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HomeMy WebLinkAbout010-1009-50-000 C)O n-0i o0 m ~ O to 0 a c o L_ f0 ° •3 c~ a°i 0 i o oNU) C 0 ~ ~ U O a) m M Er U U n CL w E w E 2 -0 a) N ' N cc, N y y U T 0 0 0. ° E C Z 0. N G Z C N N 7 (0 C E 3 c0 E fl. E LL O N LL C O - 'D U 3: ca O C U (6 N _0 m CL 0 O N N E Q O O 0 M 3 M C N Z y V1 E E O O J p O Z ~ (L C') o a m ,t (9 c co0 0 Z d c c w V O N 2 N O N z~ rn O z I c E E a~ - w o m - p o' a) ca - a> N ~ L CO i • d L C O 'm O ICI' c c © Z Z Z Z H Z 0 way d N N N ~i m 3 y W f0 l6 N (n d L J Q C to U M E m a", N C co W d ~ N C O O co o C a a Y O C a a N m N Ln U) U) U) C, V) U) V) E io IL M 15 -,T . Z a a a O O O O CL a a a ~y N [2 o o us I W m cfl o E rn rn o to J U O m 0) Z W O O Z a LO co Cl) N O M L?5_ U O N 3iz~ ]-5n N O O E W L O 0) b Q Z fP5 Q U Z 0) U') 3 a+ O O O N C U) ta N C y O C O O 'O E O C E O 00 O ° Q 3 o o a~ c ° aUi c vor no. °o °o LO O S U 9 Y d C -O N N 0 c E o l co c CO (D a~ o 0 ~o " m r m O v a~ w? No ' o o o o ° O o L y~„~' O O W S M O N S Z Q N O N O CC d y a 3# a is a d w • O. ar V d y C N y E C c c 2 o 3 m o A U a 2 0 m v 0 in c~ 'i APPLICATION FOR SANITARY PE MIT for INSTALLATION OF A !~4;DITIC TANK (Sec. 144.03, V,Tis. Stats.) A. O`JNH OF PiCPERTY _ Nam A dress (Str et, City, Zip Code) B. LOC-JICN CF PZCPE-:TY 4THEIE SEPTIC TANK IS TC B7, INSTILL..M Check 1. -City Mail ressCounty } 2. Village o", one, 3. ,Town C. IN'TALL:G2 Give License number held: Wisconsin Restricted Licensed Sewer t Plumber ~ Services Name Addr ss ' D. SPI-TIFICATICNS OF SrPTIC TAIJK Size in gallons: (check one) 1. 1,000 Gal. 5. s 4,000 Gal. 2. 1,500 Gal. 6. _ 5,000 Gal. 3. 2,000 Gal. 7. I-" over 5,000 gal., give capacity. 4. 3,000 Gal. Materials: 1. Prefab concrete 2. Poured concrete 3._Steel F,. TYPE, C-F OCCUPANCY 1. ~ Sin7le Family residence 3. Commercial establishment 2. Multiple family residence 4. Industrial establishment F. APPRCiINL1TE NUTMSJi OF P_TaRSONS SEaVED DAILY -5-- r G. P:ETI.CC:LATIC13 TI-T MADE 1.1 Yes 2* No Date 1; 7 By By whom h~ c_ (To be completed by County C erk) Date a lication is filed nd ee paid p Permit issued (,date) Permit Plumber. County. / Clerk j. EMERALD T 30 N:-R. 16EW 47 3 SEE PAGE S 59 - o s• E o ,lobe fSa./Ge • h y a Orv//e Jarn es /4/ D d✓e6sfer d .P¢/eiyh 0w J 9~.~sori Goers ~ at n v o Joe /"Je¢fh S d1, ~ Oln ice/ C 4 ~.~h ion zfg s7z Z r , 2 1 Q D\`r ~"1 1 4 2 1 4 o p 1 \ 4 3 Z 3 388 • CO °ef cE FAQ • le/. 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D l ~4 /moo V /moo ~ ~ \ /6o Be~noia~/ /'7oore //o 46 H w 0 /GO •-D U it L 0 ~ 'C v ~ 7~ c% E .U /o.