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CD m o°o 69 0 A °o i °° i Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: Safety and Buildings Division Count INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.; IX Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 344567 Permit Holder's Name: ❑ City ❑ Village ryTown of: State Plan ID No.: AUFDERHAAR, MARK SOMERSET CST BM Elev.; Insp. BM Elev.: BM Description: Parcel Tax No.: 032 - 2052 -70 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift LI ction System TDH Ft H ead Forcemain Length Dia. I Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type o Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No []Yes El No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 15.30.19.698A,NW,NW 1576 63RD STREET Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 3 E E f, E 4 ' s. E PP ,. i d em w. P° i c t 3 r k t x 3 F s , 3 i 9 e.m. e y . , i , € 1 S 4 t „ r t E E' 3 E , P t E r E i B s .m , m ... F � t ...... y_. -- -- ,,, E x m ; i a s E E i ? f Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 201 Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes E] Check if rein 4o vi ous appli tion (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION ir PLEASE PRINT ALL INF RMATION —.--_ Propert y ner e P Property Location Zia f j 1/4, S T3 0, N, R E Pro 12 nehs Ma g Addr r � � Lot Number Block lyi�ml�er- City (fie ` , , Zip Phone Number Subdivision Name or CSM Number ---vv ` II. T YPE OF B ILDIN (check one) ❑ State Owned loe . t( Nearest R d Public 1 or 2 Family Dwelling - No. of bedrooms ° Town of �*rKe III BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 S, 7 1q. 692A 1 ❑ Apartment/ Condo o3z- 2-nSZ — 7 U 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 a A) 1 E] New 2 E] Replacement 3, [] Replacement of 4_ Reconnection of E] Repair of an ______S tem System__ ___________TankOnly____________ Existing S ste Existing System B) (�A Sanitary Permit was previously issued. Permit Number ` Date Issued // V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressurg / 42 ❑ Pit Privy 13 [1 Seepage Pit „�,(?,57`1k / (� 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABS ORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Requir (s . ft.) Prop q. (Gals/d /sq. ft.) (Mip ch) on / I Feet -o./ Feet VII. TANK Capacity in gallons allons Total # of Manufacturer's Name Prefab. Site Con- Steel Fiber- plastic Ex New Exist Gallons Tanks Concrete structed glass App. T nks Tanks Septic Tank f 4w jo Fs ❑ ❑ ❑ 11 ❑ El Pump Tank /Siphon Chamber ❑ I ❑ I ❑ ❑ I ❑ I ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsi •lity for installation of the onsite sewa shown on the attached plans. "Um is Name: (Prin) s Signature: o f mps) MP Busin s Pho e N r P r kesy)( rCity,St e) de): � �� A e IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (i ncludes Groundwater F sue Iss uing Age gn ure (N Stamps) Approved E] Owner Given Initial � I �� Surcharge Fee) Adverse Determination S �c CONDITIONS�O APPROVAL/ REASONS F g DISAPPROVAL: �— Q, wV r rhl� 3 SBD- 6398 (R.11/97) 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. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on tine 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 everynew /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer.;, D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for 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. 0912211996 23:21 7153867996 HUDWORTH HOMES PAGE 01 ST CRODC COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ownowner/Buy" l ,�n 11 QTY l�L N u- P IS Mailing Address / �Pwporty Address (Verif requi ft m Planning Department for new construction) "ty/ tare � 'f� l/ " Parcel Identification Number WS 7--- 2,0 SZ. —? o DEGAL DESCRIPTION Property Location ' /., / Y4, Sec. l`� , TN - RZF — W. Town of Subdivision Lot # Certified Survey Map # . Volume . .Page # y7 Warranty Deed # 31 7 c� p , Volume o ..x? , Page # Sp house O yes no Lot lines identifiable O yes ©-aV SYSTEM MAINTEN CE, Improper use and maintenaneeof your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tarok 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 propcM owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system is in proper operating condition and/or (Z) after inspection pad p=ping (if necessary), the septic tank is loss than 1/3 full of sludge. 1/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system witb the efaadards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. CeetiSeation stating that your sep ' systear has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the throe aPiration date, " AO ra/ � / S ATUFI O APPLICANT DA'TB OWNER CEB3=ATION I (we) certify t all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of WA y descrtbe a ve. b vi a of a warranty deed recorded in Register of Deeds Office. 'I / 1 g1 = APPLI DATE » *' Any inf 6rn]ation that is mis represented may result in the sanitary permit being revoked by the Zoning Department. ri 4006 66 Include with this application: a stamped warranty doed from rho Register of Deeds Orue a copy of the certified survey map if ref=nee is made in the warranty deed DOCUMENT N O. WARRANTY DEED I� THIS SPACE RESERVED FOR RE 1 DATA STATE BAR OF WISCONSIN FORM 2-1982 i I i ` 7 r r" '7o443:179 n�oK w ...Fas,f4 _ REGISTER'S OFFICE ST. CR O IX CO., WI BRADLEY W. JOHNSON AND DEBBIE JOHNSON, husband and wife II Rea for Record .. .... ............................... .... ..... .... ............................... N 16 1988 .. _ .......... ............................... ..._. .... ..... .............................. I' of 1:30 P. N1', ............................................... rk .. D e ............ ............. ............................... i conveys and warrants to ...... Na........... u €sl.. ? �aax ... ............................... ��'" •� i' ....... ............ ............. ...... ..... 1�?¢ ;Y. Register of Deeds .......... ................... `.:......5� ............. .... 5 ` °. ............... .�. .. .....-- •----- •• ................ ...................... ...........................................----........-•......................... ......................I........ � RETURN TO .... .... ........................................................................ ............................... ..... ........................................................................... ............................... �..__ ___ -.. .. .. .. __..... -. .. ..._. the following described real estate in ...... c„t,..�rpiX ........................County, State of Wisconsin: Tax Parcel No ............................... i. Part of SWI /4 of NW1 /4 of Section 15 -30 -19 described as follows: Commencing at the NW corner of SW1/4 of NW1 /4, being the point of beginning; thence South along the West line of said Section 15, 720 feet; thence East on a line parallel to the North line of SWIM of NW1 /4, 900 feet;; thence North on a line parallel to the West line of said Section 15 60 feet; parallel SWI thence El on P to the North line of Y aline /4 of NW1 4 of NW1 /4; thence North along the East line / of t SWI /4 of t NWI /4, 660 and thence West along the North line of SW1 /4 of NW1 /4 to the point of beginning. i i. , rRANSF'M This ...... .................. homesicad property. (is) (is not) FFiF1 Exception to warranties: Dated this 15 .................... day of ... Nov :ember.................................................. 19....88 { �I ......................(SEAL) ...... ............................... .........................(SEAL) Br dley Johnson .. SLAL ......(SEAL) Debbie, Johnson %Ylkllt'.4 * ........................ ............................... ..... * .... ... ................ AUTHENTICATIC N ACKNOWLEDGMENT Signature (s) ............................................................ STATE OF WISCONSIN ;i ..................•--•--•--•--------............. ..............••-- -- ........... St. Croix ss. .... ............................... County. authenticated this ........day of ........................... 19 ...... Personally came before me this ..ls .......... day of ;! ... November ..................... .. 19.. the above named .................................................. ....... •---- •-------- •--- :7'� *�����. ICY.. 1^ I. �.. �IAhn�cn ._�nd.A�bbxe._,�nbnsnn.,. :. .....-----• ............................... ....•- •--- ••......••-- .....,r;. oe,........ ti nd.• and_. wife.............. ............................... TITLE: MEMBER STATE BAR OF V1 iSCONSI10 i;.•' a ••. ! (If not, ................................................. >< BCrbara J tbl �� ............................ ............................... 1. authorized by § 706.06, Wis. Staff.::.) qy be the person ..9........ who executed the ument and acknowledge the same. TH IS INSTRUMENT WAS DRAFTED BY ,f/s ... 'If .................. Attnrna+'s.: up of st1% . ,r ....... .... 1940 reeley $u to ri : ;a ................� .. ................ 1. StlllWi32i3f ,. MN.. 15Q :............... .• ..... .County, Wis. (Signatur es may be authenticated or a.:..nowledged. Both My Commission is permanent. (If not, 'state expiration are not necessary.) A-1 date: ...................................... ...................19..?1...) *Names of persons sicula* in any capacity should be typed or printed below their signatures. !' RamillercoeprryFR9 STATkOH MANOo. WISCONSIN Stock No. 13002 — 1982 Form - S T C 104 AS BUILT SANITARY SYSTEM REPORT OWNER r� (✓ ( q fqlelr &i r TOWNSHIP JDAr e/' e � SEC. T N -R )/ W ADDRESS 10 ST. CROIX COUNTY, WISCONSIN /f SUBDIVISIO LOT �- LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•IHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 30 Joan a w INDICATE NORTH ARROW • BENCHMARK: Describe the vertical reference point used C ettt I ° t ' / /. - Per ©tt - t5 , d e fi q, r w n Elevation of vertical reference point: N-0 Prop sed slop at site: c/ d SEPTIC TANK: Manufacturer: Y(�WeSt 6'C&A iquid Capacity: oeo Number of rings used: lJ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side ,Q Rear, O feet From nearest property line Front 10 Side I& Rear, 0 r feet i f � Number of feet from: well `7'Q , building: b (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: y Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: 3 Trench Width: , Length: 5 Number of Lines: 3 Area Built: 6 Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear, Pt. O Number of feet from well: �G Number of feet from building: �d (Include distances'on plot plan). 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 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. Dated: Plumber on job: ( L4", License Number: 3 3/84:mj r DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING ,LABOR & HUMAN RELATIONS DIVISION O N-SITE SEWAGE SYSTEMS P.O. BOX 7969 O OFFICE OF DIVISION CODES & APPLICA TION MADISON, WI 5;k707 State Plan I.D. Number: N'th, DM, S15,T30N -R19W CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Somerset ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound P ER: ADDRESS OF PERMIT HOLDER: INSPEC IC ATE: Mark D. Aufderhaar Route 2, Box 318A, Somerset, WI 54025 5 -i -8 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: Thomas A. 4Jang 3231 St. Croix 119466 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIOUP CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV: WARNING LABEL LOCKING COVER � � I ~` o f 9. G� d 3C® PROV IDED: YES ❑ NO P ❑ YES NO BEDDING: V VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIRJILET: ❑ YES NO C r ❑ YES E I NEAREST 0 DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES El NO E] PROVIDED: ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ) ❑ YES ❑ NO NEAREST -- 110- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: I MATERIAL AND MARKING: 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: M ERIAL: PIT DEPTH: DIMENSIONS 1 � 3 4 — GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: I ELEV. END: PIP LINE: AIR INLET: FEET FRM Z 7Z NEAREST --* 0 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 ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; [::]YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH /BED I 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. 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 ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: { FEET FROM LINE: ✓ , o S ❑ YES ❑ NO ❑ YES ❑ NO NEAREST"_ I nt Sketch System on file for audit. _ - "� '� °' Reverse Side. SIGNAT TITLE: - - Zoning Administrator SBD -6710 (R. 06/88) �N ` `� DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUN ���! Lai a,anr,aavnvr i STATE SANIT RY PERMIT # - Attach,complete plans (to the county copy only) for the system, on paper not less than �q&6 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION Qr '/a %,S :�' T ,N,R 1 17 E(O<G) PROPfR O)If(NER'S F1LING ADDRES� 4u folel� Q F' LOT # — BLOCK # CITY STATE * � ZIP CO PHONE NUMBER SUBDIVISION NAME OR CSM N BER So �� MW II. TYPE OF BUILDING: (Check one) ❑State Owned ❑ CITY VI NEAREST ROA e edUL' ❑ Public 1:11 or 2 Fam. Dwelling -# of bedrooms PAR ELT NUMBER( III. BUILDING USE: (If building type is public, check all that apply) s: ^– D 1 ❑ Apt/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 in line A. Check line B if applicable) A) 1. ❑ New 2. X Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 tZ Seepage Bed I4" I A 3 5- t 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) I (Gals /day /sq. ft.) (Min. /inch)�j/ ' E l l I 0 (Q K C ,3 ` &/, � e) Feet O l d Feet VII. TANK in allons CAPACITY Total # of ` ? Prefab. Site Fiber Exper. INFORMATION New ns Gallons Tanks Manufacturer s Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 6Uj,) wPS Lift Pump Tank/Siphon Chamber 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 s Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: �.rt s A0 393 Plumber's Addrest3 (Street, City State , 'p Code 09 .Y 0 IX. COUNTY /DEPARTMENT IOSE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue Issuing Agent Signature (No Sta ps) Surcharge Fee) � W, ® Approved ❑ Owner Given Initial 14S , � J Adverse a rmin tin v ' X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: �a SBD -6396 (formerly Plb -67) (R. 11/88) 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 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. 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 or the State of Wisconsin, Safety & Buildings Division, 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 and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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 in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'f 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, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) t SANITARY PERMIT APPLICATION 7 ffILHR In accord with ILHR 83.05, Wis. Adm. Code COU NTY STATE SANITARY PERMIT # –Attach complete plans (to the county copy only) for the system, on paper not less than ; ., 8% x 11 inches in size. 1:1 Check if revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION – PLEASE PRINT ALL INFORMATION. PROPERTY OWNER! - r PROPERTY LOCATION Ali L 'V/,r� 1/4,,- t /4,S T,• � E( PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE 3 ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER _1 Check one CITY AGE NEAREST ROAD II. TYPE OF BUILDING _ ( ) S tate Owned F VILL ❑ Public ❑ 1 or 2 Fam. Dwelling --# of bedrOOn1S R ELTAX NUMBER( ) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/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 in line A. Check line B if applicable) A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other r 11 0 Seepage Bed ,/(' 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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) f ELEVATION Feet Feet CAPACITY Site VII. TANK �'�` Prefab. Fiber- Ex er. in allons Total # of Manufacturer's Name Con- Steel Plastic p INFORMATION New xistin Gallons Tanks Concrete glass App. Tanks Tanks strutted Se tic Tank or Holdina Tank Lj F I F W W Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PRSW No.: Business Phone Number: Plumber's Name (Print): Plumber's Signature: (No Stamps) MP /M Plumber's Addre7s (Street, Cit State, 4ip Code): IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -8398 (formerly PIb -67) (R. 11/88) 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 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. 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 & Buildings Division, 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 and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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 in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% 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, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) Q. 2 6b \I- !�'AK ;Y; eeue�•lt� r 3 Y Q er�. V G,1 � c'h � o � ►i� s` nv `f ��o �� to woe 3a B3 o (Fs`X3S' 1 �4� 160 �r r Vv1 'to { �o God. loo' w 3f Ito. CJ Loft to r he r :!�vv `f 5o o�fi t 1 6 6 I`ve g� s a 'tip j So '90i 5 r 000 144 /ov �rese� b a q e ,� � � �o � �. a yu ev. • f 5 i �� , I GUQ W 1 . EPARTMENT'AF R EPORT ON SOIL BORINGS AND S AFETY & BUILDINGS J DUSTRY, DIVISION IABOR.AND ' 1 G P.O. BOX 7969 OMAN RELATIOJIS PERCOLATION TESTS (115) MADISON, WI 53707 • (1-163.0911) & Chapter 145.045) OCA "fIO V SECT — TON: TOWNSHIP /MffT{Y: LOT NO.: BLK. NO.: SUBDIVISION NAME: NW 14 M 15 /T 30 N/R 19fxor) W Somerset n a n a n a OUNTY: OWNER'S NAME: MAI LING ADDRESS: St. Croix Brad Johnson I R.R.#2, Bo x 318A, Somerset, Wi. 54025 S DATES OBSERVATIONS MADE NO. BEDRMS.: DESCRIPTIO N: R FI DESCRIPTIONS: PERCOLATION STS: Ze esidence 3 ❑New Replace I 10 -29 -88 10 -29 -88 ATING: S - Site suitable for system U- Site unsuitable for s ystem ONVENTIONAN: MOU - ND : IN-- GROUND PR SSUR :SYSTEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) EgS ❑U rr ❑A _ ®S Ell S �U � S E conventional I Percolation Tests are NOT required DESIGN RATE: II any portion of the tested area is in the nder s.H63.09(5)(b), indicate: ri I Floodplain, indicate Flood elevatio n/ a dprima t PROFILE DESCRIPTIONS page 34 AnC2 ORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND UEP I H (UMBER DEPTH DM ELEVATION O BSERVE D ES'T. I� GHE$ TO BED ROCK IF OBSERVED (SEE A'BBRV. ON BACK. 3- 1 7.00 99.70 none >7.00 .75bl.1. 1.00bn.s.sil. 2.83bn.c.s. .42bn.s.l. 2. .s. 3 2 7.17 99.93 none >7.17 .75b1.1. 1.00bn.s.sil. .83bn.cob. s.sil.gr. 3.001)ii.c.s. .42bn.l.s. 1.17bn.c.s. 3 3 6,92 100.08 none >6.92 1.25bl.l. 1.67bn.cob. s.sil. gr. 4.00bn.c.s. 3- — 3- 3- decimal' PERCOLATION l ESTS TEST �r WATER IN HOLE TEST TIME Oldi IN WATER LEVEL - INCHES RATE MINUTES , IUMBER 1t fRt AFTERSWELLING INTERVAL -MIN. PERIgD t 1_ PERT D R P PER INCH P .1 3.50 none 3 �— P-2 3.73 none 3 6 _ 6 6 <3 P- none 3 6 6 6 <3 P. I I .OT PLAN: Show locations of percolation tests, soil borings and the dimensions �f suitable soil areas. Indicate scale or distances. Describe what are the hori- ntal and vertical elevation reference points and show their location on the plot ),l :jo. Show the surface elevation at all borings and the direction and percent land slope. t ;YSTEM ELEVATION 96.20 ! ✓1 ( _ I ._.. ,_..- . �. ! ! I � ; j I I � I I 1 .job' + - ta % d � i 46 �' iD I I i I I i i i 4 Ou't� 1 r w ;4 �/ 1-40 b' ( y _/ ! 3 9 1��4, ` AAA (l / �e "' ' t H I i I I r i the undersigned, hereby certify that the sell tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin ldministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. VAME (print): TESTS WERE COMPLETED ON: Gary L. Steel l 29 -88 ADDRESS: CER11 FICA I ION NUMB['F1: Hi6NENUMBF.Ii(optimial). 988 N. Shore dr., New Ri Wi. 5 4017 2298 71 246 -6200 - -�� - - -� CST SIGN) (1 RE: l DISTRIBUTION: Original and one copy to Local Authority, Proper ty Ownet rein Soil T^ster. r H N ` - 9 ST C- 105 r 9 H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County z 9 H OWNER /BUYER der a r M - Awk4�&W A r k P ROUTE /BOX NUMBER {� �K j / Fire Number 15 04 / CITY /STATE 5&M e,1 ; lc� e� �, Z I PROPERTY LOCATION: 14, !V )/ A) k, Section -/ T__TJV N, R_W, Town of SGi�1P��� St . Croix County, Subdivision Lot number ( I 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. j St. Croix.County residents m_ y 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 E I /WE, the undersigned, have read the above requirements and agree Ln to maintain the private sewage disposal system in accordance with H the standards set forth, herein, as set by the Wisconsin Depart- 'b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office thin 30 days of the three year expiration date. SIGNED DATE LVI I St. Croix County Zoning Office i P.O. Box 98 Hammond, WI 54015 715- 796 -2239 or 715 -425 -8363 Sign, date and return to above address. 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 /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. Owner of Properly QQ r` Location of Property � 14, Section / , T N-R2f W Township :2A{^�'s° Mailing Address - boL Address of Site Subdivision Name Lot Number Previous Owner of Property G� n Total Size of parcel j� A Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume 1 and Page Number Vy as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING A Warranty Deed which includes a Document number volume and page number and the Seal of the Register of Deeds In addition, a certified survey, if available, would be helpful so as to 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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTy OWNER CERTIFICATIO I (We) cehtti6y that att statements on tW bonm ane true to the best o6 my (oun) k.nowtedge; that I (we) am (ane) the owners) o6 the ptopehty desc& bed in thus in6oxmation Sonm, by viAtue o6 a waAAanty eed teconded in the 066ice o6 the County Regi6ten of Deeds as Do cument No. S/ ; and that I (We) peesentty own the proposed site bon the s ewage dispas a s yst em (ot I (we) have obtained an easement, to nun with the above descA bed ptopenty, go& the constAuction ob said zyztem, and the same has been duty neconded in the 046ice o6 the County Registen o6 Deeds, as Document No. I . i SIGNATURE OF OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED _ WARRANTY DEED _ • DOCUMENT NO. I� Ij THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM a —19821 j! ! BRADLEY W. JOHNSON AND DEBBIE JOHNSON, husband and ­ifo .. ............ ............................... ..... ................................. ............................. .................................. ............................... ::: conveys and warrants to ..... .......................... If .................................................................................. ......................- ._...... �I .................................................................................. ........................ • - -•... .................................................................................. ............................... ! ................................................................................. ....._......................... i ................................................................................. ..............................- '! RETURN TO • I� .... .... ..................._.................................................... ............................... the following described real estate in ...... & t_,. .Grpix ....................... "' into-, State of Wisconsin: Tax Parcel No: .............................. Part of SW1 /4 of NW1 /4 of Section 15 -30 -19 e"" ­il::d as follows: Commencing at the NW corner of SW1 /4 of NW1 /4, being ti oi;,t of beginning; thence South along the West line of said Section 15, 7 feet; thence East on a line Parallel to the North line of SWIM of NW1 /4, ^ „? a °et;; thence North on a line parallel to the West line of said Section 1'7< "0 feet; thence Ely on a line parallel to the North line of SW1 /4 of NW1 /4 East line of the SW1 /4 of NW1 /4; thence North along the East line of 7 "1 of NW1 /4, 660 feet; and thence West along the North line of SW1 /4 of ? `''S./ ° to the point of beginning. , y This ......is .................. homestead property. (is) (is not) Exception to warranties: Datedthis ............... . ........15............ ........ day of ---- ovember. ...... ....... ................................... 19....88. V . ( SEAL)..... ..._ ........................... .........................(SEAL) Br' adleV ''. Johnson a * j�� ..... .......................... ............. ......................... (SEAL) ebb - i�, ........... ............................... ......................... (SEAL) D •= �nnson * ......................... ..............•- •......- • -_.... ..... * ..-.. f ,� ���h! -A ?'................. AUTHENTICATION ACKNOWLEDGMENT Signature (s) ............................................................ STATE WISCONSIN i ss. ...............................•-----............ ............._......---- .._.... St. C':-!.x r-- • - - -... - -•.._ ........County. authenticated this ........ day of .......................... ' 19 - - -. -- Pe. conall came before me this ..15.......... day of November .. -' 19..88-. the above named �s��• .jT �� d_z ^x..Y? :.. Qhl?sox� ..s�nd.Aebbie..,7�bnss�xi,. j ... � . •' .... 1 ff + d and wife ...... ..................................... ............................ TITLE: MEMBER STATE BAR OF V!SCONSI •' '• (if not . .................. ............................... ....y.BarbGC .... ° ..----........................... ............................... authorized by § 706.06, Wis. Stac .) _ 1Noi{oy9lhde no Hn to be the person .. *. ........ who executed the ' • 1ore;ro`l �,nstrument and acknowledge the same. 00, THIS INSTRUMENT WAS DRAFTED BY *' !' . .......... ...... ......... Atto th- A uit ol !Y>_y$ ................... i 1940 r _) y ci �... .... . . . .. . f' ...... ................. S. -65 Count Wis. M�`� Q ..:......................... Notary tI1lwalor,_ -ublic .... . - -- . . ............... y1 (Signatures may be authenticated or ac:cnowledged. Both My Commission is permanent. (If not, state expiration t ! ll are not necessary.) date: 19..1.. *Names of persons si¢nin¢ in any capacity should be typed or printed below their si¢naturca. STATE BAR OF WISCONST. ,' Stock No. 13002 H.C.MIIIer Caro" [ FORM No. 2 — 1882 y.NIY11.. M111MI,. 4J I 4 • S & N LAND SURVEYING • HUDSON , WISCONSIN 54016 ( 715) 386 -2007 Name First Federal of LaCrosse. Address 201 South Second Street Hudson, WI 54016 Description Part of the SWa of the NWa of Section 15, T30N, R19W, Town of Somerset, St. Croix County, Wisconsin. (14ark D. Auf derhaar ) PLAT DRAWING N This is not a complete Land Survey 38' ,I 6 "House N 0 26' 1 Garage W E S 0 Pool DETAIL 1" = 60' House Garage I (See Detail) I Pool (WI I WI ICI U)I i O to N I I I �1 fl I The location of improvements on this drawing are.- approximate and.are based on a �lsuai inspection of the premises. The lot dimensions are taken from cecorcled plats and deeds of county records. This drawing is for informational purposes only and should NOT be used as a complete Land Survey Fir st Federal of LaCrosse has agreed to waive the minimum standards of AE -5 Map No. 88-01 -400 Drawn By F.B. 10/24/88 Scare = -- 1 = 200'