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CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 00 FEET OF SYSTEM I D/ 36' ~ I RAI t>'a - w' - 1 INDICATE NORTH A RO Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t , BENCHMARK: /Z,yL~~/~s gs, iL/~- f1 / ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:Liquid Capacity: I -j' Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location i SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS r"O Building Sewer ST Inlet; ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: ~~✓~~~,~r~~ LICENSE NUMBER: INSPECTOR: 3/93:jt t BENCHMARK: " ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well y~ House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS t''O1c11"9 1;JK' eov f ~C- g8, Building Sewer ST Inlet: ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: - PLUMBER ON JOB: , LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of Labttr end Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPE OWNER: PROPERTY LOCATION GOVT. LOT 1/4 1/4,S T ? N,R R (ore 'ILI" 6': id / PROPERTY OWNER':S MAILING AP RESS LOT # BLOCK # SUBD. NAME OR CSM # J t CITY, TATE^ ZIP CODE PHONE NUMBER ❑CITY ❑ ,ILLAGE ]MOWN NEAR T R D :a7 41*A [ ] New Construction Use k] Residential / Number of bedrooms Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow l gpd Recommended design loading rate gibed, gpd/ft2/ ' trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate _4/~bed, gpd1ft2 ,V trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material - Flood plain elevation, if applicable ' ft 'Z'7""'// =Zd ia S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ❑ S OU ❑ S g1 U ❑ S O U El S jZ U ❑ S ®U JMS ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. C 4t. Color Gr. Sz. Sh. Bed Trench 7 Ground 1-r All )/110 ft. 31/ N"o ~l Depth to 5 y~ - - Nil Alf limiting factor Remarks: Boring # tiv\ht?::-?i:: 7.s yes* -3 - Ground elev. ft. Depth to limiting factor Remarks: CST Name:-Please Print ✓ Phone: _ Address: - 7X4'1 -5- _4 Signature: J ' %j Date: _ CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page Zpf PARCEL I.D. # i Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench - y ~ 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: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PROPERTY OWNER SOIL DESCRIPTION REPORT Page,,? of, PARCEL 1. D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends -/,0 VA 911 11/1 A11,4L 0-s 3, -AZZ _,4v _Nvo sy,~ ~/l Ground elev. ft. Depth to limiting factor Remarks: Boring # E3~ Ground elev. ft. Depth to limiting factor Remarks: Boring # 13- Ground elev. ft Depth to limiting factor i I Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SRIMMO R OSWI t".4~'~ 3 6r 3 /8/ 7~d -SEA ScJ~/~se~,T~/mil; 7~/GliJ rr G3 so -S /o", ~ F - d 1w I 30 i ter' ~ t ~ l~ 36 m ~ f 1 L~i~r~sf~ip~rtr~t~n~~lavst- 31.16w.tiV~ SGT s~~lu~ty Road Runty: . 'Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitar flit GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village `ii Town of: State PI o.. CST BM lev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9400065 /Z TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Sep ' Benchmark Dosing Bldg. Sewer Holding ( St/Ht inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing Header / Man. tion NA Dist. Pipe Holding ~,j >~S 3rd Bot. System PUMP/ SIPHON INFORMATION ' Final Grade Manufa er Demand Model Number GRAA TDH Lift Loss n Syestem t Foecemain Length Dia. FFii Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches No. Of Pits Inside Dia. Liquid Depth DI I N DIMEN I N YSTEMTO P/L BLD WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold ribution Pipe(s) x Hole Size x Ho ong Vent To Air Intake Length Dia. Length Dia. Spacing SOIL C x Pressure Systems Only xx Mound Or At-Grade Systems Only th Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes ❑ No E] Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Cylon.33.31.16W, SE, SW, Lots 1-2-3, Cty Road O Plan revision required? ❑ Yes e-9-0- Use other side for additional infor a i ~ /C2 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No D LH M SANITARY PERMIT APPLICATION COUNTY / In accord with ILHR 83.05, Wis. Adm. Code - Is - s / . " STATE SANITARY P MI # -Atfabh complete plans (to the county copy only) for the system, on paper not less than IQ() O / 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. PROP TY OWNER PROPERTY LOCATION '/a '/a, S T N, R (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CIT.y STAT I ZIP CODE PHONE NUMBER SUBDIVISION %7E OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY : NEAREST ROAD ❑ State Owned VILLAGE 4QWN OF: ❑ Public E47i 1 or 2 Fam. Dwelling-# of bedrooms - L AX N ( ) 111. BUILDING USE: (If building type is public, check all that apply) (5? 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) f l A) 1. ❑ New 2. IN Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 JZ 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. ABSO P. AREA 4. LOADING RATE 5. PERC. RATE 6. SYST M ELEV. 7. FINAL GRADE REQUIR T (sq. ft.) PROPO D (sq. ft.) (Gals/d,Ay/sq. ft.) (Min./ir)Ch) ELEVATION 1/1 / Feet Feet CAPACITY VII. TANK in al Ions Total # of Prefab. Site Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New istin Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati of the onsite sewage system shown on the attached plans. Plumbe s Name (Print): Plumber' Sig tur . ( Sth MP/MPRSW No.: Business Phone Number: ~s - PI m is dress (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa 'tary Permit Fee Includes Groundwater Date Issued Issuing Agent o Stamps) TluApproved E] Owner Given initial al JLJ O ( Surcharge Fee) -Adverse Determination w !~f / y X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-87) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s 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 renovi al 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/Rer:ewal Fom, r ! ;i X399) to he subrritteci t4) ?Ire County prior to installation. 5. Onsite -av,,1 e =ysterrr-s-must be proper-y maintained. The tank s) n•. t+ ~ icsnsed pumper w'!,anevdr necessary, usually every 2 to 3 years. 6. If you have questions concerning your on-site sewage system, contact your local cods a:l- ,iytrator or the- State of Wisccsrr`in, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's L-tame and mailing address. Provide the legal description and parcel tax nornber(s) of where the system is to be installed. It. Type of building being served. Check only one and complete of bedr.r_ ms'? 1 or 2 Farr), y =!welIing. III. Building use. It building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complrete line B if permit is for tank replacement econnection, 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 tl e total ga lors number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Conualete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only it 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; well,,; water mains water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; reply. .,ement system areas; and the location of the building served; B) horizontal and vertical elevation ref?ren4-_ - points; C) complete specifications for pumps and controls; dose volume; elevation difference;; ftictl;,n 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 c regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring gro•.9ndv.,dter, ground- water contamination investigations-arid-establishment:ostandards. SBD-6398 (R.11/88) SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations March 29, 1994 201 East Washington Avenue P. 0. Box 7969 Madison WI 53707 KO CONSTRUCTION RR 1 BOX 105 STAR PRAIRIE WI 54026 RE: PLAN S94-00466 FEE RECEIVED: 60.00 HOULE, HELENE SE,SW,33,31,16W TOWN OF THEILEN COUNTY OF ST CROIX HOLDING TANK The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. 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. Ken rely, th Stiemke Plan Reviewer Section of Private Sewage (608) 266-8230 7:00 to 3:45 Mon. thu Fri SHM6483 (R. 01/81) AIV So Y-/"S"Fc )4 ~ iT C f • E I _ r I IN ~~xo~~l ~/lay ig,X vells'S ,r,k,54,~ rt.~s S~AC'~\SY~T~M PRIVATE ~ t~~ CoIldition~ v o~ws~ .z ~z R~SPpNa~~~~ \ see COR 9 4~ a 4 6~ ? 11OLDING TANK CROSS-SECTION AND SPECIFICATIONS ti Approved Approved Locking Vent Cap Weather Proof Manhole Cpveit Junction Box 4" C.I. 12" Min „ Vent Pipe Final Grade 1 4 Min i i /Approved Joint 18 Min I , Water Ti-Rht - - eal Nigh Water Alarm Switch 1 _ \ SPECIFICATIONS Approved` J#int TANK Mrnufac turer: C'i' >rt~! Tank Size: Gal lone Ik' tendi>np ad ,$o ALARM Manufacturer 44 Model Number: } r Switch Type G.1 NUMBER OF BEDROOMS:_ OWNER'S NAME: ;i AT) 1)RF.SS 1~- LEGAL DISCRIPTION: ►t. .5 t4 It Sec. l; LN,R -4~t_W TOWNSIIIP/MUN CIPALITY:, COUNTY E SEWA~'E SYSTEM ` ~ ~ pR1V A'f ally .-LI CENS F. NUMBER: Condit'Otl DATE. ?toly IE® ONS ,rloustar,s sNu*101 R nNO BUILOGS p'~pIV►SION pP • NCE SEE ESppNDE CO 39400466 Wisoonsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page -~-of Labor and Human Relations ' Division of Safety rf< Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPS OWNER: PROPERTY LOCATION GOVT. LOT 1/4 1/4,S - ?T N,R R(ore PROPERTY OWNER':S MAI NG RESS LOT # BLOCK # SUED. NAME OR CSM # CITY TATE ZIP CODE PHONE NUMBER []CITY ❑ ILLAGE JOfOWN NEAR ?T R D [ ] New Construction Use Residential / Number of bedrooms _3 [ J Addition to existing building Replacement [ J Public or commercial describe Code derived daily flow gpd Recommended design loading rate -z64 bed, gpd/ft2 t//f trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2_(/~trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material - Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ❑ S O U ❑ S O U [IS O U ❑ S jZU ❑ S O U .®S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. C9nt Color Gr. Sz. Sh. Bed Trench Al~ L7, "I'll Ground _ ;F All Al", elev. S-~ ft. - Depth to limiting factor - I Remarks: Boring # i A- - Ground elev. ECE~ Depth to limiting LLL SA factor . IV. Remarks: CST Name:-Please Print i ✓ ✓ Phone: Address: Signature: / Date: CST Number: 117 PROPERTY OWNER SOIL DESCRIPTION REPORT Page Of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Alf' Ground a'~~ elev. ft. Depth to limiting factor i Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # t~hC: III C4~ti-4,:t.;%-x.•,t• Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting $ g 4 0 4 factor Remarks: 0 3 .30 ~ ~ caZ ~ ~~soanll~ is -1-.12o ~ t. oti ~ 3 ~a X940046 6 ,E 332 Doe-umenl No. This space reserved for recording data 513974 HOLDING TANK AGREEMENT Agreement Dale March 8, 1994 This agreement Is made between the l:~T ®CF County or Local Governmental Unit - _ (Holding Tank(s) Owner(s) ST. CRCIX CO.v W1 Pa'd fbe f2-mrd ,(Called Munic! a!i below Helene A. Houle MAR 1 0 1994 We acknowledge that application Is being made for the Installation of (a) holding 8 `3 ;0 - A tank(s) on the following property, (Provide legal land description:) at am Lots 3_, _ B1 ock "T', Plat of Vi 11 age of Cyl on Return To Century 21 Premier Group 1237 N. Knowles P.O. Box 286 New Richmond WI 54017 or that continued use of the existing premises requires that a holding-tank be Installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Slats. As an Inducement to the County of St. Croix to Issue a sanitary permit for the above described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a-nuisance as described in as. 146.13 and 146.14. Slats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60. Slats. 2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the lax roll as a special assess- ment for the abatement of a nuisance, and the lax shall be collected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d), Slats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding lank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with a. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds In a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) (Print) Owner(s) Signature(s) Subscribed and sworn to before me on this date: Helene A. Houle ~ - G Marc~~79, 1994 WIZ 4 Municipal Official Name (Print) Municipal Official Signature Gary Bar l argeon Notary Public My commission expires: $ 9 4 0 0 4 6 Septemb Municipal Official Title (Print) Z3AFfT M. EWILLh!4~~E Noul M104" SBO-6123 (R. 10185) This Instrument was drafted by the Slate of Wisconsin Department of Industry. Labor and Human Relations, Bureau of Plumbing. HOLDING TANK SERVICING CONTRACT contract oat 3;'• 13 1 ~ this contract is made between the MolCing Tank r(s) Name(s) - - - - _ - - and I Pump Name - - - - - - - - - - - - - - - - - - - I Helene A. Houle ' Na fidor 6 We acknowledge the Installation of (a) holding tank(s) on the following property: (Provide legal description:) Lots 1, 2,'and 3, Block "3", Plat of Village of Cylon - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1. The owner agrees to file a copy orthis contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of St. Croix . 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b). Wis. Adm. Code. and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following In the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; I. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract. the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) I Owner's Signature(s) I I Subscribed and sworn to before me on this date: Helene A. Houle i March 8 1994 I Q. U f PumPer's Name (Print) I Pumper'a Signature Notary Gary . Baillargeon My commission expires: September 18, 1994 umper's Registration Number Ilk. of S8D-7574 (N. 11/85) 1N~' This instrument was drafted by the State of Wisconsin Department of Industry. Labor and Human Relations, Bureau of Plumbing. n ~94004n c July 19. 1977 RECEIVED JUL 21 1977 piVIS! N Or IUZALTH UISiPICT 6 F.AO CLAM First National Bank 109 East 2nd Street Plan Identification No. 76-04276 Wow Richmond, WI 54017 Gentiamm a Res Approval for use of an alternate system lrst-NoionaI nk SE 1/4, SW Section 33, T31r19 R16W Cylon. Wisconsin S_ tv of x County The Division hss received from the official responsible for enforce- ment of the sanitary ordinances in your county both an Inspection checklist and n statement certifying that the ave described alternate system was inspected during construction. The Division has reviewed both documents and is satisfied that the above described alternate system was properly constructed. You are rominded that this alternate system was necessary because of the unsuitahi 1 ity of the, above described premises for a conventional septic tank-soli absorption field system. The Division does not gu+arant"_ and further, does not vivo ra warranty (eaitheer implied or express) that yotlr alternate system will function properly for any given period of time.. The alternate system may be used if the owner agrees to the following conditions: 1. That the appropriate local official and this office be notified of the day when use of the system is to commence. 2. That all pending conditions of approval of the installation be complied with. First National Bank Page 2 July 19, 1977 By beginning to use this alternate system, the owner agrees to accept and to comply with the conditions set forth above. The Division Hill imply acceptance of these conditions if the owner begins use of this alternate systems Sincerely, James A. Sargent Chief JASsskk ees Mr. Dave Fredrickson, University of Wisconsin '-W. Erbert Berthold, DPS - District 6, Eau Claire Mr. Harold C. Barber, Zoning Administrator Mr. Richard W. Hopkins i . l I December 7, 1976 A FC'F &r C vry,~~Jv 0 vas; o,. Ca6 i First National Bank h` 109 East Ind Street New Richmond. W1 54017 Plan Identification Ho. 76.04276 Gentlement The Oureau of Fnvlronmental health has reviewed plans, site survey Information and Installation do-..tails covering the construction of a replacement private sewage disposal system on your property located in the SE 1/4, SW 1/4, Section 33, T31+i, R16W, nylon, St. P. oynty: '.Wisconsin. The plans and Installation details were prepared by Richard W. iinpkins, Raster Plumber Restricted Sewer and received for approval on i;ovember 2, 1976. The site evnluattion was conducted by Harold C. R.3rber, St. Croix County Zoning AdmInIstrAtor. The soil Is silty loam over gravel. The soil percolation mete is 1..33. Trig premises meats the soil and site renulremelnt-, specified for the use of Alternate System i which was developed by the University of Wisconsin Sonall Scale Waste Management Project. The proposed system will serve a single family residences contaInlnn. 3 bedrooms. The system has been sized in accord with the requirements set forth in th,~ nltarnAte system design criter.rle. Wastes from the home. Oil -.ilschmrir, to A 1000 9AI)on cApAclty septic tank which will discharhe to s 1000 gallen capacity pump chamber from which a pump havintt a capacity of 33 gallons per minute against a total dynsmtc heat) of fret will discharge through 2 inch diameter pipe to the soil absorption system. utie to the existence of site soil limitations It Is of utmost importance that the system be Installed In completes accord with the plans and Installation datAils and the conditions of approval contained herein, that the appropriate county official conduct thorough inspections at specified tlr.es, reporting his findings to this (Avision and that the contractor not dnvlate from this formal approval and follow dirnctlons or orders Issued by the appropriate local or state authorities. First National Bank Page 2 December 7, 1976 In accordance with Chapter 1115, Wisconsin Statutes, and Section H 62.24 (1), Wisconsin Administrative Code, approval to construct the alternate design private sewage disposal system is granted subject to the following conditions. 1. That appropriate local officials, employees of this nivislon and/or representatives of the University of Wisconsin Small Scale Waste M'Inagement Project be permitted to have access to the premises at any reasonable time for the purpose of inspecting and monitoring the sYstem including the conducting of any necessary bore holes or other physical examinations and the collection of samples of soil or liquids. 2. That In r.vent the alternate design system or any of its component parts malfunction ao as to create a health hazard by discharge of partially treated or Into the or iintrer~ted liquid wastes onto the ground surface waters of the state, the owner will repair, modify or replace at his expense (including the possibility of Installation of a holding tank with proper Proved b disposal) the alternate design system with such action approved by the Division and the appropriate local official. 3. That any subsequent buyer of the premises be given notice that an alternate design system is installed and a copy of this letter of approval be given such buyer. 11. That at least one observation pipe shall be placed in each trench or a minimum of two in each bad. The 4-inch diameter pipe shall extend from the bottom of the bed (fill-rock interface) to the finished grade and be provided with a watertight cap. The bottom 6 Inches of the pipe shall be provided with at least 3 slots at least 1/4-inch in width. That a high water level alarm switch on a separate electrical circuit with an audible or visual alarm in the home be provided; and, the pump water level controls be set so as to prevent breaking suction and to insure the discharge of the daily sewage contribution with not more than two and preferably one pumping per day. 6. That the building sewer be constructed of materials specified in H 62.011 (2) and M 62.20 (11) (c) 4., Wisconsin Administrative Code, with the gradient of the building sewer being not less than 1/8 inch per foot nor more than 1/2 inch per foot. 7. That the top of the building sewer terminal In the septic tank be at least 18 inches below the finished grade. That the alternate design system installation be made in complete accord with the plans and installation details; appropriate sections of Chapter 11 62, Wisconsin Administrative Code, that are not varied from in the alternate design; and the conditions of approval contained herein. First National Sank Page 3 Uecember 7, 1976 In granting this approval the Division does not hold itself liable for any defects in construction; does not guarantee and further does not give warranty, either implied or express, that the system will function adequately or indefinitely; nor does it hold itself liable for any damages that may result from the installation of the system and reserves the right, after consultation with the University of Wisconsin Small Scale Waste Management Project and local personnel, to order changes or additions should conditions arise making such action necessary. In case: installation of the system has not actually commenced by May 31, 1977, this approval Is void. By order of Fdwin R. Larkin, M.D., Acting Administrator, Division of Health. H. E. Wirth, P.E., Director Bureau of Environmental Health cmc cci Mr. Dave Fredrickson, University of Wisconsin Hopkins Cement Products, Inc _-4rTert Gerthold, DPS - District G - Eau Claire Harold Barber, Zoning Administrator i S I^ 1 Icy ~ e, ~ Ih I i °u z 4< , qL yc I %~f ,o 'n .I i i ~ I i T , uvL - 5 ''-r 6 17 < j b F~ f I ! ~ I 1 r V C 100 This application form is to be completed in full and signed by the OWIler(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 n second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. owner of property - Location of property-<F 1/4 S_1/4, section' T,Z_N-R,_W .Township Hailing address Address of site subdivision name )1,/,may ',~r, Lot no.-- other homes on property? yes- ,=No Previous owner of property Total size of parcel Date parcel was created Are all cornors and lot lines identifiable? es No in this property being developed for (spec house)? Yes x/No volume_L& and page Humber 7C as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARiWITY DEED which includes a DOCUMENT NURDER, VOLUME AND PAGE. NUMBER & THE SEAL or, THE REGISTill 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 i the Certified s shall also urvey Hap be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best . of ny (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 f•fice of the County Register of Deeds as Document Ho.15!737. and that I (we) own the proposed site for the sewage disposal system orreI a (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 County Register of deeds as Document No. signature of ap~l cant Co-appl cant Date of S gnature Date of-Signature DOCI)MENT No. t WARRANTY DEED-By Corporation Vot. 6`~6 FrVi e`7V STATE OF WISCONSIN-FORNI 10 A + LJ V THIS SPACE RESERVED FOR RECORDING DATA REGISTERS OFHCE ST. CROIX CO WIS. THIS INDENTURE, Made by III SIT NATIONAL PATTT' r Recd, for Record This 6th _-__.A/K/A_First -National- Bank of New Richmond - day of__Oot A.D. 19$1 _ - _ - - -TT S_~ , A Corporation duly organized and existing under and by virtue of the laws ofthe _%MX 8:30 A sf0i1'idr}. grantor, at / of t . C roi County, Wisconsin, hereby conveys and warrants to 1/u, 146 ILclcne .[Joule grantee of St t_. Croix --County, Wisconsin, for the sum of nty Two. Thousand Five _Iiundred -and `to/100 RETURN TO Dollar, the following tract of land in t (i-roiXCounty, State of Wisconsin: 1,ots One (1), Two (2), Three (3) in P lock Three 09"), Plat of the ~Ji1.]_af of Cylon FEE In Witness Whereof, the said grantor has caused these resents to be signed by J Ohn D . Soderberg p n , its President, and countersigned by Richard F. ~Olc3r7 , its 1,*~~ ~;Sprt]gYaY~[at New RlchmQT1d,--_ Wisconsin, and its corporate sill to be hereunto affixed, this _ 23rd -,day of eptember , A. D., 19-8-1_. ~1ED f F -1) IN PR :NCG OF ` K rporate Name i cal] 1 0. ji^Teri1)y j President ohn P . . so(l, (;0UN R$ NEI V S 1 ti,r,i r. esi a nl* XXOOCDGXX 11,"1nry G. Olson STATE OF WISCONSIN, 1 1 55. 3t . Croix County. f'ersonalh, came before me, this 23rd- day of --September John D. Soderberg 1 'resident, and C11aT'd F. .~oInrz V. P , S1~Fe` MPCof the above named Cwporation, to me known to he the persons who executed the foregoing instrument, and to me known to be such --President and 1,71 . ~'%ce.'Oiffff of said Corporation, and acknowledged that the .qxecule I foregoing ' s r ent as such officers as the [Iced of sail Corporation, h~ its authority- Paul 0._ Swenb -l OTARY. his inslrnnlent drafted h) i N SEAL r Notary Public s t_. Lro1X -County, Wis. 7 My Commission (Expires) ( 1 11f $1. (Secu,;o S~.PI iI) of the tvt,coosln Statute, provides that all Instruments to be recorded shall have plainly printed or typewritten thereon the names of the grantors, grantees, wltrle,APB and notary). WAIMAN !'Y DFVD--,TA'I F 01 R 1S(')NSIN, FORM NO. 10 HCMIIIerCompsry~ E July 19, 1977 RECEIVED J~J! 2 ! 1977 piVIS10,M OF I.iALTH UIST"ICT ; 6 EAU CLAIRE First National Bank 109 East Ind Street Alan Identification No. 76-o4276 Woe Richmond, WI 54017 Centlwans Itet Approval for use of an alternate system FIY-st-Hatt "1 4 4 1/4. sW lA,3ection 330 T31Ns A16W Cylonr, Wisconsin Dtr liroix County The Division has received from the official responsible for enforce- ment of the sanitary ordinances in your county both an inspection checklist and n statement certifying that the a wee described alternate system was Inspneted during construction, The Division has reviewed both documents and is satisfied that the above described alternate system was properly constructed. You are reminded that this alternates system was necessary because of the unsuitability of the above described premises for a conventional sceptic tank-sot 1 absorption field system, The Division doers not guarantee: and further, does not gives a warrmty (eelt1mr Implied or express) that your alternate system will function properly for any given period of time. The alternate system may Iw used If the owner agrees to the following anWitionss 1. That the appropriate local official and this office be notified of the day when use of the system Is to cont*nce. x. That all pending conditions of approval of the Installation be asxeep Heed with. First National Bank Page 2 July 19, 1977 By beginning to use this alternate system, the owner agrees to accept and to comply with they conditions set forth above. The Division will imply acceptance of these conditions if the owner begins use of this alternate system. Sincerely, James A. Sargent Chief JAS:skk ect Hr. Dave rredrickson, University of Wisconsin '\Hr. Erbert Berthold, DPS - District 6, Eau Claire Mr. Harold C. Barber, Zoning Administrator Hr. Richard W. Hopkins rDecember 7, 1976 1 [~,S.'v Qp r C1,4 i First National Bank 109 East 2nd Street New Richmond, WI A017 Plan Identification two. 76--4276 Gant1emen: The Bureau of Fnvi ronmental tfeeal th has reviewed plans, site survey information and installation details covering the construction of a re placeemgnt private sewage disposal system on your property located in the SE 1/4, Std 1/4, Section 33, T31,';, R16w, _.YI'0';e, St~~Ce~~S_S~►n~ Wisconsin. The plans snA installation details were prepared by Richard W. itrpkins, master Plumber Restricted Sewer and received for approval on tiioveamber 2, 1976. The site evaluation was conducted by Harald C. Barber, St. Croix County tea"ing Administretor. The soil is silty loans over graved. The soil percolation rntew is 1.33. The premises meets the sell and site requirements specified for the use of Alternate System 3 which was developed by they University of Wisconsin Small Scale Waste Management Project. The proposed system will serve a single family residence contalninq 3 bedrooms. The system has been sized In accord with the requirements set forth in tho site:rnAtee system design criteria. Wastes from the homes will d1scharnr, to A 1000 gallon capacity septic tank which will discharge to a 1,000 yaa i l son . capse 1 ty pump chamber from which ae pump having . a .;eOp srrl ty of 33 gallons per minute against a total dynamic head of a feet''wlli discharge through 2 Inch diameter pips to the soil absorption system. Uues to the -xistencee of site sell limitations it Is of utmost Importance that the systeem he Installed in complete accord with the plans and Installation datAils and the conditions of approval contained herein; that the, appropriate county official conduct thorough Inspections at specified tlr.-,t.s, reporting his flndIngs to this Ovislon and that they contractor not deviate from this foram approval and follow directions or orders issued by the appropriate local or state authorities. 1 First National Bank Page 2 December 7► 1976 in accordance with Chapter 145, Wisconsin Statutes, and Section H Q.24 (1), Wisconsin Administrative Code, approval to construct the alternate design private sewage disposal system is granted subject to the following conditions. 1. That appropriate local officials, employees of this Division and/or representatives of the University of Wisconsin Small Scale Waste Management Project be permitted to have access to the premises at any reasonable time for the purpose: of inspecting and monitoring the system, including the conducting of any necessary bore holes or other physical examinations and the collection of samples of soil or liquids. 2. That In event the alternate design system or any of Its component parts malfunction so as to create a health hazard by discharge of partially treated or untreated liquid wastes onto the ground surface or into the waters of the state, the owner will repair, modify or replace at his expense (including the possibility of Installation of a holding tank with proper disposal) the alternate design system with such action approved by the Division and the appropriate local official. 3. That any subsequent buyer of the premises be given notice rthat approval alternate design system Is installed and a copy of this be given such buyer. 4. That at least one observation pipe shall be placed in each trench or a minimum of two in each bed. The 4-inch diameter pipe shall extend from the bottom of the bed (fill-rock interface) to the finished grade and be provided with a wateeasC ht cap. slots ateleast«i/4_incheinowldth.pipe shall be provided with at l t 5. That a high water level alarm switch on a separate electrical circuit with an audible or visual alarm in the homer be provided.; and, the pump water level controls be set so as to prevent breaking suction and to insure the discharge of the daily sewage contribution with not more than two and preferably one pumping per day. That the building sewer be constructed of materials specified in 6. H 62.04 (2) and H 62.20 (4) (c) 4., Wisconsin Administrative Code, with the gradient of the building sewer being not less than 1/8 inch per foot nor more than 1/2 inch per foot. 7. That the top of the building sewer terminal in the septic tank be at least 18 inches below the finished grade. That the alternate design system installation bm de In completeof accord with the plans and installation details; appropriate sections Chapter 11 62, Wisconsin Administrative Code, that are not varied from in the alternate design; and the conditions of approval contained herein. First National Bank Page 3 December 7, 1976 In granting this approval the Division does not hold itself liable for any defects in construction; does not guarantee and further does not give warranty, either implied or express, that the system will function adequately or indefinitely; nor does it hold itself liable for any damages that may result from the Installation of the system and reserves the right, after consultation with the University of Wisconsin Small Scale Waste Management Project and local personnel, to order changes or additions should conditions arise making such action necessary. In case Installation of the system has not actually commenced by May 31, 1977, this approval is void. By order of Edwin R. Larkin, M.D., Acting Administrator, Division of Health. H. E. Wirth, P.E., Director Bureau of Environmental Health cmc cc: Mr. Dave Fredrickson, University of Wisconsin Hopkins Cement Products, inc. ,.Zrisert Berthoid, DP5 - District G - Eau Claire Harold Barber, Zoning Administrator i Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pa e of Lataor and Human Relations g - Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT 1/4 1/4,S T N,R E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ❑rOWN NEAREST ROAD [ ] New Construction Use [ ] Residential / Number of bedrooms ( ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U =Unsuitable fors stem ❑ S ❑.U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Bountry Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench h{v Ground elev. ft. Depth to limiting factor I Remarks: Boring # I <•i\ I 4i Ground I 4r elev. ft. e Depth to , limiting _ZZ factor Remarks: 7. CST Name:-Please Print Ph arc.p - , Address: Signature: Dater N btr: a PROPERTY OWNER SOIL DESCRIPTION REPORT Page PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tw& 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: Boring # Ground elev. ft. Depth to limiting factor Remarks: con ennnio nrin~ } wr~,Por,T OF li`?S'' CT_111 1---i i': oTJaliilf T',..it~'•.;b LsJI. ~SA€, SY6 13anitarv Pcin,it • I 7t 1Le• Septic g,allogs. "'umber o:F 'onpar -ment.c Distance From: m: Y•Ja11 ft. 12111 oA greater slo e t I.i t* .ldi ng -t . ?,To L1ancis - - f L s ~ni cter t. Ars?:S r ~nAL S i TEM Tile Field or Seepage Pit(s) ?_,'tance Yro'. ~alJ. p?' a : a ri uildlnf, .Ft. Wetlands r1T'?°~wt~ ter J t . "otal length of lines ft. II=ber of lines--- ~ vengt`i of ,'1^.-+•4 +-a. T ' .c. i". fl-. ~',!i.otn o` the rench _ft. 'total absorption area q. c. T`cpt - I-oclc below the in. Depth of rock over tile in. Cover W%e.i.: roc::. y1:~r~fisi ~f -c, trench in ter 100 EL. Depth to Bedrock ,ft. Del t 1 to 1,;-roundl water ,umber of omits Outsi.'e diameter ft. Dent':i below inlet ft. Gravel around nit: yes no. Dotal absorption area sq. ft. gaare tier- of seepage trerc'bottom area required Square feet of seepage pit aren required lnspec ted by: ,Approve<i Date 197. * , ~7 • Date 7ect -d ~ = c r. Sewage -sin Geiz,rtment cf Health b Social Services tIon of Plumbing b Fire Protection Systems Plan Identification No. b*:stal red for A., Sire Investigation at onset of construction 1 U staller / ;ill D )0 1. Name of In ' ' ' to 2. County,6 fb-4 1 nspector2-J2 / r~.f 3e Package a -7 ,Date-'r 1----L-- 4. Preliminary onsite made by 5., Depth to limiting factor (50% unconsolidated rock or estimated ground r~ water level) - - 6. Percolation rate 7. County installation permit number ~ - / t/ No 8. Are percolation and soil boring holes evident? Yes No 9. Is system located in area of soil tests? Yes 10. Is system located in area shown on state approved plans? Yes= No D 11. Ground slope in area of system d l/ 12. Site data is correct as presented by C.S.T. and system designer? Yes_ No B. Inspection of Construction 1. Disposal site plowed and properly prepared? Yes No - t~ 2. Disposal site conditions wet or damp? Wet Damp Dry 3. Type of fill material ifa-'4 4. Depth of fill (1'Minimum) No 5. is a crawler type tractor used? Yes a. Blade Bucket No 6. Has site been driven on by any vehicles? Yes _ i 7• p l ans ( 8, nch spacing as indicated on approved plans? Yes U~ No 9. Have trench bottoms been properly leveled? Yes No 1C. Trench length and number as shown on approved plans? Yes ✓ No L~ No 11. Distribution piping proper diameter? Yes i 12. Holes in distribution piping properly sized? Yes_ No~ 13. Holes in distribution piping properly spaced? Yes No 14. Holes in distribution piping in a straight line? Yes No 15. Distribution holes drilled straight into piping? Yes No 16. Depth of gravel below distribution piping 17. Depth of gravel above distribution piping - 18. Thickness of marsh hay covering 19. Permanent marker at end of each trench S/6--CJ S-L'4L,- e- 20. Depth of fill over center of system Z? 21. Depth of fill over outer trenches 8 22. Side slopes j 23. Type of fill used above trenches 24. Depth of top soil 25. Seeded? YesNo C. Pumping Chamber 1 . Diameter of i n l e t 2. Diameter of outlet j. Head 4. Size of pump tank - fQ gallons 5. Draw down or, ga i ions pumped per cycle 6. Manufacturer and type of pump same as that indicated on approved plans? Yes No 7. Quick disconnect provided? YesNo 2 r e eter of manhole 9. Height of manhole above `finished grade 10. Diameter of vent (D i~ IL Height of vent above finished grade 12. Pump tank located as shown on approved plans? YesNo D. Septic Tank 1. Properly Installed? Yes_ No COMMENTS 1, the undersigned, hereby certify that the questions were answered on the basis of my personal inspection or knowledge of the construction of this alternate system and further that all data and answers recorded on this form are correct and to the best of my knowledge nd belief. Name: L Signature: Title: WE HAVE INCLUDED TWO COPIES OF THIS FORM FOR COMPLETION BY YOUR OFFICE. WHEN INSPECTION OF CONSTRUCTION IS COMPLETE, ONE COMPLETED FORM SHALL BE RETURNED TO THIS OFFICE WITHIN TEN (10) DAYS AFTER YOUR FINAL INSPECTION OF THIS ALTERNATE SYSTEM. - Date received by Section of Plumbing 6 Fire Protection Systems 3 4 ti+. k fi ; q .y~a e ~ 91t ~~r" ~ •t t` " 3. 41 • 'F,.~y !l~~l y tj~ F.ryY, S ~.J f ~ - V~'-3. r 'A T~+ ~ Ski' {~~~N- S ;~'y~~ Y ••Y ~ Y f`!,,L ?f. . r 40 Zee lit" Id -es 0- ~J * 4 --4 Tt C1101 X C l Y N` T Y Itu0 NNI'N NI N 6 O F F I C E 380411 Ex. 40 & 56 COURTHOUSE HUDSON sate October 18, 1976 Wis State Board of. Plumbing & fire '1t*Ct$o1` MW. P.O. Box 308 E7 Madison, Wisconsin,. ,43'701-. To whomtt may concern 1, Harold C'. Barber, istrator of St. Croix a County have elads im s0 > m of " tt First National Bank property locat ~fik. t lR village of d lon (unincorporated) p ►"ty- * will not ""t in the Tovnehip, o,f G V M62 t the requirewuts of k a septic . system due to the high ground water. 'tt ~ c M t have rejected installation : of a system on this paopor". yQT truly. Harold C. Betber, Z . A. 4 :a 3 h ~ ♦ '..Y; tiJ.. 5.... r Y.:?.aa'1~fW : MY,!d'wt.3fl,.. - .s ij • ' ujoy I~+Ili A) 0 Ale ~0,0&-6 00's LA~ 4's l n. ~V _ „ lo ,r And , s f 1 .q • b b.. t .r k e = S 00 5•v ? a' Ce~~►~-fit diode • EXAMINED and Porte djel Y H. E. WIRTH. P. Health Y the Division r He and Social Services of ~~31tb, fog in the I tier of a , subiect to CO of t2 e Val ndiricni V EDyyIN ctrnq 4em 4 i s ~SE~ oe, } koo~o 1426 7'igrv A( c r All 1 '/J E /J J ~O S T,p tt e o►- ;~t s" i1 uC t~1iC t LL~A.~~E /~l~z.-►~E.r~f,v~ ~tiPaJ fG~ Lli~/~~/ G!>~s'C. Iyj~d~.so,,~. /~.~-2 sd ids AWE/F yS )0,0" ~l y ` q N, Mai 4g ''y~ ~ `4 ` ~ Al k~{ "*1~ .....:tS' ♦ r ! • i t ~ r .fir e -o w 4 SUMP.PMP - '4s{ `M' VY DUTY• r Z t i- ..o > x~ Quickly, Qu '.-m* "Ii ` Mse- VIW215 2" CAST IRON ments, boiler pits, ;rt~un~'s $e, scale, elevator pits and all premises be- '!CD ` ~vt ~ct'tr P[1fR! is w JULN !~R MATINUAL DEVFC r," AND ` IoW sewer level that must be kept dry. ~RICM/12Yi&11i' a 4{ ~w •'f Ak. Av 'd"*-0'0X1A) A Ue" ov'ov~~" Idl. v rh ~ End , off i 1K r Axe EXAMINED and re rted upon b Environmental Health Y the B mu of E. WIRTH, P.E., Direct w reau of Environmental ealth T ~iPPROVED by the ivisiort of Heath, De t. of Health and Social Sere es, subject to conditio s set fob F ia,the letter of a royal A" Aar V ~ EVE s fZK. ~G if, F d ~ ~ C a~ ,f.C~'H'r i~Cit/ C~ ¢ ; Y . ri:: 70 0, f ~ •}yD JJ w A-1 lf~6W l ' 5 9• •Ztoo~ ov,,ve /•:J ~ ~~/irr9 ,GE Q I 9' I 1 I 9' t ! 1 I 1 t 1 1 I 1 / 3 Env tNED and repo lad' upon b tip mental Health of ^ j 2d' I H. F-WiQr r Dirceor,.r". Bureau of Environmenial H(A$ AAPROVEp by the Division of Htalr Q~ He Jth -arid Social Services, sub pt' or lette r of i ct to conditioru approval 6DW(~ R. t Yerj Actln9 Ad ; ~ , N` Il , _v_ t~A ~y.,~y r i.; ~ %!4f•R'G.'-ra- - . ~ '.Fl.i: ..yt..•w~p,~yyn, .,*~4"!t7A"E."u J . FK7 M }X.~ , ~f Svc rA /1670' 11(2' f tic r- file c►rra? k 4 M or r K 90, jk. and •4~" 5 s a o+ : . up" kc~'d wpm- , u~ se3t~ pf', T by sel-*,, s, subje to R.644f of o w oval Q ' J + MEW - 1w. s ..m F: a J ~N. •ilf s. see v i DC. Q o Ia G :x 4.6 O~r7 ~y5 7 e Cs"l 1,09 A. " a A _,P RE S►.z / / ,Q EXAMINED and reported upon by the, Bureau of ~vfir•G / f1►1f' `~'/D H. E. WIRTH, P.E., Director n Bureau of Environmental Id~dal]~ APPROVED by the Division of Hr.,Jth, .Dtapt..of He :l?h and Social Servicos, smh :ct w conditions set forth in thu I'l.er of do;wuwll R: KI M.0.•' i I low r a ' R. 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LQ 4'r f fix. ~?r ~.,yr = r 41 } °fl}. 1•~?Y.i3~Y~iM[o1 .,yIfc ,tC'~. i* i3~ '<.}s9~ 1~~ti 7-+~ -f* y' t~~,x Aww i 4• F +`~o • 4 rte` s ' - ?'L'~+a ~#;t ~i.Hd~ i~t•-~~,r I=- ~'S f ~X 1~~1~• ~y, n -'~i -H Zo :r ' ~l t z ~d~iJ s't8t +li ~_T # } - t a g s >,i : y T' PA T tR PP it+ .2_s Tv- ~ .•.rc' ~ 9:' ~~i~~ t ~1? f d ,`I ~ 7 ~1!H1J~ L r^ t -'Y9[ +4 *r~"F'~"' ~ ~J F`~J k'~ ,e`ri y )3. s"~ ~7A ~.~°.}~;~t' } #~rT ~ . ~ L Y~ ~ §Xj Nilwil b-41 .9+1 sS Y Z~L ~w.~ f" t~ 3<.. /i~'I~., I.~/ • ; i>i f Z~, x ` ` 4 : ~ ''~Y Tel= tl': Rit ~IG~ ,,2~ _•.f~ ^L'F t ,i: ~n 1. d•i ~ ~Sl { Fi ~ ~x~ 'SpRr 'E Y Ifi a ' { ~ - ~ '7x ~ .i , -11 tT1 !,v'• eJ t: v ti~ ~ r~ f ~ 9%'''~ rt t A 3',~5 4,', ~ $ l ' ~ 44* 11 z } ~ t > ~~Y~ 3, 'f '~F~ y~~~i man ~!TEfrv)~r~•k~ :'~Sld~~ .1 f -3i~~ ,~i sfriat,yc gg d g':. r 1 r'at< JIB.*f } t{}1 .s~ 1~ r t at:;d1~1 rtj it {I'!~? € 4 It. {eI S r x i. ;l s first lmti*vl lank c 7~ 1g7b u 1 In griattP #hts 00praval tilt Of0sta" dam t.'holt. i fl .14b4, 1 +1t sots t a tr .hoot +~s~e N +ui t r►sh.e 46" *"f,, wer"I" . *UW o~tot, i nor 404 44 bald =f191o f' itot#146 fair Ow 'Illy" ' ' ~!i► r ` ' + rssu t 'fras► 1as,i tot 1~6 lid csatioa t#i br►i*rs'y►#fR +tif tl # Ct fi : s" fr JI aid . i p*roww*t to *rVor chsng*t or 111 "24 TOM41l101164i ±s tht system loos net 4004llY E ftr Otf~~A;~~~ ~ 1qr 4r"r 0 JOWjn Larkin, M.13., Act[ his#~+y ` i Y } i 'a:A~t'II'#~1~Iol11~ - i;`_~~'f ''*^y ~ 2~`°. 4 t ii rrtl+rrid« M QUtr.tat Yau Clsi rs , 0.4 ion id tls~r r : 1 ►1~ /fy~jr►kni i"ator b b s° y, - a ~ zg. t..' 3 ~ S.. }r ~s f~ ~'-a ~ e~~-"t t t a t 4 R' `i.~ YE w« ~ "lot 17 k5'" . E. At ~ t e .fit= lip ` a fs, {a ADO .t' mt ' f?~~'~-'t"'~C,'~'u`.; "i~'?~L~'~• +a "~~~"~10;t~. ~C~F~~'?f'r i~itv.~U{~f~~ T t~ +2° '~'~~'k~'~ 4641 11~ t • ter 17N+ ,Mi .k' ~ t'. ':,Si TJ:.r-' - : . + ~,t `F!rY''.?I't'' ~y1Y'~ 1 ~ r r ` rrt}vt 'y+r3~~ f I.eVV ` ' 5 $ t1 t}t_ 9'P+ $ 1 ;tf!F( i"v ~ ~ ..,~~t,.L~ ~ ~ y~y'.k-s' S+~ ~ ~ .SR`s ~{.+f y.~ ~17~k~ '~{-~i~~✓..~ ~~I~lft ice. a. vl~t~'a 19i'.$~s}A" {yy' Yt ~~'r3''}~t' •t',SJ [ ~G S. LO ` f Psi, POW • try: too! F v. Ell AT t 1 •K r S { L' ~y w k, 5wn t} ~Y.a lot 1~ _ J t 7 µ'J 1.4`f ~wf L /~1 ~C/Fj tKFC ; CO* i POW SIT 3 'F 1 y R t4 qjjTj 11 ;q 0 1 r~ sa y Own MAY , VAT H; - - IT u Plb 67 State and County State Permit # Permit Application County Permit # for Private Domestic Sewage Systems County X *DENOTES STATE APPROVAL REQUIRED Date .Approval Received from State if Required State Plarr I.D. # A. DOWNER OF PROPERTY Mailing Address: - /,,4 10a Li Cn',4 6Aak /o r 5 Z 4U-)6-W_ B. LOCATION: S4' - %Z'Eck Section ja, T,3J_ N, Rl(~ (or) W Lot# 1-.2 -4 City Subdivision Name, nearest road, ~lake or landmark Blk# Z -3 Village tilt 0 7` C~~ G !t) Township n) C. TYPE OF OCCUPANCY: Commercial Industrial *Other (specify) *Variance Single family _L_- Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher AYES NO Food Waste Grinder YES i/NO # of Bathrooms- Automatic Washer t- YES NO Other (specify) E. SEPTIC TANK CAPACITY-/ CC o Total gallons No. of tanks / *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement_ L-- Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) Total Absorb Area sq. ft. New Addition Replacement *Fill System 1._~ Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length Width Depth Tile Depth No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land r °7c, Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certi ied Soil Tester, NAME 2/ C_ a C.S.T. # LL/ and other information obtained from (owner/builder). Plumber's Signature MP/MPRSW# /SD Phone #a yd- $ %i~~ PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). i I I 1 E , 1 e s r - I I I 3 s -t-_ "..W _,,r... .f . _ I a_ ~ i f r I t I I I j I ~ I _ y i T, t 3 LLI r a E I > # E I t j E F E 1 f p E I Do Not Write in Space Below FOR DEPARTMENT USE ONLY Date of Application Fees Paid: State County Date Permit Issued/Rejected (date) Issuing Agent Name Inspection Yes No Valid* Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 3/1/75 lZ 7704. xFYV..: x tali;y J N, 777 74F C"ri bdN' 4* Ole .1 11 r' t " r Other, - - ADDITitl?rrtr ! t ~ '3x9.h 9" z; - ",tOI>_ `APE: r= ~ a 1 SRS ' A ~tESTs1!l _ S71 ti. 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'.~.~g''~, a~x' .`e ti•,°;6 d ~j+) .f.m i >~,•,'y yRr~td TMr,-r~,r~.' •~'~~'.~i•7., ~ WC ~ 1"~~R"~!t_ .z•21. ~ rr('i'^~ 1: p ty ` a~ ' Y`r 44, x w :,~a ~et'+. ii ~ ~ ; ~~~•Sti;., it +4~'~ .t~ •5F `'~''j;r,. ty ~ t. +.~~~pty•,F~.e 'Y` ~ ~ , 5.+~ i ~r 3'. • 2, . 3 yp Y. 1U a . + G 7 1 °L,.}."t~ W M .'C ~ ~ .Y' 'a9 ti{ C}- s x 1 tl f 1^;f.,: 't ~ t F 31 ng, .N. ~ BJF~{ 'rv ~ d^y~ '~y' ,^,',P;f ` ~1'a "uf' 1~ , lot /Y2' Lo-r- 3 2 5. Ile 0 6 ~ 2y~ /7o u SGT L i loco 5 Al„ 1 ~wra irit' W~ J- ~ 100~ n loco gAk, u. m p f1gri a ov~~ .01 I O S,lo P L-- l .f 5 i A-4 v D 1o s.c C 0 01 ©u~ rZ o % s~-o pt ion /00 ' -~c sG G~~/~SC~(~/✓~S~/L~ ~CJL/~1//L~/~ST~T~I~G~ C.~~dE ~~p7L7~ , C, -7ZIZ . ~z f y/9 z r9> F r~-> f .v ~ a j F Gf'rrr Gv~se . /?~•g d, S.0 ,e i1'G22/ GC~IS 7 ii H ~ 1 / r ,y yv,4 'T/ O.~f~ ~ ~i4~ hC , yv ~ LtJ ~e~h iyi O mod, Gf/! L ~ C, 8 4 0 f . E J 7' .5 7 f /yJ / ho 71-61~ h 7- Q m ~~`7DDD f / iZ~S 7-1 7-/ d eS.CoPf ~'LC A/s bE Q I I ~ 9' I I I 9' i I I i ~ ~ I I ~ I ~E >siL I PE /1 P ~E I I ~ I 9` 28 3 GC /2 pOo S F O~ ~ / ~ ~ oSrS 7'~ /~'1 y , -31 74 State of. Wiseonsm e DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH Nciv !ebtr MAIL ADOAESS: P. O. SOX 309 MADISON. WISCONSIN 53701 n , 9 IN REPLY PLEASE REFER TO: I SECTION OF PLUMBING I I:.,,J i) 1VIU }f AND FIRE PROTECTION SYSTEMS f. j1VAG f„ou anAdentification No. Dear Sir: Re: ';*c. ,LN k1 14 ' .'own of rlon (St. Croix Co ) This is to acknowledge receipt of your plans and specifications for the above- indicated project. When referring to this plan in the future, it will be absolutely necessary to utilize the plan identification number assigned to the project. The spaces below indicate if proper fees have been submitted or if more information is required. Providing plan review is not completed within thirty (30) days, a permit to start construction may be issued if requested. See Section R 62.25, Wisconsin Administrative Code, for limitations in reference to permits to start construction. Preliminary plan review for determination of fees does not hold the department liable in the event additional fees may be required upon complete plan review. Preliminary review indicates the plan review Fee required is $ /5-- / Fee received is $ Plan accepted for review. Fee is being returned because of II Overpayment II underpayment. Providing one of the two categories above is checked, please remit correct total fee in one payment. Indicate plan identification number on remittance. I] No fee has been remitted. Plans submitted with no fees will be held in abeyance until remittance is received. Indicate plan identification number on remittance. Il Additional information required. See attached Plb. 100. The permit to start construction will not be issued until 30 days after requested information is received and accepted. Q Plans being returned. See attached Plb. 100. Sincerely, Z A. arg Chief JAS: f js State of. Wisconsin \ DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH MAIL ADDRESS: P. O. SO% 309 MADISON, WISCONSIN 53701 fttebe r 26, 1976 IN REPLY PLEASE REFER TO: SECTION OF PLUMBING AND FIRE PROTECTION SYSTEMS " kiss 01st Predsoets;, Tag heats 4 Plan Identification No. 760276 Now ltd: ft l7 9 ~ IO RrrFIVFn Dear Sir: C Nov 1 1976 Re : First NationsI Somk - (ftlvota ftworty) ZONING Aitorsata fyeitai OFFICE v 81I4 svk sere 13 TUN n61 Two of Cylaa (alt. Croix E This is to acknowledge receipt of your plans and specifications for a above- indicated project. When referring to this plan in the future, it will be absolutely necessary to utilize the plan identification number assigned to the-project . The spaces below indicate if proper fees have been submitted or if more information is required. Providing plan review is not completed within thirty (30) days, a permit to start construction may be issued if requested. See Section H 62.25, Wisconsin Administrative Code, for limitations in reference to permits to start construction. Preliminary plan review for determination of fees does not hold the department liable in the event additional fees may be required upon complete plan review. Preliminary review indicates/'5- Fee the plan review Fee required is $ received is $ -14~~ ❑ Plan accepted for review. Fee is being returned because of II Overpayment underpayment. Providing one of the two categories above is checked, please remit correct total fee in one payment. Indicate plan identification number on remittance. No fee has been remitted. Plans submitted with no fees will be held in abeyance until remittance is received. Indicate plan identification number on remittance. 1 Additional information required. --Swe h The permit to start construction will not be issued until 30 days after requested information is received and accepted. Q Plans being returned. See attached Plb. 100. Sincerely, amea A. arg Chief 3AS:fjs