Loading...
HomeMy WebLinkAbout020-1067-90-100~ ~ ~ o ~ ti o ~ D o ~ M ~ ~ ~ N C h m C w N m C Q O da ~ a "' i o ~ a ~ ~~ ~ r ~ m c~ c N N y N L " -. C + `0 o i 7 o .- o a '~ m o m ' a ~ o d N N N N > N ' . N O ~ I . '~ 7 Z N O p C N C ~ '~ 7 Z LL ~ N i6 C ~ O LL tIS I ~ m p~ mQymm =o i > ~ c p ... -o n a 3 nO Q ! ~ c E m U 3 M M O ~ r rn Z N . m ~ N W ~ d' ~ O` ' ;rp+ O` Z ~ °'w O ~. am C 'O am N {- Z C O O Z ~ c c .. ~ a~ ~ O O N w i Z a a ~ w ~ ~ .. .. ~ Z N ~ ~ .~-. N O j O to p N Q' ~~ C y . . O ~ . y ~ ami 3 °' .. ~ ~ 3 ~' o a v o L a co o L - o~ c O ~ o~ c O w Z m ~ Z (n ~ ~ p Z ~ :.~ .. m w m a t6 c, '~ .mom,, = ~ V .. ~ o. '~ Y C ~ ~ w m ~ ~ ~ d a~ ~ L ~ m ~ ~ ~ d a~ L ~~ o_ ~ N fn fn j ~ i N y ', C U ~ v ~ Z ~ ~ ~ r 3 a z r rr ~ 3~ 3 a m : o ~ aaa aaa z ~ , ~ , •~ a ~ N J (,) N N N ~ ~ y } I y N N y ~. O O O O N N O O N O 2~ a Q .-~ ~ m N N c c0 ~ .~ ~ p ~ N O~ ~ ~ D O O ~~ ~ O O N ~ D y N m o m aci -o m Q o~ ~ m CO ~ ~ m Q} in a ~?~ az in o r O 7 ~ ! 7 +m+ ~ ~ p 0 O N C M O y C 0 ~ m~ M ~ ~ ~ d o 0 r \ ~ ~ N ~ ~ N !n C ~ ~ N N V O CO ~ Ur O y _ N O ~7 C LL) l0 m ~ ~ Qj N C N N ~ Z N G O N ~ ~ ~ ~D f0 C O u • =~li ~ ' O N 2 O n N r~+ Z c H 0~ O .0.. Z c 0 ~L CA ,~ . O . ~ ~ T r. , V RS ~ d ~ € a € a ,.., ~vt a ~a~, ~ ~a~ • `I-~ ~ ~+ a d ~ E c m m c c .. ~ °f m e c +. ~ t t a ~ ' ° ~ v ° ~ ~ v A t ~ i t ~ AS BUILT SANITARY SYSTEM REPORT OWNER ~ TOWNSHIP /~t,~, ~ r~~ SEC . ~T~-RJ9~ ADDRESS "%~ ST. CROIX COUNTY, WISCONSIN. SUBDIVISION /P., ~.lr"o ~,~g~~ ~~F~ ~Q.~w,LOT PLAN VIEW Distances and dimensions to meet requirements of H63 LOT S IZE .S, ~ ~Q-~- Y TH IN G W ITH IN lUU r'~~'1' ur ~Y~lr.ri I8 f -- '` ~ i - ~ ~C r - ' i ~ - ~ ~ lC~. I di a e ~ o th Arrvw ~ ~ I BE CHMARK: (Permanent referen oint escribe :, a-h" ~'t- ~~~ Elevation of vertical reference point : `, f,- Shope at site : /~5i' 7 SEPTIC TANK: Manufacturer: (,G~'..~~,~....af~, ~~ Liquid Capacity: /~~Q~,f~, Number of rings on cover /~ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. set or ycle gallons; tota capacity o distribution n llon: size o~ pump head; gallon per m' u ,` horsepower ran name of pump and model n b Type of warning evice HOLDING TANK: Manufa to er Number of gallons Elevation of manh cover Type of warning a ice SEEPAGE PIT SIZE: um er o pits eet iameter feet liquid dept seepage pit in et pipe-elevation - - -- -- .. ~ ,._.,,,-; ,,,., feet . ,RTM~NT OF INDUSTRY, .SOR & HUMAN RELATIONS .O. BOX 7959 MADISON, WI 53707 w INSPECTION REPORT FOR ~~ SAFETY & BUILDINGS PRIVATE SEWAGE SYSTEMS ~ DIVISION ~~ ~ BUREAU OF PLUMBING ,CONVENTIONAL ^ALTERNATIVE `~~'!~' State Plan LD. Number- Ili assigned) ^ Holding Tank ^ In-Ground Pressure ^ Mound NAME P RMIT HOLDER: ADDRESS F RMiT H DER: w INSPECTION DATE: ENC MARK (P anent reference point) SCRIBE IF DIFFEREN ROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: ame of Plumber- MP/MPRSW o.. County: Sanitary Permit Number: R ~~~ -3/ SEPTIC TANK/HOLDING TANK: MANUFACTURER.: d LIOUID CAPACITY: TANK INLET ELE .: TANK OUTLE ELEV. WARNWG ABEL PROS LOCKI GC PROV E 7.' ~.~, ~ ~ f~D.Z~P 1~~ ~ ^~~ ^ ` ° NO YES NO BEDDING: VENT D I A. // VENT NATL.: HIGH WA. R NUMBER OF ROq~j J~ PROPERTY WELL: BUILDING: ~ VENT TO FRESH AIR I : ~ I / (r / ALARM T FROM _ / ~~./ ~ CX LINEI i( ~ ~ ~ Q y~ I ` ~ ` ` 7 ^YES NO ) NEAREST . ~ DOSING C A BE R: MANUF ACTUR ER BEDDING. L,/OlidD C ACITV PUMP MODEL. PUMP/SIPHON MA NUFACTURER. WARNING LABEL LOCKING COVER n PROVIDED: PROVIDED: ^YE ^NO :'` ^YES ^NO ^YES ^NO GALLONS PER CY CLE: PUMP AND CONTROLS OPERATION AL NUMBER OF 'ROPERTV WELL- BUILDING: VENT TO FRESH (DIFFERENCE BETWEE FEET FROM LINE: AIR INLET: PUMP ON AND OFF) ,d ^YES ^NO NEAREST--~ SOIL ABSORPTION SY TE eckjthe s it moisture at the depth of plowing _ ___ _ EN~i H DIA METER MATERIAL AND MARKING or excavation. Ilf soil. an be rolled into wire, construction shall cease until FORCE the soil is dry enough continue.) MAIN _ CONVENTIONAL SYSTEM: BED/TRENC DIMENSION GRAVEL DEPTH BELOW PIS H WIDTH. ~ LEN TH + NO. OF TRENCHES DISTR. PIPE SPACING: ~ COVER/ MATF1/IALt PIT NSIDE DIA.. # LIQUID DEPTH: S I ` ~ ~ FILL DEPTH DISTH PIPF DISTR. PIPE DISTR. PIPE MATERIAL: N IS NUMBER OF PROPERTY WELL: BUILDI~G: VENT TO FRESH ABOVE COVER E~j V. IN LET ~Z) O E V EN ~O ~~ ~ ~ ~ ~ PIPES' FEET FROM iNE ,f ~ ~ ~ ~ AIR~IjNL T: , / .> NEAREST- / ~~ J(~ ~r' ~ V Mound site plowed perpendic ax'`to sl a r Check the textu of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: ' mound syste to make cert ~ that it ON REVERSE SIDE. SHOW ELEVA- san _..___. - meets the cr~ ria for mediu TIONS MEASURED. ^YES NO , `'~ SOIL COVER. TE XTURE ~ . RMANENT MARKERS: OBSERVATION WELLS. >{f ~fi~ ^YES ^NO ^YES ^NO DEPTH OVER TRENCH;BED DE HOVER TR CH/BED DEPTH FTOPSOIL. ~ SODD D. SEEDED: MULCHED. CENTER EDrGES ~ ^YES ^NO ^YES ^NO ^YES ^NO PRESSURIZED DISTRIB BED/TRENCFj' vIDTI~ DIMENSIONS r -~ M NIF ceLE V.. ELEVATION AND DISTRIBUTION INFORMATJJ+ION/~ '-toLE; ~_- ~ -1--.-J- COMMENTSf '~ 7~ Sketch System on Reverse Side. DILHR SBD 6710 IR. 01182) AVEL DEPTH BELOW ES: ERIAL & V. IA. EI~V. PIPES. DIA.; E SPACI G. DRILLED CORRECTLY. COVER MATERIAL. VERTICAL LIFT CORK ESPOI PLANS: ^YES ^NO ___ _ ^YES NUMBER OF ~PROPERTV WELL: NENT MARKERS: OBSERVATION WELLS: FEET FROM LINE: ^YES ^NO ^YES ^NO NEAR~ES`T-__ - /o .2 • ~~ ~r'ARTMENT OF APPLICATION '~ SAFETY & BUILDINGS =INDUSTRY,. fOR SANRARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIOiV5 y (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. TYPE OF BUILDING Number of ^ Public* ^ Variance* ^ Other (specify)* Bedrooms: j ~1 o~Family *State Approval Required. ~ TOTAL GALLONS NUMBER OF TANKS PREFAB CONCRETE POURED-IN PLACE STEEL FIBERGLASS NEW INSTALLATION REPLACE- MENT OTHER SSpecif - SEPTIC TANK CAPACITY / - rj HOLDING TANK C A TY ' LIFT PUMP TAN S ON MBER MANUFACTUR R: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA ~~,,,,/ (Minutes per inch): PROPOSED (Square feet): New ^ Replacement ^ Experimental Il~'Seepage Bed ^ Seepage Pit ^ Alternative (specify) ^ Seepage Trench ~~ ~- Water Su ly: Owner's Name as Listed on Smoil Test Report (lf other than present owner: Private ^ Joint ^Public ~ tlh ~, h,., ~ ~ ,fJ Alternate courselsl of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DI LHR-SBD-6398 (N.03/81) COUNTY/DEPARTMENT USE ONLY Sign~atu(re Issuing a t: /,, Feed ~ Date: APPROVED Sanitary//Permit N/u~mbe : /1 L2%~~ t~< ~-C~. /rl ~ 7~'~~~~ ^ DISAPPROVED ~ T ~/ ~ O` '~~ #'' ~ ~ ~ l A ~_~ yg err. _ _ tt """~ ~. ~ ,. ,.., ~,c/~ ____.._ __ _ ~ % fir. 11 ' ~ I 6 ~ ~r-7'-------~~- ~. t ~ _~- i . ~ /'` I cs~ v poi {) ~- ~ ~ t ,y ~ IC ~~ ~~+Gfs~r i ffe.r~iGAL ~ ,~ ~ • ~~' pct L ,i~~ ~ / ~ 'I 1 ~ ~ ~ ~.P. u j~ L L ~ ..R / ~ o c,. ' ~~ ~ ~ I ~ ~ / ~ V /~ '/ / ~' fem. ~ LL 4 G.. ~r/ 9 C l rL 1 S ~ „ ,,. / J i ~ . ' ~,' , ~ t ~ ,,r ~. ;, ~" ?. . , r ~ r,r i n-i r;; sr_ ~7~~E,v~.y ~o ~~~ rFSr~P~/~aRT o~-~~,~~ ~.Po.~-~ ~i+,~ OEP~RTIb1ENT OF REPORT ON SOIL BORINGS I INDUSTRY, ~ 4 HUMAN R'~AT,nNS, , PERCOLATION TESTS (11~ LOCATION: ~ SECTION: r-- TOWNSHIP/MUNICIPALITY: L T NC ~ ~ 4 ~/ ly /T1~ N/R/yE lorl W >YvDso,J ,~ CO NTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: ,, /~~.,~== D ~4,®„ `•!f~FE. & BUILDINGS ` , ~_ DIVISION '~i . 1~,~,~ ',C .O. BOX 7969 O,c~~~C ~?MA~ ON, WI 53707 ,~ SUBDIVISI E: ~_ ~ .~ _ o (EV ~.(°M coo/X ~A,ev ~o /E,~ ST,',p ,~,p~~,pi~ Py~~' 1 ISF Residence NO. BEDRMS.: ~ COMMER IAL DESCRIPTION: New ^Replace RATING: S= Site suitable for system U= Site unsuitable for system DATES OBSERVATIONS MADE R S: TESTS: I'1~. /6~/7 /l~~/ ~ 27 l~ CO NVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:loptional) ~~ ~-~_~T If Percolation Tests are NOT re wired DESIGN RATE: S STE 9 I If any portion of the lot is in the under s.H63.09(511b1, indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H TO GROUN DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED E T. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ~ //0 9(.y~r- B- Z /o~ o~.o~r -,.re- a i . ZC~ 11~~ B- ~' `I 7 `/ 5, y Fr ~ ,~.Qcv ;ovs 3 ~~c s: r~ s B- ~d ~I~~IrF S~ rtGE P NExT %O ~ ~ I~,Jr fT- B- ~ 2 qy. ~ ~,~~~ ~ P ~UFzT To ,~~ _ ~~.y ~T- B- tiExT To ~3 - ~S ~ y ter' PERCOLATION TESTS -SffitJQ ~~STf TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-IN HES RATE MINUTES NUMBER IN C HES AFTER SWELLING INTERVAL-MIN. P RIOD 1 PERIOD2 PER PER INCH P- 33 ~~ .~.0 _ /S ~p a ~ C P- P r1 LL / G~ie~ ~ P- ~ / p_ P- PLAN VIEW: 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 r AS BUILT SANITARY SYSTEM REPORT OWNER (~~~ CU~"Ll.'~~',S TOWNSHIP ~{ ~~cO ~y SEC . T N-R W ADDRESS~~Q /Q ~'~•~ Z ST. CROIX COUNTY, WISCONSIN. p S ~ cuss ~~a ~ ~ SUBDIVISION LOT PLAN VIEW Distances and dimensions to meet requirements of H63 LOT SIZE ~ .~ EV ER YTH IN W G IT HIN 100 r EE~r ur~ 5 Y 5~r~:M . f j L a L s - ~- ~I SC di - L a }-- E: e 1 o th Arrvw ~ ' ?~ - I BENCHMARK: (Permanent reference Point) Describe:G~~~~£ Elevation of vertical reference point: )oe~'~ Slope at site: ~ Li uid Ca acit /opC~ 6'A~~ t) SEPTIC TANK: Manufacturer : ~~ J CS~~ S q P Y ~ ~ Number of rings on cover ~ Tangmanhole cover elevation: Tank Inlet Elevation • ~. Tank Outlet Elevation : leb ` bc~n.r PUMP CHAMBER Manufacturer: > Number of gallons Number of gal. pump set or a cyc a gallons; tota capacity o distribution .lines gallon: size o pump head; gallon per minute horsepower ran name of pump and model number Type of warning ev ce HOLDING TANK: Manufacturer Elevation of manhole cover Type of warning device SEEPAGE PIT SIZE : ~ _-Ca®.~ um er o pits feet liquid dept r seepage pit. in . r _ ~~~-a.. r Number of gallons -feet diameter~_ t pipe-elevation 7r~ 5~.,,,. ~ 'Foot e~'.b r R[PORT OI INS PLCTIUN - INTJIVTDUAL SLGIA(iE SySTEM• S to t s~ Sep,at.c / ~ NAM[- (ownbh.~i . O~ ~ S~t. Crt.v~ x C„un fry [.~~ca:t,i.an ~-~_ -_ /~~Se.c.t~.an,~~ Lut ~ _, Subd~.v~,~5~.an St PT1C TANK Stize ~ gaP.?an.~s Numbe.n u~ eampan.~:men:t~ Dc3.tanee {rsam: tVe.PQ ~-_~_--_ --- 8u~..?d~,ng ~ i2$ b~P.ape. tj -~ -- - H.~ghwa~en f t1MP"tNG CHAMBER S.i. z P. HOLDING TANK S .< z c'. Pumpers. D.i~~:avsce (~num ABSORPTION SITE gaQ[anb Pump Manu~(a:c..#une.n _-_c~a('Pc~na Numbers. a~ C(~mpars tmerst~ Akanm Sye #e.m H,i.gh.wate.n. ~ . Be(1 Tnench Di.htance (~n~,m: tVePQ----------j.~,~~ F[~,ghwa-ten1~'~ - ABSORPTION STTEfDIMENSTUNS tV ~i. d ~-h (, (~ ~ n. e. n c h Length a ~ e•ae.h C~ ne Numbers (,{~ 4'~ine..b To.ta P P.evsg~'h a ~ k~i.neb D~.~ Lance be twee.n P~ n'~:i~` ,, 8u~.~d.i.ng ~® Mcrde..P. Numbers____ _ 12 a ~ Pa.pe. r 2 n b ~C,rJP ~~ Requ.i n.ed anea. ~~ De.p.th a~ reach be~aw ~ti.~e. (~t ~ rt D e. p th a (~ rc a e h a v e rr. .t~i. Q e. ~ n ___~~ ~er~h o~ xti~e bQPaw gna.de. in ~ ~ ;~':P'7I~1"~"""~f {~ ; ors, e. n c. h , ,~..~.~«.~P°."""'r'1'~"~.,.`°10 0 ,5 ! T(,t-aQ ah!~a~p.t,i_an ane(~ ~~ Tr./pe a~ Caveh:. Pape. h. oh !~ tr+mu PIT DIMENSIONS Numbers n~ p.i.tb ~ _ GrcavvP rt>r(,un(( r*.t,5~~_ e~5 ~r,, y~ ,;' u ! _''~'r;~"'~ .,~.,, rte ~'..f t' ', ~ li 1. D ~~, r, (h b e. K aw ,c. n. (' e ~`-~ h ! i Ta.ta.P abtian-p~.1(rn arrea ~~ ~,o ~~ ~~ ~.~ rf ~~ // ~ A ~. e. a n e c[ u ~ n e d ---- - - ---- ~t ~ (~ .~ - ~~~I ~° I INSPECTS"D 8y ~J~%~~ 7"ITLF --- - APPR VED D TE _ - rtL~ ~ - f -- O /~_ --- __ I ~l h p ~„ g 6 ~ State and County ~, ~~, Permit Application for Private Domestic Sewage Systems *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # State Permit # ~/~~ County Permit # County ST•C~O/.N A. OWNER OF PROPERTY ~~ , ~E~~~s ~T• L-- Cry. ,('~ /~ Mailing Address: /~ulsov ~~ s. S yoi~ B. LOCATION: E '/4 NC '/a, Section 1L~ T_ N, R/ E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village ~~(~ ~~ ~_ Township UGfd~ C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) Variance Single family ,'~ Duplex No. of Bedrooms -3 No. of Persons Z- D• SEPTIC TANK CAPACITY /tea Total gallons No. of tanks _~_ HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete _~ Poured-in-Place Steel Fiberglass Other (specify) New Installation ~ Replacement ~ Lift Pump Tank. or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. .~~!~~ New Replacement ~` Alternate (Specify) Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top)_~ No. of Trenches Seepage Bed: Length Width Depth Tile depth (top- No. of Lines Seepage Pit:°_Inside diameter_~_Liquid Depth~_No. of Seepage Pits Percent slope of land- ,~ ~O Distance from critical slope WATER SUPPLY: Private ~ Joint ^ Community ^ Municipal ^ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I Have sized the effluent disposal system from the EH-115 prepared by the Certified Soil Tester, C NAME D ~ ~lGLi C.S.T. # ,7S ~Zy~2-- and other information obtained from (owner/builder-. / _ Plumber's Signature MP/MPRSW# ~w ~ Phone #~/J~~ ~dcc~ Z~S~ Plumber's Address ? ~- ~ O D ,v PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors l!~l~ property. If well has not been drilled please indicate. ~/y J ~+~ r_\~ ~,{~D.~s' S~`cT~o,l~ ~.~~w ~ a. ~P~~~~~ a~ ~' GG. ~ ~ T . ~ ~ ~cn ~ ~ , ... w. n ~. --..P .~=' ~ ~ S/c~c~ ~. . -- t b~ ~~ , ~a~ ~ , ~ a ~ ~,~ i ~,~ e ~_ e a t\ ~, ~ _ . v o o n o d ~) ,~m.~.. ~. D p o p O .m ~~z ~°~~ o o tr .~~~ aa' ~~ 0 d t7 ~. __ - ~ ~ a~ r~ r A1~DENZL.y ~fo C5T ~PEpo,~T o~ ~~~. 9, /y~0 /3)/ ~'ST ~a6~~Pr 2!/6.r~c~1,T \ ` I~DUSTRYENT OF iPEAS~N REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION LABOR AND. .PERCOLATION TESTS (115) P.O. BOX°7969 HUMAN RELATIONS ~ ON, WI 53707 E'xislGV9 p~uMdi~vy ~'iTs f~°USE" zGira~ 1.~~.fE~E,vT- DEEP ~,PywE//S ,P~4~ i.~~it~p LOCATION:N /1/~ ~/ ~4 ECTION: Zv /T 29 N/R ~ of ,or) W TOWNSHIP/MUNICIPALITY: Hv~~,~ ?4i~s~i,P . LOT NO. LK. B M I~ ~ COUNTY: 5f ~Ro /~( OWNER'S BUYER'S NAME: u/i/l~ aM Gt1E-L/sES MAILIN ADDR SS: RT. Z C~ . ~~~ ~ ~ ~ zo ,~ 1 ISF R NO.~EDRMS.: 7 / COMM R AL DES RIPTION: l ^ esidence i ~ a New Rep RATING: S= Site suitable for system U= Site unsuitable for system DATES OBS TION~ E S: ~e TVNt / ~` NCO L ©ENTIO^NAL: S U MOaUND:®~ S IN-G©ND-~ESSl1RE: S U SY~EM-I©ILL S U H~ING©NK: S U REC~MENDEDSYS~M~ptionaq ` ,SEf AGE ~~"T3' ~ 1~,~ e.~~//S/) If Percolation Tests are NOT re wired DESIGN RATE: NO A I If any portion of the lot is in the under s.H63.0915)(b), indicate: •Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL PTH TO ROUN DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS COLOR TEXTURE AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED E HEST , , , TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- / /f~"1 ~~ ~~ 1Uo~Vt ~~~o1S ly~3a. LS,/c? ' L~,B•a. Lj, /~,,~ . ~, t~ /L7 "'~ B-Z /~~ ~o~" 9" ,,~~-•., ,~"/~N. GS, ,y„G .sG, 9' Wav.-~y. ScL w,y{~ ff B- -3 /~IS 7~» Noi(J~~ d"<Ayt BeT wEfN /1"/'~/,GS~ /2"L7~'~N•SL, I~"G~~.cJ• SGL W~ ff o,P, ~ /~ • . TS F~Port •' fe 3 :, - c' B- B- /vor SiTEs or ©~P~f%uq ~8,g~,riyr~ ~Ts •{~ 1~Fpd~ of ~(" ~vE-~PE- ~f'E'-,o/`~"~ B- Qu su~v ,~- ~ Dvy .oEE~ ?o ?EsT ~or~ 1~~f'ywE/~ ,wsT~f/~~3-Tr~,v ' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME D OP I WATER LEV -INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. RIOD 1 PERI D 2 R PER INCH P- 2 v o>~ r ~ ~ > y P- Q Nom- > Co > > P- P- Gf /~T iD- .tJT' o d OsED EE gyp/ ~" S . P- __.... PLAN VIEW: 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 surfacel ele ation at all borings and the direction and percent of land slop. /1VGET p/ t ~f 1~~Py~7/S' y ~/QrWE~//s ~~ r~ x,7 y ~~~~P~y. STi~AfA~ SYSTEM ELEVATION '~''~~ Lir-p77" ~E~ow l/~Rl. ,Pt ~/~P~o •- `I S .~ , ~~aL ~qRS __ _~.. I ~~'~ ~`'~ - _ _ __ _ _ ~ i r - g ~ ~ ~l ~_ = ~~ ~~rs ~ ~ ~ __ ~ i ~~ ~ 1 ~ ~ l o - '-h ~.~ ~~~ ~ __. ... -~- ___ ._ _. . _~ . ' ~ ~ ~ ,df.... ~-~ 4 ~ 1 - ~ .- .t-+ ~ _ 3 ~,~ ~ ~~ - ~ » ~ ` ~ ~. ~ ~, Ca ~ l-S /~m.~ _~ _ t~ Q __,..,-~ .~ Ql o B f ~~o ~ ~ ~~G d~~Tti~~ ~ ~/-~~T N. ~ _.-~._ _ _ ~~ ~ TN ~ ~~ ~ ~ ~~ E R ,~f I ~ ~ ,~ ~ _ ~ . ~~. r _._ ~ _. ~ ~ _~ __ .._~ ~ ~ ~.__ ~ _ ~ __ .~ i O , ~i '~. ~ ..~ .~ n. _ _ m.~-... ~ ~ -~_ .._~ ~ ~ ~ ~ E ~ ~~ I G~ ~ ~ -~D/~ _ _ '~.~-~ .. _ _. _..~ ._ e ~ . __~_ ~_. ..~ r ..,._~.._~. '_____m~.~.____'_~__~____.~._._~_._~._ _.~_.~...~~_ .._.~_._~~..._.i._._1 .~ L PG/J,~ U/EGV 67 Lv~, . cc~~~/~E- ,~a.~~ ~-~~- ~/ ~~. y ,~~ y ~~~!~~, r z~~ /~ /y LIB y~S ~A ~~erT ®,v ~c~ /1/o~d~- ~vvSv~J Gt>/S . ~~~ oR2'~ U CoQagRc~ po~~~ ~C ~ ~ s~R£FER ~o~au ~~^~~ • ~~A ~.~; s ~' P T ~~ ,~~ ~~ ~~)~1.~ ~~~ MiAJIMJ~ Y ~ ~,~ ~~E~L -~ ~ I ~ ~d' ----~ t o i~~ ~ , 1 ~ I ~ ~~ ~ M ~ r~oN ~ ~ ~r;~~rR~l~ ~~ `~~ ~~1 x ~ ,, .` °~ ~~'5~~11 0~~ ~1. i SG~ S `. Y'' ~' 9 J~ ~~ ~' ~° r~ SEpTi~C ~/~U~iTio~v of ,, ~,pA1~, ~~ j.~M i5 IIID ~la~ ~f ~ ~ ~~ I~,eyGl~~~/S f~~ ~e , iN ~-- I ~ m ~ ~ ~ ~ ~ d N N N C ~ ~ N N N O- 7 ~ ~ ~ C A I 3 ~ o ~ °' rn ~ N '0 c~ N O ~p o ~. N I I o_ I ~ ~. N fl. Z o_ _+ w o 7 I I ~, I °~ Z ~ ~ M i m I a~ I I I I I I I I I I vii O y O 7 cn z ~ co D fl. C ~ .. (~D N W I'V o. Ic ~ ~ d O c~ fD C m m D a a 0 m z 0 m N nviOl °e °: ~ ~ ~ ~ ~ ~ ~ 3 3 .~ °.• o c v j O ~ N N ~, 0 ~ ~ w -a-o 0 c. ~ ~ ~ v CNfi ? ~ C d N N p O O O ~ o fA N fA ~ ~ v o m •• .. d ~ .. 7 .r C fn 2 j ~ 01 m d y r. N ~ C =^ N m o. o ~ ,.. ~ O C a W ~ ~o A a ~ °o :t m v w m m 3 m ~_ c a 3 d o 3 ~ 3 ~o ~ d C A N y ~ Q 7 ~ ~ ~ V O N ~ 7 ~ O N W .~ 0 0 v N O C 3 :' °. .. o ~ D w ~n rn N ~ N A ? n -~ ,Z1 L! A Z O •• ~ 7 m N co z a ~ m ~ d ~. p A~'+ ^J ~'! 0 b ~1 0 ~• O f~ C O ~• fi y C a 0 m 0 °o ~ w N O O ti A i Op O ~ ~ ~ ~ ~°, b Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Divisian INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Dornseif, Scott Hudson Townshi CST 8M Elev: Insp. BM Elev: BM Description: TANK INFORMATION E EVATIO ATA TYPE MANUFACTURER CAPACITY Septic n~ VU V °~ I~ W ,t~--~ °2l< E Aeratio -f' V' ~ rVl Holding ~~ _ // TANK SE BT ACK INFORMATION w. TANK TO P/L WEL BLDG. Vent to Air Intake ROAD Septic ~X~s ,~ ~ ~ ( / Do ' 1 r / Aeration Holding PUMP/SIPHON INFORMATION rer Ft IForcemain' ~Lengttt IDia. Dist. ro weu SOIL ABSORPTION SYSTEM county: St. Croix Sanitary Permit No: ~2 S/pS/ ~ 2.Q State Plan ID No: Parcel Tax No: 020-1067-90-100 STATION BS HI FS ELEV. B hrlpark~2 ,' ~ ~. /, `( ~ I'3~ Alt. BM ~ Bldg. S wer~xi S y. .3 Q -1 ~+ ~ Ht Inlet2 i ^~ VLQ,I~ 1v u ~ I U,s' - l StlHt Outlet ~ r 1 ~ r Dt Inlet ~ ~~ Dt Bottom f Header/Man. ~-~{' GDS n _l f Dist Piper. ~ . k b~ c. B ystem Z t ~ td . 0, ~ , rf ~ f~ v Final Grade `c f k:r r 5 5 ~ - St~o l~r-~. BM. I- co '1. ~~ BED/TRENCH N S Width ~ / Len th ~ 1~ "1 No. Of Trenches ~'7 PIT D~ SIONS No. Of Pits Inside Dia. Liquid Depth DIMEN IO S O ~-' SETBACK I N SYSTEM TO PIL BLDG W LAKE/STREAM LEACHING CHAMBE M~~ctyrer~ ,' ~ J ~r 'T~G~ 1 "J r~+ INFORMAT O Typ f System: ~ ~r I J ( / T Model Number: ..~ ~, ~ v. I(~ ~ DISTRIBUTION SYSTEM ~ ~~w A (:G.~i,..,~.6.a~v- I tn. -fi~r~-C~.tid Header/Man ol~l / r L, Length Dia Distribution ~ r Pipe(s) (_q ~ L C,',~~ ~2F ~r Length Dia ~l paang x Hole Size ~~ x Hole Spacing r/~ V~o Air Intake ~ ~/. ~- V SOIL COVER Y Proccnro Svc+amc Anly YY Mrn~nd Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx SeededlSodded xx Mulched Bed/Trench Center ~ Bed/Trench Edges / Topsoil ~ ~~ Yes U No ~ Yes [ _I, No ~P~Yff COMMENTS: (Include code discrepencies, persons present, et .~~ Inspection #1:~/ ZS / ~ y Inspection #2: f Location: 843 Polen Drive Hudson, WI 54016 (NE 1/4 SE 1/4 1 T29N R19W) NA Lot 5 Parcel No: 14.29.19.258610 1.) Alt BM Description = ~1~ .-,,~1 ~ ~~ ~~ fys-~r~ ~k~a.~~'~% ~~"' PmPe~/~e- ~la.~ 2.)Bldgsewerlength= ~3r7 ~jl~ ~v Cb'~ ~_,.~.p ~,{~-(,1~ ~dttidS(~'a.~ ~~.-Gid " V'c~~~~itLd - amount of cover = Qjy,t`f,~}~ ~ I ~~ ~,nQ a ~~~ f6~~'ttS1'~, -~W 7i-2y~~(,(l ~ ~ J 7"'" _ -- - __ ~ _- T _ _ r Use otheslside foruadditional information. No ~_~ ~S~ ~ ~~ GZ~'+!~~-~ _ -i%~~ U S ~I~• - Date Insepctor's Si nature Cert. No. SBD-6710 (R.3/97) Sat'ay ~ Buildings Division P.O. Box 7 ton Ave. W hin 201 W 162 C~ f I X , g . as Madison, WI 53707 - 7162 Six Address ,~CO~~ j~ Oe artment of Commerce L '2 ~~-C~'Z. S3/ S~ ~ oUEff D ~ - Permit Ntmtber 5~~5' Sanitary Permit Application `~ ~ ~ 2 In accord with Comm 83.21. Wis. Adm. Code. persotrat information you Provide [] Check if Revision tna be,~d for ses Priv I.aw, s15. 1 m Stax p~ I.D. Number I. Application information -Please Frlrrt All Information parcel Number property Own/er's=N~am..e L _ ' + i ,,per, O z Q - ~ ~,~ - f~ " ~' L/ ~r'. ~C~-3I~/ 7 ~ catan l L o y proper property Owner's Mailing Address ~~ ~ ~ ~/ // _ /vim 5f ~ 54: S ~ T~ N. E ~~ City, Star Zip Code Phone Number Lot Number Block umber I ^^ ` CSM Number Stirbdivision Name ~~ ~ ~fOl.~ ~ ~-~~ 6 _~yo ~'~ ~..- II, of Building (check al! that apply) ^ ^Cny ~ 1 or 2 Family Dwelling -Number of Bedrooms i ~ ^Village ~ ~ / ^ pubitc/Commercial -Describe Use Wp • Nearest Road ^ State Owned Z~ 3~ ~g.~` ~s ~ .~. III. Type of Permit: (Check only one box on line A (numbering scheme for internal trse). Complete line B if applicable) A. of 6 ^ Addition w lacement Sysxm 3 ^ Replacement For Coumy tree Tank stem stem Permit Number Dax Issued B. ^ Check if Sanitary Permit Ptt:viatsiy Issued IiV. Type of Permit: (Check all that apply)(numbering scheme is for internal nse ~iieQ ~' _ I ~ . 47 ^ Sam Fiber Non -Pressurized In-Ground 21^ Mound 50 ^ Constructed Wetland ~ ^ ~ ~,~~ 41 ^ Holding Tank 48 ^ Single Pass 51 ^ Drip Line 45 ^ At-Grade 46 ^ Aerobic Treatment Unit 49 ^ Reciicnlarin8 30 ^ Other Y. tmerit Area information: Design Flow (gPd) Dispersal Area Dispersal Area Soil A~lication T Percolation Rax Sysxm Elevation Final Grade IIevadon /Ir-ch) / (Mni 4.) Required Proposed Rate(Gals./Days/Sq. ~~ • ~• T~® Capacity in .fowl Number Manufacturer Prefab Six Steel Fiber Plastic Comrex Constructed Glass Gallons Gallons of Tanks New F.xiating Tanta Tacks Septic or Holding Tank - ~ ~ Dosing Chamber VII. Responsibility Statement- I+ the undersign asstmte responsbilit7 for installation of the POWTS shown on the attached plans. Business Phone Number Plumber's true MPMIPRS Number Plumber's Name (Print) ~ ` ~ ~fjJ~~ ~~r ~ r %''_~t~ll/' Plumber's Address (Street, City, Stax, e) / ~ " ! VIII. Cotmt /De artment Use Oral Sanitary Permit Fee (includes Groundwater Dax issued Issuing Agem Signature (No Stamps) Approved ^ Disapproved Surcharge Fee) ^ Owner Given Initial Adverse ZZS , 2~ Dexrmina6on IX. Conditions of Approvals ~easoos for D' ro tt>, ~ ~, i~ ~5 ~ ~4S ~C S. ~S 1 _ /~ ~p._ ~ ~ -!~ ~ ~^ a i - t' ~ _ t tU ~,,~--rw~~cla ~~ ~~" ab ~?/ tnnd~,t L "~'D+'~ "~ i " / ~ ' 1 ' ' o~Q.6t~fTQt- Cam- ~ 1 .~_ ..~.~ ...a_, . .t....,tem m o.oer sot tess ehaa til/2 x 11 inches x dze cRn~~4R ~R ~5/Oll P T PLAN PROJECT Scott Dornseif DDRESS 843 Polen Drive Hudson Wi 54016 NE i/4 SE 1l4s ~4 !T 29 ! 19 w TowN Hudson COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE6/12J02 BEDROOM 3 CONVENTIONAL XXX IN-G PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 10001260 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE •7 ABSORPTION AREA 684 # of chambers 22 ,BENCHMARK V.R.P. Top of Siding ASSUME ELEVATION 100° Filter Zabel A-100 ^ BOREHOLE ~ WELL •H.R.P. Same as Benchmark ---~"~ Line SYSTEM ELEVATION 92.3/91.0 System is to be installed along contours at 4.5' Below Grade 10% ~ qM~ Slope C 59' _ ? _ _ 20'B~_ 98' a~ 70' A valve is to ~ ~^~t°~"od '~ _.---~ ~ tt7'C Weeks S~ ~ 2-3' X 69' Cells with >3' spacing 13' 2 Vents F oar a 53' ~2~ Vent >6" of Cover 12" 6' Long Stan ator aching Chamber with 31.1 ft2 of Area Plans Designed Using at System Elevation Conventional Powts Manual Version 2.0 PROJECT Scott Dornseit NE 1!4 SE 1/4S ~4 /T 29 C PLAN DDRESS 843 Polen Drive Hudson Wi 54016 19 /- W TOWN Hudson COUNTY ST. CROIX MPRS Shaun Bird 226900 ~ DATE6/12/02 BEDROOM 3 CONVENTIONAL XXX IN-G PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000/260 LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22 ,BENCHMARK V.R.P. Top of Siding ASSUME ELEVATION 100' Filter Zabel A-100 ^ BOREHOLE O WELL *g,R,p, Same as Benchmark .---~ n,.,,„a,-,., r :„o SYSTEM ELEVATION 92.3/91.0 a .. a c 1 Leaching Chamber with 31.1 ft2 of Area at System Elevation Plans Designed Using Conventional Powts Manual Version 2.0 V~oconsin Department of Commerce SOIL EVALUATION REPORT Page ~ of Division of Safety and Buildings ,,.a....,.,....uti r......., oc ur,, na.., r,.a,. ....,.........~............~~.v..„~~.,......a. nu. vwc v _. County S T• C ~ ~ ~ ~ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must - ! - include, but not limited to: vertical and horizontal reference poi ~, direction and ' ' Parcel . ~ZD • G ~(!j(p'7 • !~ • d-~ percent slope, scale or dimensions, north an ow,.and loci anti distanc$ nearest road. ~'~ ! _ , , Please print all infonna`tRori: ~ ' ~-` sewed by Date Personal information you provide may be used for secgfidar~purpo~p~ w, s. 'I+~O ) (m)). ~,lt Property Owner rnw ~ ~ " ~ GFI~ «1~~ 1 1 ~~~' 2 Prop cation N S~ 3~ 1 T Z/ t ` C-; .r.; n ~ ` vt. G /4 1/4 S N R E(or Property Owner's Mailing Address ; ,;~:~1?: 8 ~E 3 '~a lam. ~R • L`~~~ Lot #~ /~ - lock # CS Subd. Name or CSM# p~. • ? 8f~ Uo 1. !! ~, . City State zp Code Ph e•iVptnbeL'W~ w t. Syo~t' {~u pSo~ v ~l ~~ :3~~ 'A~loS ^ Village ~/] Town ~', Nearest ~2oad e ~~ / , . ( . , : - uD.Sow ~ o , K. ^ New Construction Use: !~+ Residential 1 Number of bedrooms ~ Code derived design flow rate ~.50 ` GPD (.Replacement ^ Public or commercial -Describe: Parent material fOFS.S aV(,~,~ S/4.V~~/ ~G?41lf~, Flood Plain el~evQat~i~on if applicable ft. General comments ~~~ ,it,Hp~l~W ~~1~L//~~~~ 7 ice"" G(,~~,s ~jf ~/~ Q o~ and recommendations: ~~~~~`' Iii S7i~'i /3~T~'ov . ExtST/~G- S f/S T• lS ,.~ ~®~~ spy ~~N so,~s ~'~~~ ~- ~~ .,~r~t~r ~~~- f~~~/ ~~/vim ~o~P ,~i~~e ,~• ~ ^ Boring # ^ Boring Z } ~ Zd " . 9lo•y ~~ P 3 ~ ~` Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDiftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 / o • y iv yilP ,~j -- S L 2~t s,bk ~s ~. w Z f' • S • ~ ' YS ~o y~ SiL 1 ~sd~ .n, ~Li ' - S . 8 t+.y~ Boring # ^ Boring ~ O/' ~ Z }~ . ~. pit Ground surface elev. !,~ • ft. Depth to IimiGng factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 • 2D ~D /i!e - - S G / S,di~ ny, ~~ w ~ • Co ~•s R -- ,,,,,,.,Q,Q . S D, S c ~-- . ~ t . i. mF S b I S ~,e Q~ •? 1.2 ' 'effluent tF1 =BUDS > 30 < ZZO mgiL and i Ss >ao _< i 5u mgiL - emuenr ~1 = rsw5 ~ su mgiu ana i ~s ~ su mgi~ CST Name (Please Print) Signature CST Number Rat3e t~ t Zi ~~3 ~ is ~.?- ~z~ 2 z, 4 3 7 S Address Date Evaluation Conducted Telephone Number ~ 1 ? = ~ 7/S • 3BG • St6S ~~ N.gN/~~ Prtvata Sewage Vorauno~~.o 655 O'Neil Rd. Hudson, Wis. 54018 s . '11 . ~+cr' ~R y Property Owner '~o [~ N S ~ i r' Parcel ID # O ~~ ~ /f~~ ~ ~~ Uv v Pa(~e 7` of BorinB,# ^ Boring f , 0 Z- y / ~* ya. ~pjl r Ground.„~sudae~ elev. + / ft. Depth to limiting factor / in. Soil Application Rate Horizon Depth Dominant Color ~ -Redox Description Texture Structure. Consistence Boundary Roots GPD/ftz in. fNunsell Qu. Sz. Cont. Color Gr. Sz. Sh. ~ •Eff#1 •Eff#2 / 0't /o ,~/ S/L !f S~iC' ,~,,, ~iC' Cv Z f . Z .. 3 a < ~ t~ io y,~ 3 SQL 27cs ,,C ,,~ ~,e . 5 .8 y ~ 7.s - ~• s. o, s . ,~ . ~ i. Z ^ Boring # ^ Boring , ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell t]u. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 ^ Boring Boring # Ground surface elev. ft. Depth to nMiting factor r in. ^ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 • Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mglL • Effluent #2 = BODs < 30 mg/L and TSS < 30 mg/L .. The Department of Commerce i an equal opportunity service provider and employee. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.6/OOy .. ~ . Y • '~ 1, • , ~ ~ •v .r~' ' J ,LL • ~~ ~~ O~-~ _ r t~ o, ~~ N 0 ~, w t ~ ~ ©~ ~~ ~ ~' ~~°~ ~ ~ C o ~ y~~~~ 1 p~ o~ ~ • ~~`s ,~ --~-- ~_ ~~-~-r-~ ~ ~ o ~ o ~ ~, ~ t ~p,- ~ , ~~ y ~ . ~ ~ ~ ~ ~ ~~ ~~ y ~ , ~ ~ ~1 ~ i ~ C ~ ~ j ~ ~ ~ ~ ~~~ ". i ; o i ~ ; ~ L , ___ ~ ~_ • ~ C ~ °o :~ -~ ~ ~~ m W '`C ~ Q o W W ~ ~~ ~~ ~~ ~_ 0 ~~ 0 ~- ~~ C ~. - ~ C~i~ O ~ ~o ~ ~ ~~ ~T, ° is~nc +P~~ COUNTY ZONING OFFICE Certification Statement For Utilization of an Existing Septic Tank This is to certify that I have inspected the septic tank presently serving the `~ ~'`~ ~p ~ residence (previous owner: )located in: S~ ~.o ~~ ~/~ 1/4,sL' 114, Sec, T~~N, ~W, town of , County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced: i ~~~ Z~z' ~' Did flow back occur from absorption system? Yes No~(If no, skip next line.) Approximate volume or length of~ time: gallons minutes Construction: ~. Prefab Concrete Steel Other Manufacturer (if known): fl.- '°' °~ Age of tank (if known): ~~ /~~ r~ ignature) (Name) Please Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condi tank, to the best of my knowledge, will conform to the requirements Code (except for inspection opening over outlet baffle). Name ~~~-~-~-~1 Signature MP/MPRS ~- ~ ~~ G% ~~ tify that the 83, Wis. Adm. ,' c:\wp51\focnps\ceriificatioo I/97 Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent fitter is to be caned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, ce!!s are to be inspected via the inspections pipes at the ends of the cells. . 4.Owner agrees to limit greases, garbage, and water conditioner ctscharge into the system. 5. The owner agrees to save this plan. 6. [~ not plant trees nor park nor drive over system. 7. Watershed is #o be diverted away from system. 8. Disd~arge into system is not exceed those r+~.~ired as per Comm. 83 Contingency Plan 1. if system fails, c~termine cause of faikrre, use alternate area and install new system or instaff system at a bwer e~vation. 2 Replaaa any other fairng components as needed. Plumber: Shaun Bird 715-246-4516 ,--. `7/ .~- ~ 6 u~, ~~- . ~ .,-~ - ~,,--- 3~~ ~-- f ~ X36 ~~~ ~ Shaun Bird #226900 - ST CROIIC COUNTY SEPTIC TANK MAINTENANCB AGRBEMBNT ~ `7 Z o a a AND OWNERSHII' CERTIFICATION FORM OwnerBuyer ~ C ~ r¢' ~~ ~~l '/ , '~4/3~,~~ Mailing Address ~~/ ~~ ~rs~~N f~.~/[~'~' /°t ~'~SQ~ Gt.~~ 5~~~ property Address ~~-3 ~ G ~ N ~~ / v f , /~I~-'~~' ~n~ u~~ s y~/~ (Verification required from Planning Department for new construction) - City/State Pazcel Identification Number LEGAL DESCRIPTION /' property Location ~~~ %., ~ '/., Sec. ~ T O2~N-R~W, Town of ~G~c/~rl . Subdivision , _ .Lot # __~. Certified Survey Map # ~ ~ °~ °~ ~~ Volume Page # ~6 3~ - Warranty Deed # ~'y ~ ~ ,Volume ~ ~ Page # ~ Spec house ~ yes~no Lot lines identifiable yes ^ no SYSTEM MAINTENANCE Improper use and maintenanceof 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 fiaretioa of the septic tank as a treatment stage in the waste disposal system. party g~ ent a certification form, signed by the owner and by a The owner a to submit to St. Croix Zoning Departm mastor plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal system is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the ~~'~ set forth, herein, as set by the Department of Commerce 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 Zoning Office within 30 days o e three year a iration date. SI AT[JRE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this foam are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the rty desen'bed above, by virtue of a warranty deed recorded in Register of Deeds Office. SI ATURE OF APPLICANT L DATE ****** ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed p p STATE BAR OF WISCONSIN FORM 2 - 1982 5Q8989 WARRANTY DEED UCCUMENT NO. ~ , rai 119 ~acE ~ 7~ Gary P. Polen and Rhonda M. Polen, husband I an wi e, individually and each in their own right com•eys and wafrants [ CO t Dornsei an .r 1~~ fl ~.-- Dornsellf, ~tus an an• wi e as surv~vors-Fip mar'. aI-property REGiS?E~.1 S OFrIC~ 8T. CROIX CO., Wi w~alota~ola SEP 3 1996 at 9:a.s A. M ~ ~ ~~k Register d Deeds TRI$ SPACE RESER4ED fOR RECOROfNG DATA _ NAME ANO RETURN ADDRESS the following described real estate in , t . Cro1X ~,~ Ga State of Wisconsin: /0~,~!1~~~ /~~jY`/`/'/ ~l / ti' Y~~JC/ r 020-1067-90 -~~QU __ ~', PgRCEL IDENTIFICATION NCM R Part of NEB of SEA of Section 24, Township 29 North, Range 19 S~Iest, St. Croix County, I9iscons•in described as follows: Lot 1 of Certified Survey Map tiled April 27, 1979 in Vol. "3", page 784, Doc. No. 356459. '~RAN$FER s a~~--- This 1 s homestead property. (is? (LCDmId Exception to warranties: TC)C'E'PfJFjR WITH AND SIJBJI;X„T TO at,Y other easements, Covenants, reservations or restrictions of record, if any, but this stall not ba deemed to extend any Stich ottaer recorded enctanbrances beyond the teen established by law therefor. Dated this 30th day of Alx~tlst - , A.D , 19_ 96 J f 1 ~`~~d'b~ ~ (SE~i.) ? . (SE4Ll Gary P. Pb~ len RhaY3a M. Polen (SEAL) (SEAL) !j • • l AUTHENTICATION ACKNOWLEDGMENT Stacc of Wisconsin, ,j Signature(s) , ~I ss- ( St. Croix count . ~I authenticated [his day of , 19 Pers+~cszily came before me this ~'oth day of - GarysP. Polen and Rho'rida~M,named ~~ _ ,Po1en, his wife t ~. v .~ ;j TITLE: MEMBER STATE BAR OF WISCONSIN ~ ~ ~~ ~~~ '~ (IE not, j,(~~,AiZY PUSL: authorized by 8706.06, Wis. Stats.) ~ ~s~~~kn.nat to be the rzrou 5 who executed the foregoing i~ ittsiru .c :n a 'ledge the same. THIS INSTRUFdENT WAS pRAfTED BY I~ Att_v, Hugh H. Gwin, GWIN LAW FIFd~I, S.C. ~ ~ r ~~ ~~ 430 Seccnd St. , Hudson. WI 54016 ,..,... a,t..t,- St. Croix r,,,,,,«• w~< .. A :428 (pr.::.,r1.~t' "__) :LhNicOOnxin Bankers Associafl0n 199} -~'rir•~c-yo DOCUMENT N0. ~~ 1821 PAGE 33 REAL ESTATE MORTGAGE (For Consumer or Buainass Mortgegs Transactions) SCOTT A DORNSEZF and ERIN S DORNSEIF As Husband and Wife as Survivorship Marital Pzl~s3~r,,, whether one or more) mortgages, conveys and warrants to First Federal Savings Bank La Crosse Madison ("Lender") in consideration of the sum of THIRTY ONE THOUSAND FOURTEEN & DO/100 ($ 31.014 00 ), loaned or to be loaned to SCOTT A DORNSEIF and ERIN S DORNSEIF ("Borrower," whether one or more), evidenced by Borrower's note(s) or agreement dated January 14 2002 Recording Area 6i6907~ KATHLEEN H. WALSH REGISTEk OF DEEDS ST. CROIX CO., WI RECEIVED FDR RECORD 01-~3-2442 4:30 AM )IOkTGAGE EXEliPT CER7 CORY FEE: CGPY FEE: TRANSFER FEE' FE~SDIRG FEE: X3.04 Name and Retum Address First Federal Savings Bank the real estate descnbed below, together with all privileges, heredifament5, easements and 605 State Street appurtenances, elf rents, leases, issues and profits, all claims, awards and payments made as a result of the exercise of the right of eminent domain, and all existing and future La Crosse, WI 54601 improvements and fixtures (all called the "Property") to secure the Obligations described in paragraph 5 on the reverse side, including but not limited to repayment of the sum stated above plus certain future advances made by Lender. 020 1067 90 100 1. Descriptlon of Property, (This Property >,s the homestead of Mortgagor) list ti, nm1 n r o. Par of the NE 1/4 of SE 1/4 of Section 24-29-19 described as follows: of 5 of Certified Survey Map in Vol. 13, Page 3632, St Croix County, >_sconsin. If checked here, description continues or appears on attached she9t. If checked here, this Mortgage is a constriction mortgage. If checked here, Condominium Rider is attached. 2. Title. Mortgagor warrants title to the Property, excepting only restrictions and easements of record, municipal and zoning ordinances, current taxes and assessments not yet due and env securisv agreement of rP~nrd Dr_o~yQ the da o rhea rranga~rir+., 3. Escrow. Interest ~,; 7 1 nnr be paid on escrowed Iunds if an escrow is required under paragraph 8(a) on the roverse side. tws) wlil not 4. Additional Provisions. Mortgagor agrees to the Additional Provisions on the reverseside, which are incorporated herein. The undersigned acknowledges receipt of an exact copy of this Mortgage. NOTICE TO CUSTOMER IN A TRANSACTION GOVERNED BY THE WISCONSIN CONSUMER ACT a DO NOT SIGN THIS BEFORE YOU READ THE W RITING ON THE REVERSE SIDE, EVEN IF OTHERWISE ADVISED, b 00 Np7 SIGN THIS IF IT CONTAINS ANY BLANK SPACES. c YOU ARE ENTITLED TO AN EXACT COPY OF ANY AGREEMENT YOU SIGN. (d) ENTITLED TO A PARTIAL REFUND OF THE FlNANCE CHARGE. E UNPAID BALANCE DUE UNDER THIS AGREEMENT AND YOU MAY BE Signed and Sealed January 14 , 2002 (type of Organization) By: By: By: By: (SEAL) (SEAL) AUTHENTICATION OR ACKNOWLEDGEMENT STATE OF WISCONSIN Counryof St. Croix ($EAL) i ss. This instrument was acknowledged before ma on JanuaxV 14, 2002 by SCOTT A_DORNSEIF ERIN S DORNSEIF amets) o percone c ) as NOT APPLICABLE YP• oMy; e.g.. r. .. arty of N T APPLICABLS ame psrty on efts o om vMe axacut ~ any ~~ ~I~- ~ ~~.1 ` Michelle L. Becker Notary Public, Wisconsin My Commission(Expires)(Is) 2/06/05 (sEAL) SCO A DORNSEIF , • '~ (SEAL) E INS DORNSEIF ~ (SEAL) Title: Member State Bar of Wisconsin or authorized under ¢706.06, Wis. Scats. This instrument was drafted by See V. Vue _First Federal Savings Bank 'Type or print name signed above. 000278235 9 .~~ f~ .,~,,~; FILED ~ Ot APR 2 9 1999 - 002260 6 ~~~~ sccw~cco,~n ~ ~ CERTIFIED SURVEY MAP LOCATED IN PART OF THE NE >/4 OF THE SE 1/4 OF SECTION 24, T29N, R 19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN; BEING L 0 T 1 OF CERTIFIED S UR YE Y MAP RECORDED IN YOL UME 3, PAGE 784 AT THE ST. CROIX COUNTY REGISTER OF DEEDS OFFICE. PREPARED FOR: OWNER: SCALE IN FEET 1 " = 100' JIM ROULEAU SCOTT DORNSEIF 937 CARTER CIRCLE 100 0 100 200 HODS^N, WI 54016 UNPLATTED LANDS E1/4 COR. SEC.,.~4 wSEC. 2~R EAST - WEST 1!4 LINE r-K (N88'S8'20'E) s8 42' "w S89°42'39"W 438.06 S89'4z'39"w 446 .28' 398.87' CN88'S8'20'E 438,26`) C398.64') q~ 3 Qol o~ W A ~ ~ ~~ l ~i o rn Z ~ `, ~ '_' ~ . ~-r ih DESIGNATED ~`' DRIVE ro ~n ~ ~~ LOT 4 AI f ~ ~ f ~I WI 5~' G I ISSLN Z X ~J I J I DRIVE • >-- I 3. 33' ~ 3 I 3 ~, • ~ ~ o ~ LOT7 ~WS w~C WYLDWOOD ~ ~ ~~o ~~ ~Z ~ ~ ~ L \ N w Z ~~ . ~! X03 U M aw- A~~, wow ~~~ www ~~~ ~~o w F... ~- ~~A aww y3~ SEPTIC VENT D n O ~A 3.057 ACRES EXC. R\W 133,169 SQ. f T, w H^USE• 50' 1~" W E ~j ~ ~ A$' ~ M ~Ei6~52~~~ ~E 'I ° ~'S~ 'N6 59 2~ j~ 2,500 ACRES 108,911 SQ. FT, ~ ~ ..,,~ Q ~ S89'44'09"E 456.51' ~ I ~I ~ I ~ ~ U' W ,~ e {s~ CAA' ~~ .-.~ w '. ~~ ~ LOT 5 ----~. ~ N o~ ~ GARAGE .--~ ° "a ,~~ 3.314 ACRES 144,373 SQ. FT, 0 ~ 0 ~ l ~ 1~ ~ .... -•" 6,5z poi ~ ~ :, ~ , ,. w o ,~ :N A cv Z :. o M ~ M 0 0 m m d z m 0 z a J A w 00 ca w a Q' A F- Z w f N z M ~ BADS DNA S M RSA ` - _D LOT 3 C. S. M. VOL` 11L PG_ 3151 ' LEGEND 61~~ ~ ALUMINUM COUNTY SECTION C^RNER MONUMENT FOUND • 1' IRON PIPE F^UND