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HomeMy WebLinkAbout261-1283-00-000 c Si f o 0 3 w o d m S �. 3 v 7 S ... M m .. CD rA CD O O y O C 9 O fD O = n O r) O 7 Cn m Cn N _ `C • fD m CD y o CD 3° cD N m cn to m o o O OD CD 0 fA M N ET 0 7 CCDD - W O_ CD 3 cm D o a 0 N N O 7 y N 00 r (� N N N y 3 O �l Z a a w a m p a a! a • ty, CD W o f `� = 0 0 g a ° cn cn o o O O to -4 � O Z CD 00 OCOO rn C ( Z 'i N w C cl) F ! 3 ? fu �+ rr 0 0 o 3 1 O O O Y v ai ai ai a 3 N a! m (D S D m �+ CD H S n CD Ln cr y 3 d (l :3 m co eD °- z z O D ° D a o o CD m' m �' m . N fD y N N m o Oro C C CD N. C O. a p ( A Z <D v, cn o p n a a W W 'a W CD 0 c C z 3 C C w N y < < CA _CD W O A CD N 7 CD Q c Q. C. p y 0 a m N O G O fD 0 m _ C 7 7 r'O T 7 fA j T " &0 C 1 �_ C a�z a -� ?3 z a 0D to o m o m CD N m'x -0 O fi T :iJ cn Q w y co cr f° o o° a :3 3 5' cn m DI m = y 0 'a fD <<m O O N N O + _ ? N 1 O o° I N � � N CD �CD o 0 0 I CD CD Do m fn O v> O . c ' Cl o o p 0 D. o o 0 . IS S SS Parcel #: 261- 1283 -00 -000 06/14/2006 05:21 PM PAGE 1 OF 1 Alt. Parcel M 01.30.18. 261 - CITY OF NEW RICHMOND Current F?-( ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 10/16/2004 00 4 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner RETIRED JON WESLEY INVESTMENTS INC O - JON WESLEY INVESTMENTS INC, RETIRED Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 62.000 Plat: N/A -NOT AVAILABLE SEC 1 T30N R18W PT NE NW & NW NW S OF Block/Condo Bldg: RIVER ANNEXED('03) 2112/414 FKA 026- 1000 - 80(58) 026- 1001 -10 (6A) NKA PT Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) PLAT RICH RIVER TRAILS ('04) 01- 30N -18W NE NW Notes: Parcel History: Date Doc # Vol /Page Type 07/23/2004 769707 10/16 PLAT 01/28/2004 707329 2122/414 ANNEX 09/02/2003 738349 2396/349 WD 09/02/2003 738347 2396/347 PR more 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 04/11/2005 Description Class Acres Land Improve Total State Reason Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 026- 1000 -80 -000 06/14/2006 05:20 PM PAGE 1 OF 1 Alt. Parcel #: 1.30.18.56 026 - TOWN OF RICHMOND Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner ANNEXED * 01/28/03 WESLEY INVESTMENTS INC O - WESLEY INVESTMENTS INC, ANNEXED * 01/28/03 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 22.000 Plat: N/A -NOT AVAILABLE SEC 1 T30N R18W 22A NE NW S OF RIVER Block/Condo Bldg: ANNEXED * 01/28/03 2112/414 NKA 261- 1283 -00 -000 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 01- 30N -18W NE NW Notes: Parcel History: Date Doc # Vol /Page Type 09/02/2003 738349 2396/349 WD 09/02/2003 738347 2396/347 PR 09/02/2003 738346 2396/344 LC 09/02/2003 738345 2396/342 DM LT 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/11/2004 Description Class Acres Land Improve Total State Reason Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 026- 1001 -10 -000 06/14/2006 05:20 PM PAGE 1 OF 1 Alt. Parcel #: 1.30.18.6A 026 - TOWN OF RICHMOND Current LK ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner ANNEXED' 01/28/03 WESLEY INVESTMENTS INC O - WESLEY INVESTMENTS INC, ANNEXED "01/28/03 Districts: SC = School SP = Special Property Address(es): " = Primary Type Dist # Description SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE SEC 1 T30N R18W NW NW FRL EXC PT N OF Block/Condo Bldg: RIVER ANNEXED 01/28/03 NKA 261- 1283 -00 -000 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 01- 30N -18W NW NW Notes: Parcel History: Date Doc # Vol /Page Type 09/02/2003 738349 2396/349 WD 09/02/2003 738347 2396/347 PR 09/02/2003 738346 2396/344 LC 09/02/2003 738345 2396/342 DM LT 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/11/2004 Description Class Acres Land Improve Total State Reason Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 026- 1005 -10 -000 06/14/2006 05:20 PM PAGE 1 OF 1 Alt. Parcel #: 2.30.18.17A 026 - TOWN OF RICHMOND Current ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co -Owner ANNEXED * 01/28/03 WESLEY INVESTMENTS INC 0 - WESLEY INVESTMENTS INC, ANNEXED * 01/28/03 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 31.860 Plat: N/A -NOT AVAILABLE SEC 2 T30N R18W 31.86A NE NE EXC N 42 Block/Condo Bldg: RDS OF W 16 RDS & EXC PT N OF WILLOW RIVER & EXC P17B & EXC S300' OF E 600' Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) EZ -U- 1216/441 ANNEXED * 01/28/03 02- 30N -18W NE NE 2122/414 NKA 261- 1283 -00 -000 Notes: Parcel History: Date Doc # Vol /Page Type 09/02/2003 738349 2396/349 WD 09/02/2003 738347 2396/347 PR 09/02/2003 738346 2396/344 LC 09/02/2003 738345 2396/342 DM LT 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/11/2004 Description Class Acres Land Improve Total State Reason Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 N n 4 4 mD � z z o I Northeast Corner ' y Section 2 -30 18 v Northwest Corner i Section 1 -30 -18 W I North /ine of � (Set PK nail) the NW-1 /4 - -- - - - - -- - --- - - -S89 °52' " -- - -- 6 78' ± = -- - - -- ° m �77.�H = -- -- - ---- -CA1CH BASIN — - - - - -- � � RIM E'EEV 987:0 ^> - Cenferl -- 13 TEL. PED. 1 - 89' 9'38 "Ef _-668 37'± --- `. - ±Right–of–Way o N �66 I - ' SEPTIC VENT ' i y r�i HOUSE -� �CA - cd LLI C3 { DRIVE _ III' 1 1 T � P D. 1 i�s BENCHMARK: FOUND '� O A-�; { ' ALUMINUM USGS ® O. n ' I DISK ELEV= 996.03 �, w I-�. • AS BUILT SANITARY SYSTEM REPORT `:;R , TOTJ:ISHIP SEC. T;N, R��W AD RESS ST. CROIX COUNTY, WISCONSIN. 3D.iVZSION LOT LOT SIZE PLAN VIEW -Distances b dimensions to meet requirements of H62.20 SHOW EVE RYTHING WITHIN 100 FEET OF SYSTEM i - 3 +__ I I �8 I i ' I I FT i — '- I ;'TIC TANK(S)� MFGR, ���nr � CONCRETE � STEEL Indi cate Nan�h At tow NO. of rings on cover DRY Depth ' / _ De th R S ea �e - ~NCHES NO. of -- width 1 e n - t - h - . area DRY no. of line width` length Sip are , depi 1 to top of pipe r�l�' • ;:.EGATE 7 - , RATE AREA �REQUIRED AREA AS BUILT ;claimer: The inspection of this system by St. Croix County does not imply complete :valiance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for item operation. However, if failure is noted the County will make every effort to _: , cause of failure. ' 'SES AND OILS SHOULD NOT BE:DISPOSED THROUGH THIS SYSTEM. '`INSPECTOR DATED .1(� �� L - ? PLUMBER ON JOB LICENSE NUMBER �C 2 •l S .-'REPOR7' OF INSPECTION INDIVIDUAL SEWAGE SYSTEM Sanitary Permit'-7V' .z ` } State S P p.tiC 7Z NAME ��o �r / �� .�.L c- rownbhip �_�Lj�.. S Croix County Location �," '_ � Section SEPTIC TANK Size ga.t.tona. NumbeA o6 Compattmenta Distance FAom: Wett f 6#. 12$ oA gneat a.L ope '� it Buitding it. Wet.Eandz --- � . a fix. DISPOSAL SYSTEM NighwazeA Distance FAom: Wet it. 12% o gnea.t a.L ope Buitding it. Wettanda ._.. F#. HighwateA --- . FIELD DIMENSIONS: Wi o6' t ten ch S #. D ep t h oj tack b e Cow s. 2e 7 - in. Length o4 each tine � it. Depth o6 Aock oven tite Z '' in. NumbeA, o6 tin Depth of tite be"Caw grade Z tin. Totat •Cength of tinee it. S.tope o6 .trench " in pen 100 ix. Distance between tines I!; i t. Depth to bedxock Totat ab oAbtion aAea -- St2 Depth to gnoundwateA — it. Requited aAea /'"� it Type of Covet: apeA oA S traw PIT DIMENSIONS: NumbeA o6 pits� r Depth 4 around pity yea no Ou d�.ameteA St 6eCow inLe fit. Totat abaonbtio / ea z A Area A 6t2 rn INSPECTED TITLE APPROVE * ,DATE +�' t� f 197. REJECT D , DATE 191_. EI 5 Rev.9 /78 r , REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION: ,,' /4 %4, Section ,_L— ,T (or) W, Town or Municipality Lot No. , Block No. C - -- - T. �iC'e�✓ u rvislon ame County Owner's /Buyers Name: = ' Mailing Address: TYPE OF OCCUPANCY: Residence Y _ No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS Z7 - 29 PERCOLATION TESTS ,Z0- ,Z7 SOIL MAP SHEET �Aa,- NAME OF SOIL MAP UNIT 1) _ PERCOLATION TESTS TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHE NUM- DEPTH CHARACTER SOIL SINCE HOLE HOLE AFTE INTERVAL RATE I BER INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN /IN P— ) P— r Q 1 P— P— P— SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B ' S B— B— B— B— B— PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the oc!*gn and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupanc — .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. i t E 5 £ . 3 3 E X , , a s r • • F I � G N t s E , E �. s e f , State and County State Permit # � 7 'o PL P ermit Application County Per i # � for Private Domestic Sewage Systems County * DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: Y4 '/4, Section TRQ N, R (or) ' W Lot# City Q Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: * Commercial * Industrial *Other (specify) * Variance Single family )— Duplex No. of Bedrooms No. of Persons 7 ? D. SEPTIC TANK CAPACITY jnon Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber _ Total gallons Prefab concrete Poured -in -Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate - vc.;/_Total Absorb Area sq. ft. New Replacement ,_ Alternate (Specify Seepage Trench: No. of Linea) Ft. Width Depth Tile depth (top No. of Trenches Seepage Bed: _x Length , 8 , Depth " Tile depth (top��.No. of Line 3 Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land Distance from critical slope WATER SUPPLY: Private 56 Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: 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 disposal system from the EH -115 prepared by the Certified Soil ester, NAME .,1.,, C.S.T. # S`S -.f.3 j and other information obtained from (owner /builder). Plumber's Signature + MP /MPRSW# Phone A i � N7 Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. E e , e E € . .. :. M..,.. ... , , .._ ..,. f ..«. ,. ` i S m e e.w .... ....... 3 .. .{,_.,..., .,. ......,_ Ai i 1 m s a a .eo ,... s. .a..m .... »,.. . a . ., �, ' . . .. ..,..,,..... «. ,.® .mom. e ......_.,..f .. ..�. .. Q t t 1 E E .rv... _. ...� E /O( Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division bT . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitarBe�rrlitNo.: Personal information you provice may be used for secondary purposes [Privacy s.15.04 (1)(m)]. 1 tiSS 1111 LL Permit Holder's Name: PEDERSON, AMOS [Z j ❑❑ i 8H4 6 I e Town of: State Plan ID No.: CST SM Elev.: Insp. BM Elev.: BM Description: Parcel bl2�0.1005 -30 -000 TANK INFORMATION ELEVATION DATA A9800190 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft 955 1 Forcemain Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING 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 El E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 2.30.18.17C,NE,NE 1778 140TH STREET Plan revision required? ❑ Yes []No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less Coun than 81/2 x 11 inches in size. fV r C • See reverse side for instructions for completing this application State Sanitary Permit Number 31S DL- The information you provide may be used by other government agency programs E] Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. S / t/ ' Wl State Plan I.D. Number I. APPLICATION INFORMATION PLEASE PRINT ALL INFORMATION ' —'"' -- Pro rty Owner Nan^ Property Location rl�d5 AJ E � 14 1 j j 9 1/4, S -Z T 3� , N, R c (oroW Property Owner's Mailin Ads Lot Number Block Number V0 City, State f Zip Code Phone Number Subdivision Name or CSM Number ) 2 -&Zx. II. TYPE OF BUILDING: (check one) ❑ State Owned 'tia / Nearest RoAd El Public 1 or 2 Family Dwelling - No. of bedrooms _ town of J� 01 1 III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo • 3o- �D - ��� �� 1 ^ �� 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) /�p �`� A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5y Repair of an ------ System -------- System ------------- Tank Only -------------- Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11,x] Seepage 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 Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) c� Elevation 7 (; . V6., Feet 92, ci Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex p er. INFORMATION New Existin Gallons Tanks Manufacturer Name Concrete Con- Steel glass Plastic A p p stru Tanks Tanks Septic Tan g a,k O © J ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigne ssume responsibility for 'nstallation oft onsite sewage system shown on the attached plans. P e: nnt) ubv.�t� n ur Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Address 15t reet, City, State, Zip Code): 7�/�• SG, rroh A viz__ lV G/ IX. COUNTY / DEPARTMENT USE ONLY X( Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing A nt Signature (No Stamps) Surcharge fee) ❑Owner Given Initial �j�/�) � � Adverse Determination p U ` /( c� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber 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 % r, (tovsOy residence located at: 1 Sec. T 3D_ N, R 1 < W, Town of i �,� p,�G I 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 <�3 Did flow back occur from absorption system? Yes /� No (if no, skip next line. Approximate volume or length of time: 000 gallons minutes Capacity: � Construction: Prefab Concrete Steel Other Manufacturer (if known) : Age of Tank (if known) : J f� (Signature) / (Name) Pledse 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 cep tify 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 baf le). Name Signature MP /MPRS Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page J— of Bureau of Integrated Services in acgw0ne"ith s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 ir,hes in siz must County include, but not limited to: vertical and horizontal reference poin)r( ), d'i'i . " and 5 1 C. \r �'� percent slope, scale or dimensions, north arrow, and location and - distance to -ne rest road. parcel I.D. # ' APPLICANT INFORMATION - Please print all infgri!jt *1 on.�' Review d Date R/ Personal information you provide may be used for secondary purposes ((?fipq�cy Law, s %1 (1) (m)). Property Owner , .� n (� \ Property Location Govt. Lot N 1/4 M F, 1 /4,S T 3 D ,N,R I E (ore Property Owners Mailing Address Lot # Block # Subd. Name or CSM# City State Zip Code Phone Number ❑ Ci ty El villa ® Town Nearest Road N :6�1 WT I 54DI_7 (_71 s) ay1 - vt a i h �f ❑ New Construction Use: Residential/ Number of bedrooms —3 Addition to existing building ❑ Replacement �1 ❑ Public or commercial - Describe: Code derived daily flow 7 5 o gpd Recommended design loading rate —' bed, gpdtf trench, gpd/ft Absorption area required bed, ft - - trench, ft Pre serrt Maximum design loading rate bed, gpd/ft trench, gpd/ft .RaccmrweAded infiltration surface elevation(s) (as referred to site plan benchmark) Additional design /site considerations Parent material !F� I Q C ; S I n `} C Flood plain elevation, if applicable ft 7 S Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system I EP S ❑ U [A s 1:3 U E? s❑ U [59 S❑ U ❑ s R U ❑ s ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Uj 0-3 1 0 A /2 I,S F55k mvFr Ck 5 aF �7 a 3 -►x l `f I ---- --.... a M �bk w►tv- C. kk✓ a F r 5 Ground 3 1.;1 -1 to S �1 k Y /V S L- of 'a k 5 , elev. q eft. )L -X ID IR, 1 / .`�L_ �� k t�tFr t+� `� ,S ' Depth to s -35 - 7-5 19 q14 \p V� , c ► , �� ; , s limiting 5 -yD S `1 Po 11 ...,_`"" s �.. it factor L Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number d . , s`�a� ■mmummm'y .■ii■ ■IMME Emumps ME ■■■1� ■I■II�NII■�!■ ■!��!II■ . ME■■E■ ■NN■ m ■mmail ■ ■Mliiri ■il�ii ■�iii■i■■'i ■■ liiH■ ■■ ■1►�11 ! 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EMNSM MM ■■ME■■ ME■ ■E■ M ■ ■r ■YErr ■UE M■■ ■E■■ ■ ME■ ■E■ M ■t ■1�■I!�!II�!IR!!!■ ■■■■■■■ ■ ■MM■ M ■[ i iiIN ■ ■■■ M■ ■E■■ ■ ■E■■■■ ■ ■M■- Pe91[MIt1■■■ ■■ ■MINE ■ ■ ME■ ■E■ ■ ■ ■M ■I�rl ■rM ■ ■■ ■ ■■ ■ M■M■■ ■ ■■■lwo Im© ■■� Im E �■ ■ I■■■■■NE ■■■■■■■■■. ■■■ ■. ■ ■ ■■■■■ ■ ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address , � / Property Address _- (Verification required from Planning Department for new coastructioa) City/State Parcel Identification Number c� LEGAL DESCRIPTION Property Location %, yam - ` /<, Sec. _ Z . T _ N -RAW, Town of Subdivision Lot # Certified Survey Map # 3) 793� Volumed . Page # Warranty Deed # Volume Page # Spec house ❑yes ❑ no Lot lines identifiable. ❑ yes ❑. no WSTEM;MAINTENANCE of fpumpi g, out& Cs�nanocofyourrcptia sysbauoouldtesaltiaitsP tobandlewastes.Propermai�r�a= condsts can affect &e function the � C � � years or sooner, if needed a licensed yon pat into the septic tank - u.a � . What system . stage in the waste dislwsal_systcm. . The PtnPaty owner agrees to : dw* to St: Gone Zoning Dot i cagamdon f masterP ] P resedpb tactlumcr oralioeas ed 0 a1 by the ,&Pos and by a is is PR= Operating condition and/or after • that (i) the on�aita Rrasoearata system. (2) inspection and pumping. f if necessary), gm septic tank-is less than I/3 full of sludge. YWC. the undersigned have read the above requhmnents and a t wi &c private sewage disposal system with thee, standards set forth, hcrein. as set by the Department of Commerce and the Department of Natural State 'Of WiSCOnSilL. CCrtifidafi6a stating that your septic system has bcca maintained must be comp leted and returned to the S � County Zoning pace withk 30 days of the three year expiration date. �i�id URE OF � APPU � CANT DATE OWNER. CERTIFICATION the I (we) certify that all statements on this form am true to the best of my (our) knowledge. I (we) am (are) the owner(s) of ProPWY described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE 0 APPLICANT DATE s « « « «« Any information that is mis- rgxmented may result is the sanitary Permit being revoked by the Zoning Department""" «« Include with this application: a stamped warranty deed from the a copy of the certified survey map Regist reference is made in the warranty deed DOCUMENT NO. i, STA BAR OF DEED FORM t I' THIS SPACE RESERVED FOR RECORDIN9 DATA 317936 Amo ....... I. ... Peder ... son ... and - . Kathryn._G.. REGISTERS OFFICE This Deed ma a between ....................... ........... ............ . Pederson, his wife .........................................................................................................._......_ .__....._...................... ST. CROIX CO.. WIS. .._......_ ............................................................................................................ ............................... ... _ .............................. ..................................................................... ..............................I Grantor Rec'd for Record this- - -- and .. Amos P. Pederson - and - Joyce _E. - Pederson. his „wife•,_- - - - -•, day of__Au".vt,.___A.D.19_T3 ............................................ --•--........----•............--•-•-...............-------•--•... .....•--- .....----- ............ L-2- - -- M- ......... ...... ..................................................................... .. . ....................... I Grantee, Witnesseth, That the said Grantor for a valuable consideration ... -... =............ One Dollar - and - other valuable -- consideratlo- - -_- - ” " "" �; .... conveys to Grantee the following described real estate in ....... St....r..raix......... County, State of Wisconsin: RET N TO the South three - hundred (300) feet of the East six - hundred (600) feet of the Northeast Quarter of the Northeast TaxKey # ......................... .------ .------ ._..... Quarter (NE4' of NE) of Section Two (2), Township Thirty This is .................. homestead property. (30) North Range Eighteen (18) West UTANSFER $ S- 010 FEE Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining: And ... Amu .. I a... Eedersan.. and..Kathryn..�...P.esiersnn,.. his.. wif e .................................... ...•-- •__-- ...........- •• -••• -- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except ..... T19 eXCePt1011S ----- ,.......... ............ .......... .... ___ ..._ _..........................................................................---•--•-•---.........................---..........._....................... ............................... ............................................................................ ............................... _. ................................................................................... ............ .................... and will warrant and defend the same. Executed at ...... N.eW3,?:c1M9r d.q... .WiS.S41155 11........ this ..... Mx 4r day of. ........ QU 9 .......................... 19.7 .3 ..... C j ( Z e.- _ ..... ... ..... .......(SEAL) SIGNED AND SEALED IN PRESENCIR OF i'�' ... . t" ...... ... ... ........ ............ ...................... ......... .... . _ Amos I. Pederson ..(SEAL) Kath G. Peders ............................•--........---............... .......................---•--•. ........ .....................••---. ...._......................__.. ......................... ( SEAL) ............................................................... ............................... ( SEAL) Signatures of A!nos . I... Pederson . - and_ Kathryn G. Pederso his - wife, ....-------• ....................._.................._....-•-..........._.......... ..............._....----- _..... ........... - - ............ -- ......- ......- .................. - .... --• . - .........-._.- authenticated this.......... Ra,21th ........................ day of............. A S- --.. ._ ........... -- 9 ti Paul 0. enby '► Gt 4 Title: ther Fa Authorized under Sec. 706.06 viz. NQt ... .......... t an j i STATE OF WISCONSIN St. Croix County Wisconsin " �. � y t ss. My commission expires 10/21/73 ," i