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HomeMy WebLinkAbout040-1093-10-001 AS BUILT SANITARY SYSTEM REPORT • OWNER TOWNSHIP SEC . ,~Y T1-R1IW ADDRESS ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHCA THING WITH N 100 FEET OF SYSTEM E V -4- I di a e o th Arrow SC L BENCHMARK: (Permanent reference Point) Describe: F Elevation of vertical reference point: ,Slope at site: f SEPTIC TANK: Manufacturer: ~,C Liquid Capacity: 1116) Number of rings on cover Tangmanhole cover elevation Tank Inlet Elevation: - Tank Outlet Elevation. i~ PUMP CHAMBER . Manufacturer: Number of gallons Number of gal. pump set or a cyc a gallons; total capacity o distribution lines gallon: size o pump head; gallon per minute horsepower ran name of pump and model number Type of warning device HOLDING TANK: Manufacturer Number of gallons REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTEM ' Sanitary Permit_Z> v State Septic NAME TOWNSHIP St. Croix County LOCATION Section Lot # Sub fi fsion SEPTIC TANK Size gallons Number of compartments Distance from: Well Building 12% slope Highwater PUMPING CHAMBER Size gallons Pr ufacturer Model Number HOLDING TANK Size gallons Numbquilding Compartments Pumper rm System Distance from: Well 12% slope Highwater ABSORPTION SITE Bed Trench Distance from: Wall Building 12% slope Highwater ABSORPTION SITE DIMENSIONS j Width of trench / ft Required area ft. Length of each line ft Depth of rock below tile in. Number of lines Depth of rock over tile in. Total length of lines Uft Depth of tile below grade in. Distance between lines ft Slope of trench in. per 100 ft. Total absortption area ft Type of Cover: PIT DIMENSIONS Number of pits Gravel around pits yes no Outside diameter ft Depth below inlet ft J ft Total absorption pr r Area required- ft p State and County State Permit *67 Permit APplication County Permit # .r. L8 for Private Domestic Sewage Systems County F *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: i)R h J e 42 S C14 (te4? eaver fi~lg B. LOCATION: '/4 Section ,T 22 N, R E (or) 6NI Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township Th;, C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify)- *Varia ce Single family _ Duplex No. of Bedrooms No. of Persons ~l D. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete _4_ Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTE : Percolation Rate Total Absorb Area sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Li al Ft._ Width Depth Tile depth (top)--No. of Tr ches 57/ f Seepage Bed: _Length Width 22' Depth _P Tile depth (top) ~ No. of Line 41 Seepage Pit: Inside di ter Liquid Depth No. of Seepage Pits Percent slope of land Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name as Iisted on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the C ied Soil T ter,~ NAME yoKJ. C.S.T. # S'~~L) and other information obtained from Lt; a (owner/builder). Plumber's Signature MP/MPRSW# Jl Phone # Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. i I f E ~ 3 4 r a pi-ci V tog X2 } 8,e8 - • DEPAI TME'NT OF REPORT ON SOIL BORINGS AND v t, GN LABOR ANo PERCOLATION TESTS (1151 N° 69 HUMAN RELIATIONS \ / ~r A 07 LOCATION: SECT ON: TOWNSHIP/MUNICIPALITY: OT NO.: BILK. NO.: SU JSION ME:'J a /Tat N/R/9 E (or o t COUNTY: OWNE 'S B 14 UYER'S NAME: Al~t~e~ /~'S ~Q/ USE DATES OBSERVATIONS MADE : NO. BEDRMS.: COMMERCIAL DESCRIPTION : PROFILE DESCRIPTIONS: PERCOLATION ~t TESTS INResidence ❑NewReplace I /Xd~ /3~Q) J~~Q(f s_0 RATING: S= Site suitable for system U= Site unsuitable for system RECOMMENDED SYSTEM: (optional) CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: IES DU DS DU DS DU DS DU DS DU If Percolation Tests are NOT required DESIGN RATE: S / If any portion of the lot is in the under s.H63.09(5)(b), indicate: /o< 3o I Floodplain, indicate Floodplain elevation: S ee d PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HHIGHEST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ~6 /bo 0 ~rB L. ~7'' s t5''~ B- 0 99rb:~ ROME p 09'' L, y'' 1h S 16"A S L'ik S" S B- 3 /Ga' D E C) 30" "7"atkb~ S /S'uB S B-. B- B- , PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES ---PERIOD 3 NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PERIOD2 PER INCH P o E yo °~r P- E o ♦ V7 -TV P_ Q v > P-. P- P- PLAN VIEW: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the "hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. ~y,~ V~Q a, k 3 6' SYSTEM ELEVATIO r -T tor e 1 Ps es 'n I : I E + r i ' m f s e, • _ ._e '..,~..3__. 7 9 FILED AUG3 r 984 U&a 00 90NNRt ass - CERTIFIED SURVEY MAP 1S b,~i h DONALD JENSEN Part of the Southwest 1/4 of the Northwest 1/4 of Section 249 Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin UN PLATTED LA NOS ``SCONS'i S88°44'40E 339.22' 10 BARN FOUNDA TI ON LAURENCE': Z TO BE REMOVED = W MURPHY : C + S 1713 a. RIVER FALLS 64 W % 49'• WISC. • a a c LOT i •LA140 = W IL O1 3.273 ACRES i N 142,374 SQ. FT. ° NET+ 3°016 ACRES STEEL a y o °o NW CDR. SEC.24, 131,383 SQ. FT. SHED c _ p z o0 T28N,R19W, c Z ~z v F o (COUNTY SURVEYORS m 0) W MON.) ro 3 , W M 11/2 SrORYDWELLING O b 3 a o W W v, o ~ =a O h W C1 • a O 3 j I F' ^Vh H a O (a Ii 4 K 2 O N O O N • 2 ti O o a 2 N a, S89.35' 20"E 339. W APPR p W N O p j W {p !y M C < O " - AU G 0 9 V,06 N 89. 3720-W 339.14 1984 ST. ,OIX CC)Ui•..Ty COMP.,;HENSIVE PARKS PlArv::JNG 66' TOWN ROAD AND ZOIJI.f+G COMMIfTF.F UNPLATTED LANDS SCALE 1" 100' SCALE IN FEET 0 O 0 50' 100' 200' 300' =Elm ndicates 1" iron pipe found ndicates 111 x 241, iron pipe weighing 1.13 lbs./l.in. ft. set W 1/4 COR. SEC. 24, r28 N, R 19W, (COUNTY SURVEYOR'S MON.) DESCRIPTION: That certain parcel of land located in the Southwest 1/4 of the Northwest 1/4 of Section 24, Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin, more fully described as follows; COMMENCING at the West 1/4 corner of said Section 24, thence N 20° 23' 44" E 840.50' to the POINT OF BEGINNING of the parcel to be ST. CROIX COUNTY ZONING DEPARTMF'`r AS BUILT SANITARY REPORT< R Owner /1 A Address R / S Ch rte m~~ nr c id City/State ,Ip ~',~ne FQ l- Ism 1.(/Z Legal Description: Lot I Block - Subdivision/CSM # a a t/4 5bU y4 5to , Sec. 9LL/, Tag N-RAW, Town of Troll IN # MV8-1 f 3/D SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: /000 Tank manufacturer Weis er Size STS / Setback from: House /V Well 7j P/L Pump manufacturer Model Alarm location (BOLDING TANKS O"gad Setbacks: Service Vent to fresh air intake Water Line Meter locati Alarm ation SOIL ABSORPTION SYSTEM: 3 Type of system: 3 Width 79 Length Number of Trenches Setback from: House 1,5" Well 130 P/L 15- Vent to fresh air intake '/40 ELEVATIONS: Description of benchmark 7o-,p o fe Elevation /dOsAO Description of alternate benchmark Elevation Building Sewer Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distributio ines O O Bottom f System O ( ( ) Final Gra O ( ) Date of installation ~C /Permit number 307 State plan number Plumber's s' ature License number 67 (Vd Date Inspector Complete plot plan s NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW ~~QIF i =yd' rN ~ ~tle l~ .3 Sodrooh't MouS ~ /too 7a -k J~ R INDICATE NORTH ARROW ism Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: • Safety and Buildings Division INSPECTION REPORT' GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary PermitNo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]• a* M ' ?o Permit Holder's Name: ❑ City ❑ Village ® Town of: State Plan ID No.: Yla.vl Te*1sw~ Parcel Tax No.: CST BMElev.: Insp. BM Elev.: BM Description: QQ► CST+s (AD OO' To o>'~ Ael PMe f..I O'fo-X093-/~-~/ TANK INFORMATION ELEVATION DATA A0-7o0 S2-1 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. e ti 11Gst,r - tStt' too e) Benchm 101.9(0 Dosing Aeration Bldg. Sewer et• St;n Holding St/Ht Inlet TANK SETBACK INFORMATION S~YiO Outlet %l•`~/ 9F1'SS+ TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air intake epti C~tSft % w x` NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe 77 12. PJr ,t 9& Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Li Friction 2[~~TDH Ft L Dia. Dist. To Well Forcemain SOIL ABSORPTION SYSTEM BED RE Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS N anu ac SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHICHAMB R Number: INFORMATION TypeO OR UNIT System errx J DISTRIBUTIO SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x~H/ole Spacing Vent To Air Intake ~O~ S«!u~l C Length Dia. Length 1_ Spacing tic~„~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges p", ❑ Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) T{, k&,.4(, WRS M f- (IIS& II e-d of IhI✓ -hpe D ~ ► w~ ~-rr~ C~ w(1►sf VVX4l K-6iJA wf ;was 41.OV~ 14-4 Plan revision required? ❑ Yes ® No l 7 Use other side for additional information. ( G Date Inspector's ignature Cert. N . SBD-6710 (R.3/97) Y ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division 'A SANITARY PERMIT APPLICATION 201 E. Washington Ave. 6consin In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. St. Croix • See reverse side for instructions for completing this application State Sanitary Permit Number 3o7G© The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location 514 1/4 W 1/4, S 24 T 28 , N, R 19 W Nanr-y Jensen Property Owners Mailing Address Lot Number Block Number---- 1 City, State Zip Code Phone Number Subdivision Name or CSM Number 54022 1(715 ) 425-5178 CSM Vol. 5 Pa e 1456 11. TYPE F BUILDING: (check one) ❑ State Owned Nearest Road Public 1 or 2 Family Dwelling - No_ of bedrooms -3Town of Troy Chapman Drive III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 040-1093-10-001 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify 1V. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 ❑ New 2. [i4 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an, System ___System_____________TankOnly Existing System Existing-System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 [&Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. S stemfElev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) %.5 r Elevation 1125 1125 .4 Feet Feet VII. TANK Capacity Site in gallons Total # of 's Name Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New Existin G8110ns Tanks Manufacturer Concrete structed glass APP Tanks Tanks