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H.ighwaten i'iiMVIN(; CHAMBER tir : t - gat on.6 Pump Manu6dctu4e4 -Model Numb e4_. II~~I UIN(; I NK t gafton4 Numbeh o6 Cumpantme.n.t~s I'i inlr ~t At hrrr Sye te.m r,,i , (hrrrll":""'"'"litl'p"C'x. Bc4itdiny 120 s kope H.ighwa.ten~ X11, .ril l'I 10N SITE ' I„',I Th,e'nch I' (.trt~~i' Thom: We:.Qk---- Buf2" eXupe..___.__ H ighwa.te n~ ION SITE DIMENSIONS iv; I(It theneh 6t Reyudh.ed a&e,a I,•tt(ifh cr6 each tine 6-t Depth o6 hock beeow t.i.xe.- _.___._-_tn Wir bvit t,6 y4'jje.e Depth o6 hock oveh tiPe_~ do I. r~tl' Yerty,th 06 X•i-nee_ 6.t Depth o6 tite bvZow ghade __._.<rt 16 between Yinea 6 Zope oA .the.neh. en. I-,rat 100 Al I (~If' ah'so4p.tioYt ()6 Coveh 1'(l~,r~t UO elnuty I' I uIMI.NSION.S Nttutl,rh u6 yrri..tb G)Lavee ahound Ue.A nu Ou tAi de di ame.tvi. 6x De:p:th bexow i.nfe-t 6t 1i- (ttP absohp-tion ah.ea 6-t IN~I11 C11 U Uv TITLE A1'I'RoV1D DATE 198 I:I If('f['U DATE 198 ci A, (oN IOR REJECTION a State Permit # / PLB 6 7 State and County Permit Application County Perm t # ~for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: 67~4 5~ S-/. fi9UL klA A) If B. LOCATION: 00 WJJE Section G2,~, T_2,0 N, R AO E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township n"6_%re& C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance Single family 2!~, Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY 1 0070 Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete-'09,- Poured-in-Place Steel Fiberglass Other (specify) New Installations Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: Length Width Depth Tile depth (top) No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land Distance from critical slope WATER SUPPLY: Private P~ Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized t effluent disposal system from the EH-115 prepared by the Certified oi4 Tester, NAME C.S.T. # if and other information obtained from (owner/builder). Plumber's SignaturV1 MP/MP SW# f Phone N4. A-1-n Plumber's Address ° PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application jr/ FeesPaid: State County 44 Date Permit Issued/Rejeeted (date) 7- Issuing Agent Name Inspection YesX_No State Valid* Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1 /78 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS ANDIPERCOLATION TESTS y~ f,.OCATION° ',l., '4, Section , T N, R L'2 E (or) W, Township or Municipality l nt Na. Block No. w _ _County u Ivision am e Owner's Name: Mailing Addrexs: ]7Fr}}gq734@}baCYtt - ' R 'q; Pi ♦ # ~ 49,.E 17 1 TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT WSPOSALSYSTEM; NEW ADDITION_ ~ REPLACEMENT TESTS DATES OBSERVATIONS MADE: , -.SOIL BORINGS 2/27 2 PERCOLATION SOILMAPSHEET SOIL_TYPE PERCOLATION TESTS TEST 08"H CHAf ICIER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEE; INCHES RATE NUM- WCH15S THICKNESS IN INCHES- SINCE HOLE HOLE AFTER INTERVAL DER 1STINETTED SWELLING IN MINUTES PERIOD 1 PERIOD ;2 PERIOD 3 MtNN e i S P-.,. P-: r,,F SOIL $O Q0 STS A r, _ r n s. is : CHARACTER OF SOIL WITH TH1'CKNESS;4NCHES..,. TEST TOTAL DEPTH DEPT H GRC l f1IDWATER; INC NUMBER INCHES O"tFIVED ESTII~TEp°H!GHisS ~ (DEPTH TO BEDROCK if; QSSERVE6) , i 19- e } PLAN VIEW (Locate petc7olationtests,soll bore hogs and suitable soil areas.) + t Indicate ion the plan -'the locationand square feet of suitable areas. Indicate number gf-square°fnet of absorption i~ft needed, -for building type rizbntal and ve tcat refere points. Indicate sl6pe Indicate etel is or,ofst , iv*ho t tr . - A t N r 77 V 1, the undersigned', hereby certify that the sail tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Arhninistrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (Print) :d .i • rv~...r Certification No. I' . Addres _ . Name of installer if known - - CST Signature Cq# Fi OR .8C7 'tEST9$t i e1 1"):F Aj /U IS rP LT le Lu y IV F vy sec zs' rt&0 1 0~ Wood ~~~p N`~Is emPtiQr~ ~2o QnSEfl LI N ti t 5 IN5TA 11 'NSW (CAI 16t . Ssc p nC, ~X~STrN~ ~b2.ArtiF~~~.D f a ~ ~ C-,~v AT ~ ~o ~ r~D 2oo~ to 0 Mi!- AS BUILT SANITARY SYSTEM REPORT OWNER ~e N r~ S ~e~C S o r.J TOWNSHIP SECTION -T-3-L-N-R Q O W ADDRESS W d0 o) Ar)U C. ou dL r' ST. CROIX COUNTY, WISCONSIN SUBDIVISION W OoA ~'rrvr~ t1 1 S LOT ay LOT SIZE PLAN VIEW N SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM loo U G di3 11, 31, INDICATE NORTH ARROW BENCHMARK: Elevation and description: )00, Alternate benchmark SEPTIC TANK : Marl;~4L4 T -q Rings used: Manhole coves elev: 00jOFinal grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear'~-Ft. IUD From nearest prop. line:Front , Side , Rear X Ft. IS No. of feet from: Well 70' , 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 l0 o 0 SOIL ABSORPTION SYSTEM 1 Opt y, - 93.-77 a 9 D ~N n 9 -77 Bed: 111/ Trench: SS e~p gge Pit: Width: Length 1 Number of Lines:~Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: `la No. feet from nearest prop. line:Front 3 o Side , Rear Ft. No. feet from well: ~U No. feet from building l0} 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:- a PLUMBER ON JOB: ll 6ti ".r1 u LICENSE NUMBER: (J 6/90:cj ~~Si'aYtrrt~rTtbf lr4TdQSt~' ~tPH 25. 30 .PRIVATE'~~V'VAG~ SYTEM ' WOODL County: .Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 186510 PeanitHolt~ar's Name: ❑ City ❑ Village ❑kown of: State Plan ID No.: IS J & ROBIN K ST. JOSEPH CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 030-2082-40-000 TANK INFORMATION ELEVATION DATA A9200394 /a 1-7 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic /7- Benchmark e'd f Dosing C-g Aeration Bklg. SVWE Holding St/ ptinreT' TANK SETBACK INFORMATION St/O Outlet -Z-,?s 98.09 Verit irito ntake ROAD Dt Inlet TANKTO P/L WELL BLDG. A Septic >75-0, NA Dt Bottom DoSif~ NA Header- Aeration NA Dist. Pipe Holding Bot. System 0 PUMP/ SIPHON INFORMATION Final Grad t 3,90' 9MI' ~2 or ` 7 Manufactur. Demand M68el Number GPM TDH Lift Friction System TDH Ft oss mead Forcemain Length Dia. mis . SOIL ABSORPTION SYSTEM BED/TRENCH Width r Length p r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS MEN I N SYSTEM TO P/L BLDG WELL LAKE/STREAM L CHING Manufacturer: SETBACK CHA ER INFORMATION Type0 i 1 UNI Mode Number: System: S d DISTRIBUTION SYSTEM Header HFhanifefrJ ii Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length _/"7 / Dia JL Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over DDepth Over \ xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center - Bed /Trench Edges L% Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 25.30.20.701,NW,NW, LOT 24, WOODLAND CT. 4 +4r` / c V F,e,,j:'t C! Plan revision required? ❑ Yes ► IK-0 q Use other side for additional information. 116 lzo I&' ~ P/T/ / SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: DILHR SANITARY PERMIT APPLICATION couN n In accord with ILHR 83.05, Wis. Adm. Code STATESANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than It 8% x 11 inches in size. ❑ e ion to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPE OWNER A P PROPERTY OCATION P_ N N 1 4 ~S D ]J NW Y,, %a, S ;JS 0 N, R Q E (or) W PROP R TER USAILIN9 ADDRESS LOT # BLOCK # 0ODIA~P C N CI ST T N W if t I ZIP COODEE PHONE UER SUBDIVISION TLt OR C IM NUMBER r 8 A0o)7 II. TYPE OF BUILDING: Check one CITY : NEARE TROD ( ) State Owned 0 VILLAGE S 0(?P ~U ❑ Public EX1 or 2 Fam. Dwelling4 of bedrooms PARCEL AX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) o 1 ❑ Apt/Condo `J 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.E1 New 2. ZN Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit _ Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 M 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 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE O REOIJI7ED (Q. ft.) PROP ~D (sq. ft.) (Gals/da /sq. ft.) Z.-3 fc) ELEVATION Feet 7 Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New Existing Pallons Tanks Manufacturer's Name C ncr t structed Con- Steel glass Plastic App Ta ks Tanks Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signatu : (No Stamps) MP/MPRSW N Business Phone Number: :51 ryN ~Bowy\ 4 Plum er' d1re~oStr~et, C ygt C K 88 ~\v\ 'lt?75~~ )S' IX. C UN DEPARTMENT USE ONLY ❑ Disapproved Sal'tary Permit Fee (Includes Groundwater Date Issued Issuing Age Signatur s Surcharge Fee) Approved ❑ Owner Given Initial C01- 1_~ *1 71 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 It INSTRUCTIONS t 1. -•.A sanitary-permit is valid for two (2) years. 2. Yobr sanitary permit may be renewed before the expiration date, and at the time of renewr1I 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 (SB[) 6399) to be submitted to the count&riorlo~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: t 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. • Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete! for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains, 'water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems, replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump 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) E C T 67 PLO I A N 1) 0 S, S ,1,1 ..0 AEI QUA _ l_ C E NS E-~ 3`L(2 Nwrnn.rxWrwu.. Mnw. .1 a ♦ ..v. Na i. • .wrw.srn_wW.s... i . . ~r.H . a a y _x pp g 13P~ . 0 ~ Q u~ hLV" A' to T Ve ~ P` 6IJ oil ~1'~PQQ Qo~~ hoe S,'~P , C' O 1 11 I FRESH AI1'. INLETS AND OBSERVATION PIPE C11OSS SECTION Approved Vent Cap Minimum 12'1 Above J\ 9 -7'"p Fin~i1_faa ie 4" Cast Iron Above Pipe Vent Pipe ' To Final Grada Marsh Hay Or Synthetic Covering Min. 2" Aggr.oyl(o l _ Over Pipe D.i.stribution --'fee Pipe Aggregate Perforated Pip P.e 10., BAW- llencath Pipe ~t ----Coupling Ter.minai:i.ng r Bottom of System E LDINGS 'r DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS • I'fVDUSTRY„ 1 P.O. BOX 7969 + LABOR AND PERCOLATION TESTS (115) MADISON, WI 53701 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) lip CA TOWNSHIP! LOT NO.: BLK. NO.: SUBDIVI N/ S A ' L ;ION: ' ;SECTION: W U / H/R of (or)n ~o9 h C NTY: R'S YER' E: M ILING ADDRESS: Crv' pe_Ayr~mj DATES OBSERVATIONS MADE USE PROF[ D RIPTIONS: PER OL 10 ESTS: =BEDRW.: ERCIESCRIPTION: ❑ New ~ieplace esidence O z Z RATING: S= Site suitable for system U= Site unsuitable for system ONVENTION~VM 1111111 ND-PRESSURE::: SYSTEM-IN-FILL HOLDING TANK: RE COMMEE~NyDDE,yD SYSTEM (optional) ®S 0SUS El U El S CRU ElS 1.~~'~1~~"•~IONr~ O'lim If any portion of the tested area is in the DESIGN RATE: If Percolation Tests are NOT required ~y under s. ILHR 83.09(5)(b), indicate: 3 29 / Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPT L~VATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE A BRV. ON BACK.) / Z. % , ns qr r o 79, 7 All > 7.9 g, o B- 3 ,p 7~Z. B- B- 6- PERCOLATION TESTS TEST WATERINHOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES DEPT NUMBER AFTER SWELLING INTERVAL-MIN. PE OD 1 JEOD 2 P PEERINCH P- P_ 3d 28;13 c 0 3,29 Pf- 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. SYSTEM ELEVATION •G/ l7 E 4 E _ S 3 I 9 w~ , I A /44 rye` /(90,0 TO, k f, a .x 10 ell g, Pere- r E KOIc SIYCS~ O\.._-_ t ) x N Lh~ 501- _ - it 0' C - i I E 4 f"ed ll A. L c~4 csf ~c~ j° 1, the undersigned, hereby certify that the soil tests reported this form were made by me in accord with the procedures methods specified in the Wisconsin r~ 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 W E C PLETED ON: CER IFI TION NUMBER: PHONE NUMBER(optional): ADDRESS: CST IG All< DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) OVER - r ,TIONS ILE" i 11- - - - 6395 To I ° a o --irate i report n, inctude: 2. The ct:ion ri1~ residence or Commercial project; 1 MAX3,`, _ sur rrrs t. cr red; 4. Is th` £F ~t $y3€.C"ii2 h. Com _ 3ing boxes. A TL . LE FOR A ""?LDING TANK ONLY I ALL OTI+ 'ULED OUT =SED 'L CON 1Lf 6. P L E ° u s for b T! ofile descriptions and completing the plot plan; 7, 1AK' ~j )catirrg y - ~ test locations. [drawing to scale is preferred. A r S. " vat ion reference point are clearly shown, and are permanent; . Co a: names, addresses, flood plain data, percolation test exerrip- tio 10, I _ °!Oorl plain a,es not ap; Y< NA. in the appropriate box; 11. S'in ti Jr cull el our certifi3.__ 12. Make le T! id 'istribute ALL. SOIL TESTS LUST BE FILED V,,,'ITH THE LOCAL %U rY WITHIN 30 DAYS( ~CMPLETION. EVIATIONS FOR CERTIFIED SOIL TESTERS Soil ` d Textures mbols st: tover lt, X-x cob - C 1 - 1, ' _ ~Istone g#- G ( Oder 3"} = Lirnestor° : I l'gh Gi 3ti ~nr r 6 rnecl r, Sand E am BI - ? Gy r cr arm Y sc - Loam H sicl Clay Loam rnot ~)tties Clay Clay fff faint cc non, coarse y nnrr7 y, medium r9 d P pl minent HVVL Hi w sposaI V1 i ce 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. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certif Othat I have inspected the septic tank presently serving the ~Jm 1 S f)-P'1'7~ `2. f 0 !J residence located at: N b 1/4, _1/4,. Sec. T30N, R W , Town of Upon Inspection, I certify that I have found the tank and baff'lee"'to be in good condition, and it appears to be functioning properly. Last time serviced 161~56-a Did flow back occur fr m 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 k own): I a RAA^,kw 0144 (S nature) (Name) Please Print I'Yl PCz 3y U (Title) Q (License Number) (Date) Form to be completed by licensed plumber (s.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 inspectionn'opening over outlet baffle . Name ) k,,% ►M~. 'Q✓( Signature /MPRS 5/88 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~h h S S-- 4~ Q~ I R PCICLS C& ADDRESS:- W 00 d I Ld (~CU t, FIRE NO: 13,# LOCATION: 1/4, 1/4, SEC. T 30 N-Rj2_(J__W, TOWN OF: ST. CROIX COUNTY SUBDIVISION: Wo v 124~, ~ 4,]]J--LOT NO. o 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:- DATE: /'o lo =-2 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 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 1) 15 qJ- 061ry -PC r~n Location of propertyU W1/4 1/4, Section , T3N-R:~ U W Township Mailing address clod to c a, Hot) I n 1;~~ ~ Address of site (t. 4ukkll- subdivision name OCC41am Lot no. ' Other homes on property? yes__ _No Previous owner of property _ r (1 U h J Total size of parcel Ig QQy Date parcel was created ' C( 7 d Are all corners and lot lines identifiable? _x .Yes No Is this operty being developed for (spec house)? Yes )<N0 x.45 Volume ) and Page Number S as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, ;would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the offic of the County Register of Deeds as Document No. 3'7/by3 c`• 3o ~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 r ecorded in the office of County Register of deeds as Document No- 2 Mal- ~4-4- 71-1 Si ature o applicant Co-applicant Date f Signature Date of Signature Y' STATE BAR OF WISCONSIN-FORM t i iC U M E NT NO 622 ~r WARRANTY DEED -Pqy,-M VOL i AUi 556 THIS SPACE RESERVED FOR RECORDING DATA This Deed, made between Way??-eREGIVERS OFFICE Dianne ,_H-,-_Johnston-,_,-husbans3-- an.d_--wife.-ansi------ ST. CROIX CO., WIS. = Qh.- in-his-.or _hex...oca_n_-separate_.r_ight.,------------ Roca. for Reoord this 15th -....Grantor - nd . --Robin K.---Atkins,. ,.a--single--person day of Dec. A. D. 1980 IR:I t 12:2 •--Grantee, UL - vl'i'tl" eseth That the said Grantor, for a valuable consideration.--..... eamw of Dow$ '..:1,iteo Cie +ol?owing described real estate in St. Croix NTO of Tax Key No. Lot 24, Woodland Hills Addition to the Town . of St. Joseph, St. Croix County, Wisconsin. not i,;s homestead property. kkXA:kXXMx To.,zether with all and singular the hereditaments and appurtenances thereunto belonging; An,! . grantors,-Wayne---J...-_Jiahrnstan---and.-Dianne.._H..__,Johns.ton- ...-,r.nt: ,that the title is good, indefeasible in fee simple and free and clear of encumbrances except utility easements and covenants, if any, of record. I warrant and defend the same. ~ tais day of D-ecenb_er-------------------------------, I9...8.0L. - - . - - - (SEAL) - - - -a. ---------------(SEAL) Wayne J. Johnston - - - (SEAL) Z7'J'_.(,~..:;1:u 7Z_! (SEAL) Dianne H. Johnston A.UTHENTICATI0N ACKNOWLED,G3MENT atu-es authenticated this . 15th day of STATE OF WISCONSIN Dece 80 mbar 1J- - ss. - ---•------.County. Personally came before me this day of ,ga~iiuel R. Carl - - the above named - I - i..E MEMBER STATE BAR OF WISCONSIN - iY not ;lutkorized by § 706.06, Wis. Stats.) T H,S INSTRUMENT WAS DRAFTED BY to me known to be the person .who executed the foregoing instrument and acknowledge the same. IjEYPQOn,CARI-.-&. _MURRAY-_by._Samue-l--R._.-Cart Hudson, Wisconsin, 54016 - . Notary Public .......County, Wis. I Si«natures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration ,ire not necessary.) date: I9......,.,). signing in any opacity .4hould. be typed or printed below their signatures. :<3t..^ TY DEED STATE BAR OF WISCONSIN Wisconsin Lersi Blank Co. Ine. y0*19 No.f -I #I? mawauktla, 'Wia, (Job $006 ) HC Mtu`e,Caroanrlmt STATE BAR OF WISCONSIN-FORM 3 'OCUN4 NT NO. QUIT CLAIM DEED } VO! ~~.41145 THIS SPACE RESER* FOR RECORDING DATA REGISTERS OFFICE /1) /Z - cr ~ h~' ~E' ~ ~ <o~ _ ST. CRO1X CO., WIS. - Recd. for Record this 23rd h „r. c?airrs to day of J~ _ A.D. 19.8i at 12:2 P. i - - w d pods ij t:._ following described real estate in S7` County, RE N TO state of Wisconsin: 1 li Jr'../ G (214 Tax Key No. C em's I i fj i i! i~ ,I is )1 iIV r homestead property. s) (is not) this day of 19. (SEAL) (SEAL) (SEAL) li (SEAL) AUTHENTICATION ACKNOWLEDGMENT denatures authenticated this-__--day of STATE OF WISCONSIN 19 SS. ~ C; rni x _County.. ; Personally came before me, this 23rd day of Jude the above named 'CIT .E: MEMBER STATE BAR OF WISCONSIN Robin Ke Paterson q authorized by §706.06, Wis. Stats.) 1 s' instrument was drafted by e fore- o me known to ~e"'#he pQrsor0 _ vied th 11'111' , g ing instrumenCa k dehd t ' i r4 {I - * ame n O t' -'"r . . I ' Count Wis. (Signatures may be authenticated or acknowledged. Both N t ry public ,-~a+--~---- y' Y not state expiration My Commission is per•tf+ary~ts,•.~ i are not necessary.) t, , 19.) date: i I t!r c i,s«k LyF',~r) TATS BAR OF WISCONSIN' VORM Into. 3-1977 REPT131 ST. JOSEPH ST. CROIX COUNTY ZONING PAGE 1 10/20/92 09:33 REQUESTS FOR INSPECTION WORK SHEETS FOR: 10/30/92 AREA: JT Activity: A9200394 10/30/92 Type: CONVSEPT Status: PENDING Constr: Address: ST. JOSEPH 25.30.20.701,NW,NW, LOT 24, WOODLAND CT. .•Patcel: 030-2082-40-000 Occ: Use: Description: 186510 Applicant: PETERSON, DENNIS J & ROBIN K Phone: Owner: PETERSON, DENNIS J & ROBIN K Phone: Contractor: BOUMEESTER, JIM Phone: 386-9020 Inspection Request Information..... Requestor: BOUMEESTER, JIM Phone: Req Time: 12:10 Comments: /07130 Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION I~ 4b AS BUILT SANITARY SYSTEM REPORT OWNER 4~z ,r TOWNS HIP-S~~SEC N. R2aW P.O. RESS z ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100FEET OF SYSTEM paj C11-0 SEPTIC- TANK (S) MFGR. /~5 CONCRETE I---STEEL N0, of rings on cover Depth g DRY WELL TRENCHES No. of width lengt~i - area BED no. of lines width lengt. area dept toy op of pi e AGGREGATE c ~d AREA AS BUILT 3p PERK RATE ARE REQUIRED DISCLAIMER: The inspection of this system by St, Croix County does not imply complete. compliance with State Administrative Codes_ There are other areas that it is not possible to inspect at this point of construction. St. Cron County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH SYSTEM. DATED PLUMBER ON JO - LICENSE I .3 1d -PORT OI' ITISPECTIOTI--IMUftDUAL SEWACE DISPOS. STEM Sanitary Permit • • r State Septic 71Y 7A:IE TOt•TNSHIP t. Croix County SRPTIC TA ?I: ~e x z t Q E` 'f ~ Size =0 gallons. "umber of Compartments Distance Front: Well ft, 12% or greater slope GV ft Building `eft, Wetlands f Iiighwater ft. DISPOSAL SYST :I Tile Field or Seepage Pit(s) Distance From: Well f ft. 12% or greater slope 4t Building ft. Wetlands f FIELD HiFhwater ft Total length of lines 03 ft, !lumber of lines Length of each line ft. Distance between lines ~4 ft. Width of the Y trench ft. Total absorption area sq. ft. Depth of rock below the in. Dp-pth of rock over tile ^ in.. Cover ...aver.rock Depth of the below grade Slope of . trench in per 100 ft. Depth to Bedrock ' ft. Depth to ground water ''rr £t. PITS ?dumber of pits tide diameter ft. Depth below inlet ft. Grave oun pit: `yes no. .Total absorption area sq. ft. Square feet of seepage trench bottom area required Mv. Square feet of se ge pit area required Inspecte Title:. Approv Date 197 Rejected Date 197 j L i EH 115 k WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 l MADISON, WISCONSIN 53701 ,(J REPORT ON SOIL BORINGS AND PERCOLATION TEST T LOCATION: A_~E_'/a, Section V-S-, V-2N, R& E (or) W, Township or Municipality, rye/ /~~c , Lot No. Block No. County / Subdivision Name Owner's Name: Mailing Address: :21A TYPE OF OCCUPANCY: Residence No. of Bedrooms 3 Other EFFLUENT DISPOSAL SYSTEM: NEW L~~.. ADDITION REPLACEMENT DATES OBSERVATIONS MAD/E::~ SOIL BORINGS 1 PER OLATION TESTS J ~7 SOIL MAP SHEET SOIL TYPE PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- I ~ ~ C• l ~~2 - ,F~ ~ 6 ~ s^ 3 l ~1i k/1 a s~ SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) By -7 -5 S B S Z' PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate nu er of square feet of abs ion area needed for building type and occupancy. t f s ,5 - ""'r n e scale or distances. Give horizontal and vertical reference points. Indicate slope. 0 y N ~ i 16 i I i I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) i , Certification No. -41 Address 06 1 ' C_ j s Name of installer if known CST Signature COPY A - LOCAL AUTHORITY PLB67 State and County State Permit # Permit Application County Permit for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY. Mailing Address: B. LOCATION: lc> '/4 ~L Y4, Section -2 T,gN, R2.1' E (or) W Lot# City Subdivision Name, nearest road, lake or landmar BIk# Village f Township g7~ s~~ C. TYPE OF OCCUPANCY Commercial / *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms 73 No. of Persons D. TYPE OF APPLIANCES:,Bishwasher YES NO Food Waste GrinderYES L O # of Bathrooms Automatic Washer ES NO Other (specify) E. SEPTIC TANK CAPACITY / /.>2'Z- Total gallons No. of tanks 6*-y. *Holding tank capacity Total gallons No. of tanks New Installation ( Addition Replacement _ Prefab Concrete y *Poured in Place Steel Other (specify) F. EFFLUENT,-DISPOSAL SYSTEM: Percolation Rate 1) _.5- 2)~ 3) Total Absorb Area _sq. ft. New , Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length j%) Width / Depth 3 „ Tile Depth Y No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size le-1 Percent slope of land e~ % Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certifie~j Soil Tester, NAME 61T 1 c . ! a s- c f AI 0,z f C.S.T. # /y / -3 and other information obtained from (owner/builder). _ Plumber's Signature r~ MP/MPRSW# Phone #2 yb - 5+ Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). / D 0 Vol Do Not Write in Space Below FOR DEPARTMENT USE ONLY Date of Application Fees Paid: Statez(9,00-C un Date O Permit Issued/ (date) Issuing Agent Name I Inspection Ye;rNo Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76