HomeMy WebLinkAbout030-1006-95-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSM# C5' /17t LOT #
SECTION T N-R W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I~
5
d y.
BS
~
a,5
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
•
BENCHMARK: -5,-2
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ~jy~~ ~e<- ~ / Liquid Capacity: Setback from: Well ~G House /'g ' Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Q.~ Number of trenches %Z
Distance & Direction to nearest prop. line:
Setback from: well: 1~07~ House -5-102- Other
ELEVATIONS
Building Sewer ST Inlet: ST outlet:
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: LICENSE NUMBER:
INSPECTOR: t.7-
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations
gafetpanhuitbingsDivision INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
268512
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
t'i Ald' Wl;e.ed , ROBERT .,i ' .x3- ~ .r C,~: s C`: ~,EPr
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A9600222
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing a _13
Aeration Bldg. Sewer /dG} O J y,~
Holding St/ Ht Inlet Y.a/ / v v3
TANK SETBACK INFORMATION St/ Ht Outlet y S/~/ lOl05~
Verit
TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet
Air
Septic NA Dt Bottom
Dosing NA Header/Man. 8059 ,0 17, S-1
Aeration NA Dist. Pipe 8--7 3
Holding Bot. Systems q` . Y /
PUMP/SIPHON INFORMATION Final Grade G.od, , aa,oz'
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS g- A--1 DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O J CHAMBER Model Number:
System:~-&11`111 `.1..00 ~So r /UU~ N / OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over 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: s .a:rST a.FL.i;.SE~°i'i . 2 .:e. Mf ->rr: :aati , Caw"u.:.s J. v .vl s n.r%~
91,
1
Plan revision required? ❑ Yes No n ,
Use other side for additional information. 4~ I o Iq uct. H P
tfo
(116
111-
SBD-6710 (R 05/91) Date ,:ins a is Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
tttt~""`y Safety and Buildings Division
v~i~r■:~ SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O: Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. ~t--0
• See reverse side for instructions for completing this application State Sanitary Permit Number
a 1095/
The information you provide maybe used b9,U tvernment agency programs heck it revision to previous application
(Privacy Law, s. 15.04 (1) (m)). ~,~pc-l1~ r eW 1",r +ikd
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
' 1/4S'-,/ 1/4, S T jq , N, R 137 E (or)6
P operty Owner's Mailing Ad ress Lot Number Block Number
/ T
City, State Zip Code Phone Numb- ~0 Subdivj,~on N~A e or CS t Number
„
y® ( ) C-`c5 Div IJ
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ it~r Nearest Road
❑ ge
❑ Public 1 or 2 Family Dwelling - No. of bedrooms Toa Town OF
71-
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
a. a 9 ~9
030-1006 -95
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. rg New ----2. [j 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 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
75-d 1 Required (sq. ft.) Proposed (sq. ft_) (Gals/da /sq. ft.) (Min./inch) Elevation
Is- e t: i!/Gc s~ Feet 45- Feet
VII. TANK Capacity
INFORMATION in gallons Total # of manufacturer's Name Prefab. Site Fiber- Ex per.
New Existin Gallons Tanks Concrete Con- Steel glass Plastic App
strutted
Tanks Tanks
Septic Tank or Holding TankPC 1 25 v ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite s ge system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature. ,(Yo tamps) MP PRSW No.: Business Phone Number:
Plumb
4d Z9 er's Address (Street, City, State Zip ode):
r V < b
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (In` odes Groundwater Date Issue Issuing Agent Signature (No Stamps)
XApproved E] rchargefee)
Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBO-6396 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Dior ion, Owner, Plumber
INSTRUCTIONS
1 a
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, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. 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.
SANITARY PERMIT APPLICATION Safety and uilding WaterlSystems
In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave.
P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. do,
• See reverse side for instructions for completing this application State Sanitary Permit Numbeeerr
The information you provide may be used by other government agency programs Jrs -
The i [Privacy Law, s. 15.04 you (o (de E] Check if revision to previous application
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
Q 114-S-,C;j 1/4, S T , N, R E (or)16
Property Owner's Mailing Address Lot Number Block Number
7'.5'a G cf
City, State Zip Code Phone Number Subdivision Name or CSM Number
11. TYPE F BUILDING' (check one) E] State Owned ❑ Ity al ~5
Nearest Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town OF Clr'ta~?ll,~~Itls)
III. BUILDING USE: (If building type is public, check aII that apply) Parcel Tax Number(s)
oG
1 E] Apartment/ Condo 09 O
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.,kNew 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 fgSeepage 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
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
DSO ` yr I OW 9 73' Feet r 3 3 Feet
VII. TANK Capacity
INFORMATION In gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per.
g Gallons Tanks Concrete Con- Steel glass Plastic App
New Existin-
Tanks Tanks strutted
Septic Tank or Holding Tank G~ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No Stamps) P PRSW No.: Business Phone Number:
r u raa
Plumber's Address (Street, City, State, Zi C e):
6 4, -
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sal}gtary Permit Fee (Includes Groundwater ate slue Issuing Age t Sign t )
pproved ❑ Owner Given Initial Surcharge Fee) / 4r
Adverse Determination l /~~/7Co
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
• F ,
I
1
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. 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.
AL~ '
• Attach co SAN In ITgRY PERMI
"MIN
Sean 8112 mple tchles s (to the count accord with ILHR 83.0r APPCICATI Q
x 11 N
• Sa fet Wis. Adm. See reverse side size. Y copy onl ode Y and g
Bureau ulldin 'visio IPrivacf ~mation you pro for instructions for Omple only) for the system, on paper not less MO a- ashi 9 onAveter System:
completing
1 • A y Law, , s. 15.04 (1) (m))-may may be used by
oth ompl Ling this County ad#son, WI 53707.7969
other governm
ProP rty0avne T10'V INFORMAT ION _ P entagen application
cyprograms State Sanitary
Permit Number
Property 0 , Nr?" LEASE P
_ er's Mailinggddress RINT ALL II F0 ❑Check if revision to
City, RMATION State Plan I.D. eVbUs State
P114 erty L Number
ocation
11. ~ ztP Code
TYPE F Lot Number 114, S
pu BUILDING; Phone Number T • N, R
111. B(JILD
bli Ic 1 or 2 F (Check Subdivision ly~ Block Number E (Or
anvil Dwellin 13 State 1 NG USE (If bull -N O. o f Owned y Cs,e or CSM Number I
2 Q A pemnlent /Condo ding type is public, check -bed opm ❑ iZ OF .3 47
v
3 blY Hall Parcel Tax Nearest Road
4 El Campground 6 Number(s)
❑ Church/School ❑ Medical Facilit
1,111,
_ i' f w?rte
S E3 Hotel /M ❑ Mer Y/ Nursing Ho ~~O
otel 7 chandIse: Sal n1e
TYPE OF pE 9 ❑ Mobile Home parks/Repairs 10 ❑ Ou ~5~
q) RM►r: ❑ Office/ 11 tdoot Recr
1- New (Check only one Factory
12 ❑ Restaurant/ eational Facilit
_ S2. ❑ ReplaCemen box on line q. Check b 13 ❑ Service Station / / Dlntng y
❑ A Sa SYstem ox on li ❑ Other. Car Wash
nitarYPet- 3. ❑ Replacement ne6, ifapplicable specify
m1t was previ _ t of )
WE OF SYSTE oust rank Only 4.
1-Pr M; (Check only YIssued. Permit
❑ ReCOnnecti
essurizediNstri xisti
butio Y one) Number E_ _ ~g System f
n 5.
7SeepageBed Pr ❑ Repair of an
1 See essurized _Existin2
Syste_m_
page Trench Distribution Dat
seepage pit 2 1 ❑ Mound
System
-In-Fill 22 ❑ In EXPerir enta/
Ground Pressure
'SORPTION SYST 30❑Specify Type Other
~s Per Day EM INFORMATI 42 ❑ Hold*
ing
Fet
2. Absorp. Area ON; ❑ Pit Privy Tank
K Required ft) p, Ab
Posed Area 4. Lo 43 ❑ Vault Privy
DRMAT1 CapaClt 7q. ft') (Gals/dang Rate S. P
ON In gal/ Y Y/sq ft (Mi~r~-Rate 6-
New ns Total /Inch) System Elev.
'Hold anks Existi Gallons #0 f 2- Final Grade
ing Tank T Tanks Tanks Man Elevation
uf '/Siphon Chamber acturer's Name Prefab. Site Feet Feet
NS181LITY S concrete Con_
Steel F'ber-
Jersifined TATEMENT strutted
e Tw glass Plastic Exper.
(Print) , assume r ❑ APP
eSponsibilit ❑
Plumber for Installation of
th ❑ ❑ ❑ ❑ ❑
.s (Street, `l qy Signature: (N S e onsite se L 1 ❑
City, state, mps) age system shown ❑
S ~ G, IiP Code
MP on the attached
ENTUk C3 Plans
MSE ONLY Business Phone .
Number:
weer tv sa
Adverse Determi 1 nitary Permit Fee (includes Grou f
NS OF APP nation Surcharge Fee) R L / ate ssue
EASO S FOR R Issuing Agent Signature
IS OV (No St
amps)
DISTRIBUTION: Original/y~
to County.
Y 8 Rufb,:_
A INSTRUCTIONS
NNOW P
e of renewal any new criteria in the
t.im
o (2) years.
is valid for tw the expiration date, and at a
1. A sanitary permit ed before fitted to the
may be renew licable. be subm
nitary p .ermit Code \W111 be apP it issuing authority- sBD-6399) to
2. Your sa Administrative roved by the perm {er 1 Renewal Form L pumper whenever
W iscons'n it must be app it Trans
w ires a Sanitary perm licensed pump
to this perm ust be pumped by a
3 All revisions lumber req
nership or p The 5eptic tank(s) m r the State of
4. Changes Prior installation ministrator ° .
county e systems must be Property maintai ned. our local code ad
5 on; a sewa9ually every 2 to 3 Y rs wage system, contact Y
necjssary, concerning Your ons608 266-3g15-
6 D ivision,
uestions cgu ildin9s
have in, clue
. If'you number(s) o
Wisconsin, f where the
safety and must include ermit application description and parcel tax
itarY
ccurate this san p vide the legal Dwellin9-
To be complete and a and mailing address. Pro ms i f 1 or 2 Family
complete # of bedroo air.
owner's name an and orrep
reconnection,
1. property be installed. only one that apply ent,
system isto check riate boxes lacem
being served- check all approp . . for tank rep
e of building e ,s public, line B if permit is
11.
ildin9 TYP use. If building tyP Complete
stem type
111. 8u Check only one onl ine A . ending on system rs 1 through of tan ks and
ro(
anc
ermit riat box depending
ation requested for numbe ber o umpls'PhOn 1 frog
of
IV. TYPe ° P Check apPrOP a all inform listthe total gallons, num or all septic, Pct approva
stem- provi d tank, Complete mental produ
V Type of sy ation. exisalna tank material . eristem inform newlor received exP Mp etc.)
Vl. Absorption sy achy of every onstructed only If tanks
fill in the cap fab or site c royal
VII ate prefix 1e.9.
' ropri
information- me indicate Pre er. mental app m ith app
mn, Information-
. Tank Check eXp ber w
this system- e 1. nseou
holdingtanks fill in nam form
ent. Installing pluubesign application
DILHR-
statern plumber m
VIII. Respons,,nd phone number-
e only county The Plans n
address Department Use phone
the muted to n th tanklsl - Sep
M. County Use only- be sub of holding or
locatio lakes; pump
Department 8112 x 11 inches must ensions, and building se
X county than complete din' tyke; streams of the
not smaller ith a. s1water se and the location troll; dose v
cations drawn to scale or w water m and con cross s(
and sPecifiot plan' sewers; wells; ent system areas;
' in{orma
Complete Ptans in A) pl building se lacem ecifications for P umps mane a rer D)
e thefollow g' tanks; stems; rep complete s model and P omm; and F)a l sizing
includ ,the( treatmentsoil absorption sY nts; C)
reference POI curve, Pump on a 115
tanklsl or o tionboxes; vation erformance
dist6bu vertical ele loss; Pump p E) so►1 test data
tasks; , tal and b the county;
horizon friieir°n -1f requi
d►ffere tionsys
~elevation red by
of the soil absorP
GROUNDWATER SURCHARGE mber of regulated practiceswhich can
surcharges
ntamination invest igatic
form roundwater co
,993 Wiscons i n Act 410 included the creation of surcha ,
used onitoring 9
effect roundwater- es are
effect 9 through these surchar9
The monies collect of standards.
and establishment
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Wow ' "n. Department of Industry, SOIL AND SITE EVALUATION REPORT Page,,/- of _
Labor Human Relations _
Divl of safety & Buildngs in accord with ILHR 83.05, Wis. COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. R t incluc,but EL I.D. #
not limited to vertical and horizontal reference point (BM), direction and % e, SCT7
dimensioned, north arrow, and location and distance to nearest road. 1
r WED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATI j ;t;t3
.
PROPERTY OWNER: OPERTI','
1A 2 T Lcl N,R liq E (ol
ROPERTY OWNER: LING AD ESS BLOCK # E OR CSM #
CITY, TAT ZIP CODE PHONE NUMBER ❑CI OWN NEAREST ROAD
New Construction Use Residential I Number of bedrooms [ J Addition to existing building
j J Replacement Public or commercial describe 13e 4E7,,r `FDA
Code derived daily flow gpd Recommended design loading rate __,_~bed, gpd/ft2__,T_trench, gpd/ft2
Absorption area required T-51 bed, ft2 ~ ~ - trench ft2 Maximum design loading rate _,_:;_'bed, gpd/ft2 I trench, gpd/ft2
Recommended infiltration surface elevation(s) 93, 8~ ft (as referred to site I nchmark
Additional design / site considerations $i - u rP~
Parent material Flood plain elevation, if applicable It
S - Suitable for system CONVENTIONAL, - MOUND IN-GROUND PRESSURE AT-GRA S D❑ U SYSTEM IN FILL HOLDING TANK
jau
U - Unsuitable fors system as ❑ U ❑ U S ❑ U S [I
SOIL DESCRIPTION REPORT
De th Dominant Color Mottles Structure Roots GPD/ft
Boring # Horizon P Texture Consistence Bouril Bed Trertcft
13 3 1 0 d 41 in. ~ Munsell ' Qu. Sz. Cont. Color Gr. Sz. Sh.
- I ~
h2 L
S,1 21!' r CL~
Ground "1 / S 6 S ( - rA '
I, L
Depth to
limiting
l
L
Remarks: C
Boring # Z L ~f~>~- Ivri~ rJ W
U - P,K
3 ~
13
Ground
VAAi
Depth to
limiting
Remarks:
n~ y o L-
T Name:-Pl Phone:
ress: Date: CST Number:
Signatur • ~ ~ ? Y
PROPERIYOWNER SOIL DESCRIPTION REPORT Page Z of. ~
PARCEL I.D. t
Boring # frizon Depth Dominant Color Mottles Texture Structure Consistence Banclary Roots GPD/ft
in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
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Depth b
limiting
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Remarks:
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b
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limiting
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Remarks:
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Ground
Depth to
limiting
fac
Remarks: i p
Boring # D L 3/z-
77 Clime I Zw^,~ ~~If Cf~ ~'~t
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
i St. Croix County
OWNER/BUYER o IDe r 37 f 1, , 117 j4 q r ~ ry~ 0 N
MAILING ADDRESS r75 a C r e. s+ V ,10 1 Y~ a; J
PROPERTY ADDRESS 75-1- C r e s 4 V; e. uj ~y a
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 14u d S o ,j t ut s S q o/
PROPERTY LOCATION 1/4, SW 1/4, Section c;Z , T 221 N-R /9 W
TOWN OF J+. Joseph ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP,y~ , VOLUME , PAGE 53 , 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:
DATE: C)7-O cY 1(v
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property-Rob-er f __F - - k; /)y da,,Aj,2,7oAJ
Location of property.S4_ Secct`ii'o-n a T oRq N-R_Lq_W
Township rj ,ToSeph Mailing address '75-.D- CY-cs f y: erJ Tra: J
syo/(o
4u tSOAJ W=
Address of site 75.')L- C res-/ y %?cU Tra.; / ~u dso.~ Co
Subdivision name CSM J1W a. . S3 y Lot no.
Other homes on property? Yes No
Previous owner of property ~e f ,J &,k„1
Total size of property / 9(o 4 cres
Total size of parcel Ib . 8(* c'c.rC_5
Date parcel was created 1- 18- 79
Are all corners and lot lines identifiable? K Yes No
Is this property being developed for (spec house)? Yes K No
Volume W and Page Number'" 1117as 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. 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.
- ign ture of licant Co-App icant
07_0?__1G 0'7-0J3-I6
Date of Signature Date of Signature
4--~--- 26
346180 • CERTIFIED SURVEY MAP
S 1/2 OF THE S 1/2-SEC. 2, T29N,R19W
N
''I.;r ~ "ref 19(,J
Of co
BEARING ARE ASSUMED' S'89 52'-OI'E
ON THE SOUTH LINE OF-THE S.W. 1/4 8 rL1 S
OF SEC. 2
,YNI?LATTW.
LEGEND .4ANQS.
e NO.7 (.875X24) IRON-RE-BAR SET ~O a0
w
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THIS INSTRUMENT DRAFTED BY A. C.N. G' 3 0
z
JOB NO. 77- 114
LOT- I _j.
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16.86 ACRES
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- _ a
300' 100' 0, 100 150
Z
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SCALE IN FEET ~~A4
0
s3'• EXISTING
90-27'-47' HOUSE
R - 1960.08'
L : 3 23. 69' /
C = 323.36 m
~~Ao C.B.= S 45°-31-06 W a6`~ '~o
S. W. SEC. COR. 00 y9 .A3, o s0,
CO. MON. h~`y~~3• s9~ y0,, S 89- 52-OI'E
~ 345.51'
SO , , y9
Oo
c y2~ E TOWN ROAD_ p?• 120.0
-~9 o s0 N00!55-49E
S 89- 52-01 E CO. MON.
927.27' SOUTH 1 /4 COR.
UN•PLATTED• 4A P.4. SEC. 2
APPROVAL OF i i *,IS MINOR SUSDIVISIGN
• DOES NOT IAEAN AFFROVAL FOR
BUILD I^ SITE 0?, SEP11C
J [M. ~ a . f!
REFER TO H62.20.
DOCUMENT NO. STA:'E BAR OF WISCONSIN- FORM 2
• r IN)~Q7(11[M DEED
y i i) Vol, 570 rACE 2 THIS SPACE RESERVED FOR RECORDING DATA 7 9
BY THIS DEED, John T. Carroll, Personal OFF)ZE
Representative of the Estate o James M. 5T. CROX CO,, WIS.
Hartmon ( d. i-r Rewrd tt>fs 2?rd
day of Lc-. ao.1918
Grantor convey a:3bff400}f3ii>tOdo Robert J. Hartmon and LiZl: Ann t 2 ;
Hartmon, husband and wife as joint tenants
R.ghtar a
Grantee
for a valuable consideration 'RETURN TO
the following described real estate in St. Croix -County, State of7isconsia I
A parcel of land located in the South Half of the Tax Key/_
South Half of Section 2, Township 29 North, Range This is not homestead property.
19 West, described°as Lot 1 in the Certified Survey
Map recorded in the office of the Register of Deeds for St. Croix County,
Wisconsin, on January 23, 1978, in Volume 2 Certified Survey Maps, page
538, document 346180.
Subject to all existing highways and easements of record.
~..~1V~ER
r~
C.,.-(,
FEE
Exception to warranties:
Hudson, Wisconsin 23rd'. February 78
Executed at this day ej 19~.
SIGNED AND SEALEe, IN PRESENCE OF - '1 - (SEAL)
John T. Carroll, Personal
Representative o the Estate
Of t5 etme s Z lttt7 ` 'r~r'dk
(SEAL)
(SEAL)
Signaturesof John T. Carroll, Personal Representative of the
Estate of James M. Hartmon,
authenticated this 23rd day of- February 19 _I_a.
hn D. Heyw d
Title: Member State Bar of Wisconsin Hr2 U&X3? %X
Authorized under Sec. 706.06 viz.
STATE OF WISCONSIN 1
I ss.
County.
Personally came before me, this day of 19_r
the above named
to me known to be the person- who executed the foregoing instrument and acknowledged the same.
This instrument was drafted by