Loading...
HomeMy WebLinkAbout042-1063-10-000 o N d f 3 -0 0 0 0 Lol c f o c o c c 3 n .r (D rte} o a r CD (D d CD 3 (n S (n z c) m L z m (n z O (D W< N A eX • C) CO O w w O O w c 0 (D O N N C ll1xC 111 N O (D O 7 d 0 CD 0 J~ (D - ~r7 l^\ p d z O ((D O_ =3 0 1 c a (D W (D W -p Oo W O N N d 0 (n _ 3 D7 N d 0 O O O n 7 Q CD O 7 (D n n * J O CD =1 Ca 3 N CL O ~ p W O 3 N 7 in O Q Cn N N C S?° '.3 O7 m O CD w Z D CD CD C CD s CD ((h p (A ca' O D o 7 CA W : (n CD C _ CD W 7 N 3 Q O W a p 0 7 O 'A W O O W O O ( p z (O (D lr CDC W ao ~ O 0 0 0 (n 0 c Ut (n (n 3 7~ Q lD (n c G G O G G G !`ill S c- ~`M (n (cn (n o CD v (Oj (n cn cn ~ c - < U W W O N x Q CD N N K D) to ~R V; a g-0 N Qo _ CD C Q M CD I (n D7 y ~ < O S °i ° 3 CL W N N =3 C) W °zo zz~ zcnz Q a°= D D o O D D S o n z 9' O w N ~ N o O ~ d (D (D N "kA O = a (D N CD y CD (O (D O CD =3. n N c c 3 S n m m o m _ 3 m 3 ' cn N CD (6 m c o j' Z A ((DD (n CU N C z .r Z a Q A 3 d o (D 7 (n N O. N Z W 'a W o m( N w (D (D (moo z d 3 a' Q o 3 0 ; C/) 0 o m co N O N z (D < O co W N O N m D 3 (dp N N O a N (D (D N X CL CD N 'O O d C O (D d .O» d M CD O G_ N O O N (O O 0_ (D O d O C O 3- D) C 30~3~ o a A?m('p Z a 8 O CD ~ (D (Oj)j'O n "O O ==3 o - m (D (m D m j N N "0 = (p N J N 7 y -O (n < CD 7 7 CD 3 < d 0-0 t11 C ~ d ;y 4 CD O.7 0)co N CND Q - CL Z3 d m Cn O CD a (n o m m' m 0 ~i mo U) a:0 O)0~CD i c 7 < A 'O fi O n (D CO (p (D - A M n cn 3 N~ ~'~(n <Fa A D Q- 0 CD :E m cr a- 0 d 3 (n N C CD O O O d r 0 O F (D ^r. (D =3 d S d O CD O CD ft 0 ti (D Go 0 p :E p :E O Q 0 (D ' Yj 3 iE 3 rh y she ~avner's name Address i w t® i- K!s{ 3 3 ty as d Mate 1 1 '7 Z=p cede e cus ;awre uaiue(s; T[D VOC 11 L>1 ?7 } T-vpc of ocCup,Vancy in Y 3 j .vete~ _~'s~ wt 's sta53 ~_S~R 1L cnv~>+^.~. 2 :-n-rit :t:fi,mation avaalal;ie? `yr N ~ &,i report on fne, with county? Yo N 12 F• Owner- Interview k1 t j. j ° t 3 "v € Bads-yaps Yo ;4 a-Free-ze-ups Y 0 oNT G -seepage t-~ N E.✓F S cw de airs e Y N Ef~aul -don Y N ID other Y- r,~`r~ .3g;aa~sre:~ _ Rage: ~ onsite Ipspeitir p 4g;': systems: r Below grade ~z 4t grade ~goua~d e of p:itch seems E Dosed Pressure Gravity Sed ii French Pit pd Holding tank Privy +h' Usher t F ✓ B ,reai_meats z-x seftback cornpiqance: Well Uaiding Lot iia- pp Pool -Sairfac; water Utht r a., ~J iiW a, -r Lrj~ OONvr p ` Well f' Building of u_ Poo, S:arfac water Other s :;-plain other(s)- 04 - i E - - a .G...ise_:...,....i:.b.7.'_........s""..;a:..l...:_r' ~`.T'. •a~e~S:.e;e?_ 3;ac: ~.'a~~. ;r" ~f3 i. ~ '~'c,3t:~..x_~c 0' ~_qct>vxaai 0 Need replacement 4'la 7vll~ cover: R_aDIace 0 Locking device AWarning label ar.rl6rativ 1: . - i "vid ng v~ak: Size: Gallops Ma- Oh- cover: Leplace ~ Lvckirg dev-c4 0 Warning iaM E _o rat>v : ? Y 0 + ~ii5ii3~ t.`t.C31i: ~:„L;: rs ~ A3 v 6.a8it135 f , t ~~7-`-^C~f =-i-~-- L~j.~,ty.~-r• r u:at". vle c gc~_Ss. - Yi'~ ~ ~'EpS~~.t,i ~".-L "t3wA.ig device R%::IY .i. 't'tt3.i.2<Grl2.: N `74 Ponling Inches t y: i3S 3 iiZtUO iDC fill-.. t.!311a.r: ' F- N - Seepage cr svrfai:;e discha..ga: g k, ~:a asp` gu ~a ` aF replacenl.'.nt area available: 0 NN ~ u torm d: OVii' z 51 n .."J-~~Y"r~--~ ~_J-~.> ~..s ~-u~ €.°~,-~{r ~."-ems--~ .,+~`,...~•e~.fi3-~?5-,..~~"-ls cm....~. _ .,_.~.,~%=t-' :j .,,,'..%5~a'~>.- •t B,tLd~` ~.~•!1~-,.t,^r. .,,.~aa, • 1,^>++~,C."a,~.os`*-~ k ~.1 ~ sCT,ucvts~is:"~•-_ .4 j. _ , a1- e.-..._....,,..,-v.-2r-v-•.' C_.~ ~C'_v r,c,.-'t ,~s'.. fv, 1 __.4ai-~' .r i ~:C f?.~ r`i5~ t.. >L•°~.::. y....~r~ .Y~ >'~f~"~. .a ~-'Y l..:s~--"~~.~x .....:__.~a' ~ i } ~ °'"ri" .~t^~``.. "'`-~.v ,.:t C "'r CJ : _ u E. D~J . oI n a _...,..i`•.: 3 ,....S.i :sue i. a _ _ . a•- mss r .'tea ? - ..s p, IC9.Llz:..'_ aspc,w, :aaid noble ivs'!?ioi 'S iwp~a~cu axe bi~~. tt t_iii '~a4..J:~.> `ue t°.B -ne" J. ins- ec- on. ~m s 3rispf ii~e3n does s``=c $ 1 any way a?Le • `ia d. e,,.";'.. „v81_.S.°y.F.--d C; 3iloS~Y_ c the system dc.. ;:IF~~,d ~.2L._C'~`•~_ 34P x c-, f 1 --E. ;a.- > (`=~r`=%-s ~-c~ e""La~,`~0~,`{ - May, A .tea.,---{SL ` /~+-a.~.'~T'~' •'~'Y~r~""'~ '/LA~ c,- l~.' ~~-(L n~^ ~J.W-~~~✓'-~t'_.. g~tr.,r„11e..e...•C.~ ty~ _-lr 1iL ~ / ~ I ( .'!R"~.- -Y }7~ ~ ~ '~Y I I ~ " t o ca p 0 cn O I g-0 0 C ~ 1 ID 3 m \ 1 3 3 # r' A ' C o 0 0 N Z O COO O Z= N Z O~ W; < N A h• 3 w tOD CA = O O C c0 10 m IV N ~..I r]/1 O O CD Z Q N N O O Q CD 0 a -4 :E =3 7 to O M CD N W 7 7 N 03 O OD W O N N O- 3 O O O 3 O N w 07 a T O O (D p p (D C) CD 4 O o w cn m n n n 3 0 _ CD n a co 0o K 7 N O y C7 O C 0- T, 9o O (D CCD m c_n D a 2 c_n z D m° m e CD «a (D w O. ca 0 w C. o `C co (D CD co Q o 3 Q o o N O o 0) O o c0 0 0 O \ A w O a) ~,II O O Z z N (D (0 O CD uo III 0 r cn ccn 00 00 (n CP 0 0 0 SO'.' a O O O O O O CD Z• CD Cl) vi vi ~ c a m `r ~ < 6 m 0 _0 (A -u O O N CD (D (n m N 1 cn m m N cn 90 CD r CD C 6 !~i CD Cl) A N DJ < O 3 m o l f 3 m _ N CD m cn 7 .91 W _ y N =3 C) W i A p z b z Z~ Z (n Z o n~ = D D oc D CD 0 N 3 v Q m "O N 0 0 p m m CD CA 7 Z7 x -u Cn t~Vil (D CD xv R, Q. 3 3 CD CD -I cn > > o p z n A Q 7 Z m w N (D v M (D c0 o. , I CL 3 z o o F co 3 3 mao rn ; z CD w m Cl) m o cn-0 D 3 <N, D my n m m - on 7 CD N O (O 2 Q A m p T Or p v T (T ' C O G B CD U) Q z z a CD o Q°1a o D J n Ui Q ~ ( m m Q rn 3 I v+-n j 0 < O m m p S a Q m 3' CD N CD O Cn -O 0 b o -mp J 0 CD T N O N CD O ;1. 3 CD c Q CD N N CD n Q (,O a ~ O CD N CD Cn ti m rn3 _ o - o 7 0 - z N CD A m o o =3 =3 N I A CD m O~ dQ EA <-f) V .p 0 0 C7 CD O C:) CD i n ti O n cn O 3 m 0 C7 rte. o d F o it f d o (D (D> > 0 3 T (D (D M l S o • O N vi O O O Z 2 N Z O CO m 15 N N O O N O 0 3 3 O (n S c: a CD p_ N vOi O W (fi ~ O '.I N N CD C3 1 C A Z a ti O a` b O :3 :3 N m N 7 W (D m N W ^ (D 2) V a O T1 3 v O N = O W O O CD (D 0 O~ 7 CD n n V O U' 3 0 (D n co CD N N C) O N N co N N !r Dl a N C cn D m F - cn Z D a CD (5- CD N N a W (D O N G O m m o a~ c (D 3 a o a j o ° p o co O V o CL CD CD o W CD aoo oz o m o n r cn ~y N cn cn o o (g y Q N y 3 CD M -0 "a o Z D 2 D O cn 'III o c0 -0 1 cA -1 N- I N N o! m ~c A F o E O CD CD N :3 W rn m ID G' m a cp _ CD r (D = (D 0- (D .dr N N .di y O N ' 3 (D • • (D (D C CL D z CD N D D o D CD o O C: CD =1 O O a g m CL o CD N tv~ (D m CD w a Q 3 3 5 z CD CD (n Vl O N O O A Z n O_ A (Z 9 7 Q' z N N w v W v m m CD 0 3 0 CD CD A _ cn 3 3 M oC UI CAD f/! ~ < I W ~ W CD o cn -0 D 3 N D cn m -0 a (D oo a m CD CD o o N (n 3• C CJl N C Z a o m z a CD ° o 0a o C CD L N r n N N ?7 7 y 0 CD Z: CD a N y .N =r (D A j• C'D "CD 0 N -0 0 O _ (D I C> (D 3 ~ r3 N 7 7 v m a CL -O ~ N o ti m o 5 0 0 z r. mv CD _ v CD , CD o O I w O „ o0 i o o CL Wisoonsin Department of Health and Sooial Service& Pl.b, #67 3/70 Division of Health SEPTIC TANK PERMIT APPLICATION G ' 51 TYPE or USE BLACK INK ~ - • ~ h nlrn, /~ob~ A. OWNER OF PROPERTY Name Address (Street, City, Zip Coda) -Y((, I-Lt~A B. IACATION_OF PROPERTY W7-RE SYS;:.M WILL BE CONSTRUCTED, ALTE.REP OR EXTENDED COUNTY 4 Check One; CITY VILLAGE LEGAL DESCRIPTION TOWI HIP- C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO ~ PER2iIT NUMBER D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION ~ REPLACEMEN'T ADDITION MATERIALS: Prefab Conorete L Poured in place Steel Other NUMBER OF TANKS TO BE INSTALLED: E. TYPE OF OCCUPANCY -Check One: One or Two Family Residence ~ Commercial Industrial Other Specify) Number of Persons to be Acco.-modated Number of Bedrooms F. APPLIANCES, ETC: Food Waste Grinder ` YES NO Autoaatie Clothes Washer/ YES NO Dishwasher YES NO Au.. tocatio potato Peeler YLS:::~: NO Other (Specify) G. MASTER PLIJP3ER MA.KL G INSTALLATION Name: -.t -~C/~__~_L 'L•` ~i~ Address: ~J-i, License Number. MP Signature of Applicant: MP RSd Address: ~/J~'r7 H. (Too be. Completed by Issuing Agent) / Date of Application c ✓ ~ Fee Paid $ l Permit Issued (date).JPermit Number -,L,L.~.L /-n Agent (Name) Town, Village, City, County, etc. (Specify) Note: The application cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $1.00 for each septic tanx and the third copy of the permit (canar)-) to the Division of Health. Checks a:.1 money orders should be made payable to the Division of Health. Do not write in space below - FOR DEPARTMENT USE ONLY l i I. DATE RECEIVED / D - -76 ACCEPTED BY RETURNED (Initials) (Date) See Cori-ej. FEE RECEIVED VALID. No. PERMIT NO. L Yes or No REVIEWED BY APPROVED DATE ` (Initials) Yes or No COMPLETE OTHER SIDE J SEPTIC TANX PERMIT NO. R E P O R T O N S O I L P L R C 0 L A T I 0 N T E S T A N D S O I L B O R I N G S TO DIVISION OF HEALTH - PLU--LNG SEICTIL`"1 P.O.Box 309, Madison, Nis. 53701 Pursuant to H 62.20, Wis. Administrativo Coda P E R C O L A T I O N T E S T Test Depth Character of Soil Hours Water Test Tirio Drop in Water Level In-f%e Number Inches Thickness in Irohes Since Hole in Hole Interval Second to Ne t to Last To Fall 1st Watted Ovea i~l~t in Minuton Last Poriod Last Period Period Onx Inch Example P - 0 36" To Soil 10'+ Clay 26'+ 25 Yes or No 3U 12 12 12 60 . •,1-A. J, RECORD DATA ROM MINIMUM OF 3 TEST HOLES Compute size of absorption area Li accord with H 62.20 Wis. Administrative Code. S O I L B O R I N G S- Minimttm 36:' Belna Proposed Absorption S 9tS'9 Boring Total Depth Depth to Ground Water De th to Bodrock Number Inches observed Eatimited uoserved Esti,- ted Character of Soil with Thickness in Inches Example B 0 720 72" Black To Soii 12" CL ~ ~t8"• Sand 1811• Gravel 24" 1L , t III-t- ~r RECORD DATA FROM MININ:Uf? OF 3 BGR HOLES YFE OF OCCUPA.NC7: RZSIDE:gCE: Number of Badroores OTHER: (Specify) Number of Persons D WASTE GRINDER: Yes No Distasashers Yes No Automatic Clothes Washer: Yes No Frr^WEhP DISPOSAL SYSTEM: NEW _ EXTENSION ADDITION REPLACL^IENT Tile Size No. Lin. Fast /67) Trench Width Depth _ Neer of Lines Z Seepage Bed: Length Width Depth Tile Size No. Lines Seepage Pit: Inside Diameter _77 -Liquid Depth I, the undersi&ned, hereby certify that the psm olation tests reported on this form were made by me or under my super- vision in accord with the proced,.;res and method specified in Chapter H 62.20 (13), Wisconsin Administrative Coda, and that trio data reoorded and location of test holes are correct to the best of my knowledge and belief. NAME TITLE J Type or Print REGISTRATION WNO or MASTER PLUNDER LICENSE NO. ADDRESS / j DATE SIGNATURE n(A O 3"a n d `r1 o = M 0 m o CD CD (D Z v m - m o m 0 o o o` N °a °C • ~ 3 N N N !~I 9 O c f 20- Z (D N 3 co L, O OJ v N W m 1? 7 CO W CY) O ` 1 00- v N 0 1 (n C co O A7 3 p (D O O O C N O (D 0) %d - I (D (p' CD (nom Q Q O ,a1 O O O :3 cn w o CD C:, Sy ~d r1 CA CD \ a m (D ft O { lz ~ ryi cn (0 (o r cn co co cn P N Ul cn 0 C /d Q (D r ~ rn td o E' (fin fin cA ~ N H (D CY'~ Ln 0 Z N t-~ 4 j H Q_ < C,- v v vU -0 9o (D CD to h W = \ m a)i o ~ c CD- N N 0 o N D D o r~ m O c V I n W o CD Ln Ui X Cn 0 c l/q W (D a 3 H H z (D O N Z (D I;: z p (D f-h I' 'Z O 'rd LTJ ~ Z --j 0o CD m 0 00 CD a ' ~ z A~ cA 3 00 co N K n 3 Cl) i (D CD a N w m N CD o cn -0 D o cn m -°'0 a m,CD r. o a' o m c a o z ° CD 0 CD C1 (n I N~ 0 0 (D 7 4 a O (D A 0 A CD c v CD o n a CD (n N -m o 3 0 q m Q _ N ~ m o o O iv O (D 0 Ca. Parcel 042-1063-10-000 01/06/2006 02:33 PM PAGE 1 OF 1 Alt. Parcel 22.29.18.3478 042 - TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner O - XIONG, CHUA E CHUA E XIONG C - VUE, BOHOUA J BOHOUA J VUE 826 130TH ST ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 826 130TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 10.000 Plat: N/A-NOT AVAILABLE SEC 22 T29N R1 8W 10A IN NE SE COM INT E Block/Condo Bldg: LN & SLY LN RR R/W TH S ON E LN 459.5' TH W 913.5'N 494' TO SLY LN RR R/W TH E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) ON SD SLY LN TO POB EZ-U-1416/151 22-29N-18W Notes: Parcel History: Date Doc # Vol/Page Type 10/31/2005 810791 2919/064 WD 07/23/1997 458/283 660/115 2005 SUMMARY Bill Fair Market Value: Assessed with: 79425 Use Value Assessment Valuations: Last Changed: 07/11/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.200 27,600 135,500 163,100 NO AGRICULTURAL G4 8.800 1,300 0 1,300 NO Totals for 2005: General Property 10.000 28,900 135,500 164,400 Woodland 0.000 0 0 Totals for 2004: General Property 10.000 28,900 135,500 164,400 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 214 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 cl Form -STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP SEC. :;k.:Z T ~2 y N-R IS' W ADDRESS fj/r°p~ f ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE n PLAN VIEW Distances and dimensions to meet requirements of I111R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f j 76 hv, G /l7DG'r,~LX ~ , - I INDICATE NORTH ARROW BENCHMARK: Describe the~ v~er reference point used Elevation of vertical reference point: proposed slope at site: f SEPTIC TANK: Manufacturer: Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Ff Tank Outlet Elevation: 9__S~, S-~ Number of feet from nearest Road: Front, Side,o Rear, 0 feet From nearest property line : Front, 0Side, 0Rear, 0 f feet Number of feet from: well _-:?4building: / (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER r Manufacturer: Liquid Capacity: Pump Model: 3 >L`' Pump/Siphon Manufacturer: Pump Size Elevation of inlet: 9V, Bottom of tank elevation: V6 Pump off switch elevation: Gallons per cycle: - 0145251 pfri~ ~;,eAlarm Switch Type: Alarm Manufacturer: Number of feet from nearest property line: Front,O'Side, O Rear, 0 Ft.;2_&~ Number of feet from well: 'ij' 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, 0 Ft Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number-of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of""bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated : CJ! Plumber on J) 'k: License Nurn: )er : ~ 3/84:mj wisconsin APPLICATION FOR SANITARY PERMIT , DILHR XC COUNTY DEaaarmEnT DF (PLB 67) InOUSTRv,LABOR .HUMAnRELAT[ons UNIFORM SANITARY PERMIT # -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/zx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPqRT OWNER, MAILING ODRESS ) OPERTY LOCATION CITY: q l 1/4 1/4. S T-` ' N, R/ S E (or W y~L N OF: TOWN OF. LOT NU BLOC"WMER UBDIVIM E NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER ,3 TYPE OF BUILDING OR USE SERVED 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: F-1 Jew System ❑ Tank Replacement ❑ Re air Lkl' Replacemen p t"ftli -mffm ❑ Revision ❑ Privy ❑`,Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A C VENT NAL STEM COMPLETE THIS BLOCK. Seepage e ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-1 -F II ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing For hich 'Previo s Permit Is On File, Permit # issued An Exi ing stem hat Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capaci y Lift Pump Tank/Si ho Chamber Holding Tank cap city Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: Mound ❑ In-Ground Pressure Total #of Prefab. Site Gallons Tanks Concrete