HomeMy WebLinkAbout024-1013-70-000
O
a 0 0 609
a
h C c I c
M O O
o j c
N O L
l~ O c M
d O co
0 41
E I .y m e
o Z` y
O L y' ter' E
y +O+
CL:E _0
E o T
~ °?--'ppNpC Nay
N
N 0
d w
=w a
p7 w lop N t
y ~tl1 C y ~ 3
N y Y ~rC d
7
O 00 U O 0d T L
Z
c Z € CL c c
a E m
li o o y Ern a o o ~o
3 co
Q z!oE E ¢ v°c~
M M
N N
r
CL
z o o
v
aoHZ am 1 am
0
O G
c C7 m ICU
O z :t c ? V
r m ~y y 'ZZ
o Z
N H rn o Z 7 aci o i
c E -a c E
N M -O ~ M
N N N O)
O a w y 2
O C y N
Q z° co z o z° m z
Z
_0 '0
N z
y c c
d
c E N LO A E
N
r
a . N
~O I'', lC) d d O pf 0 CL
0
w CO
O C CO C:
0 .2
y 00 ~r ar _0 N N > Grr 00 ra E y (p N
d 2 O O O
E 0 3 3 3 7 3 3 3 a O N
o o 0 0 z E 0 0 0 z
• ►v E a CL a I E a a a U
IL _
7 O N~ = aMD co N O
U1 J C) N rn rn z
a~
~ C O O N O _ O O
In co U 0 00 E
U 0 0 N O O O O N O
a I p ml c a
0) co (a p n d ~ N `r M y N N
C O
c co y g ¢ in co z v ¢ to Q 0 V)
otS N N O f3N H
O ! h C y C
.w pO O E `O C E LO
9 =3 0 CD
Q p m N f0 O
O p7 O a. o N C A O O
U 'e C p C -O N ao O O- O "O N
N
n C y p3 2 m N m y y E my
c c m tv c °0 lL pp N O
O 7 pp
t'. 0 co y I ~ p y Z .d -0 O I p M U) N Z~ C N
2 E o N N p Q 3 M LO 4)
o 'w c
o E m r
• Q o a m c o z 2 I- cn N o Z? I- cn
y
r \ #6 = = €
v €
4) (L
IL
• t o m .V I 4) m e p+ /p c
r`IV a o 2 r c c c 3 c '
A to U O o
0 a N 0
AS BUILT SANITARY SYSTEM REPORT
SEC . N
OWNER C~rt~ Z4,: T0WP~
ADDRESS-,61Qiw,1;''Di' ST. CROIX COUNTY, WISCONSIN.
SUBDIVISION f~ LOT /.~"TJ LOT SIZE /4
PLAN VIEW 0 C .IC~ -7~
Distances and di ensions to meet requirements of H63
'GOell alas y9Of 01,-//1e(7 Q y--1oi3''2
SHOW EVERYTHING WITHIN 100 FEET OF SYSTN
rc e
S~
y x0
NoP
I ,
W" I
~,I b I I di at N r h rr w
BENCHMARK: (Permanent reference Point) Describe:
Elevation of vertical reference point: -ley), 1:f) Slope at site: to /G>
~~C~(_~ G'~S
SEPTIC TANK: Manufacturer: S Liquid Capacity:
Number of rings on cover Tank manhole cover elevation
Tank Inlet Elevation: Tank Outlet Elevation:
I
PUMP CHAMBER
Manufacturer: /V~ N ber of gallons
Number of gal. pump set for a cycle gallons; Total capacity of
distribution lines gallon: size of mp_~74 head;
gallon per minute horsepower _;brand name of pump
and model number ;
Type of warning device
HOLDING TANK: Manufacturer Number of gallons
Elevation of manhole cover
Type of warning device
SEEPAGE PIT SIZE; A1 Number of pits_ feet diameter
feet liquid depth A14 - seepage pit inlet pipe-elevation
bottom of seepage pit elevation feet. r
SEEPAGE BED SIZE: number of lines width iZ , length PCO the depth
GESEPATRENCH: width__ length
-47
PERCOLATION RATE AREA REQUIRED 9~ab AREA AS BUILT9
Q INSPECTOR
DATED PLUMBER ON JOB
LICENSE NUMBER ~p qj QZ
DEPARLMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
;_ABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 153707
EXCONVENTIONAL ❑ALTERNATIVE Ste a Plan ID. Number:
❑ Holding Tank El In-Ground Pressure El Mound (If assigned)
44
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INS EC ION DA E:
Zwald, Greg RR# 1, Hammond, WI 54015
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
NW NW, Sec. 8, T28N-R17W, Pleasant Valley Township
Name of Plumber: MP/MPRSW No. County: Sanitary Permit Number:
Everett Boldt 4489 St. Croix 34830
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: JT INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKJ:N
- G COVER
{ ~j' ( ~J PROVIDED: PROVDED:
V- / 0 +'V~i ` ✓,l Z- ❑YES ❑NO ❑YES ❑NO
BEDDING: VENT DIA : VENT MATL.: HIGH WAT R NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
/ I ALARM FEET FROM vV LINE: AIR I L
❑YES ❑NO ❑ NO NEAREST N
DOSING CHAMBER:
MANUFACTURER: BEDDING. ILIOUID CAPACITY. PU P ODE L. PUMP/SIPHON MA NUFACTURER. WAR G LABE CKI G COVER
PRO D: PRO DED:
❑YES ❑NO Y O S ❑NO
GALLONS PER CYCLE: PU A C ROLS OPERATIONAL: NUMBER OF PROP E RT LL BUI ING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) Y S ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil of re a the d th of plowing H uIAMErER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a re, construction shall cease until LFORCE
the soil is dry enough to continue.) AIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGT
) 1 NO, OF H TRENCH IDISTR PIPE SPACING 7NO, PIT NSIDE LIO TH:
DIMENSIONS srv~J GRAVEL D EPTH FILL DEPDISTR. IPE DISTR PIPE DISTR. PIPE ATERIAL: I RNUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIP ABOVE C ERELEVINLET ELEV NDE FEET FROM LI ~ 0 AIR T:
2 3./7 'o NEAREST-s/'
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the ture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: triund s t m mak certain that it ON REVERSE SIDE. SHOW ELEVA-
m ets th cr ria edium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE JPERMANENT MARKERS: JOBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED D T PS IL. SODDED SEEDED. MULCHED:
CENTER. EDGES:
❑YES ❑NO ❑YES ❑NO [:]YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
NG: GRAVEL DEPTH BEL IPE. FILL DEPTH ABOVE COVER.
WIDTH: LENGTH. NO. OF•, LATERAL 71
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD STR. PIP ANIFO ATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.. ELEV.: DIA.. EV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED C E LY COVER"MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS,
ES NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: OF ROPERTY WELL: BUILDING:
~ FEET FROM
❑ M
~ YES KNO -]YES ❑NO INEARNUMBER
EST
00,
6(~~
OL
VOIN
00
Retal n county flle for audit.
em on
?,ec,wSSidEr
1 a
400000~ ~,o
SIGNATU TITLE.
DILHR SBD 6710 (R. 01/82)
DEPARTMENT OF .;APPLICATION ~ SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
'LABOR AND ; PERMIT P.O. BOX 7969
HUMAN RELATIONS PL13 67 MADISON WI 53707
Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master .
Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be
included.
Propert O Mailing A dress:
z W IC' LQ IQMvY►Ow~~ ~t S
Property Location: Ab 7ph44Wge or Township: County:
11/'W11, /V'WIS g IT A? NiR / 111, (or) W PiLe09s w f 1~1,tHe CRoi' x
Lot Number: Blk No:: Subdivision Name: Neares Road, Lake or Landmark: State Plan I.D. Number:
w/ /Vg M~ /J o V T- K Z (If assigned) ,,.VA
TYPE OF BUILDING v
r
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* - - Bedroo s:
1 or 2 Family *State Approval Required. ~Z
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE I ALL TION MENT (Specify)
SEPTIC TANK CAPACITY 600 OWe. X X
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER A
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): 29 New ❑ Replacement ❑ Experimental ® Seepage Bed ❑ Seepage Pit
O 9~p Q ❑ Alternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
W Private ❑ Joint ❑ Public 010OL14 be U^4CA se "AI L F.19Rr"5 .1~C_-
I, the undersigned, hereby assume responsibility for ins Ilation of the private sewage system shown on the attached plans. b
Name of Plumber: S' atur MP/MPRSW No.: Phone Number:
G✓eje.e-'~ off. It-ne 414 (7/f C-N-337
Plum Address: Nam~ey~ Designer.
Chi's e.~ ~ i3o Lcj
COUNTY/DEPARTMENT USE ONLY a
Signatur of Issuing Agent: a* v~ Date:
APPROVED Sanitary Permit Number:
19
/ Q~ ❑ DISAPPROVED
Reason for Disapproval:
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to to county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHRSBD-6398 (R.07/81)
Form - S T C 100
,Owner of Property- Gjee ' ,.~ct//~►Gq/
Location of Property ,N10 It- /NW Section, ao JAI? N R~W
Township
Mailing Address rq "-7 e~j a ,4 (Ji•S
Subdivision Name
Lot Number p [ 1
Previous Owner of Property 1t0A~'f lr . ~1Ja
Total Size of Parcel 160 Ac- je r s
Date Parcel Was Created 5/'
Are all corners identifiable? Yes )iC, No
Include with this application one of the following.
.Certified Survey Map
.Deed
.Land Contract. or
.Other l:agal Document which describes the property
PROPERTY OWNER CERTIFICATION 1
1 (We) certify that all statements on this form are true to the best of my (our)
knowledge; that l (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty dead recorded in the Office of the
County Register of Deeds as Document No. 5 and that I (we) vp L, La
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 orrded in the Office
of the County Register of Deeds, aS Document No.~~
sli
SIGN RE O OWNER SIGNATURE OF CO ER (IF APPLICABLE)
r
DATE SIGNED DATE SIGNED
I up M NT NO. rSTATE BAR OF WISCONSIN FORM 3-1962 jj THIS SPACE RESERVED FOR RECORDING DATA ~I
11, QUIT CLAIM DEED jj
Robe-r-t---C- Zx"ld.-and--Mar-y.-.A_.....Zwa Id- I;
husband _.and- _wife.__and._each _in.__thei.r------------------
.oTm_righr - ----------------------------------I;
quit-claims to BoIIk' z,...Inc_.__.._.. I Ii
................................a..Wiacansil:l.-c-orp-or.ati._on..... I
i
the following described real estate in St . Croix . County,
State of Wisconsin: JRETURN TO
I
The West 975 feet of the North 940 feet-
of the Northwest Quarter of the Northwest ~
Quarter of Section Eight (8) Township Tax Parcel No: ~...!.~.~.25 3)_
i Twenty-eight (28) North Range Seventeen
(17) West, subject to all easements, restrictions and
rights of way of record.
This deed is given for purposes of correcting an error in legal !
description on that certain deed by and between the parties dated
April 1, 1979 and recorded October 15, 1979 in Volume 602 of j Records at Page 508 as document no. 360443. it
sTt ~G L r~ ~w~N1~ S~ 8
i
II
l
I'
~I
I.
1'.
i
li
II
i
I~
'i
This is..not_.-. homestead property.
(is) (is not)
Dated this ll.th day of - .May
19..$.3..
I ;
.(SEAL) (SEAL)
Robert C: ,,~wald f
- - - - -
nn . i
-(SEAL) (SEAL) I`
Mary Zwal
I
AUTHENTICATION ACKNOWLUDGMENT I
Signature(s) STATE OF WISCONSIN
I!
ss.
S.t.__._CrD1X...._.._....County.
authenticated this
day of 19 Personally came before me this Z-Lth--day of
..1`ay , 19...83- the above named
Robe.xt---C..... Zwald__&_.Marv •.A.__.Zwald-
TITLE: MEMBER STATE BAR OF WISCONSIN I'
not-
authori-_d by § 706.06, Wis. Stats.)
to me known to be the person _S who executed the
foregoi~gLitlt JJ acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY NcApry Public - St. Croix co., Wis.
ROBERT J. RICHARDSON Mx.C0II%Mtal011 AzOmAo.4.-1 - -
Attdrney..at--Laid-------------------- - _._.--4-I;c-e- - = .
Spring Valley,--WI...-.5.47.67-------- - Notary Public __c:*_~~ - -county, Wis.
(Signatures may be authenticated or acknowledged. Both MC Commission is permanent. (If not, state expiration
are not necessary.) date: Ls 19
•Names of persons signing in any capacity should be typed or printed below their signatures.
rr:% Ti: n:~tt of wlscoxslN
M G Miller Comperry~ FORM No. 3 - 1982 Stock No. 13003
BOMAZ FARM INC.
wl 4w
ROBERT C., GREG, ROBERT F. ZWALD
Route 1
HAMMOND, WISCONSIN 54015
- .4
/ArX
a4l 9~A4~
A'lh A, tz~
6
l
COLLEEN EVENSON
Notary Public - St. Croix Co.. Wig,
, i,-< + 1 _6 ~ My Commission Expires Dec. 4. 1983
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY BUILDINGS
tNDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115j P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
L I N:~ SEMON:' TOWNSHIP/M10MlFdl "kNMW- OT NO.: LK. NO.: SUBDIVISION NAME:
k 1Va/4 00 /T MR #or) III 101,e- A S C? n/ -r- VA t. ~ a
r` COUNTY: OWPIER'S/BUYER'S'NAME: MAILING ADDRESS:
eSf.~Rr~~x Re ;'WRLei /~A/vImoMgf , LJI'S
'X RATES OBSERVATIONS MARE
NO. B DR q MMERCIAL DESCRIPTION: ON : 1PERCOLATION S S:
/C2 _
A'
(Residence xNew El Replace
?CA
RATING: S= Site suitable for system U- Site unsuitable for system
rNs ENTINRL: MOU : ~R : S TEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:(optional)
ONUU Ns S 0 U EIS
kz- E
Y . , QESIGN RATE: . ' Fl If Percolation Tests are NOT required I
if of i any portion the tested area is the
under s.H63.09(5)(b), indicate: IL oodplain, indis cate Floodplain elevation;
PROFILE DESCRIPTIONS . 10A e 7 NC. Sa I L x
' BORING TOTAL DE TH T GROUP DWATER-I HES CHARACTER SOIL WITH THICKNESS, COLOR, EXTURE, AND DEPTH
NUMBER ELEVATION OBSERVED TO BE ROCK IF OBSERVED (SEE ABBRV, ON SACK.)'
B- 1 . ~r } ' ' " ► , . 5"'1. 16 ' 6,v S.'L /a 1 $ ✓ Sit.
r~ L{rl N er J l r rV f
Q
-es'" Ps W/S7-RfzAK'1 80V j%:
B. " (0.1) I 9q.3 / r / t E. .St C rV "S! L Q
f 1 r rg P/
- , - f w, 13 L 1r, L. /6" of r; f - 1 .
8- 9 6.0 9 > 6
PERCOLATION TESTS.
DEPTH WATER IN HOLE TEST IM DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTERSWELLING INTERVAL-MIN. P 'I D 1 OFFA 105 PER INCH 13 P- 1 3,4' a 0 .3 0
P d~ O a
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•
xontal 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 ` C,ooat4- u 9 x
y alfi
46
1po~o -re'
A l
E
~Ideic A OR
44,
9'e e~
oiR.! S.
y,3
,
(
T -f L , ' , I
'P- I w. ~`.T~t K1R. 4 d N 's
,
00, A-
loc,
b I f
f~jr
%
Y
s
i
77
i '
1
~ I S
{
a
71.
C' A 40
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:
ADDRESS: , CERTIFICATION UMBER: ~171 HONE NUMBER optional):
~~A t,. cl c.~ 1 t S 0 S~ 5- G Fq° 13
CS TUBE:
;Ott
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395(R.02/82) OVER -
~,7 i _ ____r___ a k- s .r~s:„~. r -,-ay-•-~2ra'~P"`y kT17 tt
• _6a M.
J6 tf
"f+ 9 D q
V, bol
41
CIO
t `
r s d
13
74
• ° o -+C !cif h
w UO
SAFETY & BU<DNG
DEPR~T~T OF INDUSTRY, INSPECTION REPORT FOR
-1r LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
DISON WI 3707 State Plan I.D. Number:
lj
~t~1p, NW 1W ,Sec.8 T28-Rl CONVENTIONAL
W 2' 4' ❑ ALTERATIVE (If assigned)
Town of Pleasant V leyX
Holding Tank ❑ In-Ground Pressure ❑ Mound
R Z INSPECTION DATE:
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER:
Bob Zwald Jr. Co. Rd. Z Hammond WI 54015 J",C4.. J, '15P9,0
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT EV.: ST REF. PT. ELEV.:
:S /
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Dale E. Hudson 6629 St. C 1 135538
SEPTIC TANK/Htl1c'D}11iK 2' ott vCE C'CV2 .
MANUFACTURER: V LIQUID CAPACITY: TANK INLET EL ANK OUTLET V.: WARNING LABEL LOCKING COVE~~
PROVIDED: PROVIDED:
9Y c~a2 97~ • ( YES ❑ NO ❑ YES NO
H
BEDDING: Y6N~ DIA.: d t ! ATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: AER N OFRIES
C i. C ALARM: FEET FROM LINE: i
❑ YES CONO~ 5/ 1 ❑ 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 ROILS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET`
PUMP ON AND OFF A❑ YES 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: o/` s erv
WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH TRENCHES: MTATERIAL: PIT DEPTH:
DIMENSIONS /1? 30 Co /
GRAVEL DEPTH FDEPTH DISTR. PIPE DISTR. IPE DISTR. PIPE M T a/0 PERIAL,,~ k N PIPES: DISTR. FEET NUMBER FROM OF LINE: PROPERTY WELL: BUILDING: VENT TO FRESH
T. BELOW PIPF~: COVER ELEpV. INLET: ~LEV. END: ~ i AIR INLET:
rn /
NEAREST-
MOUND SYSTEM:
Mound site plowed perpendicular o. 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:
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 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:
d d ❑ YES ❑ NO ❑ YES ❑ NO NEAREST
'7 0%
d-f-4 - t o 1 4'0 -060
U.001 Ct~ tt l_ 2 - 4
in county file for audit.
115 Sketch System on t
Reverse Side. SIGNAT E: TITLE:
SBD-6710 (R. 06/88)
TF' ILHR SANITARY PERMIT APPLICATION MOO o
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
Ezc: -MMEMOMB 5_~,
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑
8% x 11 inches in size. c isi t r ous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFOR TION.
PROPERTY OWNER 0 jVCTkz,~d1,A1&) ROPERTY LOCATION
O b ~c ,7/C~' J, ~ ; S ~7 T N, R /7 0 (or
PROPERTY OWNER'S MAILING ADD SS LOT # BLOCK #
CITY, STATE / ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBE ~f
3- 7rs ?Qf - 777/
crrn1"c) ~ all , 5
11. TYPE OF BUILDING: Check one CITY NEAREST ROAD n
C~-/►Y,
( ) State Owned ❑ VILLAGE /k, y
❑ Public zl or 2 Fam. Dwelling-# of bedrooms AR AX NUMBER(S) na _
111. BUILDING USE: (If building type is public, check all that apply) C3 /q&f/(/ 3--
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"o y one in line A. eck line B if applicable)
A) 1.0 New 2.,Z Replacement 3. Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
system System Tank Only Existing System Existing System
B) El A Sanitary Per 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
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
S~ 94 ~ Q~ o 962,31 Feet 92,-5 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New F-xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank 2_L, ~G23 ( l e e
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) MP/MPRSW No.: Business Phone Number:
~ 1e Z_, i c~.~ 4,?l x.3 781
Plumber's Address (Street, City, State, Zip Code):
IX. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing ent signatur tam
Approved ❑ Owner Given Initial Surcharge Fee)
Adverse D rmin i
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 'arid mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
11. 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'f 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; dose 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)
1
•
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 O ZG
I A-/
Location of property1L)1 1/4 A✓/.(l 1/4, Section , T N-R j 7 W
Township
Mailing address Ctv `~C 1,64 57
Address of site ~ am e,
Subdivision name
__Nr7
Lot number /117
Previous owner of property
Total size of parcel XG
Date parcel was created _
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)? Yes _N0
Volume b(,a and Page Number _g ✓6z as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. ':?&6 -x(13_.; 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 QU
(4 4~
11) C wr ;5( ( )
t J'~
Signature of er Si nat e -of wner (If Applicable)
Date of Signature Date of Signature
r_ -
b.'
71
LI~IAAW, sad Magg A' 1"14.
a-' eanh their cae-ap#
Sr Ptb
lit state is G!~itr.:
'the Sm-thosot
r
Aimp ` Mira 7)`%wt.
TM
tutee'>cae Paratim equal to the am ddt o9t .
3", r
a3f~D C ~ 14
n
Y r
ti
y~
Klz`
°A d~q' of ~tdr1,:: ~ ~ err;
MA"t
w "Y~V`
(WAIL)
mmid
~~IMMIY DUI w IwA4/
tTHiiCAtQN : A€KIiOML
7,771
sa i -aw ibis._ lst_s STATE OF WNCMSiNf:
19':.
Pe 4* domw wlw
'8m o,r WISCOli$IN $ ~
~i:Abr iMis..Stats.) `sfi ~r
y ; :r
9fq
by
to we k1f wwf to of t~! v .
t a x
try `pt ackaa.~1 $otf% No
fa~-
W 1 'RSr L A y. ~ f a Y ''6v
STATE BAR OF WISCONSIN FORK a•--1981 TN19 sp G. w70 }0.=aw~.y~rT- k~'f7
OW CLAW DEiEO r
var. Frf 438
REGISTERS OFFICE.
' _a . Inc.,
1
_a Mi>,cQneiipt Corporation ST. Citax CO.,°.1NIL
Rac'd. for Rvs ord this- Mb
tas to Robert C. Zwald and Mary A. Zwald, c;c, c; May D. JqZ
„
.husband and wife as tenants in common
$-4 2.45 p
luwma described real estate in St. Croix. County,
of Wisconsin:
West 21 acres of the Northwest
Quarter -
°the Northwest Quarter (Nwk of Nwk) of
tion Eight (8) Township Twenty-eight Tax Parcel No:.77.• 25. Q
j North Range Seventeen (17) West, subject 5
>all easements, restrictions and rights of way of record.
s deed is given for purposes of correcting an error in legal
cription on that certain deed by and between the parties dated
it 1, 1979 and recorded October 15, 1979 in Volume 602 of Recorda '
page 508 as document no. 360443.
q
: ~.i.. _ A
x,
5 t~
. Thl, is not hontesrxad property.
((IS) t is not
;x
141tv't this 11th da) May '19 83
BOMAZ INC.
t ~I•:A 1.1 / y nL r rr/l;s (SEAL)
By : C. eizo V r. C . Zwald, President V'
IMF:.\I.r ~J~tt..~
By : Mary 'A:. Z ld, SecreIrv t
AUTHENTICATION
ACKNOWLEDGMENT
Signature(s) •:\'f t: UF' R'7U.tiS IN
'1'
'
- ss ~
St Croix
authentwated tt;i- ua~ of 1' 1.1-th . day of
cr .;.:1:.. car .o h, + rc ri+i this
14ay is .83 the above nab.
('report/ C. Zwald and Yary_ A. 144.0 `
TITLE' N1F:\fYF'1 1.: \ is
t1i no'
}
ILJa lll:i_I n 3 who evc-pted the
/~i,PiK6+~u CI u.~ t:.bu~sic,l~e the ,acre.
ROBERT J. RI CHARDSON
Attorney it Law Rt'R, Val;l,ey W~ 5!767 b: t ,tit,, W;,.
1 t' \ u I,r f nt 1 not. -tat„ expiration t
u 2 -
19C 1wi'Nr Co1nP~MUV^il + ~ t s +.,R „1' q 1. ,,~.r~ 1_ ~~~r I%
03'+f , 41K,~ 1 Stock No. 13100
H
G
H
9
r
S T C- 105 r"
H
SEPTIC TANK MAINTENANCE AGREEMENT Ho
St. Croix County z
t7
a
OWNER/BUYER IR zIcIQ/~s
ROUTE/BOX NUMBER Rel-71711)z / -kW Fire Number r
CITY/STATE rj, ZIP
PROPERTY LOCATION:Ij~ c,I Z, Section i T N, R_ W,
14
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 pumyer. 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. yo
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- ro
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County 'honing Office within 30 days
of the three year expiration date. ! QQ
SIGNED°
DATE
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.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION
INDUSTRY,' G P.O. BOX 7969
.LABOR AND PERCOLATION TESTS (115) MADISON W153707
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATI N:N SECTION: TOWNSHIP/MUNICIPALITY: LOTNO.:BLK.NO.JSUBDI VISION N ME:
j f;
'/rf74 l`e 41/~ ~
/T~gN/R ! ~1(or
COUNTY: OWNER'S BUYER'S NAM MAIL NG ADDRESS:
-~7 r C. y'a i ZuJ CJ , a i'
USE DATES OBSERVATIONS MADE
STS:
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILEDES T S: PERCOLATIONTE
Residence 3 ❑ New Replace 3' QO = y- 9O
RATING: S= Site suitable for system U- Site unsuitable for system
CONVENTI NAL: MOUND: IN-GROUND-PR RE: TIS TEM-IN-FILL HOLDING fil RECOMMENDED SYSTEM:(optional)
$ ❑U 0 N S ❑U MU ❑ S o✓J veo ,aIf Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: 1 lz~ I Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN. ELEVATION OBSERVED T. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
10
B-3 Fo 9Z, 1, 7
B-
13-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P_ r z"9~ 3o a
'ok
P_ Z_ -35 OA e. -30
P- 3 2 20
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
1 , i L~1.L a
1 I ,
i I
i
1
1 ~ ~ ~ i lII 1 I
1 I 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 COMPLETED ON:
le '17
ADDRESS: ,y CERTIFICATION NUMBER: PHONE NUMBER (optional):
~~s- X06
z6 T%' l3
CST SI ^^AT~URE:
C~
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
_-J
a
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 ~
To be a complete and accurate soil test, your report must include:
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
3. 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 appropriate;
10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY 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 - Sand HGW - High Groundwater
cs - Coarse Sand Perc - Percolation Rate
rned s - Medium Sand W - Well
fs - Fine Sand Bldg - Building
Is - Loamy Sand > Greater Than
*sl - Sandy Loam < - Less Than
*1 - Loam Bn - Brown
*sil - Silt Loam BI Black
si - Silt Gy - Gray
*cl - Clay Loam Y - Yellow
scl - Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot - Mottles
sc - Sandy Clay w/ with
sic - Silty Clay fff - few, fine, faint
*c - Clay cc - common, coarse
pt Peat rnm - Many, medium
rn - Muck d - distinct
p prominent
HWL - High water level,
Six general soil textures surface water
for liquid waste disposal BM - Bench Mark
VRP Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in securirig,! -Mitary permit. The county or the Department may request
verification of this soil test in the fick] pric, ;permit: issuance. A complete set of plans for the private
sewage system and a permit application muse 0 submitted to the appropriate local authority in order to
cat>tain r -rcit. The sanitary permit mri ~ ti 3nr1 ;,aste~l pr for tv the Starr of any construction.
r`-
1v? (1/~
v 1 ~ 'v
h ~ 3 ~ N M
a~ ~ h t ~ M
00
3 p a a a ~
a H .7
N O ~1 0 ~
Q v Aell
TIN
421
10,
~ a rl
° o °eoo v ~
\ D lp O v ~ ~ ~M
e.M App° ~ Q~
`1 U