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HomeMy WebLinkAbout020-1161-10-000 \ ¥ 2 \ D \ 7 ~ 0 � 0 � & o o \ k 0 } t3 ~ � � ¥ i Cl. ! 7 ƒ / % ( ( ® � � } Q } ] }_ M )_ ® C / \ 2 7 @ 7 2 # $ k z § z ; \ 2 \ \ _ [ i a m § z + 2 c S { E E § \ , 2 _ \ 7 Z) \ / § ° # 2 ° ƒ ` / \ � m \ ) \ � � z ) z z ) z � � t � f — — k 2 E ) � R ~ c 2 ) \ b ) Q) 2 � \ � 0 m m § k \ % { j \ ° 2 k k k k ® ® ) G -� t X 2 2 2 . / 2 2 2 I }S 0 co 00 v } §z ) \ e ) \ / 6 ) E a = ° ! ] / I ° E o \ \ f / . \ . \ k 4 z / / k J ƒ / ) LO 2 § % \ a o ) = k CN _ 6 # m ) \ j 8 / a � E S / J § \ / / [ ) § \ ) / / 0 @ \ \ § % ; \ 'D k \ \ , a • § C. o $ 2 5 § g a e « § { § 2 ' o = o z R z o o z _ z e m « ¥ z k • Q m § k Ll " a a » - » . a k k ) o k ) . 3 k 3 . ; TM NT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS HUMAN R LATIONS PRIVATE SEWAGE SYSTEMS DIVISION '969 BUREAU OF PLUMBING N1 53707 1TE `�If S16,T 9N—R19W X31 CONVENTIONAL El ALTERNATIVE State Plan I.D.Number Town of Hudso ❑Holding Tank ❑ In-Ground Pressure ❑Mound (If assigned) Lot 27 Northl ne Station II NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTIO DATE: Bruce Gabra ski 515 Hunter Hill Road Unit 2, Hudson, WI 4016 ID _a3-$7 U� 'C� BENCH MARK(Permanent ref rence point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.-. Name of Plumber: MP/MPRSW No.. County'. Sanitary Permit Number: Dennis Satt r 6387 St. Croix 99099 R��JaC_e`t �` SEPTIC TANK/HOLD NG TANK: MANUFACTURER: LIQUID JAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER P O DED: PROVIDED. 0 0 YES ONO ❑YES NO BEDDING: V NT DIA.: VENT MyT L./ �.11111ATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH C 1/ ALARM. FEET FRID . LINE I ^ AIR INLET: DYES NO ❑YES O NEAREST S DOSING CAMBER: MANUFACTURER. 1111 DOING'. LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: YES ❑NO OYES ONO I ❑YES ONO GALLONS PER CYC E: PUMP AND CONTROLS OPERATIONAL NUMBER'OF PROPERTY WELL BUILDING IVENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET PUMP ON AND OFF) OYES ❑NO NEAREST SOIL ABSORPTIONS STEM.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 CISTR.PIPE SPACING: COVER =INSIDE DIA.. #PITS'. LIQUID BECK/TRENCH, TRENCHES MATERIAL: DEPTH t?IMENSIONS '', � V GRAVEL DEPTH FI L EPTH DISTR.PIP DISTR.PIPE DISTR.PIPE MATERIAL'. NO.DISTR NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES A VE COVER. ELEV.INL T ELEV.END'. PIPES. FEET FROM LINE: .� AIR INLET: NEAREST----- --r MOUND SYSTEM: Mound site plow ad 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 ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURI PERMANENT MARKERS: OBSERVATION WELLS. OYES ONO OYES 1:1 NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL: SODDED SEEDED. MULCHED. CENTER. EDGES. DYES 1:1 NO 1:1 YES 0 N 1:1 YES 0 N PRESSURIZED DISTRIBUTION SYSTEM: °-BELiTRhNCH WI TH. LENGTH: LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER TRENCHES: : I MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING 61lEVATIOAI AN,D : E EV.'. ELEV.. CIA.'. ELEV.'. PIPES. DIA.: [01NFT0=UTt0N ITN H LE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS: OYES F-1 NO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF, PROPERTY WELL: BUILDING: FEE'S FROM LINE: C� DYES 1:1 NO OYES 1:1 NO NAFiEST` , 5 Sketch System on �J'�t Retain in coun file for audit. Reverse Side. SIGNATURE: TITLE: Zoning Administrator inistrator DILHR SBD 6710(R. 1/82) INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY, PERMIT, APPLICATION ' TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly 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; Il. 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; Ill. 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 oniy,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; Vill. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/2 X 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tarks; 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 elevaticn 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 atsorption system if required by the county; E soil test data on a 115 form. GROtlND'1 ATEF SURCHARGE 3E On May �i iG+,! ir. ` '� `,^ � ' } A ) t' 0W' '`'iSIB' Cr ,3 rr . 8 '.r at..:e reSUlt W C d ' Cd. j. q? 'E' L i Q�L R SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05,Wis.Adm.Code V / • ���� x STATE SANITARY PERMIT# /Da ? q –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 ir size. -See reverse side for instructions for completing this application. rF TITION �y I. APPLICANT IN ORMATION-PLEASE PRINT ALL INFORMATION. R VARIANCE OYES tJSI No PROPERTY OWNER PROPERTY LOCATION '/a '/4, S TaL 7 , N, R '(or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME r s� r- CITY,STATE ZIP CODE PHONE NUMBER CITY i4g7- 004 NEAREST ROAD,LAKE OR LANDMARK O VILLAGE: .� 11. TYPE OF BUILI IING OR USE SERVED: Number of Bedro ms if 1 or 2 Family -3 OR ❑ Public(Specify): III. PURPOSE OF PPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. JZ New b.❑ Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an Ful System System Septic Tank Only an Existing System Existing System 2. A San ita ry Permit was previously issued. Permit## %9619,9, Date Issued 91?S_8 3. An Exis ing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The Sys tern is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYS EM: (Check only one in##1 and only one in#2) 1. a. Conventional b. ❑Alternative c. ❑ Experimental 2. a. ❑Syste - b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION YYTEM INFORMATION: (Check one) 1. a. R Seep ige Bed b. ❑Seepage Trench c. ❑Seepage Pit 2. PERCOLATIOIN RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per nch): REQUIRED(Square Feet): PROPOSED(Square Feet): Feet Private El Joint ❑ Public VI. TANK CAPACITY Site in al Ions Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic A Tanks Tanks structed pp' Septic Tank or Holding ank p Lift Pump Tank/Siphon hamber 4T---H- VII. RESPONSIBIL TY STATEMENT 1,the undersigned,a 3sume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print) Plumber's Signature:(No Stamps) TgPJMPRSW No.: Business Phone Number: 40vc 1P-41'6 Ft Plumber's Address(Str et,City,State,Zip Code): Name of Designer: .� Vlll. SOIL TEST INFORMATION Certified Soil Tester(C T)Name CST# 40 CST's ADDRESS(Stree City,State,Zip Code) Phone Number: A • „� �.3' a -,P0131 IX. COUNTY/DEP RTMENT USE ONLY pp�� ❑ Di approved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Ill A roved (, urcharge Fee pp ❑ O ner Given Initial D S 00 13_,a r��� A erse Determination �t f. X. COMMENTS/R SONS FOR DISAPPROVAL: X16/, cwlvatl 6d -tAofy" C�• A&/S&I SBD-6398(formerly Plb-6 )(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber S _. Satter Plumbs, o x � ft Pump Repair DENNIS SATTER �i Route 2 Box 405A Elk Mound, Wis. 54739 (715)879-5081 MP 6387 f� oa P) •� Rangy � yyt` C� � G'• s� c)5e,, , '0r S UN. Iro 6,4o oe, r P III t \ , y D� _...._.., INFORMATION & INSTRUCTIO4S FOR COMPLETING A SANITARY PERMIT APPLICATION k s 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. Ali revisions to this permit must be approved by the permit issuing authority. A_new permit may be needed T"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. Change's in ownership or plurnber_requires &$anitary Permit Transfer/Renewal Form`(SB6 6399)to be'`' submitted to the county prior to- installation; j 5. Private sewage systems must be properly maintained.The septic tank(s) should-be`pumped•by a licensed." ^F- 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: 1. 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; 111. 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 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plats, 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 sys'ems; replacement system areas; and the location of the building served; B) horizontal and vertical elevatio-) reference points; C) complete specifications for pumps and controls; close volume; elevation differences; fT iction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil abscrption system if required by the county, E) soil test data on a 115 form. ca4 €Jtlf.WATE= SURCH RGF -On May 4. 1"4 Mrvii consir Ac, W was sig. d into ipw .fri comrTionl) L ii t4 ate :--rote tiJn 1a4v Th 'Nq E rP,Slllt of Cv@ di, .� �.tl c�y �ti .. •i.i� ii t•iU UUi,r i�l.Ja[C ter �._._ inciude,l- i,. _ .. .. ,.,. y'_.. . ,UB- TSy:.._ _ _... .n' .�. •1i 'w irn _ n car, t gtc�u A;3', a iS Us("d system thr 4 �.i:'-,... 11 sds(Z.t);/t36) SANITARY PERMIT APPLICATION COUNTY n IL HR In accord with ILHR 83.05,Wis.Adm.Code , l.,RDI STATE SANITARY PERMIT# 4v9,? —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 ir size. —See reverse s1dE for instructions for completing this application. PETITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES RNO PROPERTY OWNER PROPERTY LOCATION ' Aje, %4 '/4, S 4 Ta , N, R / E (or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME Gtr/. I _AjpA-rM A 44,L S r,4 N-yj 2V STATE ZIP CODE PHONE NUMBER Lj CIT £/Q�j- • ?' NEAREST ROAD,LAKE OR LANDMARK D ❑ VILLAGE 11. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family 3 OR ❑ Public(Specify): III. PURPOSE OF PPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a.,I=V-w 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 Exis ing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The Sys tem is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYS EM: (Check only one in##1 and only one in#2) 1. a. Conventional! b. ❑Alternative a ❑ Experimental 2. a. ❑Syste - b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e.❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTIONISYSTEM INFORMATION: (Check one) 1. a.X See a Bed b. ❑seepage Trench c. ❑See a e Pit 2. PERCOLATIOt I RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per nch): REQUIRED(Square Feet): PROPOSED(Square Feet): / Feet ICI Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total #of Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New Manufacturer's Name xisting Gallons Tanks Concrete stCon- glass App. Tanks Tanks Septic Tank jr Holding nk QOD 1 El Lift Pump Tank/Si hon Chamber El VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print: Plumber's Signature:(No Stamps) P MPRSW No.: Business Phone Number: d / Plumber's Address(St et,City,State,Zip Code): Name of Designer: VIII. SOIL TEST IN ORMATION Certified Soil Tester(C T)Name CST# y CST's ADDRESS(Stye ,City,State,Zip Code) Phone Number: 4?,F'CdtN IX. COUNTYIDEPA RTMENT USE ONLY ❑ D 3approved itary Permit Fee Groundwater Date Issuing gent Signature(No Stamps) Approved ❑ O ner Given Initial V Sur hargeeFee per, y/ A verse Determination V co VWtt r� a < X. COMMENTS/R ASONS FOR DISAPPROVAL: Pia, f epaw b y P"ar y J ae P\)(-;P\)(-;r ns SBD-6398(formerly Plb 7)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber a i P I' �f `i Q Y'bS IZ Cl- k _ t .. *i eye ° y, 1 I DEPARTNIENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O.�,�ADl W BOX HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LO ATI S ON: -TOWNSHIP/MU ICIPALITY: LOT NO.:BLK.NO.: SUB IVISION NAME — d'/ AWN[ / N/R E (o E ,L. 1 /~ OUNTY: R'S7BUY R'S NA E: MAILING ADDR SS: // / > ' T /` �•' USE DATES OBSERVATIONS MADE BEDR COMM R A DESCRIPTION: PROFILE N A TESTS: -J Residence New ❑Replace RATING:S=Site suitable or system U-Site unsuitable for system MIS VENTIONAL: MOU D: ''II JIN-GROUND-PRESSURE:�` SYSTEM-IN-FILL HOLDI(N'G TANK:RECOMMENDED SYSTEM:(optional) �� S �U d DU D J J ®U ' If Percolation Tests are NOT requir DITE If any portion of the tested area is in the under s.H63.09(5)(b),Ind cats: Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL -DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH M. ELE ATION OBSERVED ES IGH TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) AIL B- /< T / B- B• B• PERCOLATION TESTS RD W TER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES AF ERSWELLING INTERVAL-MIN. p 1 D IOD PER INCH > PLOT PLAN: Show locations of percolation tests, soil borings and the ftimensions 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 plo an. Shgw the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION_ i - I • I,the undersigned,hereby certify that the s it 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 rec ded and the location of the tests are correct to the best of my knowledge and belief. NAME(p in TESTS WERE COMPLETED ON: ADDR S : �. CERTI ICATIO NUMBER: PHONE NUMBER(optional): CST S ORE: DISTRIBUTION:Origin and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 JR.02 82) -OVER - q o' O 40 so 5 ►)• \ ' S p°21 381E 11 1 ro Go i V �` W 38 � tia` m, tT A, ti to s o 0 o \ ? \ G r^ \ S S9,, 2 2 cv X91- N \ O O 0`\ \ \ s �o� \ \ \ \ �2�19 \ \ `tO, �2f9 /\ . 4ti cn rn rn N � .m x x \ \ cn cn \ f• v - O z z nr \, � z n 6) `.. �' 's�� �t� u► ti a -., o \ CV LO rri N A rn 'a �'1 .t oo X m Lo C) r z mo =m rnD \ \ � C < o � n rn<� � -{ \ r„ ru�ro ry r a N -n p _0 (Atn (n m �O Tjo, a�i t�v� 0 -1 MOO 000 \ m r rn n C U, G: ,. —S 2 2 •LIB'�lr:�` � � � - `_ -rIV,(n � � • I APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in. full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Shouli this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is gold and submitted to this office with the appropriate deed recording. Owner of Propert _ VkcL L;,^,�g �a� I/ct Location of Property _� S h:, Section , T 29 N-R ) 9 W Township Ca �- "Pa v �- 9 Mailing Address 51 S her? 1`] R8 �w "-} Z Lk.,) Address of Site Subdivision Lot dumber 2__7 Previous Amer of Property �a+1.4( � L a V LL-�,�5 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 VI/ No Volume and Page Number '�40 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warrantq Deed which includes a Document number, volume and paEe number, and the Seal of the Re ster of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to s Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I We) co- ti.6y 4 hat att statementz on this onm ane tAue to the best 06 my (oun) hnowtedge; that I (we) am Jane) .the e e 0wn('sl 06 the pnopehty duc&i.bed in th.ia .in40fima.ti.on 6olmi, by vi)ttue 06 a waAAanty deed neconded in the 066.ice 06 the coiutty Regusten o6 Deedh ass Document No, 42_4 0 ; and that i (We) pne�sentty aun tJwe pROpode btite 6oh the aewa, di�1p06 dyes em (on I (we) have obtained an eahement, to Aun with the above deachibed pnopenty, bon the con.6tAuction 06 said system, and ,the dame hag been duty neconded .tn the 066ice o6 the County Regi6ten o6 Deeds, ae Do No. ) . l�A/�t tc ...�✓L� SIGNA Op OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) 7 !�r-7 DATE SIGNED DATE SIGNED ��T 7 F. f } _ ry sm V to Imo+» 1 M BA-- .......«... •«._. sS Y (27) of #Qrthiine 8tsti. . .n !s e T;ra 4 6Sry� �^e 6 A� * } 4..a. Y.... ...... ........ r r Aoi/l1w ` N , .. 'I �•�M� � •kkR - �� ..«... ._..... E H . z y ' a ST C - 105 r s r . f a ` y SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d IJ a OWNER/BUYER ���reN A.davess ,r�s �t 1. �- Z, Fire Number ROUTE/ OX NUMB •I� �h: CITY/S ATE ✓l L4_J: ZIP 54 of PROPER rY LOCATION : �4, 14, Section T 25 N , R I W, Town of L' So V, St . Croix County , Subdivision 0oy4k `,hc �Lot number 2--7 Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists Df pumping out the septic tank every three years or sooner , if nee ed , by a licensed septic tank pumper . What you put into the sy tem can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St . Cr ix. County residents may be eligible to receive a grant for a maxi um 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. H 0 E I/WE, the undersigned , have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth , herein , as set by the Wisconsin Depart- �d ment 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 /Jf \ 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 . as or Legal Description 1 ■ Fri 77 TTM KAM ME 111110 1 10 q-, Wo PR • �_ '�, ` • t �.1� .�-�.•-_ .•.�L.'I .I ai .� .:_ate �►' ��i� / �, � � iL....ti ;L..� � / ,� r■�■ ■ � ■� Vii .. . � ■ ■■ ■■■ ■■: ■■ . . �. PI, ■ ~ . . INSTRUCTIONS FOR COMPLETING FORM 11G - SBD -63B5 , To be a complete and accurate soil test,your report Must include: 1 complete legal� i must clearly indiva�whether this is residence or vommo��| project; 2� The �e�� cmm 3. MAXIMUM number of bedrooms or commercial use planned; 4 is this u new o, mp|aoomentsy�em; 5' Comp|etethvSuitabiii,vmdnuboxoo. AS|TE |SSUiTABLEF0RAHDLD|NGTANK0NLY |FALL OTHER SYSTEMS ARE RULED OUT BASED Og SOIL CONDITIONS; 9 PLEASE use the abbreviations shown here for writing n,"0o descriptions and completing the plot plan; 7 MAKE /\ LEGIBLE diagram aoou,at,|v locating your test locations. Drawing to oco|o is preferred. A separate sheet.mwv be u,^d if desired; 8 Make and "v,�ioa| n|ovnhun reference point are r|eadvoho",n'and am permanent; � 9� Complete all appropriate boxes as to dates, names,o dd,e addresses,flood plain data, percolation teat exemp- tion, if appropriate;10, if the information (such a, flood plain,m| "v minn)do/snc*app|v' p|uonN.A,in the npp,op,ietobox; 11 �Qn�hokvmmndp|mwyou, �u,mntadd,asandvou, 00�ifiomionnumby; � ALL SOIL TESTS UST BE FILED WITH THE 12. Make legible copies and distribute as required. K8 LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols ,t - Stone (over 10^) BR - Bedrock nob - Cobble (3 lO'') SS - Sandstone u, - Gravel (under 3^) LS - Limestone ` °, - Sand HGVV - High Groundwater o» - Coarse Sand Pero - Percolation Rote med , - Medium Sand VV - Well fs - Fine Sand 8|do - Building Is - Loamy Sand > - Greater Than °d - 8undv Loam Than ( - Less an ° n Bn B,uv, | - Loam - °,i| - 8i|tLoam 8\ - Black si - Silt Gv - Gmv °c| - Clay Loam Y - Yn!|mm sd - Sandy Clay Loam R - Rod sic| - Silty Clay Loam mot Mottles sc - sandy C|vv vv/ - with fff few,fin: faint sic — Silty Clay — ' ' ° cc nommon coarse c - Clay - ' cx - Peat mm - Many, medium m - Muck 6 - distinct n - prominent - - HVVL - High water level, ° Six general soil mxto,a, surface water � for liquid waste,disposal BM - Bench Mark � VRP - Va,hoa| Rvfn,rnmo Point TO THE OWNER: This soil test report is the first step ill securing a sarli W�rrnit. The county or-Ole Departmcnt may re(JUeSt verification of this soil test ill ttie I S' -nplete Set of Plans for the private sewage syslern and a Per'-nit aPPlic-MiOrl MUSt tie SLAbrilitted I to,the applopriate local aull'Ofily in order to to the start of any conWriction. � . ~ \ ` � ' DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDIN INDUSTRY, DIVISIb LABOR AND ''ffitJ11i4AN RE1AT ONS \ /PERCOLATION TESTS (115) P.O. BOX 79(H63.090)&Chapter 145.045) MADISON,WI 537 LOCATION: SECTION: r TOZNS$lP-IP/MUN il ALITY: OTNO.:BLK. SU DIVISI NNAME: COUNTY: O NER'S BUYER'S NAME: MAILIN ADDRESS: } USE 5 �- NO.BEDRMS,: COMMER IAL DESCRIPTION: DATES OBSERVATIONS MADE Residence [ New ❑Replace PROFILE D S R PTIONS: R LA ION TESTS: RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND PRESSURE:SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTE :(optional) ©S0 U ®SOU SDU OS ®U OS CU l � Eundder lation Tests re NOT require DESIG RATE: �} If any portion of the tested area is in the ,H63.09(5)( ),indicate: �/ Floodplain,indicate Floodplain elevation: � PROFILE DESCRIPTIONS 11 BORING TOTAL 6A �� / NUMBER DEPTH pg. ELEVATION PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH OBSERVED EST. I HEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.► 3 _ f •� B- 7.;, /'Ia B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES NUMBER AFTERSWELLING INTERVAL-MIN. RATE MINUTES PERIOD 1 PERIOD p R PER INCH P / � ` 3 P- P P_ PLOT PLAN: Show lo ations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical ele ation reference points and show their location on the plot plan h of land slope. he surface elevation at all borings and the direction and percent / SYSTEM ELEVATION Ap j �m L a ; i i � 3 E . .. ___: . " ._ l z � JY I a(( I,the undersigned, her4 y certify that the oil tests repor this forrri" Y i accord with the procedures a ho specified in Wisconsin Administrative Code,an that the data reG6rded and the to i the tes orrec best of my knowledge and be ef. 1yt�VS:e. NAME(print) TESTS WERE CO PLETED ON: t ADD S: - CERTIFIC TION NUMBER: PHONE NUMBER(optional): CST-91 N DISTRIBUTION:Origina and one copy to Local Authority,Property Owner and Soil Tester. 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