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CERTIFIED SURVEY MAP NO.
LOCATED IN THE SOUTHEAST QUARTER OF THE SOUTHWEST QUARTER OF SECTION 22,
TOWNSHIP 30 NORTH, RANGE 16 WEST, TOWN OF EMERALD, ST. CROIX COUNTY, WISCONSIN.
UNPL AT TED LANDS
LEGEND EAST 307 00'
d
® FOUND BERNTSEN ~I LOT
l
ALUMINUM MONUMENT B7,120.80. FT, p
(SECTION/ CORNER) Wr~ 2.00 ACRES Q
O SET 314'x 24 REBAR co (WITHOUT R/W) ~6 -
WEIGHING 1.502L.BS/L.F. 1zX1 97,251 S4.FT.
"O
2.23 ACRES W l
~ DRIVE ~ BEARINGS RE-
'-I FERENCED TO
THE $T14 ~E
SCALE: l = /00 H CF TH SOUTH
OUSE WEST QUARTER
- OF SECTION 22-
0 50 /00 200 1 p A0 WEST. SUMED
~ ~ M O
WEST 30700,
140 TH AVENUE SECTION LINE-A
n 1771.05m WEST 307 00 54530
ZSOE UTHWEST COER UNPL A T TED LANDS SOUTH QUARTER CCT ION 22-30 16
SECTION 22-30-I6.
SURVEYOR'S CERTIFICATE
1, Leon R. Herrick, Wisconsin Registered Land Surveyor, hereby certify that I have surveyed,
divided and mapped a part of the Southeast Quarter of the Southwest Quarter of Section 22,
i"ownship 30 North, Range 16 West, Town of Emerald, St. Croix County, Wisconsin, more
particularly described as follows:
Commencing at the south quarter corner of Said' ,Section 22;
Thence West 545.30 feet to the point of beginning;
Thence West 307.00 feet;
Thence North 316.78 feet;
Thence East 307.00 feet;
Thence South 316.78 feet to the point of beginning.
Said parcel contains 97,251 square feet or 2.23 acres.
That I have made such survey at the direction of Ben Mortel, Box 118, Emerald, WI 54012, owner
of said land. That such map is a correct representation of the exterior boundaries of the land
surveyed. That 1 have fully complied with the provisions of Chapter 236.34 of the Wisconsin
Statutes and the subdivision regulations of the Town of Emerald, County of St. Croix, in
surveying, dividing and mapping the same.
Said survey is, subject to existing roads and easements o 9 record.
IX q,
Wisconsin Departmentof.lndustry, PRIVATE SEWAGE SYSTEM County:
Lab-^r and Hainan Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284186
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
HURTGEN, DAVID EMERALD
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
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
Loss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O CHAMBER Model 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: EMERALD.22.30.16W, SE, SW, 140TH AVE
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:
^~w:^ Safety and Buildings Division
~~■~nr. SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. '5'74 e
• See reverse side for instructions for completing this application State Sanitary Permit Number
,;?&/7l,?~
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 LD. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Prope Owner Name Property Location
v!' y s6 1/4_5'&,j 1/4, S a T 30 , N, R Mr) W
Property Owner's Mailing Address Lot Number Block Number
v to
City, State Zip Code Phone Number Subdivision Name or CSM Number
❑ / Nearest Road
II. TYPE OF BUILDING: (check one) E] State Owned ❑ city
age
E Public 1 or 2 Family Dwelling - No. of bedrooms .3 Tow
n OF F`n'1 `°IQI~ L4 14,o t.4 . 4 l~ 2
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax N//umber(s)
1 ❑ Apartment/ Condo 0 /e
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE. OF PERMIT: (Check only one box on line A. Check box online B, if applicable)
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. X Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
4-5-0 fee .0 J- C/ l' of Feet I'~. ,4~2 Feet
VII. TANK Capacity Total # of Prefab. Site Fiber- Exper-
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank 0 ❑ ❑ ❑ ❑ ❑ -4 Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (N Stamps) MP/IiNo.: Business Phone Number:
.5'd 7/= - 26.5 8'3~'
CsA L e
-M it h
Plumber's Address (Street, City, State, Zip Code):
wDOW
D G-Jgll
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sani ary Permit Fee (Includes Groundwater Date Issue Issuing A nt Signature (No Sta p
/ Surcharge fee) CWApproved]E] Owner Given Initial GP7
Adverse Determination /CO /LO
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to Courtly, One copy To: Safety & Buildings Divs ion, Owner, Plumber
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.
1 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
1_
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; 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.
' -WuUGROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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T
AS BUILT SANITARY SYSTEM REPORT
OWNER ,D tq UJ C) I_)j.2 7--G C-YU -TOWNSHIP
SECTION_a?QL_T :p N_ C , W
ADDRESS ST.-CROIX COUNTY, WISCONSIN
SUBDIVISION
_,_LOT LOT SIZE : 4cl e-
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF.SYSTEM
-
d . ~4~rc /8X3 ~
12.x' +
z
2' u~
a~.
INAICATE NORTH ARROW
BENCHMARK: Elevation and description: OJ[Te-4- ~Q
Alternate benchmark -
SEPTIC TANK: Manufacturer:~'1~_~~-s (;{--Miquid. Cap, Q
Rings used:„-„-Manhole cover elev: Final grade elev:z
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.,: Pump Size
Elevation of inlet: Bottom of tank elevation
i
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front_, Side, Rear-Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: ✓ 1 Trench: Seepage Pit:
Width:-Zl=Length -5 Number of Lines: Area Built
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to!top of pipe: 6
No. feet from nearest prop. line:Front , Side,, Rear Ft.
No. feet from well: .iL~ No. feet from building ,l Sri r
HOLDING TANK
Manufacturers Capacity.:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front , Side , Rear Ft.
No. feet from: Well building , nearest road
Alarm. Manufacturer:
INSPECTOR: n~+ 71/0.0'.l ('S e)
DBTE : PLUMBER ON JOB :
OCA,T. ON : EME~AJ,D 25.30.16.374 SE SW 140TH AVE.
iscon inDe~artmento n ustry, PRIV'MSEWAGE SYSTEM County:
Lab&.and Human Relations INSPECTION REPORT
Safety ar.d Buildings Division
(ATTACH TO PERMIT) Sanitary~it ftoIX
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village Town o : State PlaIlftlai 1
si.
V rCI X 6-4wau
CS Insp]YM Elev.: BM DescriptionParce Tax No.:
TANK INFORMATION ELEVATION DATA 010-1059-30-000 G o31
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 2
_ Dosi
Aeration Bldg. Sewer
Holding St/!i1t{Inlet ~.OS•
TANK SETBACK INFORMATION St/ Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic., NA Dt Bottom
i
Dosi NA Header/- 7. 46,
Aeration NA Dist. Pipe 7,33' CJc~ p~
Holding Bot. System 3.3-2,
PUMP / SIPHON INFORMATION Final Grade
S9 S, loe2'
Manuf r Demand
Model Number GPM
TDH Lift Friction System DH Ft
Forcemain - Length Dia: - - -Dist To well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width p i Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN f N ~U 5,311 1 DI I N
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHI Manufacturer:
SETBACK
INFORMATION TypeO if i CHAMBER Number:
System: 5F
42S: ti/$~ '>/SQ OR UNIT
DISTRIBUTION SYSTEM
Headed njoW Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake
Length _4:--, Dia. Length Dia-(L Spacing
SOIL, COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over q „ Depth Over rI xx Depth Of xx Seeded / Sodded xx Mulched
Bed / Trench Center -J~ Bed / Trench Edges ' Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMEEN~TS: (Include code discrepancies, persons present, etc.)
4/"161 CA TM- 4`
PVC, e otLR- c~ s .T•
Plan revision required? ❑ Yes L o /
Use other side for additional information.
SBD-6710 (R OS/91) Date Inspector's Signatu a Cert No.
AS BUILT SANITARY SYSTEM REPORT
OWNER
Z~ 2rG C-rt1 TOWNSHIP L"°~l r•~:c •
SECTION-a?,2_T ~36 N- W
ADDRESS 'S ( yJc-72~q-r r> ST.'-CROIX COUNTY, WISCONSIN
SUBDIVISION- 44Z r+ LOT 1,114 LOT SIZE ~
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF.SYSTEM
2.4' s
I ~4
a` 50
L
o
INDICATE NORTH ARROW
BENC101ARK:Elevation and description: n ' cJbc-c_ /DrJ
Alternate benchmark
SEPTIC TANK:Manufactx•~r;~~,~--~?rr,}J Id:'igvid Cap., cJ
Rings used:--Manhole cover elev: j -`j elev: ~'~z
Final grade
PUMP C UU4BER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufact.: Pump Size
Elevation of inlet: Bottoms of tank elevation
i
Pump on elev.: Pump off elev.: Gallons/cycle:
Alarm: Man.: Switch Type: Location
Distance from nearest prop. line: Front_, Side-, Rear_Ft.
Distance from: Well Building
SOIL ABSORPTION SYSTEM
Bed: ✓ '-Trench: Seepage Pit.
.
Width: _ Length -S Number of Lines: = Area Built
Exist. Grade Elev. V Y"' Proposed Final Grade Elev. 5 _
Fill depth to top of pipe:_
No. feet from nearest prop. line:Front_, Side„,, Rear Ft.
No. feet from well: -3.SL No. feet from building ~SJ
HOLDING TANK
Manufacturer: Capacity.:
No. of rings used: Elevation of bottom tank:
Elevation of inlet:
No. feet from nearest prop. line:Front Side , Rear Ft.
No. feet from: Well building , nearest road
Alarm.Manufacturer:
INSPECTOR:
DBTE : PLUMBER ON JOB :
LOCATION: EME2A~.D 25.30.16.374 SE SW 140TH p~yE.
Wisconsin Depart mento In ustry, PRIV~ATVSEWAGE SYSTEM County:
Lrabm.and Human Relations INSPECTION REPORT
'Safety a'r~d Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary~*{nit ftoIX
Permit Holder's Name: ❑ City ❑ Village Town of: State PlartI? N.41
v ~d X 4~~- ~a
CS IPM/EElev.: BM Description ,-;F Parcel Tax No.:
TANK INFORMATION ELEVATION DATA 010-1059-30-000 o3~Z
-2-- 2e6
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
] Benchmark Z `
Septic
lomcas~
Dosi
Aeration Bldg. Sewer
Holding St/J~ Inlet 406,
TANK SETBACK INFORMATION St/ Outlet 17-,Co
Vent
irito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Ar
Septic y` .c, 1 y i NA Dt Bottom
Dosi NA HeaderLhliie~ 3
Aeration NA Dist. Pipe 7,33 392. QS
Holding Bot. System Z~
2.32
PUMP/ SIPHON INFORMATION Final Grade
S9 S,
Manuf r Demand T cs~S T.
lv- ~S
Model Number GPM
I Loss Friction System DH Ft
TDH Lift
Head
Forcemain Length Dia. Dist. To wen
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 5 3 DI I N
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHI Manu acturer:
SETBACK
INFORMATION Type O CHAMBER
'n ~f ti >/!So
System: OR S `
DISTRIBUTION SYSTEM
Header4, A.Woi.- Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. e~ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over tc Depth Over 4 xx Depth Of xx Seeded/ Sodded xx Mulched
-✓W Topsoil E] Yes C] No ❑ Yes E] No
alc
Bed /Trench Center -36 Bed /Trench Edges
COMMENTS: (Include code discrepancies, persons present, etc.)
C,4 ( eel ,4S ?h?- 40 - 21 Z.y
,
Plan revision required? ❑ Yes B_1T0__ A Use other side for additional information. c3 cam,. l
SBD-6710 (R 05/91) Date Inspector's Signatu a Cert. No
ADDITIONAL COMMENTS AND SKETCH
M
SANITARY PERMIT NUMBER:
701LHA SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code
STATE SAN ARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ec/ I.Vious 8% x 11 inches in size. if revn papplication
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOC TION
C'~/h l /-D 7) s G:'/4 S541, S.0 Z Tad, N, R E (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE' ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
_0 I
II. TYPE OF BUILDING: (Check one) CITY r NEAREST ROAD
❑ State Owned ❑ , WW Q A,14_-7
❑ Public 01 or 2 Fam. Dwelling-# of bedrooms3 PARCEL TNUMBER(b)
111. BUILDING USE: (If building type is public, check all that apply) r CJ
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check my one in line A. Check line B if applicable)
A) 1. ❑ New 2. Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - 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 16 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
0 9113 Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
structed
_
ITanks Tanks
Septic Tank or Holdin Tank 10 L Z
Lift Pump Tank/Si hon Chamber ~y
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) P PRSW No.: Business Phone Number:
Plum 's Ad press (Street, state, zip C. _
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes groundwater a e ssue Issuing gent Signature (No S m )
Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R.11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS •
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the 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 (;BBD 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 & 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 in 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 in ##1-7.
VII. Tank information. Fill in the capacity of every new and/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% 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, ground-
water contamination investigations and establishment of :standards.
SBD-6398 (R.11/88)
APPLICATION FOR SANITARY PERMIT
STC-100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor,(spec house), then a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property --~4/c~7~rr-mil
Location of property ,§X1/9 -S_U)_1/9, Section o2 , T N-R l~ W
Township r
Mailing address E
Address of site
Subdivision name
Lot number
Previous owner of property O'ees _
Total size of parcel ,4e 25
Date parcel was created r c/1~
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)? Yes X No
Volume and Page Number HS --3 as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. X57>rf'7 ; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
ry
H
OWNER/BUYER L%~r4~J rL~-GnJ
ROUTE/BOX NUMBER C Fire Number
.CITY/STATE i~ C ~S ZIP
PROPERTY LOCATION: a~ ;4, _'k, Section~Z T_30 N, R 14 W,
Town of 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.
0
E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ►d
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 o2lJ,-
St. Croix County Zoning Office
P. 0. Box 9&
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDING.,
INDUSTRY,
LABOR AND PERC9 T T y~5 DIVISION
HUMAN I ELAtIONN ION f#T
LOCATION- SECTION. TOWN.~i ~e fs+'I~L~rv. ri/,4 B ~A : SUBDIVISION X
NAME:
S/cJ~/ ,2z /T ON/R (or W /1
COUNTY: NAME:, INU ADDRESS:
IMAIL
Sf, 5~.1~,E'itl SOS. o3 A ~4ur ,r► /y1.n11. ~"~Q/ Z .
E DATES OBSERVATIONS MADE
NO. B : MMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TEST
®Rssidence JI ❑ New RReplay e /7
RATING: S- Site suitable for system Um Site unsuitable for system '7 ..7-
0 S ❑u ICQNVENTFONAL: MQ w' ❑ JD-PRESSURE u • Q S -FIU L 0 .RECOMMENDED SYSTE :(optional)
If Percolation Tests are NOT required DESIGN RATE: LFloodplain, any portion of the tested area is in the
under s.H63.09(5)(b), indicate: indicate Floodplain elevation: y
PROFILE DESCRIPTIONS
BORING TOTAL P H R UNDWATE -INCHES A A R SOIL WITH THICKNESS, L TEXTURE, AN DEPTH
NUMBER DEPTH in. ELEVATION BSERV D TO BEDROCK IF OBSERVED SEE ABBRV. ON BACK.)
B-2 .o y-9~ , p~ 3 1. 9y~
oool
OHO D.~ ii
G ,
B-
B-
B- '
PERCOLATION TESTS
TEST DEPTH WATER WHOLE TEST TIME DROP IN WATER LEVEL-INCHES RA
44"ER IAQs" AFTERSWELLING INTERVAL-MIN. PER INCH
t' -3-,00' IV,, AI i /.,V - _
X33 i °
P-.
P-
P-
LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the horl-
ontal 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
f land slope.
YSTEM ELEVATION 91.30
i 1
N
I
_--r--
Sp_ C.. 22
RC~
Rt, 3 jB6X AJ J
.~usl.i7~ i~►J~y!•;s`s'9/Z s:t sEy s~'y
-13oN if M W
f
.4 8,/77. = BefiCh 1nQ4
IN. ilev,
INI \ os0
t S h'rea ,o GcJell cQS;ny
\ \083 ` o = 13or-e No %s
\ G : lie r-c 11o le S
1 - - = System Area
31
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II
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