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HomeMy WebLinkAbout036-1099-30-000 O N O N ~ w 0! y 0. C', O g I c 0 N c 0 O ~ L_ f6 ~ Y s co a aa) a) 'a 0 ~ m LL 00 T o c d i ~ Q w i r U i M C 0 c Z y m r~ H ~ d m i o z a c a - N C N (n C eu ((nu a) Q O m N O U O Q - N 0 cu O Z co z z o Z o w N I 0 N v ` _ co Y Syc d O 0 a a c O O FN- IN_' H _3 U M I'' 8 0 0 0 a 0 •~NV a a a a 3 4i Lr) LO ►i 7 0 NJ Z y vn J U 6 rn 0) a) rn a) _ Y a O_ fn N (p7 O O O O N N M O C, 7 r M c0 C d izz n 'd N N ~ N N y N ~j 00 O Vl C 00 00 O C U y N d 7 0 0 O O M 0 ~r Cl) p i N C C U d Q~ N N W y Y Y 'O N j„n d) f0 H Cl C~ O r C ` ED 2 N 7 OM Z O V7 ~ 'O 00 (O M m - O Z Z ~ L O > O Vl (0 N C6 O A V L 75 0 'o L a eK y c rw 0 t A 0 a~ 0cU STC - 104 AS BUILT SANITARY SYSTEM REPORT-, yy OWNER - - ADDRESS X' -57 SUBDIVISION / CSM# LOT # SECTION_--?/ T ?I N-R_'ZW, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIE d)F11 SHOW EVERYTHING WITHIN 10 FEET OF SYSTEM J i ~y y 7r ' 7c If ~ ~J ~y E,~F-ll ~ ,6f6 - - INDICATE NORTH ARROW Provide setback and elevation information o reve~r`sre o_ is form. L_ 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 22 • House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches i Distance & Direction to nearest prop. line: Setback from: well: House /s,% Other ELEVATIONS Building Sewer ST Inlet, ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade G1 Final grade DATE OF INSTALLATION: PLUMBER ON JOB: ✓ J`. LICENSE NUMBER: INSPECTOR: 3/93:jt %iscor4w Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: ❑ City ❑ Village Town of: State PIA W5.: WALTERS, ERNIE 1 `4 CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic /,llb D Benchmark ~p 3 i ; Dosing Aeration Bldg. Sewer -7 Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. Ventto Air Intake ROAD Dt Inlet Septic ~a 9o ' 91 NA Dt Bottom Dosing NA Header/ Man. $ ?y' 4y Aeration NA Dist. Pipe g. 80 yC/, Holding Bot. System 9.7 93.y.5 PUMP/ SIPHON INFORMATION Final Grade 3 5' Manufacturer Demand S o8' ~j~,S ~J' Model Number GPM ~Iz TDH Lift Lrict, System TDH Ft Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width Length 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 O CHAMBER Moe Number: System: -WIf (99 5 , 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 1u xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges PV Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Stanton.31.31.17W, SE, Sk 143rd Avenue 1 U Plan revision required? ❑ Yes ~/No Use other side for additional information. SBD-6710 (R 05/91) Date spector's Signature Cert. No. 1 ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 01LHR SANITARY PERMIT APPLICATION Bureau o oand ff Buil safety uildiinWater Systems ng Water 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. Num er • See reverse side for instructions for completing this application State Sani ,;QW117 The information you provide may be used by other government agency programs C] Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location _ 1/4 1/4, S T , N, R 17E (or~f Property Owner's Mailing Address Lot Number Block Number C' j, Cit , ate r Zip Code Phone Numbe Subdivision Name or. M ( YPE F BUILDING: (check one) ❑ State Owned ity Nearest Road 5" ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms `-a Town OF 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ir- 9~q- .Tan 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. 