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HomeMy WebLinkAbout032-2049-95-000 a 0 0 3 0 O h .o br, a~ C~ a) © E co m n-, m c N a> I C m a. N 0 a° ' o ° et m aa) p ] Y U U) N N O N 2 a) 0 -2- O z ° C N _ E 0 v LL C ~ ~ C q O c , . C C n Q H CL V ~ M z y E O z 0 z d a m W a m O c o o co O z d c o N - m Z o 0 fn h- e- ' o a> v M y N CL O L7^1J'1 (D O N U) U) a U O c O V O 2 Q ~t-- I O z F- Z o Z N _ -W ~ I N TV! C_ r t6 ~ > N ~ y co `l u, LO a U c U o c a N (0 d d z °aaa. CL 2 iI o o O N 3 0) 0) N J U ° rn rn p z z (o co 0 0 ~ o o co o E m r p m y ,Q } it? Q (o 7 o ° L w c o c o o E N o O LO V) O C N O O CO > a) IL m N £ CL - O ON C ~ m U EO d co E -r- • o C~ o y z L'i \ Yt £ `L v ~ u R ~ a I a L: a w ttww• a d d 0 c `1 E c c o L) IL o U-) FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SECTION-/ T.Z _N-RW ADDRESS ST. CROIX COUNT, WISCONSIN M SUBDIVISION LOT-11,1~LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM AUK ✓OX Zoe INDICATE NORTH ARROW BENCHMARK: Elevation and description: Alternate benchmark SEPTIC TANK:Manufacturer: Liquid Cap. F-Rings used:=2-Manhole cover el ev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear~Ft._ From nearest prop. line: Front , Side, Rear Ft. No. of feet from: Well /M 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 Distance from nearest prop. line: Front, Side_, Rear_Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: a2 Width: C~- Length /dn Number of Lines:__2_Area Built Exist. Grade Elev. 2:, Proposed Final Grade Elev. Fill depth to top of pipe: r No. feet from nearest prop. line:Front , Side , Rear.X Ft. No. No. feet from well: feet from building /A! - ' HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from: Well building , nearest road Alarm Manufacturer: INSPECTOR: DATE : 9; a~2f 26a PLUMBER ON JOB: ~ LICENSE NUMBER: 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 assigned) 'Number: SE 4 , RW 4 ,Sec .14 , T 3 0 -R19 State (i 9 1 Town of Somerset CONVENTIONAL El ALTERATIVE ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT ROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW tSanitary Permit Number: Calvin Powers, jr 1563 qf- - r 19991 3-T SEPTIC TANK/ 3.) atic e a r MANUFACTURER: LIQUID CAPACITY: TANK INLET EL TANK OUTLE V.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ;3. G' 'S 9$ YES ❑ NO ❑ YES NO BEDDING: VEaa DIA.: VFW MATL.: HIGH WATER %UMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO RESH C,O. C.O. ALARM: FEET FROM ' LINE: AIR INLET: ---►/GYM3 DYES XNO~ I/ DYES NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATION NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN ff_ET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NE ---110- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: IAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, co ction shall cease until MAIN the soil is dry enough to continue CONVENTIONAL SYSTE .3 6' ?JS' 6~: 'A' BED/TRENCH WIDTH: LENGTFF NO.-UF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID r TRENCHES: MATERIAL: - DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE rc T. PIPE MATER AL: NO. itllh-~ NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPESABOVE COVER: ELE ET: ELE /'/LPIPEFEET FROM LINE: ~m AIR INLET: / ~f C~ `CPt~1Q C/ NEAREST ? I/~/ /00 7 60 MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown to e: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO 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: :~~zD: SEEDED: MULCHED: CENTER: EDGES: YES ❑ NO DYES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPT LOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES D NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST-► 8, t at LiSketch System on Retain in county file for audit. Reverse Side. SIGN URE: TITLE: ~ SBD-6710 (R. 06/88) SANITARY PERMIT APPLICATION COON DIL R In accord with ILHR 83.05, Wis. Adm. Code E~= STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 8% x 11 inches in size. c if revs on top ious a plication -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION qfW '/a, S T__4~' , N, R E (o ZIP, PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # / j CI STATE ZIP CODE PHONE NUMBER SUBDIV SION NAM R CSM NUMBER CITY NEAREST ROA II. TYPE OF BUILDING: (Check one) ❑ State owned VILLAGE L A.iF au _91 NOW ❑ Public .v~ i 1 or 2 Fam. Dwelling-# of bedrooms ~ AR E NUMB R( p III. BUILDING USE: (If building type is public, check all that apply) - of l 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 N 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. f~) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Feet Feet /101 VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks Constructed .0 1 Septic Tank or Holdin Tank s Lift Pump Tank/Siphon Chamber , I F1 r7 Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (PrInJA: Plu is ignat e: o tamps) MP/MPRSW No.: Business Phone Number: - ,4- Ar. __1! ~i Plumbe 's Address (Str t, City, State ip Code): 16 IX. C LINTY/DEPARTMENT USE ONLY ps) ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing ent 01YFULLUf Approved El Owner Given Initial Surcharge Fee) A vers ermi i n X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-87) (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 informalion 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 81/2 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; (lose 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 forth; 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) SANITARY PERMIT COUNTY DILHR TRANSFER/RENEWAL UNIFORM PERMIT # " (PLB 67-T) PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE D~A TE: STATE PLAN I.D. NUMBER: 5- PR OPERTY LOCATION. CITY: VILLAGE: N,R 119 E (or TOWN OF LOT NUMBER:, BLOCK NU BER: SUBDIVISION NAME: NEAREST RO#D, LAKE OR LANDMARK: PREVIOUS SAN- ARY PERMIT HO DER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME. PHONE NUMBER: -11A A ADDRESS: PHONE NUMBER: A DR SS: I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PL 77E 'S SI N U PREVI US PLUMBER'S NAME ( CHANGED): BER'S AD RE : PREVI US PLUMBER'S A RESS: MP/MP W NUMBER: I HONE NUMB R: MP MPRSW BER. PHONE NUMBEFT" - 1 ) (GNAT E OF ISS DATE APPROVED: DISTRIBUTION: Original - County Copy - Bureau of Plumbing U 7 Copy - Owner DILHR-SBD-6399 (R. 5/82) Copy - Plumber y • APPLICATIONFOR SANITARY PERMIT STC-100 This application form is to be completed in full and aligned by the owner(s) of the properly being developed. Any Inadequacies will only result In delays of the petmit Issuance. -Should this development be intended lot resa h by owner/conttactot,(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 DCkVid `f slat-10, Ga-M dI - Location of property _1/4 ~ V --1/t, Section T_2D__N-R_D_V Township Sn Mailing address 157 A.4 Address of site . Subdivision name //A7 Lot number 4Ap CQCc/`Q '0uui © ,,I Previous owner of property cot, 6P;VA.V-d -d' Fwarwt CcQo~~dt-~a~a ST/eow~ Total else of parcel ,CLC_C4. Date parcel was created pe-r Z~6-zze__ Ate all cornets and lot lines Identifiable? K_Yes No Is this property being developed for resale topec house)? as x_Mo Volume and Page Number G/5~ as recorded with the Register of Deeds. INCLUDS WITH THIS APPLICATION THE FOLLOWING! A WAARAXTY DECD which Includes a DOCUMENT HUMNSR, VOLUME AND PACt NUMASR, and the SRAL OF THR REGISTER OF DEEDS. In addition, a certified survey, If available, would be helpful so as to avoid delays of the reviewing process. IE the deed description references to a Caitilled survey Map, the Certified survey Map shall also be requited. PROPERTY OWNER CERTIPICATION I(We) certify that all statements on this form are true to the best of my (out) knowledge; that I (we) am (ace) 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. '5- 6 / - 1 and that I (We) presently own the proposed alts for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, got the co stt ctlon of said system, and the same has been ul corded in the office et the ovn! eglatec of D4 da, as Document No. - _ signature of O et signature of co-owner III Applicable) Data of signature Date of Signature 859 6 5561 PAGE 1(5 Und Contract Number ' of 3 5027838 LAND CONTRACT Name of Previous Owner Low Number of Previous Owner Richard and Stewart Rivard 98 N.1, P.5 state County service Center & Branch No. Wisconsin St. Croix THIS CONTRACT, MADE THIS 28th day of December 19__U between Farm Credit Bank of St. Paul , afederally chartered corporation hereinafter referred to as "Seller," whose address is 375 Jackson Street. St Paul, MN 55101 and David J. and Gloria K. Gazdik hereinafter referred to as "Purchaser," whose address is 358 165th Ave., Somerset, WI 54025 WITNESSETH: 1. Seller Agrees: (a) To sell and convey to Purchaser land in the County of St. Croix , State of Wisconsin , described as: SE; of NW4 of Section 14, T30N-R19W of St. Croix County. Wisconsin hereinafter referred to as "the land," together with all tenements, hereditatments, improvements, and appurtenances, including any lighting or plumbing fixtures, shades, venetian blinds, curtain rods, storm ,windows, storm doors, screens, awnings, and now on the.land,. subject to any applicable building and use restrictions and to any easements affecting the land. Excluding therefrom and excepting and rewrving to Seller all mineral and royalty rights, interests, estates and titles heretofore reserved or excepted of record by The Federal Land Bank of Saint Paul prior to January 22, 1986, if any, with such easements for ingress, egress and use of surface as may be incidental or necessary to use of such rights. The foregoing exclusion, exception and reservation shall include, but not be limited to, all oil, gas,. hydrocarbons, coal and other minerals of whatsoever nature lying-in or tender the above- described lands and all royalty interests as to oil, gas and other: minerals produced and saved therefrom. It is expressly understood that the Seller will make no warranty as to the extent of its ownership of minerals, or as to its title thereto. (b) That the full consideration for the sale of the land to Purchaser is: Thirty four thousand 34,000.00 Seven.-thousand ) dollars, of which the stun of 7,000.00 ) dollars has been paid to Seller prior to the delivery hereof, the receipt of which is hereby acknowledged, and the additional sum of Twenty seven thousand? (t 27,000.00 ) dollars, is to be paid to Seller, with interest. from the date of this contract on any part thereof at anytime unpaid at the rate of 10.25 percent per annum while Purchaser is not in default, and at the rate: of 12.25 percent per annum, computed upon any stems of principal or interest not pat when due during the period of any default in payment;, Such, additional purchase money and interest is to be paid as follows: Monthly payments of $294,28 .to begin'February,li. 1990 and willbL due on the Ist each month thereafter. Thisis-based on a 15 year amortization. (Additional interest may be added to the first. installment if the initial period is greater than subsequent periods:) Such payments to be applied first upon interest and the balance on principal. All of the purchase money and interest, however, must be paid in full on or before January 1, 1995 anything herein to the contrary notwithstanding. (c) To execute and deliver to Purchaser or his assigns, upon payment in full of all sums owing hereon, a limited warranty deed conveying title to the land, subject to abovementioned restrictions, easements and to any then unpaid mortgage or mortgages, but free from all other encumbrances, except such as may be herein set forth or shall have accrued or attached since the date hereof through the acts or omissions of persons other than Seller or his assigns. (d) Seller shall upon closing provide as evidence of title, at Seller's option,-either- an owner's-policy of-title-insurance or abstract.of title covering the land. The effective date of the policy or certification date of the abstract is to be approximately the date of this contract. Seller shall have the right to retain possession of such evidence of title during the life of this contract but upon demand shall lend it to Purchaser upon the pledging of a reasonable security. 857PAGE61 ( ' 3 WITNESSES: R 3ERS: David J. dik G ria K. Gazdi REGISTER'S OFFICE FARM c x of sT. rAVL ST. CROIX CO., WI Recd for Record CEC2 91989 Thomas E. Hass, Director of Acq. Prop. of the ct 8:30 A. Name Tide Federal Land Built Association of Northwest Wisconsin Reglster of Deeds Acting as Attorney-in-fact for Farm Credit Bank of St. Paul. or: Production Credit Association of By: Name Tide STATE OF Wisconsin 1 ss. COUNTY OF St. Croix J ')n This S day of December 19-39-_ before me appeared David .7 _ and (;1 nri a K Gazdik o me known to be the person(s) described in and who executed the foregoing instrument and acknowledged that he(she)(th =cuted the same as his(her)(their) free act and deed. a V Ay commission expires 2-11-90~ ¢ `fir •3 Notary Public Mary Lou Levi O Pi area " Wi~rnna' County State a•``~~, TATE OF Wisconsin 1 ss. 'OUNTY OF St. Croix ) p he foregoing instrument was acknowledged before the on Date + y THomas E. Hass, Director of Acquired p~n~ ty ` of the Federal Lan s$4~ ed gtt, j Name Title 'ai • v {t, 4r. Northwest Wisconsin as Attorney-in-fact on behalf of Farm Cro¢ Si on St; lPagl ty commission expires 2-11-90 ,,Q,u~•J Notary Public ry. Lou Levi • " Q Pi Prima ~ , •,~ta 1p~~1 i County State ATE OF )UNTY OF 2'!260 (A) CLOSING STATEMENT (For Closing Real Estate Transactions)' State Former Borrower's Name County JOffice No. an No. 4isconqin a d d Stewart Fiiva St. Croix 036/11 3807198 N.1 P.5 Property Location Rural Route, Somerset, WI 54025 Seller Farm Credit Bank of St. Paul Broker's Name and Address Buyer's Name and Address David and Gloria Cazdik, 358 165th Ave., Somerset, WI 54b25 ~ Buyer's Social Security No. Date of 'Offer Date of Closing J 388-62-3370 11-9-1989 SETTLEMENT STATEMENT Due Seller Credit Buyer Sale Price $ 34,400.00 $ I i Down Payment 500.00. Delinquent Taxes (if assumed): For yea'tS' Tax Adjustment: Last yr's tax $ - j prorated from to Transfer Fee.........., Attorneys Fee Recording Fee ~ Abstract Extension or Title Policy Cost........ Realtor Commission: 7 $ $ Allowances For: sale price Z ler to oay all 1989 real estate taxes ;.o:_An_ closing fee paid to seller ($270) i i i TOTAL 34,000.00- $ 500.00. Less Credit to Buyer ! • ( 500.00. Land Contract/PMM ( 27i000.00 ) I TOTAL DOE SELLER $ 6,506.00 i Dated Closer ~ G ~ lam' ~ ~ ^ - PLEASE NOTE ITEMS PAID BY D CLOSI ATTA PIES Original Copy: Acquired Property File ~Tellwr py: Purchaser j L STC - 105 CA SEPTIC TANK MAINTENANCE AGREEMENT rt St. Croix County 60_WNER UYER W, fi o ROUTE/BOX NUMBER Fire Number d ZIP (3 rt Z S' w CITY/STATE m PROPERTY LOCATION:'.SE h)Wk, Section, T 30 N, RJW, Town of oc St. Croix County, Subdivision ~f Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Prover maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed 's'eptic tank pumper. What you put into the system can aT ect the .unction of the septic tank as a treat- ment-stage in the waste disposal system. St. Croix County residents may be eligible to recieve a grant for a maximum of 60% of the cost.of replacement of a failing system, whic 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 'syst'ems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and .(2).after inspection and pumping (if nec- essary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H I/WE, the undersigned have read the above requirements and agree o to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed ►d and returned to the St. Croix Count oning Office within 30 days of the three year expiration date. SIGNED~Q4 DATE S ! k~C1 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. :_'cri ~h l1. ctv l Ur "-%Ft bUILUIfNUS fNIM 1CTOV 1'ttNuR r vN* ri; IL BOkrfVC,S ANU • LABOR AND.. yy _ , Mi~YIIAIg111~ ~ I L OCA A1uJ E C CTION: 3b N/R (o /MUNICIPAUT OT NO. BILK NOISUBDIVIS O NAME: COANTY:a O NER'S BUYEtt'S NAME: IMAILING ADDRESS: r , J7 ~cSfX ~:'l;t TP' f°I'-tars Vl~~ Hou6 G1i velar USE 11 DATES OBSERVATIONS MADE N0. DRMS,: COMMERCIAL DESCRIPTION: S: ESTS: Residence New ❑Replace RATING: S= Site suitable for system U° Site unsuitable for system I CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S S EM-IN-FILL HOLDING TANK: RECOMMENgED SYSTEM: (optional) ~S_~~ aS ❑U DS ❑U EIS EU EIS ZU 2iez;CltcS Perco.d,iun Tests are NO required C=S!C l n - ` " If any portion of the tested area is in the under s.H63.09(5)(b), indicate: w J - 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 ES HIGHEST- TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.) - _ / ~ J B/ No U o C II C.~ I U 'r f s[ ry 7 /~J~r i n lJ L i ^ i L) 15, 1, B' ' ~VI i L' r J C...' / A', r Q r ~J ✓tj r /1 J J -~1 . 41 IV 2', 1 ✓ t 11 \ Lt f- Of ed T e, ew S' TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE. RAIAII ITFS ricer LL vG INTERVAL-Mite. - 01 PERIN17H P r~T- P. 1> 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 surfa::e elevation at all borings and the direction and percent of land slope. ti t'v.t SYSTEM ELEVATION *41 '10,80 fe.vv > u l~ 4- tj% r I to r'. r~~ H I 3 6! f~' ~br 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 IprinTESTS WERE COMPLETED ON: ADDR~S- ,-1 CERT1F4'17T N NUMBER: PHONE N~yl►MBER(op Tonal): T f ' 1 is l~ Y / ? /II ''i 1)cl ,a n CS I ATURE: -RIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. -IR-SBD-6395 (R. 02;$2) - OVER - its, Y ~ Sr I i! i f I PAGE OF Cro S'Le 1 0 o ~ A {~kz - SP ~120-71 / fre►h Alt Walk And Ob►etvallon Pipe ^ Approrod Vanl Cop y .C AS ~`r L~ 411nImuT 12' Above final Grade 20. 42' Above Plpp _ 4` Coal Iron To final O/ade Venl Pipe mW sh Hof Or Synihalb Co.nlny MIA 2' Ayyreyole - O.ar Pipe 01eul0ullon ' 0 0 + Pipe o Tee Ayaieaole Benealb Pipe Pulo'oled Pipe below ffl-C001AV TwMinoliny Al Balloon 01 Sy►lem £lc.J..~• Ion SOIL FILL DISTKIBU710F.1 PIPE APPROVED SyAlPETIC COVER ` ~'-/'1AT~itI~I OR 9" OF STRAW 2"OFMGREGAlE OK MARSH HA`i OF J2-ZI/z AGGREGATE ELEV. of---FEET-,.. DISTRIF5'JTI0A) PIPE TU BE AT LEAST IIJCHES BELOW ORIGIIJAL GRADE AUU AT LEASTLO IUCHES BUT 1.10 MORE THAI) 42 IIJCHES BELOW FMAL GRADE PiAXV1UM Dapni OF FX(-/lVATII)P FKOM OK16 NA-L 6KADa WILL BE _ IIJCHES /'UNimum pEFT}i of EAM/ATION r-KOM. C~14NAL C3RAOF- WILL BE z~B INCHES 51GMED: LICEWSC AJUMBER: DATE: t SAFETY & BUILDING 'DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION ISO 1(, 5 707 State Plan I.D. Number: S 44 f eC. 14 , T30-R19 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Somerset ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: DRESS OF PERMIT HOLDER: INSPECTION DATE: Dave & Gloria zdik ADDRESS S m rset WI 54025 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT ROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: John P Sykora III 21 S Croix SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑ YES ❑ NO ❑ YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER 1AREST MBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: ET FROM LINE: AIR INLET: ❑ YES ❑ NO ❑ YES ❑ NO DOSI NG CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: MP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑ YES ❑ NO PU ❑ YES ❑ NO ❑ YES El NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENTT O FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑ YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS: ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD-6710 (R. 06/88) `C]iLHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Cou STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 8% x 11 inches in size. c i vis n lous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION SE '/4 Ptd1/4 S..19 T 30, N, R !q E (or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 1 d 2 6 715 24? W / - II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE : NEAREST ROAD 2 SOwtQN' SQ I 7S7 ❑ Public 101 or 2 Fam. Dwelling4 of bedrooms AR EL X NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) o3 2 - Zo,4 ct 9 5• 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 120 Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. R1 New 2.E] Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 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) q ELEVATION LASO A j 9s 56 0 12 9 /2. 5-Feet 9 Feet VII. TANK CAPACITY Site INFORMATION in allons Total # of Prefab. Fiber- Exper. New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App. Tanks Tanks structed Septic Tank or Holdin Tank . /D Mral, [N I El I I - F] Lift Pump Tank/Si hon Chamber L1 Ej 1:1 EL Vlll. 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 Sig ature: (No Stamps) MP P W Business Phone Number: Lill 3Z i Z- 716 )S-Lg-491-46 Plum r Address et, City, State, Zip Code): 75 -7 Z4 IX. C UNTY/DEPARTMENT USE ONLY A❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing ent Signatu M Surcharge Fee) Approved ❑ Owner Given Initial Adverse l3 / Determination ` ~f 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 tojnstallation. 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 sanjtary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the systi im 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 o+standdrds. - } SBD-6398 (R.11/88) Syr.. z 5 i cly l O~ - - a) ~ ~L BORiNVS"' AND oraFt BUILDINGS !~tf111CT'RV I'1 L/ LABOR N M LOCAT ON: SECTION- #CIPALI OT NO. LK. NO.: SUBDIVISI /T3dN/RISE (.1W ome` T C NTYa O NER'S BUYER'S NAME: MAILING ADDRESS: t USE DATES OBSERVATIONS MADE NO. DRMS.: COMMERCIAL DESCRIPTION: IPROFIL DE ONS: TI ESTS: [N~Residence New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: JIN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMEN ED SYSTEM: (optional) ❑U L~- $ ❑U ❑U Eu RJU ,`~~11C~~ _ ~ATZ: :f iercu:etior Tests are iVl1 requireci I M = SI GN i ( If any portion of the tested area is in the under s.H63.09(5)(b), indicate: I Floodplain, indicate Floodplain elevation: 1111 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.) _ J '316 C, d 13- C) v U, u ll)lr B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE RA1N111 Fr ES NUM31o iN, H,E~~ f~ S'vd LLIN INTERVAL -1011 iv. PERT D 1 I-- PERIOD 1 "~~-P~RT ) PER INCH P_ ;,for J l` 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. filfv.C 11 SYSTEM ELEVATION 19 130 i4 ~0 , rte 13 -4 3b~ w 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 (pr): TESTS WERE COMPLETED ON: t 2Gi /r ~v~ 1~~~ /r/ ILL ADDR S;t CERTIF NUMBER: PHONE NUMBER( op ional): MCS'111 MATURE: J Z ~ a JA/Y~ DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - Sg, 04),f Sic.. ~'T o nPr R iq ccl /k P~~ Zf~z o-f sow set' %,I-, c"i Dc ca I ~ 5~X /DO' 1 ~ l SX -P C C4 ZOo° t j eL 'rf?9 acres r o56o' I cam', I -lie lyak s~ AQ fy/tOo) Yb I Saut► 40 l53 - s>P~Gs &01"4 r~ 6 ba„ • 19ss /aeo SCL 1 age ' • aC(L baa) r s~ Dc loo -0 F. gv;' to4k @ 9?- to-r- 041 rZ"' y osS or= crt E/~r=92.5' - r ~sl - EXAMPLE 18 - CROSS SECT N OF A BED SyS EM IL FIL DISTRIBUTIOAI PIPE APPROVED SyA1THETIC COVER 2OF AGGREGATE o '-MATERIAL OR q" OF STRAW OR MARSH FIAy • • a OF AGGREGATE ELEV. OF FEET, DISTRIBUTIOAJ PIPE TO BE AT LEAS IKJCHES BELOW ORIGINAL ADE AIJD AT LEASTZO INCHES BUT AJO MORE THAI) L42. RICHES BELOW FIIUAL G ADE MAXIMUM DEPTH OF EXCAV TIOM FROM ORIGINAL GRADE WILL BE IAJC ES MINIMUM DEPTH OF EXCAV TIOIJ FROM ORIGINAL GRADE WILL. BE INCH S SIGIJED: LICEWSE NUMBER: - DATE: