HomeMy WebLinkAbout040-1253-90-000 ST. CROIX COUNTY ZOrffNG DEPARIMMNT
AS BUILT SANITARY REPORT
Owner Ja Ae0 -\346 �M
Property Address 333
City /State
Legal Description:
Lot �-M Block Subdivision/CSM # 4 s
'/; fi /4, Sec. , T ? c-'N -RAW, Town of Z z� y P11 - Z7 �0 -- /as - _ �'�
--�-- -
SEPTIC DAM -- DOSE CHAMBER -- HOLI;IING TANK INFORMATION
Tank manufacturer 1416.s � Size 6)PC /o r o ! Setback from: House - 2, 3 --- ' Well P/L f r�
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: S.c Width Length. Number of Trenches _ 3
Setback from: House _ Well t sv P/L 3 Vent to fresh air intake -t 7r
ELEVATIONS
Description of benchmark /??cz., , 6i L� �/ _ _ Elevation / O 7
Description of alternate benchmark P ��il .- Qo- Elevation Zal l,
Building Sewer rfr- U7 - eOHT Inlet `� 7. 7o ST Outlet 97- 3q PC Inlet
PC Bottom Header/Manifold lT�'7o Top of ST/PC Manhole Cover 99 -•07
i
Distribution Lines (l) G 7 yG- 9 "7 (7) 96- r
Bottom of System O `� f - 1 O 9 i •. < I O Qr G
Final Grade O O ( )
Date of installation Permit number r ff' State plan number
Plumber's signature License dumber SS�.� 4' /, Date
y
Inspector
Complete plot plan
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Wisconsin Department of Commerce
Safety and Buildings Division PRIVATE SEWAGE SYSTEM County
INSPECTION REPORT St. Croix
.+�NERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. 344595
Permit Holder's Name: ❑ City ❑ Village ❑ xTown of: State Plan ID No.:
enn cook Jon Town of Tro
CST BM Elev. - , Insp. BM Elev.: BM Descriptio Parcel Tax No.:
QQ. . 0} �tnAeMNBCtti CBUlr = 040 - 1253 -90 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �- 25p Benchma
rK_ " G,So oSS� c lq , a : ?
Dosing Alt. BM 0.g33 I O •:jq
Aeration Bldg. Sewer c'g, i3
Holding St /Ht Inlet q T. 7(
TANK SETBACK INFORMATION St/ Ht Outlet , 4S
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic >5f > 30' NA Dt Bottom —
Dosing NA Header/ Man. g. �(,S
Aeration NA Dist. Pip 8•� 8•S9 o e ���
T 0 6.4�C )
Bot. System W q'$ E 4.4 q •&
Holding
9 Y a 9.4 t 9s ��Ce -)
PUMP / SIPHON INFORMATION Final Grade
Manufacturer Demand
St cover
Model Number GPM
TDH Lift Friction System TDH Ft
m ead
Forcemain Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM( �A.r:s e& j , J = (�!, 4tr�Q �•��
M9 TRENCH Width t Length N of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME 3 5 R' I I DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu actur r:
SETBACK CHAMBER I�a ^ 5Z� `
INFORMATION Type Of r r Moe Number*
System: CoN - 3O OR UNIT u
DISTRIBUTION SYSTEM
Header/Manifold I Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing t0a r
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.) Inspection #1: // / a./99 Inspection #2: /2/ / 9g
Location: 323 Birkdale Court, Hudson, WI 54016 (NW 1/4 NW 1/4 19 T28N R19W) - 19.28.19.1340
1.) Alt BM Description = -
2.) Bldg sewer length= 30
-amount of cover Ujeo Luc C u
l� . s °''
loi d f) AoTli4 t7--6 - C R .
Plan revision required? ❑ Yes �' No
@ D - Wl eoe s y i 2 d r� ef ra_dditi nal informatfoe 3 op 0 (R.3/97 c r , w•�h�a_ Inspector's Signature Cert. No.
e,r - to -t -94 Ss• I w =mss
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,,Wisconsin Department of Commerce
Safety'and Buildings Division PRIVATE SEWAGE SYSTEM Count y
• I 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)]. 344595
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
Penn cook Jon I Town of Tro
CST BM Elev Insp. BM Elev.: BM Description: Parcel Tax No.:
040 - 1253 -90 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic o Benchmark 3 3`J IUD, D
Dosi ng Alt. BM
Aeration Bldg. Sewer - 5 , 79 D� � g -o}-
Holding St /Ht Inlet (c,/S'
TANK SETBACK INFORMATION St/ Ht Outlet /0(0.8 3q
TANK TO P/ L WELL BLDG. Ventto ROAD
Air Intake
Septic � / NA arsouro m
Dosing NA Header /Man.
9 G La.a. �O • �
Aeration NA Dist. Pipe "P G,
Holding Bot. System I� 9Z 3 4SIG}
PUMP/ SIPHON INFORMATION Final Grade
Man rer emand St
cover
Model Number GPM I1ig 9 (s�S� 49. o 3t
TDH Lift Fric ' Sy stem TDH Ft • ( e
Force m Length Dia. FFii Dist -To well p
SOIL ABSORPTION SYSTEM 2
BED/TRENCH Width I Leng I No- Of T enches PIT No- Of Pits Inside Dia- Liquid Depth
DIMENSIONS 3 DIMENSION
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Manufa to
SETBACK CHAMBER
INFORMATION TypeO _ el Number.
System -, OR UNIT
DISTRIBUTION SYSTEM 3D ` a-4-' •�-7-V If Q
Header/ M nifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Lengthzi. Dia- L — Length Dia. Spacing /M
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.) Inspection #1: ' /t Al Inspection #2: I. 9/R
Location: 323 Birkdale Court, Hudson, WI (NW1 /4, NW1 /4, Sectio 19 T28N -R19W) - 19.28.19.1340
L 30 , r ' Sewe/ ' >I is ` U L� tad Pmr� g,
Al
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Ian revision required? ❑ Yes Ig No
Use qther side fo - r ' a dditional information.
BD R.3
\"`�� ��tOLILI, To "k4 Date Inspector's Signature Cert-No.
6
SD c a•.. t �'' 6 'Q 4 '
Vi sconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 B Washington Avenue
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302
• Attach complete lans (to the count co only) for the system, on paper not less County
p Y pY Y Y p p .
than 8 vz x 11 inches in size.
0 See reverse side for instructions for completing this application state S nitar�itNu ber
Personal information you provide may be used for secondary purposes KGheck 3
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
Property Ow er Name Property Location
X-1 Fe1 vd4r /Y 1 4 lf%rw 1 /4, 5 ( O' T Pf-; N, R 1 7 E (or)O
Property Owner's Mailing Ad ess Lot Number Block Number
Scz v
City, State Zip Code Phone Number Subdivision Name or CSM Number
S � S c ) t , r //�
(. PE F BUILDING: (check one) El State Owned C it y Nearest Road
I ❑ Village
Public 1 or 2 Family Dwelling !
- No. of bedrooms T Town OF
III 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. pq New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
System ________System ___+_________ Tank Only E S
_ __ __ Existing System __,_____ Existing System
B) EA A Sanitary Permit was previously issued. Permit Number -3��s�tS Date Issued - 7$
