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HomeMy WebLinkAbout040-1163-50-100 4 0 °'° a 0°`� 0° � 030 ao a) I y h a 0 I V I I I N f c b a .o ° U y (D C U Q II I I a) f v ID C .>_ rn E L V m t I O •s J ) I z a) O �'d zz O G7 E w ¢ M E �E I E cn o w 0 o z m an d d d O N w d m a m I a m N F- Z c c o Z a C C c m 2 w 2 r I 2 o '- Z o O a) •7 N CD 7 N N •3 7 C L y 7 n y d W N �' Vi N i y c •� a� L d� L d L O O N z m z z m z z m z o I z rn l '`iti c y d N ° r ° ' E M i° E o '° E a) La m c J! .. 16 c N 1! d N c % D — N o 'A r p p ., c z� >° ',mmm �mmm >I� 3ymm > j rr I u) O m O I m 000 m 00 z •N �oaaa wawa waaa iL w g c > > O ao ao w LO O CO) O ao w (D� } I rn rn } Cc N �l p N W N N �' O O O Q, v co a o 0 0 0 a I 0? a j `I E m') N c CL `� ml c ml c E c O1 O N N N N 'O O) p 7 7 I e} 7 V ++ ° Z y N y c N E LO 1�1 a� O p Cl) o U Y `� Y y u d °° °° O CO c .. c 0 Y O m 30 W t O N U ° C C 7 O y o w Z H 0 y 00 W y a n of I) d q to I, Co o� o a� °' c y co I m N o y� R � • O O N H S .- Z —1. O N O Z C O co 0 Z C E E S Q7 V m a €a € r`N o �`a 3 A c ; E c I 3 E o r A c�a 0 0 mv 0U) 12/13/2005 08:48 AM Parcel #: 040 - 1163 -50 -100 PAGE 1 OF 1 Alt. Parcel #: 25.28.20.633C 0 - TOWN OF TROY ST. CROIX COUNTY, WISCONSIN Current X 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 - OELLERICH, MICHAEL R MICHAEL R OELLERICH 284 GLENMONT RD RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 284 GLENMONT RD SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 4.500 Plat: N/A -NOT AVAILABLE SEC 25 T28N R20W NE SE 2.635AC LOT 1 CSM Block/Condo Bldg: 7/1895 ALSO COME1/4 COR SEC 25 S Tracts Sec- Twn -Rng 40 1/4 160 1/4) 616.36' -POB S 290' S 88 DEG W 280'N () 290' N 88 DEG E 280' -POB EZ -UT- 1503/402 25- 28N -20W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 825/369 07/23/1997 794/360 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 103309 354,000 Last Changed: 07/21/2004 Valuations: Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.500 69,000 271,700 340,700 NO Totals for 2005: General Property 4.500 69,000 271,700 340,700 Woodland 0.000 Totals for 2004: General Property 4.500 69,000 271,700 340,700 Woodland 0.000 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 211 Specials: Category Amount User Special Code Special Assessments Special Charges Delinquent Charges 00 Total 0.00 0.00 12/16/2005 05:07 PM Parcel #: 040 - 1163 -50 -100 PAGE 1 OF 1 040 - TOWN OF TROY Alt. Parcel #: 25.28.20.633C ST. CROIX COUNTY, WISCONSIN Current I X 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 - OELLERICH, MICHAEL R MICHAEL R OELLERICH 284 GLENMONT RD RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): * =Primary Type Dist # Description " 284 GLENMONT RD SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 4.500 Plat: N/A -NOT AVAILABLE SEC 25 T28N R20W NE SE 2.635AC LOT 1 CSM Block/Condo Bldg: 7/1895 ALSO COME1 /4 COR SEC 25 S Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) 616.36' -POB S 290'S 88 DEG W 280' N 290' N 88 DEG E 280' -POB EZ -UT- 1503/402 25- 28N -20W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 825/369 07/23/1997 794/360 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 103309 354,000 Last Changed: 07/21/2004 Valuations: Total State Reason Description Class Acres Land Improve RESIDENTIAL G1 4.500 69,000 271,700 340,700 NO Totals for 2005: 4.500 69,000 271,700 340,700 General Property 0 0 Woodland 0.000 Totals for 2004: 4.500 69,000 271,700 340,700 General Property 0 0 Woodland 0.000 Lottery Credit: Batch #: 211 Claim Count: 1 Certification Date: Specials: Amount Category User Special Code Special Assessments Special Charges Delinquent Cha 0 00 Total 0.00 0.00 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP_1 T N, R W P.O. ADDRESS' ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100FEET OF SYSTEM Iv dij f � SEPTIC` TANK(S) r� ((� MFGR. /�` `S CONCRETE__ STEEL NO. of rings on cover Depth — DRY WELL TRENCHES No. of width — i6figth area BED no. of lines Width J f' _ length'(.. area „ y depth to top of pipe AGGREGATE PERK RATE AREA REQUIRED AREA AS BUILT DISCLAIMER: The inspection of this system by St, Croix County does not imply complete compliance with State Administrative Codes. There are other areas that'it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is n6ted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS--SYSTEa: INSPECTi i DATED LUMBER ON JOB LICENSE # 3 j , REPORT OF I Ii4DIJIDUAL SE14AGE DISPOSAL SYSTEM Sanitary Permit T� State Septic 7 .,� HE T0WNSHIP t, roi;; p6anty SRPTIC Ucpl Size gallons. `cumber of Compartments Distance From: We 11 � l� ft, 12% or reater slope g pe Building ' /- C/ ft. Wetlands ft r Highwater ft. DISPOSAL SYSTF,:J Tile Field or Seepage Pit(s) Distance From: Well � .- ft• 12% or greater slope ft Building; ft. Wetlands f IELn gnwater ft. , Total length of lines � ft. Humber of lines 5 Length of each line ft, Distance between lines ; • f ft. Width of the trench �ft. Total absorption area ?- sq. ft. Depth of rock below tile /_rin. Depth of * rock over tile 7 - in.. Cover nver.rock, Depth of tile below grade in. Slope of trench + in per 100 ft. Depth to Bedrock ft. Depth to . ground water f t. PITS Number of pits Outsic: rle er '` ft. Depth below inlet ft. Gravel end pit' es,' no. Total absorption area - ---- ---- - q . ft. Square feet of seepage trench bottom area required Square feet of seepage pit a /ea' required Inspected b Title:.- Approved Date 197 Rejected Date 197`_ EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH .. , P.O. BOX 309 MADISON,WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS-�� r / LOCATION'/4, '/4,Section ,T9'N, R,�)E (or) Vr V)Township or Municipality /, � r Lot No. , Block No. , County ' T. ` .,eG!-<- Subdivision Name � Owner's Name: - '( 1-4 3, f L :T Mailing Address: T #5 RuiEv. Ff L-(51 Ut 5 • s Q6 . TYPE OF OCCUPANCY: Residence X' No.of Bedrooms 3 Other EFFLUENT DISPOSAL SYSTEM: NEW ? ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS 3/0/7Y i .1/308ERCOLATION TESTS SOIL MAP SHEET /fF a SOIL TYPE Eve 10E r PERCOLATION TESTS {l TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN S.-cc SoiL Oui?h\it,c__, Nol\)e Rcooke.E 0, -D.S.sfri • P- it a > (Nv K , ? Rik- P3 1 b SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) / 9 11 WOK c Ems.si,. L "IL. 5c 1 B>`�'� Cu �l�i`"1.:s:. .-> 7' ib`11l�.Kik,`�t ,.,?;4. L. /1 ��5:► .C.. /5.1 �•r la l� is i > 7' nod, , St'' .1 . - '7' �: f�`ic . > ' ►Y"S.L. 5 4,t`. c= 7 L Nc,:aE • ' CI"I, 5 5z 6e 4 PLAN VIEW (Locate percolation tests,soil bore holes and suitable soilareas.) Indicate on the plan the location and square feet'Sof su'ta le areas. Indicate number of square feet of absorption area needed for building type and occupancy. �4tJ 4,.1-,ha) / Indicate scale or distances. Give horizontal and vertical referen,• •- lope. I � QA fS Id1t�h//�l I�l' r e , fj, i je____.... 0470 (c"4' ' c. II— �o ) i V � lla / of ' ', l' kV tCZ4-��;__ tN , \1/4 '-. ' 14 . 4 b ��� 1 iirk yf S �r i.�I I, � 2- 2�4( i12M1_ b acnsI,the undersigned, hereby certify that the soil testsL6-a.n-ritorted on ts fm were made by me in accord tie proced�fres and methods specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) J EFF Cio cam Certification No. 5..5_4 f V Address V,WI h1 ILI1i"ct�E,TiVE-'�. L.L / 6 )c_'S.I it1°� - Name of installer if known -pt ` 0�:00 I 5nA S CST Signaturezzi/ 6( COPY A—LOCAL AUTHORITY • ... PL.B6 7 , ` f f State and County State Permit # 7.71 �l Permit Application County Per �# Imo. f ', m for Private Domestic Sewage Systems County 6✓ ,Z *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Q}yi B. LOCATION: / '/4 SF '/4, Section 4`d, T,,5°N, RE (or) ig Lot# City_ Subdi ision Name, nearest road, lake or landmark Blk# Village - s Township "16. C. TYPE OF CUP CY• *Commercial *Industrial *Ot er (specify) *Variance Single famil 1.--"*...- Duplex No. of Bedrooms 3 No. of Persons D. TYPE OF APPLIANCES: Dishwasher YES !/CVO Food Waste Grinder YES NO # of Bathrooms' Automatic Washer NO Other (specify) E. SEPTIC TANK CAPACITY /19600 Total gallons No. of tanks _ / *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement Prefab Concrete 1----------- *Poured in Place Steel Other specify) F. EFFLUENT SPOSAL SYSTEM: Percolation Rat tal Absorb Area ' sq. ft. New Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length Width / / Depth `jp_JTile Depth 37 " No. of Lines 02 �/ Seepage Pit: Inside diam//et��er�y Liquid Depth Tile Size � / i, Percent slope of land (p /,Ct Distance from critical slope -------- I, 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 disposalLstem from the EH-115 prepared by the Certified 1 Te r /� ,..5...3 ^‘./L� NAME C.S.T.g�C-.t,��/ # ` CP and other information obtained from owner/builder). Plumber's Signat MP/MPRSW# of Phone # �_j.b 1(7 •Plumber's Address e.Q,� PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). t 1 1 i Is.:6y04...L., I r. I ,- . 410 it r CAL/4,./. jr r C-_ _ _ L -. _ _ _ ., I I Do Not Write in Space Below - FOR DEPARTMENT USE ONLY D 6 r/ Date of Application _� l d Fes P id: State Of County 'Date 3 d" Permit Issued/R • (date) Issuing Agent Name ,1,,�g.-ree?at _. t.-t—) Inspection Yes No Valid# Date Rec'd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 ti FILED OCT 8 1987 , cues a Comm ft"MW of 0"4 430972 *%ON& 0� 4 CERTIFIED SURVEY MAP E 1 14 COR. 3EC. 23, T 2e IN R 2 w, GARY L. HAUSCHILDT f COON T Y Part of the Northeast 1/4 of the Southeast 1/4 of Section 25, Township SURVEYOR'S MON./ 28 North, Range 20 West, Town of Troy, St. Croix County, Wisconsin. b M UIYP TTED L a N 88 • 03 ° E 280. 00' E LIME SE 114 PORTABLE SHED a W m e ow �b W •r h q W O POLE SHED IL CM town , MAR PAM FIANNI" o ° y AM' taONNIG COMMITTEE 4 W t h) Q 1, J Q O N 2 I 0 `, �,tttlt1111 /I v H v o w Q W r AI j DWELLING WITH ATT. J .,..B �I Z 3 Q p p GARAGE �I ``�� •••.... " Y �, O N LO / POOL M O tu .�LAUREN i Q v 2.633 ACRES I _ m W MU Y Cr. o 1k m \I o, 114,789 7e9 so. Fr. ..%' S (J� NET a 2.449 J • co -. RIV FALLS, ,� � a h ZI 1 06, 6 7/ $o. Fr. � WISC ku CJ o • Q i AN� 66 GLE NMON7' R OAD ence W. Murphy _ N 89 =_l s' 56 "E 278.98' Registered Land Surveyor a 'de SCALE I"- S 88 22 W 280. 00 O SO' /00' 110' 2O0' 300' S LINE NE //4 SE //4 � UNPL A TTED L e OIndicates 1 x 24" iron pipe weighing "^ SE COR. SEC. 23, r29 N, R 20 W, 1.13 lbs. /11n. ft. 8 @t. /COUNTY SURVEYOR'S MON./ Description; That certain parcel of land located in the Northeast 1/4 of the Southeast 1/4 of See. 25, Township 28 North, Range 20 West, Town of Troy, St. Croix County, Wisconsin, more fully described as follows; Commencing at the East 1/4 corner of said Section 25, thence S O1 ° 09'46 "E 906.36' on the East line of the Southeast 1/4 of said Section 25, to the POINT OF BEGINNING, of the parcel to be herein described; thence continue on said line S O1 ° 09'46 "E 410.00'; thence S 88 0 3'9 211 W 280.00' on the South line of said Northeast 1/4 of the Southeast 1/4; thence N 01 09 "W 410.00 thence N 88 ° 03'22 "E 280.00' to the POINT OF BEGINNING, containing 2.635 acres, being subect to easement over Southerly portions of the above described parcel for town road R.O.W. as shown on this map and also being subject to easements of record. (For purposes of this description all bearings are referenced to the East line of the Southeast 1/4 of said Section 25, assumed S O1 ° 09'46 "E) State of Wisconsin) -D Tf2 _ - -- N 1 4 / d P . STC - 104 i AS BUILT SANITARY SYSTEM REPORT OWNER l / /(CdjCue V l! er 0 !✓I 1 'r. 1Nv " ADDRESS c SUBDIVISION / CSM# /4 LOT # SECTION C�'r T ff N- R , 1 6 W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 0 6se � H B0 (Q r X rd \� ' INDICATE NORTH ARROW, i Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: (ira E 4)(60 ALTERNATE BM: -EXE-C74;7 SEPTIC TANK )) PUMP CHAMBER / HOLDING TANK INFORMATIONIOjp� Manufacturer: (tAe k S Liquid Capacity: MI Setback from: Well 4- House Other Pump: Manufacturer Model# `- Size `— Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM ��ff Width: / Length 2 Number of trenches �"J Distance & Direction to nearest prop. line: d 77 (c:027 /%. 1 Setback from: well : 7 + House .i C' Other ELEVATIONS Building Sewer ST Inlet . .1.44e ST outlet <.4 PC inlet PC bottom — Pump Off Header/Manifold C akr Bottom of system 9-. 1„ Existing Grade — Final grade DATE OF INSTALLATIO Oejahr PLUMBER ON JOB: „P/ q. 41kr; LICENSE NUMBER: //2/4.5 . ?/r6 INSPECTOR: j'YVOul 3/93 : jt W scons* ' �rrpartment of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. MIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI .. OELLLRICH, MICHAEL X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: OCR jo- y r u f r 1 z x._ *9500365 i TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic f .,'. �� Benchmark !DD Dosi ng Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to i ntake ROAD Dt Inlet Air Septic 60 4.' _0 >dr NA Dt Bottom Dosing NA Header /Man. 6,9 Aeration NA Dist. Pipe r Holing Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH I Lift L FrictiopX System TTDH Ft Forcemain Lengt Dia. Ff Dist. To Well SO A B S ORPTION SYSTEM BED/TRENCH Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ✓A / g /J / DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Mo e N tuber: System: a � .2 / �U� 75f BOA OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing 8 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 1 C 0 "3 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION Troy.25.28.20W, Glenmont Road Plan revision required? ❑ Yes [g Use other side for additional information. 1 /U I 'a 17 Q,cri> , . ,�,, , SBD -6710 (R 05/91) Date Ins ecto s Signature Cert. No. Safety and Buildings Division Waters stem! IT APPLICATION Bureau of Building Y 0 ) County SANITARY PERM ON 201 E. Washington Ave. P.O. Box 7969 Madison, WI 53707 7969 In accord with ILHR 83.05, Wis. Adm. Code Attach complete p Inns (to the county copy only) for the system, on paper not less S-40 /prat Y, State Sanitary Permit Number than 8112 x 11 inches in size. lication a[{G� • See reverse side for instructions for completing this app Check if revision to previous application rovide may be used by other government agency programs State Plan I.D. Number �� The information you p (Privacy Law, s. 15.04 (1) (m)l r pert L cation l r N R E (O OW I, APPLICATION INFORMATION - PLEASE PRINT ALL INFORM 41� 1/4,S T Of Property Owner Name /� Block Number Lot Number Property Owner's Mai ing Address , /�� © H' �( C � Phone Nu� Zip Co Subdivision Name or CSM Number ,,r� de ry f Ci ,State c� 7 ` [] City Nearest Road a State Owned E] village e II. TYPE BUILDING: (check one) ❑ Town OF (�� Public 1 or 2 Family Dwelling - No. of bedrooms ParceITaxNumber(s <D� III. BUILDING USE (If building type is public, check all thatapPly) ClO — 1 ❑ Apartment/ Condo Home 10 C] outdoor Recreational Facility 2 ❑ Assembly Hall 6 E] Medical Facility /Nursing 11 ❑ Restaurant/ Bar/ Dining 7 ❑Merchandise: Sales/ Repairs 1 2 ❑ Service Station/ Car Wash 3 ❑ Campground 8 ❑ Mobile Home Park 13 C] other: specify 4 ❑ Church/ School 9 ❑ office/ Factory 5 ❑ Hotel/ Motel licable) Repair of an IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, I app licable) of 5. ❑ Existing Systei Replacement 3. [] Replacement of 4. ❑ Existin _System ❑ A) 1. New 2.V S stem Tank Only- - - - - -- Date Issued _ System ______ ------- - - - - -- ___Y____ B) [] A Sanitary Permit was previ usly issued. Permit Number o Other V. TYPE OF SYSTEM: (Check only one) Experimental Pressurized Distribution 30 [1 Specify Type 41 ❑ Holding Tank Non- Pressurized Distribution 21 n Mound 42 ❑pit Privy 11 Seepage Bed 2 2 [1 In_Ground Pressure 43 ❑ Vault Privy 12 ❑Seepage Trench - 13 []Seepage Pit 14 ❑ System -In - Fill VI. ABSORPTION SYSTEM INFORMATION: Elevation r .Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final r< 2. Require p ft Pro d sq. ft.) (Gals/day /sq. ft.) (Min. /inch) �0 Feet — F 1. Gallons Per Day Require (sq- ) P ose p 1 4 Site fiber- Plastic Capacity Prefab. Con- Steel glass VII. TANK in gallons Total # of Manufacturer's Name Concrete strutted INFORMATION Gallons Tanks ❑ New Existin � ❑ ❑ ❑ Tanks Tanks E'er° ❑ ❑ Septic Tank or Lift Pump Tank /Siphon Chamber IT VIII. RESPONSIBILITY i of the ansite sewage STATEME Business Phone Number res onsibility for installation system shown on the attached plans. I, the undersigned, assume RSw No P rMP 4� p/, PI m r'sSignature, St `m 04 Plumber's Name: (Print) v Plumber's Address (Stre t, ity, State, Zip Code): MENT USE ONL Y ntSigna a No St Ps IX. COON Y / DEPA (includes Groundwater ate Issue is Ag Disapproved s an, tary Permit Fee surcharge Fee) o� p 11 Disapp \sfy h� j � Approved [] Adverse Given Initial (J Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: DISTRIBUTION: Original to Courtly, One u tPy 70: safety &Buildings Divrion, r)wner, Plumbar + " UyelI P `� P LAN A oktel Del /er teA � - .� 3 8.1�/yI /IOA 9m /002) o &-o e, P / � V O _ 0 �t t L o r sfi V� I I i a3 t C'C' � Date Si ned Telephone No. �� ji natur �����, g Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3 La " "�.� and Human Relaoor� r;i an of Safety & Buildings in accord with ILNR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 ` " I st include, but not limited to vertical and horizontal reference nt on and % o e or PARCEL I.D. # dimensioned, north arrow, and location and distanc t tQlparest r d. , rs 11 �� ` SO -ZD APPLICANT INFORMATION- PLEASE PRIN _ALL INFOl1T REVIEWED BY DATE " PROPERTY OWNER:: OP ATION 1'1 t Ct �E L LPL ` Cr .. ! `)\► F 1/4 S E 1 /4,S 2 - 5 T Z 8 ,N.R E f. PROPERTY OWNER':S MAILING ADDRESS LOT OCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE14UMB ❑VILLAGE MOWN NEAREST ROAD TztU�2 l�S WI S ZZ f G��r�►otiT lZ.b. j New Construction Use Residential / Number of bedrooms 3 [ I AddifiQn to existing building [DQ Replacement (j Public or commercial describe Code derived daily flow 4S 0 gpd Recommended design loading rate o 5 bed, gpd$ 0.6 trench, gpolft Absorption area required R 0O bed, ft2 -1 S O trench, ft Maximum design loading rate o , S g pd�2 I . t�`tr ench, g 2 Recommended infiltration surface elevation(s) C� 4. S It (as referred to site plan benchmark) Additional design / site considerations `"L , )�_ Z S / 8 rieb Parent material S t S C0\K.%QT OUIR S, E G� Flood plain elevation, if applicable lV - R ft t S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ZS ❑ U ® S 11 U ® S E] U Q S ❑ U ®S ❑ U ❑ S rmu SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft Boring # Horizon in. Munsell Chu. Sz. Cont. Color Gr. Sz Sh. Bed Trench za z 6 -t3 �.s `123 c - Gtrsi Zwtsbk mkt- �s o•s o.l Ground 3 13 -U.S 1o`4tZ 3I - S 61• S m 1 C S - 0 "1 n td elev. ° 1 9.9 Depth to limiting factor Remarks: Boring # ZM S S - b• S ; o. b 2, ?� Z 1 -lb '�,S`iR 3J ` Gh Zwr S�1t 1M`Fh C a s 3 104u 1 k_ t 3 l L S Gr o S m Ground elev. L(3 -82 t u�c R �!! S et_Gi� 69, Oadi Depth to limiting factor ? SZ Remarks: CST Name:- Please Print Arthur L. We erer Phone. 715-425-0165 egerer Soil T & Design Service -P.O. Box 74 River Fal1s,WI 54022 Signature: Date: 1 Y � [_ q S CST Number: q S - 29 6 M005 76 • PROPERTY OWNER 0E-1—L--L -1 CH SOIL DESCRIPTION REPORT Page a of •3 PARCELI.D.# O- — 11 1c.3 _ So .- t oc Depth Dominant Color Mottles Structure GPD/ft2 Boring # Horizon in. Munsell Qu.Sz.Cont.Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Mend] €x a 2 ?-L S i I z, 3•101-( m -c - a.S — o•s o. 6 Z -33 1Y sh\T rn 'Ci- cS — o- S o. ` Ground 3 33-6Z 10 1,(2--3/(0 S O S YY1I CS — ( . S u• L elev. S Er G!. 0 s vn 1 — o- U. g Depth to limiting factor Remarks: Boring # Ground — elev, ft. Depth to limiting factor Remarks: Boring # F;. Ground elev. ft. Depth to limiting factor • Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks:__ �Pn-R2lnfP n5iq?\ w ti. PLOT PLAN Page 3 of 3 SCALE I"= 3 O ' f-� L e,-tn. O X1.1 ls2lCb1 ��.p � oL10- 1163- So - l�iv se � m 0 s'n e `cw•.1rz 4 �� tL.l0�.� o►v !�" r �p�tioxW►�'f8' f � � 2 LRQ 9 6.2 � a.l - q-t 9 s � >s .ti ov �Z Q�s`PLl3v`n.p►v �ipCS, 8.3 C� L �� w'1 �l►VT 12.OPc'fl c i (715 425 -016 I CST Signature Date Signed Telephone No. CST # 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 serving the Mahad Qafier(c 4 residence located at: :, ,$"'� ,, Sec. .25 T _,2t N, R _,go_ W, Town of 7"e-0y , St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced 00-fa,6Prr /9q. 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 known): W Age o f Tank (if known) : r / ✓�,, -S Dcnq/ 1 l (Signature) (Name) Please Print 11MAe's 2 � (Title) (License Number) T 10-al- (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed dispoter (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name ,� y��j /S Trl°Gl ! Signature MP /MPRS 3/8(« STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER �/j e�Q / ��ll ell e l? MAILING ADDRESS �� �—f�o 42 / � y r' `_ PROPERTY ADDRESS 5�.�»o tz c� av,+ (location of septic system) Please obtain from the Planning Dept. CITY/STATE 4Y t ✓L°r' f d�a/ aij PROPERTY LOCATION - Ie) 5 1/4, s' 1/4, Section T a` N TOWN OF rau ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER _,6LV'_ 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 year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 • S 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. Owner of property / 1 Location of property 1 /4 Section T -R Township � Mailing address Address of site Subdivision name A Lot no. Other homes on property? Yes No Previous owner of property (•-` 4 , ��. JC/-/- Total size of property 7 Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes No Volume and Page Number as recorded with the Register of Deeds. ----------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description 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 in the office of the County Register of Deeds as Document No. and that I we ) own the proposed site for the sewage disposal system or obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. • Signature of Applicant Co- Applicant Date of Slanaturp - -- nat� of • 3vctJML-N1' NO WARRANTY DEED • � : svA c er,cnvtL) FOR ec,:nen,HC DATA I STATE: BAR OF WISCONSIN FORM 2 431342 or- - - — PKE R- r OFFJCE Gary L. Hauschildt and Diane E. Hauschildt II ST. CK'01X CO., WM d wife as husband" "an ' oint tenant 's Recd. fcr R-cord this 22nd d of Oct. A. D. 1987 conveys and %varrants to Michael R. Oellerich tN 8:30 AIL ..... ........... • D.w�. fi -- — . -.. .. .. ; r . Croi the following described real estate in ..... ...... St �� - -- -- _ State of Wisconsin: .. ...ceunty, i Tax Parcel No: j Part of the NE 1/4 of the SE 1/4 of Section 25- 28 -20, I described as follows: Lot 1, Certified Survey Map filed October 8, 1987 in Volume 7, Page 1895 as Document No. 430972. t T3We ' I i . This .. - . - - - is homestead prnpprt;:. (is) (is not) I Exception to warranties: easements, restrictions and rights- �I of way of record, if any. B Dated this 16th day October J7 1 A,2 l jI �. ISEAI.) /ILCG Gary (SEAT.) .L., -- Hauschi.ldt • Diane E..Hauschildt ii II i _. (SEAL) . .(SEALi i! it............ . .. AUTHENTICATION Ij ACKNOWLEDGMENT l Signature (s) ....... -- --- -- -- -•- -- --- - ----------- -- STATE OF WISCONSIN - . I authenticated this ........ day of...................... IO...... --------- S S - t -- Croix ---.County. Personally came before me thisl.6. .... ..... - -,day of ;r --------------------- ••- - - -• -- ------ Oc.tob.er .. ..... e above named Gar.y._L....Hauschildt, Dian . e ... '1 TITLE: 3fEMBER STATE BAR OF WISCONSIN' I: _. ...._._. (If not ............. ........ E. Hauschildt authorized by § 706.b6, Wis. Stats.) - ........... - I) to me known to he the person ..... who executed the `d soinr T4:S INSTRUME instrgment alld acknowledge the sarnr , Uie� r,e,. ���_ � 1 DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1 -19U:l TNI• MACK RRSRRVRO FOR RLCOROINO DAIA WARRANTY DEED 4 eooK 825 - -- - - - - - - - - - - -- I REGIST , ER S OFFICE !` This Deed made between . . annd Diane E. � ST• CROIX Co., Wq Hauschildt Reed for Reco,d ...... ... .... ............... •- -•--•••--•-•-•-•---••-•....•••--....-•••--•-•----.. .- •- •- •-- ••••......- ••--- - -.••. I .................... ........................ OCT 2 01988 f and 1Ch . ........................ ........................ Grantor, i �y 11:40 A;M ` 1 t: /VV� ............. .......................... i .r ---------------- --------.-•----------------•--••------------------------------------ • - - - - -- ------- . -- -• -... • .. .......................:.... . Grantee, I Witnesseth That the said Grantor, for a valuable consideration...... i conveys to Grantee the following described real estate in -- _A- RRTURN -------------------------------------------- -------------------- Tp -- i County, State of Wisconsin: Tas Parcel No: ....... ....... :hat certain parcel of lard located in the Northeast 1/4 of the _ ------ - ------- i Southeast 1/4 of Section 25, Township 28 North, Range 20 West, Town of Troy, St. Croix County, Wisconsin, more fully described as follows: Commencing at the East 1/4 Corner Of said Section 25, thence S 01 0 09'46 "F (assumed bearing on the East line of the Southeast 1/4 of said Section 25) a distance of 616.36' to the POINT op BEGINNING, of the parcel to be herein described; thence continue S 01 0 09 1 46 "E 290.00' on said line; thence S 88 °03'22 "W 280.00' on the North line of Lot I of that certified survey map recorded in Vol. 7, page 1895, Of St. Croix County Certified Survey Maps; thence N01 °09'46 "W 290.00' thence N 88 0 03 1 22 "E 280.00' to the POINP OF BEGIMING. This Property has not been approved as a minor subdivision under the ordinances of St. Croix County or the Tbwn Of Troy. This property is being conveyed to add to adjoinng progeny already owned by grantee. This Property ?;hall therefore becom a part of the adjoining property and cannot be sold separately to a thud Ply whose Property does not adjoin it (unless ampliance with the town and i county ordinances is Obtained.) i Tbis ------- Jg.DDt._..... homestead property. I N �E (is) (is not) 5 _ Together with all and singular the hereditaments and appurtenances thereunto belonging; tJ�/ And ........ Y._b,... &_ D atle_.F _Hat_tisch_ildt warrants that the title is - - - - __ ___ _ good, indefeasible in fee simple and free and clear of encumbrances except easements, covenants and restrictions of record, if any, i and will warrant and defend the same. Dated this ._._ °-••-- .....•--.._..-• -•• ......•. day of ........... �r 88 ....-- • -•• -- ,19 I - I ............... -.......................... -.......................... (SEAL) -•- - -- �� y -..... l r ----•-•• --•-• -(SEAL) " L. Hauschildt -------- --- - -- ---- -- •-•-------...---••------•--°---•-••-- -- ••--- •-------•--- -- •-- •----. (SEAL) •- <C� . -- - - --•- (SEAL) s - - -- L2iAne _ E...I3auschr.ld _.. AIITHBNTICATION ACKNOWLEDGMENT � Signature (a) .Gar L. Hauschildt and STATE OF WISCONSIN --- Diane E. Hauschildt --------------------- - - - - -- es. 7 en i ay ° ........ .... 19 8 8 Personally came before me this ________________day of - - -- - -_ - . 19 ----•--- the above named Robert F. Wall -------- - - - - -- TITLE: MEMBER STATE BAR OF WISCONSIN (If not, ---•----- ----•- ----•- .................................. ........................................... ---•- --- ----- authorized b 'W --- - -- ----•--•-- -••---•-- -•---- -••- - y � 706.06, Wis. Stata.) ' to me known to be the person ....... -.... who executed the d ' {.. FILED r. OCT 8 1987 a M" a CONN= 4309'72 w ►. t . Wronib CERTIFIED URVEY MAP / E 114 COP. SEC. 2J, GARY L. USCHILDT "t r 2e N, R 20 w, / coUN r Y Part of the Northeast 1/4 of the Southe st 1/4 of Section 25, Township SURVEYOR'S MON.) 28 North, Range 20 West, Town of Troy, t. Croix County, Wisconsin. b M UNP TTED L o q N 8e . 03'22 "f 280. 00' b W ❑ PORrAOLE SHED E LINE SE 114 Meow � b W r h� Comm POLE SHED Com 1 1 IL GM . N PANICS MANrJINd AO IONM OOMMME6 ° h (� 14 k u Q M ►. J 'J 00 N is ,(`�\SGONS2I�,, GARALGEG w /rN ATr. b % �• ° " �I 3 LOT / POOL c e o W LAUREN M .' W MU Y 1 Q Q m Q 2.633 ACRES p 0) S. , 0 h N C 114,789 SO. Fr. N Q o : V NET r 2.469 N�':RIV FALLS,. °' ::3 ° 106,671 SO. F r WISc. LANDS •.• �w J 66 GLENMONT R OAD ence W. Murphy — N e9 = /s' 56 "E 279.98'__ Registered Land Surveyor ti SCALE 1" a ,S 88.03' 22 'W zeO. 00 ' e O 30' /00' /JO' 200' 300' S L /NE NE 114 SE //I OIndicates 1" x 24" iron pipe weighing I "NPL A T T E D L 1.13 lbs. lie. ft. set. $E CDR. SEC. 2J, r2eN, R POW, /COUNTY SURVEYOR'S MON./ Description; That certain parcel of land located in the 1/4 of the Southeast 1/4 of Sec. 25, Township 28 North, Range 20 West, Town of Troy, St. Croix County, Wisconsin, more fully descr� bed as follows; Commencing at the East 1/4 corner of said Section 25, thence S 01 09 11 E 906.36' on the East line of the Sout:�east 1/4 of said Section 25, to the POINT OF BEGINNING, of the parcel to be herein described; thence continue on said line S 01 "E 410.00'; thence S 88 11 W 280.00' on the South lins of said Northeast 1/4 of the Southeast 1/4; thence N 01 09 "W 410.00'; thence N 88 03 "E 280.00' to the POINT OF BEGINNING, containing 2 .635 acres, being subset to easement over Southerly portions of the above described parcel for town road R.O.W. as shown on this map and also - being subject to easements of record. (For purpos6 -q of this description all bearings are referenced to the East line of the Southeast 1/4 of said Section 25, assumed S 0109'46 "E) A+tn + o of • iJi annnn iw i ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner WTI Property Ad , 4ress City /State Legal Description: 8 �` Lot —�— Block Subdivisio SM U6 P IN # SE /., Secc T N -R W, Town of SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer [ P Size�S PC 1 2CO l � F- Setback from: House j 4 Well P/L Pump manufacturer Model ,v��.. `�to`�►`0 —�` Alarm location /4+- (HOLDING TANKS ONLY) Setbacks: Service road es air intake _ Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: Width Length Number of enches Setback from: Ho se Well P/L Vent to fresh a' e ELEVATIONS � Elevation l � � Description of benchmark rt Elevation Description of alternate benchmar ti Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover �PlC�S�"'wj Distribution Lines () () () Q Bottom of System () () ( ) Final Grade O O ( ) � �— Date of installation I�-!I &-W ermit number State plan number _ � _ Plumber's signature �y°` License number o Date Inspector on pie, plot plan A�.-E ��uDS 6tV `- �- G ao i* Ctvr�z` 7r'�p -�— �b , r • 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. IGVt v✓la✓� Ott.� PLAN VIEW ejak ,�`J JG`A� ar Flo to ass ` a v1V/I INDICATE NORTH ARROW M ae L • Wisconsin Department Commerce Safety and Buildings Div PRIVATE SEWAGE 00 PM 113 g>3 AGE SYSTEM count yST . CROIX ' INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar Personal information you provice may be used for secondary purposes [Privacy LaAV, s.15.04 (1)(m)]. O ELLERICH,mpMIKE � �] � village []Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TO'4tP-; 3 - 50 - 100 TANK INFORMATION ELEVATION DATA A9800606 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic W .e� Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORM ATION t/ Ht Outlet ;,/ TANK TO P/ L WELL BLDG. o e ROAD Dt Inlet C Septic 27i t �r 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 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 D IMENSIONS DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of 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 E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 2,'Zf o LOCATION: TROY 25.28.20.633C,NE,SE 248 GLENMONI ROAD IQT 1r, -- (9 - T rw ptu:c�w (i Plan revision required? ❑ Yes ❑ No Use other side for additional information. 7 3+j] SBD -6710 (R.3/97) Date Inspecto s Signature Cert. No. `� ' Safety and Buildings Division SC011S %/1 SANITARY PERMIT APPLICATION 2 01 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 8 1/2 x 11 inches in size. sf ; C 0/X • See reverse side for instructions for completing this application state sanitary Permit Number Personal information you provide may be used for secondary purposes [] if revi to pp / v � io lication (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N J�19 Property Owner ame P operty Location ." ®lle r."C zi /4 &�1A, S Z-157 T 2T r N, R.ZO -0 (or&/ Property Owner's Mailing Address Lot Number Block Number ,Z � G�� o� �, 1 A14 C � it , State tip Code Phone Number Subdivision Name or CSM Number : ✓O r 4 //s Gd.', S- Z 1 (7,!!r 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Its Nearreestt Road .{��/ ❑ o age CS lerj /n0/7 i! it Public 1 or 2 Family Dwelling - No. of bedrooms Town OF ►"p III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 10 - "//6.3 — SD /00 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 .0 Reconnection of S. ❑ Repair of an ______System __ - - -- System --- ------ - Tank Only ------------ - - Existin System Existing - - -- 9 y----------- - - - - -- 9 stem - - - -- B) OA Sanitary Permit was previously issued. Permit Number Z­e-/9 - 7 7 Date Issued AO Z6 jr V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11,ffSeepage Bed 21 ❑ Mound 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 GraM 171�0 Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 9 00 9,0,0 _ 65 Feet Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Plastic Exper, New Existin Tanks Gallons Tanks Concrete Con- Steel glass App. Tanks strutted ept c Tank o Y' 11 El El ❑ Lift Pump Tank /Siphon Chamber VW1 ❑ ❑ ❑ I ❑ ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: Of lr Plumber's Address (Street, City, State, Zip Code): , IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit F e (includes Groundwater ate Issued Issui ent Si na ure (No Stamps) 1� App roved [I Owner Fee) Owner Given Initial /y Adverse Determination 6 111, X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber VOL 1385 PACE516 ' X EXISTING SEPTIC 593474 c SYSTEM AFFIDAVIT KATHLEEN H. WALSH Document Number REGISTER OF DEEDS ST. CROIX CO., WI Name ,& Return Address RECEIVED FOR RECORD 1'}�1 i cl�ae (2 . ©el(�iG Gl e n h'iv n T 12 -10 -1998 9:00 AM AFFIDAVIT EXEMPT # CERT COPY FEE: COPY FEE: 2.00 TRANSFER FEE: Parcel I.D. Number RECORDING FEE: 10.00 PAGES: 1 The existing septic system which serves the dwelling being:..added on to must be verified by an acceptable soil report or be inspected by a licensed soil tester for compliance with-high groundwater and /or bedrock separation requirements as set forth in s. COMM Chapter 83.10 (2) WI. Adm. Code. The results of that inspection must be made available to this office. If the existing septic system meets these minimum requirements, and is properly functioning, an addition may be added to the dwelling without updating that system. This addition must not, however, encroach upon the required septic system setbacks as setforth in s. COMM 83.10 (1). Property Owner(s) r7 C� Q e- Property Mailing Address: 6 S 1 / G T R1 Property Legal Description: Lot # t CSM /Subdivision V O L 7 Sec. 0 , T v2? N -R v_ 2 O W, Town of 7RDY I, as the owner of the above described property, hereby affirm that the septic system serving this dwelling meets the above referenced state private sewage system codes. I realize that this addition may cause the existing septic system to become undersized for a dwelling of the resulting size, and I will make this information available to any future parties interested in purchasing this property. Signed: ���!/� Notary Public Subscribed and Date: /� Zlo/ c� of n to be r e his date: / / D >' N M. comm'ssion a ires: County Approval: dt •��� /` �G� Date: Cr < � W1SG�C� �i�7tC Qe / /eri See.25 Z8y 9&nmant Rod, �� ✓G,r r a II S 1 zd f , b oy Iwns�,�• Ga*alt Noo se. i 1 Add• L r r - "` LJ �ol O Ua • Sept; o 8� 4 D;sf. Bo E x;A• NO• r zo I I � II i� II l I in s- 'a lle of 1.0 17I- 4wn B : G1 41- Cs�► Sca _ 1 0 �y OCT 22 '96 02:28PM PRESS I14DJSTRIES P f RX 356—`tb$ 6 i /�'n• Jim i dA110 ,4 k p AW 00 e J � - AoA r�9 1 & i I R J0, b'� ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _ �.1,4e. Mailing Address ZeY Property Address (Verification required from Planning Department for new construction) City/State 'I-e r - le-7 ; ��.', Parcel Identification Number Q 410 - /AL - 50 - /Od LEGAL DESCRIPTION Properly Location N Z %., S L r /,, Sec. 7,5 N -R 2LW, Town of - V r �o �Z Subdivision Lot # Certified Survey Map # z13 D 7 z . Volume Page # . Warranty Deed # `l" l -� `76 Volume Page # Spec house O yes U Lot lanes identifiable 6d yes ❑ no SYSTEM MAINTENANCE Improper use and maiatenaaceof your septic systemoould remit is its pnemat=faflure to handle wastes. Propermamtenance consists of pumping out the septic tank every throe years or sooner, if needed by a licensed pumper. What you put into the system can affect &c function of the septic tanicas a treatment stage in the Vaste disposal :system. The property owner agrees to submit to St. Croix Zoning Department a certification fors, signed by the owner and by a masterPhml6cr Jogmcy Pm restrictodphunberor a lieensodpamperverif.&gthat (1) Ore on�ite wastewaterdisposal sysbear is m Proper operating condition and/or (2) after inspection and pumpwg.(if necessary), the septic-tanic is less than 1/3 Full of sludge. I/wo, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set fordr, harein,'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 =turned to the St. Croix County Zoning Office within 30 days of the three year expiration data SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE Any information that is mis- representedmay result in the sanitary pormit being revoked by the Zoning Department. *• « «s« •' 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 ST. CROIX COUNTY WISCONSIN Z ONING k.� ZONING OFFICE r, e r p p ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 _ (715) 386 -4680 December 9, 1998 Mike Oellerich 284 Glenmont Road River Falls, WI 54022 RE: House addition, Town of Troy, St. Croix County Dear Mr. Oellerich: You have requested the Zoning Office to review your remodeling /addition project for compliance with the state sanitary code (COMM 83). When remodeling or adding onto a dwelling you are required to examine whether or not the construction involves an increase of wastewater. As I understand the project, you presently have 2,072 square feet of total living area and you are proposing another 1,440 square feet of living area. The proposed construction equals a 69% increase in the total living area and does not include a bedroom. The construction will also involve adding a four season porch (12 feet by 16 feet). Section 83.055 (3)(b)(2) states: Increased wastewater load in dwellings results from an increase in the number of bedrooms from construction of any addition or remodeling which exceeds 25 % of the total gross area of the existing dwelling unit. The construction/remodeling does exceed the 25 % standard as stated in the code section above. The septic system serving this structure was installed on October 26, 1995 by Dennis Hewitt. Mary Jenkins, Assistant Zoning Administrator, inspected the replacement system and noted that it was installed as a code compliant system. The as-built report revealed that the septic system is sized for a three bedroom dwelling. Records of the sanitary permit are on file in the Zoning Office. Since your proposal exceeds the 25 % standard, you must have an affidavit recorded with the Register of Deeds. The affidavit shall indicate that the addition may cause the existing septic system to become undersized for a dwelling of the resulting size. You are required to complete the affidavit, then record it in the Register of Deeds office, and also submit a copy of the recorded affidavit to the Zoning Office. To prolong the life of the system, remember to have the septic tank pumped once every three years or when the tank becomes 1 /3 full of sludge and scum. Other efforts to prolong the life of the system could be as simple as fixing or replacing plumbing fixtures with water conserving fixtures, reducing shower time, washing dishes when the dish washer is full, avoid using a garbage disposal, using a wash machine with a suds saver feature, etc. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Should you have any questions, please contact this office. Sinc eco( Rod Eslinger Assistant Zoning Administrator t)UCUMkr'i= N WARRAN?Y DEED : +fA [ Rf -ERVE3 FOR RtCnPD.#41, OAT& STATE BAR (IF WISCONSIN FORM : —i9 s2 i "W" r , REUSTM O FFKM Gary L. Hauschildt and Diane E. Ha_u.- childt, ST. CROIX CO., WIS husband and wife as ,joint tenants �; 22nd _ .................._... ... -..... , Ric d. for Record Ellis - ... _ _. of 0Ct : A.D. I9s1 conveys and warrants to . Mi - chael R. Oellerich 8:30 _.. ... - .. .. .. -..... .. ..... ... .. ! P to y : .. .... .. .. ... .... . .............. .. ... ...... ...- .. .. .... ..- the following described real estate in ..._ ..... St • Croix State of Wisconsin: Tax Parcel No: .............................. Part of the NE 1/4 of the SE 1/4 of Section 25 - 28 -20, described as follows: Lot 1, Certified Survey Map filed October 8, 1987 in Volume 7, Page 1895 as Document No. 430972• M I I ii h This -. _ ...-- -- homestead i:r�rert ^. (is) (is not) Exception to warranties: easements, restrictions and rights- of way of record, if any. 16th ' October ,P7 �! Dated thi_: la. I /� . (SEA1.) 1(d -�4//1 9 G4'G% (SEAL) i! _- Gary_L.._Hau.sc.hildt_ Diane E. Hauschildt H �! - 1. SEALI - (SEALi i! AUTHENTICATION ACK? OWLEDGhSENT �I Signature (s) .............................................. ---- -- .... STATE OF WISCONSIN - i -----•-------------------------- - - - - -- ------------------------------- - - - - -- St. Croix -- ----- --- - -- -- - ----- -- --- ----...Coun authenticated this - -. -- -..day of ... .. ...... . .. ......... 19...... rersonally came before me this16 - .....day of --- ...00.tober. -- ------- ---- • 19..8z -. the above named ............................. --- -- -....•.......• ........ ... -- - ------------ .- -•• -- --------------------- -- childt - - - -- .................. ..................... ...... GarY..L- ...Haus Diane ! TITLE: MEMBER STATE BAR OF WISCONSIN E. Hauschildt � -- - -- ------------------------------ .......-- ---- .....-- ...- ....... if not. .......................................................... - ... . --- -- - --- -- - ----------------------- -•- ••-- - - - - --- authorized by 3 706.06, Wis. Stats.) to me I:r.n••cn to he the person ...-- . -.. -. who executed the �i foss -oin- instrument aad acknowledee the same. I UOCUMENT NO. STATE BAR OF WISCONSIN FORS[ 1 —IM TWO rAca R"&M+m FOR asco"ot"e DATA __. W RANTY DEED REGISTER'S OF ,A�I,3 eooK 25 ��a °E 369 its 1 , 3T. MOIX co, w1 WS Deed, made between ... C' .... and Diane E ` nee for Rewd II Hauschildt ...................................................... •------- .--- ........- .- - - - -.- - .---------- ...---- .-- - -.... ' ucT2 cress ...... ........................................... --•------------ ••----- .............._ - - -... ..... ; 11:40 A.M t .... ........ .. ................................. . sad------ ... N.i 1 .. C iQ' 4 ----------- ------------------- •----- - -• - -- -- ...------ ......... • .... - -. -- . - -•• -• « -- •-- •..•--- ...• - -_. F� -•-•-• ................. ................................................................ Grantes, Witnesseth, That the said Grantor, for a valuable consideration ... f ...... ............................••---•-•--..........._...... ........................... - -•- •.................. ----- -- ! asru� ro conveys to Grantee the following described real estate in .... Stw..Cm XX............ County, State of Wisconsin: Tax Parcel No: ................................... That certain parcel of land located in the Northeast 1/4 of the Southeast 1/4 of Section 25, Township 28 North, Range 20 West, ?cum of Troy, i St. Croix County, Wisconsin, more fully described as follows: Commencing at the East 1/4 corner of said Section 25, thence S 01 °09'46F (asr bearing on the East line of the Southeast 1/4 of said Section 25) a distance of 616.36' to the POINT OF BEGINNING, of the parcel to be herein described; thence j ocntinue S 01 0 09'46 "E 290.00' on said line; thence S 88 280.00' on the North line of Lot 1 of that certified survey map recorded in Vol. 7, page 1895, of St. Croix County Certified Survey Maps; thence NO1 °09'46"W 290.00'; :hence N 88 0 03 1 22 "E 280.00' to the POINT Cr RDGINNING. j This property has not been approved as a minor subdivision under the ordinances of St. Croix County or the Town of Troy. This property is being conveyed to add to adjoinng property already owned by grantee. This property - shall therefore became a part of the adjo property and cannot be sold separately to a third party whose property does not adjoin it (unless compliance w1th The town and a� county ordinances is obtained.) IN NSFER A 00 This -------- 1s-- npt------- homestead property. (is) (is not) Together with all and singular the hereditamenta and appurtenances thereunto belonging; [M And -------- Ga y..lr,.__ Diane- .E.. Hauschildt - - -- _ - warrants that the title is good, indefeasible in fee ----- n - d - -- cl -- - • -- - -• -• - ----- ------ s --- - - --- - ----------•------•--••-•- simple and -_ - fr ee aear of encum hr &__n' ezcept - easements, covenants and restrictions of record, if any, I( and will warrant and defend the same. 4 , Dated this ..--ZU --- - -- -- -- --•- ----- •• - - -• -- ........ day of .... SE�pt .. . .... - --- ---- ............ ........, 19.88 (SEAL) t °� . .-. - (SEAL) • .. ........... - ` - -- Gary L. Hat>st�lildt - !j - -•-- ----- --•- -- ------------------ -- • -------- -- --- ------ -- -- -(SEAL) .. -%! Lc4G!.(SEAL) --•-------- -------- •- ----- •----------------- •-- - - - - -- -- -_.... • A.ne.E...HatlsciZildt------ - -- -- -- - - -- il AUTHENTICATION ACKNOWLEDGMENT >i Signature (a) - Gary L. - -Hauschildt and STATE OF WISCONSh Diane E. Hauschildt sa. ------ - - - - -- -------- ---- -- --- - - - - -- County. n thin - -- s o - --- -- --- -- ---- r._ -__ -, 19.85_ Personally came before me this ......._____._._day of -- ------ ------- ---- -- ----- - - ----- 19- - - --.-- the above named RobertF. Wall -------- -••-•--------••---•-------------------------•---._....-----•------------ •--------- • ----- ---------_------.---•-- --- •- •-- - -• - -• ----------------------------------•--------••------- TITLE: MEMBER STATE BAR OF WISCONSIN (If not, -------------------------------- authorized by § 706.06, Wis. StataJ - - - - ------- ----------------------------------•---------••------------- to me known to be the person --- .-- -. - - -- who executed the fi FILED OCT 811987 w JAM a G MMA twww of DOG& 09`7x o r a CERTIFIED SURVEY MAP E 4 COR. SEC. 23, GARY L. HAUSCHILDT r 2B N R 2 w, /COUNT Y Part of the Northeast 1/ of the Southeast 1/4 of Section 25, Township SURVEYOR'S MON.I 28 North, Range 20 West, Town of Troy, St. Croix County, Wisconsin. b M UNP 7'TED L N 8B • 03'22 "E 280. 00' E LINE SE 114 \ W PORTABLE SHED �OO ` b W 7 UJ W O POLE SH EO 4L am Comm ~ N PMU PLANMMG p (� 30"M n commrTE6 2 W 4 b y A/ DWELLING WIrH Arr. J 0 �YI 0 W MU C GARAGE EL p p GARAGE 2 v Q 1 ° N , I 3 LO / POOL o o W .6 '• LAURE Y Q M 2.633 ACRES M I q � � 0 N //4,7B9SO. FT. Q i S 1 �- O NET = 2.449 N . �.RIV FALLS J'� �I o 106, 671 SO. Fr. Z h i •. WISC. JQ Q N 2 J ... 66� GL R OAD ence W. Murphy — N 6$ * / /s' s6 "E 279.98' I i Re 1 or y stered Land Surve h SCALE E / " r / 00' . S B8 03' 22 "W 280.00 O 50' /00' /30' 200' 300' S LINE NE 114 SE 114 � UNPL A TTED L OIndicates 1" x 24" iron pipe weighing M 1. lbs. /l ft. set. SE COR. SEC. 23, r28 N, R 20 W, (COUNTY SURVEYORS MON.) Description; That certain parcel of land located in the Northeast 1/4 of the Southeast 1/4 of Sec. 25, Township 28 North, Range 20 West, Town of Troy, St. Croix County, Wisconsin, more fully described as follows; Commencing at the East 1/4 corner of said Section 25, thence S 01 "E 906.36' on the East line of the Southeast 1/4 of said Section 25, to the POINT OF BEGINNING, of the parcel to be herein described; thence continue on said line S 01 0 09 "E 410.00 thence S 88003'92 "W 280.00' on the South lins of said Northeast 1/4 of the Southeast 1/4; thence N 01 09 "W 410.00 thence N 88 03'22 "E 280.00' to the POINT OF BEGINNING, containing 2.635 acres, being subect to easement over Southerly portions of the above described parcel for town road R.O.W. as shown on this map and also being subject to easements of record. (For purposes of this description all bearings are referenced to the East line of the Southeast 1/4 of said Section 25, assumed S O1 ° 09'46 "E) State of Wisconsin) tl—i +— of T)i arna ) STC - 104 AS BUILT SANITARY SYSTEM REPORT �j' OWNER Pte` [� �l,14GOfX�C�: ' /� .. ADDRESS SUBDIVISION / CSM# LOT # /y SECTION �� T c6 N- R Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM B� !4� °id p I r ' I INDICATE NORTH ARROW I Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. L abor a bor and apartment of Industry L PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division I NSPECTION REPORT $T. 0WIX `GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -: Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI OWIMIC8 11201AM g CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: . TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 1 Benchmark Dosing /DO . Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St /Ht Outlet TANK TO P/ L WELL BLDG. Vent to ROAD Dt Inlet Air Intake Septic aS' 50 � • , �o sus NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding x• %S. `` S Bot. System �- f 9 y 3 f PUMP / SIPHON INFORMATION Final Grade k ction r Demand er Fri System TDH Ft Lengt Dia. Dist. To We SOIL ABSORP ION SYSTEM B ED H Wi d th Length No- Of Trenches PIT No. Of Pits o'Z Inside Dia. Liquid Depth / DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manuacturer: INFORMATION Type O CHAMBER System: ,2 / J0t 7, ,cJ1A OR UNIT Mo e N m er: DISTRIBUTION SYSTEM Header /Manifold Distribution Pipes) x Hole Size x Hole Spacing I Vent To Air Intake Length Dia. Length 9 Dia. Spacing � SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over a , Depth Over xx De th Of Bed /Trench Center I a1 _� d1 , P xx Seeded /Sodded E[01 ulched Bed / Tr Edges Topsoil ❑Yes ❑ No Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Troy.25.28.20W, Glenmont Road � -fir (�T Q/L/�i `�/,.� (I'✓ Plan revision required? ❑ Yns [�No Use other side for additional information. Q,ti .B� �,�. SBD -6710 (R 05/91) Date Ins ecto s Signature Cert. No. Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water System In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. P.O. Box 7969 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. ° roc x • See reverse side for instructions for completing this application State Sanitary Permit NNumber The information you provide may be used by other government agency programs �� / 1 1 t (Privacy Law, s. 15.04 (1) (m)]- ❑ Check if revision to previous application I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION State Plan LD. Number .1� Property Owner Name c pert L cation /4� 1/4,5 ' T ,N,R E(o W Property owner's Mai ing Address Lot Number 4AZ O/� Block Number Ci , State Zi L ° /� r1i p Code �Nu✓ Subdivision Name or CSM Number II. TYPE BUILDING: (check one) ❑ Sta / t 7 e 7C Owned C1t Al Nearest Road Public 1 or 2 Famil Dwellin - No. of bedrooms village �� Town OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers 1 ❑ Apartment/ Condo f7 — 1163 ---5V --X0) 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. XReplacement 3 [:j Replacementof 4 Reconnection of ------ System -------- System Tank Only 5. [] Repair of an ------ -------------------- - -------------- 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 XSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank j 12 E] Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 E] 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 Require (sq. ft.) Proposed sq. ft.) (Gals/day /sq. ft_) (Min. /inch) N Elevation /�+ Feet — Feet VII. TANK Capacity INFORMATION In gallons Total # of r Prefab. Site Manufacturer Fiber- Ex per. New Existing Tanks uer s Name Concrete Con- Steel glass Plastic A p p Tanks Tanks strutted Septic Tank or �+�l�l ; j/' W ee k s �{ 1:1 ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber El 11 ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) v PI m is Signature' Stam /MPRSW No.: Business Phone Number: 3l Plumber's Address (Stre t, ity, S ate, WAA -I j -a — IX. COUNTY / DEPA MENT USE ONLY ❑ Disapproved Sanitary Permit Fee (ln<IudesGroundwa[er g Ag t Signa No St ps) Approved E] Owner Given Initial �`5y`� /��(( Surc Adverse Determination harge fee) dzeo X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHO -6398 (H. 05/94) DIST RIBUTION: original to County, One copy To: 5afety & Ruil,li rigs Divui on, Owner, Plumber ` e<< PLOT PLAN S i 9n7 /ac 11 o C t/erq�►(�. P /cvr a -I L /�� Yard J 117 I �N I B3 i I ignatur er Date Signed Telephone No. �� Vlfs a n d Hu Department ti ons Industry, SOIL AND SITE EVALUATION REPOR P O R T �c:;�r and Human Relations Page 1 Of 3 Givs of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 1 St include, but not limited to vertical and horizontal reference pant ( on and 9'0 o e or PARCEL I.D. # dimensioned, north arrow, and location and dista crest r d y D SO - \0 APPLICANT INFORMATION PLEASE PRIN L INFO . T REVIEWED BY DATE PROPERTY OWNER: OP ATION M1C �� ova S� ua,sZST z t 3 - Z- 0 PROPERTY OWNERS MAILING ADDRESS - • ,N,R E (06 '. `LOT OCK# SUBD. NAME OR CSM# CITY, STATE ZIP CODE PHONEWLI ILLAGE (MOWN NEAREST ROAD R t U E- t�rt,�S W I S l 61 (BLS) Ll 8' Gl.E�1�tu>uT 1Zb . (] New Construction Use Residential / Number of bedrooms 3 R Public or comm I 1 Addition to existing building Re Ib4 p [) commercial describe Code derived daily flow qS O gpd Recommended design loading rate o - S bed, gpd/ft 0 _ trench, gpolft Absorption area required ft b p bed, ft - 1 'SO try, ft2 R design loading rate o • S bed, g pd/ft2 a • (e" trench Recommended infiltration surface elevation(s) C l �. • S - 't ' gP It (as referred to site plan benchmark) Additional design / site considerations z Parent material S I t_`M S ED 11" V4jT' ova S E. G�' Flood plain elevation, if applicable %,h • ft S = Suitable for System CONVENTIONAL MOUND I"ROUND PRESSURE ATGRADE SYSTEM IN FILL FOLDING TANK U = Unsuitable forsystem ®S O U ®S ❑ U ®S ❑ U Q S U ®S ❑ U j [IS o U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz, Cont Color Texture Consistence Bour>dary Roots Gr. Sz. Sh. 1 Bed totdt l 0 -6 o�- I1Z-1 -L ` [ s�1 Z msb b►►`Ft 0.-S — o_s o.` 3L — Cl si Zw,Sbk m o.s u.L Ground elev. 3 13 -yS l0`�2 31G S61. S rrt I C S — 0 .1 n 41 g 4 i1S -)o l0`t cll - S�6�- OS9 ►'h� o.1e.� Depth to limiting facto Remarks: Boring # 0 - � 1o`1lZ ZLZ S 1 ` ZAP 51,vc q.5 - b.S r) 1, Gh31( 7yn5 o.� Ground 3 1 - u3 t u `2 3l L _ S 4G>` S Yv1 elev. 41 - t U`i R Y! -- 9D. ft. _ s G►. o S w� 1 - 0.1 2 U , Cd Depth to limiting facto ? $Z Remarks: T Name: - Please Print Phone Arthur L. We erer 715- 425 -0165 egerer Soil T sting & Design Service -P.O. Box 74 River Fa11s,WI 54022 Signature: Date: 9 S_ 2 9 6 10 -11_ q S' CST Number: M0057Fi PROPERTYOWNER SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D.#� 0 ri— Boring # [Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Qu. Sz. Cont Color Texture' Bo�xxlary Roots Gr. Sz. Sh. CO"sistence o- 11 �p •� <Z 7-t — Bed Trench El s j Z ►► � sbk m �� Q-S o -S o• Z t 1 - 33 31y — — 6` s 2r►, sbk t c S _ o. S o. L Ground 3 33 - 1p -L elev. 't S O S 5 M1 cs -- p• S U. q1.6 ft. 6z=11 v ! V S o a Depth to limiting factor T77 N Remarks: Boring # 13. Ground elev. ft. Depth to Amiting factor Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: >Rn.q�3n�R nsin ?� PLOT PLAN P age 3 of 3 SCALE 1 "= 30 7 0%10- 1163 -Sr ioo x wW - lA-tv st � Za r� — t? L. l0� C' t�P��xox�v►R'I� f v eL 4 ? a.2 a.1 L-L 47.9 9� ti w ov�Z Q�s`i1Zl3U`n0�v �tPtTs, B•3 G L V- v �-j rv7 12 o t�,9 CST Si nature s 715 ) 425 - �s 14 00576 g Date Signed Telephone No. CST # 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 serving the AM i Sec. residence located at: y� , +, s- � 4 _ T R -cgo W, Town of _ T St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced ^ / a 4 nor. /9Q§ Did flow back occur from absorption system? Yes line. No __y (if no, skip next Approximate volume or length of time: Capacity: gallons minutes Construction: Prefab Concrete Steel Other Manufacturer (if known): Age of Tank (if known) : Y�v (Signature) L (Name) Please Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name �ja�rj�S- TT�oLt! /^ Signature ` MP /MPRS /�h STC -105 SEPTIC TANK MAINTENANCE AGREEMENT �yJ / S � t. /Crroix County OWNER/BUYER -Q V /! c MAILING ADDRESS a M 11 .4-- It�oh�n.� PROPERTY ADDRESS Dt/r+ (location of septic system) Please obtain from the Planning Dept. CITY /STATE 4! y r' Call lJj SQ�� PROPERTY LOCATION 1y'� 1/4, S.� 1/49 Section .0 T � N -R TOWN OF r ST. CROIX COUNTY, WI SUBDIVISION 410 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 year expiration date. SIGNED: DATE: A St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 • This application form is to be completed in full and si ned b owner(s) of the property being developed. An inade g y the only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house) , then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Location of property 1/4 4j*� 1/4 , Section - W Township ��/ Mailing address gk'0a_ Address of site C ('�L elmCf Subdivision name AY4 - Lot no. other homes on property? Yes No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes No Volume and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description 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 in the office of the County Register of Deeds as Document No. nd own the proposed site for the sewage ' disposal t system ) oprreI (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 office of the County Register of Deeds as Document No. n / ig ? n�ature of Applicant - - Co- Applicant u , ' r �.. Q 7 O Ro o , c. > 9 o 12 _ c I I C { T N, 7 I f � 0 _ V