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TLN-R _W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of II,HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM l G' � q u � � INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference oint: P ��� (�_ Proposed slope at site: SEPTIC TANK: Manufacturer: ,) kd®L Liquid Capacity: . "el Number of rings used: -- Tank manhole cover elevation: Tank Inlet Elevation: Q _ Tank Outlet Elevation: n Number of feet from nearest Road: Front,O Side,O Rear, feet From nearest property line Front,0 Side,0 Rear,O � feet Number of feet from: well building: ,3„S (Include this information of the above plot plan) ( 2 reference dimensions to septic tank) 9pr RFVFRCF gTPF 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,Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: J& Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Q Rear,0 Ft . � Number of feet from well: 1/t1? Number of feet from building: �z2 (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O 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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: 4 Dated: ` Plumber on job: ?-'e"4-L _ SC License Number: S 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION 'P.0.150X'7965. BUREAU OF PLUMBING MADISON,WI 53707 SW4,NW4, S12,T31N-R18W ®CONVENTIONAL ❑ALTERNATIVE State Plan LD.Number: Town of Star Prairie (If ❑Holding Tank. ❑In-Ground Pressure ED gIM280 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION O T �js ,.1 Kirk Hexum Rural Route, Star Prairie, WI 54026 — "�12 0 d BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REP.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Calvin Powers, Jr. 1563 St. Croix 88477 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 ONO 1:1 YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: FLIQUIDCAPACIITY. PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑YES ❑NO DYES ONO GALLONS PER CYCLE: 771AII 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 LENGTH DIAMETER 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: LENGTH: NO.OF DISTR.PIPE SPACING: COVER JINSII CIA. SPITS LIQUID BED/TRENCH TRENCHES: MATERIAL: PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIP' 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 ❑ meets the criteria for medium sand. TIONS MEASURED. NO SOIL COVER TEXTURE: PERMANENT MARKERS JOBSERVATION WELLS DYES ONO 1:1 YES El NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER. EDGES: ❑YES 1-1 NO 1:1 YES ONO ❑YES 1:1 NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW P11 FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD of PIPE IMAN11OLDMATERIAL'. NO DISTR. ID ISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.. ELEV.. DIA.. ELEV.: PIPES DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS EYES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: DYES ONO 1-1 YES 1:1 NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE DILHR SBD 6710(R.01/82) Zoning Administrator Thomas C. Nelson SANITARY PERMIT APPLICATION COUNTY f TDILHR' In accord with ILHR 83.05,Wis.Adm.Code sr 0 n STATE SANITARY PERMIT# ?8 Y 7 —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. 7 d � —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO PROPERTY OWNER PROPERTY LOCATION ki r �.. C.l Yrl sw 1/4 N4)'/4, S /oZ T V, N, R / 8� or)W PROPERTY OWNER'S MAILING ADD LOT NUMBER BLOCK NUMBER SUBDIVISION NAME R R StQ� �dt / k I N A) A- CITY,STATE ZIP CODE PHONE NUMBER TY NEAREST ROAD,LAKE OR LANDMARK W Ls C- s )P?f VILLAGE: 5tq%-1?m►ri-4 R-4 CG II. TYPE OF BUILDING OR USE SERVED: - 1,eA• 0-30V— /05-1— 570— Number of Bedrooms if 1 or 2 Family OR 7 Public(Specify): ,>od .5 h0 Ill. PURPOSE OF APPLICATION: (Check only one in##1. Check¢#2,3 or 4,if applicable) 1. a. L1 New b.A Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in##1 and only one in##2) 1. a. �Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a.A Seepage Bed b. ❑Seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): ,,tt � � uFeet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New xisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holdin Tank ❑ Lift Pump Tank/Siphon Chamber ❑ L1 1 ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Na nnt): Plumber's Signa ". o Stamps) MP/MPRSW No.: Business Phone Number: G4 I u- +n cx•�-re"'S �� Cs�S :.� �S 7/r .9 Y6 rs/3 S Plumber's Address(Street,City,State,Zip Code): Name of Designer: G 1 Vlll. SOIL TEST INFORMATION Certified So' Tester(CST)Na*COC.a-4L—> CST# C 01 V 4h CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) S rchar a Fee Approved ❑ Owner Given Initial I v a I)O ��9 UO Adverse Determination cJ O '{( mew L X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there-is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintains d. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every.2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266=381.5. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, 'ndicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g., MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. ------------------------------------------------------------------------------------------------------------------------------------------------------------ GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground der included the creation of surcharges (fees) for a number of regulated practices which Wiscort�Sth-s can effect groundwater. The surcharge took effect on July 1, 1984. Ali of the water that buried reasttre. is used in your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. 0 The monies coliectec through these surcharges are creeited to the groundwater fund adminis tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and es'•ablishment of standards. Groundwater, it's worth protec',.ng. °3D-6398(R.0136) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR MA AND PERCOLATION TESTS (115) P.O. BOX 7969 H HUMAN 13ELATIONS l / MADISON,WI 53707 (H63.090) & Chapter 145.045) L CATI�:,J' SECTION: TOWNSHIP/MUWCIPALITY: LO�NO.:BL O.: SUBgIYISION NAME: COUNTY: OWNER'S MAIL ING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS:1PERCOLATION TESTS: ❑Residence / ! bNew XReplace I RATING:S=Site suitable for system U=Site unsuitable for system a t:Cq CO�IVENTIO�NAL: M D:�� IN-G, ASSURE: SYSTEM I�ILLHOLDIQNG TANK:RECOMMENDED SYSTEM:(optional) OS UU SS U S U EIS If Percolation Tests are NOT required DESIGN RATE: If an y portion of the tested area is in the under s.H63.09(5)(b),indicate: r � I Floodplain, indicate Floodplain elevation: P , FIL pESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER4NC"*3 CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER mod; OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) .G', B- 7 / 19707 C,rd �� d 0 — F N / dl — 0' n y� B- B- B- 8 7 P7—' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER +NGOIES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P R PER INCH —� - r` t 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 9 �� ! :k 6, 1 +. ` s Ji 3 � 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 data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): ? TESTS WERE COMPLETED ON: A RESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 1V�� It I Yk1 avc r '_��1 �T u � ► ) jt �c _ j t;. —'— CST STURE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) - OVER 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 LL »'1 Location of Property -S_W1% 1%, Section , T -43�' N - R�� W Township -5'f a r ,I Mailing Address u I %V , L-S Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes Volume 7.s and Page Number a as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. • Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTV OWNER CERTIFICATION I (We) eent.L6y that a t atatementa on thiA 6onm ane true to the but o6 my (oun) knowledge; that I (we) am (are) the owner(a) o6 the propetity descAibed in th.i,a .in6onmation 6on.m, by viAtu.e o6 a waua.nty deed n ded in the 066.iee o6 the County Reg.i.e,ten o6 Deeda as Document No. f// 7 X ; and that 1 (we) pnea entt y own the pnapoa ed 4 to bon the a ewage diZ poo.ta yb.tem (m I (we) have obtained an easement, to nun with the above dew ibed pnopenty, bon the construction o6 said ayatem, and the name has been duty %eco&ded in the 066ice o6 the County Reg-iaten o6 Deeds, a6 Document No. ) . SIGNATURE OF OWN R SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED 41'�'QS3 ljoa i 5�6 wA,�3R) RMSifItS OFFICE ST. CROIX CO., WM. Recd. for Record #9s 1QrjL day of Oct A,p, 1"6 86 at 8:30 A James O'Connell %M,a(N L) Deputy [Space Above This Line For Receding Dahl MORTGAGE THIS MORTGAGE ("Security Instrument")is given on October 9 19 86 .Themortgagoi•is Kirk E. Hexum and Joan M. Hexum, husband and wife, as joint tenants ("Borrower").This Security Instrument is given to NORTHWEST FEDERAL BANKING AND SAVINGS, F A ,which is organized and existing under the laws of The United States of America ,and whose address is 120 West Birch Street, Amery, Wisconsin, 54001 ("Lender"). Borrower owes Lender the principal sum of Forty Four Thousand Five Hundred Dollars and 00/100-----------------------Dollars(U.S.$44,500.00 ).This debt is evidenced by Borrower's note dated the same date as this Security Instrument("Note"),which provides for monthly payments,with the full debt,if not paid earlier,due and payable on November 1, 2001 .This Security Instrument secures to Lender: (a) the repayment of the debt evidenced by the Note, with interest, and all renewals, extensions and modifications;(b)the payment of all other sums,with interest,advanced under paragraph 7 to protect the security of this Security Instrument;and(c)the performance of Borrower's covenants and agreements under this Security Instrument and the Note.For this purpose,Borrower does hereby mortgage,grant and convey to Lender,with power of sale,the following described property located in S t. Croix County,Wisconsin: Lot 1, Certified Survey Map filed July 7, 1983, in Volume 5, Certified Survey Maps, page 1307, as Document #385943, being located in the SW.'% of the NWT of Section 12-31-18. Subject to recorded easements, reservations, and rights of way. This is the homestead of the mortgagors. which has the address of Route 1, Box 255 Star Prairie [Street] (city) z H • a ST C - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z c7 a OWNER/BUYER /A ROUTE/BOX NUMBER Je�� Fire Number / CITY/STATE �a !^ y hct I � ) lP W �!S � ZIP S�C3 PROPERTY LOCATION : 14, Section TJ_15.-' N , R /I W, Town of 4h 1 h 4-1 r+y , St . Croix County , Subdivision Lot number Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists 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 treat- ment stage in the waste disposal system. St . Croix. County residents may be eligible to receive a grant for a maximum of 60% 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping ( if nec- essary) , 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 . 0 I/WE, the undersigned , have read the above requirements and agree En to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning O fice within 30 days of the three year expiration date . C SIGNED DATE p St . Croix Croix County Zoning Office P .O. Box 98- Hammond , WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address . DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, C DIVISION BOX 76 LABOR AND PERCOLATION TESTS (115) MADISON WI 537907 9 53707 (1-163.090) & Chapter 145.045) L ION�j SECTION: TOWNSHIP/MUN4 'IPALITY: Oj MOB O: SUBDIVISION NAMEw / .)/ z /T3 N/R n4I(or)W ;;fi /� COUNTY: OWNER'S B4J***"jft*MF—.a MAII ING ADDRESS: USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: DE I ONS: N TESTS:❑Residence �� Q p ! ❑New Replace [PROFILE ! 2 .. l 1 1= I Z 2 RATING:S=Site suitable for system U=Site unsuitable for system �y.� C>C ( A/) �_- i OBI_�TI��• MIOS• �� IN-GUS EJU R ]SYSTEM-IMILI]O HO�ING�NK:R C MME L rDr T i c iM�(optional) 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: .l c (Floodplain,indicate Floodplain elevation: ';J�Ll F- P FIL pESCRIPTIONS BORING TOTAL PTH TO GROUNDWATER4sCM" CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER BERM, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) Cam. S 7 S -r-%/' B-3 97.07 crr�'- de � � - o' B- B- B- 87002 R 11 NIF O PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER fNGOWS AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D 2 PERIOD 3 PER INCH Y P. L/ --- P. I Al _ . 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 4 Cc TN ao AG �. STtlr � tl ,V �n 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. NAME print): TESTS WERE COMPLETED ON: A RESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): –' CST Sf qNATURE: DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R.02/82) OVER S-Nk y � -. 31 Iti► R 18 W C`fy = T 4 r 1 v,CL Bg*%ch yAq A h 00 _ .SyP+ 1 c -�a►�k, /000 PCB �w,Q►e�► vy.? l d 54) 2-J1 om R3 C 14 ss -1 F.&►k fie st Hew 03 /a,6 A , 8 '70020 tto- 4' se qO F, d - �� �._: ._ �: � h �r s�•P � a • Np � IUt Ck7 y '3,i S IV l 1N1=£ -gel P ov go ' .� +r Sror 1 41 tyw 5 NWy� P a AM r�P I P.• P , Ilk9 r . O S 7U028 �. �� S, 3Y' tit •'v .. ti t�,. r Vento - - ,t PAGE OF CrUSS Sttcllt) r1 Ot �1 Sri) SyS �tin � ;� KIInK N-ecLtr" 5 w Yy IN/W Yy 50- 12- Fresh Ak Inlets AM Observation Pipe I 31 /V je (�W STa��l�lolllt Approved V.nt Cop MlNwwr. 12.Above Ftn Glad. 20-A2'Above Pip. •-Moot boll To Final Glass :' vent - t ±�':; ;•sees•.. 1 _ T�TT►►►���`""'""'' N�� , marsh Ma r Or Srn M k t t Car k 0 N2;��erN `• 1 3 0latrlballo_ � e. Pipa Np o f cep G� G*Aggregate ��r, • � bMate Pipe b tow c D Tin w 0 Pj►ppa$it l 9 rt% .. t: • Ve-iJ tort y SOIL FILL DISTRIBUTION.) PIPE APPROVED 34IN'T11EtiC COVER. ` '— JUTERU* OR 9" 01: STRAW 4W 1\66RE GATE OR MARS" NAy �y le•OFlg-2��Z AGGREGATE V. , 3, _�� 0? � O DIS"15UTIOL) PIPE TO BE AT LEAST 30 , INCHES BELOW ORIGIWAL GRADE AW AT LEAST t0 INCHES BUT 1.10 MORE THAM 42 IIJC11ES BELOW FILIAL GRADE MAXIMUM OE N OF EXCAVAT160 FRO„ OWIMAL 6KADF. WILL BE 5`U IAICHES PONO'WM{ MTM OF MAVATION f1kOM-01141NAL GRAVE WILL BE INCHES LICEMSE MUMSER: I03 110 STATE OF WISCONSIN DILHR DIVISION OF SAFETY&_01LHR PRIVATE SEWAGE SYSTEMS BUREAU AnU OFrPLUMBING BUILDINGS Rm 4 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 back side of this form describes required plan information. Plumbing codes can be purchased from the Department of Administration, Document Sales, 202 South Tholnton Ave., Madison,Wisconsin 53703,Telephone (608) 266-3358. 1. PROJECT INFORMATION Type or print clearly) Revision To Plan Number: 7 Name of Submitting Party (Plans returned to same) Project Name Street&No.or Rural Route Projec%Location-Street&No.or Legal Description ------------- ---------------- ---- City or Village State Zip City ❑ County Village ❑ OF: I _- , ❑ , !U ... 7� r Town __J Telephone No. (Include area cod Designer Telephone No. (Include area code) Owners Narne Telephone No.(Include area code) 5 - yi 3/450 Street&No. -- Street&No. City or Vile j / State Zip City or Village State Zip 2. APPLICATION FOR: ❑ New Mound System (3a) ❑ Groundwater Monitoring (7) 9 Conventional System - Public Building (1) ❑ Replacement Mound (4a) ❑ Holding Tank (2) Replacement Pressurized System (4b) ❑ System in Fill (1) ❑ Petition For Modification (6) ❑ New Pressurized System (3b) ❑ System in Flood Fringe (1) ❑ Other Alternatives (5) 3. FEE COMPUTATIONS (Include existing tanks) 4. FEE SUBMITTED FOR OFFICE USE MAKE ALL CHECKS PAYABLE TO DILHR 3a. 750 - 1,500 gallon septic tank - 50.00 4a. s®. �© 3b. 1,501 - 2,500 gallon septic tank - 60.00 4b. ' 3C. 2,501 5,000 gallon septic tank - 80.00 4c. 3d. 5,001 9,000 gallon septic tank - 100.00 4d. 3e. 9,001 15,000 gallon septic tank - 150.00 4e. 3f. Over 15,000 gallon septic;tank -250.00 4f. _ 3g. 500 - 1,000 gallon dose chamber - 30.00 49. _ 3h. 1,001 - 2,000 gallon dose chamber - 50.00 4h. 3i. 2,001 4,000 gallon dose chamber - 70.00 4i. 3j. 4,001 8,000 gallon dose chamber - 90.00 4j. 3k. 8,001 12,000 gallon dose chamber - 110.00 4k. 31. Over 12,000 gallon dose chamber - 150.00 41. 3m. 500 - 5,000 gallon holding imik 30.00 4m. 3n. 5,001 - 10,000 gallon holding tank - 55.00 4n. 3o. Over 10,000 gallon holding tank - 100.00 4o. 3p. Revisions - 20.00 4p. 3q. Groundwater Monitoring Per Lot - 32.00 4q. (other than a proposed subdivision) Subtotal 3r. Priority plan review: walk through) 4r. Submittal of plans in person, by appointment,with double fee 3s. Petition for Variance Setback - 25.00 4s. Site evaluation - 50.00 Total Fee Note: Fees pursuant to Wis.Adm.Code,Chapter Ind.69 may be subject to change annually DILHR-SBD-6748 (R.03/84) Effective July 1, 1984 -OVER P1 b, # 60 1/78 PROJECT DETAIL DATA SHEET NAME OF BUSINESS LEGAL DESCRIPTION ......�-�._.__..l..J_i� _ .__ .L.. _ �r_ _�r�.f� .�_�� fat-:. . � ; ll.✓ t�'1_�L a/^� '�...... OWNER l r' !.d. c. Y ,4 A t MAILING ADDRESS ZIP WI'H-T-K-T, -€NGIN€€#I; _��,. �` ��� f;r ,� ADDRESS _ (, e Iii. PLUMBER U'V9n-1 ZIP J�ic7 E TELEPHONE NUMBER !S - 2- t. , S'i 3S- 1 . Check appropriate building usage(s) and fill in the information requested opposite each usage listed. Please consult Section H 62.20. Existing building I.-- 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 t ( ) Drive-in restaurant . . . . . . Inside seating capacity ry 2 80 Car-service -- Number of car spaces ( ) Dump station . . . . . . . . . . . . Number of dump stations QQ 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 RaE�preAsc'�dyS . . . . . . Total number of customers ( ) Schools . . . . . . . . . . . . . . Number of classrooms - j Meals ( ) Showers ( ) Self service laundry . . . . . . . . Total number of machines ( ) Service station . Number of cars served daily ( ) Swimming pool bathhouse,, .,,, . . Number of persons ( ) OTHER . . . (Specify) _3 e3cj COMPLETE OTHER SIDE Floor drain yes �X- 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 f ? cC c, Holding tank capacity Septic or holding tank manufacturer ,,4.. - 4. SEEPAGE TRENCHES: total square feet width of trenches, length of trenches depth number of trenches SEEPAGE BEDS: total square feet'} width /a length of bed :!VO depth w SEEPAGE PITS: total square feet outside diameter depth below inlet total depth from top to bottom of pit Signature of person completing form: FOR DEPARTMENTAL USE ONLY C. Address P ) Y r Telephone Number '�'l�`5`1 �.�,t 19 Date / -. ') - , PLOT j� �t 1 l� R 1 r k fl e.X It ran Silk SA,c. R 18 W _ h tea rk, IUc►, ihw' . €l� ! 00 . Co - v d,`"'`s ` Class l F...k-t-e -- 03 f.),6 Att R % 870 _. a,1 ue 4 h �' ✓ ! n�U� �1�1 / ± � / 33 lot _z a7.4 r* � Ri fir.6 ct W i s f F: � � 0.0.���pQ�\��\ ... •�» C3 L-4, _ . p: y 1 Vent: _. : .`. __._ PAGE OF C.roSS S � � � t � r, o � /a 13 � �� spl -) �i 1 v'K N-e. t..1 rn 5 u, %Y It/W !y 50-c, r z Fresh Air Inlets And Observation Pips 7-3; 1v ( sraslorlielffit Approvad Veal Cap Minimum 12"Above Fina�.....l 6 `:*`Cool [fee "`0 20-42"Above Pipe } To Final Grade Veal P merah may Or$ nth•tic cov Over Pip V OlatrlbWlon � Pips • G"Aaarogal• �,` �aMtaA 0• C P�`vO Pip• i of In 1 mo lom r a y ,O . 99.0 Vev•. a SOIL FILL DISTRIBUTIM.1 PIPE APPR4VE0 smurCttG COVCR .` �''PIATER141- OR 9 �l+`.STRAW Q"OF hGoREGAUL --�� OR I ARSN HAy . ',' Q �+ ' 4. O F,/z -21/2 AGGREGATE %'/G \`r' // LV. OF far?....._ M p 0 0 " DIS't RMIJTLOIJ PIPE TU DE AT LEAST �0 IIJCHES BELOW ORIGIMAL GRADE AUV AT LEAST LO IIJCHES BUT LIO MORE THAIJ 42 IMCMES BELOW FIMAL GRADE s MA"A DEPTH OF EXCAVAT1onf F014 OIL &wu 6KADE WILL BE 5 U IMC.HES PWIIWWM Mf rs of ExcavATtem fROM-011 I14IIJAL" yRAVE WILL BE D RUCHES } � SIGAlEO �r LIGEIJSE IJUMBER: DATE 110 ..l- F I L E D >� JUL 7 1983 HMELL rn 1�ep(rtor of beedt r St. Croix C"tY, p 0 L C .T.H. u H u s Wisconsin zz w W W S 890 31' 17" E 230.11' 0 z o-+D — —— O o no--I r 158.42' 71.69' 120.04' n r S86°21'37"E O 0 D °omm a� r M D _ m W Z�Z �Z� N(0 N_ —C� z� OD Z) r Z vNr� '�iO Oy (AN r opo mx �p Z -I Z m _D Dw O �— m 2 Dz� AN n� O OA rm z ((1) w Mo �O y W Co Zo m 0 fn M.KOmm A 2 N� tn-'�{ rn m� 9 O N m ,� N co N z{ v C o=� m m X z N �� Nm z omz r 0 m* ° N A cn (D C Co m OD c� v O D ° �� O 0 Z 1� 0 Z —� G7 = m N (-) m m mZ o � � 4 .22' 307.83' AO-0(A C O -n n S 88013' 35"E 350.05' c.� m m vm z v a) r- M C Xr (n _<QD C m m m -n = O C7 C (n I c N m n - `� :� s °o i v z -< 0 m o r Q N (A S '� P jD w re* Z _ o i� o m= A O Ci L w I-q N =� N m �^ N cp I° z v z O D = �� f i r > < —I C z r u' I O _w m iz r z < Io D vc o 1� -`'� ;u m o — N ` G W o° - z z i z� _UIN s m —I 0 r o (wD v n o o° z o -4 N °' CD 0 D . .4 .4 m C N N (D N A(D A N Z V W (f W wA Cho N APPROVED ° D m m m m m t -+ -� Z 3tTL 61983 N = O 0 0 A m J m r r o C ST. CROIX CJ-.Ty o D N E z COMPRENFNSM PAkK$ PLA04NiNC O 0 AND Zl:)ANO ComAutm .w A m 50 0 n • = znA O z � � c tn -< r c o0 cn d m .. Z m to p o C) Z --I =mm(n L ,r Z z n _{M m •tip �(9o�Z` D-i-I o ~°e..' �� n {AmC oo,� 43.74' 306.26' �� z �.. o� N m m(n m� in N N 89°03' 15"W 350.00' z<i;oA u+ C.S. M. VOL. 2 PAGE 485 -I m z o 0 {°o-z Vo1wTe r 1'alre 1307 Y Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER �'�' // X 4-/�? TOWNSHIP � s-�GrC// SEC. 1c;2 TZ/ N-V W r - ADDRESS 1��� t�xa2�,� ST. CROIX COUNTY, WISCONSIN tl SUBDIVISION C�� U S^�/� LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM l q � to /© w_ 01A 5� o INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used 94 -5,e- 5- Elevation of vertical reference point: _T�6a Proposed slope at site: SEPTIC TANK: Manufacturer: /6_'/,L 'e 15- Liquid Capacity: �o�O> Number of rings used: _ /j Tank manhole cover elevation: -7 Tank Inlet Elevation: J67,1 Tank Outlet Elevation: Number of feet from nearest Road:. Front,O Side,Q Rear, O l feet From nearest property line Front 10 Side 10 Rear,0 feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) - - 9FF RPVPRRR RTnF _--- --- --- PUMP CHAMBER Manufacturer: Liquid Capacity: .L Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycler Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, 0Side, 0Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width:_ Length: Number of Lines: - Area Built:dli Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, Rear,OVt . cp Number of feet from well: � / Number of feet from building: el (Include distances on plot p an). c — SEEPAGE PIT Size: Number of pits: Diameter: y Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: �— �� � Plumber on job: License Number: 3/84:mj i ........ ... 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: SW'-,jNAA,-fS12,T31N-R18W ] CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Star Prairie ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound C F P O ER: ADDRESS OF PERMIT HOLDER: INSPECTION E: Kirk Hemin Route 1, Box 255, Star Prairie WI 54026 �5^ 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. 13318 S 1 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: 4b ,q6 K INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: Jd00 T 4 RBI I ®YES ❑NO ❑YES X NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LI :� AIR INLET: ❑YES 5KNO EYE S �.NO NEAREST Ala •-- DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: P 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: I 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 DIA.: #PITS: LIQUID TRENCHES: M+�ATERIAL: PIT DEPTH: DIMENSIONS (a C1.)'a V GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL NO.DI TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET: ELEV.END: PIP LIN , f - A INLET FEET FROM at) 'S � NEAREST� �ID � �p� 9 D 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: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE I MANIFOLD MATERIAL: NO DISTR. I DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS EYES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM 2 [--]YES ❑NO ❑YES ❑NO NEAREST411- S2 3Q Sketch System on 3 L Retain in county file for audit. Reverse Side. sl ATURE: TITLE: SBD-6710(R.06/88) Zoning D„ ,LHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm.Code COUNTY �c Ce STATE SANITARY PERMIT# -Attach complete plans(to the county copy only)for the system,on paper not less than l�'�j�/.�/� 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 &:f_� /a&Y.,S .2_ T,?/ , N, R E(o PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# CITY,STATt ZIP COQ' / PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER„�� II. TYPE OF BUILDING: (Check one) CITY 1 NEAREST ROAD ❑State Owned ❑ VILLAGE ��4r G ❑ Public 1 or 2 Fam.Dwelling—#of bedrooms ARCH LTAX NUMBER(S) 111. BUILDING USE: (If building type is public,check all that apply) � �'a c�c� 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. 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 �1 REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION p2 o G 7 1.2 Feet / ® Feet VII. TANK CAPACITY Site in aallons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks oncrete glass App. Tanks Tanks structed 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 ame(Print): Plumber' Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: /'a Plumb r' ddress(Strkret,City,St/, ip Cc D rO Ge- IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued Issuing Agent Signature(No S mps) Surcharge Fee) kin Approved El owner Given Initial / �,U•, Adverse Determination V u' 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 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. 111. 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. 13134M8(8.11/88) + APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property'' i ��,� ��Q n Location of property b0_1 4 X1 1/9, Section T__I/ -N-R W Township Mailing address (Sl c) X ASS .r P�cc "Lj �J� Address of site �G(,(.� , SJ Sr' lC�UI 1. �t%-C S ��lJa�j t Subdivision name Lot number Previous owner of property LL SS _ Sa-C,o on WhA-& ' etak Total size of parcel Date parcel was created - — " Y3 Are all corners and lot lines identifiable? k Yes No Is this property being developed for resale (spec house)? Yes _ �X No Volume and Page Number 310 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. 3 ! `&O. 63 ; 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 Register of Deeds, as Document No. ) . Signa a of owner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCOMUN—►OON I NAANTY OM ESE THIS VP It RrrvED FOR RICWlDiiuG DATA 3L��:F3 VOL 6�� �a.c• ln REGISTGRS OFFICE THt DEED, ride botween Russell T, Whitenack and ST. CROIx CO., W#& 3�usan Stockman Vh tenac us and_ant_wi-fe, R«'d. for Raaord NtFs 12th as 1�tenants -� _ C,, 1 dnY of __ rantgr ., A,D, 1983 .t,erTc —HexwnlTOan M_ �Iace,---_an d�Kuene \. at L: I S P i _ - - y M.uall as pon_t- tenants and not 7 as tenants in common. am,, ---- ---- - Grantee 4r.d . W i t n e s s e t h. That the said grantor, for a valuable consideration ..._ ...__ dollar-and other valuable _Coneiderai ion --- �E7UIIN r0 conveys to Gtantee the following described real estate In _ S_t.,_ Croix county, State of Wisconsin i Darlene B . Murray Realty New Richmond, WI 54017 �� ♦ -lax Krs N , FEE Lot 1, Certified Survey Map filed July 7 1983, in Volume 5 , Certified Survey Maps, page 1307, as Dent #385943, being located in the SWk of the NWk of Section 12-31-18, ' Subject to recorded easements, reservations , and rights of way. This is homestead property (is) (is not) Together with all and singular the hvtedrlalaent�; +nd appurten.n . thervt ntu bele,nkln And Ruse-ell _T,__le[tlitenack and Susan Stockman Whitenaa warrants that the title is good, Indefeasible In fee simple .end free and clear of encumbrance: except no exceptions A l .Ind will w.rtant and defend the same p { n..iud. I llI, l\ - da, of July 1(► 83 'Lyf r {y iSEAL) 44.4 a-Russell T. Whitenack (SEAT.) (SEAL) Susan Stockman Whitenack AUTHENTICATION ACKNOWLEDGMENT Signatures euthrnticated this day „t YTA11•. ()F WISC0N,IN 19 t St, Crcix (',,,Int` I'e n,m,,lle c.eme• h,•t,rr me. thl . day of July, 1983 the .rte, ,:e• ,.,r;..•d TITLE: ti1E%113E1t .,1A11 It:>k (II- til`( ()NSIN n,,t, Russell T. Whitenack and Susan Ili ,uth<.r:t:d b, -tt1, itt,, u, stal•. I Stockman Whitenack. This Instrument was dr,med h% Eric J. Lundell, Box 157 .. cu i nr wn t" h, the pcn .;t s Ali,, r•x1tith'Al,�,rAtX New Richmond, W1 54017 r,lin�. In tnime.0 -in d nckr�uwilg1l,rd ,hri�prtr' •• `{� .4 gbta a 42 tSiKn.Wreti ma>, he .,uth,vltle:,tcd Ir ac i.n„xi,•di-e d 13„th Darlene B Murray �•x.� are not necetisar%.1 Neet,,r% 1'ul llc St, CroiX IIuLMy. W { Slt 1 It n..r,,at,de erhicel,te�I •tire,. .t I,. . , •,, In.. ,n ,,. . .�� _. a t. ,1,.1 r, 1 .. th, r :In, � 9Y� N y1 •AW WA-I I Alt HAM r:! I11?.%n1\ l_N%j %I) 1 l�': ,. .•.^...^ r,.