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HomeMy WebLinkAbout038-1171-20-000 a o I a o I a ~ 03 ~ I a 0. 0 g° ~ - I I 0 N o g ;a t m 0 o a i ' aai I ~ 3 N N O ro I N~ .n -0 E a a y C O N X C O) O T I 3 'c I N ° v m O 0 Y o ( ~ z c`arn z N L m N LL LL O 0) O y m O 0 3 Q°0 Q w'ca CD, 0. V N M N M z yj z N _ o U EO O O z £ a a W a co a co M M O Z c c r y U Z N O + O o c U) F- r c E c E ~ N N a) O co a) p fp6 m N Q O C O y d • N N N r, ir, O a) O O ly a a U1 t m cu N aI? L a O U O C a O O w z m z O Z z m z Z o aci E r E m o m E ° R E 0 LO d - d W N N N a0. N o o a o a o ~w vt~cAC~ j v~ c cvvv_ E 5 a It OE a s •N -2 a a a a a a 4. 3 I (D Co (D (D fR J V z 0) O Z O Q0 U v v m O U N w O M O O E '7 O a O :3 O j m y a (p 0 m m I O a y O ~ d O a y O U -p d Q> (n c6 U C Q z <n m C) W o7 O M 2 Cl) O o 3 - m c ~ w c w+ o O o E o a E O, J O) D1 .J a) 3 O C N f" C U y N U a) t a p 0 C a) C C U a a) C C O] O \ N Cl) 2 Y Y C a N y Y E M a V 2 °O m Q aci aci c Q N a) a) c G IL M N -7 -7 aO, a •7 O a)- co N C N c m a v Z _ O N aS p to U • M--I CM ~ 7 LCn O N co 'l~ U 7 to O O (n J N O Z N (n J N O Z N r2 z Cn .r Y E C € 4)'a a S Lai, gay d d c • a m.~ d N Co o M 3~ 1 c3 ~ Y r A 6 a 2 0 N v 0 0) 00 'WisconsiT Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor a-nd Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: PerMN is r*Ee: ❑ City [I Village E~Town of: State Plan 1 STAR ]PRAIRIE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Lriction System TDH Ft oss H Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside 'a. Liquid Depth DIMENSIONS DI I N SYSTEM TO P/L BLDG WELL E/STREAM LEACHING Ma nu allure SETBACK . INFORMATION Type Of CHAMBER Mo a Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE,13.31,18W, SE, SW, LOT 15, STAR DUST DRIVE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i T y " o Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water System 201 E_ Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code - P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. 6-7 ,Q01 k • See reverse side for instructions for completing this application State Sanitary Permit Number a59 -Y8,;L The information you provide may be used by other government agency programs ❑ Check it revision to previous application IPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Pro rty Owner Name rope r! Lo ation V 5z 1/4 1, 1/4, S 13 T 31 , N, R I~ E (or) '4 Prss~erty Owner's Mai ing Address Lot Number Block Number City, Sta a Zip Code Phone N mb Sub vision Name or CSM Number rAl<,s 5~a~ y (716 `1)66 TrKv rn&WD()Wa5 II. TYPE F BUILDING: (check one). ❑ State Owned ❑ City Nearest Road Village V ~LI ❑ Public ❑ 1 or 2 Family Dwelling - No. of bedrooms ~ Town OF'SA NRQIE S Q ~1~ I III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Num6er(s) - L~J 1 F] Apartment/ Condo V 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. jj New 2_ ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5• ❑ Repair of an ystem System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued- Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 It Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Mi /inch) Elevation ,/5Q I '7Q lb IV, J, Feet C ?8, Feet VII. TANK Capacity Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. New Existin strutted Tanks Tanks Septic Tank or Holding Tank Q ~bQ Utl ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No S mps) MP/NERSW No: Business Phone Number: i - 7_~ umbe 's Address (Street, City, State, Zip Cod z rrSS~e 15 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved anitary Permit Fee (Includes Groundwater at Issue Issuing Agent Signatu (No Stamps) ~Approvecl E] Owner Given Initial Surcharge Fee) a 9~ Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD-6398 (R. 05/94) DISTRIBUTION: original to County, One copy To: Safety & Buildings Divr ion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be 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 licor sed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrat _ir 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 numb,?r(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 `D,~,~?Iling. 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, rE cannection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers l through 7 VII. Tank. information. 'ill in the capacity of every nevv/o.- existing tank, list the total ~jallon=-- r of tanks and manufacturer's narne, indicate prefab or sits constructed and tank material. Complete ',_I c'f cpt.ic, pump/siphon and holding tanks for this systern. Check experimental approval only if tanks receivec experirn:.r t I p, oduct approval from DILHR_ Vlll_ Responsibility statement. Installing plumber is to fill in name, license number with approp-, ~)refix (e g- MP, etc.), address and phone r)umber. Plumber must sign application form IX. County/ Department Use Only. X County/ Department Use Only. t e~F t a ,oi smal x I i ~nCltti's M.;; KE Sut ' 'tie(; :3 ; f.lty. The plans must Lank(y), Se'pitl`~ F)W, or slpl?or 1.OrPt orl cj>i~_iY d c_i> E hebl.llldingserved; , doss voluf ci N,_.iK>f .'r;i< '1 rp E- ~l t.TIC `.C4 _ ..,r.f D1 cross sec' ion iz,ng information. GROUNDWATER SURCHARGE 1983 vlv!sronsin Act 410 ir"t: iuded t:he creation of surcharges (r ! or a number c,' rec. lated p~<':c vvhicii can effect aroundvvater the fTly+ fE'i C.O I:.c leu tf:' JUt~ ) these surcharges are used fC r )o1nltor~ng yrour f ."lei' (_?FIB ,r ~t'.,- iiVc'St-! atlOns and establishment of standards. ~w b b l 2~°,3 r~ N 0 m_ r O 0 O 6- I A T "T jD, C 6 o o~„ • t 1 rQ I ~ -Mir ~k. Ilk - 4_ _ 7T 4e INDUS T~MENT.OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND cc P.O. BOX 7969 HUMAN RELATION PERCOLATION TESTS (~~J) MADISON, WI 53707 ~W (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: 1/.5W V/ /_3 /T3/ N/R/BE (or) W ot, C4LI'NTY: MAILINGADDRESS: ,y 3- 9zc' r U 1'2> l0 8lp _0?1 e' o Lj,, 5-114 Z USE DATES OBSERVATIONS MADE Residence NO. BEDRMS.: COMMERCIAL DESCRIPTION: L~J r~New ❑ Replace PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: Z/ Z.Z !/9.3 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: rr_1 YSTEM-IN-FILHOLDING TANK: RECOMMENDED SYSTEM:(optional) ~S EIU Z❑U ®S DU S ®U OSOU (acv) If Percolation Tests are NOT required DESIGN RATE- If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- Z 98 © 89 ' ,c~✓; 8- z1P ,P. 1s.7.s, / Z - yd ` ~e - e4%y ell 2.61J B- 3 83 9~ S 83 _6P1 "e e17 j B- J/ 3 - G ` LT J GG -moo s /ACS: B- 9r. ~6'-~B`~lt~i~J G - D" QrrJ QG-9y+1.S FB--T TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERT D PER INCH P- Z U /0 P- Z. q `V/G 1 C3 /0 P- !C1 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope, jr v SYSTEM ELEVATION 9. - - i i E N 1 o INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use suction must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols at - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under T') LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well , is - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand - Less Than '1 - Loam Bn - Brown 'sil - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water ' Six general soil textures BM - Bench Mark for liquid waste disposal VRP - Vertical Reference Point •o Z; NO'S • -4 4' iN `c AWAL N 06, a9,o ~~a ~ oQ6 m 1 fd iv p It 66, G ? gyp !p p 2 N IT I oa co• q N00*iB•27'E N N 2 *39' 11 E 7.40' v N 505.04' v fr> R m I nl = Q i 40 C F. ; N .O n n~i G ro ro ao vi v a 10 O o L_ 11 n 1 ? ( D 16'27"W I ' CO) NIS.00.00 124.31 , I r e z I ° ,,2 3e~'• 93, rrv"/ N00 *16'27'E 41.85 ~ ew ~ 70 h o ~ I ~`oD / C D n' o y ,o / ~ ~y w i C) 14 t 5) U' ° LL) / t7 c 41 10 / X04 • 0 •00 -i rq y b a rn c. 0. d y 2 O ( °uA,~\~ (O po 0'00'16'27'E ~ ~6 0 3 2~ N J 335.30' --134.111-.- 01 - - - .r / / \ IZ\ \ 50 so Ax- -A 45 14 00 ''40 00 g0 I ' o i W N / lN~ \ N ?to. . 'Con i 3 Da N~~ coy 3 3%0C m N o ? fi g 2 m D t ~ CL OOD o n z ~ ° im, N Z 1a `U a ~ m T" 0 ' 2 I I CD) a p ti LO IS a a dti gyp. zi it -I A -4 , N o, a c~'o STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER L u~JCr~ ale MAILING ADDRESS tIJ st..st ~/ao PROPERTY ADDRESS location of septic system) Please obtain from the Planning Dept. CITY/STATE A)ft.wi RIChA4,0A10 1Afe` PROPERTY LOCATION 114, ,5W_ 1/4, Section, T_.y/_N-R f~_W TOWN OF J~~qp_ ST. CROIX COUNTY, WI SUBDIVISION C~l~UnJ RBI /'/~°t7Cr01c15' ~sf ~W, LOT NUMBER CERTIFIED SURVEY MAP , VOLUME,~'OB, PAGE LOT NUMBER /_37" Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. It St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix da te. County Zoning Officer within 30 days of the three yeaz SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 " STC - loo This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. owner of property Oeg PA/ /-L//.j ~ Location of property 1/4 J&j 1/4, Section T-_-3/N-R _LF _W Township 5)' gp, plzf+i k Mailing address S !JA s4~17w11 G' ddress of si C -00N-70Ly / eJA) teic~16t~~t~~ ubdivision name t,), 7`.ey /_`1ef7QlyrcJS f3 t %o%,/. Lot no. other homes on property? Yes No Previous owner of property ~~,✓,v;3 ~oP_ir/; v Total size of property j O i4 c,pes Total size of parcel /D R eP Date parcel was created t,'~^T/99t~ Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume /40;T and Page Number as recorded with the Register of Deeds. d 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. 7 , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. / S o '7 Signature of-Applicant Co-Applicant r Date of Slanat rP_ nAtr of Cirrnatiirc~ DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-19821 THIS SPACE RESERVED FOR RECORDING DATA QUIT CLAIM DEED ii VOL 1'08 i Gary Brunclik and Allen L. Lunde d/b/a Homestead Redtf*W Development 91994 JUL'- - S Allen L._ Lunde quit-claims to . . 10:00 a ti4 - II the following described real estate in t. Croix County, State of Wisconsin: RETURN TO Allen Lunde P 0 Box 686 St. Croix Fa 1 WI Tax Parcel No: Lots 4, 8, 6, 13, 15 and 18, Country Meadows First Addition in the Town of Star Prairie, St. Croix County, Wisconsin. This 1S. not.-_-- - homestead property. (is not) Dated this --f-- June94 day of 19......- (SEAL) (SEAL) * r nclik (SEAL X~ ......--.(SEAL) * . Allen L. L e AUTHENTICATION ACKNOWLEDGMENT Signature(s) Gary_Brunclik-,--Allen L. STATE OF WISCONSIN Lunde ss. -•------------------------------------County. authenticated this day of June 94 19...... Personally came before me this ................day of I, ST. CROIX COUNTY WISCONSIN ZONING OFFICE ■~■.6 ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road - Hudson, WI 54016-7710 (715) 386-4680 July 1, 1996 Attn: Jim Moe ReMax RE: SEPTIC INSPECTION FOR PROPERTY LOCATED AT 1330 COUNTRY COURT, NEW RICHMOND, WISCONSIN Dear Jim: An inspection of the septic system for the above address was conducted on April 8, 1996. This property is located in the SE; of the SW, of Section 13, T31N-R18W, Lot 15, Country Meadows, Town of Star Prairie, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. Should you have any questions, please give our office a call. i Si cerely, Mar J. Jenkins Assistant Zoning Administrator St. Croix County, Wisconsin db C(DP'f ' AS BUILT SANSTC - ITARY 104 SYSTEM REPORT OWNER ~L LUA[pf ADDRESS 694 l-&3() CCUNT12Y C -J, F ~cSw--T va z y SUBDIVISION / CSM# C' )uMTRy LOT SECTION / _T 3 ( N-RIg W, Town of S j ~I ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 190 FEET OF M IZXSy~~~ BM INDICATE NORTH ARROW Provide setback and elevation inf r tion on reverse of this form. Provide 2 dimensions to center f septic tank manhole cover. a BENCHMARK: ~j bN I i~ZUA L( n~E 21 C5 ALTERNATE BM: ( Ot~ Or LocK CAN 4~0' UN019Ti01") - 2S SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: VJCG KS Liquid Capacity: /3oo 6-K Setback from: Well House -j Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: ]Z~ Length Eye Number of trenches Distance & Direction to nearest prop. line: k 13 Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet. ST outlet 95 0 PC inlet PC bottom Pump Off Header/Manifold -,S Bottom of system r Existing Grade 3 Final grade ZIE DATE OF INSTALLATION: y15~~~ PLUMBER ON JOB: w)CC~ (V), Pop o LICENSE NUMBER: u. INSPECTOR: Z 3/93:jt BENCHMARK: CS ALTERNATE BM: DO t7 (jr r K Gtl1 4:;ouNpflT,Otj 25 SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: WC~---KS Liquid Capacity: Moo Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: ]2` Len th g y Number of trenches Distance & Direction to nearest prop, line: Wk~'~ 13' Setback from: well: House Other ELEVATIONS Building Sewer V,2 ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold__S, 8 - Bottom of system Existing Grade 3.6 Final grade ZIE DATE OF INSTALLATION: PLUMBER ON JOB: LAJICC j A(VI T,)::-fl tj LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Indus`ry, PRIVATE SEWAGE SYSTEM County Labor and Human Relations INSPECTION REPORT T . CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village Town of: State Plan o.: LUNDE. AL 9 CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /00. /670 I A_~4j!~ A96130047 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing l ~lYj, 9,55 Aeration Bldg. Sewer ? 7 7 Holding St/Ht Inlet 99,2-/ TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet rl Septic NA Dt Bottom Dosing NA Header/ Man. ~~85 96,15 ' Aeration NA Dist. Pipe 95, yy' Holding T-71 Bot. System Qs,67 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift I Lrictio System TDH Ft Forcemain Len Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Wid h Lengt~ No. Of Tr es PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of , CHAMBER Moe Number: System: 1-~ A-3 OR UNIT DISTRIBUTION SYSTEM [Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air intake ngth Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over v~ Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center / " tp Bed /Trench Edges 30-,k Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE.13.31.18W. SE. SW. LOT 15, COUNTRY COURT r it L Plan revision required? ❑ Yes No y Use other side for additional information. SBD-6710 (R 05/91) Date Inspe or's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH " SANITARY PERMIT NUMBER: I, .tea 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 81/2 x 11 inches in size. 57- 2o • See reverse side for instructions for completing this application State Sanitary Permit Number 1:9 ! 4183 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 Prope y Owner Name ropert Location } L N 1/4 >W 1/4, S 1,7 T N, R f S E (or)(0Property Owner's Maili g Address Lot NuJnber Block Number ~loX 60 / City, State Zip Code _ Phone Number Sub nrision Name or CS Number w 5qDZ~I (715 ) _9ads~~pot~s II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms own OF Q V 2`I eco(Z i III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 03~_ 1~~1 2o'OUD 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. XNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an -----System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued- Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6_ System Elev. 7. Final Grade Required (sq. ft.) Pro osed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 1450 /-l3 ~2a .'7 Feet c~? Feet VII. TANK Ca in galloacitns Total # of Prefab. Site Fiber- Ex per. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank /Ono VK-6 s ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP/MrftS%W-ftto.: Business Phone Number: ~ cG/ 21 171, 5., 5! 5 --3 Plum ei's dd ss (St eet, City, State, Zip Code ; IX. COUNTY/ 13FPARTMENT USE ONLY E] Disapproved Sant ry Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) G~~(~( Surcharge Fee) 4 Approved E] Owner Given Initial /94 /ea2 Al/.* ~q Adverse Determination $ 3 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, one copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit: issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrat_)r 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 numb,~r(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 Jvv~?fling. 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, nu T. r•?r of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for J/ ;E ptic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experirne it ;l product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number wi h appropr,a i? prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only X. County / Department Use Only C,, ?;Jle~d c•:.., flcatl,.?i`~s r1o~ 51''?:' !.'r Lt1an 8 11.2 X i I ii`Ctic~"> `(:u:St L)E SUS) n Itted lC, e, t I.Inty_ The plans must piot o:an, drav- i,- cale or with cor pi~: i.c, d.m.ensloii Ioco1, o;'i t i!ding tank(s), septic _rnt tanks, b~ awe!;,s vvat~:, 1'e ~ - re, stn'_. u laf;es; pumpor siphon .u" > soil c,!S:.orptio- ns; replacemen!_ system a, c.{ he lac:. f the building served, "rots, Q c0"lplete pt:(or puir:._ :controls; dose volume; 1.1C,uon o:;s, „•-mancecur-e; pumpmr-(. ru-prr,<:r~.~. ( -.Urer D) cross section ~i iA 2 the county, E) sCll ~ st dal..... _ ;.zing information. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 198 °d'~~ :r, .ct 1 u in:-J,_Aed the creation of surcharges (fees) for a number Gf r-.1 dated I.) -i which can effect arowidwater. The me ::c-_ c l;ected thr3;_:gh these surcharges are used for monitoring groundwal gent ~n ire i r investigations and establishment of standards Q IV\7ty-G / T IA w ~ 4-1 t t~ zoo A,e,vCWgv 0 N s a x Z I _'rv y, v6, l11 WiscbQsin' Department of Industry, SOIL AND SITE EVALUATION REPORT Page-/-Of-,? Labor and Human Relations Divisidn of.Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 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 PROP RTY OWN PROPERTY LOCATION GOVT. LOT 1/4 1/4,S N,R I/(or~ PROPERTY OWNER':S MAILING ADDRESS LOT # BLOC 7# SUB NAM OR CSM # CI T ZIP CODE PHONE NUMBER []CITY []VIL GE ®fOWN NEAREST OAD f iLI V New Construction Use j~Cf Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate ~2bed, gpd/ft21,y _trench, gpd/ft2 Absorption area required Z-11? bed, ft2 5 trench, ft2 Maximum design loading rate ~bed, gpd/ft2_,? _trench, gpd/ft2 Recommended infiltration surface elevation(s)`; ft (as referred to site plan benchmark) Additional design / site considerations Parent material lood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem W S ❑ U ®S ❑ U ZS ❑ U ®S ❑ U ❑ S ®U ❑ S I SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botx>dary Roots GPD/ft in. Munsell Qu. Sz. Co t. Color Gr. Sz. Sh. Bed Trench L2-21 ZIA l Ground ~elev~./ t - - Depth to limiting factor Remarks: Boring # Ground elev. _ ft. Depth to limiting factor Remarks: CST Name: Please Pri Phone: / 1Z Address: ZJZ Signature: Date: CST Numbe PROPERTY OWNER J6A~ SOIL DESCRIPTION REPORT Pale tlf PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Boundaq Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Copt. Color Gr. Sz. Sh. Bed Tw& zn~ lee Ground elev. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # i:<::::> is Ground elev. ft. Depth to limiting factor i Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) J PROPERTY.OWNER~ 414e9~ SOIL DESCRIPTION REPORT Pale e~f PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Co Color Gr. Sz. Sh. Bed Trer Ground 3 elev. 2gLft. Depth to limiting factor Remarks: Boring # . Ground elev, ft. Depth to limiting factor I Remarks: Boring # 'GCr'r`t:;4 II I Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: eon onnnio neinn% -,441we 77C, j9e~-u:z, ys ~ mac' y \ 1 \ ' CFA . ~ C i