Loading...
HomeMy WebLinkAbout042-1043-40-000 -0 C, a o h ~ o I W O C 0 I ) N w H a) L ~ I 0) 'LO Lu U) U TO d a) Co ZS N O_ c :.°o0c 0 d) d O U pE O N Q m U L C Z 3: m a LL c m°c~ o t mw 'O o0¢ °-C Q °myE M v y I 3 z " E Z " o v z y a) (D cD Z a m o z a m z ° '0 0) T a) m .5 1 ~L]^ (D _~V N n j a) N N = a) O o o O C U L is N G C O V U O O o ¢ N z~z oZa N z O " LO (D E N m m a) O 'oaa` -0t o N U) 7 V Z v a z 0 0 0 m m > a a a a CO) o } U) J L) M rn o C4 LO CO ITV r- O O) N p O o 0 O w, O N N N O p E 0 M -7 ~ . Q O ~ c2 CD 'C m y m m U) Q (n Q 06 N N ~l O m N C IV o E_ a r- (D CO co o o 4) O 0 0 M N 3 m a' a s C a W 0 V o 0 0 N N N c> 2 F- m S E E d rn rn rn M of N M N L L w 'p O 00 LO to N a0 a) a) F- F- C N m m O v, E E m L N O U) o z N ~2 U) `m m € a _Q 0 `1v a CL u d rrww L C C 3 _1 A tia2 0 U)u Parcel 042-1043-40-000 06/22/2005 04:53 PM PAGE 1 OF 1 Alt. Parcel 16.29.18.246G 042 - TOWN OF WARREN Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * SIEDSCHLAG, BRIAN E & SHERYL A BRIAN E & SHERYL A SIEDSCHLAG 1127 100TH AVE ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1127 100TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 6.420 Plat: N/A-NOT AVAILABLE SEC 16 T29N R18W 6.42 A IN N 1/2 NW1/4 Block/Condo Bldg: LOT 4 CSM VOL 1/216 ORD (5.54A IN NE NW) (.88A IN NW NW) Tract(s): (Sec-Twn-Rn9 40 1/4 160 1/4) 16-29N-18W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 962/411 07/23/1997 914/204 07/23/1997 521/410 2005 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/22/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.420 52,700 170,500 223,200 NO Totals for 2005: General Property 6.420 52,700 170,500 223,200 Woodland 0.000 0 Totals for 2004: General Property 6.420 52,700 170,500 223,200 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 552 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges 00 Total 0.00 0.00 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS r . f . SUBDIVISION / CSM9 LOT 9 SECTION - T N-R W, Town of ST_ CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM _i ~r J f i f { er y f i r ca ~r INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. I Provide 2 dimensions to center of septic tank manhole cover. IPP- I BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer Liquid Capacity: ter.,. ? , Setback from: Well House Other J17 Pump: Manufacturer Model# Size Float separation Gallons/cycle: Alarm Location :SOIL ABSORPTION SYSTEM Width: Length Number of trenches r Distance & Direction to nearest prop. line: Setback from: well: House_'`' Other r 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: J PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt LQtiy`t%'t'sTi@> a,tilT#JMWus4fi • 29.18.2 /ATE SEWAGE SYSTEM county: Labor annHuman Relations INSPECTION REPORT Safety and Buildings Division Sanitar rMit (ATTACH TO PERMIT) GENERAL INFORMATION 12 f%la Permit Holder's Name: ❑ City ❑ Village p Town of: State PI v.: nsp. Elev.: BM Description: X Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9300239 /n//9r TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. r ~ Septic Benchmark J Dosing Aeration Bldg. Sewer n Holding St/ W Inlet 6, C17 16d,V ! TANK SETBACK INFORMATION St / R( Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic --'j U NA Dt Bottom IAJV NA Header / Man. Dosing Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Ma u acture Demand 5tr S /O~ Model Number - GPM X ice/. S 7'13 77' TDH LiftFricti tFt Forcemain Length Dia. Dist. ell SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length / No. Of Trenches PIT Of its Inside Dia. Liquid Depth DIMENSIONS S 1 94 --2 DIMENSIONS LEACHING acturer. SETBACK SYSTEM TO P / L BLDG WELL LAKE / ST-H~ CHAMBER INFORMATION Type 0 s.~ k I,- M Num er: System: ✓ eMC~ OR UNIT DISTRIBUTION SYSTEM Header Imarri attt x Hole Size x Hole Spacing Vent To Air Intake Length Dia- 7 Length ~ Dia. Spacing / SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onl Depth Over r „ Depth Over xx Depth Of xx Seed odded xx Mulche fed /Trench Center 33 `36 sec/ Trench Edges 33 - %36 Tops&it Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION : WARREN 16~ 29.18.246E / 9-1f Z / • fG A - C Plan revision required - es ❑ No Use other side for addi n formation. C SBD-6710 (R 05/91) Date 4ctur's Signat re Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e ' l / (F -71 98,33' CL(G (ko2 7 ~9 7 31 - DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code g i I STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ~ y~~_~_~; 8% X 11 inches in size. Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN 1. D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION '/4 Id '/a, S T , N, R E (or) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE+ ZIP CODE PHONE NUMBER SUBDIVI ION NAME OR CSM NUMBER R -7 -119 . TYPE OF BUILDING: (Check one) NEAREST ROAD 11 E] State Owned E viLL GE : _ ❑ 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 Y:~L /eq 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPES F PERMIT: (Check only one in line A. Check line B if applicable) A) 1. L New 2.E] Replacement 3. ❑ Replacement of 4.0 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 El epage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit'' Pressure 430 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) N 9g ELEVATION 50 Liu 9$'~eet IoFeet -hat; A VII. TANK CAPACITY Prefab. Site Fiber- Exper. in allons Total # of Manufacturer's Name Con- Steel glass Plastic App INFORMATION New P-xisting Gallons Tanks Concrete structed Tanks Tanks Se tic Tank or Holdin Tank ✓ Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): j1r/1,0' Plumber's Signature: (No Stamps) Business Phone Number: A PI ber s dr ss (Street, City, tats, Zip Code): Aylij -;Z IX. CO NTY/DEPARTMENT USE ONLY Issuin A t Si nature (No S sT ❑ Disapproved Sanitary Permit Fee (Includes Groundwater late ssu 9 9 9 Surcharge Fee) oved El Owner Given Initial Xppr Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must•be properly maintained. The septic tank(s) must be pumped by a1icensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your focal 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. Ill. 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: SBD-6398 (R.11/88) SANITARY PERMIT APPLICATION ~ DILHR COUNTY In accord with ILHR 83.05, Wis. Adm. Code r Y STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than F 8% x 11 inches in size. L+~check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION '/a, S T , N, R E (or)' y11 PROPERTY O NER'S MAILING ADDRESS U LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER NEAREST ROAD II. TYPE OF,BUILDING: (Check one) El State Owned ViLTMiAGE ; E ]Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms =----PARCEL TAX NI III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE F 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 2 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: FINAL GRADE _ 1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. ELEVATION I` REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. y/sq. ft.) (Min./inch) Feet 21)o ?oo CAPACITY Site Fiber- Exper. VII. TANK ` in gallons Total # of Prefab. INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret structed Con- Steel glass Plastic App Tanks Tanks Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): ft Plumber's Signature: (No Stamps) P/MPRSW No.: Business Phone Number: 1 1 ~Nf' ~ ~ Fcku, 4 i > PI ber's dr ss (Street, City, State, Zip Code): A IX. COtIN TY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue issuing Ag t Signature (No S ps), Surcharge Fee) pproved El Owner Given Initial f 4 , / - Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber ' INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner'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. Ill. 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. SBD-6398 (R.11/88) 7 DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY Crnix STATE SAN PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER c PROPERTY LOCATION ,CL I'll 5; 5CX /a Al IV Y4 Ne%, S T;; , N, R 8 E (Or) 18 k PROPERTY OWNER'S MAILING ADDR SS LOT # BLOCK # ) CITY, S ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ StatQ Owned O VILLAGE : i . /e ~ D Q ❑ Public ❑ 1 or 2 Fam. Dwelling-#of bedrooms 3 PARCEL TAX NUMBER(5) Ill. BUILDING USE: (If building type is public, check all that apply) Q q 2 f) - 1 ❑ Apt/Condo 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE PERMIT: (Check only one in line A. Check line B if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 411 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 ❑ epage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit' Pressure 430 Vault Privy 140 System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6.' ISYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) [fQjk (?jr ,3-.7- ELEVATION X10 4100 L 4 s Feet c ~ vo Feet Vll. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank lew Lift Pump Tank/Si hon Chamber E] I Li F] a 1 1:1 Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): lumber's Signature: (No Stamps) MP7MPFIS_W N : Business Phone Number: s s- -33~Z Plumber's dress Street, City, State, Zip Code): _ 9 <7 s-~---7 IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued e Issuing Ag nt Signature (No m Approved F-1 Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A- asitary permit is valid for two (2) years. 2. foursa`nitary 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 multi 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 thanufacturer, D) cross section of the soil absorption system if required by the county; Ersdil test datde'Wr i :fe~m; and F) all sizing information.. , G"UNDWAMI 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. - t SBD-6398 (R.11/88) laN Si'~ c~ SCA /0l 1:2-n s- Mme ~r - IbOro S r "i i v a ar ~y Tye LI) j n5j . 3 L 40 -P Q - /D l , y f = loo, o~ 'KA Y N'o f s ~ DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE AN TARY PER IT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ / A f/3 8% x 11 inches in size. c ec f vi on to Obvious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP TY OWNER , PROPERTY LOCATION . 92 0h I IV -E S r,~°t s c~ L E' '/a '/a, S T , N, R E (or) W PROPERTY OWN MAI ING ADD ESS LOT # / BLOCK # Cl ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER S~~o~-3 Y S 9 II. TYPE Ollf BUILDIR~r G(Check one) ❑ State Owned ❑ )ALLLLAGE NEAREST ROAD ❑ Public 2 Fam. Dwelling-# of bedrooms PARCH TAX MB 111. BUILDING USE: (If building type is public, check all that apply) ~l 2 - 26*9 1 ❑ Apt/Condo 2 ❑ 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 50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE O"ERMIT: (Check only one in line A. Check line B if applicable) A) 1. L'TNew 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 E seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13F-]Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-ln-Fill VI. ABSORPTION SYSTEM INFORMATION: FINAL GRADE 1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. YSTEM L % M REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) g. ELfVAAO~Ii VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. Con- INFORMATION New ~Existing Gallons Tanks Manufacturer's Name oncrete strr cted Steel glass Plastic App. Tanks Tanks Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber oAP,-,t- Zy"Ar4;7 Bw Pr I El F-1 Fj VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print : Plumber' Signature: (No Stam s) MP PRSW No.: Business Phone Number: 111AC.-A ot A~4 J~~ WEI 7119 Plumber's Address (Street, Cl State, Zip Code): J IX. COUNTYIDEPARTMEN USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agen n r ❑ Approved ❑ Owner Given Initial Surcharge Fee) l3 Adverse Determination - X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SEND 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 81/2 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; Eric"on loss; pump pefti-mance 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 1981 Wisconsin Act 410 included the creation of surcharges (fees) for a numi er of regulated practices which can effect groundwater. i nir s collEwted through these surcharges are, used for monitoring groundwater, ~round- water contamination investigations and establishment of standards. SBD-6398 (R 11/88) -Vision or Safety K Buildings in accord with ILHR 83.05, Wis. Adm. Code .~/(%/t • P/lG 1114 P& S3 O 5P471Z'&// ST COUNTY D SifL~.v { 5 c.t.4 le- • 93 ?0 7 kak,`ch nomplete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but J r7- C/fD6% not limited to vertical and horizontal reference point (BM), direction and % of slope,*scale or PARCEL I.D. I dim,.~,,,jcrted, north row, and location and distance to nearest road. ow SiTE APPLICANT INFO ~iMATION-PLEASE PRINT ALL INFORMATION li~iFi~7l~a✓ REVIEWED BY DATE PROPERTY OWNER: 'gel tJ d Gf{Eti° y~ S~ ~ PROPERTY LOCATION _ l-f AM 4~ GOVT. LOT IPE 1/4 *1V 1/4,S /4 T 2-f : N,R /P E (o4D PnOPERTY OWNER%$ MAILING ADDRESS LOT Y BLOCK # SUBD. NAME OR USM 0 CITY, STATE 21P CODE PHONE NUMBER ❑CITY EIVII 1, MOWN NEA EST R AD oa~TS t!v/'- S;~o 2-3 l 715 ) 7y9--3YF w,9 •PE.v .I,LC- ( New Construction Use ll Residential / Number of bedrooms _ ( J Addition to existing building (J Replacement (J Public or commercial detcribe Code derived daily flow 7,50 gpd Recommended design loading rate Arbed, gpd4t2 - - bench, gptilft2 Absorption area requited _ bed, 112 7,00 trench, It2 Maximum design loading rate 1~bed, gpd/ft2 '6 trertF►t, 901112 Recommended infillra 'on surface elevations 'e P 6- . 3 p K (as referred to site plan benctunark) • Additional design / sitg considerations -~`E .oo7 E-s P,; 3 Parent material s -3- - 114E ,Rte /f - oar w.ts~ 0111i--f Flood plain elevation, it applicable_ / n S =Suitable for system coNVENTrONAL MOUN IQ S U D U ESSURE AT* 1 D❑ U S IN U =Unsuitable fors stem ®S ❑ U Qj S O U l~+ F_4 HOLDING TANK Os 9]u 8 r^ gi- 1`33 SOIL DESCRIPTION REPORT 3oring # Horizon Repth Dominant Color Mottles Structure GPD/ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence eourtclary Roots ::>Yr Bed dr 0-/Z /0 yie 3 3 Y y. S ii-3,S 7a ye- /l, S/ f C 9~ ~ti s Zf X • s round lev. 57L IL eplh to niGng Ictor o ,~r y D /'G-ti S s-~~ E-u f 140 lZe -Co ~P~ sre rivE-- s ,t4 s Remarks: /f ~~Lo t~ C '495 /~i1<rOS aF ~o!'~P G1f1 /-let / ~I S D xing -IV 10Ye 313 0 C5 2-f .00 7S/e ound _-/f O',Y•~'~iP ~-s f - t~ IV. 133 JP 41-5 10,~e Ci pth to s'Gc /oYz c f tg CL. O-9~ yX P3~~rJ~lo,-= ,>1 S Remarks: ~•s ~E-O S D.vzY per- iPES • W Tit'/ S y C7/oc~ ST Name:-Please print (dress: 8M O'NEIL RD., HUDSON, WIS. 54016 Phone: .MIS. MASTER PLUMBER LK;. N0.3307 M.P.R.S. gnalure: MINN. M. FALLER 6 DESIGNER LIC. NO.00663 Date: 7~~~_ 7rZ. t:STNumi~f/~Z page ,~P/,RCELI.Q.~I Lof y Bering epth Dominant Color Mottles Structure Consistence GPD/ft Horizon ° ~in. Munsell Qu. Sz. Cont. Color Texture gourday Roots /Q ,C° 3 Gr. Sz. Sh. Bed Try 13, 12 loy~e Ground 2 75 y/e s16 Depth to C1 limiting 1417 s X t facr /oyeo y~ J , fie cS x • S Remarks: Boring # 100 round elev. 3y S~ / o ~►/R S~ c, 2 . at'_ Depth to limiting factor Remarks: 5~'TE SyrT,/,Q/`c- o,oZ /721,e hd:r uy SF_.fSo-~~//y war 97-Boring ~z~n~>~>, _ n~•► f,~ S . ~ 1, S Ground C "As Z!2-9 3 - - /S - 7 - ~ elev. - i Depth to I limiting t factor Remarks: Sf7-1,1"7,6;V ' j Boring I - Y? :i <z:w t# 0 /(0 ~o yle y13 /s 0 - ")ki t 3vF Ground i I ~,~r S6K Fe CS of , s ele%~i It G • y /o f n'^ Depth to ' ire r s 12 U f- limiting l cloi - Flom arks: -5",7- 6- serr-Na:►orN.os~s2r - /l'1uN,V6I W,- f Z f>i~i (lElt/~ y L I,. T,f'E.vG~ 97, s~ . sysrE~, ~f,~~~ T.FE-uC~ ~ our S/ , Gum s T `OT L . 3 ! 13 13.9' i8 f7`oUS~ tiI 0 s7' GiE z it T 7"EST ~L~ !i'Tro~v 5 B'`'• ~ 1 gz powER PO/E ~ _ _ r37 F 133 /oo,3G I ~ /NL~ /'~il-TEO 13 3 I ti1UST ~E oiU~,PT~v iN str~r~v 13 3.16 I 4 a5 - ~v ~ SE E ti oTE r3 Edo w) IlArt 16 5ul7-4-131,E- V.uG,V ~ ,coR r`Jo U.cw iP~G .¢CEi~fE.v 7•-- \ tii o vuU S ys~c-~-, v7 ri'dv woo. /mot 1~ 70 5'e4l.4- S44--d j Y ~ ' 10L )er 70 /oowE;2 ~jp/E- ; /370 0 7-10,0 HOMESITE SEPTIC PLUMBING CO. 865 O'NEIL RD.. HUDSON, WIS. 54016 ROBERT ULBRIGHT CST 71 2 5/,P. ,'116. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. MINN. INSTALLER & DESIGNER LIC. 140.00663 ~'v.usu~T ST cpoi'X cpvvey 3 of 3 PS S N~ ~t-ss~ y;v~.pfE~'~- •¢i°r.Po~~~ s t r WaterPro Supplies Corporation „ 15801 W. 78th Street Waterfto Eden Prairie MN 55344-1894 VF Telephone: 612-9377-9666 WATS:800-752-8112 Fax: 612-937-8065 PROJECT f' 1 R Ai /F d 5' c /E< / - DATE t- /vohrk /0 ~7o 4, 4~-tY ;7-3 ID IC AA ~OD Cgb 96 7'3 4 t ~ qq' W9,,3/ Y/y Ib 9 f50 fyo y~ ~ `T~. 3 6 l3o f 1~~ /00 $ qq,y ~ _ o , 7 7 0 99.3 t° b t- 30 ©s ~ 1°I ~5~" ID 00 a o 98• q 0'/0' ;Z0.'36rY0 !O160/ I prof ~oo P°"h f~ Y is e f ~ ~ 7 ~~hc 00 0 !3 t$ o P~°~°ms~ ~~'~d yea 8-3 /00, C) 0, ~ ~ F,. 00 WaterPro Supplies Corporation 15801 W. 78th Street Eden Prairie, MN 55344-1894 4 Telephone: 612-937-9666 WaterPro WATS: 800-752-8112 Fax: 612-937-8065 PROJECT DATE x' PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS • 3~ r VENT CAP C. 1. V E fill PIPE WEATHER PROOF APPROVED LOCKING " { JUNCTIOAI BOX FRO M DOOR MANHOLE COVER ;JDUW OR FRESH 12 MIU. AOR I►JTAKE GRADE . ~ I ° MIA1. 'i A IB"MIAI. t 'F COQDUIT L"- ~i 4 ' fIULET PROVIDE I AIRTIGHT SEAL I` I i I V I I O PROVED JOINT A I i I APPROVED JOIMTS ~±r:2. PlPE I I I W/C.I. PIPE WENDING 3' I II EXTEWDIAlG 3' O SOLID SOIL $ ;2L S-` I I I ALARM ONTO SOLID SOIL I I 3~,~1 y Q, I, I ON PUMP OFF D CONCRETE BLOCK i RISER EXIT PERMITTED 0IJL9 IF TANK MANUFACTURER HAS SUCH APPROVAL 15PEC.IFICATI0uS EPTa1G. AND °r7A, MKS MANUFACTURER:~9 " IJUMBER OF DOSES: 3 PER DAy TANK :;IZE : o oo GALL01J5 DOSE VOLUME: GALL"OI~~~IS . LARM MANUFACTURER: 1E gl- Q y1r'L CAPACITIES' A- Z INCHES OR -13-L GALLOMS MODEL NUMBER: fl B=~.IMC14ES OR GALLONS. SWITCH TSPE: ~ C co- k r" ` ®Q C= 6- N INCHES OR ~9134 zGALLONS UMP MANUFACTURER: O~ 0= 9157 INCHES OR GALLONS' s. T MODEL NUMBER. 1-5 NOTE: PUMP AND ALARM ARE TO BE '{~•uhy rjct IIISTALLEI ON SEPARATE CIRCUITS a ,~f) SWITCH TYPE: _.~S.Pl o/ PUMP DISGHARVE. RATE GPM OW4 ERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE..-ZOly EET + MIAJIMUM NETWORK SUPPLY PRESSURE.. . , . . , . 2 5 FEET a.3 FEET OF FORCE MAIN X 2',Q5f/ppFTFRICTIOU FACTOR.. FEET = TOTAL DYNAMIC HEAD FAT IMTERIJAL. DIMERISION5 OF TA1JK: LE ;WIDTH / 2:pb;LIQUID DEPTH 2 7 ".,,DP 51GPIED LICEIUSE IJUMBER: DATE: STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER S- / FIRE NO. CITY/STATE f , ZIP -z PROPERTY LOCATION: /91/4 N U 1/4, Section T 'i 9 N, R l W? Town of tpnlLai±i-- , St. Croix County, Subdivision "&4v-- , Lot No. 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 $3000 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNE DATE S' St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address 1 r 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 B F ►~C-N C h hr S~ P s c ----Rug Location of propertyA~F-1/4 A/X/l/4, Section T JN-R / 9 W Township Mailing address es JC/ tea ~a N'L ~d ~h _57- Address of site Gt~- subdivision name Lot no. Other homes on property? yes No Previous owner of property Total size of parcel Date parcel-was created Are all corners and lot lines identifiable? -Yes No Is this property being developed for (spec house)? Yes ~No Volume and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. , 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. . I Signature of applicant' Co-applicant Date of Signature Date of Signature II THIS SPACE RESERVED FOR RECORDING DATA NSIN FQitM 2 1ill" STATE BAR OF R r WARRANn RO DEED %S officE I DocuMENT No. EGIS~E 832 f MZ PA~E411 Rjcd vot 486 • Recd 6 lew Nadeau pt1G0 61992 r= d L 10:40 A. M and She 1 A. d /S _ pQ_ Brian Siedschla conveys and war "ants to husband and wif a p~11M Siedschla RETURN To County. St. Croix Tax Parcel No: dpcribed real estate In the following State of Wisconsin: 29 North, Range 18 Wests f the MP 1/4 Of SeCticn 16• p 4 of Certified Survey art o N 1~2 Wisconsin cdescries aS fO~~* 331389. Pa. Croix County, ind 1, page 216, NO' 1101 f ne" p+ebrti Y 3o 19-76 is not homestead p(OWtY' This trictions of record. (is) OS not) covenants 3 res' ExcePtiontOWarrantiee: Easements, 92 day of / (SEAL) Dated this (S ) 1110911011 Z gEALt • SEAL) ACKNOWLEiQMENT AUTHENTICATION STATE OF WISCONSIN ~ sa• County ~ ~daY of Signature(s) fore me this ersonally came be 19 the above named 19--- G daY Of authenticated this-- who executed the WISCONSIN me known to be the per xson~ 7tTLE: MEMBER STATE BAR OF ing instrument and (If not W Sta 1~ ' authorized by §706 s v L HIS tNSTRUM VIC irau s public Went. lit hot. t AV mission is puma nowledg~ t~ (Sig may be authenticated or daRe: natures 9~ NtF 0°°' are not necessary) r3fesn eey. YN yuot-o~os toss >~~Nt~e Ts>x itxtna. F.Q flox 10?!!d' ~ a, Painted beta. ppgalM Win in any -px'I'Shaul d De tYt STATE eAR OF • Names of 96 'sons sift 9 r Nd 2 - 79a WAMIAPM OEED - tt, Department of Industry, L SOIL AND SITE EVALUATION REPORT Page of 3 abor and Human Relations Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code S ~I~I~ • G °/!GJ> *4Pe f fit! s3 0 To1v411 ST COUNTY S~I-Z Vq 5 c.9t~ f 93 919 7 ~T Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but t not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCE I.D. # dimensioned, north arrow, and location and distance to nearest road. &A; SiTF Q .2 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE m6r- Sorls - m, PROPERTY OWNER: PROPERTY LOCATION ,g..%,.}v Gf~~,2 f/~ S1'& pSe,-4 /C GOVT. LOT NE 1/4 tiGv 1/4,S Allc T 2-1` N,R lP E (o Wit PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # e ~ 7`~ s y cs~-, CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE VYOWN NEAREST ROAD r5 ~vi'• SVp 2- ( -715 ) 7yy jYe w,9 PE f1k ,¢v_~_ (j New Construction Use [-~j Residential/ Number of bedrooms 3 (J Addition to existing building j I Replacement ( I Public or commercial describe Code derived daily How gpd Recommended design loading rate bed, gpd/0- trench, gpd/ft2 Absorption area required bed, ft2 700 trench, ft2 Maximum design loading rate LEA' bed, gpd/ft2 -6 trench, gpd/ft2 Recommended infiltration surface elevation(s) S 4e- P6- . 3 ft (as referred to site plan benchmark) Additional design/ site considerations NOTES PS 3 Parent material ~'S 3y ' 10 B849D If - 4'1V7';j-r4s# Pl,i ,mss Flood plain elevation, if applicable / ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT•GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ® S ❑ U OS ❑ U ®S ❑ U QS ❑ U ❑ S 0 U ❑ S )k7 U /N 4e44- gi SOIL DESCRIPTION REPORT Boring # Horizon Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ~:>rA Bed Trench 313 s a, ,e,~ cs zf /6 kw f 9~e d4 e5 2f X S Ground C ?OP-/9)0 /D rile 5~~ f, s d `f, S c~ Q s I~ , elev. ft. Depth to limiting ~factor /OO a /Gti S S ~iLc-~ f Lr Remarks: ~'Za-rJ C `1f s /~~f~s of /oY•~' G// vim/ f uc S, , S fil Boring # 313 ~S l~P .r►~.e C S 2 f 2f Sh,< /rr41e C'S 2f X •5 Ground I ~p elev. ' 3 3~ ys ~yi~ ✓r~~( 5~ /~'ie °ry 7~iC S l~ ~.5 ft. "f~ c, 6_60 /01r4~ spy s , c, S s X , Depth to limiting L 0 - y /O y e q/ S~ L~) 25 Uf fact r _ - se-61VS o,~ CD T S Ti' 7-V-<1 G Remarks: Z%S T.PE-~~~r S dv~ y off` To R~~'~*ii~/~~' fr ~PES~ c7io.~ s CST Name.--Please Print 655 O'NEIL RD., HUDSON, MS. 54016 Phone: S Address: 4%. MASTER PLUMBER UC. NO. 3307 M.P.R.S. Signature: MINN. MWALLER &'DESIGNER LK,. NO. 00663 ~ Date: 7,?/_ ~Z CST Number- Si~OScl~G(r SOIL DESCRIPTION REPORT Page Z of PROPERTY OWNER 13, PARCEL I.D. 8 Lof Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench A... d -12- Hoye 313 : - s , c - - 2--F k • ~ :G••}} R V~e 12 Ground r/Al /0 elev. ft. /3 S/~ Depth to y,,e S/ S , S M'►~ S X limiting l0 d Jamie nC/e C S •~C • S factor a z 410 of 5 Remarks: '00f? C! Boring # 31 s f shk r V7"-/L s z , 7 r', E Lz Ye y 3 - is ! f s6K{,e s if . 7 l 1- 3 ~0 Y10e $ / • d Ground C 2 ~ elev. (/ay/2 S/ s'~/ 3 S4& . f2 - S , ft. Depth to ' limiting factor Remarks: '7467 SurT/ ovLYap hpvvy SF~fSo-v~/ ~T ~9T 3 Boring # 10,1,e 3/i , sb~ fe s Z f y s AVF& 16 Ground elev. ~Q ft. Depth to limiting factor i Remarks: i 7o.v G Glib 5 5.~7'yit?It T~ / T y~ Boring # -/(o /D yid' 4/3 ~S 0~`~~ n►^.Q. CS 2`F , 17 3VF ~...h 13, YR ,3 ~6 y y s/ S6K fk cs of s Ground - • elev. Rz 6 /o/~ o'~~f 5/ z he' y s y'3 • I ~ ft.. 1~- / • 5~ ~o Depth to -66 /00 , 5 S Of limiting factor Remarks: S, TE SBD-8330(8.05/92) s GUEST Gor G I B3 1 • 131 2 L. i f~DUS~ ~l UST G~~ 8y '4 7- G€4S7- ZS ' ,,f AlU.,rE i 14 tqr1v.'u -s \4 //0 0 powER PolE ' ~jt /37oPo b/-G l3 3 100,36 r _ I iNV i•o.tr~v ~ SvRi,9cE l,Rrliuh~-E'- f3 y X1.3 G way ' tilvsl- se- p1v4,P7--,> _ _ - -$6 f /F /~10Gwp Sy STt-M ` fJ 5! S ! N f~ /EV 3.rG jQ ~ ~S~'E tioTE ~✓E~ow~ o .By r-- ~i o tr-vD s ysr~~ t-14 U4 r/-d"' lei 44 ' ~'~►►tiv 93,70 S~aGE / yD /3/y = To o " 111"7- 7-0 0901-ve-k HOME-SITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRIGHT CS T Z! y , N IS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. WIN . 114231 ALLER & DESIGNER LIC. 110. 00663 i1/CI irG -MPo 1' 7-,4v7- c.~vrX Eouc~r y 57' 3 of=. .3