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Home My WebLink About040-1237-50-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner �� r � ✓� ��ti �S'�'`�n Property Addre s 1 s-, e 6 City /State � 46 Legal Description: Lot 611 Block Subdivision/CSM # /�� /a /a, Sec. �, T � N -R , ? W, Town of %re PIN # U�`� - SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: r Tank manufacturer Ldj--c ks « Size(0PC / tea/ Setback from: House 24 Well P Z� Pump manufacturer IVA 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: Width ✓ Length 1_ 7 Number of Trenches Setback from: House _la Well P/L 'L' Vent to fresh air intake ELEVATIONS ssa' Description of benchmark + o��art a Sim �� S� �'�� Elevation /-Id Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ST Outlet 65 PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover 7-1 Distribution Lines ( ) Bottom of System 7 ( ) Final Grade Date of installation y' 115/ Permit number 5 .3 P State plan number __--- Plumber's si nature 4nv - `- c. ,- License number Date Inspector Complete plot plan � r 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 VIEW D `U' i Q l I' i c� J ,o 3!' r j INDICATE NORTH ARROW Wigconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPermi IX Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)]. 3389 6 Perrpjtk piligVff, IN, JEFF ❑ Cit [1 Town of: State Plan ID No.: CST BM Elev.:- N ��11 Insp. BM Elev.: BM Description: AR Parcel Tax No.: a� , D ov , (,mss -� ,:�Q¢ _ s'!� ��,,,yi 040 - 1237 -50 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic 6m Benchmark Dosing Aeration Bldg. Sewer 4 Holding St / Ht Inlet �Z %,� f . o TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air i to ntake - ROAD D . Air Septic o25 8 f NA Dosing NA Header/ Man. Aeration NA Dist. Pipe arv�. 1 51, Holding Bot. System (2� 7.1" Z,a Z IF*`9 F PUMP/ SIPHON INFORMATION Final Grade `mfr 4 Co , S C/ S' Manu 5�1 a rte r �Q r z 6 . 3, 2/ Model Number GPM TDH Lift Fr Fie TDH Ft oss Force Length Dia. Dist. To well SOIL ABSORPTION SYSTEM 5 Q� K-j5- Width i I Length No. ches PAT No. Of Pits Inside Dia. Liquid Depth DIMENSION 3 (0.2 f T n DIMEN IONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Ma� f �ctyr r' _SicQo�yc` INFORMATION Type O �+ , r - CHAMBER M e - Nu er: _ System: C01W + 0 - OR UNIT C to DISTRIBUTION SYSTEM Header /Manifold (.� u Distribution Pipe(s) x Hole Size x Spacing Vent To Air Intake Length �� Dia. Length ia. Spacing $Q t SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) I L0 2 C 8 A , T�ION TOY 3. y2Q8f 1 C19 > , N 3� W 614 _OAK CIRCLE - COUNTRYWOOD LOT 64 ta— 4t Plan revision required? ❑ Yes S No Use other side for additional information. j Qb SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ~ Safety and Buildings Division Vi sconsin SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue I n accord with ILHR 83.05, Wis. P O Box 7302 Department of Commerce + f° . 1 Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the Sys tn; paper not unty t rf than 8 112 x 11 inches in size. ` ,X+� c • See reverse side for instructions for completing this applrcati6n � � Sanitary Perm UNu b Personal information you provide may be ecl for seconda purposes Sr 0 { k if revision to previous application [Privacy s. 15.04 (1) (m)]. y /(1 �aj Plan I.D. Numbe r 1. APPLICATION INF R MAT - PLEA E INT AL 1 33MIM A N Property O er Name N Lo I /4 1 T ,?$ , N, R J9 (or Property Owner's Mailing Address a Block Num er City, / St to Zip C de Phone Number Subdivision Name or CSM Num r 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ C t � ge Nearest Road ❑ VII a P Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town OF �! III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo dA4- 1 23 - 7 §° 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. ®, New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System ________ System __Tank Only______________ Existin _SX tem Exis tin�System B) A Sanitary Permit was previously issued. Permit Number 3,381) Date Issued /a 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 E] Seepage Pit 4— 3h 51p x 7 43 ❑ Vault Privy 14 ❑ System -In -Fill j� „l y ,alt .h (f , 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. /inch) �/� Elevation V115) �'' Z �' 7 Z 8910 Feet � . �o Feet Capacft VII TANK in g allons Total # of Prefab. on Fiber- Exp er. INFORMATION g Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App New Existin strutted Tank Tanks I Q eptic Tan or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ I ❑ I ❑ ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu er's Name: (Print) Plumbe 's Signature: ( stamps) MP /MPRSW No.: 71 Business Phone Number: 71 -- 7 — 32 Plum is Address (Street, City, State, Zip C , I ” ll&%,p ��/ L /y Z IX. COUNTY/ DEPARTMENT USE ONLY ❑Disapproved Sa �tary Permit Fee (Includes Groundwater D ate I ssued Issuing Agent Signature No Stamps) Ap Surcharge Fee) Adverse Determination pp ❑Owner Given Initial � , CM l X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11I97) 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 I 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. JAI JOB TIMM EXCAVATING SHEET NO. - OF Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED By d 4 r DATE (715) 772-3214 (715) 386-5443 MPRS #3224 W1 MPCA #696 MN CHECKED BY DATE SCALE .—T-4--y—r—r- 7 - 7 - t - T -1- ..... -4 ..... 4-- 0.4 1.1 T 9 .......... ........... . ......... ........... i .......... . ...... 1 .... ........... .14.1 .4 j— tol— ........... .......... I.— - - ***. - ..... 44-4-1 .......... ........... .. . . .. . . ........ ---------- ............ ..................... . ...... ... . . f 1 z it ............. ......... .......... ......... A .......... bd T* .......... ........... ........... ........... Of A VT ........... .......... -F7 .......... h --Tt- DL ............. AAW j— ........... .............. 01.11111-11� ......... ................... ........... ......... ... ............ .................. ....... ....... ............ ........... . ............. ........... .......... ............ ........... ........... .......... ............. .......... .............. ........... .............. .......... .......... - -------- VIA PRODUCT 205-1 Inc., Groton, Man, 01471. To Order PHONE TOLL FREE I-800.225-M Page of 3 '.Wisconsin Department of Commerce SOIL AND SITE EVALUATION 1 r Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Certified Soil Testing Attach complete site plan on paper not less than 8'/ x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, a I I d distance to nearest road. parcel I.D.# APPLICANT INFORMATION - PI sop f�t al Ih on. 040- 1237 -50 - Personal information you provide may be used ` ary , ulrp t (PrivWLLi . 15.04 (1) (m)). Miewed'By Dal W 1/4 SW ll4 3 28 - Property Owner ' '� � '' ; _, roperty location Breitenstein, Jeff f , Vt. Lot N S T N,R 19 W Property Owners Mailing Address t # Block # Name or CSM# 614 Oakley Circle ` S �f*yx 1 !ubol. Country Wood City State v C City ❑Village NTown Nearest Road Hudson WI IOW Troy Tower Road New Construction Use: Rest oaf / tlrt$>�r rooms 3 [- ]Addition to existing building - Replacement ❑ Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate -7 bed, gpd/ft' • trench, gpd/ft' Absorption area required 643 bed, ft' 562 trench, ft' Maximum design loading rate .7 bed, gpd/ft' • tr ench, gpd/ft' Recommended infiltration surface elevation(s) 88.0 ft (as referred to site plan benchmar Additional design / site consideration i nstall 2 - 2.7 'x 56.25' Sidewinder, hi- capacity 'turtle- shell" trenches Parent material sandy /loamy outwash Flood lain elevation, if a livable NA ft S= Suitable for system Conventional Mound In- Ground Pressure AT Grade System in Fill Holding Tank U= Unsuitable for system X❑ U S C_I U X S❑ U X S L) U S U ; 1 S I Horizon Depth Dominant Color Mottles Texture Structure Consistence] Boundary Roots GPDIft' Boring# ! in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0 -7 l OYR 3/2 - sl 2 f sbk mvfr cs 1 f/m .5 .6 2 7 -20 7.5YR 4/4 - sl 2 m sbk mvfr cs lm .5 .6 Ground 3 20 -30 7.5YR 4/4 f2d 7.5YR 4/6,5/3 sl 2 m sbk mvfr cs lm .5 .6 elev - -- - - - - -- 94,3 ft 4 30 -79 10YR 3/6 - Is 1 m sbk mvfr 1 cs - .7 .8 Depth to 5 79 -125 1OYR 4/4 - s 0 sg ml - - .7 .8 limiting _ factor - - -- �� - - -- — -- _. I _?_125" _ Remarks: horizon 3 mottling is typically vertical and may be root mottling; t' rule applies w/ system installed below mottling into permeable - is - & s; horizon 4 tias inclusions tOYR 3/.4 s (O; sg; mt) occasional gr, cob & st - below 30" 2 1 0 -15 IOYR 3/2 _ s1 2 f sbk mvfr cs 1 f/m .5 .6 2 15 -31 7.5YR 4/4 - sl 2 m sbk mvfr i cs lm .5 .6 Ground 3 31 -38 IOYR 4/4 - sl 2 m sbk mvfr cs 1 m .5 .6 elev 94.6 ft_ 4 38 -45 l OYR 4/4 f2p 7.5YR 5/8,5/3 sl 2 m sbk mfr cs - .5 .6 S Os -. _ f , ml - - lim iting 5 45 -124 l OYR 4J4 - 7 j 8 Depth to - - - - - g factor - �q �1 j I >124' - - its - - -- -- t I. i r Remarks: occasional gr & cob & very occasional st in horizon 5; mottling is not vertically oriented as in B -1; P rule applies w/ system installed eepinfo petmeahle s s - d - �------ - - - - -- ___ - __ - - -_ _ ._ CST Name (Please Print) Signature: ��-�- Telephone No. Henry F. Grote 715- 665 -2681 _ Cerfi$ed Soil '1`est'iri --- - - - - -- - - -- - —__. _____.__ _ _ __ - - -- _ Add ress g Dt CST Number Ref # P.O. Box 57, Knapp, WI.54749 6 1/1999 222774 1177 PROPLkTY OWNER Breitenstein, Jeff SOIL DESCRIPTION REPORT page 2 : of PARCEL LD.# _ 6 1 ?� _ —_ - -- Certified Soil Testing Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Y ! Bed Dlft� Depth Dominant Color Mottles Structure G 1 Texture onslstence Boundar ' Roots Trench 3 1 0 -8 I OYR 3/2 - sl 2 f sbk mvfr cs ! 1 f/m 5 6 m; 2 8 -30 10YR 4/4 _ - - - - - sl 2 m sbk mvfr cs lm .5 .6 Ground elev 3 30 - 39 10YR 5/4 t2d 7.5YR 5/3 sl 2 m sbk mfr cs lm .5 .6 _ 94.2 ft_ 4 39 - 83 ! 1 OYR 3/6 - -- Is - 1 m sbk mvfr f cs - .7 .8 Depth to 5 j 83 -125 10YR 4/4 - s 0 sg ml - - .7 i .8 limiting factor > 125' Remarks arge inclusions in Horizon I Ground elev Depth to limiting factor Remarks: I Ground elev Depth to limiting factor i Remarks: Grouted t r elev 7 I Depth to - limiting _ i factor i Remarks: f cJ 4 . 1r ;w Q, ►�. - 1 lot P` a�. \-ok 1.4 c .,L � ooc71 1 s. t S l JL atj I 1ri ��ew�w� S3 " ° �n � w i-,o � i-� w •�1 - ��•�s �S v cY►aw to 40 LU , x ``l S sarvti o w8• cgsq) z,r1y din N � o Q si M �s. s 'a .4 " y L ti" � zs SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Chamber Soil Absorption Systems Permit Number 9/13/99 Date x .X. Gravity Distribution only 1 Pressure Distribution 3 Ift Suitable Soil , Note 1: Bury depth as per manufacturer 17 in Chamber Height 2 g ft Maximum Bury Depth 3 450 gpd Estimated Daily Peak Flow 0.80 gpd /ft Wastewater Infiltration Rate 562.5 ft Code SAS Size 40 % Down Sizing Credit 225.0 ft Reduction ( -) 337.5 ft Min. SAS Size 88.00 1 ft Proposed SAS Elevation Soil Surface Acceptable Finished Grade EL 4 (ft) Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum Number Elevation (ft) Depth (in) Lowest7 Highest Elevation? 90.92 97.42 1 94.30 125 86.88 92.22 Yes 2 94.60 124 87.27 92.52 Yes 3 94.20 125 86.78 92.12 Yes 1. Depth of suitable soil required below the infiltrative surface for treatment. 2. Total height of chamber in inches. 3. Maximum bury depth as per manufacturer's recommendations. 4. Based on chosen system elevation, and chamber height. Top of chamber is equivalent to top of aggregate. The addition of fill for cover or the reduction of finished grade may be required to meet minimum or maximum code standards. SBD- 10553 -E (R.05/98) SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Chamber Soil Absorption Systems Permit Number 9/13/99 Date x °X" Gravity Distribution only 1 Pressure Distribution 3 ft Suitable Soil 1 Note 1: Bury depth as per manufacturer 17 in Chamber Height 2 8 ft Maximum Bury Depth 3 450 gpd Estimated Daily Peak Flow 0.80 gpd /ft Wastewater Infiltration Rate 562.5 ft Code SAS Size 40 % Down Sizing Credit 225.0 ft Reduction ( -) 337.5 ft Min. SAS Size 88.00 ft Proposed SAS Elevation Soil Surface Acceptable Finished Grade EL 4 (ft) Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum Number Elevation (ft) Depth (in) Lowest Highest Elevation? 90.92 97.42 1 94.30 125 86.88 92.22 Yes 2 94.60 124 87.27 92.52 1 Yes 3 94.20 125 86.78 92.12 Yes 1. Depth of suitable soil required below the infiltrative surface for treatment. 2. Total height of chamber in inches. 3. Maximum bury depth as per manufacturer's recommendations. 4. Based on chosen system elevation, and chamber height. Top of chamber is equivalent to top of aggregate. The addition of fill for cover or the reduction of finished grade may be required to meet minimum or maximum code standards. SBD- 10553 -E (R.05/98) N 6 ing Safety and Buildings Division %11 SANITARY PERMIT APPLICATION 2201 B Wa tonAv 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 c than 8 112 x 11 inches in size. J4 • Cr • See reverse side for instructions for completing this application State Sanit, Permit Number Personal information you provide may be used for secondary purposes ❑ Check if revision to preLs application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Pr perty Lo ation K ,�: r.,. n/ /a 1/4, S T 2Q , N, R (or) Propert wri er's Mailin Addr7s / � G / Lot Number Block Nu er City, Si to / , , , , Zip Code Phone Number Subdivision Nome or CSM Numb r B11 O� II. TYPE OF ILDING: ) ❑ ( check one S tate Owned C] c it y Nearest Road - 3 E] Village Public 1 or 2 Family Dwe t llin N . of bedroom m e� e o ed oo S Town OF � III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) ,,� 22 F3 , Ig , H2 1 E] Apartment/ Condo U �`O 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1, N New 2_ ❑ 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 N Seepage Trench 22 ❑ In- Ground Pressure , 42 ❑ Pit Privy 13 El Seepage Pit 43 Vauft Privy 14 ❑ System -In -Fill a q C. 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.) Propose (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 7`�o - 756 74 Z .4. feet 91' �/ Feet Capacit VII. TANK in Ca gallo s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in structed Tanks Tanks Septic Ta p0 ��l� (,(J C, ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I El — 1 ❑ I ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name: (Print) Plumber's Signature: Stamps) MP /MPRSW No.: Business Phone Number: Plumber' A dress(Stre City,3tate,ZpCode):� �Fiiff� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issuin entSi nature (NoStamps) proved [:]Owner Fee) Owner Given Initial s 6, h `c Adverse Determination / f� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 4 �� , F� l� o ► r v t, y ?j ' i vt pl?44 � 4t a cl ef l�t d� 10 - 1 ✓►c � �S •. 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 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mainstwater 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 investigation' s and establishment of standards. JOB J, ew 51e,,;, TI M M EXCAVATING SHEET NO, l OF Route 1 Box 192 r WILSON, WISCONSIN 54027 CALCULATED BY 16 � - t 4 c-" I DATE (715) 772 -3214 (715) 386 -5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE / .._ SCALE _ Y° ........:........... a.. ............. ..i ....... .. .. >....... ..; ... .... ... .. .... ..... .. .... .. .. .... .... .... ... .. ............. ...::..........'. 3 !� ru �.5:.... r ., .......: .. .... ..... .... ..... ..... ...... 4. ...:......:.......:... ... .... . .... .... .... ..... ..... . .. . ...... . ... ; ; w( . �... � : ........ .. ... ................... ..... ..... .... ......... 2 . . .. ... ......... �a ... ... ...... , pr . . al ®� .. .. .. . ........... ........ .. . ................ .. .....: .... Ogg . � .... ....... . Si .; ...... ► 3 Y... 7 7 1 .... ...... !��, ..� ..:. .. .. .... ....... ...... .. .. ... ..... . _.... ... ... .. .. .. �a �j . ..... . I .......... � ................ - - ................ I . G`1 //_ .............. l . ......... �� ,� � .... PRODUCT 205-1 Inc., Groton, Mass. 1471. To Order PHONE TOLL FREE 1- 800�225-W JOB TIMM EXCAVATING SHEET NO. 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PRODUCT 205-1® Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1-800 -225.83110 rx .r � 3 �e� iv `` `.� <..a. w d u uclisad PAGE 3 OF PUMP CHAMBER CROSS SECTION 41 SPECIFICATIOMS •- -VENT CAP 'P 'C.I. VENT PIPE WEATHER PROO APPROVED LOCKING - 2S' FRCM DGUR, JUkICTIOKI BOX MANHOLE COVER � WINDOW OR F RUSH IZ "MIU• ( AIR INTAKE GRADE 41 11 ti" MIIJ. I � 1818" MIAIIAI. ,^ CONDUIT 18 "MIN. �•�� -- - - -- -- - MULE: T PROVIDE - AIRTIbHT SEAL I I APPROVAU JOINT A I I APPROVED J W/C.I. PIPE I III W /C•I PIPE LIR ENDIMG 3' I I I ALARM EXTEIJDIUC, ONTO SOLID ,GIL_ B I I I ONTO SOLID I 1 I ow c I PUMP OF —� ' —� �+. F' D CONCRETE BLOCK I RiSER EXIT PERMITTED OkJL4 IF TAUK MANUFACTURER HAS SUCH APPROVAL SPECIFICATIOUS .PTIC AND >SE TANKS M'A MUF'ACTUSLER: �s CST• wMBER OF DOSES:. el DAy TAWK :AZE: 0� I/ GALLOUS DOSE VOLUME �a3, � 7 , GALLUKI� ' A LAR M MAMUFACTU _ -S T �� ?�/'�y CAPACITIES: A= �S S .T C IIJ( NES OR »0 !K"(,AI MODEL NUMBER: B= ..__2 _INCHES Ott SWITCH TyP£:' ?41Lr(j C . 6 L INCHES OR e'Z3� �? vAL t PUMP MANUFACTURER: D =_ _ tkiCHE6 OR X _ '�A, MODEL NUMBER. �J� NOTE: PUMP AND ALARM ARE To BE SWITCH TYPE: -- e' ✓C t�i� 1cc.C�j IK15TALLF-D ON SEPARATE CIRCUIT,, PUMP DISCHARGE RATE GPM VERTICAL DIFFEKEkICE BETWECU PUMP OFF AND DISTRIBUTION PIPE.. FEET t MINIMUM NETWORK SUPPLY PRESSURE . . . , . .. " . . . FEET ♦ ,.. �.__ FE O F FOR MA X 4" F YoFt FRICTI 0 M FACTOR.. " FEET TOTAL DykJAMIG HEAP '_?.. FEET kITFPk;hl. !MINTkjsio JS of TANK: LEkl&TH -. _' l_/ W� ^TH H Goulds Submersible -� Effluent Pump MODEL 3871 EPO4 '. EP05 s` Pit _ • 0igh ■ M"0! isinp ned for the stei ebl { �;. r` for Cle fat tranul. F , St rurg soli C1� { 1 lent: urab,3�x ' d! � FX ■ Molor� oo r Ti�� Fr' %plas- 4 Es c� on { 5 a� t . tic cve� ; ,inter r.. Yt,t�r#ie Molbr a bmatic and!W. AV ch att,i�!.�,t�nt w • . E ` 1A h use a... points •Watery mp 1 l W V �O X apical ■ Power Cable: Sevrr(. duty +Dews ; s RPM, bu 4jp.,we �led;ond ratel oil td water . es,st nt. A automati+e resetw r� r s B* O• "Upper anti lower` EP05 SIA (e ph' a . PECIF i 145 1� "i ,. , heavy duty"ball bearin p' a ; btliftl constnactioc,, olid capa aut rrko- • S !p A6EMCX ,1$TING Cap`0 55 GPM. •� TOtal' �,t0 2 4 : M ►11 a Zandatds AssoclaUon •D 1a /x "NPT. i?�� (CSA Us model numbs rs x k M 'carbon- I :i ' µ� end in it AC .) rota - stationary, three pig grc nding�p 9� 8U mers. (stadaon ,. ZOO d YR �s7'ik.2 e6 gn,provides 0 4° ntinuous i� ermittent. rr�iu tsistan + FatB series METERS ` FEET Stain) �� i o a � +.X4 fining dry W, age to 9 30 compo Pump.��:.. e • Sou filing capability: a 25 Y4 m aid' m , • Capaci 'p to 60 GPM. _ f ' • Total he" . p to 31 feet. s zo , • Disc 1 I NPT. • McCh - i: carbon- is � `rota tionary, a' a t = r ° _ ^r, F t, ,BUN mers. i 04 °F X W )`continuous r € IV ` r �p '140 °Frrtermittent. z' tr3 t max, fig's FU o 7 v Labor sin Dep R I of In SOIL AND SITE EVALUATION REPORT r ,. -- - — Page 1 of 3 Division of Safety & Buildings F in accord wit h ILHR 83.05, Wis A d m Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include,bu7 J .# not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or ; .# dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION 4__ REVI€ D BY j DATE PROPERTY OWNER: PROPERTY LOCAT N, Richard Stout GOVT. LOT 4 iid 3 �` R 19 8(or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # S iN 1353 Awatukee Trl 64 na CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ETOWN NEAREST ROAD Hudson, WI. 54016 (715 549 -6731 Troy Tower Rd. J New Construction Use [ Residential / Number of bedrooms 3 [ ] Addition to existing building [ ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 5 bed, gpd /ft •6 trench, gpd /ft Absorption area required 900 bed, ft 750 trench, ft Maximum design loading rate • 5 bed, gpd /ft2 - 6 trench, gpd/ft Recommended infiltration surface elevation(s) 96.45 It (as referred to site plan benchmark) Additional design / site considerations na Parent material pitted outwash plain Flood plain elevation, if applicable na It S = Suitable for system CONVENTIONAL I MOUND I IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL I HOLDING TANK U = Unsuitable fors stem I KI S ❑ U 97 S ❑ U CA ❑ U ®S ❑ U ®S ❑ U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0 -16 10yr2 /2 none 1 2msbk mfr qW if .5 .6 i 1 2 16 -34 10yr4/4 none sicl 2msbk mfr 9W if .4 .5 Ground 3 34 -84 10 r4 4 none Ifs os mvfr elev. 10 Depth to limiting factor +84" Remarks: Boring # 1 0 -16 10 r2/2 none 1 `,. 2 t '. 2 16 -29 10 r4 4 none sicl Ground 3 29 -38 10 r5/4 c2 7.5 r5 8 sicl 1 8 1 8 ' • 1 4 8 -84 7.5yr4/6 none fs Depth to limiting factor + 84" `t Remarks: CST Name: -- Please Print Phone: Gary L. Steel 715 - 246 -6200 Address: 1554 200th Ave. New Richmond, WI. 54017 m02298 Signature: Date: CST Number: 4 -23 -96 I 1 PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page d PARCEL I.D. # pending Lot # 64 Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ..4 1 0_ 10yr2 /2 none 1 2 3 2 17 -34 10yr4 /4 none sicl 2m Ground 3 34 -42 10 r4/6 c2 7.5 r5 8 sicl 1 elev. 99. ft. 4 42-84 7.5 r4 6 mvfr na Depth to limiting factor +84 ( ` Remarks: Boring # 1 -17 10 r2/2 none 1 mf if 4' 2 17 -28 10 r4 4 2ms mfr aw if -4i Ground 3 28 -38 1 scl lfsbk mfr elev, 4 8 -80 7.5 r4 lfs OSQ mfr na 98 ft. Depth to limiting facto y Remarks: Boring # 1 -14 10 r2 2 none 1 2msbk mfr i f .5 .6 5 =' 2 4 -24 10 r4 sicl 2m mfr CM if 4i -5 Ground 3 4 -36 1 sicl lfsbk mfr aw na elev. 4 6 -82 7.5 r4 6 none osg mvfr na na .5i .6 9 9.1 ft. Depth to limiting factor +82 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: S13D- 8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Richard Stout 1554 200th Ave. CSTM2298 NW4SW4 S3 T28N - R19W New Richmond, WI 54017 MPRSW 3254 town of Troy (715) 246 -6200 lot #64- Country Wood N 1 =40' BM.= top of 1" steel pipe @ el. 100 top of marker stake = 103.3' -1-- W- r� 3E' 3 6� / Cr Cl 1� 6A Gary L. Steel 4 -23 -96 5 -11 -1999 6 -18PM FROM GARY L STEEL 715 +246 +6200 P.1 1 Nfor anO Hainan Relations .+v.. 0%as ai v a a a - G V A L. V A a i V l y n c r `r n a r� _ Ln .+ DiNann at 3atety a &,sdrgs in accord with ILHR 83,05. Wis. Adm. Code MUMT Attach complete side plan on paper not less than 81/2 x 11 Inches in site. Plan must indudd, but St . cmix F101 limited to verdcal and horizontal reference point (BM), direction and -A of sbpe, scale or PARCEL I.D. s dimensioned, north arrow, and location and distance to noarast road. I pending APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION I REVIEMDBY DATE F PERIY OWNED PROPERTY LOCATION Richard Stout GOVT. LOT 1/a 110 T ,N,R 19 S(w) W PERTY OWNER':S MAILING ADDRESS LOT BLOCK • SUBD. NAME OR CSM e 1353 Ave {r n8 Coon Woad , STATE ZIP CODE PHONE NUM — SER ❑CITY QVII I A 1 QFOWN NEAREST ROAD Hudson, WT. 54016 (713 549 -6731 Troy Tdlrrer Rd. 6 1 New Cod'ucbon Use Residertdal / Number of bedrooms 3 [) Addition to e*k q bwl&g E l Replammant O I uaic or commerdai desaibe Code, derived daily pow 450 gpd. Rwmmw" design WeEd4V ran - 5 bed; gpd* -6 ire tch, gpollt Absorption area required 900 bw K2 750 trench, 11 Ab*Mum design loading rate - 5 bed, 2 .6 _ tt nrh, gptiVQ Ranmmer*d ird'iltrabon surfape eW a6at(s) 96,45 ft (as r MM3d b site plan bdnchmn ) Additional design / sire oonsiderad" rla Parent matertat pitted outvash plain Mood pWn elevation, N apploble na g S a suitable Tor system cQNVWoN& tYtC1[lND IN�ROt1Np PREsSSURE AT GRADE= SYSTEM IN FA. H�LOING TAlac U= Unsuitable furs tent XI 13 u :0 S❑ u [ S❑ U ®S 0U M S O U L p s ® u SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Iulat�es Structure GPD/ft 9 in. Munsell O S Cant Color Texture Gr. St. Sh, Coremtertce Y ROQ g� rerdt 1 1 0 -16 10yr2 /2 none 2 2msbk mfr 1f .6 2 16 -34 10yr4/4 none siGl 21nsbk mfr If - ,5 Ground 3 34 -84 10 r none dev, Ogg 1fl Depth to Nlnidng rector +84" b Remarks: Boring # 16 I /2 none 1 2msbk mfr yw If, . 5 ' .6 2 2 16 -29 1 r4 4 none s 2msbk mfr if .4 -5 Ground 1 3 9 -38 10 r5 4 c2 7.5 r5 8 icl If sbk mfr aw rim l 4 8 -84 7.5 4/6 none fs Osg mvfr na na Depth to limiting ter +841 Remarks T Name: - Please Print Phone: Gar L. Steel 715-246-6200 Address: 155 00th Ave. New Ricbmond, W1. 54017 m02298 Sipnarure: d Date: C8T Number: ..... // A �•a nc ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer TP F (z t3 ne i t en .r /e ., ix Mailing Address Property Address Lo 'f oa'L1 (Verification required from P g Department for new construction) City /State kklli G4z Parcel Identification Number - /Z 37 LEGAL DESCRIPTION Property Location AV %4, Sic. '/4, Sec. 3 T e- W N -R_Zf _W, Town of Subdivision r� zw- . G fev'd , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 471 3 'L , Volume 4- . Page # e Spec house ❑ yes Z no Lot lines identifiable A 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 masterplumber, journeyman plumber, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIG 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 09 <h z " � ' siGNAVAm 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 STATE BAR OF WISCONSIN FORM 2 — 1982 571 WARRANTY DEED DOCUMENT NO. VOL' S PAS; 501 - REGISTER'S OUICE RICHARD O. STOUT � J � ST. CROIX Cr% WI - --- F.fc'r; it•- Aac6,-4 con e a-td warrants o JEFFREY T. BREITEN and JAN 16 1998 MARY L. BREITENSTEIN, h usband and wife s urvivorship marital propert 'X <Lt�.l.. 8'00 A" 1 Ir — Ro t.T., or o..d. THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in _ St. Croix Count}: p ,Q State of Wisconsin: ; VI I �j + I'yt� F' tt � Lot 64, Plat of Country Wood Firs- Addition, Town of Troy, St. Croix County, Wisconsin. 03.28.19.1201 PARCEL IDENTIFICATION NUMBER ldZ37 — JRg4SFER FE is not This homestead property. .,�. (is) (is not) Exception to warranties easements, restrictions, rights — of — way and covenants of record,if any Dated this day of January A.D 19_ 9 8 (SEAL) _ _ (SEAL) � Richard O. Stout (SEAL) _ _ (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, i, 55 St. Croix _ County authenticated this day of _ , 19__ Persemath came before me this _ ___ a bove day of January 19 i� the named Rllcharff Stout TITLE: MEMBER SLATE BAR OrF WISCONSIN Brenda Poulin lNotary 1f not, Public _ authorized by 3701+_06,'Xis. Scats) Stxte of m Wisconsin to e to he the person %%ttu esrcuted the forcgoul� lastrur".r� ::d ackno�Cled�;C tt same. THIS INSTRUMENT WAS DRAFTED BY Janet P Stcut – L3 ••, 5 �� 3 - -Awa Eukee - Tr; - -- - — – � / t jl:i m.t) he authenucatrd of k : :os!C.lhe Ct ,....:e not tii 1y iCurlI: rot ,If not, yxpll n l.1!e nc tsar) - - - -- - - - -- - — - .- 1 ! / !_ 41is ONI1A - \x III t I) v • LD 691.5 M n S79 13 46 W M _ —_ 0 E I R I M _ -� 40• 276 S7'f 691.5 NT "E In N _ N Z 0 6 3' �- 4 in 2.09 n - - 63 N-- 7� c^ 2.10 AC. N 88.6. S 2.40 AC. 91,700 SO. FT. � 00 104,483 S0. FT. W o R 0 r s CY LL I �4� O 0 0 62 N M 2.33 AC. I / N. 101,687 SO. FT. 7 � / DD ti 0 \ 30 —O , n � _ L N I L _ CD W 1 Kf L w N 84 15 30 �� 469.73 E I— M ! Lj / I J N 61 ® / i W 1 2.12 AC. 8 92,414 SO. FT. �9Z M 0 A 8 .. 45 60 59 2 87 ,5 5 0 � 2.09 AC. o to 2.01 AC, g 90,972 SO. FT. �^� 87,555 SO. FT. 0 8 >I � ZI .I —I 5.5' 8 JI In J I 21.88 326.57' CI N89 °25'26"E .I t0 U IN PLATTED m W o • C g M " A ?• Z . C ra SW COR SEC. 3