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002-1056-20-035
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O CS :3 0 E OOMiLL NN ca. c~6+m-3 w D a~ cwrn 3 2to cow c a> s=--ao>cm Q U- r a) C U U O uml E O M N o. 'c c ~ N O w E 0 U O 0 -0 E C ° z I m. rn a m a N H •3 I c C7 O z d ° m c T E N U N U = O m v C O N- O z z NI E M m O O I C +3 y > N d d W a' oooa Q o v cn co m o zv> am ~aao0. a N N w Oo rn y J U w } o v ° o > N 2 O w N fn = N S ~ w m C N U O I o d Q} V N 7 +m+ N Lo 0) !l p O I N N C O d = 0 0 ~'~Vi C I C V V n. O O M V O O N D C: O m N N I cm N m N = = 16 M a0 N 40 2 C W N c 'O CO CD Z O O16 N G D7 v N N d O O` m U r+ N m o fn • O N m N N N ,z N S O ~ Y I V L at a , L: a Z w A m 3 o CL2! 0 u v~t~ [L ct e 1 Mai V - V III\yp^vyU~\\` 0 ~ cAl C L ~ ~ It CIO v / W VA J 5 C2 ~s 2 W,~ Q~ r\j ti ~p < o u u 61 Q O 7 ~ v . oC , w y ct J- - W< a ~ ~N 1 d CIP N cJ ~ d I I ll V 1 O 1-1 0 lS -',i ~nl G A 1 ` \ V STC - 104 AS BUILT SANITARY SYSTEM REPQ`J } ER OWN 717 ,4t t/ ADDRESS 2 5^`~~ Fier 05 ~ D SUBDIVISION CSM# Town o f SECTION~_T ST. CROIX COUNTY, WISCONSIN PLAN VIER SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 7z c-5 INDICATE NORTH ARROW - of this form. Provide setback and elevation information on rc~vc r'e ole cover. Provide 2 dimensions to center of sePtic t"`311}' lll inrl PUMP CHAMBEn Manufacturer: Pump Model: Liquid Capacity; Pump/Siphon Manu Elevation of ct.: inlet.: Pump Size Bottom,,: of tank Pump on elev.; r' elevation --,PUMP o elev. ; Alarm: Man.: ----.Gallons/cycle; Switch : Dist e ance from nearest Location prop, line: Front Distance from: Well Side-' Rear_ Ft . Building SOIL ABSORPTION SYSTEM Bed: T ench: Width: Seepage pit: ---____-Lengt Exist. Grade N! er of SLines: Elev. Area Built Proposed Final Fill depth to tol~'of Pipe: Grade Elev. No. feet fr 9m nearest prop, line:Front No. feet from well: Side_ Rear _Ft._ -_-_No. feet from building TANK Manufa turer. ~ No. ` of rings used: Capacity: 6-1-9 levation of botto Elevation of inlet: L ank: 0-k ; No. feet from' '3" nearest prop, line: From-3~ S • ~y~ No. feet from. - ides Rear~~ Ft. ' Well _ building / anufacturer: nearest road 3©C-D DATE: INSPECTOR: PLUMBER ON JOB: LICENSE `ASS NUMBER: 6/90;cj WisconsipDepartment of Commerce PRIVATE SEWAGE SYSTEM EanTID CROIX ;3afetyand $uildings Division INSPECTION REPORT l> GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)J. Pf OftVa AN LUTHERAN CHURCH &WflVe ❑ Town of: Parcel Tilyac$_.1056-30-000 CST BM Etev.: Insp. BM Elev.: BM Des cription: loo, T Q~ >n1elI ELEVATION DATA A9700493 TANK INFORMATION TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 1000 Bench r S"Of Arlo? 100 Septi I rs Dosing i i Aeration Bldg. Sewer X0.02. ~07 Holdin St/ Ht Inlet I! TANK SETBACK INFORMATION St/ Ht Outlet ventto I TANK TO P / L WELL BLDG. Air Intake ROAD Dt nlet Septic 72' +76 3o1 -r35' NA Dt Bottom NA Header / Man. Dosing Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Demand 9S' Al' Manufacturer GPM µn 13.10 Model Number TDH Lift Lrictio Ft Forcemain Length Dia. Dist.Towell SOIL ABSORPTION SYSTEM Cor►rlfa 42 ish No. Of Pits Inside Dia. Liquid Depth ED/TRENCH Width Length No. Of Trenches D,MEN I N DIMEN I N LEA CHIN Manufac rer: SYS P / L BLDG WELL LAKE/STREAM CHAMB Type SETBACK ode INFORMATION System: OR UNIT System: DIS7/M IBUTION SYSTEM -P)o s-1't in Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Headanifold Length Dia. Length Dia. SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over epth Of =xxxxxx Mulched Depth Over s E] No E] Yes ❑ No Bed /Trench Center Bed /Trench Edge ° COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: BALDWIN 23.29.16.346B, ,S,W2524 80T ~AVENUE LOT 'S's W S 10111, ~t n 6&4 Sec C"o 1b c,vle r~fi sy ~5'z6 93 ~4yc* n'C'ut . t .,N aarv~it . 'Ok planl'e ision required? ❑ Ye~❑ No Use other side for additional information. Inspector's Sign ure ° Date SBD-6710 (R.3/97) ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau Building Water Systems r~•~L■'■■'l 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison; WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County _5T 690 / 9 than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 29q` 7 7 The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number rY1~~ 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION m Sv L/L L Pr9party Owner Name Property Location " y4-l1 U G <<rC,s~C 7,49 .41 Std 1/4 s 1 1/4, S T R l~ E (o Property Owner's Mailing Ad es Lot Number Block NumbJer~ ~ o All -e to City, State Zip Code Phone Number Subdivision Name or CSM Number Q Road II. TYPE OF BUILDING: (check one) E] State Owned ❑ Cit yy ❑ Village / a !c~ JNearest Public 1 or 2 Family Dwelling - No. of bedrooms FiILT( OF III. BUILDING USE: (If building type is public, check all that apply) Parce ax Number(s) D 1 ❑ Apartment/ Condo ~4- a 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 box on line A. Check box on line B, if applicable) A) 1 New 2. ❑ Replacement 3_ ❑ Replacement of 4, ❑ Reconnection of 5. 0 Repair of an System System Tank Only Existing System __Existing System B) 11101A Sanitary Permit was previously issued. Permit Number 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 Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 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 Required (s ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 67~ ? 3 :9' 94eet 91, eet VII. TANK Capacity Site INFORMATION in gallons Total # of 's Name Prefab. Con- Steel Fiber Plastic App- New Existin Gallons Tanks Manufacturer Concrete strutted g Tanks Tanks Septic Tank or Holding Tank ~ tV I `e s 'dZ ❑ El ❑ ~ ❑ Lift Pump Tank /Siphon Chamber ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbic Name: (Pant) Plumber's Si ature: (N Stam s) R MP/MPRSW No.: Business Phone Number. It C_ Plumber's Address (Street, City, State, Zip Co~dgL, "Z 3 ,tL ~w l~lJ ~s . 4c~ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved anitary Permit Fee (includes Groundwater ate Issue Issuing Agent Si nature (No Stamps) urchargefee) Approved ❑ Owner Given Initial 1 8'~ ~ Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, one copy To: Safety & Ruilrlinga Divi ion, Owner, Plumber INSTRUCTIONS y, 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal 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 and 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. 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 on 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 for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/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 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and 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 contamination investigations and establishment of standards. SAFETY AND BUILDINGS PAGE 01 08/01/1997 10:07 608-765-9330 r SAFETY & gQILDINGS DIVISION State of Wisconsin impartment of Commerce May 1, 1997 2225 Rose Street La Crosse WI 54603 BOLDTS PLUMBING 820 MAIN ST BALDWIN WI 54002 RE: PLAN S97-40297 FEE RECEIVED: 260.00 IMMANUEL LUTHERAN PARSONAGE SW,SW & SE,SW,23,29,16W COUNTY OF ST CROIX TOWN OF BALDWIN MOUND SYSTEM' The Department has reviewed the above-referenced submittal. sub ittal. Conditional approval is hereby granted for the system and approvaXlof themsystem islbased noted items must be corrected. Wisconsin on chapter 145, Wisconsin Statutes, and chapters Comm 83 and 84, Administrative Code, and is contingent upon compliance reviewed ithtanycstipulations for de shown on the plans. This system Wisconsin requirements set forth in chapter Comm 82 or in chapters ILHR 50-641 Administrative Code. This plats submittal approval erawillrexpire onptheadayathe or if a sanitary permit is obtained, 8l~ approval initial sanitary permit expires. The licensed plumber responsible for this Depar ment's stamp installation shall keep onssitef pThesinstaller shalltnotify the appropriate approval at the construction inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Si cer yo Gerard M. Swim Plan R.ovi oreor Section of Private Sewage Po. (609) 785-9348 cc: ST CROIX Post-,r Fax NOS 7671 oadetl t From SIB LM oajowCP,~ 1% Gra • C~ co. I~ a~ Phone ~ Phone A F6x A Fax N i saa~ (a.i Bey U IMMANUEL EV. LUTHERAN CHURCH 2526 80TH AVE. WOODVILLE, WISCONSIN 54028 PHONE: 698-2500 WATER USAGE FOR PARSONAGE AND CHURCH January 1 through March 31, 1997 Parsonage hunch Jan. 2 147 2 3 160 2 4 171 1 5 143 25 [Sunday] 6 157 8 7 163 10 g 174 11 9 158 1 10 167 3 11 163 4 12 148 37 [Sunday] 13 165 17 14 146 0 15 168 10 16 177 5 17 164 2 18 172 8 19 145 40 [Sunday] 20 160 9 21 157 2 22 149 9 23 175 7 24 162 2 25 179 5 26 139 34 [Sunday] 27 169 16 28 156 4 29 166 12 30 158 8 31 165 2 Total used 4,828 306 Average/day 155 9.87 Rated at 1770 gallons per day -001- . ~u, 4,-,- M P c,-r Z2,1) 3 / PAc 2 of -7 1 February water usage RMWDagg Church Feb. 1 0 0 [out of town] 2 0 43 [Sunday] 3 46 1 4 185 3 5 165 21 6 158 4 7 171 4 8 168 2 9 140 41 [Sunday] 10 153 19 11 141 13 12 165 55 [Worship & Soup Supper] 13 159 5 14 163 4 15 172 3 16 138 38 [Sunday] 17 150 10 18 148 16 19 174 48 [Worship & Soup Supper] 20 158 12 21 167 1 22 170 2 23 142 51 [Sunday] 24 149 16 25 151 8 26 165 44 [Worship & Soup Supper] 27 158 12 28 175 2 Total used 4,173 478 average/day 149 17 rated at 1770 gallons per day CST z zo,?53 `f ~ 7 /?7 i~& e- - /-1/11~ Al P r ~ March water usage P r ona a March 1 174 2 2 136 62 [Sunday] 3 158 18 4 149 21 5 168 56 [Worship & soup Supper] 6 163 10 7 170 2 8 171 0 9 142 47 [Sunday] 10 155 31 11 140 4 12 160 67 [Worship & Soup Supper] 13 159 8 14 168 3 15 174 0 16 147 44 [Sunday] 17 155 0 18 149 7 19 162 26 [Worship & Soup Supper] 20 168 9 21 181 6 22 173 10 23 140 94 [Sunday/Confirmation/Family Dinner] 24 151 26 25 147 2 26 162 6 27 165 36 [Worship] 28 170 26 [Worship] 29 171 38 [preparation for Easter Breakfast] 30 125 78 [Easter Worship & Breakfast] 31 68 0 Total used 4,821 739 average/day 156 24 rated for 1770 gallons per day par on= Chumh Meter reading January 1 205805 56567 219630 58090 Meter reading April 1 1,523 Gallons used Jan/Feb/Mar 13,822 ? II)P GS7- ZZa~~ `PACE 4oF _ p~ G " ~Gti2%G~ C) rte. LL: ti! a Q ~ d p o-~ 0 ~ V • o Ck n ~ ~ o o h 0 00 ~a a V w 4 ~ O a o tiN u LL 1-:4 a. 2 C) y 4e ~ P+ U Cil o .;0 o d~ Q ' a y Q y~ ~'•O ® g d° v o dom. .o a o°, ~ o0 0 V lV M r r R ,r-j .V► 7 -t QY 6 , r' e r---------- I ~ I W I I I W I K M I W I ' I 'C O ~ N K ~ 3 O T - _ 3 ~~g~ MORTGAGE SUR VE Y s 97 40 BEING LOT 1 OF ST. CROIX COUNTY CERTIFIED SURVEY MAP NO. 2133, AND LOCATED IN THE S .W. 1 /4 OF THE S. W. 1 /4, AND THE 'S. E. 1 /4 OF THE S. W. 1 /4 OF SECTION 23,. T.29 N., R.16 W., TOWN OF BALDWIN, ST. CROIX COUNTY, WISCONSIN. ,..~.;ttatntlrrlr;rrrr NORTH IS REFERENCED TO THE SOUTH LINE OF THE t; z cn SOUTHWEST 1A WHICH IS ASSUMED TO BEAR WEST. art ~p°' o= W = z UNPLA TTED LANDS h "'%~pn•°°..'•°° N02'07'29"W 330.00' C r. ,,,!!!q!r'7I11111% 11111\\\\\~~~4 I I $ 296.98' 7 t 0 N 33.02' ; s i is C, I i `1 I i (`a ?tr ro 1v® A~v$~ ~ , o f!) CL ' C CT ' ~m~nn C4' t D u, SIS co -0 ' 14 .r<T ~ :;u p O O a t'h 7 Z M1 C' I t I r--^- r N N N O ~ tJ ~ Vy J b ~ c9 i If n 57 -31 f. N co Qi + I 1 ~ + 07 y C 8 cl: 01 I 1 1 I \ b t I 1 CI + n 2 r ~ cq ~ t3' ' i t 33.02' / po° N 71 214.48'/ co m S02'07'29,"E 247.50' A -1 I I ; ; - Qo t T' I 1 i I j xs1w b' ca a r1'P c7 j I , , It- K f~TE alp D m Vs-' I iD I~a~~ j O .s ~ ~ I I ' v O s f S R1j Crl t Rs o p ~rr,°~ to He"~AnoNs O 0:e.;:~ a... t , t E ~ ~ .o gE " C ~ ASP I I 82.50"~ csM ~18s S02'07'29"E iCr) PAG E l o F y s L D I t", in accord with ILHR 83.05. Wis. Adm. Code COUNTY Attach`compl'ete site plan on paper not less than 8 1/2 x 11.inches in size. Plan must include, but PAACELLO- A not limited to.vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. REVIEWED BY' DATE APPLICANTINFORMATION-PLEASE PRINT ALL INFORMATION PROPERTY OWNER / PROPERTY LOCATION -Q GOVT. LOT /t]CJ 1/4 N l/4,S 24TZQ N.R F ( W PROPERTY OJNNER*S MAILING ADDRESS lOT It BLOCK # SUED. NAME OR CSM i G STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILIA 7E , OWN NEAREST ROAD New Construction Use 4>1 Residential / Number of bedrooms j~ Replacement J>j Pubftc or commercial describe v- a So fi G Code derived daily flow /77 gpd Recommended design lo ingrate ° _bed, gpd/ft2 trench, gpd/ft2 Absorption area required/-Y75 bed, f12 trench, 112 - Maximum design loading rate bed, gpd/tt _Ibrench, gpdA? Recommended infiltration surface elevation(s) It (as referred to site plan be mark) Additional design / site considerations ~r- run d~ ) )e QrL°Q Parent material I"plain elevation, if applicable ft S - Suitable for system ENV MOUND 0PRESSURE T77 GRAD SYSTEM N FILL HOLDING TANK U= Unsuitable for s M7 tem ❑ S ZS ❑ U El S U ❑ S 2g U ❑ S (fU ❑ S XU SOIL DESCRIPTION REPORT Boring # Horizo Depth Dominant Color Mottles Texture Structure Consistence BanJ3ry Roots GPD/ft in. Munsell ad. Sz. Cont. Color Gr. Sz. Sh. Bed Trend- C, 5"1 ~ t=~ 5 Ground / =z ~:::~y~ /`l m r~p~reG~ S~ , S~ /nV Y ' :51 - elev. q, 55 ft. y' 0 y~ 3/ /~I i7I A' r G Cj ~S 11,9 Oepth to C 31' M11, S O fS limiting fact 3 Remark's: Boring # y~ /z b/onle- Alle f) -sk d s I 3 i7 -Zz 5 YR ~3 r7r red c 1 71 - Ground elev. C ~ZI&- 5 YR Z-76- An m a y-eDf ,r s; S b /Y) ✓~r I. ~o Oepth to - - - - - limiting factor 1-7 Remarks: CST Name:-Please Pr'rnt Phone: Address: F/ -D / ' /Q I'Yl S~i -BQ l(9 6,01 n Signature' r / Date: CST Number: X ;-2 f,/ S- 9 3 Boring # Horizo Depth Dominant Color Mottles Structure in Munsell ~Qu. Sz. ConL Color Texture Consistence 8cuxlay RoQ,s G(',0 ? Gr. Sz. Sh. O _ y Z. , , n G Be Try - y~yie y G'~ it , ~ Ground s-Zy s`yR l0 , , , , . . elev. Depth to limiting _ factor Al Remark's: 'rte V'00 iS q -m e ' u5 ✓'o~. Boring # f~ f Ground elev: it Depth to limiting factor Remarks: Boring # Ground elev. fL - Depth to limiting factor Remark's: Boring # ~ti N Ground elev. fL Depth to limiting factor Remarks: STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNMVBUYER MAILING ADDRESS 7-4,47- 1/ r PROPERTY ADDRESS 7/7 rJ c CeJ©®a/ ' L Z (location of septic system) Please obtain from the Planning Dept. CITY/STATE 4v 014v L PROPERTY LOCATIONS !a) 1/4, S ~C 1/4, Section 2 T~~_R_Z 6 W TOWN OF /s ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP VOLUME /-?-,PAGE a11OT NU14iBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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, 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 X,P yy Location of property S4l/4 1/4, Section Z3 T afN-R /6 S Township /~L-~w i 11 ^ Mailing address 3, °j' Address of site tlJCcnq .n u,Z/ Subdivision name Lot no. 3 Other homes on property? Yes No Previous owner of property Total size of property Total size of parcel Add .e ~ AA^ r2 Date parcel was created Are all corners and lot lines identifiable? Yes No is this property being developed for (spec house) ? Yes _"~!,-No Volume 01. and Page Number Z 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 TIfE 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 references to-a Certified Survey Map, the Certified Survey Map sti ill also be-required. .PROPERTY OWNER CERTIFICATION i (we) certify that :ell statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty domed recorded i-n the office of the County Register of Deeds as Document'-No. 3 y and that I (we) presently own the proposed site. for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been dul;• recorded in the office /_of thq_ , County Register of Deeds as LoL.. ent No. Signat eLLof Ap icant Co-Applicant 0I -1 ` Dat of ignature Date of Signature ~ /rL 0 o L.J 00 z o r , 'Q'`~~ Z - v x a r i* v Y o C7 T I O z~ to ~ I T ~ a ~ ~ ~ I /,may a z M i9 V ~ v I t- 1 O ~ O ~ r.I T W X ° m OC)N A K L C N A _K Q I p 4J 9 , X LL1 O 1 I T I 1 N co o ty , :F A N U ~ :w U 9 . Q Q{ '5 ' o Co :a a vn ~ O ow° /r. c QO d o 0 ° 0 0 -i p N S40 45 00 b4 T~~~ .a ~ ~ po •5 ~ Esc LY 7 ; C a > N cad W Ri . t..... .R+.:.-.\y...~.r.~.(., a"k.r t.•=. '.i~•J~.'.'.~h'Y.r r:..hti..-• y STATE BAR OF WISCONSIN FORM 2 - 1982 5634'76 WARRANTY DEED DOCUMENT NO. VOL 1256PAC[ 107 Ti.mothY A. Bazillp and Charlotte H. ST _Bazille, husband .and wife ~ed~i~""~ AUG 6 1991, conveys and warrants to Immanuel Evangel i cal Lutheran [rjo. 10:45 AI Church f THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described r cal estate in St. Croix County, 117AI+t a A,-ec,I LkThtror~ C hur~ /t State of Wisconsin: J'~ 9 YD'S Ave- tNOOC~V %l~t- ►'yt ~ See Exhibit A attached hereto and made SYo~B a part hereof. The parcel shown on this document is being PARCEL IDENTIFICATION NUMBER added to the parcel shown on the document recorded in Vol. 12 of Certified Survey Maps, at Page 3290, as Document No. 561680, known as Lot 3, being part of the South Half of the Southwest Quarter (Sk of SWk) of Section Twenty-three (23), Township Twenty-nine (29) North, Range Sixteen (16) West, to create one parcel, and this transaction is thereby exempt from Chapter 18 of the St. Croix County Land Use Regulations pursuant to Section 18.05 (A)(3). R a jySFER ' T„is _ i s n o t _ homestead property. 06X (Is not) Exceptionmwarranties Easements and restrictions of record. Dated this 30th day of July A.D., 19 97 t (SEAL) (SEAL) Ti othy A. Baz 1 , (SEAL) (SEAL) Charlotte H. Bazil e AUTHENTICATION ACKNOWLEDGMENT i~ Signature(s) State of Wisconsin, ss St. Croix county authenticated this _ & ii 19 Personally came before me this _ loth day of July , 19 97 , the above named Timothy A. Bazille and _ Charlotte H. Bazille _ TI FLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized h 1;1706A6, Wis. Stats.) to me known to be the person s who executed the foregoing instrument04d acknyCgledge the same. TIIiS IINSTRUNAFNT WAS nRAFT-r) AV i VOL 1 ~,rj~IPAGE1O~ EXHIBIT A A parcel of land being a part of the Southwest 1/4 of the Southwest 1/4 of Section 23, Township 29 North, Range 16 West, Town of Baldwin, St. Croix County, Wisconsin, and more particularly described as follows: Commencing at the Southwest comer of the Southwest 1/4 of said Section 23; Thence Due East along the south line of said Southwest 1/4, a distance of 942.91 feet; Thence N 02°0729" W, a distance of 330.00 feet to the point of beginning; t Thence Due East, a distance of 396.00 feet to the East line of the Southwest 1/4 of said Southwest 1/4; "Thence N 02°07'29" W, along said East line, a distance of 110.00 feet; Thence Due West, a distance of 396.00 feet; Thence S 02°07'29" E, a distance of 110.00 feet to the point of beginning. Said described parcel contains 43,530 square feet, more or less, or 1.00 acres. r •y ~n f , 7 FORM NO. 985-A r y' f /f~ `.Z Z U Stock No. 26273 S 9 G~~--lost -~o- o FILED L V JUN 3 0 1997 ► 1G L_o ti` C st-ri /z 32 51d sc aoac CERTIFIED SURVEY MAP NO. 3290 Scab ,v VOLUME 12 -,PAGE 3290 o Z 1 BEING LOT 1 OF ST. CROIX COUNTY CER77FIED SURVEY MAP NO. 2133, AND BEING A PART OF THE S. W. 1 /4 OF THE S. W. 1 /4, AND PART OF THE S.E. 1 /4 OF THE S. W. 1 /4 OF SEC77ON 23, T.29 N., R.16 W., TOWN OF BALDWIN, ST. CROIX COUNTY, M. Ny O ~ ~N ~ \\\\`\\\\\\111111111111^Ifll//////~~,/ m~~ UNPLATTED LANDS `0~.• pp~ : m .N.1 ~v~ Z • ZT *M ISE ~C• fo~ ~M m y 0 via N0210729"W 330.00' x z s a $ Nil i 296.98 ~m ~aa A v 33.02' i 1' i~~~/','O~ pigg~ I I I I ~iiunnnnm~il~iulu~~\~' \ g$ 110 I i I 1 I i ~v I i : " I I• o ~ I _i. r~ I I ~ c 1 z b 'I y p Q$~w ~ ~ 0 25 2Cv _a S°p ~ vv,~vnD p;2 N N j r U O a ro z 1 1~ ! N ~~°o r a $ 1 rT ~I vZ~z I 1 g w N S v I I a a I ~ i n Q ~ I I I . 336 ' 33' i i 3 b T~ • o cn Z o y I ~ j~ py C C~ 1 0) I _ IN fV W Z DTI ~~1 S Of 1 1 14 11 O z om I 1 j m O 1 Lq k 1A C 0 ~'1 1 ~ I I Z ~.7 ~CRi o ' S02'07'29"E! 247.50' iw Z $ ~ n~ " I ,taro 12114..48 Iw m O v y~ v 133.02 ~ ! co Rt 41. am) ' FORM NO. 985-A 4hsom- Stock No. 26273 CERTIFIED SURVEY MAP NO. 3290 VOLUME 12 , PAGE 3290 . BEING LOT 1 OF ST. CROIX COUNTY CERTIFIED SURVEY MAP NO. 2133, AND BEING A PART OF THE S. W. 114 OF THE S. W. 1/4, AND PART OF THE S.E. 1 /4 OF THE S. W. 1 /4 OF SEC77ON 23, T.29 N., R.16 W., TOWN OF BALDWIN, ST. CROIX COUNTY, M. SURVEYOR'S CER77FICAT E 1, Steven J. Waak, Registered Wisconsin Land Surveyor, hereby certify that I have surveyed, divided, and mapped a parcel of land being Lot 1 of Certified Survey Map No. 2133, Volume 8, on Page 2133, and part of the Southwest 114 of the Southwest 1/4, and part of Southeast 114 of the Southwest 1/4, all In Section 23, Township 29 North, Range 16 West, Town of Baldwin, St. Croix County, K., and more particularly described as follows: Commencing at the southwest comer of the Southwest 114 of said Section 23, Thence Due East along the south line of said Southwest 1/4, a distance of 942.91 feet to the point of beginning, Thence N02'07'29"W, a distance of 330.00 feet; Thence Due East, a distance of 660.00 feet, Thence S02*0729"E, a distance of 330.00 feet, Thence Due West, a distance of 660.00 feet to the point of beginning. Said described parcel contains 217,651 square feet, more or less, or 5.00 acres. That I hove made such survey, land division, and map at the direction of Immanuel Lutheran Church, 2528 80th Ave., Woodville, W. 54028. That such map is a correct representation of the exterior boundaries of the land surveyed, and the subdivision thereof made. That 1 have fully complied with the provisions of Chapter 236.34 of the Wisconsin Statutes, Chapter AE 7 of the Wisconsin Administrative Code, and the Subdivision regulations of St. Croix County In surveying, dividing, and mapping the some. Sold survey is subject to easements of record, and as shown. Dated this %"a day of tIP ,1997. ~.~~~~.•••••••.s%~''~ & STEVEN J. % WAAK • tA LF S-1610 Steven J. Wook R.L.S. 1610 MENOMONIE ; Q 9 WIS. O /APPROVED JUN 3 0 '97 G'/c✓ mown V STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER .1 rYJ/~C7 /Jt/C Z ul~lc "/.T)'i ADDRESS Jr b 4ye z0cO-ivy SUBDIVISION / CSM# LOT # SECTION T 2 / N-R 16 W, Town of 11~~ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM C7 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t V BENCHMARK:, n P f' o~ ~C Ot M10(l od ALTERNATE BM: off" eve-11 a7 C k'0' 'C `7 SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION PC, Manufacturer: e5 Liquid Capacity: 000 /ooo ZSOO Setback from: Well House //"7 Other Pump: Manufacturer /0/ Model#j24 QjllM Size 1 /yP Float seperation Gallons/cycle: 5O Z.5 Alarm Location 10v_m. ase P 0_y_ o rL a SOIL ABSORPTION SYSTEM Width: Length /?p Number of trenches 1Zx15 Distance & Direction to nearest prop. line: %l9 Setback from: well: 200 House Other ELEVATIONS Building Sewerf ST Inlet ST outlet/.j PC inlet 5, /5" PC bottom 90, L{ Pump Off 9 / . Header/Manifold 29. 2'7 Bottom of system-Y 9,3 Existing Grade 1? 7. 3g Final grade zV y7 DATE OF INSTALLATION: 3 PLUMBER ON JOB: 1y&jo~Sdr\_ LICENSE NUMBER: INSPECTOR: CJ r, ko yy) /2!30 r,_ 3/93:jt County: a~L. Dttr 3.2g' 16 • Ali q* REPORT Sanitar rr"i k~liart INSP MIT) Labor -a'nd Human Rep~V1OIOn ATT ACH T O PER State PI Safety and Building Town of: ° ATION ~ City ❑ village GENERAL INFORM Parcel Tax No.: ~G u Permit Holder's Name: BM Descriptio,: Ag 20 04 40 nsp. TION BS HI FS ELEV. e ev : i nn ELEVA DATA STATION 7V /w C TANK INFORMATION CAPACITY MANUFACTURER / Benchmark lj '0 TYPE r} Septic ► Bldg. Sewer Dosing ._`(_I , St 1 Ht inlet Aeration St I Ht Outlet Holding ATION ventto Dt Inlet TANK SETBACK INFORM ROAD P l L WELL BLDG. Air Intake Dt Bottom z~~ oJi y8=1~~ TANK NA TO I Man. $.d z NA Septic 1 ~0 NA Dist. Pipe i, Dosing System Bot. ~ Aeratio - Final Grade ~ cz Holding TION FORMA` Demand G cc" { PUMP ^ GPM facture 6 U Manu Model Number l~ System a TDH Ft Friction HH To Well Liquid Depth TDH Lift L pia. Dist. Inside Dia. ~ Length •n p. Of Pits Force main G?~i PIT T enches DIMEN Manufacturer: RPTION SYSTEM / NO-Of SOIL ABS - f Length LEACHING Num BED I TRENCH Width W ELL LAKE/STREAM CHAMBER Mo e P I L BLDG ( > DIMEN ► N SYSTEM TO OR UNIT SETBACK O n, ~ acing vent INFORMp`TION To A~ Inta e Sy pe (1,{G x Hole SP~ stem: x Hole size UTION SYSTEM Pipe(s DISTRIB Distribution Spacing stems Only I Mani old r _1Z~1-~~y Dia At-.Grade Sy Length xx Mound Or A xx Mulched Length Dia 5 Only xx Seeded I Sodded C1 No x Pressure system xx Depth Of No p SOIL COVER f,z e Topsoil Depth Over f Depth Over Bed 1TWAeh Edges r sons / ersons present, i ~ Bed IT~~}}Center ancies, p L . COMMENTS: (Include code discrep 6B ~ 80TS P'VENUE} ~a 6•~4 23.29-1 14. Yes No 93 inspector's e ❑ Plan revision required7 onal Date Use other side for additi information. - _"ai\ ADDITIONqL 'COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION couNTY DILHR In accord with ILHR 83.05, Wis. Adm. Code STATE SA )•I IT11RYP IT # -Attach complete plans (to the county copy only) for the system, on paper not less than I ❑ Check if revision to revious application 8% X 11 inches in size. STATE PLAN I.D. NUMBER -See reverse side for instructions for completing this application. 9u- OS _51 1. PP I oWN NET INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY LOCATION ,~l^C' Y'!a h'~ /'~a 4, S T l9N, R (Or) W L~ /~11-lC C'T BLOCK PROPERTY OWNER'S MAILING ADDRESS LOT # CITY, STATE I / ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER z~ 5 NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ viLTMLAGE Ave, Tni 15Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - P R EL AX NUMBE ) GD Ill. BUILDING USE: (If building type is public, check all that apply) ~o Z. 1 ❑ Apt/Condo 10 El Outdoor Recreational Facility 2 ❑ Assembly Hall 6 El Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash 4 19 Church/School 8 El Mobile Home Park 13 El Other: Specify 5 El Hotel/Motel 9 ❑ Office/Factory IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1 ❑ New 2. W\j Replacement 3. ❑ Replacement of 4' El ExReconnection of isting System 5.E1 Existing System Repair of an System System Tank Only Date Issued B) ❑ A Sanitary Permit was previously issued. Permit # - V. TYPE OF SYSTEM: (Check only one) Other Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 El Seepage Bed El Holding Tank 21 N Mound 30E] Specify Type 41 12 ❑ Seepage Trench 22 Irf-Ground 42 ❑ Pit Privy 43 ❑ Vault Privy 13 ❑ Seepage Pit Pressure 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 GRAD REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet CAPACITY . Con- Steel Fiber- Plastic Exper. Manufacturer's Name Prefab oncrete glass App' VII. TANK in alIons Total # of INFORMATION New istin Gallons Tanks structed Tanks Tanks Se tic Tank or Holdin Tank Do to - DU0 /1, Lift Pump Tank/Si honChamber 241Y) 21H00 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached pla B er: Plumbe usine=e;7b Plumber's Signature: (No Stamps) MPIMPRSW No.: r's Name (Print): 7 n;~~ kale ~•cr~` Plumber's Address (Street, City, State, Zip Code): Z © IX. COUNTY DEPARTMENT USE ONLY Issuing Age l raps) ❑ Disapproved Sanitary Perm lt Fee (lncludes Groundwater a e issue f 1 ~b Surcharge Fee) l/Jl - KApproved ❑ Owner Given initial ~ Adverse De- mint-X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R.11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber 4 INSTRUCTIONS 'TS 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 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. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ill. 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 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) SANITARY PERMIT APPLICATION DILHR COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than c' ,).~~(n 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN RD. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. 9 2 - e9 3 PROPERTY OWNER FROPERTYLO/CA TION ~ /a S T ? N, R (or) W ,~J- / . PROPERTY OWNER'S MAILING ADDRESS BLOCK # r: ~ E PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER (7 X CITY, STATE ZD NEAREST ROAD II. TYPE OF B ILDING: (Check one) El State Owned ❑ VILLLLAGE . 01 TOWN OF: !~,'7 Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - PARC L Ax NUMBER(b) Z III. BUILDING USE: (If building type is public, check all that apply) -.h 5 f ?U 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nu.rsing Home 10 ❑ Outdoor Recreational Facility 30 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. ❑ New 2.,R] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E1 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 El Seepage Bed 21 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 42 ❑ Pit Privy 12 ❑ Seepage Trench 22 In-Ground 43 ❑ Vault Privy 13 ❑ Seepage Pit Pressure 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch).ELEVATION /770 -7 ~ 1-5 * - Feet Feet VII. TANK CAPACITY Prefab; Site Fiber- Exper. in alIons Total # of Manufacturer's Name Concrete Con- Steel glass Plastic App INFORMATION New istin Gallons Tanks structed Tanks Tanks Septic Tank or Holdin Tank SJP El F1 M Lift Pump Tank/Si hon Chamber I Cs > ` El 1 1-1 Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: 1 nip o r .=z 'v / ~..~Z ` --a ZZ_ Plum is Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY Issuing Agent Signature (No Stamps) Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued ❑ Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determinati n X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R.11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber ~y INSTRUCTIONS `W 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 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. 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 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 Dlp HR. 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 8'% x 11 inches must be submitted to 'he 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±elis; 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 d;fferences; 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 (tees) 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) SANITARY PERMIT APPLICATION COUNTY DILHR In accord with 1LHR 83.05, Wis. Adm. Code , STATE SANITA" PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size, check if revision to prev'ous application -See reverse side for instructions for completing this application. STATE PLA NUMBER, 1. APPLICANT INFORMATION - PLEASE PRINT ALL INICORM f ION. PROPERTY OWNER PROPER LOCATION /X, ' /tea Z714, S Z,/ T? , N, R / (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK# / CITY, STATE / l ZIP CODE PHONE NUMBER r. SUBDIVISION NAME OR CSM NUMBER NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLAGE ; 0 =bl OF: /j Z2 Ale Z Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - PAR EL TAX NUM ERO 111. BUILDING USE: (If building type is public, check all that apply) 1 ff~ f 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandises 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. ❑ New 2., Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.E] 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 El Specify Type 41 El Holding Tank 12 ❑ SeepageTrench 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. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch): ELEVATION Feet Feet 7 76) k VII. TANK CAPACITY Prefab. Site Fiber- Exper. in allons Total # of Manufacturer's Name e Con- Steel glass Plastic App INFORMATION New lExisting Gallons Tanks structed Tanks Tanks Se tic Tank or Holdin Tank n El [I Ll M El ;71 , FE Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Business Phone Number: Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: r i . Pum er's Address (Street, City, State, Zip Code): 17, -7 IX. COUNTY/DEPARTMENT USE ONLY Issuing Agent Sign (No Stamps) ❑ Disapproved Sagitary Permit Fee (Includes Groundwater Eat ssue Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (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 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. Vl. 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. rX. 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) =LHA SANITARY PERMIT APPLICATION COUNTY ro / In accord with ILHR 83.05, Wis. Adm. Code n .::Nmmmmmmg y STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than El / Kill 10 8% x 11 inches in size. Cn is on to pr vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. S 9 - 0 3 PROPERTY OWNER PROPERTY LOCATION lyl'0"gnUf-t Lcc~l?¢raA, 5 W%,S0%,S a3 Tq??,N,R// E(or)W PROPERTY OWNER'S MAILING TRESS LOT # BLOCK # a.? 80 Aup, STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER W U d v` (mot/ I V y D a1 ~ ~ ~S y~'o~ II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑ State Owned VILLAGE lbw $U Tt, ~ U 2.. Public ❑ 1 or 2 Fam. Dwelling--# of bedrooms - PA EL X NUM R ) r~ III. BUILDING USE: (If building type is public, check all that apply) 3 Y& 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 80 Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1 New 2. 0 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 140 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 O REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed S Septic Tank or Hold! n Tank .0 XW, Z &A_ Li 1 11 F] Lift Pump Tank/Si hon Chamber Vlll. 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: (No Stamps) MP/MPRSW No.: Business Phone Number: a/e 1r, won Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY Disapproved Bury Permit Fee (Includes Groundwater a e Issued issuing ent Si lure (No mps ~charge Fee) Approved F-1 Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8, 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 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. 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 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 er 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',Ul 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) #029 P02f ' 09:gg ID 'SAFETY & BUILDINGS TEL N0:608/26?-0592 0.cT-12-'92 HON sxrBTy & BUILDINGS DIVIfAON State of Wisconsin nt of Iadu-strYs Lattor and Human Relations Departure l i cat/ on Office of Codes App Washington A PP VAL 201 East PRIVATE SEWA P.O. Box 7969 Madison, Wisconsin 53707 Owner: IMMANUEL LUTHERAN WOODVILLE ST 54028 BOLDT'S PLUMBING HEATING/ 2528 BOTH WI 620 MAIN ST BALDWIN 54002 October 9, 1992 Date Approved October 7, 1992 8409 Date Received: 01 RE: Plan Number* Location: Gallons Per Day% 1 770 LUTHERAN CHURCH CountY: CROIx Project Name: eviews or project Town of BALDWIN ro ect have been r l is basedlansC aaeter Acatio On in pl ns for this ans and specif de re This approva Thep The plumb g licable code Tequi rements• on compliance with compliance with app tes and the Wisconsin Adovalsisacontingent up must be corrected. 145, Wisconsin Statu approve d'. This al ionally All items that are noted shall be obtained stamped Condit the plans. Or county any stipulations shown on village, ptownshiponsible for this installation the city, lumber resa the All permits required by The licensed p , a roval stamp prior to co over set aof .plans with t shad lp not'/ f yt the apgropr i ate inspect°r when shall keep The installer construction site. inspections can be made- roved or if ermitiexpires. royal will expire two years from the date app This app it will expire the day the initial santary p code permit is obtained, plans for private sewage system of have not been reviewed fCh~ he coderequiremen s Private Sewage has reviewed these tars 50 - 64 of the The Section These plans ha plumbing or in p requirements ;on ILOR 57 for general set form AIn Sect dministrativs Code, Wisconsin components only% This approval is for the following REPLAC MOUND HOLDING TANK REPLACEMENT t#029 P03 OCT-12-'92 MON 09:49 ID:SAFETY & BUILDINGS TEL NO:608/267-0592 SAFETY Ik 13tlII.DIN08 DIVISION State of Wisconsin Department of Industry, Labor and Human Relations BOLDT'S PLUMBING & HEATING Page 2 NOTE: This approval is for temporary holding tank(s) only. The soil absorption system approved previously for this project shall be installed and in operation no later than Zmky 10 99 3 , A holding tank servicing contract shall be filed with the locarinstallation afdtheetecounty mporaryrholdingttank. issuance of the sanitary permit-or NOTE: A variance is longer required to s.ILHR83.23(1)(d). Wis. Adm. Code, in replacement situations. Even though a new church is being built on this parcel. it is actually replacing an existing church. The $225.00 variance review fee will be refunded in 3-4 weeks. Inquiries concerning this approval may be made by calling (608) 266-2889. Sinc ly, R E E. PAGE Section of Private Sewage Division of Safety and Buildings PPP013/0009n/ 2 cc: IMMANUEL LUTHERAN Private Sewage consultant -county _uw-SSWMP Plumbing Consultant Owner -Plumber Environmental Health ..1 1. k p ~j A r ~qe / Of Qr Oay. Or :.itiltigfip E:ovor~np l0riout,ion pipe ~5pnd Tglpsoil 0'T s t F' $~4R4 Q.f 2 F6re4 i oin Plowed Aqj le ~fQMr:P~rpQ` LQy¢r Cf) ~a a r e i~ppti n, Of A M,.qq S.y! ,!o A @~d For the AtiQiRtipn f T G.. GGA~a~~ 01121 , Ft t; H r Signed; y}T ' t•icepse: 127P / Ft Date: 9-Z Alternate PO5,ition Ft of Ft: Ym ;Force Main 39 77 ' Obsecxion' Pipa 15 ~r TTr_wr,_ - Force Mein W From. P. mp Oistri.ut~Qll fed Of Pipe A 4ff~' 9 Qpse►vatMn Ripe Pf rmaaent M rke CE CT 0 T I"' UREAU OF BUILDING Phan View"E f Mound 0 1 eq A Bed For TMe Absorpf;Io Ares WATER SYSTEMS 1 4 ~ ax ~ f R et 1•e98 Of t 1. 1 , D/w je' Perforated pipe Detail i Er1 Vlew } }■J.1-~ t )Por'f orats.d ~Q wait; ~ PVC Pibt lj~ 3'' 'a ~o'~ NPi~ pled Pry doFtart+,` t r t ' r 1 t t 7 r r 1r },1 t \ i Irl P C For M ,plc t t -~'ty~~t~ l , r ti ,:,,r isj , r t 1~ i. ) • , J rr.:~ t b ~ ••r 'A;a' _ 1 PYQ s Fit*''.' v ;,Wnifold, pine 11{. i t Aj1 par Po{ltion Qf LOislnpu.Jion mil, r Fort#1I r ,rFx~'r Eri pp Diat.iibulion. Ria e avout -p . t -75 if i. ~~{p1e lfi t,~r Yrlch /IC2 ~ i ~ne~ .nom-•-~ , 'Inch (es) ~,~~~~~e IP~umr: Z9 MarfQd n Z inches 4 1; A-A -3 ItlEhes Ce I of hq pi pe 4 I~ Inve. t Elevati r ti 'd b f ,t ` , 06 PAGE OF.L_ PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP li"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKIAIG 25' FROM DOOR, JUNCTION BOX'- MAWHOLE COVER WINDOW OR FRESH 12"MIU. AIR INTAKE GRADE ~ I Y• MIN. I le•MIU. CONDUIT 18"MIN. ~ 11~ IIULET PROVIDE AIRTIGHT SEAL I III `1 APPROVED JOINT A it + I III APPROVED JOIIJI W/C.Z. PIPE } I I I( W/C.I. PIPE CXTCNOIN6 3' g I I) EXTfW01uG 3' ONTO SOLID SOIL C~ ALARM B I I I ONTO SOLID GOII oN CLEV. FT. PUMP-~ D \Od► 5e OFF G COMCRETE BLOCK RISER EXIT PERMITTE GWLy IF TAWK MANUFACTURER HAS SUCH APPROVAL 3•APPJ2o BEpOIN( SEPTIC E SPECIFICATIONS DOSE Ce TANKS MANUFACTURER: Lc~~1SeJr'S NUMBER OF DOSES: PER DAy TANK SIZE: - 2 50 0 _ GALLOIJS DOSE VOLUME 7 ALARM MANUFACTURER: INCLUDING BACKFLOW: GALLONS MODEL WUMBER:- L0 CAPACITIES: A_ INCHCS OR GALLONS SWITCH TYPE: _ i " 2ey-c ar ~37 INCHES OR 7'7~(, ~1LLOAJ 5 PUMP MANUFACTURER: - rD U14 MODEL NUMBER: 2~o 3 M ///•`1 C=4 INCHES OR 5422-'6 GA L L O IUS D=INCHES OR Ga p 5 SWITCH TYPE: P.,Y' /YY MOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE KATE~GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE 5ETWELU PUMP OFF AIJD.DISTRIBUTION PIPE.. _-Z-0 FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . , _ 2.5 t,I FCET + /O FEET OF FORCE MAIN X FFYofT.FRICTIO►.J FACTOR.. FEET TOTAL OtIUAMIC HLAD = /Z' FEET INTERNAL DIMEIJSION~ OF TAIJK: LENGTH ;WIDTH ,LIQUID DEPTH SIGtJED el~C--LICEIJSE 1JUM0E 7 R. C C DATE: Y Lu-70'Xeran Performance Sue Effluent -curves Pumps Z/ of METERS FEET 90 25- MOD s F 80 SIZE /4„ Solid 70 x 20 VWI0H J F 60 0 WE07H t 15 50 WEOSH 40 10 30 yyE 20 5 10 0 0 0 10 20 30 40 50 60 70 80 90 100 110 120 GPM 0 10 20 30 m'/h CAPACITY [QGOULDS PUMPS. INC. METERS FEET S1349CA FADS WW YM 008 120 MODEL 3885 35 110 WE15HH SIZE 3/4" Solids 30 100 90 25 80 O 70 X 20 J Fa- 60 0 F 1MEOSHH 15 50 40 10 30 2Q 5 10 0 p 0 10 20 30 40 50 60 70 80 90 100 110 120 GPM 0 10 30 rtte/h 01985 Goulds Pumps, Inc. CAPACITY Effective July, 1985 C3885 n r c T flb 0 ~ m 0 ~ o 0 n 0 0 O fo oo d 0 'd ul Cb Ul Cb 0 0 N ~ CIO 'S o i w w Lyt c~ b H O O 00 o 3 r_ ~ I I I I ' I I I I j 1 1 I I - I I 1 ~ I 1 LAI It I 1 ~ - I ~ ~ o g o a i s 7 ~ q A C 1 m ~ I ? 1 ~ M w 1 I - to 06 FIB o I 1 , i I ~ I I ~ I ; I I 1 I ~ ! I PETITION FOR VARIANCE APPLICATION Wisconsin Department of Industry, Labor and Human Relations OFFICE N Safety and Buildings Division OFFICE USE N Amount Paid 201 East Washington Avenue, P.O. Box 7969 Petition No. Receipt No. Madison, Wisconsin 53707 E-Number 608/266-3151 Name o Owner Petitioner Building or Pro ect Agent, Arc i ect or En sneering Firm m.-»arJ e / L so/Q o s PI Company Tenant Name, if y Street & Number Street & Number Location, Street & N ber City ~ State Zip Code O S , ~c7 C~fcJi>7 L.c~~ S 00~ City State Zip Code City / County Telephone Number Telephone Number Plan Number, if known Nam of Ct Per on 71~-- -Z500 _,-,,77c u sod 1. The rule being _petitioned reads L3 follows- (c specific rule number and language) Ll" ~ //0//,) e flr a A . /hire d J60J7~ A C1 604 leas 2`,~ o 1-,;17 50 U r' ~a r,a -,-0)/ a ye-r- Aj;? l e?.-ouj,?z fJJ 0-5 ,'c f 6 Ifiq or 01)1rrCf bse~va~,o o-~ of n a or W/L4 2. The rule being petitioned cannot be entirely satisfied because: 01 IA)J~ey- - S Ai' rh rouv) CST 3. The following alternative(s) and supporting information are proposed as a means of providing an equivalent degree of health, safety or welfare as addressed by the rule: r- . r-T-7 1 Y-~Ca ae~J_ 110 40,61e ,~c°G2 o -7'2'a ; ✓t a . Sd~./i 7 Note: Please attach any pictures, plans, sketches or required position statements. VERIFICATION BY OWNER - PETITION IS VALID ONLY IF NOTARIZED AND ACCOMPANIED BY REVIEW FEE See Section Ind 69.15 for complete fee information Note: Petitioner must be the owner of the building or project. Tenants, agents, designers, contractors, attorneys, etc. may not sign petition unless a Power of Attorney is submitted with the Petition for Variance Application. j 4a s'~rob ~~5 h Cl~+a t ~m 4 k7 , being duly sworn, I state as petitioner that I have read the foregoing (NAME OF PETITIONER, Please type/print) petition, that I believe it to be true and I have significant ownership rights in the subject building or project. Subscribed and sworn to before me this date: Signature of Petitioner My commission expires: otary Public SB-8(R.09/88) ~I~LH A SOIL AND SITE EVALUATION REPORT in accord with ILHR 83.05, Wis. Adm. Code • COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. PARCEL I.O. r1 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNEfT PROPERTY LOCATION Z l d / GOVT. LOT j( 1 /4 ite~I4,S ~ &Z q N.R ~ ( W PROPERTY OWNER'S MAILING ADDRESS LOT rr BL K SUED. NAME OR CSM I CI STATE ZIP CODE PHONE NUMBER ~ ❑CITY ❑VILIA E OWN NEAREST ROAD New Construction Use4)1 Residential /Number of bedrooms j) Replacement 1>9 Public or commercial describe A Code derived daily flow / 770gpd Recommended design loading rate Absorption area required/V~ 5 2 9P~ff2 S trench, gpd/ft2 _Lbed, ft trench, ft2 Maximum design loading rate bed, gPdfi~ trench, gpd/ft2 Recommended infiltration surface elevation(s) Additional design /site considerations run ft (as referred to site plan be mark) Parent material Flood plain elevation, if applicable /U It S = Suitable for system 00WENTJONAL MOUND INGRO OPRESSURE AST S DU SYSTEM U L ItOLDM TANK U= Unsuitable forsystem ❑ S 19 U Pq S [I U ~S U ❑ S .WU SOIL DESCRIPTION REPORT Boring # Horizo Depth Dominant Color Mottles Structure in. Munsell Qu. Sz, Cont Color Texture Consisbertce eotrldary Roots G P D/ft Gr. Sz. Sh. Bed Trend- IT, None .SA aIS - Ground y N J eZIA P9 lev. n p ~/p / I qt/~S~ ft. y- 0 ; /'l A, i Depth to C S limiting '31 5 g Non D m$ ''7 • g . factor i Remark's: Boring # i7K Z ~T' OI S ~r!s Ground Z3 17-& 5 YR 73 G m~(~/ ~'Z° t~ C elev. C / 6 i\ /~'1 ,r • y rrj 95,13 n. ~ 5 Y~ 6 m rn ~ reo~ f s; ~ s ~ m t/~r • Depth to Wiling - - facto(,, Remarks: CST Name:-Please Print 50 Y\ Phone: Address: 7/ j S' nature Dale: CST Number. Depth Dominant Color Mottles v Structure RT, f Boring # Horizon Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed, Trued 3 y , 6rYK Ground /S'Z7 S YF~/td' t s v • T • 5' 9 elev. n. . ~ Depth to limiting factof~ ij 7Z Remarks: :rn a t,~5 ✓'oG. Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. tt. Depth to limiting factor Remarks: Boring # MOM Ground elev. ft. Depth to 1 limiting factor r Remarks: 4 ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 Aug. 12, 1992 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 To whom it may concern: An onsite soil investigation of the Immanuel Evengelical Lutheren Church property, located in the NE1/4 of the NW1/4, Sec.26, T29N, R16W, Town of Baldwin, St. Croix County, WI., has been conducted with the assistance of Dale Hudson, CST# 3413. This onsite revealed suitable soil for onsite sewage disposal to a depth of 13" while meeting the requirments of the A + 4" rule. This site should be suitable for a replacement mound septic system having 23" of sand fill. Should you have any questions, please feel free to contact this office. erely, ames K. Thompson Assistant Zoning Administrator cc: file It SOIL AND SITE EVALUATION REPORT D I L H R in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than S 112 x 11 inches in size. Plan must include, but PARCELLD. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. REVIEWED BY DATE APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION EPIROPE Y COWNEa PRO PERTY LOCATION GOVT. LOT 114 1/4,S T AR E (or) W TYONNER`S MAILING ADDRESS LOT # BLOCK # SUED. NAME~R CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD F New Construction Use [ ] Residential I Number of bedrooms Replacement Public or commercial describe de derived daily now gpd Recommended design loading rate bed, gpd ? trench, gpd/ft2 trench, gpd/ft2 Absorption area required bed, 11112 trench, ft2 Maximum design loading rate bed. gp Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design I site considerations It Parent material Flood plain elevation, it applicable S - Suitable for system DONVEI(TIONAL MOUND "ROUNDPRESSURE AT~RADE sYSTet IN FILL HOLDING TANK U = Unsuitable fors stem ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Roots GPD/ft Boring # Horizo Munsell 0j. Sz. Cunt Color ConsistenceBar ry Bed Ttt= in. Gr. Sz. Sh. 74 Ground elev. i - /i Depth to 1 limiting factor i Boring # 5 I mm, 10 Ground I elev. py- n. Depth to - - - - limiting factor E47 - Remarks: - - - F:ddr e:-Please Pr,nt Phone: Date: CST Number: : ' Boring # Horizo Depth Dominant Colorttes y y in. Munseli Qu Cont Cola Texture Structure 7.-G ?a/14tT Consistence BardarY Roots Gr. Sz. Sh. Bed Tnnnd Ground elev. Depth to limiting factor Remarks: Boring Ground / J elev. Depth to limiting factor # Remarks: Boring . ~•Y •'ri:P Ground elev. fL Depth to limiting - factor Remarks: Boring # Ground _ elev. ft. Depth to limiting factor 1 Remarks: Wisconsin Department of Indus , •LaborandHumanRelations try SOIL AND SITE EVALUATION REPORT Page _ of Division of safety Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: 1 PROPERTY LOCATION GOVT. LOT n 1/4 Cv 1/4,S a T N.R /(0 ) W PROPERTY OWNER': ILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY IJVILLAG N NEAREST RO [ j New Construction Use [ ] Residential / Number of bedrooms (j Addition to existing building j eplacement [t,~ublic or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd$ trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors steM ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trerxh S; Ground 3-„'~' C' C✓ 5, C elev. ft. Depth to limiting factor Remarks: Boring # Ground 7- 3 ~J , , - 5, / 1 rvt 3 Z,c elev. ft. Depth to limiting factor Remarks: YcS ° - x 2lJ fC1~ - ~o P`~ Z~lGrl~r CST Name: Please Print J Phone: Address: Signature: Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page_ot--- PARCEL I.D. #t Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench I Ground elev. ft. Depth to limiting factor Remarks: Boring # gpa x-la Ground elev. - Depth to _ limiting factor Remarks:, 24 Boring # 5~ cU~r ~sJ Z~ Irk Ground I i4 elev. l ft. Depth to limiting factor Remarks: • Boring # k•{~.•~ v: iii 'yy •4i tF t4t'~'yy ,ki Ground elev. Depth to limiting factor Remarks: HOLDING TANK SERVICING CONTRACT Con~ract, Date This contract is made between the Holding Tank Owner(s) Na e(s and i - - - - - - - - - - - - - - /yJ u fh e i' r-, ; ; v Pumper's Name c! h - - - - - - - - - - - - - - - - - - - - - - ,s We acknowledge thg st~ lation ov ct a) hol ifng tank(s) on the following property: (Provide legal description:) _ v, t H j~ jt cS T C Q, 1. The owner agrees to file a copy of'this contract with the local governmental unit hereinafter called the "munici alit - signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and p Y which has with the County of cS -r c Y' i `Y 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 all-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 number issued for the holding tank; e. The dates on which the holding tank was serviced; I. 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. 4. This agreement will remain in effect 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) Name(s) (Print) Owner's Signature(s) Subscribed and sworn to before me on this date: hie e s J4 q z,1^ f ~j' e 5, ~ YyLGGV 'umper's Name (Print) Pumper's Signature 1 otaryPublic ~ My commission expires: umppeNfl r's Registration Number B D-7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. V ~~r Document No. This space reserved for recording data HOLDING TANK AGREEMENT Agreement Date This agreement is made between the - - - - - - - - - - - - - - - - - County or Local Governmen~ttal Unit I Holding Tank(s) Owner(s) S l~ I;%~rnrhg17it 4ulkergn I ~ k urC.~ (Called Municipality below) We acknowledge that application is being made for the installation of (a) holding tank(s) on the following property, (Provide legal land description:) rh 3. C d ~ C cs ~c) c / _.c~TjC c2 T oZ N Return To ~'.T - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 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 sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Slats. As an inducement to the County of C to issue a sanitar we agree to the following: y permit for the above described property, 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 ss. 146.13 and 146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank 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. 66.60, Stats. 2. Owner agrees to pay all 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 holding 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 collected 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), Slats., 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 complies 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. 6. 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. Owner(s) Name(s) (Print) I Owner(s) Signature(s) e_ t......_/_ u t b y e r 4h I Subscribed and sworn to before me on this date. ctvw ~S N,rr er 19r AS , Municipal Official Name (Print) I icipal Official Signature / Notary Public 11 iC n e Jf f Q I My commission expires: aM $ E.N N44A1 I Municipal Official Title (Print) y:3 SBD-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER__ FIRE NO. CITY/STATE ,,"Ic"--,~/1'o'//E~ ZIP _ Sy~1 PROPERTY LOCATION: AIZr ) 1/4 ~ 1/4, Section , T 2'~? R /_/11W Town of _ L__5al lol , St. Croix County, Subdivision /V/Zl/ , Lot No. xl~ . 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 SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning 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 (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED ryL%~~i DATE C1 C~ G St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address APPLICATION FOR $ANITARY 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 Location of property,i/ 1/9 ✓1/9, Section , T N-R W Township Mailing address .~5Z-> l Address of site ern<' Subdivision name Lot number Previous owner of property ~rr~z Total size of parcel Date parcel was created Are all corners and int lin-- - - v' A , T'1'r y. ,A'?L;:.~'.'~~a i•.ed'3F-, '1C+~;r'~s.:~-,;~«..,:«-.', Jt R;r•,f.., +i~..,t-w, ..ta ~ x 'e'As is t:.~ W 1 DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 498553 - VOL - 1 -wiffi a/k/a Eugene G. Zimmerman., a k a Barbara A. REGISTER'S OFF{CE Eugene Timmerman and Barbara Zimmerman, ,r ~i husband and wife , and_..Brian- Zimmerman i' ST CROO(CO., W1 Reed fa Regard uel Evan el i cal Lutheran MAY 5 1993 conveys and warrants to I,tunan g•----•• f ei- -------------Qbur-cki-------------•----•--•--------------....-.....-....--•--•-- .10:41 A. M ~v Y 'f _ RETURN TO the following described real estate in .....St.... Craix. minty. K State of Wisconsin: Tax Parcel No:----- t f Part of the Northwest Quarter of the Northwest Quarter (NW'k of NW's) and the Northeast Quarter of the Northwest Quarter (NE'k of NA) of Section Twenty-six (26), Township Twenty-nine (29) North, Range Sixteen (16) West, more particularly described as Lot 2 of Certified Survey Map dated December 2, 1992, and recorded January 8, 1993, in Volume 9 of Certified Survey Maps, Page 2585, as Document No. 493804, office of the Register of Deeds for St. Croix County, Wisconsin. Ties I This ls__not........ homestead property. (is not) 1 X DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-111N TNta e1ACa RCSZRVZD VOR RRCONDIND DATA WARRANTY DEED 450629_ ~ tvc 8~~►~~(~--_ REGISTERS OFFICE This Deed, made between .....$ugene R. Zwald_-and ST. CROIX CO. WI ..Susa....B.___2wa'..A-- husband an3 w fer Reed for Record _ _ . Grantor, AUg1619" M . ,,...a_(k,(a and.... tNl4aA. g YgA8e1 S.g ...~,utheran_.C.. r h 0,00 'I;he..G.~mAAa i. x.ire.l•sz~..E. man e - R1pMNOi~ Grantee, 'i I witlle$seth, That the said Grantor, for a valuable consideration...... !j Rf_._slia~___d4.lln.i•..BtnA..R.t.h.e.r,_..yn_ nable__. ponsid•-ration - 6 RN TO j conveys to Grantee the following described real estate in ...,S.i~.,...~ r j County, State of Wisconsin: i i 1 Tax Parcet No:........ ~I Part of the Southwest 1/4 of the Southwest 1/4 (SW 1/4 of SW 1/4)- and the Southeast 1/4 of the Southwest 1/4 (SE 1/4 of SW 1/4) of i Section 23, Township 25 North, Range 16 West, Town of Baldwin, and further being a part of Lot 1 of Cer-tified Survey Map Number 2097, Volume 7, page 2097, as document number 447827, and further being ! a part of Lot 1 of Certified Survey Map Number 1186, Volume 4, page 1186, as document number 378753, described as: Lot I of Certified Survey Map Number 2133, Volume 8, page 2133, j as document number 450168 s 3• - This homestead property. (is) (is not) ! Together with all and singular the hereditaments and appurtenances thereunto belonging; AndL _ Eugene_Zwald--and--Susan---E.---Zwald__ i good, indefeasible in fee simple and free and clear of encumbrances except warrants that the title is easements, restrictions and covenants of record, if any, including the Farmland Preservation Agreement with the Department of Agriculture, Trade and Consumer Protection, State of Wisconsin, and will warrant and defend the same. Dated this . ! day of --•-----August--••-•--------------- • 19-"89 . --------------(SEAL) (SEAL) - - i u~u n Rwald : - . ~ (SEAL) ..---------------------"--"--------------------•--•------•---•------.(SEAL) . Susan E. Zwald - AUTHBNTICATION ACHNOWLBDOMENT Signature (s) STATE OF WISCONSIN St. Croix ss ------------------------------County. authenticated this day oi___________________________ 19 Personally came before me this',__ ay of Au u s t 8.%, 19--X•.. a abovifAned Eu ene R' Zwald and., S 'n1 E. 'Z1►' ld _ TITLE: MEMBER STATE BAR OF WISCONSIN l I (If not, ~a authorized by $ 706.06, Wis. Stats.) ;~~e to me knogiy_-.tcLbe,tbe person _.wRo7,ecT ST. CROIX COUNTY WISCONSIN ti ZONING OFFICE ,Kronen" ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 November 11, 1997 Chris Lickness Lickness Plumbing and Heating 97 230th St. Baldwin, WI 54002 Dear Chris: On November 10, 1997, I inspected the installation of the septic tank serving the new parsonage at the Immanuel Lutheran Church in the Town of Baldwin. According to our records, the Zoning Department did not issue a sanitary permit for the new parsonage. A sanitary permit is required for the work completed by you on November 10, 1997. The permit fee is $180.00. If you do not comply by obtaining a sanitary permit, you may be issued a citation and this issue may be forwarded to Corporation Counsel for legal prosecution. This is a serious matter. Thank you for your anticipated cooperation. Sincerely, Rod Eslinger ka & Zoning Technician CC: Clerk, Town of Baldwin file