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HomeMy WebLinkAbout040-1188-90-004 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER *Wr5 ADDRESS ~j l B~K 171 llu~ w~ 5 Zfo z z 2 . Imo. SUBDIVISION / CSM# 6A(( foRcS LOT SECTION T J N-R O/V _L__LW, Town of to.24 .I. SI / Z ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Ga~ Z5 f S x ~3 v INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide Z dimensions to center of septic tank manhole cover. ICI f ~ O BENCHMARK: Lrd A /-&t' ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING-TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well 7Z~ I House ~ Other ' p F? t -seperatiori-__ SOIL ABSORPTION SYSTEM Width: l u Length Number of trenches 13E UJ~~~ L L Distance & Direction to nearest prop. line: /0 Setback from: well: House 26 Other pi40g?~/7 9 ELEVATIONS Building Sewer ?15 o / zST Inlet. J ST outlet l/ 7/ P~' ~ ump O f f Header/Manifogd bpoot%!50~m-of system gi 7 Existing Grade Z Final grade ~~~\-`~`~~~}f~lG~f4D DATE OF INSTALLATION: PLUMBER ON JOB: ~O6 ~V ~L"3O A LICENSE NUMBER: I NS PECTOR : 3/93:jt l /✓ff// /1/0, 5 A T-)A) )e19 Cv, 4o-f6 y, Oak /C,1 /~c BPS Wisconsin Department of industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION q / 2 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan D No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /0 0 • /00, ~ TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ~,a /OU r Dosi ng Aeration Bldg. Sewer X5;3 q~.B3 d Holding St/ Ht Inlet O TANK SETBACK INFORMATION St/ Ht Outlet Verit irIto ntake ROAD Dt Inlet TANKTO P/L WELL BLDG. A Air Septic / NA Dt Bottom Dosing NA Header / Man. 79 gq 9 y Aeration NA Dist. Pipe 7,0 R?, /7 Holding Bot. System 0/, 66 g g,a D- PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction Syestem TDH Ft Forcemain Length Dia. FFii Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width p / Length / No. Of riches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS O / DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type of ecu, Model Number: System: ~dj y / 0 a 5 17,50 /V OR UNIT DISTRIBUTION SYSTEM Header/Manifold I Distribution Pipe(s) I x Hole Size I x Hole Spacing I 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 ❑ No ❑ Yes ❑ No MMENTS: (Include code discrepancies, persons present, etc.) _CAZ Plan revision required? ❑ Yes ❑ No Use other side for additional information. Wk/1 , Y FqFdod~ol SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. 7 DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY, PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ~I 8% x 11 inches in size. ❑ C6ecK tffey(sI n evious 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 u L y r j? 5 o tit U6 A)(Jk. P w'/a, S ~j TZ-c N, R E(or)PD PROPER OWNER'S MAILING ADDRESS LOT # BLOCK # i CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER dZ /4" II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD State Owned O VILLAGE I 16~2120.01?1,04e- ❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms 'PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) Q v 1 ❑ Apt/Condo V"~t 2 ❑ Assembly Hall 6 ❑ Medical Facility/1" rstng Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)" - A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 El In-Ground 42 Pit Privy 130 Seepage Pit Pressure 430 Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: ` 1. GALLONS PER DAY 2. ABSOAP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION CJ Z z Feet Feet IF Jr.01 VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed i Septic Tank or Holding Tank Lift Pu VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumb 's Name (Print): Plumyer's Signatur~ Stamps MPAMPO -NG.: Business Phone Number: / 0 rrw Plum ei s Address (Street, City, State, Zip Code): F-71 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: i SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber f- ~ INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% 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. g SBD-6398 (R.11/88) f Wfktorsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of 3 Labor and Human Relations DWision of 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 S -I'. C-7-0 bL not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. o q 0 - L [ 8 q o _ O o q APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Q U 1Pv L ( 8V I L-r S GOVT. LOT I~ 1/4 NVu1/4,S 16 T 7-8 . ,N,R 19 E (a Va PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # . %Luv $uX 7 6~{ - ort~ 2t AGL R~R~s CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE (3FfOWN NEAREST ROAD (ZIV"4-u- F+'«S 1,v1 St(o1.2 (11 S) L1 ZS- 2-14 Z_ 'j1ZU wDODRIDGt DR•w. New Construction Use Residential I Number of bedrooms Additkn to existing building Replacement Public or commercial describe Code derived daily flow qso gpd Recommended design loading rate o -Ij bed, glxW 0• S trench, gpolft2 Absorption area required ~Vz S bed, ft2 °dUO trench, ft2 WAmum design loading rate o - q bed, gpdfft2 S trench, gpdtft2 Recommended infiltration surface elevation(s) - It (as referred to site plan benchmark) 3 Additional design /site considerations SE)E- Q, M oAJ ~ E 3 OP Parent material c~v1%- N z VA Flood plain elevation, if applicable ty A • It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTM IN FILL HOLDING TANK U= Unsuitable for system ®'S ❑ U 0S 11 U 0S ❑ U IRS ❑ U ❑ S 011 ❑ S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consis~ Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rench k cs o.S o-b Z ~z zo 1O ti R 31 z s I I z'F s s►~ m fir. Ground 3 zo2Y 1 f 3,-t (Z'3 S 1 I Z S bk vn`~h Cg o. S o. L elev. qZ.l ft. 3-81 (Z- 3/6 - S 1 \csbk 1+) U Depth to limiting factor > St Remarks: Boring # b-lZ ~1~~-( ~ZZ LZ - s 1 1 Z'Fsb1~ vlq S o. b Z Z (Z-33 tot tZ 3lb s I zfsSk >n'FH eS - S L 3 3'~_~4 6 I Q LyLy R_ - s 1 ~ es b►~ in U o L( o. S Ground elev. Lit $ z l V 2 V/y ~S o s9 A - ' 0, 6 ft Al 'X Depth to v' limiting , factor UZr 'may OV/~..: G-~.. Remarks: TName:-Please Print Arthur L. We erer Phone. 715-425-016 Aftess: egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 540.22 Signature: Date: CST Number. off. °l3-t l`~ 6- 1S-93 M00576 PROPERTYOWNER QUh'U~`M 12U~Lr SOIL DESCRIPTION REPORT Page 24f , PARCEL I.D.# C) 43 1 188 -SID - OUP/ Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-11 o~-ctz z.LZ - s l Z s bk ~s - o S 0. (Q > o Y R- 31 6 - s t 1 Z'gS bk c s o- s 0.6 L i::i;........ Ground 3 3i&-q? Lu`tR316 S 1 1 Csdk vnU,& cS elev. 9~. 3 ft. y L4&- -3 LO -t 2 Y l 1 ~S v SS vh _ o• S o. L Depth to limiting factor ~ 83 Remarks: Boring # s bl~ wt `F~ cS o. <K y 11 s 1 b 4 CS o,SU.~ Z kl-qo lo`tP- 316 t Z'f s k h - 3 40-SV t o tZ 3l6 - S) 1 CSbk 1~ u `Fh - o v• S Ground t p R 3!b S1 4 elev. y SV-84 0_3 I,Iz U`F}. o• ~L o. s to ~rz - ~s Z ft. Depth to limiting factor Remarks: Boring# o_~z o z-LZ - S1 ZJ3\btic weir ~s o- S~o•b X., M1 ` } Z tz-38 \ Z01 R 3/6 - s t 1 Z'FS bk m ~H cr O- S o- b M.-`n;. 3-s y t b'-I Q 3l b S 1 ~s bk ►n U Ground elev. y S~(-$7 l b ~t 2 ~fl - `FS s m - S a. 6 °lq ft. Depth to limiting factor > S-) 1, Remarks: Boring # Ground elev. ft. , Depth to limiting factor Remarks: SBD-8330(8.05/92) PLOT PLAN Page 3 of 3 SCALE 1"= 3 O' tivoc~~R-1 D6~' -t~T?- IUG 1,~t2-Vr qq. - fit. Coo, 0 obi `TAP of ~`t~p►tpkJC P ~ Lr310 L ew, , eL 48• Q' o^v 'MP OF Zt_ cTR LC ®uu 0 0 A~PR4 X . 8 R-C1~ n i~tzeaos~ `ttu~,sE se - - - - 1- NBo~r~ OF 9 1 Dl,v 6 ci's 2,5 nua. t L-L X12. Z 8.4 Z °~o B .1 LrL q Z 0E NT Le'hsT ( sv ~`tyt"13L~ fl~~A Fci2 1AJ M 1~ L V40v y}l.'[ L/Jl'r SOS l~i'W1'l S`tS1~M A~ B.S ~°It4 S~-LST~?1S, s 5I 40 3.3- 8 Z tl, 9O S' `1 c ~ W S M LLB.:. ~6' x 6 3" 8!~ oZ i a o FaLrT Op s, kj t D `rTzev c-1+e s, "IA.). 1,' -F,~N-vLT, WMAIAJ 1~tL Sorm3LL VtzU~ 31'tOW&J, 'rte 02 TcZeve*eS, ~lz~ BE Z4 N_Ta 2S6 4 ~ PtT ` if 4 louwN S L u pe STD G e , ~1u ST~-Ll ~v ~~~~Z~tt!vE S'-tS'I~~! ~Z~I~AT7UiU ~~Cz.ltiG cduS'TRUc17u1V, 000057 6 G-:1S-43 (715 ) 42q-0169 M00576 CST Signature Date Signed Telephone No. CST # At. PLOT PLAN SCALE 1"= 3 O" 1'v o~~R-tpGE ~R-~u~ wt"ST oa °r 4 ' 100.0 , O)u hP OF -'LEpvto"e PLAZ) OM L 6 - LPL 48• Q, oAJ lov, OF • QTR tC 8ox i f .6 N~`CTo~L OF 7~fl~rvG LrLaml I. I /8 X b 3 gre watt.. ~ 8F kT' L+~k~T I S ~tttj?1 SY S1~ H El-it.~q y ~ S 7q-~..E~ s I ~L 30 8'3 8 .2, lL 90 94.4 $ Lcj~7- ~Ul ~ dot `7, 126© gg,ZZ ~0 Epl~ 9,05 77,17 i ST. CROIX COUNTY „ WISCONSIN ZONING OFFICE INKIN n . ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road s - Hudson, WI 54016-7710 (715) 386-4680 April 26, 1994 Mr. Roger Nelson Nelson Plumbing 289 Sunset Lane Ellsworth, Wisconsin 54011 RE: Sanitary Permit Informatoin for Quality Built Homes Lot 64, Oak Ridge Acres, Town of Troy, St. Croix County, Wisconsin Dear Roger: Enclosed is the information which you gave to me on Friday, April 22, 1994 with regard to the above septic system. Very sincerely, Mary Jenkins Assistant Zoning Administrator mz Enclosure D LQQ&Wi pa,trX8QM ir,366y28 . 19' 817 PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. egmx GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan ID No.: ev.: B o.: 7 Insp. ev.: M Desch t_ipn: - Parcel Tax N TANK INFORMATION 1~C' EL TION DA A A930031 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Be hmark Z I , Dosi ng 41W 1'0~ Aeration Bldg. Sewer Holding St / Ht Inlet ~4. TANK SETBACK INFORMATION St/ Ht Outlet b Verit TANK TO P/ L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic NA Dt Bottom Dosi ng NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand M g , y Model Number GPM TDH Lift Friction Syesatem TDH Ft Forcemain Length Dia. Ilff Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer: SETBACK 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 ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 36.28.19.817 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710(R 05/91) Date Inspector's Signature Cert.No - ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Cce 01 STATE S WR PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8%x 11 inches in size. ec in p viousapplication -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 7 U l l 1i6L AJ V/4IJWY4, S J T~ N, R E (or)k PROPER OWNER'S MAIL G ADDRESS LOT # BLOCK # ~T TE ZIP CODE ~ ~S PHONE NUMB~ SUBDIVISION CITY NAME OR CS ~ MB ER (4:r CA 4 4 OF BUILDING: c• - I l NEAREST ROAD II. TYPE (Check one) ❑ State Owned VILLAGE T-R-0 y OA IV ❑ Public 4:1 or 2 Fam. Dwelling-# of bedrooms AR L AX NUMBER( S) III. BUILDING USE: (If building type is public, check all that apply) Vo ' ~ - ®6)y - /I 5 1 ❑ Apt/Condo v 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 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. ❑ Reconnection of 5. ❑ Repair of an ~ystem System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 1❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 1 4::~Pl o C? pEVATION Z_ 5- ro Feet / i Feet VII. TANK CAPACITY Site INFORMATION in allons Total # of Manufacturer's Prefab. Fiber- Exper. New lExisting Gallons Tanks Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank ~vS 54- r7l I F1 Lift Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewag ystem shown on the attached plans. Plumb 's Name (Print): ~ Plum is Signature;d o Stam MP ~IMiM81W410" y Business Phone Number: Plumber's Address (Street, City, State, Zip Cod IX. C NTY/DEPARTMENT USE ONLY k ❑ Disapproved Sanjtary Permit Fee (Includes Groundwater Date Issued issuing gent Sig Lure (No mps) 'LQj6~t Approved ❑ Owner Given Initial Surcharge Fee) ~d 16-21 Adverse Determination / CJ 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 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 (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system" is to be installed. 11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump "performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if ' equired by the"county; E) soil test data on a 11,5 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) 4 PLOT PLAN SCALE 1"= -30' ►-vo~~1Z-IDGE~ ~~.~uN k~t`ST ~a 9 9 100.q Oyu `PAP OF 9A7- e. 48. Q c~, lop of z-zcTtt tC box N~Yton of 7tp,rvc i f L TL c% o a ~r V-rL at -Z. el--L I wat t. Zb 8E kT Li!*kT I S OPCW 31 S`T S H A-it~q i s I I I I ~U 40 8 .Z zu 90 5 S- 0~-PAGE I / f~lC fib? CrvsS Sec~IUn O~ ~ ~ef) SyS~e~ Fresh Air Inlets And Observation Pipe Approved Vent Cap Mialmum 12" Above Final Grade 20- 42" Above Pipe _ 4" Cast Iron To Final Grade Vent Pipe Mash ffoy Or SyntMfk covering Mtn. 2' Aggregate Over Pipe - Distribution - T•• Pipe - 0000 { Bach Pipe Aggregate Beneath Plp o Perforated pipe Below Coupling Terminating At Bottom Of System P~,,Pose~ t'Inkl 11gr~.~1{ SOIL FILL DISTRIBUTI01'.J PIPE APPROVED ~4WVETIC COVER ° MATRRIAI- OR 9° OF STRAW Z~ OF NGGR EGATE OR ('JARS" NA"J ° (e OF J2-2,1/2 AGGREGATE tLEV. OF FEET DIS't-RIF3UT10Q PIPE TO BE AT LEAST /4-71UCHES BELOW ORIGIIJAL GRADE AUD AT LEAST20 I.JCHES 130T 1.10 MORE THA1J 42 IKIC14ES BELOW FINAL GRADE MMUM DEPTH of EXEaVATImp FRoM ORIGINAL 6KAoE WILL BE ~1s> s Pull um ®Er" OF CACAVATION MOM r~IGIWAL, raRAPE WILL BE = 0 S SIGIJED: LICEMSE AJUMBER: DAT E: Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 ,.Labor and Human Relations Ditision of 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 I.D. # dimensioned, north arrow, and location and distance to nearest road. 0q0 L Lf3 `L O _ O U q APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Q U 1''r L L V3V t L:T ~l IES GOVT. LOT f VL-J 114 NkJ1/4,S 3 b T Zg .,N,R I I E (00 PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # . • RUU~tt •3 130 Y_ - 6q - 2tbGL P~C_R&s CITY, STATE ZIP CODE PHONE NUMBER QCITY []VILLAGE (MOWN NEAREST ROAD (Ztlr~R_ LS W1 SgoZ-Z (71S) uZ - 2-1 "RtA I.uDOpRtDGt DR•w, New ConsWdon Use (>q Residential / Number of bedrooms [ ] Addikn to existing building [ I Replacement [ I Public or commercial describe Code derived day flow y s O gpd Recommended design loading late o -q bed. gpdM1 a• S tench, gpolft2 Absar Wn area required k1Z S bed, ft2 °tcx3 tench, ft2 -Mabtrtum design Wntg rate o- ~t bed, gpd/ft2 S trends, gpolft2 Resonltawded ktfiltration surface elevation(s) - ft (as referred to site plant bendan* Addtional design/ site considerations Se:E "G`t tJ CAE a of S Parent material eov1- ft 'l N Flood plain elevation, if applicable ~i • A • ft S = sultable for system CWM iIONAL MOM RGROlM PRESS M AT•GWE SYSTBd N ILL HOLDING TANK U =Unsutable for system US ❑ U 0S o u as o u [as o u O S IZ U 0S O U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Texture Structure Boury Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Corlsislisirloo Bed larch O-1Z 1041L z-1*?- s l 1 7- I ~"i'Fh cS - - o. o- b lz_zo 1O`-LQ31Z S1 1 2'FSbt2 m-q-,, cs 0-S Ground 3 22-3`1 10 (2 316 - S 11 Z ~ S bk Wt o. S o • (e elev. 012. 1 ft (f 3-81 16,- (Z 3/6 - S 1 \ c s h k Yt1 U'Ft- Depth to limiting factor Y >8f Remarks: Boring # b-lZ ~O`-t~ZLZ _ st 1 Z`fSb1t VYLiv. eS _ b.S o.L Z Z 1i-33 -f it- 316 s'1 1 Z-~s~k YocF aS - o.S ' o. 3 33-'4 1610 Lf 2 316 - S N 1 es bra )VV U fie- cS _ o• LI: o. S Ground Cl elev. It. u6 BZ t by fa__ V/y o s9 wt - o• S 0.6 Dtptt to limiting factor SZN Remarks: CST Name:-Please Print Phone: Arthur L. We erer 715-425-0165 Vg rer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 540.22 Signature: ,y Date: CST Number: G~ 93-111 6-1S-93 M00576 PROPERTYOWNER QUtn.1`1~-t By~~T SOIL DESCRIPTION REPORT Page -?3 1 PARCEL I.D.# o~1~ -11 9 - 9O -()()q Depth Dominant Color Mottles Texture Structure Roots GPD/ft Boring # Horizon in. Munsell C lu. Sz. Cont. Color Gr. Sz. Sh. Consistence Boundary Bed Th & 3.. 1 0-11 ~o~-ct~ zlZ - s ' 1 Z S bh m ~v. ~s _ o. S ab Z t1-3t3 b Y 2 3! L - S i Zs ek ~h s - o- S 0.6 Ground 3 38'At? LQO-M 316 S 1 0-5 t YA U0-S O-~( o.S elev. 110.3 ft. LJ wd-~'B 1 b t R Y ! '~S O S Y9 - O• S 0. Depth to limiting 3,, factor Remarks: Boring # ' I b_1\ \XS Z Z.CZ - st 1 z`~s' 1K cs o. t~1-m 3!6 s~ 1 z`Fsdk ~h ~s - L 3 40-Sy LO'-ttZ 3lle - s l e.sbk 1» v `Fh - 0 4 o. s Ground to~tIZ 31L s d " `~~k U`~ _ o•`f!o S elev. Sq-8y 01Z 1"L ft. j Depth to limiting factor Sy" I Remarks: Boring # - ~ o-tz z-CZ - Sj 21-3~LC w~ iF- 0 . b 5 Z ~Z -38 1 O'-t R-- 3!6 - S l ~ Z'F3 b?r vh ~H cs _ O's 10.L 3 3~-sy 1 ~t rZ 3!6 S cS b t ►x U CS Ground elev. y O Lit yl - `F$ o sg m \ - o S a. b °t I • ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PLOT PLAN Page 3 of 3 SCALE 1"= 3 O' lti ocs-z) R- I P G E` -c~ T?-' I U G- W e Z-r 9q 8+_„j" - ~L. I00.0 Obi YOP OF hJC P L 6►tii - eL 48. it dv 1oP of zr=cZ-R tC Box 0 - 1}PP1to X. g h-o.1e n F t~R.e ap SlO 'l~'p~+S t of 91ouv 6 25ntra, 1 LL om Z BY ZB•1 eL9L- suit 131- flv-15A uT'Es ' I Fo(Z. L1U 1'i"! wtsLl -M 0E kT LftiT 1~ ~ t~lT 1~►R SOS PCtp~ S`iS~M H-iL.~q 8•S X914 S~tS1~~-tS, S 5I XL 9%3 S I Z eZ. 90 14 S' tso~: Tp : _~iut~ P 'sC _ _pt i _ l4i' x 6 3` BAD - otZ l `a 0 FAT OF S ' ku t D.F `nR-E v ct+A2;s =~rc~ A~-T, w~`C1ttN 1~tL Su ~T~4 Ct ~Y2-~R s tf-O w~ ..-T~t~ @~, OR TQ.t~vcbF~S, C}[~ ~ 8F Zv"To _.36" R~-`TZ1'~~ l~C1wN S LU P~ I~DG F ,__t~ S~'~t,L~ ~v ~C,`T~Z ~t t~ ~ --S Y.$ Tit ~Z E-l~l? ~ ~ ~~t?1tiG C4tiJ S'TR-U c77 0 ►v , ~J3-11q 6-:15-9 3 (715 4 .5-nj 6s I: Q 576 CST Signature Date Signed Telephone No. CST # SEPTIC TANK HAIIITEEU 11CE' St. Croix, C:)U31c•.r LOCATIO14: /V w 1/4, ~4 ► SEC. ~o T 2911-R__LLw , OWN OF: W1, C-O; h COC:'TkY _"U13DI`t'. LION: f`~,~ ry f C It0'r N0. - - - Improper usc., and maintenance of your septic system could result zrj its premature failure to handle wastes. Proper maintenance >nsists of pumping out the septic tank every three years or _.aoner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of 'L111a septic ta'nk 1'.Z :A treatment stage in the waste disposal 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. ?Lumber, 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 ml:st be completed and returned to the st. Croix County Zoning Officer within 30 dLyz: of the thre ;'ear expiration date. ~ SIONED:~ v" v ' DATE: 777 v :'t. Croix County Zoning Office 4th St. - n, WI 54016 p STC -loo This application form is to be completed in full and si the o nDr (s) of the property being developed'. An geed by dequacie will only result in delays of the permit issuance y iSho Should this development be intended for resale by owner/contract rd this Douse), then a second form should be retained and completed spec when the property is sold and submitted to this office with the appropriate-deed-recording. r p owner of property L Location of property i /4 /4, section►N-R W Township Hailing address ~ 3 8f-- Address of site LD--f- WO-0P LP-0 6 DP- Subdivision name Cn. 1211NIC G S Lot no. Other homes on property? es Y o Previous owner of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? es No Is thin property being developed for (spec house)? Yes No Volume and Page Number ~ as recorded.with the Re iste o Deeds f . q r - 114CLUDE WITH THIS APPLICATION THE FOLLOWING: A I91 RRMITY DEED which includes a DOCUMENT NUIWER VOL NUMBER & THE SEAL OF THE I EGISTLR of , U}iE AND PAGa certified survey, if available*, ;would be helpful I o asd toi av a delays of the reviewing process. oid references to a certified Survey Map, If shall also be required. c rtified Survey Map PROPK TY OWNER CERTIFICATION 1 I(wc) certify that all statements on this form are true to the best .of ny (our) knowledge that I (we) am (are) th owner( tl,e property described in this information form by e virtue virtue s) of of warranty deed recorded in the office of the Count Re Decdr _ r a as Document No. ~ Y gist er of oo:n the proposed site fe sewaget di pslalt system oprreI en tly obtained an easement, to run the above described property, We) e) the construction of said system, and the same has bee ' for recorded in the office of county Register of deeds as Document signature of ap 1 cant Co-appl cant l Date of Signature Date of s gnature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 507851 vuL 1044PAGE 69 REGISTER'S OFFICE ST. CROIX CO., WI Rolling,, Hills Development, In,-,*, Reed for Record a Wisconsin corporation t,GT26 1993 m 10:45 A. M conveys and warrants to Eugene 0. Larson Don D. Kruger, and Lawrence M Johnson, Jr., d b a Quality ~K Built Homes RETURN TO i I the following described real estate in St. Croix -County, ( State of Wisconsin: Tax Parcel No: Lots Sixty Two (62) and Sixty Four (64), Oak Ridge Acres to the Town of 'Tr'oy. The above-described property shall be used only for owner-occupied residential purposes. A r This is not homestead property. (is) (is not) Exception to Warranties: easements, restrictions, and rights-of-way of record. Dated this ADS' day of October 93 R 0 L ING H L D EL , NC. (SEAL) (SEAL) • Richard N. Fox,, President (SEAL) 11 z -G e~ ` ZD (SEAL) • Frances J. Fox, Secretary AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. Pi Prr`_P County. authenticated this day of 19 Personally came before me thi day of October ,19 9 the above named Richard N. Fox and Frances J. Fox TITLE: MEMBER STATE BAR OF WISCONSIN me nown to be the persons who ex uted the (If not, to authorized by § 706.06, Wis. Stalls.) i instrument a ackn wi ge the sam THIS INSTRUMENT WAS DRAFTED BY !~w`!.•' C. L. Gaylord, Attorney 'TARY'~- Oaren M. Engel River Falls WI 54022 tir ublic Pierce County, Wis. (Signatures may be authenticated or acknowledged, 'Bot ~vty, Gt'ommission is permanent. (If not, state expiration are not necessary.) June 29 19 97 Names of persons signing in any capacity should be typed or printed below their signatures. SB2 NTF 0021 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208 Form No. 2 - 1982