Loading...
HomeMy WebLinkAbout020-1142-30-000 � / 0 DO wo §� jk j& o w G G ts = m > ) w �� .- § k §\ m » k 2« - 2 / ) f§ W /\ / ° .9® 0 \ 2 ! k {5k k f \k LL )Cl \kk ) / &k \ -0 a) « © � ° 2 / Li I 2 / \ § � \ § . Z /\ 7 0. m a 2 % 0 § k \ 2 \ a \ e 2 \ a 2 , 2 e r ) E Q) \ m \ - ƒ § ƒ_ i \ } / / Q k/ k ) co k , . } ) § I . § % ) I I § ~ \ \ E�k \ �)k %$ §@ ! § a ° CD a c a m #§ o Cl) / ©k k } _ CO) }/ - t / a a a / 2 2 2 f IL § Lo o 2 § / / / / a ; a _ > o ¥ / a 2 / § / d t ° = c o c cc 3 ° m 3 = % #/a / \ 4Aƒ ¢ © _ LU m 3 2 2 ° C) % \ 9 § R§ > { 7 s a E E E 4\. G m b 7 G{ e e. o ff/ o a= c &= c- �_ 04 - oo 0 � 'D � . 2 - / { \ / \ / / \ 7 2.\ Q o }/ f k R c 2/) 2\ f 2 # k a k( % Z % L L: (L » C » §&§ 2 5 8 7 5 2 c o IL o m Q o U Q . r ,� AS BUILT SANITARY SYSTEM REPORT 3` a 9 /9 OWNER n� „�,d ID TOWNSHIP Vd5 d SEC. T AI -R�1 W c,I ADDRESS L,3 �( ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT /U LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i i �1 c., Indic ate N r h rr w BENCHMARK: (Permanent reference Point) Describe: ,2" t GO v. rtt r S to c.k � �a,P l,� I Elevation of vertical referent point: /OD; 0 Slope at site: c j SEPTIC TANK: Manufacturer: Iewe6 � Liquid Capacity: Number of rings on cover Tank manhole cover elevation: y, Z Tank Inlet Elevation: q Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons (� Number of gal. pump set for a cycle gallons; Total capacity of 1 hJ�� , � , , distribution lines gallon: size of pump head; 1 t ' gallon per minute horsepower ;brand name of pump '9and model number ; Type of-warning device HOLDING TANK: Manufacturer Number of gallons f� Elevation of manhole cover , Type of warning device SEEPAGE PIT SIZE; Number of pits feet diameter feet liquid depth seepage pit inlet pipe - elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines width length 13 tile depth SEEPAGE TRENCH.: width length PERCOLATION RATE ��_ AREA REQUIRED / $ AREA AS BUILT INSPECTOR )6�� DATED 2 PLUMBER 09 JOB z � LICENSE NUMBER DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINU LABOR & HUAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BO:. 7969 BUREAU OF PLUMBING MADISON, W653707 t ®CONVENTIONAL ❑ALTERNATIVE State Plan l. D. Number: ❑ Holding Tank El In-Ground Pressure F-1 Mound (if assigned A NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE David D. Smith 1 303 7th St., Hud.SUn, W1 --Y3 „6 a BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: ]CST REF. PT. ELEV.: NUJ SW, SEc. 34,T29N- R19W,Lot 10,Stewant'sAdd.Town ab Hud�so s Name of Plum ber: MP /MPRSW No County: Sanitary Permit Number: Cat Pvwets 1563 St. Ct oix 43653 SEPTIC TANK /HOLDING TANK: . MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: 11ARNING LABEL LOCKING COVER C2 I 9V / PROVIDED: PROVIDED: / �j 0 ❑YES ONO OYES ONO BEDDING: VENT DIA.: VENT MATL: HIGH WA ER Off" ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: LINE: f AIR INLET: YES ONO bt ❑YES ONO NEARESTM DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL J PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ONO ❑YES 0 N OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUILDING: I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) ❑YES — ]NO NEAREST SOIL ABSORPTION .SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER. MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: }� rf WIDTH: LENGTH. NO. OF DISTR. PIPE SPACING. COVER INSIDE CIA.. #PITS: LIQUID il f "BO - j TRENT. If MATERIAL' PIT DEPTH: ;t�IN1EN5�tON5 GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTq. PIPE MATERIAL r NUMBER Of PROPERTY WELL: BUILDING: VENT TO FRES BELOW PIPES ABOVE CQV ER. ELEV. INLE ELEV. END: LINE: ,� J �7. AIR INLET: qj. ,� ,� FEET FROM o(7S NEAREST lo MOUND SYSTEM: 0. -, Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- OYES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES 1:1 NO ❑YES 1:1 NO [CE PTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED. SEEDED: MULCHED. NTER. EDGES. DYES El NO 1:1 YES ONO ❑YES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER: DITfE1fCt TRENCHES: OwE�MO MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: E LE V.. ELEV.: DIA.: ELEV.' PIPES: ELOVA I ANO 1�RUTFOI HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED .'I'.! #FO,sAl11A�4Tl, .j PLANS: ❑YES ❑NO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER F• INE LINE: WELL: BUILDING: FEE IF ❑YES 1:1 NO DYES 1:1 NO I NIEAftE$ \Q � Sketch System on Retain in county file for audit. Reverse Side. SI AT R : TITLE: ^ DILHR SBD 6710 (R. 01/82) 10 wlscOnsln APPLICATION FOR SANITARY PERMIT r COUNTY DILHR (PLB 67) 0 oEaRRTmEnTOC UNIFOR '7�NI Y PERMIT # 0 InOUSTRV,LRBOR6HUTRn RELRTIOns �� // — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /zx 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PR ERTY OWNER MAILING ADDRESS/ / ,= SS/ S PRpPERTY LOCATION CITY: 1/4, S_ , T N, R ' (or) W TOWN OF ?- / : LOT NUMBER BLOCK UMBER SUB DIVIS ON NAME NEAREST RO D, LAKE OR LANDMARK STATE PLAN I.D. NUMBER /C T ) 1 TYPE OF BUILDING OR USE SERVED "f '' — C d0 Ly 1 or 2 Family Number of Bedrooms: Public (Specify): 7 THIS PERMIT IS FOR A: X New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. 1Z Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total # of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete I Constructed Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: ( inutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 1 Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of a private sewage system shown on the attached plans. Name of Plumber (Print y: S MP /MPRSW No.: Phone Number; Plumber,'s Address: / / Name of Designer: -� COUNTY /DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: El Disapproved g p 7 ❑ Owner Given Initial Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR - SBD - 6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber r — Form - S 'P C lou Owner of Property — A)v) �Q ,Location of Property Section ��' ,T N RW Township Mailing Address ,l Subdivision Name -- Lot Numbe Previous Owner of Property V4 S '-eAwctit`fi Total Size of Parcel Date Parcel Was Created Are all corners identifiable? _Yes No 1_aclude with this application one of the fullowing Certified Survey Map . Deed .Land Contract, or .Other i:egal Document which describes the property 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 de d record, in the Office of the County Register of Deeds as Document No. $% ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the some has been duly recorded in the Office of a County R ister of Deeds, as Document No. ), SIGNATURE Of OWNER SIGNATURE OF c -OWN .^. (IF APPLICAaLE) X DATE SIGNED (GATE SIGNED II — REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS DEPARTMENT OF PERCOLATION TESTS 115 DIVISION P.O. BOX 7969 INDUSTRY MADISON, WI 53707 LAWR A'&D (H63.090) & Chapter 145.045) HUMAN IRE p cTl N: TOWNSHIP/ 1 ^t,i =r= OT NO.:BLK. O.: SUBDIVISION NAME: F OCATIO O A E: P M I ADDR S: DATES OB SERVATIONS MADE NO.BEDRMS.: COMM R IAL ESCRIPTION: (PROFILE D S I T ONS: 1 PERCOLATION TESTS: lI ence ®New ❑Replace ..ATING: S= Site suitable for system U= Site unsuitable for system M ENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM optional) [OS S If Percolation Tests are NOT require DESIGN RATE: Q If any portion of the tested area is in the under s.H63.09(5) (b), indicate: t Fl i n d icate Fl elevation: PROFILE DESCRIPTIONS BORINGI TOTAL D PTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. H GHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 7 y 2 B: ;2 PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN, PERT 1 PERIOD2 PERIOD PER PERI 3 R INCH 4 P P- P- - P- I P PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION �� " / - _ -- -.- ss 3' _ �_. t I y tN m- E � f i I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods spelcified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAMEprint): ITESTS WERE COMPLETED ON: A E S I CERTIFICATION NUM R: PHONE NUMB Rloptional): GST,BIG A RE:' G DISTRIBUTION: Original and one ropy to Local Authority, Proper �y.OwnGr dod foil Tester. DILHr-i SBD- 6395 1,, 32/82. ISAI _ 7 91 ( Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count6T . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) San itarj®e➢rtf79.: Personal information you provice may be used for secondary purposes [Privacy Ljyv, s.15.04 (1)(m)). Permit Holder's Name: 1= Ltu,[aillage El Town of: State Plan ID No.: SMITH, DAVID 'T! bs CST BM Elev.: Insp. BM Elev.: BM Description: Parcel 0203-114 — TANK INFORMATION ELEVATION DATA A98001 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. Air I ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TD Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: UDSON 34.29.19.733,NW,SW 660 EDIE LANE A. j s Pat �4g Plan revision required? ❑ Yes ❑ No / Use other side for additional information. SBD -6710 (R.3/97) ate Inspector's Sig 'atur Cert. No. Safety and Buildings Division e.� ■�Inln SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E- Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County �1 than 8 112 x 11 inches in size. O JT'• CVo }C • 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 ❑ Check if revisio ppfe iDus a lication [Privacy Law, s. 15.04 (1) (m)]. S/) P"/^ I State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE P A LL INFORMATION Pr erty Owner Name Propert Location 1 .,,� N j t /4, T Z ,N,R1 E W Property Owner's Ma Address Lot Number Block Number L= LN, Cit , St e Zip Code Phone Number Subdivision Name o M Numb r 01 , l - � II. TYPE O BUILDING: (check one) [j State Owned ❑cit age Nearest Road Vil l Public 1 or 2 Family Dwelling - No. of bedrooms_ Town of �� cfG L h. III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 3y 01n 19 3 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 f 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: E] New 2_ ❑ Replacement 3_ ❑ Replacement of 4_ E] Reconnection of (5 e System System Tank Only --------------- Existing System - --------- Existing System B) ArA Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 1 Xeepage Bed 21 E] Mound 30 E] Specify Type 41 E] Holding Tank 1eepage 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.) (Gals/day /sq. ft.) (Min. /inch) Elevation C l 00 Z. +Feet Qlii Feet acit VII. TANK in Ca allon Total # of Prefab. Site Fiber- E p er INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic A p p New Existing strutted Tanks Tanks e tic �ir l CSC d * &4 Cam• 5Q ❑ ❑ ❑ I ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. iUllollier "s Name: ( Print) 4lilul�r "sSignature:(NoStamps) o.: Business Phone Number: `C�d Z JA lilkw 6w0s Address (Stre , City, State, Zip Code): 45' IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing ent Si ture (No Stamps) XA roved Surcharge Fee) pp ❑Owner Given Initial (�J'� � ( 1 Adverse Determination `O X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: Original to County, One cupy To: Safety & Buildings Division, Owner, Plumber ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT A FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the I 'A --\r. residence located at: 1 /4, S l�,� 1/4, Sec. "3LIL , T 'ZC1 N, R l�_ W, Town of .. c►•�na Upon Inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? YesX_No (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concret Steel Other Manufacurer (if known) i��,f C_bNG�,t� -ems Age of Tank ( if known) : 1S Y 6s , Z � v1 t.1 ) Please Pr n . o r / (S gnat (Namet tlWwar (Title) (License Number) 5 131ti (Date) Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, Wis. Adm. Code (except for Inspection opening over outlet baffle). Name Signature MP /MPRS 5/88 K . y �►� ST. CROIX COUNTY ,,0; , WISCONSIN ZONING OFFICE N N MN N N N M ■�.�� R ST. CROIX COUNTY GOVERNMENT CENTER E I�r 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 AFFIDAVIT OF SYSTEM REJUVENATION Property Owner: Address: L L L Day time phone: W) 2> 56 – 3'767 — Parcel I.D. - 2 I 1472 -3 o Le gal Description of property. NO - 514_„ i sec. ? J4 , T. 2c1 N. , R. , Tn. of �& eLE�awl T St. Croix County, wI As owner of the above described property, I acknowledge that the septic system serving this residence (40/is not) undersized by current code standards. I understand that the issuance of a sanitary permit to allow the attempted rejuvenation of the septic system does not imply that the system meets current code sizing requirements, nor does it imply that the proposed procedure will be successful. I also acknowledge that I will make this information available to any future parties interested in purchasing this property. Signature: Date: gs 5/97 Wisconsin Department of Industry SOIL AND SITE EVALUATION / Z - Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and sr percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # 620 • / /y�.. •3 D APPLICANT INFORMATION - Please print all information. Revi ed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 5 " 5 f `f 7 E Property Owner Property Location v Govt. Lot /(1V 1/4 S& 14,S 3 yT - ,N,R / E ( r) W Prope Owner's Mailing Address Lot # TF c k# Subd. Name or CSM# G D �'or, L,✓ • /D ST�w�,pD'S �9oGv'T�o.� City State Zip Code Phone Number Nearest Road AIM50 A) 4/A. S y 1 olG ( 3 �(,� 375 z- ❑City ❑ Village Town � L A-7 El New Construction Use: Residential / Number of bedrooms ` Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 7 gpd Recommended design loading rate - S bed, gpd/ft � trench, gpd /ft Absorption area required bed, ft ? S trench, ft Maximum design loading rate S bed, gpd /ft 60 trench, gpd /ft Recommended infiltration surface elevation(s) 4C ISPAJ� SST 9a . S O ' ft (as referred to site plan benchmark) Additional design /site considerations /S2 'ex63 0 A !/3D SQ.ff - Parent material %O ESS Cb( tA_ SA9.VDy © V 7 W-f d "- Flood plain elevation, if applicable It S = Suitable for system Conventional Mound IGround Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for s [a's ❑ u 0118 u ❑ u 1 2 ❑ u I g} — ❑ u ❑ s SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /11 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench o•� /ayr,� 3 Sit% �f'fXe , "Vfle s sf .,s' •� Ground 3 • / 7­5 IV elev. ft. Af 7S� '-'r S 2- Fs,l,� �t/f a - S Depth to limiting factor f (,— in. Remarks: s y s 7— Boring # , 1, 3 , Ground eiev. ft. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. 7/S • 3AG • ���5 Address Date CST Number 2N Ulbricht 8 Associates Private Sewage Consultants 665 O'Neil Rd. Hudson, Wis. 54016 OR IGINAL PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev. tt. Depth to limiting , factor in. , Remarks: Boring # Ground elev. ft. Depth to limiting factor In. Remarks: Horizon Depth Dominant, Color Mottles Texture Structure Consistence Boundary Roots GPD /fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # ; Ground elev. ft. Depth to limiting factor in ' Remarks: Boring # Z F ' Ground elev. ft. Depth to limiting factor in ' Remarks: SBDW -8330 (R. 08/95) �1 M L .. O 1 O I � T y O Ir S Od O I I � I I I I � •-c I C1 � ; � i I l I o tA `^ GA-) N N c N 1 II � uj V w 1 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ��,�', J ls t ♦ � Mailing Address A — ,c- L,., io , Property Address 0 L� N c- / r j- (Verification required from Plaaaiag Department for new construetioa) City/State h� v, c�.s ®� . ' �. Parcel Identification Number LEGAL DESCRIP'X'ION Property Location il W 1 /s, 5 ,S t /., Sec. l T -R tic- _W, Town of ) PA Subdivision ��� �e t.� o,l . S �� • -� o J Lot # 1 .� Certified Survey Map # . Volume Page # Warranty Deed # ��' <� 1 � Volume Page it L 4 L 4 e k Spec house ❑ yes L�Lno Lot Imes identifiable .1W yes ❑. no SYSTEM WAINMANCE Impxq= useandmdntcmaloeofyouropticsystemcouldrestmitsp lc tamtobu ndlewastcs.Pr%=maintenance consists of pumping oat the septic tank evcr7 three years or sooner; if needed by a Iiiocased pumper. What you pat mto the system can affect &c fimction of the septic tankas -a treatment stage in do Rraste disposal qso= The P -mputy owner agc+as to sabot to St. GY+onc Zoning DcparGmeat a ocrtificatioa form. signed by flee owners ad by a p ] P rcskictedphmg=orit licrosedpmgx:t vc fyiog that ( tine oa4ite *astearat6rdi4*W system is is props operating condition atWor (2) after hq)ectioa and pampiag.Clf nwa m v), the septic- tm*.is iess .dmn W full of sludge. . Ywr, ffie uadersigaed havr read the abm rrquir=cnts and agcy to maiatsia the private sewage disposal system with the standards sd form, herein. as sd by fire Department of Commewc and the Department of Natmal Resources; State of Wisconsin.. Certification stating that your septic system has been. maintained mast be complleted, and returned to the St. C .CmI ty Zoning Office widda 30 I== -91f DA SIGNATURE OF APPLICANT DATE OWNER CERWMCATXON 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 = W 7 Z,L �b virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE « « « « «« Any information that is mis- represented may result is 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 8 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 Location of property ,,1_ - 1/4 , Section � , T_ j jN -R Town ship �,�� Mailingaddress (,1pp %.(l e, Lwl I Address of site 4 Subdivision name S w d �' g Lot no Other homes on property? Yes Previous owner of property Total size of property 'Z. C-% o Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _ Yes No Is this property being developed for (spec house) ? Yes _)�,_ Volume - 6_ 6A and Page Number _4-4c1 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. 3g&1 , 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. 3Y�r" Aigatur I Co- Applicant Date of Signature Date of Signature iiWSCONSIN REAL ESTATE TRANSFER RETURN Wisconsin Department of Revenue ' GRANTO�.R�:. ' GRANTEE: q Name mA rd irw triflCes, S.t;. Profit marim TiM. Doid D. &dth Md May B. &dth Social Security Number (Voluntary) I I I I Social Security Number (Voluntary) I I I I Full Address - New address if property transferred was residence Full Address 113. Last BL. Street 13tH Ith Street River Fills, V1 S40n Wm 1111 5016 Is grantor related to grantee? Relationship includes, Name and address to which tax bills should be sent if not the same as above marriage, blood relative, partner, lessee- lessor, co- owner, parent corporation or joint owner. ❑ Yes ( No Grantee is Individual ❑ Partnershi [ Other Telephone: Grantor ( ► — I Telephone: Grantee ( 1 — PART I - PROPERTY TRANSFERRED Check,proper box and enter name of municipality and county Street address of property transferred include road name and /or fire number. ❑ City ❑ Village [Town of: HmLwiin County of: St. QVIX Legal Description (Fill in complete legal description in space below or if metes and bounds description attach 3 copies of it as shown on the instrument of conveyance. If certified survey map number is used in description list town, range, section and acres.) Lot No..... © Blk No........... Section........... Town Ran a ' It's Id. IWAtad im the of ............. g ......... Plat Name.._................ ... ........ .. .. ........ ...................... the Sit o Siisc 34, *WN, Ri31N. Property Parcel Number ......:::::.:: PART 11- PH SICAL DESCRIPTION AND INTENDED USE 1. Kind of Property b. Residential Units, if any 2. Principal Intended Use 3. Land Area and Type Estimated a. [xand Only ❑ One Family a. [Residential d. ❑ Agricultural a. Lot sil — x ❑ ❑ New Construction ❑ 2 and 3 units b. ❑ Commercial e. ❑ Recreational b. • Total Acres ❑ ❑ Building Previously Used [:14 or more units c. ❑ Industrial f. ❑ Other (Explain) 1. Tillable Acres ❑ Solar Design c. ❑ Rental 2. W.T.L. Acres ❑ Earth Sheltered Home 3. F.C. Acres ❑ Condominium c. Ft. of Water Frontage ❑ PART III -TRANSFER (Answer as many as apply) 1. [5 Sale 2. ❑ Gift 3. ❑ Exchange 4. ❑ Deed in satisfaction of land contract - What was the date of the original land contract? 5. ❑ Other transfers (Explain below) 6. Ownership interest transferred [3 Full ❑ Other (Explain below) 7. What is the amount of mortgage assumed by grantee? $ 8. Does the grantor retain any of the following rights: ❑ Life estate ❑ Easement ❑ None PART IV - COMPUTATION OF FEE OR STATEMENT OF EXEMPTION #' .� 1. Total value of REAL ESTATE transferred (purchase price, etc. rounded to next even hundred. Do not include personal property) $ 2. Value of personal property transferred but excluded from line 1 ..................... $ 3. Value of tax exempt property (solar, wind, waste treatment, mfg. M &E, other) included in line 1 .. $ 4. TRANSFER EXEMPTION NUMBER if exempt for Reasons 1 -13 (see instruction).. .. Sec. 77.25. l 1 43.Sa 5. Fee - thirty cents per one hundred dollars of value (line 1 times .003) (Make check payab to R of Deeds) ........... $ PART V - CERTIFICATION The transfer must be reported regardless of the Grantor's state of residence. Information on this return will be used to administer Wisconsin Income and Franchise Tax Laws. Disclosure of the social security number is voluntary. We declare under penalty of law, that this return (Including any accompanying schedule) has been examined by us and to the best of our knowledge and belief it is true, correct and complete Signature of Grantor or Agent Date Print or Type Agent's Name SIGN' �' 3 +C. L. Gaylord, Trustee HERE Signalbre of Grente or Agent Date Print or Type Agent's Name 7 Document No. Vol. (Reel) Page (Image) Date Recorded Date and Kind of Conveyance LEAVE 386142 "a 44 9 7/15/83 7/15/83 iii► TH Parcel Number 19 19 Code: County Tax District Assm't Dist A REA L L BLANK I I 1 Office 2 Field 1 3 Use 14 Reject A I B C D I E F . T Ratio Consideration in, PE -500 (R. 11 -81) School District No PROPERTY OWNERS COPY + DOCUMENT N o. STATE BAR OF WISCONSIN FORM 1 - 1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 3n "*142 VOL 6 68 fAa 4 49 la�tSTNI S oma Ga lord Law Offices, This D ed made between y 'P^ CAOIX CO., Wis. -- --- - - -- G�. Profit Sharing _ -------- ----- - - It6c d, for Record This 1 � .... -. - -- id da of U A.D. 1983 • - - -• - - -- - - -- -- - - - - -- -- . - -•- - Grantor, ---- and-_-----.-- _Dav_- _D._ -- Smith___ and_ - Mary__ E._ Smi_th_,_ - __ - .... at 2 :10 P. ___ -_ -- husband - and - _ - wife_ - , as,__joint tenants -- ---- -- -- - ,r - - - -- - -------------------- ------ -•-- --- --- --•---- •-- ---•- ------ ----- - - - - --- ---- --- - - - -- --------------- Grantee, Witnesseth That the said Grantor, for a valuable consideration______ - - - - -- • conveys to Grantee the following described real estate in ------- St •__CT 01X - - -__ RETURN TO County, State of Wisconsin: Tax Parcel No: --- --- - - --- -- , Lot Ten (10) of Stewart's Addition, located in the NW% of the SW a of Section 34, Township 29 North, Range 19 West, Town of Hudson. ,ass D This .... ._is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And ---------------- aylord___Law Offices_ S._, - C_. --- Profit___ Sharing__ - Trust -- . ................... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements and rights of way of record and will warrant and defend the same. Dated this 1- 5th. day of Jul -- - - -- -- -- - -- 19.83. GAYLORD LAW O4FFCE S.C. PROFIT SHARD G U T - - - - -- (SEAL) B : ----- - - - - -- (SEAL) C. aylTrustee ----------------------------------------------------------------- V� ��-LC e� - ---- - -- - -- ------ -- - - -- - ------ ---- -•------ - - - - -- -- - - - - -- -(SEAL) - --y' - _ - ---------- (SEAL) Sandra Price, Trustee ------- - - - - -- ------------------------------------------ - - - - -- ------------------- - - - - -- ---- - - - - -- -.........---.----------- AUTHENTICATION ACKNOWLEDGMENT Signature(s) --- _C -.__L. GaylOrd --- STATE OF WISCONSIN - - - - - - - - -- -Sand r a__ i c e------------------------------ - - - - -- S ss. -- • CY'O1X C ounty. e 2ticated this 1 . - ay of ---- l Y __._, 19.8 3_ Personally came before met is ------- Ik .... day of July ,4 93 r nymm 11 AS BUILT SANITARY SYSTEM REPORT 3 � 9 i9 OWNER Smilk TOWNSHIP U SEC. T - �J W / ti ADDRESS /�d3 �,,.d1e� -� ST. CROIX COUNTY, WISCONSIN. WL4_x- SUBDIVISION LOT J0 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM oor z E 1 3 1 � s1 %In di at N N' w c BENCHMARK: (Permanent reference Point) Describe: G Elevation of vertical reference point: /00;0 Slope at site: �j SEPTIC TANK: Manufacturer: wets Liquid Capacity: d g "�- Number of rings on cover Tank manholo cover elevation _2 Tank Inlet Elevation: '' Tank Outlet Elevation: 7 PUMP CHAMBER 1 Manufacturer: Number of gallons Number of gal. pump set for a cycle gallons; Total capacity of y6 distribution lines gallon: size of pump head; r ' per minute ; horsepower ;brand name of pump 3 ` 5and model number 1b` Type of -warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover 3 Type of warning device SEEPAGE PIT SIZE; Number of pits feet diameter e� feet liquid depth seepage pit inlet pipe - elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines width length 4,,3_ tile d ept �. SEEPAGE TRENCH: width length PERCOLAT[ON RATE , AREA REQUIRED_ / $ AREA AS BUILT //� INSPECTOR Y4�� DATED PLUMBER 0 JOB i LICENSE NUMBER 'vim �I co n S 1 f\ c