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034-1056-40-000
St. Croix County Planning and Zoning Tuesday, March 13, 2007 ar 1 l:09:20 AM Detail Sanitary Information Page 1 of I Computer p: 034-1056-40-000 Sub/Plat: metes 8 bounds Section: 25 Parcel #: 25.29.15.395A Lot: TN/RNG: T29N R15W Municipality: Springfield. Town of CSM: 1/4 1/4: SW 114 SW 114 Owner: Belling, Kristin M. 3206 70th Avenue Knapp, W 154749 State Permit: 299141 Issued: 11/0311997 POWTS Dispersal: Mound County Permit: 0 Installed: 11/07/1997 POWTS Detail: NA POWTS Pretreatment: NA Notes Issuer/Inspector As Built Not determined Yes Rod Eslinger Signed Off. Yes Maintenance Scheduled Pump Date Pumped W7/2000 11/10/2003 11/10/2006 11/10/2004 11/10/2007 Plumbe Other Requirements Ulbricht, Robert 1st Notification 2nd Notification 3rd Notification 04/01/2005 Permit: Replacement Bedrooms: 3 WI Fund: Yes Additional Notes Money Owed 28.88 acres - applied for W I fund. Woo BELLING, Kris SWi, Swj, Section 25 3206 70th Avenue T29N-R15W Knapp, WI 54749 Tn of Springfield Site Address: same as above Permit No: 299141 11/3/97 Bob Ulbricht Replacement - Mound PID: 034-1056-40 OWNER ADDRESS �/Nil I"/' �3 Z,�0 (o 7 0 tLQ �l /S . STC - 104 AS BUILT SANITARY SYSTEM REPORT 13E441iv (r- 772. - 3 z t 3 SUBDIVISION / CSMI Ao# LOT SECTION 25 T I'r N-R /S W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /v 0TF fdiPO,C 4w , /��iP e ', �a l`�G� GG l°iLs� CUSS' CO ze� . CRIC NAL INDICATE NORTH ARROWI Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. P,Gc SST: i ap of co.v et sbe�vu BENCHMARK: ALTERNATE BM: /00 W. goo Y". SEPTIC TANK / PUMP CHA�M,BER /// HOLDING TANK INFORMATION Manufacturer: &7FE Liquid Capacity: ,Qpp _ PlG Setback from: Well > l d7J House 7 f Other D [� Pump: Manufacturer Modell 7 p Size JZ lf� l/SG/ C Float seperation / Gallons/cycle: 2 D Alarm Location A/SIPE� SOIL ABSORPTION SYSTEM Width:__ Length 7 � Number of trenches Distance & Direction to nearest prop. line: 30 7(v Setback from: well: 72- '. House 7� Other J w-ts T y'.3. GS ELEVATIONS �1 Building Sewer ST Inlet: �3's7 CC ST outlet: PC inlet l % I�^PC bottom JP 7. 7� Pump Off Header/Manifold ! oQ3/ Bottom of system 1'7 7O Existing Grade 9�D• 7p Final grade DATE OF INSTALLATION:: we'. (a 1ff7 — /l/OC/ • /0 A `f � �7, h PLUMBER ON JOB: d W EQ I 4La �,AG- LICENSE NUMBER: /�tP�S 330 INSPECTOR:Cj (�oD GSSL/,v 1/93:jt t S4g4Ge-- . „ oev4e 5pfudy U&Wht & act us , ate+• sw+oo Conw 6" O'NsM Rd. Hudson. Wis. W, 366 • gr8 s 70 dk *e N� Ave f/M . 145.130%4 r PILOT f)G ,4AJ S' „_ f D E-S-P - W &VE F r CAZW7(r TANK INFORMATION TYPE J MANUFACTURER vv<,e K%Dosing PCAPACITYSeptic 1n/ ��}� Aeration Holding TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. ventto Au intake ROAD Septic q0 100 r '] I %p' NA Dosing NA Aeration NA Holding PUMP / SIPHON INFORMATION Manufacturer hoc t / Demand Model Number Y25 GPM TDH Liftlp.S7 Friction Lott, S temZ S TDH IS Ft Hea Forcemain 1 Length I (,' Dia. 2 1 1 Dist To Well 011 ABSORPTION SYSTEM Wisconsin -Department of Industry, Labor and Human Relations Safety and Builaings Division GIFNERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) ermit Holder's Name: City Village Town o TELLING, KRIS SPRINGFIELD :ST BM Elev.: Insp BM Elev.: BM Description: 1 DNj 1>Xf:> -Top of e vn,I i2orl — k'rloove- ELEVATION DATA ounty: ST. CROIX Sanitary Permit No.: 299141 State Plan ID No : q-7— /0897 Parcel Tax No.: 034-1056-40-000 x n7nnAR7 STATION BS HI FS ELEV. Benchmark_ 2.216 102. ► o0 13M _-,- . /oy. Bldg. Sewer a r t++ St / Ht Inlet 1/0 St/ Ht Outlet /ar{ 11 1 Dt Inlet 101/SV 13•1/7 "1 D7 Dt Bottom /lir/• /G Y 8'7 7 4 Header / Man. Dist. Pipe /03.1✓b �% ! ;1 Bot. System (0,2 5.7 S �17 71 Final Grade 5} for/y 1o3-44 too, AIF. y PIT No. Of Pits Inside Dia. LiqEDepth <MEWTRENCH Width r/ 7 Length 7,r No.Of Trenches LEACHING CHAMBER OR UNIT Manu rer: SETBACK INFORMATION SYSTEM TO P/ L BLDG WELL LAKE /STREAM M Num ype System: iN a" fice, gU' 77 1J17 1 nlvv 1 I VrV rFw x Hoe Size x Hoe Spa, ing Vent To Air Intake Header / Mani o rr T Distri uuon Pipes , Length 11•'• Dia. Spacing ,� / '! 7 9 ;r z Length \ Dia _ SOIL COVER x Pressure Systems Only xx Mound r At -Gracie Systems only Depth Over Depth Over xx Dept xx Seeded/Sodded xx Mulched Bed / Trench Center Bed I Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.)-4116.70 LOCATION: SPRINGFIELD 25.29.15.395A,SW,SW 3206 70TH AVENUE Plow✓ Al- (,o • N? Finial 11.7' 97 Plan revision required? ❑ Yes [:]No Use other side for additional information. [JiE7 EAjSBD-6710(R 05191) Date nspector'sSignature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: * Safety and Buildings Division �ILHR SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83 05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County ST G/e6/ x than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 99141 The information you provide maybe used by other government agency programs ❑ Giac d rensxxi to gevxm application [Privacy Law, s. 15.04 (1) (m)). sair f State PlAn I.D. Number I APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N a1f -7 Property Owner Name ^r.� SVro4ert�Location4,5 ZS T L9 , N. R /3 E (o W PropertyOwner,sM ilingAdd�dreSs Lot Number NI Block Number 3z. � City, State I Ap Code GJ/S' Phone Numbe — 7/5) Subdivision Name or CSM Number O S sP X �44e 7 ( yi .�/ ,D BUILDING:Il. TYPE OF (check one) ❑ State Owned '3 J� t O vown of sr��" �F� Nearest Road ?. � 464C ' Public or 2 FamilyDwelling- No. of bedrooms J' III. BUILDING USE: (If building type is public, check all that apply)) Parcel Tax Number(s) 1 ❑ Apartment/ Condo a5• a9 . �5. �%5.9 d 3 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 tem___ Syriem .............TankOnly _________ Exist System _______ ExistingSyrstem B) E] A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Preure Distribution Experimental Other ssMound 11 []Seepage Bed 21 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 13. Absorp. Area 4. Loading Rate S. Perc. Rate 6, System Elev. 7. Final Grade Require (sq. h.) Proposed (sq. ft.) (Gail day/sq. ft.) (Min./inch) �, 70 Elevation -► Y1--0 S 3 d r • �— .V//t Feet Feet VII. TANK INFORMATION cit Capalons in gdl Total Gallons # of Tanks Manufacturer's Name Prefab. Concrete Site Con- Steel Fiber- glass plastic Exper App. New Existin strutted T nk T nk Septic Tank or Holding Tank /Mv 1. / ZW ❑ ❑ ❑ ❑ ❑ lift Pump Tank /Si hon Chamber fou I I 46XZ44ze❑ ❑ ❑ ❑ ❑ VIIl. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) 4/6 Plumber's ignature: ( o Stamps) /MPRSW No: Business Pho Numb — go ar 147-1 33 0 7/S-3 Plumber's Address (Street, City, State, Zip Code): �SS i A ' n' L l A . A fO� / „1S - r` 91ee 'V•C ,�R (/J LAC/ J T =tp IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved S nitary Permit Fee I1n 1 0 Gro " .dW surcAugefee) �" ate issuedIssuing Agent Signature (No Stamps) /f - Approved ❑Owner Given Initial / •3' / �� r{1/CRJ� 6iiii,11 et—. Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: san- Mfx. aIMI oKTMWTxre: Otipirol totouniy. ntr copy To: seloty a auo.iing, nivnion, Fhw ,Plo iltw 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 S. 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 systerr% contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815- To be complete and accurate this sanitary permit application must include: I. 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 8 112 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; Q complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; Pomp model and pump rnar)ufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data ona 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 NVISconsin Department of Commerce 30-Oct-97 Ulbricht & Assoc Robert Ulbricht 655 O'Neil Rd Hudson WI 54016 Kris Belling Plan ID SW,SW,25,29,15W Municipality of Springfield Inspector: County of St Croix Private Sewage plans including the following element(s): MOUND 450 gpd SAFETY AND BUILDINGS DIVISION 15837 USH 63 Hayward, WI 54843 Tommy G. Thompson, Governor Wiliam J. McCoshen, Secretary 9710897 Leroy G.Jansky (715)726-2544 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for compliance with all code requirements. This plan action is subject to no additional conditions. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department. All permits required by the state or local municipality shall be obtained prior to commencement of construction/installation/operation. This project is under the supervision of a state inspector. As inspection concerns arise feel free to contact the state inspector at the number listed. The inspector for this project is listed above. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when making an inquiry or submitting additional information. Sincert r,, � Thomas Braun Plan Reviewer (715) 634-3026 O RI0.. \ p,L ULBRICHT & ASSOCIATES CO. 655 O'Neil Road a Hudson, WI 54016 715-386-8185 Reg. Designers of Engineering Systems Private Sewage Consultants PROJECT INDEX DILHR Plan I.D. A S 97-10897 Owner Kris Belling Date Oct. 30, 1997 Phone 715-772-3213 Address 3206 70th Ave. Knapp, Wis. 54749 Legal Description Part of a 50 acre farm. Tax parcel #034-1056-40. SW 1/4, SW 1/4, Sec. 25, T29N, R15W Town of Springfield C.S.T. Henry F. Grote CSTM222774 County St. Croix Installer Local Authority/ Supervision St. Croix County Zoning Dept. PROJECT DESCRIPTION An existing 3 bedroom farm home has a deep failing system. Estimated daily wasteflow: 450 gals. Soils are permiable (.5/.6 GPD/FT2) but seasonally saturated at 26" as evidenced by mottling. A long narrow mound system using 121, sand fill is proposed. The old steel treatment tank shall be properly abandoned per code. Recommended: to provide for the highest degree of effluent clarity, and to provide for the greatest pretreatment, a Zabel filter should be provided in the new 1000 gal. precast septic tank (Weeks Concrete Products, New Richmond, Wis.). P.O.W.T.S. Conditionally APPROVED DEPARWNT OF CDWE DIVW mr AMo SEE 0 Pg.l PLOT PLAN VIEWS Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS Pg.3 PIPE LATERAL LAYOUT Pg.4 DOSING CHAMBER CROSS SECTION Pg.5 PUMP PERFORMANCE SPECS Ibis design fot installation is based entirely on measurements, elevations, landscape conditions (slopes etc.) and soil suitability provided by CS, Z 2Z7 7 11he accuracy of his specs, as reported, shall remain the sole responsibility of the CSTM. Any use of this POWTS design ty any licensed plumber, or any related unlicensed parties or persons (excavaters, laborers) shall not be construed as an assumption of responsibility by the designer for the r-orkmanship, construction, placement, substitution or selection of any components not specified, or any assumptions by the plumber that any unspecified components are state approved or proper, or the effects of poor judgement if vorking under adverse damaging venther conditions (vat/frozen soils) by any such parties or persons. ^ 910 0 9 7 w T93909 {y TH;;t�t61U t l r h v It PWF orc 1/? Ittas .vo 5zt-7-/31fot A,P AeEll3) WaLL s So 30 � = �,l'iSTivf yi�Al�F .� 67/GUST<O.vS 13 ' I � fr•�ss�'v oFF ) C57-S uv�Fo�M 7-Me _Gi ves 133 E/�vtnev S — r 13, 1 S 70 %Z �lG•0 13 3 9G • 70 �, a lf-a At ne, roP 6/el), _ �oo•o CSrhT wE5r EPS-t ALL NON -CONFORMING TREATMENT TANKS SHALL BE ADANDONED PROPERLY ,Nsvpe0, .NNoef pelvz FOR ILHR 83.03(2). iNsv647r 41.va /A_ eoDe lei Pv� o NSW Pod ga t P,Pr�itsr S�PT%G T ,4VOXeS �o.v444,e 49 . r o// O&I-Vh.lfwew - 5F 56 fxoAf 11 CROSS SEcTI00 OF MOUvD - wi rP4 BED P5 z CT 5 TYPE F4akr4 pa Roci< 1369 ViSTRiGuTloo G, rktck,aFs� Pip(r- of TOP SO(L ` I , uui FORM TOE •y w Li',u E 3 F �- RA10 • � SAND -ropsol 3 ado SIoPE FORCE mAipi INvF-Rr of 7,11 F .$Co Fr• Top of Rock G /.O Fr. H /. S FT. • Top OF i i Oeo OF j " ro Agget-5ATE- Sysreo EIEVAriON 9 -7 70 -F.D uu i Fop PA � l evnroa (-)u VER (3Ev q(p •7p W CST' IATERhl S 982-0 500. SC. IATERAIS (PLAN VIEW vF MouWD - wirli BE <Z,. Fug\ II ---------13 a-=------__ EA-V FORE HAW -r-] T -� J- A i o --r - I---------- --- ----= U \ PVc. cAPPep 06SEAVATIao Pipes BEE'? OF To I i" AggRESnTE A 5 FT. f3 7& Fr K /4 Fr L 9<o Fr 8 -1 F T T Fr W z7 Fr r PEQMA►JtoT MARKERS RecgviRep BASAL AReh = 'PAiLy whsrE"Fiow _ y✓`o = %� sv�� �ai;Ir�nTw6 _ S cApAcisa, Fr, ry PRopOSEV 13ASA4 Meh = 6 X (A + r = -7&x/-5 + 14 s Q. FT. •rcr��. M/W FoLp 015TRi(3uro0k) ►JETwoRk TOTAL V vLumi_ o f L A-rG7 AL- RNV CAD LAS1- IWE 5 ►"n" 'Jr- ►j[Ef- 1•d ENb CAP 1.u�ERT' � IEv�t-�ov �1992-0 —r ��51R1 �3uT lo►J LATERAI• Pvc. FORGE M A W /yJ#/t.Pi /ScI 84,3r-5 VOID VoluAAE Fos, /%S Fr. d p Z FORCE MAW Z F jh'S. PUG f ERFORATED PIPE DETAi L Q� HolEs locATeo o,u G OTroM SH All 13E I' 'I VARiABL.E y G(g0h11y sphc�p. y WSTA ►MCE %y P 7Z 1" r NOTE Di nr,E Te R 1N L ATERA L �� lot MAm FOLD lN . X �%g ��uchE s �gRcE MAi U n Z -- Y y8 �ucl.ES of 1iv1E5/ piPE~- %9 0ISTRi13uTI0pJ 1D%S(V1ARGE RATE PER LATERAL i� Z &Aj/Mj1J• T OTAI.-D15L1,AR 61E PACE / Nlrt-WOR k 2 Z• 2-- GA 1- / M N — PO4.3 0-c- s — k 40C.I. VENT PIPE ? Z5' FROM DOOR. WINDOW OR FRESH I p � AIR INTAKE O 1/JACEr /E ^T/On/ 1 CIEv,4P ON INLE T B ROVED JOIMTI 1J/C.I. PIPE ZXTEWDING 3' ONTO SOLID SOIL ELEV. V5•9 Ft. NK '6E o� � �pl VA f PUMP CHAMBER CROSS SECTIOIJ AND SPECIFICATIONS JB c 0 VENT CAP WEATHER PROOF JuucrloN BOX — 12'MIU. GRADE COIJDUIT U \ PROVIDE AIRTIGHT SEAL I l I 31 , l3'3r� l i p�yE 9 of S APPROVED LOCKING MANHOLE COVER to/ wMNIN6 1AAE� 1 PUMP I. I I BLOCK x- RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS 40 MIN. IIi IIIIIIIl APPROVED JOIN' TS W�C.I. PIPE .IiALARMONTO ETEUDIuG 3 SOLID SOIL ON OFF vSE 3 "ow lfodP6 eF n� SUCH APPROVAL SEPTIC f S/+P,EC IFIC ITIOAIS 3 DOSE &)456KS' I-fW&41Q Cp (JUMBE OF DOSES: PERDAy TANKS MANUFACTURE0.O 0 GALL►JS O ii DOSE VOLUME 30 ISO TANK SIZE: Qr/ +$egj%V /. lD INCLUDING BALKFLOW: GALLONS ALARM MANUFACTURER: LZFII�L ArG1,P�t ' CAPACITIES: A= Iy.�O IMCRESOft 3d0 GALLONS MODEL NUMBER: ,-`-! � B= 2, 1►.1CHES ORGALLOUS SWITCH TYPE: ��Ex/ C . " IUCHES OR l �4 CALLOUS PUMP MA �, p 13' IUCHES OR 17 " GALLONS MODEL NUMBER'. p1f5yS4< R"e41,49y 047— MOTE: PUMP AND ALARM ARE TO BE SWITCH TYPE: 2-5 INSTALLED ON SEPARATE CIRCUITS MINIMUM DISCHARGE RATE GPMC, T fiAOF 5 VERTICAL DIFFERENCE BETWEEU PUMP OFF AUD DISTRIBUTION _SrrC PIPE._/� FEET nn {� , O ~J} fit 1 + MINIMUM NETWORK SUPPLY PRESSUR�TE//. //6 FYllWF 2.5 EET EAC(A- � f' F . �•? /..7J 2o'� + 17FEET OF FORCE MAIN X FRICTIOU FACTOR.. FEET �UnIC. V is, —_ TOTAL 09MAMIG HEAD = 76' FEET O u r 3 Ra/'Uo / Qq �• INTERNAL DIME.USIONS OF TANK: LE / LENGTH _7G_—iwIDTH . LIQUID DEPTH A ,1040 PER PLUMBING PRODUCT APPROVAL ,CODES, ALL ABOVEGROUND PVC PIPING (FROM TANKS 6 SYSTEM AREAS) MUST BE SCH.40 PVC MEETING ASTM 01785 OR D2665 STANDARDS. r 6 3/16 1 1/2-11 1/2 NPr 1 IOU 240 D FLOW PER MINUTE !DIAL Drnuo: HL4WLOW p[a uvwl[ [r/ W 1KI "0 0MAt1A led CAFACM HEAD UNITIVIA N FEET METERS OALS LrRa E 152 TF rn 10 axe S1 231 to 461 46 110 20 6 to 26 96 16 Lock Wee z3. CONSULT FACTORY FOR SPECIAL APPLICATIONS to Electrical alternators, for duplex systems, are available and a Mercury float swllches are available for controlling single and supplied with an alarm. three phase systems. f Mechanical alternators, for duplex systems, are available with or a Double piggyback mercury Iloal switches are available for without alarm switches, variable level long cycle controls. Standard all models - Wei ht 39 Iba - / N P N ferlee Control Selection Model V he -Ph Mode Am a elm lox Duplex M" 116 1 ulo go t o a _ — ON 230 1 Aano e.S 1 a 1 6 7 — fg0 230 1 Non e.5 2 g x i[ 2 a 6 l 6 Fa Wor^stlon M eddltlaueoa ZeM produc4 t44" le WW alog M ComD.eon Sra", FMO61e; PpQybaca Me,Cwy Swk hft FM0477; Elsclrkal AAe,nalo, FMU/M; Vvchankel Aannalo, FM6W; Nun pera,ape, FM0613; Swgyeswege B"L-A FMoaai; arw A.Vi. Ca,ed Soti 61LIECTION GUIDE 1. Inleeral 11041 operated 2 pole rrlecharl)cal *wg h, no 044(nal control lequked. 2. 61ngle Piggyback rnarcury flow awitcll Of double P49ybwk mercury, float awkchneler to FM0417. 3. MechankW 61141nator 1&0072 of 10-0073. e. 6" FMo712, lot correct Model d Electrical AllerrWor, "E Pak 6. Mercury senior now aw" loom LWWd as a corocl "Ove1w ,Peclh. duplex (3) or ([) now eyeterm 6. FS)x.N) Iple "1 Pak pnc loon boa, kx wMgagrr conrlectlorl or wired n enF Prix a duplex operado 1, IO0002. 7. Two (2) hot* "J.Pek". la wwarllotU Conn%.-_.. . aprlce CAUTION AS krele6alloa M sonkola, prolecdw "leas anS wkta6 ehe,ld be aene aye ewlF NN IkanwA elwlrblan. All alwklnal end sally sedan ah.uM be Iollewed r.d..e� Ino the owl resent Nolte" Eleclls Code (NEC) uN the C ow,poUonal •wary end NealtA Adl 1011RA6 RESERVE POWFpED DESIGN For unusual conditions a reserve salety factor 1a engineered Into the design of wary Zoeller pump. i T `0 MAN TO: r.O.SOX 16347 iNl� 0!t � XY 40256 0347 ManulacWrers . 3 60 01 A6uas lade M (ft1s -. KY 40216 Q4A[/fY 4/PS sw« /9.>79 rs02) na 2131 a FATj502)114-362/ ,.r .,..n.....t..,..a.rr,., A cnu Akin QITP FVA1 II&TION Pace 1 of 3 ;Division of Safety and Buikfings r Comm 83.05, Wis. Adm. Code Attach complete site plan on paper not less0@0 Plan must County include, but not limited to: vertical and horizontal rsfererae nt (8M), direction and St. Croix percent slope, scab or dimensions, north distance to nearest road. Parcel I.D.# 034-1056.40 APPLICANT INFORMATION - pii t a tlon. BY Personal information You provide may be ,Wr, s. 15.04 (1) (m)). informationt -4 property Owner Belmm �s� Property Location GovL Lot SW 14 SW 1/4 S 25 T 29 N,R 15 W Properly Owners Mailing Address Lot # Block # Subd. Name or CSMM 3206 70th Ave. S7 cAOx City State ❑ Cdy ❑ Village ®Town Nearest Road Wilson WI 715-772 Springfield I 70Th Ave. ❑ New Construction ® ti of bedrooms 3 ❑Addition to existing building use: ® Replacement ❑ Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .5 bed, gpdff .6 trench, gpdff Absorption area required 900 bed, ff 750 trench, fC Maximum design loading rate .5 bed, gpdff .6 trench, gpdff Recommended infiltration surface elevabon(s) 97.7 ft (as referred to site plan benchmark) Additional design / site consideration tr1°stall 4' x 95' rock bed mound on 96.7 as upslope edge of rock w/ 1' sand fill Parent material loess Flood plain elevation, it applicable NA ft S=Suitable for system Conimilional Mound InCxourld Pressure A7�rade System in Fill Holding Tank U=Unsuitable for system ❑ S ®u S S ❑ U ❑ S ® U ❑ S ❑ U ❑ S ®U ❑ S ❑ U Boring# 1 i Ground elev 95.7 ft Depth to limiting factor 32' 2 Ground elev 96.0 it Depth to limiting factor 31' Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Textirre Structure Gr. Sz. Sh. Consistence Boundary Roots GPI' Bed Trench 1 0-4 7.5YR 312 sil 2 in cr mvfr cs 2flm .5 .6 2 4-13 7.5YR 3/2 sil 2 f sbk mvfr cs If/m .5 .6 3 13-22 1 OYR 4/4 sil 2 m sbk m& gs 1 m .5 .6 4 22-32 1 OYR 4/6 SO 2 in sbk mft gs if .4 .5 5 32-40 1 OYR 4/6 f2d 7. I OYR R R 6 4/6 scl 1 c sbk mfi 2 3 Remarks: occasional lw st coats on peas I s-u-' commonyy to costs on peas zz-jz I 0-4 7.5YR 3/2 sit 2 in cr mvfr cs I Um .5 .6 2 4-11 7.5YR 3/2 sit 2 f sbk mvfr cs lm .5 .6 3 11-26 10YR 4/4 sit 2 in sbk mfr gs Im 5 6 4 26-31 10YR 4/6 SO 2 m sbk mfr cs Im .4 .5 5 31 44 l OYR 4/6 f2d 7.5YR 4/6 1 OYR l2 scl 1 c sbk mfi .2 .3 Remarks: occasional ry sr si coats on CST Name (Please Print) Signalers: j Telephone No. Henry F. Crrote , 715-665-2681 AddressP.O. Box 57, Knapp, WI 54749 Date CST Number Ref # 10/11/97 222774 185 PROPERTY OWNER: Beim& Kristin SOIL DESCRIPTION REPORT PARCEL 1.0.N 0344056.40 7a Page 2 . -of _ 3 C, Ground elev 96.7 ft Depth to limiting factor 26' Ground elev Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Taxlure Structure Gr Sz. Sh. nsistence Boundary Gp Roots -- --B-ed- - Bed Trench I 0-3 7.5YR 3/2 sil 2 m cr mvfr cs 2flm .5 .6 2 3-11 7.5YR 3/2 sil 2 f sbk mvfr es if S 6 3 11-26 10 YR 4/4 sil 2 m sbk m& cs 1 f .5 6 4 26-31 10YR4/6 Qf7.5YR4/6 1 OYR 6/2 scl 2 m sbk mfr ] m 4 5 emarks. Depth to limiting factor Remarks: Ground elev Depth to limiting factor Ramnr4c- Ground elev Depth to limiting factor Zamnrire- 'f v {,+. 0T c7 �L)~4t O �g " / ►-a Ott zt(2�_y�+��rs i � P IL -byv N C-n S%-b2 ' Vt- 04 V 4 1I' M ~~ w r1.--a. a i.t I l •to-� �,�v „ 1 M ri s'D I l •to-� �,�v „ 1 M ri s'D Wisconsin Department of commerce Division of Sefety and Buildings Page 1 of 3 QL ANP SITE EVALUATION 40pACAO) C%�Jj mm 83.05, Wis. Adm. Code �Ilv to ako I.W1 W1 via;= nut i in . Plan must include, -but not limited limited to: vertical and refererx a point (BM), direction and County Percent slope. Scale or dimermwns, north arrow, a dksta ice to nearest road. St. Croix Parcel I.D.# B APPLICANT INFORMATION - on. 034-105640 R Data I / Personal informalion you provide may be Pu�eee S. S. 15.04 (1) (m)). PropertyOwner Beling, Kristin _ Property Location Lot SW 14 SW 1/4 S 25 T 29 N,R 15 W Property Owners Mailing Address Lr) I 1i 1991 N Bloch # Subd. Name or CSMk 3206 70th Ave. ST cpa City State ❑ City Village ®Town Nearest Road Wilson WI g Springfield 1 70Th Ave. ❑ New Construction ® �ti Brooms 3 ❑Addition to existing building Use: ® Replacement ❑ Public o describe Code Derived daily flow 450 gpd Recommended design loading rate .5 bed, gpdfft' 6 trench, gpdtW Absorption area required 900 bed, fP 750 trench ft` Maximum design loading rate .5 bed, gpd/ft` .6 trench, gpd/fl' Recommended infiltration surface elevations) 97.7 ft (es referred to site plan benchmark) Additional design / site eonsiderationainstall 4' x 95' rock bed mound on 96.7 as upslope edge of rock w/ 1' sand fill _ Parent materiel loess Flood plain elevation, if applicable NA ft S=Suitable for system Conve *wW Mound In -Ground Pressure AT -Grade I System in Fill Holding Tank U=Unsuitable for system Lis N U N S❑ U ❑ S N U ❑ S N U I ❑ S C I ❑ S p U Boring# 1 Ground elev 95.7 ft Depth to limiting factor 37 2i Ground elev 96.0 It Depth to limiting factor 310 501L DESCRIPTION REPORT Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz Consisten Boundary Roots GPI — Bed Trench 1 0-4 7.5YR 3/2 sil 2 m cr mvfr cs 2flm .5 .6 2 4-13 7.5YR 3/2 sil 2 f sbk mvfr cs If/m .5 .6 3 13-22 IOYR 4/4 sil 2 no sbk mfr gs I m .5 .6 4 22-32 10YR 4/6 scl 2 m sbk mft gs If .4 .5 5 3240 1 OYR 4/6 @d 7.5YR 4/6 1 OYR 612 sot l c sbk mfi .2 .3 marks: uwaaruna, va sr coats on peas 13-22-& common Gy si costs on peds 22-32" 1 0-4 7.5YR 3/2 - sit 2 m er mvfr Cs If/m .5 .6 2 4-11 7.5YR 3/2 - sit 2 f sbk mvfr Cs Im .5 .6 3 11-26 l OYR 4/4 - sil 2 m sbk mfr gs l m .5 .6 4 26-31 10YR 4/6 - sell 2 m sbk mft Cs lm .4 .5 5 31 44 1 OYR 4/6 f2d 7.5YR 4/6 1 OYR 6/2 scl l c sbk mft .2 .3 CST Name (Pests PdnQ Signskrs: Telephone No. Henry F. Grote . 715-665-2681 Address P.O. Box pp' WI 4 Date CST Number Rai# 10/11/97 222774 185 SOIL DESCRIPTION REPORT es Page 2 of • ' 3 • . PROPERTY OWNER: Belirm Kristin PARCEL I.DJ 034-105640 K. Ground elev 96.7 ft Depth to limiting factor 26" Dominant Color Munsell Mottles Structure Consistence Qu Sz Cont. Color 'Texture Gr Sz Sh Boundary Roots GPD/M Horizon Depth in Bed Trench 1 0-3 7.5YR 3/2 sil 2 m or mvfr cs 2flm .5 .6 2 3-11 7.5YR 312 - sil 2 f sbk mvfr cs if .5 .6 3 11-26 10YR 4/4 - sil 2 m sbk mfr cs if .5 .6 4 26-31 l OYR 4/6 f2f 7.5YR 4/6 lOYR 6/2 scl 2 m sbk mfi 1 m .4 .5 Remarks: h' si 008ts on pods below 11" Ground elev Depth to limiting factor Remarks: ------ Ground elev Depth to limiting factor Remarks: Ground elev Depth to limiting factor Remarks: AIT �n�a1uqrj l 1 M � A � �• i. M (•I J �1 ter, t 1 T• j B T C - 100 ;Phis 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 ,C�iu.S %jEGGiN D— Ldcation of property SW 1/4 Sw 1/4, Section ZS Township yjei)!�5EWV Mail ingaddress 54-1 Address of site Subdivision name acre "t� ,11-- other homes on property? Yes `' No T 2/ N-R / S W Lot no. Previous owner of property 5 Total size of property ± 2- Total size of parcel 7 d 7` /} A,( 5 Date parcel was created Are all corners and lot lines identifiable? Yes No Is this pro rty being developed for (spec house)? Yes No Volume 96 > and Page Number 29/ as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRA1rPY DEED which includes a DOCUMENT NUMl1ER, VOLUME AND PAGE 11UMdER 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 l (we) certify that all statements on this form are true to the best of. my (our) knowledge that I (we) am (are) the owners) 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. 4/5'6 S C/ Z , and that I (we) presently own the proposed site for t ie 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. S ignatur�pl�cant bate of Signature STC-105 MAILING ADDRESS SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County ,(�ei /.fiea%NCr 32.0G 70 d& Ifve . ICIVIpq U,S. SY -7 YX PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 514) 1/4, Sw 1/4, Section X S IT '- f N-R (S W TOWN OF $l?e t o Cr F l t-1- 0 SUBDIVISION N/"+— ST. CROIX COUNTY, WI LOT NUMBER CERTIFIEEDSURVEY MAP N//f— . VOLUME , PAGE , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the 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: St. Croix County Zoning Office Government Center I101 Carmichael Road Hudson, WI 54016 11193 St. Croix County Planning and Zoning Tuesday, June 19, 2007 at 10:22:56 A3f Detail Sanitary Information Page 1 of 1 Computer #: 034-1056-40-000 Sub/Plat: metes & bounds Section: 25 Parcel #: 25.29.15.395A Lot: TN/RNG: T29N R15W Municipality. Springfield, Town of CSM: 1/4114: SW 114 SW 1/4 Owner: Belling, Kristin M. 3206 70th Avenue Knapp, WI 54749 State Permit: 299141 Issued: 11/03/1997 POWTS Dispersal: Mound 24' or more suitable soi Permit: Replacement County Permit: 0 Installed: 1110711997 POWTS Detail: NA Bedrooms: 3 WI Fund: Yes POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumbe Other Requirements Not determined Yes Ulbricht, Robert Rod Eslinger Signed Uff Yes Mamtenan, c Scheduled Pumo Dale Pumped 1st Notification 2nd Notification 3rd Notification 11/7/2000 11/10/2003 04/01/2005 11 / 10/2006 11/10/2004 11/10/2007 Additional Notes Money Owed 28.88 acres - applied for WI fund. Awarded grant $0.00 money - file paperwork with sanitary permit in archives .VMS see October 13, 1998 Kristin M. Belling 3206 70th Avenue Knapp, WI 54749 RE: Wisconsin Fund Grant Award Dear Ms. Belling: ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 Enclosed is your Wisconsin Fund Grant Award check. This is the amount you have been awarded for the rep lacement/rehabi I itation of your septic system. If you have any questions, please feel free to contact our office. incerely, es K. Thompson Zoning Specialist Enclosure /�i COUNTY OF ST. CROIX MidAmerica Bank STATE OF WISCONSIN •;, limo mSun<I DATE CHECK NOV813 3 5 0 HuJvml. R,. W \VIk.In•In 531I1N � 79 11 BO 91888 THREE THOUSAND EIGHT HUNDRED DOLLARS d 00 CENTS PAY TO THE ORDER OF KRISTIN M. BELLING 3206 70TH AVENUE KNAPP WI 54749 10/12/98 813350 ■ ■ : ■ ■ ■ ■T�Ti , . AMOUNT ******3,800.00 VOID AFTER SIX MONTHS DETACH AND RETAIN THIS STATEMENT GATE THE ATTACHED CHECK IS IN PAYMENT OF THE COUNTY OF ST. CROI% rtEMS DESCRIBED BELOW IF NOT CORRECT O, 1 G /9 i"A"F ' •• PLEASE NOTIFY US PROMPTLY NO RECEIPT DESIRED CHECK NO. I VENDOR NO. 813 35 0 1 VOUCHER NO. I INVOICE NO./DESCRIPTION AMOUNT VOUCHER NO. INVOICE NO./DESCRIPTION AMOUNT 4S18 PRIVATE SEWER GRANT �I 3,800.00 St. Croix County Planning and Zonin Monday, December 19, 2005 at 4:40:03 PM Detail Sanitary Information Paso J of Computer 0: 034-1056-40-OW SubMd: metes & bounds Section: 25 Parcel 0: 25.29.15.395A Lot TN/RNG: T29N R15W Municipality SlAnglieW, Town of CM: 114 1/4: SW 1/4 SW 1/4 Ownw, Belling, Kris 3206 Toth Avenue Knapp, W 154749 Sale Pwmlt 299141 Issued: 1110311997 POWTS Dispersal: Mound Permit: Replacement CouatyPermit: 0 Installed: 11/07/1997 POWTS Detail: NA Bedrooms: 3 WI Fund: Yes POWTS Pretreatment: NA Notes Inspector Rod Eslinger Maintenance Scheduled Pump 11/7/2000 11/10/2006 11110/P007 Built Yes Signed Off: Yes Date Pumped 11110/2003 11110/2004 PI m Other Requirements Ulbricht, Robert 1 st Notification 2nd Notification 3rd Notification 04101/2005 Additional Notes Money Owed 28.88 acres - applied for W I fund. $0.00 Parcel #: 034-1056-40-000 1vlsnoos PAGEE I OF 1 P Alt. Parcel M 25.29.15.395A 034 - TOWN OF SPRINGFIELD 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 O - BELLING, KRISTIN M KRISTIN M BELLING 3206 70TH AVE KNAPP Wl54749 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ' 3206 70TH AVE SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 28.880 Plat: N/A -NOT AVAILABLE SEC 25 T29N R15W SW SW EXC TH E 367 FT Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 40 1/4 160 114) 28.88A EZ-UT-1477117 25-29N-15W Notes: Parcel History: Date Doc # VoUPage Type 07/23/1997 865/281 07/23/1997 865/221 07/23/1997 7451585 2005 SUMMARY Bill M Fair Market Value: Assessea wnn: 82319 Use Value Assessment Last Changed: 05/26/2004 Valuations: Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 14.000 2,650 0 0 2,650 7,500 NO NO UNDEVELOPED G5 G7 9.880 2.000 7,500 9,550 114,000 123,550 NO OTHER ENTERED BEFORE'05 CLOSE W8 3.000 5,400 0 5.400 NO Totals for 2005: General Property 25.880 19,700 114,000 133,700 Woodland 3.000 5.400 5,400 Totals for 2004: General Property 25.880 19,700 114,000 133,700 Woodland 3,000 5,400 Lottery Credit: Claim Count: 1 Certification Date'. Batch #: 129 Specials: User Special Code Category Amount Special Assessments Special Chargas Delinquent Chargas Total 0.00 0 00 04: Parcel #: 034-1056-10-000 1u1s/zoos PAGE EI PM 1 OF 1 Alt. Parcel #: 25.29.15.394A 034 - TOWN OF SPRINGFIELD 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 - BELLING, KRISTIN M KRISTIN M BELLING 3206 70TH AVE KNAPP WI54749 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description SC 2198 GLENWOOD CITY SIP 1700 WITC Legal Description: Acres: 19.307 Plat: N/A -NOT AVAILABLE SEC 25 T29N R15W PART OF NW SW BEG SW Block/Condo Bldg: COR SEC 25 TH N 2284 FT TO POB: TH E 953 FT, TH S 964 FT, TH W 953 FT, TH N 964 Tract(s): (Sec-Twn-Rng 40 114 160 114) FT TO POB EXC LOT 1 OF CSM V 4/1078 25-29N-15W INCLUDES P394C EZ-UT-1477/17 Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 865/281 07/23/1997 865/221 07/23/1997 745/585 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 82317 9,100 Valuations: Last Changed: 05126/2004 Description Class Acres Land Improve Total State Reason UNDEVELOPED G5 9.530 7,850 0 7,850 NO ENTERED BEFORE '05 CLOSE W8 12.000 21,600 0 21,600 NO Totals for 2005: General Property 9.530 7,850 0 7,850 Woodland 12.000 21,600 21.600 Totals for 2004: General Property 9.530 7,850 0 7,850 Woodland 12.000 21,600 21,600 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges 0.00 Total 0.00 0.00 912005 Parcel #: 034-1056-30-000 'v' PAGE 1 OFA1 Alt. Parcel #: 25.29.15.394C 034 - TOWN OF SPRINGFIELD ST. CROIX COUNTY, WISCONSIN Current X Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner. C = Current Co-owner O - BELLING, KRISTIN M KRISTIN M BELLING 3206 70TH AVE KNAPP WI 54749 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 2.223 Plat: NIA -NOT AVAILABLE SEC 25 T29N R15W 2.223 IN NW SW LOT 1 OF Block/Condo Bldg: Trect(s): (Sec_Twn-Rng 40 1/4 160 1/4) CSM V 4/1078 ASSESSED WITH P394A EZ-UT-1477/17 25-29N-15W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 8651281 07/23/1997 851/43 07/23/1997 829/410 2005 SUMMARY Bill #: Fair Market Value: Assessea wnn: 0 Valuations: Last Changed: 01/29/1991 Description Class Acres Land Improve Total State Reason Totals for 2005: 0.000 0 0 General Property 0 p0 Woodland 0.000 Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Chargs Delinquent Chargas Total 0.00 00..0UU State of Wisconsin PRIVATE SEWAGE SYSTEM REPLACEMENT Safety and Department of OR REHABILITATION GRANT PROGRAM Buildings Commerce Division OWNER'S APPLICATION Instructions For Property Owners: €>T'O''BE COMPLETED BY COMMERCE You may apply after you have received a determination of failure and obtained /1ppYcatbn Number Date Received a sanitary permit Complete Part A of this form, attach evidence of your H annual Income, and send these items to the governmental unit listed below. PART A. TO BE COMPLETED BY THE PROPERTY OWNER Owner Name• social No'• Additional Owners d Their Spouses) social Security No. •• KrtSi'irN A , Ie ill rt owners Spouse Nara social Security No'• Street or Route 320(, 1& city, state Zip Code Telephone Number (wrJude area code) Kha V.) SDI -I `i l Hm', - i15- (C6q- �91� •Grant awards will be Issued In the name of this owner. "Note: Your Social Security Number may be used to verity your income and verify status of child support and maintenance payments. commercial1. Was the principal residence or smog commercial establishment constructed prior to and occupied by July 1, 1978? tat. Yes []No If your principal residence Is a mobile home, was the current unit placed at this location by July 1, 19787 ❑ Yes ❑ No 2 This application Is for (complete both If applicable): Y � ILl Prkrcipal Residence Do you occupy this residence at least 51 % of the year t�Yes ❑ No ❑ SmaN Commercial Establishment Do you occupy this small commercial establishment at least 51 % of the year: ❑ Yes ❑ No Small commercial Establishment Name: Description of Small Commercial Establishment farm restaurant etc. : 3. Was the private sewage system replaced as part of areal estate transaction or change of ownership? ❑ Yes &No If yes, explain: �y 4. As the owner, are you a licensed plumberus uor contractor engaged in the business of Installing private sewage systems? ❑ Yes Y No 5. Evidence of Income. Attach s copy of your Wisconsin Income tax return for the year of or prior to the enforcement order or determination of failure if you are applying as a principal residence. If you are applying as a small commercial establishment, subunit a copy of your federal tax forms, including all sehadules for the year of or prior to the order or determination of failure. If you were married and filed on separate forms, you must also include your spouse's Wisconsin Income tax return for the same year. You must include evidence of income for each owner (and for each owner's spouse) listed above. Evidence of Income will be kept on fib at the governmental unit and Is subject to verification by the Wisconsin Department of Revenue and by the Department of Commerce. If you or any owner gated above did not file a Wisconsin Income tax return or were a pan -year residence in the year prior to the enforcement order, check this box 0 and contact your governmental unit for further instructions. S. Property Owner's Certification. I certify that to the best of m and belief, the Information I haveprovided on this form and all attachments are true and correct. owners S%Fwbxe Date Signed Co -Owners Signature Date Signed ID-a.1-47 Paraaltal I%rirYNern you provide tnah{Se used for secondary purposes (Privacy Law, s. 15.04(1)(m)1. SBD-9163 (R 1/97) I PART S. To HF rnmpi GTcn ov Tur .......- - - - -- •.� vv�LnlYlY1 CIYINL UIVI I 1. Legal Description of Property: Tax Parcel Number jW 1/4, J W 1/4. S T a9 N. R %S ENV. El City ❑Village CYTown of.. OR Lot No. — Block No. — Subdivision Name 2. W,—hee verifying ownership, does the owner(s) name agree with the name(s) of the applicant on Part A of this application? l.y Yes ❑ No If the applicant answered yes to question 3 on Part A of this application, did the applicant owns the property when the order/ verification of failure was issued or the system installed and incur the cost of replacement? Ly Yes ❑ No What document was used 'Documeimor to verify ownership? kl[ 1�1/fin,�ln l�P2Gi Page Number 3. If this application is for a replacement structure, have the requirements outlined in COMM 87.04(4) been met? 12'Yes ❑ No 4. Is a public sewer available to this property? ❑ Yes No 5. Has a previous grant been awarded for this property under this program? ❑ Yes PJo 6. Principal Residence evidence of income. Please indicate applicable annual income: $ / , 5___T / . 0 Wisconsin income tax form �� Line f . Year /� Affidavit of Year Other form used Line Year Small Commercial Establishment evidence of income. Please indicate applicable annual gross income: $ Profit & loss form used: Line Year 7. Private sewage system failure caused by discharge of sewage to (check all that apply): Surface water or groundwater............................................................. Category1 A zone of saturation ............................................................................................................................... A drain tile or zone of bedrock .................................. Category 2 The surface of the ground................................................................... Category 3 Back-up of sewage into the structure served........................................................................................... ❑ Date of Order or Determination of Failure (mo/day/yr):_ 8. System Type: �� ❑ Conventional ❑ In -ground Pressure ❑ At -grade I� Mound ❑ Holding Tank ❑ Other, explain rJq Uniform Sanitary Permit Number I %L4 I Date Issued Plan Approval Number q�%— ��1�'q / Date Approved 9. Eligible Ineligible ❑ Reason: 10. Governmental Unit Representative's Certification. I certify that I have reviewed and verified all information provided on this orm and attachments and that thev are and correct to the best of ma knowledge and belief. Signature of Author a Governm i Representative Title Date Signed u State of Wisconsin PRIVATE SEWAGE SYSTEM REPLACEMENT Safety and Department of OR REHABILITATION GRANT PROGRAM Buildings Commerce Division GRANT WORKSHEET Owner's Name: County: rs 01 iX PART 1. GRANT FUNDW4G TABLES A. Site evaluation and soil testing. Grant Amount $200. OD B. Installation of a replacement or additional septic tank. Minimum Gallons Reouired Grant Amount 750.....................................................................................................$400 975 .......................................................................................................450 1,200 500 ..................................................................................................... 1.425 575 ....................................................................................................... 1,850 .......................................................................................................825 1,875.......................................................................................................700 ySU 2 100 or more..........................................................................................750 $ C. Installation of a pump chamber and lift pump or siphon: Number of Bedrooms Grant Amount 1 or 2...................................................................................................$875 3 or 4.....................................................................................................950 �Q 5 or more ............................................................................................11.0w $ D. Installation of a non-pressuHzed or in -ground pressure soil absorption area. 1. The following table shall be used for systems sized according to percolation tests. Grant amounts determined by number of bedrooms. Percolation Rate in Minutes 1 2 3 4 5 Each Addl for Water to Fall One Inch: Bedroom: 0 to less than 10 $375 $600 $825 $1,025 $1,150 $125 10 to less than 30 575 875 1,200 1,450 1.650 200 30 to less than 45 600 900 1,250 1,500 1,750 250 45 to less than 60 625 950 1,375 1,625 1.850 250 2. The following table shall be used for systems sized for soil morphological conditions. Grant amounts determined by number of bedrooms. Desion Loadina Rate Gallons_ 1 2 3 4 5 Each Addl Per Square Foot Per Day: Bedroom: 0.7 or more $375 $600 $ 825 $1,025 $1,150 $125 0.6 575 875 1.200 1.450 1,650 200 0.5 600 900 1,250 1.500 1,750 250 0.4 or less 625 950 1,375 1,625 1.850 250 E. Installation of an at -grade or mound soil abosrption area. Grant amounts determined by number of bedrooms. Type of Desion 1 2 3 4 5 Each Addl Bedroom: At -Grade $700 $900 $1,200 $1,450 $1,650 $200 High Groundwater Mound 1,625 1,875 2.200 2,400 2,600 200 High Bedrock Mound 1,875 2.125 2,450 2,600 2,825 225 Slowly Permeable Mound 2,125 2.375 2,575 2,700 2,950 250 Mound with less than 24' of suitable soil or greater than 12% slope. 2,300 2.500 2,800 3,100 3,400 300 •CM/11/.n\7 Personal information you Prowas may oa �,u..ew -7 w,w--- \' - -- , - .-.- • ,• , SBD-9167 (R. 1197) PART 1. GRANT FUNDING TABLES continued F. Installation of a holding tank. Number of Bedrooms 1, 2 or 3 4 5 6 7 8 Addl Grant Amount $1,250 1,575 1,875 2,125 2,300 2,500 Bedrooms $175 $ G. Installations not Covered by the Grant Funding Tables. Installations not covered by the Grant Funding Tables are reviewed by the Department on a case by case basis. If you are requesting funding for an installation not covered in Section A-F, please explain your request here, attach a copy of the paid invoice, and request 60% of the installation at the right. TOTAL PART 1. $ 3�oa.� PART 2. GRANT AMOUNT CALCULATIONS A. Enter the total from Part 1. B. Is the applicant a licensed plumber or contractor who installs private sewage systems? If yes, enter 2/3 of the amount from section A. C. Enter the smaller amount listed in sections A or B. If this application is for a small commercial establishment and the gross income of the business is less than $362,500, this the total grant award. Carry this amount forward to section F. If this application is for a principal residence and the gross income of the owners is less than $32,001, this is the total grant award. Carry this amount forward to section F. If this application is for a principal residence and the income of the owners is $ more than $32,000, go to section D. D. Enter 30% of the amount by which the applicant's annual family income exceeds $32.000. Annual Family Income Subtract - $32,000 Subtotal X .30 = $ E. Subtract line D from line C. This is the maximum grant amount for this applicant. Carry this amount forward to section F. (The amount in section E must be at least $100 to be eligible for any grant award. If the amount calculated is less than $100, enter $0.00 in section F. $ F. Total grant award for this applicant. $ �LIv =�I•riR. SANITARY PERMIT APPLICATION In accord with ILHR 83 05. Wis Adm Code Safety and Buildings Division Bureau of Building Water Systems 201 E Washington Ave P O Box 7969 Madison, WI 53707 7969 • Attach complete plans (to the county copy only) for the system, on paper not less than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application The information you provide may be used by other government agency programs l Privacy Law, s. 15.04 (1) (m)I County ST c/f &X State Sanitary Permit Number 99i�1 � Crux: it rxwsaxi to prwrrws eVeAiGAtilln State PI I Number 97— /6J?Vl-7 I. APPLICAJ1 N INI-KMHI I Iry - ra_er+ ' r"Be propert Location Property Owner Name �ie/s p�� Sof174 * 71/4, 5 2.S T Lam/ , N, R /.S E (o W Propertrb yOwner'sM n/g�AddCCdregs_ lot Number Block Number Ci state Zr Code PhoneNumbe �' SubdrvrslonNameor�MNumber (,J/S ( 76) 2/ N/ Nearest Road 11. TYPE OF BUILDING: (check one) ❑State Owned it sp��, .L/�� o � yfv� 171 Public or 2 FamilyDwelling- No. of bedrooms '3 E) vows of 7t Parcel Tax Numbers)) III. BUILDING USE: (if building type s public. check all that apply) 0 3 y_ 10S<O- 4/0 1 ❑ Apartment/Condo 10 Outdoor Recreational Facility 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 11 ❑ Restaurant / Bar/ Dining 3 E] Campground 7 ❑ Merchandise: Sales/ Repairs ❑ 12 ❑Service Station/ Car Wash 4 ❑ Church / School 8 ❑ Mobile Home Park 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) New 2. replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5• ❑ Repair of an A) 1. ❑ ----- Existin S stem Tank ------y------------------tinq - ---- ------SLrsystem tem--------System --------------------Y- B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non -Pressurized Distribution Pressure Distribution Experimental Other 11 []Seepage Bed 21 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 42 ❑Pit Privy 12 ❑ Seepage Trench 22 ❑ In -Ground Pressure 43 ❑ Vault Privy 13 ❑ Seepage Pit 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate s. Perc. Rate 6. System Elev. Elevation.Fin lGrade I/sD Re3gy(sq. ft.) Propose�sq. ftJ (GaIS/•daay/sq. ft•) (Ndh1 lr% 70 Feet • Feet VII. TANK SS CaSite 33 efabSite Fiber- Evper INFORMATION Ingallons Gallons Tanks ManuTotalfacturer# of's Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks T nk ���/� Septic Tank oEl El r Holding Tank •�V'� O / ❑ O lift Pump Tank /Siphon Chamber O Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) I Plumber's /gnature: ( cis amps) /MPRSW No Business Pho Numb 0 r �1hXiLl+% 330-) 7/S/�3� �'�r�rJ �� Plumber's Address(street.Lity,state.ZipCode):/�, A'/2/L 9f0J WAS• J Te�7 IX. COUNTY / DEPARTMENT USEONLY't/•C Disapproved S nDermit Fee OmiuOt,G`o�ndw�ier ;aessuetIssuing Agent Signature (No Stamps) ❑ pPtar narge feel [Gg/Approved ❑ Owner Given Initial "D �— •3' �%% E+ �-L— Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: ULBRICHT & ASSOCIATES CO. 655 O'Neil Road • Hudson, WI 54016 715-386-8185 Reg. Deslgners of Engineering Systems Private Sewage Consultants PROJECT INDEX DILHR Plan I.D. A S 97-10897 Owner Kris Belling Address 3206 70th Ave. Knapp, Wis. 54749 Legal Description Part of a 50 acre farm. SW 1/4, SW 1/4, Sec. 25, T29N, R15W Town of Springfield C.S.T. Henry F. Grote CSTM222774 Date Oct. 30, 1997 Phone 715-772-3213 Tax parcel #034-1056-40. County St. Croix Installer Local Authority/ Supervision zoning Dept. St. Croix County PROJECT DESCRIPTION An existing 3 bedroom farm home has a deep failing system. Estimated daily wasteflow: 450 gals. Soils are permiable (.5/.6 GPD/FT2) but seasonally saturated at 26" as evidenced by mottling. A long narrow mound system using 121, sand fill is proposed. The old steel treatment tank shall be properly abandoned per code. Recommended: to provide for the highest degree of effluent clarity, and to provide for the greatest pretreatment, a Zabel filter should be provided in the new 1000 gal. precast septic tank (Weeks Concrete Products, New Richmond, Wis.). �---- P.O.W.T.S. Conditionally A P ROVED DEPART NT OF COMMERC a�V��1U1N1�RW14J/Jy„/ ,•a C a ., Sl,� e, DIYISIO fTY ANDW 03 a`� Qj�S,�--^N `4 �`: Now rLIJLAIIW SEE CORRES NCE Ville yHUDSONIVAI /^ Pg ,1 PLOT PLAN V I EW S 9j��i�+`S I G 141 Os;`ar Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS Pg.3 PIPE LATERAL LAYOUT Pg.4 DOSING CHAMBER CROSS SECTION Pg.5 PUMP PERFORMANCE SPECS 'his design foE installation is based entirely on measurements, elevations, land9cape conditions (slopes etc.) and soil suitability provided by C. Z'2,17 % Tlie accuracy of his specs, as reported, shall remain the sole responsibility of the CSTm. Any use of this POWTS design ty any licensed plumber, or any related unlicensed parties or persons (excavaters, laborers) shall not be construed as an assumption of responsibility by the designer for the vorkmanship, construction, placement, substitution or selection of any components not specified, or any assumptions by the plumber that any unspecified components are state approved or proper, or the effects of poor judgement if working under adverse damaging weather conditions (wet/frozen soils) by any such parties or persons. 97 10897 r h U I FI�fSEv °FF uNi":':ojeM Go.c>TOv�e Gi.tJl�- O` • Z I r ` r � r r / t zs ' 3 1 � / y 0 ��aa�/fled �alop�ed9eo1/6a �mafl1e�a�ooa�� lvleT of yl lf6.cs No 5e_T131fC/t' pre&ll0e4 Af5 } • = ,8A-��� ��'TS '69 -.�4 lJ E m� rcorc� 100 c P l,t4l_5_ CO.vGr.�7�,2 /�/i'!iv r foP /E �, = /00.0 CSt rt FR°r P)ex et m)j v�R`' poel.G ALL NON -CONFORMING TREATMENT TANKS SHALL BE ABANDONED PROPERLY FOR ILHR 83.03(2). 1,V S (;twtX A4a eopE- 5e • 40 G , 1004 �-7 N&W �0 0 �d.0 p/G NWT se-1- 1014W107 5CdrIe T 0 Nvisconsin Department of Commerce 30-Oct-97 Ulbricht & Assoc Robert Ulbricht 655 O'Neil Rd Hudson WI 54016 SAFETY AND BUILDINGS DIVISION 15837 USH 63 Hayward, WI 54843 Tommy G. Thompson, Governor William J. McCoshen, Secretary Kris Belling Plan ID 9710897 SW,SW,25,29,15W Municipality of Springfield Inspector: Leroy G. Jansky County of St Croix (715) 726-2544 Private Sewage plans Including the following element(s): MOUND 450 gpd The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for compliance with all code requirements. This plan action is subject to no additional conditions. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department. All permits required by the state or local municipality shall be obtained prior to commencement of construction/installation/operabon. This project is under the supervision of a state inspector. As inspection concerns arise feel free to contact the state inspector at the number listed. The inspector for this project is listed above. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when making an inquiry or submitting additional information. Sincer y Thomas Braun Plan Reviewer (715)634-3026 �R�GiNA� Nfr=nsinDepartment ofCommerce SOIL AND SITE EVALUATION Page I of 3 Qivisiop. d4afely and Buildings cordNvi t pmm 83.05, Wis. Adm. Code Attach complete site plan on paper not less %mawWA � 1 Jin size Plan must County include, but not hmRlxt to: vertical and ref p61M (BM) -direction and $t. Croix percent slope, scab or dimemsions, north arrow, and location and distance to nearest road. Pal I.D.# 034-1056-40 APPLICANT INFORMATION - Pfease print all information. Reviewed By Dete Pwsonal tM m8t10n you p wkin may be used for secondary purpwes (Macy low, S. 15.04 (1) (m)). properProperb� Bsllih5 Go Lot N,R IS W Being, � l�Ilatm SW 14 SW I!4 S 25 T 29 Property Owners Mailing Address Lot * Block # Sttbd. Name a GSM# 3206 70th Ave. Nearest Road city �,� State Zip Code P11or1eNurrlbcr � City� Village []Town 70Th Ave. wThm WI Sy7415 627 715-772-3213 Springfield New Construction Use. ®Residential / Number of bedrooms 3 ❑Addition to existing building ® Replacement Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .5 bed, gpdffl' .6 french, gpdffP Absorption area required 900 bed, fC 7 g g .6 trench, dHP �� trench, ft Maximum design loading rate 5 bed, gpdfft' gp Recommended infiltration surface elevabon(s) r97.7 it (as referred to site plan benchmark) Additional design / site consideretions'nsWI 4' x 95' rock bed mound on %.7 as u I edge of rock w/ 1' sand fill Parent material loess Flood lain elevation, 9 applicable NA ft S arum Suitable for system Conventional Mound In.Ground Pressure AT -Grade I System in Fill Holding Tank U=Unsuitable for system ❑ S ® U I ®SOU ❑ S ©u [IS O ❑ S ©U ❑ S p U • r•r•nA19T Boring# 1 '! Ground elev 95.7 R Depth to limiting factor 37 2 Ground elev 96.0 R Depth to limiting factor 31" Depth in. Dominant Color Munseq OVIL VG•wf�ar Mottles Qu. Sz. Cont.Color • •v•. Texture • -- Structure jConsistence�Boundary Gr. Sz. Sh. Roots GPQHt' Horizon Bed Trench l 0-4 7.5YR 3/2 sit 2 m cr mvfr fl m 5 6 7.5YR 3/2 sit 2 f sbk mvfrf/m 5 6 2 4-13 10YR 4/4 sit 2 m sbk mfr 1 m .5 .6 3 13-22 IOYR 4/6 scl 2 m sbk mfi Agsif 4 5 4 22-32 10YR 4/6 Qd 7.5YR 4/6 l0YR 6/2 scl 1 c sbk mfi .2 .3 5 32-40 o.• .r, occaslonal uy s1 coats on PCU3 1 r- i Wunuvu v a --- 1 0-4 7.5YR 3/2 sit 2 m cr mvfr Cs 1 Om .5 .6 2 4-11 7.5YR 3/2 sit 2 f sbk mvfr cs lm 5 6 1 m 5 6 3 1 1 -26 10YR 414 sil 2 m sbk mfr gs IOYR 4/6 scl 2 m sbk mf1 cs 1 m .4 .5 4 26-31 5 3144 IOYR 4/6 Qd 7.5YR 416 10YR 612 scl I c sbk mL 2 .3 Remarks. occa81ona1 al COara on l vw wuu••v.. Telephone No. SST Name (Please Pnr>y soak":715-665-2681 Henry F. Grote ` CST Number Rd N Address x 5 . epp, 54 4 Date 185 10/ 11/97 222774 PROPERTY OWNER: Min& Kristin SOIL DESCRIPTION REPORT PARCEL I.D.N 034.1056-40 Horizon Depth Dominant Color Mottles Structure in Munsell Qu. Sz. Cont. Color I Texture i Gr. Sz. Sh, 3 1 0-3 7.5YR 3/2 sit 2 m cr 2 3-11 7.5YR 3/2 sit 2 f sbk Ground elev 3 11-26 10YR 4/4 sit 2 m sbk 96.7 It 26-3 f 1 OYR 4/6 Qf 7.5YR 4/6 I OYR 6/2 scl 2 m sbk Depth to limiting factor 26" Remarks: gy si coats on oeds below I I" Ground elev Depth to limiting factor Remarks - Ground elev Depth to limiting factor Remarks: Ground elev Depth to limiting factor T a-57 Page 2 of 3. J isistencei Boundary Roots GPD/ft= _ , Bed Trench fr cS 2f1m 5 6 fr !Mf, cs I f .5 .6 cs I f .5 .6 I 4 5 z Sa — - No ,� t �Q^'..'D 07 S'oJQ 4 )I-vC1 n, 1%- b2 C2- " S. .s n QC1 '(v- C�•� b7 o* -Ir Kristin M. Belling 3206 70th Ave. Knapp, WI 54749 January 5, 1998 Mr. Rod Eslinger St. Croix County Zoning Office St. Croix County Government Center 1101 Carmichael Rd. Hudson, WI 54016-7710 Dear Mr. Eslinger: Enclosed please find receipts or cancelled checks for all of the costs associated with replacement of my septic system. please include those items which are eligible for reimbursement under the grant program with my grant application which you already have on file (the fee and tax returns have also already been submitted). ion from e that ll I would appreciate nor materialslhaveibeentreceived.yIucanfbecreachedaneceby phone ary q phone during the day at 684-2914, or by mail at the above address. Thank you for your assistance with this matterl W�cerely -M, Kristin M. Belling ULBRICHT & ASSOCIATES CO. 655 O'Neil Road • Hudson, WI 54016 715-386-8185 Reg. Designers of Engineenng Systems Private Sewage Consultants STATEMENT For Services Rendered 3-2-a6 76C�- �e . /1L " � -2-7�!--3)-/3 Billing date )Mv•LY l Ito T »� �0 0 5 �6uI . � u LPL Ij-0 Unless otherwise arranged, payments are due in full upon receipt. Interest of 1.5% will be applied monthly on unpaid balance. Liens upon property and home will be placed automatically with county clerk of courts after 30 days. ULBRICHT & ASSOCIATES CO. 655 O'Neil Road • Hudson, WI 54016 715-386-8165 772 -3Z 13 A WIN 5 STATEMENT For Services Rendered 7`a ,D-1 Si ,' sT��►ArRv .r I Reg. Designers of Engineering Systems Private Sewage Consultants Billing date 0(57.30 -ii -? 3- "bleIfouY) - s/sr -. M /&�Of ' s • fq S Pe * S{46C his jx/� -/� cevz, il- 4JI 4Y47 o v�- %l t-S ff C-, 11 30 Unless otherwise arranged, payments are due in full upon receipt. Inta.rest of 1.5� will be applied monthly on unpai halancP---TAens upon property and home will be placed automatically with county clerk of courts after 30 days. M CST 12/18/97 f � Page 0002 Thu Dec 18 14:06:16 1997 rays & ju 4vAv 1068 _fK: re��a",., ;� . -key ��C. Mi-MI-TvR• fly to to es pc. tti��t�ot �$6C �� � $ '_....mrswwff ALIA L swi,�m r1:09 L804 Lton 75a11296&LN L068 0400000 SOOT! PD: 11/12/1997 MFS:04787644 DIN:440287644 FPS MPLS OC71n-QOCiv-0 �" 44 :�F'F17C•� /1 1C•f'F.r fc`, G =�n 53 .• O V — N fD f� Q PD: 11/12/1997 MFS:04787644 DIN:440287644 R Ability Business Co. A e B 9 C Complete Sewer Services (715) 665-2112 (715) 235-16M N7421 80th St. Knapp, WI 54749 Menomonie, WI 54751 ZOO) 70 IX) ae�'fllre� � •. Ifni Signature BY 1 02:05 PM CST 121ze197 Page 0001 Thu Doc 18 14:06: 16 1997 I Uyu attn: ann nq 2 pages 0� iruh',�. Purxp�� C S e o" �01 ec� �c Gt 6wv� �. dt}uc lea cl lv a l' _�tay+h► 1055 ll-mis'. An��i``•,,,EE/wr.f/X.7ir ' ' 420YfT7 L90 0394 6394 LZ $'3bo.00- WkA.i._ /gym Mapww TO�7fONAL BANK 1:09 L804 L471: 75M�1.966LMIn 055 e0000036D W PD: 10/22/1997 WS:02717190 DIN:420117190 iFREt MPL.S 09iO-0000-0 O d, j420117190 10-22-97-n1 _mi • 420117!'90 6394 8394 1. cot 0910.0091-2 XL a, PD: 10/22/1997 WS:02717190 DIN:420117190 Ability Business Co. A • B • C Complete Sewer Services KNAPP, WISCONSIN 54749 MENOMONIE, WISCONSIN 54751 Phone: 665-2112 Phone: 235-1666 - t :. • - - -. I,:ris Balling 3_06 70 th ave Knapp WI °4749 � 9 85•ov b ` Fumptn; or saps t•_ r_snK. -- • - - i DGti Frcrilcs. -- r D fa t E— s 31oo. 0 0 U41�` kmc.k 4"j Kristin M. Selling 3206 70th Ave. Knapp, WI 54749 October 22, 1997 St. Croix County Zoning office 1101 Carmichael Rd. Hudson, WI 54016 RE: WI Fund Grant Program application To Whom It May Concern: Enclosed please find my application for the WI Fund Grant Program for Private Sewage System Replacement. I have attached my most recent income tax return and the application fee. I have also included a copy of the soil test results and site map. The system is being designed by Bob Ulbricht and is scheduled to go through the state approval process on October 30, 1997. Because of the possible short time -frame before we'll risk running into weather -related construction problems, I would greatly appreciate any efforts you could make to process this grant request and do any needed inspections so that construction could begin as soon as possible after the state approval is received. Please feel free to contact me if needed at 715-684-2914 (day) or 715-772-3213 (eve). Thank you for your assistance with this matter!! Sincerely, Kristin M. Belling ` E Departrnem of the Treasury —trite n" Revenw swfce 096 1 �4� U.S. Individual Income Tax Return For the yw Jan. 14)ed. 31. 1996. or other tax year beginning (3) we use 19%, ending Label (See L page 11.) A e E Use the IRS L label. H Otherwise, E please print R or type. E Presidential Election Campaign tSee Dace 11.1 Filing Status 1 2- 3 Check only 4 one box. 5 Exemptions Bo if more than six dependents, see the Instructions for line 6c. RJ 092-56-2304 KRIS7IN M BELLING 3206 70TH AVE KNAPP WI 54749-9000 S09 30 I R S Do you want $3 to go to this fund? . . . . . . . . . . if a loirit return. does Your spouse want $3 to vo to this fund? . . . . . . not write Of stage n "" sdace. .19 1 OMB No. 1545-U( Your social security number Spouse's social secutty number For help finding line Instructions, see pages 2 and 3 in the booklet Yes INo I Note: Checlmg 'Yas' wo not charge your to or reduce yow rotund. Single Married filing joint return (even N only one had income) Married firing separate return. Enter spouse's sold aecutily no. above and full name here. ► Head of household (with qualitying person* (See instructions.) If the qualifying person is a child but not your dependent, enter thin child's name hero. ► - - Qualffying widower) with dependent child (yW spouse died No 19 (See instructions.) Yourself. If your parent (or someone else) can claim you as a dependent on his or her tax No. of boxes return, do not check box 6a . . . . . . . . . . . checked on lines da and 6b Is Spouse Ma of rout . . . . . . . . . . . . . . . . . . . . . . . . c D nm; (1) First name last name (2) 0ewoent's socail security number. If tam in Dec. 1996 sae NaL 131 Depanderd's rdaoonship to YOU (41 No. of mane lend in yam home Is 19% ( 0.urw Chni�i e t : 1 1m_ d Total number of exemptions dawned . . . . . . . . . . . . . . . . . T Wages, salaries, tips, etc. Attach. Form(s) W-2 7 as Income go Taxable interest. Attach Schedule B 0 over $400. . . . . Attach Is Tax-exempt interest. DO NOT include on line Sa . . 18b I I Copy B of your 9 Dividend income. Attach Schedule 8 if over $400 . . . . . . . .. 9 10 Forms W-2, 10 Taxable refunds, credits, or offsets of state and kcal income taxes (see insttucctions) 11 W-213,and 10WR here. 11 Alimony received . . . . . . . . . . . . . . . . . . . . . 12 Business income or poss). Attach Schedule C or C-EZ . . . . . . . . . , 12 13 If you did not get a W-2, 13 Capital gain or (loss). If required, attach Schedule D . . . . . . . . . . . see the 14 gains or (losses). Attach Form 4797 . 14 15b ristrucffons _Other 15e IRA distributions . . 15e b Taxable amount (see Irhst) 18b for line 7. 18e ,Total Total pensions and annuities 188 Is Taxable amount (see inst.) 17 Enclose, but do 17 Rental real estate, royalties, partnerships, S corporations, trusts, ec. Attach Schedule E 18 not sittach, payment q� 18 Farm income or (loss). Attach Schedule F . . . _ . . . . . . ' .' please enclose 19 Unemployment compensation 19 2Db Form 1040-V 20a Social security benefits I 200 1 1 1 b Taxable an otwit (sale inst.) (sue toinstructions 21 Other income. List type and amount --see instructions for line 82). 21 22 Add the amounts in the far right column for lines 7 through 21. This s our total income ► 1 22 Me Yotw IRA deduction (see instructions) . 23a Adjusted b Spouse's IRA deduction (see instrtactlorta) . . . . 23b Gross 24 Moving expenses. Attach Form 3903 or 3903-F . . . 24 Income 25 One-half of self-employment tax Attach Schedule SE 25 28 Self-employed health ihstrance deduction (see inst.) . 28 it line 31 is under $28,495 (under 27 Keogh & self-employed SEP plans. If SEP, check ► ❑ 27 S9,5W if a child 20 Penalty on early withdrawal of savings . . . . . . 26 did not live with 29 AlimonyRecipient's SSN ► Pad. p 29 You), see the instructions for 30 Add lines 23a through 29 . - --` line 54. 31 Subtract line 30 from line 22. This is your ell usted gross income ► 31 For Privacy Ad and Paperwork Reduction Act Notice. 9" page 7. car i4hi. ita2oe - - hildren on line iC Who: i lived with you � did ool live with ,ou due to dlvome v separation see Instructions) Mpendams on 6c at enterad above bed numbers entered on Z Ines above I. 30 (o 2(o L3 '1 W Form 1W (19W cam, loan n95161 Page 2 32 Amount from line 31 (adjusted gross income) . rax . . ' 32 3 1800 13 33a Check if: El You were 65 or older, ❑ Blind,, ❑ Spouse was 65 or older, ❑ Bllinnad. COmpu- Cation Add the number of boxes checked above and enter the total here . . . . No b lt you are married filing separately and your spouse itemizes deductions or ► 33b ❑ you were a dual -status alien, see instructions and check here . . . . . Itemized deductions from Schedule A, line 28. OR 34. Enter Standard deduction shown below for your filing status. But see the the instructions a you checked any box on line 33a or b or someone 34 (0 5 In 8 larger can claim you as a dependent. of a Single-4,000 a Married filing jointly or Qualifying widow(er)— ,700 p a Head of househo5,900 a Married filing separately ,350 Ya1. k1� 2`� I S l { 35 Subtract line 34 from line 32 . . . . . . . .ss, . . . . . . . . 35 If you want 35 if line 32 is $88,475 or lemultiply $2,550 by the total number of exemptions claimed on S t o0 UO the IRS to line 6d. if line 32 is over $88,475. see the worksheet in the inst. for the amount to enter 38 37 19 05 2 0 figure your 37 Taxable income. Subtract lute 36 from line 35. If line 36 is more than line 35, enter -0- m MW tax, see the instructions 38 Tax. See instructions. Check If total includes any tax from a ❑ Form(s) 8814 for line 37. b [I Form 4972 . ► 38 2s�1 00 39 Credit for child and dependent care expenses. Attach Forth 2441 39 Credits 40 Credit for the elderly or the disabled. Attach Schedule R . 40 41 Foreign tax credit. Attach Forth 1116 . . . . 41 42 Other. Check if from a ❑ Form 38M b El Form 8396 IMM c ❑ Form 8801 d ❑ Form (specrM 42 43 Add lines 39 through 42 4/ 2-8to1 00 44 Subtract line 43 from line 38. If line 43 is more than line 38, enter -0- , ► 45 Setf-employment tax. Attach Schedule SE . . . . . . . . ... . . Other 45 Taxes � Alternative minimum tax. Attach Farm 6251 46 47 Social security and Medicare tax on tip income not reported to employer. Attach Form 4137 47 48 Tax on qualified retirement per. including IRAs. If required, attach Forth 5329 . . . . 48 49 Advance earned income credit payments from Forms) W-2 . . . . . . . . . 50 Household employment taxes. Attach Schedule H. . . . . . . . . . . . . S1 Z fC I O 51 Add limes 44 through 50. This is your total tax , . ► 52 Federal income tax withheld from Forms W-2 and 1099 . , Payments 52 o Z10 53 53 1996 estimated tax payments and amoa,t applied from 1995 retu n . 54 Eer. Income credit. Attach Schedule EIC if you have a qua" - child. Nontaxable earned income: amount ► 1 1 I Attach and type ►........................................ 54 55 Forms W-2, 55 Amount paid with Forth 4868 (request for extension) n 56 Excess social security and RRTA tax withheld (see inst.) . 56 57 099-R the front. 57 Other par"Ifif s. Check if from a ❑ Forth 2439 b ❑ Form 4136 ► S8 58 Add lines 52 through 57. These are your total payments 301io 2.4; Refund 59 If line 58 is more hart line 51, subtract line 51 from line 58. This is the amount you OVERPAID so 2.1 S L to eon Amount of line 59 you warn REFUNDED TO YOU. . . . . . . . . . . ► 80s 2.1 S' 2-fa Have it sent directlyto b Routing number c Type: ❑ Checking ❑ Savings account! See ► d Account number inst. and fill in 60b, c, and d. 61 Amount of line 59 you want APPUED TO YOUR 1297 ESTIMATED TAX ► 61 Amount e2 ff line 51 is more than line 58, subtract line 58 from line 51. This is the AMOUNT YOU OWE. v_.. n..._ •- For details on how to pay and use Form 1040-V, see instnictions . . . . . . ► 62 r uts Una 63 Estimated tax penalty. Also include on line 62 1 63 1 1 pgm, 00\\\\\\\\\\\\\\\\\\\\\N Under penalties of perjury, I declare that I have examined this ratum and accornpsilyiN acheduba and statements, and to the test of my knowledge and Sign baaef, VM are true. correct, and complete. Decteratlon of prewar lather than taxpayer) is based on all inromnadon of which preparer has arry krawterlp. Here , for Your erg re Date Your occupation Keep a copy �-5- Il)I Lct (iFe. 6l0 IXl his return , for your 's signature. I1 a Idm return, BOTM.Zliusl ago. Date Spouse's occupation records. Paid Tate Check if Preparers social secunty no. ygnature seM-employed ❑ Preparer's Firn's nanre (or yoEIN Use Onlyand ur, ZIP code SCHEDULES A&B (For1n 1040) Schedule A —Itemized Deductions (Schedule B Is on back) Dpwure t of ra Trasay I upw Pawns serserviceA Nart*s) shown on Fonn 1044) Medical and 1 Dental 2 Expenses 3 Taxes You 5 Paid 8 (See 7 page A-1.) 8 9 Interest 10 You Paid 11 (see page A-2.) Note: Personal 12 interest is not deductible. 13 14 Gifts to 15 Charity B you made a 16 gift and got a berteet fOri4 17 see page A-3. 1e Theft Losses 19 Jab Expenses 20 and Most Other Miscellaneous Deductions 21 (See 22 page A4 for expertm to deduct here.) 23 24 25 ► Attach to Form 1040 No See Instructions for Schedules A and B (Form -Be\k Caution: Do not include expenses reimbursed or paid by others. Medical and dental expenses (see page A-1) . . Enter amount from Form 1040, line 32. 1 2 1 1 Multiply line 2 above by 7.5% (.075) . . . . . . . Subtract line 3 from line 1. If line 3 is more than line 1, a State and local income taxes . . . . . . . . . Real estate taxes (see page A-2) . . . . . . . . Personal property taxes . . . . . . . . Other taxes. List type and amount ►... Add lines 5 through 8 . Home mortgage interest and points reported to you on Form 1098 Hone mortgage interest not reported to you on Forth 1098. If paid to the person from whom you bought the home, see page A-2 and show that person,5 narm identifying no., and address ► ................................................................ ................................................................ ................................................................ Points not reported to you on Form 1098. See page A-3 for special rules . . . . . . . . . . . . . . investment interest. If required, attach Form 4952. (See page A-3.) . . . . . . . . . . . . . . . Add lines 10 through 13 . Gifts by cash or check. If you made any gift of $250 or more, see page A-3 . . . . . . . . . . . . Other than by cash or check. If any gift of $250 or more, see page A-3. If over $500, you MUST attach Form 8283 Carryover from prior year . . . . . . . . . . Add lines 15 through 17 . Other 27 Miscellaneous Deductions Total 28 Itemized Deductions or theft loss(es). Attach Form 4684. Unreimbursed employee expenses -yob travel, union dues, job education, etc. If required, you MUST attach Form 2106 or 2106-E7. (See page A-4.) ► .............. ----------------------------------------- •-----................. •............................................................... Tax preparation fees . . . . . . . . . . . . Other expenses—+nvestment, safe deposit box, etc. List type and amount * ----------------------------------------- .................................. 23 Add lines 20 through 22 . . Enter amount from Form 1040, line 32. 1 24 1 I 25 Multiply line 24 above by 2% (.02) . . . . . . Subtract line 25 from line 23. If line 25 is more than line 23, enter -0- Other—from list on page A-4. List type and amount ► ....... ........................................................................ E Is Form 1040, line 32, over $117,950 (over $68,975 if married filing separately)? No. Your deduction is not limited. Add the amounts in the far right column for lines 4 through 27. Also, enter on Form 104o, line 34, the larger of ► this amount or your standard deduction. YES. Your deduction may be limited. See page A-5 for the amount to enter. For Paperwork Reduction Act Notice, a" Form 1040 kWbuctl*M cat No. 1133OX OMB No. 1545-W74 �g96 AhnWVt se No. 07 � 200 100 �t� s'1 lvs Schedule A (Form 1040 1995 Schedules AQB (Farm 1040) 19% -•-, —Pp . ' ...1„ P,, - w ,"n e w name ant) soael security number it shown on other side. Part I Interest Income (See page B-1.) Note: If you received a Forth 1099-INT, Form 1099-0I1),or substitute statement from a brokerage firm, list the firm's dame as tree payer and enter the total interest shown on that form. Part II Dividend Income (See page B-1.) Note•. If you received a Form 1099-DIV or substitute statement from a brokerage firm, list the firm's dame as the payer and enter the total dividends shown on that form. Part III Foreign Schedule B—Interest and Dividend Income Note•, If you had over $400 in taxable interest income you must also complete Part Ill 1 List name of payer. If any interest is from a seller -financed mortgage and the buyer used the property as a personal residence, see page B-1 and list this interest first. Also, show that buyer's social security number and address ► ....................•-•--........................._........--•--....._......... ........................................................................•--•._... ............................•-••--•--.............._...._.................. ................................. .......................................................... .----•.................................................................. ...................................................................•-----... ............................................................. .. . ................. ........................................................................... .................................................................................. .......................................... ................................................. ............................................................................... ................................................................................. ..................................................................................... ------------------- ------------- -------------•-- 2 Add the amounts on line 1 3 Excludable interest on series EE U.S. savings bonds issued after 1989 from Form 8815, line 14. You MUST attach Form 8815 to Form 1040 4 Subtract line 3 from line 2. Enter the result here and on Form 1040 line 8a ► 4 Note: If you had over $400 in gross dividends and/or other distributions on stock, ou must also 5 List name of payer. Include gross dividends and/or other distributi7deduct2d here. Any capital gain distributions and nontaxable distributions willon lines 7 and 8 ►----••----- M..�n>fSJtYt�!-f'/'�fn?:Ge. Edsucr4...�1:.7srs. E.. ........................................... .._..........t1L�0. 1!14?A 4..r_ )1� t7?�4.t _(.,. ............................ .........................................................•--._........_.__.....-- ......-----•...........................•---..._.......-----•--......._......... .........---•..........................................................•-.........--•• .................................................................•••••.. ..............................................................•--....--•---....... ............................................................................................ ..............•---................---....._.._....._.....-•--••-•--....._........... ..---•--------------•--..............................._.._......._.._....-•----..........--- ....................................................... 6 Add the amounts on line 5 . . 7 Capital gain distributions. Enter here and on Schedule D' . 7 2 b8 8 Nontaxable distributions. (See the inst. for Form 1040, line 9.) 8 9 Add lines 7 and 8 . . . . . 10 Subtract line 9 from line 6. Enter the result here and on Form 1040, line 9 ► 1 Vt you do not need Schedule D to report any other gains or losses, see the instructions for Form 1040, line 13. You must com let- i th- f OMB No. 1W-0074 Page 2 ="r AftaChment sevuence No. 08 Amount 5 1 P Part Iff. mount a is p Is part you (a) had over 3400 of interest or dividends; (b) had a foreign account, or (c) received a distribution from, or were a grantor of, or a transferor to, a foreign trust. I Yes I No Accounts 11 a At anandy time during 1996, did you have an interest in or a signature or other authority over a financial Trusts ru account in a foreign country, such as a bank account, securities account, or other financial Taccount? See page B-1 for exceptions and filing requirements for Form TD F 90-22.1 (See b If "Yes," enter the name of the foreign country ►-...__, . page B-1.) 12 During 1996, did you receive a distribution from, or were you the grantor of, or transferor to, a foreign trust? If "Yes," see page B-2 for other forms you may have to file For Paperwork Reduction Act Notice. see Fam tnAn 1.,.►.....r .." Schedule B (Form 1040) 1900 SCHEDULE E (Form 1040) Depw3 fte,y w"w pm of the Trwexy yrqM,,,n eay..+r P Supplemental Income and Loss (From rental real estate, royalties, partnerships, corporations, estates, trusts, REMICs, etc.) 10 Attach to Form 1040 M Fenn 1041. ow See Instructions for Schedule E (Form 1040). OMB No. 1545-0074 1'@(J"96 Attwhn nt Ssqusnce No. 13 NW*S) Onown on return Your soolei suarmy number Y' /A. • Income or Loss From Rental Real Estate and Royalties Note: Report income and expenses from your businew of renting personal property on Schedule C or C-EZ (see page E- 1). Report farm rental income or loss from Form 4835 on page 2, line 39. 1 Show the kind and location of each rental real estate property: 2 For each rental real estate property listed on line 1, did you or your family use it for personal purposes for more than the A Yes I No A ..r�vA mem, ybr - .............................. b -1`{ B ........................................••••-................................... greater of 14 days or 10% of the total days rented at fair rental B value during the tax year? (See page E-1.) c C Properties Totals Income: (Add ookirnm A. B. and C.) A 0 C 3 4 Rents received. . . . . Royalties received 3 4 520 3 520 00 4 Expenses: 5 Advertising . . . . . 5 6 7 Auto and travel (see page E-2) Cleaning and maintenance. . . 6 7 8 9 Commissions . . . . Insurance . . . . . 6 9 10 10 Legal and other professional fees 11 Management fees. . . 11 12 Mortgage interest paid to banks, etc. (see page E-2) . . . . 12 22- 52. 12 122 J8Z 13 14 15 16 Other interest . . . . . . , Repairs . . . . . Supplies . . . . . . Taxes . . . . . . . 13 14 15 16 1 '1 oto 17 Utilities . . . . . 17 18 Other ( R....................... ....................................... ------------------------------------- 18 19 Add lines 5 through 18 . . . . 19 t5 20 Depreciation expense or depletion 9 B (see page E-2) . . 21 Total expenses. Add lines 19 and 20 21 1 39 to b 22 Income or (loss) from rental real estate or royalty properties. Subtract line 21 from line 3 (rents) or line 4 (royalties). If the result is a (loss), see page E-2 to find out 12-2) 31 H you must file Form 6198. 22 23 Deductible rental real estate loss. Caution: Your rental real estate loss on line 22 may be limited. See page E-3 to find out if you must file Form 8582 Real estate professionals must complete line ( ) ( ) 42 on page 2 . . . . . . 24 Income. Add positive amounts shown on line 22. Do not include any losses . . . . . . . . 25 Losses. Add royalty losses from line 22 and rental real estate losses from line 23. Enter the total losses here . 26 Total rental real estate and royalty income or (loss). Combine lines 24 and 25. Enter the result here. If Parts II, III. IV, and line 39 on page 2 do not apply to you, also enter this amount on Form 1040, line 17 Otherwise include this amount in the total on line 40 on page 2 0 2z MillillM For Paperwork Reduction Act Notice, see Form 1040 instructions. Cat. No. 11344L Schedule E (Form 10401 19M Schedule E (Form 1040) 1996 Attachment Sequence No. 13 Page 2 Name(s) shown on return. Do not enter name and social security number if shown on other side. I Your social securffy numbar Note: If you report amounts from farming or fishing on Schedule E, you must enter your gross income from those activities on line 41 below. Real estate professionals must complete line 42 below. Income or Loss From Partnerships and S Corporations Note: If you report a loss from an at-nsk activity, you MUST check either column (a) or (1) of line 27 to describe your investment in the activity. See page E-4. If you check column fQ, you must attach Forth 619d 27 a) Name (b) Enter P for partnership; S for s corporation (c) Check if foreign partnership (d) Employer identification number Investment At km—? (a) All is (n " w is at nsk not at risk A r Chun r ta,16 E lobs T 31 - 12-(o 9 (o a.-7 B C D E Passive Income and Loss Nonpassive Income and Loss (9) Passive loss allowed (attach Form 8582 if required) (h) Passrve income from Schedule K-1 m Nonpassive loss from Srhedu a K-1 (Q Section 179 expense horn Foorthrm4562 deduction �) Nonpassive income from Schedule K-1 20 00 B D 28a Totals LEN MEMO b Totals 2-0 d0XN 29 Add columns (h) and (k) of line 28a . . . . . . . . . . . . . . . 30 Add columns (g), n, and G) of line 28b . . . . . . . . . . . . . . . 31 Total partnership and S corporation income or (loss). Combine lines 29 and 30. Enter the result here and include in the total on line 40 below . 29 30 ( ?-Dq 0 0 ) 31 ZOq Oo Income or Loss From Estates and Trusts 32 (a) Name (b) Employer identification number A Passive Income and Loss Nonpassive Income and Loss (c) Passive deduction or loss allowed (attach Form 8582 if required) (d) Passive income from Schedule K-1 (a) Deduction or loss from Schedule K-1 M Other incorne from Schedule K-1 A B Me Totals to Totals 34 35 36 Add columns (d) and (f) of line 33a . . . . . . . . . . . . . . . . . . . . . Add columns (c) and (e) of line 33b . . . . . . . . . .. . . . . . . . . . . . Total estate and trust income or poss). Combine lines 34 and 35. Enter the result here and include in the total on tine 40 below . 34 35 ( ) 36 Income or Loss From Real Estate Mortgage Investment Conduits (REMICs)—Residual Holder 37 (al Name (h) Fnoby (c) Excess inclusion from Schadules O, line 2c (see (a income ( net loss) (e) lnwffw from schedules 0. identification nu number E-4 page38 c Schedules Q, line 1 b from Sett line 3b Combine columns (d) and (e) only. Enter the result here and include in the total on line 40 below 38 39 Net farm rental income or (loss) from Form 4835. Also, complete line 41 below . . . . . . 40 TOTAL income or (loss). Combine lines 26, 31, 36, 38, and 39. Enter the result here and on Form 1040, line 17 ► 41 Reconciliation of Farming and Fishing Income. Enter your gross farming and fishing income reported on Form 4835, line 7; Schedule K-1 (Form 1065), line 15b; Schedule K-1 (Form 1120S), line 23; and Schedule K-1 (Form 1041), line 13 (see page E-4) , . . 41 42 Reconciliation for Real Estate Professionals. If you were a real estate professional (see page E-3), enter the net income or (loss) you reported anywhere on Form 1040 from all rental real estate activities in which You materially participated under the passive activity loss rules. . . 42 ronr 4797 Sales of Business Property OMB Na 1545-0164 (Also Involuntary Conversions and Recapture Amounts �i 96 Under Sections 179 and 28OF(b)(2)) 04OW marl of trr Treeway ►Attach to Attachment hmtane Adam serve (%� your tax return. ► See separate Instructions. Sequence No. 27 Namep) shown on reuan IderiftAng numiser 1 Enter We the gross proceeds from tR64010 or exchange of real estate reported to you for 1996 on Form(s) 1 v (or a substitute statement) that you will be Including on line 2. 11. or 22 1 Sales or Exchanges of Property Used in a Trade or Business and Involuntary Conversions From other Than Casualty or Theft —Property Held More Than 1 Year (a) Oescnptwn of proPary (b) Date acquired (mo, day. yr.) (c) Date sold (ma, day. yr.) (d) Gross sale price (•) Oeoreclatlon atbwed or aikwrabie since acquusrtlon m cast a user basis, plug improvements and experme of 3" (d LOSS e r more than (d) � (�' subtract rile wen at (dl and from M 01) W ( a Idl plug W b more Isrn (Q, subeeu (Q from the am of d) and (a) 2 r 3 3 4 s 6 7 8 9 10 Gain, if arty. from Form 4684, One 39 . . . . . . . . . . . . . . . . . . 3 Section 1231 gun from installment sales from Form 6252, line 26 or 37 . . , . . 4 Section 1231 gain or (loss) from Ok"rid exchanges from Form 8824 . . . , , , . , 5 Gain, if any. from One 34, from other than casualty or theft . . . . . . . . . . . e Add Ines 2 through 6 in columns (g) and (h) . . . . . . . . . . . . 7 ( ) Combine columns (g) and (h) of line 7. Fetter gain or (lose) here, and on the appropriate line as follows: . 8 Partnerships —Enter the gain or Qoss) on Forth 1065, Schedule K. line S. Skip Imes 9, 10, 12, and 13 below. S corporatdona—Report the gain or (loss) following the instructions for Forth 1120S, Schedule K, lines 5 and S. Skip lines 9, 10, 12, and 13 below, unless line 8 is a gain and the S corporation is subject to the capital gains tax. All others-4 line 8 is zero or a loss, enter the amount on One 12 below and skip Ones 9 and 10. If line 8 is a gain and you did not have any prior year section 1231 losses, or they were recaptured in an earlier year. enter the gain as a long-term capital gain on Schedule D and skip lines 9, 10, and 13 below. Nonnscaptured net section 1231 losses from prior years (see instructions) . . . . . . . . . 9 Subtract line 9 from line 8. If zero or less, enter -0-. Also enter on the aooroonate line as follows (see instructional: 10 3 S corporations —Enter this amount on Schedule D (Form 1120SL One 13, and skip lines 12 and 13 below. All others —If line 10 is zero, enter the amount from line 8 on line 13 below. If Ins 10 is more than zero, enter the amount from One 9 on line 13 below, and enter the amount from line 10 as a long-term capital gain on Schedule 0. LOM Ordinary Gains and Losses 11 Ordinary gains and losses not included on lines 12 thhrough 18 (Include property held 1 year or less): 12 13 14 15 16 17 18 19 20 a b loss, If any. from line 8 . . . . . . . . . . . . . . . . . . . 12 3 Gain. 6 any, from line 8, or amount from line 9 if applicable . . . . . . . . . . . 13 Gain, if any, from line 33 . . . . . . . . . . . . . . . . . . . . . 14 Net gain or (loss) from Form 4684, Ones 31 and 388 . . . . . . . . . . . . . 1s Ordinary gain from installment sales from Forth 625Z Ilse 25 or 36 . . . . . . . . , 18 Ordinary gain or possi from like -kind exchanges from Forth 8824 . . . . . . . 17 Recapture of section 179 expense deduction for partners and S corporation shareholders from property dispositions by partnerships and S corporations (see instructions) . . . . . 18 Add Ines 11 through 18 in columns (g) and (h) . . . . . . . . . . . . . . 19 Combine columns (g) and (h) of line 19. Enter gain or poss) here, and on the appropriate line as follows: 20 For all except individual retums: Enter the gain or pose) from line 20 on the return being filed. For individual returns: (1) If the lose on line 12 includes a loss from Forth 4684, line 35. column (b)pij, enter that part of the loss here and on line 22 of Schedule A (Form 1040). Identify as from 'Forth 4797, One 20b(1).' See Instructions . . (2) Redetermine the gm or (loss) on line 20, acluding the kxm 0 any, on line 20b(1). Enter here and on Forth 1040. line 14 . I i 1 p1p For Paperwork Reduction Act Notice, see page 1 of separate instructions. Cat. Na 130M Form 4797 (1996) 357 Form 4797(1996) Page 2 t— Gain From Disposition of Property Under Sections 1245, 1250, 125Z 1254, and 1255 21 (a) Description of section 1245. 1250. 1252, 1254. or 1255 property: (bl Date ay. yr.) Imo.. day. yr.l old Id Data . yr. Imo.. daY, K.) A G -10- 2_ 2- e C D Relate lines 21A through 21D to these columns ► Property A Property B Property C Property D 22 Gross sales once (Note: See line 1 before completing.) 23 Cost or other basis plus expense of sale . . . . . . 24 Depreciation (or depletion) allowed or allowable . . . 25 Adjusted basis. Subtract line 24 from line 23 . 26 Total gain. Subtract line 25 from line 22 22 83`{ 57- 23 2.6 24 25 26 :'%�(•3% 27 If section 1245 property. a Depreciation allowed or allowable from line 24 . . . . b Enter the smaller of line 26 or 27a . 27a 27b 1 Z 28 If section 1250 property. If straight line depreciation was used, enter -0- on lone 28% except for a corporation subject to section 291. a Additional depreciation after 1975 (see instructions) . . . b Applicable percentage multiplied by the smaller of line 26 or One 28a (see instructions) . . . . . . . . . c Subtract line 28a from line 26. If residential rental property or line 26 is not more than line 2Ba, skip lines 28d and 28e d Additional depreciation after 1969 and before 1976 . . . a Enter the smaller of line 28c or 28d . . . . . . . f Section 291 amount (corporations only) . . . . . . g Add Imes 28b, 28e, and 28f . SBa 28b 28c 28d 28e 28f 29 If section 1252 property: Skip this section if you did not dispose of farmland or 6 this torn is bang completed for a partriershtp. a Soil, water, and land clearing expenses b Urfa 29a multiplied by applicable percentage (see instructions) d Enter the smaller of line 26 or 29b . 298 29b 29c 30 tf section 1254 property: a Intangible dnlling and development costs, expenditures for development of mines and other natural deposits, and mining exploration costs (see instructions) . . . . . b Enter the smaller of line 26 or 30a . 30a 30b 31 H section 1255 property: a Applicable percentage of payments excluded from income under section 126 (see instructions) . . . . . . b Enter the smaller of line 26 or 31a Isee instructions) 31a 31 b Summary of Part III Gains. Complete property columns A through D through line 31 b before going to line 32. 32 Total gams for all properties. Add properly columns A through D, line 26 . . . . . . . . . . . . 33 Add property columns A through D, lines 27b. 28g, 29c. 30b. and 31b. Enter here and on line 14 , • . . 33 34 Subtract One 33 from line 32. Enter the portion from casualty or theft on Form 4684, line 33. Enter the portion from other than casualty or theft on Forth 4797, line 6 34 LiEM Recapture Amounts Under Sections 179 and 280Fib)(2) When Business Use Drops to 50% or Less See instructions. (a) Section (b) Section 179 280F(b)(2) 35 Section 179 expense deduction or depreciation allowable in prior years . . . . . . . . 36 Recomputed depreciation. See instructions . . . . . . . . . . . . . . . . 37 Recapture amount. Subtract line 36 from line 35. See the instructions for where to reoorl , , 10�M R Wisconsin income tax Forahe year Jars. 1 - Da- 31. 19N, or other tax year beginning V 19"ending .19J96 Z 4 po 8 r s 4 4 Your lastru MOOR L *****ECRLOT**R001 392-56-2304-7 itaontrat BELLING KRISTIN M Ho; add' 3206 70TH AVE TSPRSCR KNAPP NI 54749-9000 City or pool tr you went S1 toga to the State I7ation ' ® You Campaign Fund check box(es). 71 Your Filing lt"A (dwdr only am b* Single 'number QUICK REFUND i Do you Quality (see page 4)? If so, fill in the number amount from line 30 less arty amount on line 32. I affix your label, and mail your return to: Quick Retund, P.O. Box 38, Madison, WI 53787-Ml. Cheddng the box(es) will not charge your tax or refund. School dhMd number (iss pogo 26) Married filing Joint remm (even it only oM had income) I 9•'•1 Mamted filing separate return. FlII in spouse's full name and social security number IXI Head of household (weft Qualifying person). FIN in qualifying paadn's name ( proper box and N in roM of city, vlhge, or and the county in which you Ilved at the and of ❑ city Of vinage 01 ® Town of it a County of 5! n: x 1 Federal adjusted gross income (see page 5) ......... ... ......... «..«_.««»..».....»»..«.......».........__»»_»«.»..«....«_.»..... 1 3l 8o 9 • to 2 Additions. Complete Schedule 1 on reverse side .................. _..«.....»»....... 2 3 4 Add lines 1 and 2......................................................................................................»................................_....._..... Subtractions (state income tax refunds. etc.). Complete Schedule 2 on reverse side.«»».....—._^_....•..««.»..._._».. 3 4 2s1 . B 5 31551 . c'j 5 6 Subtract line 4 from line 3. This is your Wisconsin income ...................... »..«_ _.— -» ............. •........ Tax (Caution: Please read page 11 of instructions.) Check If from Tax Table or ❑ SPedel Tax Wpksheet ... 6 l eri S . co 7 Dependent credit RII in number of dependents (do not count yourself or spouse) .. I x $50 ■ 7 so ' o0 8 Senior citizen credit (see page 11)..................................................................._»_»...........^_.. 8 9 3b • 07 9 Wisconsin itemized deduction credit. Complete Schedule 3 on reverse side.__- .... ..... :».. 10 School a. Rent paid in 1996-neat included ........ Fsnil taetfih from property Rent paid in 1996-heat not included..' OCIe. page 13. D 10a 2!S (4"1. OS Rid me hem bfbU, Nape 13._ _ 10b 2.00 . o o tax credit b. Property taxes paid on home in 1998 D 11 11 Add lines 7 through 10b....................................... ...............................»....«»«.........»»_...._...».«................................ 12 ITS' S 12 Subtract line 11 from line 6. If line 11 is larger than line 6, fill In-0. ....................... »_.._... ». »»».. 13 Alternative minimum tax. Attach Schedule MT .................. »»»___.....».:....»» .» 13 14 Add lines 12 and 13 «^_... ... ' 14 75 15 Married couple credit Complete Schedule 4 on reverse side »_»»».........»_..._.....»...»....» ..»_. »..».«..»«....._ 78 155 S 16 Subtract line 15 tram line 14. If line 15 is larger than line 14. N In -0•. This Is your net fax •»»» » » •••-••••»»•••••»»»• 17 Temporary recycling surcharge (seepage 14). ❑ Check if surcharge Computed On wOfkaheet If worksheet riot used, fill in nonfarm net business income ..................... x •004345 w 17 18 Sales and use tax due on out-of-state purchases (see page 16)......... ........... .................... ................. »». Is »»»• j 18 19 Endangered Resources Donation (decreases refund or increases annou nt owed) • »••••••••••••««_^••••-•»• 20 Penalties on retirement plans (see page 16)..........................................................------- x •33 - 20 SS S 21 Add lines 18 through 20................................................................................«.........___.._«...»»..»»........._... 21 .93 » «»» .03 22 1 V 1 22 Wisconsin income tax withheld. Attach readable wilhholding statements .»:.»» «. _..»_ « » 23 1996 estimated tax payments and amount applied from 1995 return ..... «... »»» —^».—» 23 24 Famed income credit Qualifying children_ Federal croM x 24 25 Farmland preservation credit Attach Schedule FC ........... »». «» .---» »-•»»»»^•••••- 26 Net Income tax paid to other states (seepage 17) .......„_..».«__.....__..»».......«..__..._... 26 H_.._. 27 Flomestead credit Attach Schedule ......................................... »«..... _.... ..................... 28 Farmland tax relief credit ........... Property taxes on famnland x .10 . 28 l'1 l01 0 3 29 30 Add lines 22 through 28........ ...................................................... _.... _................................... »................................... If line 29 is larger than line 21. subtract line 21 from lime 29.................. This Is the AMOUNT OF YOUR REFUND 29 30 20 Z I O 31 If line 29 Is smaller than line 21, subtract line 29 from One 21. This Is the AMOUNT YOU OWE ..... ««....... _...... ....... 31. 32 Amount of line 30 to be applied to your 1997 estimated tax ................................................... 32 Sign here Underrn penalties c«ne•w�thatnall attanmhLaw, true, complete to the best of my W Wledge and beget. 0 2 May retum to address shown on Attach a copy of your lradaral /neoma tax return and schedules to this return Schedule 1 — Additions to Income Schedule 2 — Subtractions from Income (See page 6) (See page 7) item Amount Item Amount State and municipal bond interest .................. State income tax refunds from line 10. federal Capital gainAoss adjustment (see page 10) ... ► Form 1040................................................... Other (list) United States government Interest ................. Unemployment compensation (see page 7) ... Capital gairvloss adjustment (see page 10)..... 0 ZS 1 .,at Disability income exclusion (attach Schedule 244OW)........................................................ Other (list) Total additions (till in here and on line 2 on Total subtractions (fill in here and on line 4 on reverse side) ......................................... reverse side) ............................................... Schedule 3 — Wisconsin Itemized Deduction Credit 1 Medical and dental expenses from line 4, federal Schedule A. See instructions for exceptions .................................... EE 2 Interest paid from line 14, federal Schedule A. Do rat include interest paid on a second home located outside Wisconsin or on a residence which is a boat. Also, do not include interest paid to purchase or holdU.S. government securities..................................................................................................................................... 3 Gifts to charity from line 18, federal Schedule A. See instructions for exceptions......................................................... © I'Lo0 .00 4 Job expenses and miscellaneous deductions from line 26, federal Schedule A. See instructions for exceptions ......... 5 Other miscellaneous deductions from line 27, federal Schedule A. See instructions for exceptions ............................. 50 6 Add lines 1 through 5...................................................................................................................................................... © -Boll . 4 1 7 Using Wisconsin income from line 5 on reverse side, find your standard deduction from table on page 27. (if Special Tax Workshest on page 11 used, fill in the standard deduction from line 4 of that worksheet.) .................... 7 2Z90. 00 8 Subtract line 7 from line 6. If line 7 is more than line 6, fill in -0-..................................................................................... 8 -I ZI . iA 1 9 Rate of credit is .05 (5%)................................................................................................................................................ 9 X .05 10 Multiply line 8 by line 9. Fill in here and on line 9 on reverse side.................................................................................. 10 3 (o , 21 Schedule 4 — Married Couple Credit When Both Spouses Are Employed (When completing this schedule, be sure to fill in your income in column (A) and your spouse's income in column (B)) (A) YOURSELF (B) YOUR SPOUSE 1 Taxable wages, salaries, tips, and other employe compensation. Do NOT enter interest, dividends, pensions, unemployment compensation, or other unearned income ............... 01 2 Net profit or loss from self-employment from federal Schedules C. C-FZ, and F (Form 1040), Schedule K-t (Form 1065), and any other taxable self-employment orearned income............................................................................................................... 3 Combine lines 1 and 2. This Is earned income.................................................................. 