HomeMy WebLinkAbout024-1042-10-050 a O
e p 6o
a y 0 \�•
0
O
N ~'
�s
a
N
S
.v
0
z
z
c
I
LL p
Q
Z yj
Z - C
a °
z m
co
M H z d m
� I
O z :t
N Z c
v j �Jti I
Q �zz
m 3
m
w
1) d L N @
v m U-) O D a
CD
0 0 0 2
0 @ a a a
n
o rn v,
n 3 o N E 0) a) a�
fn J L) a) m
E } p M r-
2 N \ O
I 0 O N N
~ O O 'U E 00 N
N 4) N N
0 O N C:S O �O CO
3 m � f Q
O c o
O o LO ~ o v_ c
Lo o> C) o a E
O O M U O N O O
O 00 a) N �U„ 0 0 0
\ N 7
w0.. =3 N N
L'i O
00 U) Q O yr N N u� t0
N N N O O O O U
co co
• >, N o M d Y m O Z 2 to
td
m m n
a L a T
• CL
.� E '� c
t A U a O U) u
Parcel #: 024 - 1042 -10 -050 01/24/2008 09:36 AM
PAGE 1 OF 1
Alt. Parcel #: 33.28.17.273A -05 024 - TOWN OF PLEASANT VALLEY
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
0 - JONES, WILLIAM C
WILLIAM C JONES C - FLAHERTY, DENISE M
DENISE M FLAHERTY
84 CTY RD T
HAMMOND WI 54015
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 84 CTY RD T
SC 0231 BALDWIN - WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 40.050 Plat: N/A -NOT AVAILABLE
SEC 33 T 28N R17W SE 1/4 COMM NE COR SEC Block/Condo Bldg:
33; TH S 89'W 50 FT TO POB; TH CONT S
89 DEG W 2120.00FT; TH S 00'W 823.05FT Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
TO S LN OF N 823FT N 1/2 OF NE 1/4; TH N 33- 28N -17W NE
89'E 2120.00FT TO W LN CTY RD T; TH N
E 823.
00 05 FT TO POB
Notes: Parcel History:
Date Doc # Vol /Page Type
09/02/2005 805402 2881/416 WD
12/29/2003 750245 2482/072 QC
12/29/2003 750244 2482/070 QC
11/19/1999 614188 1472/379 WD
more
2008 SUMMARY
Bill #: Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 06/22/2007
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 53,600 285,300 338,900 NO
AGRICULTURAL G4 38.050 5,900 0 5,900 NO
Totals for 2008:
General Property 40.050 59,500 285,300 344,800
Woodland 0.000 0 0
Totals for 2007:
General Property 40.050 59,500 285,300 344,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 12/04/1998 Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
I
ST. CROIX COUNTY ZONING DEPARTME
AS BUILT SANITARY REPORT
Owner u F n
Property Address ?Y c- 3
P
�7
t .'r
City /State 6" /d .
Legal Description:
V � '
g P
Lot Block Subdivision/CSM #
v 1 / 4 L 1 / a Sec. T - N -R Z W Town of a PIN # O 2 " 4 'OZ
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacture rr�i,10 �r`� ...v Size ST/PC / from: House ,j Well , P/L
Pump manufacturer Model
Alarm location Z[; o c
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: Width 2 Length 1iG' Number of Trenches
Setback from: House Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark .sue �,: �� �' / l Elevation /
Description of alternate benchmark S' , .• �3 ,L4oTi`a m Elevation Ll
Building Sewer ' 7f*' ST/HT Inlet 9 4�. ST Outlet PC Inlet
PC Bottom Sly Header/Manifold / Top of ST/PC Manhole Cover -'j
Distribution Lines ( ) 4r,? I;l e' ( ) ( )
Bottom of System
Final Grade
Date of installation / 0 1 / ` lPermit number State plan number
Plumber's signature /j" License number Date
Inspector o
Complete plot plan Or
X
I
l
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
j 60
D
iVI
0
y �
INDICATE NORTH ARROW
r
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
' Safety and Buildings Division
INSPECTION REPORT /
GENERAL INFORMATION (ATTACH TO PERMIT) I/ Sanitary Permit ST CR IX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338865
Permit Holder's Name: ❑ City ❑ Village [)I Town of: State Plan ID No.:
KRAFT, ALAN PL. VALLEY
CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.:
I ( 1 0 c) u,T rv- 024 -1
TANK INFORMATION ELEVATION DATA A9900094
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic kr�� I � QG �rf - ���?t� Benc z PWO /--,S/•U
Dosing - kf 1 4 A " &"Z5 lob
Aeration ' Bldg. Sewer
Holding 6)ot Inlet
TANK SETBACK INFORMATION gDft Outlet
TANKTO P/L WELL BLDG. Air to
i ntake ROAD Dt Inlet
ir
ep -�� ✓ � j�� �/ NA Dt Bottom / /,�j y/
Dosing X�> s" NA Header / Man. 70 ofD S e
Aeration NA Dist. Pipe Z �v Z•rr7Z /0
5-
Holding Bot. System ,3(.�/ /8'7
PUMP/ SIPHON INFORMATION L Final Grade
Manufacturer o r C Demand ,� � 4�i I t ,_e
Model Number 1S `°bGPM A 4 Exi
TDH Li / Friction / I S stem, TDH ' , Ft
L S Head �, l7
Forcemain Length 7&, Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
RENCH Width ' / / Length q ches q No. Of Tren PIT No. Of Pits Inside Dia. Liquid D th
DIMENSIONS `�' DIMENSION
SETBACK SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACH
INFORMATION Type Of CHAM umber:
System: ltnou nc Q �6 Z �I/t— OR UNIT
DISTRIBUTION SYSTEM T° °�
Header / Manifold Distribution Pip (s) x Hole Size x Hole Spacing Vent To Air Intake
fJ �. rl Q ,
Length �r Dia. _ Length Dia. Sparing % f�
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: PLEASANT VALLEY 33.28.17.273B,NE,NE 84 COUNTY ROAD T
j P
7
IIJ- , / �.t1 {' ` `L�; � �'.�; Ct ✓. J �/ = y,, r. '� /� t '� .... l .r ,. f a. - �'� " :rt° - �/ 6 (/°� , D T j - / 0 . / � J
_ ✓�`
A (-t , h� - 1e�, 6 ��a J `, �. 1„l c h v-f l h I r U ! �-/ ► 1* g a-F
Plan revision required? E] Yes E] N f L z z Ie
Use other side for additional information. J
SBD -6710 (R.3/97) Date InspectWs Signature ert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
�e .... _...... __ .......... �v .,
f
3 m.
r
e $
, � E
r
x r
k j
i
a a
e,e..
} E 3
r
.... _._ ,...._..� ._, r....._ ,._
e a s s e
s.,w.
r �p
...,
.. .. ____....._ .i ._ € __ _� _ p..__.. ._ _..R
F €
......, emm
m .. € { e
. . _ _!,.� _ 3 _. ___ .. m _ ... g _e _,
. ...
€ €
....�,,,., r ... ,,.,.T. f . ...,:...4 ..,. »,.
I t
r T
€ 6 }
E (
f
I
i 4
j a �
{ t
r �
1 t c
g @ a,..... .
S
,.. .._ ... ,.., .. ...,.{
m— �. „ , r ..,. —e m. m, ... ...
i'
e� v
E E i a
am. a�a. „ ,m.
4 e s t r r......
2
es
E a
s € F
e
€
3
_.g
r
SANITARY PERMIT APPLICATION Safety and Buildings Avenue
201 W. Washin Nv isconsi n P 0 Box 7302
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 1/2 x 11 inches in size. C,�a
• See reverse side for instructions for completing this application State Sanitary Permit Number
� N Go-5
Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Propert Owner Name Property Location
x'1 /4 � 1/4, S T , N, R 17 E (or)(9
Pro pert Owner's Mailing Address Lot Number Block Number
l F£' d e
City, State Zip Code Phone Number Subdivision Name or CSM Number
a cQ ! ( >
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It Nearest Road
[] Village
Public 1 or 2 Family Dwelling - No. of bedrooms 3 own OF o 4 T
III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo 33 28. 1? 21 3 13
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. 4New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ Repair of an
- _____System ________ System --------- -- T ank
------ ly____ _ ______ Existing System _`______ Exlst)naSystem
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 XMound 30 ❑ Specify Type 41 []Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 []Seepage Pit 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) s Elevation
?S _?7a c Feet l0 is, dFeet
VII TANK Capacity
in gallons Total # of Prefab. Site Fiber- Exper
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank b f60 % 4�1 El 11 11 11
Lift Pump Tank /Siphon Chamber I X IJ G l t Ie ,v 0 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Say Permit Fee (Inducies Groundwater ate I ssued Issuing A nt Signa (No S mps
Approved ❑ Owner Given Initial S fee)
Adverse Determination _D //GA
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD- 6398 (8.1 DISTRIBUTION: Original to County, one copy To: Safety & Buildings Division, Owner, Plumber
F — -
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
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 - -
Safety and Buildings
2226 ROSE ST
LACROSSE WI 54603 -1905
r
3
*isconsin Tommy G. Thompson, Governor
Brenda J. Blanchard, Secretary
Department of Commerce
February 25, 1999
CUST ID No.267341 ATTN: POWTS INSPECTOR
WEGERER SOIL TESTING & DESIGN ZONING OFFICE
421 N MAIN ST �� T CROIX COUNTY
PO BOX 74 ' -- l CARMICHAEL RD
RIVER FALLS WI 54022 IN ON WI 54016
RE: CONDITIONAL APPROVAL !
cc3 ,fir is Identification Numbers
APPROVAL EXPIRES: 02/25/2001' ransaction ID No. 213093
COUN ite ID No. 167688
,e
SITE: 4C*4fM1iG O ctCE Please .refer to both identi fication numbers,
Site ID: 167688 ` j . above, in all correspondence with ag ncy
St. Croix County, Town of Pleasant Valley
NEIA, NE1 /4, S33, T28N, R17W
Facility: Alan Kraft & Denise Blackwell
FOR:
Description: Mound
Object Type: POWT System Regulated Object ID No.: 452615
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Stats.
• Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with
the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats.
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
Sincerely, DATE RECEIVED 02/24/1999
FEE REQUIRED $ 180.00
FEE RECEIVED $ 180.00
6erard M. Swim BALANCE DUE $ 0.00
POWTS Plan Reviewer - Integrated Services
(608)785-9348, Mon - Fri, 7:15 AM - 4:00 PM
jswim @commerce.state.wi.us Ode==
Page of 6
MOUND SYSTEM
FOR
A 3 BEDROOM RESIDENCE
LOCATED IN THE 1/4 OF THE E 1/4 OF SECTION 33 ,T 2 -b N, R 0 W,
TOWN OF V 3 C (Italx. COUNTY, WISCONSIN.
INDEX
PAGE 1 'of 6 TITLE SHEET 4& 4
PAGE 2 of 6 PLOT PLAN
PAGE 3 of 6 PLAN VIEW -CROSS SECTION : dr qft
PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT
PAGE 5 of 6 PUMPING CHAMBER
PAGE 6 of 6 PUMP PERFORMANCE CURVE
PREPARED FOR
w l O e `r l+ ITV E .
�tft'►" -t w'L o�C�, w l S 4 � LS
PREPARED BY
WFEE 4 3EF : ;tEFR SO I L TEST I Iq
AND.
DES I Cril S1= zw I
P.O. BOX 74 421 N. MIM Si. ` • .••" • � ~ "•••.
RIVE. FALLS. V1 54022 k�
P.O.W.
715'41.--0165 WEGE ER
D-915 P
■ -p /LitiitlU /�'6Llly ft3 EiLSWORTH,
4 ^ W
f ,(- � E
f '4� "'
OSEE ENT OF COM RCE
AF Y ND
15 � I " ��� G T3
WINGS ����l9�
Z ZL, -
` 9
RRESP ENCE
JOB NO.
CtC)
PLOT PLAN
Page Z of 6
Scale 1"=
,t)w�jvG_ _ SST l z � Lz L 'S� :tS L r b - --
. 2
1
p12tu %,.
CL
3 bow �
�4oh•L, � U
3p
5�+1
1uZ 4L Y °lc WgW1 U1
—�.� 4461
3' o IV
F.m. N 13p h�v2 ) tip 2.S ' - 00
4461 TRNc�y
II i
��
_ N 1
�p ►v ��u''t'4 -T n'�t
►� (Sr Pf Y UkJE>
NOTES
•1. Elevations shown are existing ground elevations unless otherwise noted.
2. Install permanent markers at end of each lateral. ( 2 required)
3. Install 4" observation pipes with approved caps. ( Z required)
4. tank to be v lbso gallon capacity manufactured by
, twe_
5. Bench Mark +1- el wo.o'oo G Rs,v , b suzFwte AT Futsceb ►"'1g -r - C. Face Po sr
6. Divert surface water around system to prevent ponding at the uphill side.
Page 3 Of
Approved Synthetic. Covering
P,sTN► c 33 Distribution Pip.e
Medium Sand
_ H �
Topsoil F Elev'.
—J I
3 E p
e
y % Slope
(Force Main Plowed
Trench of 2"-2 From Pump Layer
Aggregate
Undisturbed D \•O Ft.
Soil E \- kl Ft.
Cross Section Of A Mound System Using F 0-b Ft.
1 Trench For The Absorption Area G 1•� Ft.
A y Ft. H I- S Ft.
6 qLI Ft.
I �`Z Ft.
Linear Loading Rate= 1 4 - 1 9 GPD / LN FT J 8 Ft.
Design Loading Rate= 0- 3 GPD /SQ FT
K Ft.
L 0 ( Ft.
—�+ W 2 L} Ft.
Force
B K Main �
A -- — - -- — — � Per
Distribution Trench Of
Pipe Aggregate
Observation
Permanent -J
Pipes
Markers
(Anchor securely)
Mound Using I Trench For Absorption Area
page Of
Perforated Pipe Detail
0
End View
Perforated
End Cop.) od�e�a PVC Pipe
�0 1 ,p0
a
Install permanent
at end of each lateral
Holes Located On Bottom.
Are Equally Spaced
Q End Cop
* PVC Force Main
ti
Distnoution
Pipe
Lost Hole Should Be
Next To End Cap
Distribution Pipe Layout p y 6
Ft.
X U ' Inches
Y Inches
Hole Diameter 1�y Inch
Lateral `/ Inch(es)
Manifold Inches
Force Main Z Inches
# ofi holes /pipe 1Z
Invert Elevation of LateraIs 0 Ft.
Place lst hole Z � N from tee with succeeding holes at L l � y intervals. ,
Last hole to be next to the end cap.
ICI
I Combination Sept4czTank and
PUP CHAMBER CROSS SECTION_ :ARID SPECIFICATIOAIS ' PAGE S OF
M
-VEIJT CAP �f WEATHER PROOF
JuAJCT101J BOX .
f 'i'C.I. VEMT PIPC APPROVED LOCKING
lO' FROM DOOR. MAIJHOLE COVER /NIv
'- ilMDOW OR FRESH wRRt.1lIJ6 t - agEL.
ALP, IWTAKE � cor.�uu�T
tj
c
Wit. 1 0 3 1 ( "MIK
18 "MIN,
I ---- - - - - --
PROVIDE I
W LE T AIRTIGHT SEAL
APPROVED JOIW 8>LPF��S A I I I APPROVED JOIIJT.
w /C.�. PIPEaR
W/C•I• P�PE �c
Tank construction I I
shall comply with I II ALARM
P Y - I II
ILHR (83.15 and 83.20 a I I
I oIJ
qo-
LLEY. FT. OFF
PUMP -� -'�
�
D CONCRETE
_ °t O • 00 I BLOCK
�- RISER EXIT PERMITTED OIJLy IF TAiJK MAIJUFACTURER HAS SUCH APPROVAL BED0 IN4
SEPTIC f SPECIFICATIOLIS
DOSE Pe 3.6�
TANK MANUFACTURER: IJUMTSER OF DOSES: PER DAy
TAWK :,IZE: ��J0C_) 1650 GALLOWS DOSE VOLUME I
ALARM PkAMUFACTUFCER: S -S` Z•�''T" S�LS�Tt�'•l I N CL UDING -P BACKPLOW: t3 b GALLONS
MODEL LIUMBER: 10 VAw CAPACITIES: A= t 6 IWCHES OR 3 � 0 �[ 6 GALLOWS
SWITCH TYPE: - B = Z IWCHES`OR =1 G�LLOU5
PUMP PIAIJUFACTURER: GOUL O S C = 8 IUCHES OR 3 `' GALLOWS
MODEL IJUMBER. 3 �PO D- IMCHESOR 110 GALLOUS
`riiTecL = b q b
SWITCH TYPE: IJOTE: PUMP AND ALARM ARE TO bE
M DISCHARGE RATE GPM INSTALLED ON 5EPARATE CIRCUITS
VERTICAL DIFFEREMLE DETWEEU PUMP OFF AI,ID.DISTRIBUTION PIPE.. �%,yl FEET
+ mimimUM WETWORK SUPPLY PRESSURE .. 2 S y FEET
�. FT L.t 8
+ � FEET OF FORCE MAIM X 0fT.FKICTIOtJ FAC,TOR.. FEET
TOTAL 0tJ JAM1C. HEAD = Ib•�3S FEET
Pump chamber DIAMETER — 3�
ILITEKLIAL DVALWSIOFJ� OF TAFJK: LEAIGTH ;WIDTH ;LIQUID DEPTH h
BOTTOM AREA — _ 231 = GAL /INCH
AS PER MANUFACTURER = , GAL /INCH
Goulds
Submersible
C . Effluent -Pump
w -
3871 EPO4
EP05
APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron
Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer,
following uses: • Capable of running lubrication and efficient strength, and durability.
Effluent systems dry without damage to heat transfer. ■ Motor Cover. Thermoplas-
• Homes components. tic cover with integral handle
Farms Motor:
Available for automatic and
• and float switch attachment
• EPO4 Single phase: V 0.4 H manual operation. Automatic points.
• Heavy duty sump 115 or 230 , 60 e: 0.4 HP, models include Mechanical
•Water transfer Float Switch assembled and ■ Power Cable: Severe duty
• Dewatering RPM, built in overload with rated oil and water resistant.
automatic reset. preset at the factory.
• gle phase: 0.5 HP, ■Bearings: Upper and lower
EP05 Sin h
SPECIFICATIONS 115 V, in Hz, h 550 RPM, FEATURES heavy duty ball bearing
construction.
Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo-
• Solids handling capability: automatic reset. plastic Semi -open design
3 /4" maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING
.- • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. 0- Canadian Standards Association
r • Total heads: up to 24 feet. with three prong grounding
/ • Discharge size:1 t /2' NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo -
g plastic enclosed design for (CSA listed model numbers
• Mechanical seal: carbon- length, 16/3 SJTW with improved performance. end in "F" or "AC.)
rotary/ceramic- stationary, three prong grounding plug
BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged
• Temperature: thermoplastic design provides
1041(40 °C) continuous superior strength and
140 °F (60 °C) intermittent. corrosion resistance.
• Fasteners: 300 series METERS FEET
stainless steel. 10
• Capable of running
dry without damage to s 30 s
components. _
Pump: EP05 e - — 1=r
• Solids handling capability: 0 25 j r
%" maximum. a 7 - -- - -- - - -- -- - --
• Capacities: up to 60 GPM. _ j
• Total heads: up to 31 feet. 6 20
• Discharge size: 1 1 /2" NPT. Z 5 -- - - - --
• Mechanical seal: carbon- 0 15
rotary/ceramic- stationary, 4
BUNA -N elastomers. — - -- -- — -- — - -- -- — Epps`
• Temperature: ° 3 10 iZa -o
104 °F (40 °C) continuous
140 °F (60 °C) intermittent. 2 -
5
C — ! ° 10 20 30 40 50 GPM
L -L L
0 2 4 6 8 10 12 m -/h
CAPACITY
m 1995 Goulds Pumps, Inc. Effective May, 1995
83871
• Page 1 of 6
MOUND SYSTEM
FOR
A 3 BEDROOM RESIDENCE
s y�.
LOCATED IN THE �' 1/4 OF THE E 1/4 OF SECTION 3 3 , T l b N, R 0 W,
TOWN OF COUNTY, WISCONSIN.
INDEZ
PAGE 1 'of 6 TITLE SHEET
PAGE 2 of 6 PLOT FLAN
PAGE 3 of 6 PLAN VIEW -CROSS SECTION
PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT
PAGE 5 of 6 PUMPING CHAMBER
PAGE 6 of 6 PUMP PERFORMANCE CURVE
PREPARED FOR
Ili -PSG 1Z..Ct�T �' ���,SE t3 t- RCirkwLsT.l
w 1 o 'a r}T Pvia� .
P74EPAIM BY
WEGE�tEFL SQ Z L. . TEST I NCG
AND .
DES 2 GN SERVICE
F.O. BOX 74 421 K. KAIK ST.
RIVED FALLS. KI 54022
715 - 425-0165
V ;2 T n o. U C T I u N
JOB NO.
PLOT PLAN Page 4- of 6
Scale 1 "= 4
I
2
��,�o spy plzlu
3p of
53+1
u
4 6 1 �—
F.m. TMyp ti02.S' _ 00
I llb, r TR�I
I�
103.S 00
ort-
NI
r 2
��SIvRA `�lj1S
fJ oT Ptzu�►z'l`l U�lE>
NOTES
-1. Elevations shown are existing ground elevations unless otherwise noted.
2. Install permanent markers at end of each lateral. ( 2 required)
3. Install 4" observation pipes with approved caps. ( Z required)
4. tank to be' /bso gallon capacity manufactured by
V�tbw +�1 1�C sT , t w 0 - .
5. Bench Mark +) - Lt , loo.&om GRu suzF-ftce P Feh6c eb M4_-_r - c_ FLIA•1Ce F"
6. Divert surface water around system to prevent.ponding at the uphill side.
i
Page 3 Of
Approved Synthetic. Covering
�sTN► c ?s3 Distribution Pipe
Medium Sand
Topsoil _ HG,
9 F Elevd.
3 E
b
y % Slope
Force Main Plowed
Trench of 2 " -2 2" From Pump Layer
Aggregate
Undisturbed D Ft.
Soil E Ft.
Cross Section Of A Mound System Using F 0. Ft.
I Trench For The Absorption Area G % •o Ft.
A y Ft. H i• S Ft.
6 ay Ft.
I Ft.
Linear Loading Rate= V4 . - 19 GPD /LN FT J a Ft.
Design Loading Rat = 0 - 3 GPD /SQ FT
K Ft.
L I (o Ft.
�+ W 2 LI Ft.
L
Force
B K Mail_
W Distribution Trench Of 2 — 2 '2 �YvO
Pipe Aggregate
1
Observation Permanent . Markers
Pipes
(Anchor securely)
Mound Using I Trench For Absorption Area
Page Of
Perforoted Pipe Detail
� 0
End View
End Cop. Perforated
PVC Pipe
o n
J Sa o
a
Install permanent-marker
at end of each lateral
Holes Located On Bottom,
Are Equally Spaced
Q End Cop
P f-i
* s PVC Force Main
Distribution
Pipe
Lost Hole Should Be
Next To End Cop
Distribution Pipe Layout P y 6
Ft.
X L J 9 ' Inches
Y `L 6 Inches
Hole Diameter 1t Y Inch
Lateral 1 N Inches)
Manifold Inches
Force Main Z Inches
# of holes /pipe ZZ
Invert Elevation of Laterals 04.0 Ft.
Place 1st hole Z� N from tee with succeeding holes at L I S ' intervals..
Last hole to be next to the end cap.
- Combination Septic;Tank and
PUMP CHAMBER CROSS SECTION, ARID SPECIFICATIOmS; ' PAGE S OF
-VEIJT CAP WEATHER PKOOF
JuIJCTIOAI 80X
4'c.i. VENT PIPE APPROVED LOCKING
110' FROM DOOR, MAWHOLE COVER P011%
L !4
AhNDOW OR FRESH
WAEtN1A1G
A� IUTAKE J� cowDurlr
s
tj i
CAA i 4 MI M.
`� ---- - - - - --
PROVIDE I
IAILE T AIRTIGHT SEAL
v
APPROVED JOINT A I { I APPROVED JOIAIT:
I I ( W /C.I. PIPE�P'c
W /C.1. PIPE OR Tank construction i II�
shall comply with I ALARM
ILHR ('33.15 and 33.20 d I 1
I I OA,
C i I
90•� I
LLEY. FY PUMP — OFF
-'�
y
LL CDAICRETE �-ENl _ 4 0 . DO 6LOGK APPRovft
RISER XI
ET PF- FmT(ED OULU IF TAWK MAIJUFACTURER HAS SUCH APPROVAL —DED O t N4 INra
E3ED
SEPTIC f SPECIFICATIOkIS
oosE �tDhll�J P1u1� • b
TP.AlK M/1AIUFACTURCR: AIUMfSER OF DOSES: PER DAB
TAWK SIZE: y000 16 SO GALLOWS DOSE VOLUME r
ALARM MANUFACTURER: S _S` j�EL�IMa SyS1E)"1 IIJCLUD O ACKFLOW: 13 b GALLONS
MODEL WUMBER: 10[ `A CAPACITIES: A= `g 11JCHESOK GALLON S
SWITCH TYPE: "E) C- V-(( 5= Z IUCHES`OR _=1_ G( LLOA15
PUMP MANUFACTURER: GOUT O S C- 8 IUCHES OR 2 6 CALLOUS
MODEL DUMBER: �4 D- \S INCHES OR X-l0 GALLOME
M-vt��= b46
SWITCH TYPE: MOTE: PUMP AUD ALARM ARE TO 15E
MIAIIMUM DISCHARGE RATE GPM IN5TALLED OM SEPARATE CIRCUITS
vERTICAL DIFFEKEWCE DETWEEU PUMP OFF AUD- DISTRIBUTIOAI PIPE., l3'�-j FEET
+ MIIJIMUM METWORK SUPPLY PRESSURE 2.50 FEET
T
�{ � FEET OF FORCE X F MAIM 0Fr. FRIC710u FACTOR _. \ _. FEET
.= TOTAL 091JAMIC HEAD = 1b•�S FEET
Pump chamber DIAMETER 3
INTERLIAL. OIMLWSIOW� OF TAUK: LENGTH ;WIDTH - ;LIQUID E)EPTH
BOTTOM AREA - 23I= GAL /INCH
AS PER MANUFACTURER GAL /INCH
Goulds 6 0E- (,
Submersible
Effluent Pump
EPO4
EP05
APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron
Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer,
following uses: • Capable of running lubrication and efficient strength, and durability.
Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas-
• Homes components. tic cover with integral handle
Farms Motor:
Available for automatic and
• and float switch attachment
• EPO4 Single phase: 60 0.4 H manual operation. Automatic points.
• • Heavy duty sump 115 or 230 V, e: 0.4 HP, models include Mechanical
Water transfer Float Switch assembled and ■ Power Cable: Severe duty
• Dewatering RPM, built in overload with rated oil and water resistant.
automatic reset. preset at the factory.
• EP05 Single phase: 0.5 HP, ■Bearings: Upper and lower
in
SPECIFICATIONS 115 V, in le phase: RPM, FEATURES heavy duty ball bearing
construction.
Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo-
• Solids handling capability: automatic reset. plastic Semi -open design
3 /4" maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING
- • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal rotection.
• Total heads: up to 24 feet. with three prong grounding p SP Canadian Standards Association
• Discharge size: 1 /z" NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo -
g (GSA listed model numbers
• Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for end in "F' or "AC ".)
rota /ceramic- stationa three prong grounding plug improved performance.
rY ry. p 9 9 9 p 9
BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged
• Temperature: thermoplastic design provides
104 °F (40 °C) continuous superior strength and
140 °F (60 °C) intermittent. corrosion resistance.
• Fasteners: 300 series METERS FEET
stainless steel. 10
• Capable of running
z� }
dry without damage to s 30
components.
Pump: EP05 8 - - - - — ! — - - - -- IL2.S Fr — - --
• Solids handling capability: o 25
�
% maximum. a
• Capacities: up to 60 GPM. s 20
• Total heads: up to 31 feet.
• Discharge size: 1 NPT. Z 5 - — - - --
• Mechanical seal: carbon- 0 15 I
rotary/ceramic- stationary, 4
BONA -N elastomers. -- - - -'-- - -- — - - -- - -- - -EPOS
Temperature: ° 3 10 1 1 Za
104 °F (40°C) continuous
140 °F (60 °C) intermittent. 2 — - E - - --
5
1
0 00 10 20 30 40 50 GPM
L ' 0 2 4 6 8 10 12 m
CAPACITY
®1995 Goulds Pumps, Inc.
Effective May, 1995
83871
1�Yrsconsin Departme of Industry SOIL AND SITE EVALUATION REPORT Page - ! - Of
Labor and Human Resauons
Oivision of Safety A Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but `` t
not limited to vertical and horizontal reference point (SM), direc and % of slope, scale or PARCEL I.D. N
dimensioned, north arrow, and location and distance t a e t tod� Q — Jo — z,0
APPLICANT INFORMATION- PLEASE PRI1�!'f� `> REVIEWED BY DATE
PROPERTY OWNER: ^Cr F� PFIOF�RTY LOCATION
A1. UeeaSE gL,�KlA18Ll «A -;rT' r eyrtcT NE 1/4 1L)F- 1/4,S33T z-� ,N,R V7 E>4W
PROPERTY OWNER':S MAILING ADDRESS o LOT is I' B t I SUED. NAME OR CSM it
w 1 ?9 D 8
CITY, STATE 21P CODE , PHONE NU (]CI (]VILLAGE �jOWN NEAREST ROAD
New Construction UseX Residential J N bar fit s J J Addition to existing building
[ J Repleoement ( Public or nw nera
Code derived daily stow 4 _ gpd Recommended design loading rate o, S bed, gpd/h a to trench, gpdJh
Absorption area required 3`7 S bed, f 3E- trench, h Maximum design loading rate 0,s bed, gpd /flz o, (Xtrench, gpd/h
Recommended infiltration surface elevation(s) ?o 19E DE 1AY D f� (As r eKrrad to site plan benchmark)
Additional design /site considerations _JID 3 DIEPT`tr W-' °tom
Parent material G/A('1AL- P L-L- Flood plain elevation, it applicable n[ tt
T- Unsuitable Suitable for System CONVFJ�ILiO U L D IN•GROUND PRESSURE AT•GRADE SYSTEM IN FILL HOLDING TANK
tors stem ❑ S U S ❑ U ❑ S 29U ❑ S �l1 ❑ S ICU ❑ S
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence 8CLrclary Roots GPD /ft
Boring it Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITmnch
1 t I ,- r r
Vii# Z I()- 3 Sh It ' c
Ground 3 )- 'fl NZ 3 S I C Ij b.
103tZ4rt. o e I i LL
Depth to
limiting
factor _
Remarks: —
Boring # r O 9 z z
i €.*
2 -tZ 0 f2. J St m ( Cs N(' 0,
Ground 3 17--17 3 Z cs I as o. (0
elev. 7 - 10 3l rns F C ,y 10,
lol.ZL
S
Depth to _
limiting (
f 2-5
Remarks: Cv u19Q1Pi1/Scdw Vj .
EX T a' —Plan Print Pnonv V , IS ) 421 1 7 7 .�
ST
nsa: l \j E
Date: . Number,
Si g A)W 2-L 19 9Q' A37d
PROPERTY OWNER /\Mftt I SOIL DESCRIPTION REPORT Page
PARCEL IMA 02L4-toy Z.
Depth Dominant Color Mottles Structure GPD
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
/0 VIC 2—mQ17 MA
A2::"•:2v w`:i :.'+ ,� /S.. '`/ Z. _! 5 I Z YYTrj" C.5
Ground 3 j r S) Z ►115 ky&f - CS 0
elev.
lD2� ft. L _ 10\ 3 r GS ' Aq 0,
Depth to 5 2 - 5 - - 3 2 , t o Y 5 rvt�r" Cs D , L4 0, 6
limiting
factor jo to 3 C�r4C_ LL �j _."n't Me:f �' J
Remarks:
Boring #
6::4:3 %i+k'•:4Y.•:^
Ground
elev.
it.
Depth to
fimiting
factor
Remarks:
Boring #
`•; _: is <: ;;:;? +i:
Ground
elev.
f t.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
tt.
Depth to
bmiting
factor
Remarks:
SBO- 8330(R.05/92)
Page S of 3
PLOT PLAN
Property Owner AL,)JKKAFt � MAJ5'E Legend: � �� "4;-X�Prk) `Ex&
S3 LAC.K.W 6 LL .�IOfED
Legal Description pro FLLDC 7 BM = 1 ®�2ouNo 3u��tCS� T
ZA7 1 N FL of TA E Ne`/y, 56C 33, FLAI,GX- AWrA F'C /00 "T
T PI-r--A,. 7aT *20 C- KDUNtD 3LtRPACe
VALL6 5r. CROtx Co lit AST 1 4 ) c,3Z 5cOU,5-jA1 WOODEVRMr- A-,-,�SUMED)W.0i
❑ = soil boring w /backhoe,
No anti t3 sa641 K j
n PA VF
c0>J
C3131
D
6L AR L4 U µ 0 M[f�1L FFi�C e Pta` U� c-T, #1, T 7
Ao nwr otiFStc R8
6L d ' ZJ PPRaa,ha-cc
SZrr= LLCA xo►.I : PF�lkf U ti16 — � PRo rat Y LW� L'�Ubc
y c X �� t( Signed CST
/tI 3707
Date NQIENI "Z4 OR
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
I ¢� C�J �`�fT -�- Ems• /sue ��`�c,�iveCl- 1�R��'7`
Owner/Buyer ,/�
Mailing Address c d /a'l/t �A 6 '�
Property Address a G i'<c' X S: F '7 --
(Verification required from Planning Department for n w constriction)
City/State M d &z �� Parcel Identification Number el ;2 `�" /y�/� �B Qo s
LEGAL DESCRIPTION /V6`fe'. 6 -1 ` 14
Property Location ,� '/4, /Vk' '/4, Sec. 3 -3 . V hll N -R / 7 W, Town of
Subdivision Lot #
�U�N'e �e���r�� .
Certified Survey p# Volume Page #
�3' P
ag
Warranty Deed # ��' . Volume - '7 74� . Page # YD
Spec house ❑ yes ❑ no Lot lines identifiable Oes ❑ 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 fnnetion 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
masterplumber, journeymanplumber, restrictedplumber or a hmsedpumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
WAOF year exp' date
9,
APPLICANY 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 pr 'bed above, by 'rtue of a warranty deed recorded in Register of Deeds Office.
SI OF AP I DATE
* * * * ** Any information that is mis- representedmsry result in the sanitary permit being revoked by the Zoning Department.******
*' Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
i
♦T! BAR OF �'i rya - `0411 ^ FORM 11 -19M Ian++ ansenv . I" a�eoeo+as wt+a
Wes_ %4 V W ED
. 4wjo= t1; AfA
.� . - _---- ,•• -,-.:• : , _ v � -� : Y_.__: KEGI$TER$ OffICE
This Deed, made betwe ._ e hl;< t�( tlt...! s !� „ .��” { s � gl r 4................ at. CRM W y WJ&
........
hte .>td fe .sad .ie .bar._s:t�u . right .................. ..._......... ..................
Rec'�. fcr Rlmooid � 28th
roar of .>,*{ w. Q 1917
. Greater. — .�.....�
and..... 1�an. fi .. .ar>� . I�el�se • �ackwel�- lti�at't, .............. 1:30 !
husband ary wife as surviwrshi ?nttz'ltal k??'ol?e?'t�►
................................................................................ ............................... .
.................................................................... ............................... Grantee.
Witnesseth, That the said Granto., for a valuable consideration......
oonveys to Grantee the following described real estate in .... St.. Croix ........... t esrvaN TO
County. State of Wisconsin:
Sh of NEh of Section 33 -28 -17 EXCEPT S 446 feet of -�
1987 feet thereof.
and Ta: Parcel Ne:. . ».... »..:» ....................
Part of Vh of NEk of Section 33 -28 -17 described as
follow: Cosmencing at the NE corner of said Section 33; thence S89 ° 41'30 "N 99.0 feet
to point of beginning; thence S89 2071.0 feet; thence SO'18 "N 1292.81 feet; 1
thence 389 ° 52'15 "E on S line of said * of NZh 898.89 feet; thence NO ° 18 1 10'$ on W
line of Town Road 66.0 feet; thence S89'52'15 "E on N line of said Town Road 1172.0
feet; thence N 1242.65 feet to point of beginning.
IRNSM
This ----- in .................. homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And. ........... Charles A...Beers and - Mary_ J..- Beers,-.. .--- .._-- ..----- ...---- _ - -.-
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements and zoning ordinances and building restrictions of record, if any
i
and will warrant and defend the same.
i
Hated this 5th.. day of ... . ...... ... October - - - -•
------- ------------------ ---- ----- -- - --• ------ -- -- (SEAL)
r'- •---------- - - - -------
--- (>
• ......................... ........... .............. . . . .•. ......... • ...... .......
- -------- (SEAL) j �� (SEAL)
•
Mar J �He�
. Y
AUTHENTICATION ACHNOWLBDGMBNT
I Signatures) ___ STATE OF WISCONSIN
as.
-------------------------•-••-------------------- •-•....-- •- •--•••-•- -- ....__.._ CXAU
>r. - -- -- ------- .................. County. �
authenticated this .... ....day of --------------------------- 19 ..... Personally came before me this ..... E_5.0 - ... day of
I
•----- •----- ------- ............................................................ . ........October ................ 1985_.. the above named
....hBJ IVA.. --- I}g V TM - 4nd
*_.._... ............................ ...................................................
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not- ............................................................ .............................................................. ......_.__....---
authorized by 1 708.08, Wis. Stats.)
� to me known to be the person ... @! g
....... who executed the
foregoing ' strument and know ge the same.
j�
THIS INSTRUMENT WAS DRAFTED BY
l DOUGLAS -• R. - ZILZ Attorney at Law
{ - .-------- • - - -...
•• . -
•-
Susan - - ••• A. Fox
---- - -• - -- - - - - - ------- •----- •- ••-- -
.....
Hudson. Wisconsin 54016 St. Croix Count
-- --.. ... -_. -... Notary Public y. Wis.
(Signatures may be authenticated or acknowledged. Both 'My Commission is permanent. (if not, state expiration
are not necessary.) MarCib 89
date:
- - . - - SUSAN A: t IJ - ---------••- ----- 19. )
•Names of persons sitninS in any capacity should be typed or printed below their sroilbo, s PUbI1C, State Of W SCOnSiI - _- - -- -- `_
—_.
IlG W4r Conwq® STATE BAR OF WISCONSIN
FORM Ne. 1- 1993 Stock No. 13001
Submit to non - enforcing WISCONSIN ADMINISTRATIVE BUILDING State of Wisconsin
municipalities for new 1- PERMIT APPLICATION Safety and Buildings Division
and 2- family dwellings (Wis. Stats. 101.63 (7) & 101.65 (3)) ,4
SEE INSTRUCTIONS ON BACK OF YELLOW COPY.
Personal information you provide may be used for secondary purposes. [Privacy Law 15.04(1)(mij]
'E�'�
9
J mom„ ..€'. `�..
Last Name First Name Middle Initial
Ken zj_
Stre Address
City I State ` Zip Code Telephone No. (Include area cod / e)
/V," pzz-
Building Address 4.i ;j Subdivision Name Lot # Block #
aG-
Legal Description Parcel No.
1/4, 1/4, Section J -5 T �29JJ_ R 1 60 E or W
.:11 •MOf�. , W E
,�. . �•� -a.. E
, rsr
1 Family TA Forced Air Furnace ❑ Radiant Baseboard or Panel ❑ Heat Pump
❑ 2 Family ❑ Boiler Central AC ❑ Other:
" + _ Ei, Nat. Gas L.P. Oil Elect. Solid Solar
Space Heating ❑ ( ❑ ❑ ❑ ❑
Water Heating 0 ❑ ❑ ❑ ❑
N r W 5. FQUNDATIUN
CS''TI .
Site Constructed
Concrete ❑ Masonry ❑ Treated Wood
❑ Manufactured ❑ Other (specify):
y
q C ,fit 1 x p f
Livi area = (� Square Feet
sw1 i o r O i Jtrr
I vouch that all the above information is correct, and understand that the issuance of this permit is for administrative purposes only.
I understand that onsite construction inspections will not be performed by the municipality, but that the Uniform Dwelling Code,
Chapters Co m/ILHR 20 -25, still applies to all new 1- and 2- family dwellings and must be complied with. I understand that the
issuance oat s pe _ oes not relieve a of compli €e with other applicable codes aqd ordi ances.
Appl' ignature at' ne
Musi]BE COMPLETED BY THE MUNICIPALI 4�11EFO#E FORWARDING #INIC PLY TO THE STATE DIVISI ®N OF SAFETY AND BUILDINGS
awn ❑Village? !City 0 ❑ County f:
jl
4 ,IUTI , Ty NITI4EI2 # ., `� �Sti
�?f�1tLotiau
P, IT ISSU D:
SBD -8254 (8.2/98) Whjte - Issuing Jurisdiction Pink - State Within' 'J0 Days Yellow - Applicant
INSTRUCTIONS
The owner, builder or agent shall complete and provide all required information on the application
form down through the Signature of Applicant block. This data is used for statewide statistical
gathering on new one- and two- family dwellings, as well as for local administration. When completed,
submit to local municipality having jurisdiction. Plan review or building inspections will not be
performed by the municipality.
PERMIT REQUESTED:
• Fill in building address.
. Fill in legal description of lot, subdivision name, lot number and block number.
PROJECT DATA:
• Fill in all numbered project data blocks (1 -7) with the required information. All data blocks
must be filled in, including the following:
------------------------------------------------------------------
1. Type - Check only "1- Family" or "2- Family" if that is what is being built. In other words,
do NOT use this form if only a new detached garage is being built, even if it serves a one or
two family dwelling.
2. HVAC Equipment - Check only the major source of heat, not any supplemental sources.
Mark central air conditioning if present. Only check "Radiant Baseboard or Panel' if there
is no central source of heat.
6. Living Area - Include any finished area including finished areas in basements. For two -
family dwellings, include total combined areas.
7. Estimated Cost - Include the total cost of construction, but not cost of land or landscaping.
SIGNATURE:
Sign and date application form. -
------------------------------------------------------------------
ISSUING JURISDICTION - This must be completed by the AUTHORITY HAVING
JURISDICTION.
Check off MUNICIPALITY STATUS of issuing jurisdiction, such as town, village, city or
county.
Fill in MUNICIPALITY NUMBER OF DWELLING LOCATION. If issued by a county,
indicate the specific municipality number where the dwelling will be built.
Fill in name of person issuing permit and date building permit issued.
PLEASE RETURN PINK COPY WITHIN 30 DAYS AFTER ISSUANCE TO (You may fold
along the dashed lines and insert this form into a window envelope.):
Safety & Buildings Division
P O Box 2509
Madison, WI 53701 -2509