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HomeMy WebLinkAbout040-1212-30-000 N ~ O 01 b C M O r.. C i O O N N C N i N C Z 7 ~ U. i Q i O ~ N Z fIJ LlJ O Z w O a m N n I- C ° U O Z :!t c V O w ~ y z r aci z C E d a~ r~ N CL ~I 7 N ~ y C • N it D. L O C C 001 U O z Z w O Z ~l Ylf d N V W ~ > t0 m N b V1 C 0 In ~ II ~ a d ~ ~ ~ ° o0 00 G c a E E N N 304 3o CL co y Z ~ o00 •N 0aaa W CL _ J V o W OOi ° ~l z rn to > o o tt-- a> 0) °o A _ E N m rn m p m Q z (n Q co o 0O a c E D N 0 0 O ° w c d ° io' o ° 5 n- 0 0 0 -p N N N 'L" N O) 3 I Z O N C vl O O E M d 3 I-- N CO L N N •00 C L O 0.0 L) • 2 o F- C7 o z s z cn €L a L a a • Cd a d u~ d m c rraj w E L c c f _1 A Q C I U) 0 ;'Tjw Departr'went ofIndustry, SOIL AND SITE EVALUATION REPORT Page of Lat nd Human Relations Di~rrof Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL ►.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE 4 PROP RTY OWNER: PROPERTY LOCATION -7 Y GOVT. LOT S j-, 1/4 ,''µ/1/4,S T ,N,R *(or)4V PROPERTY WNEIT S MA LIN DDRESS LOT # BLOCK # SUB . NAME 0 CSM # 11Q G rolje- d~2 CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE 0OWN NEARE T ROAD d6m a& -T3 VVe.5-X ,XNew Construction UseResidential /Number of bedrooms [ ] Addition to existing building [ ] Replacement [ ] Public or commercial describe Code derived dally flow gpd Recommended design loading rate - 7 bed, gpd1ft2 trench, gpd/ft2 Absorption area required bed, ft2 tr ch, ft2 Maximum design loading rate - 7 bed, gpd$ - Y trench, gpd/ft2 Recommended infiltration surface elevation(s) j ~ 5l It (as referred to site plan benchmark) Additional design / site considerations Parent material -13 ft a-'~" ~~loodplain elevation, if applicable It PU = Suitable for system CONVENTIONAL MOUND IN❑-GS U D PRESSURE T- S u O S M IN P0 I ~ HO S 1~~ = Unsuitable fors stem IBS [I U ❑ S Clu SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourffiry Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tenor %x a L Ground -7 L 5 l~ 1 Depth to limiting f taFo, s Remarks: Bo ring # r ~4- 2 L 09- 13 Ground l..r • d Depth to limiting facts o~•.~ Remarks: CST Nam e e Pri Phone: F 3 Address: 10 7,o 7 Signature: Date: CST Number: ••v••. ~r.vV~Uf I IVI, ncrvn I PARCEL I.D. # Paged of 33 4 Boring # Horizon Depth Dominant Color Mottles in. Munsell Qu. Texture Structure Sz. Cont. Color Gr. Sz. Sh. Consistence Botrtdary Roots GPDIft 3 ~ 2 ~ L ~ . Bed Trench S 2 y~3y is ~ Ground JY y SCL M-41 Depth to limiting Remarks: Boring # Ground elev. It. Depth to limiting factor Remarks: Boring # Ground elev. ft Depth to limiting factor Remarks: .Boring # •~x Ground elev. ft Depth to limiting factor Remarks: SBD-8330(8.05/92) Cr ~i~ l ~l 2W . A3 P~ f S. a t it i t I /S Sly 1 II • i I i 3 STC - 104 AS BUILT SANITARY SYSTEM REPORT 1\1 _ h r~o OWNER r A ADDRESS WL S ~7t'~ Q r E"f S SUBDIVISION / CSMV W Q S -t (Z(jY C,. LOT I p~ -OrR SECTION. 1 T !i'g N-R II W, Town of . 1011 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 F T OF SYSTEM cl- 71 l~a~e INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i~ p BENCHMARK: L_o,6 ACz )ti G R O P 3 L N4!ang a TiC QC ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: ~e Q K S Liquid Capacity: 000 Setback from: Well House Other Pump: -ma €~~+>>^r_gr _ Model# Size Float seperation Gallon Alarm :SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Is, Setback from: well:OW 75 House ~p Other - I, ELEVATIONS "K 1 ~i4t k~~~+ Building Sewer ST Inlet; q ST outlet T b Pe -irrhet7 PC bottom ump , 9~c,~1 qy.y~ 93.47 A# 19- Header/Manifold Bottom of system ~w yv, 13 ~,ow~K- Existing Grade Final grade `i IC 13 9~, 4 Q DATE OF INSTALLATION: II Ia PLUMBER ON JOB: LICENSE NUMBER: 3YOV INSPECTOR: 3/93:jt Y+Q1~s~;sroart XflA7stY?8.19.1011PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST_ CROIX ` (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 199923 Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan ID No.: I TROY C T BM EI v.: Insp. BM Elev.: BM Description: Parcel Tax No.: 040-1212-30-111110 TANK INFORMATION ELEVATION DATA A9300331 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic t' G Benchmark 3 2 f1~' DosirTg /,y Aeration Bldg. Sewer Holding /I K Inlet 5,93 TANK SETBACK INFORMATION St //t Outlet 7 (01~ S, TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Doi NA Headers 2 y/S Aeration NA Dist. Pipe fs.~2 1 Z p'Q3 2Y/. Holding Bot. System 9S ~p 9? p PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Num GPM TDH Lift Frictio Y ead- Ft Fi Forcemai _ ength Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length _ / No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN SYSTEM TO P / L BLDG WELL LAKE / STREAM CHA LEA MB Manu r: SETBACK ber: INFORMATION Type O 17,~,,,t re, Model NIT System: t DISTRIBUTION SYSTEM Header / PAzTltfo+d Distribution Pipe(s) , x Ho Hole Spacing Vent To Air Intake Length 1.cc Dia. ~ Length _3z Dia. ~ Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over „ Depth Over xx Depth Of xx See ed xx Mulched e Bed /Trench Edges Topsoil E] Yes ❑ No ❑ Yes ❑ No Bed /Trench Center 16 1 13. 1 COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 07.28.19.1011 r ZZe- Plan revision required? ❑ Yes No J Q Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signa ure Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION I~DIt HR In accord with ILHR 83.05, Wis. Adm. Code COUNTY ~1 C~ 0 STATEP T # -Attach complete plans (to the county copy only) for the system, on paper not less than ®8% x 11 inches in size. 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 111 A/, S k/ '/a /a, S T o1g N, R / E (or PROPERTY NER'S MAILING ADDRESS LOT # BLOCK # Hof' /.2 ICJ. p- /1;11 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Wk-j/- Use 11. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE. NE REST RO D Pe 40WW OF: 5J1/ f^D ( e r VC ❑ Public or 2 Fam. Dwelling-# of bedrooms 3 'PARCEL Ax N B ( Ill. BUILDING USE: (If building type is public, check all that apply) d 1T/0 _ lcqzc~ -j n 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 100 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. New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an System System Tank Only ~O Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit 1 _,3 3 F(a__ Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Wff epage Bed 21 ❑ Mound 30 ❑ Specify Type 41 El 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 12. 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) `1).(07 ~E TION 5( 3 570 8 8S .63 Feet'(- Feet VII. TANK CAPACITY Site in allo Total # of Prefab. Fiber- Exper. ~xisting ns Gallons Tanks Manufacturer's Name oncret Con- Steel . glass Plastic App INFORMATION New Tanks Tanks structed F1 I Septic Tank or Holdin Tank g A s Lift Pump Tank/Si hon Chamber 1 L1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite s wage system shown on the attached plans. Plumber's Name Print): Plu er's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: A A,\ to Plumber's Address (Street, i , State, Zip Code): _ i AJ IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Age o Stamps) ❑ Approved ❑ 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 bya 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. t 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) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION INDUSTRY, G P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISON WI 3707 HUMAN RELATIONS (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MWPj LOT NO.:BLK. NO.: SUBDIVISION NAME: 1 12 SE 1/4.SE1/ 12 /T28 N/R2o E, Io W TROY COUNTY: BUYER'S NAME: MAILING ADDRESS: St. Croix CARRELL MILLER Grove Huds o WI 54016 USE hone 3866765 DATES OBSERVATIONS MADE . BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER AT ON TESTS: [DIResidence NO3 ®New ❑ Replace 11-4--90 11-690 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-G IOUND•PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) 0 S ❑U ©S ❑U J S ❑U KIS OU E~S Ell conventional w/ lift atation If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: n/a 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.) 