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Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: Re t1061 m f M e fe R 6 d x ALTERNATE BM: & t~ot)' om N F Sj p~~ ~l~ 9 SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: /e ,S e- /Q Liquid Capacity: /000 - Z00 Setback from: Well House Other hie Pump: Manufacturer_ SO y Lai Model# Size Float seperation a 1 " Gallons/cycle: Alarm Location A S e- hA 6 k 7' SOIL ABSORPTION SYSTEM Width: Length Number of trenches ;Distance & Direction to nearest prop. line: Setback from: well: House Other fo f 1 ELEVATIONS r *ft Building Sewer ST Inlet: ,O ,d ST outlet: PC inlet PC bottom ek 902 Pump Off 0 7, / 7 Header/Manifold Bottom of system 9 Existing Grade , Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: M /0 ire INSPECTOR: 3/93:jt Wisconsin pepartmentofIndustry, PRIVATE SEWAGE SYSTEM County: Labgrand Human Relations INSPECTION REPORT ST. CROIX ISafety and Buildings Division (ATTACH TO PERMIT) Sanitary PermitNo.: GENERAL INFORMATION 268649 Permit Holder's Name: ❑ Cit p Village Town of: State Plan ID No.: COFFEY, JOHN C & LAURIE L FOREST CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600354 /a'. / TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic I Benchmark o q7 i / Dosing ~s0 ll~. Gd Aeration Bldg. Sewer A y3, S6' Holding St/ Ht Inlet 40.6 S' TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic 7/6 NA Dt Bottom Dosing ;0, #(q 2S NA Header /Man- Aeration NA Dist. Pipe Holding Bot. System`/ ' 9(o . 7~ PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand yy Model Number GPM TDH Lift LFrict oss ion 5g ` Head rL, ~j' TDHDuI Ft Forcemai n Length ' % Di a. , " oo~~Dist. To Well r SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 9 DIM N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA M Per: SETBACK INFORMATION Type O , CH R R UNIT Moe Number: System:9.6.0 Mn'I. ">6n DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. oZ Spacing 7f S~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over d Depth Over a xx Depth Of j xx Seeded / S c cS7ce xx Mulched Bed /Trench Center Bed /Trench Edges IaJ~~ Topsoil Yes E] No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: FOR~ES)T/J.34/ ./31.15, NW,, NE, H.WY `64 , ,t a / V • -z)l 77' 7/7 Plan revision required? ty/Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH . t SANITARY PERMIT NUMBER: r~ Safety and Buildings Division ~•~~r>.r,t 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. 4- • See reverse side for instructions for completing this application State Sanitary Permi Number 19 Z7 / 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 INFORMATION .S b~ e2 q Property Owner Name Property Location CI ® ~e A, 1/4 "1/4, 5 T , NI R -AN) W Ire 16 & Property Owner's Mailing Address of Number Block Number Nw City, State Zip Code Phone Num~b~e.r Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned LT C, (age Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms oil w n of ,0 E'S T~ w III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo o /a 7.,!~r 0 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. po Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 Dd 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 ,SO ✓t'r 7 D 9 V/ Feet Feet VII. TANK Capacity Total # of Prefab. Site INFORMATION in Gallons Tanks manufacturer's Name PConcrete con- steel Fiberglass- Plastic ExpeApp.r. New Existing strutted Tanks Tanks Septic Tank or Holding Tank 0'D'a 1" ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber Zoo r ® ❑ ❑ ❑ ❑ ❑ 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' Signature: (No Stamps) MP/lll~hfo.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEP RTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Induces Groundwater Date Issue Issuing Agent Signature (No Stamps) ❑ Approved F] Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: INSTRUCTIONS 1- A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served- Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. if building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete iine 3 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, iist the total gallons, number of tanks and manufacturer'; name, indicate prefab or site constructed and tank materiai. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. I VIII. Responsibility statement Installing plumber is to fill in name, license number with appropriate prefix (e. g. MP, etc.), address ar.d phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete ;clans and specifications not smaller than 8 1/2 A 11 inches must be submitted to the county- The plans must include the= following: A) plW plan, drawn to scale or with complete dimensions, location of hc; ding tank(s), septic tank(s) or other treatrnenttanks; building sewers; we!ls,- water mainsfwater service; streams an 3 lakes; pump or siphon tanks; dis ibution 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 cantrols; dose volume; elevation differences; friction loss; pump performan(e curve: purtip model and pump manufacturer; D) cross section of the soil absorption system if required by the col-inty; E) soil test data on a 1 15 form; and F) a;l sizing information. GROUNDWATER SURCHARGE i 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. I I Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building water systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans,(to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. X • See reverse side for instructions for completing this application state Sanitary Permitt umber The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D: Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location A( e- 4)1 /4 1/4,S T , N, R saw) W Property Owner's Mailing Address Lot Number Block Number r- City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road ❑ Village ❑ Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town OF 1'a eS III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo o / - /o 7-7 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. M Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 213 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14E] 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 ,ro 7-f - 7` 5?_?, 4.f Feet Feet VII. TANK Capacity Total # of Prefab. Site Fiber- Exper. INFORMATION in gallons Tanks Manufacturer's Name PConcrete Con- Steel glass Plastic App New Existing Gallons strust rutted Tanks' Tanks Septic Tank or Holding Tank 1006 ~yA~ e f e ? 0 1:1 1 El 1:1 1 El 1:1 Lift Pump Tank /Siphon Chamber G d M 6 ® ~ ~ Ei n ❑ 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) MP o.: Business Phone Number: A.41 -5-M h Plumber's Address (Street, City, State, Zip Code): 3 2 w 7Q~ m w o W -C % t IX. C UNTY / DEPARTMENT USE ONLY ete) -water ate Issue Issuing Agen Signatu m CIS S rchar ❑ Disapproved Sa ry Permit fee (Induces Surchargee Fete) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) DISTRIBUTION: Original to County, one copy To: Safety & Buildings Divi ion, Owner, Plumber INSTRUCTIONS r 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county- The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, 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. Hwy 1 1 i I 1 I i i gel Of - i i 1 { I , I 1 _j _ l , --.j - I- - - i - .40 1 -1 I -I - _ - -T %c Page Of Strow, Marsh Hoy, Or Synthetic Covering Distribution Pipe Medium Sand G Topsoil F _J E d b % Slope force Main l'luY.ed Bed Of 2 2 From (lump t-Oyer Aggregate Cross Section Of k t"urid (,;)'stern Using A Bed For rthe Absorption Area G License Number: L_ //`7 . f t . w 7 •.2,~2 r i . _ Jts_ - - - - - - - - i I force Main From Pump ~Dislribulion 0, Ot, L, Pipe . -Aggregote • Observation Pipe d. t:;. s• X71+«: ~Pion View Of Mound Using A Bed For The Absorption Area 596-20589 Page- ofd Perforated Pipe Detail End View Fokpt2d peR pvc ,1 a r ~ b Qts Force c,.-,in i1 orioles located cn bottom of force u main are equwl~, spaced r _ld cap ~La,st hole should -be next tc end cap Distributation pipe layout P_Z, F t K Inches Invert Elevation of Laterals S ° Inches XInches Signed: Y Inches Licenses -Hole Diameter Inches Date t LateI " _ Inches 4w r ~a s1:+ ' ANO Manifold " Inches Main Inches # of holesAipe S 11 96-20889 • PAGE OF 4 - PUMP CHAMBER CROSS SECTIOM AM) SPECIFICATIONS VENT CAP 4"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING 7-Tj JUNCTION BOX MAIJHOLE COVER ~ 25' FROM DOOR, WINDOW OR FRESH 12"MIU. i P.IR INTAKE GRADE I `I" MIM. I B" ml - CO,QDUIT l - - - - - - - - - - - ,111 PROVIDE I - INLET AIRTIGHT SEAL I II~ I III APPROVED JOINT A I III APPROVED _ C.Z. PIFE I III W/C,I. FIFE EXTEHDIIJG 3' _ I I ALARM EXTENOIN'. C)JTO SOLID SC I L B I I ONTO SOLID -)I I 0ti c I CLEV. FT. pUMF-~ OFF D { CONCRETE BLOCK RISER EXIT PERMITTED GQLy IF TAUJ( MANUFACTURER +qS 5''CH APPROVAL SEPTIC E 5PEGIFICAT10KJS cosy c'.S Cif "AIJK$ MAAIUFACT URER~ NUMBER OF DOSES: PER DA-4 TAUK :,IZE : 14 e'e" GALLOMS DOSE VOLUME ALARM_ MANUFACTURER: S ! Z--Z,= (t INCLUDIKJG BAC/KFFLOW: GALLOP' S MODEL DUMBER: 0 C 11 Ll,' CAPACITIES: A=br, Jr _INCHES OR GALLON: i SWITCH TYPE; INCHES OR GALLON. 'S PUMP MANUFACTURER: C L Q C = O' INCHES OR ~!7 GALL0$,: S MODEL NUMBER: f D INCHES OR GALLOP'S SWITCH TYPE: .f MD-&6*ftM1 ARE TO BE. 4m 6 ' 1 SEPARATE CIRCUITS MINIMUM DISCHARGE RATE.20 ~ GP VERTICAL DIFFEREUCE DETWEEIJ PUMP OFF AIJD DISTRIBUTIOIJ~PIPE.. FEET + MIIJIMUM NETWORK SUPPLY PRESSURE FEET ♦ FEET OF FORCE MAIM X 3 F/oo FtFRICTION FAEYOR.: FEET TOTAL OyNAMIC. HEAD = FEE 9 6- 2 0 8 8 9 INTERNAL DIMEIJSIONS OF TANK: LENGTH ;WIDTH U--,LIQUID DEPTH SIGNED: ~L%t~4'~ LICEMSE UUMBER' Mp`~ OATE:.L~- O WESTSURNE SUPPLY INC. /L.11/p~ 12 DUSTRIAL RD. Goulds °N, W1 54016 Submersible Effluent Pump r N 38 7 EP04 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas- • Homes components. Available for automatic and tic cover with integral handle • Farms Motor: operation. Automatic and float switch attachment • EP04 Single phase: 0.4 HP, manual points. • Heavy duty sump 115 or 230 V, 60 Hz, 1550 models include Mechanical • Water transfer Float Switch assembled and ■ Power Cable: Severe duty • Dewatering RPM, built in overload with preset at the factory. rated oil and water resistant. automatic reset. ■ Bearings: Upper and lover SPECIFICATIONS • EP05 Single phase: 115 V. 60 Hz, 1550 0 RPM, , FEATURES heavy duty ball bearing Pump: EP04 built in overload with ■ EP04 Impeller: Thermo- construction. • Solids handling capability: automatic reset. plastic Semi-open design AGENCY LISTING 3/a" maximum. • Power cord: 10 foot with pump out vanes for • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP Canadian Standards Association • Total heads: up to 24 feet. with three prong grounding • Discharge size: 1112" NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- • listed model numbers • length. 16/3 SJTW with plastic enclosed design for end in "F" or "AC". Mechanical seal: carbon- improved performance. ) rotary/ceramic-stationary, three prong grounding plug BONA-N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 1041(40"C) continuous superior strength and 1401(60°C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET i stainless steel. 1 c ! • Capable of running dry without damage to 9[ 30 i ~ +t-SGPM components. tJ Pump: EP05 e i ( 2.5 FT • Solids handling capability. o , maximum. W • Capacities: up to 60 GPM. ~ s 20~ - • Total heads: up to 31 feet. 2 I I • Discharge size: l'/z"NPT. z 5 - - - • Mechanical seal: carbon- 0 15 rotary/ceramic-stationary, _j r a 1 BUNA-N elastomers. o ! EPO5 Temperature: 3 10 -r - - 1040F 400C continuous ! rEP0114 140"F (600C) intermittent. 2 i I 5 - --1. - ---a- - -4 i 0 01 - 10 20 30 I 40 50 GPM tr~~( 0 2 4 6 8 0 CAPACITY - 2 0 V (Ith P 1995 Goulds Pumps, Inc. Effective May, 1995 83871 Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County 10 include, but not limited to: vertical and horizontal reference point (BM), direction and s 11"' e /g0 /1 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewe by to Date r Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ " / 11; ) Property Owner Property Location ST Ci:JCXX Mc- AK ,rO N C ®ri Govt. Lot W 1/4' 1/4,S3 Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number Nearest Roa ,C-/NB 1 4 / I YOM ( 1 df) .r./ Y' El City El Villa o (4- Ton d ❑ New Construction Use: ❑ Residential / Number of bedrooms 3 Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow ~r40 gpd Recommended design loading rate /A bed, gpd/fF trench, gpd/ft2 Absorption area required Abed, ft2 .~trench, ft2 Maximum design loading rate YA bed, gpd/ft2 N.- trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations 2 / fxe ,Si19 N GL' LJ N W e pie _r Ite M Parent material 42 A d /A L t Z •L ,l Flood plain elevation, if applicable /V A ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ❑ s Im u Y s ❑ u ❑ s [9 u ❑ S ©u ❑ S ® u ❑ S ® u SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Structure GPD/ft2 Boring # Texture Consistence Boundary Roots - in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench l e- 8 SQL SAA S M lCZ^ r2 Ground /4~/~ e- M ~lvit Depth to limiting factor Remarks: Boring # e- o A0 s~ L- s d rrh .4 Al Y .2 s .l a - e b w F ;s 3 ff s YR -C& -5_1L JAJ&6 -X Ground pellevv.~ Depth to limiting factor I$Jn. Remarks: CST Name (Please Print) Signature Telephone No. ('-':,4,4 e la 1`" Gv 7/'5f - 2 Z-4--yam Address Date CST Number .2 w 120 PROPERTY OWNER ~!®IC~B Y SOIL DESCRIPTION REPORT Page ~ of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 j in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench . -/J- .2 56 A S 3 v- to a &A. JEhItIll Mt-- Ground -3 M2,9 4YA ti S 4JA- d MF-r 2 3 9elev. Depth to limiting fapptggr min. Remarks: Boring # S1 Z- 1 s r~ s 2 ; d 50 C L S r i4 - Zr - ~p c s z1 r.~ 3 Ground GGelev. 7 Depth to limiting factor lain. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary: Roots GP /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) - i i - - j- I li --I-. - - - - 1 - - - _ - - - - - - !C N _!4_ _ I o N 1 I _ I - - I - r I 63 - - I- I i f ~ 1-- I I I I-- L-11-11-- Lj i I i i I ~ I I I i i 1. - ~ ! I ~ I i_ I _ i I i I I I I I I ! I I I ~ I ! ! ~ ~ i _ I I i I i I f 1 1 1 1 1 ~ I l r r I I I I--- -'r- - - r C ► r-- t i I I ~ , ~ I ~ I _ ' I I i C- r~ 1I I ~ i I f I L- i ! I I i C I I -4 I I 1 I i I I , I I ~ ~ I ~ ~ I ~ j I ~ I f I L ~ STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERMORW MAILING ADDRESS PROPERTY ADDRESS 'ia' rn~ (location of septic system) Please obtain from the Planning Dept. CITY/STATE ~ri-C~ , ~LfD PROPERTY LOCATION 1 1/4, 1/4, Section , T ,7Z_N-R5- 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. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance, Should.,th_is_:: 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 Location of prope y/1/4_1/4, Section T~N-RW Township __~piQeS Mailing address a Address of site y7 9 0~ Subdivision name Lot no. Other homes on property? Yes X No Previous owner of property Total size of property Fp G-e-z-e-- Total size of parcel 8~'D Date parcel was created If ;1 Are all corners and lot lines identifiable? Yes __4_No Is this property being developed for (spec house) ? Yes _,Y_No Volume /d. and Page Number A 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. -~`.2 , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Z/ 0 ignature of 4gant Co-Applicant Date of Signature Date of Signature . DOCUMENT NO. WARRANTY DEED I T`.IS 5►A_E RE~C~-+V E'J TOR RECORDING DATA ''STATE BAR OF WISCONSIN FORM 2 -19132 ~I II 521149 =V&IMP "s 57. CR0SX CO., W1 i! Robert J. Mell and Darlene S. Mell, husband an Rac'dfxF. Ord - - - wife SEP 8 1994 . at ~i 830 A. i~ Y i+ 1 14 John C. Coffe S_ Laurie L.. Coff conveys and warrants to y.p p prs1sK~D~9 ;i husband..-and wife.-as surv.ivorshi marital ro er - j . . - RETURN TO F n r Nao ao~l qqp 'a, t . _ - - - -x 13 aad„z:,._ Wes-5741=7- the follcwing described real state in St.---. Croix County, - - - - - State of Wisconsin: Tax Parcel No- li West one-half (1/2) of the Northeast Quarter (NE 1/4) of Section Thirty-four (34), Township Thirty-o.ie (31) North, Range Fifteen (15) West. This Deed is given in fulfillment of a land contract dated December 1, 1992, in Volume "984', page 188, as Document #492440, office of the Register of Deeds for St. Croix County. This n...n0t,-........ homestead property. Oo) (is not) Exception '.o warranties: Easements and rights of way of record, if any; Municipal and county zoning ordinances, if any. Dated this u s. day of 19_94 X - --...(SEAL) l/~) - . _(SEAL) Robert J. ell Darlene S. Mell .(SEAL) - ....(SEAL) AUTHENTICATION ACSNOWLSDGMIBNT Signature(s) Robert J. Mell and STATE OF WISCONSIN - Darlene S. Mell as III St. Croix - County. authenticated this day of 1994. Personally came before me t)I•is 18t day of 94 AuP.5S 19--- the above named Francis ' Rivar_0 $o*f__J._ Mell------------ TITLE: MEMBER STATE BAR OF WISCONSIN Darlene S._-Mell._......._------_--------------------- j (If not, h snthorized by 706.06, Wis. Stats.) ,~,,`s~`~C~*sCy% n~ known to be the per wo a uted the it N ru t a con ed the s !i THIS INSTRUMENT WAS DRAFTED SY Y s