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040-1102-50-000
y o c 03 °va ° 0 0. c ~ ~ 03 I I N' O w Q c vOj L N ti N CO N L c Cl) ° L 7 i N CL N E w C a 0 O N V crOjO N y a "M 04 LO a C c ) 0 m ivy 0) Q0) 3: ~2 rna N N X C N N O >0, c? 2 20 (D d O.y L U 0 (n C Z c a; C C 0 c 0 M m U. o ~ w £ m U 'mvi332 N O co C T 7 E Q U U: w v, n N U f6 CL O rn O Z co (D 4) N H U) d m o c 6 ° z ? c '0 U O N 0 Z V7 F- O N Z C E •O 2 m C U N N N C • "owl il, d U p p m N Z Q N Z co Z o N w m N ~ I l~l > y 75 _vi a 'wa m C H y i d O LL G D a o N N N N hr v z ~ ~+J Z > > F- F- F- Cl ( U O O O ZI '0 ►w m oaaa N a (Y a g ° 0 tq C O O to J U ti 0) a) p ~i _ Z v ~ Co C2 P- N C6 E N m d x 'C N p C33 ay ~i C o O w H Q ' 0- y C 8 - C4 O M O N E (O 5~ C) C L N 3 Q ul (D E C gay 'p N O N C M N ~ N C6 -0 Y (D n 7 p C N ~ O N ` C O O O (n Co 0 L O O N V V N I Z co v ~ E N y c +l C ° a ~~ww L O 7 _1 A 0 a j O in U i SYSTeM 1QS-fAf1G7V A10 v. Z3- Q STC-- 104. AS BUILT SANITARY SYSTEM REPORT 5~-arm- ~PP~vE-D Sc~T~c OWNER V JC- C F jO ADDRESS O)( 24 3 A"j t 1'(5 Uu S AP l~r'uE~e ntllS (fit S Syoi.L Pau ckira~ - bit-- F - SUBDIVISION / CSM# 30 7 LOT # Z SECTION, ZS T 2'9 N-R t W. Town of TR 0 y 5 . A19- t I. 3 gate. ST. CROI COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN lOv FEET OF SYSTEM &; r: PL-0 pJ x s 1~a:y INDI . `vr' N B ROW Provide setback and elevation information on reverse of this form. Provide 2 dimensicns to center of septic tank manhole cover. p -To Wert( c,4.gix1 C, p f gKNCHMARK: L i_-v /rlr •4 4) t 0 O. O ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer:" weeccs ~sUefiQ. :in - Liquid Capacity: t2~D0 Setback from: Well 7~ .~Isse 2'~ Other Pump: Manufacturer 104 Model# Size_~ - Float seperation N~ Gallons/cycle:--- /J Alarm Location -:SOIL ABSORPTION SYSTEM Width: Length 540 Number of trenches Distance & Direction to nearest prop. line: '1 No S tf-° P S k. Setback from: well: 93 ftb"q. fo Other -tb G~.QrL r• 5ep*tfG TAOK "VErR- - 17.66 C Nd R iss ELEVATIONS .O y O ST outlet. Building Sewer ST Inlet. _ PC inlet_~ PC bottom Pump Off Header/Manifold Bottom of system S hExisting Grade Final grade 3 2~1-t~~t3 DATE OF INSTALLATION: N ou . PLUMBER ON JOB: LICENSE NUMBER: APP-5 33 7 INSPECTOR: M Ap- J E~ k IN D£~¢ p ~•vI> ; JCif'OV TIE-' 1' n a n N O i t cp I t aA t 1 A ~ o~ yii Z I r N y G ~I i i ~ -1 ti . ` I I t t I I ~ d Ilk I t °p t l 1 ' ~ 1 ~ O 0~ a01 ~ • R m o fir ~ o i o j b b y c~ = .s Z 1 (A 70 3 7 U 17 V15 It) rt w b o w C D 4 w ~ -~C ~ ~ I W ~ o I+VW4 +zfr1`i3~aartrhQTKCtIr~Att?8. 19.399$RIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ' (ATTACH TO PERMIT) SanitaryPermitNo.: GENERAL INFORMATION 199920 Permit Holder's Name: ❑ City ❑ Village W Town of: State Plan ID No.: Y S BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: L 040-1102-60-000 TANK INFORMATION ELtVATION DATA A9300327 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. f, Septic ~ (At ,f ,.~i-- / 0 Benchmark c~ Dosing Aeration Bldg. Sewer 9 7 U Holding St/ Ht Inlet IA4 4411 TANK SETBACK INFORMATION St/ Ht Outlet 1 /6113 Vent TANK TO P/ L WELL BLDG. A irrIto ntake ROAD Dt Inlet A Septic >5-U " -70' A5' NA Dt Bottom ell 3 .i91 Dosing NA Header / Man. 9, ~y 19 117T Aeration NA Dist. Pipe 9131 4 4(`3/ 15- 1/ 7 3 /3 9R,g9 Holding Bot. System l0.) PUMP/ SIPHON INFORMATION Final Grade 6-4-2. qG,o 2~ 5.5 Manufacturer Demand ~d Co 97 74 Model Number GPM TDH Lift Friction Syestem TDH Ft Forcemain Length FDi. HH Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 012-- DIMENSIONS SYSTEM-TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O ✓Ca<,,) CHAMBER / Model Number: System: 4_Ienc.j. /Y,0 L3 OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia I 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 ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.)r.;r 1 LOCATION: TROY 25.28.19.3990 Plan revision required? ❑ Yes ❑ No r Use other side for additional information. SBD-6710 (R 05/91) Date spector's Signature Cert. No SANITARY PERMIT APPLICATION U ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE ~N~ARY PERMJL# -Attach mplete plans (to the county copy only) for the system, on paper not less than 8%x 11 riches in size~21A(, vi ous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. f f 3 - O 3 PROPER OWNER _ PROPERTY LOCATION V (r- J &A) FCJ J S .5,E- Y. 5W- S ZS T2P, N, R E (o W PRO%ER OWNER'S MAILING ADDRESS LOT # Z BLOCK # v, gO Z( CITY, STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER AQ 1"01,2- y.