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Home My WebLink About040-1012-50-000 (2)ST. CROIX COUNTY ZQNING DEPARTMENT AS BUILT SANITARY REPORT Owner Aj Property Ad�dFess City/Stat INI,&:,►r, i (4p Legal Description: Lot - %rA Block M-4. Subdivision/CSM # PIN 4 -F Town of '/4 '/4 See. �A T 2-S N SEPTIC TANK -- DOSE CHAMBER. — HOLDING TANK INFORMATION: I 2.00 A Tank manufacturer Setback from: House Well i 0 P ..LJ,A,,A N(- Size ST/K Pump manufacturer M.A Model Alarm location [\3 - f) - (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter loc.,at-ivil. Alarm location SOIL ABSORPTION SYSTEM: n Ia. �-wc- nA-,t0vxk--Q-- ;.-. Type of system: act-L, Width Length Number of Trenches Setback from: House q ri Well P/L Vent to fresh air intake \j ELEVATIONS: Description of benchmark Description of alternate be- BuildingSewer 9--/(e -ST/Wlnlet STOutlet PC Inlet PC Bottom Header/Mani fold q (0, To of ST/PC Manhole Cover Distribution Lines clf5 Z } Bottom of System(,,) y TA, o4 ( ) Final Grade O 1-'-s (1) q -) c �00 11 q 9 Date of installation / I/ — Permit number 3 � q �t,- State plan number Plumber's S' nature a License number Inspector Elevation V0C-). 0 Elevation i 03? Date =�A Complete plot plan mr NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. 0 Two horizontal reference points to center of septic tank manhole cover. a Show alternate benchmark, if applicable. Id 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)(m)]. Permit Holder's Name: City El Village n of. Ray, David & NancK Town of Troy CST , BM Elev-:- Insp. BM Elev.: BM Description'. I oo TANK INFORMATION ELEVATION DAT STATION Benchmark TANK SETBACK INFORMATION TANK TO P 1 L WELL BLDG - Vent to ROAD Air intake Septic 1 30' NA Dosing NA Aeration NA Holding PUMP / SIPHON INFORMATION Man r D n Model Number GPM TDH Lift Fr* h 5ys -1--, 055 Head TDH Ft Force Length Dia. Dist. To Well� SOIL PTION SYSTEM -� ENCH Width Len No_ 0,f'rr nches Q1 I Alt. BM FBIdg. Sewer St/Ht Inlet St / Ht Outlet Header/Man. Dist. Pipe Bot. System Final Grade St cover County: St. Croix Sanitary Permit No 344657 State Plan ID No-: Parcel Tax No.: 040-1012-50-000 A BS HI FS ELEV. 3.,(f 0 3 of'+M C) ------------ I ro .33 T- Z_ 7 _5z) C) it 17 iif- _, F_o I -de D Liquid Depth PIT No. Of Pits Dia. , III'_ I DIMENSIONS LEACHING Manufacturer. SYSTEM TO P / L BLDG WELL LAKE /STKLA1V1 SETBACK --- CHAMBER Model Number. INFORMATION Of OR UNIT System: DISTRIBUTION SYSTEM x Hole Size x Hole Spacing Vent To Air Intake Header / nlfolcl Distribution Pipe( - s) L Length Dla. Spacing Length _�_"_____b1a. SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Deth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched p Bed /Trench Edges Topsoil E] Yes Na Yes No Bed /Trench Center COMMENTS: ( Include code discrepancies, persons present, etc.) Inspection #1: Inspection #2: 1 1 hw Hudson, W1 (SWIA, NEI/4, Section 4 T28N-R19W) - 4.28.19.50D LoclAtion: 571 Hi ay _3j, 4Ak CAI� > 1 On Plan revision required? Yeso No Use other side for additional Informati on. 91 Cert No Date Inspector's Signature SBD-6710 (R.3/97) Vill. RESPONSIBILITY STATEMENT 1. the undersigned, assume responsibility for installation.of the onsite>ewmo,ge system shown on the attached plans. Bysiness Phone Number: 631 14& P16-mber's Address (Street, city, state, ZID co(seK' IX. COUNTY/ DEPARTMENTUSE ONLY El Disapproved Sanitary Permit Fee (includes Groundwater ate Issu Issu 1 ng Agent Sig n atu re (No Sta m ps) Surcharge Fee) PtApproved F1 owner Given initial OL 0, Ze issuing Adverse Determination I - 974 1 =5 FOR X. ONDITIONSOFAPPRO AL/PEASPNSFOR I DISTRIBUTION: Original to County, One copy TO: Safety & Buildings Division, Owner, Plumber Page I of 1 SITE PLAN Dav i d Ray SWINE,4f28,19W St. Croix county Troy Township L.. r. Jack A. Bowman MP 5875 LEGEND U --BM; 100. 1 top cif 1-21, PVC pipe (v -BM: 98.861,nail in box Older tree G-borings ScAle 111-401 except where indicated Proposing 2 trenches aft. by 75.6ft. Hi -Cap Infiltrators System Elev. 95.501 0 s3xL40 el -J 11� 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. Sol] & Site Evaluations Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County 7 include, but not limited to: vertical and horizontal t (13M), direction and St. Croix percent slope, scale or dimemsions, north ar o� 6 aM-distance to nearest road. Parcel I.D.# 040-1012-50-000 APPLICANT INFORMATION - 4.4e print 11 inform6tion. Ra^wed Date/ Personal information you provide may be �Sedjpf seconcty,�yi,p ses (privacy L s. 15.04 (1) (m)). ICZY1 -n Property Owner Property Location Govt. Lot 28 N,R 19 W SW 1/4 N E 1/4 S 4 T David & Nanev Rav R Property Owner's Mailing Address ST Lot # Block # Subd. Name or CSM# Property David v e i rt d County Parcel R rHProper� 571 Hwy. 35 South cooNpe c ity N ity State, �ip 6 Ahboftpber City Village Town Nearest Road u SC Troy Highway 35 udson W1 54016 715-3$62i�3) R� bedrooms 4 __.____.Addition to existing building New Construction F7 Replacement Use: Public or commercial describe Code Derived daily flow 600 - gpd Recommended design loading rate .7 bed, gpd/ft' .8 trench, gpd/ft2 Absorption area required 857 bed, ft2 750 trench, ft2 Maximum design loading rate .7 - bed, gpd/ft2 .8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 95.50' ft (as referred to site plan benchmark) Additional design / site considerations Install trenches using high capacity infiltrators. Parent material Outwash s & gr.-__ --.Flood plain elevation, if a2licable NA ft Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank S=Suitable for system S U S U S U U S S U=Unsuitable for system ","Is C, U L J U SOIL DESCRIPTION REPORT GPD/W Depth Dominant Color Mottles Structure Horizon Texture Consistence; Boundary Roots Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.Bed Trench 0.6 2fcr fr as 2f 0.5 1 0-9 1 Oyr4/2 None S1. 2 9-2J I Oyr4/6 None sl 2fsbk rn fr CS if.- 0.5 0.6 Ground M1 gw 0.7 0.8 3 21-31 7.5yr4/6 None Ic Osg ----- elev ------ 100.60 ft 4 31-48 7.5yr4/6 None !it. S & gi, Osg M1 gs 0.7 0.8 Depth to 5 48-106 1 Oyr5/4 None St. S 0Sg ml 0.7 0.8 limiting factor > 106" Remarks: 1 0-18 1 Oyr3/2 None S1 2fcr Mvfr as 2f 0.5 0.6 2 18-29 1 Oyr3 /4 None S1 2fsbk m fr cs I f 0.5 0.6 Ground 3 29-47 105yr5/4 None S1 2msbk M1 aw 0.5 0.6 elev 100-56 ft 4 47-71 7.5yr4/6 None A. S & gi: Osg ml gs 0.7 0.8 Depth to 5 71-108 1 Oyr5/4 None St. s Osg Ml 0.7 0.8 limiting (Ct6 factor >108" Remarks: CST Name (Please Print) Signatur" James K. Thompson Address A.C.E. Soil & Site Evaluations 340 Paulson Lake Lane, Osceola, 54020 Telephone No. 715-248-7767 Date CST Number Ref # 7/14/99 3602 1072 '4 TION REPORT Page 2 of 3 PROPERTY OWNER: David & Nancy Ray SOIL DESCRIP A.C.E. soii & site Evaluations Depth Dominant Color Mottles Texture Stru ctu re I �,Onsistence'l Boundary Roots Horizon Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench elev limiting factor Remarks: 4 . 2 Ground elev 3 Q7.2*ft 4 Depth to mnmn - -factor 0-9 1 Oyr3/2 None --- __ - 40y 5 iD Remarks' Ground elev 8r.18'M Depth to lirniting factor 3t Groundelev ' Depth to limiting--U-- --|--- -- factor I / Remarks: -F3 W r- 9 Ix L�j an cy day S7/ /��y. 35 �. gu-dsa 0/ SVO 3 e- aak • 0 y A S dX le f 9,86 A na AWL 6 al lo�pecart SL A 55"IVECA ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP` CERTIFICATION FORM % Owner/Buyer ,�; Mailffig Address Property Address (Verification required from Planning Department for new construction) N City/State Parcel Identification Number C) Ce 00 LEGAL DESCRIPTION A -R W Town of Property Location_`_*-_*.'.�'W V, I/, sec. T 2P I ,) N - Subdivision Lot # 9 Certified Survey Map # - Volume . Page # Warranty Deed # S 9. t i__ —0 q 10 lume 1 -7 �0_ 19 (-P —. ,Volume . L_ ,Page Spec house El 'L� yes U)no "r Lot lines identifiable Y"Yes El no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic s tl=, has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 f the three year expiration'4ate. I SA OAF AP I DATE OWNER CERTIFICATION I (we) certifyAha"ll statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) Of thq,,p�)perty describe abov , by virtue of a warranty deed recorded in Register of Deeds Office. vv I ( / _y DATE S I'N 'YftE 0 Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed 5,91.404 Document ;4umber , - 1�'"�� PAr - '?'?I h�'t I- - WARRANTY DEED Deed, made between ween Ervin . A. Hal'sdorf and Eloise V. H-Q-.,-:-:1d1-A, husband and wife, Graotors, and David A. Ray and Nancy A. Ray, husband and wife as survivorship m 'tal property, Grantees. ar, , is, for I valuable Witnesseth, That the. said Granto described ideration convey to Grantees the following cons'l Cf % V E,� real estate C.-nix Gounty, StudsIsCOF act of re-i estate located in the NE'/4 of That certain farce, -if land or ti 0 OAX Sect -on 4, Township 213 North. Range 19 Wnst. Troy Township, St- iCr i County, vvisronsin, further described as follows: Beginning at a pont on the cast right-of-way tine of S-s F-i -35", said P-3int being 108-2-2 feet south of the north lira of said Section 4'. thence S00034W with said right-of-way a distance of 2214.6 feet, thence S89'1'26`E a distance of 19.7 feet, thence S00,034-W with said right-ul-way a distance of 9r,.4 feet-, thence N89'00'E b - a distance 611 660;3� feet- thence N00'34'E a distarce of 330,0 feet-, thencp. S89o0r-1,'W a distenc-P. of 680.0 feet to point of beginning. The above described parcel contaiiiing 5,11 acres, Mori or less. T. kil C R c� i x C", 0. e n v 1 1998 C-?: 3 0 Recofc,injArea Name and Return Address C)AVI(D J. FS-TREEN 304 LOCUST SY HUIDSC)NI W1 54016 040-1012-50-000 (Parcel Identirwcat*r, Number) that Land r-'fontract dated 8-15-78, recorded 8-22-78, in Vol. 579, Page 54-11, as (This deed is given ir. sp�* faction of i(h, Doc. No. 351055, Regi,ste� of Deeds'office, -;t. Croix County, VVTscons�n-) /TRANSFER s/ Y5S, , FEE 7 -I'S is not homestead proPei" 1Y -vf-W-ith all and singular "he hereditarnents and appurtenances thereunto Toyeti"Of belonging- An J Ervin A. Haf sdorf and Eio.'.se V. Harsdorf warrant that the tl I good, indefec-,,�Iible fr�-and clear of encumbrances except easements, covenants, conditions .a n fee S'mple and a and restr"ctions, and will warrant and defend the same. Dated ti - �iay of No%.-e .[)e,,-, "ErAn A. Harsdorf J 21' *Eloise V. Harsdorf �kCKNOWLEDGMENT U N C,4110 IN STATE OF wjS%C'PONS`IN I COUNTY this day of Novemcer persona;ty came before ,rie 101 se V 1998. the above named Ervin A. Harsdorf and E authenticated this day of who executed the t the persons w Harsdorf to me known to be 10,f oing instrument and ackno�, ge the sa e- '59 Signature ype or p�knt -�arne Sigt-a iE Type 4s-;w!nt rime --,4 kaee4 TJTLE� MEMBER ST.- XE BAR OF W!.-.,C0NSIN 7 INC!41%�VF A C Wisconsin n t)�xrA (It not, -5 authorized by §706�06,VVIS- StIt- ssic 46. THIS INSTRUME�JT WAS '-.RAFTEU d" �13 — I -- a-,y capacity should be typeu or p, inted bekwf of p& jjgx.,% j�." i ng i tom;g"lures- C. L. Gay!ord, Attorney asLaW R;ver Falls, W1 54022 n 24.,Ged ar acknowtedged Both are n(--ii ec'essary.) ,nattifes may be Ruth—,- I 5 0 p.tAessK -C�Onsln 3W eflofmatoon -�r, ass �cr— -iny Food Ju Lac W-S 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)(m)). :4 it Wli age P Town of: Permit Holder's Name: Ed City El Village RAY, DAVID & NANCY TROY [-CST BM Elev.,.- Insp. BM Elev.: BM Description: TANK IKIF:()RMAT10N TYPE MANUFACTURER CAPACITY Septic Dosi ng Aeration Holding TANK SETBACK INFORMATION" TANK TO P L WELL LDG Vent to ROAD Air intake Septic Z NA Dosing NA Aeration NA Holding PUMP / SIPHON/INFORMATION Manufacturer Demand Model Number GPM TDH Lift Friction System I TDH Ft Loss Head Forcemain ]Length I Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches DIMENSIONS ELEVATION DATA STATION Benchmark Bldg. Sewer St/Ht Inlet St / Ht Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe / Bot. Syst Final G/ade County: Sanitary Permit No.: 338819 State Plan ID No.: Parcel Tax No.: 040-1012-50-000 IVJ900075 BS HI FS ELEV_ PIT No- Of Pits DIMENSI ACHING Inside Dia Manutacturer'. Liquid Depth LE TO P L BLDG WELL LAKE"/STREAM SETBACK CHAMBER INFORMATION Type Of— OR UNIT Mode Number: system, DISTRIBUTION SYSTEM Distribution Pipe(s) x Hole Size x Hole Spacing dent ToAir intake Header I Manifold Length Dia. Length ia. Spacing S - OIL COVER X Presses f`eSystems 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 E] yes ❑ No ❑ Yes ❑ No COMMENTS: (include code discrepancies, persons present, etc.) ki LOCATION: TROY 04.28-19.50 NW,NE 571 7 HIGHW Y 35 I! -7 I ion required? es Plan revisi El y Z740 Use other side for additional Information. 19 rr Cert No Date inspector's Signature SBD-6710 (R-3/97) W Safety and Buildings Division 201 SANITARY PERMIT APPLICATION P.E. Washington Ave, O. Sox 7969 \Viscousin in accord with I LH R 83.0 5, Wis. Adm. Code Madison, WI 53707-7969 Department of Commerce Count • Attach complete plans to the county copy only) -for the system, on paper not less County C than 8 1/2 x 11 inches in size. State Sanitary Permit Number • See reverse side for instructions for completing this application 3 [11.0 ppli7� E] Check It revision to previous a at ion The Information you provide may be used by other government agency programs State Plan I.D. Number [Privacy Law, S. 15.04 (1) (m)]. PLEASE PRINT ALL INFORMATION I 1. APPLICATION INFORMATIOR-- Property Location 0 �j -P 1/ 41S N, R E (or) W hi T Proper-tyowner Marne ► 114 P, -N4 Lot Number Block Number Property Owner's Mailing Address '07 Phone Number Subdivision Name or CSM Number Phone N 1p Code T City, state Zip Code gqo ad t&vs 0'r* W I � -,- � I - o it WNearestii.TYPE OF BUILDING: (Check one) State owned Village 35 n Lj Public 1 or 2 Family Dwelling- No. of bedrooms Town OF 3— Parcel Tax Number(s) 2,8. 0 D Ill. BUILDING USE: (If building type is public, check all that apply) * Ic rl --� ----Out� 1 F1 Apartment/Condo 6 E] Medical Facility/ Nursing Ho I me 10 ❑ Outdoor Recreational Facility 2 0 Assembly Hall 11 Restaurant/ Bar/ Dining 3 El Campground 7 E] Merchandise: Sales/ Repairs 12 E] Service Station/ Car Wash 4 ❑ Church/ School 8 El Mobile Home Park 13 [-] Other: specify 5 ❑ Hotel/ Motel 9 [:] Office/Factory IV TYPE OF PERMIT: (Check only one box on line A- Check box on line B, if applicable) New 2. 0 Replacement 3. F1 Replacement of 4. RReconnectlon of 5. [] R e i p a i air of an Existing System A) System -------- System ------------- Tank Only -------------- Existing System ------------ IT ------- Date issued B) ❑ A Sanitary Permit was previously issued. Permit Number V. TYPE OF SYSTEM: (Check only one) Experimental Other Non -Pressurized Distribution Pressurized Distribution 30 [] Specify Type 41 E] Holding Tank 110 Seepage Bed 21 E] Mound 42E] Pit Privy 12 0 �eepage Trench 22 [:] In -Ground Pressure V �1l 5 43 Vault Privy 13 ��'Seepage Pit Cc�)a�P4 14E] System -In -Fill C57X Cott 5 t-A F V1. ABSORPTION SYSTEM INFORMA-170N. 4. Loading Rate 5. Perc. Rate C. System Elev. 7. Final Grade 1. Gallons Per Day 2. Ab i sorp. Area I Absorp. Area (Gals/day/sq. ft.) (Min./inch) Elevation Required (sq. ft.) Proposed (sq. ft.) Feet, Feet 7-- Capacrty Prefab. S ite Fiber- Plastic i c Exper. Vil. TANK in gallons Total # of Manufacturer's Name Concrete, Con- Steel glass App- INFORMATION New Existin Gallons Tanks structed I I F� �ne r New 'j d "'u FX Tanks Tanks o 2 D 0 0 Septic Tank oo+fv!0ding 9,F,,nk U 0 El 1_0 10 D 'Lift Pump Tank /Siphon Chamber Vill. RESPONSIBILITY STATEMENT blity for installation of the onsite sewage shown on the attached plans. 1, the undersigned, assume responsi- 1 ,ystem s Business Phone Number: Plumber's SI nature: (No Stamps) PRSW ;> Plumber's Name: (Print) UN, �Sa T!j P1 u m be is Add ress Street, City, State Z I p Cod 1A Pj 4 IX. CoUNTY/ DEPARTMENT. USE ONLY (includes Groundwater —Date issued issuin Agent Signature (No Stamps) Disapproved Sanitary Permit Fee surcharge Fee) Z:Z jsjuinAgen, Sig t Ej Owner Given Initial .0 14 q KApproved ❑Adverse Determination 0� cz) Icl OR DISAPPROVAL: �Cmvo rw X. CONDITIONS OF APPROVAL / REASONS F I kml_z,� 1144 oyl Vrt,,,Ij-g� Vj 00 iO� OA*7 AtAi—A00m.. 7 In -A f A 11 6L 1A C)ne copy T Safet & i in 5 Vision, Own piumber Sid-6398 (R. 11/96) DISTRIBUTION: original to County. o e- T% fill PV C- AVAAO A I I I OW ft) sl�ptc Ta"t 36 of W � 1) t6 Dfc�vlp)) _35 "VALUATION Page I of 2 "V Wisconsin Department of Commerce SOIL AND SITE E. Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code EnN199, -�rorxner.tal& B�D , es J51L 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 reference point (M), direction and -Croix pefce-1, slope, scale or dini ernbsionr5, no,-tt arrow, aned llocation and U-IML-d-rice to nearest road. OIL Paro I el 1,.D.# 040-1012-50 APPLICANT INFORMATION - Please print all information. 1— -1 Date R By Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)) X PropertY. 10Mft0FF#C-F Property Owner Govt. Lot 14W 114, *E 1/4 S 4 T. 28 N, R 19 W Ray. David & Nancy,- Dave & Nanqy Lot Block # S6W. Name or CSM# Property Owners Mailing Address None Pr 571 Hwy 35 Nearest Road C City Village E]Town City State Zip Code PhoneNumber Troy Hwy 35 [Hudson W1 54016 Arlrlitnn to ayieting hUililinn F-1 Nel.A., C0nS+rUr+inn Residential I N, iMhar nf hadmnMe Sri U %ru%A19 Ij Use: F] Public or commercial describe Replacement FF N .ft de i bed, gpdWL—_:� trench, gpdff 0 .ode 450 gpd Recommended design loading rate- - ode 'U'kedved daily flow 0 A SOU .7 bed, gpd/ff .8 trench, gpd/fF so area required 64 bed, W 563 trench, fF Maximum design loading rate — Recommended infiltration surface elevation(s) 88.21. ft (as referred to site plan benchmar This bore hole is for the verification of the existing system Additional design / site considerations Flood plain elevation, if _applicable.- Na ft Parent material Loess Over Glacial outwasb wr%1#4; nr1T#3nL, M in F I! F e Ir AT 1^1 ind 0i in Prn 11-Suita 1 Ir sbys�teni %.0 V X.0 %A4 %.fssu 1 %.0 U E' U 00rJ - L We fo Y 1 7,_ j S 1-1 U F_-1 S L: El S E_� N S El U Ej S Cl U Fl, S El U U=Unsuitable for system 0 . rNill nC:QnP!_DT1nH REPORT P^r;nn4+ QjV6 I VTr Ground elev f%-7 n 4 14 Depth to limiting factor - A Ar% Remarks: This bore hole was conducted so that a tcmporan? tiooKUI) CoUt(i VC HIdUr, LU a jjJjUVL1%d LLUILIV. a new location at which time this system will be removed This tempo` residence will be replaced with a new residence at V�'CT AI a Innicl. k 1 1, r,- a 11LYnil %�011jll LUIIU 715-246-2454 Thomas C. Nelson rQT Klumber Deaf ntual By Desliggn DoLe L Address J'11vff^n-m " 3/18/99 227387 225 1432 120th Street, New Richmond, W1 54017 ENViRONMFNTAI gY DISI N 197?1120" STRFfT. NEW RKNMOND. W7SlONSiN IA51 5WU R 7WO/lAA5 HQ5W 70-21001 Dave & Nancy R Y NW�/�,, NEI/4, SECTION 4, T 28 N, R 19 W Troy "township, St. Croix County, Wisconsin Page 3 MW SCALE 191=40 BM I. TOP of telephone Pedestal ELEV., loo, BM 2. Top of tongue to MOM* home Elev 99.93 Tom Nelson 227 7 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTTNG SEPTIC TA14K This is to certify that I have inspected the septic tank presently serving -ice located at: �4_ '4 the residei N R 6 St. Croix Sec. T W, Town of County, Wisconsin. 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 fe -� �.� �M`�__��__. __. _ __ . Did flow back occur from absorption system? Yes—_ 110-/ (if no, skip next line. Approximate volume or length of time: gallons minutes capacity: Construction: Prefab Concrete steel Other Manufacturer (if known) Age of Tank (if known) W It (Signafkre) N fk �A f )W fL �A L61M (Title) 311-7 (Date) -Til M B,� C.Stf ie'__ (Name) Please Print LOA_ (Licensel 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 (exce:lpt for i".respect ion opening over outlet baffle). Name Ti r 6 1, -vx,00 � � - f SiqnattiLre��-.�.yW , __N fMP�R�: -) A 9- 0 Y 6-.r.L11 Phi(l C7 SYSTEM AFFIDAVIT Document Number Name & Return Addr 3S a 9d LV 0 L L �- iG�ta-�45o L) Parcel I.D. Number KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO. , W1 RECEIVED FOR RECORD 03-18-1999 3:00 PM AFFIDAVIT EXEMPT # CERT COPY FEE: COPY FEE: 3.00 TRANSFER FEE: RECORDING FEE: 12.00 PAGES: 2 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 - com 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) - Property Owner (s) Se� a� Property Mailing Address:_-.. Y-\ Property Legal Description: Lot # csm/subdivision T N - R Sec. 2-(j�3] W,, Town of 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 parties interested in purchasing this property Y Nota Public scribe4 and go 6W Signe4 S'-- s Il � tbqE�f o e on Date: mmissiop expires: County Approval: Date: