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HomeMy WebLinkAbout008-1024-90-100 Q o I I. ~ ° I a ~ Q 00 O o a o od 0 V O ~ l`• M ,p o E N Co _mO L M ;L v 0 W J 0 ~ ,III `S O Q C ^1 w0 0 Y _O t0 .Y C O 0 N w N ~ N 4= O N_ Z E °0 7 i co LL G w ,0 O N Q E Q Q N M z E z = 0 1 z y 0 a) z a m c O O z d fn P r C Z c -o a~ m m ` M I N a 0 N N N L 0 • O N O ~ L C 'C L O cm7 O Z F- z 0 Z N M m E N N N N LL N d O CL c Lo N d i O o C O o ° O G a 0 0 co N O E H H N _3 r.~ Z > z *a 000 d z0 m 0. CL a. EL c _ 3 3 O N "0 N N U) -j rn rn N U m } CD o o °o 00 E N O O F3 O _N .0 m M 'C 0 N N (D N d 16i O O 7 w V) N C) C N N C O E to O 0 U O O m 0 co O rn M O ° N~ E N U) co I a 0 0 0 0 \V, CV co N 0 O O C0i O N W O "L L ^ 0 CL ~ W E ~ E L CO ~I O N • 7+ O O W IIi d' r O Z yi= w it - r a; .a a L: CL E c _1 A 0 a ~ 0 in 00 • 11 AS BUILT SANITARY SYSTEM REPORT OWNER) TOWNSHIP #w NW C~ SECTION L T Z-kN-R-~Ltn ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT OT SIZE PLAN VIEW CSf ~M SHOW EVERYTHING WITHIN 100 FEEtTO F SYSTEM If I I ~ } A \D I ` • ~ v I I to B l f c _ J r f~9 r6°° s ~uK g~x . q~ D AD ~w.K r kN K h, N ~~y~ ~ t ~ e Z Soic B~a~~rz ooNe7 g_ S 9 z B y 6a L6 f TN 56 A e1q INDICATE NORTH ARROW -for 5-64" 4UE 370W ~r Q BENCHMARK: Elevation and description: L'T !!w~- ,lam € Alternate benchmark 4b le 6'~w A 6 E ~OU/-10. SEPTIC TANK: manufacturer: W1: C~ ' Liquid Cap. Rings used:LManhole cover elev: KT 4inal grade elev: Tank inlet elev.: 7, y Tank outlet elev.: 7, z No. of feet from nearest road:Front7 P ~~1 From nearest prop. line:FrontLO', Sid r No. of feet from: Well l Building: C AA A'6 6 (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: 1flf ee Liquid Capacity: Pump Model:_ Z s Pump/Siphon Manufact.: Pump Size Elevation of inlet: S Z /o Bottom of tank elevation , 7 Pump on elev.: Pump off elev.: Gallons/cycle: Z 0 Alarm: Man.: "T 10- PCL&K-T- C Switch Type: Location_lV'fiA'yI~r Distance from nearest prop. line: Front' J' Side, Rear_Ft. Distance from: Well Building_ ,6,49L,g-b~ SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: t3 ~ Width: -5--Length_2_3 Number of Lines: Z= Area Built 930 Exist. Grade Elev. 7L Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front~~ Side , RearLFt. No. feet from well:~j_No. feet from building_ ~a HOLDIN TANK Manufac ur Capacity: No. of gs used: Elevation of bottom tank: Elevati n of inlet: No. f t f m nearest prop. line:Front Side Rear Ft. No. f et fro Well , building nearest road Alarm Manufacturer: INSPECTOR: DATE : ~ PLUMBER ON JOB /t LICENSE NUMBER: 6/90:cj CRIQ ^,re~fZsa'►/ E1,LP14->10ic/5 d✓~R~ /tl lCl6~ r 50C 4e~ .,c42 6,94,e f tl~ W44- e4ecd7) (Z G57'Aj~ L/f/fEb D,Qji✓6 ~G~vA7"IfAa .4 Uu6 Z 7o2GL SoiL p 0~1N~ 5 l5 PL /--,I- &"`i 4(9f*C-vz ~~Fll~~'~a-✓ ~SrAr4L~sl~~o A CA I C; "170i'iifi2pi rtmEn£of~'uI#LE 9.28.16 PR,Vd►TE SEVIrAGE SYSTEM County: 1!, r and Human Relations INSPECTION REPORT Safety and,*. ildings Division ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 171491 Permit Holder's Name: ❑ City ❑ Village [I Town of: State Plan ID No.: UMPEL JAMES EAU GALLE CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 008-1024-90-000 TANK INFORMATION ELEVATION DATA A9200257 9 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 00 Benchmark 99 - 3S 1621, . ' Dosing GU 6 V Z_ 71, c~ 2 2G~ 3~~ Aeration Bldg. Sewer F Y71' Holding St/ Inlet 8 TANK SETBACK INFORMATION St /off Outlet x/ TANKTO P/L WELL Vent. AirIto ROAD Dt Inlet 5- 15iv Air Ito Z• 7, Septic >Sa NA Dt Bottom / S -,Y2' %L 72 Dosing NA Header/-Maw- Aeration NA Dist. Pipe G 3y, 93.33' Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 2' , Manufacturer Demand f 2.3 `~r' Model Number GPM Friction System rel. A~ TDH Lift Loss Head TDH Ft 5,37-' 33 Forcemain Length Dia. Dist. To Well 5 G y SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN IONS 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 ~t Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only u' Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/Tr nchCenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No _ COMMENTS: (Include code discrepancies, persons present, etc.) r , 3 .k, U /51 Plan revision required? Yes ❑ No Use other side for additional information. o OS 8,1 191 (R 05/91) Date Inspector's Signature Cert. No. l ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: II _ DILHR SANITARY PERMIT APPLICATION 4 e'&o 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 8% x 11 inches in size. W Check It a/io6 to pr "sous 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 0/4SLAA/4,S T ZJN,RE(o ' r✓i.6s &114W ` BLOCK # PROPERT n Vi MOWNER'S MAILIN`GADDRESS LOT # J_ I CI _ ST TA_ T, r_ f ZIPODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 1:1 TY VILLAGE : NEAREST ROAD 1111. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ ❑ Publlc 41-er 2 Fam. Dwelling-# of bedrooms PAR EL AX NUMBER( ) Ill. BUILDING USE: (If building type is public, check all that apply) f i q?011,00 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandiser 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.E1 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) Dll~k Sanitary Permit was previously issued. Permit# Date Issued 7- V-f'z 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 12XSeepage Trench 22 ❑ In-Ground 420 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.) (M' /h) 7 LE A V TION '57 1 V v 17 r 7L ~G- Feet 0 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. t Con- Steel glass Plastic App INFORMATION New istin Gallons Tanks Manufacturer's Name on we structed Tanks Tanks Septic Tank or Holding Tank fZ S Lift Pump Tank/Si hon Chamber .7"l '73Z TH_ I F1 [_1 El 1 1-1 El Vlll. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's N40 (Print): Plum s Signat tamps) MP/MEEl9w No.: Business Phone Number: Plumber's A dr (S reet, City, State, Zip Code): E,f a IX. C NTY/D AR ENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing em: Sig ure (No mp Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber . INSTRUCTIONS 1. A sanitary,permit is valid for two (2) years. 2. Your sanitarty 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 dne 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. r Complete plans and specifications not smaller than 8'f x 11 inches must be submitted to the county. The T 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 115Jorm; and F) all. sizing information. GROUN14ATER SURCHARCE 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) =:E . : SANITARY PERMIT APPLICATION ` COUNTY In accord with ILHR 83.05, Wis. Adm. CodeC STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than S` ` 8%x 11 inches in size. ch k if a isi to vious application -See reverse side for instructions for completing this application. STATEPtsANJ:D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION ryt 6-'~ 4- 1 " K R fY1 Al A.f%S L4A/a, S T 2 N, R E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # L C S F CI STA ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER [ V tai r,4-(Cf ivl 2 - 06 t- 3 PA-nl G 11. TYPE OF BUILDING: Check one CI NEAREST ROAD ( ) ❑ State Owned 0 VILLAGE : J ❑ Public 9444r 2 Fam. Dwellin Of bedrooms PARCELT AXNUMBSRO g III. BUILDING USE: (If building type is public, check all that apply) O 1 ❑ Apt/Condo 1 V 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 El Office/Factory 13. Qjher:rSpr 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 Aepair of an System System Tank Only Existing System Existing System B) DA Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) 4 Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 443 ❑ 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.) (Main./inch) ELEVATION 0 ! ~ Feet Feet VII. TANK C PACITY t Site in allons Total #0f Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank t t Lift Pump Tank/Si hon Chamber --~-F1 r-1 [j I El VIII RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's N (Print): Plumbs Signatu Stamps) MP/pai?9 p► No.: Business Phone Number: 17.] It A rmyl zol Plumber's dre ( e t, e, ip Code): 4 a IX. CO TYIDEPARWENT USE ONLY /15 ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued( Issuing Agent big ature (No mps) L Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination f X. CONDITIONS OF APPROVAL/REASONS FOR D1 APPROVA : i# 1 1 i SBD-8398 (formerly Plb-87) (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 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. . If. 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 stdndards. SBD-6398 (R.11/88) SANITARY PERMIT APPLICATION LI D1L- HR 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 t~ 8%x,11 inches in size. Ch k if a isl to vious 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 m r M C~ 1. S LtA/4, S T Z N, R/ 16 E (or -A I PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CI S A g f~~ t ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ~,`dl i{~l Q Z CITY ILLAGE : NEAREST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ V 54 w ❑ Public JK4or 2 Fam. Dwelling-# of bedrooms R LTAXNUMBERO Ill. BUILDING USE: (If building type is public, check all that apply) 01/ro O r-- 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 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13; El Other: Sppq IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) "NA A) 1.E1 New 2.E] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. El `i lepair of an System System Tank Only Existing System Existing System B) D~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 ❑ In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure rr' < 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 0 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) A ELEVATION lJ lK , Feet Feet Vtl. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App [Tanks Tanks structed Septic Tank or Holding Tank J ` f 14-J r17 F] Lift Pump Tank/Si hon Chamber 17:;: '57 111 LJ~E El F-1 0 1 El E1__ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's N (Print): Plumbe s Signatu ( Stamps) MP/MgW No.: Business Phone Number: n 1 X Plumber's Aiddrd'sif(Strd'et7OW, e, Zip Code): IX. CO NTY/D T USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue Issuing A®ent Signature (No Stamps) Approved ED] Owner Given Initial Surcharge Fee) ' Adverse Determination- X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: i Ni 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 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. SBD-6398 (R.11/88) S < I I ` `V[~~ PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VENT CAP 4"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING 25' FRCM DOOR, .JUNCTION BOX ~MAMHOLE COVER ~ WINDOW OR FRESH 12 M`"`~' I AIR INTAKE GRADE I ti" MIN. ` 18"MIN. CONDUIT t®"MIN. ~ \ ~ 11l f~ll_.F:T PROVIDE I I AIRTIGHT SEAL I I I J/ I III -7 APPROVED JOINT A I III APPROVED JOINTS W/C.I. PIPE. I III W/C.I. PIPE EXTENDIMC• 3' I II ALARM EXTEKIDIWG 3' ONTO S01.I0 SC1l. 8 I I ONTO SOLID SOIL I I I I ON C I PUMP ---f ~ 1~ ~~I OFF CONCRETE BLOCK RISER EXIT PERMITTED UNLy IF TANK MANUFACTURER HAS SUCH APPROVAL SPECIFICATIOUS SEPTIC AND DOSE TANKS MANUFACTURER: G' NUMBER OF DOSES: PER DAy TANK !,IZE : GGALLOAI DOSE VOLUME / ALARM MANUFACTURER: fC' CTS INCLUDING BACKFLOW: l z~ GALLONS MODEL KIUMBER: CAPACITIES: A= INCHES OR GALLON5 SWITCH TYPE: B = INCHES OR GA'_LOkJS PUMP MANUFACTURER: C = IAICHES OR GALLONS MODEL NUMBER: ~Z D= INCHES OR GALLONS 5WI7CH TYPE: NOTE: PUMP AND ALARM ARE TO BE PUMP DISCHAR4E RATE GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE Bt MLI PUMP OFF ARID DISTRIBUTION PIPE.. FEET + MINIMUM NETWORK SUPPLY PRESSURE , , . . . . . . . -~bP& FEET + FEET OF FORCE MAIN X FYoKFRICTIOM FACTOR.. ~ ' FEET TOTAL OtIMAMIC. HEAD = T~~ FEET INTERNAL DIMENSIOWrb OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH /O SIG E / N D:._., LICENSE NUMBER: DATE: / -11~- ~A-eyl ~s Nt >4e Y u r° c UPS pLo [ t-J C ~fi~ ~ Av I~oP (-vv Bz Trc I(P rs,~vA ~r ~~UC u/r4~ N 0 u fv IN VJ C- t-c Yc- r -s;4 CAI z Sc(j I` C-LrV RAIs~ r 1~ -~-1~ SOIL AND SITE EVALUATION REPORT QILHR in accord with ILHR 83.05. Wis. Adm. Code COUNTY r Attach complete site plan on paper not less titan 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 ONNER PROPERTY LOCATION GOVT. LOT /y 1/4 /Y 1/4,S T "Zg N.R I6 M(x) W PROZRZN S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # CITY, STA*EE ZIP CODE PHONE NUMBER CITY ❑VILLAGE WN NEAREST ROAD L 1,2 3, 3 New Construction Use ( J Residential I Number of bedrooms - j J Replacement ( J Public or commercial describe Code derived daily flowYG gpd Recommended design loading rate •1 bed, gpd/ft2_ _trench. gpd/ft? Absorption area required !7" bed, ft2 75 0 trench, ft2 Maximum design loading rate r _S' bed, gpo1tt2_,_,j~_trench, gpd/1`12 Recommended infiltration surface elevafion(s) 2-2,5- It (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable A64 It FU = Suitable for system 1 7 CONVENTIONAL MOUND INGROUNDPRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK = Unsuitable for s stem t1 S❑ U j4 S❑ U 9 S ❑ U I@ S❑ U ❑ S MU ❑ S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Fxt Structure Roots GPD/ft Consistence Bourtary in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trend f a ~-P Ground X#- 7~ 6-4 24U ILSiQ elev. ~y 2 h. Depth to limiting ~J'~j factorL~ P7 / r0J Remarks: Boring # 0-// 3s a, w 2M l.. '.i lot V [ f% lql~ A P/ M.. .2 4,411- M Ground elev. 12 Depth to - - limiting factor , Remarks: CST Name:-Please Print Phone: Address: r 3 wl © - Signature: Oale: CST Number: cC 2 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence B GPD/ft~ in. Munsell Oul. Sz. Cont. Color Gr. Sz. SI1. otrxfary Roots - Bed :Trend o>? 2'v K Ground elev. _ h. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring If Ground elev. - ft. Depth to limiting factor Remarks: Boring # { Ground elev. - tt. Depth to limiting 1 factor T- Remarks: f- 7T o y - a-A M p' - k-h-~ I ! - r-- _ .4, Al I t4 !I - I-T - 1~7 H- r----+- i i i I I I I,1 i J-J L t tj i i - -l - L- - ! - - - - - - - - - - - - ! - 1 L _ I I - r I I~ I ! ~ rr I f j ~ 1 _ I 7 - i I I ~ i ! l_ I I i - I I i - -i I - 1 - r - _ I F I I - --I r L I : IL ~i i I i i i I ~ I ~ I I I , I I I : SANITARY PERMIT APPLICATION 4DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY T # STATE SANITARY 1,4177 -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. c U f 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 ~ PROPF~iTY LOCATION d' 0% 1%, S T 2qN, R e!t E (or PROPEJqY OWNER'S MAILING ADDRESS LOT # BLOCK # l (16-4 F74-cc-5 CI STATE w ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMB R ~n o Z 0 2 f~3 El ITY ~ II. TYPE OF BUILDING: (Check one) ❑ State Owned O VILLAGE NEAREST ROA9 W =14 OF: ❑ Public 5pll1 or 2 Fam. Dwelling-# of bedrooms 'PARCEL TAXNUMBE O (a Z 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo ( l / v v 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 100 Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 90 Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. X 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 220 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 REQUI ED (s q. PROPOSED (sq. ft.) (Gals/da /sq. ft.) (Min./inch) J ~EVATION (J •.7 , ( Feet eet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks - oncret glass App. Tanks Tanks strutted Septic Tank or Holdin Tank IVPR~`^- 41 FE KT E& 1-7-- U Lift Pump Tank/Si hon Chamber Ej I [I El El D F-1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbe Name (Print) Plumber' ignatureX(N ) MP/MDA9WN0 Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issui ent Signature (No Stamps) Approved E] owner Given Initial Surcharge Fee) Adverse Determin tion / O .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 INSTRUCTIONS 1. + A-'sgnitary-permit is valid for two (2) years. 2. `Y6ur sannar§ 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 onsire sewage system, "contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurafe 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. 111. 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,cqunty; E) soij 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) i STC -loo This application form is to be completed i the octimer(s) of the n full and signed by will only result he delays of the permit issuance. Should this development be intended for resale b house), then a second form should be retainedrandric.mp eted(when the property is sold and submitted to this office with the appropriate deed recording Owner of property Location of property_4 V)1/4 1/4, Section TAN-R_L_~ W .Township I~ Hailing address Address of site Subdivision name 43 9 Lot no. ~ Other homes on property? yes~_No Previous owner of property L onr Q Pf c0 h 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 bnd Page Number as recorded. wi of Deeds. th the Register 114CLUDE WITH THIS APPLICATION THE FOLLOWING: - - A WARIWITY DEED which includes a DOCUMENT NURDER, VOLUME AND PAr.H NUMBER & THE. SEAL OF THE REGISTrR 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 state best of ments on this form are true to the y (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form by warranty deed recorded in the ffice of the Count virtue of a Deeds as Document No.- Y Register of own the proposed site for the4e-`, and that I (we) presently age disposal system or I (we) obthetaicnoned st an easement► to run the above des ruction cribed property, of said system, and the same has been duly recorded in the office of County Register of deeds as Document No. 2 Si ure of ap~llcant Co-appl cant 7 ! Dat Signature Date of s gnature ,DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 477832 VOL 930 rm,:E 1.47 _ REGISTER'S OFFI Carl A. Peterson and Leone K. Peterson, ST. CROIXCo,~W( Recd for Record as joint tenants, said Carl A. Peterson as known ---as---Carl-_A--_Pete-rso-- -Jr. Q~AN L 31992 8:30 A. :.Mt conveys and warrants to ..James-- -E-.-'.-_Rumpel.__and: Mary S /1~ ;PA V R.umpel-,._.husband and wife Re91slar of Deeds _ . - .the following described real estate in St.._._Cr0-1 X .....................County, _ State of Wisconsin: Tax Parcel No_ Part of Northwest Quarter (NA ) of Northwest Quarter (NW4) of Section Nine (9), Township Twenty-eight North (T28N), Range Sixteen West (R16W), described as follows: Lot One (1) of Certified Survey Map filed December 31, 1991, in Vol. "9", page 2439. Grantees agree that the pine windbreak will be maintained for a period of 30 years from date hereof; said windbreak, however, may be trimmed or thinned according to the advice of.the=local__fofester. This covenant shall run with the land. IPANS M' $17 FEN This 1S not homestead property. Xb[)x (is not) Exception to warranties: Easements and restrictions of record. Dated this ..................10.th---•--------------- day of J.an.uar_y 19.9.2... (SEAL)- (SEAL) _4 a Carl A. Peterson, • - -7 ......(SEAL) '~c...!..._ ..f.C........................ (SEAL) Leone K. Peterson AUTHENTICATION ACKNOWLEDGMENT Signature (a) STATE OF WISCONSIN St. Croix ss. ........•----.County. authenticated this day of 19 Personals came before me this ---jM day of January 19-9.2- the above named Carl A. Peterson, . Jr . and + Leone K. Peterson TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized b 6 by § 706.06, Wis. Stats.) to me known to be the person _5....___.. Wtto ex~eCatoa 4}1e'';. foregoing ' run nt a d a o ledg .~l~q sa~+ae. ' .°v THIS INSTRUMENT WAS DRAFTED BY O Thomas A. McCormack L e g o A. S t o n e • Baldwin, WI 54002 Notary Public t.•_.. C ro i x YC:: Aount9, W) (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If no sy kvztq-e-rpltat1on are not necessary.) date: ------Jul y y ..26----------- ----------------~=-.-~.,.,,1~'.9.~.--•) *Names of persons signing in any capacity should be typed or printed below their signatures. WAnRANTY DEED STATE DAR OF WISCONSIN 1114 nMain I.eRal Rinnlt C... lur. FORM tic). 2 1982 R! • „ t^?+ i SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER C~~1rj9~ 4 wo 10 4elrv S p, ADDRESS: ll FIRE NO: LOCATION 4 1/41 ~1/4, SEC.-T,o?fO N-R 1~6 W,_ TOWN OF: ooo, G n1~e ST. • CROIX COUNTY SUBDIVISION: )01. I Huck a q3 9 LOT NO.~ 9V 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 to help with the cost of the replacement of a failing system, which was in operation prior to July 1, 1978. St Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to the St. Croix County zoning a certification form, signed by the owner and by a master plumber, journeyman. plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating 'condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and 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 must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: 9 DATE: St. Croix County Zoning office 911 4th St. - Hudson, WI 54016 DEPnRTMENTOF REPORT ON SOIL BORINGS AN (FET ->ADIVISION LABOR AND PERCOLATV-)N TESTS (115) ~ P;O. SOX 09 HUMAN RELATIONS ••~'!S WI 5337707 0163.09(l) iv Chapter 145.045) C ~9 / ICS U)(A I I(1 CTION:- IOWNSI'lli 1MI=r41F iPAt-tT'r • 1.0T NO.: RLK., 1 SUB ISION, AMF~.~~• Ly 4 4 /T~20/11/6 W) W v 1** Ifn COUN 1 Y: OWNER'S799 fVnME: MAI IJG ADDRESS ' IY4 USE DATES OBSERVATIONS A0E NO.EIF.DF{MS.: COMMER(,I~ UFSCHIPIION: PROFILE ~f SGIiiFI IONS: F1=~7C'f10iSTES(S ~~F{esidence J wJ New Replace RATING: S■ Site suitable for system U= Site unsuitable for system COIJVFpJTT MOUND: 11IN-GROUND-PRE: SYSTEM-IN-FILI IIULDING TANK: N DED SYSEM:(optional) s u ©s o s u u~l=o s uIVECOMME =y_F==,~ If Percolation Tests are NOT required UESIGN f1ATEc If any portion of the tested area is in the under s.1-163.09(5)(b), indicate: , I Floodplain, indicate Floodplain elevation: _ PROFILE DESCRIPTIONS E3(1RING A DEPIfI TO GR UNDWATTER-IINCIIES CHAII 1CIE1{ OF SOIL WITH THICKNESS, COLOR, TEXTURE, ANDD DEPTH NUMBER DEPTH IN, ELEVATION --OBSERVED ESTJTIG11F, TO BEDROCK IF 013SERVED (SEE ADgRV, ON BACK.) 01/ ef 13- 9" I d 1l v 17 17 1) B 576 B- -7 V q 4-Z a. 0 , M :gip G s; tea rs Al ~d • S PERCOLATION TESTS IF`SI DEPTH WAI ER itt 1101_E TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER:iyJhLLING INTERVAL-MIN. i•Er,i-i~iii- _FE~+ii.u 1TIy PER INCH - Ato ---1 - _ ---i PLOT PLAN11,8how locatlons of percolation tests, soil borings and thn dimensions of suitable soil areas. Indicate scale or distances. Describe whet are the horn zontal and ve0jitmil.ralavation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and petcent of land 00041 IT4"4 y SYSTEM ELEVATION / I i 1-~-4_ r' i- lye,. i ~ u ~~.I •E-; , _ /r'q i I r I -_I . a 1' - rte , ;1 I~ IP ~ l . I Y ` l.~ y► l d e O >..1~ - 6 ~ I•- _iJ 1~ I, the undersigned, hereby certify that the soil tests reported on this fm m were matte by me in accord with the proc,,lures and methods specified in the Wi-mllin Administrative Code, and that the data recorded and the location of t}+gjt is are correct to the best of my knowledge and belief. r NAfu1E Iprint : TESTS WERE COMPI_FIED ON: AUT?HF-,SS: - CFRI1FICAI ION NUMRER: PRONF NUMRER(optimm!} CS I SIGMA I ORE: r DISTRIBUTION: Original and one corer rn i..ocal A~i~4~+ I 7S^ X 3 g ZS n' I \ '<n and ,`;aril Tester. DIIJUI-SOD-8395 (R.07-(87) / 33 +0 >;rr f2 p/ ( s43 = 830 ' i r a 7 i I 22 ~6T ~P ors rib IU 0 ~1'[~ P RePP~R ry ,,J e 5-o ~I VENTS ~v 0 BS ~zII D(Sc `(iox IOP61- SepT►C ~r U u (t~PaS~ M M 'U . t wiT 7, 0 LEtf r~RN ~'2" ~Rdunf~ v 2 6 Pip~~ .o Qy Rvcc d o .e. REPT131 EAU GALLE ST. CROIX COUNTY ZONING PAGE 1 08/04/92 10:25 REQUESTS FOR INSPECTION WORK SHEETS FOR: 8/ 5/92 AREA: MJ Activity: A9200257 8/ 5/92 Type: CONVSEPT Status: PENDING Constr: Address: EAU GALLE 9.28.16.126,LOT 1, 233RD ST. Parcel: 008-1024-90-000 Occ: Use: Description: 171491 Applicant: RUMPEL, JAMES Phone: Owner: RUMPEL, JAMES Phone: Contractor: NELSON, ROGER Phone: 273-4444 Inspection Request Information..... Requestor: ROGER NELSON Phone: Req Time: 15:08 Comments: Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION