HomeMy WebLinkAbout018-1047-10-100
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER If ~r? 014 / t tort
ADDRESS S- l o a h s t
kl 4 v w, ' r s'y~ l 5~
m
SUBDIVISION / CSM# LOT #
SECTION ,~Z/ T ' N-R~W, Town of HG G h 4
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
V) IV
4
F(GW$ e 11
J
j
i
i 4
i
x
q3~ I
F
INDICATE NORTH ARROW
v z~ vU
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK : ZGrJ o ~vC, P, t 1 a a
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: M,e d - cStc-grlylt Liquid Capacity: O U
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: S~ Length cl U Number of trenches 'Z-
Distance & Direction to nearest prop. line: U
Setback from: well: House Other
c~ ELEVATIONS G
Building .Sewer ST Inlet ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system ~ y- i(~
Existing Grade Final grade 7. G
DATE OF INSTALLATI0
PLUMBER ON JOB: LICENSE NUMBER: h'I lp G~~~,
INSPECTOR:
3/93:jt
L("=Q ert4Q8Ary21. 29.17W'PFINATREWR6E JYS+Elth Avenu County:
Labor and H,y,man Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary r it
Permit Holder's Name: El City El Village El Town of: State Plan D o.: QDP ev.: nsp. ME lev.: BM Description: Parcel Tax No.:
s'
TANK INFORMATION ELEVATION DATA A9400025 (a/,-)/
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic A) Benchmark 3 ZS~ /O~• Q~
67
/
Dosin 7 ~C3 ~~rt' 6 a
Aeration Bldg. Sewer
i
Holding e~ St/ Inlet ( 0
a3,.y
.,TANK SETBACK INFORMATION St/wOutlet
1z'i TANK TO P/L WELL BLDG. vent to ROAD Dt Inlet
/'Q",,rsS Air Intake
q Septic SOS /a ' f NA Dt Bottom
Dosing NA Header
Aeration NA Dist. Pipe g 3/ '
Holding Bot. System 7_371-7
/<3,2~ ,ZD 1~.3
PUMP/ SIPHON INFORMATION Final Grade 5 3p 7
Man r Demand
Model Number GPM
TDH Lift Friction m TDH Ft
Loss ea
Forcemai n . Dia. Dist. To Well
SOIL ABSORPTION SYSTEM 0
BED/TRENCH width Length 1 No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DI N 1
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACH Manufacturer
SETBACK CHAMBE
INFORMATION Type O n C yr. /s i Model Number:
System: t,,,<kPv IT
DISTRIBUTION SYSTEM
Header / Man) If 10 Distribution Pipe(s) x Hole Size x Hole Spa Ven l~ take
/ q~
Length / Dia. Length Dia. Spacing 1!~
r
~
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade tems
Depth Over ,r Depth Over 2 xx Depth Of xx Seeded / Sodded xx Mulched
rench Center a- 7 7- I 8j#l Trench Edges j , Topsoil El Yes E] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ammond.21.29.17W, NW, SW of , 170th AV ue
l
L K.
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e,~2, y lr z ° +
J e,
Plan revision required? El
p
Use other side for additional info ation.
SSBBD-6 ,~0,(R' ~j055/91) Date Inspector's Signature Cert. No.
SANITARY PERMIT APPLICATION
couC~ `
In accord with ILHR 83.05, Wis. Adm. Code
olv •
T
STATE SANITARY PERMIT
/Q~t
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% X 11 inches in size. Check f re sio to evious 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
h d h~ - ,e Sa rt i/a 5 ` S 11 T , N, R E (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
?qs- 7 G )113
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION yA E OR CSM NUMBER
CITY NEAREST ROAD
E:I
11. TYPE OF BUILDING: Check one)
( State Owned ❑ LAGE ~7D yid Gf
Q OWN OF:
❑ Public ❑ 1 or 2 Fam. Dwelling- # of bedrooms - PARCEL TAX NUMBER( S)
III. BUILDING USE: (If building type is public, check all that apply) , _ / G G
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 Campground 70 Merchandise: Sales/Repairs 110 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. TYPPE1 OF~PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. L-~ w-w 2. ❑ 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 ❑ SSage Bed 21 ❑ o d 30 ❑ Specify Type 41 ❑ Holding Tank
12 __eepage Trench 220 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. T E V. 7. FINAL GRADE
Serif REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch), pEL~EVATION
Feet_ 7 /r Feet
CAPACITY
VII. TANK LS te
in aflons Total #of Prefab. Fiber- Exper.
INFORMATION New fisting Gallons Tanks Manufacturer's Name Concrete nSteel glass Plastic App
Tanks Tanks cted
Septic Tank or Holdin Tank !vG rCe K RF'l F]
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber' Signatur o tamps) PRSW No.: Business Phone Number:
cJ G G .SZ 4 rz
Plumber's Address (Street, Ci , tate, Cde):
3-06 w • /lG P woo c/ v, AP_ w, S' s~u~Z Y
IX. CO TY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue Issuing A ent big No
^
Approved E-1 Owner Given Initial Surcharge Fee)
/y
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(8.08/93) 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
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 S 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 cm 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; close 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)
. SANITARY PERMIT APPLICATION
~iC'■•i R cou
In accord with ILHR 83.05, Wis. Adm. Code
STATE SA TARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 141994
8i~ 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.
PR ERTY OWNR I / PROPERTY LOCATION q
e- U Ck e( e Sc, J2 (y 41'/a S 4,1 S T N, R );;C fir) W
PROPERTY OWNEI S <M AILLNG AQf~ 4 IfSS LOT # ~ BLOCK #
? 115 CITY, STATE ZIP CODE 7PHONE NUMBER $UBBPWO*N NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD I/
❑ State Owned 2 VILLAGE Lj (,7 t4 v
❑ Public 141or2Fam.Dwelling4ofbedrnomS PARCEL TAX NUMB R(S)
Ill. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo l I
20 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. [9-New 2-E] Replacement 3. ❑ Replacement of 4.E] 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 ❑ Spepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 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 12. 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
f 5 U go u QGl~ 0, 5 7s-, Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank I,-,- l a U d
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins Ilation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumb s Signature: ( ps) PRSW No.: Business Phone Number:
ctat stun o-~ ~GG(~ ?n- L r~ 2z46
Plumber's Address (Stre ity, State, Zip Codep
IX. CO TY/DEPARTMENT USE ONLY
❑ Disapproved San' ry Permit Fee (Includes Groundwater Date Issued Issuing Ag t Si ature (No imp)
pproved ❑ Owner Given Initial c~rcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary-Permit Transfer/Renewal Form (SBD 6399). to be
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.
Ill. 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 an 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; close 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)
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VIsconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page N of -3
Labor-and Human Relations
Div ision,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
BC2 en-jb N t~~~6 E p N GOVT. LOT MIAJ 1/4 S►u 1/4,S 7,1 T Z°l N,R 1'1 E (011~
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM #
S4S t1o'n s7. - - ~Pos~ csm
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAD
'C" M b)vbW1 5LimS (-)Is))9l&_ sm'o 1_-x11" "ul_p l`»`S1f ST:
New Construction Use Residential / Number of bedrooms Z [ ] Addikn to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 3O0 gpd Recommended design loading rate - bed, gpd$ °•S trench, gpd/ft2
Absorption area required -1 S 13 bed, ft2 IS b o trench, ft2 Maximum design loading rate o bed, gpd/ft2 0. S trench, gpd/ft2
Recemmended infiltration surface elevation(s)50E k)M- aJ kz!IkG B 3 ft (as referred to site plan benchmark)
Additional design/ site considerations > Z 'V c'J1{!?S --~t S x tou lac
Parent material Flood plain elevation, if applicable tv - A It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable I stem ®S ❑U IRS ❑U IRS ❑U ®'S ❑U ®S ❑U ❑S IgU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundaly Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmrch
Z, Z ZZ LO`1.Q --Is/ L - S l I Z-'4'Sbk Yn~~, c s - o. S o,L
Ground Yv► S ~k
elev. e s - o • € . S
°15•1 ft. Ynv~►~
Depth to S _)0-7K 1b`L2 $ l S `CR 546 TS C~~ t+t ifI- - -
limiting ]
factor
Remarks:
Boring # 7 8
0-9 ~o~tR 31z S 1~ Z'~sbk m`~ BLS,;$, ,
2 Z 9-Zy ~o~~z silo - s~~ Z 3bk In l- i ^n v S ro.
4Yfi \
3 zy-~!1 ~.S`zR V/b S I lti►t sbh tm v ~1- 4;~ rCi.S
Ground 9°t w1 S•~, . S u, b
elev. yl-S S ll~`-LQ Y!~ ~ 'FS $ G►- o C
R°i • 3 ft.
SS-~y 1a~tZ b! S - `~s o~ M ufti C S - U• S
Depth to
limiting
~Y- Z lu fi. 6/8 S1~3 g O hi V FIB - -
-).S y
factor
r04 eA >v S 1 iy" n Gt'~ ffL
Remarks:
CST Name:-Please Print Arthur L. We erer Phone: 715-425-0165
ergerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: Date: CST Number:
c13 ZSS ~o-~~-°t3 M00576
PROPERTYOWNER SOIL DESCRIPTION REPORT Page?- of 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxbty Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
to~cz~l-Z S1I Z~ sMZ C-- g - o-s o.6
Z q-3b 1 l~ `12./le _ S l~ -Z S bh vn `Fh C S O. S U• 6
3 30 ~Z s~tZ 3~y
Ground Y!S hit Ak >M v' k CS O• u. S
elev.
°i $ 8 ft. Z=8 lu'1 \i VA.
vn U 0.5
Depth to
limiting
factor y
7 8Z
Remarks:
Boring #
0 o-~'' ~o-t~ 3lZ - s1~ Z`~sbk `F~ a-s - u s a•b
y z$- ~z lost 2 3l6 _ s -1 z ti►, c s - o. S u b
! ~sbn
~•S~Q ate
Ground 3 ZZbo S R VA S 6k- Vn Ulu C -S - r3. L! 0 . S
elev. to -Y 1 y if
~S•~ bb I/ LO `..t.Q 8/ It o~-►, 1n U`FL- r,. y a. s
Depth to
limiting
factor
'7
Remarks:
Boring #
-8 t~Ll 2
it s` P- Y A S) l *1 S ~1Z h1 U iI-, CS ~ o V n. S
Ground
elev. 6y-~ S Zo `'t ti. VA I'n U `Ft- - o Y n S
Depth to
limiting
factor
Remarks:
Boring #
.h'
Ki;.•
t.1
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
i SBD-8330(8.05/92)
of
PLOT PLAN Page 3 3
SCALE 1310
'
~'l~-o ~ LYE-'r~( L I N E
I~rJ`~ TO l/U S`?'f~ LL
~ i>vs~t,~. -Z `rTL~,c:IFL S ; r-~t,:itr-rv►~ S' x- bo' ~ G r` ~ooT
~ -awl 1 Q Y)T Lis T "H 2T, --T ~ c wn )-r4
1~ 1~ \ M'lU ~`'1 3 4 k 'bELTF' PrT `T11 e vA S W p eU 6 E .
tiNsT'Rt~.~Z 10 ~1~12wileviv `TlZ.~ucN ~~,.~~~`RU►uS ~fi
OF cDti S~ZUC1~olv___.
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r l~ovsF `IO RL PIT Lewr ZS AlUIZTjq OF `nZeIvctff✓S.
~I
~t,.44 3 48 e
$.Z goo' 3'3 6 o1
~ l
~h . Loo.O oN 7010
I ►~~1-~~ ~'tR ~~A
i 9''H1GH 3~y' ~1N.
? ~ve. PIPt
F 5.S 0-97 3
~ ~ A~RS~u~TE ~2L~1 I ~
o ~
Voo' a q5 J.
t'ti- 9 S ~
~~S
(715 ) 425-01h5T+I00576
CST Signature Date Signed Telephone No. CST #
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page ~ of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
S--. Q.z JK
Attach complete site plan on paper not less than 81/2 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
8R -1`I 'l, tel. GE S 0 N GOVT. LOT ULAJ 1/4 S►u 1/4,S Z1 T 7,9 N,R 1`1 E (00
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM #
eygS t1oTV ST• - - zoPos~ csm
CITY, STATE ZIP CODE PHONE NUMBER OCIN ❑VILLAGE OWN NEAREST ROAD
1 ►~-t►~-tC,> col sktolS (-)Is) -)96- S38o ti~ 1wt~, izz) -w sr.
]p~ New Construction Use Residential / Number of bedrooms Z [ ] AdditiQn to e)asbng building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow 3O0 gpd Recommended design loading rate bed, gpd/ft2'CO'S trench gpolft2
Absorption area required __)S Q) bed, ft2 boo trench, ft2 Maximum design loading rate o- 4 bed, gpd/ft2 O- S trench, gpol(t2
Recommended infiltration surface elevation(s) St- &J asM o+j PkG E 3 ft (as referred to site plan benchmark)
Additional design / site considerations 2'F_T~' CJ-e% - ~-H S toy tkyvc
Parent material S ►.,o~i Lp{~F-t 'D\-\- Rood plain elevation, if applicable A It
S = Suitable for System CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN RILL HOLDING TANK
U =Unsuitable for stem ®S ❑ U WS ❑ U ❑ U S ❑ U ®S ❑ U ❑ S C9U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bourr* Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed tench
C) -B C" S
ti0`1Q ~JL b. S G' I.
Zz~Z -1 "S ~t~i Y/ - 1 i. cs
- o `I o. S
Ground 3-S -m y/~ s YA vi ~vt S bk
elev. e S - o o• S
c1 ft. ~Z 70 ~u`12 1'~ 11 - S O~+-~ lm
Depth to S -)0-7
y~ 10 `12 $ ~~.5 `tv SAY, ~S Owl ht v - -
limiting
factor
moo"
Remarks:
Boring #
.,::v 1 0 - `1 10 `~t tZ 31 z S 0 Ot S - o S :o.
Z 9-2,y to~tz AIL - sl, Z f 3~k kn ~t_ cs 0 0.6
A^Q. `t
l•S`i2 31yy
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s SS--)y Ul)'A1Z 6/ 16 - 't s o M u~t~ c S
Depth to
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factor
y" 4 cs~ >ti s h y' p G►'VLrL
Remarks:
CST Name:-Please Print Arthur L. We erer Phone. 715-425-0165
Address: Soil Testing & Design Service-P.O. Box 74 River Fa11s,WI 54022
Signature: Date: CST Number:
M00576
PROPERTYOWNER~-C~~50ry 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
to~tcz~1Z si I 2.~ 3MZ wr a.s - o.s o.6
Z 9-313 1 l~ `t R 5A. s t 1 Z'f s bh ~n c s 1 0, s (3• 6
Ground 3 3012 ~S V 7 L S ~vl Sbk v~l^ CS O• y O.S
elev.
a 8 8 ft. Zf~ 10 ~t 1Z v lt~ - S c~~-, vn v i- - 0.4 o • S
Depth to
limiting
factor
- 8Z
Remarks:
Boring #
o-~ V)1-12 31Z . - s1 Z~sdk~h o~g - u s o.b
y Z-kZ lo`12 alb - S 1 Z'~5ek'~p- S _ o S 0.6
3 1Z6o ~~~iQ ate _ o, .5
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elev. y bb-~'{ ~o Q 8 `FS c~~► In v`~~- - a, y u. S
,11S.L ft
Depth to
limiting
factor
7 ,
i
Remarks:
Boring #
~ D-~ lb~1Z31Z - S1~ Z~SbI-z ~`F~. ~+-S _ o-So.~
S -
Z $-ZY LL~`~ 2 31t, S ! Z~ 3~1L yy) CS - o. S o• 6
P- y ~s y ~z 3 t S ~ ~ tin S~ 1c h) U~~ CS - oY n• S
Ground
elev. by-~ S ~o'-I. 2 y/j, - `FS o~ v I- - o .Y o S
Depth to
limiting
tctor S'
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05192)
of
PLOT PLAN Page 3 3
SCALE 1"= 3p '
-
%b N-. e t%f LINE
1~`~E TO 11U S`1'r~ LL
1►vsT~LL Z `('T2.~,c.l~~ S ; r-~~►:i~~tvM S` ~ bo' w►~ ~ ~ ioo
~~u►"lM'1Q~~~ CST LAST 6` N1'H2l ~uC~{~S lU
M'lU3 34r 1 _L AT `TWc v ISL eUGE.
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- 9. S r=L. c17 3
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C13 -?-SS
-(715 ) 425-0165 M00576
CST Signature Date Signed Telephone No. CST #
I I/ 1.1 / _ 1
d~ FILED
DEC 2 91993+- a
5~.1~.19 Z a st° of DeedsLL
ix co„ Wi
CERTIFIED SURVEY MAP
ANNASEL'L'E D. HANSON
Part of the Southwest 114 of the Southwest 114 and the Northwest 114 of the Southwest
114 of Section 21, Township 29 North, Range 17 West, Town of Hammond, St. Croix
County, Wisconsin.
ti
W W114 CDR. SEC, 21, r29N, R17W,
W I COON rY SURVEYOR'S MON.1
~ M I
cr~l v I LOT C.S. M., VOL..3, PA GE 629 3.44'
3 w
ZI I N901 00' 00 " E 393. 00' y, p
p
l O 33.00~ I 356.55*
`I I 3.44' I 360.00' O O
2I ( N ~ O ~~I ~ Z I 2 2
J Q
Q N I I Q I ku J
oII~ Iw LOT3 NJ 3~
N
I Q I 12 3 QI a
W I W O 2. 472 ACRES (V
O
~r I Y 107, 698 50. Fr,
~I p N ( I 2.263 ACRES EXC. ROAD R.O.W. O ~I R
N t, J O m 98,634 SO. Fr. o Q 2
W J a
h
ZI_ D b O ~
O ? -
Z) cc
6 6' I O ,I a N
360.00• v
I \ 33.00 i m W
N90• 00 00"W 393.00' I 'i 4
a..o
W i LOT 4., C,S. M., VOL. /0, PA GE 2708.
x ~ i I
J N
3 SW COR. SEC. 2/, r29N, R17 W,
1 I " IRON PIPE FOUNDI
\\,-w\
Owner's Address: V`\SCONS~
36741 Grace Avenue }
•
s
Zephyrhlls, Florida 33541 ; LAU EN
Phone No. 1-813-782-4109 + M W RPH Y•
c
713
This instrument drafted by Laurence W. Murphy ~:N~'•• I E FALLS i
r Wisc. : QJ
~ J
SCALE ! 200' t O••LQ~~•~
0 25' 50' 75' 100' 130' 200' 300 ft4
aurence W. Murphy
istered Land Surveyor
OIndicates 1" x 2411 iron pipe weighing 1.13 lbs./lin. ft. set.
*Indicates 1" diameter pipe found.
Dated: November 9, 1993
vol. 10 Page 2717
Certified Survey Maps
St. Croix County, Wisconsin. SHEET 1 OF 2
Q
-g a,
LLI Z M
Z5 O 0- ° N v "o
0
w 0 '!7 R >
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C\J
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. J
CERTIFIED SURVEY MAP
ANNABE& D: HANSON
Part of the Southwest 114 of the Southwest 1/4 and the Northwest 114 of the Southwest
114 of Section 2.1 Township 29 North, Range 17 West, Town of Hammond, St. Croix County,
Wisconsin.
Description:
That certain parcel of land located in the Southwest 114 of the Southwest 114 and the
Northwest 114 of the Southwest 114 of Section 21, Township 29 North, Range 17 West,
Town of Hammond, St. Croix County, Wisconsin, more fully described as follows;
Commencing at the Southwest corner of said Section 21, thence N 0000010011E (assumed
bearing on the West line of the Southwest 114 of said Section 21) a distance of
1213.91' to the POINT OF BEGINNING, of the parcel to be herein described; thence
continue N 0000010011E 274.04' on said line; thence N 9000010011E 393.001; thence
S 0000010011W 274.041; thence N 9000010011W 393.00' to the POINT OF BEGINNING,
containing 2.472 acres, being subject to easement over the Westerly 33.001 thereof
for town road purposes and also being subject to easements of record.
Each parcel shown on this map is subject to State and County laws, rules and regulations
(i.e., wetlands, minimum lot size, access to parcel, etc.) Before purchasing or
developing any parcel contact the St. Croix County Zoning Office for advice.
Dated: November 9, 1993
This instrument drafted by Laurence W. Murphy
State of Wisconsin)
County of Pierce)
I, Laurence W. Murphy, Registered Land Surveyor, do hereby certify that by direction
of the Owner, Annabelle D. Hanson, I have surveyed and divided the lands shown hereon
in accordance with official records, Chapter 236.34 of the Wisconsin Statutes and
the Ordinances of St. Croix County and that this map and description are a true and
correct representation thereof.
~SC O /V re
Vol. 10 page 2717 •
Certified Survey Maps = LA4713 N Z
St. Croix County, Wisconsin. M = W OHY
a
RIVER FALLS,,: J~
i F Wisc.
Q`
• q J
'.,F~ L A NO
S~►•`~
,~~If1111~1►►'•
aurence W. Murphy
Registered Land Surveyor
SHEET 2 OF 2
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 60T rN D A dt e So rt
MAILING ADDRESS 15 ~r 'rJ U t/ G( 4 yh, *ft h + S
PROPERTY ADDRESS 6 Z 7 ! y t ti y N' <<
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION N 4/ 1/4, S 1/4, Section 2 T_~j_N-R 7 W
TOWN OF H A M M a n d ST. CROIX COUNT WI
SUBDIVISION y~ I , 7 t 7 LOT NUMBER
CERTIFIED SURVEY MAP , VOLUME I U, PAGE I LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year xpiration date. .0 4
SIGNED:
DATE: - 117T
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
STC-100 .
This application form is to
be completed in full and s1 ned b
the owns 9 Y
rs
of the
will only (result in delpystofb ~theg ermitDpsau Any inadequacies
development be intended for resale by owner/contr ctor,i (spthis
ec
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 ,fe ` ply
Location of property&l/4 SA/1/4, Section , T~2 j N-RI 7 W
Township Q M „ r,/
Mailing address ~7 rj / G 19 I'll-A/GM „ll, d A,4, S-,qol 15
Address of site j 70 lbek
subdivision name Lot no.
Other homes on property? yes No
Previous owner of property 1-1,41qSC_*Al
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? t/ Yes
No
Is this property being developed for (spec house)? yes
volume and Page Number as recorded. with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & 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
test of my (our) knowledge that I (we) am (are) the owner(s) of
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. V'1-3 1 0 '1 , and that I (we)
own the proposed site for the sewage disposal system orr I e(we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
r
ecorded in the office of County Register of deeds as Document
No.-TI I/ too
f
gngnature of p~licant Co-appl cant
- ~
Date of signature Date of Signature
I
• . I III
DOCUMENT NO. I STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA
51.3108 WARRANTY DEED
w. 1W I
L-= VOL 106 PAG
GISTER'S OFFICE
This Deed, made between ..Annabelle._D.._Hanson.,__a/k/a
A»abelle_.j.11anson,_-a-_widow,an__Hanson--her Power of Sr. CROIX CO., WI
- Reed for Record
Atto=y Grantor, FEB 16 1994
A
and--- Bradley.T._.HelgaaQn-and--Bre,~?da-L i 11"; TO
husband..and-.Wie__ss.-surv~,vorship- marital--property--------------- I' 07, M
i
Grante 9t0rofDeeds
W1tI1eSSeth That the said Grantor, for a valuable consideration
One--Dollar.-and__ether--good_and_valuable_ wns]deration------ F-_--- -_-I
RETURN TO
conveys to Grantee the following described real estate in _St•...CrQj_X Bank St. Croix
County, State of Wisconsin: 2212 Crestview Dr
Hudson WI 54016
,I
Tag Parcel No:
Part of the Southwest Quarter of the Southwest Quarter (SW4 of SW-14) and the
Northwest Quarter of the Southwest Quarter (NW-14 of SW4) of Section 21, Township
Twenty-Nine (29) North, Range Seventeen (17) West described as Lot 3, CSM St. Croix
County Vol. 10, Page 2717, Document No. 511119.
FED
ii
~j
This 1S.IIQt------------ homestead property.
Xdmk (is not)
I
Together with all and singular the hereditaments and appurtenances thereunto belonging;
ii
And..... gr ran 9)r
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements,
restrictions, reservations and covenants, if any, and highway rights-of-way.
I I
and will warrant and defend.tthAetsame. _
Dated this L/'_"----- - day of --------------~~4----- 4'r 19_fc-_L!-,
L~e~eT.... l .
I (SEAL) (SEAL)
I
Annabclls. D,-_ ar-iSQ?i--by-•-------------------- *
Evan Hanson her Power of Attorney
---------------•--•-----------(SEAL) ---•--•-----.----.-•---•-••---••---------------•----•--••-----------(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) .0..EVan_ HanSon STATE OF WISCONSIN
ss.
1 i4 -----fit.---CsczlX----_----.---County.
ji authenticate this _ .--day of........ Personally came before me this __.4........... day of
__.Eehzual;)i 19-9.4 the above named
*-Edward F,_ Vlack Annabe].J.a_R.___HanaQn__hY--Exan__~I;~4______
TITLE: MEMBER STATE BAR OF WISCONSIN ilex _pgwaX Q£ a><>iszxn~y_
(If not,
authorized
by § 706.06, Wis. Stats.)
to me known to be the person who •t~je
foregoing-instrument a a4nowledge tla*~'l,~(~~~,•
THIS INSTRUMENT WAS DRAFTED BY J~/!r^~'~ , •
Edward- F.__ Vlack,__ DAVISON__&- VLACK..............
m ~'t
290 E' Elms St. 12.yer Falls,-. WI__~402.. ~~t
Notary Public _COUn
I
Si natures ma be ' Y s Commis ion is erm anen f no st
(Signatures may be authenticated or acknowledged. Both My Commission is per an nt.
P (
g Y or acknowledged. Both M
I' I'
are not necessary.) • tiQ~~?
1-
- - - date: Z
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.