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HomeMy WebLinkAbout020-1293-20-000 Q c ~ o I w , O M d 0. ° n I O N I' I y m N ~ N E H 2 y ~ N L r O M o z° o c _ LL o D Zt- Z N ~o > a ~ I I 3 cn d, ~ I rn z = °o z £ m a r-- (w d m 0 o z d c I N z a ° o tnF-~ m (D z 0 m E '2 '0 0) 0- (D ~ I N c N ~ 07 2 o c O Z H Z o N Q z fn cl m N y N 0 R d `l C N c (O N O O E „ o o c a t m WSJ = N LO N I 0 0 0 z •►v ; C a a g tn I N = M 0 N to J U = rn rn 7 7- - 0 E o _j 0 N U O 7 ` m 5 a N 1 d 'D N a) :31 N r- a~ d Q } e1~ 0 N N 00 O j, 0 N c O C c E 0) - co EN E CL CL z: A F E a-i C w N c O L L Qaj N H' (O N CO) y' O N= 0 0 N 'E U 0) 1 L EL al rw• c~ a m .2 d m c cu E A 0 IL 0(O 550 ° 4 o (D ° h O eH a try ) N CY) N Or' d o.-o z ~ ~ rn r O ~ I 3 O N 'b c F p O cL U :2 co N O C L O > C Z O O IL Ca~p (D (D to a) E Q w y m U a3 ~ v a a) Ix y rn z ; Of O Z d 0 m n H d z 0 c a is O Z a v ~ o N F N Z E ~ M 7 Y a) F- c C O = O O U O Q C - S Z D Q z C C ~ a7 CV E m' y O V N d a7 w ~ C N N dl ` p {yam d E N ° > = U - ° a co 0 L _ z 3aaa a c N • 7 O N of M w w J V T m } O S cJ a) ca O N - E 0 O co N a O m O O N o v m Q} in co ~j Al O ° O O` W C ba O C C ~O O O C a C p 0 q~ V L6 H m ( E r N O Z O . FC O N y CO 2 CO r (n F- C a) ,r}V~) N • N~ 7 01 O C O U y O S O Z (n O ~ CL L) 1 4) E ` c c STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER--5-,d hf M / [ 6R ADDRESS BOX 0- 2-1e-- I ~ //0 D~VN W:t sya (~~L-~ SUBDIVISION / CSM# 110AAF/20 HILLS LOT Z3 SECTION~_T Z.y N-R_1 , 1 l Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM B.M. IXZ woo ' THE E/: /00.Do, C L ~tK y G _ p , ~I HOUSE AKAGE i G F.Prl- /VA MT£ 2 NRTE Xz I A12E4 ~ ! Q I \N ~oS' IG NS~'~c . l; YAQ/ A Go i ~ BI~~ ~P2ut~ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: Toe J (K Z N L/ 3 I'y S /P.~ 7"7i~ ALTERNATE BM : ) a p e~ No Lts m-o u n rim vt TIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ✓ Liquid Capacity: lS6S Setback from: Well 4-f- House Zo' Other g ? ~b E~~- ref H~ Pump: Manufacturer Model# Size Float seperatiorr Gallons/cycle : Alarm Location SOIL ABSORPTION SYSTEM Width: 5 Length 6 3' Number of trenches 3 Distance & Direction to nearest prop. line: 7,7 '7,-5 -t- A'tf V__ Setback from: well: gz, House_ 3 Other ro 7-,41Y,1-- ELEVATIONS Building Sewer ST Inlet. / e S ST outlet / z, z J PC inlet - PC bottom < Pump Off - Header/Manifold f2 -7 Bottom of system ~s.SB Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER:,/_~2i_y es Z_ INSPECTOR: 3/93:jt -Kiis`coTxSepartmeenntDo IQicut"t 29. 19 Q'i'V./4 ~~1SHLTMRT? p~Y. g County: Labor and Human Relations Safety and Buildings Division r^IINST INSPECTION REPORT (ATTACH TO PERMIT) sanitary mit GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village RTown of: State PI . KILLER, SAM CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: ME), 61) 02e 1293 TANK INFORMATION ELEVATION DATA A9300341 / TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark a~ Dosi n Aeration Bldg. Sewer H ng St/ Inlet TANK SETBACK INFORMATION St/,, Outlet TANK TO P/ L WELL BLDG. Ae Intake ROAD Dt Inlet ~n Septic NA Dt Bottom Dosing NA Heacler/A4M Aeration A Dist. Pipe y - Holding Bot. System r Ain PUMP/ SIPHON INFORMATION Final Grade' Manu er Demand Model Number GPM TDH Lift Friction Ft Loss ea Force mai ngth Did. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length " N0.Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N [ -HTNr - SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEAC Manufactur SETBACK INFORMATION Type O 17 lr h CHAM T Model Num . System: DISTRIBUTION SYSTEM Header '74 /v Distribution Pipe(s), x Hole Siz x Hole Spacing Vent To Air Intake Length Dia. Length 60 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Ove(3 Depth Over " xx Depth Of xx Seeded/ Sodded Mulched B.ed-'Trench Center - 7 QQ44-YTrench Edges 5a - <-7 Topsoil o ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.27.29.19 (LOT 23~ HUMBIRD HILLS Plan revision required? ❑ Yes EJ- 0- / Use other side for additional information. W SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: j Cl,, DA~/ SANITARY PERMIT APPLICATION v'~I`Ir~i■~ 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. PROPERTY OWNER PROPERTY LOCATION SA LF- SE % N(-%,Sz7 Ti ,N,R /7 (or(TD PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # © .#22+C Z3 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR GSM NUMBER 140 O S- o/t; 3VSG -4 '71.9 14UM131RD MILLS II. TYPE OF BUILDING: Check one CITY ro EAREST ROAD ( ) ❑ State Owned ❑ TILLAGE (4 V D So 4 u E s u a E LA /Y E ❑ Public ®1 or 2 Fam. Dwelling-#~ of bedrooms f- ARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) D 2 V X29 Z p 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an j 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-ln-Fill VI. ABSORPTION SYSTEM INFORMATION: -sP f yo.go' 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 16, SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) g~ ,o: ELEVATION I 1? :84•$o. ;9o•5e -7$O 3 7 r 9 Y S g 3 8440 Feet sb Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New istin Gallons Tanks Concrete structed glass App. Tanks Tanks _71 F-1 Septic Tank or Holdin Tank X I CSC We 13 E /Z_ LiftPum 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 Signature: (N ps) MP/MPRSW No.: Business Phone Number: Doug STe- o H Z E C_ /Y ZY 7 3 2 3 3 Plumber's Address (Street, City, State, Zip Code): BOX 0/4z- 1Y9P1AACHM0yo WZ syoi7 IX. C LINTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued jissuingAg nt Sign r (No S ps Approved ❑ Owner Given Initial Surcharge Fee) 147- 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 a!/ro 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. i SBD-6398 (R.11/88) SANITARY PERMIT APPLICATION 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. 10 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. PROPERTY OWNER PROPERTY LOCATION SA MILI-F-11- ~F '/a Sz7 Tz7,N,R / E(or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # coy41 ? CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER I~.. CITY NEAREST ROAD IL TYPE OF BUILDING: (Check _ono- j1-I State Owned E3 VILLAGE' N21 TOWN : HVD $C? 3kul SP ycS LANE ❑ Public Ell or 2 Fam. Dwelling- # of bedrooms { PARCEL TAX NUMBER(S) III. BUILDING.USE - (If building type is public, check all that apply) t2D~ 129 2 0 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 12 ' Service Station/Car Wash 4' ❑ Chur)'School 8 ❑ Mohile Home Park 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑.Other Specify' X IV. TYPE OF PERMIT:: (Check only one in Iine.A. Check tine B if applicable) A) 1 ® System, 2 Systeanement 3. El Tank Onlyent of 4.0 ExReconnection of isting System 5 El ExRepair of an isting System B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) Y r Non-Pressurized Distribution 'Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ "Holding Tank 12 ® Seepagi Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit— Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill V1. ABSORPTION SYSTEM NFORMATION: 1 yd.9pr 1. GALLONS PER DAY 2. A6 ORP. AREA 3. ABSORP. ALtEA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED'(sq. ft.) (Gals/day/sq. ft.) (Min./inch) t %1.4e: ELEVATION -75o 4,1,7` 9 t/ fa- 04-po Feet tr . Sb Feet \,CAPACITY VII. TANK Site i n allons Total # of p ' Con- Steel Fiber Plastic Ex er. Mew xistin Gallons Tanks Manufacturer's Name Prefab. Concrete INFORMATION App Tanks Tanks structed glass Septic Tank or Holding Tank X ) d g ! w 7F F1 Lift Pump Tank/Si hon Charf b'er Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume r4i0onsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (Nq Stamps) MP/MPRSW No.: BuSiAess Phone Number. Plumber's Address (Street, City, State, Zip Code): IX. C LINTY/DEPARTMEN ~U., E ONLY ❑ Disapproved ` Sanitary Permit Fee (Includes Groundwater a e ssue Issuing A "m big ur (No St ps) Surcharge Fee) Approved El Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD 6398(R.08J93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber YfiiY''~Yt >•f tsR'd. T!¢-t r.♦+.. J )t f t. ♦fA. . • + - a a. a♦ a i a. 4 i• i 1 i 4 4 E♦ a fa° R ..<.A t~ i E b ~ S! i i:1~}a, lai_. . I 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) r N N SOUT14 GD? _ tINE_- 3_y5!3pb (iYOJY!ILE~__ Tri VV = D a m m o - _ to _ Ly N r 1 x N O f1"1 N o+ m rn r~r1 A U 8 ® O,n o r ° y r` o a p m > 7d r rN CD U I U m Z s l x`11 6~ m # 2 t ~ s-o i , ~ I ~ c O ~ ` O C v ' I m p3 ?t I" n I d~' r' J O LAI~ p r1 tAl °o x y a g r m Tn m 0 0 rn +F °I ~u a { n N CA ri m o w b l.!1 Ly 0 -Tl Ti • I O Rt ttn i ( t r i `Q i a f D H m_ 0 m Q W N Q N y r'I P I d t I l p ~ G 1l'1 m o I m O n, , Z Z m a i s - O X o 0 C t' i ~ b I Gtr ~ ~ ~ 70 fi b i b b m I 1 f n 'D I 4 # i ~jl f N i t i ~ I W I , f 1 i ~I m Ns *3.. 7~ 0 I s z H o 7 z r- I c r eft LA LA 4DIL R SANITARY PERMIT APPLICATION In accord with ILHR',83.05, Wis. Adm. Code COUNTY "IYI se" STAT SA 7v2on PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than Y 8% X 11 inches in size. ❑ C / if to previous application -See reverse side for instructions for completing this applicatioel. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION S L Q 5E % Z%,S -e 7 R1,9 E(or PROPERTY QWNER'S MAILING ADDRESS LOT # y~ BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned VILLAGE : O C nA , e ❑ Public R1 or 2 Fam. Dwelling-#~ of bedrooms . PARCEL Ax N J Y~G L✓~ Ill. BUILDING USE: (If building type is public, check all that apply) Q 7- L 3 - Z c7 1 ❑ Apt/Condo 20 Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 12 New 2.E] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 El Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION ys 00 SG _r GOO g .IN Feet . J Feet CAPACITY VII. TANK Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks oncret glass App. Tanks Tanks structed Septic Tank or Holding Tank /too saj/ 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) ?~~Z-P/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): AOX #/.Z L k !ti Ica n I AIX IX. OUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit F e (Includes Groundwater Date Issued Issuing ent Si re ( Stam Approved El Owner Given Initial Surcharge Fee) Adverse D terminati n / X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. -Your sanitary- permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit 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. Vlll. 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) n Ilk. tA ? 0 P w ^ D Co b' u R c Z ~ ~ by 04 W w c `v P lk p 1 °o tA • °a r v ~ y ~ J' y J N ? a ~ v1 Q~ O P ~ 1 A~j VV g I tir i~ 0 a X11 { I i A w~ ioi-l k~ VVV I-V 0 it t O~ I I 1 i l v u k Y P I- I{ o ~ ° b Ll c S Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page i of 3 .Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code . COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but t Cko r-A 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 OWNE ~ PROPERTY LOCATION Q 71'LLCl GOVT. LOT S 6' 114 NE1/4,SZ~T ~q N,R / E (or) W RAWERTY OWNE ~S MAILING A S LO # BLOCK # SUB . AM 0,~ CSM # 91 cis CITY, STATE ZIP COD4 PHONE NUMBER [:]CITY VILLAGE OWN IN REST ROAD f~ Sc>n-) 1~{ I ( ) ts4tL4iu451146 Lzi) rd New Construction Use Residential / Number of bedrooms Addition to existing building j) Replacement ( ] Public or commercial describe Code derived daily flow S C> gpd Recommended design loading rate bed, gpd/ft2 O.'% trench, gpd/ft2 Absorption area required bed, ft2 SGS ench, ft2 Maximum design loading rate bed, gpd/ft2 n,T trench, gpd/ft2 Recommended infiltration surface elevation(s) 'SE 4 ALE i~ n R 3 ft (as referred to site plan benchm Additional design / site considerations "MW046"' C~ MIf ACdtA ICE-r-A sE Uy 54_6 Nx t 14 Parent material Flood plain elevation, if applicable ft S =Suitable for system CONVENTIONAL M~~O,,UUND IN- ROUND PRESSURE RADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem s❑ U ®S ❑ U g S ❑ U S❑ U S❑ U ❑ S 211 SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boulxiary Roots Bed Tmrtdl 0_13 Q.-A 0,S ca 0~3 -1Z V4 Ground ~7-so I 'i 5 ® rh G O.1 O.T 45~ ft. -1/ n , a T _T Depth to limiting fact tQr Remarks: Boring # Z P` Z ~S- 1Ca V4 r C 0-7 :o% Ground elev. 3s ii 4p r Y~ Q.7 lo % t,h- ft. Depth to limiting Qr ~fIt Remarks: CST Name:-Please Print Phone: ov&y Oki, )Sop,/ 6 9-0 Address: 6 , dy r J Signature: r r~~ Date: / / l~ ~ ~ CST Number. 34~ PROPERTY OWNER 1.'-L SOIL DESCRIPTION REPORT Page2 of PARCEL1.D. # AJ Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourg Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench -Z 0 -A 0 1-7 3Z C- Ground 9 -21 2 S j y k 4 S /til I / c).-7 6 A4 eley~ eft. g3 53 , 3 d S l o.~ :off Depth to limiting Remarks: Boring # -Z 0A :6 ki 2.1-46 ILK?- Ground elev. 4-116 k 4-14 g:2~ ft. Depth to limiting factor >C~, Remarks: Boring # t2 Z I l ri, c r rht ©..4 k ti Kr t A 0-7 I sK r, I / o z 0.3 ?-3 is 414 Ground { ) 7 ~e`feS$ft. /a` e,4 s M rh I l 7 C~ Depth to limiting fa for } .g3 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) 'S YST&-N EUV AT I V ^J S r ~4L 3 O fi 3 Ak)bl 196,7i5. I~ ® , kkr-~04 es BE T wE-EAJ gl)'S7 a N a $~Tw~~,~ g3 s A-vA ~7.q Ldk, 51 I LaT L lay j;-A 2dOt -rc WES-, • ~ LaY L A-, Z s o A 4°~O t I CAD 45 g- S IX D got) , 36 o~ S 26 t -roSacrca Lai L 1/Jtf E L~ ~y S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER~s9hi ADDRESS_ Re.Y FIRE HUMBER __700 CITY/STATE_~u A~`l ZIP I`5~01~G PROP ERTY LOCATION: S~ 1/4 ,/y~l/4 , SECTION_,LZ, T -:L7 N-R Sf W TOWN OF/////~"~A St. croiX county, SUBDIVISION-11a,Wdic~` / IV f , LOT NUMBER z3 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix county accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification *form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1). the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/Ile, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning officer within 30 days of the three year expiration date. SIGNED: ` DATE: St. Croix co. Zoning Office 911 4th St. Hudson, taI 54016 STC-100 This application form is to be completed in full and signed by fthe owner(s) of the property being. developed. .Any inadequacies will only result ~n delays of the permit issuance. ,should this development be intended for resale by owner/contractor,(spec house), thenta 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 -!5E 1/4_1/4, section ~Z, Township Mailing ~l address -Ar rZjf L_. /~te ref S® e•- ~ Address of site -740 ,8/u g- r'rra oa. Lac. subdivision name Lot no. Z ~r Other homes on property? yes No Previous owner of property _#I. e000"06 Total size of parcel M. 1't/ Date parcel -was created 7 !'Are all corners and lot lines identifiable? Z _Yes No is this property being developed for (spec house)?.,Yes No volume/492/ and. Page Number dZ as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEbD 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. _-s O t2 0 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._SO signature of applicant Co-applicant Date of Signature Date of Signature. DOCUMENT NO. I STATE BAR OF WTSCONSIN FORM 1-1962 11 f.r n'+ED FOR RECORDING DATA I WARRANTY DEED- 502209 ; von _ ULIPAC,L 8 ~i~~s ors icy - ST. C;IOIX CO., 411'1 i This Deed, made between Humbird Land Corporation, , V d foe R.-cord A Minnesota CorRoration authorized to do business 1 in. Wisconsin JUL 12 1993 Grantor, and.... 54M..E.... Miller.. at 4:20 D,1 of Deeds i Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... RETURN TO i conveys to Grantee the following described real estate in $.~.e... r9 % OJsGI ea nJ lit..' J County, State of Wisconsin: Lots 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12 in the Plat of Humbird Hills, Town of Hudson as filed Tax Parcel No : and recorded in the office of the Register of reeds forj St. Croix Couaty on April 7, 1993 in Vol. 5 of Plats, Page 99, Document No. 497107. Lots 13, 14, 15, 16, 17, 18, 19, 20, 21,32, 23, 24 and 25 in the Plat of Humbird Hills 1st Addition as filed and recorded `'I in the Office of the register of Deeds for St. Croix County on April 7, 1993, in Vol. 5, Page 100, Document No. 497,108. SN $ ~bv~~ This x13..nRt......... homestead property. (W (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And...Huolbi warrants that the title is good. Indefeasible in fee simple and free and clear of encumbrances except easements shown on the above mentioned plats. and will warrant and defend the same. c Dated this ........12th day of ...Ju1Y.......................................................... 19..93... , Humbird Land Corporation, a Minnesota Corporation authorized to do business in Wisconsin ............................••--..................(SEAL) BY_.... (SEAL) • Austin J. Baillon, President - .........................•"-------..._....-•---•••---._............_.(SEAL) ----...._........-••---......._..._.................................(SEAL) r • • AUTH13NTICATION ACKNOWLEDGMENT Signature (a) STATE OF WISCONSIN County. authenticated this day of ..........................119 Personally came before me this day of __.July .......................1 19.9$.. the abbii"n%q,ed • - - Au;~ti.n__d:.• Bail-lQn,•- President .off o tit, t :::;:;-~r TITLE: MEMBER STATE BAR OF WISCONSIN rr ` ' y b' d an or oratio ~ ` (If not. n authorized by 706.00, Wis. States) to me known to be the person .__.....0 ~ '~ecu;ad t • ~ } foregoing ' strument and acknowledgA4e as It Q h~d~ t THIS INSTRUMENT WAS DRAFTED BY s-J ~f 14 N - , 1 I-~ ,7/.4•Q 1.• • ~•M Kueppers r..Hackel..&.XuepRera it 1350..Capital..Gentt`et._St._.Pau1,--Mti_5.5.102_ Notary lie . Al . l .............County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: *Names of persons signing in any capacity should be typed or printed below their signatures. ` WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leval Bl.nk Co. Inc. FOHX N•. 1-1362 blil-ukee, Wis. ' r^ i