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HomeMy WebLinkAbout020-1049-50-000 a o ~ o N a I I CD N c r - L N Q w i o I i' d ~ Q N d 00 m rn c O c z c 3 rno U. a o d o c ~ E ¢ a ~ I N co a) z r O Z 0) d d N H z a m I o z d v d d N 0. d (~j C 11a N O O O N ! a L t t"'4 co N C c _ ~ O N O Z F Z 0 Z CS N ' d ~ I E moo' d m (O LA W d v y N d d o 0 0 0. E Lo ' o UL co it 333 I m 3aaa N N U v ~ n n ~i 3 o N o U) J U'',, = rn rn Z 1 r- r- '0 LO co tn r- 0 C) O 1 0 0 wftk-l N N N 0 0 7 d a cq c) N Q } U) m ) O O 0 > N C 15 p (p U d c0 d 7 0 OD r O O U c 0 r \ yr, O W CD C CO V a 0 C. V Q7 ~ c N E dc d (D h O d. C Co co .d.. O 7 N N M Q O ce) N d V F-' C N (D Q7 (D O N 2> co O Z y z (n V # Q € a L: a. CL -6 2 .2 ~ 0 r A ()a STC - 104 AS BUILT SANITARY SYSTEM REPORT C > ~`~nltly~ L~ ` ° OWNER Lp N ADDRESS q- A-60'j SUBDIVISION / CSM#_ LOT # SECTION T 7 N-R 4 W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 &ok u f, Hd"n a01 U O ~x'l fl" O goo R, M ~ C ! a 5x 3 i INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: O V - -j- 52 0 JpY.~ ' Q ~ 1-~ ~ ~ U~• ALTERNATE. SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: C p~ { 1C S Liquid Capacity: b63 Setback from: Wel16Ve(i SUl House Other a . PUMP: Manufacturer Model # 5 Float seperation Size c Gallons/cycle: SU = rj Alarm Location G 30-;SOIL ABSORPTION SYSTEM I Width• S Length -4 U Number of trenches a Distance & Direction to nearest prop, line: 10Setback from: well•oVQ~ L N - .09 _ House (]U _ Other `rvb •oU m 4+, 4°v.a9 - awn -WO ELEVATIONS Building Sewer ST Inlet; - ST outlet 9 PC inlet S . PC bottom 11.1 U Pump Off Header/Manifold Bottom of system I }A - ~ 7.70 Existing Grade Final grade 1-,) _ loo, jo -00.3 DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: lw 1i INSPECTOR: 1 3/93:jt y r' ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the K1 h1 p QGt residence located at: 11 Section, TQIN, R, Town of HuosON Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: CQ 11 Did flow back occur from absorption system? Yes No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: / Construction: Prefab Concrete V Steel Other Manufacturer: (If known) : U-Q"1~k(z Age of Tank (If known): QA, 3 °'WYw S m 6o u M-e p f I e le (Sign ure) (Name) Please print (Title) (License Number) Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name J A M DO U mC4N Signature4~ goulyouRv MP/MPRS 1 ~I ~ Wisconsin Department of Commerce SEWAGE SYSTEM Y Safety and Buildings Division PRIVATE Count ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanital'if ~jtlVa.: Personal information you provice may be used for secondary purposes [Privacy L S.15.04 (1)(m)]. y 33 tts3 2u3 VP WoIdeCS plpme: [ tx ~(illage Town of: State Plan ID No.: CST BM ElevLL.:A/ Insp. BM Elev.: BM Description: 17 1v Parcel Tii1049-50-000 TANK INFORMATION ELEVATION DATA A9700203 TYPE MANUFACTUR CAPACITY STATION BS HI FS ELEV. Septii~j Benchmark CJ . co Dosing °"S ~y ^ C Aeration-- Bldg. Sewer - Holding— St/ 0 Inlet TANK SETBACK INFORMATION St/ Outlet TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet o g ~3 Air Intake Septic y 2 J , _2 0' / 7 NA Dt Bottom 9s, 9/ Dosing NA Header . Aeration ANA Dist. Pipe Holding Bot. System PUMP / StNFORMATION Final Grade Manufacturer Demand Model Number ? GPM C/ W -7 ' q (off TDH Lift Friction System A TDH Ft oss mead [Forcemain Length Dia. 2 Dist. To Well 1 ' SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length No. Of renches No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN SYSTEM TO P / L BLDG WELL LAKE / STREAM LEA Manu acturer SETBACK CHAMBE INFORMATION TypeO / ,C./a;~, Moe Number: System: ✓1, >56 T DISTRIBUTION SYSTEM Header / 9 Distribution Pipe(s) x Hole Size x Hole Air Intake Length Dia. Length Dia. ~ Spacing SOIL COVER x Pressure Systems Only xx Mound Or - rade Systems On y Depth Over Depth Over xx Dept15 Of xx Seeded / Sodded xx Mulched Byd /Trench Center 24@H Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 20.29.19.190C,NW,NW 861 W OW RIDGE ROAD J d l~ "Ai Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t{3 9-z? 057 ? 37 Safety and,Buildings Division ~~a~r■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 8 112 x 11 inches in size. ` T • See reverse side for instructions for completing this application State Sanitary Permit Number ~g9 38 The information you provide may be used by other government agency programs ❑ Check it revision to previous application IPrivaty Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prop rty Owner Nam Property Lo at ion © f 14 N v4, S Q T y, N, R/ y E (or) W Property Owner's Mailin ddres Lot Number N IQ Block Numb„ i 'v 1~1~1 City, St to Zip ode Phone Number Subdivision Name or CSM Number 5 0 ~j T, T620/ : ~ r )_ToOla 3i/ II. TYPE F BUILDING: (check one) ❑ State Owned o City Nearest Road E] Public L)r or 2 Family Dwelling - No. of bedrooms Town OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 01A 0 - 16 9 _S0 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,`R 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 12QfSeepage 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. Syste~r~ Elev. 7. Final Grade Require{( qq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Mi ./inch) I-1 9 I•ty ElAvaat*n q50 17S v M ?s Feet M j o .esfeet TANK Capacity - t VII. in gallons Total # of Prefab. Site Fiber- Plastic Exper INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. New Existing strutted Tanks Tanks Septic Tank or Holding Tank 13 - -L D-14wilf ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber. 1 CA ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: Plumber's Sign ture: (No Stam s) MP/MPRSW No.: Business Phone Number: 5A 3j4o -M6 -510 AD Plumber's Address (Street, City, State, Zip Code). 16-76 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sani ary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps) XApproved ❑ Surcharge Fee) I Owner Given Initial Adverse Determination X. ONDITIONS O APPROVAL/ REASONS FOR ISAPPROVAL: SBD-6398 (R. 05194) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divr_ion, 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 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: L 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. Vt. Absorption system information- Provide all information requested for numbers 1 through 7. VII. Tank informatior. 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 phore number. Plumber must sign application form. 1X. County/ Departrr:ent 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 anti 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 t-irough these surcharges are used for monitoring groundwater contamination investigations and establishment of s_andards. L. U I A N 1► P -'OJ EC -r N AM E AI.- _v. N AM E ~Skm ROUy%\; -e 2 CAT I L I C ENS _ Al a 3 -E 0 '1 3-rDRUUIrn GF LvI'~' ~R1GK Nvn~ AtEI°ICW o~ G,OKPe 7, ev = lob a • ~ ~y~ ~ Nofiee A~•p • G ~aod p 1 ~'1 ~ well 'Is j,r t ~r, tl p~ 8%O go Rknp C41 r,~n 3rj, a„ UR(.A Mf, •!•t ' a 0' s~' g y 5 kSC, e s A • ~ 3 a 3) FRESII AIR INLI:TS~AND OBSERVA'PIQN PIPE CROSS SECTION Approved Vent Cap • r ► ~ p ~ G Q b tie. `r Minimum 12" Above Final Gra~~__ J bO 4" Cast Iron Above Pipe Vent Pipe To Final Gradr. Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page l of~:_ Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 81/2 x 11 Inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and ST Cdr 1 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 02 APPLICANT INFORMATION - Please print all information. Reviewed Date Personal Information you provide may be used for secondary purposes (Privacy low, s. 15.04 (1) (m)). ' Property Owner 'A Property Location /'Aof X 1/06-7 Govt. Lot AIAJ 114,VW114,S _ 7-0T 29 N,R 19 E (or),w Property Owners Mailing Address Lot If Block# Subd. Name or M# M'4al-T 15.0 P5 P4 City State Zip Code Phone Number Nearest Road //UpSoN 401 5-gol & (~/S) 3SG • 3117 ❑ City ❑ Village LET Town ❑ New Construction Use: 3 'Residential / Number of bedrooms Addition to existing building 121heplacement ❑ Public or commercial - Describe: W T XP"-4f-04 Piy j>&AP Code derived daily flow y gpd 'rO Recommended design loading rate bed, gpd/fta . `O tra~nch, gpd/ft2 Absorption area required bed, ft 2_ 7 trench, ft2 Maximum design loading rate4V.--bed, gpd/ft2 • G trench, gpd412 Recommended infiltration surface elevation(s) • 3 ft as referred to site plan benchmark) Additional design/site considerations 10~ Parent material I Ts -i Flood plain elevation, if applicable it S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System In Fill Holding Tank U = Unsuitable for system p s p U Rs O U C-" ❑ U 2-s- 0 U ❑ S 2-0-- ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 In. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench -/Y loge 2/Z 5•L 1.wr ~~iC' S ~-w• • q S z y 3o /o YR 313 51- If She es * /f- .4 . s Ground 3 o•Y 7.5 LS ~s cS . ? . S elevv qQ. eft. 3. /o Y y/Ce - S a a~.~ 2 s 7; 8 . . S -1! /o yye SL 17 _)CI a. Depth to limiting of /d V/- 5✓G? -s 05. d.t 1 a'L ' factor ~s n. o / s/~ S d GQ~ i • 7 •8 Remarks: ! tYa t)6 - 61137- i S i rJ Boring# t -ti. /OYR3/2.57L f'fshk ds (4 ' •S Z Z .2-s 7 /-0 Oto 3/ SL /7~aslr ^4 ~ S • y ; . 5 17•y 7-5 '/A/I/ LS 4e/S Cw •7 •8 Ground ~8 • /01Z ole .k~X~u,.~ SL Z f ~h. Q .C , ' /DD • elf a,y. ft " /o YX 5Z ° ,S ~f' N • -7 • g Depth to limiting factor ~atsl'lr,~ S/~S T• ,8~st eN ZD .eJ y /o Q/~tl f /r T~ .5 y 9C--in. Remarks: - CST Name (Please Print) Ro sever 4 j_ (3R (Ct._r Signature 't a. a- Telephone No. 1!'~[ 715- 38G'9185 Address Date CST Number y 2- 7- f es r-lf s yJ0z-- lllhrir•hf A n-r,....m,,..•- PROPERTY OWNER vOt~T SOIL DESCRIPTION REPORT Page Z" of 3 PARCEL I.D.ff 0 Z e) - 6'0 Boring # Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 o io /o ye 3 /-L- ~L /fS& Sk ~ S 3 . y ; . S Z. O lG / 0 !//Q 31V f4o L,5 Aw .7 ' . S Ground 3 elev. 1 p Q -5-5ft. Depth to limiting factor > G / in. 7 V Remarks: Boring # cl. 2 • ~ /0 31p,P,yu L S ~,e Cs / f ; • S Ground elev. Depth to limiting factor qin. Remarks: Horizon Depth Dominant Color Mottles Structure Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # - ; Ground elev. n. Depth to limiting factor In. Remarks: .Boring # Ground elev. ft. Depth to limiting factor irt. Remarks: SBDW-8330 (R. 08/95) ~ Nk 1% " \1 IA o a y1 ~l V~1 g W v L c' Z L >e oo, N N bo- W I ~ ~ ~ I I C~ dp ILA w n ~ ~ Q ~ ~ Q X11 Mp C\ 82 ~a (c~ l a a o p p PRIVATE SEWAGE SYSTEMS • II PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP 4"C.I. VEKJT PIPE WEATHER PROOF APPROVED LOCKING JUNCTION BOX MANHOLE COVER 2.5 FROM OOOR. 12"MT IU. `dINCOW OR FRESH AIR ,AITAKE GRADE I 4"MIN r I l CONDUIT a° Mlu. \ \ IB",MIN. \ 11~ PROVIDE I INLET AIRTIGHT SEAL I III ICI v APPROVED :411JT5 APPROVED JO!PJT~ A I I I w/C.2. PI I I PE E.; C.I. PIPE I 111 EXTENDING 3' EXTENDING 3' ALARM ONTO SOLID SCIL ONTO SOLID SOIL e 1 I I I oN C ELEV. FT. PUMP____ OFF r D CONCRETE BLOCK RISER EXIT PEP,MITTED GNLy IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFICATIONS oosE -__PER DA4 BANKS MANUFACTURER: NUMBER OF DOSES: TANK :•IZE: ~OU_\ GyALLOMS, DOSE VOLUME ~s o.0 ALARM MANUFACTURER: S `J C lPV SU Ij, INCLUDING BACKIFLLOW: V V GALLONS MODEL AIUMBER: (o I I, W CAPACITIES: A= L.IMC14ES OR qo9- / (4_LALLCUS SWITCH TYPE: h"QIL(,Lr~ B= IUCHESOR 'o" GALLONS PUMP MANUFACTURER: ~ue11e~ C,=__T iUCHES001f*,U GA_k.ONS -MODEL NUMBER: {~5 0= =INCHES :R1 SJUGALLONS SWITCH TYPE: ArC,CI,riL{ NOTE: PUMP AND ALARM ARE TO BE INSTALLED ON SEPARATE CIRCUITS MINIMUM DISCHARGE RATE GPM 1 f~ VERTICAL DIFFERENCE DETWEEN PUMP OFF ANO DISTRIBUTION PIPE.. (P'V FEET + MINIMUM NETWORK SUPPLY PIR)E(jSSURE 2.5 FEET { 310 FEET OF FORCE MAIN J=F0OFT.FRICTION FACTOR.. FEET TOTAL DYNAMIC HLAD FEET IF INTERNAL DIMENSIONS OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH .Y_I1~ SIGP. EC: LICENSE NUMB=R: 3 ~L--- DATE: S '1' C - 1115 SI~,1 TIC TANK MAINTE'NANCE, Ac:I EF-M1•:NT St. Croix County OWNER/1311Y1?R .`/Q/jlff In= Pe 67- - - MAILING ADDRESS 5a1r PROPEM IT ADDRESS / (location of septic system) Please obtain from (lie Planning Depl. CITY/STATE,, ALL/ Sd? t, 44nA _ 5416 /)G PROPEIRTY LOCATION 1/4, _ 1/4, Section TOWN OF ~QScfii'1 ST. CROIX COUN'T'Y, \%,I SUBDIVISION /2/11&4j RhItt jg J 1( LOT NUMBER _ ) CERTIFIEDSURVEY MAT' , VOLUME , 1'AG1; LOT NUMBER lntproper 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. 'Ilse property owner agrees to submit to St. Croix Zoning a certification fo1n1, 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) aficr inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scnnl 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 scl by the Wisconsin DNR Certification slating that your septic has been maintained must he completed and retlnned to the Sl Croix County Zomsil, Officer within 10 days of the three year expiration date I)A'fl~• 9 7 tit ('mix l'uunty Lolling ()11ic1. ( iow-1I11111'111 ( eiltcl 1101 t':umlchacl Road I I I'► ~ 1111d.,oll. W1 '0010 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 / fix,)/ ~ee Local ion oaf property AW 1/4 Ala) 1/4, Section ,10, T_21f N-R_29 W Township Mailing address 1W 1 Pd I Addr. ess o C site 1-htL0,01 5 b~~ r Subd i vision name & f2d T° (Lot no. Other- homes on property? Yes X No Previous owner of property " Total size of property oxce-S X Total size of parcel. j akA,QZ X Date parcel was created -Pul As nV4 !n 14,75 ✓ (Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes ✓ No Yvolume _'51 and Page Number i 30t0as recorded with the Register of Deeds. 1953 INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRA11'1'Y 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 shah 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 (ate) the owner(sj of the property described in this information form, by virtue of a warranty deed recorded in the ffice of the County Register of Deeds as Iocument No. _ _ 93a(a0, and•that I (we) presently own the proposed site for the sewage disposal system or'4I (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 o.£. Deeds as Document No. Signature of Appli ant Co-Applicant IN.0-t• OI i(inat-.iire. D;ite of Signature DOCUMENT NO. WARRANTY DEED ns SPACE RESERVCD FOR RECDRDIRO DATA STATE BAR OF WISCONSIN FORM 2- 4 52260 IC,: VFASET6 REGISTER'S OFFICE ST. CROIX 00.0 WI - Reed for Record RANDALL .5-,---VOGT--and NANCY - - VOGT husband and wife UVT 10 1989 at 9:05 A M - -••LANA M. V0GT, a single person v ' . - c" comes and warrants to ...-LAN 0 ftomw of D" . . GR11\ & GM, ALMi1NEli --AW SECOND, P. O. BOX 106 _ - HUDSON, WIS(,`ONM 54016 Cro1X County, the following described real estate in St'.' State of Wisconsin: Taz Pareel No: Part of NW 1/4 of NW 1/4 of Section 20-29-19 described as foAlowes Commencing at A4W corner of said Section 20; thence SO 03'40" E on W line of said NW 1/4 1072.72 feet to place of beginning; thence N 60656'20"E 98.0 feet; thence NEly on c8rve to left, radius of 433.75 feet, central angle 7 19'11" a distance of 54.28 feet; thence S36°13'51" E~-s 409.52 feet, more or less to centerline of County Trunk Highway "A"; thence SWly on said centerline 368.3 feet, b' more or less, to W line of said NW 1/4; thence NO 03140" VA on said W line to place of beginning. Subject to easement for street over Nally 33.0 feet thereof`. and over Sly 50.0 feet thereof. also THIS DEED IS/GIVEN IN SATISFACTION OF THAT CERTAIN LIEN IN JUDGEMENT AND AND DECREE, File # 4345 Washington County, Minnesota, dated December 13, 1978 in County Court, Family Court Division. This 18 - homestead property. rip (is) (is not) IRANSFIM O Exception to warranties: Dated this lst day of August _ 1986 (SEAL) I SEALI I'atrdall S V gt (SEAL) 1-- ASEAL) Nan v li7oot AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WI'SeOMSi-4 Minne~ota ss. Washington Count authenticated this day of 19 Personally carne before me this -1St day of August---- _ 19----- the above named _-___Randall--_S-,_-Vogt,-a-nd--Nancy--Vogt, husband--and__wi-fe. . TITLE: MEMBER STATE BAR OF WISCONSIN (If not'.- authorized by 1 706.06, Wis. Stats.) to me known to be t hie person whc executed the foregoing jnstr ment and acknowlq&;ge the same. THIS INSTRUMENT WAS DRAFTED BV /~~t/ Law4consin bor Rt'e'' SOIL AND SITE EVALUATION P of r3 Division of Safely and Bulklings In accordance with s. ILHR 83.09, Wis. rrk r q1 Attach complete site plan on paper not less than 8 1/2 x 11 inches In size. Plan must County ktdtIs, but not limited lo: vertical and horizontal reference point (BM), direetlon and ST percent Mope, scale of dimenskms, north arrow, and location and distance to nearest road. Parcel I.D. # 0207 /O1~9- So .l Q APPLICANT INFORMATION - Pleas int all Information. Reviewed by Date Personal kAomrailon you provide may ed fa ry p es (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location i-AA1,f 4 PvGT Govt. Lot VW 1 /4 /UW 1/4,S Z C T 2 9 N.R E (or).W Property Owner's Mailing Ad ess Lot # Block# Subd. Name or CSM# 861 4"IMOw s is ~ /3ov, s P5 R407- State Zip Code Phone Number ~ Nearest Road UpSoN W Sao i (7i7) g~o • 3#7 ❑ city[] Village O" Town &111 de id Ri)p PAO . ❑ New Construction Use: [Residential / Number of bedrooms Addition to existing building &'Replacement ❑ Public or commercial - Describe: tike W T /P~~D~iK Ertl J~~f> Code derived daily flow f o go Recommended design loading rate _ f f~.bed, gpd/tts - trench, gpd/ttz Absorption area required " D bed, fl2_ trench, ft2 Maximum design loading rateebed, gpdHt2 • 6 tr Mh1 gpd/ltz Recommended infiltration surface elevatlon(s) $~iQ" 1 • 3 n (as referred to site plan benchmark) Additional design/site considerations CSC J ~'.tta~{ S W r' 404, ~,S~iC%iy.•~"`~~- Parent material eo1W4 15 JAV4 Flood plain elevation, If applicable xl~' R S - Suitable or system Conventional Mound In-around Pressure AT-Grade System In Fill Holding Tank U - Unsuitable or system (3S ❑ U 2S El U 2-f El U B-r ❑ U El S 2-0-- El S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPDflt2 In. Munseti Qu. Sz. Cont. Color Texture Or. Sz. Sh. Consistence Boundary Roots Bed Trench / _/f loge ii' aG l,►ri iC y S 2- y 3o 1 o yR 313 5 Ground 3 0 y 7. $ y - L5 / S CS . 7 , S elev gQ.,~fl. 3 • o Y glee s a d,~ Qs - . it"z Depth to Ail X Yc/ ' ~t ..t . • S -a O~ fimiflng /dt//C 510 -S 0 S . -7' • 8 factor y (j 4_in. do -IG io fti S14 d S Dck_ ~ • 7 :.e Remarks: 46ya I yG- S'Vs7. is 1N top- , Ce,v11i %1 v T Soi/S Boring # 1 -12 10YR31z- SL I fShk dS S 3''" q ' .S Z z 1-17 /0 9 313 5e- /_fs44t_ ,w+' 'f e_5 Z • 'l ; . S ve, glS c4 7:.8 Ground >~8 • LQ VA V16, A4,1~,,.G SL z f a _ • 5 • 6 /Ou Depth to limiting IN ' ' factor~~5ilr v Sr.ST• ,5>~ eN e /ZD.u t7&--In. Remarks: CST Name (Please Print) R o 13E RT 74 L B R (C(T Signature Telephone No. 715- 3$6 •0185 Address Date CST Number 1/0 SOIL DESCRIPTION REPORT PROPERTY OWNER L' q Page z. 013 PARCEL I.D.• 02- O + /O Boring N Horizon Depth bominent Color Mottles Texture Structure Consistence Boundary Roots 2 In. Munsell Qu. Sz. Cont. Color Or. Sz. Sh. Bed . Trench 3 I o /o 16 ye 1, s 3 ^K . y S o•l /O yR 31y LS Aw 4-r .7. . 8 (around V /O & -5- 0 Sf ~ ' elev. • - /pp.Ss Depth to limiting factor Remarks: Boring # /0 Hsit .3 -f- 's 2 •1(Q /DR 3/ CS / f • 7 : • 8 7 Ground elev. Depth to limiting factor In. 97 Remarks: Horizon Depth Dominant Color Moflles Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Or. Sz. Sh. Bed , Trench Boring H Ground elev. - N. • Depth to limiting factor In. Remarks: . Boring N - I U. Ground elev. Depth to limiting . factor In. Remarks: SBDW-8330 (R. 08/951 :b ~ ~ ~ o V -n Q o ~ ~tl Vii ~ W v 6' ~ o ' SS ilk N I f (ol 1~1 I I ~ O ~ I 1 1~1 kn ilk J b~' n o I , a ~ ~y