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HomeMy WebLinkAbout030-1069-95-000 Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM County: $t. Croix INSPECTION REPORT sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 219 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 State Plan ID No: Permit Holder's Name: (1)(m City Village X Township Parcel Tax No: Fricke, Len S. & Pamela Roessl St. Jose h, Town of 030-1069-95-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: TANK INFORMATION 26.30.19.252i ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION st/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH EWd Length No. Of T renches PIT DIMENSIONS No. Of Pits Inside Dia. quid Depth DIMENSIONS SETBACK M TO P/L BLDG WELL INFORMATION LAKE/STREAM LEACHINJR Manufacturer: ystem: CHAMBER U NIT Model Number: DISTRIBUTION SYSTEM HeaderMlanifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent to Air Intake Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over =x-x Bed/Tre nch Center Bed/Trench Edges Seeded/Sodded xx Mulched Ed Yes Fx~ No Yes ~ ]No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection Inspection #2: / / Location: 797 Aushegun Trail New Richmond, WI 54017 (NE 1/4 SE 1/4 26 T30N RI 9W) metes & bounds Lot GI-3 Parcel No: 26.30.19.252i 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Fa~ Yes [E No T Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Signature-- - Cert. No. RECEIVED A ~i I k a; County Sanitary Permit A Ica Ion PP ST. CROIX COUNTY WISCONSIN In vaccord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT 010PAbftal information you provide may be used for secondary p GjV(,j( (+(VELOPME pur oses ST. CROIX COUNTY GOVERNMENT CENTER $ Nr [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road Hudson, WI 54016-7710 (715)386-4680 Fax (715)386-4686 Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size. County Sanitary Permit # ❑ Check if revision to previous application Z 19 I. Application Information - Please Print all Information Property Owner Name Location: L~ON~A~ f'flrc~fF_ 4 J~ U 1145",C114, Sec wners Mailing Address ] U N, R E (or W Lot Number Block Number 0 11 RI VF-N R" & L 3 Zip Code Phone Numer .i ► ~ ubdivision Name or CSM NumberBuilding: (check one) Family Dwelling - No. of Bedrooms: ~itY S❑JV'illage own of LFa c/Commercial (describe use): -owned (S G k Permit: (Check only one box on line A. Check box on line B if applicable) Barest Road r45r-as A J v,,~ V r 2. Reconnectn 3.❑Non-plumbing 4. ❑ Rejuvenan arcel Tax Number(s) Sanitation 60C Permit Number Date Ianitary Permit was previously issued 1351q 7_3 T System: (Check all that apply) --rized In-ground ❑ Mound 2! 24 in. suitable soil ❑ Mound :5 24 in. suitable soil ❑ Sand Filter [3 Mound A+0 ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade equired Proposed (Gals./day/sq.ft.) (Min.4nch) J ~ l n ~ Elevation VI. Tank Information Capaicty in Gallons Total # of 7 M facturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks VII. Responsibility Statement ❑ ❑ ❑ ❑ ❑ I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installa ' n of n-plumbin sanitatio system. Plumber's ame (pr'nt) Plumbe (no a j P/MPRS No. Business Phone Number Plu Br's Address (Street, City, Mate, Z' Code) yT~f r Vlll. County Use Only Disapproved Sanitary Permit Fee Approved Date I sued Issui Agent Sin ( s) Owne / r Gi en 't a veerse 'i Z2 . 00 (,/I Wtatron IX. Conditions of Approval/Reasons for Disapproval: . J df9I 04 P BASS LAKE nn N p z C D m oX~ mGc O Dm~ pn~ ma mDz -a 7o0 z~s mr^ CyO p C z i p G~ D m z Z D w / D~~ DO yx p oNy 'yZ O3z m~~ ~ O D Z D K a_ G °i>m ZT azx mOZ / i - i a0 °O c0=x _ r / / 840 112 _ 315 905 / 920 o ~mw \ )I / Ono r) m \ \ ca Rai - \ \ \ \ \ 925 - / sol / g y c c ~ 5D y t OG A Vi y O m ~ / / r \ d 3 s yzT rn i~ cy: z.o = 3~z^ D a d o z m z~ ~ _ z u n. ~ ~ ~ ~ SJ 0 ov _o w P% E~ C a G O 0 0 0 c FRICKE ,EL= CABIN AT 979 AUSHEGUN TRAIL MVM W ST JOS"% ST. CRM CMWM, USWNM pt EXISTING C4NDIT10NS 3tFIod bve* 710-. ~ terns ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 797 Aushegun rr. located at: NE 1/4, SE 1/4, Section 26 , Town 30 N, Range 19 W, Town of St. Joseph Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service 6-16-15 Did flow back occur from absorption system? Yes No x (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: 1000 Construction: Prefab Concrete X Steel Other Manufacturer (if known): Powers Age of Tank (if known): 1990 Permi nffiber if 135466 Keith Knudtson (Licensed Plumber ignature) (Print Name) 648443 (Title) (License Number) MP/MPRS 06-16-2015 (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 ST CROIX CO UNTY PLANNING & ZONING Dear Homeowner: If you own property that is served by a private on-site wastewater treatment system you are required to provide proper maintenance on this system as per 145.245(3) Wisconsin State Statutes and Chapter 12.7 of the St. Croix County Ordinance. Proper maintenance will help to ensure the longevity of your private sewage system and avoid premature failure. Code Ad This maintenance program requires inspection of or pumping of the private sewage 715-386--4680 4680ration system at least once every three years at the owner's expense. Inspections may be conducted by a licensed master plumber, licensed journeyman plumber, licensed Land Information & restricted plumber, licensed POWTS maintainer or licensed septic tank pumper. Pranntng The inspection shall certify that the system is in proper operating condition and the 715-386-4674 septic tank is less than 1/3 full of sludge and scum. If the inspection reveals sludge R 46 and scum volume to be greater than 1/3 volume of the tank, a licensed septic tank 715-386--774677 pumper shall service the tank. The St. Croix County Planning and Zoning Department is required to track maintenance reporting so your cooperation is Re"YCA-g greatly appreciated. 775-386-4675 Please return the information below to: St. Croix County Planning & Zoning Department, 1101 Carmichael Road, Hudson, WI 54016. ST. CROIX COUNTY SANITARY MAINTENANCE CERTIFICATION FORM System was installed in /"The private sewage disposal system is in proper operating condition. ❑ The septic tank was recently pumped by a licensed septic tank pumper, or it was inspected and is less than 1/3 full of sludge and scum. ❑ The effluent filter has been inspected and/or cleaned. All septic systems approved after July 1, 2000 were required to have an effluent filter installed in the septic tank. If your system was approved before this date, you are not required to install a filter, but it is usually recommended. ❑ Describe any other maintenance that may have been performed. Signed by: Title: License Number: 9Date: Signed by Owner: Date: Parcel ID Number: 25 ©tn d~ Property Address or any changes: "2'~ p « Sr CROIX COUNTY GOVERNMENT CENTER 1 101 CARMICHAEL ROAD, HUDSON, WI 54016 715-386,4686 FAX PZOCO. SAINT-CROIX W( US WWW.CO.SAINT-CROIX WI US ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer L, A CP OAA ~ S Frt,,_kc Mailing Address a -O* N. rAl i s "s7 i R v&n 1314 Property Address 7 q7 A-fhowur., -Tfk4.( Nr-- ~,~~►~+vrvc~ u/T (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number 6 ~ 166 9 - ~S - 4C6 LEGAL DESCRIPTION Property Location 1/4 , %4 , Sec. T N R -W, Town of Subdivision Plat: Lot # Certified Survey Map Volume ,Page # Warranty Deed # (before 2007)Volume Page # Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledg . I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office Number of bedrooms $ _ j~~L 1 SIGNATURE OF APPLICANT(S) / DATE "Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) o aai °o I m °o I 3: ci can O `fl O tn3 a+ o 0 c to ° Eo N c N J v N c c m 00- 0 o c0 o 75 0) c OJ to .O N O) L N 3 .N S' a Nyoc LmX O y m m N m .a C w wNCa~Se vOiN y O m L D Na (a0-0LL '2 c, i O Y m272-0 U) co E m= Eti J O O co "02'.2 80 > n__ w N N n a m H d oM c~ E E O m O m j •N N N v N 2 In cc 0 c z v,n c z NN00 o3`o0 3 m em E U. 3 c m i L mOv0~ Co LL c 0 ~ a 0 00 0 0 7O mM 00 E ' i 0 3-' v U-0 c 3 v °v, a oE~ ~L a U d d a rn -a m L o r Q O~ E ¢ rnnw mwa coo m U -j,0, M m M N O W o" - 0 z £'''v v CL m N z ° 0 2 v c c aoi z a ° c c 0) N H S c a~ I c m E E yU a 2 a m a) (D N O O N O O n m m m m y d 4 N N y d O O O N N O I a N O m U N Z co z Z co z O z O z N c Z Y Y E E w d 0 m Y ° g A 0 N G. E! tn C d' rE+ U d Z y d N 0 N_ U) U) N Cl) O G CL ~I G a y E U' H H Fes- 0 c c H IN- H oo 3 3 3 a Y 0 3 3 3 a s 000 E 0 CL CL CL IL IL CL CL Lv, N Q U) 3 O m ° O 'i rn rn (A J U n N Z Z rn M } y _ M - a 0 0 F- N O O O 00 all '0 7 0 0 j a E r> 7 m c y CO c d co n m a rn Q rn L a rn 0) rn 2 .2 75 E m 6 Q Z U) m Q~ in m Q v p ° a ai n vii ►rl j"' °O o .6 y c 2 o a °n' c `o a O m c E H ID N U) v a °O 04 CO °o o L6 F4 V d N d N u, € m y E N N N O co N - c m a; c v a.. o z - co M Y y a~ c a Y ~o ayi a~ v H E n co n O U O O m U w 7 t • N co O U) - LL N Z y w z li O Z N Z (n C, V ~ at ;E =E C40 E 0) 0 0. CL L: CL