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HomeMy WebLinkAbout040-1233-10-000 S ° O °o y 3 0 3 0 b O sv O e» ~n ao c c o L O 0 N -O a3 -O ! C 'O N C Q) a) .00 a) o w o aci N`° c i 0 3 m x m - C= CO Hc E ~ o mm~ 0,- a~ p c w0N ° Y~6 cn \ N C C a Co N ~ CD O C ;y d C ~ cu 4) CD lp CL N N N ~ N 7 C = N N N ~ D (OL N H N 'O a) O or O E O m O -0 V C O LL N 0 C Z C C z a) N U N 7 (CS d 0 7 ca O ,a G .O W LL LL O p C N d O 3 N > O -O O> N -2 to 0 ~a Q Zm a) r 3 LO 3 Ln z z 0) w E E Z i' o v E L ° z u a CO a m M H uwi I' 0 O Z d c_ U O E O a7 Z ~ ~ ~ ~ Z to F E C O E f N a) M N N 7 N p. 7 O) W r- a) N N C CL Q co C 'O O C C O U O Z co z z z 0 Z cc _0 O L L - Q. M «L Y d Y c a) C O G G a -a E O G G d E ~p N E (n U) U N U')_ H H H 7 v i- H F d (n N _*w 0 0 0 x 0 0 0 Z O •►v m a a a a o a a a N N N 7 0 N 2 a~ O 2 rn rn O W J U a) m z a) z in co ca -j -j 00 _ N N A Q) N E 00 T E O O 7 7 7 :3 d co ~ N <I ~ ~4) Q Q z z co fr.~ -ii 0) y w m y p U) cl LO O O Y N C Y N C O U C U wO 7 O O Ln o O N c a) c rn o 3 N E~ N c c 06 Lo 0 (D L) N T w .6 7~~ O ca C t O O O 7 00 N E O 7 000 O N c6 O U • y~„~' O O I 2 ! 2 N O z N -7 Z 2 04 0 Z z ~ c L E r^ ik "y" E N (D V d w a ° a L: a • Q d V a) E C d y C C « !a1 O m Q 3 - p O v~ U A 0 a 2 0 rn U 0 M E M O R A N D U M TO: FILE FROM: MARY JENKINS DATE: OCTOBER 31, 1996 RE: RICK HUTCHINSON Bill Schumaker went ahead and installed this system on October 25, 1996 as no one from the St. Croix County Zoning Office was available to do an inspection. pe "371 4 . AQO STC 104 a AS BUILT SANITARY SYSTEM REPORT q 1,mss OWNER d. _ dAl ADDRESS SUBDIVISION / CSM Gpt`uf'~,7 ~oo LOT SECTION Tad N-RW, Town of- ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 6v / pk 60 (~O~S a? ` 3 lev, INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tan& m,F,►5~i n , ,nv BENCHMARK' g 4& ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: - tee .9 7, N • Liquid Capacity: rCS-D Setback from: Well~_ Q_` House Other t Pump: Manufacturer Model#Size Float seperation Gallons/cycle: Alarm Location ':SOIL ABSORPTION SYSTEM Width: E Length / ~s~ Number of trenches_ / Distance & Direction to nearest prop. line: .~Je~ 7` y0 Setback from: well: House_,ZE, Other ELEVATIONS Building Sewer ,S ST Inlet- e' / ST outlet PC inlet PC bottom Pump Off Header/Manifold 9 , oFF- Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284166 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: HUTCHINSON, RICK L TROY arcel Tax No.: P CST BM Elev.: Insp. BM Elev.: BM Description: 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 ventto WELL BLDG. Air Intake ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header/Man. NA Dist. Pipe Aeration Holding Bot. System EV PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIM EN I LEACHING SETBACK Manufacturer: SYSTEM TO P / L BLDG WELL LAKE / STREAM CHAMBER Model Number: INFORMATION Type of OR UNIT System: 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 De th Over xx Depth Of xx Seeded / Sodded xx Mulched [Bed epth Over p Yes ❑ No /Trench center Bed /Trench Edges Topsoil El Yes ❑ No ❑ COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY.3.28.19W, SE, SW, LOT 21, TOWER ROAD Plan revision required? ❑ Yes ❑ No Use other side for additional information. Date Inspector's Signature Cert. No. SBD-6710 (R 05/91) ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division ~~■~r■r,. SANITARY PERMIT APPLICATION Bureau of Building Water systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. L14-, Cro • See reverse side for instructions for completing this application State Sanita Per it Number The information you provide may be used by other government agency Y Y Y programs Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION Property Owner Name Property Location t 1/467,Cj 1/4, S T g' , N, R E (or Property Owner's Mailing Address Lot Number Block Number /!leach lit y' G v? City, State Zip Code Phone Number Subdivision Name or CSM Number 4 -v > .SAY ( > C 6J,7eat T II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit~ rarest Road S' o age Public 1 or 2 Family Dwelling - No. of bedrooms To ❑ Twn OF tilJCt~' Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Nummmber(s 1 ❑ Apartment/Condo 0Z j- 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. M New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ____System __System Tank Only______________ Existing System Existing System 13)__ ) `K I A Sanitary Permit was previously issued. Permit Number Date Issued g 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.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min./inch) Elevation 7S-® 1 5- ~~7r 5- If Qsr Feet , 3S Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel Plastic p New Existing strutted glass App. Tanks Tanks Septic Tank or Holding Tank So 0 ❑ ❑ ❑ _ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signatur (No Stamps) P/ PRSW No.: Business Phone Number: n 715 21-9 1 Plumber's Address (Street, City, State, Zip Co e): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit F (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps) Surcharge fee) Approved I ❑ Owner Given Initial Adverse Determination to X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to Count y, 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 licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply- IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, 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 isto fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practiceswhich can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. t_.,9Y • - ccN ~ -3 ED- 17/0 y AnT I I k r, J,w p I ~ Il I 0.: Latx:Labu'r Isin Department Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 r and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. ode 10 COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in siz I st include s r~; St. Croix not limited to vertical and horizontal reference point (BM), direction an ope, g~le PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. tft 040-1233-10 wwY, APPLICANT INFORMATION-PLEASE PRINT ALL INFORM N EVIEWED BY DATE PROPERTY OWNER: P OPERTY,LQGATION Dick LaCasse GOVT.1 Oz, 1/4 g1/4,S 3 T28 N,R 19 f*r) W PROPERTY OWNER':S MAILING ADDRESS OT;u FJ3L K'# , SU13D,'NAME OR CSM # 1220 Oakwood Lane ? na. Ctintry Wood First Addn. CITY, STATE ZIP CODE PHONE NUMBER VILLAGE_ WN NEAREST ROAD Houlton, WI. 54082 (715) 549-5693 Tower Rd. [x ] New Construction Use [ Residential / Number of bedrooms 5 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 750 gpd Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Absorption area required 1072 bed, ft2 938 trench, ft2 Maximum design loading rate .7 bed, gpd/ft2 - 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 95.85 ft (as referred to site plan benchmark) Additional design/ site considerations area of B-3 backfilled to code 18x60' bed Parent material ou.twash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem r~I] S ❑ U 11 S ®U Q S ❑ U 791 S ❑ U ZI S ❑ U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trttt#t 1 0-15 10 r4 4 none s fill CS na 2 15-96 7.5 r4/6 none cos os: ml na na .7 .8 Ground 1M ok Depth to limiting factor +96" Remarks: Boring # 1 0-6 10yr2/2 none s 2msbk mfr cs 2f .5s .6 2 2 6-24 10 r4/6 none sil 2m r mfr if .5:: .6 3 24-76 7.5yr4/6 none cos osg ml na na .7 .8 Ground elev. 98.35ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: Gar L. Steel 715-246-6200 Address: 155 200th. Ave v, New Richmond, WI. 54017 m02298 Signature: 2La=~ Date: CST Number: _ 8-30-96 PROPERTY OWNER Dick LaCasse SOIL DESCRIPTION REPORT Page 2 ofd # 040-1233-10 PARCEL IA Depth Dominant Color Mottles Structure Consistence Bour~ry Roots GPD/ft Boring # Horizon Texture in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench '1'..3...-~ 1 0-8 10 r3 3 sl 2m r mfr s 2f .6 2 8-14 10 r4 4 none S1 --2mgr- qw if Ground 3 14-98 7.5 r4 6 none elev. 100.45ft. Depth to limiting factor +98" ILE Remarks: Boring # FF Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Dick LaCasse 1554 200th Ave. CSTM2298 SE4SW4 S3-T28N-R19W New Richmond, WI 54017 MPRSW 3254 town of Troy (715) 246-6200 d lot #21-Country Wood First Addn. NI 1"=40' Hn.= top of walk out footings C el. 100, Alt. area from site evaluation of 10-25-95 31 ~ ~3` 2 Z Z I ZdJo 8~~ 9 -z- 1/0 Ar 0-3 S~ r► m M F 3,5 Gary L. Steel 8-30-96 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 268567 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: HUTCHISON, RICK TROY CST BM Elev.: Insp. BM Elev.: BM Description: [Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600276 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA He der / Man. Aeration NA ~_ist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION. Final Gr de Manufacturer Dema Model Number PM TDH Lift Friction System TDH Ft Loss Head Forcemain Length Dia. Dist. To W II SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREA INFORMATION Type 0 AMBER Mode Number: O NIT System: DISTRIBUTION SYSTEM Header/Manifold Distribution ipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Lengt 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: TROY.3.28.19W, SE, SW, TOWER ROAD 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: Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less county ~Y YI than 8 112 x 11 inches in size. 5-L - • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs a t~p OS~p (Privacy Law, s. 15.04 (1) (m)]. ❑ Check if revision to previous application State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION II Property Owner Name Property Location ` f 114 1/4, S 3 T N, R / E (or~ Property Owner's Mailing Address Lot Number Block Number City, State Zi Cod p e Phone Number Subdivision Name or CSM Number r II. P OF BUILDING: (check one) E] State Owned ❑ tity Nearest Road ❑ Public 1 or 2 Family Dwelling - No. of bedrooms ❑ village Town OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/Condo ©rY~ 12 Y3 _ld 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. 5d New 2. Replacement 3. E] Replacement of 4. E] Reconnection of 5- E] 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 aSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12E] Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy 13E] 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. S stem Elev. 7. Fin l Re uir y a Grade q ed (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) c~ Elevation ;7-5,0 6_72 111,?,6f .7 ~r Feet 1941.1F Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per. New Existin Gallons Tanks Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank X ~~fj0 r n 17i ❑ El ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber El ❑ ❑ ❑ ❑ CI VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature. ( ~qp Stamps) MP/ PRSW No.: Business Phone Number: t . r Plumber's Address (Street, City, State, Zi Code): L 417e, c a77"_ a IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing A ent stiqnature ( Sta ps) Approved ❑ Owner Given Initial 'gll e% surcharge Fee) Adverse Determination ` ~0 ~/20 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: AD-6398 (R. 05/94) DISTRIBUTION: Original to Cnunly, One copy To: Safety 8 Buildings Di-,ion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. 'The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed - II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply- IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII- Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve- pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which carT effect groundwater- The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards- I h r _ I >1Y u J l t i.1 L j 0 Ilk f~ 'wiscensinDepartment ofIndustry, SOIL AND SITE EVALUATION REPORT 9 1 1 of 3 Labor zrd -Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code I4CL! 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 ECEL. 3 dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION ED E:P~ ' i PROPERTY OWNER: PROPERTY LOCATION Richard STout GOVT. LOT SE 1/4 SW 114,S for) W PROPERTY OWNER':S MA!I_ING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 1353 Awatukee Trl. Z V- na i, ' CITY, STATE ZIP CODE PHONE NUMBER TY VILLAGE K TOWN NEAREST ROAD Hudson, Wi. 54016 549-6731 Tro Tower Rd. New Construction Use jx j Residential /Number of bedrooms 3 [ j Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 96.18 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material stream terrace Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for svstem ® S ❑ U ®S ❑ U ® S ❑ U E7 S ❑ U ❑ S E] U ❑ S 12U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bourd3y Roots GPD/ft Boring # Horizon in. Munsell Cu. Sz. Cont Color Gr. Sz. Sh. Bed Trertdl 1 1 0-13 -,-JQvr3/3 none 2msbk mfr aw 2f -9 -6 1 2 13-31 7.5 r4 4 none scl 2msbk mfr if .4 .5 Ground 3 31-84 7.5 r4 6 none s os ml na na .7 .8 elev. 99.38t. Depth to limiting factor +84" Remarks: Boring # » >N;:::>:»> 1 0-8 10 r2 2 none S1 2msbk mfr aw 2f .5 .6 :..,.2.:.,.:. 2 8-21 7.5 r4 4 none is 3 21-82 7.5 r4/6 none s os ml na na .7 .8' Ground elev. 99.18 ft. Depth to limiting factor +82" Remarks: CST Name:-Please Print Phone: Gary L. Steel 715-246-6200 Address: 1554 200th. Ave., New Richmond Wi. 54017 10-25-9 Signature: Date: CST Number: PROPERTY OWNER RCnard Stout SOIL DESCRIPTION REPORT Page 2, of 3' PARCEL I.D. # rind i Mg' -Depth Ddrt~inant Color Mottles Structure GPD/ft Boring # Horizon ( Texture Consistence Bourbary I Roots Bed iTrerx~ in, Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 3' 1 0-12 10 r3 3 none 1 2msbk mfr 2 .5 .6 12-3 7.5 4 n j Ground 30-8 elev. 99.68ft. Depth to limiting factor +88" Remarks: Boring # ;:•a„:;< 1 0-11 10 r4/2 none 1 2msbk mfr 2 .51 .6 42 11-3 7.5 r4 4 none sl 2m r mvfr C1w 1 .5 .6 Ground 3 33-8 7.5 r4 6 none s os ml na n .71 .8 elev. 98.58 ft. Depth to limiting factor +80" Remarks: Boring # 1 0-12 10yr3/3 none 2m-qbk rnfr UK 2~ 5 2 12-2 7.5yr4/4 none scl 2msbk mfr gw 1 .41.5 Ground 3 21-2 7.5 r4/4 none sl 2m r mvfr CFw n .51.6 99!N- ft 4 29-8 7.5 r4 6 none s o Depth to limiting factor +80" Remarks: Boring # Ground elev. ft. I Depth to limiting factor Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Richard stout 1554 200th Ave. CSTM2298 SE4SW4 S3-T28N-R19W New Richmond, WI 54017 MPRSW 3254 town of Troy (715) 246-6200 lot #52-Country Wood N 1"=40' BM.= top of 1" steel pipe @ el. 100. Alt. BM.= nail in Oak tree C El. 104.00' -I r r-t3 q A U 4ikdl Gary L. Steel 10-25-95 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER tc! jS ~G.~.aa~ • MAILING ADDRESS 3 i)v- • PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE; 64&Z~Ei ,,J ZV r' 5-1111 I,' . PROPERTY L_lO._CATION 1/4, 6(&,1/4, Section 3 , T 2, g N-R j 'SOWN OF _ ri :r-!2 , ST. CROIX COUNTY, WI SUBDIVISION C C, , jn, -l U466 d... LOT NUMBER a) CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. - The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expirat' n date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 1 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when i the property is sold and submitted to this office with the i appropriate deed recording. Owner of property el'z C..k L Am 1415v►~ Location of property 5 1/4 Stu _1/4, Section _,T a1? N-R /9 ®w Township-'("",r-moo k Mailing address wQAA"J !9 Address of site Subdivision name v tin►a6 A Lot no. _ Other homes on property? Yes v No Previous owner of property jtj . J- Total size of property 3 Y3 ,AC.-,-.L4 Total size of parcel X28 ~cres" Date parcel was created Are all corners and lot lines identifiable? ✓ Yes No Is this property being developed for (spec house) ? Yes ~_No Volume //F/ and Page Number y3~ as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) . certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document. No. Signature of Applicant Co-Applicant ha1-a nf ,tnn7tii sirinntitrp r ,0000MENT NO i STATE BAR OF WISCONSIN FO~u =-t9a2 II ' j WARRANTY DEED I' _1 l 8j d 1 - REGISTER'S OFFICE I' ,z X5`78 PV- I ST. CROIX CTY., M JUN 3 1996 Richard 0 Stout - - - - 9:15 . _ conveys and warrants to Ricky L..-Hut hison and I Theresa M. Hutchison, husband and Red Deeds HETUaNro ~ croi x --Coun,/. ~t_-- the following described real estate in State of Wisconsin: Tax Parcel No Lot 21, Plat of Country Wood, Town of Troy, St. Croix County, Wisconsin. s TRA S,f,ER FEE ij I This is not homestead property. (is) (is not) Exception to Warr&, ties: Easements, restrictions and rights-of-way of record, if any. I 96 Dated this 2Rth_ dayof___Ma - - -.19 (SEAL) Y- _Sii-gk (SEAL) ~I Richard O. Stout (SEAL) (SEAL) Ij Ii - I AUTHENTICATION ACKNOWLEDGMENT j I ~I Signature(s) _ STATE OF WISCONSIN ss $t _Croix County - - day of Persoraily came before me th.s_ -28th authenticated this day of 19_- may- - . 19-9 -k- - the above named II Richard O. Stout-___ TITLE: MEMBER STATE BAR OF WISCONSIN rson wh e owiedge the saw authorized by § 706.06. Wis. Stars.) tc orey me o krrg„«n t tr-o _rn beetnthe and person t3'ste of ~tr'?S'liR ff~hes f i VAWOM'n A F D B V v THIS iNSTRUtv~F r~T j(V/~S pij~•, COUNTRY WOOD N THE SEI14 OF THE SE114, PART OF (hE SWI14 OF THE SE114, FART OF THE NW114 OF THE SEI14, P~ 114, R4RT OF THE SE114 OF THE SWI14 AND IN PART" OF THE N_ I/4 OF THE SW!/4 ALL IN SECT:JN TROY, ST. CROIX COUNTY, WISCONSIN. PLAT CONTAINS 141-10 AC. (6,146,472 FT) -CR(HX QQULfC '2LAr4{IL$;_rmDuBY61s~E~1i1frs4rrurrB~Blis4i lL*~L! )1ved, that the plat of COUNTRY wow in the Town of Troy, ai C1.ARO O Sr;ur u0 T P DrCUT , owners, is hereby approved by the Rt. ^.roix County Planning m4zK fl0AR1Z34SSd1tTIQd Dev-zlopment Committee. Resolved, that the Plat of CQUhTRY-~# D in the Taw .-,r P ;roar _owners, is hereby approved by the Dorney, Chairman Data --1 j C' G Dean Albert, Town Chairman Date 'as Nelson, Zoning Date I hereb y copy of nistrator y certify that the Troy. is a co the town Bc;ard of [hP Town of Tcoy. •rLoy certify that the foregoing is a copy of a resolut::;n adopted by r St. Croix County Planning and Development Committee, Mirgan_t tnn DesLauriera, Date e' j-- ; , ? . / Town Clerk 9. Nelson, Clerk Date STATE OP WISCONSIN ► I iaLZMASURER-CRR-PS S87'39'55-E 510077 ST. CROIX COONTY l) SS. 12500' I, kobert Browne, being the duly elected, qua phi fffG1STE1s$ OF.°1<,r. rreadurer of the Town of Troy, hereby certify that `fib G recur4a in my office, there are no unpaid taxes o of--- ou any of the land included in t Robert Browne, gate ~i \\C\ cie:e ~j _ _y Town Treasurer 25 3.63 ACRES y• Ra c1 176,060 SO FT ON C , v \v J" 59. 2 i Ct" ~'✓~V Jy °o- F F N / \ 1 / Ntl 3q F~ \ `t 24 ~a 3.61 ACRES 157,092 SO. FT 1 / ~1 / 11 ♦1` ~ ~ / 0 D 71,131, J ' `o/%I J JJV. S. 1Z/ It 1 / ne5=n'gz'w 1 ' OUTLOTI 1 - / N_85'11'42':y 3e 7. 26' \ / 35.00' \ ~/~~\T \~4C'E 5~ h 1, 501, X17!50. FT. ,s. 2.26 ACRES \ 'J ` (.y `.•~i Y~ ',N J h b u 99,560 So. FT g 520 66 1 ~ cq) \ / / / 1I_ 0 22 1 Y Sf'd 2 31 ACRES j 66 \ I` 00, ~ 21. ;mil -C0,696 SO. FT.