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HomeMy WebLinkAbout040-1146-50-000 a o ~ ° I p °f» h C C eri a O I o N Lt -m ~ II / J ti C ax C Er N y 2,6 O r m 0 d '0Op O O O Z CO = c w N C O- N LL O = C y N U O 3 •o Q am 3 N I z 3 w E ° z = O z a co M O O Z c i a0i Z c o co Hr z v d M` a' (D 5 2 7 a ~ I d a t c • ~ o 0 0 zomz N z I N ~ d ~ I ~~yy ° L d c'o ~i ca a a c L.: 0 a CL 4) d U) E c I ~ rn rn ~ I 000 z •N oCL IL CL v, IL Iv ~ J V III ~ ~ I ~l Mi O I _ O O N 1[,~ O O E p ' 0) N m N C a m ! co V 41 Q (n m v 7 C ° N H C O U O d on _ m c vi va$rn cc u'° 3 y E m co N m M i- Z L aGi+ a fD r. 00 O d N H c d k d C cl € `oz Z n c c m rw r A ciao !,Ovid W4KonsinDepartment of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations f Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but S T G lx 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. /a`1-60IJU APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R IEWEDBY DATE PROPERTY OWNER: ~Q.LSO tiJ C.uD D $ CV t7 p PROPERTY LOCATION C ~o S'CC-u EtJ CQ Z) t> T Z 1/4 1/4,S 13 T V6 .,N,R 2/J E (o(W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # \\ZO ~~1~~ lZ~p~L A2L~~' 6 I-AZOposes-') V'1-PVT OF S &IS*AhW CITY, STATE ZIP CODE PHONE NUMBER ❑CI ❑VILLAGE ®fOWN NEAREST ROAD CZ~v 12 ~ r,J S~foZ2 (7!S) ~[iS- Z-15`l 11`zo`f lef`s-r coins "PC New Construction Use [)(J Residential / Number of bedrooms U [ ] Additign to existing. building j J Replacement [ ] Public or commercial describe Code derived daily flow 6 6 0 gpd Recommended design loading rate o • Sbed, gpolft2 0• trench, gpd/ft2 Absorption area required )-W 0 bed, ft2 1 eO 13• trench, 112 Maximum design loading rate o • S bed, gpd$ 0• L trench, gpdtft2 Recommended infiltration surface elevation(s) S iM PAC>E 3 of 3 ft (as referred to site plan benchmark) Additional design / site considerations loo s~D 'tC1F~ S >SVVZJ~ li~C o►~I~E~+D~` D Parent material s tQ" Sfttv49ruT- o u ffA s fiK3o 4 C -94VEq- Flood plain elevation, if applicable N . Q . ft S= Suitable for CONVeMONAL IN4GROUND system SMM IN FILL HOLDING TAW Mlbrsystem ® ❑ U ® MOUND ❑ U U PRESSURE S AT-GRADE11U ® ❑ U ❑ S®U SOIL DESCRIPTION REPORT Borng# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Coat Color Gr. Sz. Sh. B~ montch rio-JI'l o-\) 1t_ 2-15 b M A-S S e•to Z 11-27- 10--tlZ 316 _ L 2 5 bk *I FI- A b• s o• (o Ground 3 Z2 Z9 10 Y 12. 31b S 1 C 51b1 t M U •Fl. C S 0.q 5 elev. $ye.3 ft. Z9-us _).S_jZ y/G ~S o sg ~ ~ e S Depth to 5 qs 8 6 f o Y tz y - S b s g Yh o, n, 8 limiting , factor 96' Remarks: Boring # d-I1 1~ ~r2 Z12 - L Z~S ~I'C h1il,' a-S d. s l o. L 2. 13-1y 1D1i2 M. L Z`FSbk yn1-S a•So.6 a Iz 3 - s I \ c -'s ek H 1,'& c s o, q Q. S Ground elev z7 3 S e S o• o- b gyb, 6 fL Depth to S 3S-g9 !O Y R ~r, ] O S vn o•~ o. f~ limiting faZ,t ' J Remarks: N~' i= T Name.-- Tease Print Phone: Arthur L. We erer 715-425-0165 Vemg%rer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Sgnature: Date: CST Number: X13-03 -b !~I $-93 M00576 PROPERTY OWNER NA{2CZI>00, CoDD 4 CA.)D SOIL DESCRIPTION REPORT Page Z of • PARCEL LID.* Depth Dominant Color Mottles Structure Roots GPD/ft Boring # Horizon in. Munsell Du. Sz. Cont Color Texture G Consistence Boundary Gr. Sz. Sh. B FrL ~g o .S 3 ~ O-1 S 1O`-t z(Z L Z~S b l`, d1s o•s Z 1S-ZO o•!o lo`1.1z 316. Z `~Sbk 'Fh Ground 3 Z0 =Z9 I O`?Q J6 S 1 1 C-Sbk lm uiF ' C-S 0. v 0, S elev. Is C- 3 o_ S o- 6 8y elev. ft. Y Zg- L4 5 -).S v z Y/( 1 g`~S D Wt' S `Fs 4 S vn) cS a S o. L. Depth to 5 y.5_65 I o 2 yJ limiting factor 6S-91 W-1 \,L y/ o 7 °111 Remarks: Boring # L 0-t2 lo-t V- Z-1 -z- - L Z Sb~t a, s ©-S 1(3. Sbk ~ L :U111 0-s low Yn U 16. S GS o •~f Ground ' elev. Z~-yZ -7_Sy2 W(. )S *-s o g~j rn~ es o.g ip.L W-o ft. 5 y2-Lz soy t-. Orly S ~'~S s9 I cs o, s 0.6 it to limiting b 62.q I 1l~ f2 Y! - S Q S yv► ( 0.7 o-$ factor ~ a► 0 Remarks: Boring # t zl L z.`F Sb~'c t~ ~ti•- a. S o.s` o• L 4 S Z 13-Z3 l0`tR 3!` L ZiSbh r,'ft- S o. S o. 3 z 3 -28 113 `112 X 16 S) C s b1T m V `F►- C S r..' Ground e o• , o • 6 o Sg S. elev. Z$_So ~.S ` /a y/(o ~S ei S $yo. b ft. S so- b- ! 0`-1.2 Y1V S a `FS O S. I C S o• S ? ti: L Depth to S O s g o, o limiting L0-9,o factor l 0 `1 2 y /y , 14 Remarks: Boring # i ~ f I Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) . w PLOT PLAN Page 3 of 3 SCALE 1"= So ' L-ul` b Z- 3 kC Lo CA-rL -W, S K ET CST G , ®o 0 b 4 0 0 0 0 COYM- ljvv f~T L*-tv3r j S f r-=RUM j,..I p •11u Fi eLbS . B o 1 ~ O t ^ 1 v~ S4 S mm.3 -M RT LZLftL. 831,.5 P C~ 1h Pt Y. 1 x t v wl y Z" o F- cpu L.s'jL ou ~t2 'TL } E ~ S X12.\ au ~1~iv p't 1a STS , d 9 , one 8y 1. ir" V-1 g _2 ~mo_ • a.t Sr r ,s'S' lAT 1.IA,W c ,i-~ sv ~`twc'aLC PrR~'A F'oR I `0l0 ! tF~1Ttt~l. t~N~ Rt.'~rltlurrTE 1 a's e- 810 6 S4 S T e" S. I I LL 8yl°- 8r1 - M. 8gZ.oS' oN 3/y"RF-8HR w/LP,'M q3-o3 _ ~ t. -~~-93 (715 ) 425-(1165 M00576 CST Signature Date Signed Telephone No. CST # VV=onsinDepartment ofIndustry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations - Division 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 T = G\i~ lX 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. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: Q..LSOhJ GuDD 9 Ct,t]p PROPERT`fLOCATION C to S~-U f=tJ Clip GOVT. LOT Z 1/4 1/4,S \3 T Z S .,N,R 10 E (0 PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # \\Z.O vz:kvwl~- \Z1pGL bVUUe 6 - mot-05m) ?I_a OF SRI,ISNEktJ CITY, STATE ZIP CODE PHONE NUMBER []CITY (]VILLAGE ®TOWN NEAREST ROAD U C12 Ll. 4'k .)l L1 O ZZ (7IS) Sf tS- Z.-1 S'1 rZO~ efts - Goth Fw R is New Construction Use bd Residential / Number of bedrooms y [ ) Addition to ehdsting. building j j Replacement [ ) Public or commercial describe Code derived dally flow 6 0 0 gpd Recommended design loading rate 13, S bed, gpd/ft2 0• L trench, gpd/ft2 Absorption area required )-M O bed, 1`12 1 U0 irj trench, ft2 Ma)amum design loading rate o , S bed, gpd/ft2 0• ~ trench, gpol(t2 Recommended infiltration surface elevation(s) S LB' PA GC 3 of 3 ft (as referred to site plan benchmark) Additional design /site considerations bt~s~D 'C'htFUC1ti~'S NRJ~ IZCCO►'lwrt O~-p . Parent material 51-' Sao % QT' o u _ - S Ahvp G v~ Flood plain elevation, d applicable N _ R . - - ft S = Suitable for System CONVENTIONAL MOUND pFGROl1ND PRESSURE AT~RADE SYSl61d. NV FILL FIOL7W. TANK U =Unsuitable for. ®S ❑ U 1 S O U [9s ❑ U [as ❑ U ®S O u: as ® u "SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consists Bouaxlary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Thydi 1 o-\> >o "t ~t zt L 115 b vn O-S o S o. Z I)-ZZ No`0-- 31L _ L Z f5 bit M F)- As 10 -S 0.(o Ground 3 ZZ Z9 10 R 31,6 - S { 1 C-S bk )n U C S 0.q 0• S elev. 841.3 ft. Z9-14 S -).Sys y/G - 1s o sg w~l e s o.~ ;o.g Depth to S qs_86 loYtz Y/y - S b Sg N o. so,a limiting Remarks: Boring # 0_13 to'ttz zdZ - 'L ~'FS bk fh'~f. ct-S o. S o. L Z 13 Zy 1 O 2 316 I- Z iS bk 1•n 3 zt!-Z7 10yR 3l - - SI C.S bk lmUCS c, o.5 Ground 10, elev. Z-)-35 >S`i R 30I3i trhs~ g.4o.6 fL s osg V"\1 Depth to S 3S-8q )O V R O S v+n) o-~ o.8 limiting r'U I col qy - fac Remarks: 7 1, CST Name:-PleasePrutt Arthur L. We erer Phm: 715-425-0165 g rer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: Date: CST Number: $-43 M00576 PROPERTY OWNER "hktALI-013, VDU of ca.JD E-0 SOIL DESCRIPTION REPORT Page of -.a PARCEL I,D. # Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color < Gr Viz: Sh: Bed Trench Z( S,e. 1~ H OvS O .S O. o• ~o .r S Z 0-S 1 S -Z.O l o `1 lZ 3 / 6 ,,.1.,, Z..`E-S 1~k 'F V~ Ground 3 Zt) z9 J otiQ 316 - s I 1 0- sb m UiF , cs a y o, S elev. ~•S`-112 y w6 s g`~S D S yq I C S o_ S o- 6 8y°,~ ft. Z9- 4 5 1ny2 y Sags p s r►, 1 CS o s' o.~ Depth to S y,S-85 / factor 6S-91 1oH \t Y/ Q S > 9l" Remarks: Boring # M.....::: L Z o-tZ 10~ 2 zl Z - `FSbht `Fti C k, S o.5 0-1. g O• l0 -11Z 316 _ Zn 'C SVk V" -f- 1.. o. L 3 zy-2~3 lO~tQ 3/ro ties;bk Yh U i e.S o,y v. S Ground c Ip. L elev.' Z~•yZ -7.SMR 4//fe ~S ~1-` D 55 Yh CS S , 8y1-o ft, 5 y2-L2 1o`i \t v!y , S ~E v S5 p S ` cS Depth-to limiting 62- I 113 4 (Y/ - S: Q S factor Remarks: Boring # 1 0- 3 o`-t Z 1 z L Z s bk a. S o. S I o. 5 Z 13 Z3 10`tR L Zisbk ` 3 z3-2g ICJ'yfz -t s I cs* m y `Ft- C S o•4 0•5 Ground elev. z$_513 -).S via y/6 }S d `(S 0 3-1 yn 1 e S o• S o• 6 %yo. b ft. Depth to 5 so-6- 1 0 'i V L//y S a'F$ O 5. e S o• S limiting 67 -90 10 %I 2 y /y S O s q ►r) 0, 7 1z factor ` ygo" _ I FT Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: S130-8330(R.o5/92) PLOT PLAN Page 3 of 3 LuT b SCALE 1"= 50 ' Z- 3 R-C Lo cATL o_ W__ S tic ET_C---- ®o 0 b Q O O O \ q 0 a p a ab. !}OV 9F 1D \3l~ RT LerhST 15, f---Fu m DQ1~-1N Fik~t.DS w`~L 4 G so' 8 o't'rol^1 ~ S 4 S'['>'M13 `SU ~ ~ ~T tzt.~ . 8 3 b . 5 Pt.l~C~ th'Ptx lxtvti"1 ~I Z" v ~ cpu l~ ou x'12 'R}E_ ~'\512\au<~~ ~11a~S . L-- 841. c l' one 3/Y ° R~ $RR wlt.tlT~t eL emz 6 0 3 Lsn 3 (:FL &O Sr ti UT 1.1N~ V r ~L Sli ~~TK>3L Pat--% FOR ~ •j t l ti ~T1 ~~L R L"i~"'iuurrTE S 0 8'5 C'L$`!06 Sy 31'~►-tS. t \ I I I i l r ~ 840 ~ t`t 811 = W1 - N2. 8'lz.oSoN 3Jy~RE-8~R w/~A'TN 01 -o3 _ 6 ~~.