~ ~°o%/ Fred ~ y~ ~ 0 /1/oe/ /60 C~ m ° gO •~J e%'e~ tux `9~ • Zl v. ~ `D ~ ik/a. ~ ~'v` 9rrdei-.so ~ /bo ~v U ` U • Gcue/ ~e / to B° Ao i yoius • K~i'h. Johr~ Edw i1 • .q wL //en- Fr<e~/ i,E • a o D W • red rnncis ~,~m Om¢riri iTaT,es ~7 _/z is kfioe~ r Cana// ~o EO'w Q ~ ' C l"1~ 0 ~ otis q ~ /zo ue//e ~ `h Hower ~E Q /9. E/¢ o M¢ ~.n \~0 ~01~ Cl /P D \ `C 3 Edmo~o' Nk/kc~ /66 sz /moo zoo efix w ~E Hen~ich v~~ NFU r /s9s wear/ • C ~v 90 0 0 Bor~/C • it .D~ck Ginden V L ~ 0 ~ •w~ ~ ~ 7RZS (Te o/d Jhn .IJ ,Bum ec ~ ~ efa/ ~ Y G'c/der` 6 iye%n,j7avis 3O V~ ~ Francis- c a~ ~~b y~'~;~ ~ Forres7` z/y 0 ~To ee Pecr v D Nu /so r-111~P er7 1 a~ ~jeor~e i o q/be. C/Q~ e°ce v n~ w i f z y n Q C ~0 E° urf~c 1, b C me D ••o Cleo e ' • • • J Ua~l^ C ~ 0 • os,E, w C 0 Co/~ ~p~ so ti ~C7 0 • Ca o ces s. • zo • ~f uc %/e C Bo Bo oyc C ~o C ~'C ~Q Meyer 6P: • 7sGJ ° ye/so.7 n~ ~ 0 J ~ - ~ av li'eo e Ca,-/ \0' ~ D ~ V U ~ ~ h ~V~£ ce c 9¢.on boy ~ ~ ~I,D \ q 4' ~~q o Is N/o.-fa/ Cl~ ~ ~ ~J l~l v ~ ~ Q`i 0 Lcvsli~e ~z/cw " hom J - G'o//iS /z 0 E ~~9 /BO s n .41 W //Yrn.E~Pu1 C C, izs' zo ~ a V \ ~Posend4 C d o d tl" D s cH~ C ~C \~Q~ U a /zo C d - .Poi/ .B.v¢.7 c ~~h ~N ~F a m U OC4k~ 0~ Lla".e9. /Jo/ewe a n /mood p 0 a W EO ~0 l \ \'7~ tlI `c Sfeve 5 y cSr~oe eri- • ~ ~ ~ ~ crnc ~ ~ ~ W Caro/ V Maca e4 ,9oofar7 dos ~ r~pei7• • ao,s/ ~ o d cv y : 40 u~ ~ D / ° CRS'¢bo/ ~ /y-Gee z°° /moo /60 /97z oc° d • /z ° u~; ~c SEE PAGE •J DD cS/L' ax Co ~f✓., H%i. SWENBY & SON, REALTOR COUNTRY SQUIRE Lee's Drug REAL ESTATE & INSURANCE FURNITURE Store BIGELOW, ROXBURY & MYRON O. LEE 'See Vd Vedare *&a Faf,, MAGEE CARPETS & DRAPES GLENWOOD CITY, .Seel an Save- Paz" tk~ - 10"` WISCONSIN 212 SOUTH KNOWLES AVE. 386-2869 Congratulations NEW RICHMOND, WIS. 503 2nd Street Hudson, Wis. 54016 To The 4-H 715 - 246-2222 - 715 - 246-2223 Program (See the Cudd's) COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 ST. CROIX ZONING REPORT NO.! 33822/01 PAGE 1 ST. CROIX COUNTY REPORT DATE! 9/15/89 COURTHOUSE DATE RECEIVED! 9/13/89 HUDSON, WI 54016 ATTN! THOMAS C. NELSON OWNER! Alice Heinbuck LOCATION! Emerald, WI COLLECTOR! St. Croix Zoning SOURCE OF SAMPLE'+ Outside faucet COLIFORPI! 0 /100 mL INTERPRETATION! BacteriologicaLLy SAFE NITRATE-N! 10 ppm Under 10 ppm is safe for human consumption. COLIFORM + NITRATE : RECEIVED e S EP 1 8 1959 LAB TECHNICIAN: Pam Gane ST CRi01x cowffy WI Approved Lab No. 19 Z ~.\NDEVEI.pENr V Means "LESS THAN" Detectable Level Approved by! ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 4 ST. CROIX COUNTY ZONING OFFICE 1 sJ~ St. Croix County Courthouse; /g 911 4th Street ^v~V~Hudson, WI 54016 „_,-•=~=c- Telephone - (715)386-4680 The St. Croix County Zoning Office offers the service of septic and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion of this form is essential so that the property can be located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning office, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING----------------------------FEE: $ 25.00 L (For nitrates and coliform bacteria) WATER TESTING FEE: $175.00 (For VOC'S) SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00 (Determines if system is properly functioning at time of inspection) Property owner's name 1i Property owner's address yn er a ~cY L~~ 1S 3 0 Legal Description 54v 1/4 of the tV 1/4 of Section , T _N-R Town of nn Lot Number Subdivision Name FIRE ER Color of house Cp. d4 Realty sign by house? i)If so, list firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requestin sere' 1 ces : h Telephone Number G 41 - `7 REPORT TO BE SENT TO : d a e . ` e A , p " ?3 Closing date Signature L) -4 CYLON TWSP RAI Itjl . I! HEtDF77SON 8 (PAGE 3 FOREST la 7 1 ? ERICKSON r21 01 LORD ENE JAMES W. CROES, 6 (D 2 ETUX. RUSSELL E. 4 4 3 ()2 A WEBSTER, ETUX. PATRICK 3 2 104 3 I a 1 + I PADDEN 75 JOSEPH 8 KENNETH 8 4 3 1ENDERSON 8 ORRANE 2 t 3 a 5 W 4 5 6 ERICKSON OIILEN HELEN FLORENCE MARGARET MEATH A, $n, A WILLIAM 8 JAME 7 a 82 248 SALMON EHREND a ~n DARLINE WENDY KEVIN 8 r e 5 0 391 ay < ® DE MAR WILLETT ALTER SHIRLEY DALE Rw 7 a 10 e S 279 AHTER WITTMER DORIS ARY HOWARD Q~ WHI 1 JAMES 8 KAHIER 2 FOu1LS m wH1 OLETTe DENNIS 8 AVID EEBINK ANNET OORIS ADOLPH 8 RUTH D0.PIN JA MES 8 JOYCE A. 3 JANET PETERSON E x: 36 1 I$ I 1" 79 3 ENDS q KAKI gH MC NAMARA '2'22+2 m JAMES 120 I n MUTUAL OF SHERMAN 8 O NEW YORK (MARY GLORIA HN S. INCE 06 4 35 KIEKHOFER KAH ER ro RvLN a H A ER (Il T s I A.E 4 L ISE ARMERS K4 HL ' 2 i~D g2AD 8 AGENN WO NIAK w F~E1~ F H. A. BETTY bMIN. ER WIN D (3) 40 MC LiE 7 KAHLER rOt THE" HOME ADMIN. 15 774 76 76 I2 I AVID 8 IQ 107 ON N 8 I 247 160 ~BONNIE E INERT wM. a 4 0 a s LARRIE R. DENNIS 8 °DAV BONN DONALD F. H. A. NE JOHN 8 OIYIM, ETA L. GL SR. DORIS STEINE ELI ASON, E MAR ~DORO THY TE RRI JOHN a 9 SHARON ETUX. BAZILLE E1NEIM ROTHY DE MAR ERE NOS GREG A. ~~48 80 120 LLE PA HL JAMES 8 DAVID- AVID ( .31 JANET ANDERSON NOLARON 6..,~55 ~ 47 C NAMARA A 8 LAURILLI KENNETH D. KENNE NORMAN G. 3 DAVID W. ~ 8 A ®AVE. 8A7.1L+-Er 8 JULIE 0 8 8 MARY BONNIE SPEERS LILA LOGTERMAN FRANCIS S7EINERT N.a M. 8 SUSAN OGER MARIE. KLATT NV~ KLATT OGER 4 120 160 NNa I THOMAS 8O Y w ANRAN MALONEY~MAURICE 8 z 2 ILIA Rlrr 3I I I 0 t: 14 WALTER ~ I MAZZARELLA a 1RT1N IA o z 61U EVENS RATH VERNIE A ELLIUS O w u DUANE 8 JUDITH HILL EMERA O a INSEN 240+ 160 a m DAVID 'n g ENNETH 8 237 ANDERSON 27_= 2 4 1 ® A 1 114.42 ILQSCHWARTZ CL VIEW TIMOTHY 8 0 I CRES, I NC. VALERIE w (D 7 MILES J. 4 I R. 3 G 77.71 HE a y RUTH M. KENNEDY I a 1 ® 3 AY w F BURROW 3 NORMAN G. DANE ER AR _RALO Z = RICHARD 8 MARY B RTEL CLEAR VIEW VID INE WQ MARI AWRENCE 8 LOIS UDITH 8 BU IGH 8 O [U~ IZILLE will NN 8 MANIA BELLOWS (LOGTES AN ORES, INC. NJA ~ n RE 80 ILL RAME LAVONNE LARSON 220 10 y ANN EARL e 1 80 IEO. 74 El CH FEDERAL LAND BANK TRI A -24 ca x E G IFREORICK 5 DO In ALD c 10 DW 8 ILES J. 40 SCHNI7ZLER F z -E m 80NTE > RENE ENNEDY 7 0 AL 40 ® CLEAR ((~~.,~G'AEWACRES INC. JR. ~ w _j O b 4R40(? 3 HER a JOHN 1 ~..BG O 0 L ~280 5 Tn c ~z RU a IS SEIL- ND~ OMANN DENNIS 8 JAMES 8 RDTVTYtt EDWgR g ! 1 KC I'll'+t TH 9 FRED AVE. RAN is aO 100 MARI ANELL IKLA~ IRE m3 ~ULA SCHWA N. a OMANN MIKLA ALSH W RICNA O 8' ZN~IF' ELLKATH. IA JW LKER - ~CQJiJ(] ~a ~~1 2 r PATRI 40 A 7 6 J 1 W a= FRE xxx~~~GARY 8 r (I 24 9 fir, NfTq NADEAU II JC NANCY J DITH ® LINDEN a w I r%JOANNE E. SPOO 177 ZI GLER HELEN DAVIS 79.25 2 HENRY % ORREST NIwv a V A FRANCIS 8 JOYC E 6 z Al' k' OIS LARSON F Z GE 8 L 120 ~Q PERRY MIRTGEN .7 x TAS 08 AN DORIS EYERSJOYCE mjiM. AR °o .~j 3 COLLIS 3 MILLER p1 3 0- v A 4¢ 03 NI ADEATAU RENE ARD q ALL N 6 Q Q 8 h-Yi ORRE W NINA a 5 I 177.. 1 V 21 Si C j RUNE :NDA- E WA JU y 4 JAMES 14 HL ~z Fz GE RGE J. INK Z THOMAS 8 8 CAROLE 4 ER A a>_j fi DORIS = w JUDY WINK - I MEYER DONALp R._~ c-D ENE 8 JO ANNE h- uJ D F w O wF j C L IS SMITH a'L OF- GARY 8 KENNETH, 8 HOMPSON w 41 ofw =tea ANITA ® 100 oN z g FLORA 8 TZ ' NA DEAU IWILLIAM 8 MARION 8 204 OLLIg 200 /~O as ' II ti RUTH SAN IR i `.1> Ty 18 g DE JONG NAT'L z > z ROS EN D A L SANK oF~ w co 4 l'- LETTEM WSW > J ~ a ww 3 I EDWARD 8 DONALD R. BRIAN 8 FALLS VEEN- >w x IQ wir DONNA ICKMAN, MARLENE O N z m HEN 8 Jg I N WOLLACK DAHL 1 p M CAROL SABLL w o HOPKINS ETUX. HURTGEN BALDWIN 192.98 3 2 RAF 3 I ~ I ETAL 3 1 2, % 120 (PAGE I) TWSP. R PRAIRIE STANTON CYLON FOREST 20 Ig I 3 SMALL TRACT OWNERS 7 SEC TRACT OWNER ACRES SEC TRACT OWNER °f n^e on„r r , 2 4 Jerome Johmon ACRES 3 A Kenneth erd Helen Salmon 3'20 19 2 Col. Brown s 4 2 Orville Widmer 57.00 19 3ale HW,on ets k RICHMOND ERIN PRAIRIE 5 4 WIO Zweber .6 2.60 0 19 6 5 D 5 Don willio. iel pD-III GLENWOOD 6 2 Joseph It"ille 19 13.70 14 6 8 6 A Wayside Rest 5.00 19 7 D D. . Hop Peters p 3.70 8 1 Mervin Dike.- 10.00 21 I Steve Ducklw 9 2 John end AMrk 8aziile 10.00 21 3 Robert C Ce,.asFs.el 10,01 9 3 Mm. Lloyd Schmidt 4.50 22 3 Eepene oizenga 10 1 Harlan Smith 4.50 23 2 2 Thomos Moo al `WARREN I HAMMO4D 3.00 23 / R 6.00 RALDWIN 10 3 Dwid Gedvrm BDeer Sch- SPRINCFIEI_D 10 4 Robert Tdebold J., 2'00 25 1 ob Hon 25 g ( IH 10 7 2.00 26 3 Lecille i.I. g 3 14.25 Robert iriebold Sr. .00 10 8 Steve Kahle, 2,00 26 5 Larry Nielson 2.25 I 12 1 fb-.1 Gordon 3.50 27 A Flan Perry 10.00 1 5.00 26 2 Cindy Swonb- . Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Safety and Relations INSPECTION REPORT ST. CROIX Safety and Buildings s Division 9Permit No.: GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 9102 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: ACHTERHOF, TOM EMERALD CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: . crJ /G , aG' a,s fJ 010-1010-10-000 TANK INFORMATION ELEVATION DATA )o115-h7- TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic , enchmark 6 GG cam' /r, r::` G. C SUC ►K Dosing Aerati Bldg. Sewer Hold* ~g St/ Inlet TANK SETBACK INFORMATION St/ Outlet TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet Air Intake vZ Septic NA Dt Bottom 3 7j' Dosing NA Header / Man. Aeration------- NA Dist. Pipe G3' Holding Bot. System PUMP / C~MLI INFORMATION Final Grade Manufacturer c;s Demand S,oy' Model Number ~j L OZ 0 M GPM TDH Lift Friction System + TDH Ft Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside 6ia___j Liquid Depth DIMENSIONS DIME SYSTEM TO P/L BLDG WELL LAKE/STREAM LEA Manufacturer: SETBACK CHAMBER INFORMATION T pe0 el Number: System: /7A OR UNIT DISTRIBUTION SYSTEM Header / v Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia 1~ Length Dia. Spacing lolo- SOIL COVER x Pressure Systems Only xx Mound Or At-Grade ems 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.Y LOCATION: EMERALD 4.30.16.60,W SW 1759 HIGHWAY O C.11 ~ X 1,~,1 ~ ~V ~ ~G~r%~~f(~'~✓`~~ (J "L.:".~ r ~~+n' ~~.M Gt'-a7'Y ~~WC~/L~ CSQ~ Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: V~j~~7tf Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. P.O. Box 7969 • Attach complete plans (to the county copy only) for the system, on paper not less County Madison, WI 53707-7969 than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application / te State SanitaPe rmThe information you provide may be used by other government agency programs [Privacy Law, s. 15.04 (1) (m)]. State e P iflan Ir E] C.Don to r plication I. APPLICATION INFORMATION - PLEASE PRINT ALL RMATION P. Numbr Property O er Name ~G ~rwr Property Location Propert Owner's Mailing Address Ltd I So 1/4, S T 30 ' N' R f V (Or W Lot Number Block Number W C~ Cite Z Code Phone Number Subdivision Name or CSM Number Ill. TYPE B ILDING: (check one) ❑ State Owned ❑ It Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ❑ village ~e rQ /d ~f1 D Town OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) . dt©- lDl b - 10 CR7,v 1&5 1 ❑ Apartment/ Condo 01(}- 1010- an CswsOJ40 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 4 ❑ Church /School 11 E] Restaurant/ Bar/ Dining 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. ❑ Ny w 2X System epla cement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ Repair of an S stem - Tank Only Existing System ❑ - Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 C] Mound 30 ❑ Specify Type 410 Holding Tank 12RSeepage Trench 22 ❑ In-Ground Pressure 13 ❑ Seepage Pit 42 ❑ Pit Privy 14 ❑ System-In-Fill 43 ❑ Vault Privy VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch). 90.5'7 Elevation ~ SQ 90n STS. VII. TANK Capacity r 91 Feet 9ir.,5 Feet INFORMATION In gallons Total # of Prefab. Site New Existin Gallons Tanks Manufacturer's Name Con- Fiber- Plastic Aper. Concrete Steel glass App. Tanks Tanks strutted Septic Tank or Holding Tank 5Q e ❑ ❑ ❑ 0 ❑ lift Pump Tank /Siphon Chamber 75017-501 ❑ 11 1:1 O VIII. RESPONSIBILITY STATEMENT L~J I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. ~Plumber's Name: (Print) Plumber's Signature:( oStamps) MP/MPRSW No.: Business Phone Number: a'I u Plumbe -?z 0 r's Address (Street,, Ci>;y, State, Zip Code): 7 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) , XApproved ❑ Owner Given Initial Igo Surcharge fee) Adverse Determination ~ . t. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: 0-11 R (R. 05/94) 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 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. e- r 4 /ol~ tv,~ , 5''~a / Z /~'!P/CST' 2 Z o ~~•5 - Z65 - 7/~ ! 853 0 7- x-97 85 a`! O 83 9 Gar41 • 3-1 z5' Ex; sfi ~G ~ ~ousC Bi p~! ZS' 750 ~'g, Cen+bo 12 Scrt /650 q~~ A a /8 So% CONCr/ / i S .~TA@ l G GoVe r cad J~ ° o•' " P44, ,Y r • r , A 4 1 orq . P.,p e U IL H., in accord with ILHR 83.05. Wis. Adm. Code ' . COUNTY Attach.comptate silo plan on paper not less than 81/2 x i t inches in size. Plan must.include, but* not limited to vertical and horizontal reference point dimensioned, north arrow, and location and distance tto nearest direction esst road. y of slope, scale or PMCEU.O. f ` APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED FY DATE F PERTYOW R PROP t3ERTYLOCATION W-LOTLJ %L IN SW 110'1 T 30 AR /6 E(«o ERTY OWNER'S MAILING ADDRESS LOT x BLOCK # SUBO. RAME OR CSM l ti O CITY, STATE ZIP CODE PHONE NUMBER `l ❑CRY ~]V(LIAG ~~r N NEAREST ROAD L I New Construction Used Residential / Number of bedrooms Replacement ( ) Public or commercial describe Code derived daly flow gpd . Recommended design being rate • l bed. gpd/1t2. 5 wench, gpd/it2 Absorption area required $ bed. ry2~ trench, 112 Mabmum design loading rate Recommended infiltration surface elevation s) 17 bed. gpole trench. gpd/ft2 Additional design / site consi ationse Ccmnae It (as referred to site plan benchmark) Parent material v SX 5 Flood plain elevation, it applicable ME- It -moulm HG S = Suitable for system ENnoNAIPRESSURE AT~AADE N U =Unsuitable For tom ❑ U SYSTEM N FILL HMDWG T S ❑U ❑S RB ❑S U SOIL DESCRIPTION REPORT Boring # Horizo Depth Dominant Color Mottles Structure in. Munsell Qu. Cont Color Texture Conssbenoe eMnday Roots GPD/ft 3 , Gr. Sz Sh. Bed Trend- Lo r, M We cw2,~ 2.3 Ground 3 22.5' le y. elev.. 5 r /nv>~'r G W r y ~y-25 fL -79 e le y 57 Depth to limiting wor Remat : Boring r c w ~.r. . 2 ~.3 1-3QCs r2 ►~~'r G rr' 2 -2 3 Ground elev. Y7-5 ~ 5 S~' . G w < ~ - 5' 3.lev. Y>~ ~Y 9 d e w •17 Depth to 3-73 limiting /m S b ~+•~-~r w or • Remarks: CST Name:-Please PiW _ _ J7~ , o-t 0Yv Phone: Address: Signature Dale: _ Q CST Number ZZd~$3 Depth Dominant Color Mottles Texture structure Y Roots GPO - Boling # Horizon in. Munsell ' Qu. Sz. Cont. Color Gr. Sz. Sh. Bed, :Try: o-//' /cry 3.3 s-,'~ 5~~1 /yI✓ r C r,J zn, ~ I ` '3 2. !I z /AYR P S kK ✓ r C r,,) 2m Ground /D y,~ 5/ ~•m 7~ r r.J • J elev. 951 /0yy, y / ~s rra l~ r r,.~ 5 Depth to ,e> bailing Wor Remarks: Boring # ~/3 None- co 2m •7- •3 >ry YR 5y m vi('r C w zm • Z :,3 Ground y 1 elev. 3y°$I /OYR 6 1:5 C w ' c7 ' . Depth to Gaiting actor Remarks: Boring # ~ o - q ~ 3 3 ~o n L _ ..Si ~ ~ ~ ,r: t,J z„~ • ~ .,3 Zo2 'Z:-3 AE /0 YR ~zj Ground elev. O , Gtr) ' y ' • 5~ 1- 7r 95,5.3 ttbepth W Smiling Wor I Remark: - Boring # Ground elev. Depth to faiiting r factor Remarks: Qw✓1Gr o.~of Juofy 'WC ka y^ l o-~ ~raw►ti 3 y ~me►~al~, Gc~i~. 5-vo/Z MP~CST zZDg~3 7is-z6s-W4o BencH Mar 2 3D" B$ Bend. l8MAr~'. #I B3 i L 79 0 J Bx 31" Garay fz~ ' Zl Ex Q P OWs& T BI 6e. SePi'!c. Em. -40 = IOO ~ U ~ •rernovGol, D.-ywO! BM.-*Z= /00,86 Exos+rn I 31 = 91.25' sysfe.rn B z. = 93.57' B 3 = 95.91" 34 = 97,77 Q5 = 9553• Sep, Al s; w% scJ'/y PUMP PAGI / GF CHAMBER CROSS SECTIOIJ AID SPECtF1CAT10u5 /9ch fe r~a VCLIT CAP y"C.I. VENT PIPE WEATHERPROOF APPROVED LOCKING > 25' FROM DOOR JUMCTIOLI BOX MANHOLE COVER - , 'WINDOW OR FRESH 12"MIU. AIR INTAKE j GRADE 41 { I y" MIU. J} Is'rrlu. CONDUIT 18"MILI. IIULET PROVIDE I AIRTIGHT SEAL T * A I Iii I I I ALARM *APPROVED I oN JOINTS WITH I I ELEV. FT APPROVED PIPE I 3' ONTO PUMP OFF o SOLID SOIL CONCRETE BLOCK v RISER EXIT PERMIWED ONLY IF TAUK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFI-CAtIOAJS DOSE ~j TANKS MAUUFACTURER: IJUMBER OF DOSES: ? PER DAy s : TANK SIZE:_ '75fO GALLONS DOSE VOLUME ALARM MANUFACTURER: S•V. ~,/P.G~'.•+p INCLUDIUIG bACKFLOW. GALLON. 8 MODEL 1.1UMBER: CAPACITIES: A= (L7~ZIUCgES OR 3 `Z GALLON: 5 SWITCH T`JPE: PUMP 8 = y INCHES OR GALLOIS• ' MANUFACTURER: L~c~r.1 i~ MODEL. NUMBER'. - Cc)E03 G C INCHES OR &MGALLG t D - IZ- INCHES OR 0' 74GALLO SWITCH TYPE: _g!!~'~rc rr p MOTE: PUMP AMD ALARM ARE TO OE MINIMUMM DISCHARGE RATE Za GPM INSTALLED ON SEPARATE CIRCUITS t rj VERTICAL DIFFEKEUCE BETWEEU PUMP OFF AND DISTRIBUTION1 PIPE..-_ FEET + MINIMUM NETWORK SUPPLY PRESSURE " 2.5 FEET i ♦ ?s FEET OF FORCE MAIN X FyoFEFRICTIOU FAcroR. 44/0 ' FEET TOTAL OtI JAMIC. HEAD o 9110 FEET i, IUTERUAL DIMEMSIONS OF TAUK: LENGTH 39'~ ~ ;WIDTH ~~jLIQUID DEPTH ~ ' SIC,NEO: ~ nl ~Of~Oy~✓ LICEAISE LJU -ZZ08 3 MBER: 5 DATE: 7-/__=_9Z i Y Performance Submersible Effluent Curves xe~feY 16/` Pumps z of Z METERS FEET 30 100 . # L SERIES: 3885 SIZE: 1/4' SOLIDS RPM: VARIES 80 5 GPM I i p - - - 5 FT -t- 1 " Q " 1 1 = 20 V 60 } - - - - - - i - - 1 1 p i 0 40 ! , S ' ~ 10 I # 1 i 20 I 7 f , 0 00 + -j- 2D 40 .60 80 100 120 140 160U.S. GPM 0 10 20 30 M3 /h FLOW RATE [413OULDS PUMPS. INC. WMER TECHNOLOGIES GROUP METERS FEET sENEcA FAUS NEW NOW 13148 20 SERIES: 3885 35 SIZE: 3/4* SOLIDS 110 S RPM:3450 5 GPM 30 100 5 Fr 9 p t U.1 25 80 2 V 70 i a 20 } 60 1 50 a 15 1 ! 1 H E O 40 10 30 5 20 1 0 00 10 20 M3O 40 50 60 70 80 90 100 110 120 U.S. GPM 0 10 20 30 m3/h CAPACITY 019s3 Goulds P u^vs. Inc. Effective July. 1993 SPECIFICATIONS ARE SUB ECT TO CHANGE WITHOUT NOTICE. PRINTED IN U.S.A. W S~ ~[^C. ~i° cs T S? 5 7-/ - 9 c7'ss8534so 8 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 recprding. Owner of property --70 In Location of propertyc,J%Z S1-0 1/4, Section 3e) N-R-~/Z ---W Towhship Z'ee'.-0 f~ Mailingaddress Address of site Subdivision name Nfj Other homes on property? Yes Lot no. ~ No - Previous Previous owner of property A z~iG ~ , i b UC Total size of property Ar ,'P5 Total size of parcel Xr res Date parcel was created /VoV l /98 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes Volume 9J`5 and Page Number Z154 L/ No 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 references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. _ Yf - L -7 own the proposed site for the sewage ,disposal tsyI (we stem) orr Ie(we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. S ture of Applicant Co-Applicant Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER, MAILING ADDRESS- /Y/,. y i~EYC~ l .SyO~~ PROPERTY ADDRESS S6 m C (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION A2 1"Z'_ 20, S~ J 1/4, Section , T 30 N-R W TOWN OF -~~,""3~ ST. CROIX COUNTY, WI SUBDIVISION IV LOT NUMBER CERTBUD SURVEY MAP . VOLUME , PAGE , LOT NUMBER 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. /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 11193 i n0,' 1'Y1 -NT NO WJ^1PRAN 7 7 DUO f%.: :ra C A! AIVGO FOR k' :...A..,%. !?-A STA'I'N: BAR t)}' N'ISCO tiatN Fi>Kit 2 -1a2 4 v sjrl_lr -456 I E 'S OFFICE St. CROIX CO., W1 Alice M. Heinbuch, a/k/a Alice E{einbuc-.h, R 'd for R ord a single person 1196,19 W /112:05 PM Thomas P. Achterhof and Judith M. Achterhof, husband and wife Ra<~~'aFa St Croix rC-;:. Tax I':una N.,: _ - West Half of Southwest Quarter (W~ of SWi), and Government Lot Five (5), of Section Four (4), Township Thirty (30) North, Range Sixteen (16) West, EXCEPT conveyances for highway purposes to Town of Emerald recorded in Vol. 215, page 224, and Vol. 468, page 416, and to St. Croix County recorded in Vol. 302, page 109. (i? ! 3~~c?i,XK t., t,.';,r, F,: Eas.-monts and restrictions of record. 301h ; Oc toter 89 t:AI.. Alice M. Heinhuch AUTFiFN TICA i ON ACtiti0,S":{•:LrC, tF.\"T >s. St. Croix I 3Cth - October 89 c Alice M. H?irtbuctit, a/k/a • Alice He u:boch T(TLP: ~r:.:li:`,.:i; T-17'r. r": I.:~~ r~` ;r. W to+'