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HomeMy WebLinkAbout030-2009-80-000 (-0 'a D °o (D o 00 0 ~ 0 °0 M a ao ~ I ~ i a ~ C C 0. 0 0 I ~ I o E U O N co ro N N 1 D ti CL > .0 C N O - T C N > CL U O p a 2 N N N p U j ~ ~ c z I ca c z 0 3 (9 O m O f0 LL C 0 U. O (n O - N E N '0 a) -0 -0 d o E Q y 3 Cl) 3 M v a) Z N Z N rn w E E U) o w o ° ILm (L "m M~U) c I o I 0 z O Z:!t c c ~ ' w u o N o N o a) a) ar Z d c c m m Z c E c E -R 0 a) CL 4 3 N 3 co Q) N N N N O CO • d L .C IL L_ U RS O Q O N Q 0 p-_U O O jl Z F Z Z co z o N z E E ~v E E N 12 R Y i l6 Y ~i 4) CL a fD N d c a) C 1 co W d N C O O j a U) a E o p D D a E o U N Z Lo F- F p F- I- H d o w N Z i~ a a a a a a (n U) -0 C,4 '0 ►~i 7 0 N O a04 04 ) 0) N U) J 0 iI = rn Z 2 w m a) 'a LO 4 '0 D m w a' 'o •c N Q ~3> j ~ N y o7 ~ 0 a~i d Z U 0 d Q O C N N C N f/1 C 1y 0 Q o O C 'O O C E U) O .02 M y U O O O U O Q? O `O 7+ O 00 ~C 4.1 N C Y_ y C N CL O OC) V L M Q N E E N° E z5m O c N c O 'a) 0 O O I N tf` ` L CD M ` Z L ry bd ~ Cl) M N In 0y a) F- "O N LO a) F- Q) 7 O O C CO C (O E r. _ • > M y a) 00 N E o a) co N o E U O M (n J O Z N Z J O F- r V ~ a • Cl CL m m y a y E c c 3 c 1 ~1 A V a 2 ,I O in v 0 N v J Parcel 030-2009-80-000 07/13/2007 04:45 PM PAGE 1 OF 1 Alt. Parcel 34.30.19.386A 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner ROGER A MERRILL O - MERRILL, ROGER A 1203 CTY RD I HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 1203 CTY RD I SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.700 Plat: N/A-NOT AVAILABLE SEC 34 T30N R19W SW SE EXC P386B AS DESC Block/Condo Bldg: IN 652/504 & EXC CSM 5/1415 EXC TO HWY PROJ 1297/362A Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4) 34-30N-19W Notes: Parcel History: Date Doc # Vol/Page Type 08/01/2005 801820 2854/221 QC 01/02/2003 704339 2098/57 WD 02/19/1998 573276 1297/362A WD 932/191 more... 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/31/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.700 81,600 120,400 202,000 NO Totals for 2007: General Property 2.700 81,600 120,400 202,000 Woodland 0.000 0 0 Totals for 2006: General Property 2.700 81,600 120,400 202,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 143 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 EPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, " DIVISION BOX 7969 LABOR AND PERCOLATION TESTS (115 P.O. DISON, WI 53707 HUMAN RELATIONS \ ) (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/ LOT NO.:BLK. NC SUBDIV ION N E: SW 1/4 Se1/4 34 /T30 N/R 19f:¢or) W St. Joseph n/a n/a n/a COUNTY: OWNER'S WJMeITWAME: MAILING ADDRESS: St. Croix Don Norell 118 S. 3rd. St., Stillwater, 11n. 55082 USE DATES OBSERVATIONS MADE NO, BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 n/a Mew ❑ Replace ~ 1-10-92 1-10-92 1 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND•PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) [gS ❑U ❑ S EU 11 E3S ❑U ❑ S ®U ❑ S E]U split level trench If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a decimal' PROFILE DESCRIPTIONS page 42 CoD2 BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 9.00 93.0 none >9.00 .00bl.l. 1.25bn.sil. 6.92bn.c.s. B- 2 7.00 93.00 none >7.00 .00bl.l. 1.42bn.sil. 4.58bn.c.s. B_ 3 6.92 95.80 none >6.92 1.00bl.l. 1.00bn.sil. 4.92bn.c.s. B 4 6.92 97.8 none >6.92 .92bl.1., 1.08bn.sil. 4.92bn.c.s. B_ 5 7.25 98.0 none >7.25 .75bl.1. .92bn.sil. .75bn.s.l. 4.83bn.c.s. B- del mal' PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER III AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER D PER INCH p- 1 4.00 none 3 P_ Z 4.00 none 3 6 6 6 < P_ 3 3.92 none 3 6 6 6 <3 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. 91.88= upper trench SYSTEM ELEVATION 89.00= lower trench 9 ~ : e b 6, mi_ A All E € r I t . i _ ;TN C0 ! ~ . 7 1 j 3 E h ~'~i~ ~l J ~ ] E I Cb F ~u' 1 ~y 41 -Al F E 061, the undersigned, hereby certify t t the soil tests reported on this form a~ e b i with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are co st of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: Gary L. Steel 1-10-92 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. aVe., New Richmond, Wi. 54017 2298 15- 6-6200 CST SIGN U E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - INSTRUCTIONS FOR COMPLETING; FORM 115 - SBD - 6335 To be a complete and accurate soil test, your report must include; 1. Complete 1_,fl description; 2, The u.e )List clearly indicate whether this is a ice or cornmercial project; 3. MAXIMUM nurr`-e )f bedrooms or commercial use C 4. Is this a new or ement system; 5. Complete the .rit.v:I._y rating boxes. A SITE IS SUIT~.BLE FOR A HOLDING TANK ONLY IF ALL OT' `R SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. P1 abbreviations shown here for vvrriting profile descriptions and completing the plot plan; 7. ~i_E diagram accurately locating your test iocations. Drawing to scale is preferred. A V t ~ used if desired; 8. P nchmark and vertical elevatio.-i referee point are clearly shown, and are permanent; 9. Cc r ~riate boxes as to dates, names, ad food plain data, percolation test exemp- tion, if ap 10. If the inforr (-:ich as flood plain, elevation) dot~~ r, y, place N.A. in the appropriate box; 11, Sign the fc i 1 place your current address and your L_ r -_an number; 12. Make leg c-, and distribute as required. ALL SO'' TESTS MUST BE FILED WITH THE LOCAL AUTHOITY WITHIN 30 DAPS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TEST So :s and Textures Other Symbols st - S_)ne (over 10") SR - Bedrock cob Cobble; (3 - 10") SS - Sandstone gr Gravel (under 3") LS Limesto s - S id HGW - H' lh G va ~d Pere - P ltV S: I:! Bldg - 13 Iding Is L ~amy Sand Greater Than sl dy Loam -Less Than Bn Brovvn *sil Loam BI Black si - Silt. Gy Gray *cl - Clay Loam Y - Yellow scl Sandy Clay L R - Red sicl - Silty Clay L(__ mot - Mottles sc Sandy Clay wr - with sic - Silty Clay fff - few, fir, ' Tint `c - Clay cc - coma se pt Peat rnm - Mary, ,s. c~ot rn Muck d - distinct p - prorninc HVVL - High vel, S' i soii textures surfac ,Lied waste disposal BM - Bench VRP - Vertic:; < ference Point TO THE OWNER: Tl -soil test report is the fir in curing a sanitary 6':' rr T'le county or the Dep :meat riay request ve, --)n of this soil test f' I error A complete se, of ns for the private rsterrt and a permit n must I appropriate for it r ty in order to )errnit. The sanitary pet .,=t must be obtain I ;-rce I I ariorto the start of construction. AS BUILT SANITARY SYSTEM REPORT OWNER ,1 2"-Z ~ TOWNSHIP ,1, SECTION T~_N-R_- W ADDRESS ST. CROIX COUNTY, WISCONSIN AL SUBDIVISION LOT LOT SIZE PLAN VIEW N ' SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM tw G h ~C 6 ~ ~C.l,b k INDICATE NORTH ARROW BENCHMARK: Elevation and description: ~ Alternate benchmark SEPTIC TANK: Manuf acturer : 1~L~~; J, Liquid Cap. Rings used: - Manhole cover elev: Final grade elev• ~V,, Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side, Rear Ft.~ From nearest prop. line:Front , Side, Rear Ft. f~ No. of feet from: Welll 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 SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width: Length_ s Number of Lines:~_Area Built Exist. Grade Elev. Proposed Final Grade Elev._ G C~ Fill depth to top of pipe: 12:21 No. feet from nearest prop. line:Front , Side _X Rear Ft./-?~ No. feet from well: -,_No. feet from building -S~~ 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: INSPECTOR: DATE: PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj F__ LQQ4S g rPTf1 K;rtrtVt!,fQA;j H 34.30 • ia. 38 E S`EVUrAGE'SCO. RD. I County: Safety Human Relations INSPECTION REPORT Safety fety and Buildings Division ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 186535 Per Holder's Name: ❑ City ❑ Village [&,Town of: State Plan ID No.: ST. JOSEPH C ' BM Elev.: I Insp. BM Elev.: BM Description: Parcel Tax No.: 030-2009-80-000 TANK INFORMATION ELEVATION DATA A9200419 07 ~Z_ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosi Aeration Bldg. Sewer Holding St/W Inlet Y,1 / TANK SETBACK INFORMATION St/,fort Outlet , S,SD , Verit TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet Septic 7 NA Dt Bottom Dos' NA Header /-hA**. Aeration N Dist. Pipe 953':!0 957 V-3 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand N a'rs,T cv~/ 3 , 9945s- Model Number GPM TDH Lift Friction Syeste TDH Ft oss Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING nufacturer: SETBACK CHAMBER INFORMATION Type Of C r 7 Moe umber: System: ' A >7-5- OR UNIT DISTRIBUTION SYSTEM Header / McTnie#d Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Intake f Length / Z Dia. Length ;ni Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only I~ [Be pth Over Depth Over r xx Depth Of xx Seeded/ Sodded xx Mulched d /Trench Center Z - Bed /Trench Edges Z _ Topsoil ❑ Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSE~PH~34.30.19.386A,SE,SE, CO. RD. I ✓ I,, f Plan revision required? ❑ Yes moo. Use other side for additional information. 1/___3 07 S`! SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. I ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I J DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COON STATE SA ff/ARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% X 11 It1Ch@s in size. Chec if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER O ER PROPERTY LOCATION , '/4 '5Z t/4, S_ T , N, R E (or PROPERTY OWNER'S MAILING DDRESS LOT # BLOCK # 2,a! ed j 1 1 CITY, S ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) ITM NEAR T R ❑ State Owned ❑ VILLAGE: S Mg JOWN OF: ❑ Public 01 or 2 Fam. Dwelling-# of bedrooms Y_ PARCEL AX NUMBER(s) III. BUILDING USE: (If building type is public, check all that apply) ~^EC ~~EC 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. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) A Sanitary Permit was previously issued. Permit # Date Issued V. PE 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 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.) (Mi7~t nch) ELEVATION y 3N 17 M " Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holding Tank f3 O L~L+ F] I F-1 Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for install ion of the onsite sewage system shown on the attached plans. Plumbers Name (Print): i Plumb is nat re: No ps) MP/MPRSW No.: Business Phone Number: "ed Plumbe % ddre (Street, City, State, Zip Code). Alf IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Si pproved r_1 Owner Given Initial Surcharge Fee ~1 ^ - Y 9 Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary, permit is valid for two (2) years. 2. Your sanitary. permit may be renewed before the expiration date, and at the tirre e renewa 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 Tr nsfer/Renewal Form (SCi'_) 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properiv maintained. The septic tank(s) must be pumped I / 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 admiiistrator or the State of Wisconsin, Safety & Buildings Division, 60Eh266-3815. 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. ll. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family DNelling. 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, r umber 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 experin ip'ntaf product approval from DILHR, VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriatf,! prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; 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 moriss collected through these surcharges are used Par monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 R.11/8 ( 8) L "'AM .rtrSifTrrtofq,rQtRgH 34.30,. yRjVAjjS%R& S STEM . I County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: 186517 Permit Holders Name: ❑ City ❑ Village [JR Town of: State Plan ID No.: ST. JOSEPH M E v.: Insp. BM Elev.: BM Description: Parcel Tax No.: 030-2009-80-000 TANK INFORMATION ELEVATION DATA A9200402 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet rl Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer and Model Number GPM TDH Lift Friction Syesate TDH F~'f oss Forcemain Length Dia. H t. To ell SOIL ABSORPTION SYSTEM BED/TRENCH Width L th No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN 1 N SETBACK SYSTEM TO P / L BL WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Moe Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold 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 E] Yes No El Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 34.30.19.386A,SW,SE, COL RD. I i 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: , ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY ZEE ;.9,,.~...,...,~,..o. ' STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 6 816x,11 inches in size. c eck if revis on 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. PROP OWNER PROPERTY LOCATION t/a Z '/4, S T , No R t,6000 11 1,19 PR PER OWNER'S MAILING ADDRESS LOT # BLOCK # Z~21 -9 U CI TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) CITY NEAREST RO ❑ State Owned ❑ VILLAGE ❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms 1717 =N OF: PARCEL TAX N' 111. BUILDING USE: (If building type is public, check all that apply) Q30~E~C1 9'~ G?©pC~ 1 ❑ Apt/Condo 2 El Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 E1 Outdoor Recreational Facility 30 Campground 70 Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A 1. 9 New 2. ❑ Replacement jTakkOnly acement of 4.0 Reconnection of 5.0 Repair of an System System Existing System Existing System B) ❑ A Sanitary Permit was previously issued. it , Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distrib lion Experimental Other 11 R Seepage Bed 21 nd / 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 In-G ou 42 ❑ Pit Privy 130 Seepage Pit ssu a 43 El Vault Privy 14 E] System-in-Fill VI. ABSORPTION SYSTEM INFORMA LOADING RATE 5. PERC. RATE 6. YSTEM ELEV. 7. FINAL GRADE AB RP. AREA 3. JRP. AREA 1. GALLONS PER DAY 12. SO 9 REQUIRED (sq. ft.) PRED (sq. ft.) 4. (Gals/day/sq. fc.) (Min.inch) ELEVATION Feet / Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. App INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic Tanks Tanks structed Septic Tank or Holdin Tank / Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for install ion of the onsite sewage system shown on the attached plans. Pis Name (Print): Plumb 's igna re: ( Std ) MP/MPRSW No.: Business Phone Number: 9 Plu Address treet, City, tatsZip ode): 7; 'sh1v IX. CO TY/DEPARTMENT USE ONLY ❑ Disapproved San' ry Permit Fee (Includes Groundwater ate Issued issuing ent Sign ure (No Sta ps) / O~ AApproved El Owner Given initial Surcharge Fee) v/y Adverse Determinati n /60 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/86) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRW',TIONS 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 renewa 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 Ganges in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be s _ibmitted to the county prior to installation. 5. Or site sewage systems must be properly maintained. The septic tank(s) must be purnpecl b 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, re,-onnection, 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. Tark information. Fill in the capacity of every new and/or ex':sting tank, list the total gallons, cumber of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complcte for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if talks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill ii 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%4 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 mon toeing groundwater, ground- water ccrtamination investigations and establishment of standards. SBD-6398 (R.11/88) I I I I I + ~ i 1 1~ 1; 1' I I I ~ I I I I' _ I i ~ T I I I I I I i I ~ I 1 I r l l, j I t , I ~I I i I L_ ~ ~ i I L! ~ + + I ~ i ! I I ! I I 1-- I - wIGrf - - r- - I--- I _ - I t I I i ~ I ~ I -17 , I I I I i I I - i i i I ~ it I I ~ I I I I I I I ~ ~ ~ I I I , ~ I I ! ~ ( S I , r- ; - T- - I j I I I~ ~ a ~ i ! I I I I 1 _ r f ' i I I I ! --I ! I 1 I I i ll 7 I I I_ I ! I I I ~ j I ! I I I I I I I I I ' : I I I I ~ I ~ I , r I 1 ' ~ , J_ I I_ I I , ' I T I 1 ~ I i I I I ~ ~ i I I I I I I ~ I r I I I I 1 I ~I I J 1 I + T 1 -TI 7-T-1-7-7 T I I I I I I I I I ! I I I , ! I I -r ! I I ! I _ I I I I I I I-------------- I t - i I i I - ter--_ I I- -I ~ I I I : j I I I I I j ' r j ~ j I I I i I I ; ~ j I I , I I I ' I - - - - i 1 i I r r ~ I ! r i I 1 I I i i ' f I I i I r , r t r i i i ~ I I i I i , , r Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY - -Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but f 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. i APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEW BY DATE PROPERTY OW 14 ER: Ae-- PROPERTY LOCATION GOVT. LOT 1/4 1/4,S T AR E (or) W PROPEATY OWNER':S MAILIN ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # CITY, E IP CODE PHONE NUMBER []CITY []VILLAGE ❑fOWN NEAREST ROAD ~Q New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building j j Replacement [ ] Public or commercial describe Code derived daily flow= gpd Recommended design loading rate gibed, gpd/ft2 ,.f trench, gpd/ft2 Absorption area required ~ bed, ft2 M trench, ft2 Maximum design loading rate _bed, gpd/ft2_L&__trench, gpd/ft2 Recommended infiltration surface elevation(s) 1 3~ ft (as referred to site plan benchmark) Additional design / si a considerations Parent material Flood plain elevation, if applicable A, ei ft T-GRADE SYSTEM IN FILL HOLDING TANK 7m I S =Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE A U= Unsuitable fors stem ® S E] U 0 S ❑ U S❑ U jZ S❑ U EIS O U ❑ S 71U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bouxiary Roots Bed Trench f' l Ground el C ft. eh, Depth to limiting fa tq or Remarks: Boring # f / _ Ground elev. ft. Depth to limiting factor FT Remarks: CST Name:-Please Prin Phone: - C Address: ` Signature: Date: CST Number: i ~r _ S PROPERTY OWNER °i,~..c~ SOIL DESCRIPTION REPORT Page,;~of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Co Color Gr. Sz. Sh. Bed Trerxh Ground elev. -j'L ft. Depth to limiting factor Remarks: j ' - - Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) i i I ; I I I I I I I I i , - - I i , I ~ _I I,/ 4 r ~ I , , I //~~~f,l✓"./~~~j1~~°~~ JAI//Y ~ I__ i I , I I I ~ ~ I I I_ ~ I I i I I ~ I , - - I I I I i_ l i I I ~ I!' I I' i I I I I ✓ f- i I Ij I I + I i_ I tO I i , I I I I I I ; ~ I Y ' I I + I ~ I - - - I I I I I I I I I I I i i { I ' _1 + ' I ~ I I I I I j I I I I I t + ~ I I I I I , , I I I I I Y ~ f , , I I i I , l i I I I I i , I I ~ I I- I I I 1 ~ I 1 1 _T w- _ _ - - - - - - - - : I I ~ ~ ~ I i I I ~ ~ : I , I ' , i I I i 1 I ' ' I I I _ I I , I 1 I I T i , ' I I 1 : I , , 1 1 I i I i i I i I i I C ~I 1 1 i ?4'- 36 S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _J "!l _e E?s ADDRESS IdQ r~ 41 FIRE NUMBER CITY/STATE1 ZIP_q dl PROPERTY LOCATIONo_1/4, rr 1/4, SECTION, T30 N-R-1-J-W TOWN OF OJT V d SPp ~ , St. Croix County, SUBDIVISION , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification 'form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1), the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/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 stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning Officer within 30 days of the three year expiration date. SIGNED: !//.'t)U_ Yg~ 1L",t__,1 DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 STC-100 This application form is to be completed in full and signed by jthe owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. ,Should this development be intended for resale by owner/contractor,(spec house), thenla second form should be retained and completed when the property' is sold and submitted to this office with the appropriate deed recording. . owner of property Location of•property~_1/4 X1/4, Section, T+ZN-R 9 W Township ST. C, ~f a Mailing address la0 3 ;7`~ 54K Address of site Soh»= Subdivision name Lot no. other homes on property? yes =No Previous owner of property Total size of parcel Date parcel-was created Are all corners and lot lines identifiable? `L _Yes No Is this property being developed for (spec house)? Yes ~'No Volume,2-f-=2 and. Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded n the office of the County Register of Deeds as Document No._7 and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document No. sign o applicant Co-applicant I Date of Signature Date of Signature 7 a 00QUM06T MID. 40 TAT 1d E Norell and Beatrice Ann Norell, , lit te .nants' 1 . • • , ......-.L' Michael enzen,...Jr: Ar C"V"s sad wa:r.ab is . I\ -'TYRN TO . . . 1' _ . . the feaswiaQ *off*" l teal stab in St Croix county. yB e1 of land in the 3L) of the SEf ounty of it Cre ° W 19 West, Town of St. Joseph as n, ' more fully described. as follows : Commencing' Ott - I ibrner of said Section 34, thence 389'33'04"Es 1'9318-66 South line of the SEA of said Section 34 to the SE.zornv, Ift.v ne SEk of said Section 34 and the point of begin ge piion; thence N00'2534"E, 583.16 feet along the-LaaVli 4 off... the SE% of said Section 34; thence N89' 27' 37"W*. 33 z Vestor2y right of way line of said County Trunk Highway a ~t, J~ Prly along said Westerly right of way line (whiah Baat~t: dine of a Certified Survel Map dated June 21, 1982= , ,a~gcpr~ed may 3,1984 in Vol. "5' Certified Survey Maps, at .,PQ.aWment,: No. 3.93031 in the office of the Register off: De!a Wisconsin). to the point where it intorsad ' Croix County, 3~ri r bt of e, Sg%. of said, Sect ion 34; thence S89 33 d l of ti -SEk of Section 34 to the point," ` m the right' of way..for County Trunk Highway 0AW ro r in iio easel>~ents, restrictions and rights-of~-waf tiba tots record, if any day of January Ann Norell -~r~►1d'`~E. Narell Beatrice f r ('SEAL) 4 'lJiia 'Z ACKNO W LSDO" STATE OF WISCONSIN • St. Croix .cotlAt~. a sM _ p~etiarid Wocel,i , heat .Natty" Norell u7ur 84ta) to me known to the Ix""a }5 ~ f r intitru n iew! adt sue,>E. ~ . .~~k. ST. CROIX COUNTY WISCONSIN =`t ZONING OFFICE r""u""' """d ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 i September 7, 1995 Mr. Mike Lenzen, Jr. 1203 County Road I Hudson, Wisconsin 54016 RE: Septic System Dear Mr. Lenzen: Per your recent request, enclosed is a copy of the As Built for your sanitary system. If there is anything else that you need, please do not hesitate in contacting our office. Very sincerely, r Marilyn K. ais Administra ive Secretary mz Enclosure