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HomeMy WebLinkAbout030-2055-30-000 o y ate) oo ) q p °u> p ova Oq @ 0. O CO f6 X C. C (p n 3 ca co .0 ~ c0 ~ N O y N I N o a~i N ~ w c E a) 0:6 ~E cm L M LL C 0 0 3 0 0 Q0 0 C= I 0 O U j y CU C. C mlL_Q L C ID- a) C CL M C •Q 0 N C C M= OM a(9 F- SM O QO 0) C. . - co o w E co C:) CD N E O c) 0) oo m H lO w chi E p~ (n (m r CL a) ZN amp c 3 a) E o O O - O 0) co Y a (I Z y Y C EE Z .O C C ; E w a) f6 0 T C O N w E O C IL C y -0 f0 U LL N p E U O O N ON~0 _m o' o Eooac N (D O N 'O N N M I- .2 d ~o d . M-a d oi v~ E i a~ I U I 3 M a M III Z N ~ N N Z 0 00 d T E D Z 0 CL m a m Cl) N 1- U) O C U U O Z d' c c a0i Z d I O ~ a ~ o CD I? I E c E -o m O Q 0-1 a) N W (1) C a) I U) • 0) U) L_ m CL (6 C. O a a) C -0 U) Z Z m Z Z 6 z N 0 N a a`) w E £ N ~~yy W v m 0 C) CL C14 CL a) W d a) w a0 d 4' 0 a) p 0 0 > c c a L Y G G a QI n N N :3 m C,4 N co 0 1.- 0 0 0 O x 0 0 0 d N Z O O • ►r,~ a a a o a a a a _ o 0 o 0 m 0 o W 0) 0) 0 N J U 0) rn Z rn z "0 ~V L F- O N O O_ I[1'~y ` 0 F- 00 C) L N E { L O O = i C) 0 m CL r- -0 N a) U) O 04 Q p N 7 w I CD 4) N 3 o o c 3 to c a c a oo M 0 xS o a 3 ° IL) a rn o O o I- C W N C C U d o o C? Q) U') 'n a a m E U) rea C ,n o 0 0 c co E a) N N N '+r o N y 2 C O 00 ~I N M M O N O E .C L O 0 N y co O - ~ o m O O U • L' co N U) CO 0 N 2 Z U` O Z N Z F- o 4 C q w E E EL s 4) a , iL:a~ E •c 0 c L 0 Gu O t0 C 3 w 0 3 w O A Ua iIOv~U 0 mU Parcel 030-2055-80-000 05/02/2005 05:15 PM PAGE 10F1 Alt. Parcel 27.30.20.548 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * RYAN, BARBARA A BARBARA A RYAN 1364 STATE ST HOULTON WI 54082 I Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1364 STATE ST SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 0.590 Plat: 2111-HOULTON SEC 27 T30N R20W LOT 4 BLK 5 A/K/A CSM Block/Condo Bldg: 5 LOT 4 _jktAG 52 ALSO N 12' TO THAT PT OF LOT1 BLK 5 DESC AS COM SE COR LOT 1; TH Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) N 100'; TH W = TO S LN 133'; TH S 100'; 27-30N-20W TH E TO POB otes: Parcel History: 1- l ']f Date Doc # Vol/Page Type 07/23/1997 1080/566 QC 07/23/1997 1080/565 WD 07/23/1997 728/498 2004 SUMMARY Bill M Fair Market Value: Assessed with: 6181 177,100 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.590 72,000 102,200 174,200 NO Totals for 2004: General Property 0.590 72,000 102,200 174,200 Woodland 0.000 0 0 Totals for 2003: General Property 0.590 30,600 77,500 108,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 133 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 030-2055-30-000 02/14/2005 12:55 PM PAGE 1 OF 1 Alt. Parcel 27.30.20.54413 030 - TOWN OF SAINT JOSEPH Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * GILLSTROM, MARY MARY GILLSTROM 1341 15TH ST HOULTON WI 54082 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 29 CHURCH ST SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 0.760 Plat: 2111-HOULTON SEC 27 T30N R20W LOT 8 BLK 4 AS IN VOL Block/Condo Bldg: 4 LOT 8 298 PAGE 268 ORD VIL HOULTON Tract(s): (Sec-Twn-Rng 401/4 1601/4) 27-30N-20W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 876/527 07/23/1997 821/492 2004 SUMMARY Bill Fair Market Value: Assessed with: 6176 123,300 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.760 50,000 71,300 121,300 NO Totals for 2004: General Property 0.760 50,000 71,300 121,300 Woodland 0.000 0 0 Totals for 2003: General Property 0.760 25,600 58,600 84,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. RV T 399 N-Rc t7 W ADDRESS C/464 ew ST-. ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to rivet requirements of I•LHR 83 SHOW EVERtIHING WITHIN 100 FEET OF SYSTEM Pv/E ~,cf✓, iooc' f~f ~l~ FVT --1 / I I i P. X /Qesf/J~nic~ 3 7 3 ; 3 GJlic Dvef 115-0, W NTH v "~'.t ~ ° /C~o o ~pcc Stonc TiFNK OAM- 9O~ .~4v(o Sw6EP .~~OP ~~N1O -010CY Wd41. *H 40,PE401'SrAMIt INDICATE NORTH ARROW n/o Scams. BENCHMARK: Describe the vertical reference point used IAJ 00wA~t Elevation of vertical reference point: «✓.i~' Proposed slope at site: 7 SEPTIC TANK: Manufacturer: GJi~sE.Q Liquid Capacity: /000 6;'*1- Number of rings used: Tank manhole cover elevation: 103-17 Tank Inlet Elevation:/00.4;,,9' Tank Outlet Elevation: /00„ 3T Number of feet from nearest Road: Front 10 Side,aRear, O feet .From nearest property line Front 10Side ,&ear,0 '~'0 feet Number of fee, from: well building: Q1 (Include this information of the ebove plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE • 4r PUMP CHAMBER Manufacturer: Liquid Capacity: ' Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: G;.-V ~lo Trench:. Width: I- r' Lenith: 39' Number of Lines: 3 Area Built: Fill depth to top of pipe: - S VE .4~E Number of feet from nearest property line: Front, O Side, O Rear,--Pt. Number of feet from well: 7/' Number of feet from building: V/• (Include distances on plot plan).-9•~, SEEPAGE PIT f S£A,,MEST 'TANK dur~sr ESE ✓ 9Y-G S~ Size: ,13CO6v-,YA- Number of pits: / Diameter: Liquid depth: Sa Bottom of seepage pit elevation: _ r7s Area Built: O r7 Sd'. Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: 2"LLZ2Q Plumber on job: License Number: 3 3/84:mj INDOS DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS ` INDISSTRY, C DIVISION LABOR AN P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 3707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/ +61PA4=I+Y: LOT NO.:BLK. NO. SUBDIVISION NAME: s,E Ilew/ /T o N/R of (o t'loxfflow COUNTY: OWNER'S/BUYER'S SE. MAILING ADDRESS: - i T 11 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: ❑Residence ❑New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ~S ❑U DS ❑U [:]S DU JS ❑U EIS ❑U If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: CLASS l LFloodplain, indicate Floodplain elevation: fT PROFILE DESCRIPTIONS BORING TOTAL -DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH W, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) a- 3 ' N 6- B- B- Bpp- P- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD( PERIOD2 PER1003 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 _ „ wr rLoo2 _ I E Of XS1L7Z<A L ZZ -2.,.7 E t z t t E t I ~ E E , t 2 , [ _ a_.e... a .i.. f ° t [ } 1, 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: /t v 1V 1V ^.1 Ale ADDRESS: CERTIFICATION N MBER: HONE NUMBER (optional): CST SI TURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester, DILHR-SBD-6395 (R. 02/82) - OVER - L 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 roust clearly indicate whether this is a residence or commercial project; 1 MAXIMUM numb - If bedrooms or commercial use planned; 4. Is this a new or s ent system; 5. Complete the su,t ,v rating boxes. A SITE [S SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 0. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test .cac ns. Drawing to scale is preferred. A separate sheet may be used it desired; 8. Make sure your benchmark and vertical elevation reference poir. ~e clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exernp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does riot 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 col: Cobble (3 - 10") SS Sandstone gr - Gravel (under 3") LS - Limestone *s - Sand HGW - High Groundwater cs - Coarse Sand Perc - Percolation Rate reed s - Medium Sand IN - Well Fs Fine Sand Bldg - Building Is Loarny Sand `j - Greater Than sl - Sandy Loam < Less Than "I Loarn Bn - Brown *sil - Silt Loam BI Black si Silt Gy - Gray ' ci - 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, fink 'c - Clay cc - cornmor pt Peat min - Many, n'-- rn - Muck d - distinct p - prominent HWL - High wain I, Six general soil textures srarfac for liquid waste disposal RM - Bench IV VRP - Vertical TO THE )LINER; report is fir in curing a sar,, L,.=rrslit. The c( the Dr <'rt may request f 11- d prior Knee. A f the private at, I rnu f tho n order to T , '4ed prior ictio n, PEPARTMENT'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 1. DD. Number: SEk, N.,14, Sec. 27, T30-n,.20 ❑ CONVENTIONAL El ALTERATIVE (If assigned) Village of Houlton TP'6 ding Tank 1:1 In-Ground Pressure ❑ Mound C ER I HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTI T Edward Qilstrom 29 Church St. Moulton, ~,I 54952 o2--7 11.30 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: Za pa Bros. Inc. 3395 St. Croix 135422 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL L CKING OVER PROVIDED: P El YES ED] NO ❑ YES [:1 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 OVER ROV DIED PROVIDED: ❑ YES El NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: AVEENNT IR NLET RESH (DIFFERENCE BETWEEN FEET FROM LINE: 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: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER DIA.: # PITS: LIQUID DEPTH: BED/TRENCH TRENCHES: MATERIAL: IIINSIDE DIMENSIONS GRAVEL DEPTH WELL: BUILDING: VENT TO FRESH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER PROPERTY BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FRLINE: NEARESMOUND 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: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: WIDTH: LENGTH: TRENCHES: BED/TRENCH 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: 3 / 1 ❑ YES ❑ NO ❑ YES ❑ NO NEAREST r- '9 d Z U0%1 G 8/ Retain in county file for audit. Sketch System on Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) i D~L.HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COON STATE SANITARY PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ c~'~ 8%z x 11 inches in size. check revision previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. o ,c~ E.uT/.o~ 3 PROPERTY OWNER PROPERTY LOCATION /.C s-r,P© 5--r%a Alcj%, S J?? T 30, N, R ao E (o4o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 9' Chu ~N 5-r. CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER In Z.~94 II. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned VILLAGE A4a S.r. ❑ Public K1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL A NUMB R() ill. BUILDING USE: (If building type is public, check all that apply) 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 80 Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.0 New 2. Replacement 3. El Replacement of 4.E1 Reconnection of 5.0 Repair of an System ystem 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 El 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 VS-0 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION G 4~sQ. - - 7a 17 ~14 - CO' Feet 1/5~. d f Feet VII. TANK CAPACITY Site INFORMATION in gallons Total of Manufacturer's Prefab. Fiber- Exper. New lExisting Gallons Tanks Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank con /OOo / 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' ign lure: (No Stamp) MP/MPRSW No.: Business Phone Number: if,4°~1-revs ^/c.1 Pi~S 3~ 95' r~is 3s~~'sn Plumber's Address (Street, City, State, Zip Code): SJ Vw,-So aS IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) / ` ✓ Adverse 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 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; 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) 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 Gl~ J ,*0,0 , Location of property SE 1/4 X1/4, Section -9,/ , T J:70 N-RAW TownshipT-~nt,+ Mailing address rT /✓v[/LT'6,, 1~s Address of site CA1212i~;,,i„{;7. /\~'r Yad Subdivision name /VD a/ Tn>✓ Lot number 0 Previous owner of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _X_Yes No Is this property being developed for resale (spec house)? Yes No Volume 2 and Page Number la 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 (y2) 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. ; 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. Signs ure of Owner Signature of Co-Owner (If Applicable) /L - 1 2- -89 Date of Signature Date of Signature L Mama a> .r lean Ask f: ME r r r7.a.. • DEED RECORD VOL. 298 267 WARRANTY DEED. STATE OF WISCONSIN-FORM No. 9 M, C. MILLER CO::. MILWAUKEE-Y56495 v This Indenture, Made by Mae H. Slenning and Peter J. Slenning, wife and husband 224154 grantor s , of Multnomah Oregon County, Wiscnoba, hereby conveys and warrants to Joseph L. Finnegan and Laura V. Finnegan, husband and wife grantee of 6t. Croix County, Wisconsin, for the sum of One dollar and other considerations tile following tract of land in St Croix County, State of Wisconsin: Lot S, Block 4, of the Plat of Houlton, except the South 70 feet of the 'Nest 150 feet thereof. ($4.40) ( R.S.) Can.) k ~I G r 1 ~ ~I ~i ; i I i i i i IN WITNESS WHEREOF, the said grantor s ha ve hereunto set their hands and seal this 8th day of March , A. D., 1949 Signed and Sealed in Presence of l Betty L. Wartzaek I Mae H. Slonning (SEAL) Mae 11. Betty L. ;7artzack Slenning Daisy Richards Peter J. Slenning (SEAL) Daisy Richards Peter J. Slenning (SEAL) i Oregon STATE OF WjIF&W, } ss. (SEAL) Multnomah County. J Personally came before me, this Sth day of March A. D., 19 49 , the above named Mae H. Slenning and Peter J. Slenning, wife and husband i to me known to be the person s who executed the foregoing instrument and acknowledged the same. Received for Record this 15th day of Fred S. Winters March A. D., 1949 , at 10 o'clock A. M. Fred S. Viinters (SEAM) Notary Public, for Oregon f'"RSd`kiwis. David Hope Register of Deeds. My Commission expires Sept. 23 A. D., 19 52 Deputy. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYERn ~Dni~~y~. y ~~zLcAS T2o~ ROUTE/BOX NUMBER Ciyu2r_w f 1% FIRE N0. ~C 9 CITY/STATE ~~~~r~.r~.,~ L~/mar. ZIP 'aoopl PROPERTY LOCATION: ZjE_1/4 / 1/4, Section , T_2 N, R ~ O W, Town of 6 iA St. Croix County, Subdivision /VeuL.7O,.i , Lot No. OP Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping gut 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. 'y( 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 INDUSTRY, DIVISION LAE30R AND PERCOLATION TESTS (1151 P.O. BOX 7969 HUMAN RELATIONS 1 / MADISON, WI 53707 6"0Vy MEAj-r [6 3 (ILHR 83.09(1) & Chapter 145) LOCATI N: SECTION: TOWNS HIP/k46LW1Q2AjJ.U: OT NO.:BLK. NO.: SUBDIVISION NAME: 5r- V/Nw 1/ n ,iii N/RZoE to W -Sr _~oscpw /~~~LTo COUNTY: IMAILING AD R S : CIQ0jN( 9-LSTRGM USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL RIPTION: PROF1 LE DESCRIPTIONS: A Residence (AN4 ❑New Replace Nay 36 /9t5t~ DQ~ 9~ / I ~s & l S~t~s 1-1 $ - a RATING: S- Site suitable for system U Site unsuitable for system 5 tAtt~, CO1EN(tO11MAL: U MOUND,❑U INGICJS oU E:SMS :IILLH[IINGT_ANK:RECONVE"JT1p.JAL (optional) If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: CU4SS I 7 Floodplain, indicate Floodplain elevation: NQ 6'~ZT PROFILE DESCRIPTIONS BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHM ELEVATION OBSERVED TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- j /U/.HIS B- n(S~N 71 L P S I ya Q-I v is B- Z -7.4Z 9$•3s No C, 4Z- rz'' it Tz "B r -S i7+ aike E'~: s, -~_G,.Nr B- z " 1490 Fs s . Ph, Am- B- 9-1.0 146 Lr S 7~ /a" 6c.FS75 2s'8,4A1 hS /4"R&8P FS B- 3" & $4N FS 47 M T LjEt PERCOLATION TESTS TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTER SWELLING INTERVAL-MIN. RI 1 RI PER INCH P. 1 s.4p No r, INa_4 /o 1/A IA 11 P- -Z 2.4o. ate 9x.96 in - ' z / Y P. .SO n 7•1;0 I 7- Z Z P- P- 1 E~~1IaT 10~- AT ~.C _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. ~6 oU -f_-- J"L T_ , i - + I A f I I I ' _ - / dour. I< _:S- 4t L' 11 33 I 1 ~ I I --r r - --f`---i---- f`----f--- I - ---Y--7 I I I 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: HAeYP,y 1&c M ho / /4F, ADDRESS: CERTIFICATION NUMBER: PHONE NU1~ BER(optional): 46`7 SE{on,a -S /Ju 4so k/) ~to~Cb CST SI ATURE: DISTRIBUTION: Original and one copy to Local Authority. Property Owner and Soil Tester. DILHR•SBD-6395 (R. 10/83) - OVER-- ~,►~,~r - 06 Ea~V..~. oo • o - PLO 87 S 9a~ 3~, ~p ~/IUD' PLOT Qc CROSS SECTION PLANS ZAPPA BROS. EXCAVATING INC PLUMBING UNIT ~X'JiST/N !o 60", PROJECT f r , ~Ls,oENcl ~ L 6 art! ~ S ya ' c.Q f7 3!'" 36' I I I /wr -5/1 N ~lile- v i i ~ Sr ~ifbix ~ouN-rye X83 ' /ooD ~nAG Tifb10f.~'TY U/tnVeL1 ~LaT.t Tyr ' Fa~s.sri u~ ~~ivt /var.E:xvzL.C 3 Bz ow / SEOT,< Tq~/,r /JRYW,ELL FLooiL TQF / To AF i 4A joa"Eo 7EfTgD /7N/LZNG r SNSTq jL/J72or.~ / n K/~ , C ~ ~x 5, S r, NG ~ji ihf.+GE To ! AQio1Jt~ aNEA r`: E -SouTrr Y~oP~tTs'~„vim NO. -SCALE FRESH AIR INLET AND OBSERVATION PIPE APPROVED VENT CAP MAXIMUM 12' ABOVE FINAL GRADE 4' CAST IRON VENT PIPE MAXIMUM OF 42' ABOVE PIPE TO FINAL GRADE 81GNED: MARSH HAY OR SYNTHETIC COVERING LICENSE: S39!6- MINIMUM 2' AGGREGATE DATE: c, Arl OVER PIPE DISTRIBUTION PIPE TEE SOIL TESTING BY: ELEVATION BED 8' AGGREGATE • BOTTOM PER SOIL BENEATH PIPE PERFORATED PIPE BELOW TESTIS • COUPLING TERMINATING 9/, oo' FT. AT BOTTOM OFSYSTEM Wisconsin Department of Health and Social Services Plt* 7 X3/70 Division of Health i SEPTIC TANK PERMIT APPLICATION'S TYPE or USE BLACK INK A. OWNER OF PROPERTY 3 l -7/Z 3/ -70 Name Address (Street, City, Zip Code) JUNTA 70' Of - X ► Sa ` c~vr 8gl ~ f Be LOCATION OF PROPERTY WF.dRE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUN?_Y Check CITY VILLAGE LEGAL DESCRIPTION TOWNSHIP/ G C.* IS LOCAL PERMIT R UIRED FOR THIS WORK? X YES NO ;"J ! PERMIT NUMBER D. SEPTIC TANK CAPACITY C Gallons NEW INSTALLATION REPLACEMENT ADDITION MATERIALS: Prefab Concrete Poured in Place Steel Other NUMBER OF TANKS ?0 BE INSTALLED: E. TYPE OF OCCUPANCY Cheek One: One or Two Family Residence Commercial Industrial Other Specify) Number of Persons to be Accommodated Number of Bedrooms ( F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer, YES NO Dishwasher YES , NO Automatio Potato Peeler YES NO Other (Specify) G. MASTER PLUMBER MAKING INSTALLATION ~ LIt ~ .-f~.➢ 'License Numbers Name: C 1 ~e~ 7?~ , fit Address:, Signature of Applicant: i. , MP RSW / Address: H. (To be Completed by Issuing Agent) Date of Application G{ Fee Paid Permit Issued (date)/' Permit Number Agent (Name) y ~i H~!~r .lr %'L/2 Fort !Lr Town, Village, City, County, etc. (Specify) Vote: The applios.tion cannot be considered for filing until all of the above questions are answered and the fee paid. Agents wil.~ forward application, the fee of $l.OG for each septic tlnx and the third cop) of the permit (canary) to the Division of Health. Checks and money orders should be made payable to the Division of Health. Do not write in space below - FOR DEPARTMENT USE ONLY I. DATE RECEIVED ACCEPTED BY \V RETURNED (Initials) (Date) See Corres.) FEE RECEIVED VALID. No. {1 I 'll PERMIT NO. 4'za n es or No REVIEWED BY APPROVED DATE (Initials) ~ Yes or No COMPLETE OTHER SIDE } t SEPTIC TANK PERMIT NO. RIP0RT ON SOIL P I R C 0 L A T 1 0 N TItST AND SOIL BORINGS TO DIVISION OF HEALTH - PLUMBING SECTIdN P.O.Box 309, Madison, Wis. 53701 Pursuant to H 62.20, Wis. Administrative Code P I R C O L A T I O N T I S T Test Depth Character of Soil }lours Water Test Time D_o, in or Level Inches Minutes Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall 1st Wetted Overni in Minutes Lest Period Last Period Period Ono Inch Example P - 0 (3611 To Soil /1011 Clay 2611 25 Yes or No 30 1 2 1 2 1 2 /60 l) RECORD DATA FROM MINIMUM OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. S O I L B O R I N G S- Minimum 3611 Below o posed Abso Lion System Boring Total Depth Depth to Ground Water De th to Bedrock Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches Example B - 0 7201 7211 Black To Soil 12" C1 18" Sand 181 Gravel 241 3 ,2. ~ . RECORD DATA FROM MINIMUM OF 3 BORE HOLES PE OF OCCUPANCYs RESIDENCES Number of Bedrooms OTHERS (Specify) Number of Persons OP, D WASTE GRINDERS Yes No 1~ Dislwashers Yes No Automatic Clothes Washers Yes No I FFWENT DISPOSAL SYSTEM: NEW _ EXTENSION ADDITION REPLACEMENT i Tile Size No.Lin.Feet Trenoh Width Depth Number of Lines Seepage Beds Length Width Depth Tile Size No. Lines Seepage Pits Inside Diameter '7 f Liquid Deptts' I, the undersigned, hereby cart± y that the percolation tests reported -n this form were made by me or under my super- vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best, of my knowledge and belief. NAIM C ~ Z) Ly TITLE Type or Print REGISTRATION NO. Q / or MASTER PLUMBER LICENSE NO. ADDRESS ('W11J1) DATE ZZ S ~Z O SIGNATURE