~t~ -?x-93 (715 ) 425-01165 M00576 CST Signature Date Signed Telephone No. CST # STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER h/ II /du, ADDRESS SUBDIVISION / CSM# LOT SECTION l'3 T9-P~ N-R 2 W, Town of 7f-b ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM d 14Ne _ Q Iz' 0 B r ~ot~e I ~ , I I I O~ -Aj SrCale /-~©,t ~~h. INDICATE NORTH ARROW b Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. f BENCHMARK: S e ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer ~ ~(JGZ-/S e r Liquid Capacity: /(~06 Setback from: Well } -a House 2 Other Pump: Ma ufacturer Model# Size Float sepera 'on Gallons cle: Alarm Location SOIL ABSORPTION SYSTEM r Width: Length Number of trenches Distance & Direction to nearest prop, line: p2 y~ Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt LOCATION: TROY 13.28.20.576A-4,SW,NE,NORTH COVE RD. Wiscoryi Department of Industry, PRIVATE SEWAGE SYSTEM County: ST. CROIX Labor and Human Relations INSPECTION REPORT • Sa`tty and Buildings Division (ATTACH TO PERMIT) Sanitary GENERAL INFORMATION X XAft$8 Ft's QMe: Village ❑ Town of: State Plan ID No.: CST BM Elev.: i Insp. BM Elev.: / BM Description: / Parcel Ta 70, Do~.s~ Gt° s Ld'✓ ~ A9300145 TANK INFORMATION ELEVATION DATA D(P 9 •'X AL. TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. i Septic Benchmark Dosing 9~ -Z- I- , & Aeration Bldg. Sewer d~ Holding St4ff inlet 7 ' 70/22 TANK SETBACK INFORMATION St/ bkf Outlet f!~ Q/ Vent TANK TO P/ L WELL BLDG. Aii to ntake ROAD Dt Inlet Ar I Septic NA Dt Bottom Dosing NA Header/,Man, p / Z 3 7 Aeration Dist. Pipe ~A (gyp, 1b Holding Bot. System o~S PUMP/ SIPHON INFORMATION Final Grade Man 1 Demand°~ a„ ~irUt 700?, 95. Model Number GPM TDH Lift Friction Syst TD mead Forcemain Length-- a. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches pl No. Of Pits Inside Dia. Li ui th DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING anufa er: SETBACK INFORMATION Type O j' p,_j ! ~ i CH AM Model Number: System: 3Z , J~ /fo 77 1174 T DISTRIBUTION SYSTEM Headed q Distribution Pipe(s) 7 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 S s Depth Over Depth Over „ xx Depth Of xx Seeded/ Sodded xx Mu c Bed/-Tjoneh-Center Bed./Tffli,4 dges 47~Z/-3c~). Topsoil ❑ Yes ❑ No ❑ Yes ❑ No L .T 1 ~QS .~gS :~Y tP, ; 15NOR111R) COVE RDA. Plan revision required? ❑ Yes 111'19o Use other side for additional informs/atioiln... SBD-6710 (R 05/91 ) ~ /i ( Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 01 SANITARY PERMIT APPLICATION {'y DILHR In accord with ILHR 83.05 Wis. Adm. Code COUNTY J! f , ~'(Q(~('x STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /9 8% X 11 inches in size. Check if revision to revious application -See reverse side for instructions for completing this application. STATE PL~4N I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. 1v PROPERTY OWNER PROPERTY LOCATION 4 A P4'r81r1,A- /N/g/e 'LUL~ SW % EVE'/a, S T 2-1?1 N, R l0 E (or) W PROPERTY OW ER'S MAILING ADDRESS LOT # BLOCK # 94?3 5-EiA qv..e . CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) 1:1 State Owned Z ❑ VILLAGE / Ro AOARESC011' led ❑ Public Z 1 or 2 Fam. Dwelling-# of bedrooms - R LT ,jc JMBER(S) [ III. BUILDING USE: (If building type is pubyc, check all that apply) v p .7 CJ 1 ❑ Apt/Condo S 2 ❑ Assembly Hall 644, 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. ~ 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 OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 LJ Seepage Bed 21 ❑ Mound 30 ❑ Specity Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill x 3 6 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./inch) T 9 2 S ELEVATION 30 yZ 1-132- 01 * 7 Feet 743' Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank BD 4; _ Lift Pump Tank/Si hon Chamber e- L VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: 7- Zllblf 1'e-6 3,3 o? ROA& lvR,4 -?"A Plupibber's Address treet, city, state, zip Code IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved SanitaryPermI Date o6 Surcharge Fee) 6-3 UApproved ❑ Owner Given Initial VVV 8 Adverse Determination, X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398 (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 (SBO 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 tota' gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank mater al. 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 13% 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) m fri 'In , ~ip Ilia \ f A rn j / . CO . ~ ^ m ~ a ado 5' h. ~ r 0& Cl , 28 r„ Z I O~ i h Z ~ Cl. :o rn I o I i w ~t z I 3 ITI f►t .v . o r ~ ~ o ~ n MCn ~ I ~ ~ . ~ - I to c 1 1 Iw W I N N ~ ~ZJ. ~ ~ w p O O ~ • i ' nlfq to ro P A 'C r v - o ~m O o x Q ~ aZ m w ~ V a to O tA r4 y d m rn ~o~~. ~ r~3 o J o o,° ~ N (A Ov ~Z Fresh Air Inlets And Observation Pipe ( Approved Vent Cap Minimum 12" Above Final Grade ow-_ lx:1~11'S1,1-4- y,Pw /03,0 4" Cost Iron 2y~r~.v 3C~ 0 Above Pipe Vent Plot 'io Final Grade • Marsh Hay Or Synthetic Covering • Min. 2" Aggregate Over Pipe Distribution s~ x-72-9 -Tee Pipe 0 )J-72- 0 0 0 • Lo " Aggregate o Perforated Pipe Below Beneath Plpe Coupling Terminating At o , 5 6r,6 ''1 2.~. Bottom Of System ~%9•2s ' Wbconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of 3 Labor And Human Relations Division of Safety & t3ljildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY y Attach complete site plan on paper not less than 8 1/2 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. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION . zej 2j GOVT. LOT -5W 1/4 N-5 1/4,S /3 T Z< N,R ~ 0 E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD 57- fluL ~N S-510 (&124(~,W- yy30 71-RO/V 10141 Coves 721 New Construction Use [n] Residential / Number of bedrooms Z [ ] Addition to existing buildin j ] Replacement [ ] Public or commercial describe Code derived daily flow. 300 gpd Recommended design loading rate ^ 7 bed, gpd/ft2 ^ L~' trench, gpd/ft2 Absorption area required 'VZf bed, ft2 3 ~✓`trench, ft2 Maximum design loading rate - 7 bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) Co 9 Z S It (as referred to site plan benchmark) l Additional design / site considerations Parent material $GS Q/ f EiH.y,IT S ; P~TrED avTi~~rsC, Flood plain elevation, if applicable 9oZ ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem S ❑U 2 ❑U WS ❑U EIS ❑U i9S ❑U ❑S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 0-S /O YAP 3/ Z - S O, Ground 22 -yd /O lei elev. 70/ &0 ft. y S, 16Y/e ,C~ S G~x d Depth to limiting > factor Remarks: Boring # 312- 2 f 2 y 2-1 10,VX y s C r>h cs Z f, 7 -ep Ground elev./Dltllle S S C S G~,Q 7 1^ 70~ L. ffft. Depth to limiting IS to it site A ROVED factor ,i tlc S S • ;for conve tiorW s 1 Y Remarks: CST Name:-Please Print HOKSITE SEPTIC PLUMBING CO. Phone: 71_~'_- 3 oo 655 O'NE-11 RD ' HUDSON WIS 5401A Address: ROBERT ULBRIGHT Signature: r 0 Date: CST Number: ^I. ~NaTALLER « DESIGNER LIC. NO. 00663 g' 2- `J Z Z ~l~Z PROPERTY OWNER SOIL DESCRIPTION REPORT Page?- ofw PARCEL I.D. # ' Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends - 2 O r Z f ny C$ ~f .7 . 2- .2 - 2S2 -7 Ground 3 /o y~ Sl~ - s' , S G~.2 cS , 7 elev. 70 Z' 9yft. (p " yp /O ~/,P _ .s • C S GQ . 7 Jf' Depth to limiting factor Remarks: Boring # 441, Ground... 5. 71 P 11 bo !v, ft. 7 o Depth to limiting f c r i~ Remarks: Boring # /O 141 71 -1 A 1A #91 Ground elev. l)-y2 /D YX s 1/1, I-V + e s 6 76Ly?- ft. i .71 ' 40 Depth to limiting factor „ ? Z2 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) p ~ 1 4 ,r_ !n N A Y I' ' o W r 7 m „ f C p ' ? uN Z trl { r I' J • Ul~~ ~ f r• ~ t tip pl _ _ _ - - - - ~ - 00 r- * CD ' ~ r4 ^ • ✓ O r ~ (fir; i~ 03 6 ~ ~i 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 pormit 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 WILLIAM J., SR. & PATRICIA A. MARZOLF Location of*property 1/4 1/4, Section T 28 N-R 20 W Township TROY Mailing address RT. 3, ST. CROIX COVE, HUDSON, WI 54016 S Me ~ 0"J RESIDENCE 1863 SELBY AVE., ST. PAUL, MN 55104 Address of site ,s -f Co, 6 rk I~.L Subdivision name NSA Lot no. NSA Other homes on property? yes ___X No Previous owner of property PRESENT OWNER - SINCE 1971 Total size of parcel 1.16 A Date parcel was created 1971 'Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? Yes X No Volume 479 and.Page Number 70 as recorded with the Register of Deeds. INCLUDE WITI4 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. 308034 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. 308034 Sign "e of a('_Oli t Co-applicant } JUNE 28, 1993 . JUNE 28,-1993 Date of Signature . Date of Signature S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER WILLIAM J., SR. & PATRICIA A. MARZOLF ADDRESS ROUTE 3, ST. CROIX COVE FIRE NUMBER NOT ASSIGNED YET CITY/STATE HUDSON, WISCONSIN ZIP 54016 PROPERTY LOCATION: _1/4,-1/4, SECTION 13 , T_2.8 N-R 20 W TOWN OF TROY , St. Croix'County, SUBDIVISION N/A , LOT NUMBER N A . 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, 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 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/Iae, 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 d . SIGNED: DATE: JU E 28, 199 St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 ! I co.. MiIN AL, CC WARRANTY DEED.-To Husband and Wife as Joint TeBnants RM 39 P9 (E Reylstd) 11 c N LL : 09 C "llf 1 is Indentures Made this ---.22nd ...........................day of.....S----.e -1?.t.--.e--.-..-.mbe.r in the year of our Lord, one thousand nine hundred and_ 5QV.e)nty:n.0ixe between. _ George Bernard•_.Mar•zol~,,,Sr-,--,_--and...aa~la...Ann_.MarzoLf.,....his...taif.e.,......... part..ieS..of the first part, and. ...-William J. Ma.rzolf. - and Patricia A.. Marzolf_,.-_.__..--.-•-_-,._ - - , . husband and wife, as joint tenants, parties of the second part. Witnesseth, That the said parties . ...of the first hart, for and in consideration of the sum of One Dollar ($1.00) and other _valuable consideration..---.- ._.q to --..them .-..ill hand paid by the said parties of the second part, the receipt whereof is hereby confessed and acknowledged, have. given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do_ give, 1grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of the second part, as joint tenants, the following described real estate, situated in the County of__ St. Croix and State of Wisconsin, to-wit; That part of Government Lots 1 and 2, Section 13, Township 28, Range 20, St. Croix County, Wisconsin, described as follows: Commencing at a point on the North line of said Government Lot 1, a distance of 743.0 feet West of the Northeast corner of said Government Lot 1; thence. South parallel with the East line of said Government Lot 1, a distance of 1230.0 feet; (said last described line having an assumed bearing of due South) thence due West, a distance of 340.0 feet; thence due South, a distance of 788.0 feet, (to a point to be known as point "A"); thence North 67 degrees 10 minutes West, a distance of 290.0 feet; thence North 53 degrees 40 minutes West, a distance of 400.0 feet, (to a point to be known as point "B"); thence North 70 degrees 10 minutes West, a distance of 177.0 feet; thence North 47 degrees 10 minutes West, a distance of 310.0 feet; thence North 12 degrees 40 minutes West, a distance of 23.50 feet to the actual point of beginning of the tract of land to be described; thence continuing North 12 degrees 40 minutes West a distance of 133.0 feet; thence West a distance of 380 feet, more or less, to the Easterly shore line of St. Croix Lake; thence Southerly along said Easterly shore line a distance of 135 feet, more or less, to a point in a line bearing West from the point of beginning; thence East, a distance of 370 feet, more or less, to the point of beginning. Containing 49,000 sq. ft., more or less. Together with and subject to a road easement for ingress and egress to said tract, over that part of said Government Lots 1 and 2, Section 13, Township 28, Range 20, described as follows: A 30.0 feet road easement lying West of and adjacent to the following described line: Beginning at the above described point "A"; thence due South a dis- tance of 621 feet, more or less, to the South line of said Government Lot 2, and there terminating. Also A 30.0 feet road easement being 15.0 feet on either side of the following described line: Beginning at the above described point "A"; thence North 67 degrees 10 minutes West, a distance of 290.0 feet; thence North 53 degrees 40 minutes West, a distance of 400.0 feet, (to the above described point "3"); thence North 70 degrees 10 minutes West, a distance of 177.0 feet; thence North 12 degrees 40 minutes West, a distance of 450 feet, and there terminating. FEE Together Ivitll all :Ind singtdai the hereditaments and appurtenances thereunto belonging or in all)- wise apper- taining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part ,.ies of the first part, either in lav or equity, either in possession or expectancy of, in and to the above bargained premises, and their heredita- ments and appurtenances. To have and to hold the said premises as above described, with the hereditaments and appurtenances, unto the said parties of the second part, as joint tenants. And the said George. Bernard MarzolfSr...,-_.and_Ella.. Ann. Marzolf, his wife, __.part ies of the first part, their for_.themselve.s-, executor; all'I administrators, do _covenallL, grant, bargain, and agree to and with the said parties of the s^cond part, and to and with the survivor of them, his or her heirs and assigns, that nt the tune of the ensealing and delivery of these (,resents they were t1-c11 seized of the prellike; ,shove described, as of a good, ;III*(,, perfect. ;Ili;olute and indefeasible estate of inheritance in the 1;lw, in fee ;.imlile, :uul tluit the same are free an( l cle;o. from ;kll iI) III( )r;inces vch;itever, and that the above bargained prcllikeri in the quiet and peaceable possession of the said parties of the second part, as joint tenants, his or her heirs anal assigns, again-~t ;dl anti every person ol• persons lawfully claiming the whole or any part thereof, - they will forever AVAItIZAV"I' AND DF,FF.N1). In Witness Whereof, the said pv t ies of the first part have hereunto sct their 11~111ds 111(1 seal .-S_this _22nd day of . September----. - A. D., 19 7-1 r f (;r..v.) Signed, Sealed and Delivered in Presence of _C ~f_"F~ ✓ /lam f'K r I f . / George Bernar -Marzolf,_Sr.._ Ella Ann Marzolf (sr MINNESOTA STA'rr OF '1$MRXRft - Ramsey -County. Personally came before me, this 22nd. - day of.._ S.eptemher.-.__...- _ - , A. D., 19 71 the above named George Bernard Marzolf, Sr. , and- Ella-.Ann. Maraolf.,_his...wife to me known to he the person S who csecwcd the foregoing in5trument and acknowledged the same. Q - _t_, - ;rotary 1)ublic,_ - C'ountY) Nly Commission oNpires.... 19 (Section 59.51 (1) of the Wisconsin Statutes provides that all Instruments to be recorded shall have plainly printed or typewritten thereon the names of the grantors, grantees, wltnew es and notary) l~ N 0 _0 U C, O q v I LLJ W l ~ Ni o r f ! LL.I U t1J 0 k. 0' Q ° a 0 In c C`J Q H 0 v `C A o W y O U Q C4 H 0,, 8 ro, wK 6 PAGE State of W1108m b County of St. Croix 1 hereby certify that this instrunAnt It a fullil true and correct copy of the document on NO and of record in my offico and has beets compared by me. Attest June 23 19 88 ,lamP~ (LS,on ell 1onNS O, t,,ortoell R*&W of Deed{ Deputy } H Z n w s O U ~ O w D O Z Q Q # O c H~ Z cu w v a < LU Q) 00 i cc -0 ~ Z °o ~ m O a w w w Z aM H O w o m` Q Z ° W J' Z o mm .0 iVC~T O to z m ~ U 3 H. a a a mOa Fw- a U > > > Lm CL 0 0 0 Z t w cn w Q w m h O D U U Z -J a w o a v cc E a w w a z a, o z m J w ~ w Q y y om m m m cc OC m 2 2'Q F- LU Z) Z) a. 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