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4: m o ~ O ei oQ i' a~ I a 0. 0 ~ I °o I N e O L ~4 I I W a N I O N Z z Li c 0 o p C (0 Q M > Z y) W E Z O 2 ~ O Z I' a m o I o z dz`,+ (D z N H r N o N ch I C • N c ~ O Fly U Q 2 z z O N z r N U N M '0 2 ~1 w 4. N d a LO °o d w? o LO D D a u; N z N > F a" ~ o 0 0 0 O Z o ~ I o ai m fn U = rn } ~i (D M ~ ° o Q o o V o o o ~ o I N d 0 'O rn N N C° c N y C O y~ ° 3 - o o E Q r l o ao o m F o a~i E c a °o °o .'ti"J °O I C J N E C N N N O 'r.+ O-7 O N O 3 M M • iii L' O 2 J N O N Z CA \ C4 # v `n c a 4) a a w L 3 A 0CL '',oinci >F■y~ 1 ~ in accord with ILHR 83.05, Wis. Adm. Code M' ^ll. ! •.t.NtA lM COUNTY Attach complete site plan on paper not less than 8 1;2 x 11 inches in size. Plan must include, but / ` VQ ~X not limited to vertical and horizontal, oference point (BM), direction and % or slope, scale or PARCEL I.D. K dimensioned, north arrow, and location and distance to nenrost road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROP ft1 {a "`it PROPERTYLOCATION d~ I' MVT. LOT s 1/4 N~1/4,S I T N,R E W PROPERTY NER:'S MAILING ADDRESS LOT N i BLOCK M SUED. NAME OR GSM e CITY, TATE ZIP CODE PHONE NUMBER [CITY 1❑VILLAGE OWN NEAREST ROAD X New Construction Use X Residential / Number of bedrooms ( j Replacement ( J Public or commercial describe Code derived daily flow- gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required _,-bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/112 trench, gpd/ft2 Recommended infiltration surface elevation(s) _ ft as referred to site n benchmark) Additional design / site considerations AMQ~ (~yp - Ive E / ? -o Flo Parent material _ Flood plain elevation, if applicable ft S = Suitable for System CONVENTIO L ND INGR)U DPRESSURE AT-GiRAI)f SYSTEM IN LL HOLDI ANK U = Unsuitable fors stem _j S S ❑ U ❑ S ❑ S (~U ❑ S ❑ S U SOIL DESCRIPTION REPORT 1 7- - Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft Texture Consistence Et Roots in. Mansell Qu. Sz. ConL Cotor otr~fary Bed Trend ;1 Ground 3 I Yt ' 6 ►'R~ i'Y! F l -9,5 ) ✓r<rl / elev. _9 21j Ic - Depth to 7 yrf- ~SrYl1 y fl ~hL ~I' 0..'. limiting 7 f or _ - - Remark's: - . Boring # (0 y7i Vrr Ground ff ~1L~R Vit- q5 vR v~ 011) - elev. ft. I~ ~ ` ° fL- Depth to - - - - - lifniling factor Remarks: CST Name:-f'loase Print +EJRRr WE'" UCQ l1'Pt1 IIPv Phone: Address: Signature: D e: CST Number: 113 It ,G '7/ 5~~~ Z~ 196, JVIL UtbUhlt 11UN YiCF Vf1I Boring # Horizon Depth Dominant Color Mottles Structure GPDD/tt~ in. Munsell Du. Sz Cont. Color Texture Gr. Sz. Sh. Consistence Bo~r>dary Roots Bed Trend r<: V j CS M Ground ,5 Yl; y Si 1 v elev. _ 5, y 6 Depth to limiting factor Remarks: Boring # Ground 10 YP, V y F~ 6 r, C5 ► %i elev. ftI7' 0 YI 51 l1 Y A S 2('a h 1► / Q. ) Depth to limiting fa Remarks: Boring # STICK WITH US FOR YOUR COMMUNICATION NEEDS J-lole C (ores t } rr I~ e. Ground fillt- aS , elev. ft / ~tr~'d~~ 0 (e, 3 Depth to limiting /et- r Lt FI factor Remarks: Boring # BALDWIN TELECOM, INC. BALDWIN, WI 54002 715-684-3346 t.•.> `*<`:coa WIS-IN-WATS 800-423-1450 Ground elev. ft. Depth to limiting factor Remarks: Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations Division of Safety & Buildings 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 PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER PROPERTY LOCATION GOVT. LOT Lj 1/4 r) -1/4,S T N,R E (or) W PROPERTY WNER':S MAILING ADDRESS LOT # BLOCK# SUBD. NAME OR CSM # CS 5 o/S-/dw-Cw-cam ~Q CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑ I LAGE 9:MM_ NEAREST ROAD ( ) 61y& [ ] New Construction Use [ ] Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement O Public or commercial describe Code derived daily flow 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) 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 Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmrtch F Ground C elev. ft. Depth to limiting faC R 1 Remarks: Liz 'e ' tJC~ r j Boring # Ground elev. ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: Address: Signature: Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page _of ' PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends Ground elev. ft. Depth to limiting factor Remarks: Boring # }tiff' Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # 4:v Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) a ARTHUR L WFr,E-'ER S-963 a " ELLS`.NORTH NOTE: CURVE DATA TABLE AND DESCRIPTION ON REVERSE. SU CERTIFIED SURVEY MAP .,LOCATED IN THE NEI/4-NE 1/4, SE 1/4-NE 1/4 AND THE SW 1/4-NEI/4, SECTION I, T29I R17W, TOWN QF HAMMOND,ST.CROIX COUNTY, WISCONSIN. S o°09'34' 526 OWNED BY: GLEN BOLDT 3767.20 '-1 1498.76 ]SZ.O N I/4 CORNER SECTION m REC. ASSOUT, I, T29N, R17W.( I" IRON RT. 2 , BALDWIN , WIS. S114 CORNER SEC.), P W ip.~ I 1453.05 PIPE FOUND) T29N, R17W. ( I"I.P. I n m °•Z 3 FOUND.) Ln_ 01 N-S QUARTER SEC. LINE. N 0°49'05"E 66.02' FIC 3 .01 33.01 Z A 413 0, I ° 1r • . ~oGl C01983 r.. NNEL( V :C m 1. i~ •I r C.~' O SET 1"X 24" IRG 1.13 LSS. PER LI Q~ i In V z co O v I- o kD 0 a 1" IRON PIPE FOUND. cn o ;z .D OD I NO 43.55 'W ,API-i~OVE[i col rl JUL 61983 :0 oI~ S/gO33` \ 30? co ao A /s"W ?9, N~w 3q j ss ST. KOiX COUNTY m A 'CO-14F EHENSIVE PAP.KS PIANMNO lp m I S 64°24 5IAP0 ZOMNG COMMITTEE o - w % 6.00 \ 2 ~ I 6 6' \36Oi i IA S O\~'' on. 0s„ .000w 115. 14 ! II4 \ --b iT E N 90, 58 AS 115•g5) ` (REC 66'WIDE ROADW " EASEMENT 33.13' W 6 6 y1 050 'Z N79001'52"E SCALE 1"s100' ~ ~ a Z i0 f CJ-1 " Im O' 50' IOo' 200' o I I L O co , '1 Iv NOTE. BEARINGS REFERENCED TO THE 0 N-S QUARTER SECTION LINE OF I(~o /I SECTION 1. (ASSUMED BEARING C I 50009'34 "E ~o ,o ? 1` I w,~, • GARAGE 1 / J rn rTi -jq D8 W Q , "W N 10 14-00 .~.e \ z NIO°58 08 91, co Z /s co LOT ~ ' 4.765 AC. TO M.LINE ,D o (207,567 S0. FT.) \O\v ST. CROIX COUNTY .r WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 _ (715) 386-4680 .w July 27, 1992 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 To whom it may concern: An onsite investigation of the GKary Boldt property, located in the SW1/4 of the NE1/4, Sec.1, T29N-R17W, Town of Hsmmonf, St. Croix County, has been conducted with the assistance of Bruce Webster, CST #1902. This onsite revealed suitable soil to a depth of 13" and meets the requirments of tha A + 4" rule. This site is suitable for new construction utilizing a mound septic system having 23" of sand fill. Should you have any questions, please feel free to contact this office. ;es ce ely, S K. Thompson Assistant Zoning Administrator Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of Labor and Human Relations Division of Safety & Buildings 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 PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY 90 DATA PROPERTY OWNER: PROPERTY LOCATION _ ca, . Z: ~k GOVT. LOT 1 t 1/4 r' ! 1/4,S 1 T ,N,R E (or) W PROPER OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VIL E OPOWN / NEAREST ROAD [Lew Construction Use[ ] Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 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) 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 Texture Structure Consistence Bounday Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground z elev. ft. Depth to ` limiting factor Remarks: Boring# ik Ground elev. ft. Depth to limiting factor Remarks: _ Z -C CST Name:-Please Print Phone: Address: Signature: Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page _.of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench \.i:i::iii ~\tii>•' xt6fi.:i Ground elev. ft. Depth to limiting factor Remarks: Boring # k Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) ST. CROIX COUNTY WISCONSIN ` ty tY s X ' ZONING OFFICE - ~4 ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 Sept 11, 1992 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 To whom it may concern: An onsite investigation of the Gary Boldt property, located in the SW 1/4 of the NE 1/4, Sec. 1, T28N-R19W, Town of Hammond, St. Croix County, has been conducted with the assistance of Bruce Webster, CST #1092. This site is located approximately 200' northeast of the original soil evaluation. This onsite revealed suitable soil for onsite sewage disposal to a depth of 12' while meeting the requirements of the A+4' rule. This site should be suitable for a mound septic system having 240 of sand fill. Should you have any questions, please feel free to contact this office. 51zj1 erely, 'jdmes K. THo son Assistant Zoning Administrator cj Pf We erwet /Cl~ 9 s I I- n 1Olt 3/3 Sil 3F41*" M"Pv LP ()-3 ioyRi b 3GA r,vr✓ 3vqn ~v✓ ~i 3-ib 1oYOf3 ~1 ~Pj14 "F" 2~\/I-- 10- 0 R C13 sE 2 Fa N ohs r/ r rL~-30 toYR5/1z ldgti r S ltiot Mal Pole- o favest toQd cat. 041 r was rA,~O, d' s 3 d ti~le fq v Ol lOYR 3/Z AvFr 16-2 3 IMsly ~-sreslrfj 'I RF+S~' h ~.I ,11 .~3-3i IoYRy/I 5rQ MF c2p sl Z40 v~F-- 9s Y-12- tOrk7l' ST. CROIX COUNTY ZONING DEPARTM + 3 . AS BUILT SANITARY REPORT Owner ~eovt4j V18 Address 10o'- 117-r4 Awe nve City/State 041owi,7 4-yoo 1 sr cgo,X~ 98 ZOO (41~)rv Legal Description: / Lot Block # Subdivision/CSM # t/4 s Sec. :..7*,, T;I-N-RILW, Town of h r, r» P►i o o PIN # - V't SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer h)4tf hvn PYeco Size ST/PC 1 V / Setback from: House 0 Well P/L Pump manufacturer Zo e ll Model 6 / Alarm location 5oLak Wee- Corner jque#►r-,t- Ut,1;t!i Ferzer to (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: MOO Width Length_ Number of Trenches Setback from: House-790 ► Well Yf0 P/L Vent to fresh air intake ELEVATIONS: Description of benchmark I w 411(,- it QfS of J o"J Elevation Description of alternate benchmark N a m6e Wdlq- Elevation q3° y 12 Building Sewer ST/HT Inlet V " ST Outlet q3- 76 PC Inlet 93.45 PC Bottom 8 d ' 32' Header/Manifold Top of STAF Manhole Cover g 7" Distribution Lines /00 c 0 Tor Casty ~ Bottom of System ( ) I we 0 ( ) ( ) G ti y rh` P~ ~ 7 6S Final Grade ( ) oi3 O ( ) Date of installation Permit number State plan number ()!O I U7~~ Plumber's signature License number Datep4 Inspector Complete plot plan rst - vsc Nauvn 3W 3WId . AMA m o ~ Co r A s ° ~ •o ~ f C~ a- r V-4 -4 -M S ~ ~Z c ~ S AWNt ~ t ro •aigotiddr 3F `31nurgouoq o1vu olT togs •Ianoo aiogumut morel otidas jo Ioluao of slulod amonjai juluozuog omj, •ucalsAs agp jo laa3 00 t uigpinn BuiglAlana Butnnogs goja)is MaTA UUld V :Suimollo3 aqj apino.id aseald 'ajI.LOm s ? r Wiscag,sin Department of Commerce PRIVATE SEWAGE SYSTEM County + Safety and Buildings Division ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarjt1N9.: Personal information you provice may be used for secondary purposes (Privacy L , s.15.04 (1)(m)]. ~ ~1TWt,s tMNARD `jj5hi8§b ge ❑ Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel ftV- 1-~ X00 9'- 12() -?0-000 TANK INFORMATION ELEVATION DATA A9700223 _ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Gdd Benchmark p,/5!~ fly Dosing sb Aera-iion Bldg. Sewer Holding St/ ~ff Inlet `CGS ~3 ' TANK SETBACK INFORMATION St/ h)f Outlet Vto TANKTO P/L WELL BLDG. Aierlntake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA baadarJ Man. Aeratio NA Dist. Pipe ,u ioo- y~ Holding Bot. System PUMP / SN INFORMATION Final Grade 3. Boa, a ' Manufacturer Demand Le-&e-e- rr . , r Model Number 161 it GPM TDH Liftao. Loss ~a Systern, TDHai,Ed Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width I Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMENSIONS S~ I DIMENSI SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAC u acturer SETBACK INFORMATION Type 0 P..6W, CHAN Moe Number: System: /-y«_~ a d ' J~J r5 0 OR NIT DISTRIBUTION SYSTEM *ie&der7 Manifold Distribution Pipe(s) i x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing 4,A I ~c / 6 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over xx Depth Of xx Seeded /hoddec~~ xx Mulched Depth Over 4'' Bed /Trench Center ~ t' Bed /Trench Edges Topsoil l0 ( Yes ❑ No 51-fes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HAMMOND 01 . 29.17 SW,NE 1069 117TH AVENUE LOT 2~ M. 0.( l~S SD~ JS. - J Plan~r~vlsion required? ❑ Yes E3 No Use other side for additional information. SBD-6710 fR.3/97) ~7 Date 41 rlr'6pector'sSignature Cert. No. 3 r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 1 Y(i/ ' f t " f SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations July 17, 1996 2226 Rose Street La Crosse WI 54603 WEBSTER PLUMBING & ELECTRIC N3659 CTH C ELLSWORTH WI 54011 RE: PLAN S96-40762 FEE RECEIVED: 180.00 FERN, DALE SE,NW,1,29,17W TOWN OF HAMMOND COUNTY OF ST CROIX MOUND SYSTEM The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate 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. Sincerely, R card M. Swim Plan Reviewer Section of Private Sewage (608) 785-9348 SUDA-7987 (K. 10184) 3S Lo p Y T~I~ P y SE~~ jVw°~ Secl T 191v R )7 W Nq~v~►rha 3 WYm Syst.F^ pq~~ Ferm DwniC12ISEG1- l0-71 117 f~ #vrllo c X jJ k4, W's ~yozZ ~~ohf 71r s8`1 3112- 10-c ~ A-~i~n w~ysk~ c Nev D- 11/5- < Teskt- CST-m- r--sa 190 2 - NI Pay z P a~ 1sco! v (o~ p~ Mona 4~c BRUCE AL LIN q I G s D-1195 ~G t.VO55 5ecfroh o~ Mould qhd PIqh V'Ipti/ ELLSWO ~ d1 "SCONSIN Q 160 IYOh P C DeW' ~i~,,~,,,`S'lx.rG1;1,~.'.:+`,.~'~~• Q~9e P~~►P (d "der c 0. ~ 1,pe e~ 4F eke°~+~~~~ g~F~ Dom' ~vesea~ _ oND~~GE S~~ GpR D? 97.5 L cc I I , .t. 9a,4 .6 o- s I_ UJ u .L N 3 ~ o ~gpimrrnnp~ Af,ry o ~1SC01vsf°'''* o BRUCE ALLEN: WEBSTER 0.1198 BS 0,4 ELLSWORTH °l Feet \ WISCONSIN o ' c C! 16 $ 0 5 ''~~atir;trn r ttu"v I- CD W p LLI L~ TOP amgaE P10AR34 ED POST 1--~ TOP OF OARNGE m PAINTED POST Lr) L j V TOP OF OARNM PAD ca PM 101.6 O~TN TOP OF aAK%'GE MOUND PLANS FOR PARTED POST DALE FERN 2017 117TH AVE54002 SELNWIhsec II T29N R17W ~17 TOP OF OARNGE PA ED POST 96,d g SECOND BENCH - NAIL IN TREE 3 VE FEET A~vE n IN 969 MA w E 3 BDRM 514 HOUSE PROPOSED LOT DEPTH 700 FEET PROPOSED LOT WIDTH LGO FEET PINE LAKE ELEVATI414 73.4 - 75.4 A r_ ruionnrpr~~~ oc( IV 4% ONsATLLLEN WEB ' D-1195 f ex ELLSWORTH WISCONSIN Alf TOP OF DARNGE MOUND PLANS FOR sTED POST 96 DALE FERN 2017 117TH AVE BALDWIN WIS 54002 SE NW sec 1 T29N R17W TOP OF DARNGE PAI TED POST in 20 30 40 '96.4 11111 1 ~ Scale in Feet voirt -e SECOND BENCH - NAIL IN TREE 5 1/2 FEET,ABOVE 3 BDRM GROUND IN e6 DIA MAPLE 93.4 HOUSE rod pkccyt-Se PROPOSED LOT DEPTH 700 FEET PROPOSED LOT WIDTH 180 FEET PINE LAKE ELEVATION 73.4 - 75,4 Mack tprtltt. Named Scale 40 ~ C 5~... B3 et 97.5 4k% ALL in y. Ii . col - I ~ a B ele 96.9 11771 0 `aa~~t~aararrnunnn~y 400P. '~SC( gf BRUCE ALLEN ~ 0.1195 ELL8V RTii g 4 ; VISCONSIN i i' 00 OTI G 14 r a 0 4 10 2 30 B1 el 00.4 Scate ►n Feet wC.~ X00 5 as S Page_LOf a' Cross Section Of A Mound Using A Trench For'The Absorption Area I zm L'33 - H ~ Medium Sand Fill ° F .6" Topsoil f E D L Trench Of" - 2" Aggregate, aJL Plowed Layer 6" Below Pipe, Covered With D 'b Ft. Straw, Marsh Hay Or Synthetic Fabric To 0U ~ovhd Pn,)stl Gr.dt- to3,~ E 1%4 Ft.IcL`~ G.0 Ft. ' P dF BY~ T°P tol . Q F D. P,Fp< Io 1.6 $ Ft. H j •S Ft. Tip Ors~l ~lyw+ ~ay 6 Ohhr ~~yn Prp~ Plow is l . 3- Sulu, I ~n FIINa~dn ~d ~ • ~$110 IS~P CauNTOUZ [a0 f Plan View Of Mound Using A Trench For The Ab f ors ~ ~ ,k0~s1 ' Force Main Ei Distribution Pipe Permanent Markers Observation Pipe W A o - L K B \Trench Of It" - W Aggregate I ` L L A Ft. I Ft. K 0 Ft. W Ft. B' F Ft. J. '/2- Ft. L Ft. i' License Signed: RILV, ,~l-V 444j Number: D" q Date: ~~~e 30 1 ~19~ _ Page J Of 'I Distribution Pipe Detail For Two Lateral Network i Holes Located On Bottom Are Equally Spaced PUf. Farce Fain End Ca ~Y-{-- E•X~- X PVC Distribution Piiv• X ' Last Hole Should Be Next To End 'Cap p 3 Ft. Hole Diameter _ Inch X 6 V_ Inches Lateral Diameter j inch(es) 2 Y q 0 Inches Force Main Diameter Inches n # Of Holes/Pipe t~ F~ut . Invert Elevation Of Laterals 1U1,6 Top Signed: License Humber: Date: 10L 1 ! 