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ST. CROIX COUNTY ZONING � A R AS BUILT SANITARY REORT
Owner ct�
Property Address °�
ST CRC d
City/State ,�
„ourTY
ZGNfNGoFFICE
Legal Description:
�L�o��t Block Subdivision/CSM
OYIdL '/a ' /a, Se , T N -R/ W, T A PIN #
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer LJ U Size ST/PC /-20/ 73' Setback from: House 94 Well �� ' P/L
Pump manufacturer Model //�
Alarm location _ o,
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTI N SYSTEM
Type of system: Width �_ Length 7 Number of Trenches
Setback from: House 3o • Well / ft P/L Vent to fresh air intake 30
ELEVATIONS
� �i-- Elevation
Description of benchmark /y 1N �—
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet q 3, 1 ST Outlet 3 PC Inlet
PC Bottom $9� �S Header/Manifold Top of ST/PC Manhole Cover ?91
Distribution Lines ( ) g�j Z () ( )
Bottom of System () 9 7 ' () ( )
Final Grade
Date of installation S /�/ / mit number State plan number 3 a
Plumber's signatur License number a l.& 5 T — Date
Inspector kolo Complete plot plan �
t
A AIW.
J v
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.
2�
° PLAN VIEW
V
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INDICATE NORTH ARROW
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 51 CRUIX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. 324767
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
DERRICK CONSTRUCTION, INC. RICHMOND
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
V C 1 - " I i n ;
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS H1 FS ELEV.
Septic
NJ
5e� )2 Be m (,,35 l ob.3s l vo
Aeration Bldg. Sewer
Holding St /Ht Inlet V3
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ai to ROAD Dt Inlet
Air Intake
eptic ��' j off' ZZ' ry /K NA Dt Bottom
Dosing < < rr 2 S NA Header / Man. 73,
�Ho 97.9 S"
Aeration -- — _ NA Dist. Pipe g'54- 97. RY P/an
Holding Bot. System s g 96 •�r7 97,1
PUMP/ SIPHON INFORMATION '� S Final Grade C. of. /Do-3/
Manufacturer G-7 ov �d 5 Demand ( - 7. t y, 7 Lf
Model Number W C - 7 0 jt l ( C1 GPM
TDH Lift, p� Lriction System TDH9 gc/Ft
oss Forcemain Length 15 Dia. F a i Dist. To Well
SOIL ABSORPTION SYSTEM `
TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid D th
DIMENSIONS to '7a DIMENSION
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING rer:
SETBACK CHAMBER
INFORMATION Type O � r ti l 0 ' OR UNIT el Num
System(
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Co z Dia. Length � Dia. yip Spacing
A S 7 -A 1 1 - 7 ;2�
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 El r] No ❑ Yes El
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 1.30.19,NW,SW 1416 174TH AVE — WILLOW VLY LOT 15
► Cd l 1 2 ,
Plan revision required? ❑ Yes [ff No
Use other side for additional information.
SBD -6710 (R.3/97) Date Inspector's Signat&e Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Vi sconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue
P 0 Box 7302
In accord with ILHR 83.05, Wis. Adm. Code
Department of Commerce Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the system, on paper not less County
�
than 81/2 x 11 inches in size.
• See reverse side for instructions for completing this application state sanitary Permit N mber
Personal information you provide may be used for secondary purposes Check if revision iou �Zon
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATI N
Pr rtyOwnerName �14 T3�,N,R'q E(O W
Property Owner's Mailing Address Lot Number Block Number
A
City, State ` Zip Phone umber Subdivi n Name or u mber
c 16 n,.0
II. TYPE 0 F Bt )IN : (check one) ❑ State Owned o it Nearest Road
Public o 2 Fami Dwelling - No. of bedrooms o row o
1 f t c1. / o
III. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Numbers)
1❑ Apartment/ Condo O —lo D
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. Ij New 2 ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
System System __ ___________Tank Only ___ ________ Existing System ________ Existing stem
B) A Sanitary Permit was previously issued. Permit Number :3.-?4 7 1,o 7 Date Issued 1 9
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 V Bed 21 Mound 30 Specify Type 41 Holding Tank
12� ❑ [] E] 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
Loo C-) Red (sq. ft.) Propose d (sq, ft.) (Gals/da /sq. ft.) (Min. /inch) Elevation
Z�5 � ,1) Feet Feet
Capacit
VII. TANK in Ca allon
g Total # of r Prefab. Site Fiber- Exper-
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
eptic Tank ank V -11 1 150 ,Qrs ❑ 1 ❑ ❑ ❑ ❑
J � lft Pump Tank 1 kmrl!+'amber wl"' ❑ ❑ 1 ❑ 1 ❑ ❑
VIII. RES NSIBILITY STATEMENT
I, the undersigned, assume responsibility for insta of jh e onsite sewage system shown on the attached plans.
Plumber's Name: (Pri PI er' Signat re: (No St m s) r P/MPRSW No.: Business Phone Number:
Plu s Address (Street, Ci , State, Z' Code):
N
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issuing Agent Ignat re ( o S am
Surcharge Fee)
Approved ❑ Owner Given Initial z /�
Adverse Determination J 1
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: safety & Buildings Division, Owner, Plumber
I1
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:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement_ Installing plumber isto fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
I
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 mainstwater 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 bythe 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.
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SEPTIC TANK £ 'PUM_P CAAMBER CROSS SECTION AND SPECIFICATIONS
4" CI VENT PIPE 12" MIN. ABOVE GRADE 6 WEATHER PROOF'
>_ 25' FROM.DOOR, WINDOW OR JUNCTION BOX APPROVED
FRESH AIR INTAKE- WITH CONDUIT MANHOLE COVER
W/ PADLOCK &
FINISHED GRADE 4" CI RISER WARNING LABEL
6" MIN.
ABOVE G AD E -- }- .._, --- 4 " MIN
18" IN. 6" MAX.
INLET
WAT TIGHT SEALS GAS-
TIGHTi
4 1 1
PIPE .
_� SEAL : APPROVED
CI BAFFLE 4 _ ALM JOINTS W/ CI
\ B i PIPE 3' ONTO
SOL
-{- ON SOLID SOIL
SOIL
PUMP OF ELEV . � ,J -- I
OF *'t RISER EXIT
S5 F T.
D PERMITTED ONLY
IF.TANK .
MANUFACTURER
HAS APPROVAL
3 APPROVED BEDDING UNDER TANK
CONCRETE PAD
SPECIFICATIONS
SEPTIC / DOSE
TANK MANUFACTURER' 0 501 7, 5 0 NUMBER 'DOSES PER DAY: •
TANK SIZES SEPTIC 3AL. DOSE VOLUME INCLUDING
DOSE X50 �- GAL. FLOWBACK: ��5� GAL.
ALARM MANUFACTURER: s A = INCHES = �o�� GAL.
MODEL NUMBER: moo, ,y4•,� 2 INCHES = a9�� GAL.
SWITCH TYPE: �c / B =
PUMP MANUFACTURER: C = )a•a INCHES l AL.
MODEL NUMBER: (,y D &)I
SWITCH TYPE: o ,,,� D = INCHES = ��' GAL.
REQUIRED DISCHARGE RATE GPM PUMP 8 ALARM WIRING AS PER ILHR16.23 WAC
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE /y2 FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . 2.5 FEET
+ a FEET FORCEMAIN X .�FT /100 FT. FRICTION FACTOR ./6 FEET
T.OTAL DYNAMIC HEAD = ,1 l FEET
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH X07 ; DIAMETER —
LIQUID DEPTH
y SIGNED: _ LICENSE NUMBER: 41aa053 7 DATE:
1/88
' • cwt �k .�.s'�'��.��fif1�. / .
ks
'fir L I a7 Fre1n Alt Inlet► And Obtst,0110n Pipf
?i
ADProvb�
j Yonl Cep
,• • . er 12' Aeovo
heel.Crede '
20. 42 % Abero Plpp 4 Coil Iron
�e rB,el Oreoo„ Venl PIP#
Iter,A Ilel Or SrMA.Ik C. , .,
Oru 2 Ttp g9ropele ..
DIU,Ibvllon
PIPe o e o --Too e
b� Af9rojole
Oonoell, PI, ° Pulo +Uoe PI Deter
r e Ce`ptlnl Tarrnlnelino Al
Oellem Of 3161em
P r^u�o)eD T'I�e.� gFr.c�{ lam' Z -
� 1��..�
SOIL FILL
DIST ILtpt, TIOt.1 PIPE '
} r A PPROVCO S4)jpI COVER
2 " OFAGGRI:GATE --�� ,,.. `� P1A7f:ntl�l. OR 4 O F s
OR "Ay
E LEV. O / /. �� ti ° (.� 01. _P_ AGGRCGATt
.-40 > i
OIST'RIBUTIOM PIPE TO-INC AT LCAS'r
AUU AT LtASTL011JCHC;, BUT 1.10 MOIL1.3 y2 OtLOW FIfJAL GRAO
t
M1UcU1uM paP:rH OF FXCAVATIOP ROM o(ZIGwg1. 6gADI WILL of IQC,Hcs
tuKtMtJM p�pr11 of EXCAVATION 0 I C�R�4Dk: WILL ac
INCHES
SIGIJCO: SL
LIGCUSC LJUMBER: _c2 - 3a
DATE:
Ito
� •� '1 I l�: �y
ta EFF PUNIPS
EP031
;�� : ,�;i; r,�;: • :t... GJUP£P0311 142 EP0311 1/3 1� 115 V rfflucnt P:rrp 1/2" so lids I YS6.80 172.10
.�, Submersible
�}1titu:7' MODEL EP0311
Effluent. Pump
SIZE
METE IN' SOLIDS
73f✓w .. RS FEET
Vin.,,.': 25
x•�_ � 10 r�
2
1 k ,
o 00 4 H-
a 12 18 20 24 23 32 36 40
GPM
0 2.S 5.0 7.5
CAPACITY
i!
Performance
Curve 3880'
vcrtAt rtct
MODEL3bOri
SIZE 3 /, * Solid.
Y�
16 _50 .
I L U
yy 0 10 20 >o . 40 . 60 60 •70 EO 00 100 110 120 0 M
.e•• C........... ....... —. to 20 MWA
CArAC,T►
LI5f DISC.
CCX AT.0111L 142 M311L 1/J lip 115 V LOW N 3)4' rolids !<9j .SS 329.35 r.
O�.fl<E0311M 142 '4IEOS1lM 1/3 VP 115 V mod N 3�4" e6lids 491.55 329.35' t
0711PhZ0,1L1 142 tdE051`llt 1/2 IfF 115 V 111,0h }{ 3%4" .oblids ' 04.25
OXN 142 K07121i 3/4 ItP 230. V iii Q h 10. 3/4" solids $A3.65 565.25
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•o.• ..,. • "" "SEE F01.t.04It='; PTGE MIt PEIIICtzl•&CE NO SPTX:IFICA'I1Ct•1S.
DATE 10/80 Carr 30 PAGE Dh
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Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
Viscons P.O. Box 7969
Department of Commerce In accord with ILHR 83. 05, Wis. Adm. Code Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less Coun
than 8112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
3a-7
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N
PrUD erty Owner Nam Property Location
�`� /�f(,rj1/a 6j /a, S / T 30 , N, R j ?If or) W
Property Owner's Mailing Address O � Lot Number Block Number
s N
City, State , Zip Code Phone Number Subdivision Name CSM Number
.ems QC Va`C .5` O ! (`T (-S) W � vJ
II. E F BU ILDING: (check'one) ❑ State Owned [] lt Near st Road
Public 1 or 2 Family Dwelling - No. of bedrooms c Town of � �. / yo ad-
111. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1.V New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System ______ System_____________ Tank Only______________ Existing System ________ Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 21 E] Mound 30 El Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In- Ground Pressure / 42 ❑ Pit Privy
13 ❑ Seepage Pit ��. X 7� 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. 1 7. Final Grade
� �` Required (sq. ft.) Proposed ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
tl0C7 $ S7 $` T 1 j Feet 14M Feet
VII. TANK in Cap llo Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete con- steel glass Plastic App
New Existing structed
Tanks Tanks
e ti nk t/ �5� ;�PS�?rg ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins ilation of the onsite sewage system shown on the attached plans.
Plumber's Name: ( nt) P ber's Sig atur . (No Stamps) MP /MPRSW No.: Business Phone Number:
c g t*
Plumber's Address Street, C State, 'p Code)
�a J '- u �.ra7 �(
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)
ig Approved ❑ Surcharge Fee)
Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBA -639a (R.1 vss) DISTaiauna+: orb to count one copy To: safety a Nu"n i s Division. owner. nwtbw
l -
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 instailation
5. Onsite selkiage'systerns must be properly maintained. the septic tank(s- must be dumped 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 ai'd accurate this sanitary permit application must inciud
i. Property ovvner's narrae and rTa ling address. Provide the legal description and parcel tax number s) of where the
system is to be installed.
ll. 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. Pf{�nber must sign application form.
g 1.
IX. County/ Department Use Only.
X. County / Department Use Only.
Complete plans and specifications not smaller than 8 1/2 r, 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 sizinginformation.
----------------------------------------------------------------------------------------------------
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.
W i 110
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• � � (=), _ APptarld V. Cap
IIINmvT 12" j 20 42" Abor* Pl _ 4" Carl I lan
To flnol Orad*, Vrnl PIP*
1+arn Ilor Or SrntMttc Co rrin
• lrtn 2" ApQr*pot*
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bottom 01 Sy►1*m
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0 I5TRIBUTI01'.1 PIPE
APprkoVED Syl TIACTIC COVER
2 0ir AGGRE TE 11A
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OR 1AARSN F{AIJ
LEV. OF /'•� ,�E ^� _4
(. 01: ?-' /z AGGREGATE
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AUU AT LEAS7 -0 INCHES BUT KIO MORE THAVJ `12 ILICItES 6ELOW FIAIAL GRADE
M1UcU1 A DEP OF EXCAVATICIP FXoti ORIGWAL 6f ADF- WILL 6E INCHES
711K,M
0 5 F T1 OF EACAVA Fl C' 16 4 GR4vF_ WILL 6C _•.sd IK1CVACs
SIGIUCO:
LICCIUSC IIUMBE11 S te_
— — — —• -- I i o _
wiscoosn Department ofCommerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, ws. Adm. Code
Environmen By Design
Attach complete site plan on paper not less than 8 x 11 inches in size. Plan must
Include, but not limited to: vertical and horizontal reference point (BM), direction ands c ounty St C roix
percent slope, scale or dimemsions, north arrow, and location and d�tance to nea)st r ,) . - —
6 D.#
APPLICANT INFORMATION - Please print all information'� ' `• By Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 1 04(I) (m)). /
1...;
Property Owner 'Prgperty Loda 6n I P,
Derrick Construction L*tc. ' of ,T ,, 1/d Syl(JU S t T 30 N,R 1 W
Property Owner's Mailing Address L' , j BI&PONri Subd. N#e gr CSI
1505 Hwy 65 Y 4 ' Willow Valle
City State Zip Code PhoneNumber ❑City.,'! `; Millar; J Tgydn Nearest Road
New Richmond W1 54017 Tfiltt�t " l� - 140Th St.
® New Construction Use: ® Residential / Number of bedrooms 3 []Addition to existing building
Replacement ❑ Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate 7 bed, gpolfF 8 trench, gpolft
Absorption area required 643 bed, fl? 563 trench, iF Maximum design loading rate .7 bed, gpdff .8 tr ench, gpd/ft2
Recommended infiltration surface elevation(s) 97.11 It (as referred to site plan benchmar
Additional design I site consideration 1,2,3
Parent material Loess Over Glacial OutWash Flood plain elevation, if appli NA ft
S= Suitable for system Conventional Mound In -Ground Pressure AT -Grade I System in Fill Holding Tank
U= Unsuitable for system M S❑ U iN S u U I E S El U Ej S El U I CIS MU I ❑ S F9 U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure )/fP
ga Horizon Con in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. S kr,�^ ��'^ b Trench
10 >�� e�
1 1 0 -13 10yr3 /2 - sil 2msbk t l o of ° .6
2 13 -29 10yr4 /4 - sa 2msbk n �u j ?j (nor t lyt 6
Ground 3 29 -38 7.5yr5/6 - is 2msbk ml 3 .8
elev
100.78 ft 4 38 -96 7.5yr5/6 - s Os g m ; 8
Depth to
limiting
factor
>96
Remarks:
1 0 -10 1Oyr3/3 - I 2msbk mfr as 2f .5 .6
alya' 2 10 -25 10yr4/4 - sil 2msbk mfr as if .5 i .6
Ground 3 25 -64 7.5yr4/6 - cs 2msbk mvfr cw - 7 8
elev
100.63 ft 4 64 -100 7.5yr6/4 - s Osg ml - - .7 .8
Depth to
limiting
factor
>100
Remarks:
CST Name (Please Print) Signature: Telephone No.
Thomas C. Nelson 715- 246 -2454
Address Environmental By Design Date CST Number Ref #
1432 120th Street, New Richmond, W1 54017 1/20/99 227387 189
PROPERTY OWNER: Derrick Construction tne. SOIL DESCRIPTION REPORT tss Page 2 of 3
PARCEL LDA Environmental Bv Desian
Horizon Depth Dominant Color7 Mottles T exture Structure onsistence Boundary Roots GPM -
in. in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
3 1 0 -13 10yr3/2 - I 2msbk mfr as 2f .5 .6
2 13 -26 1Oyr4 /6 - sil 2msbk mfr as if .5 ? .6
Ground
elev 3 26 -36 7.5yr4/6 - vfs Om mfi cw - .4 .5
100.11 ft 4 36 -66 7.5yr5/6 - cs Osg ml cw - 7 8
5 66 -98 7. Syr6 /4 - gs Osg ml - - .7 i .8
lim iting
factor
>98
Remarks:
4 " 1 0 -11 10yr3/2 - sil 2msbk mfr as 2f 5 6
- 2 11 -23 l Oyr4 /4 - sil 2msbk mfr as i f .5 i .6
Ground
elev 3 23 -64 7.5yr4/6 - is 2msbk mvfr cw - .7 .8
99.58 ft 4 64 -110 7.5yr4/6 I s Osg ml - - .7 .8
Depth to
limiting
factor
>110
Remarks:
5 1 0 -15 1Oyr3/3 - sil 2msbk mfr as 2f .5 .6
2 15 -33 10yr4 /6 - sil 2msbk mfr as if .5 .6
Ground
elev 3 3340 7.5yr5/6 - Ifs Osg mfi cw - .5 .6
99 ft 4 40 -96 7.5yr5/6 - s Osg ml - - 7 8
Depth to
limiting
factor
>96
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
E BY DE51G
1432120 STREET, NEW RICHMOND, WISCONSIN
Last saved by Thomas Nelson
71S-246-2434
Willow Valley bT PAGE 3
NW % SW '4, SECTION 1 T 30 N, R 19 W
TOWNSHIP Richmond COUNTY St. Croix Wisconsin
�''►� 337.IS
Sl�pc
C7 �
r
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n �
cr o0
N ry
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C.Cre.S
SCALE 1" =40 Tom Nelson
BM I. SW LOT CORNER Top of iron pipe ELEV. 100 ✓ 227387
BM 2. Ground surface next to lath ELEV 99.66 r/
ST CROIX COUNTY -.
SEPTIC TANK MAINTENANCE AGREEMENT
AND .
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Utz-R -tic.. Cow N c. AAtc-"As `-`rMveH-s,
Mailing Address (!?a x p° , taw FtL#*"'o " D \t4-V S Or o 1 '1
Property Address r,
(Verification required from Planning Department for new construction)
City/State t V1 uA tAc t-'Q Parcel Identification Number G--b ' 1 OQ
LEGAL DESCRIPTION
Property Location K W %,, 1 v" %., Sec. �� T "�a N -R W, Town of P1u4 MoMD
Subdivision \44t ".ow VA-� -�- . Lot # (� .
Certified Survey Map # Volume . Page #
Warranty Deed # ` - 2-100 6 Volume . Page # �° b
Spec house Ayes ❑ 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 plymber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days the three are $tiote.
/ 19
S GNATURE bF APPLIC DATE
OWNER CERTIFICATION
(we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the pro erty descri dab v a of a warranty deed recorded in Register of Deeds Office.
SIbNATURE OP APPLIC 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
r W. ►.t. COM ►AN♦
Mt NOMON6t FALLS. WISCONSIN
42200€} �- .F
_ � �600r t f PME'16f �
STATE OF WISCONSIN ST. C off COUNTY, CIRCUIT COURT PROBATE BRANCH
SALE OF REAL ESTATE OF PERSONS UNDER
LEGAL DISABILITY —DEED BY GUARDIAN
WHEREAS, On application to the Circuit Court of $t —f'rA[ County, Wisconsin,
to sell all right, title and interest of Leo T. Domke, also known as Leo Domke
Spendthri , in and to the real estate hereinafter described, such proceedings were
41 r+ceF�'JVGisier = -er� 4aeor��e*_swL - - -1—
had that the undersigned was duly authorized as general guardian to proceed in said matter;
+Inse rt i'9pt eia+'= or- ''6trre ra+t'�
and whereas, the undersigned, as such guardian, has done or caused to be done all things necessary and required to be done by law
in such cases made and provided, before conveyance of such real estate may be made; and whereas, the undersigned,
Lois Handrahan , farm rl y Lois Asp1 and , as such guardian, was
duly authorized by order of Court herein dated on the 16th day of December ,
19 __R6 to execute, acknowledge and deliver to Derrick Construction, Inc.
a deed of conveyance of all the right, title and interest of said Spendthrift in and
(lmertr'Minar-"vr"tn�tmR7eTent ✓')
to said real estate:
NOW, THEREFORE, I, the said Lni S Handrahan, fr)rmPrl v T.c)i s Asnl and , by authority of the
Court above named and in my capacity as such guardian, in consideration of the premises and of ------------------
SixtVThousand ($6 0, 000 � ------------------ - - - - -- Dollars to me in hand paid by the said
Derrick Construction, Inc. do hereby grant and
convey unto the said Derrick Construction, Inc.
all the right, title and interest of the said Leo T. Domke, also known as Leo Domke
Spendt hrif t , in and to the following described real estate in St. 'raj X
IInsEYf �nSr�" or ^Tr�sm�€tenT — "T —
County, Wisconsin, to -wit;
The Northwest Quarter of the Southwest Quarter (NA of SWa) of
Section One (1), Township Thirty (30) North, of Range Eighteen
(18) West.
SL
XEG15 *5 O IffKE
P.
ST. CROIX d0. WI&.
j -m'd. for Record ft 2nd
,J 107 of Jan. A. D� 19 2 '
' r N
File No.
Nn 7 —GAI F nF RFGI FCTaTF nC Dr OcnNG I IKIMCO I cr_ni
f
CK E1 PAG lj x
M
WITNESS the hand and seal of said Lois Handrahan, formerly Lc)i s . / As p luri +2
uardian aforesaid, this
22nd day of December , 19 86
In Presence of
(SEAL)
Lois Handrahan, formerly Lois Asplu d
General Guardian of
1"9ert'= 6pma4' =or 4-
Leo T. Domke, also known as Leo
Domke, Spendthrift
I+neert #IFiner=- br= +necxnpeeen�' =F
STATE OF WISCONSIN,
ss.
St. Croix County.
Personally came before me this 22nd o f December , q. p, �g 86 ,
b the above named Lols Handrahan, f Asplund rr ardian,
to me known to be the person who executed the foregoing instrument 2aindac nowl edged tha s he ex,QCGtg s�rrSepy
virtue of the authority aforesaid. •. �� '•;
Tanya Glaser
f . J
Notary Public, St. CrOiX % Ct� � 3irY'
My Commission Expires 4-
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