Septic Tank 44'XfojcbjX"W 1000 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) rP71e0s gnat re: No Stamps) MP/WX39 Mo.: Business Phone Number: Paul C.J. Steiner 6780 (715) 425-5544 Plumber's Address (Street, City, State, Zip Code X. N8230 945th Street; River Fal s WI 54022 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Aglgnature (No Stamps) Fee) Approved El Owner Given Initial ?'Wl surcharge 1 Z' Z3° VI t Adverse Determination n L/ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6396 (R.1 1196) DISTRIBUTION: Original to County. One copy To: Safety d Buildings Division, Owner, plu vdw INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2Family Dwelling. III. Building use If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. P/a; n w"/ l 0 NC,p t~L 1c .1 L PC(roo/x ~ Nc~~aSe L l ~r 1~ 9f fir v6' --c r'- ,1 f %l tl,,? 16r s,We it, r',Jed ft F tC fcr.~ o T 3 ~QGk 71•Pl'1 C'h U S E' 4,2. sL Q~ waconsin Department of industry, SOIL ANO SITE EVALUATION REPORT Page \ of -S tabor~ynd Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), drection and % of slope, scale or PARCEL I.D. # dmensioned, north arrow, and location and distance to nearest road. 04 D -1 o ol3 -10 -oo l APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R 'EWEDBY DATE PROPERTY OWNER: PROPERTY LOCATION N.'-N m of -:S~se" WYFtGT S w 1/4 N W 1/4,S Ztt T Z8 N,R 19 E PROPERTY OWNER•:S MAILING ADDRESS LOT #t BLOCK # SUED. NAME OR CSM if ly S e a$ c " mwrj uE von , 5 CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAD RIUq% l3 ~V s ozz (-)Is) uzs- SI-)6 C\ o~• [ J New Construction Use [ 4 Residential /Number of bedrooms 3 [ ] Addition to existing buikting [eg Replacement [ ] Public or commercial describe Code derived daily flow `1 So gpd Recommended design loading rate __L--bed, gpol0 -y trench, gpo1ft2 Absorption area required N S oo bed, 6 WL S trench, ft2 Mabmum design loading rate' , bed, gpdAt2 • y trench, gpolft2 Recommended infiltration surface elevation(s) s IFE- Pier 3 ft (as referred to site plan benchmark) Additional design/ site considerations 3 'rrU3hJC-*M - W11M S X 1 S luN 6 S e L- V-" W Z Parent material SC3 VENT ouTwtr zA Flood plain elevation, ff applicable 1,3. A , ft S = Suitable for system CONVENTIONAL MOUND WaIOUND PRESSURE AT-GRADE SYSTEM MI FLL HOLDING TANK ms ❑ U ®S ❑ U ❑ S U S ® U U= Un-suitable for system 2S ❑ U ®S ❑ U I J_ SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bord3y Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed mnch r) ~otic~ ztz z`Fsb ck, - s • 6 Z \3 - 3O t O `f IZ- 3 l y ~ ~ i ~ Z `F's1~k 1m '~'h G1v - • S ` ~ ~ ~s b>Z- . •4 Ground 3 30= 1Z ~.S'~2Y1 s~ 0 YnVI. 3 elev. qq•3 ft. Depth to limiting faCtor Remarks: Boring # O-zo totiV--zcz - si( z~sb w►~r- Z Z 2A -38 tp `2 R 31y - Sl~ Z ~-nbl~ r►'t`~' Ctv ' S ' ~ 3 8-U$ -l.SYLZ3ly _ S` `S `C S~D1C h1V j°-3 - 'q s 'S Ground elev. IL)a-.s3 S `-l f-- -W y s 1 OWN Yr► u'4-t- C w • 3 - 94-aft 'n S 53-1S LO`'IR yl - ~S O S5 Yrt ~ - • S -b Depth to limiting o-pnrvs S J t~ rat T-tZh stv s fact s << Remarks: T Name.-Please Print Phone' 715-425-0165 Arthur L. We erer reSS' eg~rer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 signahxe: c)- - 340 Date: CST Numb 00576 PROPERTY OWNER T1S~►v SOIL DESCRIPTION REPORT Page of 3 PARCEL I.D.