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St. Croix County Planning and Zoning W ednesdRy, September 19. 2007 at 9:0?: 31 AM Detail Sanitary Information Page i of t Computer #: 030-1070-30-000 Sub/Plat: meles & bounds Section: 26 Parcel X: 26.30.19.253C Lot: 4 TN/RNG: T30N R19W Municipality: St. Joseph, Town o1 CSM: 114 1/4: Gov't Lot 4 Owner: Conway. Elmer 931 140th Avenue New Richmond, W 154017 State Permit: 240724 Issued: 07/25/1995 POWTS Dispersal: Holding Tank County Permit: 0 Installed: 09/15/1995 POWTS Detail: NA POWTS Pretreatment: NA Notes Issuer/inspector As Built Plumber Other Reouiremenis Mary Jenkins Yes O'Connell, Kim Mary Jenkins d Off Yes Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 9/15/1998 4/1/2004 04/20/2006 4/1/2007 7/14/2006 7/14/2009 Permit: Replacement Bedrooms: 2 WI Fund: Additional Notes 2 - 1000 gal. Weeks tanks Money Owed $0.00 March 8, 2007 Mr. Wayne Alverman 2301 250'' Street Deer Park, WI 54007 RE: RZ0054 Alverman Rezoning — Town of Cylon, Sec. 1 Dear Mr. Alverman: On February 21, 2007, the Rezoning Technical Review Committee reviewed the above rezoning request and had the following comments to ensure application completion and to address other items of concern for the eventual Non Metallic Mining permit. The certified survey map process should be started and will be required as a condition of the rezoning. As I discussed with you, a lot or parcel cannot have two different zoning districts. Creating a legal lot will allow the new lot to be zoned different than the surrounding Agricultural zoned lands. The Planning and Zoning Committee can give conditional approval but the rezoning cannot be presented to the County Board for final approval until the CSM map is recorded with the Register of Deeds. The next submittal date is April 2, 2007. 2. A letter of approval is needed from the Town of Cylon. You stated that you are on the Town agenda. This letter is required prior to the public hearing scheduled for March 21, 2007. This letter should be submitted to our office by March 16, 2007. 3. A reclamation plan for the portion of the existing mining operation that will not be included in the rezoning or certified survey map will be required as a part of the Special Exception permit process. You will also need a reclamation plan and operation plan for the proposed mining operation in accordance with the requirements in Chapter 14, the St. Croix County Nonmetallic Mining Ordinance. Because your property contains prime soils for agriculture, it is recommended that the post mining land use be returned to agricultural croplands. . 4. Depth to groundwater in the area of the mine will need to be determined. 5. Documentation that the new lot area is removed from the existing Farmland Preservation agreement. Parcel #: 030-1070-30-000 09/19/200? 09:09 Ann PAGE 1 OF 1 Alt. Parcel #: 26.30.19.253C 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN 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 - VAN DYK, BONNIE L BONNIE L VAN DYK 931 140TH AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description ' 931 140TH AVE SC 3962 NEW RICHMOND SP 8040 BASS LAKE REHAB DIST SP 1700 WITC Legal Description: Acres: 0,000 Plat: N/A -NOT AVAILABLE SEC 26 T30N R19W PRT GL 4 COM W 528 FT, Block/Condo Bldg: S 269.5 FT & S 43DEG E 352 FT FR NE COR Tract(s): (Sec-Twn-Rng 40 1/4 160 114) NW NE, S 43DEG E 132 FT, S 46 DEG TO LK, NWLY ON LK TO PT S 46DEG W OF POB N 26-30N-19W gaDEG E TO POB(pROPADD 1392 FROG POND E Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1129/408 PR 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 154,000 64,400 218,400 NO Totals for 2007: General Property 0,000 154,000 64,400 218,400 Woodland 0,000 0 0 Totals for 2006: General Property 0.000 154,000 64,400 218.400 Woodland 0,000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 If you have any questions or concerns, please feel free to contact our office. Sincerely, Kevin Grabau Code Administrator cc: George St. John, agent Joseph Granberg, Granberg Surveying Town of Cylon File RZ0054 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESSyam_ SUBDIVISION / CSM# LOT # SECTION N-R,/9 W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 1100 FEET OF SYSTEM ie i n r II �16 r. J,z 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: n T � SEPTIC TANK)/ PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: /'^ Liquid Capacity Setback from: Well House Other Pump: Manufacturer Float separation Alarm Location Mode14 Gallons/cycle- X1 SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other Size ELEVATIONS Building Sewer 97 yam_ ST Inlet. ..