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HomeMy WebLinkAbout040-1116-60-100 o ~ C) I M ti p ~ m ~ I cy 0. 0 ~ O U O O c C N p •c ~ m N o c O O N y N c0- 0 y0 V.~- ti C p Ur 0 0 i 0 cac 4)a y mm E 0 a= aw Co to N- c 0- y f0 Q8 (cp y V a U L OD OD 0 C M -0 1 O N x N LL m y aoo'~ a ¢ vl LL c ° t m CL o m c CO 3 m 0 o r m Ctaoo ¢ I-w m«.H~O I 3 `r m I ~ Z w I Q, E e co a m M FN- 0 O Z : c N FZ- o c Z c -a -o ~ M I hw N c V~ C C N y ~ ~ N N C N N d ~ O O O Z co z Z N ° c V y E N N ` cc d E U) CL W 0 d O N m 2 ~ O p ~r vj O O 0. a o~ N CD wN z o d I LL N J U 0) rn } LL O C13 0 _1 = p E a c v m y o> o o m ¢ m N U) ~1 U ~ p 0 0 0 (N H c 0 O o m rn co c co s e a C31 C co ~r' o c o o r m 7 N FN N C O d N F- F- C CD (D o f co y o ai E E m U O co F- 2 O Z RS t r a+ V d R € IL at a ` a . FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER `I /G t, TOWNSHIP / /`O SECTION 3 l T 9-B'N-R_ZLW ADDRESS ~j 6,7x13-P6 ST. CROIX COUNTY, WISCONSIN V- F4 1-11, YO -I ) SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM DD NDICATE NORTH ARROW BENCHMARK: Elevation and description: `6O, D Cornew SG~~ Alternate benchmark - SEPTIC TANK: Manufacturer: P1"J w P S't fy-- C -f Liquid Cap. N516 Rings used: 0 Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front Side , Rear Ft. ~J~40 s From nearest prop. line:Front Side Rear Ft. i No. of feet from: Well :,'460' , Building: 1 (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: Seepage Pit: Width: Length rS Number of Lines: 3 Area Built 9p~ Exist. Grade Elev. //}U. 6 -Proposed Final Grade Elev. /Z540.I> R Fill depth to top of pipe: A No. feet from nearest prop. line:Front , Side X-, Rear Ft.zLCS No. feet from well: No. feet from building yD + 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 DEPLARTMEAT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 NE14 ,NW4,Sec.31,T28-R19 D'CONVENTIONAL ❑ALTERNATIVE State Plan LD.Number: Town of Troy ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (tl asergned) Co. Rde F NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Michael J. Hahn Rt.3, Box 132 B, River Falls, WI BENCH MARK (Permanent reference pomp DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELE jC9TREF. PT. ELE Nam' of PI.-her. MP/MPRSW No. County. Sanrlary Perma Number: Thomas Wang 3231 St. Croix 149064 SEPTIC TANK/HOLDING TAN MANUFACTURER r LIQUID CAPACITY. TANK INLET ELEV.. TNK OUT WARNING LABEL LOCKING COVER PRO.,VIDDE PROVIDED n 9(~i 0YES ❑NO ❑YES F7}V~ BEDDING. VENT DIA.. VENT MAI I HIGH WATER NUMBER OF ROAD: PROPERTY WELL BU0.D VENT TO R H 11 ALARM FEET FROM LINE , AIR 1 ET ❑YES O c,5 ❑YES Alii~ NEAREST DOSING CHAMBER: MANUFACTURER BEDDING PMODII PUMP-SIPHON MANUF ACTUREH WARN ING LABEL JLOCKING COVER PROVIDED: PRO, CEO, ❑YES ❑NO ❑YES ❑NO ❑YES ❑ GAL S PER CYCLE: PUMP AND CONTROL OPERATIONAL NUMBER OF. e PI+aPEHTV WELL BUILDING V NT H IAF 1 7ER ENCE BETWEEN EET FROM LINE AIR ET. MAND O FF) ❑YES ❑NO Ab" 8T SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE I I N(011 DIAMF TE H MALI HIAL AND MAHKI Or excavation, (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to conti CONVENTIONAL SYSTEM Sr V 2e06 BED/TRENCH WIDTH ENGTH INO OF U15TR PIPE SPAf:IN(, COVET INSIUL DIA -PITS ~CE a/ TRENCHES ,1ATLHIAL: DIMEN SIONS r ' l' GRAVEL DEPTH FILL DEPT" 1)ISit PIPTEE UISTH POPE DI TR. PIPE. ATE NO D 1+ NUMBER OF PROPERTY WELL BUILDI VENT TO FRE$H HELOW PIPES ABOVE COVER fIEV IP LEV LNU 'T S ptpFS LINE !f FEET FR AIR INLET ' M T-P G' NEARES OM ~SC~ MOUND SYSTEM: 02 X 58 Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: ound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meet criteria for medium sand. IONS MEASURED. ❑Y ❑NO SOIL COVER TE URE I11A1ANINIMAHKIHS OI(SEHVATIDNWfktS ❑YES ❑NO ❑YES El p DEPTH nV THENI;H BEU IDEPIHOVFH TNENCFI HEU Ul VT1(D/ IDV$DIL 5Ff UFD JMULCHED DENIER EDGES N~ES. ❑NO ❑YES 0NO ❑YE ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES.OF LATEHAL SPACING (;NAVEL DEPTH HF L PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PU MA NI (ILU DISTR. PIPE IMANIFOLD MATERIAL NO UISTH UI 1 UI / I U ION I ELEV. ELEV. CIA ELEV. PIPES IA: ELEVATION AND RIAL 6 MARKING DISTRIBUTION 1 04 INFORMATION HOLE SIZE HOLESPACING UI;1LLEDC014HECItY COV EH MATERIAL LIFT CORRESPONDS TO APPROVED PLANS YES ❑NO ❑YES ❑NO COMMENTS: PERMANEN MARKERS: OBSERVATION WELLS: NUMBER OF._. PROPERTY WELL: BUILDING: FEET FROM ; L.FNE: ❑YES ❑NO ❑YES ❑NO NEAREST l 4e, Sketch System on Retain in county file for audit. Reverse Side. SIGNAT E: TITL DILHR SBD 6710 (R. 01/82) ~ILHR SANITARY PERMIT APPLICATION couN In accord with ILHR 83.05, Wis. Adm. Code &M-04 STATE SANITARY PERM # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ J~~ 8'/z x 11 inches in SIZ@. h if revision to revious application -See reverse side for instructions for completing this application. STAT PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. I - amo PROPERTY OWNE PROPERTY LOCATION )&,~g_/ T Ai, ya S 3 T o?~ , N, R E o0 BLOCK PROPERTY WNER'S MAILING ADDRESS LOT # &X B R CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER • ?a L:I I1. TYPE OF BUILDING: (Check one) CITY r- NEAREST RO D ❑ State Owned VILLAGE 6!o f s a J3a r n ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms 3 PAR T Nu e ( - III. BU ING : (If building type pu lic, check all that apply) Q;E!.'e t/C o mblyHall 6 El Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service station/Car Wash 50 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.E1 Replacement 3.E1 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 /1',X,56' 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. ftQ.)~t (Gals/da / q. ft.) (Min./inch) ELEVATION i ~V g90 G D Feet 0 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed F1 Lj e.5 S &d W Septic Tank or Holdin Tank x D Lift Pump Tank/Si hon Chamber El El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbs 's Name (Print): Plumb gnature: (No Sta ps) MP/MPRSW No.: Business Phone Number: s 40 /ZG, Plumber's Address( eet, City, Stat Zip Code): 3ZID IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved I I itary Permit Fee (includes Groundwater ate issued Issuing gent Si nature (NO S ) Surcharge Fee) Approved ❑ Owner Given Initial Q Advers Determin tin X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD4M (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber i II APPLICATION FOR SANITARY PERMIT 8TC-100 This application form Is to be completed in full and signed by the ornet(sl of the property being developed. Any inadequacies will only result In delays of the permit Issuance. -Should this development be intended tot tesali by ownerfcontcactoc,(spec house)- then a second form should be retained and completed when the pcopecty is sold and submitted to this office with the appropriate deed recording. . Owner of property Location of property -I f-114 /~~!/1 & ,l/l. Section Township Rolling address f-1113 A"Q x - 161)-ei, F-alM k); Address of site _~.a._~ - lubdlvIsIon name, - • Lot number-1- - - Previous owner of pcopecty 5 Total else of patcal Date patcal was created Ace all cornets and lot lines Identiflablet on Is this property being developed tot resale ('Spgc house)? Ito Volume Q_and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION TITS FOLLOWINGS A WARRANTY DRID which Includes a DOCUMENT NUMBER, VOLVMR AND PAGE NUMB=R, and the BRAI. OF THR REGISTER OY DSRDS. In addition, a cettiEled survey, 11 available, would be helpful so as to avoid delays of the reviewing process. It the deed description references to a CestIIIsd Survey Map, the Cettlfled Survey Map shall also be requited. PROPERTY OWNER CERTIFICATION i(Ve) cattily 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 IntotmatIon tocm, by vlrtue of a warranty de d teeocded In the Ottlce of the County Register of Deeds as Document No. .l • t and that I (we) presently own the proposed alto for the sewage disposal system (Or I (we) have obtalned an easement, to tun with the above described property, for the consltuctlon of said system, and the same has been duly recorded In the office of the Cpunt Rig s at of Deeds, as Document No. g tuce o et Signature of Co- a (If Applicable) ate of Signature Data of Signature SEPTIC TANK MAINTENANCE AGREEMENT rt St. Croix County F'J.. OWNER/BUYER ( !R P =Q U71,j 0 3 lox l . Fire Number ROUTE BOX NUMBER CITY/STATE e'roell~ lh ZIP rt PROPERTY LOCATION: Section T ~4 N, R W, Town of St. Croix County, Subdivision 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 licensed .septic tank pumper. What you put into the system can affect the .unct on of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents may be eligible to recieve a grant for a maximum of 60% of the cost.of replacement of a failing system, whit 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 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 operating condition and •(2).after inspection and pumping (if nec- essary), the septic-,tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H 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 Depart- ~r ment of Natural Resources, Certification form must be completed •d and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. n SIGNED' DATE St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. -PAR TMENT OF. REPORT ON 'SOIL -BORINGS AND SAFETY & BUILDINGS IOUSTRY, DIVISION kBQR P.O. BOX 76 UMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.09(1) & Chapter 145.045) )CATION: SE ON: 11 UNICIPALITY: OT NO.:BLK. NO.: SUB (VISION "F '/44J/4. /Ta r N/R l9 E (or In 1 NTY: OWE Ep"' La"UYER'S NAILAF.: MAIL( ADDRESS: .E _ DATES OBSERVATIONS MADE Si0.115C- PIO.B : 1COMMEACIAL DESCRIPTION: _ S: Q9 New ❑Replace TING• S- Site suitable for system U- Site unsuitable for system ® v 0 NVENTI NAL: MOUND: IN-GROUN6lmR8SU~!`Y EM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) I C. CIS EA ®S EA EJS ❑U DS DU DS ®U o a (Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the der s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS )RING TOTAL D-EPTH-TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH UMBER DEPTH IN, ELEVATION OBSERVED EST. HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) D No 81 1 S'r S 1~ n-l e d S G r, .,D ,I i aY~~ si 10 6n ze'3anc v b 19 /.00 s ` 3.5') Bh mPJ S V Cr, 9?, 0 60 B J PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES UMBER INCHES AFTER SWELLING INTERVAL-MIN. PRI ):gl_. PERIOD 3 PER INCH Z5 71~ 1721 0a 0T PLAN: Show locations of percolation tests', soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- tal 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 land slope. YSTEM ELEVATION • ~a ~ ~ I ~-'P~~ )dal' s I I I ~ I i I C. I I I I ' 5 h ed ' io0 vl PI j. A t ~.res Fare TN I k i It f• i I I i I ~ I ~ e -I I i;~ ~ox2Jp ~ I PS I I I I I g 65 0. Pro Po's A 'X000 Je. 1. U tllpl ix ~ y ~ a fed t 8~d ~ ; . I he undersigned, hereby certify th it the soil tests reports on thi f ade by me in accord with the procedures and methods specified in the Wisconsin ministrative Code, and that the da recorded and the location of the tests are rrect to the best of my knowledge and belief. ME (print TESTS WERE 7PLE7TEYN: f DRE$$: CERTIFIC tLO N NUMBER.. PHONE NUMBER (optiortal).- f o to e LcJ' o'a ~6 - s~ CST SI N TUBE: TRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. LHR-SBD-6395 (R. 02/82) - OVER DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY- DIVISION HUMk LABO" . , PERCOLATION TESTS (115) P.O. BOX 7969 HUMP-.. sELATIONS MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: N HI UNICIPALITY: LOTNO.:BLK.NO.: SUB IVISION 1/4 /T2?N/R/ E (or ro / CO NTY: OW ER'° 'DYER'S NA~~F,: MAILI G ADDRESS: -Crow ~o -b l~ l`ULff' Q6 S' 01, S'Yaz USE DATES OBSERVATIONS MADE 5 tab e NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROF L DESC IPTIONS: PER O TESTS: ce N New ❑ Replace T RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: rEJS YS TEM-IN-FILLHOLDING TAN RECOMMENDED SYSTEM:(optional) ESEIU EIS IS❑U ©U OS®UK: d . If Percolation Tests are NOT required DESIGN RATE: I 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 DEPTH TO ROUNDWATER-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- 5t'~7~ 160,D e =5~~ d~ Bl-; s',Sv 1n med Si ~ r, B- S.~D si n wed fan B-3 X110 S-o .0 6 ,3 A00 B-Cj ►~o ~fS ~5.5,0 ,D 81s ,aoB s'v6~ ec~s~~r. B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D2 --PERIOD 3 PER INCH P 3b11 O /0 P- d D iD / r 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 4 DD All. I 1p _ X1-110 , D i t 3 E It 4>e~ O ~S to i P1- ~T ~ t - t 4 N DV 1 i ~ J i a ~ F f l I I I t I E mm t _ E i 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 PLETE ON; ADDRET: CERTIFIC 110N NUMBER: PHONE NUMBER (optional): X 910 P5 d 6)e ~cl'a~a 6 a s~ CST SI ~TURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - SAFETY & BUILDINGS DIVISION ' Tommy G. Thompson Governor Gerald Whitburn Secretary State of Wisconsin Department of Industry, Labor and Human Relations PRIVA T . S=-WAGI PIAt ' APPROL'a_ Western Reo,-'onai Office 2226 Rose Street . <u le' _ RE. Plan `tu"iber. S91-40360 -e ~n - - -`1 _.~SID~\CL _ 7oT{f' n~ ST CjRO:X Tate G.?IP.Q'.e_tC -1111S 1S Se 0:. F: WJ.SCo:.., -+,t S` Ttes :lri t " e ; Cons?n A6:«-'t1iS-_'aL- -e Code. .e s ;x p eC: 0 0;?Ci.tz(1 2tlp__,;,o T,ic alt?'0V?y is ! _'E,r _an CE ?C= f; - St J' a _O:1 010t+:1 O:1 'P _~1a 5. y_' :teTl~ lat e note d, T,1is _ e cot ected. 9 aCTe ned r~Pq ?rio -o ConS'rruCtion. Tile _ c e. _ S pd r, -Iure b er e s t o T1 S e f o r t".S _ at10n tid 1 -PP: one Oe` O_ , nS 1v `h -1e Cieoa_ :en. Ci S` ? ~S~ .O:.s-ruction .._`e. _ 1P_ _:?S a! let _ac _1 :1Gt_ the a!)-- -o'), _ ,S'.leC':. i~ileil w_ lnspect_o:_s can -le !r.ade. PxiJI_f? `1+0 e..OS tr_ date F'.J;_ _ PCi 03'_i a S=are" e Sect _en of je`t?OP ?GS re-,`P-wed ;eSe Jl'?Z?-`? se;<a7e 5tiS`eTl7 c,oae on-Y. ?iE'SE Cane na~-c ,^:rie. teen : e weC. or y..~e CC ae e= e FS Set for-c-^ i iecl -J o , - Q_ fll JP:;e?-'?'_ n o _ _ o, _ ate_ s 50-5- to '_}?_S _s for }^P 4fo-' owfn-, c0' 70aents ,Jn 7.,77 %7 - naui -"es Conce-ni nQ this appro~,al may, be !"ade b Cal _'_'.o (608) S~:1CP.re r RO H. /Swim SeC On Of Private Se:tiaze Division of Sa et-, and BL?i _d_.lys PPPG39 0009n 4= .1 C. I MIC-?AEi- A:?`' X Pri 'a-e 3et:a e Cons! _ 17. is auu 6423, R. Q790, Wiscohsin Department of Industry, ONSITE SEWAGE SYSTEMS Off ice of Division Codes and Application Labot and Human Relations Onsite Sewage Section Safety and Buildings Division 201 E. Washington Ave., Rm. 141 PLAN APPROVAL APPLICATION P.O. Box 7969, Madison, WI 53707 (608) 266-3815 INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. The reverse side of this form describes most of the required plan information. Further requirements may be contained in the Wisconsin Plumbing Code, which can be purchased from the Department of Administration, Document Sales and Distribution, 202 South Thornton Ave., P.O. Box 7840, Madison, WI 53707, Telephone (608) 266-3358. Plan Number Previously Assigned ~ 1. PROJECT INFORMATION (Type or print clearly) J 0 Name of Submitting Party (plans returned to same) Project a., ge.., v. Street Address .O. Box # or Rural Route Project Address or Legal Description y box 3qj 5K e W-3 o 32 ,6 City or Village S//tate Zip Code City Vill rr4 ❑ County `0e(r ,t W1 age ❑ of ` Telephone No_ (include area code) Town r0 ro j r\ Designer Name of Owner Sao, 7~ A ~ Telephone No_ (include area code) Telephone No. (include area code) Street Address, P.O. Box # or Rural Route Street Address, P.O. Box # or Rural Route City or Village State Zip Code City or Village State Zip Code 2. APPLICATION FOR: Experimental ❑ Mound Systetn ❑ Holding Tank X1 New Construction ❑ Large System ❑ Conventional Gravity System ❑ Groundwater Monitoring ❑ Replacement ❑ At-Grade ❑ System in Fill ❑ Petition For Variance ❑ Revision ❑ Pressurized System ❑ System in Flood Plain (attach SBD-6698) ❑ Other Alternatives 3. FEE COMPUTATIONS (include existing tanks) FEE SUBMITTED FOR OFFICE USE MAKE ALL CHECKS PAYABLE TO SAFETY & BUILDINGS DIVISION. a. 750- 1,500 gallon septic tank $ 50.00 do b. 1,501- 2,500 gallon septictank $ 60.00 C. 2,501- 5,000 gallon septic tank $ SOHO QG~: d. 5,001- 9,000 gallon septic tank $100.00 e. 9,001- 15,000 gallon septic tank $150.00 MAY 2 71 .,..r 11 I. Over 15,000 gallon septic tank $250.00 g. 500- 1,000 gallon dose chamber $ 30.00 h. 1,001- 2,000 gallon dose chamber $ 50.00 i. 2,001- 4,000 gallon dose chamber $ 70.00 j. 4,001- 8,000 gallon dose chamber $ 90.00 k. 8,001- 12,000 gallon dose chamber $110.00 1. Over 12,000 gallon dose chamber $150.00 M. 500- 5,000 gallon holding tank $ 30.00 n. 5.001- 10,000 gallon holding tank $ 55.00 0_ Over 10,000 gallon holding tank $100.00 p. Revisions $ 20.00 q. Groundwater Monitoring - Per Site $ 32.00 " (other than a proposed subdivision) r. Petition For Variance: Setback $ 25.00 Site Evaluation $ 50.00 Subtotal: S. Priority Plan Review: Enter same amount as Subtotal ? ~ ao v Total Fee: SBD-6748 (R. 04/88) NOTE:Fees are pursuant to Wis. Adm. Code, Chapter Ind. 69, and OVER + are subject to change annually. s91-4o3so Coo n UCn~~on0.~ gel ~ s~fem Oup~ex ~ f/ors~ Ti'a;ln S~ab~e O~ncr 3 Bak 132 ►3 ~'oer al~S w~ ~~oaa 5 E yy N Sec 31 T9 8"N ~J lownsH~P j .C`ra~K C'/q lJ~, II 7ro~ S d d sl~ y 3~d UB d al 2) A~~r~ ~cd tic ~i t ca p ' ff Ucnt fi fe la" LA bd,1~ rnis~tc 9 e Ac n4 %VJ'e. S lope Jru if o n2 in coJPr f `MAX VP Doef s`tcnl r aver pj*pe 3 J6. 3 w c'r PUc O7a9 1aP~ of de~ o n b H,~ n a rk S EnT ma-re ma-re U'Ia~ Ferf .T.05feet16N pipe to BonOA of ig~ 5-Trn1 g7.25 -3 03y bea o4 ji rk 303V FV e- )V y" Per : a>d 9 front S pp~'iC 1°nr~ a7~9 vc %i4 Yh aa w Q rwed so1ooil we1d F`Y,4 s it nn _ -aged reom j l~-1 A-ed f om 4 #ors e 7Ainir~ sfA~l~ N ~'T ~~w Inin X r~o r B-e4ro ~ X141 3 60 ~af 3-em p1o~ eN5 w/ o reside Qu~lex 5 D ; lD SpeCtat6rs x 5jeds oLAPPROVE RE4AT1ON GCP,~I~TfJ{E t9VI)USTRY, I- R BUILDINGS ~ e 1 C` I'e u we 5 a /yS0 -a -x l~ d n T ISION ~a ~ ~~fd rP~ccrred t~ gPc~ roo S x = 636 1, ~ fro ~ ~o it io 10 c e sNx 3 x 1yo A= I8 S HUMAN RELATIONS , R nil OF INDUSTRY, LABOR ']gyp a f a re a eDu l~fd ' L DcPARTM UiLDINGS { I ION SEE COAR ENC ; $ f y 5' ' B L' d ProPo S e j ~i~ed Q,~~,°r 'n5 ~o I~~Co~VCle~.dafiov~ fro ~ans ke ~ I6 9l 1l e3o1~bt ~Ia~1 403 6 N This approval does not include review of any plumbing upstream of the septic/holding tank. See section ILHR 82.20, Wis. Admin. ay Code to determine whether plan submittal, dd~ r PQ rt` pprovai is required for that plumbing. I+er. t}rea ago ONSITE SEWAGE SYSTEM ~y o I-~ es Co~iti0►2a~~ ~ Q fft VED ~G~ } Qrese►n~ P% r va ~`~`x a 10 DE AR T ME OF INDUSTRY, LAB AND UMNN RELATIONS VISION WTI k o r s t SEE CORRE PONDENCE $o x ago'- ~ v tt-ai n i n ~renq sc le bo, N 7T Sfalf MD 141 P AweStdr . Prec4sfi Se~~'~C ►~sfX11 sCed. 410 P.U. ohfo Soli q r~ J Q cue ll > 30v' aW10 Mki, n Cover over F. M c ions ~j► /DU.U U, H,k,f Grd , RfLLlIfiICfJS ~n S fia j X t DEPAAINIENT INDUSTRY, LABOR AND H ~ t kd. ION OF N S SEE CQRRES 'yJ~ REG~STEi~'S c c~ ;4' ftanurt, and a. CRW tom., • fW Ali", x1nnemota r; e: • a A' x • • "Int s ioab" aoasidstrhtiew of aid afiAer good and, valuable ee the seoeipt aald aY"°` ZZMa : 4W Idd.Al is Dr~c'ebY • des- 4~ x "Mat" lore i Wry I seal estate in St. Croix OxMtY %turn To N 0"' Oty• $ttat's of Misoonsins W~ yF~S Tan Parcel Mo.: are exhibit •A" '.1 This is not homestead property. with all and singular the hereditam nts and-, Together #4 tbwbtn belonging.i Mentor warrants that the title is good, indefeasible in h and clear of eew antes exospt, any liens o= t to be created by the eats yr defaults of Grantee# b~i~l rPi } fedll and use laws, ordinances and regulations, state and ` ~laticas, restrictions relating to use or iaproveNnts to tiM''.opY - ` d it any, reservation of mineral rights to any a~eAaY, rights of tenant, Brian VOlmsn, and general taxes or y . yvai,1991 and thereafter and will warrant and defend. the"seer". this day of April, 1991. A fu A e N. son STATE or MINNB80TA) ) ss. HENNEPIN COUNTY ) Personally came before me't6i~ day of April, 1991 the abOY:; Grantor, Jennifer N. EastO!!, a".,silt person, to me known to be the P 011who executed the foregoing #nt acknowledge the same.. AAMI 'M STIMSON IM WAS DRAFTED BY : I"UCr-M ESOIA. HEWO M so* tlake street, suite 330 a , . Mnnowta 55391 Rota" Public rf.5[1 •3U" i n1a._ -t ._a'.:~~at~ki^.iitL':.YYu,.-sr-.xY.^,.~m:~~a"'Yl :-.a¢~ -.t''i j'. } halt (N 1/2) of the Worth halt (x 112) Of .tom T wit , Quarter (M 1/4) of Section 31, TovMhip . 28 , Worth, Fangs 19 Mesa yr y J old "w ZI N 1aa 1a F r-j N N • 30 • 143 148 1 ~ N N 3• C 44 e 1 e mont . ;We R a 112 r 31 N 102 • 104 105 \ • • NVV'/4j N~1 p.3 IJW /N\J 4 ~1,4 co • 3 .r ~oA , ~fBSA ~ , ~ co Ta i6 • ~Yy 381 • 78 • 81 12109 74 7 42 c~S ~p~s tbr~ 72 N C 215 North Ilwaco • 4 m 64 ~ 36 FL ilwa Road 19 11 South I waco T28N,FVOW T28N,R19W Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 13:, Zia_ ?'"eA TOWNSHIP ~(r SEC. T TAN-R W fi ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW G')L GEC WIt' 71-- Distances and dimensions to meet requirements of MUR 83 1,1 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 2~/c y t i r INDICATE NORTH ARIkOW i BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point:' Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,QSide,0 Rear, O feet ..From nearest property line Front ,OSide , Rear,0 `r feet Number of feet from: well building: d1 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE t PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width: Length:_ Number of Lines: ;Z Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear, 0 It Number of feet from well: &~00 Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: t 4t ^ Dated: Plumber on job: License Number: 'd 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O, BOX 7969 BUREAU OF PLUMBING MADISON, WI ,.513707 CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: (It assigned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Larry & Dianne Kasten R. R. 1, Cty "W", River Falls, WI rI--/ 9 -dFS -.0 3® BENCH R ;;..(q ermanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: W "M f REF. PT. ELEV.: CST REF. PT. ELEV.: A , Section , T28N-R19W, Town of Troy )SO Name of Plumber: MP/MPRSW No.. Coumy: Sanitary Permit Number: William Schumaker I6382 St. Croix 64930 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID APACIT TAINLET E TAN O LET ELEV.: WARNING LABEL LOCKING COVER !O P OV VED: PROVIDED. YES ONO OYES NO BEDDING: VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL BUILDING: VEN TO FRESH ALAH FEET FROM LIN~:_'y, /r LAIR ' J~~ OYES NO OYES ONO INEAREST !/(J(~l T I i DOSING CH MBER: MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) OYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing er, ,l l DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, constructions all cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH. LENGTR. NO. OF DISTR. PIPE SPACING. COVER INSIUE DIA.. #PITS. LIQUID BED/TRENCH TRENCHES MA RIAL: PIT DEPTH: DIMENSIONS g r GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE ATERIAL . DI R. NUMBER OF PROPERTY WELL: BUILDING. VENTTO FRESH BELOW PIPES. ABU COVER. E V. INLET. E V. EIV ? PIPES FEET FROM LIN .,ft AIR INLET: Y(Jv 7 2_ NEAREST V V /V MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. OYES ONO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS. OYES ONO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. is ODDED. SEEDED IM ULCHED. CENTER EDGES. OYES ONO OYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. JNO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA.. ELEV.: PIPES. DIA.: ELEVATION AND . DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: DYES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: OYES ONO OYES ONO NEAREST ce, , ©v a CL F RLJ Sketch System on Retain in county file for audit. Reverse Side. -.4111111111111 SIGNATURE: TITLE: DILHR SBD 6710 (R. 01/82) w~s~°nsin APPLICATION FOR SANITARY PERMIT OUNTY (AMLHR (PLB 67) ` I °EVFaRTmEnTOF UNIFORM SANITARY PERMIT # ~ 0 In06STR4, LRBOR 6 HUMRn RELRTIOnS / J, -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS C y is; ' 'I PA FY Vs CITY: G: ;?a V11 I 'U4 _j V , N, R E (or W " TOWN 5_0 7-k = ✓ 1 LOT NUMBER JBLOCK NUMBER ISUBDIVISION NAME 7REST ROAD, L v E OR LANDMARK STATE PLAN I.D. NUMBER r TYPE OF BUILDING OR USE SERVED K 1 or 2 Family Number of Bedrooms: I-// ❑ Public (Specify): THIS PERMIT IS FOR A: XNew System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. K Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): - 0~Q 0 ~ /2X~ Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: MP/MPRSW No.: Phone Number: Plumber's Address: Name of Designer: Gp .~e s ~1 ~ A/ ' - .%l COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved / rB{f ~ (7S ❑ Owner Given Initial A J (J Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: D I LH R -S8 D-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT STC - 100 This application form is toibe 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 !,,j e _di~d.t /rc~j S-ti✓ Location of Property ~ `d ftj 3t, Section T 2 $ N - R W Township Tl10 Mailing Address _1 0,14^ / Ad: W. Subdivision Name Lot Number s Previous Owner of Property Z11 eA Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? X Yes No Is this property being developed for ~Jresale (spec house) ? Yes No Volume --==-Z and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERTV OWNER CERTIFICATION 1 (We) cehti6y that.att statements on this 6o4m ahe true to the best o6 my (ouA) nnowtedge; that I (we) am (one) the owneh (b) o6 the pnopen ty des chibed in this .in6o4mati,on 6o4m, by vi4 tu.e o6 a wa Aan-ty deed %eco4ded in the 066.ice o6 the County Regi4teh o6 Deeds as Document No. & ap ; and that 1 (we) pnes en-tt.y own the p4opos ed site bon .the sewage posy -e ye.tem (on I (we) have obtained an easement, to nun with the above duck bed pnopen.ty, bon the constnucti.on o6 said system, and the came has been duty necotded in the 066.ice o6 the County Re9isteA o6 Deeds as Document No acs e , SIGNATURE OF OWN R SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE.SIGNED DATE SIGNED l DOOUMENT NO. STATE BAR OF WISCONSIN - FORM 2 • t ~ QAGE2413 WARRANTY cfro TMti SPACE pEBEgYEO f01111EGONDtM4 OATH MO1STERS OFFICE i Margaret Affolter, a single person and Evelyn Wfibur, a STa CRW CO., tyre, sin a person W IL iot Re"d d6 16th i day OU= A.D. 19_!5 conve & and warrants to - 8:30 A rw h s tenants in common with Lawrence H. en an Di ' tenants, an undivided one-ha it l " ft-TURN TO the following described real estate in St. Croix County, , I' - - - State of Wisconsin; The North One Half (NI-2) of the Northwest Quarter (NW4 en y-eight r (28N), Range iTax Key No. TRANSFEA This 1 S no homestead property. *A (is not) Exception to warranties: Easements to St. Croix County, dated 6-7-67, recorded in 433, page 557 and Pipeline easement dated 11-17-56 and recorded in 336, page ll. Dated this day of May - (SEAL) (SEAL) Mar et Affol etc, (SEAL (SEAL) • Evel n Wilb r n AUTHENTICATION ACKNOWLEDGEMENT Signatures authenticated this day of STATE OF WISCONSIN IL - County. Personally came before me, this S day of May 19 85 TITLE: MEMBER STATE BAR OF WISCONSIN the above named (If not, Marqaret Affolter, a single person and authorized by § 706.06, Wis. Stats.) This instrument was drafted by John E Walsh Attorney at Law h ~ regoi"g i"' ti 1 water Minnesota 55082 to me known to be t'at ~fi12~ 439-4695 ' strument and ac. d th sti. i (Signatures may be authenticated or acknowledged. Both are not . necessary.) Notary Public nty, Wis. ommission D~1~ant. .(IfJ1,et,fltate 'expiration date: •Namas of parsons signing jr. any opacity must be typed or printed below their si9naluraa. My Commission" H G H _ y ST C- 105 r SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County 0 9 OWNER/BUYER k"PfAv '.VleA~ ROUTE/BOX NUMBER (Du~✓r~ Fire Number CITY/STATE f ~a_Ll5 ~h'/5'L ZIP 640-- N '/z of-Al l~ PROPERTY LOCATION:'5~r Section, T Z8 N, R W, g00'SIlL,(~( 0~ Town of T/toy , St. Croix County, 6 ` Subdivision Lot number Cam/ ~ 0 I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of-60% of the cost of replacement of a failing system, which was in operation prior to July 1, 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. C I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with H the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed and returned to,the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED D A T E St. Croix County Zoning Office P.O. Box 98. Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. ° Lb r' S w ~v~ us ro~ p rr 1 CA ` 31 =r =r L (a ~f N~~ID 0 a, 3 t0 t0 ~ o C ~ O -0 am m ° o? z o ° ~m 3 in = ~ a o 0 w ° tG CD ~ M CD N w w - wv m m v,,a~'- Qr m m = w e o3CL oa so w 0 cow o 9 0 o •c t- C a g N Z~ w cam' wwcn 0 CL w D CD 0 oD - v < ((D U1 w fC Q A C1 °W" oDc ao ` wci,r ~aCD o ~w och °~vw~uuN, Z V1 CA ~f°i`D~~ cvv a C-D =1 U01 1D co CI. D D N m o~ g to 0 m OC Er Q N c- cD o>> w v, v;wa ~ i accCL m~ C m CD 0 0) O 0 O N (7 CD N r =r CD .pia Al Q0) = J coo p~ fA C C ~p 7 ~D Nl m 1vrU a (D C n 0 m a0 vi C aw O w° w m m N° CIL 0. CL 0 Q : (a C7 C) N c ~c° m CD 3 c~ 1. (CA 0 CD 0 CL (A ¢a 0;. a C co w fD CD C CD S ° 0 a w ° CL _EL • DEPARTMENT OF REPORT ON SOIL BORINGS AN AFETY & B DI INDUSTRY, VISION LABOR,AND AN R~LA~ NS i PERCOLATION TESTS (115) " P.O. BOX 7969 (H63.090) & Chapter 145.045) ISON, WI 53707 L) ATI~O : 'FEUTJQN- /TO H/11/F E (or TOWN / y : //}/p LOT NO : _`K. NO.: yB~I~V N N ,V ~p~O COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: t~• J40 X ~adR~Y v aE sTE>v RT• C, y W , 4 ~//s `~`~v SYo USE DATES O R O A Residence BEDRMS.: COMMERCIAL DESCRIPTION: PROFILED Rip 1 R ATIONTESTS: AResidence 3 e. Nf~" %New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system SC~ Bv~~~ s✓~ F~'~C s G CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: rYSTEIVI-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) X❑ S ❑ U 12S ❑ U © S ❑ U ❑ S k ]U ❑ S ❑ U Cow rve.V710V f / /L30Q iz 'x s 0A /Z 'K co If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the ✓y~_ under s.H63.09(5)(b), indicate: nq S S Floodplain, indicate Floodplain elevation: `C~-- PROFILE DESCRIPTIONS /N MeGwy.+L. ~C* BORING TOTAL DEPTH TO GROUNDWATER-IN. CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) o ' 41"; 10A) • 57, . S ' AV , 5-, 3 • ~ . /oo • 7i > 0 . C 7 ' ~~v vfip co, = Grp B- 2- 9, 0 /V 2• . ,P - > 9 • sI ` De-4a . s/ /o - 3 . / ~ ' ~'N ~/E~ c•f ~ 'G.e B- 3 70 > 9 d 1 GR. 3, o' v c s g C~ 1161- .62 . S/, .7S ',BN. s , . 17 Z-f PAP ,!/CX cs , . o /Zt ` Gy' s! N: , B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH P_ / 7 7~0n.L < 02 4, P- n P- < o~ . 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 /5`6 ~ ' D E 4 r- of ~y PUG. ,i..__ M. 1 W I 3 ~ ~"f ~ I ` (w~~•ivt~.~.. fi~rvyMM l _ 40, a' ~ , e 74A 0 4007 I, the undersigned, hereby certify that the soil tests reported on this form were made by mein 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): TEST WERE COMPLETED OI HOMESITE SEPTIC PLUMBING CO. ,_P7 7 / f.Ff ADDRESS: RT. 3O'N IL RD., HUDSON, WIS. 54U16 CERTIFICATION NUMBER: P ONE NUMBER (optional): ROBERT ULBRICHT ,3 f ~ CSL 5/~ 2 • 1006 WIS. MASTER PttJMBER tie. NO. 330? MARA CST SIGNATURE: MINN, INSTALLER & DESIGNER LIC. NO. 00663 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete ; I accurate soil test, your report must include: ` 1. Complete leggy:l iption; 2. The use section m st clearly indicate whether this is a residence or commercial project; 1 MAXIMUM! number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5= Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if approprir te; 10. If the infor- (s'ach as flood plain, elevation) does not apply, P'-'--' A. '-l the appropriate box; 11. Sign the form glace your current address and your certification nu r; 12. Make legi ` s=s and distribute as retluired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUT I, RITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR _ Bedrock cob Cobble (3 - 10") SS Sandstone gr - Gravel (under 3") LS - Limestone s - S no HGW - High Gr(ILIF I cs - Crce Sand Pere - Percolation med s 'i i i Sand - Well fs - a Sand _ Building Is - my Sand Greater Than Loarn Less Than I Bn - Brown sil " Lc:rnr Bl Black si - Gy -C~ *cl y scl S iuy L .?m R~ i 3 sicl - Silty C' L mot - h,-)ttles Sc - Sanely Clay w1 - Vvith sic Silty Clay fit - f fine, faint c Clay _ ;;c i ~n, coarse pt Peat mm - mediur,l rn Muck d - Ict p - p _ dnent HWL - High wat I ' Six gen 4-tures surf c- for 141 ~posal BM - Bench P. VRP -u Vertk.cc Point T in securing a sanitary permit. T' - - -,e Deg .t request ;ieid prior to permil issuance. A cc le, =r of private 't,.rion must be sul ~ it-ted t order to T- must be obt l . tion. Ile L ~~i✓ S' G'~ 4/ ~S'e 34 y L ~ A-Il i ~ ads ~ r ~ /e Yyl~~f/ Grp v~Y p e .~a v,0 oe ¢ a p Idoc lC LEGAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR02 REAL ESTATE TOWN OF TROY COMPUTER NUMBER 040-1116-60-000 Parcel Number 30.28.19.474 OWNER NAME: First %MICHAEL J HAHN PRES Last HAHN DA ROSA FARMS INC PROPERTY ADDRESS: Hse # 1/2 PD --Street Name-- Type SD Apartment SECTION 30 TOWN 28N RANGE 19W'/160 '/440 Line Description Line Description TOTAL ACREAGE 53.878 PLAT LOT BLK 01 SEC 30 T28N R1 9W 15 02 PT S1/2 SW1/4 16 03 TH SW LYI 17 B T S Z3 0 SE SW L CSM 9/2509 EXC COM OR 89 DEG 20 07 W 1338.6'; TH N 00 DEG E 21 4 n 6 K 08 855.06'; TH S 89 DEG E 22 09 447.96 TO POB; TH S 89 DEG E 23 10 209.09'; TH N 00 DEG E 24 i 11 463.85'; TH S 89 DEG W 25 (Ivy r ~S~ Sv l 6~ 1 j,rSeG~~ ` 12 209.06'; TH S 00 DEG E 26 13 461.9' TO POB 27 14 28 F1-General, F4-Prev. Parcel, F5-Next Parcel, F7-Valuations, F8-History, F10-Exit LEGAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR02 REAL ESTATE COMPUTER NU 040-1119-10-100 arcel Number 31.28.19.484B OWNER NAME: Fir ° ICHAEL ES La st HAHN DA ROSA FARMS INC PROPERTY ADDRESS: Hse # 1/2 PD --Street Name-- Type SD Apartment SECTION 31 TOWN 28N RANGE 19W %160 '/40 Line Description Line Description TOTAL ACREAGE 19.000 PLAT LOT BLK 01 S 20 AC 15 0 S 1/2 OF NE NW 16 0 AGREEMENT AS PER 17 04 VOL 880/603 18 05 19 06 07 0 21 08 22 09 23 Cl~ ~ 10 24 Cj 2 11 25 ~p 12 26 13 27 14 28 F1-General, F4-Prev. Parcel, F5-Next Parcel, F7-Valuations, F8-History, F10-Exit III All N 00° 14' 48" W z 663.90' _ WEST Lbw OF THEW 1/4 OF rHEw 114 a " I i AP-1 ' DZ- Z N i I~ a c b ~ v a A ~ a Ip 1Z 1D ~ la `-c „y a I~ a X Go co) z I mw N l 6- .,I W C) I ,ate / I , I , I I ~ I I$b o!h o I tt BULD#VG k~~~til I ' "ousE ' I I a~ z m \ i z-I O~/~ I # DAyy p~~ y I G) 2 1n I ~ SZ T7~ ~ ~ OD ~ W I ~ ~ OZ ~W+ 4~0 P $ 'lot NORTH-SOUTH 114 SECTION S 01°01' 38" W p (R-S E) LINE OF SECTION 31 a (R-151.4.31_ 399.15 - - - - - - --I~--------- 0.~~ E 151,42' S ' 01007157" W i /R- 01°V'.5.9" F) yin y T.. win kn OUTLOT 3