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HomeMy WebLinkAbout020-1325-40-000 } ST. CROIX COUNTY ZONING DEPARTMEN a AS BUILT SANITARY REPORT r' i i 1 ' Ef!1t''~ Owner :5,4M M QL E2 Address 105'1 41,OeN w-ow k0olb ` Z(7NINuJrINGOFv j ~ i iC% City/State NU D S 0!V uJ t s ~/o /4, Legal Description: Lot 7 Block - Subdivision/CSM # 'T ANJV,Ey 9 /D 6E Sec. Z, TAN-R Town of &aDS Oil/ PIN # b 2a - 13 2 S e/O SEPTIC TAN DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer WE 14E. 9-- Size ST/PC / zsd / Setback from: House / S ~ Well S 7 ~ P/L -,cP 3 tsm Pump manufacturer r- Model Alarm location _ (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: QT.b Width 12' Length Number of Trenches Setback from: House to 3' Well 1 t 5 P/L 5--, Vent to fresh air intake 15 ELEVATIONS: To rte n r- M I a c k F'o u N B AT I O N z.~ Elevation I06~ DO S Description of benchmark 7s Description of alternate benchmark IH4 t4 HD I- L .7 S' Elevation -1 z _ q L. 0 Building Sewer7, ST/HT Inlet 7 7 " ST Outlet y PC Inlet f Fq 9.ze, P9 5'51 PC Bottom HeaderManMold 9 L.R 1 Top of ST/PC Manhole Cover 3) 4 %g 3- z Distribution Lines ' Z 4= 9 3 L (z) 1-z 4.9 3 Z,/( Bottom of System (t) I .4 0 . cJ /,1 l c~, e, o " ~l• 9 l o. to a = l 9 Final Grade (t) I (z (0.1 741) ~ Date of installation -7 /If fif Permit number 3 / S10 I State plan number Plumber's A at e L P License number 012f-03500 Date 7 /A/ Inspector ('omplete plot plan t . NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. A AIJ 4N M- f~o Wvnj 61-J►Ul CK Cofea Cr PLAN VIEW 1¢G7-rZNRTE ~A 2A&E 9005E BM at5' X CID' 31 w' lJf J 13 V i ~V0 ~ f J i V)' ro W Z ~ I+-- ~/B 0 Q J INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division INSPECTION REPORT ST . CROIX GENERAL INFORMATION (ATTACH TO PERMIT) SanitartiT%ajVT.: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. Pym't Nder's~w: w maw CST BM Elev.: AM Insp. llage ❑ Town of: State Plan ID No.: LEl BM Elev.: BM ^ Description: ParcelTY2bi:1325-40-000 Elev.: nn TANK INFORMATION ELEVATION DATA A9800289 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Bench k o? j('t> /oa.) ! Dosing r' 2.3 ! q'9* Aeration Bldg. Sewer ('0 Holding S Inlet 7-e5- ?j TANK SETBACK INFORMATION t~,L St/ Ht Outlet yj,-7 -l3 TANKTO P/L WELL BLDG. Aulntake ROAD Dt Inlet Septic 5'7 .",Iqc 25 NA Dt Bottom Dosing NA Header / Man. 0-q 32 Aeration NA Dist. Pipe 12(e47. 417f- Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 6) Manufacturer D and JT-~r GAO tM/`.~' •'7~►0 Z Model Nu er GPM TDH Lift Friction S TDH Ft Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liq id Depth DIMENSIONS Is 1161 1 DIMEN I N SYSTEM TO P / L BLDG WELL LAKE / STREAM LEA ING Manufacturer:" SETBACK CRAM INFORMATION Type Qk' Model er: Syst J OR UNIT DISTRIBUTION SYSTEM Header/Manifold It Distribution Pi a s) / x Hole size x Hole Spacing Vent To Air Intake Length t2-' Dia. Length Dia. Spacing _5!~ ASIM G IC 0 2--? SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.R!dq I-&-? x.110 Syl LOCATION: UDSON 12.29.19,NE,SW 1051 MOON GLOW RD - TANNEY RDG LOT 57 h 'All -7 1)0 l9b 1-7 A Plan revision required? ❑ Yes IN No ~I Use other side for additional information. '7 7.a ~d1 f SBD-6710 (R.3/97) Date Inspecto Signature e ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ` I Safety and Buildings Division 14sconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. CS-1, Cp-D /,x- • See reverse side for instructions for completing this application State SanitaryoPPeermit~Number Personal information you provide may be used for secondary purposes v/v ' 0 per/ heck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. /Ds/ MOOf7 G/o~w y v ~Sl l . State Plan I.D. Number, 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Pr pe L ation i4 1/4,5 ?j T .2q, N, R /f E (or Property Owner's MMa~iling Address Lot Number Block Number J/ Cit), State Zip Code Phone Number Subdivision Name or C5 Number 4~ ~ Uj / ~ 1 S' 4/ 1(3th) 7. II. TYPE F BUILDING: (check one) ❑ State Owned It Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms L] Toiag OF "r IMAOA/640a.) III. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) ~Q 9. ❑ Apartment/ Condo 0219-1 417 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. 9& New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of S. ❑ Repair of an ______System 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 11VSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground Pressure + I L~1 r 42 ❑ Pit Privy 13 ❑ Seepage Pit 11_X 7 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day rRequired Absorp. Area 3. Absorp. Area 4_ Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Wq • ~ Z, Feet Q4, 4r Feet VII. TANK Capaaty INFORMATION in gallons Total # of r Prefab. Site Fiber- Ex per- Gallons Tanks Manufacturers Name Con- Plastic pp New Existin Concrete strutted glass App- T nks Tanks Se tic Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (NQStamps MP/MPRSW No.: Business Phone Number: Ito t &bgr L_ L., P Plumber's Address (Street, City, State, Zip Code): `7 0 12 11140-C ki) _'a IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issu ng 11-1 nt S n ture (No Stamps) Approved E] Owner Given Initial Surcharge Fee) Adverse Determination I X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) 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, 608-266-3151. 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 into be installed. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one 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 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with completerJimensions, 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 a115 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. s and vi`'■-'■n SANITARY PERMIT APPLICATION BureaSafetyu o off Building Systems g Water 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 than 8 112 x 11 inches in size. S4 .Cro! K • See reverse side for instructions for completing this application State Sanitary PPermis'lt Number The information you provide may be used by other government agency programs E] Check it rev?Uon to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location f' ,~G L- x__- Lj/1 /4 1,IJ1 /4, S Z T Z , N, R l E (o W Property Owner's Mailing Address Lot Number Block Number 4,Q Y 4* 1.5-1 _S_7 City, State Zip Code Phone Number Subdivision Name or CSM Number 14-a~VS o : W ! " c/a ! ( ) 7` ' /k't /e 10 II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ It Nearest Road Public 1 or 2 Family Dwelling- No. of bedrooms ❑ Villa ge 01 Ca /V w, 2 ~v 52~1U Ld D. own of Ill. BUILDIN E: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment/ Condo 6 Z D_/ 3- b 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 --------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 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 1 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit X 7 8 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 nch) c7 q Elevation 1 5; Require~2) sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./i (c,Od -7 t t Feet r Feet VII. TANK Ca in gallacit ons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel New Existing Co strutted glass App. Tanks Tanks e ti Tank 2y'( W ~j ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No St m Qs) MP/MPRSW No.: Business Phone Number: 1 w L-L--, Plumber's Address (Street, City, State, Zip Code): v. U L11 "T El 0.1 (L 1i ID ~ F_0 D~ uJ 1 0 t IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Iss ring Ag t Signature (No Stamps) Approved ❑ Owner Given initial Surcharge Fee) I Adverse Determination f U 7 l8 X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: Z,c S D-ue c~ 7 SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber s INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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 isto 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; Q 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. Gr ~O 4/ ~ ~ ~F f C T'1 fir, c~c ( araa fef-~l - - _ C1 d / 7 9 N, ` 9 YY Q N 7r " CO mom : c~ n ~ I' _ m ~ rata • " -C IL -1; LV k _ ~ ~w o o! 1 1 CD M o I ~ ~ i I I h 0 z t I cn t t m D I n I I I o j 0 o I I ~ I ~ r t t ° tt1 m I I Tn o I z I t ~ I r ~ j ~ I I ~ j It p lu :u m I I I I ~ ~ t U w I ~ I I ~ t11 lA I ~ I I n ~ ~ ~ tG n I I 1 j -Z, N t~ 0 t z t 1 2 z I I I ~ 0 1 1!r ~ tr -u 0 v m N I t. 1 cn W' I ' m s I j z to i '9 00 z 'A• Fn o ~5 NO --1 14 X rn X 9-1, 0-4 NO T Q o X o O c r*i P~ Zo ~cn A ` Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and BuRfings Page of Bureau of Integrated Servifes in accordance with s. ILHR 83.09, Wis. Adm. Code 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 5-/-, C !r percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Re ' y Date Personal infomretion you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). " 1 C Property Owner Property Location r!' S0. VV\ , C j e Govt. Lot W14 /U!/l/114,S T N,R 1 E (or) U Property Owners Mailing Address Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number V~ SU ~ ~f ~ ~yU~ ( ) City ill ~e [g Town Nearest Road Moo P J New Construction Use: Residential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2_-__Y_trench, gpd/ft2 Absorption area required Z, bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 -6 trench, 9PW Recommended infiltration surface elevation(s) (97/112 ft (as referred to site plan benchmark) Additional design/sia~ 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 for system S ❑ U IRS ❑ u .®S E-1 u .as El u ❑ S 2W ❑ S ZU 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 6 0- Y r 3/ 3 Z Y- Ground 3 12-2 90 c'I'+ C a el v q ' Depth to limiting factor j211~in. Remarks: Boring # i3 - M, "-I I (0,S CA Ground f C Jw~ elev. ' N Aa Depth to limiting ~U pfr 0- factor 42Zin. Remarks: r 2 CST Name (Please Print) Signature T Address Date CST Number /070 S a c~ s-- 1~2 7- 9~ 330 SOIL DESCRIPTION REPORT ' PROPERTY OWNER Page - of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Gep/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 13 0-1-7 Iv C r vy\ 3 elev. Depth to limiting factor Remarks: Boring # L- ma C 1 U -/L 11~r Z.3 3 M, ~S c r m c S~'' d Ground 16Y-/.3q A) r 5l M vvl 57 X elev. Depth to limiting factor JALin. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/tt2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 10-/Z L zz-y Jv L 2 c r- m~,' c Ground yi -/4 /U~ / m S r✓t ( C S elev. 9 2 ft. Depth to limiting factor A-~/ 'n. Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) e 343 ' -5/2 T w r~ - G~Q cu 2 4 ~Pr- 3 3 017 1, per, c~ M <77,70 9:L/5 no N j • 8Z m a ~y . 4~ el 22 Al ( 14L 4rf'c.~ al l ~n~ r ST CRCIK COUN! Y 4} 1'FICE ZONNG t r... , ~ l~G c a h"~ MA p Wisconsin Department of Commerce SYSTEM Safety and Buildings Division PRIVATE SEWAGE CountY ST. CROIX INSPECTION REPORT GENERAL I ORMATION (ATTACH TO PERMIT) SanitarysUT916 Personal informati n you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)]. MILLElder's S e: ❑ ~~V lage Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: ~u Parcel T325-40-000 TANK INFORMA ON ELEVATION DATA A 700527 TYPE MA UFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATIO St/ Ht Outle TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet it Intake Septic NA Dt Bo om Dosing NA He er / Man. Aeration NA Ist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Dem Model Number GPM TDH Lift Friction System TD Ft Forcemain Length Dia. Dist. T ell Fi SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN N SYSTEM TO / L BLDG WELL LAKE / STR AM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distri ution Pipe(s) x Hole Siz x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade stems Only Depth Over Depth Over xx Depth Of xx See d/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes No E] Yes El No COMMENTS: (I lude code discrepancies, persons present, etc.) LOCATION: HU SON 12.29.19,NE,SW 1051 MOON GLOW ROAD Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: . Safety and Buildings Division Bureau of Building Water Systems : SANITARY PERMIT APPLICATION 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 than 8 1/2 x 11 inches in size. Sr. GRDt 7r- • See reverse side for instructions for completing this application State Sanitary Permit Number 3d7r.~o The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 0011-0--l Property Owner Name Property Location SW iY /yI 'LLEr~ lyf 1/45w1/4,S /Z T N, R/9 E(o(o Property Owner's Mailing Address Lot Number Block Number Rp 74 1,5-1 S7 I City, State Zip Code 05,0o one Number Subdivision Name or CSM Number as a 14 Lo I Sya l ( Z 7 k, K /I/ / 4E II. TYPE F BUILDING: (check one) ❑ State Owned ❑ it~ Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms E] Town OF ~~1750 t4 Ilwootyia4ow ko, III. BUILDIN45 USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1[] Apartment /Condo D Z G_ 3 2 r S!p 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.' pJ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ------System System Tank Only _____T________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 [XSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation y SO ("y 3 7 LO -7 9 2- Z Feet y~ Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION New I Existin Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App structed Tanks Tanks ptic Ta k ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: t K> c o N L - 0 ~$~aO ~6- 96 Plumber's Address (Street, City, State, Zip Code): 0 70 AuNTFA, / D6f A-0040 L)D50W W i e IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) WApProved E] Surcharge Fee) h~ Owner Given Initial t go ~ ~ All Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: P SBD-6398 (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. 111. 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. -TlgNNE Y ~ tID LoT /osI 7Ax#o2o-~32S-5~o /V 4 Iv. i D E w ~ y Lo SG ~h ~s' 30 75~ h~/f z o 7` s8 i Howse s7 E~sr <oi <~.y£ /3r.oa Z LLI a.. ° I o w a. 4 z w pY a 0 L~ Q > 0Y Lo- x -H o 1- D J R* p x ,a \9 -4, z ao z I 1 z a I ~t Q M z R I fi a I 01 1 1 I ° I M a I a ca I ~ I I if I 1 1 O ~ I U~ 1 1 z I Q I cn a 1 LLI IL F- U . a i 1.j 10 Ld I 1 RL v 1 m t CL IL 3 ~v I I I I W z cc i m I I w U I I I I JS I Q v I 1 I ~ ~ I ~ I I I > ~ I O I I I 'd' I I I I . r Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labo and'Hurpan Relations Div, of Safety & Buildings in accord with ILHR 83.05, Wis Adrfi ' ` OUNTY St. Croix Attach complete site plan on paper not less than 8 1/2 x 11 inches in size Plop`inutt includ#,,but "r X not limited to vertical and horizontal reference point (BM), direction and % of stops, scalerW " I.D. Lp ~c dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. R .tF ED BY DATE rz•S.e7 PROPERTY OWNER: PROPERTY LOCATION . r Sam Miller GOVT. LOT 1/45L':174,$' 12 T 29 N,R 19 E (or) W PROPERTY OWNER':S MAILING ADDRESS T f BLOCK # SUED. NAME OR CSM Trout Brook Rd. 2nd Addn to Tanne Ridge CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE EgOWN NEAREST ROAD Hudson Wi. 54016 ( ) Hudson Tanne Lane ~(J New Construction Use (Xl Residential / Number of bedrooms Addition to existing building j ] Replacement Public or commercial describe Code derived daily flow gpd Recommended design loading rate 6, ~ bed, gpd/ft20 trench, gpd/ft2 Absorption area required W,3 bed, ft2 S6_ trench, ft2 Maximum design loading rate 121-bed, gpd/ft2 6 Vench, gpd/ft2 Recommended infiltration surface elevation(s) - - - - - ft (as referred to site plan benchmark) Additional design/ site considerations Soil evaluation done for plat approval. Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN- ROUND PRESSURE AT-GRADE TEM IN FILL HOLDING T K U= Unsuitable fors stem g s ❑ U S ❑ U aS ❑ U S E] U S❑ U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft Boring # Horizon in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trendl l 0_g /bly R3 / L / rh 5hv, rn r CS / , d s ~ 10'-/P4 4 - SIL 1 ni sb~k M-t( CS 2. Ground 7.S` A 4 CS Depth to limiting factor Remarks: Boring # 0-l~ /dt/~.3 / _ nt. s~ rn r c S 1 o q O .S Z 3=35 16\- 2 4 4 - S -X 1,-, sbK CS Ground elev. q.il ft. Depth to limiting factor O /L Remarks: CST Name:-Plea print Phone: 386-4080 Harve G. Johnson Address: p . O . x 91 Si natur . Date: Oct. 96 CST Number: 3484 L--A~ AA-Apil- I PROPERTY OWNER SOIL DESCRIPTION REPORT Page? of -3 PARCELI.D.# S'-7 . . Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botnclary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tw& i A o-/3 /0 3 - L l m-s m (!S Z O. o.S Ground Z9-Az -7.SYP,4 yv► r f'Y► ! CS 7 0 g I 9 ft. g'3 Z /d ,2 S m r /h 6,-? b z Depth to limiting factor Remarks: Boring # A GS 2-V D q 0.~ L4 t:: . Ground rh CS 0. 0.r4 elev ft. -I I R 4 S Q m nt V 0:7:0Z Depth to limiting fa/0 %`fZ Remarks: Boring # 1 S ~C 1 msbk r 62 / z3 /oV 9 C s A 1A •g Ground $2 Z?X 7.Sy ¢ 07 10 elev _j /p~/r2 4 Li! S m r r9 r :131 9~ ft. 0'7 .O Depth to limiting fa for y/ .U6 Remarks: Boring # ^h}4\. Ground elev. ft. Depth to limiting factor Remarks: con ooOn/D nc m i E`j LA / / Ny r~ ( dd ~ $ Q \ ~ w N dP . r 1 or / S?- Cy% LA a9 ~w r y S T C - 100 This application form is to be completed in full and signed b owlY owner(s) of the property being developed. Y the result in delays of the e Any inadequacies will development be intended for p trait issuance. Should this house resale by owner/contractor, 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 :5-,q If M /CLEF Location of property 1 4 Township / -1~'`~ 1/4 , Section I Z 29 N_R / W p U S0N Mailingaddress T3ox 0-10 N W i c S,~ yolk Address of site ( ©S ( /'j`10 0 N Subdivision name ~LO~cJ A O 148 TI~uN ~IJJG,~ Other homes on Lot no. property? Yes X No Previous owner of property k N Total size of property ~ D L 5 /1/ p P Total size of parcel 2, C Date parcel was created 9 ( - 7-3 Are all corners and lot lines identifiable? Is this property being developed for (spec house) ?Yes No / Volume ~t7 31 and Page Number of No of Deeds. as recorded with the Register INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER AND THE SEAL OF THE REGISTER OF DEEDS R, VOLUME AND PAGE In ad certified survey, if available, would be helpful so asdition, a delays of the reviewin to avoid references to a Certified Survey ss. If the deed description shall also be required. Map, the Certified Survey Map PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true best of my (our) knowledge that I (we) am property described to the in this (are) the owner(s) of the warranty deed recorded information form, by virtue of a Deeds as in the office of the Count Document No. SO Sl y s y Register of own the proposed site and that I (wey obtained for the sewage disposal system, orr I e( we) construction obtained an' easement, to run the above described the office of said system, and the same has been property, duly re for the y~ of the County Register of Deeds y recorded in as Document No. i ature of Applican Co-Applicant CIL- Date of Sig„~ature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERBUYER S ~1 YV~ Vl~ I CL, MAILING ADDRESS PROPERTY ADDRESS O S I /1~1D©N LOW (location of septic system) Please obtain from the Planning Dept. I CITY/STATE C d I*~ Ca. J ( J PROPERTY LOCATION IVE 1/4, 1/4, Section T y N-R W TOWN OF R 1 vgs O AI ST. CROIX COUNTY, WI SUBDIVISION TA U ~Ey 11 l 4~ LOT NUMBER S 7 CERTIFIED SURVEY MAP SS lp3S , VOLUME('0 , PAGE LOT NUMBER -s 7 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: 2 _ S d ` 9 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 h DOCUMENT NO. STATE BA F WISCONSI ORJI 1-198! TMs+~s eesc"vao I.. MCCOM01016 DATA • [IARRRANTY 0 0 " 504855 rol 10 31F11GE 456 =-C1STE-- OFFICE This Deed, made between Randall W. SY...n.. and Patricia E. S na . ............a...n.................. ............_..........-X.......n-.,...-....... ;ecbrRea&d husband.•.and-• vi fe Granter, SEP T 1993 and......-.. ...........................................J.......P-....._.....----......----.................. ~ 10:45 Sa~E._..Mi ..•er' ...a..sin -le....erson C1 M Witilesseth, that the said Grantor, fqr a valuable consideration...... Randall W. Synan and Patricia E Synan St. conveys to Graatea the following described real estate in Cro i x "&TUee To County, State of Wisconsin: t ' i; Tax Pared No: . . . . . . The SE1/4 of NE1/4 of Section 11; the SW1/4 of NW1/4, the N1/2 < of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of NW1/4 except the East 74 feet thereof, ail'in Section 12; all in Y' Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. AND D 'A A parcel of land located in part of the NE1/4 of SE1/4 of Secti11, Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin further described as follows: Commencing at the E1/4 corner of said Section 11; thence S89 30100"W, along the North line of the SE1/4 of said Section, 1212.32 feet to the point 'j of :,eginning; thence continuing S89 30100"W, along said North line, 66.00 feet; thence S00 281030E, 500.00 feet; thence N89 30100"E, ra along the North line of Certified Survey Map filed in Vol. "30, Page 722, 38.08 feet; thence N00 11133"W, 150.00 feet; thence N03 58134"E, 351.07 feet to the point of beginning. This .4..AQlr_... homestead property. (in) (is not) Together with all and singular the hereditament& and appurtenances thereunto belonging; And..... HAAdAll ..R!.... Y-nan.-•aknd-•Patr-icia...E.....Synan A warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except A easements, restrictions and rights-of-way of record, if any. and will warrant and defend the same. i Dated this ..1.................-......... day of Atig.US L.....................................-, it..91. a~rcc~......_..~. . (SEAL) ~ZlOfrt~~f4~!! ....!44ee.4/ ...........................(SEAL) V E' Randall W. Synan Patricia Synan eta . (SEAL) _ (SEAL) A .1 ' AUTHNNTICATION AC=NOWLaDOURNT 1 Signature(s) STATE OF WISCONSIN it St--- Croix .:...:...»....Couety. i i authenticated this .......-day of 19...... Personally came before me %3.1....... day of , August - . . 19........ the above named R 1~ li . andall M:--*.... : Pati_ _=_r_Ffii f_'.. TITLE: MEMBER STATE BAR OF WISCONSIN _ _ ~-t,-.~ - ~I (If nof, . .71'~►_.t'OlMt 3 I I~ authorized by 4 706.06. Wis. State.) .to....me... . ..known.. .to....be. ...the..........person..._a..9... .....N:9t84'the I se1...,1"d ;,..c.,...."c ."a LEO ST. CROIX COUNTY WISCONSIN ZONING OFFICE 4 A B A p p p p 1A ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road - Hudson, WI 54016-7710 (715) 386-4680 July 21, 1998 First Federal Attn: Tammy Hudson, WI 54016 RE: Septic Inspection for Sam Miller located at 1051 Moon Glow Road, Lot 57 of Tanney Ridge, Town of Hudson, St. Croix County, Wisconsin Dear Tammy: A septic inspection of the above referenced property was conducted on July 15, 1998. This property is located in the NWY4 of the NWY4 of Section 12, T29N-R19W, Lot 57 of Tanney Ridge, Town of Hudson, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a four (4) bedroom home. If you have any questions regarding this, please contact our office at (715) 386-4680. Sincerely, R Eslin er Assistant Zoning Administrator /sm