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HomeMy WebLinkAbout030-1021-70-000 ~ o °o I y 00 I o A: 0 ° 0 69, 6q o ( c p 0. O O o N rly) ~ I I I N \ ~ 1 v ~ I I C^?-`' I I a `V I I 'y I I ti I I I I w w z I ~ z C lL C LL Q ~ Q M Cl) CD (D W Z y y zt E cfl~z am am 0 0 c o z z c c a~i z ° 6 1 ° c Z m z N H C E .O c O v 2 M v 2 M O CD 'O O 0 5 0 y c C (D N vNi ~ ~ c I y ~ c •N a L p a N mc O O O Z C4) Z Z m Z Z Z N d v c y c U.) cc O I (D V! ~ _U N H E Y N IL a c c co a ~g c `n }mil N N y ` O p y d c (D .0 O ~l ° G G a N G G IL O N ~w Q p ~i N N N E N O N o Z v > rr W I N~~~ a a z I~ o~~3 a~ z0 •N 4.; 0a 0 a y aaa = fp 4. -p O N C a0 00 N = In lf) (n N J U 1 p rncn > 0) 0) } Cl) T p ` O r O O N M Q) OO Y rn o w p E O E, U 7 c U E N 4 m c a m ~ co m y LM 2 U v co ¢ < z U) cu Cl) *a O ~ N Y_N! C r. N C O O E ~j c 00 co o w L a) c U n' a) o a) y e a rn C) a c 0 -0 a 0 r- :z O N N O C M O G O O CJ C O d O N N of o to d a~ E o Z c_ o~i a4'i m v H c a~i { a) =3 0) to -6 E O O fn f~ N Z 2 H fn W N O Z_ Z (n V IL € a L: IL 4, t`Iv o R 3 3 0 3 'o t A c~CL 0 NU 0U)0 Parcel 030-1021-70-000 03/21/2006 09:55 AM PAGE 1 OF 1 Alt. Parcel 06.29.19.91 E 030 - TOWN OF SAINT JOSEPH ST. CROIX COUNTY, WISCONSIN Current [X] Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - WIENKE, JERRY W & LYNELLE J JERRY W & LYNELLE J WIENKE 1173 MCKINLEY DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 1173 MCKINLEY DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.060 Plat: 0266-CSM 02/587 SEC 6 T29N R1 9W NW NE LOT 4 CSM 2/587 Block/Condo Bldg: ALSO AS DESC 1332/530 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 06-29N-19W NW NE Notes: Parcel History: Date Doc # Vol/Page Type 12/23/2003 749962 2480/132 WD 2005 SUMMARY Bill Fair Market Value: Assessed with: 83279 246,100 Valuations: Last Changed: 07/07/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.060 92,400 131,400 223,800 NO Totals for 2005: General Property 3.060 92,400 131,400 223,800 Woodland 0.000 0 0 Totals for 2004: General Property 3.060 92,400 131,400 223,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 310 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ` AS BUILT SANITARY SYSTEM REPORT OWNER T40fr A-v GU 6 ~-1o,J TOWNSHIP -t 3-0tE- SEC. , TAN, RI W P.O. A=709 .3qa3 67- ST. CROIX COUNTY, WISCONSIN 'X 424-6!S SUBDIVISION DI&60 4MC02&E LOT 4 LOT SIZE j /7 c ,e cry PLAN VIEW Distances & dimensions to meet requirements of 1162.20 SHOW EVERY`! RING WI T11I:N 1.00A'I.KT O SYSTE c,- 77- SV ay ec's -ems 1 t SEPTIC TANK(S) MFGR./~I2 CONCRETE x STEEL NO:-of rings on cover D Depth DRY S TRENCHES No. of width length area . BED no. of lines wig ~ long: th Z,f _ area9 7 yp 1epr. rc~/l -F, 5p pi.n...._. PERK RATE 945- AREA AS BUILT DISCLAIMER: 'T'he inspection of this system by St, Croix County does noL iMply complete compliance with State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to deter rr ~use of failure. =REASES AND OILS SHOULD NOT BE DISPOSED THROt 'Tllis INSPECT O'V DATED PLUMBER ON JOB. LICENSE # 7-2- 92- r -73q -7 REPORT.OF INSPECTION-INDIVIDUAL SEWAGE SYSTEM ZR San.itany Penm t~ ~G State Septic NAME Towns h i p St. Cno.ix Caun 9 Laces ion. ~ o &Section NRl W SEPTIC TANK Size attonz. Numb r 9 en as,,Com/pa:n.tmentd Distance Enom: We.Qt~--) ..y' fit, 12% on greaten ztope it Bu.itding Cj bt. Wettand~s 6t. H.ighwaten DISPOSAL SYSTEM f Distance Fna m : W ett ` . _ 12% on greaten z Zo pe ..4- BuiZding 6x. Wetlands Ft. H.ighwa,ten it. FIELD DIMENSIONS: Width o6 trench it. Depth aj rock betow tite ~ .in. Length o4 each tine it. Depth o4 rock oven tite gin. Numb en a tines . , . j Depth of tite below grade .3, in. 1 Totat .length o j tines f~ it. Sto pe o j trench kn pen 100 it. Distance between tines ✓ Depth to bedrock _ ~ . Totat abbonbti,on area,, jt2 Depth to gnoundwaten Requ.ined area 2 PIT DIMENSIONS: Number o6 pits Gnavet around pits yeas no Outside d.iameten ! Depth below intet it, • 2 Tatat abdonbtio an a' it z Area nequ1- it2 rn 7 INSPECTED _a. TITLE APPROVED ~r DATE 197 REJECTED DATE 197 1 EH, 1 15 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES QIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION:Section , Rlf®(or)Q~pwnship or Municipality wS Lot No. , Bloc NO. r County ;~__?F Subdivision Name Owner's Name: Mailing Address: , t: 5 TYPE OF OCCUPANCY: Residence x No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW x q ADDITION REPLACEMENT DATES OBSERVATIONS MADE-E: SOIL BORINGS / PERCOLATION TESTS &6-j xA SOILMAPSHEET FF a SOILTYPE 271-2-;2- PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P / [ p SCC ors 7 0 o 3 3 P-071 411 see 0 Z 0 V. 31D 3 O X _32 S~ SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) it vJ7,1SI, it B- 86 y f4 Y a Yi [G J Ct B- Ir T 'el PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate num er o quare feet of absorption area needed for building type and occupancy. o'" ` Indite scale its di to slope. /ri'vv Sys ~+-.t//A~ or distances. Give horizontal and vertical reference 09 ~ .0 34cre- ' 1\1A IL '14PZ 4 I N M / ~ w ~JJ 3 ~ 3 iol- 84 F 34tS 71 , .3 141~- al 711f I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knoAledge an belie Name (print) v r~.► Certification No. -16 c Address tr S Name of installer if known CST Signatu ~ COPY A -LOCAL AUTHORITY PL. B67 State and County State Permit # Permit Application County Per 't # _ for Private Domestic Sewage Systems County lo~ *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing ~dre s* _3 r 7LL-~ 50AI a';k0m av B. LOCATION: Section , T 4"N, R_Zf ro (or) ot# __'V_City Subdivision Name, nearest road, lake or landmark Blk# Village Township Fic C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family ?K%. Duplex No. of Bedrooms -3 No. of Persons QV_ D. TYPE OF APPLIANCES: Dishwasher _.X_ YES NO Food Waste Grinder YES_ZCNO # of Bathrooms) Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY 00 Total gallons No. of tanks ~ *Holding tank capacity Total gallons No. of tanks New Installation X -Addition- Replacement _ Prefab Concrete X *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) -0 2) 3) 46 Total Absorb Area I 2,,;L_sq. ft. New_X Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches _ Seepage Bed: Length"' Width ~ Depth •'i Tile Depth 6 No. of Lines Seepage Pit: Inside diameter L'quid Depth Tile Size Y,o, Percent slope of land D oee y ~y b1 Distance from critical slope 3~ • -Z g .S N ettr i I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Ce ified Soil Pte NAME C.S.T. and other information obtained from owner Plumber's Signature MP/ PRSW# 7`83 Phone Plumber's Address 2246 /1 PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). Al 0"Oe- A* slam, , CIA V 04* NOW J- . IT jr a^s e- \ -30' Yom' Do Not Write in Space Below FOR DEPARTMENT USE ONLY , O Date of Application - Fees Paid: State Coun ~ Date Permit Issued/Rd (date) _ -Issuing Agent Name Inspection Yes NoPY) Valid# Date Rec'd 1. county (whitk co 3, owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, ADISON, WI 53701 2, state (pink copy) 4. plumber (canary copy) Revised Date 6/11/76 7 f _ , . " a 1 ~ ~ ~ ~ ~ t r ~ Al y R r ' . i ~ - { _ A ~ 1 ~ "Y. ~ \ • ~ _ Cy v i 4 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER T©/vl E &IV SOI/ ADDRESS 7 3 c /N 1-0 YE v 11 S p A( w t S yo / ic. SUBDIVISION / CSM#_V04, Z P.4 6 - rt'7 LOT # SECTION ~i T oZ C! N-R_Lf Town o f - 7,' TaS Af/ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Elz j o P o F 3 l oe_lc F611nIo-47101V Q '1776, m AT Al c LoR1yE/2 *F 13~~ 3y; OID s~sTEM - - - - - - o ~8I~Y•i ~ a$ ysp' r S- bs I ! IZ I,f~E 1q` 1`Io Pdz(✓e G~QRwE I 2/f1✓, t - t { INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 40nT¢r /rKE Q~ ©~10 wOy /oo, oa . ALTERNATE BM: Totem o~ l-(o,)SF ~OJnD 4-rION Z 7g/- ~ZZ,g7~ N E 6D2NE/L_ OF Flo vsF SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: LyfE (SE e_ Liquid Capacity: 100® r , Setback from: Well (o_5- House Other 50 T° NE w Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location :SOIL ABSORPTION SYSTEM Width: It Length S ~I Number of trenches Distance & Direction to nearest prop. line: :a-7 To No CULOT L/IlLZ Setback from: well: y0 House ~S Other 8"D 'f c Z -r- 0(r) CIE)) F-1,- 7,5s_ ELEVATIONS , fizd.oS Building Sewer - ST Inlet. _,5. Z S~ ST outlet fo 0 ZQ"~ S PC inlet PC bottom Pump Off t+ q•3 N3s Header/ManifoldkH `i•~o ottom of system ( a. (A = jj~ S Existing Grade 6,• = Y91G_!~Enal grade DATE OF INSTALLATION: PLUMBER ON JOB: `_7 Val Q O LICENSE NUMBER: W-P (LS - D 3500 INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 01JR10 96 Pe~~__ A N,aM E] City ❑ Village "i Town of: State Pla +NtU Parcel Tax No.: CST BM Elev.: Insp. BM Elev.: BM Description: TANK INFORMATION ELEVATION DATA I1~3~ %S TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark 1166, n6 Septic r! G Dosi n~_ Aeration Bldg. Sewer Holding - St/ Inlet yr TANK SETBACK INFORMATION St/ Outlet I lent AirIntato keROAD Dt Inlet F TANK TO P / L WELL BLDG. Ar NA Dt Bottom Septic >56 > 56' Dosing NA Heade- r Aeration A Dist. Pipe Holding Bot. System r r PUMP / SIPHON INFORMATION Final Grade 16,66 I i5•/S Demand Manufacturer Modei- ber G TDH Lift Fr' o e TDH Ft Forcemai ength Dia. Dist. To well SOIL, BSORPTION SYSTEM BED /TRENCH Width Length No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth t/ i T DIMEN I NI D`MEN I N actur SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING SETBACK CHAMBER.,. Model Number: INFORMATION TypeO OR UNIT_ System:Ci --5 DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. Spacing C~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sys s Only FBe pth Over r, Depth Over rr xx Depth Of Seeded / Sodded xx Mulched p~ Bed /Trench Ed es 3 a - Y~ Topsoil ❑ Yes ❑ No ❑ Yes ❑ No d /Trench Center 3 0 g COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: St. Joseph-6.29.19W, NW, NE, Lot 4, MCKinley r e- S~ Plan revision required? ❑ Yes o y~ Use other side for additional information. 30 Date Inspector's Signature Cert No. SBD-6710 (R 05/91) Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. S _ I Ck(i 1 y- • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number L APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name P!operty Location t/1/4IVE 1/4, S T,2 , N, R / E (o W roperty Owner's Mailing Address Number Block Number Tom SO rSutbd 1-7 3 f'n L DR /Yf Name or CSM Number City, State Zip Code Phone Number ivision so syoi~ (396) -7OL 72, AGE SS II. TYPE F BUILDING: (check one) ~J State Owned U !t( age Nearest Road ❑ Wl -ST Public 1 or 2 Famil Dwellin - No. of bedrooms Town OF 5 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) D 3 lDz-l-7o 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3_ ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash S ❑ 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 12E] Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14E] 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/clay/sq. ft.) (Min./inch) Elevation 47 7L- e 16 1 -7 Feet //c?pO Feet VII. TANK Ca aut ingal Ions Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App- New Existin strutted Tanks Tanks ❑ ❑J ❑ ❑ ❑ Septic Tank or Holding Tank /00 O LJErSF Lift Pump Tank /Siphon Chamber ❑ 0 ❑ El ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Sta s) r /MPRSW No.: Business Phone Number: / 9 Z Plumber's Address (Street, City, State, Zip Code): 4-- Z_ so ff Lo 1 IX. COUNTY / DEPARTMENT USE ONLY Disa roved San ary Permit Fee (includes Groundwater ate Issued Issuing Agent Si at re (No Stamps) ❑ pp Surcharge fee) Approved E] Owner Given Initial 14,9 Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) DISTRIBUTION: Original to County. One copy To: Safety & Ruildings 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 sanitary permit application must include: L 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. 111. 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. V1. 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. W f s7 1 e,r/f ~c . t C r t va,©v z D ,i E E MEl1(T.EI - ,1 r d 'X173 m`k/N f ~ c yo ~ ~ o ~ ~J~SO N fitJ ~ ,s_3r4-a74' v ~K~~E ~ xso' 1 N O oN NOTF= L) LL 1-uN a IVE To $E USED y r ~ sY ai I .I r I 536 k I rz • z o 1 0 ~ I p rn j z I I I rn g 1 ~ I I ~ I '1 ~ I 1 I ~ I ~ Z m I m d I -ft w 1 0: I rn I U I r I I ~ W I b C7 I ~ i i ' i j m Z I I I a rrrn j z w QM I Z LA i C f~ x o .t'Y Fri ng i X o ti No m D ~ Ll\ o ° m rn ZO I' I ~ STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County owNER/BuYER ToM E!1E/11:)e /V MAILING ADDRESS ' Ih ` /NL E f✓ ~,Q PROPERTY ADDRESS 73 ~,~/~(L,~ Y ~98 (,V k (location of septic system) Please obtain from the Planning Dept. CTTY/STATE D -S C) /V /.,1 / ) PROPERTY LOCATION Nw 1/4, WE 1/4, Section & T N -RW TOWN OF S r ~/DS~ ST. CROIX COUNTY, WI SUBDIVISION _ C S M LOT NUMBER CERTIFIEDSURVEY MAP 3c/?,?33 VOLUME 2 , PAGE S$ 7. LOT NUM 3ER 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, 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 Location of property 2Zl/4X/6 1/4, Section T~ N-R Township ST o s c f',r Mailing address /(-7-3 //J`tunkEy f{ D,5 o n~ UJ / ~S"C/o Address of site 7 /yt `/c Z- A/L D,e/u ~{yD a T•( j %vi s Subdivision name DAc)tp W,4t orc.~'•( PdZ0,00 C27-~ Lot no. _ Other homes on property? Yes-,X No Previous owner of property DA 11D w 41 12X F Total size of property -1, D 4 Total size of parcel z C Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? X Yes No Volume_ and Page Number cl 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. 3s //(-7 , 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 of fice of the County Register of Deeds as Document No. 17 Signature of Applicant Co-Applicant / ° -2 - Date of Signature Date of Signature AS BUILT SANITARY SYSTEM REPORT ADDRESS = I'OWN S 1111 Sf J-0 e S E C . C, Taj`I, R ,I ~l/dl- ST. CROI?C COUNTY, WI.SCONSTN SUBDIVISION -742 Flr1,v Gl,~~c~,eF =c a fl LOT u X 6 S LOT SIZE c ,cc, PLAN VIEW Distances & dimensions to meet requi.rements of 1162.20 SHOW EVI?,IZYTIil_N( WITHIN 1001,1'1^'i OIL Sy ;I,I M U FAT ~y J a EPTIC TANK(S) 7GR. CONCRETE! STEEL N0, o rings on cover De th RENCHES No. of width en t p DRY WELL - ED no. of l in e s g area t ()p r, F pi.i-)c 97 Gt;l I C;A'I'I. leP! }i to RATE n«rt fZlaC~i~llij:U 95Z-5-1 AREA AS BUILT TSCLATMER; The inspection of this system S Croix )mplete compliance with State Administrative Codes. TheretareootherLareaasy iat it is not possible to inspect at this point of construction. St. Croix )unty assumes no liability for system operation. However, if failure is ned the County will make every effort to deterMine-cause; of failure. MASES AND OILS SHOULD NOT BE DISPOSED THROUGII''TIIIS SYSTEM. INSPECTOR _ DATED PLUMBER ON JOB LICENSE # ~2 REPORT.Of INSPECTION INDIVIDUAL SEWAGE SYSTEM Sanitany Pexmi State Septic NAME a~J Township St. Cxoix County Location..Gea 0&& Section-,~N,R~1,~' W SEPTIC TANK gatton6. Numb en as Olt,xtment6 Size Distance Pxom: Wet 12% on gxeatex ztope 49 J_ 7/ 6t Bu-itding CJ it. wettand,6 ~ . Highwatet DISPOSAL SYSTEM ~ Distanee F,%om: we.C.CVJI .,4t. 12% ox gxeatex atope Building it. wettand.6 Ft. Nighwatex it. FIELD DIMENSIONS: Width of txeneh - it. Depth o4 xack below tite in. Length o6 each tine it. Depth a4 xock oven tite ~ in. Numbex: of tines Depth aj tiZe below gxade in. Totat .length o4 tines (o ? it. Stope o4 txeneh in pen 100 it. Distance between tine6__2_jt. Depth to bedxocfi Tatat ab.6 oxbtion axea / ~ S 2 Depth to gxaundwa ex ~ . Requited axea it 2 PIT DIMENSIONS: Numbex of pits Gxavet axound pit.6 yea no Outside diametWta Depth b eZow zntet 2 Totat aba axbtiit > 2 m: Axea xequ.i rn INSPECTED TITLE APPRO ED DATE 19 7_. REJECTED ,DATE 197 EK1 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES QIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 T~S REPORT ON SOIL BORINGS AND PERCOLATION TES' LOCATION: A /o, "1/<, Section R 111P(or)awnship or Municipality LSD( zo_5jey Lot No. __4_ Bloc No. County C~•~ Sub ivision Name Owner's Name: Mailing Address: 4 _-4 / d 044 /&ZQ640 TYPE OF OCCUPANCY: Residence- No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS 7-- 2 ' 7 F PERCOLATION TESTS '2 -2 7 SOILMAPSHEET SOIL TYPE PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- P_ Ala 3a 3 /0 w s~ SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B- ~iln, ~6„s; y SAij ztl,, wwe_ L~ ~~i c, tl rl 4e I rl l. l 19 S' 13- 3 6~~ ,cL u- 7~'6" g« s, lq"Xil ~c~~ ll S L/ bl. k -r SI` 11 of B_ 46 Jlatt ` K ~sr l 9.:.s,~~ y,~., 2 y.. s- ~O PLAN VIEW (Locate percolation tests,soi I bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate num er o quare feet of absorption area needed for building type and occupancy. ' v~r ` Ind' to scale / or distances. Give horizontal and vertical reference its di to slope. rw&- 34crc .%-Al km VOW - ~ - t N CIS vop- ao w 3' • .3 146-- al 741f I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knovkledge an belie Name (print) Aa~~ sue- Certification No. s,-/a9 Address Name of installer if known 4loo_~~~~, ~Z?t__ ^•OPY A -LOCAL AUTHORITY CST Sign atu State and County State Permit # L B Permit Application County Per 't for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing s- EvP j*A1 3 a A. c, 4,ew 4 7'LA.,As ~ • J, jb, (or) ot# City B. LOCATION: uJ Y< AZ4 '/4, Section , T N, RJO Subdivision Name, nearest road, lake or landmark Blk# Village 0lgur w,q- o1 be &L4_ Township C. TYPE OF OCCUPANCY: *Commercial Industrial *Other (specify) Variance Single family X Duplex No. of Bedrooms No. of Persons ISM , D. TYPE OF APPLIANCES: Dishwasher X_YES NO Food Waste Grinder _YESNO # of Bathrooms-/- Automatic Washer OYES NO Other (specify) E. SEPTIC TANK CAPACITY A4200 Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation X Addition Replacement _ Prefab Concrete X *Poured in Place Steel Other (specify) . ft. ` F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2)_/0 3) Total Absorb Area, 02 -sq New Addition Replacement *Fill System 9yv-" Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length"" Width Ift Depth 1" Tile Depth No. of Lines i~ Seepage Pit: Inside diameter L' uid Depth Tile Size 11101 01 Percent slope of land O oPQ j-S/0" isve from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil to NAME C.S.T. # -/9 and other information obtained from owner Plumber's Signature Sn,_2120" 00, MP/ PRSW# O~83 Phone 38633 Plumber's Address 19j. PLAN VIEW: Provide sketch below. of system (include direction of slope and all distances in accord with H62.20, including well). Norval _ t /xo- ~ f~ 11~v 50 ID f w,Ys QlJrFO' _ , 30 r . Y Do Not Write in Space Below - F R DEPARTMENT USE ONLY O 8 ~ /Date Date of Application Fees Paid: State Qi Coun O Permit Issued/Pd (date _ Issuing Agent Name Inspection Yes No Valid* Date Recd 1. county (whi copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, ADISON, Wl 53701 state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 CERTIFIED SURVEY MAP l)48 .,3"l-3 NW. 1/4-NE. 1/4 - SEC. 6, T29N, R 19W 10 11 2 CO. MON. ~ MAY Pit N i COR. O 1978 SEC. . 6 44*14 bewor Cb~ ei S 00- 11- 12 E 66.0' 66 16.5 S 89 48-42 E 424.66' o, Q10 - ~O P_ 0 ~o LOT-I M ' 3.0 A I BEARING ARE ASSUMED 424.65 S 00=11-12E ON THE S 89° 57I- 4S E WEST LINE OF THE N E 1 /4 0' 75' 150' 300' LEGEND SCALE IN FEET ~o 0 0 = NO. 6 (3/4X 24") RE-BAR M LOT-2 M SET, WEIGHING 1.5 LBS. 3.0 A. PER. LIN. FOOT ~i9o • = FOUND I" IRON PIPE 424.65' N o - -N r S 89-57-43"E o~ (D 8 N ON 424.65 0- S 890- 57-43 E Z ~~9 0 co LOT-3 o p r~ 3.0 A. rn i I 424.65' THIS INSTRUMENT WAS DRAFTED BY A.CN. S 89°-57-43 E JOB NO. 78-05 Not r 4F,.IA „ ~r ~l. LOT-4 0 ALI xm C. • i~,~ o• M Q pa 3.0 A Oc rn is 3.~ NY~IAGEN S-.407 TOWN RD. 16.5' t` N+i~i3a®i~, f WIS. rj 4 24. 65' ~;17 \66'/ S 8905i-4'W VOL. 2 PAGE 587 CERTIFIED SURVEY MAPS Z~p ~j ST. CROIX COUNTY, WI. + DOCUMENT NO. I r s STATE BAR OF WISCONSIN-FORM 2 3,51967 J~S WARRANTY DEED ~,f lj I THIS SPACE NESS RVED FOR RECORDING DATA' REGISTERS OFFICE J. Waldroff_ ST. CnO1X CO., WIS. - Recd. for Record this 26th Aday of sF,nt. A.D. 1928 conveys and warrants to-Thapgq_-W__E~Zenson ard_ JoAnn G._ EyenSOn'_ ------husband and-wife-aa- joint tenants, ~ct o • Rests w of 00eds RETURN TO the following described real estate in St. Croix County, State of Wisconsin: yr S Part of the Northwest Quarter of the Northeast Quarter Of Section 6, Township 29 North, Range 19 West, described Tax Key No. as follows: Lot 4 of Certified Survey Map filed May 2, 1978, in Vol. 11211, Page 587, in the office of the Register of Deeds for St. Croix County, Wisconsin. TR""I'NSP£R s q.~lt~ FEE This -i3 nOt homestead property. (is) (is not) Exception to warranties: Dated this 20th _ day of -$ept 4) 19 78 (SEAL) 4-(SEAL) DAVID J. WAMRDFF (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated this day of STATE OF WISCONSIN 19- (ss. St. Croix County. Personally came before me, this 20th day of -S_s'P-tanberr,_1-978L the auove named _ TITLE. MEMBER STATE BAR OF WISCONSIN (if not, `T~ Waldr►aff _ authorized by § 706.06, Wis. Scats.) _ This instrument was drafted by _ HEYWl70D AND CARI, by SAKIEL R_ CART tome known to be the person- who executed the fore- Hudson, Wisconsin 54016 going lost ent end c' d the same. kZz'`CC Signatures may be authenticated or acknowle * David F • Anderson ( 4ked. b are not necessary.) r' Notary Public -St.CrPJ County, Wis. = My CommisRion is permanent. (If not, state expiration 'z,, date 19 ►tVd;^•n, St. CM1 X Conti, \yt% r' k~ Ccnrn •ain E ~;ra~ Sr+l. 101 lot? WARRAN Y DEED-STATE BAR OF WISCONSIN, FORM NO. 1-1977 ~It~1Ht~01~lO~s~.w