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030-1042-70-100
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 582015 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Parcel Tax No: Mike & Lana Emmeck TOWN OF SAINT JOSEPH 030-1042-70-100 CST BM Elev: Insp. BM Elev: BM Description: n Section/Town/Range/Map No: 4A 4~ ' 20.30.19.157A-10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 'XI IN - 1000 ~l W<l~s Se ti 14 r` et 2 ~5/1 Benchmark O O FJZ 81 ok. It. 13M 5~ ~~1.2I ~S 105.31 Aeration _ C Bldg. Sewer Holding • • J UHt Inlet - X1~ r d TANK SETBACK INFORMATION St/ t Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet O Dt Bottom Septic IOU , Dosing Head Man. ?or, Aeratio Dist. Pipe a ~A Holding Bot. System Ivy ! • Sy PUMP/SIPHON INFORMATION Final Grade ~Dq• Z Manufacturer De M d St Cover 11 5 r l q O' Mod umber 1 / O I T H Lift Friction Loss Syste ad TDH Ft V Fo main Length Dist. to well SOIL ABSORPTION SYSTEM r NSI S No. Of Pits Inside Dia. / Liquid Depth BED/TRENCH Width /J 11-engt D / No. Of Trenches PIT DIME DIMENSIONS SETBACK SYSTEM TO P/L I-IN BLDG WELL LAKE/STREAM T LEACHING Manufacturer: c~ O INFORMATION T pe Sy tem: N 1 I I CHAMBER OR Model Number: G ~l- Jnr ?dud D l l 203 H t n IBUTION SYSTEM IN# Hea an'rfold fl Distribution x Hole Size x Hole Spacing _ Vent to Air Intake 1 Pipe(s) Length Dia Lengt Dia Spacing - I i SOIL COVER x Pressure Systems Only xx Mound Or At-Gira Systems Only Depth Over i Depth Over Z 1xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ~ Yes M No Yes Fm] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection ##2: Location: 1411 41 ST ST L ' ^ , Puy s we 1.) Alt BM Description =,"fW Wvt1l ~t f ~fJ'GGGGuu SIM KI 2.) Bldg sewer length 1nS/~ ~y v~r ~ ill - amount of cover ;n. " ko-A Cie t'ois' Plan revision Required? ❑ Yes I 15 ~ 1~7 ';VkdX, ~O Use other side for additional informati L ( ' Date I sepctors Signature Cert. No. SBD-6710 (R.3/97) ` 0CT 1 9 20,15 Safety and Buildings Division to ,~c 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) $ ST: CROIX COUNTY Madison, WI 53707-71 6 MUNITY DEVELOPMEN / ~ ~ ✓ Number sanitary Permit Application. In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(t )(m , Stets. 141 L Application Information - Please Print All Information P Owner's Name na, Parcel # Pal"/T e /h /n eck D 3 d010 1/ Zi7o•/oo Property Owner's Mailing Address Property Location / / - Y/ Sr- Govt. Lot City, State Zip Code Phone Number 5 a,, Section 2. O ~o ~o.q yair2 71f--.rYY - ~6 Z 3 l 9' cleone T N; R H ilI. Type of Building (check all that apply) 1 Lot # / Subdivision Name C2'1 or 2 Family Dwelling - Number of Bedrooms Block# eUrbe c❑Public/Commercial -Ds se ❑ City of CSMNumber ❑ Village of ❑ State Owned -Describe Use ?4 11 Town of P t~ o .JS `t 2s III. Type of Permit: (Chec on y one box o! lineA. Complete~ tine B ' applicable) A- ❑ New System Replacement System ❑ TreatmentlHolding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner IV. T e of POWTS S em/Com onent/Device: Check all that a 1 ® Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound ? 24 in. of suitable soil ❑ Mound < 2 in f suitable soil C ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) J V. Dis ersal/Trea t Area Information: Design Flow (gpd) Design Soil Application Rate Dispersal Area Required (sfl Dispersal posed (s System Bl ation 6 c~ 01 7 VI. Tank Info Capacity in Total # of Manufacturer Y Gallons Gallons Units New Tanks Existing Tanks r~/po/ S Zs Y c sn y vi 'w C7 P, Septic or Holding Tank O e/ 16906l~ I I Z 6 o z (,L eG-4I X Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number ~,(1%24 a/z ic i7 /0- ~313iy 7is=zY7 3zO3 Plumber's Address (Street, City, State, Zip Code) ue- VIII. oun epartment Use Only Permit Fee Date ue Issuing nt Signature proved ❑ ' prove $ q Ap75 L-t> ❑ eason for Denial' /a J ` I IX. Cond1l9Xfi seasons for Disapproval r j 1. `''Septic tank', eltfUerit ft hr and 4 r►: ~i v ~a► ' dispersal cell •must all be services ntained ,a,,,~ Z b Z W►~~ as per management plan provided, by plumb@r. t ell Z: k'ta0Famnts must ba aintained / saw applicable code / ordUances. Attach to complete plans for the system and submit to the County only on paper not less than 8 in x 11 inches in size SBD-6398 (R. 11/11) OWNER Page 3 of 3 Name M e - C_K Brian Parnell Address CST 231314 /-/o, i tom Date /D- Benchmark 1 71Y 1"60. 0 A Benchmark 2 -7"-0)1~1 Tc Qs I - Z, ❑ Soil Boring i Suitable Area F= 40' Scale - ----1-- I I t i j i F7 I I I ( ' j ' I i ---T- t ( I j ( j I I 4 i ~ i + I ~ I ( ~ + I I t j i I iTI j! i j I I 1 i R, 1 I i i I 1 1 1 i t I I`-, , ~I I c~ i ( i i l! l~ I i i ~~1 s ! I I ~ i l L I E31 I 1 1 1 ( 1; ~ I I 1 1 - I I i I 1 -4 i 1 _1 I ~ , N 1 m 1 .I CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE / F-, rn Project Name: ~ / ° In{ G k - Owner's Name: Awe- /Fm ~ck- Owner's Address: Ste-%~ S /y Sic :td 3d I'1 9' cu Legal Description: r^ ~ Township: > ✓ County: Subdivision Name: Lot Number: 7 Z -70100 Parcel ID Number: J b /y rl Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing Page 4 System Cross-Section Page 5 Filter Specs Page 6 Maintenance & Management Plan Page 7 Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Designer/Plumber: 1)116-1 ~a i4 t License Number: 2 3 13 f Y Date: Phone Number 7/S- Z yT - 3203 Signature Designed pursuant to the in-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 OWNER Page 3 of 3 Name M 1 k e C ~ ck Brian Parnell Address / S/ V/ Sf-- CST 231314 /,o, fm-,4, z Date A Benchmark 1 'too -/V v Benchmark 2 --t`y jP T- c as Z, / ❑ Soil Boring _ i Suitable Area 1" = 40' Scale - I 4 1 I I -J i ! i 111 All, i c a fi 7Z4 1 ! N 0 O ~ 4 R i 83s Z aVtel Sr a/, Alec, Z6 f./ we~'oe l 7-Y PC> t 7 A-- 1 c,e o f o576 /z f I / SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Page of Project Name: 'A, Ke 07 Me C /t- No. No. of cells Per Cell 3 ft Cell Width Total No of ~Z Z 03 A ' /1 ~JO it Cell Length ,q tt EISA Per Cell ft Cell Spacing 0 sq ft Total EISA Manufacturer Model Wag EiSA Rating lydv=or EZ1203H-511 5A' 25.0 EZ1203H-10ft toff 50.0 Gravelless Leaching Unit Manufacturer. Graveiless Leaching Unit Model: CZ / 'Z O 3~/ - /D ' c Typical Cross Section Finished Grade I b ft Observation Pipe with approved cap or vent Soil Backfiii Geotexttile Fabric 9~. fl Infiltrative Surface 12 in X0 I l 7t a ft Limiting Factor ~I v in Slotted and Anchored Ventl Observation Pipe with Cap ■.