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Home My WebLink About030-1099-30-200 ~ ~ 3 0 o p v~ m C c ~ rY 0 a°oo 0 ts m c Y 0 co O N .c0. N C4 . U y lC N N w O h p_ co v c N U N Vl N a0 O > O s - o~ d °om m N o o m co - wxa~ C N 0)N NP 40 N a 3 C N N W o 3: Y C C .N Vl Z 00 w -O C L C N III LL C N N O (N L O. .j ~ N N 3 a Cl. ~m~ I i ~ v lil Z w I ~ w E I a a z M M W a m M H Z •Z c (7 d O Z V N v o (D d Z a N N F c c }~w N o N 7 Q O 4 N (V C y y O O O O O • ~~11 a fn L_ 0 M f0 N N a C) c a O 'c 4. N N 0 co z m z O Z o 0 a N Z _ E N N CL l6 L - N w 0 m m rn w a L d 2 8 (D 1 O D o G. Q O = H H H O Z N O Z > 3 3 3 a m • Zaaa a 4 a O o u) in rn rn } I f/~ J V L O) W (D C14 C> z;s i:4 c, a N O c O N N N w 0 co co N ?i 01 O O { 0 0 = C d N N O C 'O m Y O 0) I N c d ¢ D in co Q O (n H y O 3 ca O N w H O O C O O W O Cl) O M L N C fOA U a 0 0 0 M 0 M L _U O CL C -O N- N N ~ Q) N C U) (n E o C 5 75 Q O N W O C O y Z = y N O I'i cl E w o ai O E R v cc co A O M (p C O Z N rL to Q ~ 1 E 1 ed I V a L d L: CL CL 4) r`1v o A 3 3 'o STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 11C1'1~Q~~ JUG ~Nrn1`~~ ADDRESS IOU CpV}"h.~, Lic~5 SUBDIVISION / SM Vol . / 1?4 as q ~a LOT ~ Q S ECTION . 3 3 T3 U N-Rja_W, Town of St 3U Se 1), ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM FoRCe MAi N 3,51 Pu~,P chA~,be2~ _ - - ~7 4, P C - - _ - - a~ G2nr'~~ - _ - - of 33' a`)x (c~ Bpi z . y epp ~N INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: S{ eel I I ~e ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING-TANK INFORMATION Manufacturer:- WeQt. S Liquid Capacity: Dob qLr4 L House 3 1i Setback from: Wel10V~R 5 6' 1 Other Pump: Manufacturer 6O1 I 1eR Model#. 132 Size Float seperation Gallons/cycle: ~~ON S Alarm Location N l~ASe r-n eN I .SOIL ABSORPTION SYSTEM Width: o~ Length U Number of trenches a~' Distance & Direction to nearest prop. line: O' Setback from: well: OV e K House 3 Other ELEVATIONS 141e R Building Sewer ST Inlet; S_ 33 ST outlet S' 05.43 - (ps.03 PC inlets. 0 PC bottom / Pump off ~a•(~a deader/Manifold Bottom of system 03. 8S ~ -30 Existing Grade Final grade l y t7 . l S 109,8s DATE OF INSTALLATION: It 30)13 PLUMBER ON JOB: Y, , 1 /al ~Jl'YLQQ~ LICENSE NUMBER: 3VO 7 INSPECTOR: 3/93:jt L W"%T5 WartSTrA ofJWBRH.33.30.AIir ME RUSTEM County: Labor4nd Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar rrni ' ❑ City ❑ Village X Town of: State PI Permit Holder's Name: I 10M tev.: nsp. BM Elev.: BM Descriptio Parcel Tax No.: GIJ, ~ 1,)d, 6) 1 c5"-~r a5 TANK INFORMATION ELEVATION DATA A9300217 ~t S TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 1 / 2Zd Benchmark /d, J _t5 40 Dosing S 53` 10t197" Aeration- Bldg. Sewer Holding- /I "t Inlet 35 TANK SETBACK INFORMATION St/,V( Outlet ' s TANK TO P/ L WELL BLDG. Ae Intake ROAD Dt Inlet Septic 5Z7' 1-?/ NA Dt Bottom Dosing M tl 5 6n -35" NA Header /fem. SZ' dS 03 Aeration-- Dist. Pipe 7U S/g5~ Bot. System PUMP / FORMATION Final Grade Manufacturer L~~e✓ /(J /0 G~. S Model Number`- / 7 GPM 9011 TDH Lifta 41 Friction System TDH Ft Forcemain Lengt1oss Dia. H " Dist. To Well SOIL ABSORPTI N SYSTEM BED/TRENCH Width i Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS C~0 D EN I N SYSTEM TO P /L BLDG WELL LAKE/STREAM LEACHING ufacturer: SETBACK um er: INFORMATION TypeO r7,-, l~o5e 1 CHAMBER M System:C"L} -LSJ7., 33 ~-j6 j ORU DISTRIBUTION SYSTEM Header / ~ i Distribution Pipes % „ x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length ~ Dia. e7 Spacing _ L SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Depth Over r „ Depth Over „ xx Depth Of xx Seeded ded xx Mulched 2 / 22 Bed / T•r*ZWCenter 3& `3 Bed / 7r~ ges 3G -J~ iTopsoi Yes 171 No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION : ST. JOSEPH-33.30.19 (60TH STREET) ft~°r 'C~t ~.G J~~2w.~--" ~'`Nl/~i • %~~i. a'°u ~ 'h°~c,~ a yQ~~-, Plan revision required? No -k 1/91 Use other side for additional i Kormaon. ( SBD-6710 (R 05/91) Date Inspector's Signa ur Cert. No. .did ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: E i SANITARY PERMIT APPLICATION 701L A 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 ~ 9 q opl b 8% x 11 inches in size. ~ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY O NER PROPERTY LOCATION A 1 d- Su S A N ~N rvt !4 /1) AV '/a Of: '/a, S 73~ T 30, N, R 1 E (or) W ' P i O;ERTxOWNE~ Rj MAILING ADDRESS LOT # BLOCK # :1 ( 9 ST ~~M C~ I W C ~TY, STTPT N ZIP Cp E PHONE NUURER SUBDIVISION NAB OR CS Vol. M NUMBER ' a's 9~ ~r1~ r i S NEAREST ROAD t O-}~ II. TYPE OF BUILDING: (Check one) ❑ State Owned ~J VILLAGE ; St J d~ 'k st ❑ Public ~1 or 2 Fam. Dwelling4 of bedrooms PARCEL N 111. BUILDING USE: (If building type is public, check all that apply) 030-/0197 V)200 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.ANew 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 ❑ 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/I' ch) ELEVATION 600 1 y o o l q 7 If/ m o to thaw 16 ' C3„ ~ 5 Feet 113b- 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 ~_K 100 0 { 211 0 El 1. F] Lift Pump Tank/Si hon Chamber q00 ~9 El El I El 1:1 1 El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: -S►m & m e e 3 SOX ) C. A yet, 9 i Some, Zip Code w - Plurq Address IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signatu _Surcharge Fee) Approved ❑ Owner Given Initial 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 e 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 z eptic tank(s) must be purriPed wry 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. IIL. 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 in,tormation. Provide all information requested in $l1-7. VII. Tank information. Fill in the capacity of every ~,ew and/or lank, fist the total ga !:;rig, number of tanks and manufacturer's narne. Indicate prel or site i;onstr ucted and tank mates ialr rrrrs !ete fcr all septic, pump/siphon and holding tanks for thi: e ystem. Cheek ux ~erimental approval on'y if tanks received experimental product approval from DILHF, VIII. Responsibility statement. installing plumber is to fill in nave, ii!-ease number with appropriwe 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 B'/z x 11 rr r.!i ^n,!st be z;ubmitted tt~ +he county. The plans musf include the foliawing: A) plot plan drawn to scale or complete dims iisrer location of holding tank(s), septic tank(.) ~-~r :ether trea.tmr,:-it tanks; building _fs, welly:; water r,ia n,!,,vater service; streams rrc+ lakes; pump or siphon tanks; ctistrihution boxes, ~fbsorptiorl systerns; rel:4.k-~rnent system areas; and the 'ocation of the bui'(,ing served horizonta ;,rtical elevation referf r (c-- po nts; C) complete specifications for pumps and contrc• s; close vi-;iume; 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 41.0 included the creation of surcharges (taws) for a number Of regulated practices ewt3ir.h can effect groundwater. The monies collected through these surcharges are used for monitoring grog-J-dwater, grounrl water contamination investigations and establishment of standards SBD-6398 R.11/88 SANITARY PERMIT APPLICATION ' D&HR COUNTY In accord with ILHR 83.05, Wis. Adm. Code C,~Q 1 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'. lL~l Check if revision to previous application -See reverse side for Instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY O TER PROPERTY LOCATION L f> d- SU$A/J rNrnAN N Y,,N S 33 TZj6,N,R 19 E(or)W P OPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # C_ C, ~)A ER SUBDIVISION NAME OR CSM NUMBER CITY, ST T ZIP C DE PHONE NU pi tiJ t u rh 9 11. TYPE OF BUILDING; (Check.one) CITY n ❑ State Owned ❑ VILLAGE S NEAREST ROAD f ` J aSQ V~ , M =N OF: ❑ Public 541 or 2 Fam. Dwelling- # of bedrooms I PARCEL TAX NUMBER(S) 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 ❑ Merchandiser `Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 120 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.E] Replacement: 3. ❑Replacement of 4.0 Reconnection of 5. ❑ Repair of an 'System System Tank Only - i 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 aSeepage 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 Goo REQUIRED (sq. ft.) PRO(P/OSr D (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION VJ V~ t o 74 V n'° f'i uti lc~ I43-~5 Feet 1Q. 1 Feet VII. T in allons Total # of Prefab. Fiber- Exper. INFORMATION CAPACITY Site Manufacturer's Name Con- Steel Plastic New istin Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Hold! n Tank . _ POO t Lift Pump Tank/Si hon Chamber OU f Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: S (A 3 ~{0 5 3 t~~ Plumber's Addregs (S rest, ity, State, Zip C e ~j s c~ 5 C. t K k K- e SOM C~t IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Agent Sign Surcharge Fee) °Approved El Owner Given initial 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, Oirner, 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 Abe 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. Ill. 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 B% 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) 82 PRIVATE SEWAGE SYSTEMS - II PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP 4"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUNCTIOW BOX MAWHOLE COVER 2.5' FROM DOOR, WINCOW OR FRESH IYMIU. AIR INTAKE I GRADE I 4° MIN. IB"MiW. CONDUIT-- 18"MIN. 11~ PROVIDE . INLET ~ AIRTIGHT SEAL I III ~ f I III v APPROVED JOINTS APPROVED JOINT A I III w/C.I. PIPE W,~C.I. PIPE I III EXTEWOIUG 3' EXTENDING 3' ALARM ONTO SOLID SOIL I II ONTO SOLID SOIL B I I I I oN C I I I ELEV. FT. PUMPS OFF r D CONCRETE BLOCK RISER EXIT PEP.MI'ITED GAILY IF TANK MAWUFACT URER HAS SUCH APPROVAL SEPTIC E SPECIFICATIOKIS DOSE We } TANKS MANUFACTURER: NUMBER OF DOSES:- --PER DAY TANK _dZE : U GALLONS DOSE VOLUME I I r INCLUDING SACKFLOW: GALLONS ALARM MANUFACTURER: 11 MODEL NUMBER: CAPACITIES: A= Il _INCHES OR J70- GALLONS ] SWITCH TYPE: B= INCHES OR 371 GALLONS 1 PUMP MANUFACTURER' L 2)Z C=INCHES OR GALLONS sue- GALLONS 0 = J INCHES --R MODEL NUMBER: }1 / - SWITCH TYPE: 1 Iq NOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE LO(pGPM ~IN~ST~ALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE..FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . 2.S FEET 0orr.FRICTION FACTOR.. -FEET FEET OF FORCE MAIN X I~FIy TOTAL DYNAMIC HLAD FEET 4 I INTERNAL. DIMENSIONS OF TANK: LENGTH O~ ;WIDTH -J -;LIQUID DEPTH 1 ) 3 !I SIGNED' 12~ LICENSE NUMBcR: DATE: II I _ _ i r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER J~h1►n'1 ADDRESS I~OV Cpl`. SUBDIVISION / SM Vol, 1 p4 o~S q LOT o~ SECTION. 3 3 T30 N-R-L~_W, Town of St o Q I ST. CROIX COUNTY, WISCO ai "D bft w P VIE SHOW EVERYTHING WITHIN 10 FEET OF SYSTEM _j Fo2ce ~A~ r~ L1 - ~ 3S, NO Q Q W _ - - a~ 0 Be D- ~oRv~b►p S,~ef t Axnlf of 54vI r►fL Al Flee= ~o~-~ ~For~ JC~ q c J S L y~ ~ J i pp,, TAP-). IOU f INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover- . BENCHMARK: I 1~e ALTERNATE BM: I SEPTIC TANK / PUMP CHAMBER / HOLDING-TANK INFORMATION Manufacturer: S Liquid Capacity: Po V Setback from: Wel l4V~K S 61 House-31 Other Pump: Manufacturer ~fo Z HIek Model#iY? -Size i Float seperation Gallons/cycle: ~~~ON S Alarm Location N QASe rn wvt I .SOIL ABSORPTION SYSTEM Width: -Q 4 Length U Number of trenches Q7% Distance & Direction to nearest prop. line: Setback from: well. o\j House 3 ~ Other ELEVATIONS Building Sewer ST Inlet.- S_ 33 ST outlet 5 ~oS•~3 -roS.o3 Q PC inlet ~5 • PC bottom Pump off l a a 4eader/Manifold Bottom of system (~3•J Existing Grade Final grade iJ~.I~ -10918's- DATE OF INSTALLATION: I 3CA3 PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt SANITARY PERMIT APPLICATION LHR 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 ~ (Q 8% x 11 inches in size. El c he `f fAv ision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PRQP ER OWNER PROPERTY LOCATION y- ES 3 T 30, N, R 4 E (or)® PROPERTY OWNER'S MAILING ADDRESS LOT # ~ BLOCK # T T 7 ZIP COPE'? PHONE NUM R_ SUBDIVISION NA OR NUMDErj, ~s J 46AJ 440 ?,cw. W-Jr &$(f t Ile. X II. TYPE OF BUILD7101r7am. : ck one) ❑ State Owned ❑ CILTMLAGE ' 1 4 NEA 0 ❑ Public Dwelling-#of bedrooms PARCEL Ax Nu T ~J 111. BUILDING USE: (If building type is public, check all that apply) 6 3 / c3C7 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facil ty 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 OFPERMIT: (Check only one in line A. Check line B if applicable) A) 1. EPNNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E1 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 0c) RE'UIRED (sq. ft.) PROPO Vq ft.) (Gals/da~/sq. ft.) (Mi . i h) 103.U EL V TION Vv 1( e~e p~ I Feet . Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncre Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 0 D Q 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. Plumb s Name (Print): Plu er's Signature No Stamps) MP/MPRSW No.: Business Phone Number: Plum e p A tress (Street, City, ~tate, Zi Code): r Mi c Pk sow s ~nJ v~ s~ v IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sarrruuu' ary Permit Fee (Includes Groundwater Date Issued Issuing A nt S=Noom Approved El Owner Given Initial Surcharge Fee) 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 sankary 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 ;SRi_t 6399) to be. submitted to tht, ; ,:.,inty prior tc installation. 5. Ontsite sewage systems must be properly maintained. The septic tank(s) must be pur ped by w-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, 668-266-3815. 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 numben:s) of where ttxe system is.torbe installed. II. Type-of buiidiilgbeing 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, reco:nrection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide. al' information request^d in ##1-7. Vli. Tank information. Fill in the capacity of eery crew and/or exist;.-ill t~-,ik. list the total gallons, number of tanks and manu`acturer's name. indicate prpfa.b or r;ite coristruc{:;d and tank material. Cowl iete for all septic, pur,ip/siphon and holding tanks for ihi:S system. Check ,,xr: ,+rimental approval,only if `;inks received experiniantai product approval from DILHF, Vlll Responsibility statement. Installing plumb er is to fill in name, lit.<, nse number with appropri,nie prefix (e.g. MP, etc.;, nl,' ireS~ 3n: phone number. Plumber must sign appi!(;u „jn form. IX. County/Departmen; Use Only. X. County/Department Use Only. Complete plans and spec +ficjtians not smaller than 8% x 11 rrs,.;i^as must be 3uwmilted fo the county. The plans mr;5t include ,}it! fo. rwv, -1: A) plot plan; ,drawn to sca ! , complw a ocaticn of holding ;arik(s sepfi( tr. ',r (,iher treatme?it tacks; bui di;- ~"~zrs weli,>, wager r air5, .alai'er service, stleams and lakes; pt iii tanks; distribution bo=.k. ~`7*4 =IbSOVI)tiOn SySiefnS; re. !i::@rrlY,rtsystem areas; and the iocaticn of fne ,-,.u, ling served, B) hcrizontal a: ^ncca elev -pet-genre point,;; :)complete specifications fo- pumps and controls; dose volurr,alevation 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 sit..ing information. - - - - - - - - - - - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1983 Wisconsir: Act 410 me uded the creation of surc' arees (fees) for r_; nurrt )er of regul ite_~d nr;i F , :,s whtcl car, effect groundwater. The monies ;;oilected through these surcharges are used for monitori J crr water contamination investigations and establishment of standards. SBD-6398 (R.11/88) 67 RO S S 5 E C T I 1\1 PLOTA 1-11) !'{L 0C/ 7 I ON o DC . NS Eel`- YD~ C---- - PLO 1- M Al 5 .X it k- -0 t t _x t • of • NUST T,* To kon-q t FRESH All'. INLETS AND OBSERVATION PIKE CROSS SECTION Approved Vent Cap Minimum 12" Above I ~O• F" ) Final , axle---`._ t 4" Cast Iron Above Pip Venj Pipe To final Grade- Marsh Hay Or Synthetic Covering Min. 2" Aggr.ey'o Over Pipe Distribution - Tee I Pipe Aggregate 1 rer-f•orat:ed Pipe Delodi SJr Beneath Pipe -Coupling Terminating'' P . Bottom of System ' I I FILPED 0 OCT O 11992+- 4 JAMES O'CONNELL Register of Dceds SL Croix Co., WI S 489353 This instrument drafted by Craig Paukert Proj. No. 83-16-192 0 Bearings are referenced to the n r C7 east line of the NE} of Section O O tom, 33, assumed to bear S0005313711W I 'L71 I Lv L A hiIL) re sL o Jr_v~ - - - - - - - = - - 'c (D z S00053137"W 30 3.03 ° ~ to Ln --4 g l i) N y I(!) n b W CI) Cn I o 0 0) o rn ME 1.1 c z e m - U1 r F aE rt 77 .s. rr .C I..i. I-_- O 00 N o lp O o+ O I Ct 0 m I U, N r Jp I -(j E I(~ 0 I-h --I a n c) n C-) j co w -3 s m o o (f a z W to Un 0 0 a -7 c m M. rt o r W (D r La O fD r o z o H rt w a m O ~ ~-1 ~ c > to > rt rt r• ~ to ~ LTJ II 11 S 7 rt u N CA 11 0 I I-I IV) O T C!1 O r (A O A 11 II II I tel.) 0 ~~r-~•-/~ O Ln N F Cn N N O O O T O O I C I l> 12> -n c,n a- Co :.j 1 .7 w -n c, N _ O O 10 z Ln ao c" I-I II 0 Ill cn v E~ C.0 = I(- o~ rr 1 P= E i O N' W n I O C 1-I W a H a y Or Y W IM - co TI x T 7 '_"I W I U o 4- rt If - n _ a a w II> to to (D w O z s IC7 ICI) O • ,p Ln I i E ~ I Cr) o m ~ O ~S O o~ c m O w n. x N _ o.. a r c~ ,p ~ a Cn d -0 " OC) I-h ro -3 C'> co -n o m c Cr co 0 o o ' -n °-r I ()1 (t x• It. v o 1c c r v ~ w ✓J w" 4 I'u M Cn rt O (D I N 'b L 3 IM to a e I~ N -n O co OD a 0 v 0 0 S0105311411W ~ 0 k 197.56' EQTH ST m w n N00053 3711E - - W W S0005313711W 203-8.861 V N00053'137"E 280.00' W wo m 313.10' w w m C o V I East line of the NE 1 I ` IDI y M. 0 -3 This CSM is Vole 9 P:~k6 y n n I o J.IV1. 1IV V. I. ( Jt~ o . I pion •,W gnu eq Ueys pnoiddE "OP 1eno.tdde papiot'ei Fou 11 eat} WWOO s){led Fite 8W107, SWUS}d enlsuayssCU~o.~_ t,1.moo XIOUD - [.a 96' 10 t~-) 9hSZ aOVd 6 3I MOA A080 •9OTAPP 3o; aoT;;o 6uTuoz A4unoo xTo3D •4S 9y4 40P4u00 Taozled Aule 6uTdoT9nap 10 6uTsPyoand a.ro;ag (oqa 'Taoaled o4 ssaoole 'azTs 'sMPT A4unoo 40T unwTutw 'spuP14aM '•a•T) suoT4PTn693 pule saTn3 pule a4P4S o4 4oaCgns sT (4leTd) dPw STU4 uo uMOys Tao;red yoPS 4 J -s, -29z. Nl~ gdasor • 4s ;o uMoy aq4 Aq panoaddV a4s(j ua gAN •0 u91iV a autss buiddeut pus buTAanans UT x1013 •4s ;o A4unoo aq4 ;o aausuTpIp uOTSTnTpgns pupa ago pus sagn4s4S utsuoosTM ago ;o b£'9£Z 3a4dsgc) ;o suOTSTnOld 4uaajno aq4 g4TM paTjduzo0 Ajjn; aneq 149144 :pagTjosap pus p9A9n.zns Aispunoq JOTla4x9 9114 ;o ajsos 04 uoT4s4u9s9ld9l 4091100 s ST dsw AananS p9T3T4390 stg4 4Vg4 A;T41aa Osjs 'I •paooaj ;o squawassa jjs pus (49914S 8409) psOJ UM04 aO; AsM-;O-4gbTl 04 4oaCgns ST taoasd pagTaosap anoq*i utuuT aq 3o 4uTO ago 04 4993 00'08Z 'auTj 4ss9 pTss buojs '3„L£,£SoOON 90u9114 :V/T EN ago ;o auTj 4ssa piss o4 499; 13'P'606 'Z,JO,£So88N 9au9144 4993 £0'£O£ 'M„L£,£9o00S a0u9114 :499; 69'TL£ 'aoT;;o pTes 49 T8£T absa IS awnjOA UT p9pI009a dsw A9n3nS paT;T4iao 3o auTj g4nos aq4 buojs 'M„TV,6Zo68S 90u9144 :4993 T£'L£S 'aoT;3o spea(l 3o aa4sT8ag A4unoo xTOaO '4S 9114 4s b8ZT absa IS awnjon UT p9pJ009~1 dsw Aan.zng pa•T;T190 ;O auTj g4nos aq4 buojs 'M„8S,VOo68N aouag4 uTUUT aq 3o 4uTO eq4 o4 4aa; OT'£T£ 'uOT409s ptss 3o b/T HN 9114 3o auTj 4ssa aq4 buojs 'M„L£,£5o00S aauag4 uoT4oaS pTss 3o leuloo HN aq4 4s buTauawwoo :sMojjo; se pagTaosap jag4an; :uTsuoosTM 'A4unoo xTo32) •4S 'gdasor •49 3o uMOy 'M6T?l 'NO£Z uoT40as ;O t/TEN ago 3o V/TSN 9q4 3o 4led UT p949001 pusj ;o 1901sd V :sMojjo; se pagTaosep ST paddsut pus paAanans jaoied pusj ago 3o AaEpunog ioTaagxa ago 4sg4 :dsw Aan3ns paT;T4aao sTg4 Aq paqueseadea sT goTgM jaoied pusj aq4 pagTaosap pus paddew 'paAanans ansg I 'wTaS U101 30 UOT409JTp 9q4 Aq 4sg4 A3T4aao Agaaeq 'JOAanjns pusZ utsuOOSTM p9394st59i 'uabsgAN •0 uajjV 'I ~s~rai3ls~~o s,~ox~n~ns RTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS STRY, _ D VISION R AND PERCOLATION TESTS (11J) MADISON BIIII 5X 76 3707 AN RELATIONS (ILHR 83.09(1) & Chapter 145) 7NNPL TION: SECTION: TOWNSHIP/1~~ffY: LOT NO.: BLK. NO. SUBDIVISION NAME: Jose h nn/ : n/a ~/4NE 1/4 33 /T 30 N/R19)Lor) W St. TY: OWNER'S ,NAME: MAILING ADDRESS: Croix Thomas Seim 529 Co. Rd. #E, Hudson, WI. 54016 USE DATES OBSERVATIONS MADE OLA ION ESTS: NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILEDESCRIPTIONS 17n/a Residence 3 n/a New ❑Replace 8-26-92 RATING: S= Site suitable for system U= Site unsuitable for system MENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) S ❑U ~S ❑U ®S ❑U ❑ S EIU ❑ S ®U conventional 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: ri/a c-1 ass 2 PROFILE DESCRIPTIONS a 42 B 2 BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AN DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-1 80 105.25 none X80 0-12, 10yr4/3, sl.; 12-30, 7.5yr4/6, s.sil.;- 30-80, 7.5 r4/4, ls. 107.25 0-10' 10yr4/34 L.,•'10-34 10yr5/4, sil.• 34-4,4 10 B-2 2 84 none >84 4 • 4-84 7.5 4 4 Co. S. 107.55 0-8. 10yr4/3, l.; 8-15, 10yr5/4, sil.; 15-41, 10- g- 3 86 none >86 5/4 S.• 41-51 1 4/4 sl.• 51-86 1 5/4,''' S. B-4 80 107.35 none >80 0-12, 10yr4/3, l.; 12-80, 7.5yr4/4, ls. 0-10, 10yr4/4, l.• 10-30 10yr5/4, sil.• 30 38- B-5 82 103.65 none >82 7,5 4 4 ls.• 38-82 7.5 4 4 co.s. B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINIl~~TES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- P- P P- P- P_ n PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale dista are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation all borings and a dir d percent of land slope. ~4 SYSTEM ELEVATION 103.85 f i ~ I i ~ rY~ z 3 "E E f < n V i ( t E fi 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): TESTS WERE COMPLETED ON: Gary L. Steel 8-26-92 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER( optional): 1554 200th. Ave., New Richmond, Wi. 54017 2 15 6-620 CST RE: - r DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - ?-T1' 1 FH E L T THE a, I ill SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER BUYER ~_~a. L(~/I d v" ` /L~I~IlI ADDRESS: J/FIRE NO: LOCATION: Al L_: _1/4, IV 1/4, SEC. _T-?Ya_N-R q W TOWN OF: ST. CROIX COUNTY SUBDIVISION: C'Sf~ 9l1~.~5" LOT NO. 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 sludq and-scum. Certification from will be sent approximately 30 days prics° -~~c three year expiration. I/ WE, tho unde : ,igned have read the above requirements and agree mainta]n the private sewage disposal system-in accordance with the Ctano,-=.cis sets forth, herein, as set by the Wisconsin DNR. 0..rtJfi at::cn form ;rust: be completed and returned to the St. Count* officer within 30 days of the three year 4X~.ryr ~^f.~ ZUAY. V4C.3 ~4~ .a ',I L lj SIGNED , - + I DATE: St. C.s:odx co".11 y 'iao!-lir+cj office 911 44 h St:. Hudson, W1 5401.6 I 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 1- Location of property_& C-114 1/4, Section T N-RW Township Jo~p~h Mailing address for J`~~~t~ Address of site P) QO Subdivision name /C$~ Lot no. Other homes on property? yes ✓ No Previous owner of property -Z AOfiga ILA= Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes ✓No volume /o-A~and Page Number J of Deeds. as recorded with the Register 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 (ve certify that all statements on this fo m are true to the bes 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.J~ o' and wn the proposed site for the sewage disposal t system ) orr I e(we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded ~thof fice of County Register of deeds as Document No. 5'gn ature of applicant Co-ap licant Da Af ~Q t ignature Date f S3 u gnat DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA Ili WARRANTY DEED 504154 VOL 1.029Pace 55 _GGr - ~ 1 OF iCE This ee made be~vegn --.na Seim ST CROIX CO., 1 Thomas n. Whim an on Mae ; Yiusbaria- eefor Reoor~ - I; and---wi~`e r AUG 19 1993 11 W: Inman a nd---Susan--W~---Inman, Grantor, •00 P• and-------------- - ----i husband and wife - '~lsterd's i Grantee, Witnesseth, That the said Grantor, for a valuable consideration-..--- St • -Croix RETURN TO conveys to Grantee the following described real estate in - County, State of Wisconsin: u Tax Parcel No: II C~ Part of the Northeast Quarter of the Northeast Quarter (NE1/4 of NE1/4al of Section 33, Township 30 North, Range 19 West, Town of St. Joseph, St. Croix County, Wisconsin described as follows: Lot 2 of the Certified Survey Map filed October 1, 1992, in Volume 9 of Certified Survey Maps, Page 2546, as Doc. No. 489353. This i_S-------------- homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And ThO_m3-s_-W.-..sp-gym and- -Donna- -Mae Seim warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way, if any. and will warrant and defend the same. - Dated this - - - - - - - - - - - - - - - - --1-9 - - - - - - - - - - - - - - day of - - - - - - - - August 19.---93 /Y•..~1~' (SEAL)--'`Y`a h..' -----------------(SEAL) - Thomas W. Seim Donna Mae Seim I (SEAL) ------------(SEAL) I. AUTHENTICATION ACKNOWLEDGMENT %i I' Signature (a) STATE OF WISCONSIN !l St. Croix authenticated this day of---__..__.--__-----_---, 19 Aug seasonally came before me 10 day of 19 the above named - Thomas W. Seim, Donna Mae Seim TITLE: MEMBER STATE BAR OF WISCONSIN via .IOy Cannars (If not, p lc authorized by § 706.06, Wis. Stats.) OkvHd'2 ~ the li to me known to be the person f going inst ent and knowledge the same. THIS INSTRUMENT WAS DRAFTED BY KRISTINA OGLAND - - ii Attorney---at---La-w------------ * Alice Jo C nors 8--E . Croix -natures ma ( Signot necessary be authenticated or acknowledged. Both date Commission is ~rma_nent. If not state x Aa~tion) are y.) I li *Names of persons signing in any capacity should be typed or printed below their signatures. I WARRANTY DEED STATE. BAR OF WISCONSIN Wisconsin Leal Blank Co. Inca.