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HomeMy WebLinkAbout004-1028-20-000 • ST. CROIX COUNTY ZONING DEPARTME b AS BUILT SANITARY REPORT' Owner jil 6 � N Property Addr s 0 i° sT Corx City/State Nry s ti Legal Description: Lot Block Subdivision/CSM # ,4y,� t /4 ,37�/ t/4, Sec. L�L, T Lg N -RAW, Town of PIN # ® - a-- a nd SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC/ / .SG Setback from: House 7e Well / P/L 7-�� Pump manufacturer Model Alarm location Z rs e (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: Width - Length S4 Number of Trenches Setback from: House k e Well /off P/L _ 1, 2 Vent to fresh air intake ELEVATIONS Description of benchmark S'C-r- �. �' ASS �r� elevations Description of alternate benchmark Elevation Building Sewer 1jQ 7 ST/HT Inlet rf S / ST Outlet PC Inlet PC Bottom Header/Manifold , S. Top of ST/PC Manhole Cover Distribution Lines () () ( ) Bottom of System Final Grade Date of installation =r ",/I-Wrermitt numb r 33 State plan number / 06 0 9: Plumber's signatur icense number -Q�5-� Date Inspector Complete plot plan J NOTIC p!veshe fcto •� '`, p o view sketc s owin ev!!��y#Nn 100 feet of the system. i/� �PiA 4 C Two-4-".4e enter of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN a 0 Bf v - C / 5� r- 3ao �� 6 M40-wv \ Se,kt /�gsSlt�CfO .7 s�pf /lJ -s f 7��k * 8 bu p �'�C CL'A F 11 p4 LVe I 13.R A !10,7 j Moire N T ©p o CO3CV -1 L ' SIM �3 r INDICATE NORTH ARROW i YC Wisconsin Department of Commerce PRIVATE SEWAGE S YSTEM v Safety and Buildings Division Count INSPECTION REPORT 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)j. ST. CR IX Permit Holder's Name: El City ❑Village 9 Town of: State Plan D o.: KEMSKI, TODD & MELISSA CADY CST BM Elev. - - Insp. BM Elev.: BM Description: Parcel Tax No.: ) DO Z e, TANK INFORMATION ELEVATION DATA A9900089 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benc m rk , 62— 10 5y Dosing 0* "— 5 I.ZL I 0 • era Ion Bldg. Sewer !�? - /0`7. 17 Holding St/ Inlet a� 67 e ?Y. TANK SETBACK INFORMATION St/ Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet irl e tic NA Dt Bottom aj/. 7 Y Dosing NA Header / Man. 74S q7. S% Aeration Dist. Pipe - Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer G o Z/-ld S Demand k �� /pp,/ Model Number c(4j q11 37. ��GPM t ' 12 / 0 7 j TDH Li ft L oss 6g SystemZ TD Ft Forcemain Length 35' Dia. F 2 ' I Dist.ToWell S ABSORPTION SYSTEM $ EDJARENCH Width >> , .r Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth ENI N 4�� �� DIMNI N SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O / r , CHAMBER Mo Number: • System r.", / f'1 60 I Z v OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s), x Hole Size x Hole Spacing Vent To Air Intake t , / Length _3L Dia. length 3-q Dia. � Spacing 3 , i/4 a� 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.) LOCATION: CADY 1 2.28.15.189,NW,SW 423 020TH ST EET Plan revision required. ❑ Yes ❑ No Use other side for additional information. G �' SBD -6710 (R.3/97) Date Inspector's Sign ur �ert ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: £ A JA E # # . , # s �.,. �. ,: F F 3 „ ....:,.� e o—vo—t n... a ®. .... .e { 4-1-1 f __.., rv.w e a.a.. I.I.J. .<..,. T_7 W.r e , _.,,.. 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I, Safety and Buildings Division ' S ANITARY PERMIT APPLICATION . o Bow3o2ngt VisConsin 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 81/2 x 11 inches in size. ST CROIX • See reverse side for instructions for completing this application State Sanitary Permit Number 33�wo Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. � rans. tate Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION # 210493 Site # 167063 Property Owner Name Property Location TODD & MELISSA Kemski NW 1/4 SW 1/4, S 12 T 28 , N R 15 ) W Pro Owner's Mailing Address Lot Number Block Number 423 30TH STREET N/A N/A Cit_StaS� WI 7 612)240-2744 hone Number Subdivision Name or CSM Number 1NVAAY 4 /CF N/A II. TYPE 0 6 ILDING: (check one) ❑ State Owned ❑ It Nearest Road ❑ village CADY 320TH STREET Public 1 or 2 Family Dwelling - No_ of bedrooms 3 M Town OF III BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 12.28.15.189 & 004 - 1028 -20 -000 1 ❑ Apartment/ Condo 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 ________ ExlstingSystem 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 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ 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 450 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 375 375 .5 N/A 96.84 Feet 99.13 Feet VII Capacit TANK in allo s Total # of Prefab. Site Fiber Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank 10001 1000 1 MIDWESTERN PRECAST ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 6501 1 650 1 MIDWESTERN PRECAS ® 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Z s Signature (No amps) MP /MPRSW No.: Business Phone Number: BENNIE HELGESON 0292 715 - 772 -3278 Plumber's Address (Street, City, State, Zip Code): W1229 770TH AVENUE, SPRING VALLEY WI 54767 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permi ee (Includes Groundwater ate s e Issuing Agent Signature (No Stamps) Surcharge Fee) Approved []Owner Given Initial Adverse Determination f X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber r 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. 111. 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, 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. ---------------------------------------------------------------------------------------------------- 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 2226 ROSE ST LACROSSE WI 54603 -1905 �sconsrn Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary Department of Commerce February 11, 1999 CUST ID No.268093 ATTN.• POWTS INSPECTOR ZONING OFFICE HELGESON EXCAVATION INC ST CROIX COUNTY W1229 770TH AVE 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 02/11/2001 Identification Numbers Transaction ID No. 210493 Site ID No. 167063 SITE• Please refer to both identification numbers, Site ID: 167063 above, in all correspondence with the agency. St. Croix County, Town of Cady NW1 /4, SWIA, S12, T28N, R15W Facility: Todd & Melissa Kemski FOR: Description: Replacement Mound Object Type: POWT System Regulated Object ID No.: 450266 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 02/10/1999 e FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 derard 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 INDEX SHEET PROPERTY OWNER: TODD & MELISSA KEMSKI 910 HAZELWOOD STREET ST PAUL MN 55106 PROJECT NAME: TODD & MELISSA KEMSKI PROJECT LOCATION: NW 1/4, SW 1/4, S 12, T 28, N, R, 15 W MUNICIPALITY: TOWNSHIP OF CADY COUNTY: ST CROIX CONTENTS Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout Page 4: Tank Specifications Page 5: Pump Specifications Name: Bennie Helgeson Signe Address: W1229 770Th Avenue Spring Valley, WI 54767 Credential number: 220292 Date: February 8, 1999 P. Co;ldit + � P M Nj Of COMER 05 t CE AF LD13'► PEN SRRES 1 ( Jrt��Jer / od�c� f � csa A C�rS�� 0 A 1yV i p l � ^ � P 70 5� �• t 1 .5ko * 8 3 �io�oS acS[- s�P <.� 7 pIIp� �X.s�r1 3� tlo, 75 /�oine `n TO� e� Cor.crc� sl&6 i Yo I -- �' ti� �►e. Tact d a ti'11 15 Page Of , Or Synthetic Covering Distribution Pipe Medium Sand r-le" . H _ _ G Topsoil F �' g !3 1 E D \ u b • /a %Slope Bed Of Force Main Plowed Aggregate From Pump Layer D Ft. E x Ft. Cross Section Of A Mound System Using F r7q Ft. A Bed For The Absorption Area G Ft. A n.2S Ft. H Ft. Signed: B Ft. License Number: K Ft. L BS S YFt. Date: '7,5/ Ft. T 19.�Y Ft. Force Main W 3 3. Y S - Ft. L i Observation Pipe--,,, J_ 6 .._.__... -- --- - -- K A l � ------------- - - - - -- ------------------ - - --.� Distribution Bed Of 2 2 Pipe Aggregate I Observation Pipe Permanent Markers Plan View Of Mound Using A Bed For The Absorption Area I • P f er oroled Pipe Oetoll 0 End Vlew ) POrtoroled End Co 1, � r'e PVC Pipe Permanent End Markers �. ° � °n O`� s Holes Located on Bottom are Equally Spaced PVC Forte •Main * From Pump / PVC ENO Monlrotd Pipe CA P ' rr 1 y P ✓c. 04irlbulion.. Pipe l.oet Hole Should Be Next To End Cop Distribution Pipe Layout t P a.9 R S r X Y 3� Signed: Hole Diameter ! Inch License Number: Lateral " Inch (es) Date: Manifold " Inches Force Main " o;� Inches holes k aic"C' J -noCr/ F 1 leu. 97. 3 r i7 � o; cA. ' To i d r Ow K .,r& i2i, t Page O f _ COMBINATION SEPTIC TANK /PUMP CHAMBER 4" Cl Vent Pipe with (No Scale) !Approved Cap, +25' ,Approved Locking Manhole Cover From Buildings With Warning Label Attached /11% Weatherproof Approved _ .Warning Label Junction Box Vent Cap 12 Minimum Final Grade -, 6" Minimum 4" Minimum 6" Maximum 41, C.I. Quick 18" Minimum Insp. Pipe Disconnect � t 1/4" Weep Hole Baffles D , t Approved Joint i A 4 w /C.I. Pipe I Extending 3' Alarm 0 B Approved Joint Onto Solid Soil On 6; w /C.I. Pipe I C Extending 3' �X 6 , $ y ' Onto Solid Soi Off D :, Conc. Block 3" of Beddinq Under Tank Note: Pump and Alarm Are on Separate Circuits Number of Doses:�Per Day Gallons Per Day /# of Doses: / / .2•S — Gallons Volume of Backflow: ...... .+ — ,57 Y Gallons Total Dose Volume: ....... . = Gallons Tank Manufacturer: ,,< <�N «�� �-7 G.-�i �or� Tank Size - Septic /Pump: so a ons Alarm Manufacturer: 15 /�f. � Model Number • o c,c� Capacities: A / 7 inc or,300 Switch Type: r 9 + B - inches or Gallons Pump Panufacturer: + C am_ inches or Model Number: + D inches or QS s Gallons Total....._ — inches or Minimum Discharge ate: ­-t �`X - �-_ Vertical Difference Between Pump Off and Distribution Pipe:�Feet Minimum Re uired Supply Pressure:. • .... ..+ a,_,5 Feet 3� Feet of Force Main x ,,[y Friction Factor /100 Feet: * / o eet _ Inch Diameter Force Main Total Dynamic Head:...= n8Feet y C? Internal Tank Dimensions: Length �79 " ; Width 95 Liquid Depth )d ' I Signature License Number Date i MODEL: 3871 Submersible SIZE: 3/4" SOLID', RPM: 1550 Effluent Pum p HP: 0.4 METERS FEET 8 _ 25 - 7 � o w g 20 �- Q 5 15 ........... _� __ ( -- J N 3 10 O -..__. .• 5 1 - -- - 0 0 0 i 0 20 30 , 40 50 GPM 0 2 4 6 g 10 12 m' /h CAPACITY (D GOULD�S Effective October, 1988 f%WAMaE WITHOUT NOTICE PRi IN U.S.A. Wiscondin Department of Industry SOIL AND SITE EVALUATION Labor ana�Human Relations Page / of - Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code 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 t ���} / percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please Pr' A " ;'»,. Reviewed by Date Personal information you provide may be used for secoy�oses (Privi Law, s�1,04) (m)). Property Owner 1 dulS Z c� �o cunC i tIj / \"rty Location W Fr+ i c3c� 46vt. Lot U) 1/4 1 101/4,5 r2 T _)S ,N,R ,S E (o WW ro Property Owner's Mailing Address -- fC�g� Lit.# Block# Subd. Name or CSM# r y 3 3 X3 T k s1- IT , ! 1, City State Zip Code nom, = City 9 ❑ Vill Town Nearest Road 14 Iq hF •' ❑ New Construction Use: L`SResidential / Number of bedrooms 3 Addition to existing building (replacement ❑ Public or commercial - Describe: Code derived daily flow 4�SQ gpd Recommended design loading rate bed, gpd/ft trench, gpd /fiz Absorption area required Z _ bed, ft 3 trench, ft Maximum design loading rate , 5 bed, gpd/ftz trench, gpd /ft Recommended infiltration surface elevation(s) 92 • V-1 0 . R V && ft (as referred to site plan benchmark) Additional design /site considerations f car 4 461 1 r aypor CA j Use Parent material �,17� Oder �jL� Flood plain elevation, if applicable It S = Suitable for system Conventional 2- Qs In- Ground Pressure AT- Grade System in Fill Holding Tank U = Unsuitable for system ❑ S �1 L- s- 11 U El 2 El n S u ❑ S 9-u ❑ S SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench � —� 0 3 v&sbl t- t s .2 53 I� S Ground 1r l.J elev. V % S fe3 L 0 1 Depth to limiting factor fta_ -in. f�5f" WC,•c?� Remarks: Boring # r r� ,�" i� 1 4 I f' 3 Ib o s 3 " 1 u s �- Uj I LJ S Ground - y!R O , - V C elev. ft. , Depth to limiting factor 11b_in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number C,0 ( aa-� ;7Z o T 4c) I SOIL DESCRIPTION REPORT PROPERTY OWNER �OCAt S Page —) of .2" ' PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed .Trench 2 s Ground C 9-� 1 V y 41 Depth to limiting factor Ji— E� �6v-), Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench Boring # Ground elev. ft. Depth to limiting factor ' Remarks: Boring # Ground elev. h. Depth to limiting i _T factor in. Remarks: SBDW -8330 (R. 08/95) 41cl CD rs e EJ2 $for e u Elev. 3- a 1 00.00 A ICY\ f, d i (3. Nl .�$ .2 I O.7 S c%� ( 'T of CC)rk(r4e_t wisconsk �epartmentof Industry, SOIL AND SITE EVALUATION Page / of -- Labor and Hugnan Relations Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code 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), directs and t C/06 / percent slope, scale or dimensions, north arrow, and location and distance ton. ,kR road. Parcel I.D. It APPLICANT INFORMATION - Please print all , q ` Reviewed by Date C Personal infomnation you provide may be used for secondary purposo,s (PAvacy Law. t mil" Property Owner L S. Z to /0,L VkC f C ZONING �PeRY Location erg S d 114 5U)1 /4,S �� T .�$ � N,R �s E( w Property Owner's Mailing Address i hoC#, $lock# Subd. Name or CSM# City State Zip Code Phone Number W ❑ City ❑ Village [Town Nearest Road K IW i ( '71 S1 ZA -5 535 3a0 t S•} r�� ❑ New Construction Use: 2fiesidential / Number of bedrooms _. Addition to existing building replacement ❑ Public or commercial : Describe: Code derived daily flow #SjQ__ gpd Recommended design loading rate 7 _ bed, gpd/ft — trench, gpd /ft Absorption area required Z 7 S bed, ft2 375 _ trench, ft 2 Maximum design loading rate S _ bed, gpd/ft • � trench, gpd /ft Recommended infiltration surface elevation(s) 1 76. V k & (as referred to site plan benchmark) It Additional design/site considerations O +' 6 r r — '� [-�� �o•' Parent material 6 Ov e,, Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S �1 ml El ❑ Pr U S '_' " ❑ S aU I ❑ S D"U ❑ S 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 f Ground _�cf (© (� �(�;✓ elev. 5 f 3 c W_ Depth to limiting ; factor Remarks: I I Boring # 0 r r" a of Fn r Q. w c. ��o S 6 1 r \j r, , S. .6 B -/� o c� 41E3 u S �` LJ 1u S 3 16 o Ground y - '11 7 S JR 50 elev. Depth to limiting factor /, in. Remarks: CST Name (Please Print) Signature Telephone No. Address ,/ • Date CST Number W ( o7e.? 7 T f7 *0 e PROPERTY OWNER 1 S !S 2 ip �4cSOIL DESCRIPTION REPORT Page -D p PARCEL I.D.