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030-2058-30-000
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'm Er a 'mom oiayfN= m�aa �o F 3 m m o MN �o F o CL 0. A O O CD V CD 0 o c 0 A w i A ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner 0Av1 D i;G N ,< Properly Address 137// S7, City /State y i' "T9082 Legal Description: Lot _ 8 Block Subdivision/CSM # &gL T- ,O. N& 1 /4A(F_ 1 /4, Sec. �, T, N -R�© W, Town of �Tr osa- PIN # 030 —,ZQ, � —30 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Wee X `5 Size ST/PC O ®E�/ N�a Setback from: House Well 7 P/L _YO Pump manufacturer ffA Model AAA Alarm location / A (HOLDING TANKS ONLY) Setbacks: Service road Vent to fr a er ine Meter location ocahon SOIL ABSORPTION SYSTEM Type of system: Tf & Width , Length 2_ Number of Trenches Setback from: House 93 Well 70` P/L /0' Vent to fresh air intake A&aox oo ELEVATIONS Description of benchmark 0 ,& 8o X'Ek"4 -- T/l& E Elevation fl1 ©_ o Description of alternate benchmark jT7Z7 o,& 51,01" o,v Aoas, Elevation / Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom ) YA Header/Manifold Top of ST/PC Manhole Cover D Distribution Lines (1) FS 83 (2) ,9,57 Bottom of System (1) 9 !Z, ,S"O (Z) Final Grade Z 9 f (2) ! cam 9, L ( ) Date of installation/60 Permit number 35/A%C2 9.5" State plan number AA Plumber's signature Lxa,-- I License number 2/ 7 y / Date /D/ sJ Inspector L 4� Complete plot plan I NOTICE Please provide the following: • 100 feet of the s A plan view sketch showing everything within stem. y • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW p�prvEu��Y 5. w 5 � 9D (3M ° INDICATE NORTH ARROW •Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y Safety and Buildings Division INSPECTION REPORT St. Croix ' GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 344695 Permit Holder's Name: ❑ City ❑ Village EkTown of: State Plan ID No.: Jonk David I Town of St. Joseph CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: Ico, CD �o�.Q N. � «� 030 - 2058 -30 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic p-Qp Benchmark 15-,`f1 05,41 Dosing Alt. BM 2" Aeration Bldg. Sewer 9 Holding St /Ht Inlet �. ��j 27,93' TANK SETBACK INFORMATION St / Ht Outlet . �IQ C17- TANK TO P/ L WELL BLDG. Air I ntake ROAD Air Septic fo ' ' T NA Dosing t'�r NA Header /Man. Aerat' n NA Dist. Pipe I c js,j ' Hold g Bot. System PUMP MATION Final Grade Manu urer n St cover . Model Number GPM TDH Lift F S s TDH Ft F ain I Length Dia. Dist. To well SOIL ABSORPTION SYSTEM VMZ RENCH Width , Length No. f enches PIT No_ Of Pits Inside Dia. Liquid Depth IME SL DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu act rer: SETBACK CHAMBER INFORMATION Type Of r r M del Number: System: CpV�/�I, 30 -h Z '� OR UNIT i DISTRIBUTION SYSTEM Header / nif u I Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing ' /OS SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only FB,d ver Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched ench Ce nter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: ID/- $q Inspection #2: ocation: 1374 Haggerty Str et, oulto WI (NWI /,4 NEIA, Section 27 T30N -R20W) - 27.30.20.562 AkAl Plan revision required? ❑ Yes g[,No Use other side for additional information_ � n SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. a Safety and Buildings Division SANITARY PERMIT APPL TCN 201 E. Washington Ave. N ) Lcons i n P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. A de w v Madison, WI 53707 -7969 , • Attach complete plans (to the county copy only) for the system, per n County ;. than 8 112 x 11 inches in size. amfar e rmit Number • See reverse side for instructions for completing this application `' 1 ' is 6c?.< ma The information you provide be used b othe t a e c ro r ms "� ' { � i]N ` � y p y y g overn y p e r )h 1 �+° ecfr If te�tision to previous application (Privacy Law, s. 15.04 (1) (m)]" 13 (� • State"P ) — "° " (an11). Number L APPLICATION INF RMATION -PLEASE ALL INF RI1A I6N Property Owner Name Prope ` O*flan_ va s tra, S T JQ , N, R ,, 4 C 0 E (or� Property Owner's Mailing Address Lot Number Block N mber .8O s 8 City, State Zip Code Phone Number Subdivision Name or CSM Number RAYP Olar d (p9,) 11. P F L IN : (check one) E] State Owned C it y Nearest Road Public 1 or 2 Family Dwelling - No" of bedrooms _ 3 own of — C III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) n � , 3 V • �. 