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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER Y ILL, , 1= 4 L~ ~
`
,ST r.
ADDRESS Gw J t`,, ap~k'X
Q-, L u try f,J Lt~
SUBDIVISION / CSM# LOT #
SECTION ;;20T2_N-Rjg_W, Town of ,wwi 4 kle v%t c
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100-FEET OF SYSTEM
3'~
i I c!~
i
V)
c~ g tM
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
rT e k•~
BENCHMARK: Spk- ivy 7) re- 1 DO D a'
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: h►►E-;Mrj ConL Liquid Capacity: ) coo
Setback from: Well w i G 00 ` Other
Pump: Manufacturer ru Model# r Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length s 3 Number of trenches
Distance & Direction to nearest prop. line: 4,5
Setback from: well: r~ HOU a other
ELEVATIONS
mg to4.31
Building sewer loz,68 ST Inlet: 1 o). j ST outlet: /Oo, S3
PC inlet PC bottom Pump Off
rt- I 97. Or .u-) 44" 9s
Header/Manifold"-? 9,,ss- Bottom of systemfa46_,
Existing Grade # 98 & 3 Final ~g o3
g a grade'r"mos
PATE OF INSTALLATION:
PLUMBER ON JOB: liyJet }
LICENSE NUMBER: ;7 SS 9
INSPECTOR:
3/93:jt f
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division County:
INSPECTION REPORT sw &Oo A
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)]. 2qq 't
Permit Holder's Name: ❑ City ❑ Village IR Town of: State Plan ID No.:
6U~t oc- 17o series bier A; c1(/ - - -
CST BM Elev.: i Insp. BM Ele BM Description: Parcel Tax No.:
loo loo i Ke i n tree, - Sou%a *s &7 3
TANK INFORMATION ELEVATION DATA A 9700 570
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
eptl t✓ I~fl Benchm r yS-6 101AS /Oo
Dosing
Aeration Bldg. Sewer Z /Ova
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 11403 lCOJ3
TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet
Air Intake
p Icy y~~. /p' /6' NA Dt Bottom
Dosing NA Header / Man. 4.7f Aeration NA Dist. Pipe
~lo~ 4'T
70 1i• 497.71 4?768'
Holding Bot. System dL3 7tal g6ja 16-1111S-
PUMP/ SIPHON INFORMATION Final Grade w8 Oct I 1#W. 99.6
Manufacturer Demand
Model Number GPM
TDH Lift Friction S st Ft
Forcemain Lengt la. Dist. To Well
SOIL ABSORPTION SYSTEM
uid Depth
Lq
BED QtENC Width Length i No. Of Trenches PIT No. Of Pits Inside Dia.
DIMENSION DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM HING anufac er: INFORMATION Type O HAMBER I Num
System(jgyft y*. NIT
DISTRIBUTION SYSTEM
Header/ Mani old of Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length -S0I Dia. Spacing 6 Adz-0►4 'S -4 Z,7&q 8'(St
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges es E] No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.) Z30 (p5
Thal /1.7g
Plan revision required? ❑ Yes RNo
Use other side for additional information. / -1?~ / ! 3
SBD-6710 (R.3/97) Date Inspector's Signature ert. No.
d 1
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Safety and Buildings Division
AN - SANITARY PERMIT APPLICATION 201 E. Washington Ave.
In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County _
than 81/2 x 11 inches in size. ST C rdr
• See reverse side for instructions for completing this application State Sanitary Permit Number
2q9 / g3
The information you provide may be used by other government agency programs C Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)J. A 3 0 L) INN. 35 ~C! Stale Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 7 - 2100
Property Owner Name V _ Property Location
TC. ► u S Y 1 w c i~ltgl 1/4 IV r 1/4, S d T o28 r N, R► '(or) W
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
' Via 1 Frcirl ir rAyu 55344 (za ) 34 -adpo _
II. TYPE F BUILDING: (check one) ❑ State Owned Nearest Road
*1 ae
Public 1 or 2 Family Dwelling - No. of bedrooms Q Town OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
R0. d9. l9 31ivA 00a-1osC-70
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ffi /f>!relery 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. k New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an Tank System - ------System------------- ly______________ Existing System---------
Existing-System
B) ___A Sanitary Permit was previously issued. Permit Number 2-6/' j Date issued /0209'0 477
V. TYP OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 'Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
.5 1 330 Required (sq. ft.) Proposed ft.) (Gals/dfay/sq. ft.) (Minn/inch) Elevation
Feet Q Feet
VII. TANK Capacity acitns Total # of Prefab. Site Fiber- Exper-
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
e tic Tan 1000 i coo f W ^ Sg- Lo,c CK ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans.
Plumber's Name: (Print) Plumber's signature: ( o Stamps) P/ or: Business Phone Number:
M n
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
A proved ❑ Owner Given Initial Surcharge Fee) ~Q044~
Adverse Determination `
X. CONDITIONS OF APPROVAL / REASON$ FOR DISAPPROVAL:
SBD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or-plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3151.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
li. 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.
l
%sconsin SANITARY PERMIT APPLICATION 20 E w sgngt e~sion
In accord with ILHR 83.05 Wis. Adm. Code P.O. Box 7969
Department of Commerce 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. ST, C, ro
• See reverse side for instructions for completing this application State Sanitary Permit Number
?-OR 160
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 q an I.D. Number I. APPLI ATION INFORMATI N - PLEASE PRINT ALL INF MATION
-7 6
Property Owner Name ,,,,,yy~ Psoperty Location
/Y t- n A, e- V I ~ $ C. XV1'14 VF W 1/4, 5 6 T a 8 , N, R P8 (or) W
Property Owner's Mailing Address Lot Number Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
EnEW Rr trct S 612 )cTs -.7a00 City 11. TYPE F BUILDING: (check one) E] State Owned Vit il Nearest Road
lag
10 e
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF ktwui c, kC:wty~ 1; 57f1
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel /Motel 9 ffice 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ,M 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 PQ 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
J s Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq_ ft.) (Min^/inch) Elevation
Cv ct 0 000 97, 0 Feet eFeet
VII. TANK Capacity acitns Total # of Prefab. Site Fiber- Exper_
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ 0- 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: ( o Stamps) PRS o.: Business Phone Number:
a 12 . ~ M ~oS ! 5 42-5 eV)
Plumber's Address (Street, City, State, Zip Code
s1 L~ r-.. is 1,t t- 540z"-
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stumps)
P Approved E] Owner Given Initial ~lt"
Surcharge Fee) lz l • 97 Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD4398 (R-1 t/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Pkwd r
INSTRUCTIONS r
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 Sate of
Wisconsin, Safety and Buildings Division, 608-266-3151.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system 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 online A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on sys-_em type.
VI. Absorption system information. Provide all information requested for numbers 1 through'.
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. Instaliing 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)( 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, Iocation 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
2226 Rose Street
Visconsin LaCrosse, WI 54603
Department of Commerce Tommy G. Thompson, Governor
08-Dec-97 William J. McCoshen, Secretary
Wegerer Soil Testing & Desig ARTEKA NURSERIES
421 N Main St
PO Box 74
River Falls WI 54022
ARTEKA NURSERIES Plan ID 9721009
NW,NW,20,28,18W
Municipality of KINNICKINNIC Inspector: Leroy G. Jansky
County of St Croix (715) 726-2544
Private Sewage plans including the following element(s):
CONVENTIONAL 165 GPD
The submittal described above has been reviewed for conformance with applicable Wisconsin
Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY
APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for
compliance with all code requirements.
This plan action is subject to the conditions listed on the following page(s).
A copy of the approved plans, specifications and this letter shall be on-site during construction and open
to inspection by authorized representatives of the Department. All permits required by the state or local
municipality shall be obtained prior to commencement of construction/installation/operation.
This project is under the supervision of a state inspector. As inspection concerns arise feel free to
contact the state inspector at the number listed. The inspector for this project is listed above.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or
at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when
making an inquiry or submitting additional information.
Sincerely,
erard M. Swim
POWTS Plan Reviewer
(608) 785-9348
SAFETY AND BUILDINGS DIVISION
2226 Rose Street
LaCrosse, Wisconsin 54603
isconsin
Department of Commerce Tommy G. Thompson, Governor
William J. McCoshen, Secretary
Page 2
~p
7
- The approved changes will become an addendum to the plans previously approved. All other portions of the
installation shall conform to the original approval.
- A Sanitary Permit must be obtained from the County where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Stats, prior to installation.
- Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with
the designated county official in accordance with the provisions of Sec. 145.20(d), Wis. Stats.
