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HomeMy WebLinkAbout042-1051-80-000 (2)St. Croix Courcry Planning and ZoningWediiesday, Jan uary 25, 2006 at ]1.-29.-3 7 AM A Page I of I Detail Sanitary Information ---- - ------ Computer 042-1051-80-000 Sub/Plat: NA Section: 19 Parcel #: 19.29.18.293A2 Lot: 3 TN/RNG: T29N R18W Municipality: Warren, Town of CSM: Vol. 03 Pg. 615 --- ------ . I ---------------------- ------ ------ 1/4 1/4: ------- NE 1/4 NW 1/4 - --------- ---------- . ..... . .............. ---------- Owner: - ---------- -- ------ King, Burt 931 Highway 12 Roberts, WI 54023 State Permit: 18019 Issued: 09129/1978 POWTS Dispersal: Non -Pressurized In -ground Permit: New County Permit: 318 Installed: 09/30/1978 POWTS Detail: Bed- Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Plumber Issuer/Inspector As Built Other Requirements Additional Notes Money Owed part of inspection form filled in but no signature or $0.00 Harold Barber No Brown, Ed date of installation on it. Brown didn't famish as - Tom Nelson Signed Off: No built or not attached to paperwork. Will file with 1993 replacement permit Owner: King, Burt 931 Highway 12 Roberts, WI 54023 State Permit: 193498 Issued: 07/07/1993 POWTS Dispersal: Non -Pressurized In -ground Permit: Replacement County Permit: 0 Installed: 07/12/1993 POWTS Detail: Bed- Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Other Reguirements. Additional Notes Money Owed Issuer/Inspector As Built Plumber 1000 gal. Weeks tank (existing) to new 12' x 60' $0.00 Mary Jenkins Yes Fogerty, Dave bed bypassing old dispersal field Jim Thompson Signed Off: Yes Maintenance Scheduled Pump Date Pumped 1 st Notification 2nd Notification 3rd Notification 7/12/1996 7/12/2006 0 ST. CROIX COUNTY SURVEYOR'S RECORD 349,572 CERTIFIED SURVEY MAP PART OF THE NE 1/4-NW I/4-SEC. 19, T-29-N, R-18-W N 880-57-28"E NW COR. 1362.78' SEC. 19 M CO. MON. •' �~ O rn � 3 dr w z w 3 z - M f.. c N M N o 0 z ASSUMED BEARI NG REFERENCED N88-5728E ALONG THE NORTH. LIN OF SEC. 19 4 NORTH SEC. LINE Ns�o 0&1 01 S9, �CV 0,, 150' 100' 50' 0 150' SCALE = 1 " a 150 `c' 6'0 ° �03 0 a .5 If APPROVE] Af J JUN 08 1979 �s'Ole ST. CROIX COU. f Y COMPREHENSIVE PARKS PLANoikiN'LEGEND ~' AND ZONING COMMITTEE SEE REVERSE SIDE FOR ( o - I" x 24" IRON PIPE SET CURVE DATA AND ( WT. 1.68 LBS. / LIN. FT. I CERTIFICATION 34,9572 THIS INSTRUMENT DRAFTED BY G.C.Shatter APPROVAL aFTHIS MINOR 5U8DlV1S! DOES NOT MEAN APPROVALOld FOR 4"2 7 7- 8 BUILDING OR SEPTIC ; Y -r1 SHAFFER co JUN 1978 � �I � c. FILED S - Z 325 RU'DSON VOL. 3 PAGE 61 G 5 CERTIFIED SURVEY MAPS ,NO ST, CROIX COUNTY f WI. N 010- 01'-'23" W- 17 0 0' w N 88'0 58'-37 4 E w M 0 w I 0 Volume 3 Page -9119 f P RE:PoP%T r \ Or' ITISPrCTION- - l.14DI'JXDUAL 'i4tirE DISPMV 1 J J.• ..i,i� ' - - S\zt,it��r y Permit •'-' • r State Septic / :_.6E TOWN S H I P S 1EP T I T t. Crol:x County ;. r Size gallons. 'tuInbL'Z` of Compartments Distance From: Wel l ft* 12% or ,greater slope r Building' ft, wetlands f Highwater ft. DISPOSAL SYST ,i1 Tile Field or Seepa re Pit (s Distance Fx•om:UeZl ft• . 121p or greater s lo;)e fL Building, ft. Wetlands f" FIEMD I-lighwat er • Total length of lines - f t. Number of ' .�,_..._ lines Length of each line ft. Distance between lines ft e Width of the trench ft. Total absorption area sq. ft, Depth P of rack below tine �.' in-@ lay th of rock ©vex file in, Cover nVer • Tocic,, - Depth of the below grade in. Slope of trench in per 100 ft. Depth to Bedrock ft. Depth to ground water ft* PITS ' ��umber of pits outside diameter ft. Depth below in nlet let ft. Gravel around pit : __yes no . Total absorption area sq, ft. -Square feet of seepage trench bottom area required . vquars feet of seepage nit area required . Inspected by: Title': r Approved ..,._.,._ Date 197 __.._ Rejected Date 197 i +rw�.u..-.^*a�rr.r.rt.rl --- -,w. -� 1 ' ..,n__:.._,.--�wa�cr.»r:.,«.. ,rv-.:. c:,•. - ,..;. ..,. EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: SectionA_?, TZ17N, R It— If (or) W. Township- r Municipality CLC- r- ro, Y-N C 4:t-_ e7i 0 ge ci Ct y Vol t�� <al 1- 0 e A Lot No. Bfmek-Ne. County Subdivisior( Name Owner's Name: a L2 r7t )7� Mailing Address: TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW � ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOILBORINGS —PERCOLATION — TESTS— EET f3SA J43 1-� �, ,e I -t 7,3 C, 0 SOIL MAP SHEET — SOIL TYPE PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- BER INCHES THICKNESS IN INCHES SINCE HOLE 1ST WETTED HOLE AFTER SWELLING INTERVAL IN MINUTES MIN/IN PERIOD 1 PERIOD 2 PERIOD 3 P- 3 CS P_ 6219 1/Z -7 X40 T-5 :s T< to 0-b CZ SOIL BORING TESTS TEST NUMBER TOTAL DEPTH INCHES DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES (DEPTH TO BEDROCK IF OBSERVED) �To 's 0 S1 S"11i r OBSERVED ESTIMATED HIGHEST 2 L 6 qM B-3 14 1 -7 B 6 n 1Z 1Z a-7- 7 :2 7— -2,r PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy. .11CL) I ET Ste:_®1= _F1 Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. .i 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) Address- 8 0 ') 0 ck, k Name of installer if known. Certification No.— �' a i C_. -.5 44 0 1 (..M tN CST Signature C - t17 State and County PLB67 Permit Application for Private Domestic Sewage Systems I *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: .4 '2 B. LOCATION: '/4 , Section T R J'12'E (or) W Lot# Subdivision Name, nearest road, lake or landmark BIk#__ State Permit # --I County Permit,* County City Village Township _:'+! 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 Grinder Automatic Washer YES —NO Other (specify) Y E S N 0 of Bathrooms E. SEPTIC TANK CAPACITY_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 10 Seepage Bed: Length Width IV Depth Tile Depth ___73 4 No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size 4e' Percent slope of land Distance from critical slope 1, 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-1 15 prepared by the Certified $,oil Tester, NAME 0, Z� C.S.T. # and other information obtained from (owner/builder). Plumber's Signature Phone # MP/MPRSW# Z-4 2'_ Do Not Write in Space I.ow y FOR DEPARTMENT USE ONLY Date of Application s Fees/ Paid: State z/. 11' t")C County Date X Permit Issued/Rejected date) Issuing -Agent Name Inspection Yes No Valid* Date Rec'd 1. county (vvhite copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 11 of Wlscq�umancompartment of Industry, Page V& SOIL AND SITE EVALUATION REPORT Relatiors Divis,on of Safety & Buildings in accord with I LHR 83.05, Wis. Adm. Code COUNTY St. Croix Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL not limited to vertical and horizontal reference point (13M), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFO RMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER- PROPERTY LOCATION OU NTY c� t PARCEL I.D.D - # V I W PROPERTY tE FRE REVIEWED 7DB Y Pairt &. Kathleen King GOVT. LOT T\T,,, 1/4 M-� 1/4,S I C) T 2 Q XR j_(9 )Nor) W PROPERTY OWNER':S MAILING ADDRESS 3 LOT # BLOCK# SUBD. NAME OR CSM # 9 qI 3 / 31 Fly, #12 n/a__ n/a n/a CITY, 1 0 ITY, STATE ZIP CODE PHONE NUMBER OCITY [:]VILLAGE)OOWN NEAREST ROAD Rol)er t s 117154023 (715 749-3441 14arren ITY. #12 L� ns1,uc1 Use Residential / Number of bedrooms Addition to existing building 11x] Replacement-' Public or commercial describe Oucilyflow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 trench, gpd/ft2 Absorption area required. 643 — bed, ft2 563 trench, ft2 Maximum design loading rate - 7 bed, gpd/ft2 trench, gpd/ft2 . 5 0, for 6T)ed Recommended infiltration surface elevation(s) 0 ft (as referred to site plan benchmark) Additional dditional design/ site considerationsfor trenches 9P.78 then 3.5' below surface level on step dovm Parent material outwash Flood plain elevation, if applicable n/a. ft t S S -Suitable CONVENTIONAL MOUND IN -GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK for system EkS E1U El S BdJ El S El U U U U Unsuitable for system Rks ®U ias 0 U iaS El U Ground elev. 99. 5 f t. Depth to limiting factor >8411 Ground elev. Q f t. Depth to limiting factor >100 tv SOIL DESCRIPTION REPORT Horizon Depth in. Dominant Color Munsell Mottles Qu. S. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots G P D/ft2 Bed T 1 0-8 10yr3 / 2 none T.j a 2/m/gr mvf r c/w 2/f .5 6 2 8-17 10yr4/4 none Sic]- 1/f/gr mfr g/w .3 3 17-28 7.5yr4/4 none Is. 0/sp, M! g/w 1 / f .7 .8 4 28—W 10yr4/4 none CO.S. 0/sp, M1 n/a n/a Remarks: 1 0-8 10yr3/2 none L. 2/m/gr raft c1w 2/f .5 1.6 2 8-47 10yr4/4 none sil . 2 /m/ sblr mfr g/w 1/f .5 .6 3 A7-58 10yr4/4 none SC1 1 / f / sb111-1. mf r a/w I / f .2 ::.3 4 58-100 10yr4/4 no I �10 �1 ,�,_ �c 0/sg - na na .7 98 / cb cbY Lj Remarks: 'hackf ill to be ci.IN CMC,�_f area i DST Print ST Name --Please Pr Gary L. Steel -9 Address- -5 15 5 Zl� 200 th. AXe. p4 �Iew Ri cbmion i017 Signature, f EMU Phone: Date: 5-2,7-q3 CST Number 2,- 298 PROPERTY OWNER -Bart King SOIL DESCRIPTION REPORT f Pagef � PARCEL I.D. # Baring #................ Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxiary Roots C P D/ft2 3 Ground elev. (17.60 ft. limiting factor >10011 Remarks: Boring # 4Ground elev. 101. 7 f t. Depth to limiting factor Remarks: Boring # S Ground elev. 102.4 ft. Depth to limiting factor 0 it Remarks: backfi.12 oil area to be cut to d i _ . used Boring # ............... Ground elev. ft. Depths to limiting factor Remarks: SBD-833o(R.45/92) in. Munsell Qu. 5z. Cont. Color Gr. Sz. Sh. Bed ITrer& 1 0-13 l�? r:�/Z none L. 1 C�-l0 1C�yr3/2 none L. ?/m/�;r rif_r �/�r l 0-9 1_oyr3/? none L. �.%rn/sY�k mfr g/��� Z/f_ .5 � .6 �� 9-2 5 1_oyr4/�� none sick_ 1 / f /�;r mfr P 1 /f 3 STEEL'S SOIL SERVICE Gary L. Steel 1Ve C.S.T. 2298 Bur King New Richmond, W1 54017 MPRSW-3254 ��TE 51-��,QI' F�l 3�.� (715) 246-6200 town of warren S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 9 3� ��y ADDR < d'e-1oz3 SUBDIVISION CSMt LOT up= SECTION T 2.1 _N-R /§::__W, Town of �`r+�1111110 07 ST. CROIX COUNT Vn SACOINqS. I;N�l S '4'0' Provide setback and elevation information on reverse of this form' Provide 2 dimensions to cent of septic tank manhole Cover op le titip BENCTIMARK: -wee"I 4!e.,; , ��� ��4fc , ALTERNATE BMO. SEPTIC TA,.,NK PUMP CHAMBER HOLDIVG -TANK INFORMATION Manufacturer:— Liquid Capaci'ty-, - 1Z7P'0 4? - /I 'IF Setback from: Well > House or Other Pump: Manufacturer �S_4 -,,.-Model Size Float seperation Ga s/cycle: /cyc Alarm Location > -.-SOIL ABSORPTION SYSTEM Width: --- 12. - Length ,o Number of trenches Distance & Direction to nearest prop. Setback from: well :.;;P,/$ .. V -House Other ELEVATIONS Building Sewer ST Inlet,. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system 4YI Existing Grade Final grade DATE OF INSTALLATION: ; 3 PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: ) j�„ 3/93 -. jt L►�'�paAWWANus� R • �`9 • �. • 2 m?1` AW%1ViitbE SYSTEM County Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitar rmi MAC GENERAL INFORMATION Permit Holder's Name: o city ❑ Village Town of: State P T E ev.: nsp. ev.: BM,Description: Parcel Tax No.: TANK INFORMATIONELEVATION DATA A9300156 1-2 TYPE MANUFACTURER CAPACITY STATION BS H! FS ELEV. Septi c _ ' Benchmark . Dosi ng Aeration Bldg. Sewer Holdin g St/ Inlet TANK SETBACK INFORMATION st/#f Outlet �, �' % r TANKTO PIL WELL BLDG.Air vent to ROAD Dt Inlet .._---- Intake -------- Septic '' _ ,;i' NA Dt Bottom;7 Dosing '`--_.r. N'e' Header f�' r Aeration NA Dist. Pipe', Holding .Bot_ System ` PUMP/ SIPHON INFORMATION Final Grade25po z-f Manufacturer Demand Models Number GPM TDH Lift Friction System TDH Ft Lo5s Head Forcemai n Length Dia. Dist. To well SOIL ABSORPTION SYSTEM DISTRIBUTION SYSTEM Header / Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing - SOIL COVER x Pressure Systems Only xx Mound or At -Grade Systems only v ,, �s Depth Uver e f, xx Depth Of xx Seeded / Sodded xx Mulched Depth C) e( ., , / Yes El No Bed / Trr�ch Center. _ �-r Bed / Try Edges ;-.�.-� 7' Topsail ❑Yes [] No C7 COMMENTS: (include code discrepancies, persons present, etc.) LOCATION: WARREN 19.2 9.18.2 9 3A2 (HWY 1,2)--- ' Plan revision required? [] Yes o D L19 Use other side for additional information. rr SBD-671 Q (R 05/91) Date Inspector's Signature Cent No. -� SANITARY PERMIT APPLICATION DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY DOW -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. El Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PRO ERTY OWNER PROPERTY LOCATION '/4 A4&�L14 S T N, R E (o PROPERTY OWNER'S MAIL NG ADDRESS LOT # BLOCK # !2?Z C. ATE ZIP CODE PHONE NUMBER ftol3tyisie!14 114 OR CSM NUMBER 7 C , ITY NEAREST ROAD 11. TYPE OF BUILDING: (Check one) State Owned VILLAGE: - OF: Z ILLA( L TA Public❑ FC! [Z 1 or 2 Fam. Dwelling-# of bedrooms RCEL TAX NUMBER(S) III. BUILDING USE: (if building type is public, check all that apply) 1 El Apt/Condo 2 D Assembly Hall 6 El Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 El Campground 7 El Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining 4 El Church/School 8 El Mobile Home Park 12 El Service Station/Car Wash 5 El Hotel/Motel 9 El Off ice/Factory 13 0 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑New 2. [Z Replacement 3. El Replacement of 4. Reconnection of 5. ElRepair of an System System Tank Only Existing System Existing System B) El A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 0 Seepage Bed 21 D Mound 30 ElSpecify Type 41 ❑ Holding Tank 12 El Seepage Trench 22 EI In -Ground 42 ❑ Pit Privy 13 0 Seepage Pit Pressure 43 M Vault Privy 14 [:1 System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE 1 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION GA ABS ORPTION ;7 0,01 S7 Feet Feet W/ 3 1 - I - V Vil TANK CAPACITY Site 111. TANK ingallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New P��isting Gallons Tanks Concrete I strutted glass App. Septic Tank or Holdinq Tank Lift Pum Tank/Siphon Chamber � UP Vill. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. PlwTrher's Name (Print)- Plumber's Signature: (No tamp t*"PRSW No.: Business Phone Number: W-i Alu r's Address (Street, City-, tate, Zip e): IX. COUNTY/DEPARTMENT USE ONLY IZI Disapproved Sanitary Permit Fee (includes Groundwater �VApproved ❑ owner Given initial $ / Surcharge Fee) Adverse Determination 1 X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: Issuing )ate lslue d, Issui;g Agent Signature (No Stamps) 9 - 2 -,�3 11 12 A 2-,1 0-00,4 1:511- SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1 v A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal ail-newcriteria in the Wisconsin Administrative Code will be applicable. d 3. All revisions to this permit must be approved by the permit issuing authority, 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (BD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be- properly .maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning yoVr.opsjte_ sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. IL Type of building being seNe`d.'4Cfieck only 6' e and complete # of bedrooms if 1 or 2 Family Dwelling. M. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. V1. Absorption system information. Provide all information requested in #1-7. VIL Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab 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. Vlll� Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, 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 81/2 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 tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and verticai elevation reference points; C) complete specifications 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 required by the county; E) soil test data on a 11.5 form; and F) all -sizing informatiorr., GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. STCr -ioo This application form is to be completed in full an the oc-��ner s of the - � d signed by �.) property being developed, Anyinadequacies will only result in delis of the permit q �' p it issuance. Should this development be intended for resale by owner/contractor,(s ec house), tlien a second form should be retained and completed when the property '.s sold and submitted to this office with appropriate deed recording. �.th the r -. -. - r - r r --- - r r r r r w - r.... ... r rr............................................... .... ....wrr...........F....-i.--w..rw--...-.--r.-.........r•..w-- r owner of property Location of propertyF1/4 /1%1/4 j Section , T r N-R W Township a.--•`,r ' ,.._ % Mailing address ress �__ Address of site r Subdivision name Lot no. Other homes on property? yes No Previous owner of property.�.1 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 Re.ste of Deeds. � r INCLUDE WITH THIS APPLICATION THE FOLLOWING: A w'ARFWITY DIED which includes a DOCUMENT NUiiBER, VOLUME A14D PAGE NUMBI'lZ & THE SEAL OF THE REGISTE*'R 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 1 0k:0) certify that aly statements on this form are true to the best in o f ny (our) knowledge that, , I (we) m (are ) the owner (s) of a the property described n this information form, by virtue of a warranty deed recorded in the office of the County Register of Deed,- as Document Pre. own ttzE proposed site '�� ► and that I (We) } presently. p 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 hae beendulyrecorded in the office of County Register of deeds as Document N o . Signature of ap lican y_ fie Date of Signature P o-applicant Date of Signature 1 35I7;�5 vot 5 8 1 -- A - ?w 5' 4 STA I-F: UF �4l5i:t)ti5)ti-t (>fttil 1 THIS SPACE RESEAVYD F02 ItUOUD(C DATA THIS WD&NTUR19, Madre this --- .— ...... _._....._..day —_---- A. D., t9 � Q . between....---R.--C..._.Cons tr...--Inc................................ __............. -. .,_._ ._ _�_. ..__._._.._ ._-----._ _..__.-_._.__._-__.._--- -- -- ----- ----•----...-•--__---a Corporation duly owred and existing under and by virtue of the laws of the State of Wisconsin, located ,. rest_ Lake , M1IlIle SOta XK� party of the Fret part and . ........... . .. _.,r_. . urt R. King._4an:a::: jkathfeen A . King_,._..husband and .----------------------------...............------._...... -_-.-- wi f e as jo_ ___ ten_an is � ................. _-------•-- RECAST' RS OFFICE S1. CROIX :0.1 Wis. Rec'd. for Record INs 14tn day of Sept* A.D. 19.76 at 2:30 r i1' - Jan4e s t (}' oI;s1a1L n i I R8014ter.01, Os�d.l r- w. -..._e__-•-•__-..-._-................-......._..._...-..-----.....---------- .--------- ........ ................................ ------- --.I . `.be part. -_-_.of the second part, E E T V A g TO W t t n s a s • t h, That the said party of the first part, for and in consideration ofthe sum of-- ----_ _ -._......... _...................... _...................... ................ __............................................ A w s� ............................ ...__.............................. ........... to it paid by the said partj-eS..of the second part, the receipt whereof is hereby confessed and acknowledged, has given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by ibex presents does give, grant, bargain, sell, remise, release, alien, convey and confirm unta the said partl.e.:iof the second parttlie_iXeirs and assigns S t . Croix 1Xd State Wisconsin, kwever, the following described real estate situated in the County of ......................... anate o, to A parcel of land in the Northeast'-: Quarter of the Northwest Quarter of Section 19, Township 29 North, Rap.ge 18 West,, described as Lot 3 on the Certified Survey Mep recorded in the office of the Register of Deeds for St. Croix County, Wisconsin, in Volume 3, page 615, document 349572. TRANSFER FL11 (IF NECESSARY. CONTINUE DESCRnMON ON REVERSE SIDE) Totether with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate right, title, intereit, claim or demand whatsoever, of the said party of the first part, either in taw or equity, either in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. To Have and To Hold the said premises as above described with the hereditaments and appurtenances, unto the said partl_!e.q..of the wond part, and to--.-th-e-i Theirs and assigns FOREVER. And the said ........... ._ R. C . Constr. Inc . ..........................• .......... --........... ...._.............. .......... ................... _................ .......__.__..-------•--- party of the first part, for 1(,elf ;end its successors, d(A-s covenant, grant, bargain and agree to and with the said part_l.e.s.of the second part,-_...__th�'.1X.......... ........heirs and assigns, that at the time of the ensealing and delivery of these presents it is well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and clear from all incumbrances whatever ..... --------------------_-------•----.............-.....................-•-----•------------------------------------------- ------ -.............. .- .............................. .......------.._...-------....--------...---- - - .._.. -.....................--•--................ i and that the above bargained premises n the quiet and peaceable possession of the said part__.le.Sof the Second part,tile-i in and assigns, against all and every person or persons lawfully claim'ng the whole or any �ppaart thereof, it will forever WARRANT AND DEFEND. In Wltnesa Whereof, the said., .R.. � � COI1s tr. . lI]c . .. party of the Cir,t part, has caused these presents to be signe-d by .......... . ............... . .. .............. .. . ...... ......... , its Pre,iclent, and countersign'-d by ......................... •. .........-.......................... its Secretary, at .............. . . . -. wixonsin, ,his....... .. Clay of ...... ...August , A. r,., try . 7.8. rn i s slGr o rA l ,l�_ v N'T'RESE�CE of { R. C. CONSTR. INC. ,� �° � /r1 .� ♦ ui txriatr Njiiit! C( T tiICNED: r --� r • �erf�11)I Minneso-in STATE OF'iil M .......................•---._......--------- County . 78 Personally came before me. this ....... .. ...day of.......A�. ............. ............ A. D.. !9_......._., .....,................................. Thomas...R.• ..Siefert... ........... ... . l'resitlenc, and .... Gloria.. S.iefer .... ,_x-croary of thv above named Corporation, t© me known to be the persons who executed the foregoing instrument, and to nir'-:nown to be such- -.. Vreside:nt � and ...................... ... ..........Secretary of said Corporation, and ar.kno%leclgid that they executedl the fork -going instrunwrl .i-�,ueh offiicery as the deed of said Corporation. by its authority. � �f �r�.r r,s►r:ar r x . i": ri}r .t.`iY ;-Ut.ti, _. rr \:. This instrument draft-d by Notas�i`� . Notary r a } , i John D . Heywood, Attorney _. �►�.. ,.I f C� ,r, i..l-L�;7r �`�y ?' r�-- . __ ►lP�+t�t/,Ij'I1�11%Ilia^1111+t1'1���� ---------•--•--------- _-•--------- My Commission [Exptres) (I*)_ _ __ - - - _......... ..------------- _ ---- (3Retfesn 5�.31 rt) of th,* R+tiii-im-41a 9t,.t1j-k4 pro-me-o thtt all Inrtrurnonts to b+ rowel" sh4111 h#4e Pt". I' yrlatwd a t; t?z��lt� rf;': n tS+ MAM'Ps of the grantor+, grsat++s, •vltne*+*s sna not"arl). WARRANTY DEED—STATP. OF %VISCO.iSIN, FORM NO. t .{ a �+ �1' � F;[i '.j�■t. it!lcl.4i.'•ii J.i,cc l f�ti.�� C'�r;-�1"'e_'Y:�1 :trif_t F:. r]'! . r f,a:• ,e rr ra rf r� S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County brNE /BUYER ADDRESS Agle�j y FIRE NUMBER A 7 01� Z CITY/STATE .1& 4-.. � ZIP PROPERTY LOCATION: e-, 1 4 1/41 SECTION TOWN OF ►St-o Croix'County, SUBDIVISION I LOT NUMBER - 6 Improper use and maintenance of your septic system could result in i t s premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, 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 to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 198o, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification 'form, signed by the owner and by a matey plumber, journeyman plumber, .restricted plumber or a licensed pumper verif ying that (1). the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/Ile, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 vvlsc . "11,5 Dr*partment of Industry, SOIL AND SITE EVALUATION REPORT Page I of 3 L.abor Uzi Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY St. Croix 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 vertic. al and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION —PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTYRoberts PROPERTY OWNER- PROPERTY LOCATION PPkirt & Kathleen King GOVT. LOT T\T�-, 1/4n-, 1/4,S19 T2C) N, R J_ R W 0 'r P t PROPERTY OWNER'-S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 931 Hy, #12 n/a n/a n/a 9 cz STATE ZIP CODE PHONE NUMBER OCITY [:]VILLAGE AZTOWN NEAREST ROAD CITY, 1.111. 54023 (715 749-3441 Warren jjy #12 New Construction Use Residential Number of bedrooms 3 Addition to existing building Jx] Replacement Public or commercial describe Code derived daily flow 450 -gpd Recommended design loading rate .7 bed, gpd/ft2 - 8 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 -trench, ft2 Maximum design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 96.50 for hed ft (as referred to site plan benchmark) Additional design /site considerationsfor trenches 9P).78_thPn_.3,5,'.. below -surface level on stQp do-vm Parent material outwash Flood plain elevation, if applicable n/a ft S -Suitable for system CONVENTIONAL MO - UND IN -GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TA U = Unsuitable for system S Elu ias El u iaS El U US El U © S Bdi 0S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Munsell Motes Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence BcL� Roots G P D/ft2 Bed Tmnch in. .................. 1 0-8 10yr3 2 none L. 2 /m/ gr mvf r Ow 2/f .5 .6 ti ............. 2, 8-17 10yr4/4 none sicl IL / f /gr mfr g/w 1/f .2 .3 - 3 17-28 Ground 7.5yr4/4 none 1S. olsg mi 1 / f- .7 .8 elev. 9 -9. 5 ft. 10yr4/4 none Co. S O/sg M-1 n 31 n/a .7 .8 4 28-84 Depth to limiting factor >84 Remarks: Boring # ................. ....... ........ ................. .................. ................. Ground elev. 9 ft. Depth to limiting factor >100 it 1 2 0-8 8-47 10yr3/2 10yr4 /4 n( n( 3 LE7-58 10yr4/4 n( 4 58-100 10yr4/4 n( 4ct ne 2/m/gr mfr C/w 2/f .5 .6 ine sil. 2 / m / sblr mf. r )/w 1/f .5 1.6 ine- scl 1 / f /sbk Dif r a /w 1 / f_ .2 .3 110f V0. O/sg ral na/ na/ .7 '.8 Remarks: --hackfill to be cu!\,- _X',.C6ft/ area IgTLT CST Name --Please Print C Gary L. Steel Address- 15 5 ZP 200 th . e � Tew Ri chmon �01 7 Signature:� - Phone: -5-2,46-62 Date: 5-27-03 CST Number- 2298 PROPERTY OWNER PARCEL I.D. # Biar t King SOIL DESCRIPTION REPORT Page of,3 _ Boring # 3 Ground elev. °7.6o ft. Depth to limiting factor >10011 Ground elev. 101.7W Depth to limiting factor >981, Boring # Ground elev. 102,4 ft. Depth to limitnng factor Ground elev. ft. Depth to limiting factor Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots G P Dlft 2 Bed TwY_h in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0-13 1 r3/2 none L. 2/m/gr mfr c/w 2/:F 1 .5 , 6 2 13-36 10yr4/4 none scl 1/f./gr r.f_r g/w 1/f .2 , 3 3 36-58 10yr4/4 none sl. 2/m/sbk mfr g/w 1/f .5 .6 4 58-�-10 1C yr4 /4 none co . s . O/sg Rd la n/a . 7 .8 Remarks: 1 2 0-�-10 10--21 10yr3/2 1Gyr4/4 none none L. sicl 2.1mlpr 1/f_/shk ref_r mfr g/w g/w 2/f 1/f .5 ' .6 .5 .6 121-43 10yr4/4 none Is. 0/sg MI g /w 1/f_ .7 :.8 4 43-98 10vr5/4 none cols., O/s _ r:1l n a na .7 .8 Remarks: 1 0-9 10yr3 / 2 none L. 2 /m/`shk mfr g/w / f_ . 5 .6 9--25 10yr414 none sicl 1 / f /p,,r rzfr g/w 1/f . 2 03 3 4 , 5 -- 5 8 58-104 10yr4/4 l r 5 4 none none- s l. cols. 1/f / o s ref r r�1_ g/w n a 1 1 f_ n a .4 .5 .7 .8 Remarks: backf_ill ow area to be cut to code if -area used Remarks: cun_0711n(o nR/091 STEEL'S SOIL SERVICE Gard L. Steel ive C.S.T. 2208 Rurt ding; New Richmond, WI 54017 MPRSW-3254 �'� �.,� S1��T�a�r�--R.�.��-� (715) 246-6200 town of Warren �3Z�y cc,)6 -�- lstC,'tae I�Z.-Zf . CERTIFIED SURVEY MAP PART OF THE NE 1/4-NWI/4- SEC. 19, T-29-N, R- 1-8-W W NORTH SEC. LINE U La 17.00 LQ N 880-57�-28"E Q CAL lollll Ln 04,� N 8 8° 581-37 lt E NW COR. 13 6:2.7 8' CD 231-79 s E C. 19 t--: t MON. -(%J cr) 0 . ..... C. Alt s (1.17A) p IVAT E 6 6' R OA D a) .50 % 0 N 88c58'37"E 0 93 6 0 w 0 lo !2 S l7cL45-35"E 66-00 Lu A. 0 w 0 z = co (D !2 to L14 I co ry 6 7 A. co w ro I 0 I--- & 0 0 N- l f ay 0 2 w 3.98 A. rr co 0.0 E5 ASSUMED BEARING oot LA 4.7 1 A. REFERENCED N68-57-28E (A (.A ALONG THE NORTH LINE' 00. OF SEC. 19 Lp Ile, 60,0 0 14 Sol, 150' 100' 501 0 150 .. %kil 0 0 SCALE 1 15 0' APPROVT�T)cr 70 ,pv JUN 08 19-78 o/ ST. C.�olx c-jLj- COMPrZEHENSIVE. PARKS PLAN—sa'- CLEGEN D AND Zo-,lr4G COmMITTE& SEE REVERSE SIDE FOR o - I" x 24" IRON PIPE SET CURVE DATA AND WT. 1.68 LBS./LiN. FT. CERTIFICATION 49 APPROVAL OF THIS MINOR SUBDIVISION THIS INSTRUMENT DRAFTED BY G.C.Shaffer a- DC7:S NOT te1,[AN APPK)VAL FCR vs I U I I p!:111, S C-t SEPTIC s coo A FILED Gem as SHAFFER co JUN 2.1 ?978 S-1325 (> fK**qWU HUDSON balow cf is.6 A06 DAVE FOGERTY PLvoOac Licensed Perk Tester & Plumber #3233 03283 Fogerty Heights Road ROBERTS, WISCONSIN 54023 Phone 749-3656 � 1 l 3 ...-mac �. ■ r...,.,W. - �.' ' � _--.-,,..r+i_ -:...ram....-�r..,,_.,��,.- Y �+--, _ ,•y-- i r v -Trvy ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the -t/— 14rm d* residence located at: 1 / 4 1/4, sec. Zf T N R IF W 01 Town 0 f 9 Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. I Last time serviced 21,71f,017 Did flow back occur from absorption systemY e s �No (if no, skip next line) Approximate volume or length of time gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacurer if known) C/ Ze le 0? IC Age of Tank (if known r ' COO/ S ignatMe) (Name) Please Print 7 1 (Title) (License gumber (Date)/ / F(I)rm to be completed by 1icen,,3,ed plumber (,,z-.;.14_cj.06,, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: I n accepting the above statement regarding existing sept icy tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspection opening over outlet baf_ Name MP/MPRS -k c-I 70 5/88