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HomeMy WebLinkAbout020-1321-60-000 C o a) o O `fl r: oq m N 4 O t3 co Cam. M O ~O N = Y ti C N C N m o co -5 L) y ami t a O lil ~ a N U) (D C CD C CD N E (n O- N N C_ C') ] N N - O O z N .N Co x C L U. N O w 4 m 10 q) 4) C z o z ~ ~ m in N ~ d m ~ z 0 o z :f C: m z v' ~ Q c m ~ u ~ N Q) O N O N i C a = Z d c O N O z E Z o N z N ~ N ~ Y N O W d i N C O C O p O a 'O O~ N _c o (fl FN- FN- U) E 3 3 3 n o 0 Z c t8 CL N o 0 ~ ^ N v~ J U -0 ~2 0) 0) } ~o LO F`J o O a0 a) O N CO O E M d (p N co ar ~ N 01 ~i O O O ~ N C © C6 00 O C O O O O X 0 ° 0 0 o' o co n N0 a 0 o 10 N aj ~ m C E E N co _M y..i C In L - O O r_ O w N M CLl 'O N O O • 'a ON 7 N 00 Q m 7.r O 2 N O Ch v ~ °i it a 0 a m rw• y C 2 m m X STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER-.54 /7.1 ADDRESS,&0->( ff L." 4) S /'V: SUBDIVISION / CSM# r,:5'0e,#A14,, . C,"19"LC-0 LOT # SECTION ) T 2°I N-R , y Town of / t.) o Al ST. CROIX COUNTY, WISCONSIN Lo7` S- Lo i PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM rn, Kar e I ~toao F 2 "V QTY A (L to AloTE soy y TAI-so, *-T ~ OF- (2 c1 Artout-lb ~1 VIU~E n- L- r s ~(a-t T p it% V C X14 'J"/VsTr3 L ED INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: / ALTERNATE BM: (p P a F-o v d i30?I a lb} 1.3 EPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: W F_ / S E Liquid Capacity: Setback from: Well „<-o House Other Pump: Manufacturer r Model# Size Float seperation Gallons/cycle: Alarm Location-- SOIL ABSORPTION SYSTEM Width: Length 3 , Number of trenches Distance & Direction to nearest prop. line: Setback from: well: S ' House Other ELEVATIONS Building Sewer ST Inlet: 7,0 ST outlet: 7, yO PC inlet - PC bottom Pump Off - Header/Manifold Bottom of system Existing Grade 7- s Final grade `S Z- S'' 4- /p, i2 VT_ DATE OF INSTALLATION: 7 PLUMBER ON JOB: LICENSE NUMBER:f INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: y Safety Safety and a Huma Buildinngs Relations Divvisio sioin INSPECTION REPORT ST. CROIX S (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284225 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: MILLER, SAM HUDSON CST BM Elev.: ~I Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA P TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S Benchmark "e J~e Dosi n Aeration Bldg. Sewer Hol g St/ Inlet TANK SETBACK INFORMATION St/ Outlet 7.0 Vent - TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet Septic ~r NA Dt Bottom Dosin NA Header, f ' Aeration NA Dist. Pipe 5sl- -o >ed Ing Bot. System ,2 5 /.2 PUMP/ SIPHON INFORMATION Final Grade Manufa Demand 7 -.T Mod I Number GPM TDH Lift Friction stem TDH Ft Loss For ain Length Dia. Dist. Towels SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length i No. Of Trenches PI No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 5 3 3 DIMEN I SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM L anu acturer: er. INFORMATION Type O rl, C' ~ CH BE ]t- 7 System: Jcr•z-nCkP1 R UNIT DISTRIBUTION SYSTEM Header / f"f+ 7r Distribution Pipe(s), x Hole Size x Hole Spacing Vent To Air Intake Length ~ Dia. Length ~ Dia. S` Spacing -2 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sys my Depth Over Depth Over xx Depth Of Seeded / Sodded Tr Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.15.29.19W.NW.NW.M_CUTHEO TOAD Plan revision required? ❑ Yes [D'IVo Use other side for additional information. d-- SBD-6710 (R 05/91) Date Inspecto 's Signatur Cert No. ADDITIONAL COMMENTS AND SKETCH ' " r SANITARY PERMIT NUMBER: ~G~u'■,ri: SANITARY PERMIT APPLICATION Bureau and uildiing Water ureau o off Builn 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 81/2 x 11 inches in size. tP6 , ~'Qr • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs Xcheck if 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 5A An /11 (LL*_ 1/4 U 1/4,S/ S Ta% ,N,R /7E(6CW Property Owner's Mailing Address Lot Number Block Number O *Z Z_ City, State Zip Code Phone Number Subdivision Name or CSM Number M L) 0S0 A/ I`F w r 15-CID V,061-4 II. TYPE F BUILDING: (check one) ❑ State Owned 11 - ity Nearest Road Public 1 or 2 Family Dwelling -No. of bedrooms vii age OF vO~N -rcUT~ _0 /V 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 E] Apartment/ Condo 0 2 0 -1 3 Z I ~-a 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) 1ew 2. E] Replacement 3. E] 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 11E] Seepage Bed 21 ❑ Mound 30E] Specify Type 41 ❑ Holding Tank 12 `Seepage Trench 22 E] In-Ground Pressure 42E] Pit Privy y4❑Seepage Pit 43E] Vault Privy 14E] System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade 7S Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) p i Elevation 3 `f S a S' y Feet 9~ r Feet VII. TANK Capacity in gallons Total # of Prefab. Con INFORMATION Fiber- Exper. Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank ~S~ SE~ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ E]_ I ❑ ❑ ❑ ❑ 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/MPRSW NO.: Business Phone Number: ®o r=1L PAS-o3sov 38~-Fr~~~ Plumber's Address (Street, City, State, Zip Code): /0 20 A IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing ent Sig ature (N tamps ,00Approved ❑ Owner Given Initial Surcharge Fee) / ,07~ s----- 10 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05194) DISTRIBUTION: Original to County. One copy To: Safety a Ruildings 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 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. IL 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. 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. i r LA ° C4 w w O C i rn :lk C v O v~ ~ ~ ~ w ~X o l Xr1 R 0 r~ r ~t~ a 0 ~ V1 o ID rr, 0 z - . 2) bye rri o ls-~, o- O I I~ LA I 1 4 I Oll 4% O I z ~ `C m LI I z ~ v r ~ Z I c~ W g 0 O's Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems rigL■7R 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 1/2 x 11 inches in size. • See reverse side for instructions for completing this application state sanitary Permit Number C 0- The information you provide may be used by other government agency programs Check if revision to previous application IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prerty Owner, a~9e Property Location % 1/4, Si -1 T~ ~ N, R E (c, W Pro e_rty Owner's Mailing Address Lot Number Block Number Cit , State Zi Code Phr Number Subdivision ame_or CSM Numbe # c.) a t ^ fti (mot..;' ' ?cf 2- /y ( c ) 2 'r` r l~c~r r ; II. TYPE OT BUILDING: (check one) ❑ State Owned ,..w ❑ ciflyy Neap-sstt Roa ~j Public 1 or 2 Family Dwelling -No. of bedrooms TI '3g OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 New 2. ❑ Replacement 3, ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an -_r- System System Tank Only Exi Existing System Existing System ❑ 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.) Propose4(sq. ft.) (Gall ~ /sq. ft.) (Min./inch) t levation e// Feet?( r Feet VII. TANK Capacity Site INFORMATION in gallons Total # of Prefab. Fiber- Plastic pGallons Tanks Manufacturer's Name Concrete Con- steel glass App. New Existin strutted ❑ ❑ ❑ ❑ Tanks Tanks _ ~ -E: "Oil Septic Tank or Holding Tank C.~;..) Lift Pump Tank /Siphon Chamber ❑ ❑ El 1:1 E VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumbei's5ignature: (No Stamps) MP/ PRSW No.: Business Phone Number: Plumber's Address (Street, Cit ,State, Zip Code): /41 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue , Issuing gent Sig re ( Stamys)' X Surcharge Fee) XApproved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: - SUD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Ruildings Divr ion, 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 a time of renewal any new criteria in the Wisconsin Administrative Code will be apIdlicable_ 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. Vl. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or ex sting 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;( 11 inches must be submitted to the county. ""he 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 (ontrols; dose volume; elevation differences; friction loss, pump performance curve; pump model and pump manufac,urer; 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. Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems ri'■L■7■1 201 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 !r v Jx than 8 112 x 11 inches in size. t • See reverse side for instructions for completing this application State Sanitary Permit Number 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 I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location c e e{t<r~1 14 N (t,l 1/4, S T 2 , N, R//' E (orf u1/ . Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Pb rte Number Subdivision Name or CSM Numberr Ti ~ ~ Q►'7 }'~i '..af ~ ~~l.t .I i'~~ (r' 'r ) eZ ~ j II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ citY Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms rowan OFf Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. 121 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an y______________ Existing -System E _____System ---System Tank 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 tj 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 Requi ed (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) y Elevation ( r t..n r' Feet Feet VII. TANK Capacity Site INFORMATION in gallons Total a of Manufacturer's Name Coec e e Con- Steel Fiber la- Plastic APPr. New Existin p strutted Tanks Tanks Septic Tank or Holding Tank El E] 1:1 11 1:1 1 1:1 Lift Pump Tank /Siphon Chamber 0 El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Iumber' ignature: Stam ) MP/MPRSW NO.: Business Phone Number: Plumber's, Addre (Street, Cit , State, Zi C)de) IX. COUNTY / DEPARTMENT USE ONLY r ❑ Disapproved S QAary Permit Fee (includes Groundwater ate ssue Issuing A ent Si a (No ta.nype Surcharge Fee) Approved ,(1 ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divaion, 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 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, pimp/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. Plumoer 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. 7 he 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 (ontrols; dose volume; elevation differences; friction loss, pump performance curve; pump model and pump manufac'.urer; 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. SAM fil l ~ L £p 4;,e4 Al 46t C-W C L F y Cow "E G 41Ae6e6Qp 40AD t3. M r o p a ,c /1" j~j c,,e,i/rrl 5 sTE /yI/k c `r M Vii. = 93.x/ V ~yi \ /l o { v C~ J C7 t~. ( r 0, j L f 0.'sj p,~r', i'~ ! 2oN _ IrL .to ve 3 NOTE : op y ' c vT SIDE To lnO 1 l-TA1 N b D g-S t7t PTN t~tQ~iR~J~~S 1 WELL S DJF k eO s4) EA.17 zoor- L INC 2 Ft~.43' o~Viof n" N o LXI C9 o o ~Y 4 o 41 o I~ t W I ~ I n- I M i o I o ~ 40 N Z ~l N I W v I z i O ~ I 'ter a I a I Ld I I , I 4 ' o z I 10 I i I a Wisconsin Department Relations Industry, S L OIL AND SITE E V A L U A T I O 1J REPORT Page 1 of abo r a rtd Human Relati • • :-Division of safety & buildings in accord with ILHR 83.05, Wis. Adm. Code COUN]~ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, butT ~i~l X not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY 0 NER: PROPERTY LOCATION 'Z:sAA GOVT. LOT ►4t,,,) 1/4,r4GJ1/4,S jS T Z~ N,R 1O E (or) W PROPERTY OWNER':S MAILING ADDRESS L 19 I C:1 T # BLOCK # SUBD. NAME OR CSM ~14ock vid Lz-c CITY, STATE ZIP CODE PHONE NUMBER ❑CITY VILLAGE 27OWN NEAREST ROAD New construction use Residential / Number of bedrooms UN [ J Addition to existing building j j Replacement [ J Public or commercial describe Code derived daily flow gpd Recommended design loading rate Q..7 bed, gpd/ft2() •7 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maxi Wm design loading rate _ bed, gpd/ft26-~? trench, gpd/ft2 Recommended infiltration surface elevation(s) f rJ"k-s tkc • ft as referred to site plan benchmark) Additional design / site considerations i e EVAZ' ATtprv &A ~6 ~ 4,T- A'P j)f8-AfAt. Parent material Flood plain elevation, if applicable ft itable for system C NVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE Y TEM IN FILL HOLDING TANK r=U~Uun suita ble for system S ❑U $]S❑ U C0S ❑ U RI S❑ U S❑ ❑ S ~U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon Texture Consistence Botx>ciary Roots Bed Trench in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 4, r r- Y LJ 0,1 r~ kf $ S l3 IO L/,2 5.4 S , L ! r-, s 16 n~ G w 17 (3 .Z Ground I~ !Z R A S r y►-) e ft. Depth to limiting factor > •cX~ Remarks: Boring # tv Q o'1~' i n 3 L 1 cr~r 2~ 0.4 0.~ 0 Y11 ~r 01 102103 Ground n9ey. ft. Depth to limiting ft > Remarks: CST Name: Please Print q Phone: [~Q~ Address: ox U~S4 t~ J Signal Date: A CST Number: z~ ~4 ~4 PROPERTY OWNER S4 111 M, L L Lt V~ SOIL DESCRIPTION REPORT Page of # PARCEL IA GPD/ft Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BaxrJary Roots Bed mrich in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ILK >~1 Gw l rJ:Z u,t'24 Ground :4-ll7 Q S 0 M r r1i I ~.1 Q c6 l,ev~. -133- ft. Depth to limiting Ictor T5 Remarks: Boring # O'l0 IO ~3 I S L. m (r /her r w Q .q d'S vig s 5 /►~t 3 All aw~z,4 S ^Ground Co~e ft. Depth to limiting f aqtQLj~ 7 Remarks: Boring # A 10-7 C. r /l~r Z~ G .4 O b 1-47 0 O cv 4 e4 4 S C3 >l r 1171 Ground elev. ft. Depth to limiting factor ? Or .67 Remarks: Boring # , Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) r v~ vn -r` ~c S w oPr ~ _ , A ` lZ' l~ r1 i L 3 a J STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S~ 9,11-e- MAILING ADDRESS -Bo)( # z 8,z PROPERTY ADDRESS 6 0 V ED Al A- o 4 .a (location of septic system) Please obtain from the Planning Dept. CITY/STATE l/c) D Sp /V 4eJ s X40 / (c PROPERTY LOCATION IV 0./-) 1/4, A/ 1/4, Section /S" N-R TOWN OF _r'-1t✓ l7 s o Al ST. CROIX COUNTY, WI SUBDIVISION (,~A A166 /,>~t1 ! C E Y'' LOT NUMBER CERTIFIED SURVEY MAP S5 o Zy3, VOLUME PAGE (a S , 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: oa~ DATE: (2 - cj 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 A M 114 1,L Location of property 10/4._/1/4 ~t4'u f 1/4, Section T 2 N-R J Township _ P cJL o Mailing address LOX 14"-p -s" r'S w / _!r- ya / ~C_ Address of site _Goo )C014A Subdivision name x,4'W6 Lot no. Other homes on property? Yes No Previous owner of property pa v C., L A S c /c f? T /vl sZ Total size of property 5.00 /A/<, A w Total size of parcel o? g 4 c 2/- S Date parcel was created 9~Z S/9 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? X Yes No Volume 11V Z-and Page Number /0 7A 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. sl y yoo , 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. A fly o.0 A a ure Applicant Co-Applicant Date of Signature Date of Signature ' Slate Bar of N1'iKonsin Form 2 1982 _ WARRANTY DEED 3. V ~ /7 Of DOCUMENT NO REGIS i KS OFFICE ST CROIX CO., W! " Rcc'd for i'•, c+d i Douglas C. Katner, Bernard J. N - et -tan - , SEP 29 19,95 and Chris -P: Neu;r~ln--- _ - ~ - at 12:30 P.M Sam F. Miller ~.r conveys and warrants to Regicter of Deods i r ~/~_F~, : 7 FOR RE C'ORDMG OA_A •AIRPA:E RESEW NAVE AND RETURN ADORES ' •w the following dcsCrihed yeal estate in St . C r o_i x County, State of Wucoasin: I cz All (Parcel Identification Number) li NW1/4NW1/4, Sec. 15-T29N-R19w, except Certified Survey map recorded' in Vol. 5, P-ge 1418 as Doc. No. 393288, and except Certified Survey Map recorded in Vol. 6, Page 1761 as Doc. No. 420627. I i is not This homestead property. li • (is) (is not) ~i ww II Exception to warrartics: easements, restrictions and rights-of-way of record, if any. 4A- September 1 Dated this day or _ ,1995-. a" I I • (SEAL) - - (SEAL) Douglas C. Ratner • Bernard J. Neuman I) (SEAL) -f r - . (SEAL) Chris P. Neuman s~ I I~ AUTHENTICATION ACKNOWLEDGNIF.NT Z STATE OF WA~W i Signature(s) Bernard J.___Neumanr ss II Chris P Neuman - - - - - - s-y- County. x k II authenticated this--- day of -September-_ , 19_95 _ iyly ea _ be:ore me this day of f 19 P -t•iF we named M _1 Ll - ugias C. Kattiee • Kristine gland It TITLE: MI.MBLIt STATE BAR OF WISCONSIN y~ Y (If not. authorized by §706.06, Wis. StasJ to me known to be the per-'on VZ ; t ~xttu'r. tFar forego«ng inA Brant and acknowted~~fti ~ G II THIS INS rPL:1ENT WAS DRAFTED BY Kristina Ogland e ~~••~,F~ - - Att~trrtP_7 at Lax • o+~~y .•`__Q,