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HomeMy WebLinkAbout016-1074-60-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS 6 2 S t~l I jLj J3 SUBDIVISION / CSM# LOT # SECTION .3 T_30 N-R~W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f r r ~ r / /Ov a Q4 ~J NDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet: ST outlet: PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and`Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit lVo.: GENERAL INFORMATION 299016 Permit Holder's Name: 7GLtEy ❑ Village Town o : State Plan ID No.: KOSKI, MICHAEL NWOOD CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 016-1074-60-000 -1 If Jl~ TANK INFORMATION EL VATION DATA A9700334 9 -,60 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. r Septic Benchmark i00 o Dosing j,.~.G ac3a q-L Aeration Bldg. Sewer Holding St/Ht Inlet 3 V, /rf' TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet 9y q7. U~+ Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe G oa, o Holding - Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number ji, - It PM TDH Lift Loss TDH 11. mead q 'Ft Forcemain Length G/U! Dia." I Dist. TOWeII SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHIN SETBACK anu acturer: SYSTE TO P/L BLDG WELL LAKE/STREAM INFORMATION Typeo CHA ER Model Number: System: , iYpt, °l0 ? vr'() A)IA OP/UNIT DISTRIBUTION SYSTEM Header / MaT49W Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length 6- Dia. Length 6 Dia. _L/_v Spacing l~ ~lq 1, L/ ~ >sd SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx9-6s Seeded/ Sodded xx Mulched Bed /Trench Center " Bed/ Trench Edges Topsoil (o ❑ No ly'es ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: GLENWOOD 34.30.15.517B,SE,SW 1202 HWY 128 v 19-R-4- act Plan revision required? ❑ Yes ❑ No Use other side for additional information. C) ca u,wj b 161 SBD-6710 (R 05/91) Date /Inspeiaor's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH ~ SANITARY PERMIT NUMBER: 5 a i ws i w Safety and Buildings Division V~~Lrin SANITARY PERMIT APPLICATION Bureau of Building Water Systems 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 o than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State nitapry Permit Number lz / ?0/4o 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 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location k $E 1/4 Sr„J 1/4, S T bo , N, R IS E-(ior) W Property Owner's Mailing Address Lot Number Block Number City, State rt t/ Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned it Nearest Road Cl Vy age ❑ Public or 2 Family Dwelling - No. of bedrooms 3 r* - Town OF G 4-,O Z >7H Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo o t b I c> 7 Lf _ ~o 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. ❑ Repair of an ------System --------Sy-stem Tank Only______________ Existing System B) 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 ['found 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 (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (MinAnch) Elevation L-1,50 r7^ 3 ri-T t o i. 5 Feet It, 3.o Feet VII. TANK Capacity Total # of Prefab. Site Steel glass Plastic EAppxper. INFORMATION in g Manufacturer's Name Pre con- Fiber- New Existin Gallons Tanks Concrete strutted Tanks Tanks Septic Tank or Holding Tank I oc-,o OOc> .1 WI .t fucsr ~L-`S7 ❑ ❑ ❑ E] 11 Lift Pump Tank /Siphon Chamber tISO Sv L7/ ❑ ❑ ❑ ❑ ❑ VIII. 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: (N Stamps) MP/MPRSW No.: Business Phone Number; 14~t Lc. %cvv 7__ Cl3 ^`4 Z Plumber's Address (Street, City, State, Zip Code). (o k b 0D Illy ' 25' C IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved; Sanitary Permit Fee (includes Groundwater ate Issued Issuing A ent Si re (Nos ) Approved E] Owner Given Initial Surcharge Fee) X_.-~o ~p ~7 Adverse Determination ~Ko O X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Ruildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valic'. 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 4he Wisconsin Administratis~e 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 kcensed 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'egal 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 Orvly. 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) fora 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. S97-4068f; RECEIVE Private Sewage System Plan Index/Checklist .1 U I- - 8 1997 All plan sets should be legible and permanent copies, organized into sets, bound with staples and coAplyy & BLDGS. by an index sheet such as this sample. No other pages need be signed as long as the index sheet for each DIV. set is signed. Your cooperation expedites your plan review and shortens plan entry time. Plan ID # Owner's Name S97-406-86 01kC,1%,V INt,cK W-0 " vt i Legal Description Address Sg5 .5LJ 34 o - 1 S l Zc Z STk 1 8a eityA414agclfown County ST Contents Comments/Special Instructions Page # Included Two copies needed for all plans 1 Plot Plan 2 Plan View/Lateral 0 Return by Mail 3 Cross Section 4 Tank & Pump/ 0 Fax Letter to (County) (Submitter) Siphon Information Circle One and Provide Fax ( ) 5 System Sizing (Public) 6 Call for Pick-Up: ( ) 7 Q Other I, the undersigned, hereby certify that the Seal (if applicable) plans and specifications submitted herewith were prepared under my direction and control. Plumber/Designer License/Registration # Address city fate 3 /0 Signature For Office Use Only Attachments: Application O .~r-sa Soil & site evaluation Pri l Rally Fee Cv Lw D Needed for Holding Tank Submittal: One copy of notarized holding tank RCE agreement. (Originals to County) A~ f010F WtAVA 1105 pEPAiCt tW~ Needed for At-Grade Submittal: N Original signed and notarized PENCE Application for "Use of an At- COQ uN Grade" $E County on-site One additional set of plans SBD-10268 (N.01/96) 1'TA ,j y~f sf2z~ 4j 14 RECEIVED JUL 8 1997 a` Lu NI SAFETY & BL =I rI =I DGS DIV. N cl J hl y~ ~ ~I 2 3 -T7 t ~ } W ,o J O \ Y 3 ~ C:f X k x X ,I I C ,I I ~ ~I I A- a i I MOUND SYSTEM CROSS SECTION i _ _-Synthetic -Covering Distribution Pipe Med. /Coarse Sand N G 6" Topsoil - F , - S(S E ~E.v . = iC l . r Plow Layer E D IN. 2 t Slope ►y - 248# Foot Aggregate Contour A = L.~ Ft. Owner's Name: B - H_-.- Ft. D a _ Ft. Plumber. E = I. oG Ft. - Signature:'( Ce t. G' F a _9_3 .Ft. License Number: ~j 3y G = Ft. _ Date: H - S' Ft. I a Iz• kg Ft. , J ° 10.83 Ft. K a 13.11 Ft. L a 121.22 Ft. W ' 2,)•31 Ft. MOUND SYSTEM PLAN VIEW Distribution Pipe J Observation Pipes V K c A Force Main W B, I Permanent Permanent Markers .Markers L ~U , f0 0 o v o rt r - (D m .A (D - fA - - - - - C- K - fA _ - - - - n ~ (D n ~ ) x(D N m:3 r , r( R • F.,. E y (AD H. a ( -I (n 446 •A O to CD c (n F W m < r. o u'~'_ -i rib x = m Z ~ = D-O D17 >e a o rn rn -v rn D n 'd Z rn Dp M X o a o Lt x Pa G K rt N ((D n -a a o d Pi (D 0 N ( D Fr O 9 (D n n (D I (t (D F" (D K rt N {L rt B N N N h? (D K rh n (D (D C~ 1^h C" ((D t'' K al K su rt (D m N r K C=1 K w N G r• n • r• (D !-1 N a r• v rt ~ . r• n (D ~0 (D v r' w m M o a w M ~ n ~ n y (D (D R a 03 WAGE OF _ PUt,%P CHAt,%?,:R CROSS SEC-10.'J AMD SPECIF'ICA•rIC)W__ 'VEMIT CAP 4'C.I. \ E'1:T PIPE I WEATHERPROOF 4PFR0%ED LOC.'I".1%. J COVE F.-- - MAIJHOLE - -UNCT101~7 BOX JoDoor,. WINDOW OR FRESH 12"MIU. I AIR INTAKE • GRADE I ' I `I" MIN, 41 L _ Jt3" MIN. COIJOUIT \ IULET PROVIDE I AIRTIGHT SEAL I I i I V ' ~ I I APPROVED JOIA17 A ( III APPROVED JOINTS W/C.T. PIPE I lI I W/C.I. PIPE EXTENDING 3' I II ALARM EXTENDING 3' ' O►JTO SOLID SOIL B i I I ONTO SOLID SOIL I I I ow c I I ELEV.. FT, PUMP ~ OFF 0 CONCRETE BLOCK SEPTtc E SPECIFICAtIOMS DOSE- ' TAUKS MANUFACTURER: a JOCK''` t'2~cosT IJUMBER OF DOSES: LI PER DAy TAWK SIZE: 7sn GALLOWS DOSE VOLUME ALARM MANUFACTUR£R: 5 S 5I -rTC~ p IMCLUDING EACKFLOW: ~q• S GALLONS MODEL WUMBEK: 101 N~a CAPACITIES: A= I5•9 IUrAES OF( o7,5 GALLONS SWITCH T`.IP£' M mac n B = 2- INCHES OR GALLONS PUMP MANUFACTURER: r= 8-'i INCHES OR q• CALLOUS MODEL NUMBER: ' SW 2S~ D- 12 INCHES OR 23`I GALLONS SWITCH TYPE: r NOTE: PUMP AMD ALARM ARE TO BE MILJIMUM DISCHARGE RATE INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF AAJO DISTRIBUTION PIPE.. FEET M/IkllMUM NETWORK SUPPLY PRESSURE FEET FEET OF FORCE MAIN X F/oo,T.FRICTIOL,J FACTOR.- `Z FEET = TOTAL DIJIJAMIC. HEAD = _I IZ FEET n I Q. S GA~Ir~G4 ~ 4 f IIJ7ERtJAL OIMEI.JSIOIJf OF TAtJK: LE`.j&TH ;WIDTH ~;LIQUID DEPTH y3 -3 H 1 G J E D: LICEIJSE LlUMBER: DATE S : Z f / ,iy tip 1141,410 [C-1 ` `r • Performance Data 32 Pump Characteristics Punt /Motor Unit Submersible r- Manual Models SW25Ml SW33M1 W z4 U. Q 1/3 HP Automatic Models SW25A1 SW33A1 W 1 TN- x Horsepower 1 /4 1 /3 0 16 Full Load Amps 8.0 10.0 T 1/4 HP J ~ Motor Type Shaded Pole (4 pole) F R.P.M. 1550 o a Phase 0 1 i Voltage 115 Hertz 60 0 0 10 20 30 40 50 60 CAPACITY-U.S. G.P.M. Operation Intermittent Temperature 120" F Ambient Total Head (feet) 4 6 8 10 12 14 16 18 20 22 24 NEMA Design A 1/4 HP 44 41 36 33 29 26 23 18 12 6 0 Insulation Class A GPM 1/3 HP 47 45 43 40 37 34 30 26 22 16 10 Discharge Size 1-1/2" NPT Ira Solids Handling 1/2p Dimensional Data Unit Weight 30 lbs. I. All dimension in inches Power Cord 18/3, SJTW, 10' Std. 3-1/2 5-7/8---- 2. Component dimensions may (20' optional) 4-1/2 --j vary 3l/e inch T 3. Not for consimction purpose J 1-1 2 NPT unless certified 3-1/2 DISCHARGE t Dimensions and weights me Materials of Construction approximate 5 Dn/Dlf level adjustable 6 We reurve the fight to Handle Steel 3.1/2 make revisions to our lubricating Oil Dielectric Oil products and Iheo Motor Housing Cast Iron speolkations without notice Pump Cosin Cast Iron I - Shaft Steel Mechanical Seal Faces: Carbon/Ceramic` Shalt Seal Seal Body: Anodized Steel Spring: Stainless Steel Bellows: Buna-N PONP 10.1/8 9-1/2 Impeller Thermoplastic Upper Bearing Bronze Sleeve Bearin DISCHARGE HEIGHT Lower Bearin Single Row Boll Bearin 3 3.112 Strainer/Base Plastic PUMP OFF Fasteners Stainless Steel AURORA/HYDROMATIC Pumps, Inc. } , } 1840 Baney Road, Ashland, Ohio 44M (419) 289-3042 Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safely and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than B 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location rntr_tiaol 'k Cnr-4, 1, W+ r-KJSK Govt. Lot S'C 1/4Sw 1/4,S 3y T30 ,N,R IS' E.(or) W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 1Zo2 S 1-A k-Le City State Zip Code Phone Number Nearest Road (slt.~wuc~u~ CtiTY L~1~ 5 013 ( ) ❑ City ❑ Village ❑✓'Town - ST H 1 Z 6 ❑ New Construction Use: u Residential / Number of bedrooms _ Addition to existing building Repiacement ❑ Public or commercial - Describe: Code derived daily flow `f 50 gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft 2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) 10 t . S Co,~ s C1~,ac t }.t M o,,4. <A ft (as referred to site plan benchmark) Additional design/site considerations -2 SA a L+Er h ooe, r-o"e- Se,%t mb-j !.r wr, iZ" Parent material Flood plain elevation, if applicable rI.A. ft S = Suitable for system Conventional rMound In-Ground ,PPrreesssure AT-Grade / System in Fill Holding Tank U = unsuitable for system ❑ s u L! I S El u ❑ s L✓J u El S L"J u ❑ S 2'-u ❑ s ©'0 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench S,1 ZG -S LV M k- A 3il" S '.6 Z 7-IZ •ct s/z - 5. rh ZM r\P Ground 3 iZ-2t !o -ta. '~K C c 5 `t L 1 s6c t- G zri- - L elev. `I `t -S ft. y Z 1- Gs 7 u `t ~Z s/ •t `t' S r.1 t d , w - _ 2 Depth to 25- 2~6 a <L s/ /`1 L - 11 t 4- oc AI V F~- - Z limiting factor in. Remarks: Boring # C7- ta`tR - ,1 2 c. C 14 r 3-'11 .5 'I.• 4 2 - J3 to`ct y~ t 1 n ri 1"t AW 2. nv 3 3 13 -?-o I 'rn- ~t •r 2•';s6 1*-14r ~J S Ground ~t ! o ~c•t 5-' M S ~ SC t t r-, C V. r"! 4r 2- elev. S' Ir-3z YY. S ft. l Y r/ - `x `i'ce S t t 5 b rz M V Fa- - Z 3 Depth to limiting factor 13 in. Remarks: CST Name (Please Print) Signature Telephone No. ka c-t l c T r71S - -t3- 3 z zz Address Date CST Number C. 3'-(i o S1>4;,~ l~ o t~c%. a I( r1.y 02. PROPERTY OWNER M►chnc 1 l.Jtc~Kosit % SOIL DESCRIPTION REPORT Page of PARCEL I.D.# 016- 101-1 • t?a ' Boring # Horizon Depth Dominant Color Mottles Structure 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Texture Consistence Boundary F2,-, 3 1 - 3 1 oKi1. c Sb -►'1 r IEs" KU. s~ ~ t qi- n t~ 3 2- S elev.nd 3 1---20 SO Depth to limiting factor 1Z in. Remarks: Boring # ?-1 2 113 l c ~t _ ,1 Ground elev. (S. -1L ft . c 1 OL Depth to limiting factor tin. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. ft. Depth to limiting F-T factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) a I ~ a F N c• S N \ 3 ►J O - o oI CD j o ( kl ~I V)l ~a w £I 3 S 3 0 2I 3 I Z Z of sl y t ~ oI c I ~ ~ dI I ~I u, ~ dl F) pl d ,I ~nl ~I i X X R R \ k x I . x X ~ X. , ~ X• I I dI dl vu n ~ I JIM I Ea ~ I I I J V~ f I Q I a - 1 Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of DiAsion of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location t-%tCb+aC'1 A C.ttca \ (.J+ CT KoSK 1 Govt. Lot Sig 1/4Sw 1/4,S 34 T 30 N,R t -E-(or) W Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 12.oZ S~tA 12.36 City State Zip Code Phone Number El Nearest Road ( ~ City El Village Town ST t1 t Z f3 (slr n~„>uc>~ C%T*r W, I n to 13 ❑ New Construction Use: u Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow `i 50 gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft 2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) 101-S7 0_Qo-5 Xa,,r-rV&L m4,,A-k ft (as referred to site plan benchmark) Additional design/site considerations Z SAK k L, Er -X'b Ouu C-o.e_ Sz t s- Ar L2" Parent material Flood plain elevation, if applicable J3 .A. ft S = Suitable for system Conventional Mound In-Ground Pressure AT-GradeSystem in Fill Holding Tank U = Unsuitable for system ❑ S Ly'J U Z'S ❑ U ❑ S ZrU El S 25`6 ❑ S Q"U ❑ S 9-10 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ' , b 16-7 -S,( -Z c. S by r+l ' h !a 3 r'h •5- ? 