2.4'Bncs w/gr. B- 1 70 100.5 none 70 1.8' Bkla w/ r. & cob 1.6'es w/ r & cob 2.9' Bnms w/ gr. & cob. B- 2 67 98.9 none 67 1.1'Bksl v/gr & cob 1.6' Bnes w/gr. & cob 1.3' Bums w/gr. B- 3 g 100.3 none 85 1.8' Bkls w/ r & cob 4'Bncs--v/gr & cob B- 4 65 99.4 none 65 .8'Bkls 1.6'Bneaw/gr 3.0' Bucs. B- 5 72 100.9 none 72 1'Bksl w/gr 2.1'Bncsw/gr & cob 2.9'Bnco. B- PERCOLATION TESTS TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATER INCH ES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. -PERIODI _PER IOD2 P R D P- 2 19 none 3 •5 P- P- 3 6 none 3 than 6 dr p in 3 minutes. .5 P-_ 25 5 P_ none 3 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. I d water Wa SYSTEM ELEVATION 97.3' I36oN,~~ scale 1" 30' I- BI l top ; of ; NSp come t rYa s , _ y~ ~ I assume_ 100 ~ 0.' . bQri>g. 1_ _ { - peik. ; E _ a. -TBp- lit e-.>1n 0, i ~ , I r . r. _ {tea-- los~-- -1?~~lal-lyF open to IN to locating.) E p t ~ I a ~ E 111 1_ a I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with .he 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. Fn--sR BM NAME (print): DAVE FOGERTY PLUMBING TESTS WERE COMPLETED ON: Licensed Perk Tester & Plumber 1 11-6- ADDRESS: #3M 03289 CERTIFICATION NUMBER: PHONE NUMBER (optional): ROBE F arty He is Road Phone 746.9656 CST SI A RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. I DILHR-SBD-6395 (R. 02/82) - OVER - I INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report mugt include: . 1. Complete legal description; 2. The use section Must clearly indicate whether this is a residence or commercial project; 1 MAXIMUM number of bedrooms or commercial use planned; 4, Is this a new or replacement system; 5.: Complete the suitability, rating boxes, A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 0. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagrarn accurately locatitg your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, ai=d are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. 1, : - information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. S form and place your current address and your certification number; 12. Mal legible copies and distribute as re(:luired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - ~i1r (nver" 10") BR - Bedrock cob C (3- 10") SS - Sandstone gr ider 3") LS - Limestone s - - High Gr r iter cs nd Per( d1 e need s - 1 Sand - Well fs Ind E 49,...- Bull is - " u1 ) - Greater Than sl Loam < Less Than *I Bn - Brown sil ant 131 Black si Gy Gray cl - y Loam Y _ Yellow - Sdndy Clay Loarn R - Red - Silty Clay Loam nnot - Mottles Sanely Clay vv - with sic _ Si' `y Clay fff few, fine, fait Ic cc cornmor , P1 rnrn Many, r, n d - distinc'_ p - promine HWL - High water level, - `soiltE:xtures surface wt f, ~'.e disposal BM - Bench Mark VRP Vertical F , Ic~ Point TO C JNER; M sa .i . The counrT r rcquest t in CT, A cr-,..,.~ arc private <=:i')rl Ast f;:~ su`~ ,f° a sn s}rtt;;i, ytlP: r local' T ;44i`tl1 , i) i1 i- order to r: it must be obtaine 1 ar rc7r,ta tde~.r.drt of my cgnstj,Vctawl, 6 7 PLOT All h OSS SEC P R0 J EC N ~ YhQ? S A M N.A N P M --3 6 M A W e -I-_I C N 5 E 3 `Ivy } C PLC i MA n, 1 W el ; 83 ' J~ } -At, lo U) PR,rnj 1770 777) 061 r 91 d ► 3 Bey rz o 6 r"r. f . FRESH All' INILETS AND OBSERVATION PIKE CROSS SECTION _ C~- Approved vent C a n Minimum 1.2" Above T r~ ~.TdAl Grad e,__~ 1 4" Cast Iron P.bove Pipe Vent Pipe To Final Grada Marsh Hay Or Synthetic Covering_ . ~ . Min. 2" A c r.eg o Over Pipe "V.-Q Di.stributi24>- Aggregate I Tee Pipe ' r`' ~n`* z~,eS ~ll Perforated Pir,~-, Beneath Pipe ~0 - {t Coupling Ter.minat:in__: ; Bottom of System g L.QQbxi;94i;,t4k'ra 1,AZry28.19.101iRIVATtSEWATGE17YS1tT GROVE ounty: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ' (ATTACH TO PERMIT) sanitary ermit o.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan D o.: ST BM E ev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9300048 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi ng Aeration Bldg. Sewer Holding St / Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction Sysatem TDH Ft Forcemain Length Dia. FFii Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSI N LEACHING Manu acturer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header /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 xx Depth Of xx Seeded/Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes El No ❑ Yes El No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 07.28.19.1011,SE,SE, LOT 12, WEST GROVE RD. I Plan revision required? ❑ Yes ❑ No Use other side for additional information. FF1 H SBD-6710 (R 05/91) Date Inspector's Signature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: AIL R SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code ~ s.wm~n v r 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 ec i evi n to p evlous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION. PROPER OWNER PROPERTY LOCATION G G ~ur~ St Y4. SE Y4, s t T& N, R O E (or W PROPERTY OWNER' AILING ADDREES~ LOT # ' BLOCK # We 0 Q O CITY, STATE ZIP CODE PHONE NUMBER SUB IVI ION LAME O CSM NUMBER ~ADSON I S S eS KOVel ~ rt~S II. TYPE OF BUILDING: Check one CITY NEA~EST RO D ( ) State Owned VILLAGE ~KO W Q Gra v ~ Rd ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms PAR EL TAX. UMBER III. BUILDING USE: (If building type is public, check all that apply) 'l, y J 3 1 ❑ Apt/Condo ~J a( 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. K New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 R 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 REWIRED (sq. ft.) P POSED (sq. ft.) (Gal /day/sq. ft.) (Min./in h) ELEVATION 4 o ~o a < 973 Feet .lo . 0-eet CAPACITY VII: TANK Site INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. New istin Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank 0 W Ott K5 Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): PI ber's S' nature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plu ber's Address (Street, ity, to , Zip Code) f4. . o) t, 8 m c, k Ae sou S _ N~ uPSo W) IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater EDate Issued Issui Agent Slgnat (No Stamps) Surcharge Feel Approved ❑ Owner Given Initial /S Adverse Determination (J X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber INSTRUCTIONS 1. Asanitary 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 tot 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,1608-266-3815. 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, ors repair. . V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. 'Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; 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 cmunty; E) soil test data on a 115 form; and F) all sizing, information. GROUNDWATERSURCHARGE 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) STC-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. -7-------------------------------------------------- Owner of property Location of property5f_ 1/4 SL 1/4, section I, T.!~LN-RoW Township _ Tiep k/ Mailing address S GK0 ~)bSC?N )SCI Address of site subdivision name T kaV,~ 7,A Lot no. /Q. Other homes on property? yes- No Previous owner of property hggg~ Total size of parcel c ,q S Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes Z_No Volume 91, and Page Number 1.