HomeMy WebLinkAbout030-1082-20-000
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations
r Page of Z.
Division of Safety and Buildings in acco An q, With S. IL83.09, Wis.
Attach complete site plan on paper not less than 81/2 x 11 "in si t County
include, but not limited to: vertical and horizontal referenc 4 (BM),
5 T. C RD f jC
24AM
percent slope, scale or dimensions, north arrow, and loca d distance to nearest road.
JUN 0 1997 Parce0 I.D.
- a
0- ~o SL
APPLICANT INFORMATION - Please print a ► rmatk CRQX Reviewed by Date
Personal Information you provide may be used for secondary purpos cY la PiMIN0Ime)),
Property Owner , i
T~ L /`t 5/6- iAj /c~A,, J.Property.L9paon
GoI . * CJ 1/4 P(-)1/4,S 2-T T 30 N,R 11 E (or) W
Property Owner's Mailing Address of # Block# Subd. Name or CSM#
l3yo Fix 1Z;OGE- i .4~L 3 CS M vo L. 3 Pj . C 1,3
City State Zip Code Phone Number
Nearest Road
Irt,To~ (,v~S 55/ogz (1/5 ) Syi-&YPZ ❑ cltysr. [:1 viols Town bx 12fDGe T -k
❑ New Construction Use: ® Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
eeR9E+vTLy/ r PAf+pSEO ~XiPrt~Sfowl
Code derived daily flow ys C gpd Co O Recommended design loading rate '7 bed, gpd trench, gpd/ft2
Absorption area required _?.S 7 bed, ft 2 ISO trench, ft 2 Maximum design loading rate bed, gpd/O trench, gpd/ft2
Recommended infiltration surface elevation(s) Sz e s Tf z&- ft (as referred to site plan benchmark)
Additional design/site considerations 6Xf 5T t ^a (r- s Y S Z ' /5 /.v
Parent material 5~1NOY 1444Z- 007- &JA
kk- Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
[:3 s
U = Unsuitable for system S ❑ u CA-S 1:1 U Q'g El U B-S ❑ U a§ ❑ U
1 0-
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure
In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2
Bed Trench
b-(v ! 0 Y)P- 57 S!L s/o' &A 4.5 2 UT - z;• 3
2- 6-12- /z> VX e116 -5 toi S"q- C-S -7
Ground
5-4
elev. 3 •Z /,Ox Slip
9~ eft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft. n lirme
UKMV
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
Ro[3EVT- 3 E%0' F18-5
Address Date CST Number
s_ I- CST,1
tllbriCht 8 Assoc ales
Private Sewage Consultants
655 O'NeA Rd.
Hudson, Wig. 54016 jCX/'5T1N6-- 51115772" ~S /'ll
~Xi S j w 5y5 T. i.s A7
S_ '77
~C
y _
SOIL DESCRIPTION REPORT '
PROPERTY OWNER Page of
PARCEL I.D.N
Boring # Horizon Deptfi Dominant Color Mottles Texture Structure 2
Consistence Boundary Roots
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Ground
elev.
ft.
Depth to
limiting
factor
In.
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Structure G D ft2
Texture Consistence Boundary Roots
in. Munsell Qu: Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
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Parcel 030-1082-20-000 05/31/2006 05:18 PM
PAGE 1 OF 1
Alt. Parcel 29.30.19.296D 030 - TOWN OF SAINT JOSEPH
Current LX~ ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
RICHARD S & SIGRUN B RENFROW O - RENFROW, RICHARD S & SIGRUN B
1390 FOX RIDGE TR
HOULTON WI 54082
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ' 1390 FOX RIDGE TR
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 4.210 Plat: N/A-NOT AVAILABLE
SEC 29 T30N R19W NE NW LOT 3 OF CSM Block/Condo Bldg:
3/613
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-30N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
09/19/2002 691012 1983/19 QC
07/23/1997 1014/66
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/31/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.210 90,100 230,600 320,700 NO
Totals for 2006:
General Property 4.210 90,100 230,600 320,700
Woodland 0.000 0 0
Totals for 2005:
General Property 4.210 90,100 230,600 320,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 210
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
.A
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. T N-R W
ADDRESS & ST. CROIX COUNTY, WISCONSIN
r i
:J % i t c 1s /y
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I114R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
% fe
A&
.f
c
fvus&
J INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: _ o o Proposed slope at site:
SEPTIC TANK: Manufacturer: /-D,/- S Liquid Capacity: /01[j
Number of rings used: w~ Tank manhole cover elevation:
Tank Inlet Elevation: j, Tank Outlet Elevation:
C
Number of feet from nearest Road: Front 10 Side, Rear, O feet
From nearest property line Front 10 Side,(Rear, ` j feet
O
Number of feet from: well , building: e
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
nufacturer: Liquid Capacity:
Pump Mo Pump/Siphon Manufacturer: P ze
Elevation of inl Bottom of tank elev n:
Pump off switch elevation. Ga s per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from neare property line: ont, O Side, O Rear Ft.
umber of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: 3(C--~ Trench
Width:` Length: Number of Lines: Area Built: (
Fill depth to top of pipe: 30 Number of feet from nearest property line: Front, Side, O Rear,O Pt
Number of feet from well: ~/O Fl~~LL
Number of feet from building: 1'1
(Include distances on plot plan).
EEPAGE PIT
ze: Number of pits: Diameter:
Liqui epth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box or distribution box O been used on an f the above soil
absorbtion sytems? (Check o
HOLDING TANK
Manufacturer: acity:
Number of rings used: E1 atio of bottom of tank:
Elevation of inlet:
Number of feet from n rest property line: Front, Side, O Rear, 0Ft.
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
EPARTMENT OF INDUSTRY, INSPECTION REPORT FOR ' SAFETY & BUILDINGS
ABOR & HUM,(N RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
.O. BQX 7969
ADISON, WI 53707 Sute Plan LD. Numher
CONVENTIONAL ❑ALTERNATIVE IltattlgnM)
O Holding Tank O In-Ground Pressure O Mound
E OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER. INSPECTION DATE
AM
Richard Renfrow Rt. 1 St. Joseph, WI 54082 CSTREt PT ELE
.
ENCH MARK IPermanent reverence Put- OESCRIBE IF DIFFERENT FROM PLAN 7EF. PT. ELEV.
NW NW Section 29, T30N-R19W, Town of St. Joseph, Lot#3 Pirius Add $an,lery Permrl NumUer:
n. nl Plundrer. MPL3205 W NO.. County
M DOnavin Schmitt St. Croix 83844
EPTIC TANK/HOLDING TANK:
MANUFACTURER p LIQUID CAPACITY TANK INLET ELEV. TANK OUT LET ELEV WARNING LABEL LOCKINGCOVER
C~~fy).. ( l~ 2' I Z 6O I> YES ONO OYES
NUMBER OF ROAD: PROPERTY WELL BUILDING IVINT TOFRESR
BEDDING V NO
ENTOIA . V ENT MAIL . HIGH WATER 9y
/ ALAHht FEET FRO LINE AIR INLET I S S ~J 2-1/ OYES NO J OYES NO NEAREST l _
LOSING CH MBER: PUMP SIPHON MANUV AC Il61E ARMING LABEL LOCKING COVER
A(ANlIf nCT URER BF DOING UOUIU CAPACITY VUMV MUUEL PROVIDED PROVIDED
OYES ONO OYES LINO OYES E1NO
Ih L SOPERATIONAL NU E OF P 111'f 44 Wt Lt tit III DING ENT TOFRis11
GALLONSPER YCLE: CONTRO V
I
(DIFFERENCE E'~WEEN FE F O Ni AIR INl E i
PUMP ON AND OF I PUMP AND OYES ONO N ARE
OIL ABSORPTION SYSTEM. Check the soil moistureatthedepth o'plow ing (E Gnl IANIIIIII MATIIOAIAND MARKIN(,
r excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
)
e soil is dry enough to continue.)
ONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF 015714 PIPE SPACING COVER NSI DI 1114 sVIIS l 1.l )(111)
TRENCHES MAT IALt PIT DFPtU
DIMENSIONS
(Y LDEPTH rill EPT/I MS 1 1 4 V f 015 TR PIPE. DISTR. PIPE ATE RIAL NO OISIH NUMBER OF PROPERTY WELL HUILOING VFNT 10110'0-
;:IA LOW PIP / - ABOVE COVER f i t V~lVIt 1 ELSE dN65 PIPES FEET FROM ,LIN~ ,1`1. n11T I /
(//1 2__ NEAREST----► l S r
OUND 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.
OYES ONO -
SO LCOVER Ttxl(IRt 1PI- HMANI N I MARKI its ( IIiSIRVATI1INWIIIS
OYES ONO _ _DYES _ LINO
DEPTHOVEH TR(NCH HEU DEVT/1 OVFH IRLNCR BED TIC Pill OF TOPSOIL 11) 011. MIA ('10 0
CE N"' EDGES
OYES ONO OYES ONO OYES QNO
PRESSURIZED DISTRIBUTION SYSTEM:
'I f It L Of PTH AHOV( COVI It
WID1H LE Nk,TH NO. OF I.ATEHAL SPACING (rHA"t"
BED/TRENCH TRENCHES
DIMENSIONS _
MANIFUIU POMP MANI1011) 0151N PIPE IMANII OLD MATERIAL ]N0OISI 11 I:IS 111 PIPE 5!%M41itI1 IINVlI'1 M P,IIRIAI KAIAIIKIN(,
ELEV ELEV UTA ELEV. PIPES 171A
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIIF ROLE SPACING 01411-1. LD COIARI Cl 1 v C)VFR MATERIAL Vill IICAI 111 I CORHI SPUNUS In AVPROV11)
DYES ONO P1.nn15 OYES ONO
OMME S:` PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF `RIOEERTV WELL BUILDING
FEET FROM
OYES ONO YES ONO NEAREST~__
/ U J~
a.
Sketch System on Z~ Retai 'n county file for audit.
Reverse Side.
SIGNATURE ~ TITLE
DILHR SBD 6710 (R. 01/82)
LH~ SANITARY PERMIT APPLICATION C T
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
ZOO
-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
&ffAIPD J % hljj%, S T, N, R E (Or _7 9 PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
S
CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK
y, - FE VILLAGE : 7,, TYPE OF BUILDING OR USE SERVED: 44w-
11. Number of Bedrooms if 1 or 2 Family .3 OR ❑ 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. Conventional b. ❑ Alternative c. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. E1 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):
Ga / (J Feet Vu Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total #of Prefab. Fiber- Exper.
INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank I S ❑ ❑ ❑ ❑ ❑
Lift Pump Tank/Si hon 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): Plumb Signature: (No Stamps) M PR W No.- Business Phone Number:
- 1r _
Plumber's Address (Street, City, State, Zip Code). Name of Designer:
r
Vlll. SOIL TEST INFORMATION
Certified Soil Tester (CST) Name CST #
CST's ADDRESS (Street, City, State, Zip Code) Phone Number:
e-49 f`G " r r S ri..q cf
IX. COUNTY/DEPARTMENT USE ONLY
W❑ Di Ad sapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
Surcharge Fee
Approved ❑ Owner Given initial y~/D0
vers
e e Determination Q
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 i
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;
your privat_- sewage syste,;f, contact your local code adi-ninistrator or the
6. If you have questions concerning
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be comp"ete and accurate this sanitary permit application mus` include.,
1. Property owner's name and mailing address Provide the legal descr'ption where the system is t:_ be
installed;
Il. Type of building or use served: I# public ';s 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;
Ill. 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"ter -
included the creation of surcharges (fees) for a number of regulated practices which Wisco min's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure
is used it your building is returned to the groundwater through your soil absorption
system or the disposal site used by y )ur holding tank pumper.
The monies :.oliectec throug" these irct-,,arges are credited ts, the gr<ourcwater fund adminis-
tered by the Department of Natural ;sca ices. These fun's are used for monitoring ground- t
water, grou:dwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
S13D-6398 (8,03/86)
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDOSTFIY, I DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS \ / MADISON, WI 53707 I
• (H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIPP IP4L-FTY: OT NO.: BLK. NO.: SUED 7ON NAME:
T,3oN/R / (ar) W
Ul7 '/a c9 q
COU TY NER'S UYER'S E: 1VAILING DDRE S: ~t fC !
USE DATES OBSERVATIO S MADE
NO. BEDRMS.: COMMER IAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: f
]Residence ? ~ ANew ❑Replace I ~ r / ` ~ 44
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMME ED SYSTEM: (optional)
S ❑U 129S ❑U S ❑U ❑ S A ❑ SEU ~.4
If Percolation Tests are NOT required DESIGNT If any portion of the tested area is in the
under s.H63.09(5) (b), indicate:
Floodplain, indicate Floodplain elevation:
~ - /J
PROFILE DESCRIPTIONS
EL i
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEP"ttN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
00 /7
/43 to- J00tj t
7
B- 7- 7 1034% /'tea p y ~ ,I, ' "%.S.,f . ~17t~
4:1 )33
B- boo>(a5 1- .
B- jp33 100~
DOM"I 1, Y PERCOLATION TESTS
TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER f4WrHf6 AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD 3 PERINCH
P-
P- z IV 0
3
P- 3 3/
-3 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.
SYSTEM ELEVATION / Er
i
z I \ I
1 _ 1 F ~
~z
_I
IN, < 4h
.
-
I, 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 Gcode, 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:
Lq- /-PC
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
~9'Q pU z z
CST SIGN
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DI LHR-SBD-6395 (R. 02/82) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
To he rrnplete and orate soil test, your report must ifldUde;
1. Ge
2. Tl- ;r v ether this is :e t;
3. M, X cial use pla :3;
4. Is
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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.
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Owner of Property ,1] icif-h2 0a2
Location of Property 40 14 N ;4, Section T3(_) N-R W
Township % 4 s
Mailing Address
T
Address of Site /
Subdivision Name cis
Lot Number
Previous Owner of Property T )`y~j/ ~~L /=/~f7
/
Total Size of Parcel
Date Parcel was Created ?3
Are all corners and lot lines identifiable?~ Yes No
Is this property being developed for resale (spec house) ? Yes _ No
Volume kL and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Deed which includes a Document number, volume and pa&ee 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.
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PROPERTY OWNER CERTIFICATION
I (We) cexa4y that a.U ~6tatement.6 on this Sonm ane thue to the best os my (ouA)
knowtedg e; that I (we) am ( cute) the owneA (.s) o4 the pno peh t y dens cA bed in this
.insoAmatton Sonm, by viA tue os a waAAanty deed teco&ded in the Oss.ice os the
County Register o6 Deedbas Document No. 3,;1; and that I (We) ptuent.Ey -3 S' X'2 own the pro pas ed .6 to Son the sewage d l6 pops .s yA em (o& I (we)
have obtained an
easement, to nun with the above descn ibed pnopeh ty, Son the construction o6 said
zydtem, and the same has been duty neconded in the Ossice os the County Reg.usten os
Deeds, as Document No.~73 )
SIGNATURE OF OWNER SIGNAT OF CO-OWNER I APPLICABLE)
DATE SIGNED DATE SIGNED
I
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County z
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OWNER/BUYER Rjcl'+ &yLJ - VCX-- M
ROUTE/ BOX NUMBER R J. Fire Number
.CITY/STATE 5+ Josue-D~ t isc- ZIP ,j Lf j~ S2
PROPERTY LOCATION:-,/ a)-k, Ady _k, Section T 3,() N, RW,
Town of j, ~7~!►i~ , St. Croix County,
Subdivision. Lot number -61
• I
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you pdt into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration.
0
E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- b
ment 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
DATE 424__ ZS` /ifll
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.
!L