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HomeMy WebLinkAbout040-1032-40-100 Parcel #: 040 - 1032 -40 -100 11/14/2007 11:00 AM PAGE 1 OF 1 Alt. Parcel #: 7.28.19.105D 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner GENIE ARABIANS INC O - GENIE ARABIANS INC PO BOX 416 HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description " 422 CTY RD F SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 17.000 Plat: N/A -NOT AVAILABLE SEC 7 T28N R1 9W THAT PART OF SW SW AS Block /Condo Bldg: DESC. IN 738/318 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 07- 28N -19W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 1083/199 WD 07/23/1997 738/318 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/23/2006 Description Class Acres Land prove Total State Reason UNDEVELOPED G5 15.000 262,000 0 262,000 NO OTHER G7 2.000 30,000 455,300 485,300 NO Totals for 2007: General Property 17.000 292,000 455,300 747,300 Woodland 0.000 0 0 Totals for 2006: General Property 17.000 292,000 455,300 747,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 IR.A F. /GI. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM CountST . CROIX Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarygeirri2Igo.: Personal information you provice may be used for secondary purposes [Privacy LXw, s.15.04 (1)(m)]. Permit ODERBERGNaAROLD T❑ Village L] Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel@agc0e_' — TANK INFORMATION ELEVATION DATA A9800 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. 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 Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Ma nu acturer: INFORMATION TypeO CHAMBER Model Number: System: 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 Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 12.28.19.574F,SE,SE 422 COUNTY TRUNK F Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. r Safety and Buildings Division NAIsconsin SANITARY PERMIT APPLICATION Po so 7969 Department 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 8 112 x 11 inches in size. s • See reverse side for instructions for completing this application State Sanitary Permit Number The information ou p rovide may be used b other g overnment ag ency programs ��� y p y y g g y p g ❑Check if revision to previous placation [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Propqrty Owner Name Property Location L, < -E`145-46 . 1/4, S L T ;p r , N, R E (or� Property Owner's Mailing Address Lot Number Block Number Z AI City, State Zip Code Phone Number Subdivision Name or CSM Number 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 0 v ow OF B I $� III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo O VO It YY — 70 — O 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_ ❑ Replacement 3_ ❑ Replacement of 4. ig Reconnection of 5_ Repair of an System System Tank Only 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 120Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill Lc VI. ABSORPTIONS STEM 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 in Capacity Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PI tier's Name: (Print) Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: 1;= p r_� 6 3?0 u er's Address (Street, City, State, Zio Code): ©x IT UNT / DEPARTMENT USE ONLY ❑Disapproved Sanitary Permit Fee (includes Groundwater ate slue Issui g e nt Si nature (No Stamps) Surcharge Fee) 'Approved ❑Owner Given Initial AD Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: ,-WDY�ijwX4 reJWA�ed, aulJ 3BD6399 (R.T DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of z Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # Q APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location 1 /4,S Govt. Lot € 1/4 Z T�dr ,N,R /9 E Property Owner's Mailing Address Lot # I Block# I Subd. Name or CSM# City State Zip Code • Phone Number ❑ City ❑ Village '0 Town Nearest Road ❑ New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building ❑ Replacement lic or commercial - Describe: Code derived daily flow gpd Recommended design loading rate z bed, gpd/ft • ,Y trench, gpd/f1 Absorption area required bed, ft trench, ft Maximum design loading rate bed, gpd/ft trench, gpd/ft i Recommended infiltration surface elevation(s) l ft (as referred to site plan benchmark) Additional design /site considerations 4/ A9 '-' N �00 Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S 1:1 U p S r U 2 S❑ u JZl s❑ u ❑ s m u ❑ s u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench cs c.r ZAA Ground e , Depth to limiting factor in. Remarks: Boring # Ground elev. ,C� ft, v r✓T ,�' r+/0 W L' , Depth to limiting E factor in. Remarks: 1 CST Name (Please Print) Signature Telephone No. Addr Date CST Number 1 Z o `c°r w Z - Q n x c e y o o v S h� c I T A 6 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND / OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address �S'S��_ �r, S ,�`, �li,as� e ��i,� T /1�rti mss? ? Property Address f � (Verification required from Pla g Department for new construction) CityJState 1 TGtCESOl�� avr— Parcel Identification Number D o 70— !!O LEGAL DESCRIPTION Property Location S;ez /a, sue /,, Sec. /2 , T 2E_ -R Town of Subdivision , Lot # Certified Survey Map # , Volume Page # Warranty Deed # _'� Bl� , Volume , Page # /f'9 Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE Improper use. and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. GNATURE '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 the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. IGNATURE O 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 TROY `W' DIRECTORY _ I HUDSON 'W PAGE 27 (Residents - Owner or Renter) ,. MAYER RD RIVERVIEW r I '■ i P v f 'r' l r! l ,r' %J •:t f ri r Bitten Case ■ I ;rh ,lUf McCrea FF MIS ■ ■�I Frontier ■ .wuuam S VanMde ' $UD ■ MIL Enloe � Richard 1T 4 i Gerald ■ Cambronne ■ Cyr Mar ilk � ■ Dean C I Ell iAasaa<r ■ I's- Ladd — — ''°"` - ckarvlew VI IL RD X31 FFF a 1 -2 Addlnon „. Ilk ■16 ■ S James ■ RED 1 80 13 STAG U burden BRICK Holt LEAP NJ ames RD viceoenaau ■ b LN Woodruff R e d G t I. ■ WHR N M ch PE Addition ■ iael n G R M adde CI ■�+� tes PINES Feyereisen I Arthur Q ■ �� . Rp cU 3 js Rldse 1 Eagle � ` S FORK I TOWNS ■ Bluff ■ r.�aa: - R �, i VALLEY RD O V ■ Sub , c B oas / �— — soanev� — Q ■4 s Salishan ' Deer I li ■i ■2 ■ Sub ■ I WHITE- Valley WEST OMAHA 03 ■4 ■6i Ronald 16 IL LN Sub RD Milton ■ rask :3z o q I Gagnon ■ ■ > Keeney ■ y im David W J I E ■ I ' I Kenyon ■ ; < ¢ 8 aq,n' ' o >o COVE RD ■ Salmon 0I 3 G� ■lo1 ■ ■ Bomar area Gf ■ a a LOST 12 13 S O, Sights i$ 14■ ■ o i ROCK Deetz V COVE D� �v � LN y J ames ■ ■vx ■ a� who Troy CROCUS I7o x e � tt ■ 11 � ] I Sub Do d HILL HD Q - ,ee.ma 7 09 - - - - - - - i - - -- - - - - - I I BIRK o Lanm Troy r ¢ Nygaard mmele W > DALE Rue ¢ a o a timti I CT ¢ ( Sub oLL��o man erhn ■ 12 G O U �z° WINDY g St Croix V /na ■ I HILL RD IV Coos a James S n b 4 Q e I o 9 Ruemmele I 2 0 z a y e Scott ROLLING C7¢ ye ? v, I Q F I ■Simenson DRADOW I W Croix I O S a MUIR- I w 6m 4 ■Thomas I Beret e ■ 1 2 FIELD ITRL¢w 5� 3■ Patnode I ■ ■ PLAINVIEW 81111m2 _ _ — _ Wd !, ■ ■M�« — — — gene - — - — — John ■ "" ° tl� Troy ■ Cernohous ■ I M sell, 015 Scherf 0 12 3,'� Sub ■Robert John W14 ■ �daii ■ o Rydberg I Bennett ■ ■13 G \P vlav I SKY- ■ Bud Wayne I ■ BEN 2 5 " P' Subs is DR 21 17■ Stock I 2 ■Carlson 16 ■ ■ uora 20 ■ I Z I ■ Row 19 ■ Z I vaa c C i is s� ■ I O . 0. 0 GLENMONTRD i 10/14 Ro; Webb ■� UO Cc cJ' ■ _3 Robert Mld el M j°"Pba H. ■ 0 ■ ■ 8dqjS11 - — - — — R m= - ■ MM ■ BLACK BASS RD W llman ■ HUI ■ ■I ■ Aug Stich I 1 1 ■ s E4 Z w � M ■ Taylgi ■ Joe Eubank I J ohn rickson ■ Q I 2 t� M L Rupert IM 3■ ■ I East I DRLANDER 2 N ILWACO RD A IIL -� Meadow ■� G George Jana : �WACO � " a Sub I Jennings g Form - STC - 104 y 1 AS BUILT SANITARY SYSTEM REPORT OWNER �����l� ✓% TOWNSHIP SEC. 7 T Z8 N -R W ADDRESS 2 ST. CROIX COUNTY, WISCONSIN Lw-'CAn SUBDIVISION _ LOT /'I/ LOT SIZE /f PLAN VIEW Distances and dimensions to meet requirements of IZHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I i A INDICATE NORTH ARROW BENCHMARK: De4crihe the vertical reference nnint IIRP_(i ,/`'� DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LAROR & HUMAN RELATIONS DIVISION PRIVATE SEWAGE SYSTEMS P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 SW —R19W )M CONVENTIONAL El ALTERNATIVE State PlanLD.Number 1 I assigned) Town of Troy El Holding Tank El In-Ground Pressure El Mound Cty Road F NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE. Harold Soderberg Route 3, Hudson, WI 54016 ��� iffirm "v BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.. Name of Plumber JMPIMPRSW No.. County: Sanitary Permit Number. Roger Timm 3224 St. Croix 102810 SEPTIC TANK /HOLDING TANK: MANUFACTURER . LIOUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER �ry P O DED PROVIDED r e / V �/ 9., 7 YES ❑NO ❑YES KNO BEDDING. VENT DIA.. VENT MATL: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: I BUILDING. JVENTTOFRESH C ALARM FEET FROM LINE AIR INLET_ DYES NO ° ❑YES O NEAREST � vf3 DOSING AMBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL. J PUMP/SIPHON MANUF AC IRER WARNIN=LABELLOCKING COVER PROVIDPROVIDED ❑NO ❑YE❑YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. OF PROPERTY WELL BUILDING VENTTOFRESH (DIFFERENCE BETWEEN EET FROM LINE AIR INLET PUMP ON AND OFF) DYES ❑ O EAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH. NO. OF DISTR. PIPE SPACING. COVER INSIDE DIA PITS LIOUID BED /TRENCH /, rRENC -ES MAIAL p DEPTH DIMENSIONS l� GRAVEL DEPTH FILL DEPTH UISTH PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR NUMBER OF PROPERTY WELL BUILDING VENT TO EET 1111111 BELOW PIP ABOVE OVER. ELEV INLET EL r /) } PIPES LINE AIR I LF.7 �o 3 j / 2 NEARESTO IaV � 7 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES 1:1 NO SOIL COVER TEXTURE PERMANENT MARKERS J OBSIRVATION WE 11 ❑YES 1:1 NO ❑YES El NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. DYES El NO ❑YES ONO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH'. LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF. FILL DEPTH ABOVE COVER BED /TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL I N O DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MAHKIN 1, ELEV. ELEV.'. DIA. ELEV. PIPES DI A.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY ff COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES b ❑NO El YES ❑NO COMMENTS: PERMANENT MARKERS: / (SERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING. 3 s FEET FROM IN LE ❑YES ❑NO ❑YES NO NEAREST o 0 0 . Sketch System on in in county file for audit. Reverse Side. SIGNATURE. TITLE � Zoning Administrator DILHR SBD 6710 (R. 01/82) DI SANITARY PERMIT APPLICATION COUNTY �� /,/ ( M R ..,.n�..,,�,. In accord with ILHR 83.05, Wis. Adm. Code lJ JC STATE SANITARY PERMIT # / / -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES NO PROPE T 0 � PROPERTY LOCATION r /45 %4, % TZ),N,R 1�! (or o PROPERTY MAILING ADDRESS LOT NUM�R I BLOCKNPMBER SUBDI�AM ISION ff / / CC . / / / / r J U/ CITY, STATE= / ZIP CODE PHO 77 CITY NEAREST ROAD, LAKE OR LANDMARK VILLAGE: TOWN OF: C II. TYPE OF BUILDING OR USE SERVED: LUG - - 50 - /40 Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ❑ New b. Y Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner /building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. Conventional b. El Alternative c. El Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In -Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b. X Seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 7_6' - L0 Feet 2 Private ❑ Joint ❑ Public VI. TANK CAPACITY # of Prefab. Site Fiber- in allons Total Manufacturer's Name Con- Steel Plastic Exper. INFORMATION New rxisting Gallons Tanks Concrete structed glass App. Tanks I Tanks Septic Tank or Holding Tank - ❑ 0 El El Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plums Name (Print): Plumber's Signature: (No Stamps) 4 MP /MPR o.: Business Phone Number: Plumbe s Address (Street, City, S�tat Zip Code): Name of _ Desi ner: Vlll. SOIL TEST INFORMATION Certified S 'I Tester (CST) Nye CST # CST's ADDRESS treet, City, State, Zip Code) Phone Number: c) IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved S nitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial ` �1n rcar rcharge Fee ` .y ��) Adverse Determination f D O ' w A • c /` L AT� � - I fl l e a"o X. COMMENTS /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber APPLICATION FOR SANITARY PERMIT STC -100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, ( "spec house "), then a second form should be retained and completed when the property is sold and sub®itted to this office with the appropriate deed recording. - - r - - - - - - - - - - - - - - r r r r - - - - - - - Owner of Prop�irty Location of Pti! Oerty ' , Section _ , T N -R 1Y W Township Mailing Address 15 10 Address of Site Subdivision N am „Lot Number ''Previous owner of Piroperty "' � � .. YW1irWr.i.r/ i tier • i 11 r�.rr�i..��.r.�r.rrr Total Size of Parcel Date Parcel was Created , °'— L�;, - Are all corners and lot lines identifiable? n Yes No Is this property being developed for resale (spec house) ? Yes N , ,/4 No Volume and Page Number 3 le 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. - - - - - - - - - - - - - - r - - - - - - - - - - - - - - - PROPERTY OWNER CFRTIPICATIO I U06 nohtlld tket o 0k AtlftomomfA no fh A lnhM nhe th11e to A0 heAt nl mu 1 mth 1 H • z En H a ST C- 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County z d � a OWNER /BUYER ROUTE /BOX NUMBER Fire Number .CITY /,STATE 461_� e:0i Vj) J ZIP PROPERTY LOCATION: j%, 'k, Section T ,26 N, R %�/ W, Town of _�oX , St. Croix County, Subdivision Lot numbe 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 put 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. y 0 I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x 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 Offkf -e within 30 days of the three year expiration date. SIGNED G� DATE Y 7 St. Croix County Zoning Office P.O. Box 98f Hammond, WI 54015 715 - 796 -2239 or 715- 425 -8363 Sign, date and return to above address. INDUSTRY, LABOR AND PERCOLATION TESTS (115) MADISON, I HUMAN RELATIONS (1-163.09(0& Chapter 145.045) LOCATION:.e- SECTION: UNICIPALITY: OT O.: LK. NO.: SUBDIVISION NAME: 70 N /R /9 (a W 7z COUNTY: • S T CIPo l T MAP$ '�° f - 77 4 C T `/ T USE . DATES OBSERVATIONS MADE LE D E SCR IPTIONS: p IPERCOLATIZ5N-_ Residence U Nk ❑New Replete 4/O V• G /$7 /ffOV � / ?- otQSs $ooh A 4 C 7 3 Sol P / A- A ti-a-r RATING: to Site wkable fa system U- Silo unaultable for system ISY I G T K: RECOMMENDED SYSTEM (op tional) Iz S U l as ❑U S ❑U RTS U ❑ S U Co VCrjr1 ) gkoyC►'( ' If Percolation Tests ar% NOT required T - If an portion of the tested area is in the under s.H63.09(51(bl, Indicate: Ctrme, / Floodplain, indi Floodplain elevation: N D - c PROFILE DESCRIPTIONS BORING ELEVATION •t S L THICKNESS. COLOR, TEXTURE, AND NUMBER TO BEDROCK IF OBSERVED (SEE ABBRV. ON BA r D B� > / . J G,r &LI 2/ `. 61 Lr cs B' > 9.25' 20" $LETS o X 82 71 N & &', GS PERCOLATION TESTS TEST DEPT WATER N HO LE RATE MINK' NUMBER MOM AFTERS ELLING INT AL-MIN. PER INCk P. 1 < S >� .�2 �-- P• 7.7 2 < P- P. t A * PLOT PLAW Show l ocilltlo nb of percolation t", brill bo rltil and the dimensions of suitable soil area. Inditw scale or distances. Describe what are m• roMel and vertloil elevoWn fbferenos points and show their location on the plot plan. Show the surface elevation at all borings and the direction and r ,, , of land slope. SYSTEM ELEvAirION 1 O I h/ �` I finbeah ' striana if �I�ssa /to ja w Ap /alt r1 • M.�� En t TI[ o IJs1 F . 1, I r. . $ , a Y ( I 44 I.. � � N Leywiw� . MoR'CU ; S j i � I �� • e Y v I v �, �"• •.. t b; i r....� *� r j � , N/ � V � r • /al+nlr Ely �w Q E ,,,� � o s ►T� Lccq� Ti mm JOB C 4: a lat2 /y HEET NO. OF Z Excavating C o . o � CALCULATED BY DATE R 1 , Box 1 92, Wilson, 111/1 6M7 J �? oa s 3z Z V GNESKED BY DATE - SCALE ! ... j..... . a ............ ....: . ... _:..... ....... ..... .... ...... _. ........... ... .. ................... ..__..i. ..._. .. .. .._. ..... _._. .......... .!..... ._...!. ... .. .. ..... _ _ t....__.. m � l .... �.� : e g... .. ., i... ...' ........., i .......i ......... ........l. .. .. ... _. ... .. ..... 14 y � ............ ... .......... ...... ..... ..... .... ..... ... 1 ... ...... .. ..... � ............. ..: ...... :..i. y i : V ... ! .... .... ... ...... ... .... ... .... i ! . Timm JOB SHEET NO. ,y- OF Z E xcavating Co. CALCULATED BY �e � DATE R 1, SOX 192, Wilson, W) M CHEC BY DATE SCALE i i I �. �L i3 , ' a 0 Lo - . i 1 . .. ........ r - u s'mc. G.W.u. Marx 01471