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HomeMy WebLinkAbout040-1210-30-000 g o ~ o I 00 O 6pn c N o M C 0 c N O > N L w N E m I L w U O O 0 O N N O U- 0.0 Eo 'c I CD E o ? a z N a c li c O o u rn Q r- O 3 ~ I m Z E N U) II, o I ' a m ui U') 04 N F- z c O C z U O Z U O N ~ O a) z m M aa) ~ cr- c W • iy a s s O- C C O U O o 2 < w Z H z O w N N z 'a 'a c C: L m E m N LM U) c N O N 2 a o A m g U _ G G a I FN- H H c cLi w CL U) !y o Z O O O aaa LL FL N M 7 O N CD a) a) fn J U ~ o 'i C: N co O O C) E C C O ~ O M ~ N N O O N C ya O E O C C E CD (D O O °o O N m 0 U LL O O M O C "7 a s a -0 N - Tr O 5 O O O O O O c O O _ L l` L L C} O 00 (=yam,! 40. N H N U) °v to o p y E E@ U Lr O N H S O z_ i9 = (n 0 ~ I .r z d m a v C~ I S- L: CL ~ a v •C C w C % y U j G U CL E 0 C c ~ I 0 0 c» o i 4 ~ I r~ °o c o c' ~ I I o ~ E I ~ o ~ I w E a> E y o z ° a) 3 ~ (n O m LL = O w O O L L N c -0 F) c Q = ~ o 'c N U) w O o Of 't z y 0 N IN- z a m o I '0 ca o z v m z d C o rn o ~ I Qt E M f~ N CL ^V 7 CD O i N N ~ I a) II ' w O C, c 0 m O o Q z z N N z d I L " E > N N c ~1 O H O X O G Co y 0 o 0 U G a a 'E z l0 N a 7 O co M fA J V O ~ OOi } M p0 Fly V c) M ~ Cl) O O N C7 O O m d M M 'Q cn N 2) ~ CO p N Q} CIO m ~ J w ~j O E N C O 'D E (D CD O N c O O O O O H a O m o_ 3 c E aa) o °D 0 0 0 0 0 :3 ce) 00 a) U') M cu LO L It U) ~ I O N H I. 2 r O Z Z M (n ~ ~ 'E y I (D # a c, CL m .0 m a rr.~ E _ ~1 A c) a 2 0 in Q y Parcel 040-1210-30-000 06/04/2007 11:30 AM PAGE 1 OF 1 Alt. Parcel 25.28.20.998 040 - 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 - HELGESON, JIMMY L & HEIDI L JIMMY L & HEIDI L HELGESON 233 GLEN CIR RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 233 GLEN CIR SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 2.000 Plat: 2495-ST CROIX HIGHLANDS SEC 25 T28N R20W NE SW LOT 13 OF ST Block/Condo Bldg: LOT 13 CROIX HIGHLANDS Tract(s): (Sec-Twn-Rng 401/4 1601/4) 25-28N-20W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 958/85 07/23/1997 804/400 07/23/1997 787/509 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/22/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 53,000 257,600 310,600 NO Totals for 2007: General Property 2.000 53,000 257,600 310,600 Woodland 0.000 0 0 I Totals for 2006: General Property 2.000 53,000 257,600 310,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 314 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 t STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS ZL33 Glrey' C l,A?. SUBDIVISION / CSM#~ lr CR~~dZgg&/Aj ryS LOT # 13 SECTION___,;Z_,T,,19 _N-R__.Z~oW, Town of Tif o o/ 1115. 29. 2" . °Catg ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHI G WITHIN 100 FEET F M v Lcr- / yon ~aus~ uec CIO C-L, pew -top 3- ~X 53` iAt ecrcH S INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 721P *L77D AEL lay a ALTERNATE BM: lL ZAt Cl1E&9)i 71?EC = ,6?L ZaQ,A SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: ~ r- F -A S Liquid Capacity: 1&0 Setback from: Well House Other Pum turer Model# Size Float seperation Gallon Alarm Location :SOIL ABSORPTION SYSTEM Width: Length _5-3 Number of trenches _3 Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet. 9J~, ST outlet _ 9 PC inlet &A PC bottom NA Pump Off IVA Header/Manifold 21/1_ Bottom of system 4`y 3 qi~ Cs Existing Grade Final grade DATE OF INSTALLATION: " is 9._3 PLUMBER ON JOB: LICENSE NUMBER: 320 INSPECTOR: 3/93 : j t It9,C n7sI9P:rt T§RyI~ld2us5try28.20,NEz PRTE jE1NA~~S MRD. LOT County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 1756957 Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: HELGESON JIMMY TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: ii TANK INFORMATION EVATION DATA A9200316 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosin ry(; S 66,9/' 10, Aeration Bldg. Sewer dx;~ / Holding St Inlet 5 , 11' 97.3 7 TANK SETBACK INFORMATION St/,O Outlet 97,06' TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic ~Cr 'a2 NA Dt Bottom Dosin NA LlOaw. 9,1 Aeration NA Dist. Pipe Gam' Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufa Demand 6J ~G C~ 7 3 , s9 Model Number TDH Lift Friction System Ft Loss mead Forcemain Length Dia Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Widths Length? 3 No. Of trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN 1 N ~ DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O cr ~,/r CHAMBER Model Number: System:,-/,, r ~GS a7 C,. a9 22,- OR UNIT DISTRIBUTION SYSTEM x Hole Size x Hole Spacing Vent To Air Intake Header / Manif Id Distribution Pipe(s) , C Length Dia. Length Jed Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over " xx Depth Of xx -B-~VTrench Center,-3 - ~fTrench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) th Lcc -77C VI /a -S Plan revision required? ❑ Yes 20TO Use other side for additional information. SBD-6710(R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code co STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than Sd S 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 OWNER PROPERTY LOCATION e-_ S-0 A/ ME .5W - '/a '/a, S A 5- T , N, R 600*W PROPERTY OW ER'S MAILING ADDRESS LOT # BLOCK # c CI TIT, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER LaEg 5,4ed 7 7 / 5, ) v2?T_,1yq-7 5TCktj4)C W _t 5 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE : y*h-,,e1j 7- &P, ❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - PAR uMe 111. BUILDING USE: (If building type is public, check all that apply) ® jrO 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 8 ❑ Mobile Home Park 120 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. N New 2. ❑ Replacement 3.E1 Replacement of 4. ❑ 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 300 Specify Type 41 ❑ Holding Tank 12 M Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 130 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)-~ ELEVATION (f 7RO U U,fcl Feet 3 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank jji& 11~_ A s Lift Pump Tank/Si hon Chamber. VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plu 1S, :(N; S m s) MP/ PR Business Phone Number: Plumber's Address Street, City, State, Zip Code : yo 5-96 olA-iljj ;U IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Surcharge Fee) 54 Approved ❑ Owner Given initial 2_ 9•.93 Adverse D rmination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the 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 cr plumber requires a Sanitary Permit Transfer/Renewal Form (SB0 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 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 arid/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'h 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 tarks; building sewers; .vel;s, water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas, and the location of .he building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; fr:ction 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 '983 Ksconsis? Act 410 included the creation of surcharges (fees) for a nunn42,r of regulated practices which can effect groundwater. Th ;otlftlif ; ihiough these surcharges are used for mo=nitoring grouridv,~.:iter, y. 01,111d- water K_,ontarnhioiiori investigations and establishment of standards. SBD-6398 (8.11/88) t ' j f "C"r V41v7"~'/ E ro P~/', T - I- - i : I ! + J , : i A.- Col : 1- I ~ I ' -SOL : I i I f : : I l - , • I i r I~ f , t f I I i I ~ I ~ ~ I I j i I I 0 - - i { i T/~ I Nip 63 7'd'P P~ : !rD i : 00 DfAWIYc LG ' : : ,2t2 I j X507 X1,1. ni1~2•4CC GUS' . "5*0 ~ ~ I j j i j _ ~i ~ ~ ' 1 ~ _ ~ ~ i ; - - r ~ j ~ " ; - - j i r _ ~ ~ ~ Ij ~ t i i _ _ i I ~ ~ ' ~ ~ i i ~ } _ i 1 ~ ~ I ! ~ _ ~ ~ ~ _ ; ~ j l f j i 1 I _ ~ _ i j ~ ' ~ I _ Rte. SANITARY PERMIT Si . Ukt -p COUNTY DILHR TRANSFER/RENEWAL UNIFORM PERMIT (PLB 67-T) 17 5 b S 7 PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: PROPERTY LOCATION: CITY: -rfic VILLAGE: '/a S10 %,S.251T.Z N,R 4 EsW W TO WN OF: tyr LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK: 3 •C L PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: PHONE NUMBER: ADDRESS: PHONE NUMBER: ADDRESS: 1, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this pro erty. PLU ER'S SIGNATURE- PREVIOUS PLUMBER'S NAME (IF CHANGED): PLUMBER'S ADDRESS: ` S PREVIOUS PLUMBER'S ADDRESS: r L TA 4Q 4,;L M W NUM PHONE NUMBER: MA~RSW NU PHONE NUMBER: 32 o0. 57- ( ►5'0- 4 cs ( ► Z/ SIISSU GENT: DATDISTRIBUTION: Original - County / Copy - Bureau of Plumbing Copy -Owner DSBD-6399 (R. 5/82) Copy - Plumber DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N W 5739069 HUMAN RELATIONS (H63.090) & Chapter 145.045) LOCATION:-PW , SECTION: TOWNSHIP/ LOT NO.: BLK. NO.: SUBDIVISION NAME: 2 S O N, / / /TLP N/R lOE (o( W 77e y 113 Sf• ix f/r/9,ups COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: SS30 1f'CiPp! Mw T~USEi✓ ~/A,vc ~ P/~so~/ /L/, 2 o z L) ff ~ USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: ROFIL DESCRIPTIONS: PERCOLATION TESTS: Residence 7 V. A , ANew ❑Replace I /v• SC" ~l" ~Hti f ' ,6 RATING: S= Site suitable for system U= Site unsuitable for system ICEJS ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLD G TANK: RECOMMENDED SYSTEM: (optional) ❑U ~S ❑U S ❑U ❑S E9U ❑S MU CoNVTro~~4 L - T R~NC 4-9- S If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: CL/~ Ss Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHE TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- j /f l Ail - 12.0 w~ T-4. H &S' ~ Port 3.6 ' -f o y. S " ZS JN . v-ie CS ~ k 7S' py- o. anti .75 a • o~4rl 2, 0 ' OAP- A) B 2 9p, 2-(o o /Q' o , 67' w Qa . ;Art S/ S, 0 ' T,}N vEe cs 7S'Af- 6a . /DAM 9.z S , ' ~N. loAr+, s' Si , 0 1 ~4r > O 7 7~ u v c s B- / S 3G 5 , G, 3 ` IV cs' PEA G R . o'" > / Z d . S > O ' a'~Y c 5 } 7~F B 24 36 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D2 P PER INCH / 2- P- P_ P- 2, Z < Z P P- L P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION - - A4 I ~ V 11 _rQ a_ . o FO~~ G f:Z ern. i o I lys S. -Ak ~v a I I • 1 ti /OS~ r _ 12-.0,__ "IF I, the undersigned, hereby certify that the soil tests reported on this form made by me iri; ccbokd vvith the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests ire icorr7trte tk)ees987 y knowledge and belief. It a L 1 NAME (print): " u TES E E COMPLETED O HOMESITE SEPTIC PLUM8IMG CO. OFFICE Fo " /f97 ADDRESS: E IFICATION NUMBER: PHONE NUMBER (optional): ROBERT U18RICIi7 .3P6 W16- WWR PLUMBER 86. NO. 3307 M.P.It! MINN. INSTALLER & DESIGNER UC. NO. 005M cs IGNATU E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - d SANITARY PERMIT APPLICATION ■ R M accord with IUtR 83.05, Wes. Adm. Code "I L STATE SANIT PERMIT - 4ftch complete plans (to the county copy only) for the system, on paper not less than ^ IPA x 11 Inches In size. LI--See reverse side forinstructions for completing this application. STATE PLAN I.D. NUMBER L APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION c l fti/ r% 5 w S c' T o, N, R v or W PROPERTY OWN S MAILING AWRESS LOT / BLOCK 8 13.4 C. 411 F Vs I V CITY, STATE ZIPCODE PNONE NUMBER 8UMMION HUE OR CSM NUMBER ti 3 4 a Z , 1 14 1/0 w+1 /t- ,e 'Ca 1 II N. TYPE OFBUILD~SgKi: (Check one) ❑ State Owned CrTy NEARESTROAD ` vatwGE : T tX"ofbed room8 tr 1 or 2 Fam. Dwellin PARCEL TAX ❑Public W. BUILDING USE: (H building type is public, check all that apply) ~t O , 1 Z) 4 ` 1 ❑ Apt/Condo 2 El Assembly Hall 8 El Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 El campground 7 El Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining Mobile Home Park 12 ❑ Service Station/Car Wash 4 ❑ Church/School 8 ❑ 5 El Hotel/Motel ry 13 ❑ Other. Specify 9 ❑ Office/Factory IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) - A) 1. Da New 2. ® Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System ExW%ng System B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued Y. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental .3c 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type < Roldirig Tank II 12 Seepage Trench 22 ❑ In-Ground 42 13 Seepage Pit Pressure 43 V TIVY 14 Syst"An-Fill. VL ABSORPTION SYSTEM WFORMATION: 1. GALLONS PER DAY 12. ABSORP. AREA 3. ASSORP. AREA. .4. LOADING RATE. 5. PERC. RA7F & SYSTEM 0". 7t; FWIAL GRADE REOUIRED (sq. ft.) PROPOSED (sq. to (GaWday/aq. Jt.) (M nJitRC .Y ELEVATION best `r-, Feet VM. TANK C~ vow owa Ilhom s Total 0 Of Prefab. ~s Fiber- E)qer> WFORMATION...___ LL Mar - adac-ture . r's Name Con- StsN -.New.. liailons -Tanks : _ ConcreW ....Qlaslt AN. Tanks Tanks _ Swft T i T Lint Pum T Chamber VBL RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of ft, 'ti hits Eewage system sfartni on the attsc tedp~yut : _ _ , , Plumber's Name (Print): Plumber's Signature: (W Stamps) MP 8tninsas Phtsls NumDsr 1 14 92 P211 , _P W e ess my, ts. p Coder C NTY (No StanW) Permit Fee ( bluing Agent Signature &WU Grounpoiar DIM WL*dy Sanr~ d4 Disapproved d F-) Approved ❑ Owner Given Initial X CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: a >z o. lima* &rnwty Pb4l?) (W 11/8%, DISTAIWTION: Original to Co". One CopyTo: $d f t BuNdhW OlrWon. Owner. P110*sr ` t t.~:. DEPANI-MENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDWIY, DIVISION NUM" 14 RELATIONS PERCOLATION TESTS (115) MADISOP.O. BOX 7969 N, W1 5307 (1-163.09(1) & Chapter 145.045) LUMATION:.;p 641, SECT[ TOWNSHI f/f4t:P►ifa : SUB VISION NAME: /Vf 1/4 1/4 2S /11•f N/R lOE ?,P 13 sf ~x fi~~'ttGt /,vDs COUNTY: OWNER'5111UYER'S NAME* ING ADDRESS: S.S30 USE DATES OBSERVATIONS MADE ND. OFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 77 N / New ❑Replap , " r I I RATING: S= Site suitable for system U- She unsuitable for system o®S ❑U IM ~JS:ou ®S ❑U ❑S UL 170 RU NKVECOMM CONUEf 3-tf0 A L TRV-•uC 44 $ If Percolation Tests are NOT required DESIGN RATE: if any portion of the tested arq is in the under s.H63.09(5)(b), indicate: c4c sr Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION -._.,.-OBSERVED EST. HIUM-T TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) / r y r S' dwe-Jejo. Sr - "I'rAHots #eoM B -f4'4 0 y S ' 7 S .m . vE,r C~ aQ - 49 Z I r .75~p~ O, eAAt .7S a 04H a 2.J0 • O AJ r", 47 d. 8.3. 0 7,1 AJ va'_cR CS r 7S 6j. MAIrt , y~ • /0AM 4( 4.1. S;, El- iv > I 6, 3 r T-4 A.0 UG/p /P CS Q PEA( 4 R r g Z •0 9~• 36 ~ ;ko, 2 . 0 '4• 0.- C313. 1Jrlher C S ~ PRc. Joie . B- ; PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME WATER LEVEL-INCHES RAT MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PER160 1' 2 MUM t PER INCH 2- P_ P- • L < Z P- r P. e P- . PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe trhat are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings snd the direction and percent of Iand slope. r SYSTEM ELEVATION s4'*.4se, p 7.~ li 1 I f ' C--A r-- 110 AS _ n A e s 't A a , t--- -1 - - MOVE N LID" ^ I (S em. 116 U, t T Al -.k I 1 r o - p E 1 - r aw- Zia- T _ 1 6106 t, the undwsWwd, herby W the the s08 tests reported on this brat frttade kt ; a srlth the proco&o" a4 methoeis specNtad M100 Administrative Code, and that the data raocrdad and the location of the wakwil kno4sledp arW W d.:' ' k NAME WnO: -9 P IGNATW; MuNH In,YmuErt & DEER UC. two oa/p D%TRIBUTFONi Original end one alopy to east 4taa+or a484+I1 f#A r 2z s DILHR 39D4M (A. (?2/d?1 c a*r I # ~ x 3~ i f ` g l Fresh Air Inlets And Observation Pipe - -=-PLAX 1!~- Approved Vent Cap f'or r MIn1mum 12" Above _ yv(~{~- ~~_Z ~gG Final Grade SO 20 - 42" Above Pipe 4" Cost Iron . ~ ~~~y t~ Y _ . Vent Pipe To Final Grade Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Pipe 0 0 0 0 0 - Tee 6" Aggregate Beneath Pipe o C-le,z 9a 45 I~ I p ARP -rvQr>,~e Prd~ L~1o-~ EL, 1oa.o • 1,0 I~ o ~cl.l I zoo lip Z - M $3 S~(17~; PI d ~ve 17 QeQrtlo M 0 ~ I + rl~`~ 111 s ` '3 T Il _921 (q Vale ~ i r G -PV _ G~pac~ ( 5 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS • INDUSTRY, C DIVISION BOX 'LAMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 539069 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/ LOT NO.:BLK. NO.: SUBDIVISION NAME: 2S /TIP N/R LOE (o ► ?~°oy 13 sf. j'x ff~'/,~.vDs COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: 51'•Ci ,u,~, T;~tISf ✓ /V~Nc ~ ~~so.~ /L /P z z o 4 z v E ff So3 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFI LE DESCRIPTIONS: PERCOLATION TESTS: Residence 7 ANew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system eo CONVENTIONAL: MOUND: IN-GROUND PRESSURE: rEIS YSTEM-IN-FILL HOLD G TANK: RECOMMENDED SYSTEM:(optional) E s Qu as E ❑u EJu os MU Coov"TrooAL- TR>EAic445 If Percolation Tests are NOT required DESIGN RATE: T If S~ t I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: o Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 12.0 Mors +Rom 3.6: y y s ~ s ~N . cs I I 1S ~.N D. Df!M .7S a • O*m 2.,0 ' 0 4 X V B-Z ~d'0 9~p 2(p /O.O , 67' ff. Ra tN.~ Sl _r10' T.tAJ yaoe CS . 7s '1Af< ao . ADAM . fa, 10,gAA, 15"41. &1. si , B-3 //0 1,0'a" 74v- > /.0 7 7~1u v' cs PeA GR ~gg B-~ 2-0 .36 2,0 AD > //.O' '3 vc-~r cs 7 B- 4 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT 2 P PER INCH P- /7 2- P_ P 2,- P__ P- Z 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. i SYSTEM ELEVATION y~' Zfe*1,4af P'rS _ _ 3 1 sjec System. , W 7-3 r-t I I • 3 1 i ~ S I _ ...T. -r I, the undersigned, hereby certify that the soil tests reported on this form made~J d with~he procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests a corr?VW ty,~`ey.Q y kaewledge and belief. NAME (print): III TE ERE COMPLETED Q W: OFFICE 30 IfF7 HOMESIfiE SEPTIC PLUMBING 00L ADDRESS: E IFICATION NUMBER: PHONE NUMBS (optional): ROBERT ULBRICHT elps MINN INSTALLER & DESIGNER LIC. NO. 0060 cs UP#E DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02182) - OVER - • 4 INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your retort must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil S and Textures Other Symbols st - S" ne (over 10'") BR - Bedrock cot) - Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Limestone *s - Sand HGW - High Groundwater cs - Coarse Sand Perc - Percolation Rate med s - Medium Sand W - Well Is Fine Sand Bldg - Building Is - Loarny Sand > Greater Than sl Sandy Loam < Less Than *i - Loam Bn - Brown *sil - Silt Loam BI - Black si - Silt Gy - Gray *cl - Clay Loam Y - Yellow set - Sandy Clay Loam R Red siel - Silty Clay Loam mot Mottles sc - Sandy Clay w/ - with sic - . y Clay fff - few, fine, faint .c - C cc - common, cc pt - rnm - Many, rrr ' m m - M ck d - distinct p - promir nt HWL - High vti level, Six general roil textures surf <Iter for liquid v disposal BM - Bench rv -k VRP - Vertical -ice Point T( OWNER: I 1 1st first '+n', ~ 'rrin<< a Th- cour*. ~ Est " rE of 'le I, for to ;te? l o ?C!77t.. 11it mus. F.. .k< a (i. ~ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code couNTY ' STATE SANIT(PPERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 11 ~ 8%x 11 inches in size. c . If isi ntopre~~ ousapplication -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 m n n1 E '/a S WS s' T , N, R a (or) W PROPERTY OWNE S MAILING A RESS LOT # BLOCK # Co iL ) 3 L ff CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER t r FrIL5 Li' S ~oZ'`- ~tS S /r14 57. vOIA, II. TYPE OF BUILDING: Check one CITY - NEAREST ROAD ( ) ❑ State Owned VILLAGE TY d N OF. ❑ Public L1 or 2 Fam. Dwelling-#~ of bedrooms 4 PAR ELTAX NUMBER(S) ) Ill. BUILDING USE: (If building type is public, check all that apply) '10-12-10 --30 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. ® New 2. ❑ 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ER 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 600 70o 99-S .76 Y 3. as Feet 98.3 Feet VII. TANK CAPACITY Site INFORMATION in allons Total # of Manufacturer's Prefab. Fiber- Exper. New istin Gallons Tanks Name oncret Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank i o /;too 1 F] F1 M _I ( 1~tJ Yes Lift Pump Tank/Si hon Chamber El I El F1 1-1 1 El LJ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/ R Business Phone Number: air c " s 337 8 ? /,f 4 ~S- a 17s Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial n surcharge Fee) (9 Adverse Determination /90 a 7 X. CONDITIONS OF APPROVALIREASONS 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•sanitarty permit is valid for two (2) years. 2. Your'sanitaryt 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 submjtted 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 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 lest 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 standar7s:" SBD-8398 (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), thenia second form should be retained and completed when the property` is sold and submitted to this office with the appropriate deed recording. t _ Owner of property 1m , J ; e114 P J Location of* propertyL.E-l/4 ~ 1/4, Section,_~5_, TJ,8_N-R_aLW Township Mailing address Address of site tot/ e r Subdivision name SA C,<0/yC few Lot no. other homes on property? yes _No Previous owner of property _~~.rJ~~,J /fJArtrr_z, ~it~L1✓ Total size of parcel Date parcel was created Are all corners and lot lines identifiable? ~_Yes No Is this property being developed for (spec house)? Yes _X_No Volume and Page Number P~3_ as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded n the office of the County Register of Deeds as Document No. 5-s-r o , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document No. ignature o licant Co-applicarit 't-5 Date of Signature Date of Signature C~~ i b Y wf 1' iz a .f a .,:5 • 410 fr'' + k " ...fin 4s . ~ Ry y„ ~ ~ fr •y.~z ~ ~i a Yp. r Q. S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYE % h1 saI")- ~ La tc t~ ADDRESS IS'~ C.C~ IC FIRE NUMBER 5 -1 CITY/STATE g ► Je/~u ~15 ZIP ~y~ r PROPERTY LOCATION :A/5 1/4 _VJ 1/4, SECTION, T2B_N-R 2 _6 W TOWN OF l K , St. Croix County, SUBDIVISIONSTUL)11l jG,Jd S , LOT NUMBER_L . 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, 1918. 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. ~~,A{ q SIGNED Q Gt~i l c i' v~ JJ DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 LL ST. CROIX COUNTY WISCONSIN i}';n-,~i ZONING OFFICE ST. CROIX COUNTY COURTHOUSE [y. - - - 911 FOURTH STREET • HUDSON, WI 54016 - _ (715) 386-4680 June 3, 1992 Jim Helgeson P.O. Box 406 Hudson, WI 54016 RE: PERC TEST FOR FORMER MARK JENSEN & NANCY CARLESON PROPERTY, KNOWN AS LOT 13 OF ST. CROIXHIGHLANDS SUBDIVISION, LOCATED IN THE NE1/4 SW1/4, SEC. 25, T.28N., R.20W., TN. OF TROY, ST. CROIX CO. Dear Mr. Helgeson: I have reviewed the above mentioned perc test and have found it to comply with the requirements setforth by the state of Wisconsin and this office. This report indicates that the site is suitable for a conventional septic system. Given the information I have reviewed and my experience with soils in this part of Troy township, I believe this report to be accurate and acceptable for the purpose of obtaining a sanitary permit. If I can be of any further help in clarifying this matter, please feel free to contact me at this office between the hours of 8:00 am :00pm, Monday - Friday. Jame K. Thompson ~Ssistant Zoning Administrator St. Croix Co. Zoning