■.........■.......■s~~fa ...................■........s u....... r........ Plumber/Designer Signature: License Z J ~ 3 1 y Date. ~.,~INSTALLATION INSTRUCTIONS MVA z I innovations in Preca t, Drainage A Zabel' E &Nlastarater Products O sfon of Pofylok Inc. PL-525/PL-625 FILTER !NSTALLATION INSTRUCTIONS r (I I i Center filter with opening i ~ rs ~0 z . 1W" C/1 E (L. o G; y. A 7 _ S i 3 Additional pipe OF Polylok Extend &.Lok- Clue forcentenng ° Step 1: Step 2: Step 3: A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the T) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe. necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the is positioned so the filter can be housing, making sure the filter removed from the tank for cartridge is properly aligned and maintenance and service. completely inserted in the housing. `MAINTENANCE INSTRUCTIONS tep 1: Step 2: Step 3: Dcate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back : if necessary. into the the housing making sure Big: ~ (B) Pull the filter out of the housing. the filter is properly alighed - r (C) Hose off the filter over the septic tank. and completely inserted. USE RUBBER GLOVES Make sure all solids fall back into the (B) Replace septic tank cover WHEN CLEANING FILTER ~ septic tank. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of _ FILE INFORMATION SYSTEM SPECIFICATIONS v'ner ~C C!L Septic Tank Capacity Z fj gal 01 i~ vex" ° Septic Tank Manufacturer u, c~eks OESiGN PARAMETERS Effluent Filter Manufacturer /r C e/it ❑ Nu-i-ter of Bedrooms ❑ NA Effluent Filter Model S- 7,5- 0 Number of Public Facility unis ❑ NA Pump Tank Capacity gal u ~Sti, d fiG d (average', gal/day Pump Tank Manufacturer 'esign flo-v (peak). (Estimated x 1.5) ( 660 gal/day Pump Manufacturer C Soli Application Rate I i) . gal/d /fit Pump Model 0 Standard influent/Effluent Quality ! Monthly average" Pretreatment Unit Fats, Oil & Grease (FOG) .30 mg/L ❑ Sand/Gravel Filter ❑ Peat Fitter Biochemical Oxygen Demand (BOD;) <220 mg/L ❑ NA 0 Mechanical Aeration 0 Wetland Total Suspended Solids (T SS) <150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality { Monthly average Dispersal Cell(s) ❑ { Biochemical Oxygen Demand (BODS) <30 mg/L 4 in-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (T SS) %30 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) <10` cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size % in dia. ❑ NA Other: ❑ t Other: i ❑ NA Other: Cj C =s typical for donestic wastewater and septic tank effluent. Other: 0 1 viAiNTENANCE SCHEDULE Service Event Service Frequency -.srect condition of tank(s) At least once every. 3 ® year(s)month(s) (Maximum 3 years) ❑ 'uc,p out contents of tank(s) When combined sludge and scum equals one-third (l) of tank volume 0 w\ ti -snect dispersal cell(s) At feast once every: ❑ month(s) (Maximum 3 years) 01 Q year(s) ❑ F P3 0 month(s) lea riuont filter At least once every: ~;cyear(s) ❑ month(s) 4 pump controls & alarm At least once every: ❑ N ❑ year(s) ❑ month(s) ❑ N t=-ais and pressure test At least once every: ❑ year(s) At feast once every: 0 month(s) ❑ N 1 ❑ year(s) ! ( 0 N 01AINTENANCE INSTRUCTIONS nspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certificatioi Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer- Septage Servicing Operator. Ta nspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or lea! measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surfac I he dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any pondi e; effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires t immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (%3) or more of the tank volume, the ent contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 11 Vdisconsin Administrative Code_ Aii other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatme units, and any servicing at intervals of <12 months, shall be performed by a certified POViTfS Maintainer- A service report shall be provided to the local regulatory authority within 70 days of completion of any service event. Page OT START UP AND OPERATION `^rarr construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals raZ -gay impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents t`e tank(s) removed by a septage servicing operator prior to use. SYz• ts- start up shall not occur when soil conditions are frozen at the infiltrative surface. wring pourer outages pump tanks may fill above normal highwater levels- When power is restored the excess wastewater will be -scharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or-surface discharge of !rMu°nt. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring pOv rer to the effluent pump or contact a Plumber or POW-15 Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank- L;o not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise-disturb or compact, the area 5 feet down slope of any hound or at-grade soil absorption area. Seduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the pOvv i S: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; ;oundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT ''then the POW i S fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is Properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code; ¢ All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator- Ali ter pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space felled with soil, grave( or another inert solid material. CONTINGENCY PLAN the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacemen'system: C A suitable replacement area has been evaluated and may be utirized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot nines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area- Replacement systems must comply with the rules in effect at that time- t ! A suitable replacement area is not available due to setback and/or soil limitations. Sarong advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. The site has not been evaluated to identify a suitable replacement area- Upon failure of the POWTS a soil and site evaluation nust be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. U Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNiNG> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT- RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS 7OWTS INSTALLER POWTS MAINTAINER e 1 e fume r ee __a a EName Phone l 7/ - Z yT _ 20 Phone iEFTAGE SERVICING OPERA TOR (PUMPER) LOCAL REGULATORY AUTHORITY Iva ,e j Name ton 06; Phone Phone -A P. 'If - s docu- e %-,7as d-a=e= =ance wrh chapter Comm 83.22(2)(b)(1)(d)&(f) and 83-54(l),(2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) I _ `~71/ sf located at: S 1/a, S 1/a, Section 'Z Town 3 o N, Range W, Town of , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: /DD,- Construction: Prefab Concrete Steel Other Manufacturer (if known): w e~X1 Age of Tank (if known): 2 Permit number (if known) 2 / ° 7 _ ,P~z -e (Licensed Plumber Signature) (Print Name) Z 313 / (Title) (License Number) MP/MFRS /a - a /j (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 I ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Are Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City/State f.•L W Parcel Identification Number 3 U / ~YZ 7o /66 LEGAL DESCRIPTION Property Location I/4 V4 , Sec. Z J , T 3 O N R Town of f~- ~T°S0l7 Subdivision Lot # Certified Survey Map # , Volume , Page # Warranty Deed # , Volume , Page # Spec house yes no Lot lines identifiable l,D no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, state of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on - form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a ty deed recorded in Register of Deeds Office. Number of bedrooms _ SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the salutary permit being revoked by the Planning & Zoning Department. Liclude with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if -eference is made in the warranty deed =REV. 08 `45} RECEIVED 10 OCT 19 Z01") Gn 1 w~. Dept~OMMU servicss SOIL EVALUATION REPORT Pape of MENT N in acxordance with SPS 385, Ws. Adm. Code 1 Attach complete site plan on paper not less than 8112 x 11 inch in she. Plan must ~7 C include, but not limited to. vertical and horizontal mbrernoe point (SM. direction and Parcel LD. 2Q c~2 r percent slope, scale or dimensions, north arrow. and location and distance to nearest road. J + Please pint aU intonation Reviewed by Personal W maw you pmvide may be used for secondary puposes (P&m L+. a.1s o4 (1) (m))_ 636 - If Z 6- 6 Properly Owner Property Location 7kke 4/lggme c/c Govt. Lot (v vaS~1i4 s ~L N Rl7 rf(or)~ Property Ownef3 Mang Rddre p, Lot # Block# Subd. Narne orCSW `State rZip Code T Phone Number 07_ QY~e Mown Nearest Road CRY Ho a /Y d U'~ SY~z (71-r) -,ryf - 6 02 J 6 ex A / st- ❑ New Construction Lim® Residential [Number of bedrooms Code derived design flaw rate Y GPD O Replacement ❑ Pubes or rommerdal - Describe: Parent material aP Pr t Piair elevation fl applicable it. General commends and recommendations: WRt~I~ v~1~-K' f0~f coo ~ . # 11 50fi ng / / BOn`yg ` 03' C~ ft. to linuTin tailor / C) ® pit Ground surface elev. 9 in. Sod lion Rate Horizon Depth Dommanrt Color Redox Description Texture Structure 3onsisterice Boundary Roots GFqA 2 in. Murusell flu. Sz. Cont. Go" Gr. Sz Sh. W1 I M2 l 0-6 127(- e C. 1A1 2 K,- 7x 17 v / /ViS~ C s /Asb/, AL w / 1'o. T ~ 16 3 e- 13 0 -/-0 f IVA ~ 0S o, 14 ~4 ,t ti F2-1 Boring # 0 ® Pit Ground surface elev. ft. Depth to Tvnbrg laWr / in. soft Rate Horizon Depth Dominant Color Redox Description Texture Stnx3ure Estenoe Boundary Roots GPDlft Z in. Munsed Qu. Sz. Cont. Color Gf Sz St> o-~ 7"5-Y iL'k 111 Aj4,t V 7 u, / rh 0. O.1 E#tluent #1= BOD > 30 < 220 mg& and TW >30 < 150 mg/L ` Effluent #2 = BOO < 30 mgt and TSS < 30 mg1L # .3a rSasre;f'ieare rirrt) S'Gnatu- CST Nuinber 15 r &'L I' /4 dl F--, 0-1 23 / 6 1 Address Date Evakration Conducted Telephone Number k'e~-s-eO~4- /4~)- / S '/s- z sr 7-.?Za3 t+ ff a v e Sot Property Owner 7 t'' ` e ' m M e of, Para! ID # y 3(/ 70 Page Z 3 of pd Gmund surtawe#ev. 0 fL Depth to *nbg factor fn. SAAppkation Rate Horizon Depth Dominant. Cotar , Redox Description Texture' Shuck re DonsMence undary Roots 43"M z in. Munsel Qu. Sz Cont. Cd" Gr. Sz, Sh. Z ~ x-f- 7 F Ivr- Bor 9orina F7,i~~ t_! Pit Ground surface eiev- ft. Depth to limiting factor in. F#iotz D.a#e } f . ; rE-,.•-.~uts G 0 et i' £}~r, sciizt ` ..s..".zus~ _ A... ..L._j a f" tc1tR 2 f i r.3a•'is% rvx_ut =^ssae z:... . Deaz:;fvuvra ; cn... x . x ri due a~Skste ice 53 Lix i Ro u G MR E z r z F z _ 'E iu~aa:' ..cv.. ~z' sa':~, k•,_h;i Yx. 3 f 2 ` $f'mF r, i g Soring Boring# pit Ground Surface elev. at.- Depth to Grniting factor in. Soit:u'ipSicat'fon Rate { r ?n =gin sep=ta D -r t C ;b-- € =cedes vescsizsran i Te ase stnxture . s nca r Boundary i r>.G:ts f _ s a 2 f F ...E - - . It # F x I ~ Effluent. #1=130D -10 = 220 n' and TS S >30 15£1 MO& ` Effluent #2 = BOD ~ <30 ma and TSS -3: 1t- The Dept. of Safety and Professional Services is an equal opportunity service provide, and employer. If you need assistance to access services or need material in an alternate format, contact the departmem at 608-26&3151 or TTY through Relay SM-$339 (Rt Ut 3) € e -:-In m Parcel ID 0 3~ io~`2 70Page 2 3 Property,,,r m Bonng # Q sonnet pd Ground surface etev. tt. Deiy2A to jimr'h'ng factor. T ~ 3 in. Snd n Rate Horizon Depth Dominant.Caior , FtedoxDesaipfiion Texture" rote nsistence undaryRoots GPM -2 -1 -W2 in Munsell Qtr Sz. Com Cotor er, Sz. Sh. J - i J .i i x 1 a i j t ~ ! 