HomeMy WebLinkAbout016-1076-95-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER S/ e /U
ADDRESS
/y, a /may ~1f /g
SUBDIVISION / CSM# 691 LOT
SECTION N-R~W, Town of
52Q' P~
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH A ROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: ALTERNATE BM: 11Z2
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: if:' Liquid Capacity: 'le ~ ~C1 a
Setback from: Well House Other
Pump: Manufacturer c~jli DN ,4 1`/G Model# + Size /i~p
Float seperation r.~ Gallons/cycle:
Alarm Location
;SOIL ABSORPTION SYSTEM
Width: Length Number of trenches f
Distance & Direction to nearest prop. line: J,2 /;eT
-?a7LJ .ems"l.
Setback from: well: House other 1v
ELEVATIONS
Building Sewer ST Inlet; r , e9 / ST outlet
PC armlet PC bottom Pump Off 90~
Header/Manifold Bottom of system
Existing Grade Z Final grade
DATE OF INSTALLATION: /
PLUMBER ON JOB :G~~CP J
LICENSE NUMBER:
INSPECTOR:
3/93:jt
LRJ ~'~r' part r~ b~ 35. 30.151WRTE SEWAGE SYSTEM County:
Labor and HurfanR•elations INSPECTION REPORT
Safety-and Buildings Division ST- CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.'.
Permit Holder's Name: ❑ City ❑ Village IR Town of: State Plan ID No.:
I v.: Insp. BM Elev.: BM Description: Parcel Tax No.:
, - 1 016-1076-99-
TANK INFORMATION ELEVATION DATA A9300316
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic /C`h? r Benchmark 07,
Dosi n
Aeration Bldg. Sewer q$>~O
Holding St/ Ht Inlet qS 0
TANK SETBACK INFORMATION St/ Ht Outlet la), a
tto
TANK TO P / L WELL BLDG. geintake ROAD Dt Inlet
Septic >as 1 7 1 ' a -1' >a 1 NA Dt Bottom I r," C/O ~t
Dosing > NA Header/Man. a,Au pd,c j
Aeration NA Dist. Pipe if /v x.341
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand j(o, (o,Z CjO C(
Model Number GPM ? y~7~
TDH Lift ~\All Friction i 3 System r TDH b~ Ft
Loss H W
Forcemain Length f Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS f 1 DIMENSIONS
SYSTEM T P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION TypeO Model Number:
System: ~Wkj I /9~1 OR UNIT
DISTRIBUTION SYSTEM
Header hVN2!rn+# Distribution Pipe(s) II x Hie Size I x Hole Spacing I Vent To Air Intake
Length Dia. I Length Dia. 1 ` Spacing I 1 ii I~It
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over ( ci xx Depth Ofxx Seeded /Sed~d~rt xx Mulched
Bed /Trench Center 1 V Bed /Trench Edges t Topsoil 10 ✓ I1Yes ❑ No Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: GLENWOOD 35.30.15.528B
~..r1~5 S t 1 ~~.H i
a
Plan revision required? ❑ Yes No 1/0 93 T-I
Use other side for additional information. / b
SBD-6710(R 05/91) Date In pector'sSignature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
r,
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SANITARY PERMIT APPLICATION
~ 0ql jL IR 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 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. 5 - /
PROPERTY OWNER PROPERTY LOCATION
he /%Nl / w y4 ' / y4, S 3 a T 2o , N, R /_5--Apor) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: Check one CITY NEAREST ROAD
( ) ❑ State Owned VILLA
GE
= OF:
❑ Public 1 or 2 Fam. Dwelling~# of bedrooms PARCE L WX NUMBER(b)
III. BUILDING USE: (If building type is public, check all that apply) , /'5-- (,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
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) 1.0 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 El Seepage Bed 21 ~ Mound 30 El Specify Type 41 El 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 rREQUIRED(sq. . ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
ft.) PR~O7P( (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
J /0 17 Feet Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank Z1 .S^ .
Lift Pump Tank/Si hon Chamber , C I l
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 Sta s) r6piWRSW No.: Business Phone Number:
4~ f .5 6 2
Plumber's Address (Street, City, State, Zip Code):
IX. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sary Permit Fe (Includes Groundwater Date Issued Issuing Ag t Signa No
Approved ❑ Owner Given Initial rcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
BD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
J
i
INSTRUCTIONS
r s
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 re-;lsions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a San.tary Perm t Transfer/Renewal Forin (SR,) 6399) to be
subruifted to the <-io irity prior to installation.
