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Home My WebLink About006-1070-10-000 St. Croix County Planning and Zoning Friday, February 23, 200' at 10:42:35 AM Detail Sanitar Information Page 1 of i Computer #: 006 - 1070 -10 -000 Sub /Plat: NA Section: 31 Parcel #: 31.31.16.479 Lot: TN /RNG: T31NR16W Municipality: Cylon, Town of CSM: 1/4 1/4: NW 1/4 SW 1/4 Owner: Powers, Marty 1849 200th Street New Richmond, WI 54017 State Permit: Issued: 05/03/2006 POWTS Dispersal: Non - Pressurized In- ground Permit: Reconnection County Permit: 100 Installed: 05/03/2006 POWTS Detail: Bed- Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer /Inspector As Built Plumber Other Requirements Additional Notes Money Owed Ryan Yarrington NA Powers, Calvin $0.00 Not determined Sioned Off: No n =, ntenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 5/3/2009 Owner: Powers, Marty 1849 200th Street New Richmond, WI 54017 State Permit: 289499 Issued: 08/14/1997 POWTS Dispersal: Non - Pressurized In- ground Permit: New County Permit: 0 Installed: 08/20/1997 POWTS Detail: Bed- Seepage Bedrooms: 0 WI Fund: No POWTS Pretreatment: NA Notes Issuer /Inspector As Built Plumber Other Requirements Additional Notes Money Owed Not determined Yes Powers, Calvin pull this permit and file with reconnection 2006 $0.00 Mary Jenkins Si Off: Yes Maintenance S Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 8/19/2000 10/1/2003 04/01/2005 10/1/2006 11/1/2006 1111/2009 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division - INSPECTION REPORT Sanitary Permit No: 100 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Powers, Marty I Cylon, Town of 006 - 1070 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 31.31.16.479 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration R 1112,31 Sewer Holding BVWInlet SF/Ht Outlet TANK SETBACK INFORMATION Vent o Air Intake ROAD Dt Inlet ep is Bottom osmg ea er an. era ion Dist. Pipe Holding t3ot. System Final Grade PUMP /SIPHON INFORMATION anu ac urer eman over GPM o e um er i nc ion oss system rtead t-orcemain I Length i . SOIL ABSORPTION SYSTEM DIMENSIONS INFORMATION CHAMBER OR t ype 01 System. UNIT Pipe(s) Length Dia Length Dia Spacing x Pressure Systems Only xx Mound Or At -Grade Systems Only Bed/Trench Center Bed/Trench Edges Topsoil Yes ' No Yes 7N. COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1849 200th Street New Richmond, WI 54017 (NW 1/4 SW 1/4 31 T31N R16W) NA Lot Parcel No: 31.31.16.479 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? I ] Yes 1 ] No Use other side for additional information. I — Date -L -- -- i — _ - - -insepctoPS Signature - - der. SBD -6710 (R.3197) RECEIVED ,►+� Coun San tary Permit In accord with Chape APPS e�tlQ�v ST CROIX COUNIY WISCONSIN i Personal information rih Sall ry Or %2& 0 1 2 0& PL NG & ZO NING DEPARTMENT You provide may be used for s nd purposes (Privacy Law. S. 15.04(1)(m)j ST. CROI COUNTY GOVERNMENT CENTER ST. CROIX CO NTY 1101 Carmichael Road Hudson, WI 54016 -7710 Attach com ete an$ for the s stem on a 386-468o Fax 715)386 -4686 ❑ County Sanitary Permit # not less than plic ti 11 inches in size. ,� WellCheck if revision to previous application Iicawne Information - Please Print ail Intor tnatWellOwner Name n tion: peo N � 1/4 SW fs 1/4, Sec roerty p Owner's m iing Address N, R E (o w icy, State of Number Block Number `' � Zip Code Phone Numer r � U-51 C - / Subdivision Name or CSM Number t lYpe of Bufiding; (shed on t 7! 