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040-1188-90-000
\ 0 : § \ � ° ® § 0 } ; �/ g 2 \MCc m \7E CL t3 � � k 2 � f/$ g ] $Cc ƒ 704 § \ /2 / \ .00 777 $ %g@ 0 \ \ z °.� j { kc gE \\7e �� } j . § � « ) e R / \ % \ § + 2 } k k k { z 2 E \ N m ( \ \ f ƒ L ; / § � _ @ - ° 3 £ k ƒ \ � ) \ C.4 ) E / j § K ® 2 a e % \ 2 \ \ 2 � } , � ƒ f \ U- 0 § § IL cl: ' k o B . « 00 00■ u A f \ 2 ° a ¥ / \ § _ E , R co , a ° § ` O / E 00 to oc) 2 2 a J E E \ f 8 E k ; 2 a a / 5 , , e / ( 2 z ¥ - 6 " / . K 3 E { , o \ ) a .. c � � 4 » E )k k a § k J a 2 v I Parcel #: 040-1188-90-000 01/18/2005 08:14 AM PAGE 1 OF 1 Alt. Parcel M 36.28.19.813 040-TOWN OF TROY Current X', ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner * ANTHONY K&SHANNON M TELLIN TELLIN,ANTHONY K&SHANNON M 73 W WOODRIDGE DR RIVER FALLS WI 54022 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *73 W WOODRIDGE DR SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 0.000 Plat: 2237-OAK RIDGE ACRES SEC 36 T28N R19W LOT 60 OAK RIDGE ACRES Block/Condo Bldg: LOT 60 INCLUDES P566B Tract(s): (Sec-Twn-Rng 401/4 1601/4) 36-28N-19W Notes: Parcel History: Date Doc# Vol/Page Type 10/07/2004 776414 2671/357 WD 04/04/2000 620618 1500/133 WD 07/23/1997 817/17 2004 SUMMARY Bill M Fair Market Value: Assessed with: 27605 200,400 Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 35,000 165,800 200,800 NO Totals for 2004: General Property 0.000 35,000 165,800 200,800 Woodland 0.000 0 0 Totals for 2003: General Property 0.000 25,300 153,200 178,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 208 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 040-1141-30-100 01/18/2005 08:15 AM PAGE 1 OF 1 Alt. Parcel#: 36.28.19.566B 040-TOWN OF TROY Current X ST.CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): "=Current Owner TELLIN,ANTHONY K&SHANNON M ANTHONY K&SHANNON M TELLIN 73 W WOODRIDGE DR RIVER FALLS WI 54022 Districts: SC=School SP=Special Property Address(es): '=Primary Type Dist# Description SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 0.140 Plat: N/A-NOT AVAILABLE SEC 36 T28N R19W NW NW.140 ACRES COM Block/Condo Bldg: MOST STHLY COR LOT 60 PLAT OAK RIDGE ACRES AS POB N 60 DEG E 168.19'S 83.25' Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) N 89 DEG W 146.14'-POB ASSESS WITH P813 36-28N-19W Notes: Parcel History: Date Doc# Vol/Page Type 10/07/2004 776414 2671/357 WD 04/04/2000 620618 1500/133 WD 07/23/1997 817/17 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: Description Class Acres Land Improve Total State Reason Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2003: General Property 0.000 0 0 0 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 0.00 Total 0.00 0.00 r D �u�� S Ct• � �� �P n e�T, "rk. x le) o , I 1�D K gl� eqe, ' s4 �► S. tom.B•�. J Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER eJ� e ? �IR TOWNSHIP D If SEC. T °) N-R W ADDRESS 60 ST. CROIX COUNTY, WISCONSIN Ir"U e r �jj I _1'_/ J SUBDIVISION �� (/� � LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM o I�DD6 q J Se� •�--h-c1� R nl1 D �a, 35' -o A l�er rea INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used &S ° lee' P 1r 0 1/ 7j? Elevation of vertical reference point: / 00 . Proposed slope at site: '92 SEPTIC TANK: Manufacturer: hjJPCSt ! f_eW iquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: a Number of feet from nearest Road: Front, Side 0 Rear, O p !�U feet From nearest property line Front,0 Side,0 Rear,@ 3�j feet X78 T Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) '� SEE REVERSE SIDE i PUMP CHAMBER Manufacturer: AJOCST (reelsfLiquid Capacity: � U Pump Model: �a U I Pump/Siphon Manufacturer: QW Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: `.0 UE j �lart^ Alarm Switch Type: SCc'liz� Number of feet from nearest property line: Front, O Side, ©Rear, Ft. a Number of feet from well: �7O� c' ' Number of feet from building: J (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: 7 Length: Z,�D Number of Lines: / Area Built: f�d c p" Fill depth to top of pipe: 0)7 l Number of feet from nearest property line: Front, 9 Side, O Rear,0 Pt . feet from well: !C Number of f � d � l ` Number of feet from building: d (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, 0 Rear, 0Ft. Number of feet from well: Number of feet from building: a Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: 1161Pe License Number: 3/84:mj 9 I 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 S(d1%,N(,U%,S36,T28N-R19W MONVENTIONAL ❑ALTERNATIVE State Plan I.D.Number: jIf Town o4 TtLG y ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 60 Oakt dge NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Kenneth Dei6.6 GO Cudd6 CUuAt RiveA FaM WI 54022 �� oc� BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.I I ELEV.. Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Thomaz Wang i3231 St. ctoix. SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER h Q PROVIDED: PROVIDED I I !� �NIYES ONO ❑YES &NO BEDDING: VENT DIA.. VENT MATL.: HIGH WATER NUMBER ROAD PROPERTY WELL: BUILDING. LEALARM FEET FRO JVENTTOFRES AIR INLET ❑YES NO I� �� DYES ONO INEARESTL--� I5o J DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY P MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER ,,1.11 PROVIDED: PROVIDED. I At4 OYES ONO �Q IGPUMOLJtd ®YE S ONO I DYES K,NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VE LINE AIR INLET (DIFFERENCE BETWEEN FEET FROM ^rr �6 PUMP ON AND OFF) OYES ONO NEAREST �`V "v SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING, or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: LENGTH NO.OF DISTR.PIPE SPACING COVER INSIDE CIA aPITS 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 FRESH BELOW PIPES ABOVE COVER ELEV.INLET ELEV.END. PIPES FEET FROM LINE AIR INLET NEAREST--► MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM 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 COVER TEXTURE PERMANENT MARKERS OBSEHVATION WELLS El YES ONO OYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES OYES ONO OYES ONO OYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH. NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVEH BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTHIBUTION PIPE MATERIAL&MARKING ELEV. ELEV.. CIA. ELEV.'. PIPES DIA.. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED OYES ONO OYES El NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING. FROM LINE 3 �.a El YES ONO OYES 0 N NEAREST LA-ql 0 B.0 g, L Sketch System on tain in county file for audit. Reverse Side. . E Zoning Adman 6tAatatL SIGNATURE TITL DILHR SBD 6710(R.01/82) f SANITARY PERMIT APPLICATION COUNTY 103 L R In accord with ILHR 83.05,Wis.Adm.Code eRo11k1 STATE SANITARY PERMIT# d —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. —See reverse side for instructions for completing this application. PETITION �y 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES L4 NO PRO ERTY OWNER ! PROPERTY LOCATION Y., S .26 Ta �j, N, R /? E ( W P O13ERy OW ER' (LING AQDRESS LOT N MBER BLOCK NFU•MBER SUBJ, VIS ON NA 6 Av1 C //� e acxp_,;� CE,,STATE ZIP C DE HONE NUMBER CITY NEAREST ROAD, KEW LANDMARK I&C fi& --f a a a ❑ " 7& c U II. TYPE OF BUILDING OR USE SERV : /w ' ow•-! ��-q&0d Number of Bedrooms if 1 or 2 FamiI OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. M 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## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in#1 and only one in##2) 1. a. NConventional 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.J4 seepage Trench c. ❑ Seepage Pit Cdr 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): `/ 7r ` � ' .106 , f t" Feet Private ❑Joint ❑ Public C CAPAITY VI. TANK Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New xisting Gallons Tanks Concrete glass App. Tanks Tanks y structed Septic Tank or Holding Tank DG�U r �K°S! e ? Lift Pump Tank/Siphon Chamber ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plu er's Name(Print): jz��nat uree:( o Stamps) MP/MPRSW No.: Business Phone Number: el 3a1r 0- Plu mber's AddYjess(Street,C' ,State, ip Co e); Na Designer: � D VIII.j0jL TEST INFORMATION Ce oil Tester 7T�ame CSTPP CST's ADDRUS(Street,C'y,Statd p Co e) Phone Number: f! IX. COUNTY/DEPARTMOWT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) Approved ❑ Owner Given Initial 812 S harge Fee � � Adverse Determination ` �v ��"`��f / y . X. COMMENTS/REASONS FOR DISAPPROVAL: J a, SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERIAIT APPLICATION ' TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly 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; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8% 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 &tO =- included the creation of surcharges (fees) for a number of regulated practices which Wisco tllt'S a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Tesuf is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. 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) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS II�DU.ST-RY, •� C DIVISION BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 537907 9 53707 (H63.090)& Chapter 145.045) LOCATION: SECTION: OWNS UNICIPALITY: LO NO.:BLK.NO.: SUBDIVIPIONNAME: Sbi /Tg E ( �-- ;' COUNTY: OWNER' Y R'S NAM MAILING ADDRESS r _ e`oix IS USE DATES OBSERVATIONS MADE NO.T": COMMERCIAL DESC�TION: PROFILE D CRIPTIDNS: ER AT TESTS: Residence CkNew ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional)E]U Ru EIS EA EIS MU I 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 D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. GH_EST TO BEDROCK F OBSERVED (SEE ABBRV.ON BACK.) /• o S 1 B- ob 97. 1 7tU 0 ,�'p,6 f,�olSh ailed ne s i %av Bn m e�S4 n B- ? '7 00 T.S 1 ,aob js� 9�o e ti e S � �o dto Ate S B- 3 7-Do 7 , e e s ` .a0'6 r,e B- �, DD 14. 5 jll.5'v /-5,;t f,5'49 bk o eg f2"' P'5 fl"ao to Ae 4 S- 'v e B- j 70o 5�,1� S'oBlr"l xea p nrhec� �e i �/,5o na�ed .� B- PERCOLATION TESTS TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PER QQ2 PERI PER INCH P- (J P- 2 D D /D 9 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 ,a � t A61VO, _ _ _' _ .___ 01-t o e :l_ � e i 1 -7 -- _ -I N E I K� i � Woo �►c1e Or, __ _ - __. ...__ I,the undersigned,hereby certify that the soil s s reported on thi g4f orm 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 gO�LE ED ON: K 8 ADDRESS: .� CERTIFIC T N MBER: PHO N MBER( tional): CST TUBE: DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER — r INSTRUCTIONS FOR COMPLETING FORM 115 - SB - 6395 To be. a complete and aecurate soil test,your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a resid ence or commercial project; 1 MAXIMUM number of bedrooms or Commercial use planned; 4. Is this a new or replacernent system; S. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TALK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT RASED ON SOIL CONDITIONS; Ps. PLEASE use the abbreviations shown here for writing protile descriptions and completing the plot(clan; 1. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used it desired; S. ?lake sure your benchmark and vertical elevation reference point are clearly shown,and are permanent; 9. Complete all appropriate boxes as to dates, names,addresses, flood plain data, percolation test exemp- tion, if appropriate; 10, If Me inforrnat:ion (such as flood plain,elevation)does riot apply, place N.A.in the appropriate box; I 1. Sign the form and place Your current:address and your certfication number; 12. Make legihie Copies and distribute as required. ALL SOIL TESTS MUST ICE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, A13 REVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st -- Stoma (fiver 10") BR — Bedrock �, cril:r - Cetar>c {.3- aC} ) SS — sandstone g; — Giav l t..�,ic4 r 3") LS — Liniestono _ Said H G W -- Hiflh Groundwater c - co i'.r;f;a=7rd Bert; P A colation Rate rlwo s LTt.tfi San{f vi — Felt r._ t -'r'e fl.�3l rltl .._ l tiltr ijty� '=S -- 1 ;➢ait��� )a11ES � — C�u .a£'r l IrilrF :,'7t Leant k3l S3 — `soft (IV — t.iray 3 Silty C,la', Loam, mot --. l't{ tt,a=s iY ) rr ir 3fl� S�ld T` ke`f — jii? fr rrt - p"'I OMI - ftlai�Y, r �.€i- no mucl, .. Six thEr eral soil i.Cx nose u'rtacFr t w"-'e'. fo, hqc i; d vt,st, disposal BM Bench ";'i:riik VI°€P V� r .Lit Ist,Prt<;i€ now,L f. ti TO THE OWNER: This coil test report is the first step in securing a sanitary per€nit. The county or the Department may request verificL&on of this soil test in the field prior to I)errnit issuance, A complete set: of plans irrr the private 5(n"v "Je systein and a permit application must he suf., iitfetl to rfw appropriate local authority in order to �rbtairr a oe'l-n.rt, The sanitary permit must be obtained and po7ted prior to the start of an construction. J STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _ & ed at-(S ROUTE/BOX NUMBER �� (% S �_t FIRE NO. CITY/STATE ecut-1_✓` f (.t 61S /Jf ZIP PROPERTY LOCATION: 540 1/9 1� 1/4, Section h , T�N, R_.z�_—W, Town of G , St. Croix County, Subdivision �� e , Lot No. . Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address APPLICATION FOR SANITARY PERMIT 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 �' L Location of property 1/9 �1/4, Section f , TR-R ,W r' Township 1,1,764 Mailing addres [J �lJll CD S Address of site U P!i` ll Subdivision name ` Lot number Previous owner of property cc Total size of parcel e 'P5 4 Date parcel was created /11/) Are all corners and lot lines iden ifiable? Yes No Is this property being developed for resale (spec house)? Yes No Volume 6l / and Page Number as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ---------------------------------------------------------7--------------------- PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed- recPA d in the Office of the County Register of Deeds as Document No. ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been ( r ded in the Office of the County Register of Deeds, as Document No. I Signature of Owner Signature of Co-Owner (If Applicable) Date f Si nature Date of Signature' ,.,,y�;y' M,C.MlIIrrCprprrp DOCUNANT NO. 17 STATE BAR OF WISCONSIN—FORM 2 .439529 eou 817 PAcE 7Ni b wAwtANTr DEED UI .R/ R rfMOAT/ Ro> > ;n wills D vel oDment . 0, * ., ST. CROIX CO., WI W; scone;n o norsltloTt `y"•` a Recd for Record conveys and warrants to Kpnnnth F np; JUL 18 1988 Q 1:15 p a n ei p /Vl huGhanri fl„a a Dt w,fe as ct v ; mar ro l tal Dp rt4, trv; or hD �pbt.►of Osed� RETURN TO the following described real estate in S t Cro; x State of Wisconsin: County, Lot Sixty (60), Oak Ridge Acres, to the Town of Troy Part of the Southwest Tax Key No. Section 36, Township 28 North Range�19tWestf Tow County, Wisconsin, more fully described as follows: Of Troy, St. Croix most Southerly corner of Lot 60 of the Plat of Oak RidgemAcres, to the in said Town of Troy, being t8e POINT OF BEGINNING, of the parceltotbe herein described; thence N 60 271E line of said 60) a distance of 168. 19' ; thenceeSr00g07'1Wt83.251 ; Chet' N 89°53'W 146.14' to the POINT OF BEGINNING, containing 0.140 acres, being subject to easements -of record. The above described parcel to be attached to Lot 60, Oak Ridge described above. dge Acres TRANspE.R This Z g not homestead property. (is) (Is not) Exception to warranties: Subject to an easement from the Cit for electrical purposes y of River Falls Dated this 6 day of Jul . Y �� , 19 $A (SEAL) V �' Ri 0 1 ,�- (SEAL) �' ($EAL) Frances � ��r AUTHENTICATION Signatures authenticated is___.�L___ day of STATE OF WI CONSIN W L E D G M E N T 19 ss. County. * C. L. Ga 10 d Personally came before me, this day of TITLE: MEMBER ST TE BAR OF WISCONSIN the above named (If not, authorized by §706.06, Wis. Stats.) This instrument was drafted by C• L. Gaylord Attorney to me known to be the person„ who executed the fore- River Falls, WI 54022 going instrument and acknowledged the same. (Signatures may be authenticated or acknowledged. Both Are not necessary.) Notary Public County, Win. My Commission is permanent. (If not, state e4piratioa ; date: . 19.._.j WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 2-1977�lY . n r Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT c� / n 'e}, [)_-es� TOWNSHIP f�0 SEC. ✓ T N-R W OWNER --, ADDRESS (? Q C S C+ ST. CROIX COUNTY, WISCONSIN tc"uer II& �jj' SUBDIVISION �a (/� `C! LOT LOT SIZE -)"-/ PLAN VIEW Distances and dimensions to meet requirements of I11iR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM o oob R t'tl 3 I A Ae 1 o � INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used &s-t Elevation of vertical reference point: /U0 . Proposed slope at site: SEPTIC TANK: Manufacturer: j�W� I frece.5 i id Capacity: 1, 606,6 0 6 Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,@ Side o Rear, O p '�U feet From nearest, propert yry�line Front,0 Side 10 Rear,0 3� feet '/ 6 T Number of feet from: well , building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE e PUMP CHAMBER r Manufacturer: '(d IJCS �/�E�QS'1Liquid Capacity: �J! Pump Model: va'U J Pump/Siphon Manufacturer: Aw Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: J.e U C. 440^ Alarm Switch Type: ' f' Number of feet from nearest property line: Front, OSide, 0 Rear, Ft. a Number of feet from well: X20 �pil�e� Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: 49 Number of Lines: / Area Built: f�d Fill depth to top of pipe: �7 I Number of feet from nearest property line: Front, Side, O Rear,0 Pt . Number of feet from well: Number of feet from building: d (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 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 Y 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 SA1,,NA,,S36,T28N-R19W XCCONVENTIONAL El ALTERNATIVE State Pa^ m I.D.Nuber Town ob Tho y ❑Holding Tank ❑In-Ground Pressure ❑Mound Lot 60 Oahhi.dge NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Kenneth. De,i6.5 60 Cu.d6 Couxct .ZP�S Raven Fa W1 54022 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: [EiTRIF PT.ELEV Name of Plumber: MP/MPRSW Na. County: San,tary Permit Number: Thomab Wang i3231 St. Ctoix SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY'. TANK INLET ELEV.: TANK OUTLET ELEV.. LOCKING COVER PROVIDED PROVIDED ai I 1 , IWARNINGLABEL [&YES ONO I DYES &NO BEDDING. VENT DIA.. VENT MATL.'. HIGH WA ER NUMBER OF ROAD: PROPERTY WELL. BUILDING VENT TO FRESH ALARM. FEET FROM LIN � AIR INLET ❑YES NO 11 �+� DYES E1 NO NEAREST I5o _ DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER G� PROVIDED PROVIDED. Q� tv ,Q. EYES ONO EYES ❑NO EYES KNO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: =NUMBE:ROF PROPERTY WELL BUILDING V NT TO FRESH (DIFFERENCE BETWEEN M LINNEE r AIR INLET PUMP ON AND OFF) ❑YES ❑NO �V 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 MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES DISTR.PIPE SPACING COVER ATERIAL: INSIDE CIA -PITS LIQUID PIT DEPTH DIMENSIONS V L DEPTH FILL DEPTH UISTH.PIPf DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER. ELEV.INLET ELEV.END: PIPES FEET FROM LINE AIR INLET NEAREST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM 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 1:1 NO OIL OVER TEXTURE PERMANENT MARKERS OBSEH VATI(7N WELLS OYES ONO OYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDEU MULCHED CENTER EDGES. El YES ONO 1E]YES ❑NO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH'. LENGTH. NO.OF LATERAL SPACING (TRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD Pump MANIFOLD DISTR.PIPE IMANIFOLDMATERIAL jPI0 DISTR DISTR PIPE UISTHIBUTION PIPE MATE HIAL&MAHKIN(i ELEV. ELEV.. DIA.. ELEV.. IPES DIA.'. ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS CAL LIFT CORRESPONDS TO APPROVED DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF E PROPERTY WELL: BUILDING'. (� FEET FROM LIN : 3 �.a El YES 1:1 NO 1OYES ❑NO NEAREST 1LAA g do 0 Sketch System on tain in county file for audit. Reverse Side. SIGNATURE. TITLE. Zoning Admi,niztcaton � DILHR SBD 6710(R.01/82) i SANITARY PERMIT APPLICATION COUNTY Q :710 In accord with ILHR 83.05,Wis.Adm.Code e/v olX STATE SANITARY PERMIT# //;? -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. -See reverse side for instructions for completing this application. PETITION I. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES Lr.S%�No PRO ERTY OWNER PROPERTY LOCATION SS Y. '/a,S ,Tog TdS, N, R /y E( W P O ER�1'OW ER' (LING AQDRESS LOT N MBER BLOCK SUB111VIS ON NA �1v, p C C//y CE STATE ZIP C DE ONE NUMBER O CITY NEAREST OAD, AKE/�LANDMARK a a a _ _ r iV/�c II. TYPE OF BUILDING OR USE SERV QC{,Q—! P�-g0'dd Number of Bedrooms if 1 or 2 Famil OR ❑ Public(Specify). 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.#: Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in##1 and only one in#2) 1. a. Conventional b. ❑Alternative c. ❑Experimental 2. a. ❑System- b.-❑ Holding c.❑ Pit Privy d.❑ Vault Privy e. ❑ Mound f. ❑ 1 G In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. See a e Bed b.RSeepaue Trench o, ❑seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Sq�are Feet): `� D �C � f� 9<, Feet: Private ©Joint El Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New istin Gallons Tanks Concrete structed glass App. Tanks Tanks y Septic Tank or Holding Tank �U 0", q? Lift Pump Tank/Siphon Chamber LJ I EDRE�FOLFTTT E1 VII. RESPONSIBILITY STATEMENT 1,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plu er's Name(Print)i PI is Signature:( o Stamps) MP/MPRSW No.: Business Phone Number: 4- 1�1' Plumber's Addfjess(Street,C' ,State, ip Co e); � � Na Designer:4 _4 Vlll. O L TEST INFORMATION Ce it Tester(C T ame CSTP20 CST's ADDRUS(Street,CV y,Stat Zip C e) Phone Number: IAJ fag IX. COUNTY/DEPARTMPNT USE ONLY 1HOwner Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) A roved & CJ S harge Fee pp Given Initial / "i-ox� Adverse Determination 70 X. COMMENTS/REASONS FOR DISAPP OVAL r- a.�.y SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDU.ST•RY, '• C DIVISION LABOR AND PERCOLATION TESTS (115) MADISON 5 W 3707 HUMAN RELATIONS (W63.09(1)&Chapter 145.045) LOCATION: SECTION: WN UNICIPALITY: LO NO.:BLK.NO.: SURDION NAME: SI�1 '/ J/ 3 /Tg E COUNTY: OWNER-2 QXER'S MAILIN AMgjs �r 60 USE DATES OBSERVATIONS MADE NO.BEDRMS : COMMERCIAL ES RIPTION: R S: A ESTS: Residence 3 DiNew ❑Replace �r 7 RATING:S-Site suitable for system U=Site unsuitable for system r ONVENTI NAL: MOUND: IN-GROUN ESSUR- :S STEM-I -FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) ©S EJU [IS ®U EIS E111 EIS ©U I OS MU I Gan t/, If Percolation Tests are NOT required DESIGN RATE: I 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 GROUP DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B- �00 97. A1D � : �,00 /,s' �! ,! o,OC4 m ed-Ox esi %vBhn,4s, B- 7,00 �', .evbls�, I.dotAiked Ate S • Yo d� S B- 3 7.oo q? ,�'o B!s;l �oBr� s • •av dS e c�S v' B- �( 7. 00 5'o64t ne 4e'5 ' sV0 v0 4 P ot eJ Pai cq B- PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERtOD 2 PERIOD 3 PER INCH P- / V D P- D D /D J 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 Q 1 pt-.( I c i I P3 yS �N1N1 �I �d > Woo gage Or. I,the undersigned,hereby certify that the soil s s reported on thi orm 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 CfO n LE EQD�ON:13 X x Y 000 A RESS:D - 1, CERTIFIC N MBER: PHO��NJ,11�B R� tional): CST TUBE: �'/J`� /may/ DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R.02/82) —OVER— a 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 �' l° Location of property 1/9 /9, Section , T N-Rz!�—w r-� Township 14 / I Mailing addres �[_I/� Address of site P(0 Subdivision name Lot number Previous owner of property CQ Total size of parcel fi �5' 4 Date parcel was created Are all corners and lot lines iden ifiable? Yes No Is this property being developed for resale (spec house)? Yes _�N0 Volume 6l'and Page Number as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ---------------------------------------------------------7--------------------- PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty dee ec d in the Office of the County Register of Deeds as Document No. —� . ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been g} red d;d in the Office of the County Register of Deeds, as Document No. s S d Signature of Owner Signature of Co-Owner (If Applicable) 7 &i Date f SYgnature Date of Signature o �A s (Z-,t �w w 3� 70� R 15 Ld `n �vl cove�e� w�tyr t *Ile K n i K s. �.B•1.