#t C)4 r3 - 1093-10- 00 ~ Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Boundary Roots Bed Trench 3 1 0 -La p -t ~Z 2-L Z s i t Z `F s b1~ m `~H c~-v ti`s S Z Zb_` *z 1 4 IZ 3 [ y Ground 3 ~(2~0 7. S `t IZ 3L s \ c elev. o~ vnU`F►- C°_-~ - , 3 CJ-2-U ft. 4 bb-13 tb`tIZVl - oSg VV, •S .L Depth to CC~rv limiting S C Sn°Ib L~n1 N~ Gwl S . factor Remarks: Boring # 3 G - 3 S L.D>v C. 1.3 1 (SN e. e~ -wtNO Ground 1 S`'iS !wc f~1 l/l/S elev. ft. Depth to limiting factor I i Remarks: Boring # i Ground elev. ft. Depth to limiting factor s Remarks: Boring # 13~ Ground i elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) Page of PLOT PLAN 3 3 tJ jl rv Gc{ T AJSMQ SCALE 1"= LSO' h NYO O~lO- kfA3-ip -00 1 w~u 3 Bvc, V-" ~'t OV ae i x e%ePTt c ~k o J BZ 010 nsb r~ a ~ qS ^S r - tXt3T= 65. 8-3 . ~.~,Z S w~a. ~L97 e~T 1 [tG~ PIPE BM ~+OT CAS, ~3~= ~-,_1000~ 0►J ~F O~ `Z"Eti~N-tl ~f~JE f~TR1- . °I-340 '71Ap~. 17_ Z 7 (715-) 425-0169 1400576 CST Signature Date Signed Telephone No. CST # 'vlmwnsinN)artmentoflndustry, SOIL AND SITE EVALUATION REPORT Page 3 Labor aid Human Relations Divisia, of safety & 13uildings in accord with II-HR 83.05, Wis. Adm. Code COUNTY S GtZZSJ~ X -S Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL ID. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. P4 D 1 ocn -10X001 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER PROPERTY LOCATION N ~N " Ste) Ste, 09VT.teT S w 1/4 N W 114,S Z4t T Z8 N,R 19 E PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # S 16L$ C 1F~1 ~vZ.1UE I CSM VOL., is, CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD Ou R l Uii"%t ~f~L-L S ~V S (3zrz (-)Is) i4ZS - S v 8 ~ C ( I New Construction Use [ 4 Residential/ Number of bedrooms 3 [ j Add'ikntD existing building jbd Replacement [ I Public or commercial describe Code derived daily flow 'A S13 gpd Recommended design loading rate - bed, gp(W -14 trench, gpolft2 Absorption area required \ S oo bed, ft2 Wt S trench, fI2 Ma)dmum design loading rate' bed, gpd/ft2 - 4 trench, gpolft2 Recommended infiltration surface elevation(s) s E~ P fh%6 tr 3 ft (as referred to site plan benchmark) Additional design / site considerations 3 Tr L* S - t_Mh S' X 15 L w 6 ~C Std ~Pt a~T Z• Parent material S a ye-1Z ov'rwksN Rood plain elevation, If applicable ~-a- A , ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for system Ea S ❑ U ® S 11 U IJ S❑ U ®S ❑ U ❑ S [RU ❑ S E111 SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bard3y Roots GPD/ftBoring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tench 0-L3 lpi VZ -?-I -Z - sb IT yn S • 6 Z \3-30 ~o`1iZ 31y ~t~ Z' 1Vt \ csblz.- 3 .4 - Ground 3 30 Z • S 2 Y l S o Yn V I. elev. qq•3 ft. Depth to limiting factor Remarks: Boring # Z . Z 2A-38 tb4R31y Z~gb1~ ,►1`~ Cw •S 3 g_y$ 7-SYtZ3Ly S,8`S ~CSb,CV'FI- 1_S 1 •q •S Ground elev. y8r-S3 '13 4 R 3Cy 1r►u'~- Cw •3 'y 94-3fL ,nN Depth S S3-lS LO`'mVI ` - 0s,% \M - •S .to to limiting C°-o ~'f~Ih/S 5 b° j t~ tit ~tZh G 31v S lactor >75' Remarks: T Name:-Please Print Phone' 715-425-0165 Arthur L. We erer egerer soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Sgr~ure_ 9- - 3 O Date. j 'z - Z_ ~j 7 CST Number: 0 5 7 6 PROPERTY OWNER _ ~1N-Ici SOIL DESCRIPTION REPORT Page of PARCEL I.D.# C04 0 , IW93-l0- 00 Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft In. Munsell Qu. Sz. Cont. Color Texture Consistence Boundary Roots Gr. Sz. Sh. Bed Trerxh El ) o-z.o vo-A IZ zLZ sit Z,`Fsbk w~~H ck, 1~ ,S Z Zo-`1.Z 1~`-t li Sly stC~ 2,`Fau1T m elti ,y' • S Ground 3 142-&0 7 • S `L IZ 31s c gblz - elev. _Q$ M U,4 ``L•O ft. 4 6b-~ 3 1(3 4 R Vl ~-S o Sg vv► 1 - • S ~ , 1~ mph to 0-0KJ w 3 C S~°!b LVvul ru% (S D ling factor Remarks: Boring # 13 3 G S- 3~ S" t_-t)>1J G 1 `tom 6 ~ l L ~ 1 NO L ~ Ground S 1wc ItiS elev. t ft. Depth to i limiting factor i Remarks: ` Boring # i i E Ground elev. j ft. Depth to limiting ! factor I Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) PLOT PLAN Page 3 of 3 V-3 fmj CAf seAJs%'tj SCALE 1"= Ll~j" ~~h tvo. 040- ~0°~3-ip -Oo ) w~u I ae i X o J 1,L9q s-2 d 0 n s, P a OASD MOM B-3 d,-~.S S raw. X197 r 1 'P'IPE Nam WT COCLwJ~„ - - C~PC~l~1PtN DR - \J4 00 1UP O'F `T"Eti~?tW ME °1 ~-340 (715 4L-0165, 1400576 CST Signature Date Signed Telephone No. CST # ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the Nancy Jensen residence located at: SW 1/4, NW 1/4, Sec. 24 , T 28 N, R 19 W, Town of Troy Upon Inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced F5 //o ~ /477 Did flow back occur from absorption system? YeS No,~_(if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: /QOO cau,(. Construction: Prefab Concrete/ -Steel Other Manufacurer (if known): Age o ank (if known) : 1 q~5 Paul C.J. Steiner (Signature) (Name) Please Print Master Plumber 6780 (Title) (License Number) JoZ~ a23,~9] (Date) Form to be completed by licensed plumber (5.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspeRi, ion opening over outlet baffle). Name J 2ei»~er Signatur ( MP/34 - 62 5/88 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Nanc Jensen MAILING ADDRESS 818 Chapman Drive PROPERTY ADDRESS 818 Chapman Drive (location of septic system) Please obtain from the Planning Dept. CITY/STATE River Falls, WI 54022 PROPERTY LOCATION SW 1/4, NW 1/4, Section 24 T 28 N-R 19 W TOWN OF Troy , ST. CROIX COUNTY, WI LOT NUMBER SUBDIVISION CERTIFIED SURVEY MAP , VOLUME 5 PAGE 1456, LOT NUMBER 1 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. 0I 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 exp' ation date. SIGNED: DATE: Ia1 ova ' / St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 Tc" 100 This application form is to be ovaplated in full and signed by the ,•ow (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 complhted when the property is sold and submitted to this office with the appropriate deed recording. owner of property NanrvAJensen Location of property_SN__1/4- NW _1/4, Section 2,T_L8_n-R 19 w Township Mail itig address 818 Chapman Drive er Falls,-, WI 54022 - - - - - Address of site 818 Chapman Drive; River Falls W 54D22 Subdivision natme Lot no, -1-~--- other homes 'on property? Yes- No previous owner of property Total, site of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes X No Volume 5and Page Number 1456 as recorded with the Register of Deeds. INCLUDE WITH THIS "PLICATION THE FOLLOWING: A WARRANTY DEED which inoludee a VOCT MENT NUMBER, VOLIm AND PAGE NUMBER AND THE SEAL OF THE REGISTER 01' 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 requited. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the rest of _y (our) knowledge that.L (we) j" (are) the owner(s) of he property described in this information form, by virtue warranty deed recorded i the office of the County Register of Deeds as Document mo. ? ?