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Wiso,xa,inD'partmentofIndustry,
a PRIVATE SEWAGE SYSTEM County:
Safety an and Human Buildings Relations Division INSPECTION REPORT
S
(ATTACH TO PERMIT) sanitary PermitNo.:
GENERAL INFORMATION NE47NE'' ,Rc.4,T30-R17, Co. Rd. T 149158
Permit Holder's Name: ❑ City ❑ Village P1 Town of: State Plan ID No.:
Vickie Lyons Erin Prairie S9' f -a 07 Ggcr
CST BM Elev.: i Insp. BM Elev.: BM Description: Parcel Tax No.:
7-751 1-1a) 7 574
TANK INFORMATION ELEVATION DATA `Q
TYPE MANUFACTURER CAPACITY STATION BS HI #FS' ELEV.
Sep Benchmark 9-2 Z
Dosing
Aeration Bldg. Sewer t
Holding e / Ht Inlet , I S'
r
TANK SETBACK INFORMATION / Ht Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
Air I
Septic NA Pt Bottom
Do Ing NA Header/ Man.
Aeration NA Dist. Pipe
Holding '>'50' Bot. System
PUMP/ SIPHON INFORMATION Final Grade 3- Or/
Manufacturer Demand ;27
Model Number GPM & 9 3
TDH Lift Friction stem TDH Ft 10
~l /d 08: 5 ~a
Forcemain Length Dia. Pist. To Well
tla
SOIL ABSORPT LON-SYSTEM 14 M. - , '
i
RED/TRENCH Width Lengt No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG ELL LAKE /STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Mode Number:
System: OR UNIT
DISTR
Hea r / Manifold Distribution Pipe x Hole Size x Ho n Vent To Air Intake
Length Dia. Length Dia. acing
SOIL COVER x Pressure Systems Only xx +Mou-nd.Or.At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seed Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No 1_ Yes ❑ No
C~O'M.MDENTS®:p ~(include code discrepancies, persons present, etc.)
* I
o P( 10-d za,,~ a
ce &I-)C4 s
u.s,6.5, 6,ell-, = 100760cv
Plan revision required? ❑ Yes to
Use other side for additional information. / .
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
SANITARY PERMIT APPLICATION
DILHR In accord with ILHR 83.05, Wis. Adm. Code cou NTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than COQ
8% x 11 inches in size. 1:1 f revision to previous application
Q0 C
-See reverse side for instructions for completing this application. STATE P N I.D. NUM R e-A
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPE TY OW ER FROPER
TY LOCATION Alr ~/a l/a, S T ~d N, R E (o~
~
PROPERTY OVI~NER'S MAJ I ADD ESZ.S BLOCK
~J1 a J
CITY, TATjE ZIP CODE PHONE N MB R SUBDIVISION NAME OR CSM NUMBER
qt, 7 ji'~t(hc ° f
t°v
CITY NEA AkT RO
II. TYPE OF BUILDING: (Check one) [I State Owned VILLAGEfy fry r 1 7
❑ Public 591 or 2 Fam. Dwelling-# of bedrooms - P L N U lob _ y~~
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Off ice/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) Repair A) 1. El New 2. [ck Replacement 3. ❑ Replacement of 4.0 Reconnection
5.0 Ex isof an
System
System System Tank Only 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 El Mound 30 El Specify Type 41 El Holdin9Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
140 System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
Feet Feet
CAPACITY Site Fiber- Ex pp
VII. TANK in alions Total # of Manufacturer's Name ancaete Con- Steel glass Plastic App
INFORMATION New istin Gallons Tanks structed
Tanks Tanks T
Septic Tank or Holdin Tank T>`~aS
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): Plu Signature: (No mps) =MMP/MPFffW_No,_'.3 Business Phone Number:
2
PI tuber's Ad ress Street, i e, ip C e):
146 (o
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issui Agent Sigri- o Stamps)
Surcharge Fee) ^
Approved ❑ Owner Given Initial
LP Adverse Determination
X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
7
DfLHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY,,/
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ° J V-
8% X 11 inches in size. ❑ G`heci 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 OWjVER PROPERTY LOCATION
S r' 1l ' '/4 ? t/4, S T ?U, N, R E (06)
PROPE TY OWNERS MAILING ADDRESS LOT # BLOCK #
CITY STATE t ZIPCODE PHONE NUME SUBDIVISION NAME OR CSM NUMBER
CITY NEAREST ROAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE 4OWU , 14V
;
r
❑ Public ❑ l or 2 Fam. Dwelling- # of bedrooms- PARCEL TAX NUMBER(
r.•"`~
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ❑ New 2. R 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 ❑ 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
f ~ -2 Feet 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
14 1
Se tic Tank or Holdin Tank F-1 Fj
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'# Signature: (No Stamps) MP/MPRSW No.i Business Phone Number:
Plu ber A ess (Street I , S te, Zip Code):'
r'
IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater ate issued issuing Agent Signature (~J\ Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial-,
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
_ SANITARY PERMIT COUNTY
.LLDILHR TRANSFER/RENEWAL UNIFORM ~RYIT # (PLB 67-T) Iq l/S
PERMIT RENEWAL DATE: PERMIT TRAN FER DATE: ORIGINAL P~ T I UAIyCE DATE: STATEJ? ANI. NUMB
PROPERTY LOCATION: CITY:
j~ s~ T N R E (or) VI y'l O
F t~4 / t~4~`7 V
LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: iNEA EST R~AD, LAKE OR LANDMARK:
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: 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.
PLUM IGNATURE;/ PREVIOUS PLUMBER'S NAME (IF CHANGED):
p e z 7~P
PLUMBER'S AD RE:~D PREVIOUS PLUMBER'S /1D l ,
DREISS: MMPAZ!
(rte h/Mo/C1BER: PHONE NUMBER: MP/ RS MBER: PHONE NUMBEI/R::vl'V/
10 7 -
3J < (9/~ )VPS
SIGN URE OF ISSUI ENT: DATE APPROVED: DISTRIBUTION: Original - County
Copy - Bureau of Plumbing
V Copy - Owner
DILHR-SBD-6399 (R. 5/8 Copy - Plumber
SANITARY PERMIT -aA Aff:~~ COUNTY
CDILHR TRANSFER/RENEWAL UNIFORM P 13/r #
(PLB 67-T)
PERMIT RENEWAL DATE: 77ETR0A7FER RMIT C/ATE ORIGINAL P IT I UAIyCE DATE: ST~ E AN I.D NUMBEQ:
PROPERTY LOCATION: p(~` (q CITY: 0('/1 / (J dnG
F '/4 E '/4,S y T3 i N,R E (or) VI E: y` /f 61-ou I to
LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST R~AD, LAKE OR LANDMARK:
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: 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.
PSIGNATURE/ PREVIOUS PLUMBER'S NAME (IF CHANGED):
PLUMBER'S ADDRE S: PREVIOUS PLUMBER'S DDR S:
'1~ 6 7a ~o d j y I t soli S~
MP MBER: PHONE NUMBER: MP/ RS MB R: PHONE NUMBER:
3 J Ir (9/~ ) Y~s - z ~S
SIGN URE OF ISSUI ENT: DATE APPROVED: DISTRIBUTION: Original - County
Copy - Bureau of Plumbing
Copy - Owner
DILHR-SBD-6399 (R. 5/8 Copy - Plumber
,
DEPARTMENT OF REPORT ON SOIL BORINGS_ AND SAFETY & BUILDINGS
INDUSTRY,' DIVISION 7969
LABOR AND PERCOLATION TESTS (115) P.O. BOX
3707
HUMAN RELATIONS MADISON, W1 53707
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTION: TOWNSHIP/ LOT NO.: BLK. NO.: SUBDIVISION NAME:
NE 1/4 NE 1/4 4 /T 30 N/R17i&(or) W Erin Prarie n/a n/a Jewitt Mills
COUNTY: OWNER'S/BLAME: MAILING ADDRESS:
St. Croix Vickie Lyons 1772 Co. Rd. #T, R.R.0, New RichmO_nd, Wi. 54017
USE DATES OBSERVATIONS MADE
R OLATION TESTS:
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCR PTIONST7'-16-91
I BResidence 3 n/a ❑New ~teplace 7-15-91 RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
❑ S ®U ~S ❑U ❑ S i~U ❑ S RN ❑ S ®U mound
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
PROFILE DESCRIPTIONS nage 29 I
vimal' BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL IT THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH I SEVOA TI ON OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 2.34 07.8 none >2.34 .67bl.1. .50bn.s.1. 1.17bn.ls
B_ 2 3.16 1007.8 none >3.16 .58b1.1. .58bn.s.l. 2.00bn.1s.
B- 3 3.41 1006.9 none >3.41 .58bl.1. 1.00bn.s.l. 1.83bn.1s.
B-
B-
decimal' PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RAPER INCHES
NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD
P_ 1 1.00 none 30 4 3% 3% 9
P- 2 1.00 none 30 54 5 5 6
P- 3 1.00 none 30 2 1% 11-1 20
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION i nOR - h7
641~
I I
6Il - -
.hy
3 3 -
d ~
0-'rl',10017 6-U)
3 E
~I ,9 len. 90
c,^ L4 d,~'- -~v t N
270
E~ 3
E
~
K
S'
~O CO c - -
3
fi
o m ~~3 A
J11 J
rr%
I, the undersigned, hereby certify that the soil t po~e gA tF~jformdwere y me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded a tl~ location of tests ar t to the best of my knowledge and belief.
NAME (print): r^ : TESTS WERE COMPLETED ON:
7-16-91
Gary L. Steel
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th- Ave.. New '"i-c-hTnond, Wi 54017 224 ~14 7CST SIGNAT 4~~~~ 61
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) - OVER -
ST. CROIX COUNTY
i `,sNT¢'yNA,
WISCONSIN
ZONING OFFICE
.?x ST. CROIX COUNTY COURTHOUSE
- 911 FOURTH STREET • HUDSON, WI 54016
1 (715) 386-4680
Aug. 2, 1991
Division of Safety and Building
Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
Dear Sir:
An on site investigation of the Vickie Lyons property, located
in the NE 1/4 of the NE 1/4 of Sec. 04, T30N-R17W, Town of Erin
Prairie, St. Croix County, showed 12"-16" of suitable soil over
crevised limestone bedrock which does meet the requirements of
the A+4 rule which makes this site suitable for a mound.
Should you have any questions, please feel free to contact this
office.
Sincerely,
. rn
Jame Thompson
As istant Zoning Administrator
cj
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
.'C\.t 1 ~~t .YI•~~ylyM~r~'~ Y ,
ST. CROIX COUNTY COURTHOUSE
r;
911 FOURTH STREET • HUDSON, WI 54016
(715) 386-4680
Aug. 20, 1991
Division of Safety and Building
Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
To whom it may concern:
An on site investigation of the Vickie Lyons property, located
in the NE 1/4 of the NE 1/4 of Sec. 04, T30N-R17W, Town of Erin
Prairie, St. Croix County, revealed 12"-1611 of suitable soil over
bedrock which makes this site unsuitable for an onsite sewage
disposal system.
Should you have any questions, please feel free to contact this
office.
incerely
~•rr~ 0' 1 • m
James K. Thompson,
Assistant Zoning Administrator
cj
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ONSITE SEWAGE SYSTEM a
APPROVED
DEPARTMENT OF IN TRY, LABOR AND HUMAN RELATIONS
DIVISI SAFETY AMA BUILDINGS
SEE RE pONOENC
r
-k
XJ1*i
abanacned ~ fade x9
~oa~•9y ~
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a- oosU . qJ 4 ~ lid ~c~in~ tan S pl.roo ~paot s od
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93, 1869) 1`i f ri
S,
S91-20949
P.
HOLDING TANK CROSS-SECTION
Approved Weather Proof
Vent Cap Junction Box
oa /Approved Locking Manhole Cover
4„ C'I•
Vent Pipe With Warning Label Attached
Minimum ~y~igba~ex~st F~cad
Pla;h Final Grade /hlny''~boue ~xis7`
Approved Joint
18" Minimum
Water Tight
Seal High Water '
SPECIFICATIONS Alarm Switch •
TANK New X Existing - - - - - -
Manu acturer: PIdwestern freosf W/ C.I. Joint
Tank Size• W/ . Pipe
Blind C.I. I Gallons Extending 30
Plug Onto Solid Soil
ALARM Manufacturer:
Model Number:-
Switch Type
NUMBER OF BEDROOMS:
GALLONS PER DAY: ~IS~D
3" of Bedding Under Tank
Owner's Name : R S
Address:' !
7
Le 'sc ription: T
A- 7G.>
wn /Municipality: r~
County: 57. ('roi X
ONSITE SEWAGE SYSTEM
PLUMBER/DESIGN
yes
Signature:
License N•m e Date:-
_ APPROVED
PARTMENT OF 1N0 TRY; LABOa AND HU- I RELATIONS
DIVOO SAFETY AND 8U00W3S
0 E
ESPONDEN .
S91- 209 49
VOL 913 PAGE 417
Document No. This space reserved for recwdhq data
473042 HOLDING TANK AGREEMENT
Agreerttent D to
/ This agreement is made between the REGISTE
S OFFICE
I - Holdin Tank 9- ~sO)--wners
Coup or Local Governmental Unit R
,6F,er1J 0_ 0A1SifXP I ST. CROIX CO., WI
S_- et?o:rX e i y W-, I Recd for Record
(Called Municipality below 1 0Idf e ,1. On _S
r~JG29 1991
We acknowledge that application is being made for the installation of (a) holding at 1' 2 P. M
tank(s) on the following property, (Provide legal land description:):
ofDe
-~J T , - D U A +-a( Return To
or that continued use of the existing premises requires that a holding-tank be installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Slats.
r
As an inducement to the County of to issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in as. 146.13 and
146.14. Slats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60, Slats.
2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the i
costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess-
ment for the abatement of a nuisance, and the tax shall be collected as provided by law. S
3. The owner, except as provided by s. 146.20 (30) (d), Slats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner
further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the date of change to the service contract. I!
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county.
S. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83; Wis. Adm. Code. In addition, this
agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit
the existence of the certification to be determined by reference to the property.
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement
to be determined by reference to the property where the holding tank is installed.
Owner(s) Name(s) (Print) 1 Owner(s) Signature(s)
Subscri and sworn to before me on this date:
I
U+C ie L i -A, 0
Municipal Official Name (Pri ) 1 Municipal Official Signature .-Notary Public j
1 My commission exp es:
Municipal Official Title (Print)
I q9157
~~sa ~KAacKL- TO~,~J cNmu ( /
i
SBD-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations. Bureau of Plumbing.
HOLDING TANK SERVICING CONTRACT
Con;r#ct Date
This contract is made between the
Holding Tank Owner(s) Name(s) and Pumper's Name
L an s ; CJWE2..s
~r y ,
We acknowledge the Installation of (a) holding tank(s) on the following property: (Provide legal description:)
NE %y a~ -0- JVE % O'~ Sec,0 T30 N- )owh d~ £r; y\ Qra;~r►e
1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of ~5T . t r , X
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) I Owner's Signature(s)
Subscri d and sworn to before me on this date:
I
I
L-t,~On s
I "
P roper's Name (Print) I umper's Signature Notary ubiltt
t
/!lG/hZT /ivG I mmission eexpir/es: _
Pumper's Registration Number y t W5
SBD-7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
=TQILH SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code couNTY
STATE SANITAjY PET
-Attach complete plans (to the county copy only) for the system, on paper not less than / [[((~P//
8% x 11 inches in size. ❑ check # revision to p j
,us application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY WNE PROPERTY LOCATION
t~E. LAs Y PROPERTY
S T 3 6, N, R E (or) W
L~• -e- C`.~1
PROPERTY OWNgRR''S MAIel A WPF Id I 0 LOT # BLOCK #
CITY, STATE ZIP CODE ^7 PHONE NU BER SUBDIVISIO NP M R CSM NUMB
II. TYPE OF BUILDING: Check one CITY : NE68ESST ROAD
ff~~11 ( ) ❑ State Owned D VILLAGE
OF: oa
NUMB ,
❑ Public [31 or 2 Fam. Dwelling-# of bedroomSa PARCEL AX
ill. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. 9 New 2. ❑ Replacement 3. ❑ 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 30 ❑ Specify Type 41 R Holding TankS
12 1:1 Seepage Trench 22 El 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
RE Min./inch ELEVATION
Feet Feet
VII. TANK CAPACITY Site
INFORMATION in gallons Total of Manufacturer's Prefab. Fiber- Exper.
New Existing Gallons Tanks Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank 001D e4,
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): Plu bar's Sign re: (No Stamps) MP/MPRSW No.: Business Phone Number:
S'rr, ak4 I`X"S pk 3 ;
Plu bar's Address (StreNypt a ,Zi p Code):
(~®8 ~ a,J - 1AD~ W Q~S'G- -S Ul lv
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuin A ent Signature (No Stamps)
9 1 Approved El Owner Given Initial _ Surcharge Fee) -Q/
Adverse Determination
` r
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
PARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIJSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
N WI 53707
HUMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
4T ION TOWNSHIP/ OT NO.: BLK. NO.: SUBDIVISION NAME
c
'tE NE 1/ 4 /T 30 N/ 173&(.,) W Erin Prarie n/a n/a Jewitt Mills
r. MAILING .
St o Vickie LyonsAME. 1772 Co. Rd. #T, R.R.0, New RichM_-'nd, -Wi. 54017
Croix
DATES OBSERVATIONS MADE
USE - I
NO. D CO ST :
R T 0 ❑ New ®fteplace
~ P~i ten~P 3
n/a 7-15-91 17-16-91
RATING: S= Site suitable for system U- Site unsuitable for system
. NVEN I IONAL: MOUND: IN•111TE - -FILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
s u t IS Du a s 2u a s 2U E ]S ®u mound
r rcolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
1l.rIR 83.09(5)(b), Indicate: n/a Floodplain, indicate Floodplain elevation: n/a
PROFILE DESCRIPTIONS 29 SID
decimal t ,
'Ii~IraG TOTAL DEPTH R UNDWATER-INCHES CHARACTER OF SOIL IT THICKNESS, COLOR, TEXTURE, AND DEPT-11
!,tJU -BER DEPTH I LEVATION OBSERVED TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
IB- 1 2.34 1007.8 none >2.34 .67bl.1. .50bn.s.1. 1.17bn.ls
B.2 3.16 1007.8 none >3.16 .58bl.1. .58bn.s.1. 2.00bn.1s.
g_ j 3.41 1006.9 none >3.41 .58bl.1. 1.00bn.s.1. 1.83bn.1s.
B- j
B- 1
decimal' PERCOLATION TESTS
~rESr DEPTH WATER 1 HOLE TES TIME IN WATER LEVEL-INCHES RAT MINUTES
R AFTERSWELLiNG INTERVAL-MIN. PERINCH
1 1
1.00 none 30 4 3• 3• 9--
2 1.00 none 30 5% 5 5 6
3 i 1.00 none 30 2 1- 20
I
PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori
a! and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percen
_ , ;In(i slope.
SYSTEM ELEVATION ; 110$-6.7 LOP 4
f?" 6) -4s`'
9D ~-it /60
A-r e4 s
T
P I
Jos,
i>, E~IZ p bbd ~i~//sda S'Isifjd v d _ .3u
1, r^ , !ndersigned, 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
r .rrarive Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
f1'I'nrl- TEST WERE O PLETED ON:
C; rv L. Steel 7-16-91
)i EIS CERTIFICATION NUMBER: PHONE NUMSER(optionnl
1 !i. _ 2QO t , New ^ i nhinon , 11-1. 5140 ( -
ATVR
DItirtlBUTION: Original and one COPY to Local Authority, Property Owner and Soil Tester,
tits r.r n.r. t,aa Ire tnmit - OVER .
,FPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
'J UUSTRY, DIVISION
P.O. BOX 76
ABORANO
PERCOLATION TESTS (115) MADISON W153707
W%1AN RELATIONS
(ILHR 83.0911) & Chapter 145)
K NO. SUBDIVISION NAME:
:'nT!~N
sECTION: TOWNSHIP/ [nn/a T NO.: L :
I/ NE 1/ 4 /T 3o N/111 7)&(,r) W Erin Prarie n/a Jewitt Mills
: Y: OWN E AM
t. Croix Vickie Lyons 1772 Co. Rd. #T, R.R.0, New Rictm)os.rid ,-Wi. 54017
'SE =NO, : COMM- DATES OBSERVATIONS MADE
ERCIAL R TON: OFILE DESCRIPTIONS- TS:
Xx',slde"Ce 3 n/a ONew Ol2eplaee I 7-15-91 7-16-91
1ATING: S= Site suitable for system U- Site unsuitable for system
F TONAL: MOUND: IN-CT,ROUN -FILL OLDING TANK: RECOMMENDED SYSTEM: (optional)
su r s au a s RU a s tau a s ®umound
at on-Tests are NOT required DESIGN RATE: if any portion of the tested area is in the
Hit 83.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a
PROFILE DESCRIPTIONS
=,oRifiG TOTAL DEPTH gR-OU NO ATER-INCHES CHARACTER O SOIL IT THICKNESS, COLOR, TEXTURE, AND DEPTH
J! M-18ER DEPTH 1 LEVATION OBSERVED EST. HIGATSf- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B 1 2.34 1007.8 none >2.34 .67bl.1. .50bn.s.l. 1.17bn.ls
B- 2 3.16 1007.8 none >3.16 .58bl.1. .58bn.s.1. 2.00bn.1s.
B- i 3.41 1006.9 none >3.41 .58bl.1. 1.00bn.s.l. 1.83bn.1s.
B.
decimal' PERCOLATION TESTS
Der i it WATER I HO TES TIME IN WATER LEVEL-INCHES RATE, INUTES
3ER AFTER SWELLING INTERVAL-MIN. PER INCH
1-- 1.00 none 30 4
34 ' 3'
? 1.00 none 30 5% 5 5 6
? i 1.00 none 30 2 1~ 1- 20
t.nT PLAN: Shove locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
n,ai 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
SYSTEM ELEVATION ioR-67 ,Q~ aye
Q
/08 .(A y.~ 1 Igo
S i
'J~~tD 54 111 C}rt~~ 10
tN
o
I I
rl~:" L 6' X05 ` r7i
~)`~t''~~ 1 " a i ''°~°'I/sdvt jFd Ir ocKd ~J~
;ire vndetsi n
edhereby 9 certify that the soil tests reported an this form were made by me in accord with the procedures and methods specified in tte Wisconsin
-1-'l -trative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
-+F !tirintl T W COMPLETED ON:
(,:Try L. Steel 7-16-91
l'r^' CERTIFICATION NUMBER; PHONE NUMBER (optionni):
_5 ~.-s~.L'h-- MVP . , Ile ri rhmand, 111 - 5401 -Al)
I
c I ftIESUT10N: OfiflinaI and ore copy to Local Authority, Property Owner and Soil Tester,
tIll 1f;0 6395 (R. 10/831 - OVER -
SECI_ 101V
R B- L, 6 7 P L OTA ( : I-' 0 S S
• k L 0 C A 10 N -12y ilt_•T . -1C
E N S E
PL 0
(UU TAB
f 1
i ~ J 1( J 1_
nil
0, O~ a.Oo C3 r
9
T~ 1 NAB k) t U
.
• ~n~ e~~T 10k 115 AP-Q
A F.Q~ ~hAN Ioo ~t LVn,
1~oia ~~y Tin; k" S-
FRESH AII: IK :TS~AND OBSERVA'rio ti PI.pE
Ct:n'"S SECTION
Approved Vent Cap
Minimum 12" Above
i+ Final Grade
j
• 9" Cast Iron
Above Pipe ~ Vent Pipe
.
To Final Grade
Marsh Ilay Or Synthetic Coveri. ny
Min. 2" Aggrcgf-i1
Over Pipe
Distribut' Tee
Pipe
Aggregate Perforated Pipe Below
Beneath Pipe ~t Coupling Terminating T
Bottom of System
• A A
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591-20736
FFFFFFFF A X X
F A A X X
F A A X X
F A A XX
FFFF A AAA A XX
F A A X X
F A A X X
F A •A X X
ST. CROIX COUNTY COURTHOUSE
911 Founzh S-t4eet
fiudaon,Wl 54016
VATE:
TO: FAX NUMBER:
NAME:
--4
FROM: FAX NUMBER: (715)386-4628
NAME:
NUMBER OF PAGES INCLUDING COVER S ET:
IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED,
PLEASE CONTACT:
NAME: TELEPHONE NUMBER: 46 F/G
o °0
APPLICATION FOR SANITARY PERMIT
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 forresale 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 5
Location of Property , Section , T.~ N-R W
Township Z Q /'ti r r i'E'
Hailing Address 1721 !Wi°Ui ~Jl:IL'(~ f~l 'TL~~fa
Address of Site J7 ,t}
Subdivision Name l 1 lI, I r I S
Lot Number
Previous Owner of Property ~,gD a~Q vg~-r,`t(t oo r P
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 No
Volume and Page Number ~ /a _ 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, and 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
1 (We) centi.6y that aCt 6tatement6 on this 6onm ahe tAue to the best o6 my (ouA)
knowledge; that I (we) am (cute) the owneA(.6) 06 the ptcapefcty descAi•bed in thiA
in6otcmati,on 6onm, by vi tue 06 a waAAa.nty deed AecoAded in the 066ice 06 the
County RegizteA o6 Deedsah Document No. V,~ 41,7o*~ ; and that T (We) ptaen,tey
own the pAopoded .6 to 6oA the 6ewage diapo.bZF6-y-,65Fe-m (oA I (we) have obtained an
eabement, to h.un with the above deacAibed ptcopehty, 6oA the condtAucti..on o6 said
b ydtem, and the same ha A been duty t coded in the 066ice o6 the County Regi.6ten 06
V eL Voetament No .
1 0~ t~o
SIGNATURE Olt .OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED