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CROIX COUNTY ZONING DEPARTME ,� AS BUILT SANITARY REPORT �� c F i vO Owner S F n 1 4 1999 Address r cox City /State - ,: a t DUNS f ' ZONINGOFF;C.E Legal Description: Lot Block Subdivision/CSM # '' /,_SM_ % s ), Sec. , T - N -RAW, Town of PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer -� Size ST/PC / / Setback from: Hous Well _ P/L 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: - Width ' �''�° �, _. Length Number of Trenches Setback from: House_ Well P/L Vent to fresh air intake r- 7 ELEVATIONS Description of benchmark Elevation Zaaa. Description of alternate benchmark Elevation Building Sewer _ a ST/HT Inlet ST Outlet. PC Inlet PC Bottom Header/Manifold a o Top of ST/PC Manhole Cover Distribution Lines Bottom of System ( ) _qs-:�, () ( ) Final Grade () 27--2�?— () ( ) Date of installation 2Ek/F Pqimit number -O> State plan number �2 Plumber's signatur License number Date Inspector l�u Complete plot plan or NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. Show alternate benchmark, if applicable. PLAN VIEW 4141 - N.SC `i y INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y' Safety and Buildings Division Count ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Personal information you provice may be used for secondary purposes [Privacy Ls x.15.04 (1)(m)]. P @rMdg /s n> Yb HAEL P T Aj e []Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel b2W-- ;1065 -90 -000 TANK INFORMATION ELE'/ATION DATA A9800128 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark / D. 6D Dosing Aeration Bldg. Sewer [ Holding St/ Ht Inlet TANK SETBACK INFORMATION St /Ht Outlet ��(- 94 y? TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic S 51 __ a I NA Dt Bottom Dosing NA Header / Man. 19 ( t q I, �7G Aeration NA Dist. Pipe Holding Bot. System G , �� PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand q( / 2 Model Number GPM TDH Lift Lricti System TDH Ft oss Forcemain Lengt Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length ,, , No. Of Tr nches PIT No. Of Pits Inside Dia Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION T�pe O /V «. ' /� S i y� , �/ OR UNIT CHAMBER m od el Number: System: / 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 j� Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed / Trench Edges ..,� -� . Topsoil El Yes 11 No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 22.30.18.334B,SW,NW 1465 120TH STREET . 1 E . Plan revision required? ❑ Yes VNo , Use other side for additional information. SBD 6710 (R.3/97) Date sp or, Signature Cert. No. � � Safety and Buildings Division •ISC011S %11 SANITARY PERMIT APPLICATION Po Washington Ave. Department of Commerce In accord with ILHR E3.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8.1/2 x 11 inches in size. :Y� ( , y • See reverse side for instructions for completing this application State Sanitary Permit Number C77`/Q. The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 56?rn p State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION —� Prope . Owner ame Property Location ,�(o Z. r v4 v4, S T , N, R Property Owner I s Mailing gddres Lot Number Block Numb •/ S Cit , tate Zip Code Phone Number Subdivision Nam or CSM Number T YPE F BUILDING: (check one) ❑ State Owned ❑ it Nearest Road , ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town of III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo a.6q• 30. 