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HomeMy WebLinkAbout030-1014-10-000 •rs o I y o o > v m x t o > c > 3 N O 0100) O O N O ~ C Y O N y c L O 0 N i 0 0 c: 'Q O CL N N N 3 N c, 0) O Z c c E Y 3 m N cc d LL O ) (D c c E Q ~mao c U ~ M N i rn z III c F2 lzt z r £ v` O W a m H Z c C7 O z d c wl N O z d c N H r ~ O c t N N N CL O N - O • }V d Cn .c PT V N O C) O o N Q O z co z Z o N w E c o O O L -0 'IT 0 a W N 06 a) ' o o a` E (D E d~rryy E 0 NO333 am ~+o O O O i M a a s a W o y rn m N N J U ~ - 0) .2:' ZF5 c 0) 4 N ON O0) O E N N CY) U O c N N 00 M y O ~ 00 O '6 rn 4) Frr LL C c u~i w a O 3 L N 0 C: C E L, (D 00 CC O O 5 O O = m 0 0 0 © L" O ~ a O N . a O O O O G C O. Ll -O N N N v of a N c E E N rn o~0- O VOi c 0 L L N N 00 N~ 3 0 w r Co m E E U cy) 00 r 4i y E ~ - E d ° a r • % a d m cj c Ir+ p +d o L c u o o Q U a E O h U AS BUILT SANITARY SYSTEM REPORT OWNER 1 l~: k) hN S W, -TOWNSHIP- SECTION T L~ N-R dJ_W P ADDRESS U C c>u ST.,-,CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF.SYSTEM Gull v~ lv e q~ YI s N - 4s.7 y so' a "'~A~ 7 ~a N w Wd 7~, S ,.(3 45 ~3 f a~ s~ 1 INDICATE NORTH ARROW BENCHMARK: Elevation and description: lo O i tiv C Wt, 1A 3("j ~f r~, (d 0. Alternate benchmark SEPTIC TANK: Manuf acturer : v~ \ w Liq 1600 j,Rings used:Lmanhole cover elev: ~ 1Final grade elev: /w-4 Tank inlet elev.: Tank outlet elev.: r~ No. of feet from nearest road:Front , Side , Rear Ft. Geer( :~u0 From nearest, prop. line: Front Side , Rear Ft. 6 60 11r No. of feet from: Well ~v Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front-, Side,, Rear-Ft. Distance from: Well Building s . . ~i. v ~e ~3. SI) SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width: Length Q Number of Lines:,-,Area Built Exist. Grade Elev.- I / Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side Rear Ft.aor r- No. feet from well: No. feet from building HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from: Well building , nearest road Alarm Manufacturer: t INSPECTOR: DATE : PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj 'WisL~conrsi9N: T of IncSEPH 4.29.19.58A NE NE °GE CO. RD. SYSTEM E County: Labor and Human Relations PRIVATE SWAGE Safety and Buildings Division INSPECTION REPORT ST, CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 180259 Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: WKINSON ARTHUR F & NANCY ST. JOSEPH CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: Ge 1OJ " ar .c0 v,- 030-1014-10-000 TANK INFORMATION ELEV TION DATA A9200340 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / _x Benchmark D in ~ . /v, O 0 10x,96 Aeration Bldg. Sewer Holding St/44t-InIet ~D-L t-, cc TANK SETBACK INFORMATION St/+ft Outlet TANKTO P/L WELL BLDG. Aierlntake ROAD net Septic /0~' NA Dosin NA Header /A4*kL Aeration NA Dist. Pipe 2. ss' 3,x1 ' Holding Bot. System W z 39~ PUMP/ SIPHON INFORMATION Final Grade 7 (o f/' , 70 ' Manufact Demand a"o d . T 14 oe~ 3 S7' /D,Z, 117 M , el Number GPM TDH Lift Friction Syste TDH Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length'/ No. Of Trenches PIT Pits Inside Dia. Liquid Depth DIMENSIONS V0 D MEN I N SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of Cmr u CHAMBER ° i Moe ber: System: !/~60° (,S SO OR UNIT DISTRIBUTION SYSTEM Header /-Mw ifotd Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- ~L Length ~ Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Sly Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes No COMMENTS: (Include code discrepancies, per ns present, etc.) na ,,fir G, r P (,n ~ ~ `7 CO. 9 97 O~Plan rev4sIon req d? ❑ us. 