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N ~ c ai °o, °o 'o °o, o e, ti O p u°s s°s v a) a) C'' 4 0 0 0 e 0 0 N O A 4 x x N N ? O O Y Y co U) U) O O N p O 0) C Z C) Z CD LL O 0) N O a) N ,4-- C) Mn p N 'a CD > a 0 (D a p a) Q e- Q w 3 Cl) z N 6)w E w 00 7 E i z Q) d ti 04 a m 0 g c i''', a m m U O Z ? c ~ c~ c '4= 1 aVi Z: c o c Z fn H O N Z N a 2 M 2 M O N 7 7 N O CL w O O N ~ G C N • W( i a L O L O U O O C -0 O O O Q w Z co z o 0 N - Z Z in c a a W O) CV CV O) L (V (9 (6 M N (O (O (O C. w w 0 G (D (O C 0) O O O O ° ~j - O 0) N T O N T 2 O N 9 ) N N v o 04 ° G G a E O H N H O O O N N O E Q) O O N N a m o v v a o v O O O Z o o Z o o ~Nv C. a cam! =rnrn V) (n aNi a (n -i U v) rn rn ~y y } } ° } } o (n V m a a 0 0 a ~ ao ,.W m o o O 14 o 0 Q CD 0 p ao o C5 O o O c c oo _ m c c n. rn co m c m co 6 Q Q } (n } (n m LO 7 Y ^l O ° O y G 0 °o 3 m v c (n (n (n m N y 0 r-- co 0 0) o a) c c c o 0 U - a) c c c - d m o CO 0 M E Y Y Y a N N CO 0) O O E Y Y Y C a N N O ~ C ..0.. C C C r W C N N C L,2 00 N 0 ~IN N 0) W U) ~N - O') 0) 00 • 2G O M N a G_ N • 'xV) N N 7 II IV N (7 tli O (9 (0 co tC O (n-5 (6 co c0 tC U rG Z N Z (n © O T Y04 O Z N Z (n V) d m £ a t o L (L w • ~ a d .V 4) y c t~Nw y E 3 3 y 7 t A u a E 0 to v v Si(~ n DOES ► T N~~1 ~D ~ and ~v -STM0- ry.TARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code C017 (~bt~ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1;? a4 6 q 4 8% X 11 inches in size. 19 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. PRR OWNER PROPERTY LOCATION OPET Z/ Lir uit-/~ 5 <U S T.2 N, R / E (or PROPERTY OWNER'S MAILING DDRESS LOT # BLOCK # -7 e~tl CIT , STATE ZIP CODE PHONE NUMBER SUBDIVISION AME OR CSM NUMBER r. /'c<s II. TYPE OF BUILDING: (Check one) El State Owned VILLAGE NEAREST ROAD ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL TAX NUMBER(5) /Li[ III. BUILDING USE: (If building type is public, check all that apply) 3 0 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandiser Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. M New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 FA Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE _ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION t/ a C1 I/ I/ S / V )R. I , I/ "Feet /e7O,O " Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App. Tanks Tanks structed Se tic Tank or Holdin Tanks / Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew system shown on the attached plans. Plu ber's Name (Print): _ Plumber's Signature. 49,.Stamps) RAP/MPRSW No.: Business Phone Number:: '74 - L '7 72 TZ Plum S Address (Street, Ci , State, Zi Cd o 13c~ a~®r rci7 S~f~i.2 3 IX. COUNTY/DEPA TMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signatur o Stam 's) Surcharge Fee) r y Approved ❑ Owner Given Initial ~n Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 1 (,l SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber w x r sa}a s ♦ sr-* • tt rtYOye x +.s'x'e`kt'4.`t't'3's`m': a.'t•t•a•a, a', ...a"a. a . .'Wi'n.' , t i f~~ b i i ~t~1 +&'#l~i.F.4 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) v ,A yy, X disc, X~ X fl` i 16- yZ' x _PVT zYXs? ' - sc a ~e..c ~ " = 3o f4E z ~ IISSGr N+ e /00. Q r ' / f 6~~ T7 us~ ~o~/ `tSsur.,e /of.7 /c7 n U = 6©✓i h1S I sk( ~ _ !OT (vrrfr- ~oU~t~, J L'j sT = 1, ~ Q l- R !w = q o /~a r u F ~v~5 # lip 11117 1 76 ~I . DAVE FQGEit1'Y PLUMBING Licensed Perk Tester & Plumber I' 93233 93289 Fogerty Heights Road ROBERTS, WISCONSIN 54023 Phone 749-3656 STC - 104 AS BUILT SANITARY SYSTEM REPORT 'c~ ii'a{ 1994 OWNER a ADDRESS All) .2 COUNTY 7 SUBDIVISION /-ee LOT # /Z2 SECTION _2 7 TAN-RfW, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEE OF SYSTEM r 36 So , 3~ roe TRW 5 , 7. /,and p.G A INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK : / W71, Lo f /2 / ALTERNATE BM.._ SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION Manufacturer: Liquid Capacity: /,©oo Setback from: Well 7 s a House i/ Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location ':SOIL ABSORPTION SYSTEM l¢7/ `~l1 4 Width: ®2 Length s_j/ Number of t-r ~ y Distance & Direction to nearest prop. line: > ~s Setback from: well: So House Other ELEVATIONS Building Sewer ST Inlet: ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade /oo.o ' Final grade /oa,p DATE OF INSTALLATION: /D to PLUMBER ON JOB: / LICENSE NUMBER: 3 r/ INSPECTOR: 7/j 3/93:jt wiscoi sin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX ' Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI HARWELL, BILL X CST BM Elev.: Insp. BM Elev.: BM Description: fludSUn Parcel Tax No.: 1,6o.0 1 Q<0 A±!=)- A9400270 TANK INFORMATION LEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 2 Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet S /Do,73- TANK SETBACK INFORMATION St/ Ht Outlet Jo0.5~ TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >5LY >50 I ly' NA Dt Bottom Dosing NA Header/Man. Q7.~9 Aeration NA Dist. Pipe 977q Holding Bot. System Cj 7,0 PUMP/ SIPHON INFORMATION Final Grade /6 0_4- Manufacturer Demand Model Number GPM TDH Lift Lriction System TDH Ft ead Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width 1 Length No. Of Tr hes PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK _ CHAMBER Mode Number: INFORMATION System: ;a 5-' a5-' 30' > L7 ! OR UNIT *10 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 R ?.r Bed/ Trench Center TT Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson/.17.29.19W, SW, SE, Lot 122, Overlook Pass Plan revision required? ❑ Yes ❑ No Use other side for additional information., ' L)w .rt~r y_ w r SBD-6710(R 05/91) Date lMpjttor'sSignature Cert. No. SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Co STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ;2Q46(44 8% x 11 inches in size. LrCheck 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 _ 84~ r4 PROPERTY LOCATION V/ rwc 1/ S49 /a S ! T2 J,N,R E(or PROPERTY OWNER'S MAILING DDRESS LOT # BLOCK # 2,1( 7 CITY, STA E ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER .57 "12 1( 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned O V TOWN OF: ILLAGE : 10h ~ N tr ❑ Public V] 1 or 2 Fam. Dwelling- # of bedrooms :J_ PARCEL TAX NUMBER( ) III. BUILDING USE: (If building type is public, check all that apply) 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) A) 1. 0 New 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 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage 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. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 4/ -T-0 5- 1 ) .v Feet O0,0.1 Feet VII. TANK CAPACITY Site in al Ions Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 4 OOG r{ Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No ps) MPfMPRSW No.: Business Phone Number: v' (~v r r r 2 ~ 3l AZlumt,s Address (Street, Ci , State, Zi od IX. COUNTY/DEPARTMENT USE ONLY 1A I L] Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issui g Agent Sigmuro s)~ ,t,j/ ^ Approved F-1 Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: L SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS r r 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 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'f 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) X- ' ~ • t A ~Z yy x f ° eK x y 60 6,7 si !oV r ~C Ct l ~ rr 30 # L J f 1 = ~dT (OYhlr ! c WC If JT = f, oGJ o / !f ~ll/hI k'l ttnr~ it Tbptl`'r ~/((m Gt.H/~G` 7"~ l I KS l~/ /1//J //`1~ ZS 1 ~G ISI.~ G h- ~d// ~{tA~Of~~ DAVE FOURTY PLUMMN4 lk Licensed Pork later & Plumber 03M "MV Fo&rty ROBERTSWISCONSINN554023 Phone 749-3656 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page s of V Labor andl-luman 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 PROPERTY OWNER: PROPERTY LOCATION g -1Z a r w e GOVT. LOT ~w 1/4 S 1/4,S,/,7 T L AR 1.7 E (otlV PROPERTY OWNER':S MAILING ADpRESS LOT # BLOCK # SUED. NAME OR CSM # 76,7 /a =i o c/ / Z:2- - w, w X, P CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [31' N WEST ROAD 6 C r// ' r I V] New Construction Use Residential / Number of bedrooms T [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow ySO gpd Recommended design loading rate _bed, gpd/ft2 . s trench, gpd/ft2 Absorption area required P6~/ bed, ft2 trench, ft2 Maximum design loading rate _ bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) 92-o ` 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 OS ❑U 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 tii:~ L n Ground elev. / //O, L ft. Z T 8 /a - Y c 2 S6 4 Depth to limiting _ factor _ 7 7.y-- 1 L s ©s Remarks: Boring # Ground elev. Z 4 - ~ 'dk s V+ ~~°•o'ft. Depth to limiting 3 2- - s 5 ©S - - • -7 8 factor Remarks: CST Name:-Please Print/ o Phone: Address: U Signature: ioo d 20~rr W.t- ~.t 3 Date: CST Number: / , ~ 3233 PROPERTYOWNER weSOIL DESCRIPTION REPORT Page of J 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 Ground elev. Depth to limiting factor 3 y_ 7. 5- s - s o f f - 1 .7 8 Remarks: Boring # U ( m- 3 s- z i S c 3 U 3 i Gro und elev. 1 e l i 1e ck s I F .s /09• S ft. Depth to limiting 7 _ l G s o s ( - factor Remarks: Boring # -13 At, -25 k..-:: ? -.?3 e- 3 2 c rv~ 6K u ~r t v. s Ground elev. /VAL~L>- ft. / e- X Depth to limiting factor y 6-~~ ~.s- s G - s o l - - Remarks: Boring # 41, / o-/S ~-3 s~ l s6 r CS y ,S Ground elev. s s o s w, - /0/ ift. Depth to limiting factor Remarks: i v. r'zc- / l,e-cfe , SBD-8330(8.05/92) SANITARY PERMIT APPLICATION V'~Lti7R CO In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PER I # -Attach complete plans (to the county copy only) for the system, on paper not less than aa/ ~ W 8th x 11 inches in size. ❑ Check if revision to p vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORM TION - PLEASE PRINT ALL INFORMATION. PRO TY O NER PROPERTY LOCATION '/a ,5'/a, S / T2 , N, R E (O PROPERTY 'OWNER'S MAILING ADDRE LOT # BLOCK # CIT92af ZIP CODE PHONE NUMBER SUBDIVISION AME OR QSM NUMBER O! tr II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) El State Owned ❑ VILLAGE en CT K ❑ Public rn ~ 1 or 2 Fam. Dwelling-# of bedrooms I- PARCEL TAX BER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 20 Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. Z New 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) i Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 0 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Y e-,A 00. .7-e 7 3 .7 91040 Feet l0 ,OFeet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank f 499~ Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage tem shown on the attached plans. Plum 's Name (Print): Plumber's Signature: (No Stem *W/MPRSW No.: Business Phone Number: u 's Address (Stree , City tats, Zip Co e): .0k / O P- AV-.r 5ye 11 OlWev K. COUNTYIDEPARTMFNT USE ONLY ❑ Disapproved Sanitaryypermit Fee (Includes Groundwater ate ssue Issuing Agent Si re (No tamps) Surcharge Fee) Approved ❑ Owner Given Initial 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, 6013-266-3815. 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.tgst 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.' i The monies collected through.these surcharges are used for monitoring groundwater, ground- water dontaminatibn investigations "and establishment of standards., - I SBD-6398 (R.11/88) PLUMONGS DikVE.F~ Pkn~r " 233 •32099 F R09EPh n X49- 7 /V 56 7L D 13, y - _L-cLt~~1' Her rih+c~ fcf~ocx_ - V #2 X 77/ 7~I- P,/, m ~of' lorH{t ~ ~atHC~. 4 = W > Ste' ~7r 1 f~T. ~Of7 S-.%. 'S' {7 fit H~ ~ pBp g Q I w sin Department of Industry, SOIL AND SITE EVALUATION REPORT Page L of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY At complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ST P,O X 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 Q DELT'A 40,JS-rRLX-sl6g GOVT. LOT SW 1/4 S~ va,S 17 T 29 N,R I I E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR C # 266 St-coN& 'Ss iZz - I,Jru.Ow t~4r L~aST~ CI , STATE ZIP CODE PHONE NUMBER ❑CITY ❑VI GE OWN NEAREST ROAD,. H U"piJ 01 2401L ( ) 64 C1 A A ,K New Construction Use k j Residential / Number of bedrooms ( ] Addition to existing building I I 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)A4c 3oR 3 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 INS- ROUND PRESSURE gT~GRADE SYSTEM IN FILL HOLDING T NK U= Unsuitable fors stem G S❑ U E S❑ U ®S ❑ U ® S ❑ U KS ❑ U ❑ S U 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 z... : A -'9 o.5 3 2 i. 1.^s6 r a Z 0.4 t {yti ,•:<>,;<; $ -IZ I I _~jjk 4/4. S rti Ir l p.? 0.`~ Ground elev. /171 ft. Depth to limiting factor > /O.O$ Remarks: Boring # ' 4x ~ Z. $ -34 D 3 3 I S bk mTr Z c~ 4 o. M14 mlye, 1 :0.8 -R 4 d ry r M Ground elev. /03.7 ft. Depth to limiting factor x/0,17 Remarks: CST Name: Please Print Phone: 336- 696 Address: U Q~ H 1 c.! Signature: Date: CST Number: 3 494 PROPER W- OWNER SOIL DESCRIPTION REPORT Page 2. of .PARCELI.D.#toi IZZ _jj,LkowR,&t F&-r Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trerxh ' tw p-Z3 /ay R 3 L 1 sbK n, ; Qt z 0.4 .S L ~r C S S7 7.Sy 0 1 s~ m Ground P>-x bK rh ~ 1 .S 0.6 elev. /o/ .0I ft. $ S 9S o le S 4 C 2 D ~ ~ s b K Depth to -14 ,bye 4 4 5 a rh Y 1 D.7 O.~S limiting > %t Remarks: Boring # Z-3,-s 10A mkkmg 4 0-17 /619 { ~7-35' oY~e3 S;~ b K t z :off A, c Ground S-~l OY+e ¢ - S r 1 0.7 O elev /OZ..Ill ft. Depth to limiting f~ qL Remarksy Boring # -2Z 10y~e~ 1 Z SbK n~ h C Z O,s %z-14 /6-Y4 1~A Ground -11 4 S © A Y !►'1~ ~ 0.7 0.% elev. /oZ.66 ft. Depth to limiting f for Remarks: Boring # aw :s :•<.:< Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PAL," 3 0~ 3 D3 1 ~ 'r q;v 33 QAEA „Aa , 7y IoNlo VD 33~ 3 , 5YS'r'EM LEV TtZ S I A+esa $ - 97. 66' ~cE(.pThl~71E1~lA~D LOA N4 RATE o \01 4R&A A 6:7 eEO,06/F 0.6 WCu,04/FZ A~e~ ~ V•4 B~~,G~FT~ ©.S TRS~ICN~GP~~F'~'Z ~ iEt'_d P& ,asr'a L ~~i mN ~T ~ASz 69- 166-06. ~EI,.,.QPubNC 1 E~AS'TpL ~ /9~/~ ~,~Al •i 2 ~ri jj 141 b .sE`.szoz • . 1£'602 .00'1►OZ .00.9Gt .00'091 .00"09t 57" N hl~ 103 m 104 105 In 106 to I AC.o 1.309 AC. 1.317 AC. 1.254 AC. 0 1.281 AC. F? H C N N fN~1 M m 209.84 206.62 t~ eb ~ft r • £9 ' t S t 182 88 ' p p55 282.32 OVERLOOK •bb• .E9'tt'Z 21. co 110 . 122 a 1.233 AC. co 107 to m to I AC, a ~ 1.267 AC. to m 123 t'D N N 0 W to 1.543 AC.T 0 .LO'LEZ N s 00.0>Z 121 m ni O 1.165 AC. I I I 40 1.085 AC. ri 108 N 8j • zsa .00 SSt •89,S~f 1.360 AC. c .se rta •dE•Erz ~L~ N 120 ti • - in 124 rn 1.458 A M 112 . £L' 6SZ = 1.077 AC. •SN• e N en 5~~~ 1A n r 1.049 AC. 119 N 26. 1.532 AC. N 0~• 0 109 a it) 226 ' A6^ • 0~• ^ I;. 290 AC. 4% W X92 II8 SNN ~'1~ 66 113 cc X966 to I. 5I+0 206 So `1A •sN 1.287 AC. m .5 114 W. V, ,62 6 •0 1 .078 AC. ~N 0 O `9, ,1 •I J P~v 69 0 N, •N 115 1.025 AC. 1.19 63 .N 116 ~%9~ o I 1.190 AC. 0. C 117 ~ifl 9 N 0 1.272 AC. 'a a. WILLOW RIDGE EAST Ir I i S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 7 d C.~2~tr'' _JS ADDRESS FIRE NUMBER CITY/STATE ZIP ~ f 12 PROPERTY LOCATION: 5~1/4, S E1/4, SECTION 7 , T_2:0_LN-R_J~_W TOWN of St. Croix County, SUBDIVISION .C~~j 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 a 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 Co. Zoning officer within 30 days of the three year expiration date. SIGNED: i DATE:- St. S T Croix co. Zoning Office,. 