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HomeMy WebLinkAbout032-2111-00-000 -0 0 ~*i Oq O I 0 0. 0 a C % 7 7 C O 0 L L .N \ U N iaa)°3c6-(DT o i T Z = ~2 y N N 0 y O 3 c- a 12 - O L C co - a) E O N O 3> U d L 2 O F C y c O O Q O N 3 a w N co N N N> U N N-- C 9 ` ~:O O O U C z O Z E a) N M O O (D w O ~ = C O 0 0 o 0 z r) E -a (6 7 O• N N E O N C LL O C C C x0 0 01 L " QN O N E -O 'O - O(6. N C O fo U z rn Z C ~ o z w a m M u, F- Z 0 c C7 _0 v o Z d c T v cr N CD o Z d c Z N H O. O c co v U M N O O 7 = C I N N O i O a 0 O o~Q O z C Z O z (6 c O C N ~ d c T LO U) Co O d d U N t CL y d i N .T. 0 0 m a. 04 U N O ? p O O O a C~ Z° •tv a a a E y a ° 0 a) r- 0) a) CD fA -j U c c 0) m 7 r LO (D 7- ~V Q N N 0 0 ~ N E w O O W CL 0) N ~11r• •0 N ~ y~m d ~ m I C c O N C " o a p oM 0I CL °O O I O O N Oi - O O) C N 17 C N ` 0 C C N N r°> E C D -wo - 6-3 C N O O 5 U • O O U) CO N O Z N Z a' (n cO ~ .r d l0 £ a v ~ t a ` a • to a m m y c E L c c 3 I rr~~ C~ 0 ~ 3 0 Wiseonsin Department of industry, SOIL AND SITE EVALUATION REPORT Page of 3 - Labor and Human Relations .Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code C UNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but St. C not firnited to vertical and horizontal reference point (9M), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 032-2017-10 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT 114 114,s 5 T 30 N,R 19 36 (or) W PROPERTY OWNER':S MAILING ADDRESS # BLOCK # SUBD. NAME OR CSM # na Cedar Valle Estates CITY, STATE ZIP CODE PHONE NUMBER ❑VILLAGE [MOWN NEAREST ROAD Stillwater M. 55082 ( 436-6172 Sanerset aye. V4 New Construction Use [ :4 Residential /Number of bedrooms 3 [ 1 Addition to existing building j ) Replacement [ 1 Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate _.2 bed, gPd/ft2 •3 trench, t Absorption area required na bed, ft2 375 trench, 1112 Maximum design loading rate • 2 bed, gpd/ft2 •3 trench, gpd/ft2 Recommended ifiltration surface elevation(s) 105.10 It (as referred to site plan benchmark) Additional design / site considerations ByStem el based o contour line of el 104.10' Parent material pitted glacial drift -Flood plain elevation, if applicable na ft S s Suitable for system CONVENTIONAL MOUND WAROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U -Unsuitable for stem ❑ S ®U El s ❑ U 0S ®U ❑ S ®U ❑ S OU ❑ S I NU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Botnday Roots GPD/ft Baring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ~rtdt 1s. 1 0-10 10 r3 3 none Sil 2msbk mfr __Ux 2f _C; J; w Y`z~r 2 10-28 10 r4 4 none Ground 28_ elev. 105 ft. Depth to limiting factor +1 Remarks: Boring # 1 10-12 1 3 if -A _C~ 2 , kg. Ground 1 406()_ riyr4 d -M Zia --A= - elev. 105.3ft, c,o Depth to L F' 7 limiting to ST ~w;)Ix co NTY 40" ~,-ajZONIN OFF Remarks: Phone: 715-246-6200 CST Name:--Please Print Gary L. Steel Address: 1554 2 ve. nd I 54017 Signature: Date: 5-29-97 CST Number: mO2298 PROPERTY OWNER Mike Tjindberq SOIL DESCRIPTION REPORT Page 7 O t3---_ PARCEL I.D. # Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in Munsell Qu. Sz, Cont. Color Texture Gr.. Sz. Sh. Consistence Bourtlwy Roots Bed mF& "01 3 1 0- Ground 3 30-52 7.5 r4 4 none scl icsbk mfr Ina .2 .3 elev. 10?. tt 4 52-70 2.5 r4/4 none sici m na na np .2 Depth to limiting factor Remarks: Boring # r-u- Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. h. Depth to limiting factor Remarks: Boring # IXN. t Ground elev. Depth to IRmlbng factor I STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. Mike Lundberg New Richmond, WI 54017 M RSW 3254 NEkNE'k S5-T30N-R19W (715) 246-6200 town of Somerset lot #22-Cedar Valley Estates N 1"=40, Bt.= top of NW lot stake @ el. 100' Alt. BN.= nail in tree @ el. 105.3' /Q f C 4k of 3~2s 10 Cp F Gary L. Steel 5-29-97 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner P~Ojyvelj n v, f )A Property Address City/State t,.) l ST CRO ~s e~ 70NING Fla Legal Description: I c l Lot -,~D Block - Subdivision/094 # &r- VAL, _ t/4 4&~t/a, Sec. , T,3QN-R-jy W, Town of 5 cD ers e l- PIN # 02>2--,20 11- 10 SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer C- Size ST/PC/990/ 50Setback from: House LS Well ZVP/L Pump manufacturer r-got..l s Model 4E22 Y// Alarm location i iq i-eA; dam cn (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: Width Length / • Number of Trenches Setback from: House>30' Welly/DO' Vent to fresh air intake ELEVATIONS: Description of benchmark ri II ~:YI S Elevation 1600 Description of alternate benchmark CS - 4 11-I1-1- levation Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold t -s Top of ST/PC Manhole Cover Distribution Lines ( ) Df3 ( ) Bottom of System ( ) _ D O ( ) Final Grade O a P7 O ( ) Date of installations / / Permit number a State plan number N. Plumber's signatur e,401icense number 1&~) Vqa 3 Dat/ / Inspector K10 d Complete plot plan It 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 INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT 34. cro v1 - GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 2A / P7 Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.: 1 u,i YA 13u~r So ev-Se CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: l coo j 4~?~- TANK INFORMATION ELEVATION DATA 749? 004/L? TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Be h IngrA q4s 0fv 16b oo A11,6M 10 3,35_ 10Y. ~S Aeration x Bldg. Sewer 10 S- (3-7 S- 9V. Z ~ Holding (2)/lift-Inlet 1 ~S1 t 3 Y~ 1141.15( TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Sew ~'l,4 t I J/,, NA Dt Bottom NA Header / Man. Iqg- Ib3. Aeration NA Dist. Pipe C ,~Q o p I, (A Holding Bot. System a (03~ (a3 0 Z7 15 PUMP/ SIPHON INFORMATION Final Grad 3 /oS Z Manufacturer 61DU(d Demand Lzec~ air e' ver b i2,ba, ~f'Sr Model Number EYDLf GPM TDH Lift 13- Friction r-7 System x TDH 3v~Ft Forcemain Length( by Di a. H iI Dist. To Well SOIL ABSORPTION SYSTEM BE Width 11 Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS K SYSTEM TO P / L BLDG WELL LAKE / STREAM EACHING Man facturer: SETBACK CHAMBER x INFORMATION Type O q, Model Number: System) "axb 5~ 32-f ~~wr OR UNI i DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length V-2-5 ~ 3~,~ Spacing r 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, etcJ50me_r""1 y,3e-1~1,53~f~~A)CIA)c Z0 ,feP 'r1,ce ® U401 clu ~ r N~c 104 Xe w s~• ~ ` d~~ / 'h"P q ~G vte~ys r 4-cd, c'i n d fa nxAr Plan revision equired? m Yes ❑ No r Use other side for additional information. 7 I SBD-6710(R.3/97) Date Inspector's Signature e< ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 12,'L5,'2998 17:12 17153,361158 GI_}ISEPT AND ESQ. PAGE 02 -~--W SANITARY PERMIT 4 S-k ( COUNT' TRANSFER/RENEWAL TRANS IJNiFOR P-RM! ISSUANCE DATE: 8Tq'PE PLAN l,Cj, NUMBER: ERMIT RENEWAL DATE: PERMITTRANSFER DATE: PNEAREST INAL PER ~ lob- ~-~8 Zp- °I rcurEFtTY LOrA/ gTtON: 'fT /a,S T N,R ~f AGE,; > UMBER ! E (orov) OF: S ~`7l ~/~f F • BLt'3CK NLIMFJER: Sy~EDI~V}gltjN N~}ME; ROAD LAKE OR LANDMARK: (cwt, PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: AME; SIGH UR PH(7NIt NUMBER: el )-y t5d -Dl l7"c HONE NUMBER! ADDRESS: cer- 3 1? _t c.tts' _ I, the ndersis~ned, hsraby assume reSparlsihility for irrstallati:7n Of the Pr•}vote sevvage system that has Previuu^IY pprc)v been a ed for this property. -UMBER'S $}(;NATURE; PRE fOUS PLUMBER'S NAME (IF CHANGED): _Uti9 ER' P S A RE55; REV t-)U$ P!_l)hg B S ADDRESS; /7Gc~ 7 ~Y' C 1~/~ . I S S lc of (o~ t~ c e v/ P/MPRSVU NUMSERt PHONE NUMBER; MP/MPRSIN JJ Et PHONE N MSER; WREI LENT: O,ATF. APPROVE(J; DISTRIBUTION: Original . County u of CnnY - ~Uro'af PlumiSinsi COPY Owner 11/25/98 16:13 TX/RX N0.1646 P.002 Safety and Buildings Division `~SC011$►11 SANITARY PERMIT APPLICATION 2 1 Box ashingtonAvenue 'Clepartrrlent of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7302 • 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 Saa,nitar_y Permit umber Personal information you provide may be used for seconda pure1Qs S' ChecTc if reQ,visiq`on to preJfous application (Privacy Law, s. 15.04 (1) (m)]. 5I l State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Prop Ow er Name P perty Lo tion 214r,4 o 4 1/4, S 5 /Z T , N, R W Property Owner's ailing Addre Lot Numbw-, ~ Block Number B, , State Zip Code Phone Number Subdivisio Name r CSM N be (7 7 s - S II. PE F ILDIN : (check one) ❑ State Owned ~ Nearest Road I, Public 1 or 2 Family Dwelling - No. of bedrooms Town OF ~01MCCSclr ` 44 III. BUILDING USE: (If building type is public, check all that ap y) Parcel Tax Number(s) 03Q- o / -60 - 00 5.30. 1q. Wf wr 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 Tank Only _____--____-__Existing System Existing System ❑ 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 fi f 2l ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 jK See page Trencl{3, n 81, A.5 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 E] Seepage Pit 43 Va I ivy 14 ❑ System-In-Fill "AlA ` ' / VI. ABSORPTION SYSTE I OR ATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loa S. Perc. Rate 6^krrlev. 7` Ide Re uIred (sq. ft.) Proposed (s ft.) (G s/day/s . ft.) (Min./inch) ' Ele ation a ~J C G r'--- Feet Feet VII. TANK Caa in gallons Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or+ki4ding-T-ank 0 ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Sid er ff ® ❑ ❑ El El El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PI tier's Name: (Print rer's Signature. ( o ps r M RSW No.: Business Phone Number: 04 r-^41 A AA 0`1 1-ki Ad Plurq a Add~ss (S re t, ity, State Zip Cod : jX1 N ILIII~ (4n r s `i IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS r t i ~ 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 aSanitary 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 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) fora number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Safety and Buildings Division Nfisconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 ~f} partrWA of Commerce Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less County < than 8 112 x 11 inches in size. J • See reverse side for instructions for completing this application State Sanitary ~Permit :!~tus Number Personal information you provide may be used for secondary purpo a heck if revision I application [Privacy Law, s. 15.04 (1) (m)]. 15tate Plan I.D. Number L APPLICATION INF RMW t N - PLEASE LPRINT ALL INFORMATION Prop wn r Name Pr perty Location e 'v 2Z-v a /4 A/2/4, S T , N, R Ems, Property Owner's M iling Address Lot Numbed Block Number S~g:~ City, State Zip Code Phone Number Subdivision-Name r CSM Nu er ( _ II. TYPE LD : (check one) ❑ State Owned ,j o r earest Road _~A 4 C Public 1 or 2 Family Dwelling - No. of bedrooms L1 Town OF Il Z~i III. BUILDING USE: (If building type is public, check all that app ) Parcel Tax Number(s) J _66 00 1 ❑ Apartment/Condo - - -~-u 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. [;g New 2. E 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 a 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank 12 [Seepage Trench' x 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 9 Va It ivy 14 ❑ System-In-Fill ~ r( , V ' VI. ABSORPTION SY TEM N OR ATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate- 5. Perc. Rate 6."V1 7./ ~ r le Required (sq. ft.) Proposed (sq. ft.) (G da /s . ft.) (Min./inch) Elevation 0 7 0 Feet eet a VII. TANK Cingalloacltns Total # of Prefab. Site _ Fiber- Plastic Exper- INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. New Existing strutted Tanks Tanks Septic Tank or Heldinq ank t > ! ® ❑ ❑ ❑ ❑ ❑ - L)0 ]I aA Lift Pump Tank /SipbanjCha4a4er 1f ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum er's Name: (Print) Plu er's Signature: (N ps) MP RSd/d-MO.: Business Phone Number: 4/0 ra I i/0 a(j- 40 P Arum oer's/p~ddrs Str a ty, State, ip C,de , C~~( tX J 0 (A )~j q if IX. COUNTY / DEPAR ENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) ❑ Approved ❑ surcharge Fee) Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS q r - i 1. A sanitary permit is valid for two (2) years- 2. Your sanitary permit may be renewed before the expiration dale, and at a time of renewal,a.ny 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 Sahitary Permit Transfer / Renewal Form (SBD-6399) tobe submitted to the county prior to installation 5. Unsite sewage systems must be properly maintained.' The septic tank(s) must be pumped by a licerisgd pumperwNhenever 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., -808-266-3151, 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, reconnectiort, or repair. V. Type of system. Check appropriate box depending on system type. VL 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 seotic,"puF»p/siphonand holding tanks for this system. Check experimental approval only if tanks received experimental product approvaLfrom DILHR. VIII. Responsibility statement- installing plumber is to fill in game, 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.abd-specifications not smallerthan 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), SRptic tank(s) or other treatment tanks; building sewers; wells; watermains/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. I Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue Visconsin P 0 Box 7302 'C'(epartwgt of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary "Permit N um er Personal information you provide may be used for seconds 7 purp9sBs, Ch rif re4ision ),o p're3Pous application [Privacy Law, s. 15.04 (1) (m)]. tate Plan I.D. Number L APPLICATION INFORFAA14 N PLEASES PRINT ALL INFORMATION ProperW Owner Name Property Location ~ : 14 A/,,,.:1/4, S T , NR mar y 1 11 Prope wner's kfailing Address Lot Numby lock Number _ A) IJt_ G y, to Zip ode Phone Number Subdivision Name or CSM Number IL TYPE OF L : (check one) ❑ State Owned o earest Road Public 1 or 2 Family Dwelling - No. of bedrooms ° 19 Town OF cvy? III. BUILDING USE: (If building type is public, check all that aPP.Y) Parcel Tax Number(s) f 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. q New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an -.-----System --------System Tank Only______________ Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank . 12 Seepage Trenc > f ' X22 ❑ In-Ground Pressure 42 Pit Privy 13E] Seepage Pit 43 Vault. Privy 14E] System-In-Fill i • - f t. i r, VI. ABSORPTIONS E A O : V 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. lev. Wee ale Required (sq. ft.) Proposed,(sq` ft.) (Gals/day/sq. ft.) (Min./inch) n 1 ` ) Feet Feet a acct J VII. TANK C in p IIons Total # of ; Prefab. Site Fiber Exper. INFORMATION' Gallons Tanks Manufacturers N'ame Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks I I-) f7 ' ! ~n ❑ El ❑ ❑ ❑ ❑ Septic Tank or Holding.1wic Lift Pump Tank /SipllcA.ChalMb. er i 7 t+ ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No tamps) MP/MPRSWAJo.: Business Phone Number: ~ s Vlu jber's Ad mess (S et, City, State .p Codey. f- / f t t's IX. COUNTY / D PAR MENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) ❑ Approved E] Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11I97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber F. INSTRUCTIONS. w. it 1. A sanitary permit is valid for two (2)'years. 0 2. Your sanitary permit may be renewed before the expirati,pn 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 (51313-6399) to be submitted tothe- 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. 111. Building use. If building type is public, check all appropriate boxes thatapply, IV. Type of permit. Check "onl"y drie on line A. Complete IineB'if permit is for tank replacement, reconnection,~or repaid: 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/siph6nsand 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 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 4f0 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Safety and Buildings Division - SANITARY PERMIT APPLICATION 201 W. Washington Avenue ri~eons~n In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 partpy~st of Commerce Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less County,_ than 8 112 x 11 inches in size. ; I - • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary urposes. ; Q Check f revision to preks application [Privacy Law, s. 15.04 (1) (m)]. tate Plan I.D. Number L APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location 1/4 -1/4 'S T , N, R Cif W, Property Owner's ailing Address Lot Number Block Number Ci y, tate zip ode Phone Number Subdivision Name or CSM Number. . e , ( ) r r IL TYPE F LD : (check one) ❑ State Owned t Nearest Road ❑ vc ge Public 1 or 2 Family Dwelling - No. of bedrooms ( Town of Parcel Tax Number(s) III. BUILDING USE: (If building type is public, check allthatapply) i 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. [Z New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an ------System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 22E] In-Ground Pressure 42 ❑ Pit Privy 12 ❑ Seepage Trench % 13 ❑ Seepage Pit - 43[:] Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SY TE ORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6, t jIev. 7/ e Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) / t-' Elevation .•y_ i t ~ f F Feet ° Feet Capacity VII. TANK in Total #of= - Prefab Site . Fiber- Exper- INFORMATION gallons Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank r ❑ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber r 0 ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print),, PI mber'sSignature:(No5tamps) ;-r MP/MPRSWNo.: Business Phone Number: I mber'sAdd rgss (Street, City, State ip Code : t i 1 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) 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. ; . p . . I 1 ! i _ ~ .._1.~.~_. y _ »..i...........4.._._....... _ C&I , I _ . f 1...........: . j.........{ ~............f. _ I T I............. . f I , e I ol. ' : I f I i i , ~~'G _ i... s _ i . _ _ _ a W tlc I I _ « _ i I . i. i ! , a (.V i _ ».....r_......,.. _ r.. _ r... ........................................._............_..I............... . : 1 l l i i I _ .............t.»»... ...........:........t...........~........ j............; r«.......... ........................1........................ f......«....~ - I , , i I -.t M _ .......«.«.......1.»___...._ . t..~/...l,A l~ , , I Dunn S ~P Lly-23 / y98 _ BRUCE PUMP & TRENCHING, INC. 0 CNJ Alm M /Ru N d N4165 Hwy. 40 y~ o lane 4Veo .C7OlUnino ,73y BRUCE, WISCONSIN 54819 Herman Glotfelty Clarence Glotfelty 868-5225 MP -4423 868-5831 CS -6 1 r [ E Y -k.Aa Fri Al- R19 VJ T Go e-+ i tA - SEP'T'IC TANK & I'Uh1} CliflHIBIIJi 4" pyGVENT PIPE 12" MIN. ABOVE GRADE & WEATHER PROOF r FROM DOOR, WINDOW OR JUNCTION BOX APPROVED Lbci*IK FRESH AIR INTAKE -WITH CONDUIT MANHOLE COVET W1 PADLOCK & FINISHED GRADE i WARNING LABEL t_r-4" MIN. - - A 1811 INLET_ GAS- \'WATER TIGHT; TIGHTS 1<7L _ -ten A SEAL APPROVED 1~Jt~ 4" P1as{ic 3~Ft=l-~- ~T~.';T -1- ALM JOINTS W/P/aar, PIPE B , ON PIPE 3' ONTO SOLID SOIL C ~FT. I OFF RISER EXIT D PERMITTED ONL IF TANK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS DOSE o (~!NDO,S)ES TANK MANUFACTURE 4-(/00 X. R: PER DAY: F 1 S c;zco 161 TANK SIZES: SEPTIC GAL. DOSE VOLUME INCLUDING DOSE jC> GAL. FLOWBACK: GAL. ALARM MANUFACTURER: aS leer,-- CAPACITIES: A ='~1_0 INCHES =qx2.-&AL. MODEL NUMBER : t~J I 1o qay B = 2 INCHES = .?j GAL. SWITCH TYPE: 1 h INCHES =c,,_~GAL. PUMP MANUFACTURER: ~`~nc tI~S C = j1 -2 MODEL NUMBER : 4 ep-4L ~A SWITCH D - - INCHES GAL. TYPE: REQUIRED DISCHARGE. RATE GPM PUMP 8 ALARM WIRING AS PER ILHR 16. 23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTgIBUfiION PIPE . FEET + MINIMUM NETWORK SUPPLY PRESSURE FEET + A26 FEET FORCEMAIN X , 6 FT/100 FT. FRICTION FACTOR . © FEET TOTAL DYNAMIC HEAD FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH LIQUID DEPTH L/5 SIGNED. LICENSE NUMBER: /V DATE: 1/88 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page / of Bureau of Integrated Services in acco ancce~ y s. Is. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in s' e P rfiust include, but not limited to: vertical and horizontal reference point (BM), a,.Ery 1, C (-p X percent slope, scale or dimensions, north arrow, and location and di new U P V APPLICANT INFORMATION - Please pdintall inf y ~ Personal information you provide may be used for secondary purposes (rivacy s 15.04 (1) COX 711 1 7 HTY a Prope Own ;PrdlfdN 44 Ol4 e-4, 314 ~ot 11 NE1/4,S 5 T ,N,R ~J i4 v 4o n "L% Prop Z.3 /a 5 e, erty Owners Ring Address , I # ubd. Name or CSW f O d CzJ o, r- V c- I le City State Zip Code Phone Number ❑ e*r ❑ wage W Town Nwilest Ronk oLOn \A4 10, 3 c 15~ a - ~Sa M e- s 59 New Construction Use: ❑ Residential / Number of bedrooms Addition to existing btdkfing / Y ❑ Replacement / ❑ Public or commercial - Describe: /Y. A „ Code derived daily flow lPQ gpd Recommended design loading rate bed, WdfiF_m_!5 trench. gpd* Absorption area required 1 S ib bed, ft2 a.C ttrr~enCh, ft2 Maximum design loading fate --l - -bed- gpd* o s trendy, gpd* Recommended infiltration surface elevation(s) Qo it (as referred to site plan berm") Additional design/site considerations - al Al•d e, eS . Parent material 4 I &C&.l :E' I ( Flood plain elevation, if applicable /V. A. ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system S0 U ISS❑ u [@ S ❑ U WS 0 U 0s; CKu ❑ S® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 D y 3 L c r C-YVI3 u 0 5 y S L /L2 l i : o f5 Ground 3 ZDZ854N c elev. _ /ab. Lft. 014" , m lc 4e o -S Depth to ; limiting o O° Z o o O f r ~in. ~q I - ' Remarks: ATUd ei 6L 14 $,;6I4e_ e7 rh y~uN' Boring # AX? ry /DM W 5L /csb ,S I CIS Ground elev. Depth to limiting f pr er 7 ,>.in. Remarks 6 CST Name (Please Print) g Telephone No. r ~o f< T 5 •-S 3l Address C~ in ~I// 5y JDa: CST Number PROPERTY OWNER, "~a r l o Y~ SOIL DESCRIPTION REPORT Page ~ of PARCEL I.D.# Oa©)7- / t~ Boring # Horizon Depth Dominant Color Mottles Structure Geptft2 g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench 2) 1 L SL c s f o ;e 5 " a / Yl S a . , (Ground 3 In Y1Z (0 Z/ !f/s a - ft. , J L V f"1a Depth to limiting Remarks: VoV/ed C.09))/C , ST AX Boring # o l.~S ;off „ 5L Ground °f " ~ ~ L4 ie d SC L. 5 H Depth to limiting for in. Remarks: 7o i o . - e ix r Horizon Depth Dominant v Structure GPD/ft2 in. Munst o ? ture Consistence Boundary Roots Gr. Sz. Sh. Bed Trench _ 2 4•`f Boring # 1f n - g5 '65 3 X5.3 J L' or 1/ o g hi s .5: 7. Sy IMcct lta i k . Cmd! ✓ P~ 6 0 Ground C L - - NP Q, Depth to ; limiting \\f > r in. Remarks: _ i3- Boring # LS r, SL ,n H ,5 s 5L - - 05 Ground Depth to limiting fact f t Remarks: /('Dra-V ~ CA h be; - ~~Y►. / LL - - f~ - 7 SBD-8330 (R. 07/96) . . _ _ nher r..x.......1 Q ..................1..... _ 1 : . . . . . . . . . . . . . : . r . . . a . . . . . . ►!e ? r' e i F 1 _%.`.........._-........._4.._...... t t33 ~ lU i i i _i t ! ......:.............i............o.........._i.._........«....._....~wre^.-.X.............:...... _ _ .F-_~ C '.i _ _ . - - .$T:3 I o toy., 1{i :........................:............:.............:............r............,.... W'. i _ ....._.............._^........~1Z ..:..........................a...........,:..........................,. _ll...........o__....:,.. i • 6 ` , e ..4 P , d ec, Ta.~s~ne~ /~ox LE, G r- . i .............:i , t i~T .e~►~ e:.k........ cnr....)......:....:~~~~fiM. v..e......... i o C -g Ro 3.D 7-7 /-;Z/ y 98 own Mold BRUCE PUMP & TRENCHING, INC. ~ M dij n Ru j:; d y0 115 ve N4165 Hwy. 40 J~/73y BRUCE, WISCONSIN 54819 Herman Glotfelty Clarenc ffieTfy A "%A 40 Yq 868-5 5 MP -4423 8-5 31 CST -611 r [L E 5 n0N &9-IA/ T (zT CA~ - S4- Ciro t)( Ila x..07 G.O Visconsin SANITARY PERMIT APPLICATION 201eE. W and shnllgtonAve sion In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 t/Z x 11 inches in size: ~St . (.~1/' • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check if rewslon to pr sous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Pro a owner Name) PsopertL ation p ~~t1/7'V l< , /fLC 1/4 tJZ5 1i4, S ~a T.3Q , N, R E (or W Property Owner's Mailing Address ~ Lot Number Block Number 3, 5 C/Vv ~0 ~ ~ City, tate Zip Code Phonedumber Subdivision Name or CSM Number r so II. TYPE B ILDING: (check one) ❑ State Owned ❑ ity Road p Village Neare Public 1 or 2 Family Dwelling - No_ of bedrooms 5KTown of 8 i7vt~ Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 038 - a~ I l ig~, 1 E] Apartment/ Condo 6 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 S ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ____System ________System Tank_Only______________ Exl-------- Exls- --stem 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) / p Elevation Q U 1,200 E1 Z ` ® S / C l,.? . 7 Feet ~v Feet TANK Capacity VII. in Total # of Prefab. Site Fiber- Exper. NFORMATION gallons Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Exist in strutted Tanks Tanks ) Septic Tank or Holding Tank ( Utz /Roo 0 e- e3TZa2yt/ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber r A ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbe 's Na e: (Print) Plumbe 's Signature: (No Stamps) PRSW No.: Business Phone Number: Z, 1 6~2 19 _ Plumber' Ac dress (Street, City, S te, Zip Code I G ~LLL 57- Z IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee (includes Groundwater ate Issued Issuin t Signature(No Stamps) Surcharge Fee) 11, )(Approved El Owner Given Initial f D A76." Adverse Determination ! UUU X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1 _ A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 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. ICY Y i 03 _ S"Ct fr, , r G` T f ~C) ~o D c--z.r~; rt,i'~„=7~ /,U ~ ~ ~ X-fh•Z~2s 1 YX 3 ~5 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 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 81/2 x 11 inches in size. Plan must include, but St. Croix 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. 032-2017-10 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION VIE D Y DATE INS-17 PROPERTY OWNER: PROPERTY LOCATION f "I Calvin Burton GOVT. LOT NE 1/4 NE 1/4,S 5 T 30 N,R 19 ]E (or) W PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK# SUBD. NAME OR CSM # 365 Rut-.bit- Tn. 20 na Cedar Valley Estats CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE DdTOWN NEAREST ROAD Hudson, WI. 54016 (715 426-1117 Somerset 180th. Ave. [x] New Construction Use [ x] Residential / Number of bedrooms 4 [ ] Addition to existing building j ) Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate ' 4 bed, gpd/ft2 ' 5 trench, gpd/ft2 Absorption area required 1500 bed, ft2 1200 trench, ft2 Maximum design loading rate .4 bed, gpd/ft2 .5 trench, gpd/ft2 Recommended infiltration surface elevation(s) 102.90 ft (as referred to site plan benchmark) Additional design/ site considerations alt. site system e.=103.90 area to be cut to code if used Parent material Cal lacial drift Flood plain elevation, if applicable na ft S = Suitable for system QQNVEkTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem S EIU I S❑ U 13S ❑ U ❑ S ®U ❑ S ® U ❑ S ® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trerch ' 1 0-66 7.5yr4/4 none sl lcsbk mfr gw na .4 .5 2 66-97 7.5yr4/4 none sl 2mgr mvfr na na .5 .6 Ground elev. 105.6Q. Depth to limiting factor +97 Remarks: Boring # 1 0-96 7.5yr4/4 none sl lcsbk mfr na na .4 .5 2 Ground elev. t v 106.8gt. Depth to limiting factor +9611 Remarks: CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200th. Av ew Rich o WI 54017 Signature: Date: 11-14-97 CST Number: m02298 PROPERTY OWNER Calvin Burton SOIL DESCRIPTION REPORT Page? 'of3 PARCEL I.D. # 032-2017-10 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends 1 0-50 7.5yr4/4 none sl lcsbk mfr gw na .4 .5 2 50-56 7.5yr4/6 none co s Osg ml gw na .7 .8 Ground 3 56-88 7.5yr4/6 none sl lcsbk mfr na na .4 .5 elev. 106.9 ft. Depth to limiting factor +88" Remarks: Boring # 1 0-68 7.5yr4/4 none sl lcsbk mfr 9w na .4 .5 4 2 168-73 7.5yr 4/4 c2d 7.5yr5/6 sl lcsbk mfi gw na .4 .5 3 73-11 7.5yr4/4 none sl lcsbk mvfr na na .4 .5 Ground elev. 108.6ft. Depth to limiting factor +110" Remarks: Boring # 1 0-43 7.5yr4/4 none sl 2mgr mvfr gw na .5 .6 2 143-49 7.5yr4/4 c2p 7.5y5/6 sl lcsbk mfi na na .4 .5 3 149-154 7.5yr4/4 none sl lcsbk mvfr na na .4 .5 Ground elev. 112.8ft. Depth to limiting factor +154" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Calvin Burton 1554 200th Ave. CS S2 3254 NE 4NE 4 S5-T30N-R19W New, Richmond, WI 54017 town of Somerset (715) 246-6200 lot #22-Cedar vAlley Estates 1"=40' BM.= top of NW lot stake C el. 100, Alt. BM.= top of ROW survey stake @ el. 107.30' -3 r- 1-5' S' tit g ` a~. 16 7 c~h ~ \ S• Gary L. Steel 11-14-97 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT &A\)1 St.Croix County OWNER/BUYER n U 'r r Ol l MAII,ING ADDRESS u ~-a n PROPERTY ADDRESS 6- ~I / 84 A)& (location of septic system) Please obtain from the Planning Dept. CITY/STATE o e r S Z /L PROPERTY LOCATION IU L 1/4, IJ E 1/4, Section T 30 N-R 9 W TOWN OF o ✓y1 P, ' ST. CROIX COUNTY, WI SUBDIVISION l~ P d ►r U~ II,~ ✓ C S ~QT f 5 LOT NUMBER CERTIFIED SURVEY MAP , VOLUME 7 75, PAGE Z 2.0 , LOT NUMBER ;'Q 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: I - - St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 recording. Owner of property Location of property /2~ 1/4 1/4, section S- T 3_N-R~_W Township Mailing address Address of site Subdivision name CL y~~ - --z- Lot no. ~o Other homes on property? Y s yc No Previous owner of property,,, Total size of property oa Total size of parcel 12- r~ =s Date parcel was created Are all corners and lot lines identifiable? x" Yes No Is this property being developed for (spec house) ? __X~_Yes No volume -7 and Page Number -{_3S 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. z~-tqs?~~ 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. fo71~ Signature of Applicant Co-Applicant //-go- 97 Date of Signature Date of Siqnature VOL Y274 PAGE 41S oooooooo:~ ~G, 7953 II SIAt ItAl1III WI',( (IN'AlI f''110.t 1W46 uoCuMLN l rlu lI WARRAN I Y DEED a Lu idgo_._CorP_, a Wisconsin Corporation 7 „ cvnve s and warrants to Calvin K Burton Y_ . - 10.45 AM r„ the foliowiag described real estate hl St. Croix State of Wisconsin REruRN TO `fi' y - ( 6, 1 X 1 ii ~Ih Lot 20, Cedar Valley Estates in the j; Town of Somerset, St. Croix County, Wisconsin Pt 032-2017-10 - z Parcel Identification Number IPINI •s 032-2017-30 032-2017-60 'I J;RANSFER X, F ~ as This is not homestead property ! list its riot) ii • Exception to Warranties ! iI 0,Iled this 31St rfay of OCR r - I.r 97 iSEALi ! ISEAU - l; ii Michael Lundberg, President I; t iSEA0 ISEAIi is AUTHENTICATION ACKNOWLEDGMENT • I L7Z '4 S gnalure(s) vs St. Croix county 1st , authenticaled this day of 19 _ I''rtionapy ranee below me t}ns 3 day of ; October t9 _ 97 _ the above named %t.;-,zhael Lundberg, President - TI rLE MEMBER STAIE BAR OF WISCONSIN Ilf not. to be fire person V01" execuled trip ! ~ - - - - ~ authorized by § 706 06. Wis Stafs 1 .•~Y ~~////~/~~~'~~'~ctr +fn1/J rod acknowledge the drop j j TIIIS INSTRUMENT WAS DRAI-IED L'' OD' I W O co OD - iy~~ I o v g r OD I mI ~ q2 ~ ~ z N i N CD a W I 1 O W OD n N I - I ° I -1 J cwn I ` I _ D N p Q 0 / m w n om 11 _w z m O a N w i i v7 N Q 0 INV/ 37, 0 102.63E If 1 z i Ul 310°38'37„ - 1 1~`, / O / ~ 8 y\ I 33' C / 8,9 _ ;IJ OD !ni Co\ it I OD \ b I I lO IF lo, / N \ ~ W I / 1L Gomm W ~m CA < u) p (0 OD L'i Ln CD W / I 00 I Cj0 w Nei? J o 1 Chi Cpw1, W n_` 1 J o IC7 / ~i L- ` J I I r~ / O C12 v I IC) N / Ln N ~ N 157.31 312.17' 2~2 00 y C S01°59'51"E 469.48' I N ` - _Q .4 i I rn - c= laD pi w o -4 IN 6 ~D N lO O cmn I I X ~ c~ w I I