HomeMy WebLinkAbout042-1071-50-100
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER To 4d L~'1001_)l
ADDRESS
RCb .~z
SUBDIVISION / CSM# LOT #
SECTION T .2 9N-R Town of a)
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
w M FY -T T
101
~ ~ ,fig mowed
N01
-opt
c
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
a
mod" C.C)~- vZ D l
BENCHMARK:
ALTERNATE BM: >Oy.9!
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Ma nufacturer:tot cc,,~~•p Liquid Capacity: 1000,d
g O D
Setback from: Well ~S House Other
Pump: Manufacturer zo~l~ Model#919 Size
Float seperation 6 Gallons/cycle: f/(p
Alarm Location yh ,gQ,yQ~
SOIL ABSORPTION SYSTEM
p1 !1/
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: ~T House_ Other
ELEVATIONS r
Building Sewer ST Inlet C? ST outlet q g,9
PC inlet 2 PC bottom Pump Off
Header/Manifold /Q/. 6a-3/ Bottom of system /p/OD
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: 9, ~ IL
`
LICENSE NUMBER: S
INSPECTOR:
3/93:jt
LQGATs ,@ rtW"p9A,.,2,6.29.18W, A SEGiPk ' Y'~4~i~ TT County:
Labor and Human Relations INSPECTION REPORT
Safety &Rd Buildings Division
(ATTACH TO PERMIT) sanitary ermit o.:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ village IR Town of: State Plan ID o.: ~f
-
Tonn Insp. BM Elev.: BM Description: Parcel Tax No.: 11
Ad, 62~
TANK INFORMATION ELEVATION DATA A9400064
TYPE MANUFACTURER CAPACITY STATION BS HI ELEV.
Septic Benchmark
Dosing
s a_l;
i
Aeratiori~ - Bldg. Sewer 7 1
H o I St / Ic~f Inlet + 9?, 9?
TANK SETBACK INFORMATION St/ I~t Outlet y I 9e 71
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
v• 4',
Air Intake 9
Septic NA Dt Bottom
Dosing NA fir./ Man.
Aer Dist. Pipe
Ing Bot. System
PUMP/ N4NFORMATION -rc~ S Final Grade
T
Manufacturer 41-1 Dew, Zp !L
Model Number hod" PM
9,0 Syesater2p. TDH Ft
TDH Lift L
oss
Forcemain Length Dia. C~ ii Dist. To Well 7
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length c No. Of Trenches pl No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I
SYSTEM TO P/ L BLDG WELL LAKE / STREAM LE Manufact
SETBACK CHAMBER
INFORMATION Type Of _ /J s Model Num er:
System: C)?c«r^-c~ -
DISTRIBUTION SYSTEM
r / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length W Dia. Length OPa" Dia. Spacing y K Vp 90
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: Warren.26.29.18W, NE, NW, County Road TT Plan revisi n required? ❑ Yes B'No c~
Use other side for additional information.
/
5~~10 R 05/9 D,a#e Inspedo sSig No.
P.n9 "7e LC'!G?:~ ~,~"~~-,G~"•..^C
SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code CM
I STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than a Q t7 9qa
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. S Q - D l Q' I /
PROPERTY OWNER PROPERTY LOCATION
~F % IP94/a, S T' N, R Af& E (or .W
PROPERTY WNER'S MAILING ADDRESS LOT # BLOCK #
CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR C ,9M NUMBER
0w o_a4,_e,-y-o zs- 1 ( 7/ 5-
II. TYPE OF BUILDING: Check one) CITY NEAREST ROAD
❑ State Owned O ILLAGE T 7-
❑ Public LJ 1 or 2 Fam. Dwelling-# of bedrooms -I PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) cf) - f -^f5 ! DO
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 PERMIT: (Check only one in line A. Check line Bit applicable)
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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 Pressure d 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) / j ELEVATION
/ 0` rFeet
Z v ? 75~-~ 7j ` L ' Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks struct
fo0
Septic Tank or Holdin Tank ;1_11+ (5,
Lift Pump Tank/Si hon Chamber O 9
VIII. 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 Signature: (N Sta M MPRSW N. Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
`Z~ 3
IX. COUNTY/DEPART NT USE ONLY
IIA~AA ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Si wqjbKStamps)
L Approved I ❑ Owner Given Initial ~1~ X31 6 Surcharge Fee) G r _ /
Adverse Determination ~l O U ~I
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(8.08/93) DISTRIBUTION: Original to County, One Copy To: Safety a 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 tosthe 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.
