The URL can be used to link to this page

Home My WebLink About020-1292-80-000 STC - 104 AS BUILT SANITARY SYSTEM REP .n OWNER ADDRESS qu,n d} Av e Z, S--L 4-3 SUBDIVISION st -G&" /yk.-6.i-o/ /902: Y, LOT SECTION % TN-R W, Town of f-/k dsdh ST. CROIX COUNTY, WISCONSIN ~q PLAN VIEW `J SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Gina CIF cw~ d~ yei -J .•H 5-dc V4,0 7 h f ~_~i pr 6 ~ s g~ N tlFt) S CFr, U ` 8~z tdp ~a fel°fir /iJA!<<o~~ 3ed ~ r el r/vv. o ~O eihf 'j6 /OS 6 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: p o7n ~~,~er~ ,Drop ~•i'! ds' S4i&,,j- 'ALTERNATE BM. SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: 66e,.rc r" &,ooe Liquid Capacity: /a,vusd Setback f rom : Well,*,ii//c jl House v~r Other N7a Pump: Manufacturer Aly Model# Size Float seperation/-13~ Gallons/cycle: k-4 Alarm Location 14, SOIL ABSORPTION SYSTEM Width: / Length .S ___rFr=._-' ~s ?w~ ~•p e s Distance & Direction to nearest prop. line: zo f-t w.s y 6f Setback from: well: s»//~ J House 7,0 'r Other Vd ELEVATIONS Building Sewer - ~f aZ ST Inlet ST outlet 717-j-.2 PC inlet t-4 PC bottom X-A Pump Off Al/?t Header/Manifold 7 S>• g Bottom of system q7 Existing Grade Final grade ? c /cv d i~.r c+, f~v~j ol` Phi ~ DATE OF INSTALLATION: //S-1p9 PLUMBER ON JOB: C/dk/u Gyt~stcv LICENSE NUMBER: /y P d-,5e INSPECTOR:- 3 9 3 j t T 41, to s ~ 6 _ _ r^ -a _ _ _ _ i - ~ _ _ - _ . _ _ _ - - -I . _ _ _ _ _ _ _ - _ _ - - _ _ _ _ - - _1 ICI _ _ _ _ , I. L Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: _Laborand'Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Pla kW 9 SALAVA, ALEX X CST BM Elev.: Insp. BM Elev.: BM Description: Huelsen Parcel Tax No.: o v ' a UrJ TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi ng Aeration Bldg. Sewer Z/, 3 t Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet sag Vent TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header / Man. /o, q~15 Aeration NA Dist. Pipe Holding Bot. System yb 91, y PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well 7- SOIL ABSORPTION SYSTEM BED/TRENCH Width Lencgth No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 5 ill ~ DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of 7 CHAMBER Mode Number: System: `*-0 ~o 6 u ~ /(J OR UNIT a„ DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake IN, t1. Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over z I xx Depth Of xx Seeded/ SoAled xx Mulched Bed /Trench Center 3 Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.27.29.19W, SE, 43 Lo 19, Blue Spruce Lane u Plan revision required? ❑ Yes ❑ No f Use other side for additional information. ! l5 (o SBD-6710 (R 05/91) Date ns ector's Signature Cert ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Couprpr I , STATE SANiRY PERMIT # S -Attach complete plans (to the county copy only) for the system, on paper not less than 0 (GY_j(R 8% x 11 inches in size. ❑ Check if revision th 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 ,Q~le S 1L 5 Y44f S ;?-7 T..2-, N, 4 &(or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 6 l vI o l CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 4 E' o .3 2 -71G tiu ! G ~.T~ ✓ b . TYPE OF BUILDING: Check one CITY O NEAREST ROAD 11 ( ) ❑ State Owned VILLAGE : TOWN OF: ❑ Public 1 or 2 Fam. Dwelling- # of bedroom ARCELTAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 1 El Apt/Condo /4//f v V ! 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 8 ❑ Mobile Home Park 120 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. C 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 .2=Z 8o `_'~`7 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 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. f.) (Min./inch) g ELEVATION or 4 f? ! -P* `~sD Feet . O Feet VII. TANK CAPACITY Site in al Ions Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holdin Tank d r,-w Z F1 Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPR8V"4*.: Business Phone Number: C HEX r %40 000' 71J Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanit ry Permit Fee (Includes Groundwater Date Issued Issuing Agent Si A Stamps) Surcharge Fee) pproved ❑ Owner Given Initial Adverse Determination CV X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: 04%0 kr ,0 L2/7 KI /S.f r/ e .P v a n o 1 s,-vu GZri~ SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ' 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 sewag&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. ll. 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) s ld°'" ~er~ ~iv ~O ~r OVA 5 b' I 50 fl~►`` y sY fi "~~c~ ~y. S4eo i Qer ~V~ Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page \ of 3 La%r and Human Relations D'ri{ftn of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY • .Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S'V` C,QA lK 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. O APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION R L_ ~~CZtZ lE g L Rv q GAVE -EAT S !v 1/4 1-3E 1/4,S Z1 T Z9 N,R Y9 E ( PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 6q1 Quxi,3m(yize Rue% X°l - w3v-va b tNFEJAREST S 1 ST I~op, CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®fOWN ROAD L.'P~~L- MN SSo~t 3 (6f~ y36-~l6`7 SON UN SpTwc.e LN. New Construction Use [.kJ Residential / Number of bedrooms 3 [ J Addition to existing building [ J Replacement [ J Public or commercial describe Code derived daily flow 4150 gpd Recommended design loading rate bed, gpd/ft2 0 • S trench, gpd/ft2 Absorption area required 6 L/ -1 bed, ft2 5 6 3 trench, ft2 Maximum design loading rate o • 1 bed, gpd/ft2 0.8 trench, gpolft2 Recommended infiltration surface elevation(s) 01-I. S ft (as referred to site plan benchmark) Additional design / site considerations - Parent material c-) vet y fN S Ji . 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 0S ❑ U w S ❑ U [as OU (4 S❑ U WS ❑ U ❑ S [VU SOIL DESCRIPTION REPORT Boring # Forizo Depth Dominant Color Mottles Texture Structure Consistence Botndaly Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 0-9 \p,-,Q -i:L - s 1 ZW. 1 tinu~~- cS Z o•s o.6 U<":;`:`A` Z 9-ZZ 10`'t~Z 3!Z - s1 z,~•s~k vrtv~- c~ o•s 0.6 Ground 3 ZZ 3cl 7 . S `1 ti y/ - S O s q Yvt~ C w - 0.1 0A elev. NM-8ft 39-`Y S `CR Yl` S 0 s9 M \ - 0 1 n.$ Depth to limiting factor > C1G Remarks: Boring # I o-9 1v`~ 1Z ~-LZ S \ Z~., ~v vv1U ~S Z~ o S o cAAj S u. Z Z 9-33 to kIZ 3IZ s~ Z+~►3\NT VA v'~~ '•._?Y•S_ ?;:,fir, 3 33-~1S S ~R yI - ~S O s vh. \ Ct~, 0.1:0-Yi Ground ev e .Bft. lLS-1D8 S `1 R 5/6 - S S°J 1 - ~.1 o. t3 Depth to limiting factor ? 