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HomeMy WebLinkAbout022-1046-30-000 r STC - 104 AS BUILT SANITARY SYSTEM REPORT Dade MLA, nk;tv«k OWNER Kalf~ty to a.l~ ADDRESS T11W fL RIC N Rd O'er Ad It W SUBDIVISION / CSM# LOT SECTIONT o2a N-R_1_6 W, Town of lli~~cKi~nic ST. CROIX COUNTY, WISCONSIN Stole I lIU' N~ r-~ a, 806 ( Lieeks SeP4)~ To, k4 1~,3 7 ~ec~rco♦ - - - - - - - i Ham e . 1 l~13J93 jvl Pole to/ C'04 e bore vrpNAa^ F/ev, To can. l~a 11 k v I BENCHMARK: ALTERNATE BM: Angnm o; a ari CQ L&v Of AO"S,-( SEPTIC TANK / INFORMATION Manufacturer: WI- e Il S Liquid Capacity: ~O Setback from: Well /00 House yy' Other Pu Manufacture Modell Size Float eperation Gallons/cycle: Alarm Loca 'on .SOIL ABSORPTION SYSTEM Width:_ Length Number of trenches 3 Distance & Direction to nearest prop. line: /OCR Setback from: well: House_5 ` _ Other ELEVATIONS Building Sewer ST Inlet: ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt L99AWI;-rtXW* t~PNIC 16.2 OA~1jU*AGE SYSTEM County: Labor and Ruman Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar rfiit Permit Holder's Name: ❑ City ❑ Village Q Town of: State Plan S ev.: Insp. BM Elev.; / ription: 1S Parcel Tax No.: :=e TANK INFORMATION ELEVATION DATA A9300269/4 D Tr c S TYPE MANUFACTURER CAPACITY STATION _85 HI FS ELEV. Septic Benchmark 7 Dosing s! . ,Q•/1!• (U,SZ7 ' Aeration Bldg. Sewer 06,42 Holding St /)K Inlet ► /'0 3, 31(TANK SETBACK INFOR ON St// Outlet TANK TO P/ L WELL BLDG. Ai ntake ROAD 5-rSf Inlet O3, Septic ,/,G6/ >S()r 00 NA ►~L J$d~.V/ Dosing NA HeaderA . Aeration Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer- Demand" OFA= 36 Model Number 7 :t C5,7 9e~, TDH Lift Friction e H Ft Forcemain Len Dia. Dist. To Well SOIL ABSORPTION SYSTE JNW TRENCH width , Length No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING manufacturer: SETBACK CHAMBER Model Number: INFORMATION Type O System:, OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) N / x Hole Size x Hole Spacing Vent To Air Intake Length lz Dia. ~ length ~_If Dia. ~ Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syst Depth Over „ Depth Over cT „ xx Depth Of x Seeded /Sodded xx Mulched Bi.cTrench Center -,:n4 Bed-/-Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: KINNICKINNIC 16.28.18.P247A ( vo Z a~ 9 _ are a.P i~d Plan revision required? ❑ Yes Use other side for additional information. fO Q 9.3 SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ° 9,57 /o 5-7 ~06 dz' ivy` 7,3z' r► 77, F E:ZE iL.H -1111 SANITARY PERMIT APPLICATION Q In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY P,MIT -Attach complete plans (to the county copy only) for the system, on paper not less thanQ 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. PROP RTY OWNER PROPERTY LOCATION t k SOU '/4 NW '/4, S lb T 2 N, R I6 W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) ❑ State Owned NEAREST ROAD [2 VI66A ❑ Public 1ZJ 1 or 2 Fam. Dwelling-# of bedrooms A AX Nu ( III. BUILDING USE: (If building type is public, check all that apply) ~a t✓y 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs I-l 4 ❑ Church/School 8 ❑ Mobile Home Park _ae~-~'C✓h 5 1:1 Hotel/Motel 9 11 Office/Factory ,V - / : IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) 1 A 1.0 New 2. [g Replacement 3. El Replacement of System System Tank Only tern B) ❑ A Sanitary Permit was previously issued. Permit # - AA& V. TYPE OF SYSTEM: (Check only one) Lr P/ Non-Pressurized Distribution Pressurized Distribution Expo /,-I,/ ~ 11 ❑ Seepage Bed 21 ❑ Mound 30 1~Ges~ 6O.N' nk 12 Seepage Trench 22 ❑ In-Ground _ 13 Seepage Pit Pressure 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADIN( ~L GRADE 6 oO REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/da) qty- tLEVATION /b a , /0 i Feet 0 Feet VII. TANK CAPACITY Site in gallons 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 c C Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu is Name (Print): Plum r Signature: (No mps) MF~f~APRSVV'No.: Business Phone Number: C S C e Plumber's Address (Street, City, State, Zip Code): 65- AV111'r, Z IX. COUNTYIDEPARTME USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued =IsaulngAge t Signa re (No Sta ) pproved ❑ Owner Given Initial Surcharge Fee) ~~4 Adverse Determin ion ' X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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 (813D 6399) to be submitted to the county prior to installation. 5 ors=site se-wa ge v:tams must be properiy maintained. The -;-ptic 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, 608-266-38151 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. It. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. lll. 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 reiail. V. Tvpe A system Greek appropriate box der ending on system type. VI ir-rnrma*i-n P lrir- information requested in ##1-7. Vl new and/or existing tank, list the total gallons, number of e`ti+ns arl^ ) r..= n,, ,le. , wic s='ab or site constructed and tank material. Complete for all s<.l,(lc, of and h0011g ar~k~ s system. Check experimental approval only if tanks received VIII r ~~!~+~5ir li;ty starement ;nstaliir,rt pirrrr~b-r is to fill in name, license number with appropriate prefix (e.g. lv P c : 3~ ' p riu.. !er_ r :rater must sign application form. IX a,,unty/ Depacilr:e 0. Use Only. X. county/Departmu'll, Use only. ro-nlF}e 7'V s •r° ">>r than 8% x 11 inches must be submitted to the county. The rlr r r a..a ,,r . drawn to scale or with complete dimensions, location of sent tacks; building sewers, wells; water mains water service; ,i,stribution boxes; soil absorption systems; replacement system - 1; B) horizontal and vertical elevation reference points; l c ?(1;):OE ,u'~c c?: o°sOun psi : -(jntrols; (Jose 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 dataon 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 use,j for rnonitoring grc undwater, grc:)nd- water contarnination investigations and establishment cli standards. SBD-6398 (R.11/88) Dave- Maitk,'/hr~ck pejjn Sale yp` ~o ~+k 1 0 3 y $cIPro,,1 .J 1-lo m e 1 I f ,Q ~ODP C~'oungfl FJPV, /C2~,0` To lOJL H.? R o a f Elev. CS ~ N~ S ~ s ~,e ►v~ D~LHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY St Croix STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ -2 8% x 11 inches in size. c ifrevision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER , .I. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION David Munkittrick & Catherine i le SW % NW Y4, S 16 T 28 , N, R 18 )&~14W PROPERTY OWNER'S MAILING ADDRESS LOT # jK76CK# 1108 Town Hall Road CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER River Falls WI 54022 715 425-1799 NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned Town Hall Road AM_ M ❑ Public 01 or 2 Fam. Dwelling-# of bedrooms 4 PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 022-1046-30 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 40 Church/School 80 Mobile Home Park 120 Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 111 New 2. ® Replacement 3.E] Replacement of 4.0 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 ® Seepage Trench 220 In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill I 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 600 2,000 2,000 .3 98.30 Feet 100.8 Feet VII. TANK CAPACITY Site INFORMATION in gallons Total # of Manufacturer's Prefab. Fiber- Exper. New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Se tic Tank anhykfiawfto~x c j(g Lift Pump Tank/Si hon 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): PI a Si nature:( Stamps) MPq6g No.: Business Phone Number: Paul C.J. Steiner ` 6780 Plumber's Address (Street, City, State, Zip Code): IX. C UNTY/ EPA THE T USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued issuing ant Si ture (N tamps Approved E] Owner Given initial toSurcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-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 gt. 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. 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; (lose 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) ple) t ft, - 5 ~ Q le 1 = `/o ~o~+h 6 SC~o Ufa ~ .Se y~~~G 7Gn Beo7r6o~t O - - - - ~1 Bz m e E f B jv1 (?o It w~ Syrn e A bone Grouh~ F/Pv, TO wtL I74/I R Oad we ~l 1S ~/W We 57. J'T E1ev. 98.3 of N a i Crn&ew f Cori 40" mux I~cr ~~.Io+h r < .z' ac k over -Pipe a $ ocodoag8~o°o 'P ° a a » e o o, n Yn iri•-Ro c k k hcle r tripe C ~ ~gU Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 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 81/2 x 11 inches in size. Plan must include, but ST, C_ k X 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. O -Z--Z _ } p l~ 6 , 3 O APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: ~PN~p f'1 UtJ~-_I TT2 i C.k 05 PROPERTY LOCATION Ct4`Rj L rJ ©U~ G G LE GOVT. LOT S W 1/4 NUJ 1/4,S ) b T Z~8 N,R 18 E (oreW PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # t\ (3'6 To w>J "L'U R-O N D CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE R FOWN NEAREST ROAD 'ZtUtNZ ~ L%.S,WI SyDZ.Z (~ls) ~tS- 17`3q ~ci/vli.)lC~cllulU lC A*,LL ~ p 16- - [ j New Construction Use [JQ Residential / Number of bedrooms [ j Additign to existing building 1J4 Replacement [ ] Public or commercial describe Code derived daily flow bo O gpd Recommended design loading rate - bed, gIxW ° • y trench, gpdfft2 Absorption area required Zoo o bed, ft2 %so O trench, ft2 Maximum design knading rate o _ 3 bed, gpd/ft2 o • Y trench, gpd/ft2 Recommended infiltration surface elevation(s) SIFe III o ki P k-6E 3 ft (as referred to site plan benchmark) Additional design / site considerations 3 `rSz Leve bbt3 S - L RCS S' x t o o' LW G, - wl tty. 36"r D we-p Parent material sm l m e)vT- lcoj t SAx-i> Q 6tZ huLL Flood pktin elevation, if applicable 9y A - ft S = Suitable for System CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for system S❑ U RIS ❑ U T OS ❑ U EffS ❑ U ❑ S E'U ❑ S gU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Cornsistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed wich Fz z-` 3bw, miIII w liui o.s o-6 `'`13 -2,0 1. ~ 7 fZ 3! Y - S 1 1 Z S ~k ►►t C S j o. S o• 6 Ground 3 ZO-yy lO Y2 3) io - S 1~ Z `f S V1T 1n f 1^ CS o- S o. 6 elev. loo, o ft. y qV-76 -)-SYlL 5/A _ s) o Yy\ b1 v i' - o - 3 O. y Depth to limiting factor „ Remarks: Boring # Z Z3_SI )T34tz 3/(0 - S,j 2-'FS ` S o.S 0,~ 3 s}-~y-S `11Z''S//b - s 1 d Yh Ur'' 0.1 o. y Ground elev. X00.3 ft Ix C~ c Depth to zt~Nhty~ limiting c~ facto ,r -7 ~y Remarks: CST Name:-Please Print Arthur L. We erer Phone: 715-425-0165 ergerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: Date: CST Number: °13- 2\S 9-16-9~ M00576 M ~v tz.~T'T-2a ctz ~ PROPERTYOWNER CW AGGL-V~: SOIL DESCRIPTION REPORT Page?- of 3 PARCEL I.D.# 0 7Z- Z- \3 \4 6 - ~O Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft ::x: in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 3 < 1 0-13 1~`~ltZ 7-IL - Si Z s~1- wr h cS 1%4 n-s 0•6 k: <ti_ Z 13-37 LO `~R 31t. - S) Z sb1T w, cS 1 o.S O- L Ground 3 3~ ~7 7 S`1R y/6 - S w~ Yn U f' - a- 3 0.tj elev. lt~o 8 ft. Depth to limiting factor > -77 Remarks: Boring # '0 k<ti 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) PLOT PLAN Page 3 of 3 SCALE 1"= 40 ' 01- Ito S So ' I Res ID9uC-E / p~ylw tou quo' et. too l S ~1~ c. sv t h'CB u~ p'fR,~sA J Q ~ BNl - LaL, 10~, o" O►" 5P\hl. t4p ~~u~ GRtJu►.~p iN Not-FH stviE of i Towru H'~t c.L D a-3S j ro N . L ~ B!`12T`1 FZOAD t27>e1STDAuG wki,L. 1S > loo' wCsT of S-LT+rl!~Le Pr1ZQ~• NoT~ To IN ST1PlU: t ti Sl'h' L 1, 3 -~v c_~ S, ~ S x t o o Lev G, r -t I lv t M uy-l Zy 1'0 3 6 , w ~`Rt tN 1l-t L S V ~T`frg L,L 1912~~ , ~~"'~tZ-wlt~v~ 'h2LvC.'cl kzTt,NUr,~U~ S ~'rT 1~~tF O'- cc1+v S~~uC~U~. 1tttlST ~V~-OT~~T70-.1 (-1-r U21ULWW/t'~f c[ZUSSa~vG. cl3-ZIS o~ 9- ! b-43 (715 ) 425-o1 h5 M00576 CST Signature Date Signed Telephone No. CST # Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of L:abof and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY s- c~ o x Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # oz-,- llo6- 3p dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: 't~sNvtp f~l UfJk 1 TT2(Gc PROPERTY LOCATION Ct\`tlj L3P.1tii Q USG 6 t_E Gov r. LOT S W 1/4 "UJ 1/4,S It T N,R ) 8 E (a Wp PROP Y OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # N73'6' Tot,,,Xj VAV-U ROhD - CITY, STATE ZIP CODE PHONE NUMBER []CITY OVILLAGE RFOWN NEAREST ROAD Wluis1Z F=AL%-s,W) SgbjLZ (7Is) qzS- 1799 Yzjk3 JICkI)lJlU ►C ".)M V}itu. P-Oml [ ] New Construction Use [JQ Residential / Number of bedrooms [ ] Add*n to e*ling building [)j Replacement [ ] Public or commercial describe Code derived daily flow loo O gpd Recommended design loading rate ___bed, 9polfl2 0 - 5I trench. gPW Absorption area required Zoo o bed, fl2 X500 trench, ft2 Mandmum design loading rate Q-:1 bed, gpcW 0 •Y trench, gpol(t2 Rewmmended infiltration surface elevation(s) s Wey-zW o►-3 P rr 6E 3 It (as referred to site plan ber d imark) Addlibonal design / site considerations 3 3 - tah(-'ll S 'y- t u o' LW G - Vn try. 36 b qLr' Patent material s L3b I M evT ow Q R SAN,4t> et GiihUEL Rood plain elevation, if applicable A It S = Suitable for system cO imnONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=UnstifWW for stem S--0 U RIS ❑ U IRS O U us 01.1- o S _NU ❑ S ICU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure CorisiStence Boundary Roots GPD/ftin. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ranch 0-\3 IoKQ zli. 2~sb~ m'Fr. w lug o.s o.6 Z 13-2,0 IoYR j!Y - S Z ~S~k `~H CS )u o.S o•6 Ground 3 20-t!Y 1072 3) 1 S 1) Z `F S V>T YvnCS - o- S o. 6 elev. VWZ" 0 It y qy-76 7- SY2 5/16 S I O vv\ M - 0- 3 o. y Depth to limiting facto „ > ~6 Remarks: Boring # x ► o_Z3 ~o~R Zlz - Sit zfsb~ m`~~. ~S )u~ o so.6 Z Z Z3_SI )x`-12 -VG - S 'l Z'F sbk >n 0-S )ui o-S o. 6 3 s1-~y D.S YrZ=Vl6 - s 1 o m W u~6 o_ 3 o. Ground elev. 10 0.3 It - f Deptlt to limiting facror y ,f Remarks: CST Name.-Please Print Arthur L. We erer Pine: 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Sgnature: Date: CST Number: 4, -iV414wt 01.1 2\S 9-1b-9~ M00576 M ,-►v V-LTT T C-k_ I PROPERTYOWNER OvxGGUe SOIL DESCRIPTION REPORT Page 2. L -of 3 PARCEL I.D. # 0 2 Z- N, \ 6 - ~O - Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends 3 l 0-V3 ~VzyQ ZVL - Si 2`Fsb1-, vn h o-S 1ut, o•S o•6 h ' Z 13-3-1 vr0.1 vt S ~ Z j 3b1T ~n c S l of O -S 0-1. Ground 3 30-'27 7 •S ` p- y/6 al o vn elev. tibc0- 8 ft. Depth to limiting factor > Remarks: Boring # f 13 0 Ground elev, ft. Depth to limiting factor Remarks: Boring # i i 13 Ground elev. ft. i i Depth to i . limiting factor i Remarks: Boring # Eli Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) . PLOT PLAN Page 3 of 3 SCALE 1"= 40 ' krL, too s so i R~zsIbgjc~e / 'b"k0-L Ln.tou° quo' eLtoo l S ~PT1 c Sv ~~L (-Z i I J Q 8!7 - L3L. lU 0, p per, SP~h tyY R'8oU GRbuuD I" N otz-~ 3 t i m OF taw LC . I Tok/,u l- WLL- ?-)A o • 3 S r►-i ~ To N . ~ B ~'2T`7 fzoaU trxlSl~~uG w~.t_ 1s > mo' OF S%-NLY*-%Le ft%4M. Nom' 1~ Ow S'M%-UzzM : tN TM L o' L_p►v G , 1 /u ~ mu" b ~`C Z t h, '1I GM k--~E u PrnU N s Wr '11M E COI= co>u %Y%-u crU Q . n~~t~~ 1'-aosr ~-,hvto` rcnoN c~T tttzcuLAwfiYr ~tZuss~~us. c/3-ZIS o~ 9- 1&-9'3 (715 ) 425-0169 M00576 CST Signature Date Signed Telephone No. CST # Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05. Wis. Adm. Code COUNTY s-r. c\-4Q ~x Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or Z Z _ O 6 _ 3 O dimensioned, north arrow, and location and distance to nearest road. REVIEWED BY DATE APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION PROPERTY OWNER: ~Pcv~ p M Ut•~tz.l TT1Z l C tic PROPERTY LOCATION CNN 07_b& A vk C. 6 LE GOVT. LOT S W 1/4 IJW 1/4,S I L T Z N,R 18 E (W PROP RTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # ~ O8 -Tbwxj "-flLL TzAhD , CITY, STATE ZIP CODE PHONE NUMBER []CITY QVILLAGE DOWN NEAREST ROAD I0ei- F--A u.S~WI syoZL (~lz) ~zs- t799 Yv~QICkt~.,lU tC ~>u 141ru R.of'~p [ 1 New Construction Use [M Residential / Number of bedrooms 4 I 1 Addion to existing buikkQ ()j Replacement [ I Public or commercial describe Code derived daily flow 6o O gpd Recommended design loading rate - bed, gpoltt2 0 - y trend', gf AbSMA011 area required Zoo 0 bed, ft2 tSOO trench, 11:2 Maximum design loading rate _a- 3 bed. gpolft2 0 •Y trench, gpolR2 Recommended infiltration surface elevation(s) Seff Y-ZTE o►J P irGE _Aft (as referred to site plan benatvw ) Additional design/ site considerations 3 `'1'Tt Ay c. e* S tgl-%C. A S' Y- loo' LW C-. - y L fty. :16" D fit- Parent material s M I M eT►vT ,o j tt S rc+~ a co," 9L Flood plain elevation, if applicable N • N , ft S = StA1abl@ for System CONVBNTIONAL MOUND W-GROUND PRESSURE AT•GPME SYSTBA W FILL HOLDING TANK U =Unsuitable forstem S - O U Iu S [1UT ®S ❑ U IRS ❑ U ____0S -®'U ❑ $ U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure C;onsistence Boundary Roots GPD/ftBoring # Horizon Ground in Munsell QU. Sz. Cora Color Gr. Sz. Sh. Bed rertdl a ) o-t3 loKtz zIZ. - sal Sbk W-t w lui o.s o.6 u~ o.S o•6 s Z ►3 -Z.0 l 0 7 R 3/y - S 1 Z S bk I►t H C S 3 zo-w lo` [z 3) 6 - sI 1 Z~sb>~ Yvn~~ CS - o-S o.6 elev. -).SY2 C/A v y\ b) U + 0- 3 1:0.y too. o ft Ll 4y-76 Depth to limiting factor _ 6„ Remarks: Boring # I C' _Z3 10 `1 R 2-! t - S 1 Z C S d1 c mE16- v Z3-SI S LITAIN mcs lui o•S o• 3 s~-~y -).S YR`y/G - S 1 C~) W" YA U.?6 - o. 3 o. Y Ground elev. too.3 (t, r Depth to limiting factor ,f 7 ~Y Remarks: T Name.--Please Print Phone: 715-425-0165 Arthur L. We erer egerer Soil Testing & Design Service-P.O. Box 74 River-Falls,WI 54022 Sgnaiure: Date: 9_ 16 -9 CST Num 0 0 5 7 6 °l 3 - Z.t 5 1 h'1 LYV W-LT C-iL4 C.tz 3 PROPERTYOWNER O-AGGLt - SOIL DESCRIPTION REPORT Page -'of PARCEL I.D.ff_ 0 ZZ- N,ll\L b - ~SO Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell' Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 0-13 1kz4bt ZVL - sit 2`f 310k vn ti cs lei e•s O.6 Z )3-3-1 vO `7R alt. - S Z'F 3bk vh `f H c.S 1 of 4b -5 0. L Ground 3 3 =17 •S ` P- y/6 vn u f v. - o- 3 0.5(. elev. ft. Depth to limiting > factor 7 I 1 Remarks: Boring # Ground i elev. ft. 1 Depth to Umiting factor Remarks: Boring # i 13 i~ Ground ! elev. i t ft. Depth to limiting factor Remarks: ,Boring # .13 Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) PLOT PLAN Page 3 of 3 SCALE 1"= 40 ' 100 c*7. too s I -DSO, I 4@D ~ e II - - -s.z Rls I bek" I l L o w e. toot too Sc~nc. S v t t"rC13 P(K•~sA J A . BVl - L3L. 1v0. ~ oti SP\tz~ tyr PrBuUt` GRc)v~p ~N N otz--~1 3 t o jE OF Raw L~• c.~ Tok/0 !'fkU- RWIN 6 o - 3 S i 1'Q - N . L t 8~'1ZT`t FzogD kzx.ISTUJG we,L IS > too' wes'r OF S'--T+VWLe Pt1L4 . NoTE~ 1N STM~~LLs2 1 sTrc 3 1~L~v c~{ S , c~-~~1 S' K MO' lam, G , I iu t wt~►~-t 6 ~ ~KR-T, Zy Tn 3 6 t) , \.'1Zt tN 11t e a v I.-T" Le- ffrta), . . ~ ~'z.`f~tl" 1. tiV ~T1Z--~J Ctl ~1-l~' V ~rfiU N S t'tT 1~r't E 01= CA~+ S~'1z-u C'1') U ~ . T~ tzdutlJ ~ 1~'RO ST t-'~Z.0`1~`~T7~ N ~T Uiu U L~►1/r~{ ~[2.US S tau G . cl3 -2.IS 9- 6-93 (715 ) 425-01155 140-0576- CST Signature Date Signed Telephone No. CST # SEPTIC TANK MAINTENANCE AGREEMENT rt St. Croix County r OWNER/ BUYER r`_ U I~ o ROUTE/BOX NUMBER 76 -vin ffot Qr Fire Number to ZIP ~~D~~ a CITY/STATE LIMA' f;`!5 M PROPERTY LOCATION:'.,. Section. T,/~a N, R_ZS W, Town of fA i vll <_St. Croix County, Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Prover maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed'se tic tank pumper. What you put into the system can affect th- unction o. the septic tank as a treat- ment-stage in the waste disposal system. St. Croix Count residents may be eligible to recieve a grant for a maximum of 60K 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 's sy t'ems 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. H I/WE, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with 91 the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed and returned to the St. Croix County oni g 0 e w hin 3 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. w 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), thenla second form should be retained and completed when the property' is sold and submitted to this office with the appropriate deed recording. ---------A a Ckc( Owner of ro ert l p p y GliYl 1 Location of'property~.4QL1/4 1/4, Section Tlg.N-R1141" W Township 10 0 LC, -Fn,,4, 11.-li a. Mailing address Fct A, Address of site ~o~ p . Subdivision name Lot no. Other homes on property? yes No Previous owner of prop rt ' ~ lVe49n~ Total size of parcel Date parcel-was created Are all corn.ers and lot lines identifiable? Yes No i Is this property being developed for (spec house)? Yes No Volume L and. Page Number 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 i e office of the County Register of Deeds as Document No. S~,L~7 , 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 offs a of County Register of deeds as Document No. igna ure of applicant Co-applicant Date of Signature Date of Signature ij DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 i THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 419`99. REGISTERS This Deed, made between RObeKt. P01)-letQri~..Lorraine,. D~FiCF Anderson.. Jo ce Nelson and David Wel ST. CROIX OO . . I - Recd. for Rf-cord ft 26th . and.. David A. Mt~rlki x G ..4aA. (s&t13gX ne. R. Qu ggj.. Grantor, d©r of NOV. 8:30 A q•pe 1916 uband and wife f 4s--a=ivaxahip. ma--ital_P ro t-- !I Grantee, 1` M Witnesseth, That the said Grantor, for a valuable consideration..One I!~ (•$1, 00), Dollar and Q~~:__g~lOd,_c111d_ valuable..oonsideration.. ~ RETURN TO conveys to Grantee the following described real estate in St_l n .ix...: County, State of Wisconsin: THE FIRST ~TfONA~ gA,N~• E3GX luG _ !I~ FALLS WISCONSIN 54022 1 i Tax Parcel No:......... j That certain parcel of land located in the Southwest 1/4 of the Northwest 1/4 of Section 16, Township 28 North, Range 18 West, Town of Kinniddmic, St. Croix County, more fully described as follows: Commencing at the East 1/4 corner of said Section 16, thence N9000010011W (assumed bearing on the East/West 1/4 line of said Section 16) ! a distance of 4379.08' to the POINT OF BEGINNING, of the parcel to be herein described; thence continue N9000000001W 550.00'; thence N00G00'00"E 792.001; thence N9000010011E 550.00'; thence S00000100"W 792.00' to the POINT OF BEGINNING, containing 10.00 acres, being subject to easement over the Southerly 33.00' thereof for town road purposes and also being subject to easements of record. S FEE ~I I! ! This iS..Wt....... homestead property. (is not) Together with all and singular the hereditament, and appurtenances thereunto belonging; And.. CJ =t.0ra.11,-_re].11....._... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except !I restrictions, reservations, covenants, and highway rights-of-way, if any of easements, and will warrant and defend the same. Dated this 20th day of wVi~ 19$(..... ' (SEAL) k~ (SEAL) * Robert Sta leton .......k.......... * e. e.scin............ he (SEAL) (SEAL) * -•-_..J * ..Ravi.d•kie].1s......................................... AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN au,?...--•----•-....County. as. authenticated this ........day of 19 Personally came before me this 2-01th...day of _.....November 19.x?... the above named . Joyce -Nelson; and. DY.i4(• W~l~s...................... TITLE: MEMBER STATE BAR OF WISCONSIN _ _ li (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person ._s ......,.~,.wtio•etc~aitdd the foregoing instrument and acknowWge h samee.• THIS INSTRUMENT WAS DRAFTED BY John W. Davison DAVI R r r c.......... SON . 111 W Walnut, ivr Falls C. MQeler•,-•• ,,~t:A ~r 54022 Notary Public t_s-- Q~giX • W ! 'is. u~ (Signatures may be authenticated or acknowledged. Bath My Commission is permanent. (IfB~• l+,expifation are not necessary.) date: Ap .1.5 *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leval Blank Co. Inc. FOR14 No. i ' Milwaukee. W4.