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HomeMy WebLinkAbout034-1044-30-000 n m o j■ n c o s , < c- o n § (D ; ] M3 �2E 7 � _Af Cl) ■ m z w - o _! e o n m o = o o, o Q, « £ m « \ R = \ a � » E E [ R ° \ CL § ƒ k § t i / 2; m \ 0 CO \ 2 ® CD E ® o ro � � CD \ / C ± % 0 \ ca § \ CL m Fp § § 0 Q / k 2 / \ § E c � © 00 ƒ� � r � "I'A. 7 z o o o i' r \/ E§ m ¥ / § a- Q v ¥� £gd \� § . - e: . CD , CO 3 & , z " & \ § ± k ° 0 \ E 7 ! o ƒ n � } » 2 w CA f z m � ` j ¥ z / P 2 ; » 1 _ T i \ 03 ) C m \ z 0 f . m 3 k .. z % / � § \ 0 f . 7 m r \ . / / z \ G o E / 3 E � � § \ A $ � CD 2 � 2 0 \ � § \� �\ LEGAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR02 REAL ESTATE TOWN OF SPRINGFIELD COMPUTER NUMBER 034 - 1044 -30 -000 Parcel Number 19.29.15.299 OWNER NAME: First MICHELLE Last MEECH PROPERTY ADDRESS: Hse # 1/2 PD -- Street Name -- Type SD Apartment 807 CTY RD D SECTION 19 TOWN 29N RANGE 15W 1 /160 '/440 Line Description Line Description TOTAL ACREAGE 37.520 PLAT LOT BLK 01 SEC 19 T29N R1 5W SW SW FRL 15 02 37.52A 16 03 17 04 18 05 19 06 20 07 21 08 22 09 23 10 24 11 25 12 26 13 27 14 28 F1- General, F4 -Prev. Parcel, F5 -Next Parcel, F7- Valuations, F8- History, F10 -Exit �vra. H(VU Ji t C t.VHLUAI IUN NtF'UH I a DI HR in accord with ILHR 83.05, Wis. Adm. Code .�.�u...«,......,.,= COUNTY Attach complete s+te plan on paper not less than 8 112 x 11 inches in size. Plan must include, but not Gmted to .vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL 1.0. +1 dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORM TION PLEASE PRINT L INFO RMATIO ,a &'Z REVIEWEDBY DATE PROPERTY ONNER PROPERTY LOCATION j GOVT. LOT 54d 1/4 _! �VW,S T 2_9 ,N,R /.� U(a) w PR PE�� NER; LING ADDRESS LOT BLOC D. NAME OR CSM CITY, STAT / ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE .D OWN NEAREST ROAD -� �Q /�'wooG✓/1. 5/09 �/Z) 77b - o03Z ri'rl r� .'e;4)e New Construction Use Residential I Number of bedrooms -3 j J Replacement ( Public or commercial describe Code derived daily now 50 gpd Recommended design loading rate • Z bed, gpd/h2 • „3 trench, gpd/fl Absorption area required 375 bed, 11 .3`7.j trench, h2 Maximum design loading rate bed, gpdA9 trench, gpd/ft Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable _ it [ �U Suitable for system �NVFMIONAL S D ❑ U ❑ NGRWNDPRESSURE AT�RADE SYSTEM N FILL HOLDNG TANK - Unsuitable fors system D S •O U JI U ❑ S ,� U EIS ,f$1 U ❑ S $J U SOIL DESCRIPTION REPORT Boring # Horizo Depth Dominant Color Mottles Texture Structure GPD /ft in. Munseii Qu. Sz. Co _ Gr. Sz. Sh. Cons Roots Bed Tr>cf s.'/ / � 6 v r as r>7 •Z •3 ..; . Z •Z -3 Ground 2 0 Z 9 7. 5 Xis' S /t/o n s din Sb7C /�I vT r C ltd • `� elev. 9 Z8- "i 2 -s/ / rrt S mi4r Depth to limiting factor z g" Remarks: C7 �-'orw —ol GcJa • C ✓ p�ese n q�' _ Boring # / r :,., ;. e -g / S& onC si cs A K /V✓lr/' AS •3 Alo n r- L Ground 3 S Z� S/ m ✓�f 6 . 4 0 / it. In Depth to - - - -- limiting, (actor _ �` Remarks: -5 e G' S BO CST Name: — Please Print Phone: Address Signal e: Dale: CST Numbo=: or h n �D M � O lI� � 3 � M c �Y wl T (< Qr- � M 0 O I ZI M N M Q O U ov��. rarvu Jr t t CVALUA 1 IUIV titF'Uti 1 ; D I L H R in accord with II-HR 83.05, Wis. Adm. Code ,.. �...... COUNTYS� i Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but (... n r0/ X not limited to vertical and horizontal reference point (84. direction and ye of slope, scale or PARCEL I.D. dimensioned, north arrow, and location and distance to nearest road. 02 /d _ APPLICANT INFORMATION- PLEASE PRINT AL IN9ORMAT ION REVIEWED BY DATE ; d PROPERTY N // � / / PROPERTY LOCATION O 4' / ,/ v, ,41i 'C`'j GOVT. LOT 1/4 54� 114,S /9 T 29 ,N.R (or) N/ PROPERTY ONNEWS MAILING ADDRESS LOT # BLOC 8 SUBD. NA t CSM s tea �� S oX�G N�9 /%� CITY, STAT ZIP CODE PHONE NUMBER ❑CITY [ MOWN NEAREST ROAD /1vJ?�/i S�Q! (7/5) Z G - �' ,r., ; 071+` v� . (� New Construction Use Al Residential / Number of bedrooms 3 L ( Replacement ( ( Public or commercial describe Code derived daily now _ 50 gpd Recommended design loading rate • 2 fed, gpdfil? • 3 trench, gpolft Absorption area required .39 5 bed, f1 trench, (i Maximum design loading rate _ bed, gpolft _ trench, gpd/ft Recommended infiltration surface elevations) fl (as referred to site plan benchmark) Additional design / site considerations Parent material ' ,'� ' Food plain elevation, if applicable K S = Suitable for system CONVENTIONAL MOUND IN"GROUNDPRESSURE I AT -GMDE SYSTEM W FILL HOLDING TANK U= Unsuitable forsystem [I S ,®U RS ❑ U EIS rm u a s U ❑ S IV U ❑ S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Roots Bed Trerxt Ground U>7e AC 1� V�� C '— elev. ' �i -� n. i Zy ► rye s/ " r- .5i 1 1/ y- I C, L.") — • �` • � Depth to 5 3$ -5 D Y1P S - /�7 Z Or - S"Y1P7 sc •Z , .3 limiting factor „ 38 Remarks: ' Boring # e -i3 /ovR. 3 3 NA e c a c� , * 3 t� Z -ZS /D Z Ar c LO / �' • z • 3 Ground A)on e S Y r. S /� v >cY G i •� • $ 9 ft. Z 7 L 3Z - 7 %S'y� �► /I/o>7e S� b /yl ✓>�r C W • `7f I • J r Depth to 7 ev- '�T 2G� S'YR 5 C- s� re WC, " • 2 • 3 limiting fa Z ,. - Remarks: t c CST Name.— Please Print a s ! Phone: Address: _ n !' / Signature: Date: r: o � b O If V 3 q � N q r � O � n � ro � n � rn � lb r T LA QL Cb � N h � v ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner if Address City /State Legal Description: Lot Block Subdivision/CSM # ,Sec. IL, T7, - j Town of5 Ore I VX q PIN # _) ti- Ib�fy -gyp• Olin SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: k Tank manufacturer t./�.� a44+ Size ST/PC / ` Qe l ' Pump manufacturer C� o� 1 roc Mode Setback from: House Well PAL 71 7 V Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent t >.ne Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: M, o u n d Width _ Length 1 00 Number of Trenches -" Setback from: House 's� Well toy PAL „�� Vent to fresh air intake ELEVATIONS q_- Description of benchmark Qarsv' �l Elevation 0 Description of alternate benchmark +- f 5 -1 e, Elevation Building Sewer 737 C 11 3 7 ST/HT In1et qiejrZ ST Outlet ". &45 S PC Inlet' �•4 PC Bottom r zy 91 . Header/Manifold •C Top of ST/PC Manhole Cover yq f, °1-9 Distribution Lines Bottom of System( �� •S� () ( ) Final Grade () () ( ) Date of installation % Permit number ' State plan number Ctl2.101&2. Plumber's signature 1�.� �-& LGjA :o jN K License number llt) 853 Date Inspector Complete plot plan ar Department dingsDvision Commerce PRIVATE SEWAGE SYSTEM y: Count nd Buildings Division INSPECTION REPORT -5 4 -e ro ENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. & '1 Permit Holder's Name: ❑ City ❑ Village K Town f: State Plan ID No.: VIA t&k P -A CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA 1 TYPE MANUFACTURER CAPACITY STATION B5 HI I FS ELEV. Sew c n a r 2 -IoZ 1 ob4o I Dos, g Aeration Bldg. Sewer Z &2 $2S 9737 Holding St 10 Inlet S 1 1 (P- %% L TANK SETBACK INFORMATION Outlet Iq�,(� .5q1 0 10 4, 5_ TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet � /`> Air Intake ) (� . (�� 3 Septic -� (66 - F vU( (s NA Dt Bottom Dosin ' 10b 3 1 36 NA Header /Man. Aeration X k X- 14— NA Dist. Pipe 9 f•(, ( S O,Z 0 � Holding X_ x_ OG_ Bot. System �� SS PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand S +- 1444A K 1AA e Model Number >�� a� LD "/GPM TDH Lift � Friction S Sy S TDH(�.7� Ft Forcemain Length 3 411 Dia. ,;� " Dist. To Well SOIL ABSORPTION SYSTEM I-S " D BENCH Width I N f Length / �� No. Of Trenches PIT No. Of Pis Inside Dia.. Liquid Depth N I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu acturer: X SETBACK - CHAMBER INFORMATION Type O I J , . Model Number: S stem: t-cl u OR UNIT >< DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) �/ ,� x Hole Size x Hole Spacing Vent To Air Intake Length � Dia. t � Lengthq�� Dia. _1Z Spacing It t l U 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 l� Bed /Trench Edges I Topsoil b KYes ❑ No ®'Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) - 8 G D� "1 I� t� C6 bw pe l C L - ,f �f� - cam, V*' �I.9S (f 1-q �� �+. gin � �til waif l aao -- te% doh ?e,P e-V z >ucf,-tk4 co�-A Ot vW a�0 V V, , ' " d UD►ti`6fr U$1� Plan revision requl ed. ❑ Yes ® No �/ 7 Use other side for additional information. 1 111 UGt( U j SBD -6710 (R.3/97) Date Inspector's Signature Cert. No �t�M sari #'� x•18 9'�•I �"8�� M,�.'vM I � � 8sga og it. Ia -3.oy 8 8•.S.r -laVW*a;A (00 .7-2- a.� sin Department of Commerce PRIVATE SEWAGE SYSTEM County: Buildings Division : ST. CROI X INSPECTION REPORT GfENDV4L INFORMATION (ATTACH TO PERMIT) SanitarySU76191: Personal information you provice may be used for secondary purposes [Privacy Lax, s.15.04 (1)(m)). "IclerpllrRELLE ❑�pR JTjown of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T& 3J4- 1044 ^30 - 000 � -,0 t L TANK INFORMATION ELEVATION DATA A9800003 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. } I c� c Benchmar to :��� � � too / �c..b C� • �1. 2 58 lo5" /D2 sv2 Aeration` ' Bldg. Sewer , Holding St wnlet TANK SETBACK INFORMATION tZtT Outlet p✓ ?;. &ti TANK TO P/ L WELL BLDG. Ai Intake ROAD Dt Inlet Septic NA Dt Bottom Dosing a -`' NA Header / Man. Sd / Aeration NA Dist. Pipe `T,SB SIS} Holding Bot. System 5 S`f 5.5 .5 PUMP/ SIPHON INFORMATION Final Grade Manufacturer f Demand ry.. Model Number �t,.�r ;_ I�,, ;. .4 GPM TDH Lift 9'7 Friction System' TDI-j/J- 7it Head Forcemain Length ` Dia. ;L Dist. To Well SOILABSORPTIO S STEM Jfs TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid D h DIMENSIONS v DIMENSION SYSTEM TO /L BLDG WELL LAKE/STREAM LEACHIN SETBACK CHAMBE INFORM ATION TypeO Number: System: 0 0 ��t ��� I OR UNIT DISTRIBUTION SYSTEM Header/Manifold r la Distribution Pi e(s) �� x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. d Spacing l� 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 d Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc. ,75 (,o ) (; • ?5- B [ �'� q�•a 95,E CATION: SPRINGFIELD 19.29.15. 299 SW SW $ *s-' SA D �9`��7,9� 13X LO p ' ' �3� �j I r5 87. 3S Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division ` •S�� : SANITARY PERMIT APPLICATION Bureau of Buildin water s 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 than 8112 x 11 inches in size. C. -O • See reverse side for instructions for completing this application State Sanitary Permit Num r 3 The information you provide may be used by other government agency programs ❑ Check it revision to previous application (Privacy taw, s. 15.04 (1) (m)]. Smr► vC/ State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 97Z / Z Propert y O ner Name Property Location �.n c e�1 �� ecch 5114 Sw 1/4,S /Q T Z9 r N, R/5 1 (o w Property Owner's Mailing � � - Lot Number �� Block Number t A � City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF B 1-DING: (check one) ❑ State Owned E] ity Nearest Road C] Village Public 1 or 2 Family Dwelling - No. of bedrooms 7 -Town of � ;rr III BUILDING USE (If building type is public, check all that apply) Parcel Tax Numlier(s) 1 ❑ Apartment/ Condo l q' � l • 2 ❑ Assembly Hall 6 -fl 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. ❑ Replacement 3. ❑ Replacement of 4 E] 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 0theC� ar QY 11 E] Seepage Bed 21 []Mound 30 E] Specify Type 41 Holding Tank 12 ❑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.) (Gals/day /sq. ft.) (Min. /inch) _ Elevation Feet Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank Znf> — /Z- B ❑ ❑ ❑ ❑ -❑ Lift Pump Tank /Siphon Chamber /000 /O00 1 ❑ I ❑ I ❑ 1 ❑ 1 ❑ VIIL RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP /MPRSWNO.: Business Phone Number: 78 Plumber's Address (Street, City, State, Zip Code): _ rr� Z 0 /, Y� E � E Q. Ltd J v', i IX. COUNTY/ DEPARTMENT USE ONLY E] Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing gent Signature (No Stamps) `l _ Approved Owner Given Initial r - �_ Surcharge Fee) All ination 1 1 X. NDITIONS OF APPROV / REASONS FOR DISAPPROVAL: �.� toy Es t b� jAsfir11e4 by Tvne- 30 19glffi SOD -6398 (R. 05/94) DISTRIBUTION: Original to Counly, One copy To: Safety & Buildings Division, Owner, Plumber - I HOLDING TANK SERVICING CONTRACT Contract Date This contract is made between the Hold, Tank Owner(s) Nam s) and I Pumper's Name I We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which h� signed the pumping agreement required in Ch. ILHR &.18 (4) (b), Wis. Adm. Code and with the County of ' r D / 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all- weather acce< road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to ps the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), W i Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agree to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contrac . the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipal it and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) I Qwne fs Signature(s)-'< rn.t tie Yl1.ee c �1 - _..-- ... ...... .......__ _ v Subscribed nd sworn to befo a me on this date: I Pumper's Name (Print) I Pumper's Signature Nctary�ub � I My com�mi on ex it s NELS E. PET AM Pumper's Regist ation Number NOTARY PUBLIC- MINNESOTA ANOKA COUNTY "�jm Np Co misslos Eggm Jan. 31, 2000 SBD - 7574 (R. 09/88) This instrument was drafted by the State of Wisconsin Department x of Industry, Labor and Human Relations Docliment No. This space reserved for recording data 57S;(;,3 HOLDING TANK AGREEMENT Agreement Date C This agreement is made between the 9 VK , ISTF 'S OFFICE - - - - - - - - - - - - - - - - - tounty or Local Governmental U Holding Tans) Owner(s)� T CROiX CO, W1 MAR 2 3 1998 (Called Municipality below) We acknowledge that application is being made for the installation of (a) holding 9:30 A M tank(s) on the following property, (Provide legal land description:) , � 0." Re later of [)Qeds 5 c- c 7 N lj� Return To Z(-? 7 :13oldts' Pl6 'r ------------------------------ 1 ,Vzo or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats. As an inducement to the County of 5 , to issue a sanitary permit for the above described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and 146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats. 2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be collected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d), Slats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm- Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. X,Owner(s) Name(s) (Print) I Owpc�(s) Signature(s) Subscribed and sworn to b fore me on t his date: Ml� ell el I t� "I 7 Municipal Official Name (Print) I Municipal Official Signature Qublic I My co pirNELS E. PETERSEN C � ls, fy, & NOTARY PUILIC- MINNESOTA OKA COUNTY Municipal Official Title (Print) tj;��71 �!� �y .1 fee j". ft e SBO-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department o Industry. Labor and Human Relations, Bureau of Plumbing r u Safety and Buildings Division ��.��■�. SANITARY PERMIT APPLICATION BureauofBuilding Water System: 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 0. 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. n -> > l., r. o • See reverse side for instructions for completing this application State sanitary Permit Num 30 - &1 be The information you provide may be used by other government agency programs E] Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION 9 7 Z/ OR 2 Property Owcter Name Property Location � e �dv4 S'U) 1/4, S 9 T 9, N, R Property Owner's Mailing Ad gress Lot Number A , Block Number�� 0 7 / t City, tate J Zip Code Phone Number Subdivision Name or CSM Num er �ov cwv, '� e Zdl 1 S# e?Z "9 ( 711' Atli II. TYPE OF BUILDING: (check one) ❑ State Owned , / Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 4 ❑ Town OF S r ,, �� e/ C ' d III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Num er(s) 1 ❑ Apartment/ Condo 0- A / — 1 ,0 — .3 r;,,1 — 0 DO 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 Ig New 2. ❑ 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,K Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ 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.) (Gals/day /sq. ft.) (Min. /inch) Elevation 4 0 5O0 - 5' p0 •3 A $9' 5 Feet /•O Feet Capacit VII. TANK in Ca gall0 s Total # of Prefab. Site Fiber- plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete con Steel glass App. New Exist in strutted Tanks Tanks Septic Tank or Holding Tank 7-06) /Z 4+r WIS ' ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber / 000 pQ o > > ❑ ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) ,( Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: r� G7 Ae / la s-o x- G't�.. �> Ell e 3i -s 2 Z D ?:5-3 - 71-6 ° jo• 0 9 �-� Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ON ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Sumps) Approved [)Owner r Given Initial TT Surcharge Fee) p� Adverse Determination V 'ff X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber SAFETY AND BUILDINGS DIVISION 2226 Rose Street N)Pisconsin La Crosse, WI 54603 Department of Commerce Tommy G. Thompson, Governor 29- Dec -97 William J. McCoshen, Secretary BOLDT'S PLUMBING & HTG LANG BUILDERS DALE E. HUDSON 820 MAIN ST BALDWIN WI 54002 Lang Builders, Inc Plan ID 9721082 SW,SW,19,29,16W Municipality of SPRINGFIELD Inspector: Leroy G. Jansky County of St Croix (715) 726 -2544 Private Sewage plans including the following element(s): MOUND 600 GPD The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for compliance with all code requirements. This plan action is subject to the conditions listed on the following page(s). A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department. All permits required by the state or local municipality shall be obtained prior to commencement of construction /installation /operation. This project is under the supervision of a state inspector. As inspection concerns arise feel free to contact the state inspector at the number listed. The inspector for this project is listed above. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when making an inquiry or submitting additional informatipn. Sincerely, &ard. Swim POWTS Plan Reviewer (608) 785 -9348 SAFETY AND BUILDINGS DIVISION 2226 Rose Street LaCrosse, Wisconsin 54603 i sC0nsin Department of Commerce Tommy G. Thompson, Governor William J. McCoshen, Secretary Page 2 97 21082 - A Sanitary Permit must be obtained from the County where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats, prior to installation. - Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(d), Wis. Stats. SBD- 5524 -E (R.07/96) File Ref: BOLDT's y Ili 4" A 4 4 Vv 1 0 8 `� JLJWAJt F A PLUMBING & HEATING INC. "Serving You For 40 Years" 820 Main Street Baldwin, WI 54002 (715) 684 -3378 Fax (715) 684 -3144 page of Vj97 2108 Date: 11- 13-97 Mound System For A _Bedroom Residence Located in the Si 1 /4 of the 5t /4 of Section / 9 , Tom, RLW; Town of _..,� L a I d , �, C.-. County, Wisconsin. Index Page 1 of 6 Title Sheet REGE E� Page 2 of 6 Plot Plan j� Page 3 of 6 Plan View-Cross Section DEC 1 9 Ag91 Page 4 of 6 Distribution Pipe Layout ' Page 5 of 6 Pump Chamber Page 6 of 6 Pump Performance Curve Q. o )N T S' Prepared For: Co�id ,pow emu; ���° I'S �k EtCE OF NGs q C Lp 1 �.:, e, •! r �LppRjMEN ESy su1 2 G S , 1v1�,►Q S 1, i r C /l P G s , yb , s RR pON�ENGE 41Z - 7 ?0 — 9 0 9 0 SSE GO Prepared By: Dale Hudson -Certified Soil Tester / Master Plumber #220863 � N a kA n O .p z � t �b w e � o p � o w � a z A N O C n 4 0 t! ! . �. oo N �h tv I \ J I tA � � b C/ Page 3 Of Cross Section Of A Mound Using A Trench For The Absorption Area Medium Sand Fill � I ° F —6* Topsoil 3 E D Trench Of '2" - 2k" Aggregate, Plowed Layer 6" Below Pipe, Covered With D /•O Ft. Straw, Marsh Hay Or Synthetic Fabric E 16 Ft. G / -o Ft. F •7 Ft. H f.5 Ft. Plan View Of Mound Using A Trench For The Absorption Area Force Main AH'err( Distribution Pipe Permanent Markers Observation Pipe For C- C' W B K t I \Trench Of - 2k" Aggregate j � I L A -Jr `t. I /0 Ft. K /O Ft. W Z 3 Ft. B /oo Ft. J 7 -5 Ft. �L /Z Ft� License Signed: - fY,+ Number: 2208-53 Date: /a 18 97 ri'if y Page__Ut � � I •y t 1 • Distribution Pipe Detail For Two Lateral Network ,E Holes Located On Bottom /)�1`e Are Equally Spaced PVC Force Main ' Y ' X X PVC Distribution Pipe F �e, P p � 1 � X ,,A;n * Last Hole Should Be Next To End Cap i P Ft. Hole Diameter Y Inch 1 � X ��_ Inches Lateral Diameter /�L Inch(es) Y �42- Inches Force Main Diameter _�� Inches I Of Holes /Pipe 1 3 Invert Elevation Of Laterals 9.3.5 Z Ft. Signed:-: License Number: 22 096r3 Date: J0 Ar i PAG 5 GF t . PUMP CHAMBER CROSS SECTION AMD SPECIFICATIONS VENT CAP - T '1 "C. I. VENT PIPE fr WEATHERPROOF APPROVED LOCKIAIG - T 1 ) JUNCTION BOX MAMHOLE COVER 25' FROM DOOR, WINDOW OR FRESH 12 "MID. AIR INTAKE I GRADE I Y" NW. CONDUIT -- _____ 16'PIIN. ---- - - - - -- j INLET PROVIDE "T AIRTIGHT SEAL *� A 1 II 1 I I ALARM B I II. I I C *APPROVED i oN JOINTS WITH I ELEV N - 6 FT APPROVED PIPE PUMP I 3 ONTO OFF o SOLID SOIL a; CONCRETE BLOCK i RISER EXIT PERMITTED OIJLy IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC E S P E C I F MCAT i OAI S TAIJKS• - MANUFACTURER: / " /r>/"e� - : ic GASH IJUM BER OF DOSES' PER DA:i TAWK SIZE: GALLONS DOSE VOLUME Z S ALARM MAUUFACTURER: w G r �CGI _ ro INCLUDING 6ACKF . LOW: GALLON MODEL NUM6EK: A2 CAPACITIES: A= 20 ' 1 9 L / 9•�Z it INCHES OR /� GALLOW ► SWITCH TYPE: __ -w_e - r (47 - v INCHES OR is PUMP MAAIUFACTURER: 090 CA C= g•g i INCHES OR 22A GALtOW MODEL. NUMBER: 0- / IWCHES OR 279 '!Z GAL1.0 SWITCH TYPE: NOTE: PUMP AUDALARM ARE TO BE s 1. MINIMUM DISCHARGE RATE �• P INSTALLED OIJ SEPARATE CIRCUITS G M i VERTICAL DIFFEREAICE BETWECAI PUMP OFF AND DISTRIBUTION PIPE.. FEET y ? t + MIAIIMUM NETWORK SUPPLY PRESSURE ......... . , FEET j { + FEET OF FORCE MAIN X Sy F/ppF<FRICTIOU FACTOR. �•�►� FEET 3_ TOTAL DyWAMIC HEAD = FEET IWTERNAL bIME1JS10N1: OF TAAJK: LEtJCsTH ;WIDTH LIQUID DEPTH / SIGNEO: �-+' �- / v �' � LICEMSE HUMBER. ��� 2 DATE. It � -P6rformance Submersible Effluent. Curves Pumps 4 / 0 METERS FEET 30 100 , SERIES: 3885 SIZE ! SOLIDS _......- - �--- .._......_.._.. ._ ..__._ ._._.._'t............1.._...... SGPM RPM: VARIES R 80 , { -- - '`}` D W i I x 20 - d - -- - - ---- -..._ - -...__ .....t -_... _ M U 60 J+ ! I ; I -j i ! ! N O 40 10 H N IJ i 20 ; FE 0 TO O 20 40 60 80 100 120 140 160 U.S. GPM 0 10 20 30 m FLOW RATE [gGOULDS PUMPS. INC. WATER TECHNOLOGIES GROUP SENECA FADS, NEW NOW 13148 METERS FEET 120 I SERIES: 3885 i 3 SIZE: 3 /i SOLIDS 35 110 RPM: 3450 S ! 5 GPM 100 I 5 FT 90 I w 25 80 ' 1 ► 1 i I 4 � 5 V 70 ' I 20 Z 60 ! 1 15 50 I ! .y o 40 -t 10 30 ! 20 5 1 I 0- 00 10 20 30 40 50 60 70 80 90 100 110 120 U.S. GPM L 0 10 20 30 m'!h CAPACITY Effective July, 1993 O 1993 Goulds Pumps, Inc. SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE. PRINTED IN U.S.A. C38853450 W. S. .7vll H N U A14U .711 C MVALUAI IUN tH 1 ®I L.. H R in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ' C roi X • not United to,vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.O. # dimensioned. north arrow, and location and distance to nearest road. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY CWNER PROPERTY LOCATION zo/ GOVT. LOT 5C,J 1/4,5ZD114,S T 2_9 ,N.R 1 t(or)W PROPERTYCWNER:'S MAILING ADDRESS LOT BLOC I SUBO.NAMEORCSM# CITY, STAT 21P CODE PHONE NUMBER []CITY ❑VILLAGE JMT OWN NEAREST ROAD �a /�' c,�oo� /�/1 • S� /09 LI 7 D — 003 Z ri'✓t -f .'e �� C f ql / e pf New Construction Use Residential / Number of bedrooms .3 j J Replacement ( Public or commercial describe Code derived daffy lbw (0 0 0 gpd Recommended design loading rate • Z bed, gpdV • .3 trench, gpd/ft Absorption area required ff OO bed. 112 K trench, ft Maximum design loading rate bed, gpd/ft trench. gPdO Recommended infiltration surface elevation(s) 89 - S It (as referred to site plan benchmark) Additional design / site considerations Parent material - /ac ; a - f 1 I Flood plain elevation. N applicable It S a Sultable for system DONVEwtOMAI MOLM NGRO010PRESSURE I AT WDE SYSTM N FILL HOLDING TANK U= unsuitable forsystem O S R1 U W S ❑ U ❑ S f �I u (1 S ' O U [3 S JM u [is o u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistenoe Bwidary Roots GPD1ft In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed T Nom / / 0 -/0 /ay 3 L , s.'/ / V as Z ro • •3 Z - oZp /0y )fy 1y M,, e 1-,0C s6k Invrr C-0 Z�' •Z •3 Ground O Z 7 -s y,P5 None s /ten s6- A9 v ) c w • y - 9 0.2 7s'YR s S� / rrl S �nvf Cu.) • `� Depth to fimi6ng . faz8 i Remarks_ 6 ` EoLA �d �cJa G ✓ A ,� g �'• ' Boring r si �s� ✓1'Il'. AS 2r� .Z I •3 2 on s /'� �' - - 3 3 -5 - Z4 .. s 5 y A s� m ✓fr cut) y• 5 Ground ye, I - `� ZG 3$ 7�Y� C2al_ 7.Y,� s� rr1 ✓�'r Cu) 'Y 5 (• Depth to failing fac j , I Remarks: S ma 0 Bo ro io% 4 CST Name:— Pleass Print �- � / Phone: Address. �Z O C•�S 2 7 / -'� 5'f' � Q /��� , �, l�.'• S" _ Signature: / Dale: CST Numboc � G� ^�-•^ SOIL AND SITE EVALUATION REPORT D I L H R in accord with ILHR 83.05, Wis. Adm. Code �• .�.•4.,...,w,.,..,,. COUNTY Attach,complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but -51 .1 r -e9l not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCELI.D. A dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY GNNER: PROPERTY LOCATION e . le, a e� �j Dour. LOT S l c) va SMva,s T 2_ .N.R W PROPERTYONNER:'S MAIL 1 AnpRESS LOT #Y ,-, l BLOC SUED. NAME OR CSM / �` CITY. STATE ZIP CODE PHONE NUMBER []CITY ❑VILLAGE TOWN / NEAREST ROAD 55X9? (9/Z) •771 S ' r� '✓! ><;'N ��1 �f G�� New Construction Use 1>1 Residential / Number of bedrooms j ] Replacement ] ] Public or commercial describe Code derived daily flow f> d 9Pd Recommended design loading rate • 2 bed, gpd/tt • 3 trench, gpd/ft Absorption area required S bed, 11 5�n trench, ft Maximum design loading rate bed, gpd/ft trench, gpd/ft Recommended infiltration surface elevation(s) 89 - S It (as referred to site plan benchmark) Additional design / site considerations Parent material c /ac ;.a/ Flood plain elevation, if applicable It S - Suitable for system amENTIONAL M IN D ❑ u T 73sn PRESSURE AT-GRADE sYSTEm IN FILL VOIDING TANK U= Unsuitable for stem 11 S 0 U J� U ❑ S ,� U ❑ S n U ❑ S J U SOIL DESCRIPTION REPORT Boring # Horizo Depth Dominant Color Mottles Texture Structure Consistence Boti Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnd- o -/a /oy 3 L // s.'/ / �' v r as r� - 7-1 •3 Nr,� �: / Iv : t Z_ 1 /o -Z e1 10 yf -- 11Y /(/ n e si 1 / f' s6 / r�v� c w Z -F • Z • 3 Ground - d Z 7 5 ,VR / A., n � S 11n Sk /v ✓fr" C l tJ • y elev. z YR 5 S� L m 5 L . Vfr G tA) - 'y • 5 Depth to limiting zog„ Remarks: rw - o� Wa rr ✓ Boring # / A I an s�� �' C sIS ✓f�' S m • 2Z •3 2 21 A lo tie . s 51 /(/ e,, s � In f r c �Ll • Al • � Ground elev. / 7/ Zl� -38 7 S' C2 0/ Depth to - -- - limiling lacy I Remarks: Sc•��� �s Ba �,', -,` CST Name: - Please Print .- Phone: 7 Address. - Signature: Date: CST Number. STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County n�+.4 MAII MQ 4PUSS /7?/ .V4,e10Xe PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY /STATE Gctoo 0j y PROPERTY LOCATION 60 1/4, -T 1/4, Section _ / 9 , T 2 �? N -R AC W TOWN OF —�-2) ST. CROIX COUNTY, WI SUBDIVISION /U LOT NUMBER Al CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER 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 fora 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 (2) 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. PATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, Wl 54016 11/93 8 T C - 100 This application form is to be completed in full and signed by the A . 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 recprding. ----------- --------------- » ----------------------------------------- owner Qf property _ i "� e Ile l e-e a A Location of property SGJ 1/4 .50 1/4 , Section / , T Z9 N -R l� W Township ,',1• :2 - ; e ��/ Mailing address / 73 1 os e r yoap Address of site g"p"] C- 7 Subdivision name A�X Lot no. Other homes on property? _Yes _No Previous owner of property Kyi- ' -v G - e n Total size of property 90 ,4 re 5 Total size of parcel Date parcel was crea Are all corners and lot lines identifiable? A' Yes No Is this property being developed for (spec house) ? Yes X No Volume /Z.3 ? and Page Number 3 Z 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. PROPERTY OWNER CERTIFTCP.TION 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. _:!S' 5 9 5'O , 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. Z' ! f Y, 1,1@fnat a of pplicant Co -A p ican+f / '� Da of Signature Datb of Signature