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HomeMy WebLinkAbout026-1046-60-000 / c I � ) � � § : � ¢ � b � 2 � � ] � � I a � U. 7 e � t $ � I @ ■ f 2 % w . E � � � • e � 2 / § : 2 § � B z . k § 7 E / c � Q } m k } ) .. k � 2 0 ■ , 7 / ca 2 to / § $ \ § # ,� { \ b b \ E e 7 CL . CL » k o B � Z E @ o ■Q / 0 a a a 2 / E 2 § .9# J I C-4 fo } \ c b E Q § j f R E $ a c ■ a § § o c = / E S . k kk ) \ . - 3 q t e § a § E 2 g $ ± a o 2 $ / 2 0 CL E ) 'E : k a ; k J a o 2 : . > r Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER �M e Lle, _ TOWNSHIP eZ�laIZ SEC. T�,�_N-R W ADDRSf/ � Grydx _ ST. CROIX Cowrc, WISCONSIN BUEDIVISION LOr --` LOT SIZE PLAN VIEW Distance• and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I la� � � y -mil �3 • '0 � �� 30 INDICATE NORTH ARROW 319MCHNARR: Describe the verticnl reference e rn P.J.nt used Elevation og vertical reference otnt: p , ._ Proposed slope at site: 8E11'IC TANK: "Hamc t u r e r: s-izs'-t�r% .1 iuld Capacity: Number of rings used: / Tank mnn)wl.e cover elevation: _ 9i Tank Inlet Elevation: Tank Out.t;A L evasion: y ,� Number of feet from nearr i R-nd: Front, S U:.�,O Rear, feet � • From nearest. ptQp(..j. ;.Jnc Iront,�>�1 1r ,0 Rear,0 - feet t r PUMP CHAMBER Manufacturer: Liquid Capacity: ' Pump Model: pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: -- Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front. O Side, O Rear,O Fr•�.. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: �_ Trc7,ch: Width: /f2t Lenfi:hs Number of Lines: Area Built: C Fill depth to top of pipe: Number of feet from nearest property line: Front O Side, Rear,O 1t� . Number of feet from well: ��,/ Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Sizes Number of pits: Diameter: Liquid depths 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, OFt.__,_, Number. of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated! Plumber on job: ` License Number: �e - 3/84:mi 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,SE 4,Sec. 15 ,T30-R18 ❑ State Plan I.D.Number: CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Richmond ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound AVE RMI OLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: James Leverty Rt. 4,Box 40 , New Richmond, WI 54017 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: Byron Bird Jr. 3318 t. Croix 128686 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑YES ❑NO ❑YES ❑NO NEAREST—� DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ❑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 ❑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 .: ##PITS: LIQUID TRENC HES: MATERIAL DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER RTY WELL BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET: ELEV.END: PIPES: FEET FR AIR INLET: 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 DIMENSIONS TRENCHES: MANIFOLD PUMP HDRILLED DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEVATION AND ELEV.: ELEV: ELEV: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: RECTLY: COVER MA TERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: 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) pIL R SANITARY PERMIT APPLICATION ---•e.....,..e..,,,,.,,�,,,e� In accord with ILHR 83.05,Wis.Adm.Code 77;j Grni . -Attach complete plans(to the county copy only)for the system,on paper not less than AR�RMIT# 8i4 x 11 inches in size.-See reverse side for instructions for completing this application. e ision previous application I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. STATE PLAN 1.D.NUMBER PROPERTY OWNER PROPERTY LOCATION c s2 (�crf % J>5nX, S T , N, R PROPERTY OWNER'S MAILING ADDRESS E (or) - LOT# BLOCK# CITY,STATE Lc.J �� �`� "`► IP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER U. TYPE OF BUILDING: (Check one) State Owned CITY (�' VILLAGE NEAREST ROAD ❑ Public LC11 or 2 Fam.Dwellin d�C. Ga . g-#of bedrooms A EL TAX NUMBER(S) III. BUILDING USE: (If building type is public,check all that apply) PP y) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing ome 3 1-1 Campground ty g 10 ❑ Outdoor Recreational Facility 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 5 ❑ Hotel/Motel 12 El Service Station/Car Wash 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. ❑ Repair of an B) ElSystem System Tank Only Existing System Existing System A Sanitary Permit was previously issued. Permit# V. TYPE OF SYSTEM: (Check only one) Date Issued Non-Pressurized Distribution Pressurized Distribution Experimental 11 0 Seepage Bed Other 21 Other 3 0 0 Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench In-Ground 13 ❑ Seepage Pit 22 ❑ Pressure 42 ❑ Pit Privy 14 ❑ System-In-Fill 43 ❑ Vault Privy VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 2,ABSORP.AREA 13.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE REQUIRED(sq.ft.) PROPOSED(Sq.ft.) (Gals/day/sq.ft) (Min./inch) 6 SYSTEM ELEV. 7. FINAL GRADE ELEVATION VII. TANK CAPACITY G - Feet '—Feet INFORMATION in allons Total of site New istin Gallons Tanks Manufacturer's Name Prefab. Con- Steel Fiber- Exper. Tanks Tanks oncret structe glass Plastic A Se tic Tank or Holding Tank pp' Lift Pum Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumber' ignature:(No Stamps) 1 MP/MPRSW No.: Business Phone Number:RZ Plum s Address(Street,City, ate,Zip Code): O � ~ IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee(Includes Groundwater Approved El Owner Given Initial .C O� Surcharge Fee) a e ssued Issuing Agent Signature(No Stamps) X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(formerly P1b-67 R.11/89 ( ) DISTRIBUTION: f)rir+t—1 to GotrntY 0 VA c'nnv T�r�sAsn�.:, _ k 14 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, REPORT DIVISION LABOR AND LATIONS PERCOLATION TESTS (115) MADISON IN 53707 HUMAN RE LHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHfP UNICIPALITY: OT NO.:BLK.NO.: SUBDIVISION NAME: /r N/WE ,� - COUNTY: MAILING ADDRESS: Gro r �Gchi,,� D i �.�C� E DATES OBSERVATIONS MADE �Q ❑New eplace*esidence IMOFILE DESCRIPTIONS: PERCOLATION TESTS RATING:S=Site suitable for system Us Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE:,SYSTEM-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) �$ ❑U R$ ❑U ®$ ❑U ❑$ MU ❑$ JRU 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: O PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROU NDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST.HIGR—ESf— TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) BJ D B- B- B- N PERCOLATION TESTS DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PEW Q1 PER 1 D 2 PER INCH p_ t P- G 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 ) i I' I sw- - ' I TN --- r L. � .. 4s. I 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. AM print : ITESTS WERE COMPLETED ON: vn l;/ r. _ /O/,ye ADDRESS: CERTIFICATION NUMBER: FHONE R(optional): o r 00/ 3 Let CST SIGN E`. DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. nu ua cans-�ua to tnia.11 nx*lr'R PLOT PLAN PROJECT e amen lov ADDRESS o Se-1/4 1/4/S/STr ' e>NN TOWN MPRS Byron Bird Jr. 3318 DATE _ COUNTY y V� BEDROOM. CLASS PERC_ / CONVENTIONA rN-GR6UfTD PRESSURE CONVENTIONAL LIFT_MOUND HOLDING TANK SEPTIC TANK SIZE LIFT TANK SIZE 60-66 TANK GIES- HOLDING TANK SIZE ABSORPTION AREA PERC RATE G , BED SIZE loX 1116 Benchmark V.R.P. Assume Elevation 100' Location of Benchmark � � * H.R.P. C3 Borehole Q Well Scale = Feet O Perc Hole System Elevation Uent 12' Grndp TYPAR COVERING 2' 12" 3- 4 6' O 3' 3' 0 3' 1 8, Sewer Rock 12' 18' hf Grp , �'• . 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 State Plan I.D.Number: SE 4j SE 4,Sec. 15 ,T30-R18W❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Richmond ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound Qtw OF PEWIT H ER: SS OF PERMIT HOLDER: INSPECTION ATE: James Levert ADDRE New Richmond WI 5401 to—A&_ l <i6 BENCH MARK(Permanent reference point)DESCRIBE FMCRIAFFR - REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: TMP/M­PRSW No.: County: Sanitary Permit Number: ron Bird Jr SEPTIC-TANK/HOLDING TANK: MANUF CTU R: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: BOO O q3 toCv BYES ❑NO ❑YES NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM �1 C)O LIN�:w AIR INLET: ❑YES X10 Cx- ❑YES NO NEAREST�♦ Vv DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO 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: WIDTH: LENGTH: NO,OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID BED/TRENCH / TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH D18TJ4.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: TNO.. R NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABO E COVER: E^^ INLE LEV.END: FEET FROM LINE: A�INLET: 11 e� n z-q I P, �I NEAREST.. V t 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 I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED D ED EPTH OVER TRENCH/B DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: 1 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: DA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION _ APPROVED PLANS ❑YES ❑NO [--]YES ❑NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMEN❑ OM ❑ ❑ FEAREST LINE: YES NO ❑YES ❑NO NEAREST i n i 70 i Retain in county file for audit. Sketch System on Reverse Side. SIGN . SBD-6710(R.06/88) ,o 1,4nince M J ILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT# –Attach complete plans(to the county copy only)for the system,on paper not less than 1:1 / 0 8%x 11 inches in size. t,( f re .sion previous application —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION ,S T , N, R E(or) PROPERTY OWNER'S MAILING ADDRESS j L LOT# BLOCK# CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER r� 16-4ol 6 O1 11. TYPE OF BUILDING: (Check one) CITY r NEAREST ROAD ❑State Owned VILLAGE; ❑ Public [X1 or 2 Fam.Dwelling-#of bedrooms AR ELTAX NUM ER( ) III. BUILDING USE: (If building type is public,check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 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) Of A) 1. E1 New 2. Replacement 3. El Replacement cement of 4. ❑ Reco Existing System 5 ❑ Ex sting System nnection System System a Y 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 Q Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 2.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION Feet Feet CAPACITY Site in allons Total #of Prefab. Fiber- Exp VII. TANK Manufacturer's . INFORMATION New istin Gallons Tanks Manus Name Concrete Con- Steel glass Plastic App. structed Tanks I Tanks Septic Tank or Holdina Tank Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumber' ignature:(No Stamps) PRSW No.: Business Phone Number: MP/M t C ? "A Atr. Plumb s Address(Street,City,state,Zip Code): © Gf IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e ssue Issuing Agent Signature(No Stamps) Surcharge Fee) Approved ❑ Owner Given Initial n- Adverse Determination v 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 t 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: I. 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. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers;wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD4M(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/contractot, (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 Location of property 6E 1/4 J _1/4, Section J` , TAN-R IS W Township w/0,h mr)yl QL - Mailing address 2L—�� d ,� O Address of site Subdivision name Lot number Previous owner of property Total size of parcel ��?�® 0 o, Date parcel was created Are all cornets and lot lines identifiable? _f�Yas No Is this property being developed for resale (spec house)? Yes N0 Volume Gam/and Page Numberp_„�5P' as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITN TNIS 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 (out) knowledge; that I (we) am (are) the owner(s) of the property described In this information form, by virtue of a warrant�c7�a recorded In the Office of the County Register of Deeds as Document No. yy//��LL ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, . to run with the above described property, for the construction of said system, and the same has been2duly recorded in the Office of the County Register of Deeds, as Document No. J ) . (-kl AA-4'A gnatute of Owner igna t u r a of Co-Owner (I A !cable) 10 - 1 (0 - 5 2 Zo - /� =W Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA 3� WARRANTY DEED L .VOL 69.1 PAGE 249 Michael L. Thielen and Deborah K. Thielen, REGISTERS OFMCE husband and wife, as joint tenants ST. CROIX CO., WI& Rec'd, for Record fits 26th James T. eve an v day of June ne AD 5 4 conveys and warrants to 3' •3' husband and wife., as o enan s at 1 :00 P co fplger Of Dwdo RETURN TO Northwest Federal S&L P.O. Box 160 the following described real estate in St. Croix County, I New Richmond, WI 54017 State of Wisconsin: Tax Parcel No: Part of the Southeast Quarter of the Southeast Quarter of Section 15, Township 30 North, Range 18 West described as follows: Commencing at the intersection of the centerline of County Trunk Highway "Q" and State Highway 1165"; thence South 89047' West 550.00 feet; thence North 00 37' 4011 West 115.0 feet to the place of beginning; thence North 00 37' 40" West 556.69 feet; thence North 850 5914011 West 384.33 feet; thence South 00 37' 4011 East 584.99 feet; thence North 890 47' East 383.08 feet to the place of beginning., containing 5.02 acres more or less. Subject to easements, restrictions, reservations, if arty. "'Y3,100 This is homestead property. (is) (is not) Exception to Warranties: Dated this 25 day of June - ' 19 84 (SEAL) (SEAL) • chae L. ielen (SEAL) vJ � r (SEAL) Deborah K. Thielen AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. St. Croix County. authenticated this day of , 19 Personally came before me this �5 day of June 19 84 the above named Michael L. and Deborah K. Thielen TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to m nown to be the on S who executed the authorized by§706.06,Wis.Stats.) for g g instr ent acknowledged HAASt?fI THIS INSTRUMENT WAS DRAFTED BY NARY rtMLIC J.R. Haasch, Broker 82vkTE OF WI SCONSIN John R. Haas chuy commumON E)xIrms Notary Public St. Croix County,Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 10-7-84 -, 19—.) Names of persons signing in any capacity should be typed or printed below their signatures. NTF 2280 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Forms,P.O.Box 1075,Green Bay,WI 54305-1075 Form No.2—1982 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER � ,. � �O� O FIRE NO. ASS CITY/STATE f- " t,A gnn-Aci I ZIP E`401-1 PROPERTY LOCATION• SE 1/4 /4, Section _._i , T 3 N, R--W, Town of C/ man 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 DATE 0 - A-) -CSC 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 & BUILDINGS INDUSTRY, DIVISION P.O. BOX 796 LABOR AND PERCOLATION TESTS (115) MADISON WI 3707 HUMAN RELATIONS LHR 83.09(1) & Chapter 145) TOWNSHIP UNICIPALITY: OT NO.:B K.NO.: SUBDIVISION NAME: 1/ - y %T N/ E to -.-� --- MAI LI A COUNTY: �i • o, E DATES OBSERVATIONS MADE '770 NO BEDRMS.:ICO ERCIAL DESCRtPTION:j�iesldenee ❑New VRReplace RATING:S-Site suitable for system Us Sit@ unsuitable for system ONV N NAL: MOUND: 1N- -IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) SS DU ®S DU ®S ❑U OS ®U I ❑S JRU I If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.ILHR 83.0915)lb),indicate: Floodplain,indicate Floodplain elevation: Q. PROFILE DESCRIPTIONS BORING TOTAL D P H TO GROUIN DWATER-INCHES CHARA TER OF SOIL WITH THICKNESS,COLOR, TEXTURE,AND DEPTH NUMBER DEPTH IN. ELEVATION OBS RV D TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B- ) o-lam /�/S�'//G -,3•?/.�'�a./,3� , B. c7 q,,% B-,3 0 B- B- B- PERCOLATION TESTS TEST DEPTH . WATER IN HOLE TEST TIME DROP 1 WATER LEVEL-INCHES RATE MINUTES fff NUMBER INCHES AFTER SWELLING INTERVAL-MIN. I/D t P RI PER INCH P- �o e— P- G 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 hors tontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percen of land slope. SYSTEM ELEVATION II. } r. t� �. r _ - . 1 I I I ; 4 .4f , 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 date recorded and the location of the tests are correct to the best of my knowledge and belief, NAME print : TESTS WERE COMPLETED ON: 4901? 1W r. _ DD CERTIFICATION NUMBER: HONE NUMBER(optionall: CST SIGN R E: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. PLOT PLAN . r • PR 'JECT amen=� ADDRESS O)e Ile � TOWN MPRS Byron Bird Jr. 3318 DATE COUNTY BEDROOM CLASS PERC�_CONVENTIONA WGRO D PRESSURE CONVENT1 NAL LIFT MOUND_HOLDING TANK SEPTIC TANK SIZE � -XJ LIFT TANK SIZE HOLDING TANK SIZE ABSORPTION AREA 6 PERC RATE 3 BED SIZE /o�X 1116 Benchmark V.R.P. Assun a Elevation 100' Location of Benchmark * H.R.P. C3 Borehole Q Well Scale = Feet O Perc Hole System Elevation Uent 12* TYPAR COVERING 2' 12' 3- 4 6' 0 3' 3' O 3' 1 60 Sewer Rock 12' 18' t I � - firs • 6 3 q4 J�lrn I Parcel #: 026-1046-60-000 02/09/2007 09:52 AM PAGE IOF1 Alt.Parcel M 15.30.18.230B 026-TOWN OF RICHMOND 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 JAMES T&KIM E LEVERTY O-LEVERTY,JAMES T&KIM E 1288 CTY RD G NEW RICHMOND WI 54017 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description * 1288 CTY RD G SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 5.020 Plat: N/A-NOT AVAILABLE SEC 15 T30N R18W 5.02A IN SE SE COM CL Block/Condo Bldg: HWYS 65&G TH W 550'N 45'TO POB TH N 556.69'TH N85 DEG W 384.33'TH S Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 584.99'TH E 383.08'TO POB 15-30N-18W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 691/249 2007 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/30/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.020 54,000 76,000 130,000 NO Totals for 2007: General Property 5.020 54,000 76,000 130,000 Woodland 0.000 0 0 Totals for 2006: General Property 5.020 54,000 76,000 130,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 306 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00