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HomeMy WebLinkAbout038-1120-30-160 . 1 0 to O ' ~ 3 -0 n Cy c f c 3c c fu (D 3 # v o co °w °C • n m N uN p =r 3 E; a CL z a N < C7 W ~D N ~ O ? N. N O) N _ O N) CL 0 w C7 Z N °-u 0 7 ol 'm 'U (D co : CD CD 0 , ° O ~ -O co z 3 o O m N rn (o ~1 c m e cD o°° p A d Z m m a CL D N CD I (7 O W ° a CD N) rQ > z CD lei co co (0 (0 0 * 0 r- Lo Z N H t) OD oD Z fn c b z 13c ~4 Nj o <,z aQ cn v m N N a o T. D Q v v v C) CD ! rn r CD 1 tj N r- 3 o d w N 3 cn CL 7 v I A z o N \ D co Z O 1 c w rn 0' O a 0. E; `1 N v) Gi O(i O ~ _ CD N (0 w (D d z CD c• a ~n -q = c z n C A Z CL 7 toW~ mw~ 0 3 O r! (n 3 m w z CD w ~ fl- D m _a o ° 3 m m c 0 o a CD o a I I Q fi A I N a N O O V ~ A CD 4 0 ONo O o r w cL Parcel 038-1120-30-160 01/26/2007 09:24 AM PAGE 1 OF 1 Alt. Parcel 29.31.18.498B-20 038 - TOWN OF STAR PRAIRIE 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 AMY RADKE O - RADKE, AMY 987 192ND AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 987 192ND AVE SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 2.072 Plat: N/A-NOT AVAILABLE SEC 29 T31 N R1 8W SE SE LOT 1 OF CSM Block/Condo Bldg: 6/1534 ALSO PT LOT 5 CSM 10/2810 DESC AS COM SE COR SEC 29;TH N 89 DEG W 417';TH Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) N 00 DEG E 1109.90'POB;TH S 00 DEG W 29-31N-18W 15.60';TH N 89 DEG W 402';TH N 00 DEG E 15.60';TH S 89 DEG E 402'POB EXC AS DESC more... Notes: Parcel History: Date Doc # Vol/Page Type 06/20/2006 827858 WD 10/23/2001 659901 1744/112 WD 10/23/2001 659899 1744/109 WD 07/23/1997 941/582 more... 2006 SUMMARY Bill Fair Market Value: Assessed with: 175725 182,600 Valuations: Last Changed: 10/15/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.072 32,400 129,000 161,400 NO Totals for 2006: General Property 2.072 32,400 129,000 161,400 Woodland 0.000 0 0 Totals for 2005: General Property 2.072 32,400 129,000 161,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 125 Specials: User Special Code Category Amount Total Special Assessments Special Charges Delinquent Charges 0.00 0.00 0.00 s Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT r OWNER TOWNSHIP ~ f ✓ l ~ SEC . T N-R le W ADDRESS ST. CROIX COUNTY, WISCONSIN , SUBDIVISION J LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR; 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM c~ r INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used// Elevation of vertical reference point: Aon Proposed slope at site: SEPTIC TANK: Manufacturer: S, Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation:- Tank Outlet Elevation: lJ~-- Number of feet from nearest Road: Front O Si.de,0 Rear, O feet From nearest property line Front I&S ide 10 Rear, O Cv feet Number of feet from: well ~ building: j r>fi -jA~j in_ (Include this information of the Bove plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE j PUMP CHAMBER Manufacturer: Liquid Capacit . Pump Model: Pump/Siphon Manuf urer: Pump Size Elevation of inlet: ottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet om nearest property line: Front, O Side, O Rear , Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: Length: n Number of Lines: _ `J Area Built: ~J Fill depth to top of pipe: Number of feet from nearest property line: Front, Side, O Rear,O Vt Z- Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Numb of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either drop box O or distribution box O been used on any of the above soil absor on 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: i Number of feet from building: i Number of feet from nearest road: -Alarm Manufacturer: Inspector: Dated: Plumber on j obi: License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS P.O.O. . BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON,,WI 53707 BUREAU OF PLUMBING CONVENTIONAL ❑ALTERNATIVE State Ptan ID Number O Holding Tank ❑ In-Ground Pressure O Mound (if assigned) NAME OF PERMIT HOLLER ADDRESS OF PERMIT HOLDER INSPECTION DATE Rich.cucd P. Donovan 234 N. Gneen, New Richmond, W1 54017 45 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN FEE. PT. ELEV.. CST REF PT. ELEV SE SE Section 29,T31N-R78W, Tows, o6 StoA PtLaiA ,e Name n! Plumber. MP/MPRSW N,,. Cni„~~ S111•tary Permit Number. GoA L. Steet 3254 St. Cnoix 69672 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY TANK INLET ELEV TANK OUTLET ELEV WARNING LABEL LOCKING OVER y PROV ED PRO ID OAYES ONOES ONO BEDDINGVENT DIAVENT MHIGH WE NUMBER OF RD. PROPERTY WELL BUILUt NG VENTTO FRESH ALAHM FEET FROM LIN AIR INLET ❑ YES NO 2~ ❑ YES D NO NEAREST t °f V DOSING A BER: MANUFACTUHEH 113111111NG. LIQUID CAPA('I f Y PUMP M(~OF I. PII~.~P SIPiI(]N ^,'A VtJI "PE I LNARN ING LABEL LOCKING COVER PROVIDE PROVIDED: OYES ONO C ES NO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUNI.BE OFPPOF HTY WE' L BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET OM AIR INLET PUMP ON AND OFF) L_JYES _❑_NONEAR _ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing it n art H na f RIAI AND MAHKING 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 LEN(JT NO Ot ')IS Tit PIFk i„ 'rJVEH 'I f f)IA -Pi rj LIQUID I ~r, c BED/TRENCH THE N+f s / OA 771 P DIMENSIONSe -f ( I PIT DEPTH G GRAVEL DF PIH FILL DEPTH DISTH PIPE DISTH PIPE DISTR. PIPE MATERIAL NO 1 Sift tN UMBER PHQPEHTV WELL BUILDING VENT TO FRESH BELOW PIPFS ABOVE COVER Fl E V, INI T T ELI V END PIP ILINE _ EET FROM OF r /C lcZ; / 1 EA REST---► 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- DYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE f HMANI Nf 11AHkf HS OW,FHVATION WELLS _ T I !YES ONO _D YES ONO DEPTH OVER THENCH BED DEPTH OVFH TRENCH BF 1) DF PTH OF T~)VS/tIL SITDOF IT JFF OFD MULCHED CENTER EDGES DYES ONO DYES ONO OYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BE WIDTH ENGT4 NO OF LATERAL SPACING (,RA V EL DEPTH FlONI'IP; - F It L DEPTH ABOVE COVER TRENCHES I DIMENSIONS MANIFOLD PUMP MANIrQLD DIV STR. PIPE MANIFOLDMATEHIAI NO DISTH DISTH PIPE IJIST H~BUTION PIPE MATERIAL&MARKING . PIPES Dlq. ELEVATION AND ELEV ELEV 111A ELE DISTRIBUTION INFORMATION HOLE SIZF HOLE SPACLNG OHILLED COHH[(-TI Y =AIIHIAL ED PLAn~s DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS. OBSERVATION WELLS NUMBER03 F 1 ~ PROPERTY WELL. BUILDING FEET FROM NE DYES ONO r_]YES NC NEAREST Sketch System on unty file for audit. Reverse Side. T TITLE DILHR SBD 6710 (R. 01/82) s _,5C0_SIn ' APPLICATION FOR SANITARY PERMIT COUNTY DI LHR (PLB 67) UNIFORM SANITARY PERMIT # OEPRRT1T1EnT OF - InOUSTRV,LR90q&HUmAn RELRT10nS -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 PROP Y O ER MAILING ADDRESS rt1 PROPERTY LOCATION C4-T-Y: VILLAGE: 1/4-S 6-1 /4, S , T/, N, R / JK, (or) W TOWN OF: c /~N9Y LOT N MBER BLOCK NUMBER SUBDIVISIOVl9 N I~p E NEAREST ROAD, LAKE OR LANDMARK STATE P N I.D. NUMBER . J TYPE OF BUILDING OR USE SERVED 0& ow- _!