Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
040-1233-40-100
Q e CD ° h O 6 c o a) C r. o ° I © Y f c y0 O O U U O O N I I a E C o CL I a n c z ca I U. c o (u a -0 > a ~ x I a v ~ I rn U) ! E ~ o I z 00 M ~ a m c 0 1 c o z d co U d p O 'z CD z c E -o m a) -~V N N O M CL Of " d O O O z co z N z O ` N {0 d O a a c (D I co " N i a) C 0 00 G G a o 75 c\ ~v U N i>n H H F- a~ N 0 0 0 d z z° • *a a a a C,1 a o **N~~' Q g ►i p -0 N m ~ } V1 ~ V 2 rn rn C M N ~ o E I E 3 7 CD ~1 _ i F- '6 d Q ~ ir. R7 Lo U) n cu c r- _ o E O(0 O E a) L) 0 " C B O O i 3 L N O' N N M O E c a) m N N O a) 0 W - N N O N .r o N` >co `r In E ca L • y~,~' O co F- > N O r+ r 4i E r cc w `y} a m L: CL CL 4) 3: 0 a _1 A L) in i~ 0 Parcel 040-1233-40-100 1o/o8i2oo7 10:23 AM PAGE 1 OF 1 Alt. Parcel 03.28.19.1160-10 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - THAO, KAREN M KAREN M THAO 513 TRILLIUM LA HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 513 TRILLIUM LN SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 0.000 Plat: 06-048-COUNTRY WOOD 040-96 SEC 3 T28N R19W NE SW SE SW LOT 24 Block/Condo Bldg: LOT 24 COUNTRY WOOD EXC AS DESC 1731/520 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 03-28N-19W Notes: Parcel History: Date Doc # Vol/Page Type 08/01/2006 831040 WD 10/03/2001 658221 1731/520 WD 07/23/1997 1213/151 WD 07/23/1997 1206/74 LC more... 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 09/06/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 108,000 361,500 469,500 NO Totals for 2007: General Property 0.000 108,000 361,500 469,500 Woodland 0.000 0 0 Totals for 2006: General Property 0.000 108,000 361,500 469,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 x r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 6fjlgLs~ ADDRESS K7 7 WA-,<j 171 t "j6 4-0 / Cr// _tv Z SUBDIVISION / CSM#_ CO c41~_14- W090 LOT # z SECTION _T 2 gN-R W, Town of-* 2 0 y ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVE HING WITHIN 100 FEET OF SYSTEM r~ 00 cSY- R'44 >ao,v INDICATE NORTH ARR W W L_ is Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: C S-f- l 10 D ALTERNATE BM: ~DGlvA~4-,<<0 3i Z SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: W t 6:t fyz Liquid Capacity: I ZS 0 - 25-0 Setback from: Well House b Other Pump: Manufacturer ~ Model# IM!5~O Size r~ Float seperation Gallons/cycle: ZZ 8 Alarm Location 9 6 N SOIL ABSORPTION SYSTEM Width: Length L 7 - Number of trenches Distance & Direction to nearest prop. line: ~s N r Setback from: well: House 7 Other ` ELEVATIONS Building Sewer ST Inlet: ~~Z'ST outlet: PC inlet PC bottom p4b efs Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: Z / PLUMBER ON JOB: f~Ej LGIZ. 1`-' DA-) LICENSE NUMBER: / INSPECTOR: Tl~" 3/93:jt ^°pE Safety and Buildings Division v■■„■■■~ 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 e~ 0 than 8 112 x 11 inches in size. 54- • See reverse side for instructions for completing this application State Sanitary Permit Number Z.8 qZ 2. ~ The information you provide may be used by other government agency programs Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Propert Location Nl f Pt'f-1f~7 51/4 L4_AA, S 3 T Z N, R t~ E (or) 6 Property Own s Mailing Address of Numbe-z- Block Number 33 A0(0 4 -f-a c City, tate Zip Code Phone Number Subdivision Name or CSM Number J t 06A r-A-LLf 4) ( l(t Z2 ( ) Cc u nl -fem. G c~D II. TYPE F BUILDING: (check one) ❑ State Owned C03 ❑ Vi ityge Nearest Road lla rooms wn of 47 0 13. Public r 2 Family Dwelling No. of bed . ~ III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number( s) 1 ❑ Apartment/Condo 0 ( ` ~ / 2 -3 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gal ns Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Req ired (sq. ft.) Prop /o d (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation v v 2 Q~ l Feet 10 ( Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 7~ T"om" ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. M Plumber's Name: (Print) Plumber's ature: (No S Mas) P/INI'WS7frlGo.: Business Phone Number: 106&.5owl 4C~7 Plumber's Address (Street, City, State, Zip Code): orl, IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination 1", JkLjjt,2 X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SHO-6398 (R. 05194) DISTRIBUTION: Original to County. One copy To: Safety a Buildings Divi.