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040-1102-60-000
01X St. Cr Co u n ty Plan n in g a n d Zo n in en esa a Detail Sanitary Information K'-Id 1.1 March 21, 2 00 'at 5.-.38:52 F41 Iagae I of I Computer #: 040-1102-50-000 Sub/Plat: NA Parcel #: 25.28.19-399B Lot: 1 Section: 25 TNIRNG: T28N R19W Municipality- Troy, Town of CSM: Vol. 07 Pg. 1955 1/4 1/4: SE 1/4 SE 1/4 Owner: Jenkins, Doug P.O. Box 213, Paulson Road River Falls, WI 54022 State Permit: 4206 Issued: 05/18/1970 POWTS Dispersal: Non -Pressurized In -ground Permit: Replacement County Permit: 4207 Installed: 05/27/1970 POWTS Detail: Bed- Seepage Bedrooms: 0 WI Fund: POWTS Pretreatment: NA N o t e Issuen'! risPec-tor As Built Plumber Other Re uirerne:qs Additional Notes Harold Barber No Cudd, Paul MMpy Owed commercial system - 2 septic tanks with 2700 gal. $0.00 Not determined �J, N o capacity and 48'x 72' bed, 36" deep and 8 the lines. State plan from 5/6/70 indicated 3 seepage pits were approved. file with Jenkins' 1993 POWTs permit for house - system may have been abandoned, but send pumping notice for owner response Scheduled Eqrnp Date Putnped 1st Notification 2nd Notification 3rd Notification 5/27/2006 It Sc-PTc -SYSTem lQsf^11�D A-DO()o Z3- �Q�3 STC.- 104, AS BUILT SANITARY SYSTEM REPORT S�-ar� DPP �'o v �� S't% Tic OWNER � t� (� •I E� �C � � S S 1� S T��`'� �/e ADDRESS P.o. pox 3 t,4uc l� r C� E� f= ,t(l c, S S y 6) 2 Z- SUBDIVISION4'/ CSmf 1 367 ff 0 U01 -� LO T SECTION. 2-5 T 2.9 14-r I I -W Town of T y x4AC�OLC- ST. CROI COUNTY, WISCONSIN car Provide setback and elevation ii--,format ion 01-1 revP-y"-;r' of tldZ) Provide 2 dimensi(-.c. to center 0j. septjc t.,-Illk manhole- cover ( c 6 B NC HMAR K : &V A �'Td � �- � 0 0 ' ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / H6LD' ING ..TANK INFORMATION ce t5cketit Manufacturer: Liquid Capacity. 5 �p r Setback from:. Well '761 24 other Pump: Manufacturer v4 Model, # /(/,j Size .,±�' Float separation Gallons/.cycle Alarm Location SOIL ABSORPTION SYSTEM Width: 'Y Length Number' of trenches Distance & Di9.1 rection to Anearest prop_ , line S too P ► t Setback from: well: e other r p * C TA 0 b cc �S ELEVATIONS I,3 e �� Building Sealer ST Inlet; _ ST outlet. PC inlet PC bottom � Pump off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: N O V • PLUMBER ON JOB: rR • 7A L(3� R jG 11 LICENSE NUMBER: kPas INSPECTOR: MAAY /D ,tad . Lo T L . 0 s S Pic s -r-------------, --- DR 5,6 180X r���T-- �rfi�+S �,P.v+ �.5 - - ----- ----� ----- - SyST£'M TMP ►� C7 3,2-57 w p 7 f 5 S SG� DG— o T OF r1 S ID 7-leE.4j 6i� E IE vA i i o 7 `f1 0 ,✓ Tz�� o f CAS+'�Cr �E ,vim 67Ajp /DAD. Q ! /fEAJ TAP �3 OUT SCA L.e ; �� 3 D 4.-�T�Qo E s "? ,, a L PI � 5 k quo r30 i Lr ~ro pATL 'DF� I�s T. pi(r . A5cr�PAO 7-&cr&o�J`k -/l CA-) ao� r'/� sr r'&- 6,0 S i/ 0� LQgA�JA�'ibartrAWXi Ir?dAt4,B0 1 9.399 $RIVATE SEWAGE SYSTEM Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) I GENERAL INFORMATION PEl City 0 Village W Tow Permit Holder's Name:n of: TROY County: C!fr CROIX----- Sanitary Permit No 199920 State Plan ID NO.: Parcel Tax NO-: SBM Elev.: In Elev.: tsivi UVIIIA-1 1pklvl 1. 40— 1 1 CT 0 A9300327 ELtVATION DATA TANK INFORMATION FS ELEV. '0 STATION BS H1 FS CAPACITY TYPE MANUFACTURER CAPACITY Benchmark r. �� Septic Dosing Bldg. Sewer Aeration St Ht Inlet Holding St Ht outlet TANK SETBACK INFORMATION BLDG. G. Ventto ROAD Dt Inlet TANK TO ke 50 N A Dt Bottom /91 Septic >-70 V Header / Man- bly N A q Dosing Dist. Pipe q NA 7 Aeration Bot. System Holding ----------- --------- ----------- Final Grade PUMP / SIPHON INFORMATION q7,74 Manufacturer Demand GPM Model Number Friction Systern TDH Ft TDH Lift L sFarce main Head Length Dia. Dist, To Well SOIL ABSORPTION SYSTEM 0. Of Trenches PIT No. Of Pits Inside ide Dia. Liquid Depth BED/TRENCH width Length DIMENSIONS Manufacturer. DIMENSIONS P L BLDG WELL LAKE / STREAM LEACHING SETBACK SYSTEMModel CHAMBER �i o JM ei Number: INFORMATION Type 0 - OR UNIT System DISTRIBUTION SYSTEM Hole Size x Hole Spacing ing vent To Air intake Header / Manifold Distribution Pipe(s) _� Length Dia — length Dia, Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only xx Mulched xx Depth Of xx Seeded/ Sodded [] yes Na Depth over Depth over Topsoil yes Na Bed /Trench Center Bed /Trench Edges present, etc.) COMMENTS: (Include code discrepancies, persons 5.28,19.399C LOCATION* TROY 2 Cl Ej Yes E] No qu red? plan revision re I No side for additional Information. Ce rt Use other si Date Inspectors Signature SBD-6710(R 05/91) umoc - cwvwn SANITARY PERMIT APPLICATION COON 17 (�t[31LHR in accord with ILHR 83-05, Wis. Adm. Code 5 1 'Or. !�Aq 6�� WIM.OT"FALM STATE S4NITARY PERM" mmon"No I , "'I /'I �) _, 4 t less than / ('_ 1--* ounty copy only) for the system, on paper no 6h.f�� /evious application ; UN Tye STATE —Attach complete plans (to the c ifrevisio�_n 6�P )iication heel 8% x 11 inches in size. r AT P1 ER STATE PLAN I.D. NUMB lication. —see reverse side for instructions for completing this app I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. �rf 3 3 PROPERTY OWNER PROPERTY LOCATION T N, R E (0 W' waoft 5E /4 /4 S \j &A) LOT # BLOCK # PROPERTY PROPERTY OWNER'S MAILING ADDRESS NUMBER SUBDIVISION NAME OR GSM NUMBER ZIP CODE PHONEIfol. 7 CITY, STATE Z L136 NEAREST ROAD I• VEA Li CITY ,I. TYPE OF BUILDING: (Check one) Lj State Owned ❑ VI LA GE' wN OF. or 2 Fam. Dwelling— of bedrooms ELTAXUU-MBER(S) Public tj /0) check all that apply) -7 L/ Ill. BUILDING USE: (if building type is public, 1 0 Apt/Condo 6 yedical Facility/Nursing Home 10 Outdoor Recreational Facility 2 0 Assembly Hall M /Repairs 11 Restaurant/Bar/Dining 3 El Campground 7 Merchandise: Sales 12 Service Station/Car Wash 40 Church/School 8 Mobile Home Park 13 Other: Specify 5 0 Hotel/Motel 9 off ice/Factory line A. Check line B if applicable) IV. TYPE 0 PERMIT: (Check only one in 1 4. Reconnection of 5. Repair of an A) 1. TYPE 2. El Replacement 3. 0 Replacement of Existing System Existing System System System Tank Only Date issued B) EJ A Sanitary Permit was previously issued. Permit# mm� V. TYPE OF SYSTEM: (Check only one) Other Non -Pressurized Distribution Pressurized Distribution Experimental 41 Holding Tank 11 epage Bed 21 [:] Mound 30 Specify Type 42 pit Privy 12 50'Soeepage Trench 22 fl . In -Ground 43 Vault Privy 13 ❑Seepage Pit Pressure 14 ❑ System -In -Fill 3 •GRADE V1. ABSORPTION SYSTEM INFORMATION: 5.PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE E REQUIREDABSORP. AREA 13. ABSORP. AREA 4. LOADING RATE (Min./inch) LEVATION1. GALLONS PER DAY (sq. ft.) 'PROPOSED (sq. ft.) (Gals/day/sq. ft.) OVA- Feet f,7.5 Feet Site Fiber- Plastic Exper. CAPACITY Prefab. Con- Steel App. VII. TANK in allons Total of Manufacturer's Name Concrete glass ABS ORPTION =G INFORMATION New xisting Gallons Tanks structed Tanks Tanks se tic Tank or Iding Tank Lift Pump Tank/Siphon Chamber Vill. RESPONSIBILITY STATEMENT shown on the attached plans. 1, the undersigned, assume responsibility for installation of the onsite sewage system MP/MPRSW No.: Business Phone Number: er's Name (Print): Plumber's Signature: (No Stamps) 1 71 4? --ft Business Plumb 3 1'r,- street, 33o"w)' ;i �mb- ium er s Address (City, State, Zip Code): mom 655 ------- (No Stamps) OUNTYIDEPARTMENT USE ONLY 9 ........... . iwing Agent Signature I t Ix. C (includes Groundwater ate Issi Sanitary Permit Fee Disapproved Surcharge Fee) A'Approved ❑ owner Given initial Adverse Determination x. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber SBD-6398 (formerly Plb-67) (R. 11/88) �i r INSTAUCTIONS 4, a 1. A sanitary permit is valid for two 2 � )Years. � 2. Your sanitary permit may be renewed before the expiration xp�ratron date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable 3. All revisions tv this permit must be a PP ble. approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanit ary Permit Transfer/Renewal Farm �SBp 83gg to submitted to the county prior to installation. } be 5--Onsite sewage systems must be proper! maintained. ned. The septic tank(s) must be pumped b a [icen Y sed Pumper whenever necessary, usually every 2 to 3 years. s- If you have questions concerning your onsite sews . ge system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-268- 38 1 5. To be complete and accurate this sanitarypermit P application must include: �. Property owner's name and mailing address. Provide the legal description and parcel tax number where the system is to be installed. �s } of ll- Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. II,I. Building use. If building type is Public, check all a g IV. .Type of permit. Check onlyone in line appropriate boxes that apply. ne A. Complete fine B if permit is for tank replacement, repair.. P ent, reconnection or V. Type of system. Check appropriate box depending P 9 on system type. Vl. Absorption system informatio n. Provide all information requested in #1-7. Vll. Tank information. Fill in the capacity of ever new an tanks and manufacturer's name. Indicate r Y door existing tank, list the total gallons, number of septic, prefab or site constructed and tank material. Complete P Pump/siphon and holding tanks for this system. Check experimental P e for all experimental product approval from DILHR. P mental approval only if tanks received VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix e. . MP, etc.}, address and phone number. Plumber must sign9 Ix. County/Department Use Only, application form. X. County/Department Use Only. Complete plans and specifications not smaller than 8' x plans must include the fvilo;�in : A [ 11 inches must be submitted to the count 9 }pot plan, drawn to scale or with complete dimensi Y- The holding tanks), septic tank(s) or other treatment tanks building ons, location of streams and lakes; pump or siphon tanks; distribute boxes- , g sewers; wells; water mainslwater service; distribution boxes; soil absorption systerns; replacements stem areas, and the location of the building served; B} horizontal and v �� Y C} complete specifications for pumps and controls; dose vertical elevation reference points; , volume, elevation differences; friction loss; urn performance curve; pump model and pump manufacturer; D pump required by the county; E} soil test data on a 11 } cross section of the soil absorption system i# 5 form; and F} all sizing-. information. y GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges regulated practices which can effect groundwater. (fees) far a number of The monies collected through these,sUrcharges are use water contamination investigations and establishmentd for rpon�tarng grq.�ndwater, ground - of standards. } SBD-6398 (R.11/88) low I ULBRICHT & ASSOCIATES CON Reg, DesIgners of Engineering Yste S 655 O'Neil Road * Hudson, Wl 54016 Private Sewage Consultants 715-386-8185 PROJECT INDEX Date vou-t- N13 DILHR Plan I*D- # Sc� 3 - 0 3 L4 L-1 kr�S Phone (.a cO 7 Z. Owner ZOE �-3 Address ?od).BOA Legal Description " -r 2— L) 56er. 2 5 T 2-9 �3 I T County �6 CPO' Town of -T RO Installer C 0 S. T. �. OU L- 6P, t C, [� Local Authority/ Supervision y 2— L L) WQ.E E,=-PECT alp s PROJECT DESCRIPTION (0(t(^ -`P17:75T 0 Izoom J10012 Dj?,AWS Bi, t APs7 FOR AvAJ /cot 6'A l f- u 1, At -E D F,IE CU S-ro).l �ks TOTAL Ee� Dt�fLy WAS-tFf/0443 .) 1-1 SbtL C0AjU.L,-0T1 - 0&.)