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HomeMy WebLinkAbout042-1020-90-300 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER_ 4 1 YYIe,S A /.e !~.S ADDRESS_ p~S( r3.C w~ sya~s SUBDIVISION / CSMJ SECTION 8 T~N-R~ W, Town of C,-) CA. QV-~ ST. CROIX COUNTY, WISCONSIN 0 PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET 0 SYSTEM fi c INDICATE' tdoRTH APPOW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole c'Ovet BENCHMARK: 6-0 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: ~4-d Setback from: Well House Other Pump: Manufacturer Model# - Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: / Length Number o oZ Distance & Direction to nearest prop. line: r , Setback from: well:-,/-6'0 4---House 7& Other ELEVATIONS Building Sewer ST Inlet. / 6 - ST outlet PC inlet PC bottom Pump Off Header/Manifold q~.S Bottom of system , Existing Grade Final grade DATE OF INSTALLATION: 7 ' a I - 9s PLU11E3ER ON JOB: LICENSE NUMBER: 36,3 INSPECTOR: 3/93: )L i Wisconsin0epartment of Industry, PRIVATE SEWAGE SYSTEM County: ,abor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division 1GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI EHLERS, JAMES X CST BM Elev.: nsp. BM Eley.: BM Description: Parcel Tax No.: t I xQ a, 1 *9500208 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi ng Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St / Ht Outlet Verit TANK TO P/ L WELL BLDG, Air Ito ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header/Man. 53 Aeration NA Dist. Pipe S U3 Holding Bot. System (p~ 4 y, 2., PUMP/ SIPHON INFORMATION Final Grade q, 7 93r Manufacturer Demand /o o Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. I 1 Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of eriches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING manufacturer: SETBACK INFORMATION Type O , CHAMBER Moe Number: System: 9Q 7 G ' >5-o AJ ! 4 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 /n A Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center 3E' Bed /Trench Edges 3a~ Topsoil ❑ Yes ❑ No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Warren.8.29.18W, NW, NW, Lot 3, 110th Avenue r Plan revision required? ❑ Yes E( No Use other side for additional information. ~v SBD-6710 (R 05/91) Date Inspe or's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: d I, i, I i SANITARY PERMIT APPLICATION ~'=1a-nln In accord with ILHR 83.05, Wis. Adm. Code COUNTY r, C v-a iX STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than A40 7/S 8% x 11 inches in size. ~ _ , Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION '11 M e j N /U L-3 U3 S 9 TZ N, R or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Vol O od5-0.a r e NEAREST ROAD II. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLAGE: / A ate. ❑ Public X1 or 2 Fam. Dwelling-# of bedrooms 25_ 'PARCELTAX NUMBS (S) III. BUILDING USE: (If building type is public, check all that apply) Q ~jla _ j O o2 Q 9 D 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.m New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Jol Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE O REQUIRED (sq. ft.) PRO/POSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 10r.3 l0 ye / 7 1U ONE ~ Feet 7i & 'Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank 2 r _H4 0 F-1 R Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Nam (Print): Plumber' s Sig atu : (N Stamps) 7MPRSW No.: Business Phone Number: C eJ u l vM 4O we.ir,S 1 c5 4 3 71S- OAC :51-Is Plumber's Address (Street, City, State, Zip Code): 1967 1 k,5 4- 41,01 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sarary Per t Fee (Includes Groundwater ate ssu Issu' g Agent Signatur (No St mpsr Approved ❑ Owner Given Initial I ~ fo Surcharge Fee) Adverse Determination Q/ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS - 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitSed to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) I I , i ` E - I fff 1 1 E ! ! E I I ' ' r S.7 .L E lQ ~{OQr~. a~•-~ I - ~.1 a.. V1- 1, I y, E , } , t 1 , I ~ a i + ! I `Yf ~ L I j i f ! i Yom- I r t I , r I ~ I f , E t ~ I E r i ~ E ~ ~ E 1 ~ I + I I I t LrU S S J ~c' I L) p~ ~am>zs ~~-e~s /V k) ~vw spek .,7/ee-D Q +r~c ~S Gt1a.~,.~-- Ff*tA Ali Inf.1► And OD►►frolton Plp1 co41Yy1 v Y1 J.J Cj l: ✓ Y~ ~S ulntmvT Appealed V.nf Cap . I2' Aoo,. fhof 0rad. 20•42•A°o,Plpj 4' Coll lion io /Inol oted.- Vent 1.1'. ►ta.n )tor Or SinrMrla Co ulnr O..r2pA19r.polo DI.Irl4vllod i PIp~ 0 0 0 -Tel Aadr►pol► - D.n..ll, PIP. ° P.rterat.d Pt ° C"01"ll T.rrninaflnp At Dollo'n of s"I.m ~~cJ•.~ ►ort ~ 5011. FILL 01STRI[}UTIO1.1 rlr[._ l~PPROVEO Sy~lP TIC COVC' 2"O~ ~GGR~GA1E ----7 0 ~_IIATI:RIAI. OR 9" OF sTa~~.~ OR ~ARS►a µAy ELEV. OF FE~Y_~ !:YLQ•, I:rOFlz-21/2 AGGftCGl~Tf ~P U~ GISTnIf)rJTI,_)IJ PIPE TU bE AT LEAST y ORIGUAL AVU AT LENS-1-10 INCHEL 13UT 1.10 MO-ftC T-FINN y2E ~ICgES Or-LOW FIINAL GR A) E MX IMUM DEPrH of F-XCAVATIOP FXotl orUGr~q> G~tAo~ WILL ©E ~ 41 112KIf1UM ()EFT-11 OF EACAVATION ~fZOM R1 AL GRAOf_ w11Lt_ Ac IIJCHES INr_►IC s SIG►JEo: LIC,E►JSC ►1UMOER: IS63 oA'rE. 9- I to i Wis onsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page J of 1.2Mr ar$d Human Relations Division of,Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. D • .;l -/6 - 9a .10 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT h f W 1/4 IV W 1/4,S g T N,R V or) W PR PER 'rY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 5 3 nu 00( ) v QUO CITY, S~TPTE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE PKOWN NEAREST ROAD f `i 61 h~~(Yl / ( ) /iJ L~AV~ ~,w L 'A U-e- K Construction Use K Residential / Number of bedrooms [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow Vsy gpd Recommended design loading rate 1 bed, gpd/ft2 trench, gpd/ft2 Absorption area required 6 f3 bed, ft2 5(=3 trench, ft2 Maximum design loading rate 7 bed, gpd/ft2 , trench, gpd/ft2 , Recommended infiltration rf su ace elevation(s) q I/ ~ ft as referred to site plan benchmark ( P ) Additional design / site considerations Parent material o LA Lz°2 6 Flood plain elevation, if applicable IV ft S = Suitable for system CONVENTIONAL MOUND IN ROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING, TANK U= Unsuitable fors stem S❑ U S❑ U FS El U S❑ U [J S U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bourtdagr Roots Bed Tmnch 4~4 51 a4, s c s 13 S ,G Ground ay~~Y 511- o 156 o -S ck /A U C .5 a 51- , 8 ele . , ft. -96 S G p S~ - - , t Depth to limiting _pr ct fa Remarks: Boring # Y'3 S/ 10 Ground 6 9 o t. S G rvl I ' - elev. ft. Depth to limiting fac or _ Remarks: CST Name:-Please Print Phone: i;j at,,9er3. Address: / 9 U -A - f Lh ~y1~ o / Alt, Signature: Date: 7 _ Soft CST Number: PROPERTYOWNER ::Ta Q-3 G k)-QY`.SSOIL DESCRIPTION REPORT Page ~of PARCEL I.D. # 6) d as 9a Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench p- Io /Ovtt Nart .2mS l< ASr CS z~ S . L :x 4?: L ' 19 a ~a n e.. CS Ground 3 /l 96 rS r ~v~~ SG _ Cs e v. *Ego Is t. Depth to limiting factor L Remarks: Boring # yyit ;:iLti _ vvG.v..v Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) pip e _ i j I I i . 1 o 1 --~1344- 1 I I I ~ I ! I i ; I ~ , f 1 , I L CERTIFIED SURVEY MAP Located in part of the NWha of the NW4, section 8, T29N, R18W, Town of Warren, St. Croix County, Wisconsin. _ _ N 2' (D CD F* W- co d 111=1ED _SU_I; `✓E-E-Y MAP VOL. 4 PS. 11 8 a - - rr -n m 0 110TH AVENUE ~ T z~ North line of the NWJ of the NWJ of Section 8 44- 0= CD 0 w o 0 so w -a a m N88056101"W o _ 913.00' _ „ o 240.00, 200.00, w r * e+ - a o o 240.00 N 200.00' N . G, N8902212711W 880.00' V N C z i C> I z o° O IG " O N .A I J IL- LOT 3 I> C2 00 LOT 4 H D 2.56 Acres Inc. R/W m rn I~ `9 n 111,422 Sq. Ft. Inc. R/W 2.12 Acres Inc. R/W M I ri W w 92,513 Sq. Ft. Inc.R/W W ICS a 2.40 Acres Exc. R/W ;r r N 104,596 Sq. Ft. Exc. R/W ~ N 2.00 Acres Exc. R/W If- p" M 87,164 Sq. Ft. Exc. R/W N I> a v Z - rn I F- I U Ic I(J) a o - r N 7 C C- 0 Z 0 t0 W Zn 240.001 200.001 tO S89022'27"E 440.00' LEGEND i..;PROS n Humbird Land Corporation Aluminum County Section Monument found 1218 Pioneer Building t" d kT.. AU G N. Roberts St. _ ~ K i6 '941336 .~,~'^y -.~_w.~ ' t.s 111 Iron Pipe Found St. Paul Mn. 55101 f•. • , O 111 x 2411 Iron Pipe Set,.- Z) " . "ROIX COUNTY weighing 1.68 lbs. per,,,,Mprchensive Plannir linear foot Zoning and 100' Roadway Setback Pork; Committee Y SCALE IN FEET V not recorded within 30 days of 50 0 100 200 approval date approval shall be -11,41A void SHEET 2 of 2 SHEETS VOLUME 10 PAGE 2802 C 9 FILED ° 9 A UG 1 6 19914 11 Jge9ser 'CO L~ 520266 sc Of., W/ CERTIFIED SURVEY MAP N Located in part of the NWT of the NW-3-4, section 8, T29N, R18W, Town of Warren., St. Croix County, Wisconsin. rF 7 r• ,,mm - - o _ _ ?s s `'aEEd 0 0 IIOTH AVrL--- SUE en rr North line of the NW} of the NW} of Section 8 to ° W. C m N88056'01"W 913.00' • O 473.00' CPA NW Corner CAL Section 8 440.00' N 33' 33' N8902212711W 880.00' G, V N N N Cn LOT 2 0 0 2.78 Acres Inc. R/W I L o 121,148 Sq. Ft. Inc. R/W cN„ O o 0 I Ti I m u° ° 2.27 Acres Exc. R/W CD ° --4 CS N If- I~~ Ln 0 98,999 Sq. Ft. Exc. R/W ° I> Ln ~ ti D eNr 1 -1 = - W OSILO o C7 C7 ( 32.78' 440.00' _ J) o eo I -1 N S$~°22'27"E 472.78' N rkA Ln _ a _ I o