HomeMy WebLinkAbout014-1045-80-100 (2)St. CroixCounty Planning and Zoning Tuesday, Jaituarj, 16, 2007 at 1: 18:08 PM
Detail Sanitary Information Page I of I
Computer #:
014-1045-80-100
Sub/Plat: metes & bounds
Section:
21
Parcel #:
21.31.15.333A
Lot:
TN/RNG:
T31 N R1 5W
Municipality:
Forest, Town of
CSM:
1/4 1/4:
SE 1/4 SE 1/4
Owner:
Winberg, Clifford 2876 200th Avenue Emerald, WI 54013
State Permit:
43637 Issued:
08/17/1983 POWTS Dispersal:
Non -Pressurized In -ground
Permit: New
County Permit:
0 Installed:
08/25/1983 POWTS Detail:
Bed - Seepage
Bedrooms: 3 WI Fund:
POWTS Pretreatment:
NA
Notes
Issuer/inspector As Built Plumber Other Requirements Additional Notes Money Owed
Harold Barber Yes Smith, Gale file with 1999 reconnection permit $0.00
Tom Nelson Signed Off: No
Ow -der: Winberg, Clifford 2876 200th Avenue Emerald, WI 54013
State Permit: 353112 Issued: 09/20/1999 POWTS Dispersal: Non -Pressurized In -ground Permit: Reconnection
Co;tnty Permit: 0 Installed: 09/20/1999 POWTS Detail: Bed- Seepage Bedrooms: 3 WI Fund: No
POWTS Pretreatment: NA
Notes
Issuer/Inspector As Built
Rod Eslinger Yes
Jon Sonnentag Signed Off: No
Maintenance
Scheduled Pump Date Pumped
9/20/2002
9/20/2005
Plumber Other Requirements Additional Notes Money Owed
Hudson, Dale find original POWTS permit in archives see 1983 permit original system - make sure it's $0.00
for this house, not #2882 owned by Winberg
1 st Notification 2nd Notification 3rd Notification
AS BUILT SANITARY SYSTEM REPORT
Ep
OWNER "4%.2,00 TOWNSHIP p SEC T,?/N-R W
S % �__ 'ONS
ST. CROIX COUNTY, WISCIN.
SUBDIVISION LOT LOT SIZE .2,00 4aee,
PLAN VIEW
Distances and dimensions to meet requirements of H63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
■� �� Di■■rr� ram■ AIMAIM MMOMEMMrr
HIM NIMINEEM11111011
IMENNINNINNE V-71 no, NMI
IN A IN 11
6A
NNW I
ME ENOT 0 ME MINION MErj", 4
NO METZ rft Rol, *-.GINN
ME RAIINPIAM RaQ..- V= I
No ri I .W %iG111 I
ON No
MM SON ma"A "1614.7-14 NEENNE11100111
INN N INNIONIN 0 EN INGIMEEME! I
IN 0 1 VA 0
101
2! Ewa 22- gh
E Ell
I E
INN L"M
0 0 N
0
BENCHMARK: (Permanent ref erence Point) Describe ; a F eAPeS� 04/
je4 e N 1-1,o 4ere, /,oal
Elevation'ofvertical reference point: ------.—Slope at site:
SEPTIC TANK: Manufacturer: 4,11 Liquid Capacity: t7 4 4r
Number of rings on cover A1,4 e_ Tank manhole cover elevation:
Tank Inlet Elevation: -Tank Outlet Elevation:
PUMP CHAMBER
Manufacturer: Number of gallons
Number of.gal. pump set for a cycle gallons; Total capacity Of
distribution lines gall9n: size of pump head;
gallon per minute horsepower —;brand name of pump
and model number
Type of warning device
HOLDING TANK: Manufacturer Numb.er of gallons
Elevation of manhole cover
Type of warning devici
SEEPAGE PIT SIZE; Number of pits feet diameter
feet liquid depth seepage pit inlet pipe -elevation
bottom of seepage pit elevation feet.
SEEPAGE BED SIZE: number of lines width length d tile depth
SEEPAGE TRENCH: width length
PERCOLATION RATE AREA REQUIRED �414- AREA AS BUILT
DINSPECTUR
ATED
PLUMBER ON JOB
LICENSE NUMBER _jqP.__4-d-jF0
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS
P.O. BOX 79139
MADISON,'NI 53707
12 CONVENTIONAL ❑ ALTERNATIVE
El Holding Tank ❑ In -Ground Pressure 1:1 Mound
SAFETY & BUILDINGS
DIVISION
BUREAU OF PLUMBING
State Plan I D Number.
(if assigned i
NAME OF PERMIT HOLDER
Clifford Winbe rg
ADDRESS OF PERMIT HOLDER
RR#I, Emerald, W1
IREF.
INSPECTION DATE
...P� ^'r-3 /400
0
BENCH MARK (Permanent reference point) DESCRIBE
IF DIFFERENT FROM PLAN
PT ELEV.
CST REF PT, ELEV
SE SE,, Section 21,
T31N-R15W. Town of Forest
Name of Plumber
MP/MPRSW No.
County
Sanitary Permit Number
LGale Smith
5690
St Croix
43637
SEPTIC TANK/HOLDING TANK:
MANUFACTURER
LIQUID CAPACITY
6
TANK INLET ELEV.
TANK OUTLET ELEV WARNING
PROVIDED
LABEL
OYES ❑ONO
LOCKING COVER
PROVIDED
❑OYES DNO
BEDDING
❑Y E S r"
L_)l N 0
VENT DIA
VENT,�AATL HIGH WATER
ALARM
❑ YES El N 0
NUMBER OF
FEET FROM
30.
ROAD
/ I I I i
PROPERTY
L IIW%
�0�/ I
WELL E14JILDING:
VENT TO FRESH
AIR NET
I I
-.,NEAREST
DOSING CHAMBER:
MANUFACTURER
BEDDING
❑YES ❑NO
LIQUID CAPACITY
PUMP MODEL
PUM IPHON MANUFACTII
WARNING LABEL
PROVIDED
OYES
Y Es FNO
LOCKING COVER
PROVIDED
OYES ONO
GALLONS PER CYCLE:
CW (DIFFERENCE BETEEN
PUMP ON AND OFF)
PUMP AND CONTROLS OPERATIO L
10
1:1 YES 7N z
�XDMBER OF
FEET FROM
NEAREST—, NO I
PROPERTY
LINE
WELL BUILDING
VENT TO FRESH
AIR INLET
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of 9
0
or excavation. P/en t
If soil can be rolled into a wire, construction shall cease I
the soil is dry enough to continue.)
F CE
N
PeAll
L E__ I (i I r i
DIAMETER
MATERIAL AND MARKING;
r(vuvr1UT1f'1KJA1 4ZVqTI=M-
BED/TRENCH
DIMENSIONS
WIDTH
LENGTH
'ON.
6r I
NO OF
TRENCHES
----`
DISTR PIPE SPACING
4 t
COVER
,
AL' �
PIT
INSIDE DIA
V PI TS
LIQUID
GRAVEL DEPTH
BELOW PIPE
FILL D PTH DISTR
ABOVE COVER E
PIPE DISTR PIPE
EV INLET 1ELEV END
j, 7�71 11 S I
IDISTR, PIPE MA TFRIAL
NO DI IR
PIPE�l
NUMBER OF PROPERTY
FEET FROM i LINE.
NEAREST
WELL
BUILDING
VENT TO FRESH
AIR INLEIT
MOUSYSTEM: 10-
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound I syste I s to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the cr)k ia for medium sand./ I'll NS MEASURED.
El YES NO
SOIL +COVER TEXTURE A ;fR MANENT MARKERS 'OBSERVATION WELLS
/I E]YES I I ' 14NO DYES E-J NO
DEPTH OVER TRENCH BED DEPTIfOF TOP OIL SODAD 4D DEPTH OVER TRENCH BED SFI ED MULCHED
CENTER EDGES
4 7 -A/[:] YES El NO El YES F_ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH 'LENGTH NO. OF L ERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH
DIMENSIONS
TREN C Es
OL
MANIFOLD PUMP N (FOLD D
PIPE MANIFOLD MATERIAL NO g
DISTR PIPE
[DISTRIBUTION PIPE MATERIAL & MAHKIN(l
ELEVATION, AND ELEV.
/FDISTR.
ELEV
ELEV. PIP S
7
DIA
DISTRIBUTION
1%
INFORMATION HOLE SIZE
HOLESf`ACI DRILLED CORFJECTLY,/� COVER mAITERIAL
'7
VERTICAL LIFT CORRESPONDS TO APPROVE D
PLANS
1:1 YES
E❑-1 NO
1:1 YES El NO
COMMENTS:
PERMANENT MARKERS:
OBSERVATION WELLS
PROPERTY WELL: BUILDING
NUMBER OF LINE:
FEET FROM
L1 YES 1:1 NO
OYES E"] NO
"/� .
,�.. cd
1 /ji
Z_
,LZ, �:
Ap
.010�0
�L
Sketch System on
Reverse Side.
DILHR SBD 6710 (R. 01/82)
Retain in county file for audit.
SIGNATURE TITLE
DEPARTMENT OF APPLICATION �FE�&BU|0|NGS
INDUSTRY' FOR SAN ITARY DIVISION
LABOR AND PERMIT, . p.O.BOX 7988
HUMAN RELATIONS (PL13 67) MAD|SON'VV|537O7
Attach plans for the system on paper not |ma than 81/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H~83, Wis. Adm. Code, must be shown. An index page or each page must besigned, sealed and dated bythe designer. If designed by a Master
Plumber, the date, signature and |immnoo number must be shown. The owners copy or a legible reproduction of the soil test report must be
included.
Property Owner: Mailing Address:
Property Location: City, Village or TownE!2j�. County:
'/4 "/4S �21 /TZ N/R 0(00 W
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
L_ Alt4 AIA i;P4 jk Ar IcIV14 (if assigned)
Number of
D Public* ED Variance* F-1 Other (specify)* Bedrooms:
1 or 2 Family *State Approval Required.
TOTA L
GALLONS
NUMBER
OFTANKS
PREFAB
CONCRETE
POURED -IN
PLACE
STEEL
FIBERGLASS
NEW
INSTALLATION
REPLACE-
MENT
OTHER
(Specify)
SEPTIC TANK CAPACITY
X
X
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
IMANUFACTURER: ZIL5
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): New F-1 Replacement Experimental 2Q Seepage Bed Seepage Pit
El Alternative (specify) E:1 Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
El Private Joint El Public
1. the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Signature: iM AAPRSW No.: Phone Number:
1,,O� Z
e- M le,
Plumber's Address: Name of Designer:
_ry ILI
1i
DEPARTMENT USE ONLY
Signat e of Issuing Age Fee: Date: Sanitary Permit Number:
V APPROVED
/�43 O'DISAPPROVED
Reason for Disapproval:
| Alternate comrsm(s)u+Action Available:
Change of ownomhip, building use or plumber requires e Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White -County, Canary -Bureau of Plumbing' Pink -Owner, Golden rod -PI umber
Smith Plumbing Heafingr PHONE (715) 265-4838
C��,�,�o,gd ��yi%;pC>R GLENWOOD CITY, WISCONSIN 54013
q '
.5'�
71-
4f dl I s' s i
P4 .� 1, R � 1,v � v � �
C'i?G��x
S1r �"o. ac � �� �
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Is
DEPARTMENT OF
INDUSTRY,
LABOR At4D
HUMAN RELATIONS
REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION
PERCOLATION TESTS (115) MADIP.O. BOX 7969
SON, WI 53707
LOCATION:
SECTION: R
/T3/N/(or)W
TOWNSHIP/
I
LOT NO.: BLK. NO.:
SUBDIVISION NAME:
COUNTY:
S4
OWNER'S TBUYER'S NAME:
Tifc%J L,
MAILING ADDRESS:
ubt: DATES OBSERVATIONS MADE
Residence NO. BEDRMS.: COMMERCIAL DESCRIPTION: New ❑Replace P11017111! DESCRIPTIONS: PERCOLATION TESTS
-3
RATING: S= Site suitable for system U= Site unsuitable for system C C 1.4 A�
CONVENTIONAL: ®s
IN -GROUND -PRESSURE: SYSTEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
a s OU rV S [:]U [MS auLei 11 , []S L),,7J1U11xS[i1U C nee l lion 4L/
If Percolation Tests are NOT required DESIGN RATE: SYSTEM ELEV. If any portion of the lot is in the
under s.H63.09(5)(b), indicate: 3 91-2 40P Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORINGI
NUMBER
TOTAL
DEPTH IN.
ELEVATION
DEPTH To GROUNDWATER-INCHES
�CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
OBSERVED
EST. HIGHEST '
B-
91.34
J?
.76' YOZ ofte d' 'T
Ap
Jop
B-
01
B-,3
lu 0
> 7 41
76"tu
6
'>r 7,
J_ sr 4:1
B-
Is
J. 3?
j4J 0
PERCOLATION TESTS
TEST
NUMBER
DEPTH
INCHES
WATER IN HOLE
AFTER SWELLING
TEST TIME
INTERVAL -MIN.
DROP IN WATER LEVEL -INCHES
RATE MINUTES
PER INCH
PERIOD 1
PERIOD2
PERIOD 3
P- Cq
1�1 b
..Z
P-
Al
^4 ZA
13
.31
P_
P_
2-
PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings; and the direction and percent
of land slop.
oe
SYSTEM ELEVATION 9 9'�
13 +i F, 73 712
lei
•
SC eft
F/ — 9 � . 19 / •
OP2 " .9-L-2.9P
4t
Q%
&
1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin
Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
DISTRIBUTION: Original -Local Authority, 2nd page -Bureau of Plumbing, 3rd page -Property Owner, 4th page -Soil Tester.
DI LHR-SBD-6395 (N. 03/81)
bbbl.,
y • til
• w
w
CiA
ft
f
1
.art
�ti c
aIkf
Form - S T C i0o
Owner of Property
/AyA
.Location of Propertys'15kSection
T N
Township *Re
Mailing Address ,%
-
Subdivision Name
Lot Number
Previous Owner of Property- #1.�gsje
�%,,� r•
Total Size of Parcel
Date Parcel Was Created
Are all corners identifiable? Yes No
.Include with this lication one of the follo
win
.Certified Survey Map
Do a
-Land Contract or
-Other Vagal Document which describes the pruperty
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 i
described I n this
Intufmation form, by virtue of a warranty dead recorded In the Office of the
County Register of Deeds d6 Document No. 2 L29' Xl�l ; and that I (we)
presently own the proposed site for the sewage dispoVI system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the fame has been duly recorded in the Office
Of the County Register of Deeds, as Docume(it No.
fil(ANAY"a Of owman
SIGNATURE OF CO-OwNLR (W APPLICAaLE)
DATE 6614W&D 6*11 DATE SIGNED
% 0 r z I I
inberg and Minnie Winberg, his wife
W I
0
County, Wisconu*X, hereby convo"
co"mys Wi
Croix County, Bute of wiscomww:
Southeast Wuaner 4 SE k of SEAS of
I the N rthea3t Quarter of the
of goetior, Twenty-oight i
air1) North, of Range Fifteen i15
rein.
'IA
'A AJ j Y !�NEF
too �a tw i po,
4,
ts i
IP
I Ac
o land contract between the
in July its, 1959 in 359
hR V 0, herfUl7ft, IWI &w4? ww
-
day�r of ocut,er A* Dow 19 66
Signo*d Aga d Scaled in Pro. senor at
lip
J�
44
L
-Was
Ip
SAL)
'SCAJL,
--4SXAL)
Wilm of
Jam" 4b6-
dr"
ju AL
Soetion Twenty -mono 2 an t e' -r-fleast wuarter of the
Northeast Quart*r (NE of NE) of Eaction Twenty -weight (Ztl
ILall in Towship Thirty -mono (31) North, of Range Fiftoon (15)
West, St. Croix County, Wisconsin,
This deed is given pursuant to land contract between the
parties, which was recorded on July 10, 11959 in Voltune 359
of Deeds,
10 8
34 WOO GUltUato the said grantor 3 ha vehereunto wn the r hand S and mW 3 Wis
4 t h day of October #A* Dop 19 b8 *
Signed =W Sealed in Prowneo of
so all=
...(SLrA L)
;o7H a r r- Y Wj. nbe
(SEA L
Y, i nn J. e W1n er
-..(SFoA L
..(SEA L)
%Wtt Of U310MOtni
St- � AL
Croix county.)
Personally came Wore me, tW# 4th dayof October A
'kill
the above named
Harry Wi,nberr and Minnie Wl&nberg, An i s wire A
to we known to be the persona who executed the forvagoiiig instrument &nd acknowledged. -same
Vloxeph W Hq U
Notary Public,, SA, Croix Wis.
my commission � �-PP rm is
qmhW Hghes A t ornevat Law
New e%hmocW13consinDrsdted 04 4 6 &W
most="" A A
mad&".)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT -
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(mg
'ermit Holder's Name: ❑ City ❑ Village aTown of:
Winberg, Clifford I Town of Forest
'ST BM Elev.: Insp. BM Eiev.: BM Description:
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
P / L
WELL
BLDG.
vent to
Air Intake
ROAD
Septic
NA
Dosing
NA
Aeration
NA
Holding
PUMP / SIPHON INFORMATION
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft I Loss Head I
Forcemai n Length Dia. Dist. To well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County:
St. Croix
Sanitary Permit No.:
353112
State Plan ID No-:
Parcel Tax No.:
014-1045-80-000
STATION
BS
HI
FS
ELEV.
Benchmark
Alt. BM
Bldg. Sewer
St / Ht Inlet
St/ Ht Outlet
Dt Inlet
Dt Bottom
Header/ Man.
Dist. Pipe
Bot. System
Final Grade
St cover
BED / TRENCH
Width
Length
No. Of Trenches
I
I
PIT
No. Of Pits
Inside Dia.
Liquid Depth
DIMENSIQNS
I
DIMENSIONS-
SYSTEM TO
P / L
BLDG
WELL
LAKE /STREAM
LEACHING
manufacturer:
SETBACK
INFORMATION
CHAMBER
Type Of
Model Number:
System:
OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold
Distribution Pipe(s)
x Hole Size
x Hole Spacing
Vent To Air Intake
Length Dia.
Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over
Depth Over
xx Depth Of
xx Seeded / Sodded
xx Mulched
Bed / Trench Center
Bed / Trench Edges
Topsoil
❑ Yes ❑ No
❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: I I Inspection #2:
Location: 2882 200th Avenue, Emerald, WI (SEI/4, SEIA, Section 21 T31N-R15W) - 21.31.15.336
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R.3/97) Date Inspector's Signature Cert. No.
a
A
sconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue i
P 0 Box 7302
Department of Commerce In accord with Comm 83.05, W?s. Adm. Code Madison, WI 53707-7302
0 Attach complete plans (to the county copy only) for the system, on paper not less
County
than 8 112 x 11 inches in size.
(_ �:2 / X
0 See reverse side for instructions for completing this application
State Sanitary Permit Number
3.5-3112--,
Personal information you provide may be used for secondary purposes
0 Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION.-
Proper-ty own r Name 3
go-*
P¢^
roperty Location
—1/4 �� 1 14S 1X 7 T N, R W
Property Owner's Mailing Address
Lot Number
Block Number
4—ego
City, State zt),
Zip Code
Phone Number
Subdivision Name or CSM Number
II. TYPE OF BUIi,DING: (check one) El State Owned
11 Cit (
C] Vil age
Nearest Road
Public 011 or 2 Family Dwelling - No. of bedrooms
i�oof ow n 0 F
/0
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 40 -
—leg 7
1 Apartment/ Condo
2 Assembly Hall 6 [:] Medical Facility/ Nursing Home 10 E] Outdoor Recreational Facility
3 E] Campground 7 El Merchandise: Sales/ Repairs 11 [] Restaurant/ Bar/ Dining
4 ❑ Church /School 8 Ej Mobile Home Park 12 E] Service Station / Car Wash
5 Hotel/ Motel 9 [] Office/Factory 13 R Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B if appll%- ble)
A) 1. F1 New 2. R Replacement 3. E:] Replacement of 4. Reconnection of 5. E] Repair of an
W�
-----_System -------- System ------------- Tank Only Existing System Existing System
B) [] A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM.- (Check only one)
Non -Pressurized Distribution Pressurized Distribution Experimental Other
11 F1 Seepage Bed 210 Mound 30 [:] Specify Type 41 E] Holding Tank
12 ❑ Seepage Trench 22 El In -Ground Pressure X 42 E] Pit Privy
13 ❑ Seepage Pit 4 ❑ Vaul Privy
14 ❑ System -In -Fill j
VI. ABSORPTION SYSTEKI0044ATION: L/
1 Gallons Per Day A
Ab?o;Yea 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. r7.Finaa Grade
12.
Requi d ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
-7
Feet Feet
VII. TANK
capacity
INFORMATION
in gallons
Total
# of
Tanks
Manufacturer's Name
Prefab.
ConcreteSteel
Con -
Fiber-
glass
Pla5tICExper
App.
New
ExistingGallons
Tanksi
Tanks
structed
_.Ajr_r1r1ZXT S e p t I c T a n k o r_T_r, T-1 T.0 F*
❑❑❑❑El
Lift Pump Tank /Siphon Chamber
❑
1:1
El
El
1:1
11
Vill. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print)
Plumber's Signature: (No Stamps)
IL
MP/MPRSW No.:
5�3
Business Phone Number:
-7 Iz, C5
e5- t?4, �3 �7,,f
Plumber's Address (Street, City, State, Zip Code):
IX., COUNTY / DEPARTMENT USE ONLY
0 Disapproved
Sanitary Permit Fee (Indudes Groundvvater
Date Issue
Issui'n Agent Signature (No Stamps)
WApproved
Ej Owner Given Initial
� 0 Surcharge Fee)
I Adverse Determination....L.--
----I
X. CONDITI.QNS F APPROVAL / REASONS FOR DISAPPROVAL:
"k tr
SBD-6398 (R. 4/99) DISTRIBUTION: Original to Counly, One copy To: Safety & Buildings Division, Owner, Plumber
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspe ted the septic tank presently
4 1 'r 7'�) -,�L
e rq. _z
serving the toelz Z�)X� c,) � o -<, residence located at:
_]_1E <-�� Section T N R W Town of
Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced:
Did flow back occur from absorption system?
Yes No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete L.-� Steel Other
Manufacturer: (If known) :
Age of Tank (If known):
(Signature)
-y-
(Title)
Date
(Name) Please print
(License Number)
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I 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 baffle).
Name P1
tY(, '� Signature MP/MPRS L)a
WI i i
I 1457WE-524
EXISTING SEPTIC
SYSTEM AFFIDAVIT
Document Number
Name & Return Addre S
11 IC-Fo 2"'. t" ?
/1/- -moo
Parcel I. D Number
OE&o :3L C)h
KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO. I WI
RECEIVED FOR RECORD
09-20-1999 1:40 PM
AFFIDAVIT
EXEMPT #
CERT COPY FEE:
COPY FEE: 2.00
TRANSFER FEE:
RECORDING FEE: 10.00
PAGES: I
The existing septic system which serves the dwelling being added on to must be verified by
an acceptable soil report or be inspected by a licensed soil tester for compliance with high
groundwater and/or bedrock separation requirements as set forth in s. COMM Chapter 83-10 (2)
WI. Adm. Code. The results of that inspection must be made available to this office. If the
existing septic system meets these minimum requirements, and is properly functioning, an
addition may be added to the dwelling without updating that system. This addition must not,
however, encroach upon the required septic system setbacks as setforth in s. COMM 83.10 (1) .
11'
Property Owner (s) r//-- — , i 0 Y'- d /� "0
Property Mailing Address :C ems
Property Legal Description: Lot # CSM/Subdivision
-EL y., sec. W, Town of ZZ 0
I, as the owner of the above described property, hereby affirm that the septic system serving
this dwelling meets the above referenced state private sewage system codes. I realize that
this addition may cause the existing septic system to become undersized for a dwelling of the
resulting size, and I will make this information available to any future pa�.t,ies interested
in purchasing this property.
Z %
zi
-A
3ILM70
Signed: Notary Public 3�SC ed &n(-.
'i. : •.
s to be f o riB da 1�4
Date
1X4
ML
My commission
4t.
County Approval: *so. i&�-
1
Date:
,.Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page I of 3
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
A.C.E. Soil & Site Evaluations
Attach complete site plan on paper not less than 81/2x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal referen poiat�@M), direction and
oe
St. Croix
percent slope, scale or dimemsions, north arrow, I&TUt I -1,94,nce to nearest road.
Parcel I.D.#
014-1045-80-000
APPLICANT INFORMATION - Please print all inforMaVon. PC
Personal information you pro\�ide may be used,lbr secondary pur�4es4rivacy La'w, s',. 15.04 (1) (m)). R _-boyl D
Property Owner Property Location
Clifford & Caroline Winberg Govt. Lot SE 1/4 SE 1/4 S 21 T 31 N,R 15 W
Prop
erty
iff
er' 0
C unty
P rcel I.
R
Property Owner's Mailing Address L! # Block # Subd. Name or CSM#
zo
PA. 0�.�
F2882,200th Ave.
Nearest Road
city State 1i e tuber city Village 'Town
17 1 1 Forest 200Th Avenue
m r�
Emerald W1
New Construction Resit ri ` bedrooms 3 Addition to existing building
Use:
Replacement Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, g pd/ft'
Abso!pbon area required 643 bed, ft2 562 trench, ft2 Maximum design loading rate .7 _ bed, gpd/ft2 .8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 93.5' bottom of existing drainfield ft (as referred to site plan benchmark)
I Existing mobile home to be replaced with new M.H. Reconnect to existing conventional system. Undersized
Additional design / site considerabons sysftin affidavit wid U!,AOILD'16 tank L.Citificatin, a .
Parent material. Glacial outwash Flood elain elevation, if applicable NA ft
S=Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank
U=Unsuitable for system S U S U S U S U S U S U
SOIL DESCRIPTION REPORT
Boring#
I
Ground
elev
- 9 5.7-3'.ft
Depth to
limiting
factor
>96'
2
Ground
elev
96-05'ft
Depth to
limiting
factor
>76"
Horizon. Dominant Color
Mottles
Texture
Structure
Consistence, Boundary Roots
GPDfft2
in.
Munsell
Qu. Sz. Cont. Color
Gr. Sz. Sh.
Bed Trench
1
0-6
1 Oyr3/3
None
sl
2 fcr
m vfr
as 2f
0.5 0.6
2
6-14
1 Oyr4/4
None
scl
2fsbk
rnfi
as
I f
0.4 0.5
3
14-24
7.5yr4/4
None
Is
I csbk
mvfr gs
0.5 0.6
4
24-96
7.5yr5/6
None
ls&gr.
Osg
ml
0.7 0.8
f
I
IL I
Remarks: rionzon 43 consiSAS cal COUSC SanU WIL11 n1gn Clay
C011LOIL. %-Aay NKHIN WC VVNCjVdUj1Z U11 111UjVjUUaj;5MjU V_JaU13. %,Aay %0V11L%,11L al"11%,1%W11L
9
justify reduced loading rate.
1 0-6 1 Oyr3/3
None
sl
2 fcr
mvfr as 2f
0.5
0.6
2 6-19 1 Oyr4/4
None
SO
2fsbk
M fi as I f 0.4
0.5
3 19-26
7.5Y r4/4
None
Is
Osg
M1 gs 0.7
0.8
4
26-76
7.5yr5/6
None
ls&gr.
Osg
M1 0.7
0.8
O�
Remarks: ZOO
FC CST Name (Please Print) Signature- Telephone No.
James K. Thompson 715-248-7767
Address
Address A.C.E. Soil & Site Evaluations Date CST Number Ref #
340 Paulson Lake Lane, Osceola, W1 4 0>2 0 9/2/99 3602 1099
SOIL DESCRIPTION REPORT goes j page 2 of 3
wr._F sail & site Evatutiom
P CWNEk Clifford & Csm w W'
PARCEL 10 014-10454M-000
Ground
elev
96.81' ft
Depth to
limiting
factor
>76*
Ground
elev
Depth to
limiting
factor
Ground
elev
Depth to
limiting
factor
Ground
elev
Depth to
limiting
factor
Depth
in.Munsell
Dominant Color
Mottles
Qu. Sz. Cont Color
Texture
Structure
Cr. Sz. Sh.
'
TnsistenceBed
Bounds
Roots
GPDlIHonzon
Trench
1
0-4
10yr3/3
None
sl
2fcr
mvfr
as
2f
0.5 0.6
2
4-16
1 Oyr4/4
None
SO
2fsbk
mfi
as
1 f
0.4 0.5
3
16-27
7.5yr4/4
None
is
1 csbk
mvfr
gs
-
0.5 0.6
4
27-76
7.5yr5/6
None
is&gr.
Os g
mi
-
-
0.7 0.8
.�D
Remarks:
Remarks:
Ir
Po. 3oC3
A,
N
vo
A 5 5 us"ed Cle Co.'
13¢-nc�. Fv(r,�r,� •' r p o� s.T C l�ea..�ou�
e E'-
q rQr!'pi � t,L�►
elyl"<Z-
7
%' x 70 C� r ■ ,83
Ate 4 e �
flame ._... � �_..,...Y... to uritJ,
e4t
A)
�--------�� jD
c'nposed d6�C�u�;dc Wt�bile Nye
cum res�dQNce)
ers�:�g .xcA`/"e 14.n-e.
v
c uj n c r:
6'4�rde eae-c/-ne &Jil bc 7
rxe�'ac.�a/ c.Z /. syor2
cc� art
;7 3/�,
�. C? r oa r
�L
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND j
OWNERSHIP CERTIFICATION FORM
Owner/Buyer --'Brcot -q/,//1o(jJPer
11111111! jf�l
Mailing Address (00=* �-7�(r)- QOD -+bL Cm Q� 11,c,c-- ��f(�l o?
Property Address
(Verification required from Planning Department for new construction)
Ci- tylS tate 5qmp, a5 q, b 0vt Parcel Identification Number -L(L- 9C:) - (Doo
LEGAL DESCRTPTION
Property Location s e L-: 1/4 Sec. - 2 T-IJ--N-Rj-,S- W. Town of -
Subdivision -. Lot # -0
Certified Survey Map #
Volume Page #
Warranty Deed 9 a Ct 3 9 �q Volume Page 9
SPC0 -house 0 yes IJ no
Lot lines identifiable 0 yes 0 no
SYST19MNANCE
Improper= and maintm P2 ^Aft
0- of your septic rfst= could regdt M its pr=a faflure to handle wastm proper m 2 in tm =cc
coasisft of out ffic -A tank every 0
ffime Y= or sooner., if =dcd by sL license pumper. What you put into the sysum
can affed &C funcfim of die septic tank -as a t=tmer, VtRV icL &e VI.Ste diq*nl -VstcrrL
A
The FLVPIaLY' '19= to Vd=ft to St mix ZOning DePutment A certification forca, signed by the owner and by a
maAcrpb=ibcrjJ0u`mcYm=P1=bCr, restrictedplurnbcr or a licensed FuLuip" vaifying that (1) the on-sit.6 wastewatcrdisposal sysum
i-S ill PIPPer Operating condition an&or (2) after wonand - 11 in
PmmPmg (if n==ary), the tic tank is less thatn 1/3 fuU of sludge.
I/We, the I.. t't"'
eUG'- i'C KcquA=c= LW ag= to mainta in &c private sewage d4osal system with the
set fOrtk herein. as set by the Dqmwx=t of Commerce and he Department of Natural Rcsourct:&, State of Wisconsi,3 Ctrdficatibn
stating thatyour Septic System has been, intained must be COMPIdLr.OdlMd =cdto the St, Croix County Zo Office within 30
days of &C three year cxpiration. date.
V'r
o6
SrGNA1TJRE OF APPLICANT DATE
O)VNIER�KJLWICATION
. I (we) certify that all statements on this form arc true to the best of my (our) knowledge. I (wc) am (am) the ownci�s) of
the Property dcscn-bcd abovc, by virtue of a warranty deed recorded in Rc&tcr of Dcods Office.
SIGNATURE OF APPLICANT I
DATE
**'**** Any infonnation, that is sans-rcprcsent0dmLaY rcsUltmi the sanitarypcimit being revoked by the Zoning Department * * * * * *
Include with this application: a Stamped warranty dad from the Registex of Deeds off -ice
a copy of the certified survey map if refcreacc is made in the warranty deed
F-.T-.,-,FF--, ..,)HLLEY ABSTRRCT Fax :715-386-7664 Sep 17 11:9`9 1 � : 59 P. 01
2 9 31,91A
06
mad. n Harry Winbe e , I rg and MinniWinberg, his wif e
P
KrAncora of St. Croix Canary, Wisconsin, here" conways
&Ad W*f f &nf* 90 C11f ford'WInberg
grantee of St Croix cQuaryp wisconaino for
the SUAR of
rho 1colow as trace of &9!Ajn St. Croix coanty. Sr&tep of -4w6iiiin.;
The Sofitheaat�Qu&rter of the Southeast Quarter (S.Ej of SEk) of
3,ecoon '79wenty-cn'e (21); and the Ngrtheast Quarter of the
ortheant Quarter (NZ of NEt) of ecvlon Twenty- eight (28)
ze----`aalj in Tawnehlp Thirty-one (31) Northp of Range Fifteen (15)
West, St. CrOIX County, W18conaln.
ThIs dead is ILv.an pursuant to land contract between the
p&rtloev . whieg was recorded on July 10, 1959 In Volume 359
of Deeds.
KEGISTERS OFFICE
ST. CROIX CO.. WIS.
Reed for R--rd this_ 2tch—
day of - - Q-c-% obvr- - _A:. D.1965
at -
Ai wed
Ile
TV' Uw add -&a-= or 8,haveAwronz"art their b=d5 and a"18 We
nth dAW of !.October A. D., zo 6 a
.Tjfmnwd mud-'Smpslod in J111A *�ncw au' 1tsda., e(sCAL)
t7H&z-rj: WJ11122be
SZA L..)
awc.4-
-MiLrLnie winbet&
.(SSA L,) -:04
RultbL Al A 11%ahnfI013
Otate of
'Croix
Porsonwaly Game botmme m X- two art day of Oc�tob or #As
the above MWUMMd �ram"o%fop, %*"g and MInnie WInberg, h1s wif 0 01� 111
'
to we ALnown to bw the persang whoo-execatad the to goin Instrujuent and led boom
eph W.
z rx ColWis.
3IC 4b Mjr ca an i a Perma"r
a
Dralead by goanph We Hughes.- Aj&grneys at; Law, New Richmond_, Wisconsin
mm 446 PA 4@7 E217
I W. UL—Aeft. M W%N6 EftmftlL UNNOW"M � as WD is MUNEWfte &%" Uwe% ftft� "ftrud 4W ft wwo wftmm ftwmw fte �r 40 "a
SPLES 3 7 1 E; 387 2931 1999. 0a - OG
RO LLO HO E
A Product of Wick Bullding Systems, Inc.
P.O. Box 530 - Marshfield, WI 54449 - (715)-387-2551 Last Pages
61 Print on this Page: 08106/1999
+4C)ULP Ct vt 'C' oci. 41M f
10 C
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VAULTED CEILING - Tm
4) 120-00 5146 D 17'-4 I1) F-4 14
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UNDRY
------------------------
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BEDH�OM 3
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BEDR OM 2 LIVING BEDROOM I
ROOM
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G G
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MEMO_
12'-0" 181-80 clfl� 0
RHFS-439 28 X 44 3BR CK 2B 2 3 SQ- FT.
C7
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7,
j� X1� deck ov+ (mac Ic
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