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HomeMy WebLinkAbout020-1035-90-000 A r o J % k 2 M 0 0 / 0 °§ c E 8 C ' § # § ; e , s _ ■ 7 @ E co ° �$§\§ CD C:03 f! /§ . S 8 § ( I. \ E CD A ! � E @ « > E E k E a e CD @ 2 C — K \ E$$ @ 0. ® § § 11 w ƒ S S A 2 E c c c $ § t ( M"0 f 0 0 0 " 7 7 § CO) ■ ■ & m _ o q ( { � m 2 CD lu _ 2 7 ^ C cn CL z , f � � / k � \ }} $c \ f } k % % . . / 7 2 CL 3 E ]} 0 j 2 z C. � [ E § f k m co , ® .I w $ � a 60E: 2 I CD \ \ / , . \ 0 0 CL = E ( z § o k ; , - 0 § ' 3z � [ B % G ( o \ g tA ® t cl i « 2 . ST. CROIX COUNTY ZONING DEPARTMENT -� AS BUILT SANITARY REPORT Owner PI RE CEIV ED �o y �� \\` Property Address /v 41 w, City /State ; cNoiX t.. Legal Description: Lot '� y/I Block Subdivision/CSM # '`�cC '/4 L 1 /4, Sec. T _aN - RAW, Town of �{��ca�'1 PIN SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC Setback from: House / � , Well P/L Pump manufacturer / Ix" Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Jj A Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: �- en c h Width 3 Length S4 • Zvi Number of Trenches z- Setback from: House 2 , ( ' Well /oO r P/L 2 O ✓ Vent to fresh air intake ELEVATIONS Description of benchmark �/� �� �� Elevation /oa Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines () () ( ) C C l Bottom of System O O O S eu ,, • ,V , �� f vP Final Grade () () ( ) Date of installation RPf /9 Permit number 33 8WS State plan number �— Plumber's signature �� License number Date Inspector Complete plot plan � 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 a� I 1 0 t 2g7 O O 9� 2 INDICATE NORTH ARROW Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit 3389 IX 15 Personal information you provice maybe used for secondary purposes [Privacy La s.15.04 (1)(m)). Per d99 kf &, ERLIN E] HH City_11,�/i11mge Town of: State Plan ID No.: CST BM Elev -: MC: Insp. BM Elev.: BM Description: UUIUJ�S Parcel Ta No.: 0 020- 1035 -90 -000 TANK INFORMATION —� 91 ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV_ Septic Benchmark 1 Dosi v Aeration Bldg. Sewer S Holding Ht Inlet TANK SETBACK INFORMATION / Ht Outlet TANK TO P/ L WELL BLDG. V n oke ROAD Septic .� 5/ Z( / (� NA D o D NA Header / Man. Aeration NA Dist. Pipe Y Hold ing Bot. System �� �/' Z 9 PUMP/ SIPHON INFORMATION Final Grade ;;3 q Manufacturer and Z Model u G TDH L oss ric System TDH Ft orcemain Length Dia. I f Dist. To well SOIL ABSORPTION SYSTEM BED / A Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Typeo f CHAMBER o el Number: System: j,�,, 2� lj OR UNIT DISTRIBUTION SYSTEM Header/Manifold c�1 Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length _tdi Dia- / Length 57tf Dia. Spacing 4 1 4 1 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.) LOCATION: HUDSON 17.29.19.155C,SE,SE 904 DAILY ROAD /X Q c,— Sewe > AA l f t�� k j /hlL f ) p et wh I+ 8 � Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. .1 ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t E ` ° . ° e , ° t E 8 j ° 3 µ a _.._.. ,- Jp- 3 { t i to S p. * ' 1 , 6 , } d � E ° 3 , s ?� F i v s i° E x i S 3 [ i [ C f 3 s. e r r E c _. .. 3....,,. ..gyp.. s n i € 4 r. 3 a s € 4 j c r t 3 � a ! 3 E 1 3 I. e � � ..... tea. ., .. ,_..� ._. .a .,q ° . .... .. ..d , t - V Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes eck if rt?Gision t�/ appli cation [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Pro ppert LO 1 . S 7 T ,2y , N, R � (or Property On Mailing Ad ress Lot Number Block Numb City, St a Zip Coe Phone Number Subdivision Name r CSM Number I Jj;r. / ( } II. TYPE OF BUILDING: (check one) ❑ State Owned 0 Cit Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms .-3 ° Tow OF III BUILDING USE: (If building type is public, check all that apply) Parcel Tax / Number(s) G 1 ❑ Apartment/ Condo vOF "' 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. R Replacement 3 E] Replacement of 4_ E] Reconnection of 5 E] Repair of an - - - - -- System ---- - - i -- System ------- - - - - -- Tank Only ------- - - - - -- Existin stem Ex)st' g System - - -- ------------ - - - - -- -- B) E] A Sanitary Permit was previously issued. Permit Number 3 � Date Issued /O # 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 E] In-Ground Pressure 42 [] Pit Privy 13 Seepage Pit 2 — 3 J�r�. L-� 43 Vault Privy G ❑ 14 E] System-In-Fill d VI. A BSORPTION S YSTEM INFO MA ON: 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/d /sq. ft.) (Min. /inch) © Elevation YXD 56 0 �� 7 Z Feet , Z Feet Capacit VII. TANK in Ca allo g Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks tic Tan /Od6 K A ❑ ❑ ❑ I ❑ ❑ Lift Pump Tank /Siphon Chamberl I I I ❑ I ❑ I ❑ I ❑ I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name: (Print) Plumb 's Signature: (N amps) MP /MPRSW No.: Business Phone Number: 7 7C — 3Z P Plumber' Address (Street, City, State, Zip Code): ,& 7,5? 26 l'-A *114e IX. COUNTY/ DEPARTMENT USE ONLY El PP roved Sanitary Permit Fee (Includes Groundwater ate )slue IssuingAg t at S mps) y Approved []Owner Given Initial 5 ,_� Surcharge Fee) y, Adverse Determination X. CON TIONS OF APPRO AL / REASONS FOR DISAPPR VAL: ru�ww C. J SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS S 1. A sanitary permit is valid for two (2) years. 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 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 subrriitted.to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. 111. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information., Provide all information requested for numbers 1 through 7. V11. 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 into 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 number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Safety and Buildings Division I SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue Visconsin Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. < 4 - C ✓O ] x • See reverse side for instructions for completing this application State Sanitary Permit Number 33 &14!r Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)1. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property 9 yne j Name Propert Location C,!'/ 1A ! e/ �i4 'r' 1/4, S j7 T - 2f , N R� Property Oavne 's Mail ng Address Lot Number Block Number City tate , Zip C de Phone Number Subdivision N� or CS um er vd1 ( ) 4 0 � C I I1. T PE OF BUILDING: (check one) ❑ State Owned ❑ C ity Nearest Road ❑ Village Public Eg 1 or 2 Family Dwelling - No. of bedrooms _ 5 IX Town of AaJ III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 1. 2 ° 1• 9 . sc_ 1 ❑ Apartment/ Condo 626 leaf f 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 gReplacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ------ System -------- System ------------- Tank O -------------- 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)R Seepage Trench 22 ❑ In- Ground Pressure 7 f 42 E] Pit Privy 13 E] Seepage Pit a S� Z� . 43 Va It f ,� 14 ❑System -In -Fill �j ` C? ) l� {I�! I VI. ABSORPTION SYSTEM INFORMATION: 71 . $ .5 �_ 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade a Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) Ti 43, y Elevation '72 r W Z �j ?. Z Feet 9 PJ , Z Feet cit VII. TANK in Cap Total # Of Prefab. Site Fiber- plastic Exper INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. New Existin structed Tanks Tanks eptic Ta k ZOHO /U� ,� G, ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum is Name: (Print Plumber's ignature: (No S mps) MP /MPRSW No.: Business Phone Number: Plumbe s Address (Str ity, State, Zip Code ;� G cJ LtJ ��� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Ag Si nature (No Stamps) �pproved ❑Owner Given Initial a I� Surchargefee) Adverse Determination � // C� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: - MIT SBD- 6398 (R.11/97) DISTRIBUTION: riginal'to County, One copy To: Safety & Buildings Division, Owner, Plumber t1..C15� iul - 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 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 P P P Y P 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. JOB TIMM EXCAVATING SHEET NO. OF Z Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY DATE (715) 772 -3214 (715) 386 -5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE ...........:...........> ...........> .......... , ........... ........... :........ ... / / i T ..... ..... ..... ..... .... .... .... ..... ...............................:...... ............................... ..... ..... ..... . .... .... ..... .... .................................................. ............................... .... ..... .... ... ........... . .......... :.......... .......... ........... .... ..... ..... ..... ..... ..... ..... �� . ..... . ... ... !.. � .. .. < ... ....... 3 ¢ .......�,� ... .,._._........, i .. .. ,.._._1 .._._.. ... ...... .... l:.......... .... _.. ... Aft . .... .. .__.. . _. ...... .,,.. 1 A ) C a .... PRODUCT 205-1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1- 880- 225 -8380 JOB TIMM EXCAVATING SHEET NO. 2 OF 2 Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY c '� �A�+�1 DATE f ' (715) 772 -3214 (715) 386 -5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE .................... .......... .. ..... .... ..... ... ..... .... ........ .. .... ..... .. .... ..... 7 Z ................... .... ..... r' r} ..... -. ... . .... ..i 2. _.. �J ._.. .... . ..__ ,. ..._.. ........ l` ........ ,.... .... 3 ........ PRODUCT 205 -1 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-800 -225 -6380 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page I of -_ 3 - _ *ivision of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Certified Soil Testing Attach complete site plan on paper not less than 8% x 11 inches in site. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Cro ix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. - -- Parcel I. D.# 020 - 1035 -90 APPLICANT INFORMATION - Mad �t affil if adon. -- - - - -- - - -- - - - Personal information you provide may be ry purposes (Piiy s. 15.04 (1) (m)). Rev' y D e Property Owner .C I I. J , Property Location Nuess Erlin =` Govt. Lot SE 1/4 SE 1/4 S 17 T 29 N 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# "';' s' 1 QT CR 904 Daily Road �_ Cox City St ' Code mber E] city Village ®Town .__ Nearest Road Hudson 01flt>wto8l�t.S892 H ludson Daily Road i] New Construction Use: i e, � /# tber f ISedrooms 3 ]Addition to existing building Z Replacement ❑ Pub I finer al describe Code Derived daily flow 450 gpd Recommended design loading rate - bed, gpd/ft- • trench, gpd/W Absorption area required 643 bed, ft- 562 trench, ft' Maximum design loading rate • bed, gpolft' 8 tr ench, gpd/W Recommended infiltration surface elevation(s) 93.2/92.2 ft (as referred to site plan benchmar Additional design /site consideration install 2 - 2.7' x 54' Sidewinder, Hi "turtle shell" trenches Parent material sandy /loamy 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 ® ❑ U ® S❑ U N SFlu X S U C S N U ❑ S X U Horizon Depth Dominant Color Mottles Texture Structure Consisten Boundary Roots GPD/ft2 Boring# in. Munsell C;u. Sz. Cont. Color Gr. Sz. Sh. Bed Trench "1 1 0 -7 10YR 3/2 - sl 2 m gr mvfr cs 2f1m 5 6 2 7 -28 IOYR 3/2 - A 1 m sbk mvfr gs lm .4 .5 Ground 3 28-42 10YR 3/4 - sl 2 m sbk fi mfr cs if .5 .6 elev - -- — -- - - - - -- ----- - - - - -- 97.0 ft 4 42 -48 1 OYR 4/4 - SO 2 m sbk mfr cs ! If .4 .5 45 10YR 4/4 - .4 .5 Depth to 5 8 -5 I OYR 6/2 scl 2 m sbk mfr cs limiting factor 6 55 -120 I OYR 4/6 - s 0 sg ml - - _ 7 8 { > 120' Remarks: horizon 5 -6 boundary dips deeper to soeets rule, mottling just above the texture change to clean sands is less than F thick; e ep system a evat tI n Vie r�stn tivetu ; m 1' ._ 2 1 0 -36 10YR 3/2 - sl i 2 36 -70 ' 1 OYR 4/6 1OYR � 2 s Ground elev - - -- - — — - -- - -- - -- - -- -- ; — _ ._ _ 96.1 ft Depth to + — - - -- - - limiting -- - ~- -- - -_ i - - -- factor i Remarks. mottling becomes c3p w increasing depth; side seep ground water obs @ 6 "; av oid this a rea CST Name (Please Print) Signature: Telephone No. Henry F. Grote 715 -6 -2681 Address C ertif ied of Testing D tg CST Number Ref # P.O. Box 57, Knapp, WI -54749 574/1999 222774 1139 PRCr' : TYOWNER Nuessineier, SOIL DESCRIPTION REPORT ® Page - -_?.- of ' PARt,:a I.D.# 020 - 1035 -90 -__ Certified Soil Testir E Depth Dominant Color Mottles Structure GPD/ft' Horizon Texture onsistence Boundary Roots ' -- T - - - -- m. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench - 1 0 -7 l OYR 3/2 - sl 2 m gr mvfr cs 1 f/m .5 2 7 -22 10YR 3/2 - sl 1 m sbk mvfr gs lm .4 .5 Gro :nd -- - - - - - -- - - - -- Gro. 3 2243 10YR 3/4 - sl 2 m sbk mfr gs lm .5 .6 elev 99.2 ft 4 43 -53 1 OYR 4/4 - scl 2 m sbk mfr CS lm .4 .5 Depth to 5 53 -60 l OYR 4/4 IOYR 6/2 scl 2 m sbk mfr cs - .4 .5 limiting — -- - - - - -- - - - - -- - - - - a - - -- -- - factor 6 60 -120 1OYR 4/6 - s/mcos 0 sg ml - - .7 .8 > 1 %0' Remarks Meels I ru e; sta Bel ow nor To Bounully y ele vation 4 1 0 -6 10YR 3/2 - sl 2 m gr mvfr cs 1 f/m II .5 .6 E, 2 6 -23 lOYR 3/2 sl 1 m sbk mvfr gs lm 1 4 .5 Ground elev 3 23 -30 10YR 3/4 - sl 2 m sbk mfr gs IM .5 .6 99.2 ft 4 3042 1OYR 4/6 - s 0 sg ml as lm .7 .8 Depth to 5 42 -53 l OYR 4/4 - scl 2 m sbk mfr cs - 4 5 limiting f2d7.5YR4/ _ -- --- - -_ - -_ _ -_— - -_ - -- ___ ___ __ -_- factor 6 53 -63 l OYR 4/4 IOYR 6/2 scl 2 m sbk mfr cs - 4 � .5 > 12 7 63 -120 1OYR 4/6 s/mcos 0 sg ml - - 7 .8 Remarks born , rue applies rom pot pi is a e onsi e =were P is rote rea an o - owar s ; onz( n is ens o Ground - - -_ -- - - -- elev _ i Depth to j limiting factor � I Remarks: ;E Ground elev Depth t..) limiting factor Remarks: o e" o- a t �, ir 1 C- 40- 40 C � K r • I<j y ft f Ir v r r � � e� a Jli 3T y A, • H 1 � ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM � w Owner/Buyer e 4^ Mailing Address Property Address g® (Verification required from Planning Department for new construction) City /State _¢�L� - dS�YI k) Z Parcel Identification Number a �G �S' - Irb LEGAL DESCRIPTION Property Location S i ' /4, _S',F '/4, Sec. / 7 , T 2T N -R / W, Town of Subdivision Aze, d�u.� �/.r , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 3 3 7� , Volume .SSl7 , Page # 3 Fd Spec house ❑ yes Q 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, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, 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. X ".vL -� 2' 16'1 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. 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 •, :: �� '�;.,xW;::ti... � :r� +: ""' �,�., ;tom s _ �,P► �r O 00CUA�.?!4 no 1 - 82'ArE U" R OF $f.,x" ; ' p� 7 J _( THIS SPXtj NKS[NVID •yt, #CQkW tC# 8 ! V `4�R 547 c .'� - - -_ _ __._. _ ._ ._......_.,.__�._ _ �__. -_ .. _..... -_ _...._ _,._.._ _..._._�,�_._._..._ _.�_ _ �e m/�ettC�ry� ?� .. •. RGV►i.7lKl4yT . Mg tit :rD, made betta�en _ st • Croix Craft 9nc3 19x1lwa , Seale a corprrat�on, by_jruS e anal p1P ;_._ _. 'S'f.CRQ1X Reed. for hewed " dd f daT1 E "rltn L. Nuessmeier and Sharon Y p --- ---�Q- ft.� and - _ 9t A Nuessmeier husband acid wife and each in their own witnesseth, That the said Grantor for a valuable cons +d�atroa conveys to Grantee the following desenhedreal estate in ..__ Cotin+y, VNii�'1�tEST MORTGAGE CORP. stair of t#rxconstn: 1 119 South Main River Fa11s WI That part of the E 13 rods of the SE';o of Section Tai Key - -'�----- ' s4 1 __... homr,t•ad property. 17 -29-19 which lies S of the railway. this to bZo 1 4 s •od FEE Together with all and singular th hereditaments and apprteaances tvereunto betonging orin anv wise appertaining; And ___5t_ Croix Craft and Millwork, Inc. a corporation warrant: that the title is ood, indefe sible in fee simple and free and clear of encumbrances except easements an3 restrictions o rec and will warrant and defend the same. t JU*cuted a Ri Fa lls Wi ; tats Sttt____ da of - . 77 . ST. CROIX CRAFT AND MILLWORK, INC. SIGNED AND SEALED IN PRESENCE. OF By Eldon L. Nuessmeiery Prey. - f 24 C ( SEAL? \uessmeier, Secy -- By -- Janet -M t _. (31K AL) Signatures of authenticated this day of M; Tithe: Member State Bar of Wisconsin or Other Party Authorized under Sec. 70ti. OF - tz- STATE OF WISCONSIN ss. PII'.RCE__._ County. Por% n same before me. this Sth ._ IQ 77 the db•,�. named Eldon L. N Uessmeier a nd Janet M. Nue oFficers of St. Croix Craft and Millwork, Inc. to mv km,wn to be the p­rson S _. who executed tht fore aid acknowledged the same. This tnstra^ient :.as drafted by r w "- Keith D. Rodli, Attorney at LAw . t v Kenneth L. Zarw River Frills, WI 5402-7 Pi erce -� �_ `�`, ,,=. Notary Public - -_ P1P. e _ w _ County. Wia_ ' ,rs' � J ,�h.• :e 1 a,lr. es is ,,. <: n _.�, j.l nal. ice'• � � , - My C :'Exptres� Is) _. � 5 , / 'vn ^.rs : t r r: s:gnrng in any- capacity should he toped , r Printed b l signaturr4. 6 —STATE BAR OF NISCOVSi -, NO t — 147'i — Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ~ GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit 338915 IX 15 Personal information you provice may be used for secondary purposes [Privacy La 1 s.15.04 (1)(m)]. Per NU99,Mk , ERLIN E] Cityt1ft _6 Town of: State Plan ID No.: CST BM Elev.: MJ Insp. BM Elev.: BM Description: tHlUUuUaUlV Parcel T a o.: 1 9900174 6T0- 1035 -90 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV_ Septic Benchmark Dosing Aeration Bldg. Sewer Holding I St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched . Bed / Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No []Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOOC HUDSON 17.29.19.155C,SE,SE 904 DAILY ROAD q5 - Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division Vi sconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 _Departm €nt of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County %60Z than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary Permit Number Personal information you provide may be used for secondary purposes eck it Mision t�� appl icat ion (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name Propert Lo tion 114 1/4, S /7 1 T 2y , N, R (or W Property Owner's Mailing Address Lot Number ! B Numb q0 � 1 . lock City, Sta Zip Co a Phone Number Subdivision Name r CSM Number ! ( , . TYPE OF BUILDING: (check one) ❑ State Owned C] ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms --3 o Town of III BUILDING USE: (if building type is public, check all that apply) Parcel Taxx Number(s) �'� C � 1 ' Is S L 1 [1 Apartment/ Condo v�d l J 7 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. ;R Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an ___ System -------- System ---- ---- - - --- Tank Only ---------- Existin stem ExistiLng System B) ❑ A Sanitary Permit was previously issued. Permit Number 3 Date Issued 7 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 '�❑ d — 3 S6, Z� 43 Seepage Pit 2 ❑ Vault Privy 14 ❑ System -In -Fill d / 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/d /sq. ft.) (Min. /inch) p Elevation Z Feet . Feet VII Cap acity TANK in allo s Total # of r Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- steel glass Plastic App New Existing structed Tanks Tanks tic Tan P0 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I El 10 1 E] El El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name: (Print) Plumb 's Signature: ( amps) MP /MPRSW No.: Business Phone Number: z 7TC - 3 zr Pumb- Address (Street, City, State, Zip Code 6 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate) ssuej Issuing . A t ' at S mps) Approved ❑ Owner Given Initial Surcharge fee) y Adverse Determination X. ON TIONS OF APPRO AL/RfASONS FOR DISAPPR VAL: AAV r K-S tW o c. SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber ST CROIX COUNTY • SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner Buyer Le r. ✓.Gc r-v Mailing Address Property Address / (Verification required from Planning Department for new construction) City /State Wu-at SyYI k) Z Parcel Identification Number 4 ;Lb J(j F[t LEGAL DESCRIPTION Property Location 5e 1 /4, _,P 1 / Sec. / 7 , T " 2 N - R_Z_9_W, Town of `udsss� Subdivision Afire dcrrc"< & Lot # Certified Survey Map # , Volume , Page # Warranty Deed # Volume S5/ , Page # Spec house ❑ yes Q no Lot lines identifiable g 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, restrictedplumber 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. I/we, 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. x "'t-t J 2� / IGNATURE 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. )( 1 . 5 / 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