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HomeMy WebLinkAbout176-1035-30-000 ~ o m o° I m °o I `MV d 03 s°s 0 6 a 0 o Y rn c N E2 oM 3 00 rn 0 ° r o- a N 0 o a C, a~ c O X X N > es NE2 O .2 8 O c c v p .a o c y o •E 0 .0 Z N CZ4 O d C O f0 N c Z :5 E c Z rn m o y ~n 0 0)= LL O 3 00 C C L ° ~ c I ° •o c a c a 8 ~o M ,It z I E E o € o 'n0)~ am am I 0 c C7 c ozv c 0 z g E w U) F- o c N Z E -2 I N N N N > CO (0 7 f6 N N C (D Z co z O Z 0 Z O O U N i w zl v a=i N c i m c I L N CL 0 CL M w m U a occa` m ocoa` a~ ° a5l rnrnrrrn `m C y, > E ~ 3 ain i~rrr aI0 - 'N aaa 000 z a S a a a U 3 3 U) V :2 LO LO U) m co co o } co 0) ~ z m rn 25 Lo co O co co O 3 0 0 ~ f0 O O ~ LL r m N = L mI C cm V rl^.i • N QI Q U) 2 'O 41 Q Z U) m H a N o Al N O 2 C N C O (D E LM 4) CO N O N C a 0 1 v 4~ M~ C ~ O N ~ O ~ N N I~ O N C O N N C Z E o N N y :r '6 m 0 2 C~ C rn O c O R U 0 m N o z_ z 2~ = E E d w~ a ~ d a I ~ a e a u a rr`w1~i r~+ E c c c 1 as c -1 A 0(L oa0 0V)0 1 Parcel 042-1041-70-000 10/03/2005 09:33 AM PAGE 1 OF 1 Alt. Parcel M 15.29.18.239A Current j X I 042 -TOWN OF WARREN - 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 FRONTIER LAND CORP O -FRONTIER LAND CORP 11530 HUDSON BLVD N #A LAKE ELMO MN 55042 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1262 HWY 12 SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 26.110 Plat: 0023-ANNEXED 05/17/2000 SEC 15 T29N R18W SW SE EXC P239B & EXC Block/Condo Bldg: PARCEL DESC IN VOL 594/378 ORD 662/101 ANNEXED 1511/438 (5/17/2000) NKA Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 176-1035-30 (220) 15-29N-18W SW SE Notes: Parc ,:I Date Doc # Vol/Page 06/21/2000 625148 1520/493 WD 05/17/2000 623197 1/438 ANNEX 1505/4 07/23/1997 594/378 2005 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/01/2000 Description Class Acres Land Improve Total State Reason Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M 203 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299012 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: BLOOM, GEORGE WARREN CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 042-1041-70-000 TANK INFORMATION ELEVATION DATA A9700330 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Moe Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: WARREN 15.29.18.239A,SW,SE 1262 HIGHWAY 12 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: S mo r''•~-"'~ SANITARY PERMIT APPLICATION BSafet and ureau of uilding WaterlSystems in accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. P.O. Box 7969 • Attach complete plans (to the count CO Madison, WI 53707-7969 than 8 112 x 1 1 inches in size. y copy only) for the system, on paper not less Count r 10 • See reverse side for instructions for completing this application State Saniitttary Permit Number The information you provide may be used by other government agency programs l 9 U ! Z (Privacy Law, s. 15.04 (1) (m)]. Check revision to previous application ❑ 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION State Plan I.D. Number Propert y ner Name j Property Location Property wner's ailing Address S(~1/4 S 1/4, $ T , N, R E (O Lot Number Block Number City, State Z Code Phone Number Subdivision Name or CSM Number ?W N II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city ❑ Public 1 or 2 Family Dwelling - No. of bedrooms_ ❑ village Nearest Road Town Ape.-I III. BUILDIN SE: (If building type is public, check all that aPPIY) Pace TaxONumber(s) /2~ 1 ❑ Apartment/ Condo ~C/a -~~j Cam/ _ ~O 2 Assembly Hall 6 ❑ Medical Facility/ Nursing Home 3 E] Campground 7 E] Merchandise: Sales/ Repairs 10 ❑ Outdoor Recreational Facility 4 E] Church /School 8 ❑ Mobile Home Park 11 E] Restaurant /Bar/ Dining 5 E] Hotel /Motel 9 E] Office/Factory 12 ❑ Service Station /Car Wash IV. TYPE OF PERMIT:- (Check only one box on line A. Check box on line B, if applicable) 13 E] Other: specify A) 1 ❑ S New stem ---2._ ❑ Replacement 3, ❑ Replacement of 4 ❑ Reconnection of _______ySystem Tank Only Existing $ 5..