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. 1 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 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Safety and Buildings Division ~~■~rin SANITARY PERMIT APPLICATION Bureau of Building Water systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x.1 1 inches in size. S CR n /x • See reverse side for instructions for completing this application State Sanitary Permit Number Z~'Z Z J 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 1--__ Property Owner Name { / P opert Location 4114A/ to JA L-, f 1/4 j"yt fl/4, S `j T Z N, R I E (or)(9 Property Ownr's Mailing Address of Numbe Block Number 3 ~ R(7 b ~ ~ c{ City,tate f, Zip Cdr Phone Number Subdivision Name or CSM Number C, t_t r./ 4- ,t G U II. TYPE BUILDING: (check one) E] State Owned 00 Cit( Nearest Road Public -or 2 Family Dwelling - No. of bedrooms [ -Town of 4 v12 U III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment 1 Condo C✓ _ / yo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1, ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. E3 Repair of an --System ___System______________Ta_nkOnly Existing System _________ExlstingSystem 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: F 1-Gall ns Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Req ired Propo~, jd (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation ~7 J e- ~ r Feet ~d { Feet VII. TANK Capacity in gallons Total # of Prefab: Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p New ExiStin strutted 91ass App. Tanks Tanks l 13 El El EIA., Septic Tank or Holding Tank Lift Pump Tank /Siphon Chamber 7-5-0 .y~U- ~tii~ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber4~5ature: (No S a s) FMP17 o.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ]Date Issued Issuing Agent Signature (No Stamps) 1 Approved ❑ Owner Given Initial Surcharge Fee) 4r Adverse Determination 42 1", 1 A . CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SH0-6398 (R. 05/94) DISTRIBUTION: Original toi County. One copy To: Safety & Ruildings Divowon, 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: 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 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 can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations' and establishment of standards. PUMP CHAMBER CROSS SECTIOW AMD SPECIFICATIOUS PAGE OF r y VEIJT CAP '1"C.I. VEWT PIPE WEATHER PROOF APPROVED LOCKING MANHOLE JUIJCTIOU BOX COVER WITH WARNING LABEL 110 FROM DOOR, I2'MIU. WIWDOW OR FRESH AIR IWTAKE I GRADE I 40 MIW. I B' MI IJ. - COWDtJIT 18"PII~I. ~ \ IWLET PROVIDE I -7 AIRTIGHT SEAL I I v APPROVED JOIAIT A Tank construction shall comply I li) APPROVED JOINTS with approved with ILHR 83.15 and ILHR 83.20 i III pipe extending .I ALARM 3 feet onto e ( 1 solid soil. I I OIJ Both sides of f tank. CLEIC7f? PUMP OFF 0 COLICKETE 9LOCK 3" APPROVE RISER EXIT PERMITTED OWLy IF TANK MAWUFACTUREIt HAS SUCH APPROVAL. 3 00iNG SPEGIFICATICIMS DOSE 61) f i? 5 TA K MAIJUFACTURrrR: IJUM9ER OF DOSES: PER OAy TANK LIZE : Z= GALLONS DOSE VOLUME t _'ZIWCLUC:..G SACKFLOW: .GALLONS ALARM MASIUFACTUKCR: CAPACITIES: A_ WCHES OR _ G.'.LLOAIS MODEL 1JUMBCR: SWITCH TSPE: B = IIJCHES OR G~ LLOWS PUMP MANUFACTURER: C:, -IIJCHES OR GALLOWS MODEL NUMBER: 1211 XD D= INCHES OR GALLOWS SWITCH TYPE: MOTE: PUMP AMD ALARM ARE TO pE GPM INSTALLED OU SEPARATE CIRCUITS MINIMUM DISCHARGE RArE _ VERTICAL DIFFERENCE DETWEEW PUMP'OFF AIJO..DISTRIBUTIOW PIPE..IZLfFEET + MINIMUM NETWORK SUPPLY PRESSURE ` / FEET + ~ FEET OF FORCE MAIN X FXFxFRICTIOU FACTOR..Z FEET TOTAL DtJWAMIC. HEAD = 11.3 FEET DIAMETER INTERIJAL DIMEWSIOW~ OF TAWK: LEWGTH ;WIDTH -;LIQUID DEPTH BOTTOM AREA 231= GAL/INCH AS PER MANUFACTURER = GAL/INCH o Cvf4 ~ S ~ dt 4 ME40 Series MYM 4/10 HP Effluent and Drain Water Pumps Performance Curve MODEL ME40 EFFLUENT PUMP CAPACITY LITERS PER MINUTE 0 50 100 150 200 250 300 350 40 12 35 10 N 30 25 8 ~ H 20 6 J ~ IS J 4 O 10 5 2 OH ]JO 0 10 20 30 40 50 60 70 80 90 100 CAPACITY GALLONS PER MINUTE F. E. Myers, A Pentair Company • 1101 Myers Parkway, Ashland, Ohio 44805-1923 419/289-1144 FAX 419/289-8858 Telex 98-7443 K3328 7/91 Printed In U.S.A. ,Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings D(vision (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284229 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: WALSH, THOMAS TROY Fa-r!el Tax No.: v.: BM Description: M Ele CST BM Elev.: I7spB Q' rtQ 1 ¢1 e TANK INFORMATION EL ATION DATA A960048 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ae. Benchmark Cg , Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht outlet Vent to T19 ~q ANKTO P/L WELL BLDG. Air Intake ROAD Dt Inlet 88. Septic NA Dt Bottom 7,'70 5 Dosing NA Header / Man, 17, P_ ~ Aeration NA Dist. Pipe .9 Holding Bot. System ~?12. 9 PUMP / SIPHON INFORMATION Final Grade .72 ' 0/,y~ Manufacturer Demand 0 1 0~- y Model Number //0 GPM TDH Lift Ip,Al Friction I System TDHtFt ea d 1- ead Forcemain Length /ai Dia. 'I Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Trenches PIT EN I N No. Of Pits Inside Dia. Liquid Depth DIMENSIONS D LEACHING SETBACK Manufacturer: SYSTEM TO P / L BLDG WELL LAKE/STREAM CHAMBER Model Number: INFORMATION Type0 /YtRUJ 3 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 Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Yes E3 No ❑ Yes ❑ No Bed /Trench Center Bed /Trench Edges Topsoil ❑ COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY-3.28.19W, SE, SW, TRILLIUM LANE Owl % i-E Plan revision required? ❑ Yes ❑ No / 9 G Use other side for additional information. Date a4so or' ignature Cert. No. SBD-6710 (R 05/91) ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: , Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau Building Water System! ri•~L.~~1 r 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 e G O / x than 8 1/2 x 11 inches in size. • 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 ❑ Check irievision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan LD. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Ow er Name Property Loc tion M S w e- $ s~r/4 5 ii4, S 3 T Z , N, R 1 E (or Property Ow er's Mailing Address Lot Numbed Block Number 1 33 (J i./ rc f c L City, St to Zip code Phone Number Subdivision Name or CSM Number t CJa~JL A s o Z zr c C o u A•-Fdt ct c~ II. TYPE F BUILDING: (check one) ❑ State Owned ❑ Cit~ Nearest Road E] VII age ~0 Public 25-4 or 2 Family Dwelling - No. of bedrooms Town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) O ~O - 2 - ~o 1 ❑ Apartment/ 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 box on line A. Check box on line B, if applicable) A) 1. c7i New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an 'System System Tank Only Existing System _-Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Vq 4eepage 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 Re uired (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) p Elevation Feet © Feet VII. TANK Capacity in gallonTotal # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New Existing Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank 2lC [a E] Lift Pump Tank /Siphon Chamber [I ❑ ❑ ❑ n VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's ame: (Print) Plumber's Si ature: (No St m s) MP/MtkPROW'No.: Business Phone Number: 005&71_ VEL$o~ Z 73 KX~ Plumber's Addre treet, City, State, Zip Code): C L$ w e-M-f 4 &t _j ~ O IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved San tary Permi Fe,4, (Includes Groundwater ate ssue Issuing Age Signa ure (No Sta jApproved a, harge Fee) Owner Given Initial !JJ► ~ ,3 Adverse Determination f~ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 0584) DISTRIBUTION: Original to Counl V. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS F r 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- 11 . Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one 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 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with, complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. San. Permit No. Owner's nature H63.05 PLOT PLAN Show: r7n Location of building served 0 Dosing chamber lam' Septic tank Vertical/horizontal reference point I~1 System elevation is C/(~57- Building sewer Effluent system Q Well Replacement system area IM- Property lines w/in 50' df system Q Distribution boxes Scale = = ~0 , orA&Merral"MM Pump and controls: Mfr. & Model No. Vertical Lift Size Force Main Friction Loss T. D. H. Vol. Dist. Pipe Gal-per Min.. Gal. per Cycle Place check mark in appropriate box, indicating item is shown on plot plan below: b~ fR 41 Pr^ V O LL Csf BM /n,o ~b By the granting or approving of the above plan, or upon the event of a subsequent permit being issued, Pierce County and the Pierce County Zoning Administrator, does not assume or hold itself liable for any defects in plans or specifications, plan 0- omission, examination oversight, construction, or any damage that may result in or after stallati I P s s a ure i nse o. e Rev. 3/E PAG 4401v\ S 4 E OF CrvSS Sec~Ion (S A Sys~e~-1 Fresh Air Inlets And Observation Pipe -Approved Vent Cop Minimum 12" Above Final Grade 4" Cost Iron 20- 42" Above Pipe -Vent Pipe To Float Grade Marsh May Or Synthetic Covering win. 2" Aggregate i Over Pipe Distribution - Tits pipe o 0 0 6' Agg tgats o Perforated Pipe Below ! Beneath Plpe Coupling Terminating At Bottom Of System Pru o1ei~ ~Iflk' qr~,~l< ~ SOIL FILL DISTRIBUTIOU PIPE gPPROVEO S4WTMETIC COVER OR 9" OF STRAW R MARSH HA`j of A6GR EGA'iE C~ °v to OF 12-ZI/2 AGGREGATE ELEV. OF FEET DI•STRIg',]T10M PIPE TO BE AT LEAST 1►JGNES BELOW ORIGINAL GRADE: AQU AT LEASTZO IUCHES 617 1.10 MORE TRAM L42 ILIC4,S BELOW FINAL GRADE F- WILL BE 3 g INCHES 110U1XIMUM DEQTH OF FXEavAT10!`9 FROM 0RI&V AL 6KA0 3- ~ INCHES rjg1MUM ®Ef T-H of FACAVATIOW fRoM ORQ41WAL GRADE WILL. BE SIGUEO: LICEAISE DUMBER: / DATE:- of 3 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Labor and Hvman Relations 411. Division ~nf Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code RECEIVE ~ St. Croix Attach complete site plan on paper not less than 8 1 /2 x 11 inches in size. Plan must include, but ELI fj not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or ing dimensioned, north arrow, and location and distance to nearest road. ED BYOpyKTy APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION `DOwNSOl~fOE PROPERTY LOCATION FROPER OWNER: GOVT. LOT SE: 1/4 SW 1l4,S 3 ~ 1 ~ (or) W ichard STout LOT # BLOCK # SUBD. NAME OR CSM # Y OWNERS MAKING ADDRESS 1353 Awatukee Trl. na ; Countr*. L4~ood OAD TE ZIP CODE PHONE NUMBER OCITY ~VILLAGET~1fOWN NToRwerRROAD d Hudson Wi. 54016 (715 549-6731 3 (]Addition to existing building New Construction Use (x ] Residential I Number of bedrooms j ] Replacement Public or commercial describe 450 Recommended design loading rate • 5 bed, gpdm2 •6 trench, gpdm2 Code derived daily flow 9Pd 5 bed m2 • 6 trench, gpolft2 Absorption area required 900 bed, ft2 750 trench, ft2 Maximum design loading rate . , gpd Recommended infiltration surface elevation(s) 96.60 It (as referred to site plan benchmark) Additional design / site considerations na stream terrace Flood plain elevation, if applicable na ft Parent material LS = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT- S DEE U I SQYST IN FILL H❑OLS NG TANK U= Unsuitable fors stem i® S El U LAS M U ['5S 0 U 13 S [3 U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence IBounda Roots Boring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. P.. q..66 1 1 0-12 10 r3 3 none 1 2msbk mfr M2f*5 •»"L 2 12-29 10yr4/4 none sicl lfsbk mfr gw Ground 3 29-54 7.5yr4/6 n one sl lcsbk mfr gw elev. s osg mvfr na 101.Qt. 4 54-84 7.5 r4/6 none Depth to limiting factor +84 Remarks: Boring # 1 2msbk mfr gw 2f . 5 6 1 0-10 10yr3/3 none <f 2 sicl lfsbk mfr gw if ..5 .6 Ground 2 10-19 10yr4/4 none mum 3 19-29 7.5 r4 4 none sl lmsbk mvfr na .41 .5 ml 9W na . 5 .6_ elev. 4 29-72 7.5yr4/6 none lfs osg 101.2 ft. na na np np none sicl m na 5 72-84 10 r5/4 Depth to limiting faC4„ Remarks: Phone' 715-246-6200 y L. Steel FAddress: e _Please Print Gar 1554 200th Ave. New Riclimond. 10-24-95 CST Number: n• PROPERTY OWNER~ = R;4- nrd Stott SOIL DESCRIPTION REPORT PARC#L I.D. I pending Page of 3 Y 1 Boring # Honzon Depth I Dominant Color Mottles Structure in., Munsell Qu. Sz. Cunt Color I Texture Consistence Bound~ I Roots GPD/ft Gr. Sz. Sh. Bed iTrerxh A3 l 0-10 }Oy 3/3 none 1 2msbk mfr gw 2f .5 .6 2* 10z21 ],.Gyr4/4 none sicl lfsbk mfr 9w if .3 Ground 3 21-34 ' 7.5yr4/6 none is lmsbk m elev. vf r gw na .5 j.6 100.3ft. 4 34-80 7.5 r4 6 none s osg ml na na .7 :.8 Depth to limiting factor +80" Remarks: Boring # 1 0-11 ].0 r3/3 none 4 1 2msbk mfr 9w 2f .5 .6 2 11-31 10yr4/4 none sicl lmsbk mfr gw if .2".3 Ground 3 31-60 10yr5/4 none Ifs osg mvfr gw na .5 .6 100.1 4 60-80 7.5yr4/6 none ft s osg ml na na .7' .8 Depth to limiting x+80" Remarks: Boring # 1 0-9 10 r3/3 none 1 2msbk mfr 5 gw 2f .5; .6 2 9-24 10yr4/4 none sicl lmsbk mfr gw if .2:: .3 Ground 3 24-53 7.5yr4/6 none sl lmsbk mvfr 9'W na .5 .6 elev. 4 53-80 10yr5/4 none 99.6 ft. S osg ml na na .7 .8 Depth to limiting factor +80" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) P9 STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Richard Stout New Richmond, WI 54017 MPRSW 3254 4SW4 s3-T28N-R19W (715) 246-6200 town of Troy lot #49-Country Wood N 1"=40' BM.= top of 1" steel pipe @ el. 100' Alt. Bm.= top of steel fence post @ el. 103.4' ZZ-' 20 ~ 3zi 75 r j A~ ' i SGr L°i~ r-YL, Gary L. Steel 10-24-95 z-`T K:_su.vo-O, rflFL LIie_ p1.e(- c: in L`7e T.vn Of Tr Jy. •.c-.o o s,,,r -0 AMET • VCuT owners, is hereby approved by the qt. "roix County P1.ulAling &nd Dev"lopment Come ttee. Resolved, that th. • i+ L~ - AhEr • STOUT'. a A Tao Docney-~i coon . . • . b ` ^ Date 7 c; G Dean Albert. Tosco Thomas Nelson. Zoning Date I hereby certify Adm►nistratir the TOwn 8c3rd of 5 i hertcy certify that the foregoing is a copy of a resolution adopted by _ the St. Croix County Planning and Development Committee. Margaret !M DceL _ Town Clerk '2 ~7 `Sue B. .Nelson, Clerk Date ~ STATIC OF MISCONSI! 510077 ST. CROIX COCIR Y SB7'~B'35'f 125 00 C, Robert Browne REGST°1e'S GfKiC_, • Treasurer u[ the records in my off ,yo \v~ - 3. P a Robert Browne. Town Treasurer t 1 / 3 65 ACRti y RL•n1N t! . 'I y r'1 ~57,BB0 SO FT a • V 0 12E A5 3 . 36 6 • J w H61 3 61 ACRES I / 157.092 s0 TT I' - 6e7•11•.2'W 422 26 35.00. N85•ll'42'yy 3e s. z6' - EY IvA / 23 2.26 y `h w ACRES 90.560 e4 \ ` g slo ~•tV~\ / 1f' y6d 2 31 ACRES 66 ~ P OWNERS 1 100.696 SO.fT Inl R tNUlo o. STOUT s JANET P STOUT V -353 A*ATU-EE TRAIL M,IOSON, WI 54016 Z 8 Sea* 30'54-W 5 69.94' W / S1R~i r 21 F ~ 3.43 ACRES 19 / 39 ACRES g 149.446 SO FT / Isr. 545 SO. FT O / V U ST! 30' ly O •U IL7 N69'21'25'C u• 27. LEGEND r vwSION TRIANGLE i LEGS ON vISON TRI ARE I 'W' LANG AL(A4 THE ROAD R/W 6EGINNING AT THE R/W - R/W CORNER t y STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ThNtn Ma c, Lk')*- Ls h , Cof h ie -j Scof k MAILING ADDRESS 10:2 N S 4- ~1 Lo L 02 PROPERTY ADDRESS l 0-' ay coctz r u aad To'Q Y1 o -r (location of septic system) Ple a obtain from the Planning Dept. C13 fVt/cw uM e-4-VE CITY/STATE ~JL& -_,0A 5~~ ~►,r', fit. E/ . c M ; t a~ .VW P4.r-&0-f- t44 NE% PROPERTY LOCATION 1/4, Wf 1%4; Section , T ZQLN-REW TOWN OF -r0 ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER T 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 an etumed to the St. Croix County Zoning Officer within 30 da of the three year ex ' tiM date. SIGNED: It J DATE: vZ I f St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 • 8 T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. r Owner of propertyTileg ct5 "y "A L- S~~~y CO CilY Location of ProPertY5g-7 _1/4-5(,-) 1/4, Section 112) T Z, A N-R f 9 W . Township f0 Mailing address rAA L 541v 2a Address of site Lot aj a &L% uaaod i F4+esen W1_ cyorb ~f3 +A/tc Subdivision name o Oo Of Lot no. 244 other homes on property? Yes__X_No Previous owner of property Ri Chan-d S E- Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes _)e__No Volume JAI 3 and Page Number 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. Sand 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. r Signature of Ap licant C -Applicant l~ 1l q~ G Date of Signature Date of Signature VOL 1:213PAU151 a~S3 ( STATE BAR OF.WISCONSIN FORM 1 - 1982 WARRANTY DEED I:. DOCUMENT NO. - REGISTER'S This Deed, made between R i (-h a rd n gt.out ST. CROIX CO., Vil ifedd for Record DEC 12 1996 ~ Grantor, and Thnmas .7_ wal soh and Si n 3TR Scott at 10:00 A. M Husband and wife Register of Deed' A Grantee, Witnesseth, That the said Grantor, for a valuable consideration i conveys to Grantee the following described real estate in St _ Crni x THIS SPACE RESERVED FOR RECORDING DATA County State of Wisconsin: NAME AND RETURN ADDRESS /o N Lot 24, Plat of Country Wood, Town of Troy, ICJ ~ f_ LS St. Croix County, Wisconsin. c This deed is given in full and final satis- faction of that land contract between ~&g1W0!S Richard O. Stout and Thomas J. Walsh and Sidney B. Scott dated October 25 , 1996, and recorded October 29 , 19 9 6 , in the St. PARCEL IDENTIFICATION NUMBER Croix County Register of Deeds' office in Vol.120j page 74 as Document No. 551431 FEE I! ~I EMS I' i ' I _ i Tl.:.. 4 nsm Department of Industry, pRIVAAE SYST ounty: labor and I;tuMciteyations ST . CROIX Safety and Buildings Division INSPECTION REPORT~r,rti; (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284229 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: WA49H, THOMAS TROY CST BM E ev.: Insp. BM E ev.: BM Description: Parce Tax No.: 3:~0 TANK INFORMATION ELEVATION DATA A9 6 Q) 413 2 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic a SU Benchmark Dosing 'JSo k 2.3 Bldg. Sewer aZ lo~ 3 5 Aeration Holding St Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Verit ir lIto ntake ROAD Dt Inlet 3.z1 o~ c TANK TO P / L WELL BLDG. A Air Septic NA Dt Bottom rJQ Dosing NA Header / Man. ' Aeration NA Dist. Pipe Holding Bot. System , l~ PUMP/ SIPHON INFORMATION Final Grade -9, 79 p 11 q Manufacturer Demand S A-V b Model Number (OGPM TDH Lift 10j Friction I System TDHFt Loss Forcemain Length ~aJ Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width 7 Length / No. Of TT enches PIT No. Of Pits inside Dia. Liquid Depth DIMENSIONS / DIMENSIONS LEACHING Manu adurer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O w-t d CHAMBER Moe 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: TROY.3.28.19W, SE, SW, TRILL M LANE pl, 7 ,t.( lrL Plan revision required? jr-Y-es ❑ No n Use other side for additional information. 9 SBD-6710 (R 05/91) Date Inspector's Signature Cert No.