3 4 Add amounts from your federal Form 1040, Imes 23a, 23b, and 27, plus repayment of supplemental unemployment benefits, employe expenses of qualified performing artists and contributions to Section 501(c)(18) pension plans included in line 30, and any Wisconsin disability income exclusion. Fill in the total of these adjustrnents that apply toyour or your spouse's Income........................................................................................ 5 Subtract line 4 from line 3. This is qualified earned income. If less than zero, fill in -0- .... 5 6 Compare the amount In columns (A) and (S) of line 5. Fill In the smaller amount here. Ifmore than $15,000, fill in $IS,000............................................................................................................. 6 7 Rate of credit Is .02 (2%).............................................................................................................................. 7 X .02 8 Multiply line 6 by line 7. Fill In here and on lice 15 on reverse side. Do not fill in more than $300 ............... 8 WHERE Mall your return to: Wisconsin Department of Revenue TO If tax due .............._........_.......... P.O. Box 2aa. Madleon, WI 537ed•0001 If hameelead uWN elakned..................................... P.O. Box 31, 7, Made. n. '3 5370 -8 • FILE If refund or no tax due .............. P.O. Box Sa, Mad4on, N 537a3-ti0o1 If Schedule FC anaened...._........_......___._..._..... P.O. Box aa27, Mad4on, Nn 5370a•aYl7 If quick refund claimed ............. See 'QUICK REFUND' on frond of fam CAPITAL GAINS AND LOSSES SCHEDULE '1 9 9 6 . Attach to your Wisconsin income tax return W D Wisconsin Department of Revenue fusma(a) shown on Form 1 or rrn INP ,.0.: .A ; . - our social aecurr mrrroer 1'(&k XW Short -Term Capital Gains and Losses —Assets Held One Year or Less (a) DaO"� . (E><BmpN, tog stursa (b) Date acquired •, (mro.,day, yG) (c) Date sold (mo., day, yr.) (d) Saba price a (1 Cost or other basis (n l If (a) is more than (d), MA*W (d) from (a) (91 N . M (d) is more Oran (e). a ftset (a) from (d) 2 Short -tens gain from Forms 2119 and 6252, and short -tens gain or loss from Forms4684, 6781, and 8824................................................................................. 2 3 Net short-term gain or loss from partnerships, S corporations, estates, and tnists from Schedule(s). K-1.:.:...::.......................................................................... 3 4 Adjustment to capital gain or loss for differences between Wisconsin and federal basis of assets (see instructions)........................................................ 4 5 Short-term capital loss carryover from 1995 Wisconsin Schedule WD, 6 Add lines 1 through 5, in columns (f) and (g).......................................................... 6 7 Net short-term capital gain or (loss). Combine columns (f) and (g) of line 6............................... ( ) :........ ..... 7 JUSUW Long -Term Capital Gains and Losses —Assets Held More Than One Year 8 9, 10 11 12 13 14 15 Gain from Forth 4797; long-term gain from Forms 2119, 2439, and 6252; and long-term gain or loss from Forms 4684, 6781, and 8824.._......................... Net long-term gain or loss from partnerships, S corporations, estates, and trusts from Schedule(s) K-1................................................................................. Capital gain distributions ............................................... _. ......... ........................... Adjustment to capital gain or loss for differences between Wisconsin and federal basis of assets (see instructions)............................................................. Long-term capital loss carryover from 1995 Wisconsin Schedule WD, line 31 .... Add lines 8 through 13, in columns (f) and (g)...................................................... Net long-term capital Gain or flossl. Combine cnlumn_c if) and IM of lino 1d 9 10 11 12 13 14 1 (. )942.1 6er 16 4 Zq I To e ,A, t-070 NOW GO TO THE BACK OF THE FORM -0 Schedule WD 1996 Nwee(e) fhUM on Fwm 1 or Form 1NPR (Do rat ea in ALMS er1O SOCW sKuhry menbw a shown on abler saa) .� YvA b*i , /A . Se.11i" Page 2 16 Combine lines 7 and 15, and flit in the net gain or (loss) here.............................................................16 Note:' It fine 16 is a loss; skip lines 17 through 19 and complete line 20. If line 16 is a gain, complete lines 17 through 19 and skip line 20. 17 If line 16 shows a gain, fill in the smaller of line 15 or line 16. Zq 10P Fill in -0- if there is a loss or no entry on line 15.......................................... 17 18 Fill in 60% of line 17............................................................................................................................ 18 19 Subtract line 18 from line 16.................. _........................................................................................... 19 Note: If you are riling Wisconsin Form 1, complete Part IV. If you are filing Form 1NPR, fill in the amount from line 19, Schedule WD, on line 7, column B of Form INPR. 20 If line 16 shows a loss, fill in the smaller of: a The loss on line 16, b $500, or c Wisconsin ordinary income (see instructions)................................................................................ 20 Note: When figuring whether 20a, 20b, or 20c is smaller, treat all numbers as if they are positive. If you are riling Wisconsin Form 1, complete Part IV. If you are filing Form 1NPR, • fill in the amount from line 20, Schedule WD, on line 7, column B of Form 1 NPR. Computation of Wisconsin Adjustment to Income (Do not complete this part it you are filing on Form 11 21 Adjustment (see instructions for Part IV) a Fill in gain from federal Form 1040, line 13 �9 6b 21a (If a loss, fill in -0-)................................................................................. 21 b b Fill in gain from Wisconsin Schedule WD, line 19 (If blank, fill in-0-).................................................................................. c If line 21 b is more than line 21 a, subtract line 21 a from line 21 b. Fill in result here and on Schedule 1 of Form 1........................................................................... 21c d If line 21b is less than line 21 a, subtract line 21b from line 21 a, Fill in result here and on Schedule 2 of Form 1........................................................................... 21d e Fill in loss from federal Form 1040, line 13 as a positive amount (If a gain, fill in -0-)................................................................................ 21e f Fill in loss from Wisconsin Schedule WD, line 20 as a positive amount (If blank. fill in-0-)................................................................................... 21f g If line 21f is more than line 21e, subtract line 21e from line 21f. Fill in result here and on Schedule 2 of Form 1 as a positive amount ......................................... 219 h If line 21f is less than line 21e, subtract line 21f from line 21e. Fill in result here and on Schedule 1 of Form 1 as a positive amount ......................................... 21 h ZS'11 ,BI of Capital Loss Carryovers From 19% to 1997 (complete this part it the toss on line 16 is more than the loss on line Short -Term Capital Loss Carryover 22 Fill in loss shown on line 7 as a positive amount. If none, fill in -0- and skip lines 23 through 26 ...... 22 23 Fill in gain shown on line 15. If that line is blank or shows a loss, fill in -0-........................................ 23 24 Subtract line 23 from line 22............................................................................................................... 24 25 Fill in the smaller of line 20 or line 24, treating both as positive amounts ........................................... 25 26 Subtract line 25 from line 24. This is your short-term capital loss carryover from 1996 to 1997 ........ 26 Long -Term Capital Loss Carryover 2t •FiII in loos from line 15 as a positive amount. If none, fill in -0- and skip lines 28 through 31 ............. 277 28 Fill in gain shown on line 7. If that line is blank or shows a loss, fill in-0......................................... 29 Subtract line 28 from line 27............................................................................................................... 29 30 Subtract line 25 from line 20, treating both as positive amounts. (Note: if you skipped lines 23 thr6ugh`26, fill in amount from line 20 as a positive amount.)............................................................ 30 31' 'Subtract line 30 from line 29. This is your long-term capital loss carryover from 1996 to 1997 ......... 31 Wisconsin Department of Industry. Labor and Human Relations Safety and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Permit Holder's Name City Village 16 Town of: BELLING, KRIS SPRINGFIELD CST BM Elev : Insp BM Clew : BM Description: I ob 1 un-T of wie H I par) — lrl o pe- ANK INFORMATION TYPE MANUFACTURER CAPACITY Septic W •C { Kc, DO Dosing W en- Gs IJU Aeration Holding TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. Vent to Au Intake ROAD Septic 6117 1001 -7i 71)0 NA Dosing NA Aeration NA Holding PUMP / SIPHON INFORMATION Manufacturer 2mc f- Demand Model Number C125 GPM TDH I Lift Jo.S-7 Friction�g3 5 temZ S TDH 1 Ft La Smead Forcemain Length Gr Dia. 2' Dist. To well SOIL ABSORPTION SYSTEM ELEVATION DATA County ST. CROIX Sanitary Permit No 299141 State Plan ID No : 97- /08'97 Parcel Tax No : 034-1056-40-000 ao-7nnAR 7 STATION BS HI FS ELEV. Benchmark Z Zro 102.2 ) 00 Bldg. Sewer e r s+'h5 St/Ht Inlet /ot/•S // O q 3.54 r St / Ht Outlet 1041514 / 1 1 9 3 4 c/ Dt Inlet loySV 13.f cl/ 07 Dt Bottom pr/. /& E/ 8'7 7 Header / Man. ---- Dist. Pipe /01,tra �/ j . 13 �'1g -S J Bot. System /o?.r/` 5,757 c/ 7 71 Final Grade 5- 111as►vIe(ovr rar/ 97.74 R, 11_ 3.Yb /0s.4/6 too A1•F. /o; fit ZCIZ /0/.0y TRENCH DIMENSIONS Width S/ Length 7 No. Of Trenches PIT DIMENSIONS No Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L BLDG I WELL LAKE/STREAM LEACHING Manu rer: INFORMATION CHAMBER ype / TO OV I� d / %2 M Num System: DV OR UNIT DISTRIBUTION SYSTEM "hey Header/Manifold it Length Dia Distribution Pipes r Length ?1- Dia Spacing x Hoe Size �/ x HoLa' Spacing 9�7 Vent To Air Intake 72 S 7 SOIL COVER x Pressure Systems Only xx Moundpr At -Grade Systems Only Depth Over Depth Over xx Dept xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.)rg6../0, ��• n LOCATION: SPRINGFIELD 25.29.15.395A,SW,SW 3206 70TH AVENUE flow H- re • if Final 11-7.97 Plan revision required? ❑ Yes []No ��/..- Use other side for additional information. !! 7 �/7 �Ti ` �/Z_ 7 f 7 SBD•6710(R 0"1) Date Inspector's Signature Cert No ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016.7710 (715) 386-4680 NOTICE OF VIOLATION No. 97-V-24 November 7, 1997 Kris Belling 3206 70th Ave Knapp, WI 54749 Dear Ms. Belling: On October 31, 1997, the St. Croix Zoning Department determined that the septic system serving the residence located in the SW, SW, Sec. 25, T29N-R15W, Town of Springfield, (3206 70th Ave. Knapp, WI 54749) is a Category I failing septic system as defined by Chapters 145 and 146, WI Statutes. The system is failing into zones of saturation, please refer to the soil and site evaluation report submitted by Henry Grote, dated October 11, 1997. The system shall be replaced with a code compliant system by October 31, 1998. Failure to comply with this order to correct will result in the issuance of a citation in the amount of $250 each day the violation continues beyond the deadline and/or this matter will be forwarded to Corporation Counsel for further legal prosecution. Funding is available through the Wisconsin Replacement Fund Program. Please find enclosed a brochure explaining the replacement program. If you meet the qualifications for the program, you may be eligible for partial reimbursement of the cost of replacing your septic system. The application must be completed and returned the zoning department no later than January 15, 1998, along with the 1996 Wisconsin tax returns and a filing fee of $50. If you have any questions regarding this issue, please contact this office. Sincerely, Rod Eslinger Zoning Technician enc. CC: Clerk, Town of Springfield Corporation Counsel file ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 NOTICE OF VIOLATION No. 97-V-24 November 7, 1997 Kris Belling 3206 70th Ave Knapp, WI 54749 Dear Ms. Belling: On October 31, 1997, the St. Croix Zoning Department determined that the septic system serving the residence located in the SW, SW, Sec. 25, T29N-R15W, Town of Springfield, (3206 70th Ave. Knapp, WI 54749) is a Category I failing septic system as defined by Chapters 145 and 146, WI Statutes. The system is failing into zones of saturation, please refer to the soil and site evaluation report submitted by Henry Grote, dated October 11, 1997. The system shall be replaced with a code compliant system by October 31, 1998. Failure to comply with this order to correct will result in the issuance of a citation in the amount of $250 each day the violation continues beyond the deadline and/or this matter will be forwarded to Corporation Counsel for further legal prosecution. Funding is available through the Wisconsin Replacement Fund Program. Please find enclosed a brochure explaining the replacement program. If you meet the qualifications for the program, you may be eligible for partial reimbursement of the cost of replacing your septic system. The application' must be completed and returned the zoning department no later than January 15, 1998, along with the 1996 Wisconsin tax returns and a filing fee of $50. If you have any questions regarding this issue, please contact this office. Since/rely, Rod Eslinger Zoning Technician enc. CC: Clerk, Town of Springfield Corporation Counsel file