Loading...
HomeMy WebLinkAbout020-1322-70-000 Y ST. CROIX COUNTY ZONING DEPARTMENT ` AS BUILT SANITARY REPORT Owner E g - 3.t Property Address 6 TV �ziCe Z,.>V r � City /State Z&j Legal Description: Lot Block — Subdivision/CSM # 4 V4 t/4, Sec. a W, Town of )Vu 06 PIN 20 i 3 .Z•Z -7v SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC Setback from: House �Lf Well S) PA� Pump manufacturer Model Alarm location - h L �xw- a� (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: ZED Width 1 2- Length . S' .- Number of T+emhes 2- S f rom: House -L, go' Well, PIL Vent to fresh air intake 2- loo ELEVATIONS Description of benchmark D oT me Elevation /DO• o Description of alternate benc ark < A , L•7' e'orner Elevation - rLZX Q- Building Sewer 8 ST/HT Inlet • I ST Outlet 1 f f PC Inlet PC Bottom Header/Manifold 9 • Z, Top of ST/PC Manhole Cover Distribution Lines (} , © Z () ( ) Bottom of System O _9y� 2 - Final Grade Date of installation 50 1 9 Permit num r , ;Z y7 Z T State plan number Plumber's signature J /� License number 2 -- ) - / SO Date Inspector z �S �wg 4� T' �— Complete plot plan � j X M 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 7 y' ry a � #� -.-- �rke i INDICATE NORTH ARROWa� Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM �6T. CR Safety and Buildings Division Count INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) San itar 1 Personal information you provice may be used for secondary purposes [Privacy LXw, s.15.04 (1)(m)]. 1"1Wod10iq TRUCTION HTg&S[]Nillage ❑ Town of: State Plan ID No.: CST BM Elev. :. Insp. BM Elev.: BM Description: Parcel — — TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. A / Septic L, Ben a �.d �, &C ! -Lt 12A Dosing A (,} Aeration Bldg. Sewer Holding Cso Inlet s 9 TANK SETBACK INFORMATION 6) Fft Outlet TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet Air Intake eptic 4't;b j� �2, NA Dt Bottom Dosing NA Header /Man. Aeration NA Dist. Pipe�65 Holding Bot. System, PUMP/ SIPHON INFORMATION Final Grade q .� Manufacturer inand �, b r p©, J ' Re Model N ber GPM TDH L Friction m TDH Ft Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BE /TRENCH width Length �- No. O Tren ches PIT No. Of Pits Inside Dia. Liquid Depth ENI N S DIM SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHIN Manufacturer: SETBACK CHAMBE INFORMATION T pe � Mo el Nu r: syst °��� --°'�� OR UNIT DISTRIBUTION SYSTEM Header/ Manifold + � Distribution Pip ! x Hole Size x Hole Spacing I Vent To Air Intake Length - -: Dia. Length Dia. Spacing \ 1V� SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sod xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) L HUDSON X 10.29.19. 1667 , SW, SE 654 TODD LANE - SCOTT ACRES LOT 7 L�EQ� f'i / E't�i�s�/t. acs vw n� t �3 P5 C. hnCk }Q" iii (: t L D rV ^ Zj b '► nre-, v c.._T� -� w� -�,, T � c�Q � � C° ��1�C' r ; E Plan revi Ion require ? Yes [4'No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Ce ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: w s. , t E r , i .. ( a l e k .. _ .... , �.... ... _ _ _.. .... m � 1 t r t s y a a i a s m e . a . y � 4 $ E m „{....� ... ...m .�'.ea... .. ,..,..�.- ...,.. «. e E i 3 .? ,..,m .,e «. g.. »,. E.... ; .....d ....... a � a e h a E � f � ,� h t & � d m,. .. a },.. a ... .,. a F ' ,_ ..�: ...�....... _ .._._...4 .m...,. ...., s. _ ._ _.� ..� .. _.. —1 --, m a L .__. I r Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue Viseonsin 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 not less County than 8112 x 11 inches in size. S'j; lego • See reverse side for instructions for completing this application State Sanitary Permit Number 3.2 Y 77-5 - 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 INFORMATION Property Owner Name Property Location �L 1/12 1/4,S /p T �9 , N, R E (orkil? Property Owner's Mailing Address Lot Number Block Number �© City, State Zip Code Phone Number Subdivision Name or-E6M-tde II. TYPE F LDIN : (check one) [] State Owned it Nearest Road p Village / Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town OF III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo O — •Z 2 O 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. 0 New 2 ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System -- - - - - -- System -- Tank Only -- Existin�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 JZf Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure o X 42 E] Pit Privy 13 ❑ Seepage Pit /� SS' 43 ❑ Vault Privy 14 ❑ System -In -Fill �,Ev VI. ABSORPTION SYSTEM INFORMATION: Sete. -s• i feort 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5_ Perc. Rate 6. System Elev. 7. Finaf ra e f Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) 7f. 3 Elevation 3 - Feet fy, Y/ Feet Capacit VII. TANK in Ca gallon Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- steel glass Plastic App New Existing structed Tanksi Tanks Septic Tank or+k0dirlg -fw* AW aV� ri(/E' g ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber -- 1 ❑ 1 ❑ ❑ I ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation gilhe onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: No ps) MMWPRSW No.: b / Business Phone Number: / G — `�fO Plumber's Address (Street, City, State, Zip ode): m E a-= az3 IX. COUNTY/ DEPARTMEN USE O NLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued Issuing Agent n ure (No Stamps) Surcharge Fee) �- Approved ❑Owner Given Initial W Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber Il 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. 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 / Departmeri'I 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 hording 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. �7. W � i bL l4ad 57 7. 3 ILI, ,00 N 3 1 do I La% i Q� � = ���' o� /USA 7` /�i9.us. �ffl�• � /D4. ©� .A- 4 72�p oFIVSp /DNS. 1°171D _ 1 O 7 r+v its } I D L/?6: 1 7 Yf �c Wiscop,in Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Z bureau of integrated Services 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 p ercent sloe p slope, or dimensions, north arrow, and location and distance to nearest road. Parcel LD. # APPLICANT INFORMATION - Please print all information. Reviewed by --1 -1 — �� Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner / Property Location Govt. Lot 1/4 S/� 1 /4,S O T Z N,R r E (o057 Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# a > 4L a T G CS City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road u �t/ .�''LG I ( ) //6 u oN P New Construction Use: 0 Residential / Number of bedrooms - Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow Y 6 0 gpd Recommended design loading rate Z bed, gpd/fi trench, gpd /ft Absorption area required �C_/& 3 bed, ft 6 y� trench, ft2 jD��� Max' um design loading rate bed, gpd /ft - - trench, gpd /ft Recommended infiltration surface elevation(s) �/ 3 ����i�,f' ft (as referred to site plan benchmark) 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 Tank U = Unsuitable for system S❑ U C4 S ❑ U S❑ U S❑ U ❑ S 7_] U ❑ S Z 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 rL syr L . D O Ground 1-S if elev. Depth to limiting factor Z Remarks: Boring # Ll Af5kO N T� Ground elev. ft. r Depth to ` 7�VC 3 D z) Az4fG'l limiting L T,�N� factor 35K y o CAW -- IO7- 407: Y - in. Remarks: CST Name (Please Print) Signature Telephone No.._ Address Date CST Number Safety and Buildings Division Vi so&ons i n SANITARY PERMIT APPLICATION 201 E. Washington Ave. In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, Wl 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 1 i inches in size. p • See reverse side for instructions for completing this application [Sria Permit Number �' 77 The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy law, s. 15.04 (1) (m)]. State Plan I.D. Nu L APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Pro erty Owner Name Property Location G W1/a t /a, S I T j , N, R E (o Property Owne Address Lot Number Block Number YY ,�- City, State Zip Code Phone Number Subdivision Name or CSM Number oi:L/4 ( 9 6 . TYPE BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms - 2 Village Town OF D/V - cc szt 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 20 " 2•Z "' 10 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 Et-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 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 /.Z 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 8 Feet Feet Capacity VII. TANK in allons Total # of Prefab. Site Fiber- Ex er. INFORMATION g Gallons Tanks Manufacturer's Name. Concrete con- steel glass Plastic A p p New Existin strutted Tanks Tanks tic Tank k d4 " Er El 11 1:1 1-1 El Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ ❑ 1 ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of4the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No S ps) ktMPRSW No.: Business Phone Number: �. a .r2. fo .. Plumber's Address (Street, City, State, Zi Code): !X. OUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuin gen ignature (No Stamps) Approved []Owner Given Initial Adverse Determination 2Z5 Surcharge Fee) I f X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety 8 Buildings Division, Owner, plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permh�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 omper wfieneves necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or tH4 State of Wisconsin, Safety and Buildingggpiuision, 648,266 -3151. To be complete - and accurate this sanit6(ypermit 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 online 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 specificatior�s:not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot p4W, drawn to scale'br with complete dimensions, location t?f Molding 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 codRifij "EY soil test data ona -1 15 form; and.F) .all sizifig information, ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 4.1 O the creation of surcharges (fees) fora number of,regulated'pRaetites whjch can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of'standards. 4 ' J sr -C S I r 9 � $ x 1 ! � � 1 il! 1 �F—Jfr' OIL � ocd � bedreah I I C sEE PLoT __ _ J i ,frsueys �ov.a " Ce 4 e , as z 41 = me car �BRN�R tr�v�yo� RoU , Y,F0AW,,- X =p czw6r r p =JWE�C L.�JtJG �o4 C A " t I ` lc,�iV • �',i�S �Q'o6i ��� �'L� i i � i „ JAbw and Human Relations w Page -/— of Division 0 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 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # nao - �22 - ?� 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 �- Govt. Lot S -� 1/4 .5 F 1/4,S T z AR E (or) tiv �PropertjOwnees Mailing AdcJress Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number Nearest Road � ( � / / ❑City ❑Village [/] Town New Construction Use: ® Residential / Number of bedrooms _ Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate c_Z_ bed, gpd/ft o 0 trench, gpd/ft Absorption area required bed, ft _7rQ trench, ft Maximum design loading rate _ bed, gpd/ft . (f_ trench, gpd /ft Recommended infiltration surface elevation(s) 3 — �l�. 6 / �f� ft (as referred to site plan benchmark) Additional design /site considerations A Parent material Flood plain elevation, if applicable_Q ._ _ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system I ❑ S ❑ U CIS Z U 2S ❑ U I ❑ S [2 U ❑ S Z U ❑ S 4 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 x. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench S Ground elev. ` i, Depth to limiting factor Remarks: Boring # �-L M r p_ L S 2- x R11d 2 - - 6 s .S elev. 1� X8 , 7 , T Depth to d Z. J limiting I I factor -- in. Remarks: CST Na a (Please Print) Signature ephone )1,11 MOMS ate PROPERTY OWNER SOIL DESCRIPTION REPORT Pag 9 __ of ., PARCEL 1.04 p r 7 Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots RIM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench �F ,{ it 6'�k t �d L SQL 6 to F'\ GYour d 3 62— y c� 5 L G elev. — Depth to limiting factor In. p3 ' . Remarks: Boring # � d ,. 6 _ }-- L_ RL I F s' • Ground elev. 9 Depth to limiting tiff factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GP /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rench Boring # ` 3 Ur S s 3 4 Ground elev. Depth to limiting factor in. Remarks: Boring # Ground r� elev. Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) DAVE FOGERTY PLUMBING AOi2 Lkwmd Perk TGSW i KNOW OM OM , ft Fload Phone 7�9WW{Wi I I I x Scr« / "= yo ZI �D WE�LS/vE /�GL� � �SSUMIc /LSO' r y sSUn�� S7 • / 5/ 14 J j L 7.2 D d k = B�RrvG' • _ l ceun.i1) L07 I 3 � Y �.r I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer sI` Mailing Address . Property Address 5 -t TOW 4 (Verification required from Planning Department for new construction) City /State �c�fcLrF w.X Parcel Identification Number 192-0 -- LEGAL DESCRIP'T'ION Property Location 'A, S )—c' ' /., Sec. /o , T_ RZVIT, Town of Subdivision Lot # �_. Certified Survey Map # , Volume "- , Page # Warranty Deed # 11 27 , Volume ? YO , Page # ' _ j 3 - 5y op Spec house U yes Who Lot lines identifiable Wyes O 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 rnrction of the septic tank as a treatment stage in the waste disposal system. ne 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. 1 /we, fire 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 stat' g that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 day of the flue ea piration date. (A SIGNATIWE O F APPLICANT DATE k OWNER CER'T'IFICA'T'ION Letoly certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of fire pscribe a bove y virtue of a }'Warranty deed recorded in Register of Deeds Office. SIGNA URE 17 APPLICANT DATE * *•�•• Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. *****# ** Include wl(h 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 1177P•j-' 380 Document Number I ct i Return Address MAY 10 i596 11:00 A 1. Parcel I.D. Number: 020-1011-00 Joseph A. Klewicki, 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: Part of SWI/4 of SETA of Section 10, Township 29 North, Range 19 West, St. Croix County, Wisconsin, described as follows: Lot I of Certified Survey Map f iled April 24, 1996, in Vol. 11, page 3083, Doe. No. 542664. This is not homestead property. I Exception to warranties: Easements, restrictions and rights-of-•ay of record, if any. Dated this ' QT I-- day of May, 1996. ph �AKIewic (SEAL) (SEAL) ACKNOWLEDGMENT STATE OF WISCONSIN ) ss COUNTY ) Personally came before i this --42tk day of NAA 1996, the above named Joseph A. Klewicki, a single person, to me known to be the pehon?4 %to executed the foregoing instrument and acknowledge the same. Notary Public County, WI My commission expires ra 2 n Joy cowwrs AW public. THIS INSTRUMENT WAS DRAFTED BY- NOWY . o nsty, Attorney Kristina Ogland State O f 'sc Hudson, WI 54016 IF I •• dal � "" " Wed i'� �wo �r..�� ��•' � .'r�1� , tnl � �t �1 � u c• b f:O o pu - IrrJ i c x = W .� n - � A ^^ J � ' G � ul Q ft �. 4� •+ 1 _JI I Ci a. 1 1 q >1 I .1 e5`�- O u c•.1 S •� 1 ' j�l'• 1O3 . fix NR w�� n�.1��1 n,C �. I 1 ..77 ��• L � Yy� V fro 1�YJJ I 1 t Jo bl i 1sr] 64'lbd 6 L2.GvN .^ m 0, 1 ; 3 — � 3-L U . .r J urE >e Y wl p_I '+ .. p . V1 y U � 1::1� ,�` ��. i � •''IK,/11 / j j ' . P FQC�s`gy" �ooiY ■Zl d� S 1\i l ° "� 1 LIJ j g �� o as q e 1 O C1 i].. � oFpQ «YaEc� �U� ✓"'� w. Y .[[ .n �• 1 $ Y + 1 � Y Z� a r� yic �Sr� i I I ♦ ' `` :; 2 Ys t a �-: : .1•fK[ r_ f7c.u,00s ` R i ` ` ` +I .r 8 / . , X0 "g- M u O y e � •p � J p � {�f ♦ y V - r er. w � / /�yy v Cr Ii Ll C P 9 0.' _ \ `� 1p_ 4• i aG.r 4 F Y J 7 C9f ; r • Ipc9\ Nu Sk eS IloX� w W UI UJN L a O /!\ ( 1 . 7 �• Y•� i �' to -Q OD wan Y / f I A ui C-5 CD A fi •Q ilw[[� .i 1 a� v 1 i 10 Y .A w•e�s � A A^tiY :c 'KG - �K.[7.yD[ �1'1011W o l nww •+nY• .rro ,I£'6bd * � M,4£.52 nln wi K�z.1 ►,Kx OMna, YI! MOIY _I - �IIf71YM]ir? 1) Q7 �Oa Owp1, a]n�IdosAd.e M7e i:7�37(+ 61s[ooq .�]OfY\1 MOj7 •]$ :IC7] ____ O.DY xOdn G7�Ox]Y •sdf A%- 6"dOTa-P0 ao &nWwV]=nd 0u07ae ' i':+]a '.,used u] vaaooe SQNV i za m ]vG •so - r] , sscsm� •typs•naw ••a•T) $VOT *3stTnaa 6 Paa 18TTU 'WMT d-rgaca4L lareorwL WOIYr .os Q3l.1ti' �d �. F, •a]ras o] ]oas,am si (2vTd) d s as\(] oo wwgg Tagsvd Yon i -