HomeMy WebLinkAbout030-2034-30-000
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Safety and Buildings Division
Misconsin SANITARY PERMIT APPLICATION 201 E. Washington Ave.
P.O. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code 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.
• See reverse side for instructions for completing this application State Sanitary Permit Number
a?9909l-
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Prop y ner a Property Location
1/4 1/4, S T , N, (or&
Property Owner s M iling Address Lot Number Block Nu er
r
/ A
City at Zip Co a Phone Number Subdivision Name or CSM Number
02 lit/ /S) - l
11. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Near st Road
❑ Village
Public 1 or 2 Family Dwelling - No. of bedrooms Town O
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) a f 3
Q,~D ~ 3 ' C.t.~Ci
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. ❑ 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
110 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
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./' ch) Elevation 99 Feet Feet
VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks r~
Septic Tank or Holding Tank [3 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, th undersigned, assume responsibility for i tallation oft a onsite sewage system shown on the attached plans.
Plu is Nam Pri / Plu er's gn o s) r P/ mPRSW No.: Business Phone Number:
/
x"f""~ - e - l ~ S~' J S
Plumber' c dress ( et, 7, State, Zi de):
7dt
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps)
Approved ❑ 1 Surcharge Fee)
Owner Given Initial / 11,b-7--?7
Adverse Determination lL
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R.1 tom) 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.
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 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.
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AisconsiN Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 299094
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
O'BRIEN, BOB ST. JOSEPH
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
030-2034-30-000
TANK INFORMATION ELEVATION DATA A97004 14
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION TypeO CHAMBER Moe Number:
System: 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 E] Yes No ❑ Yes No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH 24.30.20.463,SW,NE 274 ARBOR HILLS DRIVE
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
r
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
i
Parcel 030-2090-70-000 05/11/2007 10:18 AM
PAGE 1 OF 1
Alt. Parcel 24.30.20.761 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s)' O = Current Owner, C = Current Co-Owner
0 - O'BRIEN, ROBERT E & MARIANNE REPP
ROBERT E & MARIANNE REPP O'BRIEN
274 ARBOR HILLS DR
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): ~ jhr ry
Type Dist # Description
SC 5432 SOMERSET L
SP 1700 WITC
v ~
r
Legal Description: Acres: 1.340 Plat: 0050-ARBOR HILLS
SEC 24 T30N R20W PT NE SE OUTLOT 1 ARBOR Block/Condo Bldg: LOT 01-1
HILLS 1.34AC ASSESSED WITH OTHER LOTS
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
24-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
2007 SUMMARY Bill Fair Market Value: Assessed with:
0 030-2090-60-000
Valuations: Last Changed:
Description Class Acres Land Improve Total State Reason
Totals for 2007:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2006:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
,B,9c~/ef
Wsconsin'DepartmentofIndustry, SOIL AND SITE EVALUATION REPORT Page LOf
La- %r 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 1/2 x 11 inches in size. Plan must include, but . L1
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
GOVT. LOT 1/4 1/4 S T N,R (or CAI)
PROPERTY OWNER':S MAILING ADDRESS LOT # BLO # SUED. NAME QR CSM #
CITY ATE ZIP C DE PHONE NUMBER ❑CITY ❑VILLAGE WOWN NEAREST ROAD
O )
b(] New Construction Use [X] Residential /Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow ~F6 gpd Recommended design loading rate S- bed, gpd/ft2 / trench, gpd/ft2
Absorption area required bed, ft2 ieea trench, ft2 Maximum design loading rate J bed, gpd/ft21,/ trench, gpd/ft2
Recommended infiltration surface elevation(s) 2'a / ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood lain elevation, if applicable It
S = Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem WS ❑ U ❑ S ❑ U 21 S ❑ U 0S ❑ LI ❑ S ($1 U ❑ S U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. ont. Color Gr. Sz. Sh. Bed Trench
_2 91Y
Ground
elev. s/ w
Depth to
limiting
fact
5
Remarks:
Boring #
14
4
1
Ground s~
elev.
9,61 7-ir
~ ft. - -
Depth to
limiting
factor
> 2L
Remarks:
CST Name:-Please Print Phone:
Address: rr Y
Signature: f~ Date: CST Numbe :
PROPERTY OWNER SOIL DESCRIPTION REPORT Page-~5 of
PARCEL I.D. # '
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
6-Z ZR -Z~2 A14
Aaly 5/
Ground
elev.
Depth to
limiting
fact
Remarks:
Boring #
~Y.
Ground -
elev
Depth to
limiting
factor
>
Remarks:
Boring #
4v:.v: is
Z
Ground
eley.
ft.
Depth to
limiting
fact.
Remarks: !
Boring # 0,,
FA
Ground
" .
elev. pr r
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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%Vtsaonsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page L of
Lahr 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 1/2 x 11 inches in size. Plan must include, but _S ~J
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
GOVT. LOT 1/4 1/4,S T N,R (orcw
PROPERTY OWNERS AILING ADDRESS LOT # BL # SUBD. NAME OR CSM #
CITY ATE 1 ZIP CODE PHONE NUMBER []CITY []VILLAGE f@TOWN NEAREST ROAD
( )
L-7 7,11
New Construction Use [X] Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow lF6 gpd Recommended design loading rate , S- bed, gpd/ft2-trench, gpd/ft2
Absorption area required L.X, bed, ft2 /boo trench, ft2 Maximum design loading rate _,,y- bed, gpd/112_trench, gpd/ft2
Recommended infiltration surface elevation(s)? / ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material 4,~,- 6 3 ~Ajn2 , { . A~ Flood lain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for s stem WS ❑ U Q] S❑ U El S ❑ U 0S ❑ U ❑ S W U ❑ S RI 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 Tmnch
t-) - 5- Z~2 Y4 JV '14 T7
Ground -
elev. s/w
Depth to
limiting
factor
>~L
Remarks:
Boring #
- 3
620bg
Ground s " w,
rev. _
ft. - -
Depth to
limiting
factor
> 9C
Remarks:
CST Name:-Please Print/ Phone: /
Address: _)XW /l _
Signature: i / Date: CST Nu:
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LOQs'~rtB~tofffQ$tpPH 24.30.4Q244ATE SEWAGE SYSTEM County:
• Labor and Human Relations
-Safety and Buildings Division INSPECTION REPORT
Sa
(ATTACH TO PERMIT) nitar wit
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
X
C • s Parcel Tax No.:
7 UjV-2UJ4-JU-U00
TANK INFORMATION ELEVATION DATA A93 Wl~ng
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark o
Dosi ng
Aeration Bldg. Sewer
Holding St/Ht Inlet (r.
TANK SETBACK INFORMATION St/ Ht Outlet
Verit
TANK TO P / L WELL BLDG. Airito ntake ROAD Dt Inlet
ir
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
-1 PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss Forcemain Head
Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth J
DIMENSIONS G DIMEN I N
LEACHING Ma nufacturer.
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
CHAMBER Model Number:
INFORMATION Type O
System: 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 E] Yes E] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc1
T. JOSEPH ?4.30.20.463 - u
LOCATION
qQ it
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
t
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
DILHR SANITARY PERMIT APPLICATION couNTY
In accord with ILHR 83.05, Wis. Adm. Code
uaaa,° a.ana.atuns~
Now 1Z
STATES I Y PERMI
-Attach complete plans (to the county copy only) for the system, on paper not less than /
i ❑ C1~edk if a i revious application
8/s x 11 inches in size.
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPER WNER + PROPERTY LOCATION
t/a 1/a, T N+ (O
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CI TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
) ❑ State Owned ❑ VILLAGE
0 =W QF*,~~LLea_lj
N imtsER(S)
❑ Public R 1 or 2 Fam. Dwelling-# of bedrooms A
III. BUILDING USE: (If building type is public, check all that apply)GS
1 ❑ Apt/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 in line A. Check line B if applicable)
A) 1. ® New 2.0 Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # - 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 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 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. 17. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./' ch) ELEVAT ON
Feet Feet
VII. TANK CAPACITY Prefab. Site Fiber- Exper.
in allons Total # of Manufacturer's Name Prefab. Con- Steel glass Plastic App
INFORMATION New istin Gallons Tanks Concrete structed
Tanks Tanks
Septic Tank or Holdin Tank
Lift Pump Tank/Si hon Chamber t EE p . 0- 1 n 0 1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for install n of the onsite sewage y stem shown on the attached plans.
Plumber' Name Print):` Plumb 's n~Kui o S m ) MP/MPRSW No.: Business Phone Number:
,/7
Plum s ddress (St et, city, State. Zi de):
IX. COUNTY/DEPARTMENT USE ONLY Issuing A re Stamps)
❑ Disapproved Sanitary Permit Fee (Includes Groundwater [ate Issue
❑ Approved ❑ Owner Given Initial Surcharge Fee)
p ' /3 - 9J
Adverse Determinati n
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) 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 the 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 San tary 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 & 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
Ill. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for 6,11
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. RE!sponsibility 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 81/2 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
STC-100
This application form is to be completed in full and signed by
fthe 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/cohtractor,(spec
house), thenta 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 2~ 'AA
Location of property,_<~j,,,'~ 1/4 )/,_4' 1/4, Section Tt~N-RzW
Township 1"L L
Mailing address
Address of site
Subdivision name Lot no.
Other homes on property? yes Z No
Previous owner of property
Total size of parcel
Date parcel-was created
'Are all corners and lot lines identifiable? --,Z-Yes No
i
Is this property being developed for (spec house)? Yes No
Volume1a'~,_% 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 & 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 recordedj~ the office of the County Register of
Deeds as Document No. ~ffCy~ , and that I (we) oresently
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER e , xo/ ~i -2
ADDRESS FIRE NUMBER
CITY/STATE ZIP
PROPERTY LOCATION :_,-U.,t2_1/4 ,1/4, SECTIOPt_-'?_~,
TOWN OF x., c ~S~f~iSl , St. Croix County, '
SUBDIVISION , 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 a 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/Ile, 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 Co. Z g officer within
30 days of the three year expiration d
f '
SIGNED:-,
DATE: o ~g3
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of SE'
-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 1/2 x 11 inches in size. Plan must include, but ~J
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
GOVT. LOT" 1/4 1/4,S-2, T N,R (orcw
PROPERTY OWNER':S NJAILI G ADDRESS LOT # BLO # SURD. NAME OR CSM #
CITY ATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ]TOWN NEAREST ROAD
( ) ) L= L~ 7W 1/^
New Construction Use [XJ Residential / Number of bedrooms [ ] Addition to existing building
j J Replacement [ ] Public or commercial describe
Code derived daily flow ~2126 gpd Recommended design loading rate s- bed, gpd/ft2-,Z trench, gpd/ft2
Absorption area required Z-?CQ- bed, ft2 1,1(go trench, ft2 Maximum design loading rate bed, gpd/ft2_trench, gpd/ft2
Recommended infiltration surface elevation(s) / ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material 7 ,,202 .94a.,, Flood plain elevation, if applicable _ ft
S =Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK
❑ U S ❑ U I~3 S❑ U ❑ S [d1 U ❑ S ~1 U
21
W S
U= Unsuitable fors stem f~ S❑ U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft _g6 jV 1,4 ZA)
Boring # Horizon in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed Trench
i
'V
Ground r -
elev. 64W
Depth to
limiting
factor
Remarks:
Boring # `
3
11Z,
>a
_-2 Z //,g 'V Z'
Ground
elev. - ~5~
2 ft.
Depth to
limiting
factor
> e
Remarks: -
CST Name:-Plea se Print Phone:
Address:
Signature: Date: CST Numb f:
„PBOPE&YOWNER ~s~' 41 SOIL DESCRIPTION REPORT Page of 3
PARCEL I.D. #
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench
4~2 Al
/ -
Z"2 5-
Ground
elev.
ft.
Depth to
limiting
fact
Remarks:
Boring #
Ground " J F
e,,le~v/~
C ft.
AL
Depth to
limiting
factor
>f9
Remarks:
Boring #
lk~
Ground
ele. 9(,/ ft.
Depth to
limiting
fact
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
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r TNI• [ML. R[[[RV[D IOR R[CORpINO DATA
P&E
ppeUMENT NO- STATE BAR OF WISCONSIN FORM 1i-19" i I
LAND CONTRACT N
j lwiA111, .Ra C erp.nHN E OVER A
44'7052 =Yb00o IS FIN, EDAND N OTHERNON ONSUMER REV' ' ~I
ACT TRANSACTIONS). /X f MI
- VGA TT
_ I;
Timothy J. Slvester Reed for Reid
ii
b and between y I APR 19 V
gntraCt Y
a /a Timo~hY...Joseph SylVester.......... - ca 8:30 ,~1,-M~►
("Vendor", qq
1hj
{ -bent. br$rfen and
I V `'fMNN~V/f~
ivors
whe~)}er one or more)
m husband_andwife as_- . ..surv...
cC7LSa - r .
.__arrianne Repp-_$~_.__ .
ital _ property ("Purchaser", whether one or more).
I.
! I Vendor sells and agrees to convey to Purchaser, upon the prompt and full r-
together with the
forniance of this contract by Purchaser, the following property, ` rents, profits, fixtures and other appurtenant interests (all called the "Property"). j ^ RN TQ World
-Dowd Reliance 1
St.Croix-------- County, State of Wiaconain: Rea ty
0 in------------------------------C-------
Wisconsin
ii New Richmond, _
Tax Parcel No.
i
i
f
1
I, The SWk of the NE34 of Section 24-30-20•
easement over the Eh of the NW1i of
WITH a 66 foot wide roadway 270.
TOGETHER
Section 24-30-209 as more particularly described in Volume 538, page
SUBJECT TO AND TOGETHER WITH an easement for ingress and egress over the
NA of the SEC of Section 24-30-20, as more particularly described in
Volume 430, page 135.
!
TOGETHER WITH an easement for roadway and utilities over the NWT of the
SW% of Section 19-30-19, as more particularly described in Volume 592,
page 59.
is not
This homestead property. any place designated by him
(is) (is not)
.
T.. 00.00
perty and to pay to Vendor at
in the following manner: (a) $
W08.0 urc ase the Pro
I' Purchaser agr gr~1
• the sum of ; together with interest from date
at the execution of this Contract; and (b) the balance of $_--_-_.34s200 per cent per annum
9.5 %
. i; hereof on the balance outstanding from time to time at the rate o------------ - - ' of
until paid in full, as follows:
There shall be monthly payments of principal and interest in the amount
$318.79 per month, commencing on May 15, 1989, and continuing on the 15th day
of each month thereafter until paid in full. Vendshall,at Purchaser subdivided,
expense, partially release by warranty deed, any parcel
upon an additional principal payment of $1,000.00 per acre to be released,
with a minimum payment of $5,000.00 per release. Except as afore nttioned, prepay
Purchaser mayy not pprepay this land contract during 15th
more than $20 OO_ 80 during 1990.
Provide , however, tie entire outsta riding balance shall be paid in full on or before the.-._._.•__..._............ day of
i Aprif, 2009 ( the maturity date). 9.5
. annum on the entire amount
~ Following any default in payment, interest shall accrue at the rate of Per
in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire
principal balance).
to pay reasonably antici-
pated unless ased Vendor, agrees no pay monthly to Vendor amounts sufficient ant of
' paned annual taxes, special al assessments, fire and obrequired insurance remiums when ligations when due. Such amounts received by the Vendor for payment Vendor,
Vendor agrees to aan1Y payments to these obi g
taxes, assessments and insurance rance will be deposited into an escrow fund or trustee account, but shall not bear interest
unless otherwise required by law.
lied first to interest on the unpaid balance at the rate speecilua andl'hen to 1 i pal.(OAny
Payments shall be app J
I without premium or fee upon principal at any time after.-.-__.-....
i
amount may be prepaid t-ef`P~'*e'4a~-witi+ei>~-Pei'*''~'"yrre€-Nerdar~
ment so long
be trey
In the event of any prepayment, thi= contrac+ shall not be treated ac; in default with respect to pay
onth shall
a ~ as the unpaid balance of principal, and inter(.t (and in such case accruing interest from month to in
as unpaid principal) is less than the amoui.• that said indebtedness would hive been had the monthly payments been
being shall beecontinued t herefromhe of credit of any proceeds
made as first specified above; provided that monthly payments
of insurance or condemnation, the condemned premises
Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser
for examination except:
no exceptions
4 00 -pmt Vendor's inter"
• when due all taxes and saseamente levied oil the property
purchaser promises to Day is showing such payment. occasioned by flee, WP
in it and to deliver to Vendor on demand rwaP rt insured a~simtt loss or throes insurers approved
purchaser ahaU keep the isyrovemuats as Vendor may require, without eo-insuranca. is an amount moss
such older hassrda
•
tended coverage Perils and The polie,es SWO
full insurable value, but Vendor shall not requlr~se oc`►when
low orlgiRil
b Vendor. in the sum of = suer shall pay the insurance P
y
Vendor's interest an , y fad ,
thaw the balsnea owed ender this Cof the nd~ deposited with Vt:ndor. Purchaser e~ ~DrO°s~a~P~ aaee p
contain the standard clause in fayvsor o `haB dorotherwlssdosRleO otbsrwi"
or repair to be
insurance of all policies companies covering and the ~ " Vendor. 1.11.n purchaser and tovided the Vendor
ieallY deems the rasto be applied to feasible. ration on or repair of the property damaged, p keep the Properh►
eeonom
p-rehasar covenants not to commit wade nor allow waste to be committed on. to Property, to
air to kesp the Property free from liens superior to the We of this Contract, and
in good tenantable condition and rep at;ono affecting the Property. be foII paid and all eonfi.ions
to comply with all laws, ordinances au~ regal Z execute and deliver to
in case the purchase price with interest a ad oVendor~will Onidemaa except
liens sad encumbrances,
Vendor agrees that in the manner above speciled, clear all
shall be fully Performed at the ti aimple, of the Property, free sVe s tions
a Warranty Deed, in fee of ezcePt: no sac.-•••••-•........_...........
the purchaser, ted by the Oct or default Purchaser, and
any liens or encumbrances as td
principal
t •
of 1~; purchaser agrees that time is of the essence and in the event ie a defsnlt in eat of any D default ta
+ fo tbs evenUowin~ rrri~A notice
days following the specified due date 90 (bdaY in
interest which continues for a period of ...90.- .period of 90--- balance un er this contract
rebaser hereby
performance of any other obligation of Puuchas°r which continues for a rsonally or mailed by certified mail), then the entire outstanding law) in
thereof by Vendor (delivered Pe and by la in
. and without notice (which Pul me immediately due and payable is ng rights aendor nd remedies (8 b] termi ate this Contraprovided ct and Pure W of equi it n
Vendor may. at his ion , eonfr
shall beco
wing through strict foreclosure with any wwr's
waives), and Vendor shall also have the follo t
thereORfrom
addition to those provided by law or u rt a d mover the Property b o with interest
ousts p sly
p s eat of the entire outstanding balance.
rights, title and interest in the prePurchasees full p Ym
may otheramountsduehereunder (inwhicheac
redemption to be conditioned upon amounts
at fl if this Contract to date pof &a ren
for failur eStOtheralfill eon athis the rate in in and effect a ~~haa~
the date of default n the rate in effect on such Vdate endor and
sue for specific Performance on the
urchaser shall be :forfeited as liquidated damages
paid by P with inter portion
property if purchaser face of the eeem ntire outstanding balance, rt shall be auctioned urch
ontraas price or any po
immedistte and full paym in which event the Props Y aid p utet-title
default and other amounts due hereunder, have pur purchase
shall be liable for any deficiency; or (iii) Vendor may sue at law d efor the tentire nnP cted f of any
thereof; or (iv) r ejected from P°bsaesacti
and (v)Vendor dor or may pfits during the pendency election of any Purchaser a ingnifcant anissues Vendor. title in in al quiet-title
Vendor may declare this 0 on
y rents.
action if the equitable interest of feted to collect an nts
of the Property and have a receiver appo' gal °r written stateme or actions o
ing remedies shall it binding upon Vendor if and when pursued ~ d litigation abated or n°t~t°nt
under 0), (u) or (iv) above . only Notwithstanding any remedy purchaser, to he
of the forego _ rincipal and paid by
including reasonable atto law and expenses ofnti tlerevidence shall be added to p consents f of Vendor
extent not prohibited by u the d enL pe P~reh nd profits of
c-rred, and shall be included in any ] t the rents,
ent or during issues, and p
ndency of any action of fore interest, ~u~n+ COntraets shall be held and collected Property. in issues, an p
cluding homestead interest, profits when so ents
Upon the commence,
to the app during ointment of s the receiver pendency of of the such aet~ such action,and such rents,
the b assignment of any
h an legal or equitable interest in the PtoPei~ Y Prior written
Propertye court
applied as t shall direct. sell or term ease or in any o ther way) without the
purchaser shall not transfer, convey any long-tract or by balance payable under this Contract is as first security paid in for full i n°rdebthe news latches
, under this less either tC(tenoutstehaser's
interest under this Contract soleY
rutice.
consepurchaser's nt of Vendor un
conveyed to afer. sale or conveyance due and payable without Vendor's written consent, the entire outstanding
a pledge °r assignmeet of Purc haser's in full, to Vendor's option on the without date of
purchaser. In the event of Cank o such than y mortgage outstanding against the ro Property mded Purchaser
balance payable under this Contracents shall whe~n° aue i chaser) or under any note secured thereby. P eats directly to
Vendor shall make all Pays'' anted by eats made on
this Contract (except for any mortgage Sr
endorfails to dosohandosallupdyr this Contract. Purchaser may make any such
makes timely payment t amounts a ments so made by Purchaser shall be considered p+ Ym
the Mortgagee if V other subsequent or prior default of Purchaser. h.sentstives.
this Contract. waive any default without waiving n any and inure to the benefits of the heirs legal
Vendor may the spouse o1,% endor fory valuable
All terms of this Contract shall r binding upon and agrees to join in the execst
homestead rights in the subject o Property
successors andseat gnrei of to rd Vendor and F
consideration 3o h 19.~-..
deed to be made in fulfillment hereoLl April
15th day of
Dated this '
(SEAL) . .
Robert E. O'Brien
Timr]thq J. Sylvester •
~•E L
w )
(SEAL) Marianne Repp-O'Brien
ACENOWLEDOMBNT
AYJT88NTICATION STATE OF WISCONSIN
Signature(s) - St Cmix County.
1~X~L_..daY of
_
came before me this ~
Personally
19...--- April 19..89._ the above n~tn
• Robert E 0 Brien
authenticated this day of ..Taimothy J. §ylvesters
•nd Marianne Repp-OYBrien
• 3
.
TITLE: MEMBER STATE BAR OF WISCONSIN S ......"pho ~euted the
- • to me known to be the Person the same.
(If not, _6. Wis. State.) . •tr„meet and acknowledge /7