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HomeMy WebLinkAbout020-1322-20-000 i ST. CROIX COUNTY ZONING DEPARTNI -- AS BUILT SANITARY REPORT Owner F' o ! .a1T" Property Address .a JT City /State #qpray cyy S° 0 - 4 Legal Description: t,(y +NGU + -FIcc Lot - Block -- Subdivision/CSM # SfAL ' /4Sr 1 /4, Sec. 10 , TAN -RJ&W, Town of P # m ' ' z Z - SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer 4G6 Size ST/PC / Setback from: House . Well P/L Pump manufacturer Moue _ Alarm location — (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh m e Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: dC/2 Width / .x Length -CO Number of T+ene - Setback from: House > 2 S' Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark 0 - L 7 Elevation 104t i!9 Description of alternate benchmark Gvr �^LL Elevation Building Sewer 8,21i ST/HT Inlet 17.. ©3 ST Outlet 7. Af PC Inlet PC Bottom Header/Manifold Q 7 3i� Top of ST/PC Manhole Cover /D .2.00 Distribution Lines ( ) :'7, Bottom of System () Final Grade ( ) / ( G uT Date of installation JW Permit n er 3� I/ V 7 State plan number Plumber's signature 04 License number "x /lgC) Date/&//X Inspector Complete plot plan � I I /� NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW 6-r' 361 2Z � o _ S�ST�'•�r �cd /,�f'C�•sc" fffr.' .S'+f'w'�i� Ls�.E C)i�F INDICATE NORTH ARROW �l Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No... ST. eR IX Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. 344517 PerrrtEHELdeAr s (51�STRUCTION, INC . ❑ CityHUDSO�i Town of: State Plan ID No.: CST B Ele Insp. BM Elev.: BM Description: U Parcel Tax No.: 020- 1322 -20 -000 TANK INFORMATION _ q ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic �r / Q C) Benchmark a /66 Dosi n . 41 4 /V a Z , Q Aer� Bldg. Sewer q a Holding St /Ht Inlet �7 TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air I ntake ROAD ir Septic "�p - 7 r - Z Z / t Z �/� NA in NA Header / Man. q , L Aeratio NA Dist. Pipe L f 5' }' l � Holding Bot. System n,Z� !� y PUMP/ SIPHON INFORMATION Final Grade /o Manua errand /b Model Number TDH Lift L fiction m TDH Ft ea Forcemain I Length Dia. Dist. SO ABSORPTION SYSTEM ^111 Width , Length No.Of renches PIT No. Of Pits Inside quid Depth 'DO ENSIONS �z Ss )? s DIMENSION SYSTEM TO P / L BLDG WELL LAKE / STREA ING Manufacturer: SETBACK AM INFORMATION Type O [ y umber_ System: —�Ut ±3 / i `/ - 75 �~ OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing I Vegt To Air Intake Length Dia. Length Dia. '7 Spacing t �0 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.) L HUDSON 10.29.19.1662,SW,SE 1006 SCOTT RD — SCOTT ACRES LOT 2 SLwE -r sGG� L ldi�is s5 �.�,� d � 1� S r�5ltiv. l� / l or� AO/ LVef uiGle �h�s f/Gfr� Oils_ ? 1_ 0 J ^) to N — 7G.'f/ = Sr3 CGG. YL� toz. Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD 6710 (R.3/97) Dat Inspector' i ature Cert. No. -- pop , ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: + + + 8 E 3 " 8 m. _ i " i S a � t i a s i s t + + E " a A � e i r A n _ i s .. yam .e 3 • ...e...., ...., .. sm ..e..� e ms_ ." - .. _. ... .... s + e. ° 9 .. .... 6 . e" s ` i S i b 4 o � i � a e„ �.. ".. s... _ .. ... , �.... , ... .,....,..,„. .,. _ ....., .._ ..... , ". ... .... _,..__ Safety and Buildings Division Vi scons i n SANITARY PERMIT APP I 201 W. Washington Avenue r ,,>, P O Box 7302 Department of Commerce In accord with ILHR 83.05, W' ode p e ce '- Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the syste Pape ftf_ bl co than 81/2 x 11 inches in size. tti C • See reverse side for instructions for completing this applicati 1 ' tatelan ary Perm Number -- 7 S C+ Personal information you provide may be used for secondary purpos�j�' UNT-, k I revision 3 t previous application [Privacy Law, s. 15.04 (1) (m)l / fjb .fly 0 �,.ZONINGOFFfCle S . Pan I.D. Number I. APPLICATION INFORMATION - P LEASE PRIN T ALL INF T Pro p ert Owner Name _ 0 2ft h O ,S T ,N,R 9 E(or� Property Owner's M ll Address Lot Number Block Number .2v W ST Cit , tate Zip Code Phone Number Subdivision Name or CSM Number f0l/ r-v m l(erh / II. TYPE F BUILDING: (check one) ❑ State Owned it Nearest Road 0 ii age Public 1 or 2 Family Dwelling - No. of bedrooms Town OF ON / /�- 111. BUILDING USE (If building type is public, check all that apply) Parcel TaxNumber(s) l0`Z9. 1 ❑ Apartment/ Condo 0 — /3 a ' 2 — V- 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 or , 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_ __TankOnl�r______________ ExistingSystem _________ExistingSystem B) A Sanitary Permit was previously issued. Permit Number ,S' 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 1 X f 43 ❑ Vault Privy 14 ❑ System -In -Fill A40 VI. ABSORPTION S YSTEM 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.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 3 1. 7 Feet Feet VII. TANK in Capacit llon g Total # of Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Ic Ta u ❑ ❑ E] 1:1 ❑ Lift Pump Tank /Siphon Chamber ❑ 1:1 ❑ ❑ 1 ❑ 1 ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the site sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signat tamp j MPR*PRSW No.: Business Phone Number. Plu er's Address (Street, City, State, Zip ode): IX. COUNTY f DEPARTMENT USE ONLY ❑ Disapproved anitary P rmit Fee (Includes Groundwater F�at7el N Agent Signature (No Stamps) Approved ❑ Owner Given Initial P surcharg�) Adverse Determination a _0 PfAtlm X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPP VAL: SBD- 6398 (RA 1/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, plumber I 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,-60 &266 - 3151,. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and' manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must, sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 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. t 4� 1 w a u O 3� % £ , W " A L kx —,nsad Park Fester A-. Plumtwr #3233 43285 P arty 1 t 3ighis Road a `3BER S, Wi CONSIN W23 Phoi � 749 - 1555 Gal ,AND V SJFVY 3 � 6 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page / of —3 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. # 2;:i — d APPLICANT INFORMATION - Please print all information. Re ed by Date vie Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). W 13L- 9 47 Property Owner Property Location / Govt. Lot 1/4 1 /4,S o T 2 ,N,R E (0,(0 Lot # Block# Subd. Name or CSM# Property Owner's Mailing Address Z Z co s City State Zip Code Phone Number ❑ City ❑ Village 10 Town Nearest Road � ur;!5'VX/ o � �/s -I / -1" cd 7 r Al), New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement Public or commercial - Describe: Code derived daily flow _M gpd Recommended design loading rate _Zbed, gpd/ft _,_o_ trench, gpd/ft Absorption area required .F5 bed, ft 7 Sd trench, ft Maximum design loading rate bed, gpd/ft trench, gpd /ft Recommended infiltration surface elevation(s) pg► 9 ��Sl�'tI¢1� y ft (as referred to site plan benchmark) i Additional design /site considerations Parent material Flood plain elevation, if applicable ft S Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding ZTank U = Unsuitable for system S❑ U S❑ U S❑ U S❑ U El S U ❑ S SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench -o 1W Z c s — round elev. �p n. Gr Depth to 't limiting ; facto; 7,9'b in. Remarks: Boring # p za -3. s — undd elev. g , / oi - i n. Depth to limiting V facto r �, in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number PROPERTY OWNER SOIL DESCRIPTION REPORT Page . g � of 3 PARCEL I.D. # Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 3 ,5 s L S Of k�69 Z — Gr ntl elev. w o la o Depth to limiting 'ti1 qU' factor Remarks: Boring # / •-�- / sL 3 DL 01 EFT O . d F L GS t�f/ 3 r Jflntl , S — QS �'� L slay �Q2e Qft. , Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 3 L L I F S Z O^ sL L •S — Iy L r J�d elev Depth to limiting facto > �in. Z Remarks- ��oY Boring # E7 -Awle- x Y y �w Ground flip d G ,r/w elev. I ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) it II b `1 11 Z Z � M • QI 1� o a s� Safety and Buildings Division . SANITARY PERMIT APPLICATION 21 Washington Avenue Visconsin Department of Commerce In accord with tLHR 83.05, Wis. Adm. Code Box Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 2SIQ51 Personal information you provide may be used for secondary purposes ❑ Check if revision top evious application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Propert4 Owner Name Property Location _ 5W 1/4 Sp 1/4, S T X , N, R E (001V Property Owner's Mailing dress Lot Number Block Number City, State Zip Code Phone Number S bdivision Name O&Q&W NVMTb" ?¢C 1. TYPE OF BUILDING: (check one) ❑ State Owned V ❑ Cit Nearest Road Village Public 1 or 2 Family Dwelling - No. of bedrooms ,�_ Town OF S'Co CIA III BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Nu er(s) Ica. 2q. fv�02 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_ E] Reconnection of 5. ❑ Repair of an 1_ _System __,_____System_ __Tank On{y______________ Existing ________ Existing B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 []Seepage Pit ZZ k 43 ❑ Vault Privy 14 ❑ System -In -Fill Z ,ip VI. ABSORPT 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.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation Feet J' Feet Ca aut VII TANK in gallo s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Se c Tank ❑ 1:1 1:1 ❑ 1:1 ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation he onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No t ps) RSW No.: Business Phone Number: 7.r P m is Address (Street, City, State, Up Code): l/ cA a IX. COUNTY / DEPARTM USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued Issuing Age gnature (No Stamps) Approved [ Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11197) 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 manufactur @r;. 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. ,► '�'�/ = �np o� L07' Co l/ - v�•vr �''rP�� ,¢,fsN.rs�- /m 3• /' Lp y` �i �co�T J��, 4 f�-Z =Sit, ;�� �1- 7V X v00 T BDRI*r �L�a !'y? G•�Nw © / X z p / II I r I X�3 ! I I I I I � DAVE FOGERTY PLU MBING Licensed Perk Tester & Plumper 03233 #32ft P e ty Heights Road ROA S,J'ASCONSIN 54022 IPhoo,4* 749 -365G f eur ya �- p V Sr 3 f 6 1.2 I 47 P el , �l Do Not Write In This Space! Zoning Department Use Only! File #: Activity: Rezoning / Variance / Special Exception Proposed Zoning District: A2 -01 AG -02 AR -03 RES -04 COM -05 IND -06 Current Zoning District: A2 -01 AG -02 AR -03 RES -04 COM -05 IND -06 Overlay District(s): None -01 Shoreland -02 Wetland -03 Floodplain -04 Riverway -05 Variance/Special Exception Code(s): See Attached List Ordinance Section #(s): Disposition: Denied -01 / Approved -02 / Withdrawn -03 / Postponed -04 Date: Supporting Evidence: YES NO Plot Map or Plan / Site Plan / Town Approval Ltr. / CSM / Photos / Maps / Soil Test Other: Hardship: YES NO Linked to Rezoning: YES NO Conditions: YES NO Objections: YES NO 2/96 3•Y - .7-44 1 ° 'S ��_.,e._.._. v�. �.__._.. ��......_-__. �..-..._.,_.......___... .�.._,..._- ._.__....._._._,.... _...._..._._. ._.. ..�. _...,..__..,.._....__ �_� _�._. _.._,_..._.- �_...r_��..,�,. ._._._._....._. ._ .�_.���,.,, -,�� __.. _._. _.r____ _.____.,.____._.. � -.�.. .... y... `_�.._... ___.__.._.�_.._�_..._. _..u.r�.....� -_ __ _ __......_.�..... �__.._.._.__�..�. ...�..� I J Wisconsin Department of Industry SOIL AND SITE EVALUATION LaboLa2g Human Relations Page—/— of Di on 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 0-r percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. R iewed by Date L Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Z Property Location LTI% CO Govt. Lot 1/4 1/4,S � TZ T ,N,R 7� E (or"�N Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# -2D G ,-`� 2 - 1 1110 o83 City State Zip Code Phone Number O ( /) Nearest Road ❑ City ❑ Village ❑ Town D m New Construction Use: Residential / Number of bedrooms _ 4 1 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 4690 gpd Recommended design loading rate _ bed, gpd/ft . f trench, gpd/ft Absorption area required Fr4f bed, ft 7TO trench, ft Maximum design loading rate _ bed, gpd/ft gpd/ft Recommended infiltration surface elevation(s) /�, 1r'�/. �' 3��; �' 9z/. f ft (as referred to site plan benchmark) i Additional design /site considerations LWr 1 Parent material Flood plain elevation, if applicable 9. q,, Z 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 S❑ U S❑ U ❑ S Z U ❑ S (Z U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 6 �o_ -� �s c .s ., 9s' �.� Z_ 6 . S_ - VAI — s I F J - Ground ` 7. � _ _ elev. D G L — — P�Zft. Depth to limiting factor R Remarks: Boring # 2 Z (6L_34 0— L .2M PK M FX7 271 I S - ; 9ss AC -70 7. s - V — s sG Ground ` 1j elev. Depth to limiting r L 3 I factor -- gT CROI in. Remarks: NTY ti CST Name (Please Print) Signature a o. v 13, D E f Address Date CST Num PROPERTY OWNER jW r,4 r PAr/ - SOIL DESCRIPTION REPORT Page PARCEL I.D.# Lo7 Boris # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 2M S ... Z _z4 lo �S L t S r Ground _ S _ elev. ,e ft. _ _ '$ Depth to .7 D • .S -� 'S 6Z ' IF limiting factor in. Remarks: ,•af 6e, 6a;, 1' T Boring # — T y -G Z -- 4 .z L ! F c S • S L C Ground ?2 I&A _ s elev. 16 ft. - .5 S z Scr Depth to limiting factor —' in. Remarks: y �'4?i COB Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # L L F M L Ground L elev. Depth to limiting factor �-- � in. Remarks: 3 70 Boring # o 774, 5:'1 a 7 Z ..c^ 7` E /� L Ground elev. Depth to limiting factor `n. Remarks: SBDW -8330 (R. 08/95) I DAVE FOGER'TY PUMABING 1 T ��� < Fly sd �✓/f•1`Flt 1 ROBE W. WVI Rb 1+1023 t d tX ACE,*r � i / 3/o�cdNyY y/ LmT � z �v.' P�ttix�J� d MKT. 9Y 8 e /_ , Tp off' 16+ �3��1� L ' �X 4 z (awl I Tae �4L �- 5'C17 7 I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 6 1)Fe_7'-9 CQA4� Mailing Address ZP4' ,.7- Property Address lam_ ,�Q! �,l�d tn,v j,�- _'r4 D1`l 'C ?i/ L -� (Verification required from Planning Department for new construction) City/State � s� G �✓l/ XParcel Identification Number O ->o -- /311. - Zo vs . LEGAL DESCRIPTION Property Location ,g '/4, , _ ' /4, Sec. /o , T -R /9 W, Town of A�;� Subdivision _0D77 ,4C zl'S , Lot # Certified Survey Map # — , Volume , Page # -- Warranty Deed # Allihm s Y3 s , Volume // 7 7 , Page # X80 Spec house ❑ yes 0 no Lot lines identifiable ,J yes ❑ no SYSTEM MAI 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 licensedpumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days ¢f the thre year xpiration date. L' Q � SIGNA F 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 the pro erty described ab ve, by virtue of a warranty deed recorded in Register of Deeds Office. SIGN A F APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** i ** 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 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address lez96 (Verification required from Planning Department for new construction) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location %4, '/4, Sec. . T N -R W, Town of P Subdivision . Lot # Certified Survey Map # , Volume _ . .Page # Warranty Deed # , Volume , 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 wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 113 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. 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 the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. J J 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 i WARRANTY DEED 14 -7.7 PAS_ Document NcmNr i MAY, 10 I9')G Return Address � - 11:00 . �t A � Parcel I.D. Numtx:r: 020 - 1011 -00 �. I Inft� �i _ Joseph A. K.lewicki. a single person, conveys and warrants to Delta Construction, Inc., a Wisconsin �. Corporation, the following described real estate in St. Croix County, State of Wisconsin: g Part of SWI /4 of SEI /4 of Section 10, Township 29 North, Range 19 West, St. Croix County, Wisconsin, f described as follows- Lot 1 of Certified Survey Map filed April 24, 1996, in Vol. 11, page 3483, Doc. No. 542664. # This is not homestead property. Exception to warranties: Easements, restrictions and rights -of -way of record, if any. D °d this g _ day of May, 1996. r$ r� (SEAL) (SEAL) seph A, Klewicict Y 6 ACKNOWLEDGMENT � STATE OF WISCONSIN } i } ss COUNTY ) Personally came 'iefore me this { day of 1996, the above named Joseph A. Klewicki, a single person, to me known to be the N who executed the foregoing instrument and acknowledge the same. t ' # Notary Public County, WI My commission expires No Ai joy fors Y public THIS INSTRUMENT WAS DRAFTED BY: Sty eu W►SCo►+sin Attorney Kristina Ogland Hudson, WI 54016 ' le BEING LOT I OF CERTIFIED SURVEY MAP RECORDED IN VOL. 11. PG. 3083',' AT TF E' ST CROIX COUNTY REGISTER °OF DEEDS OFFICE.. o 13 4 . s� ._ O.Ov t13�ir ` $ 9 PLAT LOCATIUN , ra.o _ -__ i/fitYi<'S4fi:if_CYRS7.YtC�1'a • iArtinr I Alter C. Ily]>,{!-n, re loterad 11lsconala Land surveyor, heraby ce teal in full covl a .lanea vlth the provis!• -, of Chapter m or the Misc hcatutea, and undor the direction of 7lelta Corletruatlon, Inc., ovn»r o IWO dr9CrttAd oa this plat, 1 ha're su3 divided and mapped --- - -NE --- liars; that such plat Correctly represents the exterior Dwldefla• an Pp ,ppp 8ul4ivie1011 of the land evrvsyo7 and that this plat is located in pa the 01711 of the M /4, in Section 10 !7111 *1901, To-a of ft0aon L Croix Coenty, Ilisoraaln; being Lot 1 of Certified survey Mop Reeor3 Value 11, too 3061 at the at. Croix Cwaty Resister of lawdw Of further deacrtbed an follows. at the S1 /4 Cotner of S!ctltn 10; theaee 849 ale:' south line of the 8si /4 of said section, 1310.71 r+vt to the eavt It ---SN - -- - -SE --- the 8 of oke 8!1/11 thence 100 •long said east like 1C feet to the Wnrth 1104 of the of 0-wso said lot 11 thence WA)b41' ale•'�1yy raSd north llr!, 1318.21 feat to the north - south 1/4 line of 1 1 a • aectlrm; thotw* 900%S'34'11, along Bald north - south line, 1049.31 fe the �p - i &t AL. 11aA. Above described percel Contains 31.71 � J s 4G TxNl eU e C 1 p T 1CRt1 08 _. _ x- -_ --_ -_• (1, 311,179 sq. It.). � � 1[I�T 66 u L O T 2 I L, T 3. 6 }� S E..M. Y1 11 P, 3003 a - - a • - . raroN rrt rrw,,0 . I]' ai O k � wt+'os'u't, It sr f.i ... . _ N99'41'39'W 1310.2) ' � tot R.;t1+ - - - - -� � w OA w .ct a- Is:9 a :slTs' 13144' ..�. m . =+o1 `• i `...�..... ... 'isia�' .,1 LO wWL fte.w Ad 1 s C. I 7 :sfpt It 7,, a : R[t s 8.09 ACRES I I 17,4 to. 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