'IQ0 Use other side for additional infomation. /D ~Z y SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t z jQ1j.HA SANITARY PERMIT APPLICATION - COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY Y PE-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~8% x 11 inches in size. ch s 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 ki0) 50AJ G % S T aq, N, R /9 E (or PROPERTY OWN R'S MAILING ADDRESS LOT # BLOCK #V - 903 ICJ,. CITY, TAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CS UMBER ~d Aj UZT 711-- ASK -"M 11. TYPE OF BUILDING: (Check one) VITM _ NE PEST RO r, 1 ❑ State Owned V TOWN OF: ILLAGE S~ J o S r, 6 4 N I t, K A ❑ Public U1 or 2 Fam. Dwelling- # of bedrooms PARCEL TA NUMBE ( ) III. BUILDING USE: (If building type is public, check all that apply) 03o_ 101AI -/0 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. L/' N'ieplacement 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 R Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage 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 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE c ' S O REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./finch ~ JC% 810 N III a ("_i -)-IS() Feet Feet VII. TANK CAPACITY Site in alions Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks T nks structed Septic Tank or Holdin Tank " F] I [I Ll Lift Pump Tank/Si hon Chamber F i~7, 0 F~ El 1 0 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 a S' ture: (No Sta s) MP/MPRSW No.`: / Business Phone Number: 1'_,- Qayv,rVe ~ 3 1~5 )3$fo -gw . _ \ C C Plu`mber's Address (Street CityL State, Zip Codil) 1 11 /V~ Lp, 1 C..IM_~K\I~,pw , rAw\ U S 0)^I J IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved S 'taryPer Fee (Includes Groundwater ate Issued uing ent Sig ture (No St ps) Surcharge Fee) __JkT`Approved ❑ Owner Given Initial Adverse Determination / V 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`t 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. 1 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'f 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 manufaciiurer; 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) 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), then a 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 Location of property`.~IE 1/4 LJ.~ ~1/4 , Section 7 , T_,2& N-R_ZIW Township ~5 Mailing address ,d Address of site Subdivision name Lot no. Other homes on property? yes No Previous owner of property Af ~4;5T 1171 T Total size of parcel Date parcel was created Are all corners and lot lines identifiable? __N~_Yes No Is this property being developed for (spec house)? Yes No volume_ q and Page Number 3q7 as recorded. with the Register of Deeds. -"-r-- 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 the property described in this information f(are) the owner) orm, by vrt e(sof oa warranty deed recorded in the office of the County Register of Deeds as Document No. own the and that I (we) presently proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described the construction of said system, and the same has been duly o recorded in the office of County Register of deeds as Document No.4/L~ 9a3 Signature of applicant Co-applicant Date of signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN- FORM 2 WARRANTY DEED I F/ ' tJ~ THIS SPACE RESERVED FOR RECORDING DATA k/ REGISTERS OFFICE BY THIS DEED,_Ernegt A Smith and_Crystal Smith, ST. CROIX CO., WIS. his wife and in her own behalf 26th Recd for Record this-- _ I~ day of____ June ,,.D.19_73 Grantor conveys and warrants to Arthur F. Hawkinson and Nancy A_:_r M. L. Hawkinson, husband and wife as joint tenants, ar of - s -Grantee S for a valuable consideration - RETURN TO the following described real estate in St. Croix County, State of Wisconsin: The North Half of the NOrtheast Quarter of Tax Key Section Four (4), Township Twenty-nine (29) This is -not homestead property. North, Range Nineteen (19) West, subject to existing highways and easements of record. ALSO an easement for an access road over the South 60 feet of the East 60 feet of the Southeast Quarter of Section Thirty-three (33), Township Thirty (30) North, Range Nineteen (19) West. This deed is given and accepted in fulfillment of a land contract between the parties recorded May 28, 1968, in the office of the Register of Deeds .1 for St. Croix County, Wisconsin, in Volume 442, pagGs460 and 461, document 292405. FEE EXEMPT II Exception to warranties: ~I II Executed at Hudson, Wisconsin 1-1-th day June 73 SIGNED AND SEALED IN PRESENCE OF (SEAL) Ernest A. Smith (SEAL) . John -D.--Heywood Cry tal Smith - ~I (SEAL) Carol'McDaniel I II (SEAL) Signatures of-----_ Ernest A. Smith and Crystal Smith, his wife authenticated this _ 11th day of-___Jtlrie - 19 73 . John D. Heywood Title: Member State Bar of WisconsinXXX3 MXI XVy Authorized under Sec. 706.06 viz. STATE OF WISCONSIN l I ss. - County. Personally came before me, this day of 19-._.., the above named to me known to be the person- who executed the foregoing instrument and acknowledged the some. This instrument was drafted by John D. Heywood, Attorney at Law Haduan, Wisconsin Notary Public County, Wis. The use of witnesses is optional. 4~. g P,,,,9, 7 My Commission (Expires) (Is) _ Names of persons signing in any capacity should be typed or printed below their signatures. HC MMII.rCarpsry~ WARRANTY DeED-STATE BAR OF w ONStN, FORM No. 2 - 1911 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County ,f OWNER/BUYER ,l~Ftwlk", J ~ ADDRESS: ~O 3 Gg'trf-I D A- FIRE NO: 6D4 LOCATION:- AJt 1/4, _1/4, SEC._# _T_.,U_N-R_L_~_W, TOWN OF: :!5T ZS-Z15 ~fr 11 ST. CROIX COUNTY SUBDIVISION: LOT NO. 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 Count°'r 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 r.aintaln the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR, Certification form r.us be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: ' DATE ` St. Croix County Zoning Office 911 ~ th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969 N WI 53707 HUMAN.REL/~TIONS (ILHR 83.09(1) & Chapter 145) LOCA'/ N:~,/ SECJyO%T2/R/9 tor TOW~~P/MTOSe LI j LZ BLK. rP5.j SUB IN NAME: COUNTY: OW ER'S/BUYER'S N ME• MAILING ADDRESS: uIr S~_ C,,. I'/ Pt be'^Jk;r' SO' In o 6O 17U,50 A] USE DATES O SE VATIONS MADE 13 7EDRMS.: COMMEF3C1AL DESCRIPTION: PROFI D RIPTIONS: PER AT N TESTS: _1 I. esidence 3 N /V ❑ New Replace 2_ 2 RATING: S= Site suitable for system U= Site unsuitable for system S 5A OTI❑U . M❑U IN GS EOUND-POU RE: SYSTEM-I L HOLDING TANK: RECON~MED SYM'.(op Aonal) If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the ee C under s. ILHR 83.09(5)(b), indicate: , `7 Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH W1. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 7 0- r ~ 7 Ss~ 6•, s 4'3 ' it e•3 Z. z~ ~ B- //,83 /D.33 ~)10/.&' - 4. ~3 ' H . 2- 0, do; - 51 C-10 Ir n.~ s 3, B- 91.3 > B-3 ?jre S B- B- B- PERCOLATION TESTS v TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 994AZ AFTERS LING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- s 3 z 2 S~ 83 1 _ P_ -3 4 P- 5 3 y r Si 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- 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. SY M ELEVATION - - t 4- 0 " o G -ate I-~o~,' s 1- , z 9' fal)PJ- IBC 3 J wv P.& E _7 tN E E r+ pOEit B3 , N s- , ~ ~ _ ~ E~w ~ X31 ~ . _ = I 1 _3 E E I i I, the undersigned, hereby certify that the soi es s r por a on t is orm were made 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 Vint): TESTS WE EC PLETED ON: AD RESS: CERT ICA ON NUMBER: PHONE NUMBER (optional): /D o G✓,` 0 3 L Gs~li CST SI E• DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - 'h'ST TIO S FC" 3MPLETIN `nRIVI 115 - S - 6395 To br Ttl 'Curate cur r<<. tl-JS , e r r l project; . TI 1 MA- ' al use pl :nned; 4. I- rat A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTP- : SYSTE` RUL- F BASED CAN SOIL CONDITIONS; 6. PLEASE usr thr t_ here for writing profile descriptions and completing the plot plan; 7. MADE m : - ; 'ately locating your test locations. Di'awim to scale is preferred. A separate u..w, if &J-d; 8. Make sure yor ~:k and vertical elevation reference point are clearly shown, and are permanent, 9- Complete all ap i .`:e boxes as to dates, names, addresses, flood plain data, percolation test: exemp- tion, if appropriate; 10f If the information (such as £E.." Sri e, elev-it=on) does riot apply, place N.A. in Ilie appropriate box; 11. Sign the form and place your cu, addiess and your certification number; 12. Make legible copie=s and distribute as rec, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS 1) u,OMPLET"ION. k.._ I TIONS FCR ' `g IFIEI SOIL TESTERS Soil Separates and Textures st Stone (over 10"i BR - cob - Le I e (3 - 10") SS - gr- der 3") L r _ and Es ~ ° yn i, si - - Y sv; y L Sarre sic! im runt Sc sic Si ffi' Vv, 't ~c - t cc - c.~,~~trr pt Ilia) Many, rr d distinct. P prornir 'nt h{WL H(' sr level, six :tuies _ .ever .pros€al BI`u1 - Be.n- VRP Vertical ;e point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. (67 P L. OTA li 1) U \'o S S.- S E 3 N l Ate. ~NSp N.,...... ~ J, rte. DV,m _ -t~- "'C-1 C E N S E =fit- _g 3 P 0. N dfiQ f43'-~er~ 1 o s ArA fcr~ ~ • o.~ N t„ti ell , s Fi,n W e\~ S6► 104 f =jar e.!' ()d s Ie'~ , i. Btd Z L=160.0 ~ s `lu.~,~ k = P~~ poles FRESH MID C1103S SECTION Approved Vent Cap Minimum 12" Above Final Gr A" Cast Iron Above Pipe Vent Pipe 'To Final Gracie Marsh [lay Or Synthetic Covering Min. 2" Aggrcg',l1 Over Pipe " is tribe li Tee on ' Pipe f .t\ i._ Aggregate A_ Perforated Pipe Gel Dcnca h Pipe el----- Coup i.ng Ter,minaf-Jnq T 130 a,~ Bottom of System I ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT w FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the ~ ~l Ul(C ~PJ')t~lb1 S residence located at: N 1/4, N 1/4, Sec. 7 IF T- R]aW, Town of s ~b12 p Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced lllDi? Did flow back occur from absorption system? Yes No\/(if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacurer (if known): Age of Tank (if known): n t ln~'~ J I w, A04 ►►~C~ S ~ (S nature) (Name) Please Print P1~4 mfu 3 y 0y (Title) (License Number) (Date) Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspection opening over outlet baffle). /11' {j J~~ llbM1-t-,~J K Signature fm~ MP/MPRS Name 5/88 REPT131 ST. JOSEPH ST. CROIX COUNTY ZONING PAGE 1 10/13/92 15:17 REQUESTS FOR INSPECTION WORK SHEETS FOR: 10/14/92 AREA: JT Activity: A9200340 10/14/92 Type: CONVSEPT Status: PENDING Constr: Address: ST. JOSEPH 4.29.19.58A,NE,NE, CO. RD. E Parcel: 030-1014-10-000 Occ: Use: Description: 180259 Applicant: HAWKINSON, ARTHUR F & NANCY Phone: Owner: HAWKINSON, ARTHUR F & NANCY Phone: Contractor: BOUMEESTER, JIM Phone: 386-9020 Inspection Request Information..... Requestor: BOUMEESTER, JIM Phone: Req Time: 09:10 Comments: ~Iwx) Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION