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HomeMy WebLinkAbout030-2054-50-000 jj 4 K 0 t 7 / � � ) � 2 . f x § � k ) CL a/ \ » tm % } \E U. 2 = �� § \kk ) n � � � � / � K § z9 w « k 2 / \ a m \ k \ ° t I / 6 ) ) / j of '� 0- \ \ § z J z \ c z } % k E u C\1 ) CL m ( & & k 2 0 F ) 2 � ■ ■ - $ } \ § k k � ) -� $ ; % a 2 a § - 2 � v 2 G 2 ƒ 0 / � � « 2 0 c 2 � a 2 # » n , % _ . c § ` ° g c @ J o 0 k § § 0 ) S , 2 / / o � o e . \ & � c - � � , R o o 0 § $ E k \ \ ] / o z { / 2 3 � ■ � 2 ) M k I , : " a » E ' k a § cn Q 3 a U) 0 ._� Parcel #: 030-2054-50-000 02/18/2005 02:26 PM PAGE 1 OF 1 Alt. Parcel#: 27.30.20.537 030-TOWN OF SAINT JOSEPH Current �XI ST.CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): ' =Current Owner *NERBY, KEVIN D KEVIN D NERBY 1356 STATE ST HOULTON WI 54082 Districts: SC=School SP=Special Property Address(es): "=Primary Type Dist# Description * 1356 STATE ST SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 0.500 Plat: 2111-HOULTON SEC 27 T30N R20W LOT 1 BLK 4 VIL HOULTON Block/Condo Bldg: 4 LOT 1 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 27-30N-20W Notes: Parcel History: Date Doc# Vol/Page Type 08/05/1999 608095 1447/95 WD 07/23/1997 1047/278 WD 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 6170 173,400 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.500 50,000 120,600 170,600 NO Totals for 2004: General Property 0.500 50,000 120,600 170,600 Woodland 0.000 0 0 Totals for 2003: General Property 0.500 23,000 91,200 114,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch#: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 71 s -- , y — - - -1�1 4 7 4,.:1 F co, I ry { v tot 0 CJD d too f f m £99 �` 4 Y��mQ v .4 b99 m – M - d. 1n ch 999 8 a 999. 61 0), AMN 31Y1S O m �.'Pet 9a5 1n �- _ N A - �I d 919 LO (0�I (0d8Z5 w sue . � SIN _e is s)<r/ Oo `ill �I�� I`I S m--Al `ll i. I "Al — 'It alA I l[) N i K1I. .Y � ICj b I' qr \ \ U) mI OZ9 m ' a �� N .p O' S: / O/[dry z.CJ9/pnti� Z I O if') OD N d F d \ o 1S yCD3 O O to , LO k a ~o O rx ' FO �eU') O In tPJ� ~O O f mac• z n o i U*) LO r Y{ !v � I A D • • ' 1015 ST. CROIX COtHTY /yk s WISCONSIN ZONING OFFICE ST.CROIX COUNTY COURTHOUSE 1 911 FOURTH STREET • HUDSON,WI 54016 - — _ (715)386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. 0 Water (VOC's) $185. 00 0 Septic $25.00 A Water (Nitrate & Bacteria) $35. 00 (Visual inspection)Q Owner: -) i L l)-c GK Requested by; I f l i C-Ck Address: 13 5 (o S ZU • Address: (,00 "` • City & State:_ _v l jy n , (,U-4-- City & St. o Zip Code: O<a Zip Code: .5 q01 (0 Telephone N4: (11S ) 5 y -G`1 9 1/0 Telephone N4: ( 71� ) Property address (Fire NO & Street) : J'j 5 �o 5" Location: ;, ,-, Sec. �Z-7, T b N, RAW, Town of &ja n St. Croix Co. , WI. Tax ID NO n30a0sy 50 Parcel ID N4­21,_30, z46 _5:;�7 House color: Realty firm: Lock Box Combo: Water sample tap location: vvfsi /�O v5E' TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Is the dwelling currently occupied? ;: Yes ❑ No If vacant, date last occupied: Septic system installed by: Septic tank last serviced by: :'" Previous Owner's Name(s) : Have anv of the following been observed? ❑Y ON Slow drainage from house. $A. } OY ON Sewage Back-up into dwelling. OY ON Sewage discharge to ground surfa road ditch or body of water. OY ON Slow drainage from the dwelling. ❑Y ON Foul odors. \ a 7 r- Other comments relative to system operation: I certify that the above information is complete and true to the best of my knowledge. / —1 Z _q OWNERS SIGNATURE: DATE: ID (� OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION t IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? OYes ❑No Soil series per SCS Soil Survey: sheet # Type of soil absorption system: ❑Below g rd ❑At-Grd ❑Mound Approx. size ' X ❑Gravity ❑Dose OPressurized Ft.2 ❑Bed ❑Trench ❑Dry Well Molding Tank 00utfall pipe OBSERVED DEFICIENCIES ❑Other OUnknown Septic tank Setbacks: OHouse ❑Well ❑Prop. line OOther Dose tank Setbacks: ❑House ❑Well ❑Prop. line ❑Other ❑Locking cover OWarning label OPump/Floats " OAlarm OElec. wiring Soil Absorption System Setbacks: OHouse OWell OProp. line ❑Other ❑Ponding: ❑Discharge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title b COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715 - 962 - 3121 800 - 962 - 5227 FAX - 715 - 962 - 4030 ST. CROIX COUNTY GOVERNMENT REPORT NO*** 51313/01 PAGE i CENTER REPORT DATE/ 10/25/93 1101 CARMICHAEL ROAD DATE RECEIVERS 10/21/93 HUDSON, WI 54016 ATTNS THOMAS C. NELSON OWNERS Brian Lueck LOCATIONS 1356 State St.f Houlton COLLECTOR! Jib Thompson DATE COLLECTED: 10-20-93 E TIC COLLECTED: 1S15pm SOURCE OF SAMPLES Outside Tap DATE ANALYZED 1,0-21-93 TIME ANALYZED S2SOOpro j COLIFORMtWCCi 0 /100 mt ! INTERPRETATIONS Bacteriologically SAFE NITRATE-NS 13 ppm Above 10 ppm exceeds the recommended Public Drinking mater Standard. Coliform Bacteria/100 ml Nitrate-Nitrogen, mg/L G LAB TEGMICIAN: Pam Gane F,NDEGFNDf f � � o WI Approved Lab No, 19 C' o C i 5 A C Means "LESS THAN" Detectable Level Approved byl d akb. o+ PROFESSIONAL LABORATORY SERVICES SINCE 1952 i i COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 j 715 - 962 - 3121 800 -862 - 5227 4: FAX - 715 962 4030 ST. CROIX COUNTY GWENT REPORT NO.** 53608/01 PAGE i CENTER REPORT DATEi 12103193 1101 CARMICHAEL ROAD DATE RECEIVED: 12/01/93 IAJDSONt WI 54016 ATTNS THOMAS C. NELSON OWNERS William Johnston LOCATIONS 1356 State St.: Moulton COLLECTORS M. Jenkins DATE COLLECTEDS 11-30-93 UME COLLECTEDS 2S45pm SOURCE OF SAMPLES Outside fauce+ DATE ANALYZEDt12-01-9 3 TIME ANALYZEDS2S00pm COLIFORM,MFCCS 4 !140 mt INTERPRETATIONS Bacteriologically SAFE FNITRATE-NS 12 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Coliform Bacteria/100 ml Nitrate-Nitrogenr mg/L cz� OC� � f f9 CiOZ�� ti A 19 t LAB TECHNICIANt. Papa Gaw DFPF OF.NNptN j WI Approved Lab Flo. 19 D A C cleans "LESS THAN" Detectabie Level Approved by! PROFESSIONAL LABORATORY SERVICES SINCE 1952 z/a . q,3/ ST. CROIX COUNTY y� WISCONSIN ZONING OFFICE «.; ST.CROIX COUNTY COURTHOUSE _ 911 FOURTH STREET • HUDSON,WI 54016 -_- - (715)386-4680 SEPTIC INSPECTION / WATER TEST REQUEST FORM Specify desired test(s) & remit appropriate fee with application. Outside water lines are often turned off during winter months, making access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. V ❑ Water (VOC's) $185. 00 0 Septic $25.00 D Water (Nitrate & Bacteria) $35. 00 (Visual inspection) Owner: W;I h Ginn Requested by: ; AVinar C-\. i5a4 K Address: '37 5=^A�� 5. Address: 2_'19 ,i t City & State: City & St. � 5--r , w 1 Zip Code: S 5 oS a Zip Code: Telephone N4: (1,1 z, ) rq;; 0 -02-1 -7 Telephone N4: (-I(�_) Property address (Fire N2 & Street) : S S JmA, St Location: ;, k, Sec. D7 , T-- N, R ZO W, Town of St. Croix Co. , WI. Tax ID N4 Parcel ID N° ?-a6S -5 O House color: Realty firm: Lock Box�Cmbo: y Water sample tap location: TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Is the dwelling currently occupied? ❑ Yes 0 No If vacant, date last occupied: Septic system installed by: Year: Septic tank last serviced by: Date: Previous Owner's Name(s) : Have any of the following been observed? ❑Y ON Slow drainage from house. ❑Y ON Sewage Back-up into dwelling. ❑Y ON Sewage discharge to ground surface, road ditch or body of water. ❑Y ON Slow drainage from the dwelling. ❑Y ON Foul odors. Other comments relative to system operation: I certify that the above information is complete and true to the best of my e.knowled g OWNERS SIGNATURE: DATE: �r OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION t IN TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? ❑Yes ONo Soil series per SCS Soil Survey: sheet # Type of soil absorption system: ❑Below grd OAt-Grd ❑Mound Approx. size ' X ❑Gravity ❑Dose ❑Pressurized Ft.2 ❑Bed ❑Trench ❑Dry Well Molding Tank OOutfall pipe OBSERVED DEFICIENCIES OOther OUnknown Septic tank Setbacks: OHouse OWell ❑Prop. line OOther Dose tank Setbacks: OHouse ❑Well ❑Prop. line OOther Mocking cover ❑Warning label OPump/Floats " OAlarm ❑Elec. wiring Soil Absorption System Setbacks: OHouse ❑Well OProp. line ❑Other ❑Ponding: ❑Discharge: General comments: i INSPECTORS SKETCH OF SYSTEM LOCATION N Inspector Title Form S T - 104 AS BUILT SANITARY SYSTEM REPORT OWNER c /' �!1j1Jp.�� TOWNSHIP S SEC. 2 7 T 3v N-R ZO W ADDRESS '� � S Sy" ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE ----=�i-G� I PLAN VIEW 5 Distances and dimensions to meet requirements of ILHR 83 SHOW VERYTHING WITHIN 100 FEET OF SYSTEM 5ar� 171 / l l0�' 1 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used / /✓ , Elevation of vertical reference point: ! d Proposed slope at site: Z SEPTIC TANK: Manufacturer: � ��j S Liquid Capacity: Number of rings used: b Tank manhole cover elevation: ,A)3 8� Tank Inlet Elevation: /022-1 Tank Outlet Elevation: f Number of feet from nearest Road: Front 10 Sidej@ Rear, 0 feet From nearest property line Front 10 Side,@Rear,O �O � feet Number of feet from: well , building: ^f Q (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE 1 PUMP CHAMBER Manufacturer: Capacity: Pump Model: P p/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch evation: Gallons per cycle: Alarm Manuf turer: Alarm Switch Type: Number feet from nearest property line: Front, O Side, 0 Rear,© Ft. Number of feet from well: - Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: ,S I Len$th: Number of Lines:_ Area Built• „ Fill depth to top of pipe: X Number of feet from nearest property line: Front, O Side, 0 Rear,0 Ft .J`~ r Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Botto of seepage pit elevation: Area Built: Has either a drop box O or d stribution box O been used on any of the above soil absorbtion sytems? (Check on ). HOLDING TANK Manufacturer: Capacity: y sed: Elevation of bottom of tank: t:om nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: ber of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Plumber on job: Dated: 1 /Q j r License Number: 3/84:mj IL DEPARfMENT 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: SE4fNW4,Sec. 30-TR20 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of St. Joseph S ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME F PE41T HOLDER: ADDRE55 OF PERMIT HOLDER: WT U 0 62 B H IA (Permanent reference point)DESCRIBE IF V" Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Numbsr Gary L. Steel 3254 St. Croix 1 135389 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY ANK INLET ELEV.: TANK OUTLET ELEV.: I WARNING LABEL LOCKING COVER PROVIDED: PROVDED: 1100 C5 1l�c�l �c.o v r YES 0 BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM I _ LINE; �O 10 AIR INLET: ❑YES ENO C L ❑YES ENO NEAREST�� �D (p DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: SIPHON MANUFACTURER; WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER Or PRO EFITY L : 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 plowlnp FORCE TENNOTH: DIAMETER MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,construction shall cease untll MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER IN DIA,; LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS � I bC' GRAVEL DEPTH FI DISTR.PIPE I DISTR.PIPE DISTR.PIPE MATERIAL: N TR, NUMBER Or BELOW PIPES: OVE COV ' ELEV.INLET: ELEV,END: PIPES: FEET FROM LINE' AIR INLET: ILDtt �c.al qt.q a� 1 NEAREST�� 5d An �t MOUND SYSTE 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 MARKER : 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: BEDITRENCN 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 d MARKING: ELEVATION AND ELEV.: ELEV,: DIA,: ELEV,; PIPES: DIA,; DISTRIBUTION HOLE SIZE: HOLE SPACING: D I L D RR INFORMATION i APPROVED PLANS ❑YES ❑NO I [:]YES ❑NO PERMANENT MARKERS: OBSERVATION WELLS; NUMBER Or BUILDING: COMMENTS: FORT FROM LINE: S n ❑YES ❑NO ❑YES ❑NO NEAREST iii ► 7 s u Sketch System on ( � ) Retain In county file for audit, Reverse Side, 1 SIG RE: TITLM SBO-6710(R.08/88) f -� zon I n(a m 1 In 5 �� LEdG CSANITARY PERMIT APPLICATION LHR In accord with ILHR 83.05,Wis.Adm.Code OUNTY St. Croix t STATE SANITARY PERMIT -Attach complete plans(to the county copy only)for the system,on paper not less than ❑ 1135-3?' 8%x 11 inches in size. check If revision to 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 Brian Lueck SE % NW %,S 27 T 30 , N, R 20 Mr)W PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# n/a n/a 1356 State St. CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Houlton, Wi. 54062 1( 715 549-6940 n/a I. TYPE OF BUILDING: Check one CITY NEAREST ROAD Ill. ) ❑State Owned ❑ VILLAGE St. Jose h State St. ❑ Public ®1 or 2 Fam.Dwelling-#of bedrooms - PARCEL TAX NUMBER(5) 63/�'-00 a - " --��M III. BUILDING USE: (If building type is public,check all that apply) .S�j / ((JJ V vw 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 ecckonly one in line A. Check line B if applicable) A) 1. El New 2. IJ 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 21 Mound 30 ❑ S eci T e 41 ❑ Holding Tank 11 ❑ Seepage Bed ❑ P fY YP 12 El 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 . 450 500 500 .90 1 95 0 1Feet 98.71 Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Expp. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin an Tank an 1000 1 Weeks Lift Pump Tank/Si hon Chamber --- -- VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Si ure:(No Sta s) rMPRSW No.: Business Phone Number: 4 Gary L. Steel 325 715 246-6200 Plumber's Address(Street,City,State,Zip Co 88 N. Shore dr. New Riochmond Wi. 54017 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date ssue Issuing Agent Signature(No Stamps) ,�y Surcharge Fee) Jdl Approved ❑ Owner Given Initial CG J Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: I SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 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. 11. 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 J 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. Vlll. 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; close 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) d 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' d n 1'\ L, �' e Location of property,56- _1/4 1J") 1/4, Section 2— 7 T 3 N-R Z W Township Mailing address oil 5c Y05'2< Address of s i to S�(''n e— #5 -MO LI C- Subdivision name blocl( d pi V s���'a�i D #o0/1"ov) Lot number 0/ Previous owner of property Ye lert ��` l09P/e/S Total size of parcel !Z- Date parcel was created .2- 1 — 77 Are all corners and lot lines identifiable? (/ Yes No Is this property being developed for resale (spec house)? Yes _ Y No Volume and Page Number 2--2- o 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. ---------------------------------------------------------7--------------------- 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. ..a .S:4go7 C:e i ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of th County Register of Deeds, as Document No. ) . ignature of Owner Signature of Co-Owner (If Applicable) A.P li Date of Signature Date of Signature I STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER 13 �T�r� S�P�� FIRE NO. 13,5- ( l SCO.'i `. ZIP CITY/STATE I �T_C�r'1 L�� � ✓1 PROPERTY LOCATION: S4'6 w 1/4 IV 1/4, Section _� T -3 ®N, R Z-6 W, Town of 7- Jo-5 C , St. Croix County, Subdivision Div ���� �� 1�c�ir�riLot 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. I/l SIGNED).( DATE 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 DERARTI)(IENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INLIUSTVY, DIVISION LABO HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 7969 (H63.09(1)&Chapter 145.045) LOCATION: SECTION: TOWNS HIPIf TY: LOT NO.:BILK.NO.: SUBDIVISION NAME: SE 'I*d14 27 �T30 H�RzOA(or)w St. Joseph n/a n/a n/a COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: St. Croix Brian Lueck 11356 State St. Houlton Wi. 54062 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 2 n/a ❑New Replace I 10-30-89 110-30-89 RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) ®S ❑U ®S ❑U JS ❑U ❑SOU ❑S ®U conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: n/a I Floodplain,indicate Floodplain elevation: n/a decimal' PROFILE DESCRIPTIONS page 41 HsB BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTHM, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- 1 7.50 98.71 none >7.50 1.50bl.1. 2.00bn. s.sil. 4.00bn.l.s.&gr., B- 2 7.17 98.71 none >7.17 1.00bl.l. 1.50bn.sil. 4.67bn.c.s.&gr. B- 3 6.59 98.26 none >6.59 1.00bl.1. 1.92bn.cob. sil. 3.67 bn.c. .s.&gr. B- B- B- decimal ' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER MXXMX AFTER SWELLING INTERVAL-MIN. PEFLIOD t PERIOD 2 PER PER INCH P none 3 Z 2 P- 2 3.70 none 3 6 6 6 <3. P- 3 3.25 none 3 6 6 6 <3 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 95.01 Z01� _. I l� , t � € € I I i I P: tN i E 1 1 -4- _.A .., _ E I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and ethods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: Gary L. Steel 10-31-89 ADDRESS: CERTIFICA I NUMBER: PHONE NUMBER(optional): 988 N. Shore DR. , New aRichmond, Wi. 54017 2 15-246-6200 CST SI URE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) OVER — i INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 " { To be a complete and accurate soil test,your report must induce: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 1 MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; S. Complete the suitability rating boxes, A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL. NDITIONS; 6. PLEASE use the abbreviations shown here for writing profile desci iptiiIrti"and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred, A separate sheet may be used if desired; . Make sra e your benchmark and vertical elevation reference point are clearly shown,and are permanent; 0. Co piete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tiorl, if appropriate; 10. If the inforrnaiion (such as flood plain,elevation)does not apply, Place N,A,in the appropriate box; 11 Sign the form and place yerur current address and your certification number; 12. Nlake Ietpilale copies and distribute as required. ALL SOIL_ TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITH[N 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL. TESTERS Soil Separates and Textures Other Symbols st Stone (over 10") BR Bedrock cob Cobble, (3- 10") SS Sandstone gi - Gravel (under 3") LS -- Limestone "s - Sand HGW - High Groundwater cs - Coarse Sand Perc Percolation Rate r.3ed s - Medium Sand Vv - Wx ll fs Fine Sand Bld S Building is - Loamy Sand - Greater Than sl -- Sandy Loam < Less Than "I Loarn Bn - Brovvn sil - Silt Loarn BI Black si - Silt Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - vvith - sic - Silty Clays fff - few,mine,faint c - Clay cc cryrrarnon, coarse P! - Peat mill - Many, mediurn to -- Muck d distincl. p - prominent HWL -- High water level, Six general soil textures surface;;"later for hiptid vvast-e,disposal BM --- Beach Mark VRP - Vertical Reference Point TO THE. OWNER: Thl,;-,wl test report is trr3 first at'p in securinct a sanitary pormit. The county or the Departrnent may request {rific;a w" Uf ter,, so., t<aE in the field pr ioi, t:r5 permit issuance. A complete set of plans for the private �..;Sa s lira ;nd ra pe=rnilt aoplica€i�3r��i must be subrnitte'd to the apptopri to local autlmrity in order to t [lit, 24 1'?c€'rr'ait ,.lar;sat,l.ary rw!rnit S u�. l e o laii ::rl and posted I)1{(lf to f1€e start of ar}�t a-y(}[#s(rL3CtIOn. Brian Lueck • SE 4NW% S27 T30N R20W �a r 1 St. Joseph township (4 %S XV /Z/sJ ,� ►® �. g• y \ 44-6/" /00 , Iv c04 tO'i 5 Gary L. Steel 988 N. Shore dr. New Richmond, Wi. 54017 MPRSW 3245 v si i 4 X • i. - - j 9 .j {, X lltb�nsr7 w ��- � Y Y k� 1 7 € 4 4 `L r a S*d *very twfirst pen AL K