`J Repair of an System Existing System B) A anitary Permit was previously issued. Permit Number 9 Date Issued~"p _4j~- V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution 1 1 i~ Seepage Bed Experimental Other 12 ❑ Seepage Trench 21 E] Mound 30 E] Specify Type 41 E] Holding Tank 22 ❑ In-Ground Pressure 13 E] Seepage Pit 42 Pit Privy 14 El System-In-Fill 43 ❑ Vault Privy 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.) ProposC~g_ ft.) (Gals/day sq. ft.) (Min./inch) _ CJ Elevation VII. TANK Capacityeet Q% Feet .7 qS- INFORMATION In gallons Total # of Gallons Tanks Manufacturer's Name Prefab. Site Fiber-Ex. New Existin Concrete Con- Steel Plastic App. Tanks Tanks strutted glass p Septic Tank or Holding Tank x ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ~ VIII. RESPONSIBILITY STATEMENT d ❑ ❑ I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu is ig e: (No amps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, ity, tate, Zip Code): °Z ~l e~ y IX. COUNTY / DEPARTMENT USE ONLY gp,~ #Approved ❑ Disapproved Sanitary Permit Fee (IncludesGroundwater ate Issue ❑ Owner Given Initial 4 Surcharge fee) Issuing Agent Signature (No Stamp Adverse Determination X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SHD-6398 (H. O5194) DISTRI6-ow original to County, one copy To: Safety & SuilJings Div .ion, Owner, Plumber INSTRUCTIONS , 1 . A sanitary permit is valid for two (2) years. . Your sanitary permit may be renewed theexpirationdate, and at a time of renewal any new criteria in the 2Wisconsin 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 „raintained. 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 nsite 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. ons, VII. Tank information. Fill in the capacity of every new/or existing tatank, list nk matehe total Complete for ambsepti r of tanks a mp/siphon and manufacturer's name, indicate prefab or site constructed a 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. sub The hold county. t nk(s) septic t ans Com lete plans and specifications not smaller than 8 1/2 x 11 inches must bes onm Ittocati of ed t on the inclPude the following: plot plan, drawn to scale or with complete ce; strea akes; tank(s) or other treatment tanks; building and the to ation of the buiiId ng se vied; s ems; replacement system mains/watereasserv absorption sewers; systems; tanks; distribution boxes; soil a p coss sectone; B) horizontal and vertical elevation reference points; C) complete spaand s for p mapufacdtu~er;rD) ;a elevation differences; friction loss; pump performance curve; pump mode pump 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. Wisconsirt Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page 1 of 3 Division of Safety and Buildings in aoeprifance With s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less tha4i,?ii(i 1 inc*,, in size 'P n)pust County include, but not limited to: vertical and horizon renc direct r) a d 5 percent slope, scale or dimensions, north arr d locat ~tance to f hm t road. Parcel I.D. # APPLICANT INFORMATION - Plea in>atll _ 11D y L7 ~ Reviewed by Date Personal information you provide may be used for sec n purpose saw s. 15 (t (m)). Property Owner • party Location 0 P I Govt. Lot J! W 1/4 5 E1/4,S 1 5 T Q9 N,R E (ore ik t. Property O is Mailing Addres Lot # Block# Subd. Name or CSM# a city State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road EA L R b 4 _Y_ s s o~ c 7 s 33601 ❑ New Construction Use: [fit Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow (000 gpd Recommended design loading rate • 7 bed, gpd/ft2_trench, gpd/ft2 Absorption area required $S7.';t bed, ft2 -trench, ft2 p Maximum design loading rate bed, gpd/fl2 trench, gpd/ft2 Recommended infiltration surface elevation(s) 1 5 , ~J R ft (as referred to site plan benchmark) Additional design/site considerations X y 7. 7 b Parent material v' AL o v* w 4- I a G 5 S Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system s ❑ U Ff] S ❑ U ®S ❑ U 15? s ❑ U ❑ S [51 U ❑ S 1A U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ;Trench o -11 ~ p Y fZ, y/ 5. L f G r r,,~ r.,. G ~ f . ~•I lI 1p; a/9 _ 51 - a-SbK T-N f r w 4 • S elev. 99.1,5ft• -3 7.5HR ~f SGL a,-sbK Y,-\ Fr- w 1,/f .14 ,5 Depth to -4 7, S R y )j A V". 51C t,--t Fr- w 1 S ; • 110 limiting' S ytZy/t} L C w e-7 factor e / C -Win. ~O ~•SV~ ~(y ..7 U~ s L Remarks: Boring # V1 V h 'f 'i tr C Ground , elev. ft. ' Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. Address t~ ~ate CST Number a~a aoa ,~+ar ~~~,~r,e z -19_ 9 0 S Y1~ M SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Horizon De th Dominant Color Mottles Structure 2 Boring # p Texture Consistence Boundary Roots G DM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev. ft. Depth to limiting ; factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # Ground elev. ft. Depth to , limiting factor in. Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) r YJ ~y T 0 v • I _ _ . _ --I' - i _ _ ~ , C G~ - _ _ _ f - e I f _ ~ - _ i.. - ~ - - ~ - - - - G i - - 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 the Sec. serving residence located at: 5 4,) l R_Z W, Town of County, Wisconsin. St. Croix Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functionin Last time serviced 7 g properly. Did flow back occur from absorption system? Yes line. Noj( (if no, skip next Approximate volume or length of time: Capacity: / gallons minutes Construction: Prefab Concrete Manufacturer (if known): Steel Other 7' 1~ "o Age of Tank (if known) : (Signature) fy?.'s (Name) Plea Print ~ r (T~tie) ~5.2 0 (License Number) ~ ) ~ _ (Date ~ Form to be completed by licensed plumber (s. 145.0, Wis licensed disposer (NR 113 Wisconsin Administrative6Code)consin Statutes) or - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, c~'tify that the tank I to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection o enin outlet baffle). P g over Name Signature MP/MPRS • S T C - Zoo This application form is to be completed in full and signed by the owner(s) of the property being developed. An inadequac only result in delays of the permit issuance. Should s will this development be intended for resale by owner/contractor, (sp ec 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 j- Location of property" 1 j4~ 1/4, Section T_Z_g N-R_Z f:j~_W Township_ LJQI~,-e, Mailingaddress /aG Address of site Subdivision name Other homes on property? Yes Lot no. No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes Is this No property being developed for (spec house) ? Yes Volume _No and Page Number al 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) described in this information form, by owner virtue oof ha warranty deed recorded in the office of the County Register of Deeds as Document No. ~ . 's own the proposed site for the ewage ~diand sposaltsystem) orr 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 o fice of the County Register of Deeds as Document No. Sig ture of Applicant Co-Applicant Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER o MAILING ADDRESS id" PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION S Q 1/4, ,5~_~ 1/4, Section _/'5- , T!Cg_N-R_Z_y W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION 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. [/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set fo 11herein, as set by the Wisconsin DNR. Certification stating that your septic has-been maintained mu be complet and returned to the St. Croix County Zoning Officer within 30 days of the three year a tion date SIGNED: - DATE: r St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 n; DOCUMENT NO. STATE R OF WISCONSIN FORM 1-1982' . ~ Th PACE RESERVED FOR RECORDING DATA WARRANTY DEED 383635 I [V`07!" 662 FACE ---------REG1S1~$RS OFf'iCE This Deed, made between --_Robert E. Crowe_ _ singlQ__man---------------------------- ST. ClE'OfJC CM~, V& Recd. for Record ft 1st April Grantor, day of ~ D. 19 83 and George-P. Bloom. and Mary_ C._- RIOQm,_huaband•-and_____ wife in joint tenancy..--_.. at 11:45 A ' - Grantee, Rpbfb o! Dald~ Witnesseth, That the said Grantor, for a valuable consideration...... -•--•/-l _ RETURN TO conveys to Grantee the following described real estate in _S-t-._ CrDiX The East'5/8thsf Wisconsin: the nEast Half of the Southwest Quarter and all of the Southeast Quarter, all in - Section 15, Township 29 North, Range 18 West; EXCEPT the South 990 feet of the West 220 feet thereof, Tax Parcel No_ AND EXCEPT the part deeded to James G. and Georgia L. Frost, his wife, by deed recorded in Volume 510, Page 214, described as follows: The North 335 feet of the South 1310 feet of the West 1300 feet of the East 3465 feet of the South J of the South i of Section 15-T29N-R18W, EXCEPT that part within the South 990 feet of the West 220 feet of the East 5/8ths of the East I of the Southwest I of Easement over the West 33 feet of the East 2165 feet sofdthecSoion . M WITH uth11310 few eetof said Section 15, for ingress and egress from State Trunk Highway "12". AND EXCEPT the part thereof conveyed to Theodore R. and Betty A. Gulich by deed recorded in Volume 547, Page 45, described as follows: The North 370 feet of the East 700 feet of the South # of said Section 15, EXCEPTING that right-of-way of State Trunk Highway "6511. Parcel contaiiningofiveracres morelortless. AND EXCEPT the part deeded to David F. Crowe and Phyllis F. Crowe by deed recorded in Vol. 594, page 378,Doc.#357145 bounded and described as follows: The S 975 feet of the W 1300 feet of the E 3465 feet of the Si of Section 15. Excepting that portion lying within the S 990 feet of the W 220 feet of the E 5/8ths of the EJ of the SWI of Section 15. Subject to all existing highways and easements of record. All recording references are to the office of the Register of Deeds for St. Croix County, Wisconsin. This is_ not-....... homestead property. T~1\4rSFER (l!F) (is not) C! Together with all and singular the hereditaments and appurtenances thereunto belonging; FEE And--- e.............................................. warrants that the title is good indefeasible in fee simple and free and clear of encumbrances except existing highways ana easements of record. and will warrant and defend the same. Dated this --------18t11---------•-------------------- day of Ma rch ------(SEAL) (SEAL) (SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN - ss. 911 }'llvr.l•i....4...7 LL!- .fl17T~'V 1 Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER pej,M_ TOWNSHIP ~IA~Plj g rl SEC. T 2IN-R Y W ADDRESS Ro b t e?is ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE 'QIl. CF/ PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM - ~ r 1 ~ 1 ~U~r r i G F'~n u S ~ ` a 0 I ~ INDICATE NORTH ARROW Us , /I .DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS SAFETY & BUILDINGS P.O. BOX 7963 DIVISION MADISOttI, WI 53707 BUREAU OF PLUMBING MCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: ❑ Holding Tank ❑ In-Ground Pressure 1 Mound (If assigned) ❑ NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDEfl: Mr. & Mrs. George Bloom R. R. 1 H I SPECTION DATE: wy. 12, Roberts, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: SE SE, Section 15, T29N-R18W, Town of Warren REF. PT. ELEV.: CST REF. PT. E LEV. Name of Plumber: " MP/MPRSW No.: Count V: Sanitary Permit Number: Joe Stang 6646 St. Croix 64895 SEPTIC TANK/HOLDING TANK: MANUFACTURER: _ LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL ~ LOCKING C VER n.~l✓Jrt~ V /v-~~ P` ~V°E D: PROVIDE BEDDING: VENTDIA.: VENTMATL.. HIGH WATER W1 YES ONO ❑ NO / q NUMBER OF ROAD: PROPERTY WELL BUILDING: VENT TO FRESH OYES ONO t/ FEET FROM S,0 0 LIN~~ AIR INLET: YES ❑ NO NEAREST p( DOSING CHAMBER: MANUFACTURER-. BEDDING: LIOUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER OYES ❑NQ PROVIDED: Pf~~' EYES GALLONS PER CYCLE: PUMP ANOCOIVrfloLSOPERATIONAL OYES NO EYES ONO (DIFFERENCE BETWEEN NUMBER OF PROPERTY WELL But DING: VENT TO FRESH PUMP ON AND OFF) FEET FROM LINE AIR INLET: OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH. or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE DIAMETER MATERIAL AND MARKING the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO. OF DISTR. PIPE SPACING. COVER TRENCHES. MATERIAL: INSIDE DIA.. #PITS: LIQUID DIMENSIONS PIT oevrH: GRAVEL DEPTH FILL DEPTH DISTR BELOW PIPES . PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. : ABOVE COVER: ELEV. INLET. ELEV. END: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope and furrows thrown upslope: Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- OYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEx TUBE [PERANENT MARKERS: OBSERVATION WELLS. DEPTH OVER TRENCH'BED DEPTH OVER TRENCH/BED OYES ❑Np OYES CE ONO CENTER EDGES. DEPTH OF TOPSOIL. SODDED SEEDED: MULCHED. OYES O OYES ONO OYES PRESSURIZED DISTRIBUTION SYSTEM: NO ONO BED/TRENCH WIDTH: LENGTH NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. TRENCHES: FILL DEPTH ABOVE OVER. DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV. ELEV. DIA. ELEV.: PIPES DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: COMMENTS: OYES ONO OYES O NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET OYES ONO OYES ONO NEAREST FROM LINE: v2 ~a ~a Z Sketch System on Reverse Side. etain in county file for audit. SIGNATUR - f ~ TITLE: ujM`ciI'S"' ~_DILH APPLICATION FOR SANITARY PERMIT ju~~_cOUNTY OEPgi'ITfT1=nT OV (PLB 67 q'IC= V, t'4Gg" UrnRnRELRT10nS ) UNIFORM SANITARY PERMIT # -Attach Complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT MAILING ADDRESS [1PRVrERTI OPERTY OWNER c ev loo /Ii, yw ~f Q Y LOCA TION I 'A't` 1 /4 S r 1 /4, S 15 , T N, RE (or) T NUMBER BLOCK NUMBER SUBDIVISION NAME TOWN OF W / r e n /✓1 NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER ~t TYPE OF BUILDING OR USE SERVED ❑ 1 or 2 Family Number of Bedrooms; 3 s Public (Specify): THIS PERMIT IS FOR A: 22 New System ❑ Tank Replacement ❑ Replacement Soil Absorption System ❑ Repair ❑ Alternate System ❑ Revision 1--i Privy ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. X Seepage Bed ❑ Seepage Trench ❑ System-In-Fill ❑ Seepage Pit ❑ Holding Tank ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions, issued Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Septic Tank Capacity UQ Plastic Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: wl G C o ttL R IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROAtiZiUMPTION AREA POSED (Square Feet): I WATER SUPPLY: C4 lDv M Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatur C StG y) MP/MPRSW No.: Phone Number: PPlumber's Address: Jet Z Z 116 ( ?/S ) qk- " /e Name of Designer: .S' a t Sr. I✓ovdv~ ~ ~f .5`~U2 rut 4n COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ ~GC', / , ~ Disapproved ❑ Owner Given Initial Reason for Disapproval: Approved Adverse Determination Alternate course(s) of Action Available: 'ILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber Pla ~ n ~v2 i ~ YI S ~ ~re ~4sre Geo. 910607 tA/o o d V., W.'S z„ e o Sysre ~ y„_ I I 3' ~ I I I I I I ~ I i I ( ~ I , I I I 206 I _ Q i . d Notes c Q0 8. Nl ~-UP o f woad Gagne? fr7Cc- Posr 0 CJev /UO.U fr Z S y S r e *1 t/ c v q 0 i - DEPARTMENT OF REPORT ON SOIL JNDUSTRY, BORINGS AND SAFETY & BUILDINGS DIVISION LABOR HUMAN REDLATIONS P.O. BOX 7969 PERCOLATION TESTS 115J \ (H63.090) & Chapter 145.045) MADISON, WI 53707 LOCATION: SECTION: TOWNSHeI ~ ~ `S /~Z/ D/D W S~ LOT NO.: BLK. NO,: SUBDIVISION NA.MCE: COU /T!Y: OWNER'S / J E (o ~ S Cco/ ; M~S ,,5 . ~~~OM M ~L~NG ADDRESS: USE NO. BEDRMS : COMMERC /KAL DESCRIPTI DATES OBSERVATIONS MADE Residence ON: PR Fl New ❑Replace P DNS: A ON TESTS: RATING: S- Site suitable for system U= Site unsuitable for system ~/~S lOf7 13VAel'i7c CONVENTIONAL: MOUND: IN-GROUNDPRESSURE: S STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM-(o ional) sD/~S S ❑u ®.s au ©s ou [IS au o s au If Percolation Tests are NOT required DESIGN RATE: under s.H63.09(5)(b), indicate: CL~5 S if any portion the tested area is the Floodplain, indis cate Floodplain elevation; PROFILE DESCRIPTIONS Jkv DeCiHhL BORING TOTAL D P H TO GROUNDWATER-. ft• NUMBER DEPTH ELEVATION CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH r OBSERVED ES IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B. Aj B- 2- S 9~ so -AI > S ' ' G7 . Dk. 84. s s N. . s 11 B-3 13.5 oZ' , 13. s JAJ- s; ~ .2S' ~.~s t s' S , s 3 a. (F. B- 7.5 > 7 s . 14'A) 97 s AV-6y. s; aN. sI'l, s s •W; B- Ae£rF of 133 SviTAOL oA /N9 E t cL_ • N O H (r W PERCOLATION TESTS Tom" DEPTH WATER IN HOLE NUMBER IN TEST TIME DROP IN WATER LEVEL-INCHES AFTERS WELLING INTERVAL-MIN. P_ P RI Q1 p RI D RATE MINUTES O Y P R PER INCH P- P- 2- P__ D d G P 30 2 C, 11 go ~l PLOT PLAN: Show locations of iN 9 / Percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- of land slope. 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 SYSTEM ELEVATION 1,76 7,76^4 / qyU >c = I a s /1 I 7 L- , p r or a ~'F f ~7 Zoo =--•.!.~--z-► { a onat syst ,I 1 }s f •-.,T . _ _ ; _ ~ , ; v~,~r;- , ;fir . I / • Ocl~ 7 TTI -7 • z H STC - 105 a r r SEPTIC TANK MAINTENANCE AGREEMENT a H St. Croix County z OWNER/BUYER _V(;~j~Z ROUTE/BOX NUMBER B b'~ Z Fire Number CITY/STATE I) Z I P U Z 3 PROPERTY. LOCATION: SG(,J 14, Section / J T Zg N, R_Lg W Town of St. Croix County, Subdivision Lot number Improper use and maintenance of your septic system I its premature failure to handle wastes. Propermaintenancescon_in sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affe- ctthe function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents m-!.y be eligible to receivc a grant a maximum of 60% of the cost of replacement of a failing system,r 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H I/WE, the undersigned, have read the above requirements and agree to maintain the z private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- .b ment of Natural Resources. Certification form must be completed H and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE S- Z 6- g J St. Croix County Zoning Office P.O. Box 98. Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. APPLICATION FOR SANITARY PERMIT 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/contractot,("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 ?J~Z G Location of Property Section I~ . T Z~N -R W Township Mailing Address AZT l -n ~3J Q-1i C~ Z 3 Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created q S S, S Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume jo Z and Page Number 12-9 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3: Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) cekti, y that att .d•tatementd on •th-i.6 foam cute .true to the best a m knowledge; that I (we) am (ane) the owneh.(4) a6 the _ 6 y (a6 in6on.mati•on 6ohm, by vi tue o6 a waAAanty deed necandedpeLn the 06~ cedo6 the County Regiz teA o6 Deeds as Document No. pkes enttu own tti o vv n r- c n ,a . : 7 ; and that I (we) ) I'ALRTTAL RELEASE OF MORTGAGE f •Yy The Federal Lan swot 7 -f f b PAGE an o aunt Paul, a corporation, 375 Jackson Street, Si. Paul, Minnesota, 55101, CERTIFIES, that a parcel of land in the County of St. Croix described as follows: State of Wisconsin 011. A parcel of land in St. Croix Count X Co.' WIS. as follows: Y9 Wisconsin described ec'd, f"'3. kvxord this 9r 11 do?y of May __A. D. Commencing at a point on the South line of Section 15, T29N, R18W, which 1:30 1' Point w Southeast corner ofsaid 1Section 159 tt enst goof the parallel with the easterly line of g northe feet tothe said Section 15, ~I point of beginnin 345 parallel with the easterly line ofthesaidnce Torah distance of 300 feet; thence travel easterly on a line parallel with the southerly line of said Section 15 a Recording Information distance of 500 feet; thence travel southerly on a line parallel with the easterly line of said Section 15 a distance of 300 feet; thence travel westerly a distance of 500 feet more or less to the point of beginnin. To easement for ingress and egress over the southerly with an 345 feet of the westerly 33 feet of the easterly 2,165 feet of said Section 15. is hereby released from the lien of a mortgage dated March 18 1983 by George P. and Mary C. Bloom, his wife as joint tenants, executed t to The Federal Land Bank of Saint Paul, and recorded in the office of the Register of Deeds in said Co V Records County in o1. 662 of naowiiD, on page 91-98 , or Microfilm, Document, or other identifying No, 383619 The Register of Deeds is authorized to discharge the premises aforesaid from the lien of this mortgage upon the record thereof. Dated May 8, 1985 WITNESSES; THE FEDERAL LAND BANK UFS By The Fedey_al Land Bank Assoc do o roiC, By William Sazam Name T Branch Manager By ug Acting ?Under a Power of Attorney r rded in ist.. Croix Co. Records Vol. 701, Page 228 on STATE OF Wisconsin l November 29, 1984 COUNTY OF St. Croix } JJJ ss. the foregoing instrument was acknowledged before me on Ma-81985w Willin- a v 1" N S ~ .m N v w 0) m aw X, n m=03 o N f cc a o 3 v, ~~w 3 0w `UIC o c 3 c to (o 77 c n c= m •0 0 (D (D - O? (ten D (D A 0 N N f~ 0. 0 AO 00 ~ m 7 CO fD (D 7r O m M A A -0-0 CD 0. Ca = ~r o3-tea oOOMO°O° ^ 0 CD _ r_ 0 (o w 3 o c° ,c C c m 0 3 6* ~m~ 0 Q 0 'Zv c O w CD O. CO O p ((DD O - - % 131 717 0 Co m c ~ 0 (CD O C (A . (a Q O c O n ~O D W A N C c c '0 w w Wciw =°(D(D m O y to 0= w 0 Z N N =r w Co 0 z -4 _j a(DA 3~mCD ~a D -i -N CA w Q N (D - A C (D ra w a =a u; w ac f N Z7 vyaAim~• C m m m c s o o v = Cl O a (D w O Q w _ p o c° c - ao Co W 0 N N iof a,CccFw~~ maw aaa0N0 m aO ((D a=ui Q5 0 a 0 7 O to a O 0 A (A 0 C C ac3 0CCD 0 O o (D to O a O (CD • O o Form- STC-104 AS BUILT SANITARY SYSTEM REPORT OWNER C~ eu. R` O G m- TOWNSHIP ["'I'gRI? e. rl SEC. I r T ~N-R ~l W ADDRESS Rr, to f_ e? t S ST. CROIX COUNTY, WISCONSIN 8 SUBDIVISION LOT LOT SIZE ~ joys p PLAN VIEW ` Distances and dimensions to meet requirements of ILUR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM .tom 1 , ~i. `A ~y c 6 14' u s i i t a 0 INDICATE NORTH ARROW i RF.NCNMARK• Tlo~+nril.e tl... ......~s,...i ..-c_-__-- __s-~ - • 1_' 7 - µ PUMP CHAMBER f Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Z K Length: L U Number of Lines Area Built: /6 a Fill depth to top of pipe: ~ 32 Number of feet from nearest property line: Front, Side, 0 Rear,0 Ft. U 6 Number of feet from well: ~1l Number of feet from building: 3 , (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: DEPARTMENT OF'INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN RELATIONS SAFETY & BUIL_...~„ P.O. BOX 7969 , PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WI 53707 BUREAU OF PLUMBING MCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: I SP CTION DATE: Mr. & Mrs. George Bloom R. R. 1, Hwy. 12, Roberts, WI S` -2S BENCHMARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN 1S REF. PT. ELEV.: 77P7T. ELEV.: SE SE, Section 15, T29N-R18W, Town of Warren Name of Plumber, MP/MPRSW No. Count Joe Stan y Sanitary Permit Numberg 6646 St. Croix 64895 SEPTIC TANK/HOLDING TANK: MANUFACTURER. ` LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL J LOCKING C VER PP.~(J[~V~J~E yD: PROVIDE BEDDING: L VENT DIA.: ~VaENVT MATL.: HIGH WATER IN YES ❑ NO ❑ NO A R NUMBER OF ROAD: PROPERTY WELL: BUILDING: (VENT TO FRESH ( FEET FROM ©0 .L LINFj., AIR INLET: DYES ONO YES ONO NEAREST ( c(J DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PrVIDED YES ONO \ DYES O NO ❑ YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUI DING. VENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE' AIR INLET PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moistureat the depth of plowing eracnl DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO OF DISTR. PIPE SPACING COVER INSIDE CIA TRENCHES. MATERIAL: ?t PITS: LIQUID DIMENSIONS PIT DEPTH: GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. BELOW PIPES ABOVE COVER. ELEV. INLET. ELEV. END: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH PIPES FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEV..A- DYES NO meets the criteria for medium sand. TIONS MEASURED. O SAIL COVER TEXTURE. =RS OBSERVATION WELLS. DEPTH OVER 7DEPTH OVER TRENCH/BED ONO DYES ONO CENTER DEPTH OF TOPSOIL. SODDED SEEDED: MULCHED. EDGES: DYES ONO DYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.. ELEV.: PIPES. DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: DYES ONO DYES ONO COMMENTS. PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: r FRO L , 2 J O DYES ONO DYES ONO NEAREST- LINE: J g' v~ 2 a / as L-I Sketch System on etain in county file for audit. Reverse Side. y SIGNATUR - i /~y" ~ TITLE: DILHR SBD 6710 (R. 01/82) wisconsin APPLICATION FOR SANITARY PERMIT HR COUNTY - DEVwgrmEnTOF (PLB 67) WIOUSTg4,LgBOR6MUmgn-.LgTOns UNIFORM SANITARY PERMIT # 4D -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'%x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MA / r Af' RSA (~eU, Jp0 m ILfjING ADDRESS/-/ PROPERTY LOCATION "T ' r W e St 1/4 Sr 1/4,S 15-, E or ~r. LOT NUMBER BLOCK NAME TOWN OF: W e n / NEAREST ROAD, LAKE OR LANTDM RK STATE PLAN I.D. NUMBER u. S. 1 ~w l2 5 N//q TYPE OF BUILDING OR USE SERVED ❑ 1 or 2 Family Number of Bedrooms. 3 Public (Specify): THIS :Alternate MIT IS FOR A: X System ❑ Tank Replacement ❑ Repair ❑ lacement Soil Absorption System ❑ Revision ❑ Privy ❑ System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. X Seepage Bed ❑ Seepage Trench ❑ Seepage Pit System-In-Fill ❑ Holding Tank ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions, issued Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity 00 Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: g C 0 ~tL R IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY: f U Z / ~5 / / U 9 Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signatur x MP//MPRSW No.: Phone Number: Po e S t 4 h v vz°_ u•~ 4. (s lc ~~10 (7~ S ) 48 2 ~(b Plumber's Address: I / / ' / t~`7 Name of Designer: "V 7 a 'rl S r, o v d L, 1 /e W t .l U2 r, n COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: /V`~ ❑ Disapproved ~ ~ Q A_J ❑ Owner Given Initial Reason for Approved Adverse Determination Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber e INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 ' To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. pla I,n o)I S~'re t,✓4Sre Y_ A i. e /C s 0 S7 ~ ~ rO Y e Y~l I ~ I tCty 9yi ~ lo~',e a-3 ~ I I I I I I I I I I I I I I I i I I I I I 20t" ck~ Q © 10001c,nlc J ~ ~ No us IL~- a./~ 7oP wood L'oR»e? Ft»CG Posr ~N ~ t /e v Z s ys re.n t /c ✓ 9~l.0 DEPARTMENT OF ~ INDUSTRY, REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS LABOU AND P.O. BOX 7969 PERCOLATION TESTS 115l DIVISION HIyMAN RELATIONS (H63.09(1) & Chapter 145.045) MADISON, WI 53707 LOCATION: SECTION: TOWNSHI LOT NO.:BLK. NO.: SUBDIVISION NAME: Sf '/a 1/ !S /Tzf N/RIFE (o W lvrf~P~P~'~t/ AIT f 176, '4C12- 75f^., COU TY: OWNER'S S N E: M S Cco/A0, /VS . t3 ER T5 C<) i s . FYol USE NO. BEDRMS : COMMERCIAL DESCRIPTION: DATES OBSERVATIONS MADE Residence ❑Re lace PROFDILE DESCRIPTIONQS: PE DILATION TESTS: RATING: S= Site suitable for system U= Site unsuitable for system ~~J ~v~/~'~~%!~ ~ /V / ~iiC/ ~ sa/~S' ~ CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(o tonal) s ❑u ~s au ; ©s ❑u a s ©u a s au Fu Percolation Tests are NOT required DE~SI+GN RATE: nder s.H63.09(51(b), indicate: Ci`1~ S S If any portion of the tested area is in the Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS llVt'yhL F.~., BORING TOTAL D NUMBER DEPTH ELEVATION PTH TO GROUNDWATER-. _ CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) r ~ B- / 9 f y9 err > 9 S ' • 8~, 'Of'. a,,. s .u- ' . s T~ p ~ s. B- If . -2 O I 67 ~k. Q~ . S/ s 11 Ill, 1 0 N . F3 . sr s 1 o~,~.e fs . B- 3 l3. S 9a. ~Z-- > ~3 S ' • s' , -1141 B- ~ S. - A) . OF. s , -7. s . s s a. s OF. p ' r~N ~ ~e s~rNv S, s aN. s;~, s' s 7 5 97. ~z,-- > 7s- of 4AJ S. S B- 7.S 16.9d' >7s AA). Y// A 3 G~,Q,a. S• ~~'tiX a f '"~!a S. ~ S B- A4C Of~R LG. vtRI Oa`h(1 GU iNg E PERCOLATION TESTS TEST- NUMBER DEPTH AWAFTER TER IN LOLILE_ INTERVAL-MIN. TIME DROP IN WATER LEVEL-INCHES PERIOD 1 PERIOD 2 PER RAPER INCH ES P- O Y P_ P- D a / G P-_ P 30 2 & ✓ .:L It 7,V' 5-4AVP M PLOT PLAN: 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 slope. SYSTEM ELEVATION l3o Tfo.~ 9' yU f I lit g • ` /60 3 Q So QX _ Thf- ft$~ f ~for a C~ •~-z - I i TN 1 r . - Arr i =-•i V llf r 9L~ ' ~s INSTRUCTIONS FOR COMPLETING FORM 115 - SRD - 6395 f To be a complete and accurate soil test, your report must Include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence oic commercial project; 1 MAXIMUM number of bedrooms or cormercial use planned; 4. Is this a n or replacement system; 5. Comp'--- , ~uitabilit.y rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER "E=_AS ARE RULED OUT BASED ON SOIL CONDITIONS; 6 PLEASE r. the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale Is preferred. A separate sheet rnmy be'used•if desired; 83 Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. " the form arid plane your current address and your certification number; 1:. I, v 11ible copies and distribute as required ALL SOIL TESTS MUST BE FILED WITH THE L) AL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Syr st - Stone (over 10") BR - Bedrock cob Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone s Sand HGW - High Gr- --ter cs Coarse Sand Perr, Percol P, med s Medium Sand W - Well fs_ Fine Sand Bldg - Building Is - Loamy Sand > - Gt,ar Than ksl - Sandy Loam < Lc rr- -i *1 - Loam Bn Br,-:i *sit - Silt Loam BI - Bf:- - Gr si ~ t C'y "cl - _ oarn y Y scl Clay Loam R - R sicl - t:.ry Loam mot - M sc Clay vet,' w sic ~ fff fc, c cc - comn- r Pt !nm f Many, rn Mu<k d distir p - prom HL Hi±;' level, Si !ral auras s.,: ater.: d v ,,~osal BM - Berk V'RP - Verti per, ce Point r ` APPLICATION FOR SANITARY PERMIT 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/contract;Q.C,("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 G 4- 04,2--t, ~Lcryvr-, Location of Property S W S ti, Section T N - R / W Township ~22 Mailing Address la r I Z, ,6 -o 02 Subdivision Name Lot Number ' Previous Owner of Property C2~Ma &e Total Size of Parcel Date Parcel was Created 422,4 y Are all corners and lot lines identifiable?_ Yes No Is this property being developed for resale (spec house) ? Yes_ No Volume _ b Z and Page Number yZ-- j k as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3: Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPFRTV OWNER CERTIFICATION 1 (We) centi.6y that att statements on thin harm ahe tlr.ue to the best o6 my (ouh) knowtedge; that I (we) am (ane) the ownen(b) o6 the properrty descA bed in tW in6o mati.on 6onm, 'by v.tlr.tue of a wa4 anty deed neeonded in the 066ice o6 the County RegisteA o6 Deeds as Document No. Iylplg'fj and that I (we) H z H STC - 105 r r 9 SEPTIC TANK MAINTENANCE AGREEMENT H St. Croix County 0 z ,fin Q a OWNER/BUYER 00j." H ROUTE/BOX NUMBER Fire Number S~ CITY/STATE t? S6-a-T'S (J/ , ZIP U Z PROPERTY- LOCATION: &'14-1 ;4, C- k, Section / J T_.2-5 N, R/(9 W, Town of WA1a1Z&-7,-j St. Croix County, Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 0 I/WE, the undersigned, have read the above requirements and agree z to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE_ S - l Zj - J St. Croix County Zoning Office P.O. Box W Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. PARTIAL RELEASE OF MORTGAGE 4~~h!Ir~, ~IDt 7PAGE. The Federal Lah`dank o? Saint Paul, a corporation, 375 Jackson Street, St. Paul, Minnesota, 55101, CERTIFIES, that a parcel of land in the St. Croix State of Wisconsin 'County of described a8 follows: , - 5TERS OViCe ;ec:'d. f=.-)knrord this 9r1,__. A parcel of land in St. Croix County, Wisconsin described ~t~of May A .D. 1ST' as follows• , 1:30 p Commencing at a point on the South line of Section 15, T29N, R18W, which point is 2,165 feet West of the aka tie Southeast corner of said Section 15, then go north parallel with the easterly line of said Section 15, 345 feet to the point of beginning; thence continue north parallel with the easterly line of said Section 13 a distance of 300 feet; thence travel easterly on a line Recording Information parallel with the southerly line of said Section 15 a distance of 500 feet; thence travel southerly on a line parallel with the easterly line of said Section 15 a distance of 300 feet; thence travel westerly a distance of 500 feet more or less to the point of beginning. Together with an easement for ingress and egress over the southerly 345 feet of the westerly 33 feet of the easterly 2,165 feet of said Section 15. is hereby released from the lien of a mortgage dated March 18, 1983 executed by George P. and Mary C. Bloom, his wife as joint tenants; t to The Federal Land Bank of Saint Paul, and recorded in the office of the Register of Deeds in said County in Vol . 662 Records 97-98 or Microfilm, Document, or other identifying No. '183632 of on page The Register of Deeds is authorized to discharge the premises aforesaid from the lien of this mortgage upon the record thereof. Dated May 8, 1985 THE FEDERAL. LAND BANK OF S*Y. ly't',AI WITNESSES: p.. By The Federal Land Bank Assoc tiP14 ot~ CCrox, ~,P ~ 51 William Sazam . By Name By Branch Manager Title Acting ;Under a Power of Attorney cded in St. Croix Co. 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