-1 or 2 Family Number of Bedrooms. Public (Specify): (/LJ THIS PERMIT IS FOR A: N?Wew 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 # 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 151 a T) C_ 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 instal a ' n of the private sewage system shown on the attached plans. k, I Na Plumber (Print): Signature. MP/MPRSW No.: Phone Number: Plumber's ddress: Name of Designer: COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ❑ 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. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, C DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 769 HUMAN RELATIONS 07 N, WI 537 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: T~ TOWNSHI / LOT O.:BLKy. NO.: SUBDIVISION NAME: Pk* 1/45 / d// N F(or) W C1~ - - I Y! CO UN O /BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMME7024- RATING: DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: 1NResidence Alew ❑ Replace S= Site suitable for system U= Site unsuitable for system CON)~TI❑~ . MOUND: IN-G~D-PR❑ESSURE: N-FI ILL HOLDING TANK: RECOMMEND SYSTEM: (optional) If Percolation Tests are NOT required DESIGN R E: If any portion of the tested area is in the under s.H63.09(5) (b), indicate: Floodplain, indicate Floodplain elevatio rPROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER 0&+1FIN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B B UT ~ _rgf7 '-6n e?Z d,b 41 by 75 B- A) F ~14 S. B- B- A B- J~ •~~yJ~ PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER I AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- > '-A) 45 i P- Z .3 > e' / P- AhAILL 4 3 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION /20 '0 N a. P ~~s -of 104- too, Qq.\ ~'f~ of '3rd g- 2 , , - SkP . E , C~ r , I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): / TESTS WERE COMPLETED ON: 52_ ao - ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 4i-la044!~ CST SIGNATU DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - Pc, (Il -v p,SE4EIS S, . ..~i ,...3 ~..a 'w':sASE ..d 6 d a.. 4_ e . 1a a ,AFyL~i ",C- F }3 cons E-3ES; o(zCq Cy,,the j. 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CROIX COUNTY ,l r} WISCONSIN L t ixs ZONING OFFICE 796-2239 (HAMMOND) -fig 425-8363 (RIVER FALLS) HAMMOND, WI 54015 September 23, 1985 State 06 Wi6cow6in, DILHR Bureau o6 Ptumbing P. 0. Box 7969 Madison, All 53707 Attn: Canotyn Haag Dean Carrot yn: Penmi,.t #64913 (Richohd Donavin), i6Zued on June 18, 1985 i6 being nesc i.nded due to the 6act that the 6 y6zem area i6 being changed. Pehmit#69672, issued September 23, 1985 is jon the pneaent 6y6tem, and att papeAwotk is attached. Shou.ed you have any que6ti.on6 tegoAding thi6 6 ub j ec t, ptea6 e beet 4nee to contact thin o66ice. SinceAe2y, Many J. enkin6, SecAetany St. Cn ~.x County Zoning 066.Lce EPARTIVIENT of INDUSTRY aNSPECTiON REPORT FOR LABOR & HUNAN RELATIONS SAFETY & BUILDINGS P.O. BOX 7969 r PRIVATE SEWAGE SYSTEMS DIVISION MADISON-, WI 53707 BUREAU OF PLUMBING XXCONVENTIONAL ❑ALTERNATIVE S-a PI- I.D.N-b- Holding Tank El In-Ground Pressure O Mound of a s;9ndl _ I i NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE: Richard P. Donavan 234 N. Green, New Richmond, WI BENCH MARK (P--nenr reference P-0 DESCRIBE IF DIFFERENT FROM PLAN - FIEF. PT.EEEV.: CST REF ELEV SE SE, Section 29, T31N-R18W, Town of Star prairie N.- of PI-nber M PiMPH SW No Counry ary umber: Gar L. Steel 3254 St. Croix 513 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET EL V WARNIN BEL LOCKING COVER PROVI D. PROVIDED: BEDDING: VENT DIA.. VENT MATL HIGH WATER YES O NO OYES ONO ALARM NUMBER OF ROAD PROPERTY WELL BUILDING TO FRESH FEET FROM LINE: JAVENT IR INLET. DYES ONO OYES ONO NEAREST DOSING CHAMBER: MANUFACTURER. BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER I PROVIDE) [ : PROV IDED. YES ONO EYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS oPERAT oNAL NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE IAIR INLET PUMP ON AND OFF) EYES NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing N<,1 rl DIAMFTER 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. COVER INSIDE DIA. -PITS LIQUID DIMENSIONS TRENCHES MATERIAL PST OFPTH (GRAVEL DEPTH FILL DEPTH UISTH. PIPE IBELOW PIPES DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF ABOVE COVER ELEV INLET ELEV. END P IP ES I PROPERTY WELL. BUILDING. VENTTO FRESH II FEET FROM LINE AIR INLET NEAREST------o-1 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- OYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DEPTH OVER TRENCH BED DEPTH ovFR TRENCH BED ❑ YES 1:1 NO El YES ❑ NO CENTER DEPTH OF TOPSOIL SODDED SEEDED TZE ED. EDGES OYES ONO EYES ENO YS ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO DISTR DISTR. PIPE 1)I S THIBD TION PIPF MATERIAL & MAHKINC; ELEVATION AND ELEV.. ELEV_ CIA ELEV. PIPES CIA DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VEH TICAI_ LIF T CORRESPONDS TO APPHOV ED PLANS OYES LINO DYES ONO COMMENTS: 'PERMANENT MARKERS: OBSERVATION WELLS: PROPERTY WELL BUILDING. NUMBER OF LINE FEET FR EYES NO OYES ONO NEARESTO Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE. DILHR SBD 6710 (R. 01/82) MMEEM6mm wls`onsln APPLICATION FOR SANITARY PERMIT ~ DILHR (PLB 67) <~F l "S_ COUNTY MMMME&+. oERQRTmenTOV UNIFORM SANITARY PERMIT # ~a InOUSTR4, LASOR 6 HUMPIn RELRTIOnS I /I --Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT P PE Y OWNER MAILING ADDRESS PRO ERTY LOCATION CTT1Y: SSE 1/4,S/> 1/4, S,-7 , T3/, N, RIP f (or) W TOWN r r^ d ~ LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER A,1 94 4 ' TYPE OF BUILDING OR USE SERVED 'y 1 or 2 Family Number of Bedrooms. ❑ 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 # 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 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 installa on of the private sewage system shown on the attached plans. Na f Plumber (Print): Signature: I/ j _a W/MPRSW No.: Phone Number: a,-, v ~ ~ 5 '2~~ , " Q 19 . )z 6 I 7L 5 (76 Plu er's Add ess: r Name of Designer: C ?A A) COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ,J fir; ~ LI / ( Owner Given Initial Approved Il Adverse Determination eason 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 intendeu f-r resale oy owner/contractgV,(11spec 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 Qo-~ r~ Location of Property '4 6~- 14, Section N- I T~ N - R A W Township pp.Y. Mailing Address c~ -3g= YO Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel ~ gct,~& ~ Date Parcel was Created Are all corners and lot lines identifiable? L/ Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number l s,g 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) eeAt4y that aP e sta ternents on this 4onm cute tAue to the bat o6 my ( oua ) know.-edge; that I (we) am (ane) the ownen(.a) o6 the pnopetcty deackibed in this in4onmation 6onm, by viAtue of a wa Aan,ty deed &eeonded in the 066ice o~ .the- County Regi, ten ob Deeds " Document No. , and that I (we) pae/sentty own the pnoposed site ion the. sewage /sy/stem (on I (we) have obtained an easement, to Aun with the above de✓sn bed pnopeAty, 6oA the constAuctior. o6 said 6ys.tem, and the same hah been duty neco)Lded in the 066 ice o6 the Couna:y Regi6ten of Deeds, as Document No. ;x GNATU//RE``OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED H H y STC - 105 r r ' a SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County z d a OWNER/BUYER ROUTE/BOX NUMBER a3cf //[f Fire Number CITY/STATE ZIP Al., 4-0 17 PROPERTY LOCATION:Section, T,3/ N, R/ _W, Town of Or qtr , St. Croix County, Subdivision Lot number i Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you 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. ,3 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. 0 Z i O o Q) r- . c O U c N co) 0 R1 Q) ~ t C N O O H N c0 0 s: 7 C i N i O L- O w++. G O O O L) L.: N O "0 `O c 0 Z7 V CO) L O O m (D w O) o r0 . N 3 c p L- 0 N C7 ( c N vv~ W O ca U c N c0 c (a 0 o~~ 30v E c Q 5 j c rno N :3 16- 0 0 m..= O a (D -0 i -0 o ~D _ co coo 0) (D Ix -0 ►L--C CCDa - =a) W\ W d y 30300~ S~= ° M-0 t fC N c C U •N O '0 i O M O L r Q) U) cc LU C) ;6 - N Q L0 OO N O L ` U w N O U )~F-~3a) a) U) 0 Q G v C U ~ UO ` V) Z N ca ~ O vii N ~ co N - v CL c m vi 0 O 30a~i~w•0 ro V Ix o = ' 0 O c ` cu L) Co - 0) V ' w •V O 0 j CO U) st O O) Q O A~ Q CL CL CO c7 Ncc•C _c (1) c 0- O N co `0 N c0 cu 0 3 c~ r 76 0.o E O O)Z.s OHO a O - E ~0 cct oocti cn o coo Y c c Cl) y co m a) 0 U O t7 O O 0 , -ZL- CY) cr) Nk c~ V7 U) -0 0 co a) c _ C cu N O N N a cu co a) 0) c a) 0 co -6 Q) ~1 7w O N O N N C Q v) i~ W4 p C O CD (D -C C a O M Q o Z Co L- cV cep O :3 E Z) O >1 0) 3 n G co CU t t a a` O w o c O a N C O N 3 O Z: M O E (u CO VOiL m c O cc co m o N o) x _J O DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, LABOR ANU P.O. BOX 7969 PERCOLATION TESTS ( / 115l DIVISION HUMAN.RELATIONS (H63.09(1) & Chapter 145.045) ` MADISON, WI 53707 LOCATION: SECTION: TOWNSHI / ITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: c L~ '/a ~'/a z / N/R /pl (or) W ,3, , /ZIW 4,1~ COUNT S/BU ER' ME: MAI ING ADDRESS: ~JT ~G~ D j/ 2Y /t)~ 4,2 USE ~ , ~ NO. BEDRMS.: COMMERCIAL DESCRIPTION: DATES B ERVATIONS MADE L Residence 7PROFILE DESCRIPTIONS: PERCOLATION TESTS: 3 New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUNi7 D IN-GROUNcDPRES I S'URE:SYSTEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM: (optional) M 11U I Flu 1, ZS ~ V EI(~J FQU I 15,&V If Percolation Tests are NOT required DESIGN RATE: under s.H63.09(5)(b), indicate: It any portion the tested area is the Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS /I rp BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) so B- l ® N > 3 3 Gn 3 B- 2, 011 64 ion, 13- :3 't 7 -3 lea. B- -00 PERCOLATION TESTS TEST WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES NUMBER tR}2M€S- AFTERSWELLING INTERVAL-MIN. RATE MINUTES P I s D PERIOD 1 PERIOD 2 PERIOD 3 PER INCH 3 P_ Z 3 ©o IVO ~Y~ ~S` 3 P- 5 _ O - P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 1 n 3~ , I; i ~f19+'~~~Irr_, lvlltt i `11 ~ih _ i E P I'A i I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIGNATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - s`f'Jt `1~..d 1. r,.a .,s, 3 s - of ~ tr ~ r k,€Jd F',~li „i k7`~ , rk and 4r , G_.f ~ts_ P tt> c'." Fe .bt it ~frr i rit' i a i s l i i f r 3 : - des F _ a{{ r r , i Ss 1, dnt S~ i3 C'isv, k tv 1r E t._ l r{!, n r .a : i < r f r''s P-,-~ )Q SES- c2 - u /D 442 ~~~✓f~ y Lr ~,p~ J 1 ~ v~