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HomeMy WebLinkAbout032-1003-20-000 . S?601 AS BUILT SANITARY SYSTEM REPORT OWNER _A.Ypi. &L6-CiZ2 TOWNSHIP .~3 SEC. tT3/N-ReZ'W ADDRESS ~~r ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE .v s PLAN VIEW Distances and dimensions to meet requirements of H63 THING WITHIN 100 FEET OF SYSTEM wear W=0 \ . ~I dic-a e o th A ro SC LE: r ° BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: j Q©' Slope at site: ~o SEPTIC TANK: Manufacturer : jV,4 g, k~5 Liquid Capacity: . 4:;"o f Number of rings on cover / T- amanhole cover elevation: Tank Inlet Elevation: 39 9, 32"i Tank Outlet Elevation 99,z PUMP CHAMBER Manufacturer: Number of gallons Number of gal-~` ump set for a cycgallons; total capacity o distributi lines gallon: size o pump head; gallon p minute horsepower ran name of pump and m el number ; Type of warning device HOLDING TANK I : Manufactuzir, Number of gallons Elevat n of manhole cover Type of warning device' SEEPAGE PIT ZE: Number 'o pits eet diameter feet 1 uid depth seepage pit in e~ t pe-elevation bottert5 of seepage~t f: e-I va on feet. SEEPAGE BED SIZE: number of lines z`- width /Z , length 3S' tile depth 3.3'` SEEPAGE TREICH: width length PERCOLATION RATE < 3 AREA RE U D i a' REA BU T uzo a' INSPECTOR DATED - PLUMBER ON JOB LICENSE NUMBER DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR ~lz~' SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. B-OX 7969 ~ BUREAU OF PLUMBING MADISON, WI 53707 41, ONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: (If assigned) E] Holding Tank ❑ In Ground Pressure ❑ Mound NAME OF PERMIT HOLD ADDRESS OF PERMIT HOLDER: INSPECTION DATE: 7 BENCHMARK (Permanent referen p inH DE CRIBE IF DIFFERENT FROM PLA REF. PT. ELEV.: CST REF. PT. ELE V.. Ale, Na of Plu ber: PlMPR SW No.-. Count Sanitary Permit Number: 1,7 /0 OP 1-7V z Z-4-6 fif 5/ 1 SEPTIC TANK/HOLDING TANK: X. 1_1 S MANUFACTURER: LI ID CAPACITY: TANK INLET EL TANK OUTLET ELEV. WARNING LABEL JLOCKING V R P O DED: PROVID YES ❑NO ❑ NO J WELL: BUILDING: VENT O FRESH BEDrG VE NT DIRVENT MAT L.HIGH W TE NUMBER OF ROAD: PROPERTY I ALARM. FEET FROM LIN LAIR INLET: S ❑NO 4 ❑ E 4NO NEAREST OS G CHAMBER: ANUFACTURER BE DDING. LIO PROVIDED: Tv PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: DYE L NO DYES ❑NO DYES DNO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL B UILDING.IV ENT TO FRESH (DIFFERENCE BETWEE t FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ❑NO_ ]NEAREST__ ,.j SOIL ABSORPTION SY TEM. Check the soil moisture at the depth of plowing FORCE _l-_N1, I H uIAMETER MATERIAL AND MARKING or excavation. (If soil an be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: NIDTH. LENGTH JNO.OF IDISTH. PIPE SPACING. COVER NSIDE # ITS: LIQUID BED/TRENCH TREN%e IF M L: PIT DEPTH: DIMENSIONS 1 , lc f'`'" S LL DEPTH DISTR. PI PF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DIS NUMBER OF TPROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABOVE COV R JELEV. I /N~L~E7. E LEI 'I C~END. PE FEET FROM, I LIN JV/-~ ! AI-R1NLETCf NEAREST~_♦ 7C- L -7 ~Ir'•~"T tC~LI s~7 PI ~ ~ ~ MOUND SYSTEM: Mound site plowed perpendicular to slope Check a texture of the fill material f r PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: moun systems to make certain th it ON REVERSE SIDE. SHOW ELEVA- meet the It ria for medium sand. //~IONS MEASURED. DYES ❑NO SOIL, COVER. TEXTURE PE7:_1 ENT MARK S: OBSERVATION WELLS. YE ❑NO DYES ❑NO DEPTH OVER TRENCH;BED DEPTH OVER TRENCH/BED Y7 TOPSOIL. SODDED. SE DED. MULCHED. CENTER EDGES. DYES ❑NO ❑Y S NO YES DNO PRESSURIZED DISTRIBUTION SYSTEM: NIDTH. LENGTH: NO. F LATERAL PACING. IGRAV TH BEL PI FILL DEPTH ABOVE COVER. ED/TRENCH T HES: EL P DIMENSIONS R N / MANIFOLD PUMP ANIFOLD DISTR JPE MANIFO MATERI L 11,10 DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.: ELEV. fA. ELEV. PIPES: DIR.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPAC DRILLED CORRECTLY CO RMATERIAbFEET VERTICAL LIFT CORRESPONDS TO APPROV ED PLANS: DYES ❑N DYES ❑NO COMMENTS: PER NT MARKERS: VRVATION WE LS: UMBER OF PROPERTY WELL: BUILDING: FROM LINE: YES ❑NO DYES ❑NO 70 EAREST W R ~ rLc+-l (i`~! "s 0-3 v Sketch System on ta' in county file for audit. Reverse Side. SIGNA TITLE. DILHR SBD 6710 (R. 01/82) DEQAIRTMENT 0~ APPLICATION LDINGS P & INDUSTRY FOR SANITARY „ n a SION LABOR AND PERMIT/ ~TF P: B 969 ,07 W HUMAN RELATIONS (PLI3 67) _ op .lip lpy/ 19 - Attach plans for the system on paper not less than 8'/z x 11 inches in size. Include a plot plan that is dimensio rd scaRN tal and vertical elevation reference points must be shown. All appropriate separating distances and physical chara tics as~pecified i pter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the de h design G aster Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of t of est a must be included. Property Owner: Mailing Address: Pr party Loc tion: ity, Village o owns ip. Cou ty: '/4 '/4S -;Z iT.3 / N/R /91 A(or) W A. °,6 ~0 ( 114 Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: (If assigned) TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: JLISO or 2 Family *State Approval Required. COL TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 6~r HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental 14 Seepage Bed ❑ Seepage Pit ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Nam Plumber: Signature: MP/MPRSW No.: Phone Number: Plu er's Addr ss: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signature f Issuing Agen Fee: Date: APPROVED Sanitary yiPermit Number: ",.1 Q O-- ❑ DISAPPROVED 14 C/ (F7-,S_6_ R s for Disapproval: I Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (N.03/81) DEPARTMENT OF REPORT ON SOIL BORINGS ANDS) ; DINGS I I*1DWSTR•Y' SION HU AN REDLATIONS PERCOLATION TESTS (115) RE l~f N, 069 7 APR 30 1982 L C/A!TION::SECTION: TOWNSHIP/Mt tefPRt}+Y: LOT NO.:BLK. NO. lj¢ IVISIONEW. /T3 N/R' (or) W _ OFFICE COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: 15 1 , -4 Z, EQ 1 Iv~'7 _S 19 USE DATES OBSERVATIONS NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL NS: PERCOLATION TESTS: Residence JC]VVew ❑Replace ` J s z< -8 RATING: S= Site suitable for system U= Site unsuitable for system 10~ ~f CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U ❑S ®u f s ❑u ❑S zu ❑S grvN-qj u nJ'4 »>~ro frl.. If Percolation Tests are NOT required DESIGN RATE: SYSTEM If any portion of the lot is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS 41 BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AN DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- f 80 T7 17 L '7 s. . . S~ to . S . B- z/L IOZj~ri D 7~Zr~i 9y'~i•L.1~~~~,,,.,C. /~e~i~ ~S. G°S Z 0 a B- 3 f2el 02 r76 7 I. S„C c B- r2j# 92 /0Z 60 r, e- 7Z 7a" 103' N 0 E_ r 7z " L5, L, /1`' 13' rT "Ja o1 ja2'#' A)o "V_ 7 721ERCOLATION TESTS I&I40n .5,A., 'elF -,on, asc-' TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PER~IIOD2 PERIOD PER INCH P- I 36 'i I*u e) 31' 13 M~ 3 /02 X7- P- Z 39, 3 3 P- P P_ PLAN VIEW: 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 elevon at all borings and the direction and percent a of land slop. ` A Al SYSTEM ELEVATION 1Clio Pew ~A f 3-+ ~L w S "APPROVED" 3 4a~e: 540/g2 lanSpector. Te rl0, A b y,'l.~oo>c~r 4, p, f ~ 1, the undersigned, hereby certify that the soil tests rep n this form were made by me in accord with the procedures methods specified in the Wisconsin Admimistrative 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: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): CST SIGN TU _ DISTRIBUTION: Original-Local Authority, 2nd page-Bureau of Plumbing, 3rd page-Property Owner, 4th page-Soil Tester. DILHR-SBD-6395 (N. 03/81) ND s fl~ N ,°F REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS s DIVISION LABOR PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS \ / MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATI N: SECTION: OWNSHIP UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: '/a /T I N/R Xor► COUNTY: OWNER'S UYER'S NAME: MAILING ADDRESS: 54. (V~II~p r c 12. ,P42. ,`7.A 10 Q USE _ DATES OBSERVATIONS MADE NO. BEDRMS.. COMMERCIAL DESCRIPTION: PROFI LE DESCRIPTIONS: PE OLAT ON TESTS: ,Residence lxew ❑Replace 7- Z- /%-~z RATING: S= Site suitable for system U= Site unsuitable for system r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM -IN-F Ll HOLDING TANK: RECOMMENDED SYSTEM: (optional) MS ❑U ZS ❑U S ❑U ❑S U ~U rrd -Fr 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: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) H B- n I J /UD n e 7 0 / " f I "gI J/ ~t.. S. B- Z Ile ID2, ! - 9//~ , 2,r 0'2 B- 6 7 /0 pLIl. k. d ily ti ..s` J, /rte r 3-7 a r1 0 4-# " 77a /PERCOLATION TESTS ~5 /br~/~rS.• r>; '`1i / Ng/1.GS, TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD t PERIOD2 PERIOD PER INCH P- w !3 P- 2 !0o P. dc, 6 3 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. d SYSTEM ELEVATION :9 01nt - 3 , t ...w.. _...-...F a +1 J i 1 /V - 1 --(tN 6- 2. ate, 111 7/ E . r r 7, ~ Via' ~r 3 ~I i ~ i (A I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print) TESTS WERE COMPLETED ON: Z - Z_ AD ES S: CERTIFICATION NUMBER: PHONE NUMBER (optional): 66 1. 7 Z CST SIGN/} E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DI LHR-SBD-6395 (R. 02/82) - OVER - Mob- Nomopppppp 40 o - 5ep4 o- bd sc-rp,~ occl 'GA ~v►t~►~~ 1 orx ill i FORM - STC 104 AS BUILT SANITARY SYSTEM REPORT OWNERT/,,, TOWNSHIP SECTION 2 TLI_N-R 9 W ADDRESS ST. CROIX COUNTY, WISCONSIN L SUBDIVISION LOT.L~_LOT SIZE - PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 9B to m ~.J .,,,E 0,tp S ys r GL ' J/fI ~ , la ESL 'l A/use INDICATE NORTH ARROW BENCHMARK:Elevation and description: _4®.~oj 7 a t ~Alternate benchmark SEPTIC TANK:Manufacturer:-' A ES Liquid Cap. Rings used: Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear_Ft.j - From nearest prop. line:Front , Side,, Rear Ft. No. of feet from: Well_ Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER 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: Trench: ~C Seepage Pit: Widths -Length Number of Lines:-,~;2,_Area Built Exist. Grade Elev. Proposed Final Grade Elev.- --,,,C--Fill depth to top of pipe: -!Z2 - y 2 35~~ No. feet from nearest prop. line:Front , Side , Rear / Ft.2,~< No. feet from well:-No. feet from building HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: / DATE: PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj a DtPARTMENT OF INDUSTRY, INSPECTION REPORT FOR A ! /()LI / SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON WI 5 707 NE !,9ec.2,T31-R19 StatePlned) Number: CO ~ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Somerset, t 1 Count L ine Rd . Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF ERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: x. Wm. Bri s IRt.2, New Richmond, WI I:a BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. EL CS REF. PT. ELEV.: Name of Plumber: MP/MPRSW No., County: Sanitary Permit Number: Kim O'Connell 3259 St. Croix 149008 SEPTIC TANK/ MANUFACTURE RPI LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ARNING LABEL LOCKING COVE PROVIDED: PROVIDED: 9`1• `1 YES ❑ NO ❑ YES NO BEDDING: VEN+DIA.: MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY/ WELL: BUILDING: VF RESH E. o• C?, d . ALARM: FEET FROM LINE: , AIR ET' ❑ YES T5dNO Y 5 Z ❑ YES NO NEAREST ~llo (v DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATI NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN T FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEA SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: D TERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF ISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH ~ - , 4 a TRENCHE MATERIAL: DEPTH: DIMENSIONS ~ -5 GRAVEL DEPTH FILL DEPTH DISTR. PfPE DISTR. PIPE DIST PIPE AT RI/JL O. D STR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVEVE E(LEV. INLE ELEV. END: i/ ~r~r A~/L PIPES: FEET FROM LINE: / r AIR INLET: , NEAREST ~ S > U MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope a ws thrown unslope: nd systems to make certain that it ON REVERSE SIDE. SHOW ED YES ❑ NO meets criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SEEDED: MULCHED: CENTER: EDGES: ODDED:ES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BEL IPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LI RRESPONDS TO INFORMATION APPROVED PLAN ❑ YES ❑ NO ❑ YES PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO INEAREST W ~ Nei ~ ~ ~ ' il~.✓ C.C d , ~ 1 L-~EG'iC.,~E t~/~ ~~i';~ ~1 1~L ~ ^ / -tE;~- ir~rl. c..<_~ t-~Q ,vd '~,5~ ~~'.'o.~-.. ~Cd ~ . / ' ~,-C - ,7R C> c. t. (N-` x Q/ ~'1 t r V j~ Sketch System on Retain in county file for audit. Reverse Side. ` SIGN URE: TITLE: SBD-6710 (R. 06/88) 9 t =1E SANITARY PERMIT APPLICATION R In accord with ILHR 83.05, Wis. Adm. Code COUN .,.r„e. STATE SANITARY PERMI # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑~400~ 8% x 11 inches in size. Check it 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. PROPE T1OWNE PROPERTY LOCATION Z~ejaa S t/a t/4, S T-? , N, R PRO RTY OWNER'S MAILING ADDRESS LOT # BLOCK 4) s2< 1 .1J,74 CI STAT ZIP CODE PHONE NUMBER SUBDIVISION N 'FOR CSM NUMBER S' - 3 II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE ' N EST AD ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S) 111. BUILDING USE: (If building type is public, check all that apply) (0 _w _/O -,?e O 00 1~~ 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. ❑ New 2_0 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] Repair of an System System Tank Only Existing System E*Isting 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 420 Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/d 1/sq. ft.) (Min./inch) ELEVATION ~6 ~Q Feet /Feet VII. TANK CAPACITY in allons Total # of Prefab. Site Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Hold! n Tank L/4160 A JZZA__/S _LL r_1 Lift Pump Tank/Si hon Chamber El Ej El + El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for install ion of the onsite sewage systery~ 91 shown on the attached plans. Plumber' Name (Print : Plumb is ignat :(No tfim MP/MPRSW No.: Business Phone Number: Q L 7 Plumber' Ad ress treat, City, State, Zip C e): lelvv- hl~ -S 7~fxl /~1.4- A ) _-t- IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issui g Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) p Adverse Determination S 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 APPLICATION FOR SANITARY PERMIT STC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development 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 16t'4y Location of propertylVf- 1/9 4/ 1/4, Section _c,, 1 _1/ Township Mailing address ~c~k 1y7j3• /tJ2~„~ K;z~-rr~rc~_ Address of site Subdivision name Lot number Previous owner of property 1,V,'1h;9ry7 IV .4- EA-111-1Y 1q. Total size of parcel 31 Date parcel was created Are all corners and lot lines identifiable? Yes -No Is this property being developed for resale (spec house)? Yes _ X 0 Volume and Page Number &23S 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 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. 37 V_? 6 ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. Signature of Owner Signa ure f Co-Owner (I plicable) Date of Signature Date of Signature L DOCUMENT NO r? Qp ,,'j~ STATE BAR OF WISCONSIN - FORM 2 ti'Ol U J sa C cjJ WARRAMW DEED 3'782"'/6 TMa SPACE WESEnvEG FOR raCONI NO DATA William N. Briggs and REGISTERS OFFICE Shirlev_M. Briggs. husband and wife ST. CRO:X CO., WIL Recd. for Ro=d this 24th conveys and warrants to day of June A.D. 19_d2 Will' m Briggs and pt 1130 Mary R_ Rriggg, hushand anA rrifo,+ as point fprnanta, M DsNa VAN To the following described real estate in St- Croix County, State of Wisconsin: Tax Key No. A parcel of land located in the NEk of the NE; of Section 20 Township 31 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin, described as follgwst Beginning at the HE corner of said Section 2; thence S 0 40'54" W (tr8e bearing) 418' along the E$st line of said NEh; thenc8 S 89 36'22" W 313'; thence N 0 40154" E 418'7 thence N 89 36122" E 313' along the North line of said NE% to the point of beginning. Subject to an easement for existing town road on the North 33' thereof; Also subject to easements of recoid. ,f FEE Thlill is 11--teed red Na ~o Esowion to wananus&l #J14-PT Dowd ow day Of -r..A.e, 02. 3 ~v< ct 3L •i1u r (SEAL) rs. MEAL) • Robert G. Bri s _ William N. Briaas lSE1W • ' panel B~sacker Shirley-Im. Briggs AUTHENTICATION ACKNOWLEDGEMENT SwAtuws autMMIGbO oft ay of STATE OF WiMMMft Minnesota } ss yT Washington County. Persona y came afore AM 0 ► ay of Tua.E , w s2- TITLE UMBER STATE BAR OF NMSCONStN Of am the above rw nW auttiorlasdbyI?moo,Wis. Btats.) William N. Briggs and Shirley Tfw kMnmwd em dreflad by M. Briggs EckbarQ. Lammrs, Arigan i Wolff 126 South Second Street Stillwater. Minnnanta 55082 to ma known to be thep►:son$_whoexecuted the forepoirgb► F atnrment and acknowNdped the M. wiprrtw« way be autMmk:ated or acknowledged. BoM an not Hol5ert_ G. Br' s .aoo.ryo ~ 71[l~ •00000 Of aaa"w gaa.e a asr ua.ver MM to pave a rsrr sea" ua. ay.a.w• N Vary Pwift lashingto . Mimi - - MY 1. *TO a:Prattsn ds* 1! IUD'--yam e, blueness iw r u too ; - _ a _ , FORM NO. 985.A Stock No. 26273 CERTIFIED SURVEY MAP LOCATED IN THE NE1 /4 OF THE NEI /4 OF SECTION 2, T31N, R19W SCALE IN FEET' I DI wl Iv OQI `INI 1? wl QIZI CENTERLINE 0 100' 200' 300' 1 i 66 z1 al< UNPLATTED LANDS Ix PL N89°36'22"E 2613.76' EXISTING TOWN ROAD a - +w F-L - - - 'O tO NORTH LINE OF NE1 /4 N89036'22"E 313' n+ M a~ ~ N1 /4 CORNER - - - - - - - - - - - - - - SECTION 2 w N89°36'22"E 313' z N T31N, R19W POINT OF BEGINNING SET MONUMENT } NE CORNER OWNER & SUBDIVIDER SECTION 2 Q WILLIAM N. BRIGGS SET R.R. #2, BOX 148 NI U. SET MONUMENT NEW RICHMOND, W1. 54017 el Z of 00 ZI ;j s LOT 1 °O u.Il <l< V *3. oo AC± ao t-1 Jlm w *130,811 S.F.± ^ Lnl w = L _ **2.77 AC± 3`^ ~I of a °i p1m ? **120,483 S.F.± Q ZI O M wI i" H o JI QI t-I Z N zl I I Q I s, ~ .J 1 n al M zl ~I S89036'22"W 313' LEGEND UNPLATTED LANDS N w z LL ST. CROIX COUNTY SECTION CORNER MONUMENT, BERNTSEN N CAP, FOUND OR SET AS NOTED. O 0 1"x24" IRON PIPE, SET 0 Z WEIGHING 1.68#/LINEAL FOOT. 0 -I EXISTING FENCE. N ~ * AREA OF PARCEL INCLUDING TOWN ROAD RIGHT-OF-WAY. Q AREA OF PARCEL EXCLUDING TOWN ROAD RIGHT-OF-WAY, w M 3 APPROVED ' ti z z C.0" Lu MAY 18 1982 w ST. CROIX COIJ T" z ei Z COMPAEHENSWE PAWS /LkW4NG O AND ZONMIG CO"rFEE O Z U0G Drafted by Walter J. Gregory. _ U 0 L V) LL Vol. 6 Page 1633 DESCRIPTION A parcel of land located in the NE1/4 of the NE1/4 of Section 2, T31N, R19W. Town of Somerset, St. Croix County, Wisconsin described as follows: Beginning at the NE corner of said Section 2; thence S0°40'54"W (True Bearing) 418' along the East line of said NE1/4; thence S89°36'22"W 3131; thence NO°40'54"E 418'; thence N89°3622"E 313' along the North line of said NE1/4 to the point of beginning. Subject to an easement for existing town road on the North 33' thereof. Also subject to easements of record. This parcel contains 3.00 Acres, more or less, being 130,811 Square Feet, more or less including town road right-of-way and 2.77 Acres, more or less, being 120,483 Square Feet, more or less, excluding town road right-of-way. I certify that the above description and map are correct and thatI have fully complied with the provisions of Section 236.34 of the Wisconsin Statutes and Section 5.4 B of the St. Croix County Zoning Ordinance. Date: May 11, 1982. ✓J~d Walter J. Gregor S-X'224 Job No. 82-1347 Ogden Engineering Co. 123 E. Elm Street \ a+~f!~~tso~t!'e River Falls, Wisconsin 54022 S/,t . yin . GPEGC.~ i i RiVE: ~.~~_LS, i ye ~y wis. f~0G`w, •i~ < ~••'•~A ~o Vol. 6 Page 1633 v WAM STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County ' OWNER/BUYER 1.0 1' P11 '11 < ' S - Mir! ► ~n ~ ~5 ROUTE/BOX 'NUMBER G~~$ oZ C),` 2S FIRE NO. i 19 j CITY/STATE 44tJ iCI V1_10 11 C' ZIP -5 PROPERTY LOCATION: tut 1/4 1/4, Section TAN, R / 7 W, Town of Sc~:~Iz4S_Q_ St. Croix County, Subdivision , Lot No. 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 $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning, Office within ids 0 days of the three year expiration date. 2~ SIGNED DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address I, f I`/aaS - 386 - ~w 411Y _ 01,4 OJT} ~Z tT n ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certi that I have inspected the septic tank presently serving the WM 4, 11~ E residence located at: 1/4, _1/4, Sec. --2_, TjfLN, R_ 9 W, Town of ~`n,E c,,~ Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced ~.)_g/ Did flow back occur from absorption system? Yes No-~L(if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacurer (if known): h) ,zes Age Z_o (Signs ure) (Name) Please Print rx" (Title) (License Number) (Date) Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name Signature MP/MFRS 5/88 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N W 5739069 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION:Tp TOIP/ ITY: LOT ;BLK. SUBDIVIS N NAME: ' /tT N/R (or ~w"ti/ E C UN Y: OWNE 'S/BUYER'S NAME: MAILING ADDRESS USE DATES OBSERVATIONS MA E NO. BEDRMS.: COMMERC AL DESCRIPTION: IPROFI_ DES RIPTIONS: ER ION TESTS: Residence ❑New ®Replace RATING: S= Site suitable for system U= Site unsuitable for system Co ONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILLHOLDINGTANK : RECOMMENDED YSTE (optional) ©S oU ®S ❑U ®S DU ~ S ©U OS ®U If Percolation Tests are NOT require DESI 7GN ATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: / s ~F~ Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS _ each 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- > _ J -3 92 B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PERIO 2 PERIOD3 PER INCH P_ G 449A49 ZQ s P _ l / P- 13 S 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. ~2 p0 SYSTEM ELEVATION "Ilk C I 3 i F i 9 t -A7~a i 3 i ~ i ~ f I 1.~^ -:-.~,..,.~~~.L.a~~/i~... ~jj//~~yyJJ s. ..___,v O j .._}_...y.......x Y----'-i-.^"^'~ fj E F ~ TN E i ;'x s } t 1` $ i i ~ f UsE ®~f CL 0 I, the undersigned, hereby certify that the soil tests reported on this form were made by La in accord with the procedures an 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 (pr" t): i TESTS WE COMPLETE ON ADDRESS: CERTIFICA 10 NU BERT PHONE NUMBER(optional): /f!/ lel CST SI N R DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - /(/Z S~IeI7 , S Tam-"E'l &e2 ' - ;~OON /,Je ~✓ft Dm«l~r ~ a~Al~c 1~•~p ~ 5U f~ J - Sys~~,., PAGE OF CrvSS S~c~lOn p~ Zoeo 'Sp er7-) fraah Air Inlela And ODaarvollon Pipe t___ _J`~ Approved Vaal Cop Mlnlmus 12' Agora final Grade 20- 42' Above Pip' 4` Coal Iron To final Ored• Vaal PIP* Marsh Noy Or Synlhelk Co.ulnu Yla 2' Ago.aoola Over Pipe Olerrl0ulloa • Ylpa o 0 0 Tao - Aligo Sonsel agala Perlo(olad PIYo Baler aN III PIp• ° o -Coupling Tarminoling Al Balloon 01 Syelom PrppOICp PIA 1 VC.00 + Ion SOIL FILL DISTRIBUTIOM PIPE • APPROVED Sj)JPETIC COVER tea" MATERIAL- OR 4" OF STRAW Z" OF AGGR~GAIE - OR MARSH HAJ OF .Z -Zl/Z AGGREGATE ELEV. OF912 FEET, 1 DISTRI15UT1OM PIPE TO BE AT LEAST INCHES BELOW ORIGIOAL GRADE AIJU AT LEAST ZO IIJCHE.°. BUT 1.10 MORE THAI) 42 IAIC4ES BELOW FINAL GRADE M XIMUM MrH OF F-)(C/IVATIOIJ FROM OKIGwJAL 6ft)j~ WILL BE I►JCHES rimmuM OgTl1 OF EACAX/ATIOW FROM, 04~16INAL (3RnpE WILL BC INCHES SIGHED: LICCUSC DUMBER: 2~ + • L~ DATE: