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HomeMy WebLinkAbout026-1110-95-000 a I y ~ ~ o o 0 a ~ ~ I cy Q o c co 3 n co 0 Gov I ~ I a I o~ c y N ~ 3 I a I o z LL z LL o ~ c E Q m I v CL I co ~ E Ft ~ L z T I d d z a M W C O c Z d z d c O U) F- N z E M N N ~ C_ N n CO o N N N LL U) L 0 m ¢j O N Q w Z m z N O 0 0 N z a (D C141 fy i a Y N a 4) _ Y Q r, c (O p N N E N C O N 2 C 0 1 0 C m T 00 -0 J N c H F- U) U) F- U = N z° C 0 CL IL CL FL I o W a3i n n N W J v Z rn rn } C~ N v-: C) co O O ~ E 7 `c T Cp D a~ I 1~ O O C N O C © m O O > y C :3 E 0 0 O 1 o N C N (1 T C4 " C O (O c c (n N O N W O in n N t • >a c~ C`) 0 1 3 rn o N o E U T o v cn N o z_ Z: to w 01 ~t c a CL 0 CL 0) C rr~~ `'1 p 0 a 0 V) v STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER n,~ ADDRESS S BDIVIS ON / CSM ))I LOT SECTION _T_N_R_ZZ _W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM v 7f~J i yp rct- ~ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ~s Liquid Capacity: Setback from: Well / House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: / Length Number of trenches Distance & Direction to nearest prop. line: i Setback from: well : --Z--_ House--Z42_ Other. Mfr j~ ELEVATIONS ad W7,12 r ST Inlet: ~S- ST outlet: PC inlet PC bottom Pump Off Header/Manifold 9-2 Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: ,f=2 5-9 INSPECTOR: 3/93:jt ST. CROIX COUNTY ZONING DEPARTMEN' AS BUILT SANITARY REPORT Owner Property Addr ss City/State Legal Description: / Lot Block Subdivision/CSM it '/ate 1/4, Sec. ~Z, T.Yo N-R Z&W, Town of PIN # - SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: fix ,bV60 s / Size ST/PCVA / Setback from: House Well P/L Tank manufacturer LL,12~ Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: r o Width /-2 Length -7S- Number of Trenches Setback from: House Well P/L Vent to fresh air intake ELEVATIONS: T Description of benchmark Elevation Description of alternate benchmark Elevation Building Sewer ST/HT Inlet 9-1,2_ ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines Y ( ) Bottom of System 2 ( ) Final Grade Date of installation/ 7 / Pe it nu er State plan number Plumber's signatur License numberr--V9 sZ Date Inspector,,, Complete plot plan 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 f p' Q usrt io / ~ ~ y~ ~ scry-/ INDICATE NORTH ARROW II - Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryRfgiibo~ Personal Information you provice may be used for secondar y purposes (Privacy La s.15.04 (1)(m)]. Permit Holder's Name- ❑ Town o : State Plan ID No.: SWANSON, DAVID If~~Ci~ CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tff219."1110-95-000 /4 /G2) , co Q LL TANK INFORMATION ELEVATION DATA A9700427 / oIZ `197 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic L XIS f,y~~ Benchmark T. Aeration Bldg. Sewer Gam- Holding St/~f't Inlet .9910 TANK SETBACK INFORMATION St/ of Outlet nab 7Z, I Vent TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet Ar i Septic > Z/ NA Dt Bottom Dosing NA Header / Aeration NA Dist. Pipe 93,82 Holding Bot. System 9 9z. ~ PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Nu er _ GPM TDH Lift Fri stem TDH~ Ft Forcem Length Dia. Dist. To e l S 61L ABSORPTION SYSTEM BED / TR' NCH Width Length No. Of Trenches No. Of Pits Ins' Liquid Depth ~L DIM SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAC G INFORMATION TypeO / CH BER Moe Number: System: 4tal UNIT DISTRIBUTION SYSTEM Header L-! Distribution Pipe(s),, x Hole Size x Hole Spaqng-j Air Intake Length Dia. Length _Z1 Dia. S` Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ystems Depth Over / Depth Over 1 xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 4.30.18.627,NE,SE 1744 MARGARET ST tea- Plan revision required? ❑ Yes EWo Use other side for additional information. /p s--91 CRn-a71n is 1/071 Date Inspector's Signature Cert No Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. Visconsin In accord with ILHR 8305Wis. 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 in x 11 inches in size. "r/ r • See reverse side for instructions for completing this application State Sanitary Permit Number i Vj/) 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 INF RMATI N Prope y Owner Name Property Location I/F 1/4 r 1/4,S T , N, R E (or IV Property Owner's Mailing Address of Number Block Num City ate Zip Code Phone Number Su ivision Name or SM N r 7 y Il. TYPE F 6 ILDIN : (check one) ❑ State Owned °a viitage Neare oad Public 1 or 2 Family Dwelling - No. of bedrooms Town OF - , , e,/!~/ i- Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ','l 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 online A. Check box on line B, if applicable) A) 1. ❑ New 2. jo Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an System System Tank Only Existing System _ Exlstina System - 8) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM:.(Check only one) Non-Pressurized Distribution Pressurized DistributionExperimental Other 111] 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 S. Perc. R site 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./i ) Elevation Feet Feet VII. TANK Cain gallons Total # Of Prefab. Site Fiber- Exper. INFORMATION Gallons. Tanks Manufacturers Name Concrete Con- Steel glaze Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank 4= 4= 2AX -;2 i e5 3 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for inst lation of the onsite sewage system shown on the attached plans. Plumber's ame, Pr' 1) / Plumber; Si t s mps.)_ / MP/MPRSW No.: Business Phone Number: y Ph tier's c dress (Street tty, Sta 1p Code). IX. COUNTY / DEPARTMENT USE ONLY ing Agent Signature o Stamps) ❑ Disapproved Sanitary Permit fee podudesGro w"Ier ate issue Issu [.Approved ❑OwnerGivenInitial fj~ rs°"n"9eFee1 Adverse Determination - / /0 f " X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: ; f, )r 7, ( t ~.9~7,./0// ScJ,~,Jsc~l ;S,E~ - SFC T.30r✓- x~i~u~ X ll w,,~,a/o GcJI "yDi7 a So/~ G ~ y3 ~ F ~ N O I N :.;O'nsin Department of Industry. SOIL AND SITE EVALUATION REPORT Page-/ of abor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than" x~\7 i . Plan must include, but not limited to vertical and horizontal reference iA irectio . f slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and d' to no d. REVIEWED BY DATE APPLICANT INFORMATION-PLEASE TALL 1 IO PROPERTY OWNER: PERTY LOCATION C 19 -G LOT 1/4 1/4,S T N R (or& A-A15e1A R-1 - P OP RTY 0 NER: MAILING AD RESS # BLOC # S BD. NAME OR # _u/ Cl , STAT ZIP CODE 0 MBEFF 't CITY ❑ GE OWN NEAR T AD [ ] New Construction Use Residential / Number of bedrooms [ J Addition to existing building D4 Replacement [ ] Public or commercial describe Code derived daily fiow&~Pa gpd Recommended design loading rate 1; bed, gp l'L-)Ltrench, gpd/9 Absorption area required g5-91 bed, 1`12 >,sZ) trench, ft2 Maximum design loading rate i7 _bed, gpd/ft2_,l_trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN RLL HOLDING TANK U= Unsuitable for system IM S0 U 14 S0 U ® S ❑ U 0S ❑ 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 Coke Gr. Sz. Sh. Bed rertdi 13 1 9-4:2 ~E 35~/l -.14 4--Z 2!;- 1 - -1.1/1 Ground 3 27- dev. IL - - -31 xzz Depth to limiting factor >/ice Remarks: Boring # 'J dl" Ground elev. '00 Depth to limiting factor Remarks: T Name:-Please P' t l' Phone: L Address. ~~o PROPS-1. --OWNER SOIL DESCRIPTION REPORT Page-,-,-) of PARCEL I.D. Boring # Horizon Depth Dominant Color Mattes Texture Structure Consistence Bottxfty Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed nnch '7 aqe- -Al Ground 3 < elev. - - Depth to limiting factor Remarks: Boring # E3 Ground elev. It. Depth to limiting facto Remarks: Boring # 13 Ground elev. It. Depth to limiting factor Remarks: Boring # Ground elev. ft Depth to limiting factor A nm a r4c- i a~.~ 30~' ,~~;p 5~.~ ~/,~/y sue/ ~i8~ • ~ ~~e- ,~_~a-sue _ . _ _ a~ _ _ _ I ~ .G~ ,Gy{iJ , _ _ . ,gti _ _ ldQ ` lr _ _ _1 _ a y ;y ~i ,~s' yo ~ ~ Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor anid Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299107 Permit Holder's Name: ❑ City [I Village Town of: State Plan ID No.: SWANSON, DAVID RICHMOND CST BM Elev.: Insp. BM Elev.: , BM Description: Parcel Tax No.. / G'J, GPI ~~v GU `JGZ 026-1110-95-000 TANK INFORMATION ELEVATION DATA 1.2 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (,cl S O"re ~ Goa Benchmark a 3 /l/I~, GO B Dosing Aeration Bldg. Sewer Holdi - St /FInlet TANK SETBACK INFORMATION St / outlet TANK TO P/ L WELL B G. Vent to ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header Aeration N Dist. Pipe HoldingBot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 7,~ 2 9 7S Model Number TDH Lift Lriction stem TDH Ft Force n Length Dia. Dist. To e SOIL ABSORPTION SYSTEM BED /TRENCH Width I Length,,- / No. Of renches No. Of Pits Inside Di;. Liquid Depth DIMENSION o2 DIMEN I LEAC urer: 7 _7 SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM INFORMATION Type O ti /5 U , 75 i CH ER Mode Number: R UNIT System DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) le Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grades ems Only Depth Over , / , Depth Over xx Depth Of xx Seeded/ Sodded Fx Mulched 9 Bed /Trench Edges Topsoil E] Yes ❑ No ❑ Yes E] No Bed /Trench Center VP ` COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 4.30.18.627,NE,SE 1744 MARGARET ST C, 01- Plan revision required? ❑ Yes ❑ No / Use other side for additional information. l~ -2 7 z~ SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. `4sconsin 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. • See reverse side for instructions for completing this application State Sanitary Permit Number ~ 99fo~ 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 INF RMATION Prope y Owner Name Property Location 1/41/4, S T~a , N, R E (orN Property Owner's M fling Address of Number Block Numb City ate Zip Code Phone Number Sub ivision Name o SM N m r 1 - 6 i l/UU . TYPE BUILDING: (check one) ❑ State Owned 1t( Neare t oad Public 1 or 2 Family Dwelling - No. of bedrooms 0 Town OF 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) d, - /`/L, 9 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 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. R Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System _______System _ ____________TankOnly______________ 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 M 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. R to 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./in ) Elevation FeetFeet VII. TANK Ca y Total # of Prefab. Site Fiber- . App INFORMATION in g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic Exper. New I Existing strutted Tanks Tanks Septic Tank or Holding Tank i~S ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon ChamberA~2104 I ❑ ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for inst ation of the onsite sewage system shown on the attached plans. Plumber's ame Pr ) Plumber' i t S m s) MP/MPRSW No.: Business Phone Number: Plu ber's c dress (st et, ty, Sta ip Code): IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing A ent Signature amps) ,~~Pproved ❑ Owner Given Initial :1 Surcharge Fee) Adverse Determination 10, X. CONDITIONS OF APPROVAL / REA ONS OR DISAPPROVAL: ~ _ A SBD-8398 (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. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only_ X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ~i91',Q ScJA~IsdJ /YV' sF~ / ~~0~✓ 7~/~GJ /4) XlLnava GUI 1' 0/7 ~ A Zoim ~1,52 Y7S~ /"7l3 SC~'/z / ~ 4'4 ys` N / I POM ~C f i i Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and Human, Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code ' COUNTY Attach complete site plan on paper not less than 8 44 x 17 ificheis6h s` Plan must include, but not limited to vertical and horizontal reference p ft(I fOt), directio n f slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and d'k6y4e to ne t ~d. APPLICANT INFO RMATION-P LEASE/04ilf1T l LL I 10 REVIEWED BY DATE PROPERTY OWNER: )'PR PERTY LOCATION .,G LOT 1/4 1/4,S _Z/T~ N,R (06 P OPERTTY 0 NER~ MAILING A D RE~, % ; ?1 # BLOC # S BD. NAME OR # s / "uJ di, CI STAT ZIP CODE 0 MBE " 1," CITY ❑ GE OWN NEAR ST AD iJ [ ] New Construction Use ] Residential / Number of bedrooms [ ] Addition to existing building UQ Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate _,_~bed, gpd/ft21Ltrench, gpd/ft2 Absorption area required s3 bed, ft2 trench, ft2 Maximum design loading rate __7 bed, gpd/ft2 ~trench, gpd/ft2 Recommended infiltration surface elevation(s) q 7 ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem IM S ❑ U 14S ❑ U ®S ❑ U IZI S ❑ U ❑ S ®U ❑ S O U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 4K ?h 12 S_ Al 14 Ground elev. Depth to limiting factor Remarks: Boring # k:•: ti.. 12 2 127 Ground elev. - e ft. Depth to limiting factor Remarks: CST Name:-Please P 'nt l' Phone: Address: Signature: Date: n.~ ST Number: PROPERTYOWNERSOIL DESCRIPTION REPORT Page-~2 of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourd3y Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends t. t :•:::.v}wii / j Ground -31 elev. ft. Depth to limiting factor >Z42 Remarks: Boring # F" Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) 171-9 i o26' ,Gf4iJrkl • ~ G.9,~GG.E ~ ~ i i ~ i , ~f i 13 -2 i 8 T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recprding. Owner of property Dc ~U j A 1~a+f' ' 1 ~ " Y,n b /I Location of roperty &~1/4~_1/4, Section T, 2N-RW Township Mailing address I :lq (A e Address of site I-7 n S Cep- O Subdivision name f fil ) .Lot no. a~ Other homes on property? Yes No Previous owner of property ESL n nial R n n i J/10IL--c'On Total size of property 2 QC)0 so, Total size of parcel SCE- Date parcel was created Are all corners and lot lines identifiable? i~ Yes No Is this property being developed for (spec house) ? Yes __y" No Volume I& 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. ~91 , 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 2De eds as Doc nt No. Signature of Applicant Co-Applicant 1 ~ Date o Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County r OWNER/BUYER DCLO'(H Q n c( rl-,m n MAH-MG ADDRESS I L Q r n re 1 1 I S PROPERTY ADDRESS I r7q`~n a Y, CA (I r-e+ r (location of iseptic system) a obtain from the Planning Dept. CITY/STATE / V P_ t t] r. Y 1 ~M Lk,)( ~4N o I -7 PROPERTY LOCATION _ 1/4, 1/4, Section_ , T_,j2_N-R-ff_W TOWN OF / a J mo ST. CROIX COUNTY, WI SUBDIVISION l e 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 septictank 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 thisconsin DNR. Certification stating that your septic has been maintained must be completed and re rn to the St. Croix County Zoning Officer within 30 days of the three year expirati te. SIGNED: 1,4 DATE: / St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 T r . THIS SPACE RESERVED FOR RECORDING DATA DOCUMENT NO. STATE BAR OF WISe:`OkS"" COP" 1-1982 WARRANTY DEED 519387 R ST. CROIX CO., M Reed *W Re~d bewneen 1At1 This oeed, m: atni janeson HIL 2 5-1994 emon . R A. Husharxi an~..rB fe bat C~a~ a,T N___ JTMaw a5 8:30 M I at orf•: Grantor, at attorn,_2y_' Grantor. at and - busban+ an-i n. f"as ini n► tPI1C7nts of Daft - Grantee. Wltf)@SS$t~l, Thad tMe said Grantor, for a valuable coInsider'ation R[►tfl st_ Cxx~ix 1210 W. County Road E conveys to Grantee the follow. described real estate in Ej~ Road E Arden Hills, MN ::ounty, State of Wisconsin' Lot 28, Viebrock's River Valley Viers Addition P}a o I to the Town of RichTtond, according to the recorded a>tPar f Fy~ This homestead property. I (is) (is not) Together with all and sinular the hereditaments and appur•te' thereunto belonging; And warrants that the title is foram, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defend ibe same. 1994 Dated this 29 h day of -'ate (SEAL) Gam` ~l •s~~v->-~ (SEAL) Dea R. JEfTleson, by Craig Jameson his attorney in fact may, i -(SEAL) Unni Jameson, by Craig N. Jaeteson her attorney in act AUTHIEKTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. RatTS2y County. 19 Personally came before me this 29th day of = authenticated this _______ft of June 19 94 the above n med C -ai N. JalTlesc~+'t as attorney in i~act and Patricia L. 2 far David L. won Co, Swanson, husbat3d and wife ~ ~ 7 f TITLE: MEM8ER STATE BAit OF WISCONSIN Y (I I e known !o be the person, who excuted the a not.- m a ~ authorized by § 706.06.ts. Slats.) 11¢xegoing instrument and ackrwafedge the same. I THIS INSTRUMENT WAS DRAFTED BY ~ ~ a y ~