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HomeMy WebLinkAbout040-1018-10-000 p C0 v O be 0 o� 0 0 .E � tom. 7 d "O i O c � 0 0 O N N O N L_ _ y o 3 E o ) a E °? C _0 N cl N C co M E > � Z a) o o a. m @ m co d LL C •O - O LL O 00 O O N Q j C N N p > N 'B Q) N E Q L? E <1 U) w U U 4 V Co V � N N rn U) c c :!� O .. O Z E fl E O d m a m z v H III 0 c (9 O z _c c w v 'o r o - cu z O to P a O) O a) c E c E v o� o o) 2 r) N 5) 0 N Q C a� Ci w N (n �l v H MV U) i_ - L L O d d O N O C O 0 C 4 O N Q O Q = O Z M Z Z F- Z Z E N I R O p i .. d E L C 'N w d •� O O 06 O N O~ q O N O a m U o o a N a) to fn N E N N N co w O n F' F H N �i r) 0 0 0 0 0 0 Z •ry a m a _ a a s N c a O �j s ` y "O 00 00 v� Fig � N O c0 c0 7 O N N 00 00 O :3 0) 6) N fA J U = rn rn 2 0) 0) } D O N O N 00 if In - d' O _ E O O - � � 3 x O o m d in m Q Y U) w 16 7 Co 7 ++ � O � ql N Lo Y) N cl O � N C it N C O "O E ® O J N :J O O C cil; 0. p L w 3 c c c c v N �� Z L r) a -0o w CD co O O H W I- O z N H m M O z N Z d' E mil Ea E a �dt a La i, gay A U a 2 O in U 0 ) u ST. CROIX COUNTY ZONING DEPARTMENT , AS BUILT SANITARY REPORT �? 3 Owner CIA 14 Property Addre - i City /State S Legal Description: Lot -"' Block ^ Subdivision/CSM # % 'L°� 7� '/4 S '/4, Sec. �/—, Ta N -R4W, Town of �l p PIN # _ 0 0 ✓ - a-�s . 1 2 n SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: ' rr �� Tank manufact>rer j L ) jt 0 5C/, ,- S ize S)/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 es � Type of system: Y J idth _Length n � Number of Tr nc es Setback from: House _ Well 1'!�6 P/L ?/& Vent to fresh air intake ELEVATIONS Description of benchmark �Ce �.s' �a V d 3 10 41�evation Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ST Outlet Ji PC Inlet PC Bottom Header/Manifold T// 5 / Top of ST/PC Manhole Cover Distribution Lines Bottom of System Final Grade () () ( ) Date of installation// 19 /0 J Permit number d State plan number Plumber's signature License number Date /c Inspector CSC.( i Complete plot plan a Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division bT CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitarAEej%51L 5 1.: Personal information you provice may be used for secondary purposes [Privacy x.15.04 (1)(m)]. L 44 t� i Permit Holder's Name: R [],�&o Village Town of: State Plan ID No.: BARTHMAN , BRIAN 1 }}(( CST BM Elev.: Insp. BM Elev.: BM,Aescription: ,I Parcel �i �o.:101$ -10 -000 t oo (0� TANK INFORMATION ELEVATION DATA A9800512 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. pt. jZ� I ( fa' Bed r � c � ><�'� 100. /0 Dosing Aeration Bldg. Sewer - Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet 72 TANKTO P/L WELL BLDG. Ve Vent nt take ROAD Dt Inlet ept In S NA Dt Bottom Dosing NA Header /Man. �.r� A Aeration NA Dist. Pipe 51 1/ 5� Holdin Bot. System 10.05 f 0 10./ 9!9 PUMP/ SIPHON INFORMATION Final Grad . 3 yr > :� Manufacturer De and � 737 �a Model Number GPM TDH Li Friction System DH Ft oss H ea Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width f Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN ION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Man :„ INFORMATION Type CRAM R Mod N r: Syste d �U �cSU � OR UNIT DISTRIBUTION SYSTEM Header / Mani old y Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length � Dia. Length 1•Z rDia. Spacing L t tM SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 04.28.19.62D,NW,SE 565 TOWER ROAD 52 9W Plan revision required? [:]Yes 040 Use other side for additional information. SBD 6710 (R.3/97) Date Inspector's Signature Cert. No `�.�— Safety and Buildings Division l SANITARY PERMIT APPLICATION 201 W. Washington Avenue �SCOn�11 In accord with ILHR 83.05, Wis. Adm. Code p O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. E /x • See reverse side for instructions for completing this application State Sanitary P Number Personal information you provide may be used for secondary purposes ❑ Check if ion to previousication [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLI ATION INFORMATION -PLEASE PRINT ALL INFORMATI N Prope Owner Name Propert L ation �Q r NAP /a' 1 /a, S T0/' , N, R E (o Property Owner's aili gA ess Q � Lot Numberj Bloc f a. I I City, S e S4 n / I , G Zip.F�O�Q ) f (hone ;umber Subdivision Name or CSM Nu t� PE F BUILDING: (check one) El State Owned !tr st Road ❑ Vtl Public 1 or 2 Family Dwelling - No. of bedrooms Town e OF /� et III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers) 1 E] Apartment/ Condo 710—M 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. )gl Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an ------ System System Tank Only _____________ ______________ Existing System _________ExistingSystem 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 E] Mound 30 []Specify Type 41 E] Holding Tank 12Weepage Trench o�' 3 8 !f � 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 901a" 1 1 tr/^ 1 6PI 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 D Req r d(sq.tft.) Pr ( . ft.) (Gals/ q. ft.) (MI . ' ch) fy E � n Feet C/ ) �v f Feet r VII. TANK Capacity 'Site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber - Plastic Exper. New Existin strutted INFORMATION Gallons Tanks Concrete glass App. Tanks Tanks n Septic Tank or Holding Tank A_j 7 1 a a 11 ❑ 1 11 Lift Pump Tank /Siphon Chamber ❑ ❑ E VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibili r installation of the onsite sewage system shown on the attached plans. Plum er's Name: (Prin PI sSignature: o t mps) MP /MPRSW No.: Busines� neo: X o; C7 � ``// Plumber'sAddr,�ss tr et,City, "t e��ipqpe): 1 ,/ f v �Y 77 d IX. COUNTY/ DEPARTMENT USE ONLY (Ind charge Fee) ter ate ssue Issuin Agent Signature (No Stamps) ❑ Disapproved Sanitary Permit Fee , Approved E] Owner Given Initial Surcharge Fee) r/ &44_!�Z Adverse Determination / 6 d X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: ( /17 9 SBD- 6398 (R.1 1197) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber pmr 50 17 ' IYMdr� e o ' ► ' Sy sT — z C� I BM # = To z I of i1 � �l f1 • /d 0.O T 22 200 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I ha e inspected the septic tank presently serving the ` `Cc � �2�' �l residence located at: NL ;, Section , Tc::; p N, R�_W, Town of Upon inspection, I certify that I have found the tan} and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: Did flow back occur from absorption system? — , X Yes No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer: (I�known).- A ge of Tank (If known) : //M (Signature) (Name) Please print (Title) (License Number) 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 ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle), Name/ S ignature ✓ ! ! r/ M MPR hl � �;C �STlN(r S YP - e -y INS A = ,V o T xe eed'-qw E�vl>EZ� /�- /ff (o - foA Y/'v -L .9 48 Wisconsin Department of Industry SOIL AND SITE EVALUATION / 3 Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County Include, but not limited to: vertical and horizontal reference point (BM), direction and 7 /� percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # ' o yo- APPLICANT INFORMATION Please print all Information. Re ew by Data Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location a Q , J�� / ►� 4" i"I ��/� 74 Ril ltl Govt. Lot OVA) 1/45 114,S 'y T?'v ,N,R /7 E (or)o Property Owner's Mailing Address Lot # I Block# Subd. Name or CSM# City P State Zip Code Phone Number 715 Nearest Road H u PS'o� W (• S ' (o ( 3k) / /�p El Vill City age Town ❑ New Construction Use: esidential / Number of bedrooms 7 Addition to existing building leplacement ❑ Public or commercial - Describe- �V.S r oAy 61A /o4 ? Code derived daily flow gpd o C ecommended design loading rate bed, gpd /ft trench, gpd /ft Absorption area required �l bed, ft } O J trench, ft 2 Maximum design loading rate bed, gpd/fl - 'F trench, gpd/ft Recommended Infiltration surface elevation(s) S•,Q�JG 3 __ ft (as referred to site plan benchmark) Additional design /site considerations Parent material Flood plain elevation, if applicable N14 ft S = Suitable for system Conventional � M , ou In- G AT G System in Fill Holding Tank u = Unsuitable for system � ❑ U I:'' S [] U lJ�'s ❑ U RrS ❑ U D U ❑ S U SOIL DESCRIPTION REPORT B oring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 257 10 31� /fs' e .2L: •3 7 -/6 1 /o Si& /mot ar d / ,� . 7: • 9 Ground 1 5 - f l o, / y/� •S1�2 s ©f • G — Z . 8 elev. 77. i OF IS7-40 s Depth to limiting ,L�! .ST /N�T- .$ s r-S /M factor 7 �Q_ in. G'O 9d G!� .v 7 Remarks: Ir5olieT�G�2- ' ZlS �/lj�- /�t�GG �i�LUE Boring # l 0•0 1El yie 3l!( SL[. ifs�JK G�� af' /t' . Z- ' • C ��v� Ground ft. Depth to limiting fLaclor 1 In. Remarks: CST Name (Please Print) Signature Telephone No. RoBEV ��i� 71S• 306 . 8!8 5 3 MOW & Associa onsultants Pclvate SeWaQ e0 af4ell Rd. 5q�18 Nudson, W ls. `O T Z I� 0 j4 (7p , 3 N' v cu T �fip die --------- 96 49 I � � l � I B, # / = 71 8 Z 3y - i 7k4�- � #clef T 11 5 �o c5 G— I r ?2 / i a � T ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT 0 Y0 — h/)JP A0 AND OSHIP CERTIFICATION FORM 1 OwneOwner/Buyer � � Q-?r'l WN R &- Mailing Address �� 7 0 - 6k) 0 ;" f d• Property Address �� g0)1 4 c 3 / X 4 (Verification required from Planning Department for new construction) City /State l���so"?� �;' Parcel Identification Number � Q / y — A LEGAL DESCRIPTION Property Location #Z� '/4, :54 '/4, Sec. I , T 0T N -R_Zj W, Town of � Subdivision /` l �° ��S Zl G ° 1 ; f S ,Lot It Certified. Survey Map # Volume , Page # Warranty Deed # 7 . Volume _ , Page # Spec house ❑ yes ❑ 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 masterplumber, journeyman plumber, restrictedplumber 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. 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. SIGNATURE OF APPLICANT 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 1 P e prRperty escri ed abo , by virtue of a warranty deed recorded in Register of Deeds Office. / ll0/ a 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 ' , T11-8 &MMV90 FOR R[Co NA�R Rmi"o DATA ' . ( - oocuMeNS No. ;STATE BAR OF WISCONSIN FORM 1- -iY8�e r goo Wr ° REGIPER'8 Qi�iCE f This Deed, made between .... Patin.. J .,_..;•lzu9...Aly_Cg...L....... ', ST. CRQi CO. 1M1 I .Zckb1ald,.Amaband..A_A4 - -- rife..... -- ...... 'I bed for Reeem ...... ...................................................... ---- ...- •.• -• -- Grantor, , 111N 1 7 and ....... Brian.. A. --- and.. Pamela -- S..- ..B.arthman,.._husband.... and .................................. ..------......------------ ......•--- ........ - -- -- ........, Grantee, ........................................................ .....••-- •••- •................. �p4Mr d tlsa6 Witnesseth That the said Grantor, for a valuable consideration_._... .......... ------------------------ ----------- •••......... conveys to Grantee the following described real estate in _._..gt_...Croix ........ WAS County, State of Wisconsin: ASSOC A110 OF EwU ClAllE 510 20 S1REfi A parcel of land located in the NW 1/4 �Y6611ttt 3ieR'- of SE 1/4 of Section 4- 28 -19, described as Tax Parcel No: ------ _.. . follows: Beginning at a point on the E. line of said NW 1/4 of­SE �4 of Section 4 a distance of 184.4 feet S of the NE corner of said point of beginning being at the intersection of said r line and the centerline of the Town Road; thence N and W along said centerline a distance of 24 rods (396.0 feet) as follows: N60 "V a distance of 146.3 feet; N66 a distance of 186.0 feet N80 ° 52 1 W a distance of 63.7 feet; thence due S parallel with said E line - a distance of 463.9 feet; thence due E a distance of 361.2 feet to said E line; thence due N along said E line a distance of 308.3 feet to the Point of beginning, the above �i 9� g. parcel containing 3.0 acres, more or less, exclusive of roadway. Bearing used in the above description are based on the zealmption that E line of the above parcel is due N & S. Sub]'ect to existing highways. EXCEPT parcel described in Quit Claim Deed to Richard A. Bestler, recorded August 12, 1981 in Vol. "634" Page 22, Document Number 372718. TRANSF� FEE 'i This ...... ................. homestead property. 4 (is) (is not) 1. Together with all and singular the hereditament, and appurtenances thereunto belonging; And--- -•-•• -- _ _.._.... J warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except covenants, easements and restrictions of record, if any, ii j and will warrant and defend the same. Dated this 15th Tu a 88 . -- -- -... day of ....... - -... .... 19.._..... � tt - --- ---- - --.... - -- . • -- .. ... -- ---- -- .(SEAL) "` �:. C �G^ ....... (SEAL) ' ---••----------- •----------------- - - - - -- - - - - -- P ul - Eckblad.......- ..._.. ---- ----- --------------- ---- - ------ ------ - - ----- - - -- --- _---(SEAL) - (SEAL) Al ce L. Eckblad i AUTHENTICATION ACKNOWLEDGMENT Signature(s) --- ---------- ------ • -•--• - ------ ......................... STATE OF WISCONSIN --•-----•------•--------------------------------- --•- -- -- •-•-----•-- ••--- -• -- --- Milwaukee - - - --- -County �• authenticated this ........ day of -------- ............... 19 ------ Personally came before we thy L 't. of. June 19 eta - n81h Paul -- J.-- Ecicblad and - Aly, - ' -- ----- -- V TITLE: ----------------------------- MEMBER STATE BAR OF WISCONSIN .. (If not, -- --• ... ..... .... .. ..- authorized by 4 706.06, Wis. Stats.) P9irce1 #: 040- 1018 -10 -000 11/03/2004 10:04 AM PAGE 1 OF 1 Alt. Parcel #: 04.28.19.62D 040 - TOWN OF TROY Current 1XI ST. CROIX COUNTY, WISCONSIN Permit # Permit Type # of Units Sales Area A yp Creation Date Historical Date Map # Application # 00 0 Tax Address: Owner(s): ' = Current Owner * BARTHMAN, BRIAN A & PAMELA S BRIAN A & PAMELA S BARTHMAN 565 TOWER RD HUDSON WI 54016 Districts: SC = School SP = Special 'Property Ad ' = Primary Type Dist # Description " 565 TOWER RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.900 Plat: N/A -NOT AVAILABLE SEC 4 T28N R1 9W 2.9AC IN NW SE BEG 184.4 Block/Condo Bldg: FT S OF NE COR NW SE, SD PT BEING INT E LN & CEN LN TN RD; N & W 396 1/4 FT S Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 463.9 FT; E 361.2 FT TO E LN N 308.3 FT 04- 28N -19W TO POB EXC AS IN 634/22 Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 814/199 07/23/1997 547/373 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 223,600 Valuations: Last Changed: 07/15/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.900 60,500 185,300 245,800 NO Totals for 2004: General Property 2.900 60,500 185,300 245,800 Woodland 0.000 0 0 Totals for 2003: General Property 2.900 44,000 171,200 215,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 214 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 • Form— S T C — 104 ~ AS BUILT SANITARY SYSTEM REPORT 4 OWNER ��� / � Z / OWN SHIP IWOy SEC. T Z d N —R 1 7 W ADDRESS �PT ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW NOMESITf SfoYIC pf,UMBlNG CO. IT. 30'WE +i di�';c ? "! 'mS 54016 Distances and dimensions to meet requirements of I'ZHR 83 !i3H! r.' WIS. MASTER P Wit R , 4 %t .13010A.S. WUN. MSTAWt R + ULa14 lh .w, No, 0060 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM R s� a V jp .10 JO It s ysZe -q �'rro ,(ioV � � I I � g I I 1 � I I � x INDICATE NORTH ARROW 63 .fie t 4 /e tj i DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & 19 RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.Q. BOX 7969 69,, BUREAU OF PLUMBING MADISON. WI 53707 �� n El ALTERNATIVE State Plen LD. Number: (lf assigned) ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE Paul Eckblad Rt. 3, Tower Rd., Hudson, WI 54016 - -U- 9 6 3 BENCH MARK (Permanent reference pomt) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. LEV.. NW-4 SEk, Section 4, T28N —R19W, Town of Troy Name of Plumber: 7 P/M No Sanitary Permit Number: Robert Ulbricht 3307 St. Croix 79149 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER Q _ 96 , C� PROVIDED: PROVIDED'. G / �.7� YES ❑NO ❑YES GVNO BEDDING: VENT DIA.: VENT MAT HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALRM FEET FROM ` LINE I AIR INLET DYES . NO C DYES NO NEAREST "`r J DOSING CHAMBER: MANUFACTURER 7INGLIQUID CAPACITY PUMPMODEL PUMP; SIPHON MANUP ACTTIF7EH WARNING LABEL LOCKING COVER PROVIDED: PROVIDED ❑NO 1 E]YES ❑NO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING VENTTOFRESH (DIFFERENCE BETWEEN FEET F R OM LINE AIR INLET PUMP ON AND OFF) OYES ❑NO NEAREST' -!► SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I E N(,TJf J IIIAMF TEH I IIATE HIAL 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 LENGTH NO. OF j DI1T11 PIPE SPACING COVER INSIDE DIA SPITS LIQUID BED /TRENCH / THE NICHES / �TEFIIAL PIT DEPTH. DIMENSIONS �) I CY GRAVEL DEPTH - FILL DEPTH ST IT P )F DISTR PIPE DISTR. PIPE MATERIAL NO [ ..TH NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH BELOW PIP S I I ABOVE COVER ELEV. LF f ELEV END - PIPES FEET FROM LI / AIR Iy,L7 E/3 2- 7 NEAREST -- -w J d'{ S. 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- 1 YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE 'FHMANFNI MAHKFHS OBSERVATION WELLS -� ❑YES ❑NO DYES 1:1 NO DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDFI) SEEDED MULCHED CENTER EDGES DYES ❑NO 1:1 YE 1:1 NO ❑YES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: BED /TF3ENCFI WIDTH LENGTH TRENCHES ES. LATERAL SPACING GRAVEL DEPTH 3ELOW PIP1 FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV.. ELEV.' DIA ELEV. PIPES DIA.. ' DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED ❑YES ❑ COVER NO PLANS DY ES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER O F PROPERTY WELL: BUILDING. FEET FROM LINE. DYES El NO ❑YES 1:1 NO NEAREST Sketch System on Regain in county file for audit. Reverse Side. SIGNATUT �� TITLE. DILHR SBD 6710 (R. 01/82) wlsconsr, APPLICATION FOR SANITARY PERMIT ,- D I L H R COUNTY (PLB 67) UNIFORM SANITARY PERMIT # - O DUS TRT Y LR OF � IrlOUSV,LRBOR6MUTRn RELRTIOf15 � — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /zx 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS } uL fjG yCE' zt'c�l,QGif D 1' T .3 To cam.. PROPERTY LOCATION tWT: 4W 1/4 S� /4, S / , T �N, R I E (or) W TOWWN o�F• 1710/ �QTNUM 11346 F- AI�lAABF� S NEAREST ROAD, ' "' ' ^ND&4A° STATE PLAN I.D. NUMBER <>GvFiQ A TYPE OF BUILDING OR USE SERVED 7S-1 or 2 Family Number of Bedrooms. ❑ Public (Specify): THIS PERMIT IS FOR A: ❑ New System ❑ Tank Replacement ❑ Repair Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. X Seepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. f/� Total #of Prefab. Site `/r '1u G Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity,(/Ew So 7 lD Z X Lift Pump Tank /Siphon Chamber Holding Tank capacity Manufacturer: A&-" IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): � R ED (Square Feet): REQUIRED (Square Fee PROPOS Y d Private ❑ Joint El Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): HOMESITE SEPTIC PLUM W.ture: IVWtMPRSW No.: Phone Numb RT. 3 O'NEIL RD., HUDSON 54014 �d6eA-1 J,. d? (7� 06 ,low Qc Plumber's Address: ROBERI ULtJKI6N I Name of Designer: WI3, MASTER PLUMBER LIC. NO. 3307 MAR.& COUNTY /DEPARTMENT U ONLY Signature of Issuing Agent Fee: Date: Disapproved 7 �p l ❑ �ajS�� �d Q 0 t� Approved El Owner Given Initial Adverse Determination Reaso or sa val Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) 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 �� , /7A- ye� � Location of Property Aw ;4 � 3 4, Section , T N -R W Township for Mailing Address 7o� Address of Site Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date ,Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATIO I (We) eenti.6y that at t .6xatements on this 6oAm ace tAue to the best o6 my (out) knowtedg e; that I (we) am ( ace) the owneA (,$) o the pAO pen t y dens eh i.b ed in this it k! 5�4 w }, #and a lint a 46 0 - 6 the s 3 . 4 abom 0F' :LT Q y 16 7 +F f r # M1 H z cn STC - 105 r . a H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County z d 01, H OWNER /BUYER ROUTE /BOX NUMBER �, 3 / ���'�- V Fire Number .CITY /STATE 1-1VPSO-.LJ '�/ /� _ ZIP �0 PROPERTY LOCATION ?49 5 14, Section T Z N, R W, Town of ���/� , St. Croix County, Subdivision , Lot number ' I Improper use and maintenance of your septic system ,could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper What you pdt into the system can affect the function of the septic tank as a treat - ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a 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 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 veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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. 0 I /WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro ment 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 cc DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715 -796 -2239 or 715- 425 -8363 Sign, date and return to above address. c p an = m m N 3 0 ° w � * 0 0. N a 0 7C 0 n A ( o 7 ? w ` c °c0,Cr c -° c 0 113 ° a p° w o -1 0 cp ..wv m �, < `O O 3 a O n �0 C 0 ( o ° r 0 3 (0 W ° m E o w w o`° w�� � 0 3 9 a o = , a ' 0 CL O �1 O w A N C A ( O _ M O C Q o A � y � -� O D C n• (D ,..� O = 0 o - w n 0 t0 "` w o lD a 0 f °'0� o...CL 0 �m oNm °�nw v C ,. O 0 0 M -� �. pi 0 0 5D 7 O M fu cn M A? N Z 0 a M o 3 fD N= G D (D -., O ova 4 N_Fo R1 Q N �D — 0 O j O '< m u, w ac���� N o �, u, w w C M C a l 3c- vMo 0 a 0 O Coo a '� � m!�'oAvi 7D -M 0 f N c o _ o a w o 171 w °w c� - wNO a�*m aaaCL y O -4 O 0 M m 0.03 ocoa ov�� �_ ° CL C CL CD 0 Z I O DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUS %R'1', DIVISION LABOR AND ) PERCOLATION TESTS ( 115 P.O. BOX HUMAN RELATIONS \ / MADISON, WI 53707 3707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNS HIP /�: LOT NO.: BLK. NO.: SUBDIVISION NAME: N� '/ '/a Y /T�' N /R /9 E (o 7;kf COUNTY: OWNER'SH 'S NAME: MAILING ADDRESS: 5f . CPO /X Pn/ � /fb - c r - z f o 3 ?b we.�_ Ae • f �D le J 4� i' l' , S' Sio�� USE _ DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTI NS: PER OLATION TESTS: Residence ❑New Replace i1P� 3 /p�� Qom,_ 3 lse RATING: S= Site suitable for system U= Site unsuitable for system Scs 7/ '�T ,a vei�/rY,PD T— ,""' CON MO ❑U IN- GR RE: SYSTEM- 1aULHa S G�U OztJUE.vTiOVyI� SYST (optional) U If Percolation �Tests e NOT required DESIGN RATE: If an y portion of the tested area is in the under s.H63. indicate: C'LSS �— Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER - INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERV EST. HIGHEST TO BEDROCK IF OBSERVED (SE ABBRV. ON BACK.) i B ?� // 0 /0 2 .O� / /�3 " %.v . Cs-u S 3. 1 7 B -� /2.S 103 2 -C 2 > �?.� ' �t' A 64 . Is �7, " 76A, . &AJ B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL -MIN. PERIOD t — PERIOD 2 PE RIOO 3 PER PER INCH P- 3 6 --e_ u s P- CS . P- 2 P P- 1. 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 i 52� S�z af�.I Pi 6'1 - f �Ih A 3 . TN of (1*r0A15 k � i FT. _. E 3fT ell—P yi i REPORT ON SOIL C30RINGS PERCOLATIoN TESTS I15 Pao r PLAN PROTECT =. D. _tiw %y s�' % s y T-ar 2/S DA T _ 3 / ie( HOMESITE TESTING CO. ��i� V OL R s . 3, O'NEIL ROAD BOB ULBRIcir UDSON, WIS. -- 54016 C57 S — 02 YeZ PROPOSED HOUSE mosr LIE Z� Fr. O� Mode "aoct ,gL[ TEST , %eeA S, PRo PoSE 0 WELL M VSr LIE ,5'0 Fr a,e IyD,pF FRo ti ALL TEST �9,PE�s, • raw oE p/T,s O = ZX /ST /,v G- L(�ELG X � �E�G /DCgT /ONf � = yA�� Rv9EQED o,Q S�DIIEL ljp�ES ■ ` f/oeiZ . B �£,QT %CAL �EFE,Pt.UI'E Poi�JT S � - A/V 1 f�' /o � y (,— F.Z - - •�c.1, /vt's T � T Livsz> LE GE N p llar. ,p Pr / 0 0. o F . �ARh� O che Z ` o v � � GI o V r � yy W 3 o �D 190 � y /or`'� � ° ►�fl E � QU��` 4 ��W °a. PLE3 �7 PLOT and ooss t o �►R 5Ec � N PANS l 'io' 11 4z zk pow Joe- 1 io _Is To rr �riYriaf ?,Wk 7a 1 ctitck�R foR toD+e' 1 o e V �n V � rr- T =r 1 EV O i m lel/�fiDx1 /OO.d Z o � �g Fresh Air Inlets And Observation Pipe Sol rESrIag By HOMESITE TESTING ':G. Approved Vent Cap RT..3, 0 Rd , °0 HUDSON, WIS. 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