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HomeMy WebLinkAbout038-1119-10-000 ~ 1 4 p N 00• N 00 o> a aD N N O O N N x C 04 O Y I I 1 w C U O y O Y N y 4N, >N N y c Z ? C Z LL C m ( {L O 0 C O 0 O E 3 vco Q N Q > y ~ z ~ I z E ° = o 0 r,w am IL m N H Z o I I O Z c c w 4) z _q N f- C O ( O C Tl (D C E 9 Z E 01 d 5 m 9 C m N m O 06 N 1 y a m a Q z'oz z°mz z N a d c N m E 1 i4 E E 1 m_ m Y L_ y Y ICI IA d 4) C O N 2 1~ (D C .0 c is o a c m o o a o 3~ O O n.O z l 03 a 03030 0 'N Eaaa ILaaa L B w M fA J V N F F } N 00) z IZa~ tm , N aO 0 > N - O Q O _ Q O _ N N ( _ Q. ~ - N y 0 7 0) N O m Q m o a) 1 01 at Q U) N O) •O a1 Q Z UJ O p 7 as p O H C N C 0) p O E _O Q o Y_ U N N 0 a p x V C CL Y C -O 8 N O G r Cv "4: N E 01 co C C C y t~ \v, O •f6 C C o o C d f0 0 N C L "f r 'D 0 0 N ~ Z N C d H C c M az d m E v I~1 7 Cl) a) m co o E m m m o o o Q O N fn j= O Z fn 2 0 z F- Z _ € m € m V ~ «at a I da ~a CL a,adam rw - c d C d C _1 A ciao USS0 'o 0 l0U)0 . Parcel 038-1119-10-000 01/29/2007 04:59 PM PAGE 70F1 Alt. Parcel 29.31.18.491A 038 - TOWN OF STAR PRAIRIE Current I X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-owner 0 - HARTMAN, REBECCA A REBECCA A HARTMAN 940 192ND AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 93RD ST SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 15.000 Plat: N/A-NOT AVAILABLE SEC 29 T31 N R18W PT NE SW THE E 15 ACRES Block/Condo Bldg: OF THE NE SW 940 192ND AVE-NR Tract(s): (Sec-Twn-Rng 401/4 1601/4) 29-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 02/12/2002 670876 1834/234 QC 07/23/1997 995/134 WD 07/23/1997 890/301 07/23/1997 872/363 2006 SUMMARY Bill Fair Market Value: Assessed with: 175700 414,300 Valuations: Last Changed: 10/15/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 32,000 301,700 333,700 NO UNDEVELOPED G5 13.000 32,500 0 32,500 NO Totals for 2006: General Property 15.000 64,500 301,700 366,200 Woodland 0.000 0 0 Totals for 2005: General Property 15.000 64,500 301,700 366,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 133 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION / CSM#LOT # AJI SECTION,z:22_T--S'Z_N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i Lam' AuS a' DS`ivew~~ 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: Li uid capacity: ISr- `7"f / -Ij ` Setback from: We11,,2,)' 8R, House_-,2"La2 - 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 /Sr- 98 / / ~i-_ 977s Building Sewer ST Inlet 971s- 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 LQQAWs l;.rt$ ilrRxtArie.29.3 ~ TE ~ONAS~iE S~1'S IVI Avenue County: Safety and Human Relations INSPECTION REPORT • afety$n,~i Buildings Division i (ATTACH TO PERMIT) sanitary emit o.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan D o.: Lqtar Prairie Mffev.. Insp. BM Elev.: BM Description: ~C Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9400031 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic - Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet gfDz 3,Ig 7- TANK SETBACK INFORMATION St/ Ht Outlet 2-93 117, 3 s'a e 97.6 TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I Septic }/bDl 72 y lS 7 NA Dt Bottom Dosing NA Header/ Man. y~ ' Aeration NA Dist. Pipe 3 q4 '7 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand l,9 4g"~ Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ?-1 7 DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER , Model Number: System: 73612 7 a7 3S C[J! OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Tc i Dial ' Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Lj Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center c t Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Star Prairie.29.31.18W, ,NE, SW, 192nd Avenue .c~.- goo qz _ a4. Plan revision required? ❑ Yes ❑ No trr Use other side for additional information. 1-7 ' I ( J1 'Yl SBD-6710 (R 05/91) Date Inspector's Signature Cert No. I a-7 SANITARY PERMIT APPLICATION • DIL.HR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SA 11 PE MIT # NITAR -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ( C)99 8% X 11 inches in 31ze. Check if revision to pre ious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INF RMATION - PLEASE PRINT ALL INFORMATION. PROPE OWNER PR PERTY LOCATION % Y S , N, R ' (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION AME OR CSM NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned VILLAGE' ,vb QF~ ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms PA L NUMBEK(b (x -?S) III. BUILDING USE: (If building type is public, check all that apply) 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 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. ❑ Replacement 3.E1 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 ❑ 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 1 --0-7 V, JZ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min inch) ELEVATION Feet Feet CAPACITY VII. TANK in allons Total # of Prefab. Site Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank Azr „S Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for install ion of the onsite sewage system shown on the attached plans. Plumbers Nan)p (PPlum is g tur • r,(Np ps) MP/MPRSW No.: Business Phone Number: _49A 1 o -1. I mb ''a Address (Street, City, Sliate, Zip C 1910,;rll Y~Wl JL) Z IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sa tary Permit Fee (includes Groundwater ate Issued issuing A nt Sig ture (No m W proved F-1 Owner Given Initial /Q/~ Surctiar9e Fee) UC/ A v r e 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 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 hssuin9 authort y 4. Changes in ownership or plumber requires a Sani!ary Permit Transfer/Renewal Co`r^-i (SBD 6399) to be submitted. to the county prior to installation. 5. Onsite sew t, systerris must be-propev=y rnaintaired. The i e tank(s) n t be pure iced -~i i -keensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code acirni-)istrator-or-the State of Wisconsin, Safety & Buildings Division, 609-266-3815. 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 #r of bedrooms if 1 or 2 Family i'.1welling. 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, fist the total gallons, ?lumber 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 13% X 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; close volume; elevation differences friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. - - - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number or` regulated practi ;es which can effect groundwater. r a_ rt< TI ,e ; onies coli.scted through these surcharges are used for monitoring groundwater, water contamination nvestigations- and establishment of standards. SBD-6398 (R.11/88) SEPTIC TANK MAINTENANCE AGREEIENT w St. ` Croix County OWNER/BUYER rt w 0 ROUTE/tOX NUMBER' Fire Number :I CITY/STATE~Se/ d e,-l ar ZIP PROPERTY LOCATION: '.'N(~', w Section, T_3/ N, R_/rW, Town of St. Croix County, Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure.to'handle wastes.- Prover maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a 1•icbn•s•ed' 's'e' t'ip, .tank pumper.. What you put into the system can a ect the, unct on o the septic.tank as a treat- ment • s tage in the waste di-spos al sys ter . " St. Croix County residents'•maj•be eligible to recieve a grant for a maximum of 60% of the-cost-of replacement of a failing system, wh ch 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 's'ys't'ems agree to keep their system properly maintained. The property owner agrees to. submit to St.. Croix County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or..a licensed pumper veri- fying that-(1) the on-site wastewater disposal-system is in proper operating condition and .(2).after inspection and pumping (if nec- essary), the septic-.tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year'expiration. H I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with N the standards set forth, herein, as..set by the Wisconsin Depart- a' ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Of ice it n 30 days of the three year expiration.date. SIGNED DATE St. Croix.County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. APPLICATIONFOR SANITARY PERMIT 8TC-100 This application form Is to be completed in full and signed by the owner(s) of the property being developed.- Any lnadaquaclea will,only result In delays of the pitmlt Issuance. -Should this development be intended for resale by owner/contractor,(spac 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." .Ovn e r of property Location of property ww 1/4 _ G,-,J 1/4, Section Z `r T_~/ N-R l~ y Township Kallln address f7 O• ~2 yr zs T Gu S` z l l{ Address of Ito lubdivlsion name r - Lot number Previous owner of property 5~~~%'~ Sys/~ G~,CC~,•~~/~ Total size of parcel 35-Date parcel was created Are all corners and lot lines identifiable? as No is this property being developed for resale (spec house)? 7as _Na Yoluree and Page Number /-3 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWINCr A wARRANTY DYED which Includes a DOCUMENT HUMBER, VOLUME AND PADS: )(UMBtR, and the ORAL OF THE Rg018TBR Of DFtEDS. In addition, a certlfled survey, if avallable, would be helpful so as to avoid delays of the reviewing process. IL the deed description references to a Ceitlfled Survey Hap, the Certified survey Hap shall also be required. PROPERTY OWNER CERTIFICATION - I(Ye) certify that all statements on this form are true to the best of my (out) knovledgel 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.QS't 1 and that I (v•) presently own the proposed site for the new wa-ga "disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of meld ny em, and the same has been duly recorded In the Office of the Coy t l e [ eds, as Document No. signature f Owner Signature of eo-owner (If Applicable) Date of nl9nature Date of Signature DOCUMENT NO'- WARRANTY DEED TNIS NAG= RES cRV[D ,OR RLGOROIN6 CATA STATE BAR OF WISCONSIN FORM 2-IM 495594 VOL 9 i REGIS ' y Recd far Record ~ Gerald W. Germain and Susan L Germain,-.---._..., Gerald - husband and Wife .MAR 2 1993 ' - et 8:30 A. . conveys and warrants w MiChaEl_ J ..Hartman_d/b~a___ - Hartman--.9~1$tUIC.~ S2I1 dDftdB 3r - - - . RETURN TO the following described real estate in St-...Croix---------------- County, State of Wisconsin: Tax Parcel No: r W 1/2 of MNW " /4 of'SE 1/4 EXCEPT the East 33 feet thereof and the East 15 acrea.o~ NE-.1/4 of SW 1/4, all in Section 29, Township 31 North, Range 18 hest, St. Croix County, Wisconsin. y . tg :A x - ' - This f S not.-r-.. homestead property: (is) (is not) Exception to warranties: easements, restrictions and rights-of-way of f record, if any. . 1a.g3_. Dated this day of Igiareh-----•--- / (SEAL) • A (SEAL) (.tJ(d~t• - u - Gerald W. Germailt Susan L. Germain (SEAL) • •--_..._(SEAL) i. - , . AUTHBNTICATION ACHNOWL211310KIINT Signature(s) --....deer-aid-_Id.._-GCrmain-r------ STATE OF WISCONSIN Susan L. Germain a& County. authenticated ~-day of----- MarCh__------ 19-__93 Personally came before we this ----------------day of , 19_..-__. the above named u~'~ z`--~ - %X~sgt 13 _.QS1 1~ TITLE: MEMBER STATE BAR OF WISCONSIN - (I, Dark authorized by 1706.08. Wis. Ststs.) to me known to be the person who executed the foregoing instrument and acknowledge the same. ~.r TNist INSTRUMENT WAS DRAFTED BY - Rristina Ogland AttiYrn wy__-gt--L7aW------------------------.-- Notary Public County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration 19._.-.--••) am not necessary.) date- aNams of persona ilaaima is am eSWItr should be typed or printed blow their siffnatares. Wisconsin Legal Blank Co.. Inc. Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _L of & Labor an&I'luman Relations DivAlon of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPEBT,Y OWNER: PROPERTY LOCATION A~~'Z p GOVT. LOT 1/4 1/4,S T N,R i(or)f) PR RTY OWNER':S MAILIN ADDRESS LOT LO K# SUBD. N 7E OR CSM # CITY, STATE ZIP CODE PHONE NUMBER CITY ❑VIL E 14TOWNI NEAREST ROAD [ 4 New Construction Use pQ Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 1 ,66 gpd Recommended design loading rate 7 bed, gpd/ft2__'~trench, gpd/ft2 Absorption area required Ash bed, ft2 6 tren h, ft2 Maximum design loading rate bed, gpd/ft2,i,~? -trench, gpd/ft2 Recommended infiltration surface elevation(s) It (as referred to site plan enchmark) Additional design / site considerations _ Parent material !Z- zig Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem [OS ❑ U 0S ❑ U 1Z S ❑ U _1 S ❑ U ❑ S ®U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bois Roots GPD/ft in. Munsell Qu. Sz. Co t. Color Gr. Sz. Sh. Bed Trench A 21211a awl Ground LT 7_1_ elev. ft. _ Depth to limiting factor > 9,fq Remarks: Boring # dl ~ l Ground elev. ft. Depth to limiting factor >'9z Remarks: CST Name:-Please Print Phone: Address: Signature: ' Date: CST Number: 3 PROPERTY OWNER owv~j SOIL DESCRIPTION REPORT Page~of PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Bou'ldary Roots GPD/ft Boring # Horizon in. Munsell Ou. Sz. nt Color Gr. Sz. Sh. Bed Trendl Ground - elev. Depth to limiting factor Remarks: Boring # ti4 %?•::•:~tip Al 1,4 S Ground elev. - ft. Depth to limiting factor Remarks: Boring # A 14 Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) X ~OG•f /o.J o7 s." f~ l apn~~ -oo a Y~~ ys A01 t /~78 :1 PAfi t ' Crvs ~.c~lol,..ot a ~tIT•:-,, yl'e i/~}A, Mr InI~Ot, M►1! o►a/~~uoe pip (fall 4#949 i0• Ci• i N• III 40 Cool 1#04 i;•11.. 1t IMN'OI•~• YON else two oil lug O.w ►Ve (y• T•1 ` ►••••1~ /I~• • Iwlw•1•d III• YNw • C•yOs1 Twwlu0I141 AI ~ bll•~ 0/ i/Na1 ®I3TKIBUTI01.1 PIPE APPRO`/CG S•INr{[TIC COVC 2" ~16GRKGAlF. OR V OF STRAM OR MARsI• r!Ay ELEV, oF~fEC7. '`"•°P~~-t'~t ~.GGRCGgTC i ..•ti~ .fF1. OISTRIOUTION PIPe.TV BC AT 4CN'.r IWCHC3 BCLOW OROVIWAI. •;,t/,pC ~►Ut, AT. LCASTiO IWCHCL OUT MO MORC THAW 42, IuCliti tfCLOW PIWAL GItl10C I'W'MU'i DIPKI1,0F EXCAVAT100 FROM OKIWAL 6RAD9 WIL1. 9E ru K1+1Vlh pEP T11 Of EACav _ I W c H C s F ATION fRoA Q~'411JAL CjR49f. Wit.%. 6C =,?A'~ INCHCS • tic I•' \ tT 7 ~.19T~ 6'h, ,2-A.-, ~ ~ ~ /~?QSILtl ~o - f ~B 75~ 00 3G' sy' Qt r z,(~~~ I~ }2IE 29.31 V,~MEWAGE SYSTEM County: Labor and Human n Relations INSPECTION REPORT Si+fety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 199905 Permit Holder's Name: ❑ City ❑ Village IR Town of: State Plan ID No.: Parcel Tax No.: T BM E ev.: Insp. BM Elev.: BM Description: 1 038-1119- 0-000 TANK INFORMATION ELEVATION DATA A9300303 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent irIto ntake ROAD Dt Inl TANK TO P/ L WELL BLDG. A Septic NA Dt ttom Dosing NA eader/Man. Aeration NA Dist. P/pe Holding . System PUMP/ SIPHON INFORMATION ina► Grade Manufacturer D man Model Number P TDH Lift Friction System TDF4, t , oss mead Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PI No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN N SYSTEM TO P/ L BLDG WELL E / STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O 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: STAR PRARIE 29.31.18.491A Plan revision required? ❑ Yes ❑ No 71 F Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY F STAT NI RY ERMIT# In T40 -Attach complete plans (to the county copy only) for the system, on paper not less than El h 8% x 11 inches in size. if evi o us application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER WNER PROPERTY LOCATION '/a )'/4, S j , No R E (Or PROP RTY OWNER'S MAILING ADDRESS LOT # BLOCK `t CITY, STATE ME OR CSM NUMBER ZIP CODE PHONE NUMBER SUBDIV ION NA ]ZI CITY AREST ROAD I1. TYPE OF BUILDING: (Check one ❑ State Owned VILLAGE ~ b ❑ Public [0 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NU BER ) 111. BUILDING USE: (If building type is public, check all that apply) 63 1 ❑ Apt/Condo 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ud r Rec al Facility 3 E] Campground 7 ❑ Merchandise: Sales/Repairs 11 stau nt/B fining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ rvice Stati Car Wash 5 ❑ Hotel/Motel 90 Office/Factory 13 Rother: Speci IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applic ble) Z A) 1. ® New 2. ❑ Replacement 3.E1 Replacement o 4.E] Reconn n of 5. Repair of an System System Tank Only Existing em Existing System B) ❑ A Sanitary Permit was previously issued. Permit - D e Issue V. TYPE OF SYSTEM: (Check only one) Other Non-Pressurized Distribution Pressurized Distr ution ~xperimee Holding Tank 11 ® Seepage Bed 21 ❑ Mound 30 ❑ Sp e i 12 ❑ Seepage Trench 22 ❑ In-Ground ❑ Pit Privy 13 ❑ Seepage Pit Pressure ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: / ERC. ATE 6. STEM ELEV. 7. FINAL GRADE 5. P 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. tRATE REQUIRED (sq. ft.) PROPOSED (sqttsq. ft.) ~n ) ELEVATION / Feet Feet VII. TANK CAPACITY Si e in allons Total # of efab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks M u turer's Name irncre tC Steel glass Plastic App Tanks Tanks s uc d Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installat' n of the onsite sewage tem show on t attached plans. Plumb s Narpe (Print): Plumber's nat e: ~S ps M No.: Business Phone Number: 1 mbe ' Address (Street, City, State, Zip Code f IX. COUNTY/DEPARTMENT USE ONLY ] Disapproved Sanitary Permit Fee (in ludesg roue water ate Issued Issuing A gna mps) F-1 Approved ❑ Owner Given Initial r/ Adverse Det rmination 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 erxpiration 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 Trarsfer/Renewal Forrr? (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, 60-3-266-3815. 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 nurnber(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. Vt. 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) DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code v NEW STAT Ni RY ERMIT# -Attach complete plans (to the county copy only) for the system, on paper not less than , l / / 8% x 11 inches in size. ❑ ,check irrevi I t6 ous 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 1/4, /a J S_ T N,R E or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK,# 2~'l f-4 CITY, STATE 1 ZIP CODE PHONE NUMBER SUBDI%ASION NAME OR CSM NUMBER 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned ❑ VILLAGE: ❑ Public ,911 or 2 Fam. Dwelling-#of bedrooms PAR EL AX NU BER / III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo f 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 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. ❑ Replacement 3. ❑ Replacement of 4.0 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 1~17.1 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION f ~ Feet Feet VII. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks oncrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank - - Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 'a Na a (Print): Plumber's nat re: (No Stamps) MP/MPRSW No.: Business Phone Number: umberis Address (Street, City, State, Zip Code): 1 ),Z X IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signatu Stamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination J 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 rf 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 try 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'h 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) $ 1 715 240 7079 RE/MAX P01 II)u}{IMLNt - REPORT ON SOIL BORINGS AND SAFETY & k1UILUINCN INuUSTRY,• DIVISION HUMAN RELATIONS I AND PERCOLATION TESTS (115) MAOtSON,OWl 53907 (ILHR 83.08(1) & Chapter 145) T C:nT10N' - SEC`fi~N: TOWNSHIP QCLI Y LOT N~ : BLK Nf1.r SUBDIVISION NAME: ' NE ~ 5W 1 29 /T31 N/111}{(or) W Star Frarie _ 1I1a n/an/a COUNTY, -vw U ER'S NAME: MAIL: W5 DR St. Croix Jerry Germain Church Hill Rte., Somerset, Wi.'54025 _ tfsr " DATES OBSERVATIONS MADE NO. BEDRMS pR.iA . DESCRI N ' 6NS: P"ER•`'aCAT 1Z5NT~STS: OReplace -28-90 k4ltestdence - - 3 LL-11N&w D 711 n/a RATING: b■ Sltt suitable for system u- _ Bite unsultabla for system 'Or----~ a A ~,i • M S' ~ IN O,_, ~ ~ L hip tNCi TANK; F'+E(:UMMENDEO SYSTEM.(pptionel? ' - u P ~S ~ Eany Par,a>I ;ttiun atu are NOT IGN 0188$ RATE: pil tlGrt of thu ttt5tutl 6rCa I! In the uur s ILHA 83.08491tb)_Ind1 lain, indicate Floodplain elevation: n/a mac' 1 I PROFILE DESCRIPTIONS l _ as 19IIn bjOHIN(,i TUIIA UND A E • N H ER n IL WITH HICKN StS, COLOR, Tr=xr~iRE, AND~~DEf'TH Nl)WER DEPTH ELEVATION b V A 'T TO B FICK IF OBSERVED (SEE ABBRV. ON BACK-1 1-1 -7.00 102,19 none )7.00 .75bl.1. .75bn.sil. .75bn.1.s.&gr. 4.75b11.c.s.&gr.' B. 2 7.33 102.00 Wane X7,33 .75bl.l. 1.58bn.r;i1. .50bn.1.s.&ge. 4.50bn.c:.s. y g:-•3 - -6.53 101.89 none >6,83 .58bl.1. .75bii..l.s.&gr. 5.50bn.c-8.&grr. B. 6.83 101.35 none >6.83 .58bl.1. .75bn.I.s.&gr. 5.50bn.c.s.&grr` p. 5 7.16 101.05 none >7.16 .50b1.1. .83bn.l.s. 5.83bn.c.a.&gr. ~ R- PERCOLATION TESTS , LEVEL-INCHES tAF MINUTES NuMBEN IN(.Hir$ AFTERSWELLINC3 INTERVAL.-MIN. P ~.L~r P R INCH P P r,. Be desi . L r.4te - 'L U t PLAN: Show lQ%mions of pa(tolatiort Iaata, Fail kaurings and this dlmentlc-nil of sultabfs soil afoas, indicts seals er tlistafluits. buscrlbs what ere the hors. 'Jntal and vurtical uiuvwtion reference pOlnti and trhovy their location on the pl.rt plan. Show Lisa surfactt elavatlOn $t bil borings and the direction and portent A land slope SYSTEM ELEVATION 98.39 U_ r I } ,8 .t t i f j I U4 1? NO %3 1 T N f N ` r ' t Oil# the underrignad, hereby certify that the soil taut sported on this form were mare by tns in accord 'With ifie proi:ediares end math©ai specified in this Wises>nsin tiinllliliU'tltiVH COde• And that the tfetw mr.ordart and the location of the tests are eorr,,ct to the bait of my knowlodyo anti balit+r. TIM WERE 0 LETED ON: (;try L. Steel ~UUR SS. 1I--Lti-90 C IMATION Nl1MRFR: ?HONE NUMBIR(riptinnal). 1554 200th. Ave. , New Richwndt Wl.. 54017 2298 117 4 -6200 CST SIC A Tp7~ # o , 9 <o (/ZO - /0 - ISTniBUTION: Or ipi r„I and ono copy to LOCdt Autnarity, Property Owner and Soil l'urter, 14-IIH-SEtI.•5395 (F9, 10/83! - OVER L .I PAO t 0 / i ~ Ir C.roS S~..c~~v~~ o(r' ` '00e Wets A0 96611VSU$a rite aw"w v1#4 got flail . • , MWw11u Yt;A~vv i'• , • To tow 6469 ploo • w ~M INr Or ir•rMrk Ca••Mr O.w No Otrau-,- 41, Siegel$ 11Nrv~•1• i ~•NH~ INv • • ~.rlw•r.• ~1►• YNw ' • ....~~r•1 Trwln•~Mt AI • ivu•* 01 i~~l••r . • 013TKIBUTIOI.1 PI/C • APPRO`"EO S'l1ipwrIC COVC 2~O~AG6 9 EGATE ^ ~'I~ATElZI^I OR OF $TKAM OR MARs~• NAy pOPYi.tr/i AGGRCGATC 'i ELEVI oF~FEf6Y_,..., •w~~.r~~. • • 1 I .i' OISTRIgUTIUU pirc TO bC AT 4Cht r IWCHCs 5CL0W ORIVI WAS. •;-AhoC AUV AT ~CA>iT LO 1A9CHLL OUT 1.10 MOKC THAN 42 IuCHCS OLLOW r11JA1. GrkAOC • 1 1 1 M~xtrwrl DIPT•H,OF EXCAVATIOP FXoH OK16WAL 69AD0 WILL. BE 11JCHEs 1'UKIMVM ©IT" "IF EXC vATI0IJ Fl~ol~ ~.I`I►JA1. G~RADr< wlL.~ eC INCHC s IGLIC®" , Dot'; wr • i `i i , ))1 • DqTC:.- 1n~ • • 1 1 )X 9 6?~n S%zE~ ,62kz;? ~uss 4 i ~uSs 5 G I I i i sue. ~b.~a<.c