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. � New 2 E] Replacement 3 ❑ Replacement of 4_ ❑ Reconnection of 5. E] 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 ❑ Seepage Trench 22,❑ In - Ground Pressure 1a- I �I x�7 42 E] Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System- In -FiII VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /'nch) Elevation r / Feet Feet Capacity VII. TANK in g allons Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks manufacturer's Name Concrete Co " steel glass Plastic App New Existing structed Tanks Tanks Septic Tan El ❑ El 1:1 11 Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for inst tion of the nsite sewage system shown on the attached plans. Plumber' ame P ) r Plumber' Si ure: MP /MPRSW No.: Business Phone Number: Plu tier's c dress (Street ity, Stat ip Code)' >>° IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuin ent Signature (No Stamps) ,IJ Approved [:]Owner Given Initial l ,�/l CJ� Surcharge Pee) I / 3 ination R X. IONS O A REASONS FOR DISAPPROVAL: l 1 . 7 I ` Ina l�s 4µc{ c2fke -s ,jski wwsf b� «toa-al�el p. I7 /S(lX�) w keh hew � 3 (acr<J'lh dwe� ti�.c.. SBl> 6M (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber 91,7 71 3 wy w, . a /moo ,[�f17 Wisconsin Department of commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must ' County include, but not limited to: vertical and horizontal reference point (BM), direction e �+ (o �_, percent slope, scale or dimensions, north arrow, and location and distance fOrnB�ttlrpad parcel I.D. # ip L J APPLICANT INFORMATION - Please print all i►foitma>t�tpli>: - a wed by _ Date Personal information you provide may be used for seconds u ry purposes Privacy Law, s. 1564 Gy Property Owner Jw6mft Locao&t �C't ZON C�f 1/4 4,S T N,R W OCo< 3 0 . I E (o Property Ownses Mailing Address . ,` _Lou- ;` B Subd. Name or CSM# o q 4 — Ar-e— �cf State Zip Code Phone Number ❑ City ❑ village J• Town Nearest Road S+' New Construction Use: residential / Number of bedrooms Addition to existing building El Replacement M Public or commercial - Describe: Code derived daily flow W gpd Recommended design loading rate bed, gpd/if 1 trench, gpd/it Absorption area required S_ bed, ft �trench, 2 M aximum deli�n loading rate _bed, gpd/ft trench, gpd/ft2 Recommended infiltration surface elevation( C'! /r - U ft (as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system U � ❑ U ,,�� ❑ U ❑ U ❑ S MU ❑ S s9, U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 13 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground , 9 /it Depth to limiting facto Remarks: Boring # 71 V 13 .�" Ground ' Deph to limiting factor � Remarks: CST Name (Please Print) nature Telephone No. Address Date CST Number �� SOIL DESCRIPTION REPORT PROPERTY OWNE ��`' ' '' - 1' Page of . PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Glu. Sz, Cont. Color Gr. Sz. Sh. Bed , Trench Ground le Depth to limiting fa o ' ,,,Mw . Remarks: Boring # � t_ S' Oz� v Ground &1V . Depth to limiting f to �in. � Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 2 S r�- '� " m Ground el v ' > ft. Depth to limiting � Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) Soil Test Plot Plan Project Name N atalie Sanders Shaun rd Address 1384 200th Ave New Richmond Wi 54017 CSTM #3922 Lot ----- Subdivision ------- Date 3/6 /98 SW 1 /4 NW 1 /4S22 T 3 0 N /R W Township Richmond M Boring Q Well PL Property Line County ST. CROIX IL BM or VRP Assume Elevation 100 ft. T op of Fence Corner Post with Orange Ribbon System Elevation 9 4.4 /9 2.8 * H R P S as Benchmark Alt. BM Top of Fence Post with Orange Ribbon @ 97.7 B.M. 100' Prope Line 15' Alt. .M. 120' B -4 30' B -2 c Rep A Pri A' 13% 40' Slope b 5° r � 30' B -5 15' 15' B - Pro 4 Bedroom House Property Line ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �.� i ��'� �� �� k' (\ /u.. ,C Mailing Address Property Address (Verification required from Planning Department for new construction) City /Stat ey" r 1„ n. , c�� tti Parcel Identification Number - LEGAL DESCRIPTION t Property Location ' /4, �''� '/4, Sec. , T N -R W, Town of Yin c Subdivision , Lot # Certified Survey Map # , Volume , Page # Warranty eed # �� 1�� Volume / 3 I Pa e # d 7 tY � t; Spec house ❑ yes ISJ 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 ffiree year ex ation date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I e) certify that a statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the prop; , scribed abo , by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APP CANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed Parcel #: 026- 1065 -80 -000 12113/2006 11:45 AM PAGE 1 OF 1 Alt. Parcel #: 22.30.18.334A 026 - TOWN OF RICHMOND Current ' X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner THOMAS LEVERTY O - LEVERTY, THOMAS 1215CTYRDG NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: 18.970 Plat: N/A -NOT AVAILABLE SEC 2ZT X 48.3'OF W ' Block/Condo Bldg: 788' 30 RDS S •EZ- Tract(s): (Sec- Twn -Rng 401/4 1601/4) 22- 30N -18W Notes: r I History: Pa ce Date Doc # Vol /Page Type 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 177150 Use Value Assessment Valuations: Last Changed: 06/22/2006 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 18.550 3,000 0 3,000 NO 05 UNDEVELOPED G5 0.420 100 0 100 NO Totals for 2006: General Property 18.970 3,100 0 3,100 Woodland 0.000 0 0 Totals for 2005: General Property 18.970 3,000 0 3,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ` Form -STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER .. �✓de any TOWNSHIP SEC. 4 ?, e !F : T - 7e N -R�W ADDRESS ST. CROIX COUNTY, WISCONSIN l ey c01r�r. d SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•IHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 1. 0 9� 4 N, ,3 b INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: 0 Proposed slope at site: T SEPTIC TANK: Manufacturer: 'Ie 5 Liquid Capacity: Number of rings used: ank manhole cover elevation: Tank Inlet Elevation: f, Tank Outlet Elevation: �� ► 3 S� 'D Number of feet from nearest Road: Front, Side, Rear, O Z;70 feet i From nearest property line Front, 0 Side,0 Rear, O � feet r Number of feet from: well � , building: Syr (Include this information of the above plot plan)( 2 reference dimensions to septic tank '` SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle.: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear , Ft, a5'` Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: / Trench: Width: Length: / Number of ' Lines: e ::2 Area Built: d Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear, O Vt. —_ � Number of feet from well: �© / 4 Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: .�/ Inspector: Dated: 7 — !/ Plumber on job: License Number: 3/84:mj DEPARTMtNT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS ON I LABOR &HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMB DIVIS P.O. BOX 7969 5 I W MADISON, 3707 MADISON, CONVENTIONAL ❑ALTERNATIVE Stfate SPgnnIiD.Number Town ojj Richmond El Holding Tank ❑ In- Ground Pressure El Mound 120th StAeet NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE: Ftoyd Swanson Route 4, Box 84, New Richmond, W1 5401 7 - /� BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN'. REF. PT. ELEV.: CST REF. PT. ELEV.. Name of Plumber: J MPIMPRSW No.'. County'. Sanitary Permit Number: Byron &Ad 7n. 3318 St, Ctoix 112702 SEPTIC TANK /HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED ❑ . YES ❑NO DYES ONO BEDDING. VENT DIA I VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING. (VENT TO FRESH ALARM FEET FROM LINE AIR INLET DYES ONO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER J IBEDDING LIQUID CAPACITY PUMP MODEL. PUMP /SIPHON MANUFACTURER WARNIN=LABELLOCKING COVER PROVIDPROVIDED: ❑YES ❑NO ❑YEDYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL'. NUMBER OF PROPERTY WELL BUILDING VENT TOFRESH (DIFFERENCE BETWEEN FEET FROM LI AIR INLET PUMP ON AND OFF) 1:1 YES ONO NEAREST SOILABSORPTIONSYSTEM. CheckthesoilmoistureatthedepthOfp lowing 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: __ WIDTH: LENGTN NO. OF DISTR. PIPE SPACING COVER J IN';ID1 DIA -PITS LIQUID BED /TRENCH ^ TRENCHES MATERIAL PIT DEPTH DIMENSIONS / GRAVEL DEPTH FILL DEPTH UISTH P F DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR. NUMBER OF PROPERTY WELL BUILDING V NT TO FRESH BELOW PIPES ABOVE COVER. ELEV.( LET ELEV. END. PIPES FEET FROM LINE AIR INLET NEAREST MOUND SYSTEM: 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- meets the criteria for medium sand. TIONS MEASURED. DYES 1:1 NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS 1:1 YES ONO ❑YES FIND DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED =PSOIL SODDED SEEDED MULCHED CENTER. EDGES. 1:1 YES 1:1 NO El YES 1:1 NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO.OF LATERAL SPACING. GR'AV EL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER BED /TRENCH TRENCHES. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MAHKIN(, ELEV. ELEV.. DIA. ELEV. PIPES DIA DISTRIBUTION .. ELEVATION AND INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLAN SCAL LIFT CORRESPONDS TO APPROVED ❑YES ❑NO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL'. BU ILDING. FEET FROM LI NE. ❑YES El NO 1 YES ONO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLF Zoning Admin" tcaton DILHR SBD 6710 (R. 01/82) I = R S ANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code C�o� SANITARY PERMIT # /�ayv -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFOR MATION - PLEASE PRINT ALL INFORMATION. F OR VARIANCE ❑ YES ® NO PROPERTY OWNER PROPERTY LOCATION e �cc'an /4 l "S;Z� N,R E(Or PROPERTY WN 'S MAILING ADDRESS J OT NUMBER BLOCK NUMBER SU NAME TY, TAT 6 ZIP CODE PHONE NUMBER CITY : NEAREST ROA LAKE OR LANDMARK ❑VILLAGE : !C�l�a� II. TYPE OF BUILDING OR USE SERVED: out.' /W ' d — 1644 9V - CM Number of Bedrooms if 1 or 2 Family. OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b < Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit ## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner /building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. VConventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. X Seepage Bed b. El seepage Trench c. ❑ Seepage Pit 2. PER OL TION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): I PROPOSED (Square Feet): Z Feet Xprivate ❑ Joint ❑ Public VI. TANK CAPACITY r Site in oallons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber ❑ VII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): , Plumber's ignature: (No Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Ad a Street, City, State, Zip Code): Name of esigner: VIII. SOIL TEST INFORMATION Certified W Tester (CST) Name CST # , CST's A PESS (Street. City, State, Zip Code) Phone Number: IX. COUNTY /DEPARTMENT USE ONLY Disapproved Sanitary Initial Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) ' S charge Fee ❑ Owner Given Qty ,, /may Adverse Determination �� ' A pp roved X. COMMENTS /REASONS FOR DISAPPROVAL: _�Ioo CLJyrWQj SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber APPLICATION FOR SANITARY PERMIT STC -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 ; r4) tf U /Y , SGja Location of property StJ 1/4 /A ) 1/4, Section a a , T�3 0_ N -R // W Township kcb'�-"d Mailing address (2OL� -e ��?� �� ��Z' R"nhA 3,1 �J-7 Address of site 1'ae 4. RUK eS IVP/'j �,G l� h�y"IU �J3''5 Z/d Subdivision name Lot number Previous owner of property r)(,tr'n 2 -edernl Sa u ,gg l a yGt Lj Total size of parcel acneS Date parcel was created q Are all corners and lot lines identifiable? _ Yes No Is this property being developed for resale (spec house)? Yes _ No Volume :9// and Page Number 4� 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. ---------------------------------------------------------7--------------------- 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 warrant deed recorded in the Office of the County Register of Deeds as Document No. ~ 7 a ; 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 same has been dul recorded in the Office o the County Re ister of Deeds, as Document No. L1 7 �,R -0 ), Signatf6re of Owner Signature of Co -Owner (If Applicable) '7- IF, S �, Date of Signature Date of Signature I� ." •' ' z- 'gym- t .; h � .1 dIVY Atg 1 s 5 B @ �.) �T ►' HaR t► �r 1KIx►�al` r�►RW —tsr; t. w. }, DvsaOd tsderal Savings and Loan � Association �+ � Y x M UM Floyd H. Swanson and r is A Ate' Hiidred H. Swanson, husband and wife 4� O Duran! Fedora $91) state ittl /•t iviq� ItI S4A� e: t!v t.Jl..�,r.� tnrrtv+j MaY..•.e• �•, .St. Croix 1 •'+ Tss P:e %A• ... North 748.3 foot of west 788.0 feet of Southwest Ouarter of Nostbwst Quarter (SM of MA) of Section Twenty -two (22), M ; TOwsbio Thirty North (T3011), Range Eighteen west MOW). .. e t Jv M T:. is not :fit;: Subject to easements and restrict&oin of record. h 20t t r !R a � .18a • w� ,. DURAND DE:RAL S IYCS { ILr.AY by: G. /R.i.+�► Sonya J. an% Secretary ' i 6J + '] Linda L. Weber. Y:cr Presileht 1 s X914 rt; ; AVTIsftV ICATTnN sr O nN T x g.S i ^S Pry: yy f5 S, +1v an! r •�rta t 'r'.•h.•+ t ., r• Pr' ..dent sr..x�'� t h!- 'RI%;l \f AVIYAt;* \t ION Th A . Moos rat t I x q� Y �t. y. k ,•1 Baldwin, WI NA42 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER � �D, d �. �LtJGt h,S c)1 ROUTE /BOX NUMBER ©t^ � e � i � Cj � �.5� FIRE NO . J 41 - CITY /STATE / eli A Ch 1"Or_d . 1.� L ZIP S410/ PROPERTY LOCATION: SZ,) 1/4 A 1/4, Section o� of , T_O N, R Town of �� C lr, �n� , St. Croix County, Subdivision N /�1 , Lot No. 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 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 $3000 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning 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 (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE f l g 8 St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386 -4680 Sign, Date, and Return to above address DEPARTMENT OF RE PORT ON SOIL B AN D SAFETY & BUILDINGS INDUSTRY, _ c DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: NSHIP UNICIPALITY: LOT NO.:BLK. NO.7_BI IVISION NAME: COUNTY : OWNER'S /BUYER'S NAME: ADDRESS: / f�ero'• v Cc �a> Qf y �4� �1j d�o� �� , 7 - 4 O USE DATES OBSERVATIONS MADE Ix NO. BEDRMS.: COMMERCIAL DESCRIPTION: 11ROFILEDESCRIPTIONS: PERCOLATION TESTS: Residence 3 �.^ El New J 7 //, RATING: S= Site suitable for system U= Site unsuitable for system r ON STlau . M ❑� IN- GROUND -P URE: SYSTEM -I ®ILL HO TANK: RECOMMENDED SYSTEM: (optional) If Pe Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: I Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B- B- B- ���( PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- 4 P- P- G P- P- 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 j .2 o � 2 ' 1 6 oe Cj rho fN 5 Dv 1, th undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified 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. NAME (pri TESTS WERE COMPLETED ON: won 2 — ADDRESS. CERTIFICATION NUMBER: IPHONE NUMBER (optional): jo r olo� 10 CST SIG TUBE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 10/83) — OVER — V V V I IF 1wr%1 I 'PROJECT ,e ADDRESS ��jj 1/4 1 /4 /S�,2/T N/R W TOWN a COUNTY `MPRS Byron Bird Jr. 53 DATE BEDROOM_':�CLASS PERC CONVENTIONAL- GROUND PRESSURE CONVENTIONAL LIFT_ MOUND_ HOLD! VG TANK SEPTIC TANK SIZE -a LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA 6 l PERC RATE BED SIZE Benchmark V.R.P. Assume Elevation 100' Location of Benchmark * H. R. P. 0 Borehole Well Scale = Feet O Perc Hole System Elevation �- Uent 12" Grade 2a TYPAR COVERING j6" 12" 3' g O 3' Sewer Rock 12' / 1 _ A w� 6v %h o : /` 6 a y t 0 �o