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Home My WebLink About022-1057-10-000 ao ^ 0 6q ° ° I co 0 0 $ N C > ! O CL m n C ° 0 v ° c z c 3 o a I co Q ~ III 3 m v y co E z Ft U) 2 z m a~i co w a m N I- Z O O Z 'd C Q: r i 3 m avi Z d' ° c ° fn F- ~ O Z c E 7° N N O N N U d D O O N Z co z z N _ co 0) N y E (N CL m L ~ N N_ N m C O O O O d N 0 0 0 G O CL E j f6 N N N z M> U N N 0 0 0 o v v v Z O O O is CL CL IL Z5 CL LL O W ° co co fA J U F rn rn Z -0 Lo M o tm m rn oO o0 N N L O S m ~ O m 0 N a ~ w rn O) .D N _ 2 6 Q cu ° c a w 0 1 C C4 U) 'A y O O N W C O T o E LO cn rn M U O t 4) :3 0 C c x 0 0 0 CN L M C N N N N N Lc) 00 Y a) CO C N r' f0 U Y ~J Z N 'O a0 (D 00 'O N _ N C C) 0 -11-3 O N Y S N O N H Z V #t a EL rr~~ y c t ~1 A 0 a~ 0 m ~ Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Lab+~r and Human Relations Div'+lon of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY -S'r c' it Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. Q t2 - APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION O S Cf\ R C_ . I- ~ GQVr-E9T tNF 1/4 SW 1/4,S 'W T ?.F3 N,R \l~ E (0425 PROPERTY OWNERS MAILING ADDRESS BLOCK # SUBD. NAME OR GSM # X003 QVPtZ.L~ \~RD - '%-6 3ib 16 fj D~ C-S01( LoT3) CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE QrOWN NEAREST ROAD 1771 1Vt~R Fj~ LLS kJ ] Sg02Z h1.57 4ZS, Sq-jl 1-~ 1QN\C kI NtV 6S [tQ New Construction Use.[M Residential /Number of bedrooms l-»VLNQWN [ J Addition to existing building j ] Replacement Public al describe Code derived daily Ito L_?LUS d tpµt Recommended design loading rate O -1 bed, gpd/ft2 0 ` $ trench, gpd/ft2 _fV Absorption area requi bed, ft2 LB Pi tren ft2 Maximum design loading rate O•') bed, gpd/ft2 trench, gpd/ft2 Recommended infiltra9 6.5 ft (as referred to site plan benchmark) Additional design /site considerations S~ tJO)-C- `10 \ru Slfri.~~12 QN3 3 OF 3 Parent material S flyj ~ Ov1-~., 11~S N Flood plain elevation, if applicable N . A . It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem ®S ❑U ®s ❑U ®S ❑U ®S ❑U us ❑u ❑s [oil 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 mr& I o-110 \o~Q ztz s1 Z~sb Y"~h cs o.s o.6 h - ::;.N< . Z 1b-19 10 ~t R 3/3 S 1 Z S ~h Gov es o- Ground 3 l of )0-1 R 3/ ~ g Vn S ~~k ~v► U `f h CS ° 0.5 elev. \Ob•S ft. Z6-°1S lO y2 S it GV p so) wt 0 7 t3 Depth to limiting factor~S~ Remarks: Boring # e-►O 10"12 ZIZ S•1 ` Zht Sb4z wt'F1~ C LA_ - a.S 0.6 z z iu-t9 \O`2 fZ 3 t 3 - s i l Z~ sbk `f~ cw o• C 3 )9-30 1(3`12 31L - s l~sbk \V11 \3 V cS - o•v ~.S Ground elev. 3b-96 )u`ttZ V/6 - S trG►- OS-) Depth to limiting factor Remarks: CST Name:-Please Print Arthur L. We erer Phone. 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: ,p q y- 3 1 9 - Z Date: \Z..- 30 - g y ~T Number: 0 0 5 7 6 PROPERTYOWNER O.SCPM C• L SOIL DESCRIPTION REPORT Page of PARCEL I.D. ff Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends 2 q=z.~ 3 - s~ I Zw►sbh w~~~ cw - o.s o. L °s Ground 3 L~-3 L S) 1 Sbvz YA L/ elev. 93-. -Z ft. 31,-86 l0 `ttL4/!(, - S~IG~. S9 w~1 - 0 7 ;u.g Depth to limiting factor Remarks: Boring # 0-14 tp`-(R Z12. si ` Z+~►3b w~'~'~ Gw - a.S o-6 ICI-Zb lQ`i 2 3! - s )1 Zsbh l~t'~'1~ Cw o. S o, 6 :s 3 ZE, 3L/ 1Z \.I J16 _ S) ~wt S~ }n V `Fh CS n Y o S Ground S 6►. 0 S5 M elev. 3 Ll -89 4 y R v l! woo-I ft. Depth to limiting factor 9 Remarks: Boring # - o•S 6 1l1 `-RZ1Z sL1 ZvnSbh `M sc~ (D, S Z ty-zy 1 O` v- 3!3 stl Z,w► %bti c..w - u S o. b ~ 2,L) 3S 1OY2 31b - s 1 Zwt S bh wt v-Ft,. e s - o y 5 Ground elev. 3S-97 lD Ll It V/` - S 8 G~ s9 >n I - r,,1 o. 1uu •'7 ft. Depth to limiting factor ,7 01 i Remarks: Boring # • h\ti Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) • PLOT PLAN Page 3 of ~ SCALE 1"= E ` tv 3E IN C Nft S T' ZS' SOH S`i sT i~-WWS--- -8S(4•13 W LFLL ti 4 $lll . F,s`rv\-ts-z Lur ua,e s lv o~ NT gift--sr s'PRCM sv"C31 "-C% v o ~ ~t.g98 EL %b $ g' Z 8.1 _ v \14,0 10" 7WI t# - tfL Loo . o' oxi )-o %'4 aF a"NIGN, 3vvkb)A. Avc, stool R.s o. er v ~ o °t `t - @_►-t Z _ L~1 . 49.4' W TOP of 't~tGN, 3~y` 1). PV PtPtr w / wooer t,t1~ , 0 t_.O~h'nU►u St-ck?1'CN . -r s Yti 6 5 POR 3 $DTZ~ I 1`1 U1'JE - 1Z'x sy' $ Np op Z 11 ~t1Ck}@S , cN ` k S' X S1' 10~G . Fv12 Y e DRw1 H-oj-7 e ReD OR Z 11ZeucH es, EACN S'X -1S' LOQG, d Sw-Sw S t -Sw Jb2 S BbRh lit xjE )c4o' r30~) UQ -L lnIaVclfCS, eACE( s,k 9(/ ' Lou G, ~~QI 01 Y-319- Z d.'"~2% lZ- 30-~~ (715 ) 425-0165 1400576 CST Signature Date Signed Telephone No. CST # Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 1, u t x Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but s1-• c 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 OWNER: PROPERTY LOCATION O S CP P, C . I- GBVP4--@T tJ F 1/4 SW 1/4,S M T Z8 N,R k16 E (o IN PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # ~~~3 QVf'tZZ~ \ ~.D - - C~RuPos~U C_ S►"1 CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAD RlUE,~, F-1Yt_(S k.J I Sgp2.Z (GIs) yZS, S(4-)-) 1~ INNIC kl W" 1C° S`1-4 " 6S` [34 New Construction Use.[M Residential /Number of bedrooms ta~-31-LNQWN [ j Addition to existing building [ ]Replacement icvr credal desaibe Cote derived daily flo \SO y gpd yl Reoornmended design loading rate o •1 bed, gpd/ft2 0' b trench, gpd/ft2 'OkM Absorption area ref lu ed Z-XS bed, f LBa tren , fl? Maximum design loading rate Q,-) bed, gpolft2 0.8 trench, gpolft2 Recommended infiltrati 96-S ft (as referred to site plan benchmark) Additional design/ site considerations S tJO)-(Z-- `M 1fv S1wcti.~~ 2 Ott 'OKe" 3 01= 3 Parent material 5 htsaLkI c)u- ~ NS N Rood plain elevation, if applicable N. A It S = Suitable for system CONVIRMONAL MOUND IN-WMND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for stmt ®S ❑ U IRIS ❑ U ®S ❑ U ®S ❑ U I~ S ❑ U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu- Sz• Cont Color Texture Gr. Sz Sh Consistence Botrtc iry Roots Bed ilench rX s o.Z b-t9 ~R 3/3 S1 Z S~k `ih Gtv _ o-S o-` Ground lq-2I, 10 1 R 3/~ g Shk CS '4 c S elev. m-8 ft. Z(,-°tS to y2 y/` - S d GV p s~ wt I o u. 8 Depth to limiting factor 7 °15Remarks: Boring # e~lo to~2 zcZ s rw' l ^ Z 2 Iz$-t9 lo` V 313 s i) Z ~sbk ~t `f~- cw o. s -6 3 )9-30 10y2 316_ - S ~ l~Sbk \"+l~'Ftr cS - 0.4 c,.S Ground elev. 3b-96 )w-m VA - SetGl- o s~ wt 1 - o•~ °'8 C) 9.8 ft. Depth to limiting factor " - T_ Remarks: T Name.-Please Print Arthur L. W e e r e r Phone: 715-425-0165 e V gerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: y- ~ 19 - -Z Date: 1Z_ 30 `c, 11 CST N~xn 0 0 5 7 6 PROPERTYOWNER oSCP~M C, LEE' SOIL DESCRIPTION REPORT Page of 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 ` o t o R Z L Z s t 2, ti,., `tn i c,~.v - o• S a 6 ..,.r,...,....: z z~ >~~ttz 3 f3 - s~ I Zw►s~tit vr,~~. Cw ~.s a b Ground 3 Z~-31. ~~`ft2 3!(o S) ~\M Sb1, \MU`FN CS o' y os elev. -Z ft. 3~_aL l0 V_ V/16 - S s1G~, O S9 wI J - io. g Depth to limiting factor i Remarks: Boring # 6-1\4 Vl 4 Q Z.. l 2 s` 2 w, 3 b Yv\'~'Ir G~ - Z" s (21- 6 jkZi,4 t ZmSbVt 1K~'V• Ctv 3 zt;-3y ~otitZ ~!6 - s 1 1w, s~ ~v c ~ ~-Y o. s elev. Ground L 3y-cQq ~0`!R tl/b S'~ 61• 0 B~ 1^'1 0,~1 o. $ tool ft. Depth to limiting factor 89 Remarks: Boring # b _ l y ) t1 ~-t R Z l 2 S l 1 Z-►~ S \b h `M ~h cw _ o •S - u s o. 6 t S ` Z ty -z.y 10yR 313 - stl Zwt seh VA"~ 0- "'1 2 3Jf; - a 1 1 gbh >ti, vim. e S o. y `•.o, 5 Ground elev. 3S-97 1D LfIt V/6 - S 8 Gt. s9 fn ( - 0.1 ' 0. tou ft. Depth to limiting factor y Remarks: Boring # •r 4......^ t"'' Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PLOT PLAN Page 3 of 3 SCALE t~b~SE `Ib 3E Pn ~~Yt ST ZS' F-V4E'I s~ s'~ fry- s--- W n w,v wr un,~s o~ tIT Lo"r s'~ sysTsl s. v' o ~ fit. q y 8 .J~ EL %b $ g' Z $•1 _ v s `i sTC~-t - --may ¢e WNL b / Ito ion -a' o,u lv'i~ a F 00HtGN, 3/ykbIA. PVC. L'~ 100 B.. S / w~ c 1~ 1 P k W/,-v ooLl L pt T} . ~ o. erg/ ~ o \b < y S y Sri ~.3 Pt4t w / woop LA7}~ , 0 ~.Oo-r~''C1Uh~ S1~ck''1'CN S Ti 65 I S~~ Nom ~ '~5~~~~ I FOR 3 'R b" +-aw-Sw 1`~U1yE - 12'K Sy' B ND OR, Z 71 1VC!}@S , ~hC N S7 " L0~ G , x S' x, ~ ivy -Sw Foil y e DR.m H nw1 - tz 'X 1Z` R@D UR Z -12~ cfj es, RCN s' x d F~ sw-Sw SE-Sti, x FOR S 1+1XIC, I X pZw I'a O'~ 0Q Z ~ if es eAcit 9 _ S'x qY' LouG . -%EW c-He s hILG~ P,-ecom )j E1.i~LSD ,~QQ 9Y-3)9-Z (715 ) 475-0169 M00576 ST SinnaturP _ Dat Sianed Telephone No. CST # 10LR :a AUG 2 4 AUG 2 8 1995 KpSHIEEN N,WALSK islei of 0 Wl r Reg ST. CROIX COUNTY SECrolxCo.. 53297 SURVEYOR'S RECORD w CERT IF I ED SURVEY MAP /a, 000):g' - ~ LOCATED IN THE NW 1/4 OF THE SW 1/4 AND IN THE NE 1/4 OF THE SW 1/4, ALL IN SECTION 20, T28N, R 1 8W, TOWN OF K I NN I CK I NN I C, ST. CRO I X COUNTY, WISCONSIN. PREPARED FOR: OSCAR LEE i= z 2 NOTE: BEARINGS ARE REFERENCED TO THE NORTH-SOUTH QUARTER LINE. (RECORD O UNPL,A,TTED ,LANDS, BEARING). S. T. H. " 65" WIDTH VARIES S 9°38' 37"E 4.98.50' o 0 0 • " N 114 CORNER OF SEC. 20 i HIGHWAY SETBACK cn (COUNTY MONUMENT LINE FOUND). u, C. S. M. VOL. 10 WE IT LINE OF THE Z NE-SW m 'z PAGE 2944 w °o •r' cn LOT 3 ° w 10.00 ACRES 435,724 SO. FT. M :r- 0 c :n :z _ N 89°39' 12"W = N w 854.79' N ' REC. N89137'15"W Z~ M OO 2 ~ AUG 2 Cb~ hry N, W N 0 4.351 y Q S 1 /4 CORNER OF SEC. 20 m ST. CROix CG r~ l ` n~~,. (COUNTY MONUMENT FOUND). GornWehensive P na,i 5 ~ Zoning an 206. 28' Parks Comrs~t 830"'39' 12" W attllaAtM1 e~. I f 45C;C if not recorded I Aj ,o s STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS .~<«~',r 1-=rl/sue/ SUBDIVISION / CSM# ~G~ ~ayey. LOT # SECTION 2C) T N-R l ~W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHI X00 FEET OF SYSTEM c~ v, ~Q INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK : Su ~e s / / S ALTERNATE BM• SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: 1D0e Setback from: Well House / ' Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length ,3-? Number of trenches 7 Distance & Direction to nearest prop. line: old' ~ Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet: ST outlet: PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION:/ PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt ' Safety and Buildings Division Bureau of Building Water Systems `.SANITARY PERMIT APPLICATION 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 C than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number d e"2,154 The information you provide may be used by other government agency programs Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location k~o ~i~ S~ 0- IIIAI e- 4r 14J 1/4, S T , N, E (or Properf'y Owner's Mailing Address Lot Number Block Number ry" City, State Zip Code Phone Number Subdivision Name or CSM Number r lS' dJ 7" ( ) iP I. TYPE F BUILDING: (check one) E] State Owned ❑ tyage NRoad Vill- Public 1 or 2 Family Dwelling - No. of bedrooms E] Town O 'LC 4. 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo CS 9 9 - l~5 7 _ 3 l 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) 1. pI New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an 1'~System System _______TankOnly____ Exi sting System Existing System B) eA Sanitary Permit was previously issued. Permit Number 5 Date Issued ,7.3 V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 (XSeepage 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 ',-_fD Required (sq- ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation c I e", 1, - e.91 I ` Feet U r 7 Feet VII. TANK Capacity In allonTotal # of Prefab. Site Fiber- Plastic Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con steel glass App. New Existing structed Tanks Tanks Septic Tank or Holding Tank o O e, I D 0.0 1 U Lift Pump Tank /Siphon Chamber 1:1 El VIII. RESPONSIBILITY STATE-MENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans- Plumber's Name: (Print) Plumber's Signature: (NO Stamp) rMPRSW NoBusiness Phone Number: 2- 7i~' ~3PG- 31 Plumber's Address (Street, City, State, Zip Code (,f ;7 d -7-1 e- c.~ `tG IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (IndudesGroundwater ate Issued Issuing Agent Signature (No Stamps) urcharge Fee) X Approved ❑ Owner Given initial ~~A~ 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 4 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 nerr 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 VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and' manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks,- distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number a? 6ti2 ,15j~ 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 Prop rty Owner Name / / Property Location Q ~i / y~/~ µ e 7 4/.17 '41/4!S~ 1/4, S ;2 ) T ~ b , N, 'Y p E (or) . , Prope y Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number I. TYPE OF BUILDING: (check one) E] State Owned 3 it( Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Town o . u t,,c,YC III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo 6V %1 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 ______System System Tank Only______________ Existing System _________Existing System B) eA Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 E.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 (sue ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Y~ y~ r 'r - e1-1 111~ 1 Feet e, % Feet VII. TANK Capacity in gallons Total # of rs Prefab. Site INFORMATION Fiber- Plastic Exper- Gallons Tanks Manufacturer's Name Concrete Con- Steel New ExiStin strutted glass App. Tanks Tanks Septic Tank or Holding Tank )C~ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite s "age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamp) /MPRSW No.: Business Phone Number: 31'7 / Plumber's Address (Street, City, State, Zip od lel'7,01 _j, e, 6 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) A roved /Surcharge fee) - pp ❑ Owner Given Initial .✓r^' Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) - DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS L 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 acid manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Wisconsin Dppartmenr of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Hum4n Relations INSPECTION REPORT ST. CROIX Safety And Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION P1UUe,rnlji,VVger'sWAA1V.anE ❑ City ❑ Village X Town of: State Plan I No.: CST BM Elev.: IIVV Insp. BM Elev.: BM Description: Parcel Tax No.: A96500113 /00- 1 /010.' &d TANK INFORMATION EL VATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark , oo ; Dosing Aeration Bldg. Sewer Holding St/Ht inlet S,OB' 99"11 TANK SETBACK INFORMATION St/ Ht Outlet 8 I8 ' Vent TANKTO P/L WELL BLDG. Air , nto take ROAD Dt Inlet Air I Septic > 1 NA Dt Bottom Dosing NA Header / Man. , 75 Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade / Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss H Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length I No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /a2 X57 DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION 'Type O Model Number: System: 4_"0- 115' > 0 j OR UNIT DISTRIBUTION SYSTEM Header/Manifold I Distribution Pipe(s) I x Hole Size I x Hole Spacing I Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: KINNICKINNIC.20.28.18W, PTE, SW, HWY 65 Plan revision required? ❑ Yes ❑ No Use other side for additional information. 1,/// a6 SBD-6710(R 05/91) Date spelt ' 'Signature Cert No. DiLH SANITARY PERMIT SQL C TRANSFER COUNTY /RENEWAL UNIFORM PERMIT # (PLB 67-T) Z_ c-G PERMITRENEWALDATE: PERMITTRA SFE DATE: ORIGINAL P RMIT SSUANCE DATE: STATE PLAN I.D. NUMBER: PROPERTY LOCA'TI~ON: /0 ~ 96 ~J a~ ~G y- 5gv Ya S~ CITY: "W ,T'``a N,R I~ E (or) vl n I LOT NUMBER: WN OF• ~ x'1.{7 I -3 C'SM WIAI I~ Zq~~ A 53~~I~J NEAR~TROAD,LAKEORLANDMARK: 3 bs /V PIMPVSOWSANITARY PERMIT HOLDER (tP : SANITARY PERMIT TRANSFERRED TO: NAME-~ NAME: SIGNA~RE: ('ln~~ PHONE NUMBER: ADDRESS: O 2 ~ '12. 19, Ca j c n PHONE NUMBER: ADDRESS: ~ q2-5-- ~{o os the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved property. pp ved for this PLUMBER'S SIGNATURE: " PREVIOUS P UMBER'S NAME (I CHANGED): PLUMBER'S ADDRESS: 1 o S PREVIOUS PLUMBER'S ADDRE S- ~D P PRSW NUMBER: PHONE NUMBER: Z4 M SW N BER: PHONE NUMBER: SIGN TURE OF ISSUING AGENT: DATE PP VED: DISTRIBUTION: Original -County Copy - Bureau of Plumbing )ILHR-SBD-6 99 ( /82) Copy - Owner Copy -Plumber r t WisconsinDepartrnentoIImustry, SOIL AND SITE EVALUATION REPORT Page of 3 1 Lab and fA/rl Mlr flO r~ , IMism of Safety & Bullings in accord with ILHR 83.05, Wis. Adm. Code COUNTY s~-. c,~o L x Attach complete site plan on paper not less than 812 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (elan, 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 OWNER: PROPERTY LOCATION W K" -t tv E }}U1 NEE -6A E6T NF 1/4 SbV 1/4,S Z 0 T ZB N,R ) $ !r (ar YV PROPERTY OWNER'S MAULING ADDRESS LOTS BLOCK # SUBD. NAME OR CSM # l-) ZO 3t.RCl~) Ck-ez?- 1Q . 3 - S" CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE [TOWN NEAREST ROAQ I~t} ilk 3~Prit ~h `MN 5511 (LLt) V7-9- S SQZ ~zt►t j~ t c ~IJCIAvL s 6 5" jQ New Construction Use [~d Residential / Number of bedrooms 3 [ ] Additikn to wdssting building j j Replacement [ ] Public or commerdW describe Code derived daily flow qSO gpd Recommended design loading rate o , bed, gpolfl2 ° ` 8 trench, gpW Absorption area required 6 4 3 bed, 112 S 6 3 _ trench, ft2 Winum design loading rate o - bed, gpolft2 0,8 trench, gpdnt2 Recommended infiltration surface elevation(s) 9 L--1 ' It (as referred to site plan benchmark) Addifonaldesign /site _considerationsSEE WTTi `i'0 W9-ML eZ OKJ 1~Gt? 3 - ~oSE AVr'tP 1Zk~' . Parent material SMti►O`i Ov1-w h3N Flood On.elevation, if applicable tv - rt i S = Suitable for system CONVENTIONAL MOUND IN-GROl1ND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TAW U=Unsuitable for ErS ❑U MS ❑U ®S ❑U 0S ❑U 0S ❑U ❑S OU SOIL DESCRIPTION RERORT j Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BwxJ3y Roots GPD/ft in. Munsell Qu. Sz- Cont. Color Gr. Sz. Sh. Bed tench ~ ~ O-~) 1.0`-1,2 zLZ SL Zmsbk m~1- ~S - c,.S o- 6 k Z tiy-3Z t tJ-t2 3L6 g h~3~1z vn\)ii- C- S - 004 O.S _ 6►- s S \ _ o- o Ground 3 3i-yu$ -LO`1 fZ y elev. bbz. ZIL Depth b limiting factor > l Da' Remarks: Boring# o-%-Z 10`12 z[z - St~ z, sbh w► cs - o-S o Z Z 1.2 3 2 Lp~i 3/~ s 1 s~~ c g - o• o. S 3 3t-toy 1t3`0-- y/L _ S 4G~- O SC ) - o -2 €o•d Ground elev. y.oz_ztt Depth lb limiting factor + Remarks: Tf+hrue-PleasePrint Arthur L. We erer Phone. 715-425-0165 ejerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Sgnalw 9 6 _a y Date: R/ ~6 CST Number: M00576 t i PROPERTY OWNER SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence ftoota,_` @I?D/ft Boundaty- In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh, Bed Tmr& 3 O-b1 1A`-L R ZL2 St Z,~S~ `!"1- CS o•S:: o-(, Z 11-3S 1U~c12.:3~~ S M S1~h V-4 C.Z, o, y a S Ground 3 3S-loo R y/G - S rcG~ L1 Sg r,-,~ o-~ v_8 elev. ft. Depth to 1 limiting factor > oo' t Remarks: Boring # a-1z X0`-12 z!z Sl I Z~,sbh~1, ~S - o,s o.~ LI Z 1Z-zz 10Ll ti 3l:!, - i 1 2 `FSbh yn1;- Lu o. S I 0.6 Ground 25 zz 3y IoLZR 3/6 - s I 1 v►1 sbk >h u`~>, 0-S elev. 3S~-8P Io `I IL VA - S ~Gl ~ sg Y,) q9. ft. Depth to limiting factor , e 1 '7 88 Remarks,;. Boring # I p`l 'tio`1 ii z (Z S I -ZM S 'z>2 GS o• S n• S Z 10-19 lL,) y(R 313 S1) Z iS~1z 1v1'f'I C1v - o. S D. b _ 3 19-3 2 lp `-t 2 Ground 3/b - S 1 1 ti►, 11h vn u`~~ ~s _ o. I o.S elev. 32-98 10 `t 1Z YA. - S g GL O S3 M I - 0 7 o• $ Jot. Zft. Depth to - - ' ' limiting . f~tgg" F-T Remarks: Boring # r i Ground elev. ft. Depth to limiting factor Remarks: sao-e~anrR osi4~~ PLOT PLAN Page 3 of 3 SCALE 1"= q Q' Z Io_ 0 swP~s l/J S`257~"l /~RE`A v1f- ZTn 3~0 / ~~~luL ? • o° / ~ LoT f'cllZNr~TE S`1S7t`~^-15 t-77 B.S / o0 of Elul ? / O _ o ~1-a4 6 v °i WLL.L J~ -r-- r, 10 e 1 6 F"I - C'L . l 0 0, p a N HIGH, Sly"uiq . pvC 1 ~ s'rrl b s ` ~ 01, -ti~o`[~ -tD I,~, sTA ELF? 2 : _ - IWS-rfru- S. 1~►l~v~MUM S7' 1,0~~ o1Z R \Z,' W1DF 13e'b `+-l /V kM ~ S y ' U A G WV T1J 1IV `tl Z-rTfM-L Fr~ S M W N u (~~i {EL I~`1\0~ '~0 $ E s k gLj7 / ojZ 'rh r C IF- r J U RJIZ C&J vS ~Cpv►v`RFYT R ~i[GH~R_-~U1g'~7oN A" 'rT `tom Y" 1D3T SuvT>~~'2c~y Cote. sc-M.~- Iu=3o0• 'ET t'►P~1.►v 11v "fv-X . y Z GoutnL Ou lZ- ` r?t ~~5~-[ ~U1l0yV l i~~TS , S~A~~E rz-P 41Z ~V L~vi' ~o iD] yv v oU eZ 5Y Sl'E ► . ~.o ay~10~ SIz~,N ~6-sy 1~1PN( 91 (715 ) 4?.S-0165 M00576 CSTSignature Date Signed Telephone No. CST # a !r r 0 1 ~P ►f~ 1), A OHO U~ h f ~ w5 r ~ e .q 06 yea Cam` -1 f t Submersible MODEL: 3871 SIZE. 3/4 SOLIDS Effluent Pump RPM: 1550 HP: 0.4 METERS FEET T 25 i = 6 20 Z 15 I 4 -I 4- - I - - - 3- 10 O 2 5 ~ 0 0 0 10 20 30 40 50 GPM 0 2 4 6 8 10 12 m3/h CAPACITY ~GOULDS PUMPS, INC. S&CCA 94LS PEW VCW OWS P- E O l ose Go" Pun". Inc. n.ctiw October. I SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE PRINTED IN USA s PAGI GF PUMP CHAMBER CROSS SECTIOIJ AMD SPECIFICA'TIOuS VEWT CAP 4"C.I. VENT PIPE WEATHERPROOF APPROVED LOCKIMG > ?_5' FROM DOOR JUNCTION BOX MAMHOLE COVER - , WINDOW OR FRESH 12"MIU. AIR IAITAKE I GRADE I ~ _ _ 1 s° rrl u. COAIDUIT \ ~h IkILET PROVIDE AIRTIGHT SEAL i I I * A I i I l ,t I I I I ALARM d I 11 I I *APPROVED I ON C JOINTS WITH I ELEV FT. APPROVED PIPE 3 ' ONTO PUMP OFF D SOLID SOIL COAICRETE BLOCK RISER EXIT PERMITTED OAJLy IF TANK MAMUFACTURER HAS SUCH APPROVAL SEPTIC f SPEC-IFICATIOUS DOSE TAUKS MANUFACTURECUMBER OF DOSES: -PER DA.4 TANK SIZE: GALLOUS DOSE VOLUME ALARM MANUFACTURER: INCLUDING 6ACKFLOW: 7l 2 GALLONS MODEL IJUMBER: CAPACITIES: A= _26-flUCHESOR 3-13, GALLOWS j SWITCH TYPE: 3~. Q j / B =INCHES OR GALLONS PUMP MANUFACTURER: - Ga,~I yl C=L-11JLHES OR 71' ~GALLOUS I MODEL NUMBER: D=.L~LINCHES OR GALLOWS SWITCH TYPE: nI «c MOTE: PUMP AND ALARM ARE TO BE MIMIMUM DISCHARGE RATE -~-3 GPM INSTALLED ON SEPARATE CIRCUITS. VERTICAL DIFFERENCE BETWEEN PUMP OFF ARID DISTRIBUTION PIPE.. FEET + MII+AJIIMUM NETWORK SUPPLY PREESSSURT,E~. , . . . , . . . . FEET + [1st _ FEET OF FORCE MAIN X QL!EZ _ F/ ~-Ep loo FLFRICT1o1,1 FACTOR-12-E- _ FEET TOTAL 0y1JAMIC. HEAD = Id, 7r. FEET r rI / IMTERNAL DIMEIJSIONS OF TANK: LEIJGTH . ;WIDTH 6/ -;LIQUID DEPTH SIGI~JED:~~`, LICEMSE NUMBER: flATt-'( to SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Cou ~rO/~ • STATE SANITAR ERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than Gl 8% x 11 inches in size. ❑ Check if r i to rev o p ication -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY' OWNER PROPERTY LOCATION WA n P ;Fe IC, % 7t-) S PO T 9) N, R 1 E (or) W PROPERTY OW R'S MAILING AO SS LOT # BLOCK J1 6 G~ ~ W CITY STATE / ZIP COD PHONE NUMBER SUBDIVISIO NAME OR CSM NUMBER no r-7s) II. TYPE OF BUILDING: (Check one) ❑ State Owned E3 CITY 13 VILLAGE < < NEARESTRAD ~~/1 tC~/r~~t ❑ Public 91 or 2 Fam. Dwelling-# of bedroom PARCELTAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) /g 1 ❑ Apt/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 80 Mobile Home Park 12 ❑ Service station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2. ❑ Replacement 3.E1 Replacement of 4.0 Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution. Pressurized Distribution Experimental Other 11 Seepage Bed 1o? X S~O 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQU R~ED/ q. ft.) PROPO/SE~ (sq. ft.) (Gals/da /sq. ft.) (Min./in ) NATION ✓ d Y V 1® 7 t 4j / m t / 0/ t Feet / v r Feet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed .0 b Septic Tank or Holding Tank ?G --40&,* } S 4 Lift Pump Tank/Si hon Chamber ~j VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for inst Ilation of the onsite sewage system sho ed plans. ~ Business Phone Number: Plumber's Name (Print): PI Signature: (No Sta s D 9 l 1492,~ Plumber's Address ( tr e , Ci , State, Zip o 6~ D OJT- Nt e r k S IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved SanitW Permit Fee (Includes Groundwater Date Issued Iss 'ng Agent Signature No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (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 & 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. 11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new arid/or existing tank, list the total gallons, number of tanks and manufacturer's name. indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) .i ; i YlAnkt • sad Ta 303 r• _ • !A • IA i 11600 .i ~ a _ S'x57`fr~~es ev 9~.7 ow e ~er .a ~hd ~rX.a1~ ~ s ~ a~ count ~ ~ ~&,X 41 C~ 11 • 0 00 1.1 ~ . : ~ Pi ew/wo-oa katA • i0 i now., . i • n g3 1 . a f t ! ! y s- i- • • i • ! • PAGE OF /PUMP CHAMBER CROSS SECTION AAID SPECIFICATIOWS VENT CAP '1'•f..I. VENT PIPC APPROVED LOCKIAI WEATHER PROOF MANHOLE COVER W JUNCTION BOX Wo r n, /1~ I 25' FROM DOOR, "~tbr WINDOW OR FRESH ICMIU. I AIR INTAKE I GRADE I y" MIW. I 18"MIN. COWDUIT-- \ 11, PROVIDE I - . INLET AIRTIGHT SEAL I I I APPROVED JOINTS APPROVED JOINT A I I I W/C.I. PIPE W/C.I. PIPE I III EXTEWDIN6 3, EXTENDIAIG 3' ALARM ONTO SOLID SOIL OWTO SOLID SOIL I 11 a I 1 I I ON C I ELEV. FT. pump-- OFF r 0 CONCRETE BLOCK . 20 0 3•' APPROV L~ll RISER EXIT PERMITTED Ly IF TAMK MANUFACTURER HAS SUCH APPROVAL gEpflINC~ SEPTIC E 5PEC.IFICATIOKIS DOSE ~ ' TANKS MANUFACTURER: Fell NUMBER OF DOSES: - PER DAy TAWK SIZE: SJ GALLOWS DOSE VOLUME ~`d a` T,-• INCLUDING BACKFLOW: U GALLONS ALARM MANUFACTU R,CR: 1• ~ A n MODCL AIUMBER: AIA CAPACITIES: A=ao. Z INCHES OR 353• b GALLONS SWITCH TYPE: '_1 6 c~ -INCHES OR 9-',"-0 GALLOM5 PUMP MANUFACTURER: (A C= f~• IULHES OR 1~.7_LL-GALLOWS MODEL NUMBER: • 7 ~ 7/ D - 1~.L INCHES OR/_1J 3 GALLONS SWITCH TYPE: ~:!rcu~~ NOTE: PUMP AND ALARM ARE TO BE J7.OO;,~;'!,•~INSTALLED ON SEPARATE CIRCUITS d MINIMUM DISCHARGE RATE _ 0 3 -.GPM ~n VERTICAL DIFFERENCE DETWEEN PUMP OFF AND OISTRIBUTIOW PIPE.. FEET + MINIMUM NETWORK SUPPLY PKEQSSURE . . . . . . . 2 5 FEET + dE ET OF FORCE MAIN X 0' + FYo fEFRICTIOU FACTOR..-.-2Z-FEET TOTAL DyWAMIC HEAD = FEET IIJTERNAL DIMEWSIONZ OF TANK: LEKIGTH~;WIDTH-----t ;LIQUID DEPTH - ul , 1 ' 1. J SIGNED:. LICEWSE WUMBER: DATE: W mconsin•Department of Industry, SOIL AND SITE EVALUATION REPO I 3 labor end Human Relations Page _ Of Division of Safety & BUkings -T. in accord with ILHR 83.05, Wis. Adm. FPARCk loaf Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must incl t . # not limited to vertical and horizontal reference point (Bid), direction and % of slope, scale dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION BY _ DATE ERTY OWNER PROPERTY LOCA or.- PROP lv E~ NEE -691FF E6T NF`$1.1/4.S Z QT , N,R 1 a E (a 1N PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK# S 1A„ E ORC~ CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE (,MOWN NEAREST ROAD w 3 R Lhk_k `MN 53,16 (~L2) 4Z9- S soZ t- l/VN IC~rthlhJ s`-)+ 6S` ~Q New Construction Use M Residential / Number of bedrooms 3 [ ] AddiWT to existing building [ ] Replacement [ ] Public or commercial describe Cock derived daily flow qSO gpd Recommended design baling rate o., bed, gpd$ ° ` 8 trench, gpolft2 Absorption area required 64 3 bed, ft2 Sb 3 trench, ft2 Ma)dmum design loading rate 0 - bed, gpd/ft2 0,8 trench, gpol112 Recommended infiltration surface elevation(s) `3 0. r It (as referred to site plan benchmark) Additional design / sftle considerations SEE ►Jul~ )-r) 1/J:M.IeV_ 0►y lPrGe 3 - _DOStr Aywt P V_,e-,n D , Parent material S1'c►~~`1 Ov 11~SN Rood plain elevation, if applicable ".A • It S = Stitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN RLL HOLDING TANK U = unsuitable IOr 1em ID'S ❑ U El S ❑ U ® S ❑ U ®S ❑ U ®S ❑ U ❑ S IOU SOIL DESCRIPTION REPORT j Depth Dominant Color Mottles Structure G 7 PD/ft Boring # Horizon in. Munsell Coat Texture Gr. Sz- Sh. Consistence Boundary Roots Bed Trends Sz. Color :as•,a 1 O-~) tib`rb2 zLZ SL Z~+~sbk wr'4'1- ~g - 6-S o- :Y3 Z ~1--_,sZ ~o~t2 3!6 - s 1 1 yq -3~1Z vn v~~ cS o ~1 o-s Ground .3 3i-lu$ l•b`22 4tlG 't 6V- s9 M 1 _ 0-7 a•0 elev. ibz. Z.fL Depth b limiting factor > lD$' Remarks: Boring o-~Z ~p~2 zLZ - St J 7~w, S~1T Yv►.'~F C S o- So- Z Z 1z. 3 2 o >z s l 1 VA sN~ m u fl, c g 6 o. 5 3 3Z-16~ 10~R y/` S stGL O S~ - o €6-d Ground elev. ~.OZZ1L Depth b limiting factor ~to7` l Remarks: CSTNs►e-Please Print Arthur L. We erer Phone. 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Fa11s,WI 54022 Si nahw Date: CST Number: 96-S S/ yr L9`16 M00576 PROPERTY OWNER 't~ U ►JkE SOIL DESCRIPTION REPORT sPage of 3` PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxfary Roots` °'.,QPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 3 1 O-ti) 1A`1 R ZL2 1 SL ZmS~ Z 1~-35 ~U~c . 3~6 - S 1 1 n, Soh vn \j Cs C)"y o-S Ground 3 3 S_ o o IA `t rz VA. - S K Gv, O S elev. ~4~• 1 ft. Depth to 1 limiting ` factor MO' Remarks: Boring # , o-Iz tioy 2 II"Z - S~ 1 Zn, soh ~S - o.S Z \I -z z 0`1 rz S )1 2 s bh vh `Fh k, o . S o. 6 :~s 2z-w toLzR 34 - S1 w, sdk wt u'F>^ Ground elev. 14 3~-8$ to ti IL VA - SGT o sg Y►.,) q4• ~ ft. F' Depth to limiting ` factor 7 gg, Remarksi, Boring # a_I S }~12 GS o, g n. 5 Z 1D-19 loyR 313 Sl J Z ~k VVI -f. cj - o, S 3 )9-12 lU `t 2 3~6 - S` 1h S1k Yl UTV C_ o.S Ground elev. K-9$ 1(311 YlG S 1 O SS M 1 - 0- 7 o. $ J of . Z ft. Depth to limiting factor ? 98 " Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SRD-R330(R 05/9?) 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 W~ ,;70 /-/4.,J-7 ~C Location of property /4 S'01J1/4 , Section 96 , T N- W Township Mawo~. ng address A ro('7-~; e ~a 1° 53110 Address of site 35f - Adv P 44f A',('Ue;- l11S C./~. Oaf Subdivision name N Lot no. Other homes on property? Yes No Previous owner of property S C° G~ Z `P Total size of property /C) Total size of parcel d 4, Date parcel was created Are all corners and lot lines identifiable? Yes No Is this prop)13111 erty being developed for (spec house) ? Yes ~No Volume and Page Number //f1 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. ~3Z~ 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 theof the County Register of Deeds as Document No. Signatu a of Applicant Co-Applicant /020 h ~ Date f S1 nature natP of girlnAtllYP N J' . STC-105 SEPTIC TANK MAINTENANCE AGREEMENT y, St. Croix County OWNER/BUYER A 4 h MAHMG ADDRESS U L° l~C Yeg p~' G~~ ~ ~ ~P 0~1~► s'~"~~~ PROPERTY ADDRESS aGJ (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 1/4, 1/4, Section T c?F N-R_Z~L_W TOWN OF l 6/1 ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP 5 5, VOLUME PAGE 09g'PJ, 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 dis system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacemen"f a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: 5 a 9 St. Croix County Zoning Office GoYernment Center 1101 Carmichael Road Hudson, WI 54016 11/93 FILED , 2 y au~ 2 4 19 95 TNIEEN H•WA1.SN Ae4CfOlX~ N~ 5329`5 to CERTIFIED SURVEY MAP /a,oo LOCATED IN THE NW 1/4 OF THE SW 1/4 AND IN THE NE 1/4 OF THE SW 1/4, ALL IN SECTION 20, T28N, RIM TOWN OF K I NN I CK I NN I C, ST. CR01 X COUNTY, WISCONSIN. PREPARED FOR: OSCAR LEE ff NOTE: BEARINGS ARE REFERENCED TO THE NORTH-SOUTH QUARTER LINE. (RECORD BEARING). O UNPLATTED LANDS S. T. H. ` 65' WIDTH VARIES - - - - - - - - - - - - o a S 89038'37"E 498.50' 8 • • • • • • • • N 114 CORNER OF SEC. 20 HIGHWAY SETBACK cn (COUNTY MONUMENT LINE O FOUND). O 0 V C. S. M. VOL. 10 WEST LINE OF THE y Z NE-SW -0 PAGE 2944 w o -0 cb z r- y ti LOT 3 -4 0 o _ w = a~I w 10.00 ACRES :m O w 435,724 SO. FT. m o er ~ c CD N 89039' 12"W 3: :z CD N w 854.79' cn REC. N89.37'1 5"W 2 n N _ M Oj tD 0 0 0 'V w N O z p~j\y~ QQ S 1 /4 CORNER OF SEC. 20 r^ . ST. CROIX CG KT` (COUNTY MONUMENT FOUND) Gornprehensivo P nri Zoning 206.28' JO"' Parks Comrs~yt °'39, 12 " W DOCUMeNT NO. STATE B k OF WISCONSIN FORM 1-1982 THIS SP.CE RESERVED FOR RECORDIYO OAT• ' WARRANTY DEED 5335' 9 1139Pk-. REGISTER'S OFFICE This Deed, made between Oscar C. Lee Sr a/k/a Recd for Record Oscar- C.--Lec--and--Doris--M.:-Lee, -husband_an-d.wif.a---------- SEP 8 iaSJ - - - - - , Grantr, at 3:30 AM and. Michelle--A.- Bredahl and '.Iagnz Huhnke1_.wife and-_ husb---- as survivorship--marital- property---- - I Regletar of Deeds - - Grantee. witnesseth, That the said Gra==s, for a valuab,e consideration.-..-_ - - - - - RETURN TO conveys to Grantee the following described rtrl estate in St- ...Croix Croix County, State of Wizconsin: Tax Parcel No: ,t u .r •t Part of the NW} of the SW} and the NE} of the SW}, all in Section 20, if Township 28 North, Range 18 hest, Town of Kinnickinn'c, St. Croix County, Wisconsin described as Lot 3 of Certified Survey Map filed August 24, 1995 in Volume 11 of Certified Survey Maps, page 2980 as Document No. 532975- ~I rrR:Arrs - $ is FEE b~ This is not--- homestead property. - (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And---- Oscar C. Lee, Sr., a/Y/a Oscar C. Lee and Doris M. Lee- warrants that the title is good, indefeasiil-e in fee simple and free and clear of encumbrances except I easements and restrictions of record i and will warrant and defend the same- h Dated this - ----30th - day of August - - 19.85_-. ? - ------(SEAL) -<--G--c ..s.-(S'.ALj, Oscar C. Lee, Sr. - - r (SEAL)2- - y 7--`¢f y__(SEAL) ` • Doris M. Lee - i ' AIITHSNTICATIO'Y ACKNOWLEDGMENT 4 Signature(s) STATE OF WISCONSIN ss. !i - St. Croix .County. authenticated this day of_____19____ _ Personally came before me this -30th...... day of - August---•••----•--______--, 19.95_. the above named Oscar C. Lee, Sr. and Doris M. Lee 13t>Sbar~d fdife_ - TITLE: MEMBER STATE BAR OF WISCONSIN - (If not- authorized by $ 706.06, Wis. State) to me known to be the person -a- who executed the iszd,--ding instrument and pckrwledge the saine. ~