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HomeMy WebLinkAbout002-1020-30-000 Q) o0 °o 3 0 n O o o 0 o ~ g c E p a N N 0 G O I -0 O i (n I 7 +r 0 a = N E o 0 O c o CL V U) v o 0 rn a~ 0 o a z z g rn - a I 'O L c r' I c w 3 (0 L _2 w LL U. C C o aci z' c N c U E Q LL o Q - U i C I C co L M V 6i w N w E O Z O d• E O a m O N> d m r H Z O c C7 m O z c c u V O .«(n O O m Z d c m c z r ° o 0 c E c o E N N v M N d O a !v c c Q C O Z H Z Z I- Z 0 O 1 N Z '0 1c I d c c I E o E v m N O LO L LO 4) 0 CL m u; c m CL w° 06 cli - 4) (n ma G O d y °o O D d a c N FIL 3. N LO H H H d) J N E 3 F H FN- 3: 3: 3. m O O O 3 0 0 0 Z o •n.a maaa caaa CL co Z In J V L 0) m ~ co O p'``l = N O > o o N `l O co a '"D fD CO _ E 0 (5 CD C. N -5 W :3 0 211 UJ c a Q 00 Z co d N O O m O O O O co O O N W O O c a m ° co o o Q Q m co o ~ c E E Y E CD a) L o a) LO - L N a 0 Oi (0 ~o Q) }rw~J, N N o c to ci E E m C0 O O (6 N co N E O U • y' O co LL O N N O N =5 Z UJ T ..i rid Y, E a CL d • ca adad' aaw rrww m c _1 A 0a2 0U)0 Oin0 COM.M- R,CIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 -Colfax, Wisconsin 54730 715-962-3121 800 - 962 - 5227 ST. CROIX ZONING REPORT NO.: 06587101 PAGE 1 ST. CROIX COUNTY REPORT DATE: 6/25/90 COURTHOUSE DATE RECEIVEDI 6/21/90 HUDSON, WI 54016 ATTNt THOMAS C. NELSON Q©a - low -3 ~--Ot~ -3-7 E OWNER: Maureen Nobler LOCATION: 245th St. , Ba ldw i nia~/ COLLECTOR: St. Croix Zoning SOURCE OF SAMPLE; COLIFQRMS 55/104 ml INTERPRETATION' Bacteriologically UNSAFE NITRATE-N2 < 1ppm Under 10 ppm is safe for human consumption. Coliform Bacteria/100 ml Nitrate-Nitrogen, mg/L LAB TECHNICIANt Pam Gane WI Approved Lab No. 19 0&A1A0EVENpEM O < Means "LESS THAN" Detectable Level Approved by.' ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 I W`" ll 6 ~ ST. CROIX COUNTY ZONING OFFICE St. Croix County Courthouse 911 4th Street Hudson, WI 54016 Telephone - (715)386-4680 The St. Croix County Zoning Office offers the service of septic and water inspections to Lending Institutions, Realty Firms, and private individuals. Completion of this form is essential so that the property can be located. Please provide the following information, enclose appropriate fee made payable to St. Croix County Zoning Office, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING----------------------------FEE: $ 25.00 X (For nitrates and coliform bacteria) WATER TESTING FEE: $127.00 (For VOC'S) SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00 x (Determines if system is properly functioning at time of inspection) Property owner's name Maureen Hubler Property owner's address 245th St., Baldwin, WI. Legal Description 1/4 of the 1/4 of Section , T N-R Town of Lot Number Subdivision Name FIRE NUMBER LOCK BOX NUMBER Color of house Realty sign by house? If so, list firm: Edina Realty (see reverse side for directions) PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services: Hammond State-Bank Telephone Number 796-2211 REPORT TO BE SENT TO: Hammond State Bank _Box_28, Hammond. WI. 54015 Closing date June 27, 1990 Signature A= Z ( North of Baldwin on Hwy 63 to County Road E East to 245th St. North on 245th St. 3rd house on right-hand sid3 .BALDWIN T.29 N.-R.16 W 3 fir' • + DD nw gym. ~y,..r ° SEE AGE 47 rric Edwa ~d ,y P//1(.E S QUQ/q, c 'rQ'e'> l~ee..c daa ~S/moo/ f 4nl R n s~ s wcrfo L . e s Ran .P f - • s DD S H¢ c/.tl r a.ddrC'. .lea ~ne • T~ant 7s 75 L. ~ .0 74 C'y .Do~al+o/ ``d"" f~./oni ' HS/t~>~k /49 c~ Es°he bac ~ /z.~ moms D U 0 1/anem7e ee~endaa Bt 5 - efux ~,~y, • c 7g 69y Eugene F /ss zo isz • / At y0 R .ai °•A. 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[~C~~7C,~]0G~JD D ~U `1 b June 18, 1990 u, St. Croix County Zoning Office St. Croix County Courthouse 911 4th St. Hudson, WI. 54016 To Whom It May Concern: Enclosed please find a request for water testing and septic system inspection. When you are ready to do this please call Wally Fenstra, the buyer, because he would like to be there when you do this. Thank you. Sincerely, Penni Lyon, Loan Secretary P. S. Wally's phone number is 698-2917 I Box 28, Hammond, Wisconsin / 54015 / Telephone: (715) 796-2211 . , r .!~'~~~'/'cjC-~°'1 ~,,,~~~..~J f`'~''fi~~~ej- ~GtJL,~-f U 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 Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI VANBEEK, JEAN X 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 TANKTO 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 friction System TDH Ft Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION TypeO 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: Baldwin.10.29. 16W, NW, NE, 245th Street 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 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. 54-. Q r0 t • See reverse side for instructions for completing this application State Sanitary Permit Number 0:3-344s- The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I: APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Nay ~ Property Ion V & , _ -t-- &A % /4, S F~ T 2 9 , N, R l6 E (or) 'e Al Property Owner's Mailing Address - Lot Number Block Number a 6 City, Sta Zip Code Phone Number Subdivision Name or CSM Number lot ~ f ^ dt~ S l?O 2 ( ) II. TYPE F BUILDING: (check one) ❑ State Owne ❑ Gila a r. Nearest Road )l" M4 Public 1 or 2 Family Dwelling - No. of bedroo s ~ Town OF III. BUILDING USE: (If building type is public, check all that ap ) Parcel Tax Number(s) Q 1 ❑ Apartment/ Condo Q ®.Z r / ©a a -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_ `wReconnection of 5_ ❑ Repair of an System System Tank Only lfr 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 a Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 1 eepage 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.) (Min./inch) 9 7~ Elevation ~r Q o /`d eD Feet Feet VII. TANK Ca in galloacits Total # of Prefab. Site Fiber- Plastic Exper INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. New Existing strutted Tanks Tanks / Septic Tank or Holding Tank , ❑ ❑ ❑ ❑ ❑ 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' Sign r o Stamps) MP/MPRSW No.: Bu mess Phone Number: III ~ ~kn rf S.S Plumber's Address (Street, City. Sta, Zip Cod4: 07 '7 2 3 C5 T !g -4:r- IX. C UNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Age Si natur (N tam Surcharge fee) Approved ❑ Owner Given Initial v/ Adverse Determination 116 '~71 "D L$ X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 015/94) DISTRIBUTION: original to County. One copy To: Safety & Buildings Di-.ion, Owner, Plumber I. 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: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed- 11 . Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. 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 number ` throuc,` Vll. Tank information. Fill in the capacity of every new/or e(isting tank, list the tot-~ =;allons r mb- of tanks and ,nan„facturer's nam;>, indicate prefab or site constructed and tank rnat -rya' r,)'e' r~ ~li ~Fptic, ;Dump/siphon and }sc_ding tans for this systern. Check experimental approval only if tan's r _r Erin rrn prod _:ct approval from Di HR Vill. Responsibility staternent_ Installing plumber is to fill in name, license number ~A.i ,i appr;.~f, ia~e prefix (e- g. MP, etc.), addr.-,ss a r d phone number. Plumber must sign applica .ion form. IX. Co;.ar w; Department Use Only. X._ Cc>u!Jj l r:ef;artrnent Use Only ficv+tlt:~,5 no! small, t ,t 1/2 X i inches s t my The Mans must ti, (,1i , riri,,;ravv << `,•Ct~'+?CirVrltnCCii~~iE'~€= r .fl air` a( kEs~,septlC P;-~Ip or t,e lCir? 9 ,e ve- 1 i niorm:atiol GROUNDWATER SURCHARGE 19 V` +C.t 1'0 In~loded the +-'ea !.1on Gf surcharges ~ ees) ==r d rl~~il >.~r Y ~ , ai-'i1 vNfllr f1 can effe~i 1 .,_.;C;~ratr 1 th--se c h'); ge, u. E used for moni ~c`` =i <grC t c~v . tr C -aations L~'and,~f Cis r n ~ sZ y~s-- s ,'a n p2~-l o ~ S ~I STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER [JG'tf'1 XeMl MAILING ADDRESS DD ;(/a)/ 63 PROPERTY ADDRESS /,0,?/ a V 477h (location of septic system) Please obtain from the Planning Dept. CITY/STATE 0)"cJ0i lle, WT_ 5 ~14Zg A~ PROPERTY LOCATION 1/49 1/4, Section T N-RW TOWN OF Aq /J"- ? Trtiy15~G? , ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER 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 expiration date. C ~9 f SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ' S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property /lf7/ 0 ~a 12 Location of property ly 1/4l214, Section 149 , T? ~N-R__a _W Township Mailing address Address of site logl Subdivision name Lot no. Other homes on property? Yes_~No Previous owner of property W,44,E' Total size of property QC~.S s 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 _ < Volume 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. a 9 a® T5 , 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. 'gnature of Applicant C - plicant V/ ~6 Date of Signature Date of Signature i iI DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR REDORDIND DATA I, I I Ali EGjS ~ S~F~ STATE BAR OF WISCONSIN FORM 2-1982 rReedforR4,;z.d ~t L CR0, C Walter S ~ MAY ~ 2 1995 a and Sandra D. Fenstra, at •00 A.r _ husbandWandewife K . conveys and warrants to Jeannie-V3nBeek..................... ds " Regl;,erof oat r . . 4._ /D , - FIRSTNATlONAIBANKOF j - RETURN TO 166011th Ave. - BaNwin, m- N - . 1 - - _..-$t. CL'O1X the following described real estate in . County, State of Wisconsin: Tax Parcel No: ~I I The South Four Hundred Sixty-Two (4621) feet of West Six Hundred Sixty (6601) feet of Northeesc Quarter of Northeast Quarter j (NW'k of NEk), of Section Ten (10), Township Twenty-Nine North (T29N), Range Sixteen West (R16W) T it ~I II ,I~ This is Dt homestead property. (is not) Y Exception to warranties: Easements and restrictions of record. 11th May Dated this . day of 1995 (SEAL) IS - ---------..(SEAL) /6~ . Walter W. Fenstra 1 _ - . I ~ (SEAL) .....(SEAL). , Sandra.D. Fenstra._ Fy Ti AUTHENTICATION ACKNOWLEDGMENT . 5y Signature(s) of Sandra D. Fenstra STATE OF WISCONSIN t~ St_.__.CrQjX---------- County. 95 Personally came before me this ................day of ° authenticqqJ thi thday ofMaY. - 19_. 95. the above named ' ~Ialtex..W- Eenstra . Thomas A. McCormack t' TITLE: '.MEMBER STATE BAR OF WISCONSIN (If not- - authorized by § 706.06, Wis. State.) to me known to be the person ..5........ who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Thomas A. McCormack . Y S . . 'k Baldwin, WI 54002 Notary Public St,.-.CroiX.. . County, Wis. L (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration j are not necessary.) date: . . . - 19.........) •t* I •Na,nes of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN W,sronsln Leaal Blank Co.. Inc. s, FORM No. 2 - 17tl2 rd i.aukee. 'N.s~:onsln ,~2TION: BALDWIN 10.29-16.137B NW NE, 245TH ST. Wisco sin 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.: ,,GENE'RAL INFORMATION 17566J1 Permit Holder's Name: ❑ City ❑ Village EXTown of: State Plan ID No.: FENSTRA, WALTER W & SANDRA D BALDWIN CST BM Elev.: Insp. BM Elev.: / BM Description: Parcel Tax No.: I o",~) • 002-1020-30-000 O~D TANK INFORMATION ELEVATION DATA A9200319 9O a TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic - X50^ lA G Benchmark Do' j l Aeration Bldg. Sewer Holding St/A Inlet /0,/ &0 ~ TANK SETBACK INFORMATION St/A Outlet 36 TANKTO P/L WELL BLDG. vent to ROAD Dt 'Net Air Intake Septic > 7 NA p NA Header EMe 3. 9$ 30 . Aeration NA Dist. Pipe G; yv 97.. 7,z' Holding Bot. System -7, Zy PUMP/ SIPHON INFORMATION Final Grade Ma cturer Demand `E~'/~ fe~ (o, 39 Model Number \ GPM TDH Lift Lriss SY m TDH t Forcemain Length Dia. H Dist TO We SOIL ABSORPTION SYSTEM BED/TRENCH width + Len th , No. Of Trenches PIT Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Ma adurer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM INFORMATION Typeo OR UNIT CHAMBER Mo a Num Syste a_rE~~ DISTRIBUTION SYSTEM Header /-M*R4e4d- / Distribution Pipe(s) , x Hole Size x Hole Spacing Vent To Air Intake Length ~ Dia. Length 7 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 1 tvW Trench Center dbsc+i Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discre ncies, persons present, etc.) Plan revision required? ❑ Yes [~'NO Use other side for additional information. o~ SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: DIL R SANITARY PERMIT APPLICATION IZY COUNTY In accord with ILHR 83.05, Wis. Adm. Code STAT S NITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% x 11 inches in size. J.7. f evts n>n re ions application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER O NER PROPERTY OCATION (or W s '/a '/a, S ID T , N, R 16 PROPERTY OWNER'S MAILING DDRESS LOT # BLOCK # 5 2 e, 9-2 CITY STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 1 r 002- I El II. TYPE OF BUILDING: (Check one CITY - NEAREST ROAD ❑ State owned ❑ VILLAGE 'MjIqQWN O'_ ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms - AXNU BE-PARCEL TR Ill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo C JJ ! 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 in line A. Check line B if applicable) A) 1. El New 2.19IReplacement 3. El Replacement of 4. El Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit _ Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 1 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE - REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) q 7- p ELEVATION y~J U ® % ~,3 Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper., INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncre Con- Steel glass Plastic App. ,t Tanks Tanks structed Septic Tank or Holdin Tank e Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps MP/MPRSW No.: Business Phone Number: ,a,,_,,,,1 x'37 !s 3Q ~ j ""'a ~ruce eh f" Plum is Address (Street, City, State, Zip Code): o i _,u~ IX. CO NTY/DEPARTMENT USE ONLY ❑ Disapproved SaRi ary Permit Fee (Includes Groundwater Date Issued issuing gent orgugfure trip Sta U) Approved ❑ Owner Given Initial ~y~Surcharge Fee) oZ7 Adverse Deter ination / //OJ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber -71 INSTRUCTIONS 1. A sanitary,permit is valid for two (2) years. ' • 2. Your sanitarypermit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator of the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system i§ to be installed'II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. 111. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill' in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and contrpls; 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 fDrm; and. F) all sizing,information. GROUNDWATER SURCHAKGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) • 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), thenia second form should be retained and completed when the property` is sold and submitted to this office with the appropriate deed recording. -----------------------------I'-r------------------------------------------ Owner of property Location of p perty&l/4 PE 1/4, Section OIN-R XW Township Baljw, Mailing address byeh6le Vlf'DO V~~ I V, CSC hsl `V.~ Address of site 5ail-11 e_ Subdivision name Lot no. Other homes on property? ves No Previous owner of property Total size of parcel 7.~~ Date parcel was created f Are all corners and lot lines identifiable? Yes No Is this property being develo ed for (spec house)? Yesx No Volume Mand Paga 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 & 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 recordedj~l1 n t~~}} office of the County Register of Deeds as Document No. T D ~r3 , 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 he office of County Register of deeds as Document No ~C04a ignature of applicant Co-applicant APi- -r- DatFe_76f Sig ature Date of Signature J S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County I I OWNER/ Itev. % F o e. a ADDRESS f 7e"(/V FIRE NUMBER CITY/STATE WoC1 I/ i ffQ uv ~ icon O/ ZIP 7 f PROPERTY LOC TION:~ /~1/4 1/4, SECTION, T4ZV N-R[L W TOWN OF 01W , St. Croix County, SUBDIVISION , 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 a 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 Co. Zoning officer within 30 days of the three year expiration date SIGNED: / nn DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY St. Croix 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 PROPERTY OWNER: PROPERTY LOCATION Nr Walter Fenstra GOVT. LOT N"{/4 1/4,S 10 T 29 N,R 16 W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # 285 25th Ave. - - NA CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ❑X rOWN NEAREST ROAD Woodville WI 54028 (715) 698-2917 Baldwin 245th St. [ ] New Construction Use [ ] Residential / Number of bedrooms 3 [ ] Addition to existing building Ix ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .4 bed, gpd/ft2 .5 trench, gpd/ft2 Absorption area required 11?5 bed, ft2 9nn trench, ft2 Maximum design loading rate .4 bed, gpd/ft2__-5--trench, gpd/ft2 Recommended infiltration surface elevation(s) 96.3 ft (as referred to site plan benchmark) Additional design / site considerations use 2 - 51 x 1001 trenches Parent material ti i i /si ltd 1 namy sediment 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 US ❑U QS ❑U as ❑U ElS ❑U ❑S OU ❑S MU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bciundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tn?nch 1 1 0-9 10YR 313 - sl 2 m cr mvfr cs 2 1m .5 .6 2 9-19 10YR 3/4 - sl 1 m sbk mvfr cw if .4 .5 Ground 3 19-43 7.5YR 4/6 - mfs 0 sg ml cw if .7 .8 elev. w/ regular & discontinuous 7.5YR 3/4 sl bands (0 m w/ as b undaries) /2" C 3 & 1" 37 40 99.8 ft & w/ irregular inclusions 5YR 4/4 sl (0 m dense & resistant t enetratio 16-22 one pa it of `it Depth t0 & w/ irregular inclusions 22-27 5YR 4/6 s (0 sg) also 7.5YR 4/6 is beneath & above sl and limiting 4 43-51 7.5YR 5/4 - mcs 0 sg ml cs - .7 .8 factor >104 5 51-56 7.5YR 4/6 - is 0 sg ml cs - .7 .8 Remarks: Boring # 6 51-56 7.5YR 4/6 - is 0 sg ml cs - .7 .8 7 56-59 7.5YR 5/4 - mcs 0 sg ml cs - .7 .8 w/ gr small inclusions 5YR 4/4 sl (0 m Ground 8 59-65 7.5YR 4/4 - sl 0 s ml cs - .4 '•.5 elev. 9 65-70 7.5YR 4/6 - is 0 sg ml cs - .7 .8 ft. 10 70-74 5YR 4/4 - sl 0 in - cs - .3 .4 Depth to limiting 11 74-104 7.5YR 5/4 - mfs 0 sg ml - - .7 .8 factor w/ stratified 111611 10YR 3/4 s bands & w/ 7.5"R 4/4 slbands(O m) 82-84) Remarks: messy horizons! cc: Jansky CST Name:-Please Print Phone: Henry F. Grote 715-665-2681 Address: PO Box 57, Knapp, WI 5474?-0057 Signature: Date: 7/24/92 CST Number: 3065 PROPERTY OWNER Walter Fenstra SOIL DESCRIPTION REPORT Page 2 ,of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer>cfi yr M1.} 1 0-11 7.5YR 3/2 - sl f sbk mvfr cs 2f .5 .6 2 2 11-38 10YR 3/4 - sl 1 c sbk mvfr gs if .4 .5 Ground 3 38-55 10YR 4/4 - is 0 Sg ml gs if .7 .8 elev. w discontinuous 5YR 416 ense si (0 m a boundaries) 42-48 in one par o pi 99.4 ft. & w/ occasional pocket 5YR 4/6 lcs in c de band at about 30 degree dip Depth to 4 55-71 7.5YR 5/4 - mfs 0 sg ml cs - .7 .8 limiting w/ 1 2-1" irregular discontinuous 7. YR 3/4 s bands (0 m s) @ 57 & 1 & w/ rregul r 7.5kR 5/ factor _ place of it @ 54-6 & w/ tea- 7.5 R 5/8 s stratified occasionally i 1/2-1" ayers Remarks: Boring # 71-88 7.5YR 3/4 - cs/gr 0 sg ml - - .7 '.8 this Layer poorly sorted and resistant to penetr tion but not cemented w inclus ons 7. YR 4/4 sl „ Ground 1 0-4 10YR 3/2 - sil 2 f cr mvfr cs 2f/m .5 .6 elev. 2 4-12 10YR 3/2 - Sil 1 f sbk mvfr cs 1m .2 .3 9$,2_ft 0-12 it i ritt / s close to sl t xture 3 12-28 10YR 5/4 - sil 3 m abk mfr cw if .5 .6 Depth to parting to 3 f bk mfr limiting 4 28-33 10YR 4/4 = sl 0 m - cw if .3.4 factor this is abo a 2' wide pocket in one part of pit Remarks: Boring # 5 33-43 7.5YR 4/6 - is/gr 0 sg ml cw - .7 .8 C•h4 M1i\~. 4`? 6 43-59 7.5YR 4/4 - cs/f r 0 sg ml cw - .7 .8 7 59-68 7.5YR 4/6 - f sl 0 Sg ml aw - .4 .5 Ground elev. w/ v rtical root mot 58-71 10YR 5/1 - 5YR 4/6 ft. 10YR 5/1 - 8 68-84 5YR 4/4 f2d 5YR 4/6 S1 0 m - - - .3 .4 Depth to limiting dense i place factor Remarks: Boring # 1 0-32 heavy sl and W Ell-structured sil 4 2 32-67 s (0 sg) alter rating w/ bands massive sl typically 4-6" thick 3 67-100 mostly s w/ occasional thin stratified la ers is similar to B-1 Ground elev. sl banding in this pit is more prono nced and less discontinuous than pits at lower eleva 'ons 106 ft. no mottling o served but banding restrictions lead CS to prefer he lowe site Depth to limiting factor Iee- Remarks: SBD-8330(8.05/92) i T- _ i.._. 0 1 ! 1.. t +4- 32-4 ve Q' I I %A t d I f i I i + t a II I f r O. ~ I i I 1 i 13 ' J o, I _ _ f i ;1i I 1 C I , i t t l I o ~ ~ ; •t s Viol- P14t, eC 10 4A1 ok ~~~~gcer~~~►~- S~IS~ti► S 'd~► we 11 . 9 Arb, Q-el AP6537 I_. _ ~ ~ i a ~ , ~ j ' - .i _ , .i. ~ ~ o ~GG'v O~G~ 9 b' q t0` t Iv Fe.,,, S'h'y ME lr C ,SP /0 r 691dwlm 0 S 172, P Pv l, 5-)6~ 5tt 50 35 VV-* D p r 5 I I l ells 4 ~ase ?d elf ,V . V 1~ _ v---_ _ _ _ - _ _ - _ _ . _ - i_ _ ~ • REPT131 BALDWIN ST. CROIX COUNTY ZONING PAGE 1 09/08/92 13:37 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/ 9/92 AREA: JT Activity: A9200319 9/ 9/92 Type: CONVSEPT Status: PENDING Constr: Address: BALDWIN 10.29.16.137B,NW,NE, 245TH ST. Parcel: 002-1020-30-000 Occ: Use: Description: 1756661 Applicant: FENSTRA, WALTER W & SANDRA D Phone: Owner: FENSTRA, WALTER W & SANDRA D Phone: Contractor: WEBSTER, BRUCE Phone: 594-3080 Inspection Request Information..... Requestor: WEBSTER, BRUCE Phone: Req Time: 11:09 Comments: Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION