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HomeMy WebLinkAbout020-1304-80-000 ~o ~ 03 °u3 N h 4 O a ~ e r. c 0 N h, +r Y I O ti c+ _y ,o c z L ro LL O Q 3 Cl) a ~ Z y rn w E Z o z N w a m F- U) c 0 c C9 ~ is O z c V CC O w e} o N H N z c E -o I', ~ N co I ` N N 3 N UO) O '0 CL 0 O Q 0 4) O ca z co z N N U CL a 'o U) 4) c Y N 72 p d cl-I CL m CD (D y m i U 0 0 0 O d c QO N N I6 p H H H O U N N C) 0 c 0 0 0 d z o o a. a. CL a I U) LO LO !n J U y rn rn 'D C) LO :3 C) 0 0 = N N N LO r- O = .r- 0 O m N a 0) ~ a V _ Q } 00 co N N O 00 O n y C p p c O O C C 7 p M M a°o~ o Q) o a ILm0°oI r N N m ~ E E~~ v n I O C (n C O O 5 N N 42 C,) N y v s a) f- F- a a) ire v rn 04 10 C> CN z T, i9 L9 (ni cu E m dt m a E v c c f STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 5, 4129 19'1111,F4 ADDRESS Rox '4f Z ~ L 1`w9 SO /V SUBDIVISION / CSM# TANK/ RtD6~ LOT SECTION T Z9 N-R-zl_W, Town of_/•/v J So N ST. CROIX COUNTY, WISCONSIN PLAN VIEW 13 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3-2 i y!. n B- i h~ O 12 NOTE'. Al rM M`r~ 1wa5 r 3F 2s' orkMM ~k`~tbe r' ,X a {s ! I ~ I fr h M'fCP ofoo.dd. V L L ,f-E E~= g V e I p( INDICATE N TH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 1 BENCHMARK: Tp~ pF / //`'E A T S E L oT <c .CX 2 /cgs ALTERNATE BM: (p(~J o 5 (Q b R.1 UAd 1C b,^pr = T~ I 10 EPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: 1,0 )0 Setback from: Well (,S House Other S-/' To Eos7' [aT t/NAe Pump: Manufacturer - Model# - Size Float seperation Gallons/cycle: - Alarm Location , SOIL ABSORPTION SYSTEM Width: /8' Length yo Number of trenches - $ E D Distance & Direction to nearest prop. line: 34' T'o EA-S C o7- Setback from: well: /Zap House (p(o • Other y3• To SECPTIc T .Vk ELEVATIONS Building Sewer - ST Inlet.q(,!6??Z•Z0 ST outlet 10,10- ~~•7~ PC inlet PC bottom Pump Off I Header/Manifold ~~(Z Bottom of system Existing Grade ~•7S Final grade 7S DATE OF INSTALLATION: PLUMBER ON JOB: c~t-J'j2-= LICENSE NUMBER: M~~S --03 x'00 INSPECTOR: 3/93:jt I. WiscorTsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI MILLER, SAM 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 /d~ r , 6~, Dosing ' 9,~ 7 Aeration Bldg. Sewer Holding _T::~ 11,2, St/ Inlet 569-iZ 17 TANK SETBACK INFORMATION St/ t*f Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic S0~ -657 NA Dt Bottom Dosing A Header ' Aeration NA Dist. Pipe (w Jl H ng Bot. System 17, PUMP/ SIPHON INFORMATION Final Grade Y7 ZZ ' Manufacturer and r Model Number GPM TDH Lift Friction System TDH Ft oss For ain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN 1 SYSTEM TO P/L BLDG WELL LAKE/STREAM L CH Manufacturer: SETBACK INFORMATION Type O 6, CHAMBER Mode Number: System: P_A_d 30 e~ ~o r /~d r OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacin ent To Air Inta Length h ' Dia. Length 3 7 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade I Depth Over Depth Over ~7 r, xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center - Bed /Trench Edges ~ / _3v Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) . 9W, SE, NE, Lot 11, Buck RidgeV LOCATION: Hud on. ~Ic J Plan revision required? ❑ Yes ED-Wo Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. i ADDITIONAL COMMENTS AND SKETCH • SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION ~:~~i R , In accord with ILHR 83.05, Wis. Adm. Code COUNTY 0Z - STATE SANITARY PE MIT # -Attach complete plans (to the county copy only) for the system, on paper not less than v2 3 / 8% X 11 Inches in size. ~ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER, 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION .5f}/Z1 2 5 F %a %,S / T Z7 , N, R /17 E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # -W Z4? 7 Sox CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER KUOso w S1(394 274 y 7-ANK /P LZ = CITY Il. TYPE OF BUILDING: (Check One) ❑ State Owned ❑ VILLAGE : NEAREST ROAD 'M kOWN OF: elD r. ❑ Public IM 1 or 2 Fam. Dwelling-# of bedrooms3 PARCEL TAX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) Q ZO - /3 O y - p d 1 ❑ Apt/Condo 0 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. r New 2. ❑ Replacement 3.E] Replacement of 4.0 Reconnection of 5. El 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 Q Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 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) ELEVATION 4/ ~/o -IS -7 ZO Q. 7 55% 3 Feet g 7-5- Feet CAPACITY VII. TANK in allons Total # of Prefab. Site Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed / S E R Septic Tank or Holding Tank 11 /0 O d / W F_ Lift Pump Tank/Si hon Chamber . J-H Ej I L1 Lj 0 1 0 F-1 VIII. RESPONSIBILITY STATEMENT 1, 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: AI /K ~ M-5 ,Do NF L` R ~~S'03Sao ,38'4 a 9 Plumber's Address (Street, City, State, Zip Code): 41('0 f Ef;nt /9 / gE H00,50 ~4 U) S-Vo . OUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Ground roun Water a sue ssuing Age Signa Sta ) Fee) N IX pproved El Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(8.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber J C INSTRUCTIONS a 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit 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 or 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 is to be installed. 11. 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 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) SANITARY PERMIT APPLICATION WHR ~Ln~1 In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 2 / 8% x 11 inches in size. Oro, Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATIO~1- PLEASE PRINT ALL, INFORMATION+` PROPERTY OWNER PROPERTY LOCATION E (or 47 S1q/1/ /ylf c cf2 j G '/4 E t/4, ST 2?, N, R/ PROPERTY OWNER'S MAILING ADDRESS LOT BLOCK do 7-- CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER N00 .So r r 5 Y©/6 ? G 2.74 7NNNy ,x0(0 CITY NEAREST ROAD Li 7 II. TYPE OF BUILDING: (Check one) . ❑ State Owned VILLAGE I at) ~ 1?41 efo c. ❑ Public ® 1-Or 2 Fam. Dwelling-# Of bedrooms PARCEL TAX NUMBER(b) III. BUILDING USE: (If building type is public, check all that apply) y 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outd(wReoreat+anaUfacility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 1f ❑ ~Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 , ' : $fsrvtSt~tiOn%CarWash 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. 1~4 New 2. ❑Aeplacement 3. ❑ Replacement of 4-E] Reconnection of 5. El 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 x❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ 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) ELEVATION y _ vX~o `/S -7 Z-e L. 7 21% 3 Feet g 7, 5 Feet VII. TANK CAPACITY Site Exper. INFORMATION In allons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic New xistin Gallons Tanks Concrete structed glass.. - App. Tanks Tanks Septic Tank or Holding Tank lt~E # S E R, F] 10 Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY., STATEMENT t 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 I /K iE PI` Do ME C' 5 ;Yft ~ P384 z..,,._ Plumber's Address (Street, City, State, Zip Code): 114, I Er Al N/L /gAlE HV050~4 LAJ r IX. OUNTY/DEPARTMENT USE ONLY ❑'`Disapproved, Sanitary Permit Fee Mcludes Groundwater ate sue Issuing Age Signa to s) Surcharge Fee) pproved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(8.08/93) DISTRIBUTION: Original to. County, One Copy To: Safety8 Buildings Division, Owner, Plumber ae s~ e. rr<t t eye to r rr.. va+. •<ts.<t a i,a`a`<<+i.'tra • a x♦a♦ ♦ a w`arc'eS'Y:~}# N'':~a < < ~ . r . r r r tyr r r t rar r *a+r t`y`+'~'..~`+"{"{.*:~..#r=.~.. +.r + c. INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit 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 or 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 is to be installed. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ill. 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 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) w J r e~ v 3 N 0 I J ~ .i 4. s W~ I 00 ~ \ ' j•a \ ~ J n I N 0' ~ o Y k 1 ~ i M ~ •N G r' V1 I t o° tea' W Ul v M It `o ,40 tp ~ ' I ~o I I ~ ~ ~ 'V q! Ill T I~ ~N LAI /D C6 67 .a V 141 i ~ Q n 4 > ~ 4 4( 1 0 q ~ i 14 Vii p ~ \ v v ~ J 41 l3 aw 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 Co than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number a334a-1 The information you provide may be used by other government agency programs ❑ Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan LD. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location 5<IM 4_ Z_ C 2 SS= 1/4 NE 1/4, S T Z , N, R/~/ E (o Property Owner's Mailing Address Lot Number Block Number Z 'Z--_ City, State Zip Code Phone Number Subdivision Name or CSM Number o til yv/!e (3 )Z76 A /ZI GE II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road Vilae E] Public 1 or 2 Family Dwelling - No. of bedrooms ❑ To wn OF #00SON V~~ A 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo C)a<D-f 30e)' $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. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade G Required (,s. ft.) Proposed (sq. ft.) (Galslday/sq. ft.) (Min./inch) Elevation / la l S 'Z,O O«7 4S , 7~ Feet &S-7 s~ Feet VII. TANK Ca in all City Total # of site INFORMATION g 's Name Prefab. Con- Steel Fiber- Plastic Ap- New Existin Gallons Tanks Manufacturer Concrete strutted glass App- w Tanks Septic Tank or Holding Tank ~OoO E £Q- ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamberl 1 ❑ ❑ ❑ ❑ ❑ ❑ VI11. 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 514mps) MP/MPRSW No.: Business Phone Number: M H c F_ M 4 60 F- L[- -~J~ jn P!2 S- 3SOo 3 YG - ~G g Plumber's Address (Street, City, State, Zip Code): 4( 0/ 64M I L4.- I-A vA o w 0/ IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sani ry Permit Fee (Includes Groundwater ate Issued Issuing Age amps r Approved E] Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety a Buildings Division, owner, Plumber INSTRUCTIONS 1 . A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit- Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site dbnstructed and tank material. Complete for all septic, ,pump/siphon and holding tanks for this system. Check experimental approval only if tanks receivec experimental product approval from DILHR. VIII- Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County / Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted tc the c(iunty The plans must include the following: A) plot plan, drawn to scale or with complete dirriensiom, lo(-atior) of ioldinq tank(s), septic tank( s) or other treatment tanks; building sewers; wells; water mains/water to^.:ce,- stre,!rns lakes; pump or siphon yanks, jjsti ibution boxes, soil absorption systems; replacement system areas; aril the locat.ior c f the building served; B) hor zontal and vertical elevation reference points; C) complete sped f1,,Aiorr1, for pumps a-.c ontrols; dose volume; elevation di f ferences; friction loss, pump performance curve; pump mode' an'd ump r -iuf, c r!rer, D) cross section of the soil absorption system i f required by the county, E) soil test data orr <; 1 15 form; and F) ai sizirg 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. if/OPT.y to ti~vE 3~// 6S ~~~d ScgL,E~ m LA N m D F o~ o ZI, r- Z m rp T 7u N t \Q ) d N I~ O 00 o N ~ ~ 0 41- 1 a b 0 / o ~ ° m GA- o 0 f l 1 0 ^ 117 TTI U~ w fob z~ " ~ m ~ N c (v!D r\ 5 ~ ~ y x Y }F . A1` r~ j v AA a. ' ~~/T J I m I ~P~ I I ~ it z I ~ I I I Z b I I I ~ O I I I ' m z I I i F o I i i rn w i 0 I rn I (A ~ O I I I ~ 7~ I I ~ ~ Y r 1 y .p I m I I I : I I `v V) 0 f° 02 Z I I I r t o i R v I I I CA I -o I I I- T LA F m j W I m cc, rn W i ~ I m Ij I~ X O -PY J J 0 0 _ -A CA Z0 Fi x v = M ~O -ate pZ m °z -o O C P~ Z m n O Z =1 w:Fw+; wM1k.r3 rid, ..,M•, . . Wisbonsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page ! of Labor a;"uman Relations Division otsafety Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2x 11 inches in size. Plan must include, but 5~~o x 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 nea r I ~'f ~ -.4 ~V REVIEWED BY DATE APPLICANT INFORMATION-PLEASE PRINT A MATIOIII+~ PROPERTY 0 ER: „ PRO %~S LOCATION { c (or) W J7~ ~1 , !,GOVTC-- 1/4 /q L- 1/4,S T N ,R E ! LL k.~ PROPERTY OWNER':S MAILING ADDRESS. t LOT )VCK # SUED. NAME OR CS # 9'(d L14C CITY, STATE ZIP CODE PH ~r` y'' CI VIL~AGE OWN NEAREST ROAD ( Nc Nu 0 TaN c New Construction Use Residential /Number [ J Addition to existing building j J Replacement [ ] Public or commercial descri Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, 11:2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design/ site considerations rYALUA i /a„ Zi yr:R LjaT A AP-Rt YA Parent material Flood plain elevation, if applicable ft _ E4 UR EP RADE TEM IN FILL HOLDING ZANK S = Suitable for system CONNVENTIONAL MOUND IN- ROUND PRESSURE T G U=Unsuitable fors stem ® S ❑ U ❑ U S❑ U S❑ U S❑ U O S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tench A _ soli - t-, I m c_ r r c S 2 (3 0S 13 7 -,4 - Ground L 1 O f1i C):7 o ,S elev. 9It Depth to limiting faCtor Remarks: Boring # Q lo-IL /Uyr23 Z - L- I 5L k, rn r C Z>~ 0 4 0,5' S, L sbe /I,~ c w ~ p;Z 03 14°3Z y Q - S r rn1 w I O,~ 6`6 Ground elev. Z. S o r r't O,7 4 Depth to limiting ~ fact ~z Remarks: CST Name:-Please Print Phone: 1 g0 Address: , 0, eo)t v flsr) N W) Signature: Date: 1 / CST Number:~4g4 PROPLRTY'•OWNER S,IA SOIL DESCRIPTION REPORT Page Z of PARCELI.D.4 Lo; 1 AN~~>< Iae Structure GPD/ft Depth Dominant Color Mottles Bed Trench Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Sz. Sh. Consistence Boundary Roots . Gr CW 01' Ground 14-2-o 7. Yr2 4 S r- ~h CS Z D elev., B9~ft. -/2 U'/e, 4 S rh 0.7 0 Depth to limiting factor (~6 Remarks: Boring # _ Q O-7 / bvr;3 L, b M r w 2 M Q 4,5 ~4 n-► r C w 24 Ground el 9Z. e6a Ja'Q 4 S r 4 7z ft. Depth to limiting ' ~ factor Remarks: Boring # A p-~ 10'Y L 1 M S b n, ~r C -2 d, 4 p. C s Z O 0.3 .14 L I0` P,4 Ground IQ Z 7.SYre4 4 S Q m >J CS 0.7 9/lft. z'/Jg /Q~ .4 4 S r m a.7 d Depth to limiting > f t~3 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) 3 0~3 5 143 i ~ S4' / i ~ g3 ! w ~ g ~0 s i 1 ~ ~___1ooa"' k \ 110 r G 6 / 1 '~jS.rJC.1x1~'110~RIL - ~ h 1 iQa~J ~~.