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HomeMy WebLinkAbout020-1317-50-000 I sTC 104 AS BUILT SANITARY - SYSTEM REPORT OWNER r! poi i h ADDRESS Q S �'7 T C OUN Tly SUBDIVISION / CSM #��� SECTION LOT # �, N -R —_ W Town of ST. CROIX COUNTY WISCONSIN � P LAN EVERYTHING WITHIN IN 100 FEET OF SYSTEM Lor 0 i.� 33 — Z56 vc� . INDICATE NORTH ARROW Provide setback and elevation information on r Provide everse of this form. 2 dimensions to center of septic tank manhole cover. Y BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: L, /ec Cli Liquid Capacity: Setback from: Well l5 House '7' Other Pump: Manufacturer Model# Size Float seperation Gallons /cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: r Length d " Number of trenches 2 Distance & Direction to nearest prop. line: Setback from: well: House 2 6" Other ELEVATIONS Building Sewer ST Inlet: ST outlet: PC inlet PC bottom Pump Off Header /Manifold Bottom of system Existing Grade Final grade ht F bpi DATE OF INSTALLATION: Top Pf-sL PLUMBER ON JOB: 19 l�rm se LICENSE NUMBE ;0, INSPECTOR , 3b 'Zlc�e h oLe l�JPv g 3 -vs 3/93:jt Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y Safety and Buildings Division ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarylv .. Personal information you provice may be used for secondary purposes [Privacy Lam s.15.04 (1)(m)]. Pjclrl Vjlge;'s ItioxN ❑Aft @C*age [I Town of: State Plan ID No.: CST BKMElev.: tSttl Insp. BM Elev.: BM Description: Parcel T020"1317-50-000 00 1 loo 4 rd. TANK INFORMATION LEVATION DATA A9800166 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. epti f CG Benchm '� i 7 IC047 1 Oct$ Dosing A gj 1 �3 A li 'T.2 Cl 1. Ir Aeration Bldg. Sewer�� Holding St Inlet If TANK SETBACK INFORMATION N � Outlet t C? ( 41 9d,c� TANK TO P/ L WELL BLDG. v A ir take ROAD Dt Inlet epti -j- 5 S b t, Z0' NA Dt Bottom Dosing NA Header/ Man. �ti"I�� (0. �q• Aeratio NA Dist. Pipe Holding Bot. System ` ll�l y It96 SlYt1 . ,� PUMP / SIPHON INFORMATION Final Grade 7 , p' k ?,V7 012..'4 Manufacturer _ errand -, Vila.► Vim' 0% 4.0 4 15.49 Model Nu r GPM TDH Li Friction S m TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / Width r Length r No. Of Trenches PIT No. Of Pits a. Liquid D th D 3 J' L- DIMEN SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHI Manufacturer: INFORMATION Type of �Zr n' t COr CHAMBER Num . tvalT Systernc".i Vo 0 OR UNIT DISTRIBUTION SYSTEM 0.1 oe Header/Manifold it Distribution Pipe(s) Y e x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length G•25 •Dia. e4l Spacing C d t SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over K Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center ���j�! Bed /Trench Edges soi ❑ Yes ❑ No ❑ es COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 24.29.19,SE,NE 873 JANE CIRCLE — SUNRIDGE III LOT 60 t.) kA, +J M - T ajo aY dole/ S l Kot* z) Plan revision r4 uired? Yes X No q ❑ `j 1 101 1 18 1 1 3 Use other side for additional infor on . SBD -6710 (R.3/97) Date pector gnature ert. No. I I SANITARY PERMIT APPLICATION Safety and Buildi Division *6 cons i n 201 W. Washin ton Avenue In accord with ILHR 83.05 Wis. 