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HomeMy WebLinkAbout032-1031-50-500 v , ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner , 2)/ _ ; l!1Fn Property Address City /State , CC NTY Legal Description: ZOMNG OFFICE Lot Block Subdivision/CSM # t/a , t /a, Sec., TAN -R jW, Town of „c P SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC Setback from: House Z5 Well ZjL P/L � Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: 2,6, Width _� Length 7� Number of Trenches Setback from: House /,,,, Well ' lye P/L !!� Vent to fresh air intake f �� ELEVATIONS Description of benchmark / Elevation Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines O 9-if. �= O ( ) Bottom of System O 15 1 : 5- 9 ( ) ( ) Final Grade O 212, 2,2 ( ) ( ) Date of installation /.5` ermit number State plan number Plumber's signature License number : �� s Date Inspector —J,,N Complete plot plan or NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW �DIGATE NORTH ARROW 'ZI � 3 mf 5 ' / iii Scar /.c �J.0 JiZtiL�1. C.tif�'✓Gfc r Wisconsirr Department ofCommerce 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)]. 344654 Permit Holder's Name: ❑ City ❑ Village [3d Town of: State Plan ID No.: M & G Inc. Town of Somerset CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: (00 /60 032- 1031 -50 -500 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 600 Benchmark S, ,>-- Alt. BM Aeration Bldg. Sewer o. 7 q I / L ding St /Ht Inlet z -7 ?2. TANK SETBACK INFORMATION St /Ht Outlet L Z. TANK TO P/ L WELL BLDG. Air I to ntake ROAD Q4 I R I et Air Septic ±-fi �Si NA in NA Header/Man. Y 0 d Z Aeration N Dist. Pipe 3 Holding Bot. System - PUMP/ SIPHON INFORMATION Final Grade (3- Z Z nufacturer and St cover �_ P,>- Model Numbe GP TDH ift Friction stem TDH Ft L oss E6rcemain Length Dia. Dis . S L ABSORPTION SYSTEM BED TRENCH Width Length No. Of Trenc s T No. Of Pits Inside Dia. Liquid Depth I N I N (Z S Z l e DIM SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM - Manufacturer: INFORMATION Type O t /U / � ��, C B el Number: System: J Oft UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length? Dia. Spacing Z L Z Z / 7 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 El No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: /� Y%1 If7 Inspection #2: Location: 2277 County Road I, Somerset, WI (SW 1/4, NW 114, Section 11 T3 IN-RI 9W) - 11.31.19.150E -7 r , or' C® ucnr Plan revision required? ❑ Yes P No Use other side for additional information. ap SBD -6710 (R.3/97) Dad Inspector's fWature Cert No Safety and Buildings Division N * s6ansin SANITARY PERMIT APPLICATION 201 W. Washin Avenue In accord with ILHR 83.05, W is. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less county than 81/2 x 11 inches in size. , aa • See reverse side for instructions for completing this application State anitary Perm it Number Personal information you provide may be used for secondary purposes 1ACheck it revision to previous application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Propert Owner Name Property Location 1/a 1/4, S T , N, R� �or Property Owner's Mailing Address Lot Number Block Number I City, State Zip Cod Phone Number Subdivision Name or mber II. TYPE OF BUI LD N (check one) ❑ State Owned 11 !t�'" Nearest Road p VII age Public 1 or 2 Family Dwelling - No. of bedrooms _ Town OF III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment /Condo ©-ems — /D -- jV -- sm 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. q New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. E Repair of an _System ________System _____________TankOnly Existing System ____ Existing B) A Sanitary Permit was previously issued. Permit Number V Date Issued fip'38 V. TYPt OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 []Pit Privy " 13 []Seepage Pit _ 43 [] Vault Privy 14 E] System -In -Fill 2 x 5 S &Z 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) Eleva ion Feetj Feet Capacit VII. TANK in allons Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer s Name Concrete con- steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank — ❑ 1:1 ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for ins lation of the onsite sewage system shown on the attached plans. Plumber' Na : (P int Plumb 's na No s) MP /MPRSW No.: Business Phone Number. pluiAb Address (Street, " y, tate Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary � rmit Fee (Includes Groundwater ate I ssued Issui A�ent Sign ture (No Stamps) pp []Owner Given Initial i' roved surcharge Fee) 414 . � Adverse Determination l�j CONDITIONS OF APPROVAL /REASONS FOR DISAPPROV L: f , Fj l , 14 4, C1 l {J SB 6398 (8.11/97) 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. 11. 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. 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. t r Safety and Buildings Division wSANITARY PERMIT %� 201 W. Washington Avenue sconsin In accord with ILHR 83.0 dm. Co P O Box 7302 Department of Commerce on pa less Cou r - Madison, WI 53707 -7302 ��cEEv�a • Attach complete plans (to the county copy only) for the Sys r not le nty than 8 1/2 x 11 inches in size. 1 - • See reverse side for instructions for completing this applic AUG 2 � IX states ni ary Permit Number ST CRO Personal information you provide may be used for secondary purposes ` ON W o N cF ICE ©Dh if revision to previous ap lication [Privacy Law, s. 15.04 (1) (m)]. 9 ter; St a Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF Property Owner Name Ion �_ v4 1/4,S TS1 N, R/9 E (or& Property Owner's Mailing Addre5s, Lot Number Block Number CI y, tate Zip Code Phone Number Subdivision Name or CSM Number ( ) II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ !t Nearest Road ❑ Village Public ja 1 or 2 Family Dwelling - No. of bedrooms_ Town OF III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) • 2/./4e [S 1 ❑ Apartment /Condo a3�_p - /D3 /- 9 .SD -SDO 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. p New 2. E] Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. [] Repair of an ______ System ________ System -- ----- -- - - -- Tank Only______________ Existing System________ Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ®'Seepage Bed 21 [:]Mound 30 ❑ Specify Type 41 []Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit IF 43 ❑ Vault Privy 14 ❑ System -In -Fill Ity Se " VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Sate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. //i ch) Elevati n 3 < ---A Feet Feet Capacit VII. TANK in Ca allons Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks mA Septic Tank or Holding Tank r 1600 XS ❑ ❑ 1 ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ I ❑ I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for install ion of the onsite sewage system shown on the attached plans. Plumber' ame: rin Plumber' Signa e: to MP /MPRSW No.: Business Phone Number: Plum' ber's Address (Street, od 3 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved jbSanitar y Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved []Owner Given Initial I Surcharge Fee) / Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 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 line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 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. i r f s 1i1���.�. s� � - Jc%1/ _s�� /l- T-- mss.,✓ -�i9�1 X77 � 0 3 �s 6- r w t ray M � J Wiscoosin Department of Commerce SOIL AND SITE EVALUATION i Division of Safety and Buildings Page —L of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County �� include, but not limited to: vertical and horizontal reference point (BM), direction and _ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Rev iewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). f L lQ � ._� l /5- L' Property Own r Property Location Govt. Lot 6v 1/4 d 1 /4,S T N,R E (or)(S Property Owner's Mailing Address Lot # Block# Subd. Name or Cam_ :z � Z2 d 7- � &Z 1)") )/- City Stat Zip Code Phone Number ❑ City ❑ Village JK Town Nearest oad < ) s 1Z New Construction Use: Residential/ Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate _L� bed, gpd /fe — trench, gpd /ft Absorption area required Z_:�& bed, ft '17a /S rench, ft Maximum design loading rate bed, gpd /fF_ gpd /ft Recommended infiltration surface elevation(s) 89 ft (as referred to site plan benchmark) Additional design /site co nsiderations Parent material 0,ZV W_ Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system 5d S❑ U L? S ❑ U 1Z S ❑ U JZ S ❑ U ❑ S Pau EIS ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD 1ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench c Ground — el ft. Depth to limiting factor >,lj Remarks: Boring # 42 A!t Q S" 5' i Ground �elev. i a' o ft• � � �- �., , Depth to limiting factor �� in. Remarks: CST Name (PI se Pri ) Signature - Telephone No. Address ,,� f� ate CST Number 2 S �K ` PROPERTY OWNER ��('�G SOIL DESCRIPTION REPORT Pa e of 9 PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3� Al 2 - s� Ground - elev. �Z ft. Depth to limiting (u factor Remarks: Boring # / / G A, all L. < r J ' Jd Ground elev. Depth to limiting factor 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 # s S S �� .5 3 4/ Ground elev. � ft• Depth to limiting factor 22 in. Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) IAI �s O F � / J7yKSK (�� t' 1 �dy . L�7R l/ y� y83 Aggregate SAS SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Aggregate Soil Absorption Systems Permit Number 11/15/99 Date X "x" Gravity Distribution only 1 Pressure Distribution 3 ft Suitable Soil 1 6 in Aggregate Depth 2 4 in Nominal Pipe Diameter 600 gpd Estimated Daily Peak Flow 0.80 gpd /if Wastewater Infiltration Rate 750.0 ft Minimum SAS Size 89.65 Ift Proposed SAS Elevation Soil Surface Acceptable Finished Grade EL 3 (ft) Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum Number Elevation (ft) Depth (in) Lowest Highest Elevation? 92.15 93.98 1 94.50 89.65 90.03 93.00 No Cut required 2 93.80 89.65 89.33 92.30 Yes 3 91.87 89.65 87.40 90.37 Yes Fill required 1. Depth of suitable soil required below the infiltrative surface for treatment. 2. Depth of aggregate below distribution pipe. 3. Based on chosen system elevation, and aggregate depth. The addition of fill for cover or the reduction of finished grade may be required to meet minimum or maximum code standards. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. SBD- 10553 -E (R.05/98) i %��� �aCJL - / /��na (9�C.�+ - Sc,1 %y - N�%y � s,�� ��- T.3 /�i/ �igli1 �h,�S.FT � S�ti?S r � � �,e�°r� e 'few /ADO gr� _ W� // v }i'6us,e �-� 3 - I �� '� �� ��w R �y' �� � I y �. I ��3 .�.� r � WjsdW ,ii Department of Industry —�, , AND SITE EVALUATION Labor and Human Relations !, '' it Page of Division of Safety and Buildings ,'��iZ`i `accordai>E�lo�th S. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not esss Khan 8 W1,19411fles in size Ian must County include, but not limited to: vertical an heri reference point (BM), direction and percent slope, scale or dimensions, n rttrArrow gFlocation 440stance tq nearest road. Parcel I.D. # APPLICANT INFORMATION - ie�se prin�`•�� Personal information �r�natio* Reviewed by Date u p rovide m be used sAc` a n u Privac Law s. 15.04 m Yo P Y � P rP � Y 1 / I) � )) . Property Owner , r - yam -' Property Location / Q,�^ -LL` Govt. Lot 114 1 /4,S T ,N,R 4 (or� Property Owner's Mailing Address Lot # Block I S7ubdame or CSM# i Siatq Zip Code Phone Number ❑City Village Town Nearest Road f New Construction Use: IgResidential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow Zgo gpd Recommended design loading rate bed, gpd /ft 2— trench, gpd /ft Absorption area required _ bed, ft Z$'O trench, ft Maximum design loading rate _ bed, gpd /ft _ trench, gpd /ft Recommended infiltration surface elevations) , 9 ft (as referred to site plan benchmark) Additional design /site considerations Parent material �s �Ss.r —� Flood plain elevation, if applicable 4 ft S U = S ® El El for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding L Taank = Unsuitable for system {� S❑ U S U S U 1 0S ❑ U El r S � U [I 9 U SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Con Color Gr. Sz. Sh. Bed Trench 1 Ground S _ elle�v. Depth to �S - limiting � Remarks: Boring # Ground elev 2ft• Depth to limiting factor Rem rks: CST Name 7(Plea,4Print Signature Telephone No. / 1- Address Dat CST Number r� 1A)P /Zz 2 7 SOIL DESCRIPTION REPORT PROPERTY OWNER Page c:2- of PARCEL I.D.# Boren # Horizon Depth Dominant Color Mottles Structure 2 Boring in. Munsell Qu. Sz. Co t. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ;Trench -Ak, Ground Depth to limiting ; factor in. Remarks: Boring # l ®� s ej Ground ft. Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Co T. Color Gr. Sz. Sh. Bed ,Trench Boring # ........................... ......................... ........................... Ground elev. Mllft- Al Depth to limiting factor �� Remarks: Boring # Ground elev. ft. 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XV_lcJNn i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERS141P CERTIFICATION FORM Owner/Buyer tN d .,d A Mailing Address A W A k -t H x a-'j -V 1 S -00 11 Property Address A2,1 (Verification required from Planning Department for new construction) &%-� City/State S �Ys-.� Parcel Identification Number O?a - Id31 -5 `.S01 y om LEGAL DESCRIPTION Property Location P� 'A, ffA2 'A, Sec. 4_�__, T_3 t__N -R _W, Town of o MAY SztZY Subdivision - -y , Lot # Certified Survey Map # 6'5'1 37!�z , Volume // , Page # Warranty Deed 9. / , Volume �® ,Page # Spec house yes ❑ no Lot lines identifiable ,Ayes ❑ no SYSTEM - MA][NTEN AN CF 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, joumcyman 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoniuig Office within 30 days o he three year expiration date. SIG TUBE F APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pro describ d above, by virtue of a warranty deed recorded in Register of Deeds Office. 8 /a�l�iq SIGN "LURE APPLICANT DATE *` * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. `* Include with this application: a stamped warranty deed from the Register of Deeds office a,copy of the certified survey map if reference is made in the warranty deed • 08/23/99 MON 11:55 FAX 715 386 4887 REGISTER OF DEEDS Z002 wi_ 1450PAGE5 "2 +6ogo2a. STATE BAR 01 WISCONSIN FORM 2 - 1999 _ _ KATHLEEN H. WAL.SH REGISTER OF DEEDS ST. CR©IX CO. WI This Deed, made between lltiebae_i A. Salmon and Deborah K. RECEIVED FOR RECORD Salmon, husband and wife. - - -, VARRMM DEED Grantor, conveys and warrants to EXERT R M & G. Inc., a Wisconsin Co rporation. LTRT COPY FEE: CORY FEE: TRANSFER FEE:. 91.00 RECORDIRS FEE: 10.04 PA ,. 1 Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin Re�'o din Area (The "Property "): $ Ta� 032-101-50,500 FEE Parocl Identification Nutuber (PIN) This Is not homestead property. Part of the Sl;t+'114 of NW 114 of Section 11., 'Township 31 Nortb, Range 19 West, St. Croix County, Wisconsin, described as follows' Lot 5 of Certified Survey Map filed April 24, 1991, in �Iol. 11, Page 3243, Doc. No, 558374. Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of August, 1.999. * * Michael A. Salmon i 'L 1 5, �r +— * cborah K. Salmon AUTHENTICATION ACKNOWLEDGMENT Signatures) Michael A. Salmon and Deborah K. Salmon, STATE OF WISCONSIN ) husband and w ife —. - --` -- County ) Personally came before me this tray of June , t rnieatcJ this ;lay of August, 1999. 1999, the above named authenticated Y g _ to me known to be the person(s) wlto executed the foregoing instrument and * Kristina Ogland acknowledge the same. TITLE: MEMBER SKATE BAR OF WISCONSIN , (If not, _ Notary Public, State of Wisconsin authorized by § 706 Wis, Stats.) My Commission is permanent. (If riot, state expiration date: THIS INSTRUMENT WAS DRAFTED BY Attorney Kristin Ogland Hudson, W1 54016 (Signatures may be authenticated or acitnowledged- &)th are not necessary.) "'Names of persons signing in any capacity should be typed or printed below chair signatures /0 � WAItttAM'Y DEED ,S7•4TE DAR OF WISCONSIN FOILM Nu. 2 - 1998 INFORMATION PROPESSiONALS COMPANY FOND DV LAC. WI 800.655 -2021 Received: 7/30/99 9:29AM; 7152473622 -> EDINA REALTY HUDSON WISCONSIN; Page 2 07/30/1999 08:35 7152473622 REMAX TEAM 1 REALTY PAGE 02 CERTIFIED SURVEY MAP ' Located in part of the SWJ of the NWj and in part of the 821 of the NW} Of Section 11, T31N, R19M, Tolr5/ o! 3oner0dt, St. Croix County„ Mieconain. � w Career of AIWA LOT : 44EA LOT 6 7.etlan 11 .4.00 Acres (1741,k37 $9. R.)' IAe. M/11 N: . J {.12 Aare$ 6171.007 sq.;Ft.) Ina. PA ' 9.57 Acres !!67,378 Sq. ft.) Ewe. AN 3.95 Aorea (171,9N Sq. Ft.) Ga, U11 r �= 'AREA LOTS M r 4.20 Aar" (1111116.09 Sq. h_) Inc. 9J11 = 9.99 Aare. (179,990 50. Ft.) &a- no ime or as Mw v e� �1 SM - 0 - E 11113-Y6 � colon wa or *9 KIM OF M 001/1 >f �82.97..9T 239.90' 710.79! i8 1.00.7•• e LOT 5 LOT 6 �« A� k LOT 7 w 12.20 Aeroa Ino. A/Ir a Y _ 533,071 Sq. Ft. 511 ros EX6 9/Y e 1Y0.00' " g r'. « II Alawleam CC4ufty Sentlen I �.r! e' 1 Iron Pipe on ant. ly (JI CVVVJIIII �t o � t, 1.S01b6/ilraer f eet. 10 5� 1" feet Rwiry eetaaea I • r nr LO,T 4 1116 leo ; A_ 712 _ ' 400. 3i' 1 ZI - - - fM•26'02•'E 1403.03' - - li I • 1 - LO 2 CL 7 . T - 'LOT 3 1 c LOT I 5.74 Aar" Iao. ON 5.70 Aare. Ina. M9 7.96 Aorw Ina. &V 8 NI !30,002 sq. Ft. r $ 171.016 sq. Ft. y 947,E,9 !a. Ft. En /11 r 011 5.00 Aar.. o. A 3.00 Aare* Eaa. ■/II .`.�� F 7.32 Anse. ERIC. )"j I 217;607 Sq: ft. 277.6" sq. Ft- .. 327.717 Sq. Ft. >1 LA s3aar 43z.SOr l4".s ?• � � 1 I 399.0' 'k Corner or, 1 1437.52' ,..,ton 11 I ( I Z.1 of /Ia ae U1 ; Si1EM LANDS o Al�� Caanty Section Maarawt Faaad e I'• . 24' Iron Pipe cat, owl0in6 1.691bA/11aeor foot ....... 100 foot raadnay aetbaek 11" Im Joe plear," 110 Cty. ad. .1. Scala in Peet 1" 2001 seaoraet. III 54M 0 iab 2 0 TM a Inatranrnt drafted by Mlel,.el Erlekaea Job Me. 97.34 ��reGk�bn s ; RwLj 35N . Awn • CA f'{1LUS 40 1.O L we-st to aq M T 1A r( and Iol O lrkgKt . SANITARY PERMIT APPLICATION S afety and Buildings Division Vi si�ons i n 201 W. Washington Avenue In accord with IL HR h I m. d P O Box 7302 Department of Commerce R 83 05, Wis. Ad Coe 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 a It ry Permit Num er y ou p rovide may be used for second 3 f T Personal information y p y ry purposes Check if revision to previous ap lication (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location 1/4 ) 1/4, S T , N, R E(or e � Z Pr perty Own r' ailing Ad ess Lot Number Block Number City tate Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check 6n TD State Owned it Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF ; Ill. BUILDING USE (If building type is public, check all that apply) Parcel TaxNumber(s) 1 ❑ Apartment/ Condo ' 1 e -2 - 3 27 - �:;- 4 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 online B, if applicable) A) 1. (a New 2. E Replacement 3. E] Replacementof 4. E] Reconnection of 5. E] Repair of an ______System -- - - - - -- System -- Tank Only Existing System - _ Existing System ----- - - - - -- - - - - -- B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑'Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit , 43 ❑ Vault Privy 14 ❑ System -In -Fill Es 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. /�ch) Elevation Feet =Feet VII. T ANK in C apacity Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank 4 /,: ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ ❑ 1 ❑ I ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for install ion of the onsite sewage system shown on the attached plans. Plumber's ame: rin#y. Plumber's Signat�yte: ( tam MP /MPRSW No.: Business Phone Number. '!/ � -7 K UH6 tier's Address (Street, City, State, Zip Cod�p' " , IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved anitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) X Approved ❑ Owner Given Initial [I^L Surcharge Fee) Adverse Determination I I X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, owner, Plumber Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue Wisconsin In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 0 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 anrt ry Pe�rimitNumber Personal information y ou p rovide may be used for seconds � T sa t y p y second purposes Check if revisio to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location 1/4 1/4,S 1; T f , , N, R E (or) W Pr perty Owner's Mailing Address ' ' Lot Number Block Number Cit , State ' Zip Code Phone Number Subdivision Name or CSM Number ( ) 11. TYPE OF BUILDING: (check one) ❑ State Owned it Nearest Road El Public 1 or 2 Family Dwelling - No. of bedrooms O Iow of t % 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an System System _ Tank Only Existing System ________ Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑'Seepage. Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Sefepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill f 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. /itnch) Elevation f a c Feet r Feet i Capacit VII. TANK in Ca allo Total # of Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank �,� ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamberl I I ❑ I ❑ I ❑ I ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT i I, the undersigned, assume responsibility for install lion of the onsite sewage system shown on the attached plans. Plumber's ame: nnt) ., Plumbers Signature (�OStamps) 7PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): J IX. C U TY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater te I ssued LIssui Agent Signature (No Stamps) } , Surcharge Fee) Approved ❑Owner Given Initial r a I Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: i SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERS141P CERTIFICATION FORM Owner/Buyer Mailing Address I'31s'\ AVVA � 'T�l�- 1'� wO -, J yv l Property Address A2, (Verification required from Planning Department for new construction) S'N- -t- City /State Parcel Identification Number 0 — LEGAL DESCRIPTION Property Location _ ' /,, ' /,, Sec._, T��N -R I�_W, Town of 0 hnAY Subdivision , Lot # Certified Survey Map # 5'�S :3 , Volume /� , Page # Z2 �_Z 3 Warranty Deed # Q , Volume 'G ,Page # 50 2 Spec house J9. yes ❑ no. Lot lines identifiable ,kyes ❑ no SYSTEM .MAINTENANCE "Impro`per 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. Uwc, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days o he three year expiration date. I­ A - A IL wv,_ - R_ SIG TUBE F APPLICANT DATE: OWNER CERTIFICATION I (we) certify that all statements on this form arc true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pro describ d above, by virtue of a warranty deed recorded in Register of Deeds Office. k 1w_2 9 /,g4/9q SIGN TURF APPLICANT DATE « « « « «« Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.** «• Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed 77- -COX y i _ r � - a,� WisGorisin Department of Industry AND SITE EVALUATION > Labomund Human Relations �, ° ` i i Page of Division of Safety and Buildings '� accordaiW 'th s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not ess an 8 W�tNfabfies in size Ian must County include, but not limited to: vertical an ontal reference point (BM), dire ion and s;�/ percent slope, scale or dimensions, n rttr rro C Iocatign jqfj�stance tq nearest road. Parcel I.D. # ST COX 1 APPLICANT INFORMATION - le dge pr at' l Reviewed by Date Personal information you provide may be used sdc aty purposes (Privacy Law 15.04 (1) (m)). Property Owner / Property Location �� Govt. Lot 1/4 1/4,S T , 51 N,R ,E (ortf Property Owner's Mailing Ad toss Lot # Block I Subd ame or CSM# I Stat Zip Code Phone Number ❑ City Village Town Nearest Road rA New Construction Use: Residential / Number of bedrooms Addition to existing building I ff Replacement ❑ Public or commercial - Describe: Code derived daily flow �8-- gpd Recommended design loading rate bed, gpd/ft 2 trench, gpd /ft Absorption area required bed, ft ft2 Maximum design loading rate 7 bed, gpd /ft trench, gpd /ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /site considerations Parent material Flood plain elevation, if applicable 41 ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding T U = Unsuitable for system [MS Liu ® S ❑ U 1S ❑ U [9 S E) U El 21 u EIS � u SOIL DESCRIPTION REPORT Borin # Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Con Color Gr. Sz. Sh. Bed , Trench Al Ground elle�v. , Depth to limiting �in. Remarks: Boring # Ground elev Depth to limiting factor pin. Rem rks: ` CST Name (Ple Print / Signature Telephone No. Address >�U D CST Number J s :r UNPLY TT ED D)NDS �, r ..,, II II 0 C.T 'H. I 0 rl V.7 EST LINE OF THE NW I/4 N — �Nb0 035'00 "E N a N00 °3,5'00 "E a , N00 °35'00 "E 746.27' rt 578 .71' 361.00' 385 ' L L • — � p 7 385.43' I to 328.00 I T ( F N00 ° 35'00 "E �+" 713.43' g ;t � 0 g Co rt � o r 00 aD .. IC 0011 f >> ° >> r N ,— Co z o O 0 C' o ^' I- P. rn w o O o I ' = W m IY - k rt 0 0 o In o '1 —I V_ 1 — 0 tD IM Co 1C fi E c k +�- 33! 33' - o � 00 rn N rt �j 328.00' 387.70'' W r> w r 0 M Cn 361.00' 715.70' a ip n� ;0 w o N 10 0 C � C N00 ° 35'00 "E. 748.70 O. w o n n o �► O N N N .. W CD 0 0 (7 N O O N CD CD .. Ln M tA C - 33.00' 716`.92' w w 4- -4 w.. ::1 (-.. o N00 ° 35'00 "E 749.92' r^ o W w V �T1 �! .� -�I M —I N n No v) w m •n -n m rt• — n ° Co W tr rr rt tr P- .. ,. 0 M r r r 7 II �r C Vt -+ .'O .'0 A .'9 7 0 ° I� no coo En M 1.0 _ I O � c> r i V 3 Ct T m m- Ct 3 �I rn_ .. ....., A : A I w. .e..y ... . � w it � M �C u, w 7 CD ZE CL ID �. , IU) 0 0 - I ' • N (A 01 R 0 a 0 O Fh Cr — ' Co Y M p.., ,. A O V S N N 0 CD — 33.01' 720.54' 0 -mi S00 0 25 1 22 11 W 753.55' i et C r A Pr Z AR - L Ifs V. 598, PC. 531 0 0 0 o' f W P 0 0 m O o > r a z O 0) X O C C='j Co N C EI G7 NNC.. O C t a 5. Z oco I C) K � — K3 rJ MSC O 07 00 A CL to •a M 7 F ,� :K a 0 `� Bearings are referenced to the 0 o <n west line of tYfe 'NW%' of Section E Ln ° 11, assumed to bear N00 ° 35 1 00 "E. V* Of 0 ' A 7 0 7