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P ° Attach complete site plan on paper not less than 8 1/2 x 11 in a ize. n I�st County t ~`k include, but not limited to: vertical and horizontal reference M), dire percent slope, scale or dimensions, north arrow, and locatio distapce to " ,k,k ad. ` %..,. , parcel I.D. # APPLICANT INFORMATION - Please print all matiow. '' ° eviewed by Date Personal information you provide may be used for secondary purposes ri y / C +g4•1� (m)). Property Owner n a 1 1/4 1/4,S T N,R E ( W Property Owner's Mailin ddress Block# Su . Name or CSM# ✓ � � -/ 3 =- ems,, Ci State . Code Phone Number Nearest Road ( ) El City � Town New Construction Use: Residential / Number of bedrooms �. Addition to existing building Replacement Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate / bed, gpd /fta trench, gpd /ft Absorption area required bed, ft trench, ft Maxi um design loading rate o 2 bed, gpd /ft gpd/ft Recommended infiltration surface elevation(s) it (as referred to site plan benchmark) Additional design /site considerations Parent material / Flood plain elevation, if applicabl ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding T k U = Unsuitable for system s ❑ U [(Q s ❑ u's ❑ u X s ❑ u El S J ❑ s jrAJ u SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots , r, in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 0 _57 . �01 M S Gr Depth to limi ting ; , ` Remarks: Boring # .... 0 ZI Ground � Depth to limiting `. W . mK(cs: CST Name (Please Print Signa e j � Telephone No. Address_ Date CST NLImber !` b 3 Soil Test Plot Plan Project Name Clay Ed in Byron Bi Jr. Address 2220 127th St. New Richmond Wi 54017 CST 4 #3479 Lot 3 Subdivision - - -- Date 4/28/96 SE 1 /4 SE 1 /4S11 T 32 N /R W Township Star Prairie Boring O Well PL Property Line County ST. CROIX IL BM or VRP Assume Elevation 100 ft Top of NE Property Stake System Elevation 94.5/94.4 * H R p Same as Benchmark 287' Property Line * B.M. 5' 30' B -1 40 , ;:I P ro 3 or 4 _7 B edroom H ouse Pri A Rep A 0' 80' B -3 20' t� c� B -2 B -5 S lope 325' P.L. I'Y1 £ T T £ 39Vd TT 3I�MOA V � Z 10 L 1 '11 o0Z = 4ou! 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A y M I o rt o s s I i x O n SOJOD 0� l i I v CL 'Y'bs Ol9 F85' I J °S' I 0c ° o M O '<1 9N/O177OX3 b'3& �` \ . A S� s ............ �> .. ........... ... w 0 3E 8,9.100 00 Sl II i \ S�'S 3Nn 'M'o'a ;1 bs 08F£99 / ` �� 1 1 3-- ,LS'�09 M/99,��.00 S -1Z��� V3YV 1107 �I i - �— - -- p� - - - - -� (1N3WnN0W ,11Nn00) /- — - _— _ — — -- — _ - IL 1 ' 03S 83N S �\\ 3Nn 'M'0'8 ��� •(�•�•� 4/I. 3S 3H1 20 3NIl 1SV3 �� n i PeuA fit IMF!, M £1,19.00 S ,Z9'tlZ9Z - - -- -- N061 L) eg M'S M Sil►� 6j SONd� 0311d�dN It '03S d3Nd00 /L 1Sb3 sieo oeno ".fddc n:ncrnw ST. CROIX COUNTY ZONING DEPARTM + AS BUILT SANITARY REPORT `n Owner Address ��' - � �� City /State _ 717 7 Sr CF, Legal Description. Lot _ Block Subdivisio SM # 7 – _ _ ;` 'A slt� V4 Sec. T,�LN -RAW, Town of I Z L PIN # SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC Setback from: House - ? 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: WidI i.r2 Length � Number of Trenches Setback from: House 9 :s -- ' Well '' /I P/L_ Vent to fresh air intake ELEVATIONS Description of benchmark Elevation Description of alternate benchmark ,� Elevation Building Sewer 9��s ST/HT Inlet 9l. A,� ST Outlet �el � PC Inlet PC Bottom Header/Manifold 2:�-; y Top of ST/PC Manhole Cover �- Distribution Lines( S ; 22 () ( ) Bottom of System ( ) O ( ) Final Grade () 1y, -y9 () ( ) Date of installation / 1 / Pe mit number ��� 7/ ✓_ 7 State plan number Plumber's signature License number Date / / Inspector Complete plot plan s Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Countys+ INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 6'T76 Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)). "FM& lder's*aeL `�ftY VkAtR of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: o. - 6%- 1049 -SS TANK INFORMATION " ELEVATION DATA A9800057 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic '� �L :'' Benchmark r �D 3, 0 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. A Veritto irI ntake ROAD Dt Inlet Septic , �� 5 r NA Dt Bottom Dosing NA Header /Man. Aeration NA Dist. Pipe ?: Holding Bot. System g, S " w US' PUMP/ SIPHON INFORMATION Final Grade J Manufacturer Demand Model Number GPM TDH Lift Fricti System TDH Ft m ead Forcemain Len t< Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH width Len g th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /� ` --, DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION TypeO CHAMBER mod Number: System: 5y q 51 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 4/J `' Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE 11.31.18,SE,SE 2207 127TH STREET j Plan revision required? ❑ Yes 0-No Use other side for additional information. SBD -6710 (R.3/97) Date s ! ctor's Signature Cert. No. SANITARY PERMIT APPLICATION Safe w shnllgtonAvevision Visconsin m. P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Ad 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. ' • See reverse side for instructions for completing this application State Sanniitary Permit Number The information you provide may be used by other government agency programs E] Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Propert Owryer Name Property Location / ,1 /4 1 /4, S T , N, R X(ore Property Owners Mai i g Ad ress Lot Number Block Number Cit , tate Zip Code Phone Number Subdivision Name or CSU-11umber ' ( ) - I. Y F ILDING: (check one) ❑State Owned Ity ❑ Vil Nearest oad l age , Public 0 1 or 2 Family Dwelling - No. of bedrooms — S Q1, wn o III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 1 3 19. ?'O9 D o 3g - SS - U0 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. [4 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 5g Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure , 42 E] Pit Privy 13 E] Seepage Pit It 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_ ate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed.(sq. ft.) (Gals/day /sq. ft.) (Min. / ch) Elevation f Feet Feet VII Capacit TANK in allo s Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- steel glass Plastic App New Existing strutted Tanks Tanks e tic Tank Tanks ❑ 10 ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ 1 ❑ 1 ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for inst ation of th onsite sewage system shown on the attached plans. Plumbe s Nam : (Pr t) Plumb rs Si t St p MP /MPRSW No.: Business Phone Number: ,�e es ZIS Plumber' Ac dress (Str , Cit St te, ode): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Age Signature (No Stamps) fo Approved []Owner Given Initial t[ Surcharge Fee) Adverse Determination e a 11fib "1 X. CONDITIONS OF APPROVAL / REASONS FO DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber .Eve ter/ Z 5� s, ! � i r � i 3 �6 `� Wisconsinbepartment of Industry SOIL AND SITE EVALUATION 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 /21�'�u,es in sii:4rr)m t County c include, but not limited to: vertical and horizontal re(��r��,,c,e'point (BMdirectioYto percent slope, scale or dimensions, north arrow, arlillbeQtion al#.f to y e,tp neap ad. Parcel I.D. # APPLICANT INFORMATION - Please all WkW a O oq�Ir,' --- Reviewed by Date Personal information you provide may be used for secon R P" (P,f q s. 15.04 (1 4*. Property Owner e �/�4GOF�fCE P Location �— ®� ovt. Lot _)1j'9 61 1/4 .Jty'' 1/4,S El U] ,N,R] E (or W Property Owner's Mailing ddress 6 8 # Block# Subd. Name or CSM# X02 49 - /� 7 - Q�` City State Zip Code Phone Number Nearest LR1,o ( f d s ol W J 1 ( ) ❑ Ci *ay -49 _ „ Town New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate � 2 bed, gpd /ft ' trench, gpd /ft Absorption area required 4q,7 bed, ft 2 - 5 & 1 .3 trench, ft Maximum d9si n loading rate 7 bed, gpd/ft gpd /ft Recommended infiltration surface elevation(s) Pr; ��. / � A 151 ft (as referred to site plan benchmark) Additional design /site considerations Parent material Flood plain elevation, if applicable 46 ft S = Suitable for system Conventional Mound In- Ground Pressure I AT Grade System in Fill HoldinV k U = Unsuitable for system S❑ U S❑ u S❑ U S ❑ U 2� S U ❑ S SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench t Ground j 5 ft. Depth to limiting Wfw in. / Remarks: Boring # , 04k G a _V -21& 5 Ground elev. Depth to l imiting � / Yn. Remarks: ST Kame (Please Print) Signa ._ . Telephone No. Address f Date t� T. er !y l 7 Soil Test Plot Plan Project Name Clay Edin By Bird Jr. Address 2220 127th St. New Richmond Wi 54017 C #3479 Lot 2 Subdivision -- -- Date 5/4/96 SE 1 /4 SE 1/4S11 T 31 N /13 w Township Star Prairie M Boring O Well PL Property Line County ST. CROIX IL BM or VRP Assume Elevation 100 ft S E Pr Stake System Elevation 95.1/95.1 * H 13 p Same as Benchmark 312' P.L. B -2 40' B -5 N con 80' 0' 1% Slope B -3 20' o 3 to 4 Bedroom 4 40' House Pri A Rep A 30' J, 25' B -1 40 B -4 40' .M. a* 312' P.L. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer t\le oA A a A,2,� NA Mailing Address _ �-(� �� . �hCS(2 b`( L�Q _�pp 1 Property Address L ' 2.� — - �\ W anc (Verification required from Planning Department for new construction) City /Sta ±eN' IZiLh rna�� � IParcel Identification Number �g LE GAL DESC � �, Property Location � '/4, S� '/4, Sec. , T�N -R Y l�Vl W, Town of f lVl Subdivision AAAA) Lot # _ . Certified Survey Map # � , Volume , Page # Warranty Deed # I S U 4 A ?� , Volume � � , Page # Lqlu Spec house ❑ yes 'N no Lot lines identifiable K 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 wastewaterdisposal 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 three year expir i n date. r' / I olg SIGNATUA OF APPLICANT DATh. 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 Jroperty describ above, by virtue of a warranty deeo recorded in Register of Deeds Office. M AO ,gal SIGNATURE OF APPLICANT 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 F APPROVED l 2 1996 io �a ALsw 9 5451'75 JUN 1:2'96 N CERTIFIED SURVEY MAP ST. CROIX C OUNTY ocated in Part of the Southeast Quarter of the Southeast Quarter of Sectio Plarnur Range 18 West, Town of Star Prairie, St. Croix County, Wisconsin. f 'wt'��� Zonind jiul Committee Prepared for and at the request of. � Clay Edin 1 DOUGLAS J. i recorded 2220 - 127th Street ZAHLER New Richmond, WI 54017 Drafted by. James M. Braul S -2145 days of HUDSON al date EAST 1/4 CORNER SEC. 11 WIS• at shat be UNPLATTED LANDS A b void (1" IRON PIPE) / - - -- 2624.52' S00*51'13" W-- -- / $ EAST LINE OF THE SE 1/4 C.T.H, 'MC R.O.W. LINE /y\\�� S ER SEC. 11 — — — — — — — — — L — — (COUNTY MONUMENT) - - -- 656.13' - - -- ° - 1968�T � >51.46' o --- - - - - -- i I� LOT 1 AREA - S 00'43'55" W 604.37' - s; i i \� / 653, 380 sq. ft. / 15.00 acres t 1 I I R.O.W. LINE C . ............................ ... S�.A�.\ I� AREA EXCLUDING R. O. W. ° ` �- (I 58J,610 sq. ft. ~ a u fy� I i 13.40 acres C 0 x I B 6, o" o r U NI 1 x I I I LOT 2 AREA 0 v c"n QI a 68,133 sq. ft. C) ° �I m I 1.56 acres ai ai E W N ' I I w AREA EXCLUDING R. O. W. Ji i i i I W 65,340 sq. ft. OR 0- o v a I ; -_ = 00 I ' 1.50 acres Ems° �� �,� o 0 n I ; U_ Q) E °' ° °' I i ? LOT 3 AREA 0 N E `v , 68,119 sq. ft. O E 3 I 1 I 0 1.56 acres to a o 0 C i l J N I 0! I o `� AREA EXCLUDING R. 0. W. ° t o ° a I N I o, 65,340 sq. ft. 3 R. = N j I to I ° D 1.50 acres ., z W > °- �o 3 I II i o "-° o 0 W Z I i �j LOT 4 AREA t o o I I Z� 77, 328 sq. ft. O c U_ w 1.78 acres 0 .N 4) 0 �-: o ° o, ° .5 z ,' rn I <AREA EXCLUDING R. 0. W. J o °D , 65,3 sq. ft. L a v I I I I 1.50 acres C) o 0 0 z ° vw 2 i i �i� - -- S 00'55'12" W 655.89'-_ 0 N m O �X- 209.1 T �` - 209.1 T 208.48' - M 237 C): i °i W �I W i I W i .55'-# I 00 , QI Lii r:.c I •p 1 0 Ki _11 I 3 I O 3�,o N M `� ` ? 9 WT I C A LLJ N`�I ° I � Z ° a�N Mn 0 d� M O p(0 M 1 N I� '°I I F-j C LO MM C)N � J MN r O NMI CSI I -I I iA M M I , N00'55'12 "E N to rn "' I I =I F a 0 I -- �� -- 628.21' -� �� - -- I III 0 z R. O.W. LINE — �\ 209.17- �- 2 09 . 17 / ! - 209.87'-) I w o Iz - CENTERLINE - —� 209.17' 209.17'` — — — z N z ° m R_n W I we — — — - CENTERLINE OF 127TH ST.� —` 23T47'�i _� w 2