CONCRETE Z W II I n 0 FOUNDATION /-\CONCRETE c rrl rt I > I n c• Ui O PAD a I` I-1 0 ~ rn Cr `c I (J) tv > m ~p n d _ N oe LOT I C N N 0 t° tD 3.43 Acres Inc. R/W - `-tJ 149,494 Sq. Ft. Inc. R/W HOUSE 3.19 Acres Exc.IR/W SHED ° 6 6' 139,167 Sq. Ft. Exc. R /W Z C) n~ / W ,PPROt!E® SHED h+ O lc:) 4~. U7 co r • _ t1 P P SHED v a AUG 16 '941 32.52' 440.00' tzj S89022'27"E O 472.52 ST . CRO!X COUNTY C: jinprehensive Planrk O B Ns Zoning and o ;--arks Committee N ' n r_ r n r S C~ 4' If not recorded P :0 ~ . 4 OWNER within 30 days of ~ Humbird Land Corporation approval dot* 1218 Pioneer Building 3tproV61 shatltfb SCALE IN FEET 336. N. Roberts St. niAt & void St. Paul, Mn. 55101 50 d '100 200 W Corner VOLUME 10 PAGE 2802 Section 8 SHEET 1 of 2 SHEETS 0080 SOHd OT Swn'IOA •aatnpp aoj paeog Umoy aquTjdoxddp pup aoTggo buzuoZ Aqunoo xtoaO •qS aqq goequoo Taoaed due buidoleAep ao buzspgpand aao;ag •(•a-49 'Tao-7pd oq ssaoa p 'azTs qoT wnwtuiw 'spueTlaM '•a•i) SUOT491nbaa pup saTn;[ 'sMeT dTgsuMoy pup Aqunoo 194pgS oq gaaCgns si dew sigq uo uMogs Tao;tpd gaeS 'awes buTddew put buTAanzns LIT xTOaD •qS go Aqunoo aqq go aOUPUTPIO UOTFTntpgnS pupa aqq pup sagngPqS UTSUOOSTM aqq go t£-9£Z aagdvgD Io SUOTSTnOid quaz.zno aqq g4TM paTIdwoo ATTng anpq I gPgq :pagzaOSap PUP paAanans Ajppunoq aOT1agx9 aqY Jo aTpas 04 UOT1equasaadai g3alaOO e ST dpW AananS pat;Tga9D stgq gpgq A;Tgaeo OSTe I •p1009a go squawasea Ile pup (49914S g4LOT pup anuanV g40TT) speoi uMoq zog AeM-;o-ggbTa oq goaCgns sz Taoapd pagTaosap anogy uruur aq 3o 4uro aq4 04 49a; 00'£T6 'auiT gglou paps buoTp 'M„TO,9So88N aauagq :uoi409s pies go t/TMN aqq 30 b/TMN 9144 90 auTI g4aOu aq4 04 4993 08'T9t, 'S„9t,8Vo00N aOU91q4 :4P9; 00'Ott 'S„LZ,ZZo68S 9ou91q4 :499; Lt'SOT '3„9t,8to00N 90U9144 :4999 ZS'ZLP 'S„LZ,ZZo68S aauagl '4993 6Z'VLS 'uOZ409s pips' go -V/TMN 9q4 go auTI *4saM aqq buoTp 'M„bS,Sto00S aOUaq, :8 UOT40aS pies go aauaoa MN 9T44 49 uruur ag :sMOTTO; sp pagTjosep aaggan; IuisuoosTM 'A,4unoC) xioiD '4S 'uaaxeM go UmOf 'M8T2l 'N6Z,L '8 uOT4099 go V/TMN aq4 30 f,/TMN a44 go gapd UT p94POOT pupT go Taoxed V, :sMoTTo3 sp pagzaosap sT paddew pup paAanins Taoapd pupT aqq go Aappunoq ioziagxa aqq geg4 :dpW AaninS paT;TgaaD stgq Aq paquasaadai ST gotten Taoapd pupT eqq paddew pup pagT20sap 'paAaAans aneq I 'uoigpiodaoD pueq patgwng 9q4 go UOT4091Tp 9q4 Aq gpgq 'A9T4190 Agajaq 'joAanjnS pupZ UISUODSTM p9a94ST691 'uabegAN •D uaTTV 'I SSFI~I3IS2tS~ S , -dOX3AHnS STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 7-4^ P J !!~_7#// r s MAILING ADDRESS 13-5 /4 a, rY10-N, c) PROPERTY ADDRESS (location of septic system) Please obtail from the Planning Dept. CITY/STATE /?p LJ4 S-/ D PROPERTY LOCATION AAd 1/4, 1/4, Section, T __Q ( N-RJS__W TOWN OF 12A r r c N ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME /0, PAGE ,2 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 returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: 5- St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 • S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property L • sa#%e( Xe-4; Z. CAler•.S Location of property Ll/4AIW1/4, Section T.29 N-R /S W Township G✓orren Mailing address; ' r 7F_~ 11 Box /3,~ t~a~►-►mov~d; W 1 5~/0 Address of site [e)/_s //p fF, AVM f~elberf5 SVO a.3 Subdivision name /y c Lot no. Other homes on property? 4 Yes ~t No ~o-P /d / Previous owner of property Almn,t " p Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? X Yes No Is this property being developed for ('spec house) ? Yes X No Volume and Page Number 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. ignature of ~A~~~ Co-Applicant Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS arwce aeaERYeo FOR RECORDING DATA WARRANTY DEED D n<i r - --fir(} ~A7i ~~/j . 4 ~T• .a 529-8Q- SL - - a ' - ' This Deed, made between Humbi.rd..Land..Corporation_,, a--Minnesota-.Corporati:on....... JUN 7 19 5 - - - F - - - Grantor, I('~ and James- L....Ehl-ers_.and.-Vicki ..Eh.l-er.s.,__Husband..and..wi.fe--- V.~ 9.30 A.t.;~ V * e q a - , Grantee, Wiinesseth, That the said Grantor, for a valuable consideration-_... - - RETU0.N TO O Q C, I a - conveys to Grantee the following described real estate in St.._ Cr01 X. t County, State of Wisconsin: I at~`J ) o~ d Tax Parcel No- Part of the NW 1/4 of the NW 1/4 of Section 8, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin described as follows: Lot 3 of the Certified Survey Map filed August 16, 1994 in Volume 10 of Certified Survey Maps, Page 2802 as Document No. 520266. rASV This is not - - - - -homestead property. Xcbfk (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And - warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except Easements, restrictions and rights-of-way of record, if any and will warrant and defend the same. Dated this ---------10th---- day of .Ma.Y-._.._.-..._. 19.95. - -------(SEAL) HUMB.I.RD...LAND..CORP RAT ON-. (SEAL) Y By: Austin J. Bai n, Its President - _ ..__--------...._.--__..._(SEAL) _ (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF ) KXX)(>0= Mi fines to as. I . Rams - ------e -Y•------------°County. authenticated this day of 19..-..- Personally came before me this 0111.... day of AY------------------------- 19.95___ the above named _AlJStin_J_._..flai_].]_on,.-Pres.irlent__a ---Hmmb_i_rd_.Land..Corporation------------------------ TITLF,: MEMBER STATE BAR OF WISCONSIN (If not- authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foreg 'ng instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY . Paul A. Baillon Notary Public WaahingtQf).... County, MN (Signatures may be authenticated or acknowledged. Both My- Commission is permanent. (If not, state expiration are not necessary.) Ja • date: r _ _~PA 6 - NOTARY PUBLIC MINNESOTA .Names of persona signing in any capacity should be typed or printed below their signatures. WgSHiNGTON COUNTY WARRANTY DEED STATE BAR OF WISCONSIN MyCOmlwl .64k2j" FORM No. 1 - 1982 • Wisconsin De;iartmentof industry, PRIVATE SEWAGE SYSTEM County: Laboyand Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Peimitli.old s NaES ❑ City ❑ Village R Town of: State Plan No.: Warren CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 52 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht 19t/et TANK SETBACK INFORMATION St/ Outlet TANK TO PI L WELL BLDG. AirI to ntake ROAD D Inlet Air I Septic NA Dt Bottom Dosing NA Header/Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer emand Model Number GPM TDH Lift Friction Syestem TDH Ft Forcemain Length Dia. FFff Dis .To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Mode Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribut n Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Le gth Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over epth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center ted /Trench Edges Topsoil E] Yes E] No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Warren.8.29.18W, NW, NW, Lot 3, 110th Avenue Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION • ~ ~'■•iR COUNTY In accord with ILHR 83.05, Wis. Adm. Code .57, t'_ r a tx STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than a 3 345 8% x 11 inches in size. ❑ Check if revision to pr vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPE TY OWNER PROPERTY LOCATION 44 I'nes; V`S /Vk)% Nbj '/4, S k To??, N, R /,flgor) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # gk!g /3 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~)a I X D 1D , II. TYPE OF BUILDING: (Check one) CITY ~NEAREST ROAD ❑ State Owned ❑ VILLAGE : 'Jig N per-. 1/d ~ 45 IR TOWN 0 ~ ❑ Public 191 or 2 Fam. Dwelling-# of bedroom PARCEL TAX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) Q .5[ a - d a a n p~V V 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A 1. New 2. El Replacement 3. El Replacement of 4.0 Reconnection of 5.❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 9 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION ~T3 7 N/fir ".1 43 Feet •~Oe~~ Feet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank cm Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (P Plumber's riform Stamps) MIf/MPRSW No.: Business Phone Number: Galufn Vawar5 6 JX Plumber's Address (Street, City, State, Zip Code): f W-C Cu IX. C NTY/DEPARTMENT USE LY ❑ Disapproved Sagitary Permit Fee (Includes Groundwater Date Issued Issuing Age t Sig lure (No S ps) Approved ❑ Owner Given initial J~ Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/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 & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) , 1 r I • ! 9 q I , r r , , TI r AWAP 1- 7 , i r , ' . - a ow. y r ♦ , y 1 { r w • - y E r i r n.. v CUSS 101-) Cj~ C17 JySlen'1 Ta Yrl-cS. I -e• V-:~- N w jt/ w 5,,,k 7.1 GJavv~- Q r~ ~S Fr4►h Alt Inl.t► And OC►►(rallon Plp• 44"l yl10 In 01 G.) APPro..a v.ni Cop WWm- 12' ADor. Flnol Grad. 20• 22' ADo.. Plpp _ Co.1 Iron To Final Graa. V.ni PIP. ►w.n NoI Of Stnln.llc Co-lny u1n 2' Ayyr.yol► - 0-1 PIP$ 0161,1bullon Pip. 0 0 0 T.► b- AGyl. poi. 8.n.41a PIP. o P.rlorol.a Ply. h.lav o -Co,PIllg T-Inaliny At 8ollom of Sy.l- SOIL FILL DISTRIBUTIOI.1 PIPE-,,., APPROVED SWPICTIC. COVE r - -r1ATERO11- OR 9" OF STRA~..✓ 2"oF AGGREGATE OR MARSU NAy (o O F JnQ OS t - 21/Z A G G R C GATE P^ tfr ELEV. OF-/ FEAT DIS-VRIFjUTIOU PIPE TO BE AT LEAST Iti1CHCS ©ELOw ORIGI"AL GRADE AVU AT LEAS-r LO 11JCF1CI BUT 1.10 MORC TH/oj -12 JUCI{ES BELOW FIAJAL GRADE M nUM DEPrH OF ~X~/1VAT1~1➢ FKor+ ()RlblJAL OF 1\ F WILL ©E ~y _ IUCHCS 4)nUM ©EP rlt of FACAV,ATI01J FAOM a4,161W\L GRADk W 1U ILL HC INcIIC - s SIG►JCD: - LIGCUSC AJUMBER: 1-503 DA-rC: - - - - , i n Wiisconsin,Qepartment of Industry, SOIL AND SITE EVALUATION REPORT Page-,/ of Labor and, Human Relations r- O a;ision of Safety & Buildings in accord ~ .65,'Wi~. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/ inch ire. Plan rftUSt include, but Pilo, X not limited to vertical and horizontal reference point direct?" Y. of,,lope sea~e or PARCEL I.D. # a dimensioned, north arrow, and location and distanc T1 iearil ~b d. j ' t., (14Z- 0 Z~ - c/0 ++1 i-- REVIEWED BY DATE APPLICANT INFORMATION-PLEASE PRIN ALIL INFgFl i Tl~f!4, PROP RTY OWNER: 'z r ffROP4RTY/LOCATION y,,n -b d GOVf.,b~T QU LZ 1/4 /V k)/4,S 9 T ZC1 N,R 1ej IL(or) W PROPERTY OWNER':S MA!i_ING ADDRESS 'tOT BLOCK # SUED. NAME 0 CSM 19 P o f:EIZ OLd , 33~ N . Lvbt vis ►4- CITY; ST AE ZIP CODE PHONE NUMBER OCITY QVILLAGE WN NEAREST ROAD S Awe -6i0 / c~/z) z7_ z-6~ s~ to ~r~r-~ lv~` AJc [-New Construction Use [ Residential / Number of bedrooms -3 [ ( Addition to existing building I Replacement ( Public or commercial describe Code derived daily flow 6-0 gpd Recommended design loading rate c bed, gpd/0 _/9 trench, gpd/11:2 Absorption area required 6 43 bed, ft2 ~ lv 3 trench, ft2 Maximum design loading rate L z bed, gpd/ft2 j e trench, gpd/R2 Recommended infiltration surface elevations l"• F ft as referred to site plan benchmark ( P ) Additional design / site considerations A119 Parent material "A) AS k) Flood plain elevation, if applicable .4Z A It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ®-S C3 U Z-S ❑ U 2 ❑ U '0S ❑ U El S JJU ❑ S E-U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch Ground /4 '7 • 8 elev.-,, g S 0 C 'S Depth to limiting factor Remarks: Boring # /Z- Z3 L .2 0 C 51 zry/ SQi / 5 Co :Ground elev. F3'_ 4 /0 0~ fr- W2, 17 "q Depth to limiting factor Remarks: CST Name:-Please Print / Phone: ~nZoo Address: Signature: Date: CST Number: J PROPERTY OWNEFi4/linAAbYJO• SOIL DESCRIPTION REPORT Page Zof 3 PARCEL I.D.# 0+z - zd - 96 Boring # Horizon I Depth Dominant Color i Mottles I Structure I lBourriary Roots GPD/ft in. Munsell Cu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bed ITmnch 3/ C / ems rn CS ,51 Ground Z 'z~ / p ~rJth O C U S N '17 B 10 5 G-8a l? rL -5/ E 14114 Depth to limiting factor 78v„ Remarks: Boring # -iz /n zm so s a /2-20 2(2 ya 4 t5 /4- M0 Ground elev. A,~~ JIU,4 Depth to limiting factor ~ 6?0 Remarks: Boring # tin 5&) /0 A2- 4A /t /0 IV, Z V-7 Ground Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) • v STEEL'S SOIL SERVICE o4v*,'~v Gary L. Steel l4i ~t9'Y~ 9 rive C.S.T. 2298 ~G7'/ d New Richmond, WI 54017 MPRSW-3254 >~y~ /U u) V+ s f Z /Z/8u~ (715) 246-6200 5 z s` g3o` 0~o _ Iz~ Zo' -ek ~k 10 r 5 Fly o 4o ' par, ~ i