SED-5524-E (R.07/96) File Ref:
r.: CONVENTIONAL SOIL ABSORPTION SYSTEM
FOR Page 1 of
~►J OKrI Cam, f~AjD ZTrj7hGE eU l Lpla 6
e 7 ~ rw
LOCATED IN THE NWl/4 OF THE MW 1/4 OF SECTION ?D TZb N, R It W,
TOWN OF ►rJN 1C~ th11V lC ST'-c-~ COUNTY, WISCONSIN.
INDEX
Page 1 of 4 TITLE SHEET
Page 2 of 4 PROJECT DATA
Page 3 of 4 PLOT PLAN
Pape 4 of 4 PLAN VIEW-CROSS SECTION
PREPARED FOR RFCF~
194X4
1~R`CE"tcA Nv¢S~L~S, 1wc.-_ lY~ 1gg)
~~v ~~~-/t t tuC' , ~ rv ss ~y y O~v
po~TSally .
Condition
lp C 0 1 V'q
pNGS
ZMENT BF COMMA Ft
1V►S~ON PREPARED BY = ARTHUR L
WEGERER
O.TM
0.9,5 f
Y t GOELLSWOR
wrs
. ,
4 V WIS.
SE EFZER SQ I L TEST I I~tG ~ I2: c
AND &'S 13 4
DES I Gt~i S~RV = CE ~~®~1 I f~ GO
P_0. BU 74 421 X. MIX ST_ 1- ZS'-g-7
RIVM FX S. YI 54022
715-4ir-01S i
JOB NO. °I 7 - 3 3 3
PROJECT DATA Page 2 of 2
This conventional trench type system will serve a building
containing an office and storage area for supplies and equipment.
A shower is also provided for employees' use
ANTICIPATED WASTEWATER
Employees 6 X 20gpd = 120 gpd
Showers 3 X 15 gpd= 45 gpd
Total = 165 gpd
ABSORPTION AREA
165 gpd t .5 loading rate = 330 sq. ft. minimum required.
2 trenches, each 5' widw by 50' long will be installed providing
500 sq.ft. of absorption area.
SEPTIC TANK
165 + 750 = 915 gal minimum capacity required.
A 1000 gallon Weiser Concrete Products septic tank will be installed.
. PLOT PLAN Page 3 of y
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Wis6onsin Department of Industry; - SOIL AND SITE EVALUATION REPORT Page \ of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Ws. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 1 nc~64' F I', ry include, but S' [ G~
not limited to vertical and horizontal reference point (B 4i on and % of e or PARCEL I.D. #
dimensioned, north arrow, and location and distance neatest robe. << TD __2 Z _-Z - l O~~
APPLICANT INFORMATION-PLEASE PRINT Ate IN Sa IONC~ R I DBY DATE K
PROPERTY OWNER: .PROPER c ATION
l Tt TE1C A I~U2 S ~R l tT r ~jV e • - ' ►U 1/4 M W 1/4,S ZO T Z a N,R It E(
orW
PROPERTY OWNER':S MAILING ADDRESS G R # fa:, K# SUBD. NAME OR CSM #
~ 51 ~ S ►'--1 I~TLTI fJ X21 Ut G~1\ ~ti _
CITY, STATE ZIP CODE PHONE NUMBER d VILLAGE MOWN NEAREST ROAD
E~~1J ''Mk RIF NN SS3qy (6Q) 934-z1ooo".; ,t~ t~t~tCtclx~r~,lC STT} 6S
New Construction Use[ I Residential / Number of bedrooms [ ] AdditiQn to existing building
j ] Replacement kj Public or commercial describe o c~F t cC f~,"~ 'SLE12~mw c <3)ury'Vz_T-Lx re-'s
Code derived daily flow y 6 S gpd Recommended design loading rate - bed, gpd/ft2 • q-1 trench, gpd/ft2
Absorption area required I k 6 3 bed, ft2 °130 trench, ft2 Maximum design loading rate -L-V_bed, gpd/ft2 • S trench, gpd/ft2
Recommended infiltration surface elevation(s) 9-)•O - OP . O ` ft (as referred to site plan benchmark)
Additional design / site considerations _Z TSL C ~ t` N S ' x. t 0 rl ' LOO C. .
Parent material S k L-T f 5'ZW V &JT uvtl~t 6U\C4ftL 'T'tLc Flood plain elevation, if applicable 1\1 ~ ~ . ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for system ®S ❑U ®S ❑U ®S ❑U ®S ❑U ❑S ®U ❑S ®U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
:<:>l::« b_ o ~t Z z l z - s t Z s ~k vrt'F~ c w I t, • s
Z 1-1 3Y l b Q 31 y - s 1 I Z. S ~1T wl c S - 5 b
Ground 3-Sb It~`tR-3LC - S ~CS~k 1hv`~i- c S 4 5
elev.
9 ft so-6L ~.S -ttZ W,
Depth to S I,6 ~z to `t 2 yly - `Fs g5 >H 1 - . 5 b
limiting /
factor 5 e o Nil -PKI IV
l O° - 2 p L 1 Klit-G S
? 7 Z''
t~T VIN ~2 ZCV~I 01r M.L B OR1 G
Remarks:
Boring #
o_ o to zC
y_Snti.
Z <r Z ~o=z 6 Lo~2 3t si 1 Zwt gbk ►yr~1- o-S -b
v'MV:UY:>i'-i
3 Z6-SS Lv~sZ 3~(~ S1 L c sbk >n U-fh C-S •S
Ground
elev. SS ~Z tol-t fZ Yt - `F S a Sg w~ 1 - • S -
9V4.Z ft
Depth to
limiting
factor
~ 1Zn
Remarks:
CST Name:-Please Print Pfwne
Arthur L. We erer 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: f - Date: CST Number:
X17-333 l..3L, -~~°7 M00576
PROPERTYOWNER ~I'RTL-`1zA Ny1ZS~12l~S SOIL DESCRIPTION REPORT Page Z of
PARCELI.D.# b~~- LOS6-70
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
3 0-l 0 1p~ R. Z/ Z - si \ 2.`FSdk '~I- cw ~ v f • S • b
to z, s~) Z~~ s -fr eS - s . 6
cS • y - S
Ground 3 I-)-VgI uLf2 316 5 1 CS b1z yy U 41r,
elev.
9.5-5 ft. 4,jq -SS T).SytZ Sly ~S Sg N1 °LS .S i•6
Depth to S S S -)o b y rz V!y ~S O S M1 ' S ' L
limiting
factor
? Z O
Remarks:
Boring # n
`x~ o _1 S 1 b`l Q Z (Z S 1 1 Z, T Sbh Yh `fiH C? w\ v~ S
of Z ~S -3~ 1 `t ti 3! S t 1 Z h't S d ~y, cS • 5'• b
31 1 sbk v~~ s `~1 .S
Ground 3 u-6o ! o y 12- s
elev. bu~9 I U V R y/ O 5 - • L
lot, l ft. 4 g ►M S
Depth to
limiting
factor
Remarks:
Boring #
ti: x~~ ~ o-tl )per R z L Z. - Sil Z~Sd1T C~v i v~ . s ~
5 z ~~-Z-, 1 o~tZ 3!y - s) z wi sblT wl Ti- CS - • s 6
3
Ground 27-11q luy2 W6 - sl C Sdk W) V`~Ir C-S .y •5
elev. V Ll ~ S l b 2 V _ `~S o s 9 m 1 _ - S • to
19. o ft. i
Depth to
limiting
factor
? 7 S
Remarks:
;Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
PLOT PLAN Page 3 of 3
'
SCALE 1"= L )O
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y
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OD- 3 33
(715 ) 42,5-0169 M00576
CST Signature d Date Signed Telephone No. CST #
Wwonsin Department of Industry; SOIL AND SITE EVALUATION REPORT Page \ of 3
labbr and Human Relations
Divi on of Safety & Buildngs 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 S'[ G~
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. D Z2 - 1 r 6l-); -_7 0
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION r EWEDBY DATE
PROPERTY OWNER: PROPERTY LOCATION
1-TZTE1rc,A )VU2 S l~~r LJl!e • GOW.Et3T Mi-i 1/4 N 01/4,S 20 T Z8 N,R It E(ortiJ
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # _
\S1CIS WAIztTLl1m -1~)~LCut -
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY []VILLAGE DOWN NEAREST ROAD it
E,DEK3 PZPrjRIF mpj Ss3,qy (6lZ) 93y-zooo ~rc►fvutCtct>uAJ IC ST?} 65
QQ New Construction Use[ ] Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement k j Public or commercial describe o F-Fj c.iZz: tttib SLL p► w c c~~ 2 S
Code derived daily flow U 6 5 gpd Recommended design loading rate bed, gpd12 • trench, gpd/ft2
Absorption area required 116 3 bed, ft2 0130 trench, ft2 Maximum design loading rate gibed, gpd$ • S trench, gpd/ft2
Recommended infiltration surface elevation(s) °1_1 •O O r ft (as referred to site plan benchmark)
Additional design / site considerations Z S ' x. I D o I Lo►i a.
Parentmaterial stL_`N SEZt`MIFrQT uycR 6LNC-1ftt_ TtLL Rood plain elevation, if applicable N ~'k ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESS AT-GRADE SYSTEM IN FILL HOLDING TANK
U =Unsuitable for stem ®S ❑ U EIS ❑ LI ® S ❑ U URE ® S ❑ U ❑ S ®U ❑ S O U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Tench
6-t1 1oHZ lZ - si Z~ Sbk w►'Ft~ Cw 1 UA S
1
Z 1-1 3y t b 4 tz 3[ y - s i l Z w, s bk wl'~tr c S S . b
Ground 3 V--so +b~tV_ 31` - S ti `CSbk C S - .y 5
elev.
Depth to S ~6= ~o~c2 yly - `~s ~g
limiting
factor 5 eo ti w L O° - ?-0 °Jo L.1 r n t~l F +t S
? Vt
~ ~T zsv.t o~ trt~ B o~1 Gg
Remarks:
Boring #
; 0,10 1~~ 2 ZLZ St 1 2J Ab' wr'~1~ Ct~1 1 vF 5 - 6
Z j< Z 1o=Z6 loKtZ 31 st I Zwt gbk wt'~'1,- C g ' S
: = 3 z6-sS ~~~tz 3t(° S 1 l csbk to cS - -S
Ground
elev. ~Z 10\1fZVf - 'Fs Sg wl - •S
et \4,-Z ft
Depth to
limiting
factor
~ 1-
Remarks:
TName:-Please Print Phone.
Arthur L. W e e r e r 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Sgnature: i Date: CST Number:
,t, ~~G q~_333 I C-3L -~l~ M00576
PROPERTYOWNER ~'R'T~hA ~u\ZS~IZI~S SOIL DESCRIPTION REPORT Page of 3
PARCELI.D.# ~~Z-- LOS6 70
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
3 Bed Trend
o-t o 1p~ 2 Z/ Z - si 1 Z~sdk w,'~t- cw ~ v • s
Z Z-7 to'-r(z 13 !y 5~h Yn0-S - S • 6
Ground 3 ZD-~l I uy R 3 ~6 5 } 1 CS U}z `Fh cS • y - S
elev.
cl- ft. _gs `t S va- Sly ~S O S g Y►'i 1 °LS . S i•
Depth to S SS-~0 / 0 V IL Y/y `~s C~ S 5 • L
limiting
factor
Remarks:
Boring # ,
~ o_\s tp~tiZ 2-LZ - st I Z``'s~IT c.w lv~ •S
z is -~q t o,I tZ 3 / - sit cS • s ' . b
Ground foylZ31~ s1 1 ~sb>z W, kJ4~ ~s
elev. L4 6u--i9 10 V R y/ `FS o Sg r,,, - .
5
%
101.1 ft.
Depth to
limiting
'factor
Remarks:
Boring #
Z tl-Z1 lo~rtz 3/y - si I Z wl 36k wi CS • S 6
Ground 3 2~-y q l u y 2 3 6 - S C Sbk V ~y. CS • y •S
99vo ft. L/ y9 ~S l 0`72 yl o s 9 m~ - • S -
Depth to
limiting
factor
? 7 5 ~r
Remarks:
;Boring #
i rom'.]
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
PLOT PLAN Page 3 of 3
SCALE 1"= y 0 '
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3 33
(715 ) 425-0165 1400576
CST Signature Date Signed Telephone No. CST #
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER T(A) ~'any ~a(, p
MAILING ADDRESS / j
✓i t, MAj S 3 ~(4
PROPERTY ADDRESS 14 w tr ~
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE R F A-) / .=LLO Z-7-
PROPERTY LOCATION + V 1/4, -V%/ 1/4, Section D T_,-)A_N-R J,~? W
TOWN OF ~ ir)nrrK i nn i G ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60%. of the cost.