5 or 2 Family Dwelling - No. of Bedrooms: 0 � � ❑ P ublic/Commercial (describe use): -- --�.�� 45 5 y!O�' ity ❑ Village Town of ❑ State -owned i- Type of Permit: D ✓� (Check only one box on line A. Check box on line B if applicable) Ne est R A) 1.0 Repair .Reconnection ❑Non-plumbin rce ax Number(s�� g ❑ Rejuvenation Sanitation � O f Cy State Sanitary Permit was previously issued Permit Number (g j , `/ Date Issued N. Type of P (Check all that apply) K Non - p ressuriz ed in- ground Mound a 24 in. suitable soil Cl Sand Filt er ❑ Mound S 24 in. suitable soil 1 3 Mound A +0 ❑ Pressurized In- ground ❑ Constructed Wetland ❑ Peat Filter ❑ At- grade ❑ Holding Tank ❑ Drip Line DI saUTrea ❑ Aerobic Treatment Unit ❑ S ingle Pass 11 Other tment Area Information: ❑ Recirculating Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application s.ft Rate 5. Percolation Rate Required Proposed 6. System Elevation 7. Final Grade 1. 5 v/ 6 7 ✓ (Gals.lday /sq.ft.) (Min. /inch)N Tank information C /J 7 /� Elevation apaicty in Gaikms Total # of New Existing Gallons Tanks Manufacturer Prefab Site Con- Steel Fiber - ' Tanks Tanks Concrete structed glass Plastic pZrc7 If. - ❑ Responsibfl ❑ ❑ rty Statement ❑ (� ❑ ❑ ❑ the undersigned, assume responsibility for repair/ reconnenc /rejuvenation/installati of non- p►umbing for the POW rise is not required for terralift r it or the insta8atio of is Name nt mbing sanitation system. TS shown on the attached pions. A ) % Plu not a (no stam s): BPS MPR o. Business Phone Number s Address (Street, City, State, Zip / It. Coun Use on ` 5( D! 7 Approved ved Sanitary Permit p Fee Owner Giv I arse Date Issued Issui t Sign a r D ation Zoe) . 60 5 ` 3 b (� X. Conditlons of APProval/Reasons for Di SYSTEM OWNER: Disapproval: I. Septic tank, effluent filter and dispersal cell must all be services / m as per management plan provided by plumber. 2. Ail setback requirements must be maintained as Per 8PPOW* Will / ordinances. �■ a ■■ OMEN ■ M i rENN N ■■■■■■■■ ■■■■E ■■ ■ ■� ISMOM - ■, s. N® ■MN■ „ `i■ ■■■■ ■OMEN ■■■ r" • ■ ENS■ ■N ■ NOW �" 6 t I WO m ■■■ ■■■■■ ■■1 1 ■■■R■ M■ ■ ■ ■■ ■ ■■ ■■■ MEN ■■■■ ■■■ ■■ ■ ■■ � ■■ ■■■■ ■■ ■■■ ■ ■■ NEW 0 ■� ■ ■ ■■■ ME ■ 7 f r 1 r � =`► O ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT i AND OWNERSHIP CE pow TIFICATION FORM Owner/Buyer f it 4, 1✓ E/ Mailing Address fc L l C � ;? � - _ I C . cyis�to �^ C w— 'S U 1 7 Property Address Same s a } Jooe (Verification required from Planning & Zoning Department for new construction.) City /State Yt ' z'IC4 , goAC (v-7- Parcel Identification Number LEGAL DESCRIPTION Property Location /�v '/a , � CJ '/a , Sec. �� , T -- 'D I_N R I (o W, Town of /oiu Subdivision , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # �2� gN e Volume S W age # Spec house yes em�? Lot lines identifiable :=Am no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 r /✓ �"> U SIGNATURE OF AP IC (S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 1 x.`111 s p sx STATE BAR OF WISCONSIN FORM 2 — 1982 G63 WARRANTY DEED DOCUMENT NO. VOL Y27PAGE47 ' Ronald F. Ken.linQ and Vivian M. Ke t. rtarw.Ic Zk /a Vivian Kemlinci, husband and w ife, _ AUG 1.3 1997 con% and warrams to gl ary Powers _ �� 11:00 A THIS SPACE RESL4vED FOR RECORDING DATA _ NAME AND RETURN ADDRESS h the following described rea! estate in ,S t . Croix - -County, � !� State of Wisconsin / c:1 !o— coo PARCEL IDENTIFICATION NUMBER Northwest Quarter of Southwest Quarter (NWk SWk), all in Section 31- 31 -16, ST. Croix County, Wisconsin. T SFER FEE Ott This is not homestead property. (is`. (L. not) Exception to warranties Easements restrictions and rights -of -way of record, if any. Dated this day of Auaust A.D., 19 97 it • t (qa'J (SEAL) (SEAL) R F. Kemling Vivian M. Kemling, a /k /a g (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) Ronald F. Kemling, ViVAn M. State of Wisconsin, _Kemling, a /k /a Vivian Kemling 55. t County authenticated this 5N " da • of Au ua y gam 19�Z came before me this day of 19 , the above named . Kristina Og and _ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, ► authorized by §706.06, Wis. Sum) to me known to be the person who executed the foregoing ti instrument and acknowledge the same .. TL,°(. ..°.T.° °,•r.°T Att orn e y Kr 091and H udson W1 54016 _ -- Notary Public, Cour,y, Wis. y (Signatures may be authenticated or acknowledged &ah are not My commission is permanent. (If not, state ' necessary) expiration date: 19 Ixtvrns signing -n am Jpxu) should b% typed or pnnted Mu% the,, signatures WARRA%IV DttD STATE BAR OF WISCONSIN Wuonsn Legal Star* Co tnc. Form No. 2 - 1y81 Wwa&ee. WIS. 05/03/05 WED 07:26 FAX 715 388 4686 ST CRZ CO ZONING Q001 ST. CROIX COUNW ZONING OFFICIE CER.TIFICATXON STATEMENT TOIL UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that i have inspected the eptic tank presently serving the 1 c ,r h i a r- n L%1e residence located at: /4, Section 31 �, a-L_ Range L(� W, Town St. Croix County Wisconsin. Upon insper-tioil, I certify that I have found the tank(s), to the best of my knowledge, wi❑ conform to the requirements of Comm. 84.25, and it (they) Appear(s) to be functioning properly. Most recent date of service Did flow back occur from absorption system? Yes NO (if no, skip next line.) Approximate volume or length of tithe: gallons minutes Capacity: Construction_ Prefab Concrete Steel Other Manufacturer (if known): Age of Tank (i wn): nn Pot-o-kr-& (Licensed Pl rnber Signature) (Print Name) O53 gitle) (License Number) RS LIU O OCo (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) L - d dZ0 :60 90 60 AeW y iscomin SANITARYIPERMIT APPLICATION' Department of Commerce In accord with 1LHR 83.05, Wis. Arlin. Code ' iAadi on. Attach complete plans (to the count c o forthe s tem on a r ilot•res5 Count y. y. "` � ys p pe � e than 8 1/2 x 11 inches in size: ° �{ r • See reverse side for instritctfons #or completing this application State Sanitary P eititNumber : M �. ! The information you provide may be used by other government agency programs ❑ Check it ie mon to pwAo� a can [Privacy Law, s. 15.04 (1) (m)l. State Plan I.O. Number 1. P I IN R TI N - PLEASE PRINT ALL IN 1` j Prope Owner Nafn Property Location qua Iva -S T ) N• R / W) W Property Owner's Mailing Address i Lot Number Block Nu t , - ,5 C State Zip Code Phone Number Subdivision Narhe or C5M Number Ill. TYPE OF (' ` e } . BUILDING (check one) ❑ State Owned p o 't� Nearest Road V age V .: t i Public 1 or 2 Family Dwelling - No. of bedrooms Town OF �. � r' �`+ j 4. 