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022-1080-50-004
STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER G i ✓1~- ADDRESS / ~1 h r~~ `~r~M1ri SUBDIVISION / CSM# yClS 7b 3 LOT # SECTIONT,2S N-R f y W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW ERYTHING WITHIN 100 FEET OF SYSTEM l / Yo ys t! 1 I &I Crn< If-7 e INDICATE NORTH ARROW %H Provide setback and elevation information on'reverse of this form. 9 Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK: O ALTERNATE BM: Ir~r J►~ SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION Manufacturer: e'-eLiquid Capacity: J~pd Setback from: Well ~Ar- House ld Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location - ;SOIL ABSORPTION SYSTEM Width: Length Sr Number of trenches 3 Distance & Direction to nearest prop. line: Setback from: well: House-_K3 Other ELEVATIONS Building Sewer ST Inlet; ST outlet. -?G PC inlet PC bottom Pump Off r ~ Header/Manifold 3ZY p,? Bottom of system p o Existing Grade Final grade ov DATE OF INSTALLATION: .z Ssf~ PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR:. 3/93:jt LCo"' W#pert VTmQWNIC 28.2$RWAti~ 1 kGfjySyjjW RIDGE ounty: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ' (ATTACH TO PERMIT) sanitary ermit R677 GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village IR Town of: State Plan ID o.: T T ev.: Insp. BM A e- BM Description: Parcel Tax No.: Dli' o G~-1. 611 ? ~c 01~ l<<~ - - - TANK INFORMATION ELEVATION DATA A9300044 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S ~ 2CJ Benchmark ~,Ivl Dosi A_~ t~ rI , / .310 / G f/ Aeration Bldg. Sewer -2~ Holding St//FX Inlet S 33 let, . 31 TANK SETBACK INFORMATION St/~K Outlet TANK TO P/ L WELL BLDG. Airinta to ke ROAD Dt Inlet rl Septic Cv 19 NA Dt Bottom Dosin NA Header -7.5 Aeration NA Dist. Pipe,' Holding Bot. System G/ + PUMP/ SIPHON INFORMATION+al Grade '727 MawFac_furer_, - Demand Model Number GPM TDH Lift Friction SyesTDH Ft Forcemain Length Dia. HH Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width /~s Length_ / No. Of Trenches PIT - -N4, Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS Manufacturer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING-,, INFORMATION TypeOt -2 CHAMBER umber: System: 43rcl &p5Gd /v 11 OR UNIT DISTRIBUTION SYSTEM Header aaAP d Distribution Pipe(s), ~r x Hole Size x Hole Spacing Vent To Air Intake Dia- Lengthy Dia. Spacing Length 12- 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 / Tzc,adi Center yi Bed / Treflc*rEdges Topsoil ❑ Yes No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: KINNICKINNIC 28.28.18.438J,NW,NW, PINE RIDGE DR. LOT 6 r Plan revision required? ❑ Yes U3'-N'o Q~ / Use other side for additional information. 7 ~3 SBD-6710 (R 05/91) Date Inspector's ignature Cert. No. DILHR 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 1:1 8% x 11 inches in size. C rf r si r sous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEA AE PRINT ALL INFORMATION. PROP RTY WNER PROPERTY LOCATION Gel /a 41 S T , N, R E (or PROPERTY OW ER'S M G ADDRESS LOT # BLOCK # X-C, Dr i V CITY, STATE ZIP CODE PHONE NUMBER OR CSM NUMBER % s = J v 1 L; er (4T-) M41? 3 ZtZ4 jte 11. TYPE OF BUILDIINNNG:: (Check one) ❑ State Owned O VILLAGE : r c NEAR 1T ROAD " r' ❑ Public Ell or 2 Fam. Dwelling- # of bedrooms PARCELT LIMB ) Ill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 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.E] 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 410 Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) : (Gals/day/sq. ft.) (Min./inch) ,r~ ELEVATION v'~~ d. Q , 3 R k O Feet ,VAO Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 6.2W Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. PI er's Name (Print): Plum is Signature: (No s p .MR/MPRSW No.: Business Phone Number: r lu is Address ( treat, ty, State, ip ode): IX. C LINTY/DE AR ME T USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Ditto issued I ng Agent Signat o Stamps Approved ❑ Owner Given Initial ' V -Surcharge Fee) ft ~ ) Adverse De, ermination 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 hod. §ani&ry 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 bei?rg 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) soiLtest data on a 1151orm; 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) S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. . Owner of property 04~L Location of property N w1/41/4, Section Z, T N-R W 11// I Township _ K 1 N V i k I luA/ IC_ Mailing address 1c~,S,3 ,~~L1012c~I O2 /~~c^ '7-~s G~Z ~-yo22 Address of site lerG1 e i VC Subdivision name Lot no. Other homes on property? yes No Previous owner of property Zeane_A- 41 1 ~ Total size of parcel ( q q /cS Date parcel-was created 3 5lf3 Are all corners and lot lines identifiable? 7G Yes No Is this property being developed for (spec house)? Yes No volume 5 and Page Number ZLZiz as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. _ysf3od , 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. y~ 430 Signatu f applicant Cdr-~_applicant & _q Date of Signature Date of Signature ..,.i . ..........m _w~ r r-_- rr-_ - - , THIS SPA.:[ RES"V[O POn "[COOD.NO DATA DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1- ~I WARRANTY DEED ~1 I REGISTER'S OFFICE 459300 - - ST. CROIX CO., W) This Deed, made baween Kenneth .N_.- .Ste-ltz.nerl--..-r. Reed for Record and Elsie..H.. Steltzner, husband .and wife--and J~~ O l each in -.their own right g:30 A. ' of M Grantor, and William J. Davidson• and Jean. S. Davidson,. - husband. and wife with right of survivorship. .i Grantee, of Witnesseth, That the said Grantor, for a valuable consideration - - one, dollar- and-..other . good, and.-valuable -consideration I. - ~ RETURN TO conveys to Grantee the following described real estate in .-.-$t • CrQ3.X _ _1! County-, State of Wisconsin: ,i Tax Parcel No: i Lot Four (4) of Certified Survey Map recorded in Volume "5" of Certified Survey Maps at Page 1487 as Document #397707. F EXE pT This ._.--.1$._n- ot---- homestead property. (is) (is not) Together with all and singular the hereditam,nts and appurtenances thereunto belonging; And.... Kenneth N. Steltzner,.S_r. and Elsie H. Steltzner warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and reservations, if any, of record. and will warrant and defend the same. Dated this day of '/~Y 19 90 (SEAL) (SEAL) Kenneth N. Steltzner, Sr. (SEAL) (SEAL) Elsie H. Steltzner AUTHENTICATION ACKNOWLEDGMENT Signature(s) of Kenneth N. Steltzner, Sr-STATE OF WISCONSIN ss. -and-S.teltzner.......................... County. A authenticated this `:~-day of.-. ~ ~2" 19 Personally came before me this day of - 19...----- the above named -7~. - Df, l.. - - - - ' .--Peter $e-gul---....-- - - - - - - TITLi:: MEMBER STATE BAR OF WISCONSIN - - - a s - to me known to he the person who exec•lted the foregoing instrument and acknowledge 0a =an'e. THIS INSTRUMENT WAS DRAFTED BY D. Peter Seguin, Attorney at Law „ n i•:h:, iris River Falls. Wisconsin _,4022 N~,ca.,: F:hlic . p~'rmar., , 1~ not. <ta , . . - - e~:Jr.INn^ (Sienatures may he authenticated or acknowled_•ed. Roth T l 1 are not necessary.) date: -N.-- of pcnnns signing in any esriaeity shocl•! he . ~ ....t.d k~•L-x •h•~r +:R-.>.•-r - . a S'rATF: PAR OF w13f (/N.1I\ Stock No. 13001 i~fTtir FORK No. 1 - IY9. i _ f 495'703 CERTIFIED SURVEY MAP LOCATED IN THE NW1/4 OF THE NW1/4 OF SECTION 28, T28N, R18W, TO KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN NW CORNER SECTION 28 9 FILED w-T28N, R18W MAR041993► 0 C UNPLATTED LANDS JAMES O'CONNELL 0 00 - - - - - - - - Register of i co `n POINT OF St Croix Co., BEGINNING N _S_890-19-29"E_ S89°19'29"E 644.00 LOT 3 677.80' 3- LOT 7 461.94' 182.06 C2.003 Ac.± LO 4 C) W I r_- P014 7 0 0 87,248 S.F.± VOL._5 1 D0L#397707 N3200 z C) Ln A, D0~#97747 m _ 51.55 ? 30'IE ` ' LOT 6 t!1 to 1 01 '0 C I ' PN~_ Rr 2 5~ ,0 3.995 Ac.± zl Ln LOT ~=,=LE 174,015 S.F.± C. S. M. DRIVEWAY \ A~ N I VGL, EASEMENT Q\ 0 4 , " HI w1 I P 14$7 SEE DETAIL E+ DOD # 397707 570.07 ai ; Ln I I 1 00 ° LOT 3 I P l l t r. S M I ai. BUILDIN LOT 1 SETBACKG 14$8 I C' S. M. 166'1 LINE DOC # 3977Q8 VOA,-5 P 1487 LEGEND DOC # 397707& ST. CROIX COUNTY SECTION CORNER MONUMENT,FOUND. ° O 1"x24" IRON PIPE,SET,WEIGHING 1.68#/LINEAL FOOT. • 1" IRON, PIPE, FOUND. o EXISTING FENCE.?O'D E-A N M 3 DETAIL OF DRIVEWAY ,EASEMENT FOR LOT 6 & 7 f•;~' ~H SCALE: 1"=100' n.L W1/4 CORNER ° LOT Z ° Jv ti~~ F; i -F----SECTION 28 CROIX COUNTY % T 2 8 N, R 18 W C1 z 3 0 „pr~9 a Planning wwzr- f2 "5Q$ Z P4 Z W W L 0 ~ F?n_!ks Ciomrritte* SCALE IN FEET lC, rjG LOT fZ J!mtrecorded 0z \F v,' tin 30 days of O' 200' 400 z¢ 6 6 ' approval date aww OWNER AND SUDIVIDER approval shatb• "WILLIAM. J. & JEAN S. DAVIDSMf & void THIS INSTRUMENT DRAFTED BY DARIN FLATER 1453 EMORY DRIVE, APT. 6 RIVER FALLS, WI 54022 CURVE DATA TABLE CURVE LOT RADIUS ARC CHORD CHORD CENTRAL 1ST AND 2ND RZS. TENG i =GTH LENGTH BEARING ANGLE TANGENT BEARING 1-2 - 266.00'167.76'165.00'N39 3=26"w 36008108" N21049'22"W N57057'30"W 6 266.00'81.43' 81.11' N30035'35"W 17032'22" N21049'22"W N39021'44"W 7 266.00'86.33' 85.96' N48039'38"W 18035'46" N39021'44"W N57057'30"W PAGE 1 OF SHEET 1 OF 2 SHEETS VOLUME 9 PAGE 2597 USE SOW 6 3anZOA SSHHHS Z dO T SSHHS dO Z H9Vd I ~I .a ~X ZZOVS IM 'S'I'Ivd HaAIH 9'ZdK 'HAIH(I AHOWH ESVT zm NOSOIAVO 'S Naar I 'r WKI'I`IIM 'N SIOAIdW ` HSOIAIGEMS QN`d HHNMO U T S U 00 S T ' S 1 a A T ZZO~S M TTp3 2i 'wi~wun~ Baal qS gnuTpM -4saM E T T Aupdwo0 6UTJaauTbUH Uap60 086T-Z6 '0N qor 8-S Uap60 . H sTOupl3 £66T 'Z gOaPW :pasiAag Z66T ' ZZ iaquia-4daS :aqpQ =dlew pup ' buTpTATp ' 6uTAaAins UT A4UnOD xTOIO •qS pup dTgsuMo,L OTUUTXOTUUTM JO suoT-4pTn5ag UOTSTATpgns agq pup sagngpqs uTsuoosTM aqq go 9£Z jagdpg0 Jo SUOTSTAo~d aq-4 g4TM paTTdwoo ATTnj anpq I gvq-4 'appui Joalaq-4 uOTSTATpgns aq4 pup paAaAjns pupT age 3o saTippunoq JoTla4xa age TTp Jo uoT~p4uasajdai goajioo p sT dpw guns 4L-g4 'pupT pTus go jauMo a74-4 go uoT-4OajTp aqq Aq dpW AaAins paT3T41aO pup uOTSTATp pupT 'AaAins qons appui anpq 14eg4 AJT41.9O I •pjooai go squawaspa o-4 4OaCgnS •ssaT 10 alOui ' -4aad aiunbs £9Z'T9Z buTaq 'ssaT .10 au Ow 'saJOV 866'S suTp4uoO TaO-Ypd STgy •6uTuuTbaq go '4uTod aq4 04 ,00'OSZ M,LS.ON aOuagq !,SS'TS H„0£,ZO.Z£N aOUaq-4 :,00'S9T M„9Z,£So6£N sipaq piogo asogm ATja-4saMggnos anpOUOO aAjno snTpeI ,00'99Z p uo aATJG abpTg auTd 90 auTT ApM-JO--4g6Tj ATJa4spaq-4JON aq4 6uOlp ,9L'L9T ATIa4s9Mg410N aOuag4 !,LO'OLS M„OZ,LVp88S aOuag4 !,TL'00V H„LV,£T.TS a0uaq'4 =,00'tt,9 S„6Z,61o68S a0uag4 :6uTuuTbaq 3o quTod aqq oq ,08'LL9 H„6Z,6To68S aOuag4 :V/TMN pTps 30 auTT 4saM aq4 6uOTp ,00'V8S (H,LS,09 sipaq gOTgM V/TMN aq'4 3O auTZ -saM aq4 04 paOUalajaH 6UTIpag pawnssV) H,LS,OS a3uaq-4 :8Z UOT-40aS pTps 90 JauJO3 4saMg41oN aq4 -4p 6uTOUauiuio0 :sMoTTog se pagTjosap jaggjng pup sdpW AaAinS paT3T41aO A-4unoO xTOIO '-4S 90 LOLL6£ jaqunN 4uawnOOG 'L8VT abed IS awnTOA LIT papjooaj dvw AaAjnS paTgT-4jaO V qoZ 6uTaq 'UTSUOOSTM 'Aqunoo xTojo •49 'OTUUTS[OTUUTM Jo uMOI 'M8TH 'N8Z,L '8Z uoTg3as 3o 6/TMN ag-4 90 V/TMN aq4 uT pa4pOOT pupT 90 TaOlpd v NOI,LdIHDSH4 ` t w> C W CERTIFIED SURVEY MAP LOCATED IN THE NW1/4 OF THE NW1/4 OF SECTION 28, T28N, R18W, TOWN OF KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN. OWNER'S CERTIFICATE OF DEDICATION William J. Davidson and Jean S. Davidson, husband and wife, hereby certify that we caused the land described on this Certified Survey map to be surveyed, divided and mapped as represented on this map. WITNESS the hand and the seal of said owner this day of 19. William . Davidson Jean S. Davidson STATE OF WISCONSIN) S S . L(IRME k TOOORA V PUBU• INN2iOTA ST . CROIX COUNTY AIODTAOOUffly Personally came before me this Uay or 19 the above named persons who executed the foregoing instrument and acknowledged the same. NOTARY PUBLIC My Commission expires NOTE: THE PARCEL SHOWN ON THIS MAP (PLAT) IS SUBJECT TO STATE AND COUNTY LAWS, RULES AND REGULATIONS (I.E., WETLANDS, MINIMUM LOT SIZE, ACCESS TO PARCEL, ETC.). BEFORE PURCHASING OR DEVELOPING ANY PARCEL CONTACT THE ST. CROIX COUNTY ZONING OFFICE FOR ADVISE. NOTE: LOTS 6 AND 7 ARE HEREBY RESTRICTED TO THE CONSTRUCTION AND USE OF A SINGLE DRIVEWAY TO SERVE THEIR ADJOINING LOTS ON AN EXTENSION OF THEIR COMMON LOT LINE WITHIN THE LIMITS OF PINE RIDGE DRIVE RIGHT-OF-WAY, THE 20' WIDE DRIVEWAY EASEMENTS SHOWN ON THIS MAP ARE HEREBY GRANTED TO ALLOW FOR THE MERGING OF THE INDIVIDUAL DRIVEWAYS INTO A SINGLE DRIVEWAY PRIOR TO ENTERING UPON PINE RIDGE DRIVE RIGHT-OF-WAY. Date: September 22, 1992 r Revised: March 2, 1993 Francis H. Ogden S-882 'C'ob No. 92-1980 Ogden Engineering Company sCNO/k," 113 West Walnut Street ,River Falls, Wisconsin 54022 S OWNER AND SUBDIVIDER WILLIAM J. & JEAN S. DAVIDSON 1453 EMORY DRIVE, APT.6 s = RIVER FALLS, WI 54022 92 y0 V%l PAGE 1 OF SHEET 2 OF 2 SHEETS VOLUME 9 PAGE 2597 SEPTIC TANK MAINTENANCE AGREENENT St. Croix County OWNER/BUYER G(J( ( UAk- IbSG h~ ADDRESS: FIRE NO: LOCATION: lI LtJ 1/4, W1/4, SEC. _T Z N-R TOWN OF: K I tJ A), IL I n; k; -ST. CROIX COUNTY- SUBDIVISION: LOT NO. $ CA 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 to help with the cost of the 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 the St. Croix County Zoning a certification form, signed by the owner and by a master 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. Certification from will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned have read the above requirements and agree to maintain the private sewage disposal system•'in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE:- ell l,, 3 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 14UMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOC TION: SECTION: TOWNSHIP/mtwi-ehR*tt-TY: LOT NO.:BLK. NO.: SUBDIVISION NA/MEEK: mow'/ P w '/a Pp /T,i,, N/Ri,p E to ° .►,~,F,ti~, v a kir/ ~S/~ COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: r^ USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: esidence 3 ~lew ❑ Replace 1 9 1 L RATING: S= Site suitable for system U= Site unsuitable for system CONNV]ENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: K: RECOMMENDED SYSTEM: (optional) DS Eu0S go 2S EU ~S EDU ~S EA If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate;, Floodplain, indicate Floodplain elevation: -1 1 PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / 7 0/ N IF ,1 ,gAAr-C, B- 2- L r /Y/M i S 3 ' ,D' lye g4 ""s B- 3 Z oo G2 /3-1 Z5 ' B- 7 7 N > 6 7 , 7 ,r l Y, ~i %3 nr B- S 8 A) 3 s '13 , rs B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P- / -74, A)Ai P- ~ P- 2 VIM -f K"t o" P- P- s- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or di tances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevatio II b r~ he direction and percent -ym of land slope. 1Q SYSTEM ELEVATION M r 3 w1 - 47 W~ XG ,C "s rtl • E Hof 02 E i 93fu GHY and : D ~ fn tt ~ ~ ~ _ - 3 ~ E 3 m=Perk - E 19-:;L4 0 Y^ 9/41 E ,yE ~ a Gl? ✓'I N t ! ~ ~ 1 /vBi~ - OYi~ rl'H?H' . r, f GK~ I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): DAVE FpGfRTY PLUMBING TESTS WERE COMPLETED ON: ADDRESS: 2- fZ #3233 93289 CERTI I AT ON NUMBER: PHONE NUMBER (optional): Fogerty Heights Road 9 CST SIGNATURE: lot 749-3656 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - ih TO ( _ t_ fol '-6 A a 11 a n. zr o ti a x 4 S x~ ~ `0 ~ ~ o~ a 4 ~ 3 M tA l 1i ~ v p h M I~ 0 ~O h ~°e s ~ O y Z U .4- 0 ;a ~ t f t a: t s, x ~ ,ynW?' ! yn 's rt ~ ~ ,a +A ~,~°'a x i . n ' O ~ ALA DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY i 173 3 JDla ;Check E SA Y PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. 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. PROPE TY WNER PROPERTY LOCATION r 6 st- keaI4 C1irir W5_r L $ 8 T , N, R E (or 0-71 PROPERTY OWNER'S M AD RESS LOT # BLOCK # ` e - CSTATE IP'CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER /~►'vu Zz o y~ a 13 11. TYPE OF BUILDING: heck one) CITY NEAREST ROAD ❑ State Owned VILLAG N OF: E: %h Z hA el -4 r r. ❑ Public or 2 Fam. Dwelling of bedrooms Y PARCEL TAX MBE III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 14.0 Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 120 Service Station/Car Wash 50 Hotel/Motel 90 Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. 0 Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 El 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.) (dais/day/sq. ft) (Min./in¢h) ELEVATION Cw i b~ S~ Feet OD. Feet VII. TANK CAPACITY Site INFORMATION in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New lExisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank l~ an Lift Pump Tank/Si hon Chamber L-LJ -R, Vill. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu is Name (Print): Plumber's Signature: (No Stamps) 4=MPRSW o.: Business Phone Number: 7 6.AK m eras A dress (Street, City, te, Zi ode): Via . C LINTY/DE A TMENT USE ONLY Signa o b s) Disapproved Sanitary Permit Fee (includes Groundwater Date Issued an Approved El Owner Given Initial Surcharge Fee) Adverse Determination 15*& 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 INSTRU&IONS j ` 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 §ubmitted 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'f 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.coonty; 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 O v c 4R~ s W T ~ n • ~l li y o~ O S s ~ 1r ~ ~ ~ ~ ~ h P p INDEPAR QUS f Y, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IN~USfiRY DIVISION LABOR AND PERCOLATION TESTS (115)' MADISOP.O. BOX 7969 N WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: N '/a z r /T N/ E l - - COUNTY: OWNER'S UYER'S NAME: MAI LING ADDRESS: r 5 USEy DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: DESCRIPTIONS: PERCOLATION TESTS: Residence U IZ New ❑ Replace G ~ L 1 RATING: S= Site suitable for system U= Site unsuitable for system r ONVENTIONAL: IMOUND: (c`IN-GROUND PRESSURE:SYSTEM-IN-FILLrEffT]S TnAINIK:RECOMMENDEDSYST (optional) ~S~U ~J~U 1~-]vDU OSZy Z s ~ If Pe rcolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) -f 7~7 B- ` 73 00. > ..t ssc S B- 13- -7 2,P Alm-C 13- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P_ 44= P- - - - - P- S` P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION lie j { _Ew 3 e T i 4 a A I F 3 S z r E 3 O r N E I 'KIP f E E x I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): MY PLUMBING TESTS WERE COMPLETED ON: & PERK TESTING, INC. 1 4 /0" 3 130 ADDRESS: ROBERTS P.O. Bft WI 54023 CERT FIC ION NUMBER: PHONE NUMBER (optional): ,3x.33 ? -3FsY CST SI A URE - DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - .rte NSTRUCTIO < ; COIMPL.ETI~`L. Nil 115 - SRC - 6395 To Lre w. r,,=ete and accurate t:, you,' report r 1. Cc ~~scription; 2, The iise E ust clearly c'vvhrthetl_ti,is nce or commercial project; 3. MAXI' 3er of bedioor comMOrcial Ined; 4. IS Lhis a 1-1.entent s " , b. Corrlp~ _ tabifity ratir'" A SIT, IT ABLE FOR A HOLDING TANK ONLY IF ALL OTHER Sl' fL ~ RUL fT BASED ON SOIL CC : IONS; E. , f-EASE use the c f eviat ions .e for writing profit scriptions and completing the plot plan; .E A LEGIRLt diagram ly locating your test l,,i.at:ions. Drawing to scale is preferred. A _,t.e sheet may beused if S ake sure your benchn ark and it elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate- 10, If the information (such as flood plain, elevation) does not apply, place N.A. in "ie riate box; 11. Sign the form and place your current address and your certification nurnber; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST RE FILED WITH THE LOCAL. AUT14ORITY WITI-11N 30 DAYS OF COMPLETION. ` REVIATIONS FOR CERTI, " ')OIL TESTERS and Textures Other Symbols st: - ,ne !over 10"i BR f frock cob - Cobble (3 - 13") S - . dslone gr Gravel (under 3") LS - 1 tone s Sand 1-100 I ; G rouncf?vater r, cs coal'! Sand Perc ~ ion Rate . ind bldg Bud'ding k ay Sand > Greater g hair s; .1y Loan < Less Than 3n - Brown _Darn BI - Black s` Coy Gray Loan Y - `fellow y Clay Loann R Red - Silty Clay Loam root - k1oti_les Sandy Clay vv With ?ty Clay fff - fe , i r pr mrT - 1iP.t1;t7rT p ~rinent I-11=VL li, ~a dater level, Si" gel' es surface uvater for lict . ch Mark ticai Refelen€e, Paint TO THE OWNER; This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to hermit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the apprQpr aje local. autbority in order to obtain a permit. The sanitary permit must be obtained and posted prior *Q t ie_s, ggrt pf any ~onstruction. DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code f lc~ :3 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. ❑ CI.4 f re0sioKdorevious 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 '/4 S.,2,-P T N,R % E(o PROPERTY OWNER'S MA G ADDRES LOT # BLOCK # r,. oLf, CITY, STATE ZI CODE PHONE NUMBER E OR CSM NUMBER _0 E II. TYPE OF BUILDING: (Check one) CITY NEAR ST ROAD ❑ State Owned ❑ VILLAGE' ❑ Public R1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL TAX NUMBER( b) 111. BUILDING USE: (If building type is public, check all that apply) 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. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 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 ld t Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank LiftPump Tank/Siphon Ch mber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on %he attached plans. Plunder's Name (Print): Plumber, 's Signature: (No Stam _UP/MPRSW No.: Business Phone Number: K-1 - zte)a e J- i f 2 -5 umA'er's ddr s ( reet, ty, State, ip ode): I)(.- COON ODE ARM T USE ONLY ❑ Disapproved Isanitary Permit Fee (includes Groundwater a ssue issuing Agent Signature (No Stamps) Surcharge Fee) t. Approved ❑ Owner Given Initial a Adverse Determination 0 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: I 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. ll. 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) DILHR SANITARY PERMIT APPLICATION couNTY In accord with ILHR 83.05, Wis. Adm. Code 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. c If r si rious 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 '/a a,S T ,N,R E(or 'el PROPERTY OWNER'S M G ADDRESS- LOT # BLOCK # CITY, S ATE ZI CODE PHONE NUMBER E OR CSM NUMBER L ~oor IL` TYPE OF WILDING: (Check one) CITY NEAREST OA ~X ❑ State Owned ❑ VILLAGE QWN L TAX. NUMBER(b) Public LJ 1 or 2 Fam. Dwelling-# of bedrooms ~ PAR E Ill. BUILDING USE: (If building type is public, check all that apply) 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. OLNew 2. ❑ 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 ❑ 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.1) (Min./inch) ELEVATION Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New A in Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 2gW 04_4+~ I I I _F19] El E Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown vin the attached plans. PI er's Name (Print): Plumber's Signature: (No Slam MP/MPRSW No.: Business Phone Number: LPI`6ffib1fr%'Addrb9s ( rest, ty, State, ip ode). UN DE R M T USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater a ssue Issuing Agent SignatuceiNo Stamps) Surcharge Fee) Approved ❑ Owner Given Initial r-) _ C Adverse Determination 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;naintained. 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 asdministrator 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'f 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 a d controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pnp 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)