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HomeMy WebLinkAbout012-1006-30-000 / ? 0 t � R n 3 i � 2 m co @ � ) ( f ° § \ § \ � CD CD o ( / 0 o = Pi f 0 \ § 2 m 4 > ■ % § z e @ ® R — \ � ¥ o ® � ® \ $ § : / § co £ 2 E c c c % § r� Z ;z — 03 o } 0 0 0 e 3 ® § § § k : § R : ca (a ca a 2 O Q \ ® 'a o v /. E =r CD )i� ® k ; e 0 2 ®� ( / r rr 0 \ \ g �- f } § %CD % o \ } 7 § a ■ o 0 a z (D . ` ` ƒ E CL 0 2 0 . . k e � k \ � ] 7 m § F $ 2 � D $ � \ »o\ ) ! . m8k ■3 ; of / c \\\ qi ƒ a§ C'nx 2 ( r o �m \ m / k / * 0 $ / \ % 00 \/ �\ 0 C Parcel #: 012 - 1006 -30 -000 06/27/2005 09:47 AM PA IOF1 Alt. Parcel #: 01.30.17.2B 012 - TOWN OF ERIN PRAIRIE Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): " = Current Owner ` SLICER, ROBERT A & JULIE M ROBERT A & JULIE M SLICER 2061 180TH AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description " 2061 180TH AVE SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 1.500 Plat: N/A -NOT AVAILABLE SEC 01 T30N R17W 1.5A NW 1/4 NE 1/4 E Block/Condo Bldg: 190 FT OF W 564 FT OF N 343 FT Tract(s): (Sec- Twn -Rng 401/4 1601/4) 01- 30N -17W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 744/39 07/23/1997 428/41 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/10/1999 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.500 7,800 46,900 54,700 NO Totals for 2005: General Property 1.500 7,800 46,900 54,700 Woodland 0.000 0 0 Totals for 2004: General Property 1.500 7,800 46,900 54,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 123 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Property Address 41 Z244hs-e- City/State Legal Description: Lot Block — Subdivision/CSM # 11Z,�2' /a �'/4, Sec. L, TAN -RAW, Town of ,� �°� i�.r PIN # �Z — �d C) �'' ?D SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer G✓ Size ST/PC AVdl Setback from: House � Wel �PAL, S� Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Ve�ntto fresh int _ W me Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system:/;n/ Width Length 6 Number of Trenches Setback from: House 00 — Well IZ6� P/L Vent to fresh air intake ELEVATIONS Description of benchmark Elevation Description of alternate benchmark !. Elevation Building Sewer ST/HT Inlet �6✓ �s ST Outlet S PC Inlet r' PC Bottom ­­ Header/Manifold �`� 36 Top of ST/PC Manhole Cover , Distribution Lines( ) j y" 3 ' ( ) 9 ( ) 93,70 (�-2 (�VJ ��•� Bottom of System () () , �� . 7 2 ( ) Final Grade ( ) 2 s Date of installation /D 13017 Permit number 3 S State plan number Plumber's signature License number �Z6 Date/ /3/// Inspector Complete plot plan Or 4 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. D PLAN VIEW G v 0 6 3_ 3 X6a INDICATE NORTH O Wisconsin Department of Commerce Safs#y and Buildings Division PRIVATE SEWAGE SYSTEM Count y 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)]. 353204 Permit Holder's Name: ❑ City ❑ Village [2 Town o : State Plan ID No.: 9 , T c Town of Erin Prairie CST Bb Elev. : - Insp. BM Elev.: BM Description: Parcel Tax No.: 1 00. 0 ( 1 op ,0 / - IMF I 012- 1006 -30 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark o 3 .go lllJ, O Dosing Alt. BM Aeration K Bldg. Sewer ( �S 9� . 15 Holding St /Ht Inlet -Tw, - 25-- TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt millet Air Intake Septic 2. 0 r (a / `� NA Dosing NA Header/ Man. 3 o Z :94 9 , Aeration NA Dist. Pipe ��• re �---- z . Holding Bot. System 41: N. PUMP / SIPHON INFORMATION Final Grade ( 3Z '7-7,579 ManuUcj and St cover S 3° Model Number GPM TDH Lift Fr' ' n em TDH Ft ea Force Length Dia. Dist. To Well SOIL APQRPTION SYSTEM c�rw. eta c.0.` � 41W BENCH ) Width r Lengt No. f T enches PIT No. Of Pits Inside Dia. Liquid Depth DIME I 3 S 3 DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manuactyfer :� SETBACK CHAMBER Ghtvlo-► d�•r CAi� INFORMATION Typeo , / i Moe Nu er: System: CoA + ,20 7 /Zo OR UNIT �a DISTRIBUTION SYSTEM Header / Mar)ifold u Distribution Pipes) x Hole Size x Hole Spacing Vent To Air Intake Length� Dia. Len ia. Spacing (p0� 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 E] No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: /1/5 Inspection #2: Location: 2061 180th Avenue, New Richmond, WI (NW1 /4, NEIA, Section 1 T30N -R17W) - 1.30.17.2B 1.) Alt BM Description = I'M 2.) Bldg sewer length = 10 -amount of cover � ago PL/ ���t3�� � w'� �-- c� IL��e�(J, Plan revision required? ❑ Yes A No Use other side for additional information. t ( aq QQ s Z fo SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH A SANITARY PERMIT NUMBER: 7— L g � Y s` i E 2 � i s � � [ I "jT• � � 3 i e r I � � i I g e z E E i gygy I _. Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue Vi sconsin In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper ngless County C , than 8112 x 11 inches in size. J • See reverse side for instructions for completing this application , StatA Sanitary Permit Number Personal information you provide may be used for secondary purposes a U A C , � �]C�tleck if revision to o previous application [Privacy Law, s. 15.04 (1) ( m )] . h ��� (.y,] P tate P Slan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL F R N Property Owner Name Prop Location'i IC ri4- 11�,S T 3 , N, R E (or) (@ t Property Ow is Mailing Address b Block Number 'Z o ! 4 t4- � City, State Zip Code Phone Number ubdivision Name or CSM Nu er J V Il a g e II. TYP B DING: (check one) ❑ State Owned ! Nearest Road Ej Public or 2 Famil Dwellin - No. of bedrooms ow OF r) ti T d III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) .'7 U �� 2 1 ❑ Apartment/ Condo 1 ©` Z ^ /&0 G ' ` LTD 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_ Q Repair of an System ......... ystem _______ ____ __ Tank Only_ ___ ________ Existing System ____ ____ExistingSystem 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 Q Holding Tank 1 ZE,;eepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 Q Seepage Pit _ 43 ❑ Vault Privy 14 ❑ System- In -Fi11 3 3 36 a L' a VI. ABSORPTION EM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System E1ev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation Q 9 0 $ S 9 2, Feet 7--C) Feet VII TANK Capacity gallons Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank i � (,v El L1 1:1 1:1 Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plum=si ture: (No S s) MP PRSW No.: Business Phone Number: ;f �'a6g6 lam Plumber' ddress (Sjeet, City to Zip Code): ` J r IX. COUNTY / DEPARTMENT USE ONLY []Disapproved S nitary Permit Fee (Includes Groundwater ate Issued Issuin Age`Sign tu�mps) Approved ❑Owner Given Initial Surcharge Fee) `l � Adverse Determination �25 X. CONDITIONS OF APPROVAL / REASONS FOR DJ,SAPPROVAL• 191 _ 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. 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. ---------------------------------------------------------------------------------------------------- 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. PLOT PLAN PROJECT Robert Slicer ADDRESS 2061 180th Ave New Richmond Wi 54017 NW 1/4 NE 1 /4S 1 /T 30 N/R 17 W TOWN Erin Prairie COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 10/23/99 BEDROOM 3 CONVENTIONAL XXX IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 954 # of chambers 30 BENCHMARK V.R.P. Base of Siding ASSUME ELEVATION 100' ❑ BOREHOLE (DWELL *H.R.P. Same as Benchmark SYSTEM ELEVATION Alt. BM Top of L.P. Tank @ 102.3 190' Property Line ' D W Vents 10' 30' Well B- • 4% Slope T 15' S' B.M. 5 75' Existing 3 4' Alt. B -1 Bedroom M. House 15' 12 -S 10' 0 5 30' B -2 3 -3' X 65' Trenches with 6' Spacing Vent M Gl 12„ Sidewinder High of Cover Capacity Leaching " Chamber with 31.8 ft ^2 per chamber 6' Long 16 34" Grade at System Elevation a� a t~ a M M 180th Ave Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with Comm 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 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. R � e iewed b Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). llllY!! Property Owner Property Location , n Govt. Lot �/ 1/4)V 1/4,S T ,N,R E (or Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# City c � S tate Zip Code Phone Number ❑ city ty Village ,[Town Nearest Road A/ � � ❑ New Construction Use: �Fiesidential / Number of bedrooms Addition to existing building E ;k Replacement ❑ Public or commercial - Describe: Code derived daily flow Cgpd Recommended design loading rate bed, gpd /fi trench, gpd/ft Absorption area required bed, ft 900 trench, ft Maximum design loading rate z Z bed, gpd/W `s trench, gpd /ft Recommended infiltration surface elevation(s) !?2. ft (as referred to site plan benchmark) Additional design /site considerations Parent material ! Flood plain elevation, if applicable dr✓JP ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = unsuitable for system ,® S ❑ u 0 S ❑ U Z S ❑ U ®'S ❑ U ❑ S � �U I ❑ S u SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench D -9 / 0- 1/ - 31Z !' S S .� Ground 3 /yi tiJ� el� , 1;3 7 tco Depth to limiting facto, ? Z S in. Remarks: Boring # n r b (9, o`� - Yo p c Ground lev 1 ft . Depth to limiting fact 7 /m in. Remarks: CST Nam (Please Print) i ture Telephone No. 2/5 1 Address Date CST Number I r /J� OIL DESCRIPTION REPORT ' PROPERTY OWNER / `- «���L"� `-' �(: eJ � Page of 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 i Z Ground 6� ZZ 9 ,elev./ ' ft. Depth to 2 limiting factor ;�z Remarks: Boring # HBO 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 in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in ' Remarks: SBD -8330 (R.9/98) Soil Test Plot Plan Project Name Robert Slicer Shau d Address 2061 180th Ave New Richmond Wi 54017 M #226900 Lot ---- Subdivision - - -- --- Date 10/23/99 NW 1/4 NE 1/4S 1 T 30 N/R 17 W Township Erin Prairie Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Base of Siding System Elevation 92.4 *HRP Same as Benchmark Alt. BM Top of L.P. Tank @ 102.3 190' Property Line ' D W 10' B- 30' Well. • 4% Slope V 15' S*.M. `l 75' S Existing 3 4' tilt:_. Bedroom House 12 15' a 35' 30' B -2 o > ih M N N O M M 180th Ave ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND. OWNERSHIP CERTIFICATION FORM 1 Owner/Buyer t '( h Mailing Address - 2o (o ) y ` et Property Address /J-ekc ►2� v�,,�� j a S L (' 0 1 (Verification required from Planning Department for new construction) City/State Parcel Identification Number e�?�z ` /x �) �- 3(�' o00 LEGAL DESCRIPTION Property Location l� /,�1/�1/� y,,, Sec. . T 3 U N -R-L--2—W, Town of Subdivision Lot Certified Survey Map # . Volume , Page # Warranty Deed Pa Volume e # g Spec house ❑ yam_ Lot lines identifiable yes El 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, journeymanplumber, restrictedplumber 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 of the three year expiration date.