Loading...
HomeMy WebLinkAbout030-1025-70-000 STC - 104 AS BUILT SANITARY SYSTEM RE C CT 2 3 1594 OWNER G:,,WaaTV ADDRESS zCkeiNGOFffCE 'S CU ~l~ I 7 U) r SUBDIVISION / CSM# LOT # SECTION CO T p?-'? N-R l 9 W, Town of S/ QS e~OA ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 EET OF SYSTEM Scale M GeO. /004'64 /A Pik 51y Por- V 7 ~/oer'~cr Ud(a~ s. DRATIV _ - \ \ C, lOOpala~ WeSrr' \ 7rencks lya►tile3 Bec~roe Geru~c ~ f INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form- Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House Other i Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom- Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Departmentof Industry, PRIVATE SEWAGE SYSTEM County: Labor amd 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 o : State PI o.: LOHMEIER, RAYMOND W & ROBIN X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T x TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic c 1- - Benchmark Dosing Aeration Bldg. Sewer -~t1 H St /yf Inlet y7 f v, C Ci a' Cszl TANK SETBACK INFORMATION St/Id Outlet 7' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic y! 0 ' NA Dt Bottom r, Dosing ~ NA Header/ Man. Aeration Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacture Demand Model Number I I,/ GP ction System TDH Ft TDH Lift Loss Head Length Dia. Dist. To well ABSORPTION SYSTEM BED/TRENCH Width t Length / No. Of T nches PIT No. Of Pits Inside Dia. id Depth DIMENSIONS 'J DIMENSIONS SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHIN INFORMATION Type O 1 yj CH UNIT R Moe Number: System: Cr yt!1-. -/04, DISTRIBUTION SYSTEM Header /+1Axmi ullY Distribution Pipe(s) , i x Hole Size x Hole Spacing Vent To Air Intake Dia. Spacing L Length as Dia. Length la~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S s Only Depth Over Depth Over xx Depth Of r Seeded/ Sodded xx Mulched /Trench Center -80d-LTrench Edges Topsoil ❑ Yes E] No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc., LOCATION: ST. ,J EPH 15.29.19,103C2,NW, E,RIVER ROAD_ L//~e.'Grj .I.~rGC~ksf%r~ •YF^'., i7` ,b/c`~. i'C~ r L.F~ v /J~1~ / / 1 'iG''/~1-f ~I~ Ll ,/l Plan revision required? s ❑ No Use other side for additional ' formation. 6 17 ~/j ~Pl/ / BD-6 10 (R 05/91) ~ Date Irispedor's Signa ure Cert.,No. _ ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: -Oki rG 41 l 7, F) Y, 4 411 U4 SANITARY PERMIT APPLICATION COUNTY li7<~■■7 In accord with ILHR 83.05, Wis. Adm. Code St Croix STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than jXMcm a ~ ~ 0c) 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION gay & Robin Lohmeier NW '/4 NE '/4, S 6 T 29, N, R 19 XfpbW W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 383 River Road CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Hudson WI 54016 715 386-6773 II. TYPE OF BUILDING: (Check one) El State Owned NEAREST ROAD nn St Joseph River Road ❑ Public l1LJ 1 Or 2 Fam. Dwelling~# Of bedrooms -1 PARCEL TAX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) 030-1025-70 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 100 Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Ch/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ H el/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. ® Replacement 3.E1 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 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) J5 2 ELEVATION 450 1125 1125 .4 94.1 Feet Feet 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 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): PI a igna r ( Stamps) MP/)MU6TMo.: Business Phone Number: 01 Paul Steiner 715 425-5544 Plumber's Address (Street, City, State, Zip Cc e): N8230 945th Street; River Falls, WI 54022 IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sani Permit Fee (Includes Groundwater Date Issued Issuing Ag t Sign (No S mp / 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 8 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 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) i ' P SANITARY PERMIT APPLICATION COUNTY f v'■~■'■■~ In accord with ILHR 83.05, Wis. Adm. Code It r_tn_' STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ( 7 t 8% X 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER . PROPERTY LOCATION a; rZ rA =1 ??l^C 7 t/a t.l,, /a, S 1 T 29,N1 R 1 ~ _ W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 3a3 7taxtl CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER `I'.I`'~"C)'1 i.i.. 540g 1 6 715 )3_-`)6-6773 II. TYPE OF BUILDING: (Check one) ❑ State Owned T NEAREST ROAD _iyer ❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUM ER ) Ill: BUILDING USE: (If building type is public, check all-that apply) wo 1(V)-5-70 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. El Replacement 3. ❑ Replacement of 4.E] 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 H Seepage Pit Pressure 43 Q 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 LLEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION ~ w Feet Feet 11 450 1125 VIL TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. Manufacturer's Name Con- Steel Plastic INFORMATION New Existing Gallons Tanks Concrete glass App. Tanks 1"anks structed Septic Tank VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the atta ed plans. Plumber's Name (Print): Plymbb 's5ignatur (NiO Stamps) MP/f }do.: Business Phone Number: 715 425-554 d Plumber's Address (Street, City, State, Zip C e): "15430 945ti Str_Ii).V ; i^Ltv 4 IX. COUNTY/DEPARTMENT USE ONLY ' Disapproved Samtary Permit Fee (Includes Groundwater Date ssue Issuing`Ant Sig ure (No-S mps e , Surcharge Fee) r n Approved F-1 Owner Given Initial 7C7 'J r 1 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 a ..a.. . ♦ • ♦ t:~ 1'J5 t ?.S. S.,..' .5. :t't`l "i" k _'4' •'!'A' 1..V 1 'l'/ 4"*-,*'* . . . }:'4't'i.. l'i'4 4. k".! 4'!'.l~+.`~!. .!.`•e, 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 o_ where the system is to be installed. It. 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. Vlll. 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) lob plate Q SCE /e l y0 R1 e w fiLvd en c~ a ~ scale / = yo m Ian .100.0 ,ew 1/y ,s V l -,DRAIN 31 © /000.7 tke,sef Seyt,i Ta.,k by/00'4oA j \ 7~ehcks ~ ~ /-~on~e3 Be~r~ Gerrz~c ~ ~ ~ fly ~b;~ k ok M,~,er = D O p Q. cf) gp * c z W K m at z oo m OD m .40 C= 300 M ' Orr < U) + 00 m V S m T y p O n r Z C Duo p ' zN _ AD > G) m o n C) :T) X m O Q N N U) Z p . m Z D m U) p m ~ z ~b C c • C M z 04 rO n O U) n O z z m m * s~ mom ~a mo_ ov om Z 3 m" mom` ~C 1 D -:0 m n p' m m -1 ~ -1 = M o s m y J s m T m CD 01 s s~ m m m e m (Dm 3 °-a° mac 2 ~~mo Ha D r m co CD Q) O p S ° 7 C M Q ON m 3° m ° 3 'm m ' o CL 70 5r 3 I-D ID 0 CD ID CD T > >H - ms c W 1 < S O 9 p 5,- 3 s 3 M MM V1 T OEM J1J 3 n m 1D~a 103 O o Z) cc m - ° H cn CD < m ~ , day H' ~o Z D 7~ _ N Q a ~ m cn Z m cm < ac- y •Q y o m .3 0 m~ o < o• ~ m ~ ° 3 H 0 s 3 3 ~ 03 cn I~ <d a E y o 30 10 < d o H v N m m H 7 a 3 ° o ? - > CD m co m T SANITARY PERMIT APPLICATION ' In accord with ILHR 83.05, Wis. Adm. Code COUNTY St Croix ~TAR~P~ ~IT# -Attach complete plans (to the county copy only) for the system, on paper not less than STATE SA(( 8% x 11 inches in size. ❑ Check if revision to pr~us 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 Ray & Robin Lohmeier NW % SE N4, S 6 T 29 , N, R 19 AOMW BLOCK # PROPERTY OWNER'S MAILING ADDRESS LOT # 383 River Road CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Hudson WI 54016 715 386-6773 II. TYPE OF BUILDING: (Check one) ❑ State Owned NEAREST ROAD MOWN& Rt- - Th.-,t-nh J River Road ❑ Public ®1 or 2 Fam. Dwelling f# of bedrooms 4 PARCEL TAx NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 030-1025-70 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. [Sj Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 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) 70 , Z ELEVATION 600 1,500 1,500 .4 6 Feet Feet 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 strutted Septic Tank pmbMV9XIJD= no 1 e ks _-E] 1:1 171 1 1-1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): PI be s Signature: o amps) MP/~No.: Business Phone Number: Paul C J Steiner 6780 71 425-5544 Plumber's Address (Street, City, State, Zip C e): N8230 945th Street; River Falls WI 54022 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanita Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature No Stamps) -1117 Approved ❑ owner Given Initial O~ Surcharge Fee) Adverse Determination D X. CO~_WIONS OF APPROVAL/REASONS EASONS 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 & 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 a//. 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. l MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. 9 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. i I SBD-6398 (R.11/88) - i Plo pla R t U e i~ go&d 9, oll FQxc--c J cr Ab 'A l~ \ ~I /00, 0 r e w l.Z ` N~bls 3/y ~~ci 'o DC Q Cleave \ Ott \ TaK k \ ExKt►°g P ~ \ po~ Ray I &bih kAnti.eier .'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 I= COUNTY S C.P-~lx Attach complete site plan on paper not less than 8 1/2 1Rc include, but not limited to vertical and horizontal reference point ecti n and % of ale or PARCEL I.D. # j 030 - wZS--ID dimensioned, north arrow, and location and distanc to.rest (Zidd. REVIEWED BY DATE APPLICANT INFORMATION-PLEASE PRI AlL IMFO'RMATIOf!1:;,, `Fy c~. PROPERTY OWNER: 1 PROPER ATION ~P('1 $ RtJAIN LZli`F'1 ►Q tt)1/4SL 1/4,S~ T Z N,R lE(o W PROPERTY OWNER'S MAILING ADDRESS - Lt)1 LOCK # SUBD. NAME OR CSM # i CITY, STATE ZIP CODE PHON BE C ❑VILLAGE QTOWN NEAREST ROAD ~Sl))~) t W ( 5(t0 16 (-)I57 3 fS'°1S1 ° ' St-. ]~S R1U f► D [ ] New Construction Use (Jcj Residential / Number of bedrooms [ ] AddifiQn to existing building j~Replacement (j Public or oommercial describe Code derived daily flow 6W3 gpd Recommended design loading rate bed, gpd/ft2 a• ` trench, gpd/9 Absorption area required _ bed, ft2 \ S o0 trench, 112 Maximum design loading rate o - s bed, gpcVft2 a. b trench, gp 2 Recommended infiltration surface elevation(s) Se-E~7 li~~~ ft (as referred to site plan benchmark) i Additional design / site considerations S RL~_ 100't''v Wi sTt,_LtM ON t-'ftG e- 3 Parent material s ~`tY oUla~ 8 T't t- L Flood plain elevation, if applicable N A . ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN RLL HOLDING TANK U = Unsuitable fors stem [as ❑ U ®S ❑ U [as ❑ U ®S ❑ U ❑ S ®U ❑ S oil SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon Texture Consistence Bajxbry Roots in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed rertdt o -t9 ~~R Z l L 2, k7 0- w o• FZ - o.s 0.6 luLt lz31Y - sll 2`~Sbh hn'<^\ 41S Ground IS SS--)S S `7 2 3! - S 0 w~ Wt 'F - 0,1 0.4 elev. 01 Oft. 3 QrjZ-LW 6S cav w s N v aA L U- u- P LA is Depth to w t l O''l R i 3 S r'Cw~~ >~'T S limiting factor >7S" Remarks: Boring # ~ v S l0`1 ~ z-Cz - S t ~ Z `~Sv12 ~n `Fh CLti - o• S o. ~ t ~ `'Z-"` Z 15-u7 10`tR 31Y S1~ ZTSb11 yn'fh GS o Sio•6 3 L(~- 1 S S H.V - S to ~'H - 0 3 0• 37h y Ground elev. Of S -4 ft. Depth to limiting factor Remarks: T Name:-Please Print Phone. Arthur L. We erer 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Falls•,.WI 54022 Signature: Date: CST Number: gy-Z-39 g` 2;7-C? M00576 ts. ..e .S. T mss. PROPERTY OWNER `-~~1 AEI L~ SOIL DESCRIPTION REPORT Page?-of 3 PARCEL I.D.# a lO - 1b Z S -`70 r Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouncay Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 0_8 toKv- 2-tZ Z'FSbk my ~w - o•S c-. 1p -1L Sly sl I Z t'sUk M cs 0. S 0-6 Ground 3 3$-'l-) S `l IZ 31y S V 1.~J 'fit - • 3 v. elev. q 8,b ft. Depth to limiting . factor y Remarks: Boring # 5Ll•S IV C, 1 <v Zr oUtr M SstUL~ i Ground S LO P1 elev. ft. Depth to limiting factor Remarks: Boring # 1 ~4 Ground elev. ft. I Depth to limiting factor Remarks: Boring # I'M Div Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) i is PLOT PLAN Page 3 of 3 R t R-WaIQ LoNHE I-R SCALE 1"= 140, o lvo , 030- Nozs_-7o v 7 RiuR Ro - z.o.w. L«F C ►.~~rmt:ter N- 7a PAW use 1 Ae'~-CL - ►~OT P~Zt1pLs(tT`1 L1k/e ncu.u~k~l t i 'tfl - (EL . I U. Q' ON k2." IG N ~ 3/yy D f 1~ , 1, PvC plPh w/wooer ~l~T!-i, e_Z 1 V 6.~T y' X e~ IA e C p~ b i 01 s E-qb°- X ALL T~~vC S 'M $~Z-z MJ" A-T "TtiE pUwNSLuPe CTDCE. - w~ v'~+u `1 t 1~1 1~T u3`R s T 60" db u ~~Z o v Lit i~ 1 P tr utiD ~Z 121 u o~ 1►U S v~+~' ~l~ BAST ~ U ~v . ( 715 ) 425-n1 65 M00576 CST Signature Date Signed Telephone No. CST # Wisconsin Department of Industry, - SOIL AND SITE EVALUATION REPORT Page N of a Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY S-;.~.~x Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but j PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. 30 _ IS --I APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION PM $ 1?_O 1c'~1,N L O l-1 `-i t~ l L-1? OW'E61'- N UJ 1/4 SL 1/4,S 6 T Z a N,R 19 E PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER [:]CITY ❑VILLAGE DOWN NEAREST ROAD V~vDSWQ t w I Sq() 6-1-1 3 [ ] New Construction Use pCj Residential / Number of bedrooms y [ ] Addition to eiasting building [,Replacement [ ] Public or commercial describe Code derived daily flow 6003 gpd Recommended design loading rate bed, gp(W2' jftench. gPd/ft2 Absorption area required - bed, 1112 SM trench, ft2 Ma)amum design bading rate o s bed, gpolft2 ° b trench, gpd1ft2 Recommended infiltration surface elevation(s) S~ li4~G L3 3 It (as referred to site plan benchmark) I Additional design / site considerations S E L5- ►-wl'cT TO Inv s M~-L ls2 ON f-*VG e' 3 Parent material S Qr-f oU~M s l T't t- Flood plain elevation, if applicable IV A . ft S = Suitable for system (X)weTnONAL MOUND "ROUND PRESSURE AT-GRADE SYSTI M IN FILL HOLDING TANK U = Unsuitable for stem as O U ®S 11U [ S ❑ U ®S ❑ U S ®U ❑ S X11) SOIL DESCRIPTION REPORT Wks Texture Structure Consistence Banday Roots GPD/ft Boring# Horizon Depth Dominant Color in. Munsell Qu. Sz. Cont Cola Gr. Sz. Sh. Bed ranch ON W-03-11-11111 r r I 0_19 ~~-j r, Zt - L 7, ~d1rc w.F- cLv 0.l- R, -`M<: Z `l-S S 2 b `"t IL 3Z V S 1 Z S ~1 t h1 ~1 C-S Ground 3 S5_-)S1 S `l R 3 l - s 1 O o- 3 0. y elev. otb -oft. 3 ''nL Qo\ZIM6S Co,v NS N vtn~ CA-1- 0. LLyrv V6 I~F- PLAlit! 3 Depth to W t t O`12 (3 S limiting factor Remarks: Boring # € o. S NZ-1 ztz - s 1 Z ~sb~z ~h cam, _ 0-S Z Z 1S-L17 1u~cvt 31 1 s{ Z bk in ~h cs 0.S b' 3 Ln~s sLlV__ 3~~ - s1 mow. t11~~ - o•~° y Ground elev. ft I Depth to limiting factor Remarks: CST Name.-Please Print Phone: Arthur L. We erer 715-4'25`-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Fa11s.,.WI 54022 Signature: Date: CST Number: ji(_z37 q-z7_4y M00576 PROPERTYOWNER L.1~~1 ~El L h SOIL DESCRIPTION REPORT Page?-,of 3 . PARCEL I.D.# C) IO - lb Z S -0 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench fd~vSiz.i~ O - $ l O ~-t, CL Z-L Z - S l ~ Z. 'F S bk ~ ~ 6. ~w O • S Ct• ~ Z -3g to ~e Sty st'I Z~stik f~ cs ^ s 0- Ground 3 3$-'17 S !Z 31 y S v Lti 'Ft. - O. 3 a. elev. q 8 lb ft. i Depth to limiting factor 11 y i s Remarks: Boring # 13 13-14 LZ LA./ s S k-r 5`--t tNG 11 Yn Z' Tysoue M S3fuL- , Ground elev. ft. Depth to limiting factor FT i Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # i Ground elev. ft. Depth to limiting factor Remarks: SB D-8330(8.05/92) PLOT PLAN Page 3 of 3 s • R'~-t ~ 2.03 ~1J L v N ~ ~ t ~'R SCALE 1"= 140' >>o NV, 030- 1013_-713 1 ~.o.w. uuE C ti~~rcQ~~sr N~1R~o PtmIry L-Iwe) ~r~c.E - +~oT PtZ.e1PL~TY l.liv@ n~.1.ue'ti.~KY t BM~1 -(=L,Ib0.01 ON VZ."tALGN, 3/y`o11) 1, ~vC p~P~ w/wooer Qf'Tl . ei.9 S `1 az OCi-tR~J Ftl'Z.~? S V QQT X rb I O~ , P j x cK*~h \0 g 0 1 aoN~v~ o i ~S L t, ia-~,j C -Q 5 as tom., cis _ ELg6 = x LL ~ CSC. ~ 1 Iy S'jY~L 1. tsl2 w~~'~~►U l~T Ll3'hsT 60" ct)u~~2 Uul iii Pt uti~N~Z )12-lu<fi`f OR- l S v~ h~ ~l~ ~-(1ST' 1~-1z-u 1Z~~ U 1v . Z3 9 715 ) 42.5-01 65 M00576 CST Signature Date Signed Telephone No. CST # .389'746 • • 0 rn ro 19 g °O rn 9Qc"R?^C O z O ~H N C7 d -r (2 OTl z O O Z H~7 C) X N~ y H f ri d c~ z d q ~4-7{ 0 U) T H C O = Z D ~~9 .u m ~ D fJ 2 U) 0 nIV>O o~z v dz CCTTJJ o ` v Z P `COO d Cyl~ O C1 x~ It foot 11 0 c: ~4 ~~i O t" ~ US O N W p z o 0 H Tl C7 ~ K y ~N FILED w z DEC 8 1983 H r JAMES , H lEaQitdsr oA IYoadt z 0 PINE fECE ROAD 84 L]v!s canrr. r 1','hcans7n W~=W-QFLn-E NE S 07' 28"W (SOO°21' 55"W) i r~ Ic0 w o Cn 000 1 ~A C--) Iro z o rn L H NN C~1 0 0 8 I~ Ww N -n ITI ' - g 0 rrn w i° o rn r~ n SOCP10'33"W S00°23101"W 636.19' -I n 602.30' (603.191) ~I APPROVED H N O 0 ~ z Nov 1 :i 1983 r t A O O F- CO N ~ A O cn H F) o ~o I ST. CROIX COUPM N Q0 0) w N I I tOMPREHENSNE PARKS PLANNINo l0 v H~ t-I N l I AND ZONING COMMITTEE Z o N Cdr! £J xl O y N _ I I O 0) O N _ H UJ ~H _ I (p 00 :E: 0 1-Q H SZ _ O O 0 622. 141 I w ' N00026'33"E 655.14' rn w w w ALL BEARINGS ARE REFERENCED TO THE EAST-WEST cn 1/4 LINE ASSUMED TO FEAR S89°52'22"W. N I~ N 02~ r ILn 0) C7 Volume 5 Page 1377 Ti-aS I ETRU=r DRAFTED BY DOUGLAS ZAHLER JOB M. 81--06-183 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER(BUYER gay & Robin Lohmeier MAILING ADDRESS 383 River Road PROPERTY ADDRESS 383 River Road (location of septic system) Please obtain from the Planning Dept. CITY/STATE Hudson, WI 54016 PROPERTY LOCATION NW 1/4, SE 1/4, Section 6 T 29 N-R 19 W TOWN OF St Joseph ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME, PAGE , 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. UWe, 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. ~o o DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Ray & Robin Lohmeier Location of property NW 1/4 SE 1/4, Section 6 T 29 N-R 19 W Township St Joseph Mailing address 383 River Road; Hudson, WI 54016 Address of site 383 River Road Subdivision name Lot no. other homes on property? Yes X No Previous owner of property G tc cGv L'/~u~ ~l c,U Total size of property Total size of parcel A,~ 3 / Date parcel was created /V OU . 17 19 83 Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? Yes ___x __No Volumes 07 and Page Number 33gg as recorded with the Register o - 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. , 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. Signature of Applicant Co-Applicant Date of Signature Date of Signature . DOCOMENT NO. ST:1TF BAR OF NlilgCONST'ti FO!-N1 1--~1J~tB THIS 67A; P._i RYEn /G :d RECOR^IN-3 DATA 1 • ) MILS Dad, malls between . Sam E. ltiller $T, CR IX C0,, W1 Rac'd fo, R - cned Graz' )r; atad Raym nd W. Loh,neler and Rcbin A Lodi-,- er, hushsnd 1 and wife as joint tenants at 10:15 AM . li v V C11 -•jiv Grtnt V RMy 5107 ~1 Ds .-+f3 W1~Tl8SS~1h That the sa.3 Grantor, for a valuable consideration-_ ,i RETi-RN TO con^eys to Grantee the following des~r:bed real estate to -t_.-.._ro--... x County, State of Wisconsin: A parcel of land located in the North 0-.Ze-1'alf (N'-Z) of the Northeast Quarter (NE ) of the Southeast Quarter (SEA) T%x Parcel No: of Section 6, Township 29 North, Range 19 West, Town of St. Joseph, St. Croix County, Wisconsin, described as " Lot 1 of a Certified Survey Map recorded in the office of the Registe- of Deeds for St. Croix County, Wisconsin in Volume "5", Page 1377. Except commencing at the Northwest corner of Lot-1 of Certified Survey Map, Volume 5, Page 1377, said Northwest corner is also the point of beginning of this description; thence South 0°10'33" West, 340.99 feet; thence North 89°52'22" East, 676.51 feet; thence North 0°26'33" East, 341.00 feet; thence South 89°52'22" West along the East-West Quarter line, 678.09 feet to the point of beginning. H between the above parties This deed 1 in fulfillment of a certain land contract1dated December 29, 983 and recorded February 4, 1984 in Vol.. 681, Page 545 as Doc. Number 391006 in the office of the Register of Deeds for St. Croix County, Wisconsin. tl s is a This not homestead property. 'i *'~r I 0xk (is not) Together with all and singular the hereditaments and app,.irt~-nances thereunto bele .bing; And --Sam E. Miller warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, covenants and restrictions of record, if any, and any liens or encumbrances created by act or default of grantees and will warr4nt and defend the same. . -p Dated this ~ 1- day of I!` - , 1988._.. e w -------(SEAL) - .......(SEAL) Sam E. M Iler r s 1 ------(SEAL) (SEAL) 3 r AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ga. St. Croix -------...County. - authenticated this -..-_.-day of 19._.... Personally carne before me this _C?..day of ......-.Fah u_grri'f~~ 19_S8._ the above named Sam E. Miller • TITLE: MEMBER STATE BAP, OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats,) . to me kno-. n to be the p?i on who executed the foregoing instrument 4 owlel~; the same. "d THIS INSTRUMENT WAS DRAFTED BY .1 R - A ' HEXW40D,".CARJ..& .MUAF4VY - " - 4 - - by Samuel R. Carl r-- - - ~i-I . I - - p" Nota- y PL §St.. Croix----- ---County, Wis. O :"Box 229 " Hudson, WI" 5-4Or 1-6 (S~ignatiures may fie authent.cat_pd or acknowledged. Both 3fc con"t in is ptrf Ianent (If not, state expiration are not necessary.) date: - - - - , 19.~L..) -Names of Dezson- aiSnin% in any tapicity should be typed or printed bclou- the=ir 'ig' .'un I W.k7tAA?e'1'Y DBF7 BT aTg HER. OF W:31"Ov":9f14' Wi;can;in Ie.•a! Ruck Co- inc. F+~r~>4 tin. t 7943 Mil- 0 - , W'. K--S:_w v. .i F:JR HE ~R';>IN OA'A Dt-~C tt:+ . rF_•. , . ti;A" OF F-1:..M f • TW5 Ss'n_c _T NO STATE 'U ' { N Thi-,, Deed, San_-E._ ~ti llez' e:: 2901 ma~1~• bctwcen , d single . poser, day Dec A.D. 1983 10 30 A M Grantor, t And Raysloud W. Lo}Im.=ter and Robm A.. I,oh:neier James O'Connell a ltIlesIeth, T wa the :ca 1 Grantor, for a valuab uen. ;M rat.o.t _ Deputy REt.. 4tN TG eonv,-,s to Grantee the following des:r'bed reN1 e.st,,te in St. Crain . Count,', State of Wiseon.sin: A parcel of land located in part of Lot-1 o;_ Certified Survey Map, Vol. 5, Page 1377, which is located in part of the North One4ic if cfthe Northeast Quarter of the. Southeast Tax Parcel DIo:..._._-.._._-.__-._..____.._.--- i Quarter of Section 6, Township 29 North, Range 19 West, Town of St. Joseph, St. Croix County, Wisconsin further described as follows: Comrlencing at the Northwest corner of Lot-1 of Certified Survey 'tap, Volume 5, Page 1377, said Northwest corner is also the point of beginning of this description; thence South 0°10'33" West, 340.99 feet; thence North 89°5222" East, 676.51 feet; thence North 0°26'33" East, 341.00 feet; thence South 89°52'22" West along the East-West Quarter line, 678.09 feet to the point of beginning. The above described parcel. contains 5.31 acres including right-of-way and 4.79 acres excluding right-of-way and is subject to a Town Road easement. A~ is not This homestead prolerty. (X) (is not) Tngether with a!1 and singular the hereditaments and ; ^purtenances 1` creunto belor:ging; And Sam E. Miller w;.rrants that the title is go<)d, indefeasible in fee sin:p"e and free arid clear of en,curnhrances except easements, covenants and restrictions of record, if any and will warrant and de.`end the same. Datsd this _ 28th day of December 1983 (SEAL) C I ~IC tA_~J (SEAL) SAM E. MILLFR, 'a single person _ (SEAL) (SE A L) t AUTFIENTICATI0N ACKNOWLEDGMENT n Sig;tature(s) STATE: OF WI3CON: IN ss. 't.._ Croix ..County. authentlc:itrd this _dav of--..---. , 19 I'eronal!a came me this 28-0 day of -------..OGCc lbt~r---- - 198.3-... the above nam?d TiTI:E ll,.~It EEZ 3T:1TF. B-~R 1~F I--S~ ONSIN (1, not, aut^n aed b «:3 Sta;.) ❑ f c tI n v .n r~ t.t S >t ~~'e i to ?III, h,r rr. U 11~..a :t.-:rrr~~!~ t_',` tl."• ~;;~'~e./ O TH -S FELY4OE)D, CARL & ''UR t Ay by Samuel R. Cari, P.O. B r:. 229Hur', ~n,`~I - Stj I .....-.1 CFI;:'. &0': , 19 - 2 9 WA7R N Y Dr,£D _ "f-\i'F I \R OF' K, ~i~~15 ,if ti: t• Ic ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the ..r residence located at: &)_114, s~ 1/4, Sec. To241 ' N, R / W, Town of Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced /g4e Did flow back occur from absorption system? Yes No ~<(if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacurer (if known): W elsey' Age Tank (if known): cZ~-^ had (Signatur (Name) Please Print ``X11 P ( 790 (Title) (License Number) /01/9 Lqy (Date) 11 f Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILNR-83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Signature MP/MPRS 5/88 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. C T'2 /N-R I qW ADDRESS l 1* ou ~~'DUrr ST. CROIX COUNTY, WISCONSIN. J 1 a d C- 4"-640T LOT SIZE U G~ P S SUBDIVISION PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM - J-T AH I di at N r h rr w BENCHMARK: (Permanent reference Point) Describe: 1017fl G f S ' f~nor ro f a7/rf Ora 4gn ~,ok tiLof E~I n Elevation of vertical reference point: d 0 _ Slope at site SEPTIC TANK: Manufacturer: Vltcfe~ Liquid Capacity: 1 G O C' G( i Number of rings on cover Tank manhole cover elevation: Q.(, Tank Inlet Elevation: 7.Z Tank Outlet Elevation: ~7, c3 y~ PUMP CHAMBER A/ 14- Manufacturer:_ Number of gallons /V Number of gal. pump set for a cycle A111- gallons; Total capacity of distribution lines /V A gallon: size of pump //'/I' head; gallon per minute ~/4- ; horsepower ;brand name of pump and model number A111 ; Type of warning device 111A HOLDING TANK: Manufacturer AlAt Number of gallons Elevation of manhole cover AI A ; Type of warning device dz, SEEPAGE PIT SIZE; Al A Number of pits 1114 feet diameter 14'11~- feet liquid depth Al /F seepage pit inlet pipe-elevation IAI bottom of seepage pit elevation 1414 feet. SEEPAGE BED SIZE: number of lines width length., 7- depth / /f//9' SEEPAGE TRENCH: width length PERCOLATION RATE AREA REQUIRED AREA AS BUILT 2., INSPECTOR DATED PLUMBER ON JOB LICENSE NUMBER tij - ti 9 17- SyS~n~ C~ ~G~G~ L ~ ~ /h c GZe S ~cC ~~f P oro7y~ f o srt r C / 6?79r l v jqg' S 1 G,~ ~ jI Y To A~r L L N AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP e H M. b TRIN-RAW ADDRESS,k0w7-g1200/< A&I ST. CROIX COUNTY, WISCONSIN. ,41 SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FgET OF SYSTEM . 2 i s I dilate N r h rr w BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: liOO Slope at site: .Z O SEPTIC TANK: Manufacturer: elc er Liquid Capacity: lOQ d Number of rings on cover :--E- Tank manholo cover elevation: Tank Inlet Elevation: Q,? Q Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set for a cycle -gallons; Total capacity of distribution lines gallon: size of pump head; gallon per minute horsepower ;brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE; Number of pits feet diameter feet liquid depth seepage pit inlet pipe-elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines ~I? width-/,? lengthJ73o'*' tile dept Sty SEEPAGE TRENCH: width 9 leng h PERCOLATION RATE 3-/ O AREA REQUIRED cS1 AREA AS BUILT INSPECTOR DATED PLUMBER ON JOB LICENSE NUMBER DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HYMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.'BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 ®CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number: (lf assigned) ❑ Holding Tank El In-Ground Pressure El Mound NAME OF PERMIT HOLDER: F11DrRESSOF PERMIT HOLDERINSPECTION DATE: Sam Miller out Brook Road, Hudson, WI Z : BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: NEB SEA, Section 6, T29N-R19W, Town of St. Joseph w Name of Plumber: MP/MPRSW No.: County Sanitary Permit Number: Doug Strohbeen 5432 St. Croix 43696 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV : WARNING LABEL LOCKNG COVER ✓ PROVIDED: PROVIDED: yj l C f ❑YES ❑NO ❑YES ❑NO BEDDING. VENT DIA.: VENT MAT HIGH WATER NUMBE OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH u JALRM A ' FEET FROM LINE: AIR INLET. v YES ❑NO ❑YES FIND NEAREST ZOO DOSING CHAMBER: MANU FACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER IPROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL I BUILDING. AER NLO FRESH (DIFFERENCE BETWEEN FEET FROM LINE ~D I PUMP ON AND OFF) ❑YES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check thesoil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH. N0 OF DISTR. PIPE SPACING. COV INSIDE DIA.. #PITS. LIQUID BED/TRENCH TRENCy / MgSG AL: PIT DEPTH: DIMENSIONS L/~lJl (t~ (/'tf) GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH PIPES FEET FROM LINE ( AIR INLET. BELOW PIPES ABOVE COVER. ELE LET ELEV.^END. H 2~ S r'1~ 01 - NEAREST-----p- MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED-. CENTER EDGES. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.. ELEV.: DIA.. ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY T OVER MATERIAL. PLANS. ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: ❑YES ❑NO ❑YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. nrLE: SIGNATURE: DILHR SBD 6710 (R. 01/82) I • ~5c°nsln APPLICATION FOR SANITARY PERMIT L H R a1~ r?OUNTY DewaRTR1E^T ov (PLB 67) UNIFORM SANITARY PERMIT # PIDUSTRV, LRBOR 6 HUTRI"1 RELRTIOrlS 6~24 M -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PRO~P`FRTY OWNER MAIL NG ADDRES J as /V I r / C ~ i✓' s N t /'U 4 PROPERTY LOCATION CITY: c / VILLAGE: J ,LI /F-1/4 5 1~1/4, S C , TN, R /I400r) TOWN OF LOT NUMBER BLOCK NUMBER SUBDIVISION NAME INWEST ROAD, L E OR N ARK STATE PLAN I.D. NUMBER t L' r 4 TYPE OF BUILDING OR USE SERVED v 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: e NPEew System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. [~rSeepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank ❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed v Septic Tank Capacity O L10 Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: u~ p h IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch). REQUIRED (Square Feet): PROPOSED (Square Feet): 4-- 0172- Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Si na e: MP/MPRSW No.: Phone Number: p o K l o s S 4 Be en gou A- 3 3~ ~-r o Plumber's Address: Name of Designer: ¢ 161~w ,lac'ic4 mo4W W1s ~ 7 Pdu 5f•.d46ar COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved El Owner Given Initial IyApproved ~ Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD•6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber F INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. ER 115. R.'11. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS . WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 34g~ &I - LOCATION7Iem4ENa, Section 6 'T1E:j_1N,RAe2& (or)40Township or Municipality Lot No. , Block No. County A Subdivision Name S Owner's/Buyers Name: Mailing Address: 720scl" v' j S *WZ TYPE OF OCCUPANCY: Residence -No. of Bedrooms -3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW _ X REPLACEMENT ALTERNATE SYSTEM DATES OBSERVATIONS MADE: SOIL BORINGS 4-.aIna PERCOLATION TESTS SOIL MAP SHEET y~ NAME OF SOIL MAP UNIT C95 409L C140 PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P- / O" t ors Q .A?Y /0 0 3 a o2JAf 1/ P- 30 e_ Are ,2 30 's .120 P-2 1 Q" se-e- Are 01 q P- P P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- H L K B- pf " N B- oy N ON Ia A 4r B- s`- q JB- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the _plan the location and square feet of suitable areas. Indicate number of square feet of absorption area neededFfor building type and occupancy a/ Indicate scale or distances. Give horizontal and vertical reference points. Indicate Alpe. ~t~ ise *P-14 - ec "i - Per- 7~- 4~- 14 sy-s . fin P e4 44 E 3 s ~o„ I I t 1, the undersigend, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) Certification No. Cs * Address av /PLC rG/ C -4 165i r, SyAe .Name of installer if known Copy A - Local Authority CST Signature •a 1 t 4 ♦ s. ~ ; it ..R. ..k-,_..y ..i ..-.«-K•-•~i~'-• 7w'- ~ ♦ ~ ~ .a a,~.y. ~yi►... ,r.,}C 4fv r • y It i 1-14 vet L* P. L rno g ZD' 9. P[ ~ A 8 A4 fajh4eW a f l~r.n~c gfr,J 'reecc OroI~C o ~ j,] 13 CBaetj-hre, t `~d> 1 Qa G Pecs l-#4 tbaVo11i' L 4 6141 -too, v; 10 OF D~- -tote' - k1, 9~r , A~c•c s V#4 r f,4 0- G u ~ rt r f ~ S~ ~a 3 /66o y«! S~ fr 3~. D l~ S it f feh Q /'t ~t tvn NG4se b Qrw~9 L+ r S t ` i l .l. y- r 4 r i i t I I~ i j{ 4 ♦ t 40 g Vpy f • '4'~ PA1140M e so t '7`777! ~ . ha 00* G dGU G 1n'f ~tf To?; ~ Tkal~ li 1 4 , '1 s ♦1 'L i Ira It, ~7 ti t 1:' C J 2 r ~ v p v _ \ C