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CROIX COUNTY, WISCONSIN PL VIEW SHOW EV R ING WITH~N 100 FEET OF SYSTEM P RSf Mf AlT ~ L ~j I c 8. n~. rto PO S 0 ~ c~ - ~~G~• I s J~ o`rf : fl ~ ~E~ I l ~tl ~y► 9~ f j W LL INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ~oP of bn0.C> r ALTERNATE BM: T6 2V R1005- AT NE /a y S SEPTIC TAN UMP CHAMBER / HOLDING TANK INFORMATION Ma nufacturer:~) Liquid Capacity: /d o O 6,4-~L_ V r Setback from: Well House Z~ Other -'.I? ro /~/~E GdME,~~ Pump: Manufacturer- Model# - Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: S Length ~_o Number of trenches Z_ Distance & Direction to nearest prop. line: `o To 40.a¢~ t~T Z Setback from: well: 00 * House `/J Other / i ST ELEVATIONS Building Sewer ST Inlet: 5.28 = 7.SZ_sT outlet: = 3/ `PC inlet PC bottom - Pump Off U P 455' 95.sS CJp t~.Ss Qy, Header/Manifoldzo,o py57Bottom of system Existing Grade 7q.eoFinal grade ' S ~a DATE OF INSTALLATION: PLUMBER ON JOB: y LICENSE NUMBER: S' - O3,~o 0 INSPECTOR: 3/93 : j t Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labdr'ago Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 268645 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: WAXON, GLENN/MILLER, SAM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: G~. 6/61 dU, c~Crm TANK INFORMATION ELEVATION DATA A9600340 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic e Benchmark S,Sa~ CIO Dosi nq- d 75 /,13-77' Aeration Bldg. Sewer Holding St/,w Inlet 52,1 7/' TANK SETBACK INFORMATION St/,Ids Outlet Vent TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet Septic >z NA Dt Bottom Dosing NA Header / Man. 973' 9S. 79' d,5s' 951271 Aeration NA Dist. Pipe 9 D K6z1 972' Holding Bot. System S 3.67 PUMP/ SIPHON INFORMATION Final Grade ac> 993-2 Manufacturer Demand, Model er GPM TDH Lift Lriction stem TDH Ft Forcemai(1 Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length , No. Of Trenches PIT No. Of Pits In Liquid Depth DIMENSIONS IS' d DIM N SETBACK SYSTEM TO P / L BLDG WELL LAKE STREAM ING Manufacturer: Number: INFORMATION Type 0 ew Cry ~CHA MB System: Y,111Z3 ~ 9d~ >SO' OR UNIT DISTRIBUTION SYSTEM Header Distribution Pipe(s) cx Hole Size x Hole S aci Vent To Air Intake Length L Dia Length Dia. 7 Spacing _4L 2L I SOIL COVER x Pressure Systems Only xx Mound O -Grade Systems Depth Over Depth Over xx D Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.26.29.19W, NW, SE, KALLY Plan revision required? ❑ Yes Ldl Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signatu Cert. No. ADDITIONAL COMMENTS AND SKETCH s SANITARY PERMIT NUMBER: ~j Safety and Buildings Division v~G::.'r~■ : 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. o 1 • See reverse side for instructions for completing this application State Sanitary PPermitNumbe The information you provide may be used by other government agency programs El Check if~sio?i 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 4m 0/ / C. C E/Z _1~fif/ GPJ~4 O / i{! ul 1 /4 ,r 1/4, S Z ¢ T Z of , N, Re'f' E (orTE) Property Owner's Mailing Address Lot Number Block Number 13 0 x- `11 Z Z „3.O City, State Zip Code Phone Number Subdivision Name or CSM Number 11-1211A>310 N L'o i dl / 0 r(o) Z? C. 7 / 411 Nfr,# o 44-1,5 7LL II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City LL Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms E] ToVillage 1~ wn OFf~cJDS 0 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo C~) 2- c3 - / Z F- r 3 D 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. Ef New 2. ❑ 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 ❑ 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 S. Perc. Rate 6- System Elev. 7. Final Grade 4/ 5 O Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft-) (Min./inch) r94,-0 Elevatioq O© t QS.co~ Feet y 94, mo ~ Feet TANK Capacity VII. INFORMATION in gallonTotal # of 's Name Prefab. Site Con- Steel Fiber- Plastic Exper- New Existin Gallons Tanks Manufacturer Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank QO L7 It (mil S ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber A ❑ ❑ ❑ ❑ ❑ ❑ 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 S gnature: ( tamps MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): Jt CA- JC? O1•( l IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing A nt Sig NOS mps) Approved ❑ Owner Given Initial Surcnargeree) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1 _ A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at 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 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, 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. iaKT,a cp7 G ~A.C %/y cu 11nn I ~ ` nl r N - _ i 'Its r rl) ~I i ~ rnl ~ ~ n e t\ z _n 2 'C 1 z IT, cW -p ~ N o W F o t N , t p rn I a I r n ~ a 0 1t C ~ N ~ 0 7-H -7 c m I A~ ~,A ~A t,/) I L^ cl I 2 ' rn I n ~ I ~ ~ u ~ 1~ n n rn i r j !i 0 j ' v I ~ \ m I ' I O ~ ~ i o cn ' n NJ r 1 Z N, ~ I I Z W I ~ ~A s ~ Q -10 w 9 O ~ O Z m Q N O tr O o ~0 1 ~ fn LA Go~ Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of - Labor and Human Relations Division 61 Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 5T 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 PR RTY OWNER: PROPERTY LOCATION A th iuk"2 GOVT. LOTH W 1/45L 1/4,S-Z& T 29 N,R C' E (or) W PROPERTY OWNER':S MAILING ADDRESS T # BLOCK # SUBD, ~AME OR CSM #'0S - 1- O H)6 N A F CI STATE ) ZIP CODE PHONE NUMBER ❑CITY ❑VI LAGE OWN N EST ROAD J V ~S diU w 1 ( ) Ho Asn>J JIS 1 N M 0 -As [Al New Construction Use [Pd Residential / Number of bedrooms UN K [ ] Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate ~27 bed, gpd/ft2 O trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate 0.7 bed, gpd/ft2 d.9 trench, gpd/ft2 Recommended infiltration surface elevation(s) - 4. &o 2 sz _ft (as refe ed to site plan benchmark) Additional design / site considerations 4&8 - Z WAS aLG.L pQ S f -IC AV &V f() " F_\(A WA TI Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING K U=Unsuitable for system ®S q( W S ❑ U ®S [:3 U ®S ❑ U 9 S ❑ U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends Ground &Z 0 f 27 16VA14 Lmlr n, (5 S l 7 ele IbD-y, Depth to limiting factor Remarks: Boring # 4 6-14- c L I'h c r M~r r C5 ) 6A 6.5' /4,31 1 5 Z t n,slol~ r►►7 Ground 1-12- 16YII` ~ Depth to limiting factor Remarks: CST Name:-Please Print 14A y 14 Sa N) Phone: Address: ubsc~>u ) O Date: a ^ CST Number: 94 Signature. 7 PROPEMYOWN__ER ~h 11pakyZ. SOIL DESCRIPTION REPORT Page Z of PARCELID.$//WT" 30 l611 Mr-4&"S -L Boring Horizon Depth Dominant Color Mottles Structure GPD/ft g in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed rends O-8 /D 3 L Z rh c r m r C z S ML 1 r~ cr mr CS 2~ p.~ Ground 92 6 SL l rti r ih~; s / T 5 ~ rit r rh 1 g Depth to limiting faQct/ or. ' .l Remarks: Boring # /Q 6-15 10`/ 3 Z L 2 mcr C5 2Sr O,S 0,~ S l 7 Yt2 S~ r /h r cS r# p S Ground 31-64 10YA4 `f 5 M r M/ C5 elev. 63 -19 y ~4 4 5 ' f CS ~oo.6t. 0 .S 6.6 Depth to 79-ab 1 b`1 4 5 QM r m 7 fl limiting fac/DQL 3 Remarks: Boring # S .S 44 D$> 3 7, Syi2 414 - 5~ 1 r1 r 1 Gs 1Sr 0A 6G round $ 6'~Z 4114 S yvi 7r- tN 62 dg ele q~ .§7f t. Depth to limiting factor Remarks: Boring # 204 5 :z . M~`~ Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PAZ. C. 3oQ 3 f~o2T~1 I ~ WOO A LA a ~ I b4 P, 17-0 I I I $s,jc.tAN Alt V- - 4oA r u "vr CURo" ~ Gam' ~Y,71S - TA RJR E End ~4rtJG 1C . ELEYA-ri bi,j c ! oO,o6 . - r M i S EVs4Uj4"',aa• jS RLIkk h 6 n J l r 854ALYSrT I NL£ NOLISL s&-r cai P4-4T dF --nu PQL.VIUALY Pl~UE,3 4v2LCA, i I Wisconsin De`partmentof Industry, PRIVATE SEWAGE SYSTEM County: Safety ty and and Huma Buildinngs Relations Division INSPECTION REPORT ST. CROIX t, S GENERAL INFORMATION (ATTACH TO PERMIT) 5anitaN8620 Permit Holder's Name: ❑ City ❑ village Town of: State Plan ID No.: WAXON, GLENN/MILLER, SAM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600324 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer F Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Ventto TANK TO P/ L WELL BLDG. Air Intake ROAD Dt Inlet 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 F Loss riction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of 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 -F-C] Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes C] No ❑ Yes No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.26.29.19W, NW, SE, KALLEY RD Plan revision required? ❑ Yes ❑ No Use other side for additional information. I F SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH + SANITARY PERMIT NUMBER: u I Safety and Buildings Division v~■`r■■,• 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 1/2 x 11 inches in size. _ r r'p X- • See reverse side for instructions for completing this application State Sanitary Permit Number age a~ 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 Property Owner Name Property Location GLCAWAXaN SA/Y1 lcLE.2 E1/456 1/4,S Z(_ T zg ,N, R/9 E(ot® Property Owner's Mailing Address Lot Number Block Number t~ IC Z ~l 2_._ .3 O City, State Zip Code Phone Number Subdivision Name or CSM Number 1+0 O's-6 N w I :D (38(. ) 2 (G/, &ex Do a) ' II. TYPE F BUILDING: (check one) ❑ State Owned El City Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms-.. volag OF 14 U 's 6 Ef~ III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/Condo ZO _ L 1?- 3 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. rp44ew 2. ❑ 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 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12NfSeepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 1 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 S. Perc. Rate 6. System Elev. 7. Final Grade ESQ Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft_) (Min./inch) 1w',^a MIW+ Wation S (0 Is:, C) 117. ce Amu Feet Q 3, too,•o Feet VII. TANK Capacity in gallons Total # of Prefabcon Fiber- Tanks Manufacturer's Name . Steel plastic Exper. INFORMATION New Existin Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank / /OQC7 (R,~/~j~~ ❑ ❑ ❑ ❑ 0 Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (N Stamps MP/MPRSW No.: Business Phone Number: Ii~E `I~ON~LC 4~at~S63Sbo Plumber's Address (Street, City, State, Zip Code): olo N tjv~rt EiZ t t ra c .S ( It IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing gent Si ature ( Stam ) Approved E] ~ surcharge Fee) /Q Owner Given Initial a c~ 7 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOO-6398 (R. 05/94) DISTMILITION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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 systntm 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. kA« Y k0 4 o No2TH LoT / /V y/5'• O6' ~i//o S~ ,ycF~ N Ern m- 3 r, 'NK ~ol _z o 0 ~ r r ~ 1 ~ s / 1 o A n / ~ m r 0 Coll ti 8 Mud fib w • .h Gv °a Q lobo 'V M 1. ZO\ EA) I I -b 1 c7 ~ \ x r~ I O o i ~ L1 rri I , I GO 0 p n 6 j m i i z N I A I Z ~ o M a Gu - a µ F m o ~ ~ o o ~o N 4. kA r' z -u 0 ~'z! ~ mL►Goz DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, ' C DIVISION .LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53769 KliMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATIO : SECTION: TOWNSHIPtiottt4tetp*ti+Y: OT NO.:BLK. NO.: SUBDIVISION NAME: N~11/ 5E 1/ z& /T.?-9 N/R 0 E (or) W H u PSo j 30 ~ H f(-1f MEALOWS-= COUNTY: MAILING ADDRESS: !5+CRO(K 6-LEti Cv~Xo t~ 7Z CQ C00.10 ?y ?-L) - A3 U D Soa W I S SVO C, USE -225t DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: ROFIL i TS: Residence 3 oR 4 &Ne. ❑ Replace 4 l S I g 9 i J•UN1= I S j t 9 y} 5C5~ 6URKti~Qa'~ RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM: (optional) CIS E1u 0 S CIU I EIS ❑U EIS (DU EIS [1u s ``',0, sox _ ois ~w row If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the Z - under s. ILHR 83.09(5)Ib), indicate: CL74,$ S = Floodplain, indicate Floodplain elevation: /`tom PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST.HIG HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.1 0-1z" 10 YR 31, Sfl p lowc0; " /0 VR /y Sr, z Sbk A; B- I 140 q1, Ng '-a- 7 ~y0 2C,"-W10 YR 51,f 51 2nx5bk,MAR qF 140 /oYi? 416 eS / 1-12-"10 V4 311 S//, p/ouolo i2 iG io yip '7114 Si / 1-956,4-, B_ 2- I/O ~1 ~4 > (la R z(.-yP~/a yR 51y S/ 2n+sb,~ FR; zq- //0 iv CS Q ' D-zp"/o y/231i Srl trr pt ti c,e; zp„-36'/ /a s ~/~P%y I) B-3 to ~ Id8 2f 13kI~ 47i'- 3G'-So /O ylP`4114G 5-/; 1Cr.~'Q,i-Ile -0--tea 10 -YR '11L_~o -S B- 1 /DID ~~~DSf ~tb >loo o-p„/aM 413 ~s/6w ; ~'-/oo•`/0ye4/G .S. E-S 12Q 13,0 ~,Cp >12~ 0-& /o y,P 31, 5;1, plow' ; G-z6' "io yk 5/y 5111 /c k, f5'b* B- Y~G 12" 9 -CIE ~PPt~~ ~ ~cP d-I S ° mots lZo^ /o y,e /-RC 51&PERCOLATION TESTS } EST DEPTH . WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES f NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD I- PERIOD 2 PERIOD PER INCH Z P_ t . ~ 95, o r Y3' P. Z f3 ~-l0 9y & z P-3 .o Z P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. N ~ ~ 9/ Q L b W ~i L~ iU L°!~ - ~ ~ r SYSTEM ELEVATION. . I i i i i i i sE pro r P&,4N _ _T - - t H 9 Lo r~ G • ' /3~c~h'aE Prrs _ ,ocRc 5~7~"5 32 r p°! 51 ~s Q~ G6 r P LoT 32. X10 "e LOT 3 i i STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERBUYER 6 I E N V)4 X O S Jg f L L MAILING ADDRESS © X =t Zg - z--PROPERTY ADDRESS 7 I A L L Y R O (location of septic system) Please obtain from the Planning Dept. CITY/STATE ~4 U b S o ►J W I S yy ~,6 PROPERTY LOCATION /V w 1/4, S£ 1/4, Section T S N-R W TOWN OF tJ O S 0 W ST. CROIX COUNTY, WI SUBDIVISION g / t A M150fOO uJ s LOT MJM 3ER 7_ 2 2~ PAGE LOT NUMBER CERTIFIED SURVEY MAP 'V7-5_40 VOLUME 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: ~j~ L%. zh.. V.- DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road 11/93 Hudson, WI 54016 STC - loo '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 S,q e~'J / L mac' Location of property/1 W 114.5E 1 4, Section T e7 N-R / 9 Township IV Mailing address ao X 0-c} L) s© V4 w S yo /.6 Address of site - 7 / -,t A L t- Y k-6 0, D Subdivision name ff (G H 112 FA oo w S 4M Lot no. Other homes on property? Yes,~(No Previous owner of property N p w N b6 L FF Total size of property , ( 3 A- Total size of parcel 13 ~r c-, Date parcel was created /I- 7n Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house) ? ,,~c_Yes No Volume .S'/ and Page Number s,3 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. o2S 67 4. 5/ , 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. Signature of Applicant Co-Applicant /fi r i Date of Signature Date of Signature WARnANTY D86D To Husband and Wlfe As J01nt T*Mnts FORbt 399 (Redsed) u•c ni((ip co..w(u~vur a -2 5 ><7 6 s 'ThIS" II1C,@ntUC@~ Made this , ~f~d .ray of .7nl~ay[ in the ye:►r s , a n _ f k~a l Hdwig, W of our Lord, one thousand nine hundred and,. fift7tq between Hattie W inaolff party.......-of the first part, it i and.. Glenn Waxon and, Vycgl?,a M, Waxon, husbanc,ad wife i ' , of Hus93f.~ ..1~~4~74T71.._ husband and wife, as joint tenants. parties of the second part. Witnesseth, That the said party....of the first part.' for and in consideration of the sum of Six;Thousand:-(. 6,UQU..QUl- - - to .:.lien., ..........in hand paid by the said parties of the second part, the receipt whereof is hereby confessed and • :acknowledged, ha..Y.e..... given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by ~ these presents do -.-.......give, grant, bargain, sell. remise, release, alien, convey and confirm unto the said parties of ..the second part, as joint tenants, the following described real estate, situated in the County of. .S.t..-Craix .....:...............and State of Wisconsin, to-wit: The North One Half (N112) of the Southeast Quarter (SE1/4), the Southwest Quarter (SW114) of the Southeast Quarter (SE1/4), approximately .54 acres of land located in the northwest corner of the Southeast Quarter (SE1/4) of the Southeast Quarter (SE1/4) described as follows: Commencing at the northwest corner of said Southeast Quarter (SE1/4) of the Southeast Quarter (SE1/4), thence East along-the North line of said Southeast. Quarter -(SE1/4) of the Southeast Quarter (SE1/4) a distance of 76 feet; thence South and para- Tell to the West line of said Southeast Quarter (SE1/4) of the Southeast Quar- aer (SE1/4) a distance of 312 feet; thence West and parallel to the North line of said Southeast Quarter (SE1/4) of the Southeast Quarter (SE1/4) a distance I ` of 76 feet; thence North along the West line of said Southeast Quarter (SE1/4) of the Southeast Quarter (SE1/4) a distance of 312 feet to the point of begin- ,I i ning; all of the land described above being in Section Twenty-six (26). Town- I` ship Twenty-nine (29) North, Range Nineteen (19) West. I Also, the Northwest Quarter (NW1/4) of the Northeast Quarter (NE1/4) and i i all that portion of the Northeast Quarter (NE1/4) of the Northeast Quarter (NE1/4) lying West of the re-located town road, all of the above being in Section Thirty-five (35),,Township Twenty-nine (29) North, Range Nineteen (19) West. ~ff i i VA -~4 Hedwi Windolff, a/k/a Hattie Windolff And the spid............ .............E. r, part.y..... ...o the first part, for...:,.,....... her .................heirs, executors:lnd administrators, do-es `..covenant, grant, bargain, and agree to and with the said parties of the second pa-t, and to and with the survivor of them, his or her heirs and assigns, that at the time of the ensealing anal delivery of these presents. 0he..is well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and that the same are free and clear fronvall incuntbrances Whatever,,....... ' i - i and that the above bargained premises in the quiet and peaceable 'possession of the said parties of the second part, as joint tenants, his or her heirs and assigns, against all and every person or persons lawfully claiming the whole or any part thereof,....... ehe .............will forever WARRANT AND DEFEND. . i , In Witness Whereof, the said part y.... ...of the first part ha 8......... hereunto set.... her ._hand...... and ! seal...... this...... 2nd....-'........... clay of.....January A. D., 19..59.... + Signed, Sealed and Delivered in Presence of ...C~..C -.(SEAL) . i Hed Windolff , 11 ....!tac?w..................... (sr AL) John W. Davison ~j ..............(SEAL) ..~4~tL-~tfr'c?...~'~` f~1.Gt................... .........(SEAL) I Kathleen Tobias STATE OF WISCONSIN, ss. Pluc 0 ..........County. Personally came before me, this .9..... .......:.nd ..............da of.....Januar.K..................... A. D., 19.5 I Windolff,....... ....a/k/a Hattie Windolff . HedwiE.... the above named , . . . . 44 to me known to be the person ..who executed the foregoing instrument and ackn wl ged the same. s . THIS INSTP.l110T WAS DRAFTED o t , WHITE, DAVISON & MUTE. ATTORNEYS . John W . Davis AT LAW, RIVER FALLS, WISCONSIN *-f Notary Public My Commission e'xpires'.. , Dditf., (Section 59.51 (1) of the Wisconsin Statutes provides that all lastrurnente to be reemded *ban have plainly printed ttt ratfiett'oh''tbe' names of the arantors, grantees, witnesses an notary) 1 O td~ I 1 3 Q 1n 'b ,st l 3 0 a „o c, r1 CA 3 • x i W ~ 'off „ ~ ~~-+j' }