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HomeMy WebLinkAbout016-1051-40-000 • FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER pJar SS~i4C~l TOWNSHIP (~•Ce:A)UJDd SECTION T_3_g_)N-R_L.,:j'W ADDRESS /cp iZin, `X ST. CROIX COUNTY, WISCONSIN uJ~~ ~ S : 5ycl r 3 SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM rr J //y, INDICATE NORTH ARROW BENCHMARK:Elevation and description: /D 11`0 25P v cjcn- Alternate benchmark / Liquid Cap. SEPTIC TANK:Man facture~~'"' Rings used: a -over elev:Final grade elev: Tank inlet ev.: Tank outlet elev.: No. of fe from nearest road:FrontSide, Rear___,Ft. From no rest prop. line:Front , Side , Rear Ft. No. 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 i Distance from nearest prop. line: Front-, Side Rear Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit ~►rea Built Width2deph ength Number of Lines: _ ExistElev. Proposed Final Grade Elev. Fill o top of pipe: No. f m nearest prop. line:Front f p Side'Rear,_Ft._ No. feat from well: __No. feet from building HOLDING TANK Manufacturers /)y- /K:-Capacity: No. of rings used:_ Elevation of bottom tank:. gvva Elevation of inlet:- No. feet from nearest prop. line:Front Side,,,, Rear ___Ft.a No. feet from: WellL1- ' , buildin 9 , nearest road j L Alarm Manufacturer:- A. J rZ CC' INSPECTOR: Q DATE: Z d PLUMBER ON JOB: t~ a LICENSE NUMBER:_ ~Z/y~' 6/90:cj 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 MADISON, WI 53707 State Plan I.D. Number: SW 4 , NEB , Sec . 23 , T30-R 5 ❑ CONVENTIONAL El ALTERATIVE (If assigned) Town of Glenwood ❑ u nd Holding Tank E] In-Ground Pressure Moo A E MI OLDER: ADDRESS OF PERMIT HOLDER: INSPECTIO D E: John Rassbach 1455 Co. Rd. X,Glenwood City, WI BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. EL V.: CST . PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Lyle Myers' 6219 St. Croix 128705 $6 -l NK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: 3 CUD _ ~ ZI YES ❑ NO ES ❑ NO VENT DIA.: VENT MATL.: HIGH WATER UMBER OF ROAD: PWELL: BUILD G: VENT TO FRESH BEDDING: l I AIR INLET: ALA LINE: / [AFEET FROM ❑ YES NO YES ❑ NO NEAREST 2,1 DOSING C AMBER: 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 CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF S ❑ NO NEAREST - - SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of wing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease it MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: C ER INSIDE DIA.: PITS: LIQUID BED/TRENCH TRENCHES: MA RIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DIS . NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: EAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fAsan PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for meELEVATIONS MEASURED. SOIL COVER TEXTURE: ERS: OBSERVATION WELLS; NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODSEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO 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: NO. DISTR. DISTR. PIPE DISTRI ION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT C ESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES [__1 NO E:] YES ❑ NO NEAREST -41" fain in county file for audit. Sketch System on Reverse Side. SIGNAT E: TITLE: A f SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION R In accord with ILHR 83.05, Wis. Adm. Code COON 9=5=1 STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ a ZQ 8% x 11 inches in size. Check if re ision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. c5 - PROPEtD~Q)QQVER PROP RTY L CATION G '/4, So? -3C) , N, R 15-E (or PROPERTY OWNER'S NAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 7 OIL i~Ljaf at) r d1 ' ,26 0 ITY ~ II. TYPE OF BUILDI & (Check one) ❑ State Owned ❑ VI AGE NEA ST ROADR ` ❑ Public 91 or 2 Fam. Dwelling-# of bedrooms AR EL AX LIMBER(S) Q//_ _ /05`( -00 ID BUILDING USE: (If building type is public, check all that apply) 9Q CJ 0 1~ G 3(v-3,13 1 ❑ Apt/Condo J 2 El Assembly Hall 6 F-1 Medical Facility/Nursing Home 10 El Outdoor Recreational Facility 3 1:1 Campground 7 ❑ Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining 40 Church/School 8 ❑ Mobile Home Park 120 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) 1.0 New 2. Replacement 3.E1 Replacement of 4.0 Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 Pit Privy 13F-]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 Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank dd J 10 'J7 r ST f8 I Li Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) P/ RSW No.: Business Phone Number: 2- S 2~ 4 It /Y7 s A Plum Address (Street, Ci , State, Zip Co e): le- , , I., ? A x- Y-2x cde S IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e slue lissui g gent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination Q~y X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; close volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) 4) e' 14-r-7 Y~ ~L L~`7~c 1J ck~i7 l ; r r S /7-3o YDr3 /1Z 16- U) ?ZU L !2 ~ ~ GS sYS~~M SY SEE C©"~c IC2 \l"1~ ~l ~ ~ s s 7-~ y ~ ~.I~~ TF+E fac~sTi~tz ' SEPTIC 5`f STEM ~.SR !LHF- 43;5. 03 (2) HOLDING TANK CROSS-SECTION Approved Weather Proof Vent Cap Junction Box , 4„ C.I. "--7- /Approved Locking Manhole Cover i With Warning Label Attached Vent Pipe And Padlock Minimum 12" _ t /Final Grade 4" Minimum (Approved Joint Minimum Dater Tight--'' ~ j )eal High Water ' SPECIFICATIONS Alarm Switch TANK New Existing Manu of cturer• Approved Joint 7- w/ C.I. Pipe Blind C.I. Tank Size:_ Gallons Extending 3` Plug ALARM Manufacturer: V --1- Zz Onto Solid Soil Model Number: jo, 1 ©a2, Scf.~ Switch Type NUMBER OF BEDROOMS: GALLONS PER DAY: 3" of Bedding Under Tank Owner's Name: o Address: scri pt ~1 Legal Di on: 171,12 I ~STownship/ County: j PLUMBER/DESIGNER Signature: ' YTM License er gl~ Date: PG'E 12 . l~ V R> e 1 i,.~Ji'1 x~AC PC ST. CROIX COUNTY r 5 {r: WISCONSIN <h ZONING OFFICE ST. CROIX COUNTY COURTHOUSE . 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 July 3, 1990 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation of the John Rassbach property, located at the SW4 of the NE4 of Section 30, T30N-R15W, Town of Glenwood, St. Croix County, revealed no suitable soils for onsite waste disposal on the property. Should you have any questions, feel free to contact this office. Sincerely, James K. Thompson Assistant Zoning Administrator cj ~p3 1~ ST. CROI X COUNTY WI SC0 N S I N ZONI NG OFFICE (715)386-4680 `C".% Yf: ,t 911 Fourth Street j - Hudson, WI 54016 O W N E R P U M P E R A G R E E M E N T PLEASE BE ADVISED, rhat unt.it you ate again no.ti6 ied, I w.itt c o n.tx a c,t with 0 W is cons in, ( Pumper) , box the puxpo6 e o6 removing aZt wa6,te 6tom the sanitaxy 6 y6tem to be .located on the ptaperty and 6utute home 6.i.te .located in St. Cxo.ix County, W i6 cond.in, Township o6 (j,-u IJ. being in the SL o6 the 4J~ 4 o6 Sec.,7.3 T.3(-,_N.-R. /S W. (Ox moxe 6utZy de6ct.ibed a6 6ottow6: ) Dated th.i-6 _ day o6 14?,v• (OWNER) State o6 Wi6 co n.6 in) ; County of St. Croix) Pet6onnattyappeaxed be6oxe -me this 9th day ob July 19 90 the above named Robert Cassellius to me known tto b.e°..-he pex4on who execute z e Joxegox:ng kn6txument and acknow.Ledged the same. ota y• u .cc, t. xoix- o'unty, My Comm. (i6 pexmantY (Expi)e6) 03-14-93 I Robert Cassellius , hexe.inbe6ore re6 exxed to• 'a,d _PumpeA, join in< the-"above agteem ent to the extent that I have e=. co'nttac wih Ownex a6 above 6tated. ` ~ (PUMPER) V DEPARTMEPtT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION H LABORr P.O. BOX 76 UMANtRA"E°LATIONS PERCOLATION TESTS (115) MADISON WI 53707 HUMAN (ILHR 83.09(1) & Chapter 145) it- ATIZSIV:-- SEZ'fT~N;-- TOWNSHIP%Mbl'AFMft,4klry; LOT NO.:BLK. NO.: SUBDIVISION NAME: F'/ • /T30 N/R f(or)W CCOUNTY: OWIWER'S/ &yl-l6 NAME: MAI N R SS: USE DATES OBSERVATIONS MADE _ ~j~b,_BEEDRMS.: COMM-~RZIAL DESCRIPTION: - TESTS: ~Res~drnce ~JNew Replace 77 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: r-GFtOUNaPReE 8DRE:S STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) EIS ®U ~U Au ®U m$ ❑U l-w ' If Per colation T e sts a re NOTreyuired~ESIGN [Floodplain, RATE: I an ~j y portion of the tested area is in the fonder s. ILHR 83.09151(u), indicate: indicate Floodplain elevation: L PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GR UNOWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK) . be, 0 7 JP 4~4/. 1. 1.33 71 RAI ' B'_ o~ BO B- tY:2 fto ~Zff Y NO 6 L B- 6 .7' L B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. p 1 1~j PERIOD PER INCH P- P - P- P- P PL -itahlx soil areas. Indicate scale or distances. Describe&I be hori- 10 0l S DEPARTMENT OF REPORT ON SOIL 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: TLOT NO.: BLK. NO.: SUBDIVISION NAME: 1/4 /T3,o N/R a ,t(or) W - COUNTY: 41 O EWS/ S NAME: MAILING ADDRESS: ~tywood e2te / 4,2 & I I/ USE DATES OBSERVATIONS MADE 13 NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: Residen54 ce ❑ New Replace t 4 RATING: S= Site suitable for system U= Site unsuitable for system l CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) os®u osZu osZu ❑s®u ®s au ;A/ 1~ )tA IV If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: Floodplain, indicate Floodplain elevation: 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 ABBRV. ON BACK.) B- ~2, 17 q7.) 11 .1 1 r B- d2 fJ0.0 D ' 9Z !2z L B- 3 c, No . o ` ,G ;'L L B- 7, d 7 .67 10 1 3 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD .-2 PERIOD PER INCH P- P- P_ 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 s 1, d~ ~cFf~ 10 0' --'.Its ~o ~hR ll ~ s~o s Q V Gr L~ 6W /o O. ~01~7`O/VI p 8r a S"a~iHoq oN TN IQ use House oaj n' bQSe/J1 ~'1T 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: 64 e, Ity S" t O ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): o 61 w Q r / S' s- CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - I' `IONS FOR COMPLETi N,_ 11- S BD - To be, a your repoi"t must iii" Comiffl2) ;E<?I (FtC3J;;Ca; 'MrTi- C iai lisp p~ , 4. A SITE 13 SUITABL HOLDING ALL L _ Y1 t ? U U i F BASED ON SOIL, Tl-- N-; 6i PL EA-"L the , ut,o _ u.. rare for writing profile "d <comi.1.___ g ' plot Plan; 7, is='i.-sKE A LEGIBLE grarn accu -tely locatiriq your test location ~g to scale is p eierred. A may I3e used if desired; 8. K4 re , ,€r hmark and vertical elevation reference point are )wn, arit: a Herat; 0, CoriipWte ciil i-te boxes as to dates, names, addresses, flood p;,a i , percola'°=>iE ~ rx€,mp- tion, if app ;.t= r 10, If the into °r. I ich as flood does not apply, place e iwe box; 11 ° Sign the t, m p' ce your c , , °;1 your certification t 12. Make legil~}le i )pies and distribu.. as required. ALL SOIL TESTO 's BE FILED WITH THE LOCAL AUTFs'~ORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Sepatates and Textures Symbols St Stone (over 10") BR Bedrock cot) - Cobble (3 - 10") SS Sandstone gi, Gravel finder 3"? L;; - Limestone Is -Sand H_ , i ligh Groundwater cs Coarse Sand PF - Percolation Rate med s - Medium Sand trti _ Well fs Fine Sand Bldg - Buildin- is Lo array Sandi > Grea rrr , sl - Sanely Loam < - Less Tha. 1 Loam Bin Brown sil Sill: Loa-:-,) BI Black si - Silt Gy - Gray `cj Clay Loam Y Yellow sc1 ,..~}dy Clay Loan) R Red sic! "I -v ",oaffl Mot Mottles sc, wl y VV with sic S gay fff - few, fine, faint CC common, coarse Pt: - mm, ! riy, medium rn d net It - )H _-It HWL - P,gh water' Six general Ei(.3lI SLi r"f$c': 'ov ea' for liquid vvaste (:i€s.:r: ~ at BM Bench M ` 'i VRP - Vertic.: Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be sul:)mitted to the appropriate; local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. ST. CROIX COUNTY k, r WISCONSIN ` ` a K -5 . ZONING OFFICE z ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 July 3, 1990 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 • Madison, WI 53707 Dear Sir: An on site investigation of the John Rassbach property, located at the SW4 of the NE4 of Section 30, T30N-R15W, Town of Glenwood, St. Croix County, revealed no suitable soils for onsite waste disposal on the property. Should you have any questions, feel free to contact this office. Sincerely, James K. Thompson Assistant Zoning Administrator cj ST. CROI X COUNTY W1 SCO NSI N Z O N I N G O F F I C E (715)386-4680 .,x. 911 Fourth Street Hudson, W7: 54016 0 w N ER P U M P E R A G R E E M E N T PLEASE BE ADVISED, That until you ate again noatijied, I wilt Wi,6 consin, ( Pumper) , 6or the putpod e o6 removing att wa.bte 6rom the danitary a ydtem to be .located on the ptoperzy and Jutute home zite .located in St. ~Ct~oix County, Wi.d con,6in, Townzhip of Gh__2Je4JJl,_"D being in the _-Sz5~ 14- o6 the ivy % o6 Sec.o23 , T.3e,) N.-R._Z~E_GI. (Ot mare 4utty de4crabed ad Jottow.a: ) Dated this day of je~~ , 19~. (OWNER) State of wibcon.6in) AS County o6 St. Croix) Perzonnattyappeated be6ote me thi.a 9th day o6 Jul 19 90 the above named Robert Cassellius , to me known to-FT-tie peraon who execute the Jotegoing indxtumen and acknowledged the Same. , f~ ota y u tc, I., toix oun y, My Comm. (iz permant) (-Exp.i,%ea) 03-14-93 I, Robert Cassellius hereinbe6ote te6etre.d to as Pumper, join in the above agreement to the extent that I have a eor.ttac**with Owner aA above .waxed. PUMPER ) 9Y~ syss~ S 15PAG:540 Document No. This space reserved for recording data 00371 HOLDING TANK AGREEMENT Agreement Date This agreement is made between the REGISTERS OFFICE + County or Local Governmental Unit I Holding Tank(s) Owner(s) T. CROIX CO•, WI `7Reed four Record (Called Municipality below) I at JUL 101990 Wis,acknowledge that application is being made for the installation of (a) holding 11 : 20 A. M tank(s) on the following property, (Provide legal land description:) • Register of Deeds Uju Return To - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats. As an inducement to the County of to issue a sanitary permit for the above described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and 146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats. 2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be collected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) (Print) I ner(s) Sig ature(s) 'S 0. SS_- I~'''-d 'J Subscribed efore me on this date: t N 0 a FT 4 Municip Official Name ( rint) I Municipal Official Signature ; A Notary Public I My con4rA kon fb1r-es:: , , Irt,, I vr~c.,... O~. Munic Titti~ ThAIVWtAlt-N in I MarC?P,,,f49F190 pu.eNS~ SBD-6123 (R. 10/85) This instrument was drafted by the Sta of Wisconsin Department of Industry, Labor and Human }3e1 ti ofl~mbin~ A parcel of land located in the Southwest Quarter (SW 1/4 b\ ' I' of the Northeast Quarter (NE 1/4) of Section 23, Townst# 4 North, Range 15 Nest, and being further described as '90aaencing at the center of the aforementioned Section 23, thence due North (assumed bearing) along the West line Ot said South:Mest Quarter (SW 1/4) of the Northeast Quarter (NE 1/4) ' 150.0 feet to the point of beginning; thence continuin dues North 180.0 feet; thence North 89° 59' East 250.7 feet; thee., South 4.53', east I M65 feet; thence South 890 59' West 2f .-O feet to the beginning. Except for a 50 foot strip adjacent to and parallel to the West edge of said parcel reser•virtg #Or;. roadway purposes. I, r; _ M 1 a• r e H z ' a ST C- 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d ~ a OWNER/BUYER _jJo k) L ROUTE/BOX NUMBER Fire Number .CITY/STATE ZIP PROPERTY LOCATION k, ~CC !4, Sectiong,23_, T,36 N, R Z,S 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 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. 0 I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ►a 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' DATE - 7 O 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. 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 ~~j SS' Location of Property . Section , Ts?ybN-R1 W Township el, Mailing Address Address of Site Subdivision Name AY 6 Lot Number Previous Owner of Property / Total Size of Parcel I to~eG Date Parcel was Created /(/Z Aee ,x Are all corners and lot lines identifiable? Yes No k Is this property being developed for resale (spec house) ? Yes No Volume and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) ceAtiby that att statements on this Bohm ane tAue to the best ob my (ouA) knowledge; that I (we) am (are) the owner. (s) o6 the pro pen ty des ch ibed in this inbo.tmati,on bonm, by vi tue ob a wa4 anty deed teco&ded in the Obbice ob the County Register ob Deeds as Document No. ; and that I (We) pnesentty own the proposed site bon the sewage dispoS .6ys em (on I (we) have obtained an easement, to nun with the above deschibed pnopenty, bon the constnucti.on ob.6aid ,system, and the dame has been duty keco&ded in the Obbice ob the County Reg.usten ob Deeds, as Document No. c`~.~` Z 1 ATURE OF OWNER SIGNATURE IOF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED DOCUMENT NO. STA•1'E BAR OF WISCONSIN FORM 3-1982 rHIS SPACE RESERVED FOR RECORDING DATA M DEED .QUIT 06PAGE205 I. 4532-_-_--- _ REGISTER'S OFFICE ST CROIX CO., WI First National Bank--of of Glenwood - • - a Fed@r-al-Banking Corporation @C or Record NOV 0 91989 quit-claims John -P-:__Ras§b_S- i---and. Coya;l: Rassbach; _••-._••-.-•_---_•-dt 8:3o A M Nusband and_wi-fe;:::as: S-urvi:vorsliip M;wi-tal:- P r -•---••-•--•---.operty spts~►of0e the following described real estate in t • Cro i X y County, Count , State of Wisconsin: RETURN TO 1st Nat'l Bank of Glenw od 204 E. Oak Street L -Glenwood City. WI 5401 Tax Parcel No: .....r~ A parcel of land located in the Southwest Quarter (SW 1/4) of the Northeast Quarter (NE 1/4) of Section 23, Township 30 North, Range 15 West, and being further described as follows: Commencing at the center of the aforementioned Section 23, thence due North (assumed bearing) along the West line of said South West Quarter (SW 1/4) of the Northeast Quarter (NE 1/4) 150.0 feet to the point of beginning; thence continuing due North 180.0 feet; thence North 890 59' East 250.7 feet; thence South 4053' east 180.65 feet; thence South 890 59' West 266.0 feet to the beginning. Except for a 50 foot strip adjacent to and parallel to the West edge of said parcel reserving for roadway purposes. F This -----_:-is not homestead property. - (is) (is not) Hated this 7th-------------------------- day of .......................................I SEAL....--------•••-..... (SEAL) * -----........--E,--.Larson, V.jce- Presi-dent. -------------•--------....---•--•---------•--------------------------(SEAL) /77 a/, (SEAL) Maxine Timm,_ Vi_ce__Pres.ident/Cashier AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN Ss. St. Croix County. authenticated this day of.._.. 19 Personally came before me this ...?th....... day of November 19.89 the above named * John E. Larson and Maxine Timm TITLE: MEMBER STATE BAR OF WISCONSIN If not GA- w----------------------------------------- authorized by § 706.06, Wis. Stats.) ss S S to me known. t~,be•thB.~i@p!f who executed the foregoin ins~trume t and'•ac~fAwledge the same. ~ C I _ THIS INSTRUMENT WAS DRAFTED BY ) ~ f John E. Larson, Vice President d_ ~ V 1. .a 3~lSr~ 1~U La S Notary Public . County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission *W Wmanelt (If not, state expiration are not necessary.) Mar~C4r, 14 'a''a 93 date: f. N•+„u••~'- 19- ) •Nanes of persons signing in any capacity should be typed or printed below their signatures. STATE FORM No. 3 WISCONSIN S FLC fY1111ar Stock No. 13003 FORM NO. 985-A r' ~14_C,~Y1111M ~ Stock No. 26273 f 2 N MAP OF SURVEY BEING A PART OF THE SOUTHWEST 114 OF THE NORTHEAST 114 OF SECTION 23, T. 30 N., R. 15 W., TOWN OF GLENWOOD , ST. CROIX COUNTY, WISCONSIN. NORTH 1/4 CORNER 23-30-15 ( SET P.K. NAIL PER TIE SHEET OF RECORD NORTH IS REFERENCED TO THE WEST LINE OF THE NORTHEAST 114, WHICH IS ASSUMED TO BEAR DUE NORTH. N Os 59 O I P,li Z92 L AR; Ol N 1141B"510.00 BY Q u+. 14 1 N89459=00°E 1041 yl N t 200.70 =1 U! } of z XI w 1 = _ 2 O O M Wt of I J d °o VOL. 856-PG.205 10 M zl 0 37503S.F./O.66AC. ° %nin of JI co 0~ 01 ►W-i w =i j m _ q ~I ql h, al al I JI z= 1 216.00' J _ S89°59,-00°W I ~ S9os UNPIzATTEQ LA QNS Z - -06 OO.t BY QTHffRS W °O °T~ O O ~ 11 CENTER I14 CORNER 23- 30-15 FOUND I ° IRON PIPE OF RECORD LEGEND PREPARED FOR: .....GOVERNMENT CORNER (AS NOTED) MR. S MRS. JOHN RASSBACH 0„,,,,,,FOUND I V4" IRON PIPE 106 OAK STREET „,,,,SET 3/4°x 24302E BOD WEIGHING GLENWOOD CITY, WIS. 54013 L.ILINEAL FT. ( ).....RECORDED AS ~•,,,,,SEPTIC GRAPHIC SCALE: 1 100' F- ism O 50 100 200 300 1 , STEVEN J. WAAK , REGISTERED WISCONSIN LAND SURVEYOR, p~~u~\~lptttlt111NUU~i~q CERTIFY HEREBY THAT THIS SURVEY CORRECT AND C 0 ACCURATE TO THE BEST OF MY KNOWLEDGE AND BELIEF. STEVEN J. ; WAAK .<< • S-1610 ° STEVEN J AK R. S. / y` ; MENOMONIE DATED THIS DAY OF 1990. ~i,~"[/O'•.•,,,. J~y s_u CEDAR CORPORATION 604 WILSON AVE. MENOMONIE, WIS. 54751