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HomeMy WebLinkAbout042-1016-70-200 \ ` \ C) \ t C 4 0 $ G o 2 CL / cc:ti CL m � c =o [ . 7 )\ 0 # 2 (D£5 )/ . "� )_ ƒ { R$ $) t CL C R §�#2 W =22 =a uco 0 , 0 Z 2 {3 ) , 2 { c § �� oak) §\} )2CL C_ g �eV) 0.= e < < ug<� cc ± � % � � z / co § z / § 2 § i a m § B z 2 co k k z E � \ o f . \ [ ƒ .� . k / & § � \ � . Q k ) ) $ , § ` 9 & 2 $ c ^ ' 3 . / A k m e S ) \ to / } \ j k -� tk a 2 a � R � \ § 0 k \ ° § 5 _ \ \ _ \ § , c / . < { / i . © \ § 3 7 0 5 R a 0 = E ( § E / \ . 7 $ S = E a @ \ j ` c ~ /\ k \ E 2 = 2 $ k � ® � {� E � " a » E & � . ka § . . k J a 2 o & U \ 2 ` Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER n S`/ ,4 TE�t/TOWNSHIP � /�/T/!'f=L1,�' SEC. _ 7 T N- �0 ADDRESS 8=J. A/_l./,� ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IMP. 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM /v /$X y 3 s T ?5, LS ysa` .2.N' �Dus� INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used , �j�/ 8�` TP,A Elevation of vertical reference point: /Q©, O Proposed slope at site: SEPTIC TANK: Manufacturer: —­ /S Liquid Capacity: Mdo Number of rings used: —1.7— Tank manhole cover elevation: Tank Inlet Elevation:_qj 37 Tank Outlet Elevation: Number of feet from nearest Road: Front,M Side ,O Rear, O / feet From nearest property line Front 10 Side.0 Rear,0 feet Number of feet from: ell building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: _ Liquid Capacity: Pump el: Pump/Siphon Manufacturer: P ize Elevation o let: Bottom of tank elevat Pump off switch elev on: Gallo per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest roperty e: Front, O Side, O Rear.,Q Ft. er of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM' Bed: 4X,5-3 Trench: Width: �g Length: Number of Lines: 3 Area Built: 9sy Fill depth. to top of pipe: Number of feet from nearest property line: Front, O Side,Rear,O Ft . Number of feet from well: J&J=LL Number of feet from building: ?S (Include distances on plot plan). EEPAGE PIT e: Number of pits: Diameter: Liquid the Bottom of seepage pit elevation: Area Built: Has either a drop box O o istribution box O been used any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: acity: Number of rings used: E vation of bo om of tank: Elevation of inlet: Number of feet from n est property line: Front, O e, 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 COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715 - 962 - 3121 800 - 962 - 5227 !; FAX - 715 - 962 - 4030 ST. CROIX ZONING REPORT NO.S 41233/01 PAGE 1 4 ST. CROIX COUNTY REPORT DATE« 5/17/93 COURTHOUSE HUDSON, WI 54015 DATE RECEIVED: 5/12/93 ATTNS THOMAS C. NELSON /`�!/6 OWNERS Al & Judy Weingarteu LOCATIONS 999-10th Ave., Roberts COLLECTORS M. Jenkins DATE COLLECTED$ 5-11-93 TIME COLLECTED*# 3*#34pm P SOURCE OF SAMPLES Qutside faucet DATE ANALYZED*#5-12-93 TIME ANAL.YZEDS2S00pa COLIFORM: 0 /100 ml INTERPRETATIONS Bacteriologically NITRATE-N*# 6 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Coliform Bacteria/100 ml Nitrate-Nitrogen, mg/L g 10/ Cb ~ f r s� � > oD QyyG,''L�9c v a.tNDEPFNOFNr LAB TECHNICIANS Pam Gane 0 0 "Za WI Approved Lab No. 19 J -0 A D { Means "LESS THAN" Detectable LeveL Approved by** PROFESSIONAL LABORATORY SERVICES SINCE 1952 W n ST. CROIX UNTY WISCONSIN �0 11 %' ZONING OFFICE ST.CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON,WI 54016 M ),0 3 (715)386-4680 00 A 1993 CO.�.qo- SEPTIC INSPECTION / WATER TEST REQUEST FORM ro N117-y C-0�n;GOFF°Cis y desired test(s) & remit appropriate fee with application. '9 .� M 1de water lines are often turned off during winter months, ing access to the home necessary. Please make arrangements with this office to insure a time when entry can be gained. } ' V ❑ Water ( OCs) $185. 00 I( Septic $25.00 Water (Nitrate & Bacteria) $35. 00 (Visu inspec on) .1 l � sr».r1S Owner: �, � le� Requested by: �T Address:_-e(qc gyp* Address: 700 07 tits City & State: City & St. Os-ey S YO1 Z ' od pa Zip Code: �/4 Telephone elephone N°: tzi� 6_- Property a dress_Mne.._R &_S.t.re QriCj Location: 5c , /l�C" Sec. 7 , T_)_ R ( W, Town of St. Croix Co. , WI. Tax ID N° Parcel ID N° Xr,- s lTyC-L.i House color: Realty firm:P I✓(/�J Lock Box Combo �� Water sample tap location: TO BE COMPLETED BY PROPERTY OWNER *PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORM* Is the dwelling currently occupied? CA' Yes 0 No If vacant, date last occupied: Septic system installed by: �,; �_ �►"�rYea Septic tank last serviced by: �'�,� „✓ i9�� Date: Previous Owner's Name(s) : Have any of the following been observed? ❑Y EW- ..Slow drainage from house. 0) fie' OY [IN' Sewage Back-up into dwelling, ❑Y OlY" Sewage discharge to ground surface, / road ditch or body of water. '� , � OY 01� Slow drainage from the dwelling. 3 ;t., ❑Y E Foul odors. Other comments relative to system operation: I dertify that the above informati n'' i best of my knowledge. om lete and true to the OWNERS SIGNATURE: Nt�(, I G � DATEi Y r� > ,,( ✓ ",, r �n t Ana•'�} '+ ^ S • r • I OWNERS DRA ING OF HOUSE & SEPTIC SYSTEM LOCATION IN 3 � L TO BE COMPLETED BY INSPECTION AGENCY System design &/or permit on file? )Yes ONo Soil series per SCS Soil Survey: sheet # Type of soil absorption system: VBelow grd OAt-Grd OMound Approx. size IX ' X _5�V' )RGravity ODose OPressurized Ft.' Bed OTrench ODry Well OEiolding Tank ClOutfall pipe OBSERVED DEFICIENCIES 00ther OUnknown Septic tank Setbacks: OEiouse o2oI OWellfSll OProp. line JISU 00ther Dose tank Setbacks: OHouse Well OProp. line 00ther OLocking cover OWarnIng label OPump/Floats OAlarm OEl c. w ring Soil so t o S e Setbacks: 011ouse-�3-o_OWell1`7o OProp. line2 ZD 00ther OPonding:_ `yta'hA.,, ODischarge: General comments: INSPECTORS SKETCH OF SYSTEM LOCATION N r l - !:Q S� , , , ..ry.;gf•Ir1'+. ;:1 7 l R•.....y .. ,. .r n..,u. )� .i.. r w.. r E Inspec tot, + , Title a ���a; M � ��'��' ,� , ,1 1 •;, .�� S p ro p. s ST'. CROIX COUNTY } WISCONSIN i ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 -- .� (715)386-4680 May 12, 1993 Kathy Smith Edina Realty 700 - 2nd St. Hudson, WI 54016 Dear Ms. Smith: An inspection of the septic system on the property of Dell & Judy Weingarten, located at 999 - 107th Ave. , Roberts, WI was conducted on May 11, 1993 . At the same time a water sample was obtained for testing. The results of that testing will be sent to you as soon as we receive them back from the laboratory. At the time of inspection, the sanitary system appeared to be functioning properly. The inspection of this) sewage disposal system was based upon a surface inspection of said system, and did not involve any excavating or chemical analysis. Accordingly, there is the possibility of hidden defects in the system not discoverable by this inspection. This does not in any way warrant or guarantee the continued proper functioning or operation of this system. It is recommended that the system should be pumped once every three years. Therefore, the prolonged life of this system may be dependent upon proper maintenance of the system. Should you have any questions, please contact his office. Sincerely, Mary J. Jenkins Assistant Zoning Administrator cj FILtb AUG 2 219900- 3 JAMES O'CONNEII itegister of Dee4S 4�±�1t^� C71.U� is S4 Croix Co.;Wl CER TIF_IED'-.!'. 4SUR. VE Y /W R Located in the SE 1/4 of the NE 1/4 of Section 7,' T29N, R 18W , / _10 0 t h ST Town of Warren, St. Croix_ County, Wisconsin. NE Cor. Owned by: Robert and Lucille Mello, Rt.. 1.,-`-R-oberts Wi. 54023 Sec. 7 4 � T29N North line of the SE 1/4 of the NE 1/4 ♦ / R 18W 107th N.89� 4f3'19"E 640.32-' ' N01°23'55"E —— -- 1p _ 397_48'- - 251.90'__ aja-8 i 6 .98 1326.82' AV E._ t0 49.43' N 89-42- 10-W 423_89' 52.23' = 'K I. g LEGEND 327..72' 96. 17' Section corner I monument ® �- I I 6 • 1" Iron pipe fnd. 439, 892 Sq. Ft. 197, 003 Sq. Ft. I 0 1"X24" Round (10.099 Ac.) (4.523 Ac.) I iron pipe weighi g Including ROW Including ROW I a 1 ,68 lbs/lin. ft, 423,246 Sq. Ft. 142, 926 Sq. Ft. of i set. (9, 716 Ac.) Excluding ROW ".I w1 --t- Fenceline Excluding ROW (3.28 1 Ac.) wl� ul t R ) Previously 2I �I N recorded info. -\ R WI cl � o APPROX. LOCATION OF PERC TEST m1 QI to East line of the NE1/4 I of Sec. 7 . Beaxings..reference I 6 to th'e';East-West n Ouarte.r* section n°i a line-' previously m recorded as ~ (�► .( N 89'06 248.71'9"W 312.i 7' c' M N90 00'00"W . W n l _( W NI . N to z !2 APPROVIED n N m Certified Survey_ :u Map I AUG 2 7 1990 Zi o o Vol. 7, Page 2054 I S1:Cf:OIX Courm a1 Z Z of o J1 �1 W c'o1Ai'12DiF.tVt�1VE PARKS Pi.�iivNlN•' AND?ONING C('wr4,Nrnr of a1 LL ►W-1 co Ia00i aI z °o d l of I(n :D — — J I 0) (n I W 0- —_ !O W J ��0een+i��oi w: 3 'D 3 ,. ��oo�yS� m o,aa HARVEyON IOC Imo, JOHNS d ° p S'1899 f w O En HUDSON W!S .� ter. .� < SO 0 E 1/4 Cor.. Section 7 4632.48111 312.815' T29N, R 18W N 90'00'00"W 336.68' W 1/4 Corner Section 7 South line of the NE 1/4 UNPLATTED LANDS This instrument drafted by: HGJ 4901774 Vol. 8 Page 2261 t 130 £ FILED DEC 131988 .)aeMQS O'COMELL N 443768 Z ° CERTIFIED SURVEY MA P"��� Located in the SE 1/4 of the NE 1/4 of Section 7, T29N, R 18W , 1 100 th ST_ Town of Warren, St. Croix County, Wisconsin. 6 s NE CORNER Owned by: Robert and Lucille Mello SECTION 7 T29N, RIBW Rt. 1 Roberts, Wi. 54023 NORTH LINE OF THE / ,1326.82' -N89048'19"E LEGEND =� 60.98' 107th AVE__ _ _ \ I Section Corner Monument "� / N54°00'36"WHO I 61.95' I 0 1" Iron pipe found CURVE DATA I 6' I O 111x24" Round iron pipe weighing 1 . 16 A = 14059'22" I I I lbs/lin. ft. set R = 253.00' — Existing fenceline L = 66.19' I ` i CHORD = N59030'50'E I= (399o.n') Previously recorded information 66.00! I i c TANGENT m$ °¢ N67 000'$1"E „I m L_ Note: The roadway shown on this map is a private roadway. 1; y Ir Any maintenance costs, after its approval by the Zoning 0-_ N hI Administrator as a standard road, shall be shared pro- 21,4 - ° rata by the adjoining property owners . Should the private of o a h roadway be taken over by a municipality as a public road, z I W a maintenance costs thereafter would be a public expense. ; F I0 oI \ APPROVED I � I W I Z DEC _UNPLATTED, LANDS I I6' I '' L-'Dh4PW COUNTY S 89'06'39"E 312. I pAPKS ANDX)►�Cp�� 246.77' I6 .I z J Bearings referenced to the 32 a East-West Quarter section W line, previously recorded L O T 1 I zI as N90 00'001tW . 1z I 5.00 Acres I SCALE IN FEET 1"= 150' _ L 17, 808 Sq. Ft OI m LLI l 0 100 200 350 co I m ED W 1 a I z 1 I I Q n AAPPROXIMATE 3 z� .JI SEPTIC SYSTEM I • In TEST SITE In F D I m I :v U UJ I a )- Z I (A Qz J a zl I CERTIFIED SURVEY NAP = ' VOL. 6 PC 11896 I LOT I I 35� (3990.65') I I I Is, t 3990.56' 305.64' I 672.96' SOUTH LINE OF THE NE I/4 T II II I1 E I/4 CORNER WI/4 CORNER N90 000'00"W 5282.01' (5282.10') N 90.00'00"W' 312.85' SECTION 7 SECTION 7 T29N, RIBW —UNPLATTED LANDS T29N, RIBW This instrument drafted by: Vol. 7 Page 2054 488-1494 DEPARTMENT Or INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING . LABOR'&HUMAN RELATIONS DIVISION P.O.BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION MADISON,WI 53707 State Plan I.D.Number: SE'-,,,NE 4,S7,T29N-R1V 99:CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Warren ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound P ER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Del Weingarten 733 Girard, Hudson, 1 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: Donavin Schnitt 3205 St. Croix 119461 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTL T ELEV.: WARNING LABEL LOCKING COVER PROVIDED. ❑YES ❑NO ❑YES ❑NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: 1PROPERTY I WELL: BUILDING:I VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑YES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: 1PUMPMODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF ROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM DINE: 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 DIMENSIONS TRENCHES: MATERIAL: PIT DEPTH: GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF ROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET: ELEV.END: PIPES: i FEET FROM DINE: AIR INLET: �♦ MOUND SYSTEM: NEAREST 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 ❑ O ❑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: I GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: DIMENSIONS TRENCHES: MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO DISTR. DIST .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: PERMANEN MARKERS: OBSERVATION WELLS: I NUMBER OF PROPERTY WELL: BUILDING: FEET hh�ROM LINE: �q y YES E]NO ❑YES [:1 NO NEAR EST—� eA 5 I Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: Z D-6710(R.06/88) 9 q %ing Administrator DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05,Wis.Adm.Code COUNTY MEMO STATE SANITARY PERMIT# –Attach complete plans(to the county copy only)for the system,on paper not less than 11941W 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 1. APPLICANT INFORMATION–PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION 1F'/a =/4,S T,Z , N, R $ E(or PROPERTY OWNER'S MAILING ADDRESS LOT# BLOCK# 733 GbOARD VA I )VA CITY,STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 3 I. TYPE OF BUILDING: Check one CITE' NEAREST ROAD I ( ) 1:1 State Owned VILLAGE 01J ❑ Public W 1 or 2 Fam. Dwelling–#of bedrooms J_ PARCEL TAX NU R( ) Ill. BUILDING USE: (If building type is public,check all that apply) 'V ©out `70 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. LrnV 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 Vl. 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.) `f Gals/day/sq.ft.) (Min./inch) ELEVATION 1/5-0 / 57 s7� , 'Y' C96, Feet Feet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete structed glass App' Tanks Tanks Septic Tank or Holdin Tank G Lift Pump Tank/Siphon Chamber Vlll. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name(Print): Plu 's Signature:(No Stamps PRSW No Business Phone Number: �fS Plumber's Address(Street,City,State,Zip Cod : T ' IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee(Includes Groundwater pe ssue Issuing Agent Signature(No Stam s) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination OCR ,`Q' � a/` �i...� X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber 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 this 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: 1. ' 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/siphlon 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) 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 Q., i� , W�-��� � � �� Location of Propert k Section , T-21 N-R I W Township ed� Nailing Address Z Z Address of Site 107 /9 " Subdivision Name . Lot Number Previous Amer of Property Total Size of Parcel ,�' ,�Cre b Date Parcel was Created X67 L �8 Are all corners and lot lines identifiable? / Yes No Is this property being developed for resale (spec house) ? Yes Volume _7 and Page Number ,2051y 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION i (WO cutU6y .that aCt statements on this 6oltm me, #hue to the best o 6 m y , hncwtedge; that I (we) am (me) ,the own e k) 06 the pnopehty de�scAibed inthiA .in604md.t on 6o4m, by viAtue 06 a we Aanty deed kecokded in the 066.ice 06 the Coiu�,ty RegiA teh o6 Deeds ass Document No. �t, c Q , and that i (We) pneb en Ltc awn Use pnoposed dote 602 the sewage dtsp0�5 46 em• (ok I (we) have obtained an ea.aement, to nun with the above deAcAibed property, bon the con.a.tAuc.Lton o6 aa,id aystcmv and the name has been duty kecokded In the 066.ice o6 the County Reg.ia.teA o6 Deeds, as Vocment No. ------- SIGN A Op OW6R SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE 51 DATE 4I OED' ,t DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 444052 REGISTERS OFFICE (� ST. CROIX CO., WI Robert L. Mello and Lucille C . Mello as Recd for Record -----------•-------------•------------ .............................................. / h i s—wife a_n.....i n-_h_er---°.w.n. rig_h t--•...................................... DEC 2 2 1988 _..--••-------------•-•--.....-•---....------•--•--•--•-•-••-•-....._..__. ..•---•---••-------•-- of 2:10 P. M .----•-•-----------------•---••---••---•---...._._.__..._.........._..-•---...-----•--._........ conveys and warrants to ..._Del_l_•R_,•_-tae.in•garte•n and ----------------------- ......Ju_d_z.t_h._A____['te_i-ngax.taz� hu_abs nsi._.aad___wx. 0.1.............. RsgtaferofDeeds ......as...su.r.�ca.xo_rshz.p...raazi za_1...p>;_o_ge_r_1<.y_.............................. --------------------------•---........------....----....._._._._........._.__._......._--•••--•---•--............ -- =--- _ — I I RETURN TO _________________________._.______.___._._......_.______ ••_.._.............._ _______ __________•_-----------------------------------------____-----.__._.___._-__.___.._....._.__ -- the following described real estate in ...............t , Croix --•County, State of Wisconsin: Tax Parcel No: .:0 4 2=1016 7 0 i I i Lot 1 , Certified Survey Map recorded in Volume 7 , { page 2054 as Document No . 443768 , together with an easement for ingress and egress as described on said Certified Survey Map i I{ i i i This --••----- 1 S_ homestead property. (is) (4W Ko` K Exception to warranties: Existing highways , easements and rights of way { of record Dated this ............. --------••------- day of ................December . i i •--__----•-(SEAL) -•_e......o., . .. ................(SEAL) ---------------------------•--------------------•----------------- • _Robert L. Mello ....................... .............................................(SEAL) ...__. . .............(SEAL) i Luc•i 1.1e,•-C_.__•Mello AUTHENTICATION ACKNOWLEDGMENT Signature(s) --._Robe C"'i, , Mello and STATE OF WISCONSIN -------------------- as. L r le Mello i --------------------------------------County. a thenti ated s : _�:.d y of D e c e m b e r-- 18-8 8 personally came before me this ................day of / ..........................................1 19........ the above named E-----`--- - ---�-'-----------------•---- i ••__David•_ J Estreen ------------------- --- --------------•--------------•---------------• ........................................--...................................... TITLE: MEMBE TATE BAR OF WISCONSIN i -------------------------------------------------------------------------------- (If not, authorized by § 706.06. Wis. State.) �f to me known to be the person ------------ who executed the foregoing instrument and acknowledge the same. i THIS INSTRUMENT WAS DRAFTED BY David J . Estreen -------------------------------•---...-------••---------------------...._.------ A t t o r n e -------------------------------•-----•-------------------------------------•---- 621 Second S t . Hudson W I '----•----•--•-----...--•------------------------------------•---•-------_-•--- •---•---------------------------------t._.__... - ....................... Notary Public ------------------------------------------County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration are not necessary.) fdate- ---...................................................... 19......... I{{I *Names of persons signing in any capacity should be typed or printed below their signatures. �FICfTr� STATFORM No. 2 IS1 82 SIN Stock No, 13002 STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ll 4 ROUTE/BOX NUMBER S Z Z it FIRE NO. CITY/STATE L -o ZIP "sYOG� J PROPERTY LOCATION: 114 /✓ 1/4, Section _� T_z?f__N, R­/6 W, Town of LjA-f'gA; St. Croix County, Subdivision , Lot No. ,Z 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 Zoni g Offic within 30 days of the three year expiration date. SIGNED DATE 71-z St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address DEPARTMENT of REPORT ON SOIL BORINGS AND SAFETY& BUtLDINGs •INUUSTR Y, DIVISION LABOR AN HUMAN RELATIONS PERCOLATION TESTS (115) P.O.MADISON WI 53707 9 (1-163.0901&Chapter 145.045) N TOWNSHIP jl_OT O. LK.NQ: BDIV I NAM : sE '/E 1/ Mc? N/R1aIto Wed 1p h/ — — A4 fP s ttm C LINTY: 'Sr► Gtb IV )N@1_ Pik DATES OBSERVATIONS MADE NO.1111501`045, COMMERCIAL DESCRIPTION WOFILE DESCRIPTIONS: r OLATIgN TES '7,11 9dRaidena 0— 1 New ❑Raplaa ©cam- /O BS Orr / if 'Solt.S t�k. A�l� Sf 'Sotcs "' 1• nftQ�f RATIN(G�:S•She W11ab1a for�yete111 IN Site YIMYItaWe for system ► 'S f r i1 U:IM20UND:S CCU S ❑u V• �L ❑�7 iIEJVK:R�N1/QMTIONd M:IoQtionsll I f Percolation Tests are NOT requlred DE ION RATE: rs [if,any portion of the tasted arse fs in the undkr s.H63.OW511b1,Indicate: CLsl4S f oodplsin,indicate Floodplein elevation; WA C�' PROFILE DESCRIPTIONS !aORING yq� ELEVATION V A_AXCTG T OF So WiTH'THICKN€'SS,[r(SLOR, TEX7UfiE.AND DEPTH K IF OBSERVED(SEE ABBRV ON BACK) /O�QLt.TS IO��4nrL 20��c C Z7�IgQwi Iq.S �z•7S 9fi.3.3 N& > S Z.7 / c lktxx K' •Sb ►3"QLt.TS /ti eelwt L ��'�8e.,,tMS fQC B- Nos, /L'6tNL /6'BicNSc�lt,Rt 3 +c /0.7t 3 e as' BLc•cs Zee egNt 36"8��1 s- d .d Nov-jitc B' f I'7 90.46 0 > 1 l''& .L 00 aoimu tam F-t PERCOLATION TESTS D H . AFTER I ELu INT VAL•MIN. PER INCH P. too 9t, l0 2 P. Z -7 0 3• /& /0 Z o .p / e P• EL #61J OM v. PLOT PLAN: Show locations of percolation testa, soil boring, and the dimensions of suitable