Loading...
HomeMy WebLinkAbout040-1036-70-120 oNo o CO) ff'cmod c c o C) w G frt il I -Z -0 :1 1 q .0 n • o'Z m p p m o ra (D X FJ ((D - o OD (n Z o ao < -I o c 0 -1 2 ",.1' rt H rt C'~ O N N O, 0CA) 00 CD d O d r o 00 ? (ND O N p O C ID Cr CD 3 O ID 00 Sv 00 Z V .I N a CD 00 _ N G7 N C1 ID Z a N CO (D O I O) ~'9 O v GD ~ r CD W 7 7p. fl ID 3 y W 7 CL CO Cc) -P, Ili N 0) Cl 0 N ..1 O - ' V a _ N -o .2 _ O 41 N Or CCDD CD r o C O m n r O OD ° 3 rn m No Z N d U) W c H 0 Z ~ ~ o ~ ~ to < D to ~a rn to D a col m to N N a w ao CD c° -i CD - CrJ N 0 o~ M 0 ~ o o~ ~i C7 lln < 1 a I\ I`n v v ' Qp 0 CO CD Oz 00 OODD ID n r to rn rn rn c N^ O' N 0 1 n l a l 3 H H m n O Nm v~ v=I 0M "0 3: 00, 00 7 O o O c z Wi z! o 0 o 1-3 o oh7d ~ y C.0 v> .0, D En ~jv CD m 1 0 Fl- 3 N _ rn (D r KI t I L1 rr IT oz N rt ~~D n D a 0 0 ~ O N C~ N • (D CA CD .0 cn 'a U) (D w c v c I I co ICD c m CD c m C1 3 ° CD z ~-q N o i,ZID C c ; 0 G~ a o G (D 0 ((DD Or Z Ill N OD rt Cj CD co CD IUD w r~ a N z Z ;o o z rI H t + O G !2 Cp • 3 z z o, o wCD WCD Ul a, nD N a - J 0 o • li y N C 3 N C o a o o a I CL m S CL N N ~C %.0 - y CD Q CD C, I.t rt 00 s m • (D o m o = o ro rr g o II o I ti o o b ° i ao CD CD O ~p rn ~ p to p ti, e H ° ° f o Fj I O O L 0 Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC._ T N-R~W ADDRESS f~ S`t' ST. CROIX COUNTY, WISCONSIN SUBDIVISION' LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of IIHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 f 4,,,E44 4.75' crud 7. / / - 9s" .5r( I y ,Yy - y-/ 73 Igo- i INDICATE NORTH R~W BENCHMARK: Describe the vertical reference point used,, Elevation of vertical reference point: ~)j~ej,C) Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: - Tank manhole cover elevation: Tank Inlet Elevation: f5-;~i7 Tank Outlet Elevation: FS's Number of feet from nearest Road: Front, Side, Rear, 0 feet From nearest property line Front,O Side, Rear, O feet Number of feet from: well building: 3)' (Include this information of the above plot plan)( 2 reference dimensions to septic tank) RR.R. RR.UR.RRR CTnR ti PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: Number of Lines:._ Area Built: ,C Fill depth to top of pipe: ,2Z i Number of feet from nearest property line: Front, ~ Side, O Rear, O Ft .//D Number of feet from well: i Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: G Inspector: Dated: ,1,42--~ Plumber on job: License Number : 3/84:mj s DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 (CONVENTIONAL ❑ALTERNATIVE State Plan l.D. Number- ) E] Molding Tank E] In-Ground Pressure El Mound (if assigned NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Larry Vennendall 4th St. N., Hudson, WI 54016 1,;2 ,j.-P'wl BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. LEV. SE NW, Section 8, T28N-R19W, Town of Troy, Lot #4 Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Cal Powers 1563 St. Croix 88449 SEPTIC TANK/HOLDING TANK: MANUFA ER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL JLOCKING COVER 9PROVIDED: PROVIDED: f~"Vt V{ _df 7 S YES DNO DYES DNO BEDDING: VENT IA.: J I VENT MATL.: HIGH WATER NUMBER OF ROAD: ` PROPERTY WELL: BUILDING. ALARM. FEET FROM ` LINE: AIR INLEYES DNO DYES ❑NO NEAREST JVENTTOFRESH I♦~~ DOSING CHAMBER: MANUFACTURER. 7INGS JLIQUID CAPACITY: PUMP MODELPUMP/SIPHON MANUFACTURERWARNING LBEL LOCKING COVER PROVIDED: PROVIDED: E❑NO DYES ❑No DYES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL. BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ❑NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER ]MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH: 10 LENGTH: IND. OF DISTR. PIPE SPACING. COVER JINSIDE DIA. #PIT, LIQUID BED/TRENCH TRENCE~s MAr IAL: PIT DEPTH DIMENSIONS ` ~l GRAVEL DEPTH FILL DECPTH DISTR. PIPE DISTR. PIPE DISTR. PIP MATERIAL: NO TR. NUMBER OF PROPERTY WELL BUILDING: VENT TO FRESH BELOW PIPES ABOVE OVER: ELEV. INLET. ELEV. END:9 PI FEET FROM LINE: AIR INLET: NEAREST ► G' / I MOUND SYSTEM: !rte 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- DYES NO meets the criteria for medium sand. TIONS MEASURED. D SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS DYES 1:1 NO DYES 1:1 NO DEPTH OVER TRENCH/BED JDEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED. SEEDED MULCHED CENTER: EDGES: DYES DNO DYES ❑NO DYES DNO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH TRNO. LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. INODtSTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV.: ELEV.: DIA.. ELEV.. PIPES DIA.: DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ❑NO DYES DNO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: -1 NO DYES I DYES DNO INEAREST---~ Sketch System on Retain in county file for audit. Reverse Side. SIGN ATUR TITLE. DILHR SBD 6710 (R. 01/82) r. ~ILHR SANITARY PERMIT APPLICATION Cou Y In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # 0d y -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 OCATION '/4, S R T2,? , N, R , (or ROP RTY WNER'S AILING ADDRESS LOT NU BER BLOCK MBER SUBDIVISION NAME t CITY STATE ZIP CODE PHONE NUMBER CITY :14) NEAREST R D, LAK O LAND K .pQt is--i6/ 7 1 It EX TOWN E3 VILLAGE: 1 Xe~,-b 41 -7~~ j(,F ,E 11. TYPE OF BUILDING OR USE SERVED: D ~d Yv Number of Bedrooms if 1 or 2 Family OR Public (Specify): / III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. 2 New b. ❑ Replacement c. E1 Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System 3. Existing System 2,M A Sanitary Permit was previously issued. Permit # gg SS Date Issued y 8~ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. Conventional b. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. seepage Bed b. ❑ seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Feet Private ❑ Joint ❑ Public VI. TANK CAPACITY Site m ,gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xisting Gallons Tanks Concrete structed glass App. Tanks Tanks S - ❑ ❑ ❑ ❑ Septic Tank or Holding Tank 1412~_ /,1Ze7 Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation oft a pri to sewage system shown on the attached plans. Plumber's Name (Print): PI er's Signature (No Sta ps) MP/MPRSW No.: Business Phone Number: umber's Address (Str et, City, St pp, Zip Code): Name of Designer: ` VIII. SOIL TEST INFORMATION Certified Soil Tester (C T) Name CST # / •,1 CST's ADDRESS (St et, City, S te, Zip Code) Phone Number: r S IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps) ^ X Approved ~ri Surcharge Fee ❑ Owner Given Initial v~ 9 %V Adverse Determination v ✓"O X. COMMENTS/REASONS FOR DISAPPROVAL: I SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2, Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of 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 to3 years; 6. If you have questions concerning , your private sewage syste ) r . ontac your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/2 X 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the r result of over 2 ears of steady negotiation and public debate. The groundwater bill Y~ Y Groundwater included the creation of surcharges (tees) for a number of regulated practices which WiscorTSsn'S , can effect groundwater. The surcharge took effect on July 1, 1984. All of th.- water that burin + {reasure is used in your building is returned to the groundwater through your sail absorption ~o system or the disposal site used by your holding tank pumper.` The ironies code tecl through these surcharges are credited {o the groundwater ;and cirn"nis. tereG by he Department of Natural Resources. These funds e re used for i Monitoring 0 ou d- ~ establishm.:nt of standards. Groundwater, water, 8raurr~iwater contamination investigations and establishm~.,nt of standards. Groundwater, it's worth protecting. SBD-6398 (R.03/86) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MAD,soN wl 7969 HUMAN RELATIONS (H63.090) & Chapter 145.045) LOCATION: SECTION:T~ TOWNSHI MUNICIPALITY: Z1BLK. NO.: SUBDIVISION NAME: /bC y?E (or k)Lsr A- C/ COUNTY: OWNER'S BUYE 'S N ME: AIL G ADDRES i / USE DATES OBSERVATIONS MADE NO. BEDRMS.: 1COMMERC71L DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence New ❑Replace ' 9/ RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:G I ISYSTEN NTANK: RECOMMENDED SYSTEM: (optional) sou sou ; [Z s❑u ❑s u as u - 4.241 If Percolation Tests are NOT required DESIGN RATE- If any portion of the tested area is in the / under s.H63.09(5)(b), indicate:~/~T 7 Floodplain, indicate Floodplain elevation:/ PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHtN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B-977 'IhA,~v B- B- C- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERT D 3 PER INCH P- P- l , f P- P-_ _ 121,4 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 q-5, T I E I i Ji- E i E E ~ I 3 t ~ i W r w E E 3 E E 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 Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME print : TESTS WERE COMPLETED ON: AD S: RTIFIC TION NUS ER: PHONE NUMBER(optional): CST AT E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - R[7 - 6395 To rv a ^°arnplete and accurat- -ail test, your report n1ust include: 3. ^.f d descriptio-- 2. oust clew 'y :e whethe s or com jest; . MA csamn 4. Is m; S Doxes, A SITE IS 7AMi< ONLY IF ALL CUT BASED 6 own here fa g the pleat plane T M I ,.,curately locatin preferred. A se 3r; t; 8. :-cal elew,'"i .a at are cl, I e nerrnanent; 9, to states, i lood pla I-, test exemp- t 1Ct eIrN,A_ in e ax; 11 number; MUST BE D 'ITl1 THE RR--' " -IC-I'- V -'ITIFI - ' TESTERS der S") in #i s c _ P. I, T I lest at, to 7CJ~G ~~J,ts r AJZ- ~ ~ spa i /1ou5A la0 I PAGE OF o~ ~e~ SyS C.rC) S~c'101-1 Sr Fresh Alt Inlets And Observation Pipe Approved Von# Cap / Minimum 12" Above Final Grade 20- 42' Above Pipe _ 4" Cost Iron To Final Grade Vent Pipe Idren May Or Synthetic Covering min 2" Aggregate _ Over Pips Distribution - Tee Pipe -ioQ000, V Aggregote 0 Psrlarc.te4 Pipe 8: ca Beneath Pip s Coupling Terminating At Bottom Of system ton SOIL FILL DISTRIBUT101i.1 PIPE APPROVED $41IJTMETIC COVER MATERII~1 OR 9" OF STRAW OF06RE(GIATE OR AARSM 14Ay (eOF 12 -21/2 AGGREGAT E"8 r&LEV. 0F2 .2FEF.T DIS-rRIF3%JTIOA) PIPE TO BE AT LEAST INCHES BELOW ORIGIAIAL GRADE AQU AT LEASTZO IKJCHES BUT 1.10 MORE THAlJ 42 INCHES BELOW FILIAL GRADE MAXIMUM DEPTH OF EXICAVAT100 FK014 OKI&*JjkL 69AIDE WILL BE INCHES MIKIMUM Wnt OF EXCAVATION FK0M•0IKlG1agL (jRi49€ WILL BE ___f~__ INCHES SIGIJEO: LICEMSE AIUMBER: Jlf; ji ' DATE r J x J ST. CROIX COUNTY WISCONSIN F ~r <h l f x } ZONING OFFICE 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 December 5, 1986 Ms. Carolyn Haag Bureua of Plumbing P. 0. Box 7969 Madison, WI 53707 Dear Carolyn: Permit 483855., issued on 9-4-86 is being rescinded as the system area had to be changed. The plumber was unable to obtain that permit card. Permit number 88449 has been issued for the system installation. Should you have any questions, please feel free to contact this office. Sincerely, Mary J. Jed ins, Secretary St. Croix County Zoning Office DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS P.O. BOX 7989 PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WIC 63707 BUREAU OF PLUMBING CONVENTIONAL ❑ALTERNATIVE state Plan l.D.Number ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If aF~ignetl) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER Larry J. Vennendall 4th St. N., Hudson, WI 54016 INSPECTION DATE: BENCH MARK (Permanent reference polntl DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV. SE NW, Section 8, T28N-R19W, Town of Troy, Lot 4 Name of Plumber MP/MPRSW No 1c.."'y- Sanrtary Permn Number- Cal Powers 1563 St. Croix 83855 SEPTIC TANK/HOLDING TANK: MANUFACTURER. EA D CAPACITY TANK INLET ELEV. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER I PROVIDED. PROVIDED- ❑YES ❑NO ❑YES ❑NO BEDDING: =DIA. =TM- NUMBER OF ROAD. PROPERTY WELL BUILDING. VENT TO FRESH FEETFROM❑YES DNO ❑NO NEAREST DOSING CHAMBER: MANUFACTURER BEDDING LIOUIO CAPACI IY PUMP MOUE( Pl1MP. SIPHON MANUI A(; TI IFIEH WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF.. PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST---W SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I F Nc. nH I)IAMF TF H MATE HIAt ANO MAHKING or excavation. (If soil can be rolled into a wire, construction shall cease until =OC the s oil is dry enough to continue.) CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO OF UISTH PIPE SPACINI S COVEN NSIIJE Ills DIMENSIONS TRENCHES h1ATEHIAL x PIT PI F DEPTHD GRAVE L DEPTH FILL DEPTH UISTN PIPE UISTH PIPE DISTR. PIPE MATERIAL NO DISIH NUMBER OF PROPERTY WELL BELOW PIPES ABOVECOVER EI EV INLFI ELEV ENU BUILDING VENT TO FRESH PIPE S FEET FROM LINE AIR INLET NEAREST - MOUND SYSTEM: _ Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER TEXTURE PI RM11AN! N1 MAHKE IS ~OIISEIIVA(S TIN WELLS DEPTH OVER TRENCH 57 HED DEPTH gVFH THENC,H HEU YES NO YE❑NO CENTER OF PT11 qF iOl'SOR SOOOfU ISEE UFO MULCHED EDGES ❑YES. ❑NO ❑YES 0NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH HE LOW PIVf FILL DEPTH ABOVE COVER TRENCHES DIMENSIONS MANIFOLD PUMP MANIF OLU DISTR. PIPE MANIFOLD MATERIAL NO UISTH L`ISTH PIPE UISTItIHlI1tON FIVE MATERIAL & MARKING ELEVATION AND ELEV. ELEV DIA ELEV PIPES DIA" DISTRIBUTION INFORMATION HOLE SIZE ROLESPACINO URFLLEDCOHHECILY COVERMATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS OBSERVATION WELLS. JIF UMBER OF PROPERTY WELL. BUILDING: EEROM uNE T T YES ❑ NO YES ❑ El NO EARESF Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE DILHR SBD 6710 (R. 01/82) D~LH SANITARY PERMIT APPLICATION COUNTY _ R In accord with ILHR 83.05, Wis. Adm. Code C d~ . . ' STATE SANITARY PERMIT # -Attach co lete plans (to the county copy only) for the system, on paper not less than ~'3 ass 8% X 11 in~hes in size. STATE PLAN LD. NUMBER -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 L go~ S '/a Gt 14, S ~q T 2 8, N, R It (or) W PROPERTY WNER'S MAILING AP RESS LOT NUMBER BLOC NUMBER SUBDIVISION NAME CITY TAT ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK ~Q, 0 VILLAGE : II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): 111. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable) 1. a. 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. P, 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 (S uare Feet PROPOSED (Square Feet): 410 " ~4s ,f J07 g I S101 3Feet Private El Joint ❑ Public VI. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank.. I-p ❑ ❑ ❑ 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 (Pri Plumber's S' nature No tamps) MP/MPRSW No.: Business Phone Number: 4 UG v~i-~ c r5 S(~ 7/S '910, -s/~3s Plumber's Address (Set, City, State, Zip Code): Name of Designer: 'gy`p a / ~cc/~m o~•~ Gvu~ sA- VIII. SOIL TEST INFORMATION Certified Soil Tester (CST) Name CST # ~,~•tence &J. Mar `t S 2 y y~ ST' ADDRESS (Street, City, State, Zip C de Phone Number: IX. COUNTY/DEPARTMENT USE ONLY X F-1 Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee Adverse Determination U X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT. APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revilions 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) shouid be pumped by a~Iicensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include:: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address., and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot-plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; welts; 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`ma're' commonly known as-the groundwater protection law. This change in statutes was the -esuWof over 2 years of steady negotiation and public. debate. The groundwater bill Groundwator included the creation of surcharges (`ees) for a number of regulated practices which Wiscorisin's can effect groundwater. The surcharge; took effect on July 1, 1984 All of the water that buried freasure ~ t is used in your. building is returned to the groundwater through your soil absorption o bystern or the disposal site used by"your holding cank pumper. The monies r:ollected through these surcharges are credited to the groun~ wafer sand adminis- tered by the (Department of Natural Resources. These funds are used for non torir~g ground- Water, groundwater contamination in-vestigations and establishment of standards. it's worth protecting. 3D-6398 (R.03/86) Si APPLICATION FOR SANITARY PERMIT S T C - 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. - - - - - - - - - - - - - -A - - - - - - - - - - - - - - - - - - - - - - - Owner of Property l_Q rHy e~ h cC~ I/ Location of Property Section T 2 N- R W Township T1A U Mailing Address S d !~-fit- Lk crSah W Subdivision Name Lot Number y Previous Owner of Property _61,e 11 (,cJ I P_j Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume 7,41X and Page Number 4a5 as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. Other recordings filed with the Register of Deeds Office 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 Map, the the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We.) eenti.6y that aU statementz oft th,u, 4o4m ahe tAue to the best o{ my (ouA) knowledge; that I (we) am (cute) the. owner (,s) o6 the pnopen ty de.6cA bed in this .,n6onmation 6o4m, by viAtue o6 a waAAcanty deed Aecoh ed in the Oj6ice o6 the County Regi6teA o6 Deeds as Document No. 31 ,3 ; and that I (we) pAmentty own the pupo.6ed bite SoA the .sewage po~sa~ ~y~tem (oA I (we) have obtained an eazement, to nun with the above desnibe.d paopeAty, 6oh the con stAuction o6 6aid system, and the same has been duty recorded in the 0jjice o6 the County, Regi6te4 o4 Deeds, ass Document No. ) . SIGNATU 01' OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) D WE SI ED DATE SIGNED I z Y- a ST C- 105 r SEPTIC TANK MAINTENANCE AGREEMENT H St. Croix County z i c7 a OWNER/ BUYER /T t7l H ROUTE/BOX NUMBER %lt~ ST. No. Fire Number CITY/STATE ZIP 5 V~ w - PROPERTY LOCATION: Section T 2_F' N, R I W, Town of p Y St. Croix County, Subdivision C, -S, 11 Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St." Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H I/WE, the undersigned, have read the above requirements and agree m 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 ys of the three year expiration date. , v~ SIGNE c7v DATE St. Croix County Zoning Office P.O. Box W Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. DEPARIIVT OF - REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUS i'RY, C DIVISION LABOR AN P.O. BOX 76 HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 (H63.090) & Chapter 145.045) LOCPJION: SECTION: TOWNSHIP UNICIPALITY: OT NO.:BLK. NO. SUBDIVISION NAME: NE 1/4 NJ/ 8 128 N/R /9 E (or W TROY 4 C. S. M. COUNTY: WN 'S BUYER'S NAME: [MA11,LEING ADDRESS: ST.CR0IX GLEN WIESE RIVER FALLS, W/ 84022 USE DATES OBSERVATIONS MADE NO. BEDRMS.: CO NA ERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 ®New ❑Replace NOT CONDUCTED RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUNcD: IN-GROUND-PRESSURE: SYSTEccM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) ®S DS DS ~V ©U ~S ®u CONVENT/ONAL If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: NO T CLASS 2 Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST, HIGHEST- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ! 8,2' 100.3 NONE 8.2 Bn / 10.8'1 Bn / s ! O. 3'J 8n r / T. / 03.3' B- 2 8.3 / ~ 8.3 Bn / /0.8'1 Bn ri/ /O. 6'J Bn s/ /0.8'J Bns !6. / B- 3 8.5' /02. 7' 8.8' Bn J O'1 Bn sJ/ 1 2. 0'J BP s / S. 5'J B- 4 8.9 /01. 9' 8 g~ Bn / ! 0. 9'J Bn s// / 8'J an s 16.2'1 B- 5 8. 5 103. 3' 8J7 / 1 0.9'1 8n / s ! 0.4'1 Bn s / 7. 2'1 B- S O / L MA P S H E E T 74 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PER D3 PERINCH P- P- P- P-_ P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. /N/T/AL 98,3' SYSTEM ELEVATION REP, 99. 7 ' S R. O. W. TOWN ROAD iSCAEI 4-1 R. P. TOP P/P A SOME 100 ( I r _ WES7L/N L T4' 41, CC r ~i 8ACKH6 E..;PIr B/ {Q P/PE i i ? I I E 10 t 3 ( I ~ I I 3 8 2' S s { F a o a 1 ( 4 ! G 3 U! A° E A 3_360' , 360 SO FT.` s T_ I ?0 1 Qv t ; i 1841 Ir I i [l r i t rn~ i( E i 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 Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: LAURENCE W. MURPHY ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): R/ SOX .36A RIVER FALLS, W/ 54022 55-2445 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - L. : 3M 115 - S - 5395 To a it to repot t include: t 1. C`m 2, 6 is is a residence }ject; 3. } panned; 4, 5. "TABLE FC r' 1-17 P11,11- TANIK ONLY IF ALL 6. s sh g profile descri the plot plan; 7. am acc Saar test locations. I preferrc i A de v arei M if V, x; ui -S. f D TH THE TI-II ~ S of Ht I it _ CERTIFIED-SURVEY MAP GLEN WIESE Part of the Northeast 1/4 of the Northwest 1/4 and the Southeast 1/4 of the Northwest 1/4 of Section 8, Township 28 North,_ Range 19 West, Town of Troy, St. Croix County, Wisconsin. O Indicates 1" x 24" iron pipe weighing 1.13 lbs./tin. ft. se lam'-1~ , TpM,N ROAR l ~ LINE , I yAppA6LEwlptNN/S 114 ux~4ATrgQ ,ASl- I Sp0' 09 ~ lE 388.00 q ` '-N 00' 36 ?6 N t Z m / p 0 / b 6TOON. ?119W, b G'0R SEC R rS NON.1 Q s / Q. rw V ^ / y ~ W uNT Y $ uVrVOR Q 4L N I14 Mry A ' ^ O h f CO b 4 O \ 0 0 O a ^ C3 4b b y W. n N O O \ o o° 0 ~l .33.00 N~~•O ~ Ql tO THE N/S 1/4 bry,~ 4 ~ti o Oou~ O off ALL.6EARIN66 280 .9 y\~i Z •~p/, L1NEOFSASNOO'OS 52"', ~t REppRDEp % p Q h a Dated : 30 August l J5 ^ a O 16 ; 4 ° a^ Z 2 f Wry 3 3/ , 41 r~ O 000 0C %G 4j % a y t , rR' ~ 44 a aO/~ / / y ry R ry / ? a Q/ % A" % 4 0 O y ti o~yoy ow h b to • ry Z W o v oy a ~ • ~ T qr O b 0000'• J~4 a O ~~E~NW 4ft J* r 40 4Q • Z 0) , ms's E FI yeti e~'~ti ry' ~Q y o o• , o WISC. • p /ne h a s 4 Ma 400.0. LAND mow` / Laurence W. Murphy Registered Land Surveyor 42 0-00 466.74' Vol. Page / ~I so y_ E LAND Certified Survey Maps •7 LA rTt~ St. Croix County, Wisconsin 'jp 4JMMMT / or & Iv T /Vc , ~-r l rrj P ~ sL "003 2c; ~ t i cel PAGE OF h C r o S S S e c jl u rl O ~ A Zc o S s t e r~ J, u 5 T, Fresh Air wells And Observation Pipe ( Approved Vent Cap Minimum 12" Above Final Grade 4" Cast Iron 20 - 42" Above Pipe _ To Final Grade Vent Pipe Morsh may Or Synthetic Covering Min. 2" Aggregate over pipe Dletributlon Pipe 0 0 0 0 0 - Tee 6" Aggregate o Beneath pipe Perforated Pipe Below o Cooping Terminating At Bottom Of System s ii d PrUPoSCn f'ink' 9re At ~L~CJw~ toll y SOIL FILL DISTRIBUTIOA] PIPE APPROVED S4MIETIC COVER oFA6GRE6A1E-~'J c4 c MATERiII+I OR 9" OF STRAW OR fiARSU HA':j 3 (e 0F/2 AGGREGATE DIS-rRi5UTIOU PIPE TO BE AT LEAST IPICHES BELOW ORIGIMAL GRADE AMID AT LEAST?-0 IUCHES 131JT MO MORE THAM HZ INCHES BELOW FINAL GRADE MAXIMUM Dami OF I~Xe-AVAT160 FROM 0KI&NA1. 6RAK WILL BE IUCHES PUI41MUM IMr•H OF EXCAVATION FROM. OIKII(AelAL GRAVE WILL BE INCHES I i SI&MED: UGEWSE WUMBER: _ r DATE: 9 ` 3 ` Parcel 040-1036-70-120 02/07/2007 09:59 AM PAGE 1OF1 Alt. Parcel 8.28.19.118E 040 - TOWN OF TROY Current X 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 O - VEENENDALL, LARRY J & DIANE W LARRY J & DIANE W VEENENDALL 468 TOWNSVALLEY RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 468 TOWNSVALLEY RD SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.231 Plat: N/A-NOT AVAILABLE SEC 8 T28N R19W 2.231 ACRES E1/2 NW1/4 Block/Condo Bldg: LOT 4 CSM 6/1653 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 08-28N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 744/605 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/19/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.231 53,000 189,500 242,500 NO Totals for 2007: General Property 2.231 53,000 189,500 242,500 Woodland 0.000 0 0 Totals for 2006: General Property 2.231 53,000 189,500 242,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 135 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00