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HomeMy WebLinkAbout030-1026-40-000 m I oa c a 4 0 ~ I ~ I o I 0 N h •o I ~ I I Q I O I a I Z I C LL C 3 ~ I I I Cl) O I Z W ~ E O r 00 V 0 cc H z a m I o I c z o Z r 13 95 Y o I M FZ- c E M N N 3 f0 d ~ tq (~1 y N N y ~ C Q. ~ L O I ' O N o (D O Z m z N ~ Y ~ Z I CX) m tm N j Cl) y E o° O R a a 'R y cD ao y y CID N o 0 o o a E r N E N> ! (I~ fAtn > oN cD 3 a in o O O O Z •rv aaa a 0 N N rn 0) o N J U }}v~~ CO a, 2 c~ m E N O o m I m y c (L _ y N O ! ~ d m I p > 3 a~ I~ ~ y y O O y ` r..+ O W O Cep O C C LO O Q q°_ E a) a s cCL 0) N I co CL (D E E 0 co r co o r' m C o o 5 N N (n - - I I 0 Lo 1-- -C 6 O N N d O F-H C N M O 04 :3 • O O fly r O Z N c'7 cn 04 V d m a m at EL IL CL z .2 r`Iv o R ! 3 oo r A Ua2 0 v1U WFONvi-- - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP j'Y. .Jcsc.'~t SECTIONT 3 p N-R / W ADDRESS 8eX2 8 Z- ST. CROIX COUNTY, WISCONSIN l~k.,5a°, Syn/ t SUBDIVISION C.s M. VOI. 1 _ 00 LOT Z LOT SIZE - z Z /rC PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Nou anti x St ' b~' I /17'• t et V -fl 4k I 1 I a J .t^ Q.h 1 j 125 143 - 51d Id /or $ M Tod S r y s-fQta cx~c t C L. = IOO.oo ' INDICATE NORTH ARROW BENCHMARK: Elevation and description: Tor of SJAk, lYS"w-sfiof 3.,6 4wM•.✓ Alternate benchmark_7d aP 41•`~~ S. 2 SEPTIC TANK: Manufacturer: W &; Sa..r Liquid Cap. 10004-,0- Rings used: _Z- Manhole cover elev: 7./4 Final grade elev: 7-2 5 Tank inlet elev.:/v.?o Tank outlet elev.: /d.6 No. of feet from nearest road:Front~C , Side , Rear Ft. 3 (o0 From nearest prop. line : Front , Side X , Rear Ft . 13 S" No. of feet from: Well Building: 18 (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE 1PPFPP" it ~ . . ".'sue PUMP CHAMBER I Manufacturer: Liquid 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:L/o,,v«-V;& -J Trench Seepage Pit:--- Width:, /S~ Length Number of Lines: -3 Area Built 7ZOS'?7* . Exist. Grade Elev. 7, Z 5" Proposed Final Grade Elev.--7-Z5" Fill depth to top of pipe:_4Z No. feet from nearest prop. line:Front , Side X , Rear Ft./25' No. feet from well: 74 No. feet from building 'S' HOLDING TANK Manufacturer:-/// Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Sides, Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: M DATE : PLUMBER ON JOB: LICENSE NUMBER:,r~JL- 6/90:cj LOCATION: ST. JOSEPH 6.29.19.104E,6,NW,SW, RIVER RD., LOT 2 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 149254 Permit Holder's Name: ❑ City ❑ Village)] Town o : State Plan ID No.: MILLER SAM ST. JOSEPH Parcel Tax No.: CST BM Elev.: Insp. BM Elev.: BM Description: 1 030102640000 TANK INFORMATION ELEVATION DATA A9200151 TYPE MANUFACTURER CAPACITY STATION BS =HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P/ L WELL BLDG. Ai,Ito ntake ROAD Dt Inlet Air 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 oss 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 LEACHING Manufacturer: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER Mode 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.) Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710(R 05/91) Date Inspector's Signature Cert. No. 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.: GENERAL INFORMATION NE,SW,Sec.T29-R19,L0t 2, River Rd. 149254 Permit Holder's Name: ❑ City ❑ Village k7 Town o : State Plan ID No.: Sam Miller St. Joseph CST BM Elev.: Insp. BM Elev.: ' BM Description: Parcel Tax No.: 1r)d a, 1030-102640 DATA TANK INFORMATION ELEVATION TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic WT o- Benchmark -503 S D~ Dosing ' 99,96-", Aeration Bldg. Sewer Holding st/~4 Inlet TANK SETBACK INFORMATION St/,KOutlet o 94 31 TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt I rl Septic >1d3, NA UL_9e++&M Dosing NA Header/-fir. Aeration NA Dist. Pipe Holding Bot. System z g z ` i?ZZ PUMP/ SIPHON INFORMATION Final Grade Ma Demand •T 4 e 9 OS Model Number GPM TDH Lift Friction System Ft ead oss Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 4(~ EN I N LEACHING u acturer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM INFORMATION Type O ewe , r / CHAMBER Mode Num System: OR UNIT o, DISTRIBUTION SYSTEM Header / Ma++ifofd Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. / Length Dia. LL 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 ❑ Yefkj:o No COMMENTS: (Include code discrepancies, persons present, etc.) / afc 3~3 c '7 413 6- -2 Min. Etettz 90-Z7 o' i es No Plan revision requ ed ©~Y ❑ 02 J~~ Use other side for additional information. Fj 11-3 SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No. SANITARY PERMIT APPLICATION U. DILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 C/ 8% x 11 inches in size. Ch k i revision to previo 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 r' Y. S T.7N, R E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOC' 2„- 47, /Y CITY, S TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER W oleo V'~ 3 7 G G., S. /y1 # 7 / Il. TYPE OF BUILDING: Check one) CITY NEAREST ROAD ( ❑ State Owned ❑ VILLAGE : f r S~ O ❑ Public V11 or 2 Fam. Dwelling-#of bedrooms- AR EL TAX NUMBE III. BUILDING USE: (If building type is public, check all that apply) D Y,6 Z G d r 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 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 N 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 D Z U 72-0 !P 16- D. R.z 97• W Feet /M.,So "Feet Vll. tNKORMATION CAPACITY Site in Ions Total # of Prefab. Fiber- Exper. Ta ks Plastic Appp New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber F] F-1 I E] I F] 1 11 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/MPRSW No.: Business Phone Number: p«~ Sfiro~.b~.aL ~ M 3 3~- ZV 7 3 7- 3 Plumbers Address (Street, City, State, Zip Code): IX. C LINTY/DEPART ENT USE ONLY ❑ Disapproved Sa 'tary Permit Fee (Includes Groundwater Date ssue Issuing gent Sig re No Sta ps) rproved ❑ Owner Given Initial Surcharge Fee) Adverse Dote t*on X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber J 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 re,rewal 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, 6D8-266-3815. 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. C-Jmplete 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 dimensio-is, 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; model and manufacturer D) cross section of the soil cr pump pump ab. ptron 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 oi' standards. SBD-6398 (R.11188) S T C - 100 This application form is to be completed in full and signed t by he owner(s) of the property being developed. Any inadequacies ade uaci will Y 4 es only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Sa ,•j•, rlj; //Q r- Location of property_&L_1/4 541114, Section 4. , T _al N-R 19 (P Township Mailing address Boxz Z ~u. ~so~ W ~ S~lD/G Address of site mgr 'Ram subdivision name G ,S, rn 4 71 3 r Lot no. 2 Other homes on property? yes x No Previous owner of property E~( u,o-,, A LLsa.r Total size of parcel 3. O 3 Gra.-r Date parcel was created '7- 2 2 -47/ Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)?)< Yes No Volume and Page Number as recorded. with the Register of Deed 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 in the office of the County Register of Deeds as Document No. ~Z 7.1a-39. , 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. 4-7 Zig of applicant Co-applicant Date of Signature Date of Signature I i t: DOCUMEN1 No. j~ WARRANTY DEED THIS f►ACl R[R[RV[D ►OA R[compoe DATA STATE BAR OF WISCONSIN FORM 2-1982 472239'',. ;i L - REGISTER'S OFFIr- Edward R. Hauser and L-vol A. Hauser Carol. Augus a ST..-ROIX CO., W- i e d for Record II ~ .i to r} v 1J 11 ('011%k' s :md ...mutts to San F• Miller a si le, rson 2:35 P M ~...-.......-.pe.- i _ of D"as the fulwwt St.' Croix n(; described real estate in ..Count), - - State of %Visconsin: Tax Parcel No: A parcel of larid located in the tM-. of Sa of Section 6-29-19 descritn•j as follows: Lots 2, 3 and 4 of Certified Survey Map filed July 22, 1991 in Vol.. tr8", Page 2380. To)rether with an easement for ingress arxi egre6s over the u6 foot access easement as shown on said Certified Survey Map. Maintenance of the Easterly 100 feet of caid acce:;s (,a:.u;.rrnt ..hill b- nr'or,:ted equall,Y between the owner, of Lots 1 £trtd 4 of :paid (7-.-t i :~rFrv b tr, thelr• heirs, successors and assigns. 111)e ow'tanof U,t ! )f fkpj,j Certified `,urvey Map, their heirs, successors and assigns, stall be mspon.nble exciu.,ivelyr for -e rle,'Taining Fxrt•ion of Bald access easerm-nit. 00 13 riot hotue~t ;,d r. a: t c. 1 't (is) (IA non) ExtePliao to wartanti": easeuierlts, vestrictions, curd ril-ltt_;-of-►,ri3 of tt ~"34tT /da, of /'tw~l.,t lyal ~(r t:AL) tsrv~t.f (st:At.► (SEA! r AUTHENTICATION ACKNOWLE DGSIENT ( uahrn'tsl _ STATE: OF \Vl1,t:1\SIN c auth•v•,ticated this da\ of. _ 19 !'.•r> na:i~ ruue h. (er• me t:.:s 1kda\ of ,.~~r„1.•b lat. the :wove nar;thi ~•_tY: t1 `.1 ;au-'O r` 1 u 1 A. ~;iUt?er' TI'r1,E: ~1t:UHt:I; ~lTNTF BAIL OF WISCO\SIN (If not, auti,orimi hp ,tats.) to mr 0~ know- t I% ho evttated the f r ant i r n nd~ a tie xatac. t N ,t:r 1'uhl C A ("mints, Wm tSi'ntt rn:rc a,:t hrnfi'.att•d ur :uknnrlr+l.r,I, M,th \I> ('nnum<siorr~)tR, .tat,• car:rttiort :ere not T-v" ~arv I . (Inte 93 •N.rn.y of :,•r. .u. riRrun¢ rn er,r ,sP.e,t7 at-.M h, t.tr.t ur r. .L,I b"I'- their •K„w:"r- / WARRAWT DEKal STATR OAR or WISCONffIY w'prnMiw lwrtwl lNaw\ l'w, f.._ This instrument drafted by Fran Bleskacek Proj. No. 90-38 C) z UNPLAIILQ LANDS Bearings are referenced to the o S00°11'1211E east-west 1/4 line of Section 6, 396.00' LQ! ktStUt 4-11 assumed to bear S8905212211W 2 I. " o N3 C IN YQL., Zi. H C) C~ °f r N O 0 C, z a 0 C2 ~~i I$Q~ H o N - ro o ` ff a s ~ W v CO O • N' fm C" 0 C1 01 (SO000512711E) 247.5H W ~O h CNO x C) 'LnS00°1111211E LO 3C -1 L0 M M r 7 e ~ O N M Q 5 (t 'o"° NE}of the SW} t° A m'4W. n aOM A C O M NW} of the SE} a w M 0 S N rt W. c rt M a ° to r• M M 7. N rt 4 E 0 ; O O 4r ca _ cD o M. 0 10 1-h ? m me Cp U3 3C cn cu O ra " -1 I"' S000 1 1 1 1 211 CO r° a~s~ t CO d 198.00' rt 0 a r rn. 0 0) rri s' (0 0 :j CM Ln CD r,.l C t tll t~ a r I r "3 rf a Id z L t t7 rt n o 100 I o 0 'L7 N N •;F ~ m ;•.'s' ~.'ati.... S00°07129"W 541.06' w N= O :r S00007 2911W 365.1' - 508.06' o " tz 0 M 298.72' N = ire- N• z m In ro N I :3 tzj CD CD rl 11 / 2 -1 rr O = \ It"tl 0 Co. Its M a oo I c r Q I C"i o 'D c a r~ Cl) w D L^ p l ; S0000712911W 586.811 rn m - I= in o ? 0 - ° 553.81' ,I 1 o ¢ ss' r joint Drive/ 33' 33' c • O N N Ol r ~ rte; a m O w o ± I~ 3y O W n'' F.J I N O O Oa I m o_ I I 306.22' g 568.28' X"/ 240.22' f L w _ N0000712911E 874.50' _ n E+rt - s • _ - c 305.93' w - 601.57' = I z ~u c p N00°07' 2911E 907.50' o RIH SIREEI East line of the NW} of the SE} I o (S00021155"W) o ~ ~ I U1a1M1 IN Mi. It EQ. 195 HALL IRAQI ~ N W. APPROWD L5d1 13LZ -n UL 2 2. 1991 7M,Ml IN YQL, 5t ST. an- Cc,!}~,i'iy SHEET 1 OF 2 SHEETS SEPTIC TANK MAINTENANCE AGREEIIENT St. Croix County OWNER/ BUYER Sa /h ~r o ROUTE/BOX NUMBC Fire Number R Gtr = o CITY/ STATE H ZIP n PROPERTY LOCATION:~~G'► _ ► Section:, T~N, RL_7_ Town of-St. Tos e L St. Croix County, Subdivision G, s M_ # Y70:Ef, Lot number. 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 licen's'ed' 's'e t'ic tank pumper. What you put into the system can a ect t He .unction o, the-septic tank as a treat- ment-stage in the waste disposal system. St. Croix County, residents'•maz be eligible to recieve a grant for a maximum of 60% of the cost.of replacement of a failing system, whic 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't'ems agree to keep their system properly maintained. The property owner agrees to. submit to St. Croix County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or..a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper ec- operating condition and •(2)•after inspection and pumping (if essary), the septic~~iikbe is sent appthan 1/3 roximately 30 days prior Certification form three year'expiration. y 0 I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards set forth, herein, as.set by the Wisconsin Depart- s Natural oStCeCroix Certification County a Zoning Office t within completed 30 day.ment of s s and returned Co the of the three year expiration-date. SIGNED_( DATE St. Croix County Zoning Office 911 4th St. Hudson, WI 54016. 386-4680 Sign, date and return to the above address. 1 DEPAhTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, • • DIVISION LABOR AND PERCOLATION TESTS (115) MADISON W 7969 HUMAN RELATIONS (ILHR 8$.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP/4SMTY: LOT NO.: BLK. NO.: SUBDIVISION NAME: NE 1/4 SW 1/4 6 /T 29 N/Ri%&(or► W St-Joseph 2 n/a n/a COUNTY: OWNER'S/ NAME: MAILING ADDRESS: St. Croix Edward Hauser 1616 Pinewood Lane, Hudson Wi. 54016 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ERCOLATION TESTS: Rinesidence 3 na/ New ❑Replace 17-16-91 n/a RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN_ -GROUND-PRESSUR SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®a ❑U C=S ❑U ~a❑UE:❑ S ZU ❑ S ®U conventioanl 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: .8 Floodplain, indicate Floodplain elevation: n/a deciaml' PROFILE DESCRIPTIONS page 49 SIB BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH= ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-1 7.25 100.33 none >7.25 .75bl.1. .50bn.sil. 1.00bn.l.s. 5.00bn.c.s.&gr. B-2 7.00 101.36 none >7.00 .67bl.1. .83bn.sil. 1.00bn.s.l. 4.50bn.c.s.&gr. B 3 7.08 101.58 none >7.08 .75bl.1. 1.50bn.sil. .83bn.s.l. 4.00bn.c.s.&gr. 4 6.59 99.28 none >6.59 .67bl.1. .67bn.s.l. 5.25bn.c.s.&gr. B- B-5 6.91 99.98 none >6.91 .83bl.1. .75bn.sil. 5.33bn.c.s.&gr. B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- P- P- P_ see qesign rate 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 97.50 Czz f Coo Ca ' z N 3 r E E E E E 3 rad- 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 7-16-91 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. Ave., New Richmond, Wi. 54017 2298 7,1 1715-A46-6200 CST SIGNATU DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. y-7 I7 3S Vol 8 ?'S"- a38o. Lat Z s y sta vr~ E l Y.. 9 so' mss; r~f~ 5ca~la.. ~~y ~o ~ O B. M.'~srt~...T,P err ;pa.-E~. , ~DD,o' YT I- I-t ~i za _ZO_ all- , a 61.E ,e ED 4 20 Al ~~4~~ Noctisd~ ay Kul as 'x zf h d r f i Q',I 'J 90 r i C M ~ r, r 1 ~ dr a C W 'y a - Li N Z U ~1 L~ U d' Z Ls CL v ~ w a CL Lit p _Y.. LLI > LL x Li ci U U , v r? O Oo x~ a X .16 LLI s z ! O U ira z LLJ sc. r~: f~ ; ti li 0 Z it ! L'- ct- 1 r~ Ei~ l'' I!! > ! ! iil II~ ~ If w r ~ ~ i ~ ! 1 i ! p., IL w ~ ~ ~II i~ c.~ o ~I 1 r_ . ` iA I f Ld ili I°! f II E-- Ili jf I'f r ~ M I R ll z ~-Q- LAJ -Hi .y it DEP0' ENT OF REPORT' ON SOIL WRINGS AND I T& 4, ~ CAI=E''~-Et f~U1VISIO;.' _ DIVISION If GU , (1 )l P.O. SOX 7969 AND PERCOLA iON TESTS MADISON, WI 53707 HUMAN RELATIONS (ILHR 83.09(1) &Chapter 145) SUBDIVISION NA LOCnTIQN: SECTION: ~r TOWNSHIP/}~JOhDiLl~)C7TY: LOT NO.:BLK. NOT 2 n/a n/a NE SW 1/ 6 /T 29 N/R19~c(or) W St Joseph COUNTY: OWNER'S NAME: MAIL N DDR SS: St. Croix Edward Hauser 1616 14pewood Lane, Hudson} Wi. 54016 U°C-- - _ DATES OBSERVATIONS MADE NO. BEDRMS. COMM R IAL DES RIPTION:pT[ZT3Tir`i`I S: A S S: -Iidenca 3 na INNeYJ ❑Replace 17-16-91 n/a RATING: S= Site suitable for system U° Site unsuitable for system I cr);; . NTIONAL ~M-OU-ND: IN•GROUNDPRESSURE: SYSTEM-IN-FILL BOLDING TANK: RECOMMENDED SYSTEM: (optional) S O u~ S❑ U O S ~~E] S)@U❑ S conventioanl DESIGN RATE: Ipoion of the tested area is in the , Aron Tests are NOT required I L H R 83.09(5) (b), indicate: r n, indi cate Floodplain elevation: n/a deciaml' PROFILE DESCRIPTIONS page 49 SIB lsi , TOTAL PTH TO GR UNDWATER-INCHES CHiIRACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH Ni i! H DEPTH~IX ELEVATION OBSER EIJ SOH S EDRQCK IF OBSERVED (SEE ABBRV. ON BACK.) ~g ] 7. 5 100.33 none >7.25 .7ibl.1. .50bn.sil. 1.00bn.l.s. 5.00b .c.ftf_'yr. B 7 O~Q 101.36 none >7.00 / ~ .64bl.1. .83bn.sil. 1.00bn.s.1. 4.50bn.c.s.&gr. r O A4 SZf,. ~g 3 7.08 101.58 none >7.08U .75bl.1. 1.50bn.sil. .83bn.s.l. 4.00bn.c.s.&gr. Ste, 6.59 99.28 none >6.599 .67bl.1. .67bn.s.1. 5.25bn.c.s.&gr.-ks.,3,0N, P,5: jB ~B 6.91 99.98 none >6.91 .83b1.1. .75bn.sil. 5.33bn.c.s.&gr. 13- , PERCOLATION TESTS , I F';T DEPTH WATER IN HOLE TEST TIME )ROP IN WATER L V -I H RATE MINUTES rauntlSC:R INCHES AFTER SWELLING INTERVAL-MIN. PER INCH 1,. N _ P - see esi.gn rate N- PLOT PLAN: Snow iocatMm or pertso+atromtyscd + 1~"r'r'Gs'~d- tc d)m®ttsons of,.;uitable soil areas. Indicate scale or distances. Describe what are the hori- ru c:! and vertical elevation reference points and show their location on the plot plan. Show ilia surface-aiuvation at aff ltarUtgs area ti~anttree +g* a*~ rsrtr I ~ SYSTEM ELEVATION 3 , t %ilz f /o~~w 3 ~ ~ a N Ilk I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. F print): TESTS WERE COMPLETED ON: L. Steel 7-16-91 SS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 200th. Ave., New Riclaond Wi. 54017 2298 715- 4- CST SIGNATU DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soi Tester. UIL.HR-SBD-6395 (R. 10/83) OVER; F_ ~a •2 • ~f o o IL 05 ?y+ DILHR SANITARY PERMIT APPLICATION 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 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 Sa Cr '4 5(,, 14, S (o T27 , N, R 14 r) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # .9a -W Z8Z va CITY, STATE _ ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER AiLorl- tl 1(gn).2749 / 11. TYPE OF BUILDING: (Check one) ITM NE REST ROAD ❑ State Owned V VILLAGE St g?s----,PA '✓ar 9.4 ❑ Public N1 or 2 Fam. Dwelling- # of bedrooms P R LTAX NUMBER(b) 111. BUILDING USE: (If building type is public, check all that apply) /O~ C - qo 1 ❑ Apt/Condo G 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 12 ❑ Service station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~4 New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 300 Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 420 Pit Privy 130 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. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 7 ELEVATION 7 ZQ ~o Z S U S.-2/ Feet f6..Sd Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete strutted Con- Steel glass Plastic App Tanks Tanks 0 Septic Tank or Holding Tank X+ -1 1 El 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. i Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: ~1~ ;r 3 z~ 32-33 51 ('5 k ate. V., I ~ ~0 Plumber' Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing Agent Signature (No Stamps) Surcharge Fee) 40 Approved F-1 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 INSTRUCTIONS -'?ia r'+-'rr r!f ;s valid alit two `2) years. I if any new •itrlo. •r tr,r r'V +J'..e )1 -ti.?r :I t1?dtriC .,IC vYi,: ~a a~i ~ylli.dt~i:.. `_ry t'f~b jseilrrr': iac:u.flg aaiiu+,iy. -t ,r 1 n j":-;,rear r eq iir ;'9 a ,canitar., Pn-rrmlt ! r' n{.. t { b39 to be 7 Par'', '.t r a~ ''r+ t_i,Ty })eii,! to irrstailati,wl ISt bp r rC, P'IE' a 1t xir r'^n a r, t.r 3^.k!, ct tie pump': by a I!censed ,.~;.1' y usually t: Y to 'i is h 4in rj!;f ,n cor'cerning your onsite sewagv System, contact your -af cod£ ,i~T'nistrator or the r.ttr , t vVS t'tirf,;rrr, ; <i5r ty & Buildings Divisiut?, 608-266-3815 To ua: arrll al curate th,s sanitary permit application must include: I Pra:)pt; ly I("+",~ ""i'Mf dull oiailing Prt-)vise the legal desc(iptioo and parcel id), lrumber(s) of vvi zero tilt. sy stn rn i~, to be installed it. ZVt)G !yf oUridrnfP heir!( SetveCl Check Y)rliy 00e and Cor;fs e'e ;ft or r.t,ilt(iii~nS 't I o! ' F-tr11j%/ Dwelling. Ili. bullijiIy use. if buoclvrcu typtr ;s Pkibllc; t;ht cr, all appropriate boxes that app ,y lG i ype fit perinit. Ctiack cniy one in line n Complete lint, B it pernut is to= ?a14, ! eplak uwr etlt, i econnection, or repair system. vllech: oppr(,q)r; itt- hr,X dept-:n;1wq on system type. Prnvid i . infnrmrt'X rr=ques.ed 41 - e o., Ldrilloi of to tx,s ao(, „rer' narne. o. Site constructs„ ; i)I_] (arlh rnater~a+. :p t tt: tar m t-eptly. fa:~ i ~ .incy rmldinq tank-, (itrt C:k r?x_.' i 'rt;,i !i t'proval i. 3_nk_ti 'eceived ~:f= 1 ptt dLICt af!piUVdi I'roin Dit_HH Vlll Responmbihty statemcrt Installing plumber is to till in name, license number with approp,rate prefix (e.g. MP, etc, address and phone number Plurnber rnust sign application form IX. County/Department Use Only. X County/Department Use Only. Complete plans and specifications riot smaller than 8% , 11 inches must be submitted to the county. The plans triust inc lode the fa'iowing: A) plot plan, drawn Io scale or with complete dimensions, location of h( l: o"J tW'k(s' - :`;+tic tank; ) J" othe! tredtr rent tanks, building sealers; wells water it aolr >,'water service; streams arRa lakes; pump or siphon tanks; distribution boxes; soil absorption systems: replacement system areas and the ocation of the building served, B) horizontal and vertical elevation referent-s points;, C) complete specifications for pumps and controls; dose volume; elevation differences; fr;7;tion loss; pump pertorroance 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. I The monies, collected through these surcharges are used for monitoring groundwater, ground- water contamination; investigations and establishment of standards. ill SBD-6398 tR.11188)