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HomeMy WebLinkAbout034-1022-40-100 r s r STC - 104 AS BUILT SANITARY SYSTEM REPORT ADDRESS ~2 SUBDIVISION / CSM LOS' ~ SECTION. ~C T ,2 f N-R W, Town ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i ~ gm < Ct\ i V lit l L,_ 42C' c' M h ~IV ~s I N D 1 Cn`1 F 14OR11i APPO~~ Provide setback and elevation information on reverse of this Corm. Provide 2 dimensions to center of septic Lank manhole cover. x ' o BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: 12 e, Setback from: Well House Other Pump: Manufacturer. -t ModelV4' G Size Float se eration P Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: _ Length Number of trenches Distance & Direction to nearest prop. line: ;2,e Setback from: well: House_ _Z Other ELEVATIONS Building Sewer ~i~ J ST Inlet. 6~6,. / - ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system ~7j'" Existing Grade C Final grade' edor DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: r 3 1) 3: )L Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: S ~ affety ety and a H Burhauildinngs Rela Divvissio Division INSPECTION REPORT ST. CROIX S GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: @Q~e~Q~ M99 W ; : PAUL ❑ City ❑ Village R Town of: State PI Pl CST BM Elev.: Insp. BM Elev.: BM Description: X Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing / Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet rl Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number 11142 GPM TDH Lift I Friction System TDH Ft - Loss Fiea Forcemain Length/ Dia. ~ Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Lengt 3` No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of f•~~ CHAMBER Model Number: System: r~ L't-:- Q 4 J N OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 2 Dia. Spacing `7/ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) j LOCATION: SPRINFIELD.10.29.15W, SW, SW, ST. HWY. 128 o9- 1~y r = ' 1 S Plan r4d a ired? ❑ Yes ❑ No Use other side f7 additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i ~ , 1 1~ k CE S, ~7 SANITARY PERMIT APPLICATION Busafetyreau o off BuiuiildinWater Systems ng Water ~ 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 4 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. '74_ d /C®/;)( r • See reverse side for instructions for completing this application State Sanitary Permit Numbe The information you provide may be used by other government agency programs ❑ CFieckitt feGision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION S 9 - 7A Propert Owner Name Property Location 1i4 ~1/4, S /d T a2 , N, R/5-20w) W I~.SS e iv 54J - Property Owner's Mailing Address Lot Number Block Number 7,* 142 - A ® y City, State Zip Code Phone Number Subdivision Name or CSM Number Ci II. TYPE F BUILD[ : (check one) ❑ State Owned ❑ 'tv Nearest Road E] Public 1 or 2 Family Dwelling - No. of bedrooms ❑ town of /i1/ Fela~ s /yLv Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 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. Dd 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 M 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 'amw / Elevation o v i b Feet /d'D,?_5'Feet Ca acct VII. TANK in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Tanks Manufacturer's Name concrete con- Stee plastic l . New Existing Gallons strutted glass App Tanks Tanks D M ~JD Septic Tank or Holding Tank / ~2 OD l ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber JH O / S N El El 1:1 1:1 ❑ 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: (N tamps) MPMIIRWAMONQ,.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): ly2 2 / 70 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamas) JJONDITI0 pproved I Owner Given Initial Surcharge Fee) f - Adverse Determination CQ0 VVV N S OF APPROVAL / RE SONS FOR DISAPPROVAL: DISTRIBUTION: Original to CnuNy, One copy To: Safety 8 Buildings Di-ion, Owner, Plumber I 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: 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 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 isto 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/wat_; scr .e streams ar-d lakes; pump or siphon tanks, distrii~ ution boxes; soil absorption systems; replacement system area,.; ar i the lo:ati(~n of the building served; B) horizonWi and vertical elevation reference points; C) complete specifict,tion, for pumps an( controls; dose volume; elevation differences, friction loss; pump performance curve; pump rnodei and ;)ump manufac_urer, D cross section of the soil absorption system if required by the county; E) soil test data on a 1 11 'orm; and F) a l sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) fora number of regilated practices which can effect groundwater. The monies collected through these surcharges are'used for monitoring groundwater contaminatior investir and establishment of standards. Q w e 4 z 0 a FROM : 1'3T NAIL BAr,& GLENWOOD 715 265 4388 1'9' 6. X E-2'3 14:31 #017 P. 01:'01 yl I i I D' _ _...3 h--' _ N_.f.. ~o i~?encwy s~% ~s"~ .L/n~ c.°.~ ~ >`~r~ I - ► I ~ - - - A Ag•~d0' ;A-qtr Ik s - - - - ~b~- - ~ i - c r GAS SG-oAP, ' ~ I~ I~ I ~ ~ f ~ I i I f . _ i I ~ ! ~'I . ..I .I. ~ x~ty'"~~ I - l--•-~~~----j. I _ _j _ i - _ i . I _ ~ l I ~ ~l -40 . `__.l 1.... - ~ I _ P-~LVAT-E--~ -eo IrT -dEPTjQF USTRYJA O I& MAN R ATIpNs. 77 i 5E E-E© NDENCE - - ~ j { _ - - - _ - !SCI , I 1 I I I . 1 0 I ; 1. _ I 1 i 1 I I I I ,l r I ~ I I ~ I - - -?L-6AS LE Al P- AA ~r T-Q T ~~1-I~~j~ t~ I- : I 1 o ~ J DS . ; I ~ y 1 I _ I ; I ~ L - !-1- i- - ~_~~-----i- - --1 I- - 21, Page 2 Of Straw, Marsh Noy, Or Synthetic Covering Distribution Pipe A% c3~ Mv4jum S a n d _ p-- G Topsoil = F _J E D 3 ' % b Slope Bed Of 2'- 2 (Force Main Flowed Aggregate From Pump Layer D Cross Section Of A Mound System Using , F -1 77_ A Bed for The Absorption Arec i G Signed: t)35. [ t License Number: Date: z f t . h - - - PA Force Main _ _ J From Pump Z Pl~IV E SFeVV n G7 SEf M `2 Distribution Bed Of 1 o, Ti Pipe Aggregate A DEPT D IN US servation Pipe Permanent Markers Y, LABOR HUMAN RELATIONS IS N SAF Y SEE C RRESPONDENCE Plan View Of Mound Using A Bed For The At,sorphon Area Page. Of Perforated Pipe Detail i End_ View ~1~ 1 FP'tOr 01eC - . En': CoD~ Vc, f.pp in Holes Loco led On [Initon Are Equally Spaced l K- f.-,O 14 /At yATE SEWAGE SYSTEM i~ y, LABOR & HUMAN RELATIONS IIr' `~'t GI ; M : Ty AND BUILDINGS I~oe I,,, ` vr~ :r-, F Ft. 702._ Inc.hn~ 142, _ Inches 1h1 c. r)i, -ter ~V ; nc.fl l at,era1 / 1' Encl ' l icensc IJu ' ~r: M~9v Ha nifold p 1nchr,~ flaiC, 6 " 7- Force (lain 02,0 Inche,. - ; of I101 es/pi Pe 2 Invert. Elevation of Lateral s9p_4?Ft. 0 I It 724 PAGE OF, PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP 4' C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUNCTION BOX MANHOLE COVER 25, FROM DOOR, ~J~i/fc.~4,L+t1~~l16rCN/SCC, W NDOW OR FRESH 12"MIU. PIP, INTAKE I ww RADE 1 A"t ) Z4-,O 4° MIN. CONDUIT _ r- fI-kii",D INLET PROVIDE I AIRTIGHT 5 '~4TE SEWAGE SYS APPROVED JOINA PR' III D J C.I. PIPE C,d~j~ tas~ PE EXTENDING 3' 9145°'°~. nwi f ACUTO SOLID SOIL S)1 O N C DEPT OF IND USTRY, LABOfi Hip,"v-AN RE rCK - ELEV FL - IbISiON OF SA ETY AND S J OFF SEEfyRCSrG~~`~I aSd 4 C E~ RISER EXIT PERMITTED GULIJ IF TAAJK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFICATIONS DOSE "AUKS MANUFACTURER: eSeiT IJUMBER OF DOSES: PER DAy TANK SIZE GALLOMS DOSE VOLUME ALARM_ MANUFACTURER: S.1' ~e ~QD INCLUDING BACKFLOW: 17Y GAI-LLw S MODEL UUMBER: - ZO Z Ld CAPACITIES: A= INCHES OR We GA Zfok; 3 SWITCH TYPE: M e, cl v INCHES OR Q~~GALLOWS PUMP MANUFACTURER: Gay 6 dS C = INCHES OR~-'~ CALLOW.: S MODEL NUMBER: 41150J ~ DINCHES OR 6y,~ GALL01,1S SWITCH TYPE: S.T ~Le~7`Ra I2FFy OTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE -rs .1 ~3 .PM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTIOUY'IPE..-22.0 FEET + I1t M NETWORK SUPPLY PRESSURTTE~/.. . . . . . . 5~ FEET +I~ FEET OF FORCC MAIN X • A F/ppFXFRICT10M FACTOR. ..z'! _ Ff T . TOTAL D9UkMIC HEAD = AS LlZ FEET 1 INTERNAL. DIMILUSIONS: OF TANK: LENGTH 6 ~ ;WIDTH •;LIQUIO pEPTH a, 041-? SIGNED: LICEMSE NUMBER: DATE: Goulds Submersible Effluent Pump 3885 1 CANADIA% STANDARD ASSOCIATION SP APPLICATIONS • Three phase:'/2 HP - FEATURES Motor: Fully submerged in Specifically designed for the 1'/2 HP 200/230/460 V, Impeller: Cast iron, semi- high-grade turbine oil for following uses: 60 Hz, 3500 RPM. Class B open, non-clog with pump- lubrication and efficient heat • Homes insulation, overload out vanes for mechanical seal transfer. • Farms protection must be Designed provided. in starter unit. protection. Balanced for for Continuous • Trailer courts smooth operation. Silicon Operation: Pump ratings are • Motels Shaft: threaded, 400 series bronze impeller available as within the motor manufacturer's • stainless steel. Schools • Bearings: ball bearings an option. recommended working limits, Hospitals upper and lower. Casing: Cast iron volute can be operated continuously Industry without damage. • Effluent systems • Power cord: 20 foot type for maximum efficiency. standard length (optional 2" NPT discharge adaptable Bearings: Upper and lengths available). for slide rail systems. lower heavy duty ball bearing SPECIFICATIONS Single phase:'/3 and1/2 HP Mechanical Seal: Silicon construction. Pump: -16/3 SJTO with three carbide vs. silicon carbide Power Cable: Severe duty • Solids handling capabilities: prong plug. 3/4-1'/2 HP sealing faces. Stainless steel rated, oil and water resistant. W maximum. -14/3 STO with bare leads. metal parts, BUNA-N Epoxy seal on motor end • Discharge size: 2" NPT. Three phase: 'h-1'/2 HP elastomers. provides secondary moisture • Capacities: up to 128 GPM. -14/4 STO with bare Shaft: Corrosion-resistant barrier in case of outer jacket • Total heads: up to 123 feet leads. On CSA listed stainless steel. Threaded damage and to prevent oil TDH. models - 20 foot length wicking. • SJTW and STW are design. Locknut on three Mechanical seal: silicon phase models to guard 0-ring: Assures positive carbide-rotary seat/silicon standard. against component damage sealing against contaminants carbide-stationary seat, 300 on accidental reverse rotation. and oil leakage. series stainless steel metal parts, BUNA-N elastomers. • Temperature: METERS FEET 1040F (400C) continuous 90 140°F (600C) intermittent. - _ _ - i__-- sERIES:3885 • Fasteners: 300 series 25- SIZE: 80 wE1 RPM: VARIOUS S stainless steel. j __W SGPM - - r- ! • Capable of running dry 70 E1 5 FT _ i without damage to 20 _ - _ components. W 60 E07 H-N Motor: So ! • Single phase: Y3 HP, 115 z 15 I - - or 230 V 60 Hz, 1750 RPM; 0 40 'EO '/2 HP, 115 V, 60 Hz, a - - 3500 RPM; '/2 HP -1'/2 HP, ° 10 30 ~ I . # 230 V, 60 Hz, 3500 RPM. wEO Built-in overload with 5 20 ! automatic reset. Class B insulation. 10 _ A 0 0 0 10 20 30 40 50 60 70 80 90 100 110 120 130GPM I I I I 0 10 20 30 m3/h CAPACITY © 1994 Goulds Pumps, Inc. 7 -Effective May, 1994 11 B3885 SOIL AND SITE EN - PURE Pap -/.I- °i 4 DILHR in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete'sits plan on paper not less than 81/2 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 PROPERTY OWNER: PROPERTY LOCATION )Of y 1 y GOVT. LOT sW 1/4 1/4,S G T .2 N,R / VMW PROPERTY OWNER'S MAILING ADDRESS LOT / BLOCK # SUED. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE BrOWN NEAREST ROAD a!~ (7 la?~,S = /.S' e d S /-Z8 G /./or CIO/ eltx (j New Construction Use Residential / Number of bedrooms Addition to existing building L4 Replacement Public or commercial describe Code derived daily flow Zaa gpd Recommended design loading rate ; bed, gpd$ trench, gpd/82 Absorption area required 00 bed, 112 trench, ft2 Maximum design loading rate : bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) 7 8 it (as referred to site plan benchmark) Additional design / site considerations Parent material GL A 6,1:4r Flood plain elevation, if applicable /Y .4 it S =Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem [IS ®U ®S ❑U [IS ®U DS ®U OS QU OS ®U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench a -/o D ;z S 1 J • 7 - 9 IS U_""~~ 110-1912, 04 M 2 If/ V Ground 3 W-91 7, 5rg,* fL 91- 6 o M C S 5'--7 114 7 elev. ;;t e - l0 Depth to limiting factor Remarks: Boring # 10-7 ~0 s /R /V -14S 3A i OF ;ry 1 4 _q 3 ;z 1-3 L z s w C /d .3 a .-r s Se 36"Ar Al v Ground / elev. .S ft. RE CE LCE V... L9 e~ e Depth to I f ! ,iv limiting factor i..A $ ; r, n V -A C~:1 .IT 1~ t, Remarks: Ile CST Name:-Please Print G~ L SM Phone. Address: 3 2 8 G1J 170 ~r~ e N Rio a d C/ Signature: Date: _ 9~, CST Number: PRMERTYOWNER- 414 R,4S/ 9rj r4601L DESCRIPTION REPORT p of PARCELd.0 ff Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourd3y Roots GPD/ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tw& ,3 /0 S F S 7 81 lo .311 ;2 /Z Ground 3 .1~-5 O 6 c .5" S" ~ s F//►'~ L- Gc1 elev. ys ft. -6 /0 -6-le .,s s 3 V-0. v r M Depth to limiting factor F-F i 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: I ! I - i - - - C i I i C 1 _ © - LL - - i I ; f- I I ~ i- i y ' • Pe-F - - • - --I--- - i - 00, i i i- I I I F , r - I 1 ~ I' Ij , I I I I ~ ( I i i I I i I a I I , I II , I ` I r I I r I I I I I i i , I I ~ C i i i-- I- I-=-- I I I + i I ~ I 2L LIL I - ~ i ~I I I , ~ I I I , a . I I I ' - r - - - , r.-_ I _ - I ~ i I i I } I r. I i I r I j -_I - --L - - - i- - - - - - - - - - 1 - - I t - - - - ~ r- i - _ _ ` i- 'I ~ I it I , I 1 I , , I I I-I - - - I , I ~ I i I - I I ~ I_ I I -I - I I ` ~ I I I I I I I i t I I - I _J I I I I I ! ~ i ~ I. I I I I- I i Wacr,.d Department bons Industry, SOIL AND SITE EVALUATION REPORT P ,labor and Human Relations age Of 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 PROPERTY OWNER: PROPERTY LOCATION a ~ti e~ GOVT. LOT e ~ 1/4 w 1/4,S /,0 T ,N,R S- E (or f 7 PROPERTY OWNER':S MAILING ADDRESS LOT If BLOCK # [SUBD. NAME OR CSM # CITY, ESTATE ZIP CODE PHONE NUMBER ❑CffY []VILLA E ECOWN NEAREST ROAD K, 4-A ItIl S7 [ ] New Construction Use ( /1 Residential / Number of bedrooms [ J Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow G0 gpd Recommended design loading rate , Z bed, gpd/ft2 trench, gpd/ft2 Absorption area required .5-do bed, ft2 trench, ft2 Maximum design loading rate bed, gpolft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) 0 .7. It (as referred to site Ian benchmark) Additional design / site considerations Adlr( mss, o Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ❑ S 0 U D S ❑ U ❑ S B U ❑ S l~ U ❑ S 'o u ❑ S 0 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouldaty Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench a-/o ✓ 71r a S _T J41 -S-4t *f Ground elev. ft. i 0 - 5 .z. - s f o .15' !si / ,r H+ Depth to limiting factor -az s _ y 6 s n► / v ,,2 07 L/ 2- 2 _S7 - L O f Aof I - D 8 Remarks: -z.2" solo c a7< z<~r sr G' ~r4 Boring # Ground elev. z _ _ 6 e pA ' i s 7 95 ,10,4 ft. Depth to limiting 3 r_ s 'r 7 factor , 91 Remarks: fiel -3 - 7' _2 > 57-D CST Name: Please Print v f7 Phone: P r s Address: / / o ~ r fi~ ~ s 3 Signature: Date: j j/f 7 CST Number: 3,233 PROPERTYOWNER f~wurse•-c_ SOIL DESCRIPTION REPORT Page - of 3 PARCEL I.D. # ' Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BOUnd3y Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench a'~'»~ D^ 2 2 ry hr v r S h1 , d' Ground elev. aa.D ft. ~i - S 2 rit Depth to limiting factor 56 3 k, i~-r ~i - . D , d Remarks: ;4 f / ~r > S~ I c f 1/ Boring # SS~{n'? s'::i: yT yGround elev. ft. Depth to limiting factor Remarks: Boring # r Ground elev. ft. Depth to limiting factor Remarks: Boring # ;A,;:; . Ground DAelev. & Plum ft. 289 Depth to F t36556 ROBEE limiting one 74 factor Remarks: SBD-8330(R.05/921 a c~ g v N 1 0 l' M s ~ CLI M j t. ^o ~ 6 %kO f Oo 1 ti ~ d 530893 CERTIFIED SURVEY MAP Located in part of the SWj of the SWj of Section 10, T29N, R15W, Town of Springfield, St. Croix County,- Wisconsin. N Wk Corner of Section 10 FILED 0 o to z JUL 6 1995 o g At.o - KATHLo H. WALcli ~ d ~ 0 ~ R11`1 of Oe s L. o a St Croix C0, WI d- y 01 `mom Z ip.-ON N .1.> UNPL-51 TEID L, NDC, _ ; CO io N UO N89°13'58"E 425.00' 12 4J W 00 X59.43 VII -65.57' , 0LI 1 <I JI ' 12 ' LOT 1 n1 Y. OM `I 7.74 Acres Inc. R/W w _ UJI <1 I 337,073 Sq. Ft. N I tf py~,,. ~I o oI w; nI _ 6.20 Acres Exc. R/W W 269,889 Sq. Ft. 0 71 wl>>I 00 Ln 011 <I . Q- JI ac 27 006141 11W 3 ~I °MO 126.17' v> o O d O Z M O Z to . O APPROVED OO 9 OWNER so' 65 f^ 3 David and Margaret Rasmussen 1051 Highway .128 w ~Nf Glenwood City, WI 54013 JUL 5 95. 0 _ o BEAVER CREEK CO o o i•1" . CROIX COUNT`( LT-8 9°13'44 WI L'ornpr an Ptanr~ir 211 78' Zoning Parics Committee N89°13'58"W 272.18' `D SW Corner of 100T I-I AVENUE If not recordation 10 933,1 1 50, witfdn 30 days of - - approval data I L ,".4 & void d South l i ne of the SWik +Qproyal Sn E3 LINPLA-I TEID LANDS I _ 55' 50' LEGEND Aluminum County Monument Found 0 Berntsen Survey Marker (Nail Set) Scale in Feet 1" 200' O 1" x 24" Iron Pipe set, weighing 1.68 lbs per linear foot 0 50 100 200 300 • • • • • • • • • • 100 foot roadway setback line - 75' water setback line This instrument drafted by Michael Erickson Job No. 95-53 VOLUME 10 PAGE 2952 J A f\J STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER P,# 4Z eA 5 /mil 41SS& N MAILING ADDRESS 3f1 ~C lea j/ ,4 PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATIONsl41 114,,54-J 1/4, Section TL25? N-R ` W TOWN OF SRR/Na~ a/ ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER E;m' CERTIFIED SURVEY MAP , VOLUME, PAGE2Y~, 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: da_n~-.= DATE: C( . St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, W1 54016 11/93 STC - loo 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 &A/ /`FNS /~1 ~fSS` /`r Location of property (r,i 1/4, Section /O ,T,y2XN-R~-W Township &.Z Mailing address ,30 Address of site. /p / ~/lvy 1~2y Subdivision name Lot no. Other homes on property? Yes_ X No Previous owner of property ~f) Pfd A'/fs /v) Total size of property 7 t A a e e Total size of parcel 7 7- 4,C Date parcel was created Are all corners and lot lines identifiable? _X -Yes No Is this property being developed for (spec house) ? Yes A No Volume ~ and Page Number !V-2 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. C7 ~6 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 office of the County Register of Deeds as Document No. 5 signature of Applicant Co-Applicant 6 -a2 6- Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 3-1982 THIS SPACE RESERVED FOR RECORDING DATA QUITCLAIM DEED 530767 0_ 1128PAGE425 r.. ,mil e4 i/*i j David E. Rasmussen and Margaret J Rasmussen, Husband and wife as joint tenants JUL 3 1996 quit-clalmsto Paul A. Rasmussen and Janice M t 9:30 A.fA Rasmussen, Husband and wife as survivorship marital property. ~gn.. the following described real estate In St. Croix County, State of Wisconsin: RETURN TO n 3 C 110 100th (3o'o' Part of the Southwest uarter (SWk) of the Southwest quarter Mk), Section sy 3 Ten (10), Townshi Twenty-nine (29) N, Tax Parcel No: Range Fifteen (15~ W, more particularly described as follows: Be innin at the SW corner of said Section 10; thence N00°46'02"W; along the west line of the SWk of said section 953.27 feet; thence N89°13'58"E) 425.00 feet; thence S00°46'02"E, 459.58 feet; thence N890 06141"W, 126.17 feet; thence S02°16'22"W, 505.34 feet; thence N89°13'58"W, 272.18 feet to the point of beginning. Above described parcel is subject to right-of-way for State Trunk Highway "128" and town road (100th Avenue) and subject to all easements of record. Also described as Lot One, Certified Survey Map No.530893, in Volume Maps, Page No. q.5 Register of Deeds for St. Croix County. EXEMPT This is not homestead property. Tip (is not) Dated this day of 01 o 7, c,,- 19 95 (SEAL) (SEAL) David E. Rasmussen (SEAL) -;'-rG~GI/r e ~(SEAL) Margaret J. Rasmussen AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN St. Croix SS. County. authenticated this day of , 19 Personal ame before me this day of 19 the above named Devi d E. Rasmussen and Margaret T_ Rasmussen TITLE: MEMBERSTATE BAR OF WISCONSIN (If not, to me know p~t'Q A _an S who executed the authorized by § 706.06, Wis. Slats.) foregoin'tr i I~~bb rio.wledge the same. THIS INSTRUMENT WAS DRAFTED BY 1 - Francis X. Rivard Maki Hal ist g e ni = Glenwood City WI 54013 t Notary;-p -County, Wis. (Signatures may be authenticated or acknowledged. Both My Com 9~on Is pear t~ (l.f not, state expiration are not necessary.) date: Ma'',71•0'1 19 - ~ yy 'Names of persons signing in any capacity should be typed or printed below their signatures. SB3 NTF 0023 QUITCLAIM DEED STATE BAR OF WISCONSIN FORM No. 3-1982 Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208