911 4th St. Hudson, WI 54016 F- 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), thenia 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 propertyJ6d 1/4 Sr- 1/4, Section T N-R W Township Mailing address _7 Address of site Subdivision name Lot no. other homes on property? yes V No Previous owner of property Total size of parcel q 3 Date parcel-was created Are all corners and lot lines identifiable? LYes No Is this property being developed for (spec house)? Yes No Volume'bl3 and Page Number Y~ 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 best of m knowledge t that I e am the owner(s) (our) (are) 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. Aos-'g s a , 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 Count Register of deeds as Document No 39S-&A G Signature of applicant Co-applicant a J` ~ ~ / 7 f Date of Signature Date of Signature RNASTER OfflCE ST. CROIX Cq., wh$ ~ PAGE 110P Val Roc'u, fca Rocord Us 23rd • day of ImlyL A.D.1 P811 of nt55 ♦ Mr ' LAND CONTRACT laWa Contract, by and between Arnold R. Bertelsen afk/a A. R. rtelsen an Virginia A. Bertelsen,' husband and wife,-Vendor, and B. 6 H. velopment, Inc., a Wisconsin corporations Purchaser: : Vendor sells and agrees to convey to Purchaser, upon the prompt and full performance of this Contract by Purchaser, the following property, together with the rents, 'profits and other appurtenant interest (all called the "Property"), in St. Croix County, State of Wisconsin: South 53 1/3 rods of South Half of Southwest Quarter (ASWU and South 53 1/3 rods of Southwest Quarter of Southeast Quarter (SWkSEk) of Section 17, T29N, R19W. That part of Northwest Quarter of Northeast Quarter (NW's NEB) and of Northeast Quarter of Northwest Quarter (14A NWT) of Section 20,;;T29N, R19W, lying Northerly of the centerline of St. Croix County Trunk Highway "A" (formerly known as Hudson-New Richmond Highway), TRM, EXCEPT the following parts of the above described tracts: $ 0 All land included within the Plat of Willow Ridge Second 1 Addition to the Town of Hudson as described in Vol. 4 of Plats, 'page 25; Parcel deeded to Marlin 0. Amdahl and Riith L. Amdahl as described in Vol. 517, page 26, Document No. 324368; Parcel deeded to Roger E. Hetchler as described in Vol. 517, page 114, Document Number_324430.` TOGETHER with an easement for street purp03es over the Easterly 33 feet of said parcel deeded to Roger E. Hetchler as described in Vol. 517, Page 114, Document Number 324430. SUBJECT TO the right-of-way of said St. Croix County Trunk Highway "A" and to telephone easement adjacent to said highway as recorded in the office of said Register of Deeds. Purchaser agrees to purchase the Property and to pay to Vendor at: St. Croix Heights, Hudson, Wisconsin, the Base Purchase Price of $100,000.00, together with additional payments per lot, as follows: 1. Base Purchase Price. The base purchase pr'ce of $100,000.00 shall be paid in the following manner: $15,000.00 at the execution of this Contract, and the balance of $85,000.00 together with interest on such portions thereof as shall remain from time to time unpaid, at the rate of 10% per annum, until paid in full, as follows: (a)` For each individual lot developed and sold by the Purchaser, Purchaser shad pay to Vendor a $2,000.00 principal payment, to be applied to the $85,000.00 base contract balance outstanding. (b) A minimum annual payment of $15,000.00 principal shall be paid each year, excluding the year of sale. Each per lot principal payment required above, shall be credited toward this $15,000.00 annual payment. (c) On December 1, 1985, and on December 1st of each year thereafter, Purchaser shall pay to Vendor the differential between the required minimum principal payment of $15,000.00 and the total $2,000.00 per lot payments made during the preceding twelve (12) months, until the Base Purchase Price has been paid in full. (d) Interest on the principal balance of $85,000.00 shall accrue from the date of closing, with annual payments of interest due on the 1st day of December, each year, commencing December 1, 1984. 2. Additional Per Lot Payments. In addition to the foregoing Base Purchase Price payments, Purchaser shall pay to Vendor additional per lot payments totaling not less than $;50,000.00, as follows: (a) No interest shall accrue on the principal suns paid to Vendor under the terms of this Paragraph.