^L -TE' PER '�Oj5-& 50 E: A, C& K P& QU,REIDJA0Qf AlUM7 T F=7 Pg,l PLOT PLAN VIEWST- Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS 0N.S �� 14F L 4 Wis. 4r 40i lam/ AJ E Jo - - 1C _ --1 --- - -- --- -- i - i �ysrAE-M 40 D - -- --133- y cr �o �} ' xPRO . S 5 � I--___------ - a - h s y s rE ►� 13 z 7 0 r • 7 r • s TiPE,V C G, �� 3 0 i G W 33 • • _ 134 rt-f{oc- P1-7-5 � H yp,PAwr zy'xyz,/q, 1 /2 coo sE}�rl II . - Ta OJT +GCS t4` /I j tv Ar PA'a%��SED � v i MANufhtlupte' sh'°�' • at I �u e T s 604 /E � . ............. ..... ..... .... ............ ST r3 � y s rveA ('E r3/� T-4 � z 0 wA) Ipp C.. t7// C> vim t r� dF ::iUs �A i/ Av 6w S ffo�o • ,°/a ds D Sys 7C t14 T'4v A' SYSTEM CROSS 5G��C1[(OA3S Fresh Air Inlets And Observation Pipe TTREPC Approved Vent Cap 10 Minimum 12' Above Final Grad • le5lW1,5& ZD 40 Cost Iran ,$`�'+�'�► Above Pi pis V VWS 'lo Final Grade w *tlonallY Call Synthetic Covering d Min. 24 Aggregate Over Pipe Val Distribution SC4, nt-7:2.,? Of Pipe 1 0 0 a 0 0 SIDS c1p Aggregate 0 Pert a 0, p0t41DEtACC 6 V!STE M Beneath Pip . 4 0 '"'--' C U. rnflno Ing'Al I E L) AT-/ 0,AJ Bottom Of ystom Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12* Above Final Gr- ode �/ NIS z5) -TRIE c ti 11014 w 01 76 40 Cost Iron 2� Above Pipe Vent Pipe' "io Final erode Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Too Pipe -0 a 0 0 0 0 " Aggregate 0 Perforated Pipe Below Beneath Pips, 0 �Couplinq Terminating At �-y5�-�� Bottom Of system LL MT101J Wesconsin Departrnent of Industry, SOIL AND SITE E V A L �! AT I ©N REPORT Lobar and Human Rotations Division of Safety & Buitdnngs in accord with ILHR 83.05, Wis. Adm. Code Attach, -complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must induder, but not limited to vertical and horizontal reference point (BM), direction and % of sbpe, scale or dimensi ned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION SOIL DESCRIPTION REPORT Ground elev. el5r�7 t L- to limiting factor � w Remarks: � Your/ 'zew 5 Boring # _ Ground elev. �5, i-Z�- tt Depth to limiting factor rr > o 10 Remarks: I `1 CST Name: --Please Print �06 -P 7- ,Z1/h,,P1 C"/l Phone, 71� 3 e6 Address: ��� �'�'©� '�p.SQ,•.� c zo �3 T.1 Signahxe: Dots: CST Number: TEA* - PROPERTY OWNER PARCEL LD. Boring # 13 Ground ow. ;-- 2-- fL Depth b limifing bcw /i Boring # Ground elev. fL Depth lo err Ang bm /" 7! o e Ground elev. �'6,2- 2-- fL Depth to knMV Boring # 13 Ground elev. tL Depth ID IwAing bw SOIL DESCRIPTION REPORT Page,--7 Of Horizon Horizon Depth in. Dominant Color Munsell Modes CkL Sz. Cont. color -M Texture Structure Gr. Sz. Sh. Con ore Bourday Roots G P D/ftZ Bed T—mrc]h -0-2-5; 10)(R �Z/ ------- 0 104;1-1 /,f , 516& 11, 4��, 5 2 /3, -25 -9P /0 YIC 31(, 1 S61< f -3 Remarks: 0 - /0 icy yez/ / s� 1141 I.///< 2 yid s/� S C� S9 AI Remarks: "4 //-"0/? /, ze✓ 4 e 0 e e,-) a - i o y,� 2,1 2- ra ,�, S-/0.4t- fe s z f . s 0 Is%,2V -7,sye 15 a 4*1 � s . , Y/ 0,C Remarks: Remarks: ocon wv)rwo ^cjnrw% — r C � rl'7 QJ' rY _]�p/ � �✓31 S S C7 - ? ^r�cY9a-L 44-9.)H s 4FJ , rj 9, 0-ft S ��' e 79 5rYo.4.4'el Ovvy CI�Svdv�a i 4 � J I oL o Sno t-✓ a ©7 '?.V rr«cd/C7 -9 c"i15 r X z� ol— - �y --y C�-7 ON O� r do//s rs�sod pad thx,hz Q dJ� M Date LIZ // / r -3 APPLICATION FOR ZONING APPROVAL IN EXTRATERRITORIAL AREA CITY OF RIVER FALLS WI Owner '00LJo I)qs Phone���� ��l'j71 2 7 Address —110 z ! V Y s v-- Type of Building Township rr—o—L Location: Section %_ �� / 9 � Quarter Section Site Zoning District ZA Minimum Lot Size Required low APPROVED: i��lntGU���f�Yol/�o�P� ��� �J/j�'/ �i D� NOT APPROVED: NOTE: This approval does not constitute a permit to build Building permits are issued by the Township only, sp9wv 3 SAFETY & BUILDINGS DIVISION State Of Wisconsin Department of Industry, Labor and Human Relations November 1. 1993 Wcisii'lny-4toti Avenue 0. [lox 7969 Madison W1 53707 ULBRIC[i,r & ASSOC 655 WNFILi. ROAD HUDSON W1 54016 RL: PLAN S93-03944 JENKINS, DOUG FEE RECEIVED: 110,00 SE,SE12592871%2 TOWN OF TROY COUNTY OF ST CROIX NON -PRESSURIZED IN -GROUND SYSTEM The Department has reviewed -1-1he above -referenced submittal. Conditional approval is hereby granted for the SYStem plan submi-t-tal, fJl noted ite"Is must be corrected. The review and' approval of the SYstem i�� based on chapter 1459 Wisconsin,Stattites, and chapters 11HR 83 and 84, Wisconsin Administrative Code', and is contingent upon colopliance with dr) stipulations shown on the plans. This SY00m has'not been reviewed for theycode ,re-(m1re'ments set forth in chapter ILHR, 82 or in chapters li.�iR 50-641 Wisconsin Administrative Code. This plan submittal approval ill expire two ,years I from -the approval dat(--, or if a sanitary permit is�obt w initial Sanitary ' ained, plan approval will expire on the day tf1p Oclttm'it expires'. ,The licensed "Plumber, responsible for thi�, installation shall kPPP one..set of plans with the Departmenl-'s stamp of approva at flip- (!unstructi on S 1 te The instal ler sh,11 -1 fl0t) f inspector when iy the appropriatp nspections cart, he made. All permits required by the city, v-1 11d90 . township or county shall be obtained prior to installation. Inquirips should be directed to me at the n Umber listed below. to the plan number shown above. refer Sinceroly, Ke ne h Stiemke Plan Reviewer Section of Private Sewage (608) 266-8230 7:00 to 3:45 Mon. thu Fri SOM"M in. 91tol I 1. 1 1111111W, S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER BUYER e9Cam-E'A) /<I A 44 Ai I i A) Lr- C9 ADDRESS - 90�, FIRE CITY/STATE P'4pVtk, ��� 01- NUMBER 1 ZIP - PROPERTY LOCATION SECTION 4*'.r a TOWN of TeoW SUBDIVISJOI�C5L �'34 )VI Sto Croix County, .7 *1 > LOT NUMBER 2-- P- Improper use and maintenance of result * -1 n Your septic its premature failure system Could maintenance consists Of PuMping out to handle wastes. Proper years or sooner, the septic tank every three if needed by a licensed septic tank Pumper. What YOU Put into the sYstem. can affect the function of the septic tank as a treatment stage in the waste diSposal system. St. Croix County residents may be eligible for a maximum Of 60% Of the to receive a grant system cost of re 0 a failing p which was in operation prior to Sul y 1, County accepted this program in August of 1978, Sto Croix requirement that owners Of all new 1980f With the system Properly maintained. systems agree to keep their I The property owner agrees to submit to St. certification form, signed by the owner and b Croix' Zoning a journeyman Plumber/ restricted y mat Plumber, verifying that (1) Plumber or a licen sed Pumper the on -site wastewater disposal System is proper operating condition and (2) aft in necessary), the septic tank is 1 after inspection and Pumping •(if SCUM. I/We ess than 1/3 full Of Sludge and 1 the undersigned have read the above requirements and agree to maintain the private sewage disposal syst in accordance With the standards set forth, herein , as set by the Wisconsin DNR. Certification stat' Ing that Your septic has been maintained completed and returned to the St. 30 days of the three Croix CO, must be Zoning offi 0 9 year expiration date. within SIGNED: DATE,-. St. Croix coo Zoning off' 911 ice A %-'" St, Hudson, WI 54016 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/con'tractor,(spec house), then, I iasecond form should be retained and completed when the property s sold and submitted to this office with the appropriate deed recording, --- ---------- ------------------ ---- a -------- Owner of property �v o 6- S&)o Ki Aj-.5 Location of - property 1/4 Sge7- 1/4, Section 'Z 5 T_aN-R_!1W Township -rfao y • Mailing address Address of site 1�w Subdivision name- 17 Lot no Other homes on property? yes No Previous owner of property 5i Total size of parcel -3,. (,,-, 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 Number1as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WMZRMTY 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. 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. Signature of applicant Date of Signature Co --applicant Date of gnature • may^ �� I �' FILED APR 2 0 1988 .FAMES O'CONNELL 43G4:11. Register of Deeds co St. Croix Co., W1 CERTIFIED SURVEY MAP 'Q LOCATED IN THE SE1/4 OF THE SE1/4 OF SECTION 25, ST. CROIX COUNTY, WISCONSIN T28N, R19W, TOWN OF TROY ' o E1/4 CORNER SECTION 25 •--'r fi SCALE IN FEET T28N3 R 1 19W 3.6' 0 { 120' 240' , .��ED — o 33' N76ZL6E)' 3.5a �I u — r � 0 26 26 BB 7 6 354 . �! f 1 4�E� (N750� p, �aE 35' 355:�+6' zJ �I riiobile home � house HI s h e ci r, I 1 1 SPIELHAUS , ' ,n -; 3.43 Ck �' 149s 613 S'r' _ °, �' aI zl 1 BA j R 1 ' W , � ,► 1 1,0'i _ 1 C"n O N r' � 3.4� AC+ 677 S ,F ce rn I w oo 2.94 1�` , 28,ps� s•r' `� o Koa p Easement N 230 S ne 550.0 oR0 N79 1661 � � 3 1.41 o j y LQT _ O I 1 217, $oo s •� 00 wl � W P, U)I CDs.r.+ � 4.383 AC+ 19 0 , 91.5 Eas ement cam' �' 1 H! w c.� H 120 bG' awa Exclucling Roa y �I w �I N 51 8 1p L I 60` ( 85 2.61 ::DI ----- _I 2.6 — Q 5B9 CIO • �o I'�G cn 5 u 1 a w! 57��50 x 0 H _ Wy co , 60 o o i APPROVED H 014NER AND SUBDIVIDER APR 2 Q DOUGLAS , LJ. BOX 213 .'JENKINS & RITA J. . JENKINS ' C SE CORNER RIVER I''ALLS , W1 . 54022 SECTION T28N , It19W� 25 'l'llis (11 ,-1f Cccl by James T. Swanson Volume 7 flake 1955 w DESCRIPTION A parcel of land located in Che SE 1/4 of Troy ► Sc. C r o i ,� C o u n c Wisconsin �` ' .,- :a..'e►'y ;: �;�i 4 i .. Y1 sconsin descri.bedhasSfoliowof S.�2r5,�`•,' 8 "� ,��fd said Sec t ion 25; hence NOR'I'1I Town o f 30$ , 0D' Conrme n�C ifir a C-• eiI c!•� SE corner of beginning; thence S74° "long the East line of. 'aid SE ;1+� t s0'18"W 583.40' thence Northerly 169.03' oil� �r 2924 93thraroirlt of curve corlc�rve t�'esterly whose chord bears N2°32' " line of SCr1Ce Trtrnk ifiI;I)wrr 30 IJ 169.01 "' along the E,'15yterl of-t,r+y lure; 'herice NorCherly 73l3G7' thence Nd5°��£?' 10"I: y ri8ht-of-- chord bea!-s r\ 1 1 ° 13' zrlon f a 2934 , c G0. 0Q' rrl.onR `Jfl iCI 1:.ir, c • !0 fJ 729.3�, €�° �3 1-acll.us carve concave [JcL r1y rif;lrc- thence Souch 902.00, ; thence N74 50'!8"'I: Z80.00`-;terly whose along said Easterly ; thence N76°26' 2b"1' 393. 46' y line of the SE i/4 to the ' This parcel concaj-ns 11, point of beginning. 848 Acrc ,, more or less, be irzg 516, U9U Square, . Subject CO e�~r,crrrent , of 9 "irc. Feet, , inUrc' or record. I certify that the abov description the e de.,cripCion and map are correct and that 236,34 pt"ovisions of Chapter 18 of the Sr. of the of Statutes. Croix County 2onirrg Ordinareiceualy complied rici section Dace: ?March 1, 1988, Revised April 13, ���a���I yeti`ri✓�� '�i♦�r,AA1 _�SA,- NSUN S 1988. rs 1' 2Og(len I4iJob N. 1GEngineering Co. �► 113 SJ. Walnut Street ItoJANIES T. �s River Falis, Wisconsin 54022 SVJANSON s• 1 �tii2 w : OIJNERS AND. SUBDIVIDER RIVED, PALLS, DOUGLAS W. WIS. 1� Box 213 JLNKINS and RITA J. JENKINS • a • River Fells, Wisconsin 54022 r �. latatio ST. CROIX COU 0 it NTY SECTION CORNER AIONMENT, BERNTSEN CAP,I`OUND. IRON PIPE, WEIGHING I.681// LINEAL FOOT, SE`!'. • 1" IRON PIPE, FOUND, r\'82I;) (G8I ' ?) (1'REVIOUSI.y RF;C0R1)I�D (1 ° 2 (PREVIOUSLY Rl;C0IZDI:I) BEARING) IJ} lxzSUM FFvcE CURVE 0.1 CURVE: DATA '!'ABLE NO �. LOT RADIUS AIZC CHORD • P,"U , LE'NG'i'jI -- CHORD CE N'!'IZr1I_ .----__ LE '!I 1ILARING _ _ - ! 5_1` & N1) A N G_L 1: 1 2 ; 3 2924 , 93' 1 G9 . 03' 16 ! [.N- n1tTNc; 9.0!' N2°3l'3U"W 3°l81 Z,0--�_ N0053' 1 rj'°kr 3-4 2984,93" 731.67" 729N1+°1!`50"ld .84 N1I°!3'!0"W !4°02'�,Oo� N4 ° 11 ' 50"W 3 2934. 93262 . 39' 262.42 62 , N 18 °,11,' 3Q"�W 31 N6 ° j +2' SG"W 5°0?' 12�� N4011'50"W N90 I Z, 02"W ! ?9f34 . 93' 469. 28" 468, 79, N13°44' 16"W 9 ° " Ot,'\'EIS CERTIFICATE N18°11r'30%, OF D E D I C A T I O N DOUGLAS l,'. JENKINS :rrrcl RI'1'A J , oil this Cerc{ Jl:NKINS, lticrel�y cerei!'y thnr wc� ctr�r5eC1 the ltrr�cl _Fitt! Survey I�lfr1) to be surveyed, diviclec, irnel rnap, "IPPec! as representc(l o n`c'Cltr.is3c�cl S%'ITN'E.SS the h�-rnc! and seal of snid owners thi. S ___� C1 , l y of 1983. DOUGL:IS I,'. JE,NKINS I2 I I' A J ------- STATE OF IdISCOINSIN) ,1 fN !SIN 5 ST. CROI \ ) SS PcrsonarllY ctirne before me tiri s persons Who executed the forego---- deny of 9 Fi itz�Cruin enC an IcrrowledP,cdt e Shc' 1'l�ov4' rr.-)rirecl 1�I' U IS L 1 ��' � ----------�. MY C u n i n i :1 !r n .i Oil c x p .!. r e fr r VOLUME 7 PAGE 1955 .' DOCUMENT No. ., STATE BAR of WTSC'OhSI,i- FORM VOL 544 P0 THIS SP WARRANTY DEED E RESERVED FOR RECOROING DATA THIS r)p:Fj) 11(te bo-tween Kenn ----- i' —.� .—Sumner: husband arch Sumner-n �--- f�-...r-- -- --J-Q ann a. Mae Q �Ft L � __ _---- °W�?- `? _t_ w _f __and_ -each in �he.i sr .�, and DO U - -- -�'�---`---� C - _- g I a Je n k i---.�- r d this _ to d F - - ---____�-- -- ant S c "tQ._ ., c e r at IneHeeth 00 That the said t,ra __`-------.--..._ � nt��r for valuable e Grantee, _ `- --.------�__.� cotiside-btian __ conveys to Grantee the fo1l..)�" :. wing descried real rs ``��~- ` Register of Dead State of Wisconsin: tare in S —;- --' County, RETURN To ' -- _�`_ .� ► A parcel of ' Of the SE', o f . 9 acres located in t � he SE Range 19 iVeSt Section ..5, Tawnshi 2 Tax trey tt4 _ From the so I further described P 8 North, _ U t h e a s t C O a$ follows : This is _ n O t homestead property. i Section line a dz rnvr of said Section - for the parcel to Of 308. on 25 go tirorth aloe th f► ' 0 feet to the g �' ng the section line o be conveyed herein• point of be inni thence continue North along West a distance of distance Of 902.0 Of 891,2 f 389.7 feet"feet, thence Sout760261©ng eet, thence North 7Sothence South � � � h to the '' Point o'L beginning 04' East a distance a distance g f 288.3 feet r (This deed Parties dabs given in fulfillment t dated December 24, 1�97I n� ©f a Land Contract betty Vol. 47g, page 508 nd recorde eej the Of Deeds' as Doc. No. 308335, St• d December Z7, 1971, in Together with all and sin©ffCe • CrOIx singular the hereditaments County Register And Ke 11 R e t h and aPpurtenanceS there r ��—Sumner_ and warrants that the title is - Joann-'� ��ae unto belonging ar in any wise a good, indeteasihIe Sumner appertaining; eaSemen t in fee sim to a s and P and free and clear of encumbrances ex � -- .�_r i.�h t s of ceps �� --_�------.�- wa�o f record_ and will warrant and defend the record—_.------- ++ ` - Executed at River Falls., Isconsln ----� this Z 9 t h day of OCt{7jer . 19 76 SIGNED AND SEALED-' IN PRESENCE OF !iJnne th Sumner (sEAt,) -_ Joanna Mae Sumner (SEAL) F (SEAL) — ------------� rY (SEAL) 1 j P i Signatures of 1 `_Rneth Sumner and Joanna —�---_� Mae , ;i this Sumner authenticated 1day of ---� dj L� ` -- C • '� Gaylord J Title, Member State j' Authorized under $r of Wisconsin f 7 or Other Party f STATE OF WISCONSIN / 06.06 viz. Pers33. -)n:�11 - County. Y came before me, this -- F the above n,, med ._ " _` - -- - - - - ----.` day of +` +� to me known to be the l4 Person - - - who executed the fore _.�4---_.__.__—�----�� going instrument and acknowledged (� d the same. This instrument was drafted by F CoylordAttorney - _ - -------_�__ x River Falls } _- +��1SCOn51Ft. Notary Public-� The use of witnesses is optional. County, Wis. f - - MY Commission (Expires) (Is) I Names of ----� persons signi ng in art .. Y capacity should he t Yped or printed below their signatures." 0 - Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pap of 3 Labor and Human Relations Division of Safoly & BUlikings in accord with ILHR 83.05, Wis. Adm. Code COUNTY a .5777, CoeOIX Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and % of sbpe, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION -----IREVIMO BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT 1/4 1/4,S 25 T 24-� N,R I cl E (or) W PROPERTY OVYNER'-S MAILING ADDRESS LOT # BLOCK 0 SUBD. NAME OR CSM # 0 2- CV6lele STATE ZIP CODE PHONE NUMBER E]CITY [3VILLAGE OTOWN ROAD 4/4 -2- (71 ��l /Y L. NEAREST 14,fNew Construction Use Residential / Number of bedrooms Addition to eAsting building Replacement Public or commercial describe 7 eP U4E - 774,6125 ). q 'X 112,' -- G00 S? 6 " I Code derived daily flow gpd(/76 a4 S/V'-Of P5) Recommended design badirg rate bed, gpcLt2 trench, gpd/ft2 Absorption area required bed, ft2 '005 trench, ft2 Mwximum design kedng rate bed, gpd/ft2 0' trench, gVW Recommended infiltration surface elevation(s) —ft (as referred to site plan benchmark) Additional design / site considerations Parent material AP-4 eOr 4Flood p6n elevation, if applicable ft --e - -- - 4 /'IV J; S = Suitable for system rINTI0 OVAL MOUND IN -GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TAW U = Unsuitable for system U E3 9 1:1 U OS" 0 U E3-S 0 U 3 IS El U 0S Boring # Ground elev. q5'97-ft. Depth to limiting factor -;, ?p Boring # Ground elev. y�5' '2- 2- ft. Depth to limiting factor > O SOIL DESCRIPTION REPORT Horizon Depth in. Dominant Color Munsell Mottes Qu. Sz. Cont color Texture Structure Gr. Sz. Sh. Consistence Bwtbiy Roots GPD/ftz Bed Tmr& 2- Piomnrkq- /0 2-11 h& 4" -Oc- yle Remarks* CST Name: —Please Print Phone: 71,— 3e6 ele5- Address: %, - 2 0 ,4,7 e 4c)/. S te/ CSC ' Signature: Date: CST Number: ills Sys CA., ORIGINAL O PROPERTY OWNER e:1). PAFICEL LD. I Ground elev. 17, Depth to limiting facw // Boring # Ground elev. 7 Depth to Imiting Wor 7 cl Boring # Ground GR elev. 1 7 ft Depth to lirrfing bcbr 2- Boring # E- 3.- SOIL DESCRIPTION REPORT PW of Horizon Depth in. Dominant Color Munsell Moftles Qu. Sz- Cont Color Texture Structure Gr. Sz. Sh. cor�isbenoe aw3ry Roots GPD/ft2 Bed Tmrch qmrr-h 0-2 0 YIC 211 ------ 5 ;-5 /0 y/e 31(.e 5711 f 5 6K 132- 61 31 7, 5 Ye Y10e ------ 15 Is Ground elev. ft Depth to firnibng factor COM 003pq^ID Rom-qrkez- 7- A) /V/ MomorL-e- fie -2- /5/ /0 V/f3 '.' —= Jul' 7'c 5,� ,mot-, ,� �'�' Z j� �/'- S 134,K fle4 / /0 yve 0,C PamnrL-c- Remarks: i ©sodoye ! L-✓�1 S /{ $ d �'' .��'OY wcy/ 5 CY77(y � 1- �✓ o�g X , o� �� ! ry F'thA,ht 1�„7 52, Jot QL 1 S<7 p7/ w Csc C7 �, ►} r'"��`cV o % n'/.l �.1 X ' _ _ _ _ — _ , , lot/ -- _ `�1 1 �.5Fn 1 i ,oll � 1 a� 0 FILED AP R 2 0 ig8a JAMES O'COjtiIVL-LL Register of Deeds co St. Croix Co., wl CERTIFIED SURVEY MAP 2% LOCATED IN THE SEIZ4 OF THE SEIZ4 OF SECTION 252 T28N, R19W, TOWN OF TROY___� , ST. CROIX COUNTY, WISCONSIN _%-j I I --I �7 �* N _'� % � E 1Z 4 T El/4 CORNER C 0 RNER SECTION C SECTION 25 0 I N 25 SCALE IN FEET T28N, T 28N, 9 Rl 9W R19W 3 6 y 0 9 7 1) 'D 7 4 120' 240' (3B9' N"" 3 3 D 6 0 354. 46 358' 50 0 41 120 40 50 \4 ()0 mobile house home <> shed 1,C)T 3.43 + SPIELHAUS '% 149,613 1-"'- BAR oe Ln CD P 1 `I ` } Lp,� 1 �-, r- t 3.41 0 48677 S*Y*t 2.94 Pic+ ]L2B 0 g6 S.F.+ CD rn 'z Roadway'3.0 sement Ln Ln E-4 0 550 061 apt r 07- I 1 13.99 % 1 "E 79 501 IB 6 6 1 L0,1 3 < 0 + 5.00 AG t 217,800 04 wl 4.383 P'c + I 190)915 SoF-+ Easement Ea E-1 w � �; I � 1201 1661 FXcludiaS RoadwaY 60.00 3 a0. 601 I 1011E zl U 60 (NS�044'E) ` 2. 61 a F4 0� 2.61 44 (D ?0 � w � I � � o ,�$„W 5a0.7 , � BEG1'�� 004 � 'D L va 60 601 C4 00 APPROVED OWNER, AND SUBDIVIDER DOUGLAS W. JENKINS & RITA J. JENKINS APR 20 10 SE CORNER BOX 213 RIVER FALLS, ST. SECTION WI. 54022 CC 2 8 25 This instrunient drafted by James T. Swanson Volume 7 Page 1955 r DESCRIPTION E located in the SE 1/4 of the SE 1f4 OE S," `WW, Town of ., 61 A ..parcel of land Troy, Sc. Croix: County, Wisconsin described as follows: Camin�ii� vwsr-, corner of r ,. said Section .25; thence NORTH 308.00' along the East line of+;paxd; SE to the point of ° E' ' -1 169.'03' an` a4.9.3' rr�cliu.� beginning, thence S74 50 18 W 5.83. 40 , thence Northerly y curve Concave Westerly whose chord bears N2°32'30"W 169,01' along the Eastarly right-of-- way lire of State Trunk Highway 35 , thence N85°4`7' 10"'L 60 00' � - �� ,�� �, � along sai.cl Lasttri,y riLl��. ,of —way', -�line; 4hence Northerly 731.67' �ilong a 2984,93' radius curve concave Weoterly whose. {chard'bears ti11°13'10"W 729.84'; thence N74°50'18"L 280.00'; thence N76°26'26"E 393.46'; fh'enc.e South 902.00' along said Easterly Iir�e of Tale Sr 1/4 to the point of beginning;. This parcel contains 11.848 Acres, more of less,beLng 516,090 Square Feet, more or less.. 1 Subject to easements of record. I certify that the above description and map are correct and that I have fully complied with,the provisions of Chapter-18 of the St. Croix.County Zoning Ordinance. and Section 236,34 of the Wisconsin Statutes, Dace: March 1,1988. A ♦♦ JAMES T. . SWANSON S-1482 Job No. 88�-1716 Revised April 139 co jb 1*0� 1988. ` .� � Ogden Engineering Co. 11.3 W. Walnut Street .LAMEST. �i River Falls, Wisconsin 54022 i SWANSON S_1482 OWNERS AND SUBDIVIDER RIVET FALLS, DOUGLAS W. JENKINS and RI.TA J . JENKINS 1 '$ WIS. f� Box 213 '% River Falls, Wisconsin 54022 1 LEGEND �f• ND� . U-r:.��o ST. CROIX COUNTY SECTION CORNER MONUMENT, BERNTSEN CAY,FOUND. Q5 O 1" x 24" IRON PIPE, WEIGHING 1,68#f LINEAL FOOT, SET. • 1" IRON PIPE, FOUND. I (b$1,2) (PREVIOUSLY RECORDED DISTANCE) (N81 ° 2"2.W (PREVIOUSLY RECORDED BEARING) EKIST'. U MCE CURVE DATA TABLE CURVE LOT RADIUS ARC CHORD CHORD � CENT 1S'!' & 2N1) ---�---- -—•---�- � TANGENT . BEARING 1 NO.. NO, LENGTH LENGTH LENGTH BEARING ANGLi: .__ i 1-22924,93' 169.03' 169.01' N2032'30"W 3°18'40." NO°53'i0"W N4" 11' 50"14 i-• 3-4 2984.93' 731.67' 729.84' N11°13'10"W 14002'40" N4°o11'50"W N18 1+ 30 W, 3 2984.93' 262.39' 262.31' N6042'56"W 5002112" N4011'50"W N9014'02"W 2984,93' 469.28' 468.79' N13°44'10"W 9000"28" N9°14'0�"l1 1 N18°14'30"W OWNERS CERTIFICATE OF DEDICATION i DOUGLAS W. JENKINS and RITA J. JENKINS, hereby certify that we caused the land describiecd ' lecl and ma ed as represented on this on this Certified Survey Map to be surveyed, chiv�c pP t lITN1•:SS the hand seal of said owners this _ 20th d3 f April 1988. DO GLAS W. JENKI RIT!' J . JE K iNS STATE OF WISCONSIN) SS ST. CROIX COUNTY ) Person ly, came,,,before me this? *h - day of April , 1988, the above named Berson ho executed the foregoing instrument and acknowledged the same, 1989 ' My Commission expires April 30, NOTA PUBLIC VOLUME 7 PAGE 1955 V Plb to NAME OF BUS f INE3S LOCAT I ON . l� 1 � M street or higtmra, ,,, I 17 city or torrnahip LEGAL DESCRIPTION -1 ..r. , county OWNER r 41�.4 ri r r mail ing address A.BC HI TEC T OR ENGI NEEjt z I P Address PLUM ER A/ Zip fr w Address 1. Chock a , 7 Ppropriate build ussSe(s} and till in the Exist building information requested opposite each usage listed: It` addition to exist Now building build Addition building attach detailed. memo for each. ( } Drive in re stau rant } Restaurant • • •Car spaces } Dining hall . . Seating aapa4 ity(10 • Per meal served Motel } Motel +( } Hotel } Cott aga . r Toilet waste Ye ` . Number of units = 2-----.-- No TOTAL Persons/unit �+ 4 persons unit } Churches . . . . . . Numbs NUMBER OF UNITS } Bar or 000ktail 1 r of Persona Kitchen Yes } Nora i lounge • Seating capacity 4 1p �-- No or rest home sQ r fte/person) _..,. }Mobile hams ' Number of beds--------- rk • • • r Number of units -dependent temper trailer) } Retail store nondependent (mobile home) } � } Service station � � � � ' Number of employees �------.� Number of aunt©mere � 10 sq. ft,/person} School r Number of oars served-TTL1 ) . . . . . . Number of alassrooms-....._. Showers Meals served Yes No � } Factory or office building � er Providedof persons Yes ���" No �► • total } Residence all shifts�7 « . Apartments f • • r • r • Number of bedrooms r • • • r r • • • •-�*�,.....�. Other • der of bedrooms • Speoify 2. Indicate whether Ile_ or not the following/ facilities are ooruzeated: Food waste r d g �.I7 8r r • • • r Yes No Dishw►"her r . . r Yes Automatic clothes washer � Yee Na 3r Fill in the appropriate No information for the following as indicated: Septic tank capacity Planned 7, 9 ' � '�• TOTAL Septic tank capacity required -.�C. �' .- Perwolation test results •• ATTACHY q fired ._ w� � � PERCOLATIbN TEST AEnRT SHEET Seepage trench bottom area planned width linear Teat Seepage bed area planned width depth linear Feet Seepage pit., Planned 1. / depth outside diameter � -- � depth below inlet � depth Seepage trench bottom area required width-IWO --- ft -------- — 1 in ear feet Seepage bed area required depth width linear feet Seepage pit, required depth outside disrneter 007 depth below, inlet Signatu7(-"t of person oompletin_,forni: .". r STATE DIVISION DF HEALTH P .. -r!,� i '' r j LtT�II31NG SECT Address , ,� � .� Pr 0. Box 309 Madison# `Wisconsin 537011C�N Approved: Dates Date: THIS APPROVAL IS BASED ON STATE PLUMBI1% CODE REQUIW-MTS AND ,DOES NOT EXEMPT THE INSTALLATION FROM CITY, VILLAGE $ TOWN- SHIP OR COUNTY REGULATIONS DR PERKI`r (OVER) REQUI ANTS . �. INFORMATION REQUIRED FOR SUBMISSION OF PLANS e tic tank and effluent disposal system,, of property on which s p {. Legal description • taped. be ins test hoses. Tests are to be conducted is to ' test data from a minimum mum of three 2. Percolation ed effluent absorption system. Where ground • and to the depth of the proposed from grade level to same shall #n the area conditions exist, -the vertical depth water and/or bedrock con building be indicated.specifying the location of the . d plan of the proposed installation a+1e absorption system with location and 3.• A detailed P effluent abso p Y size and design gn of septic tank, served, numerical identification of percolation test holes. ank effluent disposal system and plan lateral distances between septic a4. Indicate on p ted use of t uildin well and lot lines. he building. See Section H 62.20. 5. Include complete data on exp b g' ac LAKE ap S EA M ,rr PA�50� NC Hl 75' P A G pA Q nGo 3 p G p L. �s 6 r P-4 3 1000 � 4 19A I 2541 Of 5� P T P. P L0T L! NE Q.�. p ■ peroolation test hole NCH SEEPAGE BED AND SEEPAGE PIT SAMPLE PLAN DEPICTING SEEPAGE THE , SEPTIC TANK PERMT N0. R E P a R T O N S O I L P E R C 0 L A T I O N T E A N D S O I L B O R I N G S S T TO DIVISION OF HEALTH • PLUMBING SECTION P.Q.Box 309# Madison, Wis. 53701 Pursuant to H 62*20 f Wis, Administrative Code NAME A PROPERTY AI)DWS le,;7-- LOCATION (Cheek One) City village �. PCs , Town /` �" �" WATER SUPPLY FRCH, Public Utility County City o r T wnship Cooperative SEWAGE DISPOSAL INSTALLED Bys Private well Address —4L '� EPTIC TANK SIZE __T_ :', �- fit• Q • Meterial ►-r ,,, ,�� Pero slat ian � Soil Borings� EFFLUENT DISP. � Tile Sits Teat Date Noe Lin, gt, Trenoh Width Seepage Beds Length Width Depth of Tile Seepage Pits Outside Diameter Depth of Tile TYPE OF QOCUPANCY jMOMLiquid Depth mom RESIDENCE s Number of Bedroom Q, THERR: eoi r ap fY� .> , c v— k FOOD WASTE GRINDER: Yes � Number of Persons EM"M ,.�...,. No Dishwashers Yes NO Automa -4 tia Clothes washers Yea No Minutes To Fall O-ne Inoh RECORD DATA FRCyM MINIMUM -OF 3 TEST HQL� -V Compute size of absorption area in aaovrd with H 6 2.20 Wis,. Administrative Cade. S O I L B O R I N G S• Minimum 36n' Test Total De Depth W- Pra used Abev tion S stem Number A De th to Ground Water De th to Bes�ro Inohes Observed Esti�.ted ok ExempZC observed Estimated Cha.re.cter of So Bm 0 �21, it with Thlokn".e in Ir�ohee _ 72 H Soil 12't ClAy 1ate Sand _18'11 Gravel 2411 r. RECORD DATA FFbOM MINIOF 3 TEST HOLES I, the undersigned, hereby certify that the Percolation vision in accord with the procedures p 1 Lion tests reported on thus form r� that the data and method speo3f ied in Chapter H 62.2Q �13 wisre made by me or under my super, recorded and lunation of test holes 8-re oorreot to the ): onsin Administrative Code an best of V knowledge and belief. ' d NAME � /� � i Type or Print} TITLE , REGISTRAT I ®N NO, MASTER PLUMBER LICENSE NO, ADDRESS 2u2 DATE/-7/) SIGNATURE Percolation Test Procedure (1) Type of hole: ,, 4 to 12 inches in diameter, in the area Dig or bore at least three verti.al holei� or drainage field. (Contact the of and to the depth of the proposed seepage p puled areas.) Division of Health for special consideration of tests In new (2) Preparation of hole: ent to Roughen the sides a expose the -natural soil. ndRemovebottmthe loose material f romOf the holes with a atherp Pbottom ofointed sthe mholes and place two inches of coarse sand or gravel in, the holes. (3) Saturation and swelling of soil: to lly filled with clear watery i� lled9 s swithurplusaminimum d (a) The hole shall be carefung if necethessary or by supplying reservoir 12 inches over the gravel, refilli of water such as an auo�heicravet�forsa periodsofhateleast,four hours* wat�ater a depth of 12 Inches over9be remaining in the hole after fou1h�o �sshall moretthanrem O�hours soethat ,ithwijbe � ring the allowed to swell not less than 6 itions t��inW��eriodstheuperc percolation test shall wettest seasons of approach the condproceed easespecified Immediately after the swe g P in Sections 4 (a) and (b) below. (b) In sandy soils containing little or no clay carefully orlessrepeat the water over the gravel. If this water seeps away in ten minutes procedurehe testhcanecond proceed1ling of 12 immediatelyIashes of specifledeinSSectioneeps a4 (c) below. or less t (4) Percolation rate measurement: shall be removed. The water level (a) Any soi l which has sloughed into the hole s a he ravel and the h of not more than s i x i nches above t g of shall be adjusted to a deft a fixed reference point at intervals wa ter level l shall l be measured fromwith th water to a po l nt drop i n o f four hours , refilling the holes The test 3� minutes for a period empty. el when the hole becomes nearly r not over six inches above the gray two successive readings do not vary urinated in less than four hours if hall not be made during may be ter Adjustment of the water level s more than 1/1� of an inch. j limits of the last measured water measurement periods except to the li p minute interval shall the last 3 urea r level that occurs i n the last 3 level d rop . The drop i n water be used to calculate the percolation rate* in less than 3� minutes after (b) Whe n the first s i x Inches of water seeps away n is shall be taken as period the time interval between measureme that occurs the soil swelling P one hour. The drop in water level ten minutes and the test run for o l col ate the percolation test* in the last ten minute period shall be used to calculate the ravel as specified filling l l i p of 12 inches of water over g hole to a (c) !f the second g es or less add water to the ho 'Section 3 (b).seeps away In ten minutes m a fixed reference point �n paint not more than s i x Inches over the gravel and from iod of one hour, measure the drop In water level at ten minute Intervals a point nfor a per he _ ravel . refilling the hole when necessary to pot older six inches above he ravel Seeps away !n cases where in less than the six x inches of water above t g final na l water level drop otter test interval should be used$ e ten minutes a sh percolation ratee shall be used to calculate the shal l more than six inches of Water be above the gravel during the In no case ercolation test. � 't i Plb. /,i67 10/C>9 1j, M Part'nPnt of Health and Social SPrvjoeq Division Oe, PE'VIT APPLICATION .4 v for • PRIVATE DC''ESTIC SE6rl,GE SYSIU,3 A. CW414ER OF Nam e 1j";' BLAiCK INK r e s 5 Zip C o J1 0 Z I B. -LCw,'%AT10N OF PROPERTY W,; Count S ro T Er-1 WILL B F, co Pi7l) A L,'LV y Check D OR 'X T P D L if A B. CITY > v I LILA G E LEGAL DESCRjp-pjc)-*T TOWNSHIp C. 1S LOCAL PERMIT Ft-EQUIRED FOR THIS YES NO P E;.FZ-4 IT N LY2 R D. SEPTIC TANK CAPACITy, �1(4 /"' Gallons NFv4 126TALLATI,31,4T '.ADDITIOr01 D MA IT, R IALS Prefab Concrete vk Poured in Place Steel AW-0 TANKS TO BE INSTALLFD: other . ......... E E. TYPE OF OCCfjp.A, Cy D. N Check One: O�le or 11vyo Farni],y Residence Commercial Industrial Oth e r Number of Persons to 'be -ACcorrimodated Number of Bedroom-, (specify) F. A?�ILIANCESJ ETCS Food Waste Grinder NO Dishwasher Aut=,atic Clothes Washer YE S NO Autor140 Other (specify) ratio Potp.to peeler NO 'S YES NO ------------ G. EFFLUENT DISIPOSAL SYST&II NEW EXTENce-SION Tile size ADDITION "T ...... Jq- Trenqh---wi,4 th - REPT.,..4CEMvN, �=-NdkVir of Lih-6-s- See;)P-e,e Beds Length WiduL h Depth Ti I e z e lot '" SPagO Pitt Inside diameter Liquid Depth No. Lines ... ............. -PE R C 0 L A T 1 ON TES T Test DeDth Character or soil Number e r I ri Ch Thickness in Inches si Hours Water Test Time Drop i -noe Hole -n Water Level—Ino.hes N m.-.- - - Is Wett d in Holt I nt e inra 1 Second to N 0 e 11 xt -- to La -9 t iinutas Ove I Excvn 18. . ht in 11 j To Fa I I Test P. C) 361, Last Period Last Perio Period Inch -.1022-AS ZOillL.11 20�" : �:Cl :av ►2 6 25 ---Y-es or no 30 2 1 2 60 16 R-ECO,cO DATA 'i CAM NITNIrU1% OF F-3 TEST HOLES Qaiput.e biz of absorption area in accord with H 62.20 14is& in i s t r_a W.A.ve Code. oring I L B 0 R I N G S - Minimum irn um 3 6 5a Total Depth De Pro osed Absorption System Der)th P umber Inches to Bedrock e r*ve s+imated ""Linple "ved Est =i:lat (93d Character of Soil wjt,�., -M Thi��krass in 0 Inchas 7211 7211 Too Soil l2ri. Cla Bit y Sand 1 Gravel 24;0 tj ------ IL . . . . . . .............................. RECORD DATA FROM PlINIMLiM OF 3 BORE HOLES-- COMPLETE OMER SIDE 7"! It the under-s.J.:-ned hereby certif'y that t',je pe,,col, ti,)r, te 2 "1 'Sts reporLc:d on this fond were made by me or under by supervi�3jo.,, in 8-00ord with the' procedures, Pv-j(j sI)OCified in Chflpter H 62,20 ( 3)�o �visoonsin Administrative Gods;, a-"'d t"'I t110 cl!!.t,% recorded rind la�,.,,a'bion of test holes are the best Of mY kilowled6o and belief. -fo NAME (Typ o T ITLE or-, Print) -------- ADD)r:S3 Ov MAS-11ER PL''!I�DER LATCOENL�F i,;o. DATE MAS'I'E,R pj;pjD 4 - L-TCATIONT License 1jj,jjjp-• MP S isna -lu- L2 r e: 7,J rip Rs W (To be Co�Tlpleted by Issu-irig Agent) rx Da' to Of APPliCation Fee Paid POMit Issued (date) PeMit Nuriiber Agent For: z'- Town village, city'�C-- Ou n eve. (SP cannot be considered for filing until &.11 of the above ques-tion-4 am answered Noto: The application c, ec' fy) and the fee paid. Agents will for-aard appliGation, the fee of W-00 and Copy (bof the Permit (yellow copy) to the Divin ion of Fqalth" ) payable to the Division of He-aith. a Checks and money orders sho,,ild be made DO not Write in SP&CO beLytr - FOR DEPAMIENT USE ONLY DWANE RECEIVED (-D ACCEPTED BY RE T j RN KD (Initials)• (Date) (See Correa.} FEE RECEIVED VALID. NO. (Yes or No 61 e147P REVIEWED BY (Initials) DATE (Yes or No) CUM i, ",'SNTS: ----4