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HomeMy WebLinkAbout010-1047-60-100 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER / ADDRESS SUBDIVISION / CSM# LOT # SECTION T N-R_,&_W, Town of }A,f,oj.jQ ST. CROIX COUNTY WISCONSIN WWII PLAN V EW SHOW EVERYTHING WITHIN 10 FEET OF SY ez6 ie8 INDICATE NORTH ARROW Provide setback and elevation infor t n on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ALTERNATE BM• /4aa SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: "Le-19, Liquid Capacity: Setback from: Well ^-o 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: C~/~ Setback from: well: House 1R Other ELEVATIONS Building Sewer~g 4~~ ST Inlet; 97., 7 ST outlet 42.odZe- qB.G' PC inlet PC bottom Pump Off Header/Manifold Bottom of system 93 7~ z,✓os - 95/6 / t Existing Grade q y q Final grade !27 9 DATE OF INSTALLATION: - / PLUMBER ON JOB: - LICENSE NUMBER: INSPECTOR: 3/93:jt Wa De partment of Industry, PRIVATE SEWAGE SYSTEM County: nd Human Relartions INSPECTION REPORT ST. CROIX Safety and Baildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 610 3 Permi HQQ~~dg~ e: ❑ City ❑ Village Town of: State Plan ID No.: 5Z PIA", DANIEL Q I CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /00- /on, 5a4ya et", TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic J _ nchmark ~93 00 Dosi ng a?, 7~ boo 1 /7 Aeration Bldg. Sewer Ln' Holding St/ Ht Inlet 15,66 97.d 7 TANK SETBACK INFORMATION St/ Ht Outlet j.~ 3 970 / Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic )50'- > 6 p G r NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe qq, (p / Holding Bot. System 9•f 9 93: PUMP / SIPHON INFORMATION Final Grade j,03 Manufacturer Demand'.-:, )tr Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length W No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of I , Model Number: System: 1_" ~aob /fly 130 V 1A CHAMBER OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) . x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges I S r Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Emerald.20.30.16W, NW, NW, Lot 1, 220th Street Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date 61 rispector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITAR PERMff # -Attach complete plans (to the county copy only) for the system, on paper not less than L7/C/V 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 '/4 '/4, T , N, R E (or w 11 440AIS.:~C PROPERTY OWNER'S MAILING A REDS OT # BLOCK # may' Cl STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NU BER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned ❑ VILLAGE 1 or 2 Fam. Dwelling-## of bedrooms PAR EL TAX NUMBER(S) ❑ Public 141 - r7U 111. BUILDING USE: (If building type is public, check all that apply) 0)0 - /0L17 - 60 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 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. ~1 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) Q A Sanitary Permit was previously issued. Permit # SA y k 0 3 Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 X Seepage Bed 21 ❑ Mound 300 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 /da sq. ft.) (Min. inch) ELEVATION 5z Feet Feet VII. TANK CAPACITY Site in al Ions 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 ' Lift Pump Tank/Si hon Chamber F-1 F-1 F-1 F1 I F-1 [_1 Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installatio of the onsite sewage system shown on the attached plans. Plumbe ' Nam (P ' t): Plumber' Sig at : ( to s) MP/MPRSW No.: Business Phone Number: r Chi Plumber's Address (Street, City, State, Zip Cod y i IX. COUNTY/DEPARTMENT US ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater jDate Issued suing Age Sig re o S mps) Approved El Owner Given Initial Surcharge Fee) r Adverse Determination X. ONDITIONS OPPROVAL/REASONS F DISAPPR VAL: t? 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 r 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) `r 1 64- SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY ER # -Attach complete plans (to the county copy only) for the system, on paper not less than 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 PROP S k)'/aIVtG '/4, T O,N,R E(o PROPERTY OWNER'S MAILING A DRB$S LOT # BLOCK # Cl , STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUJIABER E:I II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned VILLAGE : ❑ Public 211 or 2 Fam_ Dwelling-#of bedrooms PARCEL TAX NUM4~,~ / BER(S) III. BUILDING USE:, (if building type is public, check all that apply) oil) - J ©L/ ] > L 0 " DU 1 ❑ Apt/Condo I 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 9E] Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2.E] Replacement 3. ❑ Replacement of 4.E] Reconnection of 511 Repair of an System System Tank Only Existing System Existing System B) ® A Sanitary Permit was previously issued. Permit xo~ y b D 3 Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 n 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-ln-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/da /sq. ft.) (Min inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank 60 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. Plumbs Nam t): Plumbe s Si at e: t ps MP/MPRSW No.: Business Phone Number: iS - cal Plumber's Address (Street, City, State, Zip Coc)e): IX. COU TY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee pncludes Groundwater ate Issued ssuing Ag t Si ure No mps), Surcharge Fee) s' Approved JHOwner Given Initial Adverse Determination r Gam' "ONDITIONS O ,APPROVAL/REASONS Oft DISAPPROVAL: _ SBD-6398(8.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber t 'R'1. R_R t t` k, 3. T k_T.?'T.1 T Cv f.~-a-i a t R c'4 4Y.'Y 4 ix51rST'S k141L RYY IIR\.9RhrA+iri R;~6tx1Ri.~kRS+f t12 l 4e '}''4 * } 'i i ~f }''k R ''&fi 4i}'}'{,} ~.d:,+t.d.l i•1`:d. d;d~S.rd 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. 11. 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) 4.4 74/0 wEll So& ~I 0 ~d D i n, 98' ~ 3 719 70 ~f~,~~ fflr LHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code couNTY 87`.6 1 STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than E& S~i~t X 11 Inch@S In SIZ@. ❑ Check if ious 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 0A. Gf % AQ1/4, S -20 TAD, N, R 14 or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM N BER a.td~h W T syau~. N J4-. Gs 1/0-4 a 0 'W II. TYPE OF BUILDING: (Check one) CITY AREST ROAD ❑ State Owned ❑ VILLAGE : ❑ Public P1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUMBER(S) III. BUILDING USE: (if building type is public, check all that apply) ~N 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 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. New 2.E] 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 t;dSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank a2 El 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 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE -7S~ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/da /sq. ft.) (Min./inch) el ?4 ELEVATION ~e2.$ . Ila,r * _N 7i4 7.3 7 Feet , Feet VII. TANK CAPACITY Site Prefab. Fiber- Exper. in allons j;V INFORMATION New istin Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank A_AAA6--1 I W7 F-1 F-1 I Fj_ F-1 Si hon Chamber Lift Pump Tank/ Vill. RESPONSIBILITY STATEMENT / I, the undersigned, assume responsibility for installation of the onsite sewage system } Name (Pr hone Number: i Plumber's Sig a : (Nomps) Plumber'iuty% w.2+r).d. Jam'/3~ a o Plumb is Address (Street, City,jWe, Zip Code): IX. COON /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee pncludes Groundwater LDate su e Issuing Age t Sig ture (No mps Surcharge Fee) Approved Owner Given Initial I j& ~ / Adverse Determination CJ / X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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. Onsitesewage systems must be properly maintained. The`sep~ic-tarik(s~j r>*iust oe pumped by a lidensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onaite sewage system, contact your local code administrator'or`the State of Wisconsin, Safety & Buildings Division, 608-266-3815 To be cOrnple'te 9nd accurate this senitw-y 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 performapce curve; pump model and pump manufacturer; D) cross section of the soil absorption system. if Iequired by the'eounty; O-Soi(iest data on a T35 form; and F) al[slzing information:u:• 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 rponito,ring groundwater, ground, water contamination investigations and establishment of standards. r s SBD-6398 (R.11/88) P/0 NW -/Atv Sao » J~o~-/~ ~a T s yrn n- nc sk 4 Iln m at /y 93 - aae~"s~, v`\ v~ 0 M Said .16000 mow% 21! ~ o n O , ,~t-e. 7 - 9y Av /Vol T4-3 ~r D r`. i a `r . ~s Y+ ~ f. y «r .4- • x''r;~y i • . • •A 'r • ' r • t .d i~ t' oP A 1. to s s~en-j 1 t 16 &.0 w n t at-1.5~~~ frl►A Ali Int11► And OD►•trollon Pip• ~-.J Appr•r11 . Cap Von1 klMrn ui11 12' A•or• ' rl11~l Gr°1• 20. 42• A►..o P1pp 4' Carl Ire" To 1`11141 Or••• V4411 pip, ►!«rn N•y 01 SrnlMlk Co.rrln° 1w1ft 2* Or.r PIPj/r•/•1• ' Olrlrt►vllo11 Plp• e o e T•• j All►•1.1• e:11041► PIP, ° e PCee1 .p1t0l1n4l 1•• pip, 0,1'. TossninUlnl AI of syliefs • Prupd~c~ ~►n•.~ g~~.c~•c 9•x.9 ~.11:,J.:~'1on ~ SOIL FILL DISTRIBUTI01,1 PIPE , • • . 2"0F 11GGR>;G111E APPROVED SwipETIC COVC ``-MATl:Rll~l. OIL 9" OF. STRAW .~r.T,Y.. OR MARSN. 9&%j wqP LN•O P 1 r " ~ ~ ELEV. OF l3. FEC1 d1B'. t-2/2 AGGRCGATE , OISTR115UTIOM Pipe TU BC AT LEh5'T A1JV AT LEAST LO IIJCHES BUT 1.10 MORE TH 1~1CHE5 BELOW ORIGIMAL GRAOC': • AM 42. IMCHES OELOW FILIAL GRAD C, MR)ciMUM pF-PtH OF F-XcAVATIOP FXoM ORIGWAI, 6t~oF WILL BE 711xIMUM p~Prli of ExcavArioN 1GIN . IlJCHES H\OM ~ AL GROE WILL 0C INCHES SIGMCO: ' LIGCUSC LJUMBER:r DATE: 9 110 . Wiscpnsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and- Human Relations pi.ision.of, Afety & Butldings in accord with ILHR 83.05, Wis. Adm. Code COUNTY St. Croix 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 Loren Derrick GOVT. LOT NW 1/4 NW 1/4,S 20 T 30 N,R16 f(or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 1310 fiy. #65 n/a n/a n/a CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE 9TOWN NEAREST ROAD Clew Richmond WI. 54017 V15)246-5425 Ernerald 220 th. St. [ flew Construction Use [x:k Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 4 bed, gpd/ft2. • 5 trench, gpd/ft2 Absorption area required 1125 bed, ft2 900 trench, ft2 Maximum design loading rate • 4 bed, gpd/ft2 •5 trench, gpd/ft2 Recommended infiltration surface elevation(s) 93.72 ft (as referred to site plan benchmark) Additional design / site considerations recommend trench system Parent material Glacial drift Flood plain elevation, if applicable n a ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem )M S O U )m S ❑ U Ed>G ❑ U US ❑ U ❑ S [3U ❑ S 1:111 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-12 10yr3/3 none L. 2/m/sbk mfr c/s 2/f .5 2 12-3 7.5yr4/4 none scl 1/f/gr mfr g/w 1/f .2 .3 Ground 3 33-8 7.5yr4/6 none sls- /Sg mvfr n/a n/a .4 .5 elev. 95.80 ft. Depth to limiting factor >80 Remarks: Boring # w:4 1 0-11 10yr3/3 none L. 2/m/sbk mfr g/w 2/f .5 i.6 2 11-25 7.5yr4/4 none sicl 1/f/gr mfr g/w 1/f .2 .3 2 3 25-40 7.5yr4/4 none s 'W 2/m/sbk mfr g/w 1/f .4 .5 cl.ski s Ground ft. G 9 n/a n/a .5 .6 roundt. 4 40-84 7.5yr4/6 none S1.- ll!k 1S. ~i Depth to limiting Remarks: CST Name: Please Print Gary L. Steel Phone: 71 -6200 Address: 1554 00th. Ave p, New Richmond, Wi. 54017 Ir ` , Signature: 5-541e: 2298 CST Number: PROPERTY OWNER Loren Derrick SOIL DESCRIPTION REPORT Page _Lot 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 1 0-12 10yr3/3 none L. 2/misbk mfr g w 2 f .5 .6 2 12-19 10yr4/4 none sicl 1/f/gr mfr g/w 1/f .2 .3 S1. w 2/m/sbk mvfr Ground 3 19-46 7.5yr4/4 none l.skin g/w 1/f .4 .5 elev. sl . - 97.55ft. 4 46-89 7.5yr4/6 none ls, 0/sg mvfr n/a n/a .5 i.6 Depth to limiting factor >89 Remarks: Boring # 1 10-12 10yr3/3 none L. 2/0pl mfr c/s 2/f n/p n/p 2 12-2.6 10yr4/4 none sil. 2/ms/bk mfr g/w 1/f .5 1.6 3 26-42 7.5yr4/4 none scl 2/m/sbk mfr g/w 1/f .4 .5 Ground 7, 5 4/ S1. 2/m/sbk mfr elev. 4 42-70 Yr 4 none g/w n/a .5 ::.6 97.70. 5 70-88 7.5yr5/6 none S. 0/sg ml /a n/a .7 .8 Depth to limiting r Remarks: Boring # 1 0-9 10yr3/3 none L. 2/c/pl mfr g/w 2/f u/p n/p 5 2 9-19 5yr4/4 none sl. 2/m/sbk mfr g/w 1/f .5 .6 3 19-80 7.5yr4/6 none fls. 0/sg mvfr n/a na/ .5 .6 Ground elev. 95.6 ft. Depth to limiting factor >80 Remarks: Boring # >4 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE 1554 2efth. Ave. Gary L. Steel C.S.T. 2298 Loren Derrick New Richmond, WI 54017 MPRSW-3254 NWkM,1,, S20-T30N-R16W (715) 246-6200 town of Jberald. ( d0- Y3 P, 100' w1 m~-~ K 0 v ~4 N 43 5019 52 CERTIFIED SURVEY MAP Located in part of the NW4 of the NW4 of section 20, T30N, R16W, Town of Emerald, St. Croix County, Wisconsin. OWNER I Richard Robert Derrick 1310 HWY. 116511 New Richmond, Wi. 54017 UNPL ,1TTED LANDS r NORTH LINE OF THE NWI/4 OF SECTION 20 j" NW COR. C.T H. "G N 1/4 COR• I - - - SECTION SECTION 20 20 ~ N88°29'33"W N 330.00' s8s°29'33"E - - 2326.00' N' N88 °29'33"W 296.95' w N ct C 6 6' APPROVED a (n A N Z 7 931 m --1 O O o E o 0- I c- M I N p O W ;r. CROIX COUNTY ° I? I N c CONC. a O I C' n t O N FOUNDATION W 1 ;cwwehensive Planning 0 N I _U Zorw>tq and ? j Z I = m r*i LOT I > Parks Committee 0 1--I I 1-1 I Ln S WELL I -1 If not recorded I ~D I ---I co I n l within 30 days of o I x 10 naval data W IM aDPr U) I I I I- M IM cnl BARN approval shatbe D I m cn reA & Void (r _ 0 0) O co OSILO: iJ> j~ N I(!~ o O 4.24 Acres Inc. R/W p O 184,544 Sq. Ft. I(!) 3.53 Acres Exc. R/W O I 153,812 Sq. Ft. N 8 ~2 1.3S 33' FLED ' 0, L ,1U1. 0~' 1993• 1 0'CONNELL JAMES o W 3. : 296.95' OJ Register oi Deeds S88°29'33~~E 330.00 SL CroixCo•,WI I0 0 r• rn o ~ ~ n o 0- N o LEGEND p i(o w o A I 11 1 r L S Aluminum County Section ° J~.P ,1TTED Lit JD w N - Monument Found 0 = m 0 1" x 24" Iron Pipe Set, o rt VOLUME 9 PAGE 2642 weighing 1.68 lbs. per o linear foot 0 0 N_ n SCALE IN FEET \ 1001 Roadway SetbaFk p r ' Existing Fenceline \ oO 0 50 100 200 --Existing Driveway L STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~4Yn 1 lei S Z y 17j h S t MAMING ADDRESS S/ S 9C PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE 4L 1A 1 o o 'Z PROPERTY LOCATION AU 1/4, 1/4, Section T 3 O N-R__H,_W TOWN OF E r%+ -e, r ck ST. CROIX COUNTY, WI SUBDIVISION CS ln,_ LOT NUMBER 1 CERTIFIED SURVEY MAP CS VOLUME _.L._, PAGES G9 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 ofreplacement 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: 1 DATE: - 19 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 Mvl i e,, T 5.z-y 2j" sJk 1 Location of property W 1/4 1/4, Sebtion Q0 T 30N-R /b W Township Mailing address 3 oA. ; c, p r Address of site L ydoZ Subdivision name G5~^ 2_ 9q 2 Lot no. Other homes on property? Yes No Previous owner of property RIGAq,rcj Z-0. Total size of property Total size of parcel o~ y Ct.G.ta•~-. Date parcel was created Are all corners and lot lines identifiable? _ Yes No Is this property being developed for ('spec house)?, Yes No Volume /Df-7 and Page Number .3a 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. _ .519'/ -5 le,- , 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. Si nature of cant / Co-Applicant Date of Signature Date of Signature DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982., 51915 REGISTER'S OFFICE _VOt.7~a,~~~--- _ ST. CROIX CO., WI _-Richard- L-.-.:Derr-i-ck-,and---Robe-rt-_-J.---Derrick--- Rec'dfOrReoorrd as---tenants.... n--- ommon,. - - JUL' 19 1994 at 9:30 M conveys and warrants to -..Da.ni_e.l_---J-.--.S-z_yman_sk,i-s------------------- Register of Deeds - RET§AMNON MORTGAGE, INC. 228 No. Keller Amery, WI 54001 the following described real estate in t-.---- - - -i-x----------------------County, State of Wisconsin: Tax Parcel No_ Lot 1 of Certified Survey Map recorded in Volume 11911, Page 2642 as Document No. 501952, being a part of the Northwest 114 of the Northwest 1/4 of Section 20, Township 30 North, Range 16 West. This warranty deed is given in satisfaction of the land contract between Richard L. Derrick and Robert J. Derrick, as tenants in common, as Vendors, and Daniel J. Szymanski, as Purchaser, dated July 27, 1993, and recorded in St. Croix County Register of Deeds Office on July 30, 1993, in Volume:1024 of Records on Page 595 as Document No. 503133. E This .-...i-s_- no:t homestead property. This property was not the homestead of the (is) (is not) Vendors on July 27, 1993• Exception to warranties: Dated this - - - - - -10-th day of Jun.e 19-94... r (SEAL) - (SEAL) -Richar-d--L..---De_rr_i_ck------ * ---------Robes ---J-•---De_rr_nck------------- (SEAL) -------(SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WISCONSIN ss. 5t_ Ciz'a1X County. authenticated this ________day of 19 Personally came before me this 10_th....... day of JJune............................ 19.94___ the:gbovle•naified R-ab.ert---1- Derx_zc.k-- Richax_d__Lj._._I2e_r_r.i_ck_.:__'~ TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, . .r t1•-~3-- . authorized by § 706.06, Wis. Stats.) t~^_ , to me known to be the person Sr__._~,'_^rb ~?lf t ``v foregoing oinsyument and a knowled-` THIS INSTRUMENT WAS DRAFTED BY ``%~Jl~-rafl~~'•~••'• ..BAKKE-NORMAN ' S.C. - F VJ I c+ NEW RICHMOND , WI 5 4 017 Debra---LVxi e.ze--------------=--.~ = ount.y. **is._ . Notary Public S-t-•---C-1'0.11--- - C . state (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, ex On are not necessary.) date- 11-5 • 19 ) 'Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM M. 2- 19R9 Milwaukee Wivrnnsin