Loading...
HomeMy WebLinkAbout042-1046-50-200 , 7 7 . � ; 710 ST. CROIX COUNTY ZONING DEPARTMENT ' AS BUILT SANITARY REPORT r' RECE Owner 14 Address ! o ! 9 10 0 !� �- - ' 5T CFok City /State R *AA w �3 ` ccx;aTr Legal Description: Lot Block Subdivision/CSM # �. '/. / - V - L ) - '/, N 0 , Sec. L7 , T 9 9 N -R ! 6 W, Town of L) tx-� PIN # o Y A - I o ti6 -So -0 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC /- o°/ Setback from: House As Well B P/L .�2 3 Y Pump manufacture_ r, AbQ Model /V Alarm location /V4. (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: S- o= 9-- Width Length Number of Trenches Setback from: House '5 S Well at P/L z 'I Y Vent to fresh air intake ELEVATIONS Description of benchmark !&V-40, Elevation / o0 Description of alternate benchmark ,& /lie :A N E e �,._ . Elevation °/ 3 IF Building Sewer ST/HT Inlet 9 0.6 4, ST Outlet- S PC Inlet NA PC Bottom /V/9 Header/Manifold Top of ST/PC Manhole Cover / Distribution Lines ( ) s �j — ) ( ) Bottom of System( Final Grade R Dateofh / / Permit number 31 S - 9 � - 3 State plan number Plumber's si nature _ Y� License number 04 -1 1 o Date /' Wi Inspector I /� �� l qq� Complete plot plan Or 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 boattt -I) � I I i 01 O \ 1, " jl a.rn, , —( INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division INSPECTION REPORT ST . CROIX GENERAL INFORMATION (ATTACH TO PERMIT) SanitarjjecgWt�.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. P �L Holder'iNaple� [7,�i#y illage [] Town of: State Plan ID No.: AMAIVIV �L,UU wtjtc CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TY0QZ- "1046- 50-000 1 Ca /aZ�. TANK INFORMATION ELEVATIO DATA A9800218 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S b?T7� Benc ar �. 5 $ /oS. Dosing ism vS'.Ss� G sa" ld� 3 Aeration Bldg. Sewer Holding V* Inlet �o •7.2- JS 6( - TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to I ntake ROAD Dt Inlet ir Septic NA Dt Bottom Dosing Header / Man. Aeration NA Dist. Pipe Holdi Bot. System PUMP INF N Final Grade Manufacturer Demand S%, JJA,,,,, Model Number; GPM TDH Lift Friction System TDH Ft oss H ead Forcemain I Length Dia. Dist. To well 7— SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu acturer: INFORMATION Type of CHAMBER model Number: System: OR UNIT DISTRIBU ON SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: WARREN 17.29.18.262B,NW,NW 1019 100TH AVENUE )ns ctl��'1 c lr,J, -7 1 3 0 jam►8— V' If - for Vlo�g` ( °-E ConyVcc�) - 0o�(ow\6 .ASIA llec� I �A o vs e . "(�b1(?. f0l�� N hl u�t, �jv f �c,u�eG4 b Ire � InnSpnC� �g 8� ' � liywt l al r Sr art t `� C, � � ,�(r, �• �,`.rcl+� ln.. l�cwc �z Ia�`i � �' -�^Ut 6 — Plan revision required? ❑ Yes ❑ N6 Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Sig ture Cert No. ` ' 1 r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: : 1,:viC1,1-le___1,1,0,2 -4� G — « r� r_ 1 F 1,/ - ti rr rt i vial`'' ` 1 n` 13 eily p, - ` rn`«-= { / 14 4a'A'(/'( -" (tnAZ 6• L�►�I, F41 No'-:- 0,,,,,i--"'' rli e,_lcvx -fes_. ( fin✓ 2t,edr « ir}le(YYt yr E .d7 rs''''' WP {.:),F 0 c r 1, IAA"- A..... q er/1 a-f 7/.., ,pe. ,-4----;.17 -7/?,.,,„'5,e, Z." ' / bar ' " v le t r,:r ( '' - ^ Safety and Buildings Division *6consin 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 t , than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanita�f Permit Number Personal information you provide' may be used for secondary purposes E] Check if revision to previous aplplication [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name Property Location 5 Do OL h 11 /U/)1 14AI0 1/4,S /7 T ,,27 , N, R / 6 E (or W Property Owner's Mailing Address Lot Numb gg�� Block Number /6/7 /a D �. A - q. V 7� 1 N.4 Cit ,State Zip Code Phone Number Subdivision N me or CSM Number �Q,� e� r 5 ( -719) 9a 3 /� II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road Villae _t4 Public R 1 or 2 Family Dwelling - No. of bedrooms • ° Town OF /00 A v-a f III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) t'94/.7, vy to - 5'6 — oo o 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2_ ❑ Replacement 3_ ❑ Replacement of 4_ Reconnection of 5. E] Repair of an ________ System._ ____________TankOnly___________ xlstingSystem E B) A Sanitary Permit was previously issued. Permit Number 4 q 156 b Date Issued - 95 - 9 5 V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 JASeepage 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:��`- 17 t 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System ev. 7. Final Grade Re uired (sq. ft.) �pelAl(sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation !� J - O .2 . �a2 , Ai !� • c Feet Feet cf VII. TANK Ca pa t in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name concrete Con- steel glass Plastic App New Existin strutted Tanks Tanks eptic Tan /OD U /doe ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber IV.4 AIA ❑ ❑ ❑ 1 ❑ ❑ ❑ VI11. 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.: 7 7 17 s Phone Number: LJ �. l-� ►- lA) �. �. v, l l e- Q �a� l v -? �t `i - 3 3 a z Plumber's Address (Street, City, S A e, Zip Code)C � � 9 l 11 14 IX. COUNTY / DEPARTMENT USE ONLY ��//. ❑ Disapproved nitary Permit Fee (I surcha r a et) water r�e e Iss ng ent Si natu. a (No St amps) pp roved Surcharge Fee) ❑Owner Given Initial �1 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOW DISAPPROVAL: `ike_ rwo elntov tKe.GtJ od tre- 4v.- -k, ?Paper t ow. calkhr SBD- 6398 (R.11/97) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber 7 / Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER DO /144/i/X/rd/ TOWNSHIP (2' Hj g-N SEC. / 7 T ? N-R fL de ADDRESS©„, 69 /T7 ej . ST. CROIX COUNTY, WISCONSIN eo6El;.fs/ WIs SUBDIVISION MA LOT /v j4 LOT SIZE /Pt6 E PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 q SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 NEB 0 _t -c iti i ) , Co.,, 2- Z' -7--itejt44)4' Box . 40 "►' �C4- 16`'1,. - E LE'U, _/oo ,0 5, .›y 0 -, ..k(r ij9-___. _ - - - - - , /- .. ----. ... .... -4 -- 46 / ' :?,y,s,/ ri _t,, I 1' j.5 I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used N it.) Tvfo Atn de. /i-1 v Elevation of vertical reference point: //gyp, 4. Proposed slope at site: SEPTIC TANK: Manufacturer: /,(}'-F/("5(�,,,, Pry, Liquid Capacity: /z-on W . Number of rings used: / Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side rei Rear, O ,-/ 1{#1 feet From nearest property line : Front,aSide,O Rear,O f! feet Number of feet from: well '7 , building: /j} $ (Include this informat �?-6 the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacti -r: Liqui: Capacity: Pump Mod-1: 'ump/Siphon Ma faiturer: Pump Size Elevation of nlet: Bo om o tank elevation: Pump of switc elevation: . .. sons per cycle: Alarm anufactur-r: Ala Switch Type: Number of feet frim earest proper y line: , rout, O Side, O Rear, 0 Ft. ber of feet f om well: Number of feet from building: (Include distances on plot plan) . SOIL ABSORPTION SYSTEM Bed : v Trench: Width: / 2- Length: 5- 5 Number of Lines: Area Built: Fill depth to top of pipe: d Number of feet from nearest property line: Front, agide, O Rear,O Ft .%?A/5 Number of feet from well: 1Q. Number of feet from building: p / 7' (Include distances on plot plan) . SEEPAGE PIT 1 I Size: Number of pits : r,iameter: Liquid depth: But om of seepage p t elevation: Area Built: r O O Has either a drop box or dis ribulion box •een used on any of the above soil absorbtion sytems? (Check one) . HOLDING TANK Manufacturer: C- •acity: 74 l Number of rings used: Ele atio of bottom of to . /� l7 Elevation of inlet: 1D Number of feet from near st property li e: Front, Side, O Rear, O Ft. Number of feet fro ell: Number of feet from bu ding: Number of feet/ from nearest road: Alarm Manufacturer: / k Inspector: �� Dated: r�Qa�9 Plumber on job: �titl�1 � iJr��%Cp License Number: 35. 3/84:mj Wisconsin Department of Commerce SOIL AND SITE EVALUATION f .Division of Safety and Buildings Page i of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location l li 0 HR W R N Govt. Lot N /,J 1/4 Al 1�?1 /4,S l7 T a q ,N,R E (or Property Owner's Mailing Address Lot # I Block# Subd. Name or CSM# lat4 %o,� kq V City State Zip Code Phone Number El city El village LK Town Nearest Road R o b cz, I W 5 q 0 d-4 ° z ! (7 4 ) d 3 1 LA) o�.1- I-- -- to I l U ' A VC ❑ New Construction Use: ® Residential / Number of bedrooms Addition to existing building C ❑ Replacemg Vailyy ❑ Public or commercial - Describe: U ode derived ow gpd Recommended design loading rate +� bed, gpd/fl� -- t g � 3 trench, gpd* Absorption area required 6 y r2 + bed, ft ft Maximum design loading rate 0 bed, gpd/ft —S trench, gpd/It Recommended infiltration surface elevation(s) Y 9 ft (as referred to site plan benchmark) Additional design /site considerations �`^ `~' r d�0� 1 Parent material Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in FlII Holding Tank U = Unsuitable for system 52S ❑ U ❑ S PR U ❑ S C& U S U ❑ S ®U ❑ S 0 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDht2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench YA /-V 51Y oevE & Rc C o $ 0 C 5 o -5 2Y- 7 :- Ground a4 -41 !v ( � /J oNC (� R� �� d f $ hA � R W s 5" , o elev. 1 OD S ft. yt - 7. s '4/ h!o AI 5 L i V4 S vy1 Cx- L.) Depth to tl° i0 A o Al 9- G Q 5 o limiting (o 10 A 1 4/ 4, /J0/11 e- CYa °.� 0 ►^1 5 /i!/} "'_ I C Y 08 factor 7A,j.in. Remarks: 15 /9,9 5 -/00 ` Boring # L3 Ground elev. ft. Depth to limiting factor in. Remarks: CST Name (Pleas Print) Signature Telephone No. Ck /� 11 7'f - 3.3 9- 2, Address Date CST Number i I I i -- - 1 Nei e S T L fi L i " kio- 7s i - r X = l�F -:TES, S ' l / o } ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that that I have inspected the septic tank presently serving the e I lA residence located at: fVIs ; , AILA) ', , Section 1'7 , T25_N, R 18 W, Town of b3 . 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: / j 9 & Did flow back occur from absorption system? Yes '�4- No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concret Other Manufacturer: (If known) : L3-o- Age of Tank (If known) : (Signature) (Name) Please print o2 7 1 (Title) (License Number) &- -5 -50 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 (� a R e 1'U e-C�V / I I (f- S ignature c M MPRS oq a 1 � ge T ST CROIX COUNTY �� SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyerl Mailing Address /00 A Ve Fiq K r)i S'i +e- Property Address nn Mrificatioa required from Planning Department for new construction) City/State 61) +., o D q o y lo- `"a r ° Q Parcel Identification Number .LEGAL DESCRIPTION Properly Location , 1 U r/, N w /, S 1 T ( N R / 6 W, Town of uJ ate-► Subdivision Lot # Cecfified Survey Map # - NA Volume . Page # Warranty Deed # /n 9 R S I Volume a . Page # Spot house 0 yes ® no Lot lines identifiable ® yes ❑. no Imp+operasesm3 ofym tYst=eoaldresaltii itsprca�atai�afa ,etchaa,dlevnstcs.Proper consists of pumping oat the septic t=kcverytt y orzowcr if aaededby 9 U=sedpumper. What you put.iato dro system eaa affect the - fuoctioa of dw septic U*as.a ftatmentstav is Su stedcsposalsystcai. 110 pmpatyowner erg ees to tabmix to St Cwk Zix ft Dqtrtment iL'cerffimfim farm, signed by do ow= wdby a mstrictedphmiberort &=odp=jperv=ifft t5at( 1) tareoa4itewastewatimd igmsdsysbcm- isis properoperating eoaditioaand/or (2) if inspcctiaa nerd pumping .Cif necessary), der; septic tm*.is ions than W f O of dadge. V,, the gw dha7. ad tare above hnquih==* sad sgwe to aaaimtaia tare private sewage disposal system with tare standards tact fork Ise+ cktssdbydoDepartmentoficewdfireD ofN' dacalR sources, State of Wisconsin.. Catificxttoa sating the year septic system has been maiataincd mast be eompldcd sad rctwmod to the St Ctoix.Cou&y Zoning - Office withia 30 days-of the dx= year expiration date. SIGNATURE OF APPLICANT DAZE OWNER. CERTIR'ICATION I (we) certify duct all statements on ties form are true to the best of my (our) knowledge, I (we) am (are) the owner(s) of the property descnW abm by virtaee of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT�Y DATE « « « « «« Any information that is rnis-rop =ntcd may result is the unitary pemmit being revoked by the Zoning DVutmemt. 00400* «« Indude with this application: a stumped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty dead � � •�� '11I��I���t�0111ta�0a0aD01IRA` O= WM W �x: Recd for Rewd 06 -2616 rr day 0.19J1 A t i,� � ir�i■YW� ax rbs to _ ��� - afar1teNbibig41 - a !a Aii%"M opW slaw of WMoMON Its onr'Ulf Tait Key No\ The Nest half. Northwest Quarter (N% of Mh) excepting that pairt,lying'Worth of the road. and j also excepting the'9ast F ift y (SO) feet of the Northwest QuarterLk6f the northwest Quarter (Nft of all of Section SeVebteen (17), Township Twenty -nine (29) North, Range F.ight4en'(181 Nest. SUBJECT tb I i Ld �- takes. (This deed is givan�,in full,satisfaction of Grantor's one -half interest of a land contract dated October 15, 1975, in Vol. 530, page 43, Document No. 329824.) TNaia.11t1t Aan.Na.d o�o�1f► SFF� na r. moa Eom f an cow MN ` "19th d of March » 'M JOHN i KAY, INC. OWA14 B i�ALI a L. rr Prez4jant (►UU Jr I M. Carrell, Secretary AUTHENTICATION ACKNOWLEOOEMENT { Sjjp* M M#W tA t1ft _N ZA day of STATE OFMOOMItN MI OTA 19 Vaahintttln Cot�l7 s peteM aNY came b log no, tMS 19th day of March TM& MOMM !RATE SAM OR WISCONSIN Qe above named Form- S T C- 104 AS BUILT SANITARY SYSTEM REPORT OWNER jE]L 0 0 WA)WX &d1 TOWNSHIP U Hh ArN SEC. _ T N -R 19 W ADDRESS ��x2 69 ,?T? I &" . ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE CP S PLAN VIEW > Distances and dimensions to meet requirements of IIHR 83 a SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM P T Bo x L _ , T ' F Irv, _ /DO , o F F INDICATE NORTH ARROW DEPARTMEINT.OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LA`BO'R.& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 XXONVENTIONAL ❑ALTERNATIVE Sta assigned) te Planl.D.Number: (if El Holding Tank ❑ In- Ground Pressure El Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPE TION DATE. Eldo Hamann R. R. 1, Box 269, Roberts, WI 54023 _9_�'S BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.: NW- NW- Section 17, T29N -R18W, Town of Warren Name of Plumber: MP /MPRSW No County: Sanitary Permit Number: Henry Nechville 3258 St. Croix 64860 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV. IW AG LABEL IL O5 VER PED: PR ES V/ ❑ NO ❑ NO BEDDIN G: I VENT D I VENTMATL J WATER NUMBER OF ROAD: PROPERTY , WELL: BUILD191G: VENT TO FRESARM. FEET FROM / / LI.W6: I q AIR INLET. ❑YES ONO ( ❑YES ONO NEAREST L I ( %- ll l/ TS DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. J IUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO ❑YES 0 N OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROP ERTV WELL BUILDING. VENT LE FR ESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) 1:1 YES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH LENGTH: NO.OF DISTR. PIPE SPACING. COVER INSIUE DIA. - . *PITS. LIQUID OED#T 2, S J S TRENCHES MATERIAL: I}IT DEPTH. Ga1MENSIOI�S J'. 11 GRAVEL EPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELO PES"� ABOVE COVER. ELEV. INLET ELEV. END: PIPES FEET FROM LINE � O / ? A NL T:- U NEAREST T/ - 1 MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. 1 YES NO SOIL COVER I TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES El NO 1:1 YES El NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED: CENTER. EDGES. ❑YES 1:1 NO 1:1 YES ONO ❑YES El NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER: 0l"R NCH TRENCHES: MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL &MARKING: ". '. ELEV. - . ELEV.: DIA.: ELEV.: PIPES. - VILR}/ATIM ANI L ISTR14UT ON HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED ,IIN -O ATfON = PLANS. ❑YES ONO El YE S ONO COMMENTS: ( PERMANENT MARKERS: TION WELLS: NUR °O PROPERTY WELL: BUILDING: F,"TI., LINE: ❑ OBSERVA ,d ❑YES NO OYES 0 N �IEARST 7 Sketch System on ain in county file for audit. Reverse Side. SIGNAT TITLE: DILHR SBD 6710 (R. 01/82) REL wco nein APPLICATION FOR SANITARY PERMIT �s _ •� � 1 L H R ���'� r' OUNTY (PLB 67) UNIFORM SANITARY PERMIT # OEPRQT Y, LR OF IrlOUSTFIV, lfiBOR 6 NUTLifI RTIOf15 — Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8' /zx 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS PROPERTY LOCATION CITY: VI VtG' 1/4 '61 S `, T , N, R /� E (or OWN OF� Ck � c /L" LOT NUMBER BLOCK NUMBER SUBDIVISION NAME EST ROAD, LAKE OR LANDMARK STATE PLAN I.I.D. NUMBER TYPE OF BUILDING OR USE SERVED ..I' for 2 Family Number of Bedrooms: ?i ❑ Public (Specify): THIS P RMIT IS FOR A: N eal System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy E l Alternate System ❑ Reconnection ❑ Petition for Modification IF THA IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System -In -Fill ❑ In- Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity 5 Lift Pump Tank /Siphon Chamber - -- - Holding Tank capacity l Manufacturer: `r h �/ IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In- Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump /Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): N � rivate ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print ): Signatuure� MP /1�5_, .: Phone Number: : l_ 7 /'I / -' 4 r i � �._ _ Gc'a ��^ S` (7/5 7"/9 33. Plumber's Address: / Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved p ❑ Owner Given Initial Approved Adverse Determination Met Reason for Disapproval: Alternate course(s) of Action Available: DILHR -SBD -6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber A NY z 'v 1v'r V. No rub ST ht � � rah F /pn,�,' _ -� a E IP/ 14 z d; E LOY 1;2 A 96, L);77 T p v 7e O DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIQ, / MADISON,WI 53707 (H63.09(1) &Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICtPALI'TY: .LOT NO.:BLK.NO.: SUBDIVISION NAME: AA/ 1/ 1/ /7 /T 11 N/R ICE (orw wgie/eE. /A,I7 of A GG Au..- f,I.PM A/e COUNTY: OWNER'S/BUYER,S NAME: MAILING ADDRESS: SI CtOi x e I 0 0 (-{,4 M A•,d x./ a o i( 26 ?/ "77� /ea/ rS• Cv/S . USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:/ y 1 Residence 2_ 4/4- cit New El Replace 3Ji1r 26_ S7t/ *lift 30 ' d7 RATING:S=Site suitable for system U=Site unsuitable for system seS 'S 9 AAfa�/-• Ci0j�/&i// M06� sii S]' 74 5 • CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:loptional) Vsnu nsu Fels -u ns ;AnsnuPA9/-.0/c/EG27 StopeS ,,„cs,„, If Percolation Tests are NOT required DESIGN RATE: 20 Sc q 5 FT' If any portion of the tested area is in the under s.H63.09(5)(b(,indicate: Pl. / t'.P,1A4. U Floodplain, indicate Floodplain elevation: /N peCri1AL FT• 94 14)/c/Ecc-)• PROFILE DESCRIPTIONS BORINGI TOTAL. !ELEVATION DEPTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER[DEPTH OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) / r • • Z'/.3,u £y 125'/3N• SW, . 8'3' 6, S/ `V/Ye •. //7'0/e. Sc/ B q.5 /oo.2/ S (iv/pr. oi•6y. 745 Ar 3.3 'to y/ ') •F,P',r44 Si, y75 ' P-„., rj(2. 4 / , •67'/3d. Si, . 33' Bv• s;/ yR, 2.0' ,erf I.P• j /s) •5'/3,0. cs B- /D. 9 / 3g ' >/o ,S •47'Av. /S 4 pt,h 6R, 4.3 0,e. cS 4 ,�E-4 6-.e . / I / a. fa AP. 3 P• S. . 12 B-C /3.0 /03.7y >/ 0 'fi'S'/3 s;/, . i 5' /3,�. s;/ 2•s"o' P �y s , 3 /e� 6,.e. , /s ,p, v p • PE;- 6.-43. 1 a / , , .lc ' i3,v-6y. 5/ /7S''Au. s/ w/?Ad. / 67 'ay. CS ..„ .. B-- /.b /�• %' >/o-D /E4 f 4 • I7'ft...Q sr, 6. /7 ' /3N. cs 0,,14 p G-R. • / / . Am-G s/'1 /.r7 ' rev . sal, ! 7S' /3N, cc P �.P. B-E- /0.0 5�6P 210 7/0. O 3S.2 ' AA). V-e7 cs ' 2 • 71. ' lam. ye . wfs/ • B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH E P- / 2 y' 9u- < 2 PE7:00•�•t E"r e •0/3e-s co E,�� P- r S&T /N /7 9,4 UEL -t S9A)L) I P- 2 3. 3i — 2_ s7'�p4T4s. Cp ' ev ' t z < P- Gv /e-ss a A'/ti 9t S . P- .3 7. ?0'—�,i--- < 2- . P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface �e e_vation at all borings and the direction and percent of land slope. /30 77011 6 AE/� 6Xe/5 U-1-T/0� �`0'-Q-- //E— / 1_ ?6.0 r 7- SYSTEM ELEVATION A LEY AA)PEA ,Q17. a,P -2432) 5•74• /a Y + ' r���%: j �. ' s • ' /3�4C-hob' ri'Tf � . y- PNoposei2 iris' • Toofr X =/7Ek S%TES . X Q dip 0 �ff �°N4 014-iFe- Si,ver. 7-sr /s o,v varv,(J_ 4•30�o I I ,•los. �(?_ sLopt' of muoll, O ; 5i TE wilt If If g1.r eRiv i — yy, Trim/ N. 3O' , .2 C / 4 -Tt,PAIA re P x�. 1p QR /�• a 1.• ik Ho42' BM ‘ ° i Pr• /`s „ N.us W. Top a//' Cr/0E6'V Hi0 / "/ -' //PE sfr. ` G AVELLy k�vp// lr647- .66x , fr. /E'U = /OD: O I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): AOM T T' TESTING CO. TESTS WERE COMPLETED ON: STATE APPROVED SITE EVALUATIONS (PERC TESTS) 3 D - ! �� ADDRESS: MINNESOTA LICENSE NO.00663 CERTIFICATION NUMBER: PHONE NUMBER(optional): WISCONSIN LICENSE NO.55-02482 S S-6 i Y,Z- 3 S)(-P/Pf 3.O741EILLW. UDSON,WI 54016. CST SIGNATURE: . —V Y 'RIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. 'BD-6395 (R.02/82) —OVER — � N s � �m�� CA -o� N O N K Ti C ? 3 O (D (D O -P, y1I 2 0 c S N a .. co N *� ( _] N m °aoo w0 wwa w � w � (OD E; =- r► w n L 7 (gi . ? n O N 0 W o 3 O CD •+ tp o w O W O L C O n 3 c o c3oCL 0 co c � cr f O wz ���PjA^:�' o�onm' m w ( - 00 - v -% 0 c o CD v' c ccn o cn o D w coo co O c co n O ,. t C N j r = CD ° Z w m N m o m � n v( mvi:07p.(,w N a ac n cv C ° a 7 �NU�i N o � N► c n N N p� w V� ' 30- N� cawo m aof m 7(pN7 ?: CL a � N (z L7 4an � CD CD 3 g N O �t o N w bi moc p(G c� c a Q .;.. a C w -• W A V a Sccoo° o 2. .. N o Town of Warren Roberts, Wisconsin 54023 Chairman: Clerk: Dale Frederick Vftfflace C Supervisors: Tr=ulrer: r n Archie Denucci Mrs. Donna Ray M"U" Assessor: (ra Gardiner Graham a..�+�'w pl�L+-- t�c�'7-�1 � G2.�t�Ltc..,•c, ���) ,, � �� _ o — Form - S T C 100 V Owner of Property yF� _&x ' M Iry .Location of Property N W k AlUl Section 17 ,T ..7? N R j$ W Township OJ a, f- i - K: ' 0V Mailing Address R/?/, /LA" Subdivision Name V Lot Number '0 4/2;7- Previous Owner of Property CJ 9 Total Size of Parcel 2Wc C.1A" Date Parcel Was Created / g 75 Are all corners identifiable? Yes No Include with this application one of the following .Certified Survey Map .Dead .Land Contract, or .Other I:egal Document which describes the property PROPERTY OWNER CERTIFICATION y 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 recor ad in the Office of the County Register of Deeds as Document No. 36 9 / ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the some has been duly recorded in the Office of the County Register of Deeds, as Document No. ). SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DA E SIGNED DATE SIGNED z.. H 9 STC - 105 r . H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z t7 9 OWNER /BUYER �•� /l' �+- ri- a�+�c, ROUTE /BOX NUMBER �/P� Fire Number t R CITY /STATE 0 p,pGi fS ZIP PROPERTY LOCATION: � n , T N, R f �1 � � s /Y !+V l t om. � Section Town of �C1,�,�lrl��y�� , St. Croix County, Subdivision _�s/1lE Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper What you put into I ! the system can affect the function of the septic tank as a treat - ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 E I /WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with H the standards set forth, herein, as set by the Wisconsin Depart- 'b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. S I G N E D e5Z4V DATE St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 715- 796 -2239 or 715 -425 -8363 Sign, date and return to above address.