HomeMy WebLinkAbout010-1022-40-100/*
YlVisconsiDepartmentofCommerce PRIVATE SEWAGE SYSTEM
Safety an~.$uildings Division
. INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [Privacy Law, X15.04 (1)(m)1.
Permit Holder's Name: ^ City ^ V' e n of:
~'r1~er~c~`)'"ownship
Smith, Harlen & Charlene
CST BM Elev.: Insp. BM Elev.: BM Description:
9~ s
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic ~ O(,b
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO P/ L WELL BLDG. vent to
Air Intake ROAD
Septic ±~Q ~ ~ ~5~~ Z.~ ~ ?~.f ~ NA
Do ~ NA
Aeration N
Holding
PUMP /SIPHON INFORMATION
Man Demand
Model Number PM
TDH Lriction m TDH t
rcemain Length Dia. Dist.
SOIL ABSORPTION SYSTEM
ELEVATION DATA
county$t. Croix
Sa n ita r~ i~®r~ra~t3No.:
State Plan ID No.:
Parcel ~`~°1022-40-100
STATION BS HI FS ELEV.
Benchmark ~ , 3 <b d
/) 9~ ~~
Bldg. Sewer ~+' D~
Ht Inlet .SZS~ ? ~ 4 S~
S~/ Ht Outlet S sZ ~v ~~
Header /Man.
Dist. Pipe ~~~~' .y
Bot. System ~~ T i ~' T ~~" Q
Final Grade x
a0, Z
t cover
3 - 9
oa:
BED / T E Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN ~
'~ ~ ~ DIMEN 1 N
SYSTEM TO P / L BLDG WELL LAKE /STREAM L ,nu acturer:
SETBACK
,
INFORMATION TypeO
C / Z / i ~. ~ Sl ;~ OR UNIT um er:
Mo e
System:
am, Z
DISTRIBUTION SYSTEM
Header /Manifold
Length a ~ u ~ Dia. L Distribution Pipe(s)
Length ~,~ Dia. ~~ Spacing ~ x Hole Size
N x Hole Spacing
/~/'/~ Vent To Air Intake
7 Z,s ~
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.) Inspection #1• ~ /~~/00 Inspection #2: / /
Location: 2455 170th Avenue, Emerald, WI 54012 (NW 1/4 NE 1/4 10 T30N R16W) - 1030161370 -Lot 2 /I
1.) Alt BM Description = S£ ~a f C err,rr S ~~
2.) Bldg sewer length = 2 S ~ ~• <w~cc~' ~ a w,se ~('e
-amount of cover = >/ P `'
Plan revision required? ^ Yes (~ No
Use other side for additional information. ~ Z~ Qv
SBD-6710 (R.3/97) Dat Inspector's S ature Cert. No
~- z ass- 1 ~ ~ a4~-
~~isconsin
Department of Commerce
SANITARY PERMIT APPLICATION
In accord with Comm 83.05, Wis. Adm. Code
Safety and Buildings Division
201 W. Washington Avenue
POBox7162
Madison, WI 53707-7162
• Attach complete plans (to the county copy only) for the system, on paper not less County ~ /f
~~~ C
~
than 8 vi x 11 inches in size. {r~
~
• See reverse side for instructions for completing this application state sani~r~mit Number
~3
Personal information you provide may be used for secondary purposes s application
^ Check if revision to pr
[Privacy Law, s. 15.04 (1) (m)].
State Plan Review Transaction Number
I. APPLI ATION INFORMATION -PLEASE PRINT ALL INF RMATI N e
Property Owner Name
' Property Location
i4 v4, S ~Q T ~~ , N, R ~E (or
Property Owner's Mailin Address IO_
Z ~ ~ t~`` Lot Number ~ Block~tmber
City, St ~. Zip Code Phone Number Subdivision Name or CSM Number
N. TYPE F B i I (check one) ^ State Owned
~ ^ It~ Nearest Road
^ VII age
Public 1 r 2 Famil Dwellin - No. of bedrooms own of
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
(~ ~ 0 -- ~ 6 ?~Z- t-+-O -~ d d
1 ^ Apartment/Condp Lo .moo- t `. t3~t_
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 t~ox on line A. Check box on line B, if applicable)
A) ~ ew 2, ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5, ^ Repair of an
-_____System ________System_____________TankOnly______________ Existing System _________ExlstingSystem
B) ^ A Sanitary Permit was previously issued. Permit Number Date Issued
V. T PE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental ~ Other
11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank
1~'~eepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy
13 ^ Seepage Pit 43 ^ Vault Privy
14 ^ System-In-Fill ~x ~ ~ '
VI. ABSORPTION SYSTEM INFORMATION: • o ~ 9S, o
1. Gallons Per Day + 2. Absorp. Area 3. Absorp. Area 4. Loadinlg Rate 5. Pert. Rate v., 7. Fina ra e
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/ q. ft.) (Min./inch) EI ation
~ 3 - ~ -~' eet Feet
VII. TANK
INFORMATION Ca aat
in allo s
g
Total
# of
Manufacturer s Name
Prefab.
Site
con-
l
e
s
Fiber-
Plastic
Exper.
N
E
i
i Gallons Tanks concrete e
t g{ass App
ew x
st
n strutted
Tanks Tank
Septic Tank or Holding Tank ~C/ ^ ^ ^ ^ ^
Lift Pump Tank/Siphon Chamber ^ ^ ^ ^ ^ ^
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) dumber' 'nature: a s) MP/MPRSW No.: Business Phone Number:
Plumber's A~ress (Street, City State, Zip Co
1
IX. COUNTY /DEPARTMENT USE ONLY
^ Disapproved Sanitary Permit Fee tlncludes Groundwater
Surcharge Fee) ate SSUe Issuing Agent Signature o Stamps)
+~
~j 4pproved ^ Owner Given Initial d'~
~a'~ o~/Z
Adverse Determination • r
-
C~ONDITI NSOVAL/ R ASO~N$ FO~R~~DI~SAP VAL~ ~. ~,_~_ n
c
SBD-6398 (R.12/99)
DISTRIBUTION: Original to County, O~ copy To: Safety & Buildings Division, Owner, Plumber
0.
INSTRUCTIONS
~. - ,
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a 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 and Buildings Division, 608-266-3151.
Tb be complete and accurate this sanitary permit application must include:-
I. Property owner's name and mailing address Provide the legal description and parcel-tax number(s) of where the
system is to i7e 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 on 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 for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/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 1/2 x 1 1 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 1 15 form; and F) ail 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 contamination investigations
and establishment of standards.
;',
PLOT PLAN
PROJECT Harlen Smith ADDRESS 2453 170th Ave Emerald Wi 54012
NW 1/a NE 1/4S 10 /T 30 ~~ /R 16 W TOWN Emerald couNTY ST.CROIX
5/25/00
~ 3
MPRS Shaun Bi rd 226900 DATE BEDROOM
CONVENTIONAL XXX IN-GR D PRESSURE CONVENTIONAL LIFT HOLDING TANK
SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE
MOUND
HOLDING TANK SIZE LOAD RATE •6 ABSORPTION AREA 763 # of chambers 24
,BENCHMARK V.R.P. Topof Steel Fence post ASSUME ELEVATION 100'
^ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 96.38/95.8
B.M. 98, _ ~ALt. B.M. 366' Property Line
84'
5' 27 ~ B-2 Vents
B-1
3
65' _ B,_,5 ~ ~ ~ ~ With no
1'
53'
15'
2-3' X 77' Trenches with 6' spacing
Vent
>12"
of Cover
6' Long116"
ve
Sidewinder High
Capacity Leaching
Chamber with 31.8
f\t^2 per chamber
.LGrade at System Elevation
D I ~ H R ~ in accord with ILHR 83.05, Wis. Adm. Code
.•a° •ni~W~MAw+tM
• At1acA'c`omplete clle plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
rat limited to vertical and horizontal reference point (t3M), direction snd •/. of slope, scale or
dmensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL. INFORMATION
COUNTY
-~~ Coo>'x
PARCEL I.D.1
REVIEWED 8Y DATE
PROPERTYWVNER:
`~ ~ PROPERTYLOCATION
'
~
l!r ri ~ Q011
T. LOT tl4
t/l,S T ~~ ,N,R /~ ! ( W
PROPEL UNNER:'S MAIU~~ ~RESS
r LOT f 8! ~~ SUBt). NAME OR CSM R
CITY. STATE ZIP CODE PHONE NUMBER
G'
'
' ^CITY ^VILLAGE ,®TOWN NEAREST ROAD
~ n cvoc+ V/.~
7/39
) 2,1' ~ ine,-~c~r/ ~O~ ~r /e ,
~' New Construction Use ,Q~J Residential / Number of bedrooms
j ] Replacement ( J Publ'K: a commerdal desabe .
Code derived deny rbw _y5a 9Pd Re~~mrttended design bad'ing rate • 5 bed, gpolft2~~trench, gpd/ft2
Absorption area required 90D bed, ti2~ trench, ftZX Z Maximmtxn design baling rate • 7 bed. gpolftZ ~ $ trench, 9Pdlft~
Recommended inititration surface elevation(s) ~. ~`i ~ 9638" T #a 95;$ Dft (as deferred to site plan benchmark)
Additionaldesign /site considerations, 2 ~ Te S
'
S fir! 75
_
_ _
Parent material s " ~ a r~ s ~ Flood plain elevation, i(appCKxbte .__N~__ ~_ ~ -
S ~ SUItaWe for system
U= Utuuil~le f« s rem t)ONVENT10NAl
~J S^ U MOllr10
S O U PRESSURE
,L9 s a u AT~RADE
j~ s^ u SYSTBd Flll
^ s ,~ u F10LDNIG TANK
^ s :~3'u
SOIL DESCRIPTION REPORT
BArirKJ #
Ground
elev.
99 3~ it.
~ ..
findtirg
~-Z.
Boring ~€
~Z
.... a
Ground
9~tt.
Depth b
P'~n9
~ 7Z''
Horizo Depth OominantColor Moities Texture Structure ~ ~~ Roots GPO/ft
in. Muctseil Qu. Sz. Cor>t. Color Gr. Sz:
Sh. Bed Trerxt
/ ~ ~ ~Z 0 C. )
Si/ /
Sb /~Jl~ r QS ~ ~Z '3
.3 33-s 5 y ~.. 5/~-- z~s~~ ~~ / -.~ •~
~j so-G8 s ~ y /s Z S cw • ~ •G
~' LS-gZ ~" y ~ ~ ~ S s ,7 , 8
Remark' ; 1 ~ i 1 ~
• I ~ - ,
l
~'7 ~
~5' ~Z ~
/l/o -~ e.
Si ~
."r~ v~,-~
Qs
2 I
•Z • 3
~
$- 't /f~
Jr' C7 ~
S~v .~
_ r
.';1 V
Vv- ~~..
...1G
CST Name:-Ple:se Print ~~~e ~y /~ // ~ Phone: ~ ~ ~ ,
J vG!/XSO~'~, ~ ~ ~'
Address: ~~ ~ ~Q i r~ sf ~p ~C~w ~'r~- ~ C-r~, _'Sr5/dC~ ~
~gnalurr. / ~ -
/"~~~ ~. _ ~ / Date: CST Number:
- ly 9-~-Q~ zzo853
Boring #
3~
Ground
elev.
~~,,~ / n.
Depth to
smiting
for Z~~
-Z_
Boring #
Ground
99 r7Zft.
Depth to
limiting
lact«
~~
Boring #
S~
Ground
elev.
9 +/7 ft.
Depth bo
Gmi6ng
~~t~ ~'
Boring #
Ground
elev.
K
Oeplh to
limiting
factor
Norizo Depth
in: Dominant Color
Munsell Molites
(~, ~, Cont. Color
Texture Structure
Gr. Sz. Sh.
Consistence
.
Y :~ GPfr''ll
.Roots
K
~ Bed:7r~Y
O l7SYR5 Z G Si //
~5b QS 2
3 /7-65 5 ` `~ S Z.r~ cuJ ~
G5-7 ~l
~ ~ ...
s~. r
.?~5 ~
~ I rrI {~r i
Remarks:
y s% ~ /r/ Y~'r c w Z~
3 s3 ~ y~
s
z~ s>~
~w a ~~~
.
38-50 5' '~
.Zr~ s~
GLJ ,
z~~~_ , ~
5 so-At .~ Y ~ Z~~ 6 ~n~--
Remarks: _
l
9-27
7-~ Y~ y y
s; l
~
r~ /
c w
z ri.,
,,~,
.3 z~-y~ ~~! ~ S~ m
~
~ Y5-73 s .~Q..~~6 `
S
.~
Remark' s:
nemarxs:
•z ~ s"3 / 70~ St,
7rs-X65-7139
B,N, ~ l = /oo.o'
,C31 = 99- 38
B3 = 9G-6/
ay = 99,72
t~ s = ys, l7
QM.~_ 98~ _______~M ~ z
N
V
$y• sr
,V ~
z~ BZ
~M
h .~
w,
0 s
65' Bs
h
53 '
B3 6 ~ BN
M,cs i z2og53
/9-~-9'7
7i5-~gy-33 78
~~~~ s ~41~. 1 ~ 5D~
Ga.~y ~X;s ~„9
Plop, r 1
_ _ s,~f~m ~ I
Pfdp. 3a.. f ~e I
ON~i O~~Oh~ I
1~
~~
.~ ~ooosAl. I
Sep-f,'` ~n ~ I ~
Leon ~`II
'~_ ~ ~jt i 5'i' i n A ,/
1""), 6/e, dt~i olG fr 1 r i
DEC-09-99 10:20 AM P. 01
I..~I,L H t~ In accord wllfT ILfIR 87,05, wis, ndm. coeo
" COUMY LL
Ahat~i;coir+jale~i cTle pl4n on pe(~er not fees Ihen 8 1r1 x 11 Incl+sa In dle, plan muse Include, but ~7• -y'~!X
not Gmlted Io verilcel aM horizonlel reference point (eM). direction end ti of clopo, dcals or PARC'l.i.D.!
diener,sio/,sd, roAlr arrow, and lotltion en0 dislence to nearest rosd.
APPLICANT ikft)Ii~tATION-ht.EASt: pliiNT All ThIfOAMAT1oN aEvlCwt:b6Y OA1F
PROPERTYQNNEF PAOPErITYLOCATION ~~ •~
- ~y
n'' /~ ~/~~ ~ GDM1IT'. LOT v! ~"ul.s T ..~~ ,N,11 ~~ t (u~W)
tAOi•'E ~NCFt'S MA1lING A~ITESS ~-~~ "~""-- "-~`'
f 3 ~ 7P ~. LOT I elOClc 5u60. NAME orT CSM s
CITY. SThTE '~ Jl~' '
IIP CODE PRONE FJUTAOEIi ^GTY ^vIIUGE OWN NF9JlrtEST ROAU
~%r.n ~c~c •, J '. (7/SI ~6 r%- ~7/.3~ in. c' i~A~. 70~ ~/C'.• .
,(~lj New Construtxion Use p~ tiesldential I Number of bodroon~s _ ~ 5 ~
(I Ret~tacemrnt I I Pub1'c 'a-desube ~;'~ ~ •
~"6Z-~
Cade derived da~r bow ~~ 9I~ Y~_ ~ Fieaorrwr~cndcd deslpn badn9 r ~ =~ bed, gpdRt?~~bench, 91~~t'
Absorption area tequlrrd ~_ ~ i X Z M3~dmur~ design rate . ' 7 bed_ 9PdAt2~$ `'~bencF~, gF~d/lr?
Hec~orNnetfded Inf~tra6on suAace efcra, r. •.. 963 ~ T'tL 9s•$ a~ referred to site plan berx~rnark~
Additi~t+gf Resign /site cmSlderiEa:s _ .:? ' ~:.~ ^ r ` S ~~~,~, 15' . .
Parent n+alerial~~.• ~, ~ ,., s ' ~~ • ~' t'lood plain elevation. Kapp~icable. /~~ n
S . Sellable Fot system wF1v@rTlotrAl bteuNO ~cgol vl+ESS~IaE Arc+uoE sYSTet FILL o TAkC
U = uruuitabfe for s tent ~ S ^ U S ^ U ~9 S ~ u ~ s ^ u ^ s ,~ u C7 s'u
SOtI DESCRIPTtbN gFanAT
Boring A
G(ound
per.
4:'~ IL
i~b,
j S~ ,:
Horizo Deptlti
i Dominant Color ~~ Texture Structure ~
~Y
Roots Grt
n. MurtSelt Du. Sz Cont Nola Gr. Sz.
Sh, Bed
//
Z- 6- 33 7, 5 y ,_~;l /mar s ~~. ~; /~'.-
I cG.~ -Z- n, • Z
3 ~
~
so-G~
~ ~ ~ _ ~
.~
/s
Z
~
s
cw _/
5
S' L~- L .may " `~ ~ ~
~ kG ~~ . 5 ,
~
s /~ .
'7
1
I
i ~ -~ Z
~
_
I/lam
iit3rYi
.~
•3
•G
.~
_g
EorG'1g S
Z.
Grourd
eten.
9~~t_
OepAt b
imiGng
~7
~ 72 i.
..c. uor
Remarks; ~,
CST N,rn.•~I.,.. O.L~ • -
r
•3
.~
.~
. ~
Address: ~S C~ (?/ 7~- ,~.~ .~:.7(.7~/•~-Lt~; •~ ;,- . ~rnn z / .._ .-.
~ga7Fa~: -- - -- -- ~ra-. T _
~e ~~. /4lC-t-~# ~.s-{.-)tiJ n Dale: CST Nunba; . -.
DEC-09-99 10:21 RM
Bori p
3
Ground
elev.
9~,6 / n.
IJep~t to
Cntidng
~1acla Z.
_Z
goring N
Gr4urtd
~.
99.7Z~,
Oe~,lh to
imiMng
~l« g
~~
Boring N
Ground
t:~ev.
9 ~/ R
OepQ11o
SSini6rg
=~.iL 4
8o<<ng II
Ground
elev.
K
OepQt to
GmiGng
facia
P. 03
DEC-09-99 10:21 AM
,« ti
a BOLDT'S PLUMBING ~ HEATING, INC.
820 MAIN S?BEET
BALDWIN, WISCONSIN 54002
(715) 684.337$ • fax 1715 684.3144
BILI TO: r' ; ~ .''~'; ~ ~ ; '
'' '.
., ' :i: ~ '
PRODUCT DE5CRIPTIO
h1tJFl~f-i+al..,•O~a Y ~'AL I~~,POr+''f'
~:
,~ ':iUEi#"17 S~ C i':11•~ C?F' RL. L_ Fly.
F..
i~\'
r'
t~:..: ,.
r .
INVOICE NO.:
INVOICE DATE:
PAGC:
JOB. ~,;•, i'. !.!;.
P. 02
a ~~
~_
~~~
~..i ~' i.. ~ .. ':. I ~ '.' C'•
COST. ID.: , T'! T 'ti ~ I ~",
P.O. NUMBER:
P.O. DATE: 1 U!'1.5 i `~d'I
SALESMAN:
DEC-10-99 09:12 AM
Ogre r;
,. , . ~Ar/e~J .~,y,;t
.~ys3 i7p"~-st
7/,5- ~G J ~ 7/3 9
ail = 99, 38
B z : q~ . 33'
B3 i 9~,G/~
~s = 95-1~~
r~
V
'. J
~~
h
~5~ 8~q,~k
""~ '~Looo Q/.
6 ! B~ Se~~~~~~ ~
~a. Y~-
P. 01
yv'cio.,~YI {fir
M~csT~ ~2og53
9 - ~ - 47
7rS-~~l1-3375
c, w~orc. Irl~'-
J
~M ~ 9$, 3M'~ z ~ S ca ~e ! ' S0~
~--~~ -_ .~G~
BOLDTB PLBG & HTG Fax ~ 715-684-3144 Jun 01 ' 00 1045 P02
~~' i~:.ia;.M.a - :- - - --•--~ - ---......... __.._ COUNTY
KIIsZfi~ ~i~t:'s~i~ plan ort p^p^r rot lass Ih^n O 1~ x 11 Ineh~^ In d:~. frl^n n^,st Induda, but ~/ • CrDi~
nel ~ tsd W +Jsetloal and hurl:oMal talaranea pefnt (9M~. diracibe ard~% or sops, aeali a iA4~lID.I
6M~e~ieMd, north arrow, ar+d leeadon aed d'islsnu 1o nssrasl road.
APPL~CANT (HFOR(r1AT10N-PLEASE PAINT AlL INFOpMAT10N AEVIEWE08Y
hROPER11rOdME PHOPEATYLACATION
' y. ~ ' GDVi, lOT V~ ~ UPS Y ..3Q ll.q /~ ! ( W
PAOPERTIf OINNEiCS lLlAllINO AD~RCSS _ l0'T f BLOdt ~ SUBO. NAME OA CSI~I If
gTlf;STATE j YlP CODE PHONE NUL~EII pcrlY pvlllJ4GE ,~fcmN ar~,nt„ .,wu
p~ New C.~ttsaucQon use pet F~sldenral ~ Ntt+nber d Bedrooms s3 ~ -
l I RePlat~nen! f I ptlbl~or mi+wea-dai desar~e "
Cede derived daAy bow ~S _OPd Reoortrnendeddedpn badlrtq rale • 5 beds OPdAf~~,-,eench.9poll~
'AbsotpRon Brea ~AgtAree 900_ _ ted, n2,~.~ rer-cfi. (t~ x L bta~enwrn dssi~n IoRah~ red _ • 7 eba, opam~~$._tre~h ap0~
peaonnterl0ed Irrtlllf<adon wrtaot+ devatlen(s) , s . , ¢t Dll ~ rolerred to stk plan bettdvttaAQ
Ad60ottil dasbn I slte taorrsldaraQons z ' ' /1//9 n
Parent malatd ,~+ s '* Floed plain elevation, f< appocable
t( w
Boring E
G~
eta.
~.3$a.
_~ C~
~ia~ior-
BorlrtS r
Ground
9~
~a
>?,~'
~a 1ar~ em J~p ~s ~ U ~ S [~ uE ~ s C~ U ^ s ,~ u
sOit_ OESCRIPTIOtI REPORT
Horn Depth
in. Dominant C'~olor
MurtPeq ~~
Qu. S~ Cent Cdoe' TexWre Stltiature
Cx Sz: Sh. Car~rtoa Boil Hook GPO
Bed /((
Trt~
y so-~~ s y ~ ~ s Z s ~~ .~ .~
__ b~o~ r ~ ~ .. ..
..
~ ~~
o. s(o
~ - ~ i I ~ I I
~ o- .. -S~Z.. Il~o~~ s: inv~ as 2 •z ~~3
~-
1~: ~, ~ - Gay -,~3,~.~
pab: t3lNumbw:
/_ - Q~~ ,,~ZO g ~
BOLDTB PLBG & HTG Fax ~ 715-684-3144 Jun 01 ' 00 1045 P03
Boring.N
3
G~axtO
l1ey.
9~.6 / n.
Oeplh to
uniting
,~lacta Z -.
~_
E3oring p
Grot~M
99 7L~
Depth to
irriiling
~~~ 4
goring a
S
t~wnd ~'
a
98L2
~b
~~'
boring 11
Ground
dpv.
K
~a
irri6ng
(aria
1{orizo vdyu~
in: ~amrnant r,,;olor
Mu
tlftAil
MolOes
qu. Sz. Corti. Caior Tercture
Suucture
Dr. Sz. Sli. C.or~~ianap
~~
~~~
OPDni
Bed Trt~
o- .sr ~ i s crs. .Z ~ , z 1, ~
._
_
-3 - s s
2 ...
c
•S i
`
~
5 y _
_
/
... ;
Remarks:
{
_
~ ° - 9 '~~ S + ~ ~ n ~. ~_ ~-,' ~r~~ a s Zen • Z •~
~ s-3 s y/ ~ ~~s~ cw -5-:,6
38-50 S `f _ . ,Z ~~ G,.J ' s • L
~
9/a .~
. - -
~•~~
Fiema.rks: r - '
~
I ~- 7'•S y s/z o ~ 5, f b v->~,.~ a s z r~ ~ 2 -~
. -
.ate 9S' o ~
~' '•
Remark
s: . 3~ o y o _._
Remarks'
' ST CROIX COUNT'
SEPTICTANK MAII~T'ENANCE AGRELIviENT`
ANA
OWNERSHIP CERTIFICATION FORM
.. ~_
OwnerBuyer
Mailing Address
Property Address a ~'ss l "7 ~
%s =~7.~-
~~ Srs~/ Z
(Verification required from Planning Department for new construction)l ~`' ;'~~ ~
City/State ~~~ .~~ ~~_ Parcel Identification Number ~ / d ' ~ ~ ~ Z " ~y " ~ p U
LEGAL DESCRIPTION
Property Location ~'/., ~ 1/,,, Seel U , T~ N-R~W, Town of
Subdivision ~ Lot # ~.
L~ ~
Certified Survey Map # ~/ ~~ ~/ ~, Volume ~ Page # ~O -S .
Warranty Deed # `~ ~~ 6 ~(~ ,Volume ~~ ,Page #/_a~~~~~ _•
Spec house ^ yes no
Lot lines identifialale Les ^ no
SYSTEM MAIlVTENANCE
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 pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on-site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days. f the three year a iration date.
ATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our} knowledge. I (we) am (are) the owner(s) of
the pr erty described above, by virtue of a warranty deed recorded in Register of Deeds Office.
s~
S ATURE OF APPLICANT DATE
****** Any inforniation that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ******
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
• OCl;1.aR+eN1 !VO 1~1/~~.`t~2'~"~'rf ~.''~t~
STATE BAR dF W1SCd;tiJ1N F^~R>i 2-1'@+3~
_t
..~;
~u::ton- E~ .Smith an+;l Mac~dale=. F.• .Smith., ........... ..
hasband and wife as 3oint tenants,---- ----------------_---
con~rgs and «-arrant~ 0. , tIc1Y1~:I ST(lith. lnS~. ~ha.~'~8I1~ .ST~1J.~Y1,
hus~~rld. aid .4'rife..as 3oia} tAnantsa - . .. .......
the fe!}nu•in~ deeritxl real. est,•i.e in ...... .........~t-•--C.1~t~.i.Y....-.--.CoanSy,
Ste.!e o` :L' l;coasin
iH i! lf:ac:L RF SF ~Y £O fOR RYCO ROIN 3- D~Ta
~~~J ~~~~
Si'. C~iX Qom,, W3S.
iiae',~, ¢~ REU-,r'i his 2 6 t h
~'~ ~' ~ . s
RETUPN TO
Tax Parcel No: -._....... _.-.--.
Part of NW; of NEB of Section 10-30--16 described
as follows: Cr~~~~•mencing at NW corner of said Nr^^.~;
thence S 361 feet; thence E 361 feet; thence N 361
feet; thence W 361 feet to point of begir,fi=ing.
I~u~SF~
~_,_+~
FEF
Thi; 1S nit.. .. hor.:estea~l p*~;},erty.
(is) (i~ nit)
Exceartion b> wacrantie~:
ilat _al this - _ ~... ~ - _. .. _ _ _ day of
~ y~
TJ..Lc•~~G~•-~;~ti' ~~~Z-~~1!. (SEAL)
Eurtc,r I'., S-n th _..
t r_ ~.Z~`~ `~_ryyrL.<~~.~' .. (SEAT.)
/-~~
Magdal~'~a F.__Stnitn. _ .__._ __..-
A C~'x Kr^.:Y S'ICATION
Signature(s) -.~ta~:_tc;%.-E..-.Smith..-.and -.......-.
authentic' - the C_"_..day of $~~.t~I11~:;2.1;.. , 19- ~.~
--' ~'
•..Jot:.: _ G...-~e~t.i.ns,n:~-_._ ....... .. .. . ..._ ..
T1TLF:: 3tE31BER sTATE sRx ~,~, wlscoti~l:~
(If not- ------------ -
authorized by § 706.t~B, `r4 is. Strat;.l
Septem~zr ,1936 .
_. (SERI,)
-._ _ _ _.
_. (SEAL.)
Aclit7C; :.'LEi7C.1?~I~:iti T
ST 1fir^^. OF` 'rVL.~CO_`: >>i:tii
s~.
- _- ._-- County.
. _ Per~o.v~l}y came ` :_ me this ----- -.day of
... -. -, 19 _ the above named
to me k~.~r:~>. to be the pr">~n .----- --.. who ex•°cuted t}:e
foregoing instr~Iment ac=.d ackuowl~ dge tre ;;=amc.
,
" r.l
FILED ~~1
hiaY U 8 2000 - f
SlCraxCo.N1
~ ~~ ' .
CERTIFIED SUR VEY MAP
Located in the NW %, of the NE'/, of Section ]0, T30N, R16W, Town of Emerald, St.
Croix County, Wisconsin.
OWNED BY:
HARLEN & CHARLENE SMITH
2453 170' AVENUE
EMERALi7, WI.54012
N1/4 CORNER, SECTION 10,
T30N, R16W, (ALUM. CAP.) UNPL.ATTED LANDS
170Ty AVENUE
- ~ _ ~ NORTH LINE OF THE NE1/4
~ S 87° 56' 33' E 361.23' i ~ i - -
198.23' ~ 463.00' S 87° 56' 33" E 2,295.10'
- - ~ 198.23' _ 163.00'
N
O CV s '
'"' S 87° 58' 33" E n t„i 361-23, o NE CORNER, SECTION 10
~"~ = T30N, Ri6W, (COUNTY NAIL )
I
Q~ DWELLING M ~ I
ZI •~~___~___ ('' O C
SHED W ~ ------- two I~
0, - ~ $ ~ LOT2 4Nt~ o ~~
W I N GARAGE O N ~_ ~ I ~I
~ y
~I ~ SHED o .. - - - ° I Illl
gl Z •. I~
Q,I Z ~ • PERCAREA,i- I O
>I ~ LOT 1 •, _ I Z
~ ° 81,336 SQUARE FEET (1.587 AC.) '~ '• ~ ~ SCa~@ 7 ° $ ~ ~0'
INCL R.-0. W. 163•[)0' -
74,794SOUARE FEET (1.717AC.) S 87° B' 33" E
~ ExcL R.-o.-w. o LEGEND
~ ° -~ INDICATES SECTION
~ CORNER MONUMENT
(iE 87° 56' 33" W 361.23' (AS NOTED )
=O ~ ~ INDICATES 1" IItON PIPE
UNPLATTED LANDS FouND.
coo INDICATES 1° X 24" IRON
~ ~ NOTE: LOT 2 CONTAINS O PIPE WEIGHING 1.13 LBS. /
~ 49,0 SQUARE FEET (1.126 AC.) LW. FT. SET.
Z V1 INCL. R.-0. w. '`~' INDICATES FENCE.
bC 43,BBD SQUARE FEET (1.Q70 AC.) -- - - INDICATES 100' BUILDING
EXCL. R -o.-w. SETBACK LINE FROM R-0.-W
c Bearings referenced to the
° North-South % Section line,
Z assumed N00'00'00"E.
T30N, R16W, (ALUM. CAP. )
S1/4 CORNER, SECTION 10
APPROVED
sT. cROlx CouNTY
Planning Zoning and Parks Comminee r~,,...., 3/y
MAY 0 8 2000 * ~f JOSEPH YJ •~':
GFiFNcEnC. ', x- '
s-z25s
[(not recorded widen 30 days of s HEW RICH~dCND
approval date approval shall be { ~'I '
null and void ~ ~~ ~ Ayp~
PREPARED BY: ~•~
GRANBERG SURVEYING '
1239 C.T.H."E"
New Richmond, WI. 54017
TEIIS INSTRUMENT DRAFTED BY: Phone (715) 246-7529
JOSEPH W. GRANBERG. Job No. 00-009 SHEET 1 OF 2
V'ol, 74 Pare 3645