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HomeMy WebLinkAbout040-1016-40-000 a•°i o I a•°i °o o 03 O O e°a v o a) m CD a a O D p "O O C U a 0 CO -0 U) O O O D C N N M C M CL 0 0M _ O - _a -°cy c (6 co co C O L a) En LL C U - N c ~.:2 CL O U 3 N- O W p 0CL cc a~a4)~ Ira ee pE~ CD 0 a~ • -0 o U S y Y a) c •C fQ .0 N Co CD O 'gyp ttC~, E N C N o E Z t> z r-)C8 75E z m csi `6ya) CCo m ! LL CO O m LL c y 0 u 0 0 LL C O N wO 3 3:0-0 aEiD co c 2 LL ¢ aw cot O O E ¢ a~ i U I M •fp M ~ M m l o o o Z m m m m `m d vHCwi~ am am am I .o I o z g c v ~ ~ ~ N ~ N ~ ur w fA H N m N 0) N Z E c E c E cm Cl) N°' N0 Q) w NQ .C ca (D .c a) .c (D N U) U) (D W 42) 0 Q z co z z co z z I` z r o N _ Z d d d C14 R E E A E y N 75 4) = I w c m C. E .d`. C LO d v a .~L. m LO M m c ° :3 D D a` n d G G a` n V) G G m m y 'm N w frrn rNr U) O U) U) U) E v lA fn N U 5E Q EL cn a- 0 -.4- A ~,aaa =a.o.a c,CL CL IL N v CL > m 0 U y 00 00 u1 O U = 0 0 co N rn rn 3 00 00 } o rn rn M ID C, (D C) a, Cl) O > O C) 4 aa)i 0 N ~I c O N O O _ "p E E ~O U tc IL a7 7I _ I ) N of > m p m y 1 Lo N 'p m co d 16.4 C/5 ~r,.i C 7 O 7 a( It E Q CD o II L) N > > o d Cl) o \ 'T c°c C t e o a' o O a) c ca- -0 - N v ~"q CO 3 O N m M j c Vl m (D U) N E f6 p Q D7 p C m y C m c O O c N «n o F- co .O z E 1 v z E cc ) L w Cl) U) (D (a d N' '0 O v a E ~ w 0~ E E ~ .0 c °ac n ao • ~f O O W I~ O N O (D ~p O m N p O N O (D O E U Q O O I- U M Z m I- x N Z~ 2 I- 2 0 Z Z g Co cc C7 v~ E1 Ed Ed 4) CL CL CL L: IL 0 CL 4, 4, u IL u (L A UIL2 I'0Uci 0 aici 0 cn Parcel 040-1016-40-000 11/30/2006 09:02 AM PAGE 1 OF 1 Alt. Parcel 04.28.19.601-1 040 - TOWN OF TROY Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner STEVEN J & JEAN HERREM O -HERREM, STEVEN J & JEAN 530 VALLEY VIEW DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 530 VALLEY VIEW DR SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.510 Plat: N/A-NOT AVAILABLE SEC 4 T28N R19W 2.51 AC IN E 1/2 SW 1/4 Block/Condo Bldg: LOT 1 OF CERT SURVEY MAP VOL III PAGE 720 ORD Tract(s): (Sec-Twn-Rng 40 1/4 160 114) 04-28N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 584/340 2006 SUMMARY Bill Fair Market Value: Assessed with: 157816 213,200 Valuations: Last Changed: 07/15/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.500 54,500 140,000 194,500 NO Totals for 2006: General Property 2.500 54,500 140,000 194,500 Woodland 0.000 0 0 Totals for 2005: General Property 2.500 54,500 140,000 194,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 210 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ' • y I Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER '5~IFU'P f7E~~E~" I TOWNSHIP Two SEC. T N-R W ADDRESS A)ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILRR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 5E E SE PER tTE PLO T INDICATE NORTH ARROW -r~ p 6- Elevation Describe the vertical reference point used Elevation of vertical reference point: 10(9,0 Proposed slope at site: Z )a SEPTIC TANK: Manufacturer: 73-1- wiE:SLR- Liquid Capacity: ~7 Number of rings used: 1:~1 Tank manhole cover elevation: ?0VIEn- TL'PiLD-,~oT ~NOw,✓, Tank Inlet Elevation: NOT'XWOwAlTank Outlet Elevation: Number of feet from nearest Road: Front,O Side 0 Rear, O > feet VI From nearest pr©perty line Front,O ide,O Rear, O 7 S~ feet Number of feet fro 7 /2 - (Include well ;lot (Include this information of the above plot plan)( 2 reference dimensions to•septic tank) SEE REVERSE SIDE l E~ S~ t7 • ~ - F- L ICU E PUMP CHAMBER u ESL 2 / ooo Manufacturer: Liquid Capacity: 55 / -3 3 pump/Siphon Manufacturer: Pump Size Pump Model : lcZ -7S Bottom of tank elevation: y Z S - ~e~•'uS~D Elevation of inlet: • ' v-tS T Pump off switch elevation: Gallons per cycle: 12-0 F Alarm Manufacturer: LE U E L LA PM Alarm Switch Type: M E A(- v P y 4,10A D k)AvJ R_ W y S'p Number of feet from nearest property line: Front, O Side, O Rear, © Ft• FT, Cv 5 Number of feet from well: 23 ' Number of feet from building: (Include distances on plot plan). CI) S ' X 6. cs ~ CZ/ S' X C~ g SOIL ABSORPTION SYSTEM ~l ~3 • Trench: Width: -s Length : 9 Number of Lines:-2- _ Area Built: Fill depth to top of pipe: 36 Z SD w. Number of feet from nearest property line: Front, O Side, O Rear,O ~Z. Number of feet from well: Number of feet from building: (o7 (Include distances on plot plan). SEEPAGE PIT / Size: Number of s: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 0 0 or distr4bution box been used on ,any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: pacity: Number of rings used: E1 ation of bottom of tank: Elevation of inlet: Number of feet from ne est prop line: Front, O Side, O Rear, Oof feet from we Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: -TO L"/ Plumber on job: License Number: HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54816 ROBERT ULBRIGHT 3/84:mj W45.N ISTALLER & DESIGNER UI.~ OOM MIN HOMESITE SEPTIC PLUMBING CO. 658 O'NEIL RD., HUDSON, WIS. 54018 1 y~ Z ROBERT WRIGHT os r \W. MASTER PLUMBER LIC. NO. =7 M.P.R.S. MINN. INSTALLER A DESIGNER LIC. NO. 00663 ScAtE. 1"=2C) :!3L ke • • 8,4t& Aoc- pi T$ = P 1z c S I TES M sy57rE_49 ° S5,0 r Div ~ o M~~S~t~~ F I Q S cR4~s ~ I ~ 2 .TEST ~ I I I I I I I I ' I i I I I I I I ASSURED _ `~I I I I gySTr-^~ LEI EUAT16/3 u l; I I I I to _i I u 97.$o III Ivy I p I I I y, I I ~ v 1 I , I I t~ I I ~ I I I I c~ ~ 0 I'' 20 ICI W I I I \ In 1 IAA ► 'I' ' t` I IN~£ ~ ~ i ~ I I h 4^ Box - ro Mow ( x I r pL, 7 Golfer ,y'f iv ~i900~"~' eF :ry 2 eF I'S T 13 cx 60 `'of ~ M c 4SSu~H~D I slc f r C 5i2t IObO . T3oT?°r r o Fn~fE 0 ` 1 1444i,41 g9. zG 4d',4 G X418 Ef~sT~o c- p i- -k - , sE pri c /Goo dos li 4 d 1 too SAS • 43 S-r i 'a c' ti~ -1-op o Well /bd.O I f 6,A4 o, 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 SE 4 , SW 4 , Sec . 4 , T28-R19 xCeNVENTIONAL El ALTERATIVE State Plan Iassigned).D. Number: Town of Troy Lot 1 (If 17.Q I 1 10 17 Ili ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: .0, t- P17P ~ 5_11n View Rd., Hudson, WI 119D -2--34- BE C MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLA REF. PT. ELEV.: CST REF. PT. EL 2 /IJU. v' J Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: ]Rr)hprt- TTlh-ri,rht- 3307 St. Croix 128 SEPTIC TANK MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: G ~i eSe.-r ) C j © YES ❑ NO ❑ YES NO BE DING: JVL'f01'DIA.: VQIT MATL.: HIGH WATER UMBER OF ROAD: PROPERTY WELL: BUILDING: VALARM: FEET FROM LINE: r AIR INLET: E-1 YES NO YES ❑ NO NEAREST--111I ~4 DOSING CHAMBER or' , 4 vqf Sw' _ $98 MANUFACTURER: BEDD LIQUID CAP CITY: PUMP MODEL: PUMP/SOW" MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: WTC,6. ❑ YES NO / CQ)O SS M3 ® YES ❑ NO 0YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: f / AIR INLET: PUMP ON AND OFF ES ❑ NO NEAREST 5~ ;),3 >~S SOIL ABSORPTION SYSTEM. Chec a soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled ire, construction shall cease until / of C1 the soil is dry enough to continue MAIN I? ScQ• PVC ~ 57-M' -9" CONVENTIONAL SYSTE = 95-.` eF esr+. R. Q, (o - 02.1 BED/TRENCH WIDTH: LE H: NO.OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PIT : LI / TRENCHES: I MATERIAL: DE DIMENSIONS Q~ ~c \ GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: N DISTR. NUMBER OF PROPERTY WELL: BUIJ• I)IG: VENT TO FRESH BELOW PIPS: ABOVE COVER: ELEV. INLET ELLEV. ?ND, y("5j VO 00A C, PIPES: FEET FROM LINE: , / ++.~f•• ~~jDe IR INLET: J((OO 7/b,~ ~~((oo ..J SCR/ /'!.S T r~ NEAREST -01- ~•S 7 ~o/n Z 7~.5 b 4~WIOUND SYSTEM: Ylot c`, Mound site plowed perpe cular 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 [__1 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: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: R MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ED YES ❑ NO COVE ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: re FEET FROM LINE: ❑ YES I--] NO ❑ YES ❑ NO NEAREST AREST zw °"""icGMF ( •-n l9Q'/ JC"°v'"t/O Ct~G~k7 2~~8 t u'is,P ac tain in county file for audit. Sketch System on Reverse Side. SIGN URE: TITLE: SBD-6710 (R. 06/88) ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY ZEE er $T. Of 0i" STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El l ~l 8% x 11 inches in size. C eck i XeZslen t previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER / PROPERTY LOCATION 5reve- l~;OA,~-*l E %4sw S T ZP, N, R l9 E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # D ~E'Lv I CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME O SM NUMB 10jD•t/ !s Sys 3 ' ~3 F-137(p 70 / o C . 7,5Zn U 171 CITY NEAREST ROAD II. TYPE OF BUILDING: Check one ( > State Owned ❑ VILLAGE : Uh/~~ ❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms R ELTAX NU / Ill. BUILDING USE: (If building type is public, check all that apply) 10 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 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) Q AL S A) 1. ❑ 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 21 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure t 43 ❑ Vault Privy 14 ❑ System-In-Fill Z S JC_~f - V Y67// 6_ VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE y~0 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 7d~ " G ELEVATION YY 5 7 Feet / Feet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete structed glass App' Tanks Tanks Septic Tank or Holdin Tank k O DES OO.v Lift Pump TanWSi hon Chamber Od (,rJ IeT NC. 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 Stam D) MR/MPRSW No.: Business Phone Number: Waco- 4IL15"Vehr 330 Plumber's Address (Street, City, State, Zip Code): S IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued issuing ent Signature (No S mps Approved El Owner Given Initial surcharge Fee) Adv Irse 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 r INSTRUCTIONS K . 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 systE!m. 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; vtells; 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 oil 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 ovnez(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. -Should this development be intended got zesale by owner/contcactot,(spec house), than 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 ptopetty , i E-uem ~_T AA) -:~3 EAn) 1~. 1~Er°r2~/l~l Location of property 2f:_1/4 S,tA:~_ _1/4, Section `A T Z •R 9 V Township -rRoy Malting address 5 3c'~ d-ALi-ey 06'z-0 _D.-o_iu .b 50A) 44)J; Address of alto S~/n subdivision name Lot number 'lam Previous owner of property Jow C419s OFVrNF_ Cy~D Total rise of parcel S~ ~4C~2~'S 0,f c, ~ /Data 28 parcel was created Ace all cornets and lot lines Identifiable? an o Is this property being developed tot tesale Caper house)T_Yes 0 Volume nd Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWINCt A WARRANTY DIED which Includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMSIR, and the SEAL OF THE RIGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. It the deed description references to a Cat:tllled Map shall also be required. Survey map. the certified Survey . PROPERTY OWNER CERTIFICATION I(Ve) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (ate) the owner(s) of the property described In this Information form, by virtue of a warranty deed teotded In the Office of the County Register of Deeds as Document No. ?_s'-? v Jr-'s- ; and that I (we) Presently own the proposed alto for the sewage disposal system (or I (we) have obtained an easement, to tun with the above described property, tot the c structlon of ssld system, and the same has been dui 3 recorded In the Oftlee the County Register of Deeds, as Document No. VoPS signature owner elfin use of Co-owner (tf Appile el ) 7--q0 ~_r'_9o Date of algnatute Date of Signature ~o~ - r • y' 1 t. F s T f ~ ~ .f. LA r aA ` i a a ' N NOW -owl V " w I ~*it~f 4.4 40 %lei ow, SI f.~ room STS /o o a - ~p.v~:v G- Obi STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/fir SVc_ ROUTE/BOX NUMBER 53 Olew 1`e FIRE NO. s3 CITY/STATE UG.~ ~t1 ZIP YY61 PROPERTY LOCATION: s~ 1/4 S~ 1/4, Section , T~N, R W, Town of f~ S~'✓ , St. Croix County, Subdivision , Lot No. Improper use and maintenance of your septic system could result~in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED p DATE / / 9,0 St. Croix County Zoning Office P.O. Box 98 Hammond, WI 54015 (715) 796-2239 or (715) 425-8363 Sign, Date, and Return to above address utrAn I MtIY I ur KtNUK INDUSTRY; v/ DIVISION LABOR AND PERCOLATION TESTS (115) P.O. Box 7707 HUAAAN RELATIONS MADISON, WI 53707 (1LHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP/ OT NO.: LK. NO.: SUBDIVISION NAME: sE aw /TZ 111111 ' E for W -r R OY - £-4s r Pi ?T- COUNTY: MAILING ADDRESS: 54. c9of k STLWE #C R RE A4 15,3_0 thilliE (/~E W 1-4f , 14 U DJo •J CtJ/.$ E 2 DATES OBSERVATIONS MADE r~t NC# 1COMMERCIAL DESCRIPTION: : ; re LATION TEST tAlResidenc@ N, New Replace A P RIL I e- IrI QD 4Aeil ( I C ~O PNIOT Sil I R ( I RATING: S= Site suitable for system U= Site unsuitable for system ONVENTI NAL: MOUN IN-GROUNDPR ESSURE: SYSTEM-IN-FILL ULDING TANK: RECOMMENDED SYSTEM; (optional) ®s ou ®s ou (-s ou os ou os au C_oAJUF, W"1rL ,-,yew 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: e- J'A-- S S Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H T GROUP DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION __OBSERVED TO BEDROCK IF OBSERVED SEE ABBRV. ON BACK.) ,,ll r ~ B' V ~.&0 Qlk, Sii) 'S' IB. y • Col.) s. f o B- Z d~-D ~l~.SZ~ > g'•D " 0 • RIle, S;1 1.0 IS N. Sr~~ Z.0 P At j)(. a s/ V. a VAft <S 2 B-3 ZS•0 f. so 7td >049,Q f, 3311 k.S"I I.I veQ'0.sr1 1.S . a/' ' ~c s B- NOTE 8012E 3 h,40 I UICJ -3 PERCOLATION TESTS ►nJ U& (~Q Y G S 57-AA r* S TEST DEPTH WAT R -IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. P R10 D P R PER INCH P- e Y P z 17'. P Y P Y-1. P_ PLAN: Show locations of percolation tests, soil borings aria 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. S Y S T>E /s'` -k S E- 2 r1 PlQ G k Uej D a-fa SYSTEM ELEVATION _ 'S i I -r 0 H A AJ L - !SC /-oT ~L~4~J 3, S ~~k~ rtl o v c r 6-. S P t G f !r Q t G~`'1 ~t D~tTr D ~f . _ 1.. ~ ~ s~ •~.~,~-~ci p A-Ti o.J Tl►.y T ~ 5 SYIe S1. Mrt l;.c, 4J -4 6 R IQ U P aQ Y oc c T s o Div 5 0r- s/ c s_ r 1 EUiDf ucEZa -lj_ Boo e# 3~ W! p _ _ _ ! T~ f~SSu Su-F~~cifNT ~~•tSS ~1'.;_ 6 X GS 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. HOMESITE SEPTIC PLUMBING CO. NAME (print : 655 O'NE1L RD., HUDSON, WIS_. 54016 TESTS WERE COMPLETED ON: ROBERT ULBRIGHT 4P P". 4- t- I G T f O ADDRESS: WIS. MASTER PL RtIG'~ 3307 M.-RR,-S,- - - - - - CERTIFICATIO NUMBER: PHO NUMBERIo tional): MINN. INSTALLER & DESIGNER LIC. NO. 00663 11y; Z 3r fv cPl CST SIGNATURE:- i DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBO-6395 (R. 10/83) - OV~H - F PLb-F 'Pj,.-jAJ HOMESITE SEPTIC PLUMBING CO. 6N O'NEIL RD., HUDSON, WIS. 64016 25/~Z ROBERT ULBRIGHT os r WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. MINN. INSTALLER d DESIGNER LIC. NO. 00663 l :y 5«IE, 20 z~ • _ $,4c~ l,o~ pi TS ITES ~s J ^QlE 00 NE 540 05$_ "t'E5 T lob ASYur.~D 3ySTE"1 EI a uAT10,J 97.5 0 I- I 1 o I I ~ P• Zo 3z_.. . i I ~ x ~ ' 3 1 w I ' ~Frsria(T pVr~P ~p GG.hn at:(2 \ Assu,&vAt o ` f goT? o~ s i 2.t ~ 106 D ~ . O r-'~ e' gg. zG elf! - iylg SEpTic /ODO - 43 , 4oI1o0SWS 64(STiAb6- WELI L&-vr. Re>F. 'Pr. ti -ro p 0 4~ wt 11 cASla . Sn e~~ 3 ~t ~eH . / d d . 0 HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., HUDSON, WIS. 54016 ROBERT WRIGHT es r tt WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. MINN. INSTALLER r>. DESIGNER LIC. NO. 00663 r Sc,41E: ( LO ~Z- Pz~ • 8,r}c& Aoe- pi TS = P~~ c S tTE-S NO r sL OP~s; I o /4 S I I I I ( I I I i I I I I I I I ASSUn~D 'r l I I I 3YSTE^1 ~I I I i. F I EUATIO J u l I I i i 97. $ O i I to _I j I I ~ I ~ I I I I I i I ~ I I ~ i I I Q i 2a ~ ~ I I I ~ W I I I I 4) l~PP2auE 0 /'i STQr/~uT~e~ I ~ i ` ~ ~'oR f ~T uRE t w ~ >r0,vuccf~on1 I UL RouCD e sYs\_1 - ~ e ~l,T T?pK p Of ~RC~ MR I (p D Gr^Rnt3ff2 ,Ir^~ ! of flE✓AI F%vfi7io✓ IQ - °T of silt 1064D so-e . BoTTp,~ fai~E Teak , I Eq. zG yd',O P 5e,17ivG- ~ Iy1g sspric /oeod'~Ps Iz~ , 4c, 1 -13 E,cisT;4c- wEtl ~y - - L& PT. 9e F. ~r. - -roP o 4~ well ~ASIaC;. I f~•H- oQ ~ Fresh Air Inlets And Observation Pipe N, Approved Vent Cap i Minimum 12".Above i Final Grade I MA ~ • ~'3 , 4" Cost Iron yy Above Pipe - Vent Pipe 'to Final Grade a Synthetic CovIn Min. 2" AggrOver Pipe Distribution y Tee Pipe 0 0 0 '~~vg Aggregato Perfbrated Pipe Below Beneath Pipt1 o Coupling Terminating At OWWAMM Bottom Of System -retof Fresh Air Inlets And Observation Pipe h Approved Vent Cap 0. Minimum 12" Above Final Grade i IS• P` 4" Cast Iron ~i Above Pipe -Vent -Pipe' 'to Final Grade Marsh Hay Or Synthetic Covering s, Min. 2" Aggregate . Over Pipe ,TJ Distribution Tee pipe [TO 0 0 0 , Aggregate Beneath Pipe 0 Perforated Pipe Below ' 0 Coupling Terminating At Bottom Of System ~ i PAGE OF PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS VEIJT CAP 4"C.I. VENT PIPS WEATHER PROOF APPROVED LOCKING JUNCTIOLI BOX MANHOLE COVER ~ 25~ FROM DOOfI, G,/(~j4(,OI,O(,- ~A WINDOW OR FRESI~ 12 MIU. AIR INTAKE 1~~D~ GRADE i 4" AIL). IB" MIDI. CONDUIT ~ 111. IAILET PROVIDE 1 - AIRTIGHT SEAL I ( I I~ v APPROVED J01 T A ' I (I ( APPROVED JOINTS W/C.I. PIPE I / ~o~I 12 I (I I W/C.1. EXTENDING 3' i EXTENDING 3' S ALARM pNTO SOLID SOIL. B a I i ONTO SOLID SOIL 4Z" `~~~IO I I ON c I I LLEV FT. __J PUMP OFF 1AP K CONCRETE BLOCK RISER EXIT PERMITTED GMLy IF TAIJK MANUFACTURER HAS SUCH APPROVAL. IC E ~5 fy~It v /G ~~L SPEC, IFI•CATIOKJS DOSE TANKS MAW U FACT U R E It: /E St WMBER OF DOSES: PER DAy TANK SIZE: 000 GALLOQS DOSE VOLUME u2 ' ALARM MANUFACTUKER: LE lJt 4 ~L rE'~ I INCLUDING BACKFLOW: O GALLONS ,S MODCL IJUMBEK: 2). U' L ' CAPACITIES: A=-' 7 WCAE5OR j~0? GALLONS SWI'TGH TYPE: M ale C 0 Qf ~l0,4 7- B= 2 INCHES OR y6 GALLONS L~° r I S (PUMP MAWIJFACTURER: alet~NC C= s IAILRES OR /219 GALLONS ,T MOREL NUMBER: 55i4133 Y3 N P D w INCHES OR -113 d GALLONS SWITCH TYPE: ~1ERCUR y Flp~ MOTE: PUMP AND ALARM ARE TO BE INSTALLED ON SEPARATE CIRCUITS MINIMUM DISCHARGE RATE 30 GPM VERTICAL DIFFEKEWCE 6ETWEEM PUMP OFF AND DISTRIBUTION PIPE.. ~ZS FEET ~rak SPECS + MI IJ -S•StIR-F . . . '--161 . FEET EAGLr,. ~ O Pitt- /S. '0 FEET OF FORCE MAIN X S Fo is FRICT1011 FACTOR.. 77 FEET4Ur S . 23, 8 /1 A TOTAL DYNAMIC. HEAD 0 2 FEET I ~ovAJ n yz INTERNAL. DIMEIJSIONS OF TAWK: LEN ;WIDTH iLIQUID DEPTH 51GUED: LICENSE MUMBER: DATE: Cv ~~:S~ ~ s~'zt v .w t Ate. AS BUILT SAVITARY REPORT OvIrb"M Township P.O. ADD sconsin Subdivision Lot Lot size PUN vMf Distances & dimensions` to me-et requirements of Sec. F162.20 - Septic tank(s) /®DO :•If €r.., . e No rinos_ Dept to cover of A gregate i. Jew ,5 /,~P C otrered witk~ r :pth of seepage system Vent caps in Place number used Fy Cu~I: FFI Th e inspectiart'o this system by Pierce County does not "inp complete liance with State Administrative Codes. There are other, areas_th+t it is impassible sped at this point of construction. Pierce County assum no liability fors ►.en `ion. - FLUYMER MIT REPORT OI' I11SPECTIO!t--I:dDIJIDUAL SEWAGE DISPOSAL SYSTEM Snnita_ry Permit rState Septic / • T&MISHIP I Croix county I • ~~xze ; C 1s ( gallons. `umber ,of- Compartments Distance From: rJell G4~ ! f t, 12% or greater slope f t. Building ft. Wetlands f: liighwater ft. DISPOSAL SYSTM-1 Tile Field or Seepage Pit(s) Distance From: Well - ft. 12% or greater slope ft Building; Wetlands FIELD High-water. ft. Total length of lines ~r I f t, Number of lines ~ Length. of each line ft. Distance between lines ft. Width of the trench ft• Total absorption area _ sq, ft. Depth of rock below tile in. Depth of rock over tile in. Cover - -over. rock., ~ Depth of tile below grade • min. S•lope of trench in ner 100 ft. Depth to Bedrock - ft. Depth to Pround water ft. PITS ?dumber of pits Outside diameter_ ft. Depth below inlet ft. Gravel around pit: des no. Total absorption area sq. ft. .Square feet of seepage trench bottom area required :square feet of seepage nit area required - Inspected by : Title: Approved ' Yr' ~•.1. Date L~ 197,E Rejected IN Date 197 13r ~j'L P L B 6.7 " State and County State Permit # Permit Application County Perm' for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Addr 'lop'! A 0 G2L B. LO ATIO '/a, Section T N, R E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: ishwasher YES NO Food Waste Grinder _YES_ O # of Bathrooms Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation Addition Replacement Prefab Concrete *Poured in Place Steel Other s eci 1 p fYl - F. EFFLUENJiDISPOSAL SYSTEM: Percolation Rate 1) 2)_Z 3) /-Total Absorb Area sq. ft. New/Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth - Tile Depth No. of Trenches it ~2,v 0, -a Seepage Bed: Length L_-.' Width f ° Depth OfT ile Depth No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that 1 have sized the effluent disposal system from the EH-115 prepared by the Certifi Soil Tester, NAME . C.S.T. and other information (owner/builder). obtained fro 4iez r 2 = Plumber's Si Vture IMPRSW#~ Ph ne Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). G r E E E E 3 E t 3 E r 1 € ~ 3 E z i 1 E E I ' )o Not Write in Spac Below FOR DEPARTMENT USE ONLY ,te of Application - - Fees Paid: State Count Date nit Issued/~~R//eje~ted (date) Issuing Agent Name sit ,._fi:_ r7 ; lion Yes No Valid# Date Recd ty (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 'Pink copy) 4. plumber (canary copy) Revised Date 6/1/76 EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES - DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 !~C REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: 0/14, Section 4 , TZ&, R 1 f2jcrj W, Township 9* MAunioipali4y 79pY Lot No. Block No.C-0> S UIt.~ MA'P County 5' -Geolx- Subdivision Name Owner's Name: DOU4 C)aVZ/J4_ ~T~fk Doha FOR IM I KE 7440M P501V a-00 0 ~ WAI-70 GS, Mailing Address: 32390 A CE4iEsB L^Nar tfymo ~yI/~//~/ ` GEN a•L~R ~+TY TYPE OF OCCUPANCY: Residence No. of Bedrooms 3 Other EFFLUENT DISPOSAL SYSTEM: NEW X ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS /40&.5-l7S PERCOLATION TESTS /Z /7 It SOIL MAP SHEET 1-12-1 SOIL TYPE t-c-c7r PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- 40 sew 3~>z.~ } ,~>G Qp~-rA JYZ. NaNc 3 PZ 40 I, I, I I J Z A10AIc 3 3 3 3 SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B_ t 9 vajv4 >9f, Pmiw SITS, e, IL~ Igo) FSn L,&j >fEi/Z, G L 94 No~v ' B 7 B 1 TS 7' /8' _ 3 g4 NoniC >°aGi~• g i . 5 It-,, 16) 5H 600 i di 4 O Vc= OSic /G' S if _6 Za B_ /vonrE y94AMm- atTS, sic , /G; 8n s c~/ 44; ts, ig~ S t6CG,1& 94 o c IL LS G,cZL 6 PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy. to/S Sck P. lsoez QMCLV 19- qltb Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. i K. Ayr 1 ?o r ro All I O o ° o t- 4 C3 A"4_W-t01j Mir g ae "Les ® N S !L- All- ~ t >v ,d E E o ~ I o' 1~o St L - / tk -t-FF 7- v LLeY V(e w p R4ve- I, the undersigned, hereby certify that the soil test reporte 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 location of test holes are correct to the best of my knowledge and belief. SS -S'~ 8 Name (print) t /q-M ES ~ • Zu SG/4 Certification No. Address & ~I t~4 ZEE L ST 1Ile72-~itL Lf W/ i S -S y ZZ Name of installer if known CST Signature - 6?tr OPY A -LOCAL AUTHORITY 1- t y ji - 3 J, ~Oi My / { y~yy°rMmx i{1.feI iY let q { `fA i F ~d t ~ v j ;Y :fit ~ • ~e. ~L''9,~ ~ r8 } f ~ s. r El } 4~- IS h j pil .S Fx Fk # r e q ~ x T rAiy} i I + Y` Y i i r + y Y i i y`F T. ti { ~ S yt d YIf ~ 1 ~ ~ T•.i: • ~t~Sy~ .f K.. l Y 1-k r~~ L Y P~ x ~ x S4 ~a rM r SKY r . 4 Fx4~ ~F}. ' ' r t 7 sue' A+ - , f - 'yyr y;•2• - a.'a 7 t S FF ~ T k. , E. C r x' x f a!„a S REPORT OF INSPECTION - INDIVIDUAL SEWAGE SYSTE g.172, Sa~i4 Permit-2/4 ~ a State Septic -1fp3e NAME_4- C A 14C -TOWNSHIP d y _ St. Croix County LOCATIONS S Section ~Lot Subdivision SEPTIC TANK 6 Size gallons Number of compartments- Distance from: Well Building 12% slope Highwater PUMPING CHAMBER Size gallons Pump Manufacturer Model Number_ HOLDING TANK Size gallons Number of Compartments - Pumper Alarm System- Distance from: Well Building 12% slope______ Highwater ABSORPTION SITE Bed Trench Distance from: Well Building 12% slope___ Highwater-- ABSORPTION SITE DIMENSIONS Width of trench '1 Kred area N1 0 e th of rock elw t e in. Length of each line If, 4,. Number of lines hc'-p/t"h' of rock over tile in. r\ y / Total length of lines s f ?-A-ept~i~oC "tt11e~elow rade in. Distance between lines ft Slope of trench.---in. per 1.00 ft. Total absortption area ft Type of Cover: PIT DIMENSIONS Number of pits Gravel around pits ycrs no Outside diameter ft Depth below inlet ft Total absorption area ft Area require ft INSP TITLE APPROVED> DATE -1--98 . REJECTED DATE 198 REASON FOR REJECTION Wisconsin Department of Industry, Labor & Human -.Relat:ions Safety 4 Buil,dTh9s. Division ame o remises Bureau -of Plumbing, Platting $ Fire Protection ' a e -Plan o. .Street ~ ~=Z3-Ff~ oun -c T8N l r To r no ame ass c r C~6/X s. A E~g t " rL4L- er cc ourneyman am er tSlU)C.cS ~uL 50~ L.. ress . ner _ AdIdIres ~ ~ 27Z /~b5o N Gtl.~ /(o W AC . ~i J i v-~tl ~r - .3-3 ,I _v i J ~ 1 111.1 1 70, Ge w C M gna .ur : - - t tAttached.' k 76192(N.09/80) -grta o s ~ : um ~ ng ;,n- i s lp;WeC ector` - Yellow-Local Inspector Pink-Plumber ar~Itesponsible rt , U . - y f:r- r . _ . "M r. ~ . -F A h _ - i , ~Y_Y____._ . _.a ~ ~ y _ Xw ~ ~yM.... ^ w.~MY* ~ t, t ♦ .e~ ♦ ~ 1 Y1 r.~ u:. 4 , _ _ . r,r; . r. F n i i k . , - . Y '+r)~5 r.31t b tax (1L PLB.67 I State and County State Permit Permit Application County Permi # ` for Private Domestic Sewage Systems County C *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: Section A T R f OE (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township J C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New Replacement Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches Seepage Bed: Length Width Depth Tile depth (top) No. of Lines Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits Percent slope of land Distance from critical slope WATER SUPPLY: Private ❑ Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, NAME C.S.T. # and other information obtained from (owner/builder). Plumber's Signatur -gyp/MP SW# Phone #'~aa~ 9 Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. x a s E , r m n c E 0+j6~ , A o. F i 3 Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY Date of Application Fees Paid: State ~y County / Date, Permit Issued/Rejeeted (date) Z Q a 3-~~ Issuing Agent Name ~No State Valid* Date Recd ite copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 4. plumber (canary copy) Revised Date 7/1/78 66 i 44. Nk -70 s, Ya: r r: ..._..,,,..,..,m.~...~..._._....~ mom.,...,:.. IP,S`tRUCTIONS TO SENDER: 0 INSTRUCTIONS PERSON ADDRESSED: WRITE REPLY AT BOTTOM OF FORM; REMOVE CARBON FROM FORM. IILMOVE YELLOW COPY FOR YOUR FILE. 17 155) 4 SEND REMAINDER OF FORM INTACT WITH CARBONS TO PERSON ADDRESSED. RETURN PINK TO SENDER, RETAIN WHITE FOR YOUR FILE. REPLY ,MESSAGE STATE OF WISCONSIN FORM AD-1 FROM Leroy Jansky O.W.S. SUBJECT 13 E. Spruce Street S q ST,F-I Chippewa Falls, WI 54729 ~~-Fr2~E 715 723-8786 N ST-)Or L LI4T'~a ~vd~t N ~Sv ~ TO, DATE MESSAGE Z C-Ak1 E4T > PPH-1 CL1 t) l-1) ~a - ! q -§sl) A N l~ ?oc.l~ l~ 11~''~ TwA-T -tE- R B I` -3-z~ A te's -5ooci 5 w0 u L-L----> PE4(A i Pz, Ar 40L-I-A . j 196.21IA r- si x PEST 4 1 rA -In Cut iF- ~ SIGNED REPLY DATE co .1 1V h l v SIGN THIS COPY FOR PERSON ADDRESSED ~ 4 - T a, 1 t; ~ ~ ~ e..~ ~ _ {:,r _ F . . y .:t i _ +~~'1 ~ r u a~ i ~r, r +4 a t _ 5 _ - i ~ ~A/_. .t~.. Y .s _ •A ~ ; ~ _ ~ x ~ Wits~00stn wee-ai o - muso* kabor & Homan ati.8ns PECT I OPT REST n, 5ar ~144419sri'~ion . . Bliveav f Plumb in Platting... W"Pretec.ttan e - a e U. o. o ry Pre rm sr ~ Z' CRO r 'ter 111 -16 M f i q xa D , n .4 w . ^.YJ or , WA C 'y3 ~1-'k - r ^.4 711 I .1'7 :ary K 3' t s'.,:•w r x ~ , aka a v : ~ - 1 A --A O. -4 ACC4 00 D.I.L.H.R. eroy ans y O.W.S. 4 S_ treat Chippewa Falls, WI 54729 (715) T23-b IM Discussed w1th signature ( )See Attached. DILHR-sBD-(r92(N.09/$0) Signature o is um in p. i e peci White-Inspector Yellow-Local Inspector Pink-Plumber or Responsi a Party Green- er. F ^ e r ~ j A , i v • T ~ 1 . tjY .Pa, fi l -IV . . c ~ x , y~ t 77, - - - ~ - t~ ~ y~ cam. # 4 .~>5~ . w tl . e Y» M , Trw t {-F__ -t4'9 i°-- ,'fit. ~':{is3 'd,;j.}.di--{t: 7'J 14`~.rl '!i.'~li~ :Vi 1 • Sy 1, _ - ~ - F . Y~. :9 . _ - ,ti 1AftS~N61IN-DEPARTMENT-Of H"tT1+* 90Cf*L 9ERVIeE$ " -Sectioi of Plumbing & Fire Protection Systems VA ON-SITE WASTE DISPOSAL INSPECTION REPORT Nameof Premises y'J YAM j. F~ _.X..' K.1..1•t; treet.. City County Master Plumber 'D Address Owner Address s "County Permits aAppropriate State Permits Type of Building: ❑ Public Q 'Single Family m-Duplex-- CHECK APPROPRIATE BOX FOR VIOLATION TYPE OF TREATMENT SYSTEM ❑ Building Sewer i'tJ' p `Conventional Soil Absorption System ❑ Septic Tank ❑ Conventional System-in-fill ❑ Holding Tank ❑ Alternate Mound System ❑Seepage Bed ❑ Holding Tank ❑ Seepage Trench ❑ Seepage Pit ❑ Experimental System BRIEF, FACTUAL COMMENTS AND SKETCH: ! '`ri, , a-- 1' J.: - fl'✓ is-_:_ .i r _ < -71 ~ t ~ ...F G' ,tom-' .~i if.J i/' ~%4 _ Al, f ...i' . .(_-1. f Y 7 :?`7 : " -`i :z,: r ,;x -f / L~1J , f - . f i 1 ,1 y , , w r t . f. , ❑SEE ATTACHED F DISCUSSED WITH PLUMBER ( ) Yes No SIGNATURE (Voluntary) DATE OF INSPECTION Signature of Inspector ,.r White - Inspector Yellow - Local Inspector Pink - Plumber or Responsible Party • FORM NO. 985•A , is ~ , KSU;RVEYQ;RNRERD 352'70 1 CERTIFIED SURVEY MAP N 89036150"E E-W 1/4 SECTION LINE 748.00' 3 W 1/4 CORNER UNPLATTED LAND SECTION 4 T28 N7 R19W W 0 O N 890 04' E 1346.88' IN 896.93' 10/1 224.98, 449.95 224.97 a , 00 POINT OF RECORDED S 450.26 BEGINNING z O z a VOLUME 510, PAGE 98 z w PARCEL NUM ER 9 m ClW n ZIo of w J~z -°o E 1/9 SW 1/4 _ o d; co F- cD O 6 J W C2 o - 10 00 n -~-fo 10- 2 W 2 BIZ ED W 2.51 ACRES 2.51 ACRES I--I o Z12 - 3 Qi m N M -i W N Ll. 1 SCALE IN FEET o a 0 G7 (n O 0 100' 200, z N N O Ld LEGEND z 111 IRON PIPE FOUND 11 89004 W 450.12 0 1 X 24" IRON PIPE WEIGHING , cp ECORDED AS 450.26' 1.68 LBS. /LINEAL FOOT SET 041 0 0p 225.0 225.06' NORTHERLY RIGHT-OF-WAY LINE TOWN ROAD _ EASEMENT EASEMENT DESCRBED IN DEED VOLUME 510., PAGE 98 ~1 8 9 m F1LE~ 0 A40ftCs 30,0 1978 G ~ APPROVED APPROVAL OF THIS MINOR SUBDIVISION 351978 DOES NOT MEAN APPROVAL FOR BUILDING SITE OR SEPTIC SYSTEM, ST. CROIX C01.1NTY REFER TQ H62,2Q, .,O&rRIMINiIVE pARKR'IANNINQ COMMITt1i AND 2014I0 N Volume 3 Page 720