HomeMy WebLinkAbout040-1245-10-000
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AS BUILT SANITARY SYSTEM REPORT
OWNER 7b-D~-
f "
ADDRESS-Q O ~t
'V L
I'Y) s
SUBDIVISION / CSM#
SECTION---/?-T--Q N_R W LOT
, Town of
ST. CROIX COUNTY, WISCONSIN
SHOW EVERYTHING WIITHIN I100 FEET
YSTEM
A
T
6 4 ~ Vp
11
O
INDICATE NORTH ARROW
Provide setback and elevation information on rev
Provide 2 reverse of this form.
dimensions to center of septic tank manhole cover.
7
L
V
BENCHMARK: A) a tom, S/g 9. 2
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Vss... Liquid Capacity: I DSO
Setback from: Well 4 House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle.-
Alarm Location
SOIL ABSORPTION SYSTEM
k'
Width: Length t0,6 Number of trenches
.,Distance & Direction to nearest prop. line:
Setback from: well: aQ House aL~ Other
ELEVATIONS
Building Sewer ST Inlet: 3944(v ST outlet•3 q3?'gj
PC inlet - PC bottom Pump Off
Header/Manifold r?92' A
Bottom of system g 9Y`'3 1
-814
7. a
Existing Grade g ~ ep Final grade IN. r$
4v . 70
DATE OF INSTALLATION: PLUMBER ON JOB:
CaA6~nn
LICENSE NUMBER:
INSPECTOR:_ v
3/93:jt
r
Witconski Department of Commerce PRIVATE SEWAGE SYSTEM Count
~Safotyand Buildings Division INSPECTION REPORT County: CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary289 i
Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)).
Permit Holder's Name: it village Town o : State Plan ID No.:
TROY DEVELOPMENT CORPORATION ~RO a
CST B~MyElev.: Insp. BM Elev.: JB Parcel
TANK INFORMATION ELEVATION DATA A9700206 Ea
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing ~ ; > , 7 ?S
Aeration Bldg. Sewer
Holding St/ t~f Inlet
TANK SETBACK INFORMATION St/0 Outlet
TANKTO P/L WELL BLDG, ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosin NA Header/Man. 'f
Aeration - A Dist. Pipe
Holding Bot. System
PUMP / SIPHON INFORMATION Final Grade
Demand
Model Number GPM
TDH Lift Fr' 'on Sys DH Ft
oss Forcemain, ength Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length No. Of eny PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION DIME
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LE ING a INFORMATION TypeO -CHAMBER Moe Number:
System: 1-Z OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) , xze x Hole Spacin o Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ys e
Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes E] No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY 19.28.19.294,SW,NW 259 TROON COURT LOT 11
~ r
T 1,
i
Y'
'Plan revision reclui>ial ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (Fi.3/97) , Date Inspector's,Signature Cert. No.
S
ADDITIONAL COMMENTS AND SKETCH z
SANITARY PERMIT NUMBER:
00- r13c~ i -7.
/a.ao'
16
I
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size. -S,,,t C c
• See reverse side for instructions for completing this application State Sanit999 Permit Number
3x1
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Prope Owner N e Property Location
III fi01/4 N X1/4, S 1 T 2 , N, R JCJ fir) W
Property Ow per's ailing Address Lot Number Block Number
u z A)
`State Zip Code Phone Number SubdiviTIName or; SMlyumber
II. TYPE O BUILDING: (check one) ❑ State Owned ❑ Citr Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms vown of
Ill. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s)
l 0
1 ❑ Apartment/ Condo 1
o -7 (y - S
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System ---------Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 Seepage Bed 210 Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7- Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ja Elevation
O~ Q ® 1 S /1/' 7 Feet Feet
VII. TANK Cap
in allo acits Total # of Prefab. Site Fiber- Ex er.
INFORMATION Gallons Tanks . Manufacturer's Name Concrete Con- Steel Plastic p
New Existin strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank r ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber E] El 1:1 1:1 1:1
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Pri P tier's Sign ture: No St ps) MF/MPRSW No.: Business Phone Number:
C9 i --,c L-S
t
-7(S S/
Plum er's Address (Street, City, !tat Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved nitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps)
Surcharge Fee)
*pproved ❑ Owner Given Initial ~ a~
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To:. Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than °8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or-with complete dimensions, locatior-of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells,- water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served,-
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls,- dose volume;
elevation differences,- friction loss; pump performance curve; pump model and pump manufacturer, D) cross section
of the soil absorption system if required by the county-, E) soil test data on a 115 form; and F) all sizing information-
- - - -
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pace cf 3
3bcr am Au-man Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
C~0~1C
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but .ST
PARCEL I.D. #
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or ~,.y
dimensioned, north arrow, and location and distance to nearest road. q Q V
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DA-.
PROPERTY OWNER: PROPERTY LOCATION Z, S Zu, 'r7-% J4, KZ-0 W
so NW TFru MISS R-%A"m mLz 'aey;F.'I:9T W hJ 1/2b*.S 19 T Z.? N,R 19 ~.WW
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
2(00 C.T. 14' I I - T KO u -P, rz
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD
UD W~ S`+01 IJ13SL-Zg02 914 T.
DQ New Construction Use Dq Residential / Number of bedrooms L4 ( j Addition to existing building
j j Replacement ( I Public or commercial describe _
Code derived daily flow bil iA _ gpd Recommended design loading rate - Q .14 bed, gpd/ft2 0.5 trench, gpd/9
Absorption area required 1:500 bed, ft2 1 ZO 0 trench, ft2 Maximum design loading rate - D ,y bed, gpd/ft2 0.5 trench, gpd/ft2
Recommended infiltration surface elevation(s)70 1A T)E-T = P-miAir- sV t7r-&r( 4e~~d to site plan benchmark)
Additional design / site considerations -
Parent material G LA _lA-k--"1 LL -Rood plain elevation, if applicable At ti. ft
S = Suitable for system ONAL ' MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM !N FILL HCLDING 7A.NK
U= Unsuitable for system S❑ U 0S ❑ U I RS ❑ U ®S U 13S O U I S CRJ
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft~
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. ( Bed ,Trercn
-7 10.9
-G I 0\1 le 3JL4 0 :,,a
0.
< y. Z - 40 to Y 3 3 Y I .-7
J
Ground
elev.
gt5 ft.
Depth to
limiting
factor
> 40
Remarks:
Boring #
Z -16 to ~
S 16- 26 3/z- 0 - ~S c m~
Ground
elev. Z6-147 to 1 - 1 - 4.4 10,
J% ft.
S 47_5'5 I0 Y 3/14 rh -"h Std W - 0.2 0,3
Depth to '
limiting 3-8 O U - ~S - 0• .01
fac~toll i
Remarks: 130KIZIM11 P S K1ZOA1 ~C,4UEL
CST Name:-Please Print Phone:
o s e2 CIS 4Z5-91gd'
Address*
650-44N s'T t V iL ;:-A I. S, W S 2
Date: Zi660 7$W
CST Number:
Sign r 7-
(~l/~, NOV. Z7 191{o /%0,3707
PROPERTYMNER r4UC:MM1=LS, -'TOF+./V SOIL DESCRIPTION REPCAT Page--,, oi~a
PARCEL I.D. S.
Depth Dominant Color Mottles Texture Structure Consistence Bwvay Roots GPD/ft
Boring # Horizon in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh.
Bed iTrerxri
b U-~z toy 3 - sal 2 M v ~r c5 S
xl 2- Z- 31 10 Y V 5► I Z rn wl O.S O. L
Ground 3 3 h K 10 14/w n4 S - -7 D•
elev. .
SSA ft.
Depth to
limiting
factor
Remarks:
Boring #
nay«::;w 1 0-10 101 3/3 - 51I I Z ry, a Y- 6t S - 0.5 0.4
< r~-b Z 10-Z3 i 3 - 511 Z m b rn C5 - .5 10.4
Ground 3 Z 3 -8'7 0 yt- y
elev.
ggt~3ft.
Depth to
limiting
factor 11
Remarks: 4oj1ZON Z Nd+s SOME G4,AQ e
Boring #
<50 Z 1z-,9 o r sl - sl I 2m5b1 rh c S - 0.s a,b
"Y 3 14-z4 ►o y 311. - S Z m5b rr~J 5 r 0. (4
Grrou ound
elev. y z4 40 I o yie '41b S - 10.7 ~ 0,
Ml.-7 ft.
Depth to
limiting
factor
o„
Remarks: AUKI ZZ N L + S6M1= o KAVEL -
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
Page_ O_` 3
PLOT PLAN
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1505 HWY 65 • PO BOX A Project I Fp
10 1 Page # of
NEW RICHMOND WI 54017
PH (715) 246-2320 i
DERRICK FAX (715) 246-4948 Re t _ 4o,
O by Date L 2 3
CONSTRUCTION
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PAGE OF
CroSS S~c~lol~ p~ ~ 3r 17 Sy15 0-)
A If flesh Alt Inloh And ODutvallon Plp•
ne z' -4 dry
Lam----Approved Vaal Cap
Minimum 12' Above
Final Clad*
20.42' Above Plpp _ 4* Coat Iron
To Final Orade Vaal Plp$
Mwoh Noy Or SymMrk Covering
,In 2' Aggregate
Ovet Pipe
OlevtOullon
a
Pepe - a o o -Yes
6' Aggregate o perloroted Pipe below
aneellr
B Plpe
o -Coupling Termlaoting At
Balloon Of System
s9y~
grr,rl•c
~ttJ•.~ eon
SOIL FILL
• DISTRIBUTIOM PIPE APPROVED $41J1'HETIC COVER-
2"OF&GGREWE Oil MARISN OAy9" OF STRAW
lt -Zt/2 AGGREGATE
8Ff&' 7 ' b~ (;OF
~LF_V. 0FSE>~T
DISTRIDUTIOU PIPE TO BE AT LEAST IIJCHES BELOW ORIGIMAL GRADE
AIJU AT LCASTLO INCHES BUT L10 MORE THA►J 42 MICHES BELOW FINAL GRADE
MAXIMUM Qf rVi OF F-XCAVATICIP FKOM OWWAL 69AK WILL BE INCHES
MilmuM AF 7-ji of EACAVATIOW fj o0 CA~161NAL. FIRADf- WILL 5C 3"12 ' INCHES
SIGUCO:
LICCUSC IJUMBEIt:
o~ /
DATE:
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
^ St. Croix County
OWNER/BUYER `TUfly Ve Lip MEN; COP-IE-
MAILING ADDRESS Z'"zIa I Ga'al'(ll. !p'~!E ~G f l.Al E-~c M t s q-3 y' lie
C;sq
PROPERTY ADDRESS )-4t-K
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE O"OSOt-1 \4V1
PROPERTY LOCATION SW 1/4,5W 1/4, Section T 1A0 N-R q W
TOWN OF -I-PA?y ST. CROIX COUNTY, WI
SUBDIVISION 1`n-a v V1 L-L A tn LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the 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.
-S'
SIGNED:
p ,
DATE: -7
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property __5~y l.T~c~IEIApIME~T Come
Location of property `7W 1/4 ~AW1/4, Section 19 ,T 1,1b N-R 19 W
Township 'TI v Mailingaddress 12~a
A\fz L-& t tJ 1a S 43 4 ~
Address of site ~~Q►.l 6o\A!?r 4MO SO 1J _
Subdivision name ~?.oy VIU-,A. a'qE Lot no.
Other homes on property? Yes No
Previous owner of property )C}+N P~A ErA Mc L;-:-*
Total size of property Q►C~ fi
Total size of parcel Q-~
Date parcel was created 5-710 - 9'1
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes No
Volume and Page Number OLr4 as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on -this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in th office of the County Register of
Deeds as Document No. 5;CAA kO7j , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the,;,gf~icc o of the County Register of Deeds as Document No.
&Ok
Signature
of Applicant Co-Applicant
Ple&_I5 i b Q r
fo -Z--/ -0t 7
Date of Signature 4-•..--.
CONTINENTAL DEV CORP TEL NO.612-757-2532 Jun 24,97 9:02 P.01
r 4 SIATIK: MAKCM' WISLYJNSMVMM 1 • 1932
571I~t9?3 WARRANTY DEEP
Doctimedt No. rl(`-
This Deed, male between
_ ,1cti~L7. itudnnteie but H r ,..ra A. XWMjt1 Qk Wjtte ,ind'fhomas d. MAY/ 7 .tt~~ j
ltnie and Noil R.ttemt~feic, hie wife
Granter, .3-15 I'M
and _ W..+• --R jdil41,, '
rr~Sftk1:~1S~11jC14!Itt CMI',ctr~tlnn ltt1tg11►Ae w) UI.wrNI a
~ ~IGranirt:,
W itnexseth, 'llist the said Orantor, rot a vnlaable t ansi;leratlnn MrNMtC nkPn'k"=-"Whey VdW
conveys to 6raniee the following described real aerate in St. Croix C,o)ip(k I PAT,
I
county, Stale 01 wisctSnaln:
(1'r1:et hkuditulUua Kund6a/
tots I throuEh 45, Lols 47 liuout h 65 nrld LOU n8 thl'nuESh 70 of file Plat or Troy Village, St. Croix County, Wisconsin and that
Polio[" OfUutlut 6 of the Pht of J';oy Village deserihod on Exhibit A alluuhed hereto,
and A ' ~`-Ep
drC.Sa
Ltntiots 1 and a to the i61ht Ilf 1 illy Village, SL Croix County, Wisconsin ~-w
i
A It,ni, 11 nt aw aW° a demAilbd ;W,k)&Iv 16 tioauncad p!otK'ra}' of Mc t.rantots, John,!. Ikiwarn le and hwhora x. Kmminii:W
(ii) (1911M)
Tnptelhea will) All and sin(tulnl rile W=411wwnts and np;wncnanm iharcunfn W- v gmg;
wartanis ihal:he title Is good, hxic Amm1hr in ret sinwiv mid nee t9nl ci:m1 :rrl MNrglt„19 key V'mgm
cascatt7us, covenants, restrictions and highway rights ofway of recrnd
nod will t,xranf mW d•clhad rile sam
Dat~A this.. day OF 19
,17 yrL!7?!!J7: i...... (SLIAL} ~ + 7 ys a ~~y V (SI t >
4tthn ,l, R tmt l Tbp1 'it
t-t
-(SEAL) .je. e..~L -fslnl:)
" Htn b ra A, Kuenunele • 1ve11 L. ltuammeia
f
i
AUTHENTICATION ACKNOWLEUG TENT
gnatwasj Jni n J xummialo and Rarharn A uuemflwle, llk,Witt and Y'IA'rr ot+ WX:C NS'A )
'!'lw+nm, t. k>__nnMI and Nalt t_P41rpltrK!c. It*s wi}1+,........ )
aulhctttirmted this ll, of mgv'. 1922 _-_-~('nunty. ?
Personally cane before Pic this day of
.19 the above named
Smile R. Uri
.1 ]UL: Mls, lilk3T`h'I'i> HAk 01, WISCONSIN
RUAIrir d rly s,tx W,, W h. aWN.t to me knuwo to be file potsvu who LKI Gulf:, I IG
furepping inatrtatt nt and lickuuw1odge file aan[c.
-1'Ifll lNB-1'Na1MtiN'r WA51*AWi'h17ItY
° ^vwtwd Ce 1, w, SattlmUi~ 1t. t:ri " "
24.m tau tjt SL. P.Q. Box i 75. I I~Idson, WI W.1-6, Notary Public C;wll(y, Wis.
(Sigmixae may tK malkrnticated or m km+wicdgc9, 111.0 kre N" My carrnnksilm is permamm (If not, state cxpfrstlon der
ne7ns?ary.) I'J I i
• rl:Vil'.f116a,drn,n,t'6lu~i~)dN,.W be U'I"al ,,liw,d Lv4,w a"i. ul,i.nav>.
riwwc a• ,
- - fll,W tW. 11961 ~
.:,Ireun6^JI
VY-consin Department of Industry. P3C° C' -'3
;lor,~n. !~-man Relations SOIL AND SITE EVALUATION REPORT
Division of Safety & Buildings ! in accord with ILHR 83.05. Wis. Adm. Code
COUNTY
.ST
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. #
not limited to vertical and horizontal reference point 'r ctjort % of slope, scale or ~a Tr-Gtr
dimensioned, north arrow, and location and dista s est road.
APPLICANT INFORMATION-PLEASE P I AL INk AT14 REVIEWED BY DA-=
N
PROPERTY OWNER: cy P PERTY LOCATION 1= Z TZg ,
SO Nt1~ TNT M u i, T -W VJ 1/2b*.S Jq T Z$ N,R 19 PROPE OWNER':S ILING ADDRESS ST CROIX # SUBD. NAME OR CSM #
260 C.T- N , T KD i 6~
CITY, STATE ZIP CODE NFGE OWN NEAREST ROADF
uO WZ .5 31 Z9 Y New Construction Use ➢Q Residential I Num y [ J Addition to existing building
j J Replacement [ J Public or commercial describe _
Code derived daily flow gpd Recommended design loading rate 0_y bed, gpd/ft2 0 - ~ trench, gpd/ft2
Absorption area required 1:500 bed, ft2 1 ZO0 trench, ft2 Maximum design loading rate _D ~J_bed, gpd/ft2 0.S trench, gpd/ft2
Recommended infiltration surface elevation(s) -T'0 RE T)Ert= je m wEn " oF4,( e d to site plan benchmark)
Additional design /site considerations -
Parent material to LACtA-t_-T 1 i -Rood plain elevation, if applicable All DA ft
S = Suitable for system TIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM !N FILL MCLDING -ANK
U= Unsuitable for system S❑ U RS ❑ U I ~ZS ❑ U ®S ❑ U ❑ S O U I ❑ S ($7J
SOIL DESCRIPTION REPORT
Depth Dominant Color I Mottles Texture Structure Consistence Botrtdaiy I Roots BeGPD/
Boring # Horizon in. Munsell Du. Sz. Cont Color Gr. Sz. Sh. d Trt?t-d7t
Ground
elev.
ft.
Depth to
limiting
factor
X90"
Remarks:
Boring # - 0 5
}fit Z -1 10 yw, - ml C S 0•~ 0.
1/6- 26 3/ - IS c m[
Ground
elev. y zb-U~ to 1 - 1 - 0.4
gee •9 ft. I
.
S 14-7 I
Depth to _53 1DY 3 -W 0.Z `0,3
- i
~s
limiting r 153_g O y o !o•
factor
I
Remarks: D P S -to Nuar. K1z ON 44-uEL
CST Name:-Please Print Phone:
Q46 s e2 (715-47-5AIT.F
Address'. 2:: g- t= s 2-
Sign u Date: CST Number:
A10. Z7194(0 %0370
PROPERTYOWNER rIUEMMELE, ~~►iN SOIL DESCRIPTION REPORT ;-age - at __4
PARC-0-1. I.D. " -
Dominant Color Mottles Structure Consistence Bouncsary ! Roots GP D/ft
rerx~t
Boring # Horizon Depth Du Texture Gr
in. I Munsell . Sz Cant Color . Sz. Sh . Bed IT
» U -IZ toy 3 - S'A 2 ~h v ~r c s
<Il«< 3/ - 511 zm
n -7
Ground 3 314! 0 Y 4 _ S D.
elev.
Sgg.S'"It.
Depth to
limiting
factor Remarks:
Boring # S 0.4
~•.„v: Ez ,001- 1K
I 3 Z m 0.1• 10 Yr, A4
y
Ground
elev.
g9~ ft.
Depth to
limiting
factor
787
Remarks: ZON 5 o,mG ►I E
Boring # - rn I S - I O,
- s1I ZmsbJ yv c S J" o.s a.b
l9 o y VIP
FIE z
3 19-z4 ►e Y 3 t - S 7-m5b Mq 5
Ground
elev. y z4 -qD 10 ti b - S - O.7 0.
MI-1 ft.
Depth to
limiting
fact? , I
Remarks: ° (Z I Zo N L 1 MS SbM~ a KAVEl
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
Page_ o c 3
PLOT PLAN
Property owner ,~UF~~M1E ,c
Legend: / - 'V a,c
AVIEZ
Legal DescriptionLDT 11,,-TgDY VII--[Aag BM =~~M 18-SPIX~I~I Al "IAEoF
LOMT? Q IN 7tfS EYz, 5 2y. 729A)~ Z=w ~ Pln►E TRH FLAGGE 7 -EL Yq9. 36"
p3Z- SPIKE W 'U1= Size OF: P MF_
w /2, 519, 7 ZBnJ, ~C Iq vJ~ 'TaW,~1 0 F'1>~Y/ Sl: ?R~ 1=- FLA 6CM30- EL 8'9 . S/ '
CKOIX C-OunRU, WISMMSIA). I,_] soil boring w/backho
(-<EF 5u,cvrY MAPS RIL ~~x[-~r
/SOT LINE AAI &Le-3.,
LOT )0
E~ ~9Q•`~I°~
j 05502.
r EL BQ4.3
~~•~o s~ ~L $V.5'
PE
0
j35o3
EL 391.1
B 9.99
E 6.3'
O
-B500 ,
aM 2 Z.
® E~ 89.51
X05
Signed CST JjA
D
M03707
Date
~p~, Z ILjQl2
Lor IZ /997