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HomeMy WebLinkAbout040-1156-50-000 o y o N ~ O vy M C 4 a 0. 0 ~ I I I N N o I i Lo a I > I 'o y I I z Y - - I~D U o a o"i y I a~ $ I F+ N N Z z.=_N c Cl c ' Li c m m o a3i U. o ' m N O o c c Q fA Q I I M M v aa) m Z Z o yz o o €M Go g d d d d N w a m a m N H ~ O i O Z ~ C C d Z o r o c o z to I- E E v E (D m ` N `e) . 5 N CL a~ y N y Cf) U) y ` c a L L_ a L L E O C O c O a O Z H Z Z H Z N _ z y d d N C ` 10 V y O utS fA C d R' C O a ~0aCL E ~ mecca` E E mN n i= dH Zo E u 3 3 E u 3 E w o 000 000 "Nil 4i CL c c C%j tn~Cmi CO) o vrn o ti =n ~ I `J ~ ~°o I m O O E N p = N ~ coo p = O O N ml C y ml y c Ll O) w O > 9 y N o d Q Z fn o m Q UJ N U 3 r CM 7 C O CO (~yq G co N 0 C nw O CV O p w j '0 'O 6t ~ LO co CD O N C O C V a O CD 0 O to f0 LL LL c .O r.. N v O CD p O C p = N co b 00 F- y y o~ y N v C N n Qp N y _ • 0 clq o 0) O r o O O O y U O N F fA O Z Z CA O Z Z rd' fn ~ I I r~ ~ sk ~ E I = E I v as 'a 0 CL ate • eC a d d o d d c tt`N~ o R 3 « 'o c 'o ~1 A vat '0 mu U) HOMESIT.E SANITATION CO. SEPTIC CLEANING - SEWER SERVICE. ROUTE 3, O'NEIL ROAD HUDSON, WISCONSIN 54016 4 •;~iy~ ~ Mao= :,i`` qa~ No-nw" ao w°"*Vs Jot ~ ~ *"a ern tT TTY AMPAO ys aT~MZT*~+~= it ah~t♦ti»M/ "ago"" Wit! .hem" Jmh#~ ~ Je_a*t% im '$A "memad A%Tgft al a* =I t our ..OVOti e! *!`KSM a .r %,80.3 t y; I I r ILI 4 \ 1~ t- ~ i s •'OTOS l ~ ~ is . t• 1 -log 04 (A, 05 14 d1o 10 LA C3 0 10 \cp Sp u N p9V ~j . 0 ',Jf ~ 4Sti-gip w i ` \y Q O 'jo '14~ h 10 110 o t~ ~ o 5, o 0 o~G l.. o yJ 0. 'q Q ' Wit` V V10 \fl c± 10 ! 141.53 14A r o, ` 6 ~r o O J S'` r' aoay, lb! I a• ,Y•~ p r X41 1 \ Sr _ ~ y' k, P-i -ILI Parcel 040-1156-50-000 12/14/2005 03:05 PAGE 1 OF 2 F 2 Alt. Parcel 24.28.20.612A 040 - TOWN OF TROY Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - SOBOTTKA, FRED H & SANDRA F FRED H & SANDRA F SOBOTTKA 263 COVE RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description ' 263 COVE RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.800 Plat: N/A-NOT AVAILABLE SEC 24 T28N R20W PART OF SE 1/4 OF NW Block/Condo Bldg: 1/4 SEC 24 DESC AS: COM SE COR LOT 27 ST CROIX COVE SUB: TH S 38 DEG E 66.13 FT Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) TH N 47 DEG E ON SLY LN COVE RD 278 FT 24-28N-20W TO POB;TH N 47 DEG E ON SLY LN 130 FT TH N63DEG EONSLYLN 70FTTHS22 DEG E more Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 895/462 2005 SUMMARY Bill Fair Market Value: Assessed with: 103237 559,800 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.800 101,200 437,600 538,800 NO Totals for 2005: General Property 2.800 101,200 437,600 538,800 Woodland 0.000 0 0 Totals for 2004: General Property 2.800 101,200 437,600 538,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 214 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER- rl ral TOWNSHIP i D SECTION- i~T N-R6 W ADDRESS- ST. CROIX COUNTY, WISCONSIN SUBDIVISION -LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r COA t (oil t r r INDICATE NIDkH ARROW BENCHMARK: Elevation\and description:`'' . CL 1 b0 Alternate benchmark SEPTIC TANK:Manufacturer:_ jjp, Liquid cap._ (Drop Rings used:_12_Manhole cover elev:_Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road: Front , Side,, Rear Ft.- I= From nearest prop. line:Front____, Side , Rear( Ft.- No. of feet from: Well__ ~o Z! , Building:: /V (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE f . • PUMP CHAMBER Manufacturer: Li quid Capacity. . Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.:.pump off elev.:......Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front,._,, Side-, Rear-Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench t X seepage Pit: Width: Length__ L o Number of Lfnes:__Area Built Gores Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to top of pipe: 47 N 4 No. feet from nearest prop. line:Front_, Side-, Rear_ Ft. /a' No. feet from well: -7 No. feet from building Z (11 HOLDING TANK Manufacturer: ________.Capacity: No. of rings used: _Elevation of bottom tank: Elevation of inlet: No. feet from nearest .prop. line:FrontSide Rear Ft._ No. feet from: Well , building nearest road Alarm Manufacturer: INSPECTOR: DATE: PLUMBER ON JOB:;.:- y LICENSE NUMBER:. 6/90:cj 4 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT St. Croix Safety and.Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GtNERAL INFORMATION Se, NW, Sec. 24, T28-R29, Cover 149259 Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.: Fred Sobottka Troy CST BM Elev.': Insp. BM Elev. BM Description: / / n Parcel Tax No.: reAll- Ila, 64D, ~ '60 _ ~ C6.~~-C+ E. Jlo~ a-,e~ 612A TANK INFORMATION ELEVATION DATA p A TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 14,E . S r~ , ~9 Dosi Au- Aeration Bldg. Sewer 3' Holding St/)A Inlet 1-7 % 9170 TANK SETBACK INFORMATION St/ bK Outlet 97 Vent ir Ito ntake ROAD Dt Inlet TANK TO P/ L WELL BLDG. A Air Septic ` NA Dt Bottom osin NA Header/-Men. 91~ Aeration NA Dist. Pipe " 7 9/O . RS Holding Bot. System qua r f PUMP / SIPHON INFORMATION Final Grade 'C c u Demand , , Model Number GPM V TDH Lift Friction Forcemain Length Dia. Dist. To we SOIL ABSORPTION SYSTEM BED/TRENCH Width I Length r No.O Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Jr SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING ufaaurer: SETBACK CHAMBER INFORMATION Type O ~ n/ Z Model Nu r: System: /o ,L, OR UNIT DISTRIBUTION SYSTEM Header h+#slEl 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 it xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed / Trench Edges , F-(/0 ' Topsoil E] Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 4~c LCJ~;7C Plan revision required? ❑ Yes a-K Use other side for additional information. SBD-6710 (R 05/91) Date Inspector s Signature Cert. No. M ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t 1 LOCATION: TROY 24.28.20.612A,SE,NW,SEC.24, COVER Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 149259 Permit Holder's Name: [I City ❑ Village X] Town of: State Plan ID No.: SOBOTTKA FRED H & SANDRA F TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 040115650000 TANK INFORMATION ELEVATION DATA A9200110 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet rl Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK 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.) I Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. I ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: a ~ 3 SANITARY PERMIT APPLICATION HR In accord with ILHR 83.05, Wis. Adm. Code COUNTY „~.,e. T0=41 STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 ~ ,rQ 8% X 11 inches in size. Check if reVslto prevlo s application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION P-yya a6-bz)-4ko, 5E t/4 rVOY4, S zlf T N, R Z.G (or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Cue ezL AA114 1 1444 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: Check one CITY NEAREST ROAD (Check one) ❑ Stat@ Owned ed ❑ 1771 TOWN VILLAGE : ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms 3 -PARCEL AX NUMBER(S) 60-000 ILIIN III. BUILDING USE: (If building type is public, check all that apply) j 2- 14 1 ❑ Apt/Condo C. 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 50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPPEE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. C New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5-0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. 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 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SY5TEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ?-t ,_c ELEVATION C.`' Feet KCC 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 M F] F1 [I Septic Tank or Holdin Tank ! G Lift Pump Tank/Si hon Chamber Vill. 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 Signature: (No S mps) MP/MPRSW 1.: Business Phone Number: /y; L 3ZIY~ Plumber _ dress (Street, City, State, Zip Cole): /Ci//> r G , IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes roue Water Date Issued issuing em Sign a (No S mps XApproved ❑ Owner Given Initial ~ 1`7 Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2: Your sanitafy 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 (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: I . 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 3% 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; 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 these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) f APPLICATION FOR SANITARY PERMIT STC - 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 b~! intended for resale by owner/contractgv,("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Property- c/i.) k, Section T N - R Z W Township Mailing Address Subdivision Name jl Lot. Number PruVious Owner of Property -4E Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No is this property being developed for resale (spec house) ? Yes _e- No Volume and Page Number ? as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register-of Deeds Office 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 Mai), the the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) eeAti.6y that at .btatementb on th.ib 6ohm are true to the but ob my (our) knowledge; that I (we) am (ane) the owner (a) o6 the pnopen ty deb cA bed in thi.6 insonmati.on Soam, by vi tue o6 a wahAanty deed teco&d d in the 066iee o{ the County RegiAften o6 Deed6 ab Document No. - _ S ; and that 1 (we) pnebentty own the pnopo.tic.rl s4te 6o.4. the aewage poa by_,-frn (on I (we) have obtained an eaeemeni, to n.urt w.Uh the above debc_Aibed p&ope/L y, Do)t. the eonbt&uct(.on ob said eybtem, and the bame hab been duty keco&ded in the O~6ice o6 .the County RegiAten ob Deeds, ab Document No. J IGNATURE OF OWNER IGNATURE OF CO-0 R (IF APPLICABLE) L) X11 V - f - - L DATE SIGNED DAT S GNED ,t fJCt>wAE14S iVfi. n0191 W* A* Aleppo" R~ M>t A P~Cf, n t Richard-G-Ste--Marie. and Margaret M. Ste Marie MAR a 1 . 11:30 A: . con eys and warrants to ..-!?Y'ed-.H Sob - ----ottkd-. Sandra F. Sflbott . y hus !r►d mod.-wife . ag.. t.jvQ "h.-i~p- ~ ...PAY 3 . . - . . . . R QN ~I - - . ETU TO - . II the following described real estate in ...SC-.GlCQ:LX............. ,--County, State of Wisconsin:' Ta: Pared No:................. t 1 c Part of the SE% of NW4 of Section 24, Township 28 North, Range 20 1a West, St. Croix County, Wisconsin described as follows: Commencing at the SE corner of Loc 27, dSt. Croix Cove Subdivision; thence S38°30'E 66.13 feet; thence N47 50'E on Sly ~ine of Cove Road, 278.0 feet to the point of beooinning; thence N47 50'E on said Sly line, 13060 feet; thence N63 14'E on said Sly line 70.0 feet; thence 4 S22 35'E 680.0 feet; thence S86°45'W 203.8 feet; thence N22 351W 563.9 feet to the point of beginning. sr Together With a non-exclusive easement and rights in and over the ! private roadway, private walkway and beach areas as described in a F Warranty Deed recorded in Vol. "344", Page 425, Doc. No. 252015, and membership in the Winford Lands Home Association, Inc. with all of fE the rights, benefits and obligations of the same. NSA QQ.lt s This - 18 -AOt:_- homestead property. Q (is) (is not) Exception to warranties: Easements of Record I hated this day of Y, it C~ 19,11 p (SEAL) (SEAL► Richard G. Ste Marie_ • Margaret M Ste Marie 'h 'ra a (SEAL) ISEAL! ~..e-c ~►i~ ~k -tom i• ti AUTHENTICATION ACHNOWLEDGMANT J` _ ~~>t4~s) ~•hOt1.l~-- _~r_..S'j ~.~1R~L'1~ STATE OF WISCONSIN E I C..•. ` ss. i /~•-~"'i-• -T------------ - ✓T l ✓t. - X ! County. LL atlthentj&ated tlris 4-~ day of IGi? 19_A'. Personally came before me this t;Pkday of t - _A-4 et x-.C_ ~t 19.1--- the above nauleti a ' L ' My Commission Expires August 1. 1993 - i~ s,-- d1Nn ran re TiT1 1C1~ STATE BAR OF WISCO N~Iti _ a authorized by § 706.06, Nis. Stats.) to me known to he the person who executed the I I ° SW ;4oiA instrument and . phpo_wird/ge theJ me. y T -4'S INSTRUMENT WAS DRAFTED nV 6DII 1J4 I.~ C?~. ~Ci!i`'~•-• fill tl CI-ex r ~ - -r-r--- ~r Notw-r Public . 5f. r~ tX County. Wi4. (Signatures may he authenticated or acknowle&red.4-I .-M`- rpnimissi-n is permanent. (If not, state expiration • are not necessary.) • : ~I Names of parsons aiming in any capacity should he typ"I .•r pI-int'4 N~ :a r WAARAW" DUM STAT1< eAti OT R ~YIlCONSt!! ~1►eo4HR t YQR~ SM. ~YNi mom, r N . y r STC - 105 r' Y y SEPTIC TANK MAINTENANCE AGREEMENT '-o St. Croix County ' o OWN ER/BUYI:It ! ;r ROUTE'/BOX NUMBER Fire Number CITY/STATE ~!~1 Jj• 'ir -.__k?..-_ _ 11It(Jl'IiRTY LOCATION: y>= I~~c_> !r., Section _t N, ft--~~ W' . 'Down of St Croix County, Subdivision Lot number ~V. I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank p.LLu 1) e r. What you piit into the systellk can affect the function of the septic stank as a treat- meat stage 1n the waste disposal system. St.-Croix County residents muY be eligible to receive a I,raiit 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 s sytems agree to keep their systems properly maintained.u _ " The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (it nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. o I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with H the standards set forth, he•rei.n, as set by the Wisconsin Depart- 'd ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. i • SIGNED DATE IV St. C,,oix County Zon Lng 'Office P.O. itox 95. Hanuno'pd , WI 51,015 715-7 16-2239 or 715-425-8363 Sign, date and return to above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (1 5) MADISON, BOX 707 HUMAN RELATIONS , WI 533707 (ILHR 83.09(1) & Chapter 145 L ,Sc OCATION: SECTION: TOWNSHIP/ LOT NO.:BLK. NO.: SUB IVI ION NAM~1 Nw 1/ Z.¢ /TZ~ N/Ran E (o C,r2i4 - ~Teeb lX (-_bVC C NTY: OWNER'S/BUYER'S NAME AILING ADDRESS: T_4&A 4 / T"rr 4A'Mcl Q CAGE MA) ss/Zi USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: IPROFILE D CRIPTIONS: PER OLATION TESTS: Residence New ❑Replace Q 1992 ~AN -7 i9 yes 1 aGs - ~Z - $t~ V_iq.4 A RATING: S= Site suitable for system U= Site unsuitable for system E~CNc, CO ENTIO❑NAL: MOUND: IN-GROU P RE: S 1LHOLDINGJJ((''~~~/'TA~VK: RECQMMENDED SYSTEM: (optional) S, S U ,FfZJf S EA ~((J]~JIJ'S ❑u ID OS ❑u DS ~JJ(UU f~.,.~ KA If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: ~JQ Floodplain, indicate Floodplain elevation: A/ A PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH 1d ELEVATION OBSERVED EST.. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- f Do 4`6 ? '1".00 ",~5c s "Se")SL 46 10 4D"AR1, C Sk4 B- B- ~.Z< ~9.C►Z a1,rF 16.Z5 13'$z L-S r'61R~► 4~'~k~ n'1S CCS~~geaC'5t 4A B- - I A B- U./ /7 c3 > 9J7 ►Z"6L-S4 1S iY&..St. 4 '&oj :S 41 B&CSi6Z B- PERCOLATION TESTS Nacv.r TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER J~RPQPY6t~ AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P_ 12.0011%is P-'Z C ~b > >Z >Z P_ lti ~O` >2 > P- P_ I-Lc A 110,. km 0Q<_ 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. Sh the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION ik~acH A QS.CA o 94 E - - r- 7 -r C>T6 ,I CC P.- t, Ake, r _.E . a q.Y _ZA V-3 MAR d N t , P rative Code, and that the data recorded and the location of the tests are correct to the best o my knowledge and belief. LDISTRIBUTION: dersigned, hereby certify that the soil tests reported on this form were made by me in ac tbr-prQcec6esind ethods specified in the Wisconsin print): TESTS WERE COMPLETED N:' S CERTIFICATION NUMBER: PHONE NUMBER(optional): 10 r-, CST SIG RE: Original and one copy to Local Authority, Property Owner and Soil Tester. BD-6395 (R. 10/83) OVER - 1 INSTRUCTIONS FOR COMPLETING FORM 115- ` - 6396 To be a complete acid curate soil test:, your report rriust it ciurie: 1_ Complete legal desc 2. The use sect=ion must ` arly indicate i its is a rasiderice or comirielcial project; 3. MAXIMUM number of bedroorras or t °<~ial use plarimed; 4. is this a I-- or retalzlc'-rlent sys^eni; S. Complete the suitabi' vratirg t --E IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHE'' v TT . - RULES.) OUT BASED ON SO t_ CON tITIONS; .PLEASE a the a bb. is shown here for v,~ritiiag ;;s descriptions and cram. ;ing the plot plan, 7. MAKE A LEGIBLE c i - : clr ~tely locating your to locations, F . ;1 to , is preferred. A separate sheet may bu us ,f Make sure your benclinta , ar ical elevation reference point are cl -,rl, shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood pla l percolation test exemp- tion, if appropriate; 10. If the information (suc=h as flood plain'', r at:--I) does not apply, place N.B-~. all the appiropriate box; 11. Sign the form and place your curl ent s and your certification number; 12 Make legible copies and dist=ribute as rc dined. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL. TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Sandstone gr Gravel (under 3") LS Limestone Ks Sand f 1 CaHigh G, cw ?dwater cs - C<aarse Saud -rc - PPP-colat:ion Rate rn,ed s - Medium &md W Well Is - Fine Sa-Id Mori i cling s Loamy Sand > l nan 1 :irii - 3 t 1 ~ -t1 Y t [ i7 ui' SO - x C; Reza sicl C L runt - rvlottles sc - `sandy Clay v' with sic; - Silty clay fff - few, fine, °-=int c --Clay Cc - comt"rv~"n, €;caar-"a pt Peat III r41 - Many, ri ill Muck d dist ;.,1. Ia prorylin~,nt HWL High vdater level, Six genes"al sot( -textclres surfac=e water for t;'quid .vas? e r1isposal BM - Bench Mark. VRP Vertical Reference, Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county orthe 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 applic=ation 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. /eaS~ JOB TIMM EXCAVATING ~ Z Route 1 BOX 192 SHEET NO. OF DATE 7 WILSON, WISCONSIN 54027 CALCULATED BY (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA 0696 MN CHECKED BY DATE SCALE < . , I~ 3 p 1 1. s . . a 7 p 1....~,~SS. , k f/" QY I "tom .__.'a.. ley" to .S rte-.. `4 d Tel, (~l rte.:.....: PRODUCT 205-1®Inc.,Groton,Mass. 01471. To Order PHONE TOLL FREE I-800-22 380 JOB d /eo/ s TIMM EXCAVATING SHEET NO. 2 OF Z ' ' . Route 1 Box 192 WILSON, WISCONSIN 54027 CALCULATED BY r DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE cc t~~ y u.... 4:... . 1 a~ z k. r . V 1 Ell- A w, ~e L . , PRODUCT 205-1 ? Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1.800.2256380 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM co nty, Laboran4 Mum,an Relations INSPECTION REPORT St. Croix Splety sn&Buildings Division ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION Se%,NjN%, ec.24,T28-R20, Cove Rd. 149114 Permit Holder's Name: ❑ City ❑ Village aTown of: State Plan ID No.: Fred Sobottka Troy CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM I Loss Friction System Head TDH Ft TDH Lift Forcemain Length [D ia. Dist.Towell SOIL ABSORPTION SYSTEM BED/TRENCH Width 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 T x Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes E] No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) } Plan revision required? ❑ Yes ❑ No Use other side for additional information. AH -H SBD-6710(R 05/91) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ' , SANITARY PERMIT APPLICATION CHLHR couNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El 1~ 8% x 11 inches in size. c eck i revis o to previ us 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 n V c- n /1 k~ -'S~' % 4/✓ '/4, S a~ T 7-W, N, R '-6 (Or) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # /o-' 14 CITY, STATE ZIP CODE PHONE NUM SUBDIVISION NAME OR CSM NUMBER CITY NEARE,fST ROAD II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE / j f~v~ v _2 a ❑ Public N 1 or 2 Fam. Dwelling-# of bedrooms A III. BUILDING USE: (If building type is public, check all that apply) J _ f z yi 1 1:1 Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 50 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. New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. 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 ❑ ln-Ground 420 Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 140 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) 7-! 7Y.;73 ELEVATION eet Feet VII. TANK CAPACITY Site in gallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xistin Gallons Tanks Concrete strutted glass App. Septic Tank or Holdin Tank Tanks Tanks de 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' ignature: (No S ps) MP/MPRSW N4.: Business Phone Number: pp~ 1 % 2 / Plumber' Address Street, City, State, Zip Pods): IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater Date Issued I ing Agent Signature (No Stivrips) / Surcharge Fee) Approved C1 Owner Given Initial 7-91 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 a 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 Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsitb sewage systems must be properly maintained. The septic tank(s) must be pumped by 'a licensed pumper whenever necessary, usually every 2 to ;i 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 tYPa is Public, check all appropriate boxes that aPPIY. 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; (Jose 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) IL DEP,ARTM~NT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,, 1 DIVISION A .AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 N WI 53707 HUMAN RELATIONS ' (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: c TOWNSHIP LOT NO.:BLK. NO.: SUBDIVISION NAME: SE t/4 NW 1/4 24 /T28 N/R201(or)W Troy n/a n/a n/a COUNTY: BUYER'S NAME: MAILING ADDRESS: St. Croix Fred & Sandra Sobottka 4872 Knottingham Cir., Ewen, Minn. 55122 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PR FI DESCRIPTIONS: PERCOLATION TESTS: I~Residence 3 n/a New ❑Replace ( 2_1$_91 2-18_91 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) tren h ❑ S ❑U ®S ❑U~ LiiS ❑U ❑ S ®U ❑ S ®U conventional split level D If Percolation Tests are NOT :SIGN RATE: required If any portion of the tested area is in the /a under s. ILHR 83.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n decimal' PROFILE DESCRIPTIONS page 8BrC2 BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTt-DM. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-1 6.00 102.93 none >6.00 .67bl.1. 1.58bn.s.1. 3.75bn.c.s.&gr. B-2 6.00 102.93 none >6.00 .50bl.1. 2.33bn.s.1. 3.17bn.c.s.&gr. 113-3 6.00 101.58 none >6.00 .50bl.1. 2.00bn.s.1. 3.50bn.c.s.&gr. B-4 6.00 100.38 none >6.00 .42bl.1. 2.33bn.s.1. 3.25bn.c..s&gr. B-5 6.00 100.13 none >6.00 .50bl.1. 1.58bn.s.l. 3.92bn..c.s.&gr. B- decimal' PERCOLATION TESTS TEST P H WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD PER1003 PER INCH P_ 1 3.00 none 3 6 6 6 <3 P_ 2 3.00 none 3 6 6 6 <3 P- 3 3.00 none 3 6 6 6 <3 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. 99.93= upper trench SYSTEM ELEVATION 98.58=lower trench A2cgC. /2 tJ¢rt~ 'SAX I I , fC 10 C cv, _ n~ 1 I :dz t- ,Q lot ti f vO~ CIO C% i j 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. NAME (print): TESTS WERE COMPLETED ON: Gary L. Steel 2-18-91 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. Ave., New Richmond, Wi. 54017 229 17A5-246-6200 CST SIG I)F RE: - 91/ ~r LZ zi DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - JOB TIMM EXCAVATING SHEET NO. OF Z Route 1 Box 192<'~/' E - WILSON, WISCONSIN 54027 CALCULATED BY DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE ; : . : ; .......v . i . s , i . > . i c.l5crc I~ r ~s r x c r," n jean p /~F ~al'1 1 1. ...4 , ` F..i;. r i . ~r Ia _ _ l o 1 , _ g~ , u r y ~Dh- 1 1... . PRODUCT 2051 Inc., Groton, Mass. 01471. To Order PHONE TOLL FREE I-800-225.6380 . >/c/ ✓ >l.y kw JOB TIMM EXCAVATING SHEET NO. L OF Route 1 Box 192 { WILSON, WISCONSIN 54027 CALCULATED BY / `7 / DATE (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN CHECKED BY DATE SCALE . ; lG V J~ ~r + a i _ ,y:_:.. ~..r. _ i~ ! - I !r>~Sl f PRODUCT 205-1 ~Inc,Groton,Mass. 01471. To Order PHONE TOLL FREE I-800-225-6380 _