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Parcel 032-1026-10-001 01/08/2007 09:59 AM
PAGE 1 OF 1
Alt. Parcel 9.30.19.127D 21-101 032 - TOWN OF SOMERSET
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 - SAHNOW, ROBERT A & KAREN
ROBERT_A & KAREN SAHNOW
j 485 222ND AVE
C SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 485 222ND AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 3.030 Plat: N/A-NOT AVAILABLE
SEC 9 T31 N R19W SE SE 3.03A-LOT_1_CSM1 Block/Condo Bldg:
VOL 5/14.67
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
09-31N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 697/501
2006 SUMMARY Bill Fair Market Value: Assessed with:
145141 228,400
Valuations: Last Changed: 07/23/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.030 48,100 125,100 173,200 NO
Totals for 2006:
General Property 3.030 48,100 125,100 173,200
Woodland 0.000 0 0
Totals for 2005:
General Property 3.030 48,100 125,100 173,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 115
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
f • C'~
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER j ~ TOWNSHIP ~j ,,~SEC. T&/ N-R_/?W
ADDRESS ST. CROIX COUNTY, WISCONSIN
j
SUBDIVISION~~~~~ LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
f
1' I+
G
9
i
I
INDICATE NORTH ARROW
a
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: ~Q Proposed slope at site:
SEPTIC TANK: Manufacturer:V~Liquid Capacity:
Number of rings used: Tank manhole cover elevation: Ac 91
Tank Inlet Elevation: Tank Outlet Elevation: ,37
Number of feet from nearest Road: Front, Side,0 Rear, 0 Q- feet
From nearest property line Front,0 Side ,Q Rear, O 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 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
Fill depth to top of pipe:
Number of feet from nearest property line: Front, /O Side, O Rear ,/v) Ft.~
Number of feet from well:
Number of feet from building: Z
(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, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on job: ! ¢ _ S
el'o
License Number :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707m
tik-'ONVENTIONAL ❑ALTERNATIVE State Planl.D. Number
(If assigned)
E:1 Holding Tank ❑ In-Ground Pressure 1:1 Mound
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTI N DATE:
Bob Sahnow Somerset, WI 54025 _
BENCH MARK (Permanent reference P-0 DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT- ELEV.
SE SE, Section 9, T31N-R19W, Town of Somerset
Na- )f Plumber IMP/MPRSW Nn.. County Sanitary Permit Number_
Cal Powers 1563 St. Croix 64859
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL JLOCKING COVER
PROVIDED. PROVIDED.
DYES LINO DYES LINO
BEDDING: VENT DIA.. VENT MATL fill -ATE NUMBER OF ROADPROPERTY WELLBUILDING: VENT TO FRESH
LARM FEET FROM . LINE. LAIR INLET.
DYES DYES LINO NEAREST
DOSING CHAMBER:
MANUFACTURER JBEDDING. JLIOUID CAPACITY PUMP MODEL. JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
DYES LINO DYES LINO DYES LINO
GALLONS PER CYCLE: PUMP AND coNraoLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES LINO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing IL FNC;TH 1111AMETER 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 LENGTH NO. OF DISTR. PIPE SPACING. CV -F J~K:JN
SIUE DIA. St PITS LIQUID
BED/TRENCH r T=ENCHES o-V AL y DEPTH
DIMENSIONS
GRAVFL DEPTH FILL DEPTH UISTH. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. D} R NUMBER OF PROPERTY WELL. BUILDING'. VENT TO FRESH
BELOW PI FS~ ABOVE COVER ELEV. INLET ELEV. END. PIPES 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.
DYES LINO
SOIL COVER TEXTURE JPERMANENT MARKERS JOBSERVATION WELLS
DYES LINO DYES NO
DEPTH OVER TRENCH BED DEPTH OVEH TRENCH 11111 pEPTH OFTDPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
DYES LINO DYES LINO EYES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH NO.OF LATERAL SPACING'. GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
~ MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. CIA.. ELEV.- PIPES. DIA..
I ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
DYES LINO DYES LINO
COMMENTS: PERMANENT MARKERS OBSERVATION WELLS NUMBER OF PROPERTY WELL BUILDING:
FEET FROM LINE
DYES LINO DYES LINO 1NEAREST----7)P-
U~_l01
LA (I
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. TITLE.
DILHR SBD 6710 (R. 01/82)
wlscons" -7 APPLICATION FOR SANITARY PERMIT D-~
COUNTY
(PLB 67)
0~ T V,LA OP
InWUS UNIFORM SANITARY PERMIT #
- InWUSTRV,LRBOR6 HUTRn gELRTlOnS
-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
PRO TY OWNER MAILING ADDRESS
PROPERTY LOCATION Crf,(:
4-t)L" 1/4, S ZjJ N, R (or) vILLA
TOWN 0
OF:
LOT NUMBER BLOCK MBER SUBDIVISION NAME NEARE T ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
, OF-
rt J
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms. 3 Public (Specify):
THIS PERMIT IS FOR A:
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.
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 G'eV 2 9 issued 12, .2 -7 `kV
❑ 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 G
Lift Pump Tank/Siphon Chamber /
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
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):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installatio the private sewage system shown on the attached plans.
Na / of P mber (Print): Signa e: MP/MPRSW No.: Phone Number:
Plumber ress: _ Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
l y ❑ Owner Given Initial
.~7 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 syste:- ,
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.
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS
INDUSTRY, C DIVISION
LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969
HUMAN RELATIONS
(H63.09(1) & Chapter 145.045)
LOCATION: SECTION: TOWI~j,SH~lP/MN1~~Y: LOT NO.:BLK. O.: SUBDIVISION NAME:
I ,
4j '/4 /I3 N/R E (o ^'°'Ff'
s'
COUNTY: OWNER'S/BUYER'S NAME: AILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: CDESCRIPTION: I PROF E DESCRIPTIONS: PERCOLATION TESTS:
Residence 2 New ❑ Replace I .J ) l j rJ
RATING: S= Site suitable for system U= Site unsuitable for system `r-
CONVENTIONAL: IMOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHO DING TTAN~IK- RECOMM NDED SYSTEM optional)
®S ❑U WS ❑U ®S ❑U ❑S U ❑S L~JU -
If Percolation Tests are NOT requir d DESIGN RATE: If any portion of the tested area is in the _71
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: La I PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH r4, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B
B- 5
B - r
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER 4NC4+E-S AFTERSWELLING INTERVAL-MIN. PERT D 1 PERIO 2 PERIO 3 PER INCH
P-
- A16 Ato
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 th direction and percent
of land slope.
i • ~/0
SYSTEM ELEVATION
s`y
su.~c.+s>.~ I
-
,
7
,
€
i
€
3 €
x
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods spe ified 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~rint) TESTS W RE COMPLETED ON:
3
AD R SS: CERTIFICATION NUMBER: PHONE NUMBI R(optional):
h~IJ
CST I TU
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
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-someil:64, /J r C r (J s S J z C' I u r ~ p r i~ S
S~~Ws-
froth Air InI11e And Obeorratl0n Pip*
Approved Vent Cap
Minimum 12" Above
Final Grade
2U - 42" Above Pipe _ 4° Cost Iron
To final Grade Vent Pipe
Marsh Hoy Or Synthetic Covering
Min 2" Aggregate
Over Pipe
Uisiributl0n
Pipe 0 0 0 0 0 - Too
Aggregate Pipe Pip• e
Beneath Pertoroled Pipe Below
o Coupling Terminating At
Bottom 01 System
Proposer 4Ptnr. gr j
SOIL FILL
DISTRIBUTIOt.I PIPE
APPROVED ~4Wr-IETIC COVER
° MAT~Itll~l OP. v" OF STRAW
rOFhG6REGATF- OR JAARSN HAS
1
(a0 FAGGREGATE
ELEV. OF%-. FEET-,,
lam-- `
DIS""Ri@'JTIc~IJ PIPE T() BFF AT LEAST. INCHES BELOW ORIGItJAL GRADE
ARIL AT LEAS-I"ZO INCHES BUT AIO MORE THAQ HL IKICHES 6EL_OW FINAL r'RAOE
MAXIMUM DEQTW OF EXCRVATODO FKOM OKI&WJAL &KhDF- WILL BE INCHES
MINIMUM! Orf" OF FACAVATIOW fK0/A- 1*161WAL GR49f- WILL 8E INCHES
SIGI.IED:
LIGEuSE LJLIMBER:
J D AT E .3~
1 >>o
lee 6
I
I
9-~/d K •--~iLll
nL
war-' .sy~ 3, {
LC 93 d' >r
1
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMA*11 N RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7965 BUREAU OF PLUMBING
MADIS6N, W153707
CONVENTIONAL ❑ALTERNATIVE state Plan LD. Number
111 assigned)
E Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER'. INSPECTION DAT
Robert Sahnow R.R., Somerset, WI 54025 - p
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT ELEV.
SE SE, Section 9, T31N-R19W, Town of Somerset
Name of Plumber. 7-7 W NoCoun[y Sanitary Permit Numher:
Cal Powers 63 St. Croix 58929
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIOUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED
EYES ENO EYES ENO
BEDDING'. VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD. PROPERTY WELL. JBUILDING. VENT TO FRESH
ALARM. FEET FROM LINE: AIR INLET:
EYES ENO EYES ENO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY JPUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
EYES ENO EYES ENO EYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY JWELL BUILDING. IV ENT To FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) EYES ENO NEAREST ]PI
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LEN(,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:
BED/TRENCH WIDTH LENGTH NO OF DISTR PIPE SPACING COV EH JINSIDE DIA -PITS LIQUID
TRENCHES MATERIAL: PIT DEPTH.
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR PIPF DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PR OPERTV WELL: BUILDING'. VENT TO FRESH
BELOW PIPES ABOVE COVER Et EV.I NLEr ELEV. END. PIPES. 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 OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
E YES E meets the criteria for medium sand. TIONS MEASURED.
NO
SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WELLS
EYES ENO EYES ENO
DEPTH OVER TRENCH; BED DEPTH OVER THENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED
CENTER EDGES.
EYES ENO EYES ENO DYES ENO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES
DIMENSIONS
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 DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
EYES ENO EYES ENO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE.
DYES ENO EYES ENO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE' TIT LE.
DILHR SBD 6710 (R. 01/82)
Wisconsin APPLICATION FOR SANITARY PERMIT -
1:~~D,I LHROUNTY
OEF'FlRTR'EnTo" (PLB 67)
UNIFORM SANITARY PERMIT #
In OUSTRY, L.R6OR 6 HUMRn RELRTIons
-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 MAIL~I ADDRESS
i
PROPERTY LOCATION CITY:
~p~~~ VILLAGE: ~Y
1/~/" 1/4, S N, R ' (or wl TOWN OF.
- LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST BQ&0, LAKE OR LANDMARK STATE f I AN I.D. NUMBER
I
104
TYPE OF BUILDING OR USE SERVED
1 or 2 Family Number of Bedrooms: ❑ Public (Specify): A
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.
,ice 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 Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity ,ILTD
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer: Ot y r'
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
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):
? / 7 ~.'A Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installatio o e private sewage system shown on the attached plans.
Na ,)of Plumber (Print)s f S na ur) MP/MPRSW No.: Phone Numbe%
Plumber's Address: 1 Name of Designer;
~g Z,7
4- A)
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
e p~/ ❑ 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 ~li✓~tl~~ G{ t
Location of Property
Section , T N - R W
Township
Mailing Address
Subdivision Name
Lot Number '
Previous Owner of Property C/" e Sc:~7 Q ~ /'1 r'
Total Size of Parcel 3
Date Parcel was Created A/
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
C,~
Volume , and Page Number 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) ee tiby that aU dtatementd on this bon.m ahe tAu.e to the bat ob my (ouA)
knowledge; that I (we) am " e) the owneh (b) o6 the pnopen ty de d cAibed in th,%d
knbonmation boAm, by vi, e ob a wannanty d_ eyed neconded in the Obb~.ce ob the
County Regidten. o A DeeDocument No. and hat I (we)
pneaentty own the pnopoae site bon, the .sewage poe - tem (on 1 (we) have
obtained an easement, to nun with the above dedch,i.bed pn.openty, bon, the
constn.ucti.on ob eaid .6y6tem, and the tame had been duty tecmded in the Obb.ice
ob the County Regidten. ob Deeds, a,d Document No. ) .
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
H
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9
• ST C- 105 r
9
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SEPTIC TANK MAINTENANCE AGREEMENT Ho
St. Croix County z
9
OWNER/BUYER
ROUTE/BOX NUMBERA , Fire Number
CITY/STATE
t'om',/" -zip PROPERTY LOCATION:~,6: Section, T- 11 N, R~` W,
Town of ,~°S~i - St. Croix County,
Subdivision 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. yA
E
I/WE, the undersigned, have read the above requirements and agree cn
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ro
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,>~~'~ ( I
z L.,.t'.
DATE 2
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 SAFETY & BUILDINGS
INDUSTRY, C DIVISION
LABOR AN P.O. BOX 76
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.09(1) & Chapter 145.045)
LOCATIOP.':S SECTION: TOWNSH
W IP/RA NtCIPALITY: LOT NO.: NO.: SUB IV SION NAME:
,5F Z '/a 9 /T~ N/R 4 (or) BLK
;y S~~i Q
CgUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEORMS.: COMMERCIAL DESCRIPTION: I PROFILE DESCRIPTIONS: ER LATION TESTS:
IXResidence 1~ New ❑Replace { Il A -xi/~ r~I&
RATING: S= Site suitable for system U= Site unsuitable for system ~S _ Jv f K
moimb~] N-GROUND-PRESSURE: SYSTEM-IN-FILL OLDI G TANK: RECOMMENDED SYSTEM:(optional)
yS❑U DSEU ❑S U
If Percolation Tests are NOT required DESIGN RATE: If an /
r y portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
-r PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH Iff, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
J.7
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B "77 7. S n > ) h
7 1-11 /9 7
S
B_ /4
B-
PERCOLATION TESTS
r
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER ING+ES AFTERSWELLING INTERVAL-MIN. PERT D 1 PERIOD 2 PERIOD 3 PER INCH
P_ t ' • I /,j% 7 / / /
P- r 7
P-
P-
P ~ ~f
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 10-61 L
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A4rs J
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I, the undersigned, hereby certify that the soil tests reported on this form we(a made bly
a ifi accord with t, a procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests ark correct e
best of my knoyvledge and belief.
NAM print): ) I TESTS WERE COMPLETED ON:
ADDR SS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
CS G ATU E:
7
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
t✓
PAI;E OF
CruSS zQ~lL) off- 5y<~~-11
Froth Air I11161ii And Obcarvallon Pip•
1----~- Approved Vent Cap
Minimum 12" Above
Final Grads
20- 42° Abovs Pips _ 4° Cost iron
To Final Grads Vent Pips
Mash Moy or SynlhsUc Covering
min 2° Aggregate
Over Plpe
Distribution
Pips 0 0 0 0 0 - Tee -
6" Aggregate
Beneath Plpe ° Pertorolod Pips Below
o _ Coupling Terminating At
Bottom 01 Sysle,n
i
01
SOIL FILL
DISTRIBUTIOF,i PIPE
APPROVED S40T1-IETIC COVER
`'-MATERIA- Oa 9'' of STRAW
2"oFAGGRE6ATE OR MARS►~ NAB
7n F P 2-AGGREGATE
ELF -V OF fEF-T\~
DISTRIF~'JTIOIJ PIPE To BE AT LEAST c~ ILICHES BELOW ORIGIIJAL GRADE
AK1L AT LEASTLO IUCHE-'~ 8L1T AIO MORE THAK. 42 INCHES BELOW FIAIAL. GRADE
MAXIMUM ®F-QTli OF FXcAVATI00 FKom OW WAL (3KApF WILL BE _ IIJCHES
MINIMUM OFT" OF EXCAVATION FPOtA Ii*14I AL 6R49f- WILL. BE INCHE S
SIG►IED: 6
_at_ , 1 LICI- USC AJ13 MBER:
I
DATE*
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W W I SC O N S I N
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ZONING OFFICE
_ 796-2239 (HAMMOND)
425-8363 (RIVER FALLS)
HAMMOND, WI 54015
April 30, 1985
State of Wisconsin, DILHR
Bureau of Plumbing
P. 0. Box 7969
Madison, WI 53707
Attn: Carolyn Haag:
Dear Carolyn:
St. Croix County is rescinding permit 458929 due to the fact that the
location of the system was changed. A new permit, 44 64859 was taken
out. The plumber is unable to obtain the original permit(4458929).
Should you have any questions regarding this subject, please feel free
to contact this office.
Sincerely,
Mary J. Jenkins, Secretary
St. Croix County Zoning Office
CERTIFIED SURVEY MAP
M LOCATED IN THE SE1 /4 OF THE SE1 /4 OF SECTION 9, T31N, R1 9W, TOWN OF
SOMERSET, ST. CROIX COUNTY, WISCONSIN.
~ NE CORNER
SECTION 9
I
UN P L A T T E D LAN DS 37
S89059'W
7 92.12'
- - `J .5ua' p~2o16,1r326~uo -
LoT_8\~~
C. S. M.
O`I~~ ' G I z
C .j
EPP~ OF % r 136.82 \G~\ OF' ?O\G NN~NG'
00
u- w
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N r,
SOV I w Z u O
<I N W
/ o W Q Ln z
LOT 1 O w
132,108 S.F. z^ LI z m m Ln
/ 3.03 Acres± -4 ~I - Q_
Wu0 C) I w
• ti O -Z: 1 N J
h. I = Z W
/ o f- -j H h .
N ° 0 zl rr,
O V X 1 0 0
z
/ •"v~A N8905TE 516.14' z CD
II
pl 228.25' 287.89'
Wa!I ~ I
C1 U N P L A T_ T E D. L A N D S_
-I - - _ SE CORNER
a l / SCALE IN FEET SECTION 9
T31N, R19W
0' 100, 200' 300'
CURVE DATA^ TABLE
CURVE RADIUS ARC CHORD CHORD CENTRAL TANGENT
w N LENGTH LENGTH LENGTH QBEA 2-LNG ANGLE @1A
N
u- I-IA 766.48' 15.00' 15.00' S890 2522"W 1°07'16" S88°51'44"VV
0 O 1A-2 766.48' 226.91' 226.09' S80°22'52"W 16°57'44" S88°5114411W
3-4 2.04.09' 199.77' 191.89' S430 51'31"W 56°04'58"
w
uI u- LEGEND
UI z ST. CROIX COUNTY SECTION CORNER MONUMENTS.
~I J 1" IRON PIPE, FOUND.
OI p 1 1/4" x 30" IRON PIPE, SETS WEIGHING 2.27#/LINEAL FOOT.
-j N
Drafted by Walter J. Gregory.
Job No. 84-1485
V