11 - t2- 10 't t7' On V 1; 1'- AL4 2- -1 rN .3 Ground 3 iz-2t wu I C, 5 It t~ sbo ri 't- G z^- L elev. - 2. 'j~{•~ ft. 2i•ls 1u t+Z S/ - `t Sc,1 A b w r-, y Depth to limiting factor Z in. Remarks: Boring # 3 01 2 2 ~ 3 t o ~c t i A'k 1%k r m A..j a n, I s - 3 l.3-Zz to`en. r -t ,g. S,t z.,.5.M&r ' Ground `d 94 i c 'ttt 5--', M& 3- aC l f r ; rrr i"`1 ~r 2 ~ elev. _ ~Y•.S ft• -S 14-3z ( Y r/ -~t 'f'r, St I, "bra YtiVFtr- -L :3 Depth to limiting factor 13 in. Remarks: CST Name (Please Print) Signature Telephone No. / `JIS- `(3-37L3 Kam ` Address Date CST Number L5 3 Lt i c, S7)4re ~t.Q ti o 30,oce V ( ~ OZ PROPERTY OWNER SOIL DESCRIPTION REPORT Page ~ of PARCEL I.D.# OL 6 y 10'l `4 ' Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench I OK q1- 3.1-1 Z 13- 1 Z. 10 `1IIR ` 1 ✓it t + t c~ u ~'C 111' elev.nd ti-Zo c Y►t '~K C `t P. Sal f"isrc~ _ S qf_•_ ft. Depth to limiting ; factor 12 in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fl in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # ; Ground elev. ft. Depth to limiting F-F factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER (h ; c)a j 14 Ck. r_ j l Lea ~ MAILING ADDRESS % A c,,2 $trf-P HL,-x4 PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE C~ Is n UOC 3 d C, t Z 5 11 o)'3 P OPERTY LOCATION- <1r, 1/4, 0 1/4, Section ~ T ✓0 N-R Gl W TOWN OF y ~`QhLkDOO CL-, ST. CROIX COUNTY, WI SUBDIVISION N LOT NUMBER CERTIFIEDSURVEY MAP~ -IPr~ 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. 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: .-n I DATE: 1 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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. c Owner of property 1A Location of property C_;~l/4_ S &c! 1/4, Section O N-R S~ W Township Mailing address boa Sfa~'e, Boa J 700 Address of site _ SAme~ ~Gl~t Subdivision name Lot no. Other homes on property? Yes k-----No Previous owner of property ~ , fP S ),f W 15 Total size of property p a arc Z Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No is this property being developed for (spec house) ? Yes _k--No i X j Volume -and Page Number = as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: X 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, wou be ielp ul 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. 5.7" ice' 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 duly recorded in the office of the County Register of Deeds as Document No. (w; (k'V,,k2I/- ignatu of A 1icant Co icant Date of Signature Date of Signature r ~ R. J STATE BAR OF WISCONSIN FORM 2 - 1996 DOCUMENT NO WARRANTY DEED Charles R. Lewis and Gladys N. Lewis_L 7-- husband and wife as survivorship marital_ t proper conveys and warrants to Michael J. Wizykoski and MAY 16 17 C_h_eryl A. Wizykoski, husband and wife as survivorship marital property _ s W 9:30 A h1 the following described real estate in St. Croix -_County. State of Wisconsin: "E7'-1V_tT NATIONAL BANK OF GLENWOOD 204 East Oak Street South-half (S~) of Southeast Quarter P.O. Box 338 (S E y) of Southwest Quarter (M) of i Gkinw00d Gty, N 54013-0.138 Section 34, Township 30 North, Range - 15 West. Parcet i*ereiliicatron Number (PIN): FFE EXEMPT- This s deed is given in fulfillment of a land contract between the parties dated August 12, 1994, recorded August 15, 1994, in Vol. 1091, ii page 146, as Document #520191, Office of the Register of Deeds, St. Croix County, Wisconsin. This -j 5-__no t-_- homestead property. (19f, (is not) i Exception to Warranties: Subject to easements and rights-of-way of record, if any; municipal and county zoning ordinances. 19 _9L Dated this 14th day of -_-M_-_- - - (SEAL) (SEAL) • Charles R. Lewis (SEAL) rz ~a u~ _ (SEAL) • Gladys Lewis AUTHENTICATION ACKNOWLEDGMENT i STATE OF WISCOFt&" I' Signature(s) - i ss. St. C r O i X County. i persoratt, n before me this - 14th day of authenticated this _ day of .19 May .19 97 the above named Charles R Lewis and Gladys N. Lewi$ TITLE: MEMBER STATE BAR OF WISCONSIN - (If not, to me known tx who executed the authorized by § 706.06. Wis. Stabs.) fore lhstry .J dux ledge the same- THIS INSTRUMENT WAS DRAFTED 8Y? s i ' $ 19 ~ Im 0, VEB Srp 5 5 Fl- fgg~7 r i ~n Sr cF?O,X NTy 2 U ~IAI OI:PtCe I ~ i I S ' J III \ I y ~ T ~ \ x p l4 3 \ p I~ \ P O \ o, m 13 \ Cj A- 3 O I I T 7~ ~ o I II \ I ~ ~ I~ ~ n IS ~ y, m Iv N ~o - J IDO m r 0 8 G c s- ~ N c d ~ N s 7 t . 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N ru ' O L]. tt :j .t to rD C) !D rt a N• VAGE OF PUMP CHA.Ml;---R CROSS SEC-101J AMC, SPECIFICA'rlu"!.`_ 'VEDT CAP 4'C.I. \•E'UT PIPE _ WEATHERPROOF APPROVED LOCAiMi. _ to R O GOOK ,I000TIOU BOX - M . WINDOW OR FRESH 12"MtU. i AIR IMTAKE GRADE I 41 • COIJDUIT IB"MIN. PROVIDE I - INLET AIRTIGHT SEAL I r . ~ I APPROVED JOIKST A I APPROVED JOIWTS W/C.Z. PIPE W/C.I. PIPE EXTENDING 3' M EXTEXIDIMG 3'' ' 01ITO SOLID SOIL OIJTO SOLID SOIL 6 I I ON , c I i ELEV.. FT. --J PUMP OFF 0 CONCRETE BLOCK SEPTIC E SPECIFI'CATIOUS DOSE TANKS MANUFACTURER: ~IS cosT WABER OF DOSES: LI PER DAy TADK SIZE: GALLONS DOSE VOLUME ALARM MANUFACTURER: S T. 51 INCLUDING 6ACKFLOW: IZ'I GALLONS rrT1Z_O MODEL NUMBER: I o 1 N ..1 CAPACITIES: A= 2z•6 UICHES OR 3 53 GALLOWS SWITCH TilPI<' M c B= Z INCHES OR 21 GALLONS PUMP MANUFACTURER: c- 6 y INCHES OR 12'1 GALLONS MODEL NUMBER: ~SLJ 25 D- 12 INCHES OR Z14 GALLONS SWITCH TYPE: Me.~c MOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE y Irl `IrI.S' GPM INSTALLED ON 5EPARATE CIRCUITS VERTICAL DIFFERENCE 15ETWEELI PUMP OFF AMD DISTRIBUTIOM PIPE.. S FEET + MINIMUM NETWORK SUPPLY PKESSUKE/. Z"S FEET + FEET OF FORCE MAIN X F/oo rT.FKICTIOLI FACTOR. 2 FEET TOTAL D'JMAMIC. HEAD = Io•9 FEET Gal lncM INTERNAL DIMEWS'lONS OF TANK: LE~.IGTH 61 y ;WIDTH (,''"-;LIQUID DEPTH ti3 • i SIGUED: Zi 42:P LICEWSE DUMBER: ~3K DATE: y `.r --T~ Performance Data 32 Pump Characteristics Puns /Motor Unit Submersible Manual Models SW25M1 SW33M1 W za LL Automatic Models SW25A1 SW33A1 °a 1/3 HP S Horsepower 1 /4 1 /3 1s Full Load Amps 8.0 10.0 Z 1/4 HP > IN, Motor Type Shaded Pole (4 pole) a R.P.M. 1550 0 8 Phase 0 1 I 1A Voltage 115 Hertz 60 0 10 20 30 40 50 60 CAPACITY-U.S. G.P.M. Operation Intermittent Temperature 120" F Ambient Total Head (feet) 4 6 8 10 12 14 16 18 20 22 24 NEMA Design A 1/4 HP 44 41 36 33 29 26 23 18 12 6 0 Insulation Class A GPM 1/3 HP 47 45 43 40 37 34 30 26 22 16 10 Discharge Size 1-1 /2" NPT Solids Handling 1/2" Dimensional Data q1 17 Unit Weight 30 lbs. I All dimensions in inches Power Cord 18/3, SJTW, 10' std. 3-1/2 5-7/8 - • 2 (omponeor dimensions may (20' optional) 4-1n eory±l/einch 3. Nor for construction purpose 1.1 2 NPT unless certified 3-1/2 A~ ill DISCHARGE 4 Dimensions and weights are Materials of Construction approximate S On/Ofllevel adjustable Handle Steel 6 We reserve the right to 3-1/2 make reunions to our lubricating Oil DIeIBCIrI( 011 produus and their Motor Housing Cast Iron speoficalions without notice Pump Casing Cast Iron I Shaft Steel - - Mechanical Seal Faces: Carbon/Ceramics - Shaft Seal Seal Body: Anodized Steel: Spring: Stainless Steel r.r 11 1,8 Bellows: Bung-N PUMP 10-1/8 ON 9-112 Impeller Thermoplastic Upper Bearing Bronze Sleeve Bearing DISCHARGE HEIGHT Lower Bearing Single Row Ball Bearing - . 3 3 1!2 3 Strainer/Base Plastic PUMP OFF Fasteners Stainless Steel AURORA/HYDROMATIC Pumps, Inc. 1840 Baney Road, Ashland, Ohio 44805 v~ (419) 289-3042 Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location f-jtctiRc1 i~~ 1 (..)+G KoSK Govt. Lot 51: 1/45;w 1/4,S 34 T3O .,R 1.7 &for)W Property Owner's Mailing Address Lot # Bloc k# Subd. Name or CSM# 12-02 l Z i3 City State Zip Code Phone Number El ' Nearest Road ( ~ City El Village O u Town STH t Z ~i Gk,-1wL>c,,A C~"CY L,); S o 13 ❑ New Construction Use: E -Residential / Number of bedrooms 3 Addition to existing building 2"R'epiacement ❑ Public or commercial - Describe: Code derived daily flow 4 50 gpd Recommended design loading rate bed, gpd/ft2 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) 10 l . 5 CohSllLac.t~raC rt911,A-%A ft (as referred to site plan benchmark) Additional design/site considerations Z SAKj_ 1-+6r Tb our c.x ewf, Sr, + MbxH s- AT- 12' Parent material Flood plain elevation, if applicable J')A. ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade / System in Fill Holding Tank U = Unsuitable for system ❑ S 0 U ~S ❑ U ❑ S ~U ❑ S L'"J U ❑ S [U ❑ S 9U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 5- 1nKGL 5iz - s, ( 2 C 5 fir. M h A - 641 .4 2 7'lZ pct s~~ S. +'h A.o 2M P Ground 3 Ikx. SL L elev. `1 ~t •S ft. It 21-a ) It vZ S. k 4; Z. Depth to 25- 2y, ct. r`1 Z -V S' t 4- s v. m v - Z limiting factor Z in. Remarks: Boring # C,- 1. ~ 4t t. - , i 2 u k H (N !F 3 M 5 t; 2 -!3 to~c S% I n r 1"t A+„~ 2. 11C 3 3 13 -Zo l Yri K C, x •t 'I.-V At S~ t 2 .+z s h1 4 , Ground K Lal 94 or, tit" -,2 M& s `t '1-4 5,C.1 t r:'~ K M 4►- elev. S' Y2 S ft. 2.1-32 1 fk 14, k' y% -T 4L S1 1 Sb W+V Ft., - - Z . Depth to limiting factor 113 in. Remarks: CST Name (Please Print) Signatur Telephone No. t74 Z 'I~l c- r7LS- `t3-S Z3 Address Date CST Number l: 3+(i o Sraz \2~., . t a 63r`:r r.+ I( oZ. PROPERTY OWNER P' id%Ae l Wlcij KOSIK SOIL DESCRIPTION REPORT • Page of PARCEL I.D.# of I. - 101 ,4 - 1.a I Boring # Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench '3 3 1 o K<z ku S i c- S b ►'''t 1- s 3 Sys Z 13- 12 (o 1410. "l q4- . ~.a 2 w? 111' 3 wt~►. S elev.nd 3 lz-Zo c Y~i spa L (e, S'1 2. k Depth to limiting factor i. Z in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) ~ X v -o -v v F K' r" ? D I~ ~ Ia z I D ~ ID ~ - a rc~ p h x X x Y ~ X x x X X ~C X 0 ~ to I3 I" a 1 ~ I~i m p o o ° ~ F II 1 F T 33 r \ ~ IQ T,I N \ E L . I 7 -77 I~ ~ I~ _ } pl 3 ~ ..C r 4 v` m Iv ~ IN ~ p M I~ 0 3 r d ~ h IP IS' IDO A N 0 ~ I n'