1 ~ 1 ct vl•e `r i5 s 4~1co~sr ~ a1t9s f EtLWORtH ' ~ Y'ISt0ir3iM ,f c 1 G M 'd V8899ase 191 *ON xdd d3O0 Hf 60:61 3(11 96-91-I f . PUMP CHAMBER CROSS SECTIOIJ AND SPECIFICATIONS PAGF E GF Vic VE WT CAP 4"CW VENT PIPE 4 WEATHERPROOF APPROVED LOCKING 25' FROM DOOR, JUNCTION BOX MANHOLE COVER. WINDOW OR FRESH 12"14IU. AIR IAITAKE I GRADE I I 4" MIAJ. L _ _ 18" /KI IJ. COAJOUIT 18"MIAI. ~ 11~ INLET CONS PROVIDE RTIGHT SEAL t II I~ To,0f ~ a t II r7 A WEBM I I C I 11.1115 I Pr~c7 ISCONSIN , $ I I I LAR IA JOINTS WITH ELEV FT I t APPROVED PIPE 71-0 PUMP --j d o SOLIDTSOIL OFF 76'~ CONCRETE BLOCK RISER EXIT PERMITr•ED QIJL IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SP GIFI'CATIOAJ DOSE MM TANKS MANUFACTURER: M BrBCUS~ IJUMBER OF DOSES: PER DAy TAWK SIZE.: 75-0 A GALLONS DOSE VOLUME 132.+113 ALARM MANUFACTURER' L2vet Avm INCLUDIMCp 6ACKFL0W: Y GALLONS MODEL NUMDER: I)1^ CAPACITIES: A= 1 7 INCHES OR 2_ GALLONS SWITCH TYPE: - ercowy -,7 B= 2 INCHES OR g 7_L GALLONS PUMP MANUFACTURER: 204I(er r-=- I OR 2-5-7 GALLOAIS MM ILL MODEL NUMBER' _Losnu: RI r- pm4 xy/ j~tcD~;i lrG1 D-- INCHES OR ~ GALLONS i SWITCH TYPE: NOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE. RATE-- GpM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BET WEEAI PUMP OFF AND DISTRIBUTION PIPE.. T6/s is wliti Ov~p oFF 77,C~C~ FEET + MINIMUM NETWORK SUPPLY PRESSURE . , . . . ?•5 _ FEET + 900 FEET OF FORCE MAIN X 1'61. FJooFLFKtCT10Ll FACTOR._ 5,0 FEET TOTAL Dy1JAMIC. HEAD 32.2 FEET INTERNAL DIMENSION!: OF TANK: LENGTH -;WIDTH I ,LIQUID DEPTH DAIJ SIGNED: LICENSE NUMBER: DATE 6'~ • n ~ Z!~ Alri7i?i'!: 3 « ° « a ~QN mb R: lei°I ~~i 1.1.1_ _ =i-' - n ~ ~i~'~jy u+ IL ~ ~•?-'R,R• MR1 Q 450 i ~w ~"'t ° i;titi S e x~^ A r,Pii i;»~r»r*a U ~ Ri~iZ:t~S xZZIZZM'?tt= a t:ri fi~ t i of- ti F gi I I? is R x ti°p`lpQ A 1: 3': =s~~•a.~ 0.x.0l ill y Zi g•Ai Q .i 3~zxsRx~~:,za.. $c ol:i•j: w Zryjo q «st milli 10, 0 Sir. -t- Is . LU t7 = s a 06 F I , W ~ 111 I• i. j _ ~ 1 i ! 1r ! " I . ^ I A IS` 91 -A 1 ' o d 4Z - co c:zl .5-0100 4 V 0 S~L• 4c~ / b0 'd b88992 191 'ON XU dN00 Hf O I : £ I Hfl.l 96-91-lnf 8TC-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 ~ e B h 4 rJ L-J,2- he v- Location of property_.~F, 1/4 11hl 1/4, Section ,T.2~ N-R_1.7 _w Township_ ~~~Wisad Mailing address / 32.00 V 14111 %hhC~Do~r'S /'/~ANe1df" S'Sy f ~ ~Phyh,e ~~Z y2f~ ~ ~~'''t+y Address of site_ 206 C/ a{, Subdivision name Y.eS Lot no. Other homes on property? Yes No Previous owner of property -DAIe 1",h Total size of property V, 3 S1 arVe Total size of parcel Date parcel was created c f-- 3,1 , Are all corners and lot lines identifiable? 4-Yes No Is this property being developed for (spec house) ? Yes No Volume and Page Number -31-72 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. S51 and that I (we) presently own the proposed site for th 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. 55IH6~ 4gnataurAeo-TZAAp~Pp~~ Co-Applicant - Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT f St. Croix County OWNER/BUYER Lf Oh g,-d L,,'1-z yell' MAILING ADDRESS z o w J/ loo y ?qkh u*y 111h4r4oj11s PROPERTY ADDRESS AX~ 117 fiA &e h J t- (location of septic system) Please obtain from the Planning Dept. CITY/STATE u•.j W JS COti S ti ~~Q 2- PROPERTY LOCATION 1/4, YV 1/4, Section T_21_N-R_L~ W TOWN OF ~Svh►'y~ny ST. CROIX COUNTY, WI , SUBDIVISION y~ I PS LOT NUMBER 2 CERTIFIED SURVEY MAP Yc f , VOLUME1L 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 ex p. tion date. SIGNED: Ll&' DATE: Z-3- St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ~ r STATE 1Alf Of Num 11-IM DOCUMENT NO. ,1ct cnatn Co*M=:t, by and beuteen e _W_. IP Rra aa4t tiiaris 11 • `e=n. onabastd add tri i.~>, ` MOW. a C~wc#+~ae' arc ar aia~e). WtttdOr t~ Ms SOM p to ?'m up= *4 POOM" a" t d f& ooanoct by p- *a Mkmft popeft kttexas (A dhd *e 'Piapat. IN Bta>,ee+t a O y s iM pottNyoliorls tton► ...4t crQlx C,oV" No 4MOODOW - paft of the put of Governmft Lat TMo (2) and s~ soutbwast Quarter of the 1!lcirtttssst OwmrW, -alas lloa ~t(~ oae 1). Townddp mil' T or 9~ction ( tow( 2 ) ' of MCI pRSticelsrly dwtDcribd as Lot Certified SnrwT asps tiled Ocisobejk '!0, 7 7777 is vola" 11 at Certified surv*Y Ma" 317T as pacmtent No. 551464r- Office 09 COu r r >ReQister of t>~eeda !or 'St. Croix ' Wisconsin. y cer"it, ~n NZTpi Ito inns` ]recorded October 26, 1 4 In volts 1"5 t, , ~ Docwwnt no. 5512". is not ftoatttetedpop~y ~ ~{6 r q t a . _ Flo yp p~a~e AR T~ap~J amt 10 PQi6 V~do~,~k - Ibt tit. 0f . • a wwA nn it tbt ~ _ , tAillwt~tc Bw1 ite at dK OKWAM d d& CO mwx'. and GO ft bdoee of bated ao do bdum awtat=WM& fom dot to tree s the Doc d / ks i ~ . "Ie SUN of =13,060-W PVI=iPsl tlAnil.l be plt# ' a sF; lower nitb no at accruing cn the six M) Per )fir tail accrue as patemat "Imft in full ziav, lto+rWed.boerew~lbemdleoeastaodYtsbd~toeshallbepaWtlrfeKoaotote-r- ddeat t~ 19~.. >aate~i<y ~ A ft Dec rltm-0 011 tbf Mao ttimm in FaOosriltt de6~k prys0e0~+ kttaelt sbai tlDfttl6 K nwoe d...~.e4f ~ - is&&, wkbErnbmkmdM ime" nod, vp a acadess&8 er waaft *0 ea" p bsbaW pia. w" a=wd by %m" ssea to pay =and* to WtOM 6 000= au~cieat to pep ensaorbiy aced tae N be ad wgtdted bpmm p~omktms v.bw due. ~ the s~arat ttttsivtd by Meador o¢as p ~ pey~ a these o *Vtwm wbw &w- Suds atomm oeod d by the V=dor for pgmgOm of taxes. Ow.emmem sad ban== wid be druid, Me r" # ad c r wdm &moo*. buc dat9 ant bettc iotsw =us odterw* eegdoed by IVA Belt to intadt ao tba aapdd bdtttae o tAe tnac tpeciBd sod tbml eo prbrdpf-7~ be applied ~ tLme tatgr6e wMhoot pttnalesloa 41 i*QW- bl the CKS of my pmp"mmt. dds mama *An not be ranted a in &F&A vdeb tapes to "WAN eo loop ata4e tR~/eY b"M d prktcV4. and iltetw (ecd in mch are aoclrntre W... 6ao month to moede *4 be m and tN =pW pbdpQ tt3 Im Ow 6t m=u dw said ktdeboAmm WMM Lave bona bad the monthly payments bam m& a But VadW &GWK posvldttd *A ms ft Coates fist be awuknled b d+e event of M& of nay ptooeeds of kmm m of at coodeamsd ptttmw b ft dt ommbt olttl "berebee pw&aaer mm that Fu= wa is ago" with the title r dwm by dte d* atdtaakesd 10 twcbm fw cawIrAdw =Not hone all 1996 reateax-es when due. Purchaser shall paY 4mdor $hal l par v all subsequent real estate taxesa vh+darti.mereKklk.adtodteSimKia rlurAaaer ptsemhea to pq ~rMt due a0 taxes and aaaawaents levied m the rape.. upon art demamld eeaelpa inlepa Ps~a~ an y Im or &=W mccoWsed by he. em ded oo p ill td bomb nVmWm wkbm m m wsawm oppe*vW byd Mmdor, in tht sms d f IN I e bet V2rdortllsA no a~ M""V b an MOM mm dm the bahsroe owed under ft Coearx. racl~aaer SW ph' the "M MM praeitmtvalue _ wiw due. The POAN dal me% the tuttdttd dwee d ward the VOW06 k>tetew snd, unkm Vte Am odterwbt arm w wtitia+, OR ~,o~~oto1 d a1E eeweb~ die hap dal be depeaked wI& Vlmder. Pwdww dtall ptomply"tlodm of lom m ittworett" aoampemia am+d vlepdes Twtdwar attd Vkdor otherwise spec b wrkhts, lasrelce proceeds s be apphed to mmandoa or 120* of dw Ae1~X dhwrded*a *2 vNAioe iaM da watoratlaa or wpok w be aoanoanlca~► bm". to tMe Yt pfd tatnwele ettwmeama trot r ostm~mit wawa aor dow wam tar be aam o tted as the Pa4erty. bwp Pteperty bee ham BM auperror b the lien of tW Comma. aid m comply wtth sl aatbaanom Md Vlada~m tbt is see rite parehm price wilt k uvw and other tmmeys shall be bAy peed and Am edkiwr Ad be fif perfarttted at 60 tkae std In do tttemwa► aboae ~Vkrtdor we an detmwA. own ad ddtuet to the ftcho . a vhr=q Dmd. is In ewwk of drl4opimlt flee ad der dart tkaro sud awmhmmm comps #M lima eaaobemmmoes a+emd by the act of defdt of Ptlealtlaat; amd eaaept VA) 11 aye prktdpml ac ieaa eel trpme tkme Y die eaaeam teal (0lea dw ewmt of • daWk In the of a lot e apecMid die Gate ar Eb) iw the eamt Of a deidt iw pertorm.moe d try ieet~dre asaoilemesbra d A KwtkeatalomdtewatblVMador( erectperaortdyarecitedbl O*W " emttyiomdktdbo ee der di►aewmau abmlf beosmte 4iseiac and iw idl. at Vktdorb option sad wkhaa aadoe (wiidt Pttaeltawe wshsr). and 1irmlor tiaE slashers the foira~itd tlatu amd 1a (ambler assay )baintiotla pr'or~ by W Is adilMw m tiad ley bee w Ims~a1qr. O Vkedir mtq w his ter*klete thls C= ma sad Purdm a OeMs. dde and kattatat to do good baeletboea~ onsa frsecbssae wilt of dtaptlos to be aardkio od upon Pmteiamb ii {tg~att S i%wgne wtttwiraiirrd , wli ieioaett sseaa tNOOa rile foie d at it not Is deer as swig &a and other dmetmtr dot bekt+kirt sower at teoemm lm+Y~h► t~ twcbrrm ahdl 6o twldrod tm % I I Ie fw bftw w bM d& CswfA "w lie " t Prseheer ftb m ae Ali Mtr~ot trt~arle it #poeMc ddisCttaaset a crropd imMtiliiyte spit on amrsmldMS bebtase, aNit imlrseat ~laassa at dre nee let tit as dte dtae ddeimk Mwl albs smamteta doe Mm+rrtdat; Mt . do popery elal! be arttMma~Gm Mt4i M die wA psms#waar ahal{ ba l "lbrewy deldeaey; ar w Vksdot avow s pw tie, ~ r prise ar say pmlkatbews~ sr Vkmdir arly deebw dth t3wom a m ad aid un ow dds Cwreeset m e dad"40 tube d - tldrstriw if tlrr tt;eloabie kMaeMt d llmahsser i amd (W) *ad= mW bwe lhaaebaaar efecoed km pomodwt of bras s sosaitar appelerd s: esrert sbr ssortr~ kttrm ar drdmd the d o y aedoa under CU. Ot! a pA titsae Aw wd a ro wa memo" as s o ms ofvmwh m r oiaadeat d amy d die itmadtes abdl qtly be 6 ima' klattredaemfosoe aamdy pm~wdw sectiartsamdeapatembttlsir~taaronabie leekof alkmad w wet) m dis aottmt low" probhited bl hew dearp es d da Ad be added to p thdpd ad pd by atatiabsiibardmdd'iasagrim~sattt. tJMeii the ar amdrtdthe psado~q d e yi maka d twedaa 1 d mh Casa w. Pwd+a aoeaemrs +s dk to s wooM and poets die hopmy d tae pw,damcy~aaeloe asmosbet dtdte rsrpetyt kttfid ma baeeatera kltetsm, a cdb a the ms. aaod tease, kataeq sect se a ftmd Ad be betel mad q"W m the coon &A dkect. litasba w Ad ttat taalrfen stb a ooaray say ltpt a Owma lr leases in the raoperty ((Ny aaaiptmerlt d any d Ttodiaeebaai~ mdec vlnldor loins ekhar file baLmtoc this Coatemm or by NO- base or m = ` f tier wq) wkbomt d1r prior w:iatem comsent of papik amder this islet it a the leaser art.ysd Is a pw* or aatlRetell of Pwchmeft i mau cadet ibio C;kllnrpt wtely as swttoigr for sa YidebMdoeaa d in the emeat d any swat ttamfe- sale a on ymloe wkttout VttdoA wrkiett amoap k de a Ow bdmtae 1erler tbM Casttnx abaU baasde kmm+eiwaly dqc std pyabte is Imtl. at vtm" Coos was= softe. tisi t pryt>Iaaw who daK SAM eiwur dRtd a~oitit dw PtoMty an the dne of d* CAvAme (="t fwwy tawiptpe Tossed by faadtesr) ar ceder any sore sac~d i~lwuided tmad~rar whe: t~ Mf~'x d the ktnonmt tltgt iR ratoil' Itib Can a. lti eloetr --Amk oak PI &a* m da Uw*W d VEmda b6 to do so ad al psymemts so made by yiorA'ere &d be asaaiitrd payrai" aorde m do CoaumL Vttotiar ~1a/ waiae say dtiamk wkl►out waiMktj aha snbaequam a prbr debut d Pwdmc. *it scents atddcCamteant d aY be bMftg tt m and kmae w 6e bettdks of dte Wok ho rep. I to lan=d and @A dVm" ad pmmchaae OF mt • O ww ddte ptaptragr the of %vkx for a athletic oataidersdon/okts hommd eon to dw sobjeet Poap:ny d epos ID JO lea rho e>a UOM to be wa& in Matt hereof ) i1D~ra er 19 timed this„ day at (SlIiU Date 0 onard C. "tans • Gloria A. Tern . Mara et E. Litz r AU TiCA' ION ACKNOWLEDGUM State of Wisconsin, 3t. Croix a aadmoeie td d* dy of raaoaa ly came before me thda igr of jfpomaber -1 mamed nato V. Fern, Glo • 1PitE: iiRAM STATE SAtt or w 5co"Sm ittaner ; fl[ nat. smlhorlsod by VwAk Wh. Sws) tome !mown a be d1e. ' ~..n,....oe ed4ieY~ellrfYeee.` ~ S ar I, Safety and Buildings Division Nf&eonSin, SANITARY PERMIT APPLICATION 201 E. Washington Ave. Department of Commerce 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 than 8 112 x 11 inches in size. • See reverse side for instructions fnr ~~^^nl^*:..° State Sanitary Permit Number « O~ Leonard Litzaer 6;2 3200 W Calhoun Pkwy Apt A The information you provide may be used oC y y Minneapolis, MN 55416 ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N - 42 7 6 Z Propertv~Owner Name Pr pert Loc ion ~o~ s. 30 W Can 4 AIP~4, S .1_.. T-2 , N, R 17 E (ici Property Owner's Mailing Address Lot Number Block Number O 1 5 rreehbr; eV a. 12 `IZ06 CA I City, State Zip Code Phone Nu Sub ivision Name o C Nu er P'l; j Wv ►t c6t2) CS . y0Q, 3/17 II. TYPE BUILDING: (check one) ❑ State Owned !ty Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms own OF d4m 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 E] Apartment/ Condo © ©F 0 ~ /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. ❑ Repair of an ystem System 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 1 1 E] Seepage Bed 21' Vlound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench T2 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 D Re uired (sq_ ft.) Proposed (sq. ft.) (GalVday/sq. ft.) (Min./inch), Elevation -6-551-37T -h4f $ 14 A91 Feet 10.2., Feet TANK Capacity VII. NFORMATION in gallonTotal # of 's Name Prefab. CoSite n- Steel Fiber- Plastic Exper. Gallons Tanks Manufacturer Concrete glass App. New Existing strutted Tanks Tanks Septic Tank or Holding Tank d / ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber --t, -2 ❑ ❑ ❑ ❑ ❑ 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: (No Stamps) MP/MPRSW No.: Business Phone Number: 41 "I'll e W5* r Ap er715'` 91 ~~17 Plumber's Ac dr ss (Street, City, State, Zip Code): IX. CO TY / DE ARTMENT SE ONLY , ❑ Disapproved San' ary Permit Fee (Includes Groundwater ate Issued Issuing Ag tSignatops. am Approved E] Owner Given Initial ~j Surcharge ~ Fee) Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R.111,96) DISTRIBUTION: Original to County. One copy To:. Safety & Buildings Division, Owner, plumber - . ca t INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permitmay 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 i~ 5. Onsite sewage systems must be properly ma ntained. 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, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and ma'i'ling 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. Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X_ County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must.Asubmitted 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. k su 4L S 9 D ss~.4s4 ~'~g96 • 10 o CERTIFIED SURVEY MAP NO. 551464 VOLUME 11 , PAGE 317 ti BEING A PART OF GOI/ERNMENT LOT 2 AND PART OF THE S. W. 114 OF THE N. E. 114 OF SECTION 1, T.29 N., R.17 W., TOWN OF HAMMOND, Sr. CROIX COUNTY, WISCONSIN. WEST f/4 COR. 1-9-17 fD. 2" I.P./CONC. p \A \\\\a\\\\\~ • O 1 14 °v' ~ ~\rp $ Z y Q`J~ (Cry i 1 i Icy L! co: zop 5266.47 S00109 34 E !y s p o 7K 2 O O 2 C -Z Dr, y 2611.33 2655. 14' o ,~\I•• m k R: ryl •~o v O 1lllllllll 1 1\ 2 M'o O UVO ~O R.. N~ • „1 NHS. s~~~ ` y v ~3~F GNp 2 b.N 5 0 \ ~-O • F R.- AAOyfOIO-E I •9 8 5,R, \ N04.34'33"E' I 447.67' I a a = - R- +a»s• Ili y ~ ~ i ~ ~ - 'Sa o~°p • by \ A\ ~ ~ ~...~e ~ ao I~I ~ 36,E o o ~ ~ ~ o0 4:44 rq NOT 19'02'W 2 251.00' 514' g.ESS ne' r' >t 15• 8 1 y i 37T.2 i , - _297,08• //~•VI .35•''8 1 2 v " v o, a 9, .i (K~,t%• ~2f 35g-~ ~ 1'l3• O V 1014.48 44 Q! 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