L: IL c m m c o 'o 3: a 0 N U 0 N U A U l R DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI $3707 c State Plan I.D. Number: M,, SE a, Sec. 26,T39-R19 CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of St. Joseph ❑ Hol Ing Tank ED In-Ground Pressure ❑ Mound r)n-rr1Tnn-n g NAME-OF H ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Walter Fricke 372 St. Peter St. #218, St. Paul 14N %1 14 ' BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: PER PT. ELEV.: CST REF. PT. ELEV • 93 r %y1 Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: (•C! Calvin Powers Jr. 1563 St. Croix 135466 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INL TANK OUitET€LEV.: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: (S G' YES ❑ NO ❑ YES NO BEDDING: if~#T DIA.: YEftT MATL.: HIGH WATER MBER OIF ROAD: PROPERT WELL: BUILDING: VENT O FRESH p, ALARM: FEET FROM LINE:,~,/~ AIR INLET: DYES NO .S- YES O NEAREST-► >..5(/jl- DOSING CHAMBER: MANUFACTURER, IPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: MP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WE)£L„ BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF PU ❑ YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID DIMENSIONS TRENCHES: , MA IAL PIT -DEPTH: GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. I TR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: E V E D~ PIPES: IFEET FROM LINE: i i AIR INLET: ~e r ff NEAREST >S MOUND SYSTEM: , Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER i PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: r 4 - { ❑ YES ❑ NO ❑ YES ❑ NO NEAREST X 1~ . ' C G2c Q` 4" ,,G 17 Sketch System on etain in county file for audit. Reverse Side. SIGNAT E: TITLE: _ SBD-6710 (R. 06/88) jLHR SANITARY PERMIT APPLICATIONaa~~ t l g In accord with ILHR 83.05, Wis. Adm. Code COUNTY -Attach complete plans (to the county copy only) for the system, on paper not IeSS than STATE SANITARY PERMIT 8% x 11 inches in size. 5%0 -See reverse side for instructions for completing this application. ❑ ChPL revision to previous application 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. STATE PLAN I.D. NUMBER PROP RTY WNER _ PROPERTY LOCATION P PERTY OWNER' M LIN ADDRESS Y' T N, R (Or ~ Fes- LOT # BLOCK # CI ZIP CODE PHONE NUMBER _ SUBDIVISION NAM OR CSM NUMBER II. TYPE OF BUILDING: (Check one) 1:1 State Owned CITY L-i 2 VILLAGE NEAREST ROAD ❑ Public W 1 or 2 Fam. Dwelling-# of bedrooms PARCELTAXNUMBERJS) 111. BUILDING USE: (If building type is public, check all that a ©3~ 1- ~Q T 7 S'~rJ PPIY) 1 El Apt/Condo r 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 3 11 Campground 7 El Merchandise: Sales/Repairs 11 11 ❑ Outdoor Recreational Facility ❑ Restaurant/Bar/Dining 4❑Church/School 8 11 Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 9 El Office/Factory IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) 13 ❑ Other: Specify A) 1 • E1 New 2. [K Replacement 3.0 Replacement of 4. System System Tank Onl ❑ Reconnection of 5.E3 Repair of an Y Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # _ V. TYPE OF SYSTEM: (Check only one) Date Issued Non-Pressurized Distribution Pressurized Distribution Experimental 11 M Seepage Bed Other 12 Seepage Trench 21 F-1 Mound 300 Specify Type 41 ❑ Holding Tank 22 ❑ In-Ground 13 El Seepage Pit Pressure 42 ❑ Pit Privy 140 System-In-Fill 43 ❑ Vault Privy VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (s . ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION VII. TANK CAPACITY Al Feet W, e5f Feet INFORMATION in ailons Total # of Site New istin Gallons Tanks Manufacturer's Name Prefab. Con- Steel Fiber as Exper. Tanks Tanks oncret structed glass Plastic A Septic Tank or Holdin Tank pp. Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation a onsite sewage system shown on the attached plans. Plumber's jilIame (Print): Plu is ign ure: o _ ) MP/MPRSW No.: Business Phone Number: a' Plum rs Ad ress ( treat f , State, Code): f IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary permit Fee (Includes Groundwater Iii Approved ❑ Owner Given Initial Surcharge Fee) ate ssue Issuing gent Signa o Sta s Adverse Determine !n X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-639g (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8, Buildings Division, Owner, Plumber INSTRUCTIONS 3 1. A 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. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. every 2 to ed. The septic tank(s) must be pumped by a licensed 5. Onsite sewage systems mast be properly years. pumper whenever necessary, usually 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. ist the VII. Tank information. Fill in the capacity of every new Indicate prefab oras to construe taandnk, matterial. Complete oerra/l tanks and manufacturer's name. royal only if tanks received septic, pump/siphon and holding tanks for this system. Check experimental app Y experimental product approval from DILHR. appropriate prefix (e.g. bility VIII. MRespons P, etc.), a dress and Installing plumber is to fill in name, license number. Plumber must sign application formber with MP, etc IX. County/Department Use Only. X. County/Department Use Only. locount of he mensions the Complete plans and specifications not smaller than 81/2 x 11 inchw sh cmust be omp ete d submitted plans must include the following. A) plot plan, drawn to scale ns/water service; holding tank(s), septic tank (s) hoonhta ks; distribution boxes; so I absorption) systwater ems; re~pla cement syst m streams and lakes; pump or p volt mand vertical e; elevation d elevation r enceseferencefriction points; pump areas; and the location of the building served; B) horizontal C) complete specifications for pumps and controls; dose 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; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) s r + ' 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 Location of property / 1/4 S /4, Section , T-,ZQ N-R,~W Township Mailing address n Address of site Subdivision name Lot number' Previous owner of property Total size of parcel Date parcel was created /::iw / j Are all corners and lot lines identifiable? -Yes _,_No Is this property being developed for resale (spec house)? Yes =No Volume and Page Number as recorded with the Register of Deeds. ---------2~ 5 INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, If available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Nap, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION M~ I(We) certify that all statements on this form are true Ae he best of my (our) knowledge; that I (we) am (are) the owner(s) of thoperty described in this information form, by virtue of a warrant ad r ed i n the Office of the County Register of Deeds as Document No. ; and that I (We) presently own the proposed site for the sewag isposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No, Signature of Owner signature of Co-Owner (If Applicable) /-7 5 e) Date t Sign ture Date of Signature ± Al- DEPARTMENT QF < REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS ` INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 HUMAN RELATIONS N WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: &TOWNSHIP/M CITY: LOT NO.:BLK. ]SUBDIVIS1 N NAME: AIA_ 's =_1 _7 I OL~N O S/ UYER'S NAME: AILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIA+ DESCRIPTION: PROFI DESCRIPTIONS: 1PER-C Q ATION TESI~S~- L-W Residence ❑New Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYS M-1 M=Tt rD4,`_1-111_. f~~•__..E i~ STC - 1.05 SEPTIC TANK MAINTENANCE AGREEMENT ` St. Croix County OWNER/BUYER 7 f~ iJ1 $ FIRE NO. ROUTE/BOX NUMBER ZIP CITY/STATE 1/4 Section s T -~N. R W, PROPERTY LOCATION: 1/4 Town of St. Croix County, Subdivision , Lot No. Improper use and maintenance of your septic system c oulofr suit inoitstprem tore failure to handle wastes. Proper maintenance tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grantwforin M XIMUtiof $3000 of the cost of replacement of a failing system, which 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 ast riflinber~hatou{1)~the ponmsite restricted plumber or a licensed pumper verifying and (2) after wastewater disposal system is in proper operating inspection and pumping (if necessary), the septic tank is less than 1/3 full of 30 days prior to sludge and scum. Certification form will be sent approximately three year expiration. I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED !.J, DATE `7 St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address - OVER - r i a 1 r-T-,--O -11 r :Tll\lf- cnoM 115 ° - - test, yo z ' t I 1 ' ' I i ! I i 1-- I ,I J A j l ' ' -I-- ; -j-----~~ ~ ~ --j- -~--I- I I ~ I-I--~- I I ~ -1- i ~ --J---~ - I I I i ~ I ! I i fI I i I { } I i ; I I I ~ i i I 41~ - t -i-f--fir-' ---L - -'I---F-- + '-ti---}--F--- i ;----t-- i I , I ~ ~ I~ I ! rt I i I I I I I i I I I I I I ! , I I I I I _ it .fT I ' I ,I I ! 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