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016-1064-50-000
c (D o p p ~ I ~ ! I r\ 0 0 N c Q j I I II I I I ~ I aNi z z c c _ O 9 ' O N LL CO LL o N U C ~ 'C) C ~ 'O f0 E Q E Q ° o M CD Q) w N N W Z O O O O °am am Cl) H z i o I U O Z U r N O Z (n H r N N a) co U N ~ II ~ C I •"Nib L s O O O Q Q O 4U-__ Q Z Z Z Z o N Z W iCl) C C ~ I O co N o2S N N N 01 y N y N U O a in a w G O a m Q) CU v) ~n fn H FN- H E (E o EL 3: E 3 0 0 0 -0 0 0 0 z • ►ri m c a a a o a a a N a~ +i c 7 .O N m ! OOi in O (D J U -O O Z O) O) } _ O O\ 'O 00 L O O O C 4 04 C4 4 O j 00 00 00 d O N I j =3 M O N Q C 'C (n N a) O Lo Q o U 3 C O C N N C LO U) U) 0) a C O m p N O 'O "O ^ O 'D E 0) m O) O N a) w U N W 7 U C m O O r `O v~ (a E E ° E Y o N v O C N N (n C N c _ Lo 'i N ° 0 00 co .~i M 3: -a) r- 0 CD = M ~ 10 ~o Lo 0 E :3 Z r o (o C _N fL N O O N (00 in O U • O yam„ i' O M C~ d N C) TZ Z (n N O 7 N Z ~i = Y v E N E N a; d a a `IL yaw • a c, u 4) y c d y C r`Mv E i c I c c Y 0 A ciao !Om0 OvU lq~~ STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER/ J ~/~'I a ADDRESS' rv m /may SUBDIVISION / CSMJ - LOT - SECTION- -qo T 3,0 N-R W, Town oflNt..U,omcd ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM a 914 61T 23 ~~M,lo°r ~®tt°►~ ~rsp 1v fi INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of sentic- rant- r-o ..1 BENCHMARK: O ~ p F BOQ/ ~ ~ ~ QS~- /6A~ 40 ~ ALTERNATE BM: ro cs La SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: - Liquid Capacity: leD p - ~oa Setback from: Well ~j House Other Pump: Manufacturer Cro y Model #)-A-~ o size Float seperation /p Gallons/cycle: Alarm Location j9_4 S-&M ear 7' -:SOIL ABSORPTION SYSTEM Width: Length i Number of trenches 1 Distance & Direction to nearest prop, line: Setback from: well: rHouse Other ELEVATIONS Building Sewer / ST Inlet. ST outlet PC inlet ,.,.-4...7 PC bottom_ pump Off AV, Header/Manifold Bottom of system Existing Grade i Final grade ' DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CRO X ` Safety and Buildings Division ATTACH TO PERMIT 5anitaryPermit lVO.: GENERAL INFORMATION (268573 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: SAMP, SCOTT GLENWOOD CST BM Elev.: Insp. SM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA g// 6 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (j,'e SP r n y,~ , of Benchmark /LL . > Dosing Aeratio Bldg. Sewer Holding St/lWt Inlet /D, S// TANK SETBACK INFORMATION St/ VII Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom f ~~a 13.9z Dosing NA Header / Man. Aeration NA Dist. Pipe 3, ~tL.1,g Holding Bot. System 113 ' X74.2 5-' f PUMP / SHMODN INFORMATION Final Grade Manufacturer Demand b S GG d Model Number E P0 ?;711 GPM TDH Lift Friction System TDH Ft Loss hie 71 Forcemain Length Di a. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Lengt No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS r DIME HING Manu actu SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type Of OR UNI System: r^n~l (70 79 OR UNITi- DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length _d 2l Dia. o14 Spacing 16-` 7 5 V SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over i Depth Over 1-6 1, Depth Of fi xx Seeded/ Sodded--- xx Mulched Bed /Trench Center l~L Bed /Trench Edges I Topsoil L es ❑ No ffYes E] No COMMENTS: (Include code discrepancies, persons present, etc.) r LOCATION: Glenwood. 30.30.15W, NW, 1~TE,! C'otinty,`~c~~td" U r-iv be 9G,a8 Plan revision required? ❑ Yes ❑ No iU F_ I FT 1-11 se other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. f~ ~ ADDITIONAL COMMENTS AND SKETCH v SANITARY PERMIT NUMBER: r, Safety and Buildings Division v~■L■71t■ 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. • See reverse side for instructions for completing this application State Sanitary Permit Number 5 73 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 S _ c~® Propert Owner Name Property Location W i4 `c 1/4, S T N , R -OW) W Property Owner's Mailing Address Lot Number Block Number City, State • Zip Code Phone Number Subdivision Name or CSM Number 11. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road / E] Village G3dviWoOG, Ci0 d E] Public 1 or 2 Family Dwelling - No. of bedrooms Town of 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) l 1 ~D 1 ❑ Apartment/Condo Q//"- l0 v 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 / Mote[ 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. A Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ 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 IN Mound 30 E] Specify Type 41 E] 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 y-~yD 7 I7 9 , O Feet 1 Feet VII. TANK Capacity ing all0S 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 / 41 /'exile ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ®Q d ® ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb is Signature: (N Stamps) MP No.: Business Phone Number: A W i fA Clv 90 7/,S"- 2 Plumber's Address (Street, City, State, Zip Code): 1.2 2. P A/ w 4 /7 / 6--4 ,f1V cc-' O d (9i ! / !ir O/ IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signatu N (tamps) charge Fee) /O(Approved ❑ Owner Given Initial 41 ~y ~ 15-0 - l~ Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 015/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber I INSTRUCTIONS R 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. x 3. All revisions to this permit must be approved by the permit. issuing authority. 4. Changes i! .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 bya 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 DvNelling. 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, nc m''-:er of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for ;Eptic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks receives experimE nt it orodu( t approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in )ame, license number with appropriate orefix (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 t.:) the Linty. --he plans must include tie following: A) plot plan, drawn to scale or with complete dimensions, location 7i' ,c (ding tank(s), septic tank(s1 o- other treatment tanks; building sewers; wells; water mains,water service; stre,"i s n lakes pump or siphon tanks; di-,tribution boxes; soil absorption systems,- replacement system areas; ar~c.l the lo:at Di ~ f the building served; B) horizontal and vertical elevation reference points; C, complete specifications for pur^p " rontrcls; dose volume; elevation. differences; friction loss; pump performance,: urve; pump model and puma na ,rer; C; cross section of the so i absorption system if required by the county, Q soil test data on a 1 15 Form; a; ac' d sizing information. ..GROUNDWATER SURCHARGE 1983 Wisconsi n Act 410 included the creation of surcharges (fees) for a number of regcilated practi,J which can y effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contaminatic;ri investigations and establishment of standards. - - - -i-- - - CIO, N N -r ~i-~. - 1- - - - - - - - - - - - 1 - - . _ _ - r- I PRIV CQn APP DEPT. OF IN UTWY,( I NYC II - - i ~.M..w- DIVISION OF lAFETY I I / - SEE O R PONDENC - o M par : /-may c~~ 4~tcd ~~NC!~ Iv~S7"- - re tv'e e, e- Tip S : i ~l /V - ! ~ f1 _ L2,tt~ ll'Ir/~r,~ - . /If/1"ic ji JI•~ti[;c .~4 G do m N Ao 01 6F /0 (7. Sy /v A a f-?&- a r ~ Son 4 e /0 n X/ 7` vy ' J6 c~Co c~ GR kde ...%x c:A-kk C~ -0 j r i. - - ) c~-M-e - - _ _ - - /.7q/✓2 vA k~e i i i 1 ~ I 03voflq9 owllt+o1i11 ~14*Kjllvf "A Intl Page Of S Straw, Marsh Nay, Or Synthetic Covering 11 Distribution Pipe Medium Sand G Topsoil F E D b _ % Slope Bed Of 2- 2 2 (Force Main flowed Aggregate From Pump L.oyer D 1, ew Cross Section Of A Mound System Using A lied for The Absorption Area D _f3 1,01 Signed: License Number: P r Gate: t. . J h - Force Main W From Pump Distribution 13 e d O f z i Pipe Aggregate 1 Observation Pipe Permanent Markers Plan View Of Mound Using A Bed For The Absorption Arco S96-20'71'7 Page Off Perforated Pipe Detail End View poRAt,34 pie pVIP a ev%sitov, -Force riai n PVC "'-soles located on bottom of orce :,aln are equally spaced End cap st hole should _rj--- next to end cap Distributatio:. pipe layout P472 Ft /_3,,. Invert Elevation of Laterals 9G~- r t R --Inches S Inches Signeds X//;?Inches 4Z%C(,~ Gt/~ ~„6 9 p YInches P Licenses Dates a 2 ` 6 Hole Diameter H Inches 'l Lateral " 2 inches Manifold " - Inches Force Main " Inches # of holesAipe 596-20'71"7 PAGE OF PUMP CHAMBER CROSS SECTION AMD SPECIFICATIONS' VENT CAP 'i' C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING 2 JUNCTION BOX MANHOLE COVER ~ 5' FROM DOOR, WINDOW OR FRESH 12014I U. ' PAR Irv TAKE ~ y GRADE 1 4" MIND. ' IB"MIU. CONDUIT 18"MIN. INLET PROVIDE I AIRTIGHT SEAL, I I i I I I AFFROVED JOINT A I III APPROVED J' C.T. FIFE I III WIC.I. FIFE EXTENDILIG 3' II ALARM EXTE~1Diu'.. C)JTO SOLID SOIL I II UNTO SOLID A I I ON C I U I I_LCV.J~©pFY. - PUMF-~ --J OFF I-In CONCRETE BLOCK 8 .TRISER EXIT PEP,MITfED G►JLy IF TANK MANUFACTURER ETAS SUCH APPROVAL SEPTIC E SPEGIFICATIOKIS LOSE + (TAQKS MANUFACTURER: NUMBER OF DOSES: PER DAy TANK SIZE: ~D"~D d DD GALLONS DOSE VOLUME / ALARM. MANUFACTURER: "A;;:Lec to O INCLUDING BACKFLOW: D~ GALLOI S MODEL HUMBER: /D / HW CAPACITIES: A= IAICHES OR GALLOK; i SWITCH TYPE: MeR d 14 R V B = INCHES OR 22 WLLO'' 3 PUMP MANUFACTURER: C= IUCHESOR 147 GALLOk. i MODEL NUMBER: -~POy D= INCHES OR - Id Z c,ALEOIkIS SWITCH TYPE: p E: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF AND 013TRIBUTIOU'PIPE.. FEET + MINIMUM NETWORK SUPPLY PRESSURE F-LET + FEET OF FORCE MAIN X ''?d F/u0FtFRICTIOU FACTOR.,...La >[zo FEET T ~ r~ ~ TOTAL 013MAMIC. HEAD FEE1 9 6 2 0"71 7 INTERNAL DIMENSI0M% OF TANK: LENGTH;WIDTH ;LIQUID DEPTH ~b SIGNE D:'Zc~! - - LICEMSE MutABER: MIS'I9a DATE:. -2 /Z i ~I i~~rlu true li N ~'~►*9 Al Amw Idm k*vftw WESTBURNE SUPPLY INC. • 12 &DUSTRIAL RD. Goulds Ori, W1 54016 Submersible Effluent Pump 3871 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. tic cover with integral handle Motor: Available for automatic and • Farms manual operation. Automatic and float switch attachment • Heavy duty sump • EP04 Single phase: 0.4 HP, points. y p 115 or 230 V, 60 Hz, 1550 models include Mechanical • Water transfer RPM, built in overload with Float Switch assembled and ■ Power Cable: Severe duty • Dewatering automatic reset. preset at the factory. rated oil and water resistant. Single SPECIFICATIONS • EP05 Single phaise: se: 0.5 HP, ■ Bearings: Upper and lower 60 Hz, 1550 r RPM, FEATURES heavy duty ball bearing 115 V. Pump: EP04 built in overload with ■ EP04 Impeller: Thermo- construction. • Solids handling capability: automatic reset. plastic Semi-open design 3/4" maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING • 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- (CSA listed model numbers Mechanical seal: carbon- • length, 16/3 SJTW with improved plastic enclosed performance. design for end in "F" or "AC".) rotary/ceramic-stationary, three prong grounding plug BUNA-N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104" F (40"C) continuous superior strength and 1401 (601C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 1 c . • Capable of running dry without damage to ° 30 - j - -.-t-SGPM I components. Pump: EP05 e' I 'E-2.5Fr I - • Solids handling capability: a 2' 3/4" maximum. w • Capacities: up to 60 GPM. s 20 j • Total heads: up to 31 feet. • Discharge size: 11/2" NPT. Z 5 • Mechanical seal: carbon- 0 15 rotary/ceramic-stationary, a BUNA-N elastomers. o ! EPOS • Temperature: 3 10 1040F (400C) continuous I 140^F (600C) intermittent. 2 ! EP Oa j 5 -----..i. - ' a - 1 i 0 00 10 1 20 30 - 40 50 GPM . L L . 0 2 4 6 8 10 12 ml/h CAPACITY S96-20717 n 1995 Goulds Pumps, Inc. Effective May. 1995 B3871 Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page L 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 include, but not limited to: vertical and horizontal reference point (BM), direction and Sf- e "j a / " 9 ~ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # 00 /6 ~d d -4/ 4 APPLICANT INFORMATION - Please print all information. Reviewed by ( Date-. ~,~,pl Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location ST S" C~ M p Govt. Lot /V&r 1/4 1/4,S N,R O ~ Property Owner's Mailing Address Lot # 7ftck# Subd. Name or CSM# City State Zip Code Phone Number ❑ Nearest Road City El Village ( Town (/eNdve, 0C f" 44''7,3," o, Gam d ❑ New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow C2 gpd Recommended design loading rate .2, bed, gpd/ft2 -9 trench, gpd/112 Absorption area required. N 4 bed, ft2 3 /~Jr trench, ft2 Maximum design loading rate 7 bed, gpd/ft2 - trench, gpd/ft2 Recommended infiltration surface elevation(s) ' 0 ft (as referred to site plan benchmark) Additional design/site considerations I j 5A A1c1 L i1Ncle ;'Y STf' M Parent material 45: 4 4 G= i 4 r/ ~ 4' 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 ®S ❑ U ❑ S ®U ❑ S Z U ❑ S 21 U ❑ S © U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 - Zo /4 G' /!6 /'/V Mi-".r L~ t~cJ V r~ Ground rJ.. fit- 5 s L.. & GfJ 7 ele y ft. 3 6 6 S c~ h 4-14 .y r .Z 3 AI d Depth to limiting factor ; Remarks: Boring # SS n2 is / 6/ M M ~Z G' rv l VT 3 a s G M-z Ground elev../. qft. Depth to limiting factor 2 -3 in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number PROPERTY OWNER -S C' e /2' S,9 Al p SOIL DESCRIPTION REPORT Page PARCEL I.D.# 0%Z" le Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 49., 5// is6 r, M vtf/? 2 3 (2,4 1.2 4.d 1-i Jr- C 4ev 14 Ground ele 40,61! -7 c~ 56 1 6 /S Ai N a J yft. ; Depth to limiting factor 2e) in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ 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) - -rFl i i 1- ae Jog - - ~A~ e i I - vi - I - I I I i - - L- _ i I 1 - I I I 1 G -L J i I I t I ` I I r----- I--- - - r--- - Imo- " - . - L--l- - I ~ ~ - - - I - I. _ , I I I I t I I I I - - - ---1. - - 1 - I I t- - I I 1 - I 1 I l I i I i I I - I I 1 I _ I }I ~ I i ~ j r I_ ~ T-- - t I I I I I I I I I I I I- I 1 ! I ~ It I I I I I i ~ 1 I ~ f I fi I I 1 j I I I I I I ~ I _ I I ' I ~ I t 1 j STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERMXMR S^C d f S,4 M MAILING ADDRESS o 6- f 0o Rd 6~- ° PROPERTY ADDRESS 4_4 Al 6 (location of septic system) Please obtain from the Planning Dept. CITY/STATE GL- &tV Lwd O d PROPERTY LOCATION ~ 114,N.0 1/4, Section T ~O N-R W TOWN OF ~L NCO 0 O~ C/~~/ Lv / ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIEDSURVEY 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 et b the Wisconsin DNR. Certification stating that your septic has been maintained must be/jornpI d r turned to the St. Croix County Zoning Officer within 30 days of the three year expira on da 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 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. Location of property _N4/1/4,#,E 1/4 , Section ?O , T_24:;,_N-R__1j-- W Township /y&<JO ad Mailing address a 7.S" 9 a, da/ 66V CAlltJO O O/ ~ V. Address of site .54 M Subdivision name Lot no. Other homes on property? Yes No Previous owner of property M elge d /BRA' f' h e,, T Total size of property /0 Aa A! Total size of parcel /p X C R Date parcel was created / 9'.1/ IF Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes _j( _No Volume P and Page Number 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. - h/& 90 d , and that I (we) presently own the proposed site for t e 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. Sig a re o ;ppt`iAnt Co-Applicant 7 Date o Signature Date of Signature a.'. t`t:y~~U \1 \ItitANil DF:F;U r 11 ~~p i~ ? REGISTER S CFFIC~ ST. CROIX CTY., INI Pet: ; by ?aid Milared L. Prather, i single person, JUN u i9?6 surviving spouse of Elvin K. Prather k- 8t 10:0 ~ M Elvin Keith Prather, deceased, n,nlto Scott E. ;lamp and Kristin Register of Deeds J. Samp, husband and wife, as survivorship marital property, L t:x Fdloµmg dexnhed real estate in St. Croix ('(:uvli,. Stale of Wi,consln: 016-1064-50 P.rcel Idcm-ficauon %umher) The North 470 feet of the West 927 fee_ of the NW;, of NEk, Section 30-30-i5;- St. Croix County, :+isconsin. s T homr.trad ~.r, t,rr1 Ihi is n~i In n„t ECcertion zo -"'rr:'nl'e` Municipal and zoning ordinances of record and recorded e.,.sements restrictions and reservations. Dated thtc day of IQ 96 tSFAL) Jt ~t~ i~ f 1~✓ _ tsh V1-) - ldred L. Prather AUTHENTICATION ACKNOWLEDGMENT \11SCONSI` Signantrel~l ~ . J1k ount\ .4J 41, auth_nticated thi, da% of 19 r1It. ame hdl„ri me thi, da, of i9 96 the ahoec ^aaned :•_ildrec.. L ex I I I I L MIAME;R SrAIL BAR OF 'N% IS( O\S11 (If not. r NOTARY G9 - authoriied h~ §106:06, %V'i.. Statb,l ,ern tit he 1.1 Pe t rn ho cae~.tvcd the _ 41 .trti 4f..d is o edL, t fiF n' ,r, > iN5TPt MENt .'JAS r),RAF~FD 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 262388 Permit Holder's Name: ❑ City ❑ Village g Town o : State Plan ID No.: Txvwn Parcel Tax No.: CST WARM Insp. BM Elev.: BM GLENWOOD 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 TANKTO 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 Head Forcemain Length Dia. Dist.Toweli SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N 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 E03 Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) GL,ENWOOD.30.30.15W, NW, NE, CTY RD G V LOCATION: 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 P. SANITARY PERMIT NUMBER: • Safety and Buildings Division v~i~r■ra SANITARY PERMIT APPLICATION Bureau of Building Water System, 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. yf d O f'x • See reverse side for instructions for completing this application State Sanitary Permit Number ,;L 6.2 -5 Y9 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 4v7- l I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION -S' Property Owner Name Property Location M/ d e P e y&A/4NR 1/4, S 3o T 2e , N, R fir) W Property Owner's Mailing Address Lot Number Block Number o, d G City, State Zip Code Phone Number Subdivision Name or CSM Number j GL.e woo C/~' o/ c7/.s'>~~.s= II. TYPE F BUILDIN : (check one) ❑ State Owned ❑ city Nearest Road E] Public 1 or 2 Family Dwelling - No. of bedrooms : ToWg of 61e*WA#0( Gl p !~d G III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) U 1 ❑ Apartment /Condo O X© ~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. jX 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 Dq Mound 30 ❑ Specify Type 41 ❑ Holdi ng 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 . v 7-5- 7X /1.2 o 7 ~7,.S Feet 119,' Feet VII. TANK Ca in ga city llons Total # of site INFORMATION Manufacturer's Name Prefab Con- Steel Fiber- Plastic Exper. New I Existin Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank e ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber X_+ 6 Q © ❑ ❑ ❑ ❑ ❑ 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) MPAMPOW No.: Business Phone Number: 90 71=.2 d,5'- 5,~8 Plumber's Address (Street, City, State, Zip Code): 3a w 70 6:,4 .e woe IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Ag nt Si ure (No amps) Approved ❑ Owner Given Initial r! Surcharge Fee) Adverse Determination ~av`w r9((i' X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber • f 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 systern, 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 VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, n! m;_„~r of to -rks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for if! ;E htic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experiment :l 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 t' e <c unty. 1-he plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location ,.rI r.Aing lank(s), septic tank(s) or other'reatrnent tanks; building sewers; wells; water mains/water se,- ce; stye ,r: .I lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the loc.:, a `the building served; B) horiz.)mi-! and vertical elevation reference points; Q complete spec f ications for pump a3 controls,: dose volume; elevatio-) clifferences, friction loss; pump performance curve; pump model and pump rr;in rf, urer, D) cross section of the scil absorption system if required by the county; E) soil test data on a 1 15 form; and ) sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) fora number of regulated practi(,~, whicl-, can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contarr imAi, - investigations and establishment of standards. PAJ 'e Ldj w Afwy sit 7" umK4rt✓ WOO !Vogt . ~ C}~!h fai ee D ,/41i~ , I I I. 17 ~60 4o~,hq ' !fie ~f (CY ~.M+' ` -7 _ ~.77 L:w{ &-TY R~ G PRIVATE SEWAGE SYS- I- iv !J R f1 `U 1V ~7 y ~~~tiC~ C DEPARTMENT 0P INDUSTRY LABOR AND HUMAN fly' I DIVI N OF SAFETY AND BULDINGS U~Vdost~R6ed .4Re,h ONCE v h M1 d Nb~ Sy.r7°e SEE C, ~,RRES N I I \ ~ i I I o s- ~q~ i I t O. M1 ' I I i NO IIS9, 4334 I I t i ' I l~ ~ ~~G ~ I I t od Wl H3HES 9T99 999 9TL xvd i~ fem. Of 5 Page Straw, Morsh Nay, Or Synthetic Covering Distribution Pipe Me44*m S a n d G Topsoil _J I E u U b % Slope Bed Of 2.- 2 z Force Moin Plowed Aggregate From Pump layer U 4.67~ Cross Section Of A Mound System Using F A Bed For Fhe Absorption Arco G /fO ~ f, E t. li 1<~~ EGtS'-d M S1gnc~l. It . License j Fiate: DEPARTMENT OF INDUSTRY LABOR AND HUMAN Rh.AIIONS L i~_~O I t . DIVISION OF SAFETY AND BUILDINGS p F t S E C RRESPON NCE ~,;Lt;rVOtlC~rl E'II-~ 1 A I-------- - Force Main From Pump W f - -----r E3ed Of 1'_ ~Distrit,utio ~ z Pipe Aggregate l Observation Pipe Permanent Markers S96-20334 Plan View of Mound Using A Bed For Tl►e Absorplion Arco Page Of Perforated Pipe Detail PE iVATE SEWAGF SYSTPA End View A& , d -onaitiollaz~ r Fl l Fo PV V PI`Ne A, F P DEPARTMENT OF INDUSTRY LABOR AND HUMAN RFL.Al10NS • ,Si A ;ZIN OF SAFETY AND BUILDINGS 15 0 E C RESPO, ENCE / Force rain ~noie iccate c,n bottom of force main are equal~• spaced End cap Est h;;le should .rn next to end cap it i stributation pipe ia;;.:y p P / 02 F t q, O ft Inches Invert Elevation Laterals / Ft S Inches X~I nch" 1 S igned e 96-20 334 M p 70 Y_!~_LI nche s _ Liaenset Hole Diameter Inches Date: Lateral " Inches Manifold " Inches Force Nain Inches # of holes pipe -f PAGE OF PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS ' VEMT GAP 4"C.I. VENT PIPE WEATNER PROOF APPROVED LOCKING 25' FROM DOOR JUAICTIOU BOX 1 MANHOLE COVER ~ 12"MIU. WINDOW OR FRESH, P.IR INTAKE GRADE 1 y„ MIN. IB"MIU~ COWDUIT PHi'VATF 18"MIN• r y T 44 \ 11~ IAILET 064 Cg~3`t2 I"R6r7VIDE I 1 - AJ R-T : --T A L ! I I AFFROVED JOINT A fit1 I I I APPROVED _ J• C.T. FIFE Of , PARTMENT OF INDUSTRY LABOR AND HUiv1AN RIL.A110NS I I ( ~✓/C.I. PIFE EXTENDIIJG 3' DIVISION OF SAFETY AND BUILDINGS I I ALARM EXTENDI►JC. C')!TO SOLID SOIL 6 I I ONTO SOLID N / I O KJ C S CORFU SPONb CE I CLCV. FT. - PUM,F OFF PROPERL S ® ALL TANKS ILHR 83 1 CONCRETE BLOCK ANCHOR TAN KS AS NLULZ~~,:)Am y ILF*8'Yf6(4 x ,FCp, iTiED 111-1 IF TAUK MAQLIFACTURER IIAS S''CH APPROVAL SEPTIC f tS.~ BUJ ~V/~V///~~ SpEGIf ICATIOhIS COSE TAIJKS MANUFACTURER: WJ ,BER OF DOSES: PER DAy TANK :,IZE : /a71Z~ d -0 GALLOMS DOSE VOLUME ALARM_ MANUFACTURER: SJ- ^AILq INCLUDING BACKFLOW: J'~~M(AJ GALLON S MODEL NUMBER: CAPACITIES: A= a INCHES OR Yj-5- GALLOti i SWITCH TYPE: M B = INCHES OR 3 GALLOW S PUMP MANUFACTURER: 04' L d C= INCHES OR 11627 GALLOW.'S MODEL NUMBER: D= -INCHES OR 7 GALLOPS SWITCH TYPE: S.7" E~+✓CfRO //f rQ OTE: PUMP AVJD ALARM ARE TO BE KIMIMUM DISCHARGE RATE GPM INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFEKEUCE DETWEEM PUMP OFF AWD DISTRIBUTIOUTIPE.. 10'Q FE + MINIMUM WETWORK SUPPL. PRESSURE !.6 . 2-6 F1 6 20 3 3 4 + -lcz-FEET OF FORCE MAIM X _lilk ooFtFRICT101,! FAiYOR.~ FEET TOTAL DUIJAMIC HEAD FEET •4~ INTERNAL DIMEIJSIOWS OF TANK: LENGTH ;WIDTH =1.-.;LIQUID DEPTH 16.76ar-4L PeR 1,VC4 SIGWE D: LICEMSE NUMBER: ~p 6 9o DATE: 4!5-27-9; WESTBURNE SUPPLY INC. 12 NDUSTRIAL RD. Goulds ON, W1 54016 Submersible Effluent Pump 3871 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, • Capable of running lubrication and efficient strength, and durability. following uses: dry without damage to heat transfer. ■ Motor Cover: Thermoplas- • Effluent systems components. tic cover with integral handle • Homes Available for automatic and Motor: and float switch attachment • Farms manual operation. Automatic • Heavy duty sump • EP04 Single phase: 0.4 HP, models include Mechanical Points. • Water transfer 115 or 230 V, 60 Hz, 1550 Float Switch assembled and ■ Power Cable: Severe duty • Water Dewatering RPM, built in overload with preset at the factory. rated oil and water resistant. automatic reset. ■ Bearings: Upper and lower SPECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing 115 V, 60 Fiz,1550 RPM, Pump: EP04 built in overload with ■ EP04 Impeller: Thermo- construction. • Solids handling capability: automatic reset. plastic Semi-open design AGENCY LISTING 1/4" maximum. • Power cord: 10 foot with pump out vanes for • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. " Canadian Standards Association • Total heads: up to 24 feet. with three prong grounding IN EP05 Impeller: Thermo- • Discharge size: 1'/2" NPT. plug. Optional 20 foot plastic enclosed design for (CSA listed model numbers • Mechanical seal: carbon- length, 16/3 SJTW with improved performance. end in "F" or "AC".) rotary/ceramic-stationary, three prong grounding plug BUNA-N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 1040F (40°C) continuous superior strength and 140°F (600C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEETI I stainless steel. 10 • Capable of running + dry without damage to s 30 __b~f -1~ a-sGPM 1 components. Pump: EP05 $ i 2s Fr • Solids handling capability: 0 25 3 /4" maximum. Q W z • Capacities: up to 60 GPM. 6 20 • Total heads: up to 31 feet. • Discharge size: 1112" NPT. Z 5 j - - • Mechanical seal: carbon- } 15 rotary/ceramic-stationary, _j 4 BUNA-N elastomers. is EP05 - • i Temperature: 3 10 - - t---- - - 1040F (400C) continuous 3 140°F (600C) intermittent. 2- 0- 1 I I _ 0 --1 0 10 20 30 40 50 GPM 0 2 4 6 8 10 12 W/h CAPACITY O 1995 Goulds Pumps, Inc. Effective May, 1995 B3871 Wisdbnsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of 3 `Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code - cou Q ~ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road d/(e'°.?SS EVIE ED BY ' APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION -3 F PROP TY• E z:1 Aj PROPERTY LOCATION JKI~,,• GOVT. LOT A/ / 1/4 (4,S. +fi,r ,N,R l (or) 10 PROPERTY OWNER':SMAILING DDRESS LOT# BLOCK# SUB IGi'F'r7~ w CVY, STATE ZIP CODE PHONE NUMBER ❑ VILLAGE owr - f E ~T/ n o d c,,T ItiZ rg011 (7rS11Cv`- Y$3cl rt z✓er'D New Construction Use K Residential/ Number of bedrooms 3 [ ] Addition to existing building bq Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate 1. z bed, gpd/ft2 / Z trench, gpd/ft2 trench, ft2 Maximum design loading rate . Z bed, gpd/ft2 trench, gpd/ft2 Absorption area required 3 )S' bed, ft2 373"' Recommended infiltration surface elevation(s) 1 S y ft (as referred to site plan benchmark) Additional design / site considerations Parent material A442• ! - Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK ❑ U U = Unsuitable fors stem ❑ S ®U ❑ S [RU ❑ S 9 U ❑ S ®U ❑ S ®U RS SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 0-7 )S- rl .2,s'// ~ 5. c [ h1t:sd1l ~~f co., lr , Z .3 Ground 3 ~ c~ '7 s'Y~' y~.j ~ a- slR 111° C4 IleyaK - - el q'T ft. Depth to limiting Trio, Remarks: Boring # 0, 7 7, Sfi~J.S// - Si C L Aor5ee, A, 1/,4 2- ..3 7.23 24M //3 c~ #7j/~, mp;c C7W x a4 -30 7 s WWj dlft/ft c L Cs/ ti~lsrl7 Ground elev. 9.0 7 ft. Depth to limiting factM .2- Remarks: CST Na ~asePrint / Phone: 7!S"= G r- `G 3,2 Address: L /yv 7x 5 T ~3'yo m / S~e_ G ~CaNumber: Signatur : A PROPERTY OWNER SOIL DESCRIPTION REPORT Page of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench j4y}ti ytiivtiti::::-:vvvLti?vP ,z a 2ry,P y/3 CL Sit' M00 aw ~G~ t Z .-3 Ground 3 0 L„7g /e2 0.2 =sj' ,Vk C L S K elev. 7477 ft. Depth to limiting factor,, .2o Remarks: Boring # ^ Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor F-1 Remarks: SBD-8330(8.05/92) i Al 1 oe A - - _ = to I t w I _ I I _ f I 7 1 - I - ~ I~/G ~ I i ; ; E t I i I I I i i t i t r YOTA -1 I ' I I i c, R i _L - I i IF ~ C. I I i I i I ~ 1 I I I ~ j I ~ I- 1 I I I 1 ~ I I I_ ~ i 1 I ( , I 'Oro - I I I I L I i i ; I I ~ ~ ~p f I ~3 I , I ! i I I , L. __I I ~ I L - I I ! I ' lip I I, I i I ' ! ' I i ~ - - I I I ~ , i I ~ I I i t ~ I I I _ _ i - - i • A • i._ I, i _--t-- - - i_ r _ _ . _ -_r _._i.__ . I__._. ~ 1 . i i I STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/ MAILING ADDRESS .2-7-4-5? Ca /?a/ G' PROPERTY ADDRESS SSA A4 e (location of septic system) Please obtain from the Planning Dept. CITY/STATE 4EZen/woQ PROPERTY LOCATION Nto 1/4, _A(zlt 1/4, Section 20 , T 30 N-R /,s" W TOWN OF eN~v o a d 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. fi SIGNED: A ;1~ 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 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 )9iy1/ f'17 L°R Location of property_ht~J 1/4_1/4 , Section Y_, T_QN-R W Township 6 eNw o c a/ Mailing address 7,59 ecL/Y~ Cr- G/- eNwood' C?/' . Lvi.syo/3 Address of site T4 M t'=- subdivision name Lot no. Other homes on property? Yes__X_No Previous owner of property yc~~ N e S`G~'`i Re e,q Total size of property /p A A Total size of parcel /D .4 C R e Date parcel was created 19Jr" 9 Are all corners and lot lines identifiable? Yes _,~(_No Is this property being developed for (spec house)? Yes _X_No Volume 917--f- and Page Number '?7j 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. #X7;2 g6 , 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. L1~ 67°~~' 1141 8ignature o APPlicant Co-Applicant Date of Signature Date of Signature THIS SPACE RESERVED FOR RECORDING DATA DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-i99a' WARRANTY DEED ~ c~ REGISTERS OFFICE VOL 095 PA~E•,9J III ST. CROIX CO., W1 46'7286 ~ - - ~ Recd for etoru This Dead, made between She.rri..A,-. I Q;i Wn,.. a/.lc/a--. S..herri.A____Uhreiber,..hus-band... MAR1 a 1 91 'i and..wife_ and.each in.their..own right of 11:30 A. M I; Grantor, II, and.. Elvin K.,_-Prather-- and.. Mildred.. L,._-Prather,-.husband R egWer of Deeds and.-wife. as.. survivorship-.marital .p operty . , Grantee, II Witneseth, That the said Grantor, for a valuable consideration...... I RETURN TO _ . . conveys to Grantee the following described real estate in St_ C.. .r......oix ' ~I County, State of Wisconsin: r Commencing at the Northwest corner of the Northeast ! Quarter (NE 1/4) of Section 30-30-15, Town of Tax Parcel No:.... Glenwood, thence South 470 feet; thence East 927 feet; thence North 470 feet; thence West °^_7 feet to the place of beginning. I 66.l3 $I_ I This ........15- homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; . And................ warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions, and rights-of-way of record and will warrant and defend the same. Dated this . . - 15 - day of March.... -V.,./`!.. ..................(SEAL) ----..(SEAL) • -..Gene re' j ! C tt ♦ (SEAL) . Sherri--A.-.Schreiber-------- -f.. ' - _ a - 11 AUTHENTICATION ACKNOWLEDGMENT' , + - j; STATE OF WISCONSIN Signature(s) -$-t C.r.0iX---•--------- County. authenticated this day of-------------------------1 19.----- Personally came before me this 15-....... day of Ma-r- ch__-_----.------., 19--9-1. the above named ~I • A. Schr-e b-eg........................................... TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by 1 706.06, Wis. Stats.) to me known to be the person __5 who executed the foregoing strument and acknowledge the same.