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HomeMy WebLinkAbout036-1071-95-000 j 2 \ ) o * 0 _ i= j/ @6 a� . , $ 4 4 ` Cc 2 - %%mgd % ==-2 k ( §)�\ o� CD Cc / / E2 Its f7 % ° & 2aD 2 0 CL 2 /a Z CN 2 #a = &' 0E _ o\ � � ■ a $®tee (D ) J«f7 & � $ o .. o R § $ I a � q � B z C \ M , B z ° c \ ■ e 2 ' � ƒ E { ° = E e .r- (D \ � k D \ -� 0IL / \ e _ E ` 2 : § k w / } a S % ; 0 4) o D �ƒ § E / \ I 0- \ k k k z a a a ! CL j \ ) k k ° : § \ \ \ _ ro 0 £ V 0 2 a 2 J z m , � � ; / ■ 5 ° � a / _ % \ / ) E co Q § @ \ 2 c c 8 £ E @ @ § 2 / v 0 z z f D a l - k \ \ k § o $ k / ) \ a k dl CL - s " CL » k ( o o Q a 2 \ 0 ■ 0 DEPICRTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS • LABOR& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 NV4-NW,jS30,T31-R17W ❑CONVENTIONAL 1:1 ALTERNATIVE State Plan l.D.Number Town of Stanton El Holding Tank El In-Ground Pressure El Mound (if assigned) 145th Street NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION 4,T t: Stanton Town Hall It. 3 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: Calvin Powers Jr. 1563 St . Croix 128650 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO OYES ONO BEDDING: VENT DIA.: VENT MATL: NIGH WATER NUMBER OF ROAD: PROPERTY- WELL: BUILDING:JVENT TO FRESH ALARM. FEET FROM LINE: AIR INLET. ❑YES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: DOSING MANUFACTURER C A BEDDING: LIQUID CAPACITY. PUMP MODEL PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ONO ❑YES ❑NO DYES ONO 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) OYES ONO MEARES SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing �ENCrH JbIAMETER MATERIAL AND MARKING or excavation. (if soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: :WIDTH: L NO DR ANG COVER INSIDE DIA #PITS LIQUID OEO/TRENCH TRENCHES MATERIAL' PIT DEPTH. C�tMEN510NS I ', GRAVEL DEPTH FILL DEPTH DISTR. IP DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES ABOVE COVER ELEV.INLET.ELEV.END: PIPES: FEET FROM LINE: AIR INLET: NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS 1:1 YES ONO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED. CENTER. JF.GES ❑YES ONO 1:1 YES ONO ❑YES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: � N WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. TRENCHES. MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEV.: ELEV.: DIA.: ELEV. PIPES: CIA,: EIy ESiA t ION,ANtI =k ,, i� • 1 -.HOLE SIZE HOLE SPACING: DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED E 11'7Y PLANS. ❑YES ❑NO —]YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: I + ig` PROPERTY WELL: BUILDING: LINE: / I , ❑YES � 1-1 NO OYES 1:1 NO RI,EAEfi Co, Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710(R.01/82) L J Mill SANITARY PERMIT APPLICATION rDLHR I In accord with ILHR 83.05,Wis.Adm.Code COUNTY , —. .,.a.�.�.,_,..� E SANITARY P RMIT -Attach complete plans(to the county copy only)for the system,on paper not less than I A �i �-0 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 -' V4 %a a '/a, S � " T N, R f E(or PROPS TY OWNER'S MAILING ADDRESS LOT# BLOCK# JV CI STAT ' ZIP CODE I PHONE NUMB SUBDIVISION N E OR CSM NUMBER d ' f II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD El State Owned VILLAGE ., th Public ❑1 or 2 Fam.Dwelling-#of bedrooms— PARCEL TAX NUMBER(S) (0 /67 1`q,5--0J O III. BUILDING USE: (If building type is public,check all that apply) S 1 ❑ Apt/Condo 2 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. El New 2.�Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 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 VII. TANK CAPACITY Site in aallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks oncret glass App. Tanks I Tanks structed Septic Tank or Holdino Tank Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation ofthe,,onsite sewage system shown on the attached plans. Plumber' Name(P int): Plumber's Signatur :(No tam ) MP/MPRSW No.: Business Phone Num er: Plum rs A dr74�"if)treet,Ci , te,Zip Code): -, ifilz IX. COUNTY/DEPAR:KfENT USE ONLY ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No Stamps) , ,/ Surcharge Fee) Approved ❑ Owner Given Initial &d , Advers a Determin lion i 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 L m 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. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398(R.11/88) SANITARY PERMIT APPLICATION A 'LHR In accord with ILHR 83.05,Wis.Adm.Code COUN E SANITARY PERMIT -Attaoh complete plans(to the county copy only)for the system,on paper not less than ❑ 8%X 11 inches In size. Check i 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 y PROPERTY OWNER'S MAILING ADDRESS LOT# ' OCK# Cl STATE, ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER r j f �r X 4,4// Li CITY / NEAREST RO#D II. TYPE OF BUILDING: (Check one) ❑State Owned VILLAGE:f , - RA W Public F]1 or 2 Fam.Dwelling-#of bedrooms_ PARCEL TAX:NUMBER(S) / III. BUILDING USE: (I#'building type is public,check 1 ❑ Apt/Condo 2 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2.N 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# _ ate Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 112.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 VII. TANK CAPACITY Site in lions Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete strutted glass App. J Tanks Tanks Septic tank or in T I d r .: '�( "rte v '� c'1 Lift Pump Tank/Siphon ChamlSer .. VIII. RESPONSIBILITY STATE ENT I,the undersigned,assume responsibility for installation of onsite sewage system shown on the attached plans. Plumber' Name(Pint): Plumber's Signature:(No Scam ) MP/MPRSW No.: Business Phone Nu mper: Plum is Address treet,Ci $fate,Zip Code): IX. CO INTY/Dr-PARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater Date Issued Issuing Agent Signature(No Stamps) r Surcharge Fee) ,�1 Approved ❑ Owner Given Initial ,� C q 111 Adverse D t rmin tion �L �! 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 INSTRUeTiONS 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:aSanitary Permit Transfer/Renewal Form (SBD 6399)to be, submitted to the county prior to installation. 5. Onsite sewage systems-must be properly rimintained: 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-?66-3815. To be complete and accurate this sanitary permit application must includes I. . Property y owner's name and mailing address. Provide the legal description and arc el tax ndmber(s) of where the system is to be installed. 11. Type of building being served. Check ontrone-and complete##of bedrooms if 1 or 2 Family Dwelii p, r IIL Building use. If building type is Public, check all,appropriate.boxes that apply. 2.>... 1V. ;Type of permit.;Check only one in line A.Coreptete line B if permit is for tank replacement, reconnection,.pr repair., V. Type of system.Check appropriate box depending on system type. VI. Absorption system Information.-Provide all information requested in##17 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,approval4rom DILHR. VIII. Responsibility ty statement. Installing P lumber is taf)il imname, license number with a Pp roPiate refx (0-g* ,- MP,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 o1 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 vofutne; elevation differences; friction loss;pump performance curve; pump model and pump`manufacturer; D)`dross'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-8398(R.11/88) OOCUMENT NO. , _ WARRANTY DEED—By CoFporatton lg s ��j' STATE OF WISCONSIN—FORM 2 /�yy V�� r• t•� n - A THIS SPACE RESERVED FOR RECORDING DATA G_( THIS INDENTURE,blade this..-... l .......day of..............JUne............................ A. D., 19..6.3..,between......►TC.1I3 ....4S.G�1Q.S1�....D1 StY iCt...#...Z...Of...the......... ST. CROIX CO, W;S. City...o.f:..stew...R�.ckmnozld,.....ot....a1.,....a..�.c.?�Q.Ql...district... Recd for Record this 19t-11- duly organized and existing tinder and by virtue of the laws of the State of Wisconsin,located day Of-- JUrie -A U 19fi3 I, at..............Ne4Z...R1 ChIT1Q.Ild......................................Wisconsin, party of the first part and at__ 2_)t5`____P. M. I Taw n...of....Stanton......St.......Croix...Gou. ty.;.....W.-. scans n,.._•--......... ..............._.............. ............... a, Is art... p y....-..-ot the second part, RETURN TO W i t n e s s e t h, That the said party of the first part, for and in consideration of the sum of ..�?ne...�?Q�.�r�x. �-s�-a-`-QQ.)..... .nd Qt11C. ...va�,uab .......- j ..cons idex.ati.on......... ........................ -• .......................-•-•-••••..................-.........._.to it paid by the said part...y......of the second pact,the receipt whereof is hereby 'I confessed and acknowledged, has given, granted, bargained, sold, remised,released,aliened,conveyed and confirmed,and by these presents does give, grant, bargain, sell, remise, release, alien,convey and confirm unto the said part..y....of the second part....1t.Sheirs and assigns lil, forever, the following described real estate situated in the County of.............St....._C..1�Q. x.......and State of Wisconsin,to-wit: Commencing at the Northeast corner of the Northeast Quarter of 'the Northwest -Quartet (NE4 NW4) of Section Thirty, in Township Thirty-one North of Range Seventeen West, thence South Fifteen. rods ; thence West. Eight rods; thence North Fifteen rods; thence East Eight rods to the. place of beginning. II � I t (IF NECESSARY, CONTINUE DESCRIPTION ON REVERSE SIDE) Co�ether with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining;and all the estate V I right,title,interest,claim or demand whatsoever, of the said party of the first part,either in law or equity,either in possession or expectancy of,in'and to the above bargained premises,and their hereditaments and appurtenances. To Have and To Hold the said premises as above described with the hereditaments and a j ppurtenances,unto the said part-Y..-----of the second part,and to.....it.S-....heirs and assigns FOREVER. And the said ....Joint_..Scol-_District # 1 of the City of New Richmond . -. -- .. . ..............._............. 1r.Lri� of thv hrri hart, for itself ;Lid its successor,, does covenant, grant, bargain and agree to and with the said part ---- of the second part.........its......... heirs and assigns, that at the time of the ensealing and delivery of these presents it is well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance in the law,in fee_ simple,,and that the same­e frce and clear from all incumbrances whatever............................ ........---------°----- ------- ----_ ..............----------------------------................°--•..............._............_...................... ---..-------------- --------------- ------- ............. ...................... .--------...........----- ......-............._-....................................................... _................-.............. .................... it that the above bargained premises in the quiet and peaceable possession of thesaid part..y....—of the second part,.i.tS-heirs and assigns, against all and every person or persons lawfully claiming the whole or any part thereof, it will forever WARRANT AND DEFEND. In Witness whereof,the said-.- Joint. School -District_-#$_1of„-the Cit-y-- of New Richmond, h.utv of the first p,ut, has cawscd thcsc hrc:cnt-� to be signtd by_ ---Stanley...K.__Groth---- -, its I'rr:ident, and ­n w r>i n,'d h.\ _..-.Cora-. B.._ -Sias,,--_its_-Cle.rk New Richmond \i>con<in,:uul ifs curporat,•secl to be hereunto affixed, thi, _-_l8'thda� of-_--__ June _------._. , .�. I)., 19..63... - SIGNED AND SEALED IN PRESENCE OF JOINT SCHOOL DISTRICT # 1 of t - `J? (� CITYI OF NEW RICHMOND-,"'—, et al FRED._W.- SUBKE--_.-._.... _ rr�•.�<�L„E STAN-LEY_K GROTH. / ( COUNTI SIGNED: FRANCES..R-,.-..SIGNOR--..... -----• Sccrct.iry . .-- ....-- - _-------- STATE OF WISCONSIN, ss. SRj'.•....CR..... ......:..........County. Personally came before me, this.....1. .tb.day of..-.-...!71dI3 ......................A. ................. President,and ..Cora.--B--� _Sia ......__... .�WKY- ,of the above rained Corporation, to me known to be the persons who executed the foregoing instrument,and to me known to be such............ .-President and .-Clerk ._----xXoXiXtXa};t of said Corporation,and acknowledged that they executed the foregoing instrument as sl�ch olticers as the decd of said Corporation, by its authority. 1 � tt • ' v �! ' .. TC .... .S..-R TOR. ea.-_ G ... ................ 11 is , This instrument drafted by P � t Doar & Knowles .... Public ...............Notary•-••-..... s hjY Commission( 9 6 — bflt -- - (Sectlon 59.51 (1) or the Wisconsin Statues provides that trmeati-Y�1 8u recorded shall have plainly printed or typewritten thereon the names of the grantors, grantees,witnesses and notary). r Ii � WARRANTY DEED—STATE OF WISCONSIN, FORM NO. 2 - �✓—µ. C.NILLE0.CO.,NIl WPl1REE it w - Wisconsin Department of Industry, ONSITE SEWAGE SYSTEMS office of Division Codes and Application Labor and Human Relations Onsite Sewage Section Safety and Buildings Division - 201 E.Washington Ave.,Rm.141 PLAN APPROVAL APPLICATION P.O.Box 7969,Madison,WI 53707 (608)266-3815 INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. The reverse side of this form describes most of the required plan information. Further requirements may be contained in the Wisconsin Plumbing Code,which can be purchased from the Department of Administration,Document Sales and Distribution,202 South Thornton Ave.,P.O.Box 7840,Madison,WI 53707,Telephone(608)266-3358. Plan Number Previously Assigned 1. PROJECT INFORMATION(Type or print clearly) Na o2bbmitti party(plans re urned to same) Project Na e _ A/.;, I 1 Stre Address,P.O.Box if or Rural Route Proj' ect ddress o Lega Description City r Village State Zip Code city []I County j 1,11, c Village Q of f Telephone o.(include area code) - ���>° Town Designer Name of Owne Telephone No.(include area code) Te ep one No.(include area code) Street Address,P.O.Box#or Rural Route S re t Address,P.O.Box#or Rural Route City or Village State Zip Code i or Villag¢ State Zip Code 1 2. APPLICATION FOR: ❑ Experimental ❑ Mound System ❑ Holding Tank ❑ New Construction ❑ Large System ❑ Conventional Gravity System ❑ Groundwater Monitoring X Replacement Q At-Grade ❑ System in Fill ❑ Petition For Variance ❑ Revision Q Pressurized System Q System in Flood Plain(attach SBD-6698) ❑ Other Alternatives 3. FEE COMPUTATIONS (include existing tanks) FEE SUBMITTED FOR OFFICE USE MAKE ALL CHECKS PAYABLE TO SAFETY&BUILDINGS DIVISION. 5 a. 750- 1,500 gallon septic tank $ 50.00 b. 1,501- 2,500 gallon septic tank $ 60.00 C. 2,501- 5,000 gallon septic tank S 80.00 u d. 5,001- 9,000 gallon septic tank $100.00 e. 9,001- 15,000 gallon septic tank $150.00 't f. Over 15,000 gallon septic tank $250.00 g. 500- 1,000 gallon dose chamber $ 30.00 � � A 1 h. 1,001- 2,000 gallon dose chamber $ 50.00 i. 2,001- 4,000 gallon dose chamber S 70.00 j. 4,001- 8,000 gallon dose chamber $ 90.00 k. 8,001- 12,000 gallon dose chamber $110.00 I. Over 12,000 gallon dose chamber $150.00 m. 5010- 5,000 gallon holding tank $ 30.00 n. 5,001- 10,000 gallon holding tank $ 55.00 o. Over 10,000 gallon holding tank $100.00 p. Revisions $ 20.00 q. Groundwater Monitoring-Per Site S 32.00 (other than a proposed subdivision) r. Petition For Variance: Setback $ 25.00 Site Evaluation $ 50.00 Subtotal: s. Priority Plan Review: Enter same amount as Subtotal Total Fee: 5o SBD-6748(R.04/88) NOTE:Fees are pursuant to Wis.Adm.Code,Chapter Ind.69,and OVER + are subject to change annually. —'- -- — —- --- -- -- — - - - - ----- L-�- - - -- -- — I co oor - -1_ �- --�--t-- - -- --7 -- - - -�-- --- =` -- -- - - -- - - It o I I C y r— -- -- 1 —1 --I—{ — i i-- — — -- — — E + N�O--N_ Ile 9 ,,.1w i PAGE OF S IO1, �' S. 489 + 40310 C.r S S s o A � S � Fro►h Air Inlith And Ob►ervollon Pip• Approved Vent Cop Jy� ) Minimum 12"Above Final l Grade 20-42"Above PIPIT — 4"Coef Iron i To Final Grad• Vent Pipe Marsh Hoy Or Synlhelk Covering 'Ain 2"Aggregate Orar Plp• Distribution Pipe — o 0 0 —Too - ' b"AggregaU 8eneolh Plpe ° Perforated Pipe below 0 —Coupling Terminating AI bottom Of Sy►Lem I PrO oseD �I�e-� �rHd< • 0""r, ,V51 V10-51E SOIL FILL DISTRIB.UTIOF.I PIPE APPROVED $414PETIC COVER 2"oFJ�6GREGATE -�r n o o —OFl MAR'SN HAy9" OF STRAW 'c � !e OF 12 -21/Z AGGREGATE El-EV. OF FEET_.- NY r DIS•T-R1F31JT10At PIPE TO BE AT LEAST INCHES BELOW ORIGINAL GRADE AMU AT LEASTZO INCHES BUT KIO MORE THAM 42 INCHES BELOW FINAL GRADE MAXIMUM DEPTH OF F-)(cAVAT100 FKOMI OWWAL 69AK WILL 6E INCHES rdKIMUM ®EprN of EXCAVATIOM F0,01A. 0 1(.IWAL FaR49E WILL BE 7 — INCHES .i..l 1 9 SiGAJED: LICENSE AJUMBER: vEr:', is °:`) hl V RELATIONS DATE : — — ----.. 1 1 0 I r i 1 EP R F EL iov� � J�.'CE .. • � /i J{yet. � �J V Pi b. # 60 1/78 PROJECT DETAI DATA SHEET — 40310 NAME OF BUSINESS LEGAL DESCRIPTION i OWNER MAILING ADDRESS - ,, ���ZIP ARCHITECT, ENGINEER, ADDRESS PLUMBER OR DESIGNER •) � ZIP TELEPHONE NUMBER 4 L_-4�L_�� 1 . Check appropriate building usage(s) and fill 'in the information requested opposite each usage listed. Please consult Section H 62.20. Existing building X New building Addition ( ) Apartments and condominiums . . . . Number of bedrooms (� Assembly hall . . . . . . . . . . . Seating capacity ( ) Bar . . . . . . . . . . . . Seating capacity # of meals served ( ) Bowling alley . . . . . . . . . . . Number of lanes ( ) With bar ( ) Campground and camping resorts . . . Number of sewered—sites Number of unsewered sites Total number of sites ( ) Camps . . . . . . . . . . . . . . . ( ) Day use only Number of persons ( ) Day and night Number of persons ( ) Catchbasin . . . . . . . . . . . . . Number ( ) Church . . . . . . . . . . . . . . . ( ) No kitchen Number of persons ( ) With kitchen Number of persons ( ) Dance hall . . . . . . . . . . . . Number of persons ( ) Dining hall . . . . . . . . . . . . Number of meals served daily ( ) Dog kennels . . . . . . . . . . . . Number of enclosures ( ) Drive-in restaurant . . . . . . . . Inside seating capacity Car-service -- Number of car spaces ( ) Dump station . . . . . . . . . . . . Number of dump stations (�() Employees ( total of all shifts) . . Number of employees & ( ) Hotel ( ) Motel ( ) Cottages . . . . Number of units with 2 persons per unit Number of units with 4 persons per unit ( ) Medical and dental office bldgs. Number of doctors, nurses, medical staff Number of office personnel Number of patients ( ) Mobile home parks . . . . . . . Number of sites ( ) Nursing homes . . . . . . . . . . Number of beds ( ) Parks . . . . . . . . . . . Number of persons ( ) Toilets ( ) Showers ( ) Restaurant . . . . . . . . . . . . . Seating capacity ( ) Dishwasher and/or disposal? ( ) 24-Hour service Retail store . . . . . . . . . . . . Total number of customers Schools _. . . . . . . . . Number of classrooms _FT Meals ( ) Showers ( ) Self service laundry . . . . . . . . Total number of machines ( ) Service station . . . . . . . . . . Number of cars served daily ( ) Swimming pool bathhouse . . . . . . Number of persons ( ) OTHER . . . (Specify) . . . . . . . COMPLETE OTHER SIDE 2. Indicate whether the following facilities are present. Floor drain yes no Number of drains Food waste grinder yes no Dishwasher yes no Automatic clothes washer yes no Number of clothes washers _ 3. Septic tank capacity Holding tank capacity .,,,,,,. �. Septic or holding tank manufacturer 4. SEEPAGE TRENCHES: total square feet width of trenches length of trenches � depth number of trenches SEEPAGE BEDS: total square feet width length of bed depth SEEPAGE PITS: total square feet outside diameter depth below inlet total depth from top to bottom of pit Signatur of pers n co leting form: FOR DEPARTMENTAL USE ONLY Address �. Telephone Number. Date ' DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION INDUSTRY, LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 1 HUMAN RELATIONS t , ., SN,1QI1 jy07 (H63.09(1)& Chapter 145.045) � � LOCATION:I / SECTION: / (o ' TOWNSHIPIU d ITY: LOT O.:B K : SUBDIVI ON NAME: 4/ T� N R c' COUNTY: O NE 'S B YER'S AME: MAI NG AD ESS: USE DATES OBSERVATIONS MADE NO.BED MS.: COMMER A DESC P ION: PROFILE DESCR TIONS: R A O TESTS: FE Residenc� / ^ New ; Replace I 2�w RATING:S=Site suitable for system U=Site unsuitable for system T -r _71 CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILL HOLDING TANK:RECOMMENDED YSTE :(optional) I©s ou INS out s ❑u EIS 2u o s ou If Percolation Tests are NOT require DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: a PROFILE DESCRIPTIONS , ' a .@C y -,- It BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL W TH THIC NESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH 0. ELEVATION OBSERVED EST. GTO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B- - > — B- 7 7 _-2 1 - B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER A4W_ .ES AFTERSWELLING INTERVAL-MIN. P IOD PERIODe =PR PER INCH I j i P- P 3 9 P- P- P- _ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensi ns 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 p of plan. Sho the surface elevation at all borings a d the diregion and percent of land slope. SYSTEM ELEVATION x^30 , -. e ,E L� 4 _ _ STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ROUTE/BOX NUMBER p'f2.3 FIRE NO. CITY/STATE A)" IA.t-J.,�{' isC S C s ria< ) ZIP PROPERTY LOCATION: 06 1/4 AJ W 1/4, Section 3 , T 3/N, R `�W, Town ofct+�'��^ , St. Croix County, Subdivision /(f%q. Lot No. w�h 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 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 ^ APPLICATION FOR SANITARY PERMIT S T C - 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,\ Location of property _&L_1/4 Af 1/9, Section , T N-R_�2 W Township _ inrx Mailing address �IQ Address of site /l�a-,rj �c� y`cf L c Subdivision name_____ Lot number IU,(�t Previous owner of property S� s'(c�'fw K cGhrr�e,^rJ� Total size of parcel Date parcel was created 3 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes No Volume 3 ?end Page Number 2 ` �—> 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. *:? '7A 7.l , ; 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 the County Re ister of Deeds, as Document No. ) . Signature of Owner Signature of Co-Owner (If Applicable) is / (Y (T Date of S' natu a Date of Signature