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HomeMy WebLinkAbout038-1067-80-100 n (y 0 o (n 0 Cr 0) - o C7 C :3 ? CD A 3 A ~ r+ ~ ~ ` ll 3_ rr z= N z O ~I H= N z °-4 n c m W ~C Oyr` . ° N c ° °O 3 DJ Ei- 3 v c O O° Cn 7- CD - CD M'h CD d N W d Z C. :7- 0 <D 00 Ij a) U) 2) CD W < N) CL 7 O (D Q 0 -D 7 p Q CD N Q O WO O i CD CD m° o c ° n H n A CD 0 d O W 0 3 3 N CY ) j O Q A N N r~ ~1 d s Q N A ,y Z D a o v (n G D a o tC~r CO n D N m CL n' m N a ~y N W O C (D m c° D V O 0 CD 3 O o o o C. 3 0 co (D 00 00 CD (n 0 c I ~ v v~ l ~ O O O O O O U) Z O W O O (A U1 fA io 00 N N N C) D ~f CD O u o C) 0 CD v p v o :I cr -0 ((D 7d ~ CD - (D rd d v ° A (D CD M (D rt 1l (D Cl S A)) y S D1 N N. 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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 - SCHACHTNER, JOSEPH E & PATRICIA N JOSEPH E & PATRICIAN SCHACHTNER 1064 210TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 1064 210TH AVE SC 5432 SCH D OF SOMERSET d !V~ d SP 1700 WITC U °jy~- oV (yd Legal Description: Acres: 3.250 Plat: N/A-NOT AVAIL BLE SEC 16 T31N R1 8W PT SW SE LOT 1 C.S.M. Block/Condo Bldg: 7/2075 3.25AC EZ-UT-1281/607 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 16-31N-18W Notes: Parcel History: Date Doc # V©Npag l- l Type 07/23/1997 837/53 2005 SUMMARY Bill Fair Market Value: Assessed with: 119138 175,900 Valuations: Last Changed: 10/13/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.250 38,300 134,600 172,900 NO Totals for 2005: General Property 3.250 38,300 134,600 172,900 Woodland 0.000 0 0 Totals for 2004: General Property 3.250 38,300 134,600 172,9000 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 209 I Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 PRAIRIE T31 N.-R.18W. 55 IL POLKI COUNTY 7 go. • ~ ~ 3B Lesfe~ sn..TR.s Henny iese 0 _Don¢/a/ -7- 7ouy/¢s C one . s 0 C : Lp~son 6 6S C p ern r crs n Oj 9 ~ d~ rE' vQr'a' P W`C 0 p r~eNJuf/i~`y h ~U c SNP ~ ~ rn ~ y~ ~ /zo. aG E h c CEDAR L. 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V • / _ ancT ad eor- e Cje/-¢/cL_ q_P 3..y h h v~ K2>fh >i 7i~omas~ r~ f M¢nCe//¢ ~s ~en evre ve N/GHTHAWoK DR. 7 7 Lyl fSackes e Fna~co/s efa/ B e?'a./ •Le73n~ 4* d Thomas L 676 • ~ ~ l • ~u~-o vv - • ~ Jr' . Q y~j DK 140 PH CO cO '~U zoo /oo d j - /eo ed~' o ha:hs ~ 0 95TH • AVE iiB zs 0 0 ti Ql 0 O ~ Noi-Yfj ~ 90 ~ mil ~ i l' K obey- fyo f ~ ~ ~ S/Qfas v•w~CO i° Ffs ✓°w (32.72 fowe>- w I CO hv.p ~d~ SN.. rch- 8o cc ~rd n(l~ o, SS Co. W Z p 0 tl 1 irz 7B ~ orarnr~ • 1921V• AVE. g Bur,Q c • mco7d. ~i o /`9cLeod d 0 go ~zo -Zsaba//e • was fante V 4o a a 39.1, 140 zasF79/ . A7rICYEL t QO .Y r7¢mc° S L ;y q eca 19/ex Cj can ' 64 c C o Qay £ C ayn S` Cno/x y0 ~ ~ • /°a ~./ii/P qo -9 40 40 ~v 0 /60 /Uorrr/• v~c /2usse// ~ ~ may r >ua,.~ \ ~ Coup fz~ o ~ /o/a. h- o F cz>-y `C ~ ~ o no efu a F/c1 /ck, w~ /sue h~ / n c y ' y 0 ~/o • i'~ C o ~1~ Q ~zresr t h K eI'a r • 11d © ti~ Cady p ` ~/t F7s~ 44s E R, EW k~ C hay~~ %s/ a F g' Oo w sMn~~ o(ie~f VN C ffe~be^> f ti V?Jh ~c'rs ~ .h CS'1~ctub 0 Z G'°~ Liz c>nQ W T.D o¢! Q'~Vy' :~SCp 64 ~ '.K- f Ca/~/ /6v s F ~ ZJu• ~ ~ o T x Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER f.1 I C TOWNSHIP S'i,-;,- oprar ^I t SEC. 16 T N-R W ADDRESS I'(/ elaxj22C ST. CROIX COUNTY, WISCONSIN ..So:Y,~~.o.-SST ~✓;S ~ SUBDIVISION fv//,z LOT /2-// ~y LOT SIZE' PLAN VIEW Distances and dimensions to meet requirements cf ILHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ALL ,.~1,~ ~ V, ro 0C. ti 00 _ U 3 i~'3~ Sy S R SAC ' y ,.CC, \Jq a I - l IL oc d INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: j,,, SEPTIC TANK: Manufacturer: L,/2,'s~ r ._Liquid Capacity: Number of rings used: _ Tank manhole cover elevation: Tank Inlet Elevation: °j1( Tank Outlet Elevation: Number of feet from nearest Road: Front 10 Side, Rear, O }feet ..From nearest-property line Front, 0Side, @Rear, 0 /-s-Y feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE F PUMP CHAMBER A 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: ~c Trench: ~ v' Width: Leng(th• .5-_3 Number of Lines:__ Area Built:-Z'36 Fill depth to top of pipe: 1 pd' i Number of feet from nearest property line: Front, O Side, O Rear, Ft./7y i Number of feet from well: 9 Number of feet from building: ) 0 (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, Q Side, 0 Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Plumber on job: r. Dated: License Number: 8'g 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR kpi~ SAFETY di BUILDINGS LABOR & 9HUMAN 69 RELATIONS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON,•uVI 63707 BUREAU OF PLUMBING MCONVENTIONAL LIALTERNATIVE Sfe1a1`18n1,10Numbv, (IfiPnntll Holding Tank ❑ In-Ground Pressure I_J Mound NAME OF PERMIT HOLDER ADDRESS Of PERMIT HOLDER: INSPECTION DATE. David Cook R. R. 1, Box 132C, Somerset, WI 54025 BENCH MARK (Pe~manent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF PT ELEV SW SE, Section 16, T31N-R18W, Town of Star Prairie Name of Plumber. MP/MPRSW N,, Cn„n 1, ~ Sarii[ary Permit Number Michael E. Wilson 6388 St. Croix 75004 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY } TANK INLET FLLV TANK OUTLET ELEV 11 TV111~11NG LABEL LOCKING COVER IDED. PROVIDED YES ❑N0 DYES DNO BEDDING. VENT DIA n; VE MATT HIGH WATER - ALARM NUMBER OF ROAD JPROPERTY WELL BUILDING JVENTTO FRESH FEET FROM LINE, AIR INSET DYES L=NO ' L iY NEAREST l r DOSINGACHAMBER: IMANU FCT UR ER BEDDING FLIOUIO (.APA 1.I 1Y PUMP M111)EL i'L,,ip SIt"ION MANUI ACf llfil R WARNING LABEL LOCKING COVER PROVIDED PROVIDED. DYES ❑NO ? DYES L NO [:]YES ❑NO GALLONS PER CYCLE: PUMP AND CO rROLSOPErl Nn NUMBER OF HOPFRrv wELL BuIlDING VENT TO FRESH (DIFFERENCE BETWEEN ` FEET FROM L14T AIR INLET PUMP ON AND OFF) DYES L_ NO NEAREST--->_SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing n~2,F rl if MArI RInL n.ND 44ARKINv or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) I MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH No OF UISiH PiP[ SPACIM1I. CnGFI, E =PITS LIOU ID 44 THFN::I, FS 1 II AI PIT DEPTH DIMENSIONS t GRAVEL DEPTH FILL DEPTH OIST17 PIPE DISTH PIPE DISTR. PIPE MATERIAL NO Dl~ifl NUMBER OF PROPERTY VVELL BUILDING. VENT TO FRESH BE LOW PIPES ABOVE COVER ELEV INLI T ELEV END . s„ PIPES FEET FROM LINE AIR INLET I 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- meets the criteria for medium sand' TIONS MEASURED. YES ❑NO SOIL COVER TEXTURE PEnM NINr11AHk1EtS OBsERVAT~ON wVt IS ._J YES ❑N0 DYES DNO DEPTH OVER TRENCH BED DEPTH OVER THENCII HFD I,[ PT I1 OE TOPSOIL SfiDOE E) ISEF DED MULCHED C:FNTER EDGES YES ❑NO DYES NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: I BED/TRENCH WIDTH LE N(;TH NO. OF LATE HAL SPACI (;RAVE L DEPTH BE LGLV PIPE FILL DEPTH ABOVE COVER TRENCHES If DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR PIPE MANI F OLD MATERIAL NO DIST=UR__~E DISTHIBU TON PIPE MATERIAL&MARKING ELEV ELEVDIA ELEVES ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING, ORILLEDCOHHF CTLV VER MATERIAL VER TICAt LIFT CORRESPONDS TO APPROVED P DYES DYES ❑NO C( COMMENTS: PENMANENT MARKERS LS NUMBER OF PROPERTY WEL L FEET NE YES NO ❑ NO NEAREST- f - .01 - x v Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE. TITLE DILHR SBD 6710 (R. 01/82) wisEOnsin APPLICATION FOR SANITARY PERMIT •DILHR (PLB 67) &a~ ; COUNTY OEPRRTMEnT OP UNIFORM SANITARY PERMIT # Ir1OUSTRV, LRBOR 6 NUn1Rn RELRTIOnS 175- 6' 0 -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS PROPERTY LOCATION CITY: S c. 1/4 S 1/4, S /E: , Ts/, N, R E (or)& VILLAGE: LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST, LAKE OR LANDMARK STATE PLAN I.D. NUMBER - !29 TYPE OF BUILDING OR USE SERVED , " _ D :~_4 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): &Z411 THIS PERMIT IS FOR A: XNew System ❑ Tank Replacement ❑ Repair El Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. F~ILSeepaye 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 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 installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: /MPRSW No.: Phone Number: y/1. h rL f, Lj f,. -.4, C.1a' y' X 1ZS`17 Plumber's Address: Name of Designer: Gex 1 o ri r 5'Y~.z", ry COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved C S ❑ 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. ~:T Low c 2, r~ •c'' LA t h Z n ®ro vI ~C3 n r f , t,; u ( ^M` k t7vE T r, n. C r NDU TRY V. P011^g" r` 74 SOIL BORI AN i SAFETY & BUILDINGS Iiv!,US~'fiY, ~ ~ 1 (,f DIVISION LABOR RELATIONS PERCOLATION TESTS (115) P.O. ROX 7969 HI.IMAN RE / MADISON, WI 53107 ' (H63.090) & Chapter 145.045) r LOCA N; S ET, TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: c(i COUNTY: OWNE BUYER`S NAME: MAILI^ " UD SS: ti USE N0. BEDR DATES OBSERVATIONS MADE COMM RCfAC-D'ESCR14T10 PRUFIL UE~OfiI~lILSN PE CA~T~R'T STS:: Residence New ❑Replace RATING: S- Site suitable for system Us Site unsuitable for system CONVENT7(-S- MOUND: u___TIN-GROUNDPRCS>UR :S`-YST W- N-FILLHOLDING'TANK: FiECOM MENDEDSYSTEM:(optional) C]s r-i u os o ' os ❑u [is au ❑s u _ _ f Percolation Tests are NOT required DESIGN RATE: F Ii lii^{ I If any por lion of the testers err is ;n he under s.1-163.09(5)(b), indicate: II Floodplain, irtriirate Floor{I,lain_lev,~tion: /r~,.t PROFILE DESCRIPTIONS BORING TOTAL NUMBER E L ~(,t I11 l : 11 1!)Ilr)V1/q't(IT•IfdCHES CHARACTER OF SOIL WITH T111CKNFSS, COLOR, TEXTURE, AND DEPTH UEPFH IN, EVAT IO N Utl I I,, 1.;7 f. FITC,hI S' TO BEDROCK IF OBSI, iVLD (5;1_L ABRFIV. ON BACK.) Tp'kjo 10 , (T' AJ/t.11..f ~ a,r'.:~. ~ ~b r s~ • '~r ~J /IS J? M~ -el - Q- t y. , B- G' s~/t7hl r 'fi - vw'r r=y,ti! t> yyf~ B' i O ~ A ~r,.`~'1 r 1 Q li~'~''r(,/ w 4", i~d`•~,• s'Z'~ B. _5 -Ie? - =-APE-RC-OOLATION TESTS TkSt DEPTH WATER IN 1-101-F. l' EST' TIME UROP IN WAl LFi LFVFL INCHES HATE MINUI"ES NUMBER INCHES _AFTERSWELIING INIFRVALMIN. ~YpC~j _ PF:R.141__'PER_INCfI 1 1 P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scab or dibtances. 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 "n,l / ' 'f • L+V .f / 1~~ ' i 1. c,:~ d 1 .A. a ! w cl r I " -r t N s m Ott I ~ ~ I ~ i ~ I ~ I i I i I- I I 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 : - 1 fS75 WERE CCiMPLETEU ON: CERTIFICATION NUf.1ItF IT Pf10NE NUMB ERfo tionall: -Y 1:7 407 ff CST 4IGNAT6111 : 'I RIBUTiON: Original and one coley ut 1_-A Awhoi ity, Property Owner and .,.61 l ester. SE?L? , ern'^` ~~Eli JI i I 1 ' it t ~I t I t I I ! I i i t I 1 I { i I 1 i I I p any 14 • III I I i ~ ~ 1 1 I ~ ~ I ,I ~ I i 1 i I I ~ I I I I 1 I 4. I a~ ( 1 I 1 , , I I I I ~Y 1 I I I I I i. I t . 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U) C G7 to O o 0 7 o~ CD n c c o 0.0 :3 oco r a C n = C. CD O O a 3 2- o - 7 ° wn:3 jn Oo Q.3 CD o o y O A ST. CROIX COUNTY WISCONSIN ZONING OFFICE ` 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) ~W HAMMOND, WI 54015 November 20, 1985 State of Wisconsin, DILHR Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Attn: Carolyn Haag Dear Carolyn: Permit#75004, issued 11-21-85, replaces permit#74953, issued 10-16-85. which has been rescinded. This was necessary as the system location had to be changed. We were unable to obtain permit 474953, as it had been destroyed. Should you have any questions, please feel free to contact me. cerely, Mar Jenkins Secretary St. Croix County Zoning Office :PARTMEIJT.OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS ,ABOR BO & HUMAN RELATIONS P.O.O. . 60X. 7969 PRIVATE SEWAGE SYSTEMS DIVISION BUREAU OF PLUMBING MADISON, WI 53707 L CONVENTIONAL ❑ALTE R NATI VE state PI.. I.D mbar (It assigned) Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER INSPECTIO TE David Cook R. R. 1, Box 132C, Somerset, WI 54025 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN PT. EL CST HEF. PT. ELEV SE SE, Section 16, T31N-R18W, Town of Star Prairie NIITII• Ili P unit~er MP/MPHSW Nei C<,u ~ty Sang ry Per i bar. Michael E. Wilson 6388 St. Croix 4 SEPTIC TANK/HOLDING TANK: MANUFACTURER EQU CAPACITY TANK IN[ El ELLV TANK OL'T LE?ELEY WA NING LABEL LOCKING COVER PRO I.ED PROVIDED ❑YES ❑NO ❑YES ❑NO REDDING. VENT DIA_ VENT MAI t HIGH WATER tNEARF UMBER OF ROAD. PROP ERTV WELL BUILDING VENT TO FRESH ALARM EET FROM NE AIR INLET ❑YES ❑NO ❑YES _]NO ST 1 DOSING CHAMBER: IMANU FACTUR ER BEDDING L IQ77PUM:P PUMP M()OL L f'()~.^.P 51`I ~c)N +,1.1N ~,V ni.It;I(C R WARNING LABEL LOCKING COVER PROVIDED PH OVIDED. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: ANDCONTROLS O PERATIONAL NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM NF I aIR"LET' PUMP ON AND OFF) ❑YES NO NEAREST--). SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I''Mih IEH F F"'AT ANDMAHKINc or excavation. (If soil can be rolled into a wire, construction shall cease until LFC RC E the soil is dry enough to continue.) IN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LEN", T" No r)F uIS)R PIVF st•nt INt, rr)VFR uLi- - _P~TS L UID DIMENSIONS RENCHF ATLRIAL PIT DEPTH GRAVEL DEPTH FILL DEPTH D1111, H PIPE DISTH PIPE DISTR. PIPE MATERIAL NO Dltill+ NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH BELOW PIPES ABOVE COVER EL FV INL[ C ELf V f NU PIPES LINE AIR INLET. FEET FROM -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- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PIPMANFN'IN+ARK -FR 0I1SE14 VA nON wF(LS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED DEPTH OVFH THENCH BFI) I)E PTH OF if)VS(1IL Scl l)I )f I) JFE UFI) MULCHED CENTER (EDGES ❑YES ❑N0 ❑YES ❑N0 ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO OF CATERnL SPAGNG jF;;;;;Invf_-I FIL P7~i HFl uw Pl Pf~ FILL DEPTH ABOVE COVER TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTH PIPE MANIFOLD MATE RIALNNO-0! DIA [)ISTR UISTR PIPE L)ISTR IB UiI()N PIPE MATE HIAL& M1IAHKING ELEV.. ELEV. CIA ELEV P~Pf ELEVATION AND DISTRIBUTION INFORMATION HOLESI/E HOLE SPACING, DRILL ED CnRHFCI L Y COVFR MATFRIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ❑NO ❑YES ❑NO COMMENTS: PERMANENT MARKERS: O B S ERV A TION WELLS.NUMBER OF PROPERTY WELL. BUILDING. (FEET FROM LINE ❑YES ❑NO L -YES _ F_ I NO NEARES Sketch System on Retain in county file for audit. Reverse Side. LE sIGNAruRE E DILHR SBD 6710 (R. 01/82) EM wlsconssn APPLICATION FOR SANITARY PERMIT (PLB 67) COUNTY L H R OEPgRTTEnT OF UNIFORM SANITARY PERMIT # In OUSTf-, LROOR 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 MAILING ADDRESS PROPERTY LOCATION CITY: 1/4 515 /4, S VILLAGE: c , T 3Ig N, R /sfE (o r)26 LOT NUMBER ]BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms. ❑ Public (Specify): y/.4 THIS PERMIT IS FOR A: New System ❑ Tank Replacement ❑ Repair ❑ Replacement Soil Absorption System ❑ Revision ❑ Privy i❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. NL 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 - El 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 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): Ei~S .2 y Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature: l 1&/MPRSVV No.: Phone Number: h-1 sa e- > 1--C _ t,4,.f, 6.1 Y.? (7 i>' - l.;z e.rP r2~'7J Plumber's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signatur of Issuing Agen /I Fee: Date: a,~ /-(J,~, ~{//4,~1 I v ❑ Disapproved T L~1'CN~ 2` rj~, J D -~s ❑ Owner Given Initial n' Approved Adverse Determination _It 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 fornn 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 _i.ntended 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 dee(; recording. ~y - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property ay t c(n)c,- Location of Property _~4 Section 3L N - R W l'ownship Mai fling Address G~ 1,3,~Z - 1 C> ~ m e l ~ e.T, LJ Subdivision Nance Lot Number /V Prcv ions Owner of Property ~jCG~ c 'Total- Size of Parcel V"y Date Parcel was Created Ar,• all corners and lot lines identifiable? ~ Yes ~ No is this property being developed for resale (spec house) ? Yes 71~ No Volume _ and Page Number' as recorded with the Register of Deeds INCLUDE Willi THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 1. Land Contract 1. Other recordings filed with the Register of Deeds Office in addition, a certified survey, if available, would be helpful so as to avoid delays 0f 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) eenti6y that aU statement6 on .thus ~onm ane .true to the best 06 my (own) hnowtedge; that I (we) am (ane) the ownehk) off) the pnopenty d"cAibed in this -u16o,'Lmation ~oacm, by vii aue o6 a waAAan-ty deed neeonded in the 066iee o6 the County Reg-istteA o6 "Deets ae vocument No. 3'- ; and that I (we) paesen .ey own the p)iopoeed site, bon .the -sewage dizposcL~ %y,~tem (on I (we) have obtained an basement, to nun. with the above de cAibed pnope&ty, bon the c_on sVcuc ti.on o{ said s y,~te.m, and the sarne hay been du-ey neconded in the (J 64-, ce u4 the County Reg,ist n o6 Deeds, as voewnent No. 3y7 ~-3 C-CT-V SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED ri U! rj . y S T C - 105 r r-' H SEPTIC TANK MAINT NANCL ACRI?L:MLN'1' 0 St. Croix County OWNER BUYER 1 OUTE/ hOX NUM1iLR__Rf 7( /3LZ C_ Fire Number C I I' Y/ V A'1 1 a L: t'r1 t o- 1 1, NROPE1kTY LOCATION: ' r c (,i✓ 4 5 c t 1. u n N , It --t~ - - W, Town St . Croix County, Subdivision _y- /1 Lot number improper use'and maintenance of your scptis system cOUld result in its premature failure to handlu wastes. Proper utai-utenance con- sists of pumping out the septic tank every three years or sootier, 11: needed, by a licensed seT,tic tank pttutler. What you put iritO the system can affect the function of the suptfc tank a;: <t trrnt - ment stage in the waste disposal- system- St. Croix County residents mad be elig -i b icy to ruc~ i VC a ra11 t l u r it III axi_Lit Lt III of 60% of the cuss of replacement of a Iailing system, which was in operation prior to July 1, 1978. St. Cruix- County accepted this program tit Aut;USt of 1980, with the rc({uiruIII ent that Owners of it iI itCw `r.Yut:-~ .1 1L'c It) 1(2 01) t_hcrir ;j Y,,tCtIIS 1,1 u1) ..!rly Ilia ill tained . The property UwttCr itgI L'C Lo Sltbtltit to St. Cruix County l.oIt iu i certification Corm, sighed by the owner and by a ma_.ter plunther, journeyman plumber, restricted plumber or a licensed pumper veri- 1ying that (1) the un-site wastewater disposal system is in proper Operating condition and (2) after inspection and puutping (if nec- essary), the septic: tank is less than 1/3 full of sludge and scum. Certification forth will be sent apprOximately 30 detys priur to three year exp-ir-atiori. O 1/WE, the unders1-git ed, have read the ab0Ve recluireIll ents it nd agree ILL) maintain the private sewage disposal. SyStent ill acCOrdauce with x r~ tile staudarus set iurttj , )tct"S set by v,'?-;consin Uepeirt - ~ lit eii t of Natural. It esuurces. Curt I Cat Ion 1 urlit must be completed and returned tU the St. Croix County GLt it ing Office witlti11 30 clays u1 the hree year expiratimi date. S I G N L U J D ATE St. Croix (,ourity Coning Office p.0. 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