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CROIX COUNTY, WISCONSIN OLD TXSCR01 REAL ESTATE TOWN OF SAINT JOSEPH COMPUTER NUMBER 030 - 2057 -80 -000 Parcel Number 27.30.20.557 Claimed 1 Date Re- certified / / Relate Number: OWNER NAME: First DAVID W & JESSICA Y Last JONK 3 �rp l Z CO -OWNER , I, S�r�� �✓cs�� ✓� Mailing Address 1394 H r v City HOULTON State WI Zip 54082 - Type Vol Page Doc # Rec.Date Type Vol Page Doc # Rec.Date HISTORY WD 2395/ 485 73825109/02/2003 WD 1969/ 348 689440 09/06/2002 PROPERTY ADDRESS: Hse # 1/2 PD -- Street Name- Type SD Apartment Post Office 1394 HAGGERTY ST APT A School District: 2611 - SCH D OF HUDSON Special District: (1) 1700 - (2) - (3) - W ITC Plat Code: Last Changed on: 09/17/2003 Book Number: 1 SECTION 27 TOWN 30N RANGE 20W '/4160 '/440 Map Number: 00 - Sales Area: Parcel Control 0 TAXABLE Number of Units: ZONING: Permit Number: Type: Bank Numbers: F4 -Prev, F5 -Next, F6- Legal, F7- Value, F8- History, F10 -Exit, F12 -More ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT q ti Owner lteIIZN 4C L ! i Z Address 13 11A 4- E T 4 City /State at-ro n< Wi` Sy0 82- Legal Description: \ Lot 3 Blook _Z Subdivision/CSM # `- - t /4 A t/4 • A[E, Sec. , T J N -RBI W, Town of S' ��Sg=�i� PIN # 030 - -Z DS7 - 6'0-000 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC W1 Setback from: House j 0 Well P/L Pump manufacturer MA 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: IV rn�ao n S Width _ Length � Number of Trenches Z Setback from: House -3< Well 7 6'_ P/L 6 Vent to fresh air intake ELEVATIONS Description of benchmark &5%6 AIR C otiMir-IaALE4a At Elevation Description of alternate benchmark NAI ini ZA Elevation ? 93 Building Sewer ST/HT Inlet ST Outlet PC Inlet A(A PC Bottom YA Header/Manifold Top of ST/PC Manhole Cover 21 Distribution Lines ( !) 9 5", 9 9 ( ) Bottom of System (() -� y s (�) Z y ( ) Final Grade 70 (.i) 9IF ( ) Date of installation Ylj,71 Permit number ' c State plan number �I/A Plumber's signature ' License number 111 Date ly .c7/ 9a Inspector Complete plot plan Wisconsin Department ofCommerce PRIVATE SEWAGE SYSTEM County: ST. CROIX Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitarystIT : Personal information you provice may be used for secondary purposes [Privacy La Permit Holder's N ❑lity� ❑�r�l�e� Town of: State Plan ID No.: ERLITZ , MYN 511" CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tff _2057-80-000 Cock Co l�. a v n s'4 TANK INFORMATION ELEVATION DATA A9800089 TYPE T MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark x .21 A0 S 1 4 v Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet 313 G TANKTO P/L WELL BLDG-j ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 4- 9Co9 Manufacturer Demand 5 88.68 Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. I-f Dist. To well SOIL ABSORPTION SYSTEM BED ENCH Width Length�2 S No. Of hes PIT No. Of Pits Inside Dia. quid Depth DIMEN I DIMENSION Manufactur SYSTEM TO P / L BLDG ELL LAKE / STREAM LEACHING SETBACK o el Number. INFORMATION TypeO ,�r � — OR UNIT S otiWmvc,Car.� DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air intake Length 10 Dia. Length Dia. f Spacing 10- �r14c.,.�i+�d _ �p 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 E] Yes E] No Yes ❑ No Bed /Trench Edges Topsoil COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 27.30.20.557,NW,NE 1394 HAGGERTY STREET Pla lei lon required? []Yes Q No g ` 7 Use other side for additional information. F-cl Date inspector Signature ert. No SBD -6710 (R.3/97) Vi SANITARY PERMIT APPLICATION 2 01eE shingt'o Ave. Division sconsi P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. S Giro/ x • See reverse side for instructions for completing this application State sanitary Permit Number 30� 7 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)]. S6U71j& State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property w Name Property Location / 7' 1 V 1/4 C 1/4, S T Q, N, R D E (or Propert Owner's Mailin Address Lot Number Block Number il City State Zip ode Phone Number Subdivision Name of CS% N mbQr. a ki. T PE OF BUILDING: (check one) ❑ State Owned 5 1t es�Rojad Near ❑ village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) oZ ? 340, o'ta, 55 1 ❑ Apartment/ Condo 03 © — — 00 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. q Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5 ❑ Repair of an ------ System ________ System _____________ Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ($Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 b 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 �kq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation '7 0 0 1 _1 00 O p, — y, 6� Feet 9ef Feet Capacit VII. TANK in Ca gallo s Total # of r Prefab. Site Fiber- plastic Exper. INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete Con - Steel lass App. structed g Tanks Tanks Septic Tank cIr" kWTTrM IU ..� 5 Ex ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ I ❑ I ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew m shown on the attached plans. Plumber's Name: (Print) Plum er' Signature: (No Stam W N Business Phone Number: AA z 15 y G s Plumber's Ac dress (Street, City, State, Zip Code): L I O IX. COUNTY / DEPARTMENT USE ONLY (Includes Groundwater N Iss ued Iss A ent S No Stamps ❑Disapproved sanitary Permit Fee g ( p Surcharge Fee) Approved E] Owner Given Initial t Adverse Determination � /4C r l� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: original to County. One copy To: Safety & Buildings Division, Owner, Plumber' IL PV C U E AUT +INSPECT /on1 PIAE RPPeo X. G,e4D, F8, o Z6" z6�� S�cEwl/vaF- t? SiaE w�NAF e *��►aEe cAlaaGk0 Et. qy. s ' E L. 'I q- s Asok'rH PQOPEerY LANE DQ�4�NrB�LA f,,J DUPLEX DQ1VEu�A� O }3'OU 390 BM Svc o F Du 5LOQE 93 A �c(✓ / nJ6 C i gal 0 w E« 'ni 6 Ln GAeA6 E I k y Cb W Z 3'xs0 IN Flc.'reATOe � Sao6wlwee - reinucffes t /Lr ,Ree 5e cria n< scAc,e 1" = yo'' RM SASE 1,(, /00, DO AL/ •Bm NA!c .N Te6t g1. l 8. Y3 .DRAW iN b FOR ` q-7-I8 PeAw 6 B o� 131FY 44(-)Cg6PTY ST, 5 V,4tcev UiEu) T qOtALT 0AJ WI �L- -1067 SalnEeS6T W l .sYOa s # 7 9°/ Wisconsin`Department of Industry SOIL AND SITE EVALUATION Labor and Human Relations Page of —� Divisign of Safety and Buildings 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 and � r ©/ � percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel I.D. # rl _ _ 1 APPLICANT INFORMATION - Please print ► view w r e // -- d , w .. by Dat / Personal information you provide may be used for seconda o s 5. (t) (m)). �Y7 t Property Owner 1 , r, s {� arty Location i ��,, �E'f> °,YtLot N 1/4 ly/- 1/4,S TJ ,N,R ;(or)W Property Owner's Mailing Address L t Block# Subd. Name or CSM# .J Ali. �' - City 5tate Zip Code dhone Nu ity - 1 g/ /�7 �/ Village Town Nearest Road / s ❑ New Construction Use: ®Residential / Nu ` of be( Addition to existing building 0 Replacement ❑ Public or commercial - Describe: Code derived daily flow - gpd Recommended design loading rate bed, gpd /fi trench, gpd /ftz Absorption area required 400 bed, ft 5 � trench, ft2 Maximum design loading rate - bed, gpd /ft 0 trench, gpd /ft Recommended infiltration surface elevation(s) Y7 ft (as referred to site plan benchmark) Additional design /site considerations d Parent material Q /CCC,'zL 4 l A Flood plain elevation, if applicable /YX ft U S = Suitable for system Conventional Mound I System in Fill Holding Tank U = unsuitable for system 0 S E] U ®S E - 1 U L,' S ® u El S ® u SOIL DESCRIK \4 (JA ha/t 1 Boring # Horizon Depth Dominant Color Mottles ( y / in. Munsell Qu. Sz. Cont. Color 6d U f ( -e Boundary Roots GPD /ft2 Bed , Trench Ground - 3 � �� � 7' "r elev. A0 �4C 9A�2ft. Depth to limiting factor f 0 in. Remarks: Boring # CW e 3/C% c . 7 Ground elev. Depth to limiting � fact R in. Remarks: CST Name (Please Print) Signature Telephone No. T S� � /f" Address _ Date CST Number �� /J rzc�� me 5�7� l�Z C� �"- o?P -`.P Q c 3 /{O Bas QP A, Cond, u"j L /0U. CEO' �in� It Sz �ri JE tj&y s� doo Q 1, f Dl A /ve ep(rny e��vrM l� kn D +e ld Ga 4-OL /Jla•✓f►�g �d vY. ✓ � 9� eJ ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the �CEVIAI C L/ z residence located at: � 1/4, 1/4, Sec. T_QN, R W, Town of 5 .0 /V - - . Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. o Last time serviced Did flow back occur from absorption system? Yes No K (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete _V Steel Other Manufacurer ( if known) : Age f Tank (if known) : 419 /Y yR,S dJVA 6Cy/'> > 7 T (Signature) (Name) Please Print q/ (Title) (License 9 A- y -Z r./ (Date) Form to be completed by licensed plumber (s.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 IL"- 3, Wis. Adm. Code (except for inspection opening over outlet baffle) Name DD/(fAP-lA ' 3C11171 /7 gnat ure 5/88 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer eE U,/,/1/ lc,� L. Mailing Address 13 1A e rA" Property Address _ Una —A s , U� ��// (Verification required from Planning Department for new construction) f1 City /State Dr1LTDAO IVV 3� Parcel Identification Number O &S 7 D - ' 4040 LEGAL DESCRIPTION Property Location &W ' /4, '/4, Sec. , T 3 N -R _,9&_ Town of Subdivision , Lot # 3 Certified Survey Map # , Volume , Page # Warranty Deed # - 1 /7 V O 3 ? , Volume g/ _ , Page # 3 3� Spec house ❑ yes PC 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. A iin = �a A1_ / / 1 19 8 SIGNATURE OF APPLIPtNT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. / / SIGNATURE OF APPLI T 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