5. Onsite sewage systems must be properly maintained. Thtc .,-pti:; tank(s) mu:~t be r 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.
IL 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 4_,~1 7.
VII. 'rank information. Fill in the capacity of evert new and/or existi "i '.st the total gallons number of
tanks and ,manufacturer's name. Indicate prefoj or rite construe„=d ..r tank. material. C^mnieto Por all
septic, purnp/siphon and holding tanks for thi ystem. Check et<;:~ ~ r ;tan approva; s tanks, received
exper=.rm r:':al product appRcvai from DILHR
Vill. Responsibility statement. installing plumber into fill in name, lire,rse nufnber with ao_?roFriate prefix (e.g.
MP, etc.,, address and phone. number. Plumper must sign application form.
IX. County/ Department Use Only
X. County/Department Use Only.
Complete ;•iuns and specifications not smaller than 8'/2 Y 11 inches he s-,,b nit's d'~ the ~.;ounty. The"
plans rm,s' the following' pl -f r)san, draw to scale or with coht;p'E',c.; 1'"lier:: -n:_ ko,.atlon of
holding n+c i^nk(s) or other ireatment tanks; b,_ridinrl s.; na,i!s, Poater service;
streams aiwd lake'z ournp or siphon tanks, iistribution boxes; soil r-,placer+lent systern
areas; and the I<;r_. ~~urf of the building .,aried; B) horizontal amd -.IP,19tic r. 1-M.-retire pGirtR;
C) complete specifications for pumps and controls; dose volume, elevat or, differences; f{ iction 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 num~)er of
regulated practices which can effect grUndwater.
The r;ionies collected thrcugn ",ese surcharges are used for qlc C1 3i r3 Car t:iEnt::
water contamination irvestic REF r?s ano establishment ct' star rds.
SBD-6398 (R.11/88) /
R ,
Laverne Hoitomt - Mound
S93-4dMW
-7
Location: NW 1/4, NW 1/4, Sec. 35, T 30 N, R 15 W
Town: Glenwood
County: St. Croix
Date: October 5, 1993
Owner: Laverne Hoitomt
Address: 3162 HW 64
Glenwood City, WI 54013
Plumber: SA7 //h/
Signature:
License #
Attachments: 6748-Plan Approval Application
115
,I
SEwA~~ S°'Y ST RA
pRIVATe
1: cover on4jitionaftl
page j
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2: calculations IE: 3: plot plan ApI?R~~ aN REVAAI►ONS
4: system cross section y. uSoR e H B~~EO►'ASS
5: plan view, lateral detail OEM ontiv~so p So
6: pump tank exit detail
7: pump curve J >E
ESPONDENC
SFE no
page 1 of 7
S93-21214
System Calculations
One family residence 3 bedrooms
Loading rate gallons/sq ft per day
Depth to ground water t in
Depth to bedrock 4o in
Q o....~~. ~
Cross slope %(,...w
Force main length ~~^3 ft of Z in
Manifold header length K
/ ft of in
Drainback Z~^•~ gallons
Lateral length 7 @ TIM ft of in
Lateral elevation z•Z ft (bottom of pipe)
Lateral hole size in @ lsz'~~ in ( ft) spacing
It holes/lateral, L4' holes total
Lateral volume gallons
Total lateral discharge rate Zg'O$ gpm @ ft head
Elevation difference ~1•t~ It
Friction loss Z•~~O ft @ gpm
Total dynamic head ft
Pump/si%vdion 3o gpm @ b ft of head
Manufacturer R%.rov..~li.~ Model #
Dose volume ,Z gallons
Lift/si'*Pbon tank W gallons
~
Septic tank gallons
Measurement pump on & off in
Height alarm from tank bottom in
Reserve capacity gallons
talcs page Z of }
593-212 1 4
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RELATIONS
ETY AND BUILQtNGS
DEPT. Of ►Yi5 ON OF SAFLABOR
COFt SPONDENCE
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S93-21214
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S93.21214
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• ' W E AT•N ER PROoF
n LOCKING COVER JUNCTION
~Oc
awctc Dl~toy~eGT--1
4.1 C.T. tNaPatnwORFw106 -
6.. 1 s~ IZ~
:.I. PIPE
!TO NDISSURB£D
SOIL. 24" T.D. i 4 C.L.
VENT
13EL" MANUOLE
MIN.
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AF/TLE3' -
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Z3.~r'. NO:t
AppRovtO A
51Cz.T.. zbwR'S C.T. PIP.
ESPFFLES iAL&PXC awo
.I- PiFS - ?N r(NECTiONS. ON - IINL~.ST~tBT_
GROUaD
C lA3 ..~A.~ ~i~•.se~ q.3" 41.E
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p 47
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SEPTIC E SPECIFICATIOKIS ~ CE
DOSE y ~
t SES CID ESPA
TAAJKS MAUUFACTURER: kJUMBER F DOSES: PER DAy
TAAJK SIZE: k~ (o`er GALLOAJS DOSE VOLUME
ALARM MAAIUFACTURER: S J` %C-\ a.a. y% IMCLUOIAIG BACKFLOW: \ g GALLONS
MODEL IJUNIBER: CAPACITIES:.A = Z3'~ INCHES OR 3 3' I GALLOWS
SWITCH TyPIL: (O IO 2 Z~l •S~
B = INCHES OR GALLOAIS
PUMP MAMUFACTURCR: 4 S l 3 L~
C = I►JCHES OR GALLOWS
MODEL MUMBER: S w n- D= L' INCHES OR GALLONS
SWITCH TYPE: ~-A6 MOTE: PUMP AMD ALARM ARE TO BE
MIAIIMUM DISCHARGE RAT t~ •1 GpM INSTALLED OIJ SEPARATE CIRCUITS
VERTICAL DIFFEREAICE BETWECU PUMP OFF AAIO DISTRIBUTIOM PIPE.. FEET
+ MIAJIMUM AIETWORK SUPPLY PRESSURT,E/. . . . . . . . . . . 2.5 FEET i4•°~
+ ASS FEET OF FORCE MAIM X j f- F/ FRICTIOAI FACTOR.. 2~-A t° FEET L° 30y
100 iT. o`l
TOTAL, Oy1JAMIL HEAD = 16.1 FEET
IIJTERAJAL. DIMEAJSIOMG OF TAIJK: LEAIGTH ;WIDTH $ ;LIQUID DEPTH
~(A t- C 6 or
S93,-21214
1
ENGINEERING DETAILS - SW25/33.-
Performance Data
Pump Characteristics 32
Pump/Motor Unit Submersible
Manual Models SW25M1 SW33M1 U za
U.
Automatic Models SW25A1 SW33A1 u°ar 1/3 HP
Horsepower 1 /4 1 /3
Full Load Amps 8.0 10.0 z is 1/4 HP
Motor Type Shaded Pole (4 pole) °
a
R.P.M. 1550 0 8
Phase 0 1
Voltage 115
0
Hertz 60 0 10 20 30 40 50 60
CAPACITY-U.S. G.P.M.
Operation Intermittent
Temperature 120°F Ambient Total Head (feet) 4 6 8 10 12 14 16 18 20 22 24
NEMA Design A 1/4 HP '44 41 36 33 29 26 23 18 12 6 0
Insulation Class A GPM 1/3 HP 47 45 43 40 37 34 30 26 22 16 10 i
Discharge Size 1-1/2° NPT
Solids Handling 1/2' Dimensional Data
Unit Weight 30 lbs. 1. All dimensions in inches
Power Cord 18/3, SJTW, 10' std. 3-1/2 5-7/8 2. Component dimensions may
(20' optional) - 4-1/2 vory t 1/8 inch
T 1-1/2 NPT 3. Not for comtrudion purpose
3-1/2 ' DISCHARGE unless certified
Materials of Construction; 4. Dimemimandweighhare
approximmate
Handle steel 5. On/OH level adiustoble
3 1/2 6. We reserve the right to
lubricating Oil Dielectric Oil make rev'nions to our
products and their
Motor Housing Cast Iron spedficotions wiW notice
Pump Casing Cast Iron
Shaft Steel
Mechanical Seal Faces: Carbon/Ceramic
Shaft Seal Seal Body: Anodized Steel -
Spring: Stainless Steel 11-1/8
Bellows: Buno-N PUMP
10-1/8 ON 9-1/2
Impeller Thermoplastic
Upper Bearing Bronze Sleeve Bearing DISCHARGE
HEIGHT
Lower Bearing Sin le Row Ball Bearing
3-1/2
Strainer/Base Plastic 3 PUMP
OFF
Fasteners Stainless Steel
AURORA/HYDROMATIC Pumps, Inc. n-~ } o. +
1840 Baney Road, Ashland, Ohio 44805
(419) 289-3042
593- 21214
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor Ad Human Relations
Division of ~+`afety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
St. Croix
Attach complete site plan on paper not less than 8 1/2 x• c in s Plan must include, but
not limited to vertical and horizontal reference point 2tjr ataod % osylope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distan Barest road.
APPLICANT INFORMATION-PLEASE PRIFW ~KLL~INPOR'M ATION ~o REVIEWED BY DATE
LOCATION
PROPERTY OWNER: PRO?
Laverne Hoitomt r GOVT- ' T NW 1/4 NW 1/4,S 35 T 30 N,R 15 AK" W
PROPERTY OWNER':S MAILING ADDRESS L07 # BLOCK # SUBD. NAME OR GSM #
3162 HW 64 NA
REST ROAD
CITY, STATE ZIP CODE P MB~R11'1'''' ❑VILLAGE MOWN NEA
Glenwood City WI 54013 (71"'sc Glenwood WSHW 128
[ ] New Construction Use kx] Residential I Number of be r 3 [ ] Addition to existing building
jx] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate .4 bed, gpd/ft2 .5 trench, gpd/ft2
Absorption area required 1195 bed, ft2 9nn trench, ft2 Maximum design loading rate -a bed, gpd/ft2--5 -trench, gpd/ft2
Recommended infiltration surface elevation(s) 101.7 ft (as referred to site plan benchmark)
Additional design/ site considerations install 3' x 125' rock bed mound w/ upslope edge following 100.7 contour
Parent material SS Flood plain elevation, if applicable NA ft
S = Suitable for system CONVENTIONAL MOUND IR OUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable El S 7 U xF~7 S❑ U S O U ❑ S O U ❑ S U L ❑ S U
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 Tmrch
''.....1....•.• 1 0-8 10YR 2/2 - sl 2 m sbk mvfr s 2f .5 .6
r<>'sss<% 2 8-28 10YR 2/2 - sl 3 m-c sbk mvfr cs if .5 .6
Ground 3 28-31 10YR 3/2 c1d 10YR 6/2 sl 1 m sbk mvfr as if .4 .5
elev.
100.7ft 4 31-38 10YR 5/3 m2d 10YR 6/2 si 0 m - - - NP .2
Depth to
limiting
factor horizon 2 generall parts to f sbk an is occa ionally mfr
28"
Remarks:
Boring #
1 0-6 10YR 2/2 - sl 2 f-m sbk mvfr cs 2f .5 .6
?4 2 X-N
2 6-14 7.5YR 3/2 - sl 1 m sbk mvfr gs if .4 .5
3 14-23 10YR 3/3 - sl 1 m sbk mvfr cs if .4 .5
Ground
elev. 4 23-31 10YR 3/4 - is 1 m sbk mvfr cs if .7 .8
99.4 ft.
5 31-33 10YR 3/4 f2d 10YR 6/2 is 1 m sbk mvfr cs if .7 .8
Depth to c 1 d 10YR 612
limiting 6 33-37 10YR 2/1 f 1 f 5YR scl 0 m - - - NP .2
factor 5/8
31"
Remarks:
CST Name:-Please Print Phone:
Henry F. Grote 715-665-2681
Address:
PO Box 57, Knapp, WI 54749-0057 -
Signature: Date: CST Number:
9/26/93 3065
PROPERTY OWNER Laverne Hoitomt SOIL DESCRIPTION REPORT Page 2,'.of 3
PARCEL I.D. # r
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BoundaFy GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
0-6 IOYR 2/2 - sl 2 f sbk mvfr cs .5 .6
2 6-11 10YR 2/2 - sl 1 m sbk mvfr cs if .4 .5
Ground 3 11-21 10YR 2/1 - sl 1 m abk mvfr cs 1f/m .4 .5
elev. 4 21-29 10YR 2/2 - is 1 f sbk mvfr cw 1m/f .4 .5
100.7 ft.
Depth to 5 29-36 10YR 4/4 - is 0 sg ml gs if .7 .8
limiting
factor 6 36-40 10YR 4/4 f1d 7.5YR 4/6 is 0 sg ml .7 .8
36"
FT
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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ITTI~ I I~ I
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SEPTIC TANK MAINTENANCE AGREEMENT ~
St. Croix County
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OWNER/MAIM LIU n
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ROUTE /BOX NUMBE Fire Number 0
R ' ~ • lbw / ~ ~ c~
ZIPS rt
CITY/STATE 6~4e4~~ydval/~, / -
PROPERTY LOCATION: k,,y A, Section, TZIp_N, R /5-W,
Town of o a! 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 con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licen'sed' 's'e'ptic tank pumper. What you put into
the system can a ect the ' .unct on of the septic tank as a treat-
ment-stage in the waste disposal system.
St. Croix County residents may be eligible to recieve a grant for
a maximum of 60X 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 County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or..a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and •(2)•after inspection and pumping (if nec-
essary), the septic-.tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
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 Depart-
ment of Natural Resources. Certification form must be completed •d
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration-date
. ,J
SIGNED
DATE 020
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
STC-100
This application form is to be completed in full and signed b
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 e,4
Location of property~/f~1/4 IV41 1/4, Section T,?O N-R /,:5-W
Township wo o
Mailing address Xc;2
A 1 17 Z'
Address of site
subdivision name.
Lot no.
Other homes on property? yes___.,~'_NO
Previous owner of property _ 6-Q ,-z SF, a
Total size of parcel- S ArI/CS
Date parcel was created
Are all corners and lot lines identifiable?
Yes - S, No
Is this property being developed for (spec house)? Yes No
volume and Page Number _ b;2C_-? as recorded. with the Register
of Deed .
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. ~
own the ~.n , and that I (we) presently
proposed site for h 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
;1 rs u i f ~i
No.
'Signature of applicant Co-appl cant
Date of Signature Date of Signature
1
3
• I SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
October 24, 1993 209 West First Street
Route 8, Box 8072
Hayward WI 54843
SMITH PL
GALE SMITH
3228 HWY 170
GLENWOOD CITY WI 54013
RE: PLAN S93-21214 FEE RECEIVED: 180.00
HOITOMT, LAVERNE
NW,NW,35,30,15W
TOWN OF GLENWOOD COUNTY OF ST CROIX
MOUND SYSTEM
The Department has reviewed the above-referenced submittal.
i
Conditional approval is hereby granted for the system plan submittal. All
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not been reviewed for the code
requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to the plan number shown above.
Sincerely,
Carl Lippert
Wastewater Specialist Sr.
Section of Private Sewage
(715) 634-3484 Mondays
SHD-64'23 (R. 0 1/81)
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• VOL' o v~ lv E920
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25444 2
This Indenture, Made byc.,r,r ^.,.~f, and Rebecca T SPm}~f, 14u,-,hand and
Wife, as Joint Tenants.
warran •
rantorS of St. Croix County, «'isconsill hereby conveys and
to Chest r n Camp and Arlene 7e Camp Husband and Wife as,Tnint
j Tenants • grantees-,- of St Croix _County, Wisconsin,
I r~a
,i for the sum of F:i ~,ht, hiindre_d Si x~~r Fi ire and 5n/1 nn (~',fkh5. 5(1) Dol ;
the following tract of land in County, State of Wisconsin;"
A parcel of land located in the N91 of the NWI of Section 35, II
Township 30 North, of Range 15 West, described as follows;
nit
beginning at a point 460 feet east and 563 feet south of the north
!I west corner of the above mentioned NW4 of the NWT,, Thence east at
right angles to the west line of said Section 35 for a distance
of 488.8' feet, Thence southwesterly on the Center line of State
Trunk Highway 1112$" for a distance of 785 feet, Thence west on the
~I
south line of the said NWT of the NW4 for a distance of 281.6 feet,
Thence north parallel to the west line of the above mentioned
Section 35, for a distance of 74$ feet to the point of beginning.
j Containing 5.77 acres more or less, exclusive of lands heretofore
released for State Highway Purposed.
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IN WITNESS WHEREOF, the said grantor .s_ haVE-hereunto set their handS--and seal-this 27th.
day of NTaV , A. D., 19 o
(N (SEAL)
S ND SEALED PR OF G11,qtqv W_ f
SEAL)
Richard P. Rivard RAhPnna T,_ Semnf
(SEAL)
H _I,e~_cv0,1d
.(SEAL)
ii
S'L'ATE OF WISCONSIN,
j St. Croix County. Ss
Personally came before me, this. 27th. day of MaV A. D. 195-- i
.
the above named
Joint Tenants, tj
to me known to be the persons - who executed the foregoing,, instrument. atid acknowiedged t
Received for Record this 29th day of ~May A. D., 19-58 at 10:3 o'clock-A& M '
fsEal.)C a Richard P Rivard
Dtary Public ~~,St Croix County, Wis.
Register of Deeds. ~$IY commission
axpires Sept- . nd - A. D., 1966
Deputy Register of Deeds.
WARRANTY DEED-STATE OF WISCONSIN. FORM NO. 9 N. C. roux CO., ruweucct
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