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HomeMy WebLinkAbout040-1209-80-000 Q ~ 3 ° i r.. I c i er N y I II I I 41 I N ~ U I p O Z O Z C C ~ m ~ ro LL O U. p Q ~ Q I 3 CO 3 V v II o a~ I z w z w N U) 0 00 z m m `m m 00 LO C4. w' I a m a m N F Z O O Z d' c C U ~ o o o I v I c d Z c z cn I- r ~ N i ~ N c ~ c E ~ a M O N O N ca CD m a) CL CL N dy v C (D d L du . ) L O 0 CD z z co z ° p Z co N N C Z M 44) E d L ; E W E N N N N x N a W w N N CL tC Q N T O° O V N N U~ V y N IV ° LO c O ai .a E O O a .o N E a) U ° N in m H H d m H H E Lo E N ►~i O O O O O O z° •w,, LL76 aaa LLaaa ►Ni a a~ I a~ ►i g ° y 3 o N N J U rn Z rn rn a) i _ N N U O O c O ° 0. C6 co 'n (D M L Q Z M Q f0 N 7 t0 N O N C N C °O = O r "6 p ~L. M O U y C a N C C U d a 00 0) LL N r` , C N co 0 r- O 0 O o C O a N C CD 0) C oo ~ o H v a~ o Z Z • ~ In ` C co o N :3 E O 0) C C3 N m m v't5 U O N F- ! Q O Z Q O Z 2 2 U) p ~ £ I w t w ';I E d E d E a y a • CL d a a c y c m A 0 a 2 O in 00 O 0 v FORM - STC - 104 + AS BUILT SANITARY SYSTEM REPORT dry TOWNSHIP OWNER-42",~1 W SECTION _2 T~N-R '20 ADDRESS S << t~~ri+ ST. CROIX COUNTY, WISCONSIN SUBDIVISION S~.--NLOT--,L-LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /7 ' r n INDICA E NORTH ARROW r BENCHMARK:Elevation and description: //1C-►f1~ j"^°~` Alternate benchmark SEPTIC TANK:Manufacturer: Liquid Cap. /-I-ee Rings used:.a"Manhole cover elev:_Final grade elev: Tank inlet elev.: /DS'.~L Tank outlet elev.: id t-~~ No. of feet from nearest road:Front , Side, Rear Ft.> From nearest prop. line:Front , Side/, Rear Ft. > /5 / No. of feet from: Well y ' Building: f 7 (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:_ ~i Trench: Seepage Pit: _ 2 Length Number of Lines: Z Area Built YO Width* Exist. Grade Elev. ;girVb T--'(Proposed Final Grade Elev. Fill depth to top of pipe: No. feet from nearest prop. line : Front , Side v, Rear Ft. >7.y-f No. feet from well: lrX~~ 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: j/ PLUMBER ON JOB: LICENSE NUMBER: 6/90:cj aa Q~ T F INDUSTRY / ~SAFET~BUILDING DEPARTMEN o INSPECTION REPORT FOR LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION 1V F' -1IS J 1v. 5 7Q7c 2 rJ T 2 8 - R 2 0 State Plan I.D. Number: i,, C ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town o~ Troy, Lot 8 Glen Circle ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTIO DATE: Paul Anderson 1S6 S. Liberty Rd.,River Falls, i Y'~~-~ 3;3c) BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: t=r! J c' +G ACC e +.,c, a / Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: David Fogerty 3289 St. Croix 14901S SEPTIC TANK/HOLDING TANK: MANUFACTUR R: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: a p C, Y O,') / G~ , 1YES ❑ NO ❑ YES ~NO BEDDING: VENT DI .:f/ VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTV WELL: BUILDING: VENTTO FRESH FEET FROM LIN : AIR INL(=T: ❑ YES ZNO Cy ❑ YES ENO NEAREST I S 7.S 7 SC? DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: u P A D TROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST -11 SOIL ABSORPTION SYSTEM. Check the soil Oisture t the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wir , construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: / MA ERIAL: PIT /i DEPT DIMENSIONS (r? (j Y GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. STR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE CO E ELEV. INLET: ELEV. END: PIPE : FEET FROM LINE: / A~ INLET: 'L" NEAREST lL' d ~ f ~ MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the 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: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE' ~dJ~1 w~ ❑ YES ❑ NO ❑ YES ❑ NO NEAREST~~ Y `fr Retain in county file for audit. Sketch System on Reverse Side. SIGNATURE: TITLE' t ) SBD-6710 (R. 06/88) .1 tr l'. r t c l/~ E17ZDiILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COU•~ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ I Y9 8fZ X 11 inches In size. Check f 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 NE '/a SW %,S25 T 28 , N, R 20 E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 156 S. Liberty Rd. 8 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME River Falls WI 5 022 25 2134 St. Croix iii hlands III. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ) ❑ State Owned VILLAGE : Glen Circle ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms 41 PA RCE L TAX NU BER( ) III. BUILDING USE: (If building type is public, check all that apply) 3 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 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 5.0 Repair of an System System Tank Only Existing System Existing System B) x❑ A Sanitary Permit was previously issued. Permit # 128774 Date Issued 9711790 V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 0 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 600 820 820 .73 2 97.74 Feet 100.0 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank 1200 1 Weeks r Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): W! (Pie slamps) MP/MPRSW No.: Business Phone Number: David B. FogertX a, -G'~ L 1 749- 3656 Plumber's Address (Street, City, State, Zip Code): Fogerty H ts. Rd. Roberts WI 54023 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial i/' q~ A/0 4~ "]o~ dverse 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 CSEPARTMENT OF REPORT 0 BOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,* DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISON WI 3707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP/M"F11811"Aiiti`: LOT NO.: BLK. NO.: SUBDIVISION NAME: W St Croix HUhianda NE '4 sw '/4 25 /T28 N/1 120E r)WI Troy MAILING ADDRESS: COUNTY: OWNER'S St. Croix Paul Anderson 156 S. USE Phone' 42 -2134 DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PRO IL DE CRIPTIONS: IPE-R-C-OEATION TESTS: Residence 4 ®New ❑Replace Il 4-21-91 4-21-91 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U ®S ❑U 1..x1s ❑U s ❑U ®s ❑U gravity 12° X 69 ESI DGN RATE: of the tested area is in the If Percolation Tests are NOT required If any portion under s. ILHR 83.09(5)(b), indicate: x/ I Floodplain, indicate Floodplain elevation: None. PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.-HIGHEST- TO BEDROCK IF OBSERVED (SEE ABB.BRV. ON BACK.) B-1 77 99.44 ':-77 4'Bkls_L 2.1'~Bals, ' 3.9'Bncs none B12 85 102.54 none >85 .4'Bkls, .8'Bnls 5.9'Bncs. B-3 57 99.44 none >57 .4'Bkls, .9'Bnls, 3.4'Bncs. 92 102.34 none >92 .2' Bkls, . 8' Bnls, 6.7' Bncs . B-4 B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RAPER INCH ES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R D P-1 20 no 10 31% 3 3 2 P- P- 57 none > than " drov-in • 5 P- P_ 20 none- min- han " d 3 .5 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. Glen Circle SYSTEM ELEVATION 97.74' _ E E i extstin W E go~ F 3 o ?C N;_ salmi" 20' EVI BM, assume` 100.0' - may, top of spike at base .,1?RIMARX of large vhite -o*s = or n _~~o Nl~ ' x - j ; } t pper 'C A6 old borings SEE ATTACHED .PREVIOUS PERK TEST.,_, T11 SE; BORING ARE ESSENTIALLY IN THE ALTERNATE AREA. PERK TEST IS BE~NG AREA, 1 REDONE DATE TO THE ~ BM,; BEING ALTERED AND, THE PREVIOUS—' IG~ OC fiIbNS BLURRED'. THE PRIMAE ON"THE -ATTACHED, Eli 115 VILA SERVE-A0-THE ALTRRNATE. SYSTEM_NASw.A 50 3 3 E ENLAGINEDI TO FOUR BDRM. 3 E ~ e E E 3 3 3 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: 4-21-9I ADDRESS: CERTIFICATION NUMBER: [PHONE NUMBER (optional): Licensed Per Tester 9 Plumber #3 .1 Fogerty Heigms Roa C NAT R08E phone) 749 3656 X23 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - t v b a H w (A 4) m :2 ~ a N 2 ro a fn w N J ca%mZin t co %0 0 CI w N t~f N ~o' Pa -4 Ctii Ln - 0 * ~M 3 c ~°'aNc N L&W a MA w 11 :0 c o 3 n W CO o, 0 0 a a~ 0 a+ v 44 41 I ° 4 oU) ~o M w ~ . 0 cd 4) 14 $4 W 0 as r O a$4 0 CV PU w i+ .G a F-4 ON a n n n n n A r t 3 a I ~ n (fir , ~ 1 v • a. rte.." DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING DIVISION LABOR &,HUMAN RELATIONS L LAB BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION 1V ~q ~ "§!'e c . 2 5 , T 2 8 - R 2 0 State Plan I.D. Number: ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Troy, Lot $ Glen Circle I-I Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Paul Anderson 156 Liberty Rd. River Falls WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: David Fogerty 13289 St. Croix 128774-T SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑ YES ED NO F-1 YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL, BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST 1111~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL 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 DISTR. PIPE SPACING: COVER INSIDE DIA.: PITS: LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N0. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the 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: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Retain in county file for audit. Sketch System on Reverse Side. 7~_ TITLE: SBD-6710 (R. 06/88) DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MNN,', S%~~- 11 5707 .25,T28-R20 St ate Plan I.D. Number: El CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Troy Lot 10 G1 Circle Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Paul Anderson 1156 So. Liberty Rd River Falls WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Jim Bo meester 3404 St. Croix 128774 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST -1110' DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO El YES ❑ NO El YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL 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: BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END. PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the 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: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) I _ SANITARY PERMIT x COUNTY ®ILHR TRANSFER/RENEWAL UNIFORM PERMIT # .a a mA.a, o (PLB 67-T) t 7 PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: PROPERTY LOCATION: CI A/ '/4 liU t/4,S ,T N,R E (or v E: e LOT NUMBER: BLOCK N MBER: SUBDIV I NA NEAREST AD, L&_E6.RLA DMARK: PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: PHONE NUMBER: ADDRESS: PHONE NUMBER: ADDRESS: I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PL M E SIG URE: Ole PRgVIOUS PLUMBER'S NAME (IF CHANGED): e e R'S S: EVIOUS PL MB 'S ADDRESS- /r/~/J c~.,.t 153 O MP PRS NU BER: PHONE NUMBER: P/MPRSW NUMBER: PHO E NUMBER: SIGNAT RE OF IS DATE APPROVED: DISTRIBUTION: Original -County Copy - Bureau of Plumbing Copy - Owner ` DILHR-SBD-6399 (R. 5/82) Copy - Plumber ~ R SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY, " v ~ ue,aNww„~wrs~ ~ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ /;2 -7 `7 8!Z x 11 inches in size. check if r ision to prey us application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY ER P OPERTY LOCATION rAU DP,, 16 (3 D`1 %s SD_ Tc)$, N, R E (Or W P OPE TY OWNER'S MAID ADD SS LOT # S BLOCK # 1!5 , I it <J ZIP GODE PHONME~ MBER SUBDIVISI N NAME OR CSM NUMBE TY, STATE 0,1 II. TYPE OF BUILDING: (Check one) CITY NEAhEt R AD 1:1 State Owned El VILLAGE DJ N ❑ Public I1 or 2 Fam. Dwelling--# of bedrooms PA L TAX NUMBIERR( III. BUILDING USE: (if building type is public, check all that apply) qq3 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. Vew 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) Noessurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE 91sal I 1 RE cR q. ft.) PROPOSkD ( q. ft.) (Gals/day/ sq. ft.) (Min./inch) ELEVATION l.J e set eet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New jExisting Gallons Tanks Manufacturer's Name Concr to Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank 7 Lift Pump Tank/Si hon Chamber F1 El El I El EIL VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. MP/MPRSW No.: Business Phone Number: Plumber's Name (Print): Plumber's Signatu : (No Stamps) 1 -7 bak,r~e Au ► /5-3 a~ gb Plumber's Address (Stree City , Zip C e): ~p-t k 6~ W' v b IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Age t Signatu m Approved E] Owner Given Initial Surcharge Fee) / Q q,7 Adverse Determination 7 <C/ 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 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. --------------------------/------D/ 7------------------------------------------------- Owner of property l /.moo-t~JsoC-, Location of property 1/4 s 9~ 1/4, Section S , T --70 N-R_26. Township, 'T;~c, 4 Mailing address v~v )C- t1/s Address of site Subdivision name -571-7 C--, / Lot number Previous owner of property C 41v /V ~S c---,7 Total size of parcel2 r Date parcel was created f' 22 Are all corners and lot lines identifiable? z-~Yes No Is this property being developed for resale (spec house)? Yes c-- "No Volume Band Page Number ?-3E 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 warrant deed recorded in the Office of the County Register of Deeds as Document No. 3 5-7-2,L/ ; 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. 9 3 7 ;2Ll Signature of Owner Si ature of Co-Owner (If Applicable) Date of Signature Da e o Signature P " G • DOCUMENT No. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 43572 ! REGISTER'S OFFICE j ST. CROIX CO., WI ' This Deed, made between --Kari L. Nelson and Clark E. Nelson , husband and wife - Rec d for Record MAR 31 19$8 I Grantor, and-----Paul D. Anderson and Synneva A: H._ - Anderson s I 0~ 1:00 PM - husband-_and_ wife-,:sur-vivor-shi--marital----r©--ert-- ~A V Re seer of Deeds j , Grantee, I 9~ Witrlesseth, That the said Grantor, for a valuable consideration...... •SERVtCES - - conveys to Grantee the following described real estate in St . Croix RETuff:r fRUIX VALLEY T= 21g North Main Street Count State of Wisconsin: 11 River Falls, Wisconsin 54022 Lot 8, St. Croix Highlands in the Town of Troy. Tag Parcel No: i I I~ I! i f I fRANSF j 316 0 j I! it i! ~i 4 I ~ ii This is not homestead property. Owk (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; ii And K i-:L----A1 is ~ £1 ere -s warrants that theile is good ml~enfeasi re Inee slmlilei re and clear of encumbrances except easements, covenants and restrictions of record, if any, I and will warrant and defend the same. 'i Dated this 30th March 19__88__. day of March I; (SEAL) EAL) Kar L. Nelson ~ •---(SEAL) (SEAL) I * * Clark E. Nelson j! AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. $Z, __CZQ~X--------------------County. ~ authenticated this ________day of___________________________ 19______ Personally came before me this 30th___day of Xal~_(;kl---------------------- 19.88 the above named C7,axk__ _~_.1~ l;zQn._-__K-axl`_&.Rel's-m----------- TITLE: MEMBER STATE BAR OF WISCONSIIQ„ (If not, _ j - by § 706.06, Wis. StatsJ;•' . authorized to me known to be the person 8----------- who executed the r4or;going inand acknow ge-tl~e`game. i THIS INSTRUMENT WAS DRAFTED BY' J ♦ n HEYW OOD, CARI__& MIJM9 Allen P. Penfield ~U D - - - - - - - - - - - - - i~ by Samuel R. Cari ~ Notary Public __________>=..__Gxolx-------------County, Wis. (Sign cures may; be Hudson; authenticat authenticated IIor r a Icknow nowle t ilfg PPtltr' , My Commission is permanent. (If not, state expiration ii are of necessary date: ____-......February S, 19__89__.) *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc- FORM No. ! - 1982 Milwaukee, Wis. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER acv/ ROUTE/BOX NUMBER FIRE N0. CITY/STATE r pier~lS ZIP ,2/022 PROPERTY LOCATION: A F1/4 S W 1/4, Section T 27N, R 2 O Town of ro i , St. Croix County, Subdivision Lot No. ~T. 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 30 days of the three year expiration date. SIGNED / DATE / f~ 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 's 1 i , SL Croix H Ighlends nw. w ■e .««e e«..w.r 1 ` • c.wn.rnti,.«I.■ ■ n....aM M Ru■.ow nr I...rq w.,nR■. d ■r !1 G.r N t a t ns.lw.« .Rw,Iw r..l N' .n« ■ ..ullvl...p.w.. r, nw .x.y ■+•O .r,wq a e«R.e.. n Rw«r R«r4M. M ■l CM. Rpn,rM..r b xr «I■ M.M ..w MnIR A - a IM.W Irw■ Fi01t ■wD.x .«.r r.«- «N.11 M1 ■..«.1. w IM w«.y HUDSON HUDSON ■«..Inras,..nrx«gr.w««« ' r u.nw Oe" di° Tca~.«rw.w ads n ■nle ra nw. angwq r . SLCn w:4nrro. w . r.r er,. _ -1.94 Iw .a •w ur 12 y, .a • ..■■iwRr BERTELSEN-CUDO CO. ..t F 4 .6: g 1 3 t.7RM 19th St. & Coulee Rd. 1 - b.en Vf 2 13 ller« aw Freedom Center n.iu : ,K„ ; 715) 3.°6-0307 (715)385-530? C" g 7 udscn, ::isconsin 54016 `232. b.. ` 12 HIOMnnd■ 13 =.1 ~ 5 9A. MLS_ St. hin1d, • w en • a , 1.0 A . ,w. I j 11 10 g . H-276 LOT 8, ST. CROIX HIGHLANDS CO- M~ - in Anon •b. Ce..1, C l ■«•V •nwr . Wooded, 2.32 acre parcel in area of 1 s.1. P.A Fine Homes off Glenmont Road, St. Croix River sandy access--Perk test is done & ready for your Dream Home. Addr al t. L Of Fire # Dist SW SE'/4 Sec 25 Twsp Cty . # Acres 2-12 A Lot Size 2, 3 21 Front 921 ft. R. Side Rear L. Side Sub. Div. S Hig Mtg Bal. roix hland [N] Wtr Frontnear [Y] Perc Tests ~1J Well Abstract [}C] Trees [Yj Elec 141 Septic [M Easements o~' ~.r. [Yl Rolling [NJ Gas [YJ Pvd. Str. IN Restrictions - Fence [N] Sewer ~tJ Curb [I Covenants Sur/Stares [N] Mr. [NJ S/walk [ Sign Tax Yr 19-86- Spec. Assess. NA Poss Date Nego . $ 279.60 r Legal/Disclosure Lot 8, St. Croix Highlands Wooded 2+ acres-6 miles S. of Hudson off Glenmont Rd. Area of Nice Homes with close access to St. Croix River Sandy Beach at the end of Glenmont Rd. Perk test is done--Your Dream Home in the Woods. S/B/C 4.0 lister Sandee Lowr Ph 386-3363 i PRICE-$17,900 Brkr Century 21 Bertelsen-Cudd #230 Ph 386-8207 DIRECTIONS: Take I-94 to Hudson Exit #2-Left on Frontage Road (past Hudson House)-- take a Right on Cty Rd. "F" South to Glenmont Rd. (6 miles) Right on Glenmont into St. Croix Highlands Development & watch for signs. Information is considered accurate but we accept no liability for error. Listing may be• r-h an -~,i nr w; thdrAvn wi th~"t a^t!.^r. , lJ#PAI'0MFNT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INIDUS fRY, DIVISION P.O. BOX 79139 I ABOR'AND PERCOLATION TESTS (115) MADISON WI 53707 I~IUMAN,RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: I SE T OjT N/R2v/lor, TOWNSHIP,M NICIPALITY: OT NO.:BLK. NO.: 0VISION ~I tM : 1/4 Cp(JNZY: NER'S BUY S NAME: 'IMAIIJNG ADD S ~IJ 1( 1 S 0 USE TES OB ERVAT NS MADE _OIATI NO. BEDRMS.: CO E IS: R SCR TIO An New ON STS: /NJ New ❑Replace ~i'~ 3~ S•/~ F esidence RATING: S= Site suitable for system U= Site unsuitable for system YSTEM' o 'on t: NVENT ONAL: MOUND: IN--GROUND R : S 5 N-FILL HOLDING TANK: ER~ECOMMENDED S Dins ❑u ~s ou ❑s Pu os00 If Percolati on Tests are NOT required DESIGN RATE: If an any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: 3 Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTA DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHIM. ELEVATION OBSERVED EST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-/ 3 es 9 B- z %S, B B B_ PERCOLATION TESTS TEST PTH ATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER jtDE ++eSAFTER W LLING INTERVAL-MIN. p R P RI D 2_ FF. H90 a PER INCH z-- 3 P. Z 6 C 3 P- L 3 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. ~i el -7 SYSTEM ELEVATION i QM foP ~,r~. 9..~1/il~,• +b 5;4v./Vi='i'-,,~~.,- Q P~ - TN p ' ~M Oil 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 WER IF CO ETED ON: ADDRESS- _ CERTIF ATI N NUMBER: PHo,r11 BER( tional): CST DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR•SBD-6395 (R. 10/83) - OVER - 1", 0 S S f~ Q L 67 PLOTA N I i 1A 0 .1 NAME °;ti) , _ fir, r~Sc~I~► NAME 0 C AT 10 Eik AT T it' - - - P L 0 I M -A _P -6M Tr of I-A J_, ►1fl - ~ ~ qJr-a ~.1Q~ •t-o ste 4~ roe u WIC Will vf i -run . 1 6x ?oc Lie U f 14 • la' Say p~ o~y o1 FR oln Ce► f r i U Pt . , i FRESH IPiL,I,ITS ~AND OBSERVATION PIVE CI;OSS SECTION Approved Vent Cap Minimum 12 Above Final Gra~le___~ _ 9" Cast Iron Above Pip Vent Pipe To Final Grade! Marsh Hay Or Synthetic Covering Min. 2" Aggr.cylil _ Over Pipe Distribi-iL-io+J- -Tee pipe I _s Aggregate AJ Perforated Pipe Below h\C~~ Deneath Pipe Coup].i.ng Terminating T 1 3 1~ BoL•tom of System