5 �oZ 1 ❑ Apartment/Condo 0, 3 f, ,r 0 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. n New 2. CrReplacement 3. ❑ Replacement of 4. E] Reconnection of 5 [:]Repair of an _____System ________System_ _ Tank Only______________ Existing System ________�ExistingSystem 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 XSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 [] Vault Privy 14 [] System-In-Fill 3r _f '5" = Z4 VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System,Elev. 7. Final Grade � Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min. /inch) Elevation Feet Feet Capacit VII. TANK in Ca allo Total # Of Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete st noted Steel glass Plastic App Tanks Tanks Septic Tank or Holding TankQ — — ❑ ❑ ❑ ❑ ❑ Lift Pump Tank !Siphon Chamber ❑ El 1-1 11 13 El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu b is Signature: (No 5::r M RSW Business Phone Number: Plumber's Ac dress (Street, City, State, Zip Code): ic « rX � o IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sa Itary Permit Fee (includes Groundwater Surcharge Pee) Date Issued Issuing Agent Signature (No Stamps) Approved ❑Owner Given Initial �— Adverse Determination 1 � Z6 X. CONDITIONS OF APPROVAL REASIQN.S FOR DISAPPROVA SBD -6398 (R.11/96) `DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber 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. 111. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. 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. Vill. 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. , IT { { AA — i , { r I I _ , I a ; I � i I i 7 , I f - , tt 1dJ ,/QQ -4 GrL t i , f , , , , nn -_ { I E V� : I y , lC P77 z , , 1 ' , Msconsin impartment of Commerce SOIL AND SITE EVALUATION Divas of Safety and Buildi Pa �` 9 Page a of Burea of integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code 4 9^ County Attach complete site plan on paper not less than 8112 x 11 inches in iv1 larzxr�d§t ._' f �. r include, but not limited to: vertical and horizontal reference point ( ttio and percent slope, scale or dimensions, north arrow, and location an ` I ce to rat ad. `c; rcel I.D. # VITT APPLICANT INFORMATION - Please print all infpnrltation. IN Ida iewed by Date tt rrg /AMigl {i1r/1 /it1gIM /11 ye/11 hmVlfln IIMY {111 YNNI{ i /11 9An /IfUlnly IIIIIIPIAn9 (r' {imp 1 nw, ��� 114 11 (lY — Otq rop rty ner 11 jon f G k 62 � NW,j i/4 N&1 /4,S ? T3© ,N,R ZW) W Ag 7A Property O11w�/ner's Mailing Address Lot # Block #� Subd. Name or CSM# 3 77 /'7a Y tA City S ate Zip Code Phone Numbeerr ❑Village Nearest Road DIrfTO� 1 �8-� (�Ol..�� El city To ❑ New Construction Use: ErResidential / Number of bedrooms , _ Addition to existing building Replacefnent ❑ Public or commercial - Describe: Code derived daily flow M gpd _ Recommended design loading rate ._. bed, gpd /112 gpd/ft Absorption area required _ bed, ft �� p d � / tren h, it Maximum design loading rate bed, gpd /f1 gpd/ft Recommended Infiltration surface elevation(s) / 7's It (as referred to site plan benchmark) Additional designtsite considerations 1t Parent material Q i' l Flood plain elevation, if applicable /VA ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U Unsuitable for system ,®S ❑ U ®S Cl U ®S ❑ U rR S El U FI S ❑ U El S 04 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Q? Illn /Q /T --- .5'1'L d k A / P c✓ .? Ground 3 r? t✓' G✓ • s . C ev. 91ft 7s - ------ -2msdk Depth to limiting `f factor - min. Remarks: Boling # E rn Ground ft. Depth to limiting factor ffin. Remarks: ic CST Name (Please Print) Signature Telephone No. Address Date CST Number j 5 SO� DESCRIPTION REPORT FRN'ERN OWNER p 105 � n� Page _2Z: _ PARCEL I.D.# 630 — 02 -30 Boring Horizon Depth Dominant Color Mottles Structure 2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench _V /01/2 0/ S/ .y✓ns j �� wf Tr t� G� �rr7 . J , . Ground -3 Ys -_ 9j, 7 5' t11v _ __ C cif a ts� Nt �i • S` . elev. Depth to limiting S � , 2 0t� - factor Remarks: Boring # . Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; '1 < u K - ?,._.gin...... Ground elev. ft. Depth to limiting factor ' Remarks; Boring # ��. Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) 1 . Q .. t io U 77 741 - - - - -- -- - -- s .