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HomeMy WebLinkAbout020-1307-00-000 o m ° I 03 a ~ rr 0. cc0 V L °o I O I ~ I V m I I O Z m ~ z I LL 3 I 3 O I m Z a rn w c ~ d € o rn a co N FN- f/) O O Z co c d 2 o c o fn F- Y, N Z C m '2 m 'a 0) N C CL C; C L t L p 0 0 C O N O Q O Z F- Z 16 Z o N o m c 7 i A E N "Its j H p I Cd. 10 w y ~ N tVl1 Y E ko E 5 Q :3 LO E L) LO EL 0 O O O ° •~l maaa N o. m o r- co m O W m tn~c~ lo0`irno~ } n N N m f0 r O .a E y m G CL =3 1 _ N O co ~ .D N q } Cn co '.3 ° C I O l y H C O O N m f 0 0 o R o o l O o ~ D _ Y M 7 y N O W C N N N o m • N f- N O O C O N U O yr O N 2 2 M O Z- ~L ~ I as ~v € a V a • a d C m `iv r.+ E c c r rrww a> > 6 (L 0 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT RECEIVED Owner @~e d- 1SSA ~A~Ue~SOnl MA? 1 Address Hur,\6zd Hills 3 ddJ, 7/90ri'6le L,-oe- - STCROx M ~c City/State UuDSaw WiSc. ZONINGOFFICE" s Legal Description: Lot ss Block Subdivision/CSM # rti m d Rd R t: , '/4SF V4SE , Seca? , Tag N-RJJW, Town of Nurasvw PIN # 02o-13a7-Od - SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer _ e-e kS Size ST/PC ON) / - Setback from: House 33:WelloW9 9P' /Lo mz 5W Pump manufacturer Model Alarm location (HOLDING TANKS ONLY Setbacks: Service road en a Water Line Meter location Alarm location _ SOIL ABSORPTION SYSTEM: 4Seo 14,1 aA oti ~_lo Type of system. S Ms e rh Width 3 Length 5 ' Number of Trenches Setback from: House G4 Well oitit j°``P/L`]a, Vent to fresh air intake 0402 luu' ELEVATIONS: Description of benchmark _ro v at 1'12' _PV (1 Elevation 00- 0 Description of alternate benchmark Elevation Building Sewer ST/HT Inlet 100-0) ST Outlet 27-73 PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover 0~1. y Distribution Lines (N) 9 a- t 3 (L-) 91. b I ( ) WAS g4, 73 WAS 9(- 00 Bottom of Systerr#,_ is46 16P 27-:U U (Q k;a S J L'' 9 iLS O ( ) Final Grade 14) 161. $8 (L) 100.80 ( ) Date of installation /8 / Permit number 3 0-7 GO to State plan number Plumber's signature License number NIV Dater) /17/ Inspector u S I N ~-t R Complete plot plan Or NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW N,k (AArk f rev- ~~o.p & 7a / CwER d~~"~e~ 13 r.,i~G)e 0 0 d- 3,x 15 '(6N~hPs USING( 1~-~- ~p ~N T~ I I I l~~u R t~ S i n rvi 6, (oy 6?~ .9p) Sept, SeptI 0 L 9"S, $"DRooN H~Me r INDICATE NORTH ~ROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: .Safety and Buildings Division INSPECTION REPORT Sr, G12d 1 GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 0 O Permit Holder's Name: ❑ City ❑ Village © Town of: State Plan ID No.: - STEVE MELISSA ALVMSW Hu DSOA/ CST BM Elev.: Insp. BM Elev.: BM Description: p„6" G 0.S GST)S Parcel Tax No.: IOD~ 00~ To d+ Pvt- ily, G tatine- 020- /307-00-000 TANK INFORMATION ELEVATION DATA A 9?0052 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septi GKS 11190 Benchma k 9•ypj /09 ~8 !oo Dosing e m /0q-: eration Bldg. Sewer Hol I lnt~ SDi-W Inlet 9•~~ 00.07 TANK SETBACK INFORMATION (137ift outlet .7 75 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake eptic 75 h2 (or 3' NA Dt Bottom Dosing NA 7^',41w, Aeration NA Dist. Pipe /a" 11•b7 14193, 8'1 Holding Bot. System v SS 9 •S ~ PUMP/ SIPHON INFORMATION Final Grade ,pp q. o!•~ t •S~$ Manufacturer De d V. WbNko (o vt T., S 00 ( OS! ll e GPM TD Lift Friction TDH Ft Forcemain Length I Dia. Dist. To we SOIL ABSORPTION SYSTEM BED Width t Length No. O Trenches PIT No. Of Pits Inside Dia. Liquid D DIMENSIONS 3 ?5 DIMENSION SYSTEM TO P/L BLDG WELL LAKE/STRE LEACHING Manufac SETBACK INFORMATION Typeo , AMBER a Number: System Q~ ~5 n~G OR UNIT DISTRIBUTION SYSTEM - (eV{L((, IL I~.~, l{,ru taf ~~dc~ ~v~c1 S er .fr Header/Manifold N Distribution Pipe(s) r( g Vent To Air Intake Length Dia. Length Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth xx See odded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes o Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) C"rl% fJr/ole la~~~ Avrx do 3& L+ L~ ~9 w G y - ! GAL gt~~~ t4 ftv_ 4q$ t-w- 6Me- 3 Tr *k A wA6 Iral,~d -1 D i n c,,,.4 4YLKG ~ G ► h okW -6 44, yot( (,0 d fhwS aV-d Ike &~~e4 trk,% j Pt6W _PromA_ k hOkA&did K'4 Vita 1v (Wks dUf • Plan rrev sion(re~r dP ❑ Yes © No Use other side for additional information. SBD-6710 (R.3/ Date Inspector's ire ADDITIONAL COMMENTS AND SKETCH 4 SANITARY PERMIT NUMBER: I I, I (EIIIIII i°`iilr+ BSafet an ureau ofBuUding WaterlSystems ■~r■r■SANITARY PERMIT APPLICATION 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. , C.eC3 • See reverse side for instructions for completing this application State Sanitary Permit Number ~ 0-7 490(,4 The information you provide may be used by other government agency programs ❑ 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 Owne Name Prope Location ve SS VeRSoN $E 1/4F 1/4,S.)7 T N,R lg E(or)W Propertypwner's Ma ng Address Lot Number Block Number /A City, St-at/~ / Zip Code Phon Number Subdivision me or CAM mber IV e N RN ~ lls 3 d 1"~~17 N S 6l ~ II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Near st Roa ❑ VIII age Public 1 or 2 Family Dwelling - No. of bedrooms own of U054 A) Id A)III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) S-3a 1 ❑ Apartment/ Condo 0c;0 1 a7 ( 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10E] 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 ___Nystem 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 21E] Mound 30E] Specify Type 41 ❑ Holding Tank 12 C&Seepage Trench .51M rJINDrt ltS 22 ❑ In-Ground Pressure 42E] Pit Privy 13 ❑ Seepage Pit TkiRi le 54)1) 43E] 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. Sys i Elgv. 7_ Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/d y/sq. ft.) (Min. 'nth) :,i jC75 EIQv'Sip t,S ~ / I. r0 Feet 11~~ oo." Feet (p Q 6 VII. TANK Ca n gallons t i Total # of Prefab. Site Fiber- Ex per. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks 10 Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: Print) Plu tier's Sig ture: (No MP/MPRSW No.: Business Phone Number: 5t - - 38(o- Plumber's Address S reet, city, State, Zip Code): Wr 67 w 3 lJ U Vnloj )s S ! IX. C NTY / DE ARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue JuiSignaujQ ng Age No S mps) a,f~lJj' Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination CONDITIONS OF APPROVAL / REASONS FOR D 4APPROVAL-~..e.~ SBD-6398 (R. 015/94) DISTRIBUTION: Original to Counly. One copy To: safety & Buildings Divi ion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is vaI id 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. Provideall 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 1/2x 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; 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. l• vt, . n. L. • ) ( 1-1 L U I A N I ) (.... I U `D L) `.) 1" L I I ) IN P I.: 0 J EC -I I) 1.) Ivi 8 f: k • i... 1NAME 5 \),et.s, 4- &IQ I'l 3-5A 0410floc,,.) NAME ...;., L 0 C A. I 0 1\1 ft 1?', ,r,( 1-111L LICENSE ://: .----)---R-4. /1(1 D A T E - ..• •• .1 . , P L 0 -I- M A P __...... .._ •-.!. ...! . i. :;,• . . . • . • . . . . • • • q Be9K,,°' , . \JAciloT . • .. . . ,. • Q' k)6k..? : Well "f 5 FAO 1,r, 1 Iso ki . . • . . . e 5 AI 5(NI • ., . Ifs' -7 , . • 69 a • 1 g3 • . . . 1 S • .. , .c) - 3 • . . . . - -rR.11.1cws- • ... Lt5)k),„ s.11)„,,,,,,,0,11. •••_6 . 468 Ali 6Y . .. ...a -r,.,,,,t1i) 514)i, 0-,,P • k-------- • ::, .;. • sit, (oldS1PR . .. t fb g7 . . i' • • \/ t 'FI, )1 ..! • i ,', (..00 703, Is c 1 :. ... . L ) 1.1 5V 144),A‘ • • • ' • • .;::,78' • -.. ..,, i . :. • 1 • :• . ..:,..: 1% -fat ch 1%2' . ' . • NI• . Y, • E lev-- iobi:Nk 4, 1-1;i 51.k.an fr"(t 1\ • . . • 1:: _____, x < C) _ \,‹ , FRESH Ain INLETS AND OBSERVATION PIPE CROSS SECTION (77.-Th_. )< Approved Vent Cap • Minimum 12" Above FIN P) G . itr1104) .. • • .: ..,i. • Final Gr \ ade H • • ,, . L. •. . 4 " Cast Iron , Above Pipe (, Vent Pipe To Final Grade • — • - • Marsh Hay Or Synthetic Covering . . . . _ , • . Min . 2" Aggregp1:1 • , • . Over Pipe \l' Y, , -- . • . Distribution 11\i _ Tee Pipe . ----)>- • ViAggregate • /N_....—L Perforated Pipe Below Beneath Pipe 4 Coupling Terminating I% - • L clP•Ob \f Bottom of System ....... . • . • :• _ . _ ....___. . . . .. - ..7 • , ` A.p pe,0 2 U.r-( 7'-0 ex/ 6-/',j4 L 7 E S 7 OF- //' /• Y r. .. Wisconsin Department of Industry, SOIL AND SITE EVALUATION / 3 Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County Include,but not limited to: vertical and horizontal reference point(BM),direction and ST au,X percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# APPLICANT INFORMATION- Please print all information. Reviewed by Date Personal Information you provide may be used for secondary purposes(Privacy law,s.15.04(1)(m)). Property Owner , Property Location S/ at eke//1S 4- , /� f5-6, Govt.Lot SE 1/4 Se,1/4,S 27 T 2-/a ,N,R /9 E(orC) P or perty Owner's Mailing Address Lot# Block# Subd.Name or CSM# 3 'O3 .'4-/3 7 57 . 55- f�U"ir3/g,0 44//5 - ,9a)/r: City State Zip Code Phone Number ] f� Nearest Road h-9.4 C�f}/�E I �v/. I sv-03 I( 7/s ).gr3/•o(06� ❑ City /f U,5-5 y 0.✓ Town I ejQ/o/E L.J . i Q New Construction Use: esidential/Number of bedrooms f/ Addition to existingti building ❑Replacement ❑Public or commercial-Describe: A//e- NO/ /f &--e,O,pH��A,.9�-D Code derived daily flow (07a gpd Recommended design loading rate ��/,p` bed,gpd/ftz • trench,gpd/ft2 Absorption area required N,. bed,ft2 0/ trench,ft2 Maximum design loading rate N'/' bed,gpd/ft2 trench,gpd/ft2 Recommended Infiltration surface elevation(s) �..€t- I GJ, • 3 ft(as referred to site plan benchmark) ,, . Additional design/site considerations 2(SC L'elZ' ' UU/U �W /n 4'V s to/ P�/ 4O~ / Parent material_LDsS5 ' '' $4,t•/fly O Zt�4- v(Flood plain elevation,if applicable ' 4.—. ft S = Suitable for system Conventional Mound, , In-Ground/Pressure AT-Grade, System in Fill Holding Tank U = Unsuitable for system Lg"S� IA/❑ U ❑ S U 5 ❑ U ❑ S LN'U ❑S El'o-- 0 S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots U in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed , Trench ( o'g /°YA. /, -ill j 4-C toil y 14/2 2 s 3--F- .7 •e 2- 11.2-7-, /oy/eY/ , fi// ! r s o sj_ dl 45. . '7 .S Ground 3 2:- ' 9 /ay, 3/3 13h e.: 20. S/L l S/,� /3�+ �/' CS - N p ; N r elev. /0 p 15 ft. Vim! C- ��L D d— - / Z y yz /0 a y/y .SC__ //file .f,e 4 — •1l ; . S Depth to q�j 7 ; , g limiting c 4 /Oyu(' s/� S d, S� dX , factor -� , 7 IQ In. Remarks: Boring # / D 2- /d yie 3/3 — 5-Z- /1$It 444r e 2 5 if • ct , •S , 71 7 i2•30 /6, we e6, 5 aS 1,e. as -- • -) ;-$ /aYR 5/6- S n s1_ d.Q .7 . 