Loading...
HomeMy WebLinkAbout022-1075-60-200 i STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER \,IA- d4 ADDRESS f 3 It i t'`` zo co Nov)," ?g SUBDIVISION / CSM# LOT # SECTION. T N-R W, Town of //7 /7 lckP740 /I i c ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW Provide setback and elevation information-on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. PUMP CHAMBER / Manufacturer: i es e oe colovoGd Liquid Capacity: ®O d~ Pump odel: P /Siphon Manufact.: Pump size 269 ~C~ ~t Elevation of inlet: rS Bottom of tank elevation 611 Pump on elev.. Pump off elev.: Gallons/cycle: 21D e,;kG Alarm: Man.: .~fl Switch Type: ocation 7 Distance from nearest prop. line: Front~4e6i Side 'Q Rear. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: 'V / Trench: Seepage Pit: Width: _Length_ ] 7 Number of Lines: _~/_Area Builtlf __7__9 Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: fd~No. feet from nearest prop. line:Front, ~4p Side le)" Rea Ft. No. feet from well: feet from building ~ CD HOLDING TANK Manufacturer: Capacit No. of rings used: Elevation of om tank: Elevation of inlet: No. feet from'near prop. line:Front Side , Rear Ft. :Well building No. feet f nearest road Alarm Manufacturer: INSPECTOR: DATE : PLUMBER ON JOB: LICENSE NUMBER:A)!n>l- C 6/90:cj PLOT PLAN Page of 3 SCALE 1"= yQ ' r t?Lg~ 9 e 3 i ~t l tzar B. `I PLPt►' -tom' Mtn • ~,oT rje 8.S r r .y sw r \ $ ~M+11P 1 tioT 1U S Uf~k' 1 luvTt11L "T-t, b• F11 t I V-1 1 3 c- - ~jl / O , o~ Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT 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)]. 2. do t00 Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.: Joza. Amd&A ho _ i CST BM Ele Insp. B lev.: BM Description: Parcel Tax No.: E00' S iKe - 10"OaKT -E' OZ2-l07 - G'oc -mod TANK INFORMATION ELEVATION DATA G'DD 3 Z`1 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. epti D00 BenchmarAC ..r, 3 L 0;-21 osi n Aeration Bldg. Sewer S.DO 9S24 Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake eptl ' 5 , 27, NA Dt Bottom /Z, g0•B'6 Dosing NA Header/ Man. szsv 74 Aeration NA Dist. Pipe Holding Bot. System 61•7/ PUMP/ SIPHON INFORMATION S-2 979 Manufacturer ?_o Demand 1 "Llwu lie ea ye, 737 1.5-Ty Model Number 37 GPM C/ ,a1r,,Ude 1A71 C/Y. 51, TDH Loss X0-7 System TDH 7VelFt Forcemain Length 0~ I Dia. Dist. To Well SOIL ABSORPTION SYSTEM E TRENCH Width ,Length No. Of Trerrttfes PIT No. Of Pits Inside Dia. Liquid Depth MEN I N 2~ DIMENSIONS LEA HING Manufact SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER- Mo el Number. System 101 &of ~D6t OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length - Dia. Spacing ' A'STM '7 L ? Z~ f SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx f xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges psoi s ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) alt. XM - %f o-W14oi- V„A i -11-,- q7 Plan revision required? ❑ Yes IX No Use other side for additional information. 1,5 a17 SBD-6710 (R.3/97) Date Inspector's Signature rt. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ' ^ ■ ■ Safety and Buildings Division r.•a.nR 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 ^~/J than 81/2 x 11 inches in size. J • enr • See reverse side for instructions for completing this application State Sanitary Permit Number Z q qd0r'"o The information you provide may be used by other government agency programs ❑ Check i( revision to previous application [Privacy Law, s- 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFOR TI ON PropeA OwneC gii e' D Alf /0opert L a/4, ~P 1/4 vio S T , N, R 0 E (or W Property Owner's Mailing Address Lot N mber Block Number t 4© o M I'L Gon "at o l CSon Cit , State ? Zip Code Phone Number Subdivision Name or CSM Num r en .S- o /0 (76f-)3 C.6 X304 II. TYPE F BUILDING: (check one) ❑ State Owned D City Nearest Road ? Public 1 or 2 Family Dwelling No. of bedrooms E3 Village _ / l 14191 -C J Town OF C T/y J ✓ - III. BUILDING USE: (If building type is public, check allll that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo a 7 a 8 ch' 18.4 aQC c° A,2- 10 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ..New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank 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 30E] Specify Type 41 ❑ Holding Tank 12E] Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy 13E] Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (s ft.) Proposed 1(s a. ft.) (Gals/day/sq. ft.) (Min./inch) Q Elevation l /,2, / 1 02 J. 45 F Feet eet VII. TANK Ca in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Exist in strutted Tanks Tanks Septic Tank or Holding Tank f 4?L4❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber' )ignature: (No tamps) MP/MPRSW No.: Business Phone Number: lel Plumb r' Address (Street, Ci , Stat ip C r p IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved anitary Permit Fee (includes Groundwater ate Issued - Issuing Agent Signature (No Stamps) XA roved Surcharge fee) pp ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Di-,ion, Owner, Plumber INSTRUCTIONS 1. A sanitary, lpermws 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 WisconsirrAdmirli5t ague-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. ll. 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 isto 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. S'c ~f: c r A /7 J 1 Alm 0 ~v 41 _ ~~oo lzi r PACs OF Lhu 5 S ~`c ` 1 Uri p J/S f(°n-) Fre6A Air Inlele And Obiervallon Pipe ^J•--- Approved Vent Cap Minimum 12' Aaove F In al G, ad• 20 - A2' ADo.e Pipe - 4" Call Iron . To Final Grade Vent Pipe Morrh Noy Or Synthetic Covering Min 2. Aggregale 0.a Pipe Olalrlhullon -rod Pipe 0 0 0 0 0 6* Aggregate 0 Perloreled Pip. Belo. Heneolh Pope 0 -Coupling Termineling At • Cullom 01 Syelem ~ru c5~h , SOIL FILL DI ST RIeSUTIOVI PIPE APPROVED Sywpr-TIC COVER PIATCRI4 or: q" 0F STRAW 2"oFAGGRf.GATE OR MARS" HAy ELEV. fEr DISTF!"'.;TI )AI 1'IrV. TV, )~L AT LE4S7 Ifk.IGNES ,B,E.LOW ORIGIAJ,A,L. G,RAO.E A,AJIII to L F. A S A ',2 0 I l`4,C ,I.{ E ~V%LJ T k I,0 GQ rL IG I H A AJ 4 ? LAJ,C E .E.,L O W F,I N.A ,f,.l~' r;LD,E I E ~IAJCN•E~ M+zMW N-phi Or r=XtAVAT100 r-90M ORI&NAAL 69AD WILL LS J'1,.~III' 11Ia C(~E(~TH OF EXC~VATI~I~! ~OM• i(,I,NAL 6R4.9,L WILL 1bE =1-- INCHES SIGmco: L ICEU5C ~.Il1MRE.R:. DA VV / j' PUMP CHAMBER CROSS SECTION AND SPCCIFICATIOLIS ' PAGE S OF •VCWT CAP WCATHCK PKOOF JUWCTIOW bOX ti" C I. VENT PIPE APPROVED LOCKING 10' FROM DOOIC, MAWHOLC COVER ki-)'V .lil,)pOW OK FRCSM wARr~ING LABEL, Atk IIJTAKC S CorJDU)r b; rj i 4sLhall PIPc PROVIDE AIRTIGHTSEAL APPCA APPROVED .IOIy1' struction AL&KM mply wi Etl 15 and 33.20 ° I I I I o►J c I I I CLCV. FT. PUMP1 OfF 0 COMCKLTC 6LOLK L -T'- " Sao X ry~ KISCR EXIT PERMIT(CO G►JLy IF TA►IK MAIJUFAL'TUR'CR HAS SUCH hPPKOVA 3 AOR L EiCDOIN4 SLP~IG f SPCCIFICATIC)KJS 005E TAL WK MA►JUFACTURCR. "ESE'R Cu"C•Lt-~ WuMBER OF DOSLS: L Ff=K DA4 o00 /600 G TA►JK SIZC : GALLOIJS DOSE VOLUME ~KtN MAUUFACTUKCR: S T'~ S'75 1'~IS IMCLUDIWG GAGKfLOW: GALLONS MOOGL WUMbEK: \el 16W CA-PACITICS: A= 30 WCHI~ UK Y--L4iLL0wi swlTCH TyPc: Vl%,E -CUP-Y B=_ Z IIJCNES~GK t'C'~ G(~LLO►15 pump MAWUFAC.TUKCI(: ZS--- ~T- L L-H~Z eon C ~wLHLS UK „ALL01J$ MODEL MUMBEK: S3 Dw INCHES oK 14,E &ALLOU£ r7- z ' ~N IJOTE: PUMP AND A<_AK1'' SWITCH TYPE: E TO 6L 1dAR MIIJIMUM DISCHARfaE RATE GPM INSTg LEO OIJ 5LPAk,4,TC CIKCUIT5 VCKTICAL DIffEKEWCE DETWCCI~J PUMP OFF AIJO.OISTRIBUTIOW PIPE.. ~ / FELT t MIUIMUM NETWORK SUPPLY PRESSUKC!~L3~EET + _6 S FEET OF FORCE MAIM X p'°IS FYo tLFRICTIOU FACTOR.._ 'I_L'Xr tET TOTAL OtJWAMIC HEAD = ~6 LET Pump chamber DIAMETER S I IuTEK1►IAL OIMEIJSIOIJ~ OF TAUK: l-ENi,TH ;WIDTH - ;L.IgUIO DEPTH BOTTOM AREA - - 231= - GAL/INCH AS PER MANUFACTURER = 11. 2, GAL/INCH 3 15/16-6 5/32 pr fG C OF O • x I HEAD CAPACITY CURVE 53-57"-"55-59" SERIES a s/e 'r 1 1/2 -11 1/2 NPT ?5 TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE EFFLUENT AND DEWATERING 3 15/16 6 _ 0 50 SERIES - Ft. Melers Gal. Ltrs. 4 1/16 U 15 - 5 1.52 43 163 Z 4 10 305 129 I O - -I - - 15 4.57 19 72 a 10 - ~a. va.• 19.25. I I r0 2 S - 10 1/16 0 U.S. GALLONS 10 20 30 40 50 I 3 3/32 LITERS 0 80 160 FLOW PER WNUTE s1a•r °N•" CONSULT FACTORY FOR SPECIAL APPLICATIONS • Variable level Float Switches available. • Available with special cord lengths of • Variable level long cycle systems available. 15', 25', 35' and 50'. • Alarm systems available. - Duplex systems available. SELECTION GUIDE Standard cord length - automatic 9 ft. 1. Integral float operated mechanical switch, no external control required. Standard cord length - nonautomatic 15 ft. 2. Single piggyback variable level float switch or double piggyback variable level float MS 55 and 57159 Se ies Control Selection switch. Refer to FM0447. 3. Mechanical agemator'M-Pak' 10-0072 or 10-0075. Mogel_ Volts Ph Mode Amos Simplex Duplex 4. See FM0712 for correct model of ElecUical Aftemator, E-Pak. MSSl55 & M57159 115 1 Auto 8.0 1 or 1 & 7 5. Variable level control switch 10-0225 used as a control activator, with E-Pak (3) or 115 1 Non 8.0 2or2&6 3o(4&5 ~5 - (4) float system. E53r55 b E57159 230 1 Non 4.0 2 or 2 d 6 3 or 4 8 5 6. Four (4) hole J-Pak, junction box, for watertight connection or wired-in simplex or 2 pump operation, PM 10-0002. 53 Sales • Wt 22 Its; 57 Series - wt. 27 lbs. 7. Two (2) hole J-Pak, junction box for watertight connection or splice, 5', :a•nrs Wl 24 IL* 59 Series . Wt 30lbs PM 10-0003. CAUTION For inbmlabon on additional Zoeller products refer to catalog on Combination starter, FM0514; All installation of controls, protection devices and wiring should be done by a qualified Piggyback Variable Level Float Sodches, FM0477; Eledrical Allomalor, FM0486; Medanical licensed electrician. All electrical and safety codes should be followed including the most Akermlor,FM0495;SunpJSerrageBasins, FM0487;andSiglePhaseSimplexPump ContmVAlann recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). Systems, FM0732. RESERVE POWERED DESIGN For unusual conditions a reserve safetyJactor is engineered into the design of every Zoeller pump. 4W HAIL T0: P.O. BOX 16347 \ 4W ow-k%' Lorisvk KY 4025643(7 Manufadraers of - . SNP TO 3649 Cane Run Road 'W 16 1 O Lou snVe, KY 40211-1961 PUMP L O. (502) 778-2731 o 1 fflW) 928-PUMP FAX(502)774,G14 Old- Sc#~ z h IR L4/7'o L e ,J to ~ ©n N ,g ' Sca ~ vtiQ ' lea ~O e, N4 to ~ I t PA !V e M k I I - ~ ~i rAC.E OF 1 ~ c , Lru55 10 Froth Air Inlets And Obtervollon Pipe J Approved Vent Cap Mlnlmum 12" Above Final Grade pipe _ 4" Cool Iron To e Vent Pipe 20- ;-2 Marts Nor Or Syring ugate O0letrlbulln Tee Pipe 0 0 6o Perlorab0 Pipe BHow Pe0 -Coupling Terminating AI Bollom Of System r_IcJr. 1 SOIL FILL DISTRiBUYIOf.I PIPE SyWTMAvvRC)VED ETIC COVER o ~-MATERIAI- Of; 9,r OF STRAW 2"OFAGG9EGATE OR MARSH HAy 4 3 4,r (c ()F AGGREGATE cF^`ti~'~ D I S r F ~,R T l c' 1~I P I:r F. T Q A.C AT L E k S T IA A C H E S A,E ,L. O u/ O R I G I KAINL_ 1511"I'mE Q ,k~IU Aj. L,E A S I' 20 I AJIC,I.{E ALI T IJ,O /A.O~RIE TH.A J 2 1;NG11bE S P.L.LO W FAIN L ,r✓tf'ir AI~, . MAXp,ut ,A Dkprij o FXtAVA-rico r-xc>l'9 dt{ tiwu bK/1:K WILL BE ~~/®I~ICM.ES M, !,N;►l,'a,Il'M 19EFT11 OF FX WATIDtij fp-.,OM. c!. IGI,NA~ GR4,9IL WILL BE r INCHES i • SIGMED: LICCUSE DA-r E 0// 9/ 110 W~ipscocynsiaHu~ ea°ao~istry, SOIL AND SITE EVALUATION REPORT Page ~ ofd tDivLswrr of safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ST= C(tU 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. C) Z-7- - Q 1 S . 6 O APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTYOWNER:L~, tV\~1-SON PROPERTY LOCATION ANJD\ZPR F►Av0 Se S ft`t A 1-~T tt Qe GGIV 666 S i r 1/4 N~.' 1/4,S Z1 T Z b N,R . L Z E (orz PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # I gr3o fvk►'tij~7tA GOty I'- Z08 1 - ~2opo s~ C.'J,". CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE DOWN NEAREST ROAD "7-0 !-`v4so1., 1-11 IWOIL (-)IS) 3S&- 06 11U>J\C\zll~►1J1C LUv+~ ' TS' ~Q New Construction Use ( Residential / Number of bedrooms 3 [ j Addikp to existing building j) Replacement Public or commercial describe Code derived daily flow y S gpd Recommended design loading rate - bed, gpd/ft2 S trench, gpd1112 Absorption area required l1Z 5 bed, ft2 °t b o trench, ft2 Maximum design loading rate • S bed, gpd/ft2 ' trench, gPdjft2 Recommended infiltration surface elevation(s) 9L_8 I It (as referred to sita plan benc*mark) Additional design/ site considerations C2Z M M !r;,-jb 24 'X 47 ° R~ w/ ~0 s C- pv►~ p Parent material S'Kf~p %1MI J t Flood plain elevation, if applicable N A- It S = Suitable for system CONVENTIONAL MOUND IN ROUND.PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable forsystem IK S ❑ U ®S ❑ U ES ❑ U 1 ❑ U ❑ S Lau ❑ S W 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 rertdt v-S \0"lZ'13 \s lw►s1~`R w►v~r C"' S . ~ Z 3-14 S 10 `11Z y/ g (3s-) m v'Vr- 0--,& •S .6 Ground 3 4S-69 l C1 `2 2 51 ~S O s 9 m y 'V~ - - S . 6 elev. `c'oo L0►v 3 f=- PrrL\- _'V_4ZVJAjG3 -M VM O 5 ~f Depth to r~l V 'Flo- S\ - NOT Climiting factor! ti R 1~11i1 ~tivD L> ~tC ~1 U~t'D t G Z. OF . G D \S b o~.► EPc~ S ~ c- S o t ~v C, Remarks: Boring # o-b 1o~-t\z 313 - S 1 V1 a -1 LI W4 2 sly ~S Q) \+v • 5 _ L Ground elev., 92A ft Depth to limiting ` • factor VT CpqK Remarks: T Name:-Please Print Phone: Arthur L. We erer 715-42 Z' g rer Soil esting & Design Service-P.O. Box 74 River Falls,WI Signature: Date: CST Number: q`~_tS2 lZ-~ 7 M00576 PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of 3 A PARCEL I.D. # Z-Z -1 q-1 S - 6 0 ~V`1~R ; N't'j LF Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouttiary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench a13 - \ S ~m Sb r" v a• S - -I o s 6 Ground 3 Ln- ?Z l tW-1(Z S / S O g h1 U `~1- - • 5 • elev. 98.9 ft. Depth to limiting factor Remarks: Boring # ~ ~ -y 1by,~ 3~ 3 ~ 1 S 1►~. Sb~ w,v`ft~ a., S ~ • -t ? , y Z ~ -y 8 1O`1 R ~1 ! ~ `FS v S 9 >'n V ~ ~g - , S • 6 3 yg ~p LO `t 2 s /y S O s U,F> • 5 Ground el v. 9f-1 ft. Depth to limiting ' factor € ? O'` I Remarks: Boring # v-y 101 ti 313 - 13 \msbk vhv ~ a-S _ .g S Ar Z ~1-U~ ~0`iR y1 - '~S o s9 )M U`& eS _ • S . 6 Ground 3 U6 ~Z I~yIZ Sly - ~s ~ S5 tiv \Ah- _ . s L elev. 98.0 ft. Depth to limiting factor '2 1 Remarks: Boring # ~ 0-5 102 3l3 ~ 1S tweSl~k mv`(~= ~-S •1 Z S -u7 1p`i2 V/ s O 39 vnvt. cg C. Ground 3 W) fU`t2 S/y Gsg ►S R elev. 99-Oft. Depth to limiting factor Remarks: seb-9330(R.05/92) PLOT PLAN Page 3 of 3 SCALE 1"= 0 8.3 @. M PLPe Soo ~ -6 10 ~ \ d" a S ~w111N tL a9°! 8.Z ~1.9q y Splht~, ZZ`prCtou~ _ GRaiw~ 1~ 1p" DOH llz~. _ t---sNvm- enr L-or Lirj ter'LetriT s' F-o 8fo s , cl is z -9 (715 ) 425-011;5 - M00576 CST Signature Date Signed Telephone No. CST # c~ s ~ ~ FiLEp ~ 9 ~uL 2 31997 SC27 0 - ~TM o o ~ + ~o CERTIFIED SURVEY MAP N MERLE NIELSON Part of the Southeast 1/4 of the Northeast 1/4 and the Southwest 1/4 of the Northeast 1/4 of Section 27, Township 28 North, Range 18 West, St. Croix County, Wisconsin. Owner's Address: 1295 Evergreen Drive UNPLA rrED LANDS River Falls, WI 54022 S 89-16'45"C 512.71- 479.53' I 50' 33' I y Q' OII CO Q I0 i L O T2 IN 3.002 ACRES ti O I Q WI ~I /30,760 SO. FT. (V VI p 3 Q/ 2.804 ACRES EXC. ROAD R. 0. W. 3 I` 7 Q O Ip (b ~ 122, 140 SO. FT. O o ~ o I Q I V 2 y 10 0, I J 493.93' 979.76' 33./8' 460.77' E/W 114 LINE ~O N89• /6'45"W 5286.27' W I14 COR. SEC. 27, r28 N, R/8 W, E114 COR. S£C.27, T28N, R/8W, I2"IRON PIPE FOUND) UNPLA rrED LANDS /COUNTY SURVEYOR'S MON.) 3 ~ a 7 O - SCALE /00' LU . O 50' 2 /00' 150' 200' 300' 400' °j O o 3 Lu 73 73 W y W y Z Q O Indicates 1" x 24" iron pipe weighing 1.13 lbs./lin. ft. set. Indicates watercourse W 4: e ~t- Indicates fence. 2 N This instrument drafted by Laurence W. Murphy W 0 N -4 4j Dated: June 4, 1997 \,BconIS's,'',i~~ Q 77 B T C - a This application form is to be completed in full and",sigfied by the owner(s) of the property being developed. Any inadequacies w'-1 R only result in delays of the permit issuance. Should this be intended for resale .,y._.QWner~contractor, (end development house), then a•second form should be retained and completed when the property is sold and submitted` to',thig office with the appropriate deed recording. - -------.----+--ir--~1Y3 -Y~i•YY~r--..---~•----... L o e B. e owner of property lJ 41~S,kv~- 1. 7 r ~T~N Location of propert lJ'4 Sect -R Township r Maiiing'addr`e:s Address of site l ~:5' fi v 3 3 o y Lot no. Subdivision name f Other homes on property? Yes No Previous owner of property I~ Total size of property Total size of parcel Date parcel was created ! 9 Yes _ No Are all corners and lot lines identifi le? Yes ~C No Is this property being developed for (spec house)? Volume / and Page Number _.2 s as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWINGS A WARRANTY DEED which includes a DOCUMENFT DEEDS. , InL ad ition AGE NUMBER AND THE SEAL OF THE REGISTER certified survey, if available, would be helpful so as to avoid If the deed description delays of the reviewing process. references to a Certified Survey Map, the Certified Survey Map 4. shall also be required.; PROPERTY OWNER CERTIFICATION F9 I (we) certify that all statements on this form are true to the the best of my (our) knowledge that I (we) am (are) the owner(s) of property described in this information form, by virtue of a that I Register of warranty deed recorded * the ff ice o the presently Deeds as Document No. ~S 3 7 and 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. -3 7 d 3 9 Signature of Applicant Co-Applicant Date of Signature Date of Signature xa STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER h- MAILING ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION _ 1/4, 1/4, Section ;t 7 , T-2,p N-R_z p w TOWN OF '14 /1 /G/'z~ ! .4 n ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIEEDSURVEYMAP5&OLUME PAGE LOTNUMBER 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: L" DATE: St. Croix County `honing Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 STATE BAR OF WISCONSIN FOnd 2 - 1982 563703 W DWED DOCUMENT NO. ~ ifff Et,om Merle C. N ielsen, and Maxine P. Nielsen, XCD..W1 us an an wi a 1997 conveys and warrants to Josaya thole and Andrea thole. 10.30 AM husband and wife, of u.adi THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St. Croix County, State of Wisconsin: PARCEL IDENTIFICATION NUMBER Part of SE 1/4 of NE 1/4 and Part of SW 1/4 of NE 1/4 of Section 27, Township 28 North, Range 18 West, St. Croix County, Wisconsin I described as follows: Lot 2 of Certified Survey Mao filed July 23, 1997 in Volume '12', Page 3304, as Document Number 562730. N ~ ~ e II FEE j~ II i This is not homestead property. I~ I (is) (is not) Exception to warranties: 1 Subject to easements, reservations and restrictions of record. Dated this day of Aumtct A.D.. 19-92- (SEAL) (SEAL) . MERLE C. NIELSEN ii (SEAL) , ,Lll (SEAL) Maxine P. Nielsen I AUTHENTICATION ACKNOWLEDGMENT I' ~i Signature(s) State of Wisconsin, i1 ss I I~ St. Croix County U I~ authenticated this _ day of 19 Personally came before the this Wday of Ii August 19__9L , the above named it Merle C. Nielsen . Maxine P. Nielsen ~j TITLE: MEMBER STATE BAR OF WISCONSIN it (If not, n• BEER authorized by §706.06, Wis. Stats.) NOVAp PUBLIC v we ImCha1T to be the person who executed the foregoing and ac wledge the same- THIS INSTRUMENT WAS DRAFTED BY