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 �f than 8 1/2 x 11 inches in size. ✓T • �� X • See reverse side for instructions for completing this application State sanitary Permit Number 3 Personal information you provide may be used for secondary purposes ❑ Check it revision to previous aj5plication [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Propert caner (ame Property Location 3� 9 `L - 1/4 � 1/4, S T 2 , N, R (or) Propert Owner's Mailjog Address Lot Number Block Number City, Sta a Zip Ddy Phone Num er Subdivision Name O CSM Number / c' > II. TYPE F BUILDING: (check one) ❑ State Owned ity Nearest Road Public 1 or 2 Family Dwelling -No. of bedrooms Pi Pi Town OF r4 III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 .❑ Apartment / Condo — / l7 o 2 ❑ Assembly Hall 6 E] Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Cam Merchandise: Sales/ Repairs 11 [] Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash Hotel M I 9 Office/ 13 Other: s ecif y S / /Motel ❑ p ❑ ❑ 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) N A Sanitary Permit was previously issued. Permit Number 3o - 7&1 - 7_ Date Issued .. 8 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 In Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade J Req�ed (sq. ft.) Propos d (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 0 9 0 d6 , 5 Feet Qo 5 Feet VII. TANK i Capacit allo Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in structed T nks Tanks ,e eptic fan >r Holding Tanks !� .dfZ Y ❑ ❑ El 1:1 1:1 Lift Pump Tank /Siphon Chamber ❑ ❑ 01 ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name: (Print) Plumb is Signature: ( Stamps) MP /MPRSW No.: Business Phone Number: Plumbe s Address (Street, Cit , State, Zip Code): le., L IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued Issui g A t Signature (No Stamps) KA roved Surcharge Fee) pp El Given Initial Q' Adverse Determination u w« � If /qb s X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11197) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber • w 1I 7 g � r CA v g � V n r � r i to � e r , N r . JOB TIMM EXCAVATING SHEET NO. Z of Z Route 1 Box 192 �d WILSON, WISCONSIN 54027 CALCULATED BY '~ DATE 3 �� (715) 772 -3214 (715) 386.5443 MPR3 #3224 WI MPCA #696 MN CHECKED BY DATE SCALE ..... ......... ..: ....:.. .. .. ...... ............ ... ............. '. i.... ......;... ..... .. .. .. .. .. ... ... ... .................. ... ....... �4 .. ,.. ..... :.... . ,fr" , ?.. ! .. __, ... .. ..., �► G 1 ..... ....... 3 PRODUCT 205-1 Grodon, Mon. 01471 To Order PHONE TOLL FREE 1 -8&225 -6380 Wisconsin Department ofCommerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings 3 in aecrpkd with Comm 83.05, Wis. Adm. Code Attach complete site plan on paper not We than ag34 x I I W' 1 � "{ 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, and location and distance to nearest road. Parcel I.D.# APPLICANT INFORMATION - Please print all Information. 020- 1317 -50 Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). R Da , y c Property Owner Property Location Jarvis Brian Govt Lot SW 14 NE 1/4 S 24 T 29 N,R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 873 Jane Circle 1 60 Sunrid a III City State Zip Code PhoneNumber ❑ City Ej Village ®Town Nearest Road Hudson WI 54016 Not Published Hudson I Jane Circle ® 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 .7 bed, gpd/ft' .8 trench, gpd/ft' Absorption area required 643 bed, fl' 562 trench, fl' Maximum design loading rate .7 bed, gpd/f? .8 trench, gpolft= Recommended infiltration surface elevation(s) 883 ft (as referred to site plan benchmark) Additional design / site considerationai 2 - Y x 54' Sidewinder, Hi capacity "turtle - shell" trenches Parent material sandy/loamy outwash Flood plai n 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 NS El U N S❑ U ® S❑ U N S❑ U ❑ S N U ❑ S® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPDR Boring# Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz Consistence Boundary Roots ;Trench ................. .................. 1 1 0 -12 10YR 2/2 - sl 1 f sbk mvfr cs l f/m .4 .5 2 12 -19 10YR 3/4 - sl 1 m sbk mvfr cs l m .4 .5 Ground 3 19 -28 7.SYR 3/4 - lcos 0 sg ml cs lm .7 .8 elev 92.7 ft 4 28 -67 10YR 4/4 - cos 0 sg ml cs - .7 .8 Depth to 5 67 -94 1 OYR 4/4 - fs 0 sg nA - - .5 .6 limiting factor > 94" Remarks: _irregular 1/2 -1" 10YR 3/4 sl (O,m) band at about 67 "• some gr 28 -67" ................. .................. ................. 2 1 0 -10 10YR 2/2 - A 1 f sbk mvfr cs If/m .4 .5 2 10 -21 10YR 3/4 - sl 1 m sbk mvfr cs lm • .4 .5 Ground 3 21 -28 7.5YR 4/6 Icos 0 sg ml gs lm .7 8 elev 94.5 ft 4 28 -76 10YR 4/4 - cos 0 sg m1 cs - .7 .8 Depth to 5 76 -110 7.5YR 5/4 - s 0 sg ml - - 7 8 limiting factor > 110" Remarks: some gr 28 -76" CST Name (Please Print) Signature: Telephone No. Henry F. Grote 715 -665 -2681 Address P.O. Box 57, Knapp, W1 54149 Date CST Number Ref# 5/5/98 222774 270 PROPERTY OWNER: Jarvis, Brian SOIL DESCRIPTION REPORT z7o Page 2 of . 3 PARCEL LD.# 020- 1317 -50 Depth Dominant Color Mottles Structure GPD/ff Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. nsistence Boundary Roots Bed Trench 3 1 0 -6 10 2/2 - s1 1 f sbk mvfr cs 1f/m .4 .5 2 6 -24 10YR 3/4 - sl 1 m sbk mvfr cs lm .4 .5 Ground elev 3 24 -33 7.5YR 4/4 - sl 1 m sbk mfr cs lm .4 .5 92.3 ft 4 33 -40 7.5YR 4/6 - is 0 sg ml cs if .7 .8 Depth to 5 40 -53 l OYR 4/4 - mcos 0 sg ml cs - 7 8 limiting factor 6 53 -86 7.5YR 5/4 - s 0 sg ml - - 7 8 > 86" I Remarks: 4 .. 1 0 -6 10YR 2/2 - sil 2 f sbk mvfr cs lf/m .5 .6 2 6 -19 10YR 5/4 - ail 2 f sbk mvfr gs lm .5 .6 Ground elev 3 1 -4 8 10YR 4/4 sl 3 m sbk mfr cs if .5 .6 90.1 ft 4 48-61 7.5YR 4/6 - sl 1 m sbk mfr cs - .4 .5 Depth to 5 61 -75 l OYR 4/4 - cos 0 sg ml - - .7 .8 limiting — factor > 75" Remarks: Ground elev Depth to limiting factor Remarks: ................. ................ Ground elev Depth to limiting factor Remarks: d R f j N tj qf tA loel Qj J off, ;r u n- .r c� � � N s J LA �' a Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 `Division of Safety and Buildings n r Comm 83.05, Wis. Adm. Code Attach complete site plan on paper not Q x i e. Plan must County include, but not limited to: vertical and h r nt (B , direction and St. Croix percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D.# 020- 1317 -50 APPLICANT INFORMATION - Please print all information. Personal information you provide may be used for secondary purposes (Privacy Lew, s. 15.04(l) (m)). R e A Property Owner Property Location Jarvis Brian Govt Lot SW 14 NE 1/4 S 24 T 29 N,R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 873 Jane Circle 60 1 Sunrid a III City State Zip Code PhoneNumber ❑ City ❑ Village ®Town Nearest Road Hudson WI 54016 Not Published Hudson I lane Circle ® 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 .7 bed, gpdff .8 trench, gpolft' Absorption area required 643 bed, ft , 562 trench, ft' Maximum design loading rate .7 bed, gpdfft: .8 trench, gpdfft' Recommended infiltration surface elevation(s) 883 It (as referred to site plan benchmark) Additional design / site consideration s} ""12 - Y x 54' Sidewinder, Hi- capacity "turtle- shell" trenches Parent material sandy/loamy 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 ® S ❑ U ® S ❑ U ® S ❑ U ®S ❑ U ❑ S ® U ❑ S ® U SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Structure GPDfftz in. Munsell Qu. Sz. Cont Color Texture Gr. Sz Consistence Boundary Roots Bed Trench 1 1 0 -12 l 0YR 2/2 - sl I f sbk mvfr cs 1 f/m .4 .5 2 12 -19 10YR 3/4 - A 1 m sbk mvfr cs I m .4 .5 Ground 3 19 -28 7.5YR 3/4 lcos 0 sg ml cs lm .7 .8 elev 92.7 It 4 28-67 l OYR 4/4 - cos 0 sg ml cs - .7 .8 D to 5 67 -94 l OYR 4/4 - fs 0 sg ml - - .5 .6 limiting factor > 94" Remarks: irregular 1/2 -1" 10YR 3/4 sl (O,m) band at about 67 "; some gr 28.67" .................. ................. .,, 2 ... 1 0 -10 1 OYR 2/2 - sl 1 f sbk mvfr cs I f/m .4 .5 2 10 -21 ` IOYR 3/4 - A 1 m sbk mvfr cs lm • .4 .5 Ground 3 21 -28 7.5YR 4/6 - lcos 0 sg ml gs lm .7 .8 elev 94.5 ft 4 28 -76 10YR 4/4 - cos 0 sg ml cs - .7 .8 Depth to 5 76 -110 7.5YR 5/4 - s 0 sg m1 - - .7 .8 limiting factor > 110" i Remarks: some gr 28 -76" CST Name (Please Print) Signature: Telephone No. Henry F. Grote 715 -665 -2681 Address P.O. Box 57, Knapp, WI 54749 Date CST Number Ref # 5/5/98 222774 270 PROPERTY OWNER: 4rh%Bri- SOIL DESCRIPTION REPORT 27o Page 2 0 +• 3 PARCEL I.D.# 020- 1317 -50 Depth Dominant Color Mottles Structure GPD/ft' Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. nsistence Boundary Roots Bed :Trench _,,.,3 1 0 -6 10YR 2/2 - sl 1 f sbk mv& cs lf/m 4 5 2 6 -24 10YR 3/4 - sl 1 m sbk mvfr cs lm .4 .5 Ground elev 3 24 -33 7.5YR 4/4 - A 1 m sbk mfr cs lm .4 .5 92.3 ft 4 33 -40 7.5YR 4/6 - is 0 sg ml cs if .7 .8 Depth to 5 40 -53 10YR 4/4 - mcos 0 sg ml cs - .7 .8 limiting factor 6 53 -86 7.5YR 5/4 - s 0 sg ml - - 7 8 > 86" Remarks: 4 1 0 -6 10YR 2/2 - sil 2 f sbk mv& cs l f/m .5 .6 2 6 -19 10YR 5/4 - sil 2 f sbk mvfr gs IM .5 .6 Ground elev 3 19 -48 10YR 4/4 - A 3 m sbk mfr cs if .5 .6 90.1 ft 4 48 -61 7.5YR 4/6 - sl 1 m sbk mfr cs - 4 5 Depth to 5 61 -75 1OYR 4/4 - cos 0 sg ml - - .7 .8 limiting factor > 75" Remarks: Ground elev Depth to limiting factor Remarks: .......... Ground elev Depth to limiting factor Remarks: I � y V r rp N tj Qr tA c l r O J J J N. o � (4 C Q JP �. Qj