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CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i l 5`D sc~~l I / ,s SS 00 INDICATE P ORTH ARROh' Provide setback and elevation information on reverse of th s form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK' ALTERNATE BM' SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer' - Liquid Capacity: Setback from: Well-. House other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: y/,2 Length Number of trenches Distance & Direction to nearest prop. line:„ /j~-- Setback from: well:,/~L House= Other I ELEVATIONS Building Sewer ST Inlet:/~ S ST outlet = i PC inlet PC bottom Pump Off Header/Manifold 2,: a9 Bottom of system p Existing-Grade Final grade DATE OF INSTALLATION: - - PLUMBER ON JOB: a LICENSE NUMBER: INSPECTOR: ~j 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor.and Human Relations Safety and Buittlings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 233403 PeRMYOWKR INa ❑ Cit ❑ Village Town of: State Plan ID No.: SYomerset CST BM Elev.: / Insp. BM Elev.: 7BM'Description: Parcel Tax N TANK INFORMATION ELEVATION DATA 5 S TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic (L)W_5 Benchmark O.w /Ov, 0 Dosing ' Aeration Bldg. Sewer - H St//Hl` Inlet g TANK SETBACK INFORMATION St/H,(Outlet Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic NA Dt Bottom Dosing Header+ 7 0 9,3 Q9 Aeration ___N A ~ Dist. Pipe -7,7J' ~V-96 ding Bot. System 'K/ PUMP/ SIPHON INFORMATION Final Grade Manuffiij: urer Demand 3 G/ 9Z OZ' Model Number i:EP,M E~~ c9 j. O$ /D. 5l~ ! TDH Lift Lriction system - TD7H Ft Forc in Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length ✓ No. Of Trenches PIT No. Of Pits Inside Dia. Li h DIMENSIONS DIWENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING M cturer: SETBACK INFORMATION -Type O ~7c~ r CHA Model System: OR UNIT DISTRIBUTION SYSTEM Header / Distribution Pipe(s)/ x Hole Size x Hole Spaci Vent To Air Intake Length Dia. Length 2: Dia. Spacing Ce SOIL COVER x Pressure Systems Only xx Mound Or At-Grad stems Only Depth Over Depth Over o xx Depth Of xx Seeded / Sodded xx Mulched Bed/ Trench Center 3 - Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) -S LOCATION: Somerset. 10.30.19W,~NE, NE, 170th Ay v Plan revision required? ❑ Yes 9-60, / Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i SANITARY PERMIT APPLICATION ' 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 ❑ r~ mod 8% x 11 inches in size. check if revision to pre ous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPE TY OWNER PROPERTY LOCATION % X '/4, S T__?,o , N, R /gr (or PROPERTY OWNER'S MAIL N DDRESS LOT # BLOCK # CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 0 CITY VILLAGE : NEAREST ROB 1(,71-5- II. TYPE OF BUILDING: (Check one) El State Owned E3 ❑ Public ® 1 or 2 Fam. Dwelling- # of bedrooms `S PARCEL TAX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/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 in line A. Check line B if applicable) A) 1. ❑ New 2. 0 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 51-1 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 ~ Seepage Bed 21 El Mound 30 El Specify Type 41 El 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./i ch) ELEVATION Feet Feet 5!~11 9e 15) 1 VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank o Lift Pump Tank/Si hon Chamber E] 1 0 E] VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati of the onsite sewage system shown on the attached plans. Plumbe s Name (Print): Plumber Si at Nd ps) MP/MPRSW No.: Business Phone Number: , 07 l -9 1 20 72 5 - lumbers Address (Street, City, State, Zip ode): JJZ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitalao ermit Fee (Includes Groundwater ate Issued I Issuing Agent Signature (No Stapal rO Approved ❑ Owner Given Initial Surcharge Fee)/~~ TTj Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber i INSTRUCTIONS , 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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/Renewah 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. 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 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) ` 47 acs"' ~/EQ ~f B/ti G/ ~yO a aa' ,t36 ~ `/as.~ i ti1f~~ r PAGE OF CrUSS Sec~Iun p~ 1~1 ~e0 SySTe~ ~ A (~15/~li RCr Fresh Air Inlels And Observation Pipe 1 Approved Vent Cop Minimum 12" Above Final Grode 20- 42" Above Pipe _ 4" Cast Iron To Final Grod• Vent Pipe Marsh Hay Or SyntMlk Covering i win. 2" Aggregate Over Pipe Olstribullon Pipe 0 0 0 0 0 - Too 6" Aggregate a Perforated Pipe Below Beneath Pipe o -Coupling Terminating At Bottom Of System PruPose~ ~tnk~ qre ccVc "LieJeJ ton SOIL FILL D1STRIBUTIOU PIPE APPROVED S~ItlTMETIC COVER 2" OF l►6Cry. R F0.AT6. a e OR MAR'SN mk`j OF STRAW 0 8 e (o OF 12-Zi~2 AGGREGATE ~f . MEV. OF22 Z FEET i DI-S-rRItj+JTIOW PIPE TO BE AT LEAST -:;z;_ INCHES BELOW ORIGIMAL GRADE AQU AT LEAST20 WCHES BUT AIO MORE THAM 42 MICHES BELOW FINAL GRADE. /'MAXIMUM ®EQTH OF EXERVAT100 FROM 0KI& NAL 6KADE WILL BE - - IAICHEs MINIMUM ®EPm OF EACAVATIOW FROM. OlikI(,INAL GRAPE WILL BE INCHES SIGMED: LIC-OUSE UUMBE"R: - DAT E : Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page --L of Labdr and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPE OWNER: PROPERTY LOCATION GOVT. LOT - 1/4 114,S T N,R Z~Z Z(or& PROPERTY OWNER':S MAI~(IV ADDRESS LOT~f BLOCK# SUBD. N ME OR CSM # v 1 CITY STATE 1 ZIP CODE PHONE NUMBER ❑ ITY ❑VILLAGE OWN NEAREST ROAD [ ] New Construction Usej~4 Residential/ Number of bedrooms J? [ J Addition to existing building LA Replacement [ ] Public or commercial describe Code derived daily flow er gpd Recommended design loading rate bed, gpd/ft2 j~_trench, gpd/ft2 Absorption area required ,9,n0 bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2_,~trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material IG 4-2/ Flood plain elevation, if applicable ft S =Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ® S E] U MS ❑ U ®S ❑ U [US ❑ U ❑ S 0, ❑ S ICU 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 Trench Ground _ elev. ft. _ Depth to limiting fact Remarks: Boring # 'EM Ground elev. ft. Depth to limiting fact ~L Remarks: CST Name. Please Print Phone: Address: Signature: Date: CST Number: PROPEUYOWNER ~~fi cx rYA) SOIL DESCRIPTION REPORT Page,-.Z oi PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD/ft Boring # Horizon in. Munsell Ou. Sz. Co t. Color Gr. Sz. Sh. Bed Twich p, mu 04 JY14" el) 2,ev- 4 Ground elev. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) zv,- iy~'`~) x .U~y sic /1~, r~o~l,~i~4J AWL eg ~ f/eus~ i STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERIBUYER MAILING ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION -,~LC_ 114,11/C 1/4, Section Z,,~)T __Z4::) N-R-)-~?_W 'SOWN OF s~F,esF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE , 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 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. UWe, 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: ECG, G2~~ 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 AIZ _1/4AIZ 1/4, Section T_N-RW Township Mailing address l ? Address of site ry„o~H~ Subdivision name Lot no. other homes on property? Yes__,* No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for or (spec house) ? _ Yes --No I Volume///f and Page Number 7% a,-, 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 decd 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. _ 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. S.iynature of Applicant Co Applicant Date of Signature Date of Signature (YTATa OF WISCONSIN) F1 1104d by "a C111n a.a 1ud'1.g1 C.` -96 No, S-P, Pl.rrlnty DN4-9hvrt Forty. Soe. 236.31. W St•ty Fors Na f 'VOA"111~~a~F27~ ~{{,,jB ~ri~YttfltXpr Made by tntma Belisle and Edmond Belisle, her +t husbands County, Wisconsin, hereby conveys of St. Croix Bockrzan, his wife, as grantors and warrants to John H. Bookman and Norma A. point tenants, St Croix County, Wisconsin, for re grantees ,of Bother valuable consideration receipt of which.is the- gt Croix County, State of Wisconsin: e the sum of l the following ac o an In Northeast Quarter of the (30), North of Commencing at the Northwest corie0~ °Township Thirty ter Section Ten ( , Rarge Ninet North line o said said Northeast Quar (19) West thence East on the line of said ' I en h parallel with the West h Forty 560 feeet, thence Soul Forty 364 feet, thence West Parallel with the Northto place of of said , thence Forty to the Y! beginning. This is to include the well locate~Sotheretobove described Forty with the right of ingress and eg e Grantors agree to pay all of the 1953 Taxes on the real estate hereby conveyed. i ~ I head s and seals this ~ yn alttntoo MILCUOtt the said grantor x ha ire hereunto set the it 71CK _ day of ,day r~~~'r''~ ✓ ___._---!Seal) Signed and Sealed in Presence of Emma Belisle'* 1 / ems) - Edmond Belisle w-Ifi-------'."_ I Henr C ke Ivah L. Krause state of tatoconoin, ss. I County. btay , A. D., 19 53 . ~ Personally came before me, this 7~ day of Emma Belisle and Edmond Belisle her husban , the above named nt and acknow/ed ed the same. to me known to be the person s who executed the foregoing inst Henry C. Oa key _ County, Wis. Notary Public, o• D„ 19:rS` My commission expires L y.r.w•uw a..sd-u~-s*a.urw I ~-C14;9-WIf. 4k.1~ KMW~Y.R ~D'M•••'~' J