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030-2014-50-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST. CR IIX Personal info rmation you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. 338876 Perrplt}i�Lder'; Na ❑ City Village EP n o f: State Plan ID No.: ttSSL � ri j AA J_ H CST BM Elev. - , Insp. BM Elev.: BM Description: Parcel Tax No.: 030- 2014 -50 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer [ Ho lding St / Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet Air 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. 1 f 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 INFORMATION Type Of CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. I 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.) LOCATION: ST. JOSEPH 36.30.19.412A,NW,SW 1225 COUNTY ROAD A Plan revision required? ❑ Yes ❑ No (� Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Vi SANITARY PERMIT APPLICATION 20 w shn sconsin In accord h ILHR with Wis. Adm. Code P.O. Box 7969 Department of Commerce 83 O5, Madison, WI 53707 -7969 0 Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. < 5(6 C �D� • See reverse side for instructions for completing this application State Sanitary PPPe erm � it Num The information you provide may be used by other government agency programs E] Check it revision to previoous applic ion [Privacy law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name Property Location 14 s` /4,S �, T , N, R E (or Property Owner's Mailing Address of Number Block Number NA City, State , Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF RU ILDING: (check one) ❑ State Owned !t� Nearest Road Public 1 or 2 Family Dwelling - No_ of bedrooms 01 'Town g n OF Ac 0 j4 111. BUILDING USE (If building type is public, check all thatapply) Parcel Tax Nu ber(s Y eJ a, d3o�dal�: 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. ❑ New 2. ❑ Replacement 3_ ❑ Replacement of 4_X Reconnection of 5_ ❑' Repair of an System ________ System _____________ Tank Only Existing System Existing System ______________ xistiny _________ B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 $ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation a00 — j b.3 9S r 0,7 Feet ,�;' Feet VII. TANK in Capacity Total # of Prefab. Site Fiber- Exper- INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con Steel glass Plastic App New Existing structed Tanks Tank eptic Tank ank 00 Z 000 a ,� ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 01 ❑ I ❑ 1 ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plum r' Signature: (No Sta PRSW Business Phone Number: Plumber's Ac dress (Street, City, State, Zip Code): j IX. C LINTY / DEPARTMENT _USEONLY ❑ Disapproved Sanitary Permit Fee (IncludesGroundwater ate ssue issuing Age t Signature (No Stamps) A roved l ull Fee) pp ❑Owner Given Initial�oo - ?(V Adverse Determination 1 Dp X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: "C-t05 s� C OK-VVo k VK� b� ) kskl t�PZ4 I ✓! Pei 07 � bLl rn t G�frvz�ia�'1 , SBD-6398 (R.11/96) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber I INSTRUCTIONS 1. A sanitary permit is valid for two (2) ye.jrs. 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 property 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 )nsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Divisicn, 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 pub ic, check all appropriate boxes that apply. IV. Type of permit. Check only one on I ne A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate hox depending on system type. VI. Absorption system information. Prc vide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacii y of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate pref,ib 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 nat 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; be ilding sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absor )tion 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; close volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if requ red 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. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOP tIT11,1ZATION OF AN RXISTTNr SEP TIC TANK This is to certify that I have inspected the septic tank presently serving the ,�` /� /L' &A)qA residence located at: X 1 /4, SLID 1/4, Sec. .3� TAN, R W, Town of Sal. 6 ©5, Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes No (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: ,2 /1000 GL- Construction: Prefab Concrete X Steel Other Manufacurer ( if known) : W&1FA -S /° 0 � © S l Age of Tank (if known) : �4 /'R (Signature) (Name) Please Print (Title) (License Number) (Date) Form 'to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the, best of my knowledge will conform to the requirements of ILHR -83, Wis. Adm. Code (except for inspection opening over outlet baffle . Name _�6jy 1 g� /� i f Signature M� 5/88 n i I INNS ME BEN MEN WE 71 W I Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page _Z_ of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S-/' percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D. # 3. 1 . 30- 19. II- 1 36. 30 . 19. APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location . 6 8 ky Govt. Lot 14 SAJ 1 /4,S _? T 70 ,N,R 11111M) W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# a A # IYX Ci State Zip Code Phone Number ❑ City [I Village W Town Nearest Road u d'Sa» IJZ. 1 .s3 01ol I (7 /f k i-TOS A 4 , 1 ❑ New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: �Q��o�n��•1�s "on �o G'Xis��n9 sys fie, -.-, -'7 Code derived daily flow gpd Recommended design loading rate - / bed, gpd /fi - p � trench, gpd /ft Absorption area required bed, ft trench, ft Maximum design I ading rate bed, gpd /ft . trench, gpd /ft Recommended infiltration surface elevation(s) /OX G i)1 I S. (as referred to site plan benchmark) Additional design /site considerations r leec i v" d"AA 0 Parent material ©Lt .�LJ AS Flood plain elevation, if applicable %zie � ft. S = Suitable for system n F Conventional Mound In- Ground Pressure AT -Grade System iill Holding Tank U = Unsuitable for system [ S ❑ U ®"s ❑ U ®s ©u I ❑ s ©u 9 0 ❑ s [RU_ SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ,e y/6 — Ins 6yq PI 11) /� • Ground 3 164 541 Q jam` fns 7 - O-gft o 6 10, X14 ✓r► S DS P Depth to limiting f r _, in. Remarks: Boring # Sam Ground elev. n. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Page of a PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench Ground elev. ft. I Depth to limiting factor in. Remarks: Boring # Ground elev. _ft. Depth to limiting factor in. I Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) i � 4 I ' i i , e o e I ,�• 35 DI Atra S Pw P fat '�e �Dus se r► s '�^ i i i i i I _ i � I I Q ra i I s X39- � I i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer r, ezr . 131,$1,1A Mailing Address Property Address (Verification required from Planning Department for new construction) 3 6 0, / 9, 4- j /2 A City/State S a Az' Parcel Identification Number :16, 30r/ 9 . W) A LE" DESCRIPTION Property Location _�' /e, � '/4, Sec. _3 C . T_20 N -R�W, Town of SI Subdivision Lot # Certified Survey Map # , Volume . Page # Warranty Deed # 83 7 f 4 f , Volume / 3 �f 3 , Page # 2 9 Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site 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. ay 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 th property described above, by virtue of a warranty deed recorded in Register of Deeds Office. fAOX SIG NATURE 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 0 1 4`�oACF ?98 �g3� 583754 QUIT CLAIM DEED Document Number G CRpI Co., WE . .......... /`1o,r., A........ .............................................. I.......................... R�ghl hN Ih�oni ................................................................................................................................. ............................... JUL 81998 9:00 A. .`` quit - claims to ........................................................................................................ ............................... Roolletw of Do"% ....... Y1nc?j?f .......... 81.t1 ... ................................. ............................... 1 ........... !..... kn oN! n.... ..as.........4o'c ..... inaeni.... ............ Recording Area .............................................................................................................. ............................... Name and Return Address the following described real estate in...!5.t...c rRiA ........................County, ErIC Q 10, 110, laa cr �� � State of Wisconsin: opt'' /� N /T po.�ce d lae)A /oco ed in 4e 1 /a 0� 4Jie. $H/l /4 W Secf►on 36, T30N, Amw,, 36 .30. /q, WRA 36.30. 7 1X1,15 So Sher ly c (Parcel Identification Number) C e r,-} ef- i1 i ne o � Coy n4y Te'tin k 14 , 91. wAy " fi and IV'or�l+er� o� f�1e. yJ'; lion✓ Rtt��r, This......... ... ....... mestead property. Dated this........`.... ..... ..............day of............ l /► ' 1 .e ............................19. (q 131. (is) r is not) •...... Q �,�q.......�A l. 9 .... is n�er ........................... •............................................................................................... ................... ............ ............................................................................................ ............................... .................................................................. ........................................ ............................... • ......................................................................................... ............................... •............. _ ...................... _,......................... ...................................................................... I AUTHENTICATION ACKNOWLEDGMENT Signature( s) ............... . .......................................... .............. ............... .. STATE,OF WISCONSIN ,(,�� � I � y� e .1j\'. I . 1 h4 ) `�..i.... ....................... County. Personally came authenticated this .............day of............ ............................... 19............... before me this.�..7�..l..dayof....... �" ^. ....... .. \/ ,19 ` theabove named sig . . 0 .. .......................................................................... ............................... .... .. ...... .. ..................... ................. ............................... .... ....,.......................... ............................. ..........I....a � .... ..Y. ........... ..S ....... .............. 10 type or print name .......................................................................................................... ............................... TM-E* MEMBER STATE BAR OF WISCONSIN (if not ............................................................................... ............................... ....................................................................... ................................... ............................... authorized by SS 706.16, Wis. Statutes) to me known to be the person............ who executed the foregoing inst 'e t,q" po dge the s e. si c � r ... ... �,� .........:...�....�.. ..................... Names of persons signing in any capacity should be typed ty nt d . " "" or printed below their signatures. 2 I�atiny Pubjic... .. ...............County, Wis. M y :Cor�tmisaion is Permanent. (I[ riot, state expiration ............... �� � p This instrument was drafted by (type or print name) date:....... I ..f.....,.., !.:............... ) v. ��iv',u� Irhu., n•�� S & N Land Surveying, Inc. 212 Walnut Street Hudson, Wisconsin 54016 (715) 386 -2007 September 10, 1998 Ha Eric a s, 1225 Cty. Rd. A Hudson, WI 54016 Dear Eric; We have completed the work that you requested on your property. Two stakes were set downhill from the house at the ground elevation of 902. This is the elevation of the one - percent flood as shown on the Flood Hazard Boundary Map along the Willow River for your location. We also set a 1" iron pipe 54 feet east of the house for a benchmark. The elevation of the top of this pipe is 912.60. Also established was the elevation of the first floor of the house by the east patio door. That elevation is 917.04. All elevations are in feet above mean sea level. If you have any questions please feel free to call me. Sincerely; Dougl ahler R.L.S. i A X m k_ s n a i N 1 a I I w I m I I � I � r 1CJ= I I N 3 I I I C I 3 � ^ K V4, s. 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S -: .:x.. /. :. r. A'f:•.v::: +ix:}: �- :....... r.x}: �-vr::: } }i:{: }i::: }} iii} }} :i: :;i ::::::......... ... v }:vi }i•: {{::: : :::.i } %. }- v: •v: v:: .: ..; ....:.. .:..::.:..:::.: -... ....�.....n...: ................ r..........:...... ::: :::::...............w x:: { }' ..:....::::::.:: {::: {:: i :v:vv: :::::.v:n : v :::: ::::::: ::::::::.v:::::::::: v: i':::: •.v:: : w.: v.:...:::::. .::::.:::::::. :::.v:::::::::::: ::w:::::::::::::::: .., � • I�p��4a�K' JG�frr"rr T , L^ App lic an t: / App /r� C 01.A AA Y Name Daytime telephone number Uez,5' 4-7 YD A ' 5 ya/ Street address, city, zip c6de - landowner. 4,q Name Daytime telephone number � 5 GT L4 f1 Street address, city, zip code Location of the building site (complete as appropriate): , /j_LtjV,4 quarter of Section C . Town -74 IV N., Range Lot &A Block GT 4(,0J0JV Street address T Instructions: 1. appropriate es and com letin the site ram. dia Com fete this plan by filling in requested information, marking box g g P P g � g (� P 2. In completing the site diagram, give consideration to potential erosion that may occur before, during, and after grading. Water runoff patterns can change significantly as a site is reshaped. 3. Chapters ILHR 20 & 21 of the Wisconsin Uniform Dwelling Cale, the DNR Wisconsin Construction Site Best Management Handbook, and UW - Extension publication Erosion Control for Home Builders can be referred to for assistance in completing this plan. The Wisconsin Uniform Dwelling Cod+, and the Wisconsin Construction Site Best Management Handbook are available through State of Wisconsin Document Sales, 608266- 3358. Erosion Control for Home Builders (GW0001) can be ordered through Cooperative Extension Publications, 608262 -3346. 4. Submit this plan at the time of building permit application. i y fr 4Site ° Diagram- Note: Any base map of useable scale cah be substituted for this sheet. 1 Q A LO 1 O r/0 F Y g, to oa r . a� ou/ .4 a T e r x i ! 7 i ts I LL / L Site Diagram Legend Please indicate north direction PROPERTY SILT by completing the arrow. LINE FENCE EXISTING STRAW DRAINAGE BALES TD TEMPORARY ?ti. GRAVEL DIVERSION �T FINISHED TREE I -' DRAINAGE PRESERVATION LIMITS OF STOCKPILED GRADING TOPSOIL VEGETATION 1O SPECIFICATION Scale AREA 1 inch i I feet cafe t strategy by checking (.�e.) the *pibi Late 1660c Management Strategies �( ❑ ;Temporary 'stabilization Of disturbed ar` :.�. Note: Although not specifically required by C bde, it is recommended Nutt distutbed areas and loll piles left Inactive for extended periods of time be stabilized by seeding (between April 1st and September 15th), or by other cover, such as tarping or mulching. Permanent stabilization of site by re- vegetation or other means as soon as possible. �4 ❑ ' ' Use of downspout and/or sump pump outlet extensions. Note. Although not.specifically required by. Code, it'is recommended that flow from downspouts and sump pump outlets be tatted to stable areas.such as established sod or pavement ent during dewate . operations. ❑ sedim g rutg pe Note. Although'not specifically required by Code, it is recommended that sediment -laden discharge water from pumping operations be. ponded behind a sediment barrier until most of the sediment settles out Proper disposal of building material waste so that pollutants and debris are not carried off -site` �+ , Mainteaanoe of erosion control practices. • Sediment will be removed from behind sediment fences and barriers before it reaches a depth that is equal to half the barrier's height. o Breaks and gaps in sediment fences and barriers will be repaired immediately. Decomposing - : • ;straw bales will be replaced (typical bale life is three months). • All sediment that moves off -site due. to construction activity will be cleaned up before the end of the same workday. • All sediment that moves off -site due to storm events will be cleaned up before the end of the next workday. Gravel access drives will be maintained throughout construction. All installed erosion control practices will be maintained until the disturbed areas they protect are stabilized. :::i i:;f' �•:3ij ?:iS;ri% iii'.•`:: r<:;:. i•: Y;.:: i` :.'Y:;::S::::.>:.>:.;:.>:>•..:: i<';:>i.' :. :. < i <" ..: '.S: .,::>... .. �... t. ....::::. ..........:.:::: ....... tarid:> the :eonstraction;sitei.:erosion; control provisio ns of he. W>scoftst Uniform i?wellin �Gode, and that 1 accept �responstbiltty for carrying out the abo . erosion control plan as approved by tied�tiforcemetit authori . Signaur`f applicant Date A publication of the University of Wisconsin- Extension, Ron Struss, UWEX Water Quality Education Specialist (12192). This publication may be freely duplicated. Additional copies are available through the UWEX Environmental Resources Center, 216 Ag Hall, 1450 Linden Drive, Madison, Wl, 53706 6081262 -3652 Ch a ro riate low w and nm letejthe site frith mformatton. s J ,PP P '+us r e�r 1 t���y,,� a ""��j� ��'��'rN�s.��+,�'xy, l' Wit' � L•.y; t c.l�, a 74 �rt9F .`^:�.� � iT :` sy.-.t c'.`•�..M1 ;k � r 'k�, � n u Site Cha�&s J81 North arrow, scale, and sits. boundary. Indicate and name adjacent streets or roadways. ❑ Location of existing draina,;eways, streams, rivers, lakes, wetlands or wells. ❑ 04 Location of storm sewer inlets. R7 . The gradient' and direction di' slopes before grading operations: �1 The gradient and direction of slopes after final grading operations. . Location of existing and proposed buildings. and paved areas ❑ Over land 'runoff (sheet`flow) Coming onto the site from adjacent areas Erosion Control. l Rj ❑ Location of temporary soil storage piles. Note Although not specifically required by Code, it is recommended that soil storage piles be, placed behind a sediment fence or more than 25 feet from any downslope road or drainageWay =W 1� Location of grave] access drive -.(s). Note: -Recommended gravel drive, design is 2 to 3 inch aggregate stone laid ,at least 7 feet wide, and 6 inches thick. Drives should extend from the roadway 50 feet or to the house fouridatuin (which ever is less). ❑ Location of sediment fences I'filter fabric fence, straw bale fence) or vegetative strips that will prevent eroded soil from leaving the site. ❑ Location of sediment barriers around on -site storm sewer inlets. ❑ Location of diversions. Note: Although not specifically required by Code, it is recommended that concentrated flow (drainageways) be diverted (re- directed) around disturbed areas. Overland runoff (sheet flow) from adjacent areas greater than 10,000 sq. ft should also be diverted around disturbed areas. ❑ hQ Location of practices that will be applied to control erosion on steep slopes (greater than 12% grade). Note: Such practices include maintaining existing vegetation, placement of additional sediment fences, diversions, and re- vegetation by sodding or by seeding with use of erosion control mats ❑ R4 Location of practices that will control erosion in areas of concentrated runoff flow. Note: Unstabilized drainageways, ditches, diversions, and inlets should be protected from erosion through use of such practices as in- channel fabric or straw bale barriers, erosion control mats, staked sock and rock rip -rap. When users, a given in- channel barrier should not receive drainage from mo' re than two acres of unpaved area, or one acre of paved area. In- channel practices should not be installed in perennial streams. ❑ �' Location of other planned practices not alrean _roted. r M 0 2. • — m .�` 3 1 CD _ 'D I 3 it I 3 I i , X : O 0 o o 0 ur o p w m I �� N o p o w � rn s � • CD PJ A A a CD m 00 A fD CD y W m Z Z 0 co 0 N O "ft rn 3 m m w C y ? -0 Co A K N N a O 0 A O O ? V1 !! O O C ID N I 7 Cf D N Q O CT N 3 a 0 N O N O p C 5 y to I y p S{ O o O z D �� u_? g `D eo c m to D m •O•' o y 1 a C a W o o f C L W m O lot (D r. rn in D l o 00 D a c m a l y 0 00 c CA o e CO CO cn v v a 3 ;� Q 7 I O '. 000 - 000 �i CD z gg gg gg gg I c N N N o I ?� �� y j m 3 0 �vvrnl s� ov y v m '—� 'm 3 m I cg 3 3 g <, N I Z I O O Z W z Z Z O D a I O D m o j m I m co • I co CD CD CD m N. I CD 0 N CD CD co a CD n 3 7 3 m 5 z m cb m cb fn cn w CL a A z O Z w am I m CD �z CL 3 .. 3 .. cn 0 CD v A 7 A N O m a D n m D 3 � a a O <D 0. 00 a ,00„ y 7 m c � X yv m c co 'm N z I m <, N m d o I 3 c a m m m m . m a y �m a 0 . n t � o 0 m I I 1 N a Ar f_-^D CD 7 j vC n . �_. p ( 0 A 3 = N p O S C7 CJ1 m N CD X y N qtl co 77 I o C� O o b �^ CD f A O I I p 0 o O N (D O b O O L CL I o I o Parcel #: 030 - 2014 -50 -000 05/04/2006 05:04 PM PAGE 1 OF 2 Alt. Parcel #: 36.30.19.412A 030 - TOWN OF SAINT JOSEPH Current LXI 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 LARRY A & ROSALIA J ANDERSON O - ANDERSON, LARRY A & ROSALIA J 1431 S BIRON DR WISCONSIN RAPIDS WI 54494 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1225 CTY RD A SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 13.000 Plat: N/A -NOT AVAILABLE SEC 36 T30N R19W THAT PT NE SW LYING S Block/Condo Bldg: OF CEN LN HWY "A" AND NORTH OF WILLOW RIVER Tract(s): (Sec- Twn -Rng 401/4 1601/4) 36- 30N -19W Notes: Parcel History: Date Doc # Vol /Page Type 06/04/2003 724448 2263/420 WD 07/28/1998 583754 1343/298 QC 1128/29 WD 757/02 more 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.890 128,000 125,600 253,600 NO PRODUCTIVE FORST LANDS G6 10.110 85,600 0 85,600 NO Totals for 2006: General Property 13.000 213,600 125,600 339,200 Woodland 0.000 0 0 Totals for 2005: General Property 13.000 213,600 125,600 339,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 137 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I I E Form -STC - 104 AS BUILT SANITARY SYSTEM REPORT j OWNER �� "��`S �G /V y��B L� TOWNSHIP S � Ta S E P I+ SEC. 34 T N -R ` 1 W ADDRESS �� y� A " ST. CROIX COUNTY, WISCONSIN Al ,.�v SUBDIVISION L "`--- -- - PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 i SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ftof e 4 v-00 0/ INDICATE NORTH ARROW -T P o BENCHMARK: e - D scrib e the vertical reference point used i Elevation of vertical reference point: 00. 0 Proposed slope at site: /0 SEPTIC TANK: Manufacturer: Ne`'` cd,A. Liquid Capacity: ' ?00 ( � Number of rings used: �d 'v�- Tank manhole cover elevation: N4�Lv 9.3. 32 q G 1 N' Inlet Elevation: /�� /� Tank N � u Outlet � Elevation: (06, c[7 Number i f feet from nearest Road: Frt ny,6X Side,Q Rear, O feet From nearest property line Front,O Side, XO Rear, O - �� feet Number of feet from: well Odd 1 60 building: vEw - 3/ .elude this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE I PUMP CHAMBER y « n Manufacturer: Liquid Cap ty: Pump Model: Pump /Siphon Ma acturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of fe from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM X ^Q ' Bed: Trench: II'' t C►) Width: S Length �2) G �' Number of Lines: Z Area Built: Fill depth to top of pipe: -76 46 �{ Z Number of feet from nearest property line: Front, O Side, O Rear,0 It . ST Number of feet from well: 7 Number of feet from building: ' (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: meter: Liquid depth: Bottom of page pit elevation: Area Built: Has either a drop box distribution box O been used on any of the above s absorbtion sytems? eck one). HOLDING TAN Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of f from nearest property line: Front, O O Side, Rear, Ft. O Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: HOMESITE SEPTIC PLUMOING CO. RT. 3 O'NEIL RD. HUDSON: WIS. 54016 ROBERT ULBRICHT ' "S.jk+IASTER PLUMBER LIC. NO. 3307 M.P 3/84 •m .R.lR • J MINN. INSTALLER & DESIGNER LIC. N0. 0060 i 1 , mot W N W � 4c Q l� i AC ti � YO ir 1 1 ► ► ► 1 I ► ► 1 ► ►t i ► ► 1► V O ►1 1 I + w 1 t► o 4 ► 1 I c�� 1 ; I� vl Cx YI N o "- . v o 1 13 3 • 3 00 2 tom. 0 H k � O rJ a a� I J .� o cn ,� 2 ul W VN -3 �� DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR &,HUMAN RELATIONS DIVISION PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O. BOX 7969 MADISON, WI 53707 NW'-4, SW%,S36,T30N -R19W CONVENTIONAL ❑ALTERNATIVE State Plan l .D. Number (11 ass Town of 1St. Joseph El Holding Tank ❑ In- Ground Pressure El Mound igned HWY A NAME OF PERMIT HOLDER. J ADDRESS OF PERMIT HOLDER: INSPECTION DAT Mr. & Mrs. Al N e 10- � yhag n Route 4, HWY A, New Richmond, WI 54017 c� ® ��- BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELE V.. Name of Plumber MP /MPRSW No. County Sanitary Permit Number. Robert Ulbricht 3307 St. Croix 102799 SEPTIC TANK /HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELE V.: WARNING LABEL LOCKING COVER /is PR DEO. PROVIDED: - �,�,� r �(- YES ❑NO DYES NO BEDDING: VENT DI VENT MATL: ROAD: HIGH WATER NUMBER OF - WELL BUILDING VEN TO FRESH ( ALARM FEET FROM PROPERTY LI / IAIR INS DYES NO J ❑YES NO NEAREST /�� -5 L/f DOSING C AMBER: MANUFACTURER BEDDING - . LIQUID CAP ACITV PUMP MODEL PUMP /SIPHON MANUFACTURER WARNI NG LABEL LOCKING COVER PROVIDED. PROVIDED. I DYES ❑NO ❑YES ❑NO ❑YES 0 N GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY I VENTTOFRESH WELL BUILDING LINE AIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED /TRENCH WIDTH LENGTH NO O I DISTR PIPE SPACING COVER INSIDE DIA .PITS LIQUID /r 46 THE Nf � MATERIAL : PIT DEPTH DIMENSIONS d` G / /' GRAVEL DEPTH FILL DEPTH DISTR PIPE. DISTR PIPE DISTR. PIPE MATERIAL: NO. DI R NUMBER OF PROPER 7Y WELL BUILDING VENT TO FHE SH BELOW PIPES �.. ABOVE C VER E jIN T E V _ •,�� PIPE. LIyY FEET >2 NEARESO — J MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. El YES El NO SOIL COVER I TE XTURE PERMANENT MARKERS I OIISIHVATIIIN WELLS ❑YES ONO DYES NO DEPTH OVER TRENCH /BED D ED DEPTH OF T EPTH OVER TRENCH /BOPSOIL SODDED SEEDED MULCHED CENTER EDGES. DYES ❑NO DYES El NO ❑YES NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED /TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO DISTR DISTR PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA.. ELEV.. PIPES DIA: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING. DRILLED CORRECTLY COVER MATERIAL PLANS El LIFT CORRESPONDS TO APPROVED ❑YES , ❑NO ❑YES ❑NO COMMENTS: r PERM ANENT MARKERS: \ 4 OBSERVATION WELLS: NUMBER OF LI O ERTV WELL BUILDING \ FEET FROM �t �) 3 DYES N10 ❑YES El NO NEAREST Sketch System on ZRetain r unty file for audit. Reverse Side. SIGNATURE. ✓ LE 7 --' Zoning Administrator DILHR SBD 6710 (R. 01/82) r f' ' COUNTY SANITARY PERMIT APPLICATION Y DILHR In accord with ILHR 83.05, Wis. Adm. Code fr -� STATE SANITARY PERMIT # iva � 9 —Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES NO PROPERTY OWNER PROPERTY LOCATION y � / 6/t, 5- W4 /'i /�/�/� NW' /afW %, S 3G TS" , N, R E (o W PROPERTY OWNER'S ILING ADD ESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ¢ V 7 o 2d s JV lei CITY, S�T ZIP E PHONE NUMBER LE3 VILLAGE: NEAREST ROAD, K TOWN OF II / TYPE OF BUILDING OR USE SERVED: 13 - �4 - o?o .- S� Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): Ill. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b. Replacement c. El Replacement of d. El Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit #¢ Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner /building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. 9 Conventional b. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In -Fill Tank e V. ABSORPTION SYSTEM INFORMATION: (Check one) 2 L/ F : 5 x i S 1. a. ❑ seepage Bed b. Seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): RE UIRED (Square Feet): PROPOSED (Square Feet): AM Z Q - Z Feet xPrivate ❑ Joint ❑ Public VI. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank R 7 66i , qAlA 1 Li FF I El er G>a S 4 &AAc 0 El 1 ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): P mber's Signature: (No Stamps) PRSW No.: Business Phone Number: R - 214 VC/ hl - _ ?/S te Plumb is Address (Street, City, State, Zip Code): Name of Designer: ef4 VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name RT. 3 HOMESITE SEPTIC PtUMis%.G Co. O'NEIL RD. HUDSON, VWJ 5401# CST # L�f� Z� ROBERT Ill RRIrHT CST's ADDRESS (Street, City, State, Zip Code) WIS, MATSTER PLUMBER LIC. N0. 330719.RR& Phone Number: o MINK. INSTALLER & DESIGNER LIC. NO. 00663 IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwa Issuing Agent Signature (No Stamps) JX Approved ❑Owner Given Initial S cha�rgge �1Q Q Adverse Determination 1 2 0 `o 3L7 °�C� _O X. C MMENTS /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid fcr two (2) years; 2. Your sanitary permit may be r:newed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Admi iistrative Code will be applicable; 3. All revisions to this permit mu 3t be approved by the pbrmit issuing authority: -A new permit may be needed if there is a change in your bu Iding plans, system location, estimated wastewater flow (number of b €!d= rooms, etc.), depth of system, Dr type of system; ,. 4. Changes in ownership or plun ber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be subm to the county prior t) installation; 5. Private sewage systems must be properly maintained: The septic tank(s) should be by a `licensed pumper whenever necessary, usually every^'2-to 3 years; 6. If you have questions concern ng your private sewage system, contaayour local code administrator or the State of Wisconsin, Bureau of 'Iumbing, 608- 266 -3815. To be complete and accurate this : anitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use servec: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in numbe of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with Universi y of Wisconsin, V. Absorption system informatior: Provide all information requested in ##1 -6; VI. Tank information: Fill in the capacity of every new and /or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a// septic, lift /siphon chamt er and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Insta Iling plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone lumber. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County /Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specificat ons not smaller than 8 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) )r other treatment tanks; building sewers; weals; water Rl ins,'water service; streams and lakes; dosing or humping chambers; distribution boxes; soil absorption systems; replaae system areas; and the locatior 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 moo el and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test dbta on a 115 form. ti I ------------------------------------------------ --------------------------------------------------------------------- GROUNDWATER" SURCHARGE On May 4, 1984, 1983, Wisconsin A,t 410 was signed into taw This_ legislation is more commonly known as the groundwa:er protection law. This change. in statutes was the result of over 2 years of steady neclotiation and public debate. The'groundwater bill Ground Ater -- included the creation of surchargesi (fees) for a number of regulated practices which Wiscor*n's can effect groundwater. The surch<.rge took effect on July 1, 1984. All of the water that buried reasltre is used in your building is returnee to the groundwater through your soil absorption o system or the disposal site used b� your holding tank pumper. The monies collected through thes: surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD -6398 (R.03/86) E 4 APPLICATION FOR SANITARY PERMIT S T C 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, ( "spec house then ,a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - timer of Property Location of Property /VW 5 ,Section �3 , T N -R W . Iowftship 7 ' s & f ......_.�..r.........._ _� ...�..� . Mailing Address `� �� AzljUl X 1 1 61t 4VL0VV f �1 �1 r Addtess of Site �� ict�t tsMper ;of.: property ..-J QV\ S f TOW.&!.�►:, wixarael -lam z Xlatta P.axcel aasrXreated Are :all corners and lot lines identifiable? Yes 7 No Is this property being developed for resale (spec house) ? Yes No t.►olume and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING A Warranty need which includes a Document number volume and . page number and the Seal of-the �Rdgister of Deeds In addition, a certified survey, if available, would be helpful so as ; td avoid delays of the reviewing process. If the deed description refer - :ences to a Certified Survey Map, the Certified Survey Map shall also be required. A . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATIO I (We) cV 6y that att 6tatemen4.... 4t min_ - avice to the beat o6 my (ouA) know.tedge; that I (we) am (au-1 the owneA(,$) oS the pAoo' descA b in zhib injoAhki,6n Soam, by vi t "A6 a warranty deed %ecotded 'n a 064ice o6 the Cou►tty Reg i,6xeJc a � �emda Do _ "en-t No . l 3 and th 1 (Use) pn ea en Zy awn the pAopoe ed 6 i to A the s ewag a d i h poa .a y� em (ox :L�e constAuction ) have obtained an Mement, to Am with .th above ducA bed pnopeAty, Son os said `,6yA tem, and the bame ha6 be gee as the County Reg c azeA as ' Deede, a,a Doe ment No. I . x, SIGNATURE OP OWNER `SIGNATURE -OWNER Q ICABLE) tip' � �.. Q � Z, ��G:>• 7 ;5IGNLD r „ . DATE ED Y A r l' v tee � h h STC - 105 '' r " r � SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County,'„ t3 a' OWNER /BUYER y ROUTE /BOX NUMBER k -/ '4 Fire Number /J � CITY /STATE A�(f �� (i( /�J - ZIP PROPERTY LOCATION: A/ , 34, Section �w , T 3d N, R _W i Town of S% , St. Croix County, Subdivision Lot.number. Improper use and maintenance of your septic system could result in +:I, its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper What you pit into the system can affect the function of the septic tank as a treat - ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that' owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic •tank.is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 I /WE, the undersigned, have read the above requirements and " agree z . to maintain the private sewage disposal system in accordance with H the standards set forth, herein, as set by the Wisconsin Depart- �d ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Off:LVe within 30 days of the three year expiration date. ��IInn SIGNED I.X�L. C DATE St. Croix County Zoning Office P.O. Box Hammond, WI 54015 715- 796 -2239 or 715- 425 -8363 Sign, date and return to above address.►. S INDUSTRY, KLPUKT ON SOIL BORINGS AND S AFETY & BUILDINGS LABOR AND PERCOLATION TESTS DIVISION 115 HUMAN RELATIONS ( � � P.O. BOX 7969 (1-163.090) & Chapter 145.045) MADISON, WI 537Q7 ' LOCATIONr SECTION: P /MU*W4PAt}i'Y: LOT NO.: BLK. NO.: SUBDIVISION NAME: '/4 36 /T3o N/R I? E (or W r � o s � p t (— f'�.e of COUNTY: OWN R'S 46HFEfFS NAME: MAI LING ADDRESS: S f - C'L X M R . H RS /+L N yr'n �GEcJ R{ 4 +f w . f}- Ju P "o R i c �,,�., L7 AL; t� t-0 i s - USE Z - / DATES OBSERVATIONS MADE NO. BEDRMS.: COMMER I L DESCRIPTION: PROFILE I NS: N TESTS: Residence A/ ❑New .Replace C) CJ_ 2_ ,_ ,•7 0 C-1- Z.i •� SC `(3 C RATING: S= Site suitable for system U= Site unsuitable for system MM feT C S i - ONVENTIONAL: MOUND: IN- GROUND PRESSURE: SYSTEM IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U QS ❑U CAS ❑ ❑ CU ❑ �U Covui rAiroAjtt - - row"� S Q If Percolation Tests are NOT required DESIGN RATE: I Rojp OX If an y portion of the tested area is in the _-- under s.H63.09(5 ►(bl, indicate: G� S S Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS NUMBER DEPTH IN, ELEVATION IrJ DECiry,4t_ �+ - Y BORING TOTAL P H TO GR UNDWATER - INi: v7n CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH r OBSERVE EST. I HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / ?.0 �y �i �4r- > y D ' '7 S Rw 3 w ; oar , 12 s ' 3A-) j OA," 740 • v-� CS R Ce �, B_ Z /o•o 9S 30 �fi _ > ��, �K.13a lo4A �' S >r'l,a vv Cs 5 k w I q.-&- t` B -� gds .5 'Dte -3a /04H f,s' T". &-4-S �•O ` T tit 0E e B- v B- 9 I J� ANN@ PERCOLATION TESTS TEST WATER IN HOLE TEST TIME DROP IN WATER L CHES RATE MINUTES NUMBER ft - s AFTER SWELLING INTERVAL -MIN. PERT D t P RI D 2 PER INCH P- P _ Z P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM N' �`' TI�E.ucl,` ELEVATION = 90• Z o /ow 2 0 ' SG�4LE ; n � 3 V U 'ritrr. Per, O of P Palv - m I • _ (3J4C 1Cdc 0 E p x raC .. i r 3 _ E �rfni.+lr Iena IF 11 Y 1 � t BhRN I o oueR9 _ M I C'ID- Cyr VCv pPPie- RIVE !, I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMb"AG CQ OC./ ADDRESS: ROBERT ULBRICHT CERTIFICATION NUMBER: PHONE NUMBER (optional): WIS, MASTER PLUMBER LIC. NO. 3307 MAR.B ti '.4INN: INKALLER & DESIGNER LIC. NO. 00663 CST SIGNATURE: GN-- DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. '- IR -SBD -6395 (R. 02/82) OVER - y. 4 I ! 41 v V I 9X'`• w .A :�. �} Mn- niM...wrw�.w.M • � ��wwrr�ww. � ' tN � f� n r`- .,� On part of N tj of Sw k of $action 36-90-19 l�rias . of CAntsrlins of Comty Tcwk 24OW "A and ` V4 of tlw Willow River Tea: PWW filet t ` rs: t� JJ R Y� t p S r r 'j'1ia .....is.stot » heatntae� paVatt►. # (b) asaut'R ,g , Twee uft all ar abedar ft ha•titameaw ow appurte� tha•aate wiseoie6; t t Aad.».JQhaJ.. "",mama dot *A *b b bdi�"Ab fa sm shmpk am free and dm et �rmmm =a"* wssnrata sad ptrotactivtt cavem is or rsstrictioos of record, if mW am +sill wumut am &&w tie tray. �1. thii► ........_«»........ .... »........., itT at ......... OIrCobl�c.... ..... .... ..._ ......................... » 1111•. f ...... ....... ... .....................( ....... ........ ..,.. ......................... ...._ »... »._.......css�►w ....... .... ...... ...... .. _..._. .is.r►w ; fi ' ............... - -. ...... ............................... • .. AUTURN TICATZO• ACKNOW162DOM ? STATZ W vnscousix st• Croix ` O ctober r , the chats sam" John • !1liis MUM STATS "R W WWOMM _ � rwlw ia► i tN:if: wii� sb j y m. ........ w wev,� em ..w 1`e ++«a M+rTet+"wrr ws oMrtso w M. ��'�..i _ John D. Ue of ill[WWW CM, i JnU _ .. ... « p.r a-• apr-- sZ O„•- Wri .o..- .lit....SiQ1l6�-- .»....... 1►.tan► Pv�e .. sc _ croiz' , w1.. a n ae�Mtr� ..a w aiaeai�ti ft* Dr cl.nnit.i.. �� U :..f..m. ................ . ................. ..............• ...�.) •Mnw e! *NOW Q%Wft 4 ew ORMW *t t• %*W W e.ww ato. 60ir d O&%W=6 �AYiaa>!M aer �'� t �� �� 11tnu► sa Mw i • ' ' s�lfEH srsr�"` . yo.L' �r91 usE �E N, �� pol Bz 1 , i o �- I i 1 } 1 Rt`F I t 10 9. �� t i�o I t 1 t 1 y 1 9 IN 0 ITNA) f, VF.ur � /P/�cv�0 � Fxvsnr6.. V ppp (� (1ox ._ srsr � sue ��' you �a� f�rrrwc - --� o sEpnt� i0 � 4 6 oil/ J Q 9 v Fresh Air Inlets And Observation Pipe h ?I Pi ci L� o Iz Qo+G. T le etit.," S J O Approved Vent Cap Minimum 12" Above Final Grade F A14E19 SRAOts Mkx , pow = 1 S3 1/2- '1 Above Pipe 4 Cast Iron — 1 Final Grade Vent Pipe' Marsh Hay Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Tee �ev� T16t's Pipe --•- 0 0 0 0 0 11 �1 NG� � Zo Beneath Ag greg a t e to ° Perforated Pipe Below T�f "` � p o Coupling Terminating At ` Ld Bottom Of System