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AS RUITT .S~iiiii:R'• :i'! f;hf &1;PC:?'r
i4vNE,R~C3U 4 4 ~~S t'1 e„
ADDRWs
lit,
SUBDIVISION / CSM$
SECTION 2 0 T ~2q N- G LOT
- R ~ W, Town of
ST. CROIX COUNTY, WISCONSIN
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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BENCHMARK: N a e S d P d t e ALTERNATE BM:
f P':',:: TI►:t::. / Pa i'i'r' l:Ki.t'iIIF:,& / l;:IuuIIt(4 `1`" r, L1IF!:F.lfA'.Z::~u
Mciftil..`aCitl1er .-C7 G~~ 'e Cc'ek: Liquid Capacity: 1600
Setback from: Well 1/0 House S ( Other
Pump: Manufacturer t~~l Crc' Model# 7 Size
Float separation Gallons/cycle:
Alarm Location
L J'
Width: J Length SSG Number of t_z_:-,ches~
::u nearest prop. line: 3 00 r
Setback frc m we-, 1 Douse Other
ELEVATIONS
Building Sewer ST Inlet. RU )~Y ST outlet
PC, inlet PC bottotr_ Of:
header/Manifold 6 Bottom of system
g_r de_
DATE OF INSTALLATION
~ - - -v
PI Jt' fE3 Ot J )B:
L F SE N 1MB. 12:
I t;Pl c:TOF
'93: jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labo n.d Human Relations INSPECTION REPORT ST. CROIX
Safety rd Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
PeI.[n,lt Vffs Nj%UGLAS ❑ City ❑ Village a Town of: State Plan o.:
CST BM Elev.: UU Insp. BM Elev.: BM Description: t~ Parcel Tax No.:
66 /6 1 A95003'18
TANK INFORMATION ELEVATION DATA S-
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Z
Sim ~C'CG-S/ DD O. Benchmark S, v7/
Dosing orvi~JihC~e ~o_'v ~,rt(. .35~
Aera o Bldg. Sewer
Holding St/~,A Inlet
TANi SETBACK INFORMATION StOutlet
TANKTO P/L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic NA Dt Bottomy/G~ O,~~
Dosing NA H-/ Man. Z !
Aeratio NA Dist. Pipe
Holding Bot. System
P FORMATION Final Grade
Manufacturer a r- Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Tr nches PIT No. Of Pits Inside Dia. pth
DIMENSIONS DIMENSIONS
SETBACK LAKE / STREA CLiJ_ Ma acturer:
SYSTEM TO P / L BLDG WELL
, Model Number.
INFORMATION Type Of kie'121 CHAMBE
System: ewd OR UW
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Aid-
! j !r
Length Dia Length Dia. Spacing /
~1'
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of 7 xx Seeded /Sodded xx Mulched
Bed /Tq*Wh Center Bed /Jt9om-h Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) .{r 1c' , 1,e/_s 1*
LOCATION: Baldwin.20.29 16W, NE, NW, 90th Avenue
Id 97
Q~
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signat re Cert No.
fwe~~i an aw
SANITARY PERMIT APPLICATION BureaSafetyu o oand ff BuiluildiinWater Systems
gWater 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 Coun
than 8 112 x 11 inches in size. cr,
• See reverse side for instructions for completing this application State Sanitar ermi Number
All-7
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 %5-umlrl
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Pro rty Owner Name / Property Location
d /r~ V7 t l' e, N 1/4 1/4, S 2 O T ~ ~ . N, R /(o 'L(or) W
Propeer y 0 ner's Mailing A 1!qress 14 U, / Lot Number Block Number
CitState Zip Code Phone Number Subdivision Name or CSM Number
P1 W , 'S -L
II. TYPE F BUILDING: (check one) ❑ State Owned E] Cityy NearestR d
Public or 2 Family Dwelling - No. of bedrooms N Towan of N 4 (~w~~t1 q~ /r~~
911. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo U O Z - / Z U - a
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. [g Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank OnlyExisting 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 rA 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
ReSLuired (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min./inch) 1 Elevation
3bU 1_0 2 S~G d / 01, 5 Feet /0-3 Feet
VII. TANK Ca
in galloacitns Total # of site ber- INFORMATION Gallons Tanks Manufacturer's Name Conc ete Con- Steel g ass plastic App-
New Existin strutted
Tank Tanks
Septic Tank or Holding Tank GG /1?t iNCS tt/' ❑ ❑ ❑ ❑ ❑
lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility r installa ' n of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plum r'sSignatu Stamps) *"17 IPRSWNo.: Business Phone Number:
Plumber's Address (Street, City, te, Zip Code K/
5-66 t el (rs w /DW w d (./I k-4 S 5--4 G 7-
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa tary Permit Fee (Includes Groundwater Date Issue Issuing Ag t Sig ture (N to s)
pproved I ❑OwnerGivenInitial ~a~~%d Surcharge fee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to Couniy, one cupy To: Safety & Buildings Divi ion, Owner, Plumber
L
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 systern, 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 re;olacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers ' through 7
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, njmber of tanks and
manufacturer's name, indicate prefab or site constructed and tank materia'. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experiment product approval from
DILHR.
Vlll. Responsibility statement. Installing plumber is to fill in name, license number wi .h appn>;,) is e prefix (e.g. MP, etc.),
address and phone number. Plumber must sign applica Jon form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
J )C! SF Cif:CiltiC:r!S not. SmaltEl' f a^ ? 1/'2 X f", }lE ; USt S:.' c nty 'he plc,'ns must
~o' 1-1ri, ii,o V _ c(ale c- wi t I JInf' lank(s', set]tfi
1, b_ diilG :E lf, p'
,I o if r Id' n, -veN
is
GROUNDWATER SURCHARGE
983 A...1 lf'idudeCdl the _'eauon of sLIrchargeS (fees 1,or a Can
effect
rr_ca tnr._ Aq h uit~se_urcliargesare.used forrnomioringgru! :Ii: nve,tigatiora
and establishme. ,t of standards.
SAFETY & BUILDINGS DIVISION
State of onsin
Department of Indu 4I a; 6f: Human Relations
October 4, 1995 Rose Street
s T 1 Crosse WI 54603
f q
WEGERER SOIL TESTING
421 N MAIN STREET 19 ij
PO BOX 74
RIVER FALLS WI 54022
RE: PLAN 595-41291. FEE RFCFIVFD: 360.00
OFSTIF, DOUGLAS
NE,NW,20,29,16W
TOWN OF BALDWIN COUNTY OF ST CR.OIX
MOUND SYSTEM
The Department has reviewed the above-referenced submittal.
Conditional approval is hereby granted for the system plan submittal. All
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not been reviewed for the code
requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to the plan number shown above.
Sincerely,
&.ratr. Swim
Plan Reviewer
Section of Private Sewage
(608) 785-9348
2738R/ 1
SUDA-7997(8.10/94)
G `
291995 V Page of 6
SPF~G MOUND SYSTEM S95-41291
FOR
A Z BEDROOM RESIDENCE
LOCATED IN THE NF 1/4 OF THE WUJ 114 OF SECTION ZO , T2q N, R l6 w,
TOWN OF '~s INL,b LW I" ST. C.t2.U1)( COUNTY, WISCONSIN.
INDEX
PAGE l 'of 6 TITLE SHEET
PAGE 2 of 6 PLOT PLAN
.PAGE 3 of 6 PLAN VIEW-CROSS SECTION
PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT
PAGE 5 of 6 PUMPING CHAMBER '
PAGE 6 of 6 PUMP PERFORMANCE CURVE
PREPARED FOR
---QOUGLR S _ 0F-S r) c-
7--Z-3 1 9O `rH sue
8f'v\-bkJ1R1j kil Sal UZ
PREPARED BY WECEE~EFt ~3Q I L TEST I NG
AND . b API-H"q L
i9 • EA.LSYl~?IiTH,
el YIIS.
F.O. B01 74 421 K. KAIK ST. a
RIVED FALLS. BI 54022 •N•H••N•••• Q
71S'4L.,-016J ~~Oe~: S I G N ~ 1~~•~
inNM
S_ Z 8 G
JOB NO. C l
PLOT PLAN Page 'Z-of
Scale 1 30 '
St-,
91
4 1[
0-1~) M1 TO c;-j
Z -W T'" 1. 4. f.AFf
two= tr15.~ +
l'~S Q ~2 CVO - CTX IST ~ G L
Z I S y
-tzq I eC1
PV
~-5 0
` F 1 ti S U LftTjF hj Z
P,Z.UST ~?~a'f~t.~U~J ,U~~ •.r
of~ 7,
tilt
` S~oPE puts- / ~ ~ 6
\ 4~ $ Y Trudre ezev. too, p' aU SP t` I "WJ k (SeauxA*) - a. Z
NOTES:
1. Elevations shown are existing ground elevations unless otherwise noted.
2. Install permanent markers at end of each lateral. ( 2 required)
3. Install 4" observation pipes with approved caps. ( 2 required)
4. Septic tank to be 1botaAS0 gallon capacity manufactured by
5. Bench Mark
6. Divert surface water around mound to prevent ponding at the uphill side.
Page 3 Of S 41.
Approved Synthetic Covering
Distribution Pipe
~sTM c 33
Medium Sand _ -aG
Topsoil F Elev. l7 \ cj
3 E „
,
„
' b
Z % Slope
Force Main Plowed
Trench of %2"-2 2" From Pump Layer
Aggregate
Undisturbed D \ . l7 Ft.
Soil E 1 • 1 Ft.
Cross Section Of A Mound System Using F o•S Ft.
I Trench For The Absorption Area G N • n Ft.
A S Ft. H )-S Ft.
6 SO Ft.
I 1 S Ft.
Linear Loading Rate= ~-'%PD/LN FT J 8 Ft.
Design Loading Rate= 0.3 GPD/SQ FT
K lU Ft.
L 7Q Ft.
W ZS Ft.
L
Force
B ~K Main
A - - - - - _ - - _ - - -`RTR 3 P~
uC~1~ll S tTZ:.
W Distribution Trench Of 2 - 24~ gip' C -
Pipe Aggregate ,N~
a
Observation PMa khgen
Pipes
(Anchor securely)
C!
G~
Mound Using I Trench For Absorpti r a
r
Page Of
Perforated Pipe Defott
0
End Vie-
End End Cap] PVC Pipe permanent-marker
at end of each lateral
Holes Laca~~ On Bottom,
,t
drle Lpually Spaced
Q End Cap t O.gyp
i~~
Wm 4 •t
d go
it
* PVC Force Main
GO
Distribution'
Pipe
Lost Hole Should Be
Next To End Cop
Distribution Pipe Layout P Ft.
X 3D Inches
Y Inches
Hole Diameter "V Inch
Lateral I y Inch(es)
Manifold Inches
Force Main Z Inches
# of Moles/pipe 10
Invert Elevation of Laterals IOZ:OFt_
Y- Z_ Z3.4 GpM
~I
Place lst hole 1 S from tee with succeeding holes at 30 intervals.
"
Last hole to be next to the end cap.
Combination Septic;Tank and
PUMP CHAMBER CROSS SECTIOU ARID SPECIFICATIOMS ' PAGE S OF 6
. -4 -VEA1T CAP WEATHER PROOF
• • S e~ 1t JUIJCTIOIJ 90X
'i'C.I. VENT PIPC APPROVED LOCKING
'_.10' FROM DOOR, MAWHOLE COVER tJIV
imoow OR FRESH wRR N1UG LA48EL.
ALR INTAKE S corJDul r
'i~ MIIJ.
tel. a b A 46J. tn I
PROVIDE I
IA1LE T AIRTIGHT 'SEAL I I I
_ ~ I III v
34F~~~S A I I I APPROVED JOI)JT:
APPROVED JOIWT. I I I W/C.I. PIPE4pt'
w/C.Z. P►PE tank co%struction I III ALARM
sbail, Tmply with I II
3.15 33.20 ° I I
C
I
CLEY. FT PUMPS
OFF
J
C OLIC BETE
~L 8 S. dl0 9LOCK
3" APPROr
-X- R15ER EXIT PERMITTED 01JLU IF TANK MANUFACTURER HAS SUCH APPROVAL. %E00IN4
SPEGIFICATIOAIS
SEPTIC f
DOSE 1~'l~l~W HS`ilZl`l 1ST 2. 61
TALIK MANUFACTURER: IJUMBER OF DOSES: PER D"
TAIJK 51ZE: /650 GALLOWS, DOSE VOLUME Z
S S SyS`fY'I S INCLUDING BACKFLOW: l s 3 GALLONS
ALARM MANUFACTURER:
MODEL WUMBER: yt1~N !~W CAPACITIES: A= ~S wCHC5OF, z-SS GALLONS
SWITCH TYPE: Y-)E2CUyr_Lf B= IWCHWOR 4LLOU5
PUMP !~'%ANUFACTURER: Zy ~Z(-LlZ C = IUCHES OR S 3 GAt.LOfJS
MODEL WUM9ER: 98 D= 1 _L 114CHES OR Z.0 GALLONS
SWITCH TYPE: 'If1L`RCJr1t~'~i MOTE: PUMP AMD ALARM ARE TO BE
MIWIMUM DISCHARGE RATE_Z-,~"q_GPM INSTALLED OW 5EPARATE CIRCUITS
VERTICAL DIFFEREAICE DETWEEIJ PUMP OFF AUD..0I5TRIBUTION PIPE.. V3-00 FEET
f M11J1MUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . 2.50 FLET
+ s FEET OF FORCE MAIN Y, 1'1S FYo►rFKICTIOLI FACTOR__ 1.10 FEET
TOTAL 09UAMIL HEAD = 1 b __Up FEET
Pump chamber DIAMETER _ 3a
IMTERIJAL. DIMEW5MW~ OF TAUK: L.EM&TH ;WIDTH ;LIQUID DEPTH
BOTTOM AREA - 231= - GAL/INCH
AS PER MANUFACTURER - 1,•v_. GAL/INCH
~ b HEAD CAPACITY CURVE 3 7/9 6 1/4 F 4 OF
MODEL "98" _
30
'w I
8-
25 6
3 5/8
6 20 rD
Zo O
} 15 4 3/16
o
J 4
0 10-
~ 1/2-11 1/2 NPT
1
2--
5 S95-41291
0
U.S. GALLONS 10 20 30 40 50 60 70 80
LJTERS 80 160 240
0 FLOW PER MINUTE
TOTAL DYNAMIC HEAD/FLOW PER MINUTE
EFFLUENT AND DEWATERING
i
CAPACITY 12
HEAD UNITS/MIN
FEET METERS GALS LTRS
5 1.52 72 273
10 3.05 tit 231
31
is as7 a5 170 1JJ
20 6.10 25 95 3 5/16
Lock Valve 23'
CONSULT FACTORY FOR SPECIAL APPLICATIONS
• Electrical alternators, for duplex systems, are available and • Mercury float switches are available for controlling single and
supplied with an alarm. three phase systems.
• Mechanical alternators, for duplex systems, are available with or • Double piggyback mercury float switches are available for
without alarm switches. variable level long cycle controls.
SELECTION GUIDE
1. Integral float operated 2 pole mechanical switch, no external control required.
Standard all models - Weight 39 lbs. - '/zH.P. 2. Single piggyback mercury float switch or double piggyback mercury. float
98 Series Control Selection switch. Refer to FM04T7.
Model Volts-Ph Mode Amps Simplex Duplex 3. Mechanical alternator 10-0072 or 10-0075.
M98 115 1 Auto 9.0 1 or 1 & 7 - 4. See FM0712. for correct model of Electrical Alternator, "E-Pak".
N98 115 1 Non 9.0 2 or 2 & 6 3 or 4 & 5 5. Mercury sensor float switch 10-0225 used as a control activator, specify
duplex (3) or (4) float system.
®98 230 1 Auto 4.5 1 or 1 & 7 - 6. Four (4) hole "J-Pak", junction box, for watertight connection or wired-in sim-
E98 230 1 Non 4.5 2 or 2 & 6 3 or 4 & 5 plex or duplex operation, 10-0002.
7. Two (2) hole "J-Pak", for watertight connection or splice.
CAUTION
For information on additional Zoeller products refer to catalog on Combination Starter, FMO514; All installation of controls, protection devices and wiring should be done by a
quali-
Piggyback Mercury Switches, FMO477; Electrical Alternator, FMO486; Mechanical Alternator. fied licensed electrician. All electrical and safety codes should be followed includ-
FMO495; Alarm Package, FM0513; Sump/Sewage Basins, FMO487; and Simplex Control Box, ing the most recent National Electric Code (NEC) and the Occupational Safety and
FM0732. Health Act (OSHA).
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
Z MAIL TO. P.O. BOX 16347
Louisville, KY 40256=0347 Manufacturers of .
O Q 1(50;2) IP TO: 3280 Old Millers Lane t~UAI/7Y PUMPS aS~cE /A9a~9
OE~Z' 1 TLouisville, KY 40218
~J 778.2731 0 1(800) 928-PUMP
FAX (502) 774-3674
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 0D t4 a /a S ~S 1
MAILING ADDRESS 2 3 I G t
PROPERTY ADDRESS SA k, -e-
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE S ! O (w ` ti uj1 S
PROPERTY LOCATION N /C 1/4,N/4/ 1/4, Section ~ U T --<i 6 N-R ` W
TOWN OF ~3 4 ! w n ST. CROIX COUNTY, W1
SUBDIVISION , LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME , PAGE , LOTNUMBER
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 properly 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.
SIGNED: o
DATE:
St. Croix County Zoning Office
( iovernmcnt Center
1101 Cannichacl Itoad
I Iudson, 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 1-,-)o 4 q /4.5 o'f -t i
Location of property(VAt 1/4 (V/4-f 1/4, Section 9() , T N-R ! (o W
Township 134 /C(111 1`^ Mailing address Z:231 Se, Id ti, n 4-4. 5-y6 0-L-
Address of site 2 3( 4 v 4 U~
Subdivision name Lot no.
Other homes on property? Yes L----No
Previous owner of property
Total size of property
Total size of parcel 16 K.5-
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes &,-'No
Volume's and Page Number l5~ 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. `.Zcf' s ~y , 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
4
the office f the County Register of Deeds as Document No.
Sign ure of pplicant Co-Applicant
Date of Signature Date of Signature
-Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page \ of _3
Labor and Human Relations
Dr,vision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S_r
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. O O Z - 0 S • ~7
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
17 QU GV_rrS Q FST►E GGVF.-t9T- NZ 1/4 MW 1/4,SZO T Zq N,R 6 E ( W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
Z Z- 011 "1 EN`Rt tlv 1C . -
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAD
12kkQbkAXj SLLo1bZ F)Is) 6811-24SI $f~~_t)knV..i °t~`ttt NE.
Residential / Number of bedrooms Z Additi4n to existing building
New Construction Use
Replacement [ ] Public or commercial describe
2 0 3 trench, gpd/ft2
Code derived daily flow 3Ub gpd Recommended design loading rate - bed, gpd/ft
Absorption area required ZS~ bed, ft2 ZS'O tench, ft2 Maximum design loading rate o •5 bed, gpd/ft2 o, 6 trench, gpd1ft2
Recommended infiltration surface elevation(s) O l I S It (as referred to site plan benchmark)
Additional design / site considerations Y'1ou+-,-., 14j/ S' Y- Sr~' 1•Tccx)vCt{ . Hoy, I r a'F Sf yub R L t_
Parent material G \e.L h-_ 'IRL\.. Flood plain elevation, if applicable f-Z • 01% - It
S = Suitable for System CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable brs stem []S [dU ®S ❑U []S ®U []S ®U ❑S ®U []S ®U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bo rdary Roots GP D/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
0-8 t~~i\L 3Jz sl 1 Z~s~1t m'~~ a,S - o.s o.
4 > ' Z $-tS to `1 3I S 1 Z`~3blz ►n'~1- C3 0.S o.
Ground 3 ~S?~ ~,S`l1Z 31 - S1 Zrn S~~z v~t-Ft, r~ w o .S o' 1.
elev.
to ft y 2@-36 7•S`iR-3) SCll
Depth to
limiting
factor
Remarks:
Boring #
``>Z Z $-ZS to~tz~li: - 51~ Z~`sbk v~n'~1 cS - o.S 0.b
wL~'►. -
3 ZS-y ,•s~~ 3~ sKtz Sep sC' oN\
Ground
elev.
100.0 It.
Depth to
limiting
factor
ZS"
Remarks:
CST Name-Please Print Arthur L. We erer Phone: 715-425-0165
A gerer Soil Te ting & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: g S_ Z 8 6 Date: _ Z Z- q 5 CST Number: M 0 0 5 7 6
PROPERTY OWNER C~ FSTI E SOIL DESCRIPTION REPORT Page Z of .3
PARCEL IA # OC)Z- 1z %-1 S - O r
Boring # frizo Depth Dominant Color Mottles Texture Structure Consistence Botxxlary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
-1 to K %z Z s t Z ►n s U vnS s Ground ~8 30 s 3l y s \ s big m ~f t- r~ s o s
elev.
gift. 3~ ~i~ ~•S~tt23lV SJb Sc~ per, rn~~.
2
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
a
r.'sam,"
I
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
M
I . roc
I
Ground
elev.
ft.
Depth to
limiting
factor
Remarks: _
S13D-8330(8.05/92)
PLOT PLAN Page 3 of 3
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q-ZZ-~ S (715 ) 42A-D7.6.5M00576
CST Signature Date Signed Telephone No. CST #
eo 454 96
second part, their heirs and assigns, against all and every person or persons, lawfully claiming the
whole or any part thereof, they will forever WARRANT and DEFEND.
An MitntOO Mbrttot, the said part ies of the first part hwehereunto set their hand s and
seat this 19th day of August , A. D.,19 69.
Signed and Sealed in Presence of
Paul Lokker
Geraldine T okker---_- -
Roy Nadeau
Cheri Radunzel
Otatt of MtOconOin,
ss.
.St._._Cr_aix . _Couaty.
Personally came before me, this 19th day of August , A. D.. 19 69
the above named Paul Lokker and Geraldine Lokker
to me 111N11Y4 ~4,; persons who executed the foregoing ins nt and agknow] dged the same.
~N 0 T A R Y Roy Nadeau
N P U B L I C Notary Public, St w Croi % V. P- x-. County, Wisconsin
~•..ti4~ _
4
of W ie' O My commission expires March 25 , A. D.. 19 73 .
G-
11If///IIIU>>,,`.
Drafted by Gavic and Richardson? Attorneys at Law,S~rin~ Valleys .~isconsin
(N.H.--Ch. 69 Wis. Stats. provides that all Instruments to he rsoorded shall have plainly printed or typewritten thereon the names of the ¢ranton
Brant-. witnesses and notary.l
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