-!K and that S. (we) presently own the proposed site o the swage disposal system or 3- (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 ature f ppl ant Xc-Appl ant Dane o Signature Late of Sig}iaWm -x 4,1 • Av VOL 12S PAOR Kf~S OLD SG94'70 TERMINATION OF DECED PROPERTY INTEREST DECEDENT'S NAME Daniel C. Jensen a/k/a Dan C. Jensen ADDRESS OF DECEDENT AT DATE OF DEATH Cm STATE ZIP OFFICE I C E 818 Chapman Drive River Falls, WI 54022 W1 DATE OF DEATH SOCIAL SECURnY NUMBER ST. CROiX June 28, 1997 397-46-8138 PRESENTATION OF DEATH CERTIFICATE I certify that I have viewed a certified copy of the decedent's death certificate. a3a ply// ~ s y ~ gEQISTER OF DEEDS 310 TuRE 1 Re 111111' Recording area Interest in property is terminated under (pleats check appropriate statute): Name and return address: x s. 867.045 which pertains to property in which the decedent was a joint tenant' Nancy A. Jensen had a vendor's or mortgagee's interest, or had a life estate. '(You must provide a copy 18 Chapman Drive of the document establishing;oint tenancy or life. estate.) River Falls, WI 54022 s. 867.046 which pertains to (1) property of a decedent specified in a marital property agreement, and also to (2) survivorship marital property. (You must provide a copy of the document establishing survivorship marital property.) Presentation of recorded document establishing joint tenancy, life estate, n y0 /D g',3 - / d O O survivorship marital property, vendor Interest, or mortgagee Interest in real estate. PARCEL oENrIFICATroN NuMeER This document number is ~997ti0 volume 704 page 280 of (check one) RecordsX Deeds Description of the foal estate. t` ..►e.oetl ;n L~nfi at the time of the decedent's death. H thA extent of land is exactly In 1u t for vendor the same as on the document a copy of that document may be attached to describe the real estate. The legal description of the property and the persons receiving the property are as follows: (If more space is needed, attach pages.) See Attached Deed'- Description of personal property (if any) being transferred. You may list savings accounts, checking accounts and securities on attached pages. Indicate person(s) receiving property. DECLARATION: I, we declare that this document is, to the best of my (our) knowledge and belief, true, correct and complete and is in confor- mity with the provisions and limitations of the Wisconsin Statutes. (If more space is needed, attach pages.) Name and Address of Person Receiving Property Relationship to Decedent nature INotariz ed) Date Nancy A. Jensen n ? 818 Chapman Drive Spouse (~~J t Q> River Falls. WI 4022 i n STATE OF WISCONSIN, County of a, P Y This document was drafted by: Signed and sworn to before me on_' ~L/~I M~ ay~t •d'i;emed person(s). -cam. (print or type name below) Nancy A. Jensen Signature of notary or other person o authorized to administer an oath (as per s. 706.06, 706.07) I NOTE: SEE DIRECTIONS ON REVERSE SIDE. Print or type name V ect n ` W Title ~I n `Y) ` ►r r W~-Date commission expires . 120 w6~m Rp4Nr a D..af Aasadalbn Form HT•110 (1+96) 21516 (11196) p L 'F • DO...._-.T rw. STATS BAs Or Wt>SCC1.istl! lWSssl1-Ifr TMy sryea assasv~.oe sacawoRe a r. . WARRANTY oas MOTM6 OriiCE ms's Deed. me& k ST CR'-,(X CO.. Wis. Dona ..ld W. Jensen and.. Jaanet.tR..Jensela. wand.