8 Ground elev. , Ib 7 L-Q—h. , Depth to ' limiting factor 7 y y In. Remarks: CST Name (Please Print) Signature Tiale hone No. APo/3ERr Z�/,b� e47- 7/3-• 3re6 .1/85- Address Date CST Number Ulbricht&Associates Private Sewage Consultants 855 O'Neil Rd. Hudson,Wis. 54016 41/ 5/611titfillidi . --)1 C �% \5) PROPERTY OWNERSOIL DESCRIPTION REPORT Page of PARCEL I.D.N Boring # Horizon Depth Dominant Color Mottles Structure Texture Consistence Boundary Roots In. Munsell Qu.Si. Cont.ColorPD/ft Gr.Si.S Sh. Bed ,Tre , t a•/z /0pe 2- s/L. 2--f- p,e_ /in 7e/ cs s i OD•_7�-rt. ' ., , .4OYI, Grt-V SL5L" /�' 4< 40101; • CSri►Attd / �s cs • 7r 0'ff /°7/ sy Depth to limiting — , factor — 7/, Y O Remarks: Boring # - • • 6 Ground elev. —' iit1ITi — o limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Structure in. Munsell Qu.Si.Cont.Color Texture Consistence Boundary Roots GPD/It2 Gr. Si.Sh. Bed ,Tren Boring # Ground elev. ft Depth to -- — limiting factor __in. Remarks: Boring # Ground elev. - -- — ft. Depth to — - —limiting factor In. Remarks: SBDW-8330(R.08/95) w iE$7— z oT A . \,.% \IN • ` ma' o `� o s w k 1 G D GIN 17') , '---- T .— ------- , , . .._. .... , c,._ , ...._ ..... -.-____ ... .... . ‘..,. , , , -4- sk..) \, . ..... ..._ , ____-. ._ ,1 .... ,,, ...... _ _, ., .... o v► ..... .,.._ , , 0 __ ___ 00. , ,........- \---\ , 0-6 rl, '`'„c) V . 1' _ St' �— --.4 \ NZ * J c• (AJ N I I 1 -� ° (, o o Q �p - ,°C o w G o • 14 n c\ k,, o t.. 1 ki) % . i , N \A ,.., 4 t„, f„ , . ,%- ..z --, . z . .... J t k VT s. ! -k. • k b iy? --I b 4 7` h wvl li kl N.. t t rtt 4. N .� . , t •a • ti'l'l'- 1115 SEI''1'IC TANK MAINTI,;NANCE, AGRI?P.t\ ENT St. Croix County OWNr.R/131)Y1?IZ rL NMANC ADDREISS j~" S7" t- wX ,5_x_7,0 1'ROPER'1'1' ADDRESS 115.__ r. (location of septic system) Please obtain lions the I'Ltruunl; Dept. CITY/STA• E.. n L!> - - PROPERTY LOCATION .S 1C I/4, s 1/4, Section ,~7 -I' osq TOWN OF !&/j & c /t ST. CROIX COUNTY, %VI SUBDIVISION tfUm i k ~ ~f'~ Yleq~' J~WIiO'? LOT NUM1 EIR CERTIFIEDSURVEY MAI' , VOLUME , PAC1; , L.U7' NUM13t;lt 3~5~ 'i 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. '111e properly owner agrees to submit to St. Croix Zoning a cerlilication Cotin, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the orl-sire wastewater disposal systcrn is in proper operating condititm and (2) alter inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scam /We, the undersigned have read the above requitements and al,rce to maintain tl►e private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR Certification slating that your septic has been maintained nntsl he conlplewd arnl retuntcd to the St ('toix Comely Zoning 011icer within 10 days of the three vear expiration date I )A*11:. tit t'11►tx t'onn1V 7.4111611, t )flirt. t it►vcnunt~t►1 1't•ttlt•t 1101 1':umtcltat I Road Ilnd',t,n. W1 '140111 1t/'t~ 8 T C - 100 r 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~t~CI"t ~ l7j C~%SS~ ly~'hSo !Z Local ion of property 59- 1/4 _1/4, Section 9~7 ,Tg~? N-R_ /Q t . Township ,C[u W--o - Mailing address #v4Son W X _ T7 Address of site Subdivision name 'j- Lot no. Other homes on property? Yes _No Previous owner of property t~^cl Total size of property Total size of parcel, Date parcel was created Are all corners and lot lines identifiable? )_Yes No Is this property being developed for (spec house) ? Yes No Volume /,Z-Y- and Page Number ,37 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 Sul-Vey 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 (ate) the owner(d) 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. 9U 7 and•that I (we) presently own the proposed site for the sewage disposal system or'fl (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.E Deeds as Document No. r gnatur of App scant Co-Applicant GG i~.►t~ c,t : i~t ~t ur~~ Dato. c,f Signature . ` roe 1279FAri237 nODUMI-r„ NO WARRANTY GEED i` A STATE BAR OF WISCO:. a~E -1982 56907 ii . Y I Humbird-Land-Corroration, a Minnesota Corporatx.a-- I~ r. ; P<u'r 1997 nviYs nd w grants to Steven E. and Melissa G. Halverson,- co _ Husband and Wife - 11:15 AM . t..., r,. L~ . _ . Fo Is sr of Deads I - I (IETVAN TO ,S (aunty, . the fulln.vinf; described rr:d estate in Sc- Croix NE"M State f Wiscunsin: Tax Parcel No: Lot 55, Humbird Hills Third Addition Town of Hudson, St. Croix County, Wisconsin I TRANSFER.. ~ S I # :t This S.. n.O.t....... . homestead property. I (j@}; (is not) i Exception to warranties: Easements, restrictions and rights-cf-way of record, if any. t- . _ 1 97 Mated this . . day of Novesber 9.._..... 21st HL _ 1$-T LAND CORPORATION ......(SE:AL) . . (SEAL) . Austin J. Bai ion, Its President (SEAL) . (SEAL) AUTHENTICATION ACKNOWLEDGMENT STATE OF ~ppptdAM MINNESTA t j '3aasey............... County. authenticated this ........day of 1J----- f`tesssenaliy came before me this 21at.... day of 4- . :2.97.. the above named . TITLE: MEMBER STATE BAR OF WISCONSIN A- . - - (If not, authorized by 6 106.06, Wis. Stats.) to x kzuvwn to he the person who executed the !®.e=yffi_ inArum/ent and agfcifoablcdj=t:t}je' E ~'.i!1A~1 s ~l oL- rate-ur_s~:nre 1274.44 EAST LINE OF THE SEI/4, SECTION 27 S00°39' 1 66.00 470.00' 101.50' _ 1 571.50' 729.' ip I i N co 1 3 N o / ir o tp - W V N ti a w O Z w 0 o N I O N W CO _j N I ~a W I ° ~ I O N W I I 1 z ~ Owc ai I 33' 133' a I I N00°39'13"W 210.00' M IA O N ~ I N \ S00°39'13"E 555.04' \ 3351 \ M l l ) t0 v I w O CY ` Q N ti c0 ' •`r% SS O N 01 OA~ 030° 4 e 1 6 o q9 V/ ^ v o~s2 N ~ P ~3D~ Zg rO ~ o ~ . L0 a, s'~ ro \ co Lo w (D cli 90 c; rt) \ I O O • • Z z Cn LL a ~t o w `r M NO0°39'13"W 354.46' o u tan fl- r z o w N I d' 0 m , w u lei I \ m O N m co ocv w lsl (n 0) 0) 4 00 OD w v / cn LL. U) ( z L0 w N M O O ZI W 34 A. in w~1 _ c-) Wisconsin Department of Industry, SOIL AND SITE EVALUATION / 3 Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and 577 441101;x ` percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please print all information. Re ' wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).~ ~Z • R •Of Property Owner ~j~/~ Property Location 511012 'i 11*5Sf - f1f}1Aso,f_j Govt. Lot SE 1/4 Se, 1/4,S 17 T 2 / N,R 19 E (oro Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# ~O3 ~i'G/~ % s/~ J~✓r /~U~'113/12~ 1115- 3A01 City State Zip Code Phone Number Nearest Road '~,ij C~~/if'E~ Sy70 (7/S ) 8,31 • &9& ❑ city v ' a e Town ~iQlD/E" LiJ . New Construction Use: esidential / Number of bedrooms _ Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: A// - NO7 /P~LQ,N,4fF~D~Z,~1 Code derived daily flow (lgpd C Recommended design loading rate bed, gpd/fit [ trench, gpd/ft2 Absorption area required T/A bed, ft2 ;7 trench, ft2 Maximum design loading ratebed, gpd/fl2 trench, gpd/ft2 Recommended infiltration surface elevation(s) _C4!U_ ALL • 3 ft (as referred to site plan benchmark) Additional design/site considerations It/S& 1-~o~~ N/ I~Owls w~ de)k Parent material - Ld~Ss D~ S.9,vl~y DLt>~ Flood plain elevation, if applicable 'y/~ ft S = Suitable for system Conventional Mound In-G_r,,ou/nd Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system 2's ❑ U ❑ S Ll"U El S ❑ U ❑ S E~j ❑ S 0-0- ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench / 0'9 /oy/ez 3 ~i/l . GS 141t ~lr V- 3-F- .7 g 2 /O y ! 1; S D S dle Ct . 7 S Ground ' Z /D 3 7 Y/,/ ~1+T/• - N h'a All -I& elev. zi-C 100 -1.5_ft. / C Depth to ' q!Y2 /0Y/C S/7 /L►'i ~i~ 4 G!~ L~ . S limiting -l d /O $1lQ .7 factor Remarks: Boring # p /Z /d e_ 313 SL 17"Jile 1;"I W 4 S 2 ' . S 1 1.2• f~ S d d as '-g Ground elev. Depth to limiting tactor 7 In. Remarks: CST Name (Please Print) Signature I Tele hone No. Address Date CST Number ,r SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL LDI Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 0-17- /D ,Q Z S! L ? 4M -ir/ ' Cs s N N /0 VA31-3 v i 3 ivy S/ L" 44 A /J►~r v~. " C•S' Ground Z-5 41" /lf CS -7 • ~j elev. GG Depth to limiting factor YY Remarks: Boring # ' G Ground elev. ft. , Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: ~vFST ~ ol- . iv~ w` ~ G D G acs r i V O J t o~~~ p o a ;C O r -y Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page l of 3 Labor and Human Relations Division of Safety 6 Buildings in accord with ILHR 83.05, Wis. Adm. Code Attach complete site plan onpaper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or TIEE orx dimensioned, north arrow, and location and distance to nearest road. DATE APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION PROPERTY OWNER: 1 f U,yy3/,PD ff i~S ~'1 tiD O /d PROPERTY LOCATION B/L- 0 % O.v - G~Al,P,ti y GOVT. LOT 5,C- 1/4 ,SE-1/4,S 2 7 T 2Y N,R /f E (or) W PROPERTY OWNERS MAILING ADDRESS / ✓2~8 f iD.v~t7~ LOT # BLOCK # SUBD. NAME OR CSM # 334 ?!>s..PoB~'TS sT C S) S ~IUMRi~l7 HI~~S ~~ti~S~ 3 CITY, STATE ZIP CODE PHONE NUMBER (]CITY VILLAGE 9MWN NEAREST ROAD /YN. 55/0/ (G&) Zit-5.SS5 -H uflso,J New Construction Use (residential I Number of bedrooms ' 3 [ ] Addition to existing building I ) Replacement ( j Public or commercial describe YSa - Code derived daily flow moo g Recommended design loading rate bed, 9Pd1I2 trench, gPd/tt2 Absorption area required bed, ft2 trench, 112 Maximum design loading rate ~ bed, gpd/tl2 " F trench, gPdjft2 Recommended infiltration surface elevation(s) S.~ 3 It (as referred to site plan benchmark) Additional design/ site considerations SSE L° v LcJ S Parent material CGS Flood plain elevation, if appiiFable 41,4- it S = Suitable for system co MGNAL MOUND / IN-GRO D PRESSURE AT-GRADE SYST FILL HOLDING T U = Unsuitable fors stem E5 ❑ U ❑ S o 0 U ❑ S ❑ U ❑ $ SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Ekxxxi y Roots GPD/ft Boring # rI,,z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed vxh e z 511 z f s6,C' AM V~2 6o [.3 2- 1, AJP opi Ground - 3Co ~ ~ `~lP Sl 2 f s,d~ fie CS - , S - G S el T ft. - ~fy ✓o v~i~ / f <56~' ~nr~i ' ~S - `f Depth to 7~~~ .00 limiting factor > %0 Remarks: i Boring # 0-/3 1-90, 4M700e 5 r/7c- Z z l3 -lo /o W 5/~ 5~ L~ Shy f e s - 4 er( . S - Gr ound P ft. ~ S - Depth to limiting faciqr PROPER" OWNER SOIL DESCRIPTION REPORT Page ?of 3 PARCEL I.D. # /-Of ZT s S WM 13 1 PP /,////15 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botrd3y Roots GPD/ft In. Munsell Qu. Sz. Cor!t color Gr. Sz. Sh. B~ rerxfi 3 ` o - /o ,P 31z f.~ S L 7-16 1o fie y1q" sl 2f sk ff, Ground 3 elev. ,ul~l QE-- /oo. Sy ft. ~ Depth to 7 S YiP y/~P ~M, 56,E `l - . S € • G limiting facto .i -s lz2 y ~s ) If pl;T Remarks: Boring # / 10- /pyi~ 2-12- - S/ 2fsG.~ El Ground / /,,,e 17LR. t i Depth to limiting facto ~i > f4 Remarks: Boring # ~ 0' ~Z /O!✓iP 3/Z ,S~ Z fs.6~ ~~.r° S S.. 2 /L- zo ,a y s/ a s6,~ r.~P 1 l , S Ground elev. 6-(gyp 7,sy,~° y~l{ - • s ~~C CS ~00 y 7 2- rt. S ° 1604- S/ CS f 1,7 Depth to limiting facto Remarks: Boring # I i f Ground sie~ o N~ DoT 13 /ti = TAP of y „ rP sP c6/EV~4T% d~J /OO 0 ~ 1-0t SS 55-CA IE 30 • = ~ -Ar y P%TS - 1670 Z(P , ~Z g 3 1~ W N °30 10 W 664.12' S . e 99oO ~ ~ y6 30~ e .7 Ile, S 45%0' 00" W c 86.82' S44°10'00"E--I 66.00' y S76 27' 41"E 463 /3 I I V u so s9 ~o s~ s~ s8 y, S y AML-i 57 c S69°3015°W 942.42 rE_ i "Sky S offict, • . tl. c9e1[ to. WIL tPdrq k. t.wd u_ r( VP A. V HUMBIRD HILLS THIRD ADDITION ail A a It LOCATED IN PART OF THE NEI/4 OF THE SEI/4 AND IN PART OF THE SEI/4 OF THE SEI/4, ALL IN SECTION 27, T29Nr R19Wr TOWN OF HUDSON, ST. CROIX COUNTY= WISCONSIN. L•Nvrp..a OWNED DY• LEGEND IUwe MO WO Id1MMaT10P1 AUNIMN CMM laCVm M&b CNT r0s0 ION ►NYI[rr aua O~Na t- WON owe FOUND a3. Nd11N MOe(Mr R e,, r.lll, W s5wX O or r acs MON II►[ YT. WCM040 3.99 LOL K• LWUI Poor NOf all ena 101' tpKMf wentAw NTOO MITP f. a.• IU j WON PA. M wUe al lH led. rlM LW(M LOOT s I 109111111TV a/3[w[NT LOT 21 i !,OT 20 -yf IU I -...._eo Ilaowa, aTUCM cat I IfR ~r0 0110 aPO oMasuo[ [satbprr io ntw, oN =I DM.1 I ~IU)d61RD HILLS IST ADDITION I LOT 30 I I __I 11UNBIRO HILLS 2CJ0 1 0 1'•a.•WONrot OCT. MrlaNNOlutaaK•uNUVlMT N Sype AC01T10?! I tL•93a iZ I NOTE n_ 1 Irn' Co1*TMVCTION OF DRIV92. MtUCTUN[a 0e0aIWI - LOT 46 W=(sKuls ►MOI.Yr[O INOaS.-Ic WJ{/N MO J." a0rtl lu.ate ft n. OewTr uewrm MO.aa.nlri'~ iw I"(101 u • Poaa \ tRr101 My ?p?~~ / \ SOOT aLn h .S45.50'00"W ! OT 31 s'tlb# 86.82 HUMBIRD HILLS 2ND LOT 47 ' .1. awls 4 'I '00"E AODITIOt! 3 _ 13e,eN fO.R 66.00' S76- 7"931 E a aasroa'u.[ / / r 463.13, $ LOT 48 [.M !/Jltl ' ~ f•T'7Y [L • 100] LOT 62 laa.T.r Mn P ~ 3.30 KMtl ,C hre•a►, r w' 00'"a fart •,j 12: •a-w i Jr, 1' 60T 61 3 Z LOT 49 j ° - 34.41 'c-Es i I ~1 I1.91. sa.n. w IC) O 1... •cKf 4" r• C) O w,:+l ra.rt 1 f" I Y aaa•ro'.r1+ MA, . r7l Ic r f d f a•rre'sr[ I P Ls..aa •N I LOT 59 .n LOT 50 ae o• w S 1.30 .a,(9 1r ~f a y oD.ar. aa.n. y ly IaO,Ye SO.It }I i + I 3.00 Into CD 1 ~ 11I , 11 1 r A LOT 60 I~ MN•15'O•w 7s0.Te• ( 4It 1t 3,01 aT1.00' 71.357 so. Ft so. Ft all ra' \ d1 \ Ir+ \ ` ; 1 r --__-_2a! ~ OIL Iv LOT 52 LOT 51 , 4 $at >).r•w too. lt~ N,asa Mm 2.26 ACRES \ \ , - - JAY tt - L!}NE Q a►,of so.) } ~ „ ~ N.••ad.r'c :e9.lr LOT 58 2.03 AMES % F 1 9v toYYw n..o, tart 141*1 PIa9"7e'.r [ [a*.TI't _ORIOLE _LANE LOT 56 t` care ae.I "e - ~ 2.23 cues r1 9 ed.f.a Mm. w1 9 tedh p.... I rbow. an LOT 53 LOT 55 cap (Piet) I. f[ Ma..olo M f subj.ot to state, n,re >a LOT 57 Cava,, and Tavo.blp 3 •LOT 54 93,n9 fart r r lava, rula• ►nd Lit •sa_ au n to aoltl ~a >S !i ra[ulatleDS N 93.359 fart. v.t(s•d•, elalwwe lot Oise, access to r parcel, ate.). j 4• sefor. purcba8100 or \1 d.vef cal en sat tb [L•930 St. Cc _a C.Ott7 ' ib Ta.as ;8 S Zoning l[fle• sad arep fart. Teva teard [or sdvla.. _ 1ONA.. ]ll. tl' 3H. ' S89'3015 W 942.42' ' )(uLTrr axtnmlrs • No pe!• or burled $ INTERSTATE '94• placed sre to b. .AT LOCATION lnatallrtl etvouldh. dl sled rb m~ •urw L/C9 MOLD IL _ _ u _ atak•, er a at[vatT r A WkconslnDeparbnenlofIndustry. SOIL AND SITE EVALUATION REPORT Ptlpe 0l3 Labor and human 14talons Division of solely S &lktings In accord with IL11183.05, Wis. Adm. Code COUWY ST. Alloch complete file plan on paper not less than 8 1/2 x 11 Inches In eize. Plan must Include, but pAI1CEl I.O. S not Amited to vertical and horizontml ralerence point (BM), dreclion and % of slope, scale or dmensloned, north arrow, and location and dslonce to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PnOr'ERTYOWNER: .O PnmERtYIOCAIION f ?4y - ;8~~/r0 GOVT. LOT j~ 114 -5-6- 114.3 t 1 T 2y NM /f E (or) W Pn0PEnTY QWNFR:S MAILMINO ADDRESS /2~8 PLO v~6P LOT 1 BLOCKS S11BD. NAME On CS1 IF 336 ,AoBx4Pr5 ST y~ - 1jum t RD 11015 PbnsE 3 CITY, T TE ZIP COD HONE NUMBER CICITY ILUIOE NunEST RO O vL I!N• 5-5101 IG21 X2.1-5,3 { upso,,-) O~t?~EiE ~ti. P, r ew Conseucnon Use I I. I hesidenf al I Number of bedrooms - 3 I I Addition to 9ASIng bulldrlg l l ReplaDemenl I I Public a eommerdal describe Code derived d* now e00 gpf necmmended design bmlr g rate bed, ObW Ranch, M)W Absorption area retired bed, 112 Ranch. 112 Maximum design landing tale bed, gpd/0 ' Bench, gpm? nemffwmded Infiltration surface olrwallort(s) .3~ • 3 n (as referred b site plan benchmark) Addillmal design / sue consldereflom *SE <eA~' ,f/IW401(.~6 $ Parent material _r, 5 G''~' /ge-, flood plain elevation, n aW6able II S - SUIMdaae b System oNYFNTIOML LOW IN 01101,11,10 PRESSIME AT-WDE SYS?M IN FILL NOLORO TAt~y us [BY w S LIU us L3tf 0 S O U L] S C-ilT U- Urlstlnabb bi stem Ids 01 SOIL DESCRIPTION REPORT t)oring N I lorizon depth Dominant Color Monies Texture Structure Consistence aw fty Roots Gpo/11 In. Munsen. Ou. Sz. Cant Cola Gr. Sz. Sh. Bed I o-rte .b ,P l L S/ z {s6,~ Mr ~fiE cs ~ f , s . ~ /1=/f_ 2 Q i'41 ' 4 S /f AJ fu Ground /0 1XI Depth b S1',F f~ S • . S~` . • 7 ' Imiflng V facial N nemarks: Poring IF a ~3 /~y/P l/z s/ .2 s 3 o • Y0 7 syle Ground / /4►+ .e ~~Q cs 8 reppln to - 136'ng far nemarks: ,ST Name:-Pleue Print tP 0 Q 15P T- 74 L-(3 E I' C A T-- Phone: 715-- 3 P6 re,s: ~s s o' Ne. PD. H uVso J 401,s-5016 Signahxe: Dale: CST . T COPY h ls /1 tpst sttc~ Pn1"{AVEIJ for $ convAntic±r,:~~ s~ntic system Ak ESCRIPTION REPORT Pape? of I S 3011 D PROPERTY OWNER _ ~~13 ; Q~ Si// c _S J PIIRCEU.D.1 LG 1! Slruclure Gpt)/Il ~Y 9ed oeplh llominsnl Color Mo1Mes Texture Or. Sz. re C40MISe.M Roofs Rorkig N horizon in. Munsell Qu.Sz.Co-t.Cda S sh. Or. 2-66 /of/ vei( ,P 9 PV/t ~s /4 Grmrncl 3 G " fG y elev. - ,u// vQ- - 7-s Y,e f/6, " pepAr to x / ~ d Remarks: Boring N o_ /oye Y2- /-F -5 • G ? Y"e V/0 o ~.pnro t - I111 Inckx ,i - _ Remarks: / f S Rnrlnq II / D' /Z /O f /Z s~ 1 ~sd~ M^fX S rl .22 ~aY~P~~ Ground s f CS ,A elev. _-(-o 7sr,P Y/4 S ib e S/ o~ppnr ro ImiOng lick% Remarks: Roring A Ground elev. II. - - oepm to Amitlng lackx Remarks: f got n of l r~ sP /oo•D f /C- VAT/oJ i iol S # S 1-0 30 91 P%rs Gj ~ • ~5 13 L /3 3 w fle unzro~S - ~ /~,S (oG ~ ~/Eve-r~ov 5 /j Z _ BY 13y ~3 3 loo, sy - /3 1o z y,, Nip 7.P~N 0 /3 s /6 cv 7~~~ sy-7 z fir.,