1 ~ t i 1 { t 1 ~ i } 1. i i } r ' Boring 9 ~ ! ► H Pit Ground surfi-ace eiev ~ Depth to firniting factor in aeii x~' cr ay o { J i f S _ r € i € i 1 t 1 # i } i P 2 goring- v.'U:€.:Csib-fa.e" -7t. -O-p2stofim, factor ui. { T Soil AppgC~ R. ri-> €r g=-- t r i><~p=~n e' 'te =cam i' 'aitttra'te ~vs WY i P'~ s yr J ' i F L F s`- e : s s i _ie;#t 1 = > S t ' Tj _ 3 t j c > < 3 [ ; rL ' Efflu 42 3C , _ s e ?iii? TSfi = rr?:dL I he Dept. of Sa€ety and Prcriessicnal Services is an cauaI Opp. Fc~t~Iit's SEr'ri%e prGVidu and a:~tp.tsyer. if you need ~sistance access services or need material in an alternate format contact the department at 608-266-3151 or `i°€'`€' thrmdggh Relay. SSD-5339 l €f i }i OWNE r Page 3 of 3 Name i e/~m eC Brian Parnell Address CST 231314 Date 1O - a-/ /00, o AL Benchmark 1 T rop 3/y 7. + y e f::-_: / A Benchmark 2 %D~ Tee FL . /oz, ❑ Soil Boring Suitable Area 1" = 40' Scale a ~ ~ i n C =-d E ~ r! 1 r> Q ~ O N O t -0 0 -0 0 Q c (D q (D q a 0 °u~ 0 b09 d c O r II, c C (D 0 a O O N i ti C I ~ t cu O rn c_ N N N N N p O C Z 2 a) C 7 S CL 7 N LL w U. 0 a Q w I Q ~ I M o a) z " z a v 0 o z m a a O~ a m a m 04 C/) c 0 0 2 d a 41 v o o 0 (n H °1 aci z c E -a c v v M c m y N a~ co a n n Co o •N a 0 ca a 0 o 0°i Q 0 aa)i Q z m z Q Z CD Z N z N N R E N N t6 Y i R Y - L - CL m CL cc O W N d C 0 N a) i C O N G 0 0. c ' N O D a 0 Z > d H F- F- 3 U y= F F- F- b U iri ?r d O Z 'n O O O d 0 • ~aaa ~aaa a c c !y ° v v o *i 7 M p N 75 rn rn CD 0 a) z° to -i L) 0 2 _0 rn M LO 2 a) o) 0 0 (O (.0 E :7- N N T (n O O 5 C N N O~ (n C c17 QO 6) m N 'a N Q N Q} co d Q Z N io „v„ O O O_ C N C r N C 7 Q 0 a) 7 a N (O CO Q) N a) O O O O Y C C o n F- Y y C E,3 (L N N N N E E ir5 V O L E Y C 0 - U N C =3 N ~ N N N ° M ! E (o in ao rn E CY) v v o Q) o _ E a0 0 N 0 m as cLi E N o CY) 0 • yam„' O ON (n W N O N z (n W O N Z Z (D CL CL 0 L: 4) L a a a 1~ it a • •(Q a d U a1 y N r C +E i C c 7 C _1 A c0aE 0 U)0 0000 kc~~ c.~~' C <S `'v DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 6370 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: UNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: A41 , 20 /TAN/R E ( O ~f~ p: 5 e r ~ I - COUNTY: OWNER'S BUYER'S NAME: MA ING A RESS: L 5 1, Gro,,~ i i ~ ec/f - ~y u/1e (/i mow , ` o4~fo•Y u-`~" USE DATES OBSERVATIONS MADE Y-Z NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: esidence 3 PA" ❑Replace 1119 a-9-1 7 - U= Site unsuitable for system -2 RATING: S= Site suitable for system CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) OS❑U S❑U S❑U ❑SES1 ❑S U e If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: G~~ 0"' 1 Floodplain, indicate Floodplain elevation: D PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 7 - f-, a d - > -;7- ;2 B- 4- 6 A- 0 -moo l _Z? B- A B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUM ER I>td9IIIIIIIIIE AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER D PER INCH P 3 P_ a~ 3 P_ p 7 7 Mae -1 P_. P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at aWborings and the direction and percent of land slope. SYSTEM ELEVATION 3 E re }j{ i 1 ~ Q I L F / I I ^s E I lc- i E 10 E 3 E E Q. N //,o Ile f 10 11, 3 elD S F } so © 'tom e. t e, g re c e soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrativ n t h recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (printTESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 54 7,11P CST SI ATURE: loo, DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - INSTRUCTIONS FOR COMPLETING FORM 315 - SR® - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate vti this is a residence or commercial project; 3. MAXIMUM number of bedrooms or cornn- arcial use planned; 4. Is this a new or replacement systern; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for v t iting profile descriptions and completing the plot plan; 7. M,'.KE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A , e sheet" -ta r~ !-ed if desired; 8 i°.a your ark and vertical elevation reference point are clearly shown, and are permanent; 0. : ail app ,tri L~ boxes as to dates, narnes, addresses, flood plain data, percolation test exemp- ti-~ if appropria ; 10, 1` flood plain, elevation) does not apply, plan l' C1. it) the appropriate box; 11, rm _ irrent address and your certificatior...r.. a C'stribute as required. ALL SOIL TESTS MUST BE FILED WITH THE L' AL FHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIES SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Irr-k rob Cobble )3 - 10") SS ~ 'I gr - Gravel (under 3") LS - Limestone *s - Sand HGVV - Nigh Groundwater cs Coarse Sand Parc _ Percolation Rate; med s Medium Sand Well fs Fine: Sand ",:Idiny Is - >my Sand > - Than sl - y Loam L an I Bn - i sil - Li-,ani BI k Gy - ry cl Clay Loarn "ow S<= 'y Clay Loam R - t lay Loam mot - - Clay wi - sic - lay fff - 1 ,v lint", faint x c cc c mon, coarse pi - min - #t --tedium rn - [ d - p - I _ :i-ni~ -jit. HVgL F ~r. textures Ii_,i- disposal BM L,,.,, , VRP - Verti P :off' .•a . TO THE , T =t ~-uring a _ i t b '~~?r tL) STC - 104 AS BUILT SANITARY SYSTEM REPORT , 7~T, OWNER ADDRESS Ste SUBDIVISION / CSM# LSECTION l -TA N-R_L!W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM w~ 1( /A yoscrk m~ - A;2~ y' o 9Gq 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: ~k S Liquid Capacity: 11)W ~ Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location i SOIL ABSORPTION SYSTEM i Width: Length Number of trenches i -_Distance-&-D r-estion--o--nearest ro l-i-ne: s Setback from: well: Housed 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: 1 LICENSE NUMBER: 7~--9 INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety ,d Buildir~s Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: PeEMMECer s N MIKE El City 11 Village f1 Town of: State Plan o.: R J Ste joseph - CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /00, O O A 9400392 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S ! t~--6-v Benchmark w~~S 4, Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet -y~ 9 g TANK TO P/ L WELL BLDG. Aier intake ROAD Dt Inlet Septic 7' < / q ' 70 ' NA Dt Bottom Dosing NA Header/Man. Aeration NA Dist. Pipe i Holding Bot. System q(, PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Shy q~ q7, Model Number GPM TDH Lift Friction System TDH Ft Head Forcemain Length Dia. Dist. To Well 71 SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /.4' 1 s ` / DIMENSIONS SYSTEM TO P/L BLDG WELL LA E/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O \ CHAMBER Model Number: System: /yS/ o?~D' Sa~`~ / y 2-(!-)ff5j( OR UNIT DISTRIBUTION SYSTEM Header/Manifold I Distribution Pipe(s) I x Hole Size I x Hole Spacing I Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only /9,j / ,c•:1. FLU Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center y Bed /Trench Edges 1 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) CATION: St. Joseph.20.30.19W, SW, SW, 41st Street /S mar SC_ f' -7 Plan revision required? ❑ Yes ❑ No / Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. SANITARY PERMIT APPLICATION vaiiR couNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PE MIT # -Attach complete plans (to the county copy only) for the system, on paper not less than a 1890:7 8% x 11 inches in size. ❑ Check if revision to pous 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 t/4 z t/4, T , N, R /91 E (or& PROPERTY OWNER'S AIL G ADDRESS LOT # BLOCK # S CITY T ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM N BER 7 4e 4./ r II. TYPE OF BUILDING: (Check one) ❑ State Owned O VI AGE ~ NEAREST RO St Est ❑ Public Q 1 or 2 Fam. Dwelling- # of bedrooms _S_ PAR EL TAX NUMBER(S) Ill. BUILDING USE: (If building type is public, check all that apply) p,y ~~Q y y0/Oa 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. X1 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 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 ./'nch) ELEVATION Feet Feet CAPACITY VII. TANK Site in allons Total # of Manufacturer's Name Prefab. site Steel Fiber- Plastic Exper. INFORMATION New xistin Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber L1 I [A F-1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installa ' n of the onsi sewage system shown on the attached plans. VPlumbe s Nam (Pri Plumbe s S' jare:_ s) MP/MPRSW No.: Business Phone Number: R Plufriber"i9f'Addr ess (Street, City, State, Zip Code): IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Age big a (No a a~ Approved ❑ owner Gi en Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPR VAL/REASONS FOR DI APPROVAL: 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 eixpiration 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, 60B-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal descriptioh 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 131/2 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 i 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) SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ADDRESS:/ yI ~ l1~~r LOCATION: 5~,=1/4 _,-1/41 SEC.__T N_R c W TOWN OF: ST.•CROIX COUNTY SUBDIVISION: a67 &T NO. 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 to help with the cost of the 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 the St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman. plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating 'cond'ition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification from will be sent approximately 30 days prior to three year expiration. 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 form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: J ► _~JA C I. DATE:_ Pay- Co 1993 St. Croix County Zoning office 911 4th St. . Hudson, WI 54016 492G 12 Each parcel shown on this map is subject to State, Town and County laws, rules and regulations (i.e., wetlands, minimum lot size, access to parcel, etc.) Before purchasing or developing any parcel contact the St. Croix County Zoning Office for advice. CER TIEIED ~ AP v++'i v+ e rl,+° t'• Located in the SW 1/4 of the SW 1/4 of 5ecti6n Z a►nd •~he NW 1 /4 of the NW 1/4 of Section 29, T30N, R 19W , Town of St. Joseph, St. Croix County, Wisconsin. Owned by: Harold & Marjorie Best NOTE: Lots 1 & 2 may be su, 1425 41st Street assessment should Houlton, Wi. 54082 S1/4 Cor. ever be paved. Sec. 20 FILED ' DEC 0819920- Bearings referenced to the South o 1 I S~CIVE " JAMES O'CONNELL i~ahe SW 1/4, assumed ° 6.35'SL Gr* Cq,W1 N88°36(07"W . ! Z S2019'32" W _ 54.07 ' ST. CfI *000 T1Qnplatted Lands_ t \ a t rnP I DETAIL- NOT J 0 ' 00 ' 34"E 579A3' ~I I I R.O.W. TO SCALE 566. 67' ~LINES ~ - - N 6.35' gaots LOT I 1 LEGEND 'Mrapp ~s 556,050 Sq Ft. 2 1 appmY SIMSbel (12.77 acres) I - Section corner monument Cult valid Net project area 0 6.58 acres 6 T • 1" iron pipe found QI p SES6PCK NV) P 0 7 "X24" iron pipe _JI 0 4b of LD 114 ~NO~'MpL/H N6° 0o'47"w \;11 I \ a o~ weighing 1.68 lbs. / lin NI ,L~ 0 147_1I~ V N. I N.~ ft'. set. aI O Kati 6 If) Fence _J 00 Z) r 9o2~ ? \ 3 LL r (0 ( 187.5) Previously recorded m s6 \\5.sl o~ I o \0 Ito 3 information p a1 oI of Q . tJ t I N QI _J 1. O 1 UJ n7 x O C\J al W N .0 O S490, V -m N 349 332.53' \ ZI''• ..Z~ Z <4 m I PREVIOUSLY RECORDED INFORMA- N ° ° _ S 1~'0 I ~ TION FOR CURVE NO. I = (Cyr) ` T 11 i.W 877 7~ RADIUS - 867.00' OD 4LS~ S ~1 1L CHORD- 202.84' Z N ` 14 _1 N 76° 20' 09 "E p8.11~T/€ 7~ 903.p`1OUT LOT I VOL. _75_4_ al n LOT 2 PG. 529 r~ 397,590 Sq. Ft. 01 (9, 13 acres). n p \ \ Ji Net project area= ,o~ \ \ V OI 6.09 acres I °.M \ \ >I W I/4 COR. 100' highway setback lines \ SEC. 20 \ \ 4, ~.'t N 00'31'58"W 534.86' N 03'30'22" \ E 667.50' WEST LINE OF THE SW 1/4 SW CQR. \ N00°31'58"W SEC. 10 MONUMENT WEST LINE OF THE IOW 1/4 2002.93' OF' SECTION 29. UNPLATTED LANDS SCALE IN FEET - 7 = 200 -NOTE: OUTLOT I CONTAINS r./Z4 177711117 155,747 S0. FT, 0' 50' iod 200' 400' 600' ( 3.576 AC.) 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This application form is to be completed in full and signed by the OW'I1er(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 JJ4,J ~2 Location of property-,SO 1/4Section*~ , TAN-R-Z2_W .Township ,-J - Nailing address loz Address of site -4,15 -W Subdivision name la , .1517V Lot no._ Other homes on property? veS--~,/ _,No, Previous owner of property Total size of parcel 7~ Date parcel was created / L2 ' Are all corners and lot lines identifiable? -___,Z~_yes No Is this property being developed for (spec house)? Yes X--No volume~J~,nd Page Number 7 as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIWiTY DEED which includes a DOCUMENT NURBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTr.It 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 Hap shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of ny (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 Ho. 'f-~/ , and that I (we) own the proposed site for the sewage disposal system orreI (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 county Register of deeds as Document No. signature o 'app1 cant.' Co-applicant l0 t~ r . Date of S g ature Date of 9 gnature • DOCUMENT No. STATE BAR OF WISCONSIN FORM 1--1962 Tans NAca wasaw4co Me; 012com'"O DATA r WARRANTY DEED 495504 VOL 994rwU557 This Deed made between drolCl. o.*---sgsjt --aA5i......... REGfSY R~S 0 ar7or. e..E.... est.~..husban- anj._V j.fel__ ST CM CO., Recd for Record r, and... .QtlEte .._FrxO3tlECif..,aL1f~..I~aIlr~..1~._. i►dC~fs ~.FEB 26 1993 3 t 00 ..husban.d..and.mif as..aurvivorship.mal;ital............. zo er.c IItdDifldl j Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... { ..o.f..oma..doll.ar..and..other ..walu abla-aons.i.de.ratio.n RKrUftHTO Conveys to Grantee the following described real estate in ...St_«._ Craix......... , County, State of Wiscona-a: is Tax Parcel No:..... Lot One (1) of Certified Survey Map in Vclume Nine (9) of Certified Survey Maps, page 2574, as document number 492612, filed in St. Croix County Register of Deeds Office on December 8, 1992, being located in the Southwest Quarter of the Southwest Quarter (SW 1/4 of SW 1/4) of Section Twenty (20) and the Northwest Quarter, 4 of the Northwest Quarter (NW 1/4 of NW 1/4) of Section Twenty Nine (29), Township Thirty (30) North, Range Nineteen (19) West,_ Town of St. Joseph, St. Croix County, Wisconsin -.1, AID This homestead property. (L) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And•..Barold..A._.]3eat.._aad.. Marjair--. E..-Best---•-•--------•--•---------------------------•-•--•-•-•---..-.---- 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 will warrant and defend the same. day of "w~cl_d~..•--•- 19.93.. ..............0` ' Dated this . = ~Q `•s.. .......................................(SEAL) ....(SEAL) • 1arold..O...Beat---- (SEAL) `L--- (SEAL) a ._Mar-jorie.._F---.Best AUTHENTICATION ACHNOWLBDGMBNT Signature(s) STATE OF WISCONSIN ,..a...,„„~ _ - ~ St. Croix a authenticated this ........day of 19 all y came before >~e. 4.. of iahied r K ~.i 3 t' tti~ee Harold O. Best anck...>o►' st., - - - - - TITLE: MEMBER STATE BAIL OF WISCONSIN (If not, f= $!T /;~4ftr`•.--._- anthorizcd by 1706-06. Wis. State.) to me known to be the person eebn-ei'ecated:the fop jitr:ument and owled It THIS INSTRUMENT WAS DRAFTED BY Robert F. Wall 1 bs 4- WALLr--f --KE- d,£R------------------•----------------------------- , vV 522 Second Street - Notary Public __......._at_.---CXQ!X----.-----County, Wis. n g My Commission 18 permanent. (If not, state expiration na res may au en sated or acknowledged. Both I ST ) are not necessary.) date: r 19_........ .Names of persons sianiaa in any capacity ebould be typed or printed below their slanaaturaL WARRANTY DEED BrATE BAR OF WISCONSIN. Wisconsin Loral Blank C0. Ine. PORK Nw 1-1982 Dlllwaukee. Wks. Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of ,Z Labor and.Human 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 # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT 1/4 1/4,S T N,R X(o& PRO ERTY OW ER':S MAI ING ADDRESS LOT f# BLOC J# SUBD. NAME R CSM # A.> 4 ,t may` / CI A ZIP CODE PHONE NUMBER CITY VIL GE ❑fOWN NEAREST ROAD New Construction Use [M Residential/ Number of bedrooms Addition to existing building [ ] Replacement [ ] Public or commercial describe Code derived daily flow. 1 gpd Recommended design loading rate ~7 ed, gpd/ft2__,L~trench, gpd/ft2 Absorption area required bed, ft23 trench, ft2 Maximum design loading rate rt~?bed, gpd/ft2^ .f%' trench, gpd/ft2 (as referred to site plan benchmark) Recommended infiltration surface elevation(s) ft Additional design / site considerations - _ G - Parent material' o fir- r 2 L, Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND 75?", OUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Ufor s stem ® S El U ® S El U ❑ U 0S ❑ U El S J U ❑ S R U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench -iiiiii ✓5 ~ Poc Ground - - elev. , ft. Depth to limiting factorZ Remarks: Boring # s~ q-) 7 42Z Ground elev. Depth to limiting factor Remarks: CST Name:-Please Print Phone: Address- Signature: Date: CST Number: PROPERTY OWNER 27`nAlffK SOIL DESCRIPTION REPORT Pagq,,,,? 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 Tech } ' Ground elev. s ft. Depth to limiting , factor Remarks: Boring # h+ Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) yf>T X r i f o~"~i9 'Ore / U S n r~ ~~✓J~ihC'.t/nta~~ /~R"Ci} 7Xd/^ /K~S''~ ~C3J ~q do, e PAc-c or F146%. All Wets AAA 0►6*1>r4114n Pipe . - ' MN•h1I Y.•1 Cy • YWw„n• /II4tfleco i . to• 4t• ~ti..• ms c•.1 W•Q '.;j. _wv~• INS 0~ >{t•~MIts C•min• OIN/1~•11~ • , five Too ► ' 2416 f1#6 • ~Hlw.l.• PIF• YNw op As • ••11•* 01 i/~l•• ti 9 r#% • ~ viii ~`,Q,i•~%~\Q so1L F1LL' 01"MIBU1101.1 PIIC APPRO`1r 0 S'IwpiCTIC COVC 2" OF ^66RCGAlK ~ MA7CR►^I. OR, 1' OF STRI. OK MARsl. N.hy ~I.EY, °l.OYYt~P-1 AG 6KCGHTC ~P ~k FEILT, 1%, OISTRIbuylow PIP( •VV DC AT 4fAtY 11JCHCS 5CLOW 01U61WA1. '~rwOE A1,1U AY LEhSr40It"N" GUY 140 MOKC THAW tit WCHES OCLOW FINAL. CiIAOC M1Ucv~►ur1 DEPTH OF E'ACAVATIpu Fi~oM OR16WAL 64ADF. WILL. 9C _'`L/_ tucHes tNNItAVM p£F711 OF EACAVATIoN FRor~ O~IGINgt_ GRAPE. WILL ec -~5-.~.. INGHCS LICCIJSC UUM5ER: -.ZZ IDATC: 0' 0 4 roll rd-3 4~0 • 0 ST. CROIX COUNTY WISCONSIN ZONING OFFICE I IN r u u ■ a. 00■.e ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 June 29, 1994 Temple Inland Mortgage 110 West Road Towson, Maryland 21204 ATTN: Kelly Hensen RE: Septic Inspection for Michael Emmeck Dear Ms. Hensen: An inspection of the septic system for Michael Emmeck's property was conducted on June 27, 1994. This property is located in the SW', of the SW'-, of Section 20, T30N-R19W, Town of St. Joseph, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions with regard to the above, please do not hesitate in contacting our office. Sincerely, M vy . Jenkins Y Assistant Zoning Administrator mz L9q&TJAVl;tarA Rto49§WH.20.30. Labor and Human Relations IVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ' (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 199932 Permit Holder's Name: ❑ City ❑ Village 91 Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9300 v TYPE MANUFACTURER CAPACITY STATION BS I FS V- Septic Benchmark Dosing Aeration Bldg. Se er Holding St/ Ht e AS, TANK SETBACK INFORMATION St/ At utlet TANK TO P/ L WELL B M4' Air Inta O D let Dt Bottom Septic N Dosing Healy / Man. Aeration NA ist Holding Bot System PUMP/ SIPHON INFORMATI6(`iilj ~U Inal Grade Manufacturer Dema Model Number PM TDH Lift Fri I System jTyQ, Ft Forcemain Length Dia. Fi Dis well SOIL ABSORPTION SY TEM BED/TRENCH Width Le No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manufacturer: SETBACK SYSTE O P/L BLDG WELL LAKE/STREAM INFORMATION Type O 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 ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH.20.30.19 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: DIL.HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE Sj1 PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% X 11 inches in size. Ch k if ev tapplication -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER ER PROPERTY LOCATION Y4 Y4, T' , N, R E (O PROPERTY OWN 'S AILING ADDRESS LOT # BLOCK # CITY, S AT ZIP CODE PHONE NUMBER SUBDIVISION AME OR CSM UMB ~ II. TYPE OF BUILDING: (Check one) ❑ State Owned VILTMLAGE NEAREST PP7 Laz~ ❑ Public [A1 or 2 Fam. Dwelling- # of bedrooms '3 PARCEL TAX E J 111. BUILDING USE: (If building type is public, check all that apply) p;~p /oy 76 /acs 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. R 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 ® 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 V1. 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 Feet qeelr~ 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 or Holdin Tank - A JZ, a d' Lift Pump Tank/Si hon Chamber F-1 F F-1 F] El El Vill. RESPONSIBILITY STATEMENT I, the unde igned, assume responsibility for installati of the onsite wage system shown on the attached plans. Plumber's me int • Plun'~s re• m MP/MPRSW No.: Business Phone Number: Plum ddress (Stre , City, State, Zip Co e): r 1 ti IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Si o Stamps) Surcharge Fee) w~L ❑ Approved ❑ Owner Given Initial 1 . 9~,3 Adverse De ermin tion X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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 t7e permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form ;SP!? 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properiy rnaintai red. The ,=-rtic tank(s) must be t s it ~>ci ' ~ :T licer•sed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your gnsite sewage system, contact your local code Adwlnistrator 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 ri,rnber(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 !--)welling. 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, oconnection, 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 mfornrration. Fill in the capac'lty of every new and/or exiting tank, list the tvlal ns "urriber of tanks and °ianufacturer's name. Indicate prefab or site constw uc'ted and tank mai~;ri<f). t :o±drlE w ar all septic, k:j f7 p/siphon and holding tanks fob this SystE!m. Check expe m: rrt:al ,:-pprova, ~`ranks received exper"sir,::=';J' product approval from DILHR. VIII. Resp nbibility statement. Installing niumher is to fill in name, h,:er se r umbel with. aopropri=•ie prefix (e.g. MP, etc.), a.ddress and phone number. Plumber must sign applica ion form IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specificatio . ,iof smaller than 8'/z x 11 inches, rn !~t be submit'wd r? 1k,,, rocnty. The I .an-, r.-iost i+sclude the following: ) ploi t,!an, drawl to scale or with dirr;E n: :wation of )Li'- tar- -,s), Septic tank (s) or tattier area tmgnt tanks, building wall'-, n~atg> service; stream.b ewd lake=s pump or siphon, tanks distribution boxes; soil systN Y - 6-01erit system arts J, n, ttao i~,catdon of the building ved; Bj horizontal and rlica, --I P% u,ir,,- ,.f,.~r.,r. „t C) cornpiete specifications tot pumps and controls; dose volume; e:evatiord d;f erenc~?s; f, dctis n loss, pump perforr ,ante curve; pump model and pump manufacturer; D) cross section of the soil ahsior-tion 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 surcharoes (seas) for a number of regulated practices which can affect groundwater. The ' i1 ,n,es Y-.._!: Cted throng ti" escJ sud chi g. . `e ;tC: r;9 f d F. dler nt wcar.r co."itanUndtion lnVes0gatii--s anti establista=, e ..l ;a t rl~ie-1 - SBD-6398 (R.11/88) r~ TA) i ile ~~f°Dio45ao N1 F_// 366' PAfi C or ,r 1F Q ` l ~rVS~ J~CC 1N11 0~ r1 ~r17 .7 S1c:M~ y • I••1A Air Imet• MN 06601wp•11 Pipe . i vool cap . iio• a:• ►1p 4• C••1 Ireq.',~'', 5 1• IW1 0•e•• veal ►V• ,1 I O.w Pipe ' Well 1•.1 • • T• hI• ~ 11 • • ' /•M•1~ ►1~e • ►N1N•1•• Pipe Yele• • "Ceyllw• • Twni/MN•1•M Wife 01 M . 99"! - GOIL rILL• M~T iouY101.1 PIPC ♦ R APPRO`Ig6 S•IM IET1C Cow "~"'/'1ATl:RI~t STRAM 2" of AcGRCCI►1E WFL OR 1" OF OR MARsi• N&I ELEY, OF FELT, •M Ores-t~~s A.GGRCGATE % 01WRIOUT10N PIPC To bC AT 4r6h 1►JCNCS BCt.OW ORiG'IIJAI, •t1►OC A1Jt1 AT. LCAiT&C 1:JCHCL OUT 140 MOIIC THAW 4% IuCHCS CCLOW /11JAL C1MOL PWIMUM DEPTH OF E%cjAVhT1oN FXoM OK16WAL 6AAK WILt. bE - 1WCHEs 1vHlmvm ©EFnt OF EACAVATlu tl~~r; .1f{~r,INg1. GRAPE wlt.t. Sc 0 wcHCa sic wc- 1 1 . •J . LIG CuSC UUM6CIt: DATE: 5 DEPARTMENT , OF REPORT ON SOIL BORINGS A (Q~ ® & BUILDINGS INDUSTRY, ~7 J ~'1 DIVISION BOX 7969 LABOR AND PERCOLATION TESTS (115) TF HUMAN RELATIONS M O N, WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: _r W_U O UNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: S /a oz0 /LAN/R / E COUNTY: OWNER'S BUYER'S NAME: MA IN A RESS: / Gro r,( i yldi C C a ~/e (/i c w /mot, e~ ot Lr/r USE DATES OBSERVATIONS MADE r~ fO y NO. BEDRMS : COMMERCIAL DESCRIPTION: PR I E PERCOLATION DESCRIPTIONS: TESTS: ~esidence ~lew ❑Reptace - -yam RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) 2 s DU s Du S DU DS [2v DS u If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: G1 Floodplain, indicate Floodplain elevation: D PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED ES GHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 3 I'- B- 13- Ll 177.9Z AlIc 47 - B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUM ER INAIIIIIIIIIIIII& AFTERSWELLING INTERVAL-MIN. P RI D 1 PERIOD2 PERIOD PER INCH P- J P- o~• o .2 7,4z '3 P- O 7 ~y 7 P-. P- P t PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION i 4N Ile' _ _ I f l_ . C i0h stn ofl / o lope_ e g e c e soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrativ n (t h recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): v TESTS WERE COMPLETED ON: 69- ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SI ATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - '7 DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY S_ / k1 STATE SVITrA~ PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than °i ).1C,4 8% X 11 indhes in size. ❑ Ch- 9tro'evious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER L APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER W ER PROPERTY LOCATION '/a '/a,S T? ,N,R E(O ~Sjj PPRdPgRT'Y OWN jFR'S MAILING ADDRESS LOT # BLOCK # _ CITY, ISAT ZIP CODE PHONE NUMBER SUBDIVISION AME OR CSM NUMBE r; NEAREST R AD II. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLLLAGE Ax NUMBER(5) ❑ Public ~ 1 or 2 Fam. Dwelling-~# of bedrooms AR EL N =4i;4 III. BUILDING USE: (If building type is public, check all that apply) C ?O 16 773 /a0 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. R New 2.E] 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 M Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 El 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.) PROPOSED5 q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet ` Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New istin Gallons Tanks concrete structed glass App. Tanks Tanks Se tic Tank or.Holdin Tank q Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the under igned, assume responsibility for installati of the onsite sewage system shown on the attached plans. Plumber's Me( int); , Plumber's S n re:.(N~o'Stamps) MP/MPRSW No.: Business Phone Number: PI m e ' ddress (stre , City, State, Zip 7Coe): J X T IX. COUNTY/DEPA TMENT USE ONLY ❑ Dis Owapproved Sanitary Permit Fee (Includes Groundwater [ate ssue suing Agent Signat o mps) Surcharge Fee) ❑ Approved ❑ ner Given Initial - j ✓ - Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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 ganitary 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 can system type. VI. Absorption system information. Provide all informat on 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. Comp ete 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 3% x 11 inches must be submitted to th, county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, ')cation of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mainsi4vater service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replak.ament system areas; and the location of the building served; B) horizontal and vertical elevation reference joints; C) complete specifications for pumps and controls; close volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. - - - - - - - - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a numhz)r 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 i I- I i 4 i -Tel 0 a~ _ ~,~°.Tic--~✓~=-.~~~CS _ /DOD~rt-!. - _ - - - - y l + . t i--= - - -'A - - i fi 33, 36 ~ tN'n, STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION / CSM# LOT SECTION. T N-R W, Town of ST_ CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 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 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 /,3 C_~ C~s~ DEPARTMENT OF REPORT ON SOIL BORINGS A O ply & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) .O. BOX 7969 HUMAN RELATIONS / ON, WI 53707 (H63:090) & Chapter 146.045) LOCATION: SECTION: C MEP LOT NO.: BLK. NO.: SUBDIVISION NA ME: E r~ COUNTY: OWNER' BUY S NAM MA aINU A R SS: / (Gror,( i ~ ec' ~3y /e i-r-, o4- //0, GC/r USE DATES OBSERVATIONS MADE x•05( NO. B DR MS.: COMMERCIAL DESCRIPTION: TR-OF1 LE UESCAIPTIONS:PERCOLATION TESTS: 83esidence Xlew ❑Replace, - -yam RATING: Sa Site suitable for system U- Site unsuitable for system CONVENTI NAL: MOUND: IN-GROUND U : S M•IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ZS❑U S❑U S❑U CJSCS1I DS U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: D PROFILE DESCRIPTIONS BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED E HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) o- G , ~ - 26K B - f2al 3 13- B- J PERCOLATION TESTS TEST EPTH , WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUM ER I*t&M6- AFTERSWELLING INTERVAL-MIN. p I PERIOD2 PERIOD PER INCH P- 3 0 3 Y14 S .1.3 J11K P- o?. Q 3 P-. P PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all' borings and the direction and percent of land slope. SYSTEM ELEVATION G a E i '01! .y _......F.._.... ' - e • g e c e soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrativ n ~t h recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): ~r - TESTS WERE COMPLETED ON: &2f ADDRESS: CERTIFICATION UMBER: PHONE NUMBER (optional): /Y► -C e- t r ew 9447-10, / S~ 7G~ CST SI ATURE: 1100, DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - CHECK LIST FOR PERMITS Owner or Builder Pero Test or Soil Profile .Blueprint of House 4( ,XWarranty Deed With seal;doooument nu;volume & page nu. X Tax Nu. of Land 0 3© /o Ya a %,bm ACertified Survey Map if Available County Forms * STC 100 *`STC 105 * Filled outd signed Name *-address *,*phone nu. * If not on Pero test PLUMBER All of above forms PLB 67 Plot; Plan Cross 9eotion Cheek for Permits