV: PIPES. DIA. ELEiI'ATION AND twoRBATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY VERTICAL LIFT CORRESPONDS TO APPROVED . CO ATERIAL: FNFORMATIt?N PLANS. ❑YES O OYES ONO —] COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMSERe��a.� I PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ONO OYES ONO NE Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TIT LE. DILHR SBD 6710 (R. 01/82) ` DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than BY x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address:' 0 0 u. L 0. o lQ ©�1 E' r�s (� .5 S - mom. Property Location: City, Village o wnshi County: AIE '/4 %aS iT 99 NiR 13 E (or Ltd k - H r - Al fpm ' JC Lot Nu bar: Blk N Subdivision Na e: Nearest Road, Lake or Landmark: State Plan I.D. Number- V (If assigned) TYPE OF BUILDING J Number of El Public El Variance ❑Other (specify) n(j', /�J , Q�p7" �Q —�- rQ('}U' Bedrooms: qT or 2 Family * State Approval Required. TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGL NEW REPLACE- OTHER ASS I GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY J000 S © — ICS HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: f,,(,9 P— E X S C m N C `• �7`�S_ c� L S EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑_ Seepage Pit �, El Alternative (specify) ❑ Seepage Trench Water Su ply: Owner's Name as Listed on Soil Test Rod (if other than present owner): Private ❑Joint ❑Public D o v a s /1 ©GC � 1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of �I of Plumber: Signatur MP/ SW : Phone Number: // /r c � v g ar 2 (7 1S - ) 7y9 -33%2 Plumbe 's Addr s: 17 Name of Designer: COUNTY /DEPARTMENT USE ONLY Signat of Issuing Agent: F / e: Date: p Sanitary Permit Number: !oO C G G �a�'�3 ❑ SAPPROVED 3 �a Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod - Plumber DILHR -SBD -6398 (R.07/89) --, `� � .'. ,, ��� _ f v ;. ,, ,� ..... _ ... ' ' ... -.. __ ..... _ .. c� ... .... .. 1;. ,,< .. _ y � .� t "... .,, y _ .. __.. .. .. .. .... _._ � 1 ''d ,... ,,1 � — � .. 1' �. -:`. r Form - S T C 100 Owner of Property S 4 � 7 , ^ ���� Location of Property 1 4 / E Section 21 ,T�_N R Township Mailing Address �T O��rf�,`S Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel -� Date Parcel was Create J r, tV F R — /9 72 Are all corners identifiable? t , -' Yes No Include with this application one of the following .Certified Survey Map Deed .Land Contract, or .Other I:egal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. ©9 3 ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an casement, to run with the above described property, for the construction of said system, and the some has been duly recorded in the Office Zof County Register of Deeds, as Document No. ). SIGNA E Df DWNER L SIGNA RE OF CO -OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED V ; NAi:ItJ L'' l,LIiAL 1'UNM CO. A NTY A=II. STATE OF 'WYSCONSIN -- FORM Iyo. } _ Lz 3 (IL Long Descriptlon Space) Section 236.16, Wisconaia Statutes M ade this..... 8t h........... day of. ... ......... June , A. D., 197 ?.., ' ' r Tpm,, ,_,__ ake •• Rq..Verla - _R. Baker husband and wife, ..... as joint tenants and y ........................................... Bach in his or her own right partes.._...of the fast part, and ... ,. ........................ . ... a •... h ... .. _._......__............... a _,_ Rode and,Fay_F Rode ,husband and wife, as joint tenants ....... ..... ...... ­ v ........................ ............ a , .. ..................• ......... , •.........•........... .............• .. .............:: ..._..........I................ _part. ies .....of the second part, ' W i t n e a a e t h That the said part.. 9. e.....of the first part, for and in consideration of the sum of Q.11Ar ... and..Qt leer ..g4Qd1.AAd... ..... ........... w ............ ......in hand paid by the said partigg ....... of the second part, the receipt whereof is hereby confessed 'towledged, ha..xe .... given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and presents do give, grant, bargain, sell, remise, release, alien, convey and confirm unp the said parties ...... p """second part, .their ......... ...heirs and assigns forever, the following described real estate, situated in the pj , .... .....St, .... Croix..........., .and State of Wisconsin, to - wit: ' 9ast one -half of the Northeast Quarter (E+ of NE4) of Section 21, T29N, R18W, LOT TO e and rights of way for highway and other purposes of record, and TING the South three rods thereof and FURTHER EXCEPTING that part thereof lying 4 Orly of the Chicago, St. Paul, Minneapolis and Omaha Railway Company right - of - way PPRTHER EXCEPTING lands previously conveyed to St. Croix County for highway purposes #;pranty Deed recorded May 4, 1966 in volume 423, page'20 as document no. 284224 4e office of Register of Deeds for St. Croix County, FURTHER EXCEPTING the following g Commencin at the Northeast corner of Section 21 thence along the sped parcel; dan ;line of S.T.H. 65 on a true bearing of S 0 14' W, 1331.7 feet; thence N 89 46' W, '. dept to a 1" iron pipe located on the Westerly right -of -way of S.T.H. 6 This I ;) the ,point of beginning of this survey. Continuing N 89 46 W, 495.0 feet to a orl'pipe. TheacQ_S 1 41 W, 1033 feet to a 1" iron pipe. Thence S 88 13' E, t feet to a 1" iron pipe located on the Westerly right -of -way of S.T.H. 65. Thence 1, 28 1 E along said right -of -way 28.7 feet to a 1" iron pipe. Thence following the xly Tight -of -way on a 0 301 curve left, N 2 28' W, chord distance of 890.0 feet ! iron p ipe. Thence N 0 141 W, along said right -of -way, 128.7 feet to a 1 , ipa,aAd the poiAt- be inning of this survey. t .° , ooaaiste q _56, ores more or leas. I f � TRANSFER 1. rK � V . �I , FEE s �( *, I I f 1, ,1 T ogether with all and singular the hereditaments and appurtenances thereunto belonging or in any wise a3�ning; and all the estate, right, title, interest, claim or demand whatsoever, of the said part ...ies....... of the either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and er , -ditaments and appurtenances. A Have and to Hold the said premises as above described with the hereditaments and appurtenances, unto of the second part, and to ... ths_ir ........... heirs and assigns FOREVER. fl „ p } ANTY 11JA D STATIC OF WMOCONSIN' I�Qjt� op�� }IY�n Space) (OVER) 4 - 11344A �, � ; l 4 �.�. r >>� �, ; i - ��._ � •� r '�. �, ,,_ „ . S „ ,' ,; 't �� � - . _ ��,� �� ;. ���, '' � �b _ _ _ ' '� �.�'3 .,. - �' i ... - <,i ,` _ _ ... � i �� � 1' -• ,,� ' ' , - .,. _�.{ .. � ,. � .r _. .. _,� 4 Ro 485 tlt-16i24 - _. his wsfe�s Tom L. Baker and Ver1s. R Baker, =a Ahct t he i3;id..... ..:........ .. _ ... - .......,. ................ ...... .. ......... . ..... ........ for., •heir heirs, exece3tars and administrators, do..:... ..covenant, grant, bargain, an to and with the said part.ies . ..... of the second part, `t he! i Z ....... heirs and assigns, that at the tine of the ensl l " and delivery of these presents. ..they...are. +dell seized of the premises above described, es of a good,, perfect, absolute and indefeasible estate of inheritance in the law, in fee simpie, and that the same are"ree and clear }_ all. incumbrances whatever,....... ;.. g ....:.................. ............. ........ -.... .......... ,- ............. a and that the above bargained premises in the quiet and peaceable possession of the said part ies of the part, ...... theix -- . .... ...heirs and assigns, against all and every person or persons lawfully claiming the whole or any" thereof, ..they.. ........ :..will forever WARRANT AND DEFEND. r �l { In Witness Whereof, the said part zes...... of the First part have .. reuhto set ... their _..hand -.r. dnd 5 ', ....... day of...--& ......... .......... ....., , 1972...... Tom L. Baker SIGNED AND ALED IN PRESENCE or Y Alex S. Kos .+...... ...................... ............ Ver R. Ba er ...:........ . . .. ......... "RA- .. .. . . 17� ene, :.Rueoke _ . ............................... ....... f, State of Wisconsin, St. Croix 8th June ........ t County. Personally came before me, this...... ..........day of ............ ... : , A b , the above named Tom- .L..- Baker..- and..Vlerla. R.... Baker ,..his...vife .................. .. to me known to be the persons . who executed the foregoing inst nd acknowle ed the same. THIS IN WAS gRAP• sr_A1 Pub ii c, St ...::. Coun �.. Croix TLD 8Y NOTARY 11 1 Afl ;1 n � tary . .... ty� o . Eft Law My commission *#k r.. J .' alr S i) of the Wiuonsln Stauues provides that all instrvmtnts to he recorded shall have plainly printed or typewritten thereon a �q o 4q grantors grantees, witnesses and notary. Section5 °.513 similarly requires that the name of the pe rutn who, or govern -fia hich, drafted such instrument. shall he printed, typewritten, stamped or written thereon in a legible manner). . �.' i � � J ,+o o 43l 01 41 c w a rom w o e E ° E?r art to ' O` ° m Q O " v (� va c, Cn , a O �v 0 �i o !D Cry �ts9�s� o O F V , , t ? , C 1 N i 1 H CO M b to 4 ; v t i .J Z . C , w yy n u o ;' CL Fa LL ai oc> , DEPARTMENT OF REPORT ON SOIL BORINGS AND pIV . SAFETY & BUl1_ ISI !V(7t1STRY, BORINGS LABOR N RELATIONS ! f4U AND' PERCOLATION TESTS (115 MADISON W) 53707 } {UN1A (H63.05(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP! Y: O NAME: I . 1 4� 1 21 /T N/R i a l', COUNTY: OWNER { 'S N A E: MAILIN t ADORESS: ST. f'� t� 2.� o C3ltr'a -T 'v \.l 54 USE DATES OBSERVATIONS MADE NO. BEDR COMMER L DES RIPTION: ! RO CIS 7N. N TResidence A New ❑Replace � 24 5, R S- Site suitable for system Ua Site unsuitable for system ONVENTi NAIi 1,IOUNO: IN GAOUNaPRES�URE: S STEM -IN -FILL OLDWG TANK: RECOMMENDED SYSTEM:loptiunal) rMS [DU �ZS ❑U L]S CCU . I1ZS ❑U ❑S �U car�v�r.l; $�� ((Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the A + under s.Hfi3.09(5)(b), indicate: C C- •�; Woodp i n d ica t e Fl eleva 1 V PROFILE .OESCR )PTIONS BORING TOTAL ELEVATION P H TO R UNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH I'A"ER OEPTH - W 8S VED L TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) p, -ii 5 , )3L L. t. 5' F3 5 � w Gtr;• 5 00' 8+4 M ap w � �j �} O. - 3L L• 0. C) '5' S r.l ${ w aR. (o•SO 5 >e? D �- G,J °1 L1 0 . o' f3 L L 1.4-o' &..+ S i W G,R- ; 0. a Ai S L 8 - 77.9 w -m• m ` 5 w /.4o BL 1-; C),90' 8N S; L w /Uz; 57,60' 3AJ S-- / 0 9 t >8./ M E D l• l 0' 13 L L 1.3d' 13r..t S; w (:; m.� 0, "'rO' P - ra P -1 12)9,3cd M10-21 " s P - 3 DRIZIMAk- PERCOLAtION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER L V L- INCHES RATE MINUTE fA)MBEfl INSI 1ES AFTER SIPIELLIN INTERVAL -MIN. PFRIOBT PERIQ02 PERIGO 3 PER INCH P. ! `;• of -Z '3 3 P- RI P- , P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- mntal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. / y G� C , P t o tT H i N �3 t (r'„ Z t 6 F3 3 , BI . SYSTEM .ELEVATION U.S. 4\0v *12 " ❑ e-M t- sT Ae - VON N Ito I tit 41 Y +Z O If►ft - - - d' SITE 2>p tai` k I + 10H 5' v P-t M i i . ► w the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin -administrative Code, and that the data recorded and the location of the tests are correct to the best of my knov.ledge and belief.- i 4AME (print y'. TESTS WERE COMPLETED ON: i AODRES : I CERTIFICATICfN NUMBER: PHONE NUMSER(optional): a N r,> -S I 60 1 . C SIGNATURE' i )!STRIBUTION: Oriq+nal anr• nn- ^opy to 1 nr:at Auth nity, Propel ty Owner and Soii Tester. a 1 7 M a' VI 3 d � Q�� q t , o L t i� � t I ~ y � - C a n - i -- �w�t $ u w 4' W A UA cQ � 1 ` J i I I I r I I II 1- I 4 I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: ► 420771 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)]. I # 2 =.7' Permit Holder's Name: city Village X Township Parcel Tax No: Bobtown Barn Inc, Chris Germaine I Warren Township 042 - 1058 -80 -000 CST BM Elev: Insp. BM Elev: BM Description: Sectionlrown/Range/Map No: W.�' tOro -a (ctn,p� 21.29.18.324C TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic — Benchmark 6t SEAL vv� ,L3 Dosing � k s l Alt. BM S.T. Aeration Bldg. Sewer Holding St/Ht inlet s bj TANK SET ACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic > / UD ( �o ' Dt Bottom Dosing / 1 Header /Man. Aeration C / Dist. Pipe C00 Lao Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Numb TDH Lift 1 n Loss System Head TDH Ft Forcemai Length IDia. SOIL AB ORPTION SYSTEM BEDITRENCH Width Lent o. Of Trenches PIT DIMENSION Of Pits Inside Dia. Liquid Depth ENSIONS SETBACK SYSTEM TO P L BLDG TREAM LEACH G Manufacturer: INFORMATION CHAMBE OR Type Of System: UNI Model Number: DISTRIBUTION SYSI EM Header /Manifold istributio x Hole Size x Hole Spacing Vent to Air Intake Pi s) Length Dia Leng Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded T Mulched Bed/Trench Center Bed/Trench Edges Topsoil :- Yes % - ° No „ Yes No I-, COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: oa73 Inspection #2: 7 Location: Location: 1177 Hwy 12 Roberts, WI 54023 (NE 1/4 NE 114 21 T29N R18W) NA Lot Parcel No: 21.29.18.3240 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = - � — --- —� -- - — -- — -- Plan revision Required. aj Yes �No t � Use other side for additional information, SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. Safet y and Buildin gs Division County \ V i W 201 W. Washington Ave., P.O. Box 7162 � 0 sconsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 08) 266 -3151 TL0 :i qq Sanitary Permit Application State Plan I.D. In accord with Comm 83.21, Wis. Adm. Code, personal information you provide �2 1 o � "T�bKC. A* may be used for secondary purposes Privacy Law, s15.04(1)(m) (if different than mailing addres I. Application Information - Please Print All Information Property Owner's Na me Parcel // Lot # Block # Bob-�owir) V3o-rn - Enc., L {. � Property Owner's M ailing Address Property Location tk-t-T la - a1 ly ',4, !N � 14,Section City, State Zip Code Phone Number 0�+( wT I 5y oa - 5 - - 745 — �✓Ot -1 (circle e) II. Type of Building (check all that apply) T a� ❑ 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Number ^s _ �1 �^ �( ) Public /Commercial -Describe Use - TW o ►x6 Y �/� ",,� JO m I TV> t, , (3 i4f, TCC Ck II 11 State Owned - Describe Use 5{'Ol ❑City ❑Village`�Township of W III. Type of Permit: (Check only one box on line A. om lete line B if a2glic le) Ll Z — I QSJ f3tIL`� , 3L C A ' ❑ New System ❑ Replacement System Treatment/Holding Tank Replaceme l h 12C s k B. El Permit Renewal ❑Permit Revision E) Change of ❑Permit Transfer List revious Permi Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: (Check all that apply) ❑ Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 6 0 9.3 3v 1 7 f. �o VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Galion Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank ' erbbi tAtc' �At.l m e VII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) is t MP.44PRS Business Phone Number 7/5- 615V II Plumber's Addre ss (Street, City, State, Zip Code) LJ N ? 30 gy sw , 3 VIII. Cou Use Onl K Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is u' g Agent Signature N Stamps) Surcharge Fee) /� 0 %_ ❑Owner Given Reason for Denial IX. Conditions of Approval/Reasons � for Disapproval W l t4aw A Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) Av N F S.tl T qN C outdoor ar ena t I U --- � feed 90 arkin P 9 i store <�o� field S ev a�n d{ well v lean to r arena indoor OU . �7 g pen round parkin 1__,. `50 177 H . 0 ac wl 634.56RIV� Bob Town Barn -Feed Store Site Plan 1" = 100' �n V Safety and Buildings 4003 N KINNEY COULEE RD , A LA CROSSE WI 54601 -1831 \ViTDD #: (608) 264 -8777 sconsn www.commerce.state.wi.us/sb Department of Commerce www.vAsconsin.gov Scott McCallum, Governor Philip Edw. Albert, Secretary April 26, 2002 CUST ID No.225451 A7TN: POW7S Inspector PAUL C J STEINER ZONING OFFICE STEINER PLUMBING & HEATING ST CROIX COUNTY SPIA N8230 945TH ST 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 04/26/2004 Identification Numbers Transaction ID No. 729907 SITE: Site ID No. 643846 Bobtown Barns Feed Store Please refer to both identification numbers, Town of Warren above, in all correspondence with the agency. St Croix County NE 1/4, NE 1/4, S21, T29N, RI8W FOR: Description: Non - Pressurized In- Ground System Septic Tank Installation - Commercial/Public 427 gpd Object Type: POWT System Regulated Object ID No.: 849040 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: General Plan Approval Requirements: • The soil boring data gathered on 4/8/02 must be given to the county inspector for review to verify that there is at least three feet of suitable soil between the system elevation and the limiting condition of bedrock or estimated high groundwater. If there is not enough distance, then corrective measures must be taken to ensure that the system will be code compliant before continued use. This may include a need to abandon the system and investigate the area to find a replacement area. • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. • Comm 83.22(7) - 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. Owner Responsibilities: • Comm 83.52(1)(a) - The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) - A POWTS that is riot maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. P.o.W.T.s. CondihOually PAUL C J STEINER Page 2 4126102 • The owner is responsible for submitting a maintenance verification report per Comm 83.55, that is acceptable to P g P p F the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 ed M. Swim POWTS Plan Reviewer - Integrated Services (608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm WiSMART code: 7633 jswim@commerce.state.wi.us cc: Leroy G Jansky, , Wastewater Specialist, (715) 726 -2544 CONVENTIONAL SYSTEM FOR BOB TOWN BARN -FEED STORE AND APT. CHRIS GERMAIN 1177 HWY 12 ��� ROBERTS, WI 54023 �� PAGE ONE - CALCULATIONS 40 /p PAGE TWO -PLOT PLAN ' CALCULATIONS FOR SEPTIC SYSTEM SIZING FOR TWO BEDROOM HOME AND FEED STORE DRAINFIELD GRAVITY BED SIZING PUBLIC, 100 GAL /BEDROOM/DAY X 2 BEDROOMS 200 GAL EMPLOYEES, 13 GAL /EMPLOYEE X 2 26 GAL CUSTOMER 2500SQFT SALES FLOOR AREA X 70% _ 1750 DIVIDED BY 30SQFT /CUSTOMER= 58.34 CUSTOMERS X I GAL /CUSTOMER 58.34 ESTIMATED FLOW RATE /DAY 284.35 MULTIPLY BY 150% TO GET DESIGN FLOW RATE X 1.5 DESIGN FLOW RATE 426.51 SOIL INFILTRATION RATE .7 DIVIDED BY 426.51 D.F.R. = 609.30SQFT WE WILL USE BED 12 X 52- 630SQFT SEPTIC TANK DESIGN FLOW RATE 609.30 X 2.088= 1272.22 PREPARE D BY PAUL C.J. STEINER STEINER PLUMBING AND ELECTRIC N8230 945TH STREET RIVER FALLS, WI 54022 715- 425 -5544 MASTER PLUMBER6P C 225451 DATE Safety and Buildings 4003 N KINNEY COULEE RD LACROSSE WI 54601 -1831 [ ECEIVED TDD #: (608} 264 -8777 ,scons/n www.commerce ns ov www.wisconsin.gov Department of Commerce `� 6 2002 Scott McCallum, Governor Philip Edw. Albert, Secretary CROIX COUNTY ONfNG OFFICE II I April 26, 2002 CUST ID No.225451 ATTN: POWTS Inspector PAUL C J STEINER ZONING OFFICE STEINER PLUMBING &HEATING ST CROIX COUNTY SPIA N8230 945TH ST 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 CONDITIONAL APPROVAL i PLAN APPROVAL EXPIRES: 04/26/2004 Identification Numbers ii Transaction ID No. 729907 SITE: Site ID No. 643846 Bobtown Barns Feed Store Please refer to both identification numbers, Town of Warren above, in all correspondence with the agency. St Croix County NE 1/4, NE 1/4, S21, T29N, RI 8W FOR: Description: Non - Pressurized In- Ground System Septic Tank Installation - Commercial/Public 427 gpd Object Type: POWT System Regulated Object ID No.: 849040 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: General Plan Approval Requirements: • The soil boring data gathered on 4/8/02 must be given to the county inspector for review to verify that there is soil between the system elevation and the limiting at least three feet of suitable g condition of bedrock or Y estimated high groundwater. If there is not enough distance, then corrective measures must be taken to ensure that the system will be code compliant before continued use. This may include a need to abandon the system and investigate the area to find a replacement area. I • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. II � • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with I I' the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats. I • Comm 83.22(7) - 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. Owner Responsibilities: • Comm 83.52(1)(a) - The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. PAUL C J STEINER Page 2 4/26/02 • The owner is responsible for submitting a maintenance verification report per Comm 83.55, that is acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Gerard M. Swim POWTS Plan Reviewer - Integrated Services (608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm WiSMART code: 7633 j swim @commerce. state. wi. us cc: Leroy G Jansky, , Wastewater Specialist, (715) 726 -2544 { Wisconsir fiepartmentofComr erce RECEIVED s IL EVALUATION REPORT Page 6 of vt Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code APR ry 5 �(��2 County t Attach complete site plan on aper not less an 8 x 11 in es in size. Plan must ` X include, but not limited to: vertical and h riz Anta Qrpr! poi t (BM), direction and Parcel I.D. percent slope, scale or dimen ions,�;r R lion nd distance to nearest road. ZONIiN Ple n orma ton. vie `ed by Date Personal Information ou rovide may be used for seconds purposes (Privacy Law, S. 15.04 O Y P Y secondary P ( Y 1 (t (m(b Property Owner Properly Location ' L b i -S � j er \ Y� Govt. Lot (l � 1/4 A/& 1/4 S Z � T � �t N R / � E-(er) W Property Owner's Mailing Address Lot # I Block # Subd. Name or CSM# t - 7 1-�LU H I a City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road 7 Q49- Z!Ql1 c, yr er) ❑ New Construction Use: ❑ Residential / Number of bedrooms Code derived design flow rate GPD C3 Replacement. - Public or commercial -Describe: Tw t I Yl Parent material Flood Plain elevation if applicable ft. II General comments i and recommendations: ❑ Boring # Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF in. Munseii Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff #1 *Ef(i12 1 -Q0 I by rZ 31a [t1 n St 1 - Qm s6K 30- 3`7 I OYI2 41(o i Si t (Y) a6 IK ) c - �- 37 -y$ `I L am -\ hK rn i z oO - S X15 -40,4 s r ✓?1 c iY) C - (��I�(a F-1 Boring It ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil ADDlicatiOn Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 _< 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg /L CST Name (Please Print) – Sig a CST Number 1 L S I pe r C ZZ SAS Address U Date Evaluation Conducted Telephone Number �L �L30 q4 5`ftk t �tvci' `MI1tl W T 6 0 1 Z y - 3 -0Z- 7 15 -YZ 5 5gY APR -07- 20 - MON 06:27 ID:STEINER PLL)MB & ELEC TEL:715 425 9818 P :01 ST CROIX COUNTY SEPTIC TANK MAINTWANCB AGREEMENT AND OWNERSHIP CERTIFICATION FORM r 2- t'htintierlBuy Mai • Address Property Address (Veil Ieation required from Planning Department for new construction) �3 citylstate O v � ol Identification Number 11 39 'S f -52 "/' I<.EC;i L DEBCHIPTION 1 Property Location r,-- J' /4, Sec. 1L TN -./ Town of l/,V Subdivision Lot # Certifled Survey Map # Volume . Page # Warranty Deed # Volume Page # Spec house D yes -P40 Lot lines identifiable yes ❑ no 9YST�14C MA1N'I'RNANC� Itaproperuse and maintenance of your septic system could result in its pretnatum failure to badlo wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a 1TCeused pumper. What you put into the system can soot the ibmction of the septic tank as a treatment stage in the waste disposal systeut. The property owner agrees to submit to St, Croix Zoning Deparunent a certification form, signed by the owner and by it master pl umber, Journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site waatewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if neoossary), the septic tank is lea than IA full of sludge. Uwe, the undeaWwd have read the above requirements and agree to mAntain the private sewage disposal system with the standards set forth, herein, sit set by the Department of Commeroo sad the Department of Natural Resources, State of Wisconsin. . Cmd ication sadpg that your septic system has been maintained must be completed and returned to the St, Croix County Zoning n Sj�� M � ' Of year lra'IOn date. q L..L:�.� 3 APPLICA NT DATE OWNER CERTIVICAT' ION I (we) certify that all statements on this form are true to the be or my (our) knowledge. I (we) am (are) the Owntx(s) of ray describe above, by virtue of a wamuty deed recorded in Register of Deeds Office. Z 7 a SIONATuRE t]F APPLI ANT DATE **41*** Any information that is mis- represented may result in the sanitary perm revoked by the Zoning Dc artment. P it being *• Include with ibis application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey clap if reference is made in the warranty deed 1 0CUMICNT No. M STATE BAR OF WISCONSIN FORK I IM 'MIS e►"s SUMMED roe *WOMINe DATA WARRANTY DEED VOL REGISTER'S OOFICE SEOMMWt- 'hilt Deed, made between ....... 41t� $..Dr...,Sttt ............... fa . ... ......�.... MAY 101993 and..: cr1iimA..:... � ►7p�xA�. : :A..� ..... 8 . ..................... .1t :.PSQtI ... " ' d 11:ao A: .iL.n...i.r.N . i� ' ... ........... ...., ll5emtee, RphMt�>fl Witnesseth, That the saw Grantor, fw a valoahle conswerstme ...... r ' ............. ...... ................................................. Q}, .... go~ "A to Grantee the following described rest estate in ..��w..S.�X2�i.. ... asrus» To County, Lb of W4eonsial A pparcel of Tana located in the NO of the NE's and the SM of the NZ% of Section 21, Tae Past No: ......... Township 29 North, Range 18 Pleat, Town of Warren, St. Croix County, Wisconsin, described as follows: Commencing at the North quarter corner of Section 21; thence 888 1332.99 feet to the point of beginnings thence continuing S88*57 634.56 feett :thence S00e04 1350.77 feat: thence N89e37 161.71 feet] thence S01 1033.61 feed thence N88 756.89 feet: thence N00e07 feet to the point of beginning, containing 1,655,162 square feet (38.000 acres) more or less, and being subject to all easements, restrictions and covenants of record. " WIMAI 14F - 1k FTC This ..... i.$._Ag.t...... homestead pmpsrty. (is not) ; Together with all and singuisr the hereditaments and appurtenances the!eunta belonging: And.... 1; rant ox . .. .................................................--•---------......------........ ............_.................. warrants that -the title is good, indefeasible in fee simple and free and clear of encumbrances except munIci and zoning, ordinances, easements for public utilities, and recorded building restrictions, if any, and will warrant and def the saws. Datedthis ----- 3. 0 - •- • ............... ......... day of ....... l.. r ..... -- ........................ ............ 19..9.x.. ..... ......... ........... _ .................... (SEAL) ........... - --.... ............. a '.._.....(SEAL) ...... • ..._.Douglas D.. Rode ... ..... . ................. .......... ..............- - --• -_. ( SEAL) ....... .----------- -- ........................ ..................... (SEAL) • .. . ... .. ............ ...._-- -- - - -- # .............. -- ............................ AUTBBNTIOATION AOSNOW LBEIGUBNT Signslnrs(a) ....... ........ ........... STATE OF WISCONSIN .........._... __........ .............. ._ ...............County. authenticated this ........ day of :i ............... «. »... It...... aaase thb ...fir! day ....»......... ..................... 3 «------- - - - - -- *� before me of � .........« » « 19.1 th. above names e. _ « — tt--- -' --- -- ---- ..--- ..... .... « . «.. N :.�w... «.» »» TITLE: Y STAT>i: BAR OF WISCONSIN ....... S satkwrisad by t 700.06, Wig. Stets.) .,I,a�'....._. Y.. to known to be the person o tat the to Inc insb went and ack' is a THIS INSTRUMENT WAS ORAr'TED SY Stuart J. , Rruec�ez :, . ..... River �Falls,..Wisconsin . 1 2 _ _ � 1 ' ttpy (Signatures may be • authenticated, or acknowledged. -Both J!1 Commission is Permanent (If not, stir% arpir4A are not necessary.) date: .._«L ............................ *x ro at pomm swing is w a n eies .bouN be bwa W o rinad s k+w dMtr SIPWWra NOWZt PA&KO N d WIBCOIISI{I svAasAXTT ne�ssl STATe i►o ° su xo.F �NSIN xu �t A sl..k " INS. - _ -mac« ,: n,.a*.a ♦ :�_..,.r,., .yr r:s .�. :a, r;..A'M_'5V � .,. •;laiY 'Ta ?L .Y�±.a`I!at..�1'°L�h$ "A:9 r. -:lick 9if4:. . :3Y t`..� 'M,A,p�:?'',iSh ii'.. AS BUILT SANITARY SYSTEM REPORT OWNER c ��� c ^f TOWNSHIP 1 • j 1 -. f�/' SEC . T N -R j_C0 G ADDRESS �t� -�„'1� �_ ST. CROIX COUNTY, WISCONSIN. Al SUBDIVISION LO LOT - SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I I I f Ildic at N r i h rr w BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: Slope at site: Y SEPTIC TANK: Manufacturer: �� ;,, iquid Capacity:_ Number of rings on cover /?" Tank manhole cover elevation:'�. t Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: / Number of gallons Number of gal. pump fo ' cycle_ gallons; Total capacity of !_^ llon: iz° �f pump head; b distribution lines gallon per minute --� _, horsepower ;brand name of pump and model number Type of warning device HOLDING TANK: ManufacturAe Number of gallons Elevation of manhole c Type of warning device SEEPAGE PIT SIZE; Number of pits feet diameter feet liquid depth seepage pit inlet pipe - elevation bottom of seepage pit elevation feet. SEEPAGE BED SI number of line width tile depth SEEPAGE TRENCH: width length PERCOLATION RATE �/�r_, AREA REQUIRED _ AREA AS BUILT INSPECTOR 04 A DATED PLUMBER O JOB,v�� LICENSE NUMBER DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILC LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIV P.O. BOX'7969 MADISON-, WI 5370'! BUREAU OF PLUN ®CONVENTIONAL ❑ALTERNATIVE State Plan l.D. Number: ❑ Holding Tank El In-Ground Pressure El Mound Ilf asslgne NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: - INSPECT( N A Douglas Rode Roberts, WI O /s 8 3 •. 3 BENCH MARK (Permanent reference Point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.. NE NE, Sec. 21, T29N -R18W, Town of Warren Name W Pl MP /MPRSW No. County. Sanhary Permit Number: Henry Nechville 3258 St. Croix 38464 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET EL V. AN OUTLET ELEV.: I WARNINGLABEL LOCKING COVER PROVIDED: PROVIDED. ! S ✓ DYES El NO DYES C BEDDING. VENT I V TMA L. HIGH WATER ALARM NUMBER OF ROAD: PROPE � WELL BUI�G: JVENTT . FEET FRO LINE / AI E] YES — ]NO ❑YES ❑NO I NEAREST DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAP V MODEL PUMP /SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED ❑YES ❑NO DYES ❑NO DYES ❑ GALLONS PER CYCLE: UMPA D CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING VENT T( (DIFFERENCE BETWEEN FEET FROM LINE AIR INLI PUMP ON AND OFF) DYES 1:1 NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of lowin LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH NO. OF DISTR. PIPE SPACING COVER J INSIDE DIA #PITS I LICU1 BED/TRENCH �I TRENCHES MA RIAL: PIT DTI DIMENSIONS j /� RAVEL DEPT FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIA NO. R_ NUMBER OF PROPERTY WELL. BUILDING: VENT T( BELOW PIPES AM ER ELEV. INLET E 1 2-7 PIP FEET FROM LINE AIR INL 4/ � NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the text of the fill material for PROVIDE A DIAGRAM OFSYSTEN and furrows thrown upslope: mound sys make certain that it ON REVERSE SIDE. SHOW ELEVA YES NO meets th cr' eri for ium sand. TIONS MEASURED. ❑ ❑ SOIL COVER I TEXTURE P MAN ARKERS OBSERVATION WELLS ❑YES ❑NO DYES ❑NO DEPTH OVER TRENCHBED DEPTH OVER TRENCH /BED D AWqfE O SEEDED MULCHED CENTER EDGES DYES ❑NO ❑YES 1:1 NO 1:1 YES ❑ PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH 8ELOW PIPE FILL DEPTH ABOVE COVER. BED /TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE M (FOLD M RIANO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKIN E LE V.. ELE V.. DIA.. ELEV.: PIPES. ELEVATION AND A.: DISTRIBUTION INFORMATION,_ HOLE SIZE HOLE SPACING DRILLEDCORREC7L CO ATERIAL VERTICAL LIFT CORRESPONDS TO APPRC PLANS: ❑YES O DYES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF'. PROPERTY WELL: SUIL( FEET FROM', LI NE: ❑ YES F NO ❑ YES 1:1 NO NEAREST Sketch System on Retain in county file for audit.. Reverse Side. .1 1 SIGNATURE "'_. � TITLE DILHR SBD 6710 (R. 01/82) DEPARTMENT OF APPLICATION > INDUSTRY, FOR SANITARY SAFETY & BUILDII DIVIS LABOR AN'D PERMIT P.O. BOX i HUMAN RELATIONS (PLB 67) MADISON, WI 52 I Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizc and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in cha H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Mi Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy mus included. Property Owner: Mailing Address:' Property Location: City, Village o owns i County: '/a ' /oS 1T N/ R 8 E (or )E) W A �- {- <' h- ' x Lot Number: Blk Nq:: Subdivision Na e: Nearest Road, Lake or Landmark: State Plan I.D. Numb / � c+ 1 (If assigned) TYPE OF BUILDING J Number of El Public* El Variance* ❑ Other (specify) /� . 0 — /Qy- 12 —��('j Bedrooms: 93 or 2 Family `State Approval Required. TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTH GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Spec SEPTIC TANK CAPACITY D ES © HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: LO S C A,' C `• 97 EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑. Seepage Pit ❑ Alternative (specify) ❑ Seepage Trench Water SS ply: Owner's Name as Listed on Soil Test , R e port (If other than present owner): Private ❑ Joint ❑ Public D v 1- 0. 5 I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Signatur MP/ SW Phone Number: IT tZ A/P c Z v "ur Plumbe 's Addr s: Name of Designer: �� COUNTY /DEPARTMENT USE ONLY Sign a re of Issuing Agent: F //e: Date: Q APPROVED Saniiittary pPeerrmit Number: LPQ O � V_�a ❑DISAPPROVED .JOT�p'j� Reason for Disapprdval: Alternate course(s) of Action Available: i Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior ti stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White - County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod - Plumber DILHR BD -6398 R.07 1 - 1 /8 ) o I , .'V A_41 1, if d t►% it '9 Y 3- r./ it %J Z 1 �./ (U I t i+ AN RELATIONS � f MADISON, WI 53707 (H63.04(1) & Chapter 145,045) A ION: SE,,T,0N TOWNSHIP/ Y: O VISIONNAME: N 4 /• / N/R i 8 W 1 O NTY: OWNER S 'S NAME: MA IN ADOR SS: �ouG LAs o of ST. N "� 2" C) e) s v�.l ► ���. SE DATES OBSERVATIONS MADE NO. BEDRMS,: COMM R L DES RIPTION: II R A N E TS: %Residence ` N , A [ZNew ❑Replace t S o 24 6 3 X011­ l.3 o�(G (� 5 5 cc) AT1NG: S- Site suitable for system U- Site unsuitable for system ONVENTI N;V MOUND: IN-GROUNd7RES$UR : S ST M- IN•FILL TAJVK: RECOMMENDED SYSTEM:(optiunal) ®S ❑u 1 �S 11U EIS ou I MS a l ❑s HOLDING Co r�v �.l� ,t7rfA � Percolation Tests are NOT required DESIGN RATE: f If any portion of the tested area is in the Weer s.Hfi3A3 (5 (b), indicate: :.f 1 ` Floodplain, indicate Floodplain elevation: N t R D�cl vat_ PROF ILE.DESCRIPTIONS ORING TOTAL P H T R N WATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH UMBER pEply*y, ELEVATION 8 RV H TO BEDROCK IF OBSERVED (SEE ABSRV, ON BACK.) x 0, 95' FS L 1..1 5' l.3 N S A w C-0 S 00' e ►d M irD 7,80 N o w y 7 8 0 c J 0, as" 15 L L-. O. �j 5 � F'R m S,' w � li;.� �o • rj• r 9, '` o f.lE �' 8, 30 r t D 1 G tz c. z o,�o' r6L L � 1.4a' at.., S t w GR.- 0.40' BA S; L 7 o e 7 7, 9 0 �, -, r� M XD s ,�. 1.10' l.3 L I. 3U' 'gkj S \-4164 c_ 8 'S 0 `) 07 8, 50 LS O r 15 Mme f C.) PERCOLAtION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTE UMBER If+lBf *6 AFTER SWELLIN INTERVAL -MIN. p P 1 PER INCH 4 S' t. �-- t t 3 ., OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- Ital and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent land slope. 7gZt� sq,1sT s o 1rA- - %i -E j w1THIN �F)(3ZIB�} -� g3 � Bi . YSTEM . ELEVATION Le Ca p 54,A /'r z 0 '� � sT Ac ro 14 U io Vy ''rz h A SIT E PCF I~ I r�� IT i I -Z I Y he 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 ministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge atttl belief,. ,ME (print): TESTS WERE COMPLETED ON: 'DRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional). N� p S o .J oie 38G 9CSIGNATURE : �2 'cj tTRIBUTION: Oriclonal ene nn. ropy to 1_c>r,t Aurhnrity, Property Owner and Soil. Tester. J i arm 8a(P IN L oZ �r�Pi rfrir �p n� JVe 15(v) , -1/ vo Fx�sll;r� Bed T,, stilied STOIz Is 7C) rr� r N - -- _ -- - -.._ _. �l ►�Y l 2 _ - - -- aro 8afn C C1 fie 1 / Yfl = a W o �� /ili:,� 8e� T�� ST f- n9 Lam` W O G j Ca 5 - T(-') RAGl Y