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HomeMy WebLinkAbout040-1177-70-000 O `fl 0o ao > o ti ~ w o_ o o N C N~ O r Y c R y O C `O C co Lm c O O c O p 0 N' w c c V N O O r«N" co a ' ~$'N Ey m > `LL -a 0 $ o~ w 0 0 m~-v E r y O y > III N p C Co Cp C O L € C c0 'a O C Z r O C p. C 7 f6 ' N CL U) _O N LL 7 F y 0 C C C 3 t5 E a a 2 cco -0 0 E O c `O Q U O -.9 M 3 UJ Z E O O Z € ai j am 0 o z :t c d z ~ ~ ~ o z c E -o a") M v I a~ - N .c O) I fp N a N ~ ~ c I ~W a U L O C - O a~ Q I Z m z Q 0 z Cl) N w~, d c E U ~ - ac0i 5 x aE a cco U eGa` n `m 0 cNI O c m ..j 00 Z co co a N z~I o O O O • a a a ~ a O O N 0) T U) J U I C O W O O r r Z = o o ~ E R ml c a ¢ cn m lith c (n c O O N ` O O In 0 cON V d Tr E m C c N O N O f6 M C O v N T y N'0 'D d AZ Z g U '6 € a a ` IL • a '2 m `Iv w+ E c c Cc r~ r A c0 ao o3aiti 3 ~ R 3 wig 0 ~ ~ x a ~ IN ltd US 0 3 o ~ a c~ I t ~ r I / i I ` V 2 i v\ DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION ~HUMA AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969 N WI 3707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: NSHIP/ Y: LOTNO.:BLK.NO.:SUBDIVISIONNAM SWI/4sic 1/ 13 /TZ'rN/RZbE (or) WTOW ka - a S-rCeo Ix W COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: 5r C20 Ix I lD -eO L. USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DE IPTIONS: R pLA I N TESTS: Residence tANv- (New ❑Replace 44/ Z4 9/ 45mu--, V4 'Z-1 &Its RATING: S= Site suitable for system U= Site unsuitable for system P C. WLp)v ~ CONY NTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILL HOLDING TANK:RECOMMENDEDSYSTEM: (optional) S ❑U S ❑U S ❑U S ❑U ❑S U r/o-vs4L ` C_W DESIG RATE: If Percolation Tests are NOT required If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: I Floodplain, indicate Floodplain elevation: IV4 1~_ PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH W. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- , p,7S t%.41 !46 tj S: > /6,75 %%L.SLT~ 5/ '$QNihS 7~"$e,~c'S~l B- Z .7 163 V ,541c >9.'75 7 BLS L'TS S -7 B>Q~u ~'1 S L-r g-w.► o; S B-3 9,ZS 161.6-- IVook- >92 'ALSLr5 /3~(Dk$a~MS 2$~~Qtt~vN15~2"CT$R..MS,G 13-4-116.17 /o/.V; r4o N >16.17 "$1-SLTS i4"8a~►5~5c. 29"RaBaNMS&79PArhS B- ,S6 p6,76 10. S6 >~~'~5crs z-7''ak 8~sL ,Sc 23nQ.o8~N 115 B- 70"6k~1 n15 4 R PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IpdGYpE'S AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R D > VZ 0 oN ID .6 3 90 > > Z > 3 80 N"V. > Z PLOT T 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 a e ction and percent of land slope. SYSTEM ELEVATION 7•~~ _ _ _ fl _ ,1~ E E E ~ E E f6f'~ or GO, G P3 q) i~ 3 E N E ~ E ~ E i E ~ E € 3 1 3 E E E 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 the location of the tests are correct to the best of my knowledge and belief. NAV (print): TESTS WER COMPLETED ON: ,akv~ >JSaUSUlevc„~~1,L -24- 1991 AD R SS: CERTI ICATIO NUMBER: PHONE NU ER (optional): Hu &Sd-~j Q I. I CST SI Qp^ E: Qt;vl~l~l~ /~s ALT&*,ljArc Auk F RIAOP Y AP-GA 5 5t,) I 1--C-11 CA. DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - 3TRUCTIONS FC FI COMPLETING FORM 115 - SRO - 639 To be a cc) in e and accurate ~ oisi' rer)ort must 1. Complete legal description; 2. The use ioia must Clem 1y' her this is a 'r'- <ic' comMei,cial plojcct; 3. MAX111"' imb r of Ebedi .z, minercial Use plann'°.'; 4. Is this a , ilcernent 5, Camplet th aihty ia1.iK' A SITS 13 SUI AC I. R A HOLDING TANK ONLY IF ALL. OTHER SYSTL- ,E RULE )-.JT BASED ON SOI~ I ,P, DITIONS; S PLEASE use the ah 1zviations shay - i for vvritirig prof€' lescript ions and completing the plot plan; 7. MAKE A LEGIRL. ai ram a€ ourat=:l,, ' your test Inca3:ioiis, to scale is preferred. A separate sheet may,, it desired; 8, Make sure your bencl , k and ver1 •cal refeience pti ita a c' ,arly shown, arrtl arw pet*mafiei~it; 9. Complete all appropriate boxes as to awes, addresses, fl _i data, percolation test exemp- tion, if appropriat(:'; 10. If the information r flood plain, does not allr c N.A. in the appiot)riat:e box; 11. Sign the Norm are. your cui rent td your certifi€; iniber; 12. Make legible c- d distribute as d. ALL SC, L STS MOIST E FILED WITH THE LOCAL AUTHC 7Y WITHIN 30 DAYS( C:OMPL.., i'= ABBREVIATIONS FOR t; ERTIFI -j _L TESTERS Soil Separates and Textures r~ :iii -ibols st - Stolle (over' 10") SR - ` ~drock cob cobble (3 - 10-) 1ne gr Gi v~el (under 3") nestone i h Ground -vatei c; :.cf c; - Pr.~reolatian Rate rned ; it Sand W Wei! f~4 I Fc~ i3ui! 1. - Greg Scl - L,rri F sic! rrxt SC sic Silt';` taay fff fine, faint. X Clay cc =rrr°)r>, coarsa pt - Peet MM - .an" mediuM € r t H V L " Six neral yogi water d vas BM f'tlark ,tRP i ua' R3 Pc)i;l't TO THE OWNER: This sail 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 pe i mit 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 he obt :I d r, I ar'sor to the start of any construction. d-- P/an Do v" j, Roe L... n SGaIe ;~Q / r ~r ~ o S of t) 'C- Tan k R tA r C L4,q&WjdW art R91yff IA,2 /13.28.20 Labor acrd Human Relations MVATt S WA E ~YTEM RD • County: Safety and Buildings Division INSPECTION REPORT ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 171475-T Permit Holdfir's Name: ❑ City ❑ Village [R Town of: State Plan ID No.: TROY CST M Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 040-1177-70-000 TANK INFORMATION ELEVATION DATA A9200397 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ~yJ Benchmark Dosi ng Aeration Bldg. Sewer Holding St/Ht Inlet 00-Z,3 TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet .2 7 rl ~ Septic NA Dt Bottom 2 Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width I I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER Model 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/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 695/13.28.20 SW,SE, LOT 38, COVE RD. I Plan revision required? ❑ Yes ❑ No T-1 I Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: TU ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITAR PERMIT # =Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 1 / ~8%'x 11 inches in size. C ec ireapplication -See reverse side for instructions for completing this application. STATE PLAN ).D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNE~R PROPERTY LOCATION T17 IV- v R!.t) Y4Sj '/4,S J3 T,22,N,R 2t rtplcw~ PROP,!<RTY OWNER'S MAILING ADDRESS QA LOT # ~ ~ BLOCK # CITY, STATE 7 C ZIP CODES PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER iHads W-_ 16`1614, 1(7/§' 113k6-mig 5 II. TYPE OF BUILDING: (Check one) ❑ State Owned y- : NEAREST ROAD Be Roa 15a 42WN O~: Co u e ❑ Public S 1 or 2 Fam. Dwelling-# of bedrooms - PARCEL TNUMBER(S) IN. BUILDING USE: (If building type is public, check all that apply) e- Jr^60 ~7 7 w 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 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. Is New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 511 Repair of an System System Tank Only Existing System Existing-System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 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 / 50 6/5- L; -3 el) *Feet /0 J. 0 Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank Ot~U QO e e- ks Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): _ Plum ignature: (No Stamps MPtMPR9VIFI Business Phone Number: /Pa, I C S el n lei Igo z~ 5~ yY lumber's Address (Street, City, State, Zip Code). 230 wr~,h vP klI IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sam ry Permit Fee (Includes Groundwater a e Issued Issuing Ag nt Signatu urc Approved E] Owner Given Initial harge Fee) 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 I% - A sanitary permit is valid for two (2) years. 2. Your "sanitarypermit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped bya 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 ipstal led. 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. Vlll. 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 r 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collVcted through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) I DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CouN STATE SAN A PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than l/ 8% x 11 inches in size. ❑ Checkif ri3visi to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP TY OWNER PROPERTY LOCATION v • '/4 '/4, S T2S , N, R E (Or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME CSM NUMB R 11. PE F BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned O V LAGS ; dl f I~ G ❑ Public Lld7 or 2 Fam. Dwelling- # of bedrooms M PARCEL TAX N ) 111. BUILDING USE: (If building type is public, check all that apply) 400- Y77 D 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPPEPO OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. New 2. El Replacement 3. ❑ Replacement of 4. El 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-Pres urized Distribution Pressurized Distribution Experimental Other 11 Ego 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 YS'a Z G j `j`am Q.XS-Feet . Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank T O© Lift Pump Tank/Siphon Chamber L1 F-1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PI m is Name (Print): L=uwbe ' S' nature: No Stamps) WMPRSW No.: Business Phone Number: a 7 tier's Address (Stre , Ci ,State p Code): Z IX. OUNTY/ E RTMENT USE ONLY ❑ Disapproved S itary Permit Fee (includes Groundwater Date issued Iss ' ~g r 1 Surcharge Fee) V Approved ❑ Owner Given Initial / f Adverse D termin i n / u 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 ~f 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 f criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5_ Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 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 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 rnains,'water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replai~ement system areas; and the kocation of the building se(ved; B) horizontal and vertical elevation reference points; C1 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 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 4 i0 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies r,o:^! cted through these surchargesi are used for monitoring groundwater, ground- water contamination investigatians and establishment of sMnttSr'd§." SBD-6398 (R.11/88) t n , 1Tn ~ i lea (2 z (Q t m W OK I V ' .9 _~n 52 , 'i _ 01 • 4 I. SANITARY PERMIT St Croix COUNTY DILHR TRANSFER/RENEWAL UNIFORM PERMIT # ° (PLB 67-T) PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: PROPERTY LOCATION: E SW '/4 SE '/4,S 13,T 28 N,R 20 W TOWN OF: LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK: 38 Cia Thompson G v>✓ a e PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: E: SIGNATURE: NAME: PHONE NUMBER: ADDRESS: PHONE NUMBER: ADDRESS: I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLU ~VS S~ GNATU ~iE. PREVIOUS PLUMBER'S NAME (IF CHANGED): J t O PLUMBER'S ADDRES PREVIOUS PLUMBER' ADD SS: N W Y 0- 5 ca 14 &_& GUS s Roberts, WI MP/IdPTTSpPfVUMBER: LONE NUM ER: /MPRSW U R: PHONE NUMBER: Syy 3Z (715) 749 3656 SIGNAT E OF ISSU DATE APPROVED: DISTRIBUTION: Original - County Copy - Bureau of Plumbing Sr ~Q Copy - Owner Copy LHR-SBD-6399 (R. 5/82) - Plumber STC - loo 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 D Ot") j r. R-- d Location of property-5W/4 .~&1/41 Section Za, T .ZFN-RZo W Township l^p Mailing address _ 2t': ~r) tj to fk-~?g ~f^a v ,se Address of site Zrj `7_C 0~-~ Subdivision name fOyuA Lot no. Other homes on property? , -Yes-- ...~No Previous owner of property Total size of parcel _ I A crP~ Date parcel was created Are all corners and lot lines identifiable? Yes No is this property being developed for (spec house)? Yes /JINO volume and Page Number as recorded.with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WNRIUVITY 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 office of the County Register of Deeds as Document No. own the , and that I (we) presently proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly reco d in the office of C my Register of deeds as Document Nap~l can Co-appl cant Da of Signatur Date of signature + aed ..w. 1 Jim . rliMllre awu ~r t+f. a =r*+ 1fi~lor setts and "Tess to conver to tmsehassr, WW Seayt "d 41tx ~1►ei -of this snub" by Purchaser, the td wft psr/rf1& 6000 trbh Me 9 t ooW 9"096 fixtures and other appar"Went 4tsnsla (sY "d tM IDerf MaN of Wbomobt werwa+,o ~ lis.,:......