HomeMy WebLinkAbout004-1015-20-100 o
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Safety and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)).
Permit Holder's Name: ❑ City ❑ Village ❑own of: State Plan ID No.:
Ile Town of Ca
CST BM Elev.: f Insp. BM Elev.: BM Description: Parcel Tax O..
GSi` cwt
TANK INFORMATION ELEVATION DATA 7• ZT, /S 913
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
�
Ytil C�� � � � / °% $O �,a '
Dosing BM Z 9g. 5 - Ir
Aeration Bldg. Sewer ((, 30 '? -, '; - 0 '
Holding St/ Ht Inlet 0
TANK SETBACK INFORMATION St/ Ht Outlet (2.2 d D,4.0
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic �(� 'Z I NA Dt Bottom
Dosing NA Header / Man. `� 72 -$,s�
Aeration NA Dist. Pipe 0 j 2 -R5
Holding Bot. System r�, ;6 s 70-60
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand — =`� St cover
Model Number GPM ;.o
TDH Lift Frict' TDH Ft
Forcemai Length Dia. Dist. To we
SOIL ABSORPTION SYSTEM , 2 �G C I
$E&/ RENCHJ Width [ Le th Np. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
IM DIMEN 1 N
SYSTEM TO P / L BLDG I WELL LAKE/STREAM LEACHING Manu adurer:
SETBACK CHAMBER _t���
INFORMATION TypeO / l Moe Numb
System: I D ZSD 6 / OR UNIT _ /
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
r
Length Dia. Len ia. acing 7 Z Sa
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over n j Bed/ epth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Center �� T rench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.) Inspection #1: 0 l(o /ob Inspection-#2,
Location: 2761 50th Avenue, Wilson WI (NW1 /4, NEIA, Section 7 T28N -R15W) - 7.28.15. 3 -&D S
1.) Alt BM Description = I of `� �"` °C"'� 6A e3
2.) Bldg sewer length = (o
- amount of cover = y K Z
Plan revision required? ❑ Yes No f7S I (o o� ` � fS Use other side for additional infor atlon.
SBD -6710 (R.3/97) Date Inspector's Signatur Cert No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Vi sconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 B Washin 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 8 112 x 11 inches in size. j
• See reverse side for instructions for completing this application State Sanitary Permit Number
Personal information you provide may be used for secondary purposes ec k if revision to prprevious application
[Privacy Law, s. 15.04 (1) (m)). Ch
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Property O ner Name �� P operty Location � N, R � �) W v%A ti4 1/ T ,
Property Owner's Mailing AAddrye,, Lot Nu ber Block Number
—i-Y) s
City, State Zip Code Phone Number Su r SM Number
S >9- S
IL TYPE OF BUILDING: (check one) ❑ State Owned Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms 3 rX Town of
Ill. BUILDING USE (If building�pe is public, check all that apply) Pa Tax Numbers)
1 [] Apartment/ Condo /,
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Hom ❑ 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 System
B) _ %A Sanitary Permit was previously issued. Permit Number 35 205 Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed w 21 E] Mound 30 E] Specify Type 41 ❑ Holding Tank
12 Dd Seepage Tren�,�,75 53 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑Seepage Pit 43 ;V2uZPriv
y
14 ❑System -In -Fill . D U 41 " OAM
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Propo ed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) Elevation
S O 50 , s '—� Feet . t_> Feet
Capacity
VII. TANK in Ca gallo s Total # of r Prefab. Site Fiber plastic Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App.
New Ex istin strutted
Tanks T nks
Septic Tank oak / , ❑ ❑ ❑ ❑ ❑
Lift P Mn ❑ I ❑ I ❑ ❑
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibilit for install ion of the site sewage system shown on the attached plans.
PI is Name: (Print Signatur : ( S m s) NMPIMPRSW No.: Business Phone Number:
S CE - t3t� � sa3
Pum er'sAddress Set, ity,State, ip Cod
e): /,er
IX. COUNTY /DEPARTME USE ONLY /
E] Disapproveg 72 ary Permit Fee (includes Gmund ter ate Issued Issuing Agent Signature (No Stamps)
�^
pproved [:3 Owner Given Initial � Surcharge fee)
Adverse Determination � 1 3 -
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11 /97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS `
1. A sanitary permit is valid for two (2) years_
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the
county prior to installation
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:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from.
DILHR.
VIII. Responsibility statement. Installing plumber isto 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 81/2 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.
----------------------------------------------------------------------------------------------------
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.
V
State of Wisconsin County
Safety and Buildings Division SA ARY PERMIT S+ C M i k
Integrated Services Bureau r fe Renewal Uniform Permit Number
Personal information you provide may be used for secondary purposes [Privacy Act, s.15.04 (1)(m)].
Permit Renewal Date Permit Transfer Date Original Permit Issuance Date State Plan ID Number
Property Location _ JK T wn El Village El City of:
1/4 (� 1/4,S T N,R -5 64m) W
Lot Number Block Number ubdivision ame 7 � �5 0 '1* Road, Lake or Landmark
PREVIOUS SANITARY PERMIT HOLDER - IF CHANGED: NITARY PEPM100TINSFERRED TO:
Name (Please Print) Signature Name (Please Print) Phone Number
Address Phone Number Street Address City, State, Zip Code
I, the Lytoersigned, 4Asume responsil for installation of the private sewage system t ha reviously approved for this property.
1 njy Signature ; Previous ��e f changed)
—�
PI r ber Address Previous Plumber dress
Alqq 5 D'I C)9�
*IP/MPRSW Number Pho a Number MP /MPRSW Number Phone Number
Issuing Agent Signature Date Approved T — I J ^ -Z�
SBD -6399 (R.04/96) Copy - Owner; Copy - Plumber
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C ence Glotfelty .11 1 so w' A y e, G,`l� l � SIjH , to l
Enviro-Tech Systems & Se ices �t
N4955 Swmy Hill Road
j ............. Weyerhaeuser, WI 54895 Ta M R S
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Wisconsin Department of'lndust�
labor and Human Relations LAN SITE V W T )
lions / Page age / of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. C ` I
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. #
APPLICANT INFORMATION - Please print all information Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). _ 3 _ >C
Property Owner Property Location
J� L W J mot 1i4 AV/4,S T� ,N,R W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
i _su" Ave-, � ( C 1 0 4 Ly M Qm)
City State Zip Code Phone Number El 1:1 Nearest Road
ES New Construction Use: LK Residential / Number of bedrooms Addition to existing building N- �•
❑ Replacement t �p ❑ Public or commercial - Describe: / mil•
Code derived daily flow 9 ,5 V gpd ��..—�, Recommended design loading rate bed, gpd/ft gpd /fl
Absorption area required DQ bed, ft 1 trench, ft Maximum design loading rate bed, gpd /ft2 s ( trench, gpd /ft
Recommended infiltration surface elevation(s) o a ft (as referred to site plan benchmark) `
Additional design /site considerate ns 1� v ►� fi eA - t r \)
Parent material r. J o e S Flood plain elevation, if applicable Al ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = Unsuitable for system ❑ S ❑ U ❑ S ❑ u 1 ❑ S ❑ U ❑ S ❑ U 1 ❑ s ❑ U [- ❑ u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
;,;. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
N �
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Ground " 7 '7 5 7 Cos VY\ ` a o�
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Depth to
limiting
factac
�in. .Z $5• Z ,
Remarks:
;11 !✓
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
CST N Please Print) Si ature Telephone No.
Address ate CST Number
Ii
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.#
Boring Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Boring #
F
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
' Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW -8330 (R. 03/95)
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Wisconsin Department of'lndustry, SOIL AND SITE EVALUATION
Labor and Human Relations Page j of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and S a C C'
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
APPLICANT INFORMATION - Please print all Information Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
jug L � mot 1/4 /4/ /4,S ] T ame } W
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
V A ve— , I I U M Ll CS M
City ` State ` Zip Code Phone Number �j E] ❑ Nearest Road
lS ! t�7 ?) 'o� D T wn VC.
New Construction Use: Residential/ Number of bedrooms Addition to existing building 4.
❑ Replacement ❑ Public or commercial - Describe: / 4.
t , _
Code derived daily flow _' i 5 C) gpd '7 ��f Recommended design loading rate bed, gpd /fl trench, gpd/ft
Oa
Absorption area required bed, ft v
� � trench, ft 2 Maximum design loading rate - bed, gpd /ft trench, gpd /ft
Recommended infiltration surface elevation(s) t ft (as referred to site plan benchmark)
Additional design /siteconsiderati ns 1C ID v1a f"tom.�.1„ 4;a7 ep �A yUi'.Set t t"c&,4r - t!ewdm 1 mjsi
Parent material 61 v —S S Flood plain elevation, if applicable N.
fc
Eu = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
= Unsuitable for system El El ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
9 Texture Consistence Boundary Roots
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
1 :7
Ground 7y ' , 5 \1 Im co m e o 8
M -ft. "S _ 0 o - 8
Depth to
limiting
1_QV in,
Remarks:
Boring #
Ground
elev.
ft.
,
Depth to
limiting
factor
in. Remarks:
CST N
Please Print) SI ature Telephone No.
Address ate T Number
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V isconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 22001 B Washin in
Department of Commerce In accord with Comm 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 81/2 x 11 inches in size. ST doo ( X
• See reverse side for instructions for completing this application State Sanitary Permit Number
36 2OG
Personal information you provide may be used for secondary purposes 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
Propert wrier N me / Property Location `
�3 Irr t 14 Q l FIC K /p W / Ne 1/4,5 7 T 7.9 , N, R l,-E (or)&/
Property Owner's Mailing Addre lock Lot Number B Number
o" ~_
City, tae Zip Coe Phone umber Subdivision Name or CSM Number
Sorg
II. TYPE OF BUILDING: (check one) ❑ State Owned Cit Nearest Road
Public ar 1 or 2 Family Dwelling - No. of bedrooms C] Village o f
III BUILDING USE (If building type is public, check all that apply) Parcel T
/�' Number(s) ! -2 1�� [�a�
1 E] Apartment/ Condo U0 Lf , , to/ S 2,0 r r 6P
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. p'New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
System __ ____ _____ __ Tank Only Existing System
-------------- Existing System ________
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 XSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit f / 43 ❑ V ul Privy
14 ❑ System -In -Fill 3 X
V ABSORPTION SY STEM INF ATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
0P 1 750 403 . "�!' O Feet - 7 q , 9 Feet
VII. TANK
Capacity
in allons Total # of site
INFORMATION g Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New Existin Gallons Tanks Concrete structed glass App.
Tanks Tanks Af
Septic Tank ofFlekhr g 1mr WD --- l 74OM0TelliAlf ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I❑ I ❑ 1 ❑ 1 ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility� the onsite sewage system shown on the attached plans.
Plumber's e: (Print) Plum 's Si n to : ( Stamps) MP /MPRSW No.: Business Phone Number:
l vvv Z- sip
Plumbf s Address (Street, City, State, ode) -
tp0 708 W6 -'5_q7s_
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee (includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee) aC-
Adverse Determination ��S ` 11 < / `
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD -6398 (R. 4/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6899) to be submitted to the
county prior to installation e
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. s s a
6_ If you have questions Qnsite sewage system, contact your local code_a,dm.inistrator of the State of
Wisconsin; Safety and guildi'ngs# WislbA,�608 -266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name -arid mailing Mdess. 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, etf,),
address and phone number. Plumber must sign application form.
IX. County /Department Use Only.
X. County/ Department Use Only.
Complete plans andspecifications not smaller than,;,8.1 /2 x 11 inches submitted °;Z} the county. The pTansmust
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 bss; pump periormpce curve; pump model, and pump manufacturer; D). cross section
of the soil absorption system if'required by the county; �) 1;oil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
198 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater, „ ,
.3
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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• Wisconsin Department of Commerce ORj%ftr SITE EVALUATION Page 1 _ of - 3
Division of Safety and Buildings m acc� ith Comm 83.05, Wis. Adm. Code
Certified Soil Testing
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (SW direction and St. Croix
percent slope, scale or dimemsions, north arrow, and loeoion and dista ,to nearest road. -
Parcel LD.# CSM pending
APPLICANT INFORMATION - Please int an information. -- -
Y Y �Y P ,.... ( (m)) iew�d By Date
Personal information y provide ma be used for seco d urposes: jPnva Law, s. 15.04 1)
s
Property Owner r _ Property t,ocation
Lund Sue ? Govt. Lot NW 1/4 NE 1/4 S 7 T 28 N,R 15 W
-- - -- - - -
Property Owner's Mailing Address , r. M Lot # Block # Sut1d. Name or CSM#
2771 50th Ave t t rr 1 ` 1 l Cliff Lund CSM
Cit State Zi Code Phonel�ur�liiir �'CP i�/ L] Village X Town Nearest Road
Wilson WI 54027 715- 698 -2781 Cady 50Th Ave.
>' New Construction Use: Residential/ Numbed a oms [ !Addition to existing building
Replacement [ ] Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .5 bed, gpd /ftZ 6 trench, gpd /ftZ
Absorption area required 900 bed, ftZ 750 trench, ft- Maximum design loading rate .5 bed, gpd /ftZ .6 t rench, gpd /ftZ
Recommended infiltration surface elevation(s) 71 ft (as referred to site plan benchmar
Additional design I site considerations install 2 - 2.7'x 75' Sidewinder, Hi- capacity "turtle- shell" trenches (Or I - 5' x 112.5' gravel trench)
Parent material loess over till & outwash Flood plain elevation, if ap licable NA ft
S= Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U �
U- Unsuitable for system U S❑ U X S L.I U
S�_,U S l�U
S x U ®
Depth Dominant Color Mottles Structure GPD /ftZ
Boring# Horizon in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. �Consistenc� Boundary Roots Bed - -` Trench
i f/m
1 0-12 l OYR 2/2 sl g
m r � s cs
2 12-33 10YR 4/3 - sl 2 m sbk dsh cs 1 m .5 .6
Ground 3 33 -72 7.5YR 4/4,4/6 - Imcos 0 sg r ml cs I -
7 .8
elev — - - -- - -- -------- - -- -- - -- — -- ! _
74.8 It 4 72 -80 10YR 6/4 - s 0 sg ml cs - .7 .8
i
De th to 5 80 -84 7.5YR 3/4 - sl 1 m sbk mfr � .8
P
limiting
6 i
factor
Remarks. Note: "turtle- shell" sizing is 0.6 for trench because sides will occasionally be in moderate structured sk gravel sizing is 0.8 for
trench because system elevation (and gravel side- walls) will be in 0.8 lmcos & s; some Gy si coats on peds in horizon 2;
2 1 0 -6 10YR 2/2 - sl 2 m gr dsh gs 1 f/m .5 .6
2 6 -12 lOYR 2/2 - sl - 2 f sbk dsh cs 1 m .5 .6
Ground 3 12 -27 10YR 4/3 - sl 2 m sbk dsh cs - .5 .6
elev
74.3 ft 4 27 -84 7.5YR 4/4,4/6 - hncos 0 sg ml - - 7 8
-- --
Depth to X1.6
i
limiting _4
factor
8
Remarks, occasional inclusions 10YR 6/4 s in horizon 4; occasional gr, cob, & st
CST Name (Please Print) Signature: Telephone No.
Henry F. Grote 715 -665 -2681
Certified Soilfiestin - - --
Address g Date CST Number Ref #
P.O. Box 57, Knapp, WI.54749 629/1999 222774 1216
Lund, Sue SOIL DESCRIPTION REPORT t3+� 2 3
PROPERTY OWNER: [_� Page of
PARCEL LD.# __CS pending Certified Soil Testing
Depth Dominant Color Mottles Structure GPDIftz
Horizon in Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. onsistence Boundary l Roots B i Trench
3 1 0 - 10 l OYR 2/2 - sl 2 m gr dsh cs I f/m .5 .6
2 10 - 24 l OYR 4/3 - sl 2 m sbk dsh gs I IM .5 .6
Gro 3 24 -37 7.5YR 4/4 - sl 2 m sbk mfr gs IM 5 6
- - - ---- - - - - -- - - -
7 cs 7 5.0 ft 4 37 -58 7.5YR 4/4,4/6 - Imcos 0 sg ml .8
Depth to 5 58 - 86 10YR 6/4 - mcos 0 sg dl - - .7 .8
limiting
factor
> 86" t i
� I
I
Remarks:
4 1 0 -4 10YR 2/2 - sl 2 m gr ds gs 1 Gin 5 6
2 4 -1.1 IOYR 2/2 - sl 2 f sbk dsh cs 1 1f /m ' .5 i .6
Ground
elev
3 11 -19 7.5YR 4/4 - sl 2 m sbk mfr cw If .5 ( 6
90.5 ft 4 19 -33 7.5YR 4/6 - sl 1 m sbk mfr cw - .4 ! .5
Depth to 5 33 -56 10YR 6/4,6/8 - scl� 0 m dvh - - NP NP
limiting
factor
33"
j
Remarks: Hori 5 is very fignt, resistant to penetration; e e ive
5 1 0 -8 l OYR 2/2 - sl 2 m gr ds cs I f/m .5 ; .6
2 8 -24 l OYR 4/3 - sl I m sbk mfr cs if .4 .5
Ground
elev 3 24 -30 7.5YR 4/4 - sl 1 m sbk ! mfr cs - .4 .5
- - -- - - ----------- - -- - -
90.7 ft 4 30+ SSBR
Depth to
limiting
factor -
1 A
- i I
I
Remarks: mono r rc, we c m n e, rests o pene a ion
1 0 -5 j _ l OYR 2/2 sl - 2 m g r ds gs 1 f/m .5 .6
f
2 5 -10 ! 10YR 4/3 - sl I m sbk mfr cs if .4 .5
Ground
elev 3 10 -29 lOYR 5/3 - is 1 in sbk ds cs - .7 .8
89.9 ft 4 29 -48 l OYR 5/3 f2d 10YR 6/2 Is 1 m sbk j mvfr - - .7 ! .8
Depth to
limiting
factor
29' -- -- - - -- - - -- - - - - - - - I -
Remarks:
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
/ OWNERSHIP CERTIFICATION, FORM
Owner/Buyer ZanD
Mailing Address Z 7? / S7o /f UE W1IS 7 W 1 5q0 0 j
Property Address �` 7 G / ,r 6 4 v - c , V
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Location /U U) y., /y` 1 /4, Sec. 7 , T � g N -R / S W, Town of L -
Subdivision Lot #
Certified Survey Map # 7 Volume I , Page # _ 3731
Warranty Deed # 56 ip q� Volume Page # ZS
Spec house ❑ yes W no Lot lines identifiable ❑ yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenanceof 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, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the' re eats and a e to maintain the
quirem gre _ private sewage`disposal system with the standards
_- .
set forth, herein, as set by th �"arlment of Commerce and the l�i*int o'Iatural Resources, State of Wisconsin. Certification
stating that your septic s has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
7 e yea iration data
( SXKNA 1 ftZ0F APPLICANT DATE
OWNER CERTIFICATION
I (we) certify all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
t rope descri above, by virtue of a warranty deed recorded in Register of Deeds Office.
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
t
t? WARRANTY DEED. —To Husband and Wife as Joint Tenants F U 399 tl(cVlsedj
Thi Indenture, Made this.. ........ - - -�..� _ _day of November__ -.- _ -_ ..._. in the year
sixt six ... ... Emil Jacobson .and
of our Lord, one thousand nine hundred and
_....- ... - -- y'_ ...... ......... ....between. - -._ -.. .
Jacobson, husband and wife, and said Irene Jacobson in her own individual - _,right,
- . . .. ... .................... . .. . •-- - -.... _...................parties.... of the first part,
and -- Clifford F. Lund and Alice C. Lund
.......... - - -- - -- -
--- -_. - .. - -- -- --- • - - - --
-
o f Woodville, Wisconsin
husband and wife, as joint tenants, parties of the second part.
WItnesseth, That the said part- of the first hart, for and in consideration of the sum of j
Forty - two Thousand ($42, 000. 00) ------------------------------------ - - - - -- _
... _.
i
to them in hand paid by the said parties of the second part, the receipt whereof is herebv confessed and
acknowledged, ha Ve.- given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by
these presents do --- - give, grant, bargain, sell, remise, release, :Mien, convey and confirm unto the said parties of
the second part, as joint tenants, the following described real estate, situated in the County of St. Croix
and State of Wisconsin, to -wit:
North Half of Northeast Quarter (N'r of NE- and Northeast Quarter of North-
west Quarter (NEµ of NWu) of Section Five (5), Township Twenty -eight (28)
North, of Range Fifteen (15) West, St. Croix County, Wisconsin.
I
s
North Half of Northeast Quarter (N of NEi) and Northeast Quarter of North-
west Quarter (NE4 of NWu) of Section Seven (7), Township Twenty -eight (28)
North, of Range Fifteen (15) West, St. Croix County, Wisconsin.
The above described real estate is subject to highways and to easements of
record and conveyance of land to St. Croix County for highway purposes.
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Together kli all .n d the hcredit;unent.� and appurtenances thereunto belonging or in any wise apper-
taining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part les of the first part,
dither in lav: or equity, either in possession or expectancy of, in and to the above bargained premises, and their heredita-
ments and appurtenances.
To have and to hold the said premises as above described, with the hereditaments and appurtenances, unto the
said parties of the second part, as joint tenants.
And the said Emil Jacobson and Irene Jacobson, husband and wife, and said Irene
Jacobson in her own individual right, _- parties of the first part,
fnI themse Ives ,theigteirs, executors and ;uJntinintr ;hors, du
.._.covenant, grant, bargain, anti abree to and
. ith the said parties of the wcoml px anti to and with the survivor of them, his or her heirs and assi ns, that at
th(• time of the cnscalin and dcticet of these lwcscnis they are - well seized of the premises alxnt,
ii w 1 ilw(l, ns of a fond, 'ur(, pelfert. al),;olutc ;111(1 indcfc;l.;ihle e5t;ite of inheritatwe in the I;tw, in fcc simple, and that
the s;une are fret ❑ id clear front :ill in Mimever,
and that the above bargainc(1 ltreniisc, in the ttuict anal peaceable possession of the said parties of the second part,
;u joint tenants, his or her heir; and ;tssi,�ns, ;) - ,ain �l Al ;ind every person or persons lawfully chiming the whole or am
h,ut thereof, they v611 11ARR'AVI' AM) DEFFNI).
In Witness Whereof, the s.1i�l p,u t ies of thi• lira part ha x'e hereunto set - their bonds and
T-t't
"%il s this C.) l'I" of November A. D., 19 66.
Signed, Se; le(I and I )cli�crr(I in Presence of
`j Emil Ja
I o e Ja cobson
Harold D Olson
- - -- - - - - -- -- - - -- ... - - -- -- -..- -- - --
-- --____ _ SEAL
PeZ)rl GrC) tc nhuJs
STATE 01" WISCONSIN, 1
St. Croix Count.
Personally c;intc before nu•, thi- C' day of November A. D., 19 66
the above named Emil Jacobson and Irene Jacobson, husband and wife, andsaid Irene
Jacobson in tier own individual right,
to me known to br the person s \vho (I the foregoing instrmucnt and acknoicle(IL�ed the same.
H 1). Olson
Notary Puhiic,__.,S - t - , ..Ct,O.jX County,
is permanent
My ( . . , 1 { I -
Drafted by Harold U. Olson, Atty.
(Sect Ion 59.51 (1) of the Wlacnnsln Statute. pror Ides that all lntrumenta to he recorded hall have plainly printed or typetrrltten thereon the
name* of the grantor., Qrentees, wit—. end notary)
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BOOK �.f� FiICCEtJ
'MJICT- -05 -99 TUE 13:01 NELSEN -WEBER LAND SURVEY 171523:56611 P.01
F TRANSACTAL 0 of
t P, znnf FnoM:
NELSEN W a
LOOM suRVEYNJ4
DEFT PHONE: (11512r. -Mi
FAX i FAX i (715) 235611
comWN"
611121
CERTIFIED SURVEY MAP
LOCATED IN THE NW IM OF THE NE lib OF SECTION 7, T. 28N., R. 13W..
TOM -OF CADY, ST. CROIX COUNTY. WISCONSIN
•� N ,� PREPARED FOR.
APPROVED CL t FFORD LuND
St. CROIX COUNTY O
AM ZOGN Nd Ps*s coo!.-Ill i •
SEP 2 61999 tt 5 0 2� w ` 6
Ir na aeoMs4 wNNO ao s ays � �,�' �
sov►evar MA MW VoldN 0nau ee
NORTH QUARTER CWWER NORTHEAST CORNER
SECTION 7 - ro
NAIL 7 - FOUND
COUNTY SURVEY NAIL 3i4' IRON REBAR
UNPLATTED L9A(DS
NORTH L INC OF 7w NE 1,
_ _ YQ46
N89�33' t9 '_E_ R .+ 0TH N89 z9'£ 592.3,9-
92. 38' -- 76 7,90 W
AYEMMIF 10 .17.F.__...�
67_00'
CA: $ $ to
,+; s 10MWAY SETBACK LINE .1:
....................... ...
3. a� c Es ..... �c
168,583 50, FT. a
J: 3.42 AC. EXC. Ro-W
X: M9,036 60. FT. xi .
589 29' W 592.38' y
,UNPLATTED LANDS
LEGEND
O • SET 1' X 24' IRON PIPE *EIGIIING
1 - 13 LOS. PER LINEAR FOOT
DEAR MOS REFERENCED TO THE NORTH
L ME OF THE NE l,% OF SECTION 7.
WASURED AS N89 !ST. i18p{
CROIX COUNTY COORDINATE SYSTEM )
• I ••ISO' 'y� y O Q
suRv�
O 73 150 300 i
• SHEET I OF 2 JAWS K NUMER S -1804
NELSEN -1 BER LAND SURVEYING
99213A THIS INSTRU/1EN7 DRAfTED BY JIM ME @ER DATED • -Z
V01.13 Page 3731
r �
A parcel of land located in the Northwest Y of the Northeast JK of Section 7, Township 28
North, Range 15 West, Town of Cady, St. Croix County, Wisconsin, more fully described
as follows:
Commencing at the North Quarter Corner of said Section 7;
Thence, North 89 0 33 1 29" East, along the north line of said Northeast V., 286.88 feet to the
POINT.OF BEGINNING;
Thence, continuing along said north line, North 89 °33'29" East, 592.38 feet,
Thence, South 00 °3524" West, 284.63 feet;
Thence, South 89 0 33 1 29" West, 592.38 feet;
Thence, North 00 °35'24" East, 284.63 feet to the point of beginning.
Contains 3.87 acres or 168,583 square feet. Subject to right of way for 50 Avenue as
shown. Also subject to any and all additional easements, right of ways, or conveyances of
record.
SURVEYOR' CERTIFICATE
I, James M. Weber, registered land surveyor, hereby certify: That in full compliance with
the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions of the St.
Croix County Subdivision Ordinance and under the direction of Clifford Lund, I have
surveyed, divided and mapped the above described parcel of land and that this map is a
correct representation thereof.
co Dated this day of v ,1999, `�
MM M.
— --� -� "�� � � 1AIE817t 'k
James M. Weber S -1804 swot
NELSEN -WEBER LAND SURVEYING, INC.— - _ <_ M V' OQ
NOTE: y� SUpV�y
The parcel shown on this map is subject to State, County, and Town laws, rules and
regulations (ie. wetlands, minimum lot size, access to parcel, etc.) Before purchasing or
developing any parcel, contact the St, Croix County Zoning Office and the appropriate
Town Board for advice.
. f
99)13R This instrument drafted by Jim Weber,��,
-„� •tl � w k
SHEET 2 OF o
N� r
Vot -13 Page 3731
State of Wisconsin County
Safet and Buildin Division SANLTARY PERMIT S+ - C r - O x
Integrated Services Bureau Uniform Permit Number
r fe Renewal
Personal information you provide may be used for secondary purposes (Privacy Act, s.15.04 (1)(m)].
Permit Renewal Date Permit Transfer Date Original-Permit Issuance Date State Plan ID Number
7 7
Property Location _ J T wn 11 Village El city of:
1/4 L 1/4,S T N,R - 5 94M) W
of Number Block Number ubdivision ame Nearest Ro�Lake or Landmark
J 50
PREVIOUS SANITARY PERMIT HOLDER - IF CHANGED: NITARY PERMIT TRANSFERRED TO:
Name (Please Print) Signature Name (Please Print) Phone Number
Address Phone Number Street Address, City, State, Zip Code
I, the LgVersigned, ume responsi for installation of the private sewage system that has been previously approved for this property.
to a Signature Previous Plumber Name (if changed)
PI ber Address ���� yy Previous Plumber Address
�S l� u / s S
/MPRSW Number Pho a Number MP /MPRSW Number Phone Number
Issuing Agent Signature
SBD -6399 (R.04/96) Distribution: Original - County; Copy - i /
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