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HomeMy WebLinkAbout040-1216-30-000 C o -0 ° p ~ I a ~ o I ~ I N 4 0 o; - ~ I ~ z _.c II c E 0 a I M m z E z r o oZO € (D U) i o I O Z v ;p 7O U _ o v CD Z 72 N M (D 10 f- a ~KJ a~ • C Ai a L o c c O Q Z H Z N z ' w d co E N j m 12 M. ~ O. n. w J CO c 0 IL FS N ~ O S~~ O T ~L- N O p • Al 3 000 Z IL 0 CD CD M J V ~ rn rn e=ach a o o d n ~ L C n ~ Q } N cn co 7 w CD ( O M H C O C~ O II~ > N COL A y U d 0 0 r G M 0 c COL O. c -O N V ~o CO~o _oo 'I H C y L L nd„ co m I~ N T -8 co d = I- ~ C L • 4 to 2 7 O S E E U O r m .2 O Z - L (n 0 ~ I :E E~ V ~i v~ `m R € a d 5 EL a. • em a m m r'~l E c c t Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP 77 SEC. T9 N-R f W ADDRESS) CROIX COUNTY, WISCONSIN SUBDIVISION ! ~Si74 LOT / LOT SIZE A C,t2 PLAN VIEW Distances and dimensions to meet requirements of IIHR, 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM S ►CE ,1P7 ` f! cck~ g. o 9A1 i INDICATE NORTH ARROW ~ n BENCHMARK: Describe the vertical reference point used wAnE o Lev (:7z $ C Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: 1Ooi c4z" Number of rings used: 4j Tank manhole cover elevation: 1, Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road.: Front,ko Side,O Rear, O feet ..From nearest- property line Front, OSideRear,©~ feet Number of feet from: well Q / , building: _33 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAbdER 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 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: K Width: Len$th:/ e)O Number of Lines:D/(jc7 Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear, 0 Pt Number of feet from well: l0 . Number of feet from building: e,z (Include distances on plot plan). SEEPAG IT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box 0 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, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector:- ~d) 1111-A /&"J/, Z_ 5 d Dated: d Plumber on job: ~ A va e?-f License Number 6 2 3/84:mj DffPARTME1IT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION OX 9 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION r~ S'O I 3707 State NYC, ~2 SN-R 19G1 ~E, (If a s fined D. Number: Town a4 Tuy ldt q ?n CONVENTIONAL ❑ ALTERATIVE Titan Ouititu. Vista ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERM IT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Catvin Bwttan 314 Ptea6ant S;fteet, Robes, W1 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: L 2e J. Myeu 6219 St. cuix &8 /2 °G SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER / PROVIDED: PROVIDED: ! Cr" ES ❑ NO ❑ YES O BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT T FRESH r ` ALARM: FEET FROM LINE:O w AIF INLET EYES NO EYES A NO NEAREST (p/ !J~ DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: E] YES El NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) I ❑ 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 INSIDE DIA.: # PITS: LIQUID BED/TRENCH TRENCHES: MA RIAL: PIT DEPTH: DIMENSIONS ,J /,Yv /111 GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH LINE/' / AIR IN ET- BELOW IPA ABC: OVER' ELEV. INLET: ELEV. END: PIPES' FEET FROM 44. 2-72-7 NEAREST -011- 91 1 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 E NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: 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 a~"2 03 in county file for audit. Sketch System on Reverse Side. SIGNATURE' TITLE: Zoning A&n " SBD-6710 (R. 06/88) ama6 an al LHR SANITARY PERMIT APPLICATION oouNi/ In accord with ILHR 83.05, Wis. Adm. Code ATE SANITARY PER )L_ -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 1Avislon l tc~ 8% x 11 inches in size. to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PRgPf RTY OWNER PROP RTY L C TION Tr2 , 4R/ E (or PROPERTY OWNERS ILING ADDRESS LOT # BCITY, STATE C ZIP CODE PHONE NUMBER PARCEL DIVISION NA OR CSM NUMBER EAREST ROAD II. TYPE OF BUILDING: (Check one) El State Owned VILLAGE ❑ Public 01 or 2 Fam. Dwelling-#~ of bedrooms ~ A NUM 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 20 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 120 Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. %New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 M 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. PER. RAE 6. SYSTEM ELEV. 17. EFINAL LEVATION GRADE RE IR~sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Mn~ ` ~15?s I? Feet d a2~ / Feet I VII. TANK CAPACITY Site Fiber- Exper. in allons Total # of Prefab. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App strutted Tanks Tanks _ Septic Tank or Holdin Tank w 1600 0 ~ Lift Pump Tank/Si hon ChamberQt1 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' ignatu e: (No Stamps) MPRSW No.: Business Phone Number: ~ J . C°2.s X02/ ~SZd Zi Cod Plu er's Address (Street, Wty, State, t on 7i C GL is, IX. COU /DEPARTMENT USE ONLY Issuing A Wit Signature ( Stamps ❑ Disapproved Sanitary Permit Fee (incrchar Groundwater Date ssue Surcharge Fee) *Approved ❑ Owner Given initial _ 'T -D Adverse Dote i X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS a 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 accgrate this sanitary permit appligation 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 13% 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 Ow,~12' Z~a /C) Location of property 51/9 N`_1/9, Section• T e N-R W Township Mailing address t ojo~ 6dr S Address of site Subdivision name ;i_ / Lot number Previous owner of property /lazes Sc e gaarz ekyv ?yr71L Se4gz)R~e,n Total size of parcel DS_ 14C/2C--,r Date parcel was created ~Rrt~ /gam /9 iry Are all corners and lot lines identifiable? es No Is this property being developed for resale (spec house)?--L-Yes No Volume. ,and Page Number 841 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described In this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. ~VW ZV_l ; and that I (Ye) 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 u y ecord,d in the Office f the County Register of Deeds, as Document No. Signature of Owner Signature of Co-Owner (If Applicable) :--I C~ Date of gnatu a Date of Signature 71, "T I THIS MACa NKGSMVM ,wA B •m. /TAT2 SM OP PORN 2-i s s ch rtz need f ......,a 0! MA.0.1 j JAN 1919A9 d 12:05 P M Y~ ~ ~a r »~..~.lsi1►..l►r►. Alu~tioW....BUxS.K1Y.. ~ •+j ~ ' tit..' ...a M II 09TUM To . . w r........~.. » MIa l~Mew dnnid wl Mrs it x.>ti...f►111 1E ..................County. Tax P ' No:.... ; Lot S and Lot: 6 Lot 70 Plat of lcanquility vista in the Town of Tcoj# St. Croix County, Wisconsin. : - . XMpdM fa wwroRths: Subiect to easesenta, reservations and restrictions of record. this 4e J77 day of bwe.... ~!IY.(/! f'.............. .....................................................................(SEAL) x >~~.v... ~,?....................(3lAL) SCHWARTZ H • • (SEAL) ~ 2 • .....RUTH. E. SCHWART; 5 AOTRUNTICATIOW ACKNOWLEDOXXXT ~a itfeRSrns(s) STATE OF WISCONSIN s 4115. St.....Croix................County. wsdmmtieatd this ........day of 19.. Personally came _be-fgre me ~thi~sp dq d . j ~iocoa+l~wr 3!~VIJA w....... aisw mow N r Roger,. H.. Schwartz and Ruth B. • Schwartz I TITLE (U got, : MZitBER STATE BAR OF WISCONSIN _ _ Udlootind by 1 406.06. Wis. Stats.j.......,......:,`,to me know S... who.eseeatad..tM • n to be the person 'J toreaoing instrument and acknowledo the same. 1. THIS INSTRUMENT WAS DRAFTED BY-• 44 ~I . Fill.... •...a.13~~_ - - a7 ............btu Notary Public sj . Croi.X Coggr, Wis. (/itaatures map be authenticated or ack ~Bcth My Commission is permanent.(If not, state expiration we set neeesearp.) date: . _ I9..9 L..) y •~e/ M aArr sbba is w e.Msity should bs typed or grin" below their .isnatur.•n. + STATR DAR OF WISCONSIN FORM tie. a - list STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER A"i ROUTE/BOX NUMBER FIRE NO. / CITY/STATE T7 ~SL` y ZIP Sy0 /6 PROPERTY LOCATION: 50) 1/41/4, Section T g N, R__/F_W, Town of 7-zw9 / , St. Croix County, Subdivision It IT-Li 1 , 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 DATE 9 10 St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDING INDUS~l,'RY, - DIVISION N LABOR 7969 AhD, PERCOLATION TESTS (115) MADISOP.O. BOX N W 53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNS P/MUNICIPALITY: LOT NO.: BLK. NO.: SU IVISION NAME: 5W1/ 44 / S /Ta 81'1/11/9' E (o Q T COUNTY: OWNER'S BtTYER" o}E: Wo NG ADDRESS: 57- a I TS V/1 Sq0,?'3 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: Residence 3 New ❑Replace /4-9-d'x RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLrHOdLDIS NG TANK: RECOMMENDED SYSTEM: (optional) ES ❑U ❑S®U ®S~U ❑S~J`ll ®U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the ,Q under s. ILHR 83.09(5)(b), indicate: ~Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- Z-- AQ&'atf S B-a 02. q B- 3 Yq o- y s s B- 7f ,off B-S a 9X - 7 79 B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD 3 PER INCH P y 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 A = PER L° HoL~S p =3086 No~Es F r A/y /11h t 4?te'n1few'I 27 - w ~N. T /pRr - fro R oAQ `gip '50 uT~+-a~ovER {~o~o PRo Nose I, the undersigned, hereby certify that the soil to s report on this form were made by me in accord with the procedures and methods specified in the Wisconsin Admini'strative Code, and that the data recorded a d tIf to tion of the tests are correct to the best of my knowledge and belief. NAME rintTESTS WERE COMPLETED ON: (a - 7- JW AD ROSS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CS7 36'jt8 ;?6S- a6/ CST SIGNATURE: o DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - INSTRUCTIONS F -MPLE FO M 115 - _ - 395 1"~ a cc,m; your repo clud"6: 1. Ce 'Aete leg<,,': description, seci.iorr must clear r,,ate whether this a residence r s cominei vial [)r iect; 3. iviF„~ !P nu~ttl°u, comMerc:,.. planned; 4. Is or repla€ ;:x in; f Col y iting boxes. A SITE IS DING TANK ONLY IF ALL OTI, ;IS ^vRE RULE[ =JUT BASED u . 6. PLEA ~ievi~ition. here for writ,. cc r the plot plan; NA F diagiarn y locating yo >t locF'io s, wing to e is preferred. A red ii a irl< a elevation -It are cl~ 3 t=?rmanent; Ch dates, names, a flood p6ca _ Li-.it exemp- 10. €;levaticni do( ply, place N,, ? at~prcpi~iate box; 11, S ce your curr Tess and your f ~:a(iort nu, 12. Flake k, ad distribute regUired. ALL TESTS iVIU br- FILED WITH THE LOCAL Y VIIT iIN 30 DAYS OF CON'IPLE ION. IEV ATiO S FOR CEI 3 SOIL TESTES Sc sand Textures t ymbols 10"3 -frock 10"l .one Jr { °ider 3") ,tone ` H _h Grour y S "d - Percolation Rai ined s [rieri.rm Sand Well is - Fine Stand 2u is Loalny Sand - T i1 I Sandy Loan L I l:,im Bli B o n c i =3in B Gy f y '_oarn y low Clay Loam R s, cl ay Loaln rnot - IV1c' s, iy W1 11 sic. v, fIf - fev4 aint *C CI cc .3 SO pt Peat rrla'il P HWL Six of al soil texrli'es y , c st disposal BM E `yRP VVertic.; Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private n a permit application must be submitted to the appropriate local authority in order to obtain a e sanitary permit must be obtained and posted prior to the start of any construction, DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code Z: STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO PR ERTY OWNER PROP TY C TION -Oh % /a, S .5/ T..2 X, N, R E (or PROPERTY OWNER'S MAILING ADD ESS LOT NUMBER BLO NUMBER SUBDIVISION NAME L 7_ -51-1 / 5 6IJ 77 ZIP CODE PHONE NUMBER q CRY NEST ROAD, LAKE O 4/-L NDMAR,KC C Y, STATE _Zp of U ,:Z VILLAGE : G. 7 7 3Z( ,5") 19' TOWN OF: II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 0SEdLLl WOR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable) 1. a. XNew b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in ##1 and only one in ##2) 1. a. Conventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ seepage Bed b. See a e Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square F t): PROPOSED (Square ZFet): Arv Feet Private ❑ Joint ❑ Public '_7 _S ZV A(7 VI. TANK CAPACITY Site incal allons Total of Prefab. Fiber- Exper. INFORMATION New xi sting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank 40-w - O ~C ❑ Lift Pump Tank/Si hon Chamber [7 El . El 1 ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Sign ure: (No Stamps) ' P PRSW No.: Business Phone Number: Plu ber's Address (Street i , State, Zip C d . Name of Des' ner: 11*- g ! Vill. SOIL TEST INF MATION Certifie 'I Tester (CST) Name CST # CST's ADDRESS (Street, , State, Zip Code) Phone Number: i IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate issuing Agent Signature (No Stamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee Adverse Determination ~ E I X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, systemlocation, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; Il. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair,- IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than E31/2 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the r result of over 2 years of steady negotiation and public debate. The groundwater bill Grounds ater included the creation of surcharges (fees) for a number of regulated practices which Wiscor~in`s can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried 'reasure a is used in your building is returned to the groundwater through your soil absorption E o f system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398 (R.03/86) i °F REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS RY, G DIVISION P.O. BOX N WI 53707 LABOR AND PERCOLATION TESTS (115) MADISO HUMAN RELATIONS (H63.090) & Chapter 145.045) MVqMW9;=V: OT NO.JBLK. NO: SUBDIVISION NAME: LOCATION: SECTION: TOWNSHIP/ r 5 vv /4 / /Ta ON/R J9 lor) W p 7 ~ Tiq Qu. 1! ' ~ST 96 COUNTY: OWNER'S BUYER'S NAME: AILING ADDRESS: ,5T. o/ G c o To 'Al 5y USE DATES OBSERVATIONS MADE g Residence BEDRMS.: COMMERCIAL DESCRIPTION: PROFILED CRIPTIONS: OLA ION TESTS: IAIResidence VNew ❑Replace / RATING: S= Site suitable for system U= Site unsuitable for system r ONTIO❑NAL: IMOUND: ~ IN-GROUND-~ URE: SYSTEM-I L HOLDING TANK: RECOMMENDED SYSTEM: (optional) 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: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 13-a ~ o~ . 8 S F s 131 B-3 $ loo-y E .4 C .95 a/ B-5 72 9F7 7 S / ~5 B1 B- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERT PER INCH P- O ~ P_ 8 E 3 ;k q 41 U. V-0 M 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 A.p i E a 1 • ~&qI'- 7 r e / b i E } s ~ e j E , F C) C7, Vill- c"-i P 04tH 41 0VeR Ro'g o oP°st Noys'r I, the undersigned, hereby certify that the soil to s 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 an J the to ion of the tests are correct to the best of my knowledge and belief. NA (print): TESTS WERE COMPLE D ON: `0 AD RE S : o D CERTIFICATION NUMBER: PHONE NUMBER (optional): C STc~~ s ab~ CST SIGNATURE:( DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. LILHR-SBD-6395 (R. 02/82) - OVER - TRUCTIONS FOR COMPLETING FORM 115- SILO L To be a c d accurate sail test, your report must include: 1. C gym; ' , _ ion; arly icate vvhetl is a residence or c 1 project; t, )r commE, d e - ~ planned; 4. ~ ant A S[ : ABLE FOR D ~IG TANK ONLY IF ALL j BASED CON' , . ~sre for ms and completing the plot plan; 1. ly locating } cations.~ving scale is pre" med. A tical elevatio-i r fit a r, , 1 e it; L ~xe.s as to dates, r-1 J~ tIood p1 a, p r xernp- -1-in, el-v(aiior does zut apply, p l-- A - box; 1 ` rt 1 ' s and your certification n, d" E.C. ALL. SOIL TES FILE[ VVITH THE , l Y ? VITf 1 , ~F COMPLETION. __RTIF._ -DIL TL_ S cols ;3"1 f-l C - r !s Than i Bn - B! Gy - L:arr R 1_o. n mot lC: f1I - CC ~l d - HVVL - L i siY I BM - VRP V " ci;' Point t . I . Lo. ~a r r r, k t3`'f r DEPARTMENT OF. REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDGSTRY,, DIVISION P.O. BOX 76 LABOR AND PERCOLATION TESTS (115) MADISON W1 3707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOT NO.:BL NO.: SU IVISION NAME: LOCATION: S TION: TOWN P/MUNICIPALITY: K. w'/ 0/ / S /Ta A/R/9' E (o O , r COUNTY: OWNER'S Bt1TEFr3-NA1%t: MA IN ADDR SS: N firs IAA L6:'y Q 2,3 STC0 Ac. USE DATES OBSERVATIONS MADE NO. BEDRMS : COMMER AL DESCRIPTION: R I S7/0-Ler ESTS: (Residence 3 (New ❑Replace /O_ R ATING: S- Site suitable for system U- Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSUR : S STEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) us EA ❑S®u MS❑U ❑SSM ❑SP? 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: Floodplain, indicate Floodplain elevation: _1100~ '7771 1 _A~ PROFILE DESCRIPTIONS BORING TOTAL P H T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVER- EST. HINTS TO BEDR CK IF OS ERVED SEE ABBRV. ON BACK.) B-1 61q /02 B-~ ~y 02. y :;7 yy B-3 (FIf > y S B-S a 9~ S > fio ~a B- PERCOLATION TESTS 4TE DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PERIOD PER INCH 1~ 3 14 (7 :Y- 4& are . 3 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 I - - t a- r ,d `p QeR yb~ ~s I I q0 t a,1 ' i TN 006 i b4 . . . g~ ► gar ~ p ~ oAQ P t ' A► I .50N 031.0 vlgkRo # o PRov /ao~,s~ 1, the undersigned, hereby certify that the soil to s report 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 a d ttf to ion of the tests are correct to the best of my knowledge and belief. NAM rint : TESTS WERE COMPLETED ON: ~d-7•(f8 D ROSS: C RTIFICATION NUMBER: PHONE NUMBER (optional): 157 36 # 264- 26/ 62 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - Parcel 040-1216-30-000 10i18i2006 09:46 AM PAGE 1 OF 1 Alt. Parcel M 15.28.19.1041 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 O - KRUPKA, THOMAS A & BERNADINE I THOMAS A & BERNADINE I KRUPKA 366 RUTHIE LA HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 366 RUTHIE LA SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 2.053 Plat: 2548-TRANQUILITY VISTA SEC 15 T28N R19W 2.053ACRES LOT 7 Block/Condo Bldg: LOT 07 TRANQUILITY VISTA TROY TWP ALSO AN EASEMENT DESC IN 875/154 &883/504 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 15-28N-19W Notes: Parcel History: Date Doc # Vol/Page ~/Ir ul Type 07123/1997 l~ 07/23/1997 885/22 07/23/1997 8 _ 2006 SUMMARY BillM Fair Market OValue: with: 60 , G, Valuations: Last Changed: 07/22/2004 TO Description Class Acres Land Improve Total State Reason ~L RESIDENTIAL G1 2.053 48,400 147,900 196,300 NO Totals for 2006: General Property 2.053 48,400 147,900 196,300 Woodland 0.000 0 0 Totals for 2005: General Property 2.053 48,400 147,900 196,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 316 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00