Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
040-1032-95-200
§ ~ 0 60. d 6 > o ) 0 { c= k ff � == o } \) § % �kD a )ƒ § $ ) [ § \ k / Em f 0 $7 2 ca � 2 � i k � CD CL C kf2� LL \ D 2 k §\— - .2 �2E « § � � � \ E E \ ƒ & I z {\ 2 2 2 � e m, I I q \ z / 2 m 2 k k 7 k { ) \ : $ E 2 4 2 k Cl) ? . .N CC 5 N CL 9 = e \ E / § a @ \ ƒ 2 e � c 0 + § @ « § § § § § } z w § \ z ) \ .. z .. Cl) .. 4) & a.6 0 § 7 _ = a M _ ) � » E % - ) \ \ 2 k 2 ) / \ � k & k a ) \ < o / % £ k .1 U) U) m m \ ~ _ _ k \ § z 6 0 k \ ]e a a CL - \ 0 B _ _ u j2 CO / } )+ z ) k $ £ a � o i % § / ° E � % � � 2 @ � \ ° I ) k $ \ ƒ / i G $ / k f ■ / § 2 ° � \ 2 a % � Cl)I 2 ` § < If $ / ) 8 E \ § \ / \ j . { m * ) k j $ 2 , k -� - a " ƒ § a ` ± 7 a o = G § e � } o z / ] G ) \ z / z k ( CL { 2 ZZ L: CL§ � » Q 0M 258 X250 Q u IL 0 U) u , 0 U) u Parcel #: 040-1032-95-200 11/23/2004 09:03 AM ' PAGE 1 OF 1 i Alt. Parcel#: 7.28.19.109D 040-TOWN OF TROY Current ❑X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units 00 0 Tax Address: Owner(s): *= Current Owner * VIRGINIA A BOUMEESTER BOUMEESTER,VIRGINIA A 393 S FORK CIR HUDSON WI 54016 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *393 S FORK CIR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.000 Plat: N/A-NOT AVAILABLE SEC 7 T28N R1 9W SW SE 2 AC LOT 2 OF CSM Block/Condo Bldg: 7/1930 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 07-28N-19W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 897/546 07/23/1997 892/94 07/23/1997 839/371 2004 SUMMARY Bill M Fair Market Value: Assessed with: 211,500 Valuations: Last Changed: 07/19/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 80,000 172,600 252,600 NO Totals for 2004: General Property 2.000 80,000 172,600 252,600 Woodland 0.000 0 0 Totals for 2003: General Property 2.000 44,000 159,500 203,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 305 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 /29 A ' Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /y0xl�- 5 TOWNSHIP 'ROY SEC. �7 T 1z N-R W ADDRESS .2-/3 ST ST. CROIX COUNTY, WISCONSIN SUBDIVISION �(5 Up w /�� LOT T' ?` LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•I.HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW 7MP Oh &,<i s7Ti,Pe,-- BENCHMARK: Describe the vertical reference point used Zj_---/l CT i Elevation of vertical reference point: ./0'0' 40 Proposed slope at site: 6 �� 4vE,6X'5' 60 ,c,e-�e- ,2,o PO C7S SEPTIC TANK: Manufacturer: Nov Ye1eAH0,0P Liquid Capacity• 141-J-0 Number of rings used: / VA'2!, - Tank manhole cover elevation: Tank Inlet Elevation: / S' / � /Tank Outlet Elevation: Number of feet from nearest Road: Front, V Side o Rear J�C! feet r14 ST From nearest property line Front,O Side 0 Rear,O zz� feet i _ Number of feet from: well , building: // fF , (Include this information of the above plot plan)( 2 reference dimensions to septic tank) ) SEE REVERSE SIDE w • PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact er: Pump Size Elevation of inlet: Bot m of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nea st property line: Front, O Side, O Rear,0 Ft. N ber of feet from well: tuber of feet from building: (Incl a distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Soy ,5 � Width. 5 Len the Number of Lines: 2— Area Built: Fill depth to top of pipe: 3 4 Z d cG ' Number of feet from nearest property line: Front, O Side, O Rear,O Ft . / i Number of feet from well: 9 U Number of feet from building: Ia 3 ' (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 0 or distribution box O been used any of the above soil absorbtion sytems? (Check one) . HOLDING TANK Manufacturer: Xionof Number of rings used: m of tank: E levation of inlet: Number of feet from ne/of perty line: Front, O Side, O Rear, O Ft. Numbt from well: Numbe of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: HOMESITE SEPTIC PLUMBING CO. ROBERT ULBRIGHT WAS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. MINN,s1STALLER i DESIGNER LIC,NO.00663 3/84:mj z V It) 5oi � �� >✓���S.�e� �T,oa � SGT{- % � -' Zy 9g �s °F t jop /. 33 a'^j�,f r_— � I I $/ople- i I I In y� I I �r2op 9071 , whSka 3/q" T 12F,� �- "lee p� Peeps I S 3 1 N LET To PP-Op r O - - /oao PAP- (A S T- . i 13b4 : ej",ATto-J = g3.NY I SE p-1 rc Tm if< 1,3 ' co,%�-- �P oDocfs - Q To P ceo .4 k of t m We: Yf i (0tar. etf- ?'J �5 100• Q� f}s i3 u ( L T j DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING LABOh&#iUMAN RELATIONS DIVISION 1D.'O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION MADISON,WI 53707 State Plan I.D.Number S,,SE,,S7,T28N-R19W CONVENTIONAL ❑ ALTERATIVE (if assigned) Town of Troy ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound E R9M IT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Moser Homes Inc. 213 Locust Street, Hudson, WI 54016 3 'gR- ��o� BENCH MARK(Perms nt reference point).DESCRIBE IF DIFFERENT FROM PLAN: r REF..PT.ELEV: CST REF.PT.ELEV.: Nameo lu MP/MPR No.: County: San um Robert Ulbricht 3307 St. Croix 11945 1 SEPTIC TANK/HOLDING TANK: MA OF TURER: LIQUID CAPACITY: TANK INLET ELEV: TANK OUTLET ELEV.: WARNING LABEL R r PROVIDED: ;PR VIDED: Wee kS 0 u 0 �- a � ° C J -�nES ❑NO YES-ENO BEDDING: VENT IA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH L 1 1 ALARM: FEET FROM / LINE: r AIR INLET: ❑YES 2NO l (11-1 ❑YES 2 N NEAREST---*I IL 0 { DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACIT [U7 DEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER ," PROVIDED: PROVIDED: [:]YES ❑NO ✓ ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: P P ND ON ROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ❑YES [:1 N0 NEAREST—� SOIL ABSORPTION SYSTEM. Check the soil oisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID TR CHES: MATERIAL: DEPTH: , DIMENSIONS 5 ( r PIT J_. GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE I DISTR.PIPE MATERIAL: NO. S NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE C VER: ELEV.INLET: ELEVJ^ D: PIP FEET FROM LI f Q C� AIR INLET: NEAREST M ND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑YES ❑NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH/BED 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 MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: `•` t ❑YES ❑NO ❑YES ❑NO NEAREST—� �a ] })- 0 A r j t _ t i Sketch System on 1� Retain in county file for audit. Reverse Side. ` F-' , Si TU TITLE: SBD-6710(R.06/88) ZOnln S Adminis trator 3 , 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: S, SE,7,28,19W XEd CONVENTIONAL ❑ ALTERATIVE (if assigned) Town of Troy ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Wayne P/Ioser 213 Locust St. Hudson, WI 54016 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: Ulbricht 3307 St. Croix 119528 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.:I WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑YES ❑NO ❑YES ❑NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑YES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO ❑ ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF) ❑YES ❑NO NEAREST--* SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE 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 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 I 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 ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: El YES ❑NO ❑YES El NO NEAREST Sketch System on Retain in county file for audit. Reverse Slde. SIGNATURE: TITLE: SBD-6710(R.06/88) Zoning Administrator Thomas C. Nelson 'DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm.Code COUNTY _ sTr Ciev�X MMOMEMMEM STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than / /Q5 8%x 11 inches in size. 91 Chedk i�evision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. ^/• , PROPERTY OWNER PROPERTY LOCATION �+ wdywe- At®sjff� k.L.%as£ '/4, S 7 T'4� N, R ` E(Ora PROPERTY OWNER'S MAILING ADDRESS LOT# Z BLOCK# z13 G&coST �S r - CITY,STATE / I CODE PHOIJE NUMBER, SUBDIVISION NAME OR NUMBER I. TYPE OF BUILDING: Check one c/ CITY`? O NEAREST ROAD I ( ) State Owned3 ❑ VILLAGE ❑ Public 01 or 2 Fam. Dwelling—#of bedrooms PAR L TAX NUMBER(s) !- III. BUILDING USE: (If building type is public,check all that apply) �� ` Z> 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 Cj Existing System Existing System B) ILA A Sanitary Permit was previously issued. Permit## ` s Date Issued l V. TYPE OF SYSTEM: (Check only one) (Z) JC' `X 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 r VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. . FINAL GRADE ��O RUEQUIRED(sq.ft.) PROPOSED(s ft.) Gals/day/sq.ft.) (Min./inch) tt G ' C ELEVATION 7 d0 • ! r S Feet / • S r Feet CAPACITY VII. TANK Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New istin Gallons Tanks Concrete structed glass App' Tanks I Tanks Septic Tank or Holding Tank 92t�o Lift Pump Tank/Siphon Chamber J2. Vlll. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signatur :(No Stamps) T/MPRSW No.: Business Phone Number: 4 7 336'7 Plumber's Address(Street,City,State,Zip Code): s° o `,v el L led IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee(Includes Groundwater ate Issued Issu g Agent Si nature(No Stamp Surcharge Fee) Approved E] owner Given Initial Adverse Det rmin tion '��– +O�J X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398(formerly Plb-87)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber INSTRUCTIONS r 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers;wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398(R.11/88) s * A DAE.v vM 7`6 aj=- e-4- S`7 DEPARTMENT OF REPORT_ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMA N RELATIONS ' HUMAN (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/MI.,'�:��T�-;,zpTY: LOT NO.:BLK.NO,: SUBDIVISION NAME: S>7'- !/41E V44 7 /T4N/R 11E (or)W 7P10y Z So �FORk So13D- COUNTY: OWNER'S/ MAILING ADDRESS: 40 W+YA-� Mps�r_ 213 LoCUS7- 5 77. h�0,AfOAJ 4J6 144/6 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESC IPTIONS: ER LATION TESTS: Residence ❑Re lace New P J"yaE Z'�^ RATING:S=Site suitable for system U=Site unsuitable for system SAS ?3 rpI L`o 1 — FkAER y — CONVENTIONAL: MOUND: IN-GROUNDPRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM:(optional) DS ❑U S ❑u S ❑U I ❑S ©U I E DU rif-4�-vz: 'w7/dA,,,lL-, If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate: C L� SS Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, p OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- l� �'s r ✓' �Q / j > 8,S 314 S�/ ?.S; ) /.O ' f�.f C3,•)• S% � /.S-' T-}.v s./ CA CS B- �' 9✓l✓f y ?� > s ' l3i�- s,. i s ' T4,v 5"*/, . 9 ' r,,N Pte/ Cs 8 B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH P- 3. ' dC Y P- I P- P_ P_ 60 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 E E E 3 3 3 ! - .....,e.._...._ __. __. . ..... .. 1 E ' i r ka Lp L ' TH -a= 7 M 7 j E .....,_... _.........r-_...._ .j_,......_ t t [ t I ( ' c 7 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 Ofy,: HOMESITE SEP'i1C PLUMBING CO.Fisfi IL RD. OJDSON,WIS.54016 Z-2 ADDRESS: ROBEPT ULBRIGHT CERTIFICATION NUMBER: PHONE NUMB R(o tional): W9TER PLUMBER LIC,N0.3307 M.P.R.S. � MINN.w'�TALLER d Gt t CST SIGN77ATUR t� DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) —OVER— iL r :r INSTRUCTIONS FOR COMPLETING FORM 115 - S D -5395 To be a corrtPIeUi and accl,iate soil test: oil,-report ini.Isr, inc VAO"*� �/ Complete legal description, ���5� /!JD cV^ 1e �E 2, The use section €must clearly irrdic to whether t pis Is a rya�iclence car corranieroial pr � 3. MAXIMLl�:1 number of bedroorns r con]SED use planed Top 4, 1s this a ne-w or replacement systei . Complete tf�e suitability ratittq bo e,. SUITABLE FOR A HOLDING TA �3o4lf#16 JI� OTHER SYSTEMS ARE UL iJ C)I / 1L DClt�1t3(TitC�1S; PLEASE ii,r the a€,k see°i t ican l riti rofile descriptions and cornpletiry the plot plant; y, MAKE A L,�IBLE diag ant�cctr ` g your test l2W, ons. Drawing to scale is preferred, A SEFpa at€?Sne 7=ilay be use I if dash ed; i:1ul«, sure your€ertchrnar< al 5 eferert€;r=paint are clearly shr3v ia,a ncI are permar�ant; Coiplete apprapriatc� )o3`Ius,addresses,flood plain data,percolation test exe�ai tiff i ar�� (Brl tte, 10. If the information (such as flo� (plain,a=levador)does not apply,place N.A. in the appi opriate box; 1. Sign the form arrcl place your Yrrent address an I your certification number; 12. Make lec;ible copies and dirt ibute as require ALL SOIL TESTS MUST BE PILED WITH THE LOCAL AUTHC 30 DAYS OF C NIPLETION. �s 0 i 0 �F��h��KE�T ftRf�I (7e �x 30 ) ABBREVIATIONS FO C RTIFIED SOIL TESTERS ` 3 . Soil separ&V Textures 4 ` tither Symbails st - Stone (over 10") \[�R - Bedrock cots Cob le {3- 10") "S �- Sandstone ��0 r -- Gravel (under 3") LS\- Limestone `�� ...._ Sand NC�4vr'-��ligh C�roI Cl 1 .,r cs Coarse Sand Perc - Percolati ate i €:d s Medium Sand W - hell O' fs _- Fine Sand i Bldg -..._ B ilding N�W S yST�M (� - Grr ter T n CI �1 is -_ Lfaarriy Sartci � � �� 1 i < _.... Less han .,. - windy Loam Loam Bn _.._ Brown sal - Sil# Loam BI - Black K � s Silt Gy ....._ Cara '7 cl Clay Loan y - yell it, , sc - Sandy Clay Loans � R .... Fled sicl - Silty Clay Loam of Mottles sc Sandy Clay vv" with sic; - Sixty Cl�y� ffr - few fine, faint SC/4 c. - Clap- ��11JJ c;e corstnon,coarst. x I rntt� - Many, rnedium nt M ck - distinct P ....... prominent --'—'- l-iL�#L• - High water Ir:=,v.;l, Six(Ir rte soil text€ l'es surface watei for liquid waste disposal BM - Bench Mark VRP Vertical Reference Point • �PcG rru O�I il(r5 �C C siS TO THE OWNEF�, HpMESITE SLF',Sl1I,C PLIJMW 54016 ,gyp L- ,6t aWLP1QiW� rEt i�tji@ fir? ep in securing a sanitary permit.The county or the Department may request veR 3%jMjk A the field prior to permit issuance. A complete set of plans for the private WIQ mikj g p-1e.No plication must be submitted to the appropriate local authority in order to MINN.Ii`S;M permit.7;h i s ryrt ermit must be obtained and posted prior to the start of any construction. 2 7 PL-OT Z(pQER C.V Fresh Air Inlets And Observation Pipe ` 4 �, �.-------- Approved Vent Cap `y Mini mum 12" Above V Final Grade S11 ! 36 4" Cast Iron IL Z '' Above Pipe — Vent 'Pipe 1 I Final Grade Or Synthetic Covering Min. 2" Aggregate ' Over Pipe h Distribution Tee Pipe 0 0 0 0 0 Aggregate o Porfbrated Pipe Below Beneath Pipe 0 Coupling Terminating At Bottom Of S.ystem SEP:PLI "S50 yy�i !�W Ep 01L �UM�B�P L gR6g1 or N6G t440p.�M R S Vic. 41C.V10'OOW M NAlip VFresh Air Inlets And Observation Pipe J � Approved Vent Cap Minimum 12" Above Final Grade of '9y sv 4 4 Cast Iron v Above Pipe Vent Pipe' i 'to Final Grade Me"N-49y- Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Tee 0 0 Pipe • 7 " Aggregate o Perforated Pipe Below Beneath Pipe 0 Coupling Terminating At Bottom Of System 1h1 . r E r Sfipte REF• ?o%NT. fO _ TOP of WEII witSi�lr- �(Ev►4T�o.J '3 q o' � I , ivoa S°� O , (\ UUt-EIKS 3'07'iG S bD E n C J:A( ✓ 1 3 0 f eB 0 TANK ft Rf� (7b� �z l / OP (9 o X. - „� New S ySTE-1-'1 � I S U • = Q,�� �fft�� I� o l� i��-S HOMESITE SEPSIC PLUMBING CO. 655 UNEIL RD.,HUDSON,WIS.e.!;I- y y8 L-- ROBEFIT QLMG14T 7 MY.R.S. WIS.MASTER PLUMBER LIC•NO.' MINN.ip;STAILER 6 OES GNER LIC.No.gm z � , ���� Pc-0r I.ofi 7 So vi-t,. Fo R SCR M OXEA- -- �pp� �,p�'•v lCt, Fresh Air Inlets And Observation Pipe I • t Approved Vent Cap l� Minimum 12 Above , v Final Grade 5-o 36 i 2- 3 G 4" Cast Iron Above Pipe Vent Pipe' -ro Final Grade r Synthetic Covering ' Min. 2" Aggregate Over Pipe Distribution Tee Pipe 0 0 0 0 0 Aggregate 0 Perforated Pipe Below V Beneath Pipe o Coupling Terminating At Bottom Of System Pt.UUS14G Go. NOM t.RD••4jDSO G 0- r1 �.�' iwya 14p'N 3307 M P V � � S.MpgTEFi Pt•UMB��N�FI I.IC• ' ..,`�. � WIINN•iNST�LI�R�'7id �7�j . Fresh Air Inlets And Observation Pipe J 0 Oe Approved Vent Cap Minimum 12" Above Final Grade - i OF 9y Sv 1.. 4y Above Pipe 4" Cast Iron -ro Final Grade Vent Pipe' M Or Synthetic Covering 'y Min. 2" Aggregate Over Pipe Distribution Tee Pipe FO-0- 0 0 0 " Aggregate o Perforated Pipe Below Beneath Pipe 0 Coupling Terminating At Bottom Of System At Lo 7- I i 10L vice �Ei �OiNT 0 TOP ,F LoEll corsi�G-- � 3 qo, 3 CMS 13�: �n F�EAlr 30 / rk ` 3 3 opop f 00 ySTE�-► „` ys,o 5-CA : ( 3C� sysrGAl SytTO E��v�fTio�/ El�v y0, S0 � H0y1ESITE WyjIC PLUMBING CO, v 655 O'NEI ���H IS.c SST yy8 R UC.N0.3307 M P•R•S• MS.MASTER PLUMBE MINN.It;STALLES&DESIGNER LIC• 00 3 PL-or Pi.A � =- �ot zz So uli^- Fo R i:� Sc�f3 =zZaRSANITARY PERMIT APPLICATION LHR In accord with ILHR 83.05,Wis.Adm.Code COUNTY STATE SANITARY PERMIT# -Attach complete plans(to the county copy only)for the system,on paper not less than 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 PROP RTY LOCATION /"65f j� � �� � � 5 � S ? T��, N,R E(or)W PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# CITY,STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSY NUMB II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD State Owned VILLAGE f�� ❑ Public Kj 1 or 2 Fam.Dwelling-#of bedrooms R L TAX N III. BUILDING USE: (If building type is public,check all that apply) 3 Z _ r 1 El Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestaurarWBar/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.K 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 Ej Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure f 43 ❑ Vault Privy 14 ❑ System-In-Fill ,. �l, 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) f ELEVATION / �} ' r• 0 Feet Y3, 5 Feet VII. TANK CAPACITY Site in aallons Total #of N Con- Steel Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret glass Plastic App Tanks Tanks structed Septic Tank or Holdina Tank Lift Pump Tank/Siphon Chamber '°v Vlll. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system sh n on the attached plans. Plumber's Name(Print): Plumber's Signat re:(No Stamps) #AP/MPRSW No.: Business Phone Number: • Plumbf is Address(Stre/et,City,State,Zip Code): to IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e Issued Issuing Agent Signature(No Stamps) Surcharge fee) ®Approved El Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-839(3(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber t INSTRtiMONS 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. Ali,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. i 5. Onsite sewage systems--must be properly maintained. The septic tanks must be pumped b a licensed -' pumper whenever necessary, usually every-2 to 3 years. 6. if you have questions concerning your onsite a rago system, contact Xour local,cgde:administrator or the State of Wisconsin, Safety, Buildings Div4 ion, 608-266-3815. , To be complete and accurate this sanita0,permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax numbers)of, . where the-system is to be installed. - - 11. Type of building being served. Cheek'only one and-complete#of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of.system.Check appropriate box depending on system.type. VI. Absorption system information:Provide all information requested In#1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank,`list the total gallons, number of F. tanks and manufacturer's,name, Indicate prefab or site constructed and tank,ipaterial. Complete for aU septic, pump/siphon and.holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VHI.,Responsibility statement. Installing plumber-13 tcrfill 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 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 dimepsions, locatioh'of-' holding tank(s), septic tank(s) or other treatmenitanks;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 lossr pump performance curve; pump model and pump Manufacturer; D) cross section of the soil absorption system if required by the county; E) soiIjest data on-a 115jorm.; 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.fdr monitoring groundwater, ground- water contamination investigations and establishment of`standards. T SBD-6398(R.11/88) :a,B°l`rA"° PERCOLATION TESTS (115) P.O.BOX 7� HUMA�N'RELATIONS �K MADISON,WI (H63.090)&Chapter 145.045) A I• N SECTION: p TOWNSHIP/MCRfTCTPArrrY: 0 NO. LKNQ: SUBD 1 ,•, `'�5;.'' $yz 1/ � 7 / t h N�R E(or)w -r;2 d� 12— GSM f AID IA(.— COUNTY: 'W 'S AM : MAILINGADDRE St.CROIX ftlsoa sos &,*IA6 *P NO- HU194013 Wis. 590/e. us E DATES OBSERVATIONS MADE COMM DESCRIPTION: p Residence ?'+0 4- J/• (Klew 0Replace A L�6' y ' �OJg'� fl • 9" `JS RATING:S-Site suitable for system U-Site unsuitable fors stem Y ► ONVENTI NAL: MOUND: IN GROUN RESSU : S EM-IN-FILL OLDING TANK: :Iop�bnat) �$ ❑� QS ©$ ❑U ❑S ❑S ©U erL Nkt._ If P ercolation Tests are NOT required DESIGN RATE: If any portion of the tasted area is in the •,;. under s.H63.09(5)(b),indicate: L. $ $ S Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS.COLOR.T R ,AND NUMBER DEFM IN. ELEVATION -OBSERVED H TO BEDROCK IF OBSERVED ISEEABORV.ON BACK.) /W f �iQ y e S 3, G R ' r / ' 7 ' • Q&BN S,) /l S' N• S 2.O 1 TJAI e-S� I/ C g.3 �1 v� ��• /D' )Zf^ >,/2 . 0 /� /o' 3 a S• � .S ' $,.�. S I � G-R , q/ 9 S -TA 0 u cs G-Iz ' B- r�.v• /�•9�r >/� O ' /,0 S� 1.5 " Ba. SO� 7. s" T�1N v� c5 G ' // R z � s 7 v " 1 P .0 B_ PERCOLATION TESTS 4d dEVr 40 1 &iP• S7�/p�f n}S -.•... DEPTH WATER IN HOLE TEST TIME DROP I RATE MIN PE NUMBER INCHES AFFT-E-RSWELLING INTERVAL-MIN. R N H P- • �' /`ice '� P_ P-x, 70 P_ i P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate sale or distances.Descrlbs what ete 00 hors• zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direadw and mom of land slope. i : ZC4v, Aaec_ A rs SYSTEM ELEVATION p9 O X ` Pe.,ec s'•re-s SCALE: �/0,' lot I s s ,N A 13 90 dab I I i jj I I yo �NY (. ' h%s t test sit APR IV ED 18 c .r id: System , _.. T I — — — ,k all. W I I ?0 1,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods spedfied M tIN Wltoonslp 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 0 • M ,tuMESITE SEPTIC PLUMOD, AV6•-- I+ I Ii? ADDRESS: CERTIFICgqjjION NUMBER: PFf�N NUYBE lap R Lwlal OBERT ULBRICHT ��(2 J '.Zlati ER b DESIGNER LIC.NO.00iifi3 CST S NATURE .�kt ' " r' DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. NOTE : H00-re Mom t-It' > 24 .46M' Tes T AREAS . i DILHR SBD•Fi395 R.02 82 _ .. 1 / _ 1 OVER �, G1f iC S O I r 1 S01004140t1E 69.89' west line of the SE} c axa s � .i" 000 _ mmm a :' a CA um W H 71.41 N cnH "' 2 0�� o w � za � Z 0 o co In O ° a °' M rt m cn tIn N CO N N V 1' coo N S )•• .� C-3 V o N O o 1 1-^ O H trj aC M a S o N C-n to O :0 to - CJ1 V F 1 _ r o W V V N 7 7 0 2 2 V to - _ to 1- O -t1 m -rn - IT _ 1 m � O O O to N CL t7 V Ir Mc '- 1 o O. O O O G 0 ac 1 t7 CD a. OI I � x % s s�00 1 N m c• Ln to to r co m v v H v to • Io a CIO C/) ' f'Oo�t�'t�. `� Y d d v Lnn v '* c -ry M _ Cl 01>1 F o E•t 1 z w 0 Z O 7 ? r• y c . �� o x rC x d N rt ,t V Z ' O 7 4M F cm C') ' N I'O D 1 d Cn F Cn n O ►•+ F r• I O 7 W Cn W C') 7 o I v �� . I O to r to m a7 rt ro r• r 1- r r rD 1 i w `� `� s o w o -< di o 0 0 0 0 0 1 I m . r• to 01 cn m N rt CIP r w N to N cn cn cn o v N 3 d rt O w s t o a 3c rn M r• tt v .• CID O m o �� •'. : r r �'•' W t t n n Co F N N N c:> 1 f1 rh V % rNF o r• Clom it- r cc 1 O O t0 . n� N r N N N 0 y �. �, ' SOlo04'4011E ,�„ w° 1.1 w t" o a o :� '° 255.771 % - - - r = �- -y -" -n M rt r► tt n fu •„ rt In o H -i n c CT 1 Ic 0 1 o s m co C/) C1 I r rn Z F N F N N N N it V 1 d "t co CA N 7 a W W > Z m Cn V V rt O O O -n H 1rt o z Q1oao t-1• o o 1 m . d F IV F I O. = OT V N w to n n A CD co _ - O co i Q) W r- w- 0 0 CA > I C 40 1 M I Z N 2 0 1 7 [7 O 1 m C-1 C7 O O r t0 I� s-n 1 o a S" 0 0 0 -1 0 1a N d 1 rt co to 1 7 m D N to 01 Z ' rn i m to 255 711 "0 °-' 1 c. x n cn to o rn I N 1 d Of W to ; to O I CT -1'1 Of - -+ 1`c )C m m 17 Cn 0, :1 t0 1 C'- r to m 1 CL - - W F ��, O-4 n a l y 01 m p1 N 1 rt n Vf 2 c M r O co 1-i 1 •0 1 rt m O t-. to z 0 1 L m •t0 01 1 O N O <T Ito F W •N• 1 9 2 N O •+ Cn ••y�l'�''r�:tu�L"4. i' 1 a O r -1 w rn o to _rrSs9a�+ ., 4► 1 c its o. W .o ° x o � � c:lat H O V k7 co 00 C2 cn I to rn / o t7 o r i•w Li .�w �`%- ! `^r -n rn v m n r i> :.� r .b r 17y �w -1 T 1 ^ 255.771 \ o �, = z I co N o m �,\ •S 4d'� i L7 i coo -4 I m �•�, �. r W 1j= OMA�A�y:... t�.•eS -1 �. 1-4 rn O� ..+i x CO N o_ o o r C"2 A*- 0 0000 " 44 z In o ;° w"' 220.00' -+ r N F Z m ac C71 V = N I c tti N rn 248.77' '80' iv � 91- 1 1� o I co I d 2 0 O VI I tt N H W ►•• 1 A O V (a CO 2 N Ib Z t0 N Cn 00 Z I d O (� O N m CD CO O WO N u+ - _ w a c a c► I jy o o W• Cr Ln o is D H z r• 1 N •- - F - I to O M N W. N 1 c. 0 01 cn I o o. a V 1 r N r z - 01 l0 o d 1 1-• - co V O - 1 Z •.y rt -) l a rn a0 •• I o 0 O CD -r 1 7 t0 O I Co z y1 N I D_ 01 W O 1 0. S -) C7o CIO N to kn 'c, 1tT O T d S tit m m t o to I•e m C-) I=C7 r I o m N N N O I rp 1 CD m 0 O 1 V W N I d t0 r1- n m o °o r i n 1.0 o V 70 I (.< O O F I A Cn •1)' n N- a ro O - A t?F m rt S cr Z fLb O O o• ro I M O 7 ' F V t E r r O y �l � o � 1p w El m ; �, ► � 30 ffoME i ' rfl � '1 1 ` x , 1 H� � ► /000 s�pric r 90 ' 3 3, Igop Boy, 14� LoT -i5ta SD v 7'L� Fa�fC ti 50U) V l S ,, aAJ x so. God Lives 3yU� ol ti yC� Nor _ MUSS' HOMESITE SEPTIC PLUMBING CO. 855 O'NEIL RD.,M)PSON,WIS.54016 �X /7 - ROBERT ULBRIGHT / �! ,� d� WIS.MASTER PLUMBER LIC.NO,3307 M.P.R.S. 0 !,11NN.OISTALLER&DESIGNER LIC.NO.00663 ; PLO ���. NI Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12" Above / Final Grade 10 4" Cast Iron III 30 '' Above Pipe Vent 'Pipe ? �eC 'To Final Grade j Margh—H*t Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution 0 0 V 2� Tee 0 0 Pipe (, " Aggregate 0 Perforated Pipe Below Beneath Pipe 0 Coupling Terminating At Bottom Of System SD�v t �y y v HOMESITE SEPTI PLU1,15ING CO. 655 O'NEIL RD.,hIPSON,WIS.54016 ROBER i ULBRIGHT WIS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. iINN.WSTALLER&DE SIGNtR LIC.N0.G0663`-+ .' 9 Fresh Air Inlets And Observation Pipe v t4j Approved Vent Cap Minimum 12 Above Final Grade M-4d"1 of _ 4" Cast Iron ° Y2, " Above Pipe Vent Pipe ��s5 -To Final Grade r Or Synthetic Covering Min. 2" Aggregate Over Pipe Distribution 27.a 2 — Tee Pipe 0 0 0 0 0 " Aggregate o Perforated Pipe Below Beneath Pipe Coupling Terminating At 0 Bottom Of System ,a m, DILHR SANITARY PERMIT APPLICATION COUNTY .�.e.,.,,..v,.,..,..,�.,,e,. In accord with ILHR 83.05,Wis.Adm.Code .57, t'WO f K —Attach complete plans(to the county copy only)for the system,on paper not less than STATE SANITARY PERMIT#/l 8%x 11 inches in size. 0 Check��e on to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D.NUMBER 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. . PROPERTY OWNER PROPERTY LOCATION r , %4 1/4,s 7 T'4•, N, R /f E(o PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# CITY,STATE ZIP CODE PHO E NUMBER SUBDIVISION NAME OR CSM NUMBER I. TYPE OF BUILDING: (Check one) CITY @ NEAREST ROAD I ❑State Owned 3 ❑ VILLAGE ❑ Public 01 or 2 Fam.Dwelling—#of bedrooms PAR�IEL•�A�� uM O 111. BUILDING USE: (If building type is public,check all that apply) �F � ` 1 ❑ Apt/Condo "❑ 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# `T 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. FINAL GRADE REQUIRED(sq.tt.) PROPOSED(sq.tt.) Gals/day/sq.ft.) I(Min./inch) Erj ELEVATION 00 90, 9 Feet Feet VII. TANK CAPACITY Site in callons Total #of Prefab. Fiber Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdina Tank lC Lift Pump Tank/Siphon Chamber El VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. RPlum,ber's Name(Print): Plumber's Signatur :(No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address(Street,City,State,Zip Code): 5- r 01Veic IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved nitary Permit Fee(Includes Groundwater a e Issued Iss g Agent Si nature(No Stamp Approved Owner Given Initial Surcharge Fee) L Adverse Det r in ion � �F � ,"ri X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb437)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber 1 INSTRkTIONS r 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 arty new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by.the,petpit-issuing authority.,, 4. Changes in ownership or plumber-requires avaanytaryPermit Transfer/Renewal Form (SBD 6399)to be submitted to the county prior to installation. , S. Onsite-sewage systems must be-properly maintained. The septic tank(s) must be pumped by> licensed pumper whenever'necessary, usually every 2 to 3 years. 6.- Af you have questions concerning your onsite-sowage system, contact your local code administrator or the State of Wisconsin, Safety, & Buildings f3ivision, 6�8-�66r3815. To be complete and accurate this sanitary permit applicatiokmust 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 oi*,ene and iisinplete#of bedrooms if 1 or 2 Family Dwelling III. Building use, If building type is Public, cheer all app!opriate:boxes_that apply. IV. :Type of permit. Check"Only one in line A. CompleWline B if permit.is for tank replacement, reconneclion, or repair. 3. V. Type of system. Check appropriate box depending on system type.,,..; VI.' Absorption system information. Provide'all lnftfrfnation requested In##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank;'Iist the total gallons, numfier of ' tanks and manufacturer's name. Indicate prefab or site constructed'and tank material. Complete for alA: septic, pump/siphon and holding tanks for this system:;Ctieck xperimental approval only if tanks received experimental product approval-from DILHR. a M Responsibility statement. Installing-plumber ieto MI-in-name,license number with appropriate prefix(e g.•- MP, etc.), address and phone number. Plummer must sign application form. IX. County/Department Use Only. X. County/Department Use Only. r Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the'county 1f -e "plans;must include the following: A) plot plan, drawn to scale of with complete dimensions, locatio of holding tank(s), septic tank(s) or other treatment tanks; building sewers;wells; water mains/water'servibl� A streams and lakes;pump or siphon tanks; distribution boxes; sail"absorption systems; replaeemen"ystenv areas; and the location of the building served; B) horizontal and vertical elevation reference points;.. C)complete specifications for otimpe and controls;dose volume;elevation differences;friction loss;pump performance curve; pump modeY'.and pump MAnufacturer; D)croft sectiorf of the soil absorption system if k, required by the county; E) soil test data on a 115 form; and F) all sizing information. -GROYN@>rIIATER SURCHARGE ..` ,. 1983 Wisconsin Act 410 included the creation of surcharges (fees)for a number of regulated practices which can effect groundwater. The monies col lected.through.these surcharges are,used.for'monitoring groundwater, ground- water contamination investigations and establishment of standards. F SBD-8398(8..11/88) APPEZV t __/o ;'eP6_,_9r aF- Q-4- 8-7 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS JNDUSTRY, DIVISION tABOR HUMAN AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (ILHR 83.0911) &Chapter 145) A I TOWNSHIP/Ma +3P4L ITY: NO.:BLK.NO.: SUBDIVISION NAME:S Y4 SE / 7 SECTION. TRO Z So FoRk SO W- C UNTY: OWNER'S MAILING ADDR SS: L aoo( U*yN(: Mosey, 213 zoevs7- 577 4U6 s9o�G USE DATES OBSERVATIONS MADE NO.B 1COMMERCIAL DESR PTION: ROFILE DESCRIPTIONS: A TESTS: Residence ¢ New ❑Replace �v�E Z 6 1y� 11_b e- I c 6 / Q RATING:S-Site suitable for system Ua Site unsuitable for system SAS �3 �f �`o'�` — c M ER y — �V R k�1 i Q/)fi C OEl ST❑U . MOUND.❑U IN-GROUN ❑U E:ES EM-I©UL []S E]U :REC rw U��T/aA/,i 4—, l I S S (� If Percolation Tests are NOT required DESIGN RATE: if any portion of the tested area is in the under s.ILHR 83.09(5)(b),indicate: C GIf s 2� .S Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED ES HE TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) > 8,S 1,o- '31'e; sil T s io • ��-as. s% , i s• 7��. S•/ So IC B- �� q 9s.�y ?�- > �' ' . S 131,17- s,'; i s T?N 5 �. 9 r4AI v�y es B.g d •S , /7• yy �0 > �.s ' �.o ' Bir s; , o r�ti s; , 6;,� `T7N �- .45 B- r I B B- PERCOLATION TESTS _FE_PTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD t P RIOD PER INCH P_ 3. y P_ i P4- .r 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. N t'G %/i�.l>G(� _ 2. SYSTEM ELEVATION _ TpE-o� = 90, So _ _ �--- _ _._�. -. _. I T.Y — -i —- — �_ r 4 - TN _ I � 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 CO'PL TED OIL HOMESITE SEP'iIC PLUMBING CO. 4. ��+7 NNDSON,WIS.54016 ADDRESS: RMFIT UL13RIGHT CERTIFICAT ON NUMBER: PHONE NyMB R(o tional): MASTER PLUMBER LIC.NO.3307 M.P.R.S. 2 y/f �� 3 NO (O_ � o MINN.94STALLER d t CST SIGNATUR : DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILH"BD-6395(R.10/83) —OVER— E or lwo v - TDB a WE(1 cif SivCr- �lEv�4T�o,J .40� Co.Jri"C i tiQ 1 0 �f��h��•�Ea� � ftRf-A ( e x 30 ` 3 13v G EA- 57CA IF : � 70 �3 � New SYSTEM • = Ric Ff� o g 0 7( - ��C- s ids ' HOMESITE vyi1c PLUMBING CO. W aNEIL RD.,t 00 j Wise-50 5*1- yy f Z' ROBEPT OLBRIGHT X07 M R PLUMBEFI UC.NO. WIS.MAC NER UC.NO-QDW MINN.�;STALLER DESIG / Z I �of 2 So FO R SANITARY PERMIT APPLICATION ILHR C LINTY In accord with ILHR 83.05,Wis.Adm.Code MEN STATE SANITARY/PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than /� 9 T41 8' 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 PROPSCTY LO�C6TION f'1 Q,S> / V.�tf 5 .S I'/ WY.,S 7 T �, N, R If E(or)W PROPERTY OWNER'S MAILING ADDRESS LOT# Z BLOCK# z Z-o cv s 7' . CITY,STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CS NUMBE JA B,✓ fir//. SY®/G So U 7 /C II. TYPE OF BUILDING: Check one CITY / D NEAREST ROAD ( ) State Owned VILLAGE ❑ Public 'N1 or 2 Fam. Dwelling—#of bedroom AR EL TAX NUMBER(S) III. BUILDING USE: (If building type is public,check all that apply) 7 2-9' 7. /O Z_ 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.eNeW 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 Z Pressure , 43 ❑ Vault Privy 14 ❑ System-In-Fill Z 4" _ � X VI. ABSORPTION SYSTEM INFORMATION: 1.GALLONS PER DAY 2.ABSORP.AREA 13.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 /�D ,� o 0 1 7*• 0 Feet f 3- S Feet VII. TANK CAPACITY Site in oallons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Siphon Chamber 'e Ej _FJL+ F-1 1:1 Ej F] VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system show on the attached plans. Plumber's Name(Print): Plumber'&SIgnaltre:(No Stamps) MP/MPRSW No.: Business Phone Number: � . ui+QP I'ck�' 07 � 3� Plumber's Address(Street,City,State,Zip Code):n L IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(includes Groundwater Date Issued ssuing Agent Signature(No Sta ) Approved ❑ Owner Given Initial ` Surcharge Fee) C �G Adverse rmination �/�S 1 d 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. II. Type of building being served. Check only one and complete ##of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers;wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. i SBD-6398(R.11/88) Fresh Air Inlets And Observation Pipe N, — Approved Vent Cap _ 4 Minimum 12 Above Final Grade pe- y d 4. IT 4" Cast Iron 30 Above Pipe — Vent =Pipe' , -to Final Grade Or Synthetic Covering Min. 2" Aggregate ' Over Pipe Distribution_4 2?1 Tee Pipe o 0 0� o o Aggregate 0 Perforated Pipe Below Beneath Plpe Coupling Terminating At 0 Bottom Of System • ��� f HOMESITE SEPTI PLU',IBING CO. a 655 O'NEIL RD.,HIPSON,WIS.54016 ROBERT ULBRIGHT T WIS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. b11NN.iNSTAMR&DESIGNER LIC.N0.G0663 vFresh Air Inlets And Observation Pipe 0 Q--- Approved Vent Cap _ Minimum 12" Above Final Gradej;�/i 4" Cast Iron oje yZ '' Above Pipe — -to Final Grade Vent Pipe Wer3 -Ht7-Or Synthetic Covering A Min. 2" Aggregate Over Pipe p' Distribution 2922 Tee Pipe 0 0 0 0 0 " Aggregate 0 Perforated Pipe Below Beneath Pipe 0 Coupling Terminating At Bottom Of System • �w dEP� 3y , ff0 (D� well 4. 3 Ti DQH Ln .?► l� r,l li I i � � v l 1 • 1 � SewER If = m I 1 ? S�-pric r. c3, �RoP (io x • fi �qo LET r sD v Fo K a 5� 1�1�iurs � o ,� x - _ �• `TOP O lam' �. LdT &T5- - A M HOMESITE SEPTIC PLUMBING CO. ' O'NEIL RD.,AJOSON,WIS.54016 ' f f D ROBEfi7 ULBRIGHT WIS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. t:IINN.WSTALLER&DESIGNER LIC.N0,C0663 SCi9l� ! V n - - APPE.Wm fe RE-PoAT or— f-4 8-7 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, c DIVISION HUMAN AND PERCOLATION TESTS (115) MADISON WI 53707 HUMf4N RELATIONS ' (ILHR 83.09(1)&Chapter 145) A TOWNS HIP/M IJf�}++@+P46+TY: LOT NO.:BLK.NO.: SUBDIVISION NAME- ,7_ �� s>F �4 7 /T V N/R 19E(or)W Tt2oy 2- 1 So FoRk S013D- C�1UNTY: OW MAI LING ADDRESS: �1 G.00( (v+FyNC_ Mos,`IZ 213 LOCUST 577 h'CJDJdA-) 4U(5 140/6 USE DATES OBSERVATIONS MADE NO,B COMM R D S RIPTIO F NS: A TESTS: Residence ¢ ^f X �()�E 2 7 Z New ❑Replace �� O*UAJr �j / C �J�j Q i RATING:S-Site suitable for system U-Site unsuitable for system SAS D-1 r0f Ll,, — c1I ERY — 13 V R k4,Pill- ONVENT ONAL: MOUND: IWGROUNDPR UR S STEM-IN-FILL OLOING TANK:REC MMENDED SYSTEM:(optional) i �s ❑u sou s ❑u ❑s au as au NV,6 T71a�,4� If Percolation Tests are NOT required DESIGN RATE: (! If any portion of the tested area is in the under s. ILHR 83.09(5)(b),indicate: C Lq S.S =_ Floodplain,indicate Floodplain elevation: ' PROFILE DESCRIPTIONS BORING TOTAL P H T ROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED E HES TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) �! B' l0 0 's ( �7 /� > S' 40 S%/ 7.5- /o ' D.F a.J• 5,il S-- -r-f , S./ S,D' &A y cs I B- g' q 9�✓f y ??o' > -r.+Al s,�� . 9 ' rfN 41,9ey �S B- ' B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER L V L-I NCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN, PERIOD 1 PERIOD 2 P PER INCH Y P- i P- Z - dL Z 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. N►'(r-�, %/t��,(JG� _ �• � � O i /ate SYSTEM ELEVATION 90. So F — - _ 1 ;�o i I P� -- TN f I �� ._ - ' I I 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): HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED O� ADDRESS: RD. 141 JDSON,WIS.54016 -- ROBEF?TULBRIO CERTIFICATION NUMBER: PHONE N MB R(o tionat): MASTER PLUMBER LIC.NO.3307 M.P.R.S. 1 t/Q L. 3 / do MINN.INSTALLER d 1, CST SIGNATUR t0' d op DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R. 10/83) —OVER— T /.PD.c1 - 1 �aD ,1 ���f REF• �OiNT o TOP aF WEll c/-S'06— � I �IEv�T�oa = /DO . 4 4 (�,.�s . qof co.�sTR�ci i tiQ o 12 LA (�� x 30 •-7o' �3 New S ySTE�I • fix � � 1 L Sc/ \//{ Iu f ` i • I i s HOMESITE SEPTIC PLUMW S`Co. y y8 1� 655 O'NEIL RD-, LBFtl T C S Ro R LIC.N0.3307 M.P•R.S. "S.MASTER PLUM9E NER LIC.NO.00�3 MILAN. ;STALLER&GESIG PL-or PL.-.Ao i 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 1(40seA 11&4 E7 5 CX� - Location of property 5 1/9 S5 1/4, Section 7 T_�Z_N-RfW Township Mailing address Z13 L D C US T .� A Address of site Subdivision name.__ Sb u-0-1- R k-- } Lot number Previous owner of property /E/=sr� ��fr�-►/J Total size of parcel a 0 Date parcel was created - 7 Are all corners and lot lines identifiable? _ Yes No Is this property being developed for resale (spec house)?—4—Yes No Volume and Page Number 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. ; and that I (We) presently , own the proposed site for the sewage disposialtsystem (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. ) . Si na ure of Owner Signature of Co-Owner (I --Applicable) Datfe of Signaturw Date,4f Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA ' WARRANTY DEED 4729 839, PAGE371 REGISTER'S OFFICE ST. CROIX CO., WI Charles R Ellefsen a/k/a Charles Ellef en Recd for Record a/k/a Charles Ellefsen II and Michelle E Ellefsen and 011989 �l Roger Ruelin a/k/a Roger M MAY Ruelin Y 00 8 M conveys and warrants to Wayne F. Moser, Individually R"Ift Of Deeds RETURN TO the following described real estate In St. Croix County, i State of Wisconsin: Tax Parcel No: I I Part of S 1/2 of SE -1/4 of Section 71,' Towns,hip 28, North, Rang'e X19 West,' St: .Croix � County, Wis Iconsiti described- as fo'llowg: .Lot- 2 of Ce7tified Survey Map filed December 29, 1987 in Vol. 7, page 1930, Doc. No. 433278. Togethex_ with.66 foot private road as shown on said Certified Survey Map. 9 0 �o u This is not homestead proper. (is) (is not) Exception to Warranties: Dated this 98th day of A ril 9 (SEAL) (SEAL) • Charles R_ Fll fsen a/k/a Charles Roger Ruelin a/k/a Roger M Ruel;n Ellefsen a k/a Charle 1 fsen II (SEAL) (SEAL) • Mi chPl 1 P F.- F1 1 efsen AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St- Croix County. authenticated this day of 19 Personally came before me this 29th day of April 119 89 the above named Charles R_ Ellefsen a/k/a Charlps F11Pfsen a/k/a Ch rl s F.11 fsen TT. MichpIle F. F11PfsPn, Roger RnPlin a /, a Roger M Ruel TITLE:MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the p rson who executed the authorized by§706.06,Wis.Stats.) �pSrY%1- Finn u nt a kno dge the same. THIS INSTRUMENT WAS DRAFTED BY N0Tp%k%1 PU7U 1"Ll 'nn S'= ": collsin Y11�O�Yy Y r l (� Notary Public County,Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not stat expiration are not necessary.) date: My Commission Exp?res Ju! STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County 11ript S OWNER/B $, N S ' ROUTE/BOX NUMBER �� -7 LU�/U s J / FIRE NO. CITY/STATE_ G(, ZIP Sy�f PROPERTY LOCATION: 1/9 �c 1/9, Section _�, T N R—/—W. Town of 1 F9-0 tf , St. Croix County, Subdivision S611 /C — , Lot No. Improper use and maintenance of your septic system could result in its premature failGre 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 $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE 2 St. Croix County Zoning Office St. Croix County Courthouse 911 9th Street Hudson, WI 59016 (715) 386-4680 Sign, Date, and Return to above address � c P.O. BOX 7s➢8p ` , (Hfi3,09(1) Chapter 146.045) s, R -- MADISON,INI E N. v I ��d N/R// E(orl w TOWi SHIP/�TCIP7CCTTY: •j R OT N0. LIC N4 SUBDI SI i; " G UNTY: N fi:GAO/X RSI ff V Lr/M.sE' MA L G SH A) 113 .. Ig- E eft IsoN sus Gh�►INty '� . No. ff uD.roa' his. _ S�o�G:NO.BEORMS : COMM A RIPTIO DATES OBSERVATIONS MADE Residence 3+o+ • /y /�^ . ow ❑Replaq p V� I fT 9$ c �$��� fl��g • 9� t RATING:S-Site suitable for system U�Site unsuitable for system SC/ 73 1'�� y ONVENTI NAL: MOUND: IN-GROUIV FH�RVj BUR SQI�.�ii SC]U IQ CA ©S ❑U :S�S E(N 1NJ�FILL OLD' G©U Co�iuEi 7 T olV� tW) If Percolation To are NOT required DESIGN RATE: , under s.H63.09(51(b),indicate: f=LA$ S S If any portion of the tested area is in the Floodplain,indicate Floodplain elevation: /V— PROFILE DESCRIPTIONS BORING TOTAL P HT R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEX NUMBER DEPTH IN, ELEVATION g RV H TO BEDROCK IF OB ERVED EE ABBRV.ON BACK.1 TURF,ANI) ode , 6�k 75 A0 �g-.3 �1 V 9/�� TI ��.• O Q 9"0.GS R' 7�,� Tvi E/,��/Y O'S�' Bs� 7�41� $ I � /Q a S>/2 trR -TA u `S 6-#Q_.v 9 a a. S11 S S TAN v CS I 6-R_ 7- 41 j PERCOLATION TESTS W NE,01v EST DEPTH WATER IN HOLE TEST TIME -- NUMBER INCHES AFTERSWELLING INTERVAL-MIN. DROP I RATE MI PER NCH P- ` P-. P- < { OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distanop,DesCrlbe tail and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at All boon land slope. what are t11�hurl• 1. ., • s W anti the diinctlwt and W YSTEM ELEVATION �9 O � fill - - nor e �3 /Rom r .f_ :— T po r `hs t st sit a cmn -n Io SIR D ! 17 - . - a ;se fib s st M - ' 1 f i i I FI i undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods r fled inictratiw Code,and that the data recorded and the location of the tests are correct to the best of my knowledge > I U the w�Nip edge and belief. `1uMkSlTf SEPTIC PLC 00 TESTS WERE COMPLETED O : ) aESS: 006-- g ROBERT ULBRICHT CERTIFIC ION HON NUMBER: P NUMBE y�Z-- 3 I� an.l "NAII ER A,DESIGNER UC.N0.00f>�i3 CST SI NATURE: IBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester, N oJ SE MUST'ST t ! r sS� i -j'Roh• I-SBD-6395 (R.02/82) TEST- AReAS —OVER— rlf � LI O W _3c L N y 41 I O _ Y ..+ • 0 � 1 Z a+ u N N In J O nl I `` .-. O -t - �`. y II. 1A W I O J O O C t� �`♦ Ot • O O w M O •+ -Ir I 1 1' y 1 co V7 O Z Z = u.•N LT m 1 fA N N n N 1 CO O .� Y v) GO W GI =_ �♦ 3 1 V V 1 O I W W C Y Y L LU T I u7 I N N tt- Z b V O Z Y y Y 1 O - O 1 co L .o 'a I O M O C 1 ` F•- Y O O C 1 Z O-• O. • 10 1 i' ` y tom• i I O 1� to W b Y O O I to 2 J N J 1 r` C •t7 O 1 r N •-1 Y w -y N 1 - - 4-t 1 uj ►••I •.t N.L N b 1 O to M O O 1 y ut rJ -.I o+ - ld1 - to �M o0 0 I W • Y O 10 O of Z p � N Of Z O 7 1 N 2 m N r\ O Y I O M I ~ N y Aj I r\ O+ o 0 -1•► ° tOo;-�; - ILC8hZ W N C 1 � 3 3C - 7 7 u') J H Y• 100.044 W,M•t O rS o I.- mllho r ho00S Jo N O o - rMI U J O O O CD ul) w O O J tu Cl r •`S' `r�g.••m W Ir / 199 a [� Q K r'r'+� y S'• �`� W co ►-•-� 136 1J Z o YC• �M.:.:j:tfi,n:+tr.A{l �.f!w%{ 1l::5 1 (�r:�.�• �r V 4 :+. •i 2 L ri.:'; o t ILLSSZ U- o �r1 O <L to I t— H ° � 'i X �" rI J : 't O . J z J Y 1 N W U 7t: S i L" z cc - O ++1 n ' E •- L") v O 1 co O O d I!'r • w S 3e p to - co Cl c0 �.I 1 11 `�t�• 4� VW - - - M .- J M Cl •v 1 ,x:.. •tdlr• In O to M • M J 4); •�r� >�r��.�.�tr••• N .� O N 2 L 1 _ c" M C O I.7 O O O. C3 0 Y I to O. W 3 1 •-7 2 LT O W y 1 M ••r co O J t- M a..l C Ln 2 V) -x b l tV to W to N I L W O O d l Ot 40 N G I .--i o] _ J J I f\ to •+ 1D 1 t 4- 4J W N W .c 1 O to ' O• ~I N to Z rl 10 to rr O 1 Z Go �1 O t!'f tff U C N �O m ILC•SSZ Ln y; p I ro Z to In an Q W C 1 to o 4j 1 -r Q N ..•t .r In Z 3 1 - t7 b l Ot t- O O O 1 C o 1 ul .-t l 7 OJ co co O U to 1 O Q - C 1 p 2 N Z 1 -o 1 01 �• 7 1 J !- C 1 co ^4 T N N N-y O N bl Z Q - _.co f I. r_ t o - W w 1 co 1d - _ - x I I 10 10 b M N N O y 1 O O Cl to J to J J C O y l E-r M M to O O O 4.; n n W z A I L jV C N to co f -+I "t• N N N Y N -t 2 W O-I > C W Z al O y U 1••- 7 I H ..• m ! Q + o 4j -w w .+ W W W ILL'SSZ u 3 J P e I_ W rn r, o 3u0titOO10S I d Q IS tr Q yr .• Y d v o w e oo co .� O ~ J N J Q N N N M w to J Y L> y n ^ I` ..y Y • O I.. d . M -Id 1 Y GO Co co .+ d y •.t Q W W 3c Al ,% O 1 L ul •.t O a.t Q - - - E t •--i 1 41 ..a N M J In G ty. Y IA to to ul \ ,\% •C 1 tt.. y C N w to to to •.• • t Y I 1 O y y y y O L O M O L \ t N O O O O L Al T ++ . o: Y .� C C U M IA M C • tp( O I — W L..N o = O O O O r�i •¢ ,tt dl J 14 O N J to C) - N L,) t0 J t0 C O •C n t L Z Z N 2 C ptI y t \ N t Z O d Ln 3 d l O ,` ..A O N O Wa+ = In u`ni uui o to J In a v) a s � Y i I y�0 is ,tt i !. O " I t . _ °s t° — °n t° Al our U. In 0 r- • .•• JJ y 1 W V -� - •i C O - - - Y of __ -1 S_ C r` Z Y J O O O .L 'C _ _ Lj tl N In O O O ►- Y ...1 N O LLI N - _ to r\ Z Z O C " ty. 9= • J J n In - to ¢ O Ln Cl 3c •nt 'Z7 O ••-1 • co to In •• o_ to - =7 IT .••N U I-- H N N •-t ►1 J •••t N rl o 7 N 7 W = I1'f O ,1 o t0 N O t` L--) C (� G c. O O I.i 1 r N N Of W-14 OC: •-t S N l0 •1 n N co In N Cl) Y W � � r .. Iho 000 2 .,. NI �NWIL b 3o c o r• s+ a » > — w O In z cv x x = _ 13S ay; 3o autj is IWO 3o0hlh0oi0S