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CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner ��T Property Address �-�-� City/State �'��0� Legal Description: Lot _lam Block Subdivision/CSM # t /a ,L t / a , Sec.,41, T N -RAW, Town of /. ti PIN # O , �z SEPTIC TANK — DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer �� � Size ST/PC, � Setback from: House � Weli' P/L Pump manufacturer Model Alarm location i (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM 121 Type of system: Width Le� /� Number of Trenches ac Setback from: House�'� Well P/L Vent to fresh air intake �s ELEVATIONS r Description of benchmark Elevation Description of alternate benchmark 11, er Elevation Building Sewer ST/HT Inlet ST Outlet o PC Inlet i PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines Bottom of System p Final Grade O O ( ) Date of installation �/ ermit number State plan number a��� f� Plumber's signature ��- License number � Date � �f Insp ector CocVlete plot plan � I 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 VIEWo of 6 49?- � GN -1� INDICATE NORTH ARROW VWisconsin Department of Commerce Count PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST CR IX Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 338858 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: TART, RAYMOND SOMERSET CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: 4d. oar f /00,00 r. r "_ . 6 .. '�'.. >....� 032- 1093 -10 -000 TANK INFORMATION IF ELEVATION DATA A9900105 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Z ' �U� 00-. Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet �' 9/, 3 ' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic �0' ,sU' 'l15 r 7 C NA Dt Bottom Dosing NA Header / Man. i.�`T qa4 Aeration NA Dist. Pipe Holding Bot. System 13, g 9, 0 , Q PUMP/ SIPHON INFORMATION Final Grade Manufacturer ✓ Demand Model Number GPM TDH Lift L oss rictio System TDH Ft Forcemain Len g Did. F f Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 10D DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of a CHAMBER Mod Number: Syste • . II °� 6 0 N11 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 ❑Yes [] No ❑Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 33.31.19.437F,NW,SE 465 184TH AVENUE — LOT 12 I . i Plan revision required? ❑ Yes ❑ No Use other side for additional information. I Z (a �SBD -6710 (R.3/97) Date I sp tor's Signature Cert No Safety and Buildings Division ITARY PERMIT APPLICATION 2 1 Washington Avenue VLconsin In accord with ILHR 83.05, Wis. Adm. Code Box Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County k than 8112 x 11 inches in size. _ yrp • See reverse side for instructions for completing this application State Sanit ry Permit Number 33 Y. Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Own ame Property Location F , /-t . h f 14 1 ra, S T , N, R Property Owner' ailing Address Lot Number Bock Number City,state Zip Code Phone Number Subdivision Name or CSM Number II. T YPE N BUILDING: D : (check one) ❑ State Owned 0 Cit Nearest Road Village Public 1 or 2 Family Dwelling - No of bedrooms own OF III BUILDING USE (If building type is public, check all that apply) 'Parcel Tax Number(s) �j %j. ;64-19- 3 V 1 ❑ Apartment/ Condo Q 1� lv / % /�e5: 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 VtReplacement 3_ [] Replacement of 4. [] Reconnection of 5 E] Repair of an ------ System - _ - - ___ - `'System -- ---- -- - -- -- Tank Only --------- _---- Existing System -------- Exlstigg 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 54Seepage Trench 22 ❑ In- Ground Pressure , 42 ❑ Pit Privy 1 ❑ Seepage Pit � 3 X 1b('D 43 E] Vault Privy 14 E] System -In -Fill X P, c VI. ABSORPTION SYSTEM 1. Gallons Per Day 2. Al�U 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade � Reqt �' �� _ (Gals/day /sq. ft.) (Mi /in ch) �`Y Elevation gf - 6 Feet �?. Feet VII. TANK INFORMATION Manufacturer's Name Prefab con steel Fiber Plastic Exper. Concrete structed glass App. 1 i Septic Ta ,. �J ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I I ❑ ❑ ❑ I ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu is Name: (Print) Plumber' gnature: (No Stamps) MP /MPRSW No.: Business Phone Number: P5 er'sA Tres (Street. Zi Code): !� C� 7/ � r�-C /72 49 , 1 7 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing A ignature (No Stamps) [( A roved surcharge fee) q Ap proved []Owner Given Initial ac -S UU �/ � Adverse D etermination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber IrLV I VLAN PRO JECT _L�ZZ'me, /? ADDRESS : �c%y�e, ��✓r - ���t /W/45 1 /4 /Sj�/T N /R/ W "TOWN l `,, COUNTY f�rG• MPRS Byron Bird Jr.. DATE BEDROOM CLASS PERC_ CONVENTIONAL _KIN -G UND PRESSURE o'l -z 7 CONVENTIONAL LIFT MOUND HOLDING TANK SEPTIC TANK SIZE FT TANK SIZE DOSE TANK SIZE "HO DING TANK SIZE ABSORPTION AREA PERC RATE _ BED SIZE ► Benchmark V.R.P. Assume Elevation 100' "91f Location of Benchmark * H.R.P. 0 Borehole Q Well Scale Feet 0 Per Hole System Elevation er A —- 3 q � ao�G AI 15- r� I . 30 l qt` to i i r:. Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page 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 J _ o ! �G percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Rey;ery b Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot kv 1 /4, L 1 /4,S 3 T N,R E (� Property Owner's Mailing Adclfess Lot # Block# Subd. Name or CSM# 6 /a? // / 4� City State Zip Code Phone Number ❑ City ❑ Village C Town Nearest Road ❑ New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement Public or commercial - Describe: Code derived daily flow 4 gpd Recommended design loading rate = bed, gpdAL trench, gpd /ft Absorption area required gi bed, ft ,3 trench, ft Maximum design loading rate bed, gpd /ft i trench, gpd /ft Recommended infiltration surface elevation(s) r ft (as referred to site plan benchmark) Additional design /site considerations Parent material cc G. i2 / 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 S❑ U S❑ U S❑ U ,Z S❑ U ❑ S U ❑ S ,�U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground l l ev � Depth to limiting factor p Tin. Q Remarks: Boring # Ground elev. - ) I z/ it. Dept to P limiting 8 factor -lee in. Remarks: CST Name Please Print) Signature Telephone No. Address Date CST Number �� ��y�SOIL DESCRIPTION REPORT PROPERTY OWNER Page of 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 Ground elev. Depth to limiting factor �0 in. '1 Remarks: Z /ing # ........................... .......................... .......................... .......................... .......................... 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 # I I Ground elev. ft. Depth to limiting factor in. Remarks: Boring # i I , Ground elev. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) Soil Test Plot Plan Project Name ll u r Byro Bird Jr. Address —/ ", '601n pr Ste/ l S�a��� CS Lot - ----- Subdivision ---- ------- Date LI&I /4 1 /4S�� � N/R ,fW Township F1 Boring Q Well PL Property Line County jf. G ro BM or VRP Assume Elevation 100 ft ;a 6 P�a System Elevation .7 $� * H R P Same as Benchmark 1 I r y � � �/.� ,•� yel p,, �� w a o A ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at: Section, T N, R /JW, Town of Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: _l,(J,l /�G �Q,�ur� s�- �•� lT��f Did flow back occur from absorption system? ,>�, Yes No (If no, skip next line) Approximate volume or length of time: gallons Iv minutes Capacity: Construction: Prefab Concret Steel Other Manufacturer: (If known) :� --� Age of Tank (If known) .: 02 (Signa e) (Nam Please print c2, a, 5 Z (Title) (License Number) Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wis. Adm. Code t for exce ( P inspection opening over outlet baffle). Name Signature d " � P/MPRS _ z: ;9 5� �� V ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address ? l� (Verification required from Planning Department for new construction) City /State > ly, ef Parcel Identification Numbe LEGAL DESCRIPTION Property Location 1/4, 1.� ' /4, Sec. T,_,[_N -R_Z �W, Town of ^ SF rn s Subdivision _ __ , Lot # Certified Survey Map # ? Volume / , Page # �� 3 S! g Warranty Deed # � �' 7 i �'' � . Volume � �` . Page # Spec house ❑ yes JS no Lot lines identifiable ❑ yes 0 no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days o year date SIG9A OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the propertydescribed above, by virtue of a w anty deed recorded in Register of Deeds Office. r SIGNA OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed MOOS — W.r*e+rty Oe+1. 1e►f1v114et p Joliet TvwrtwtrA Form Me. S. If *00000 weft h pewvetra "i" &DOW flit). Adw 327706 x'525 P�ti� i� � US �ri�tritUCt, .Ifutlr tltix ......22.'1'3.. dwly of ua]t 8175 Hnlresb�..his w±!e. I of the County of ........ st..._. C :r :..L.A.....__.. ........:................_..and staff of.._......:d.scnZS'._n._.__ ..... _.... ., Iwtrli *d_ I� 44 { of the first pArt, and ........_. imond .a...Tart..ar3..3L iron .Tart. husband aru.1...C-to. ..... ... . ....... ..... - § ........ ... .. .. ... .... ................... ............................. .. .. .... ....... ... .... .. ....._, of the- t'oil of .............. tend State of.. iTnasot& ...... .... /rtlrthe-xof the xrtY►Mel /mtrt. E UitAIM111*0111. Thri1 the sniff pnr•t..... the fi rm /ctrl, to rwnxidrttirlion of Nee xnnr nf ................_ s 0� 40.11 83... and.. oth� r.. eoe ....: , }...YSl�R fie.. eone+ �l.3 ►+� .} , . � — Jxl /.1 I it Y. fa._ -they ._...._in hrtnd Meld hy- Ile,• xoid ltrth•firx of the xrrrmd Inert, thr rrvri /rl n'hrl'rnf ix hrrrhy wrkworl- I relird, elf* ..................hrrrby (hart, llfirgain, Sell, (tnd convey nnfo the weid /xu'firx of fhr —tomel lurrt rfx piinl tt•manty .it'll melt 019 Irn,intx in rvfnoton, !heir axvibFnx, the .'It rivul. of .furl /xeTfirv, marl Ihr hrirx rtnd rlx- ( sign, of flip vnrrirelr, Former, rill ►hr trurt..- ......or par,-e of /riorf lyij #a furl Grins; in Ihr t'outtly of _._�t.e...rrro x.........___ ......._ .............find ,Stole of .fXiA �#, rlr«•rilrrd ax futluwx, fu - sit: 1 W1 scon sin s Tax :fey x _ Ct10:2 as 0 Oas; z cD1_'.c:_ J:: Sa1 5 :t =0:2 3'1 " h n c 31 ° 07t2u "^ of E 1 Z:.@ �^f r �.r 1 — :Y�J ° .:G ., 1745.02 fee t0 : coint of .;77.0 'eat; 585.1 feet; ' +t 012 3-Y _ __ -: 2e Of p oi 1J OrosaG yy tcti ✓:: road 376.91 feet; J ! ... -.. __v.L ✓1 r 'SJ ' X3 573. la C�iL :.o p nt of cy nnin t f2tGISTERS OFFICE VE ST. CROIX CO.. WIS. fro )babe anb to *o the libame, Tn_6ether ht'ith rt// the hrrrvlilrerornl.r rend nliptirletlrtttr•rx there- ' trnln IN ln,+ it' if2 011 in frtoyt+•i >e uplN'r•lfirtinQ, to the said lxtrtto.v 01f' fhr• woustl pivf. their o. +.,idmv, the- . +rtr- 141+ 1• "1 "fill prirtirs, rind flee heirs rued t of the xorviror, Forrr•rr•. Ihr solid /xu•lirx ref the ,rr•nnrl /xu•1 ffAirt_ ,+, jriitol trvoritot, flood pilot as tenant, in contntun. .101,1 the xmll i'1 A r: u71cnnr`, h g. ife...... /+rip.,, r.rr,v+l,o•, tr nil m/ntioi,hvriwx the_.. ... ,,,r,01„01i with the .mil lwrlics „f'tho ,t'rurrrl /Nrrt, ttrir,r,xi. the , orriotri of xreitl lantirn, ft'rl thr lrrir•v loo,/ f/' the corriror, Hurl_ - _feel! sri:rvl in %r,• to/ the- hrrod, ,sod preitti,r•x trfrtWnreiel and id ✓e orNNl r•ii;hl to .,eel rtnd rwivey the , fort tit nueru+rr ind file to, rtpwrttid, arttl that flu• xrrrnr are leer' ftYt01r illy ire rrl 01tlMrUer•rs, I � t ♦ A .lo,l the oth we lion o;fitr,vl rend �;rfrttvd blonds ,end pre,tti..vrv, in Ihv gh+iree .end lxncr %rh`Tr' jxixxr'x i of fire .fill p,rrfir, 'Al the .r,vmd purl, their f.c.,i dn.v, the- survirwv of -,rill lxn -firm, rend the heir, rtnel tex4gnx of the ,u)- vir rr_srri01.t loll /Nrvntt, 7,110.111 11rf rlait.,imp nr to lfi01r the• whsle nr ,fort part thrr -rof, xfrhjrr•t It, in- rrin,hr „01rr,, it ,,nov hrtrti01hrjnrr nrrnti t/te .sfiol poor, of Ntr fir.! lrrtr't tf•i/l Il'ft•rrurl report ltr•- fr rod . I i i J n Testimonp Mbered, flee ,etid lxtrl. ttf the lint lam lilt �_...hrrr+ +noel wt..S.hae.i r - • - 1 h of (1 Mo ,Iffy .miff rjr it first al»rv ri i In 1're. u% v �� J • r y f. y _ - f � Within �gtex"I � �E Os _ 22nd .,� :. ► ol.. MA Y ...... ..._...:.. _ • OZ, ie Me. Geor a d Ho2a�esb ' filad�rs ]Cr ie wss lasowa to be &" rsoas -- dolerlbed in, a" who O"Cuted the forefoiq instrument, .,._...._..�. _ ._. ..; _... asd acknmvledled that.. _t... As sans@ as_ S�e Jhsa oat OW deed .. ���•' .r°tar� .YiRJ►. oMsM `tea 44 Xp canawa/ssion � M.w.w.�aMs MOM 7b Mal w ; k - i i I C = Q N in Y c Cam` W� 3 �" R ' .. Ui is 1 CA r — ie. C 1 TOWN ROA I SOUTHERLY RIGHT- ( 2 - _� EXISTING TOW ROAD fp S88 895.09' D 6' 818.18' 376.91' - - -- 1 33' ° 0 E 1/4 CORNER 2 SECTION 33 T3114 RISW 33! O I o N W T/- SE 1/4 CP a 10 13 W 12 I I ` Z 3 6.78 ACRES * o 5.03ACRES ; W o 1 ti - 0 0 1 I� 0' h (6 h N N H 0 0 h ti d t IQ Z Z IA N O EASIg 1 - LINE N 33' W POINT OF 33' a00 � BEGINNIING Zo\ gy p., o �6 6' 9 462.61' 377.00' N89 30 W N 89°30' W 859.61' 1745.02' W ST SCALE EAST LINE OF SE 1/4, SEC T40N 33 200 0 100 200 SE 1/4, SECTION 33 SURVEYED FOR: GEORGE HOLCOMB R.R. #1, STILLWATER, MINN. 55082 DESCIRPTION A parcel of land located in the NW1 /4 of the SE1 /4 of TRUE Section 33, T31N, R19W, Town of Somerset, St. Croix County BEARING Wisconsin described as follows: Commencing at the E1 /4 corner of said Section 33; thence S1 ° 07 1 20 "E (true bearing) 1320.00' along the East line of said SE1 /4; thence N89 1745.02' to the point of beginning; thence N89 ° 30'W 859.61'; thence N1 ° 40 1 W 596.79' along the Easterly right -of -way line of an existing town road; thence S88 ° 14 1 20 "E 895.09' along the Southerly right -of -way line of another existing town road; thence S1 ° 45'40 "W 576.81' to the point of beginning. I certify that the above description and map are correct and that I have fully complied with the provisions of Sec. 36.34 of the Wisconsin Statutes. FRAN CIS H. OGDEN S -882 MAP NO. 73 -142 DATE: February 17, 1975 ( LEGEND Ir SECTION CORNER MONUMENT. 0 1" X 24" IRON PIPE FRANCIS H. 9 10 WEIGHING 1.68 # /LINEAL FOOT. OGDEN * fl { s -882 F/l ED RIVER FALLS, 4 19 75 N A%ft Deed Volume .' Page A3