__ re l o7 A2 - Y' 1 SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Chamber Soil Absorption Systems Permit Number 9 /20/99 Date x "X° Gravity Distribution only 1 Pressure Distribution 3 ft Suitable Soil 1 Note 1: Bury depth as per manufacturer 18 in Chamber Height 2 8 ft Maximum Bury Depth 3 450 gpd Estimated Daily Peak Flow 0.60 gpd /ft Wastewater Infiltration Rate 750.0 ft Code SAS Size 40 % Down Sizing Credit 300.0 ft Reduction ( -) 450.0 ft Min. SAS Size 94.50 ft Proposed SAS Elevation Soil Surface Acceptable Finished Grade EL 4 (ft) Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum Number Elevation (ft) Depth (in) Lowest Highest Elevation? 97.50 104.00 1 99.00 96 94.00 96.83 Yes 2 99.73 96 94.73 97.56 No 3 99.10 96 94.10 96.93 Yes �C 1. Depth of suitable soil required below the infiltrative surface for treatment. 2. Total height of chamber in inches. 3. Maximum bury depth as per manufacturer's recommendations. 4. Based on chosen system elevation, and chamber height. Top of chamber is equivalent to top of aggregate. The addition of fill for cover or the reduction of finished grade may be required to meet minimum or maximum code standards. SBD- 10553 -E (R.05198) ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer r'/f1// G ric , <.5 5 t G Mailing Address P �3 S� 3 Property Address /` (Verification required from Planning Yepartment for new construction) City /State H�)4 , C�✓y Parcel Identification Number Ma — go 3f — LEGAL DESCRIPTION Property Location _ V4, NE V4, Sec. ,7 T_dO - N -RJd W, Town of : s Subdivision Lot # B Certified Survey Map # , Volume Pa g e # Warranty Deed # „ ,�D ( 2!o to , Volume tg Page # 5' Z- Spec house ❑ yes 1 no Lot lines identifiable p6 yes ❑ no SYSTEM �� NANCE 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 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. 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 ur septic systemj been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days o Le y exp n . 9 -? T1 t ?F APP CANT ,�*,;,. DATB OWNER CERTIFICATION e) certify that a tements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the ope Idesc ri dab y drtue of a warranty deed recorded in Register of Deeds Office. JIM4& OF APPLICANT Dom" d " ** * * ** 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 DOCUMENT No. STATIr BAIL OF WISCOXRKM FORK 1— Im WARRANTY DEED s t£►C11=Ilea • ma�yy,, Vol. 1 4 mms �B I�XH�CElDEES" This Deed, made between Al-en.-Johnson - _Constrvt.tfl?n,... :.. KMM FIR Snc ...,._a..- Rinneso.ta..Corpora.t. ion. ...................... _............................. W14 -11" 1#00 .I ..................... ..•-•-.....---...........------ .------------- ._............. ......... ...... ......... .. ..................................................... .__ - - - -- -- - - --+ Granter. INFA no *nd ........ Jallid..W_..Jonk.. and.. Jessica_. Y_..Jonk.__lusband_.and....._.. am 1 Idi.f�.as.mari_tal.ayrvivDrshi CM �i Fffs .r - T 217.31 .... , Grautes, Ili NE/ i 01 w�tT1 BSS @1, That the said Grantor, for a valuable ......................................... . ............. .............. ....... - ---------- ........ .. _. _. _,• _ c*"veas to Grantee the following described rW estate is . - St...Ct�aix........... 1 117mom Stillwater Titl CO G,t►nt;- State of Wisconsin: Box 206 Stillwater, MN Tax Parcel No . 7.: 30.20 562 Lot 8, Block "7 ", Plat of the Village of Houlton 1 _ This ------ U- AOt........... bon,estead property. fie) (is not) Together with aB and siarwar the hereditament* and appurtenances thereunto belonging, And.... ........................ - - warrants that the title is good, indefeasible in fee simple and free and clear of enermbrances except and will warrant and defend the same. Dated ........ :.... ........12th. ......... day of - - -kri 1 .......................... .............................. G1 hn n nstruction, Inc. : (SEAL) ' L�'-^ .. .............................. (SE11.L) • Glen.- Johas4c.,. .Pxesi_dent- .................. .............. - -•---- - -- --------- ------- -- ----------- --- - - - -- --(SEAL) • -- ...(SZA1) s -•• .........................•--°--- AUTSRNTICATION ACKNOWLRDGMBNT Signstnre(s) ._ ..................... ............ STATE OF WARNHA' Was aa. Q.4............ Cou nty. anW.aticated this -------- day of .......................... 1S______ Personally came before we this ............... at --- -- Ap Johnson April as President ..0....., 19 __95 _ the above named ` ......................................... ............................... Glen of Glen Johnson ' _ Construction n behalf • : �f _ the _._. ..............a. Inc. . .............................. .................. ------ - - - -- TITLE: MEMBER STATE BAR OF WISCONSIN . CArpordtI011 �� anihorised by � ?08.06, Wia. State.} - -_ – ........................................ ---------°___......---------- to me known to be the person ............ who ezecat*A the forecoing Instrument and acknowleige the THIS IMSTRt�MENT WAS GRAFTED BY / �r Holsten Law Office P.O. Box 206 -------- !./l . ► » i ... �t{ YTwate�;-- t�N.. 55D82 '--- •• .... ................... 1--------- ....._.. , ...... ............................... Notary Public 1Yir . (Ssgnatares may be suthevticategi or acknowledged. Roth My Cetnmissi an:� IT ate not necZssary.) NOTARYPl: LIC.IR cz _._ date �°Jas}{tFFSi$r1i c4k)l, •) *V-gym of par-. denlne in any eupa[9ty sbxmm !� typed or -inted bale- tb +y _': Y• Qq £Y :' _ — r SfiAttRA1YrT D.fi•• a?ATR RAC ^8 1rRAOt►?IeRei wbrorstw Gana! Shut Cw t,, —ism ::iMwl ►.� wls. - wz -? Wisconsin Department of Commerce SOIL AND SITE EVALUATION / 3 Division of Safety and Buildings Page I of Bureau of integrated Services in accordance with s. IL.HR 83 ;" Wis. Ad . Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Coun include, but not limited to: vertical and horizontal reference point (BM j, directio d* j 7 Gr01/f percent slope, scale or dimensions, north arrow, and location and distance to n 'AW*fl Parc4 I. D. # APPLICANT INFORMATION - Please print all infor atlon: + R,evie�ed by Date Personal information you provide may be used for secondary purposes (Priva X�' , s. 15.04 Property Owner ,govt. Lot f4 NC1 /4,S ? T 30 ,N,R) W Property Owner's Mailing Address Lotfl Subd. NAme or CW# S City S ate Zip Code Phone Number Nearest Road ❑ City ❑ Village Ej�r Town ❑ New Construction Use: WResidential / Number of bedrooms Addition to existing building R Replacement ❑ Public or commercial - Describe: Code derived daily flow - � gpd _ Recommended design loading rate . bed, gpd /ft • 6 trench, gpd1ft Absorption area required ,OCIC _ bed, ft 76 0 trench, ft Maximum design loading rate bed, gpd /ft _ trench, gpdht Recommended infiltration surface elevation(s) / 7•r It (as referred to site plan benchmark) Additional design /site considerations Parent material A 1r,e r a / `7 Flood plain elevation, if applicable IM It S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system 9 S ❑ U ® S ❑ u ® S ❑ U ©c S❑ U IRIS ❑ U ❑ S 24 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground J ( mo ' 7' `��. Si ` /`' ! ✓' Y� • S . 6 elev. 9 ft. 057e 7S A -2m Depth to -" limiting S , l factor 74 in. Remarks: Boring # lam ?12 Y19 Z4 Ground elev. 92 ft. Depth to limiting factor f g in. Remarks: CST Name (Please Print) Signature Telephone No. Add Date CST Number 7A( `� l ,•�� ! e ,e�J �u,� 4�Z - �eur S =7 -g9 02.2 7 S�.19 f PROPERTY OWNER ✓i ti✓ �ASSiCc• �OnOt�j. DESCRIPTION REPORT Page ;t ,, of PARCEL I.D.# Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground 3 5= 94 7 ��� �I�s f1�iC ✓�Tr e elev. Depth to limiting, Z 0 � Remarks: Boring # Ground elev. ft. Depth to limiting factor in. 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 ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) i i zIo' ' ! f t'Gli i .h ewe ( / � l � ��Yj'�� �r \/ /�/ /► ( /,y( /yam `I __. I 1� • I w _� Q �V►-, Q � +.J � `�1 �� V h � f VWS�, - � - �� � �,. � I �!._ . — -. i i � I I � i - I i 4J" ,M �✓S ;�y` 76' rI � I I t I ! Y'4AJ1�"►Q ,_ t'Ciy`_ _ ✓� - - �'SS��C_a Qh _ _ !`a+.�t�� �/� ml ,---�' _ _ A e & ids ' s) _1 -� ,� I r- 08/27/98 THU 07:47 FAX 715 386 4686 ST CRX CO ZONING 0 002 Y -74 ,qg ,-- ST. CROIX COUNTY WISCONSIN OFFICE �. ST CAOfXOOUNTY GOVERNMENT CEWER 1101 carmtchae, Road Hudson, WI X16 -7710 SEPTIC ( 3 86 -4660 INSPECTION 'PATER TEST "QUEST FORM Please specify desired application. Outside test (s) � winter months water lines remit appropriate arrang making access are often turned fee w ith with this office to the home necessar 'Of during to insure that entry Please make 0 Water y can be gained. Water � (VOC s) (Nitrate & Bacteria) $185,00 L7 fJ Water (Lead COncentration) ______4S. 00 �j Septic'" $50 21.00 Nitrate & Bacteria Address: Owner: r etest'$15 .00 ��.4�5 a S Requested by: ASS^ Telephone Ne: ,` ZI c Address: l3 v� (�`") � ._ can � Property elephone No • 2 P .5 2- Y address (Fire M & °c aion: $. 3 Street) Sac e% ' Y c;ealty firm: '�' • `R W ' of b�Q _ 8 - V " k Bo omt,o it f _ .9 - -LL- closing Date: l ? To ROViDE A SKETCH OF E COMPLETED HOUSE � SEPTIC pROPBRTY _N :►ter Sam SYSTEM ON REVERSE ple t ap OF THIS FORM* t he dwelling currentl t vacant, date Y occupied? e of septic s last occupied: /._ a -O Yes N "Ptic tank last Ystem: 42 vious o pumped by G'ner s Name Date; Dany of the following been observed? 0Y ON Slow draina ON Sewage Back- house, OY ON sewage discharge dwelling, OY ON Foul odors, ga t° ground surface or ro ° E'r comments ad ditch. relative to system operation 5 ^y I ertif Y that t bE ;: my kn owled ge. the abo v °f a information ge. 1 om ete nd true t o the OWNERS SFGNATU ii R.E 1 �� DATE: n r 08/2;/98 THU 07:47 FAX 715 386 4686 ST CRX CO ZONING f7j003 OWNERS•DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION n.t TO BE COMPLETED BY INSPECTION AGENCY � System desig V & or permit , on.-file? Yes Oft . Soil series per SCS Soil- Survey:: sheet .,:w��.. . TY e�of sozZ absorption system DBelow grd ,pAt -Grd DMound Approx. a x pGravity OAt-G ppressurized fiSed - 0Tranch ❑D e _ OHoldin �` W OBSERVED,DEPICIENCIES g Tank OOutfall pipe Se tic Wi t - in k ;zj . " Other Ounknown Setbacks: Mouse Dose t L . OProp• line Othe ank -~�- Setbacks: OHouse Dwell OProp_ line 00ther Mocking cover LlWaining labeler ppump /Floats_ C1Al'ara . - .� .lec wh in Soi �E l, Abso�ntion S 9 stem Setbacks: []House OWell -� ❑Pro lin OPond n . , �`_' ... P• OOther G neral c mments: ODischarge; INSPECTORS S TCIf 0 SlxS 1 1Em LOCATION V vv� Inspector y Title V 1 t 0 1 �I L ST. CROIX COUNTY WISCONSIN ZONING OFFICE r r N N w ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road A4 Hudson, WI 54016 -7710 (715) 386 -4680 January 6, 1999 David Jonk 1398 Haggerty St. Houlton, WI 54082 RE: Existing septic system inspection Lem Lot 8, Block 7, Sec. 27, T30N -R20W, Town of St. Joseph, St. Croix County Dear Mr. Jonk: On January 5, 1999, in your presence, I conducted a surface inspection of a septic system serving a duplex located at 1374 Haggerty St.. The inspection revealed that the septic tank was full of sewage with no evidence of septic effluent ponding in the drainfield. The dwelling was last occupied on October 18,1998. The existing permit information could not be found, so the date of installation and size of the system is unknown. I did observed a group of small trees that have been cut near the drainfield vent that indicates that the system may be at least 10 -15 years old. I recommend that you contact a licensed pumper to service the septic tank. The septic tank should be inspected it for structure soundness, and also verify that the baffles are still in place. The inspection opening on the septic tank should have an approved inspection cap installed. To prolong the life of the system, remember to have the septic tank pumped once every three years or when the tank becomes 1 /8 full of sludge and scum. Other efforts to prolong the life of the system could be as simple as fixing or replacing plumbing fixtures with water conserving fixtures, reducing shower time, washing dishes when the dish washer is full, avoid using a garbage disposal, using a wash machine with a suds saver feature, etc. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. This inspection of this sewage disposal system was based on a surface inspection of said system, and did not involve any excavation or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. Should you have any questions, please contact this office. Sin ely, w4qe Rod Eslinger Assistant Zoning Administrator 0 v, 0 3-0 0 d v1 c 3 ^° v5 ''` ► ma y o U) m 0 0 ° O » V W `C • n p Z 0 H p o m N o •�••, c c (D o o O 4 ^ co o Q 3 > 0 0 s in w C CD 7 O N p o 7 7 N 7 C lr d C v Cl) Z v> D 0 �a e � CD co D co y N a d C =1 c W o CD CD C Q Q C J to Z 0 = 0 r N lei 0 0 COCD 3o a �r 0 0007 �. o� CAww �0 o @ ;, vv_v,� - ppp =r ? y < 7 7 M y 7 E Z 0. M N ZWZ x o ' O D a CD 0 0 o l�1� d c =. C CD N w m a a 3 � z (D 0 a a z n N v CL A (z 0 W m o -4 a Z o x z ° 3 m !^ z CD / 1 w m 7 - 0 CD X w O, O n a fD 7 0- 03 D jai � 3 m � C'8 6 3 S a � ( \ v (D m ° j�o w ��a o a O N� 5 v c O 7 > cr (D y CDD - X 0' o < z O. o° aao 0 0 0 a= 0 0 O C O S N O O (0 Q 3 Cl fOD N O O 0. 3 7. �T O O d O 3 0 ' d m 0 O=v a Rr 3° l ei N O - R Z. m��mo�im a 3m� q �-0 ° cOD m n a m o x a� 3 s 3 f0 m 3 C N O• S O -^ N 0" Z r l xa< 3 : , _,; y nc ec �� fD D) 5 �. 7 S. W O 0 0. S fD 3 m ' v_i CD CD Q a a N O N (%1 (!� 7 d- O CD 3 0 N 01 '3. fD J 7 0p N'1 O 0" (Q :t O .1 H m x OD m o o v 0 0 c O O R I Parcel #: 030 - 2058 -30 -000 02/18/2005 02:41 PM PAGE 1 OF 1 Alt. Parcel #: 27.30.20.562 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * DAVID W & JESSICA Y JONK JONK, DAVID W & JESSICA Y PO BOX 553 BAYPORT MN 55003 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1374 HAGGERTY ST SC 2611 SCH D OF HUDSON SP 1700 WITC L I Description: Acres. 1.000 Plat: 2111 - HOULTON EC 27 T30N R20W LOT 8 BLK 7 VIL HOULTON Block/Condo Bldg: 7 LOT 8 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 27- 30N -20W Notes: Parcel History: Date Doc # Vol /Page Type 04/14/1999 601266 1418/522 WD 03/05/1999 598870 1408/339 WD 07/23/1997 1086/375 TI 07/23/1997 1083/95 TI more... 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 6195 171,600 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 50,000 118,800 168,800 NO Totals for 2004: General Property 1.000 50,000 118,800 168,800 Woodland 0.000 0 0 Totals for 2003: General Property 1.000 28,200 101,000 129,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: 123 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 � n>• , - Y VJ �s Ti �1 tr YA� > o sn � t A — s e ll T j N 48b E6AR : ST. Cn Ut O O n (n c a rvv /a I /rq �nj� W e CIE N' Lnl A Ln O �Q m I(A 52 I L A ,. 519 10 �� am,v u 1Q) to 4a ' 518 At I cn 0 cn� 'v` y1 t I- o 517 N �,' Or W a INIn HIV W �� \ 516 y — ; �� c�U 1 r 0 ue B v�t °ter STATE r _ I 9 y/ y� 528A� I� N a �' , 516 A = � aw 526�� STATE NW Y. owr +/� �, I "i + -r Cn : Y; ` _��k - ern . � . � e " 567 B. %_ W 567A W w ly A 566 ro s 565 — €� �- m. _..�7 564 { a 56 3 y - r � I o I tU. : (D h co N \. - 417.80 1 Y -�. O W m m t Form- S T C 104 AS BUILT SANITARY SYSTEM REPORT OWNER G!e(. (j �_� TOWNSHIP SEC. _ T 6 N - R'�W ADDRESS ST. CROIX COUNTY, WISCONSIN LOT LOT SIZE Q &)<, M2 Q L� �f`•C...L�. �Tl PLAN VIEW 13'7F llazrl�_ Distances and dimensions to meet requirements of I•ZHR 83 3U SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM `Q K At C'� tfow r � C/ �, ++ r 3•�, all 4 INDICATE NORTH ARROW + BENCHMARK: Describe the vertical refere a g7int used �O �u. O r mewLr r it Elevation of vertical reference point: �'! Proposed slope at site: SEPTIC TANK: Manufacturer: („(3Qe�� Liquid Capacity: � ri Number of rings used �_ Tank manhole cover elevation: !�N gg� rr Tank Inlet Elevation : / ti = (%! f Tank Outlet Elevation: 7�C i � ;L q(p` 7 Number of feet from nearest Road: Front Side,O Rear, O � I feet y r From nearest property line Front,OSide,QRear,O i feet f e� Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) 0Lw hTf7S!nL Sa vvTw PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: I Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, Side, O Rear, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Beds +/ Trench: Width: /Z: Lenokh: S Z Number of Lines: Area Built: Fill depth to top of pipe : Number of feet from nearest property line: Front, O Side, ® Rear, Ft. Number of feet from well: /Q S Number of feet from building: �'7 (Include distances on plot plan). f i SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). ' HOLDING TANK y t Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: V ?'(��„ A da P, Dated: Le lleI 6 Plumber on job: � , .'L, "�� License Number: M� 3 /84:mj r QEPARTWNT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: NW, -, NE %, S 2 7, T 30 N- R 2 0W (If assigned) ® CONVENTIONAL El ALTERATIVE Town a4 St. Joseph ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound C noif# rr rr PEI4MIT HOA*�3K-/"V ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Gtenn Joh"on 40 Peteti on StAeet, Houtton, W1 54082 i (�-;) I- ) • BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV: Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: John P. S Dana 111 3212 St. ctoix 119 396 SEPTIC T ANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: J I ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER I NUMBER OF ROAD: PROPERTY WELL: BUILDING: I VENT TO FRESH ALARM: FEET FROM LINE: � AIR INLET: F-1 YES ❑ NO IS (,l ❑ YES ❑ NO NEAREST —► �j � �.? DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED ❑ YES ❑ NO ❑ S 0 ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROP TY ELL: UILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST — 0► SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAME R ERIJ AND ARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF DISTR, PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID ' TRENCHES: 1 MATERIAL: P DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE I DISTR. PIPE DISTR. PIPE MATERIAL: NO. DIMR-1 NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH B OW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: ''!� PIPF FEET FROM LINE ^ AIR INLET: tl .`.. � a_ NEAREST •�� Q °� }-r MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES [__1 NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE I MANIFOLD MATERIAL: NO. DISTR. I DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO 1 ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑YES ❑ NO DYES L::] NO NEAREST —► z1 0 3 S e Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD -6710 (R. 06 188) Zoning Administ .atan �ILHR SANITARY PERMIT APPLICATION CT t O In accord with ILHR 83.05, Wis. Adm. Code �' ° �� STATE SA ,TARY PERMIT # —Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN } 3 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 ,� #.IW 1 /4 NE '/4, S �'f T 30 , N, R CO E (or W PROPERTY OWNER'S MAILING ADDRESS LOT NUM E BL K NUMBER SUBDIVISION NAME 'I CITY, STATE ZIP CODE PHONE NUMBER CITY : *, 1,9 EAREST ROAD, KE OR LANDMARK . q LL Aj 4 r � '' `� VILLAGE: '_ N WI. J !1 ✓GZ 1 (7 1 5 s6• CAW 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family -3 OR ❑ Public (Specify): III. PURPOSE OF APPLICATION (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b. U9 Replacement c. ❑ Replacement of d. ❑ 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. KConventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In -Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. X Seepage Bed b. ❑ Seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet) : PROPOSED (Square Feet): _ �^ q J ' G / 5 / 5 Feet ❑ Private K Joint ❑ Public VI. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank L El ift Pump Tank /Sit Chamber VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MPVVff SW .. Business Phone Number: lumber's Address Mreet, City, State, Zip Code). Name of Designer: Vlll. SOIL TEST INFOR MATION Certified Soil Tester (CST) Name CST � CST's ADDRESS (Street, eft, State, Zip Code) Phone Number: qAJ IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved S Hilary Permit Fee Groundwater ate Iss g Agent Signature (No Stamps) .Approved ❑ Owner Given Initial r ar a Fee A dverse Determina . a e XV` X. COMMENTS /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCT'IONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed - rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; 11. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number 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 University of Wisconsin; V. Absorption system information: Provide all information requested in ##1 -6; Vl. 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 all septic, lift /siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; Vill. 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 specifications not smaller than 8'/z 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; dosing or pumping chambers; 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. ----------------------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4,1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground after included the creation of surcharges (fees) for a number of regulated practices which Wiscor'tn'8 can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasurei is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. a The monies collected through these 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 (RM /86) • APPLICATION FOR SANITARY PERMIT STC - 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 /contractpr,( "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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property r Location of Property It N J 14, Section T -::U N- R o W Township Mailing Addres Subdtutston mw Lot Number ' Previous Owner of Property Total Size of Parcel .� CT `v Date Parcel was Created �;, �- i .3 Sz� L Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume n and Page Number J 3L as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING 1. Warranty Deed 2. Land Contract .�• 3.• Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. -------------------------------------------- PROPERTY OWNER CERTIFICATION I (We) ceAti.6y that a t dtatementd on thiA 6oAm ane .tn.ue to the best o6 my (oun) hnowtedge; that 1 (we) am (cute) the ownen(d) o6 the pnopenty dedchi,bed in thi,d .in6onmati,on 6oAm, by viAtue o6 a waua.nty deed teco4ded in the 066ice o6 the County Reg-iAten o6 Deedd ad Document No. /(v`> ; and that I (we) pnedentty own the p!topoded 4 to bon the sewage d4i poiat dydtem (on 1 (we) have obtained an easement, to Aun with the above dedchi.bed pnopeAty, bon the condt4ucti.on o6 said dydtem, and the dame has been y AecoAded in the 066.ice o6 the County Reg.cd o6 Deeds, ae Document No. � 1. , -L kd—, SIGN RE OF OWNER SIGNAT RE OF CO -OWNER (IF APPLICABLE) DATE SIG ED DATE SIGNED J �` , ,�,� �, :rte e � ``'� ". r '`� �,� •� '.v � I ���� < i AL . Vii. • h . Gran is fir. i�rr� 0 P11TRI s! +'� wrrw tO a o nt ten is aarum To d mar" led sRota is ct - Czoij -- Coomy, fi f k {n ` Tax Key tio. Lots 7 and 8, Block "7 Plat Of'wr Village of Haniton.` TAMASUV g e.{ ` <� fit.,.— ;�--•— , day of A11yu1" x!X (SEAL) ■ere _ John F Goo ; .••fir (SEAL) • gn r: ° ACKj40VL11*"1911T AUTHENTICATION •,, ' Si tUm authenticated thi �r of STATE OF . E� C � N/A Praasoaaily emu MfOSS so. dds r tM aAouf: �. i TITLE: 1NEMBER STATE BAR OF WISCONSIN John !'. CAttr Md i (it ..ot. � 3 • butbonsed by 7M.%, Wis. Statit.) p - aw a s is0 was drafted �i; At Gilbort, Shia 6 ?% dge to tee katowlt to .>r! lts pr�swi spin ie tae s�R atad t 51016 � MgAmttttem may be iWoutieated ea sciuwwtedged.. Both am 1"Cessaey,) M7 re tr t ' jl/dtlY DXMB H • z a ST C- 105 r r 9 H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z cy H ( :OW:NE ) BUYER C__4mj, kJ ROUTE /BOX NUMBER 4 16 � s�4� �� Fire Number CITY / STATE 6 'z Z IP �`��"Z!L} � PROPERTY LOCATION: 1 4, k) p 1 4, Section T �iLj N, R W, Town of St. Croix County, Lot number Improper use and maintenance of your septic system could result in 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 put 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 N to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart - ry ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix Count Zoning Office Y g P.O. Box 98. Hammond, WI 54015 715- 796 -2239 or 715 -425 -8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY, DIVISION HUMAN A ND MADISON PERCOLATION TESTS (115) MADISON WI 53 69 (H63,09(1) & Chapter 145.045) LOCATION: i � ' /��/ SECTION:��� � /6Z0 r ( ) TOWCSHI UNI�� LITY: LOT .: BLK�NO.: SUB / /� V1�31 ©N NAME: COUNTY: OWNE 'S UYER'S NAME: MAILIN ADVfD\RESS: (f iir/r USE DA ES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTIO - (PROFILE DESCRIPTIONS: PERCOLATION T STS: RResidence el� ❑New Replace L 11116-106 /1/16/ RATING: S= Site suitable for system U= Site unsuitable for system & y A Q,rA � V ++ e. Gdcaq . ICY. 2N6I S /d Q- ONVENTIONAL: MOUND: !N- GROUND•PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) sa s ❑u as u ❑s u Xs , If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s,H63.09(5)(b), indicate: Al lFloodplain, indicat Floodplain elevation: / PROFILE DESCRIPTIONS BORING TOTAL PTH TO ROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST, HIGREST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK,) L, p� B- B- B- PERCOLATION TESTS EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PERIOD I PERIOD Z PERIOD3 PER INCH P_ P- 1 4 P -_ P- 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 ELEVATION 95 O AV Z 7 k E _. w_ _i e 1 � ( � 1 �• 1 i r j i I V - f e s F Z ��f' 4 _ E 7 1 t 7 _ _. t i 7 � 1 t , 7 I 3 i j ve 1, 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: o& ADDRESS: CERT FICATION NUMBER: PHONE NUMBER (optional): Rt* ?- R e x - 75 - ac �� Z`/ Z3 Z 7 CST SIG A , RE- DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. ` DILHR -SBD -6395 (R. 02/82) — OVER — Q let, u S o � ,,t S,6 ,A b' NLU'K BEY Se z- r 7,0 � � z L'3 Sca G� y . lc) r P E 0 A ' ,&M tai ,� p� st p - �VIC, c� t3 0 y kc 1 ' a • t + RKSHEET - MOUND SYSTEM DESIGN PROBL Design mound system for a The site characteristics are: Depth o groundwater or bedrock fn. Landsl op Percolatio rate min./in. Distance fr dose chamber to distribution system ft. Elevation diffe nce between pump acrd distribution system ft, Step I. WASTEWATER L / gal. Step 2. SIZE THE ABSORPTI ARE A) Area required = sq. ft. B) Bed or trench engt (B) _ ft. C) Bed or trenc width ( ft. D) Trench snificing (C) Wast Ater load : •24 al /ft /day B = ft, renc es Step 3, MOUND IGHT A) F 11 depth (D) _ ft. B) Fill depth (E) = D + % slope (A) ft. Bed or trench depth (F) _ ft. D) Cap and topsoil depth,(G) _ ft. E) Cap and topsoil depth (H) = ft. �t'4 v � 're t' y � s e �t" r , t A � h4°\i� r , `t°yr T� �c r k • • � �� �,� w,%%��'i �. i¢ %� x�b ra rrif .� ' �riyg;i T. . � ti , •f � y 1 � , . ,a n v q j! 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