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Wisconsin Department of Health and Soolal Services `N
Plb. #67 10/69 Division of Health
PERMIT APPLICATION Sl'
f
PRIVA E DOMESTIC SEWAGE SYSTEMS
A. OWNER OF PROPERTY TYPE OR USE BLACK INK
Name Address (Street, City, Zip Code)
1 4 0
PA 41 �
� County
B. LOCdTION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED .1R EXTENDED
Oheok One:
CITY VILLAGE LEG L DESCRIPTION:
_ TOWNSHIP /
/cJ —4' -- --
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? `A YES NO _ 2 PERMIT NUMBER ,C
D. SEPTIC TANK CAPACITY / f C' _ Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete �� Poured in Place Steil Other
NUMBER OF TANKS TO BE INSTALLED: --
E. TYPE OF OCCUPANCY r /
Check One: a or Two Family Residence Commercial Industrial Other
~ Specify
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETCs Food Waste Grinder YES 'N0 Automatic Clothes Washer I / Y E NO
Dishwasher YES __k NO Automatic Potato Peeler., YES
Other (Specify)
G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT � k el
Tile Size No.Lin.Feet Trench Width Depth Number of Line O
Seepage Beds Length Width Depth Tile Size No. Lines DI~I!"K 7-
Seepage Pits Inside diameter C � Liquid Depth V
PE RC 0LATI ON TES T C "AI RS fjl
Test Depth Character of Soil Hours Water ITest Time Drop in Water Level Inches Minutes
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overnight in Minutes Last Period Last Period Period Cie Inch
Uample
P— 0 36 Too Soil 10" Clay 26" 25 yes or no 30 1/2 1/2 1/2 60
/ RECORD DATA FRUM MINIMUM OF 3 TEST HOLES
omputs size of absorption arek. in accord with H 62.20 Wis. Adninistra6ive Code.
S 0 I L B 0 R I N G S— Minimum 36" Below Prop osad Absorption System _
oring Total Depth Depth to Ground Water Depth to Bedrock f
umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches i
xample
— D 72" 72" Black Top Soil 12 18 "• Sand 18 Gravel 24"
RECORD DATA FROM MINIMUM OF 3 BORE HOLES
I, the undersigned, hereby certify that the percolation tests reported on,this form were made by me
or under by supervision in accord with.the procedures and method speoified in Chapter H 62.20 (3),
Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to
the best of my knowledge and belief.
NAME L TITLE
Type or Print)
REGISTRATION NO ( 5�� J,� S or MASTER PLUMBER / ER / LICENSE No.
ADDRESS_ ✓C J S �'✓ S D ��I S�
DATE / O �' !� S IGNATU RE
MASTER�PLUM ER MAKING APPLICATION
_ MP
Signature: License Numbers
MP RSW
(To be Completed by Issuing Agent)
Date of Application / Fee Paid $
Permit Issued (date , Permit Number
Agent (name) ' , v u -✓ For:
Town, Village, City, County, eta.
(Specify)
Notes The application cannot be considered for filing until all of the above questions are answered
and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the
Permit (yellow copy) to the Division of Health. Checks and money orders should be made
payable to the Division of Health.
C / c�Do not write in space below FOR DEPARTMENT USE ONLY
DATE RECEIVED 7 ` / ACCEPTED BY RETURNED Y �V
(Initials) / (Date) (see Correa, r
FEE RECEIVED ✓ VALID. NO. �y PERMIT NO.
