HomeMy WebLinkAbout030-2071-60-000
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"Parcel 030-2071-80-000 01/09/2006 08:29 AM
PAGE 1 OF 1
Alt. Parcel 36.30.20.619E 030 - TOWN OF SAINT JOSEPH
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
OKE BANDA O - BANDA, OKE
1236 HWY 35
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 6.120 Plat: N/A-NOT AVAILABLE
SEC 36 T30N R20W NW SW THE E 632.75 FT Block/Condo Bldg:
OF LOT 4 CSM 4/1117
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
36-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
05/27/2005 796129 2811/079 TI
04/27/2004 760746 2557/551 QC
07/23/1997 983/434 WD
07/23/1997 641/53
2005 SUMMARY Bill Fair Market Value: Assessed with:
84712 52,100
Valuations: Last Changed: 07/09/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 6.120 47,400 0 47,400 NO
Totals for 2005:
General Property 6.120 47,400 0 47,400
Woodland 0.000 0 0
Totals for 2004:
General Property 6.120 47,400 0 47,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Total Special Assessments Special Charges Delinquent Charges
0.00 0.00 0.00
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Parcel 030-2071-60-000 01/06/2006 02:40 PM
PAGE 1 OF 7
Alt. Parcel 36.30.20.619E 030 - TOWN OF SAINT JOSEPH
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 - BANDA, OKE
OKE BANDA
1236 HWY 35
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description " 1236 HWY 35
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 4.410 Plat: N/A-NOT AVAILABLE
SEC 36 T30N R20W NW SW LOT 3 CSM 4/1117 Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
36-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
05/27/2005 796129 2811/079 TI
04/27/2004 760746 2557/551 QC
2005 SUMMARY Bill Fair Market Value: Assessed with:
84710 253,800
Valuations: Last Changed: 07/09/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.410 113,100 117,700 230,800 NO
Totals for 2005:
General Property 4.410 113,100 117,700 230,8000
Woodland 0.000 0
Totals for 2004:
General Property 4.410 113,100 117,700 230,8000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 139
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
00
Total 0.00 0.00
Parcel 030-2071-80-000 01/06/2006 02:40 PM
PAGE 1 OF 1
Alt. Parcel 36.30.20.619G 030 - TOWN OF SAINT JOSEPH
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 - BANDA, OKE
OKE BANDA
1236 HWY 35
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 6.120 Plat: N/A-NOT AVAILABLE
SEC 36 T30N R20W NW SW THE E 632.75 FT Block/Condo Bldg:
OF LOT 4 CSM 4/1117
Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4)
36-30N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
05/27/2005 796129 2811/079 Ti
04/27/2004 760746 2557/551 QC
07/23/1997 983/434 WD
07/23/1997 641/53
2005 SUMMARY Bill Fair Market Value: Assessed with:
84712 52,100
Valuations: Last Changed: 07/09/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 6.120 47,400 0 47,400 NO
Totals for 2005:
General Property 6.120 47,400 0 47,400
Woodland 0.000 0 0
Totals for 2004:
General Property 6.120 47,400 0 47,400
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
II
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 3/4 IV /_7 f4 TOWNSHIP ,j , ~ SEC. T N-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
~fC{!7 `5CI,/V
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
lr
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13i-1 t :"L i fail, C
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f46, Lk
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INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used C_ ffiY-
Elevation of vertical reference point: ~j( Mfr Proposed slope at site:
SEPTIC TANK: Manufacturer: Liquid Capacity:
Number of rings used: Tank manhole cover elevation:-`/
I ( Tank Inlet Elevation:
Tank Outlet Elevation: Number of feet from nearest Road: Front, Side 0 Rear, O feet
\ZY
From nearest property line Front,O Side,0 Rear, ) feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump
Elevation of inlet: _ Bottom of tank elevate
Pump off switch elevation: Ga4on'9--per cycle:
Alarm Manufacturer: "Alarm Switch Type:
Number of feet from nearest property line: Front, 0Side, O Rear , Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: j Length: _j Number of Lines:
Area Built: Fill depth to top of pipe: 7 e)
Number of feet from nearest property line: Front, ® Side, O Rear,O Ft.~
Number of feet from well: /(/~~~-L,
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 af'the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevion of bottom of tank:
Elevation of inlet: X~.
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.h
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
/Alarm Manufacturer:
Inspector:
Dated: Plumber on job: mac"
License Number. n
3/84:mj
w
K r ~r
Oil c
13.4
-xsre~i'
eO
s ~~n
a c f I ; ►L~ I t~
I
y G h 5 i / /z' c rf L
6 t~ eft ~ .L~' z~'T ypma c~
V
917, (Y
R r i T
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR tic SiUMAN RELATIONS SAFETY & BUILDINGS
P'O. Box 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
CONVENTIONAL ❑ALTERNATIVE SHolding Tank In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER:
AOF PERMIT HOLDERINSPECTION DATEJoe Banda . R. 2, Hudson, WI 54016
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
REF. PT. ELEV.- CST REF PT. ELEV
NW% SW% Sec. 36, T30N-R20W Town of St. Joseph, Lot #3
N.7e t~l Plumber ,
MP,MPHSW N,, C~ur~y Sanitary Permit Number:
I._Donavin Schmitt 3205 St. Croix 69671
SEPTIC TANK/HOLDING TANK:
MANUFACTUHER.
LIQUID CAPACITI' TANK INLET ELEV. TANK OuTL. ET E LEV WARNINGLABEL
r LOCKING COVER
PROVIDED
i.~,,' PROVIDED
BEDDING J ES LINO ❑YES LINO
VENT DIA. VENT 9A1I J HI(;H WA iE Ft
/ ALA M NUMBER OF ROAD PROPERTY WELL BUILDING VENT TO FRESH
❑YES NO ,f FEET FROM LINE / A (AIR INLET
_1YES O NEAREST-
DOSING CHAMBER: -
MANUFACTURER BEDDING. LIQUID CAPACITY - -
PIIMP -VIP SiPW)N r,TANUI n(.lUHf H
~I WARNING LABEL LOCKING COVER
L-1 YES ❑ NO PROVIDED PROVIDED.
GALLONS PER CYCLE: EYES ❑ NO ❑ YES ❑ NO
PUMP AND CONTROLS oPeRArioNaL (DIFFERENCE BETWEEN NUMBER OF PHOPEHTV WELL BUILDINGIVENT TOFRESH PUMP ON AND OFF) FEET FROM "E AIR INLET
❑YES LINO _ NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing L__ -
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE :aF TEH ~Arl HIAL A D MARKING
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENC,n+ No of DI,rH PIPE sPACIti u~EF+ -
THENI+ES INSIUE D:n -PI T$ LIQUID
DIMENSIONS ( I- ` PIT
DEPTH
H VEL DEPTH / FILL DEPTH )ISTH PIPE UISTH PIPE DISTR. PIPE M HIAL NO )1S 7 NUMBER OF WELL BUILDING VENT TO FRESH
(4 LOWLIFES ABOVE COVER rIFV (P I ELEV END PIPE S PHIPEHTV
FEET FROM LINE AIR INLET'.
`7 j y t d
MQLIND SYSTEM: 5 NEAREST
Mound site plowed perpendicular to slope
and furrows thrown upslope: Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
❑YES LINO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE ____1 ~j -
PE wntAN1 NT MAH'F HS OHSE HVATI/1N LNF Lt S
DIITH0VFH THENCH H F D DEPTH OVFH TRENCH HFU- LJYES LINO _❑YES LINO
(CENTER EDGES DEPTH Of Tf ]PSflll M1 SFf UFU
MULCHED
YES NO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
ABED/TRENCH wlDn+ I ENGTH FN LAI CHAL SYINM(FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP DISTRPIPE IFOL DM AT EHIAL NO UISTH UISTH PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV ELEV ELEV PIPES DIA
DISTRIBUTION
INFORMATION HALE s zE HDLE SPACING Cllv
COVER MAI ERIAL VEH TiCALLIFT CORRESPONDS TO APPROVED
PLANS
COMMENTS: PERMANENTMARKERS~YES LINO _ ❑YES NO
oas ERVATiON WELLS UMBER OF PROPERrv WELL BUILDING.
EET FROM LI"E'
❑YES LINO ❑YES LINO ]NEAR
ES
T-
-
!It
Sketch System on ~
Reverse Side. Retain in county file for audit.
SIGNATURE TITLE
DILHR SBD 6710 (R. 01/82)'/~~~~~-~
wls`ons: APPLICATION FOR SANITARY PERMIT
~COUNTY
OEPRgTnlEr1T OF (PCB 67)
InOUSTRY.LRBOR 6 HUMRn RELRTIOnS UNIFORM SANITARY PERMIT #
~9fA ~i
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/'x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
v
d-4-AII)A
TY LOCA N
CITY:
VILLA,GE~:
lc 1/4j_/: 11/41 S %x, T N
1 R E (o0A o~ °
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME Rt&7XREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
_y 'i.'''~
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. 'j ❑ Public (Specify): 4'
THIS PERMIT IS FOR A: ~ 0,30 c X71 0~
U New System ❑ Replacement El Repair W
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IFTHIS-IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
k Seepaye Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
❑ System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity 6 -
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: 't
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total # f Prefab. Site
Gallons T k V Concrete constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
2 F rivate ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): T'gnature MP RSW No.; Phone Number:
i t. t_;.....L-.,-
Plumber's Address: /2 _t
Name of Designer:
f
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
❑ Disapproved
r
fX G l Owner Given Initial
Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.) ;
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13, Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Location of Property Section j , T Ct N - R W
Township
Mailing Address ~j 2Z
Subdivision Name
Lot Number
Previous Owner of Property J //tl✓ /~f}/V /C 5
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 (l f and Page Number V 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.
PROPERTV OWNER CERTIFICATION
I ' I ceAti6y that att 6-tatement6 on thiz 4on,m aAe t ue. to the best o6 my 4o")
knowledge; that I 4ac} am 4w&w) the owner ts0 o6 the pnopeh ty deb c lbed in .th.i6
.in6onmation 6otm, by vi tue 06 a wa4Aa.nty deed n Bonded in the 066.ice o6 the
County Regis ten o6 Deeds a.a Document No. 3$'S`;L ; and that I b=)
pneaen.t£.y own the pnopoaed zite bon the aewage po6 6y6.tem (on 1 hm) have
obtained an easement, to &un with the above de6c&ibed pnopenty, bon the
co"ttnuc lion o6 6a.id 6 y.6 tem, and the Game ha.a been duty tecoxded in the 066ice
o6 the County Reg•ia.ten o6 Deeds, as Document No. ) .
SIGNATURE OF WNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE S GNED DATE SIGNED
it
H
y
a
ST C- 105 r'
r
a
SEPTIC TANK MAINTENANCE AGREEMENT H
St. Croix County z
d
OWNER/BUYER ale`l t~- I)AI A
~ ny
ROUTE/BOX NUMBER
Fire Number
CITY/STATE ZIP
PROPERTY LOCATION: A&_', d' 14, Section,3_, T _N, R W,
Town of S St. Croix County,
Subdivision Lot number .3
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
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- v
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 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.
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DEPARTMENT OF.
REPORT ON SOIL BORINGS AND Y ` VISION
INDUSTRY, 0. 7969
LABOR AND PERCOLATION TESTS (115) - ~0 3707
HUMAN RELATIONS (H63.090) & Chapter 145.045)
LOT NO.:BLK. NO.: DIVI C!~
LOCATION: SEC1-ION: TOWNSHIP/~+TY: C,
/av/a'~ /T3UN/R7vlor)W s~
c
COUNTY: OWNER'S/ovrcn=~, NAME: MAILIN A DDRESS:
USE DATES OBSERVATITIOONS:A w
_ SCRIP TESTS:
NO. BEDRMS.: COMMERCIAL DESCRIPTION: _
~esidence 3Alew ❑Replace PROFILE DE ON
- -
RATING: S= Site suitable for system U= Site unsuitable for system
r NVENTIONAL: Inn : IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional)
❑S ❑U ❑U ❑S ❑ U OS ❑U ❑S ❑U
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.1-163.09(5)(b), indicate: } Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS '2-
CisYl01(
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH 1
ELEVATION
NUMBER 7/,q AL OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.
`i
/ /L?O 1o I~UU/31.rs-L, , E ~ 3Zh.5.1., nCJ d
B / _S 2
C7( ZO o/ , (a-r (,7 S0 l ,7
B-~3 C> 0 A) E 1/ 0 -ji.5, L, )_61-5- x., / ;,1. L~--s, ~ J~_S.4
B-
B-
B-
PERCOLATION TESTS
OfSlinA~ ~
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE PER MIINNCHUTES
NUMBER +ftt2t+ES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 <
So b
G
P- 2- .37z A10 _3
P_'3
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
0'. -
a~
Dm. N
E
or- COJ61
{
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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.
TESTS WERE COMPLETED ON:
NAME (prim
CERTIFICATION NUMBER: PHONE NUMBER (optional):
ADDRE/SS~:r Z Z 5;~"*
yrC> 1- t " CST SIGNA I
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
sksi. c le, sredY M.3',_aa'tc' ,+Yc, ,tf l,s
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
i XCONVENTIONAL
❑ ALTS R NAT( VE sHolding Tank ❑ In-Ground Pressure ❑ Mound NAME EPI-h~, H. ADDRESS OF PERMIT HOLDER'
INSPEC
TION DATE.
nks R. R. 1, St. Joseph, WI 54082
BENCpoint) DESCRIBE IF DIFFERENT FR REF. P
CST R E F PT E LE V
T. ELEV.Section 36, T30N-R20W, Town of St. Joseph
Name of MP/MPRSW No. County Sanitary Permit Number.
Don Schmitt 3205 St. Croix 58884
SEPTIC TANK/HOLDING TANK:
MANUFACTURER.
LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
BEDDING VENT DIA VENT MATL HIGH wnrEH ❑YES ❑ NO ❑ YES ❑ NO
ALARM NUMBER OF ROAD, PR OPERTV WELL. BUILDING. VENT TO FRESH
FEET FROM LINE' LAIR INLET
❑YES ❑NO ❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING. LIQUID CAPACI TV PUMP MODEL P
UMP!SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
❑YES ❑NO PROVIDED: PROVIDED:
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL ❑YES ❑NO ❑YES ❑NO
(DIFFERENCE BETWEEN NUMBER OF PROpEHrv wELL BUILDING IvENrTOFRESH
FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO
NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing
ILE Nr;TH 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: CIDBED/TRENCH WIDTH LENGr"' TNHoIN oCfHES DISTR PIPE SPACING covEH
ID
DIMENSIONS MATERIAL' PET GRAVEL DEPTH FILL DEPTH DISTRPIPE DISTR PIPE DISTq. PIPE MATERIALNO DISTR
BF LOW PIPES ABOVE COVER ELEVINLET ELE VEND NUMBER OF OPERTY WELLBUILDINGVENT TO FRESH
r7:=7-71'TH
pIPES FEET FROM LET.
NEAREST--s
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-
❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE
PERMANENT MARKERS. OBSERVATION WELLS
DEPTH OVER TRENCH BED DEPTH OVERTHENCHBED ❑YES ❑NO ❑YES ❑NO
CENTER DEPTH OF TOPSOIL SODDED SEEDED MULCHED
EDGES
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GHAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
DIMENSIONS TRENCHES
I
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEVATION AND ELEV ELEV CIA ELEV. PIPES DIA .
[DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING ORI LLED COR R EC TLV COVER MATERIAL
VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
COMMENTS: PERMANENT MARKERSE]YES ❑NO ❑YES ❑NO
OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
Sketch System on Retain in count file for audit.
Reverse Side. Y
SIGNATURE. TITLE.
DI LHR SBD 6710 (R. 01 /82)
%uIsconsln APPLICATION FOR SANITARY PERMIT
DILHR
(PLB 67) COUNTY
DEPgRTIT1Ei-lT OF
- InDUSTRV•LF:BOR&HUMRnRELRTlOnS UNIFORM SANITARY PERMIT #
oni~ f A7 t7
Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER
MAILING ADDRESS
All / S' ! r
PROPERTY LOCATION
CITY:
LLAGEQ
114-5014, S _36;, T_70N, Rule- E (or roW
N -/1 cT~'~E y
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK
STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
X 1 or 2 Family Number of Bedrooms: 3 ❑ Public (Specify):
THIS PERMIT IS FOR A:
X New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
X Seepage Bed ❑ Seepage Trench ❑ Seepage Pit
❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit #
issued
An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity y`)
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: V 7 /?/-7
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY:
d c-SiC ~r /Z1i 1L-' _
Private ❑ Joint ❑ Public
I, tLnd ned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Namr (Print): Signat •1
't MPRSW N Phone Numb er:
" ~c iy~rT' ter- Oise
Plumber's Address:
r _ { Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
Get / El Disapproved
/ / / v 7 ❑ Owner Given Initial
Approved Adverse Determination
Reason or Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD'& 98
To be complete and accurate the permit application must include:
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.);
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
I
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property _5 LAW rM N/rC S
Location of Property
~
_a Section 3C- T :3Cl N- R W
Township r/.
's F . y
Mailing Address
~t ~Ti~E/-yy
Subdivision Name
Lot Number
Previous Owner of Property
't'otal Size of Parcel
Date Parcel was Created ;Z
/1f.r
Are all corners and lot lines identifiable?
Yes No
is this property being developed for resale ?
X Yes No
Volume _ -1 and Page Number 'f as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
l /Wzrranty Deed_,
tF
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 aft statements on ,thiz 6onm oAe tAue to the best o6 my (ouA;
knowkedge; that I (we) am (aAe) .the. owns (s) o6 ,the pnopnty dac i.bed in this
tn6o4mation ~onm, by v,vutue o6 a waAAanty deeed~ `Leeond d %n the 066 'ce o6 .the.
County Regi~5.teA o6 Deed5 as Document No..3-_!s1__J L 1
and that 4-1 (we)
paesentXy own the pnoposed site 6oA the sewage. osc system (OA I (we) have
obtained an easement, to nun with the above dmcAibed pupe&ty, 4on the
const, ucti.on o6 said system, and the same has been duty heeonded in the O{() ce
o6 the County Regi,5.teh o6 Deeds, as Document No.
j
ZL
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
S T C - 105 r
r
y
y
SEPTIC TANK MAINTENANCE AGkEEMENT H
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St. Croix County
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ROUTE/BOX NUMBER T, Fire Number
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PROPERTY LOCA1'lUN:At (L 4~' 1 , Section 1' N, R ;z ~~'-W,
Town ofSt. Croix County,
Subdivision Lot number
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loiproper use and maintenance of your system C0Uld rrsult in
its premature` failure to handle wastes. Proper mairitenaucc 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 s~pIiC tank a:, a tCeat -
ment stage in the waste disposal system.
St. Croix County residents maw be eligit>l Li) rc,ccivc it grant for
a maximum of 60% of the cost of replacement of it failing system,
which was in operation prior to July L, 1978. St. Croix County
accepted this program in August of 1980, with the requircmcnt that
owners of all ucw sStems agree to keep thcfr systems prupe.rIy
iliainta'ined.
The property owner agrees to submit to St. Croix County 'Louing
certification form, signed by the owner and by a master plumber,
journeyman ,,:_urut.er, , -1 ,,lumber or a l iconsed pumper ver1
fying that (1) the on-site wastewater f-posai system is in props:
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
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I/WE, the undersigned, have read the above requirements and agree W
to maintain the private sewage disposal :system ill accordance with x
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the standards set forth, herein, as set by the Wisconsin Depart- 10
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.
ACC ~
S ICNED 1) ATE
St. C-0 ix County Zoning Office
11.0. iox 93
ffanuno 1d, W- 54015
715-7)6-22'0 or 715-425-8363
Sil;n, date and 1-etu►n to A)OVL'
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