HomeMy WebLinkAbout030-1012-10-000 •
County: St. Croix
Wisconsin Department of Commerce PRIVATE SEW INSPECTION REPORT 53AGE SYSTEM
Safety and Building Division Sanitary Permit No: 0
8762
(ATTACH TO PERMIT) State Plan ID No'.
GENERAL INFORMATION
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Parcel Tax No:
Permit Holder's Name: City Village X Township 030 - 1012 -10 -000
Kath Properties LLC, C/o Christo her Kath St. Joseph, Town of
Section/Town /Range /Map No:
CST BM Elev: Insp. BM Bev: BM Description: 03.29.19.55L
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY HI FS ELEV
Septic
Dosing
Bldg. Sewer
Aeration
St/Ht Inlet
Holding
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Header /Man.
Dosing
Dist. Pipe
Aeration
Bot. System
Holding
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
B Length jinches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
LEACHING
TO DG WELL LAKE /STREAM CHAMBER OR Manufacturer.
ystem: UNIT Model Number:
DISTRIBUTION S YSTEM x Holes Spacing Vent to Air Intake
HeaderlManifold Distribution x Hole Size p g
Pipes)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At- Grade xSSeeded /Soodded xx Mulched
Depth Over =Bed/Trench xx Depth of
Depth Center ges Topsoil Yes No Yes No
/
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / Inspection #2: / / p
Location: 1103 Cty. Rd. A Hudson, WI 54016 (SW 1/4 SE 1/4 3 T29N R19W) metes & bounds Lot
Parcel No: 03.29.19.55E
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? 0 Yes 0 No
Use other side for additional information. Date Insepctor's Signature Cert. No
SBD -6710 (R.3/97)
afe s Division County
commerce.wi.go > 7
201 W. hin�
't ' M dison, Sanitary Permit Number (to be filled in by Co.)
sconsin p n o I � State Transaction Number
Sanitary Permit App ica U ( tat /9X
y36a
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission o this for$ ovemm OWT are Project Address (if different than mailing address)
unit is required prior to obtaining a sanitary permit. Note: Applic ti�>$, �Io Dry
submitted to the Department of Commerce, Personal information yo 1 o
ur oses in accordance with the Privacy Law, s. 15.04 I m Stats.
I. Application Information — Please Print All Information Parcel # e930 — !D 3
Property Owner's Name V 4.?4- i dlz Property Location , Z1 � Property Owner's Mailing Address
' /a
q. Govt. Lot one X
City, State Zip Code Phone Number /o, , Section A
,f (circle
1 Gt O� Sd .r/ LtJ • T a N; R ! I E o
#
II. Type of Building (check all that a Lot S e
El or 2 Family Dwelling - Number of Bedrooms '
Block #
Public /Commercial -Describe Use 9 City of
S �� `C�'/ v v
❑
CSM Number [I Village of - - --
❑StateOwned - DescribeUse
III. 'I'ype of Permit: (Check only one box online A. Complete line B if applicable)
A. stem Replacement System El Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
P
List Prevt us er it Num and aJ� Issu�
Renewal ❑ Permit Revision ❑ Change of Plumber Permit "Transfer to New / f� —
iration Owner
IV. Type o f POWTS S stem /Cora onent/Device: Check all that appl
Non- Pressurized In- Ground 11 Pressurized In- Ground El At-Grade ❑ Mound a 24 in. of suitable soil ❑Mound < 24 in. of suitable soil tiv
o Pretreatment Device (explain) /( a,o Sp,e.
❑ Holding Tank ❑ Other Dispersal Component (explain) f k/ ii GVG g
V. Dis ersal(Tre fitment Area Information: is ersal Area Proposed (sf) System Elevation
Design Flow (gpd) Design Solt Application Rate(gpdsf) Dispersal Area Required (sf) P ✓r✓ �— e Q 4 .R u
yrx L,/ Y y� ` fIca A/ 7,0 e- e-
'total # of Manufacturer
VI. Tank Info Capacity in °
o
Gallons Gallons Units /� � 2� �� w c U r,
New Tanks Existing Tanks
wv
Septic g Tank
Dosing Chan»ber k/ on the
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS P °w RS Numbe Bus ness Phone Number
Plumber's Name (Print) Plumber's Signature
.�
P lumber's Address (Street, City, State, Zip Code)
- d?d S° ci .w�Sa,� GJ <<< Yal
VIII, 'oun Use Onl permit Fee Date Issued Is ng Agent Si nat
Approved El Disapproved g 7 76
❑ Owner Given Reason for Denial
IX. Conditions of Approval/Reasons for Disapproval 3
SYSTEM OWNER:
1 Septic tank, effluent filter and �3, j
3
dispersal cell must all be serviced / maintained CG(
as per management plan provided by plumber.��
ac -t 1 eaa and submit to the County only on parer not les than S l!z x 11 inch ze f
All as per applicable co e/ordinances. ®�� f
SI3D -6398 (R. 02/09) Valid thru 02/11
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Safety and Buildings
3824 N CREEKSIDE LA
commerce.Wl.gov HOLMEN WI 54636
Contact Through Relay
i sco n s i n www.commer isco sin.go /
www.wisconsin.gov
Department of Commerce
Scott Walker, Governor
Paul F. Jadin, Secretary
April 15, 2011
CUST ID No. 227990 ATTN: POWTS Inspector
WILLIAM C SCHUMAKER ZONING OFFICE
SCHUMAKER PLUMBING ST CROIX COUNTY SPIA
1070 SCOTT RD 1101 CARMICHAEL RD
HUDSON WI 54016 HUDSON WI 54016
CONDITIONAL APPROVAL
identifi 1 9 4300 Num bers
PLAN APPROVAL EXPIRES: 04/15/2013
Transaction ID No. 1924300
SITE: Site ID No. 765756
Kath Properties Gas & Convenience Store Please refer to both identification numbers,
1103 County Hwy A above, in all corres ondence with the agency.
Town of Saint Joseph
St Croix County
NWIA, NEIA, S10, T29N, R19W
FOR:
Description: In- ground Non - Pressurized , Gas Station /Convenience Store, ATU
Object Type: POWTS Component Manual Regulated Object ID No.: 1308249
Maintenance required; Replacement system; 2,442 GPD Flow rate; 109 in Soil minimum depth to limiting factor from
original grade;
System: In- ground POWTS Component Manual, SBD- 10705 -P (N.01 /01); Aerobic Treatment Unit, Commercial
System, Effluent Filter
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06,
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
Reminders
• This system is to be constructed and located in accordance with the enclosed approved plans and with the CQndl'nl
component manuals listed above.
• The leaching chambers must be installed in accordance with the manufacturer's printed instructions, the plan M
approval and Comm 83, Wis. Adm. Code system sizing criteria. If there is a conflict between the ,
manufacturer's instructions and the plan approval, the plan approval and code requirements will take fG J
precedence.
• The (Three) SludgeHammer S -86 units must be installed in accordance with the manufacture's printed
instruction and system sizing criteria found in Comm 83, Wis. Adm. Code. If there is a conflict between the
manufacturer's instructions and the plan approval, the plan approval and code requirements will take precedence.
• A maintenance and monitoring contract for the (Three) SludgeHammer S -86 units are required for as long as the
unit is in service.
RF_0F1\ /r INDEX AND TITLE SHEET
Apbb i 1 2011 NON - RESIDENTIAL IN -GROUD POWTS DESIGN
SAFETY BUILDINUS Design based on Component manuals:
In- Ground Soil Absorption Component Manual SBD- 10705 -P (N.01 /01)
Version 2
Project: Burkhardt BP Gas Station & Convenience Store
Contact: Kath Properties, LLC - Chris Kath
Address: 1103 County Highway A
Hudson, WI 54016
Legal Description: NW1 /4NE1/4, Sec.10, T29N, R19W.
Township: St. Joseph County: St. Croix
Subdivision: Na Lot No.: Na
Parcel ID Number: 030 - 1012 -10 -000
Plan Transaction Number: Unknown
Index and Title Sheet Page 1
Site Plan Page 2
Daily Flow & Design Calculations Page 3 & 4
Dose Chamber Cross Section & Pump Page 5
Curve
Distribution Box Cross Section Page 6 tlllty
System Cross Section Page 7 WED
System Management Plan Page 8
SludgeHammer Design Certification Page 9
Attached: Soil Evaluation Report COWMOME
,
;SPONDEN
Designer: Bill Schumaker License Number: 227990
Signature: A/ - Phone No.: (715) 386 -3121
Date: April 5, 2011
co
` Proposed L-D; ess,-
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398 36'
Burkhardt Gas Station & Convenience Store
Kath Properties, LLC
JOB DESCRIPTION: Existing Restaurant to be converted to proposed Gas Station/Convenience Store. No food
preparation or service will take place on site. No automobile service, 6 employees all shifts, 4 floor drains. BOD levels
assumed to be 600 Mg/L.
DAILY FLOW CALCULATIONS:
1. Design Wastewater Flow: 2,442.00 gpd
(500 patrons)(3 gal. /patron) = 1,500.00 gpd
(6 employees all shifts)(13 gal. /employee) = 78.00 gpd
(2 floor drains)(25 gal. / drain) = 50.00 gnd
Estimated wastewater flow = 1,628.00 gpd
(1,628.00 gpd E WF)(150% conversion factor) = 2,442.00gpd Design Flow
ABSORPTION AREA SIZING:
1. Existing grade elevation: 90.33'-97.62'
2. Depth to limiting factor: >154"
3 Proposed system elev.: _86.00', 87.00', 88.00' & 89.00' (see system cross section)
4. Infiltrative capacity of soil at or within 36" of system elevation = 0.5gpd/sq.ft.
5. Absorption area required: 4,844.00 sq. ft.
2,442.00 gpd design flow / 0.5 Gpd = 4,884.00 sq. ft. absorption area required
6. Absorption area proposed: 4,846.40 sq. ft . (240 Infiltrator Q-4 Plus Standard Chambers)
Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end cap (pair) = 5.80 sq.ft, EISA
4,844.00 sq. ft. — (8 pair endcaps)(5.80) = 4,797.60 sq. ft.
4,797.60 sq. ft. required / 20.0 EISA per chamber = 239.88 chambers required
Number of trenches per cell: 8 (a, 30 Infiltrator "O4" standard units each (256 chambers total)
Trench width (A): 2.83'
Trench length (B): 122.00'
Trench spacing: 6.83' on center
System area: 50.64' x 122'
TREATMENT TANK CALCULATIONS:
Manufacturer & Capacity: Two (2) W2000 -MR & One (1) W 1,000 Wieser Concrete septic tanks set in series
1. Design wastewater flow = 2,442.00gpd
2,442.00gpd / 75 gpd = 32.56 gpd person equivalency
2. Minimum required capacity: 4,721 Gallons
(2,442.00gpd) + (11.61 x 32.56 x 2 *) + (46.77 x 32.56) = 4,720.88
*(Requires a two year maintenance cycle)
3. Proposed Capacity & Manufacturer: Two 2) W2500 -MR Wieser Concrete septic tanks in series
Actual capacity = 5,044.92 gallons
4. Baffle at outlet of first and second septic tank, PolyLok PL -625 effluent filter at outlet of third tank.
Pg. 3 of 9
AERATION TREATMENT APPARATUS CALCULATIONS:
Manufacturer & Cqpacity: SludgeHammer S -86 designed to remove 3.0 - 6.0 Lbs BOD /day.
BOD: Assumed to be at or below 600 Mg/L with daily flow of 2,442.00 GPD = 12.22 lbs. BOD to be removed/day.
Installation: Three (3) SludgeHammer S -86 units placed below outlet of first 2,000 gal. septic tanks and
beneath inlet and outlet of second 2,000 gal. septic tank.
DOSE CHAMBER CAPACITY & DOSE VOLUME CALCULATIONS:
Manufacturer & Capacity: Wieser Concrete W3000 -MR (51.00" @ 58.94 gal. /inch = 3,005.94 gal. actual)
1. Force Main:
Diameter 2"
Length 225'
Flow rate 37.50 gal. /min. estimated
Friction loss 6.615 ft. (225')(2.94ft./100ft.)
2. Total dynamic head:
Min. supply pressure 0.00'
Vertical lift 15.75' ( elev. (a ) invert of distribution box inlet = 93.00' ±)
friction loss 6.62'
Total dynamic head = 22.37'
3. Pump selection:
Manufacturer: Zoeller
Model number: BN 152
Min. discharge rate required: no required minimum gpm
Pump discharge: 39.00± gpm @ 22.50' TDH
4. Pump Chamber Calculations:
A) 24 Hr. holding capacity: 31.00" = 1,827.14 Qal.
B) Alarm setting: 2.00" = 117.88 gal.
C) Dose volume + flow back: 6.00" = 353.64 gal.
(1,628.00 gal. /5 doses per day) + (.163)(225') = 325.60 + 36.68 = 362.28 gal. maximum dose
D) Reserve storage: 12.00" = 707.28 gal.
TOTAL: 51.00" = 3,005.94gal.
5. Fluid Flow Calculations:
Effluent velocity = (408)(39 gpm) = 3.978 gpm (flow through PVC pipe to be 2 - 10 ft. /sec.)
4
EQUALIZED EFFLUENT DISTRIBUTION:
1. Distribution box to be installed to equally distribute effluent to all trenches. See distribution box cross section and
detail at page 6.
2. Gravel or other synthetic material to be placed below distribution chamber inlet to dissipate energy of effluent as it
enters trench to prevent scouring of native soil.
Pg. 4 of 9
Dose Tank Information Locking cover with warning
label and locking device and
1e / sealed watertight
Electrical as per NEC 300 and -♦
Comm 16.28 WAC 4 in. min.
Disconnect
Tank component is properly vented L E- Alternate outlet
location
Forcemain diameter
Wieser W3000 -MR Manufacturer 2 in.
Capacity] 3005.94 Gallons T
Volume 58.94 gal /inch A
Weep hole or anti -
Dimension Inches Gallons B siphon device
A 31.00 1827.38
B 2.00 117.88 C P ump off elevation (ft)
C 6.00 353.40 76.00
D 12.00 707.28 D
Total 7 51.00 3005.94
Do se tank elevation (ft)
3" Bedding uncTer tank. 75.00
Alarm Manuafacturer Sj Rhombus
Alarm Model Number SJE 1011421
Pump Manufacturer Zoeller
Pump Model Number BN 152
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
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® Copyright 2004 Zoeller Co. Adl rights reserved.
di PUMP PERFORMANCE CURVE MODEL 151/152/153 TOTAL DYNAMIC HEAD /FLOW
PER MINUTE
14 K 153 EFFLUENT AND DEWATERING
2 \\ MODEL 151 152 153
s 35 152 Feel Meters Gal. Uters Gal. Uters Gal. Ulan
= 10
5 1.5 50 189 69 261 77 291
10 3.0 45 170 61 231 70 265
,2-2. 37 6 25 151 15 4.6 38 144 53 201 61 231
5 20 6.1 1 29 110 44 167 52 197
e 20 25 7.6 18 61 34 129 42 159
30 9.1 - 23 1 87 33 125
15 35 10.7 -- - 22 1 85
40 12.2 - - -- 11 42
0
Shut -o6 Head: 30 ft. (9.1m) 38 ft. (I 1.8m) 44 fl. (13.4m)
2
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° 715- 248 -7767 800- 325 -8456 FILE: custom boxes 2011 CE Sols custom dbt box Bill Schumakar
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Management Plan
"AT- Risk" high strength waste
Pursuant to Comm 83.54, Wis. Adm. Code
General
The Dose - Conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be
maintained in accordance with component manual SBD- 10705 -P (N.01/01). All local and /or state rules pertaining to system
monitoring and maintenance shall be complied with. The sewage effluent generated at this site could potentially exceed high
strength effluent concentration levels as established by the Wisc. Dep't. of Commerce. Influent entering the dispersal
component of the POWTS must fall within a range of 30Mg/L - 220mg/L BOD5, 30Mg/1 - 150 MG /L TSS, and less than
30 mg /1- FOG. Influent flow may not exceed maximum design flow specified in the system design and sanitary permit.
Septic Tank
No individual should ever enter a septic tanks or pump tank as dangerous gases may be present that could cause death.
Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tanks are no longer used as
POWTS components. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and
soundness. Exposed access openings shall be secured by an effective locking device to prevent accidental or unauthorized
entry into a tank or component. The operating condition of the septic tanks and outlet filter shall be assessed at least once
every year by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the
liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code,
by an individual certified to service septic tanks under s. 28 1.48, Stats. If the contents of the tank are not removed at the time
of the annual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than
1 i3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. If
the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. The addition of biological or chemical
additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for
septic tank use by the Department of Commerce, Safety and Buildings Division.
Dispersal Cell
The dispersal cell shall be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection.
Traffic (other than for vegetative maintenance) on the dispersal cell is not recommended. The installing plumber or other
properly credentialed service provider shall check for effluent ponding annually. Levels above 4" indicate an impending
hydraulic failure. Ponding levels of 4" or more will require biannual monitoring. Ponding levels of 6" of greater for two
consecutive monitoring periods will require testing of effluent strength. Samples will be collected at 8 - 12 day intervals for a
period of 30 days with a total of 3 samples collected & submitted for analysis of BODS, TSS & FOG.
Continp_ency Plan
If effluent concentration levels are found to exceed Dep't. of Commerce standards as enumerated above, additional
SludgeHammer components will be installed. Effluent quality will again be assessed with samples collected at 4 -6 day
intervals for a period of 30 days with a total of 6 samples collected & submitted for analysis of BOD5, TSS & FOG. The first
sample collected at 45 days after system start up. Results of testing will be submitted to the County Zoning Dep't. System
monitoring will then revert to original plan. If effluent concentrations are found to be within the standards enumerated above
and the dispersal cell hydraulically fails, it will be replaced with a code compliant dispersal cell as identified on the soil and
site evaluation form. A diversion valve will be installed to allow future re -use of the failed cell.
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the
system in proper operating condition. If the aeration unit, dosing tank, pump, pump controls, alarm or related wiring become
defective the defective component shall be immediately repaired or replaced with a component of the same or equal
performance.
Questions on system operation or maintenance should be directed to the Installing Plumber or County Zoning Inspector.
Pg. 8 of 9
SludgeHammer 336 S. Division Road Group ltd.
Petoskey, MI 49770
Ph: 1.231.348.5886
Toll Free: 1.800.426.3349
Fax: 1.720.834.3102
www.SludgeHammer.net
April 5, 2011
Sirs:
As T chnlcal Director and President of SludgeHammer Group Ltd. I certify that the
Slu geHammer® device, when applied using standard engineering calculations for aerobic
,digestion as outlined in the USEPA Manual of Practice for Activated Sludge Treatment is
capable of reducing BOD to the desired amount in the application described in this permit
request.
While the SludgeHammer S -86 model is certified in Wisconsin for "residential' waste, it qualified
for certification with data demonstrating the capability of reducing BOD in large single family
homes from approximately 300 mg /l to less than 30 mg /l, a reduction of greater than 90 %. The
nature of the organic waste, in the permit request, is such that there is no reason to expect that
digestion will be any less effective than with standard residential waste.
Design estimations at the Kath Properties, LLC site indicate the potential generation of
approximately 12.2 Ibs of total BOD per day. A standard S -86 unit aerates at a sufficient rate to
degrade approximately 4 lb of BOD per day. Thus, three (3) S -86 units would be capable of
reducing the proposed effluent from 600 mg /L to less than 200 mg /L.
The plan will incorporate three S -86 SludgeHammer units in the treatment train, more than
adequate for the above treatment goals.
We hereby request the State of Wisconsin give us permission to install the SludgeHammer S -86
units as part of an engineered design for the system described in this permit request.
Respectfully,
Dr. Daniel Wickham
Technical Director and President
0{'9
2239
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of 4
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations
Attach complete site plan on paper not less than 8%: x 11 inches in size. Plan must County St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and —
percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D.
030 - 1012 - - 000
Please print all information. Reviewed By Date
Personal information you provide may be used fors d purpo (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
GB Curley's / Chris Kath O T Govt. Lot NW 1/4 N E 1/4 S 10 T 29 NR 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1103 Co. Hwy A
City State Zip Code Phone Number _f City Village J Town Nearest Road
Hudson WI 1 54016 1 715 - 549 -5499 St.Joseph I Co. Hwy A
New Construction Use: J Residential / Number of bedrooms Code derived design flow rate 1678 GPD
✓� Replacement ✓J Public or commercial - Describe: station & Convenience store
Parent material Glacial Outwash Flood plain elevation, if applicable na
General comments
and recommendations: Site suitable for in- ground POWTS wit�erminecl d loading rate. Trenches to be installed at approx. 48"
60" below grad - exact elevations to by designer. > 3 r"0,4 �ed�
Boring # —I Boring
✓J Pit Ground Surface elev. 91.88 ft. Depth to limiting factor >109" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAI
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -17 1Oyr3/3 none sil 2fsbk mvfr as 2fmc 0.6 0.8
2 17 -31 1Oyr4/6 none sil 2fsbk mfr cw 2fmlc 0.6 0.8
3 31-48 1 Oyr4 /4 none Ifs Osg ml aw 1 vf,f 0.5 1.0
4 48 -51 7.5yr4/6 none Ifs Osg ml aw 1vf,f 0.5 1
5 ! 51 -96 1Oyr4/6 none Ifs Osg ml cw lvf,f 0.5 1.0
6 96 -109 10 r4/4 none gr s Osg ml - - 0.7 1.6
F�l Boring # —I Boring
✓J Pit Ground Surface elev. 90.33 ft. Depth to limiting factor >110" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 - Eff#2
1 0 -22 1 Oyr3 /3 none sil 2fsbk mvfr as 2fl m 0.6 0.8
2 22 -36 1Oyr4/6 none sil 2fsbk mfr cw lfm 0.6 0.8
3 136 -51 7.5yr4/6 none Ifs Osg ml aw 1 of 0.5 1.0
4 51 -58 10yr4/6 none s Osg ml aw - 0.7 1.6
5 58 -74 1Oyr4/4 none Ifs Osg ml cw - 0.5 1.0
6 74 -110 1 Oyr5 /4 none gr s Osg ml - 0.7 1.6
' Effluent #1 = BOD? 30 < 220 mg /L e nd TSS >30 < 1 0 mg /L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
CST Name (Please Print) Signatu CST Number
James K. Thompson 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola, WI 54020 3/4/2011 715- 248 -7767
Property Owner GB Curley's / Chris Kath Parcel ID # 030 - 1012 -10 -000 Page 2 of 4
37 Boring # J Boring
0 Pit Ground Surface elev. 97.62 ft. Depth to limiting factor >154" in.
Soil Application Rate
Horizon I Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -8 10yr3/3 none sil 2fsbk mvfr as 2f1 m 0.6 0.8
2 8 -24 10yr4/6 none gr Is Osg ml cw 1fm 0.7 1.6
3 24 -60 10yr4/6 none gr s Osg ml aw - 0.7 1.6
4 60 -120 7.5yr4/6 none gr s Osg ml aw - 0.7 1.6
5 120 -154 10yr4/6 none fs Osg ml - - 0.5 1.0
a Boring # Boring
1/ Pit Ground Surface elev. 85.36 ft. Depth to limiting factor 88" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -14 10yr3/2 none sil 2fsbk mvfr gs 2fmc 0.6 0.8
2 14 -36 10yr4/4 none sicl 2msbk mfr cw 1fmc 0.4 0.6
3 36-49 10yr4/6 none Is Osg ml gw 1fm 0.5 1.0
4 49 -88 10yr5/6 none Is Osg ml ci 1f 0.5 1.0
5 88 -107 10yr6/2 m3p 7.5yr5/8 3S Resid na na - - na na
Horizons #3 8 4 contain thin bands of 10yr4/4 IN and have a high percntage of fines throughout horizons. Loading rates reduced to reflect
anticipated reduction in permiability. H #5 consists of weathered in place sand stone residuim.
Boring # Boring
16 Pit Ground Surface elev. 83.73 ft. Depth to limiting factor 84" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -20 10yr3/2 none sil 2fsbk mvfr g 2fmc 0.6 0.8
2 20 -36 10yr4/4 none sl 2msbk mfr cw 1fmc 0.6 1.0
3 36 -52 10yr4/6 none Is Osg ml gw 1fm 0.5 1.0
4 52 -84 10yr5/6 none Is Osg ml ci 1f 0.5 1.0
5 84 -106 10yr5/8 none LSBR na na - - na na
Horizons #3 8 4 contain thin bands of 10yr414 Ifs and have a high percntage of fines throughout horizons. Loading rates reduced to reflect
anticipated reduction in permiability. H #5 consists of >50% fractured LS, voids filled with 10yr4/4 Is, fs, & s.
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD -S.30 mg /L and TSS < 30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (R.07 /00)
A.C.E. Sal &Site Evaluations
Property Owner GB Curley's / Chris Kath
FIS Parcel ID # 030 - 1012 -10 -000 Page 3 of 4
Boring # J Boring
✓l Pit Ground Surface elev. 83.88 ft. Depth to limiting factor 82" Depth in.
Horizon Dominant Color Re Soil Application Rate
dox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Si! . Cont. Color Gr. Sz. Sh. *Eff#1 Eff#2
[ —� 0 -17 10yr3/2 none sil 2fsbk mvfr cs 2fm,1 c 0.6 0.8
—j 2 17 -39 1 Oyr4 /4 none scl 2msbk mfr cw 2fm,1 c 0.4 0.6
3 39 -69 1Oyr4/6 none Is Osg ml gw 1fm 0.5 1.0
4 69 -82 1Oyr5/6 none s Osg ml ci -
0.5 1.0
5 82 -102 1Oyr5/8 none LSBR na na
- - na na
Horizons #3 & 4 contain thin bands of 10yr4/4 Ifs and have a high percntage of fines throughout horizons. Loading rates reduced to reflect
anticipated reduction in permiability. H #5 consists of fractured LS, voids filled with 10yr4/4 Is, fs, & s.
77 BBoring # J Boring
N Pit Ground Surface elev. 83.76 ft. Depth to limiting factor 106" in.
H Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots p
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -17 1Oyr4/3 none sl 2fsbk mvfr gs 2fnnc 0.6 0.8
2 17 -41 7.5yr4/6 none scl 2msbk mfr cw 1fmc 0.4 0.6
3 41 -50 7.5yr4/6 none Is Osg ml gw 1fm 0.5 1.0
4 50 -72 7.5yr4/6 none s & gr Osg ml gw 1f 0.5 1.0
5 72 -106 10yr5/6 none s & gr Osg ml ci -
0.5 1.0
6 106 -128 10yr6/2 m3p 7.5yr5/8 3S Resid Osg mi - _
na na
Horizons #4 & 5 contain thin bands of 10yr4/4 Ifs and have a high percntage of fines throughout horizons. Loading rates reduced to reflect
anticipated reduction in permiability. H#6 consists of weathered in place sand stone residuim.
❑ Boring # J Boring
1 Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in, Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 Eff#2
Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (R.07/00)
A.C.E. Sal & Site Evaluations
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MAY IU ORIGINAL 2239
Wisconsin Department of Co merce 3 /0l SO L EVALUATION REPOR Page 1 of 4
Division of Safety and Buildi Sl CMG /Atr dance wi Comm 85, Wis. Ad T, A.C.E. Soil &Site Evaluations
�N�V/NG & ZON rY o
Attach complete site plan on paper no : Q n size. Plan muse un tY St. Croix
include, but not limited to: vertical and horizontal re a (BM), direction an
percent slope, scale or dimemsions, north arrow, and location and distance to rest road. Parcel I.D.
Please print all information. 1012 -10 -000
Rev i wed By Date
Personal information you provide may be-used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). U& S /
3 �
Property Owner Property Location �.3 f � 24. N , � 1
GB Curley's / Chris Kath Govt. Lot NW 1/4 N 1/4 S 10 T 29 N R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1103 Co. Hwy A
City State Zip Code Phone Number _j City J Village a Town Nearest Road
Hudson WI 1 54016 1 715 -549 -5499 St.Joseph I Co. Hwy A
J New Construction Use: J Residential / Number of bedrooms Code derived design flow rate 1678 GPD
✓f Replacement a Public or commercial - Describe: station & Convenience store
Parent material Glacial Outwash Flood plain elevation, if applicable na
General comments i 1
and recommendations: Site suitable for in- ground POWTS with 0.5 d loading rate. Trenches to be installed at appr 48" -
60" below gra de - exact elevations to be etermined b desi n r :r� 3 (p rr
1 Boring # J Boring
N Pit Ground Surface elev. 91.88 ft. >109" in. Soil Application Rate
Depth to limiting factor pp l
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 *Eff#2
1 0 -17 1Oyr3/3 none sil 2fsbk mvfr as 2fmc 0.6 0.8
2 17 -31 10yr4/6 none sil 2fsbk mfr cw 2fm1c 0.6 0.8
3 31-48 1Oyr4/4 none Ifs Osg ml aw lvf,f 0.5 1.0
4 48 -51 7.5yr4/6 none Ifs Osg ml aw lvf,f 0.5 1.0
5 51 -96 1Oyr4/6 none Ifs Osg ml cw 1vf,f 0.5 1.0
6 96 -109 1 Oyr4 /4 none gr s Osg ml - - 0.7 1.6
Boring # J Boring
0 Pit Ground Surface elev. 90.33 ft. Depth to limiting factor >110" in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2
1 0 -22 1 Oyr3 /3 none sil 2fsbk mvfr as 2fl m 0.6 0.8
2 22 -36 1Oyr4/6 none sil 2fsbk mfr cw 1fm 0.6 0.8
3 36-51 7.5yr4/6 none Ifs Osg ml aw 1vf 0.5 1.0
4 51 -58 1Oyr4/6 none s Osg ml aw - 0.7 1.6
5 58 -74 1Oyr4/4 none Ifs Osg ml cw - 0.5 1.0
6 74 -110 1 Oyr5 /4 none gr s Osg ml - - 0.7 1.6
*Effluent #1 = BOD 30 < 220 mg /Lan TSS >30 < 150 mg /L ' Effluent #2 = BOD S30 mg /L and TSS < 30 mg /L
CST Name (Please Print) Signet re: CST Number
James K. Thompson %_ 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola, WI 54020 3/4/2011 715 - 248 -7767
Property Owner GB Curley's / Chris Kath Parcel ID # 030 - 1012 -10 -000 Page 2 of 4
a Boring # Boring
ej Pit Ground Surface elev. 97.62 ft. Depth to limiting factor >154" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -8 10yr3/3 none sil 2fsbk mvfr as 2fl m 0.6 0.8
2 8 -24 10yr4/6 none gr Is Osg ml cw 1fm 0.7 1.6
3 24 -60 10yr4/6 none gr s Osg ml aw - 0.7 1.6
4 60 -120 7.5yr4/6 none gr s Osg ml aw - 0.7 1.6
5 120 -154 10yr4/6 none fs Osg ml - - 0.5 1.0
4] Boring # Boring
Pit Ground Surface elev. 85.36 ft. Depth to limiting factor 88" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rood PD
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -14 10yr3/2 none sil 2fsbk mvfr gs 2fmc 0.6 0.8
2 14 -36 10yr4/4 none sicl 2msbk mfr cw 1fmc 0.4 0.6
3 36 -49 10yr4/6 none Is Osg ml gw 1fm 0.5 1.0
4 49 -88 10yr5/6 none Is Osg ml ci 1f 0.5 1.0
5 88 -107 10yr6/2 m3p 7.5yr5/8 3S Resid na na - - na na
Horizons #3 & 4 contain thin bands of 10yr4/4 Ifs and have a high percntage of fines throughout horizons. Loading rates reduced to reflect
anticipated reduction in permiability. H #5 consists of weathered in place sand stone residuim.
F-5� Boring # Boring
f Pit Ground Surface elev. 83.73 ft. Depth to limiting factor 84" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rood P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -20 10yr3/2 none sil 2fsbk mvfr gs 2fmc 0.6 0.8
2 20 -36 10yr4/4 none sl 2msbk mfr cw lfmc 0.6 1.0
3 36 -52 10yr4/6 none Is Osg ml gw 1fm 0.5 1.0
4 52 -84 10yr5/6 none Is Osg ml ci 1f 0.5 1.0
5 84 -106 10yr5/8 none LSBR na na - - na na
Horizons #3 & 4 contain thin bands of 10yr4/4 Ifs and have a high percntage of fines throughout horizons. Loading rates reduced to reflect
anticipated reduction in permiability. H #5 consists of >50% fractured LS, voids filled with 10yr4/4 Is, fs, & s.
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg /L and TSS <30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (R.07 /00) A.C.E. Sal & Site Evaluations
Property Owner GB Curley's / Chris Kath Parcel ID # 030 - 1012 -10 -000 Page 3 of 4
6] Boring # J Boring
VJ Pit Ground Surface elev. 83.88 fl. Depth to limiting factor 82" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots QPD1ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -17 1 Oyr3 /2 none sil 2fsbk mvfr Cs 2fm,1 c 0.6 0.8
2 17 -39 1Oyr4/4 none scl 2msbk mfr cw 2fm,1c 0.4 0.6
3 - ' 4 9 b 1Oyr4/6 none Is Osg ml gw 1fm 0.5 1.0
4 69 -82 1Oyr5/6 none s Osg ml ci - 0.5 1.0
5 82 -102 1Oyr5/8 none LSBR na na - - na na
Horizons #3 & 4 contain thin bands of 10yr4/4 Ifs and have a high percntage of fines throughout horizons. Loading rates reduced to reflect
anticipated reduction in permiability. H #5 consists of fractured LS, voids filled with 10yr4/4 Is, fs, & s.
7] Boring # J Boring
/f Pit Ground Surface elev. 83.76 ft. Depth to limiting factor 106" in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -17 1Oyr4/3 none sl 2fsbk mvfr gs 2fmc 0.6 0.8
2 17-41 7.5yr4/6 none scl 2msbk mfr cw 1fmc 0.4 0.6
3 41 -50 7.5yr4/6 none Is Osg ml gw 1fm 0.5 1.0
4 50 -72 7.5yr4/6 none s & gr Osg ml gw 1f 0.5 1.0
5 72 -106 1 Oyr5 /6 none s & gr Osg ml ci - 0.5 1.0
6 106 -128 1Oyr6/2 m3p 7.5yr5/8 3S Resid Osg ml - - na na
Horizons #4 & 5 contain thin bands of 10yr4/4 Ifs and have a high percntage of fines throughout horizons. Loading rates reduced to reflect
anticipated reduction in permiability. H#6 consists of weathered in place sand stone residuim.
F-1 Boring # - Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDjft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS <30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777.
SBD -8330 (R.07 /00) A.C.E. Soil & Site Evaluations
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State Bar of Wisconsin Form 1 -2003 8 0 1 8 4 4 7
WARRANTY DEED Tx: 4014110
931233
Document Number Document Name BETH PABST
REGISTER OF DEEDS
ST. CROIX CO., WI
THIS DEED, made between GB Curleys Restaurant, Inc. 01/26/2011 2: 3 0 PM
EXEMPT #: N/A
REC FEE: 30.00
( "Grantor," whether one or more), and Kath Properties, LLC TRANS FEE: 1275.00
PAGES: 1
( "Grantee," whether one or more).
Grantor for a valuable consideration, conveys to Grantee the following described real Recording Area
estate, together with the rents, profits, fixtures and other appurtenant interests, in Name and Return Address
St. Croix County, State of Wisconsin ( "Property ") (if more space is Commonwealth Land Title Insur. Co.
needed, please attach addendum): Attn: Recording - File No. 230628
Part of SW' /a of SE' /a of Section 3, and Part of NW t/a of NE t/a of Section 10, all in 222 S. Ninth Street, Suite 3060
Township 29 North, Range 19 West, St. Croix County, Wisconsin described as Minneapolis, MN 55402
follows:
Starting at the intersection of County Trunk "A" and the N -S town road on the E 030 - 1012 -10 -000 & 030- 1035- 80 -000
quarter line of said SW t/4 of SE t/4 of Section 3; thence S along the center line of Parcel Identification Nurnber (PIN)
said town road 450 feet; thence due W 531.5 feet to an existing fence which This is not homestead property.
represents the E boundary of existing lots. Thence N along said lot -line existing OA (i not)
fence to the center line of County Trunk "A ", thence Ely along the center line of
said County Trunk "A" to the point of beginning.
Grantor warrants that the title to the Property is good, indefeasible, in fee simple and free and clear of encumbrances except:
casement, restrictions and covanentes of record.
Dated January 26, 2011 GB Curleys Resta ant, Inc.
(SEAL) C (SEAL)
*
*By: Mark Hanson, President
(SEAL) (SEAL)
*
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF Wisconsin )
) ss.
authenticated on St. Croix COUNTY)
Personally came before me on January 26, 2011
* the above -named GB Gurleys Restaurant, Inc.
TITLE: MEMBER STATE BAR OF WISCONSIN by Mark Hanson, resident
(If not, to me known to e th ���(I��i(s) who executed the foregoing
authorized by Wis. Stat. § 706.06) ins ment We.
0
THIS INSTRUMENT DRAFTED BY:
Heywood, Cari & Anderson, S.C., Sam Cari Notary Public, Mate okl'Q%pnsin
P.O. Box 125, Hudson, WI 54016 My commissiorG(j,� `�pirs:? 9 t )
.. . p
9. . -.�
(Signatures may be authenticated or acknowledged. Both afe not neces aryl � �Z
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM 5I}OU,I D liE C � IDEN TIFIED.
WARRANTY DEED 02003 STATE BAR OF WISCONSIN ''t���� OF o � FORM NO. 1- 2003
*Type name below signatures. 14fw Loyal Forms • (800)655-2021 • intoprolorms.com
1 of 1
Parcel #: 030 - 1012 -10 -000 05/03/2011 E 1 PM
• PAGE 1 OF 1
Alt. Parcel M 03.29.19.55L 030 - TOWN OF SAINT JOSEPH
Current IX-1 ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
0 - KATH PROPERTIES LLC
KATH PROPERTIES LLC
568 WHITE OAK LN
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): " = Primary
Type Dist # Description ' 1103 CTY RD A
SC 2611 SCH DIST OF HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE
SEC 3 T29N R19W PT SW SE SEC 3 & NW NE Block /Condo Bldg:
SEC 10 COM INT CO HWY "A" & E LN SW SE, Sec Twn -Rn 40 1/4 160 1/4)
S 450 FT, W 531.5 FT TO FENCE, N ALG Tract(s): ( 9
FENCE TO CL HWY A, TH E ALG CL TO POB AS 03- 29N -19W
DESC IN VOL 482/499 ASSESSED WITH P1 20G
Notes: Parcel History:
Date Doc # Vol /Page Type
01/26/2011 931233 WD
01/10/2006 816090 WD
07/06/1999 606294 1439/551 QC
07/06/1999 606293 1439/547 TI
more...
2011 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/07/2004
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 0.000 199,300 214,300 413,600 NO
Totals for 2011:
General Property 0.000 199,300 214,300 413,600
Woodland 0.000 0
Totals for 2010:
General Property 0.000 199,300 214,300 413,600
Woodland 0.000 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
s
' Parcel #: 030 - 1035 -80 -000 05/03/2011 04 14 PM
PAGE 1 OF 1
Alt. Parcel #: 10.29.19.120G 030 - TOWN OF SAINT JOSEPH
Current 1X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
KATH PROPERTIES LLC O - KATH PROPERTIES LLC
568 WHITE OAK LN
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description
SC 2611 SCH DIST OF HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE
SEC 10 T29N R19W PT NW NE SEC 10 & PT SW Block /Condo Bldg:
SE 3 AS IN VOL 482 PAGE 499
SSESSED WITH P5 Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
10- 29N -19W
Notes: Parcel History:
Date Doc # Vol /Page Type
01/26/2011 931233 WD
01/10/2006 816090 WD
07/06/1999 606294 1439/551 QC
07/06/1999 606293 1439/547 TI
more
2011 SUMMARY Bill M Fair Market Value: Assessed with:
0 030 - 1012 -10 -000
Valuations: Last Changed:
Description Class Acres Land Improve Total State Reason
Totals for 2011:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2010:
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
Document Number Document Title 8 0 2 7 1 5 6
r.
Tx: 4019178
St. Croix County
AEROBIC TREATMENT UNIT (ATU) 935773
BETH PABST
SERVICING AGREEMENT REGISTER OF DEEDS
ST. CROIX CO., WI
State Plan Transaction Number - 1924300 RECEIVED FOR RECORD
05/04/2011 11:58 AM
K Q ; c { -F1 e s
L L L , EXEMPT #:
Name — (Owner) Typed or printed REC FEE: 30.00
Being duly sworn, states, under oath, that: PAGES: 1
He /she is the owner /part owner of the following parcel of land located in
St. Croix County, Wisconsin, recorded in Volume — Page
Document Number 932133 St. Croix County Register of Deeds Office: Recording Area
A parcel of land located in the SW '/4 of the SE '/4 of Section 3, and NW '/4 of the Name and Return Address
NE' /4 of Section 10, all in T 29 N — R 19 W, Town of St. Joseph, St. Croix County, Chris Kath
Kath Properties LLC
Wisconsin, being duly described as follows (include lot no. and subdivision /CSM or 1106 Cty. Rd. A
detailed legal description): Hudson, WI 54016
Starting at the intersection of County Trunk "A" and the N -S town road oil the E 030 - 1012 - 10 - 000 & 030.1035 - 80 - 000
quarter line of said SW '/4 of SE 1 /4 of Section 3; thence S along the center line of --
said town road 450 feet; thence due W 531.5 feet to an existing fence which Parcel Identification Number (PIN)
represents the E boundary of existing lots. Thence N along said lot -line existing
fence to the center line of County Trunk "A:, thence Ely along the center line of
said County Trunk "A" to the point of beginning.
Agreement Date: 5 _ y ,2o 1
As an inducement to the county to issue a sanitary permit for a POWTS equipped with an Aerobic Treatment Unit on the above - described properly
we agree to do the following:
1. Owner agrees to conform to all applicable requirements of Comm 83, Wis. Adm. Code relating to Aerobic Treatment Units (ATU) and f�)e
maintenance requirements for the proposed POWTS (Private Onsite Wastewater Treatment System) technology. If the owner fails to have
the POWTS and ATU properly serviced in response to orders issued by the governmental unit or the Department of Commerce to prevent or
abate a human health hazard as described in s. 254.59, Stats., the governmental unit (St. Croix County) may enter upon the property and
service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment
for current services rendered. The charges will be assessed as prescribed by s. 66.0703. Stats.
2. The owner agrees to maintain a contract with a licensed POWTS maintainer for the life of the system. The POWTS maintainer wiu perform
periodic inspections and maintenance as required by the manufacturer and the Department, including, but not limited to: the blower, electrical
controls, and treatment unit operation and sludge depth. These inspections are to be scheduled every 6 months for the first two years of
operation and yearly thereafter.
3. The owner agrees to contact the POWTS maintainer immediately upon any malfunction of the treatment unit and to maintain the unit so as to
not create a human health hazard as described in s. 254.59. Stalls.
4. The owner recognizes that the county, Department of Commerce, or POWTS maintainer may make periodic inspections of the components
to complete performance monitoring of the unit.
5. The owner or the owner's agent agrees to report to the department or designated agent at the completion of each inspection, maintenance or
servicing event in a manner specified by the department or designated agent within 10 business days from the date of inspection
maintenance or servicing.
6. This agreement will remain in effect only until the county office responsible for the regulation of POWTS certifies that the aerobic ueafnie
unit no longer serves the property. In addition, this agreement may be cancelled by executing and recording said certification with rererence
to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property
7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreemen
to the Register of Deeds, and the agreement shall be recorded in a manner that will permit the existence of the agreement to be determ red
by reference to the property where the Aerobic Treatment Unit is installed.
Owner(s) Name(s) - Please Print Subscribed and sworn to before me on this date.
Lo
Notar(Zed Owners Signature(s) Notary Plic
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.COMMERCIAL TESTING LABORATORY, INC. Nor
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715 - 962 -3121
800 - 962 - 5227 C:
ST. CROIX ZONING REPORT NO.; 0334 PAGE 1
ST. CROIX COUNTY REPORT DATE; 3/30/90
COURTHOUSE DATE RECEIVED; 3 /28/90
HUDSON, WI 54016
ATTN; THOMAS C. NELSON 6 1,9 —
i
30 /a 10
OWNER; RutJen--) Ile
LOCATION; Rtd. A Hudson
COLLECTOR; M.
SOURCE OF SAMPL E; Bar faucet
COLIFORM; 0 /100 ml
INTERPRETATION; BacterioLogicaLLy SAFE
NITRATE -N; 3 ppm
Under 10 ppm is safe for human consumption.
CoLiform Bacteria /100 mL
Nitrate - Nitrogen, mg/L
LAB TECHNICIAN; Pam Gane
WI Approved Lab No. 19
.OF .NDEOEMDE ryr
J� O
z ° ( Means "LESS THAN" Detectable Levet Approved by;
�� o PROFESSIONAL LABORATORY SERVICES SINCE 1952
z
Na-
0 ST. CROIX COUNTY ZONING OFFICE 1 C
St. Croix County courthouse
a V 911 4th Street
Hudson, WI 54016
U st. Croi Y
Telephone - (715)386
f
The .
C ount y
Zoning office offers the service of sep i
and water inspections to Lending Institutions, Realty Firms, an
private individuals.
An be_
OU2 et 3 on of this form
- esee.,t; Al so that the r�roDerty c
x.
i oca%ed •
enclose appropriate
Please provide the following information, e office, and mail,
!ea made payable to St. Croix Count Zoning will be done as
along with form to the above a ddress
soon as possible after fee and form are received.
WATER TESTING-- -
----------------- - - - - -- -FEE: $ 25.00
(For nitrates and coliform bacteria) FEE: $175.00 _
WATER TESTING
(For VOCfS) FEE. $28.00
SEPTIC SYSTEM INSPECTION------- --- - -- _ - :
(Determines if system is properly functioning at t me of
inspection) SJ
Property owners name ;: E 6_
Property owner's address .1 of Sect on
Legal Descript on _1/4 of the 1/
Town of Lot Number Subdivision Name
1rTRR EMMER rN+r AAY 1ft1MB�A'R _
Color of house Realty sign by house ?_ If so, list firm:
PLEASE INCLVDB, IF AT 0 � POSS A LIST SHEE
F PLAT BOOK,
WITH LOCATION SHOWN, AN
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary.
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services:
Telephone Number a
REPORT TO BE SEpT TO:
2 06 -
Closing date
Signature
Y ' c ST. CROIX COUNTY
t.+k WISCONSIN
• T fir.
ZONING OFFICE
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
(715) 386 -4680
March 28, 1990
David Anderson
706 19th Ave. S.
Hudson, WI 54016
Dear Mr. Anderson:
An on site investigation of the septic system on the property at
Rt.2, County Road A, Hudson, Wisconsin was conducted on March 27,
1990. At the same time I also obtained a water sample and
submitted it to the laboratory for testing. The results of that
testing will be sent to you as soon as we receive them back from
the laboratory.
At the time of the inspection, the sanitary system appeared to be
function properly for the existing use. It was observed however,
that one of the vent pipes was lying on the ground, and more than
one vent pipe did not have an approved vent cap. Please contact
a plumber licensed in the state of Wisconsin to make these
corrections.
The inspection of this sewage disposal system was based upon a
surface inspection of said system and did not involve any
excavating or chemical analysis. Accordingly, there is the
possibility of hidden defects in the system not discoverable by
this inspection. This does not in any way warrant or guarantee
the continued proper functioning or operation of this system. It
is recommended that the system should be pumped once every three
years. Therefore, the prolonged life of this system is totally
dependent upon proper maintenance of this system. Should you have
any questions regarding this subject, please feel free to contact
this office.
Sincerely,
Mary Jenkins
Assistant Zoning Administrator
MJ:cj
11/30/2009 11:56 AM
Parcel #: 030- 1012 -10 -000 PAGE 1 OF 1
Alt. Parcel #: 03.29.19.55L 030 - TOWN OF SAINT JOSEPH
ST. CROIX COUNTY, WISCONSIN
Current X
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
O - GB CURLEYS RESTAURANT INC
GB CURLEYS RESTAURANT INC
1103 CTY RD A
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description " 1103 CTY RD A
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE
SEC 3 T29N R19W PT SW SE SEC 3 & NW NE Block /Condo Bldg:
SEC 10 COM INT CO HWY "A" & E LN SW SE, Tract(s): STRn 40 1/4 160 1/4)
S 450 FT, W 531.5 FT TO FENCE, N ALG (Sec- wn -g
FENCE TO CL HWY A, TH E ALG CL TO POB AS 03- 29N -19W
DESC IN VOL 482/499 ASSESSED WITH P120G
Notes: Parcel History:
Date Doc # Vol /Page Type
01/10/2006 816090 WD
07/06/1999 606294 1439/551 QC
07/06/1999 606293 1439/547 TI
07/23/1997 868/391
more
2009 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/0712004
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 0.000 199,300 214,300 413,600 NO
Totals for 2009:
General Property 0.000 199,300 214,300 413,600
Woodland 0.000 0
Totals for 2008:
General Property 0.000 199,300 214,300 413,600
Woodland 0.000
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges 00
Total 0.00 0.00
i
IT
Plb 67 State and County State Permit # /
Permit Application County Permit #
for Private Domestic Sewage Systems County
*DENOTES, STATE APPROVAL REQUIRED
Date Approval Received from State if Required '- 2;7. 7S State Plan I.D.
A. OWNER OF PROPERTY / Mailing Address:
:t , 1 . G�
B. LOCATION: ' '/4 %, Section /&, Tg5 N, R (or) W Lot# City IF
Subdivision Name, nearest road, lake or landmark Blk# Village
Township 0*
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance
Single family Duplex No. of Bedrooms No. of Persons
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste GrinderYES_NO # of Bathrooms —
Automatic Washer YES NO Other (specify)
E. SEPTIC TANK CAPACITY ID66 Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation Addition Replacement _ Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area sq. ft.
New Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length/66 Dept Tile Depth t'� No. of Lines
Seepage Pit: Inside diameter Liquid Depth Tile Size
Percent slope of land 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 disposal system from the EH -115 prepared
by the Ce"ied Soil Tester,
NAME /CCI�i�G- �'��/`✓.(��� C.S.T. and other information
obtained from (owne.[hhuddar) .
Plumber's Signa MP /MPRSW # 'C� Phone # �G �3
PLAN VIEW: Provi etch b ow system (include direction of slope and all distances in accord with
H62.20, including ell).
r
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REPORT OF INSPECTI0:7-- 14DIVIDUAL SEWAGE DISPOSAL SYSTEM
Sanitary Permit D
slat Septic
TOWNSHIP
roix ounty
SEPTIC TA "IR
Size gallons "lumber of Compartments
Distance From: Tlell _7) ft. 12% or greater slope f
Building ft. Wetlands __ f
l' ighwater ft.
DISPOSAL SYSTEM Tile Field or Seepage Pi "(s)
Distance From: T,Te11 /J- 4 t. 12% or greater slope
Building; ft. Wetlands ft
FIELD Hig;hwater ft.
Total length of lines ` - d dumber of lines. Length of
each line � ft. Distance between lines ft. Width of the
trench ft. Total absorption area sq. ft. Depth
of rock below tile I lo- in. Depth of rock over tile .7in. Cover
over mock �. Depth of tile below grade 4 Y5 in. Slope of
trench � In per 1CC ft. Depth to Bedroc: _ft. Depth to
ground water - 4 — f t.
"I
Nlia +ber of nits . Outside diameter ft. Dept! below inlet
ft. Gravel around pit: ____des no, Total absorption area
sq. ft.
Square feet of seepage trench bottom area required
Square feet of seepage pit area required
Inspected by: �Q i� Title: A Z _ —
Date 1976.
Approved —� 197
-
Rejected Date _
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S tate of Wisconsin \ DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH
MAIL ADDRESS: P. O. BOX 309
t"* r 27, "7 M ADiSON, WISCONSIN 53701
IN REPLY PLEASE REFER TO:
SECTION OF PLUMBING
AND FIRE PROTECTION SYSTEMS
74 a Hastlas 730260
$19 S$ee"od Str"t Plan Identification No.
8 grae ,r 36016
Dear Sir:
Re: 1UrUa Wl rth - rastan iot
M $10 T29�- * 219W, 6t• Jo"pk Tw mb4 fit. Creft Owaso
stufto Dupes"
This is to acknowledge receipt of your plans and specifications for the above -
indicated project. When referring to this plan in the future, it will be absolutely
necessary to utilize the plan identification number assigned to the Project. The
spaces below indicate if proper fees have been submitted or if more information is
required. Providing plan review is not completed within thirty (30) days, a permit
to start construction may be issued if requested. See Section H 62.25, Wisconsin
Administrative Code, for limitations in reference to permits to start construction.
Preliminary plan review for determination of fees does not hold the department
liable in the event additional fees may be required upon complete plan review.
Preliminary review indicates the plan review
Fee required is $ S
Fee received is $ .�'� Plan accepted for review.
Fee is being returned because of EJ Overpayment E] underpayment,
Providing one of the two catagories above is checked, please remit correct
total fee in one payment. Indicate plan identification number on remittance.
No fee has been remitted. Plans submitted with no fees will be held in
abeyance until remittance is received. Indicate plan identification
number on remittance.
Additional information required. See attached Plb. 100. The permit to
start construction will not be issued until 30 days after requested
information is received and accepted.
Plans being returned. See attached Plb. 100.
Sincerely,
ames A. Sargefit , / -4
Chief
JAS: f jz
I
State of Wisconsin \ DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH
MAIL ADDRESS: P. O. SOX 309
MADISON. WISCONSIN 53701
YSi ! • I IN REPLY PLEASE REFER TO:
SECTION OF PLUMBING
AND FIRE PROTECTION SYSTEMS
*noun Seats"
4
ftis"l, jx 3403.6 Plan Identification No. 7502"9
Dear Sir:
Re: r1artain W06XVIeftht llea'fanna#
N'd', ► y 10, 229-30, R15V, jam. 2. , 'BFI (ft. Cdr ce. )
sovace missal
This is to acknowledge receipt of your plans and specifications for the above -
indicated project. When referring to this plan in the future, it will be absolutely
necessary to utilize the plan identification number assigned to the Project. The
spaces below indicate if proper fees have been submitted or if more information is
required. Providing plan review is not completed within thirty (30) days, a permit
to start construction may be issued if requested. See Section H 62.25, Wisconsin
Administrative Code, for limitations in reference to permits to start construction.
Preliminary plan review for determination of fees does not hold the department
liable in the event additional fees may be required upon complete plan review.
Preliminary review indicates the plan review
Fee required is $ --
Fee received is $ / S n Plan accepted for review.
Fee is being returned because of II Overpayment P9 Underpayment.
Providing one of the two categories above is checked, please remit correct
total fee in one payment. Indicate plan identification number on remittance.
No fee has been remitted. Plans submitted with no fees will be held in
abeyance.until remittance is received. Indicate plan identification
number on remittance.
Additional information required. See attached Plb. 100. The permit to
start construction will not be issued until 30 days after requested
information is received and accepted.
Q Plans being returned. See attached Plb. 100.
Sincerely,
Z A. Sarg
Chief
JAS:fjs
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REPORT OF INSP7CT1GN--- INDIWAL S3/TAGE- DISPOSAL SYSTal
PRIPI;RY TRIMMENT consists of Ta
nick Other (Describe)
1 r b 3c�r.A
SEPTIC TANK: Distance from: Wel ;Mft., Lot Line ft. Buildin ft.
High watermark ft. 12% or greater slope ft. Wetland ft.
Cistern _ft. No. compartments: Liquid capacit
EFFLUENT DISPOSAL SYST"M consists of Tile field." Seepage pit (s).
Seepage Pit or Tle Field Distance from: Well -� - ft. Building Xt..'
Lot Line ft. G�istern ft. High Watermark of water course ft.
Slope 12: or greater ft. Wetland ft.
TotaL length of the linesI�t N ber of lines A_k . Length f each
2 .
line ft. Distance between liLs ft. Width o trench n.
Total effective absorption area of trench botto ar ft
tr ,� .
Depth of filter material below the L in. De fil 4 material
over tile in. Cover over filter mater
ial - �
Depth of tile below finished gr de in. Slope oft nch ttom_in.
per 100 ft. Depth of bedrock /�C/ft. Depth to ground water 'ft.
Number of Pits Outside diameter ft. Depth below inlet ft.
Lining material Gravel around pit: Yes.
No. Total sbsorption area so. ft.
Square feet of seepage trench bottom area required
Square feet of seepa pit area required
Inspected by: /-� "-. ___�
a
Title:
Approved Date ,19
Rejected Date ,19
e
° C ounty, Town of
Owner - 7 , 0
Sanitary Permit No._j ?? Addres
Septic Tank Permit No.__�.( Subdivisions
'Parcel #: 030 - 1012 -10 -000 03/20/2007 04:46 PM
PAGE 1 OF 1
Alt. Parcel #: 03.29.19.55E 030 - TOWN OF SAINT JOSEPH
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
GB CURLEYS RESTAURANT INC O - GB CURLEYS RESTAURANT INC
1103 CTY RD A
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): " = Primary
Type Dist # Description ' 1103 CTY RD A
SC 2611 HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE
SEC 3 T29N R19W PT SW SE SEC 3 & NW NE Block/Condo Bldg:
SEC 10 COM INT CO HWY "A" & E LN SW SE,
S 450 FT, W 531.5 FT TO FENCE, N ALG Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
FENCE TO CL HWY A, TH E ALG CL TO POB AS 03- 29N -19W
DESC IN VOL 482/499 ASSESSED WITH P120G
Notes: Parcel History:
Date Doc # Vol /Page Type
01/10/2006 816090 WD
07/06/1999 606294 1439/551 QC
07/06/1999 606293 1439/547 TI
07/23/1997 868/391
more
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/07/2004
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 0.000 199,300 214,300 413,600 NO
Totals for 2007:
General Property 0.000 199,300 214,300 413,600
Woodland 0.000 0 0
Totals for 2006:
General Property 0.000 199,300 214,300 413,600
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
! #6 7 7/'71
i Wisconsin Department of Health and Social Services
Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE OR USE BLACK INK - PLEASE PRINT
A, OWNER OF PROPERTY
Name W i /how 0 t �.- I M °r 576rt' Address (Street, City, zip Code)
B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY ,
Check Ones
CITY VILLAGE LEGAL DESCRIPTION
TOWNSHIP "' (Block, Lot, Sea.) '- � 1 " L/�
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? -, (/ No / Y ERMIT NUMBER
D. SEPTIC TANK CAPACITY L GALLONS NEW INSTALLATION REPLACEMENT ADDITION
MATERIALSs PREFAB CONCRETE L - 'P'OURED IN PLACE STEEL OTHER
NUMBER OF TANKS TO BE INSTALLEDs ,
E. TYPE OF OCCUPANCY
Check Ones One or Two Family Residence Commercial L--"f ndustrial Other (Specify)
Number of persons to be Accommodated Number of Bedrooms
F. APPLICANCES, ETC= Food Waste Grinder YES 4#0 Automatic Clother Washer -- . . YES C- Na
Dishwasher YES TW O Automatic Potato Peeler YES''
OTHER (specify) YES
G. MASTER PLUMBER MAKING INSTALLATION
Names Address A
70 0
SIGNATURE OF APPLICANT tG�17d�13 "✓�37
License Numbers MP
ADDRESS: ju, ASW
H6 J (TO BE COMPLETED BY ISSUING AGENT) J
Date of Application _ / / �' Fee Paid
Permit Issued (date) — _ ,.' Permit Number - ~
Agent (name) / %, C C ;% /Fors
town, village, oity, county, eta, (specify)
NOTES The Application cannot be considered for filing until all of the above questions are answered
and the fee paid. Agents will forward application, the fee of $1.00 for each septio tank and
the third copy of the permit (canary) to the Division of Health. Checks and stoney orders should
be made payable to the Division of Health.
COMPLETE OTHER SIDE
P # 60
PROJECT DETAIL DATA SHEET MAY N 6 1972
V3/7
• PLUMBING Si CT10N
NAME OF BUSINESS W 9 ` P
LOCATION RT. W=m. (ST.- .1M
street or highway city or township county
LEGAL DESCRIPTION _ SW . W SS 3 ?29'-3W RIVIN W. t k ';T. X'. V lzl_
OWNER {' Mai 1 i ng address ;, _�.W
ZIP
ARCHITECT OR ENGINEER Address
ZIP
PLUMBER 111 -P '. ► Address 1`1. �' � ` RIC X17 ----
ZIP
1. Check appropriate building usage(s) and fill in the information requested opposite
each usage 1. sted:
Existing bui ]ding ll L T New building Addition
If addition to existing building attach detailed memo for each.
( ) Drive in restaurant ......... Car spaces
( ) Restaurant .................. Seating capacity (10 sq. ft. /person)
( ) Dining hall ......... Per meal served Toilet waste Yes No
( ) Motel ( ) Hotel (•) Cottages .. Number of units: 2 persons /unit -
4 persons /unit TOTAL NUMBER OF UNITS
( ) Churches .................... Number of persons r Kitchen Yes No
( ) Bar or cocktail lounge ...... Seating capacity (10 sq. ft. /person)
( ) Nursing or rest home ........ Number of beds _
( ) Mobile home park Number of units - dependent (camper trailer)
- nondependent (mobile home) _
Retail store ................ Number of employees 2
Number of customers T10 sq. ft. /person)
() Service station ............. Number of cars served (daily)
( ) School ...................... Number of classrooms Meals served Yes
No
Showers provided Yes No
( ) Factory or office building .. Number of persons (total all shifts
( } Apartments .................. Number of bedrooms
( )
Other ....................... Specify
2. Indicate whether or not the following facilities are connected:
Food waste grinder Yes _ No U Dishwasher Yes No
Automatic clothes washer Yes No Automatic potato peeler Yes
Other . . . (Specify) y^ _ _.___._____ No
3., Fill in the appropriate information for the following as indicated:
Septic tank capacity pIanned S GAL*
Percolation test results - AT TACH P ERCOLATION , TEST A ND S OIL BOR REPORT SHEET
COMPL OTHE SI DE