Constructed Steel Fiberglass Plastic Septic Tank Capacity -Z-_ - Lift Pump/Siphon Chamber e Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA W (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY: I srivate ET El Joint El Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber (Print): Signature - / MP MPRSW No.: , Phone Number: PYumbey's Address: Name of Designer l f f - r COUNTY/ DEPARTMENT USE ONLY Signat e of Issuing Agent: Fee: Date: 7 ❑ Disapproved K-~(~LG"~ ❑ 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 INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WI 53707 BUREAU OF PLUMBING r ❑CONVENTIONAL fxI ALTERNATIVE State Plan I.D. Number: ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound ur assigned) 8405013 NAME OF PERMIT HOLDER. T DDRESS OF PERMIT HOLDER. r INSPECTION DATE: R ert Johnson Route 1, Roberts , WI 54023 /6-/q B H MARK (Permanent reference paint) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELE V.. SE-1, Section 22, T29N-R18W, Town of Warren Narne of Plumber. MP/MPRSW No.. Coumy. Sanitary Permit Number. Henry Nechville 3258 St. Croix 69611 SEPTIC TANK/HOLDING TANK: MANUFACTURER: L IOU ID CAPACITY. TANK INLET ELE V.. TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED. ~I OYES ONO OYES ONO BEDDING: VENT DIA.. VENT MATL.. HIGH WATER ALARM N UM B E R OF ROAD: PR OP ERTV WELL: BUILDING: VENT TO F FRESH FEET ROM LIAIR I LEr. OYES NO OYES ONO NEAREST ~rJ DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER 7 / ( PROVIDED PROVIDED. OYES ONO DYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPEHA T IONAL NUMBER OF PROPERTY WELL BUILDING VENTTOFRESH INE (DIFFERENCE BETWEEN FEET FROM L.2 q IAIa,INLEr~ PUMP ON AND OFF) YES ONO NEAREST I ~P J ~/O t SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MgaKING or excavation. (If soil can be rolled into a wire, construction shall cease until MARK E 7 [7~ J the soil is dry enough to continue.) 1~p J CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH NO OF DISTR PIPE SPACING COVER INSIDE DIA -PITS LIQUID DIMENSIONS TRENCHES MATERIAL: PIT DEPTH GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR NUMBER OF BELOW PIPES ABOVE COVER ELEV. INLE1 ELEV. END PROPERTY WELL. BUILDING. VENT TO FRESH PIPES FEET FROM LINF AIR wLEr: 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. 114Y NO SOIL COVER TEX TUNE PERMANENT MARKERS O OBSERVATION WELLS DEPTH OVER TRENCh1;7ED DEPTH OVER THE YES N OYES NO NC HBED DEPTH OF TOPSOIL SODDE EDED IMULCHED. C ENTER D EDGES ` SE ' 0 ) / OYES NO O3`ES ONO YES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER DIMENSIONS TRENCHES L, I 11 S' MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV 21 ELEV DIA ELEV. PIPES Dla DISTRIBUTION J I L1 0 INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ®YES ONO I DYES ONO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS. NUMBEROF PROPERTY WELL BUILDING. FEET FROM LINE DYES ONO DYES ONO NEAREST ~G7 Sketch System on Retain in county file for audit. Reverse Side. S : FTILE/ DILHR SBD 6710 (R. 01/82) ~ APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequaoies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property Location of Propert~ Section , T ~ - N - R f -S ~W Township Aill Mailing Address :7- e- tj V Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? / Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: ~1.i Warranty Deed 2. Land Contract 3.• Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERTV OWNER CERTIFICATION I (We) eeht%6y that atte 6tatement6 on th.i.6 6onm are true to the but o6 my (ouh) know.tedge; that I (we) am (ate) the owner (6) o6 the pnopen ty dead ch i.bed in thiA in6onmation 6onm, by v.ihtue o6 a wat.anty deed neconded in the 066ice o6 the County RegiAten o6 Deed6 " Document No.,~~ .~fllS~~~ d that I (we) p4e6entty own the ptopobed 6.c to bon the 6ewage pob 6y6.tem (on 1 (we) have obtained an ea6ement, to nun with the above debeni.bed pnopenty, bon the con6tnucttion o6 6aid 6y6.tem, and the 6ame hab been duty neconded in the 066.iee o6 the County RegiA ten o6 Deeds, ab Document No. 1. SIGNATURE /OWNER SIGNATURE OF CO-0 ER (IF APPLICABLE) DATE SIGNED DATE SIGNED i z H • a STC - 105 r' r a SEPTIC TANK MAINTENANCE AGREEMENT ~H+ St. Croix County z a O W N E R /_.-12 ROUTE/B6~{-I~tJPIBER/'i Fire Number CITY/STATE r ZIP - c N~ PROPERTY LOCATION•_ Section Ti' N, R Town of{1/%r'-/~~ 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 i 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. 0 E I/WE, the undersigned, have read the above requirements and agree z 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. v W x s O N Al W? C C N ~ O -t ~ 0 O a cc S- S, 0') Jz H O O C O w C tL] C O 7r `G O cc. co Ti Z O (D n d (D (D p p. cn CD CD yi o =3 -1 O w -0 (D O O `G N (~D O ? CD Zn (D omm°D o3oa O (D C W O w O =3 to - 3: 0 0 L C F C F' 3.zcn C 2z 3 O n0 W C * z O w CD o 10 a~ ch 100, -0 ' < CO) A co r p n 0 c- v c o D N O A = w" O o c s v m a c (a a w (ODCn Ja~~ ai C ? cn CD w CD V 5D ~ cn Z m n p Z °'m-1 OD --j o a O O 0 0 ( m? a CD E~ Ch * a o= o?o m Cr A a =r c~ c j _N CL Cl) u, ~a(0 ~ N CA 0) CL c --1 0 ~ a v can CD cn CD ~ Cn n -0 CA o< co (a ° c c~ S-o vi w a CD o o w w ~ n S or c w " i a o ccS. a o' m aaaCD N M CL i O CD Qa?N. L~ w a C sm _ A CA O (D fD m p cD A C (a O C1 (D c a0 oco CL "c a ; c CD _w o ~ CL 3 0 oo3 a~ wa_3' ja o 0 3 N c 0 2 DEPARTMENT OF R PORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N W 5739069 HUMAN RELATIONS (H63.0911) & Chapter 145.045) LOCATION: - SECTION: TOWNSHIP LOT NO.: BLK. NO.: SUBDIVISIO NAME: SE '4 Zz- /T2-7N/R WE (o w,4,e~t'F,v 4,e7- o .f4.e- COUNTY: OWNER'Sf3ttl'~6Fi'S NAME: MAILING ADDRESS: 5Y C4i X ?o13ERj V_,5//WSo.4) 151~(IfWAJ,o,4iE- C74. '~?oaERTS w ► S . syoz3 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PE OLATION TESTS: XResidence 2 /L ❑ New Replace RATING: S= Site suitable for system U= Site unsuitable for system SC ~D JE~~r/ ~~EEO SAC T L O/ A-IS CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ❑ s ®u ©s ❑u ❑ s au ❑ s au ❑ s au Iqo If Percolation Tests are NOT required DESIGN RATE: __71 If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS /N ~C t/-tdS_ FT• BORING TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) r • 83' A," lea. 57, . S !3a '5"/, . q2' L/• Qa. i B 9'0 16.60 3. 9 A- ate. SI Wf.f. Ole - Gy. "10+s ".0 B- 3.9 ' '4° P.O 3 .5' A7.13 P. l, S'- 13 B- Z 9.0 53• 0 9-4u- R-4 - B'a . S1 •h'/34ao cf C, Si/ w~d4 !tf disT • R-4- y. bfs /67 a W OR'by. M0 5 , 1.O kiX o B- Sid wide. "S ( • -6 Y- NdfS ~ S?. C/ .F)' Gy Si ( •7,S r3u. Si/, 1 '0ip-60 . 57 / B-,3 6. 0' /,7 • /0 y/ 01 N S I. 3 ' Si/ S wit'SITED - S~ w~1 / B- r SEEP ~e gT 7•/,l SUPFifC~e G~IEU• OF Pt-,PC SITES PERCOLATION TESTS / TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFT~EERSWELLINpG INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- P- 2i Z a 60 P- r P- 1 S. Co ~o /~C 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. D1S7I?i5vi- o tJ upAEQ C5 1 SYSTEM ELEVATION Pipe- Woe-T-s - 97 3 'DiST• ~ I'; pis P'PEs_. 5A WD , 3 ~o su QfACE 61LtVA'V o►a ) f 5.8 - is test site NOT APPROVED f r~~ conventional se-PLI lanaton.system. ~e e~p . 'Iovw tN I se- .sF 4r.5- : Ae fs : r E F 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): ~p/~/ti' j~l~I11T7N TESTS WERE COMPLETED ON: ~1llJJ1v1 J1TIE~EVALUATIONS (PERC TEST 2- 3 P ADDRESS: MINNESOTA LICENSE NO. 00663 CERTIFICATION N MBER: PHONE NUMBER optional): SE NO. 55-02482 e3 'O.2 Z" 3~ - d RT. ' p'j11Bji. R.D.# HUDSON, WI 54016 CST SIGNATUR DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - L -w a-ecmnplete and wan w sad test, Yom =".1 my W& T €s use ~'aC.a, rp f Uis OV KghC, r OhO lel VAS IS 0 E:4K..a '.;i. ".d a.OM01 ,.,id; ,.,r,)pe tx ' 3. i".unnbei or 6)# t Ion'w; Q" C'„ rl a¢£..a`{ -3 s i'~t:;?t ap i". WfiSw.. tefi t, F, S.y u r q} vw.ni... B xE 2 E SUITABLE Fw, i A N.>LL 1,K TANK ORILY IF ALL ARE RULED OUT BASH) ON ...3U;1_. COND 3 1 IO NS'; PLEASE w uz of ➢Bhvv;?, aJt eo shown -z., for uc` omg i7!#E. (N CJ£ S{ 1liat lC: r)j and " 'AKE A 'LIE IB F .''."_ar =.t:t,wcltdy k wM y it tat lmabom, € carving Lo scale is [xefe _ J, A e, . g „ o .o 3ia, K ami l . rkM id aiton . . e jai m Hrm clearly sh v, , wKI are peti3ii?fi83 : 3 s hat':` r a6-pine ,E€it:'- box w es u, dxtd€ t ,a., .,x. y,cs plain, .=,3ta, t E„'.,ti [<a t'~Y7 test ;;PYY2}i° , e p (F a.' Yq b ` t. F n a .tw a , 1 hood r ai q WwHw) does i a .S Ali Ia'A-a NA, in th-. 1 _2 nn d dish ot e '„_I SOIL TESTS MUST BE F;3_F'!~ t`.j3 Cii TI E Ot,C.'I',"- i- IT VFsni;='s" o DAYS * C1.M'9€_E a)r°'. SG d o . ? ws at Tasp* vet Ot` a ,rmbois ( t ( [ +1i 37 L. . i .a $wc i",a' - fvl'Aijw~ a n el WK € Loop, o€_! ~ Cis al ,..~~E SWAY 1 Own Luss Than Lww I [A 01m VP BI 0; ~ ~J< Gra"i y 3 0 vv C a Lon; FA foli P~ Coy Low mot May'v- Y My Wh r y ilw~ m ` _ _ l - i _ Lo w0m; Comm A wouOmp - w_ Won Ea t ~~I r3/b9 t.~