+.,... STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County I/ OWNER/BUYER I���/� cind ��bl n lk X U n/-) ROUTE/BOX NUMBER CIN nn X FIRE NOLL.// /- CITY/STATE 6 ZIP PROPERTY LOCATION: ->!A)) 1/4 n)CL) 1/4, Section /2-31'/x, T__31_N, R__J.6W, s Town of � l,r Poa"('La , 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 $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after Inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE S/ St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address f DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, . DIVISION P.O. BOX 796 LABOR AND, PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS ILHR 83.0911) & Chapter 145) LOCATION: SECTION: NS /MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: �1 �/ X /T �N/R E (or ��, '^(t� -10, 5� Us COUNTY: L MAILING ADDRESS: S 9 DATES OBSERVATIONS MADE -- O,oZ 6,f` NO.BEDRMS.: COMMERCIAL DESCRIPTION: A TESTS: e �^ w Replace �$/ RATING:S=Site suitable for system U=Site unsuitable for system CONVENTION'AIIL: MOUND: IN-GROUND-PRESSURE: SYSTEccM-IN-FIIILL HOLDING TAN RECOMMENDED S $TEM:(optional) �S �V S �� �v �� �J Y �S ®U DESIGN RATE: If Percolation Tests are NOT required If any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST.HIGP_EST_TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- B- -TU 0`2 x/otic B- B- B- PERCOLATION TESTS u TEST DEPTH . WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTER SWELLING INTERVAL-MIN. P RIOD 1 PERIOD 2 PERIOD PER INCH P- t 5— C I G P- 1 ell, 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 qL/"Z G o E 1 � a t : 4 ;. t- `a P - / E ` � , ,F , 6?00 p -_ .. T - e . '� tN , ... .. Q I`.5� _ n.._.�... E E o' a il- I � E -_ .. . . �. ... - _ E _ lt 'r w 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 data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME print): f ITESTS WERE COMPLETED ON: A601 ow AY1 ^c/ ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): p ee 13 q 7 111 .l vz� 761G CST SIG NA R I DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) —OVER — INSTRUCTIONS FOR COMPLETING FORM 115- SBD - 6395 To be a complete and accurate soil test,your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes.A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations.Drawing scale is prefered.A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete all apropriate boxes as to dates, names,addresses,flood plain data,percolation test exemption,if appropriate; 10. If the information (such as flood plain,elevation)does not apply, place N.A.in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 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 — Standstone gr — Gravel (under 3") LS — Limestone 's — Sand HGW — High Groundwater cs — Coarse Sand Perc — Precolation Rate med s — Medium Sand W — Well fs — Fine Sand Bldg — Building Is— Loamy Sand > — Greater Than 'sl — Loamy Sand 'c — Less Than '1 — Loam Bn — Brown 'sil — Silt Loam BI — Black si — Slit Gy — Gray cl — Clay Loam Y — Yellow scl — Sandy Clay Loam R — Red sicl — Silty Clay Loam mot — Mottles sc — Sandy Clay w/ — with sic — Silty Clay fff — few, fine, faint 'c — Clay cc — common, coarse pt — Peat mm — Many, Medium m — Muck d — distinct p — prominent HWL — High water level, surface water Six general soil textures BM — Bench Mark for liquid waste disposal VRP — Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance.A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit.The sanitary permit must be obtained and posted prior to the start of any construction. I PLOT PLAN PROJECT__ s� e . �(' �Xcts� ADDRESS �'�,/r�1�x��� ,i/4Xw 1/4/S%�/T � N/Rl �W TOWN �f� r ,�;c COUNTY . MPRS Byron Bird Jr. 3418 DATE --4!s� -3— BEDROOMS CLASS PERC_ Z CONVENTIONALIN-GROU D PRES RE CONVENTI NAL LIFT MOUND_HOLDING TANK SEPTIC TANK SIZE ./�� LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE ABSORPTION AREA PERC RATE BED SIZE L Benchmark V.R.P. Assume Elevation 100' r Location of Benchmark ��e �� /e jAs ��_ Z)5 * H.R.P. v -- C] Borehole Q Well Scale = Feet 0 Perc Hole System Elevation - Uent 12" TYPAR COVERING 2" 12" 3' O 6' 0 3' 1 6„ Sewer Rock 12' �a U&J 30 Ap i