~.daT1oU' /L)bxu). 0 Irv •0■e•N•<•rnfl • e'•.••.wv.•weE•0 r<• v1•el R• • rt -0 • O Y • C .00 • i C•• r Y V n r••^• Ir. 13 •~•~W °YO"vi °v ~o^w P Y w e e S s. w• •EMe1Of UK AEIERENLLO TO THE EAST- WEST i 00 Ott aF Are w~ M r0 O.v6 f L~~QIW BERLIN 11, 1ff YYEO TO SEAR u K y t.~~ a Mpv a O v ..e Sw :r.0::r• 00, 00 - 6 w e e w _ g : a: e w 6 • e eB e q d E UNALATTED LANDS T ST LINL OF THE K -W V THE KW, KCTION II ~x4 WE x0?T•?T•• n~ x ox rpx ITT • r o £ oa -tit Q o a SF O o ~ a -I s , Q ~3s Co. t 01 lq + • ; i Oa:n' -130•••' - . ~ •s, 'S'Fr o3 179.n ~ • ~ -.W rues- ~vJ ` - gCATED 4a• PUBLIC o 8~~ aoA-D-- MOUND --ROAD-SOUTH'-8 R n Jeri ~D {'yo• y'.°.•1. fI ~ V • ~ ~ > Z I-1 = I _I O IN.T9 fJ ~r , J ~t if r ' -I m IC 1m 70 a / i A y » Q ro IV m o 8 m ralo In, i 4 O Ir N j m B Z" Y • x w m - p 10 -n 171 4 i• a $ I 0 ~'~^1 j ;D lv w IM F s P y W I:1. I m N F5 lass' 504 44 08 E 240.24 I yy I I w O e R N = N 1. / / q J -0 w 14 Ij~s w Pmt u~ IOD 1~ / f•I.Tr p F ~K4.33' _ / 500 '03'20"W 481.72 110.00 6 IN p { '~?e / /T 141 IO IN 10 Y~ m 03 1 I If- ly '-I ~6~ 0 N~ IlM „ ~ a 4i ~1 y N r Qg / Q O p 1 (we 11 .pA rw,:1,•i ,L Q I a.~~•~ D l' '~+I~~~°~JE ~L~`- ' N Co. 1 ' nil ~ ~.~1 R.~\ - ~ fex• ro .r m p I I f 2 n ~ o ~t 8 ~ W _ }T!i i ~ m In 1 i~ ` ac qw J-~ L~ Q gyp= % g In ' . i r 0~ ~ ; ~ /off I• .a ♦ I QQ SJ• gF ! a a a 0 z x =g ~~209• I a $ a~ O ` rye r• J 0, p 3 E » ` a N n 1 ~1 J p Sit Lo sd4 ♦w J f 41 ~ Js s Q - ~L~~ / I 45,6 <'J,00 o_ Ca y9 g ~ 8g `~J,• 2e9 Ir f ,,y } T1N/rY L1N[ i F ~ ~p~Y. 1 $ i 4 LANDS r ° s m a , ~ _ D r 31 C • =Y1•r~•!P: wMiwv ..w v:wsi= ~~gr~pcr~n•r•. w~ rni°~ ~Slt ~ iZ i2w=: -"s $ a i ~ s` s "s ~ a UNPLATTED ~A,yp~ .or irr a M aw s n,r srwf, aresp ■ I ° f a- U 4"o ~ r r) o \ A a as m sR 0 s OR~ _ y OD 179.17 ggz ~--~MOUNDP--ROAD-~SOUc R D~ % Z- C4 I~ s8 Q ^ i- rl 1 Sq 0i SAO rn :1 -1 G) aim n y { t- 1 y l O w % IP IJ ~p.N• y ,yg~ , 4406 E 240.24 # ,~i) v 1 H M r7l / Rm a~ r.~ ♦ J N ~d 0 / 8 oszow ~e,.sz r x Z A D r / 'N 0 n v IWO , x 9 ~ o ~O9w ' a .p f+ d~ m ''~4 J @: O g ~ m -04 \ ~ ~ ~ 3 6 s3 Y =v 88.41 ~'a' c :8L I 1 e~ p J~ ~ c• e e ~*U V"'..r STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER S 4-M /17 /z-L EGL MAILING ADDRESS /-So x, Z S z 0 M" hL L-4 j ( r /l- PROPERTY ADDRESS 10 7 R U c le- /Z I .D h, (location of septic system) Please obtain from the Planning Dept. CITY/STATE v S 0 4 w'r- S_f e? PROPERTY LOCATION S 114,-Alt-l- 1/4, Section T q N-R_ TOWN OF A j A s N ST. CROIX COUNTY, WI SUBDIVISION T 1k S N T P, f D to E LOT NUMBER ~ CERTIFIED SURVEY MAP59 5 W~, VOLUME ~ , PAGE a 5 , LOT NUMBER 1;9- 11 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. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, W1 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. - - g---------------------------------------- owner of property 5,4/M /1.1 i E 2 Location of property S F 1/4 1/4, Section T_A_7 N-R / W Township 1-*) S D N Mailing address M OX l~ Dso,~ L1, 1 -s-':5'0fti Address of site to -7 7__ Q ve- l~ Ai De-jE Subdivision name 7 4 A//V Y R1046 Lot no. I f Other homes on property? Yes k No Previous owner of property RaaySYNAy Total size of property I A4 c. Total size of parcel 2. SI -Ae Date parcel was created 7- . g Are all corners and lot lines identifiable? k Yes No Is this property being developed for (spec house)? X Yes No Volume /b 3/ and Page Number y~ 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. .SD S- 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. MA 1 M7 A S` ature App i ant Co-Applicant Date of Signature Date of Signature 190CUMENT NO. $TATF BA F WISCONSI ORM 1-•1M THIS f✓ACt R[ftRVtD FOR R[COROINO OAYA ARRANTY DIED ' , 04855 YOL 10 3JPAGE 456 r:_GST",WS OFFICE y This Deed, made between Randall_ W. Synan and Patri.cia_ E.__Synan, ' usband and..vife_ ecdhxRocO,d Grantor, I SEP 1' 1993 and Sam E. Mn.ter, a single person Grantee, f R-*sa» ~1 Oeada t Wit~lesseth, That the said Grantor, f a valuable consideration...... ia E. Synan _-__Randall W. S~+nan and PatrIf, conveys to Grantee the following described real estate in ..-St . CrO i.. RaruRN TO County, State of Wisconsin: y Tax Parcel No- The SE1/4 of NE1/4 of Section 11; the SW1/4 of NW1/4, the N1/2 'r of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of NW1/4 except the East 74 feet thereof, all in Section 12; all in Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. FF ~i AND • !W A parcel of land located in part of the NE1/4 of SE1/4 of Sectio' 11, Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin further described as follows: Commencing at the E1/4 corner of said Section 11; thence S89 3010011W, along the North line of the SE1/4 of said Section, 1212.32 feet to the point of --eginning; thence continuing S89 30100"W, along said North line, 66.00 feet; thence SOO 28103"E, 500.00 feet; thence N89 30100"E, along the North line of Certified Survey Map filed in Vol. "3", Page 722, 38.08 feet; thence N00 11133"W, 150.00 feet; thence N03 58134"E, 351.07 feet to the point of beginning. a I` This i_s__r1_Q-t.._ homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances titereunto belonging; And..... Ai41dalI_ W-,_--Synan_. and-_Patr.ici-a.. E-,_-.Synan................. - warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. t and will warrant and defend the same. Dated this rJ 1 3.. day of At1g-ASt....................................... 19 __9. G(iYl -----(SEAL) ~GlaflF.u .E. ~K!*-------•----- (SEAL) Randall W. Synan e Patricia rSynan (SEAL) ----(SEAL) i I - i i AUTHNNTICATION ACHNOWLBDOMBNT Signature(s) STATE OF WISCONSIN i I a& - St. Croix County. authenticated this day of___________________________ 19------ Personally came before me 31........ day of August 19•. the above named -••-a l----l W •-Syna• n-- Pa--- t--•r- i•-ci-,---a---- E - ' R and 1 TITLE: MEMBER STATE BAR OF WISCONSIN Synan (If not, ----------•------••-------•----•-•-----------C I07 ~I'S authorized by 1 706.06. Wis. State.) e i to me known to be the person . $------_H9wy.)MR going instru nt and n wle&{fte# THIS INSTRUMENT WAS DRAFTED BY Rristina Ogland - At-corney--a_t_-taw............................... Alice Joy on~tlors Notary Public -....fit _CY_oi... ---County, Wis. I 7 (Signatures may be authenticated or acknowledged. Both My Commission is permanent. f not, state exp• ation are not necessary.) I~ date- 1Q`1•- J F ONanwe of persons signing in any opacity should be typed or printed below their signatures. WARRANTY DIKED STATE BAR OF WISCONSIN Wiseonsin Lewal Blank Co. Inc FORT/ Ne. 1- 1982 Milwaukee. Wis.