~;- 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. 1} q a q 3i4 , 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. LC Signatures of applicant Co-applicant Date of Signature Date of Signature DOCUMENT NO. i~ ' j WARRANTY DEED IRIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2 -1982 492934 I; a---- r . ---_-_----~I-- -~10L--s7QUPAGE _~5-----j Kcals R's OFFICE ST. cROIX CO., W1 Murra A Kn Reed for Record . .....................Y.... ,........echt and Wayne F. Moser a pEE161992 t 9:45 A. M conveys and warrants to Nag X_..Ii~.. Gx•1~1~.............. Roister of Do@& ,I I ~L (i i (C 7 TILRN! TTV-> the following described real estate in .t_,_..CxQai x ...................County, State of Wisconsin: Tax Parcel No: Lot 12, Plat of West Grove Estates in the Town of Troy and 1/12th interest in Outlots "1"-and "5" of said Plat SJy IA Flub ! ! Ii This _---._1S...nmt........ homestead property. )(k) (is not) Exception to warranties: Existing highways, easements and rights of way I of record. Dated this day of -C.. - 19...92.. !j (SEAL) ....................................(SEAL) ~I - (SEAL) (SEAL) ~I ' .....-n--e Ft t Moser Wa X-- AUTHENTICATION ACKNOWLEDGMENT Signat~u (s)J STATE OF WISCONSIN Cro a entie Personally came before me this .-An-d---- day of Lj ! i D. c.e wy p 8 1992... the above named Murra A. Knecht. an W - - Moser TITLE: MEMBER STATE BAR OF WISCONSIN • (If not, authorized by $ 706.06. Wis. Stats.) i' to me known to be the personbL who exes*tStAle' ! • foregoing instrument and acknowledge the s too PRo THIS INSTRUMENT WAS DRAFTED BY. h o ._..Ai;z 8 • ....621...2Jad..~ii_..,..RudsQn. i.~z..... 5_4.Q1.6..._. '•---~~-x-<-.--- - ~ + - -..~1.~3.T.a.R Notary Public ,5:--•--• YO-.......... ....._o nty°W.is. e ` (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not," . stage t'o i q I C are not necessary.) s . ) date.... LL .s~4.19... + ! ~T DoT .Names of persons signing in any capacity should be typed or printed below their signatures. JJ~;. Gp lV-c NSs ~ ~~Of STATE FORM No. 2 IS1 82 SIN Stock No. 13002 c • t !f I fiJ • 1. • ~ r f H r 4, ~ • \ Ai I ' CA M, ca 0 rn H O rn •yam J~ OCE D r rn ~s`•`} cn 1 1JJ ~l e}~~C41F SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County i i OWNER/BUYER i c~Afj .FIRE NO: ADDRESS: _ o w-R _ 1 LOCATION' _1/4,_1/4, SEC. N-R ~W, i TOWN OF: ST. CROIX COUNTY SUBDIVISION: Mje- -7r LOT NO. J.;_> 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 ?-e-a`ter?t_ stave 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 scrum.. Certification from will be sent approxir "e1y. 30 days prior to three year expiration. I f the undersianeci have read the above requirements and agree t~.:~-aintain the private sewage disposal system- in accordance with :-;et forth, herein, as set by the Wisconsin DNR. C4.: r:; f x c7 , for:yn mcs - by completed and returned to the St r r.. County Zoning Off ices within 30 days of the three year S hp:.. L at.ion date. SIGNED: !l DATE : St. Croix County Zoning Office 911 4th St. Hudson, W1 54016 B, L 7 P 't~,, Off " A H I ► 10. 5 S--..-. i lie-J I Z 0 V Uf j-~- T I.) . ATE Cc rNfi slab l~ -QM rip o NIP A.rsu~ ~ Ib00 , o . . N -P r IF W MAR-4k 4 SyJlkm i l a i 110 (V a~ ; Ike l l ~I s I i i B, ~ ~ o A TPP-fi~ i~,Lj a p_ l ys S~ ) KUM I~c~~~1CPMer~ I 0 -41 ~ ' i I s (f M . 5 I~~ L U Sep Ndfi mu C Iv u w,fi~ of -rf N W~ S~ ~2UV@ r(OAP FRESEI 111;: INLETS~AND OBSERVAT100 PIKE Be D. ROSS SECTION Approved Vent Cap A , Minimum 12" Above top 6fi.AI2Q qy 4" Cast Iron A1:,ove Pipe Vent Pipe To Final Grade Marsh lla.,i Or Synthetic Covcri ix~j Min. 2" Aggr.cyl,I ( j Over Pipe 1~ Distribution n ~ » Tee I Pipe 1~ ~b Aggregate Perforated PiF?r !Beneath Pipe - -Coup]-ing Ter.minati.r 7 Qo ~r 11 Aol font of System