10 S" Remarks: CST Name: Please Print Arthur L. W e e r e r Phone: 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: p ~Sb Date: , O V`Z-~~ CST Number s....,_,._._ ....d..:. .......,tea:. PROPERTY OWNER SOIL DESCRIPTION REPORT Page 't 'of 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 Trerxh k. ^C~'4 ;v$.vvv I o- 9 ~Z. Z 1,Z s ~ Z ►y► "n v C S Z o- 5 0_ ~ 3 Z 4-~Y 1o'ttz 3IZ 1 S) Zw►Sb~1 ~nUfi. Clu 1 o.S v• 6 Ground 3 3~l _4 R Yl - g O 3 C S O. 7 0 elev. ut. L/ 44448 S O s9 ht ~ O.7 O. Q, Depth to limiting factor '7 Remarks: Boring # 1 o-q )v-l~zzLz - s) ZmR~.v~~, ~S Z~ o.S'o }x Z q -3 3• S `t tZ ~!l - L Z s b h ►m 'F4. e S I a S o 3 33_ 3 S Ground vt y/6 muU' C S - o•~! Io. S elev. ~,S `112 vl6 - S S5 vh - 0 1 ° q-t.2 ft. Depth to limiting factor 70'' '2 Remarks: Boring # o Li -E~ • S 1Z MI PQ ZZ~ -Z - 9 Z a:~.s'ss's~xi:..• I Ground ~ ~ 1 -L L, S I\) C~IV ~'2.L, p)2. elev. ~p - S Ls- 'M ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) of PLOT PLAN Page 3 3 SCALE 1"= 30 ' p t= Z, y °l l 11C, r ~ LoT . t'ttoua I\N 5a ~LIoZ~ 8•Z a a b r _ 6 N L`C'1 P+r 1, Pth+'p q 9 ~TLR ►v1tT~ \3k g Z .3 ? ~,Lq1 z 101 J . i ~ r3.3 o^. r a~ / $41 R 0~1 2~ Z \kTeC~ t3oRtr.j Gs V) 's J . '3`t 6fm1 y L . STt't=L a►J lZ P°vt-r S--oR j~ 1. "E Iq ~ Lblr lfl ~~fil~(, ~Y~'[L'~ 9 -ZS-4Z o' x C,U t_- O ~ -S kC \o ~.bC.p~710►`1 S lz~l-C N ti i @r 1 _ L3L, - 1 U U . O orJ z N \ IZ o►v P l P ~F LOT czRAXSR WvQS IZE- ~Tp q L )fiT LEA s r Z S~ wN3t~_ So' iyU`T~' 't'O tIV ST'~u.ISR ~ -~1'rt+~TPC1N Mtc~c . ~lZ~ CUU~TSt out N)13ml1~U T)u►J h~«es , CIL/, 2. (715 ~ 4 5-01 65 M00576 CST Signature Date Signed Telephone No. CST # i STC-105 SEPTIC TANK MAINTENANCE AGREEMENT ~I St. Croix County OWNER/BUYER T► /e -,k MAILING ADDRESS eS l r~c.~, %2 rr~ a rc V e, Z.) /Ce~d y d PROPERTY ADDRESS 7X-7 eA.-c (location of septic system) Please obtain from the Planning Dept. CITY/STATE hJ Ce/" 3- `f o / PROPERTY LOCATION s-~ 1/4, w,- 1/4, Section T~N-R__L7_W TOWN OF cc, ST. CROIX COUNTY, WI SUBDIVISION fj ~c~y o~/ji 15- LOT NUMBER CERTIFIED SURVEY MAP , VOLUME -"7PAGE oZ3 `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 expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - loo 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 X/e,* Sd /a4- a Location of property, 1/4 VZ- 1/4, Section -?-Z ,T N-R W Township Mailing address 6-41 Z Address of site 7s'7 w S ~ Subdivision name Lot no. 17 Other homes on property? Yes No Previous owner of property r:d Total size of property .2. Y/ a~ • "r Total size of parcel 9~ ,cam • S Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes X No volume /o 3 7 and Page Number a 3 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. ,s"o6 71 , 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. So 6' 7/ 4-~ Signa u of Applicant Co-Applicant 9 „ 2.3 / Date of Signature Date of Signature P,~ r 4',e it z v r _s t ..s.- i~. S''.£=~~, r~-.~-1 ,~i ,.~r",f,.i v ..x-'l s` fi E~!~: ~ „*;S•i'a ,~~F~~:`. t,. DOCUMENT NO.' ~ WARRANTY DEED TIIIS rFACe. nr:,Cnvco Fnq NECn-DING DATA 5af'.4 STATE BAIL OF WISCONSIN FORM 2-1932 2 4 . -3 OFFICE Recd tur Rooo•d Sam..E....Mi1 ipx,...a...s.i-ng.l.Q_..peas.on_......... OCT b ]993 conveys and warrants to Al.eX.-- Pi 1.AYd_- 3Iid ThereSe.-L..' 11 :50 A;~a . Salava~...husband..ansi Wife *qvsw drxlaa --CTLInN TO . the following described real estate in U.,-.-CrOIX .................County, State of Wisconsin: ~ _ Tax Pnrcel No: Lot 19, Humbird Hills First Addition, St. Croix County, Wisconsin. s 003• FED This is nOt--------- homestead property. (is) (is not) Exception to warranties: easements, restrictions and rights-of-way of record, if any. Dated this A-----.: say of Octo-- ------..D.a._.r.._........................._.. 19 .~.3. 1JLJ5!~'~. _ . (SEAL) .-(SEAL) _ Sam E. Mil er • (SEAL) . . (SEAI,~ a AUTHENTICATION ACKNOWLEDGMENT Signature (a) STATE OF WISCONSIN sa St. Croix County. III authenticated this day of........................... 19...... Personally came before me this !,~=.day of October 19 the above named . S -am E. Miller TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by $ 706.06, Wis. State.) tom now be the person who executed the fo roing is ument and acknowled ee s THIS INSTRUMENT WAS DRAFTED BY ~ • Kristina Ogland . . / /Tr a Q,,l17~-" Attorney at Law /.Q_.....~-C_.....- . Notarv Public f!.LY.... .Count}•, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is pe:rianent.(Ir not, stnte expiration I• are not necessary.) aNames of persona s?rniny in any caps Ity ahmdd be typed or prime.! below their sLSnnf;,rr:. i WARPANTT DE$D STATE BAR OF WISCONSIN, Wisconsin Legal Blank Co.. Inc I; FORM No. 2 - 19tlZ mowal.kee Wisconsin Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and"Duman Relations INSPECTION REPORT ST. C X Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Perm o.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State P SALAVA, ALEX X CST BM Elev.: Insp. BM Elev.: BM Description: arcel Tax No.: TANK INFORMATION ELEVATION D A TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchm Dosing Aeration BI g. Sewer Holding At / Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P/ L WELL BLDG. A to ROA Dt Inlet irIntake Septic Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Loss Syste TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Leng h 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 TypeO CHAMBER Model Number: System: 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 Topsoil ❑ Yes No E] Yes El No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.27.29.19W, SE, NE, Lot 19, Blue Spruce Lane Plan revision required? ❑ Yes ❑ No Use other side for additional information. L SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i, SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY ~r C~oiX STATE SANIT~A TR {MIT # -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 pr 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 N,R )w Ale s111 6)_ s 4&6'Sa.? TYBLOCK# PROPERTY OWNER'S MAILING ADDRESS LOT # S- ' ^0.*- Ay CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned ? 1& ~OWN VILLAGE :/~3 ~lt<< s Ira C@ ❑ Public % or 2 Fam. Dwelling-~# of bedrooms J PARCEL TAX NUMBER(S) Ill. BUILDING USE: (If building type is public, check all that apply) /~aQ l q~ _ ~'o 1 ❑ Apt/Condo W74 VJ 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 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.A New 2.E] Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 19 Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 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.) (Gulls.//day/sq. ft.) (Min./inch) ELEVATION g5 e- ¢ 3 i~' 8 1010.1 Feet /OA 00 Feet VII. TANK CAPACITY Site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New isting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Sig ature: (No Stamps) MP/MPRBW No. Business Phone Number: Plumber's Address (Street, City, State, Zip Code): /1/ .S'*1Y- ? T o .,,4 Jr IX. COUNTY/DEPARTMENT USE ONLY O( r_1 Disapproved San711n Permit Fee (Includes Groundwater ate Issued I g Agent Sig atu (No Stamps) O Approved ❑ Owner Given initial Surcharge Fee) _ r Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety a Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. - 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 1-15 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) ` , • f'Lat PL ~N off' L 5,1~9vv9 ~G ! off' .Z Na,dsov rvw.v s N / 1° N s ~ a o ~ ~ e R tL ~ar pp P~ a~. scP~ ~o It ray 1yy K b` y a Y°G 4 oe Sd~. I ca Y >+e QI Qy~ b SW- j~Q p a Ah ~c xctr~' a./+e~e ~rterr,o.. ad CG~dY/ts L , uic 6sfe~ PAGE -2 0 IF c;;,? CroS Sectlo 04 A &-f) SyJew Fresh Air Inlets And Observation Pipe 1 Approved Vent Cop Minimum 12" Above Final Grade 20- 42" Above Pipe _ 4" Cast Iron To Final Grade Vent Pipe Mash Hoy Or Synthetic Covering win 2" Aggregate Over Pipe pipe ton - Dls - pipe 0 0 -0 0 0 Tee i 6" Aggregate B/MOth PIP e o Perfaabd pipe Below - - Coupling Terminating At Bottom Of System PruPoselJ t'Inkl qre% 4- , ~C a a cr"d/~~adJ ~ItJ•:~ Ian" vl. o = eX•~'~,N~ .9 ,/spew ;.14r r,04 SOIL. FILL DISTRIBUTIOK] PIPE APPROVED StfWPETIC COVER ---1UTRR1h1- OR 9" OF STRAW Z~ OF AGGR EGAIE OR (AARSN NAy ° ° (e OF12AGGREGATE V,LEV. OF aQ FEET DIS-11151JTIOW PIPE TO BE AT LEAST 3O INCHES BELOW ORIGINAL GRADE Ak)L) AT LEAST?-0 INCHES BUT MO MORE THAM HZ IMCNES BELOW FINAL GRADE I'°MIMUM DEPTH OF F-XERyATIOWI FROM MOO.L 6RAoR WILL BE ~ IMCNES PUMIMUM Wr1i of FACAVAToom fKOM 01K14.11aAL GRAVE WILL BE 2_ INCHES G2~ SIGIJED: ~ LICENSE NUMBER: Mp o S DATE: Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page L of 3 JA5~ or and Human Relations un, 'sion 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 cil GOVT. LOT SL 114,WL'114,S 27T Z 9 N,R X,(or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. N ME OR CSM # 7D ~eonca / wA A. rd . CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VIL GE [SOWN NEAREST ROAD E-I-u-d 5 YI u-9 r. S f-al (7/5) 34!2~ - 612 s j0,4,41 & t,Ls 2d K New Construction Use D>J, Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow OgtCO gpd Recommended design loading rate . 7 bed, gpd/ft2 , 9 -trench, gpd/ft2 Absorption area required 4~x3 bed, ft2 4 3 trench, ft2 Maximum design loading rate 7 bed, gpd/fit . B irencit, gpd/ft2 is Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations ✓ 4 Parent material 0 w4 k j As h Flood plain elevation, if applicable xJ f9 ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL H❑OLS NGTAK U = Unsuitable fors stem fisS El U ®S ❑ U Un El U El U El S l- SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bounck3y Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench Z 4e- C' C') ca VZ.Z0 /01M */Z/ lye W90 G, e,) A-a e7t 51 Ground o- 28 p YI/ to /V o C Wit/ 6 . Z 3 ye) /0 -3$ . 5 o- No X')G 1-5 CJ -F -Y ,in / 6 uJ ~l~- i 7 Depth to , 5 2 (o p rt1 E ae S limiting factor Remarks: Boring # 0-7 D rz Z/ 4-,~/C S o? m r /Y~ ✓ rp &D o-t , S • 40 0? 5,6 X, M 4Z Z- I- /t/0ry Ground elev --89 D 4f S o /vim /Dft. ; Depth to r' limiting factor Remarks: CST Name:-Please Print Phone: Address: Signature: Date: Number: - zp_ 19.3 C z~y~ PROPERTY OWNER C 4n,~ '-At4Y SOIL DESCRIPTION REPORT • Page z of 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 Tnnch 5 • ro Ground . -?o 7 ~0 A-) S 69 5 elev~ o ( 03 Q-/01/ /0 Ki S/ SLY CJ S l rV,¢ i Depth to limiting factor > 10¢'' Remarks: _ Boring # >x•<:: < / C~ z o /L z/Z- nom, e Ground 7' Y16, V D G C O •S m/ w4 y~ $ elev. /00da ft. Depth to limiting factor Remarks: Boring # pp_ G e) -7 ya Groundz 7 5" elev _ 8z 7 y^K 4/0 O /Jf s O s evv r¢ 6' `60 a=tt. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel 988 N. Shore Drive C.S.T. 2298 Ydina Realty New Richmond, WI 54017 MPRSW-3254 y (715) 246-6200 town of Till son Z'- 0 i sr~ SDKs '4~ Z, C f Oa ' ~001+- p.6 1 o z' g0t, SE• On-711 eve Gary L. Steel O-M-n3