- Recd for 219t and.w.1fe .as. joint . tenants,., . - _ dor of J~ Cr=tW. D. :9 85 and _ .Dan. C... Jensen and.Nano A_-. J 10:30 A husband and wife. as joint tenants,_-. - - - s - - - G7rant*% Witnesseth. Tlat the said Grantor, for a valuWM* w.amidl®mw.0ne y (51.00) Dollar and other good. and-vahhTo considUu qn conveys to Grantee the following described real estate is F County, State of Wisconsin: Tar Parcel No: 09'tyA-_ 109 ...10..: Part of the Southwest Quarter (SWIx) of tine Northwest Quarter (NWk) i of Section Twenty-four (24), Township Twomty-eight (28) North, Range Nineteen (19) West, more particularly described as follows: Lot One (1) of that certain Certified survey slags recorded in the office of the St. Croix County Register of Deeds is volume 5 of Certified Survey a Maps at page 1456 as docurient number .""970. r F,CEI,Y rT This is not.. homestead property. (is) (is not) Together with all and singular the hereditaments and apomartmesamod thereunto belonging; And grantors warrants that the title is good, indefeasible in fee simple and fae aired dear of encumbrances except easements, restrictions, convenants acrd 3sighway rights-of way, if any, of record. and will warrant and defend the same. Dated this 20th day of 3rvvember.. is 84 . r (SEAL) (SEAL) pcma<ld J In (SEAL) ~ f ~~c (SEAL) .7eaasette Jensen AUTSSNTICATION ACSNOWLSDGUBMT Signature(s) . Of Donald. Jensen-and.,,,. SZAZ= OF WISCONSIN Jeanette Jensen se. County. authenticated this 2O.tlu 0: November , Ill.. 8.4 l~saaally came before an this ................day of L;~ 4~..."..:.(L.".l~~t 1l........ the above named D Td •Tensen and Jeanette Jensen • - Edward .F.. Vlach... 1 LE: MEMBER STATE BAR OF WISCONSIN (If not, . authorized by 3 705.05. Wis. State.) to m= Tizsmwe to be the pe-son who executed the faesrawmg nestrument and acknowledge the same. THIS ~•1 iTRU."c NT *AS DB.FT ED BY Edward F. Vlack, DAVISON & VLACK - 111 West Walnut River Falls-, WisEonsin 54022- Wasar Irubtic County. Iris. (Si,nature.+ may he authenticated or acknowledKed. Both xv" rwwmmi<sinn is permanent. tf not, state expiratio' t . 4 ~ s Y ~yq,p~.hW17M -.K Ay01 l00£ i 'ON 11"s ~rasa,.i» ~a jo U%a II VL% g..aa.m uu a~a r m FILED AUG o 1198a CONNrg,1, CERTIFIED SURVEY MAP 1S Caft DONALD JENSEN z Part of the Southwest 1/4 of the Northwest 1/4 of Section 24, Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin ,~t~1i111Ia~r~,~ UN PLATTED LANDS ~\rJ S' y 588.44'40"E 339.22' NL~ Vim= CI BARN FOUNDATION LAURENCE-* Q TO BE REMOVED + = W MURPHY S 1713 w C i RIVER FALL S~:~ , w ''ice WISC. ` o Ila 3 L o r 1 LAND 'S W o 3.273 ACRES •rt~~~~s~ x e IL 4 2 a 142,374 SQ. FT. ,I a NET• 3.016 ACRES STEEL H LL 0 NW COR. SEC.24, 131,383 SQ. FT. SHED c _ W 0 r Z8 N, R 19 W, C m Q i Z I COUNTY SURVEYOR'S O Ep J ~ W MON.) ~ 3 w F M O ~ y 1 1/2 STORY DWELL IN8 3 O W W y O O ~ ~ • Q o 3 W O J F OI W C uJ IL O ZI W O ' y co O n' O ~ • Z o _ v o s 2 N Q - - D to W ro 1 -S89. 35' 20"E 339. 14' W " APPR O °0 1_ J to 8 ~ (L O ~ M < O " O N 89 35' 20 W 339.14 AUG 0 91984 a h o COMP,tHENSIVE PARKS PIA i-; Nr, O N E-:66'TOWN ROAD A141 Z01,4040 COMMlr7E£ O ~ o UNPLATTED LANDS SCALE 1" = 100' SCALE IN FEET • O 0 50' 100' 200' 300' 2 • Indicates 1" iron pipe found o Indicates 1" x 24" iron pipe weighing 1.13 lbs./lin. ft. set W114 COR. SEC. 24, T28 N, R 19W, (COUNTY SURVEYOR'S MON.) DESCRIPTION: That certain parcel of land located in the Southwest 1/4 of the Northwest 1/4 of Section 24, Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin, more fully described as follows; COMMENCING at the West 1/4 corner of said Section 249 thence N 200 23, 44" E 840.50' to the POINT OF BEGINNING of the parcel to be - I.,... _ ~L---- o QQo )0 11 )1n11 v . 7-AO '191