% -- Iv lZ 3 SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this forma are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, 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 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 10, kl�ff "m . _. 9TATJ1 UN OXOX N'ISWNSIN YORK 1— I= , TNU WkWA roe seoawa0! OATA WARKMM Ono RECASTERS OFFICE .e ms between Bill .e7c8�ex aid. Hazel ST. CROIX CO.. �- a .,........— x... ., w. .j 2tti ................ «... � for Roo:xd this_ 18 h 1 �ts .....--- • ..... .............. ............................ d► O L June AD l9 a6 _.., Rat A..Si.ncl.aJulie kl...S..ic _..._ (ate. 8: 30 A A ........... �d_.tecu3. ...aa_sux�i.�rcaratg_._ ....... _ i ........«.. PT OPert3T ..................... . . .. ............ ......................... . ... .... . w. ..............•............................._ ...._.......................... .I Grants*. Witnesseth, That the said Grantor, for a valuable consideration....__ . Qt. rV8111r >�..CO[18 dBr8t3C11 .. -- - -• -•- — — NsruRN T T HE FIRST UATITIAiL BMI( ; eoo"ya to Grantee the following described real estate in ......... St..Aknix...... , c,�,unta, stag of w iaoonain: BOX 1 5 RIVER FALLS, i lSC 54022. i NS Tax Parcel No: .. .................... ..._........ S –� r i Beginning at a point which is 374 feet Fast of the NW comer of � the NA of the NEk of Section 1 30 - 17; thence East 190 feet; � thence South 343 feet; thence West 190 feet; thence North 343 feet to the point of beginning. Subject to recorded easements, reservations, and rights of way. �j I is is This ............................ homestead property. II I (is) (is not) 4 Together with all and singular the hereditamenta and appurtenances thereunto belonging; l it And.--- - -.... E-:4 .. Berger_- and.litzel_.D... zg - ..... - -.... ----- - - - - -- - warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except !' no exct Lions j I . aid will warrant and defend the same. 1, Dated this -- ----- ---- - -- ---- ----- ---------- day of - - - - - -- ..----- .Jl - - - - - -. -------- - - - - -- -- - - - - -- ......... i it l! (SEAL) GAL - - -- --....(SEAL) Einor - Berger . .. ......................... .... --------- --- -- -(SEAL) .. e= .... J- l{ (SEAL) a el D. Berger ---------- - - - - -- - -- .......................... ............... ---- - - - - -- ----- ------------------------ AUTHENTICATION ACHNOWLBDGMBNT 3ignatnre(a) �' -•--------•----•-------•-------- ----- -- --- -•--- --•- --•-• -- -- STATE OF WISCONSIN II ---------------------- - - - - -- - St. Croix as. --- ---•------•--- --- --- - -- -- ---- County. authenticated this -------- day of ...... .. .................. 19 ----- Personally came before me this ._j2- ---- day of _..'ZL1C a - ------ -----•---------------- 19M-... the above named Eirnor_ .Berger an . Haze _ Berger TITLE: MEMBER STATE BAR OF WISCONSIN ................ ----............................................................ (If Mt, ............. •- -- -- ---- ---- --- ------- •- ._._... authorized by 1 706.06, Ilia. Stats.) to me known to be the person ._ ------- who executed the foregoing / instrument and da a S it owledge the same. THIS INSTRUMENT WAS ORAFTED BY Eric J. Lundell BOX 157 -- --- ----------- ........................ -- •-- ••----- - - - - -- '-- - - - - -- ------------ - - - - -- Gerald F. Harvieux New Riclmrnd r Wisconsin 54017 - -- t. 011{ ......... ... County, Wis. i .. - Nota Public -- -- --------------- -- - (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: may 8, 88 - -- • 19 -- -- •------ ) F. HA1 /;EUX -Naaxs of persons sltnlny in any espaoity should be typed or printed below their signatures, Notary Public — - State of WiscorlS NL WI.r C:onY>ry &TAT BAR OF WISCONSIN MY Commission F �� ......,. FORM Ms. 1 — 1982 U f VAsr,onsirsDepartment of Commerce Count PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) ' aefrn Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)). 353204 ° V4 W" I Permit Holder's Name: ❑ City ❑ Village (R Town of: State Plan 593 Z-6S Town of Erin Prairie CST B E ev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 012- 1006 -30- TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM 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 NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIME NSIONS DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING manufacturer: INFORMATION Type of CHAMBER Mod Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Mani old Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 2061 180th Avenue, New Richmond, WI (NW1 /4, NE1 /4, Section 1 T30N -R17W) - 1.30.17.2B 1.) Alt BM Description= &/2/D� 2.) Bldg sewer length= I� e I h own r - amount of cover Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3197) Date Inspector's Signature Cert. No. _ Safety and Buildings Division w' >`IfS %/f SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue In accord with ILHR 83.05, W's�m, Code P O Box 7302 nt of Commerce ' ' Madison, WI 53707 -7302 teach complete plans (to the county copy only) for the system, on paper ngless C unty lik u than 8 1/2 x 11 inches in size. , r � '1 at Sanita Permit NUnlbei` t See reverse side for instructions for completing this application �Q ' t_ 'San Personal information you provide may be used for secondary purposes S Ckck if revision to previous a tlon (Privacy Law, S. 15.04 (1) (m)1. t.9 PPS Plan I.D. Number I. APPLI TI N INFORMATION -PLEAS PRINT ALL�INF Property Owner Name %, Prop L ion' t <" ' 1 T 3 N, R E (or) W Property Ownf'Mailing Address 1' b Block Number ` L� City, State Zip Code Phone Number ubdivision Name or CSM Number L. TY PE OF BUILDING: (check one) ❑ State Owned ° v la a Nearest Road Public or 2 Family Dwelling - No. of bedrooms Town OF r, r_ j d III BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0/z—/&o6 — 30 — aoti , 2 ❑ Assembly Hall 6 Q 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. E] Reconnection of 5. ❑ Repair of an - _____System _____ ystem___ ----- Tank Only______________ Existing System ________ ExistingSysterT 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 1 seepage Trench 22 ❑ In- Ground Pressure .42 ❑ Pit Privy 13 ❑ Seepage Pit 2 43 ❑ Vault Privy 14 ❑ System-In-Fill ( 3 x 6 5 �r .36 �a a 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 Grad( I Q Regor d (sq. ft.) Proposed (sq. ft.) (Gal y /sq. ft.) (Min. /inch) Elevation 92, Feet 1 '7,0 Fee Cap acit VII. TANK in ltos Total # of r Prefab. Site Fiber Expo INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic Api New Existin strutted Tanks Tanks i Septic Tank or Holding Tank — P ow I w 0,0 L 9 ❑ I ❑ ❑ ❑ C Lift Pump Tank /Siphon Chamber ❑ 1 ❑ ❑ 1 ❑ 1 ❑ 1 C VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plum=si ture: (No S s) MP PRSW No.: Business Phone Number: ,f �"a 6 g 6d 1 _ �- PI� �is ddress (S�eet City to Zip Code):' IX. COUNTY / DEPARTMENT USE ONLY ❑Disapproved fS nitary Permit Fee (Includes Groundwater ate ssue Issuing Age�tsign to , d(No Stamps) Approved ❑ Surcharge Fee) Owner Given Initial � Adverse i n Adv a Deterrr1 na tio X. CONDITIONS OF APPROVAL/ REASONS FOR D APPROVAL' �l SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety a Buildings Division, Owner, Plumber