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HomeMy WebLinkAbout042-1099-95-000 \ ¥ c � ® } I \ � � ~ I R ) � $ � � $ 0 ] 2 � 2 / § ) § c I 2 7 § » g k � k c n � (D \ j E g / \ IL m § � k Z k : 2 ) k k / \ 7 \ N 0 5 ) [ ) � Q) Q ) k }} .. } 7 G ) k 2 n 6 k ) ) / { E : § m § ( 7 2 2 2 koBQ) OD � p p Q ; 0 \ CO D / \ a 22 ' ID § & = o EQ / 2 2 g \ 7 § k J } ƒ f _ \ § cc (D $ k { \01) / \ \\ \ K , & ) ( k § i § { \ / ~ \ � � 3 g $ ] / m A � § E 2 I 2 E ( C � ) ƒ B � f i & J a 20 to 3 INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION ' TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's.name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and.phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground .at.r— included the creation of surcharges (fees) for a number of regulated practices which Wisco ir 'S ° can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure ' is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. c 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) AL SANITARY PERMIT APPLICATION COUNTY JZ1 01LHFR 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 ��JJ, I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES No PROPERTY WNER / PROPERTY LOCATION le T-0 5Gf '/a '/a, S ' T , N, R �ff E(orW PROPERTY OWNER'S MAILING ADDRESS LOT NU ER BLOCK MBER SUBDIVISION AME CITY, ZIP CODE PHONE NUMBER O ILLAGE: NEARES ROAD,LAKE OR LANDMARK -°,zj II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family _ 4DL499- 0R ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable) 1. a. X 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. Wconventional b. ❑Alternative c. ❑ Experimental 2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tan k V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. El Seepage Bed b.,I�I.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 F t): PROPOSED(Square F t): �/J . _,$ O ) / 2 Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site Fiber- Exper. in allons Total #of Prefab. INFORMATION New xistin Gallons Tanks Manufacturer's Name Plastic Concrete Con- Steel glass App Tanks Tanks structed Septic Tank or Holding Tank /1�tl0 61d® F W/o 1'�T ❑ ❑ ❑El 0 ❑ Lift Pump Tank/Siphon Chamber ot`' "/�3 VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system sho on the attached plans. Plum er's Name(Print): Plumber's Signatur :(No Stamps) P/ PRSW No.: Business Phone Number: Plum er's Address(Street,City,State,Zip Cod Name of Designer: VIII. SOIL TEST INFORMATION Certifiedr�joiI Tester(CST)Name CST# CST's/A`D—D'(RESS(Street,City,State,Zip Code) Phone Number: IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Dat e Issuing Agent Signature(No Stamps) ®Approved ❑ Owner Given Initial S rcharge Fee Adverse Determination I a0'0C) �S' ��-'y g'l `�11 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 f 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 HArUI n L Ruci n Location of property It it, Section �5 , T_?,.�N-Re_ W Township Mailing Address Rix 17 - eoh4 r, I A)1- :ogi3 Address of Site <-0 2- Subdivision Base . Lot number Previous Amer of Property L e, Total Size of Parcel Date Parcel was Created C, Are all corners and lot lines identifiable? -4- Yes No Is this property being developed for resale (spec house) ? Yes No Volume `/9_0 and Page Number ZyC_ as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number, volume and a 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 s all also be required. PROPERTY OWNER CERTIFICATION i (goo) co-t.Li6y that &a statements on this orcm wce tJcue to the best o6 my (out) hn�vCedge; that i (we) am (she) the owneA(a� 06 the phopent dmcAi.bed in th,i.a i"Wmd-Uon 6onm, by vi)ttue 06 a waAAanty deed neconded in he 066.ice 06 the County Reg ' teh o6 Deeds ah Document No.Lf ; and t{ a t i (Ule) pnea en t£y awn t1:e pRopoaed Aite bon the sewage cu-� .0oa ays em (oh I we) have obtained an cdAt +ent, to nun with the above dehe"VItbed pnopeAty, bon the con tAuc ion o6 aat.d system, and the name has been duty neemded .tn the 066.Lce of the County Reg•i.a.teA o6 Heeds, " Voecm+en.t No. ) SIGNATURE 01? OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATi SI D DATE SIGNEII __- DATA THIS SPACE RESERVED FOR RECORDING DU C un�ENr No. WARRANTY DEED ; STATE BAR OF WISCONSIN FORM 2—1982 M �I �3 2685 '" , CR R CO- ,WI �---- Recd for Rerd Lucille Hansen, a/k/a Lucille G. -•--.-•.-_. -..___•. DEC 3 1987 ......._..........