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002-1021-40-000
ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner j1 _ &v Property Address City /State Legal Description: Lot F ---- Block --- Subdivision/CSM # '/� ' /a, Sec. jam, TaN -P,/ Town of 1 PIN # © — SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: r �a o PO $ � 5� :House D Well P/L Tank manufacturer �° Size ST/PC� � Setback from Pump manufacturer Model EPD Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM k e tald T e of system: Width OR Length Number of Trenches Setback from: House Well loo' P/L aD ' Vent to fresh air intake ? /OO ELEVATIONS Description of benchmark S 0 Elevation W Description of alternate benchmark 1 , o j ) e C 1 '1/) A S Y Elevation } � Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines O O ( ) Bottom of System () () ( ) Final Grade jj Date of installation / / Permit number A G State plan number 0S 1 Plumber's signature A 9 4, License number 0 Date Inspector Complete plot plan � 2 sn �"'�✓ ` L� P t NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW b sip 0 •� o at 1 INDICA W v A. Wisconsirf Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.. SFr Cj Z( IX Personal information you provice may be used for secondary purposes (Privacy Law s.15.04 (1)(m)]. 3 Permit E Holder' s DAVID ❑ City Town of: State Plan I No.: CST BM Elev.:- Insp. BM Elev.: qBM D ecription: p WWll Parcel Tax No.: .O ,� �_ " ' 8� 1 !02 1021- 4Qr000 III A 11114 A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic CbMk 0X* 65T Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >S00 .— NA Dt Bottom ��� $$•SS ~f Dosing >S0 NA Header/ Man. 3.6 8 4'9- $- Aeration NA Dist. Pipe 3 - }0 ' Holding Bot. System 4. 96,gs PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand q6 . TO Model Number >�S 3GPM I Friction System TDH Lift �,� L oss 'c(.3 Fie a.15 TDH�S.`� Ft Forcemain Length �b0 Dia. Z " Dist. To well SOIL ABS RPTION SYSTEM ��,.,QLJ 4PWY,TRENW Width / Leng h� ► N f PIT DI MENSIO NS No. Of Pits Inside Dia. Liquid Depth DIME N '( SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION TypeO ' Mode Number: System: 1 ys ��°O >� OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s M x Hole Size x Hole Spacing ti Vent To Air Intake K q �� S ..._ to Lengtr� Dia. 2 Length Dia. pacing 3 SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) `{ J LOCA!RIQR: BALDWIN i4. ?,9.16 . �S, SW, Still 1919 240TI� ,STREET 3 �...c � Sew �.,...� • � U 14OWLA CO t L Plan revision required? ❑ Yes �) No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. t ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: F �m ,m r � . ,�� mv_ — - — � e i 1 0 A t L --Z-- E t e s d § _. 3 I K 3 ; s } i z Ad-- ., k .,. _ ,.,.. ee>P 9 z s,.. ,..... . eAa � s e� 01 T T T— F k ¢ w€ } _d• € 4 A e , y m«va � em ee ee ve. ✓m e,.. em.e.n veem° _.e.. .a.e.,. ...�. , „ , .., „ .« .. ,a ° E B t 3 Ad em me. } 4 j t o ,... ,., mm. a .., ... § ad 3` e e a e.e. ....,, .. ......, 1, q 3 e, € q7 3 t - t - 1 i f � [ i 3 �k„ .. j e S eP f a t e � F i 3 # { � p e.. .k 3 3 i A ^?Y 7 t 7 1 8 d f j t a E s 3 E i t } i a f n 14 +—L Ein s �. ' n e 4 r E A _ ®s E in! Safety and Buildings Division A SANITARY PERMIT APPLICATION 20 0 1 �X��hin Department of Commerce In accord with ILHFt 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less Count�c , than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State S nit�y?P rrrmi�3mber The information you provide may be used by other government agency programs ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION . 3m S' Property ner game Property Location V n )n 4)1/43A, 1/4, 5 /,� T �Q , N, R` E (or& Property Ow r' M iling Address Lot Numbtr_. Block Nur r City, tat . Zip C Phone Number Subdivision Name or CSM Number I1. YPE B L IN : (check one) ❑ State Owned it� A ,� N ear a ❑ Vil age Public 1 or 2 Famil Dwellin - No. of bedrooms Town OF 01 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo OOZ —10V 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5 ❑ Repair of an ------ System ________System_____________ Tank Only______________ Existing System ________ Existing B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 211n Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit � 43 E] Vault Privy 14 E] System-In-Fill eet- 0UI 7 VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Requir d ( . ft.) Pro a (sq. ft.) (Gals/day /s . ft.) (Min. /in ) EI vat ion 7 . t� Feet Feet t VII. TANK in Ca g u gallons Total # of Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufac rer s Name oncrete con- Steel glass Plastic App New Existin "� structed Tanksl Tanks Septic Tan or Holding Tank Id a , g I ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tan iphon Chamber ❑ ❑ ❑ ❑ 11 El NSIBILITY STATEMENT 1, the undersigned, assume responsibili r installation of the onsite sewage ip shown on the attached plans. Plum is Name: (Pr Plu ignature: (No S amps) M RSW Business Phone Numb r: S 7 S Pumber'sAddre Street, City, �te_ Zip Code) 1U1� // � n n IX. COUNTY/ DEPARTMENT USE ONLY `/ � S p � E] Disapproved S itary Permit Fee (Includes Groundwater ate ) s Issuing A nt Signature Stamps) p roved Surcharge Fee) /1f 7 pp []Owner Given Initial / Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD 4M (R.11)96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 3 t r 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative.Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing author ty. 4. Changes in ownership or plumber requires a Sanitary Permit: Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage systern, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608- 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailin4address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/viater service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system .areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. . , Safety and Buildings t * isconsin 2226 ROSE ST LACROSSE WI 54603 -1905 TDD #: (608) 264 -8777 www.commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary June 24, 1999 CUST ID No.267341 ATTN. POWTS INSPECTOR WEGERER SOIL TESTING & DESIGN ZONING OFFICE 421 N MAIN ST ST CROIX COUNTY SPIA PO BOX 74 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 06/24/2001 Identification Numbers g 10 ansaction ID No. 233654 e D No. 175503 SITE: refer to both identification irumbers, p Site ID: 175503 I�� above,; all correspondence.with the agency. St. Croix County, Town of Baldwin SWIA, SWIA, S10, T29N, R16W JUN 2 q 1999 Facility: David & Chris Fern s 3T) FOR: ", Pe Coo Description: Mound System - Three Bedroom e ' Object Type: POWT System Regulated Object The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The following conditions shall be met during construction or installation and prior to occupancy or use: • 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. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to' inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 06/21/1999 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 terard M. Swim BALANCE DUE $ 0.00 POWTS Plan Reviewer - Integrated Services (608)785-9348, Mon - Fri, 7:15 AM - 4:00 PM jswim @commerce.state.wi.us WiSiV�" code:, 7b3 i Page 1 of 6 MQUND SYSTEM FOR A 3 BEDROOM RESIDENCE LOCATED IN THE Sw 1 /4 OF THE 3W 114 OF SECTION V) ,T 1°1 N, R b W, TOWN OF ��.pW ,`"�'. C.�2t�lX COUNTY, WISCONSIN. INDEX PAGE 1 'of 6 TITLE SHEET PAGE 2 of 6 PLOT PLAN PAGE 3 of 6 PLAN VIEW -CROSS SECTION. PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT PAGE 5 of 6 PUMPING CHAMBER PAGE 6 of 6 PUMP PERFORMANCE CURVE PREPARED FOR `�3S �35It+ STET RECEIVED JUN 18 1999 h7UEPP,RED BY SAFETY & BUGS D1 V. ' WEGEE�ER St7 I L TESTING Its AND. AND . �' �I�' �i DES I cam SI=F;tw I CE F.D. Blll 74 421 K. KAIK ST. = ARTHUR L d W3' ?ER ;�. a 1 � RIVER FALLS. VI 54022 o-y,s R [ ELLS bYGRTH, • �•� '• 1011 115 -42`.► -0165 = Wrs. c o1latt �` 4 I G Iy� U �G U nC Seat Mt J� JOB NO. PLOT PLAN Page z-- 6 Scale 1"= I Afi Lj�(BT S 0 1= A4 "WO—t AT LIE7" - r zS ' j- 17�1wi T11'+v1cS. �s a c� 2 G �O 1 UM WI C m s Olt r PrL. SOU .0 ON SP \kF 3U l' �E G�zQUVD Iry 3Z eL 94.3' Z-►" K � S "Dtr� woub CDGTr. NOTES 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install permanent markers at end of each lateral. ( Z required) 3. Install 4" observation pipes with approved caps. ( 7- required) 4. Septic tank to b e l boc)A S O gallon capacity manufactured by r"t t � k► TIZN 1> 2 r 1.v C- 5 Bench MarkS : S fUUr; .6. Divert surface water around mo4nd to prevent ponding at the uphill side. P age 3 Of* Approved Synthetic Covering t�sZt�► c 3 Distribution Pipe Medium Sand H �G Topsoil 3 E b ZJ fZ % Slope Force Main Plowed Trench of %2 " -2 %2" From Pump Layer Aggregate Undisturbed D Z��3 Ft. Soil E - ?-. I Ft. Cross Section Of A Mound System Using F 0• b Ft. Trench For The Absorption Area G N•n Ft. A y Ft. H I- S Ft. B q� Ft. I 13 Ft. Linear Loading Rate= U•8 GPD /LN FT j \\ Ft. Design Loading Rate =o - GPD /SQ FT K 1 Ft. L N Ft. *, e Position of Force Main W ZS Ft. L Force B K meir, " RA - - - -- -- - - - - -- W Distribution Trench Of Pipe Aggregate J Observation Permanent Markers Pipes (Anchor securely) Mound Using I Trench For Absorption Area I • . Page 4 Of Perforated Pipe Detoll 0 End View Perforottd End Cop. ' PVC Pipe c lY _ �o� go o er Install permanent at end of each lateral Holes Located On Bottom, Are Equally Spored Q End Cap PVC Force Main i Distnoution Pipe Last Hole Should Be Next To End Cop Distribution Pipe Layout P Ft. X 3Y Inches Y 3� Inches Hole Diameter 1fL( Inch Lateral !_ Inches) Force Main Z Inches # of holes /pipe t6 Invert Elevation of Laterals 9.I -S Ft. t6xt. ts. 3�. cI� Place lst hole L�4 from tee with succeeding holes at :14" intervals. Last hole to be next to the end cap. 9 i Combination Sept;ic-Tank and PUMP CHAMBER CROSS SECTION. ARID SPECIFICATIONS' PAGE S OF (C) -Vl:'iJT CAP WEATHEK PROOF Jumr-TIOM e0x '1'C.I. VENT PIPC APPROVED LOCKIMG lO' FROM DOOR, MAWHOLE COVER tNI ,i 1 MDOW OR FRESH 7 wARNI►JG L1+�6EL.. AtRIUTAKE cor�Dutr i tj J 5' I I8' MILI. I V PROVIDE IIJLET AIRTIGHT SEAL APPROVED JOI►JTS APPROVE D JOIAIT A J J ( I I I W /C.I. PIPE�F"c W /C.I. PIPEaR Tank construction I (I ALARM shall comply with ILHR ('13.15 and 83.20 a I I I i oIJ C I I LLL. V. fT. PUMP - -� . ` OFF D CONCRETE BLOCK DDIN -� RISER EXIT PERMITTED OIJLy IF TAIJK MAI,IUFAGTURCR HAS SUCH APPROVAL B 6DflIN� SEPTIC E 5PEC.IFICATIDLIS DOSE I V✓1�pw�'� - (�N �1Z �3T WUMbER OF DOSES: 3 ' 4 PCR DAy TA►JK MAIJU FACT URCR: TAWK :,IZC: 1001 I l,sO GALLONS DOSE VOLUME r ALARM MANUFACTURER: S. S- �L.�C`CRO S�LS71�t IMCLUDILIG 6ACKFLOW: 1 -10 GALLOWS MODEL NUMBER: l0I HW CAPACITIES: A= la IIJCHES OR 30 1 6 1 GALLOU5 SWITCH TyPC' (nzCUR -(f g = Z I 3 T G�LLOUS PUMP MANUFACTUREK: GOUI_�S Cr ILKHES OR GALLOIJS MODEL NUMBER: 3$ LSO S ()= 8 INCHES OR 13b GALLOmS SWITCH TYPE: �Z�V�2�j NOTE: PUMP AND ALARM ARE TO 6E MINIMUM DISCHARGE RATE 3 �'� GPM INSTALLED OQ 5EPARATE CIRCUITS VERTICAL DIFFERENCE CETWCEIJ PUMP OFF AUD.DI5TR16UTION PIPE.. 22 a, FEET + MII.IIMUM NETWORK SUPPLY PRESSURE .. . . . .. . . . 2 S� FLET F T. + F OF FORCE MAIN X Z '�� /OFLFRIC FACTOR.. �'� FEET TOTAL DtJUAMIC HEAD �1 S FEET Pump chamber DIAMETER - NJTEKAIAL. DIP' LWSIOLI i OF TAIJK: LEAI&TH ;WIDTH - ; LIQUID DEPTH BOTTOM AREA s 231= - GAL /INCH AS PER MANUFACTURER = � - 1 - O GAL /INCH Goulds pE 6 ot=6 Submersible Effluent Pump 3871 EPO4 EP05 uw�P F ER F AM 1) I J E C. E APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, • Capable of running lubrication and efficient strength, and durability. following y lowing uses: g without damage to heat transfer. •Effluent systems dry g ■Motor Cover: Thermoplas- • Homes components. tic cover with integral handle • Farms Motor: Available for automatic and and float switch attachment • EPO4 Single phase: 0.4 HP, manual operation. Automatic • Heavy duty sump models include Mechanical points. • Water transfer 115 or 230 V, 60 Hz, 1550 Float Switch assembled and ■ Power Cable: Severe duty • Dewatering RPM, built in overload with preset at the factory. rated oil and water resistant. automatic reset. ■ Bearings: Upper and lower SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing 5 V 11 , 60 Hz, 1550 RPM, Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo - construction. • Solids handling capability: automatic reset. plastic Semi -open design 3 /4 " maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING - • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP Canadian Standards Association • Total heads: up to 24 feet. with three prong grounding • Discharge size: 1 1 /2 " NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- (CSA listed model numbers • Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for rota prong grounding plug ry/ceramic- stationary, three ron improved performance. end in "F" or "AC ".) BUNA -N elastomers, (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40 °C) continuous superior strength and 140 °F (60 °C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 i • Capable of running -- {" �4 1 dry without damage to s 30 - - ; ,, components. Pump: EP05 _ • Solids handling capability: 0 25 1 /4" maximum. a -------- I ! - - -- - - -- - -- - • Capacities: up to 60 GPM. X s 20 • Total heads: up to 31 feet. • 1 Discharge size: l /� NPT. Z 5 • Mechanical seal: carbon- 0 15 - I rotary/ceramic- stationary, 4 T BUNA -N elastomers. o EPO>-- • Temperature: 3 10 104 °F (40 °C) continuous a y 140° (60 °C) intermittent. 2 5 i � � 1 0 L. 10 2 30 40 50 GPM L ' 0 2 4 6 8 10 12 ml /h CAPACITY ©1995 Goulds Pumps, Inc. Effective May, 1995 8 __ Wwonsin Deparhmnt of Industry, SOIL AND SITE EVALUATION REPORT Page•. 1 of 3 Labor,and Human Relations. Division of Safety '& 13uild6rigs in accord with ILHR 83.05, Wis. Adi Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include but not limited to vertical and horizontal reference point (13kt , direction and % of dope, scale or PARCEL LD. # dimensioned, north arrow, and location and distance to nearest road. O OZ- APPLICANT INFORMATION- PLEASE PRINT NT ALL INFORMATION REVfflE B D T PROPERTY OWNERS= PROPERTY LOCATION • . '. TJ l`�Ut IR ( tMU % GOff. I: S ,j 1/4 S W 1 /4,S 11 0 T _Z, N,R 1(, E (orOW PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # — CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ZFOWN NEAREST ROAD �3ft�- pwlfv,W1 S�o�z (ifs) 68y -z��3 L_LlVJI NJ 0 `DF 5r, New Construction Use [xj Residential / Number of bedrooms 3 (j Addition to existing building Qd Replacement [ j Public or commercial describe Code derived daily flow y S D gpd Recommended design loading rate bed, gpd$ • _ 7 - 8 trench, gpd/ft Absorption area required 3 "] S bed, ft �"1S trench, ft Maximum design loading rate - Z. bed, gpd /ft , 3 trench, gpolft Recommended infiltration surface elevation(s) — It (as referred to site plan benchmark) Additional design/ site considerations 'I"WK)n D w,V mH a M Z V H . OF • S Rota R U-. Parent material S L \_ r l S STD I M OP' Flood plain elevation, if applicable N R ft S= Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL. HOLDING TANK U = Unsuitable fors stem ❑ S ® U ®S ❑ U I [IS ®U [I S IR U EIS O U ❑ S IZU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color ' Mottles Texture Structure Consistence Boun 3y Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch ' 0- 1 D Ll �Z -t,(. SL 1 2 -` - s bk � C S Yn► Ground 3 19_ Z% , . S H tZ VI L/ q . S elev. t ° lS.1 fL y Z$ - 3 S S I RV 7 �S 1 - 4 R- S s 1 Depth to limiting factor Remarks: �zr" Boring # j -7 V o - tZ z I Z - sl 1 Z S6k M 6-S Yhs �-S yR SAY, S 1 1�shh f �`. - • Z' - Ground elev.� R 9� ft JV Depth to ti limiting factor a S Remarks: LO �. CST Name: Please Print Arthur L. We erer Phone. 715- 425 -0165 ege rer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022' Signature: Date: CST Number: � "( 220254 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of �. PARCEL I.D.# Depth Dominant Color Mottles Structure GPD /ft. Boring # Horizon Texture. Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed. ITIrench .� -- 1Z- tzZL't — S i - ."+% b k Z -t3 LD `t R yC3 St ( `� S yyt'�t� Ground 3 t3 Z'1 t O `C IL Y/3 �l S`-t R S 1$ S i J �S� j yyj �y, • Z. 3 elev. OLq S ft. Depth to limiting S i Remarks: Boring # 1 AJ Q 9 'TU Ground elev. ft. i s Depth to limiting ! factor -1 I i - A Remarks: Boring # [ 3. Ground elev: ft. Depth to s limiting factor Remarks: Boring # 13 Ground ' elev; ft. Depth to limiting factor Remarks: Pa of PLOT PLAN 3 s I 3 BDR.r'I I � j I J LL ° o 2 � - r �l as \` 4 i i > U) v @h16 - �. 0 0 01v SP�k.F, 3y F�3UU� G1Z -au►�A !ry 3Z �I F� . � . k S" DIra wnuc� Pu3T. G 9- 3y '7) S y Z S- O 1 6 S Z ZO Z S T Signature Date Signed Telephone No. CST # wuconsinoepartmentoftndustry, SOIL,AND .EVALUATION REPORT Page. i of 3 Labpr aril Hyman.Relations:: _i Division of rigs in accord with.ILHR 83 05,.Wis. Adiit' Code COUNTY Attach complete site plan on paper not less than 8..1%2 x 11 inches in size. Plan must include but Ste. Cam. not limited to vertical and horizontal reference point (BM), drection and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. O OZ - APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION RE VI 8Y 7•: AT5f PROPERTY OWNERS; PROPERTY LOCATION !'.•t I`J1hUL FCC 1 - ��jZ/U GeW.+GT -SLV 114 SW 1 /4,S t0 T Zct ,N,R l(, E( W PROPERTY OWNER' MAILING ADDRESS ; LOT # TBLOCK# SUBD. NAME OR CSM # c �"� S z35 I Sr. — CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®TOWN NEAREST ROAD 'L $ Z, 5 `T1f T , [ ] New Construction . Use K Residential / Number of bedrooms - [ ] AdditiQn to existing building Replacement [ ] Public or commercial describe 2 S p r —bed • 213 tench Code derived duly flow � gpd Recommended design loading ate , gpolft , gpd/ft Absorption area required 3 7 S bed, ft2 - 7S trench, ft Maximum design loading We Z- bed, gpd$ ' 3 trench, gpddt Recommended infiltration surface elevation(s) — ft (as referred to site plan benchmark) Additional design / site considerations t" 19un'p w/ y `kq y ' - r1z �ivc - t�f[WtM yM Z �! h.:oF: SfJD l.. Parent material s t �_ J: j S eD I M 6'wT Rood plain elevation, if applicable N Pt ft nV uitable for system � MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN F LL HOLDING TANK nsui hdble fors stem ❑ S ® U EIS ❑ U [IS ®U ❑ S IO U [I S ®U 11 S IR'U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color . Mottles Texture Structure Consistence B=xIary Roots GPD /ft in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed rends 0 - lo�I \Z �:(. SL1 Z�S � - C S N� •-S .� - I o - 1'�Sb►z 0-S - • Z 3 Z � �t tz- �l3 s ► I m Ground 3 19 - z.$ S Ll R VI - s �S bh v� FI- �S • q " S elev. SE ` q • ft. Lf Z$ -3S .S 4 tZ-- V hy S {Z SJ5 S wFi Depth to limiting factor Remarks: Boring # �o-t tz 2-f Z — st 1 Z�sb►� �a E li 1. 4 R y[3 � .S Ground elev. a rl Depth to limiting factor 11" ti Remarks: TNarne=- Please Print Arthur L. We erer one 715- 425 -0165 egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022 Signature: /� ?-6Z /j 9` 3 Date: 6 -t L q CST Number: U 1 PROPERTY OWNER �'z-l�1 SOIL DESCRIPTION REPORT Page?- of Boring # Horizon Depth Dominant Color Mottles Texture. Structure Consistence BWXJ&Y Roots GPD /ft. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITrench 3- Z - I -i3 LIZ) `1 Ground 3 t3 2'1 l O `t R Y/3 — i S`-t R S �8 S i J �5� yy/' _ • Z , '� elev. a4. s ft. Depth to 11MIUng factor , Remarks: 6 N Boring # E Ground eleV. ft. Depth to limiting factor Remarks: Boring # Ground' elev. ft. Depth to limiting factor Remarks: 13 Boring # iS:. s ,.• tt Ground - ft. Depth to limiting factor Remarks: PLOT P LAN Page � °f GPM 3 8 �2r�1 �I t I x�S1D G V tihv LT t' ttlV`( Ld } o LL CP 0 3 �� *1 � � LT 01 S v � �7l j two tiVOt' Csi1���4ttr opt � I r ++ >� 1 p @ 1 �L. ll1U .p C►v SP�1z.F, 34 \3Y l t+Z 94.3' t' I Is i c CST Signature Date 5 gne Telephone No. CST # Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanit�jggryd No. : Personal information you provice maybe used for secondary purposes [Priva Law, s.15.04 (1)(m)j. 33 33 ttSS // P RN, : & CHRIS E3At&IN ge ❑ Town of: State Plan ID No.: CST BM Elev - - . Insp. BM Elev.:r T''alalm2) Description: Parr,@LT x Npo21 -40 -000 0 1 1 .6 4- 3 ; ,fir 9 U 1 TANK INFORMATION EL VATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. a, Septic :' al ;� Benchmark /OD .9 /I LL % 9 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. Air I ntake ROAD Dt Inlet ir Septic y f i NA Dt Bottom 3S 8 g S Dosing NA Header / Man. Aeration NA Dist. P; Holding PUMP/ SIPHON INFORMATION Manufacturer AP „Z, 94.7 Model Number "' ,a TDH Lift Frict I , Forcemain 4` � ( Q SOIL BED / /� 1 f °'' ( -iside Dia. Liquid. Depth DIMEK SETBACK � U" INFORM, el Number: m V _ DISTRIBUI Header / Manifol , x Hole Spacing Vent To Air Intake Length L SOIL COVER �,�� 1 �,V l,° _ xx Mound Or At -Grade Systems Only Depth Over xx Depth A# ,, xx Seeded / Sodded xx Mulched Bed/ Trench Center s Topsoil Yes ❑ No ❑ Yes []No COMMENTS: (Inclk epancies, persons present, etc.) LOCATION: BALDWIN 1 ,.16.146,SW,SW 1019 240TW STREET 0 ,13/12 a - e wc Pla revisi required? �Yes EJ'No 1 1 1 6 Use other side for additional information. 7 I P SBD -6710 (R.3/97) Date W s ctor's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 3 t ee.e..... m p ¢ I € 8 d sm r # e _ _ _ .. ao.. m., .. ..m .. -- , [ l g e £ e 1 1 e : aem.. �� m� IL a m .. E 3 E E 55 f S r 1 i i c E W., E $ ........... e e� ..... .. ®.. _.. epee ee. 4�mame . r � z { Y 4 # { g � t . . i t .. ...� en.,, .....a.. ....z .m 4 i _. m .. w e. i 3 i d 3 5 { ¢¢ F r Safety and Buildings Division N)Lconsin SANITARY PERMIT APPLICATION 201 Bo Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 - 7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. 5 1 - Cfv j • See reverse side for instructions for completing this application State Sanitary yPPerrmmmitt N,ummberr Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property O er Na m J (1 Property Location t /a S t ia, S T� , N, R d E (or& Property wn is ailing Lot Number Block Num er City, ate t Zip a Phone Number Subdivision Name or CSM Numbe T YPE F BUILDING: (check one) ❑ State Owned ity QQ 1 ] ] Nearest Road ,,[ Public 1 or 2 Family Dwelling - No_ of bedrooms N Town 0F�UQ AL) ' a� � d Sl, III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 10 , 2A . ' jo . 1 Jft 1 ❑ Apartment /Condo uc) �02 PU 0 2 Q Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 Q Hotel/ Motel 9 Q Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2 ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an _System ________ System____ _________TankOnly______________ Existing System ________ Existinq System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 Q Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42*Pit Privy 13 ❑ Seepage Pit 43 E0 Vault Privy 14 ❑ System - In - Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Require sq. ft.) Propose (sq. ft.) ( . Is/da /sq. ft.) (Min. /inch) Elevation N r Feet ''�~ Feet VII. TANK C apacit y gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank } ODD / 4J& S 2 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 5� ❑ I ❑ I ❑ I ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage syste shown on the attached plans. Plum is Name: (Print) Plu r' Signature: (NQ �prr►ps) � Business Phone Numb Plumber's Add ess(Street,City te`ZipCode): kiv II,-_ , 5 � v C) IX. COUNTY / DEPARTMENT USE ONLY Q Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued ssuing a Signature (No Stamps) Surcharge Fee) 7 Approved Q Owner Given initial 4 Adv erse Determination X. CONDITIONS OF APPROVAL / REASONS FO DISAPPROVAL: fk4v,c 4 cw.,.o-1 a 440'k0&. t^ ! �`„ rl�, • Qes� SBD 6398 (R.11/97) D TRta ri in t o nty, y s Division, Owner, Plumber INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4_ Changes in ownership or plumber requires a Sanitary Permit.Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608- 266 -3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX_ County / Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- I GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. scu- �en,�+�waw ._ 1 US`Thll. U A�RI't uu7- PRpnF/ wsEc.T pp -ooF Ar- DAR G E i 1 ti � N LtT ^� ccy f�V/�'nplV LiA-)E 3 �� s►�p -t > s LZE �voY1 / 6 S 0 6 rt . CO M 91wRDoru 'TMk .Owner's name San. Permit No.. H63.05 PLOT PLAN Show: Location of building served NA Dosing chamber t�A Septic tank Q Vertical/horizontal reference point tiiastue 'refWA Building sewer System. elevation is Sumo+ 5 Effluent system FNAJ Well P P- 1 Replacement system area N q Property lines.w /in 50' of system uA Distribution boxes Scale = ti — ��� , or dimensioned WA Pump and controls: Mfr. & Model No. Vertical Lift Size Force Main Friction Loss T. D. H. Vol. Dist. Pipe Gal. per Min.. Gal. per Cycle Place check mark in appropriate box, indicating item is shown on plot plan v V)i o 44 47 o 0 3 Biel y z a� z. a rMo\:Ie GtZOvr.p lrV S" �tq. 1,.p� �o9T, G� �tv 3i" nth TZ.•� By the granting or approving of the above plan, or upon the event of a subsequent permit being issued,St.CroixCounty and theSt.CroixCounty Zoning Administrator, does not'assume or hold itself liable for any defects in plans or specifications, plan omission, examination oversight, construction, or any damage that may result in or after Instal lation. A'? P um r s signature License Date VOL 144UPAGE e ;f j Document Number Document Title CS Z �y �►� KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 09 -21 -1999 9:00 AM AGREEMENT EXEMPT A CERT COPY FEE: COPY FEE: TRNSFER FEE: RECORDING FEE: 12.00 Recording AJ AGESO 2 e and Return Address f 3 s a. ,3 ( *k s 1 QA��ow l A J , w I s `i oo a /0.2 Parcel Identification Nmnber (PIN) "THIS PAGE IS PART OF THIS LEGAL DOCUMENT -DO NOT REMOVE" This iafomution mutt be completed by tubmitter. doewnOf axle, name A return address, and ELM (i f rtodred). OdurWonnadon Such as the granang clausu, legal descrlpaon, etc. "wy be placed on ads fiat page of dhe docwnent or may be placed on addWonal pages of die docwnent, &EE Use of this COW page adds one page to your doewnent and $2.00 to the recordinr tee Wisconsin statues, 59.51 R • WADA 2196 V1111 4 204GE 238 PRIVY INSTALLATION AGREEMENT St. Croix County, Wisconsin PRIVY INSTALLATION AGREEMENT -COPY TO BE ATTACHED TO THE SANITARY PERMIT APPLICATION, Property Owner($): Reserved For Recording Data �Av i 4 CAS 1=-Q—R.tV Mailing Address: Z.3s - Tv Sr. 3Pc�Alv1/v t&j I S coo z Location: SWI, "w I. S f0 T2.9 N R J6 E or W City, Village, owr$sh f: Parch Taz Number: 00 Z - 10 Zd _ LIQ lega oescnption: S►.)/ )t� -- Sry Jc� - S��, IQ , T L9 1v, �Z-Lb _jowl OF $PIt S7' - e tx caw' Ty 1. No plumbing will be installed in the privy. 2. No plumbing will be installed in the premises served by the privy unless a code compliant soil absorption system or holding tank exists, or a valid sanitary permit to install such a system has been issued. 3. A privy vault/ pit shall maintain minimum setbacks as specified in Table 1. Tablet Well Building Lake /Stream Additional County Setbacks Open Pit 50 Ft 25 Ft Min. 75 Ft Sealed Vault 25 Ft 25 Ft Min. 7S Ft 4. Privies for public buildings shall comply with ILHR 52.63, Wis Adm. Code, S. Privies used for one- and two - family purposes shall be constructed in such a manner so as to exclude flies, rats and other vermin. Doors should be self - closing and vault ventilators should terminate at least one foot above the roof. 6. A privy vault shall be constructed of watertight plastic, fiberglass, coated steel or monolithic concrete. Materials shall comply the intent with ILHR 83.20, Wis. Adm. Code. Counties may, by ordinance, establish minimum sealed vault sizes and type or construction within the guidelines of ILHR 83.20, Wis. Adm. Code. 7. The privy shall be kept clean and sanitary. The contents of the pit or vault shall be disposed in accordance with NR 113, Wis. Adm. Code. 8. -This agreement shall be binding on the owner, their heirs and assignees. This document shall be recorded by the register of deeds in a manner which allows its existence to be determined by reference to the property where the Privy is installed. Printe wner s Name s : SubscrA ydandsw rn to bef a me on this date: G✓ wrier na re: Nctary Public My commission expires on: NOTE: This document was drafted by the State Department of Industry. Labor and Human Relations, Bureau of Building Water Systems. Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page.. 1 of 3 • Labof ,md Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code ` COUNTY Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. o APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: R l e 1 PROPERTY LOCATION 'E( t tt jz. -: Z GOW. LOT 1/4 S W 1l4,S It) T Zq ,N,R 16 E (orQ) PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # s za,s 'rtt sr. — — CITY, STATE ZIP CODE PHONE NUMBER [)CITY VILLAGE ZrOWN NEAREST ROAD C3 P;u�!' vii fQ Suouz. ( bay -z-) ��wN Zug Tit- sT, [� New Construction Use [ Residential / Number of bedrooms 3 [ ] AddibQn to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow U S O gpd Recommended design loading rate bed, gpd/ft - trench, 9pd/ft Absorption area required -_ bed, 11 - trench, ft Maximum design loading rate - bed, gpd /ft - - trench, gpd/ft Recommended infiltration surface elevation(s) — ft (as referred to site plan benchmark) Additional design / site considerations R NZt0 1 m t_� V RU PRI UY �v / R.TN�l upk C t` r?�vT Nit 0 U h.t�. Parent material S l �_nj S Em ) I I~'hV? Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE I AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem EIS ®U [IS O U I [IS O U O S ® U EIS ®U ❑ S ERU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rRench iiRiYaw:: . a xn ti 0 - to IR ZL - sti1 2 ` sbk wig- C'S 1� 5 `t tz- yl3 3 Ground 3 19 - za -� s H tz y! - s I l c S bit q . S elev. ° •� ft. y Z$ - .� -S 4 R_ V Ll(Z sib s 1 Oy 1'vl`k Depth to limiting factor M Remarks: Boring # S 1 0 -' �o�I tz ZfZ Z�'sbk 3 l� - t,pti R y(3 �tS `fR S/� s i J � `�sb\, ►M fit- - • z-' .3 Ground elev. I_ a ft Depth to limiting cf ' factor .. cRoqx •Remarks: ' CST Name: - Please Print Phone: Arthur L. We erer 715 -4 �--" Add ress: egerer Soi Testing & Design Service - P.O. Box 74 River Fa11s,W Signature: Date: CST Number: l� g� -��C � -z z_9 2202 PROPERTY OWNER PE�� SOIL DESCRIPTION REPORT Page Z oP 3 PARCEL I.D. # _ D d Z _ 1 O Z. \ - `4 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDlft FZ- in. Munsell Chu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground 3 v3 -uI 1 O `t R Yi3 �l S`�t IL 5 L$ S i) �S� }� yyJ �y _ • �- . 3 elev. 0 Lq, S ft. Depth to limiting factor Remarks:`i Boring # I hl Cy 13 iZ �1 L f y"tU`TTUAJG i Ground elev. ft. Depth to limiting i factor ' i Remarks: Boring # I ro"a I Ground elev. ft. i Depth to limiting i factor i Remarks: Boring # 13 f Ground elev. ft. Depth to limiting factor Remarks: cnrl.RZaNR nc,n ?m PLOT PLAN Page 3 of SCALE 1 "= �Q ' a z B� ti I D pw►©I � �� / �3 �g4s 7 Olt I � ` III r \/ ft I �� 5" Dtl� wouD bust. eL 715 42.q- CST Signature Date Signed Telephone No. CST # Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page.. of 3 Lpbor and Human Relations Diveaon of Safety 8 Buildngs in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, tut not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE le� 2 • i1• PROPERTY OWNER: R.1 0 - r=-eTLQ PROPERTY LOCATION 1�Ut �� 'F( C,ttlz / % E_t=_ /V GE WT- LOT Sb,j 1/4 S W 1 /4,S t 0 T _?_9 ,N,R 16 E (or' 6 PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # ° 1 � S Z 3 S TTf S7" • — -- CITY, STATE ZIP CODE PHONE NUMBER E]CITY E]VILLAGE ®TOWN NEAREST ROAD Q Lvl 1 1 L'o l S uo u Z ( - 7I S) 68t/ - L - ) 3 t� w l Z u 7t1 5 [� New Construction Use Residential I Number of bedrooms 3 [) AdditiQn to existing building j ] Replacement [ J Public or commercial describe Code derived daily flow y S � gpd Recommended design loading rate bed, gpd/ft - trench, gpd/ft Absorption area required bed, ft - trench, 111 MaAmum design loading rate - bed, gpd /ft = - trench, gpdAt Recommended infiltration surface elevation(s) — ft (as referred to site plan benchmark) Additional design/ site considerations R.NTc0rv1 flt;1 V AVUT PRI U`t' w/ EyvT W1 o y K'e- . Parent material S t S ED ) M t'hJT Flood plain elevation, if applicable it S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDWG TANK U= Unsuitable fors stem O S ® U ❑ S O U ❑ S ®U ❑ S O U EIS 9 O S IC SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed reach Lf v- y Y, cS - • z 3 Ground 3 19 zg • S H R V/ L/ S elev. t q S•'7 fL ` rL. V/y � S `-ltt .S7 f5 Depth to limiting factor M Remarks: Boring # 0 -`7 �o\-tR Z. Z Z -l�. �o`L�� _ S t J ��Sb 1'r'1F► Cg •Z. 1 3 t'T -ZED t uti R y13 -� �S kQ S /r6 s i I \ `�sbh lM►— -- .2 - 3 Ground elev. aj f Depth to limiting factor Remarks: w `r CST Name: - Please Print Arthur L. We gerer Phone. 715 - 42.5 -0165 egrsrer SoiA Testing & Design Service -P.O. Box 74 River Fa11s,WI 54022 Signature: - Date: - CST Number: 9$ - 306 N'z -2Z_9S 220254 i PROPERTY OWNER SOIL DESCRIPTION REPORT page Z- of _ PARCEL I.I).# 00 lOz \ - y0 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITmr& 3 3 - 1D - - si Zs Iz •s ,� Ground 3 13 Z.'1 t O `t R Y13 t . Sit tZ S 1 $ S i J �Sb ►� y,� �y _ • Z • 3 elev. q1 j ft. Depth to limiting factor Remarks: Boring # C3 i < �� �� 1-tU tTl i e Ground elev. ft. Depth to limiting I factor i Remarks: Boring # CA�'�ti ?A • :v ±tip Ground elev. ft. Depth to ' limiting i factor j I Remarks: Boring # 13 Ground I elm ft. Depth to limiting factor Remarks: Cnr).nQ7ntn nr 'nn, . PLOT PLAN Pa 3 of 3 J • SCALE 1 "= yQ ' 4- 1 � ~ LL 2 C i �6 wt`�►�Z % J� D are *1 / ,,�� � � 3 � 94 s ,,��ll � al p � / • r I C LO F ' v I y v 8r1 - �L. SOU. D 0� 0 tv r 715 ? 42A-0169 14 00576 CST Signature Date Signed Telephone No. CST # ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 0 ,6 v 1 0 /9w n LA r t I s F tE R w Mailing Address 92 S s 7" PA io W ► Aj W Soo Property Address 10 19 a 40 I s T (Verification required from Planning Department for new construction) City /State &LOW I K) Parcel Identification Number LEGAL DESCRIPTION Property Location S '/4, S l.J '/4, Sec. 10 , T -R(_W, Town of 15!9L e w `,1 Subdivision , Lot # Certified Survey Map # - - Volume - , Page # Warranty Deed # 6n / rf D , Volume l q j S , Page # �� y Spec house ❑ yes 2f no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification L� ' t your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 y. of Whe three year expira 'on date. 1/ �- 4 7 X/ SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of e p operty d cribed 7ae, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed /o vex_ 1419PAG 4:94 601480 KATHLEEN H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD Richard Fern and Clarice Fern, husband and wife, holding 04 -19 -1999 10:00 IN as survivorship marital property, conveys and warrants to YARRANTY DEED David H. Fern and Crystal L. Fern, husband and wife, EXEMPT li 17 holding as survivorship marital property the following CERT COPY FEE described real estate in St. Croix County, State of COPY FEE: TRANSFER FEE: Wisconsin: RECORDING FEE: 10.00 PAGES: 1 Recordin Area Name and Return Address e Thomas A. McCormack (� 740 Main St. Baldwin, WI 54002 002 - 102140 (Parcel Identification Number) Southwest Quarter of the Southwest Quarter (SW ' /4 of SW '/) of Section Ten (10), Township Twenty -nine (29) North, Range Sixteen (16) West, St. Croix County, Wisconsin. This deed is given in partial satisfaction of that certain Land Contract between the parties dated April 14, 1999, and recorded in the office of the Register of Deeds for St. Croix County, Wisconsin, on April 19 1999, in Volume 1 q/q of Records, at Page _�L% as Document No. wig?� Exception to warranties: all easements and restrictions of record, and except any liens or encumbrances created or suffered to be created by the acts and defaults of the grantees, their heirs, successors or assigns. This is not homestead property. Dated this I I day of 0 , 42 ri , 1999. -�t * *Richard Fern *Clarice Fern AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ST. CROIX COUNTY N � Personally came before me this day of =A 1999, the above named Richard Fern and Clairce Fern to authenticated this day of me known to be the person(s) who exe a foregoing instrument an cknowledge the sam . signature type or print name signature ttiAc type or print name ! '1 A TITLE: MEMBER STATE BAR OF WISCONSIN Notary Public St. Croix County, Wisconsin. (If not, My commission is permanent. (If not, state expiration date: authorized by §706.06, Wis. Stats.) .) THIS INSTRUMENT WAS DRAFTED BY *Names of persons signing in any capacity should be typed or Thomas A. McCormack printed below their signatures. Baldwin, WI 54002 Information Professionals Company Fond du Lac, Wisconsin 800 -655.2021 FAX ST. CRODC COUNTY ZONING OFFICE 1101 Carmichael Road Hudson, WI 54016 (715) 386 -4680 DATE: 5 A 9 TO: Fax Number: Name: jjL A - ./ z FROM: Fax Number. 386 -4686 Name: Number of Pages Including Cover Sheet IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE CONTACT: NAME: A,"���/ TELEPHONE NUMBER: Y .. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county: Safety and Buildings Division INSPECTION REPORT ST CROIX GENERAL INFORMATION (ATTACH TO PERMIT) sanga#�P6r,�btNO.: Perso information you provice maybe used for secondary purposes [Priva Law, s.15.04 (1)(m)). F RIV c D & CHRIS ,j ge ❑Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parca�Tax N 621 -40 -000 .3, 4.3 uLLl TANK INFORMATION EL VATION DATA TYPE MANUFACTURER CAPACITY STATION BSS HI FS ELEV. Septic I Benchmark �� /' ��, , °� "� G*` / i?'�"'':;� Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic > i NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand AIK d2, , r f Model Number GPM TDH I Lift Lrictio System TDH Ft oss Fi Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Mod Number: System:��I�/� (,1 .t3 f-} OR UNIT DISTRIBUTION SYSTEM Header / Manifold ution Pipe(s) x Holes x Hole Spacing Vent To Air Intake Length Dia. Lengt Dia. Sp SOIL COVER x Pre ssur ems l xx Mound Or At -Grade Systems Only Depth Over epth Over xx Dep xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed / Trench Edges Topsoil Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 'LOCATION: BALDWIN 10.29.16.146,SW,SW 1019 240TH' STREET w &-v kae' �4 dam C &4) Pla revisi required? �Yes Ej' Use other side for additional information. 1 a 7 I can_a71 n rD 7/07\ Date s ctor's Signature Cert. No.