Boil areas. Indicate sale or distances.Describe whet we the fors• aon"I and vertical elevation reference points and slow their location on the plot plan. show the surface elevation at all borings end the direction and percent of lend slope. SYSTEM ELEVATION 8& 4-b i 4g'- / � 94 A 1 P_3 L � TN i / _T . � t t SCIIILC ! � 7S oP�'pry (t►�r 8.1 _ 41 _1 1 .,$arXNt+a.tkK•"SIPt" IN &"&AlC E LE 4 AT ldkl' /00' 1,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods s1„tcilied In the Wiswnslrr Administrative Code,and that the slew recorded and the location of the testa are correct to the best of my knowledge and belief. p►nt , T ESTS WE-RE COMPLETED ON: R AoN H Su R 14L y/NC c T & R /1 /986 CERTIFICA ION NUMBER: PI�sf�c6 E N CST 31 BER1�iotw DEMOS, sEwfv N Vol PRE: DISTRIBUTION:Original and one copy to Local Authotity,Proparty Owner and Soil Testes. DILHR•SOD-0395 1R,02/921 —OVER I ;, I - � I I I I - I fp r� S I I - - i I I 000, f ACr j I f { I i ' I I I I I c'- O I fi I I 3 i JEL _, -rt Q� I � rt F , poposeb - - - I f 4 I I i I i I I I i J : f i i I I >1 14, , � L - ;- - � I I I l- - , ✓' 1 t 15 1_ I t T- I I j + I � I ! I ' + E I t I I - I _ I - ,_ f 1 _ 1 1 I J i I - + I f -+ I I 4 i I I I t I , I I t � I I I I i t I � I t t - i } I } 1 t T { 1 I , I i � I I � ' -LL e D eL CVEr>vGAI??cti� } s) r'9 �j�c�pF2 T` Sri N�/� �CJA/?!I�/V %ocuNsh�i� � r oy�.�lo1b -70 -�----- .. . ---- -..._....---- h !n� Y-S c- PMca�i 6, ysr GA, 136 � � I I � , I � ice, / -r , � _) 3 i .......... I i J At, 1 lFwT I [ � ( f 1 I I � �I '17 1 7 5PAI zVol ,,vI--r! D LPL We//vc,,4 / SIC- Alo • l'I��PF� T� s�%y NE/y S7 i�9 GUA/�/1�� %ocuvsJ�/�'• l Dye-/ol b -7D nr- V,"y, -EILDINGS OF REPORT ON SOIL BORINGS AND SAFETY& B DIVISION .LABOR AND PERCOLATION TESTS (115) MADISON W X 7969 HUMAN RELATIONS 11463.090)Ili Chapter 145.045) ` LOCATION: TOWSHIP OT NO.: LK.NO.: SE BDIVISI N NAM 1� % /TZ9 N/R1�1I Wr,e IP h/ 1"e6 p s I4 M COUNTY: . -ST CQo Ax 3 M.)44Q ti _ DATES OWE RVATIONS MAOa DfResidence ( vc .... New ❑Replace �,ola IL,--P- 4501t.% MW C.1 SQ►� �f t R Y RATING:S-Site suitabte for eyatewt W Sits urouigbla far system I U M L O I G A : ECOMMENDED SYSTEM:1 onet S S CCU S ❑U Nus ou [Is 29 1 C v��wNta� If Percolation Tests are NOT required DE IGN RATE: If any portion of the tested area is in the under s.HS3.09(5)(b),Indicate: Cc,14E,�, 2 Floodplain,indicate Floodplain elevation: e PROFILE DESCRIPTIONS 30RI dG TWAL bEPTA - NUW&eR H-W ELEVATION i f H t.htT,RACTE—R–U-10,1L ilVl1 N THfCKN SS �O FAR•TEXTURE, AND DEPTH TO BEDROCK IF OBSERVED ISEE ABBRV.ON CK.) B- 1 1z.7S .3.3 > /2.75 B' 113"akkTS llae�`SM( ii 't���QNi�ISf4� lo' Bc c-rs eft."BeNL �b"B+tN S�>�►lstit 19 R em Olt 4WD 8 g- d 8' � ./`� 'IrU•i11�. o , 7 1 I'6« i`' �� 1''Bile SC ®~$RN•M 3 PERCOLATION TESTS TWT W NkM H AFTER11iELLIN INTERVAL-MIN. PER MI P. Z -7.1 a 3•� /0 l P - . Z Z. 6.7 P• ELI[ Anb wl A-r J- . Y....... '.1. 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 86 .4-0 i � L �'H A � P-�} � i t SCALC � 9 N L. AAt 7 l AZ Polk (nnlr Sri 4VL_ g-Z Pf�oplQ`tY�t.,t E LE 4 01' �QQ� 1,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods sptncified in ilia Wisconsin Administrative Code,and that the deft recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): T S TS WERE COMPLETED ON: oN S T R /I ADDRESS: .4� � � H u Q ANC •v c ,ter ERTIFICA ION UMBER: P14ONE NU BER(optiondl): 7 S�CGty J�" ON 'SA at �q?6 M6 CST 510 ATUR DISTRIBUTION:Origmai and one copy to Locnl Authority,Property Owner and Soil Tester. DILHR•SBD-8395;R.02182) OVER –