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648455 012-2003-40-200
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township TIMOTHY & ANNETTE ZERBY TOWN OF ERIN PRAIRIE CST BM Elev: Insp. BM Elev: Description: J IBM TANK INFORMATION TYPE MANUFACTURER CAPACITY Sept Dosin Aerati 8� Holding l ✓ f'�"U TANK SETBACK INFORMATION =�Mm - - --w �-M= W.000F M�Mrsapapp-= Me W.0— =--� W W.- - a—Pd. WME W Manufacturer Demand GPM Model Number TDH Lift Frictio Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 648455 State Plan ID No: Parcel Tax No: 012-2003-40-200 Section/Town/Range/Map No: 04.30.17.574B STATION BS HI FS ELEV. Benchmark I q I l j oDq. I 100�. fop Alt. BM Bld Sewer D03.32� SUHtInlet lj too 1.59- SUHt Outlet G/- •43f Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System �nal Grade 3 �D p9oS.16Y St Cover aE [ Im2.2$f �. 0 00 132 wr Z BED/TRENCH DIMENSIONS W th Length No. Of Trenches PIT ENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTE TO Type Of S stem: P/ BLD I VVEV L LA /STREAM LEACHING HAMBER OR UNIT acture Zodefl—N umb DISTRIBUTION SYSTEM Header/ Distribution ole Siz x Hole Spacing Vent to Air Intake IL ipe gth Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Over xx Depth ofxxSeeded/Sodded xx Mulched BedtTrench Center TBedprench Edges Topsoil Yes ❑ No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 411912.02.3 Inspection #2: f J00`j•3`{ Location: 1772 CTY RD T I 1.) Alt BM Description = o t f! 2.) Bldg sewer length = .`-I [J /�' 7 �6'� W[ amount of cover = � /L eU2nL _ 3j 3o` la c ti%s ©k- N �� GrorzS Z's R �e �S �5L. a=1*�.IO/ ?/ �e Plan revision Required? XNo � cj/k�„Z� P'-� � Use other side for additional ation`,K�Its►'�fa a elFIn�sepctor Signature�r,Q TS PAbr.6W L4Ct rt. No. SBD-6710 (R.3/97) s4P `/fin yy{/� � W ,�,�� 1 Y V I AA �� W �'-� � M-Q. +UOk vl "� 4` D l L�' cS In iutiln Sen ice, Division 4822 Madison Yard. kk County l %4 �SP Lt\ Matlitior. 'k l 53705 t�►V Permit Number he filled ut by Co MAY 15 202-1 SAN-2023- " (to f �iu _ 11.0. Box 7162 Madison, Wl 53707-7162 S —Sanitary Pe-�1t Application tit:ue I r.tn,acffii��+n tiunibrr —� In accordance with SPS 383 21(_' I- \A r> adrn lode, submission of flu, ionn r0 the appropriate overnmental unit Proik l \ddre.. iiI di11creni than mailrnu addre,,) is required prior to ohlaininw a .anrtan pwrnul \Mc Apphcr3lwn Inrms t0r sl:rtr mot i N A% I S air suhnvued to the Department of Salcty and Professional Ser ices. Personal utfisrnralion you provide ruay be used li,r ;econdan d purposes in aecordancr wiv ith the Privacy Laµ s. 15.04(1 y(rn), Slats. 1. Application Information - Please Print All Information Propcny s )oner", Namc # ILD Parcel p Tlmo AA ttf{t 2Cr Property Location. Property Owner-s Marl)ng %,!dT'; / 1-772 &Y 7 Gout, Lot 0ty', State / i I•..I. Phone Number Section t n 5 !�/01 L- ""' _ T ]t j F m c 11. Type of Building (check all that apply) Lr t ri r 2 I°amtly Dwelling- Number of Ik.Crooms _ .(-cJ _ 3 3 r� O'ublic/C'ommercial - Ikscribe Ilse L - - ❑C'ity of — FTtiiie t ]caned - Describe Use illage of C'SNf ['vurnhcr nG '� • �,�, —- �i oAS, 61&W ! IL of I Ir Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable online A. Check one box online B. Complete line C i applicable.) A. ❑Vcw Spstent Replacement System °r Mo IlcatiOn to IlXi'li Sy(,lem plain) LJ 4 cAddi6onal Pretreatment I;nit (erplain) if c �►"l f B. f!olding lank 0In-Grnrrnd t-Grade ■1,+und Individual Site lJesign Other T�pc (explain) (Cotttenlion:ti) ❑ Rrnrmsl k3eti,re I Rev ltiwri ftafELC (if PlllmheP Eli rarrsfer to New t:)wrter I i.t Preyrous Permit Number and [late Issued 1�j'> .piratrr,n , fJ `r `2 x IV. Dispersal/Treatment Area and Tank Information: I i, i I'd) Design Soil Application Rawgpd/sf) ❑ispersal .Area Required Is 1) Dispersal :1rc;r Proposed (sf7 System Elevation Capactty in -Total 0 01- Manwacrurer Tank Inforrllation Callons Uallcrns Ilnils New Tanks 1 r. 1 L 7 Sprit of Iioldinl; lank .W%eicoL,Zib .A. AO Le ze0— l 7,, it nL C'harn beer 7 ====1 1H Responsibility Statement- L the under,irgmd. assume r"pun.ibilit,, for instal thin (it the P(M I 1� %ho%%n on the attached plans. P In cr�s[1Samc (Prino Plumb• '. gn`ture WIRSNumbee�r Business, PI I (j ,I 13 urnher's Address (Street. Cily. Stale, Zip Code) V1. County[Department Use Only NL,Approycd El [)I." Per'mfit FeeI)tte ]ss)ued Issuing Agent Signature ❑ (]w vrrl anon r Wnial (`onditionti ol`, PI' oval al 3) off tt-� (:uv2t^S qw�s ea �%ar �= lrtow- r �C ervrtca SYSTEM OWNER: 18As - 2 .D f71 e Qpu=as6. 19 l 1. Septic tank, effluent filter and dispersal cell 4,��,,;, a,\ 2.0 a-hat� -ire. R FE m .� aril e.N'�rQ �iula t must be serviced / maintained as per management fir' °`P "-�►� %� - '� w, by plan provided plumber. P t'6,l 2 Sr �e e �'-�va ton a r. — ,ro r SeC2% v2 I 2. All setback requirements must be maintainedAd �. spy c�Qes, as per applicable code / ordinances. Attach to complete plans far the system and submit to the 'pnjomlr pSpaper _not less then 8 ti7 x 11 in S11D-6398 (R. 031211 rp, 285 COUNTY RIVER FALLS 800-828-3723 715.425.8466 06/9/2023 St Croix County Community Development RE: Permit # 648455 As -built and tank substitution Owner: Tim & Annette Zerby 1772 Cty Rd T Town of Erin Prairie Holding tank Replacement Due to potential buoyance; Two Wieser WLP2000-HD were substituted for the planned Wieser W2000's. The WLP2000-HD are heaver and have a larger cover surface area that eliminated the need to add ballast. We also added bituminous tar coating to the exterior of the tanks Enclosed- Revised page 3 of 10 — As -built Cross section of the two WLP2000-HD showing the elbows in the inlet piping, 1 fir of14" clean crushed stone bedding under the tanks and extended up between the tanks to bed the inlet and outlet pipes, 30 to 40" of installed soil cover over the tanks, and alarm setting of 30" off the floor to allow a 10% reserve above alarm setting. Fine sand was also used to back fill the sidewalls of the tanks. Revised Page 5 of 10--WLP2000-HD Detail drawing, Revised Page 6 of 10 -- As -Built anchoring calculation using the smallest dimension of soil cover (30") installed over the tanks. Ballast is not required. Thanks Michael Rodewald MPRS 931384 w 0 �o o G cn o W © n. 14k . . Cps�!D� Ls rA .f? C.,kr urll..oao } a w AP Zoos win � twi o� — 38 9 x 1� RQ�e•�� 1 y ,�1 �� a ; ' 3 fA 2J3a -'it'd p! aac L C 6 u C -v. t '4 0 — WLP2000—MR --44�P TANK SPECIFICATIONS 164" hl� AST -A -SEAL 4' CAST -A -SEAL FILTER OR BAFFLE d TOP VIEW a v x 16IM7*11 in UO SIDE VIEW TANKS ARE MANUFACTURED TO 'MEET OR EXCEED ASTM C-1227 REQUIREMENTS DIMENSIONS. WALL 3" BOTTOM: 5" 4 COVER: 6" MANHOLE. 24" I.D. PRECAST CONCRETE RISER HEIGHT: 55" O.D. LENGTH: 164" O.D. WIDTH: 96" O.D. BELOW INLET: 43" O.D. LIQUID LEVEL: 36" WEIGHT: BOTTOM 14,060 LBS. •^ COVER 8,170 LBS. INLET AND UIO]Lti: 4" CAST A -SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY. 56.27 GAL/IN LOADING DESIGN: S' 0" UNSATURATED SOIL HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 2,138 GALLONS TANK CAN BE USED AS: SEPTIC/ HOLDING/ PUMP OR SIPHON COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #9 (SMALL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE DRAWINGS SUBMITTEDi FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: mi z Z I Cs Q 0 0 N C7 0 T7- LLJ U) SHEET NO. 'QF &A- "Ke,)1stb wA 1j1,Pzo0b tr a e'.AIL_.- Pg __6 of /0 war g50W11e&-Dwft5,CA. RECEIVED Private On -Site Wastewater Treatment System (POWTS) f Treatmen or Holding Tank Anchoring Calculation � 4IUN 0 9 7 g g sT cRo►x When a holding tank may be installed in saturated sails (see Ch. SPS 385, Wl Administrative Code for more , information on how to determine soil saturation) and/or in an area that is considered part of a 100-year floodplain, the tank shall meet provisions of SPS 383.43(8)(g), Wis. Adm. Code. All tank(s) must be anchored whenever they are at risk for being installed in an area where they may be located in saturated conditions all/part of the year. 'Using soil as the anchor has become an acceptable alternative to concrete. Flotation potential is the displacement of the tank calculated by its volume in cubic feet. Line A: Calculate cubic feet of tank. inches high, x^inches wide, x inches long, _; 5'q Z a inches3. Divide this number by 1,728 to equal Jr / cubic feet. Line B. Convert the displacement to the weight of water. (from line A) bubic feet x 62.4 (weight of I cubic foot of water) x 1.5 (safety factor) _ lbs. of lift potential. Line C. Calculate weight needed to counter buoyancy. lbs. (Displacement weight from pine B.) - 2 Z Z Z b lbs. (weight of tank per manufacturer) = lbs. of soil needed to anchor tank: �2 _ lbs. -- Line D: Weight of the soil media including safety factor needed over the tank to anchor the tank adequately. Tank cover width 4. inches x tank cover length /' inches, divided by 144 _ �/ G q square feet x 0.083 (1 inch in foot decimal) cubic feet (volume of 1 inch of space over the tank cover). Line E: Calculated weight of 1 inch of space over entire cover. 1 I __ cubic feet of space (from line D) x 100 lbs./cubic foot o_f = %C] lbs./inch space above cover. Line P: Calculate inches of soil needed to counter buoyancy. �l lbs. (from line C) divided by 116 lbs. per inch of soil (from line E) 7 inches need over tank cover. ANCHORING SYSTEM COMPONENTS per ch. SPS 383 Appendix A-383.43(8)(g) The anchoring of components to counter buoyant forces due to saturated soil conditions can be determined using the following formida: Weight of the component — 1.5 times (volume of water the plus the weight of the anchor component displaces) times [the weight of water (62.4 pounds/cubic foot at 39°F)] 285 COUNTY RIVER FALLS 800-828.3723 715-425-8466 05/15/2023 St Croix County Community Development RE: Request for expedited Sanitary Permit review Owner: Tim & Annette Zerby 1772 Cty Rd T Town of Erin Prairie Holding tank Replacement Reason: Failing as per 141.245(4). Bottoms of both holding, tanks are cracked. sewage is leaking to groundwater. Heath hazard ichael Rodewald MPRS 931384 Pg ( of Private On -Site Wastewater Treatment System (POWTS) Index and Title Sheet Owner's Name: I ZA44 7A!:-f !! / Site address: l 7%Z R-1) 7- ��,a�f .5 Location: Lot , Blockg�-, Subdivision/CSM being part of the 1/4 of the �r'/4 or Gov. Lot # , Section _, Town__3aN, Range-0 W Town of Fit# PkA,O,O I-C , Pam ;-WI. Sic r�X CdK.. Lj Parcel Identification Design: In accordance with Department of Safety & Professional Services (SPS) Wisconsin Administrative Code Chapter SPS 381 through 387 and 391, this plan is using ® Holding Tank Component Manual [VER 2.0, SBD-10855-P (N. 03/07, R. 1/12)] Contents: Page 1: tJDCN A-t'i'fl e Aee_ 4 Page 2: FLo f TOZ&AJ Page 3: WV/J)fre g iLot k_ /*,eo ss Page 4: ;/ W,4 e? Page 5 : JAJ Zoo 6 — Af A 7";t.A _ Spf�r Page 6: AAG kor L Page 7: _ 6r-J' NKtn P"ts //a1A 0 fif At*-ft "A- 4L Page 1: .rl. / K f ' AJ - ee nd Page � ji N�'h4,/7 S ys k!✓/ ew,, ,A��/ ,�l g r'v✓-, Attachments: Plumber/Designer: 411—kf ,QE4�/tut� Credential Number: l 3 1 3d' ( �A? #-- to --rim t),14 ,�-66cp4 7-l'dY A der Q . 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INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN. SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 42.92 GAL/IN HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 1,085 GALLONS LOADING DESIGN: 8'-0" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC / HOLDING / PUMP OR SIPHON COVER: MIX DESIGN #8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WIESER CONCRETE REVIEWED BY REVIEW DATE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: OF [TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS 1710169 r•�i 0vfiL j ,jK • ` � sf � Gs -• o'7L ; h�"-5--�� � �-.I- � v � �CP� is f. r� 7y�/C :' 17- - 39d, �t3 in we' 44 1 leg g S 5 Ac .t Altle Cw d04.111 �� La's y''�,` '� /• 3 3 w�. i iiuo �W e a Alo7 s'- *P -.►it = 1,6ds s—m a /Qot Z#'' of U ,* y 4- /(Qs� per:,Z Pgof_� Private On -Site Wastewater Treatment System (POWTS) HOLDING TANK SYSTEM - USER'S MANUAL A. SYSTEM OPERATION: The holding tank system serves to contain wastewater on a site until the contents are pumped and hauled to a proper point of disposal by an individual certified under WI Admin. Code Chapter NR 114. Wastewater from your interior plumbing system enters the building sewer that terminates at the inlet of a prefabricated concrete holding tank system. The tank system has a switch that is set to activate when the liquid level reaches a point 12" below the tank inlet invert when one tank is installed or 90% of the tank volume when more than one tank is installed. The switch activates a high water alarm located inside a tank alert box that is installed on a pedestal or inside the dwelling. When the tank is full of wastewater, the switch will be activated and cause an audible alarm to sound. A switch located on the tank alert box can turn off the audible alarm. The liquid waste carrier contracted to service the holding tank system should be called immediately after the alarm is switched off. There is only a limited reserve capacity left in the holding tank system after the alarm has been activated. B. DESIGN FLOW: The holding tank system has a total wastewater capacity of "1 oat) gallons. Servicing intervals cannot be predicted, as every household has varying water use habits. Use of water conserving fixtures and water conserving practices will increase the number of days before the tank needs to be serviced by a liquid waste carrier. C. WARNING: Failure to have the holding tanks serviced on a timely basis may cause wastewater to backup into the dwelling and/or discharge from the holding tank's manhole cover. The discharge of sewage to the surface of the ground is a public health hazard and subject to enforcement action by AiZl�t}r At cjlla,arC&• Soil settling around the tank perimeter may occur after it has been backfilled. All depressions caused by soil settling should be filled with soil material to prevent surface water collection. Depressions left unfilled may allow surface water to freeze and cause frost damage to the manhole riser ring joints or the other tank components. Do not drive over or near the buried holding tank system with any vehicle or construction equipment. This action may result in a cracked tank(s). This type of damage may allow groundwater to enter the holding tank(s) and increase the frequency of pumping. Many disease -causing viruses, parasites, and bacteria are present in the holding tank's wastewater. Even the slightest exposure to wastewater may adversely affect one's health and increase the risk of serious illness. Please note that the, owner of this POWTS must provide the septic servicing operator with reasonable access to the tank(s). This may include (but is not limited to) construction of a designated drive or servicing pad to within 25 horizontal feet and/or to within 15 vertical feet to bottom of the tank(s), foot traffic over and through property, or vehicle traffic over and through property. D. TROUBLE -SHOOTING 1. Wastewater backs -up or overflows manhole cover: a. High water alarm not working. b. Tanks not pumped. 2. High water alarm not working: a. Tank alert box not plugged into electrical outlet. b. Audible alarms switch on silent mode. c. Tank switch installed improperly or defective. d. Tank switch electrical connections faulty. e. Electrical line to switch defective. 3. Groundwater entering tank: a. Tank manhole riser ring joints leaking. b. Tank sidewalls or base cracked. P 9— of /b E. MAINTENANCE: The tank alert boy: has a test button that should be pushed once a month to assure the high water alarm system is working properly. The float containing the high water alarm switch may need to be cleaned whenc\ er scum or solids build up on its outer surface. Accumulation of solids on the float ma. interfere with switch activation. All manhole covers padlocks should be oiled or greawd periodically to ensure free moN ement of lock components. 4. The locking device should be inspected after each tank servicing to prevent unauthorized entry. F. CONTINGENCY PLAN IN THE EVENT OF FAILURE:: A badly cracked holding tank may need to be replaced depending upon the amount of damage and the crack's location. The tank manufacturer should be contacted to make a determination as to whether the tank can be repaired or needs replacement. Groundwater may enter the cracked tank requiring more frequent servicing by the contracted liquid waste carrier until the tank is repaired or replaced. G. CONTACTS IN THE EVENT OF COMPONENT FAILU'PE REGULATORY AGENCY: NAME OF INSTALLER: Name: Address: 9 e,. S� toefr�d Phone: /S-- 2S'r tQ Zoa TANK MANUFACTURER: Name: —__Z.( Address: &63 %/C CdS /o Phone: HIGH WATER ALARM / SYSTEM MANUFACTURER- Name: Address: Phone: Pg 9 of /6 Private On -Site Wastewater Treatment System (POWTS) HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and maintained according to Ch. SPS 383, WI Administrative Code, the Holding Tank Component Manual [Version 2.0, SBD-10855-P (N. 03/07, R. 1/12)], and Pierce County Sewage Disposal Code Ch. 191. 1. This POWTS is designed to accommodate all wastewater generated by a 3 bedroom residence. 2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in the attached Holding Tank Servicing Contract and Maintenance Agreements. 3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet (at which time the alarm will activate), the pumper listed in the current Servicing Contract must be called to empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code. 4. At each service event, the service provider should visually inspect the condition of the tank, risers and manhole cover(s) and verify that the alarm system functions and manhole locking devices are present. Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions shall comply with the county sanitary ordinance and SPS 383 and 384 Wis. Adm. Code. 5. All service events or inspections of this POWTS shall be reported to the county in the semi-annual report. 6. The owner may not remove any of the wastes from,the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes a failing POWTS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. 8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank may be installed in the same location (a new sanitary permit is required for such a replacement). Connection to municipal services would also be considered at this time if they are deemed available to the property. 9. if this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in accordance with s. SPS 383.33 Wis. Adm. Code. 10. If there is a problem with, or question about this installation, the following persons should be contacted: a. Installer: �i%/I k FJ&JO -P /� 7VeAsl� Phone: b. Service Provider: Nat ffs Phone: c. Regulatory Agency: .s� ('�a� (�cyA Phone: 6 pt3 4e°f 5 r: C� — ><a `� SANITARY SYSTEM f Office {�ee use Only .. OWNERSHIP/ADDRESS FORM cmoted2J2o2T Community Development Department will L,tilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. If you would like to view your issued sanitary permit online, you can do so by using the Property Files Scanned weblink. OWNER/BUYER INFORMATION Owner/Buyer /4BI!!i1 Mailing Address City/State/Zip Phone Number (required)_ � _ � 6 0 Email Address (required `" Szerb'/ Q sloth,/-/ . 6d'm Parcel Identification Number 3 L�d (found on the property tax hill) NEW SYSTEM: LEGAL DESCRIPTION Property Location 1/4 , k '/4 , Sec. T .20 N R-aW, Town of 024 N PO-4VCI f Subdivision Plat: / q t S (ac, KA z Certified Surrey Map # Volume Page # Warranty deed # _" 6 G 7© 1&�_ (before 2006)Volume Page # Number of bedrooms Spec house 0 yes 0 no Lot lines identifiable{] yes 0 no OFFICE USE ONLY New Property Address j0AM e (Verification of new address required from Community Development Department for new construction.) (Staff Initials) (Date) This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form 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. Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center cdd@sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 715-245-4250 Fax I rAzz.►LTrM►r►L.(� j State Bar of Wisconsin Form 1-2003 WARRANTY DEED Document Number I Document Name THIS DEED, made between Jeremy J. Brathol and Jenny Brathol, husband and wife'', ("Grantor," whether one or more), and Timothy Joseph Zerby and Annette Lynn Zerby, husband and wife, as survivorship marital property ("Grantee," whether one or more), Grantor, for a valuable consideration, conveys to grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Lots 19 through 33 in XX; * Yi1(Block Eight -two (82) of the Plat of Jewett Mills, lying South of the Willow River, Town of Erin Prairie, St. Croix County, Wisconsin. 1 i �ll 1 Illll�ll IIII�I�I Illlllilll 8198016 Tx:4164347 989768 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI 12/02/2013 10:42 AM EXEMPT#: NA REC FEE: 30.00 TRANS FEE: 615.00 PAGES: 1 Recording Area Name and Return Address Timothy Joseph Zerby 772 Dresden Drive Chaska, MN 55318 012-2003-40-200 Parcel Identification Number (PIN) This is homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: Easements, ('�1�' i� encumbrances '�and restrictions of record. IV Dated: O,e 2-1) 2-:, 13 (SEAL) *Jere J. $rathol AUTHENTICATION Signature(s) authenticated on TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis.Stat § 706.06) ( �o /1/-1 (SEAL) * n Brathol ACKNOWLEDGMENT TATE OF WISCONSIN ) ss. !OUNTY OF ST. CROIX ) ;ersonally came before me on N ON • 2_4 , `Z-o ) 3 the above -named Jeremy J. Brathol and Jenny Brathol to me known to be thgqp� (s th o executed the foregoing instrument and ackl�b d same. \ THIS INSTRUMENT DRAFTED BY: 1 Tony R. Schrader Attorney Notary ibli •, State o Wisconsin /3 (715) 523-9409 File No. OR-13-03517 My Commission (is pe anent) (expir (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. ANTY DEED ©2003 SI'A'I'E BAR OF WISCONSIN FORM NO. 1-2003 Byname below signatures. 991'-�(0� St. Croix County Holding Tank Agreement Permit Number - Name — (Own Typed printed being duly sworn , states, under oath, that: 1. He/she is the owner/part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume Page Document Number 1191 1 ,R St. Croix County Register of Deeds Office: A parcel of land located in the NG '/4 of the NC % of Section 9T 3a N—R1-1—W,Town of E,�in ?{a+ {%e , St. Croix County, Wisconsin, being duly described as follows (include lot no. and subdivision/CSM or detailed legal description): F aj c> — JeN eit y�+115�ii�� o� y11�cw1.rP Ve5�5 lcrsS 1°( a3 33 Agreement Date: S+o+ 3• L �. 3 Name and Return A dress O (a - 3Loc -3- L\()- HOC) f Parcel Identification Number (PIN) We acknowledge that applicafion Is being made for the installation of (a) holding tank(s) on the above described property or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. SPS 383, Wis. Adm. Code, or Ch. 145, Wis, Stats. As an inducement to the county to issue a sanitary permit for the above -described property, we agree to do the following: 1 . Owner agrees to conform to all applicable requirements of Ch. SPS 383, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the governmental unit or the Department of Commerce to prevent or abate a human health hazard as described in s. 254.59. State., the governmental unit (Town) may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats. a. The owner agrees, pursuant to s. SPS 383.54 (2), and SPS 382.40(3)(e), Wis. Adm. Code, to have a water meter installed in the structure. The water meter shall be installed by a plumber authorized try the Department to make such installations, with said installation complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation, maintenance, and repair of the water meter, and agrees to allow the governmental unit or the Department of Commerce to enter the above - described property on a regular basis to read and/or inspect the water meter. 3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 4. The owner agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the governmental unit within ten (10) business days from the date of change to the service contract. 5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the county on a semiannual basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained. 6. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment systems certifies that the property is served by either a municipal sewer or a private onsite wastewater treatment system that complies with DSPS 383, Wis, Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) - Please Print Subscribed and sworn to before me on this date: `lltyttill Iltltrt Z ``�NN �IFNS O5 Notarized Owner's Signature(s) Notary Public ax Govemmental Unit vial Name, Title- Please Print My Com^misslon Expir wry••. • op v MSOO 11 r1f117iI I1111111w\ Governmental Unit Official Signature Drafted by: Personal information you provide may be used for secondary purposes trnvacy Law S. u.ugSlxmtl "THIS PAGE IS PART OF THIS LEGAL DOCUMENT- DO NOT REMOVE" This information must be completed by submitter. document title name & return address. and PIN (if required). Other information such as the granting clauses, feagal description, etc. may be placed on this first page of the document or may be placed on additionaf pages of the LaLox sin D %Trtmela iof oIndustry. PRIVATE SEWAGE SYSTEM Safety a n Hu ild n Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATIONIVE' {ATTACH TO PERMIT) �, ec.4,T30-R17, Co. Rd. T Permit Holders Name: ❑ City ❑ Village IN Town ❑ : Vickie Lyons Erin Prairie CST BM Elev : Insp BM7Elev.: ' BM Description: 7 TANK INFORMATION TYPE MANUFACTURER CAPACITY Sep Dosi n g Aeration Holding TANK SETBACK INFORMATION V TANK TO P/ L WELL BLDG. Ai ntake ROAD Septic NA, Da I ng NA Aeration NA Holding S PUMP / SIPHON INFORMATION Manufacturer Demand Model Number GPM TDH Lift Friction stem TDH Ft Loss d Forcer Length Di a. Dist_ To well SOIL ABSORPTJOWWBEM rj vunty Sanitary ermrt No 1 491 58 State Plan ID No.: S Cl i --o? 09 <4C? Parce Tax No 574 ELEVATION DATA 1 r1--Io Al A011n9l,,7 STATION BS HI FS ELEV. Benchmark s 599' Z n U z+ mo■ Xi Bldg. Sewer a 1 Ht InletIr -5' I Ht. Outlet Dt Inlet Pt Bottom Header/ Man. Dist. Pipe Bot. System Final Grade r �� S ( :27 1 /4a - 0.M. 5&,Xr, BED / TRENCH width Len gt No. Of Trenches PIT No Of Pits Inside Dia tiqu:d Depth I N I SETBACK SYSTEM TO P/ L BLDG ELL LAKE/STREAM LEACHING Manu acturer: INFORMATION CHAMBER TypeOf Model Numaer. System: OR UNIT DISTRI HeadAr /Manifold Distn4utivn Pipe x Hole 5,z x Ho J Vent T, Air intake Length Dia length Dia acing 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.) T. G . s ire- e rr. - 166 6 0, Co A AJIuA Plan revision required? Y ,�,� ❑ e5 i{�" ry a Use other side for additional Information Li dx SBD•6710(R 0"1) Date I nspector's Signature Cert No St. Croix County Planning and Zoning Thursday, January 31, 2013 at 1:09:54 PM Detail Sanitary Information Page 1 of 1 Computer #: 012-2003.40-200 Sub/Plat: Jewett Milts Section: 4 Parcel #: 04.30.17.574B Lot: Blk82 TN/RNG: T30N R17W Municipality: Erin Prairie, Town of CSM: 114114: NE 1/4 NE 1/4 _. ....... Owner. __._ ... Lyons, Vickie 1772 County Road T New Richmond, WI 54017 State Permit 149158 issued: 08/29/1991 POWTS Dispersal: Holding Tank Permit: New County Permit: 0 Installed: 11/20/1991 POWTS Detail: NA Bedrooms: 3 WI Fund: POWTS Pretreatment NA Notes Issuer/inspector As Built Plumber Tom Nelson No Wang, Tom Jim Thompson Signed Off: Yes Maintenance Scheduled Pump Date Pumped 11/20/1994 3/23/2007 3/23/2010 5121 /2008 5/21/2011 8/21 /2008 8/21 /2011 8/4/2009 8/4/2012 2/1/2011 2/1/2014 11/1/2011 11/1/2014 11/26/2012 11 /26/2015 Other Requirements Additional Notes Money Owed transfer Boumeester to Wang - South of Willow $0.00 River formerly parcel #.574 - owned by Couch. See floodplain maps - mortgage query in 2007 for re- build approval Notification Notification 04/20/2006 C iL. I SANITARY PERMIT APPLICATION COUNTY I Now In accord with ILHR 83.05, Wis- Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ec I} revialan to prwloua applicat+an wee reverse side for instructions for completing this application. STATE P N LD. MUM R I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPS T ti ER PRQPERTY LOCATION S T _?0. N, R E o PROPERTY Q Ea'Sa Al AD(� S LOT # BLOC CITY, T E ZIP CODE PHQNE N MB R SUBDIVISION NAME DR CS NUMBER 11Y NET 11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE: �n !�'r i.r TQN ❑ Public 51 or 2 Fam. Dwelling-# of bedrooms , a ra �00]?�- S/ J- 111. BUILDING USE: (If building "is public, check all that apply) *� 1 ❑ Apt/Gondo !!! 1Q 2 ❑ El Hall 6 Medical FacilitylNursing Home Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Checkline B if applicable) A) 11.❑ New 2. Lei Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In -Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. AB'SORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERG. RATE fi. SYSTEM ELEV. 7. E ELEVATION E REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch} Feet Feat V11. TANK CAPACITY Site Fiber- Exper. in allons Total # of Manufacturer's Name Prefab- Con- steel Plastic INFORMATION New lstin Gallons Tanks oncret strucied glass App. Tanks Tanks Septic Tank or Holding Tank � —ed Lief Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT i, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plu Signature: (Na mps) MPI W No Business Phone Number: PI tuber's Ad rasa Stree i ip ) t f i r"� f lv�A f% IX. COUNTY/DEPARTMENT USE ONLY ieaui Agent Slgnatu o Stamps) Disapproved Sanitary Permit Fee (13urIudasq roun water a e sou eo rchar Approved © Owner Given initial I Adverse o —g r n X. CONDITIONS OF APPROVALJREASONS FOR DISAPPROVAL: SBD4M (formerly Plb-67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division. Owner, Plumber 0 SANITARY PERMIT APPLICATION COUNTY;' In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # —Attach complete plans (to the county copy only) for the system, on paper not less than `/ (_ ? �';k- - � 8% x 11 inches in size. ❑ Cnall revlsion to p"vious appltcation —See reverse side for instructions for completing this appiication. STATE PLAN I.D. NUMBER 1.APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. 1,r � � � ` 4 y PROPERTY OV44ER PROPERTY LOCATION PROPS TY OrER'S MAILING ADDRESS LOT # BLOCK # r r. CITY. STATE ZIP CODE PHONE NUMBIfR SUBDIVISION NAME OR CSM NUMBER D i IL TYPE OF BUILDING: (Check one) q ITT NEAREST ROAD ❑ State Owned VILLAGE r ❑ Public ❑ 1 or 2 Fam. Dwelling-¢ of bedroomsrf ) fill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other- Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line 6 if applicable) A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE. OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In -Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill Vf. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. ABSORP. AREA 3, ABSORP. AREA 1 4. LOADING RATE 5. PERC• RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. M) (Gals/day/sq. ft.) (Min.linch) I ELEVATION { • '�' •'f � `] Pact Feet VII. TANK CAPACITY Site in gallon Total Of Prefab. Fiber- Exper.. INFORMATION New Istin Gallons Tanks Manufacturer's Name oncret Con- Steel glace Plastic App structed Septic Tank or Holding Tank �' '" "'' Lift PumpTank/SI hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. IPlumber's Name (Print) Plur"r'ii Signature (Na 5tamps) MPIMFFRSIIV No.:. :] Business Phone Number:. f w -r �um Plu ber A Mesa (Strest'Cify. Stdta, Tip Code):' IX. COUNTYIDEPA TMENT USE ONLY Disapproved Sanitary PermIt Fee (Includes 3roundwsW a', eissued Issuing Agent Signature iNo tamps) surcharge Feel UApproved ❑ Owner Given Initial Ve X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-SM (formerly Plb-67) (R. 11186) DISTRIBUTION: Original to County, one Copy To: Safety & Buildings Division, owner. Plumber Ll INSTRUCTIONS 1. 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 any new criteria in the Wisconsin Administrative Code will be applicable. 3. •All revisOns.t9 this permit must be approved by the permit issuing authority. 4' Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SED 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 your onsite 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: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. 111. 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. VI. Absorption system information. Provide all information requested in ##1-7. VII. 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 131/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimension!:, location of holding tank(s), septic: tank(s) or other treatment tanks; building sewers, v{ells; water mains/water service; strearrs and lakes, pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical 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 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation 0I �urchargos (fees) for a numu;,r of regulated practices which can effect groundwater. The inonh.s i;c through these surcharge,% i.;ro ;,a;i �d fs3r rywiiitoring growidwater, ground water contamination investigations and establishment of standards. SBD-6398 (R.11188) INSTRUCTiONS 1. 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 rerewal any new criteria in the Wisconsin Administrative Code will be applicable. 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 (SBD 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 your onsite 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: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. 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. VI. Absorption system information. Provide all information requested in #1-7. ViI. 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. VIII. 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 tar+k(s), septic tank(s) or other treatment tams; building sewers; wells; water mains/water Service; streams and lakes- pump or siphon tanks: distributicn 6oxes 'soil absorp!ionsystems; rep!acemeni system areas: and the location of the building served, B) ho•izontai and vertical elevation refererr--e points; G) 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 abs�)rp-ion system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. They monir�s col'ected through these surcharges are used for monitoring growidwater, ground- water contamination investigations and establishment of standards. SBO-6398 (R.11/88) �..� SANITARY PERMIT COUNTY �'DiLHR TRANSFER/RENEWAL UNIFORM P R IT IF (PLB 67-T) r PERMIT RENEWAL DATE: PERMIT TRAN FER DATE: ORIGINAL PER I 1 UACE DATE: STATE AN I.D. UMB SUS' PROPERTY LOCATION: it I VI CITY: NE '/4 '/4,S y ,T 5 D N,R E (or)(& ;0V 'V Ito LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: N EAR EST RQAD, LAKE OR LANDMARK: PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: _ n PHONE NUMBER: PHONE NUMBER: JADDRESS: 1, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. IGNATURE PREVIOUS PLUMBER'S NAME (IF C ANGED): PLUM es7C PLUMBER'S ADDRE S: PREVIOUS PLUMBER S DDR S: f� Soh ho�a�o�,�� MP MBER: PHONE NUMBER: MPl R MBER: PHONE NUMBER: 72. SIGN URE OF ISSUI ENT: DATE APPROVED: DISTRIBUTION. Original - County Copy - Bureau of Plumbing Copy - Owner Copy -Plumber DILHR SBD-6399 (R. 5/8 DEPARTMENT OF REPORT ON SOIL BORINGS AND INDUSTRY, LABOR AND PERCOLATION TESTS (115) HUMAN RELATIONS (ILHR 83-09(1} &Chapter 1451 SECTION: 70YJ".SNIPE LOT N BLK- NC NE 1/4 NE 1/4 1 4 /T30 N/R171t(or, Erin Frarie SAFETY & BUILDINGS DIVISION P,0. BOX 7969 MADISON. W1 53707 Jewitt Mills St. Croix Vickie Lyons 1772 Co. Rd. JT, R.R. 0, New Richmo`.nd, Wi. 54017 USE DATES OBSERVATIONS MADE bck:�,lidence 3 "New RARoulace 7-15-91 7-16--91 RATING: Sy Site suitable for system U- Site unsuitable for system ONVENTI N MOUND IN-GROUN : M-IN-FILL OLUINGTANK'RECOMMENDED SYSTEM: loptionall El 6ou �$ ou 10S 6u a S 9U ❑ =DESIGN:IfPercolation Tern era MDT required H any porti�otth,ased area as "n theunder s. LHR 53.0915]{b), indicate: Ploodpsain,dodplam eievsl�an: TI'a PROFILE DESCRIPTIONS __ ors ern BORING. NIJSABER TOTAL DEPTH LEVATION P H R UND Og V D AT R-INCH H A A TER F SOIL. 17 THICKNESS, COLOR, TEXTURE, AND DEPTH 7D BEDROCK If OBSERVED ,SEE ABBRV.ON BACK.I N 1 2.34 1007.8 none >2.34 .67bl.1. .50bn.s.1. 1.17bn.1s g_ 2 3.16 1007.8 none >3.16 .58b1.1. .58bn.s.1. 2.O0bn.1s. 8-3 3.41 1006.9 2 none >3.41 .58b1.1. 1.00bn.s.l. 1.83bn.18. B- 8- B- .4-4...,,t t PERCOLATION PESTS NUMBER DEPTH WATER IN HOLE AFTERSYyELLING TEST TIMF INTERVALMIN. R V -1 HE RATE MINUTES PER INCH 9 6 20 p 1 l7- 4 5% 2 P 1% 5 1 3' 5 1' P_ 1 _ P- 2 P. 1. D0 1.00 1.00 none n ne 30 3D P- P- P• PLOT PLAN: Show Io=ions of percolation tests, soil borings and the dimensions of sultahlo so4l areas. indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the Plot Ploy.. Show the wrfaca elevation at all borings and the direction and Percent of land slope. SYSTEM ELEVATION 4= IP 4.6 r- �- �s�jr�llsbrd � loa��° �� �Sts�,�� r�r�"�. � - - - _ _ r — �� � 'tt�C• Cy f rfi}rl ? r rr 9-Yl 40 0E A71L4 � ' F P tN n.."a O.1, the undersigned, hereby certify that the soil sy me in accord with [trB procedures and mathads specified in she Wisconsin Acirrimistratlw Code, and that the data records,t to the best of my knawledga and belief. (NAME (print): Gary L. steel DISTRIBUTION: Original and one cony to Local Authorrly, Property Owner and Son Tester. DILHR•SSD-6395 (R. 10M) — OVER — DILHR SANITARY PERMIT —dA ,t—COUNTY, TRANSFER/RENEWAL UNIFORM P REl #(PL6 67-� - 7— PERMIT RENEWAL DATE: PERMITTRDAN FE ( A E� pJt� (q ORIGINAL Phi IT 1 7CE DATE: SOr� ST� E� AN�NUMBER: PROPERTY LOCATION: CITY: '/<,S y ,T 43 5N.R E (or)(k/ V1 p w LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: 0 NEAREST R AD, LAKE OR LANDMARK: PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATU E: NAME: PHONE NUMBER: ADDRESS: PHONE UMBER: ADDRESS: 1, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLUM SIGNATUREy PREVIOUS PLUMBER'S NAME e(IFa C GED): A PLUMBER'S ADDRE S: PREVIOUS PLUMBER'S DDR S: MP MBER: PHONE NUMBER: 3 J < �1i� ►yes- MP/ R MBER: PHONE NUMBER: z ( , IGNATURE D 1 LH R •SBO-6399 I R. DISTRIBUTION: Original - County Copy - Bureau of Plumbing Copy - Owner Copy - Plumber 0 INS-, F.'JCTIONS FOR COMPLETING CORM 115 SBD 6395 To 61; ntiu 2. the use .,'Illy ij h S S:I jC!,;Ce,"C. 3. -,PAX .0 hv(11C;,-fr )('. 1. 15 tics a Ile,v o: luc. frTirim ,v5l-,::I: Jai% it / - "ll?v! :)oyj� fl Si' L jb F-(Y� -ti H- I) i 'IG TA:,]'< i):v- f IF ALL PIT AIERSYTEM&AW, VOINPIMMS, 6 PI EAK ow A a oarmw.can shhv e :01 qQ xm= 40aq,— w UP&MWIn m okn Ellin; A WKE A LA..:AL d:—r*;:-- ll1ealiri-t You- +,1 nl-inm . CI to A M,K(! e V:fOr )G'IT:..!, i..: vj! In r 10!,mow, , poin'.ni; in. t, J!. ii.lj.io �; 1:;1, 1 IJ i fI. r'; i:0110 'Xer-k :j- f 0 P 12. Makr r nti!t- L SiCIL ; -ST.--, ;IU31 3E FILE[, TH THE UC,',Al, ir; rrtor,i. JA&BREVIAI 101NS FOH CERYFIEU SML TEE ERS TO THE OWNER: This wo min rqmi 0 Va 10 •AY d w"&v :x ma Pw rvwn, v KnD pw cows imy, I v,fulls'. VsAmav= Or NO smi Z101 & We Wy im 0: 13 10"11 mumv. A mrilm , y of Non Iv- H- pivat,,- "Wee WV01 Mid a M,...:! awyn, - - I.!,: . — w-L!;" "'. 'it, 0. (;,1 i, III-r;Iov In L)Idffl to awyn a pwmm Tn. Wnwo UwMA 0101 no -.;I, ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 Aug. 2, 1991 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation of the Vickie Lyons property, located in the NE 1/4 of the NE 1/4 of Sec. 04, T30N-R17W, Town of Erin Prairie, St. Croix County, showed 12"-16" of suitable soil over crevised limestone bedrock which does meet the requirements of the A+4 rule which makes this site suitable for a mound. Should you have any questions, please feel free to contact this office. S'ncerely, Jame Thompson I / As istant Zoning Administrator cj I Aug. 20, 1991 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 To whom it may concern: ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST, CROIX COUNTY COURTHOUSE 911 FOURTH STREET 0 HUDSON. WI 54416 (715) 386-4680 An on site investigation of the Vickie Lyons property, located in the NE 1/4 of the NE 1/4 of Sec. 04, T30N-R17W, Town of Erin Prairie, St. Croix County, revealed 12"-16" of suitable soil over bedrock which makes this site unsuitable for an onsite sewage disposal system. Should you have any questions, please feel free to contact this office. incerely Fames K. Thompson, Assistant Zoning Administrator Cj U;ckic t�oil s i770 c0. k a T ,eV�3 few A Ammd a Series � din 9 €a�,e u Ilona f;uer O1�taiTE SE1NAGE SYSTEM C ' (K44 APPROVED DEPARTMENT OF IN TRY, LABOR AND HUMAN RUATMS DIvm BUILDma SEE DENC Old s�s. to be '~ A ,tnab,nea 1 fade . f£xrs?�Ky t .7y q41 ga�din tan S J 4AeJ6 acre Owdl-Pfed Rs �ti � 93, IG69) . EI e a. VO, 7y Quo pes a L.o0-4,t a Ne -)y S91- 209 49 S HOLDING TANK CROSS-SECTION Approved Vent Cap 4" C.I. --�- Vent Pipe Water Tight Seal Weather Proof Junction Box DD.D Minimum 9Y )4bo#e x�St F/ead I p/A;h/Final Grade Approved Joint SPECIFICATIONS High Water ' Alarm Switch to, proved Locking Manhole Cover th Warning Label Attached I 1�1n �y"�boac �x�s FToocl'P1Qin or$�r��eu i TANK New x Existing V- - - ` Manu acturer:M.,d p tt faosl Blind C.I. Tank Size:ADo Gallons Plug ALARM Manufacturer: Model Number: Switch Type NUMBER OF BEDROOMS: 3 GALLONS PER DAY: V-50 3" of Bedding Under Tank Owner's Name:' Address:�3 L scription: .. _ Y,Municipality: County : 5' f. I to; X PLUMBER/DESI Signature:�`� License Ntt��mbe Date : A, . ? �d ty, — 0�100o �4 G.1 18" Minimum Approved Joir w/ C.I. Pipe Extending 30 Onto Solid So ONSITE SEyygGp gyg� qm- G�1_"�'.7APPRD*VEID S91- 20949 VOL 913FAC9 417 473042 !! - `1/ FAriJ T00AI&tor jT" C't2v:r%f e T 4 W r. HOLDING TANK AGREEMENT This agreement is made between the — — Wolding Tanks) Owne(s) — — — — — I L.0 oh s We acknowledge that application is being made for the installation of a) holding tank(s) on the following property, (Provide legal land description:) _ V_ r oe u C .Q A n +;�! ------------------------------ REGISTER'S OFFICE Sr. CROIX CO., WI Reed for Record arr AdG2 91991 w V- ��OfQ1e� . or that continued use of the existing premises requires that a holding -tank be Installed on the property for the purpose of proper containment of sewage. Also, the broperty cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. iLHR 83. Wis. Adm. Code, or Ch.145. Slats. As an inducement to the County of to issue a sanitary permit for the above described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83. Wis. Adm. Code relating to holding tanks. if the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in so. 146.13 and 146.14. State. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the ow. r placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribedby s. 66.60. Stals. 2. Owner agrees to pay ail charges and costs incurred by the municipality for Inspection, pumping, hauling or otherwise servicing and maintaining the holding tank In such a manner as to prevent or abate any nuisance or health hazard caused by the folding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. in the event the owner does not pay the costs within thirty (30) days. the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be coliected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d). Slats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with s. ILHR 83.18 (4) (a) 2.. Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d). State., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that compiles with Ch. ILHR 83. Wis. Adm. Code. in addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 8. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. r(s) Nan**) (Print) Owner(@', I eki e L voh Municipal OKI" Name Wdgft) )1Afaficip0 Official i Municipai Odicisi Tide (Print) Cp,T-i ?tZAziai_ Tp�,,.v CNIhW S604123 (R. 10185) This instrument was drafted by the Stale of Wisconsin Department of industry. Labor and Hunian Reiaborm Bureau of PkanbkV. HOLDING TANK SERVICING CONTRACT conir+ct Oate 0� j `��`—+— This contract ismade between the --------1--------- Ho1dMpTank_jOwner(ss) Name(s) and �� 7PuPer's Name Lyons I No acknowledge the Installation of (a) holding tank(s) on the following property: (Provide legal description:) ►JE %y a-� }�-+e jJE ��/ 4 Scc, 0`/ , Tao 1�._ r 19 W ) 1o, h £r'.vim Prai+'',E) C jc d ; x (! ours,, The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required In Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of IS�- . C V 0) X 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the ail -weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges Incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank Is installed; d. The sanitary permit niimber issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes In gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 1. This agreement will remain in elfect until the owner or pumper terminates this contract. In the event of a change in this contract. the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. )Wner(s) Names) (Print) I 1 =' Name (Prins) z G,�GiueO w/�sT L` Subscri d and sworn to before me on this date: Nftry Pu R mmission expires: }(/Jf 5 1 / /. ✓ r 8D757� (N. tt/eS) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and human Relations, Bureau of Plumbing. I SANITARY PERMIT APPLICATION In accord with ILHR 83,05, Wis. Adm. Code CDUN ��LH � STATE SANriA$„Y� E�T -Attach complete plans (to the county copy only) for the system, on paper not less than [:1CLk 8% x 11 inches in size. fi revision[[//^�� to p lone application —See reverse side for instructions for Completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROPERTY PVVNE J PROPERTY LOCATION N `f4, 0, E W C C)NS L S T� N, R or PROPERTY O R'S MAI�I A � 117 LOT # N Pi. BLOCK # CITY, STATE ZIP C DE}} 71 PHONE NU BER SUBDIVISk NP M R CSM NUMB Ri c It. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE � �`t � NE E5T ROAD T Public [3 1 2 Fam. Dwelling-# bedrooms A � ( or of Ill. BUILDING USE: (if building type is public, check all that Apply) s� ~J 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1, Z New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System 13) ❑ A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE Of SYSTEM: (Check only one) Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 4Hold1ngTank5 12 ❑ Seepage Trench 22 ❑ In -Ground 42 LJ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ 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 RE Min./inch) ELEVATION Feet Feet Vil. TANK INFORMATION CAPACITY In allons Total Gallons # of Tanks Manufacturer's Name Prefab. Concrete Site Con- Steel Fiber- glass Plastic Exper. App, New isti Tanks Tanks strutted Septic Tank or Holding Tank 14 1 Lift Pump Tani hon Chamber Vlll. RESPONSIBILITY STATEMENT 1, the undersigned, assure responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): PI u ber's Sign re: (No Stamps) MPIMPRSrW�No.: Business Phone Number: ]} I Pl ru bar']s�Addre�s'ss ((street, City, Sta , Zip Code): i } Z �) IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ssuin A ant Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adve i� X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-87) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. 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 any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by t1e permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 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 your onsite 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: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. 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 repai r. V. Type of system. Check appropriate box depending on system type. VI. Absorption system Information. Provide all Information requested in ##1-7. VII. 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. Vill. 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 8'% 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 vertical 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 115 form; and F) all sizing information. 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. SBD-6398 (R.11/88) -; .RTMENT OF REPORT ON SOIL BORINGS AND ILDINGS SAFETY & B DIVISION ;,JSTRy, -,FOR AND PERCOLATION TESTS (115) P.O. BOX 7969 MADISON, WI 53 70 7 it��l•A1M RELATIONS 41LHR $3.69(1) &Chapter 145? . ,iN. "` I/ NE f� Tp NNSHIPt %T 30 N/R17lorl W' Erin Prarie T N nla n/a UBRIVI I N Jewitt Mills 4 =t. Croix. Vickie Lyons M 1772 Co. Res. fiT, R.R.IC3, Nev R3Chmo'.nd, -Wi. 54017 GATES OBSERVATIONS MADE _� •cx>., Wane. l 3 1� nee Nrw ®fa apLau � 7-15-91 7-16-91 AT ING S' Sit suitable for, system U- Site urtsuilsble for system ',vrj EiIbi AL'f=Uspic N-t`, L LQ NK:fiECOMMEN'OEOSYSTEM,lootlonall $ a ❑ S 2U E] OU ❑ S ®U mound Tests are NOT tepulted DESIGN RATE: If any loorlion of the tested area If In the r +1.1In 87119151iol, Incitcatr: n/a Floodplsin, Indloate FloedPUln*level rnn. n/a _. PROFILE DESCRIPTIONS 7 OTAL ]Ftr'YM LE WATIOH H A ND AT R•INCH 5 ACT 1 IT 1 KN LOR, TEx URE, AND EPr11 TO BEDROCK IF OBSERVED SEE AB®RV. ON BACK-1 �V 2.34 1007.8 one >2.34 .67bl.1. .50bn.s.1. 1.17bn.ls 3.16 1007.8 none >3.16 .58bl.1. .58bn.s.1. 2.00bn.1s. 3.41 1006-92 none >3.41 .58bl.1. 1.00bn.s.l. 1.83bn.1s. decimal' PERCOLATION TESTS •'' n o,rirt AFTERS.IN 1LING INTERVAL -MIN- IN WATER LEV PER hUCA .S J 1 1.00 nong 3 -DROP 4 t 34 9 -- 2 1.00 none 30 5= 5 5 b 1_OG none 30 2 1' 1 20 _ Ot,Ot Pt AN Scene. Incatinns of nercnlation tests, edit bonnet and the dimensions of sultable soil areas, Indiata scale or distances. Describe what are the hon .. u ,—1 - e'e�ation reloranco points and show their location on the Mot plan. Show the surface u ryation at all borings end the dlnetlon and percen SYSTEM ELEVATION , IOQR_67 it I �A1 �r �gSj� A a 17 - 4 1 t i l4n ► 41"e ��{ ia1 sort E " ` I+ d r to E A^J � . I? .; -t 1 a' 210 ILn LT ��► a R �, a-��tv�trg s� sd v,,.oee�d 3� sG'd6a.fi"` hereby Certify that the sod tests reported on this form were made by me in accord with the procedures and methods speclF4d in the Wisconrin • "' '",�- Code, and that the data recorded and the IoCation OP the tests ere CDrre Ct to the best of my knowledge and belief L. Steel _'OrrJL1--AY " vc r nIatITtoN: Orininai oM ena eaft its Local Authority- PICOUty Owner and So it Tesler. ,DUS RY, OF REPORT ON SOIL BORINGS AND SAFETY cat BUILDINGS . DIVISION PERCOLATION TESTS 115 P.O. BOX 7969 aBOR BOR AND { ) MADISON, WI 53707 !UFdAN RELATIONS 11LHR 93.09(1) St Chapter 145) T T3U—Na:jSUSDIVI9I0NA . 4 %730 N/R17A((o.)W Erin Prarie n/a n/a Dewitt dills -.., i Y- Croix Vickie Lyons 1772 Co. Rd. OT, R.R.43, New RictlBa.'.rd, Wi. 54017 sE v DATES OBSERVATIONS MADE p{ 6TrUF 1'9Mr PTf ION TESTS 'cN "id— 3 n/a ON �+.wac. I 7-15-91 7-16-91 1ATiNG: S= Sitasuitabie for syrtah U-Site unsuitable few -,W% Fi b4tMV sR ESE sLJ 6U I (as ❑u I ❑ S ®V 0,1— Tests are NOT requited DESIGN RATE: It any portion of the tested arse is in the .. u-lin83.09(5)(b),Indicate: n/8 Floodploin,indiuteFl _ pOdplaln elevation: n/8 riprimilt PROFILE DESCRIPTIONS .'?sBERPTH 'iOnir,IGr:2.34 U'AL 1 B_1 B. 2 I j 3.16 B B 3.41 B i decimal' PERCOLATION TESTS —TT -r3'Bcrt O rill AFT ERSWELLIN 1 INTERVAL - FAIN. PERT CH _ 1 1.00 none 4 g_ 2- 1 -00 , n -die 5 5 5 6 j_. 2 1 1 20 I,OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable sole steel. Indicate scals or distances, Describe what are the horn •+•ai and �*rltcai elevation reference points and show their location on the plot pion. Show the surface elevation at all borings and the dlraction and percent 3YS�TEM ELEVATION AEON ,e ; 1fY1R_ I� r` 16A. B Al `iZ9}JA,tr J I X� ��// r ry 9 I Olt Bch Art,+ 1 . •i--� C i 9.. _ I i i fir. o f -� b t< S i o p �d �% 1d , Yft j i qo 'Abe t 5r . vs� fdv tea. 3 i i I 10 -md•rsigned, hereby certify that the soil tests rep orted on this form were made by ma in accord with the pronduras and methods sWciiled in ,.r n, ,,,,iw. Code, and that the dote recorded end the location of the tells are correct to the best of my knowledge and belief. +<I IttBUTION: Original and one Copy to LOCH Authority, Property Owner and Soil Tester. LEVATION •IN H A L KN SS, COLOR. XTUR NO DEPtH T 8 OR K IIs OBSERVED EE ASSRV. ON BACK•) Y 1007.8 none >2.34 .67b1.1. .50bn.s.1. 1.17bn.ls 1007.8 none >3.16 .58b1.1. .58bn.s.1. 2.00bn.1s. 1006.9 none >3.41 .58b1.1. 1.00bn.s.1. 1.83bn.1s. i. U. I-L, « r _I— L A N I A M E - r �_ _ N A M E T. �� � �Y, �- , 0 C AT 10 nl ...'rrr.. e i� L I C ENS E r//-- ti:To3.e_�_. T E � ca ��! loN 1671, j� , Try kls _ ( I I t I( s fAAC AN fcort HdW).J TAAJk5 10k 6 k I k r,RQ F�+� kerL -r�An, f 6o 1�0rd',�;��n�K 5 J , FR85FI AIf1 INLFi8-RND OBSERVATION PIQr CROSS SECTION Appreved Vent Cap Minimum 12" Above Ei nAl nrade Above Pipe To Final Gracie Marsh Hay or Synthetic Coveri Min. 2" Agcjrec,i1 Over Pipe Distribution Pipe Aggregate f;crcath Pipe 4" Cast Iron Vent Pipe _-__ T e e Perforated Pipe Below —Coupling Terminat•i.ng P Bottom of System Weather Proof -� gent %Ivored' t Cap Junction so. C ap Approved Locking Manhole Corer Apprent With War Locking Manhole Corer With j With Warning Label Attached And Padlock Warning Label Attached And Padlock --- 1' C.I. 12' Minimum 0 --- C.I. Vent Pipe rival Grade 12' Minimum_ Vent Pipe rfnal Grade a' Minitxar A' �o �l •' M1n) ' Approved Joint /Approved Joint •' C.I. 1S' MinLuxa 3.., Teter Tight a• C.I. I 18' Mtn - j; _—_ I High Water Alarm Switch � ••_L. Approved Joint Blind C.I. Approve v/ C.I. Pipe Extending 3' Plug w/ C.1. Extendi Onto Solid Onto So Soil Soil . 31. Bed 1«9 Utipea pr- •��dln:G 3 " li• )n9 Uft ArIK 3' of Bedding Under Tank 31 of 1. UNo-ft, IAU J Owner's Nre: 1�Y\ a L_ i.i;, C SPECIFICATIONS Address: . _ Legal Otaer a wo HLTANK loth Tanks Typical New Existin of Each 0 Township/Nwiictpal 1J: County. I - GILY/1 IRI Wr.r, Tank SIX - c ons 0. 1 a r1 Ol 1 S � , ! (d PLUMBENKSIGM ALARM Manufacturer: f p Node1 Number: Signatwo: .,.. t,�i,,,Yr „ ' Switch Type : At VRPt5 Covers be . License NUMBEp Or gEOR00MS;.� will GALLONS PER DAY:�s<; ONS;TE SEWACE SYOTEM ) 6 D V 60 RVELAPUIS L -IS.'44 t" Si .l rf i /:i1:1 EE CC I^ESPUNDEINCE DATE: TO: FFFFFFFF A X X F A A X X F A A X X F A A XX FFFF A AAA A XX F A A X X F A A X x F A A X x ST. CRO?X COUNTY COURTHOUSE 911 Founzh Szneet Hud6on,WI 54016 R- I q-q I FAX NUMBER - NAME: Ch 1 FROM: FAX NUMBER: /�_ NAME: ,L,G�. 7151386-4628 NUMBER OF PAGES INCLUDING COVER STET: ssss**sssssssssssss*ssssss**sssss**s**sssss***sss****sssss IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE CONTACT: NAME: &-0,411 -9- TELEPHONE NUMBER: ( — 7 (S - 32 C 6 0 r-) q-4!� t �u a�y� APPLICATION FOR SANITARY PERMIT S T C - 100. This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property __, 'P_kie_ Cr �/UA15 Location of Property , Section T_10 N-R 7 W Township Mailing Address tk 127a (_o T Address of Site Subdivision Now ,Te_ W f' i+ A I , 15 Lot Number Previous Amer of Property I7iADQ�e_{ of r, _ mop . Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) T Yes No Volume and Page Number o2/2 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I We) centi6y that atet btatementd on th.ie ¢onm ane true to the but o6 my (ouh) knowledge; that I (we) am (ane) the owneA(d 1 o6 .the pnopehty deacn.i.bed .in .this .in6onmation 6onm, by v.ihtue o6 a waA a►uty deed neconded .in .the 064ice o6 the County Regi4ten o6 Deed6a6 Document No. va SIQa ; and that We) pnuentty own .the pnopobed bite bon .the bewage pohatbyes Ion i (we) have obtained an sabelnent, to nun with the above debbed pnopehtrl, bon .the conbtnuction o6 adid byatem, and the dame has been duty tecoAded in the 066.ice o6 .the County Reg.i.ateA o6 Dceda, ae Document No. SIGNATURE Op OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE IS�CNED ? DATE SIGNED is ry �j /