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED: Ams I dl)
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - loo
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property
[1j,
Location of property ,_1/4^ - 1/4, Section a,T_,2&N-RIA2 W
Township ht?ir ,;U e Mailing address 153(o tau lc~P!/
k7/7 /t 1,V1 f, 3
Address of site__ z3o WW Y (off
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property -Tj--rjv~j j
Total size of property 7,~ pC- eS
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 and Page Number 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.SS~(~ and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
ignature of Applic nt Co-Applicant
/ viti-hr,
Da e f ignature Date of Signature
N
4
D04UMGNT NQ. STATE a" OF WISCONSIN FO1tDi 1- Ion r MOM O4"M FOR aeCeae11M *AT&
WARRANTY oEED
455463 ►~sc2"f f - WGIMWS OFFICE
SE: CROIX CO.,
This Deed, made between ji WI
.C..~GibsoniFamil~t...Trus.t* 4
. J rryA,Gibson,}--------.-_. AN 2 91990 ~I
~ruatee er 1
. . Grantor, 4:15 P.
. M
ow.... David..K,....Luse.. and.-,Iulian.~n...L,us-e~--husband-•---
..sad--Vife. as sal;vi uolishiR..mar.i tiai_-RxoRe. o.
M►efOwd~
Grantee, j i
Witnesseth, That the said Grantor. for a valuable consideration
conveys to Grantee the following described real estate in ._.St.....C
raix.---------
County. State of Wisconsin:
A pparcel of land located in the SWk of the
NE# of Section 20, T28N, R18W, Town of
Kinnickinnic, St. Croix County, Wisconsin,
4 described as follows: Commencing at the Wk corner of said Section
thence N88 54'40"E 2588.22' along thS East-West # section line to then
center of said Section 20; thence NO 17'12"W 1312.12' along the West
line of said NEk; thence N88 45'43"E 285.08' along ttae North line of ;i
said SW* of the NEB to the point of beginning; thence SO 17'12"E jl
803 b63'' • thence N89°42'48"E 151.00'• thence SO°17'12"E 200.00';
+ ~ thence it
N83 2035"E 460.00'; thence Northeasterly along the Northwesterly
right-of-way line of State Trunk Highway "65" and the Northeasterly
extension thereof to the East line of said SWk of the NEk; thence North ii
I along the East line of said SWk of the NEk to the Northeast corner
- thereof; thence S88°45'43"W along the North line of said SWk of the
NE# to the point of beginning. Subject to the existing town road right-
of-way of 107th Street. This parcel contains 20_1 Acres, more or less,
excluding town road right-of-way and 20.6 Acres, more or less, including
town road right-of-way.
This _.i8_.nOx............ hempt.aa property. S1 70-
(is) (is not)
Together with all and singular the hereditament, and appurtenances thereevtr belonging;
t
And.... .Iarry..A,....Gibsom,.-.Ju.na..L_.-..Gibson,-.and-
warrants that the title is good, indefeasible in fee simple and free and clear of des except
easements and rights of way of record
` and will warrant and defend the same.
Dated this 0V.:?_1e day of January... 90 Ii
LEN E G MILY TRUST
(SEAL) .
4ojr w . (SEAL)
7ja.rry..&,.-_G b.voxt,_..Trus.tee_.._.._ Ja .ry._ , _G_ibsion- _
(SEAL) _.l-
i-~ l•.ls~~/...-... --••---(SEAL)
une L. Gibson
ADTSSNTICATION ACKNOW16ZDGURNT
(y STATE OF WISCONSIN
.._.__.___._~l.-l-- Coanty. !
aathentleattd this ........day of 19 Personally masse beige me this
~4--day of
January - 19.90_. the above reamed
•Je.r1iY___A- _Gibson_,._- ndiyidual.ly---and as
'----•------------------------•----•.......'ru$tee_•oF the Len.4
TITLE: MEMBER STATE BAR OF WISCONSIN Family__ Tralst. and__June.. L.•-•Gb•Qn.
(If not .
authorized by i 706.08, Stats.) fore
to me known to be the S
lers°° P ~e~naw the
going instrument awl acknowledge t ~j,Yne. `y
THIS INSTRUMENT WAS DRAFTED BY 'r'•~ It C. L.
Gaylord. Attorney
900C I 'oN 31.10aS wsI -I -M KXOA
- KIsxoasid to ava aa.vas
-
i'
-s'u.gwSjs maps mopq palvud Jo PMRI OR PInORS 4IMdp trs a( aalaa}. =a"" yo awtg~
-
io, 31) '3~ a ao[Smtuuioo aA3q RIOU T92PaIroux- JO PigT3Ruagpv as Le ~ ~sarne
- ZZOt/S i[Il rBIi$3 Aig
SAFETY AND BUILDINGS DIVISION
2226 Rose Street
~~~~~►~7/' La Crosse, WI 54603
De artmerl of Cc~rrtrne
/ ..r Tommy G. Thompson, Governor
13-Nov-97 ' - William J. McCoshen, Secretary
Wegerer Soil Testing & Desig TEKA NURSERIES
421 N Main St
PO Box 74 FFICE zotAiNc" River Falls WI 54022
ARTEKA NURSERIES Plan ID 9720798
NW,NW,20,28,18W
Municipality of KINNICKINNIC Inspector: Leroy G. Jansky
County of St Croix (715) 726-2544
Private Sewage plans including the following element(s):
CONVENTIONAL 465 GPD
The submittal described above has been reviewed for conformance with applicable Wisconsin
Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY
APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for
compliance with all code requirements.
This plan action is subject to the conditions listed on the following page(s).
A copy of the approved plans, specifications and this letter shall be on-site during construction and open
to inspection by authorized representatives of the Department. All permits required by the state or local
municipality shall be obtained prior to commencement of construction/installation/operation.
This project is under the supervision of a state inspector. As inspection concerns arise feel free to
contact the state inspector at the number listed. The inspector for this project is listed above.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or
at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when
making an inquiry or submitting additional information.
Sincerely,
Gerard M. Swim
POWTS Plan Reviewer
(608) 785-9348
SAFETY AND BUILDINGS DIVISION
2226 Rose Street
LaCrosse, Wisconsin 54603
~sconsin
Department of Commerce Tommy G. Thompson, Governor
William J. McCoshen, Secretary
Page 2
97 2079
- This approval does not include plans for the general plumbing systems or sewer piping leading to the septictholding
tank that may be required for this project. See section COMM 82.20, Wis. Adm. Code, to determine if plan
submittal and approval is required.
- A Sanitary Permit must be obtained from the County where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Stats, prior to installation.
- Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with
the designated county official in accordance with the provisions of Sec. 145.20(d), Wis. Stats.
SBD-5524-E (R.07/96) File Ref:
CONVENTIONAL SCIL ABSORPTION SYSTEM
FOR Page 1 of 4
~:B~SL~.;'pYnl G e.Ur~~k►1N~.. 1'~'~ OF~>CE -
LOCATED IN THE ►-Ik11/4 OF THE MW 1/4 OF SECTION ZO TZS N, R 1Qi W,
TOWN OF k.tK3tj W-V-LtQlV lC ST-C IX COUNTY, WISCONSIN_
INDEX
Pape 1 of 4 TITLE SHEET
Page 2 of 4 PROJECT DATA
Page 3 of 4 PLOT PLAN
Page 4 of 4 PLAN VIEW-CROSS SECTION
PREPARED FOR RECEIVED
9R` eE tpk NOY - 5 19,97
T.S. ~s q s v-~ 1~rcZ-t~ Dv tvE
p.p,.W. ~wst~. d'V.
Gondl tionaltJ'
RovE®
A Of COMMERC
UILDINGS
OEPARj 500y
ISIDo
EE CORR ONDENCE r400
PREPARED BY C 10 N,
O ~
WE GE ARC ER ARTHUR L.
SQ I L TEST I i~tG WEGEREA
40 ~ D•915 f
AND ' ELLSWORTH.
DES IC Ghi !:-3T=RV I CE s
~ Y
P.U. BU 74 421 K. KAIK ST. ®'N ~ 'r G'
RIM FXLS. VI 54021
",BN/AK~0~
115-4L`r01Ss%,
L1 - ZS -~7
JOB NO _ 7 - 3 3 3
PROJECT DATA Page Z of
This conventional system will serve a building containing an
office and sleeping quarters for 3 seasonal employees. A washing
machine and shower are provided for the seasonal employees' use.
There will also be 3 additional employees.
ANTICIPATED WASTEWATER
Employees 6 X 20 gpd = ------120 gpd
Washing machine 1 X 300 gpd = 300 gpd
Showers 3 X 15 gpd = 45 gpd
Total = 465 gpd
ABSORPTION AREA
465 gpd - .5 loading rate = 930 sq.ft. minimum req'd.
2 trenches, each 5' by 100' long will be installed providing
1000 sq.ft. of absorption area.
SEPTIC TANK
465 + 750 = 1215 gal. minimum capacity req'd.
A 1450 gallon Midwestern Precast septic tank will be installed.
A
PLOT PLAN Page 3 of y
'
SCALE 1"= L )O
y
F-e%1C4:F- lour
v Ioo.
P~
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Z r S'oFq"nur C cotilvA\L LI. g9-
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d B. ~ y
47 Ol
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2Qh'1 - ~L , lOU.O GIv S ntt. @
F'iBOV~ GR.UVnIp IN
ClyrtiP w X12 5
1-'I ~'1..~ 021 u t
7 r Lv~Tt.L To QE '~T L~ST SO' ~.oGq 'h~~1CL~S H►vD_
F}1- c.QmsT ZS' PA I-j 711 %E'4 f)C..
I
_ _ sTl3 6 S
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y
• pf~GE '4 o~ Y
ono
44 cT ama'T PtPeS W" P v , numn Rim pipe
W/ R~PaOV~b Ums
sl p
GZoSS SQ-C--n
Wor benT- P1pr w/PipPti2nv~ Cf~P
'P)T t_MSY \ZyA$OUill -iAjtSjeb (,pWAjje
C-~cl S`nN G G 2.Pf1~
SOIL
111 ij 1~pP~Z.(}Ut~ S~[rv~j-~z C
o a o COU~2ING
G °
1, U~ J 6 ~ ~ d
0I)• OI ~Lt31. Q7. d v v
"AA MAW pipe
Hr.~Q Z o~ HGG(Z~ Gn7~
Awayt P1 PL:.
' i Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E.Washington Ave.
Isconsin In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969
Department of Commerce 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 1 1 inches in size. ST- C ro 1 yl
• See reverse side for instructions for completing this application State Sanitary Permit Number
26P1 t(i3
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
I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 17 c2 G 7 9 5
Property wner Namee Property Location
H -t /Lc u.. tSev1cs 1wc- 1 )iji{�1i4y)W 1/4,Saa To�8 ,N, R tie, A(or)W
Property Owner's Mailing Address / Lot Number Block Number
/ 19 5 f►r1 ct,,r ).w 7,c;-e --
City,State Zip Code Phone Number Subdivision Name or CSM Number
-PEN1 P ra t t•r t ,S S.14 f (d/2 )R'3 q—,3 o oa
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
ge
El Public 0 1 or 2 Family Dwelling-No.of bedrooms qr Town OF IN
t VNi c 4,5wwi.c. S7// los
III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s)r
1 0 Apartment/Condo U _ t pc-co--to
2 ❑ Assembly Hall 6 0 Medical Facility/Nursing Home 10 0 Outdoor Recreational Facility
3 0 Campground 7 ❑ Merchandise: Sales/Repairs 11 0 Restaurant/Bar/Dining
4 ❑ Church/School 8 0 Mobile Home Park 12 0 Service Station/Car Wash
5 ❑ Hotel/Motel 9 0 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. El 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 IN3 Seepage Trench 22 0 In-Ground Pressure 42 0 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
41 J s Required(sq. ft.) Proposed(sq.ft_) (Gals/day/sq.ft.) (Min^/inch) Elevation
Co �t3 0 /D00 597. 0 Feet exc)T=Cf Feet
—
Capacity
VII. Site
IFORMATION in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
New Existing Gallons Tanks Concrete strutted glass App
Tanks Tanks
Septic Tank or Holding Tank I — NSO I Attiaiweckvri AearZ. ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ ❑ ❑ El
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:( o Stamps) M MPRS o.: Business Phone Number:
Car/ P J/c45 auir a.2ossf _ 7/s 423 , l7 c
Plumber's Address(Street,City,State,Zip Code
Io4Z S. ni Gt 1vt - rwlls Lui 54ozz-
IX. COUNTY/ DEPARTMENT USE ONLY
0 Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature(No Stamps)
Surcharge Fee) (,Q
]Approved 0 Owner Given Initial /50 °� /2,''7•97 �"fAcia
Adverse Determination [ iS� (i" t
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
DISTRIBUTION: Original to County.One copy To: Safety I1 Buildings Division.Owner,Number