# 0 O Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots s in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench / a Q-1 ( vt 3 � S S i t � S� I- e ,« Ground e J tr Depth to limiting factor FSt 0• W, Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # £k , A Ground elev. ft. Depth to limiting factor in. Remarks: Boring # J Ground elev. ft. ' Depth to limiting factor "'' Remarks: SBDW -8330 (R. 08/95) 3 e d -3 • � ' t X1.0 �f �_.___.._.1__Q �.._- - -..__ .__ _______ �c�ne -ou.ic ��1&DaV � To . 4...._'.! ���.!_�� Kc v►� s Sod X r� ' � � r 1 So o 16 y Ekv, 97 R.M.01 too-00 ` �'7C1 r �1 i 8.\ � �-Y•c` 11 Jta l � r kz b6 c S�', .ZU ,zo .• �sS woc�� 1 �.;F -.-' c�� c r E IC�.%� I I i � •3 Q C c: � �. M #.� 110. 7 S ao d T f o P o �OhCref slab i I i I �r t j n 1 , ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address �/o WC, .a e / cv C, Q �( _S7-, tt � P, ( V g 0 6S ) 0(1, Property Address 9) 3Av 57R / (V required from Planning Department for new construction) City /State 'k NfiP' w 5Yf'W Parcel Identification Number /o� • �8• � LEGAL DESCRIPTION Property Location Al Ct1 '/4, SGO '/4, Sec. /a . T , 18 N -R /5 W, Town of Subdivision , Lot # Certified Survey Map # . Volume , Page # Warranty Deed # , Volume NOV Page # Spec house ❑ yes ❑ 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, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days ee year expiration date. II�` / g 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 �the7prope d scribed above, by virtue of a warranty deed recorded in Register of Deeds Office. ! G 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 YOL 1404 M[581 STATE BAR OF WISCONSIN FORM 1 — 1982 59$10.4 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS DOCUMENT NO. ST. CROIX CO., WI RECEIVED FOR RECORD This Deed made between Louis Zupanci and Jane 02 -19 -1999 10:00 AM - E. Bungum, 'husband and wife WARRANTY DEED EXEMPT # Grantor, CERT COPY FEE: and Todd A. Kemski and Melissa E. Kemski, COPY FEE: TRANSFER FEE: 367.50 husband and wife RECORDING FEE: 10.00 PAGES: 1 Grantee, Witnesseth That the said Grantor, for a valuable consideratio conveys to Grantee the following described real estate in St. Cro THIS SPACE RESERVED FOR RECORDING DATA County State of Wisconsin: NAME AND RETURN ADDRESS The Southwest Quarter (SWI) of the Southwest E1/ VRUM28ffMMMN& Quarter (SWJ) , in Section Twelve (1 2) , p080X750 109 ILMMSL Township Twenty Eight (28) North, Range BNVERM"MA MW Fifteen (1 5) West 9 -5 !� q 1 2.28.15.189 PARCEL IDENTIFICATION NUMBER O o �l- /D� �- �o - po 0 This i homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend the same. Dated this day of February ' 19 99 (SEAL) (SEAL) = A Quis Zupancic (SEAL) (SEAL) dw = ane E. Bu AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. Pierce County. authenticated this day of , 19 Personally came before me this L day of February , 19 99 , the above named Louis Zupancic and Jane BunQum, husband and wif _ ":^��. TITLE: MEMBER STATE BAR OF WISCONSIN '• (If not, authorized by §706.06, Wis. Stats.) to me kno a son o executed instrum edge the am '• • • :2 i THIS INSTRUMENT WAS DRAFTED BY u •: •� a' Louis Zupancic G.F. Gunderson 423 320th St., Knapp, WI 54749 Notary Public, Pierce . Couhcy, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) 10/22/2000 ,) • Names of ,xrsons signing in any capacity should by typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., tnc.