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 / , 4, � ,L 42 ❑ Pit Privy
13 ❑ Seepage Pit /016 K Vault Privy
14 ❑ System -In -Fill 3o ' vK
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
Vo (:> I 75 -lV GFeet 9'9- / eet
VII. TANK Capacit g allons Total # of Prefab. Site Fiber- Exper.
INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete st acted steel glass Plastic App
Tanks Tanks
Septic Tank or Holding Tank x 19 ro / r 5 ems' ❑C ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I ❑ 1 ❑ 1 ❑ I ❑ 10 1 ❑
Vlll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber' i ature {N m ) MP /MPRSW No.: Business Phone Number:
7i; - 30 - 0�-
Plumber's Address (Street, City, State, Zip Co
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved S nitary Permit Fee (Includes Groundwater ate I ssued Issuing Agent Signature (No Stamps)
®Approved ❑Owner Given Initial Surcharge Fee)
r Adverse Determination 2 - �B�Q`I 140�
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber
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NVI ONMEN BY DE 51GN
1432 120`" STREET, NEW RICHMOND, WISCONSIN
715 -246 -2454
PROJECT NAME: TROY VILLAGE 2nd ADDITION
DESCRIPTION: NW%, NW /, SECTION 19 „T 28 N, R19W
TOWNSHIP: TROY COUNTY: ST.CROIX
LOT: ' 89 SUBDIVISION: TRAY VILLAGE 2 ADDITION
107. 5t)
Q2 to 3. 37
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SCALE I"=40' Tom Nelson
BM nn1_ c5 OS
e �2 V �`� 1 o o S -7 .. a- (,_ 9 9 j � rJ `��
3tYl I :lap of Iron el P e SL- )c)j Corner � - leJ 10b
Q r'1 2 1 0 ro t, P I P 0 �'{ �o Qo S� q (o . S� / 6,71, ,, /gj
i LvA — nsii Departirfefrt of Commerce SOIL AND SITE Ey,� 4pA ijdk Page l of 3
Division of Saiely and Buildings in accord with Comm 83.,95 Wis. Adm. C de r t
Aflach complete ate plan on paper not less than 8% x 11 itches in size. Plan must ril j ,f
nn
i County
include, but not knifed to: vertical and honzonial mference point (BM), &echor) iitd' ?
St. Croix
�+
percent slope scale or emsions north arrow. and location and distance to W rq�4 f r, Paroei i.D.#
�
APPLICANT INFORMATION - Pteaw print all inforntation. "i._-
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f0=`l11,-.wY1�1 _.- . . - pro F— .1 � w _l - --4 l as L w - ..- ..-- J... 4 wy _ - W _.� Nos-- . iAJ
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Properly Owner
wn /!
Continental Devel9pT Govt , M 1#\ NW 1/4 S 19 T 28 KR 19 W
Properly Owners Mailing Address Lot # : Name or CSW
1 12301 Central Avenue NE, Suite Lau 89 1 - 1 Troy Wage
City State Zip Code PhoneNumber City ❑ V111age ®Town Nearest Road
1V fill! llJ MEN - 55.4.4 " . 8 .2-.574 568 1 ; — vy ` nL - 'ua1c Cahn.
New Construction Residential / Ntltnbw of bedrooms 4 DAddition to wasting building
Repacenalt Public or commercial describe
f'l FQQ ,a,�r O..d..ds.l �n . 7 l.e.l ...d/Rt R W l�
J • -- �. . IfGfNl411 � I wv, �lfru 8 M
A�itat area required 857 bed, ill= 750 trench, fe Mwdmun design loading rate .7 bed, wpdr .8 tench, wW
Rec lvirnended irdiraim Su*" elevaion(Sj 96.50 H (as relerr6d ilD sic pan bentxtlw
Additional design / site consideration
Parent lnahNial LOESS OVER OUTWASH SAND Floodplainelevafim — .Naft
S= Srrtable for sysiem �Comren6onal Mound In-Ground Pressure AT- fade I SV*m in Fill I Holft Tank
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Ys
i S v a l; I l; i S u i; Su i3 I c=s 5 ids ii
='ins S o u
SOIL DESCRIPTION REPORT
DWM kbnzort 1 Dominant Color " ' - Moldes - - Texture Ii Structure a eoi,,,�ary ( DAP
ryry
Bo fm# h in � klurMll � (Nil_ S,7 cant rnlnr � far_ S7 S1►_ �" � Roots
1 0-19 lOyr2/2 - 1s 2msbk mvfr cw 2f .7 .8
1
2 19-36 7.5yr4fi - is 2msbk mvfr 3 cw $ 1 f .7 .
Ground p q -� r 6 B Y _q p C
q i � -, -
3 36 ,.5yT4j u - 1 n Osg 1 ml W - p .8
99�° �# tl ii0g 7.Syr4i6 p - i s B � mt
Depth to 6 r I G
Iin'il�'sg d I V N R h
factor 7. T I n. Y
>110 tl p tl tl n II N
\QIIO foil.
2 i 0-1- ivyr"z - is Z UUWK mva vw zt 7 a
2 18 -102 73w3/4 - s Osg ml - - .7 .8
Ground
elev 'I gg pp „„ II ryry pp g
% C 1 4 !I tl R II II
99.524 it 8 R k B tl II b
Dwh itio n Z.Z'f� tl k q U I I N
>1UZ Y i n d ii tl tl
Remarks.
(;b ; Name (Please t'mM 5lgna drre: 1 eleptione No.
1 Thomas C. Nelson 715 -246 -2454
mmieen
Address Envirotai By Design lie CS ivumlber Het #
1432120th Street, New Richwoud,.Wl 54017 j 2/1' 2273 193
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rTCOPE �W tiWAM SOIL DE7CMF REPO i N Page 2 o1 3
PARCEL I RS Env ro t D�si
N u" N uoiMun �ru'iu q q Texbjre II ouwua� � � N Rocks N ` inn
u in. Y Munse® Qu. Sz Cont Color Gr. Sz Sh. I I I Bed ° Trench
3 1 0-13 lOyr2/1 - sl 2msbk mfr cw 2f 5 .6
2 13-40 7.5yr3/4 j - sl 2msbk mfr cw 1 f .5 6 I
Ground
slev. 3 N 40-110 q 7.5y�!6 q _ N g N {� N � N _ II _ N 7 .8
N II N I N @ II
1mn7it
N I I! N N q N II N
D N
IllR @
>110 I I C N O
II a N N q q a II �
a I a o N N N II N
n r o i n u u u p
4 i � v-10 IWZJ� - its imsox mvfr cw if 7 8
2 161 7 5vrl /4 - c ow ml - - 7 R
Ground
elev
96.92ft
NO b� - - - �
limking
N I a G II A a I� N
II N I I I
Rernaft:
r, 1 N 0-16 1Oyr2/2 - Is 2msbk mvfr q c 2f .7 .8 I
- 2 16-94 7.5yr3/4 - s Osg ml - - .7 .8
Ground
elev II q a N a N a N II
96.37 ft
NO I N I I ii I
1. to A
facer I I N I N a q I
>94
'I I I! II II II N N N
Rp wk-n-
Ground
ear I I N I N I I
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factor
!I N N q I pp I g q � I N
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Relnarks:
I
- - EAV s
1432 12e S nIEET, NEW RICHMOND,WlSCONSnq
715 -246 -2454
Tam Nelson
Cuftfied Scii TCSW 2M87—A SR00713
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%6 consi n SANITARY PERMIT APPLICATION 20 Safety and Buildings 1 E. WashinggtonA erosion
In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969
Department-of Commerce Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less Count .
than 8 u2 x 11 inches in size. C "m [x
• See reverse side for instructions for completing this application State Sanitary Permit Number
The info , . you provide may be used by other _gove mer agency progry ms V �� 11 Check if revision to previous application
[Privacy Law, s: 15.04 (1) (m)]. " -[G ~ , } l State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N
Prop rty Owner N me Property Location
d•-% Jr i^ cad Nli r/4 A-14 /4, S o f T 1', N, R /`C E (or)
Property Owner's Mailing Address Lot NumberBlock Number
S " t
Cite„ � � Zip C (hone ;umb Subdivision Name or CSM Number
Pi -^ Or l
V a
11. TYPE OF B IL DING: (check one) ❑ State Owned ❑ It� Nearest Road
❑ VII age
Public 1 or 2 Family Dwelling - No. of bedrooms Town of Qirct-, att C
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) (Gr 1q, f3 40
1 ❑ Apartment/ Condo 0 ^ c o /
2 ❑ Assembly Hall 6 ❑ Medical Facility / Nur ' 10 [] Outdoor Recreational Facility
3 ❑Campground 7 ❑Merchandise: Sal, i 11 ❑ Restaurant/ Bar/ Dining
4 E] Church /School 8 ❑Mobile Home P >> 12 ❑Service Station /Car Wash
5 E] Hotel /Motel 9 ❑ Office/ Facto "� 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on li Check box a B, i ,� licable)
A) 1. RI New 2. ❑ Replacement 3, Y ep!>me�ttDf . Reconnection of 5. E:] Repair of an
S�!stemSystemVa k0 r E_xisting System_ __ E --- - g ----
-----(p�R----
B) ❑ A Sanitary Permit was previously issuedmi. D ate Issued
V. TYPE OF SYSTEM: (Check only one), ?'
Non- Pressurized Distribution Pressurized Distrf a Ct, xperimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank
12�g Seepage Trench 22 ❑ In- Ground Pressure .- .'( —is f� 42 [] Pit Privy
❑
13 Seepage Pit ❑ Vault Privy
14 ❑ System -In -Fill L.2—) 7S t * -ciLt -2- ((,q.4e1_r 7,�v-,6,i C r
VI. ABSORPTION SYSTEM INFORMATION: 16; S Cam / - �P
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
oppo Required q. ft.) Propose. ft.) (Gals/day/sq. ft.) (Min-finch) - EI o�o�pn
et I eet
Capacity
VII. TANK in Ca allo s Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank nk x l�f a/ (�er c ❑ 1 ❑ ❑ 1 ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum 's Name: (Print) Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number:
Plumber's Address (Stre"ty, State, Zip Code j:
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issued Issui gent Signature (NO Stamps)
�pproved []Owner Given Initial Sur`ha r � L
Adverse Determination ��)�� `
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-Mg8 (R t 1J96) 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:
1. Property owner's name and mailing address. 1 rovide 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.
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.
VI1. 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 mint
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.
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GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for 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.
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- Wisconsin Department of Commerce SOIL AND SITE � �,
EVA UAT ON Page 1 of 3
Division of Safety and Buildings in acid with Comm 83 05 Wis. Adm. Code
• . Enzirotuxtsttt:l BY Be=rt
Attach complete site plan on paper not less than 8%z x 11 inches in size. Plan must County
include, but not Waited to: vertical and horizontal reference point (BM), direction and St. Croix
oeroed" i afepe, aetle or divhei nbiorrt,, riorth &ftrw, and 6edboh ar d d6tArioe to tneereet woad. Parcel I.D:#
APPLICANT INFORMATION- Please print al! information. t'/�1 R Dst
Personal iMormation you provide may be used for secondary purposes (Privacy lava, s. 15.04 (1) (m)).
Property Owner Property Location
Continental Development Govt. Lot - 114 NW 1/4 S 19 T 28 N,R 14 W
Property Owner's Mailing Address Lot # { Biotic # I Subd. Name or CSM#
12301 Central Avenue NE Suite 230 89 i - Troy Village Second Addition
City State Zip Code PhoneNumber City [j Vi Iage ZTown Nearest Road
Minneapolis MN 55434 612 -757 -7568 Troy I Birkdate Court
New Construction Use: Z Residential / Number of bedrooms 4 Addition to existing building
Replacement " Public or commercial describe
Code Derived daily flow 600 gpd Reco .7 bed, gpdhV .8 trench, gpd/F&
Absorption area required 857 bed, flr i myrn de&V loading rate . bed, gpff .8 tr ench, gpd/fF
Recommended infiltration surface a on(s) l ft (as re ed to site plan benchmar
Additional design I site consideration
t Parentmallerial Loess Over Glacial Outwash Flood lain elevation, licable NA ft
ble for system I Conventional Mound In- Ground Pressure QT -Grade System in Fill Holding Tank
itable for system ® s ❑ u ® S ❑ u ® S ❑ u ® s ❑ u I ❑ s ®u ❑ s ® u
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/t>?
goring# Horizon in Munseil Qu. Sz. Cont Color Texture Gr. Sz. Sh. nsistenc Boundary Roots Bed ? _ Trench
1 0 -8" 10yr2/2 - sl 2msbk mfr cw 2m 600' ! 600'
.;. _ 2 8 -17" 10yr3/3 - 1s lmgr mvfr cw 2m 600 ! 600
Ground 3 17 -32 7.5yr4/6 - s osg ml cw lm 600' 600'
elev
107.99 4 32 -39 , 7.5yr4/5 - s osg ml cw - 600 600''
Depth to 5 39 -90 7.5yr7/4 _ s ( osg ml - - 600 600'
limiting
factor
Remarks:
2 1 , 0 -12 14yr2/2 , - , is lmgr , mvfr ew 2m , 600 5 i 600 .s
2 12 -27 10yr33 - is lmgr mvfr cw lm 600' ! 600'
Ground
v 3 27 -90 7.5yr7/4 - s asg ml _ _ ? 600' 8
103.37 ft i
Depth to
limiting
factor
>90
Remarks:
CST Name (Please Pdrnt) Signature: Telephone No,
Thomas C. Nelson 715- 246 -24-54
Add Environmental By Design !! CST Number Ref #
1432120th Street, Nero Richmond. W1 54017 -7 7387 8
PROPERTY OWNER: ContincnW Devc1opmcnt SOIL DESCRIPTI REPORT Page 2 of 3
PARCEL J.DA Environmental By Desi
Horizon , Depth Dominant Color , Mottles structure � onsistenc j GPD/ftz
i in. I Mansell Qa. Sz, Cont Corr Gr. Sz. 81h. Bed !Trench
is lmgr I mvfi cw 2m 600' 600'
2 8 -20 10yr33 - is lmgr + mvfr cw lm 600' i 600'
Ground
elev 3 20 -90 ' 7.5yr7/4 - gs osg ' mf - ' - ' 600' 600'
108.i3ft
Depth to
limiting
factor
Remarks:
4 1 ` 0 -14 10yr2/2 ` - 1s I lmgr ` mvfr I cw I 2m ( 600' 600'
2 114 -23 10yr33 I - is I lm 1 w,& I cw I 1m , 600 6ce
Ground I I I I I I 1
elev 3 23 -95 I 7.5yr7/4 - gcs osg ml - - 600 600" 8
108.07 ft
Depth to I I I I I
limiting
factor
>95
Remarks:
5 1 I 0 -16 I 10yr2/2 - I is ( lmgr I mvfr I cva I 2m 600' ; 600
2 ' 16 -29 ' 10yr33 " - is lmgr ' mvfr cw Im 600' 600'
Ground I
elev 3 29 -90 i 7.5yr7/4 I - i gs usg ttil ` - I - 600' ! 600'
104.17 ft 4 `
Depth to I I i I I ( il
limning
factor
>90
I I I I
Remarks:
Ground
elev
Depth to
limiting
factor i f
t f
Remarks:
Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Environm By Design
Attach complete site plan on paper not less than 8'h x 11 inches in size. Plan must County
include, but not limited to: vertical and horizon rprida (BM), direction and _ St. Croix _
percent slope, scale or dimensions, no o\v laid locdflon a d distance to nearest road. parcel I,D.#
APPLICANT INFORMATION */�'as . rift all information.
Personal information you provide may be sad '6r seco (Privacy Lavy, a. 15.04 (1) (m)). R ieweo By Dat
Property Owner # Property Location .
Continental Develop °` tG0 Govt, Lot - NW 1/4 NW 1/4 S 19 T 28 N,R 19 W
Property Owners Mailing Address ', sr r t; ;+ ' Lot # Blcck # Subd. Name or CSM#
12301 Central Avenue NE \Suite 2 COUNTY 89 - Troy Village Second Addition
City Gtke . dip e ne ��; ❑ r'ity ❑ Village ❑Town Nearest Road
Minneapolis MIS . Troy Birkdale Court
LN New Construction Use: ❑ Resl tuber of bedrooms 4 ❑Addition to existing building
❑ Replacement ❑ Public or commercial describe
Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/fP .8 trench, gpolft
Absorption area required 857 bed, fl? 750 trench, ftz Maximum design loading rate .7 bed, gpolftz .8 tr ench, gpd/f 2
Recommended infiltration surface elevation(s) By Designer ft (as referred to site plan benchmar
Additional design / site consideration
Parent material Loess Over Glacial Outwash Flood plain elevation, if applicable NA ft
S= Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable for system MS D U N S u I El S❑ U I E S❑ U ❑ S® U ❑ S® U
SOIL DESCRIPTION R EPORT
Horizon Depth Dominant Color Mottles Texture Structure �Consistenc Boundary Roots GPD/ft2
Boling# in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
1 1 0 - 8 " 10yr2/2 - sl 2msbk mfr cw 2m .5 .6
2 8 -17' 10yr3 /3 is lmgr mvfr cvv 2m 75 ° .6
Ground 3 17 -32 7.5yr4/6 - s osg ml cw lm .7 .8
elev
97.2 ft 4 32 -39 7.5yr4/5 - s osg ml cw - 7 8
Depth to 5 39 -90 7.5yr7/4 - s osg ml - - .7 .8
limiting
factor
>90"
Remarks:
2 1 0 -12 10yr2/2 - Is lmgr mvfr cvv 2m .1.5 i • '.6
2 12 -27 10yr33 - is Imgr mvfr cw lm -15 ° 6 i Cw
Ground 3 27 -90 7.5yr7/4 - s osg ml - - .7 .8
elev
94.3 ft
Depth to
limiting
factor
>90 0,
Remarks:
CST Name (Please Print) Sign i G � Telephone No.
Thomas C. Nelson ` ✓� 715- 246 -2454
Address Environmental By Design Date CST Number Ref #
1432 120th Street, New Richmond, Wl 54017 2/3/98 MO2605 8
'PROPERTY OWNER: Continental Development SOIL DESCRIPTION REPORT ® Page 2 of 3
PARCEL I.D.# Environmental EY Desi
Depth Dominant Color Mottles Structure GPDlftz
Horizon in Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. onsistence Boundary Roots
Bed Trench
3 1 0 -8 10yr2 /2 - is lmgr mvfr cw 2m >75
2 8 -20 10yr33 - is lmgr mvfr cw lm ,7.5 •0.6
Ground
elev 3 20 -90 7.5yr7/4 - gs o sg ml - - .7 .8
95.2 ft
Depth to
limiting
factor
Remarks:
4 1 0 -14 10yr2/2 - is lmgr mvfr cw 2m J5
2 14 -23 10yr33 - is lmgr mvfr cw lm ��5 `'6
Ground
elev 3 23 -95 7.5yr7/4 - gcs osg ml - - 7 .8
97.14 ft
Depth to
limiting
factor
>� I ( I
Remarks:
5 1 0 -16 10yr2/2 - is lmgr mvfr cw 2m 1 5 `'6
2 16 -29 10yr33 - is lmgr mvfr cw IM 75 v .6
Ground
elev 3 29 -90 7.5yr7/4 - gs osg ml - - .7 .8
92.3 ft
Depth to
limiting
factor
>90
Remarks:
._ .............
Ground
elev
Depth m ling
factor ff
I
Remarks:
t
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
. AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 1 4q 00%
Mailing Address ,2o a3 .2- P � M iJ 6
Property Address 3a ,,- /l l i i J
(Verification required from Planning Department for new construction)
City /State /rai evl ___ Parcel Identification Number (r,V
LEGAL DESCRIPTION
Property Location W '/4, /kW 1 /4, Sec. I T Ak N -R Town of
Subdivision „ T -LEV VlWct , Lot # .
Certified Survey Map
' # Volume , Page #
Warranty Deed # 6 "' 0 - 1 6 ���� _____ , Volume / e ( C � Page #
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ 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.
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 Zoning Office within 30
days of the three year expiration date.
`7/ /3 /
GNATURE 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.
- 2 //3/g9
GNATURE 7 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 of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
I
FAX
ST. CROIX COUNTY ZONING OFFICE
1101 Carmichael Road
Hudson, WI 54016.
(715) 386 -4680
DATE: 1 - PL 1 7 L
TO: Fax Number. ��S I l r 22—cj 2
Name: � gtt�s)
FROM: Fax Number. 386 -4686
Name:
Number of Pages Including Cover Sheet
9 9
IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE
CONTACT:
NAME:
TELEPHONE NUMBER: ��� r� 3 ' �4 i
/( -[ z
e
u
2�
40
STAIE 13AF1 or wiscotimm r( 2 — 1996 KATHLEEN H. WALSH
DOCUMENI NO. WAnnANTY DEED REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
Tr o y _ - D!!yg j2pp_2�! t __Corpora of a ti nnesota
Corporation, (3rantor 07-07-19" 10:35 AN
conveys and wnrmnis to UNRANTY DEED
EXEMPT 11
Jon M. Pennycook and Michelle M. Michel CERT COPY FEE:
COPY FEE:
TRANSFER FEE: 269.70
RECORDING FEE: 10.00
PAGES: I
mn
St. Croix
since of Wisconsin:
lot 89 of the Plat or Troy vilincle in the Town of J n ennycook
'Troy, St. Croix Comity, Wisconsin. 2 2 Henslow Avenue'
0 dale, MN 55128
Subject to Declarations of Cowmatits, Conditions
and Restrictions for Troy vilInge, r(-(-nrdrd In
- - --
Vol . 1241, Paqr- 256, as Voc. No. 559964, and 19.28.19.1318 0
the Declaration of ( Course covenants, j3TiiI1icniIonT4
Conditions and rasenients, recorded in Vol. 1241, arce umber jPIN):
Page 301, as Doc. No. 559969, all as appearing in the
office of the Register or Depfls, for St. Croix
County, Wisconsin, and such other easements,
reservations, restrictions and reservations of
record, or in use, and obligations contained
in the Purchase Agreement for this lot.
11119 is –n
(is) (IS not)
E to mitt.-twie
Dnl . cc) 1149 23rd June 99
(illy of
S E A L) (SEAL)
• Ka
0 k V.c P
thy M.
AX V*ce President
Troy Development Corporation
(SE-AL) (SEAL)
•
AUTIIENIICAtION ACKNOWLEDGMENT
• MINNESOTA
S FA I E or
Anoka Ss.
Comity. I
authenticated this clay of Personally came before me 114% - 23rd day of
June —.19 99 the above named
Kathy
m cook, Vice President
--T-r-0Y--j!e--v-e-1
T17LF: MEMBER SIAIE BAIT Or WISCONSIN
(if 1101, In nin known to he the porron who executed the
ntitholl7•d by q 70G.06, w1n. •litnj Inr�trmnnnl�sndlckrio �pjolge�lflesam�,O.
IIIIS INSTNIN1171`11' WAS DnArTro ny
TROY DEVELOPMENT CORPORATION'
Na c cv L
L. Clift
Y--!:�-
Nnfnty ritmic.- Anoka
(S'911 may be authenticated of ncknowledged. Both nip not CotmIrwj MIN
necessnry) My CommIsMon Is permanent. (11 not, state expiration
aalw—january-31 rmp000
9.1wil"IT In na cnpn,"y should bo ivrerf n p1hited hMow lh,h Orp,fam., 992 tilt M7 1A
wAnnANTYVEED SIATIT nArl or w*,rotmw twro rorms. P.O. Pow 10208. Oreprofty WI 54JO7.020A
rn Il 7 1996
NANCY L. CLIFT
Notary Public - Minnesota
ANOKA COUNTY
My Commission Expires Jan. 31, 2000
:F: j 84 63097 S.F. o
s \ _ _ ° I 1.448 ACRES
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