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HomeMy WebLinkAbout032-1027-10-000 O N O Y O 'S O ~i O a O ua op Oq O c p 0. 0 g ~ N h, 'O E '6 O N ~ O p i N N > N y C N D O ti c N n f6 O N ~ OC ~ O M C OO ~ .O p N 3 m O N " a ~ C U E N a E ° m ~ Oo ' I' ~ Ya o N~ 5 c Z= O C z J N E it 7 (0 a O ~ O G U. LL C ro y C D 6 O F- a c a Q LL F- i M 3 Cl) N N z y z N Obi C W O Z O E 4) d z l E d m W a m ~F-z o o z O Z :1 c - 2 15 0 Z 0) 0) z (n F- CD c E m N O O N O N '1~~11y1~~ .N O L f9 • a .C U) CL ' O O N Q O c.O-. C -0 0 (D v Z co z Z co z o z C N co y ~ E - E R co E N ~ R Y y Y lwv~ d in `n p v o ° 'C O d n c °v 13 O a E o cul 'n M fA N E j `n to N N U ~ N • a~aaa a;aCaa zt Q y g Ili N E co M N E c,) fq to J O O) O n 0 a) a) 0) O N U cA O) Z - } co 'O Cl) N (6 O ej ON o v E 00 C: p O O m y LO CD ` C0 < Q a O 6 d QI Z =O O d } O `F~i' y V d R y y W 7 O C Z5 E ~Cj O O W N C N N R O Q Q I'.. N O O W C N C U) 4) C3 LL rn O O O' N N C -O r N_ 04 CL 17 (n CD cn co C:) (D E v; = a) 4N) M a~ No r) a 112 L~" ~ O Q M 7~ -0 CL CL M 0 7 C N 0 z Z Y m o Z Z • M o o s., o u) , Y o - 4 w E w E - d E d y as a 4) a a • a m 9. d m c 3 O r % = A v a t o y 0 0 V1 L) .3t. ~24Jk 10 44 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS VISION CSM# _3 LOT SUBDIVISION # T / SECTION_,IT_N-RW Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 644-4G.t W411 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this -form. Provide 2 dimensions to center of septic tank manhole cover. I BENCHMARK: ALTERNATE BM: fff SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: well- House- Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location ':SOIL ABSORPTION SYSTEM Width: Length Number of trenghes Distance & Direction to nearest prop. line: Setback from: well: 2D Housed/ Other ELEVATIONS Building Sewer 7 ~ ST Inlet; 107, -Z ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system 9-4!86 Existing Grade 97e, Final grade 7~ DATE OF INSTALLATION' 9 PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt 1 LOCATION: SOMERSET 10,31.19.128A (CTY RD I) wiscons. in Department of Industry, PRIVATE SEWAGE SYSTEM County: lsbor a-d Human Relations Safety and Buildings Division INSPECTION REPORT Sanitary ST. Permit CROIX CR s (ATTACH TO PERMIT) 193539 GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: IPPES, JERRY & TINA L SOMERSET Parcel Tax No.: CST BM Elev.: Insp. BM Elev.: BM Description:,., 032-1027-10-000 1) :7„ r,. A9300194 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic , Benchmark a a OD, Dosing Aeration Bldg. Sewer 3y ~ I , q 3 Holding St/ Ht Inlet 7 TANK SETBACK INFORMATION St/ Ht Outlet U FMS' TANK TO P / L WELL BLDG. Ventto Air Intake ROAD Dt Inlet + NA Septic Dt Bottom NA Header/Man. 7.3~~ -71 Dosing Aeration NA Dist. Pipe Bot. System J3' 9 o V Holding q7 d PUMP / SIPHON INFORMATION Final Grade 5 ~ -7 Manufacturer Demand d'; Model Number GPM TDH Lift Lriction System TDH Ft Forcemain Length Dia. Fi Dist. To well SOIL ABSORPTION SYSTEM BED / TRENCH =Width Length 77FIL, PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N Manufacturer: SYSTEM TO P / L LAKE/STREAM LEACHING SETBACK CHAMBER Moe Number: INFORMATION Type 0 II/FCr;i OR UNIT System: /s5 - DISTRIBUTION SYSTEM Header J Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER X Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over 1 xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes El No 11 Yes EE] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 10.31.19.128A (CTY RD I) Plan revision required? ❑ Yes ❑ No Use other side for additional information.y-~--~ Date h+ p~ctor's Signature Cert. No. SBD-6710 (R 05191) ADDITIONAL COMMENTS AND SKETCH _ Z SANITARY PERMIT NUMBER: i SANITARY PERMIT APPLICATION COUNTY E:z~131LHR In accord with ILHR 83.05, Wis. Adm. Code „a STAT ITA Y P RAFT # -Attach complete plans (to the county copy only) for the system, on paper not less than El Check f revision to previous application 8% X 11 inches in S)Z@. IlCatlOn. STATE PLAN I.D. NUMBER -See reverse side for instructions for completing this app 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION ERTY LOCATION PROPER'VY OWNER o 14 1/4, s N, R (Or A/Z PROPERTY O R'S IL ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION AME OR CSM NUMBER NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned [I VILLLLAGE I@ TOWN 4: ❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms--? L X NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) d s__V - lea7 -fie 1 ❑ Apt/Condo 10 ❑ Outdoor Recreational Facility 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 11 ❑ Restaurant/Bar/Dining 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 12 ❑ Service Station/Car wash 4 ❑ Church/School 8 ❑ Mobile Home Park 13 ❑ Other: Specify 5 ❑ Hotel/Motel 9 ❑ Office/Factory IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) Existing of an 2. ❑ Replacement 3. ❑ Replacement of 4.E1 EXReconnection ' sting System 5.0 Repair System System A) 1.0 New System Tank Only 3 Date Issued B) ® A Sanitary Permit was previously issued. Permit # V. TYPE OF SYSTEM: (Check only one) Other Non-Pressurized Distribution Pressurized Distribution Experimental 41 ❑ Holding Tank 12 21 ❑ Mound 30 El Specify Type 42 ❑ Pit Privy 43 El Vault Privy 11 ~ Seepage Seepage Bed Trench 22 ❑ In-Ground 13 ❑ Seepage Pit Pressure 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE 'nch) REQUIRED i ~ Feet ELEVATION 1. GALLONS PER DAY 2. ABSRED (sq. sq. ft.) AREA PROPOSED (sq. ft.) 4(Gals//day/sq. ft) (Min./ Feet Prefab. Con- Steel glass Plastic APP in allons Total # of Fiber- Exper. VII. TANK CAPACITY Site Manufacturer's Name oncret structed INFORMATION Now Tanks Gallons Tanks Se tic Tank or Holdin Tank Lift Pum Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati n of the onsite sewage system shown n on on the the attached plans. MP Plumb 's Nam (Pr' Plumbs 's S' nat re: S No.: Business Phone Number: ) 9 r lumber' Address (Street, City, State, Zi Code): pal IX. COUNTY/DEPARTMENT USE ONLY Issuing Agent Signature (No Stamps) F-1 Disapproved Sanitary Permit Fee (13urcha gerFeej Water rate ssue ❑ Approved ❑ Owner Given initial Adverse D t rminati n X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS s a 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 (SBC 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line 13 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 a experimental product approval from DILHR. pproval only if tanks received VIII. Responsibility statement. Installing plumber is to fill in name, license number with a MP, etc.), address and phone number. Plumber must sign application form. pPropriate prefix (e.g. 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 gizing 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) Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page _ of r and'Human Relations Mion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPER OWNER: PROPERTY LOCATION GOVT. LOT 1/4 1/4,S T N,R 0/(oreN PROPERTY OWN :S AI ADDRESS LOT # BLO # SUBD. NAME OR CSM # CITY ATE ZIP CODE PHONE NUMBER ❑CITY ILLAGE jff0 N NEAREST ROA New Construction Use fl Residential / Number of bedrooms -5 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate 7 bed, gpd/ft2__,,~trench, gpd/ft2 Absorption area required bed, ft2 S'/ 3 trench, ft2 Maximum design loading rate 1_bed, gpd/ft2 , f3 trench, gpd/ft2 Recommended infiltration surface elevation(s) D ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable 464 ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for s stem C] S ❑ U El S U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. ont. Color Gr. Sz. Sh. Bed Trench Ground -29 elev. t. Depth to limiting factor Remarks: Boring # _-2 K Ground elev. ~2&ft. Depth to limiting factor Remarks: CST Name:-Please Print ` Phone: Address: Signature: ) Date: CST Number: PROPERTY OWNER SOIL DESCRIPTION REPORT Page,,;~ of PARCEL I.D. # ' Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench Ground I _ elev. ' Rj7 ft. Depth to limiting factor a 9R Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor L Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) i I ~ ! ~ I I i I ! I ~I I I I I I i I t - 14 i ! ~ I I j I ~ i ~ ~ j I I A - I i -r-- ---i --t- i I i -r- i tt T-- - - I ~ I I i ~ I ~ ~ fi I~YI_ f I t I I I i I - ~ ' I , 3 I r ---r----~--- ~-f- -art I I r-- -I-- I ; ~ ~ i` I ! I I I I t + - - i t-- - 1 T-4-4--4- ~ I I i ~ I I I I I I I ~ j - - I I i I --r- ~ 1 ! I ~ 1 - - - - { - - - - - 1 ~ II ~ I i ~ ~ ~ I I - --1 -r- ! / - I i ~ I I I i ~ I I I I r I I I_ - - T I _ - I - I , I - - I I 1 I i I ; I I t C 54 ~ I ~V I I ~i I , r ~ r- - - - I L I I I t---- I : j I i I I I T I ~ I _ I I I ~ I I a I I ~ I ~ i , I Jr i I I I I I I I I I . I I ' I = - I I I I i i j I F- I I i YTa~ ~ I i i I I I I : I , ' I I I i i I f- I ~ ` I i-~-- - I - I I -I----l - + - - I I II/ I. i -t I : i : I I I i I t : i : i Tom. y i i - : I i RD • County. G~ ~ Sanitary mit ° ~ RT o . 31 • lg' QECSIQN R~ R I~~ State Plan D o.. ~ 1 1N5 CH Tp PE AT 03040.. r fnp*v'artr~ e"~atirons \,illage L,Qm d'`'' oman R pi~isron Crty $ Eabor aan0 Buildings 03flDD3 E~EV . FS Safety RA`1NFQRMATION tion pATp` H1 GENE er s Name BM QescriP E`EV p`-~IQN B5 permitHO1d BME1e~ (J insP ST AT 10 S BM E1e~ ' CP pp CITY Benchmark INFORMATION VRER u TANK MPM F ACT Bldg Suer TYPE t I Ht Inlet Septic S t St Ht putle Dosing p,eratlon Dt Inlet Holding CK INFORMASION A "t take BOND Dt aottofo Header IMan tANICSETBA WE~1- g~DG ir,n tip, TANKTO p NA st \Pe NA t 5yste Sep-6c 8 Dosing Final G j perat%on d Holding INFORMp`TION De a 1 SIP N M PUMP HO t UQuid DePth Manufacturer ystem TDH 1ns~deDra Model NuMber Friction SN e gist TOWe11 No pf Pits Manufacturer. TDH ~~ft Ola ~ Mo e` "um er~. length EM N° o i l renches pIMENSTREAM CHp,MgER d Forcernarn ORpT1QN SY51 `en9th WE`D 1pK pRUN11 ventT Intake o P',, .50%L AgS W;ath ` BLDG Note SPadn9 D ~ TRENCH TO p ~ x pIMEN 1 N SYSTEM x HoleSlte i I SNF p,cy, N SP e o 0 S Stems On 1 xX Mulched No RPJV 1 SYSTEM elsl SPa~in9 / Or At_Grade seeded Sodded Yes QN pigtributron P Y. P pia. / Mound No TIt1BUT1 X Yes wS length / OnIY anifo~d S Sterr~5 Xx pePthp{ Header 1 M Dia- / X pressure y ToP5Or1 ` _ s / Dength th DQP Oyer e RD . CQVER ~TrenchEdges tC•~ I e"t' CO s ,50%'L beIles, gets on P OT 4 peP res raPan 13E i3E ~ I' th over code disc r ren . ~h Center u n Bed ~T de MMEN I1nc1 1D .31.19 ' 12 r . - ~i~ . ~ CO SOORSVI 1nsPe~ -tl 0 No- v5e nfort'natl0n. Date n reau%fed!t~oO plan rev .No a for adds other ov") cBD-6~ 1 0 lR gDDITI Nq SA/V/ T qRY PERMIT COMMENTS A N ND S UMBER. KETCH f DIL R 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 l 913(:5 8% x 11 inches in size. ❑ Check if revision to previ us 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/4 '/4, T , N, R E or PROPERTY 7)ER'S I G ADDRESS OT # BLOCK # "q _Z1, ::z , CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER - 674 L 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLLAGE - NEARS OAD ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms_~? 12 WAN P PARCEL N ( ) Ill. BUILDING USE: (If building type is public, check all that apply) y 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdo& Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2.E] 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 [Z Seepage Bed 21 ❑ Mound 30 ❑ Specify T 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground IO 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 (s c1. ft.) PROPOc (sq. ft.) (Gals/day/sq. ft.) (Min./Inch) ELEVATION a Feet 97, Feet VII. TANK CAPACITY Site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank F] 1 F1 1 Lift Pump Tank/Siphon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for install ion of the onsite sewage system shown on the attached plans. Plumb is Na 9 (Print): Plumb is ignatu tam MP/MPRSW No.: Business Phone Number: i - / / - Z2 2Z P lumb r' Address (Street, City, State, Zip Cod 2! IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved San' ry Permit Fee (includes Groundwater Date ssue Issuing pent Si Approved F1 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 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';' name and mailing address. Provide: the legal description and parcel tax number(s) of where the systettis 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 arid/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. Vill. 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 specification's 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) 1 _ I I I i I I I I I I ~i I I I I I I 1 ) I I r 1 r f r I I I + , I I j f - - - - - - I I f I I 1- I T I I j ' I I I - I I ~ I I , , I I I I f i , ~ l I i I I ~ 1 I r ' I I I j , ~ I ! + r r I - 1- ~ I I I I I I I 1 1 -1 i ~ r I' I ~ I 1 f + I I I I I i ' f I ' i I _ I _ I. , I , I I -L L I i I t I _ A I I I I I L/ ' ' 11 i 1 fJ I I I I r I I I I , r I ! 1 i ' - I- I I I I I-~----- j , i i ~ , , I i i N~, PAfi c or A 0.1moli 4#4 06641voosm Pips Q~--Awqos Veto 6" llf i foul Of9de 90. 4t•Above ilk ~4 Coss MM -11 Q 1• I" 0••s• Veal Py ; MW,ON 1%$ 00 {too%%W Chinni • ; ' • 111• t• A~~.,•t•1• • OWN !'Ip• ~ -yet fit# • 11•Milb 1y• • ~-pNIN•1•d VIVO YN•vl • C•./11~~ T.•wM•IMe AI w Ate, i,V„ •..ww.. r t•ll*& 01 t/•1•w • PrV(~oDtD u►•.~ rh AA 013TR19UTi01.1 P! Y'£ APPRO`K0 Syur1CTIC Cove OF AG O RKGmrrL OR MAK0, MAV OF STitAM 2M + •d' f."O~'ls-t'/s AGGilC6ATC ~t r&LEV. oF~FE T •w~~h•.rv~• 01SYRIOUT10I,1 PIPe *TO K 1%T I.CAt1T IWCHC3 5CI.OW ORiVIIJAI, •;-AAOE AIJO AT. LrEAST i•0 11JCHCto OUT 1.10 MOKC THAI) 42 IUCIICS OCLOW F WAL 41#440L 1 tWIMUM DEPTH OF EXCAVATION FKOM OKIOWAL 6KAD9 WILI. 6E _ IWLHC5 M(JAVM ©EPT'11 of CACAvATMN F&O^ CokIGINAL GRADIL WILL »C INCHCS 5 wuco4. OAT C :.._._..low ~..1~ E DEPARTMENT OF REPORT ON SOIL BORINGS AND SAF DIVISIONS INDUSTRY, P.O. BOX 7969 LABOR A,D PERCOLATION TESTS (115) MADISON, WI 53707 HUMAN R LATIONS (ILHR 83.09(1) & Chapter 145) TOWNSHIP/ UNICIPALITY: LOT N0.:BLK. NO.rSU DI VISION NAME: LO ATION: SECTION: 1 1/4 f0 /T31N/RC E I. SM`n NG DDRE 3S~S Y17h~ COUNTY: OWNER'S/BUYER'S NAME: ~ Y ~h err' DATES OBSERVATIONS MADE SE I PROFILE SE RIPT ONS: ER OLA ION TESTS: NO. BEDRMS.: COMMERCIAL DESCRIPTION: „~yNew EDI Replace 6 - J- Residence RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRE URE: SYSSTTEM-IN-FILL HOLDIN3 TANK: RECOMMENDED SYSTE '(optional) ®s ou s au S U S U FIS %U DESIGN RATE: If any portion of the tested area is in the If Percolation Tests are NOT required under s. ILHR 83.09(5)(b), indicate- 4- Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION D PTH TO GROUNDWATER INCHES CHARACTER OF SOIL WITH THI CKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE Ado .175. K•-4O-3d AP 49 7 de 40/7 7 B- 0 B- ;L B- 3 00 4AZI 4::f/ B- 7, O- h S` - B- L PERCOLATION TESTS T DROP IN WATER LEVEL-INCHES RATE MINUTES TEST DEPTH WATER IN HOLE TEST TIME PER INCH PERIOD 2 PER D NUMBER I AFTER SWELLING INTERVAL-MIN. PERIOD 1 P_ Z P- P- P- 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. fill SYSTEM ELEVATION F .13 E R I I 7 VV • Of.4- ~i J e--, $o ~i koe 4d • E j 4. 4r- ~C_ i location of the tests areecomade y me in accord rrectt the best of mylknowel dge andrbeliep methods specified in the Wisconsin I, the undersigned, hereby that the data recorded and the reported Administrative Code, and t TESTS WERE COMPLETED ON: NAME (print): ~ r CERTIFICATION NUMBER: PHONE NUMBER (optional): ADDRESS: 411 CST SIG UR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHRSBD-6395 1 10/83) - OVER - I JCTIONS F( MLTINC ill 115 - D - 5395 To be a Corr 'd accurate soil your report angst include: 1 _ Coanp` ` ~,~ription; 2. The use,. r,,a;t clearly in( ether this is a or cornnaercial project; 3. MAXIM, _ imber of bedroor commercial use, 4. Is th a replacement sy~ ; 5e Corn.'" actability rating' x es. A SITE IS S ~ =OR A HOLDING TANK ONLY IF ALL OTHER, S,-CMS ARE RULED OUT BASED ON SOIL CONDITIONS; 5. PLEASE €as,a the abbreviations shoran here for writing pro ile descriptions and completing the plot plan; 7, MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A 'ate sheet rm,v ')e used if desired; 1a. N a sure yo€ ' chmark and vertical elevation reference point are clearly shown, and are permanent; 9. C -implete all -Ppr I;, ;utr= boxes as to dates, names, addresses, flood plain data, percolation test exernp- tion, if appropriate; 10} If the information (suc) as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and plan: your Current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN. 30 DAYS. OF COMPLETION. ` ABBREVIATIONS FOR CERTIFIES} SOIL TESTERS` j rs and Texturk Other Symbols st - ~ (over 10") BR Bedrock cob Cob .;iv (3 - 10") SS Sandstone gr - C° , el (under 3") L - Limestone *s Sand HGir13 High Groundwater :s Coarse Sand Perc Percolation date med s Medium Sand IN Well fs - Fine Sand Bldg Building Is - Loamy Sand > Greater Than ~sl Sandy Loam Less Than 'I Loam Bn Brown s :J Silt Loam Bi - Black si - Silt Gy Gray 1,cl - Clay Loam Y - Yellow scl - Sar r~ < Clay Loam R Red sicl S~' Loam 1-not Mottles sc - vv i with sic lay fft - few, fine, faint c I t: ,r cc cornrnon, coarse pk ruin - Many, medium a d distinct p Prominent I`f /L - High water level, 'feral soil textures surface water ~qurd wa sal _ Bench Mark - Vertical Reference Point . : l . y TO THE OWNER, 7 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 permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. i SEPTIC TANK MAINTENANCE AGREE1ENT St. Croix County OWNER/BUYER r1 2~2 IN4 K-P~ ADDRESS: c UU%q~7'y _SDIM&zt FIRE NO: /t//,4- LOCATION: /CIE 1/4 , _IV15 1/4, SEC. CCU T 5t N-R_aW, TOWN OF: 5GPtFk!5 e='l ST. •CROIX COUNTY SUBDIVISION: /x W 9 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 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: oC,iL ' . DATE: St. Croix County Zoning Office _ .911 4th St. Hudson, WI 54016 STC-100 This application form is to be completed in full and signed by the ot,'ner(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. j/ owner of property Location of property Ne 1/4 ~1/4, Section /b , T 31 N-R /q W Township 5VM612~6~ -I Hailing address ~ u~ JP~IAv(o ~'1 c7G Wl ET~.S t-"'7" G11 S ~ `ZS' Address of site cor.WTv ('Cp Z GoygaZ~E7 ~J I.S. Subdivision name / 111/1 JW. 9 Lot no. other homes on property? yesNo Previous owner of property 05GPR /4• GoULD -_1_ftM(CE L. Gouc,2~ Total size of parcel 7d oc) /Acee- Date parcel was created g -21-42 ' Are all corners and lot lines identifiable? X_Yes No is this property being developed for (spec house)?_,Yes _-Z,_No Volume / and Page Number 2530 as recorded, with the Register of Deeds. 114CLUDE WITH THIS APPLICATION THE FOLLOWING: A 14A1ut,A ITY DLLD which includes a DOCURENT NURDER, VOLUME AND PAGE, 11U11UI R 1. THE SEAL of THE ILEGIS'1'LIt 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 referencos to a certified survey Map, the Certified survey Map shall also be required. PROPERTY OWNER CERTIFICATION 1(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (nre) the owner(s) of the property described in this inforriation form, by virtue of a warranty deed recorded in the office of the county Register of Deeds as Document No. $579 485795 , 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 alas been duly recorded in the office of County Register of deeds as Document No. , r//wAQ . Sig ature of ap~lica Co-applicant Date f S'gnature Date f signature Vol 959 PA E 70 WARRANTY DEED v• Date: 1992 FOR VALUABLE CONSIDERATION, Joseph A. Gould and Janice L. Kouls convey and warrant to Jerry inp e St. husband and wife, Grantors, hereby and Tina L. Kippes, husband and wife, Grantees, real property Croix County, Wisconsin, legally described as follows: An undivided one-half interest The South 900 feet of the NE 1/4 of the NE 1/4SoofmersSeetctStion 10, Township 31 North, Croix County, Wisconsin. together with all hexeditaments and appurtenances belonging thereto, subject to the following exceptions: and all Subject to encumbrances of record and any encumbrances placed against the subject real estate as S OFFICE a result Grantees interest from and of after r Cthe ontra 4 e, REGISTER ST. CROIX CO., WI day of I' ~U' 1987, the date Recd (of Record pursuant to which this deed is given. jUl 131992 Joseph A. Gould Ot 8:30 AM , 0 C~ Qn 9anice L. Gould ~gtsta of Deeds STATE OF MINNESOTA ) )SS. COUNTY OF RAMSEY ) I The for going instrument was aweA~edGouldrande Jthi anice L. day of , 1992 by Joseph Gould, hus and and wife, Grantors. LORALEE KERSEY P u b l i c I aoury ►tbue.M~oa t a r y mennepen cosh My Comm. ErP. 3.26.96 THIS INSTRUMENT DRAFTED BY: Tax Statements for the real property described in this Edward L. Pardee Instrument should be sent to: Attorney at Law Jerry Kip es and Tina L. Kippes 4856 Banning Avenue White Bear Lake, MN 55110 487436 av~2 ~1 NEIL CERTIFIED SURVEY MAP s~ 304 A PARCEL OF LAND LOCATED IN THE NE 1/4 OF THE NE 1/4 OF SECTION 10, T31N, R19 , TOWN OF SOMERSET, ST. CROIX COUNTY, WISCONSIN. v ,!iv u , W NE CORNER SECTION 10-31-19 'le vy 1 t ~d MW 7 ~y0 Z LOT 2 LOT I r C.S.M. VO_L.5 P. 1437 C.S.M. VOL.2 P.9 N° ~ N SOUTH LINE OF LOTSI I AND 2 / N88.48'27"W 669.70' R=N38.47'48"W 670.18'- 1-63.46'40"W 833.05' R= 1-88.47'48 833.77' 373.44' 188.60' 122.88' t,: --667.35:--- r 633.05, ` - - - - - - - -1-88051'54"W 1333.40 666.05 - I 1 NOTE: 1 :LOTS TO' SE ANNEXED TU 100'-s+~ ;LOT 2 OF, C:S,Irt. VOL;5..P.. 1437 W I I N ` N 0D 6 0 in i 1 c C6 ln LOT 3 M o $1= I= 01 I _ 298 795 SQ.FT. Z (nl in 6.86 ACRES gl 1 pi 01- LOT 4 4 jR ZI ZI 80 901110028 SQ. FT. 8' of ~j 01, 20.68 ACRES W ` i z. m 011 . pi z 50 INCLUDING R/W 7 J1 I p~ WI 3 = l 673 }I WI wl ZA \ 871,328 SQ. FT. 3j of F-I ql 0 N i 20.00 ACRES ~I ~,I gal _p o EXCLUDING R/W j I ?t o I -~I _j 0 N pOND IN SWAMP AREA zo 1 W 01 ir ZI z 21 ~~yy1 ..rl W J. O w JI Y i~ 1 i t o I: ~ 1 y IK i [SE OUTH LINE OF THE I m I I/4 OF THE NE 1/4 I ly 1299.87' DRIVEWAY 33.00~J.~ I<W S 88° 51'54" E 1332.87' DNQLATTED LANDS o_ Z- N OWNER SURVEYED BY BEARING ARE REFERENCED JERRY KIPPES A S E LAND SURVEYING E 1/4 CORNER TO THE EAST LINE OF THE 509 SPRING ST. P.O. BOX 325 SECTION 10-31-19 NE 1/4 ASSUMED TO BEAR SOMERSET, WI 54025 NEW RICHMOND, WI. 54017 N 00.35'03"E. (715) 247-3562 (715)246-4319 NOTE: This subdivision is exempt from the County Zoning Ordinance under Chapter 18(A)(3). SCALE 1" = 200' LEGEND 19 COUNTY SECTION CORNER 200 loo O 200 MONUMENT, FOUND. o~tGO/'tISI~e~~o O 1" x 24" IRON PIPE SET. 7/2 7/91 a A'4s a ~1 RONA1.1) F. ~r y • 1" x 24" IRON PIPE FOUND. JOHNS11)I-I REVISED 8/20/92 IRc R- Recorded as Y. E VVI ,F- - fence C Q•"""`~ •f 4' w' VOLUME 9 PAGE 2530 it;!_I P /It~r!' 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