Yes or No)
REVIEWED BY �� APPROVED DATE y �✓ `��
(Initials) (Yes or No)
COMMENTS:
Parcel #: 040 - 1115 -50 -000 06/04/2007 12:16 PM
PAGE 1 OF 1
Alt. Parcel #: 30.28.19.473B 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
MARK GERARD NELSON O - NELSON, MARK GERARD
DEBORAH JEANNE SEIBERLICH C - SEIBERLICH, DEBORAH JEANNE
158 SKYLINE DR
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 158 SKYLINE DR
SC 4893 RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 3.050 Plat: N/A -NOT AVAILABLE
SEC 30 T28N R19W 3.05 AC W 168 FT OF E Block/Condo Bldg:
672 FT OF NW SW SC CSM 1/213
EZ- UT- 1499/305 Tract(s): (Sec- Twn -Rng 401/4 1601/4)
30- 28N -19W
Notes:
Parcel History:
Date Doc # Vol /Page Type
08/19/2004 736233 2378/302 WD
04/26/2004 760723 2557/413 QC
08/19/2003 736233 2378/302 WD
01/29/1998 571992 1291/350 WD
more
2007 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/23/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.050 60,500 184,700 245,200 NO
Totals for 2007:
General Property 3.050 60,500 184,700 245,200
Woodland 0.000 0 0
Totals for 2006:
General Property 3.050 60,500 184,700 245,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 116
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
+ 3�3
3
CERTIFIED SURVEY MAP ST. CROIX COUNO
Part of the NW 1/4 of the SW 1/4 of Section 30, Township BEY
Town of Troy, St. Croix County, Wisconsin
Michael Dado
N 90 0 0 0'00" W
168.00
o Indicates 24 long iron pipe
stake weighing 1.13 + /ft.
�331r-2 b ti �
Pit
8 8 3
JAN 27 t::
uo lea o. co 876 a o
Register o/ p p O
,y, N Z Scale
j
e
N 90 °00'00E
168.00' P.O.B.
To Rd• i n
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A ,
2� ?
S.W. Corner Section 30
Description:
That certain parcel of.land located in the NW 1/4 of the SW 1/4 of Section 30 Z
fully V
T 28 N, 2 19 W, Town of Troy, St. Croix County, Wisconsin, more fuy describg
as follows; " Commencing at the Southwest corner of said Section 30, thence go 5: vi
N 27 0 20 00 E a distance of 1512.23 feet to the Point of Beginning of the a
parcel to berherein described; thence N 00 03 4 0" E a distance of 518.57 fe 0
thence N 90 00 00" W a distance, of 168 «80 feet: thence S 000 oil 40" w
Parcel #: 040 - 1116 -10 -000 06/27/2006 11:29 AM
PAGE 1 OF 1
Alt. Parcel #: 30.28.19.473H 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
O - HIGGINS, GARY T
GARY T HIGGINS C - KLAWITER KAY A
KLAWITER KAY A
308 GLENMONT RD
RIVER FALLS WI 54022
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description 308 GLENMONT RD
SC 4893 SCH D OF RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 2.000 Plat: N/A -NOT AVAILABLE
SEC 30 T28N R19W 2 AC IN NW SW LOT 1 OF Block/Condo Bldg:
CSM IN VOL I PAGE 213 ORD
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
30- 28N -19W
Notes: Parcel History:
Date Doc # Vol /Page Type
08/15/2005 803321 28661125 WD
07/23/1997 1138/267 WD
07/23/1997 531/504
20015 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 50,800 157,800 208,600 NO
Totals for 2006:
General Property 2.000 50,800 157,800 208,600
Woodland 0.000 0 0
Totals for 2005:
General Property 2.000 50,800 157,800 208,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 101
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
3�_1;�� 0 : 2 .
3 � /q SD
CERTIFIED SURVEY MAP Part of the NW 1./4 of the SW 1/4 of Section 30, Township
Town of Troy, St. Croix County, Wisconsin
Michael Dado
N 90 0 00 W
168.00'
o Indicates 24 long iron pipe
stake weighing 1.13 # /ft.
Q
G
co Fit ED
$ 8 3
JAN 27 o o v
U') 11013 ° 97 6 0 0
RoObhr , 0 - O O
54 4aX X64 N O Scale I =100'
why, z
wr '�++w `
. _�...,.✓ frinK W.rJt
N 90
16 8.00' P. 0, B.
io
To Rd. rn
ih
M
/SW.C orner Section 30
Description:
That certain parcel of land located in the NW 1/4 of the SW 1/4 of Section 30 Z V
T 28 N, 1 19 W, Town of Troy, St. Croix County, Wisconsin, more fully describ; P
as follows; Commencing at the Southwest corner of said Section 30, thence go 5: N
N 27 20 00" E a distance of 1512.23 feet to the Point of Beginning of the 23 a
parcel to berherein described; thence N 00 03 4 0" E a distance of 518.57 fet 0
thence N 90 00 00" W a distance of 168 «80 feet; thence S 00 031 40" W _
a distance of 91P_ faa+.- Al ono Ant AA" r A4-4._-_ _a 444 L__. Q
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RLPORT OF INSVLCTION - lNVqWUAl. SlWAGE. SYSTEM
State septic___
Oik f�
to- Towns hip le) Lid St. CfLo�x County
wool
c (I e c ti o n3a L o t # - Subdivision
V[ I C TAN
9 a ff )wt, NumbeA. o4 compa4tment4
8 ui f di n 9 12% sfo.pe
jHighwate4
1(�:(:IM�PING �CHA�Mg@
Size qattqn4,_,"'I P manu6datultivt Modet Number
l(OlVING TANK
Size gattons Nambeiik o6 Compaoktments
P 14 M r.) Vh Ata,%m System
taki ce 6Aom: We4t Buitding___ 12% stope___
Highwatet
11-;SO[:PTION SITE
8 d 7h
foklco Thom: W e t f 7e 4, t di n g t2% 6fope____
Highwate,q
\1;1;0111' `VlON SITE DIMENSIONS
W.('(Ith o4 .trench At Req,uiAjd a4ea
Len gth og each tine At Depth o6 hock below tite 4n
Number 04 tine.6 Depth oA hock ovek tite in
Totat Length o6 tines
— 6t Depth o 6 t,4te below grade S in
OisLance between tines 6 t Itope. oA t/tench in. p ek 100 At
Totat abAokption a4ea Z At Type o6 Cove4: Paper n s th
If PIMINSIONS
Nrr mh r h ( i A Pit's Grave akound pits _yes no
Oil r.1 ide diamete4 —At Depth below intet
1, ab a4ea
.6t
Altea heqcci&e At
W " I'l C f 1 , V 8V TITLE
PL B- State and County State Permit # 9 99S
g* Permit Application County Per 't
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
B. LOCATION: All W. '/4 '' /o, Secti n L', T R / E (or) V Lot# City
+ Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) * Variance
Single family _jf� Duplex No. of Bedrooms 1 No. of Person
i
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured -in -Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Pr fab c Crete Poured -in -Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: ercolation Rate Total Absorb Area sq. ft.
New Replacement A Alternate (Specify)
Seepage Trench: No. of L' I Ft. idth Depth Tile depth (top of Trenches Zft Seepage Bed: Length_- r Depth .�2 Tile depth (top 6!�jg No. of
Line q � Y
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of lan �i� Distance from critical slope
WATER SUPPLY: Private ❑ Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than p owner:
1, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Certified Soil es
NAME C.S.T. # and other information
obtained from (owner /builderT - �
Plumber's Signature .4tlrMPRSW# d / Phone
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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E1+ 115 Rev. 9/78 �91 9 I�
REPORT ON SOIL BORINGS AND?ERCOLATIO% TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701 MAY 141981 rti
ZONING
OFFICE -
LOCATION: N W ' /o, SW ' /e, Section ^' �� ,T ; N,R J3 E(w) W, Township or 4c4aaUy 7 IZ��
Lot No.—, Block No. County ST • C n` n)
S ubdivision Name
Owner's /gmyen Name:
Mailing Address: V /L� CAJ (..L S. w/ SS�o 2
TYPE OF OCCUPANCY: Residence ✓ No. of Bedrooms 3 COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT — ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS �� 1 i / PERCOLATION TESTS
SOIL MAP SHEET `� NAME OF SOIL MAP UNIT
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHE
NUM- SINCE HOLE HOLE AFTEF INTERVAL RATE
BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN
P ,- t�l A"`' 09 (_S
P—
P–
P N07ZS )AJ S LL 1'sT 1/ 9Z 5 L(> / n-,' wJ k/ UXI Ll
P–
P—
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- ) 11 > Sn ) LTS )6' 3 a n L Szy Gr S/
B - Z SO -- 2 a b I/ , Z6 i I I 2f�s • u X3 '
B 3 C>� vorvE �'L. I RnsJT I 1 V ' R n ��'�G � - 1 2 L' — bh 2-
B- L/ S$ �otis= > 3S 'Dc - _ - 1 Ts, )Z• Leh L S Gh 6Z
B–
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy B Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope. 1
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ST. CROIX COUNTY ZONING DEPARTME
AS BUILT SANITARY REPORT
Owner
`v .s •3
Property Address lHn o
City /State r 15 yd 9.0
Legal Description:
q
Lot Block ' Subdivision/CSM # bD /
' /4 �t7 '/4, Sec. 2a, T 2b 4 -Rf_W, Town of !moo PIN # Oqc) — / / / /o — OcX_.�
9o. 2- 3 N
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
p OC� Tank manufacturer HS 1 d'�ize ST / � Setback from: House Well D P/L �
Pump manufacturer Gai dd Model ,EO P
Alarm location
(HOLDING TANKS ONLY)
Setbacks: Service road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: Width Length 7� Number of Trenches
Setback from: House Well P/L Vent to fresh air intake
ELEVATIONS
Description of benchmark 6 ! C� Elevation ,6G,
Description of alternate benchmark e P _)zeg Elevation .
Building Seweer ST/HT Inlet f ST Outlet PC Inlet
PC Bottom U b ► Header/Manifold �D + 0 Top of ST/PC Manhole Cover
Distribution Lines (l) 9b 9 ( ) 7, Z S�
Bottom of System 0)
Final Grade (3) ( ) ( / ( )
Date of installation � number 3>4(p3q State plan number 1
Plumber's signature � number Oc 11 / Data' % / ✓U
Inspector DnWA
Complete plot plan v
,AMP
NOTICE: Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
x L x lSTi 111 ey\ t
fon \ 141 r• ., Ruh 'vettut
gynr
pj Eol/ory S ; 1v0.0
g biPI ' t 1 Dir 7; 5'i 9 )
INDICATE NORTH ARROW
Wisconsin Department of Commerce
Safety and Buildings Divigion PRIVATE SEWAGE SYSTEM Count
INSPECTION REPORT CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar�ilo.:
Personal information you provice may be used for secondary purposes [Privacy , s.15.04 (1)(m)].
Permit Holder's Name: 6y y [l Village ❑ Town of: State Plan ID No.:
IGGINS, GARY I 'm
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel ftOQ -1116- 10-000
O l?,�t
TANK INFORMATION E VATION DATA A9800511
TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV.
Beni
Dosing n4 .
Aeration rta>7
g•9r o. �
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Air I to ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosin ' NA Header / Man.
Aeration NA Dist. Pipe 4 `N 4 Z5 (; -
Holding Bot. System 5;56 US 5 -SS
PUMP/ SIPHON INFORMATION c�5 Final Grade
Manufacturer Demand
Model Number �P GPM
TDH Liftq,/ Friction / Systems TD *, Ft
Forcemain Length Dia. HH Dist. To Well
SOIL A TION SYSTEM
Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME DIMENSION
SETBACK
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Ma nuf�p•
INFORMATION Type o CHAMBER Moe Number:
Syste (4 15 " , - r + -�— OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To — Air Intake
Length Dia. Length - Spacing 1�
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Se eded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑Yes ❑ No E] Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY 30.28.19.473H,NW,SW 308 GLENMONT ROAD — LOT 1
Va (vt 4 1 �'d
f u '�) 1 :�l
PI
an revision required. ❑ Yes V] No
Use other side for additional information. C1— �Cl
SBD -6710 (R.3197) Date Inspector' ignature Cert. No.
i
N*Sconsift I Safety and Buildings Division
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 8112 x 11 inches in size.
• See reverse side for instructions for completing this application State sanitary Permit Numb r
Personal information you provide may be used for seconds _3a 4 3
secondary purposes ❑ Check if revision to previous pplication
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner N e t Property Location
4,)i4 S V 1/4, S �� T C /o , , N, R E (or&
Property Ow nrlei s Mailing d r s Lot Number Block Number
ty, State r Zip C d �� ( h n j>umber_ Subdivision Name or SM umbe d/
11. TYPE OF BUILDING: (check one) ❑ State Owned it� Nearest oad
Vil age B r ,
Public 1 or 2 Family Dwelling - No. of bedrooms 3 To wn of dry
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax N umber(l) /
1 C] Apartment/ Condo i j � r\111 � /d
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. ❑ Reconnection of 5_ ❑ Repair of an
- - - - -- System --- - - - - - system ------- ------ Tank Only -------- - - - - -- Existing System Existing System
B) E] 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 f I 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank
12PSeepage Tren / 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit , 9 43 ❑ Vault Privy
14 ❑ System -In -Fill it l
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
Requi ed (Sq ft.) Proposed( . ft.) (Gals/da / q. ft.) A n. /' ch) EI ation
- 7 5 �. Feet r Feet
VII. TANK Capacity
in gallons Total # of Prefab. Site Fiber- Ex er.
INFORMATION New Existln Gallons Tanks Manufacturers Name concrete Con- Steel glass Plastic A p p
structed
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber x BPS ' 12°C ❑ ❑ 11 El ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sews tem shown on the attached plans.
Plumber's Name: (Print) P nature: (No tamps) Business Phone Numbe
Plumber' (Street, GUL Stailte, Zi Code): f
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps)
$Approved [:]Owner Given Initial I's Surcharge Fee)
Adverse Determination :2
X. C OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
PLOT PLAN Page 3 of 3
SCALE 1 "=
y, N
0
x v �vt •
8 • BLDG _ 2
Z.O.
I �
3`
Iuu.o' oQ um of "ovsz s\o),ur,
�31- Ol S. 1 ON 7 m - mm OF POIf 8\,Dc . Stbl"G
W@L� �s > SO' FR- m SL1S7C� �A .
ci (7i 5 ) 4q5 —ni i;5 1400576
' PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
VEMT CAP
4'C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
JUNCTION BOX MANHOLE COVER
� 25� FROM DOOR W�rn�n �4be��
WINDOW OR FRESH I2 '141U . i
AIR INTAKE I
GRADE I
I 4' MIM. -li
cowDU1T 7C
19 "MIN.v ---- - - - - --
INLET PROVIDE I - - --
��1RTIGHT SEAL
APPROVED JOINT A I III APPROVED JOINTS
W /C.I. PIPE I (I I �/ /C.I. PIPE
EXTENDING 3' ( II ALARM EXTENDING 3'
ONTO SOLID SOIL B I II ONTO SOLID SOIL
I 1
I I ON
c-
I i
I
ELEV. FT. PUMP —� - -�
� OFF
D
CONCRETE BLOCK
RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL
SEPTIC E SPECIFI'CATIOUS
DOSE `` �1
TANKS MANUFACTURER: Ifl i tlmlf sl Cry c w� � NUMBER OF DOSES: PER DAU
TAWK SIZE: -75o GALLOWS DOSE VOLUME a ! - <I
ALARM MANUFACTURER: �a•, k �I0 ft INCLUDING BACKFLOW: GALLONS
MODEL NUMBER: A CAPACITIES: A = INCHES OR AA$ GALLONS
m
SWITCH TYPE: - ' tr Q o f ,,/ B= INCHES OR -� GALLONS
PUMP MANUFACTURER'. �ro��� C= .►JCHES OR Z �`
Q __ - uALLONS
MODEL NUMBER: F•'J3 L- D= rF t INCHES OR GALLONS
SWITCH TYPE: C r C NOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. -LL- FEET
+ MINIMUM NETWORK SUPPLY PRESSURE /.. . . . .... . . X FEET
♦ (J FEET OF FORCE MAIN X L F /OOFLFRICTION FACTOR.. 11 3 1 _ FEET
TOTAL DtI JAMIC. HEAD = FEET
IAITERNAL D SIOIJs: OF TA►JK: LENGTH ;WIDTH (. I ;LIQUID DEPTH y3
SIGUED: LICENSE HUMBER: ' ( DATE:
Submersible MODEL:3871
SIZE. 3/4 SOLIDS
Effluent Pum RPM: 1550
HP: 0.4
METERS FEET
8
25
7
O
w
= g 20
U
5
Z 15
4
.J
0 3 10
H
2 -
5
1
0 00 10 20 30 40 50 GPM
0 2 4 6 8 10 12 m /h
CAPACITY
[QGOULDS PUMPS, INC.
SBC-CA FADS WW VM 13MB
i
O 1988 Goulds Pu Ef(ectiw October, t 989
^W 1 w• SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE PRINTED IN U.S.A.
C387I
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
s�e/r/v�ing the SLY` residence located at:
l b '+, S ;, Sec ion ,��, N, R_Z1 W, Town of
Upon inspection, I certify that I have found
the tank nd baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced: 'ye
Did flow back occur from absorption system?
Yes � No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete Steel Other
Manufacturer: If kno
Age of Tank (If known): 106
(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
inspe i n opening over outlet baff
Name Q S Signature MP /MPRS 'a'g/5 / b /
L an d Department o f Industry SOIL AND SITE EVALUATION REPORT Pa
• Labor and Human Relations P Of 3
Division of Safety rr< Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S " Cizq. UC
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and dista gegr�s Toad\ 010 - �� b - [O
APPLICANT INFORMATION - PLEASE - iC1 INF w N R I DBY D TE
PROPERTY OWNER: c�et;f@ : ` . 1/4 SW 1/4,S 30 T Z.8 N,R \,q, E PROPERTY OWNERS MAILING ADDRESS «; '; BLOCK # SUBD. NAME OR CSM # G u� M tv�11
C �' T n ? 199$ r-I ) PHON ( � js Y ❑VILLAGE ®TOW CITY, STATE ZIP C N NEAREST ROAD �- �z.n`1 Gt_aino�tr ��_
[ j New Construction Use Residen4i N 3 [ ] AdditiQ to existing building
KReplacement `
[ ] Public or com
Code derived daily Bow y S0 gpd \1_tf�y4KQM -J% fa Recommended design loading rate __ — _ bed, gpol t2 < 4 trench,
9Pd/11
Absorption area required � 1 IS bed, ft a o o trench, ft? Ma>omum design loading rate _ bed, gpd/ft . S trench, gpolft p�
Recommended infiltration surface elevation(s) q S • 0 ft (as referred to site plan benchmark) S11:9� kEuev kn t i
Additional design / site considerations 3 7Rpve t=ftCN 3'X is " W /"I s1y cAptler'?y S1D LW , Oqft L l e1 y zg s
Lremantterial L,o�3S :5 im S\ -PML Ov)WVv T1 Flood plain elevation, if applicable 1v.9 ft
= Suitable MOUND IN- GROUND PRESSURE for system CONVENTIONAL A S D ❑ T I L ING TANK
S EM � ❑S = Unsuitable fors stem [� S ❑ U [� S ❑ U IBS ❑ U �U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure jBedrrmn
in. Munsell Qu. Sz. Cont. Color Consistence Barxiary Roots
Gr. Sz. Sh.
S , 1 zm s U k h e S - Ground 3 t y -S� '�.S R V/ elev. d S c s bk s a S� cs _
limiting
t o ng S 7z _9 6 1 S k fL 31 s9
>
u
Remarks:
Boring # n
�`� l�`11Z3J2 S1�
J.
G��� �S� CS 1 v`� •S` -
Z: L Z_ q-Z . lU`t IZ 3l 6 — s ) Z�
Ground 3 2 [ -v� -S `123! S of s o s` 0 -s 1 b 1 " �M v `FI- CS 0 1 . S
elev. t f L/ 6-b6 -) -S L Y R 3!y o
Z
ft
Depth to
limiting
facto
Remarks:
CST Name: - Please Print Phone:
Arthur L
egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022'
Signature:
�`�- � C L 3 - Z q Z Date: Z - � CST Number.
M00576
PROPERTY OWNER '1GGlivS SOIL DESCRIPTION REPORT Page -2-of Z.
PARCEL I.D.# `\113— l u
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Trench
in. Munsell Qu.Sz.Cont.Color Gr. Sz. Sh. Beded Trench
„mo-D ) o-t o Vo\-1\z 31 z - s i I z`C-Sbk c-s 1\)-c - s - L
Noma<> Z �b � O R s; ) Zw►slil-r cQ \i �S -S .
Ground 3$ S2 S`1R 3Ly S 1�Sb1� �M T� CS . .S
elev.
q`1•Sft. y y/b \C.3 sg s .1e
Depth to
limiting
factor
> 7 Z"
Remarks:
Boring#
mom
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring#
mignm
� t>4w
4'•�
Wit:v�
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring#
tameN
Ground
• elev. •
ft.
Depth to
limiting
•
factor
Remarks:
SBD-8330(R.05/92)
PLOT PLAN Pa 3 of
SCALE 1 "= yp '
Ta.�
S% r
0
x v �-
I
8.3 �Lfl6
z i 9
i •
SZVTI 'L /
' � �CfC►./vc / 3 � D RY")
3`
2
T�1 or _r\l
sc,R -`.�. � l - �t. �uu.o' o►� �'rn�� d� �-1 -ovs� s���,v6
L1-. OLS.2' OF PoL� 8�.D6 . S\-Duu6 ,
98 -2y Z
L , - ( 715 ) 423-0169 M 00576
CST Signature Date Signed Telephone No. CST #
v
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer cow
Mailing Addres
Property Address
(Verification required from Planning Department for new construction)
� 1 /�
City /State A r Parcel Identification Number
LEGAL DESCRIPTION
Property Location '/4, ��; '/4, Sec. T N - �� W, Town of / �O
Subdivision , Lot #
Certiried Survey Map # , Volume Page # D
1
Warranty Deed # �� � Volume 1 � Page # �O
r
Spec house ❑ yes 'j] no Lot lines identifiable Ap yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site 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
the three year e " iration date. �._ o 1�
SIGN PL 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
t#ie property describ above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNA OF jR ANT 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
State Har of \\'i.Consin Form '_ 1112
X33338 WARRA DE REGISTER'S OFFICE
`
11: ST. CROV CO.. W1
DOCUMENT NO PAedwReMd
SEP i i? )
Michael L. Dado and Diane M. Dado, husband at 11:00 ��.
A. M
(,
and wife, � +
0V
concvs and warrants to Gary T Higgins, a single
person, and Kay A. Klawiter, a single G
person, as tenants in common,
NAME AN FIE. T.uN
the following described real estate in
$t._CCO1X
County. State of Wisconsin: l ��++
n y'`� (Parcel Id Numher)
FIB
Part of NW,SWk, Sec. 30- T28N -R19W described as follows: Certified
331 5ey tap
recorded in Vol. 1 of Certified Survey Maps, page 213, as Doc. No.
This is homestead property
(is) )q5D"
Exception to warrantie, Easements, restrictions and rights -of -way of record, if any.
Au g ust . Iv 95
Dated this day rr(
ISE. \LI Y\��
�C� 1( t S I \i
Michael L. Dado
iSEALI
Diane M. Dado
i
AUTHENTICATION ACKNOWLEDGMENT
Michael L. Dado, STATE OF WISCONSIN
Signature(s)
Diane M. Dado C ount%
- 2fin� 95 Penonalh came hclF +re me this
authenticated this i � day of A ugust 19 .19 the ab++Ne named
Kristina Ogland
TITLE \IE\IBI :R STATI B \R OF \4'ISCOSSIti
(If not, t me I+n„ssn to he the {w �+ +n
%% ho : se, ut: d m;
authorised by §706 06. \11. Stats.l
°
f. +regotng m.truutenl :mJ :.Am \slydgr the game
THIS WSTRUMENT'vVA5 DRAT TED BY
r i
331 . 2
CERTIFIED SURVEY MAP
Part of the NW L/4 of the SW 1/4 of Section 30, Township 28 North, Range 19 West,
Town of Troy, St. Croix County, Wisconsin
Michael Dado
N 90
168.00
o Indicates 24" long iron pipe
stake weighing 1.13 # /ft.
331250
O
is
10 3
_ W
o
o 0
N Z Scale I" =100'
fwmc lb..r.
N 90 00'OOE
168.00' P.O.B.
Town Rd. M
i4
M
.�V
.OQ
O
0
N '
A
2 ti ��N
S.W. Corner Section 30 - 28 - 19
Description:
That certain parcel of land located in the NW 1/4 of the SW 1/4 of Section 30 Z V
T 28 N, 1 19 W, Town of Troy, St. Croix County, Wisconsin, more fully describg a
as follows; Commencing at the Southwest corner"of said Section 30, thence go 5 v`
N 27 20' 00" E a distance of 1512.23 feet to the Point of Beginning of the a
parcel to berherein described; thence N 00 03' 40" E a distance of 518.57 fe 0
thence N 90 00' 00" W a distance of 168.00 feet; thence S 00 03' 4 0 " W in -