111. BUILDING USE (if building type is public, check all that apply) Oarcel Tax Numbe c) t ❑ Apartment/ Condo C) oto (3-1 U - I 2 ❑ Assembly Hal[ 6 ❑ Medical Facility / Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑Campground 7, ❑Merchandise: Sates /Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/School 8 ❑ - Mribile 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 8, if applicable) A) 1, New 2, ❑ Replacement 3, ❑ Replacement -of 4, ❑ Reconnection of - 5_ [].Repair of an System ___._____System ______TankOnl�r ^, _'_________� Existing System ____ y l l B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressuriz Distrib Pressurized Distribution Experimental Other 11 fi4 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit 13 ❑ Seepage Pit 43 Q Vault Privy 14 0 System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate_ 6. System Elev. 7. Final Grade _ Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation t: ( ` j `�. Feet d Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Manufacturers Name Con- steel Plastic New Existing Gallons Tanks Concrete glass App. Ta Tanks strutted Septic Tank or Holding Tank Lo C f �r • i'' ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber rn ❑ 1 ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Pri Plymber's Signatu :Stamps) MP/MPRSW No.: Business Phone Number: �" - a ` n Ci � «: :. t #_�� :�._ t � � `� t � °� tom' •,,.i r _ �.;j Plumber's Ac dress (Street, City. State; Zip de): (^ E ems:✓ 4� s J I �' < a te^ • l e -Alp IX. COUNTY / DEPARTMENT USE ONLY ❑ Di sapproved Sanitary Permit Fee pndudes Groundwater ate ssu Issuing Ag�ht Signature (No Stamps) pproved ❑ Owner Given Initial - surehargePee) Adverse Determination /o rr > !' 4 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: f SBDB (R.tt198) DISTRIBUTION: Original to county ono espy To: Safety & BuNdings Division, E)vww. Plumber `i■ I SO dommommommomm■ ■■ ■ MEN F.. moo ns ■■ ■��r No . 4 r■■ RIFASUiii ■■ ■■■■■■ a 11 � `11■lrii ■!,lrii■■i■■i ■r�i■■ r. �� . - �■■ ■NEN m■■ ■■ ■ ■■■ ■■■ ■ '''�■ r1 w ■■■■■■■ ■■■■ '► ■ �■�. ■■■■i ■i ■■ ■■■ ■ ■■r�ur ■■■m■■■■ ��■■ ■■■■■■r ■■k■■■■■■ ■■■■■■ ■ ■r Ii■ ■ ■ MEN ■■■S i ■■■■■■■ ■■■ ■■■■ ■ r■ ■■ `■ � ■■■r i MOM rr■■r i■ ■ 11 `� ■■ r ■■■ ■■ rOEM ►10 No ■ ONE s■■. .. ■■ i ■■■■r■■PA rr ■■■ ■ ME OEM— Ems Me p - .�..�.�r� ■!■lei■■■ PAGE O Cro Sy Qw•4 c S *NI fresh Air Inlets And Observation Pipe •� I WAS � J i l_T •�^�AOOrowd Vaaf Cap A f� t�� ttlnlmum 12' Above final Credo 0 / y 20-4 Z* Above Pipe r 4" Cod Iron T 3 ( N �� W To flnot Creda Van$ Plea c - Marsh l (OA tiny Or ik Syolha Covarinq Over 2' Ae9raaota at Plp• of itribution — Pipe Too a e e i 6' AOareQ 8anael a Perloreled Pipe 8aion ' A Pipe — "Coupiinft Ternminetlna.At • Bottom Ot Sritaa► .SOIL FILL, O1S7KISUYIOEJ PIPE APPROVED SjtJVcTiC COVER q . ° ° "•'/jATgRj, % OR 9" OF STRAW 2 � AG�tR�Gil'IE —�'� >,,' '" -. • . •�, � OR MAIC HAy' e t - (e ".OP,IZ -2 AGGREGATE 01 PIPE Tp bE A t_EAS•{' .c 1144114l_4 BCLO•W ORIGIUAL GRADE AQU AT LEASTLO IUCHES •BUT,)dO MORC T14A.VJ 4Z MICHES BELOW FINAL GRADE P"IMUM ®E N OF MXCAVAT1 FK01 VJ AI. 6 M0F.' WILL 9E sy ' INCHES mmmuM A£Qrit of EACAVATiON FP, -Qk. 0� I4IVJ AL G RA DE WILL 6C INCHES SIGIJCD: LICCUS£ UUMBER: �� co 5 DAT E Wts Dep artment of industry, SOIL AND SITE EVALUATION Labor a > Human Relations Page of. Division of safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach. complete site plan on paper not less than 81/2 x 11 inches In size. Plan must County Include, but not limited to: vertical and horizontal reference point (BM), direction and . V% C % `✓ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please printail'Ift Reviewed by Date Personal Worrm lon you provide may ba used for aecomxlwy purposes (Privacy Law, 8..15.04 (1) (m)). , Property Owner Properrty Locatlon b W-4 d�S Govt Lot /Uw 1/4 S(,,1 /4,S 3) T 3 / & 4p W Property Owns Melling Address Lot # block# Subd. Name or CSM# City State Zip Code Phone Number Nearest Road (� ft 4�gYx ❑ ity ❑ Village Town S•. I�. % New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement Public or commercial - Describe: r. Code derived daily flow 56 gpd S Recommended design loading rate ± lfts ; bed. gpo— trench, gpdAl Absorption area required _4 it trerh, ft 2 Maximum design loading rate, gP 'r._ .�, 9p Recommended infiltration surface elevason(s) 4 it (as referred to site plan b en ) Additional design/site coonside s C��S.�d/ :.. Parent material � �la Flood plain elevation. if applicable � • ft S - Suitable for system Conventional Mound In- Ground Pressure AT -Grade System kt Fill HokNrig Tank u- Unsuitable for s ❑ S u Os 0 u Os O u Os O u O s O u ❑ s ❑. u SOiL DESCRIPTION REPORT 2, Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots d In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed . Trench t 0-1 /6V K A 1111111111110 1 s.. s 1) L ..,�.. i .2 sb C r 5 '• 6 Ground � elev ^ , S 0 M1 7 Depth tar � '`� � m , , , • limiting y , factor , ( n' Remarks: Baring # 0_ 10 1 OVA L Slk Im 4v- 2b taf - K ; A Y& Ground 191 N 6 ns- 5 a nt s at m LA v- -•a i7 :. 'q�'tt .� o rp S 0 rr s 1'r1 •�- ; r Depth to , limiting Ar tt��;;cc��rr in. Remarks CST (Please Prt Signature Telephone No. Address • DaTe CST Number /96 - lej R W PROPERTIOWq I D t. ^�_ SOIL DESCRIPTION REPORT Page -a7 of.3--, PARCEL LD.# Boring # Horizon Depth DominaM Color Mottles Texture Structure Consistence Boundary Roofs x In. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Bad , Trench v- Nom- SDK C . '.S Ground wall : s Depth to limiting , factor , Remarks: Boring # �-� /V n'`Q- ahn sb Ground 4 , Depth to , limiting jgppr in. Remarks: r. Horizon Depth Dominant Color Matdes Structure Texture • - Consistence Boundary Roots Bed , Trench In. MunaeN ' Qu. Sz. Cont Color Gr. 3z. Sh. `Boring #- ,• ,� M ow-$- C: 1a I 'Ground ' 49 S p elev CLn Aug Depth to ' limiting factor z =- ---! ": Remarks:.:. 'Boring Ground v 1 elev. ft. • Dept, to limiting factor Remarks•' SBDW4330,(R. INN ■■■■■■■■■■ ■■■r mom ■■■■■■■■■r■ t ■ '►, ■■ ■■■r■ ■■■■ ■■■■■ ■■■■ v ■ � , ■ ■� ■ ■ r , nl - t3r a � e STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER (` 1 ADDRESS W 3 �5 �. y 1 ' SUBDIVISION / CSM # LOT 10 SECTION T N -R1(,, W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I V 4-9D � 4 8-' I /Z INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. s� m x BENCHMARK: A&J U. ,, +J -4-A- ALTERNATE BM: i SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Li v' Liquid Capacity: /o-s-o Setback from: Well House X 56 'r Other Pump: Manufacturer - u /,p Model# - Size - Float seperation — Gallons /cycle: Alarm Location --- SOIL ABSORPTION SYSTEM Width: /cZ- Length Sy Number of trenches I Distance & Direction to nearest prop, line: 64S6 Setback from: well: House 70 Other ELEVATIONS Building Sewer ST Inlet: (o �6 ST outlet: PC inlet PC bottom Pump Off Header /Manifold Cy-T, Bottom of system ��•.3 IF Existing Grade / Final grade 0 DATE OF INSTALLATION: C) - PLUMBER ON JOB: LICENSE NUMBER: 154-3 INSPECTOR: v,r� 3/93:jt Wisconsin DepartMnent of Industry PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX ' Safety and Buildings Division (ATTACH TO PERMIT) S anitary Permit No.: GENERAL INFORMATION 289499 Permit Holder's Name: OLON City El Vill E] Town of: State Plan ID No.: POWERS, MARTY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: - 1 1 I-do - f i r �� J 006- 1070 -10 -000 TANK INFORMATION ELEVATION DATA A9700315 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic y /¢,� p Benchmark /� o Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet 7.5 S' , '7 TANK TO P / L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic > a NA Dt Bottom Dosing NA Header /Man. -7 ,9'V' � -fi Aeration NA Dist. Pipe 7_ g 9 qs, Holding Bot. System 8 PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand f�' [� rot Model Number GPM TDH Lift Fri ' n System TDH Ft ss m ead Force main ength Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Len No. Of Tr nches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION a ✓ DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Mode Number: System: v 1 70 1J11— OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing 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 i 31 17 1-3& 1 Topsoil ❑ Yes ❑ No 1 ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: CYLON 31.31.16.479,NW,SW 1849 200TH STREET Plan revision required? ❑ Yes C9` No Use other side for additional information. All h SBD -6710 (R 05/91) Date ns 's'signature Cert. No. Vi scons i n Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. I n accord with ILHR 83.05, Wis. Adm- Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. S , C `v • See reverse side for instructions for completing this application State sanitary Permit Number The information ou p rovide may be used b other government agency p rograms � ° y p y y g g y p g C heck if revision t o previous application [Privacy Law, s. 15.04(1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Propert Owner N e Property Location Off. „J1/4 _SQ 1/4,S _ 31 T 31 rN,R /(O& Property Owner's Mai Address 1 1_ _S-r- Lot Number Block Nurrb tj 76 i , State Zip Code Phone Number Subdivision Na a or CSM Number � � C ("r(5) (D I II. PE OF BUILDING: (check one) ❑ State Owned '.ty Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms � r Tow OF C III BUILDING USE (if building type is public, check all that apply) Parcel Tax Numbe s) `h ,��, I (P. Lill 1 ❑ Apartment/ Condo a Oto — 10-7 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_ ❑ E] Replacement 3. Replacement of 4. F] Reconnection of 5. Repair of an _System System_____________ Tank Only______________ Existing System ________ ExlstingSystem 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 11fiQ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 []Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4_ Loading Rate 15. Perc. Rate 6. System Elev. 7., Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation SC) ( J I-3 6Y ly 17 1 / 93 5 Feet 97•k Feet Capacit 1/II. TANK in gallons Total # of r Prefab. Site Fiber- Plastic Exper. INFORMATION New Existin Gallons Tanks m anufacturer's Name Concrete strurted Steel glass App. Tanks Tanks Septic Tank or Holding Tank If�pO �, /'` ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Pri PI =ber'sSiatu: (No Stamps) /MPRSW No.: Business Phone Number: a ISM `7 ( w 5 /S Plumber's Ac dress (Street, fit State, Zip de): IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate Issue Issuing Ag t Signature (No S ps) ,e Approved � ��p� Surcharge Fee) pp ❑ Owner Given Initial (J Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -8398 (R t 1/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1- 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 -3151. 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, 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 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 mustbe 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. It i r q' , , - !_ -- cj I I Y - -- . I I I i � I 1 i I I r �cj I IA.5 - V 3 - I : y , I , I I I , f } i I I I i - I- f--- i� - -- - - - - ' - - -- - - i �- I I I i i I t I L _ } I r -- I I I I I � 1 - --� -- I i J r 4�Qt — 1 1 ! I 1 , I I i Wisconsin Department of Industry SOIL AND SITE EVALUATION Page _ _ L _ of�� Labor and Human Relations Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and , r o 1/ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Pr�.cy Law, s. 15.04 (1) (m)). Property Owner Property Location Im 9L AU ? C) LA a 4-s Govt. Lot N W 1/4 5 U11/4,S 3) T 3 ,N,R /b dFor) W Property Owner l§ Mailing Address Lot # Block# Subd. Name or CSM# 3 w Ct *!� JP- ! !a. A ) A City State Zip Code Phone Number Nearest Road f�R t _ _ t LAS:k, s ( )13 ) a L —Q-S L8 ❑ ity ❑ Village Town �• T. New Construction Use: D <Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow �Sb gpd Recommended design loading rate gi bed, gpd/ft $ trench, gpd/ft Absorption area required .6AR bed, ft .543 trench, ft Maximum design loading rate r - bed, gpd/ft?, - trench, gpd /ft Recommended infiltration surface elevation(s) i _ ft (as referred to site plan benchdi Additional design /site considera 'ons Parent material Lcto Flood plain elevation, if applicable ft S = Suitable for system Conventional T Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [- El El ❑ u ❑ s ❑ u El El u ❑ s ❑ u EI ❑ U SOIL DESCRIPTION REPORT 2 2. Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 1 0-1 /NR i cti.n. -4 -&- Z s o L #%-#- 56 C 5 Q e � u� � 3 l5 3) o o s a o rr , g 1 - 37.6/ a Depth to - S -`� Yrl 7 limiting factor Remarks: Boring # �- o -ia v2 a 0-0 SA 1.1 n 5.1 4 Ok .3 0 a .rte !s r4 r , 5 , Ground a L 8 d P , U tin S 4k rn elev. s s a te s M Depth to T-1 limiting L f ptor in. Remarks: CST � 'J*J ul ' v . ' me (Please Pri Signature Telephone No. 71r-2 #4 513--�' Address , Da a CST Number W yap 9-// - g CSC. 53/ PROPERTY OWNER 41 - u1� ^ SOIL DESCRIPTION REPORT ' Pa e s �2 af.�� PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench O- A A) &Yr Q- m ShK ; C .S Ground - 6rt. S-f Cv QC -, —' i 7 elev. �* `� ft. •` Depth to limiting factor Remarks: Boring # 0 - 1 a L N ann sh � c ��l 3 I-4 24 J A 4 ml Ground S D_rv%' 3 , i g elev. Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture . Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # C I S g Fts. -- ► a z Ground e?9 'J ~ 10J ER 0M �" 17 elev. I , s o - /vA AM41 &_ 3 — 1 Depth to limiting factor in: Remarks: Boring # I F zY:.... Ground elev. ft. Depth to limiting factor ' Remarks: SBDW -8330 (R. 08/95) -� I ! I ! I I C I I I - � I •t L I �._ � I f ( SI77�- I I I { { I I I I I I I I I I I I I I I I 1 - - - -- - I�...r - -- - •+ -_. - 1 --� { _ -..1 -- � - - -- _._( - i -- t —_._ { r- -- — ..,fir. --- , a I i - i I I I I I I I I I I 4 I I � I - _ r I I I { } t - I I , -1— I I f {— �__ , l �— , , , I - -- I I I I too r - ; 1 STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County £. OWNERBUYER - r— 4 � , lit MAILING ADDRESS _ 3 S , � `l " S - T- 0 ,off V DO PROPERTY ADDRESS c 1 — ao (location of septic system) Please obtain from the Planning Dept. CITY /STATE M , ,2 : �L •C� 1°1tiC� n� , �� PROPERTY LOCATION N` 114, 1/4, Section _ , T 3 j N- R _LL--� , — W , TOWN OF C +� ST. CROIX COUNTY, WI SUBDTYISION 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. 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 P rned to the St. Croix County Zoning Officer within 30 days of the three year expi 'on te. SIGNED: DATE: St. Croix County Zoning Office Government Center ; 1101 Carmichael Road 11/93 Hudson, WI 54016 4 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 �Q r' S Location of property ±1 �A J 1/4 -Sw 1/4, Section �_, T__3_LN -R L (Z W Township Q- t, o Mailing address Q,p Address of site Subdivision name Lot no. Other homes on property? Yes No Previous owner of property Total size of property La Total size of parcel ( Date parcel was created - l 3 c f Are all borners and lot lines identifiable? ^ Yes No. Is this property being. developed for' ('spec house)? Yes —IL— Volume lla.� and Page Number . ,�j 99 �l 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. ( , 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. SIgnaturX of Applicant Co- Applicant Date of gna ure Date of Signature 563848 STATE BAR OF WISCONSIN FORM 2 — 1982 WARRANTY DEED DOCUMENT NO. " "__ """ VOL 1257PAGE40 77 Ronald F. Kemlinq and Vivian M. Kemling, twdaWklill xi a /k /a Vivian Kemling, husband and _ wife, AUG 199 1111 conveys and warrants to Mary W. Powers tk- 11:00 z* "�- -4k L)A�& ►ttaytsti+t o9l5a�ds THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in S t. C Li o i X County, State of Wisconsin: �- oob PARCEL IDENTIFICATION NUMBER Northwest Quarter of Southwest Quarter (NW4 SWh), all in Section 31- 31 -16, ST. CRoix County, Wisconsin. T OFER FEE �I This is not homestead property. (is) (is not) Exception to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of Auciu s t A.D., 19 . (SEAL) (SEAL) , ROn F. Kemling T Vivian M. Kemling, a /k /a (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) Ronald F. Kemling, Vivian M. State of Wisconsin, Kemling, a /k /a Vivian Kemling ss. County. authenticated this day of A u ciu s t , 19 Personally came before me this day of 19 , the above named , Kristina Og and j TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) to me known to be the person who executed the foregoing ji instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY j Att or n ey Kristina Ogland i Hud WI 54 Notary Public, County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (if not, state expiration date: necessary.) ) !~ J ` Names of persons signing in any capacity should by typed or printed below their signatures. STATE LIAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED Form No. 2 — 1982 Milwaukee, Wis.! I, j rj•`\ PAGE op �fvSS SeCj 1 freth Air Well; And Obcarvallon Pipe 3 n Approved Vent Cap Mlnlmum 12'Abova /v` -E`er R�L.�M<n Final Crade S•� y N`A��1, 20- 42' Above Pipe 4' Coe. iron T N Q To final Crada Vent Pipe �� _March Hay Or SyntA411C Covering Or 1 Ylt1. 2' Agprvpala Over Plp$ Olitrlbu110n PIP o 0 0 0 6" Aggregate Beckett, Ptpe ° Perlorated Ploe Below o �Covpling Tsrminoling Al Bottom Of Syilem •. QruposeU PmcJ gre.Cl< 9 i .SOIL. FILL DISTRISU'YIOU PIPE • AQPROVEO SCI CTIC COVfR 2 ° oF q�GR� GAT� • MATCPJAX OR q" OF STRAW OR MARSU HAy t:.OF2 /i AGGREGATE 01STR15UTIOU PIPE TO BE AT LEAST -122 y 1 UCHE5 BELOW ORIGtIJAL GRADE AUU AT LEASTLO INCHES BUT'JU0 MORE TNAw 42 IuCHES BELOW FINAL GRADE tWIMUM ®EQrH OF EXCAVAT100 ROM .ORIGINA-L OKAva WILL BE �9'y IMr—HE M�rr�MUM W T of E xcav AT1ON F.ROP\. Ok le WAL GR 49E WILL BC � INCHES sl�uEO: LIG EU SE UUMBE R' DATE: O c