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HomeMy WebLinkAbout006-1057-80-000 Co o 0 > Oo 3 69 o O 69 O 00 N O a 0. 0 g c o c 0 0 o N N 0) CD E •2 C (p E N.52 . C O -N a 7 O U CL U W L O v o L y ; "O p •p N I6 "6 L (O i 0 L co m r N O co (0 O 3 `L > O O U O N O N O. Z 7 •o N N (0 (O J a ~ 4.- O 0 0 (n > O N co N N E E -b c-4 N "E - mt (6 °c m m M. LL o y Y E (a LL o a N > "p -C C N> C a - c 7 m (2 N 'O 'p d r (D w m E d (n N O M 2 V C ca Z G pO Z~ m a m N Cl) a m U) O c C7 a L o z c d z c z Q, N M w N O p Y V~ N N C O 0-1 ~ ~ O •'V a L c _ nl O r_ '0 ~i O N d O O Q Q = O P- Z M Z = Z Z Z N _ N ~ d I m r £ E N ~~Tt u;;i E 2, °o H m Y ~i co a '(o w ' a 'M w = c (O d _N N i `N (n O d 0 N C 0 0 y 0 a a Y G a O N y_ N Q I~ E Q Y N V) f/~ j U 0 U) co p H F' H O ~'/N1 E O 0 0 0 a O O O a 0 z° ~ ~ a a a ~ a a a N a O LO U') (n o N n n O 0) rn N (D m J U N rn rn Z U) } to w! O ~I N Lo O w= w 0 0 00 N O N M 0 C0 E N M M V N O O pj N co d N m LO _ JA N 'D N d s"31 O) N m o d Z d d Z UJ Q N ~ 3 O O t N C N C O 'O E O O m O O O O M U O r p W W ° & O O Y O (O C QQ) N C a 0 0 l 1 TL,ir 00 M 3 N (n m cLi (n C +r v ~ w c co 4) a LO 5 a? N 3 O u p N a~ Cl) U CL) n GS No 'f 's c M N N O ~ :3 cr) (n 7 m • 7( O O T V O N W O 1 co Iq p O f0 n+ O)j y,i O N V fn O Z_ 2 Z J N O Z_ Z Sn O CQ II I' = I E \rl v~ d ~a ! a E a L: (D w 3 EL IL CL • CL N V' N c~ c c C rw E !,I c w? 0 3 o D U a 0 U) 0 0 V7 U ` .'Peon~r "Lepartmentoflndustry, SOIL AND SITE EVALUATION REPORT Page of LAbor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARC 441 dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION D B PROPE OWNER: PROPERTY LOCATION a GOVT. LOT 1/4 .4-'04') l-z' PROPERTY OWNER': MAILING ADD~iESS LOT # BLOC # SUED. N R CSM ~C v`~ 00kiNTY 14 A CI STATE ZIP CODE PHONE NUMBER ❑CITY LLA E [2I7 TOWN [ ] New Construction Use P1 Residential/ Number of bedrooms [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 tre ch, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) r¢ ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ❑ S 1 U ❑ S O U ❑ S O U ❑ S 29U ❑ S U P9 S ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Baxtdary Roots GPD/ft in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed Tmnch lop Ground elev. Depth to limiting factor 1lL Remarks: Boring # Ground elev. /fit. Depth to limiting factor 7_1 Remarks: ZZ /71' CST Name:-Please Print Phone: Address: Signature: Date: CST Number: PROPERTYOWNER=~/~_ SOIL DESCRIPTION REPORT Pag€ aoi 1 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 Trench s Ground 3 "Ov elev. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) l JW sa' ~j le - yo Gi f5*7~ Gldsy.~~ d~~ l~ STC - 104 ; Jam,: , ti AS BUILT SANITARY SYSTEM REPORT 1995 OWNER ,t 7Y tCE ADDRESS SUBDIVISION / CSM#_ LOT # SECTION _T 3Z N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 8 60, b p 29 .r// 9 ~ 4'o sc.-r ~ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ALTERNATE BM• SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: - Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELE`TATIONS ~.yS~17✓x Building Sewer ST Inlet: t " T outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: L-2 INSPECTOR: 3/93:jt T`` Wiscons?r-6epartmentofIndustry, PRIVATE SEWAGE SYSTEM County: taboranci Human Relations ST. CROTX Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Pe1jb Wa~Q:' aJ''AN E] City ❑ Village R Town of: State Plan o.: CST BM UU'EElev.: L` iii Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark S Gov. Dosing Aeration Bldg. Sewer Holding O ` a oD 5e/ Ht Inlet Gott f9,21 1 3 TANK SETBACK INFORMATION St/Nt Outlet ~y gg,aG TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 8v NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding a5 jo, 3v Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction Syesatem TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of CHAMBER Model 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. Sparing 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 E] Yes E] No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Cyl©n.26.31.16W, SW, NW, 240th Street Plan revision required? ❑ Yes g No Use other side for additional information.' SBD-6710(R 05/91) Date nsp6ct4'sSignature Cert No. .t. Bureau o of f Building Water Systems ~~i~'r'■ : SANITARY PERMIT APPLICATION Safety and Building l ng Water Sn 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. -S)Z~~'4Z 4 See reverse side for instructions for completing this application State Sanitary Peermit~Number The information you provide may be used by other government agency programs ❑ Chad 4eG,si6n to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Propert Owner Nam Property Location va Ilk) 1/4, S T , N, R E (or& Property Owner's Mailing Address , Lot Num er Block Number City, State may` TT7~ Zip Code Phone Number Subdivision ame or CSM Nu ber ( ) J II. TYPE F BUILDING: (check one) ❑ State Owned o ityage Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms C] Vill Town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number ) 1 E] Apartment / Condo ©0~ _ /e5-7- FO 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 ❑ Mound 30 ❑ Specify Type 41 JQ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill W. 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) Elevation Feet Feet VII. TANK Capacity acctns Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank 0 2ZW+=r I - ` ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for' stallation of the onsite sewage system shown on the attached plans. Plumbe 's Name: (P inlt Plum is o tamps) MP/MPRSW No.: Business Phone Number: /P: Plumber's Address (Stree City, State, Zi de): IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee (includes Groundwater ate Issued Issuing Ag t Sig No a Approved ❑ Owner Given Initial Surcharge Fee). p Adverse Determination X. CON ITIONS OF PPROVAL / REAS S FO I PPR VAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS , 1 _ A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815- To be complete and accurate this san4ary,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 online 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. I i ST. CROIX COUNTY ZONING OFFICE, CERTIFICATION STATEMENT I FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently,, serving the residence located at: IT/1) 1/9,01/4, Sec.TN, R Town of Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced ,L/Is- ~ Did flow back occur from absorption system? Yes No (if no, skip-- next line) Approximate volume or length of time: gallons minutes Capacity: A5:c ~ Construction: Prefab Concrete-,Z Steel Other Manufacurer (if known): ~t Age £ a ( i f wn) : 4' (11 97 (Signature (Name) Please Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) ` or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - A Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, is. Adm. Code (except for inspectio ope ing over outlet baffle). Name 111-7 Signature - MP/MPRS 5/88 SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations September 29, 1995 2226 Rose Street La Crosse WI 54603 K 0 CONSTRUCTION KIM 0 CONNELL 308 MIDPINE CT STAR PRAIRIE WI 54026 RE: PLAN S95-41188 FEE RECEIV60.00 LAUTERBACH, JEAN SW,NW,26,31,16W TOWN OF CYLON COUNTY OF ST CROIX HOLDING TANK 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, Dennis o;eson Wastewater Specialist Section of Private Sewage (608) 785-9336 SUDA•7997 (x. IWN) Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Safety and Buildings Division Labor and Human Relations Bureau of Building Water Systems REVIEW APPLICATION Hayward Office La Crosse Office Madison Office Shawano Office Waukesha Office 209 W 1 st Street 2226 Rose Street 201 E Washington Ave. 1340 E. Green Bay Street 401 Plot Court, Suite C Rt 8, Box 8072 LaCrosse, WI 54603 P.O. Box 7969 Suite 300 Waukesha, WI 53188 Hayward, WI 54843 Phone (608) 785-9334 Madison, WI 53707 Shawano, WI 54166 Phone (414) 548-8606 Phone (715) 634-4804 Fax (608) 785-9330 Phone (608) 267-5119 Phone (715) 524-3626 Fax (414) 548-8614 Fax(715)634-5150 Fax(608)267-0592 Fax(715)524-3633 INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submittal. Fill in all applicable data and submit this form together with fees and plans/information. Your submittal must be received at least one working day prior to the appointment at the office or"vha i r do to where your review was scheduled Please call any of the listed offices if you need help filling out the form or hav u 9o5 4 submit. PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your reference. 1. APPOINTMENT INFORMATION - If you have scheduled an appointment, fill in the information requested below to save time: Appointment Date Review r Name Plan Identification Number 2. PROJECT INFORMATION If this review is a revision or extension to your existing plan identification number, provide that number here: Project ame City ❑ Village ® Town Of: County Project Location- GOVT LOT 1/4 I 1/4, T.5 N,R or W 3. APPLICATION F6111 4. FEE COMPUTATION FEE SUBMITTED System Type (check one): System Type t (include new and existing tanks) Up To 1,500 gallon septic tank . $110.00 A ❑ At-Grade 1,501 - 2,500 gallon septic tank $120.00 H " Holding Tank 2,501 - 5,000 gallon septic tank $160.00 M Mound 5,001 - 9,000 gallon septic tank $200.00 9,001 -15,000 gallon septic tank $ 300.00 N ~ Non-Pressurized In-Ground (conventional) P Pressurized In-Ground Over 15,000 gallon septic tank . $ 500.00 O Other: Up To 1,000 gallon dose chamber $ 70.00 1,001-2,000 gallon dose chamber . $ 80.00 Building Type (check one): 2,001 - 4,000 gallon dose chamber $100.00 4,001 - 8,000 gallon dose chamber $ 120.00 D Dwelling, 1 or 2 Family 8,001 -12,000 gallon dose chamber $140.00 P Public Building Over 12,000 gallon dose chamber $160.00 . 5 State-Owned Building Up To 5,000 gallon holding tank $ 60.00 5,001 -10,000 gallon holding tank $100.00 Code Derived Daily Flow _ gpd Over 10,000 gallon holding tank $150.00 . ® Check If Replacing Existing System Experimental System (additional onetime fee) $ 300.00 . Revisions To Approved Plan 2 $ 60.00 Petition For Variance: Setback $100.00 Petition For Variance Site Evaluation $ 225.00 Plumbing $22500 Revision $ 75.00 Groundwater Monitoring Groundwater Monitoring - Per Site $ 60.00 . (other than a proposed subdivision) E] Site Evaluation in Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring $ 60.00 . Subtotal: Priority Review: Enter same amount as Subtotal: ~l _ MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: 5. SUBMITTING PARTY INFORMATION Telephone No (include area code & extension) Compan me Contac Per No. & Street Address Or P O. Bo~ City, Town r Villag~tate, ip Code 1 x'L 1 Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers 2 Revision fees are not applicable to temporary holding tanks or extensions to existing approvals NOTE: Fees are pursuant to Wiz Adm Code, Chapter ILHR 2, and are subject to change annually The information you provide may be used by other government agency programs IPrivacy Law, s 15.04 (1) (m) 1. SBDW-6748 (R. 09/94) OVER voi_ 1132 PAGE 1 75 S _ ° 41 1 8 8 -9 Oocuhitnt No This space reserved for recording data 531696 HOLDING TANK AGREEMENT Agreement Date This agreement Is made between the - - - - - - - - - - - - - - - - - County or local Governmental Unit I Holding Tank(s) Owner(s) Called Municipality below I J U L 2 6 1995 We acknowledge that application Is being made for the installation of (a) holding I tank(s) on the following property, (Provide legal land description:) 60 Return To ° r 3L 154/00 7 or that continued use of the existing premises requires that a holding. lank be Installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Slats. As an Inducement to the County ofT t x to Issue a sanitary permit for the above described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced In response to orders Issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and 146.14, Slats. the municipality may enter upon the property and service the lank or cause to have the lank serviced and charge the owner by placing the charges on the lax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Slats. 2. Owner agrees to pay all charges and costs Incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the lax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be collected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d), Slats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding lank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain In effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement In such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds In a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank Is Installed. Owner(s) Name(s) (Print) I Owner(s) Signature(s) Subscribed and sworn to ";prw49# on this date: ^.~~r J~f~~ ~all~l'~(bO~Gf l i July 26, a Municipal Official Name (Print) ( Municipal Official Signature Not"Riblic My commission expfTes: Irf/`ih il!d P7,0 .5OLD Municipal Official Title (Print) I If a SBD-612 (R. 10/85) This Instrument was drafted by the Slate of Wisconsin Department of Industry. Labor and Human Relations, Bureau o IUMBhib J HOLDING TANK SERVICING CONTRACT, Con;ractDate VOL .1132PAGE ~ ~ - 41 8 8 531597 This contract is made etween the Holding Tank Owner(s) Name(s) and I Pumper's Name I We acknowledge the installation of (a) holding tank(s) on the toll wing pro erty: (Provide legal description:) Wis. ~ ~ ~ s- ~o~ • ~ i - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required-in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the Countyof RECE/VSD SEP 2 ~j 'en 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantesc~s~ ~errmit th5 p0jar to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner s~'U~?in the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment The`16iivAWurther agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; aY. C: b. The name of the owner of the holding tank; io cC r- c. The location of the property on which the holding tank is installed; JUL 9 6 1995 d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; 8:00 A. 1. The volumes in gallons of the contents pumped from the holding tank for each servicing; B~` Y g. The disposal sites to which the contents from the holding tank were delivered. i 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract. the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) I Owner's Signature(s) Subscribed and sworn to before n)A pn this date: (9~`l 5 ~No I ci~g Pumper's Name (Print) I Pump r s Signature -.ZNgt .ubtic (DA/LEN pd iA EA_S I 'e, My commission expires. • d ~•.•'+c Pumper's Registration Number a 0 SBD-7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pagel of Labor and Human Relations Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code FPARI NTY Attach complete site plan on paper not less than 8 1/2 11 Irioh i ®iz Pt~n st4~lciSe, but / not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or ECT A # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPS TY OWNER: PROPERTY LOCATION GOVT. LOT c 1/4 Al) 1/4F ' T N,R ~(o& PROPERTY OWNER':S MAILING ADDRESS LOT # BLOC # SUBD. NA E OR CSM # CI STATE ZIP CODE PHONE NUMBER ❑CITY LLA E [MOWN NEAREST ROAP [ ] New Construction Use 0 Residential / Number of bedrooms [ ] Addition to existing building Replacement [ ] Public or commercial describe trenc h, gpd/ft2 Code derived daily flowZfG gpd Recommended design loading rate bed, gpd/ft2 4J, Absorption area required bed, ft2 tre ch, ft2 Maximum design loading rate bed, gpd/ft2 _trench, gpd/ft2 Recommended infiltration surface elevation(s) y c) ft (as referred to site plan benchmark) Additional design /site considerations Parent material z~L ,QS, l Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ❑ S O U ❑ S O U El S ~I U ❑ S VI LI ❑ S J3 U 4S ❑ U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Pont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Tmrch -Z _1Z A410 AIJO Ground T* elev. Depth to limiting factor 1f~ Remarks: Boring # 4-42 )V/ Ground elev. /~~ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: Address: Signature: Date: CST Number: c - PROPERTY OWNER ALI - SOIL DESCRIPTION REPORT Page of OARCEL I.D. # 5 -41188 S9 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerxh S Ground I,?',- 3 ALL 1757 Z4 elev. r~ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # %~\itiii ~4:::: i:• Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) /YcJ so' ,OK~J~ wn~ 7f ~Ikt 3 14 &j* ke II~~ ~ - ~ ~Ctlr't i.:; Sri !'~~U tt''r.i t;~. ?~L/~~I~i•!S d.\ ~f f F1f~ ~ :~J~~ 4 i ~ +f r: • iJ i~ "ate ~1: tW, --T;' ~l ,~,r:aJ u F } d-> r C O O D. M N i E T7 Ol e' G G. ~ •r .C r- 4-3 C 0) 0 C) .E = > b N E 0) O U O CX 4-) to ~j co C.\ X C W r' ~~Q 3 W O - 1- b i U Ob ~ t 04-1 C Q C y c C 1m O O 0 1_ cu ca •r J « v r- Jhid O U tm O C7 O C •r Cf C •C L n- z O L Stri 1 ' OD 1 a •{J 4 3C,, E O 4 r. •r - N W L 0) OJ Ol N Z CD O 5 H O Y- r r N O 01 4J V F. Z U 10 t G G W O 10N 4-r U W 0) 4J M F- O aL 14 uj do 0 a- N V 037 b b m m N O O a~ f V Y W O ~i cy, • ~ co J Z ~ r (yt O 1' " 1 J 1 O 1 = 1 1 1 1 1 .Z. V t i 4_ 0, 4J ? 3 N L m 1 a 4J tm O C 10 4J U cu Q 10 C ~ p ~d > U C 0 4J N tt 7 d O cc 0 " W M- C ch • • L ? ►~1 O1 r'r 10 UE W OD a 2•~Q- D 4J Z 1 d N N D •r ce O Ol LU 4J L4 s- $A O V 'r' 0) i0. 1ra c C co 10 C 5- 4J r- v CM 3C U 4-) 06 C v (D b N ~ /n 895-41188 so' sc R- I ? II f N3 SI i F SEWAGE S'~ ~vruli~.k~ruf~fr. RECEIVE ZJ4 SAFETY SEP 2 6 1995 DEPARTVI t 0 NOUSTRY. ± AVOR AND HPI iA.M RELATIONS BLOGS. DIV. !`.,'I,,;, id O ~,1 E AND RUii.D;i,GS /gypRRIBCrViVE {'CNCE / S%E CO. Y.Y.. f S T C - 100 I 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. 1 Owner of property Location of ProPertxSo 1/4 [VW 1/4-Section , T 31 N-R I W Township (1 Mailing address S4OU Address of site Subdivision name Lot no. other homes on property? Yes No Previous owner of property Gtr Total size of property 3~ A~►-e~ _i - Total size of parcel p 7 Qe Date parcel was created _~q Are all corners and lot lines identifiable? \>e-_Yes Nom/ Is this property being developed for (spec house) ? --Yes _No Volume and Page Number !/~~/-/r;7_ 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 statement: 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 off.ic(., of the County Register of Deeds as Document No. and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deed: a15 Document No. Signature of Applicant Co Applicant_ 4 Date of Signature Date of Signature •X. ~~Y ♦t_k us. -s !tis Y-1'~~i;. `w.... .e ''~t.d.#_v:;. a•i; .y,.." s1ci S1r,~•r y DOCUMENT NO. WARRANTY DE M RECORDING INFORMATION ;E' 97 RcG1STER'S OFFICE 520217 VOL I091-PA" ST. CROIX CO., WI Recd floc Rv ord THIS DEAD, made between Gary LILY sad linens AL Kahl, husband and wTe se AO G O 5 1994 A ..a.orehip vital pWw% Grantor, and Jean hL lsalme.dk a ragas prsso% Grantee, et 1'~'~+G. M z wnWE SSEnf, Ttat the said Graawr, for a •aluabk comidemtios oats 00- sad other ash abb coaaideratim cot reya to Grantee the following dacnbed real estate is SL Gois County. State of Wiaooaisc d a The North 245.0 feet of the South 515AS feet of the Weal 560.0 feet of the Southwest 1/4 of the NorthweN 1/4 is Section 26, Township 31 North, Ranee 16 Weal. RETURN TO, Bahhe Norman. 8G Now Richmond, WI Tea Parcel Not This is homestead property. Together with an and singular the hereditameau and appurtenances thereunto belonging; and Grantor warrants that the title is good, indelew%le in fee simple y and free and dear of encumbrances except: Easeseents, highwaye, utility 06k asd rese-dons of reanr~ and will warrant and defend the same. Y 6 tinted this nth any of Auswt -19-94 (SEAL) ACKNOWLEDGEMENT p STATE OF'WISCONSIN } (SEAL) ) m Sr. CROIX COUNTY ) ` Jeanne M. KaM i Personalty dame before me this 4th day of Au¢ust 19 94 , tt~44m pamed Gary L Kahl and t ~ Alf711EN77GTION Kahl, kan M. husband a wit - Signature(s) of Gary L Kahl and Jeanne M. Kahl - i , tomeknowsto be the oersoos who executed thL t and ~c~cnowkdgod the • saa>G v t-a t authenticated this _4gL day of Ausust . 19 9 x • G.E. Norman Debra L Vriae Q'~. ,,Cr T TLE MEMBER STATE BAR OF WISCONSIN (If not, Notary Public, St. Croix' COUdty,:Wisooruin y authorized by 706.06, Wis. Ststs.) v~11 e ; My Communion is permanent. (If net; state esprratipadatez November 2S 19~ THIS INSTRUMENT WAS DRAFTED BY: - x: BAKKE NORMAN, S.C. NEW RICHMOND, WISCONSIN •Nama of peraoes signing is any capacity should be typed or printed below their signatures. a a: 6 ..y;,+.w,:~1-...,.,.,y sat[q.t5tr},„~,~ A q•.t, p.. y .,t .•~r : K• tI•.: 1I\..'~d., A ~~''~+,.~1.. w. 1W Wisconsin Department of Health and SooiA1 Services ~;Fd.bA 3/70 , Division of Health SEPTIC TANK PERMIT APPLICATION TYPE or USE BLACK INK A. OWNER OF PROPERTY Name Address (street, city, zip code) LOCATION OF PROPERTY WFTRE SYSTEM WILL BE CONSTRUCTED ALTERED ;-R EXTENDED COUNTY ~.J ~-L - Check Ones CITY VILLAGE LEGAL DESCRIPTION TOWNSHIP C. IS LOCAL PERMIT QUIRED FOR THIS WORK? YES NO PERMIT NUMBER D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION N.ATERIALSs Prefab Concrete Poured in Place Steel Other NUMBER OF TANKS TO BE INSTALLEDt E. TYPE OF OCCUPANCY Check Ones one or Two Family Residence y Commercial Industrial Other (Specify) Number of Persons to be Accommodated Number of Bedrooms F. APPLIANCES, ETCs Food Waste Grinder YES NO Automatic Clothes Washer YES NO Dishwasher YES NO Automatic Potato Peeler YES_4 NO Other (Specify) G. MASTER PLUMBER MAKING INSTALLATION Names 91C, jfr' l~ l/T.~~~h'i~'•_S Address= / License Numbers Signature of Applicant: MP RSW Address# A0 U,) H. (To be Completed by Issuing Agent) Date of Application Fee Paid P.ermit'Issued date: ( Number~( Agent (Name) ~.r a. , Fort 1~9 ~i1 A4 _ Town, Village, City, County, eta (Specify) Notes The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $1.00 for each septic tank and the third copy of the permit (canary) to the Division of Health. Checks and woney orders should be grade payable to the Division of Health. Do not write in space below - FOR DEPARTMENT USE ONLY I. DATE RECEIVED LO ACCEPTED BY RETURNED (Initials) Q (Date) See Corres. FEE RECEIVED L/ VALID. No. PERMIT N0. es or No REVIEWED BY APPROVED DATE (Initials) Yes or No COMPLETE OTHER SIDE • SEPTIC TANK PERMIT NO, REP O R T O N S O I L P E R C O L A T I O N T E S T AND SOIL BORINGS TO DIVISION OF HEALTH - PLUMBING SECT1611 P.O.Box 309, Madison, Wis. 53701 Pursuant to H 62.20, Wis. Administrative Code P E R C O L A T I O N TEST Test Depth Charaoter of Soil Hours Water Test Time Drop in or Level o as Minutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall 1st Wetted Overnight in Minutes Last Period Least Period Period Ona, Inch Example P - 0 36" To Soil 10" Cla 26+' 25 Yes or No 30 1 2 1 2 __Y2 60 1 10. le C )0 do L RECORD DATA FROM MINIMUM OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. S O I L B O R I N G S- Minimum 36" Belov o posed Abso Lion System Boring Total Depth Depth to Ground Water Depth to Bedrock Number Inches Observed Estimated Cbserved Estimated Character of Soil with Thickness in Inches Example B - 0 72" 72" Black To Soil 12111 CW 18"1 Sand 18111 Gravel 241-11 :2 Aal RECORD DATA FROM MINIMUM OF 3 BORE HOLES PE OF OCCUPANCYs RESIDENCES Number of Bedrooms OTHERS (Specify) Number of Persons FOOD WASTE GRINDERS Yes No . Dishwashers Yes No Automatic Clothes Washers Yes No FFLII,ENT DISPOSAL SYSTEMt nV EXTENSION ADDITION REPLACEMENT Tile Size No.Lin.Feet Trench Width Depth Number of Lines Seepage Bed: Length ~ Width Depth~,7~ Tile Size ~ No. Lines Seepage Pits Inside Diameter Liquid Depth Ie the undersigned, hereby certify that the percolation tests reported on this form were made by•me or under my super- vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of mkv knowledge and belief. NAME C CC~ . /4 C TITLE Type or Print REGISTRATION 90. or MASTER PLUMBER LICENSE N0. A!~ S ADDRESS l J i DATE ~J 7! SIGNATURE