_..... St- i~; ter: . 38, St. Croix Cove Subdiviaialf"VO. 3, Town of Troy. ' 'Past Pared X& tx E.. y yxv. l . y This 8 Apt homestead property. (is) (is not) lace to be deal Hated w• :r Purchaser agrees to purchase the Property and to pay to Vendor at ..1' the sum of (x..23 t 50oe 00..................................... in the following manner: (s) t 5Q0.00 = at the execution of this Contract; and (b) the balance of a 21-,000.00............... to; ether with iaterest ` ' bereof on the balance outstanding from time to time at the rate of...... 10._0_ 1a cent par ammo, until paid in full, as follows : Monthly payments of $318.66 beginning July ,5, 1991. and the same day of each month thereafter. Provided, however, the entire outstanding balance shall be paid in full on or before the........ 15th day,# July---- i9 l4... ( the maturity date). This is a Balloon Payment; Following any default in payment, interest shall accrue at the rate of ...1.0 % per annum as tba eaflfts in default (which shall include, without limitation, delinquent interest and, upon acceleration or mattrity, the principal balance). z Purchaser, unity excused by. Vendor, agrees to pay monthly to Vendor amounts sufficient to pay reanolplM pated annual tax", special assessment, fire and required insurance premiums when due. To the extent reefiwsd by;, Vendor agrees to apply payment to tbese,obligations when due. S.ich amounts received by tbe-lV'"*W`fW taxes, assessment and insurance will be deposited into an escrow fund or trustee account, but shalt met ~bW. unless otherwise required by law. 2 Payment shall be applied first to interest on the unpaid balance at the rate specified and than topriatiyal amount may be prepaid without premium.or fee upon principal at any time after-....-Ju.1"Y..15__...--., li►11... , Vender In the event of any prepayment, this contract shall not be treated as in default with respect to-payment=sa • as the unpaid balance of principal, and interest (and in such case accruing interf t fr•)m month to month 9W M: as unpaid principal) is less than the amount that said indebtedness would have r n had the monthly, psyme made as first specified above; provided that monthly payment shall be continued i the event of credit of auP of insurance or condemnation, the condemned premises being thereafter exclude(! -from..- Purchaser states that Purchaser is satisfied with the title as shown by th, title evidence submitted Is - { for examination except: None r ~ ' the of t1t1`' Purchaser ees to ( retained,ty Vendor until pig l e, $040 -bq~Atltiecf fa 1"r_"' -'mot ~ • ~ J•i} 4 ` ' t WAX -10-4111 )OW01104 awl odor - vat s 1" WIN 4 . !'~~liaanL eisslr et F F aira~taR~)Ilie a* ae ~M'ttlt aC`~sl ant ~e4naPR: ......._~..;~.,.i.. 1.... _ pw*ww saw" timme la'et ten Meuse and (a) in the event of a default i#,Ailt M' ~t WtA k eentiass IW • Pw'W M - 4L.. -+sye following the specified due date or VIA: My otbee at ~ wh" continues for a period of 4. if 3,s ►y ear~tiei wail), then the entire on asa_'ial mwko* due and payable ii fns, at VWWW's option = -id %,shout notice (sehielt she m endow . by M~ this iotle~tsg'rights 4" ewedies (subject to any UseltatiNy "it so, ItY::(1) Vendor may, at his option, terminate -this- yPtoperty aod ~e vee the PrW~srt I baelt through striet 1 t►-ii1 eoodl(iottei t'Y full payment of the entire outstanding balande, with. ilb~dk ai tuts effect on such date and other amounts due hereunder (inwbic111l3,ost . M'• faeoteited as liquidated damages for failure to fulfill this fade to redeem); or (it) Vendor may sue for specific performaAee 'tii11 000 1 ref the eatlreoutstanding balance, with interest thereon at the der bereunder, in which event the Property shall be au °onsd at or (iii) Vet.dor may sue at law for the entire u mid pureitsse osndsr,way dat are thin Contract at an end and remove this C ntractssaclood an irlMka 60 isbaseaCof Purchaser is insignificant; and (v) Vendor may have Purchaser s ts)id have a receivers pointed to collect any rents, issues or profits during the at (sba"-Notw ,Itnding any oral or written statements or actions of Ven sba8 only be binding upon Vendor if and when put. tied in litigation A" a_40rue s fees of Vendor incurred to etdorcead'FWniedy h(reunder (w16etber Aid" std esposses of title evidence shall be added to principal and vahl ' in any judgment slut or during the pendency of any action of foreclosure of this it ravel or of the Property. including homestead interest, to colltet the 4o4Ma. ~R• of such action, and such rents, issues, and profits when so vot lransfet, sell or convey any legal or equitable interest in the Prep r saber this Contract or by option, long-term tease or in an other wa 1001040 ekher the outstanding balance payable under this Contract is first)paid a ee assignment of Purchaser's interest under this Contract soleiv as security - dlna event of any such transfer, sale or conveyance without Vendor's written con,ent, "Witt, this Contract shall become immediatelydue and payable in full, at Vendor'tn 'Inalte all payments when due under ariv mortgage outstanding against the for any mortgage granted by Purchaser) or under any note ser,ired thereby pet of the amounts then due under this Conttact. Purchaser may make any such pa ;BFetlilr fail$ to do so and all Payments so made by Purchaser shall be considered ' V0 AW-OW any default without waiving any other Rubsequent or prior default of p All wft et this Contract shall he binding upon and inure to the henefits of the 1611113,46litrsl'? it. of Vin&w and Purchaser. (If not an owner of the Property the upouse of 4 Ito t tehNeefh;mestead rights in the subject Property and agrees to join !ly 911 J -w .`1 - day of June X14 . SEAI) J n F. Alden 1Q. ltoe :f _ ( S E A I Xl 1. / f 3 Meredith B. Alden AUTHENTICATION ACKNOWLEDGM111*1 STATE OF WISCONSIN ~ i - St. Croix County. Ainrstieatad this day of._......... Pki-sonally came before me tbla'.. June . John F. Alden_ 6. Meredith a. . . F David E. Roe 6 AnA D, Aaw y 1t;LZ: lAt)rMBEIt STATE BAR OF R'iSCt1KS1`~ 4111 snot. tir attthatiired by f 706.06,. Wis. Stets.) to the known to be the Pe o - _ fc:ic~~ing inats;datent aqd i 1°FNS yNSTRUMQNT WAS DRAFTED FY - - • 'Vir"nla A., 1 _ - Notatsy.l'ublic a • array be, suthentieated or ackai4iwledre&-Both ` MY f-mntissioa it IMII'th ~.r4 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER i y j Q GZV` Roe ADDRESS: 2-9 7 C Q y ~ Roo FIRE NO: Z LOCATION: 1/4, 1/4, SEC.~T UT N-R W, TOWN OF:_ 7-r~Y ST.-CROIX COUNTY SUBDIVISION: LOT NO._ 3 A0/ 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 d returned to the St. Croix County Zoning Officer within 30 ays of a three ea expiration date. SIGNED: ' DATE: St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION INDUSTRY, P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISON WI 3707 HUMAN RELATIONS 0LHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP/ Y: LOT NO.: BLK. NO.UBDI VISION NAM S?Ceo Ix w Sw~14S& 13 /Tzg N/RZ6E (or) W ka T COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: 57 Cria lx A-41;& o DATES OBSERVATIONS MADE USE PROFIL~pE~RIPTI NS: : NO. BEDRMS.: COMMER IA L DESCRIPTION: q LAT Residence New ❑Replace I 41Z` !1 4 24 I9 NTESTS / (AN~ RATING: S= Site suitable for system U= Site unsuitable for system to C Lp)U F4 " CONVENTIONAL: MOUND: IN-GROUND-P URE: SYSTEM-IQILLH~ING TANK: RECOMMENDED S~Y'~EVM~i (optional) S ~U S U S U S U CN~S U S U I 14J [u'nde',7 Pelation Tests are NOT required DESIG RATE: ' If any portion of the tested area is in the ILHR 83.09(5)(b), indicate: AS Floodplain indicate Floodplain elevation: rl__ PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH W. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 ^7< 'o6,g1 45 j E: >/0,75 %%L_SL-rS SAR►r{hS 7D"$e,0CSq-&R B-Z .7< l 3V1 01JE •75 7J'BLSL•T5 S7"'8anoMS 5rur &,-if1iS B- 3 9161,6 Z NoiJU- AzZ 5 'Bj_S4__r-5 /3'(DI~$rZ~MS zg'Qa,~M56~"L~-$a~.MS,G+~ B-4- 6.17 161-T`6 f4oNe WO-17 "$LSL.TS 2.4" 8Rii15,/5L 79 hAA BaN MS&"8 R. thS B- .S6 06,1( tqE / . S6 C•'6k5C.T5 27-' hv- 8RIUSL ,51_ Z3'W 4N 1115 70" 6arj rh5 4 Iz B- ~EL PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 4'4lGYPE'S AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R P_ / A10 o'3 101,66 3 >~r > P_ Z $ 4o i 11 mixo 3 >Z >Z c P- 3 8~ Nv~ti 166:0 > > Z > Z L P- P_ YAT10W A P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate sox)1 stances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the su ce elevation a a b s and the direction and percent of land slope. n r .O~ SYSTEM ELEVATION , 9 o~ t N _V\ V 1 t Cow i__ v ~ 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 the location of the tests are correct to the best of my knowledge and belief. NAME (print : TESTS WER COMPLETED ON: ~~RVe /99/ AD R SS: CERTIEICATIOfV NUMBER: PHONE NUM ER (optional): 1.~ 344 3gB- 6 u &S6 CST SI E: SL,) i Tc.44 C4 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INbUSTRY, DIVISION LABOR AND PER LATION TESTS (115 P.O. Box 7969 CO MADISON, W1 HUMAN RELATIONS ` (ILHR 83.09(1) & Chapter 145) LOCAT N: SECTION: TOWNSHIP/ L T NO.:BLK. NO.: SUBDIVISION NAME: 1 k vcC ! ,~aY8 S~-C~eo , Go SW s~ /T7a N/R2a E (o W) k CO NTY: BU R'S NAME: MAILIN ADDRESS: CEO Ik dV~D USE DATES OBSERVATIONS MADE STS: TIPN NO. BEDRMS.: COMMERCIAL DESCRIPTION: N A New ❑Replace Z J~ 23 4/ Residence uNK 4 Sous K G al Saks mT RATING: S= Site suitable for system U= Site unsuitable for system c• 1-lid)NFt~~ CON _Tla~ . MOUND: ~~D~ IN-GROUND-PRESSURE: (YJr YSTEM-IN-FILLHOLDING TA K: RECOMf~IENDED SYSTEM:(option S ~jl~/}~J S U '~IJ S aU EJS U L//ANV~^~T101.~A 1 LA fbAxm If Percolation Tests are NOT required DESI If any portion of the tested area is in the e / under s. ILHR 83.09(5)(b), indicate: ,dss RATE: I I Floodplain, indicate Floodplain elevation: A PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IM ELEVATION OBSERVED EST. IGH TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 105 /b(,.q I N~ >!O.7~ Ng •'eQN MS 7~~ CS~E-G Z 93.5 /0311 ti16 NE >9-75 7" s 7" N1hs 53"CT 1?fJAS 3 9.zS .62 No > 9 ZS ~s i3" NMS 2 " N(hs Z'Lr M'S GQ 4 ►o•I'7 161.$$ oNg >lo•0 9..&.s 7S i4" S, z9"4 84-, 60'& R-1 AZ > /bso G., xTS 2 8QNS 5154 z3"Qe$aa MS ~o'BRN~s~4 PERCOLATION TESTS EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES MBER ItMOM AFTERSWELLING INTERVAL-MIN. PERIOD P RI PER INCH .6S NoN 000 3 > Z > > Z 3 4 sue 146 4 Le 10?. 1%6 > Z > 2 > 2 <3 5 .40 3 > z > t > z < ~lAT1aN ~ T PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scat or distances. Des ibe what are the hori- al and vertical elevation reference points and show their location on the plot plan. Show the surface elevati at all borings and the direction and percent nd slope. Q.ZS STEM ELEVATION , EAST ,Net 2 ?A 1 , bF Z,► ~ P~ ~ 1 'tL"' t 1, 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 the location of the tests are correct to the best of my knowledge and belief. ME (print : TESTS WERE COMPLETED N: y 31MuN56 110 J !J NS~~J Y ~Nc it -Z 3: 199I CERTIFICATI N NUMBER: PHONE NVMMBBERR(optional): aST l~IU1(~5ou ~J) Sib 16 31;R 1:386-jogio, CST SIGN URE: to Local Authority, Property Owner and Soil Tester. - OVER - (C0 pe) f y ,6~ ter,' . tMO~Is a-rot l; A~III O 40 2\4, Arrp-Zp it a~ s Or, stroo. \~Nb81n0 ~ \ ~ ° wog - ~ 00 \ 0 0 t i~ b^\ ~ C19 t o N pa ~ ~ \ ~:f,• ~ \ 6 N of ; . ~b41 a^1&0 of •9/ P_ oa bo SOdo~d 40 p- 1 8 P L zon of I S t 01 10 tot ~ 1 , \ d0 + of Ob ~fyM 8 % b t,yyy~ 0 of 3xb ti % rr 4 Q t ~Z ~ r' 6 ` E '80. , 3c• N N ' mod' O Sa t~ ` '8 ~ o o t \ - 01 ~ °s t ~ s oz s C7 t. -moo ti .-a 4b r\ -"%e IMF I I ,o, > i M ' 60 , I , $0 0 ¢ 100 A