-•- I Hansen, a sin le erson .................... ................................ ................ 01 -------------------------------•--------------- rshi - Marvin L Burton and Jill K of0e� i conveys and warrants to Bux-tan.t...h-usband..axxd...w1f.e_,-._ae..su .. . . .. p.. inax.i.tal...px.Qua_ext_y-------------------------------------------------------------- `. ••................ ----...•---..... ................................. RETURN TO ................................... �._.. _ _______ ___ I. the following described real estate in •.....................County, State of Wisconsin: Tax Parcel No_ ______________________________ ! The Southeast Quarter of the Southeast Quarter (SE4 of SE4) of I Section Thirty-five (35) , Township Twenty-nine North Range Range Eighteen West (R18W) , EXCEPT that certain (Conservation Commission) conveyed to the State of recorded March 26 , 1963 in Volume 393 of Records, at Page 70 , as Document No. 271895 , Except any land in said Southeast Quarter of Southeast Quarter (SE4 of SE4) lying North and West of the above-excepted parcel , said parcel being conveyed ii containing twenty-six acres, more or less . it �i r; li ii _ZXE1IIM 4 II l This .-i 5...n_Q.1;............ homestead property. 1 (is not) - Exception to warranties: easements and restrictions of record f ............. Dated this ......--•--•-1 i.r.•-• day of .._I CP�+!�P✓.._._. - 1f _ X ¢� ................ ......•(SEAL) ..... �o ......(SEAL) Lucil-le-_-G-, --Hansen-.-••.._._._._._.._ 'k -------------------------------------•-•---•-•_-______--------_•_- +. li ..................(SEAL) -••-(SEAL) ----_--- " --------- ------------- ACKNOWLEDGMENT ii AUTHENTICATION STATE OF WISCONSIN �iSignature(s) ` ----•----•--------- --- -•----- ---------•---- ----•- --• ---- ------....... ss i .���i�... .County. __-.-_• . 19,--..- Personally came before me this _. es" aY+v�f, aj �! authenticated this ........day of............. v I' ----f� .'�t!--------------- --� 19.-8T' 1 Q;a p�e n'�.am� .................................. •----•• - -j ucille Hanson,-.dll `: u � 1e __.. •_ - ....._G_.__.Hans.erl---•--------- ......... .. ._.�._.*� ------------------ TITLE: MEMBER STATE BAR OF WISCONSIN t --------------------------- .-----------•- a..!c ,�'��P •e-- . (If not --------------------- authoriaed by § 70.6.06. Wis. Stats.) to me known to be the person ... .... Ti'��E�etlt�d'the foregoing i trument and acknowi ge THIS INSTRUMENT WAS DRAFTED BY � C ! Thomas A. N:cCormack . # / .......................... ----------_--- ___________ Baldwin_t_ WI 54002 .._ Notary Public STS Iti° .................... 9� (Signatures may be authenticated or acknowledged. Both MY Commission is perrnaneict.(If not, state expiration.. are not necessary.) date: _._ - _...•_..------..-.-._-------------- 19- ) i •Names of pins signing in any capacity should be typed or printed below their signatures. �~~ 'STATE BAR OF WISCONSIN Stock No. 13002 KGMiI!erCamparqffW5 FORM No. 2— 1982 i I d J• l N 9 r r 9 N O Z T C _ 105 S E AGREEMgNT VA TENANC � SEYTIC TAN St Acroix County Fire Number-- �RIBA3-j ` Z iP 0 gOX MBER # R � Q _W , NU 121%-N , JZti �TEI E ection ,�� cr 0 i County • ITY I SIT XT �, S � st . ��• er-- 10 ' ATION •�� � Lot nu mb 1 PROPERTY Town of suit in Subdivision tic SYstea ntenancsooner .into tenance ° e wa tese a yr tp re hate You Pu a treat- roper use e f allure the septic c t`k eve" the Sept c tank ay r Ims prematumPing 0utnsed se t�tion °f em. a Brant fo its of P by a lice e�he fk"c sYst rec`i�` sYstemi eeded , nth fe e lisp le t° failing County if n stem ca a vast a el-A-10-' b nt of a (',roix C nt that mntsstage in residents m�fbreplaclem19�8 ' the rc�uir per t . Croix ofu 60 of the rior u° o£1i980 , their systems p S maximum oPerati i Aug e to keep n a a S in rograim ems agre County Zlumber , 'which this all pn` s s�� St . Croi a master P er veri- ers of ubmit to and by ed pump roper maintained• agrees t bys the ° berr or a l lc system Inv, (it P n cum i s roperty ° for'"' Sig ewater dition and 'Pump sludge and to The tif icati°lumber . re site after inspec 3 full °f days Pri°r V_°urne tt at (1) it ion an A.iS less P r°X mately 30 as N oil fyin% g con septic tal e se d reh v b nt ire an ce wit ~° oP the wit uir rdan Certi icati xPira ion • e read the salo syst;e W isc°n el c° jeted ays ea av s by t ust b 30 d set three Y e under ivate se$rein i as cati°n toy pf f ice within IIWE, th in the P forth , herein, Zoning to maianaards seResource�roix County the s of Natura o the St . anon date meat turned t r exPir SIGNED ofd the three year DATE Zoning Office Croix ou Cnty YC 0 . a, W� 500 X15-425-836ab°ve address • 15�7 9 date e3 and return t° INSTRUCTIONS NS FOR COMPLETING FORM 115 - SRi - 6395 To lbe Ea €;carnpl€tie and a c r','ate soil ti'.St,�.C3:.r r.;por" n'iust 1. Complete legal dest.r-iption; 2. The use section must clearly indicate whether this is a residence or commercial project; 1 IMAX INIUMi number" of bedrooms or commercial use planned; 4, is this a new or replacement systern; cornplc'te the s.,i aodity rating boxes, A SITE IS SUITABLE FOR A HOIL SIN 1 8NK ONLY IF ALL 0-1-HER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for Writing profile descriptions and com plating'the plot plan; 7, Ik�1AKE A LEGIBLE diagram accurately locating Your t 5t locations. Drawing to scale is preferred, A st:parale s,hee—' may be if de sired; 8. lake sun?do'u'r r;ei=c rn�lrk anal e'ticai elevatrc:i i"E:ft ,:34.,:: oint ar'e,,clearly shown anj arc, per-maner-lt; 9, C,o€nplete all appropriate boxes as to dates, names,addresses, flood plain data,percolation test exernp- tiorY, if appropriate; 0, If the information such as flood plain,elevatio-n) sloes riot apply, place N,A, in the appropriate box; 11, Sign the forrn and place your current address ar-d your certification number; 13. Make legible conies and distributer as required, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS Of: COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st — Stone (fever 10") 8R Bedrock cob ._ Cobble (3- 10") SS .._. Sandstone gr Gravel (render 3") LS Limestone Sand HGkAJ High Croundawater cs Coarse Sane} Perc Percolation Fate coed s ;tedium Sand W — Well I's Fine Sand Bld(., -__ Building is L€names Sarre.,+ > — Greiu,,i Them sI Sandy Loam ' Less Than I Loam Cin -._ Brown 'Sdf Loam Bi Black Si Silt Cy ..._.. Gray r;l .... Cay Loarn Y _-- Ycliovv Sandy Clay Loam p _.._ Re( sE:°l ...... Sr€t,y Clay Loanr sc _.. Sandy Clay ""v"' ...... vv lh sir:; - Silty Clay fti — few, fine, faint c .. Clay cc - cornmorn,coarse pt — Peat mrrr -- lylar€y, medium Muck cI -- distinct P prornirner;t HWL — High water i('We" r=,x c€ ,r r -- avail textures :,r.rrface water r kuuid guar>>t�r d sposal B _ Bench Irrlarlr VRP ....- Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS DEPARTMF' DIVISION IN9USTRY P.O. BOX 7969 LAaOR At PERCOLATION TESTS (115) MADISON,WI 53707 HUMAN II (ILHR 83.0911) &Chapter 145) LOCATIO/43 SECTION: TOWNSHIP/MUNICIPALITY: TTIR O.:BLK:NO.: SUBDIVISI N NAME: E f 5 /TQ?N/R 1�E (o MAILINGADDRE N OLI N OJp�NER'S/BUY R'S NAME: �1&.411 C!(� DATES OBSERVATIONS MADE USE , IPROFIL DES IPTIONS: PERCO AT N TESTS: �� NO.BEDRMS.: COMMERCIAL DESCRIPTION: �w Replace r/ L�IRe,nce If4 A RATIi:S=Site suitable for system U=Site unsuitable for system C CO URE: SYSTEM-IN-FI HO^LDING TAN RECOMMENDED SYSTEM:)®ptional) a U U S LJI S El 1',2"nd rcolat DESIGN RATE: If any portion of the tested area is in the If E ion Tests are NOT required under s. ILHR 83.09(5)(b),indicate: Floodplain,indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BAC .) R OhK n s, f >rx � n s > B o it 170—R-6 n sIL, III an I�s, i1 ns�., n s B- (o W 3 10 K ns14,E Cg enLs, 1I l3r) sL,, q > ,a w /1 K16n5 r14P) I.A.)Z K r l.f 2 an4.91©13ns Lf Qn s PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN W RATE MINUTES ATER LEVEL-INCHES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PER D1 P IOD 2 R D PER INCH P- O 17 rZ 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 th hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all rings&nd thg�ji(ection and p rcent of land slope. ` SYSTEM ELEVATION c1 y o y E e � 3 19 13 , _ -3 , F E r o TN p �- E 3 E F I,the under hereby certify tha\t e soil a is reporte on this form w r ma e y me in accord with the proc dures nd methods specified in the Wis nsin Administrative Code,and t recorded and the location of the tests are correct to the best of my knowledge an elief. NAME(print): �_— WERE C9M LE E ON: /a lqlyz ADDRESS: /1 o CERT F ATIO NUMBER: PHONE NUMBER(opti nal): .� - a� 3 -,r CST N To RE: cq I DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester. DILHR-SBD-6395(R. 10/83) —OVER — i Ll �.. b ra C r �, N n _ u► ;� �c � � { a N r -v A \i r, 0 0 � 0 ---� Z�O& �_