Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
026-1035-50-050
~ I o 0 6q o `L o o o Fa a)-rU N E W CaU > E E nw o umi � w a E ° = CO m� �o1°ay > o j,Co N V a c ad o L ' O V oy Lwm t I° � am CL � @ m of-o c E X �Zt E 3 y [ "8L 0�`c c m I N ca C z C N C z N 3 V wO C "' I Li c @ UO c C y C ) U m N m ; 3 3E 3 � �� �@c)�, atpEp a M'ya� c ,c°c'T Q H U Q !n�.0 m —N I I v N N N y z y Z y o o Cf) a m a m I I O z :!t c avi Z ° c E c H rn Rp E a� N C. N N ami a) 7 a co y a°'i •Oki, n_ a L L n a CO L ° C C r ° C 'C Q ' °z � z ' zcaz N U') ° E ° E N E .. R J E L• a L_ o R .`. m v a .`. o ° 3: G G d 3 G G m CO Z ;.- N Nr W Mr w N U) U) N j zo o 3 3 a cn 3 a m N a a a y a a a• o y E ao to 2 E ° ° z rn rn fA J V (D 7 z a co a !mil o >, ca m 1- CD E O ° O o co m c c m y c co (n O m co V (n N m Qz � Ai ~ L n y C n U) O U U c 3 c c �o to � 'o. o z o aCi ' M `o O (D N U fOD F�1 O M '....'. 0 0 C N G f00 O N O • O U J tOC) O Z c Z J O Z S Z m E d •• m a a a m m 3 e a •� - - 4) • ee o• d .� d e d y e E 2 c c c o m 3 3 9 0 3 m O V) c) O v) V w SCALE IN FEET 1" 200 0 100 200 400 W 1/4 rna SEC;. 11 /17.00Y Ole N N . 1 .0 t 1 114 EASEMENT 52 5 160A- 10 e Parcel #: 026-1035-50-050 08/25/2005 05:20 PM PAGE 1 OF 2 Alt. Parcel M 11.30.18.160A-10 026-TOWN OF RICHMOND Current X ST.CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O-DERRICK DEVELOPMENT DERRICK DEVELOPMENT C-LIMITED PARTNERSHIP LIMITED PARTNERSHIP 1505 HWY 65 PO BOX 445 NEW RICHMOND WI 54017 Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 23.060 Plat: N/A-NOT AVAILABLE SEC 11 T30N R18W 37.25A IN NW SW EXC Block/Condo Bldg: PARCEL IN SW COR 150'X 183'&EXC �VVOL 2/456&EXC ADDITIONAL PAR CONVEYED Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) S IN 690/613&EXQ PT ANNEXED 11-30N-18W NW SW 1N511/627 FKA 026-1035-50(160A)EXC PT ANNEXED IN 1596/457&EXC PT FOR HWY more Notes: Parcel History: Date Doc# Vol/Page Type 12/06/2001 664217 1782/302 NAME 07/12/2001 650873 1678/346 WD 04/20/2001 643334 1622/325 ANNEX 03/06/2001 639827 1596/457 ANNEX more 2005 SUMMARY Bill M Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 06/20/2005 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 23.060 3,200 0 3,200 NO Totals for 2005: General Property 23.060 3,200 0 3,200 Woodland 0.000 0 0 Totals for 2004: General Property 23.060 3,300 0 3,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch#: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 S �9 e �# k POIX C01INTY CERTIFIED SURVEY MAP NW CORNER SECTION II 8 9 �o SCALE IN FEET FILED c� AUG 291977 �'� loo 50 25 0 yAjUS a CONNEr>I -- ��� x®q1:Esr of n.edc ss, Croix cwxdyr 0 co — NPLATTED LANDS cc z �' t_- m 0 Z N POINT OF BEGINNING N 89054` 30"E 198.84 W 1/4 CORNER — _ o SECTION II 40.00` T30NIR18W X90 -1O `SO CP I O � � N N W Z CD = I N HOUSE N LO N (n A' wW� cDi W Ot �[ Z r� >- - o moo~ 3i a If M wI _ i — Z— O_� W APPROVAL OF THIS MINOR SUBDIVISION o Q� W J ZO =I Z 0 O DOES NOT MEAN APPROVAL FOR O JI m 3 1 i n I F' BUILDING SITE OR SEPTIC SYSTEM. Z I Z I Z REFER TO 1462.20. w W W �I W c9 �I } I,-1 Z W F- O I Qo Qi U � w 1. 01 ACRES c~n I X90 sp, 0�0 4Q00 c — — — — S 89° 54! 30" W 198-84 F' NW- SW UNPLATTED LANDS APPROVED LEGEND AUG 17 19; r SECTION CORNER MONUMENT .r FOUNDt BERNTSEN CAP ••n* RAILROAD SPIKE SET OVER ST. CROIX COUNTY NAIL FOUND' COMPREHENSIVE PARKS COM COMMITTEE IN6 0 ( I/2"X 2 4` IRON PIPE SET V+ AND ZONING COMMITTEE X )f— EXISTING FENCE 0 1 TNIR IIJCTRIIMFNT IlitAFTFII RY S_ R 1 OHMAN Volume - page 456 a0 Parcel #: 261-1216-28-066 09/08/2005 09:43 AM PAGE 1 OF 1 Alt. Parcel#: 911-002-043 261 -CITY OF NEW RICHMOND Current [X( ST.CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner 1505 HWY 65 0-DERRICK DEVELOPMENT DERRICK DEVELOPMENT PO BOX 445 NEW RICHMOND WI 54017 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *RICHMOND WAY SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 0.000 Plat: 1311-CSM 15/4129 SEC 11 T30N R1 8W PT NW SW BEING CSM Block/Condo Bldg: LOT 07 15/4129 LOT 7 EXC THE E 30 FT Tract(s): (Sec-Twn-Rng 401/4 1601/4) 11-30N-18W SW NW Notes: Parcel History: Date Doc# Vol/Page Type 10/19/2004 777485 2679/065 EZ-1 06/11/2003 725336 2271/050 QC 12/06/2001 664217 1782/302 AMEND 09/05/2001 656022 1714/540 EZ-U 2005 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/27/2004 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 0.000 115,000 0 115,000 NO Totals for 2005: General Property 0.000 115,000 0 115,000 Woodland 0.000 0 0 Totals for 2004: General Property 0.000 115,000 0 115,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch#: Specials: User Special Code Category Amount i Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 S } �1 F mi A wiw Se f , .. ........ ...w.... ............ro.r;.i ... 'A IrM L+ii'�Nr to Aft Itooll 4D w law s SF Form -- STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 1,411 TOWNSHIPv SEC. ll T N-R/0W ADDRESS � 4 ST. CROIX COUNTY, WISCONSIN 0�60 JVAA-�_ SUBDIVISION LOT LOT SIZE o? 4 PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM oa v r I � INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used ,G� Elevation of vertical reference point: Proposed slope at site: %v SEPTIC TANK: Manufacturer: _____Liquid Capacity: 0,1W / ' Number of rings used: Tank manhole cover elevation: g� Tank Inlet .Elevation: 9 Z 3i Tank Outlet Elevation: 9 -7 lb ° Number of feet from nearest Road.: Front ide o Rear, O 70 feet From nearest property line Front 10 Side,0 Rear,O feet Number of feet from: well - � building: (Include this information of th Z above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER I Manufacturer: quid Capacity: Pump Model: Pum iphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch a vation: Gallons per cycle: Alarm Manufa urer: Alarm Switch Type: Number feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM / Bed: Trench: `•-� Width: Length: Number of Lines: Area Built 0 0 of i �z Fill depth t top pipe: Number of feet from nearest property line: Front,O Side, Rear,O Ft .� Number of feet from well: ,l Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Nu er of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Bui Has eit r a drop box O or distribution box O been used on any of the above soil abs btion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings use Elevation of bottom of tank: Elevation of let: Number feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: II Inspector: Dated: _ ' � Plumber on job: License Number- ' umber 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 r. IS,,,,Plan I.D.Numbe NGIi �, S� ,S11,T29N-R1Kw CONVENTIONAL ❑ALTERNATIVE Town o4 Richmond ❑Holding Tank El "'9911 In-Ground Pressure ❑Mound 02 101 NAME OF PERM( HOLDE ADDRESS OF PERMIT HOLDER: INSPECTION DATE: JeSj Lauc12 Route 4, New Richmond, III 54017 '-' —�Z—'::�q 1 •)Q BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: ICSTREF.PT.ELEV.. Name of Plumber MP/MPRSW No.: County: Sanitary Permit Number: Garay L. Steed 3254 St. cuix 112693 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV_ WARNING LABEL LOCKING COVER PROVIDED. PROVIDED DYES ONO DYES ONO BEDDING. VENT DIA.. VENT MAT1 HIGH WATER NUMBER OF ROAD. PROPERTY WELL. BUILDING. (VENT TO FRESH ALARM FEET FROM LINE AIR INLET OYES ENO ❑YES ONO NEAREST DOSING CHAMBER: MANUFACTURER 7INEGS S. LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. Y ONO ❑YES ❑NO DYES ONO GALLONS PER CYCLE: JPUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH. NO.OF DISTR.Pf PE SPACING. COVER JINSIDE DIA st PITS LIQUID BED/TRENCH TRENCHES MATERIAL! PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH UISTH PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO F RESH BELOW PIPES ABOVE COVER. ELEV.INLET ELEV.END'. PIPES FEET FROM LINE AIR INLET NEAREST— MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ❑NO SOIL CO- ER ITFXTURE PERMANENT MARKERS OBSERVATION WE LLS DYES ❑NO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. ❑YES El NO DYES ONO OYES El NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL.&MARK IN(; ELEV.' ELEV.. DIA.. ELEV. PIPES OI A.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS❑YES 1:1 NO 1:1 YES ONO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING FEET FROM LINE. 1:1 YES ❑NO ❑YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE. i DILHR SBD 6710(R.01/82) Zoning Admini6 tc.atot j Iq SANITARY PERMIT APPLICATION COUNTY T DILHR In accord with ILHR 83.05,Wis.Adm.Code St. Croix STATE SANITARY PERMIT# a q3 -Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%x 11 inches in size. 15 FOU-01? -See reverse side for instructions for completing this application. PETITION I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ® NO PROPERTY OWNER PROPERTY LOCATION NW % SW %, S 11 T 2j , N, R18 xF- (or) W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME R.R.##4 n) n a n CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK New Richmond, Wi. 154017 715 46-3660 VILLAGERichmond St. Hy. #65 II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR 9 Public(Specify): RV sale s III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. ® New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit## 8408064 Date Issued 11-6-84 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2) ^ 1. a. U Conventional b. ❑Alternative C. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b. GISee a e Trench c. ❑ See age Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): 10 320 325 Feet rivate [-I Joint El Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xiss Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank x Weeks C.P. x ❑ ❑ Lift Pump Tank/Siphon Chamber El El VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installat' n of the private wage system shown on the attached plans. Plumber's Name(Print): Plumber' gnature:( am �t /MPRSW No.: Business Phone Number: GaRY L. Steel 715 246-6200 Plumber's Address(Street,City,State,Zip de): L Name of Designer: 988 N. Shore Dr., New Richmond, Wi^. 54017 VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# GaU L. Steel CST's ADDRESS(Street,City,State,Zip Code) Phone Number: 988 N. Shore Dr. , New Richmond Wi. 5401 7 715 )246-6200 IX. COUNTY/DEPARTMENT USE ONLY �7� I F-1 Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) I Approved I❑ Owner Given Initial Surcharge Fee Adverse Determination I�' C� �s•L / —�' O 1�(; C.h!1 h � X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03186) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit maybe renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; Vlll. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. --------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground .8tef included the creation of surcharges (fees) for a number of regulated practices which Wisco iWs a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure! is used in your building is returned to the groundwater through your soil absorption system or the disposal site used by your holding tank pumper. a . The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) PLAN APPROVAL Safety and Buildings ��� Division Bureau of Plumbing P.O Box 7%9 ❑ General Plumbing Plans Madison,WI 53707 1_ Private Sewage Plans Telephone:(608)266-3815 171 G1 �� r %/ '�PQ _...._._ r E Project Name J.dA%c 4-Project Location - Street No. or Legal Description ounty ❑ City ❑ Village 1 Town of: The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145,Wisconsin Statutes and the Wisconsin Administrative Code.The plans are stamped"conditionally approved".This approval is contingent upon compliance with any stipulations shown on the plans.All items that are noted must be corrected.All permits required by the city,village,township or county shall be obtained prior to construction.The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site.The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: This approval will expire two years from the date approved below.If construction has not commenced before the`expiration date,new plan approval must be obtained. ;[ ] FOR PRIVATE SEWAGE PLANS' r This approval will expire two years from the date approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. Comments: By: � i James Sargent 7 Bureau Director If Questions Plans Approved By: Date Approved: Contact ♦ r cc: EJ OWS ❑ DPS ❑ H&R & Rec. San. Section fl County O Local PI ❑ Facilities Need Analysis Section ❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099(R.01/84) ❑ Owner ❑ Other DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS P.O.BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON,WI 53707 BUREAU OF PLUMBING NONVENTIONAL ❑ALTERNATIVE IState Plan l.D.Number : COMMERCIAL Holding Tank ❑ In-Ground Pressure El Mound Ilt assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Jeff Lauck R. R. 1 , New Richmond, WI 54017 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.P CST REF.PT.ELEV.. NW SW , Section 11 , T29N—R18W, Town of Richmond Name of Plumber MP/MPRSW No. County: Sanitary Permit Number: Gary L. Steel 3254 St . Croix 58900 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: DYES ONO ❑YES ❑NO BEDDING: VENT DIA.: VENT MATL: HIGH WATER ©I+' ROAD: PROPERTY WEL L BUILDING: VENT TO FRESH ALARM: FEE,I, Z LINE: AIR INLET: ❑YES ONO EYE S ❑NO NEAREST '°" DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPAFPUMP=CONTROLS EL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED OYES ONO : OYES ONO OYES ONO GALLONS PER CYCLE: AND OPERATIONAL PROPERTY WELL. BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN 'F' €T F€OM PINE AIR INLET: PUMP ON AND OFF) ❑YES ❑NO 111 ,AF#EST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until 1=01ktC the soil is dry enough to continue.) A1±IAi CONVENTIONAL SYSTEM: °e WIDTH: LE NG TH. NO.OF DISTR.PIPE SPACING: COVER .INSIDE DIA.. #PITS. LIQUID i' TRENCHES MATERIAL: l- DEPTH_ GRAVEL DEPTH FILL DEPTH DISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR , PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER. ELEV.INLET ELEV.END. PIPES I ,LINE: AIR INLET: f�" (:T F" CI1Uf MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- ❑YES 0 N meets the criteria for medium sand. TIONS MEASURED. SOIL COVER ITEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO DYES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED: MULCHED. CENTER. EDGES. OYES ❑NO ❑YES ONO OYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: jF a WIDTH. LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. TRENCHES: MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. ID ISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. a ELEV.: ELEV.: DIA.. ELEV.: PIPES: DT: HOLE SIZE HOLE SPACING. DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: ❑YES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: , PROPERTY ELL: BUILDING: LINE: ❑ ❑ W YES NO OYES NO "� ._.�, Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710(R.01/82) lulsconsln APPLICATION FOR SANITARY PERMIT DILHR OUNTY (PLB 67) UNIFORM SANITARY PERMIT# �DEPFIRTTEnT OF //��.. InDUSTRY LRBOri 6 HUMRn RELRTIOnS ` O O —Attach complete plans in accord with s. H 63.05,Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROP TY TR n MAILING ADDRESS dyS' 1 0 PR RTY LOCATION Vr�. 49=e4d '1N, @rE: ON 01/4, S , T (or) W TOWN OF: o LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST OAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER <-/-O'go 6 TYPE OF BUILDING OR USE SERVED ❑ 1 or 2 Family Number of Bedrooms: Public (Specify): THIS PERMIT IS FOR A: ew System El Tank Replacement El Repair El Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Seepage Bed Seepage Trench ❑ Seepage Pit ❑ Holding Tank El System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: ,S IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): �� a5 Private ❑ Joint ❑ Public I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name Plumber (Print): Signature: MP/MPRSW No.: Phone Number: a4r 1Z Z, _,� Zd-&Iv 4 1 4,�o Plumber's Address: Name of Designer: Z�4y 4 e,!!fM4a k v I __ COUNTY/DEPARTMENT USE ONLY Signature o Issuing Agent: Fee: Date: ❑ Disapproved L4 i El Owner Given Initial �,, Approved Adverse Determination WeJTn for Disapproval: Alternate course(s)of Action Available: DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber i INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system,circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis.Adm. Code will be applicable. 10. A new permit will be needed if there is a change in,estimated wastewater flow, (number of bedrooms,etc.), location of the system, depth of the system,type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan,drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances,distances between beds if appropriate,tank locations,effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit.Private sewage systems must be properly maintained.Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years.If you have questions concerning your system,contact your local code administrator or the Bureau of Plumbing,DILHR,State of Wisconsin. L _ V c w`` O L i w Of , O c N E 0c ° 'v cvcd C i N 7 ai E N A a) a) O) O C O H 'M o � C73M CD 0 0 vEc ca Nmc °' 0 = O° oN N ` O IUD IM V r 0 oc � 4) 01 yNLa� ' .. W ~ 030 » ° � N IL C cc C 0 N N CD_ 'N L N CC W c ° % 3 = 0 (D Ca ° NV 3 � � Z v� 3,aj w ai ~ c z O N vi O A vs — � atc 0) ; 0 30- :? Oa LM - O V V tv — i ` O N O L. 7 Q N O N V 7 d CD M O CL M CD C C im 0) C W O O N O c 0 3 C M >+ 7 Of Z C VC � E > °>, :3' E N O O Ca cc O c c CD L C c i 0 c0 O O "- a) O c� CM O ►- 0 0 0 E V � L L C N L... V a) C Jg 0 (n a) m0. a C) c N V3 C N ° y N O �O i 0 a O Y O 0 rnE O M d a c Z o O •- w (aLL - C' E .0 O N C N U V Y C a) a) w 3 3 O O >, L " C ` ti C\j r N OE m cn N i m of Q J_ N 0 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 7969 (H63.090)& Chapter 145.045) LOCATION: SECTION: TOWN P/11RUpLLCLPALITY: 75TT;O_.T.B_LKN0.: SUBDIVISION NAME: /�'/a // /Ta9 N/R/Mor)W of CeeO NT OWN R'S S AME: MAI ING ADDRESS: USE D NO.BEDRMS.: MERC AL DESCRIPTION: DATES OBSERVATIONS MADE LEI Residence /� p / PR FILED S RIPT10NS: R LATION TEST/S:: 7� 6�,,&.f eG o New Replace G r // la RATING:S=Site suitable for system U=Site unsuitable for system `f CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK-RECOMMENDED SYSTEM:(optional) S ❑U EA . , A LJU CJSZV ❑SZU ti F Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the �> der s.H63.09(51(bl,indicate: Floodplain,indicate Floodplain elevation/ V PROFILE DESCRIPTIONS '49 c / BORING TOTAL EEL;VATI/ON D PTH TO GROUNDWATER-INCHES CHARACTER OF SO WI THICKNESSS,COLOR,TEXTURE, AND DEPTH NUMBER N ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B_ 05 �7S /7j .S " / g- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN, PERIOD 1 PERIOD 2 P 10 PER INCH P- P- P- P-_ P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION � — + '- - 3 i I Y , E t r .. I _ 1 I,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print►• TESTS WERE COMPLETED ON: ADDR S: /o -.3 a , S CERTIFICATION NUMBER: PHONE NUMBER(optional): '2 2 5 -Z CST SIG U DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER— INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6595 To he a complete and accurate soil test,your report must ir,clUde: 1. Complete legal description; 2._The use section must clearly indicate whether this is a residence or cornrnercial project; 3, MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here far writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 3. Male scare your benchmark and vertical elevation reference point are clearly shown,and are permanent; . Corrapfcte all appropriate boxes as to elates,names,addresses,flood plain data, percolation test exemp- tion, if appropriate; 10, If the information (such as flood plain,elevation) does not apply, Place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number, 12. Make legible copies and distribute as required. ALL SOIL. TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIES SOIL, TESTERS Soil Separates and Textures Other Symbols st --'Stone (over 10") BR Bedrock col) Cobble (3- 10") SS - Sandstone gr - Gravel (under 3") LS Limestone *s Sand HGW - High Groundwater cs - Coarse Sand Pere Percolation Rate cried s - Medium Sand W - Well fs - Fine Sand Bldg - Building Is Loarny Sand > - Greater Than 'sl - Sandy Loam < Less Than *1 Loarn Bit - Brown *sil Silt Loam BI - Black si - Silt G - Gray 'cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay W/ with sic - Silty Clay fff few, fine, faint x.c Clay cc .- common, coarse pt -.. Peat rnrn -- Many, medium m - Muck c1 - distinct p -_ prominent HWL - High water level, Six general soil textures surface water' for liquid waste disposal BM - Bench Mark VRP Vertical Reference Point TO THE OWNER: Th, _oH t�,- F eport is the first stop in securincj a sanitat'y permit.The courtty m I-r,�4�tpai °tE�rlt may request VE3r."ifi '_ftil-sn r"", tlli5 `'o;1 t.Etit in the fkIcl priol iio oerP?w issuAtli... A colnlllC't' ti£;t. C:lf plan,` for the pi " f( tlt uetl £if�� {£ )�'£ 'r "o'a pei ', o a lion n-'u�t i"- slInllltej t� the sanii :,ar rv"r clil nnlsl LE. f.l';•t§.[,LiJ and rw sj£':.,IIr t m ti`s rt,i; arl e t F AI L?MKAL • k6le v'F,q �J &-7-7,,q l //� h�� l� '!;q/-os As �- C-�kc PLUMBING gall 5 A"PP-X AND HUMAN RELATIONSL / DEPARTMENDIVIISIONDOFTSAF LABOR AND ILDINGS. E CORRESPONDENCE. ross I . 840 80 '34 �e� 4422i� se //17,4212 s w -3r2 s� /2:::' STATE OF WISCONSIN DILHR DILHR PRIVATE SEWAGE SYSTEMS DIVISION OF SAFETY BBUILDINGS BUREAU OF PLUMBING 201 E.Washington Avenue,Rm 141 PLAN APPROVAL APPLICATION P.O.Box 7969,Madison,WI 53707 608-266-3815 INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. The back side of this form describes required plan information. Plumbing codes can be purchased from the Department of Administration, Document Sales,202 South Thornton Ave.,P.O.Box 7840,Madison,Wisconsin 53707,Telephone(60M 266-3358. 1. PROJECT INFORMATION(Type or print clearly) Revision To Plan Number: Name of Submitting Party(Plans r 91urned to same) Project Name �C.• �v/ Street 8 No. Rural Route Project Location-Street 8 No.or Legal Description City or Village State Zip City ❑ County �j�� " Village OF (�`'� I / Town I yYbYU Telephone No.(Include area code) �oo Designer Telephone No.(Include area code) O rs e p Telephone No.(Include area code) of ,/s� Street 8 No. eel 8 No.� 11$� City or Village State Zip CX7�7 State Zip M a A)', , =6V;v,,2 2. IbAPPPLICATION FOR: ❑New Mound System(3a) ❑Groundwater Monitorinig(7) �LConventional System-Public Building(1) ❑Replacement Mound(4a) ❑ Holding Tank(2) ❑Replacement Pressurized System(4b) ❑System in Fill(1) ❑Petition For Variance(6) ❑New Pressurized System(3b) ❑System in Flood Fringe(1) ❑Other Alternatives(5) 3. FEE COMPUTATIONS(Include existing tanks) 4. FEE SUBMITTED FOR OFFICE USE MAKE ALL CHECKS PAYABLE TO DILHR 3a. 750- 1,500 gallon septic tank - 50.00 4a. Od 3b. 1,501- 2,500 gallon septic tank - 60.00 4b. 3c. 2,501- 5,000 gallon septic tank - 80.00 4c. 3d. 5,001- 9,000 gallon septic tank -100.00 4d. 3e. 9,001-15,000 gallon septic tank -150.00 4e. 3f. Over 15,000 gallon septic tank -250.00 4f. 3g. 500- 1,000 gallon dose chamber - 30.00 4g. 3h. 1,001- 2,000 gallon dose chamber - 50.00 4h. 31. 2,001- 4,000 gallon dose chamber - 70.00 41. 3j. 4,001- 8,000 gallon dose chamber - 90.00 4j. 3k. 8,001-12,000 gallon dose chamber -110.00 4k. 31. Over 12,000 gallon dose chamber -150.00 41. 3m. 500- 5,000 gallon holding tank - 30.00 4m. 3n. 5,001-10,000 gallon holding tank - 55.00 4n. 3o. Over 10,000 gallon holding tank -100.00 4o. 3p. Revisions - 20.00 4p. 3q. Groundwater Monitoring Per Lot - 32.00 4q. (other than a proposed subdivision) Subtotal - 3r. Priority plan review:walk through 4r. Submittal of plans in person, by appointment,with double fee 3s. Petition for variance Setback - 25.00 4s. Site evaluation - 50.00 Total Fee �© NOTE:Fees pursuant to Wis.Adm.Code,Chapter Ind.69 may be subject to change annually SBD-6748(R.8/85) Effective July 1,1984 -OVER g DEPART&►ENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115 P.O. BOX 7969 ) HUMAN RELATIONS \ / MADISON,WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWN P/MLIpLLCEP{t1 ITY: OT NO.:BLK.NO.: SUBDIVISION NAME: COUNT : OWN R'S S AME: MAILING ADDRESS.— USE DATES OBSERVATIONS MADE NO,BEDR M A DESCRIPTION: S: TESTS: ❑ `�� / New ❑Replace I /D ` �G h _/ /� O ^9 RATING:S-Site suitable for system U-Site unsuitable for system (7 CF ' CONVENTIONAL MOUND: IN-GROUND-PR UR : S TEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) S E3U 01s ❑U EgS ❑U 0 S Zu ❑S C11 I tit If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b),'indicate: Floodplain,indicate Floodplain elevation / PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GR UNDWATER-INCHES CHARACTER OF SO WI THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER DEgRtiN, ELEVATION OBSERVED EST.HIG HE TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) 13- 2_ I gg B 88 - 021-01 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER -INCHES' AFTERSWELL•ING INTERVAL-MIN. PERIOD RI 13 PERI0133 PER INCH P. P- P- P- P- P PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope, q CVCTFRA P FVATinN / �� P1 b. # 60 1178 PROJECT DETAIL DATA SHEET NAME OF BUSINESS LEGAL DESCRIPTION '51 ,7�a9/4� /S . OWNER MAILING ADDRESS ZIP .-:53 l2 ARCHITECT, ENGINEER, � / ADDRESS PLUMBER OR DESIGNER ' I P TELEPHONE NUMBER 1 . Check appropriate building usage(s) and fill in the information requested opposite each usage listed. Please consult Section H 62.20. Existing building New building �/� Addition ( ) Apartments and condominiums . . . Number of bedrooms ( ) Assembly hall . . . . . . . . . . . Seating capacity ( Bar . . . . . . . . . . . . . Seating capacity # of meals served { Bowling alley . . . . . . . . . Number of lanes { ) With bar ( Campground and camping resorts Number of sewerecasi'tes 8408064 Number of unsewered sites Total number of sites ( ) Camps . . . . . . . . . . . . . ( ) Day use only Number of persons ( ) Day and night Number of persons ( ) Catchbasin . . . . Number ( ) Church . . . . . . ' ( ) No kitchen Numbpr of persons ( ) With kitchen Number of persons Dance hall . . . . . . . . . . . . . Number -of persons . Dining hall . . . . . . Number of meals sereU daily ( ) Dog kennels Number of epclosures ( Drive-in restaurant . Inside seating capaci Car-service -- Number of caY spa e � Dump station . . . . . . . . . Number of dump stations . Employees ( total of all shifts) Number of employees / ( ) Hotel ( ) Motel ( ) Cottages . . . . Number of units with 2 persons per unit Number of units with 4 persons per unit ( ) Medical and dental office bldgs. Number of doctors, nurses , medical staff Number of office personnel Number of patients ( ) Mobile home parks . . . . . . . . . Number of sites ( ) Nursing homes . . . . . . . . . Number of beds ( ) Parks . . . . . . . . . . Number of persons ( ) Toilets ( ) Showers ( ) Restaurant . . . . . . . . . . . . . Seating capacity 3a )(Q4 "161--AY1,19 ( ) Dishwasher and/or disposal? J�x ►z' showroom ( ) 24-Hour service bQ Retail store .. . . . . . . . . Total number of customers { ) Schools Number of classrooms Meals ( ) Showed ( ) Self service laundry Total number of machines ( ) Service station . . Number of cars served dairy l ( ) Swimming pool bathhouse . . . . . . Number of persons ( ) OTHER . . . (Specify) . . . . . . . COMPLETE OTHER SIDE Floor drain- yes no Number of drains Food waste grinder yes no T Dishwasher yes no �_ Automatic clothes washer yes no �_ Number of clothes washers 3. Septic tank capacity /000 Holding tank capacity Septic or holding tank manufacturer o f 24 u,rEul 4. SEEPAGE TRENCHES: total square feet width of trenches .:5— length of trenches 66 depth number of trenches / SEEPAGE BEDS: total square et width t5!!gW of bed depth SEEPAGE PITS: total square et outside diameter depth ow inlet tal depth from top to bottom of pit Signatur person completing form: FOR DEPARTMENTAL USE ONLY Address 8408064 Z i .) T Telephone Number 2 17Zv-lv Z00 Date x88 - 02101 OPTIONAL WORKSHEET 1. MOUND SYSTEM II. IN-GROUND PRESSURE SYSTEM•Continued- i. Wastewater Load,Total Dally Flow= gal. 10. Force Main: Use s. ILHR 83. 15 (3) (c) Minimum Dosing Rate• fP►n• Adm.Code and PROVIDE A DETAILED Diameter= /head. in. LIST OF SIZING ON PLANS. 11. Total Dynamic Head2. Depth to Limiting Factor= It. System Head= ft. 3. Landslope= % Vertical Lift= ft. 4. Distance from Dose Chamber to Friction Loss= ft. Distribution System ft. TDH ft. S. Elevation Difference Between 12. Pump Selection: Pump and Distributbn System ft. Pump will dischaAbsorption Area Sizing: at ft.tArea Required= sq.ft. Pump model and Bed or Trench Length(8)■ ft. Bed or Trench Width(A)■ ft. Xe e: Trench Spacing(C) ft. s id Volume of 7. Mound Height: on Lines= gal• Fill Depth(D)_ ft. stewater Volum e+Fill Depth Downslope( _ ft, In 24 hr (� gal. Bed or Trench Depth )= ft. ` 8 4 O 8 V gal. Cap and Topsoil Dep (G)= ft. Dose gal• Cap and Topsoil D th(H)= ft. ber: S. Mound Length: Volume= gal. End Slope(K)= ft. Total Mound ngth(L)= ft. 111. CONVENTIONAL PRIVATE SEWAGE SYSTEM c r� 9. Mound Width: 1. Wastewater Load,Total Daily Flow= .1L gat. UpsiopeC rection Factor sm. Use s. ILHR 83. 15 (3) (c) , Wis. Upslope idth(j)= ft. Adm.Code and PROVIDE DETAILED Downsl a Correction Factor= LIST OF SIZING ON PLANS. �.ZZ Down ope Width(I)= ft. 2. Required Septic Tank Capacity 3c' -gal. Tot Mound Width(W)= ft. 3. Percolation Rate= -�_ min./ 10. Basal rea: 4. Absorption Area Sizing: iltrative Capacity of Refer to Table 2 in ch. ILHR 83 atural Soil= gal./sq.ft./day and PROVIDE A DETAILED LIST OF Basal Area Required at sq.ft. SIZING ON PLANS. Basal Area Available= sq.ft. Required Area= .ate sq.ft 11. If Standard Tables from Chapter ILHR 83 Length= ft. are. Indicate Table # width ft. For'the Distribution Network,Use Numbers 5.14 in Section Ii. I ; - Number of Trenches= Trench Spacing= i ft. 11. IN-GROUND PRESSURE SYSTEM S. Distribution System: 1. Depth to Limiting Factor= f. Lateral Length= ft. 2. Landslope s Number of Laterals= 3. Percolation Rate= min./in. Lateral Spacing= in. 4. Proposed System Elevation= ft. Distance from Sidewall to Pipe= '- In. S. Wastewater Load,Total Daily Flow: gal. System Elevation= ft. Use s. ILHR 83. 15 (3) (c) , is. Adm.Code and PROVIDE A DETAI D IV. SYSTEM-IN-FILILI /� ® -/ LIST OF SIZING ONTLANS. Fill in All Items f V t mr 1 Required Septic Tank Capacity= gal. 6. Absorption Area Sizing: V. SEPTIC TANK Percolation Rate= min./in. 1. Capacity- 1eQQ gal. Area Required= sq.ft. 2. Manufacturer;..(t c�S 12 4S. System Length= ft. 3. Show Site Constructed Tank Details on Plan System Width= ft. 7. Distribution Pipe Siz g: Vi. DOSING TANK Hole Size= In. 1. Capacity= 1. Hole Spacin ft. 2. Manufacturer: -- Lateral L- ltth - (l. 3. Pump Manulaclurcr. L.ileral to in. 4. Pump Model: L.u' spacing fl. S. Operating Head= 1t• I)' once from tiil�+wali•11i Pipe iu, G. Flow Rat'= Slim. N. 01 Ibution Pipe Disch.trgu Rate: 7. Show Site Constructed nk Details on Plans Number of I Inlus Per Pipe 1 tow leer Pipe gpm, VII. HOI.I)ING TAN W. Manil•old Siting: 1. Capaci - gal. 'tyre(center or unl) 2. Iacturer: Length= It. 3 Show Site Constructed Tank Details on Plans Diameter= In. -SHOW ALL INFORMATION ON PLANS- DILHR SBD-6761 (R.03/92) . CIF STRY, LAn. R A p1�SG� ENT pF IN SASE i1D RIM "�3� ESppND ND SEE o -� ON TE SEWAGE SYSTEM 1 TRY, LABOR NO HUMAN R�T� S X11 P E T O !t� 5 t4� (11Vi5i H OF SAS AN EUiLDINGS ��� EE CORRESPONDENCE )p00 •L �L0 5Al. Oi t - -i ----ids r o tp,�►d .S f e-p E a 2 1-0,0 of p6re. A-✓rE03 plans for the general ar Sewer�V Pe to the sepu�holding n Ttris aDProval does ,rnq those Ply (` , tcm. this project. With 1J1 C' plumbing sYs required for roved rn �cotdance JtJ lament tbe submitted and aPP ch, IttIR 82 WAC• 9�/rte, • CU f- U � 1 `AQpR At, k10) rAy UUS1Ry�� A�iD cr DIE?PR�MENDIVI 1N Qf S� Ec10E . � 84 o 4,10,1q.0 Igo e &J08064 a � b �a'ld9 0•aE � 1- � a � d a c ga* 02101 / AGE SYSTEM ° CI 1 p TES EM NAM MIED i I� Y + o S Q a x ) 1-4 I.�XIONS '[ , LABOR AND HUMAN RE FEIY AND UiLDINGS E GOFdRESPONQENCE • ` PAGE OF FL,Ujomi dG / DEPARTMENT OF INDUSTRY ETYt3 AND\^BUILDINGS RELATIONS DIVISION OF SAF , S C F2 O E �r�hGh Cj �� mlom OF A�fl SYSTEM ONSITE — 4 U 80 b 4 YAW ND KUMAi� RELATIONS DEPYMEN� I Iip OF SAFLTY AND UiLD1ld05 E CORRESPONDENCE SOIL F L DISTRIBUTIO PIPE APPROVED S'�LITNETIC COVER --MATERIAL Z" OF AGGREGATE'S e� log OF Z— /Zl AGGREGATE o8 �% ��•, ELEV. OF1cpT� FEET_. DISTRIBUTIOM PIPE TO BE AT LEAST IPICHES BELOW ORiwWAL GRADE AMD AT LEAST20 INCHES BUT NO MORE THALI y2 IN B LOW IKIAL GRADE - U210 /r MAXIMUM DEPTH OF EXCAVATIOM FROM ORIGIAIAL GRADE WILL BE INCHES MINIMUM DEPTH OF EXCAVATIOKJ FROM ORIGIIJAL GRADE WILL BE 8 INCHES SIGWED: sz LICENSE AJUMBER: 1 DATE: • °o h 74/&7-7 A )-7 c h �EC rF)q d-7-7 4 4 ba C W'd-n 1-7107�'d- 4VWn6 h %/0 6 �3�• �o��c7` Worl�(.sh�Ef ',old pw �„ ��• � rass S�a��are � �r�,-��h � � � .,� RELATIONS G FA P,T��E t ;-'61DINGS SEE CC3RRE:�3'p ONDENCE, m�/ZS ud 3 z s•�/ STATE OF WISCONSIN DILHR DIVISION SAFETY& PRIVATE SEWAGE SYSTEMS BUREAU OFF PLUMBING BUILDING 201 E.Washington Avenue,Rm 178 PLAN APPROVAL APPLICATION P.O.Box 7969,Madison,WI 53707 608-266-3815 INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are receive The back side of this form describes required plan information. Plumbing codes can be purchased from the Department of Administration Document Sales,202 South Thornton Ave., Madison,Wisconsin 53703,Telephone (608)266-3358. 1. PROJECT INFORMATION (Type or print clearly) Name of!016 tting Party (Plans retufr red to same) Project Name Cza9i-v1 ?Gtc / /87J Street&No. C Project Location -Street&No.or Legal Description City State Zip Code ❑ City County Village / X Town Designer Telephone No. (Include Area Code) 2. THIS APPLICATION IS FOR A: ❑ New Mound System (3) ❑ Holding Tank (2) ❑ New Pressurized System on site not suitable ❑ Petition For Modification (6) for conventional (3) ❑ Replacement Mound (4) ❑ Replacement Pressurized System on site not ❑ System in Fill (1) suitable for conventional (4) ❑ System in Flood Fringe (1). ❑ Pressurized System on site suitable for ❑ Groundwater Monitoring (7) conventional (1) Conventional System- Public Building (1) 3. FEE COMPUTATIONS(Include existing tanks) 4. FEE SUBMITTED 8408064" OFFICE USE 3a. 750- 1,500 gallon septic tank 4a. 3b. 1,501 - 2,500 gallon septic tank - 40.00 4b. 3c. 2,501 - 4,000 gallon septic tank - 55.00 4c. 3d. 4,001 - 8,000 gallon septic tank - .70.00 4d. 3e. 8,001 - 12,000 gallon septic tank - 85.00 4e. 3f. Over 12,000 gallon septic tank - 100.00 4f. 3g. 500- 1,000 gallon pump chamber - 30.00 4g. 3h. 1,001 - 2,000 gallon pump chamber - 35.00 4h. 3i. 2,001 - 4,000 gallon pump chamber - 50.00 4i. 3j. 4,001 - 8,000 gallon pump chamber - 65.00 4j. 3k. 8,001 - 12,000 gallon pump chamber - 80.00 4k. 31. Over 12,000 gallon pump chamber - 95.00 41. 3m. 500- 5,000 gallon holding tank - 30.00 4m. 3n. 5,001 - 10,000 gallon holding tank - 40.00 4n. 3o. Over 10,000 gallon holding tank - 50.00 4o. 3p. Groundwater Monitoring - 32.00 4p. Subtotal 3q. Priority plan review: (walk through) 4q. Submittal of plans in person, by appointment,with double fee 3r. Petition for Modification Setback - 20.00 4r. Site evaluation - 50.00 Total Fee �� Op COMMENTS: 0 ILHR SOO-6748(R.5/82) _ .-OVER OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS ( P.O. BOX 7969 115 HUMAN RELATIONS \ � MADISON,WI 53707 (H63.090)&Chapter 145.045) LO A ION: T TOWN P/MUN1Ci.Pfr1.ITY: OT NO.:BLK.NO.: SUBDIVISION NAME: V // /Ta5 N/R/®, (or)W COUNTY: OWN R'S AM : MAI LING ADDRESS: 4. /21�•A tc�i m .54� USE DATES OBSERVATIONS MADE ❑Residence B 1M. A D 0 P IO/ New ❑Replace TS: IVA , a D —� -�CF/I / RATING:S-Site suitable for system U-Site unsuitable for system ONVENT NAL: MOUND: IN-GROUND- S EM-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional) sou zs ❑u cgs 1:1 osZu ❑sZu If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the �> under s.H63.09(5)(b),indicate: Floodplain,indicate Floodplain elevation. v Sy / PROFILE DESCRIPTIONS l BORING TOTAL P H R UNDWATER-INCHES CHARACTER OF SO WI THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER ELEVATION OBSERVED HE TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B- �-s � �S i7 j 9g ; /. .�, �"Win, E. 13- 1. /1•esi� 1Z%_,7- 5,141�?2- gjl- B 49:9 B- PERCOLATION TESTS TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELL'ING INTERVAL-MIN. PERIOD RI 002 PERIOD 3 PER INCH P- P- P- P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION } i C �_. _.. IN r— 1, the undersigned,hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print TESTS WERE COMPLETED ON: / D '_0 0 ADDR S: CERTIFICATION NUMBER: PHONE NUMBER(optional ): ' '2 2 y - CST SIG U a-`74 ae_02�.�7 DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R.02/82) —OVER — Plb. # 60 1/78 PROJECT DETAIL DATA SHEET NAME OF BUSINESS LEGAL DESCRIPTION / /S . /g OWNER , MAILING ADDRESS �, �, "le ZIP ARCHITECT, ENGINEER, / ADDRESS PLUMBER OR DESIGNER TELEPHONE NUMBER Cal Za I . Check appropriate building usage(s) and fill in the information requested opposite each usage listed. Please consult Section H 62.20. Existing building New building Addition ( ) Apartments and condominiums . . . . Number of bedrooms ( ) Assembly hall . . . . . . . . . . . Seating capacity ( ) Bar Seating capacity # of meals served Bowling alley Number of lanes ( ) Wi 4br „Campground and camping resorts Number of sewere�s tes A Number of unsewered sites Total number of sites ( ) Camps . . . . . . . . . . . . . . . ( ) Day use only Number of persons ( ) Day and night Number of persons ( ) Catchbasin . . . . . . . . . . . . Number ( ) Church . . . . . . . . . . ( ) No kitchen Numbpr of persons ( ) With kitchen Number of persons ( Dance hall . . . . . . . . . . . . . Number of persons ( Dining hall . . . . . . . . Number of meals served daily Dog kennels . . . . . . . . . . . Number of enclosures Drive-in restaurant . . . . . . . . Inside seating capacity Car-service -- Number of car spaces ( ) Dump station . . . . . . . . Number of dump stations (�. Employees ( total of all shifts) . . Number of employees / ( ) Hotel ( ) Motel ( ) Cottages . . . . Number of units with 2 persons per unit Number of units with 4 persons per unit ( ) Medical and dental office bldgs. Number of doctors , nurses , medical staff Number of office personnel Number of patients ( ) Mobile home parks . . . . . . . . . Number of sites ( ) Nursing homes . . . . . . . . . . . Number of beds ( ) Parks . . . . . . . . . . . . . Number of persons ( ) Toilets ( ) Showers ( ) Restaurant . . . . . . . . . . . . . Seating capacity 32i1a4 ( ) Dishwasher and/or disposal? Retail store ��X!Z_ sh. . . .+-�. , • Total service Schools . . . . . . . . Number of classrooms � Meals ( ) Showers ( ) Self service laundry . . . . . . . . Total number of machines ( ) Service station . . . . . . . . . . Number of cars served dais ( ) Swimming pool bathhouse . . . . . . Number of persons ( ) OTHER (Specify) . . . . . . COMPLETE OTHER SIDE Floor drain- yes L/no Number of drains Y Food waste grinder yes no T Dishwasher yes no Automatic clothes washer yes no _� Number of clothes washers 3. Septic tank capacity ___,/000 Holding tank capacity 4 Septic or holding tank manufacturer �, E KS CO-0 0,rdE 10 645 C&- o ) 2Fp a,P_.,1 4. SEEPAGE TRENCHES: total square feet _3_?.5 width of trenches length of trenches 66 depth number of trenches / SEEPAGE BEDS: total square t width len of bed depth SEEPAGE PITS: total square feet outside diameter depth ow inlet tal depth from top to bottom of pit Signatur person completing form: FOR DEPARTMENTAL USE ONLY Address / Z ��� 8408004 Telephone Number �27� 2 00 Date OPTIONAL WORKSHEET 1. MOUND SYSTEM 11. IN-GROUND PRESSURE SYSTEM-Continued. 1. Wastewater Load,Total Daily Flow= gal. 10. Force Main: Use s. ILHR 83. 15 (3) (c) Minimum Dosing Rate= gpm. Adm.Code and PROVIDE A DETAILED Diameter i /ead., in.LIST OF SIZING ON PLANS. 11. Total Dynamic Head2. Depth to Limiting Factor= tt. System Head= ft.x Vertical Litt ft.3. Landslope= ft.4. Distance from Drse Chamber to Friction Loss=Distribution System= ft. TDH= ft.5. Elevation Difference Between 12. Pump Selection: Pump and Distribution System= ft. Pump will discha6. Absorption Area Sizing: at ft.tArea Required= sq.ft. Pump model and Bed or Trench Length(B)= ft. Bed or Trench Width A = ft. 13. Dose Volume: B ( ) Trench Spacing(C)= ft. 10 Times L Volume o/ 7. Mound Height: /Dose on Lints- Pl. ft. stewater Volume+ Fill Depth(D)= n 24 hrs.= gal. Fill Depth Downslope( = it. Backflow = al. Bed or Trench Depth ): ft. Minimum g Cap and Topsoil Dep (G)- ft. Dose= gal. Cap and Topsoil D th(H)- ft. er: 8d Length: Volume= gal. d Slope(K)= ft. tal Mound ngth(L)= ft. 111. CONVENTIONAL PRIVATE SEWAGE SYSTEM 4�•'�/�y d Width: I. Wastewater Load,Total Daily Flow= jai. slopeC rectionFactor= Use s. ILHR 83.15 (3) (c) , Wis. slope idth O)= ft. Adm.Code and PROVIDE DETAILED wnsl a Correction Factor= LIST OF SIZING ON PLANS. wn ope Width(1)_ _..r._ tt. 2. Required Septic Tank Capacity= gal. t Mound Width(W)= ft. 3. Percolation Rate= min./in. rea: 4. Absorption Area Sizing: iterative Capacity of Refer to Table 2 in ch. ILHR 83 tural Soil= gal./sq.ft/day and PROVIDE A DETAILED LIST OF sal Area Required= __�. sq.ft. SIZING ON PLANS. ���-���-,, sal Area Available= sq.ft. Required Area sq.ft. ndard Tables from Chapter ILHR 83 Length= ft. Used, Indicate Table # Width= ft. he Distribution N etwork,Use Numbers S•14 in Section II. Number of Trenches= Trench Spacing: ft. 11. IN-GROUND PRESSURE SYSTEM S. Distribution System: ( `/ 1. Depth to Limiting Factor= ___. f. Lateral Length= ft. 2. Landslope= Number of Laterals= 3. Percolation Rate= min./in. Lateral Spacing= in. 4. Proposed System Elevation= ft. Distance from Sidewall to Pipe= in. 5. Wastewater Load.Total Daily Flow: gal. System Elevation Use s. ILH12 83. 15 (3) (c) , is. Adm.Code and PROVIDE A DETAI D IV. SYSTEM-IN-FILL O 8 LIST OF SIZING ONTLANS. Fill in All Items from Section V Required Septic Tank Capacity= gal. 6. Absorption Area Sizing: V. SEPTIC TANK i� Percolation Rate= min./in. 1. Capacity= gal Area Required= sq.ft. 2. Manufacturer. .L���r�S �''�M9 E D S. System Length= ft. 3. Show Site Constructed Tank Details on Plan System Width= ft. 7. Distribution Pipe Siz X. VI. DOSING TANK Hole Slzc= in. 1. Capacity= I. Hole Spacin - ft. 2. Manufacturer: Lateral L gth . f1. 3. Pump Manufacturcr: Lateral fe in. 4. Puntp Model: ft. L.IIC• Spacing fl. .5. Operating Head= 1A .111ce from Sidewali•tit Pipe in. 0. Flow Rate= gpm• K. Di. lhutiott Pllx Di.cit.trge Rate: 7. Show Site Constructed nk Details on Plans Number of I loles Per Pilx- 1 low Per Pipt K11m. VII. IIUI.UING TAN V. Manifold Sfifng: i. Capa_I - gal. 'fype(center or end) 2. fadurer: Length= ft. 3 Show Site Conslructt d Tank Details on Plans Diameter= in. -SHOW ALL INFORMATION ON PLANS- 01LHR S80-6761 (R.03/821 38 i9'�c r^Nr��i�mra/ h % -5,44�s f��c.cff qIZJ aF , , A j C1. DEP RTME1% plvlSl� S E cp1�F�Espo DENCE' 0 It 000�O loon SpI. ,00' Ay� SE 4rin�h - -i -.-- s Oro" S 1 e-P E nr� , ,3 ��o sa r}►1 d,v`L�G�L �,,� 8408 064 6 ICE,^n. ftoe-#16-Z. �6 /vo� �o SeAI� 7<0 , > �.C/s v/E QL 0 80 7 o u 0.7-Irl 914 ol t d C I' 0 tip ` , ifl�� RE 0 d 'iL�iluS, S E COPIR SPONDEI�I 8408094 PAGE OF PLUM ^,,, � I a � , QEQARTMEN�IVI� 0, SEE CORRESPO '''I' CROSS SECTIOM " OF ADD S,9STEM 0 i SOIL F L DISTRIBUTIO PIPE APPROVED S4A1THETIC COVER " MATERIAL 2" OF AGGREGATE J A Z ° z5 �OR tAA?.S4—H*ti 4o1 OF — /Z AGGREGATE ELEV. 6F2.Z— FEET_.... DISTR15UTIOU PIPE TO BE AT LEAST .38 IKICHES BELOW ORIGIMAL. GRADE AND AT LEASTLO INCHES BUT NO MORE THAN 42. IMC14ES BELOW FINAL GRADE ,r MAXIMUM DEPTH OF EXCAVATIOIJ FROM ORIGIIJAL GRADE WILL BE IMC14ES MINIMUM DEPTH OF EXCAVATIOM FROM ORIGIkJAL GRADE WILL BE IMCHES SIGAIED: LICEiJSE IJUMBER: DATE: H a ST C - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT 0 St . Croix County 2 d ' ^ a OWNER/BUYER �� G '�- Ei✓�/� /� LAL40e ROUTE/BOX NUMBER I !i/ ��C�/►s�r 4tLZ7 Fire Number`} CITY/STATE !V SW �ccgt o �r IIP_��/O�, PROPERTY LOCATION : ,#,W �,5,4, Section , T 3 N , R fir, Town of St . Croix County , Subdivision Lot number_. Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists of pumping out the septic tank every three years or sooner , if needed , by a licensed septic tank um er . What you put into I the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1 , 1978 . St . Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained . The property owner agrees to submit to St . Croix County Zoning a certification form, signed by the owner and by a master plumber , journeyman plumber , restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary) , the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration . Ho E I/WE, the undersigned , have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth , herein , as set by the Wisconsin Depart- ro ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Office wi hin 30 days of the three year expiration date . SIGNE DATE St . Croix County Zoning Office P. O. Box 98 Hammond , WI 54015 715-796-2239 or 715-425-8363 Sign , date and return to above address . L APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house") , then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Property �4 sW �4. Section T30 N - R W Township _ 94.."L_ Mailing Address &. ! /146411 if,4/ing� 4.Zr- 1d/7 P Subdivision Name Lot Number Previous Owner of Property 4 CN� Total Size of Parcel �� Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes _� No Volume and Page Number 7,,2 � as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Dee 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTV OWNER CERTIFICATION I (We.) eeAti6y that att statement6 on this 4otm ante true to the best os my (ouA) knowledge; that I (we) am (cute) the owneA(s) o4 the prtopeAty deseh coed in thin in4onmation 4onm, by vi tue o� a wa vtanty deed tecoAded in the 044ice o� the County RegZ6ten o{ Deeds as Document No. 351a7// ; and that I (we) pA"entey own the proposed site ion the ,6ewage dizposa y6tem (on 1 (we) have obtained an easement, to nun with the above de.6cA bed ptopeAty, 4on the con6tAuct%on o� baid sybtem, and the same hays been duty teco,,ded in the O�4ice o4 the County Regtisten o{ Deeds, aQ Document No. ) . i V4)UUIE OF OWNER Cl SIGNATURE. OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED