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040-1209-30-000
� o I o ~ 0 O � � I I m o 0. 0 0 � I I o € I I o a N a� i •o a v 0 I d L) L -o c y 0 c Z Z c �i ca € U. c o °- 3 U) 3 w Q Q co Cl) Ii y N z E z E U) o :: o V LO C-4 am am N O to O_ Z C C p Z y q, (D Z to H r c c E -a E r) N m :3 n y CL c z Q w z m z o z° m N y c = N y 2 d N V1 E Its V7 L E l0 Y E 'a = N 0i — O N Cf ow ar O N CL ' °° o O N El U) c) 3r EV33 Z •N m a a a m a a m u,LL *i D �i B :: ti > 0 o U) oo o i2 co co O N o v a (M z m z a Cl) 1\V U O tF ` 0 0 p N U N w V Y E ° _N O m C N m C d �' 0 m w Q co d Q Z U) co d Q Z U) Q 04 l�l O �N 7 N NM H #C A E � O C c p N N M F- CD l4 W V 0 0 O p N IF co 3•"n O � 4t _O O r °�}} N ` a O N O N N N O R U • O N H CO co O Z C Z m 0 0 Z c Z U) O co ad m R € a € a IL Q6 0 � a E O V p `p 7 3 r O A c� a2 Ov� c� Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. Z5 T �N-R ZO W ADDRESS q �`uu5r_T LjI ST. CROIX COUNTY, WISCONSIN SUBDIVISION i;�O-Te OT 3 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ry 7"y 43 U� O 4 ,..L"'0 INDICATE NORTI ARROW BENCHMARK: Describe the vertical reference point used _jp:L ;C. IN 4" O.C-pl4l2. ZEu- Elevation of vertical reference point: /4x)-C'6 Proposed slope at site: jp°jam SEPTIC TANK: Manufacturer: Vj Liquid Capacity: /Ccx�, 64UU--Al Number of rings used: S Tank manhole cover elevation: 29 Q 7 Tank Inlet Elevation: <1-;5Jo i Tank Outlet Elevation: 013,48 Number of feet from nearest Road: Front,O Side 0 Rear, 0 OvIGe— AXI feet From nearest property line Front,0 Side,O Rear,0 a}.� feet Number of feet from: well Ivy Lufffti. -;,-building: IS'•II .(Include this information of the above plot plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 5 9 GLCAaA TOWNSHIP SEC. ZS T 21E� N-R ZC W ADDRESS A& LAw- ST. CROIX COUNTY, WISCONSIN grle�_ t 5� .64d;?Z SUBDIVISION 4.. t fgoTa /,L, OT 3 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used _-jpY,yF_ IN 4" e -b IRF-p- Elevation of vertical reference point: /W.C4 Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: /ow cuu.oll Number of rings used: S Tank manhole cover elevation: 243 7 Tank Inlet Elevation: C4 1LJaj Tank Outlet Elevation: 013.4.$ Number of feet from nearest Road: Front,O Side, Rear, O ,1C-:r_ feet From nearest property line Front 10 Side,O Rear,0 ski,-0 feet Number of feet from: well Ajo W1fftt 3r-building: IS'-I1" (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear,0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: i Width: 12,E-6 Length: SZ-d' Number of Lines: Z Area Built: 6ZAZ Fill depth to top of pipe: 3-0 Number of feet from nearest property line: Front, O Side, O Rear,G)Ft . 'C` Number of feet from well: Ne, WIU-L `� T Number of feet from building: 4-1 (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, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 3/84:mj i DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS DIVISION -LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMBING P.O.BOX 7969 MADISON,WI,53707 State Plan I.D.Number: S�5 T28N—R20W UCONVENTIONAL ❑ALTERNATIVE (11 assigned) NE ,$W , 'down of Troy ❑Holding Tank O In-Ground Pressure O Mound Lot 3, St. Croix Highlands NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION ATE: Thomas Belongia 926 Sunset Lane, River Falls, WI 540 2 REF.PT.ELL EV: CST REF.PT.ELEV.'. BENCH MARK(Permanent reference Point)DESCRIBE IF DIFFERENT FROM PLAN: Name of Plumber: IM P/MPRSW No.'. County: Sanitary Permit Number: Thomas H. Cody 6593 St. Croix 92487 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING ROVIDED: L PROVIDED VER R3 ,3� YS YES ONO ❑YES O ROAD: PROPERTY WELL BUILDING: VENT TO FRESH BEDDING: VENT DIA.: VE T MATL.'. HIGH WATER NUMBER OF LINE: t�lE,ll AIR INLET'. _ ALARM' FEET FROM DYES �NO `- ❑YES O NEAREST 1f `__ DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY: PUMP MODEL PUMP/SIPHON MANUFACTURER ER. PROVIDE PROVIDED:CK DYES ❑NO ❑YES ONO DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPE RATIONAL'. NUMBER OF PROPERTY WELL BUILDING: AIR NT TO INLET FRESH FEET FROM LINE (DIFFERENCE BETWEEN ❑YES ❑NO NEAREST PUMP ON AND OFF) LENGTH: DIAMETER MATERIAL AND MARKING SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire,construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: IN7D :]j*PITS LIQUID COVER BED/TRENCH WIDTH: LENGTH: TRENCHES DISTR.PIPE SPACING MATERIAL: PIT DEPTH �� �1 DIMENSIONS Ia. GRAVEL DEPTH FILL DEPTH CISTR.PIP' DISTR.PIPE DISTR.PIPE MATERIAL: NO.DI NUMBER OF RTY BUILDING: V NT TO FRESH BELOW PIPES: ABOVE ' LEV INLET ELEV.END: PIPE FEET FROM NEA I "t 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 PERMANENT MARKERS. OBSERVATION WELLS SOIL COVER TEXTURE DYES ONO ❑YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED CENTER: EDGES. OYES ONO DYES ONO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: FILL DEPTH ABOVE COVER WIDTH: LENGTH: NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIP'. BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL'. NO.DISTR. DISTR.PIPE DISTHIBU TION PIPE MATERIAL&MARKING ELEV.: ELEV.: CIA.. ELEV.: PIPES CIA.'. ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS ❑YES ❑NO OYES ONO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROP=BUILDING. COMMENTS: FEET FROM LINE: J OYES ONO OYES El NO NEAREST �f Sketch System on Retain in county file for audit. Reverse.Side. SIGNATURE: TITLE Zoning Administrator DILHR SBD 6710(R.01/82) CA San. Permit No. Owner`s name H63 X 5 PLOT PLAN (Show: Location of building served Dosing chamber ✓ Vertical/horizontal reference point Septic tank � System elevation is Building sewer Effluent system Q Well Property lines w/in 50' of system Replacement system area -I - `1 I Scale - ` 3 C , or dimensioned Nth Distribution boxes � Ew�T sS N Pump and controls: Mfr. & Model No. Vertical Lift Size Force Main Friction Loss T. D. H. Vol. Dist. Pipe Gal. per Min. Gal. per Cycle Place check mark in appropriate box, indicating item is shown on plot plan below: 3 ELLt::V, lof.3/oN y" r. G 35of � L4" Sod Dw�cl� ,2\ Svc PIPE a o00 6RLLOM Sc'pinc 1p�h C3 14' C�0 v N�T2.E5T 0 By the granting or approving of the above plan, or upon the event of a subsequent permit being issued,St.CroixCounty and theSt.Croix-ounty Zoning Administrator, does not assume or hold itself liable plans or that may in or i omission, examination oversight, after Lallation. icense o. a e Plumber's signa u ]t� 3i �LOMG) R I-Z)h vn E CROSS SECTIDU OF A BED S STEM t , 2 OF AGGREGATE _ c — SOIL FILL --� tL PtiC--- DISTRIBUTIOh3 PIPE APPROVED 513W -TIC COVER MATF AR j_ OR 9" OF STRAW MARSH HF.y ` (o"OF%2-21� -AG GREGATE ELEV. OF�Z.Z FEET T ORIGIIJAL GRADE DISTRIBUTIOU PIPE TO BL AT LEAST tIJCIiES BELOW✓ AUD AT L>=AST 20 1►JCHES BUT )JO MORE THAI.f 42- IUCHES BELDW FWAL GRADC — � � IIJCHES MAXiMUN� DEPTH CF >rXCAVAT10ki FROM ORIGII.IAL GRADL 'JILL BENCHES `~ MINIMUM DEPTH OF EXCAVATIOIJ FROM ORIGIUAL GRADE WILL BE 51G0C LIGEUISC UUMBER= 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 K7 CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number El Tank [11 In-Ground Pressure El Mound (lf assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Thomas Belongia 926 Sunset Lane, River Falls, WI 54022 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.'. NE t` SW 14 S25 T28, N,R20W Lot #3 Town of Troy Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: homers H. Cody 6593 St. Croix 88471 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LAB L LOCKING COVER PROVIDED: PROVIDED: DYES ❑NO DYES ONO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM FEET FROM LINE: AIR INLET DYES ❑NO DYES -]NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: - YES ❑NO ❑YES ❑NO DYES ❑ FR GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING. AERNTVTLOT FRESH (DIFFERENCE BETWEEN FEET FROM LINE PUMP ON AND OFF) -]YES NO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: TRENCHES: DISTR.PIPE SPACING MATERIAL: PIT INSIDE DIA nPITS D QUID H DIMENSIONS GRAVEL DEPTH FILL DEPTH UISTR.PIPF DISTR.PIPE DISTR.PIPE MATERIAL: NO.DISTR. NUMBER OF 1PINE WELL BUILDING'. V NT TO FRESH BELOW PIPES: ABOVE COVER: ELEV.INLET ELEV.END: PIPES: FEET FROM AIR INLET. N EA R 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- meets the criteria for medium sand. TIONS MEASURED. DYES 1:1 NO OIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES NO 1-1 YES ❑NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED S MULCHED CENTER: EDGES. ❑YES ONO []YES ❑NO YES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH: LENGTH: NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING ELEV.. ELEV.: DIA.: ELEV.: PIPES DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING: DRILLED CORRECTLY. COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION PLANS. DYES 0 N I DYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: 1-1 YES ONO DYES ❑NO --]NEAR Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE'. DILHR SBD 6710(R.01/82) INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY'PERMIT APPLICATION Y 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 maybe 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 pxoperly 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; ll. 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 ail 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'/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 tither 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 ang'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 at4r --- included the creation of surcharges (fees) for a number of regulated practices which Wisconl irt'S a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried rea5t re' 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. , a The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398(R.03/86) (� SANITARY PERMIT APPLICATION COUNTY L1�DILHR In accord with ILHR 83.05,Wis.Adm. Code S - 01?0/ �� �•w^^�+� STATE SANITARY PERMIT# 9 a y9'17 —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8%s x 11 inches in size. —See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE El YES �NO PROP TY OWNER PROPERTY LOCATION L4�,:, 'IS %, S "PL5- TW , N, RHO E (or PROkRTY OWNER'S MAILING A RESS LOT NUMBER B SUBDIVISION NAME. C( � r.t:-� '.ttfe a ;' / r is C Y,STATE f ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE R LANDMARK er a��5 jl-�Or} ❑ VILLAGE : y p C1 10 II. TYPE OF BUILDING OR USE SERVED: 7 ' 0 O!t`0 Uc7 3 Q—dj Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): 111. 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 Onl an Existing System Existing System 2. A Sanitary Permit was previously issued. Permit# 9 717 Date Issued �—? !7 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. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. Seepage Bed b. ❑Seepage Trench c. ❑Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): L Feet W Private ❑Joint ❑ Public VI. TANK CAPACITY Prefab Site in allons Total Manufacturer's Name Con- Steel Plastic Exper. INFORMATION New xisting Gallons #of . Fiber-Tanks Concrete glass App. Tanks Tanks strutted Septic Tank or Holding Tank El ❑ 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): Plum 's Signature:(No S mps P MPRSW No.: Business Phone Number: ^• n Plumber's Address Street,City,Stat ,Zip ode): Name of Designer: �r Lje Vlll. SOIL TEST INFORMATION Certified oil Tester,(CST)Name CST# hxhw, 4a CST's A DRESS(St eet,City,Stat Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY N[�p( ❑ Disapproved Sanitary Permit Fee Groundwater ate r Issuing Agent nature(No Stamps) Approved ❑ Owner Given Initial /' n charge Fee O (k�� Adverse Determination —P/ d � �. X. COMMENTS/REASONS FOR DISAPPROVAL: It SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber APPLICATION FOR SANITARY PERMIT i r� 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 I house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Property _JilE-;4 , Section o?� , T , -R -2Q W Township L2 C) Mailing Address � �� /� c'- Address of Site� ,} r1 2 l Subdivision Name Lot Number Previous Owner of Property( Z Lo 1)u , 4a�,�- /i/cT-ol e,^/ U_S Total Size of Parcel -S. 9 0(Li, a S Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume 172 3 and Page Number X93 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and page number, and the Seal of the Register of Deeds. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPFRTV OWNER CERTIFICATION I (We) ce4ti.6y that att statements on this 6onm cvte t tue to the best ob my (ou&) knowledge; that I (we) am (ate) the ownett(s) ob the prtopehty de6cA bed in thus in6otcmati.on 6onm, by v.c,�tue ob a waAAanty deed teco&ded in the 066ice o6 the County Reg.usteh o4 Deeds as Document No. ; and that I (we) ptesentty own the puposed site bon the sewage dispozat system (oA I (we) have obtained an easement, to nun with the above descni.bed phopeAty, 6oh. the con3tnucti,on ob said :system, and the same has been duty aeconded in the 046ice o� the County Reg-usteA ob Deeds, as Document No. ) . SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) ZJ2 3f2 DATE SIGNED DATE SIGNED ��!G► Jao L 10J Purchaser promises to pay when due all taxes and assessments levied on the Property or upon Vend'or's-interest. in it and to deliver to Vendor on demand receipts showing such payment. t Purchaser shall keep the improvements on the Property insured against loss or damage occasioned by five, ex- tended coverage perils and such other hazards as Vendor may require, without co-insurance, through insurers approved by Vendor, in the sum of --------------------_---_-.•__--_-_, but Vendor shall not require coverage in an amount more than the balance owed under this Contract. Purchaser shall pay the insurance premiums when due. The policies shall contain the standard clause in favor of the Vendor's interest and, unless Vendor otherwise agrees in writing, the original of all policies covering the Property shall be deposited with Vendor. Purchaser shall promptly give notice of loss to insurance companies and Vendor. Unless Purchaser and Vundur otherwise agree in writing, insurance proceeds shall be applied to restoration or repair of the Property damaged, provided the Vendor deems the restoration or repair to be economically feasible. Purchaser covenants not to commit waste nor allow waste to be committed on the Property, to keep the Property in good tenantable condition and repair, to keep the Property free from liens superior to the lien of this Contract, and to comply with all laws, ordinances and regulations affecting the Property. Vendor agrees that in case the purchase price with interest and other moneys shall be fully paid and all conditions shall be fully performed at the times and in the manner above specified, Vendor will on demand, execute and deliver to the Purchaser, a Warranty Deed, in fee simple, of the Property, free and clear of all liens and encumbrances, except any liens or encumbrances created by the act or default of Purchaser, and except: ---no-ne------------------------------------ ----------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- - - ------ - ------ -------------- -_ ..-. - ---- - ---- - -------- Purchaser agrees that time is of the essence and (a) in the event of a default in the payment of any principal or interest which continues for a period of ---rbo..-days following the specified due date or (b) in the event of a default in performance of any other obligation of Purchaser which continues for a period of__.(_Q__- days following written notice thereof by Vendor (delivered personally or mailed by certified mail),then the entire outstanding balance under this contract shall become immediately due and payable in full, at Vendor's option and without notice (which Purchaser hereby waives), and Vendor shall also have the following rights and remedies (subject to any limitations provided by law) in addition to those provided by law or in equity: (i) Vendor may, at his option, terminate this Contract and Purchaser's rights, title and interest in the Property and recover the Property back through strict foreclosure with any equity of redemption to be conditioned upon Purchaser's full payment of the entire outstanding balance, with interest thereon from the date of default at the rate in effect on such date and other amounts due hereunder(in which event all amounts previously paid by Purchaser shall be forefeited as liquidated damages for failure to fulfill this Contract and as rental for the Property if purchaser fails to redeem); or (ii) Vendor may sue for specific performance of this Contract to compel immediate and full payment of the entire outstanding balance, with interest thereon at the rate in effect on the date of default and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser shall be liable for any deficiency; or (iii) Vendor may sue at law for the entire unpaid purchase price or any portion thereof; or (iv) Vendor may declare this Contract at an end and remove this Contract as a cloud on title in a quiet-title action if the equtiable interest of Purchaser is insignificant; and (v) Vendor may have Purchaser ejected from possession of the Property and have a receiver appointed to collect any rents, issues or profits during the pendency of any action under (i), (ii) or (iv) above.Notwithstanding any oral or written statements or actions of Vendor, an election of any of the foregoing remedies shall only be binding upon Vendor if and when pursued in litigation and all costs and expenses including reasonable attorneys fees of Vendor incurred to enforce.any remedy hereunder (whether abated or not) to the extent not prohibited by law and expenses of title evidence shall be added to principal and paid by Purchaser, as in- curred, and shall be included in any judgment. Upon the commencement or during the pendency of any action of foreclosure of this Contract, Purchaser consents to the appointment of a receiver of the Property, including homestead interest,to collect the rents, issues, and profits of the Property during the pendency of such action, and such rents, issues, and profits when so collected shall be held and applied as the court shall direct. Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property (by assignment of any of Purchaser's rights under this Contract or by option, long-term lease or in any other way) without the prior written consent of Vendor unless either the outstanding balance payabir imder this Contract is first-paid in full or the interest conveyed is a pledge or assignment of Purchaser's interest under this Contract soley as security for an indebtedness of Purchaser. In the event of any such transfer, sale or conveyance without Vendor's written consent, the entire outstanding balance payable under this Contract shall become immediatly due and payable in full, at Vendor's option without notice. Vendor shall mnke all payments when due under any mortgage outstanding against the Property on the date of this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaser makes timely payment of the amounts then due under this Contract. Purchaser may make any such payments directly to the Mortgagee if Vendor fails to do so and all payments so made by Purchaser shall be considered payments made on this Contract. Vendor may waive any default without waiving any other subsequent or prior default of Purchaser. All terms of this Contract shall be binding upon and inure to the benefits of the heirs, legal representatives, successors and assigns of Vendor and Purchaser. (If not an owner of the Property the spouse of Vendor for a valuable consideration joins herein to release homestead rights in the subject Property and agrees to join in the execution of the deed to be made in fulfillment hereof.) Dated phis .- -5 day of -----QctQbe - - ------------- 1935--.-. Pa� M 1 Fie 1 � .�,, 4 ------(SEAL) PJ±�c,to- ------(SEAL) --------- ----- - - -- - - ------ ---------------- W�J lia S. Tty r Thom�ls T-.---Belongi-------------------- rr P rson a C Nn s -----(SEAL) `Bar �i7a-A. BelOLa �CG1- {SEAL) * -- --- -- -- !yL� . ---------- Del H. Finess State of Wisconsin ACKNOWLEDGMENT Sty. -Croix:.County - STATE OF WAN M i h 12 1 a.�fiQ1�Iu�.,,;Fliomas fF-;--$er�nz3ia--�ni3------------ A.. .Y�n i a -------!`'-- co ......day of is ',, �y of_____�ctabcr 19.$5_ �ersona y came before me this __._.�s . Z-" ------- --C1^�=?r ------------- 19--S,5- the above named --------------- 1 ' �►l n 1Ci M. He T.' u� - *- n- ,s 7 ' ' 1986 --------------- -•------- ----------------------- ''���,,,,,...•• to me known to be the person ----- who executed the foregoing instrument and acknowledge the same. }}r1r1 THIS INSTRUMENT WAS DRAFTED BY ^y ------------------------------- fqY Russell E. Berg ,-_) --- ------ ------- ------------•--------- 125 N. Main *--------��^ u=------------------ - --��J .. ----Rite-r--F-al-1-s-;---W-I-----54-02-2----------------------- Notary Public -- ----=� ik.>_� -------------------County, wj'I111112,1. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: _-, A "/,�/n�/n�/�/n�/n�/,,AA 4\ . At �t���� y \ ---- 'NpnuSa of poraor,i 64;,6,-+,- +a ally I.)i—i J.roiled below Ih,ir ,I,nuhro,. f.A,ND r0l1TTnAi'T—lollivl+ , - ! t'n*n° ' gl;1< + qr of Vo' - ( uocUMEN I No. STATE BAR OF WISCONSIN FORM 11-1982 THIS SPACE RESERVED FOR RECORDING DATA LAND CONTRACT © .p Individual and Corporate .;ti (TO BE USED FOR ALL TRANSACTIONS WHERE OVER $25,000 IS FINANCED AND IN OTHER NON-CONSUMER ACT TRANSACTIONS) i0 REGBSI ERS OFFICE ContraCt by and between .._Paul T, F1e_ tln_•_._jaj,],�j, S . M ers C�iff_ord A. Peterson Lance_ __A,_________________ `T. 01ZOEX Co., WIS, - - - --------- --------- ---------------------- Norderhus,-_and_•Del__H_.___Eines$_________________ RecV. r ,. ecord this 15th - o d •--- ("Vendor",---------- whether one or more) and--lb-Oin1s__T�___� S2JClg1_s�-_and.................. �Y Of Oct A.D. i9 85 .Baxb.axa...A.. 13.tl-angia-,...husband..nnd_-w-ifn..as...}oint_ 2:25 P — t nanta_________________________________________ ("Purchaser", whether one or more). • Vendor sellsm d agrees to convey to Purchaser, upon the prompt and full per- ormanctof%U.contract by Purchaser, the following property, together with the w o4 bide ien'O,profits, turea.nud other appurtenant interests (all called the"Property"), . � rox -------------------------------------- County, State of Wisconsin: �r� • RETUR TO Croix Highlands in the Town of TrO17 Tax Parcel No. --------------------------------- This is not--- homestead property. (is) (is not) 5100 Edina Industrial Blvd. Purchaser agrees to purchase the Property and to pay to Vendor at Ed ina Mrd 5 5 4 3 5 the sum of $_I �.QQ.._Q ------------------------------------ in the .following manner: (a) $_5,D.00.._Q-0---------------------------- at the execution of this Contract; and (b) the balance of $_._.1D9_QD_..DD ----------_ together with interest from date hereof on the balance outstanding from time to time at the rate of----1.1-0------------------------------- per cent per annum until paid in full, as follows: Monthly payments of $150. 1-6 C: incg November 15 , 1985 , and on the 15th day of each and every month thereafter. Provided, however, the entire outstanding balance shall be paid in full on or before the....15th__________-_ day of ..-..._OQtQ be.r---------------- 19__$_8__ ( the maturity, date). Following any default in payment, interest shall accrue at the rate of---11---% per annum on the entire amount in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire principal-balance). �13f']S��r�'�d't#?�d$C�t�Q }�#d�5i'{]Q$a7d60?t8C�t34'�Gt74�?�DC�C iZ4Dd01?Q�fl4U�Q�G�ifk'i�t�?L�4IIy{I�iE0�fA1s�C][t1�3Ci4 t�>��csesam�r�x>���aaxc*� irse�>�pcsitet�nat<a��c�fam�Y�>K�����l�xbla���xita�ii�>e�ioa�C x Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. Any amount may be prepaid without premium or fee upon principal at any time after---OGtober_.-15.__, In"the event of any prepayment, this contract shall not be treated as in default with respect to payment so long as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shall be treated as unpaid;principal) is less than the amount that said indebtedness would have been had the monthly payments been made as first specified above; provided that monthly payments shall be continued in the event of credit of any proceeds of insurance or condemnation, the condemned premises being thereafter excluded herefrom. Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser for examination except; none Purchaser agrees to pay the cost of future title evidence. If title evidence is in the form of an abstract, it shall be retained by Vendor until the full purchase price is paid. Purchaser shall be entitle to take possession of the Property on_QCt_0be z_._1 5----------- _____________________ 19.3. .._. 'Cross Out One. >ANb C6NTI ACT-- Individual and STATF. BAR OF WISCONSIN Wisrongin Legal Blank Co. Inc. Corporate FORM No. 11-1982 Milwaukee, Wis. ......._...... H cn " a STC - 105 r r y. H SEPTIC TANK MAINTENANCE AGREEMENT 0 St . Croix County z a OWNER/BUYER 220 ROUTE/BOX NUMBER .3 �YV Fire Number CITY/STATE_ ? �� f ZIP V��C/�� ) o?& N , Ran W, PROPERTY LOCATION : Alf- �_�, Section S , T Town ofn_� St . Croix County , Subdivision "' } ,� f)ilC 17?gh Lot number_. Improper use and maintenance of your septic system could result in its premature failure to handle wastes . Proper maintenance con- sists of pumping out the septic tank every three years or sooner , if needed , by a licensed septic tank pumper . What you put 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 . • F I/WE, the undersigned , have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth , herein , as set by the Wisconsin Depart- �w ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoni.ng Of ice within 30 days of the three year expiration date . SIGNED 1 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 . mum INSTRUCTIONS FOR COMPLETING FORM 115 - SB® - 6385 To be a complete and accurate soil test,your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3, MAXIMUM number of bedrooms or commercial use planned; 4. Is this a nevv or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; B. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shovin,and are permanent; 0. Complete all appropriate boxes as to dates,names,addresses,flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain,elevation)does not apply, place N,A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Mahe legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS aril Separates and Textures Other Symbols st - Stone (aver 10") BR - Bedrock c€ab - Cobble (3- 10") SS Sandstone gr - Gravel (under 3") LS - Limestone �s Sand HGW - High GE"OLIFT VV<ater cs Coarse Sarni Perc - Percolation Rate coed s - Medium Sand W - Well fs - Fine Sand Bldg Building Is - Loamy Sand Greater That) "sl Sandy Loam < - Less Thar 'I -- Loam Bn - Brovvn X-siI - Silt Loarn BI Black Si - Silt. Gy - Gray Ycl - Clay Loana Y Yelloirr sc.l _. Sandy Clay Loam R - Red sicl - Silty Clay Loam mot IVlottEes sc - Sandy Clay vv/ --- vvith Sic Silty Clay ffi' - f€;vv, fine, faint Ciav cc --- con'mor7, coarse m - meat vn n - (Via;ly, rned;urn rn Muck d - distinct P -- prorr1llwnt HWL - High water lCVel, Six general soil textures surface vvater for liquid waste disposal B M1 --- Bench Mari: VRP -- Verti..a; Referenctr Poo nt TO THE OWNER: This s-n,g t est report is the first step in seCUrilIg a sanitary permit. `the county or the Depe.,-trr-rew rriay r(:ctuest v t i iu [i n o_ this soil test ill the field prior to permit issuance, A complete scat of alaw� for thr: orivate sr a,vagc ws>,,v s and a permit application must be S,,jbniitted to che at>hrotrr rate local autltt>rrt,r in ordra°r o obtair, <t she n.anitar ras!asg: he otatair-,ed and of 5'e;cE prjur to the start J "iffy con,Aructiol). INDQS M. Y, OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSY'RY, C DIVISION BOX 76 HUMAN F EDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090)&Chapter 145.045) LOCA fl ON: SECTION: OWNSHIP UNICIPALITY: OT NO.:BLK.NO.: SUBDIVISION NAME: n>� /S�/a zs TAN/RAE(o ��oI-r 3 COUNTY: I OWNER'S UYER'S NAME: MAILIN ADDRESS: Ste'•C,?Jz� �'�Uu�1 PAS $�l-0NG l °!ZG So SST Lhos !Z)t)e4t TAUS 4 kU I . SV0 Z Z USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DES TIONS: ER AT STS: Residence 3 XNew ❑Replace RATING:S=Site suitable for system U=Site unsuitable for system �y CONVENTIONAL: MOUND: IN_-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:lop t ) �' S ❑U L�[S ❑U �$ ❑U ❑S,®U DS,®U If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the �v under s.H63.09(5)(b),indicate: • A Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL EPTH TO GROUNDWATER-lid@mIeS CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH Wd, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) 13- i , 0.6' LTS; J•LJ '$n LaO.8' Bill, IS;3.9`Bn"oq.S B- Z 8.5 100,2.' > S.S ' O-S 'I ; 1 S' I1 , o.�' If ;S•g ' )f B- 12 � > 8. 6 i o .b' ll ; 1. 1 II ; I.y ' it B- 4 > �.Z ' o.�' ►� i 1.3' II ; I. 3' I( j 3.q ' >> B- S 8. 9 ' 9'7-8 I.�oN� > `3 0. I) O. 9 � , o, y' �� 6.9 � 'I B_ PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERI0132 PERIOD PER INCH P- \ 4Z "-A. S PISL IL R g3.0 5 a G 3 P- Z 3- Ir F wR N ou'- im LL-SS Jv Z )71IJUTMS < 3 P- 3 A - v7." f=I mot.I ru s s < 3 P-_ 1 I rt L 1 99.0 ' P- Z EL I O e,6 p_ 3 I eL I q .-L 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. LN L-M f\L — q ,'a/ AGE L Lt:iT SYSTEM ELEVATION R'Ep`p'c'�" 2121 - 2S-S ' I u 7-1 S b Oy r IpI }� tN i rT bA i ! N u eti I I I -- \ A�,E 1 —y0 �C,C�T � S14oWN SEC. ZS I,the undersigned, hereby certify that the soil nests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: R TTFU EZ L. W Gi7GGF7z Z 1 - 9- S S ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): Qr y 13u zZ6 E�Ll�Swo�'T , tau ) 550 S-)6 0/6y CST SI DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER— ST. CROIX COUNTY WISCONSIN ZONING OFFICE 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 April 7, 1987 Carolyn Haag 201 East Washington Avenue, Room 141 P.O. Box 7969 Madison, WI 53707 Dear Carolyn: I am rescinding Permit No. 88471 which was issued on February 3, 1987 due to the fact that the alternate and initial system areas were changed. Reissued Permit No. 92487. If you have any questions, please feel free to give me a call. Sincerely, Roxann Croes Secretary 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: Property owners name and mailing address. Provide the legal description where the system is to he 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'/z 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 b '+l Ground �Atet - included the creation of surcharges (tees) for a number of regulated practices which KSM in S. can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried teasure is ued ir: your building is returned to the groundwater through your soil absorption �, 6 system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adn'linis- ° tered by the Department of Natural Ro.sources. These funds are used for monitoring grour;-- t %water, gr�)urdwater contarninatiori in�.estigations and establishment of standards GrourdwaiF i°'s worth protecting. E,3D..: ',98(R.03B6) SANITARY PERMIT APPLICATION COUNTY DILHRO In accord with ILHR 83.05,Wis.Adm. Code _ C/611 P—'°" STATE SANITARY PERMIT# ` —Attach complete plans(to the county copy only)for the system,on paper not less than SATE PLAN I.D.NUMBER 8%x 11 inches in size. —See reverse side for instructions for completing this application. [FOR TITION 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. VARIANCE ❑YES ❑ NO PROP TY OWNER PROPERTY LOCATION eowra t/a St✓ %, S ;5- T , N, R olo E (or) PROPERTY OWNER'S MAILIN DDRESS LOT UMBER BLOCK NUMBER SUBDIVISION NAM `ia C Y,STATE ZIP CODE PHONE NUMBER NEAREST ROAD,LAKE?3R LANDMARK �Ll aa I ro II. TYPE OF BUILDING OR USE SERVED: 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. kr 1P New b.❑ Replacement c. ❑ Replacement of d.El 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. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ZSeepage Bed b. ❑See a e Trench c. ❑See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSE**��D(Square Feet): // G(5— (pa t Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New Existing Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank oft 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): Plum 's Signat a (No S amp MPRSW No.: Business Phone Number: Phimber's Address(Street,Cit tate,Zip Code): N me of Designer: a , r 0 VIII. SOIL TEST INFORMATION Certified Soil Tester(C//ST)Name CST# L CS DDR S Street,City,State, Code) Phone Number: 's R. £l Ism CtA . IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature( o Stamps) jcfj Approved ❑ Owner Given Initial / Surcharge Fee Adverse Determination �/ D0 X. COMMENTS/REASONS FOR DISAPPROVAL: 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 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 systern; 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; 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'/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 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�, ater — —�, included the creation of surcharges (fees) for a number of regulated practices which Wiscorisir{'S can effect groundwater. The surcharge took effect on July 1, 1984. Ail of the water that buried treasure' 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 try the groundwater fund admirnis- tered by the Department of Natural Ra sources. These funds are used for monitoring ground- f water. groundwater contamination in.estigatinns and establisF;rnent of standards. Groundwater, it's worth protecting. SF-ID-6398(R.03/36) SANITARY PERMIT APPLICATION COUNTY LHR In accord with ILHR 83.05,Wis.Adm.Code STATE SANITARY PERMIT# —Aftach 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 '/4 %4,S T , N, R E (or)W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER I BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER 0 CITY NEAREST ROAD,LAKE OR LANDMARK ❑ VILLAGE : El TOWN OF: 11. TYPE OF BUILDING OR USE SERVED: 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.❑ 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. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. [] Seepage Bed b. ❑Seepage Trench c. ❑Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Feet -]Private ❑Joint El Public VI. TANK CAPACITY Site in gallons Total ##of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete strutted Con- Steel glass Plastic A pp' Tanks I Tanks Septic Tank or Holding Tank I 1 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber ❑ ❑ I ❑ I ❑ I ❑ 1 ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume resp `ibility 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: Plumber's Address(Street,City,State,Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Di Surchar a Fee proved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) h •j Approved ❑ Owner Given Initial g Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Piurnbing,Owner,Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION - TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit 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 cr the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owners name and mailing address. Provide the legal description where the systen 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'/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 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 ��1 result of over 2 years of steady negotiation and public debate. The groundwater bill Ground\' Ater included the creation of surcharges (fees) for a number of regulated practices which Wiscorl�in`s can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried ��asurE is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by y.,)ur holding tank pumper. 0 The monies collected through these surcharges are cred"ted to the groundwater fend adminis- tered by the Department of Natural R=sources. These funos are used for monitoring ground- t water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SGD-6398(803/86) �IR SANITARY PERMIT APPLICATION COUNTY DiL .�..v. In accord with ILHR 83.05,Wis.Adm.Code. 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 1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ❑ NO PROPERTY OWNER PROPERTY LOCATION '/4 '/4, S T , N, R E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME CITY,STATE ZIP CODE PHONE NUMBER 7n CITY NEAREST ROAD,LAKE OR LANDMARK ❑ VILLAGE: II. TYPE OF BUILDING OR USE SERVED: 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.❑ 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. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one)` 1. a. ❑ Seepage Bed b. ❑seepage Trench C. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet): Feet ❑private ❑Joint El Public VI. TANK CAPACITY Site in gallons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- plastic Exper. INFORMATION New xisting Gallons Tanks Concrete stCon- glass App. Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ El 0 ❑ 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: Plumber's Address(Street,City,State,Zip Code): Name of Designer: VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# CST's ADDRESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature(No Stamps) Approved I❑ Owner Given Initial Surcharge Fee Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal governrfient,unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report,the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system,circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis.Adm. Code will be applicable. 10. A new permit will be needed if there is a change in,estimated wastewater flow, (number of bedrooms,etc.), location of the system, depth of the system,type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan,drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances,distances between beds if appropriate,tank locations,effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit.Private sewage systems must be properly maintained.Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years.If you have questions concerning your system,contact your local code administrator or the Bureau of Plumbing,DILHR,State of Wisconsin. wisc°nsin APPLICATION FOR SANITARY PERMIT DILHR COUNTY (PLB 67) TEf7T OF UNIFORM SANITARY PERMIT# -OEPRRT IIIObSTRV,LRBOR 6MUTR1-IRELRTIOI-IS —Attach complete plans in accord with s. H 63.05,Wis.Adm. Code for the system, on paper not less than 8'/zx 11 inches in size. —See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS / T.- a� cc- 4 a S e 11 PROPERTY LOCATION CITY: VILLAGE: 1/4 1/4, S , T , N, R E (or) W TOWN OF: Ti^D LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, AKE OR LANDMARK STATE PLAN I.D. NUMBER �� J TYPE OF BUILDING OR USE SERVED X1 or 2 Family Number of Bedrooms. 3 ❑ Public (Specify): THIS PERMIT IS FOR A: XNew System ❑ Tank Replacement ❑ Repair El Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. Ik Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed `peptic Tank Capacity (]0 Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: 'e-Aer aNC*%dZ1,Q IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): L 3 (P P (P-4—LA X Private ❑ Joint ❑ Public I,the undersigned,hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signat e: M MPRSW No.: Phone Number: 7k kU _ G�•� 5�3 ►'ter 33S_ Plumber's Address: /�D go&A, �t 1 ����� N�eyo�Designer: oo //li l 1 i'3 f 1 K,- C I �.- COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ❑ Owner Given Initial EJ Approved Adverse Determination Reason for Disapproval: Alternate course(s)of Action Available: DILHR-SBD-6398 (R.5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing,Owner,Plumber ulrr 1L� ,ut ..7.r � hB� .�t I, 1 .. .rh) f cd �D S rJ C ;Mel cial u. e SITE ;S S' tTr�.Es_E FC'H l HCL _ �, LL _ 'S _ _ _ . OUT EASED ON SC,iL CGNDIT10',JS r:"lake N iii . r , ,i anr. dishi:nr,f: as requires . ALL SOIL TtJ S :SST BE FILED UtiITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. 14Er REVIATIO%IS FOR CERTIFIED SOIL TESTERS Cl ` :vM, I _ SS - sm- is — Flne San'J Bicip — ✓Uii .li g Loamy! Sand > — Greater Tha!� S_nd�, Loam — Les Tnw. -- Lon LSD. _.. E CM, LOP! TOT'-!F .. l �St ,. dnital Tt. Lt:�0r1y u. c eo!_I SAFETY & K !,DINGS OF REPORT ON SOIL BORINGS AND DIVISION TRY, P 0 BOX 7r'69 ;iCR ,ND PERCOLATION TESTS (115) MADISON Vi ti_-,707 FFLATIONS (H63.09(1) & Chapter 145.045) SECTION: _r0\rjFNSHIP' UNICIPALITY. LOT NO.:BLEt�0. SUBDIVISION NAME: LOCATION.- C =)Al COUNTY �-E-W-S-YU Y E R'S NAME: F7-A LL-S) "J I DATES OBSERVATIONS MAUL S: `VT 10 Y� BEDRMS.': COMMERCIAL-DESCRIPTION: (PROFILE DESCRIPTIONS:IPER C Ci I ATI ON TEST 4, �1.) a '�O F<�Ne w �EO]Rep�lace XResidence RATING:S=Site suitable for system U=Site unsuitable for system r b-N VD4-T-i 5-N-A-L--TM-O-U-N-D--------- I-N-GROUND-PRE���u-RE jssTEM- N-F I C L HOLDING TA N - RECOMMENDED SY ST EM:(optio nal)- 0s ❑U M S ❑u ZS lu_luS JC�U_J_[JS klul_ If Percolation Tests are NOT OT required DESIGN RATE f any Pori on ol the area is in the J-') 'L\ F Ion. under s.H63.09(5)(b),indicate: LF, ociplain, indicate 'ioodpia,n elevation: PROFILE DESCRIPTIONS DEPTH TO GRO C_ -_ - I WITH THICKNESS,COLOR, TEXTURE, AND DEPTH BORING TOTAL GROUNDWATER-Ifte+4t-e- CHARACTER OF NUMBER DEPTH khf ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON B ACK.) L .2!,' E?.N '13t\% S•Z fa B- S' > B > 0 .6- - 3 _S-G tl B- 4 j B- tN tza > 8 cy o. 97 6.9 r II B- PERCOLATION TESTS --f-EST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN.. PERIOD ME R 10_D2 PERIOD 3 PER INCH It PZ L Z H Url�!7 3 < P_ Z :1-7 46 Q>E= -C>Q'r ) < 1 lu G -S P. L/ A FTIE:R P_ N EE L C101•o P- Z EL 0/ P_ 3 oily- 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. N L SYSTEM ELEVATION o LT V 11 I 7- 1N It's 77- L>7_S 'VJ�ST t>F 7516 N/' Irk E__r C H 411 64�_A/ T 1,the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: CERTIFICATION NUMBER: ONE NUMBER(optional): ADDRESS. x Z z' SY C� S-)6 _ CST SJINAT7E: LIST RIBUTiON: Oriqlnal and one copy to Locai Authoritv,Property Owner and Soo Testel, 11h, DILHR-SBD-6395 (R.02182) OVER - l�Wl t\S U, -3 Cam? f� ,Owner's name San. Permit No. H63.05 PLOT PLAN Show: : ��� !_"J Location of building served NA Dosing chamber Septic tank Vertical/horizontal reference point QBuilding sewer System elevation is S S FT Effluent system Q Well QReplacement system area Q Property lines w/in 501 of system NA Distribution boxes j—i� Scale = � � $0 , or dimensioned .E - �� cCi��T AS SW"AIQ NA, Pump and controls: Mfr. & Model No. Vertical Lift Size Force Main Friction Loss T. D. H. Vol. Dist. Pipe Gal. per Min. Gal. per Cycle Place check mark in appropriate box, indicating item is shown on plot plan,below: vE�T gr12. 6��V, 101.3�oN \� ti � �j�6, l SPIFz.E /N B �CicbAR )SIo'P y i1 SoL1Dw.�,Ll. `.a pv� r MOCK (SALLOM Sc�T)C jjrM C ra• o►J S�!� �N. SE / MI"PtTt E ST e LI-►J� �.oe��o►a By the granting or approving of the above plan, or upon the event of a subsequent permit being issued,St.CroixCounty and theSt.Croix2ounty Zoning Administrator, does not assume or hold itself liable for any defects in plans or specifications, plan omission, examination oversight, construction, or any damage that may result in or after •nstallation. 6 a���2 P um r s signature icense o. Datie 1?r,v. 3/F. � r CROSS SECTIDJ - OF A BED 5-'1 STEM - t 4- SOIL FILL 2 OF AGGREGATE DISTR15UTIOLI PIPE AppROVED 5!3UTHETIC COVER JPAATERIAL OR 9" OF STRAW OR MARSH HF.':3 1"OF%2-ZI °AGGRE CG-ATE ELEV. OFRS.S FEET _ DISTRIBUTIOU PIPE�CHES BUT UO MORE THAM `12EIA1CHES B OW FIIMAL GRADE BE AT LEWr IUC, AUD AT LEAST P-0 1 - � IIJGHES MAXIMUN� DEP-j-E{ OF >_%ACAVATIOIJ FROM ORIGiviAL GRADE WILL BE ` MINIMUM DEPTH OF EXCAVATIOAI FROM ORIGIUAL GRADE WILL BE 3L/ INCHES SIGIJED: LICEUSC UUMBER: l S ;; w `o q v m u > i o f T co o Q Q n � � — — 4 m — m — o. y m rn cQ o rnE E m - m w E E o N 10 e °- > c Q �- E d D a o -02 O Q ca N o „� �o � 'o, E _ w (n l0 O .� N N L ^ _Z O CO N cu p C > a�j Q •� N m >u 1 1 1 E N a 3-C > LLJ U E a a o-°« ° „V m o E o t-% Cr a E Y >m � m rn E drn � M oM O o � m LnC(p >_O zO C >O �' >' « ? Na m m o E 3 d 'o w m h co �- € E � 3 €� _ - O � v o �', a E `° m e n ° � 0 w of - mmm !0d � � E m m `L C w a o? c :° TO ,w dam' oE m 0 30 U am om c� " c .- 3= Nm ow w w m 3 m Z m ° m E C: - m� >m ` L m L L C L m L O O. W T ~ m ~ O ~ u O 0 ~ m C m _ ; _� Q z �� m mm E c m w � n uNom c a, od -cc a z w �oC z z • z 9 v) F— O O 0 o w p U U Q U) z Z LL cr x O a �° m o Q z o� w O O N E— 0 cr U c/) 0 T- = O J Q Q F- Z n� O C) m i CC LL ltd w J U) m U � U)w � > U) x IL t w N w O w c ao w z O ,� .. ir O m o ir 0 z O �- Q F- tl ` A INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 r� M To be a complete and accurate soil test,your report must include: 1. Cornplete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a nevv or replacement systern; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A sepavate sheet may be used if desired; B. Make sure your benchmark and vertical elevation reference point:are clearly shown,and are permanent; 9. Corn let:e all appropriate boxes as to dates,narnes,addresses, flood plain data, percolation test exemp- tion,if appropriate; 16. If the information (such as flood plain,elevation)does not apply, place N.A.in the appropriate box; 11. Sign the form anti place your current address and your certification nun ber; 12. Mahe legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, Y ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Sail Separates and Textures Other Symbols st -- Stone (saver 10") BR — Bedrock cat? -- Cobble (3- 10") SS — Sandstone gr - Gravel (under 3") LS — Limestone *s — Sand HGW — High Groundwater cs ._ Coarse Sand Perc Percolation Rate med s Medium Sand W -- WeII Is - Fine Sand Bldg - Building Is — Loamy Sand > — Greater Than �sl Sandy Loam < - Less Than 'I — Loam B Brovin *sii - Silt Loarn £11 - Black si — Silt G'V — Gray *cl - Clay Loam Y Yellow scl — Sandy Clay Lo am R — Red sicl _ Silty Clay Loam mot Mottles sc — Saifdy Clay v-v/ Lvitlf sic — Silty Clay fff - few,fine, faint c __ {;lay cc; - comnle?n, coarse pt Peat mill -- Many, riledIUM m ._ Murk d -._ distinct 1) prorninent HWL — High water level, Six genrsral soil t.extrrres surface water for liquid waste disposal BN1 — Bench Mari: V RP - Vertical Reference, Poinr- TO THE OWNER: Ths s k test rO[lort is the fi€'St st€rp in sr.;ctrrirrcl a sanitary_permit. The county or the,Dr.prart ne=e,may re tuest v(";iii;.atiw1 o-1 this sr> 1 test fry the field pr>oi to pi�rrnk Ns'u fnf�e. A coniplf�te ;tai of pl�ff,s fr r the p iv�jte vw'!f. system and a Pei'mrt application must be subrt"fitted io the appropriate local awhorfty !n order to oktam'21 13c';'i`YE?t`,. The sammty p-unit rust 1:3P obtained and posted prior to tn.`,twt of aRV ,CS.=.= LJCli(. 1. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115 P.O. BOX 7969 HUMAN RELATIONS 1 � MADISON,WI 53707 (H63.090)&Chapter 145.045) LOCATION: SECTION: TOWNSHI MUNICIPALITY: LOT NO.:BILK.NO.: SUBDIVISION NAME: NE sw'/ 1/ zS Tz8 N/RAE( COUNTY: OWNS UYER'S NAME: MAILING ADDRESS: F3�L.oNGi IUE7e FQ�L._s w I TV ZZ USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMER AL DESCRIPTION: I'PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 113- 141. New ❑Replace —-� _$ .) N•A.". RATING:S=Site suitable for system U=Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED SYSTEM:(optional) ®$ ❑U ®S ❑U $ ❑U ❑S OU ❑S WU 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: �l �. Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-1440dfS CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.) B- �, b Q0.�' >vo�L > 7. o'�'D��hLTs; I.Z'12�V%L;b-7 '13h Is ,s.o�,,)ha S B- Ll �_-2,' 95. 9' K3I)Ai(-�j B- `CO V:� UIWZ rr 2EpL,01<E iOvT 1 MefN -rcl A_\t,W W B- G 2-. l =•L1J ry o v � �t PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 PERIOD PER INCH P- P- — �' � - �O 9-�5 g 3 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. 12 L_w�-c,E, t-,ts_�T' r �-�9 �!L 0 T SYSTEM ELEVATfO CLIv i 'Z I i Lo S h ' P t S � i 1 � f � ' , 8 to •3�� N \, A, )'I=30 1 HovSe oF:- slfs'r� PcR-w S, I,the undersigned,hereby certify that the soil tests repo ad on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code,and that the data recorded and the I cation of the tests are correct to the best of my knowledge and belief. NAME(print): .� ( / TESTS WERE COMPLETED ON: S�a.`C1�vZ L. w (9 f,9� ADDRESS: ��- L4 Zic � ZZ 6 �i A CERTIFICATION NUMBER: PHONE NUMBER optional): E L.L_S LIv o R W I S y� ' 'qA �(�` S-)b 71 S.4 L S- 01 6 CST SIGNAL/ DISTRIBUTION:Original and one copy to Local Authority,Property o' w_and Soil Test!'.;."V; DILHR-SBD-6395 (R.02/82) ?`W R ' DEPARTNJFNT OF REPORT ON SOIL WRINGS AND SAFETY & BUILDINGS DIVISION INDUZTRY, 1 C LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHI MUNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: Ne Std/ 1/a -zs Tz8 N/R2zE ( —F�o'� 3 - sT• e. lx. l��GHLE�JbS COUNTY: OWNER' UYER'S NAME: JiVIAILING ADDRESS: ST-C�IV- #\S zoELOAj a1 A USE DATES OBSERVATIONS MADE INO.BEDRMS.: COMMERCIAL JPROFILEDES IPTIONS: PER ZOLATIONTESTS: Residence 3 4j RATING:S=Site suitable for system U=Site unsuitable for system �CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) S ❑U ®S ❑U S ❑U [IS MU EIS ,JU z-nr - jr-R�s- �-�.� s 'xso' [under Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the s.H63.09(5)(b),indicate: '�_ Floodplain, indicate Floodplain elevation: ' PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IBS CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH NUMBER DEPTH Mr ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- B- �, 6� G10-Ot No�1L > 7.(� o`>I�1Z�hLTs; 1•Z'�3�L�o•7 �$r 1S �S.���hhtec� S B 1 6•`� I c1S .Z' Yvb►V 7 6.� C) ; ).y Y ; 0.4, B- B1 ,mss o)v P.� R� f�� 10-9 -8S .X1'1 S T r S Y1)0 w A B- G.2L& =to I - C v t Z PERCOLATION TESTS TEST I DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBERI INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P E RI PER INCH P- P_ — ���-� Y �� s 1 < 3 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. Snow the surface elevation at all borings and the direction and percent of land slope. - i 9 Q1 L.L O 7— ��,�L I'v�� k�K�V�" Q q O.O ' F SYSTEM ELEVATION 2`� �t+� I g �7 Alm_ t\j-Leo I 1 I I —+ 1 f le L-_-L $H-tr?—21D3.3 IQjL 1 'CLTD b SO Sw7�.tt=30 01= SyS'r A�1.LYt S. S�. ZS 1,the undersigned, hereby certify that the soil tests repo,,ed on this form were made by me in accord with the procedures and methods Specified in the Wisconsin Administrative Code,and that the data recorded and the I cation of the tests are correct to the best of my knowledge and belief. NAME(print): TESTS WERE COMPLETED ON: ADD—RE SS: `T L� ��x, 'ZZ s CERTIFICATION NUMBER: PHONE NUMBER(optional): �LLswolz wt Syuti S-)6 7ts_�4LS- 016y -- — CST SIGNATURE: DISTRIBUTION: Or iginal and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395 (R.02/82) —OVER —