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HomeMy WebLinkAbout036-1034-95-000 c °U "�'� St. Croix Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM sanitary Permit No: Safety and Building Division INSPECTION REPORT 538831 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Parcel Tax No: Permit Holder's Name: City Village X Township Stanton, Town of 036- 1034 -95 -000 Frank, Robert &Tamara SectionlTown /Range/Map No: L CST BM Elev: Insp. BM Elev: BM Description: /. 15.31.17.223 /&> ELEVATION DATA TANK INFORMATION STATION BS HI FS ELEV. TYPE MANUFACTURER CAPACITY Benchmark / Septic X: t ? �O U �� All BM cj Dosing / � J pp _ + _ 1( J O , f T � Bldg. Se r t 4- Aeration • St/Ht Inlet Holding fl St/Ht Outlet 'q `7 TANK SETBACK INFORMATION TANKTO P/L WELL LDG. Septic Vent to Air Intake ROAD Dt Inlet `/�, + 116 Dt Bottom /ar � 7 ! � Header /Man. - 7,' Dosing /60 f� IG3 Dist. Pipe 7' 9y -3 Aeration 5 ' 6 Bot. System Holding Final Grade �$• PUMP /SIPHON INFORMATION 3 ` t • (O Manufacturer !� ( Demand St C er Q.i GPM � Model Number C2 - 3 J g �� TDH Lift Friction Loss System H TD ¢ Ft Forcemain Length Dia. Dist. to well 7 a, 1 41 Z SOIL ABSORPTION SYSTEM Length/ o. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid BEDITRENCH Width =,i. DIMENSIONS `? I 1Z d^ Z �•/ BLDG WELL LAKE /STREAM LEACHING Manufacture y ^ r SETBACK SYSTEM TO P/L 1 CHAMBER OR f INFORMATION Type Of System: / ` '� UNIT Model umb �r: /�0 T DISTRIBUTION SYSTEM x Holes S p acing Vermo Air Intake /� Distribution x Hole Size p` � HeaderlManifol�, ✓ Pipe(s) Length_ Dia Length ~ Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only xx Mulched F Depth Over xx Depth of x Depth Over To soil ` es No Yes Bed/Trench Edges [] No Bed/Trench Center N � � N", p Inspection #2: COMMENTS: (Include code discrepencies, persons present, etc.) Inspection / Parcel No: 15.31.17.223 Location: 2109 170th S et New Richmond, WI 54017 (SW 1/4 SW 1/4 15 T31 R1 7W) 80 nacres Lot - n 1.) Alt BM Description = 2.) Bldg sewer length - amount of cover Plan revision Required? Fs� Yes o lo� Use other side for additional information. Date Insepctor's Sig ture Cert. No. SBD -6710 (R.3/97) CO mer Safety and ounty —f J �1 - - - T O1 W. Washin on Ave., P. o x 71 �� ' S nt �' L O I Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) pplieation State Tra ac ion Number In accordance with s. C J fission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary p urposes in accordance with the Privacy Law, s. 15.04 I (m ), scats. 40 Z J d q I. Application Information - se Print All Ini' tion Sp 114 / Property er me A Mp Parcel # ' l Property Owner's Mailing Address Property Location C City, State ? Zip Code Phone Number e�/ y, Section / leony II. Type of Building (check all that apply) Lot # -- - - - -- T < - N; R - I yf W� lor2 Family Dwelling - Nutnberof edrooms _— 1 Subdivision Name Block # ❑ Public /Commercial - Describe Use -- ❑ City of- --- - - - - -- - - -- - - ❑ State Owned - Describe Use C5M Number ❑ Village of s (� / / f / / r- Town of-24 III. Type of Permit: (Check only 16ne box on line A. Complete line B if applic able) A. ❑ New System Re lacement System Y P Y ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber List Previous Permit Number and Da te Issued g El Transfer to New -7 Before Expiration Owner 2 & - ��71 1 9 /D IV T e of POWTS System/Component/Device'. Ch all that app w on- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound _ >_ 24 in. of suitable soil ❑ Mound < 24 inn.. of suitable soil — ❑ Holding Tank El Other Dispersal Component (explain) — ___ ❑ Pretreatment Device (explain) q - f V. DispersallTreAtment Area Information: Design Flow (gpd I Design Sgil Appl' t te(gp Dispersal Area I �sf)� Dispersal Area Proposed (sf) yytem Eleva ' n I , � K AaA, ,, 7 i - e VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o d U New Tanks Existin Tanks p w� ° a 15 ` v v iic - — — Sep tic or Ho lding - - - rank Dosing Chamber 4 � -- VII. Responsibility Statement I , the undersigned, assn sponsibi for installation of th e POWTS shown on the attached plans. Plumber's Name (Print) Plumber' i aturc MP /MPRS Number Business Phone Number Plumber's Address (Street, City, State, Z Code) < )-i, r &li SYTI-7-- IC VIII. County/Department Use Only Approved ved Permit Fee Date I sued Issuing t Signature tven Rea for Denial 5. � IX. Condit aeons for Disapproval 1. ieptic tank, eMuenffikerand 3 btl 6 tt � -" ` dispersal cell must all be services / maintained JJJJ 1. 1 as per management plan provided by plumber.loU 2. A114e ck regtill'ements must be maintained apW At A fte W b o to complete plans for the system and submit to the County only on paper not less than s 112 x 11 inches In size SBD -6398 (R. 01/07) Valid thru Ol /09 Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715- 246 -4516 Date: 8/25/11 Owner: Robert Frank Location: SW1 /4 SW1 /4 S15 T31 N,R17W 2109 170th St. Stanton System type: In- ground absorbtion system(conventional) Manuals Used: In- ground absorbton system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4 -5. Maintanance and Contingency Plan 6. Filter Specifications Sheet 7. Pump Chamber Cross Section 8. Pump Curve 9. St.Croix County Existing Septic Tank form 10. -12. Soil Test Signature License nu e . 226900 PLOT PLAN PROJECT Robert Frank ADDRESS 2109 170th St. New Richmond Wi 54017 SW 1/4 SW 1 /4S 15 /T 31 N/R 17 W TOWN Stanton COUNTY ST. CROIX p MPRS Shaun Bird 226900 8/23/11 BEDROOM 3 DATE CONVENTIONAL IN- GROUND PRESSURE CONVENTIONAL LIFT XXX HOLDING TANK MOUND SEPTIC TANK SIZE 1000 galkjns LIFT TANK SIZE DOSE TANK SIZE 630 HOLDING TANK SIZE LOAD RATE .4 ABSORPTION AREA 1 170 # of chambers 57 IL BENCHMARK V.R.P. Bottom of garage siding ASSUME ELEVATION 100' Filter B SRR@ lter ❑ BOREHOLE O WELL * H. R. P. Same as Benchmark -�- SYSTEM ELEVATION 92.9/92.8/92.7 4.5' below qr 170th St. 800' Plans Designed Using Conventional Powts Manual Version 2.0 Well 15' Existing 3 W bedroom ' 15' house 40' % Slo e 5' 3 -3' X 78' cells 1 , with >3' spacing - Ven 10' 5' T �b Old System is to be pumped and buried ` Scale is 1" = 40' Dw 110' unless otherwise B.M * 10' B -3 noted DT 80' 10' Garage -\35 40' 0 ' Vent 100' B_j25' L Grade >6 uick4 Standard -W of Cover eaching Chamber ith 20.0 ft2 of Area 4' Lon 8ft ^2 /pair of end caps at System Elevation 34 97 1320' property Line Cross Section of Quick 4 Standard -W Leaching Chamber Typical cross section for 2 of 3 cells Quick 4 Standard -W Leaching Chamber with 20.0 ft2 of Area per Chamber 10.1ft ^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation 97.3 Vent Ae Grade Vent 4' 4" 4' ��30134 Septic Tank 4' Long 1 19 5 ' 4' Long 1 3 4" Grade at System Elevation 3 4" Grade at System Elevation Spacing 5' 3 -3' X 78' Cells Observation tubeNent Same on other end To be located on end of Cells % A B System elevations: C A B 92.8 19 chambers per cell C___92.7 Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 Contingency Plan Option #1. If system fails, determine cause of failure, use alternate area and install new sy m in sted replacement area. ption #2-` Install system at a lower elevation, by removing chambers, removing biomat, 5all new system. Option#3. No adequate area is suitable for replacement area, and system elevation cannont be lowered. Install holding tank as last resort. 3. Replace any other failing components as needed. Plumber: Shaun Bird 715- 246 -4516 St. Croix County Zoning 715 - 386 -4680 Pumper Tom Mondor 715- 246 -5148 Shaun Bird #226900 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer L). A- Mailing Address o� 5 / Property Address (Verification required from Planning & Zoning Department for new construction.) City /State Parcel Identification Number ©56 LEGAL DESCRIPTION s Property Location �/ , Sec. T RaW, Town of )5 IL, 7 Subdivision ��� , Lot # �— , � , Certified Survey Map # Volume Page # �-1 -� I Warranty Deed # :> / , Volume 4� , Page # Spec house yes / nb J Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. .The property owner agrees to submit to St. Croix County Planning & 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 system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number o SIG edrooms _ �:?- - O PLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 4,5 Ll 5" l II 1 i � 1 I - I , 1 I I II 11 II it � . , I I I � 1 I I I I I I ' 4I 1 i II I 1 I I I 1 NOTE; INLET AND OUTLET ARE FEMALE SOCKET WELD JOINTS FOR .3" PVC PIPE. I l l A(- OlaS�l; fl[11'111P1 unY Nilf' �:lJ DCIYN: MY, Ml 1 jjM!lh�Fl I ll.ill AS�; y 11 IAII PAfL.PII `�?LJLr15 " GA(cY kIf1L'wll **[.Y I:ItWN['l. 90/60 39G8 03 dWfld Q3683338,d 898LPt89TL Lb :0T TTOZ /9AIla Dose Tank Cross Section And Pump Performance Specifications Tank Manufacturer Minimum Pump Performance Required Tank Model Number 0 0 2 42 GPM @ Ft TDH Total Tank Capacity 0 Max. Bury Depth Total Dynamic Head (TDH) - Feet Pump Manufacturer Zo Elevation Head Pump Model Number 0 6&1 S' DistaJ'Pre6spre Alarm Manufacturer U LI ' e Loss Alarm Model Number VC.. Force Main Pressure Loss $- [ switch Type CPC Total Manhole Min. 4" Above Grade With Locking Device Vent Min. 12" Weather -proof Above Grade Junction Box — ► 1 With Cap -- •- - Finished Grade Depth of Cover Ft Disconnect P1 �! J C- Means r r r a a r r r r r r a r r r r r r s s a tr{ Outlet a r < Switch Settings and Reserve Capacity - - - -- Inlet } s Tank Volume GPI t { a > < i a< Dimension Inches Volume Gal. A in 1� : < (reserve) A Weep (alarm) B 2 to B Hole a '< (dose) C �.5 Off Elev. C {;< >< i < (dead) D / Ft > t r 't Total r D > a Q r { ' Bottom of Tank Elev. Ft ?; r r r r a a G ENERAL INSTALLATION: The dose tank is bedded and back filled in accordance with the manufacturer's product approval specifications. Maximum depth of bury as specified by the manufacturer may not be exceeded without prior approval. Manhole covers exposed to grade have an effective locking device (padlock) installed. Piping at the inlet and outlet is of approved material, connected to the tank with watertight fittings, and laid on stable soil to prevent settling or sagging. The force main is sleeved with 4" Sch. 40 PVC to bridge the excavation and is sealed ' watertight. Electrical service complies with NEC 300 and Comm 16.28 Wis. Adm. Code. 03/051gj Page of 101 DYNAMIC HEAD /CAPACITY cn- HEAD CAPACITY CURVE PER MINU Ld EFFLUENT AND DEWATER.NG w MODELS 53/55/57/59 Model 53/55/57/59 6 20 -- Ft Meters I Gal. Ltrs. Q . ' S 1 1.5 43 '. 63 15 10 3.1 34 29 z 4 1 15 4,6 /2 CD r �. Q 10 I S hut —off Heod 19.25 ft. (5.9(r) 0 2 5 -- + 3 15/16— 6 5/32 1 '/2 NFT 0-- y _ 10 20 30 40 50 U.S. GALLONS I LITERS gp 160 FLOW PER MINUTE 009897 4 l S 4 h I Variable level float switches available. Variable level long cycle systems available. Available with special cord lengths of 15', 25', 35' and 50'. Alarm systems available. 1 0 -,/•,6 Duplex systems available. 3 3/32 -- +T SK86a Seal Control Selection Lietl ngs .�- f.'4tiP� Model Vone p Bode I Amps Simplex Duplex CSA UL 1. Integral float operated mechanical switch, no external control pg` k u va� able level M53155 & M57159 115 1 Auto 9.7 1 - Y Y 2. Single piggyback-v ariable level float switch or double iggy N53I55 & N57159 115" 1 Non 9.7 2 3 or 4 & 5 Y Y float switch, Refer to FM0477. -_ 115 1 Auto s.7 N Y 3. Mechanical alternator "M -Pak" 10 0072 or 10-0075. BM BN57 115 1 1 AU to s .7 Y Y� 4. See FMO712 for correct model of Electrical Alternator. ivator, with Electrical . ByJ7 230 1 Auto 4 . 8 Y y 5. Variable level control switch 10 -0225 used as a control act D53155 & D57159 230 1 Auto 4.8 1 3 or 4 & 5 Y Y Alternator (3) or (4) float system. E53155 & E57159 230 1 Non — 4.8 2 J Single piggyback switch included. s caunor+ , < i rs mg ForinformatienonadditionalZoellerproductsrefertocatalogonPiggybackVariableLevelFloatSwitches ,FM0477; j r eft ta , aret a ss : de we �r�tnerc t Alternator, FM0495; Sump/Sewage FM0487; and Single Phase Basins, Electrical Alternator, FM0488; Mechanical Simplex Pump ControllAlarm Systems, FM0732. RESERVE PE4� For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. _ , --------- .- - -..__ MAIL TO: P.O. BOa . - - - -_ - - -� - Louisville, KY 40250:° Manufacturers of . . SHIP T0: 3649 Cane Run Road a ® Louisville, KY 40211.1961 rAWIrr Pusl SNCf 1939 1 AAMP !O. (502) 778-27 31 -1( 8 0 0 ) 928-PUMP FAX X (5 (502) 7774- -3624 - -- - hffpYAVWW.z - -- _ _— -- 0 Copyright 2002 Zoeller Co. All rights reserved. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK `Phis is to certify that I have inspected the septic tank presently serving the )Q < residence located at: Section T 31 N, R W, Town of sLy✓v 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: J e '�? l� Did flow back occur f om absorption system? Yes %Z No (If no, skip next line) Approximate volume or length of time: gallons minutes capacity: /Z�� construction: Prefab Concrete Steel Other Manufacturer: (If known) :412/f r ---,, Age of (If known). :ZZ / na ure) (Name) Please print (Title) (License Number) Da to 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 fisting septic tank condition, I certify that the tank to the be of my knowledge will conform to the requiremen s of ILHR 83, Adm. Code (except. for inspecti opening over tlet baffle). Nam L"'o � / Signature MP /MPRS�� .,.�M $ �•, 1^N Jt.' _'n Y�i'.!Iti:'�'i ? {3 _�.�.::+m3�G! .. ...—_ �a= +- o.++..- .,.- .�.- -xy....., _Q.��.r. _ . /0 VOL 5C3►�� STATE BAR OF WISCONSIN FORA 2 - 1982 � WARRANTY DEED DOCUMENT NO. A PI- TT_7•r` 1 James A Ste henr a and Helen L Stephens ST CROIX CTY.. W! �S marita•1 orooerty 1b' ` - MAR 6 1997 E conveys and warrants to �jpbpX� T Rr aTSk AUd T - aMara K _ Fran'' _ 9:30 A. M and .4F- aG marital propert .x�• -}� �J�ets — Rei)ls rr of Deaca THIS SP AC E R ESERV ED Fn.9 RECORDING DATA NAME AND: RETUR14 ADDRESS the following described real estate in St. Croix _ County. !� State of Wisconsin: BANK OF NEW RICHMOND 355 South Knowles Avenue New Richmond, WI 54017 The S 1/2 of the SW 1/4 of Section 15 - 31 , ! PARCEL IDENTIFICATION NUMBER it FEE ! f � !� 1 This _ homestead property. Exception to warranties: I� �{ I Hated this . 96 2 6th day of December. , A.D., 19 If — (SEAL) Ja A . Ste hens. (SEAL) �o� - (SEAL) r Helen L. Stephens f! i� AiJT33ENTICAT'iON A Sigtruure(s) —_- -_ State of Wisconsin, ss. :! — _ — — — H — Barron County. I! authenticated this day of 19___._ Personally came before me this z C? t day of it December _ 19 96 , the above named James.A. Stephens and Helen L. Stephe it TITLE: MEMBER STATE BAR OF WISCONSIN � (If not, — -- �i authorized by §706.06° Wis. Seats.) to me Vown to��aC "I `�4 who executed the foregoin ' i lost t� nt a ooiedge t>y3!s A R THIS INRTRtIMFNT WAS DRAFTED BY V I Liden S Dobberfuhl S.0 µ Gerald ttiden J h-a:.m M. Nels ' t , + Notary PA)jc'. Ba4 i-ri>Z__ — County, Wis. (Signatures rr.ay be authc ncicated or acknowledged. Both arc not my comrnis% 8 PermanenwalF' not, spate expiration date: n, cessary) 1 Ma 9 A + Namrs of t -+n. signing to an • ca a it should b • typed or printed brlo th l sl natures t Ix " & 8 ) P Y > !x P B w,sca Legal [tame Co.. tnc + ' ! STATE BAR OF WISCONSIN - WARRANTY PF.Eb Form No. 2 - 1982 n. Miweukee. W,s -A.0 1%..v Property Owner _ Parcel ID # Page of Boring # ❑ Boring ��� IS it Ground surface elev. ft. Depth to limiting fador� rn Soil Application Rate Horizon Depth T Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 J Boring # Boring Pit Ground surface elev. ��— F ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. `Eff#1 ff#2 , VIA a Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. • Soil lication Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 266 - 3151 or TTY 608 - 264 - 8777. sao-aaw (R.(oo) Soil Test Plot Pla Project Name Robert Frank Sh ird Address 2109 170th St. New Richmond Wi 54017 S M #226900 Lot ------ Subdivision ----- -- -- Dat /23/11 S W 1/4 S W 1/4S 15 T 31 N /R W Township Stanton ❑ Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Bottom of garage siding System Elevation 92.9/92.8/92.7 *HRPSame as Benchmark 170th St. 800' Well 15' Existing 3, O�� bedroom 0 15' house 40': 5 0% Slope T 10' B -1 15' Scale is 1" = 40' DW unless otherwise B.M. 10' B noted 80 ' 10' Garage 35' 0 ' Vent -- O�4 100' B -2 25' 1320' property Line c ' 0 to p 3 I 0 o d f I c� o c CD (D �• ID •0 w M m sp m cr rr O m g Z= m Z ° NCl) C/) p ° w C • a o m o m d 0) - a !2 rn CD a o � m rn N d. 3 CD a �_ (D 7 ° M N m W 3 : V W O N a ,^.,3 N N N N A ^S W C aN N N 0 O ' A7 CL O _ _ 0 TO 3 3 H N ID 0 o O N W O m vs Z D ¢ ° N scz 0 y G 3 ci o 0 0 r_; s L N W Z -4 -4 I �, N 0 C �1 0 0 o CD Z O O O F)* 7! A E w p�j fn fn fn 0 co a u G G a 0 O 1 » d -0 y CD 3 m m m ( D CL o a It J N z o zcnz D m 0 0 CD O o @ m �. N !mil CD ro - _ C N W CD CD a 3 7 z m cb 0 = p Z n 0 C K n 7 Z N a 7 m CL Z 0 00 cn 3 C _ -m 0 A W p� 0 CD N D 3 CD 0 CL ma C:) Q m CD m co � D o c 0 m 0 I c C? o A m L CD 2 '0 N C V y N N ' p p V A 0 N CD ° a o O o m O CD ti t Parcel #: 036- 1034 -95 -000 06/27/2007 02:02 PM PAGE 1 OF 1 Alt. Parcel #: 15.31.17.223 036 - TOWN OF STANTON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner ROBERT J & TAMARA K FRANK O - FRANK, ROBERT J & TAMARA K 2109 170TH ST NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 2109 170TH ST SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE SEC 15 T31 N RI 7W 40A SW SW Block/Condo Bldg: Tract(s): (Sec- Twn -Rng 401/4 1601/4) 15-31N-17W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 1226/185 WD 07/23/1997 908/425 2007 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 04/16/2007 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 18,000 183,400 201,400 NO AGRICULTURAL G4 37.000 6,000 0 6,000 NO UNDEVELOPED G5 1.000 700 0 700 NO Totals for 2007: General Property 40.000 24,700 183,400 208,100 Woodland 0.000 0 0 Totals for 2006: General Property 40.000 22,800 183,400 206,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 146 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Health and Social Services Plb. x #67 10/69 Division of Health PERMIT APPLICATION for PRIVATE DOMESTIC SEWAGE SYSTEMS 034 /63 --I S" x , 2 3 A. OWNER OF PROPERTY TYPE OR USE BLACK INK c�l Q 9 7 Name Address (Street, City, Zip Code) County B: LOCATION OF PROPERTY WF vRE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED Check One: U CITY VILLAGE LEGAL DESCRIPTIONt �'` �+ J` TOWNSHIP �. r"r4N• C., IS LOCAL PERMIT REQUIRED FOR THIS W RK? —4— YES NO t' PERMIT NUMBER D. SEPTIC TANK CAPACITY N CO Gallons NEW INSTALLATION REPLACEMENT ADDITION MATERIALS: Prefab Concrete Poured in Place Steel Other NUMBER OF TANKS TO BE INSTALLED: 1Y }� E• TYPE OF OCCUPANCY, Cheek One: Otte or Two Family Residence 4 Commercial Industrial Other # Specify Number of Persons to be Accommodated _ Number of Bedrooms . F. APPLIANCES, ETC: Food Waste. Grinder YES NO Automatic Clothes Washer .' YES NO Dishwasher YES NO Automatic Potato Peeler YES NO Other (Specify) G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION J REPLACEMENT Tile Size No.Lin.Feet Trench Width Depth Number of Lines Seepage Beds Length - rr/ Width Depth, Tile Size No. Lines Seepage Pitt Inside diameter - `Gf' Liquid Depth - a P E R C O L A T I O N T E S T Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inc "linutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last to Fall Example 13t Wetted Over �in Minutes Last Period Last Period Period One Inoh P- 0 36" Top Soil O" Cla 26 25 yes or no 30 1/2 1/2 1/2 60 /t r •� '� �s' J� mac' ,Z•4 5' R:CdRD DAT FROM MINIMUM OF 3 TEST HOLES ompute size of absorption area in accord with H 62.20 Wis. Adninistre.tive Code. S O I L B O R I N G S- Minimum 36" Below Prop osed Absorption System oring Total ;epth Depth to Ground Water Depth to Bedrock — I umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches xample 0 72" 72" Black T02 Soil 12 "• Cla 18 "• Sand 18 "• Gravel 241 Zen • RECORD DATA FROM MINIMUM OF 3 BORE HOLES COMPLETE OTHER SIDE • y , . s I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge an be4ef. /�+ NAME TITLE �C "'� l Ty a or Print) REGISTRATION N0. ' M_1 7( "� or ..MASTER PLUMBER LICENSE No. ADDRESS " / L e !C - �� t S IGNATU RE DATE � ! � � MAS'PER PLUN3SR MAKING APPLICATION Signatures _ ���.' ���- xci�LL� License Numbers MP RSW (To be Completed by Issuing Agent) Date of Application Fee Paid Permit Issued (date) Permit Number Agent (name) ' T ✓ Fors f Town, Village, City, County, eta. (Specify) Notes The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the Permit (yellow oopy) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below FOR DEPARTMENT USE ONLY DATE RECEIVED `I a / 7U ACCEPTED BY RETURNED (Initials) /- (Date) (See Corres. FEE RECEIVED VALID. NO. �° PERMIT N0. (Yes or No) REVIEWED BY APPROVED DATE (Initials) (Yes or No) COI MINTS: N- K• It W �. 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SEE PAGE 5� Crorr oe y Wis. POLFUS I Gran Ric Wor s MPLEMENT INC Works CANNING CORPORATION PHONE: 246 -20II PHONE: 246 -6565 - MAHKERS - MONUMENTS BRONZE TABLETS NEW RICHMOND, WISCONSIN NEW RICHMOND, NEW RICHMOND, 54017 WISCONSIN 54017 WISCONSIN