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HomeMy WebLinkAbout040-1217-40-000 a ° kl, c o~ y M p: o a ~ r. c > N co L O N •O• h it E 3 I LL Q (D 3 c 3 co r 0~ cc L O N U > O O > p O c zm FaC 7 (6 N V LL C Q m O m 3 ~ a O N Q ca 3 M 3 aD r Z N m W O U) O L E a z co w a M r F- U) c 0 O z d c O O V d Z c fA F- r' m N z I c E '2 M _0 N N C3) 0 j Vl ~ pJ N C • ~l a U) c N 0 N V O m Q z co z o 0 z N Q U) > N Its N (V 0 (D IMF L CL LL y y C d L > O _ O _ V L G G a a 'C N 0 o E ~ U) U) (n U.) 1- H H O _333 ° LL 0 a z •N~ 3aa ►~i a c g o ~ N 7 O N O N J V M m z ~V 2 o o "o co E Y O O LL (D S~ a U) N d Q} 1 Q yy 7 w C O N ul C .wd O 0 c c E f0 CD - :3 + O CL CL c o III L K E E N N n N - V) LO H q L L CO 06 C~ • o N ` I C co ~ I- F s =3 c ca m E E C.) • y' O O F- O N O U} E L d d . -~t C. Ly • c~ a a, .2 N CL C r1~1 E i c c = A U a 2 O U) U ST. CROIX COUNTY `J WISCONSIN ZONING OFFICE N N N N N r r ,1 CRC}'X ST;/CROIX COUNTY GOVERNMENT CENTER COUNTY ZON!NGOFRCE 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Please specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure that entry can be gained. 0 Water (VOC's) $185.00 0 Septic $50.00 0 Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria In Water (Lead Concentration) 21.00 retest $15.00 Owner: i n Requested by:~.~s~~va Sirs ~/y~d/ GlA/crt Address: Address: ZIP afs ZIP4,~Iva~ Telephone W: ( ) _38ti, ,Pppg Telephone : Property address (Fire W & Street) : •?7 0 jr Location: Sec. , T N, R W, Town of Realty firm: Lock Box Combo: Closing Date: OVO - 1217 -'VO - od o ?619. TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS e ~ressw~-~_ Water sample tap location: ek Is the dwelling currently occupied.. ❑ Yes a No If vacant, date last occupied: Q Age of septic system:_ 41 P,S y , Septic tank last pumped by: Date: ~e-/ 1~f Previous Owner's Name(s): Have any of the following been observed? ❑Y ON Slow drainage from house. ❑Y fflN Sewage Back-up into dwelling. ❑Y 9N Sewage discharge to ground surface or road ditch. ❑Y AN Foul odors. Other comments relative to system operation: I certify that the above information is co plete and true to the best of my knowledge. OWNERS SIGNATU (:LATE: 1/94 f f t' t OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? ❑Yes ❑No Soil series per SCS Soil Survey: sheet # Type of soil absorption system: OBelow grd OAt-Grd OMound Approx. size 'X OGravity ❑Dose OPressurized Ft.2 OBed ❑Trench ODry Well ❑Holding Tank 00utfall pipe OBSERVED DEFICIENCIES OOther ❑Unknown Septic tank Setbacks: OHouse OWell ❑Prop. line 00ther Dose tank Setbacks: ❑House OWe11 ❑Prop. line 00ther OLocking cover OWarning label ❑Pump/Floats OAlarm ❑Elec. wiring Soil Absorption System Setbacks: ❑House ❑Well ❑Prop. line ❑Other OPonding: ❑Discharge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title r ST. CROIX COUNTY WISCONSIN ZONING OFFICE l o n g N n ow ST. CROIX COUNTY GOVERNMENT CENTER '""e` 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 September 24, 1998 Westconsin Credit Union Attn: Greg Kaiser 1207 N. Main River Falls, WI 54022 RE: Water Test Results for Sharon Dunn located at 427 So. Fork Drive, Town of Troy, St. Croix County, Wisconsin Dear Mr. Kaiser: Enclosed are the original water test results from Commercial Testing Laboratory for a water sample that was taken at the above referenced property. If you have any questions regarding this, please call our office at (715) 386-4680. F ely, slinger Assistant Zoning Administrator cc: Sharon Dunn Enclosure COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121 800-962-5227 FAX - 715-962-4030 ST. CROIX COUNTY ZONING OFFICE REPORT NO.: 73151/01 PAGE 7 ST-CROIX CTY GOV.CTR REPORT DATE: 9/23/98 1101 CARMICNAEL F%%D DATE fF.MIVED: 9/22/98 HUDSON. YI 54016 ATTN2 JIM THOMPSON OWER: Sharon Dunn LOCATION: 427 S. Fork Drive, Hudsor COLLECTOR: Rod Edinger DATE COLLECTED: 9-21-46 TIME COLLECTED: 10:30ae SOURCE OF SAMPLES Pressure tank tag DATE ANALYZEDI9-:2-98 TIME: ANALYZED: 2:00ps COLIFOM,WCC1 0 /100 ml INTERPRETATIONS Bacteriologically SAFE NITRATE-NI 5.5 ppe Above 10 ppe exceeds the recoeae-nded Public Drinking slater Standard. Colifors Bacteria/100 nl Nitrate-Nitrogen, mg/L LAB TECHNICIAN: Paso Sane YI Approved Lab No, 19 RESULTS: _ FAX'D ON: CALL: P: _ < Means "LESS THAN" Detectable Level. Approved by' FAX ST_ CROIX COUNTY ZONING OFFICE 1101 Carmichael Road Hudson, M 54016 (715) 386-4680 DATE: cl. A 4- qg TO: Fax Number: ` A 5 , FS q - Name: G~ FROM: Fax Number: 386-4686 Name: Number of Pages Including Cover Sheet: IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE CONTACT: NAME: TELEPHONE NUMBER: J COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 stj 715-962-3121 800-962-5227 FAX - 715-962-4030 ST. CROIX COUNTY ZONING OFFICE REPORT NO.1 73151/01 PAGE 1 ST.CROIX CTY am.CTR REPORT DATE: q/23/98 1141 CARMICHAEL ROAD DATE RECEIVED' 9/22/98 HUDSON. WI 54016 ATTNI JIM THOMfSON OWNER: Sharon Bunn LOCATION: 427 S. Fork Drive. Hudson I COLLECTOR: Rod Eslinger DATE COLLECTED: 9-21-98 TIME COLLECTED: 10:30am SOURCE OF SAMPLE: Pressure tank tap DATE ANALYZED:9-22-98 TIME ANALYZED: 2:00pm COLIFORM,MFCCI 0 /100 mt INTERPRETATION: Bacteriologically SAFE NITRATE-N: 5.5 ppm Above 10 ppm exceeds the recommended Public Drinking Water standard. l II Conform Bacteria/100 ml Nitrate-Nitrogen, mg/L LAB TECHNICIAN: Pam Gane WI Approved Lab No. 19 RESLILTS. FAX'G CALLF"s: Means ''LESS THAN'' Detectable Level Approved by* i 4 f II STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER fLic.T~t%hK. ADDRESS ~/Z 7 S ~Dr~C ~r. SUBDIVISION / CSM# LOT # SECTION 7 TAN-R~W, Town of J ,?0 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM tY w< < /w Na INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. I BENCHMARK: ALTERNATE BM: /y~. //•~ic SEPTIC TANK / PUMP CHAMBER / BOLDING TANK INFORMATION Manufacturer: Z~i,,ers Liquid Capacity: oeo Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM I Width: L Length Number of trenches Z Distance & Direction to nearest prop. line: 7 ~o Setback from: well: House Other ELEVATIONS Building Sewer 103. d / ST Inlet; ST outlet PC inlet PC bottom Pump Off Header/Manifold / 0P, 3~ Bottom of system CB ✓'"r Existing Grade /'o ~(r z Final grade / f3,,l DATE OF INSTALLATION: ZT AI PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: ----~7 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Hpman Relations INSPECTION REPORT ST. CROIX SafRty and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Pel,(p~tli,Qlder~aame~N M • ❑ City ❑ Village Town of: State Plan ID No.: UUiUJ1NVINV t HHAAIIZZ CST BM Elev.: Insp. BM Elev.: BM Description: 1 Parcel Tax No.: /&%d - c5g) 4) , , Id a,,, Q. X ~ TANK INFORMATION ELEVATION DATA ~0_ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 'geT Septic /77- n~ JJ Benchmark U/ 4 Dosing -2 7F' Aeration Bldg. Sewer G Holding St/ Inlet /3~ X03. a TANK SETBACK INFORMATION St /Jf outlet 635 TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Ar I Septic NA Dt Bottom Dosing NA Headers 7' ~Gl?, 7 r Aeration NA Dist. Pipe Holding Bot. System .2~ PUMP/ SIPHON INFORMATION Final Grade Manu Demand Ta zd 03,77' Model Number PM TDH Lift Fri DH Ft Forcemain Length Dia. I Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width : / Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~a Q DIMENSIONS--------- SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING nufacturer. SETBACK INFORMATION Type 0 /J~- dnr 1 11 CHAM Model Num System: & 41o 3 O IT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) ~ ~ x Hole Size x Hole n To Air Intake / Length ~ i Dia. Length 5 7 Dia. `f Spacing ~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade is Only Depth Over I Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Center 3 - ~ Bed/Trg~i-Edges _ 7- fo Topsoil Yes E] No E] Yes ❑ No - i_~ COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Troy.7.28.19W, SE SE, Lot 9,,Count Road F uqo Plan revision required? ❑ Yes Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. =SANITARY PERMIT APPLICATION V'~Lr■■7 In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than # 8% x 11 inches in size. check i revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - P ASE PRINT ALL INFORMATION. PRO TY OWNER PROPERTY LOCATION 0491-al ;R 9 4 f %4 fOE '/4, S 7 T , N, R E (o W PR PERTY OWNER'S MAILING ADPIESS LOT # BLOCK # V1 7 /V k- Py, 1' 1) -C CI STATE ZIP CODE PHONE NUMBER SUBDIVISIONblAME RCS N E~ ey o~2 1 ( - 5,' Y' r L_J II. TYPE OF BUILDING: Check one) CITY NEAREST ROAD ( State Owned yILLAGE : C ❑ Public 01 or 2 Fam. Dwelling f# of bedro, 4O oms ~ PARCEL WN TAX O NUMBER( Ill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 [A 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: /b 3• 1. GALLONS PER DAY 12. 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 7 0 > }O Feet Feet VII. TANK CAPACITY Site in allons Total IN of Prefab. Fiber- Exper. INFORMATION New P-Xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holding Tank D 0 G✓ Lift Pump Tank/Si hon Chamber El El I L] Ll I El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewag s stem shown on the attached plans. PI b is Name (Print): Plumb 's Signature: (N s MP/MPRSW No.: Business Phone Number: I 's Address (St et, ity, Cod IX. CO NTY/DEPA TM NT USE ONL A❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Ag t Signa s Surcharge Fee) Approved ❑ Owner Given Initial E/y Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3: All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if "required by the county; E) soil test data on a 115 form; and F) all sizing information. - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) SANITARY PERMIT APPLICATION COUNQJ ■n In accord with ILHR 83.05, Wis. Adm. Code 11 Sv( S STATES I %M T #-Attach complete plans (to the county copy only) for the system, on paper not less than 41TA 8% x 11 inches in size. ❑ Check if revision to previous application -See.reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER OWNER PROPERTY LOCATION 141f it AfAA '/4, S T L~, N, R E (or P OPERTY OWN R'S MAILING AD S LOT # BLOCK # CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER E3 CITY 11. TYPE OF BUILDING: (Check One) El State Owned ❑ VILLAGE NEAREST ROAD 0 TOWN ❑ Public 01 or 2 Fam. Dwelling- # of bedrooms- PA CELTAX NUMBER( 111. BUILDING USE: (If building type is public, check all that apply) 0 l 1-(7 "~~Q 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. Z New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ,p t ELEVATION d ~ 7Lo , D i Feet Feet VII. TANK CAPACITY Site in al Ions Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank ^ _alne 4-L n F] f- 76 1 F-1 El El n I n Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewa system shown on the attached plans. Plu is Name (Print): Plumber's Signature: (No She) Io4P/MPRSW No.: Business Phone Number: ME Address (Street, ity e, Zip 3o o r !tAc D1-3 IX. COUNTY/DE ART ENT USE ONLY ❑ Disapproved Sanit Permit Fee (includes Groundwater Date Issued Is uing Agent Sign ure (No Stamps) `UT Surcharge Fee) Approved ❑ Owner Given Initial //ux Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(8.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber T 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. - 0nsite sewage systems must be properly'rtiaintairie`d. The septic tank(s) must be pumped by a licensiid pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your focal 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 histalled. 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 tine 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. Vill. 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 lest 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) a s C s s' e I S a e y ~ x r DAVE FOGERTY PLUMBING Licensed Perk Tester & Plumber #3233 #13289 Fogerty Heights Road R08ERTS, WISCONSIN 54023 Phone 749-3656 . 3~ 49 V TEVY ) 6 3I I Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of 5 Labor wOHuman Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but J CRO I ~I not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY S~ LOCATION 4S~ 1/4,S7T Z'.$ , N,R E (or) W SN,q t2o f4 1 o/V4 GOVT. PROPERTY OWN R':S MAILING ADDRESS L(~ # BLOCK # SUP. NAME OR CSM # 4s 35 - No*,-rw '1 ~aUTN Vbf,l< CITY, STATE / ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAP EST ROAD Aj DSa h/ ~(J New Construction Use [k] Residential / Number of bedrooms [ ] Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate gibed, gpd/ft2 d',6trench, gpd/ft2 Absorption area required bed, 112 trench, ft2 Maximum design loading rate 61-2 bed, gpd/ft2 D trench, gpd/ft2 Recommended infiltration surface elevation(s) r.>j~! PA-W 3 4V- 3 ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S =Suitable for system NVENTIONAL M UND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING T K U= Unsuitable fors stem IS ❑ U ®S ❑ U ES ❑ U ® S ❑ U '~l S ❑ U ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trend 0.30 /by / L / bK r C Z r►t~r C 2. s4 10-Y4 L / th -..z 15 4~ Ground -tZ /p 4 75 elev. /4SiDsfL Depth to limiting factor > /D:i-7 Remarks: Boring # Q_31 6Y I SDK M C 1 8 t•61 avl~e4 3 ~ r nil QbK m~ G all &U 16'Y4414 to -1 s r round elev. /D A ft. Depth to limiting factor > /D.~ Remarks: CST Name:-Please Print r f~ Phone: gl. O-b Address: Signature: W Date: G p~ CST Number- 804 D (A PROPWYOWNER 54,AOZP4 ~UNN SOIL DESCRIPTION REPORT Page G of ~ .PARCEL I.D. # Lo'f 9 50,~+1~o~RtL Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G-ym r Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bedre A 10-7-Z /m/9311 al , ~Z47 10 4 3 sbK MFY. Ground elev. /c1•3gft Depth to limiting factor ? Remarks: Boring # 5 L r ' C $ 0-5 /6W 4 3 5 .0. M r m 1 C Ground elev. g Z -15 6` A k14 5 Al r 1 IQ.17 ft. Depth to limiting factor 12.7 Remarks: Boring # A 1~ /DY~ 2 t "SIC. 1 C~' C S 1 7, 416 /d 4 3 - S, L / 4bK ry,~r C / Ground S r 1 elev. 4/4 111 A ft. Depth to limiting factor > l0' ~3 Remarks: Boring # Ground elev. ft Depth to limiting factor Remarks: SBD-8330(R.05l92) PA 4r dg 3 c-4 ARC 0, Cb 1 eU cr 1 ~ o J 4 d QZ cr T 4. ' d 4 a[ u 2 t3? Q Z UNPLA I I LU LA14UJ vV1lIVGU 0 1 v a • NORTH LINE OF THE SE 1/4 OF THE SEI/4 OF SECTION 7 S89021'15"E 770.46 9.98' 166.03' 354.45' I 33'' 33' w O 21W in 0 ti wp 7 N of N a N 80,328 S0. FT. N SO. FT. ACRES N 1.84 ACRES / I N 89o15' S6" W 19015'56"W 354.46 950.00' \ °D CD r ING IOR FILLING r in .LEVATION OF 866 N N TEMPORARY CUL-DE-SAC TO BE °D OD REMOVED )R T HE CONSTRUCTION UPON ROAD EXTENSION TED ON LOTS 6 AND 7; (SEE DETAIL FOR PLACEMENT) ih VAYJS. I 9 1 F' ~ cu r- w N 87,382 S0. FT. N of w 2.01 ACRES r` I F- S 89° 15' S6" E ZO N I I N 354.46' N c 1 O N 6 1 W °3 w N N HI 6= M ~ ~n 412 SO. FT. Oi 3 ACRES O O I 0 I 00 Q } 1 O 0- w_ m i Z `n 10 t0 W 0 I tD t0 of z a 87,382 SO. FT, a = WI I 2.01 ACRES ~ Z I w ~ i ° o Ol U_ I w rn l •J N 89 ° 15' S6 "W N O i ~ ZI D 354.46' w J t i a ~ ~ 01 350 : 00 in w U. V89°1556" W = wl to UJI " I 3 ' I O J QI N01600 51 W © O J, 47.93' 87, 135 SO. FT. 2.00 ACRES OD O a Zi i N W D i S89°1556"E M 25.40 . E'04 W 0' ~ 3e 3656"N, 9.gs { S T C - 105 r , SEPTIC TANK MAINTENANCE AGREEMENT ' St. Croix County OWN ER/R- .ADDRESS lip Y47 .Si►f`-ol~ ! r FIRE NUMBER JV f ->-7 CITY/STATE zip PROPERTY LOCATION:L4_1/4,.CIE 1/4, SECTION?T:~ N-R /9 W 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. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of, a failing system, which was in operation prior to July 1, 1978. St. Croix County 'accepted this program in August of .1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning Officer wi n 30 days of the three year expiration date. SIGNED: i ' DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 :r. I I'Y. S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), thenia second form should be retained and completed when the property' is sold and submitted to this office with the appropriate deed recording. r Owner of property Location of-property-,EC-1/4 5jP- , Section Township /Zo L/ Mailing address iff :L.5-Z Address of site jffqj S ° G Subdivision name Lot no. Other homes"on property? yes&,-~No Previous owner of property cad Total size of parcel ~•f Date parcel-was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec. house)? Yes No Volume and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the ffice of the County Register of Deeds as Document No. ,!r 3 and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in he office of County Register of deeds as Document No. gnature of appl cant Co-applicant Date of S/Ignature Date of Signature . DOCUMENT NO WARRANTY DEED THIS SIAI:E RESERYEO FOR RECORDING DAFA STATE BAR OF WISCONSIN FORM 2-1982 ' 51s534 'OUPAGE341 rZGjt4ER ' IS0FFJCE r ST. CROIX CO,, W1 I, ZAPPA.,BROTHERS,.. INC,, a. Wisconstn..COrpo>~atiop,.... _ . . llhddtbrT~`aoor~ a/k/.a..Zappa..Brothers- Excavating,. Inc.,.-Grantor " APR 18 1994 P: . 1:10 . . conveys and warrants to SRARON.M,.-DUNN, ...a, Grante.e Ar~psOerlp/p G. . F . PETURP4 TO . . the following described real estate in ._.St.,,•Cro- x_.....• .............County, State of Wisconsin: Tax Parcel No: I~ Lot 9, South Fork Addition in the Town of Troy, St. Croix County, Wisconsin. k R • y ELF l r TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and rights-of-way of record, if any. ,I This is not homestead property. (is) (is not) i t Exception to warranties: I i April 14th .94. Dated this _ _ . . . . . day of ZAPPA OTHERS,,,INC I~ . ..(SEAL) (SEAL) j: BY.'... _ary.. T.c-..... ppg . . (SEAL) .(SEAL) Y I AUTHENTICATION ACKNOWLEDGMENT II ~'y • Signature(s) Gary-.T....ZapFa STATE OF WISCONSIN sa. St Croix County. ................day of i I 4t h A it 4th I~ lg9•..4__ Personally came before me this 1 !i oath ated this . 1C y o Aptil 19-9.4 the above named I.. ....Lundeen GarY..T~..ZaPPa................................. . Ba.....rre . . C........ee II TITLE: MEMBER STATE BAR OF Vi, ISCONSIN `V.., (If not . authorized by ¢ 706.06, Wis. Stata.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY I r At torney__Barry_•C.__Lundeen DGE, PORTER & LUNDEEN, S.C. S Second Street Hudson Wisconsin t Croix I 1.-Q......_ s...........r Notary Public St.........-................. County, Wis. My Commission is permanent. If not, state expiration I (Signatures may be authenticated or acknowledged. Both ) are not necessary.) date: . 19......... Wanes of persona siEnina in any capacity should be typed or printed below their siznat:res. Wisconsin Legal Blank Co.. Inc. WARRANTT DEED STATE BAR OF WISCONSIN FORM No. E- 1992 Milwaukee. Wisconsin i