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 test data on a 115 form; and F) all sizing information.
j 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)
rPROJECT INDEX SH';ET
0WNER :
7oDD 0/D / -
/1.t 7 .S 7 y 9~ z .s z.
ADDRESS : /Z 9 /j v,P,p sT ~a /.s' T S Gv i S . S ~O z 3
SITR LOCATION: Z,Q fi /gl/LC S
Nom' %y, Al 41 %y S,ec . z~ T 4VIfle loeAj
PROJECT DESCRIPTIOTr' : S7FL `O vu 7'y
.(JE ~'D o,S~ ~D ~ E"` ,v S 7`,E' U c Tip .,v - 3 $ t D~E'~-t S .
12 v T s it sv,v it/i~ Sit T~R~t rEO
~T
NCw ca,u v E.uTio,~~t L ~?o v v ~S Gb~Qv~o 5 1~
PAGE 1. PLOT PLAN VTE';dS
PAGE 2. MOUND CROSS SECTION & SYaT??P~ P,,AiT 'II' ','!S
PAGE 3. PIPE LATERAL LAYOUT
PAGE DOSING OR SIPHON CHAMBER CROSS SECTIONS
PAGE 5. PUMP PERFORMANC SPECS OR SIPHON SPECS RECEIVED
JUL. 2 2 1993
OFFICE OF DIVISION
CODES AND APPLICATION
PLUMBER: ST.T'? :?VALUATME / DESIGNER
NE CA
y ~E
HOMESITE SEPTIC PLUMBING CO.
655 O'NEIL RID. HUDSON. WIS. W16
ROBERT ULBRIGHT
DATE: 1 Q W115. MASTER PLUMBER LIC. NO. 3307 M.P.R.S.
MiI~N. INSTALLER 6 DESitI~ NER LIC: N0.00663 --14 "k4j SIGNATURE : C~ rte! .2 y,FZ_
7 R s -3
c cry. T T
HOMESITE SEPTIC PLUMBING CO.
655 O'NEIL RD., HUDSON, WIS. 54016
~I BERT LBRIGHT
416. MASTER PLUMBER LIC. N0.3307 M.P.R.&
- ' NN. WGTA~I.BR i 0681ONES IJ, NO, 00083
~srM z~r?i ~y- q3
1 30
~ L~U ~T~ro tils
_ 13ACIc- C PATS
99, zG
F3 9 9, 4;
yolk SyST>C~-k-CELCVAW0Aj
cv ~d'G, l i'' S~4 N 0 (3 3 /O D , Z~
.r o
Y(-s--s- cn h
r-`
I ~
~ g1 13 Z
rope T33
(3M St T' : Ivt w C-oo 5j . Al to iooo 6k-e .
PPEcAST PAP&-44-57- StPfi'G
o
eLeVATioAj - loo, 'Q
l,o
w E 11 Ro r o 5tt~ 1~1/E✓~P%O n--7
~ X03. D
HOMES Ct -
~ /aP~ , SEZV~~
99. ~ Die ifs' 6~
Prior To P16T-Ping- Installer will carefully
shift or orient round position ( toe line
and Brea under bed agoregare) so gruu.uu
elevations across slope are as uniform as
posQible. Suggested elevations (staked on
site with lathe markers) are shown herein
and on pg. 2.
~D
~,vaER i of /,9 r~ r' is j o/,
EGEU,triO,vs r Op OF4 ROCK /O / -72
Page Z Of S
ro p OF I IATE P ra L 5 101,60
Synthetic Covering
Distribution Pipe
Medium Sand
S y ITEM
r - H 16 EIEVATI oN
Topsoil = F
3
3 % slope
Bed Of iN Force Main Plowed
Layer
Aggregate
D /.0 Ft.
E 13 Ft.
Cross Section Of A Mound System Using
A Bed For The Absorption Area F 75 Ft.
G Z O Ft.
K,. A Ft. H Ft.
7
B y Ft.
K /D
_ Ft.
iN l.)'i.6• vAi3
7
J i?
Ft.
1 12- Ft.
Force Main W 2-9 Ft.
L
71-
Observation Pipe
B K
o
A O
~
----------------------•I
N
j. Distribution Bed Of 2
Pipe Aggregate
~ .
I ;
Observation Pipe Permanent Markers
y Iv PdG clf'q SfE~L Roos .
Plan View Of Mound Using A Bed For The Absorption Area
- 0-1991
Page 3 Of 3'
~ 0/ v U o /vM 2-5 FT of ~ 1'uc ~ORCF
Perforated Pipe Detoll
E
(rti T five UAt 1)'41
e- vACuAi~'ow
End View
)Perforated
End Cop) ,ya PVC Pipe
I.
~o~\e oe
oi
Holes Located On Bottom,
IIYY Are Equally Spaced
R
Q
► PVC Force Main
+ w
Q PVC
Manifold Pipe
Alternate Position Of
Distribution Force Main
Pipe
Lost Hole Should Be
Next To End Cap
End Cap Di9trib0ion, Pipe Layout P 2Z Ft.
R ye '
Y419`e OF i:`MJStRy, YipF X 72( Inches
r Y yZS
Inches
Hole Diameter r~ Inch
Signed ESPO~i;~'LNCE /
• Lateral Inch(es)
License Number: Manifold Z Inches
Date: Force Main 2 Inches
# of: holes/pipe
Invert Elevation: of Laterals Ft.
D / 5 7-X i13 U 7io.v
Vlen. o,'; S 2-7
To Tfi / Z 8 /M^cK
• T/S71~i/3Ut/O,J 27I:s'G6i AR (rE' AD97-E " ~-DIC'
1
• s9c 99
r
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS PACE ~f pF S__
VENT CAP
H"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKIMG
JUNCTION BOX MANHOLE COVER
25' FROM DOOR, w/ 4 A,(NAal1 AfWl
WINDOW OR FRESH 12"MIU.
AIR INTAKE I
g4p,e GRADE I y"MIAI.
41 la,
I
zl- '01, LL
CONDUIT
3 (p i
~IEt/~fi• on. ~ 11~
PROVIDE I
2~.~ INLET T ` AIRTIGHT SEAL I I ~
IT G I III v
I APPROVED JOINTS
97 APPROVED JOWT A ~NS~~r) K I I W/C.I. PIPE
W/C.I. PIPE EXTENDINC" 3'
%XTENDING 3' DO I ALARM ONTO SOLID SOIL
ONTO SOLID SOIL B Q w IT. .
yy'~ oN
(3,6 ELEV. FT
OFF
D I C~ I c .u.~
p pp.) 6-
Z .yC RISER EXIT PERM11TED ONLY IF TAIJK MANUFACTURER HAS SUCH APPROVAL ,
SEPTIC E S P E CI F I•C AT I OU S
WMBER OF DOSES: PER DAy
DOSE MANUFACTURER
TANKS
TANK SIZE: Ro O GALLONS DOSE VOLUME
ALARM MANUFACTURER: LEaEL INCLUDING BACKFLOW~ C'ALLO145
MODEL NUMBER: T. L, U CAPACITIES: A=INCHES OR .300 GALLONS
SWITCH TYPE: ME1LUR-4 Fl oA T IIJCHES OR 340 - GALLOWS
PUMP MANUFACTURER: 7- oalIE4 CT=.LINCHES OR GALLONS
G
MODEL NUMBER:1~ra /f/9 go v D= INCHES OR GALLONS
SWITCH TYPE: '~I GVR YCldh-T5 ' NOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATi: 3d GPM INSTALLED ON SEPARATE CIRCUITS
S ,
VERTICAL DIFFERENCE BETWEEN PUMP OFF ARID DISTRIBUTION PIPE.. S FEET ~AlO PlECS^~.
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . 2.5 FEET FAdA, Of' y} P
+ ZS FEET OF FORCE MAIN X -~F o FT.FRICTION FACTOR... -38 FEET 40A) 2-
Als.
TOTAL DYNAMIC. HEAD FEET
• ~ov~D r
IMTERNAL DIMLMSIONS OF TANK: LEKIGTH;~Z ;WIDTH --,;LIQUID DEPTH
HEAD CAPACITY CURVE 3 7/8 6 1/4
MODEL "98"
30 4 5/8
8
25 e
3 5/8
=
2
6 m
v -I- +
.r - O
15 4 3/16
' 4
1O'
r- 10 -
` 1 1/2-11 1/2 NPT
5
0
tJ.S. GALLONS 10 20 30 40 50 60 70 80
LITERS 80 160 240
0 FLOW PER MINUTE
TOTAL DYNAMIC HEAD/FLOW PER MINUTE
{ - EFFLUENT AND DEWATERING
y CAPACITY 12
HEAD UNITS/MIN
FEET METERS DAIS LrFIS
t 5 1.52 72 231
I 10 3.05 61 23t
15 4.57 45 170
20 6.10 25 05 3 5/16
y
Lock Valve
>r ,
i. CONSULT FACTORY FOR SPECIAL APPLICATIONS
fi * Electrical alternators, for duplex systems, are available and • Mercury float switches are available for controlling single and
supplied with an alarm. three phase systems.
Mechanical alternators, for duplex systems, are available with or • Double piggyback mercury float switches are available for
;without alarm switches. variable level long cycle controls.
? SELECTION GUIDE
Standard all models - Weiht 39 lbs. - 1/2H. P. 1. Integral float operated 2 pole mechanical switch, no external control required.
2. Single piggyback mercury float switch or double piggyback mercury, float
t 98 Series Control Selection switch. Refer to FM0477.
Model Volts-Ph Mode Amps Simplex Duplex 3. Mechanical alternator 10-0072 or 10-0075. r
M98 115 1 Auto 9.0 1 or 1 & 7 - 4. See FM0712, for correct model of Electrical Alternator,
5. Mercury sensor float switch 10-0225 used as a control activator, specify
N98 115 1 Non 9.0 2 or 2 & 6 3 or 4 & 5 duplex (3) or (4) float system.
D98 230 1 Auto 4.5 1 or 1 & 7 - 6. Four (4) hole "J-Pak", junction box, for watertight connection or wired-in sfm-
` "E9B 230 1 Non 4.5 2 or 2 & 6 3 or 4 & 5 plex or duplex operation, 10-0002.
7. Two (2) hole "J-Pak", for watertight connection or splice.
°t . CAUTION
w„ For information on additional Zoeller products refer to catalog on Combination Starter, FM0514; All installation of controls, protection devices and wiring should Ira
done by a quali-
41 Piggyback Mercury Switches, FMO477; Electrical Alternator, FM0486; Mechanical Alternator, tied licensed electrician All electrical and safety cod" shouts be followed
indud-
FMO495; Alarm Package, FM0513; Sump/Sewage Basins, FM0487; and Simplex Control Box, ing the most recent National Electric Code (NEC) and the Oooupolkmal Safety and
,ell FM0732.
_ Health Ad (OSHA).
RESERVE POWE D DESIGN i
For'unusual conditions a reserve safety factor 's gineered into the design of every Zoeller pump.
.y
s MAIL T0: P.U. 80X 16347
LoUisvills, KY 40256-0347 Manulacturers o/.. .
Z ZZI) 01 SHIP W. 3280 01.4 Millers Lane t~ g~ a
0 M
Louisviili, KY 40216 QUAL/1Y AIP9 ~NCE /~J•-
(502) 778-2731 • FAX (502) 774-3624
-
Wisconsin'Department of Industry, SOIL AND SITE EVALUATION REPORT Pa
Labor and Human Relations - of -
Division of Safety ~ Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY y
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but S?, C~o/" t
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL LD. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
TODw /a /,00 M GOVT. LOT tiE 1 /4 Nw 1/4,S Zoo T L ,N,R E (or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAM OR CSM #
/ Z 9 lg v eR 5)-. ~s,~-~ E-~v~ - r of 0'o 4C,c~5
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑❑VILLAGE EVOWN NEAREST ROAD
-FoT3_AW GUi• 5yoi3 _71 _7v9-Yzsz w11,P,P~.v C71 7
New Construction Use (n] Residential / Number of bedrooms -3 [ ] Addition to existing building
j ] Replacement Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpolft2 trench, gpolft2
Absorption area required 3 bed, ft2 J j trench, ft2 Maximum design loading rate 's bed gpd/ft2 I trench, gpolft2
Recommended infiltration surface elev tion S~ 3 r f i I
a (s) ft (as a erred to s to p an benchmark)
Additional design / site considerations
Parent material $eS G ? J •ew>E 77- Si/ Flood plain elevation, if applicable N ft
E r L
S =Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ❑ S U [9S ❑ U ❑ S [9U ❑ S &U ❑ S O U ❑ S QI U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon Texture Consistence Botrtdary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed fEnch
d- /Qye 3 L Si• 2-,4vl S~ wfe cs 2f S
y ~ ~f,~ ~s Zf Np .3
z f-/U /o ,e 312 S Z, ~,r►
Ground O-/6 /0oe ~ 3 s~/ ~,f s6K nNf R ~S zf .s ,G
elev. ft i3~ 6 -)y ~o vie zi 4 5i• 2. f, Sd~ ~tf/~ s z f S
Depth to 2. tf /O yX vl(e o ' s 5,/ /,1, Sh A S i •3
limiting
factor „ C y 1cJ 7,s lliP y(! 3 Py 5/ f 5/& „M fib . y S
Remarks: £,?Vy 4C7~y -PPIF 411 S~~pyr~~ ~T 5!~
Boring # A O /C) ye 3/z 2, , S 6~ f / - C 5 3 f S • • (r
c
S . 3
3 Z. ~ i~,,.f'/e f N
~ /off l S~ 3 P
y
Ao ~o Y)e 3 S / sd,~ n,,,~,~ c's 3 f , S- , G
Ground
elev. -Z(~ /o YA Y s~~ , f, S~,e th, f1 S 2f , S ~v
Depth to
limiting a
factor
a
Remarks:
it CST Name:-Please Print Phone:
PLUMBING CO. (o
ress: 655 O'NEIL RD., HLWON, WIS• I ~r e.~y~iZ, '
Signature:
Z(~,•~~~r~S. MASTER PLUMBER LIC. N0.3307 M.P.R.S. Date: ` o`,,;
~~.N. ttdSTALLER & DESIGNER LIC. fd0.00683
RAG
~A
I worms ro %usf~/l - ~ h~~.zo.LJ w~ s /0/oaveo -
A '~o w % ore o-v .~,t c.~S -OF ~
/3 /t'!-tom`- 1,,- Gv il°F / f/20~ 7~ir•9C7h,P ~4t' D
.S~ 'Tc s v~~ /3 tai Q E sv /o-v ~9 S s
. C Lj S L - lcJ EL7 -i ~v'// /•v ~tit~ v~°~ 7` J~i~L
/ p
S -M vc fv,P ~ ~ ~ •v ~ ~ti Od ~v `vn
PROPERTY OWNER SOIL DESCRIPTION REPORT Pagez- . of 3 `
PARCEL I.D. # CS-41 Gd~D~-V Cr-
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxlary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed t
41 f /a- O 3 S/ Z f Z n^^ fR cS 2-f 3
Ground J3' -1 1 /O 3 S~ ~J/~ f~° G' S f ~S -6
elev.
7. S 151
Depth to / -i Af S D-v .S./ at AZ 1"d
limiting
factor of
a
Remarks: "~Ti U~ /fGW s7~i4~E T 3
Boring #
>
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
i Remarks:
Boring #
LIM- I
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
OWN 01213^00 ncinn%
JAM10190
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HOMESITE SEPTIC PLUMBING CO.
655 O'NEIL RD., HUDSON, MS. 54016
ROBERT ULBRIGW
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INN. INISTA"R & 0681ONER W. NO. 00083
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C 33TIFIED SLFNEY MAP
GEOFGE AND MARY ELOOM
Part of the Northwest 114 of the Northwest 1/4 and the Northeast 1/4 of the Northwestl/4
of Section 26, Township 29 North, Range 18 West, Town of Warren, St. Croix County,
Wisconsin.
N 114 COR. SEC. 26, r29N, R18W,
!COUNTY SURVEYOR'S MON.1
NW COR. SEC. 26, r29N, R /8W, UNPLAT TED LANDS
(000NrY SURVEYOR'S MON.) N L/NENN\W //4
^h) N 89•/9'09"E 26/2.0/'C•/•~,_MTTII
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N 89. 19'09"E 4.75' Z O
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SET BACK LINE W m
Owner's Address: h - OI x a
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1?62 Highway "12" R N - T l
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9oberts, WI 54023 LO I a QI °
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2.235 ACRES ° Q R
This instrument drafted Q W h 97, 347 So. Fr. a
W) b 2. 00/ ACRES EX C. ROAD _ WI Z
b Laurence W. Murphy o h o
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O M 87, /60 SO. Fr. ° I ~
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Dated: July 10, 1993
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UNPL A T T ED LANDS
SCALE /00' FILED
0 25' 50' 1001 150' 200' 300' 400• A " OCT0119930- 2
JAMES aCONNELL
ReglMK01 Deeds
0 fAI444 SL 0* CO.,
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O Indicates 1" x 24" iron pipe weighing 1.13
lbs./lin. ft. set. Z
'LAUR C
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9 W•C.. JQ►
Vol. 9 page 2693 LaNO•S
Certified Survey Maps #sss„gssss
St. Croix County, Wisconsin.
Laurence W. Murphy
egistered Land Surveyor
.a SHEET 1 OF 2
}
SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
PRIVATE SEWAGE PLAN APPROVAL Office of Division Codes and Application
201 East Washington Avenue
P.O. Box 7969
Madison, Wisconsin 53707
HOMESITE SEPTIC PLMBG
ROBERT ULBRICHT
655 O'NEIL ROAD
HUDSON WI 54016
RE: Plan Number: 593-01991 Date Approved: July 22, 1993
Gallons Per Day: 450 Date Received: July 22, 1993
Project Name: BLOOM, TODD Location: NE,NE,26,29,18W
Town of WARREN County: ST CROIX
The plumbing plans and specifications for this project have been reviewed for
compliance with applicable code requirements. This approval is based on Chapter
145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are
stamped 'conditionally approved'. This approval is contingent upon compliance with
any stipulations shown on the plans. All items that are noted must be corrected.
All permits required by the city, village, township or county shall be obtained
prior -to construction. The licensed plumber responsible for this installation
shall keep one set of plans with the department's approval stamp at the
construction site. The installer shall notify the appropriate inspector when
inspections can be made. ,
This approval will expire two years from the date approved or if a sanitary
permit is obtained, it will expire the day the initial sanitary permit expires.
The Section of Private Sewage has reviewed these plans for private sewage system code
requirements only. These plans have not been reviewed for the code requirements
set forth in Section ILHR 82 for general plumbing or in Chapters 50--64 of the
Wisconsin Administrative code.
This approval is for the following components only:
- NEW MOUND
Inquiries concerning this approval may be made by calling 1608) 266-3937.
SOD 7987 iR. 01/9
y
SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
HOMESITE SEPTIC PLMBG
Page 2
S cerely,
JAMES AN'l
Section of Private Sewage
Division of Safety and Buildings
PPP012/0009n/ 8
cc: -Private Sewage Consultant -County UW-SSWMP Plumbing Consultant
Owner Plumber Environmental Health
SBD 7997 tR. 01/911
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 7,
MAILING ADDRESS
PROPERTY ADDRESS 'T 14
(location of septic system) Please obtain from the Planning Dept.
5
CITY/STATE U-5
PROPERTY LOCATION 1/4, Al Vy 1/4, Section- _ 2 T. I ` N-R_~ S
TOWN OF LUnAA Q.'1A ST. C.ROIX COUNTY, WI
SUBDIVISION wr~-✓J LOT NUMBER
CERTIFIEDSURVEY MAP , VOLUME PAGE S, LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost,
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
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
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:
DATE: -~3 a 7 l
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
Y 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
Location of property/YE_l/4 4/14~-)1/4, Section , T; ` N-R._[__W
Township G~~cz,` `s1
Mailing address
Address of site
Subdivision name Lot no.
other homes on property? yes No
Previous owner of property
Total size of parcel 3 S
Date parcel -was created
Are all corners and lot lines identifiable? v Yes No
Is this property being developed for (spec house)? Yes No
Volume /-"&9 and Page Number ; 3 8 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 office of the County Register of
Deeds as Document No. ~5~~y17Z , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for
the construction of said system, and the same has been duly
recorded in the office of County Register of deeds as Document
No. '
~GGe`
Sig ature of applicant Co-applicant
I'
3/d
19 1~
Date of ignature Date of Signature
I
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA
' WARRANTY DEED
514173
L pAG~ (REGISTER' , FICIE
ST. CROIX CO, W1
Reo'd The Rewrd
George P. Bloom and -W ary C. Bloom, husband and wife
as loin enan s MAR 16 1994
at 8:30 nAA.
conveys and warrants to Todd A Bloom and Julie M Bloom, as
husband and wife, as survivorship marital property
RETURN TO
the following described real estate in St. Croix County,
State of Wisconsin:
Tax Parcel No:
Part of the Northwest 1/4 of the Northwest 1/4 and the
Northeast 1/4 of the Northwest 1/4 of Section 26, Township 29 North,
Range 18 West, Town of Warren, St Croix County as recorded in
Volume 9, Page 2693 of Certified Survey Maps - St. Croix County, WI.
This is not homestead property.
(is) (is not)
Exception to Warranties:
easements of record.
Eleventh day of March 19-94
Dated this
(SEAL) 6 (SEAL)
George P. Bloom
(SEAL) (SEAL)
• Mary C loom
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
SS.
G~~c CSC f County. fL -
authenticated this day of , 19 rsonally came before me this-,day of
19_5_'~the aboy_e named
1
A &%1
kuSfeo+-~ e LJ% p
TITLE: MEMBER STATE BAR OF WISCONSIN
tt[[ s
(If not, to me known to be the person iv (.,fell the
authorized by § 706.06, Wis. Stats.) foreg g instr me a d .~1 •11ne same'••.;9C,f,
THIS INSTRUMENT WAS DRAFTED BY T A
Mary C Bloom
Notary Public 1 01- PO un , W,
(Signatures may be authenticated or acknowledged. Both My Commission is permanen * (1 ~rjt, state V ikai~n
are not necessary.) date:
Names of persons signing in any capacity should be typed or printed below their signatures. SB2 NTF 0021
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, Wl 54307-0208
Fnrm Nn 2 - 1982