f, ? a ti ci T on • rj N a z ' 0 Ja 41 v .r ^ ? ' a Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3�rp�ixNQ.,: Personal information you provice may be used for secondary purposes [Privacy La S. 15.04 (1) (m)]. ii // bb 11 dd Permit JARVIS ,r s BRIAN f LSD %Y I lage Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: SUN Parcel Tl ffh-_1317- 50 TANK INFORMATION ELEVATION DATA A9800001 TYPE MANUFACTURER CAPACITY STATION BS HI ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFO ATION St /Ht Outlet TANK TO P / L WELL I i , BLDG. Air I to ntake ROAD Dt Inlet Alt— ir Septic NA Dt Bot Dosing N /Bot. Man. Aeration N Holding m PUMP / SIPHON INFORMATIO N de Manufacturer D and Model Number GPM TDH 1 , Lift Friction System DH Ft Loss Fi Forcemain Length Dia. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Lenyr I No. Of Trenche\ PI No. Of Pits Inside Dia. Liquid Depth D IMENSIONS SYSTEM TO P / L BLDG WELL KE / STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of Mode Number: System: OR UNIT DISTRIBUTION SYST Header/Manifold Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or Grade Systems Only Depth Over Depth Over xx Depth Of V Seeded/ Sodded xx Mulched Bed /Trench Cent Bed /Trench Edges Topsoil Yes ❑ No ❑ Yes ❑ No COMMEN : (Include code discrepancies, persons present, etc.) LOCATI HHUDSON 24.29.19,SE,NE 873 JANE CIRCLE Plan revision required? ❑ Yes ❑ No Use other side for additional information. T-1 I SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. I %L con s iSANITARY PERMIT APPLICATION 2 01 afety and E.W shngtonAve lion n In acco d r with IL Wis. A m Code P.O. Box 7969 I Department of Commerce th HR 83 05, d Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County L // � _ than 8112 x 11 inches in size. 5 , .6,0 tx • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs E] Check if�si previouus application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Ow er Name Property Location X om 1/1 ,51 /4 hIC 1/4 S ,� y T ap , N, R / Q Vor) Property O ner's Mailing Address Lot Number Block Number J /1/ City, State Zip ode Phone Number Subdivision Name or CSM Number II. Y E F B ILDING: (check one) C] State Owned !tia Ne a Road Public 1 or 2 Family Dwelling - No. of bedrooms Town OF �J4i0t2 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo /317 _ tjp 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.A New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of S. ❑ 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 12,0 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq, ft.) Proposed (sq. ft.) (Galslday /sq. ft.) (Min. /inch) Elevation Y/ 5 0 �6 5 Feet 9W, S Feet VII. TANK in Capacit Total # of Prefab. Site Fiber- Exper- INFORMATION g Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tank Septic Tank or Holding Tank , avy ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ 1 ❑ 1 ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu is Name: (Print Plumber's Signature: (No amps) MP / MPRSW N Business Phone Number: 77Z 1 V PIumbe s Ac dress ( treet, Cit , State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued Issuin Signature (No Stamps) 1R pp []Owner Given Initial roved Surcharge Fee) ! // �(// � � !� �' • ( • t Ac�' ,( �� Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber L 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. & 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 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. JOB TIMM EXCAVATING 2 Route 1 Box 192 SHEET NO. r' OF A WILSON, WISCONSIN 54027 CALCULATED BY / ��+ DATE (715) 772.3214 (715) 386 -5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE .............................. ..... ..... .... ... ..... ..... ... ..... .... �D .. . TP, .... ... .. ........ : ... ....... . .... ...... .... :........ ........... .... .................. ...... . �. G �...:.. ........:........:. ..... .. a .. .. f :... ..... .... .. Ell ;. . ........ :........... .. ..:.... r Q G ..... ... , ' ,. . 3 . 1` fi r /f ,^ !3 2 / ....... ��/ ' �/ ... -.. LD� / . f ....... .... .. ........... !' 1 . .. ... a .. ib , _.. . i ... ....._ _ �..?. ....... s- s k •-- . ... _,.. � /._.. it ..... .. ...................... ... .. , Ida ... ... .. ... . PRODUCT 2051 ®Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1- M225 -M JOB 'fY lkrL TIMM EXCAVATING SHEET NO. OF Z Route 1 Box 192 j WILSON, WISCONSIN 54027 CALCULATED BY ! LJ1'_"^ DATE - - (715) 772 -3214 (715) 386 -5443 / MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE . .... .... .. .. .. .... .... .... .. ...:........... .. ........... :........... >... ..... .... .. .. ... ..... .... ....: ' .....:.. .. ... ....... ... ; .. .... ..... ... .. .... I I ...... ..... .. �u i ... .. .. U �. t ... ... ,,,,� �`� --�► ............... PRODUCT 205 -7 � inc, Grow. Man . 01471. To Order PHONE TOLL FREE 1-M -225 -M Wisconsin Department of Industry, Labor and Human Relations SOIL AND SITE EVALUATION REPORT P age ` Of 3 Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code ST C�P Attach complete site plan on paper not less than S W � "p2ze. Plan must include, but COUNTY not limited to vertical and horizontal reference p i��AA . fi►eeti' _ ipf slope, scale or PARCEL I.D. A dimensioned, north arrow, and location and dis6An yto nearest road «. APPLICANT INFORMATION- PLEASE - 'PRINT ALL INI~dHt�/I`TIb,N'' REVIEWED BY DATE PROPERTY OWNER PROPERTY LOCATION ( ') i''1 /v y e1 osc, A 'f GENT. LOT $E 1/4 NE 1 /4,S2K T 2-9 ,N,R E PROPERTY O�J W 1. OWNER MAILING ADDRESS e ° '. BLOCK >t SUBD. 5 U (Z L7 Cr E /y/� 3+- 5 T--. Y CITY, STATE ZIP CODE PHONE NUMBER a71 []VILLAGE OWN NEAREST ROAD gil0 I C f-Fup.S o '(..�N5) OSeF AJ You --jC, 'AD - It Oew Construction Use It,"esidential I Number of bedrooms 3 - to f/ (] Addition to existing building (] Replacement ( ] Public or commercial describe yse - Code derived daily flow _ ( O gpd Recommended design loading rate - 7 bed, gM trench, gpd/ft Absorption area required . KY bed, ft 75� Wench, ft Maximum design loading rate I bed , At2 6 F Wench 2 9Pd , gpdm Recommended infiltration surface elevation(s) S- M - 3 It (as referred to site plan benchmark) Additional design / site considerations NSE �- 7Z'CN 4(,l S C&,&4 W 10 CO,& u R $ . Parent material SGS 5 y /,3 v pKy,f -RpT Flood plain elevation, if applicable NIA ft S = Suitable for system CONV MOUND IN- GROUND PRESSURE AT -G E SYSTEM IN FILL HOLDING TANK U= Unsuitable for sy stem La S L7 U 0s ❑ U ®-S' 11 U 0 0 U D-8 [IS 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 ITmrich i `� � / 0 -� / o Y/� �-' /Z- �Si� l� 5.6.E ii. vf� � 2 . f . S • � �6 YR 3l3 5 /,-o x4k "W fie �S i� , 4( S Ground 3 - .2 3 /0 Yk 3/4 Sid. J -%, 6,r IVA+P- -C s I S , G elev. 9a r ft. �{ Z3 3 / Vg / s � � �► s l�k - 5 �c cv — , �F I Depth to S 3� - yv 7 5 YX dX C! limiting e ; factor ,, �' 1� � ylP �/� � d S �� — — 7 :s>i�>rwab I �oloe} i A r PROPERTY OWNER S, 3 FU 5C A-- SOIL DESCRIPTION REPORT Page ' of 3 PARCEL I.D. # - 5 7 0 AJ R /D6 LC` Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed curo 10 io y R 2-F s bit ,w.u C s Z s Ground 3 y lo yk Sl f- S . © s 7 elev. 8�n I Depth to smiting fa c tor q I Remarks: Boring # Z ,e 'Im v CS 2-A* 5 / 0 yR 313 R C Ground:: 3 >06, 7, S Yk s y l ees �s 1 , 7 z' � y� 7 rt. 5 VP i Depth to `s Y6 0 /0 Y/2 ,5 D S limiting factor Remarks: Boring# o -� /C) z n R S ' S ,(c Z VIAlOVAP-313 f it Ground 9� L Depth to limiting 7 factor i Remarks: Boring # : : Ground elev. ft. Depth to firnofinn (y) S oupay ^M � o W W V M � � _ r 9 co on cl 40 AJ vi w 0 3 N o • r }}�� • • • , • � f ir, •1;!y� ��,1��y t kf I V ► 1��tl7� + Y"rY' *S� r ��µ "t�, �.' , S4",�tti'•, � � + K tt'r ^w a� • � its , < i tr ��i,t f jam` � n Tb t — • _.d J �'fi, xtJ � ?„{•:t r S.r � � + t { , v 0. Z � !�' I�t • y'L.,S�...r�h1 � � r,' y�'t 1�, �.� ?AA�, t 1 • �• F' • 6 ay. t y p c • �. . Ya, 1 T `�`,4'� �' (r ;� • 7. , r'I Of,' r Y. � 1,i �� • � • • * .j��li�, b� 1 Si. t t l s��� � � y • y�, 1 is .� ,ti ♦ a � • L` . FAR ,�� t 7 ` qp ! l � 7fi rte, yam,. , �.•• , ��t r 1 �Yc• i t 1.t ft •'Ta ..�a � 1. � jj4 .���� ��� 1� NfJ Ir T^X2✓: STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER /IM& - T y AS - MAILING ADDRESS �J / PROPERTY ADDRESS n Z 3 -JA,41� 6 ✓� /� - (location of septic system) Please obtain from the Planning Dept. CITY /STATE " /�° PROPERTY LOCATION S! �' 1/4, /U 1/4, Section , T c >25� N -R �J'� W TOWN OF � ST. CROIX COUNTY, WI SUBDIVISION �6c Sr a�'� ,G sL LOT NUMBER _ 7� CERTIFIED SURVEY MAP ,3 , PT , VOLUME ! , PAGE `'& , LOT NUMBER O 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (Z) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR- Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11193 +`. S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. -------------------------------- ------------------------------------ Owner of property �J�/ � �J�k Location of property s l/41/4 , Section d�/ , TN - RW Township Mailing address Address of site �Zrc Subdivision name -Y&.q ��r Lot no. b Other homes on property? Yes k No Previous owner of property Total size of property Total size of parcel a, v Xcle - _ Date parcel was created -fV m& 12-, 1 cp Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house) ? Yes _,?!�_ Volume / /e and Page Number OJ as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. J�ti/ 76' and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Sign ture Applicant Co- Applicant Date ofSignature Date of Signature H \H If 1 A IN i "V%RRAN DLF-D RE& z' DCV�U%IENT,No 11 01 ST. CP C7( �V: J U 1 2 'riiis Deed. m.,de tct%k,�vn c,� (I f-n t r a Wisconsin corporacion at 9:00 A. --tk 1JLt,;, Reg,,,re c c and Brian Jarvis, a sin,110 pors,3n — - — — - — — AKA Brian W. Jarvis W I tnesseth, That the said (iranti let a ..IiUJNC Ll 11111L dollar and other 000d and Laltiable consi eri* A co -%e„ to Grantee the follo%king de real e in C, r o o n Entorf ri -3(zs, Inc. State of Wisconsin 1 16 �1 i rd S r rec t if k Son, ij 54016 (Parcel IJCI--dfiLaii in Number) Lot 60, of the Plat of SunRid Ill, filed in ti- - If f ice of the Register of Deriffs for St. Croix County, Wisconsin, on January - 1 in Volume b of Plats, at Page 46, as Document Number 538046. TRAM PF 1 , JR70 I This is not ho..ic,te3d pr (is) (is not) Together with all and singular the hered(Tarr.ints and appurtera-1—. And Greenwood Enterprises, inc. warrants that the title is grad. indefeasible in let: -imple and free end -'-3r 4 easements, restrictions and reservations, if _-iv. Df record and will warrant and defend the same. Dated this jj% 't June GREE)7D ENTERP,41 INC. FNTFRPRI- ) ,IN4r-, By: FV- er S F I C 0i E. 1, ames E. Rusch, its president a r_ R tsch, its secretary (SEAL) SFAI i AUTHENTICATION ACKNOWLEDGNIENT Signature4) James E. Rusch, its president ;TOTE OF 1kl[SUONSI% 11. CROIX Count%, atathea tir4d this da f June .19 96 P arrw before me this dj%ot 19 the named Lois A. Murray .-ary R. Rusch, its secretary TITLE: MEMBER STATE BAR OF 1% (If not, authorized by §706.06• \Vis. Slats.) ,:,,wcd the he the per \kh cx I '-UI1ICr1( a JL oll'! THIS INSTRUMENT 44; CRAFT17D 9Y Lois A. Murray, Zilz and Fstreen. Y? 621 Second Street Hudson, WI 54016 (Signature, may he authenticated or ackrio%%Ictl Kith are rte t 1,1 L' '\ I rA t I f 1.1! p IwFD [\IF R\R(11 i (1R\1 V. LOCATION SKETCH IIX COUNTY WISCONSIN U.S. HW i 4V ,� S1 E UTILITY EASEMENT SHALL -WA LINES, EXCEPT THAT JD CLOSER THAN 1.5' TO SR IRON ! OR ANY IRON I I DS OF CURVES. 0 SECTION 24 NT— ALUMINUM CAP, FOUND T29N, R19W IND IND WEIGHING 3.65 Ibs. /ft. SET Owner & Developer: S MONUMENTED WITH I" X 24" Greenwood Enterprises, Inc. G 1.68 Ibs. /ft 1416 Third St. EASEMENT PARALLEL WITH LOT LINES SHOWN THUS Hudson, Wi. 54016 ITS IVEY MAP _ VOL. 9 PAGE 2629 i S 89'25'51 "W 1028.22' � 329.65' 395.00' a 0 :qo 5.71' (n ' C) " 61 o Ln APPROXIMATE LOCATION Z 89,983 Sq Ft. O OF EXISTING WELL p" F. O t . p 2.07 Ac. � c i 62 gyp• Op pp• I� N 88,581 Sq Ft. N 15000. N / � 2.03 Ac. O � N 7 a 26.00 . o e 13 • 3S • - S7go301 "E� \ pQ C� 4 • in .m ' 80.00, ® \�� ��Q 2 0 �0 4 0• 89,328 Sq Ft. I � O M z o I ` a ti`O . 2.05 Ac. co O 6 - p y O S 7 tD N86 a 2�' 00 ' 0 �� 0 3a 31 I � / 59 O E S27 p0 �� 30 87 •700,E� 109,858 Sq Ft. Nes °oo 2.52 Ac. - 00 LO 0 O in \ \ O \ 0 \ YO _ _ i - - 26, 125 • 0 56A° 6 , m 14 UNG RO N S3 °45 0 —_ ` �2 OD 0 0 � „ r • __f N S 83 °45'0 W _ 35 ,(O YOUNG ROAD 3 r 6 a - -- 1. 00 I ;u 3 00 p8 0 „ 5 1 2 — — — — — _ 6a ° 0 54 s°- a .� i 518 Sq, Ft i 18 y s° o� o �i 21 58 O 6.28 Ac 89,312 Sq. Ft. � 1 N a / i — _ 2.05 Ac I i 2 � I bo a I � J