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HomeMy WebLinkAbout020-1305-30-000 P ppppp, IP ST. CROIX COUNTY ZONING DEPARTNEfi AS BUILT SANITARY R9PORT Owner S / t1 (L L Cr _d ,y Property Address 10 4 - 1 7 IV K 1" L !4 N. r tom" City /State 44 y Q -Sp N l..t� ► r' 4/� 11 4, ST t,P Legal Description: Lot ,1 (o Block Subdivision/CSM # %4 / ' /a, Sec. f l , T N -R /`� , Town of SEPTIC TAT DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer t:, l5 / Size6PCr Setback from: House 2S Well 80 ' 2, Pump manufacturer - - Model �-- Alarm location ,... -, (HOLDING TANKS ONLY) Setbacks: Service road - ` Vent to fresh air intake Water Lune Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: LfAe-H Width 3 Length _ Number of Trenches Z--. -- Setback from: House I V Well 7 - ZS P/L Y Vent to fresh air intake 12 ELEVATIONS Description of benchmark I LOT PIP 6? 5 u/ C 0 1AI' t l -= f % Elevation Description of alternate benchmark 5 / L L 0 #OeX- 3 r Elevation _ Building Sewer. Z ST/HT Inlet T Outlet �� PC Inlet —"°- PC Bottom -- Header/Manifold 10 A, Z-' Top of ST/PC Manhole Cover $ 7 Distribution Lines () 1 t) , 7 5= `►o, 95' ( ) 10 ,7 S' r Bottom of System Final Grade () * 7 too =14- ( ) Date of installation / r d/ 0 4ermit number � /,Q 7 _ State plan number Plumber's si nature 4 ` A' X License number Z?, S'Q 3 Date Inspector ` Complete plot plan PF F"M0000— 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 1 11MtqF_�, AtF k acs , f Doe k f f. Z 2. ± StA K ay.ao ; Y f r t r r 2 -- —_. INDICATE NORTH ARROW Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count 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)]. 353107 Permit Holder's Name: ❑ City ❑ Village EkTown of: State Plan ID No.: Miller Sa I Town of Hudson — /VA -- CST BM Elev.:- Insp. BM Elev.: f BM Description: Parcel Tax No.: o GD. 0 ST 020- 1305 -30 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS tHI FS ELEV. Septic Z5'D r Benchmark d SZ , D Dosing Alt. BM 4 /' 32 - .20 r Aeration Bldg. Sewer Holding St /Ht Inlet 13. -a- y TANK SETBACK INFORMATION St/ Ht Outlet `l.bS ?:Z $v TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet -- ------ Air Septic / �-� r 2q 1 NA Dt Bottom v. Z Dosing NA Header / Man. Aeration NA ei5t"fi}�e 90, 02 Holdin Bot. System E ' / . r ' • 3 , 9 v 3, t} � -3S PUMP/ SIPHON INFORMATION Final Grade 5 - R3, + Manufacturer mand St cover. O c tq•4 2 1 Model Nu ber GPM TDH Lift Friction S st Ft L oss ad Forcemain I Lengt Dia. Dist. To well SOIL ABSORPTION SYSTEM RENCH Width Length , No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth DI EN I `J S' DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufa tur r: SETBACK nw INFORMATION Type Of t t mod Number System: ^ �6 > ZM r CHAMBER �� OR UNIT DISTRIBUTION SYSTEM Header/Manifold �t Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake _ r Length e_ Dia. Length — Dia. Spacing >(,SQ SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded UE1 Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 3/ 1 o/Z - b Inspec Location: 1059 Tanney Lane WI (SE1 /4, NEIA, Section 11 T29N -R19 ) - 11.29.19.1521 "' � gWl = ke&v S Aan"r Plan revision required? ❑ Yes No I Z Use other side for additional information. 3 I O OO t SBD -6710 (R.3/97) Date Inspector's Signature Cert. No , ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ° r , r e s - f _.. E ., ee vw�ee, ee_ .,. «,. ,�, a vex.. .. ,e .•a. __..,�., .e F.. e. �v _ - - - m..�A,. i m p � i a i w v t n t t o . i e i 4 bF _ 3 , ...0 , e . , 4 i 3 ° t i n i tom€ E Y 4 € r i e. «. «... .....�.�' s { c i 9$ t 7 < v 3 ....< __„ E , .,a m. .`i..... .., .. � _ee . ...... ... ....... .s .. ;.• `"E =_., -3 m...... � .. ,e ....m 7 � U t ¢ 3 � z � i f ®m .�,..,. ., e. .. .. ... e. Y ,L s t i ._ a e_..e ._...,K . °.,. �. ,� M.,....... Vim.,.. .,._.. m ¢,.�..�...;._ .... , ,me. 2. ..ww,.. .....� _.. .... .. ..... ... .. .... _ f " ' e P a h P 0 i Safety and Buildings Division A sconsin SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue -- P O Box 7162 Department of Commerce In accord with Comm 83.05, Wi ° `w Madison, WI 53707 -7162 `,•. • Attach complete plans (to the county copy only) for the syst pap�.m less Co t than 8 vi x 11 inches in size. �jT "r` 'f C- • See reverse side for instructions for completing this applic t:WA thy . St!t41@ Permit Number A 3 /Q7 y ou may Personal information p rovide be used for second ` y p y ry purposes >�X if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. N N s0te n Review Transaction Number I. APPLICATION INFORMATION - PLEA E PRIF "' " M `� Property Owner Name i rt Loc bR I L 114NE - .1i T Zy , N, R /9E (o W Property Ow ers Mai li ng Addrpss Lo ei Block Number City Statp Subdivision Name or CSKJN� �er U j y II. TYPE F BUILDING: (the (\.p K ��\ O It Nearest Road Public 1 or 2 Family �- 9 ro w a n OF III BUILDING USE (If building Parcel Tax umber(s). 1 ❑ Apartment/ Condo ©Z �' 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 PE RMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1.M E] E] E] New 2 Replacement 3, Replacement of 4 Reconnection of 5. ❑ Repair of an _ __System _____________ Tank Only_,____________ Existinc�System _________ExstingSystem 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 12A Seepage Trench L E 4C f4 22 ❑ In- Ground Pressure -- 42 [] Pit Privy 1 ❑`Seepage Pit 0 /A! F/ <T A T012 3 k 7S' 43 ❑ Vault Privy 14 ❑System -In -Fill 31,E SQ 1- - T S10E\Aj/ C 43pk 5 2 - To7 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 7S0 7 V 3 Feet �iS,o Feet Capacit VII TANK in gall0 s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con Steel glass Plastic App r New Exist in structed Tanks Tanks Septic Ta or Holding Tank I Z�b / Y� E / £ /e ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Prin Plumber's ignature: Stem MP /MPRSW No.: Business Phone Number: � ZSo 3 2-- Plumber's Address (Street, City, State, Zip Code): 6 0 A011f R 10 04,0 2 a N o IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved itary Permit Fee (includes Groundwater r I ssuing Agent Signature (No Stamps) Surcharge Fee) Approved [] Owner Given Initial , Adverse Determination � , Z5 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: IbIL D- 6398 (R.12199) 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 sepu ! .�e pjr� ;)ed 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 coc!t .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 par el t..,x 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 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 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. i N N 0 f. c. LoT 7o -Prfe m7*3- 40 - To lz� tc N tile Al Toe of I evN Lc /q TA,tE P-I-- 100,00" *fisconsin Department of commerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than W1 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D.# APPLICANT INFORMATION - Please prin( all infonnO#on 020- 1305 -30 -000 wed By Date Personal information you provide may be used forseconoary pi�pos (Privacy L*v, s. 15.04 (1) (m)). 2 2 �� Property Owner Property Location Miller, Sam Govt. Lot SE 114 NE 1/4 S 11 T 29 N,R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# P.O. Box 151 ` 16 NA Plat Of Tanney Ridge City State Zip Code, n *rnber City [] Village M Town Nearest Road Hudson WI' 54016 (715 386 -276 Hudson TanneyLane Z New Construction Use: Residential/ Number of bedrooms 4 ❑Addition to existing building ❑ Replacement Public or commercial describe Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ftz .8 trench, gpdfft Absorption area required 857 bed, ft 750 trench, f{2 Maximum design loading rate .7 bed, gpolftz .8 trench, gPd/W Recommended infiltration surface elevation(s) 89.50' ft (as referred to site plan benchmark) Additional design / site considerations Install trenches using high capacity infiltrators. Pressurization required to reach replacement area. Parent material Glacial outwash Flood plain elevation, if applicable NA 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 N S [I u ®S ❑ u ®S ❑ u ❑ S ❑ u SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Texture Structure Consisten Boundary Roots GPD /ftz Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0 -10 10yr4 /2 None Is Ifcr mvfr cs 2f 0.7 0.8 2 10 -27 10yr4 /4 None Is Ogg ml cs if 0.7 i 0.8 Ground 3 27 -112 1Oyr6 /4 None gr.s Ogg dl - - 0.7 0.8 elev 93.65' ft Depth to limiting factor >1 IT f 8 • � Remarks: Horizon #3 contains approx 10 %cobbles and stones. 2 1 0 -7 10yr4/2 None is Ifcr mvfr cs 2f 0.7 0.8 2 7 -25 10yr4/4 None is Ogg ml cs if 0.7 0.8 Ground 3 24 - 110 10yr6/4 None gr.s Ogg dl - - 0.7 0.8 elev 93.06' ft Depth to limiting factor >110" Remarks: CST Name (Please Print) Signa e: Telephone No. James K. Thompson 1-- 715- 248 -7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, WI 54020 11/30/99 3602 1137 �OPERTYOWNER: Miller, Sam SOIL DESCRIPTION REPORT tts7 Page 2 of 3 PARCEL I.D.# 020 - 1305- 30-000 A.C.E. Soil & Site Evaluations Horizon D�Pth Dominant Color Mottles Texture Structure sistence Boundary Roots GPl>� in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 1 0 - 7 l Oyr4 /2 None Is 1 fcr mvfr cs 2f 0.7 0.8 2 7 -25 10yr4/4 None is Osg ml cs if 0.7 0.8 Ground elev 3 24 -34 1Oyr3/2 None A 2fsbk ds cs - 0.5 0.6 95.74' ft 4 34 -116 10yr6 /4 None gr.s Osg dl - - 0.7 0.8 Depth to limiting factor >116' Remarks: Horizon #3 is burried A horizon. 4 1 0 -7 10yr4 /2 None is l fcr mvfr cs 2f 0.7 0.8 2 7 -25 10yr4 /4 None is Osg ml cs IMM 0.7 0.8 Ground elev 3 24 -110 1Oyr6/4 None s Osg dl - - 0.7 0.8 100.91 ft Depth to limiting factor >110" Remarks: 5 0 -7 1 Oyr4 /2 None is 1 fcr mvfr cs 2f 0.7 0.8 2 7 -20 10yr4 /4 None is Osg ml cs 1 Mm 0.7 0.8 Ground 1 F elev 3 20 -88 1Oyr6/4 None s Osg dl cs - 0.7 j 0.8 100.53 ft 4 88 -117 1Oyr6/4 None strat. Osg dl - - 0.7 0.8 Depth to limiting factor >117" Remarks: Ground elev Depth to limiting factor Remarks: ■ 6 1►1 Obsar :oeI A T n ney (Cane A Ele% Cr) • locaie-yap. 544k • 1501 / ch-Wa44101 pi e✓a/u&a ed by / ✓ey yarn rn. Iler - folnsah P o.8•y�s/ , kot /to PZa-z` o1� Tanne x , • Sc`�rr�l�y, See. P, ? J.9/r. / -�P. T of f✓Ld '50". G'/aiX ee �( Garage i � Proposed • 14 bedrmk— re5 %�w 320.eV j _- Ty of &mcrzie 0 'f' eq ysr ■ gam. B ■ Gk f ✓�f o � OT /off ys�� 54med elegy: = ice �'' I I � ► s ( zo E E v X N CA to X� co M N O ZN co Q) a co g. rn N o c M 3 = ai c 0 CD M D 0 V p • L t � �' C;) \ = N > O Q) ;; c c uti EO= c to N W ® R\%N chi Sz NOW 0 r r Z 7 rD 09 o o • h • V r « W co C OV a� Safety and Buildings Division A scons i n SANITARY PERMIT APP N 2 1 x ashingtonAvenue In accord with ILHR 83.05, ., CCidel Bo Department of Commerce f Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the sy em, eon ess o my � than 81/2 x 11 inches in size. ' - CY o t • See reverse side for instructions for completing this appl' �f bn to Sanitary Permit Number SEP Is Personal information you provide may be used for secondary purposes Q J k if re vision ion'"[ 1 Q io application [Privacy Law, s. 15.04 (1) (m)]. 41 Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINVALL Property Owner Name Propert n 5th AA LL-F t'2_ . a / , it T2-1 , N, R / I E (or)dD Property Owner's Mailing Address Lo Bloc Num ber ity, State Zip Code Phone Number Subdivision Name or CSM Number � D l I SK ) 7-7 k N-F Al-1 I. E F B ILDING: (check one) ❑ State Owned ❑ ItJl Nearest Road Public or 2 Family Dwelling - No. of bedrooms 0 Town OF R U4?SD I. NNE I f 1-4 NE III. BUILDIN SE: (If building type is public, check all that apply) Parcel Tax Number(s) 11"W 1521 1 []Apartment/ Condo 30s- 30 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 ___ystem ________ System _____________ Tank Only _____________ Exlst)ng System _______ Exl ---- 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 E] Mound 30 [] Specify Type 41 []Holding Tank 12 Seepage Trench LE11C14 22 ❑ In- Ground Pressure ' 42 ❑ Pit Privy 13 Seepage Pit %4 / N F/t*ic , 4 To - ' Y, X G r Z S ✓ 43 ❑ Vault Privy 14❑System -In -Fill Ii j SG? * r, r OF t Aw I> �, � /4Aot as,(2_ / Y Ta ?d4- / VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 13. Absorp. Area 4. Loading Rate 15. Perc. Rate 6. System Elev. 7. Final Grade equired (sq. ft.) Proposed (sq. ft.) Gals/d y /sq. ft.) Min. /inch) � Elevation . .feet 9 &,6 Feet VII. TANK Capacity gal Total # of Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks tic Tan ank l ( W ( !;)f 11L ❑ ❑ ❑ ❑ ❑ LAU Rump TaPI44444cia ❑ ❑ In 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: ( o Stamp MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): /� C � / IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) , 4 Approved ❑ Owner Given Initial Surcharge Fee) i - Adverse Determination 7 �� y '�Z l �� / X. CONDITIONS OF APPRO REASONS FOR DISAPPROVAL: 5ltla� lac 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.Ir 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be "44. 4. �", x? 3. All revisions to this permit must be approve. th'�e permit issuing authority. 4. Changes in ownership or plumber requires' permit Transfer/ Renewal .Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septictank(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/ Department Use Only. Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil.absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Lb 3� � 41 v C5 cL v i a — to 00 �l V 3 W Q n � � 4 v 4A tv �- n Z �." - a N i M stu V ol IA 1 tJo c< , i V ` fl c co Lu E -o c'? .. x. Q c` cv s cn cu a co � aCi ° ~ T ca O .:. x rn co cn 0 yy r o (D ro o � Iz V U C N o t- N d 0 ca 00 0 Q) x n c 1 . N cc CL fl > L O U 7 L - ?. E O t C �9 41 ](LD) a� b p,C� > —°'o� cz > O a� O J cu LL E O 2 v-, U W • • • • Zu ui t, \ 'P Q) N a . "J . V� y 5 o O = Q a s coo a 8 co n C -6 3 t cc i v 3 OLL Q) C") f fl E • • Q U3 rn $ o � 5 x Y U coo m chi �i 0 .� O 0. R qqE Lr ��,R •� • +i; ZI` 7 cu cc W . U . ° ° L N cu �- t1� V J p p A! 7 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of J Labor and Murrtan Relations i.D;Asion'uf1afety r£ Buildings in accord with ILHR 83.05, Wis. Adm. Code ' COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but J x not limited to vertical and horizontal reference point (BM),d�6 of slope, scale or PARCEL I.D. # ff dimensioned, north arrow, and location and distance t a e�t 'J REVIEWED Y DATE APPLICANT INFORMATION PLEASE PRIN V FO,RMIOt��, PROPERTY OWNER: #, :n PREP TY LOCATION /� LF r, G01Tt� T'S 1/41V 1 /4,S I/ T 2� ,N,R / 9 E (or) W I �llL f° r` y PROPERTY OWNER':S MAILING ADDRESS s' 4; . LOT BLOCK # SUBD OR CSM / ►4 N&I l CITY, STATE ZIP CODE Pt.ME A .. ' ILLAGE � OWN NEAREST ROAD (. ) ` v r v ANN [Da' New Construction Usti pj Residential ! Number of bedrooms : ' U [ J Addition to existing building [ ] Replacement [ ] Public or commerfal describe Code derived daily flow gpd Recommended design loading rate bed, gpd /ft trench, gpd/ft Absorption area required bed. ft trench, ft Maximum design loading rate bed, gpd /ft trench, gpd/ft Recommended infiltration surface elevn(s) ft (as referred to site plan benchmark) .Additional design /site considerations EVJdLL) j!cto-ns Pare"t material _ ;__. ^ Flood plain elevation, if applicable It S = Suitable for S CONVENTIONAL � UND ' • IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING "K U= Unsuitable s Stem 1 %CWS ❑ U S b os ❑ U co S U cr ❑ U ❑ S RU t WL DESCRIPTION REPORT Depth Do Ipant Cdlor Mottles Structure GPD /ft Boring # Horizon in Mwsell Texture Consistence Roots Qu. Sz. Cont Color Gr. Sz. Sh. Bed rertdt 3Z A L 2 0.4 O . S / L k rh f f r C O, ,s Ground g 1 /3 - -/Z l j r O ,? O elev. t 99;Z�ft Depth to v limiting ' factor Remarks: Boring # 10 -n 71Q_ 4 Oak Ground elev. Depth to limiting factor Remarks: CST Name. -- Please Print Phone: Address: N I t S:d�` 1 .. Signature: Date: � CST Number: 4 V ,� 0 PROPEUYOWNER SAM MILLt?2 SOIL DESCRIPTION REPORT Page � of 3 PARCELI.D.II L a -- ) 16 �ArvN�` ►�� Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Cons�snce ' Roots Bed Trench 0 ,19 FI LL 4T -37 e i L- A' S W< a« ' p .4 13 4 Ground - 71 Q y P, 4 07 c �S elev $ 71 -12 l y d r 1 0 Depth to limiting Remarks: Boring # L / �� A . A 10- /oY� I s tr El Q, . ' oY - 0, 4A 0 n,1 Cw Ground 9 f - i Jjb-loe 4 5 Depth to limiting -' y 4 ctor Remarks: Boring # A 3h L D 4 - [3 5- 1 .4 i6YQ4 3 — 5C. sbk nr r w Ground $ 14'124 W O,? 13 elev Depth to limiting Remarks: Boring # I Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) r R1 tires 1 G I� VN q xi W C Z ` CWI C � ° i F r':i�r'� ^SAS ^ v 3 r- pnqvtt CC • r r 3 p A A = O [ O C w :: C i • w •EMaiOS ARE 11EIEREHO2O TO THE GET- WEST • F C "^ A I s••� IM( 9F KR ao'o• ION 11, AEEUYEO TO BEAR E W. o r vp ".Do wi6 iiP ooewi • 000 • �ci. 8 = : P. r r r n / • g V Y • UNPLATTED LANDS �- --- - - - - -- - - -- WEs7 �1HE OF THE SEW Or THE rE IN, SECTION a I ^^i / 30{.66 , i D \i AND I� W 11 m O •\ x O% k O x N w� r\ �• A o • •Y1 �X ° I.. 0 m = r fa _ a _ O •� � 03 179.17 1 w _977 /y ` - -\\��' /'-- EDICATEO 11E. I P118UC R % 0 8 //- _\. \ ROAD -- - MOUND - --ROAD —SOUTH � g NWOM are 40.W 4 r 1,7 _ ......... . ... ...�..... rill LA rp ow cn Ia y � s x p �U r �` / 0� ; M i —I o 166.'9 n a / 9 1 1 1 Tl QX �/' /� I n7 M 1 0 8 � V� C 10 / N " �/ R rr' • w Y'V i� O u m IU /w R v1 ia7 F 1 O Q a g jP � Ir- Tl I 122.66' /• O • L4 ^ i N E 240.24 1 9, X n4'i 1.2.1x' 504 4408 / 1 o z /w w I yy � j "I m Lp r 8' s2 T.s• O ES..ss' •' (A rl �2 / SDO OS 20 w 481.72 "0.00 , Tn I4 IO ,yE A l3 } e4 � 0 3• 1 / IN 'f i+ ' 9' 0 - y "Al 1T ;0 0 p m e *.,�...,' •��..,` � 17_ I n I •� D 1 • /+ E°c 1 J � \ N I � "'I WOO k OVA \�''' tiVi y ! r 8g z p a D,,, l X y 4 •� ' �O OJ ,$• 1 r � a a SE A C, o L �o L TAHHh LANE ••/ I— F . p () 8 n z z r I I I O• 01 m y O F w.. = r �! i t! � I c J ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer S # ` / �1l L fL Mailing Address _'O )e' Property Address / O T 1VM4F � L 0 �4 1114 Y (Verification required from Planning Department for new construction) City/State f yD -S a N W Parcel Identification Number LEGAL DESCRIPTION Property Location jf %., ' /., Sec. / T N -R C. W, Town of 4 00l/ tbdivision 9 1051F -� , Lot # _. Certified Survey Map # S 2 - �° , Volume - �° . Page # Z S Warranty Deed # SO 'V'g S S� , Volume 3 / . Page # `� S 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 wastewaterdisppsal 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 St. Croix County Zoning Office within 30 days of the three year expiration date. rU E OP-APPLICANT G DATE WNER 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 • .described above, by virtue of a warranty deed recorded in Register of Deeds Office. (� O XPPLItANT DATE * * * * ** Any information that is misrepresented 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 • r.L 4! � w p r Y ' I SCIJIi , ORM A TMIa 1.rI. J — '0l 1031 ►IIGE 456 e ., Thin Deed, made between . ......... ................. ............................... Randall W. S 1! nan and Patricia E. a nan, ........................ ...................... Y .................._ ^.ec•a >be R • husba n v d and ile_ .......... ...................................................... ............ .................. I Grantor. S�i 1 1993 and ... S i1 g1e... Person . .............................. . ' _ _ �t • ....................................................... ........ ... ............................ ....... 10.45 O ;: M ... .................. , Grantee, s Wit S eth, 'I hat the said Grantor, f r a valuable consideration...... Randall W. Synan and Patr�cia E. Synan _. ........................ ............................... conveys to Grantee the following described real estate in ...St . Croix aatuaN To County, State of Wisconsin: Tag Pared N o:... ........ ....................... . " The SE1 /4 of NE1 /4 of Section 11; the SW1 /4 of NW1 /4, the N1 /2 -< of SW1 /4, and the South 53 rods (874.5 feet) of the SE1 /4 of d 74 NW1 /4 except the East 74 feet thereof, al 'in Section 12; all in Y Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. F� IL �? AND _ WW-# A parcel of land located in part of the NE1 /4 of SE1/4 of Secti nt 11, Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin further described as follows: Commencing at the E1 /4 corner of said Section 11; thence S89 30 "W, along the North line of the SE1 /4 of said Section, 1212.32 feet to the point ' 1 of : thence continuing S89 30 "W, along said North line, 66.00 feet; thence SOO 28 "E, 500.00 feet; thence Neq 30 "E, „ along the North line of Certified Survey Map filed in Vol. "3 Page 722, 38.08 feet; thence N00 11 "W, 150.00 feet; thence NO3 58 "E, 351.07 feet to the point of beginning. This ...........$ : >ritS?t.... homestead property. r (i (is not) Together with all and singular the bereditaments and appurtenances thereunto belonging; And ..... R4111.4_11 -•.If., „$ynaq -- A n • ,Patr • ic • i- a._ -E.- • .Synan warrants that the this is . ......................................... . good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights — of — way of record, if any and will warrant and defend the same. _ Dated this .............. 1 ............................ day of .......... .... PkQg. LIB ......... ............................... to ..9. -. '!lc ✓ ...(SEAL) �C7?lit«i ..4F �it ✓ .. .........................(SEAL) tV/ Ra . ndall . . ... W . . • Synan Patricia Synan ....................... ............................... .................................. ............................... .......... ............................... .........................(SEAL) .................. .................................................. (SEAL) ....... • .......................... .......................... i 1 AUTHANTICATION ACE:NOWLEDGURNT Signature(s) ..................... STATE OF WISCONSIN .z z . ................................................. ............... •••---- ......... St Croix I authenticated this .y of ..................... .... lg_ •----- -.. »:............County. ...- ... da 1 - - - -- August nay came before an ' 3 1 ......day of A ll ................................................ ............................... ..... .......... ili........ the above named 3° it .........................••--•-........ ..........................__.._ Randall nan S + � ........... MEMBER STATE BAR OF WISCONSIN SXriari "' .... P ia.. ... ......... atri c c ».... TITLE i (If no ..... » .................... . f II authorized by 4 T0eA8 Wis.*S tats.) .......................... » .................... i l to me known to be the person JP ......H4 : c he i go g instru nt and n wleftft.* 300 ij THIS INSTRUMENT WAS ORARlD eY Rristina Ogland At'corne a ay.......• . .... ........ Y" Alice Joy o ors l .................... 5 Notary Public .................. ........................County, Wig. t" (Signatures may be authenticated or acknowled °ed. Both My Commission is permanent. f not, state axpjtation ° are not necessary.) date: ...................... .� _ ..... .... lA... r *Nana of persona sienine in Say capacity should be tlpvd or printed below their tianaWrsa. WAARANTT DaRD STATE BAR OF WISCONSIN Wisconsin lirrat Blank Co. Inc. • roRal No. l —lftt Mi lwaukee. Wis. i • .Y 64 .. LIP O ~ I Fp�a B j /)/ �N•jt� �; N CY Hb� 0i ✓+ :Y WI U •�, ` q t r�r��r r rsati cal! v,Otin