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Home My WebLink About004-1052-30-000St. Croix County Planning and Zoning Friday, January 19, 2007 at 10:51:41 AM Detail Sanitary Information Page 1 of 2 Computer #: 004-1052-30-000 Sub/Plat: metes & bounds Section: 22 Parcel #: 22.28.15.348a Lot: TN/RNG: T28N R15W Municipality: Cady, Town of CSM: 1!4114: NW 1/4 SW 1/4 Owner: Neisinger, Daniel 239 & 241 Highway 128 Wilson, WI 54027 State Permit: 241 i6 Issued: 06/15/1982 POWTS Dispersal: Non-Pressurized In-ground Permit: New County Permit: 85 Installed: 06/25/1982 POWTS Detail: Trench -Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Requirements Additional Notes Monev Owed Harold Barber Yes Helgeson, Bennie this mobil home installed just north of the south $0.00 Tom Nelson Signed Off: Yes property line along an existing fence. See plans in 1990 for an additional mobile home, just north of existing driveway. Plans did not show this mobile home south of proposed "new" mobile home. Not shown on 1990 as-built Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 6/25/1985 Owner: Witt, Terry 239 & 241 Highway 128 Wilson, WI 54027 State Permit: Issued: 05/12/2006 POWTS Dispersal: Non-Pressurized In-ground Permit: Reconnection County Permit: 102 installed: 05/12/2006 POWTS Detail: Trench -Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes issuer/inspector As Built Plumber Other Requirements Additional Notes Monev Owed Kevin Grabau NA Mittlestadt, Tim Reconnect to new mobile home. $0.00 None Signed Off: No Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 5/12/2009 Owner: Witt, Teny 239 & 241 Highway 128 Wilson, WI 54027 State Permit: 149051 Issued: 05/20/1991 POWTS Dispersal: Non-Pressurized In-ground Permit: Reconnection County Permk: 0 Installed: 05/20/i991 POWTS Detail: Trench -Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Requirements Additional Notes Monev Owed Jim Thompson NA Helgeson, Bennie Permit to remove mobile home and install house $0.00 Jim Thompson Signed Off: Yes file with 2006 reconnection Maintenance Scheduled Puma Date Pumped 1st Notification 2nd Notification 3rd Notification 5/20/1994 5/6/2005 S't. Croix County Planning and Zoning Detail Sanitary Information Friday, January 19, 2007 at 10:51:41 AM Page 2 of 2 Computer #: 004-1052-30-000 Sub/Plat: metes & bounds Section: 22 Parcel #: 22.28.15.348a Lot: TN/RNG: T28N R15W Municipality: Cady, Town of CSM: 1/41!4: NW 1/4 SW 1/4 Owner: Witt, Terry 239 8~ 241 Highway 128 Wilson, WI 54027 State Permit: 135537 Issued: 06/21/1990 POWTS Dispersal: Non-Pressurized In-ground Permit: New County Permft: 0 Installed: 08/09/1990 POWTS Detail: Trench -Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Requirements Additional Notes Monev Owed Jim Thompson Yes Helgeson, Bennie this POWTS connected to a mobile home at $0.00 Jim Thompson Signed Off: Yes #241- 1000 gal. Midwest septic to 750 gal. pump chamber to 2 trenches 5' x 75. This is immediately north of the 1982 mobile home at #239 -see Neissinger permit 12/29/05 -Owners want to change to a new mobile/manufactured home and will apply for reconnection permit in 2006. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION ~, (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Witt, Ter Cad ,Town of :ST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TANK SETBACK INFORMATION PUMP/SIPHON INFORMATION anu ac urer eman GPM o e um er I nc Ion oss y em ea o mal n I JVIL HOJVRr I IVIY X71 J 1 GIYI ELEVATION DATA County: St. CrOIX Sanitary Permit No: 102 State Plan ID No: Parcel Tax No: 004-1052-30-000 SectionlTown/Range/Map No: 22.28.15.348a STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer t/ t n et u et ne 0 om ea er an. Is . Ipe o . ys em Ina ra e over Pipe(s) I I I Length Dia Length Dia Spacing 'DTC~d4 Y Pressure Svstems Onlv xx Mound Or At-Grade Systems Only Bed/Trench Center Bed/Trench Edges Topsoil ~ Yes , No ,Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Location: 239 Highway 128 Wilson, WI 54027 (NW 1/4 SW 1/4 22 T28N R15W) metes & bounds Lot 1.) Alt BM Description = 2.) Bldg sewer length = -amount of cover = i ~ - _ li Plan revision Required? ~.:~ Yes No ~~ l Use other side for additional information. 1 insepctor's Signature SBD-6710 (R.3/97) Inspecuon mac. ~ ~_ Parcel No: 22.28.15.348a ~~ ~ Cert. No. ~ `~'y County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN o~ ~ Gp In accord with Chapert 12 St. Croix County Sanitary Ordinance P i b PLANNING & ZONING DEPARTMENT CROIX COUNTY GOVERNMENT CENTER ST ~ G ersonal informat e used for secondary purposes on you provide may . 1101 C i h l R d [Privacy Law. S. 15.04(1)(m)] arm oa c ae Hudson, W 154016-7710 (715)386-4680 Fax (715)386-4686 Attach com lete tans for the system on pa er not less than 8-1/2 x 11 inches in size. County Sanitary Permit # ^ Check if revision to previous application 0 oy I. A lication Information -Please Print all Information Location: Property Owner Name `,/ 1/4 1/4 ~ S ~ , W ec `,~/ ( ~ ~ `I V) ~ t'1~ t ~ ~ 0`2 N, R ~5 E (or)~ Property Owner's ailing Address Lot Number Block Number ~ 3~ ~ /~8 - City, State c1 ~ Lso 1 ~ i Zip Code ~~va ~ Phone Numer s~ ~ a-~ 7~~ S ~ , ~ r _ ~ 22,d ~ --~ s II Type of Building: (check one) amity ^ Village ~JTown of '~J i or 2 Family Dwelling - No. of Bedrooms: 3 ~ ~ ^ PubliGCommercial (describe use): ~ ^ State-owned Nearest Road ll. Type of Permit: (Check only one box on line A. Check box on line B if applicable) S ~'~ ~ f Parcel Tax Number(s) _ 3 1.^ Repair 2.~ Reconnection 3.^Non-plumbing 4. ^Rejuvenation A) vay-i6s~- 3a~ Qdo Sanitation B) Permit Number ~~~ Date Issued State Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ~11 Non-pressurized In-grown ^ Mound ? 24 in. suitable soil ^ Mound 5 24 in. suitable soil ^ Mound A+0 ^ Sand Filter ~~S-j--t ~ ~ ^ Constructed Wetland ^ Peat Filter ^ Drip Line ^ Pressurized In-ground 9-~~ ~ ^ Holding Tank ^ Single Pass ^ Other gt t ~ . , ^ At-grade ^ Aerobic Treatment Unit ^ Recirculating . Dis ersal/Treatment Are Information: ~STrNf~ ~n+FO ; 6nrDS , 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Eletvation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min./inch) 43.21 Elevation x-50 ~-So 0 . f~ ° p . 0 9 2- ~-9 VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks ~ ~ ^ ^ ^ ^ ^ ^ ^ ^ ^ V!I. Respors: i!ity Statersent I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installa ' n o - lumbing sani tion system. Plumber's Name (print) „, ` ~ lu Signat a ps MP/MPRS o. - Business P o e Numb r TT 1 'SJ~ ~T 22~-5 ~{- ~ Plumb 's Address (Street, City, Sta ip Cod ) w VIII. Coun Use Onl Disa ved Sanita Permit Fee Date Issued Issui Agent Sign tur No stamps) Approved ner Giv ' ial Adverse n ~ ~s~41,.~-- Ut/ / 2 ~ ~ Determi ation 1p IX. Cond itions of Approval/Reasons for Disapproval: p J~~ ~Y./~M n ~~Jl,~/~~" ~+'f/ ~ "uv :: Ur ~T1~- ~ . ~ C •" (f l ~-~ S ~l ~'~ ~ ~~"~ ~. May 12 06 02:34p RBC SEPTIC 7156652112 --• --•- moot ~~ PORM - STC - 104 1!3 SUIlIP Sl1tiZTMY SYSTEi( REPORT aW'NER TowNSHZPs • S$CTIOIf ~~ T~N-R,~~FI ~+noaESS S~~ / 0"39 ~1M„11R' sT. cRO=x covx~x~r; t~=sooxsiH SBBDIVI57pN ~.as•:1s . '~F~~ ror "war srzs~3 ,d~c acs __. - . PId-Ni ViBN __ SHOH EVERYTHING WITHIN I00 PEST oir svcmo.. -------°-....ivn ana aeseription: .5,:14 ~-. P~(, ~~ ~3" rekd+~ Alternate benehmark ~ ,;, u v l.~qn . SEs'TIC 'rwd:MianuFaoturdr:~ ~ !2o [GL advc .~~,. Tuiquid CaP•__1DpO Rings ucsd; ~ Manhole oovCr •lev: / ~.~ Final grads slwv: .~ /. 7 Tank inlet elev.;~g~Tank outlot elev.: ~~.1 No_ of fast from nearest road:Front _ _•-~•~• ~ ?~ Sxds , Rsar Ft,~ Fron nearest prop, 23ns:Front +!, gid ~• Resr Pt. /n ~ No. of fQet troll: Well oy ~ ~_, Bullding:~ ~'~ (Include this inrormation in the above plot plan) (2 rstwrenee dim ensxons to septic tank) SSS RBVER,g SIDB-~ %1M /TT~ES;r~~~ p.l ~ ~ ~ z ~ FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~ TOWNSHIP C ~N SECTION ~~ T~N-R~_W 1 ADDRESS ~~ I ~~J 1 ~lM~ I ~ ST. CROIX COUNTY; WISCONSIN (.~~ e ~~ ~~ f ~~~~~ 7 SUBDIVISION ~ • o~g, 1~->' • ~ ~~ LOT LOT SIZE ~ 3 ~C ~ ~-S PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 9 /, ~,\ Kc ~v(c,La w ~4 ~.~ ^R~ LI ! a t~ ~~ N ~ ~ 9ra~. 7 Y a ~ c~a~.tl .F~~~ ~. INDICATE NORTH ARROW g.r~ . ~ nom. BENCHMARK:Elevation and description:,i , ~ "~~_ ~~~~o~, ~h ~~° z~kd~~ Alternate benchmark ~,o, ~ . ~ R" . r C~~ r-- SE~3'IC TAN~C:Manufacturer: ~,~Qcx~s f~.~h ~ Lir~uid Cap. /ao ~ Rings used:.2 Manhole cover elev:~Final grade elev:~.~7 Tank inlet elev.:l~,~,~Tank outlet elev.: ~'~.~ No. of feet from nearest road:Front Side Rear Ft.~ From nearest prop. line: Front's , Side Rear Ft. /n S~ No. of feet from: Well ~©~~, Building: ___ /'3 ~ ~~ (Include this information fn the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE .-, ~ _, Q•~ fpp.oo s ~~- ~.,. • T • 4 • ~ r r s PUMP CHAFER Manufacturer: ~t~~cr~r2.sk~.wc-. ~r~~~. ~1 Liquid Capacity: ~~c3 Fump Mode1:~~S~ ~ s-PumpjSj~e~---Manufact.: `Pump Size Elevation of inlet:?s .! s~ _Bottom of tank elevation S~~ ~/7 Pump on elev.:~~~•3Pump off elev.: ~5 Gallonsjcycle: ~OC~ ~_~.~ Alarm: Man.:~~~_Switch Type: a ~ Location Distance from nearest prop. line: Front_~Side_„_, Rear_Ft.~/5 r Distance from: Well ~ ~~ Building ;7~3 SOIL ABSORPTION SYSTEH Bed: Trench: ~/ Seepage Pit: ' ~~ Length-2'~ ~s ~ Number of Lines:~Area Built~0 ~' Width: ~ ~ Exist. Grade Elev. ~ ~ 3 Proposed Final Grade Elev. Fill depth to top of pipe: ~.~ ~~ No. feet from nearest. prop. line:Front , Side Ci-Rear Ft. a8 ~ ~ No. feRt from well:_„~~J No. feet from building ~ly HOLDING TANK Manufacturer Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. ' No. feet from: Well , building , nearest road Alarm Manufacturer: ,, INSPECTOR: ~,1 ~ ~ DATE: ~ ~ ~ PLUMBER ON JOB: F~Y+-~ ~-~(~ t s ~ ~ .~---- LICENSE NL?MBEP.: ~ ~ / ~ 6/9G:c~ p RHC SEPTIC- 7156652112 p,l COVER S{{EET TO: , -~ FROM.. n11~ FAX: 3 ~ (~ _ C,l !~ Sr PAGES: 02 PHONE: = - y ~ ~- DATE: v~~/ 2 RE: CC: URGENT O REVIEVy O COMMENT O REPLY O RECYCLE O SIGNA 7'URE OMMENTS:------- J -- ~ I D 1. ----~ ! `~l~! ___-- ---'B8E REV -„`~: ~atix) B'RSS SIDB . ,~ ' fJEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY 8 BUILDING LABOR & HI~MAN RELATIONS DIVISION P.O. BOX 7969 ~ ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MAD SON W 53707 NW~, SW~, Sec. 22,T28-R15 ~~~~ (It assigned D. Number: TOW11 of Cady ~ CONVENTIONAL ^ ALTERATIVE ('.n T-T~.,~r ~ ~S2 ^ HOI inOTank ^ In-GroundPrPSSUra n M~~~r,ri w.~_....~ __ ~.. NAME OF PER IT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION ATE: Sy/d J ~~ ' R 1 Wils BENCH MA (Permanent reference point) DESCRIBE IF DIFFEREN FROM PLAN: fj WI 2 -- ©y F. PT. EL $ C T RE . P . EL ~ // ~ v Name of Plumb MP/MPRSW No.: County: Sanitary Permit Number: 1 acr ~ w ~ r~rvnm !(. 5 ' MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTL ~ LEV.: WARNING LABEL LOCKING COVER r~ C ~ J ~ ~F ~ A- ~~~5 ~/ - PROVIDED: PROVIDED: ~ , C, J~ I YES ^ NO ^ YES NO BEDDING: ilEidT DIA.: ~EN~MATL.: HIGH WATE NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH G ' V' ~/ Cr • 0- ALARM: FEET FROM LINE: r ~ ~ AIR INLET: ^ YES NO ~ ^ YES AREST -~ ~~ ~p7 ~ f 3 DOSING CHAMBER: ~-' - ~,,•,,~ /(, ~ = 8 , y ~ o ~ (~T, MANUFACTURER: BEDDIN LIQUID CAPACITY: PU L. PUMP/8FPH9N MANUFACTURER: WARNING LABEL LOCKING COVER PROV ED: PROVIDED: YVl t..J ~ ^ YES NO ~_~~ ~. ps P33 /-f ~~r'a ~ti~i C~ YES ^ NO ES ^ NO GALLONS PFR C;YCL.E: PUtviP AND cONT OL5 OPERATIONAL: NUMBER OF PROPERT WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: ~ ~ AIR INLET: ~ PUMP ON AND OFF YES ^ NO NEAREST -• ~r} ~~ o? ~.S SOIL ABSORPTION SYSTEM. Check the soil moisture at th depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled in a wire, c struct~ hall cease until r rr the soil is dry enough to continue.) , q,2. ~ ~ ~,/r.M ~-' MAIN ~7 ~ _ ~ ~~ *jlr-. ~~ _ '~aCo CONVENTIONALSYSTEM• .ZS [~ ~rr~ ~' 3~~,x.JL~j: rf9>r?aa% ` ~~' ~, o~ F. n1, 8b~ .~ S -rQd BED/TRENCH WIDTH: LENGTH: NO. O DISTR. PIPE SPACING: COVER d~' INSIDE DIA.: LI ~ ID ~ ~ ~ ~ TRENCHES: / ~ ~ MATERIAL: PIT DIMENSIONS ~ -~ GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DIST .PIP MAT IAL: N I TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVF COVER: ELE LET: ELE D: n ~~ Tj i (.~ 2a-C, 5c,{~,c~ '~ IPES: FEET FROM LINE:~,.p~ ~ ( ~ AIR INLET„ ~.:/ ~ 'G~wLt~t{.` A~,Trti1,-~~s- ~"" NEAREST~~ ti.~ >~ ~ ~l r/11 /GIL MOUND SYSTEM: ~,'T"`r ~'~~-F Mound site plowed perp~id~talar`~o ~ ~ Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ^ YES ^ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ^ YES ^ NO ^ YES ^ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ^ YES ^ NO ^ YES ^ NO ^ YES ^ NO PRESSURIZED DISTRIBUTION SYSTEM: BEDITRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DR{LLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ^ YES ^ NO ^ YES ^ NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ^ YES ^ NO ^ YES ^ NO NEAREST ~~ ~/~.~'nC~ ~"'t ...E-1~~.~°[-'~2J`r1.tQ .cn'l~~ .,.,~.-t. , ,4~ ~- "- . ;y. Sketch System on Reverse Side. SBD-6710 (R. 06/88) ~f ~' To ~ ` ~ Co./Dept. Phone # ~~.- / _/ S' 2 ~ ! L Fax # Vii,-- ..- ...er_ From mss. 3 ~ - ~ ~ ~i DATE: S~l Z~D ~ To: -~ 2 ~~ ~ "^ 2~~ 386-a6so~~ .-~ FAX NUMBER: ~ l Ste. ~~P ~. Lrt»d Information - p~g FROM. -~J~~~J ~~s386-a6~ FAX NUMBER: 715-386-4686 gc~p e11~, PHONE NUMBER: 715-386-4680 NUMBER OF PAGES, INCLUDING GOVER SHEET: RE: ~ I ,,~~;;~~~~~ U ,,~,~ p-,r ~. s t ~ ~ ~ ~--~- ~ ~ Cam. ~ S S v2- ~1-e,-wt. i~- , _~ I S 6M PZ@CO.SAINT-CROIX WI US °(. ~~oe~c c®UN i~n~„n ~ ,~ ~Onir~ 0 ~, ! a ~p Pages ~ f 57. CRO/X COUNTY GOVERNMENT CENTER 1 101 CARM/CHAFE ROAD, HUDSON, Wl 54016 715386-4686 FAX WWW.CO.SAINT-CROIX WI US ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBu er e r ~' u~ ~ ~ W ~ ~' rt y y ~~ IC~6b~n c, Mailing Address o2 ~ ~ ~GU ~/ (0~2 $~ /~/ /~S~ /~^~~ / , $`~~01` Property Address o2~~ ~rtJ S/ /~3C~ ~~LS~'f?,.. - s- ~o~ ~ (Verification required from Planning & Zoning Department for new construction.) City/State ~~/ ,LS G/~, G~~ .- Parcel Identification Number ~ 6 ~ - jp S~ " 30 _ ~ ~ ~ LEGAL DESCRIPTION ~~ 3~8~~ Property Location ~'/a cS f~'/a ,Sec. ova , T ~' N R /S W, Town of ~ a ~ ~/ ~~. Subdivision l ~ ,Lot # ^ Certified Survey Map # ,Volume ~--- ;Page # -~- ~5 s- Warranty Deed # ~S 3 ~ S ,Volume ,Page # 36.3 Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Deparhnent within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms -~ SIGNATURE F APPLICANT(S) ~/Qa1 dlo DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 05/12/08 FRI 14:28 FAZ 91b J88 4888 ST CR% CO ZONING FORM - STC ~ 104 AS BLfII1P S1SN1'1'l1~RY SYSTllL RERORT dWNER~~~ri~i¢ 4 TOWNSHIP SECTION ~,.~ T N-R w --~ / ~_ ~~ auaRSSS ~'~ l X3`1 ~1tit„ la$' sx. cROZx cavNT~r~ wzscoxsiN ~ 002 /~ RECEIVED MAY, 1 8 2006 ST. CROIX COUNTY svBDIVxSIOx ~:. aS..1s . 3'-~'r~ „ _ I,OT r~aT srzs ~ ~-~ ~ cs PLi1N vrsw _.. SHOW EVERYTHING WITHIN 100 FEET OF SXST$H hlternate u ! cGb r SEPTIC T.1NRsMlanufaature~r:~,r~~dpslxkr.'~ Liquid Cap, lQOO Rings used: ~ Hanhole ever elev: R~.~ Final grado elev; •9/.~ Tank inlet elev.:,• 4 ~ Tank outlet elev. i ~'~'. No. of feet from nearest road:Front side,', Raar_„`Ft. From nearest prop. iins:Front ~'~, rgide,~, Rear____Ft. /"C?S?~ No. of feet from: Well , Huilding:____. ,13 ~ (Include this information in the above plot plan) (2 rsfsrenae dibeensions to septic tank) SEE REVERSE SIbE __„ 6'~ urn~3E~2: ~ ~a75P~~ rm ~rr~E~~~dr $sxcEU~xl~sElsvntion and dsscription:,~~;!4 ~'`ow,_Q,~luo..,,,~.. 13" Cb.kdr~ May O1 06 12:14p RHC SEPTIC 7156652112 ~bility Business Co. S A. . B . ~i Com Clete Sewer Services E742HWY12W KNAPP, WISCONSIN 54749 PHONE: 665-2112 !~- id~ ~~~, ~~ w~ p.l MENOMONlE, WISCONSIN Phone: 235-1666 ~,~c at ~ s ~~ ~ T~ ~~ ~e~s~ ~w ~y sw, U ~~` ~' ~ 7S5i~ _ Post-it`s Fax Note ro ,, . ~ v Co.1De n,'C Phone-~~~ )~C ~ _~•, DD rL~ , 7671 ~ From ~ ~ Co. Phone /,.~ Fax N pages- A . U Sc- of i ~ , ------ ~Ii~-mb~,.~~, _'1i5- LnJnS-LiiZ -1 / S• -ln/~ ti• 2 kn~ May O1 06 12:14p RHC SEPTIC 7156652112 ~ ~ I .. • No~~r~ :T~~~w~E .~-o~ - ~ . ~ . ifs ~ 162~3~Highway 53 Chippewa Falls, Wl 54729 I (715) 832-6003 (715) 832-6009 Fax - - - - -- - - - ._ . -- THE FEST ' North Towne Homes features included ' _ in rice of home: *2a6 Exterior Walls 16" O.C. I *Exterior GFI Rece tacle * R-31-19-11 ~nsuIation *Exterior Frdst Free Faucet Doors w/Keyed Alike Dead Botsn*Plush Carpe ~ooC$ /r torm**Fro~nt & Rear Throughout *Lighted Walk-In Closets *Brushed Nickel Hard ~ eIIT finds *SO Gallon Electric Water Heater *Smoke Detectors in All Bedroo~s & I,ivihn ut Area *jyl'a~ water Shut-Off *18 cf. Door Over Door Fridge *DeIuze Electricg Range *Solid Oak Picture Frame Cabinet Doors *Stainless Steel Kit hen Si *Ceramic Tile Backsplash Throughout *Congoleum Vinyl FIoorin ~ nk *Mirrors above Sinks g~ *Low E Vinyl Windows *9 Lite Rear door *Cabinet over Fr' Utility Cabinets *1 Piece Fiberglass Garden Tub MBA edge 'Overhead *Extra Window in Kitchen *Extra La~ ge Bedrooms *Skylight in Bathroom I *ALL INCLUDED I:N SALE PRICE S ~~Yc31 Series Model'.s763B . _ -~ ~ y'40' ,~uar~ eft p.2 y~ :,: Message Kevin Grabau From: Kevin Grabau Sent: Tuesday, April 25, 2006 8:43 AM To: Jessie Nye Subject: RE: reconnect Page 1 of 1 We also need: -e "~°r -system evaluation plumber--check tary,,and drninfield -we n soil pit verification (if we don't have a soil test, or "questionable" soils -existing system elevation (if we don't have paperwork) - sizing (if we don't have paperwork) house plans- to verify # of bedrooms ~ ~ I„ ~-,~~,.,,, /~,~ -~,~ /'V_I' f { - oun application Vl -----Original Message----- From: Jessie Nye Sent: Tuesday, April 25, 2006 8:34 AM To: Kevin Grabau; Pam Quinn Subject: reconnect What is all needed for a reconnect application? Original Application Recorded Deed Maintena greement Z~•~ Jessie Nye Administrative Assistant ~ f ! ~~G~ St. Croix County Planning & Zoning /Q ~ .,- ` (715) 386-468o Fax (715) 386-4686 ?~ l www. co.saint-croix.wi. us f~ Q Q ~~ l~ ~- G ~ ~' ~ ~ ~ r- I~ Gam` ~" ~ I ~ ~ "l T~ ~- ~ 4/26/2006 ~~- .. , . N .9'~W E' 47 ~. ®Farm & klome Publishers, Ltd. W a .~.1 V I°d ~b r `~` ug~ L~ n ga 118 M LADY PLAT T28-N~R15W ~~ I' , ~ ~,~ ~~ . . See Pages 115-116 For Additional Names. ~ i ~ ~' .;, ~'6:~'~'Z~a s ~ ~i 3 e n ark ~ 5 ~ Anne , aaS M 4 Mueller Gary & . zo L 3r D 2 e O LGOnard Deus Mas Kasprzak r yse $ uL"i Herman $ 1 140 ~. tPauline my ~~ Basbara Mark$ s schutk m 117 s ,tie " n earbua a e rr„atY vry "" 'aoueutt MBndler sda ~ P ~ ~ r ~ u+i 117 saM. w I ~ } ! '10 3 ' L 53rd VE ~ Gary $ l F, e ~w MelaWe b 6m P s arbaa l~ Gervau 35 er e - 5 c ~, n,eD,a, @ $R daB B$s~, Br d< WaBa« dl M a 7 errY Danny ~LOis $ Ma* l4 eY omPSeD 75 ''~gdg{ pp d y an $ suso 4a Y BIIY 73 Goss 65 M ~ar tlm P N effre Y Maw eriser Deborah Mks GGeerxaldine prueger ~ Klatt 4D .ml 4U Pa+olny 120 775 1i0° ~ c t~t Bra ones & Katherine Mikla 2Q 4cebulia ~s~ a ~' 1 ~ l0 143 20 'D1~ Ted 8 c Jae t ~~ii 1 y Ice r m ~ $ Lane $ Julie om $ BI. sam~:u audc SOderson 4trarate 4D Backus 70 70 a0 dreg d am 2 1 Pe41 i 70 w~ v e~o $ ~I.ms kstra Rlthard $ ~ ~O° c C' r c en F 77 ~ B$5 y ~ S~ $ ~~~ t 4 s asamr "' ~. .,.. , Hoel4ta ,y pae eaolne °yk ' " 7^---_._ a ~ 1 o bpenc M i Nn 36 a 11 Eb-+av 0 $M ver n n-D`~ Patrida rd"n^. ~ soc O>•4a~1as ae,,... ~°- E ~ B4Ba cnwrk k ~ ao 3 3a ~ L5 M 9 $ eer p 109 102 +w.Im-e l ea ~°° ~ $ ~ ~~ ~ .~ w $$ sa rl Bonet D~ePpa O o U 4 Z ~ Bttdce ~,ri3to phtt ,~ °,..~, a sealev e ow ww Z wn' 7nDt 75 Kleine k 78 w B ertram Pmde (~ $ Dean Delmaz $ N'B"° $ """ 7 nmaen ~ o uo ryt Timm Mazlene r zo b 78 ~ s Ellingbce 80 Holldorf Geratd $ ~$ ~ B N$ G~ Ea $ Eurme 3 ~ ~hdBh ~ k s+ n 75 msee so r 75 veto pSOp1 Denis !t~ y realoff peMy. $ $arbaza a amPe r mm Blegen 90 80 & ~ 80 _ _ _ _ Orville rr z ~ 3 Joyce ` De e BT + Bo 80 $ Velta Trealoff 80 k rtavta rye, + Larson ~ 4 .a .~J'hII .,. ~ ~- PIERCE COUNTY "SPECIALISTS IN FLAVORED NATURAL CHEF Over 90 Varietiev~~~4 GIFT ITEMS - C~~'k1 ~ ~•~ CHEESEFV~~ ~ ~~ BUY DIRECTLY ERflM C~ F ~ Cheese Malletl Anywh~n' ~. S SERVICE WEEKDAYS (7i 5) 772-421 S ~ 'y Y 24 St. Croix County Planning and Zonin Thursday, December 29, 2005 at 4:56:59 PM Detail Sanitary Information Page 1 of 2 Computer #: 0041052-30-000 Sub/Plat: metes & bounds Section: 22 Parcel #: 22.28.15.348a Lot: TN/RNG: T28N R15W Municipality: Cady, Town of CSM: 1/4 114: NW 1/4 SW 1/4 Owner: Witt, Terry 239 Highway 128 Wilson, WI 54027 State Permit: 135537 Issued: 06/21/1990 POWTS Dispersal; Non-Pressurized In-ground Permit: New County Permit: 0 Installed: 08/09/1990 POWTS Detail: Trench -Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Inspector Jim Thompson Pam Quinn As Built Yes Signed Off: Yes Plumber Other Requirements Helgeson, Bennie Mittlestadt, Tim 1st Notification 2nd Notification 3rd Notification 04/01/2005 Additional Notes Monev Owed this POWTS connected to a mobile home - 1000 $0.00 gal. Midwest septic to 750 gal. pump chamber to 2 trenches 5' x 75' 12/29/05 -Owners want to change to a new $0.00 mobile/manufactured home and wiN apply for reconnection permit in 2006. NA Signed Off: No Maintenance Scheduled Pump Date Pumped 7/4/2002 5/6/2005 5/6/2008 8/9/1993 Notes Inspector As Built Plumber Other Requirements Additional Notes Monev Owed Jim Thompson Yes Helgeson, Bennie this POWTS connected to a mobile home - 1000 $0.00 Signed Off: Yes gai. Midwest septic to 750 gal. pump chamber to 2 trenches 5' x 75' Pam Quinn NA Mittlestadt, Tim 12/29/05 -Owners want to change to a new $0.00 Signed Off: No mobile/manufactured home and will apply for reconnection permit in 2006. Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 7/4/2002 5/6/2005 04/01/2005 5/6/2008 8/9/1993 1 •.'~ • X FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER -~ TOWNSHIP ~ cN SECTION ~..-''' T~„_N-R l~W ADDRESS ~'~ I ~~J 1 ~~In ~~ ST. CROIX COUNTY; WISCONSIN SUBDIVISION ~•~g, ~S • ~ -r~~ LOT LOT SIZE ~ 3 s~"C ~ ~S PLAN VIEW SHOW EVERYTHING WITHIN 200 FEET OF SYSTEM '- . ~,.,9~a~ 17 gyn. ~.~ ~.o~ ,/~ ~ ~ S ~~ ~L ~~ ~f-...1 [:-G. o~~ ~°r ~ aR ~°~ ~ a j ,9a' iwl_ ~~. ~~/~' ~ /hebi ~ ~.r~ ~~I .FHC.t d~ Neancs'f` ~"nE+~r...~ Lrat ' I I INDICATE NORTH ARROW g.~. ono. ~~ BENC~DlARIC: Elevation and description : ~~~ ~ "~ ~,. ~~~OO ~, rH ~ 3" Z~ k~~-~- Alternate benchmark ~~, ~-~ ..-. R" j ~~5 ~ SEPTIC TAFii~:3~anufacturer: ~`''I„~x~s t~e~h i,iquid Cap. /~0 ~ Rings used: ~ Manhole cover elev: ~,~ Final grade elev: T~. 7~- Tank inlet elev.: ~3R,4,~Tank outlet elev.: BK.~ No. of feet from nearest road:Front Side ~, Rear Ft. From nearest prop. line:Front '~ , Side , Rear Ft. /©S~ No. of feet from: Well ~a~ _, Building: / 3 (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE _ ~. / \ r . PUMP CHAFER Manufacturer:. /~'1~~cc~s~c~-c-. ~,~~~~1 Liquid Capacity: ~~v Pump Model:~s~° ~~Pump/~a~re~°r-Manufact.: `Pump Size Elevation of inlet:_~~5.( K Bottom of tank elevation Ry , `~7 Pump on elev.:~~~•3Pump off elev.: ~~ Gallons/cycle: ~~(7~ ~~ ~` Alarm: Man.:_ ~ ~~Switch Type: a ~ Location Distance from nearest prop. line: Front_~Side_, Rear_Ft. //.~ Distance from: Well ~ ~~ Building SOIL ABSORPTION SYSTEM Bed: Trench: ~/ Seepage Pit: ., ~ s Width: S~ Lengthy r ~5 Number of Lines :_~Area Built '7,~0 ~' Exist. Grade Elev. ~ ~ 3 Proposed Final Grade Elev. Fill depth to top of pipe: ~L~ ~~ No. feet from nearest. prop. line:Front , Side C , Rear Ft. ag U / No. feRt from well: 3~c~ No. feet from building ~l~ ~ HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. ' No. feet from: Well , building , nearest road Alarm Manufacturer: DATE: ~~ , ~ ~ C~ INSPECTOR: ~~~ j~ PLUAiBEP. ON ,3'OB : f ~ Y'~ -t (~+ t s ®c~ LICENSE NUMBER: 3 ~/~ 6/90:cj ~~ , • ' DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES 8 APPLICATION MAD SON W 53707 State Plan I.D. Number: NW~, SW~, Sec. 22,T28-R15 ON EV NTIONAL ^ ALTERATIVE (If assigned) Town of Cady ., ., n Hnl inn Tank n In-Ground Pressure ^ Mound 1~C.`.Zrcwr~,r^~ 1.C1i NAME OF PER IT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION ATE: 59 ~-~ ~~ ' R 1 Wils n WI 02 --~ °~ N FROM PLAN: BENCH MA (Permanent reference point) DESCRIBE IF DIFFERE F. PT. EL C T RE . PT. EL r , 8 U ~ ~~ d' T N.~cn/'1 r~ / ~ ~y l..Y / Name of Plumb : MP/MPRSW No.: County: Sanitary Permit Number: 1 ~• WIDTH: LENGTH: NO. O DISTR. PIPE SPACING: COVER L INSIDE DIA.. LI ID BED/TRENCH DIMENSIONS ~ / ~~ TRENCHES: / ~ ~ MATERIAL: PIT GRAVEL DEPTH PIPES BELOW FILL DEPTH ABOVF COVER: DISTR. PIPE ~ aN LET: ELE DISTR. PIPE ELE D: DIST .PIP MAT IAL: ~ (~J n~ ~ N I TR. IPES: NUMBER OF PROPERTY LINE: ~ WELL: ( BUILDING: ~ VENT TO FRESH AIR INLE T : / ~~ ~ v / / ~ / ~ Zr ~ 5 J ~' FEET FROM -~ 't.'~ y,~., ~d J 7~ , Q,. ~/ I C/ V ia-'Lt7~.~ A~trrt-~~- (_. NEAREST --C MOUND SYST EM: ~~%srr ~ '~' ~ wE Mound site plowed perp~idi~ular ~o Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unsiope: mound systems to make certain that it ON REVERSE SIDE. SHOW ^ YES ^ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ^ YES ^ NO ^ YES ^ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ^ YES ^ NO ^ YES ^ NO ^ YES ^ NO PRESSURIZED DISTRIBUT ION SYSTEM: RENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/T TRENC HES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS INFORMATION ^ YES ^ NO ^ YES ^ NO PERMANENT MARKERS COMMENTS: : OBSERVATION WELLS: NUMBER OE PROPERTY WELL: BUILDING: ROM uNE: ^ Y ES ^ YES ^ NO ^ NO FEET F NEAREST-• ~/ /~~ D ~ /~ jn ~~-~y~ ~~.// ~~ ~' 9~ -~ ~ 9~0~' 9-3.2 ~~~ ~,r~ 9 ~. Sy' 9.3.5' q,2.,y / Sketch System on Reverse Side. SBD-6710 (R. 06/88) SEPTIC TANK/H • /~ "• ~ MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: / TANK OUTL LEV.: WARNING LABEL PROVIDED: LOCKING COVER PROVIDED: II G r~-S~ J ~ . ,Gp~ 'f ~ ~%~ YES ^ NO , . ^ YES NO BEDDING: aiE18T DIA.: ilEN~MATL.: ' HIGH WATE NUMBER OF ROAD: PROPERTY LINE WELL: BUILDING: VENT 70 FRESH AIR INLET: G.V• .r ,.0. L ~ ALARM: FEET FROM : ^~r ~ / ~ + 3, ^ YES NO ~~ ^ YES N AREST ~~ d r DOSING CHAMBER: ~' - ~~xr-~ ll. ' _ ~ ~ o ~ ~ (~T MANUFACTURER: BEDDIN LIQUID CAPACITY: PU L. PUMP/81PFi6N MANUFACTURER: WARNING LABEL LOCKING COVER PROV ED: PROVIDED: JJ--tt m uJ (' ^ YES NO ~Sc.~ ~ ps P33 /-~~ c:Cr'o »2a~,~ C~ YES ^ NO ES ^ NO GALLONS PER CYCLE: PUMP AND CONT OLS OPERATIONAL: NUMBER OF PROPERT WELL: BUILDING: AER INLET:RESH LINE: (DIFFERENCE BETWEEN ~ -~ ~ aA ~~ o? o7S~ ' ES ^ NO PUMP ON AND OFF NEAREST Y SOIL ABSORPTION SYSTEM. Check the soil moisture at th depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled in wire,~c,Q~nstruct~ " hall ceas_ e_ until MAIN ~~ '- 0'1 " ~5T~- -?loco =' "' • the soil is dry enough to continue.) . q.2 • !7 ce-/ ~ CONVENTIONAL SYSTEM• .ZS Cowry 3~~ xJG~I = ~/9.,a aa~ sF ~ • o~C' F. n . 8d ~ /a~% ~~•.~ CAI-IITAQV DQQSAIT ADDI IC_OTIAN In accord with ILHR 83.05, Wis. Adm. Code ~~- St . Croix STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ~~~^"") 8'/z x 11 inches in size. ^ c if revi on pr vious application --See reverse Side for Ir1StrUCtIOr1S for COmpleting this appllCatlOn. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION Terry Witt NW '/a SW '/a, S 22 T 28 , N, R 15 ,E/(or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Rt. 1 N/A N/A CI STATE ~G1il WI ZIP CODE 54027 PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER N/A son, 715 772-4748 I1. TYPE OF BUILDING: (Check one) CITY ~ NEAREST ROAD ^ State Owned VILLAGE Cad Co Hw 128 ^ Public ©1 or 2 Fam. Dwelling-#of bedrooms 3 AR EL TAX NUM R( ) III. BUILDING USE: (If building type is public, check all that apply) 004-1052-30 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 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 in line A. Check 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) ^ 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 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 93.2 Upper 96 L~VATIiOJ N e 450 750 750 1.666 10 92.8 Low Feet e~t VII. TANK CAPACITY in allons Total # of 's Name f t M Prefab. Site Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks urer anu ac oncret glass App Tanks Tanks structed Se tic Tank or Holdin Tank Lilt Pum TanWSi hon 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: (No S mps) MP/MPRSW No.: Business Phone Number: Bennie Helgeson 3215 715 778-4425 Plumber's Address (Street, Ciry, State, Zip Code): Rt. 2, Spring Valley, WI 54767 IX. COUNTY/DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing gent Signature No Stam A roved pp ^ Owner Given Initial ~ Surcharge Fee) _ Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety ~ Buildings Division, Owner, Plumber '_ INSTRUCTIONS t 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. Ta be complete and accurate this sanitary permit application must include: I. 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. II1. 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. Vli. Tank information. Fiil in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a// 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. v Complete plans and specifications not smaller than 8%z 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 use for monitoring ,groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11l88) APPLICIITION,FOR SANITARY PERMIT STC-100 This appllratfon form is to ba completed in full and signed by th• owner(s) of the pcopesty being developed. Any inadequacies will only result in delays of the pecmlt le~uance. Should thlo development be intended for ze:~i~ by ownee/eontcaetoc,lspee house), then a saeond Eotm should be tetalt-ed and completed when tha psopesty la sold and submitted to this oElle• with th• appcopclate deed cecocding. ____________________________ Ow~ec of property Terry Witt Location of pcopesty NW _i/~ S.. W__~1/~, Seetlon 2~._.• T~.$-~~R-1.5--r Township Cady Msllinq addsess Rt. Wilson WI 4 27 Addsess of site Same . iebdlvlsion name N/A Lot nua+bes N A Previous ownec of ptopecty D Total •!se of pascal ~ ~ ~ Dale pascal was eceated /~" 3~ _ ~/ -- J1c• •11 cosness and lot lines ldentlElable~ .-,~ Yes __.Jlo is thl• pcopesty being davaloped Eos sesaie (spec house)?_,_,_Yes -,~= o Yoiua+e ~S=_snd page Nu~nbes ~ as secosded with the Reyistes of Deeds. INCLUDE WITH THIS APPLICATION THS FOLLOVINai A wAIlRANTY DaRD which includes a DOCUNI:NT NUMBBR, VOLUIIS AHD PACK NUMB=R, and the B~AL OF THB RB(iIBTBR OP OBBD9. In addition, a cestlEled survey, lE avallabl~, woutd be helpful so as to avoid delays of the seviewinq process. IE the deed deaccfptlon teEetences to a CestlEled Susvey Map, the Cectltled Susvey Map shall also be required. PROpgRTY OVNER CCRTIPICATION EtMe1 cectlEy that ail atatemants on this form ass true to the bas! of my tom) knowledgef that t (wet am tare) the owner(s) of the pcopesty described in this intocrostion Eocm, by vis~ue of a watsant deed secosded !n the OEEIce of the County Register of Deeds as Document No. ~S`3dlo5~ • I and that E tVe) .. pcrsentiy own the proposed site for the sewage disposal system for I twei have •- obtalned an easement, to sun with the above 'described property, for the constcuetlon of satd system, and the same has been duly seconded In the OEEIee of th• County RegisQar of Deeds, as Document No. 1. ~lq~at i of Ownas lgnatusa of Co-Ownac tiE Applicable) Dale of slynalute Dats of Signature • /, '' ---Daniel---F-,---Neisinger_.a_z~sl._.~,0.7~S---M-•---1~Jeis_ingex.,..._..... ....husband_•and-_wife-~-------...--• .................................................•------ ! - conveys and warrants to•.._~..4'.~r:~..,~,....[~T~.~~...al1.d..~Qb.].n...P.....hT1.tt, ----husband _-and-.wife .. ............................••------------....-----------....------- '' the following described real estate in ..._........-~t;..._. G.>Cl~7.X ..............County, State of Wisconsin: NWT of SW~, Section 22-28-15, excepting therefrom the S 16~ acres, more or less, as set forth on a deed recorded with the Office of the Register of Deeds, St. Croix County, Wisconsin, on 3-6-86 in 734-16, #409796; further excepting easements, right of ways and privileges of record. This ______.__ S..xiQ~.._.. homestead property. (is) (is not) Exception to warranties: Dated this ..............~--~...--••---•--••--•--•-•-- day of _...----- -•---------•----••--•-•-----...---•--•--••---• ...................... (SEAL) ----------•-----•-••-----------•-----•--•---------------------••---- (SEAL) - _ _. _ _. ___ THIS SPACE RESERVED FOR RECORDING DATA ~I I REGISTER'S OFFICE !'. ST. CROIX CO., WI '' Recd for Record ct OCT 3 11989 i' 8:30 ii~Nl ~~ ~ , Register of Deeds RETURN TO Taz Parcel No :.............................. IR N S ~ FEL ~~~>v ~!'."~~~--...(SEAL) . -Daniel-- F..--Neis-finger------------------- . -Lois---M._--Neisinger ........................ ;, AUTHENTICATION ACHNOWLEDC~MENT ,, Signature(s) ..................... STATE OF WISCONSIN .------•--------------------------•--•- ss. ------------------------------•--------------------•-------------------._....... Pierc -------------------- ~ -----._.._.....County. ;: authenticated this __.__._.day of___________________________ 19._._.. Personally came before me this _.__.___..__.___day of li •___--_OCtOber_-_..•.-..--.-.., 19..89. the above named '~ +___•_---__-.__ _-__-,_,Daniel_•F,•__Neisinger_and Lois•.•_ ~~ TITLE: MEMBER STATE BAR OF WISCONSIN ___ __ M._ Neisinger___•...••. -__•-•___••.•:•_•__-•• ..._. ... (If not, ---------•------------•------------------------------------- -.__.._._...._.........---------------.......-•---------•-------•--•----~-•~•: .~ authorized by § 706.06, Wis. Stats.) to me known to be the person S______..._ who~i~pn~d she •~ 4 f strument and acknowledge the saixie.. ~ . • i:,lyy THIS INSTRUMENT WAS DRAFTED BY , ~ ~ • 'I ----..._~ahz'•_.G-~---~[~S.~il:?8~~s._A~torney.------- ,• ,~ Beverl Bune ,•. •~ Baldwin Wisconsin 54002 •~" -------------------------~---•--- ------.....--------...--------------------•- Notary Public ----•-••-•-------P.i.~rCC----_..'1Q~qunty, Wis. I' My Commission is e`f~bi~>Yt. If not, statiF firs forth ••-„ !; (Signatures may be authenticated or acknowledged. Both ~ ( ~~ it !; are not necessary.) date• •• 19•~..~~.'.:~ ~ •~ i Notary Public-Puce Co . Wisootisin •Names of versons ei¢nia¢ in any capacity should be typed or Drinted below their signatures. ~ ~ EXpire$ d',t. ~3. ~99t '! ~! ~M,crll~m STATE BAR OF WISCONSIN FOAM No. 2 - 1982 Stock No. 13002 - ~ ~! ii I' 5TC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Terry Witt ROUTE/BOX NUMBER 1 Fire Number CITY/STATE Wilson WI I.IP PROPERTY LOCATION: ~ ~, SW 1L, Section 22 T 28`N, R 15 __W, Town of Cady St. Croix County, Subdivision N/p Lot number N/A Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a l.lcensed septic tank dumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents m_~+ a maximum of 60 Y. of the cost of which was in operation. prior to accepted this program in August owners of all new systems agree maintained. be eligible to receive a grant fc~r replacement of a failing system, July 1, 1978. St. Croix County of 1980, with the requirement Chat to keep their systems properly The property owner agrees to submit to St. Croix County 7.oning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 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 Depart- ment of Natural Resources. Certification form .must be completed and returned to the St. Croix County ''/.oning Off. ice within 30 days of the three year expiration date.. SICNE r ~~ ' U p .I, E ~ __._ ~ ~ ~ U --- - - St. Croix Cc-unty Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. i,~i i~li i i,~~l~ I ul INDUSTRY, LABOR AND: HUMAN RELATIONS k~l'UK I UYV SUIL h1U~iNVS NNU J" " `~ `~ ' DIVISION PERCOLATION TESTS (115) ~•7 ~- y 7~~ P.O. BOX 7969 MADISON, WI 53707 (H63.09(1) & Chapter 145.045) 7GLX # ~y--IOS..?- 30 LO I ~/ ~/ O - W T~$ N/Rr S~E TOWNSHIP HAI16fi RTITY' ' QT O.: 1// BL .: SUBQIj~/ ION NAME: N a 4 to • ~ / COUNTY: W ER ME: • -}-1 d ~ USE LU r, y .B CO S TI Residence '? /(, New ^Replace RATING: S= Site suitehle fer system lJ~ Site unsuitehle fer system ~Q~1 Z ~, DATES OBSERVATIONS MADE • ~ ~~ ~~ ~rn-ner~ CO~ENT~~ : MQ~1~, a~ IN-G~~ Pa~ .. S~ ~ -1N-FILLHO~ ING TA~ : RC~~ E'~~ $~n((,:~ptional) a R ~~S ~~ If Percolation Tests are NOT required DESIGN RATE: tf any portion of the tested area is in the under s.H63.091511b1, indicate: /U Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL PTH TO GR UN DWATER•INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED ES . HI HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) . Y' ~% S; l is 1. p' .t Sr; , q' "~ 1. ~ r, 8-3 ~•~I' 9'~~0 ~, y .a ~ k3~ S,l is /.o .~ S,•( c~bb , B. ~I ~'.9" 9~.6~ t~ ~ S. y~ .3', e~ s;l rs t.3' 8.. s;l ~%~~.b 6'~ I.0' 95.90 I` i .G" J B- F/ ~~.~ ~ / 1. So I ~ 3 ~ ~ tf - •' f31 s s 1's ~, o ' .\ { I ~co b ` PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP N WATER LEV -IN HES RATE MINUTES INCH NUMBER INCHES AFTER SWELLING INTERVAL•MIN. P R1 P RI PER P_ ~0 .L F- ~ r 1 1 / P- r~ /~ - - 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 horn zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation et all borings d the direction and percent C // bra. i of land slope. Yi~~" rLci U`fP~r• 9.3, .7 fZe~~u~rhe.1'T /~rlre~ ft~p~r SYSTEM ELEVATION ~~W ~s ~:~ ~.cr~s~r 9 /. '1 ~4 - ' _ - - --- _ _l ..- _ , ~ i ~ 9. - ~.." .. -~ ~_. _ ~ ._.._. ~ 1 I . . ._ i i _ ~ to }t M , ~ ~i ' ~ ~ I 1 I i ~ ~_ ~ _ . . I I i ' I ' ` i ~ ._ ~-._._ ~j LL• i T i.15 ---~~- 4-- ~--- ~---- }---- _ f _-__ a.K ___ f^G - y • `lo --- ~ ; -~- --~--- _ t ___ . ~ __ - . -- ~ _- - - _~ -- ' t _.._.... 1 r t4~11 ~ ~ ~ ---_r.+ ~ ~ ~ ___ .__ : _ ..._ _._ ~ - ..__._...._._ ~ -- --- ~ ----_ - ~ _.._ I ~,-- --- I . ~-~ L..... . ,.... ~ .",_._t, -- ..... __ °- .. S ._. t- I ys _. - ~ _ ~ i . --- ~ - - --- -- / ~.~ - j~- s - __ 1~- ~ It1 'T -~ ~ I ,; .._~_; 1 -_~._ .. i f i _}__ 3i .t3S i - _. _ _. _ 'TN k ~~ ~ra~ irL~.c. , . ~ --i - Q: a ~ Gtni rc. c,<..aE ~' Pt-i ~~ r }'y ~-•ir-L' . I, the undersigned, hereby certify that the soil tests reported on this form were ~ade b me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME rint : TESTS WERE OMPLE ED N: O O- •~ ~ O / ADD ` ~ CERTIFIC TI N MBER: PHONE NUMBERIoptional): ( ~ ~ :309 ~~-y a - x CST SIGNAT E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR•SBD-6395 (R. 02/82) -OVER - -ew r ,~~, ' ~ eso~ 3~~5> PAr;F DUfr~D rHAr~p,_R CROSS ctr-~C~~ ANG ~?ECIFIChI 10~"_ VEUT CAP `i~~C.I. VEUT PIPE ~ 25~ =ROM GOOR, WIIJCOW OR FRESH AIR INTAKE I8"M I A1, ~ IAILET T APPROVED JOINT A 6 C ELEV. gs•®FT. 0 WEATHERPROOF JUAICTIOAI BOX 12"MIU. I I GRADE I I COAJDUIT ~-- V PROVIDE AIRTIGHT SEAL PUMP -~, COtJCRETE 6LOCK W~C.2. PIPE CXTENDIUG 3' 0-JTO SOLID SOI L APPROVED LOCKIft1G MANHOLE COVEn ~~ F 'i" MIIJ. ~ I S^ r~I IJ. \~~ 11~ I lii I I I I I 1( II III I I I) LARM ( I I I I I..... OIJ I --~ OFF V APPROVED JCu W/C.I. PIPE EXTEUDIIJG 3' OAlTO SOLID SC g'~ "75' ~L RISER EXIT PERMITTED OIJLy IF TAIJK MAAIUFACTURti`R HAS SUCH APPROVAL ~Ob~ ~~ ~ SEPTIC E SPE C1 F I GATI OA1S OOSE ~ TA1JK5 MAIJUFACTURER: COs~ /",r~~~~~~'~ ~IUMBER OF DOSES: PER DAy TAA1K SIZE : ~~~ ~ GALLOAlS DOSE VOLUME a0O.8~ IAlCLU011~JG 6ACKFLOW: GALLON ALARM MAAIUFACTURER: ~ .~. ~ ~Pc~G-a~ S~„~~ MODEL -JUMbE1C: f ~~~ ,~u-1 CAPACITIES: A= '~~ IIJCHES OR 300 GALLOIJ SWITCH TyP[: ~I- -cc~,rti ~Ibc~-4' g= ~ IAICHES OR 37'~ GALLON: PUMP MAAIUFAGTURER: ~I ~~w~ ~~. '~`~ a ~, -7 C= ,f •7 1AlCHES OR~~~`g drALL01J MODEL AIUMSER: ©S P 3 ~ D =,LL_..~..INCHES OR -L~!_ GALLON: SWITCN TYPE: ~e~ lt /"l,Pi~('r~,ir~~ ~ IJOTE: PUMP AWO ALARM ARE TO DE MIIJIMUM OISCNAR6E RATE ~GPM STALLEO OfJ SEPARATE CIRCUITS W VERTICAL DIFFEREAiCE DETWEEIJ PUMP OFF AAlO ~` ~~ ~ PIPE.. ll. FEET ~- MIAIiMUM AIETWORK SUPPLY PRESSURT,E/.. .. .. .. ~' FE.ET • _.11,51_ FEET OF FORCE MAIIJ X -•~• ~~Ioo FLFRlCT10-J FACTOR. (O~•-3~EET = TOTAL Dy1JAMIC HEAD = ~~~FEET / ~ rr r~~,-,~ ii IAITERAlAL DIME1J5501JS OF TAA1K: LEI~.IGTH ;WIDTH ~L~.;LIQUID DEPTH SIGNED: L-CEil1SE IJUMBER: ~~~ S DATE: ~ -~~qU ~~ s h 9- ~I P N "P O n Z ~r~'' r ~, .-. ~ Q~ ~ ~~ ~ --- ---, ~a ~o ~o-~ ~~ ego ~ ~~ R ' ~ x ~ J ° ~ ~ .g}. n ~. .n 0 ~s m C A i ~, ~~ ~~ -` ~ ~~ S O ` ~ Y K ~ ~ ~ ~P ~ ~ ~' s ~` 3 F A - i N W n H r '~ -- -_~( 5~~ ~ . i i . ~~' ~ ~ `__ ~~ ~ ~ c ~ ~ O, °r' ~ ~ ~.r O ._ J ~_ -4~ \ d;~ ~' ` a~ ' ~ ` ~ 1 p \ ~ ~ ~ A ' ~yp 3 ~ 1 \ ~~ 2 ~ s~'~ ~ ~ ~w ~ , n ~ 4 ~~ J t ~p ~~ °~ ~ ty ..j V-t S ~ ~ o r~ ~ ~ } (~ , o° b JO 0 1 1 ~ 9 3 D _~ 't- '~J `a '~ hrhe~~t ~ ~U e:~- ~, toss +-e~nc ~ m~ ~,.Str,6~~~~„ C~P~1 </,' So I ~ c,~ PtJL ~«~~~ x_92. g a-, ~,.« ,~ru,~. -~-ow. ~uW.,~ _----- 0o y~, C~~~:l ~~ ~~ a~ ~'~c~rc ~5, 93. ~ v~ r-~ ,. M~,YIMLu~Y~ ~~~~ ~~ ~XCava~,d~ ~'row~ pr~S 1~a~ C3-racQ'e. W,l~ be~ `~~+c~i ;. .J/ '~S ,1`/1~,~,w,t,_w~ 1D~~p~bL e~ ~xc~~~~,o~ 'Jro/v~ er,~i~~` Grac~t. G~,~,,~~ lo.e, ~~-- .~~,c(n~~ ,.~~~ ~~. .~,`.H4~DR-O-mATIC t PUMPS ,~_ . MODEL: OSP33 9~/a 16 ~ ~DA~~e l4 - &~ -`fib `' SECTION 100 DIMENSIONAL DRAWINGS & PERFORMANCE DATA NOTE: CASTING DIM. MAY VARY ±'/s DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION ''P.O' 60X+.7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES 8 APPLICATION MADISON, WI 53707 State Plan I.D. Number: NW a , SW y ,Sec . 2 2 , T 2 8 - R 15 ^ CONVENTIONAL ^ ALTERATIVE (lf assigned) Town of Cady ^ Holding Tank ^ In-Ground Pressure ^ Mound NA E OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: BENCH MARK ermanent reference point) DESCRIBE IF D E RO L REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number : 149051 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ^ YES ^ NO ^ YES ^ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILD ING: VENT TO FRESH AIR INLET: ALARM: FEET FROM LINE: ^ YES ^ NO ^ YES ^ NO NEAREST -~ DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ^ YES ^ NO ^ YES ^ NO ^ YES ^ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ^ YES ^ NO NEAREST ~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) v WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIOUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST ~~ MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ^ YES ^ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ^ YES ^ NO ^ YES ^ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ^ YES ^ NO ^ YES ^ NO ^ YES ^ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MAN ELEV.: ELEV.: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRIL INFORMATION MANIFOLD MATERIAL: P PES~STR. I DIATR. PIPE ~ DISTRIBUTION APPROVED ^ YES ^ NO ^ COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY FEET FROM LINE: ^ YES ^ NO ^ YES ^ NO NEAREST -~ ~"' Sketch System on Reverse Side. SBD-6710 (R. 06/88) 8 YES ^ NO ~-~ ce~~TeQV DCLt111A~T e~D1 Ilf'_eTl[1N In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 11 I I I 8' h ~ ^ ~ ~ C~G S J nc n S Ze. X es r Check if revision to reviousapplication See reVerSe Slde fOr InatrUCtIOnS fOr COmpleting this appllCatlOn. STATE PLAN I.D. NUMBER i. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION TERRY WITT NW '/a SW '/a, S 22 T 2g , N, R 1 W PROPERTY OWNER'S MAILING ADDRESS LOT# N/A BLOCK# N/A RT 1 BOX 53 A CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER WILSON WI 5402 715 772-4748 I1. TYPE OF BUILDING: (Check one CITY ~ NEAREST ROAD ) ^ State Owned ^ VILLAGE ~ CADY HWY 128 ^ Public ®1 or 2 Fam. Dwelling~# Of bedrooms ~. AR LTAX N M ER( !!!. BUILDING USE: (If building type is public, check all that apply) 004-1052-30 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 8 ^ Mobile Home Park 12 ^ Service Station/Car Wash 5 ^ Hotel/Motel 9 ^ Office/f=actory 13 ^ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ^ New 2. ^ Replacement 3. ^ Replacement of 4. 0 Reconnection of 5. ^ Repair of an System System Tank Only Existing System Existing System B) ^ A Sanitary Permit was previously issued. Permit # 2411 h-R5 Date Issued fi-15-R2 V. TYPE OF SYSTEM: (Check only one) Nan-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^Seepage Bed 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 450 495 495 1.1 Class 1 90.7 Feet Feet VII. TANK CAPACITY in allons Total #of ' N f t M Prefab. site Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks urer s ame ac anu oncret glass App Tanks Tanks structed Se tic Tank or Holdin Tank 1000 1000 1 WEEKS CONCRETE Litt Pum Tank/si hon Chamber 800 800 1 WEEKS CONCRETE x VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumbe 's Signature: (No S ps MP/MPRSW No.: Business Phone Number: BENNIE HELGESON ~ ~X$ 3215 715 772-3278 Plumber's Address (Street, City, State, Zip Co RT 1 SPRING VALLEY WI IX. COUNTY/DEPARTMENT USE ONLY Approved ^ Disapproved ^ Owner Given Initial S itary Permit Fee (Includes Groundwater ~~~ surcharge Fee) a e ssue S~~ Issuing A nt Sig No mps c~ / Adverse Determin ion < ~ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS 1. ,=~ sanitary permit is vaiid for two (2) years. 2. Your sanitary permit rr~ay be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. Ail 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: I. 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 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. Vt. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. indicate prefab or site constructed and tank material. Complete for al/ 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'f~ 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 mUr,ies ct~l':ei;ted thro~;:~h th~yse surcharges are used for mGnitoring groundwater, ground- water consa.rnir,atian investigations and establishment of standards. S8J-63~sF, (R.t ~~88j APPLICATION FOR SANITARY pSRMIT STC-100 Th1s epplicatlon EoLm fa to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies viii only result In delays of the pellnlt lesuance~ Should thle develoQment be intended for resale Dy owner/eonlcaetoc,lspae houee)• than a second Eosm should be retained and eowpletad when !ha ptvpasty le sold and eubmittad to this otile• with the appropriate deed recording. _______________„__.__..__ Owner of pcopetty Terry Witt Location of property ~ ._1/~ 5..;._l/~• Sactlon 22 T_2$,~'R-~„~-r Tovnehlp Cady Melling .aacee. _~ Wi,_ i,.~;,:=WI 54027 - Addeeee of site Same lnbdlvlelon name N/A Lot nue-bes •, N/A _~ Ptevloue vwnec of pcopetty Daniel NPiG,nQe - Total else of parcel hP('I'~,f ~~-3 -~ - ~ Oale parcel was created /~" ~'~' ~~ Ace ail cocnera and lot ilnee ldentltlabla? ,Yes ,_~to is this pcopetty being developed Eor resale ~apec houselT__Yae •,,,~-No Voinwe ASS" and Page Number~~(=,.ee seco:ded with the Register of Deeds. INCLUDE WiTM TNiB APPLICATION TIIB FOLLOWINC3s A WARRANTY DBiD which includes a DOCUNIiNT NUMBSR, VOLUNQ AND PACs NUM81<R, an0 the B~AL OF THB RSOi8T6R Ot 086D8. in addition, a cettiEied survey, It avallabl~, would ba helpful so as to avoid delays of the reviewing ptoceas. IE the deed description tetetencee to a CettlEled Survey Msp, the CectfEled fucvey Map shall also be required. PROPERTY OirNER CERTIFICATION 1(Ye) certify thst sii statements on this form ate true to the best of wy (oy.~) knowtedge= that t (we) sm (acel the owner(s) of the pcopetty described In lhls fn[ocn-atlon form, by vlr'tua of a wattsnt dee~1 recorded in the Ottlca of the County Reglatec of Deeds as Document No. ~5`3o(c5~ • j and that I (Ye) pceeent2y own the pcopoaed alte for the sewage disposal system tot I (we) have obtained an easement, to sun with the above 'described property, Eoc the conetcurtlon of said system, and the same has been duly recorded !n the Ottlee et the County Regls~Qja~s of Oaede, as Document No. ). .C~"L ~ ~ / signet ~ of Owner lgnatute of Co•Ownac (it Applicable) Oate oe signature ~ Date of signature THIf f/ACE RESERVED FOR RECORDING DATA Daniel...F_....Nes.)}grx~..a~~...~,o].s...M.....H~a.s.i.nger.,.....---• ...husband and wife,...--.••,---.,_„ conveys and warrants to ...~'C');~'y..,P-,...[~I~.:~>~...and..~Qb.7.n...P......I9T1tt, ....husband and. wife.....--• ..........................•--•---.............................. the following described real estate in ............St.....C.xS~1.x ..............County, State of Wisconsin: NW's of SW's, Section 22-28-15, excepting therefrom the S 16~ acres, more or less, as set forth on a deed recorded with the Office of the Register of Deeds, St. Croix County, Wisconsin, on 3-6-86 in 734-16, #409796; further excepting easements, right of ways and privileges of record. This ..........~~..X1Q~_.._ homestead property. (is) (is not) Exception to warranties: Dated this ..............~. ~....---..........._...... day of ........ .... ..... . .......................................................... (SEAL) ..................................................................... (SEAL) REGISTER'S OFFICE ST. CROIX CO., WI Recd for Record cr OCT 311989 /8/30 IYVt V LAYN~ Register of Deeds RETURN TO Tss Parcel No:......... TR N S~ FE@ -_~ ~~ i~. .-------:.7 ..................Q~~Qb~~....................., 198.9.... .,J/.~>~ ...:.........~~11u~'~.... (SEAL) . Daniel F. Neisinger ............. .. v;!F:~e..~~.rl:...~f.~~.~?,~-!~~-t/`e'.:........ . (SEAL) . ,Lois.-,M.,_-Neisinger.....,..- ............... i AUTHENTICATION ACBNOWLEDfiiHENT ij j; Signature(s) ............................................................ STATE OF WISCONSIN '~ as. i -----...~ ?. ~ Y:.Cr ~ ...............County. authenticated this ........day of ........................... 19...._. Personally came before me this ................day of ii -.------October ................. 19..89. the above named • ............................•-----------...---....._........---•---.........._ ....... Daniel F._•_Neisinger-.and••Los.... TITLE: MEMBER, STATE BAR OF WISCONSIN M. Neisin er .,._ •-------------•-----------g ..------•------- ..._..--- •----.....----.... >; ,. I (If not- ---------------•-------•---...-----...........-------------- ..._................_._....------•--.....----•----•-•--....._._.... _. ~.. ,. . ..~., '~ authorized by § ?06.06. Wis. Stats.) to me known to be the person 5.......... wlro.lpai~on~d ~he ~~ 4' f strument and acknowledge the ss.Irie.. ~ , ~ iy ~ • ~r THIS INSTRUMENT WAS DRAFTED BY ,I ._.._.._>7ohm_.G..__~t~s.~~x~.g~~s...~~t4r~~.Y.------- ~ ' Beverly Bune ~ a ~' aldwin Wisconsin 54002 _ _ • -'~ .._..._.~ ......-•----...~...-•-• .............................................. Notar Public .... P.lares....... ~, unt ,Wis. Y -- Y ii (Signatures may be authenticated or acknowledged. Both My Commission is ~e~rYiYt. (If not, state erxpira~ion~ ••`•~~ are not necessary.) date • .............: 19.d '.:; ~ ......................•--...._.............. E ~~ Nolary Puab-Pierce co.. wisoo~sm , I •Namea of vereona sltnint in any eapaclty should be typed or Drlnted below their sitnaturea. ~ ~ ~(pi(~ ~. ~3, ~~~ ~~ (------------_-- _-__-___.._----.~_---.._.....____ .~_-- -- - ____.. _. _.. _.1~ i~HGril~ar ~ATFORM NoF g ISQ 82NSIN StO~IC NO. ~ .3Q~Z 'J . H a r STC- 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a •~ OWNER/BUYER Terry Witt ~ ROUTE/BOX NUMBER 1 Fire Number CITY/STATE Wilson. WI ?.LP 54n~7 PROPERTY LOCATION: ~ '~, SW ~, Section 22 T 28 N, R 15 _ W, Town of Cady , St. Croix County, Subdivision N/p Lot number N/A Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance cun- aists of pumping out the septic tank every three years or sooner, if needed, by a l.censed septic tank ,pumper. Wiiat you pcit into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents m-Y. a maximum of 60X of the cost of which was in operation prior to accepted this program in August owners of all new systems agree maintained. The property owner agrees to submit to St. Croix County 7.onink a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nee- essary), the septic 'ta~ik is less than l/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. be eligible to receive a grant I'ur replacement of a failing system, July 1, 1978. St. Croix County of 1980, with the requirement that to keep their systems properly I/WE, the undersiKned, have read the above requirements and al;ree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed and returned to the St. Croix County ''/.ontng Office within 30 days of the three year expiration date. SICNE ( ~'J~ St. Croix Cc+unty Zoning Office P.O. Box 98 Hammond, WI 54015 715-796-223n or 715-425-8363 Sign, date and return to above address. H O E ae b ~..,.....,..~. ~ w.., „~...__,, _ ._.. m..~..,.,....,.__.,,,, .,.,_.,__ _;. ,„ . ~~ I ~ Y~EI'Uk I UYV SUIL t~UK1iVU5 NIVU J , ~~ "~ , : . INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) ~•~ ~- y 75~~ P.O. BOX 7969 HUMAN RELATIONS MADISON, WI 53707 (H63.09(1) & Chapter 145.045) ~a>r # ~y-IDS..7- 30 LO A I '/~/a O T~$N/Ri•s'E io iW TOWNSHIP dPl~@ff'fCC1T1"T ' ~ QTj O.: //vl BL .: SUBQIjJ ION NAME: N COUNTY: WNER M ~P-~.~t.n.n_.~r ' i~--~--1 ______ v ~ USE U ~ ~ NO 8 Residence A , New ^Replace RATING: S= Site suitable for system U=Site unsuitable for system ~~,~ 't " O~ D TES OBSERVATIONS MADE U . ~ ~~ J ~ . LCm m~r~ C0~ ST^~ . MQ~J~. ~~ IN G~~ ^U S~ ~ •~~LHO~LDING TA K: REC~~ E'~ ED YSnEM: ptionsliL lJ ~ If Percolation Tests ere NOT required DESIGN RATE: If~any portion of the tested area is in the I' ' under s.H63.0915)(b-, indicate: /U Floodpiain, indicate Floodplain elevstion: N PROFILE DESCRIPTIONS BORING NUMBER TOTAL DEPTH IN, ELEVATION P H TO R UN OBSERVED DWATER•INCHES E H CHARACTER F SOIL WITH TH KNESS, COLOR, TEXTURE, AND DEPTH E ABBRV. ON BACK.) F OBSERVED (SE TO BEDROCK I T p ~ ~ l Si rS i•~ Srg1 i ..~ h ~s ~ ~~'• s-~ ~,~ IrS.9o " 6. ~' .Y' ni S;l is I.rJ' .. Si_ .Q' .t ~. ~ r, ,4' , B. ~' ~ 9~ 9~ ~ v t' r / / y ~ ~ 3 . Bl Si' 1"s ~ ~ 3 r 8n Si ~ '~'~C'o j. . . 6' ~ ~ .b' 95.9 a i ,, I B- r ~ .V r r r. ~O I t ~ ~, c r~ ,/~ L r y e V 1 JI i i.~ /. V, t { i ~CC V J r PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP WA ER L V H S RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL•MIN. PER INCH P. ~p 1 P. ~ , r 1 1 / P- /r P-. P- P PLOT PLAN: Show loeations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scsle or distances. Describe what are the horn zontal and vertical elevation reference points and show their location on the plot plan. Show the surfaLce /elevation at all borings~Q• ~ e direction and percent of land slope. ~nl' - rtrt.. V/1Q~r 9.3 .7 fZeP~atrneti'~ fslrte~. (!~!(.1rr' o: •~ SY STEM ELEV ATIO : N ~~W `~~ ••~ ~°i-t'`'~ ''' ` -- - - - ~- ._ _ . _.~ r._.. - -- --- - . - ._ .__ .. ~ 1 1 ~ __ _I ~._ _ ._ ..._- - _r .. .P.i ~ ---- ~ - _.. __.. __.~.. --- . .._ _ ~ P ~ M ~, I ` - _., . ~. . ~._._ ._ , _._._1 _ _ .,...._..___ ~ .__ ---.. ~._~_l ._ ~._._ ~.__ _.__ ~ ~ _ r -- . :~- , ....,..,~ y o R b , _._ .. -~ - - B - .M - 4 ~ V.R ~ ~ j>? il~r. o LL. j _i_ _L.I S I ~ ~ _ r ` ` ~ ~ Q,K ,s n y 'qo ~ ; .y._. -- 1 - ~ _ ~' I ' ~ t I ti ~ ~ ~ 79 tir s -1 ~ . , ~ ~ .# ti.. ~~ • `. t.. ~. . _ . r __ ~ _ i . r .._ ~._ _i _ i "--- , .. ~~; -_ .. ~ - ?N •~rG~ a ___.. i ..._ i ~_ .~. _ ~ ..~ s fix- . I, the undersigned, hereby certify that the soil tests roported on this form were ado by~me in accord with the procedures and methods spocified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief, DILHR•SBD•6395 (R. 02/82) -OVER - DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soii Tester. O~ ~ ~T~ ~1 j~ ~ ~ ,, ~~o~oS~ ~ to R~~o~.~L M®~<<~. ~~~.~ ~rd r.~. ' `k (5 T ~ ~+ ~i ~® St v+n,Y.'~T ~.~ f"'~ 6 ~+-L-ei ~ f l~~ ~pcx,i E ~(ASeuv~e[~v~~ 1'iOb1r ~It-tl. ! ~. 1 Z ~C9,p O` 1 h S p Cc.~h ~3 ~ C~cS ~~ ~x~-~~ ~ ~S ~~~~~, 1-~3e~n't P w~ ~ ~~~~ '~r ~ v Q. 3 /j'c ,1v ~__._-- ----- ~--._) ~~o, ~~.~ U e~~ /' i tau ~~, N°'" r ~t I~ [ x• s~~"5 g pct G a..l p ~,,,..~ CL~aw, b e r / '~~ ~poo 6.,~ S<p+•~ ~ a'~ '~ grN(, Ioo,oc~ f~ ,~oP s~ (~o-St"wtw~ ~~l ~ 7`S ~ u' `C ~ ~ "4' o ~ ~ ~ ~ C p _ ~~9!~ ~ ~ov»t {~tFSer,1 c~~- ~ ~~.~ 1 J _-----~--~- ~---~ " ~ Y'o~erl~ ~1~.{ ...., ST. GROIX COUNTY ZONING OFFICE n CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic serving the ~~ ~ residence .~(,~. t(~1 / 4 , ~(~ 1 4 , S e c . ~~ T~~N, R~~_W, _ Upon inspection, I certify that I tank and baffles to be in good condition, and it functioning properly. tank presently located at: Town of have found the appears to be Last time serviced ~,~~, j ~` (c:) Did flow back occur from absorption system? Yes No `'(if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete ~ Steel Other Manufacurer ( i f known) : ~e.~-~S v~ cn c ~ e-I c~S~ 0 (Name) Please P nt (License Number) Age of Tank ( i f known) : ~ Ye,;w~s (Signature) S ~~ _S (Title) /~~-~ ~ a I~~I (Date) Forir- to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspection open'n over outlet baffle). Name ~c-.v~ ~ -e ~ cs o~~ S ignature ~~ti~-c / P/MPRS ~l ~ 5/88 C~~~~XJ~ ~~',~n,~; _ ~~'a C'l~G~.z~:?~C' <'('`~/U~ `'~Ci 2`%1~'..~ ~ ~U`u'~., ,~?~`'.~ic.`~-"~a- ~ ~ AS BUILT SANITARY SYSTEM REPORT OWNER ~~,~ c e I r S~ i~l~ TOWNSHIP SEC ~T~I-R~fi ADDRESS ST. CROIX COUN Y, WISCONSIN. GIs©~ ~~~ SUBDIVISION + LOT LOT SIZE PLAN VIEW llistances and dimensions to meet requirements of 1163 ~~ ,~ lnl _ EV ERYTH IN G W ITk iIN lU U 1~ 1.1 ,'t' ui~~ 5Y 51 i.t~ e...- ~.~ -~ ~i _ ,~ ~o _. s-~ -- - , ~ a _ _ __ - __ __._ - -- --. _. - --- `~ - - - - - - ---- -- - - ~ j` _ __ _- - -- - - - - - _ _- - .~ __ _ .- _. o ._ ~- ~ -_ -- -- - I - di a te orth~ A - r~~w _. . _.~ e/ ~ - - ~' ~ti ~.._ _ ~ BENCHMARK: (Permanent reference Point) Describe : ~~~ &S 1~ ~ ~" kr '~ ~~ Elevation of vertical reference point : j~p~ p Slope at site : ~~~-~ /y3v SEPTIC TANK: Manufacturer: Number of rings on cover Tank Inlet Elevation: Liquid Capacity : 100 ~~ ~_ manhole cover elevation: ~~,~~/ Tank Outlet Elevation: ~~ ;~ PUMP CHAMBER Manufacturer: ~Q,e.~S Number of gallons Number of gal. pump set or a cycle /'~`y gallons; tota capacity o distribution lines., s'/ gallon: size of pump ~~ S'',2 head; gallon per. minute ~*~T-; horsepower ~j brand name of pump and model number _ ~ - /YI~f rc. Type of warning evice HOLDING TANK: Manufacturer Number of gallons " Elevation of manhole cover Tye of warning device _ SEEPA~E PIT SIZE: um er o pits eet iameter___ feet liquid dept seepage pit in et pipe-elevation_ bottom of seepage pit e evation feet. SEEPAGE BED SIZE: number of lines width le~~th the depth SEEPAGE TRENCH: width ~ ' length PERCOLATION RATE Criss % -AREA REQUIRED AREA AS BUILT ~ INSPECTOR '~ DATED ~ PLUMBER ON JOB ~ LICENSE NUMBER~"3? ~ S~ DEPA~iTMENT OF INDUSTRY, INSPECTION REPORT FOR ~ ~~ LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS P.O. BOX 7959, L~.~ . MADISON, WI 53707 CONVENTIONAL ^ ALTERNATIVE ^ Holding Tank ^ In-Ground Pressure ^ Mound SAFETY & BUILDINGS DIVISION BUREAU OF PLUMBING State Plan I.D. Number: 11(assigned) NAME OF PERMIT HOLDER: 4 ` ADDRESS OF PERMIT HOLDER: INSPECTION DATE: ENCH M (Permanent reference point) D IBE DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: ~- ~ a~ ~y~ me of PI ber: MP/MPRSW No.: County: Sanitary Permit Number: SEPTIC TAN C HOLDING TANK: MANUFACTUR LIQUID CAPACITY; TANK INL T EV.: TANK TLET ELEV. WARNING LABEL PROV DED LOC G C E PR DED ~'')' Kd~ n ~/,l-~ ~~~~l. : YES ^NO NO BEDDING: VENT DIA.~ VENT MATL.. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: ENT OFRESH C~ ALARM. FEET FROM ,~y-~ py''~~ LIN,E~t~ / _ G % l ~ ~ AIRI LET: YES ^NO ^Y NEAREST VV ~+~! y v DOSING CHAMBER: MANUFACTURER BEDDING; LIQUID CAPACITY PUMP MODEL. PUMP/SIP HON NUFACT UR WARNING LABEL LOCKING COVER sn ~ RO DED: OV ED: ^YES ^NO r 4"` `+~) •.•+ ( T YES ^NO YES ^NO GALLONS PER CYCLE: PUMP AND CONTRO LS OPERA IoNAL NUMBER OF 'ROPERT WELL BUI DING. V NT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE. , /~ AIR INLET: z ~ PUMP ON AND OFF) ^YES NO NEAREST_~~ l~ U ~ VJ ' SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowi _ FO _ - ~~~ ~ ~ L,~..METER MATERIAL AND MARKING ' or excavation. (lf soil can be rolled into a wire, construction shall cease u til ~ RCE the soil is dry enough to continue.) I MAIN LL SYSTEM: CONVENTIONAL - ..P ' r+- _ NIDTH~ LENGTH. NO. OF DISTR. PIPE SPACING: COVER NSIOE- IA.. #PITS. LIQUID BED/TRENCH ' ~ ~ TREN HES ~° `°` MA I L PIT DEPTH: DIMENSIONS .,, ~ t, - - ~F.:,.__ La I:! FILL DEPTH UISTH. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DIS R. NUMBER OF PROPERTY ELL. BUILDING: VENT TO FRESH BE LO PIPES ABOVE COVER. ELE V.INLET ELEV. END: ^7 ( PIPES FEET FROM LINE. `/ U/~ Y' AIR INLET: /~Q •~ ~^f (, 7 ~ (~ NEAREST _~ 1 T 0 d y'~ AAA11w11"f CVCTC1111. R ~ ~ L! lowed per Mound site endicular to slope p p Check the t xtur the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: ound sys m to ake certain that it ON REVERSE SIDE. SHOW ELEVA- eets the it is fo medium sand. TIONS MEASURED. ^YES ^NO SOIL MOVER. TEXTURE. P AN ENT MARKERS: OBSERVATION WELLS. ^YES ^NO ^YES ^NO DEPTH OVER TRENCH BED DEPTH OVER TR ENCHBED DEPTH OF OP OIL. SODDED SEE DED: MULCHED: CENTER EDGES. ^YES ^NO ^YES ^NO ^YES ^NO PRESSURIZED DISTRIBUTION SYSTEM: `~ .NIDTH. LENGTH: NO. OF BED/TRENCH TREN ES: DIMENSIONS MANIFOLD PUMP M LD ELEV.: ELEV. D ELEVATION AND DISTRIBUTION INFORMATION TOLE SIZE HOLE SPACING. RIL ED R YE _ COMMENTS: PERMANENT MARKERS: ~-C~~ ^YES ^NC Sketch System on Reverse Side. DILHR SBD 6710 (R. 01/821 L ERA PA ING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER: DIST, PI E MANIFOLD MATER IAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKIP ELr~V. PIPES. DIA.: TLV COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPR~ PLANS. ^NO _ ___ __ ^YES ^NO OBSERVATION WELLS: NUMBER OF PROPERTY LINE: WELL: BUIL ^YES FEET FROM ^NO NEAREST ~O ' ~ I I 0~ It-~ ~,s ~?' . ~, _ _ `~ v :, o 7 ~ ~~ t t'~ o- ti ~- - ~# ~~~ r~ ~~ cn 3-~ ~ ~- ~*' .._ .~ "~ ~ C S ! n. ~ Q ~, i ~t ~ ~ ~ 1 _ ~ .. .... ~...,.,...,~.. ~~~ ~ ~~' .: _ s ~ ...,t,. ~....~...,.. .,..~ ... i i ~ ~ c ~ ~ ~ -- - °' ' ~. 3 ~ ~ i ~. ~ ~ ~~ ~ ~~ ~ ( i ~~-- ,, , _ ~ ~ ,~ ~ ~ ~ ~ ~ '~~ ~ M O ~ -' ! ' i -~ ~ .~ ~ ~-.,~~ ' ~ ~ ~ti ct - W • ~ ~ ~ 0 ~ r JI ~ ~~ ~ ~ e ~ Q ~ ~~ i ~ ~ ~: s - ~ ~ ° .~ ~. .0.. 1 w I ~ ~~, ^~ ~ _._ ' .. ~L_ . ! _ ~ Z { ~ ~.i O O ! i ~ '' ~ ~ ~ i ~ t h,. ~ 1 ~ ~ N ~~ + ~ --~---., ~~ ~ o , :: ~ :~ - ,~,: . ,.. &~ ~x~ ~ ~ ,., r - a ~. > ~4 f ft `~ ~ ~ ~~ ~ ' ' t ~ ~ ~ N 1 ~~:H '711 ~' : , ,r r r. w. 1~ . a l 'S. f J ...~~~ ~, . ~ .i di ~..~ ~.. - ...mss ~ i. n.. .~~ DEPARTMENT OF >~ APPLICATION INDUSTRY, FOR SANITARY LABOR AND PERMIT HUMAN RELATIONS (PLB 67) ~; Attach plans .for the system on paper not less than 8'/z x 11 inches in size. Include a plot plan that is dimensi and vertical elevation reference points must be shown. All appropriate separating distances and physical cha H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction included. BUILDINGS ~°~ ~ . !1 i / VISION `~ ~- P.b. 7969 ' Rr~Fi~~~N,• 707 e JUN l a~.1982 or dra~pf~cale. H ntal ~ristits ~ified i pter er. If designed br aster must be Property Owner: Mailing Ad ress: 1 Property Locatio City, illage r owns ip ~ County: ~q U~ t/a,SU1/aS~ iT.~~ NiR /~ ~+4a1~ ~Cc r Lot Number: Blk No.: Subdivision Name: Barest Road, Lake or Landmark: fate Plan I.D. Number: /~w ~~Q (lf assigned) 1 YYt Ut KUILUINl9 Number of ^ Public* ^ Variance* 0 Other (specify)* Bedrooms: ~1 or>~.:.ay *State Approval Required. 3 TOTAL GALLONS NUMBER OF TANKS PREFAB CONCRETE POURED-IN PLACE STEEL FIBERGLASS NEW INSTALLATION RE L'AC'E= MENT OTHER ISpecif ) SEPTIC TANK CAPACITY / ~~' HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER ~ V L MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PR POSED (Square feetl: ~ ew ^ Replacement ^ Experimental ^ Seepage Bed ^ Seepage Pit f2r *S~ ~ ~`' S ~~ ^ Alternative (specify) seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owned: Private ^ Joint ^Public I, the undersigned, hereby assume responsibility for installation of the-private sewage system shown on the attached plans.. N e of Plumber: Signature: MP/MPRSW No.: Phone Number: ~~~~~~ cl ~ o ~~ Plumber's Address: Name of Designer: / ~ ~ \ ,Gf lvS Q ~.~ C / /' PA11111TV /11CDADTEAGIUT I ICG AIUI V Si na r f Issuing Agent: ~ Fee• Date: Sanitary Permit Number: /~ ~ ~~J !. / G APPROVED / ~J f/iT1.C.!//' ~' ®/IAliF! ~~ ~ C9 ~~~'A ~ DISAPPROVED ~~,~b " 8~ Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber D I LH R-SBD-6398 (N.03/81) _ ~ `~ • ?'~ DEPARTMENT OF REPORT ON SOIL BORINGS AN ~\ ~FET ILDINGS INDUSTRY'- , ~ RECF~vF[~ IVISION LABOR ANA CC u P. OX 7969 HUMAN RELATIONS PERCOLATION TESTS (11J, JUN 14~1~S0 153707 c~ ZONIN6 LOCATI~'/~ ) ~ SE~O~~ ~u e W TOWNS~P~UNICIPALITY: OT NO.: BLK. .: UBDI NAM~~v 4 N ~ / ~~) R 1~ n . Z CO NTY: OWNER'S UYER' NAME: ~ M ILIN ADDRESS: _ t ~ l~ ~ . ~e er s o ~, r~ I: c. 1SE / mm// NO. BEDRMS.: COMME ~ AL DESCR PTION: ,~--,~/ LiQResidence Ll7New ^Replace DATES OBSERVATIONS MADE STS: ~"' ~ 7/ p~ RATING: S= Site suitable for system U= Site unsuitable for system L !''1~1 ~1/t C ~~ ~Q Q c V 8 CO NV STIO^NAL: MOUND: ~ IN-GROU~ a~ RE: S SQTEM-IN-FI H OaLDING Ti - iV : RECO O ~ I.JC n ~EM~:(,o~ptan~l) If Percolation Tests are NOT re wired DESIGN RATE: S T M Q A If any portion of the lot is in the' O I~ under s.H63.09(511b), indicate: ~QSS !De ~ .Floodplain, indicate Floodplain elevation: n V l PROFILE DESCRIPTIONS BORING TOTAL PTH TO GROUN DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED E T. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ~ ,~v© ~ g ~ do °e, © y'~ 1~% ~;~ 7.,5 ~`~ "fir S L Y2 '' 6n B-a ~ /~ t ~ ~ CO U 3 ,' O/ Si/ ~S s~Y ~' S! 37" n .S B- (O~ ~ ` 1 ~c~3 ~~g> ; ~j~c, Fy Si 17"~~, SL !Gr. .. B- ~ ~ 0 15 I I ~ ~ ~ 3 „ g ~ s; / ~s ~ 3 ,'Bh ~v" r3,, `"~ -s` v~• B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. RIOD 1 P RIOD 2 P I PER INCH P- P- P- P-. P- P- PLAN VIEW: 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 elevatiDon at all bor' gs and the direction and percent of land slop. / r~hL~ ~7 517' -1C~u~Yc~ i~a- SYSTEM ELEVATION ~~, 7 S'~ ~ / '' = y~ _~~~~_. _ .. __~ _~~ ~_ ~~~ e _ ~ _ ~._ _~ ~_ _~. _. ~ ~_ 9 ~ ~. .. ~ ~._ ~~ .~ __.. ` ~~_ _ ~_~ ~.i ~ __. ~ .. _ ~8.~~ ~~..__ _~ ~ _~_ ~. ` - i~ ~~ .~. ~~"~rt.,a-~i _`7 ~ lac mss" .... ' C-` E ~_5 ~>7~ 5~-c.. e _.~... „ ~ ~ _ M' ... ~~ ,,.,.d /~ , ~~~~~~~ ~~~ 1/Q / / ~ ~. ~~"~, ~ , , B f ~'~' - - - - - i- - ~ _ pis^g,S ~ Ff .. I ~ ~~t~~ _. `P too,b _. i < { ~ ,p `~r~ ~` '~f~a~ o.~,.w,~ ~_.m.....~,~^~ e~S ~e ._. ~.. e ' ~ro~0 5 ~ ~O~-~~'t. ~-~jOWle _... ..~' . ~~ I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE CO PLETED ON: ` e ~ ~ ~'-2 ADDRES CERTIFIC I N MBER: PHONE NUMBER optionall: 1 'e 34 ° CST SIGNAT E: t LION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th pageSoil Tester. 395 (N. 03/81) :~