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HomeMy WebLinkAbout020-1325-50-000 r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER~~,j & f LL-Q2 ADDRESS g X S Z f{v ~l. Sa ~ W r f 1-(t AL SUBDIVISION / CSM# 1 & g N E y9 k-u(0E LOT # SECTION Z T-~?-9 N-R / , Town of ST. CROIX COUNTY, WISCONSIN ~•PLAN VIEW Ik,0 SHOW EVERYTHING WITHIN 1-GU FEET OF SYSTEM r 'b .a~i t t 3 L 1 tee ,se-ALE IlgC': INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. J BENCHMARK: T! ~F r 1 P CA, O'14 z-O7'L/,y c / Z t, g '~"~•s ~ ALTERNATE BM : Te Q O l d C cJ Al L)T `1 '+t~ L = SG = SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION acturer: w S 9 oi_ Liquid Capacity: 12.- ~ Setback from: Well House v; -7 Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location 'g-' SOIL ABSORPTION SYSTEM Width: ~ Length (0 © Number of trenches -31 Distance & Direction to nearest prop. line: 3 3 4,!5 NQ o 7- ' 0 Setback from: well House ,3s Other r- 46~ Oct LC V. - 716,, 777 ELEVATIONS c Building Sewer ST Inlet: /,0t re: /VrT outlet: It Z40 i 17r 3 PC inlet PC bottom gym-' Pump Off Header/Manifold Bottom of system Existing Grade Fina rade DATE OF INSTALLATION: PLUMBER ON JOB: Q' LICENSE NUMBER: INSPECTOR: 3/93:jt ST. CROIX COUNTY WISCONSIN ZONING OFFICE N x u p 4 g M - ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 _ = s- (715) 386-4680 August 28, 1997 RE: Septic Inspection Tanney Ridge Lot 58 - Tn of Hudson To Whom It May Concern: An septic inspection of the above referrenced property was conducted on August 5, 1997. This property is located in the NEY,, of the SWY/, of Section 12, T29N-R19W, Lot 58 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, /Ja es K. Thompson ~A sistant Zoning Administrator sm ' ~ ► ' /0 LOT< t+ f' f, IL od AL T6 T'f i \ ~ ~ -r 3 3 FfO r, Safety and Buildings Division 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 than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 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 Property Owner Name operty Location - L Fji4 1A, S Z, T , N, R E (o W Property Owne 's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number i>DSOW )L? lQ1* II. 'TYPE BUILDING: (check one) ❑ State Owned ❑ .'y Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF, U e 114404) &AD III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo Q Z _ ( 3 L. 5'- 4r 40 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, d 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 11 ❑ Seepage Bed 210 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.) (Mi ./inch) Elevation d Q 4 70 - % a C? ~ I Feet Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name ont:rete con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Yank or Holding Tank 1 j ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ~ 1 _L ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATE-MENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: ( Stamp MP/MPRSW No.: Business Phone Number: abe JE 114 - . i &j A,. 2_.~4 sczo -5w Z_ Plumber's Address (Street, City,, State, Zip Code): . 13 9 40 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater 1=1 Issuing Agent Signature (No Stamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 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. 1 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 systern, 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. Vl. Absorption system information. Provide all information requested for numbers 1 through 7- V11. 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 DILHRVIII. 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; Q 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. V STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER S°,fM 1p14 e- ADDRESS /O S /1-10'0 /y puJ moo,{ lq L) A) „ r S"yp /L SUBDIVISION CSMf 4N)/Fr k1j%,e LOT 9 -5-Y SECTION / 2. T ? % N-R /9 (,Town of P=SCN ST. CROIX COUNTY, WISCONSIN PLAN VIEW 4T59) Lo SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM J~AtE 3p/4L74 a /VI~Tf. S fg- - - Ica GF,~ . s TT ~-v7 r4 ~ A, ~M ~ Lb _ J Provide setback and elevation information on reverso of fors- Provide 2 dimensions to center of sc-pt"(tank rl![ ( i BENCHMARK: 10'r O F / 1A ON,r/QIQ~~} LD//,rY,t 9d~ ' Z.16 ALTERNATE BM: Toh oc I~/oG.K F0uAtDAT/aN E 2.76 SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer t4,00,1~ 1s,0!Frz- Liquid Capacity: /OOO G.4t- Setback from: Well 7$" House 3 d r Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches 2- Distance & Direction to nearest prop. line: 32 to /✓r1/ 7AO' L4T Setback from: well: 77 House 3,$Other ELEVATIONS Building Sewer ST Inlet..T 97 - ST outlet ~P~ 30 %93.2 PC inlet-"'- PC bottom Pump Off 14 4,1 d) qq. -7 X RAI Header/Manifold Bottom of system C Existing Grade 2140' 9 ~l Final grade .3.,6-:-- DATE OF INSTALLATION: P LU t B E R O N JOB :-r~~~~ - LICENSE NUMBER: INSPECTOR: 3/9 t f 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 No.: GENERAL INFORMATION 284290 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: MILLER, SAM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: gg 89i 020-1325-50-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark /03.7'! 1 N' 9Sr. r Dosing a- ~3 Aeration Bldg. Sewer Holding St/ Ht Inlet 121 95.L 2_ TANK SETBACK INFORMATION St/Ht Outlet 4'5.3 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom V NA Header / Man. , 7G' Dosing 4 , 7(, Aeration NA Dist. Pipe 4' a 9y yg` /O•a5 93-V9 Holding Bot. System /o. a 7 PUMP/ SIPHON INFORMATION Final Grade 7.89 Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Fi Forcemain EengP Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width_, Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS c7 O DIMEN I N LEACHING Manu acturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type O ,,a CHAMBER Model Number: System:'f~ 3 S ld OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing 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 p Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes [I No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: H 12.29.19,NE,SW MOON GLOW ROAD LOT 58 Plan revision required? ❑ Yes [B/No Use other side for additional information. 1 "141 SBD-6710 (R 05/91) Date #s "s Signature Cert No. ADDITIONAL COMMENTS AND SKETCH L SANITARY PERMIT NUMBER: r Safety and Buildings Division of BuildingWaterSystem: SANITARY PERMIT APPLICATION Bureau 201 E. Washington Ave. In accord with ILHR 83.0 5, Wis. Ad m. 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. SL • L' Y'O • See reverse side for instructions for completing this application State Sanitary Permit Number a9Li Z9a 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 INF RMATION Propert Owner Nam ~ Property Location 1/45 14, S (Z- . T N, R E ( W Property Owner's Mailing Address Lot Number _ Block Number City, State Zip Coe Phone Number Subdivision Name or CSMM Number J>.% C) A Uj l S??' 4o) 1761 T C_ Y, IG _SW / 6, 1 II. TYPE F BUILDING: (check one) ❑ State Owned C] City ;;/1 village t Road 1 or 2 Famil Dwellin - No. of bedrooms Town of ~w Public MO. III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) aZO- ~3Z~~3 O 1 ❑ Apartment/ Condo. 2 Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 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. XNew 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 11 ❑ Seepage Bed 210 Mound 30 ❑ Specify Type 410 Holding Tank 12Weepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 1 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) Q~ Elevation s d b 7 31 / Feet r Z Feet VII. TANK Ca in gallons Total # of Prefab. Site Fiber- Plastic Exper. Manufacturers Name Con- Steel INFORMATION Gallons Tanks concrete glass App. New Existing strutted Tanks Tanks Septic Tank or Holding Tank /00 0 El Lift Pump Tank /Siphon Chamber ❑ 11 VIII. RESPONSIBILITY STATEMENT 1:1 1 El 1:1 1 1:1 ET 1. 1:1 I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) , Plumber's Signature: QLp Stamp ) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code : L) 04 C) Y4 L4-.l IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing iygent Sig ture (No a I Approved 171 Owner Given Initial Surcharge Fee) 7 - /Q Adverse Determination X. CON ITIONS OF APPROVAL / REASON FOR DISAPPROVAL: 96 qt5) 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. 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 E: 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 8 112 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. a ^E Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Wash ingtoiCAve. 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. -4 r ca f • See reverse side for instructions for completing this application State Sanitary Permit Number e7 • d 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 Pr~erty Owner Name Property Location , ,r r `it } l"f f /:°;`ry -1/4 S T N, R ' r E (cef W Property Owner's Mailing Address Lot Number Block Number Y City, State Zip Coe Phone Number Subdivision Name or CSM Number II: TYPE F BUILDING: "(check one) ❑ State Owned ❑ ity Nearest Road Village ❑ Public - 1 or 2 Family Dwelling - No. of bedrooms ' k!kT OF /~1 i ~ / /~/G1 r Lc.2r-' / III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 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 _ ,K New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ___'___System _______-System Tank Only______________ Existing System ExistingSy~tem 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 1 2~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 C c~1 r f 1rY'' Feet : Feet TANK capacity VII. INFORMATION in gallonTotal # of Manufacturer's Name Prefab. CoSite n- Steel Fiber- Plastic Exper. New Existing Gallons Tanks Concrete glass App. Tanks Tanks strutted Septic Tank or Holding Tanks-^' / (,jam FRI ❑ ❑ ❑ ❑ ❑ 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 Sign ture: JAipo Stam ) MP/MPRSW NO.: Business Phone Number: 1p, 1 K C. d✓a ~ ~t/ - _ 17A,6'1_- F p'° d C a P ~ 1 5 ice ~"rs rte' Plumber's Address (Street, City, State, Zip Code f if ty co 45r C, VN -b H k/ oz -n N IX. COUNTY / DEPARTMENT USE ONLY E] Disapproved Sanitary Permit Fee (Includes Groundwater Date Lssve Issuing gent Sig re (No a S) ^t n Surcharge Fee) Approved ❑ Owner Given Initial t Adverse Determination l CONDITIONS OF APPROVAL / REASON FOR DISAPPROVAL: 9e, 60 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 pufnper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; 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. ~ ~ ~I r c f Z ~U ~2 cod c.v7~ s S8 I'c>S.3 /110041 4LOW dQ014 0 vlSroN ra ~ 0 / r i~ uz r t ~ "tl yOE r u~ e B" p,2rl1-s. ,air ti t 3b ve,E' t y~x 3 z 1'~ I ~ s ) 3S ~oTG~ o ~ . o N O Jr N n f x G') V1 W - ! Z C9 2 '~V til z 0 O 'et O F-~ o N ~Y O 41 o ? r- ~ a. I w I - it M i a i M I o I I V) I ~N + , I w " a I ' ~ a A9 I , 1 s I Q%e I I Ilk, aiO. v~ I ~ 3 w I u v I 4 k4k w > I a 14 Safety and Buildings Division ~~~~ir•~r'i SANITARY PERMIT APPLICATION Bureau of Building Water System,. 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. (y-lb • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs 0 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 Nr- 1/4 Zw 1/4, S / z T 39 , N, R )`T E (or)ID Property Owner s Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number w i 5Yo ~ >27 W7 I Tft F a2104£ II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ~t Nearest Road ❑ Public 1 or 2 Family Dwelling - No. of bedrooms 3 ° roan OF f{u S 011 q~ g (~,/vcJ III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) OZO Z S S 1 ❑ Apartment/ Condo - r 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- tg New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank OnlyExisting System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 R 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 ct Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation f ~;-b Coo O Q~r I Feet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex per. INFORMATION New Exist in Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App structed Tanks Tanks Septic Tank or Holding Tank ~ObO to F~ SF ❑ ❑ ❑ ❑ ❑ 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: M k~ M~ o ~-L~- S Q t~~S o 3Soo 3 - gds Z Plumber's Address (Street, City, State, Zip Code): (b?v Nv l Q13 r1+JflSCK s'4'''l~ wor- .IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing A nt Sign No S s Ad Surcharge Fee) pprove❑ Owner Given Initial 0~ Adverse Determination (CJ/ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 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 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 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. SAM LL ErL (~N~I~ v~/p~~ ~oT~~ ~ /cS3 Moon ~owk?a~kl~ v~/GLG~ /~'/~i~J C~ 3--G1 C) EpIS~" ~oJ L/~YF 33836 ~ 3~-- 13- A4. !oP of I~ PIPE ~S Sc AL6 /lq /O qy cl sa 3i LoT ~ S8 ~ a g a !A c, ~ ;S 5 (Do <Z% 5/oPE ~ 1y l a,~ `,t F tia~sE ~1 0 Lc;T v y z l i ~ - 10 N v E I .4 Z) ' ~ m I O I t z i .d d1 IA 0 ~ --1 ~ i X11 S 1 ° u FM m i 0 m 1 ~D Z' s 1 i ht O I ~ ~ G %IJ Z4 Z -n i I ~ ~ °r o I N` I z L4 I Z m w v -o Q b C ~ 9O . F O No O ;ao -1 z 'm Wisconsin Department of Industry, Labor and Human Relations SOIL AND SITE E V A L U A T I O R T Page 1 of 3 Division of Safety a Buildings in accord with ILHR 83.05, 4s"A'a~- OUNTY St. Croix Attach complete site plan on paper not less than 8 1/2 x 11 inches in size: Flan mustiriptude,-but not limited to vertical and horizontal reference point (BM), direction and of slope, scale or CEL I.D. # dimensioned, north arrow, and location and distance to nearest road. q APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REV EWER BY DATE PROPERTY OWNER: PROPERTY LOCATION Sam Miller GOVT. LOT /l 1/4-SL,..)/4,S 12 T 2 9 N,R 19 E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # Trout Brook Rd. 2nd Addn to Tanne Ridge CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE E]TOWN NEAREST ROAD Hudson Wi. 54016 ( ) Hudson Tanne Lane New Construction Use [ ] Residential / Number of bedrooms [ J Addition to existing building j j Replacement (J Public or commercial describe Code derived daily flow gpd Recommended design loading rate (1. 7 bed, gpd/ft2b, --wench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate D,`? bed, gpd/ft2Dtrench, 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 It FU = Suitable for system C VENTIONAL 0 NO IN- ROUND PRESSURE AT-GRADE SYSTEtd IN FILL HOLDING T _ANK =Unsuitable fors stem S❑ U S ❑ U S O U S O U COS ❑ U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BRoots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmr& ~ ' - S YX SbK nt~r' d Z 0.3 Ground $ S' 2 7 - S Yh c' m 1 t~ O 7 63 ev. ft. 93 - lb'M+6 n rkgr A s 1 _ :7 '1~ Depth to limiting factor F7 Remarks: Boring # -23 Q I rh c r m r C W Z 0 i7.S CLO LID 0.1 Ground U-0 - S M r rn W - r7 O elev. KO 1) Yt° S r !'1't O,- O.g /6.7 fL Depth to limiting factor Remarks: CST Name: PleaHarve G. Johnson Phone: 386-4080 Address: P.O. B 91 Signatur Date: Oct. 96 CST Number: 3484 PROPERTY OWNER SOIL DESCRIPTION REPORT Page 0Y3 PARCEL I.D. # ' Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Trey Lai /~y~e 3 1 rrnsbK r C w 1 d,~ Ig i8-44 ioye.4 4 - S,L 1 MsLk ~r 5 1~ 0.1 03 Ground 87 ~A -6z T3 y~ 4.14 SIL I Sub m Cs l 0:5 I v$ft. 93 -Rfb IOYP,4 S rn r, A Depth to limiting factor > /Q Remarks: Boring # /0`/Q3~~ L ~ rh5bk r Gw ~ r~ 0 g O.S' B -sz ,sY.e 4 L I m sb n, / Ground cs 0 `T I`Z ft. $ -IZ >O` 24 _ S rh r 0.7 61 Depth to limiting f ctor ~ ~D 7S Remarks: Boring # ' Isr 0 . q os ,~Y - by 3 / - J m see M-Cr c w /a e4 - S, L 1 m sb -fir 1~ o.z .3 Ground t-S3 7.SW, _ SL J ►n r yh 1 CS _ 5 D 4 1A -3 r- v ~'h a.7 CS .l ft. Depth to limiting factor 7 Remarks: Boring # x~ ; ; mo'w` • Ground elev. ft. Depth to limiting factor Remarks: cnn ooonro nFr~rn. 4p~ 6 o w ti4 1~ rn Fn w is CO N' ss- CD ~ w Op ~ 37~ 3S S T C - loo • 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. Owjier of property_ SAW M ILCO(L Location of property_&ir 1/41/4, Section i 2 T Z N-R Township L)6.S d Al Mailing address _J'dX *'z k 49__ U U l) e) V L'U { <0'-0 t C, Address o f s ite 10 4 3 lW o(r lV co4 e w (e e l4 L Subdivision name '7 ff k f r V Lot no. _ Other homes on property? Yes e No Previous owner of property.. ,4U p A LL s y~,p g/ Total size of property Z , R'V 4-c, Total size of parcel 2l gb )4<-. Date parcel was-created - ?j Are all corners and lot lines identifiable? k Yes No Is this property being developed for (spec house)? Yes No Volume 1031 and Page Number 'f_ a! 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 tht-I 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 fc-rm 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- SS , 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. V4 S' attire Applicant Co-Applicant Date of Signature Date of Siqnature ;r - STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 1,K (M I LLF MAILING ADDRESS aft Y_ -W 2 g 2._.._ PROPERTY ADDRESS / OS 3 M 0 n A/ ~;/.o W ro OA b (location of septic system) Please obtain from the Planning Dept. CITY/STATE y DSOK W PROPERTY LOCATION *5 1/4, S 1/4, Section /T A-7 N-R /7 C TOWN OF A-U 14 So N , ST. CROIX COUNTY, WI SUBDIVISION rA At N r Y t 0 4- , LOT NUMBER Z'T CERTIFIED SURVEY MAPS' y 4 3 " , VOLUME Co , PAGE S , LOT NUMBER S _ Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ' DOCUMENT NO. STATE BA F WISCONSI ORM 1-1983 THIS SeACS ResaRV[n FOR RscoRO."a pArA • ARRANTY 0 D + 504855 YOl 10 31PAGE 456 r. _ C►ST"4'S OFf 1CE This Deed, made between ► ; Y C0.• gyp Randall W. Synan and. Patri_cia_ E. S nan, husband. and wife ~'d c Grantor. SEP 1' 1993 and .Sam...E.. Mi .l er,.a_sin9... person t0:4~ a ~~M Grantee, I R"^s'e' d Oesd~+ Witpesseth, That the said Grantor, f r a valuable consideration...... Randall W. Synan and Patricia E. Synan conveys to Grantee the following described real estate in S. t..'. CroiX RaruRN To County, State of Wisconsin: T" Parcel 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 SEl/4 of NW1/4 except the East 74 feet thereof, all in Section 12; all in Tovnship 29 North, Range 19 West, Torn of Hudson, St. Croix County, Wisconsin. AND AND A parcel of land located in part of the NE1/4 of SE1/4 of Section 11, Tovnship 29 North, Range 19 West, Tovn of Hudson, St. Croix County, Wisconsin further described as follows: Commencing at the El/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 q of -eginning; thence continuing S89 30100"W, along said North line, 66.00 feet; thence S00 28103"E, 500.00 feet; thence N84 30100"E, along the North line of Certified Survey Map filed in Vol. "3", 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 .25 ---AQ.t... homestead property. (is) (is not) Together with all and singular the hereditament* and appurtenances thereunto belonging; And..... Ril.n14.ll.. W-'--.Ey.nan_ and.... Pa-tr.i.c.i.a...E.,...Synan warrants that the title is goad, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. .~1 and will warrant and defend the same. Dated this ,J..) . day of ..............Aug.US.t............................... 19...9.3.. GI~Ytd' 4--- G~''J...(SEAL) ~7aL1~1< je✓........ (SEAL) • Randall W. Synan Patricia Synan ~r (SEAL) (SEAL) • • c. AUTHENTICATION ACENOWL11IDGM3NT Signature(s) STATE OF WISCONSIN Ma. St. Croix County. authenticated this day of 19 P naUy came before we .3 ......day of August 19 the above named Randall W. Synan, Patricia E...... TITLE: MEMBER STATE BAR OF WISCONSIN Synan i ~.....rpM01'1 (If not, - .lice. authorized by ~ 708.08, Wis. 3tata.) to me known to be the person . 3....... N4i 7.9c ~e I . - - . 1 W w