0 Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank OnlyExisting 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 MSeepage 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 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inxh) Elevation Feet Feet Capacity Fiber- Exper. VII NFORMATION in gallons Total # of Manufacturer's Name Prefab. CoSite n- Steel Gallons Tanks Concrete glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank - J, rk, , g ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the ndersigned, assume responsibility for i stallatio he onsite sewage system shown on the attached plans. Plumber's !ja t) Plum er's gn o St mps) MP/MPRSW No.: Business Phone Number: /r Plumber's Address (Street, City, tate, Zi ode) - -_a IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanl~ery Permit Fee (Includes Groundwater ate Issued Issuin Agent Signature (No Stamps) (CYL, XApproved ❑Owner Given initial (6//[l,-n Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBO-6398 (R. 05/94) - DISTRIBUTION: Original to county; One copy To: Safety s Buildings Division, Owner, Plumber r . 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 is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. i 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 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. rat d 'well .13, n 1.7 Axe i9 70 ~ y ` 7 rl 0 30 >ro S SN • rr ~ ~ 1 {3 11 . o rl l~ ~ r 17 ~ 3 • y • INM, Ak IMot AAd Oki,60VO 1Mb ►y~ ww.,..IStA••.• ' rl"l of • , 'r 800 480 Above 1410 I. flow 0/••• Via No • : „ 1 r 0.N ►V• 01•NQ•11~ ~ I•• i • i• A/it•pt• , • i • v l•M•1.Ili• • /Nlw•1•d pipe Y•1•• • ~"CwNNvi i«••1••1M~ AI V ••u•. 0/ i/Na1 r • Pro p os t o An"I 9 r& cl< NOV", 01STKIDUT101.1• PIPE • AP►RO'/f G S-jwp CTIG COVc » _'/'►ATERI^I. aR tr OF 2 sTaA~ OF Ar, GRC4Alit •-•~r oR MA1c•1. NAy ELEV• oF~ v"Cie Yi-L'/s AG6RCGATC FELT._.+. OISTRIQUTION PIPC TO pC AT 4CAlIT INCHES SCLOW 0;UVIMAI. •t.i/►OE Ayl/ AT. LCAiT EO IMCHCL SUT b10 MORC THAN 42 I1jU1Ci CELOW /INA, G~~AOC MNcvwt+► "PTH E%CAVATIOP F0.1 OWWAL 69AK WILT. BE _ IIJCNEs tvHlmvm IDEFTN OF EACAVATION rAAm\ 0d1411JAL GRADL W11.L. sc , INCHCS SIG1.1C0: LIGCUSC UUMBCIt: I9= • DATE: 110 f Wisconsin. Department of Industry, SOIL AND S11 VALUATION REPORT Page of Labor,9nd Human Relations t)wision'af Safety 8 Buildings in a ' E MR, §3.9Ei, WIS. Adm. Code _ r COUNTY / ~f . Attach complete site plan on paper not less tharY81`a-x 11 inc*10.size.'PW must include, but not limited to vertical and horizontal reference plait .4E1M), direction, - ' % of -lope, scale or PARCEL I.D. # dimensioned, north arrow, and location and dis'tao~e to nearest roan: ' APPLICANT INFORMATION-PLEASE PRINY ALLiNFORMATION REVIEWED BY DATE PROPERTY OWNER: ROP,ERTY LOCATION '-GOVT. LOT 1/4 1l4,S T N,R i(ag PROPERTY OWNER' IS (LING ADDfiESS 1 LOT # BLOC # SUBD. NAM 0 CSM # z ' CI TA ` ZIP C /ODE PHONE NUMBER []CITY VI GE OTOW NEAREST ROAD [ J New Construction Use DCJ Residential / Number of bedrooms 3 [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow er gpd Recommended design loading rate ~ _bed, gpd/ft2_2trench, gpd/ft2 Absorption area required bed, ft2 ' trench, ft2 Ma)dmum design loading rate bed, gpd/ft2_,,y__trench, gpd1ft2 Recommended infiltration surface elevations ft as referred site ( to s plan benchmark) Additional design / site considerations Parent material - Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL-11 HOLDING TANK U=Unsuitable for s stem j7 S❑ U O S ❑ U U S ❑ U ®S ❑ U ❑ S OU ❑ S IOU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture structure i GPD/ft Cons stence Botxtciay Roots in. Munsell Clu. Sz. nt Color Gr. Sz. Sh. Be T d rertch Ground 9/ .7 A elev. ft. Depth to limiting factor 991. Remarks: Boring # >;a f r Ground " elev. A-3 ft. Depth to limiting factor 9 Remarks: CST Name:-Please Print Phone: Address: Signature: ! ~ Date: - IT Nu r: PROPERTY OWNER / SOIL DESCRIPTION REPORT Page - of PARCEL I.D. ft Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bmsxl3y Roots GPD/ft in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed rerxh Ground - elev. Depth to limiting factor Remarks: Boring # •.hii Ground elev. ft. Depth to limiting Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # ILK Ffy 10011 M Ground elev. ft. Depth to limiting factor I Remarks: SBD-8330(R.05/92) i t- r I dI - IAA ~I I I , ~~S e y - - - x ~ I i w / as ; "ell VIC j a i / 9 i , I i , Al, Pdi l i I - _ _ - - - - - } i I I I I STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION E 1/4, _:ij 1/4, Section T_, ~ j_N-R_W )TOWN OF 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 (I) 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 dat SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ' 'I 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 -rJiir &l~ Location of property _5,e_1/4 _5,~,,1 1/4, Section ~E/ ,T_,-7/ N-R__Z-7-W Township _,J _M ilia address Address of site - - Subdivision name ~7C1a~S' Lot no. Other homes on property? Yes_-')~_No Previous owner of property /Wt-/ -A rS a,)-- Total size of property Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (:spec house) ? Yes _,2-_No Volume ffy and Page Number,," `-141 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICA'T'ION 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 dead 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 off-ice 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. W S.icjll re of Aj)pl.i.cant Co -hl)plican Dc~tc of Signature, Date of Si.gnaturc ` 1Y6CUMENT NO. I WARRANTY DEED I Y I THIS SPADE RESERVED FOR RECORDING DATA IISTATZ BAR OF WISCONSIN FORM 2-1982 492464 OL 984PAGE 24 - 3abel.H_...Pe.t.e"rsoa,..also.-known, as..Mable H.._Peter.son,..a._._. I) ST. CRQI C9•, W1 single..person ~I R-e'd for Record - - - - DECO 41992 ecnveys and war.ants to .liraest.W._.Walt_ers_and- Kathryn. A------_-._-- I of 10.30 A. M Walte-rs,--husband -and oFi-Fe,-.a-s-survi-vorshi.p-mar-i.tal------------ I property-•-----•-------------- C'°""~.x1C RegtNer of Deeds RETURN TO II !I the following described real estate in _..__.St. Croix Count State of Wisconsin: Tax Parcel No- - i Lot 3, Hook's Addition to the Town of Stanton j I I 'A i lAN3~r/))L(c9 JEES :his i$------------------ homestead property. (is) (is not) Exceptior to warranties: Dated this . --.24th day of ..November----- - , 19.93... .(SEAL) .-(SEAL) I :Sabel H. Peterson .(SEAL) ....(SEAL) AUTHENTICATION ACHNOWLEDGPdENT i Signature (a) STATE OF WISCONSIN ss. • St. Croix - t - County. authenticated this day of_------------------------ 19____ _ Personally came before me this ------•----da3' of NDVEmbE-r.--------- 19.42.._ the above named -Mahel__H__.Peterson,.-also-.known-.as-_Mable._ ' ~ Peterson-- - _ TITLE: MEMBER STATE BAR OF WISCONSIN -,a - (If not, - authorized by § 706.06, Wis. State.) to me known to be ~cL~ ~'%wlfo`ex4cuted the foregoi instrupi' g d getfnow a THIS INSTRUMENT WAS DRAFTED BY L~ 3':r• Reinstra, Van Dyk 5 Needham, S.C. - -ti _ s. ~-t ea 201 South Knowles Avenue, Box "1-27- a Theresa ic` Oltats~Cia 4. Ric-,+a17- ° t r- New-- Notary Public tr!',-S{ Grunty, Wi (Signatures may be authenticated or acknowledged. Both M" Commission Is b S~ jFi state expiation ~I are not necessary.) 02/06/94., date: ~.__.fit. 1' ) I - -Names of persons signing in any eapacky should be typed or printed below their signatures--------- i WARRANTY DEED II STATE BAR OF R+LSCO143rN WISCOns!,i Legal Blank CO-, Inc. FORM No. 2- lust Milwaukee. Wisconsin ` Wiscdnsin Department of Industry, PRIVATE SEWAGE SYSTEM Safety and Buildings Division Labor and Hkimain Relations REVIEW APPLICATION Bureau of Building Water Systems Hayward Office La Crosse Office Madison Office Shawano Office Waukesha Office 209 W 1 st Street 2226 Rose Street 201 E. Washington Ave. 1340 E. 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 have questions on what information to submit. PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your reference. 1. APPOINTMENT INFORMATION -if you have scheduled an appointment, fill in the information requested below to save time: Appointment Date Revie er ame Plan Identification Number 79'- 9-5- 1 - f952- D- 26 7 2. PROJECT INFORMATION If this review is a revision or extension to your existing plan identification number, provide that number here: Project Name City Village L6j Town Of: County Project Location GOVT. LOT 1/4 1/4,S T N,R E 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 E] At-Grade 1,501 - 2,500 gallon septic tank . . $120.00 H Holding Tank 2,501 - 5,000 gallon septic tank $160.00 M El Mound 5,001 - 9,000 gallon septic tank $200.00 9,001 -15,000 gallon septic tank $ 300.00 N ~ Non-Pressurized In-Ground (Conventional) P Pressurized In-Ground Over 15,000 gallon septic tank $500.00 O ❑ Other: Up To 1,000 gallon dose chamber $ 70.00 1,001 - 2,000 gallon dose chamber . $ 80-00 Building Type (check one): 2,001 - 4,000 gallon dose chamber . . $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 Building Over 12,000 gallon dose chamber $160.00 S State-Owned Building Up To 5,000 gallon holding tank $ 60.00 5,001 -10,000 gallon holding tank $100.00 Code Derived Daily Flow gpd Over 10,000 gallon holding tank $150.00 Check If Replacing Existing System Experimental System (additional onetime fee) $ 300.00 Revisions To Approved Plan 2 . $ 60.00 Petition For Variance: Setback $100.00 ~ Petition For Variance Site Evaluation $ 225.00 - . Plumbing $225.00 Revision $ 75.00 Groundwater Monitoring Groundwater Monitoring - Per Site $ 60-00 (other than a proposed subdivision) Site Evaluation in Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring $ 60.00 . Subtotal: Priority Review: Enter same amount as Subtotal: '/en - MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: ....../BOA 5. SUBMITTING PARTY INFORMATION Telephone No (include area code & extension) Com an ame Conta Person l ) / No. & Street Address Or P O. Box City, Tow or Villa State, Zip C e 1A ~'r 1 Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers. 2 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 may be used by other government agency programs [Privacy Law, s. 15.04 (1) (m)). SBDW-6748 (R. 09/94) OVER H T ~ ~ 1 O 2 w_ O •.C YI On H O C O Z; S D N I W O o o N D+ < H d O m N.~a N a p~ m D< io ym 0 D D N M~ c oCD ❑ ❑ 91 ❑ A ❑❑0 m ❑❑C~J❑❑❑ 3 y ~ 'Z o.dc m~°o.dc m 2 D o r~ 3 T m 79_0 n y m y 'a m H p r~ m m 3 L1 Y! 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PETITION FOR VARI"CE APPLICA110 11 OFFICE Wisconsin Department of Industry, Labor and Human Relations FF E ONLY USE ONLY Safety and Buildings Division O USE Amount Paid 201 East Washington Avene, P.O. Box 7969 Petition No. Receipt No. Madison, Wisconsin 53707 E-Number 608/266-3151 Name o Owner P ti inner Building or Project Agent, Architect or ng neering Firm Company Tenant Name, if any Street &Number Street & Number Location, Street & Number City State Zip Code 3~a - City State Zip Code City County elephone Number Telephone Number Plan Number, if known Name f Contact Pe ' son S- - 1. The rule being petitioned reads as follows: (cite specific rule number and language) 2. The/rule/being petitioned cannot be entirely satisfied because: l/err ~J S'/.24 Q r /a T n / c ii cf~~t~ 4`W list ll 8&A-Z1L41 :3. The following alternative(s) and supporting information are proposed as a means-of providing an equivalent degree of health, safety or welfare as addressed by the rule: Note: Please attach any pictures, plans, sketches or required position statements. VERIFICATION BY OWNER - PETITION IS VALID ONLY IF NOTARIZED AND ACCOMPANIED BY REVIEW FEE See Section Ind 69.15 for complete fee information Note: Petit L'gnpetition st be the owner of the building or project. Tenants, agents, designers, contractors, attorneys, etc may not u nless a Power of Attorney is submitted with the Petition for Variance Application. being duly sworn, I state as petitioner that I have read the foregoing (NAME F PE TIOPiER, Please type/print) etit'on, that I lieve it to be true and I have significant ownership rights in the subject building or project. Subscribed and sworn to before me this date: d Signa ur'elof Petitioner ry~'. I - - . v My commission expires: _ LzIlk Ict IA /I 0 Notary Pub - SB-8(R.09/88) + PETITION FOR VARIANCE APPLICATION Wisconsin Department of Industry, Labor and Human Relations FF E ONLY OFFICE USE ONLY Safety and Buildings Division O USE Amount Paid 201 East Washington Avenue, P.O. Box 7969 Petition No. Receipt No. Madison Wisconsin 53707 Pt 608/266-3151 E-Number Name o Owner /P ti loner ui ng or Project Agent, Architect or Enoineerin5 Firm I A7 Company Tenant Name, if any Street & Number Street & Number Location, Street & Number City State Zip Code Z2220 /_/1) ) JA&MIZIE 1City State Zip Code City County elephone Number Telephone Number Plan Number, if known NContact Pe son S- - 1. The rule being petitioned reads as follows: (cite specific rule number and language) 2. The~rule /being petitioned cannot be entirely satisfied because: l/h~, •Y~.d _ S/ZLr !7 ~ /a ~ f CfT~,=-.+t'e 1~ f~ ~ ~/.N+f .►il-/~ 3. The following alternative(s) and supporting information are proposed as a means•of providing an equivalent degree of health, safety or welfare as addressed by the rule: A dote: Please attach any pictures, plans, sketches or required position statements. VERIFICATION BY OWNER - PETITION IS VALID ONLY IF NOTARIZED AND ACCOMPANIED BY REVIEW FEE See Section Ind 69.15 for complete fee information Note: Petit ner must be the owner of the building or project. Tenants, agents, designers, contractors, attorneys, etc may not 'gn petition unless a Power of Attorney is submitted with the Petition for Variance Application. , being duly sworn, I state as petitioner that I have read the foregoing (NAME '5F PE TIONER, Please type/print) etit'on, that I lieve it to be true and I have significant ownership rights in the subject building or project. AL i~ Subscribed and sworn to before me this date: ! a I A 1. Signa ure f Petitioner Notary Pub , My commission expires: U SB-8(R.09/88) 1 SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations July 27, 1995 201 East Washington Avenue P. 0. Box 7969 Madison WI 53707 K 0 CONSTRUCTION KIM 0 CONNELL 308 MIDPINE CT STAR PRAIRIE WI 54026 RE: PLAN 595-02307 REVISION TO PLAN S93-41059 FEE RECEIVED: 100.00 WALTERS, ERNIE SE,SW,31,31,17W TOWN OF STANTON COUNTY OF ST CROIX PETITION FOR VARIANCE TO CODE SECTION(S): ILHR 83.10(1). The Department has reviewed the above-referenced submittal. All of the statements and supporting documentation included with the petition were considered. Since your request is similar to other petitions approved by the Department (e.g.S93-40398), the petition is conditionally approved. This petition approval is granted conditionally with the understanding that all of the petitioner's statements included on the variance application form and any other documents submitted to the Department will be carried out. This variance is specific to the subject petition and cannot be used for any additional modifications. The petition is to allow a replacement soil absorption system to be installed less than 25 feet from the existing residence. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sin rely, en th Stiemke Plan Reviewer Section of Private Sewage (608) 266-8230 7:00 to 3:45 Mon. thu Fri 1569L/ 1 SBDA-7897 IR. 18/841 y i'~'~" 4A1tf ~ ~ 1 SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations July 27, 1995 201 East Washington Avenue P. 0. Box 7959 Madison WI 53709 K_0 CONSTRUCTION KIM 0 CONNELL ( 308 MIDPiNE: CT f STAR PRAIRIE. WI 54025 kE: PLAN S95-02307 REVISION TO PLAN S93-41059 FEE RECfAYE,}; 100.00 S' i ERNE SE,SW,31,31,17W TOWN' OF STANTON COUNTY Of- 51 CROIX PETITION FOR VARIANCE TO CODE SECTION(;): IL,HR 83,10(1). The Department has reviewed the above-referenced submittal. All of the statements and supporting documentation included with the petition were considered. Since your-request is similar to other petitions approved by the Department (e,g.S93-40398), the petition is conditionally approved. This petition approval is granted conditionally with the understanding that all of the petitioner's statements included on the variance application form and any other documents submitted to tho Department will be carried out. This variance is specific to the subject petition and cannot be used for any additional modifications. The petition is to allow a replacement soil absorption system to be installed less than, 25 fret from the existing residence. All permits required by the city, village, township,or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. i Sinc,- rely, , Awl' en =th Stiemke Plan Reviewer Section of Private Sewage '(606) 255-8230 7:00 to 3 : 4 5 Mori.. thu F r i 15b9L/ 1 SBDA-788718. 10/94/ - n TN CHECK LIST FOR PERMITS Owner or Builder Pere Test or Soil Profile Blueprint of House Warranty Deed With seal;docoument nu;volume & page nu. Tax Nu. of Land Certified Survey Map if Available County Forms * STC 100 * STC 105 * Filled out gnd signed Name * address *-phone nu. * If not on Perc test PLUMBER All of above forms PLB 67 Plot; Plan Cross S*eotioa Check for permits State Wisconsin D`epa WELL/DRILLHOLE/BOREHOLE ABANDONMENT rrc.'hent o f Natural Resources Form 3300-5W Rev. 4-94 All abaRoonment work shall be performed in accordance with the provisions of Chapters NR 111, NR 112 or NR 141, Wis. Admin. Cbde, whichever is applicable. Also, see instructions on back. G N A N MA ION 2 A Loea/Dnillhole/Borehole County tgtnal ell Owner (If own) { f y f E sent Well er 1/4 of 1/4 of Sec T. u N; R. 7 W (I applica 1e ' e r Duce Gov't Lot Grid Number Grid Location it y, cafe, ode . ft. ❑ N. ❑ S•, ft. ❑ E. ❑ W -Civil own / Name ac ty e No. an or ame (if pp t e ue a o. .y. 1 n 1, t P H mq Street Address of-Well Reason or Abandonment City, tl age t5 yt? p e 5..~ S~ :5 ate o Abandonment , WELL/DRILLHOLE/BOREHOLE INFORMATION Original el nllhole orehole onstruction Completed (4) pth to Water (Feet)- eet (Date) C w ~4..._ Pump & Piping Removed? Yes ❑ No ❑ Not Applicable Liner(s) Removed? ❑ Yes' ❑ No 1?5 Not Applicable ❑ Monitoring Well Construction Report Available? Screen Removed? ❑ Yes No Water Well ❑ ® Not Applicable ❑ Yes ❑ No Casing Left in Place? Yes ❑ No ❑ Drillhole If No, Explain ❑ Borehole Was Casing Cut Off Below Surface? ❑ es No Construction Type: Did Sealing Material Rise to Surface? ® Yes No Q ❑ Driven (Sandpoint) ❑ Dug Did Material Settle After 24 Hours? ❑ Yes No ❑ Other (Specify) If Yes, Was Hole Retopped? ❑ Yes ❑ No Formation Type: (5) Required Method of Placing Sealing Material ❑ Unconsolidated Formation Bedrock ®.Conductor Pipe-Gravity ❑Conductor Pipe-Pumped ' ❑ ❑ Total Well Depth (ft.) Casing Diameter (in.) Dump Bailer Other (Explain) ~ (From )Sealing. Materials For monitoring wells and groundsurface) Casing Depth (ft.) -,j ❑ Neat Cement Grout monitoring well boreholes only Lower Drillhole Diameter (in.). ❑ Sand-Cement (Concrete) Grout ❑ Concrete. i ❑ Bentonite Pelslets ❑ Clay-Sand Slurry i Was Well Annular Space Grouted? 13 Yes ❑ No Unknow ❑ Bentonite-Sand Slurry ❑ Granular Berttonite = j ❑ B ranulae - Cement Grout If Yes, To What Depth? 4 peat . Bentomte Chips; _ A ❑ Bentonivi-CINps (7) Material Used To Fill Well/Drillhole Fiom (Ft) tTo (Ft.) No. Sacks Sealan az s' (Circle Mix Ratio t or Volume One or Mud Wei ht Surface ~i/ [fir=) Comments: (9) Name oPerson r Ding Se I' FOt.:DiR..UR CQti11TY .#1S GG~•tc1r ` yy &rQr1!tl: »;::>'<:<: rI 'xf •~l ;>„~t„'~..::dF,•.~.Lb.L,,....'. v; :.;::.;.;::."::':ii:'`:i?%ii`?%isi % •.t>•t..:4>.,: Jt19Si I~ti!rt Sig of er Doing Work Da Vi ed •:....::::::.I::...... i r z;. Scree[ or ojAq Nuo 1 hone ber ' ` ' y~ k ' .f > Pte'! . v ?tY, State, zxp ode :•~N::>~`r''<>. :.;>~:a,;;;;:;;;;>;:;•;:<:.;:;.;:•;;•;;:.;;;>;~:>::; t r WELUDRILUBOREHOL F OWNER J n to p A, ° " f ° 'a-" v 0 t7 d M z M ^ m 3 s 3 a~ Cn K z y p N p et 0 v O N ° A N :i j _ W (D a N ~ (VO - O) pr _ c- CD Cl N `V N V C• V O` C N a. T N m O O W W co C N N n 7 O O O 3 a O , p ram„ N N W - C) Q ~ y ~ O lei v C D m a j m E N N a Q7 A CD 0 N 3 p se a V p (D W N D ~r c° ° ` n D y to m m CO) C C CD M T 10 v. o O p = W _ o n c N N N 3 o N u D _G =1 x O A_ .y. y a y ° m m a ty 3 m oA ii 3 N z I Zco Z m p D a l Z CD (n y y (D N c CD CD w CD a Cl 3 z (D -1 N ° o p z N C 0 m `A z 0 v_ry 3 o D m w CD CD '.i z 0 3 A X °o 3 -4 ~ i * CA ;o CD W N CCD CC D CC CL I Q' N C o a I ~ I 'I I I I y I I as a I ti N O O O N ~ b H> O p * O a O ti , isiin Vepartment of Industry, SOIL AND SITE-EVALUATION REPORT Page of Lad Human'Relations ` Division of Safety & Buildings in a 14R/0,05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less tharn I x 11 inc*,1n.size. must include, but not limited to vertical and horizontal reference Ooi ft BM), directiM d'% of 'slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and d4tanoe to nearest road APPLICANT INFORMATION-PLEASE PIR_I0 ALL'#NFORMATION REVIEWED BY DATE PROPERTY OWNER: +v , AOP,ERTY LOCATION .51 1/4,S T ,N,R ~ie i(orw " `GOVT. LOT 1/4 ,Z;-A1h4_ 6L PROPERTY OWNER':S WILING ADDRESS 'OT # BLOC # SUBD. NAM OR CSM # CI TA E_ J' \ ZIP C /ODE PHONE NUM~R ❑CITY VIL GE ©fOW NEAREST ROADp [ ] New Construction Use NJ Residential / Number of bedrooms 3 [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flower o gpd Recommended design loading rate ed, gpd/ft2_,,~E_trench, gpd/ft2 Absorption area required 4-512 bed, ft2 ~ trench, ft2 Maximum design loading rate _,7 bed, gpd/ft2trench, gpd/ft2 Recommended infiltration surface elevation(s) 9& ft (as referred to site plan benchmark) Additional design / site considerations 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 [Z S❑ U .0 So U ES ❑ U ES ❑ U ❑ S VIU ❑ S E311 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 Tmnch A/ -14 {4 •ti 14 Ground - elev. ft. Depth to limiting factor > 9/ Remarks: Boring # t Kid r P Z_Z Ground elev. ft. Depth to limiting factor 7 ~l Remarks: CST Name:-Please Print Phone: Address: Signature: t Date: CST Nu r: PROPERTY OWNER I~~ SOIL DESCRIPTION REPORT Pa PARCEL I.D. # Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed Trench Ground ZJ- 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 # E4 Ground elev. ft. Depth to limiting factor Remarks: SBD-e330(R.05/92) sw ` e 4/, s1C c 3/, T3//✓~ 17A) .x rGOG~~,m•J a~s:'Y,~ G~ eaz< ~eLir 1.3 .Exs~N~ i9 ` ~ a9` L r' i ` I A /1aus,~ ig• ~a ~ ~1 Ci I 30' t~