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HomeMy WebLinkAbout030-2027-40-000 �' O O O N OO• N ti 0 6 0 m M O O �O O Y �C cz N O.O V N N C v; N 3 N >'N y N N o N N N a W. N N 2)-S C O C f6 O(p C O p >' Zt •O O 0).2 a O N i •a C p :1 10 w U (6 f6 COL U N N aCC (mo oL •d Z _ O C A z p C c y O N D LL Y LL N N p �CO _ C YO N X 2 O N U 3 a co �_ E Q co m°r°.0 Q 1L E U N a N O N > � y >O M E •• O N o =o E o z � v` " v 0 o a m a m N H C7 I O O Z C U - s m Y O O • d'd Z O m c Z N H C N E C N 01 7 ml 7 C N N CL •� m = O 0 a)1 o ' O @ O Z m Z Z m Z N z 0 N ��V E N I y L N N W a R N ;a U d N N A H U a) 0 0 a d N ai c O D d > m 1� a) E (A fA frA _9 (� N (r� y U� a = o 3 a z o z •►rJ ' a a a O a m m u m m o N ! 0 0o 0o U) o w 00 O Cl) J U o) o)_ O _ M o) Z >- p= O D O (o o p o o d p� .a m � C 'O m N CO m Q in m m Q in o ° 3 �_ w e ° H c E C14 co O a N w a oo C, 0 v O N O CD Q O m • 'w~Q iii O O a)O N (n � U C N O O p p W N O O _ N M CD O O N C Z 10 N U) 0) O Z O Z U O E E v 0 � a 1 a � a a L: a �`wN y E E '3 c ? 3 w o _1 A u(L2 IOincv Om V Parcel #: 030-2027-40-000 02/25/2005 08:31 PAGE10F I Alt.Parcel#: 22.30.20.439G 030-TOWN OF SAINT JOSEPH 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 *WOOD,ALVIE&CRYSTAL ALVIE&CRYSTAL WOOD 1440 TRIANGLE DR HOULTON WI 54082 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description * 1440 TRIANGLE DR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE SEC 22 T30N R20W PRT GL 3 S 127 FT OF N Block/Condo Bldg: 508 FT OF E 340 FT Tract(s): (Sec-Twn-Rng 401/4 1601/4) 22-30N-20W Notes: Parcel History: Date Doc# Vol/Page Type 2004 SUMMARY Bill#: Fair Market Value: Assessed with: 5929 101,000 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 50,000 49,400 99,400 NO Totals for 2004: General Property 1.000 50,000 49,400 99,400 Woodland 0.000 0 0 Totals for 2003: General Property 1.000 28,200 43,300 71,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch#: 112 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 PUMP CHAMBER �` 3 Manufacture iquid Capacity: Pump Model: Pump/Sipho Manufacturer: P p Size Elevation o inlet: /Bottom of tank elevation: Pump off s i ch elevation: Gallons per cycle: t Alarm Manu a turer: Alarm Switch Type: Number of ee from nearest prop rty line: Front, O Sid , O ear,0 Ft.� Number of feet rom well: e N mber of feet fro building: (In lude distances on plo plan). SOIL ABSORPT N SYST M Bed: Trench Width: Lengt Number of Li es: rea Built: Fill d pth to to of pipe: Number of feet fr m nearest property line: Fro O Side, Rear,0 Ft . umber o feet from well: Numb r of fe t from building: Include dist nces o plot plan). SEEPAGE P Size Numb r of pits: Diameter: Liq 'd depth: Bottom of seepag pit elevation: Are Built: Has eith r a drop box O o distribution box been used on any of t e above soil absorbti sytems? (Chec e) . HOLDING ANK Man facturer: Capacity: Num er of rings us d: Ele ation of bottom of tank: Elevation of inle C Nu ber of feet fro nearest pro line: Front, O Side, Rear, O Ft. 3_ —T � Q►e�� du..,�-w.; .;tic. � �— Number of feet from well: l/ N er of feet from building: Number of feet from nearest road: 44 sr— Alarm Manufacturer: Inspector: Dated: Plumber on job: ..�-nom License Number: 3/84:mj MEW K Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /� !iJ j 15 TOWNSHIP �-OSgA..� SEC. ;7, T SON-R-c_p W ADDRESS I' ���px B�S''S ST. CROIX COUNTY, WISCONSIN Woo i 1 b,y 3 .� �.tJ�'1'< i<+.�i\..� •.'!r ..7 !�A.�...<.. .k..i', �,�--iR. �.,rrYt 7 � V 11v III �y fp 4 BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,Q Rear, O feet From nearest property line Front,0 Side,O O Rear, feet Number of feet from: well building: (Include this information of the above plot plan) ( 2 reference dimensions to septic .tank) SEE REVERSE SIDE. DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS P.O.ElOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON,W053707 BUREAU OF PLUMBING SE' ,Sw4,S22,t30N–R20W MCONVENTIONAL Repair ❑ALTERNATIVE State Plan I.D.Numberc Town of St. Joseph El Holding Tank ❑ In-Ground Pressure El Mound (1f assigned) HWY. 35 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION E: I Alvie Wood Route 1, Box 298, St. Joseph, WI 54082 �! — $-7 2.'d U BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.: Name of Plumber: MP/MPR SW No County Sanitary Per mrt Number: Henry Nechville 3258 St. Croix 95991 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ❑NO DYES ❑NO BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER ROAD: PROPERTY WELL: IBUI LDING VENT TO FRESH ALARM: FEET , LINE: I AIR INLET: OYES ❑NO ❑YES ONO INEiREST DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: OYES ONO DYES ❑NO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBEROF PROPERTY WELL. BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET. PUMP ON AND OFF) ❑YES ONO NEAREST' SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIDE CIA.- #PITS. LIQUID TRENCHES: MATERIAL: PI DEPTH: IAINS ,? GRAVEL DEPTH FILL DEPTH IS PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR. MBER,OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES. ABOVE COVER. ELEV.INLET.ELEV.END. PIPES. FROND -.LINE: AIR INLET: EST MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM 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 ITEXTURE PERMANENT MARKERS JOBSERVATION WELLS. DYES ONO OYES ONO LENTE:R TH R TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED. EDGES: OYES 1:1 NO 1:1 YES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: °I.WIDTH. LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: +lt TRENCHES: MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. JDISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING. E LE V.. ELEV.: DIA.: ELEV.. PIPES: DIA.: V STN 6if HOLE SIZE HOLE SPACING: DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. Xo ❑YES 1:1 NO ❑YES 1:1 NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: " PROPERTY I 7LLBUILDING: LINE: ❑YES 1:1 NO OYES 1:1 NO i11A >f` Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE: DILHR SBD 6710(R.01/82) Zoning Administrator L 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 tq-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. Prcaerty 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. Cheek 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'h x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimerisions, 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 &t8r included the creation of surcharges (fees) for a number of regulated practices which Wisco iws can effect groundwater. The surcharge took effect on July 1, 1984- All of the water that buried reasur.e. 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) E��— S ANITARY PERMIT APPLICATION COUNTY DILHR In accord with ILHR 83.05,Wis.Adm.Code G: ST 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 NO PROPERTY OWNER PROPERTY LOCATION //1 �d✓O -'4 N-.5 co '/4, S � T , N, R E(or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME C STATE ZIP CODE PHONE NUMBER Q CITY NEAREST ROAD,LAKE OR LANDMARK ��OS� ❑ LLAGE II. T PE OF B ILDING OR USE SERVED: cRO — U Number of Bedrooms if 1 or 2 Family 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.211 epair 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 O�TEM: (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. ❑ IGP In-Fill Tank V. ABSORPTIOWSYSTEM INFORMATION: (Check one) 1. a. ee a e Bed b. ❑seepage Trench c. ❑seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: rY es per inch): REQUIREDre Feet): PROPOSED( q re Feet): Feet Private ❑Joint ❑ Public Vl. TANK CAPACITY Site in ga ons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tank T nk structed Septic Tank or Holding Tank 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. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: /xx /^ �c i,LLB 3�- s- 3 3--2 Plumber's Aefdress(Street,City,State,Zip Code): Name of Designer: Vlll. SOIL TEST INFORMATION Certified o I ster(CST)Name CST## CST's ADD E /(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Approved F-1 owner Given Initial c rc`h�ar�ge Fee Adverse Determination ' ' `1� i1J 71�7' X. C MENTS/REASONS FOR DISAPPROVAL: (1►P[.�.�cl ® mss �? - �Je is SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber 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 I/ Location of Property ' of ' , Section ��2 , T 3 O N-R O W Township Mailing Address r -a© Address of Site n Subdivision Name Lot Number Previous Ownerof Property 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 All No Volume 3 and Page Number YZLfffOas recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and pa&e number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as; to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) cex;ti.by that att statements on thi.6 6onm cute ttcue to the best ob my (oun) knowtedge; that 1 (we) am (ate) the owner(,$) o6 the pnopen ty da n i.bed in th us inbonmati,on jotm, by viAtue o6 a wa�rnanty deed %eco&ded in the 04jice of the County Regi.6ten o4 Deeds as Document No. s7 — ; and that I (We) ptuenfity own the proposed site bon the sewage dispozat zys em (on I (we) have obtained an easement, to nun with the above ducA bed pnopehty, bon the connstlruWon o6 said .system, and the ,same hays been duty recorded in the 044ice ob the County Register o6 Deeds, as Document No. ) . SIGN URE OF. OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED Warranty Deed Miller-Davis Co.,Minneapolis Individual to joint Tenants Form No. 5-M Minnesota Uniform Conveyancing Blanks-(1931) Made this...............171h...............day of........N.WAM Pr.............................. 19..... 5, between,........qidnf�X..N .. and Linnea E. _Johnson. husband and wif ..........................I............1:....... ...............I......I.................................................!�.I.............................................. of the County of...............Hennepin- .......................7nd State of.........M......n...n...e...s...o...t...a.. ...................... part.le$.. of the first part, and-Alvie ...And...Qry;�t.41...H.'..Y9 .,_h:q4.!;APd....amt..K:U 9............................................. ........... ........I..............................................a..........................................................................................:.................................................. Of the County of .............P.olk......................:......................and State,of.......................Wls.cons.in............................. parties of the second part, Witntg;.Itff), That the said part.. e's of the first part, in consideration of the sum of... .................... .........0ae....D.ollar...and...other...cQns.idgratiQn....Qr...value,77=- --------- '7:---AMA1,10 1, to..........them.............in hand paid by the said parties of the second part, the receipt whereof is hereby acknowl- edged, do. ......... hereby Grant, Bargain, Sell, and Convey unto the said parties Of the second part as joint tenants and not as tenants in C0771,7nOn, their assigns, the survivor of said parties, and the heirs and assigns of the SUI-VIV07', Forever, all the tract...... or Parcel...... of land lying and being in the County of ......Qr.qJLX....................................and. State o *171414161, described as follows, to-wit: Wisconsin The South One Hundred Twenty-Seven (3 127) feet of the North Five Hundred Eight (N 508) feet of the East Three Hundred Forty (E 340) feet of Government Lot Three (3) in Section 22, Township 30, Range 20, according to the government survey thereof. i is ZO�()abt aRb to JbOlb the Hanle, Together with all the hereditaPIents and appurtenances there- unto 1)610ndinc; or in anywisr, appertaining, to the said parties of the second part, their assigns, the sur- vivor of said parties, and the heirs and assigns of the survivor, F07-ever, the said pal-ties of the second part taking as joint tenants and not as tenants in COMMO71b. ✓n,d the said..............�idn.Qy..N......Johms-on....and...Linnea...F Jobn.aon............................................................................ ..............................I.............................................I........................... ..............*... ......... ... ...... ......*...... ...............*........*...... part.1Q*. of the first part, for...... ..................heirs, eXCC?1,t07,s and administrators do............ covenant with the said parties of the second part, th,-cir assigns, the survivor of said parties, and the heirs and assigns of the.survivor, that-they...a.r 0..........well seized in fee of the lands and pi,einises aforesaid and ha....ve food right to sell, and convey the sanze, in manner and form aforesaid, and that the same are free fl-07,?, all i7?cUn7,b7'anCC8, .471d the above bargained and granted lands and PY01711ses, in the quiet and peaceable possession, of the said parties of the second part, their assigns, the survivor of said parties, and the hC17's (171d assigns of the survivor, against all persons 7C1711fUlly clai 77'1,i?16 or to clai7n, the wholf, or any part thereof, subject to 1n,euYnh7-a7?,CP,S, if any, hePeinbefore mentioned, the said part—ies of the fl7'St 1)(17•t will 'U"arrant and Defend. 111 TeMimanp Mbereof, The said parties of the first part ha Ye.. h67'rIt71tO Set their............. h a 7?,dS... the (lay a7?.d yr(17' fll'St above written. In nee. o' ...................... .. . ...... ........ .............. . .. ............. ...... ...........................!.. ........... ................... ... ...... ........ ............... .. ......... .... ..... ..... ................. ......... §tate of Ainne5ota, ss. County of..................Hennepin................................. 1 th...................................daz o November-.......................................1 195.5......, before me, a On this..,...........................7..... J f.............................. . . f .............Kota,X.y...Pub?.li c......................................................................; within and for said County, personally appeared ..........Sdney..N. Johnson...and...Linnea..E......Johnson.,....husband...and wife ................................. ........................................................................................................................................................................................................................................................ to me, known to be, the persons..............................described in, and Who executed the fore�doins instrument, ..............................................................................................................and ack710LVIedged that .....they..... executed the same as (See Note) .........them'....................................free act and deed......................... . ......... . ..... ............_.. (See Note) .............C. 1W0*N A. iE &it Notary Public, .... --H.erne.pin..................County, Minn. .)l y commission expires........April...5.................... 19.58..... NOTE- The blank lines marked "See Note" are for use when the instrument is executed by an attorney in fact. i to eb c. 14, O F ppW44 ° -om: ON Z 14 ti llei,— �+ R P.`Cti ppp w \ en IZ3 ZS 1 • r+ z y H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT 0 St . Croix County z eo a r H OWNER/BUYER L//fi r �/�,��/� M r ROUTE/BOX NUMBER-/ Am.0 �;s 9 Fire Number .CITY/STATE Lye- Ile�e�� /el ZIP PROPERTY LOCATION: SE It, S 4��k, Section -__Zp T QN , R AW, Town of �, _ , St . Croix County, Subdivision Lot number 3 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 pumper. What you pdt into 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. 0 E I/WE, the undersigned , have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x r+ the standards set forth, herein, as set by the Wisconsin Depart- *v ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Offkge within 30 days of the three year expiration date . SIGNED i.?/' AIL DATE C 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 . . M �o �C-a � — IV a.�,,;,� .��►, � - rod E � 1 N lW r k 44 S I i e y AS BUILT SANITARY SYSTEM REPORT OWNER �L �. C</Da� TOWNSHIP f' �O SEC.ZT�ON-R2e�W ADDRESS o X lz 3 ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 EVERYTHING WITH N 100 FEET OF SYSTEM -40000 WA Ir C - r 1 I di a e No#hl Arrow 1 I SC L ooRZ. B 4 $W T/o of 1*^fc BENCHMARK: (Permanent reference Point) Describe: Uggr 6R -pp g eokx& rECstep) Elevation of vertical reference point: Zig7f_v Slope at site : 0 i SEPTIC TANK: Manufacturer: �/l _ /.S _f r/2 Liquid Capacity:AOO 4,qL.- Number of rings on cover : Tank manhole cover elevation Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gala pump .set For a cyc a gallons ; total capacity of distribution lines gallon: size o pump head; gallon per minute horsepower brand name of pump and model number Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE: Number of p is feet d iameter feet liquid dept seepage pit inlet pipe-elevation bottom of seepage pit elevation feet . SEEPAGE BED SIZE: number of lines�_w t length 3� tile depth SEEPAGE TRENCH: width length PERCOLATION RATE 1,S MA RE tUMD__ /,/ S BUILT 8 INSPECTOR DATED AC PLUMBER 0 J B LICENSE NUMBER 4�Q tv .o 0 • RLPORT OE INSPECTION - INDIVIDUAL SLWAGE SVSIIM Sarr.i .ta4 Penrni t �,.• State Sept4 CO - ;AM! Tow nahip %50 St.' Cnuix Coun.tq r „ ti ran Sectionoji►vt M Subdiv.i.a.i on IPTIC TANK Si %e gaY.Pona Numbers oA Compantmen.ta tano v Anum: G!e'YY Buy ding S 12 o eYo . e .^ s n —- H.ighwaten _ QMPING CHAMBER ,Size gattona ._ Pu*p Manujac-tuxen Mode.Y Numbers_ 01 PING LANK S4, ze ., _Tgattona N44e.n o6 Compa4xme.nt,6 Pumpcn AA Am Syatem -- - - -- --. — � s tan ce A m: Welt Buitding 12% aYa�e. H.i.ghwaten \IiSORPTION SITE Bed—_�-�� , Th.e.rreh ,i ! tance 440m: Wett - Buit,ding_ �f2% a.Yope —.- Highwaten :l.ORPl ]ON SITE DIMENSIONS W( dth „ 6 tne,neh / —{t Requ.i 4e.d ane 6t Iength ob each tine 6t Depth oA hock bexow .t.i.Xe _— -4n Number o6 Y.i.nea_ Depth oA Kock oven tole _ _4. TistaY eength o6 t.i.nea At Depth o6 tif-e beYow grade_ <.n Die tanve between t.i ne.a At Stope (PA tKeneh 2 in . pen 100 At I �J 1114 ,44 ub. vVAP.i.,iun aneu 140 At Type v6 Coven: Papers oar. atnaw I D I M! NS I ONS urnbeh (14 pats Ghavel an and pit's_ ye.a -_-----nu Ou-te.i de d,i ameteh At Depth below •i.nY.et_ TotaI abaoapt. on a4e.a At A,kr�a, neyu.iaed At r NSPECTID By TITLE 1111ROVt D - --- DATE _( — --- 19V I'1 II CTI D DATE 19 K '1 AIWN 1 OR REJECTION State and County State Permit # PLB 6 7 Permit Application County Per 't # for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Alulk Gulp /?- / 13eX/z3 S7%ZIW,972�7,P B. LOCATION: 7L'/_ 5AJ* , Section 2-2, T,,?O N, R ZO E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village 3--1 tlWt/- �J� Township .S`7� TOSE10�- C. TYPE OF OCCUPANCY: Commercial 7 /*Industrial *Other (specify) Variance Single family _X Duplex No. of Bedrooms No. of Persons Z— D. SEPTIC TANK CAPACITY 10'a Total gallons No, of tanks / HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete X Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement X Lift Pump Tank or Siphon Chamber Total gallons Prefab corcrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rat 2''7 z -Z Total Absorb Area sq.ft. New Replacement X Alternate (Specify) Seepage Trench: No.of Lineal Ft. Width Depth Tile depth (top) No.of Trenches Seepage Bed: X Length 35--' Width /,? ' Depth VV ', Tile depth (top) L No.of Lines -3 Seepage Pit: Inside diameter Liquid Depth No.of Seepage Pits Percent slope of land— !Q Distance from critical slope WATER SUPPLY: Private X Joint❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, _ NAME AQ6 T AlheIC-111' C.S.T. # 5-3-023&,L and other information obtained from Sv/L TASTE , (owner/builder). Plumber's Signature MP/ # /&/5/ Phone #.3M —L8✓`�a Plumber's Address 2-Z— O OA9 VD �✓ GJ/ S . PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20.Well loca- $ tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors !� wl property. If well has not been drilled please indicate. z E r ' n m E F )/I i I IA"014 L �A r 3 I li .rn £ £�Q . '+,.. 3........a .. -.e... w...., ..8.. P..a e. m .«,.«. P. � P..c . R L �.. G P s liE _,, + r � 4 !�� .. _. _ _.... . . , o � r i 3 O E 0 Do Not Write in Space Below FOR COUNTY AND STATE DEPARTMENT USE ONLY 1 �± Date of Application — - Fees Paid: Stat u t e to Permit Issued/Rejected (date) Issuing Agent Nam Y 1 Inspection Yes No State Valid# Date Recd 1. county (whit copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON,WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 ` L17 '1i5 Rev.9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS rJ�GEs �C� FiPos� WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309,MADISON,WISCONSIN 53701 6 7 NX LOCATION:N '/a,•'4_V Section 22 ,T 30 N,R:LE (or)W,Townshi or Municipality TOS �! Lot No. ,Block No. County (//E (1,OOU Subdivision Name ,P� -yG, 90 Owner's/Buyers Name:) Mailing Address: 7 eX s/11wA7-z-� 1-11;4w o u4-7 TYPE OF OCCUPANCY: Residence No.of Bedrooms L COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT X ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MAD 2 OIL BORINGS/yi9� i 2-X Af&-PERCOLATION TESTS SOIL MAP SHEET SAS 3 NAME OF SOIL MAP UNIT �3v�Pk�i��PDT PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TESTTIME DROP IN WATER LEVEL,INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P_ �- P-3 24 F"/,A'. SL 4f G>'/3,), S L P- "v sL 4-k jv . SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B— N611 O $N, 5 G j "L7'i3,V—01f? SG 13" Bowe Pq— Ll.B,u B_ Of. SL Pte+- 3 9 7 SL3 3 l B— Z 7 Nary i` 2' 7 ,. RA;.S G 1 13 " Z/B IV.'Fw+c S L 2 " V aP. L B_ PA& lie . L3" H f3A).fI•.K S&r.Q a,k L4Cf1(&.t ro•G— B_ o•►" > 7 '' " BA), SL "G�/ /3n� 44 O L •/S,v PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy 61.S 3'0•P' Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. D.0114%.,13EI0 10� 4. .eQ i a 4 , S (RA ._ _—_. IV 01 . . ° E O i 1 00 N k s I f i a 1 f 3 1,the undersigend,hereby certify mat 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 location of test holes are correct to the best of my knowledge and belief. Name (print) h°J � /G�I Certification No. Address �.JE�L CJQSON S Name of installer if known OS• XG U 71A/ 0• tJ!'SOti ICJ/S Copy A—Local Authority CST Signature Zr6QJ Z� f ` \ '.k Ali flyi - ��✓ t j v �u{.� ' �,46E2aIc Z n Rev.9/78 n,4 _ 6� REPORT ON SOIL BORINGS AND PERCOLATION TESTS 1!/ WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309,MADISON,WISCONSIN 53701 LOCATION N�%,!ra) '/4,Section LZ ,T e)N,R?�E(or)W,Township or Municipality ��`E,Mj Lot No. , Block No. County s�' �OIX Subdivision Name Owner's/Buyers Name: 462k &2002 Mailing Address: TYPE OF OCCUPANCY: Residence No.of Bedrooms 2 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW REPLACEMENT—ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS h"44 l y 21 PERCOLATION TESTS ^-' -- SOIL MAP SHEET 57-CS 3_3 NAME OF SOIL MAP UNIT dge4- PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS I WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE NUM_ INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTEF INTERVAL BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2. PERIOD 3 MIN/IN P— P— P— P_ P- P— SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- 3 ealslycft aa ,PIOM J1 s 4 eJ Ati ? .e . 0c, B— "%A L 5-/o..t Coe, — A T 7 yE,tcTt B— B— B_ B— PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the Ian the location and square feet of suitable areas. _ Indicate number of square feet of absorption area needed for building type and occupancy Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. � r , APAII vot _ /ohs N w� e g 2 t X � i s /�� cdpj O�U S �S gl '.Al - - - o . i '041 � � =w� A S•+-cif Se 1,the undersigend,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 location of test holes are correct to the best of my knowledge and belief. u�,�y� �Name (print) K Z/)1V,1 C�7— Certification No.���so Address &)1 Name of installer if known U 1'v Copy A—Local Authority CST Signature 1,01,2 6 7 //r�iE /voo� � s��P.e�� ' 3 /�ovLTo�� WIS. � 1�0 s LIao� w� 0 3 p4,ijjS w1a Poo t 1 1 Q �6P f Ofco ` �. Ila2, 13M — Sic, 11 #r �r4,? Poo, . o SF �zrs nN� /j j�W*c,e �bi�uT ��/�l �`5 fJ,; lvoaD Z,e,&o 7vtAll. 070 3�" i� I .:.... ,+�Ai,A�F��qu.'�„t,A•-S.h.,.....,'"'!'�,..�.•...t�"`�'�""�.......s'"6-w?"i,«,�',!^p^"t'"...:.t e-+^"'...a.».„,w..wrC'"`.'wwA+�lr'.`."tir+�+'''"""y''pN"''y�r`.f"'Q'�,,,/ 'w"+►�MM..rw.r.,:..4.......,.:.......r... I i r i i . .4 l t i r , r a a , i'. r r t , f + 4tF - s r' ..r r. , s A. 13784 REPORT ON INSPECTION OF SANITARY PERMIT # 91 1 Name and Address of Permit Holder Person/Persons at Site (2)Date of Inspection Time of Inspection Name, Aaaress, License No. OT Instailing Plumber le INSTALLAT STS OF: ❑ Septic Tank ❑ Seepage Trench []Dosing Chamber ❑Seepage Pit ❑ Seepa a Bed ❑ Holding Tank [—] Fill System ermanen reference Point) escri e: Elevation of vertical reference point: Slope at site: (5)MATERIAL AND DEPTH OF SEWER: (6)SEPTIC TANK: Manufacturer: Liquid Capacity: Tank Inlet Elevation: Tank Outlet Elev: # ft to lot or property line: # ft to well M DOSING TANK: Manufacturer: # of gallons : # of gallon pump set for a cycle gallons; total capactiy of distribution lines gallon; size of pump head; gallon per minute ; horsepower ; brand name of pump and model number Is the warning device installed? []YES ❑NO Wired? []YES ❑NO 8 HOLDING TANK: Manufacturer o ga ons construction depth to the cover ft; If septic tank is being used are baffles removed? YES [] NO; ft from residence; ft from well ; ft from property line. Type of warning device Is the warning device installed? ❑ YES ❑N0; Wired? []YES ❑N0; Locking device on cover? []YES ❑ NO; Diameter of vent and material Distance from building to vent (9) SEEPAGE PIT SIZE: # of pits; ft diameter; ft liquid depth; ft to residence; ft to well ; ft to property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than seepage pit inlet pipe-elevation ft; bottom of seepage pit elevation ft. (10) SEEPAGE BED SIZE: ft width; ft length; tile depth; li.neal feet tile; ft to residence; ft to well ; ft to lot or property line; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches Elevation of tank discharge line entering bed ft. 11 SEEPAGE TRENCH: Total length of seepage trench ft; width ft; tile depth ft; ft to well ; ft to ordinary high water mark of lake or stream; ft to edge of slopes greater than 20% falling away toward lakes, water courses or drainage ditches; elevation of tank discharge line entering seepage trench ft. (12) Has system been installed in area indicated on EH 115? ❑YES [] NO (13) Has system been installed in floodway? ❑YES ❑NO Floodplain? (DYES Q NO DILHR-SBD-6095 N.0 /80 Signature of Inspector: