Loading...
HomeMy WebLinkAbout020-1326-40-000 4 0 0° I a CD ~ I o N N Y I ai . o c co c > 0 o o. I O N L z a) c Z o a U- c O -0 Q) I 3 M v y z ~ I C) z Y z ~ d y I aNW n.m o E z :!t c I 13 m 'o w w m Z c z cn I- IT a~ S Q ~ aai I 0 U) c w c 'D co • N IO a U L ~ C O 0 ¢ o 2 ¢ 75 z H z N z a u, O R E Y `N N I (O W d N C O C C O a 0 O N N E CD Z o •N aaa UL fn0c~ C) 0 N m o } o ^V r o 0 C,4 E a, co o _ ^i E o D y d m o I co o o e 5 °o o o $ E CD co TO O (O O N C6 0 4) o c) C C a o N 0 l N H N C E N (D CO O - r O Cl) Q rn y ayi a~ F- Z c N • C_ co O Z N g Cn O ~ = I #6 a ` IL 3: 0 _1 A t0 a2 !;Oaio ~t rn -C x u P U 00 CPO S f r i r ! t, °l Rl S N A k 1 n N W T, , n 6 s- f ~ >Fi o U5 _ (A U~ I I r I 95 1 e 4 I ti o ~ z ! r oQw Z G N M P 6 I 1 1 6 ~ ' 1 I ~ ~ ers I m I tt I `Q I I o I w I Z I I r Q I NO z ly ?It o F o ~o P v=~tQii SANITARY PERMIT APPLICATION Safety and Buildings Division 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 8112 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)]. O'State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Pro ert Owner Na a Property Location 114 W 1/4,S Z T 2g N,R E( W je2l IL 1,F 1% s r- _ P erty Owner's Mailing Address Lot Number Block Number to 11 Z (o 7 City, State Zip Code Phone Number Subdivision Name or CSM Number c3 ) Z TINE Ilt 61 II. Y F BUILDING: (check one) E] State Owned ❑ Lit ~ Nearest Road E] Village Public 1 or 2 Family Dwelling- No. of bedrooms own ol#1'[JO s0 N1 111. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 6 Z, a C 3 Z (!o 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. mirl New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an System ________System_- _________TankOnly______________ Existing System ___-_____Ex----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 eepage 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 y Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) /o2,s Elevation L. 3 7 SO S d co Feet 7192 - 0 Feet VII. TANK Capacity gallonTotal # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank x / ZSi~ / S - ❑ ❑ ❑ ❑ ❑ 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. PRSWNO.: Business Phone Number. Plumber's Name: (Print) Plumber's Signature:~(Namps) MPffiPRSW No.. Business Phone Number: l f~ 1.! Q' iN"L t~ r.=r% f` /"Z S •O SGI - G y 2 . Plumber's Address (Street, City, State, Zip Code): ,10 7d T r- /o R_G/O a f{u o sM k,., 's IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) ❑ Approved E] Owner Given Initial Surcharge fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy Tod Safety & Buildings Division, owner, Plumber INSTRUIZ-TIONS 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. 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 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. Safety and Buildings Division (Ei~R 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 f [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prl pert Owner Na Property Location r ~ f 1/4 r) ° 1/4, S T 1 , N, R Ord E (O6W P erty Ow er's Malin Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number (?">1-,) 7 T F1 n r rf' / t 4 rr' II. TYPE OF BUILDING: (check one) ❑ State Owned qty Nearest Road p Village w~ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF Ill. 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 E] 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. I)g 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 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12,Meepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14E] 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 L r° ; 'r < $ y r Feet Feet VII. TANK Ca in gallons Total # of Prefab. Site Fiber Plastic Exper. Manufacturer's Name Con- Steel INFORMATION Gallons Tanks Concrete glass App. New Existing structed Tanks Tanks Septic Tank or Holding Tank / C' / C -o & (L° E] 1:1 ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1:1 ❑ ❑ 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 mps) MP/MPRSW No.: Business Phone Number: 10~/X 41 Plumber's Address (Street, City, State, Zip Code): r yen /t7 7e' MUNTt f- *106° 1(`i4)044 14"1["iAV IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing Agent Signature (No Stamps) ❑ Approved E] Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One (opy 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, andat 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. 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 it revision to previous application [Privacy Law, s. 15.04 (1) (n% 'State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Pro rt,Owner Na a Property Location T E(or W - 1/4 'Ji 1/4 P erty Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) E] State Owned El city Nearest Road rt El Village F E] Public 1 or 2 Family Dwelling - No. of bedrooms ili~rTown OF _4 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo y 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 Exl-----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 [3Seepage 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) ~t"Elevation f f w`r r '7-),5 Feet Feet VII. TANK Capacity site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION Gallons Tanks Concrete glass App. New Existing strutted Tanks Tanks _ E9 I n 1:1 1 El 1:1 eptic Tank or Holding Tank S Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ 1:1 ❑ 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 Sumps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): p ! . A' li ~ J } :1~-•. a J~9 k) f+: ~y.'.'.: _r~ s..s.,.i .+r w v IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination 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 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 3 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 submi tted 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) &oil 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. Safety and Buildings Division W~ SANITARY PERMIT APPLICATION Bureau Building Water Systems fii7L.■7■1 201 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. • 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 p Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan LD. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Pr9peOyNner N Property Location 1 /4 1/4,S T , N, R E (or) W P erty Owner's Mail in Address Lot Number Block Number City State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Ity Nearest Road ❑ VIIIage - Public 1 or 2 Family Dwelling - No. of bedrooms « Town of " Ill. 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 E] Campground 7 ❑ Merchandise: Sales/ Repairs 11 El 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 online B, if applicable) A) 1 ❑ 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 410 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) J = Elevation r h: S Feet Feet VII. TANK Ca acit in gallons Total # of Manufacturer's Name Prefab. Site steel Fiber- Plastic Exper. INFORMATION New Existin Gallons Tanks Concrete strutted glass App- Tanks Tanks El Septic Tank or Holding Tank X r aG t t .-f / - L JZ ❑ El El 1:1 El Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. MPMPRSW No.: l` Business Phone Number: Plumber's Name: (Print) Plumber's Signature: (N9,5 4amps) r Plumber's Address (Street, City, State, Zip Code): f c^ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Surchargeree) ❑ Approved E] Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05194) 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 instbllation 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 question; 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 ,lame 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 orle and complete # of bedrooms if 1 or 2 Family Dwelling. M. 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 systern. 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. c 3 d o C 3 3 0 3 ~ CD A) n I N N O ° OND 3 C N N • (D .r (D Q- iv O '„y a M m y CO p C R l^l C CD ° C/) _ ' N 1 I-'OQ3 F° ~ o CCD O r m N N CO O A~ O O r♦ 3 f'N N co 0 O O p R v> ~ D CD CD (O m N G ca Cn cc m W 3 3 = o o°~o CD O l CD O CD = co co (D Co 0 4 -4 CL 7 o M p C, ~rl ch fA N V m 41 o Q o v q° :3 Im a ~ Cmt N Cfl N CD 3 m z 'iD3' Na 7 ~ a a a O 7 j a o o ~ o m m m ' m 0 D CD CD C N a c w a z CD -1 CA O A Z m C M = 0 CL A Z O_ 0 m m m z N 0 o Cz y y G Z CD A O I CL a 0 'm c z Q 0 z CD w 0 i 3F 3 I m A t-m A I ~ N N I o° A o p CD Oro S9 F " A wisconn~nn Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of s LaboP'nd4luman Relations Division of Safety & Buildings in accord with ILHR 83.05' M COUNTY - St. Croix Attach complete site plan on paper not less than 81/2 x 11 inches in sizV. P*0f ust dude, but not limited to vertical and horizontal reference point (BM), direction andra~O of.slopta, A a CEL I.D. # dimensioned, north arrow, and location and distance to nearest road. r ~BW APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION IEwED BY DATE PROPERTY OWNER: PROPERTY LOCATION Sam Miller -GOVT. LOT 114 `,fil4,S 12 T 2 9 N ,R 19 E (or) W PROPERTY OWNER':S MAILING ADDRESS 1-9 8L CK # AME OR CSM s Troiit Brook Rd. Addn to Tanne Ridge CITY, STATE ZIP CODE PHONE NUMBER ❑Cf VII GE- OWN NEAREST ROAD Hudson Wi. 54016 ( ) Hudson Tanne Lane j J New Construction Use (J Residential / Number of bedrooms (J Addition to existing building j j Replacement Public or commercial describe Code derived daily flow gpd Recommended design loading rate in. S bed, gpd/ft2 h. L trench, gpd/ft2 Absorption area required bed, ft2 trench, 112 Maximum design loading rate 0.7 bed,gpdjft2CkS< trench, 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 S - Suitable for system ggNVENTIONAL MOUND IN• ROUND PRESSURE AT GRADE 7jeTFJA IN FILL HOLDING -T MK U-Unsuitable for system ~9 S❑ U cgs ❑ U WS ❑ U WS ❑ U S❑ U ❑ S il SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bo~ Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rter& ~ p-ll /4 -123 3 L ~ K m r eS / .5 $r 1131 /rh51oY, mFr w _ 6.1 3 Ground 31-81 loy?4 3 0. $ elev. ft Depth to limiting factoL Remarks: q Boring # d-. l /b4~ L /h 5b~' yYf Lv f' 5 , L / rn sl~~ v - .Z 0,3 16\4,4 - 5, L ) yr, sbf~ M\ f LA, - Z Q.3 Ground elev. A 12~ ,i?4 - S G /til r' 11n 0.7 ft Depth to limiting factor Remarks: CST Name.-PleaVarve G. Johnson Phone: 386-4080 Address: P /O. Bo 91 SiEnature: Date: Oct. 96 CST Number: 3484 PROPERTY OWNER SOIL DESCRIPTION REPORT Page PARCEL I.D. # 6 r Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Y Bed rem L- 1b 6A -77 0-a /by+23 3 - 1 /hs K m r o.,5 i~- 6 1611p,4 - S? L / rh '56-PI 4r W ,3 Ground bZ Z-I /b ~4~ S m r 11, - 0.7 elev. ft. Depth to limiting i factor >/fl,g3 Remarks: Boring # n O_ /Ot~ 3 J~ - L I m bk M~r S I !0 S 4 -32 7•$~/~ 4 4 S, C. ~ p►15bk fir S 0.2 3 n 7 ~t 0`/r2S S~ C. 1 n., sb ~r S .2 =0.3 Ground elev. gs _r3 /d`r~4~3 a r m 6,7 ft. Depth to limiting y cl°og Remarks: Boring # t1h 8z 3-74 Z .S' 6 S' 1 m Sb K /ht~ S - -2 Ground elev. e 4 -l2 16v e 3 s »t r /h j -7 ft. Depth to limiting factor Remarks: Boring # 's E3 Ground elev. ft. Depth to limiting factor Remarks: CILM 01),),,,o „r,n~, ,L A 4 4 4 a C4 05 i J~ MO l / Cb I Q / ~ w J z ~ i ST. CROIX COUNTY WISCONSIN ZONING OFFICE `t ST. CROIX COUNTY GOVERNMENT CENTER N~MMNNAM■ _ mine, 1101 Carmichael Road • Hudson, WI 54016-7710 (715) 386-4680 u _ December 29, 1997 Mike McDonell 1070 Hunter Ridge Road Hudson, WI 54016 RE: Lot 67 Tanney Ridge Dear Mike: It has been brought to our attention by a concerned citizen the septic system on lot 67 in Tanney Ridge subdivision. The citizen was specially concerned about the loose connection from the header to the distribution pipes in the trenches. During our inspections we do not inspection every joint to see if it has been properly prepared. This is not a order to repair, but something I bring to your attention for the future. Please call if you have questions regarding this issue. Sincerely, Rod Eslinger Assistant Zoning Administrator cc: file STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER --5X Y" /j7 ~Z I CIL. ADDRESS 029 /P061it( SUBDIVISION CSM# 17^V5 y Q-l Der Low LOT # Ce 7 SECTION T 2 c~ N-R ~9 49, Town of N IJ S p r! ST. CROIX WISCONSIN 6A.1~ I PLAN VIEW SHOW EVER THING WITHIN 100 FEET OF SYSTEM _ Sciltf ~/y_ /o ~~•Y5c aGy2s -y1 `L 31zIJ' ~y, ry y~ ' f7C Tlr~ iYr1 i o ~ ' w y tbG.oi r0 { INDICATE NORTH A ROW 1;1-76o IV S~/9 /71 Hof{ P Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: To e o h z ~ d'/P " ,o~T sF f.- Go"4NhlL /,o 0,.o 0 ALTERNATE BM: lo J1 o 6,(ocA- FauNV/47toA, e = 3.14s z "7 EPTIC+ TA K'/ PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: _ W c /3 r,rz, Liquid Capacity:1 2 „I-C G-44, Setback from: Well House Z Other 3/ ' 7o = (A- Ce-1Ae )FR of Flav ;t Pump: Manufacturer Model# - Size - Float seperation - Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM 10, Width: Length (a<=) Number of trenches 30 Distance & Direction to nearest prop. line: 1dS 7`® H /_07 IVA14 Setback from: well: Ct'~ House 3 'V Other To s"r ELEVATIONS Building Sewer ST Inlet: g, y$ ST outlet: 818 1= /aV 3 3 PC inlet "'7-- PC bottom Pump Off F14 RH &.0-t 9.5,-" /a 6Z. N ~,S? 9.53 1 I.0Z Header/Manifold Bottom of system Ai 1 I,Ty /3,08 Existing Grade 7. 30 Final grade °I, 3 0 = /O 3.1 S 114,174 N"1Z t I-F ~I,oZ 102, 1 3 r`'► t3,o~-= Ioo,o7 DATE OF INSTALLATION: 1? 7. z PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit 289488 8 Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. r~i~l fer's~l fhj%k#lage Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description`:21U~J Parcel T x No. (~20-1326-40-000 TANK INFORMATION ELE TION DATA A9700304 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic. S v Benchmark Dosing 5S Aeration Bldg. Sewer - Holding St Inlet TANK SETBACK INFORMATION St/ot Outlet 95' /v V, y3' TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet rl Septic o 1,r~ as NA Dt Bottom le'1.<o0' 9'.7 E ~ Dosing NA Header/Man. 7a- Aeration NA Dist. Pipe ou o C .O q~l.3y. Holding Bot. System J mss; ~o y.~b; PUMP/ SIPHON INFORMATION Final Grade SS ~04, 78 Demand y/ Jiz,Iza C.r u , a a 6, 3~/ / Manufacturer Model Number GPM TDH Lift Lric n System TDH Ft ead Forcemain Len th Dia. Fi Dist. To Well I I E SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 1.-9 DIMENSION LEACHING Manufacturer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM INFORMATION Type O) CHAMBER Model Number: 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 Bed /Trench Edges Topsoil E] Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 12.29.19,SE,NW 828 MOON BEAM LOT 67 r l .Ill Plan revision required? ❑ Yes a]/No Use other side for additional information. SBD-6710 (R.3/97) Date 's ecZi's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division 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. I Ct • Ciro t' • See reverse side for instructions for completing this application State Sanitary Permit Number ae9s~~ The information you provide may be used by other government agency programs E] Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. Oos M0Or &am ~ State Plan I.D. Number 1. APPLICATION INFORMATION Q - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ►~LF-2 1/4 6~t/4,S Z T N,R E(o W Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number 2 nd pSON W1 11cli o/ (11~): 9 7" 0 11. TYPE F BUILDING: (check one) ❑ State Owned City Nearest Road Village Public 1 or 2 Famil Dwelling - No. of bedrooms Town of MooNSEA III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) 9. /p. n 1 ❑ Apartment/ Condo D ZD-(3 Z4 - Q 7 7 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. V,7 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System ________System_____________TankOnly- EwstingSyste-_________ExistingSystem 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 12gSeepage 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 S. Perc. Rate 6. System Elev. 7. Final Grade S~ Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) C?4r. Ehyation 1jaj to Feet O I40 Feet VII. TANK Capacity gallonTotal # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. New Existing structed Tanks Tanks Septic Tank or Holding Tank 1600 We II S IF4__ E] 0 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ E ❑ 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 Stamp MP/MPRSW No.: Business Phone Number: Wit ' 46 L C.e Plum er's Address (Street, City, State, Zip Code): le.- 7,o LIB pru D l Q IX. OLINTY / DEPARTMENT USE ONLY Z ❑ Disapproved Sanitary PermktFee (Includes Groundwater ate issued Issuing Ag nt Si ature (N tamps Surcharge Fee) ,:;Approved ❑ Owner Given Initial (J 1/~( dverse Determination A 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 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 Pegal 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:-Z) -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. 00 ~~'04 1 cp w N i-w o C~ °s _ Q? ~ ~ ~ 7Cr ~ O d ~ d w •fi w ~ d r y- s I \ ~r ,F r / r VV V _ N t, 4 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of A_ " rand Wman Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but >-T ) x 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. REVIEWED BY DATE APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION PROPERTY OWNER: PROPERTY LOCATION Q -5Afh / Ukk e GOVT. LOT 5 C 1/4 t4Ld 1/4,S 17- T 29 N,R / 7 E (or) W PROPERTY Off ERy- WILING ADDRESS =QV)LLAGE SUBD. NA~pE OR CSM # !C Z~1~ N.A.M? To 7NAlty 1lS.G~' CIT,Y,~sTATE ZIP CODE (HONj NUMBER ❑CITY tdL OWN NEAREST U~Y NUA.sav L D6 New Construction Use Residential / Number of bedrooms Uri V_ [ ] 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 Max.' um design loading rate bed, gpd/0trench, gpd/ft2 Recommended infiltration surface elevation(s) L ' o ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MO ND IN-?ROUND PRESSURE AT-GRADE ITEM IN FILL HOLDING TANK U = Unsuitable fors stem S ❑ U ,PS ❑ U RS ❑ U Q9 S ❑ U S ❑ U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Twich -11 Iowo 3 - L 1 n, s rtit ,.3 tih n, sLt n•, Ground 1-120 Y~e4 3 elev. x,19 ft. Depth to limiting factor Remarks: Boring # L. Sb~ m~r 6A: 0 S - I8 love 3 5 L rt, 5't I~ ~ Tr w 0,2 0.3 `Z & r~-6Z o`~ie 4 4 0,13 y 4 3 2 o. Ground elev. f 00a ft. Depth to limiting factor ')/0.193 Remarks: CST Name:-Please Print Phone:~6_ ~O g-O 14W Q fqNSON Address: t S O1 Signatur : Date: 7 / CST Number: 5,/ PROPERTYOWNERS4YhM'Li-CQ SOIL DESCRIPTION REPORT Page? oA PARCEL I.D. L 67 -r4h n1 tl # . Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bw-d3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ranch M L 517- MF-T C, 5> Ground -6g dY Q 3 elev. S 4 S, L 5~1~ ~'h r s 6,2 /QK-fft -t3 / y 3 SG m I 4,7 a,8' Depth to limiting factor y 11 .DDS Remarks: Boring # A 0-19 /0`/R3 L / yh 5~K m~~ CS 1 4,4'b.S s - s, l~,sbk .Y,~r s - o.z 03 Ground elev $ /&D ft. 4-127 /,6Vk 4 Ms gC~ 1 `1 0.7 03 Depth to limiting factor ~ Remarks: Boring # A -41 16y?,3 1 14vy 0,iQ61ditlc- L 1 yv, cr fv,~r 10 . Alt 14"V I r. y M TTLIFA -SILT- Ground elev. / 6 ft. Depth to limiting factor SA Z Remarks: Boring # A 6-29 1611A 3/1 2~-49 16W', 5 IL / msbK M~r ~ 6,20 PU\j LY AaTrUt:n -SiL-C - A/6 4&0& U -Q 4c Q, Ground Q ~S elev. Depth to limiting f ctor Remarks: BD-8330(8.05/92) ll~ PROPERTY©WVER SOIL DESCRIPTION REPORT Page of _41_ PARCEL VD. # ,7 b~ ~PN Nth Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ranch l~ A O-JZ pbe 37 A L / 1k er r W Zr'1 6. r Iz-3(- /6"/te 4/3- ss / r,,7 s1K ^-Fr- Lj 1-~ o:z o.3 Ground b SZ /Db - . L SG !h 1 w ~ -6.4 L) elev ft. 8 5z-> »~iQ'~~3 /hS m , o g Depth to limiting factor Remarks: Boring # Q 16-2c) >b~/r2 / yhcr- ~r Z b. D.S 46 d\/,e srl_ n,sb n,~a~ w 1~ z d .3 SL 1 J145LY r l r~ l~l is 8 -S7 I D IJL14 3 Ground elev. Ms -S e4 A5 Depth to $ 7 Il / ~/~2 a 3 S Ca rh l d 7 d $ limiting f~tor I~. U - ~'1 Llf 11 F7emarks: O-Z cp y 5aoyt~ $C 1QE MOVC& C,O rh PL SLY ~F'+20 rt S~ ~-F Born9 # 0-16 ZOVO-3 ZS' S L l w. sb~ r C w l~ .2 b 6 A 4 14 S / rti 5bK n, W h4 :5 Ground 1 ` elev. 8_ al 16\IP- 4 M5 4 rn 02 O . /06.7 ft. Depth to limiting factor Remarks: Boring # 4 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) r \ a a PnG.~- 4 of 4 ' O A-D Li 10 N 4 arc q z r ° Epp'. toS ~S~~ w VJ T ~ w ~ \ DD ep S ➢jyti~ O ca 6 op (`k J V \ 3 , "C / j a a P~c.~ 4 of 4 ~ z ~ CD 0 ca tl- 6Z bb. cD r ~2~t pRy ~ 6 i V) \ J z 4 P i' 'J_~FL,a7T_i_c ~ar». I -WONT" Lod Or Tnt 301TN 63 PMS!b,4.]'1 of Tn( Kva 01 tnt Nwlra - v`L. 1 '24'0211w 9o' II.eM q As U20363' 4. /1 r 7L~07T, llfvaT 9,6., LOT 64 L0T 6LOT 67 Ac.. \ \A \ m Q."9 so fI 'i n.nv so If ♦ . "7.745 SUJI. w 4'>' p m Y \ r ` ♦ _ i_O ri I as K. yl 7 ]a f.c ES», - "LOT 65 c.:\p Ebt "m, a Tv.. I 7 C N) ` ♦ SAS \ 113. abe to /T I o \ \ \ / • 200 K. FT. Y, ~p \ LOT 66 x D Z♦~y 3 r♦ j 3, At c.c. t]»r IS Ac 7 Su. I it* . 4(a go FT c6 .7- 114 Ac. Imc esm, a. (to -CID 90 /T I - - LOT 4 ??1 41' I SO .f - fn a Jlas 926., eC w.. \ \ C..t'/.'/~ •✓J _ _-...1 Ib/ 19. 1 ♦ I` ♦"w~••. _ 8 -PUBLIC - -WEST - +1 ~b _ - --THE ~b> 2 26 K e■c cs», 'R+. s r / - BEAM 97,522 fit is' 240. 2A, 46 9.- S } r 3 zy ~f gal ti, - 311 _ _ - - 29:.,s......_ _ - - I~• t~w.:'T . ?3 -~=-•-s'~ \ \ "!,'23'7,'[ - J F 5 LOT 45_ Nw s ~1 LOT 59 LOT 60 ".mg so "0 1 1~ ( 2 w ¢ i Oo AC• 1.62K. PIC. Lfl»T. \ \ 91,f )1 so. FT. xY af. U9 !0. 1T. ' LV .s \ l.a06 f0./r ( •s \ N "wL 144. 00 `9' *b l Q . N 1. w 1 v K E.E. Es»T 35 1~~~►' IDj~ ` JJ \ b6.60 son E "wt • w b \ w ~ l- 1" . ,,..2 d LOT : K 46 II. SO ,T. . J`.`~ \~Rq`~~►` ♦ 1.~ 1.16 K. LAC. E3»,. 2 22 K. S0 n + 66.71) 60 [T. lye X, • ]0. T!6 . O 1 6 Q it{ ♦ 7,022' (J~'2 a0.x1' 2.01 K. 'IC. CS»r. ♦+oel' ♦ - 01.714 go. FT. ~ J ~ / -'(r ~ ls~ati ~ ~ :6,•x,'oz'w 511121' , 2.60 K /'LOT 3d SLOT 4? 1, 58 N • • LOT \ 1 1 1217,72 21 2 00 AC. / I o J I .1? aT4 7 C~ fT.060 S0. /T Gi i Y N~•yQO IfwE • X 1 ' ~b ='w ~i r e 0 38-0 aie ! V ♦ tp• K "wG • 9)f.W PT, n I a. as," wnI~ I f~ ' ' OT N r^►,._ - - . •:.-r......,._+...•-..~ - SO W rt ,,s2 K cbc c »r , 1 K IT 0. n. END 6J~N• IO!Z-- LOT. l. stcTlaN tUBRI.` \ / : / + I r 1 0 J :.~•IUI IJ7NU 49 •r. 3784 ~(a lull PIMI rUUW{I \ / ' r yr r r ~ ~ 11'07'[ ll sYi )6. I as Ac JN 1,1.1 ruuw I' E~ / 12f. sea $u.n. ~ •k 560 Our sCt, ",0.- 58s taS ,`u O pS~7 r;i;r LOT ~ may: ~ , • (♦r At t R Olnl lnT CJrN/b'. +./.UFb HIED _ - , C) , y,.in , • 24' I.. IN .'.tl 1•I141..ny - I f-. 1]1,191 IV 11 / I bb VI.) •'lW .INIAN Irt.JI Vw. b,•. .•NAINA4E IA31 »t NI --(/~J 1 1, tll! 1.1 II j/ rl„A•.wpr I '..r thKr 1.W L0 T3 'l I \{f\ t o y / • ._,a n Vt. r•wE • 042 To2: 3 K ' \i `t•;1 y , _ r►~~--1~' y .10T 55 Ask .,•N.. n.w-b1 ~VIN.N,. el 7]O At IRr, CSWI S~L:. ' w11 1 w w I.I V a nw~ b'f -IIS..,Vb 1v./1 . ; .U r i N•.ll.u n.IV1 I/IN4 UbIVI 1..•61 WN 31 '016.] :`R•,D (•J•~` 11~ ` ~ _ . :1 Int 0.:i wt 11./. W In! / ~ i3 I'' 'I\nwR,•'t.l yv` '1 1 . 262 K tIC f:Mf v ♦(Jl \ \ 1 1 1 "I'v91 sU Ir 917 3 / II I:l 1 Ilr 1 hb~ j LOT _7( LOT 51 • _ ^".J♦." " i 1 W v J I 117..,09 8.3.257 30.71 a Ne8•le',: ~.,13G C q~ 33';33' dzv r 320- . 6f;.NG319'Af16 rn A(..tl,"wwl tiI ( _ C) ..a.<I' av 1 r-' -r STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Si#/7,i 67I LL f g- MAILING ADDRESS EknX ,3!rZ g. 7 44 e~ 054014 PROPERTY ADDRESS FS Z 8 - N L:> ~ 4 rte (location of septic system) Please obtain from the Planning Dept. CITY/STATE L) 4S Q W lr t~ 1 JI - Ko- / e, PROPERTY LOCATION-SE 114, - 1/4, Section I Z-- T Z ? N-R W TOWN OF 9 y (7~4 ~4 ST. CROIX COUNTY, WI SUBDIVISION A Ai ME LOT NUMBER 67 CERTIFIED SURVEY MAP VOLUME/d 31, PAGE LOT NUMBER _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 _axkiration date. ^ SIGNED: DATE: I i I St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 • S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property _S j+ rM 41 / L- /Z Location of property,,51E 1/4AI-4.,/ 1/4, Section TZJN-R-PS 79) Township flula--w Mailing address Utk-sca)-L I C-,410 1L Address of site ? him ? t:; k,! Subdivision nameTqk 4 ( '1 JZ„ E Lot no. _ Other homes on property? Yes No Previous owner of property ~ A 14 Total size of property 2 , 7 p Total size of parcel Z '7 p / L Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes No Volume 1031 and Page Number ~f~ 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. -6 9/ ~ , 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. _dnp 'Signatu e o Applicant Co-Applicant Date of Signature Date of Signature DOCUMENT No. STATE BA F WISCONSI ORM 1-1982 T"IS Sr AC[ ReSCRrtO.OR RSCOROIRO *AT^ ARRANTY D D 504855 VOL 16311kGE 456 11GSTE,4'S OFFICE This Deed, made between . 1 Y 1 CO..%yp Randall W. Synan and Patricia E. Synan, ec'4 'br R • husband...and..WiEe . and Sarn. E' MI 1.ier.. .a.._.....n9.1e...Ferson Grantor, S EI- T 1993 to:45 O A: M . 01 Deeds Grantee, WitI1esseth, That the said Grantor, fqr a valuable consideration...... i, Randall W. S~+naa and Patricia E. Synan conveys to Grantee the following described real estate in ...St CZOix.......... RaruR" TO County. State of Wisconsin: 't Tax Parcel `Jo: 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, all in Section 12; all in Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. AND ` A parcel of land located in part of the NE1/4 of SE1/4 of Section 11, Township 29 North, Range 19 West, Town of Iludson, 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 28103"E, 500.00 feet; thence N8q 30100"E, along the North line of Certified Survey Map filed in Vol. "30, Page 722, 38.08 feet; thence N00 11'33"W, 150.00 feet; thence N03 58134"E, 351.07 feet to the point of beginning. This ......._.1.,4..r1Rt.... homestead property. r (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And..... Rl.17% d4.11._ Fl-.-•.Sy-nall,, and--. Patr.ic.i.a_,.E-.._.Synan _ warrants that the title is good. indefeasible in tee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. and will warrant and defend the same. Dated this ,J...... day of AUgUSt......................... ~ D 19...9.3.. RG~LYtd!~ LC', 4---(SEAL) ~G'tOf2L.ecsti.CC.A ~t✓ .........................(SEAL) Randall W. Synan Patricia rSynan .r, - (SEAL) ......(SEAL) • • . AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN r., S_ t. Croix ..................................County. r) „ authenticated this ........day of 19--_.•- P nall came before me .~j_.i........day of Auguste 19........ the above named a i Randall W. Synan,...Patri_cia E........... TITLE: MEMBER STATE BAR OF WISCONSIN Synan (If not...-... W...- .Z'OAflpjS_ authorized by 706.06. Wis. State.) to me known to be the z he I i N~~ person ~3 s m I rte- cl c~ I -d I ` O ~ 6N I r~ I ( l I I I I O I I I I ~ i m J { O g0 F o i ~ O G O p NO c } \ (A O ~ ~ L~ lnV1Gp~ - C