~S 64072- C5,11 y,3G 9'// !90/• 7 P 5 .igSS II. TYPE F BUILDING: Check one CITY TiQD NEAREST ROAD ( ) State Owned VI LAGE Public ❑ 1 or 2 Fam. Dwellings of bedrooms - FAR GEL TAX N 111. BUIL ING USE: (If building type is public, check all that apply) / iJ l~ ~j f✓ "D 1 ❑ pt/Condo 2 ❑ ssembly Hall 6 pEledical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ ampground 7 erchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 hurch/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE O PERMIT: (Check only one in line A. Check line B if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE F SYSTEM: Check onlYone Non-Pr ssurized Distribution Pressurized Distribution Experimental Other 11 ❑ epage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ee a e Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ eepage Pit Pressure 43 ❑ Vault Privy 14 ❑ ystem In FIII VI. ABS JR PTION SYSTEM INFORMATION: 5' lG •O 32- 1. GALLO PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 2-5 ELEVATION GS Feet Y5"5 Feet VII. TAN CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFO MATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank r Holdin Tank /aOd F] Q Lift Pump T nk/Si hon Chamber VIII. RES ONSIBILITY STATEMENT I, the and rsigned, assume responsibility for installation of the onsite sewage system showrl on the attached plans. Plumber's me (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's dress (Street, City, State, Zip Code): ~ S D ~N z /Y. fJIUPSO,.1 4V/S. .S lvf/ ell~ IX. COU TY/DEPARTMENT USE ONLY ❑ Disapproved Sani ry Permit Fee (Includes Groundwater ate Issued Is uing Agent Signature (No Stamps) Approv d ❑ Owner Given Initial IdA Surcharge Fee) r Adverse Determination 13 D ~j( X. COND IONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (fo merly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTAUCTIONS 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 F=orm (SEID 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 8, Buildings Divisim.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. 11.1. 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. Corr plete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only i ` 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 point:,,; C) complete specifications for pumps and controls; dose volume; elevation differences; fric':ion loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil abso,ption system if required by the county; E) soil test data on a 115 form; and F) all sizingAnformatior. 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) UL RICHT & ASSOCIATES CO. 655 O'Neil Road - Hudson, WI 54016 Reg. Designers of Engineering Systems Private Sewage Consultants 715-386-8185$ 394 PROJECT INDEX ILHR Plan I.D. # S~3-O 3 yl-) Date N q 3 Owner -Do u 6- SE t S Phone -l5- yzS - 6P 7Z Address ?,0. Boy z13 FAGS, Wis. 540 12- egal Description ~-o r Z c5 m ~ -6 C. y i t Vol • '7) -V /r1'~S S sEi 5C, SF,cT. 2 5) T .L9 N, 1 W Town of TROY County 6T. CROi C.S.T. -uL r5 p,ick-'- GS TM 14 SO Installer Local Authority/ Supervision 5T• C12o0( Cov-0TY ZD,.*3 i A-1 C- DEPT-• ROJECT DESCRIPTION 6w,uER p (AQS -'o E-~PECT -r Lo o m ETA L 13115 &0,,Z go, (.c-5 ( tf, No Lv^-t a IQ S,ERV r'c c ) ? (2- ) A -"I ' X ~ Z ' w i rG i2~5 T 'Room -2 ilooi2 DI'AiAjS w i 1t, I Ejt p1oyEE (64,,,uek) . ThiF TROposcD L- 0~ S . APs7 fc) R &Q RNTI'QUE/Cot Ic~Tf/3/F 13vS['jb j-5S . COK(3i4eD SAL CAlf-ULA-t-ED (TA(31F Ii> (2eTA(L cu5ro)i F- QS = ►3~ . TOTAL ESTI'HATED DhiLy ASY'Ef=16W - 3~-7 gds . PER. SOIL TEST - Ak-i •io,31 poUjD cONu~'UTiO-JA L TP£QC-& SyST+tM 's ppoposeo. ( y05' 50. M r Ur'M om pe-Q u1'I~fD> - G- 'T' R t JJC-G,t;- S eAq, q I K SS yy0 5Q. -F r) ) Mj'NihUM PtQUjpeo T^p.~jk - 10-7 P12oposeo = user I I zoo SEP+rc.~ T^A3I, g.l PLOT PLAN VIEWS PRE-( Cvac FETE . g.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS `$@Lttf9Clt~® ' dw ~ EiOBIrRT W. ~ Z d3I0~i1CM A p't 1 X50 r, HUI)SCW. WIS. ID % °'®c• IFS I ©N~ ~FA~m&O~il1f~~ ft-J t We t 'M y 3.57 So, T W ~ Gs itiona ,4 4 colli 0AN gill HVM p1t1G~ N _ ~ ~ V1S~ °m ~ _ N "CE i S o ~ P I ~1 1SI w x la HMO I I 1 AN, Q~ 6 N- i ~ O IN N 0 1 1 `1. ti 0 8~ \ x ~ I _ 1 1 ~O I ~ I \ n~ b I I 1 1 ~ P ~ P _ ~ 1~ I I I I ~ y Z /p 111 y,y i C 0 A-` O h ryoE 0 p O-. O yam,---o a C £ M fR * Q y~o I ~c r Z: Jo v r, Z. ~ ~ b 1 I y ~o 3 o a~ rA~ 'o 0 O \I ` O r[A~ C V1 - N Cy ~ n r ~v to rn ~ Z 1 r ~ d ~II n \ N -4, W D o N m rN - C~ ^ R r dS~ O 0 ~ r } J w SYSTEM CROSS SEC-NoA3 S Fresh Air Inlets And Observation Pipe S93.-03944 TREK c Approved Vent Cap Minimum 12' Above Final Grade Zy 'Above Pipe _ 4' Cast Iron GE SYSTEM 7o Final Grad. •Ve~~~E SON A a~l~ - ondition Synthetic covering p 116N$ F1rA ruin. 2r Aggregate ~ HU ORB Over Pipe ~ tj18 1lO1N•G5 R'f . Distribution su. z7ay OF DUST gAFR11 A Pipe 0 0 0 0 0 S10N OF Co * Aggregate o Perf • Sp~NpEN~'' Beneath Pips n At ysr~M IE uhr/ O,v Sol om Of ystem 5 Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12' Above Final Grade- ff~J~ 9/t?ig~z~ till ~VIS -TR N c Q ` 9~' So 2t` "Above Pipe _ 4' Cast Iron -to Flnnl erode Vent Pipi Synthetic Covering min. 2" Aggregate Over Pips Distribution WET y55. - T•• Pips 0 0 0 0 0 ' Aggregate 0 Perforated Pips Below j Beneath Pips 0 -Coupling Terminating At Sy TAM Bottom Of System ff L VATIO,-J a,5d' r Departrnentcflndusky, SOIL AND SITE EVALUATION REPORT Pape of 3 Labor arx Flamer Relations Wsio" safety & Buildups in accord with ILHR 83.05. Weis. Adm. Code COUNTY ST. Attach complete site plan on paper not less than 81/2 x i t inches in size. Plan must indude, but PARCEL I.D. fi not limited to vertical and horizontal reference point (13", direction and % of slope, scale or dares ' ned, north arrow, and location and dstance to nearest road. APPLI ANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPE~TY OWNER: PROPERTY LOCATION 0 U G - T~N~i NS GOVT. LOT 6.E 1/4 SE 1/4,S 25 T 2,P ,N,R I y E (or) W PR? ER':S MAILI G ADDRESS LOT ! BLOCK # SUBD. NAME OR CSM # a X 2,1 Z Cs.N v 4'-y// 1/4" I Q1f,~ ATE~it//S S S ZIP CODE PHONE NUMBER NEAREST ROAD 7 1,41 tieddaly ctiort Use l j Resiaendal / Number of bedrooms ((Adf>xlion b e>ostirg buiidrg 1 A~"r%¢uE- //~cr~//3~~ ~ET•t%L Sao s ( (y~Pudic a oommercW describe y' x y2' -e- 6p0 0 Codnow 32 gpa(i~~ Recornm design loading bedgpdRt2 trenchl Absequired `/61 W. g2 f65 trench, 9 Mamum design lowli g rate bed, gp"2 ' J' trench, gog Rom Wded infiltrab ri surface elevation(s) sEE` P 5 .3 ft (as referred to site plan bertdmark) Adds ' design / sine considerations Parent SLS 9/ D.q ,f or.f - 104,-j- Ri'T7E1D RW on elewfim, I Wicable f w ivM ~E$suRE ACJ ~-yX 1 U a U We for system s O U o U Q3oyo ,7 0 U w u FILL 1 ~ Ua ;Alec ~ Os SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consisterloe Bolxd3y Roots GPD/tV in. Munsell tau. Sz. Cont. Cola Gr. Sz. Sh. Bed lertdl o- io /o Y/~ -a/-z- s o, 41, sh,~ 4" v{~e ~s 2 f • '7 • ~o Ground U elev. Depth b ~ N tlnating 1 i fector 0 h'oK, zoW s z: ,P0P E y oF~ Remarks: 14 Boring # ~Exy o.PG.}.urc 0- 3? /o 1,--2 a// /0" s6& S C y 3ov- y 7, S s C yf-9o ~o yk 4,/i S D,C, s V% Ground elev. ~ ys, Zz--fL Depth to limiting > o y Remarks: p T Nam :-Pleass Print -R0,5EV7- Phone: 71✓-- 3e(a _ 8lp s- ress: loss' o'~~G ~v . yvvso•~ wl s~o~~ oc + z.o - q3 csrM iyP~.. sipnatur Date: CST Numbrarw. N rf, 5 SOIL DESCRIPTION REPORT Pape?' d 3 • PAMELID. Depth Dominant Color Mottles Texture Stricture CorWmvs Boundary Roots GPD/ft Boring # Horizon In. Munsell Ou. Sz Cont• color Gr. Sz. Sh.- 14- Bed n 0-2-5 ~~YR 211 /0" 51& ~ CS Zf • Y • S -14 12 3 If f C s L -3 i3 , zs dP /o Yjf 3/4 s 6K Grand 132. 31 y 7 5 Yid j C,- cs . 7 - Yle Depth 10 imitinp WOW Li I L L 1 1 Remarks: 7 s~✓,t 4.,v~>e e5 2-F 49, Boring 10-/0 /o I C 10190 ~o Yie. S~~ s GrourW elev. 17.17 (l, Deo b kni" po " Remarks: A t eonng D - 9 /oYie L/2- C s L f Y €,S 2-f 41 73, /S Yle 3/ ' i32 is-ly ~SY~ -J0 Ground elev. 9z /oY G/~ - - ~G,2L Doo 1) finri`np faC10r y 7 2 Remarks: Eod # FE- Growl elev. ft Depth faiCtor Remarks;` can 012 nIo ncw,rn _ i v f/ 3S So , r~ W w y o ~ ~ Z s/opE ~ x 7 w w O y $e N C f `C ~ y~o I c 1 bl. I i I ~ i rn ~ ~ Z 7 z 3 S - 9.~ W u' p o 0 ~ r i y %Its I d ~ r Date /I APPLICATION FOR ZONING APPROVAL IN EXTRATERRITORIAL AREA CITY OF RIVER FALLS, WI Owner .J~ V ~n ► Phone Address . d 2 Y S Type of Building -yo~ Township Location: Section 2~7~ 1 Quarter Section Site Zoning District Minimum Lot Size Required lY APPROVED: l col G D~ n W l~ Yo1~ v° ~ ~f~~ NOT APPROVED: Z G ADMINISTRATOR NOTE: This approval does not constitute a permit to build. Building permits are issued by the Township only. ST L`✓Z4; Ty - •✓N C S• C : L c,I~AIR'R SAN . r w~n~ ~ S ~ -s-r~~; H~.;. n s ~ Mme. - 1 T' B L o L Sfft~s 4y-j ~ Qc6L~~-rrl3CFf I ~ LA r1~r/2 x idc'R11 (,IS A • t M r ^1 ('t I `7 rtrR~s s J , M .R D~Tt r1 µN N PR OP• 1.95' 4 coe:~ s /how SAFETY & BUILDINGS DMSION r- State of Wisconsin Department of Industry, Labor and Human Relations November 1, 1993 201 last Wa%hinytori Avenue P. 0. Box 7969 Madison W! 53707 ULBRICHT & ASSOC 655 O'NFILt ROAD HUDSON WI 54016 RE: PLAN S93-03944 FEE RECEIVED: 110,00 3ENKINS, DOUG, SE,SE,25,28,19W, TOWN OF TROY COUNTY OF ST CROIX NON-PRESSURIZED IN--GROUND SYSTEM The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. PJI ~ noted items must be corrected. The review and approval of the system i~,. based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Codo, and is contingent upon compliance with any stipulations shown on the plans. This system has not hPen reviewed for the cone -requirements set forth in chapter ILHR 8? or in c.haptPrs I1HR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval dat(=; or if a sanitary permit is ohtained, plan approval will expire on the day the' initial sanitary permit expires. The 1lrenst=,d plumber rwd.)on~llhlp for this installation ,hall kep.p one set elf plant with the DepartmeW 's stamp of approval at the construction site. The installer shill rir,tify the appropriate inspector when inspections can he made-.. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. inc"rely, Ke ne h Stiemke Plan Reviewer Section of Private Sewage (608) 266-8230 7:00 to 3:45 Mori, thu Fri SBDA00? IR. 01011 1 a S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER//BUYER IK►AJ s A401 AX, .0 - pp 2~ z 1 3 O ADDRESS la FIRE NUMBER l CITY/STATE P,Vz~" CIS /S. ZIP S l Z PROPERTY LOCATION :`sue 1/4 ,`sue 1/4, SECTION z' `S , T ~ N-R L / W TOWN OF St. Croix County, SUBDIVISIOIC5A1 Y34 .7 LOT NUMBER Z 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 for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1918. 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 St. Croix Zoning a certification form, signed by the owner and by a mater 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. 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 stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE : I - L2 - `j St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 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), thenla 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 X006- TEX3 K N'S Location of • property SE1/4 1/4, Section L S , T ~ N-R W Township 7-0.0y .Qo a, Mailing address P. t3 Address of site OY• 3 ye?e_ lf' LIJ~• S y0 Z-L_ Subdivision name Ciy ylkel /10A 7 7 Lot no. Other homes on property? yes No Previous owner of property Total size of parcel 3.0 S Date parcel-was created I ` Are all corners and lot lines identifiable? Yes _No Is this property being developed for (spec house)? Yes No Volume Sy and Page Number 57-7 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, o fice of the County Register of Deeds as Document No. 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. . ti c '2 Signature of a licant ' Co-applicant Datedf Signature Date of gnature ~ l .r 1 11 1? J f Q FILED APR 2 0 1988 JAMES O'CONNELL r Register of Deeds Cu 43G~~, St. Croix Co., WI \ CERTIFIED SURVEY MAP ~ 0 LOCATED IN THE SE1/4 OF THE SE1/4 OF SECTION 25, T28N, R19W, TOWN OF TROY, ST. CROIX COUNTY, WISCONSIN E1/4 CORNER SECTION 25 SCALE IN FEET T28N, R19W ® 3.6' of 120' 240' D L A N D S 3 3. 4Sg A T T 16° 26, E)~ 3• Ni U N Y L ' , (N °26' 26 4,g8' ral N16 35 56 46' zl \ ~ 3• \ 15°p %~E) „E 35. ~I ° la a I \ N14 50 lZo \4 Zap • 00 \ i ca I \ 60 \ ~i w I \ mobile lipuse HI home HI 1 > shed 1 N , : ~ 'LO'T' 2 .a I 1 n 3.43 AC± + oN rw SPIELHAUS 149613 S•r - ^ zl 1 BAR C14 x l N1 ` 1 1 O 1 ~ O X11 11 LO I. 1~ (rl N sl ^ 1 3.41 AC± + i in c:) 148,677 S•F•- T N w 1~ 1 2.94 AC± + 1 N C) cl 10 Cal N :11 128 pg6 S • Roadway 11 3.0 cl 1 ding _ u w i 1 Excl w NI ' ` 1 Easement H x 236.07 -c 1 M ~0 1 1~1y OADWAY LASI:MLN' 06' o al 1 z i R 99 550. 313• 711 1 1~ ) t479050118 E z nl N 1 1 166' a v,I I N 1 ~ A I 1 I LOT 3 W _ al z I ~w 5.00 AC± + cal H ' ~i I3 217,$00 S.F•- r° WI 1 6C± n HI ' 1 I 4. 915 S.F.'- W o cni Roadway Easement HI 190 x ral I 1 0~ dl W H zl ~ 120 11 166 Excluding wI w ~ ¢I I 60. /3 I wI fzl c~ al I 601 2 N 508' 10-r' I 2.61' xI 60' 8. 1114,E) w I MI cn Q I ' 2 . 6 DIt1~It4 U owa H Hi P o &-41 I DITCH 80 19' 3 40~ 4p~N'L ING 5 3,, W 5 X0.7' uI:OI~N v"'i rt+ a I S7 50'4 D S o .a al (S75 O D n H ° I 1 •L x o0 Z I U P L l+' o zz .:D I I 60, 60 ' I N 1 i APPROVED E" OWNER AND SUBDIVIDER APR 20 o DOUGLAS.W. JENKINS & RITA J. JENKINS SE CORNER BOX 213 ri .CPA= SECTION 25 R1VRR FALLS, WI. 54022 " T28N, R19W~ This insr.rument drafted by James T. Swanson Volume 7 Page 1955 DESCRIPTION 4 -Y A parcel of land located in the SE 1/4 of the SE 1/4 of Sec:f?&;1-221 5 ~.-X4Wn-191J, Town of Troy, St. Croix County, Wisconsin described as follows: Commeii'*ci6k"a'tl"e4"e- SE corner of said Section 25; thence NORTH 308.00' along the East line of-said. SE;W'-I to the point of beginning; thence S74°50'18"W 583.40'; thence Northerly 169.03' on'`a 2924.93' radius curve concave Westerly whose chord bears N2°32'30"IJ 169.01' along the Easterly right-of- way line of Stnte 'trunk Highway "35"; thence N85048' 10"E 60.00' nl.ong snid Easterly right- of-way line; thence Northerly 731.67' along a 2984.93' radius curve concave Westerly whose chord bears NI1°13'10"W 729.84'; thenc6 N74°50'18"E 280.00'; thence N76°26'26"1i 393.461; thence South 902.00' along said Easterly line of the SE 1/4 to the point of beginning. This parcel contains 11.848 Acres, more or less,being 516,090 Square Feet, more or less. Subject to easements of record. I certify that the above description and map are correct and that I have fully complied with the provisions of Chapter..18 of the St. Croix County Zoning Ordinance and Section 236.34 of the Wisconsin Statutes. Date: *(arch 1,1988. Revised Aril 13 0%4011 X011 qqh 82 J V AJA~iLS 1'. SIJANSUN 5-1482 ob No. 88-1716 p, , G0~ 's1-1.0 1988. vqOJAE ~ `SI Ogden Engineering Co. i 113 W. Walnut Street 4 River Falls, Wisconsin 54022 OWNERS AND SUBDIVIDER w DOUGLAS W. JENKINS and RITA J. JENKINS Box 213 z-% River Falls, Wisconsin 54022 LEGEND ~;Np' SURD eoReoceed~~~ ST. CROIX COUNTY SECTION CORNER NONUPIENT, BERNTSEN CAP,FOUND. 0 1" x 24" IRON PIPE, 14EICIIING 1.681// LINEAL. FOOT, SET. • 1" IRON PIPE, FOUND. (681.2) (PREVIOUSLY RECORDED DISTANCE) (N81°221,) (PREVIOUSLY RECORDEI) BEARING) 1MSEING F1fi]CE CURVE DATA TABLE CURVE LOT RADIUS ARC CHORD CHORD CENTRAL- 1sT S 2ND NO. NO. LENGTH LENGTH LENG'1'II BEARING ANCL . TANGENT BEARING 1-2 ,3 2924.93' 169.03` 169.01' N2°32'30"W 3°18'40" N0°53'10"W N4°11'50"W 3-4 2984.93' 731.67' 729.84' N11°13'10"W 14°02'40" N4°11'50"W N18°14'30"W 3 2934.93' 262.39' 262.31' N6°42'56"W 5°02'12" N4°11'50"W N9°14'02"W 1 2984.93' 469.28' 468.79' N13°44'16''W 9°00'28" N9°14'02"1J N18°14'30"W 01,NERS CERTIFICATE OF DEDICATION DOUGLAS W. JENKINS and RITA J. JENKINS, hereby certify that wet c,iuscd the land descrtbed on this Certified Survey hIap to be surveyed, divided and mapped as represented on this map. WITNESS the hand and seal of said owners this day of 1988 DOUGLAS W. JENKINS RI'l'A J. JENKINS STATE OF WISCONSIN) SS S'r. CROIX COUN'1'1' ) Personally came before me this day of _ 1988, the fibove named persons who executed the foregoing instrument and acknowledged the same. Hy Cummi.,inion expire NOTARY PUBLIC i ; 4' VOLUME 7 PAGE 1955 i DOCUMENT NO. STATE BAR OF WISCONSIN FORM t WARRANTY DEED • • VOL 544 PAGE THIS SPACE RESERVED FOR RECORDING DATA ~ t;3.3b3b;3 4 V ~ f,EGSTERS OFFICE M THIS DRED, made between Kenr~et.h_ S.umn_and_,LQanna_--A1ae $7. CRUIX CO., WIS. ._Sumn.er, _husband and_wi_fe,and each in their_ own ri_ght_ Rec'd, for Record this lst Grantor day of :Iovet:cerA.D, 19 75 and Grantee, W i t n e s s e t h , That the said Grantor for & valuable consideration _ Repastar of Deed$ `I conveys to Grantee the following described real estate in St. Croix County. RETURN TO I State of Wisconsin: A parcel of 6.9 acres located in the SE4 Tax Key It of the SE4 of Section 25, Township 28 North, This la not homestead property. Range 19 West, further described as follows: From the southeast corner of said Section 25 go '.North along the section line a distance of 308.0 feet to the point of beginning for the parcel to be conveyed herein; thence continue North along the section line a distance of 902.0 feet, thence South 76026' West a distance of 389.7 feet, thence South 6025' East a distance of 891.2 feet, thence North 75004' East a distance of 288.3 feet to the point o beginning. (This deed is given in fulfillment of a Land Contract between the parties dated December 24, 1971, and recorded December 27, 1971, in Vol. 479, page 508, as Doc. No. 308335, St. Croix County Register of Deeds' office.) _ Together with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; R And Kenneth Sumner and Joanna Mae Sumner TAM-kkjSEM warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements and rifts of way of record $ - FEP and will warrant and defend the same. Executed at River Falls, Wisconsin this 29th day of October . 19Z SIGNED AND SEALED IN PRESENCE OF 2 (SEAL) Kenneth Sumner (SEAL) - Joanna Mae Sumner - (SEAL) (SEAL) Signatures of Kenneth Sumner" and Joanna Mae Sumner l^ authenticated this 29th _ day of October i j L- V C. L` Gaylord Titre: Member State r of Wisconsin or Other Party Authorized under S~. 706.06 viz. STATE OF WISCONSIN s s. - - - - _ County. Personally came before me, this - day of 19_, l the above named____ _ i t to me known to be the person who executed the foregoing instrument and acknowledged the same. III This instrument was 'drafted by _ C. L. Gaylord, Attorney Notary Public County, Wis. isconsin. River Falls, WE The use of witnesses is optional. My Commission (Expires) (Is) I - - - - - X11 Names of persons signing in any capacity should be typed or printed below their signatures. RGIMb.pwppglrNrl , ,rYa,89N~d+orr•.•-ns.,~;,.:;... ,wrrsaw~awaa -'s!+?r;i IAN DepantrnentofIndustry, SOIL AND SITE EVALUATION REPORT Pap/ of 3 Labor and Humes Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ST. c~c°o/'X Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must indude, but not limited to vertical and horizontal reference pant (BM), drectieon and % of slope, scale or PARCEL I.D. # dmensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Do L) V- tT~.ve~i ~n'S GOVT. LOT 5E 1/4 sE 1/4,S ZS T 2-P N,R 1 > E (or) W PROP RTY ER':S MAIDfIG ADDRESS LOT # BLOCK# SUBD. NAME OR CSM # / D • ~a x yi 3 Z _ GSM CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE GFOWN NEAREST ROAD K16'&X 41llls "v/. S4;'-02--4- T,Po 111-Y 35- (proilew Construction Use [ ) Residential / Number of bedr~oms [ ) Addition b existing building J Replacement [ Public or corrtrnerdal desaibe ,9 r%¢uZ--- r?~3i~ RtT~iL - Ito s Code derived daily flow 3 2 gpd/ jr, ur S,+,,,-Ps) Recomme design loading rate 7 bed, 9PdAl2 trends, gpw Absorption area required ~/Co bed, 9 4165 trench, fl2 Ma)dmum design baring rate ? bed, gpdW -'0' trench, gpolit2 Recommended infiltration surface elevation(s) SEE' P 3 R (as referred b site plan benctmarlc) Additional design / site considerations Parent material SAS D.q ~oT~! ~O/qM - s~iTTED Flood on elewdon, ti applicable - ft w /N Ij'1 U= Suitable nllfor e to S 0 U 0•S 0 u ar O UEss"I~ T Ado u ms-a U 0 l TAI` SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed WnCh D-/O /o yle 2/2- 4►n vj'R cs 2 f Ground elev. 415,97 iL Depth 10 N limiting fado \0 Remarks: 114' ff "'ZoyS .E~Op~I~ OF~- N Boring # ,4 o/041/2 2-11 a~xy o,PG /0~4/-/ /,f, 5h& 4" -,4-i• C S • y s C -5 ox, Sa- Ground elev. 415, lztL Depth to limiting factor o Remarks: F Name:-Please Print ~pQPhone: 7/ress: ZP h/vvso,0 01 x4101& oc4 . 2.d c5T~ ZyJZ nature: Date: CST Number: N fit pax- a y -c s 4~;('~' t i.i~.. ORIGINAL PROPEMOWNSR SOIL DESCRIPTION REPORT pap 2- of PAWMIA# Boring # Horizon Depth Dominant Color Mottles Texture S#ucbure Gonse~oe But 3y Roots JG in. Munsell OL SzCont. Color Gr. Sz. Sh. o-is io rig 2 /0/" I,f, si& 2f Zs a.9 io Yip 3/4 YV f, 5 6K ewf c S 132-131- y 7,5 Yve r,l~~ c, y,e -2 cs , /0 Yle c, /Aln Dq* to # &Mng 1 1 Remarks: Bonng # 10 /0 io Yk 2_/2- s o sl,~ 4, es 2-F C AD '90 /a Ground elev. 17-2-7 tt Depth b tsti~ng Remarks: Boring # D ' 9 /DYie a,/Z 104H l f;5-h& ~ -IR C s Z ~ y ,S 132 ~s-ly ~S 1~1, 414, cs ? Loo Ground S r, elev. C 9Z /o YR Gl , S 1r., - 7 d 2 z_ ft Dept to few 7~Z Remarks: - Boring # Emma Ground elev. ft. Depth b ++9 Remarks: con 01"^10 ^clnm A-a oFF f/ 355-' So , r~ W w o ~ o d H t c o y~G 1 ~ t w. - i 11~ °O b s% p K N I m Z ~ P rP H -o alp t' S/off T ~h I ~ ~y 14 N 00, ' N nn I L T , Z u rn L z 6 o 7~4 ft, L 3 9u W p to o 0 o Coo O Z 0 It h W 11 1? FILED N APR 2 01988 JAMES 0=iVNELL Register of Deeds co i 43G4:11 St. Croix Co., W1 C' 14 CERTIFIED SURVEY MAP LOCATED IN THE SE1/4 OF THE SE1/4 OF SECTION 25, T28N, R19W, TOWN OF TROY, ST. CROIX COUNTY., WISCONSIN E1/4 CORNER SECTION 25 ? SCALE IN FEET T28N, R19 3.6' S V 'D (399. 0' 120' 240' Z T E D Z, A 2,6 E) 3 3 46~ 3,58, v'I U V L A r- -gl-026354 88'~ QI \ 358.46 zl \ ~N75 o t" 1a „E 35- al 4 120' \4 28p .00~ ~i a I 60 ~ w I le /ihouse H~ \ home \ \ Q shed ¢I LOT 2 - a I s "I 3 43 AC± wI \1 \ 1 SPIELHAUS 149,613 S•F•* t zl BAR 'n cn 3.41 AC± + °n rn 148,677 S'F 1 a 1 0 2•94 ACS w N S,F.± A~ 1 a ~1 12s,086 ng Roadway Xr 3.0' w 1 ^ ~ Exc lu L- r/`" h x NI ` 6 ~3 Easement J E +1 1 3 s - = _ _ ° 236.07 ::D r~ _ N ~ .0 0 0 i YEAS r 11rt ROADWA , 550.06 ow cn al 2 i 13 199 „E ~1 I r' N79° 50 1$ 2 pel 1 I w I ~ ~I x ~ W ~ W I w al II 1 I 1 c LOT 3 z 5.00 p,C ca I 1 I 217,800 S•F-t wl E°+ II ` i 13 I 217 ,383 AC+ H I I~ 4' F.t HI w PA ,nl 190,915 Easement z a; ra I W U I 1201 1 I 166, 1 gxcluding R° dway i al W H zI w I ,i / I al I I 60.00 3 1 ~ /z I 'N~g'10 E i' z w aI I 60' 602 1 N(N85°44'E) 2.61 ~i Lv- H ~ QI I _I 2,6' wl I I DRAINAGE P f-4 HI i ( ~DITCR B0.19 g3.401 ppxET IF1G w I I 050% 8"W (5g0.7 BEGINN - ~z-+ al I S74 041 W~ A S x o ~ a w l ( 1 ~S7 5 E D L a co ~H zi L p,T 00 w I j 60' 60' ° APPROWD F" OWNER AND SUBDIVIDER APR 20 08 DOUGLAS W. JENKINS & RITA J. JENKINS SE CORNER BOX 213 SLGS'30M SECTION 25 RIVER FALLS, WI. 54022 28N, R19W This instrument drafted by James T. Swanson Vol> u, e 7 Pale 1955 DESCRIPTION A.parcel of land located in the SE 1/4 of the SE 1/4 of. S4 W, Town of Troy, St. Croix County, Wisconsin described as follows: CoilAeMM t SE corner of said Section 25; thence NORTH 308.00' along the East line of,.vg&id;SE,; Ito the point of beginning; thence S74°50'18"W 5.83.40'; thence Northerly 169.03'' on`a ML4.93' radius curve 'concave Westerly whose chord bears N2°32'30"W 169.01' along the Easterly right-of- way line of State Trunk Highway "35"; thence N85°48'10"E 60.00' along said Easterly right- of-way';line; thence Northerly 731.67' along a 2984.93' radius curve concave We:;ter.ly whose chord bears N11°13'10"W 729.84'; thence N74°50'18"E 280.00'; thence N76°26'26"E 393.46'; th'encelSouth 902.00' along said Easterly line of the SE 1/4 to the point of beginning. This parcel contains 11.848 Acres, more or less,being 516,090 Square Feet, more or .less.. I Subject to easements of record. I certify that the above description and map are correct and that I have fully complied with the provisions of Chapter_18 of the St. Croix County Zoning Ordinance and Section 236.34 of the Wisconsin Statutes. Date: March 1, 1988. Revised Aril 13, ~r JAPIES T. SWANSON S-1482 Job No. 88-1716 1988. ~ONvS~,Ogden Engineering Co. ~I~ 113 W. Walnut Street JAMES t.j~~ River Falls, Wisconsin 54022 ` it SVJANSON o S•1482 OWNERS AND SUBDIVIDER RIVER FALLS, DOUGLAS W. JENKINS and RITA J. JENKINS WIS. J„ Box 213 f~0River Falls, Wisconsin 54022 LEGEND ~ ~Il1~OOS1s•' t~ ST. CROIX COUNTY SECTION CORNER MONUMENT, BERNTSEN CAP,FOUND. o 1" x 24" IRON PIPE, WEIGHING 1.6811/ LINEAL TOOT, SET. • 1" IRON PIPE, FOUND. (681.2) (PREVIOUSLY RECORDED DISTANCE) (N81°2,'210 (PREVIOUSLY RECORDEb BEARING) MgrDU FENCE CURVE DATA TABLE CURVE LOT RADIUS ARC CHORD CHORD CEN'T'RAL 1ST S 2ND N0. N0. LENGTH LENGTH LENGTH BEARING ANGLE' TANGENTBEARING 1-2 ,a3 2924.93' 169.03' 169.01' N2°32'30"W 3°18'40" N0°53'10"W N4°11'50"W 3-4 2984.93' 731.67' 729.84' N11°13'10"W 14°02'40" N4°11'50"W N18°14'30"W 3 2984.93' 262.39' 262.31' N6°42'56"W 5°02'12" N4°11'50"W N9°14'02"W 1 2984.93' 469.28' 468.79' N13°44'16"W 9°00'28" N9°14'02"W N18°14'30"W I OWNERS CERTIFICATE OF DEDICATION DOUGLAS W. JENKINS and RITA J. JENKINS, hereby certify that we caused the land duscribed on this Certified Survey Map to be surveyed, divided and mapped as represented on this map. WITNESS the hand seal of said owners this 20thda f April 1988, DO GL:1S W. JENKI RI'1' J. JE KINS STATE OF WISCONSIN) SS ST. CROIX COUNTY ) Pe son ly came,tefore me this 2nrh day of April 1988, the above named person ho executed the foregoing instrument and acknowledged the same. My Commission expires April 309 1989 NOTA PUBLIC ' VOLUME 7 PAGE 1955 A • i ~Plb 10 • NAME OF BUSINESS LOCATION 1Z/UY 33 /V/ CIE W IS 7R-61 / ( X street or highway city or township county LEGAL DESCRIPTION S C 2 T T ~Z d 1tl / OWNER Mailing address its/ '2 ~C /UE z j zip ARCHITECT OR ENGINEER Address ZIP _ PLUMBER a b 'D Address ZS ZIP G 1. Check appropriate building usage(s) and fill in the information requested opposite each usage listeds Existing building X New building Addition If addition to existing building attach detailed memo for each. ( ) Drive in restaurant . . • Car spaces ( ) Restaurant . • . . • • • . . Seating capacity Z 10 sq. ft./person) ( ) Dining hall . . . . . . Per meal served Toilet waste Yes No ( ) Motel Hotel ( ) Cottages • . Number of unites 2 persons/unit 4 persons unit TOTAL NUMBER OF UNITS ( ) Churches . . . . . . • . Number of persons Kitchen Yes No O Bar or oooktail lounge . Seating capacity (10 sq. ft./person) ( ) Nursing or rest holm . . . . Number of beds ( ) Mobile home park . • . . • . Number of units - dependent (camper trailer) - nondependent (mobile home) ( ) Retail store • . . . . . • Number of employees Number of customers 10 sq. ft./person) ( ) Service station . . Number of oars served-T y) ( ) School . . . . . . . . Number of classrooms Meals served Yes No Showers provided Yes No ( ) Factory or office building . Number of persons (total all ahift- ( ) Residence Number of bedrooms ( ) Apartments . Number of bedrooms Other . . . . . . . . . . . . . Specify F) f~ tilJU«~/z 2. Indicate whether or not the following facilities are connected: Food waste grinder Yes No X_ Dishwasher . . . . . . Yes No ` Automatic clothes washer Yes No R 3. Fill in the appropriate information for the following as indicateds Septic tank capacity planned TOTAL Septic tank capacity required Percolation test results - ATTACH PERCOLAT N TEST REPORT SHEET Seepage trench bottom area planned width linear feet depth Seepage bed area planned width linear feet depth Seepage pit-)planned If outside diameter depth below inlet depth Seepage trench bottom area required width linear feet depth Seepage bed area required width linear feet depth i / 1j Seepage pit required L/ outside diameter depth below inlet Signatur of person oomplet ones STATE DIVISION OF HEALTH, PUMING SECTION / i P. 0. Box 309, Madison, Wisconsin 53701 Address a- Approved s ZIP ' Dates Dates THIS APPROVAL IS BASED ON STATE PLUMBING CODE REQUIREMENTS AND DOES NOT EXEMPT THE INSTALLATION FROM CITY, VILLAGE, TOWN- SHIP OR COUNTY REGULATIONS OR PEWIT (OVER) REQUIREMENTS. INFORMATION REQUIRED FOR SUBMISSION OF PLANS 1. Legal description of property on which septic tank and effluent,disposal system is to be installed. 2. Percolation test data from a minimum of three test holes. Tests are to be conducted in the area and to the depth of the proposed effluent absorption system. Where ground water and/or bedrock conditions exist, the vertical depth from grade level to same shall be indicated. 3. A detailed plan of the proposed installation specifying the location of the building served, size and design of septic tank, effluent absorption system with location and numerical identification of percolation test holes. 4. Indicate on plan lateral distances between septic tank effluent disposal system and building, well and lot lines. 5. Include complete data on expected use of the building. See Section H 62.20. LAKE OR STREAM 50' ~ S PAGE 50 TRENCH Piizp t - J 75~ l S E P A G B E D 25' ~o0 25~ c~~ W E L L 50 - ~ _ _ _-I BLDG . 3 6 P - + r, 77&I GAL. ' ks P" 3 4EI 5 0 WELL SE E P LOT LI NE 0-e-- P • Peroolation test hole SAMPLE PLAN DEPICTING SEEPAGE TRENCH, SEEPAGE BED AND SEEPAGE PIT P* # SEPTIC TANK PERMIT Noe ` REPORT ON SOIL PERCOLATION TEST AND SOIL BORINGS TO DIVISION OF HEALTH • PLUMBING SECTION P.O.Box 309, Madison, Wis. 53701 Pursuant to H 62.20, Wise Administrative Code NAME PROPERTY ADDRESS d G LL/~ /-~L G . S LOCATION (Check One) City Village _ Town X _7_200) Y County C5 City or hip X WATER SUPPLY FROMs Public Utility (//-//)A Cooperative Private Well SEWAGE DISPOSAL INSTALLED BY$ All Address Date SEPTIC TANK SIZE ` -17L G^a,C Material l~~l.ta rnreG.Peroolation & Soil Borings Test Date EFFLUENT DISP.s Tile Size No. Line Ft. Trench Width Depth of Tile Seepage Beds Length Width Depth of Tile 1j Seepage Pits Outside Diameter i Liquid Depth TYPE OF OCCUPANCYs r) RESIDENCES Number of Bedrooms OTHER: (aPaoify).Dawcr, /a ~ L (umber of Persons FOOD WASTE GRINDERS Yes ! No 1 Dishwashers Yes No Automatic Clothes Washers Yes ` No P E R C O L A T I O N T E S T Test Depth Charaoter of Soil Hours Water Test Time Dro in or Level Inches Minutes Number Inches Thickness in Inches Sines Hole in Hole Interval Second to Next to Last To Fall 1st Wetted Overnight in Minutes Last Period Last Period Period One Inch Example P• 0 361, To Soil 10n Clay 26~ 25 yes or no 30 1/2 2 60 7.2 Al~ RECORD DATA FROM MINIMUM OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. S O I L B Q R I N G S- Minimum 36"'Below Propose d Absorption System Test Total Depth De nth to Ground Water Depth to. Bedrock Number Inches Observed Estimated Observed Estimated Character of Soil with Thioknasn in Inches Example B- 0 72" 72" Blt& a Soil 12'!' C 18M Send 18» Gravel 24" i 77, 2 7 Z ' RECORD DATA FROM MINIMUM OF 3 TEST HOLES I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under may super- vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of spr knowledge and belief. NAME 4 G '0 TITLE Yc l Type or Print) REGISTRATION NO. or MASTER PLUMBER LICENSE NO. 7 ADDRESS J DATE ` / 7/) SIGNATURE L~ / •3sa3 uol3elooaa 043 ul.inp lanea6 043 anoge aq a03eM 10 sayoul xis ue43 ajow lle4s as" ou ul •a3ei uo p eloojed 843 a3elnoleo o3 pasn aq lleys doap !anal a93em feUld 841 •pasn aq P1n04s lenaa3ul 3s93 JDZJ04S a sa3nulw ua3 ue43 ss91 ul Aeme sdaas lanej6 943 anoge Ja3eM 3o sayoul xls 043 aJ94M saseo ul 'l9neJ6 043 anoge sayoul x1,s JOAO Sou 3ulod a o3 Aj essaoau uayM 0104 843 6ullll3aJ 'jno4 auo jo poked a jol S1eAJ93U1 a3nulw ua3 3e !anal aa3eM ul dojp 043 aanseew 3ulod eouaa03aa paxll a woi3 pue laAea6 043 JOAO sayoul xis ue43 OJow Sou 3ulod e o3 21,04 043 03 aa3eM ppe ssal jo sa3nulw ua3 ul Aeme sdaas (q) F uol3oaS ul pailloads se lanej6 043 JOAO aa3eM 10 sayoul Zf 10 6ulllld PuO3QS 844 31 (o) •3sa3 uo p elowed 943 a3elnoleo o3 pasn aq lfe4s pol.ied a3nulw u93 3sel 843 ul s.inooo 3e43 !anal aa3eM ul doap 841 *jn04 auo jo3 uni 3sa3 243 pue se3nulw ua3 se ueje3 aq lle4s s3uawainseaw u0am3ag lenae3ul awl3 043 po ped 6u11lems ffos 943 aa3ie s93nulw o£ ue43 ssal ul Aeme sdaas J23em 30 sayoul xfs 3sJ13 043 uayM (q) •93ei uol3elo2jad 843 a3elnoleo o3 pasn aq ffe4s lenaa3ui a3nulw o£ 3sel 943 ul s.inooo 3e43 !anal ja3eM ul doap 041 •doap !anal aa3eM pai nseaw 3Sel 043 40 s31wff 043 03 3daoxa spol.ied 3u9weinseaw £ 3sel 043 6ulinp apew aq 3ou lleys laA9l ja3eM 043 jo 3uow3snrpy •40ul ue jo 91/1 ue43 ea0w Ajen Sou op s6uipeaa an1,ssooons oM3 31 sanoy inol ue43 ssal ul pa3eulwa3 aq Aew 3s03 941 •Aldwe i(faeau sawooeq 0104 043 uayM lanej6 843 eAoge sayoul xis JOAO Sou 3ulod a o3 J93em 431m sa104 043 6ul1ff3aJ 1sjn04 inol jo polied a aol sa3nulw of 3 0 slenae3ul le 3ulod aouajajaa paxlj a woaj pa.inseaw aq fle4s !anal aa3eM ul dorp 043 pue l9nea6 943 anoge s840ul xis ue43 avow IOU 10 43dap a o3 pa3sn(pe aq ffe4s !anal J93em 941 •panowei aq ffe4s 0104 943 03ul p946nols sey 4014m llos Auy (e) :3uaweinseaw a3ej uol3elo2aed •molaq (o) h uol3oaS ul pallfoads se Ala3elpawwl paaoo.id ueo 3se3 943 ssal Jo sa3nulw ua3 ul Aeme sdaas a83eM 10 sayoul Zl 30 6ulllll puooas 043 if •ainpeoo.id 043 3eada.i ssal ao sa3nuiw u93 ul Aeme sdaas aa3eM s143 11 •lanea6 043 JOAO ja3eM 30 sayoul Zf .nod Alinjaaeo Aelo ou jo a13311 6ulule3uoo silos Apues ul (q) •molaq (q) pue (e) h suo!3oaS ul pallloads se paaoo.id lle4s 3sa3 uop eloo.iad 043 polaad 6ulllaMs 043 ja3ie A1a3elpawwl •aeaA ay3 40 suose0s 3sa33aM 943 6ul.inp 3slxa [Jim 3e43 suol3fpuoo 943 4oeoidde film 3i 3e43 os sjn04 0£ ue43 aaow ao sanoy 91 ue43 ssal Sou !lams o3 p9molle aq lleys 110s,941 •panoweJ aq 3ou lle4s sjn04 inol a03;e 9104 043 ul 6ululewaa ja3eM •sanoy .inol 3seal 3e jo pol.ied a aol (9Aea6 043 JOAO sayoul Zf do 43dap e o3 ja3em 431m p91113 sl 9104 3se3 043 os 'uoydls ol3ewo3ne ue se 4ons je4em 4o a lona2s9a snid.ins a 6ulAiddns Aq jo Aaesseoau 11 6ul l f llai ' lanea6 943 aano sayoul Zl 10 43dap wnwlulw a o3 aa3eM aealo 431m polfl3 Allnjaaeo aq lle4s alo4 a41 (e) :llos jo 6ullfams pue uol3ein3eS (f) •sQl04 043'ul l9nea6 Jo pues asjeoo 30 sayoul om3 aoeld pue s9104 043 jo wo33oq ay3 woaj lelJa3ew asool 043 Onowab •1!os le.in3eu 043 asodxa o3 3uawnj3sul pa3ulod d.ie4s a 431m s9104 843 jo wo33oq pue SONS 044 uQ46noV :3104 jo uol3ejed9ad (Z) (•seeie pally Almou ul s3sa3 jo uol3ejeplsuoo leloads and 43leaH 10 uolslAl0 ay3 3oewoo) •plal3 96eule.ip ao 3ld a6edeas pasodo.id 9y3 10 43dap 043 03 pue jo e3.ie 943 ul 'aa3awelp ul sayoul Z1 03 h 'se104 le:,13Jan aaJ43 3seal 3e aaoq ao 610 :8104 4o adAl (1) a.inpaooad 3sal uol3elo0Jad s ' i jI i i g6k T - - - - - - - - - - - - - - - - WiseQncin Department of Health and Social Services P1b. #67 10/69 Division of Health PERMIT APPLICATION for PRIVATE DOMESTIC SEWAGE SYSTI-J iS ._~C iiiy J►2;:1~,'~ f~S . A. OWNER OF PROPERTY 1 TYPE OR USE BLACK INK Name Address (StreetCity, Zip Code) County B. LOCATION OF PROPERTY WFUFRE SYSTEM WILL. BE CONSTKUCTED, AL-IFRL7D.-OR EXTENDED Check One: / CITY VIL;AG£ LEGAL DESCRIPTION: / _ `Gf _ TOW1 1SHIP L C. IS LOCAL PERMIT FEGIUIRED FOR THIS WORK? 4 YES NO PERMIT NUMBER D. SEPTIC TANK CAPACITY;(Gallons NE4 INSTALLATION / RE?LACEPLNT ~C ADDITIONS MATERIALS: Prefab Concrete 1~ Poured in Place Steel \ Other f:'?~ NU9,a33R OF TANKS TO BE INSTALLED: E. TYPE OF OCCUPANCY Check One: One or Two Family Residence Commercial Industrial _M Other (Specify) Number of Persons to 'be Accommodated Number.of Bedrooms F. AP?LIANCES, ETCH Food Waste Grinder YES NO Autocratic, Clothes Washer YES NO Dislnvasher YES _x NO Automatic Potato Peeler YES NO Other (Specify) G. EFFLUENT DISPOSAL SYSTEM NEW EXTENSION ADDITION REPLACEMENT Tile Size NoI.inrFeeQ.._~~f Trenoh_=Ni~2t -j 'T Depth- ~-Kumber cf-Lines' ; 7 iiL Seepage Bed: Length Width 4-LDepth=`/ Tile Size _1 No. Lines 'IF Seepage Pit: Inside diameter Liquid Depth -P E R C 0 L A T I 0 N T E S T Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches r;inutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall lst Wetted Overnight lin Mimtes Last Period Last Period Period One Inch Example P- 0 36" To Soil 10" CIa 26,t 25 es or no 30 1L2 1 2 1/2 60 i _77~ J RECORD DATA FROM MINIMUM OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. S 0 1 L B 0 R I N G S- Minimum 36" Below Pro osed Absorption System oring Total Depth Depth to Ground Water Depth to Bedrock umber Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches I xacnple - 0 72" 72" Blaok To Soil 12"• Cla 18"• Sand 1811• Gravel 2411 l RECORD DATA FROM MINIMUM OF 3 BORE HOLES COMPLETE OTHER SIDE I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under by supervision in accord with the procedures and method specified in Chapter H 62.20 (3), Wisconsin Administrative Code, and that the data recorded and location of test holes are oorrect to the best of my knowledge and belief. NAME, TITLE (Type or Print) I REGISTRATION NO. or MASTER PLU'i'BER LICENSE No. ~~_1i= ADDRESS GNATUT✓/ DATE SI MASTER PLUT'BER MAKING APPI)ICATION \ M Signatures License Number: - MP RSW -1=--=-~- (To be Completed by Issuing Agent) J ~ Date of Application Fee Paid $ C) Permit Issued (date) Permit Number -~'4-, 6' Agent (name) C,77 Town, Village, City,,,Eounty,'etc. (Speoify~-- J Notes The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $10.00 and Copy (b) of the Permit (yellow copy) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below - FOR DEPARTMENT USE ONLY DATE RECEIVED 1!5! a r7 C ACCEPTED BY RETURNED _ (Initials) / (Date) See Corres. 47A FEE RECEIVED V VALID. NO. PEF&U T NO. a D Yes or No) c~ Q 17 REVIEWED BY APPROVED DATE (Initials) (Yes or No) COMMENTS: I