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HomeMy WebLinkAbout032-1092-40-000 ti -0 0 o O c o o N x O N 0) N i O ~ M a0 O C y -0 0 (1) w I O V m E N O M C NO O " O Ct co i a O C a.C C) m I CO ~I '7 L V tll O 4 O N tn C Oi O w C N O LL O N C 01n C N O N Q U O ) 3 ~ v ~ Z N a) LU C O Z y y M z a m o z ° O N d N 1- C N E (D O O O CL N O) (D O O ro O 04 •N d U) O O Q N CJ Z CO Z O N zo c E o R CL 4)r, cl 06 ) ~ y .a r i 0 0 0 a 0 16 E u~ 'T F Fes- ~ 0- i° 3 3: 3 • m a a a v o N E C' C' N N U rn rn ►~w Q) o 00 °o 04 Q) r- 00 p^'1 Q o o =3 0- LO w o m n ~ N Q ~ z Q m 0 C O 000 N C C In co o UJ (D 0) C) O" ~ M f" N O C Q Q. 0 O V _ - y G O N > c C E 0) o L 00 Un trx,] O c > CO M ~V Cj 00 N m E > n ca E U F O y w ~ E N v~ 0) n. #f c L: a w rr~~• u a d d c ~1 A ci a g 0 in 0 AS BUILT SANITARY SYSTEM REPORT OWNER ^l > U (1G~ TOWNSHIPs~r~S" SECTION T : /N-R d W ADDRESS a ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT : LOT SIZE GtGcfld PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f L7 `/7 r ' ,J l 1 a+/ V L.f. ~f. ASH/ r 7/l$Q f r' s1 G - 7S- B y INDICATE NORTH ARROW BENCHNARK:Elevation and description: ©Oc Alternate benchmark SEPTIC TANK: Manuf acturer: s' Liquid Cap. i Rings used: -L manhole cover elev: ±Ly Final grade elev: Tank inlet elev.: ®e_Tank outlet elev.: No. of feet from nearest road : Front , Side _z,, Rear Ft . 7 From nearest prop. line:Front , Side, Rear Ft. SD No. of feet from: Well Awe , Building: f (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE 1 i PUMP CHAMBER A , pp Manufacturer: Liquid Capacity: z5W Pump Model: Pump/Siphon Manuf act Zm 1-41ele - Pump Size Elevation of inlet: 2X 3 Bottom of tank elevation Pump on elev.:77Pump off elev.:-Z. Gallons/cycle: 2 2 S_ Alarm: Man.: Switch Type: -W Location - "i' I /I Awl. Distance from nearest prop. line: Front_, Sidej/, Rear_Ft.:;,:s-e Distance from: Well /~/A?l t Building SOIL ABSORPTION SYSTEM Bed: &1" Trench: Seepage Pit: Width: Length Number of Lines: Z Area Built_-2,O Exist. Grade Elev. /a 3. L Proposed Final Grade Elev. lD -X . 2 Fill depth to top of pipe: ~?O oil No. feet from nearest prop. line:FrontAW, Side v, Rear Ft. §2` No. feet from well: ~~N{ 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: INSPECTOR : DATE:-R/5-,/f- PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj LOCATION: SOMERSET 26.31.19.352B LOT 5 ~r~ VE. Count Wisconsin Department of Industry, PRIVATE SEWAtSY11~ y' Lauor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) sanitary ermit o.: GNERAt INFORMATION Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan I N6.: SOVA, WILLIAM SOMERSET B 7cr ption: Parcel Tax No.: CST BM Elev.: Insp. BM Elev.: 1 -7. TANK INFORMATION ELEVATION DATA A9200252 571OS-1~~ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark da,e2i Dosing CID . e. 7.3' Aeration Bldg. Sewer ' Holding St/ Ht Inlet gay TANK SETBACK INFORMATION St/ Ht Outlet g' SS Vent TANK TO P / L WELL BLDG. AirIto ntake ROAD Dt Inlet 03~ Air Septic NA Dt Bottom ,/,6 ' Dosing y 5 > NA Header khSasii-.- 6_2 143 Aeration NA Dist. Pipe 1 Holding T-771 Bot. System Zf~l 9Z 60 PUMP/ SIPHON INFORMATION Final Grade SDI ,o Manufacturer Demand d s. r SS k , 0/. 3 Model Number GPM g ~2 TDH Lift LOction System _ TDH x•(09 Ft mead Forcemain Length 3S'Dia. Dist. To Well S SOIL ABSORPTION SYSTEM BED/TRENCH width , Length i No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIME I N LEACHING Manufacturer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM INFORMATION Typeo CHAMBER Model Number: OR UNIT System: It f` DISTRIBUTION SYSTEM F eadeHDistribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake ength Dia. _ Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ` Depth Over i Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges ~0 Topsoil ❑ Yes ❑ No ❑ Yes F-1 No COMMENTS: (Include code discrepancies ersons present, etc.) _ I ~1 C 7 ~p~A 4 "r` F C~ n~t~2f 6 l Ft r > i Q1, , - /(C 4 C > c.l < J6, Plan revision required? es ❑ No Use other side for additional information. O g r S r SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH i SANITARY PERMIT NUMBER: " r ~ SANITARY PERMIT APPLICATION L1 DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% X 11 inches in size. Check 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. PROPERTY 70NER PROPERTY LOCATION ~ e- '/a S 7 Tj , N, R /f E (or)eV PROPERTY OWNER'S MAILIN ADDRESS LOT # BLOCK # d 4C- 5--CITY, STATE ZI CODE PHONE NUMBER SU DIVISION NAME OR CSM NUMBER r r t riot Z o 11. TYPE OF BUILDING' Check one CITY NEAREST ROAD ( ) State Owned ❑ LLAGE " G ❑ Public Yor 2 Fam. Dwelling4 of bedrooms .2- PAR EL X NUMBER(b) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo ~ - ~ ^ DOD 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 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. Eg/New 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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 O'eepage 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.) (Min./inch) ELEVATION -5-0 20 '?.P- Feet P-2.1 Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App INFORMATION Tanks Tanks structed Se tic Tank or Holdin Tank 'l eve 1 F] Ej Lift Pump Tank/Si hon Chamber wo o F-I F1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumb 's Signature: (No Stam ) MRlMPRSW No.: Business Phone Number: C/f c 2- 8 7 1~~ u er's Address (Street, C , State ip Code): GUS 57'y,, 2 IX. CO TY/DEPA TMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Do e Issue Issuing A ent Signa Approved El Owner Given Initial Surcharge Fee) ~ S A dverse Determination X. CONDITION OF APPROVAL/REA ~ /S,FO R DISAP VAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Saritary Permit Transfer/Renewal For-n (S''D 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. ll. 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. Compete 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 appropricte 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, !ocation of holding tank(s), septic tank(s) or other':reatroent tanks; bui;Ding sewers; wells;; water mains/water service; streams and lakes: pump or siphon tanks; distribution boxes; soil absorption systems,; replacement system areas; and thc- location of the building se red; l3) horizontal and vertical elevation reference points; i) complete specifications for pumps and =controls; dose volurne; elevation differences, friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil ,absor;rtior. system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 41n included i.he creation of surcharges (fees) r a number of regulated practices which can effect groundwater. Tr? ~ i~ionies collccted through there surcharges are used fair monitoring groundw;kler, woi,nd- water contamination investigations and establishment o"starrd:ftrda' SBD-6398 (R.11/881 7ffiLHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANIT P~ # -Attach complete plans (to the county copy only) for the system, on paper not less than I~t / ~ 8%s x 11 inches in size. u ch~Cklf Zsion to revious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION i" Q S®r/Q ,U_'/aS~'/4,S 33 T N,R / E(or PROPERTY OWNER'S MAILING ADDIjESS LOT # BLOCK # CITY, STATE ZI CODE PHONE NUMBER O SM NUMBER P o?Z vD/. 9s~ ' yysisrG Li TY II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ cILL AGE NEAREST ROAD Pr AT Y P ublic LJ1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUMBER( S) III. BUILDING USE: (If building type is public, check all that apply) 0 3 s- o Z- Ya - 002> 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 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. ET/New 2.E] Replacement 3. El Replacement of 4.0 Reconnection of 5. El 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 LJ 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 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 40.0 60 6D , 6 3 ..5 7 Feet L . Z Feet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xistin Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank ZOV 2Dd Lift Pump Tank/Si hon Chamber c9 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): ber's Si -A71P/MPRSW No.: Business Phone Number: ley -er -3 .2- 3 91 .7 Y'9 3,CS lumber's Address (Street, Gfty, State, ip Code): /3 p w~ 023 IX. COUNTY/ EPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater a e Issue Issuing Agent Signature (No Stamps) Approved ❑ owner Given Initial Surcharge Fee) ~--7 Adv a Det rmin lion / X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renevral 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 (SED 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 seviage 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 applicatiomust include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must irclude the following: A) plot plan, drawn to sc de or with complete dimersions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; v elis; water -Tlair,:Jwater service; streams and !apes; pump or siphon tanks; distribution boxes.; sni! absorption systems; repl.;cement system areas; and fh`? location of the building served; B) horizontal and vertical elevation n~ f~,r=n:;~~ points; C) complete specifications for pumps and controls; dose volume; elevation difference!;; `ric ion 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 19F3 'N;sconsin A4t 410 r,cluded the creation of sw charges (fees) for a number csf regulated practices which can effect groundwater. The rnonies collected through these surcharges are used for monitoring groundwater, rgrc>ai?d- water contamination investigations and establishmd ofVatndard~. SBD-6398 (R.11/88) 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. N of property k_') N S © v Location of property_ F- 1/4 -6F-1/4, Section , T 3) N-R~W Township a+n ev- s C } Mailing address V/ 9 ST/L L W i-%A E aA). Address of site Il017~~ Subdivision name- phi GCf( S Lot no. Other homes on property? yes_X No 7 ; Previous owner of property Total size of parcel 5• Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume 1-17 Page Number <9 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 t'n t e office of the County Register of Deeds as Document No. 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 record d i the office of County Register of deeds as Document No. Signature of applicant Co-applicant Date of Signature Date of Signature I ~I i I~ DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA ~/qq 85 pp STATE BAR OF WISCONSIN FORM 2 -1982! VOL 9D 1 pt, E 09 = REGISTER'S OFFICE Wallace A. Billy and Katherine M. BillY•: husband ST CROIX CO, m and wife & Recd for Record JUN 26 1992 conveys and warrants to William--A..-Sova 2 :20 P. M . - - - . Req!ofDee& . _ • RETURN TO the following described real estate in St.-Croix • County, State of Wisconsin: Tax Parcel No: Parcel #5 - A parcel of land located in NE 1/4 of SE 1/4 of Section y~~ C 33-31-19, Town of Somerset, described as follows: Commencing at E 1/4 corner of said Section 33, thence N. 89 degrees 30 minutes W (true bearing) 915.04 feet along N line of said SE 1/4 to point of beginning; thence S 1 degree 45 minutes 40 seconds W 793.54 feet thence N 85 degrees, 09 minutes 30 seconds W 61.02 feet along Nly right-of-way line of a proposed town road; thence Nally 239.51 feet along Nly right-of-way line of a proposed town road on a 1333.00 feet radius curve concave SEly whose chord bears N 71 degrees 27 minutes 10 seconds @ 239.19 feet; thence N 1 degree 45 minutes 40 seconds E 714.79 feet; thence S 89 degrees 30 minutes E 290.00 feet along said N line of SE 1/4 to point of beginning, St. Croix County, Wisconsin. ,dq~ 5 ~3 lob .:S (lot) This is not homestead property. (is) (is not) Exception to warranties : Dated this 16th day of Jurie,,...... 19.92... (SEAL) (SEAL) Wa lace A. Billy - - - .....(SEAL) .....(SEAL) W Katherine -M.Billy- AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF 'NWY,~6~ MINNESOTA i ss- Washington County. 16th authenticated this day of 19 Personally came before me this .-..............day of June 19.92_. the above named Wallace A. Bill acid Katherine M. Bill + husband and wife TITLE: MEMBER STATE BAR OF WISCONSIN (If not- authorized by § 706.06, Wis. Stats.) me known to be-.t erson who who executed the ' for oing instr ent an acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY First Security Title _ aula M. J 4525 White Bear Parkway ~ltgg $ear TT~aake~, Y© Notary Public ------R----Sey------------- Count , 5 Minn. (signatures may~Ee al~thenticate1or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date o .sa.sc - 19 4 of persons signing in any capacity should be typed or printed below their signatures s N r I' ' ' ry.. MY COMMI.SS.QtJ EXRiR15 1.12•F7 WARRANTY PFFD- STA'rF BAR nF WISCnNS1N T,,r-p; Wi~rnnsin na Rl;ink nr S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER (mil L ( Crl "1 " ' YA ADDRESST~ Av Co WE LZ FIRE NUMBER CITY/STATE( l l ~(/~-~~GL ~✓lJ ' ZIP PROPERTY LOCATION: NE 1/4 , F 1/4, SECTION 33 , T I N-R_-Z-W TOWN OF Flo hers , 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: DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 ' • N~ j TDM HEAD 6 ] tU 301- TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE EFFLUENT ANDDEWATERING SS SERIES 53-55-57-59 97 137.139 163 165 kf M LTRS 1 LTRS LiRS ( LTRS ',..1 LTRS t 28 -r`-1152 163 248 <7 394 f 231 231 It EFFLUENT AND DEWATERING 3.05 129 216 300 1 231 231 jj 4.57 72 163 s~ 242 1 227 227 26- \ f . % 1223 227 SEWAGE AND D6: WATERING •-6 1-0 104 136 7.62 8 30 216 '7 223 9.14 j 206 s 220 \ 24 12.19 172 206 ` 15.24 11125 '1191 a .-1 \ 18.29 1- 57 41 161 \ ; J 22 21.34 114 ? \ \ 24.38 4 53 R ~V~e O DE11-\\ MODEL Lock Valve: ~ 19 24.5 26' 66' 87' 20 1631- \ 1165 TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE F!t~ \ SEWAGE AND DEWATERING l` \ SERIES 267 268 282 284 293 I1 18 \ \ M LTRS LTRS L LTRS LTRS ^.G LTRS 1.52 408 'i 386 492 681 t?'i: ! 3.05 227 273 360 598 49 16 ` 4.57 76 163 f 238 ' 511 6.10 0 30 3125 7.04 401 \ 7.62 288 14 \ 1 9.14 163 292 t \ 10.67 60 227 12.19 ~6` 174 \ - 13,72 28: 106 12 \ 50 15.24 45 ` MODEL Lock Valve 18' 21' 26' 3s' 53' 10 .55 \ 293- 30 MODELS 1115- , 137 139 j 6 8 w w` MODEL 15 284 i 4 MODEL MODEL c i 282 r 10 268 - 2 MODEL 5 53, 55, MODEL MODEL 57,59 97 267 0 - GALS..' .1~i ` 20 0 407 "50_ 50 1 z/5'"'80.1 1 90 in ..10 120 1140 150. 1"67777-6 190 190 LITERS 80 160 240 320 400 480 560 640 650 FLOW PER MINUTE 3280 Old Mllle ns Lane Manufacturers ol.. . Zj2LLEf'' TZ Box 16347 I Louisville, Kentucky 40216 l (502) 778-2731 ,OUa[,rY PUMPS jiNCE /939 E I 8 F PAGE OF PUMP CHAMBER CROSS SECTIOW AND SPECIFICATIONS VENT CAP l"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING __T JUNCTION BOX MANHOLE COVER 25' FROM DOOR, 12"MID. wIM00W OR FRESH I AIR INTAKE GRADE I y" MIN. I I 18"MIA1. _ • COIJDUIT IB"MIN. \ \ ~11 ~ PROVID Im1-.F:l" AIRTIGHTESEAL I I i ( -~--f- v T APPROVEC JOINT A I III APPROVED JOINTS J/C.Z. PIPE. I III W/C.S. PIPE EXTEND[A]C+ 3' I *ALARIA EXTENDING 3' lQTO SO!.ID SCt• ONTO SOLID SOIL ow C I I . I PUMP ~ OFF D CONCRETE BLOCK - RISER EXIT PERMITTED OWL4 IF TANK MANUFACTURQR HAS SUCH APPROVAL SPECIFICATIOUS TIC AND TANKS MANUFACTURER: ~~lf •fc 'NUMBER OF DOSES: ~ PER OAy TANK SIZE : GALLOUS DOSE VOLUME ALARM MANUFACTURER' INCLUDINCP BACKFLOW: 3V-3 GALLONS MODEL NUMBER: n v L CAPACITIES: A= 2 INCHE5 OR -i74 GALLONS SWITCH Ty1121[6: -r B= Z INCHES OR 34 GALLONS PUMP MANUFACTURER: .2g 1/-4/7 CINCHES OR 1 GALLONS MODEL NUMBER: if 7 D- INCHES OR GALLONS y5^ figD SWITCH TYPE: hlt!~gdddgg NOTE: PUMP AMD ALARM ARE TO BE PUMP DISCHARl.E RATE I GpM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE Bi9'WEEAI PUMP OFF AND DISTRIBUTION PIPE.. _/~p FEET + MIUIMUM NETWORK SUPPLY PRESSURTT,E//.. . . . . . . FEET FEET OF FORCE MAIN X 2 F/ooFLFRICTION FACTOR..FEET TOTAL DtIWAMIC. HEAD FEET INTERNAL DIMENSIOWS OF TANK: LEMCaTH ;WIDTH ~2 .;LIQUID DEPTH SIGNED: LICENSE DUMBER: DATE: 16 92 -117- ~ . M Na - z LDINGS D2 USTRY, T OF REPORT ON SOIL. BORINGS AND SAFETY & BUILDINGS •IIVDUSTRI( P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707 HUMAN RELATIONS (ILHR 83.090) & Chapter 145) LOCATION: SECTION: TOWNSHIP/MINE-W-A- LTV LOT NO.: B K O.: SUBDIVISION NAME: 1/ 3 /T~ N/R E to c r COUNT OWNER'S BUYER'S NAME: JVILINGADDRES3.:: S OL9 r 49A I& -r /N -G., O A. N USE y 2 ~JS~ DATES OBSERVATIONS MADE FNONE-DRMS.: COMMERC AL! ESCRIPTION: PROFILE DESCRIPTIONS: ER CATION TESTS: TT3esidence [~~w ❑Replace Z ,r AL RATING: S= Site suitable for system U= Site unsuitable for system -771 CONVENTIONAL: MOUND: IN-GROUND•PRESSURE: SYSTEM-IN-FILL HOLDING TANIK: RECOMMENDED SYSTEM: (optional) ❑ U ❑ S CAN ❑~J s ❑ u ❑ s ❑~u ❑ s If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGH-EST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) ~6 B- r 9/ 63,2' dH{ > T/ 3'1, i4 ms. J F ,7 S A P/ 0.2, Z < / /S/ •9 ~pi~S . 7' n~ 8 n A'3111 t /.3 li hf Bq oz B- B- > 3 lJ.r -c s B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH 3 ~ P- I P- n P- Z P- P- 3 3 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- zo t 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 o la d slope. Y TEM ELEVATION 9f, - " _mm___ - - 3 e E : 3 g t a tN5 m i nR, _~~a I h Al I _ i ~ ~Ik . x E.. nt ~B"Njvto v 3 3 ' , s # ~ r# =Soo°n~ u Ld V s !d2 ~/j' *3 = b~ 1 i I17SP 3 2.2 I, t eundersigned, 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: DAVE FOGERTY PLUMBING Jr ADDRESS: Licensed CERTIFICATI N N MBER: PHONE NUMBER(optional): 63233 #13289 ROBE S, WISCONSIN 54023 CST SIGNATUR Phone 749-3656 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) OVER - r~ I i DAVE FOMTY PLUMB11% h Licensed Perk Tester & Plumber 63233 a #43289 ROBE WISCO NS 66 jq ~x ~ ss XL/ /8' sy " #3--- -J s i e L ~ 3 10 ,z oz h4 ® ~ - RJSN NI f/00.'D 1 ~ 1 h a.~ a7 `P)f ~ 7Al I I o Pet- k ~ ~ _ ~i~-rC t co Y' N r ✓ '~os f I l REPT131 SOMERSET ST. CROIX COUNTY ZONING PAGE 1 08/05/92 10:58 REQUESTS FOR INSPECTION WORK SHEETS FOR: 8/ 5/92 AREA: JT Activity: A9200252 8/ 5/92 Type: CONVSEPT Status: PENDING Constr: .Address: SOMERSET 26.31.19.352B,LOT 5, 184TH AVE. Parcel: 032-1072-40-000 Occ: Use: Description: 171486 Applicant: SOVA, WILLIAM Phone: Owner: SOVA, WILLIAM Phone: Contractor: FOGERTY, DAVID Phone: 715-749-3656 Inspection Request Information..... Requestor: DAVE FOGERTY Phone: Req Time: 14:08 Comments: Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION j SANITARY PERMIT APPLICATION LHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY .os.,.,..,.r.~ ZED STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% X 11 inches in size. Check 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. PROPERTY O NER PROPERTY LOCATION S 3 T , N, R/ E (or CPROPERTY OWNER'S MAILING ADDR SS LOT # BLOCK # CITY, STATE ZI CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER r Ifi BPS/~ II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE OF: ; _ G ❑ Public 121 or 2 Fam. Dwelling-# of bedrooms.. PARCEL TAX NUMBER(U) III. BUILDING USE: (If building type is public, check all that apply) 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. TYIPE OF PERMIT: (Check only one in line A. Check line Bit applicable) A) 1. PE LJ New 2.0 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 U-S I eepage 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 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION P 4?X. Feet ,_2, Feet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Prefab. Con Fiber- Expp. INFORMATION New lExisting Gallons Tanks Name Concrete structed - Steel glass Plastic App Tanks Tanks Septic Tank or Holdin Tank l' Lift Pump Tank/Si hon Chamber I F1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumbers Signature: (No Sta7~- Iftffibir's ) MP/MPRSW No.: Business Phone Number. e? I- 21V ddress (S eet, C4y, S ate ip Code): 77- - " Gv It COUN /DEPA T ENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ra issuing Agent Signikture.ft-.%am;is} Surcharge Fee) Approved ❑ Owner Given Initial ' Adverse Determination r'" ' r r~ ~r X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 1.1/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber w. w INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (S8D 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. H. 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'anks 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, iacation of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water rrainstvater service; streams :an(' 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; close 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 thase surcharges are used for monitoring groundwater, ground- water contamination investigations-and establishment of standards: SBD-6398 (R.11/88)