� y ST outlet PC inlet �a '?� �/Rf PS"9 f- Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: C, PLUMBER ON JOB: LICENSE NUMBER: /yam j INSPECTOR:- 3/9 3 j t T' Wisconsin Department Of Industry, Labor and HWan Relations Salty and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Permit Holder's Name: 0 City ❑ Village Town of: CONWAY ELMER I X CST BM E lev : Insp. BM E ev.: BM Description: St. 'Juse;dI TAa1V t&rtfls.trT. &A .... w two 1 I will TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding 'C (d (a) / J / 1 TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. Ventto Au Intake ROAD Septic NA Dosing NA Aeration NA Holding PUMP / SIPHON INFORMATION Manufacturer Demand Model Number GPM TDH I Lift Friction S stem TDH Ft Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM tLtVAIIUN UAIA County: ST. CROIX Sanitary Permit No.: State PI Parcel Tax No.: STATION BS HI FS ELEV. Benchmark d O �• ' Bldg. Sewer Sr/Ht Inlet q�• 4y !Ht Outlet („03' qc,J/ Dt Inlet Dt Bottom Header / Man. Dist. Pipe Bot. System Final Grade BED/TRENCH DIMENSIONS Width length No. Of Trenches I PIT No. Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER TypeOf Model Number: System: OR UNIT UI51 KIBU I ION SYSTEM Header / Manifold Distn ution Pipes x Hoe Size x Hole Spacing Vent To Air Intake Length Dia Length _ Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Svstems Only Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched Bed / Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No 1 ❑ Yes ❑ No LUMMLN15: (Include code discrepancies, persons present, etc.) LOCATION: St. Joseph.26.30.19W, NW, NE, Frog Pond Lane L Plan revision required? ❑ Yes EJ'No Use other side for additional information. SBD-6710(R 05191) Date nspe or's ignature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: nd �`• SANITARY PERMIT APPLICATION Safety 0,BuillingWaterSy ngs Division Bureau of Building Water System 201 E. Washington Ave. In accord with ILHR B3.05, 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 Canty than 8 w x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Nuum' ber The information you provide may be used by other government agency programs Q Check rb pev6us appcaran, (Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number I. APPLICATION IN - PLEASE PRINT ALL INF RMATION Property Owner me Arj Property Location v 114, S T , N, R E(or& Property Owner's Mailing dres le of Number Block Number Cstate 7I Zip Code Phone Number ( ) Subdivision Name or CSM Number 11. TYPE OF BUILDING: (check one) ❑ State Owned O ty mown of Nearest Road Public 1 or 2 FamilyDwelling- No. of bedrooms 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) -30 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 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 tem________System_____________Tank Only _______ _Existirj9 tern __ ____ 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 J,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 S. Perc. Rate 6. System Elev. 7. Final Grade Requir (sq. ft.) Propose (sq. ft.) (Gals/da /sq. ft.) (Min./i ch) Elev ion Feet Feet VII. FORMATION tft in gallons Total Gallons # of Tanks Manufacturer's Name Prefab Concrete core Steel Fiber glass Plastic Exper. App New Existin structed Tnk Tanks Septic Tank or Holding Tank '— ® ❑ ❑ ❑ ❑ ❑ litt Pump Tank/Si honChamber ❑ ❑ ❑ ❑ ❑ ❑ VII(. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility fof installation of the onsite sewage system shown on the attached plans. Plum is me' (P t) Plum r' squat mps) MP/MPR_SW No : Business Phone Number: Plum is Adaress (Stree ity, St te, ZVode). IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee 11nrN+def Grwr4warer Issuing Agent Signature (No Stamps) (Approved ❑ Owner Given Initial 's"�`'er")Adverse ratessue S Determination 5 U X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: S004396 (x. 051941 01SI11111 YN: 0,4mil to county. nno cony to: S,d.ry a NuMiings Qirwvon, fhvner, Plumber INSTRUCTIONS M 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: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed 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, reconne(tion, 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 1/2 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 115 form; and r) all sizing information. GROUNDWATER SURCF(ARGE 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 SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations .Tul,v 1n, 1995 K 0 CONSTRUCTION KIM 0 CONNELL 308 MIDPINE CT STAR PRAIRIE WI 54026 RE: PLAN S95-40646 CONWAY, ELMER NW9NE926,30919W TOWN OF ST JOSEPH HOLDING TANK 2226 Rose Street La Crosse WI 54603 FEE RECEIVED: COUNTY OF ST CROIX The Department has reviewed the above -referenced submittal. 60.00 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 ■e at the number listed below. Please refer to the plan number shown above. Sincerely, e Sw Plan Reviewer Section of Private Sewage (608) 785-9348 1496R/ 1 NUM -I ►ialMo 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 2Q9 W 1st Street 2226 Rose Street 201 E Washington Ave 1340E Green Bay Street 401 Pilot 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 where your review was scheduled Please call any of the listed offices if you need help filling out the form or navenons_on ylhaUnftizmatlon io submit. PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your refere 4 U LI�J 4 6 1. APPOINTMENT INFORMATION -If you have scheduled an appointment, fill in the information requested below to save time: Appointment Date I Reviewer Name I 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 Name El CityElVillage � Town Of: County Project Location GOVT LOT 114 AIZ 1/4 T N R or 3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED System Type (check one): System Type I (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 S200.00 N Non -Pressurized In -Ground Icawenvo a0 9,001 -15,000 gallon septic tank $300 00 P E] Pressurized in -Ground Over 15,000 gallon septic tank $500.00 ... . 0 ❑ Other: Up To 1,000 gallon dose chamber S 7000 1,001 - 2.000 gallon dose chamber S 80,00 Budding Type (check one): 2,001 - 4,000 gallon dose chamber S 100 00 4,001 - 8,000 gallon dose chamber $120 00 D Dwelling, 1 or 2 Family 8,001-12,000gallon dose chamber $ 140.00 P Public Budding Over 12,000 gallon dose chamber $160 00 S State -Owned Building Up To 5,000gallon holding tank $ 6000 5,001-10,000 gallon holding tank $100-00 Code Derived Daily Flow gpd Over 10,000 gallon holding tank $150 00 r� Check If Replacing Existing System Experimental System (additional one time �v��+E' S 300 00 Revisions To Approved Plan z uw0 Petition For Variance: Setback JUL ' 0 gigoo OSite Petition For Variance Evaluation 4 00 Plumbing �f $225 00 ETY b BLDGg, Bliplumn Groundwater Monitoring Groundwater Monitoring - Per Site S 6000 . . (other than a proposed subdivision) Site Evaluation in Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring $ 6000 Subtotal: ......... Priority Review: Enter same amount as Subtotal: ........ MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: ...... l6 — ITTING PARTY INFORMATION No (include area code & extension) Box or I Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers z Revision fees are not applicable to temporary holding tanks or extensions to existing approvals NOTE: Fees are pursuant to Wis Adm Code, Chapter ILHR 2, and are subject to change annually The information you provide maybe used by other government agency programs If rivacy Law, s 15 04 (1) (m)I SBDW-6748 (R.09/94) OVER �� WOconi in bepartmentof Ind ultiy. PRIVATE SEWAGE SYSTEM Sal ety and Buildings Division • Labor and Human Relations REVIEW APPLICATION Bureau of Building Water Systems Haywatd Office La Crosse Office Madison Office Shawano Office Waukesha Olbce 209 W 1st Street 2226 Rose Street 201 E Washington Ave 1340E Green Bay Street 401 Pilot Court, Suite C - ' 08. Boa 8072 LaCrosse. An 54603 P O Boa 7969 Suite 300 Waukesha. W1 53188 I laywa,d.W1 S4843 Phone 1608) 785. 9334 Madnon.W153707 Shawano, W154166 Phone014)S48-8606 Phone(TIS)634 4804 Fax (608)785 9330 Phone (606) 267 5119 Phone VIS)524-3626 Fax(414) 549-861A To. (71 S) 634.5150 F..(608) 2670592 Fax(715)524. 3633 INSTRUCTIONS: To save time, schedule your review with one of the offices lnted above prior to submittal Fill in all applicable data and submit this form together with fees and planyinformation Your submittal must be received at least one working day prior to the appantment at the office where your reviewwasscheduled Please call any of the listed offices if you need help filling out the form or have questions on what information to submit. PLEASE PRINT VERY CLEARLY. AsompleoN<l7mpletedformhon lid nwrw sWe la yow reftlante. 1. APPOINTMENT INFORMATION -If you have scheduled on appointment. lill in the information requested below tosave time: OAppointment Date Reweave, Name Plan ldenbficabon Number 2. PROJECT INFORMATION 0 this renew n a revision or extension to your existing p plan identilicat ion number, provide that number here: o oI Project Name I Tim .TO b ❑ City ❑ Village ®igwn Of: county Project Location GOVI LOT Si:! 114 SW 1145 141 T 10 NR A or W eQQY llu r OZf1. .i.L T�et„v 3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED System Type (check one): System Type l pnchFde new andnktYq tanks) A ❑ At G,ade Us To 1,500gallon feptrc tank ... $110.00 H ❑ Holding Tank 1501 2,500 gallon SeplK tank -. _... 2.501. 5.000gallon WptK tank ... _. ._ _.. S12000 $16000 M ❑ Mound O 5.001- 9.000 gallon wptc tank .. S200.00 ... N ® Non-Pressun7ed In Ground l(an. xw) 9,001 .15.000gallon septic tank ...... $30000 ... p ❑ Pfessurized InGroundOver I S,000gallonseptK tank $50000 O ❑ Other: Up To 1.000 gallon dolor chamber S 7000 _._ 76.00 1.001- 2,000 gallon dose chamber ... _.. $ 9000 .... _. Budding Type (check one): 2,001 4,000 gallon dose chamber $10000 _. 4,001. 8.000 gallon doss chamber 1120.00 ....... D ® Dwelling, I or 2 Family 8.001-12.000gallon done chamber $14000 .. P ❑ Public Budding Over 12.000 gallon dote chamber $16000 S ❑ State Owned Building Up To S,000 gallon holding tank $ 6000 5,001 10.000gallon holding tank $100.00 .. - CodeDerivedDidyFlow gpd Over 10.000g►llon holding tank S1S0.00 ❑ Check if Replacing Existing System Experimental System (additional one time- Feel _.. S30000 Revmons To Approved Plan 7 S 6000 Petition For Variance: Setback 110000 100. 00 ® Petition For Variance Site Evaluation ....... S225 00 ...... Plumbing .. S22500 ...... Reatmn s 7500 ❑ Groundwater Monitoring Groundwater Monitoring - Per Site .. ....... $ 6000 ...... (other than a proposed subdivision) ❑ Site Ev41uab0nmLgPof Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring s 60.00 ........ Subla.l: ......... a1 SO .00 Prlority Review: Enter same amount as Subtotal: ........ MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: ...... Ago. 00 Telephone No (include area code 8 extension) Company E (414 ) 3-75- ii 1190en- I Aerobic or prepackaged treatment system fees are calculated baud on equivalent pre sep[K tanks and done chambers 2 Revnton fees are not applicable to tempo,ary holding tanks or extensions to existing approvah. NOTE Feet are pursuant to Wn Adm Code. Chapter ILHR 2. and are subject to change annually. SBDW 6748(R 0994) OVER xxxxxxxxxxxwllh� ® An appointment to have a submittal reviewed should be made. You do not have to present a submittal in person. Making an appointment will go much quicker if you complete parts 2, 3 and 5 of this form prior to calling. The information needed in part 1 will be given to you after the appointment is made. ® Remember to record an existing plan identification number if submitting for a revision or extension. © System Type, Building Type, Daily Flow and System Replacement must all be completed when submitting a plan for a private sewage system. If System Type is not listed, fill in System Type after "Other." ONote that "Conventional" system is "Non —pressurized in —ground." ORemember to record your telephone number, it is the key we use to recall your address from our data file. Plans are returned to the submitting party. CHECKLISTS FOR PLAN REVIEW SUBMISSIONS Checklists are available to assist submitting parties in evaluating their plans for completeness before the plans are sent for bureau review. Exceptions are petitions for variances, groundwater monitoring, and site evaluation in lieu of groundwater monitoring. The checklists are presented by system type and are organized in the following order: forms and fees, soils information, documentation, plot plan, plan view, system cross section, system sizing, tank and pump/siphon information, and other information specific to system type. Each checklist is intended to be a general guide. Conformance to a list is not a guarantee of plan approval. Additional information may be needed or requested to address unusual or unique characteristics of a particular project. Where specific forms are required, be sure to complete all sections. Please contact any of the offices listed on the front of this form for a copy of the checklists. VOL 1129PAGE247 S95=40646 530941 1 HOLDING TANK AGREEMENT I his space reserved for recording Agreement Date 1 U LY -7 19 S- This agreement is made between the ----------------- County or Local Governmental Unit I Holding Tank(s) Owners) Sr CouNrY I M CoNwAY ST. JogGPH -rVWru sh I�P IGAR`( We acknowledge that application is being made for the installation of (a) holding lank(s) on the following property, (Provide legal land description:) RECEIVED , Lek, ATrAiC u Cn F02nl JUC 10 1995 �pp��sqO�y�cE SEVsitJ1l C3.9 VYO PACrd G7! Ra,w .71C7 I 1995 L I'el�" �. 45�. o a l) ' - .?_- I Return To IIII l A� or [hat continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment ( sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted unde Ch. ILHR 83. Wis. Adm. Code, or Ch. 145. Slats. As an Inducement to the County of to issue a sanitary permit for the above described propert; 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 th. holding lank properly serviced in response to orders Issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 an: 146.14. Slats. the municipality may enter upon the properly and service the lank or cause to have the tank serviced and charge the owner b placing the charges on the lax bill as a special assessment for current services rendered. The charges will be assessed as prescribed t 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 mainlainin the holding lank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall nolit the owner of any costs which shall be paid by the owner within thirty (30) days from the dale of notice. In the event the owner does not pay Il,• costs within thirty (30) days, the owner specifically agrees [hat all of the costs and charges may be placed on the tax roll as a special asses! merit for the abatement of a nuisance, and the lax 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 I 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 owne 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 withi ten (10) business days from the dale 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 ; 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 unde s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in ellect only until the local governmental unit responsible for the regulation of private sewage systems certifies lha the properly is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83. Wis. Adm. Code. In addition, Ihi agreement may be cancelled by executing and recording said certification with reference to [his agreement in such manner which will perm 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 I 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 agreemer to be determined by reference to the properly where the holding lank is installed. Owner(s) Name(sl (Print) I 0wncr(s1 Signature(s) Subscribe and sworn to befor me on this date Municipal Official Name (Print) I unicipat icia Signature a tic G. LQ �%, �.� I My commissleuroomILPill A FAORELNIS WPM C fA 11N11E8pTA Municipalial Title ( rinl r �� 1 l ) 1/31,1 , 7D ea�, 31.200D . A 1 1 DE ' 'of C'overnmpnt Lot Fo r 4 S on At thAt r-ir• _Fh �F, qjr.ce! 19, ti-?,cribe-1 -s.R follows. to -wit: Conn-ncina at the N.S. corner of the HWt of the HE4 of said Section 26, thence rinnino We-t 529 feet; thence runnina South 269.5 feet; thar.T- r,annincy .'I'oljth 43 leeireen. 40 minutes East 352 feet to the i-:.e of bs!r, i nn: no ; thence r1innInn South 43 degrees 40 minutes 7F4rt 132 feet; then-e runni -in So,ith 46 decrees 30 minutes West to 1 the Fitt shore of Siqr Like; thence running Northwesterly on said V, r ..4-t !^orT of 9IV.3 1.4ke to -i point which is South 46 r1acrees and 3-1 ;list of the point of bec-nnino, thence running North 40� '--r-p- -ini 3f inute Fast to he point of beginning. VOL 1.129?Arj1248 ---- - ------ wbocandHumanmelations say, SOIL AND SITE EVALUATION REPORT Page Labor.and Human Relations ag /— Of Division of Safery% Buildups in accordWitli {LtrfR 83.05. Ms. Adm. Cnda. • 0 v a o 4 U 6 Le COUNTY` Attach complete site plan on paper not less than B 1/2 x 11 inches in size. Plan must include, but S-S J , ' not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION —PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION _ GOVT. LOT AILJ 14 All • 1/4,S T ,N,R o q PROPERTY OWNER':S LING ADDRESS LOT # BLOCK # SUBD. NAME OR CS # C TY TATE ZIP CODE PHONE NUMBER []CITY ILLA¢E QTOWN f _ NEAREST RO I New Construction Use jA Residential / Number of bedrooms j Addition to existing building JA Replacement ) I Public or commercial describe Code derived daily flow. ?69 gpd Recommended design loading rate' bed, gpd/112 N/ trench, gpW Absorption area required AIi bed, 1112 Ae trench, ft2 Maximum design loading rate bed, gpd/ft2—4Z—trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design I site considerations Parent material 4JLA1 Flood plain elevation, if applicable ,2:5/ It S = Suitable for system U= Unsuitable fOf S stem CONVENTIONAL ❑ S RIU MOUND ❑ S Q1 U IN GROUND PRESSURE ❑ S C U AT GRADE ❑ S U SYSTEM IN FILL ❑ S RIU HOLDING TANK Z S ❑ U Boring # u Ground elev. yam_ ft. Depth to limiting factor /.2_ Boring # Ground elev. kz ft. Depth to limiting factor R SOIL DESCRIPTION REPORT Moil W Remarks: 0 i xsst r8 a _A11a Number: A(* /3P i`.z'.� �i���✓ ,� S95.4o646 x �S G/1S�O17 141, y-9s E s�st� spa° Poll Aze ditlonatty Con a OO lw t ^ABANDUJ 'MQ EX19TI► G SEPTIC SvSTErh &S rot wog 83.Q31L1 rleelyz�2,, i /VI XSk) ASS`/ S 95 w 406 46 At56 '14f,rf Approved Vent Cap Dater Tight Seal Weather Proof Junction Box' ,48 Vent Pipe Blind Plug roved Joint High Water, Alarm Switch HOLDING TANK CROSS-SECTION S95-40646 Owner's Name: a// Address: / -2 - �� .� �rs�i Legal Discr pt on:7. Township/ County: PLUMBER/DESIGNER Signature: License Nu License' �y Date:. 7- �/-9t- Approved Locking Manhole Cover With Warning Label Attached Final Grade 12" Minim rt� 4" 7 d ra V o °' i 3' of Bedding Under Tank 4" Minimum 18" Minimum Approved Joir w/ . Pipe Extending 3" Onto Solid Soi SPECIFICATIONS Both Tanks Typical of Each Other TANK New Y Existipg Manu acturer: )� ,!;_S Tank Size: 1,0M Gallons ALARM Manufacturer: _ ,�-, ^ f Model Number:_,��,�� Switch Type t� � 0,4 NUMBER OF BEDROOMS: c::� HOLDING TANK SERVICING CONTRACT mlracl Dale v This contract is made between the y 5" 4 0 6 4 6 .7 % s--—— — — — — —— ——————————————————————— olding Tank Owner(s) Name(s) and I Pumper's Name GARS M OD A) ; .5 �,iv le acknowledge the installation of (a) holding lank(s) on the following property: (Provibe legal description:) ME 197To4 C N Fo The owner agrees to file a copy ofthis 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 County of 2. 0-2n 1 X The owner agrees to have the holding lank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding lank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 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; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding lank was serviced; 1. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding lank were delivered. 1. This agreement will remain in ellecl unlit 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 cohtract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. lwner(s) Namels) (Print) el 9 AR� M. (jtuwa� 'umper's Name (Prinl) Noss 1/G90L 'umper's Registration Number i� z Owncr', iflnalure(s) /� I I t I Subscribe and sworn to before on this date: Notary ublic My commission commissiOn eft � STUM9TA. FAGRELIUS' $TUM9TA, FAGRELIUS NOIARYPUIIIIX MINNESOTA w OOrinlIll�31. 2MWAWWWWWAMW ;a0•757+IN. rues) This instrument was drafted by the Slate of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. S95m40646 A1! •het pir: o' GoverncnAnt Lot Foar (4), Sect �oh'26Townah:'P ti Qirc 19. Ianrribel a4 follows, to -wit: Co:n'.-nci-r: 3t 'he Y.F, vorner of :!ie NWJ of the NE- of said Section 25, thence r-tnnino Beat 529 feet; thence runnina South 269.5 feet; t' —r-^ r-inninq :io,jrh 43 ieoreen 40 minutes Fast 352 feet to the of becinn:na; thence runnina South 43 degrees 40 minutes Fa-t 132 feet; then-e runntnn South 46 decrees 30 minutes +hest to the =1st -;hone of 91it Lake; thane running Northwesterly on said ..i-t =`.ore of ?t=s Lake to a pornt which is South 46 decrees and ;1..<.t of •h-� ootnt of bea:nninc., thence running North 1 4r -ini 3) inute!: Fat t to he Point of becinntna. VOL 1129?AGr 248 Wisconsin Department of Industry. SOIL AND SITE EVALUATION REPORT Labor and Irluman Relations Division of safety & Buildinas Page / of .. .,...,.,,,"„..... ..,�.,.,,,,.. ,. COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D.0 not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION —PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION V i GOVT. LOT 114 114,§-,21 T N,Ro PROPERTY OWNER':S LI 0 ADDRESS LOT f I BLOCK a1 I SUBD. NAME OR CS a CITY TATE ZIP CODE PHONE NUMBER []CITY ILLA E ®TOWN NEAREST RO [ ] New Construction Use Residential I Number of bedrooms �2 [ ] Addition to existing building (�Q Replacement [ J Pudic or commercial describe Code derived daily Dow,?w, gpd Recommended design loading rate -4Z -bed, gpd/ft2_dx-_`trench, gpolft2 Absorption area required 0/ bed, ft2 Aslo trench, ft2 Maximum design loading rate _ALf bed, gpd/ft2_.4Z_trw&, gpolft2 Recommended infiltration surface elevation(s) It (as referred to site plan benchmark) Additional design / site considerations Parent material aL&A&,y d;e/2 z2i2 =w-.Ll'.r Flood plain elevation, if applicable It S = Suitable for System I CONVENTIONAL MOUND IN -GROUND PRESSURE AT -GRADE SYSTEM IN RLL HOLDING TANK U = Unsuitable for stem ❑ S ® U ❑ S IOU ❑ S X)U ❑ SLOU ❑ S ®U ® S ❑ U Ground elev. Depth to limiting factor -Z.2-- Ground elev. 2'�ZfL Depth to kmiting factor R SOIL DESCRIPTION REPORT �MIN M �' MM ��MmmNN r'mmmMM Rwmarkc- xsx' MT Name: -Please Print J Phone: 4ddress: ) I Signature: Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Pwge Of� PARCEL I.D. I Ground elev. ft. Depth to limiting factor Momwil �- Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # X, Ground elev. n. Depth to limiting factor Remarks: SBD-8330(R.05192) r°�,� 1 efa • J . S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT _ St. Croix County OWNER/BUY ADDRESS_/37,g2 i l';C G FIRE NUMBER /3 g� CITY/STATE1u&Q Lox ZIP 1!1 2/ 7 PROPERTY LOCATION:_hLU1/4, hK-1/4, SECTION TOWN OF ST. JOS Pik , St. Croix County, SUBDIVISION , LOT NUMBER_ Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 19so, 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. Zoning Officer within ]o days of the three year expiration dq� gypll SIGNED: DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 STC-100 This application form is to be completed in full and signed by Ithe 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/cohtractor,(spec house), thenla second form should be retained and completed when the property' is sold and submitted to this office with the appropriate deed recording. ------------------ C -ttv r----------- ^------------------------------- owner of property Location of - property -&LW 1/4 fV r- 1/4 , Section (r , T_20_N-R1�_W Township ST, JOSUR Mailing address —"6 /�310 .4o f Address of site Subdivision name I Lot no. A. Other homes on property? _yes. No Previous owner of property -F1rl(� �. Total size of parcel 132. xzzs' Date parcel -was created 19410 Are all corners and lot lines identifiable? _ YeS No i Is this property Oeing developed for (spec house)?_ -_-Yes No Volumes" and Page Number 57(_ as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. .In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded n office of the County Register of Deeds as Document No. 31`��j , 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 County Register of deeds as Document No. Signat re of applicat Co -applicant S 1 Date f &4gnature Date of Signature