HomeMy WebLinkAbout040-1212-30-000 (2)St. Croix County Planning and Zoniiz
n #-,ail qnnit'% V Information
section; 7
Computer #: Q--Q49-1212-30-000 Sub/Plat: West Grove Estates T28N R19W
07Lot: 12
Parcel , TNIRNG.
114 114: SW 1/4 NE 114
Municipality: Troy, Town of %..I ,a IV 11: -
Owner: Graham, Nancy 318 VVest Grove Road Hudson, W1 54016 d Permit: New
State Permit: 199923 issued. 11/03/1993 POWTS Dispersal- Non -Pressurized In -ground
BedroomsWI Fund:
County Permit: 0 Installed: 11/03/1993 POWTS Detail-. Trench - Seepage - 0
POWTS Pretreatment- NA
Notes Plumber Other Reguirements Addit!'.)rial Notes
lq�ipeqtQr A,� Built Boumeester, Jim
Not determined NA
Signed Off-, No
Maintenance ffication
Est Notification 2nd Notification Ord tificatio"
Date PLirriped _L[o�
Sch�.duuleed_ PU111
714/2002 10/25/1999 04/0112005
4/1,4/2008
10125/2002 4/1412005 04/0 1 /2005
I
FridqjJuly 22, 2005 at 10:36.-22 AM
111age I qj']
Mgnej Owed
$0.00
DepaiiVnent of Industry, SOIL AND SITE EVALUATION REPORT Page "of
Lat - ,,aznd Human Relations
Td-r-of Safety & BuildiNs
or, in accord with ILHR 83.05, Wis. Adm. Code
Colu NTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
0"NT
not limited to vertical and horizontal reference point (BM), direction and % of slope, SCale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
V
EVIEW ED BY DATE
APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION FR
PROP RT-YOWNER:
6 A
PROPERTY LOCATION
�GOVT. LOT 1/4 �y"��*7 T 2 �',,R X
PROPERW[OWNER's I A)LIN ,IDRESS
LOT #
BLOCK #
SUB , NAME 0 CSM #
CITY, STATE ZIP CODE
PHONE NUMBER
EICITY ®VILLAGE UTOW
NET ROAD
1 .'`'New Construction Use4-iol Residential/ Number of bedrooms Addition to existing building
Replacement Public or commercial describe
Code derived daily flow
I I gpd
7 b ed r g 2
Recommended design loading rate pdVft trench, gpd/ft2
Absorption area required bed, ft2
Ue ch, it Maximum design loading rate 7 _bed, gpd/ft2 trernh, gam`
Recommended irifflfrathion surface elevation(s)
(as referred to site plan berichmar
Additional design / site considerations
- I/
Parent material
'3 _5 - 1� lood, plain elevation, if applicable Ift
S
S = Suitable for system
U = Unsuitable for system
CONVENTIONAL
9S 1:1 U
MOUND
Os 5V
IN-GROURD PRESSURE
Os M
AT- GMQE
E] S 'C5 Ur
SYSTEM IN FILL
0
HOLDING TANK
[Is I
Boring #
G round
Depth to
limiting
[a tor.
Boring #
X."O
0"X
Mo ..'X
Ground
01
Depth to
limiting
factor
4. /?
SOIL DESCRIPTION REPORT
Horizon,
0 r
Depth
in.
Dominant Color
Munsell
mattes
QSzu. . Coat Color
Texture
Structure
Gr. Sz. Sh.
Consistence
2curchy
Root s.
GPD/ft2
Bed
Tmnch
X
4 1"
0 F
1
AAA
C
4r"
IL
R e. m a r1kz:
Lo X)
F,
Z:
ell,
y
19 r I
Remarks:
CST Nam : Ple se P J t Phone -
Address,
Signave:',. Date: 001f CST Number-
PARCEL I.D.
4- b-0 L- IIJ UO I I I V n C t-
Page4o Of
■
Boring # Horizon Depth
Dominant Color
Mottes
Structure
2
in,
unsell
CCU. S . Cont. ColorTextur
fir.
Consistence �
Roots GPD/ft
`
Ground,
}
'4.
y l7
Depth 'to
--
«
limiting
«
f } 1
•
Boring
Ground
Y
Y
elev.
r
1
Y
Depth to
!
'el 7 4 i t ny.il
V
i
factor
Y
!
«
Rem ark +
+
rI
!
!
Y
Y
i
!
Boring
found
«
elev. T��I
.
«
Depth [} e
fimlbng
factor
e
Remarks:
.Bering #
Y
Ground
Y
elev.
Y
�ee�eF
Depth to
limiting
factor
-
/� ry Y�5 Bey any +Remarks:
/ Crr i(�c I � S.�o�
oz,
..... . .... ..............
STC - 104
AS 13UILT SANITARY S ?YSTEM REPORT
OWNER
N C
19
ADDRESS
SUBDIVISIOIN CSM# 4? LOT
SECTTONT T N R W Town of
toll
ST. CROIX COUNTY, WISGoes IN
INDICATE NORTH ARROV
Provide setback aiid e-levatiori information on reverse- of this orm-
cO-
Provi-de 2 dimension ,<s to center of'.- septic tarik manhoL le ver
4110 y k cw.l-
Henww;
Ewvi
qq,q7
O WTI
Zow�11T
�Qp"OtR
� ENA
gl'.i3
i 9�4'
BENCHMARK: P'1Z )N- GROIAr-IL NQ C��' 1) t1_ 9
ALTERNATEBM:
SEPTIC ANR PUMP CHAMBER HOLDING -TANK INFORMATION
Manufacturer urer: �. L id a ace
-ty:_1 ()Q
Setback from: Well House Other
Pump : -m-a r diode I t Size
Float seperaior
Alarm
Gallon
-:-SOIL ABSORPTION SYSTEM
Width: Length 57dumber of trenches
Distance & Direction to nearest prop, line
Setback from: well:()Hou e Other
ELEVATIONS-
BuildingSerer ST Inlet; ST outlet .
bottom
Header Manifold Bottom ofsystem 93-47
Existinq Grade
Final grade yU` LAW Tg-..,w
No
OF INSTALLATION: 93
PLUMBER ON JOB:
LICENSE NUMBER:
3/93 :j
'part' f 1rAZ_4,B & 19 " 1011PRIVATE SEWAGE SYSTEM
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TOP E RMITS
Permit Holder's Name : El City [] Village R Town of.
MRAHAMg . NANCY TRQY
I- CST BM Eh5v--, Insp. BM Elev.- BM Description.
County:
ST, CROIX
Sanitary Permit No
199923
State Plan ID No.-
r Parcel Tax No.:
040—IL212-30-000
TAN - K INFORMATION
ELEVATION DATA
A9300331 1/hZ,6�f
TYPE
MANUFACTURER
CAPACITY
STATION BS
HI F S
ELEV.
Septic
k's
1221, S C
A
Benchmark
Dosing
Aeration
Bldg. Sewer
Holding
St / Irl" inlet
TANK SETBACK INFORMATION
St /,)4 outlet
'
"."
TANKTO
P f L
WELL
BLDG-
Ventto
Air Intake
ROAD
Dt Inlet
Septic
>
NA
Dt Bottom
NA
H ender
C�Z,
371
Aeration
A
1pe
Dist- Pi
2,29,
Holding
Bot- System
.0"13 1
PUMP/ SIPHON INFORMATION
Final Grade
Manufacturer
Demand
CS 7_
7 -, c >.,
e M�L
7,31
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No, Of Pits inside Dia- Liquid Depth
CIMESIoI DIMENSIONS
Mn u
TO P/ L BLDG WELL LA K E S T R E A M' L EA C H 646----
a
SYSTEM
SETBACK CHAMJIE� Modelllbq_be r:
INFORMATION Type Of /7 NIT
1-system: Fl- 0-�L
DISTRIBUTION SYSTEM
Header to /11 rli-10-ri Htinn PinpPipes)x Ho Hole Spacing Vent ToAir Intake
Ll Length Spacing I
Length Dia _LL Dia. _Az
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx See e'
Topsoil Yes ❑ N 0
Bed ?I Trench Edges
Bed /Trench Center 16
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATICAN 44 TROY 07,28o19*1011
4
Plan revision required? El Yes O'No
Use other side for additional 1 niormati on
SBD-6710(R 05/91)
xx Mulched
L] Yes ❑N o
u�i 9
Cert No
F77 ww� I L
DHR
q1C%'=Tjft&=
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code
-Attach complete plans (to the county copy only) for the system, on paper not less than
8�6 x 11 inches in size.
-See reverse side for instructions for completing this application.
I. APPLICANT INFORMATION - PLEASE PRINT ALL INFOR MATION.
PROPERTY OWNER PROPERTY LOCATION
lm6 6
tk/4 , 5'WI4 S ) ' '
PROPERTY&NER'S MAILINQ ADDRESS LOT #
I ;.- �' I I
COUNT)51 . c 4K ej ' p(
STATE S,A,N ITA RY PEW ' T #
D1C6tif_r�e' /isionto-14vious application
STATE PLAN 1. D. NU M BE R
T,.-PlY., N, R E (or
T—BLOCK#
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION M
N NAME OR CSM NUBER
1 7 -1 j � / -w— 'i 1Z / /I '. y . r
7
11. TYPE OF BUILDING: oe (Check one) State Owned
ElPublic [g3
1 or 2 Fam. Dwel I i ng-# of bedrooms —
Ill. BUILDING USE: (if building type is public, check all that apply)
1 ❑ Apt/Condo
7�7W-
77 CITY NE REST R
E VILLAGE:
rV T
=U
PARCEL TAX NUMBER(
cl) All-- .
2 El Assembly Hall 6 ❑Medical Facility/Nursing Home
3 ❑Campground 7 ❑Merchandise- Sales/Repairs
4 ❑Church/School 8 ❑Mobile Home Park
5 ❑Hotel/Motet 9 ❑Office/Factory
0
10 0 Outdoor Recreational Facility
11 El Restaurant/Bar/Dining
12 1:1 Service Station/Car Wash
130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. E900ONew 2. 0 Replacement 3. 1:1 Replacement of 4. El Reconnection of 5. El Repair of an
System System Tank Only Existing System Existing System
13) A Sanitary Permit was p rev i ous ly i ssu ed - Permit # Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 epage Bed 21 ❑Mound 30 1:1 S,pecifyType 41 D HoldingTank
F�
1Seepage Trench 22❑ In -Ground 42 El Pit Privy
13 El Seepage Pit Pressure 43 El Vault Privy
14 F-1 System-1 n-Fi I I
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY
2. AB RP. AREA
3. ABSORP. AREA
REQUIRED (sq. ft.)
r
PROPOSED (sq. ft.'
5?0
Vill. TANK
CAPACITY
in ciallons
Total
# of
INFORMATION
New
xistin
Gallons
Tanks
Tanks
r. Tanks 0,
4. LOADING RATE
(Gals/day/sq. ft.)
16, 8
Manufacturer's Name
Septic Tank or Holding Tank 1 10 U
Lift Purr Tan k/S i P hors Chamber
Vill. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite s
Plumber's Name Print): Plurnber's Signature- (No Stamps)
Ate
Plumber's Address (Street, it, State, Z i p Code); I
'-_
IX. COUNTY/DEPARTMENT USE ONLY
q, F
5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
(Min./inch) (�' 7 EVATION
pmp� ii.
Feet Feet
Prefab. Site Fiber- Exper.
Concre!Con- steel glass Plastic App.
,9 strutted
ge system shown on the attached plans.
MP/MPRSW No.: Business Phone Number:
A I
Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Age 0 Stamps
F] Approved Owner Given Initial Surcharge Fee)
Adverse Determination
X. CON[ ITIONS, OF APPROVALIREASON S FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
DEPARTMENT OF REPORT ON SOIL BORINGS SAFETY & BUI LD I NGS
AND DIVISION
INDUSTRY, P.O. BOX 7969
LABOR AND PERCOLATION TESTS (1�15) MADISON, WI 53707
HUMAN RELATIONS
(1163.090) & Chapter 145.045)
LOCATION: SECTION: TOWNS H1 PLOTMO.:BLK.NO-: UEDIVISIONNAME:
/M4!"G IRA it!l+
SE '/4 S E '/4 12 /Tz8 N R2o E (or) W1_ TROY =_
'COUNTY: BUYER'S NAME: MAl LING ADDRESS:
St. Croix CARDELL MILLER W. Grove Rd a_ on WI 54016
USE Phone 386-6765 DATES OBSERVATIONS MADE
1 PROFILE DES TESTS:
NO.BEDRMS.: COMMERCIAL DESCRIPTION� DESCRIPTIONS: PERCOLATION TESTS:
T11 New Ll Replace , 1 -6 _90
IRResidence 3 11-4-90 11-6-90
RATING: S= Site suitable f o r system U , = Site unsuitable for system NDED SYSTEM: loptional)
CONVENTION MOUND: IN-GROR :
UND-PRESSU,SYSTEM-IN-FILL HOLDING TANK: RECOMME
0S EA 6:1 S E1U R S E1U a S Elu I � S E1 U conventional w/ lift station
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
Linder s.H63.09(5)(b), indicate: n/a_1 I Floodplain, indicate Floodplain elevation: 11/a
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER -INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER IDEPTH IN, ELEVATION ORSERVE_PEST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
2,4'Bncs w/gr.
B- 1 70 100.5 none 70 1.8' Bkls w/gr. & cob 1.6
2.9' Bnms w/ gr. & cob.
B- 2 67_ 98.9 none 67 1.1'Bkgl w/gr,.& cob 1.6' Bncs w/gro & cob
1.3' BnMs W/gr.
B- 3 85 M0.3 -none 85 1.8' Bkl8 w/ gr & cob 4'Bnes
B_ 4 65 99.4 none 65 .8'Bkls 1.6'Bncsw/gr 3.0' Bucs.
13- 5 72 100.9 none 72 l'Bksl /gr & cob 2.9'Bncs-I
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE
TEST TIME
DROP IN WATER LEVE L-I NCH F-S
___7
RATE MINUTES
PER INCH
NUMBER INCHES AFTERSWELLING
INTERVAL -MIN,
FRIOD 1 PERIOD RER101) 3
P- 2 none
3
P-
'3
3
than 6" driop in 3
.5
P- 3fa none
p - 44 none
3
P_
PLOT PLAN: Show locations of percolation
tests, soil borings and
the dimensions of suitable soil areas, Indicate -scale or distances.
Describe what are the hori-
the direction and percent
zontal and vertical elevation reference points
and show their location on the plot plan. Show the surface elevation at all borings and
of land slope.
dry water way
SYSTEM ELEVATION
97.3'
scale I" = 30'
of ?JQP cevne"t slab
DrIg LWF 9
assume 100.01.
boring*
c = perk.
& = NSP gas line marker.
(hale® left partially open to
faciliate locating.)
QT r-12
0
3
TN
I the undersigned, hereby certify that the soil tests reported on this form were made by me in accord witi-l'.he procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
En ask15
NAME (print): ME MOING TESTS WERE COMPLETED ON:
Licensed Perk Tester & Plumber 1 11--
ADDRESS: M CERTIFICATION NUMBER: P,1H40NE NNUMBEIR(optlonal):
Fogerty Heights Road
ROBERTS,- CST S)7 A7,R E:
Phone 749-3656
P-7
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 CR.02i82) —OVER —
C T
0S,
I-D E), I. -A 6 -7 PLOTA f I I I (. . .
..
....... E.� I
P R () J C T -,.-q *,w. 6'.
NAM
1�1 t's N-A y a _ __
C E
}1.- ._ __ -
P L C M A
_.__ _
IS)K 5-7
Sol, I L It-
wd k
"X� L
/j/ j
4. 11 7, � �lc r,
46P
—:f
FRESE' All� IPLETS AND OBSERVATIC)�l PUDE
C11015,S SECTION
Approved VenL
MiT)lmum 12" Above WP)
__i,;'jnal Grade--_\_
4 of Cast IroT)
Pbove Pipe Vent Pipe
,ro ina1 G r a d c,
& )a rsh 11cny Or Synthetic Cove i: i n(i
Aggree.j1I
Over Pipe C
FAs t-r ibu Li - o ii,. T e e
Pipe 4
Pei: for r--i ted
Aggregate ,!-.
Holleath Pipe _Cout-)l ing Teems
I�pj � ) nottcln of Syster�
#rtrr�ln,t GROVE
� E��?ySfNT
Labor and Human Relations INSPECTION TION REPORT
Safety and Buildings Division
(ATTACH T PERMIT)
GENERAL INFORMATION
I MI TI nATA
A9300048
IAN 1 rUKMPkTI I
a.anft,::
TYPE MANUFACTURER CAPACITY
STATION
BS HI I FS E LEV.
Septic
Benchmark
Dosing
Aeration
Bldg. Serer
Molding
t 1 Ht Inlet
TANK SETBACK- INFORMATION
St I Ht Outlet
TANKTO
P L WELL BLDG. Vent to ROAD
Air Intake
Dt Inlet
Septic
IAA
Dt Bottom
Dosing g
A
Header/Man-
Aeration
IAA
Dist. Pipe
HoldingBot.
System
PUMP / IPHO INFORMATIOI
Final grade
Manufacturer
Demand
Model umber
GPM
TDH
Lift Friction TDH Ft
or emain
Length Dia-
Dist. To WelI
OIL ABSORPTION YSTEl
��� � TRENCH
Width
Length
�
o. f Trenches
PIT
No- �f Pits
Inside Dia_
Liquid Depth
DIMENSIONSe
DIMENSIONS
LEACHING
Man acturer
SYSTENti 70
P l L
BLDG
WELL
LADE / STREAM
SETBACK
CHAMBER
Model Number:
INFORMATloN
Type Of
R UNIT
System:
DISTRIBUTION SYSTEM
xHole Size x Hole Spacing Vent To Air IMake
Hader I Manifold Distribution Pipe(s)
Length Dia_ Length Dia. Spacing
SOIL COVER Pressure Systems Only
xx Mound or At -Grade sterns only
Depth Over
Depth Over
L__1
xx Depth Of
xx Seeded � Sodded xx Mulched
No El Yes E] No
Center
Bed f Trench e
Bed /Trench Edges .
Topsail
❑ Yes ❑
COMMENTS: (include code discrepancies, persons present, etc.)
LOCATION: 'TROY . j 9.1.01.1, SE , E , LOT 12, WEST GROVE R .
Plan revision required? ❑ Yes ❑ No
Use other side for additional information-
Date inspector's Signature Cent_ ruo.
B D-7 1 0 (R 0 19 1)
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code
I
—Attach complete plans (to the county copy only) for the system, on paper not less than
81/2x 11 inches in size.
—See reverse side for instructions for completing this application.
1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION.
PROPER OWNER PROPERTY LOCATION
SE Y4,S E /43 s
E7 0 t%- 1 1 r%lr "
COUNTY
STATE SANITARY PERMIT
ElC/ecfilsr3evi h Oevious application
STATE PLAN I.D. NUMBER
T22P,,N,R_o E(or
Fal nrK -A
rmurcm I T k'jVVrjr_'rj 31YINILI1Y
III -Ali It 5--L
k-3 P% U LJ r-t
K 0Aa
A
C TY, STATE
ZIP CODE
PHONE NUMBER
SUBDIVI�ION ME C 0 CSIVI NUMBER
NA
4�5
KTA
Y�' j '0 V��5
111. TYPE OF BUILDING:
(Check one) State Owned
C
CITY
VILLAGE,r�� y
NIEAVES�T RO
Kj
❑ Public IN 1 or 2 Fam. Dwelling—# of bedrooms
[2 JQWN OF
PARCEL TAX NUMBER(S)
Ill. BUILDING USE., (if building type is public, check all that apply)
1 ❑ Apt/Condo
2 E]Assembly Hall 6 El Medical Facility/Nursing Home
3 El Campground 7 ❑ merchandise: Sales/Repairs
4 El Church/School 8❑ Mobile Home Park
5 El Hotel/Motel 9 El office/Factory
10 ❑+outdoor Recreational Facility
11 El Restaurant/Bar/Dining
12 El Service Station/Car Wash
130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. K New 2. El Replacement 3. El Replacement of 4. 0 Reconnection of
System System Tank Only Existing System
B) El A Sanitary Permit was previously issued. Permit # Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non -Pressurized Distribution
11 Seepage Bed
12 ❑Seepage Trench
13 ❑ Seepage Pit
14 ❑System -In -Fill
Pressurized Distribution
21 El Mound
22 [1 In -Ground
Pressure
Experimental
30 El Specify Type
5. El Repair otan
Existing System
Other
41 El Holding Tank
42❑ Pit Privy
43 ❑ Vault Privy
V1. 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
5 G
R5 RED (sq. ft.)
PROPOSED (sq. ft.)
(Gal /day/sq- ft.)
(Min-/ipph)
'7 3
ELEVATION
10 1 /Aeet
Feet
-
"II. TANK
INFORMATION
CAPACITY
in gallons
New xistingGallons
Total
# of
Tanks
Manufacturer's Name
Prefab.
Concrete
Site
Con-
Steel
Fiber-
glass
r
Plastic
Exper.
App.
Tanks
rTanks
structed
Septic Tank or Holding Tank Q (� C W 0.& 1 \04 L.J L.J
Lift Pump Tank/Siphon Chamberi- IL Lj F-1 F-1 Ll
Vill. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): PI ber's S' nature: (No Stamps) MP/MPRW Na.: Business Phone Number:
I'l De
Plu ber's Address (Street, yty,staT, Zip Cqod () a le).\ N C k 4
E I
IX. COUNTY/DEPARTMENT USE ONLY
r7 Disapproved Sanitary Permit Fee (Includes Groundwater D ate I slue issuirLu Agent Signatu (No Stamps)
Approved ❑Owner Given Initial Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVALI REASONS FOR DISAPPROVAL.*
SBLS-6398 {formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
MSTRUCTIONS
1. A za.nita-ry�permit is valid for two years.
. Your_.san-itatry.permit may be renewed before the expiration date, and at the time of rene wral any n
criteria in the Wisconsin Administrative Code will be applicable.
. All revisions to this permit mast be approved by the permit issuing authority.
. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form ( BD 399) to be
submitted to the county prior toi installation.
. Onsite sewage systems must b properly maintained. The septic tank() mist be pumped by a licensed
pumper whenever necessary, usually e' - ery 2 to 3 gears.
. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisc n in, Safety & Buildings Divisi n, o - 1 .
' r
To be complete and accurate this sanitary permit application -must include.
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed,
11. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling.
Ill. Building use. If building type is Public, check all appropriate bones that apply.
IV. Type of p rmi#. Check only one in line A. Complete line B if permit is -for tank replacement, reconnection, ors
repair.
V. Type of system. Check appropriate box depending on system type.
V1. Absorption system information. Provide all information requested in ##1- .-
V1l. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicateprefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
IMP, etc.), address and phone number. Plumber must sign application form.
IX.County/Department Use only.
X. -County/Department Use only.
Complete plans and specifications not smaller than 3% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tanks), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution bones; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
complete specificatins for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
•. " -Arequired by thei c unty; ) soil test data on a 11 form; and F all sizinq information.
R UNDWATER'SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies colt bted through these- stircharges are used for monitoring ;groundwater, ground-
water contamination -investigations and establishment of standards,
SBD-fi 8 R.11 f 88)
S T C - 100
'This application form is to be completed in full and signed by
the owner(s) of the property being developed, Any inadequacies
will only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor,(spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording,
---------------- --- 66.� -------- --------- --------------
Owner of property f,! � V 9,
t
Location of property -7sr- 1/4 -S 1/4, Section T N -R W
Township
Mailing address I tsc
Address of site
Subdivision name
Lot no
Other homes on property? —No
Previous owner of property MU&gfi� d
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes No
volume and Page Number ( -
as recorded -with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER,, VOLUME AND PAGE
NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available-, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required,
PROPERTY OWNER CERTIFICATION
I(we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of
the property described in this information form, by virtue of a
warranty deed recorded in the office of the county Register of
Deeds as Document No./-
_J� and that I we presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in the office of County Register of deeds as Document
No* a
Signatur of applicant
Date of Signature
Co -applicant
Date of Signature
I DOCUMENT NO, �
; r+rs sr'�c �trs�v FOX naRECORDINGHa a,►Y,.
WARRANTY DEED
' • i j STATE BAR OF WISCONSIN FORM 2 —1982 .
492934REG) S 'FICE
t - + . CI coo, W1 i
I�u� r a ..................................... Knechtfor-...and __!�ayne-_ F . __ Maser ...............•_•. �
______________________________________________ ________________________________....._.-__._.-_...___.._-.. + DECI 61992
................ ._----------......._-----.............._..---------- ..............+................... 9 :45 A.
corive�•s and warrants !to-.__..�sl�� _.,�.�---�� '-------__....__. , ...................
i I aInjam-................................. , � oft)" a
--------------------------------------------------------------------•-------------------------- _
I' -----------------_----------------------------- ............. .......................... _----..................... _.
!' .__....__...................... +..... + ...__•__•_••__ .,......__..___•_••__'•-_• .. _. +... .+... ..._._.._.... 3 -- � --- _ � '_ _.___—�— is
�![ .__...,..._.._-..------------------------------------------.-+.._....__.___,._......_..___-------- .:..... . _
.-------..—_-- +----------------------------- -•.. _.....__.._ .-----. + R f
the foIlov►►in-- descrii�e----------_•.__._..-------...................................................... --- �-
g d real estate in ........ .�._. . .................. County,
E State of Wisconsin :
Tau Parcel No ----------------- ------------
Lot 12, Plat of Nest Grove Estates in the Town of
Troy and 1112th interest in outlots "I" -and "5" of
said Flat
This ------ i.&__n0.t-------- homestead property.
3(jq) (is not)
Exception to warranties: Existing highways, easements and rights of way
of record,
Dated this .................. .4_-----------_-_- day of --------- -- --• - 01
-- •---............................
_._.,
--------•.-----.-...-_------•-------------------------------------- +(SEAL) -- ---...----_._------.•_SEAL)
*------------------- - ------------•-----------------------------. # . urxy
....Knecht_..._.--.-__.......- ._....
7
.+ ........- --------------------- --++_.._.....__..-------(SEAL) .-- ..._._. ---................ SEAL)
* .--• .......................................... .................. .Wa np-__F.... i ser..._.....--...---......-•----
AVTN.1 NTICATION
r
Sign 3 IeLzlll A y
I.-/ ------------------ --__ .----_-..-_------.-_.-----
de-
enti
.. ... -............................................................
.� ..--......_....._..._ -------------------------------------------------
TITLE : MEMBER STATE BAR OF WISCONSIN
(If not, . -- ---- -- -- }
- - ---------------------
authorized by j 706.O6. Wis.State.)
THIS INSTRUMENT WAS DRAFTED BY.
.... . a.�r .si_.1_....Eatree.0 ................
(Signatures may be authenticated or acknowledged. Both
t are not neeessary.)
ACKNOWLEDGMENT
STATE OF WISCONSIN
SS.
..__! _ C r o :. ..-.-. _____County.
Person ly came before me this .. A n-d__-.day of
.._ ! :.w• ! .... - ---, I99 _ . the above tamed
_ Murray. A.---Kne eh t ..and_. way.ne J............
............. ..........................................
to me known to be the person ---- who exec tsib,%4.0 �� _
foregoing instrument and acknowledge the s
���sas••.saaiaV`��
)127 A P
.9 ................ .......
Notary Public
My Commission is permanent. (If not; 1 ta% t-01 � :!
date: ..................... .... ........ -,0 IO-
0
*X&i as off ua siuiug in any capacity should be typed or printed beicw their signatures. w�o�Y� Gt �� i a ���7IL -
Wr. rrvw
STATE BAR OF WISCONSIN
FORM No. I -- 1982
Stour No. 13002
� .
WEST GROVE ESTATES
&u. ' ! . �� •
� -If 8.6000"�
,
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oil
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one
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.
_ • a � � � � | � ' \
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$
,
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_�- . - IN
-
--�_• �le's.&M" 4w qh111 __,Mill 1_ ,o "oof grip -me w
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RUSCH SURVEYING INC.
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SEPTIC AN MAINTENANCE AGREViENT
St. Croix County
OWNER/BUYER
r W NO:
ADDRESS:
LOCATION: 11/4,
ST CROIX COUNTY
TOWN Of
SION LOT NO
SUBDIV.L
improper use and maintenance of your septic systems could result
in its premature failure to handle wastes o Proper maIntenance
of pumping out the septic: tank every three years or
consists. tank pumper, What You
sooner, if needed, by a licensed septic ptic tank as
put into the system can affect the funof ction the se
a �tarjin the waste disposal system;
St, Croix county residents may be eligible to receive a grant to
th the. cost of the replacement of a failing system, which
It 1978. st �Croix county accepted
was in operation prior to Ju`Y with the requirement that owners
this program In August Of 19801 their system properly
of all new systems agree to keep
M ZlIntained.
The propertaster
Z-y owner agrees to submit to the St. Croix County
and by a m.,arling a ce�i tifcaticn form, signed by the ner gneowA
T. ricted plumber or a licensed
1)1u-lmtber, �our-.neynan plurber, rest
the on - site wastewater disposal sYst`�7
ifya.ng that t il 4P
p-,Ur,,per ,,c-rl % and (2) after inspectlolr.
j a-1-ing condition
in proper ap4c�r
ptic tank is less than .1/3 ful' Of
v
p- the se
n g n e, s will be sent apprOx"
S
na su.4..., ce-t'lication from
c -In.Lu ge a
T.,z7i o- 'Lo -three year expiration.
3 C days
read the above requirements and a
ce
.L 11 system- in accordan
t
it °firx 1; }, ° t sewage d..sposa,
-ej hex .11, as set by the wisconsin
eted and returned to the.
f_':0 U.
-� �-_- I:Z� - L t 0 r'n she C(-�ITIP' the he t
1 3 0 days of r e
w i t 1"-,6 1 n
r I .4L
datim..N.
vp
GN E D
J� - .V zariirlg Gltt
92.1.
udsone, W1 54016
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F S i I �: 1 t LF''TS AND
OBSEItVAT I OU P IRE
l O �S SECTION
Em
Approved Vent Cap
Miv+imum 12" Abovetop)
1
4 " Cast Iron
1 Al:,ove Pipe
Vent Pipe'
To Final G r a d c*-------�
Marsh Ilay Or Synthetic' Coveri. ng
Min. ,Z " y q r. c (jI I I
Over Pipe
Dis tribu ti��
.. Tee
p
(3 Aggregate ._,.�
Per -for i ted Pi-Flrl
r Ben ath Pipe
c;
C0up.1 ing Ter.mi nat_ i.r,
_._ . �.. .
y ...�
.
RoL tom of Sys w