Loading...
HomeMy WebLinkAbout018-1059-80-100 ''C o ~ ° I ~i °o• I N p c» I p O I O 0 4 c o o ~ o I 0 - I c N 00 ON. X c 04 cz ~ a) 9020? N O y N C L O N LL 4) ca cNa I °_n-.:~ ti O N O c I co o o,E~ ti N y O C 0 C • 0 E _ tl O O pD U L x y L On - f0 0 a GN C O N no0 mEcm O LO r O U) w N ~0 E C O N f0 C' I N 0 N L 0 C 0 'OVO_O O Z 0 E UY I M Z NtC))C', 7 (6 O C N 7 f6 N C QOj C U. C ~L CL I LL c'2 f0 0 CD CD - O L -p O W N` Q aE 3a I Q °cy 0 2 a c ~ 3 m U N O O Z E E 4i 0 Z I I m O cwN am i am I 0 0 z a c I ccci re r N 0 c_ mZV ° o •o m rn z ~ c E c E •a O Q2 M c N O m O N 42 L L L 0 a O O 0 N Q 0 N Q Q z m z z m z - z° N m C co N ~r C rr ~ N ~ t0 <p CL N a 10 O a r to a) O 0 G d O W d r~ O C O O O G G a L° N N Z r> N H F- O I O U) N N jl o I .0 S o o n m I a 2 0 z • 3 a a a I a a a y a 12 c O O m m OD W I N N N J V 0) rn rn ° I cc rn 0) ° z Im z X00 fn t0*> M _ N N N 0 N L_ f0 co Q I ltn Lln 0 E 0 0 0 = •p I m 0 0 > ) a N O m y c L m d Q (n I 0) 'O d Q) z U) i0 0 y N l u~ w m w O C V! C ~ II) C Or 3 c O I O E ,n Q o H Y a0i £ c I a"i O u d OO OO O i Ci i- CY) y N R D N r co U, 5 O O C m N I O T -c •O-• d N N W . ° 0) Mo ai `O o Z I y `O v O 0 Do 04 .U In a. 7 E rU a+ 7 C L • O N S Q. Cl) 0 2 2 I°- I d 0 z z Z 'd In Q cd IL U d a aCL 0 is a. 4' c n. rw• ca a 47 d C d O c f A E 0U)L) O t/~ U) ° ~ 0 LOCATION: HAMMOND 26. 29.17.404A,NW,SW, 9 E.Ia~JLt~~ Wisconsin DeSartmentof industry, PRIVATE SEWAGE SYSTEM County: LaboYand Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 171429 Permit Holder's Name: ❑ City ❑ Village )U Town of: State Plan ID No.: KEN-RICH FARMS INC HAMMOND CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 018X'05920000 TANK INFORMATION ELEVATION DATA A92 0193 TYPE MANUFACTURER CAPACITY STATION BS HI EV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth _7 DIMENSION DIMEN I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type 0 Moe Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Mani old Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/Tr nchCenter Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i I DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNT I STATE SANITARY PERMI -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ / "la 8% x 11 inches in size. C eck if revision to pr wous 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 ' / /'I/A% 5td%, S Ze-, T N, R 17 Lv(or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) 11 State Owned ❑ VILLLLAGE : NEAREST ROAD /vO~ ❑ Public ~ 1 or 2 Fam. Dwelling- # of bedrooms PARCEL AX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 0 D 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. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2.E] Replacement 3. ❑ Replacement of 4.JZ 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 22 ❑ In-Ground 42 ❑ Pit Privy 130 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION _~1150 9y~ 9l 0 .,V'-7 I~ 10 Feet Feet VII. TANK CAPACITY Site in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank /e%o a ee%D Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, 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: Plumber's Address (Street, City, State, Zip Code); IX. COUNTY/DEPARTMENT USE ONLY ~f ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate issued Is ing Agent Signat tamps) ~yJ Approved El Owner Given Initial 47 Surcharge Fee) Adverse Determination dDP-W 11A 767 51 Iff 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 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 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. GROUNDWATEIR 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) AS BUILT SANITARY SYSTEM REPORT 0~ER te SOn TOWNSHIP A&,RE2 ST. CROIX COUNTY, WISCONSIN. O~116 ` c%v%~ Gr~~ .~yDpZ c• ION_ LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 0 _ZZ b 10 go, i ~ ~ r a e °Q I di at N :)r h rr w BENCHMARK: (Permanent reference Point) Describe:_J,0~P 010 ~~oh Sfn e base of s`f-ino ,'4 ~ei7cC p~ Z ;Y7 11 Elevation of vertical reference point: /DD~Q Slope at site: ~ /O SEPTIC TANK: Manufacturer: 16"ee7s Liquid Capacity 11000 Number of rings on cover : Tank manholta cover elevation: Tank Inlet Elevation,: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: /VX Nu ber of gallons /yf/ Number of gal. pump set for a cycle gallons; Total capacity of distribution lines gallon: size of pump head; gallon per minute horsepower ;brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE; _Number of pits-_feet diameter feet liquid depth seepa pit inlet pipe-elevation" bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines u/d width /eO' length,rO the depth SEEPAGE TRENCH: width lepgth PERCOLATION RATE AREA REQUIRED AREA AS BUILT INSPECTOR DATED 7 PLUMBER ON JOB ~~,/G salt LICENSE NUMBER ?5?s DEPAR- SENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS P.O. . BOX BOX 7 7. 969 UMAN RELATIONS P PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WI 53707 BUREAU OF PLUMBING CICONVENTIONAL ❑ALTERNATIVE State Planl.D.Numbx: ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (lf assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: IDS Kenneth Peterson R. R. 2, Baldwin, WI 6°O BE 41 Iy~gRK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: ~J REF. PT. ELEV.: CST REF. PT. ELEV.: SW, Section 26, T29N-R17W, Town of Hammond Name of Plumber: MP/MPRSW No.. CounS~tt -Sanitary - Permit Number: Everett Boldt 4489 Croix 38503 SEPTIC TANK/HOLDING TANK: MANUFACTURER: ^ LIQUID CAPACITY: TANK INLET E V . IT;NK- OUTLET ELEV.WARNING LABEL LOCKING R ~ P EDPRO DE Z5 YES ❑NO S ONO BEDDINGVENTDIA.: VENTMATL: HIGHW TER V 2- O .;V, ALARM NUMBER OF ROAD: PROPERTY WELL BU1401 ~.r VENT TO FRESH ❑YES ❑NO FEET FROM LIN ,~~jj`y/%% AIRIryL(/ NO NEAREST\~F~~GGAAJJ ~ DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPAC ITV. PUMP DEL. PU /S WHO AN FACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND C T LS OPERATIO AL U PROPERTY WELL BUILDING JVENTTOFRESH (DIFFERENCE BETWEEN ET FROM LINE AIR INLET PUMP ON AND OFF) YE NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at th dep of plo ing ENoTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construn sh I ce until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO. OF DISTR. PIPE S~CING CAIAL:_ INSIDE DIA. #PITS LIQUID DIMENSIONS ul 45 v TRENCHES C/ M PIT DEPTH: GRAVEL DEPTH FILL DEPTH- Df~T,F PJt Dljff&p1 p DISTR. PIPE _ MATERIAL: N0. D R. NUMBER OF PROPERTY WELL BUI DI G: VENT TO FRESH BELOW PIP ABOVE C VER: EI~V, 13. ELp7 PIPE LINE: C e~ FEET FROM AIR INLET: L 41 2- L-- NEAREST-i► MOUND SYSTEM: O - Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems &o m7diurn certai that it ON REVERSE SIDE. SHOW ELEVA- meets the criter for n TIONS MEASURED. ❑YES ❑NO SOIL COVER TEXTURE ANENT MARKERS OBSERVATION WELLS PE ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSO 7DED ❑YES 11EEDOEUNO CENTER: EDGES. MULCHED: ❑ ES E~<o El YES ONO EYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH WO -OF LATERAL SPACI R VEL EPTH BE W PIP FILL DEPTH ABOVE COVER. TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIP MAN OLD M RI NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.: ELEV.: DIA_ ELEV.: PIPES: DIA.: ELEVATION AND : DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY VER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES ❑ ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION ELLS: ]NU MBER O.F J PROPERTY WELL BUILDING: FEET FRO10, LINE` L ❑YES ❑N ❑YE6 NO NEAREST 4~~.h 5,55 ~ ~ 11~ 1~ ~ ll•G Z.. .77 I r f Sketch System on ~ n 61 lln R tain ' cou file for audit.,e Reverse Side. / ' ^ SIGNATUR TITLE: DILHR SBD 6710 (R. 01/82) DEPARTMENT OF APPLICATION INbUSTRI', FOR SANITARY SAFETY & BUILDINGS DIVISION LXBOR AND PERMIT P.O. BOX 7969 HUMAN"aLATIONS (PLB 67) MADISON, WI 53707 r- Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's -copy must be included. ew - I`-Ale ryS Property Owner. f~ u Mailing Address: Pro N e- perty Location: City, Village or Township: County: L '/a3 -5 (.J%S26 1T29 N1R /7 H (or) W p nr~Io -~7 Cro: X Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: (If assigned) LA T 5?& 1 TYPE OF BUILDING Number of El Public* 1:1 Variance* ❑ Other (specify)*~a 1aa-7d-4V(J` Bedrooms J 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY f~~a HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: 6jee EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental ,9 Seepage Bed ❑ Seepage Pit 715 I! E3 Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (if other than present owner): Private 13 Joint ❑ Public I, the undersigned, hereby assume responsibility for in lation of the private sewage system shown on the attached plans. Name of Plumber: Si natur MP/MPRSW No.: Phone Number: eRe 4 ~oLq/f- my ('!/-5)66-337k 1/4 12 Plum Address: ' - q Name of signer: , COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: Sanitary Permit Number: APPROVED 14-,36 -*P3 I ❑ DISAPPROVED O~ Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (R.07/81) 16 III ~ ~y ~ ~ y P ~ r aclll~ i. 1 looN' Form - S T C 100 Owner of Property R D~ -i1 c h C n Location of Property Nw k 5cd k, Section 94 T N R_Z2 W Township 17/?/"M0/VC/ Mailing Address 8 w►h) S N a Subdivision Name Lot Number t 1~ Previous Owner of Property Qky / Q. 1 <~Q r'P Q,rA Total Size of Parcel 5' ck"L , Date Parcel Was Created Are all corners identifiable? _Yes No Include with this application one of the following: .Certified Survey Map .Dead .Land Contract, or .Other I:egal Document which describes the property PROPERTY OWNER CERTIFICATION I I Me) 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 rded in the Office of the County Register of Deeds as Document No.11 '17 of -I-,, ; and that I (we) presently own the proposed site for the sewage disposal system (or 1 (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (if APPLICP%#LF.) DATE SIONED DATE SIGNED i 1 I N U M B E R C 7 1. j 4 ' ABSTRACT OF TITLE 'M the following described `Deal Estate situated in ST. CROIX COUNTY, WISCONSIN 1. SW i of SE of Section 26-29-17. (Continued from Oct. 25, 1951 at 10:45 AM). 2. NWu of SE1, N2 of SW' and Part of S! of NWu lying S of the Chicago, St. Paul, Minneapolis and Omaha Railway extending from and commencing at a point 50 feet S of center of said railway and extending to S line of said 1/4 Section, being 191 rods wide at E end and 11 rods more or less at W end, including all the land in said 1/4 Section S of a point 50 feet S of the center of said Railway, all in Section 26-29-17. (Continued from Oct. 16, 1951 at 2:45 PM). PREPARED FOR Harold D. Olson Attorney at Law Baldwin, Wisconsin ST. CROIX COUNTY ABSTRACT CO. Hudson, Wisconsin APPROVED MEMBER AMERICAN LAND TITLE ASSOCIATION W SCONSIN LAND TITLE ASSOCIATION, INC. it INWST NtIF1fVT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INF~USTR Y, DIVISION P.O. BOX 769 LABOR AND PERCOLATION TESTS (115) MADISO N w 53707 HUMAN RELATIONS (1-163.090) & Chapter 145.045) LOCATION: N: TOWNS IP/mi"000i OWKY: OT NO.: BLK. NO.: SUBDIVISION NAME: Nut i/4 t/ .9 /Ta9 ~/R t? (or) W !lrYa~7iaNc~ WA NA ,~/A COUNT((~. OWN .'S U 'S' NAME: NI NG ADDRESS: ~S 0, 4:~O ~ Jt CwI✓e 4ea s o/v 'j E 0 it Gtv - R. C AR MS DATES OBSERVATIONS MADE ! ION TESTS` NO. B MS.: 1COMMERCIAL DESCRIPTION : ~yNew -PROFILE LA Residence X New RATING: S= Site suitable for system U= Site unsuitable for system VENTIONAL: MOUND: IN eiROUN PRESS E: S EM-I =FILL HOLDING TANK: RECOMMENDED SY~STEM:(optional) rMS ❑u Z su sou ❑ s ou EIS CCU /V A if Percolation Tests are NOT required DESIGN RIV ATE: I If any portion of the tested area is in the A undor s.H63.09(5)(b), indicate: A Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL T R UND ATE -I CHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION BSE V gQ EST. I ST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B l 6, 4~ } D x4 . 9/46 5c C i + nto# Lis B. J 6"0 7 Flo tt , n • Fib,/ el- S,L 0 4J♦4' (c .7 SL o~r S"7 acL 67 B^ 4 6"o° /ipQ~(r rr I .J• s cT 3 "fees, . $N S:t~ oZr sL (r~scG. F3- ~ ~ + I 6" 7S 755 '4f4 1..2 5' i3NS" i 3, o y s 4 . ~ ~5c L - x, g. i 0 01a r f cS Sa ~r N~- L..rsf ~of4S PERCOLATION TESTS TM' DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES. RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 RIOD PER INCH P- NO /0 P /0 x CI f ~~z P.i P O l /35~`r s 911 L. P- P P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontat and vertical elevation reference points and shove their location on the plot plan. Show the surface elevation at all borings and the direction and percent Q r ` of land slope. SYSTE ELEVATION 9 ~ , o . I 1 ; - - /Q0. D yip /B~t OF l~dK~ 4X 1 A°.t t ` ~./NG /V'x Ta sfuMf~ 11:1 6.0.04 1401 7' _ ' r~ s? lie I . 5 Jrc t"~'.o~ .f i leC- _ TN . a : I Ft { I I tifp I, the undersigned, hereby certify that the soil tests reported on this form were rtlade by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME print): TESTS WERE COMPLETED ON: Zve~'e % aLe/,4 In- 17- F3 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CS SIGN RE`. DISTRIBUTION: Original and one copy to Local Authority. Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) OVER lok 'ftGrtl~:o..'w~.cw,..Cxep'rra~eoMP~Cw 1 y '8J l1 rxA ~~a. 4~ ~`si~*C~y ~p !1 w~• i^M , - /~1 " 'Tea ' O Y L P p --Z77 -I /U®~~ -.pr of AK~ i 13 q 9 5" r , Igo, 5~ q~+ PC I't J" IF :5aALc -40 Re; AAVJ~ ! z• ~ , . APPLICATION FOR SANITARY PERMIT 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), then a second form should be retained and completed when the property is sold and submitted to this office. with the appropriate deed recording. ---------------------------,--------------/------------'-~-1------------------------- Owner of property 1~~s Location of property A/&I' l/4 QtG,l 1/4, Section 7 , TZf N-R L7 W Township Mailing address / /JCS Address of site Subdivision name /✓X Lot number fly Previous owner of property i Total size of parcel Date parcel was created .re all corners and lot lines identifiable? /C Yes No Is this property being developed for resale (spec house)? Yes No Volume : If'and Page Number 7'~- 'as recorded with the Register of Deeds. j i INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and 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.`?- fy 75 ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. Signature of Owner Signature of Co-Owner (If Applicable) Z>Y 23~9A `Date of Signature Date of Signature • G • N H' S T C- 105 r H SEPTIC TANK MAINTENANCE AGREEMENT a St. Croix County z OWNER/BUYER ROUTE/BOX NUMBER z,7_ Fire Number CITY/STATE 'LIP PROPERTY LOCATION: Section 1 TN, R /Z W, Town of__r7~✓rr~y'~ , St. Croix County, Subdivision k1w Lot number /t 1 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank hum er. What you put into i the system can affect the function of the septic tank as a treat- ment 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 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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. H 0 I/WE, the undersigned, have read the above requirements and agree to maintain...the.private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- v ment 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. SIGNED D A'1' E St. Croix County Zoning Office P.O. Box. 98- Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign,.date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, ~ C DIVISION LABOR AN P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090) & Chapter 145.045) LOCATI N: SECTION: TOWNS IP/M13M*9111M[I-TY: LOT NO.: BLK. NO.: SUBDIVISION NAME: Nc✓ ~4 a6 /Ta9 N/R i~ (or) W A/9mmoNql PIA NA NA COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: Qo i x ~e+vNe fl fie -~e,~ s onl ~,C. d w~,~ , S USE 012 e-" - G ARMS DATES OBSERVATIONS MADE NO. BEDRMS.: COMM R AL DESCRIPTION: ~y (PROFILE DESCRIPTIONS: A ION TESTS: Residence 3 r A latNew ❑Replace Il 6 _ -3 / -7- F3 d ~O RATING: S= Site suitable for system U= Site unsuitable for system CONVENT NAL: Ms ND: IN-GROUND-PRESSURE: JSYSTEM-IN-Fl LL HOLDING TANK: RECOMMENDED SYSTEM:(optional) MS❑u ❑u ®sou. CJs ©u os©u A If Percolation Tests are NOT required DESIGN RATE: If an A/ y portion of the tested area is in the under s.H63.09(5)(6), indicate: /Y A Floodplain, indicate Floodplain elevation: ~r A PROFILE DESCRIPTIONS, BORING TOTAL ELEVATION DEPTH T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, BS HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / lp, O 9914.5 A/0li > O Y-,& 5-148"vS,L 3O S4 . 916 Sc L B- oZ I& C ?9, 5- f m o a t i:~~ , J'3`f gL S/ L iz-a 3, 0 9s,C . 6 5 5C L B- 3 16,0~ 9?,0 ' S;3a~ , 667 el-5 0 9L ~,Ia'7,5' 5-7 S-, G• /,.98 S' 75 %Ls,L 5' I3,.,$5,L 9,0`I ski ScL B- CO , 0 f y) o -f- S o L- i S f So i C S 'Tc K T PERCOLATION TESTS TEST TIM NUMBER INCHES FTERSWELOLING INTERVA MIN. P I D DROP IN W P ER LEVEL-INCHES RAPER INCH ES P ,3 NO / /o P- , Z CI 7 P_ P_ , a o /o ~3 s 9~ 6 P-- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical' elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. Q~/fir Q r d SYSTE ELEVATION l ; 9 /40 t ~ cue r-- Nix # ?ro ~f~M~ lol~~ 2-D Gs s; ~C Q ~ : I I 8 l I- i .,J .311 N , I Aki i i I f m 1` I /00 o As ' v ~s ARew .1 ; I r ' P ! f3p _ I, the undersigned, hereby certify that the soil tests reported on this form were rrlade by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: e~o[.q/f to - 'l- ?3 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): ~A 4 ca/ w L J i S 3371 CS SIGN RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) OVER - let* t~ w7 a IQ- p _ ~a9N R~~w 64 71 A~T - ' G'J,7~ °.a000~J.aO bV-4~4s4 pT •'yV ~O i-+ as Ui 14~$RA$A'~ 6" $C~ow PIP e 3 67 01- M A e, 1 x :Sm- /vo,o' TnP of SStAKe. L't P3 q 9 g 9,94 A x S - 9 < ~j _ 4.12. a /-t o lc 5 x ' I ° o~e5 a o - Pe R !4 Jay 'L~r/~vL' ~a SeP~".c 1S• o T n~ 33-~- /ao ~ i O o /JC a,J i SCALC `F0 N tie.I~ r X fa r wr~ By i f 66Z9 CST 3-1113 3 -Z `f -Q~