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HomeMy WebLinkAbout040-1217-80-000 Z t , STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS 7 l 1 ()ukt f1 ~Uk r,t SUBDIVISION / CSM JiSl~~r1 t <?k F LOT SECTION . l TAN-R 1 W, Town o f ST. CROIX COUNTY, WISCONSIN P IEW SHOW EVERYTHING WITHI 00 FEET OF SYSTEM 3 BcDRao r ~ a8' as o~ aC, ly°, - at f~,o - Sep 6v, _ i ~.1 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. s BENCHMARK' J ~RUIv ~~~Q. ALTERNATE BM: SEPTIC TANK HO TION Manufacturer: W,;7 e,S Liquid Capacity: Setback from: Well _ House L) 0 Other PUMP ---XM=fZ=tU-r6r S iM7U- .F1Akit-seperatiori"- A SOIL ABSORPTION SYSTEM F Width: Length -')(a Number of trenches ~ y Distance & Direction to nearest prop. line: ~p Setback from: well: House `00 Other r~ 8U ELEVATIONS Cc~ve ENO Building Sewer ST Inlet; ! ~~1 f ST outlet PC inlet- PC bottom Pump Off Header/Manifold Bottom of system 7.00 Existing Grade_ Final grade 11 DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: y 3 I O / INSPECTOR: 3/93:jt ~rR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code U STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~to 8% x 11 inches in size. (hec if revision previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION C, T-)p,N,R 9 E(or)W d 20 I Swy-5 Y.,S 7 PROPERTY OWNER' MAILING DD ESS a LOT # BLOCK # C IZ R f~ A CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~N sc 5 0 'l " 38 -0~ A~ EJ f CITY NEAREST OIAD II. TYPE OF BUILDING: Check one ) ❑ State Owned ❑ VILLAGE Sv in h b fL O 3 j5i TOWN OF: ❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(SI/ III. BUILDING USE: (If building type is public, check all that apply) 1 14 0 ;Z 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 100 Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.~ New 2. ❑ Replacement 3. ❑ Replacement of 4.E] Reconnection of 5. ❑ Repair of an II~~ II System -System Tank Only I a Existing System E listing System B) ,Y~I A Sanitary Permit was previously issued. Permit # ~~1 o Date Issued /a g V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 19 Seepage Bed 21 ❑ Mound 300 Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 420 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 _ RE UIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) QQ,'ELEVATION ~Q 13 Cq, a .2 -7 (97-0 0 Feet 1• U Feet CAPACITY VII. TANK Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concre a Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank IU u u I Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: . M BU rne~ 3 yU y IS 3~ W O Plumber's Address (Str et, City, State, Zip Cod -y 8 h ) e, h2jsb).4 S . 1) ~ w)Io",4 W t s, c> ~ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Age t P~1 Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber S 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. 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. 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. I 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) P 1-11) C LOT B. .6 7 RO SS..~ I.. _ P I--, 0j ~'.._.13 L. I N A M E A M L O GAT I - 0 N IC E N S E L 0 4} S , l.u~ Cpnn~ o K 0 0, Sept i.c t Sy14r►~ ; No~c Wpl l JS rAIZ I-4m, t l.A;v o 4 ; r ~ U t Faun, , - } • ; i rr'►~it i av ~pRpv1~ d5 + T11 S - - 4,i 4 ) r t FRESH All' INLETS AND ODSERVA7100 PI.VE CROSS SECTION npprove(I Vent Cap Minimum 12" Above 4 " Cast Iron Above Pipe Vei)i Pipe To Final Gradc- Marsh Hay Or ~Synthetic Coveri ny Min. 2" AUgr.crjI I I Over Pipe ~~r•~~ Distribut•i-> I Tee j Pipe ~3?-U Aggregate v I'civ oratod Pipe Delo 1 t)eneath Pipe --.Coupling Terminating r Bottom. of System.. ~-r Wisconsin D9partment of Industry, SOIL AND SITE EVALUATION REPORT Page I of Alr_ rd.'a6r ai I Human Relations Division, of Safety 8 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 Cho '1 r( not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION I KS GOVT. LOT SF 1/4 S,E 1/4,S7 T Z$ N,R E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # i3 S4tst- l-/ Fro CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST R AD J New Construction Use (xJ Residential / Number of bedrooms (J Addition to existing building j J Replacement ( J Public or commercial describe Code derived daily flow gpd . Recommended design loading rate 3,7 bed, gpd/ft2 6_'FS trench, gpd/ft2 Absorption area required 3 bed, ft2 X5(,3 trench, ft2 Maximum design loading rate n.-7 bed, gpd/ft2 6.$ trench, gpd/ft2 Recommended infiltration surface elevation(s)q't 6o A4.& ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL M UND IN-GROUND PRESSURE MS GRADE SYSTEM IN FILL HOLDING K U= Unsuitable fors stem ZS ❑ U S ❑ U S❑ U ❑ U 0S ❑ U El S ~J U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Botr>c~y Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trertdi s 13-33~ / 0 3 4 Ground elev. C6 .1-7 ft. Depth to limiting factor Remarks: Boring # }4 `vv}•M1': i?''•: i:: i'.i tii Ground 17-120 16Y -sJ M S M I g elev. qL'y' ft. Depth to limiting factor > 10.00 Remarks: CST Name: Please Print Phone: N ~ION~.fsarl Z ~-qo ~ Address: /6 &SQ Signature: Date: CST Number~44,4 PRO_PERTYOWKER 3,4AI . ~IE~KS SOIL DESCRIPTION REPORT Page G ofd PARCEL+I.D,.`# L r.3 'S -7 -n- 9 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends - !Z, Uy~23 ! b rrr C Z 0. O 3/4- s~ d 0.4 a., Ground 1-/Ad S q- /yj S 7 .8 elev. ga.-.3 ft. Depth to limiting factor > !1. C7 Remarks: Boring # ~ O 65~ )nil 3-3o a 3 _ 5L ~r 0A o.5 Ground -1~ lOYa2 4 M I 8 elev. 07 ft. Depth to limiting factor Remarks: Boring # "h 193 4 /yiS 1 ,7 4.~ Ground elev. cl . 44 ft. Depth to limiting factor >17-0 6 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PRQPEF;TYOWNER 34AIC j IEPIKS SOIL DESCRIPTION REPORT Page -3 ofA- PARCEL I.C. # L~ 13 SOUY u F0 Q.K Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourbay Roots GPD/ft in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trends A -16 7.S 2~ L 1 sb~ m ,r Z Ground $~Z 7 / y Z S, f! Stir, m-r G t,J elev. Oxi4Lh -1/9 li)yk44 5 r fD? 8 0.8 Depth to limiting factor > 4.~3 Remarks: Boring # r f~ 0-"Z4 7.SYe 6 L I ih1 r S Z n, th stir n, S 1 24- 3t 7. Sne C, Ground O'r'~23 ~ SC. n•► r C w 1 elev. t $3 -12~ ~i►2 4 ~ ~ S r n, l I ~ ~ FS Depth to limiting factor > ILL Remarks: Boring # A -a -7.sy -Z6 _ L 1 sbK r -rr C S 2 nh El . - 7 16Y k 4 3 SS► i s bt MfY C s 1 Ground -49 OY S r /h elev. 0Y 4 Q s r /h1 ,7 p.$ i6ft. Depth to limiting factor I&E Remarks: Boring # Ground elev. ft Depth to limiting factor Remarks: SBD-8330(8.05/92) V PA4c ov 4 zo ,4N1 tC * L i3 S 2$--19 ~ 10 N pp / ~ N 'Qv x~ N lwv M ~ r- ~ I _ Ira 1 ~ i MIS 1i ~ ~ o 0 N Cf; q ~ - v T~EGDMt.~ EJU ~J~ SyST~/.~ ~e..t~U ATIO+J ~ ~ Q ~DR IVgw T-IZi1h~1LV N~ '97.60 121 m N ^N IREVIS&& >O/z6/94 - ©L& PRim4p,) SYsrcm 140T Us£& &G OS,r $A & SWL - W45 mat L44 I L L- EXCAVA-s1 ~ 1q=O-2 Sys-) EM Dr4 Ew A P, cA $ F, wc&& j D~~~nIZS 6- 7- \O` SANITARY PERMIT APPLICATION 0I COUNTY L■7IIR In accord with ILHR 83.05, Wis. Adm. Gode S STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ' X 11 Inches in 312e. ❑ Check if revision to previous application 8/z -See reverse side for-instructions for completing this Application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION = PLEASE PRINT ALL INFORMATION. PROPERTY LOCATION PROPERTY OWNER !-art PlZ S S 7 T-) O, N, R 9 E (or) W 4CA2ol ti c, PROPER TY OW ER' ILIN DD~iESS BLOCK # if OU ~Vrzt'~ ~~f)1+ LOT# 13 IP COD ~IME I rW_ PINE C17fiST S E Ij~IS ZS v© 10 ( 1.5NU3 V boo V~ SUBDIVISION U L& II. TYPE OF BUILDING: (Check one CITY NE ) A ST ❑ State Owned VILLAGE K() 0L& Cr h Furt K KO .4 1 ❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - PARCEL TAX NUMBER(S III. BUILDING USE: (If building type is public, check all that apply) O ` ItVl ` /l 1, 7 $ U 1 ❑ Apt/Condo V y ! ~4 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. ❑ Replacement of 4.E1 Reconnection of 5. ❑ Repair of an System System Tank Only 73? Existing System Isting System B) -M A Sanitary Permit was previously issued. Permit # 18 Date Issued 7/143 17 y V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 [9 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 420 Pit Privy 13 ❑ Seepage Pit Pressure 430 Vault Privy 14 ❑ System-ln-Fill YI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE RE UI (sq. ft.) PRgPO ED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 7.00 ELEVATION Iq 5U ~3 \p v Feet 1 r.30 Feet VII. TANK CAPACITY Site INFORMATION in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New xisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank U u p Q f7 1-1 1 F] Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's ignature: No Sta _ MP/MPRSW No.: Business Phone Number: I i& ft ji~~ f Y o v _T1 M V W4_ (71S) Plu bar's Address (Str et, Ci ,State, Zip Cod f f f CJ g s L ?fie S4N S- 1^lU h f ~ti W 1 I S Y C~ 1 L IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Aggn a Surcharge Fee). e ❑ Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To Safety & Buildings Division, Owner, Plumber « r r , : x •`.,i • {.1 iR ~i # 4«i~;:R«i«i1«4 i. i. IL S . s.f ketra-:«Y «a«t tr.~. .#«s «a'a~~n~ s a w a . -e r s s a r--. r~ r♦ 4 a. i x a a r. .,..aria. a. a qa A 6 9 4 b ~ 4 } S 1. 1 > i ► i ''F i S # i 3. i / ~4a°arf r4• + x. + a a • as 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. 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. 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) _ P. Q.L. 6 7 P OTA H 1) 0 S,~ r) r' ET-r N A M /~C"'( C~2 o "-ct N AM E L 0 GA 10 ~ ._~_._Srzu.t~ I C E N S 0 -I-M A P r B r,l' ,Tr Qr. P I I G i c> I ;,)p p I _p Wells r.,►~, . 14 fort- f-J- Sept' I.c ~ Sy f~e~ ~ No~c WPI I i S rA"? L~ ILA' 0 L5 r r ~~GU rJ i' W .F~trstt n1l;ira%[ is nrlU OBSeriVA71O!I*'tlI.t,c CROSS S~;CTION Approved Vent: Cap Minimum 12" Above I r' 3l~ ' n cl G _ rr r\ w )Above Pipe \ 4 " Cast Iron To Final Graclc- VU-11l Pipe . i. Harsh Ilily Or Synthetic Covcri 11(j Min. 2" Acjcjr.c~j,,il ~ f Over Pipe Dis tribu tio`~ E ~'ee pipe I Aggrge athePat Vux,Foratad Pipe tlclo , ~7U 1)cnc ipe \ --Ccur)•ing Terminating r TIol• tom. of System. Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Laboranq Hurran Relations INSPECTION REPORT ST. CROIX .Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION PQDm1ihWk r, ' MIE/CAROLYN ❑ City E] Village L7 Town of: State Plan o.: CST BM Elev.: Insp. BM Elev.: M Description: X Parcel Tax No.: B - A9400224 TANK INFORMATION ELEVATION DATA 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 Inlet TANKTO P/L WELL BLDG. A Air Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Head Forcemain Length JDia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Mode 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: Troy.7.28.19W, SW, SE, Lot 13, South Fork Drive Plan revision required? ❑ Yes ❑ No Use other side for additional information. I ITI ij SBD-6710(R 05/91) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY r 51`► CKoi k STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ) q- 2A 8% x 11 inches in size. ❑ Check if rev sioA to p4vious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP T QWNER R PROPERTY LOCATION P KKS SW %4S F. %4, S TZ$ , N, R E (or) W PRQQ R] Y OWNEOR MAILINQAKD SS K1 p LOT # 15 13 BLOCK # ^ CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION N ME OR CSM N BER ~woSoN ~ iS 3 v FoR II. TYPE OF BUILDING: (Check one) El State Owned VILLAGE: NE 4 O~D OIC Rlve CINJOW OF: ❑ Public 91 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX NUMBER III. BUILDING USE: (If building type is public, check all that apply) L ` 14 / _ 90 1 ❑ Apt/Condo 7`- 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 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPPEOF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. RNew 2. ❑ Replacement 3.E1 Replacement of 4-E] Reconnection of S. 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 RE UIRED (sq. ft.) PROP ED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 1~ ELEVATION .7 r",-0 Feet .crO Feet VII. TANK CAPACITY Site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concr a structed glass App. Tanks Tanks Septic Tank or Holding Tank 6U 0 Lift Pump Tank/Si hon:Cha ber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Nam (Print): P er's Signs e: (No Stamps) MP/MPRSW No.: Business Phone Number: ~IM oV,r,, r 3,,,- VY 36 40)U Plum be 's Address (Street, ity, te, Zip Code). / 1 0 8 M) e, J)A1)bll,~ '511- A) -P s 0ti IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Ag t 5i ature Sta Approved ❑ Owner Given Initial ~~pyc / Surcharge Fee) 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) Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor ahd Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ST COO 1 x( Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION f KS GOVT. LOT SE 1/4 S 1/4,S 7T Z$ N,R /9 E (or) W PROPMJ OWr~ ILINVDD SS LOT # BLOCK # SUBD. NAME OR CSM # Jo Yore ®fzl p !3 55c 14poky, C Wp TATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST R AD:' „ s oN E sc s vi b (719) 384 v~ a , (j New Construction Use P4 Residential / Number of bedrooms [ J Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate gibed, gpd/ft2 6.3 trench, gpd/ft2 Absorption area required M 3 bed, ft2 '563 trench, ft2 Maximum design loading rate -6,-? bed, gpd/ft2 61 trench, gpd/ft2 Recommended infiltration surface elevation(s)B,~Ec~j qZ,6 d4& It (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S =Suitable for system ONVENTIONAL M UND IN-GROUND PRESSURE EGRADE Y TEM IN FILL HOLDING K U= Unsuitable fors stem S0 U tips ❑ U VS ❑ U E GRADE ❑ U IkD S❑ U E] S 1 i 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 Tmrich .5 /o ! m sbK sir C Z 6.4 6 $ 13-33 /0 3 4 SL r. , in ~'T 0A o,S Ground I6 :5~4 Ms wt I 0•~ 6X elev. 45.17 ft. Depth to limiting factor >9z~ Remarks: Boring # slo ~~sr C Z p, 16-sr O > C Z 6,4 F7`1 MINQu i Ground 16Y4 M S M , O~ 0 elev. 9LAL ft. Depth to limiting factor >16,06 Remarks: CST Name: Please Print ~ / ~ ON ijSo N Phone: h/ J 140 ,96 Address: U &So Signature: Date: CST Number'~4g4 iz i~ 9Z GROPER-70W//NER ~~lYti~c IE2KS SOIL DESCRIPTION REPORT Page Z of 3 PAKEL1A#L~f.3'S -7 - Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 3 - z oy~U ! - M b ~r e O . .S 2_ 0. Ground k&-/A6 S /17S elev. qq.V ft. Depth to limiting factor Remarks: Boring # -i3' ioy~e3 L sb Mir O. a.S' p 3 SL 0.4 0.5 Ground elev. 0-1 ft. Depth to limiting factor wha• Remarks: Boring # io 3 1 L 1 ~K n,~r, c 2 0,4 o.s i >•\4 - 14+ A /AS Ground elev. O E44 ft. Depth to limiting factor ~lz.oa Remarks: Boring # tY L:} #YM1:.`•~?:: Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) P"L 3 ov 3 JQMrc 1~~~21~s 4 Li3 5~•~--/9 " 4 N op q0 d N ~ ( 1 ~ ( I i 5tV h~ I ~ I ~ I 1 ~ 1 ME] ~o ~ a a 4 ~ ~ ( Qa I r I ~ ~ I w 1 ~ 7 4 1 m l1 N 1 A,\ _ P. 67 PLOT • - - ~M..l L I 71, N A M E Arn~~ -1v I C E N S E'/' O C Ali 0 Ni o ~~I~-.2, Ili . w . _ -w ....ter....`......... ~ _ h 0 I ~16Q; -r- a° - - - 8 A ifieRr~R~P p 3o' lood ~P : . 3 Be r(,- pct _ ~ • ' ~~r,Coy►~~R . w " ,y FRESH All' IULETS AND ODSERVNMir'Yip C1103S SECTION _ Approved Vent Cap Minimum 12" Above Fi na_1__S_raSler.-_• I I ~ l •I 4" Cast Iron Above Pipe~J Vent Pipe To Final Gradr- Marsh Hay Or ~Synthetic Covering Min. 2" Aggrco i I Over Pipe Tee `I Dis tribu tioi~ E- Pipe `t\ Aggregate rei:f.arated Pipe Below "citcncath Pipe --coupling Terminal:ing' i Rot• t-om. o f Sys tem..: • • w• • •«ulr • wII •.I • •.•1• we w1 •••1w• 1 Lj • ,fl•1ff1 I; t,OV •IVt if 1 TV = I : 1 ; . is u••n Ir/.r 1• Lr .••1« ` Z; 1 1• } . nr r ~ i ~ I ° F y• •r1 M•fn ail N s i •y~N1 • ~ ~ i. • . «,/1.11« • • •N~••• • ~ ~••..•fi ~N a West mums 1 ~ „ r ° F• FA I x ;p ~ ~ Q ; ~ ~ i s i ~I a~ .1• :1• ~ it ~ • • + 1' j;+• go-w -Off id IM Ii iS:1.+d PAM 41114W.t • I ;$J ~ •1'•~/f wl TS ' ~,1• /00ti • Itl'a~i • • I _ •n 1.11 O ~ 4 O y • p A IT Q N • M + •1 •IMII• • I/N - ' , INI•IIN N• •1•••IN 1,~ • p ~i..=.~ ke a 1!! ' o, • J = • ps ♦ r MI w11.1 ' V - ♦1 • w o M v ; +1 • f' pl P•~ Q on •1• ♦ 1 N ,r'1 •t ~ N ' i 1y _r . vs aft wl ~ r n ~ s i I O. w 1 w ILL 3st C 1 N + r o v~ d N o Y 1 • O r w. 1 E•1 ps r 1 w 09 •1 • ac It(•!St •y ' MOt11O~ 1 ~ . 1 ~ Y . 1 A Y•/ M 1 nS 1 1' 1 + = Iw~ • 0•f I V •II s x^ Goettem, r ~i It I.1•i wh 000 v „ STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER J ( 4 canlLm ble'r45 MAILING ADDRESS q~o q44-L CJ" U. Uj/ ~l ! Ol PROPERTY ADDRESS Q ~~f 1~ 1 (location of septic jsys em))Plleease obtain from the Planning Dept. CITYISTATE VlJ 61 V/ PROPERTY LOCATION 3W 1/4, 7~) U 1/4, Section _ T 120 N-RW TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME PAGE LOT NUMBER-13 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. UWe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned tot St. Croix County "Zoning Officer within 30 days of the three year e iration date. - SIGNED: DATE: 7 - 7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property __Jamie, Location of property3w-) 1/4 5-C1/4, Section TZ N-R W Township _.~264 Mailing address e~ Address of site subdivision name Lot no. Other homes on property? yes No Previous owner of property 6W Total size of parcel 2.0 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 C49 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 '(we) certify that all statements on this form are true to t best of my (our) knowledge that I (we) am (are) the owner(s) the property described in this information form, by virtue o ,warranty deed Xcorded ~*n e office of the County Registe-. Deeds as Document No. own the , and that I (we) prey proposed site for the sewage disposal system or 7 obtained an sement, to run the above described propert the cons truction>-of said system, and the same has bee. recorded in the 'off, ice of County Register of deeds as No. signa ure of- ~1 cant Co-ap 1 a:_ Date of signature / Date of ' DOCUMENT NO. WARRANTY DEED TIIIS SPACE RESErVED FOR RECORDING DATA ~gpp,~yy~p STATE-BAR JSCONS§~FORM ~I2-1982 - - REGISTER'S OFFICE f' ST. CROIX CO., VA ZAPPA BROTHERS, INC., a Wisconsin corporation, RSt'd f r Record r - a/k/a Za Inc Grantor PP a - Bro ..-.thers Excavat _ng i- 'AN 2 7 1993 - 9 at 00 A 11 - N conveys and warrants to .-JAMIE- A. --DIERKS - - and CAROLYN- A.- DIERKS, q husband and wife as survivorship marital property, Reg;ster of Deeds - - Grantees ti - r.ETURN To - - - the following described real estate in St. Croix County, State of Wisconsin: Tax Parcel No- Lot 13, South Fork Addition in the Town of Troy, St. Croix County, Wisconsin. ,5 FEE TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and rights-of-way of record, if any. This _1_S_.SLo_t-------- homestead property. (is not) Exception to warranties: Dated this 1 9 day of --January - - 19.9.3- 1 ZAPPA BROTHERS, INC. --..(SEAL) (SEAL) - * -BY:-- Gary-- Zappa.-.--- President ------.-,-(SEAL) - - - (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) C-,4 , STATE OF WISCONSIN SS. St. Croix ---------------------------County. authenticated this fE.-day of___ 19.-_~ Personally came before me this day of January------------------------_, 19__93__ the above named TITL Gary T' Zappa ~~EMBER - TATE BAR OF WISCONSIN I~ not, (If - - - - - authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. II ------_-THIS INSTRUMENT WAS DRAFTED BY - - - - - - - - - - - Attorne Barry C. Lundeen 11.0_GS_e_C_4~dStr~etHudson~WI_-54016 (--I- f Notary Public S.t_.___CS-O-LX. County, Wis. (Signatures may be authenticated or acknowledged. Both M~ Commission is permanent. (If not, state expiration are not necessary.) date: 19--------•) 'Names of persons signing in any capacity should be typed or printed below their signatures. i% it WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc FnnM Nn 2- i- , ~A~heia~iknn Wiccnncin \ ~C5 r r'_