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HomeMy WebLinkAbout040-1049-90-000 ST. CROIX COUNTY ZONING DEPARTi AS BUILT SANITARY REPORT - A Owner 41 1 Address Ca,e 4C4 City/Stat e 5Y0 .12 Legal Description: G 0 " X Lot _ Block — Subdl*vlsl*on/CSM # '/ , :!� 4j /4 /Vzu S ec. Z�_7 Tag N-R /d W, Town o P -4 - /c5 -9o- SEPTI TANK - D )SE CHAMBER -- HOLDING TANK 12 W 19. 193 1�3 ATION: Tank manufacturer 6,_) e s-,,? Size ST/P0 ( 00 Setback from: House /9,C' Well 'P/L Pump manufacturer 4,o— Model ✓ 714 Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SO ABSO SYSTEM: Type of system: I.Y(o.,uo /a do Width Length Number of Trenches Setback from: House Well a 1,2 P/L _5'F ' Vent to fresh air intake ELEVATIONS: Description of benchmark Description of alternate benchmark Elevation 00 00 Elevation Building S ewer ln77.03 .1 0 3 Inlet - "r(, STOutlet­ - PC Inlet — PC Bottom 'Z?. / 2 " Header/Manifold /02• Top of ST/PC Manhole Cover IF1 .6 17 Distribution Lines Bottom of System Final Grade Date of installation IL-r-W-1W Permit ntimber 3 (!>-17 3 r State plan number 3 Plumber's signat re License number-iVY-7.zS_�_ Date 43 Inspector complete plot plan Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 315938 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: TRONRUD, LARRY TROY CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.: 1 7 1k�C " AL 'eJ P ( 040 - 1049 -90 -000 TANK INFORMATION EL NATION DATA A9800326 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Ic / Benchmark Aeration Bldg. Sewer Holding t/ Inlet FC . TANK SETBACK INFORMATION t/ W Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I eptic U� t bU` 1 av/ NA Dt Bottom osin NA Header / Man. A Aeration A Dist. Pipe /DO, Holding Bot. System e� �.yv /p/ PUMP/ SIPHON INFORMATION C Final Grade Manufacturer Zti � Demand O Cj 9110 Model Number W F_07 S6 GPM TDH Liftaoj( I Friction �i 4 Syetemj TDH31 .) Ft ad '0 oss Forcemain Length' Dia. HH ' Dist. To Well SOIL ABSORPTION SYSTEM ENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 g I I DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBE � _ � � Model Syste d [ I OR UNIT DISTRIBUTION SYSTEM Header/Manifold �j Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake Length � Dia � Length / Dia. Spacing / 3 p SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.)�� LOCATION: ��T 12�28.19.182B,N 804 COULEE TRAIL 1 �� q3 c ll rr '� 4L vue.- z- tY�` e e- 1 ') `0106 1 eLv lrc. �JA `7 �a ��' Plan revision required? Yes [�No Use other side for additional information. � (� 7 SBD -6710 (R.3/97) Date Inspe is Signature Safety and Buildings Division A Lconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue 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 8lrz x 11 inches in size. !` • �► °'/` • See reverse side for instructions for completing this application State sanitary Permit Number 1`15 Personal information you provide may be used for secondary purposes ❑ 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 RMATION Pro rty Owner Nam --� Pro pert Location Q Q f 1 �,. n 1 to � n 6,I /4 1 5 T N, R 0 1060 W Pro eity Owner- ailin Addre o Lot Number Block Number ( 1 rt7�1 i y , S to Zi Code Phone Number Subdivision Name or CSM Number . T F E [1] Vll a BUILDING: (check one) State Owned ❑ iI r �--- -- N crest Road g ro �� U 1 e Public 1 or 2 Family Dwelling - No. of bedrooms Town OF III BUILDING USE: (if building type is public, check all that apply) Parcel Tax Numbers) q 1❑ Apartment/ Condo 0 H 0 — 1 0 �.i 9+ " U 000 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 / 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. X Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an S - _____ystem ________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 hilGlound 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 2 4 5 0 1 ,2 10 I . 5 Feet ) 0S, a Feet Capacit VII. TANK i Ca allo Total # of Prefab. Site n Fiber Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App 1p00 00 cCN16O New Existin structed T nks Tanks (q� Septic Tank or Holding Tank 1000 loo a w le-5er tJJ ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber dU I Lj I -¢ S � - ® 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility r installs ' n of the onsite sewage system shown on the attached plans. Plumber's Name: t) ?: � 7 is gna t mph) MP /MPRSW No.: Business Phone Number: a J I ar,1(* �..T?s� 1 - 1 15 -U6- 2850 Plumber's Address (Street, City, Sta , Zip Co P7l , G '��' a•% W t SQL IX. COUNTY / DEPARTMENT USE ONLY AApp roved ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No St�rlps) �( Surcharge Fee) ❑Owner Given Initial Adverse Determination U X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber ` Safety and Buildings " 2226 ROSE ST LA CROSSE WI 54603 -1905 is consI n Tommy G. Thompson, Governor Department of Commerce William J. McCoshen, Secretary June 16, 1998 CUST ID No.383548 ATTN.• POWTS INSPECTOR ZAPPA BROTHERS INC 715 SIXTH ST N HUDSON WI 54016 -0 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 06/16/2000 Identification Numbers Transaction ID No. 89217 Site ID No. 10431 SITE: Please refer to both identification numbers, Site ID: 10431 above, in all correspondence with the agency. St. Croix County, Town of Troy SE1 /4, NE1/4, S3, T28N, R19W LARRY TRONRUD FOR: Description: Mound Object Type: POWT System Regulated Object ID No.: 26332 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED The following conditions shall be met during construction or installation and prior to occupancy or use: • 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. Adm. Code. • 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. 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, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 06/11/1998 FEE REQUIRED $ 180.00 GERARD M SWIM, POWTS PLAN REVIEWER FEE RECEIVED $ 180.00 Integrated Services BALANCE DUE $ 0.00 (608)785-9348, MON - FRI, 7:15 AM - 4:00 PM JS WIM @COMMERCE. STATE. WI.US O RECEIVED J h � a JUN 1 1 1998 SAFETY & BLDGS. M DIV. o " k= a Q \ a v V fl C n O V a cat P.O.W.T S. v► a N a Conditionally �t � `^ pp V f,PPK`0VED fl D EPARTMENT UN F Of COMM 1 INGS `' } V, ( e � :. SEE CORRESP DENCE V W v , q M z o CIr N �1 o 0% �t V Z w - 3 \44 w W a 4 'V \ n m O � n \-+ F) � � \L' \9 *k ' o t �y t ° ' ( I i " I f I i � w � � s� ►' I L r era N I Z 3 i '44 a h C O ' 4 M 1 V � O I � � J c 1 v w J J �a oh m ��- _i , 4 Q o � Z 0 4 � _ W Q �\ W At S Q- a � v o O O� � Qo 1�► � p V 4 a �'OC *4 x F p i Or t w z � o W S � � c s i J �j vi t n O CI I.. 1 71— or ' vi fit Il - j O V w �/ O w U l ' 9 C� rt LL L 1 U G v W 01-- b 0 Jn w a0 '- m m 4 tl �h O "ern Vi m r. L O O I!) r"J Lv ED 3g 0. I O lJr4 +Y O0DUIKC� - <<< ® r ~ F • lii w w (L � G $ LL C Q. i t TT �G t II 4 I I � 1 IL I I 7 I I I t r j m j I CJ I � t•J ; I � � � � � � t�J w (— �I 11A Co- el • �_ I I I ,, I t l ,o +Iln � � K' S� t'�'�' � _ i •� �. '? . �N'1 ►l11'1 N:�S31M ' �' 811 I �Ifl.i.' cN •(i11- Nlb 3885 APPLICATIONS • Overload protection must smooth operation. Silicon can be operated continuously Specifically designed for the be provided in starter unit. bronze impeller available as without damage. following uses: • Shaft: threaded, 400 series an option. ■ Bearings: Upper and • Homes stainless steel. ■ Casing: Cast iron volute lower heavy duty ball bearing • Farms • Bearings: ball bearings type for maximum efficiency: construction. upper and lower. g p ■ Power Cable: Severe dut • Trailer courts 2" NPT discharge adaptable • Power cord: 20 foot y rated, oil and water resistant. • Motels _ for slide rail systems. • Schools standard length (optional m Mechanical Seal: SILICON Epoxy seal on motor end • Hospitals lengths available). CARBIDE VS. SILICON provides secondary moisture • Industry Single phase: • Effluents stems •'/3 and % HP –16/3 SJTO CARBIDE sealing faces. barrier in case of outer jacket y with 115 V or 230 V three Stainless steel metal parts, damage and to prevent oil prong plug. BUNA -N elastomers. wicking. SPECIFICATIONS • 3 /4 -1 % HP –14/3 STO with ■ Shaft: Corrosion - resistant ■ 0 -ring: Assures positive Pump bare leads. stainless steel. Threaded sealing against contaminants • Solids handling capabilities: Three phase: design. Locknut on three and oil leakage. 3 /4 " maximum. •'/ - 1'/2 HP -14/4 STO phase models to guard • Discharge size: 2" li with bare leads. On CSA against component damage AGENCY LISTINGS • Capacities: up to 128 GPM. listed models - 20 foot on accidental reverse rotation. • Total heads: up to 123 feet length SJTW and STW ■ Motor: Fully submerged in SA Canadian Standards Association TDH. are standard. high -grade turbine oil for • Mechanical seal: silicon lubrication and efficient heat Underwriters Laboratories carbide -rotary seat/silicon FEATURES transfer. carbide- stationary seat, 300 0 Impeller: Cast iron, semi- ■ Designed for Continuous series stainless steel metal open, non -clog with pump- Operation: Pump ratings are parts, BUNA -N elastomers. out vanes for mechanical seal within the motor manufacturer's • Temperature: protection. Balanced for recommended working limits, 104 (40 continuous 140 °F (60 ° C) intermittent. METERS FEET • Fasteners: 300 series 90 stainless steel. 1 ._. 1 j 1 /r SERIES: 3885 ` • Capable of running dry 25 e0 ,.1 -..- - 1.__ — _. `_.. i SIZE: SOLIDS WE1 i RPM: VARIOUS w without damage to -► 5GPM I_ components. 70 i 20 Et _ 5 Ff I 1 I Motor G a 60 Single phase: Eo _ i I • '/3 HP, 115 V, 200 V, 230 V, " 50 60 Hz, 1750 RPM; 1/2 HP, z 15 ' 115 V, 60 Hz, 3500 RPM; '0 40 WEO H -- ---- _ .-_. ' %HP- 1'%HP, 230V, _J I 60 H 3500 RPM. 0 10 30 • Built -in overload with _ _ EQ automatic reset. 20 - - -- --- - - --- -_- 5 ....- ... ... -...... ..... • Class B insulation. 10 Three phase: • %: HP -1'/z HP 200/230/ 0 o L_.._ _ _ l _ 460 V, 60 Hz, 3500 RPM. 0 10 20 30 40 50 60 70 80 90 100 110 120 130GPM • Class B insulation. I I I I 0 10 20 30 m /h CAPACITY ®1995 Goulds Pumps, Inc. Effective May, 1995 tt 83885 Wisconsin bepar4nent of Industry, SOIL AND SITE EVALUATION R E P O H ' I I' Cdr t of Labor aM Human Reladons gwision�r' atvry & 9utldinpn In accord with ILHR 83.05, Wis. Adrn. Code COUNTY Attach complete site plan on paper not lees than 8 1/2 x 11 inches in size, Plan must include, but not limited to vertical and horizontal reference point (SM), direction and /o of slope, scale or PARCEL ID a dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION nEVIE4 C3Y DATE P 0PFM OWN PAOPERtY LOCATION AR Q Y / ft �tJ p Gov LOT St J t,a N W IA,S f Z 'r z N,R iq E (oil yr PROPERTY OWNEIT S MAILING ADDRESS LOTH BLOCK $I SUBt) FJAr.Ir QR C.SP,1 a & CITY STATE ZIP CODE PHONE NUMBER OCITY CI VILLAGE 6M NFARFS'I AU ) 1 So "i ' o r l I New Construction Use Fif Residential) Number of bedrooms .1 �) Addition to exi;Gng building Replacement I Public or commercial describe Code derived daily flow �_ gpd Recommended design loading rate _G- , bed, g(,d /1t? /, Irench. (0/11? Absorption area required , ,gy bed, tt ?t trench. f1 Ma)tirnum design loading rate ,bed, gpd /ftZ -.X ,JZ. Irench, gpd/ll? Recommended infiltration surface etevdtitM (9) Ti L r JrSTERM afiS S Y it (as relerred to site plan bcnchrnark) Additional design / site considerations 1pv; 1APLC P - Parent material Flood plain elevation, if applicable It S • Suitable for system CONVENT�UIL Np IN- GROUND PRESSURE AT- SYSTFM 111 tILL HOLDING LANK U. Unsuitable fors stem O S U S Cl U o s No O S au u s O U O S WU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure G P p /ft - oring # Horizon in. Munsell Qu. Sz. ConL Color Texture Gr. Sz. Sh. Cor's'slenc� E3cxrcl)ry Floots - -- - -- 6ed71ra�d� f o .'� pp `�+Ra n rs ;round D, r 144 lev. -e )�, j N YR 4 3 c r �� �� )epth to miting _ sctor Remarks: - ioring # 83 - L �} C I � ��� 141g eve= MV. r .. �> 1J � ijF ;round ev !g ft. 72 -98 MAO — 1rS SG l Y )epth to -- ....._.... _ ... . miting Remarks: CST Nartte: -- Please Print 1 4A u Phone:' A ddress: C) 6x IR V, A u uQU r Stnattue: Dale: CST Number z 9- �� I= 3 WIAM u -.. S�m 1-015 It .19 z r Lk) a L. D n p L _r Z ,,, W f�1 b a P a A-JT .2 OR LelIV &L NP JE LJAV I 1 fi I o I �. SLe ►�' , l T I b lb N w I , W 1 / m p r � -0 W I G W 17' I scon:,� Qepartment of Industry SOIL AND SITE EVALUATION REPORT , C" Page of 3 Labor and Human Relations Division of Safety &Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less th 1 i in size. Plan must include, but not limited to vertical and horizontal refers e'o� n d % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location i anc ©© e to*earest a . — / d — S� APPLICANT INFORMATION - PL PRINRUM OR I N REVIEW BY DATE P OPERT ' S E P O R 1997 GOVT. LOT S J�1/4 N l-J 1/4,S i z T N,R i - 1 E (or) W Avi OWNE v d PROPERTY OWNER':S MAI ADDRE COUfdTY LOT # I BLOCK # SUBD. NAME OR CSM # ESCS C r fti ca ZONINGOFFI CITY STATE ZIP C ',- PHONE NUMBER [ ❑VILLAGE OWN NEAREST FjOAD l � L) &�o;v �! 6 Y (J New Construction Use K Residential / Number of bedrooms [ ] Addition to existing building Replacement ( J Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd /ft trench, gpd/ft Absorption area required bed, ft trench, ft Maximum design loading rate bed, gpd /ft trench, gpd/ft Recommended infiltration surface elevation(s)s) ii) 9c mP'M ".x& 6 Y ft (as referred to site plan benchmark) Additional design / site considerations /AJ-4 1/%LC P Parent material Flood plain elevation, if applicable ft r S = Suitable for system CONVENT O MOUND IN- GROUND PRESSURE AT -GRAD SYSTEM IN FILL HOLDING TANK IJ= Unsuitable for stem ❑ S LSD U fly S❑ U ❑ S QI U C3 S U ❑ S O U [3 S ICU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench $ Kk \ \ h ij 16 Ground g, 45-TA J6 YR 4/ 3 ' C 5farsan c� S L 5 N� s �!� �i�l r elev. L0 ft. $� q- /o YA4 3 ct S S6 n, I NP NP Depth to limiting factor Remarks: Boring # /C YP 4/1 `� > (� J d!7 - bC r, r 2 3 Ground $ - 7� 4 3 � r r� a: , � �^"d �5, �„� r r 5 r" l� e' l 3 72 -` 1,4 -- 1, 56 vh ,,gift. Depth to limiting f IL Remarks: CST Name Print ' A k \tL- � �� Phone: Li Signature: Date: ), /T CST Number: �^ 7 `f z g D Z z 76 g z y 0 A,MLe OR LIe#IVtL bQkf&:L)AV &� R Z II f 1 r� 1 V z I c I 1 o � C: rn r � 1b� N W rte- , G � � r/ ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND O CERTIFICATION FORM > Owner/Buyer Mailing Addres Property Address / (Verification required from Planning Department for new construction) City /State J7(J /J �� �C/ Parcel Identification Number y D 9 ' C I S LEGAL DESCRIPTION Property Location ' , ` ,Sec. , T ;9 N -R (a W, Town of r" Subdivision , Lot # Certified Survey Map # 1 , Volume tj , Page # N/ Warranty Deed # -� a a � , Volume r a i , Page # 5 Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes 5j 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. Itwe, 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. J ` 7//'� I SIGNATURE bF 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.. SIGNATURE & 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 Wisgonsin'Department of Commerce PRIVATE SEWAGE SYSTEM County - Safety and Buildings Division INSPECTION REPORT ST CROIX GENERAL INFORMATION (ATTACH TO PERMIT) SanitnPgn4VD.: Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)). N®itwft 's NtT&RY E�J� f] Village ❑ Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TdO:Ll049- 90 TANK INFORMATION ELEVATION DATA A9700312 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO 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 L oss H ead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O model Num 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 12.28.19.182B,NW,SW 804 COULEE TRAIL Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION l��a.nlln In accord with ILHR 83.05, Wis. Adm. Code COUNTY ` STATE SANITARY PERMIT # —Attach complete plans (to the county copy only) for the system, on paper not less than ❑ �9 7 7 8%z X 11 inches In size. check if revision to revious application —S reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROP RTY OWNER PRO ER WLC T I N �rr�� (( I T O n !"� Tc/V N, R / E (or ow PRO ERTY WNE 'S M ILING 7DDRESS / LOT # BLOC — CITY, A 'A I ZIP E PH � M ER SUBDIVISION NAME OR CSM NUMBER CITY NEAFWST RO D II. TYPE OF BUILDING: (Check one) State Owned VILLAGE: Q 1A L°L° 3 2 TOWN OF: ❑ Public 1:11 or 2 Fam. Dwelling -## of bedrooms — RCELTAx NUMBER( 111. BUILDING USE: (If building type is public, check 1 ❑ Apt/Condo 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 in line A. Check line B if applicable) M A) 1. ❑ New 2. LnReplacement 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## 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 El Holding Tank 12 El Seepage Trench 22 In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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 REQUIR D s . ft.) PROPPO Eq sq. ft.) (Gals /day /s ft.) (Min. /in ) /, / ELEVATION Y� 6) 1 3 3 L ( "b Feet Feet VII. TANK CAPACITY Site in allons Total ## of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New xisting Gallons Tanks Concrete glass App. _ Tanks Tanks structed Septic Tank or Holding Tank d g Lift Pump Tank/Siphon Chamber t / FR r_1 1 F1 ::I F1 Fj VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum per's Name (Print): Plu Signature: (No Sta s) /MPRSW No.: Business Phone Number: � ar � 5 Plumber's Addr ( treat, City, State, Zip 'ode) IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Fateissued Issuing Ilent Sign re No S Approved ❑ owner Given Initial - Surcharge Fee) �— Adverse Determination 2x4L 1 Z X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD- 6398(8.08/93) DISTRIBUTION: Original to County, One Copy To: Safety ✓f< Buildings Division, Owner, Plumber SAFETY & BUILDINGS DIVISION 201 E. Washington Avenue P.O. Box 7969 Madison, Wisconsin 53707 State of Wisconsin Department of Industry, Labor and Human Relations July 14, 1997 1340 Fast Green Bay Street SUTTF 300 Shawano WT 54166 WANG FXCAVATTNG THOMAS WANG W9672 770 AVE RTVFR FALLS WT 51022 RE: PLAN S97 -30728 FEE RECETVFD: 180.00 TRONRIJD, TARRY W TOWN OF TROY COUNTY OF ST CROTX MOI?ND SYSTEM The Department has reviewed the above- referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must he corrected. The review and approval of the system is based on chapter 115, Wisconsin Statutes, and chapters Comm 83 and 81, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter Comm 82 or in chapters TLHR 50 -61, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can he made. All permits required by the city, village, township or county shall he obtained prior to installation. Tnquiries should he directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, Ross J. Fugi l l Wastewater Specialist ( 715) 524-3626 7 : 4 5am - 4 : 30pm &=n - - SEDA -6928 (H. 10/94) SAFETY & BUILDINGS DIVISION 201 E. Washington Avenue P.O. Box 7969 Madison, Wisconsin 63707 State of Wisconsin Department of Industry, Labor and Human Relations July 14, 1997 1.140 Kant Green Ray Street SIJTTE 300 Shawano WT 51166 WANG EXCAVATTNG THOMAS WANG W9672 770 AVE RIVER FALLS WT 51022 RE: PLAN S97 -30728 FEE RECEIVED: 190.00 TRONRUT), i.ARRY W,12,2R,19W TOWN OF TROY COIJNTY OF ST CROTX MOUND SYSTEM The Department has reviewed the above- rpferenced suhmit.t.a.l. Conditional approval is hereby granted for the system plan snhmitttal. All noted items must he corrected. The review and approval of the system is haled on chapter 115, Wisconsin Statutes, and chapters Comm R3 and 84, Wisconsin. Administrative Code, and is contingent upon compliance with any stipi:lations. shown on the plans. This system has not been reviewed for the code requirements set forth in chapter Comm 82 or in chapters TT.TIR 50 -64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plijmher responsible for this installation shall keep one set of plans with the Depa.rtment.'R stamp of approval at the construrt. ion site, The installer shall notify the appropriate inspector when inspections ca:n be made. All permits required by the city, village, township or county shalt he obtained prior to installation. Tnquiries should be dir-r.t.ed to me at the number listed helow. Please refer to the plan numher shown above,. Sincerely, Ross J. Fngill Wastewater Specialist (715) 524 -3626 7:45am - 1:30pm o0e" .r SND A -66'28 (R. 16/84) Trop f LA SCale _S.D� GtCreS P.O.W.T.S. l�1 ,ed Conditionally APPROVED DEPARTMENT OF COMMERCE r aYl$IQN OF WW NO N" 2 010 SEE NCE g M g 3 )00 ® U ) q0 1 {ka g i / 26 By e ' T $2 ► c i t - �-- 215 `--- e vnt binafion 3 p um p be �arc� Ma la _ , ft> a on 160 d OI.Qa (cD 'brorn hou5� Coulee, 7Ow4 2oa S 97 - 3072 8 e0l S 9 4 w 4191'7 Pa _ of _ Straw, Marsh Hay, Or Synthetic Covering , Distribution Pipe IM�m Sad H' G s 6" Topsoil = = - -- - - - -- F _J o 3 E COnd ition .. Slop �« Plowed D Bed Of .� 2 � Force Main p A VE ggrw , Jig Layer ■ P >W' Below PT gEtJ1110 � e) P pEpT. OP �S 0 Y` tJ D Ft . qv � %, I E L� Ft . Sec. < +on. Of A Mnlind System Using PONDENC A Bed For The AI, . -rption Area F , $Q_ Ft. S G J�.Q Ft. A Ft. H Ft. Signed: B ! +� Ft. 3 K I D Ft. P.O.W.T.S. 1, i ci ;,se Number Conditionally Date: $ Ft APPROVED DEPARTMENT OF COMMERCE Ft. DIVISION Of SAFETY Amn BiIiLWNGS - W - Q -i- Ft. 7z' 41 ` . 1 �-- SEEc6i DENCE I Observation Pipe--,,, J g I _ K _-------------- - - - - -- I Force Main VV to --- _J--- _ - - - - -- - - - - - -- Distribution Bed Of i 2 %2« Pipe Aggregate 'I Observation Pipe Permanent Markers 597 - 307 Plan View Of Mound Using A P - 1 For Th l Abso•intion Area s94p41017 Page _ Of _ P.0.W.T.S. Conditionally Perforated Plea Oetoll AP PROVED DEPARTMENT OF COMMERCE av1SION 9F SAFETY AND BUILDINGS • SEE Pecte►eud NCE a" cap 71 PVC Pipe Holes Located On Bottom. d Are Equally Spaced A PR(AGE SYSTEM C `ditionally AL Ro VE E uTvntls . Il i Hll [t Distribution WT. OF us u8D V s/IIrETY AND GS Pipe Lest Het. Should B. Nest To End COP E E NDENCE Distribution a out P & 0 Ft. R 3.0 S X Z Inches Y 77- Inches Hole Diameter ' Inch Signed. . Lateral 1 '/y Inches) License Number: Manifold Inches ` Date: 30� Force Main " _� Inches of holes /pipe l� Invert Elevation of Laterals S Ft. S9 307 S 9 4' 0 4 0 1 L Page Of SEPTIC TANK PUM;` CHAMB CR SECTION AND SPECIFICATIONS 4" CI VENT PIPE 12" MIN. ABOVE GRADI' E WEATHERPROOF 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COV W/ PADLOCK E FINISHED GRADE 4 CI RISER WARNING LABE y 1 --4" MIN. 18" IN. 6" M 5 -4s � * INLET P w n , tit � �ti, GAS. , ' TIGHT , ' 4 1 S L APPROVED �lgoa► G` A , JOINTS WITH APPROVEDs�� -�-- ALM APPROVED PIPE PIPE 3' . ma B ' ON 3' ONTO 0160 SOLIDI pENG� f ' SOLID SOIL SOIL I --- RISER EXI P. LEV . 85. 5 FT. OFF Con t nu y PERMITTED ON! IF TANK AP MANUFACTURER DEPARTMENT OF COMMERCE I " APPROVED BEDDING UNDER TANK HAS APPROVAL DIVISION OF SAFETY D BUILDINGS SPECIFICATIO CONCRETE PAD SEE RRESPONDE^JCE SEPTIC / DOSE TANK MANUFACTURER: ft) QA Q5 - VeCA f NUMBER DOSES PER DAY: TANK SIZES SEPTIC lXo GAL. DOSE VOLUME TNCLUDING X 12 5� y5 DOSE - 7Z GAL. FLOWBACK: 157• GAL. N ALARM MANUFACTURER: 5j 1� CAPACITIES: A = _i INCHES = 11 GAL. MODEL NUMBER: tol N Vi T� SWITCH TYPE: et B = 2 _ INCHES = 31 GAL. I � A PUMP MANUFACTURER: C = 10 INCHES = GAL. M, MODEL NUMBER: SWITCH TYPE: W NW M D = -2. INCHES = Z /(y GAL. p� REQUIRED DISCHARGE RATE �o GPM PUMP & ALARM WIRING AS PER ILHR 16.23 WAS M' VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE J(p_ FEET v + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . . 2.5 FEET M + 2`15 FEET FORCEMAIN X 1-5 FT /100 FT. FRICTION FACTOR -- 772 - 7 FEET TOTAL DYNAMIC HEAD = 22, FEET ` INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; ID �H ; DIAMETER _� I LIQL` `, ISEPfiFT' q z - S IGNED: _ LICENSI` NUMBER: DATE: / 1/88 S94- 1 3 Eft 1I31E0 SU MERSIBLE PUMP CLASS I AND I I DW 2 SRO 11 CLASS IN DIV. I AND: E T 1 • . . ETL TESTRIO LABORATORIES, INC. WMAND. NEW YORK 13018 010;, +SO CAMI,WIAN STANDAN ASSOCMTION PERFORMANCE RATINGS (ganons per minute) MODELS — wE1S11N WE0311NN Series HP Vans Phase Max. Arnp. RPM Solids VA. Serifs WE0512M WE1712N WE1012M WE1112M WE1512MN WE1612NM WE0311L 115 9.4 N0. WE0311L WE031114 WE0532H WE0732M WEIN2N WEIS32N WE1532NN WE1S72MM VE0$12L 230 4.7 WEN12L WEN12M MOWN WE0734M MOM WE1531M WEOS3/NN WEI534NN �� 1750 WE0311M 115 9.4 11r % % A 1 1 1 % h N WE0312M _73 _ Rpm 1750 1750 3500 3500 300 3500 3500 35 WE0511H 115 13.0 F 10 80 90 106 — 60 — WE0512H 230 6.5 10 80 65 76 87 102 112 56 84 WE0532H 208/ 1A 3.4 15 60 57 72 84 100 108 53 82 WE0534H 460 3 1.7 20 36 45 65 79 95 105 48 7 1: 25 4 1 1 45 _:...1� WE011HH 1 � 115 1 13.0 U 30 50 6 85 96 40 72 20 6.5 35 40 61 79 92 05 35 70 ;� 3 —165 3 3 40 26 5 72 8 3 67 WE0 71 4 5 10 43 64 80 25 64� WE0712H 230 1 10.0 v WE0732H 1. 208/130 5.4 3500 �5 30 54 73 18 WE0734H 460 3 2.7 �55 17 42 65 12 7 60 0 4 5+1� WE1012H 230 1 12.5 _65 WE1032H 1 082 7.0 _ 7 5 26 16 40 47 WE1034H 460 3 3.5 7S 14 43 WE1512H 230 1 15.0 1 4 _ WE1532H 208230 9.2 3 WE1534H 460 3 4.6 8 WE1S' 'H 230 1 15.0 100 -- WEt M 208230 9.2 110 — WE1534HH 460 3 4.6 120 s ^fetal parts, BUNA -N - lastomers. METERS FEET • Temperature: 160° F (71 • C) maximum. MODEL 3885 • Fasteners: 300 series 25- 80 i SIZE Y4* Solids ! st nless steel. WE/sH • Capable of running dry 70' 1 wihout damage to 20 wE10H I ° ` components. a 60;.. sePM Motor: • Single phase: 1 /3 HP, 115 or 230 V, 60 Hz, 1750 RPM; 0 40; W E05M 'r4 HP, 115 V, 60 Hz, ! i 3500 RPM; 1 /z HP through 10 30 WE03M ` _ . , ._. _ .. L .. ........ ,......_.... :....._..:. _.__ i 1 1% HP,230 V. 60 Hz, 3500 RPM 20! 5 ' WE03L Built-in overload with �0 • automatic reset, class B 10 .. } i Insulation. ' 1 ! I ? ' • Three phase: % HP through o o� _.. ,.._._ _..,. _ . - -- 1'% HP 208/230 V, 460 V, 0 10 20 30 40 50 60 70 80 so 100 110 120 60 Hz, 3500 RPM, o i0 I 30 Class B insulation, overload CAPACITY protection must be provided i in starter unit. e 597 1 i partme!�tofIndustry, SOIL AND SITE EVALUATION REPORT 1 ,5 5-cCG Page l of .j Human Relations Fn of safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ach complete site plan on � � 81/2 x 11 inc'ti'es to size. Plan muslinZ'I(rdjbuT PARCEL I.D. t limited to vertical and horizontal reference point (BM), direction and % of slope, scale or O y0 - 10 qq - 90 nensioned, north arrow, arA 21orgpnWnce to nearest road. REVIEWED BY DATE 'PLICANT INFORMATION- PLEASE PRINT ALL INFORMATION 'ROPERTY OWNER: 1 PROPERTY LOCATION "I" r ud &C�kAT (,0 � #� — 40+,S I Z T z 8 N,R 1 9 >Lon W �Cl t'Y 'ROPERTY WNER':S MAILING ADD LOT # BLOCK # SUBD. NAME OR CSM x Bout cis ;ITY, STATE ZIP CODE PHONE NUMBER OCITY QVILLAGE WOWN NEAREST ROAD son WI S O I 0151 Tr oL ee.&.TroM I New Construction Use ( J Residential / Number of bedrooms 3 ( Addition to existing building kA ,' Replacement ( J Public or commercial describe N ;ode derived dally flow _ Q 15a gpd Recommended design loading rate 15 bed, g�pdM trench, gpdM lbsorption area required R o 0 bed, ft ?fib trench, 112 Maximum design loading rate _ 0 ,5 bed. gpd/ t 0.(P trench, gpd/ft. lecommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Ndditional design / site considerations Parent material Af A- Flood plain elevation, if applicable A! Ir ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN 1111 HOLDING , 1 K U= Unsuitable fors stem ❑ S R U N S C7 U ❑ S � U ❑ S ,[S U ❑ S J� U ❑ S , U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots CPD /ft , ing # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed !Trt& �w < Z 12 -2q, to yr: /q = SI I 2 5b )und q - 37- /0 y '94 5 i 2 r1 r m .6 t 5 — 14 - 1. ft. Li 3Z -1.0" 10 Yx `4 ��- I -F5 — �pth to l ,iting Aor , �Z Remarks: _t� r4!?�n 3 �S Vpr; cLArssT o r,a� I!n��e orInf -4 V% on feg� z'ring # _ ) g 0 -13" )0 y� 3/Z r - �tl z - Fsb m -Fr' as 2 2 13 A 10 YR y/( � �� �-�sbK Mir CS 3 3b -53` / e v U � l d y -F s d s m C s - - -T round ev. . )0: ( ft. epth to niting v - 'CtO Remarks: z on r o n rfe eArOr- o r, -( _Lto ���� � I' t _ Phone: CST Y Y l YY 10 x'10) 1SYe r 7� 5(o"y� l - - - -- (Address, S, S-o-A S`�. )6 0,12, kier Fa I LS (J_ •S90 2 ? Signature: ( / / . n A.. r - Date: C P Q - 04 q14 M 6 2 )7 1; 7 EROPERfYOWNER ']r'Onrtud , ! - r y SOIL D9SCRIPTION REP - " Page 7 PARCEL.LD. o 104 go 9 4 = 4 10 17 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounctry Roots GPD /ft in. Munsell tau. Sz. Cont. Color Gr. Sz. Sh. Bed tern D Y K 3)z I Z m 2 ZH -3'Z o Y12 4 Z- - F ,5 mfr C - . 7 YK 4/y Ground 3 32- p yg 4 d . S ►. �-- el� a a V��it�J7 Nmib _ Reii:arks: A lzon .3 d �, S Boring # • f Ground f Depth to fimiti fac rig tor _ �..w.::...... Remarks: Boring # Ground tt , , • Depth to t� Remarks: Boring # _ Ground elev. ft. Depth to limiting fa6.i Remarks: cnn e�ewiA nr.nn. • !�' P age of S o 4 01 ,L 3 PLOT PLAN 9 Property Owner Lamy T- ron Legend Legal Description BM = 0 Fcse 0elecrNc pole cL.S5uu rn ed 100.0' TZgN , IQ t9 t,�, Town o�Tra� N _ ' q soil boring w /backhor ID Se bacX pmjD)em s • Well9rGu�•e� shun 100 5e.ule : I'•y �excrp� „here h {<� q foihe �nor-1+ .acres t \` • �O \� A [3 \'ti P°I c►ton 100.0 �urd en .. _ . area. p � �Pe eleo��e►` 100-4' I P ❑ 6-1 I -0- .g I So dYywel M A i elc on 99.4 I E J area.. 9► � ���, v r0-. I — (op t from house. Co, )cc- Town S 9 '7 - 3 0 7 2 8 Signed CST ` r /!1G 3 7U7 Da te - ` �c X Wisconsin Department of Industry SOIL AN I D SITE EVALUATION REPORT Page l of 3 talwr and Human Relations 9 Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code 10 COUNTY Attach complete site plan on paper not less than 9�d tnc ie z n must include, but St Ct�IX not limited to vertical and horizontal reference M), diction an pe, scale or PARCEL I.D. # dimensioned, north arrow, and location and e to ku�. Q Lf Q - 10 L19 - 9D APPLICANT INFORMATION - PLEASE _� TALL INFORMATIO . REVIEWED BY DATE °;� a� PROPERTY OWNER: - ' ERTY ION o L_ac( Tror 1 f �,..,, _' �t +� ik (�I �2 #�S — A S T Z 8 N,R I R >,Lcrl W PROPERTY WNER':S MAILING ADD ZOWN iOFFit;£ T # NAME OR CSM # 0 e0 Lkl 'J" cit 1 CITY, STATE ZIP CODE P> ❑CITY ❑VILLAGE MOWN NEAREST ROAD lit son WZ S 0 I hI S� 1 Tr o f e� .Tra t I (J New Construction Use (] Residential / Number of bedrooms 3 [ ] Addition to existing building Replacement' (] Public or commercial describe N k Code derived daily flow L{ .S0 gpd Recommended design loading rate 0, S bed, gpd /ft 0• (.o trench, gpd /ft Absorption area required q d0 bed, ft '76b trench, ft Maximum design loading rate 0 bed, gpd /ft (Me trench, gpd /ft Recommended infiltration surface elevation(s) ©1.1) r (, I ' --AM 4 � ll 1 It (as referred to site plan benchmark) Additional design / site considerations Parent material Af A - Flood plain elevation, if applicable 41 Pr It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE 7T- S DE S M IN FILL HOLDING T NK U = Unsuitable fors stem E] S OU J� S ❑ U ❑ S 11 J'U E:] S W, SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouriary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed jTrench 3/Z — slI Z-F b �r aS - 0. 1 v....... Z Iz. Id y 3l4 — SI I Z 1 rn Fr S — p.� 0•b Ground - 32 10 y 9 4 s'i 1 2 Kn r m s elev. 7, 5 y/W .-q ft. L{ 3Z -Lo 10 YX 14 10 :ACA -Fs 6Q ni — Depth to r, 2 limiting fact , r Remarks: k4w) —on 3 is very dotes r- c4 a K nd -e- 1 2fne y 6u)r l06 Boring # 0 -0" )0 Yl2 3/Z 5" Z - Fsb mfr as 13 ID Y q /f, Z-�SbK rn - P r C5 Ground 3 a- i o Y e L4A 5 OSI fn C s — elev. 100 y ft. Depth to limiting fact i Remarks: zon e n ife n e Frcu o { CST Na Please P , t I I ( 1ST.. Phone: aly ► 715 lzb -y9►I Address � ([ &S S- -. l . Ib IZ` er Fa I I wl� Spa 2Z Signature: Date: CST Number: t Df _0q ' r 3 PLOT PLAN Page of Property Owner Lorry 1 ronrudk Legend: Legal Description Lk)� 2 3-Q-C. 12) BM = • gasp CFelec4rrlc Qole 2 - t N le i9 (A) , Town &F'TY-0 y a s6u-mfdd 100.0' N I soil boring w /backhoe, o �3� la Sep bac..K P ►�,b)em s Wel19r +kan 100. 5c0.)e q -k 4vt m r ash � � a cre eled�� , �e� or► � pole- -- - - - -- Vird areOL--/ g t � � • 2 °� surer f slope. cl Q ayr s5v' 3 nB -► Irts drywe►� M f 60 70 hou � Cowl-ce= Town Rea u<— g S i ned CST (h $ 2N IM6 3 W7 5 Date A (,�q (.l5'�" � )�q� 8 T C - 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. -------------------- property 4 a kr4 ----------------------------------------------- Owner of kt rad Location of roperty a 1 M Section / ,To? N-R 7 j W Township rO Ll Mailingaddress 14 l ee Address of site 4 /A Subdivision name Lot no. Other homes on property? Yes Previous owner of property - Total size of property Lo Total size of parcel Date parcel was created 1 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes *)< No Volume RD k and Page Number �JK 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 CERTIFICATION 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 n the office of the County Register of Deeds as Document No. �1 ,06 , 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 f � ce of the County Register of Deeds as Document No. k Ajl� �jn f Signatu a of Applicant Co- Applicant P)/ in Date of ignature natP of Cinnatiir�- STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS PW C n (e e T �' W PROPERTY ADDRESS '3 � 1417 e (location of septic� system) Please obtain from the Planning Dept. CITY /STATE Gl c�Sey lti` 5'��l PROPERTY LOCATION _ `Z 10, 174, -- S ection T (> 0 N -R_12 W TOWN OF b' ST. CROIX COUNTY, WI SUBDMSION LOT NUMBER 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 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 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 y expirati ate. SIGNED: f /) DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93