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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 - BENSON, GERALD & KATHLEEN(LE)TRS GERALD & KATHLEEN(LE)TRS BENSON 651 150TH ST ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 651 150TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE SEC 31 T29N R17W 1 A IN SW NW S 170 FT Block/Condo Bldg: OF W 256.24 FT OF SW NW Tract(s): (Sec-Twn-Rng 401/4 1601/4) 31-29N-17W Notes: Parcel History: Date Doc # Vol/Page Type 09/18/2001 656813 1720/155 QC 09/18/2001 656812 1720/154 QC 2005 SUMMARY Bill Fair Market Value: Assessed with: 90683 107,900 Valuations: Last Changed: 08/24/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 21,000 68,200 89,200 NO Totals for 2005: General Property 1.000 21,000 68,200 89,200 Woodland 0.000 0 0 Totals for 2004: General Property 1.000 21,000 64,800 85,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 206 Specials: User Special Code Category Amount 010-GARBAGE SPECIAL ASSESSMENT 60.00 Special Assessments Special Charges Delinquent Charges Total 60.00 0.00 0.00 Department", I # Labor and Human Relations wlsconsln D' $ n of Safety & Buildings ~ DILHR t!a Bureau of Plumbing OEPRFI,menT ov-..-~. P .O. Box 7969 -InIXJSTRV,LRBOP6NUTRn raELFiT10n5 lam; Ip~'~,9~ Madison, WI 53707 OF,c~'y6 Tel. (608) 266-3815 IN ALL CORRESPONDENCE r--~ Z T REFER TO PLAN ,'7 IDENTIFICATION NO. NAME OF PDAJECT RI ATE SEWAGE ONLY - ❑ GENERAL PLUMBING PLANS ~Q Fee Received: LOCATION Priority Plan eview Only CIT R TOWN COUNT Examination of plumbing plans an specs ica ions or this project has been completed. In accord with Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code, the plumbing plans and specifications are approved contingent upon compliance with the stipulations shown on the plans. Please review your code for the requirements of each code section noted. The licensed plumber responsible for this installation shall keep at the construction site one set of plans bearing the department's stamp of approval. The installer shall also notify the appropriate inspector of when required inspections are to be made. begi-rr. In granting this approval, the Division of Safety and Buildings does not hold itself liable for any defects in plans or specifications, plan omissions or examination oversight, and reserves the right to order changes or additions if necessary. This approval is based on Wisconsin Administrative Code requirements. It shall be necessary to obtain and fulfill the permit requirements of the city, village, township or county in which this installation is to be made. Failure to obtain local permits will automatically void this approval. Sincerely, / For Private Sevvage Systems Only: This approval is valid for two w z years or it will be valid until James Sargit; the expiration date of the initial Bureau Dire or sanitary permit. S RE IE B DATE: 2 v cc: DPS - Owner H & R & Rec. San. Section Local PI Plumber Bur. of Health Fac. & Services G<!= Other DILHR SBD-6099 (R. 05/82) ST. CROI X COUNTY T t ZONING OFFICE 796-2239 (HAMMOND) - 425-8363 (RIVER FALLS) HAMMOND, WI 54015 bebnuoAy 2, 1984 Division o j Safety and Buitd.bng Bureau o j P.bumb.ing P. U. Box 7969 Madison, Wl 53707 Dean sit: An on site investigation done on December 1, 1983 on the Gerabd Benson pnopWy toca,ted at the SW% o6 the NWzl4 o' Section 31, T29N-R17W, Township ob Hammond, St. Creo.ix County, teveafed suitable zoi,fz at a depth o6 28 -inches, below which seasonabte high ground wateA was noted. This -e.%te should be su.itabte bon a mound system. Should you have any questions, ptease beet 6nee to contact this o66.ice. S.ineehek Thomas C. Nebon Ass.i.stant Zoning Adm.inistAatoA TCN: m1 WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING P.O. BOX 7969, MADISON, WISCONSIN 53707 Verification of Exception Status for an Alternative Private Sewage System In the County of St. CILOkx Location SW 1/4, NW 1/4, Sec. 31 T 29 N, R 17 AXX W Town db(QXA0W4A)q Hammond Street Address Lot No. Block Subdivision Landowner's Name: Gecatd Bernsvn The application for this site is for: ❑ new construction use. replacement system use. If this is NEW CONSTRUCTION USE, the alternative private sewage system is: ]to have one of the first five approvals guaranteed for this year. This is number - - of those applications. (Use one of the first five quota num ers i sueato you.) I one of the applications needing a quota number. The quota number assigned to this application is - - -for one additional homesite on a farm to be occupied by a parent, child, grandchild, sibling, niece, nephew, or first cousin. [ Ifor an-individual lot for which a sanitary permit was issued but was later ruled unsuitable due to new or changed soil criteria established by the department. I _Ifor an application on file prior to February 1, 1980. 1_.1for a lot that meets the criteria for a conventional private sewage system. If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is replacing: [XAa failing conventional soil absorption system. La holding tank that was installed and in use prior to February 1, 1980. a privy that was installed and in use prior to February 1, 1980. If this is a REPLACEMENT SYSTEM USE and the lot meets the criteria for a conventional private sewage system, check here.l I certify that the above information is true and accurate to the best of knowledge. Name Thom" C. N ?Json S • ure County Official Title A4,sista.nt Zoning AdministAoufot Date FebtLuany 2, 1984 DILHR-S13D-6158 (R 12182) STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING P.O. BOX 7969 - MADISON, WI, 53707 APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM Location: Towns h i p A'ilbCTC*: SW NW 4 S 31 IT 29 N/R 17 W Hammond St. C"LoiX Street Address: Subdivision: County: Landowners Name: Mailing Address: GeAatd Beeson R. R. 1, RobeAtis, W1 54023 I (We), the undersigned, hereby make application for an alternative system on the above-described premises. I recognize that the above premises are not suited for a conventional private sewage system. If approval is granted, I agree to have the system installed in conformance with the Bureau's approval of plans and specifications. I further understand that an alternative system is more complex in nature than a conventional private sewage system and as such will require detailed inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged with administering county sanitary ordinances and Bureau employes or other authorized persons to have access to the above described premises at any reasonable time for the purpose of inspection the construction of or monitoring of the system. I further agree to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system. I understand that this application does not permit me (the applicant) or my agent (the contractor) to begin installation. If the system is approved, the Bureau will send the applicant a letter of approval which authorizes construction of the alternative system after all necessary permits have been obtained. I agree to give notice to any subsequent buyer that an application for an alternative system has been made and if installed, that the premises are served by an alternative system and further agree to give the buyer a copy of this application. The Bureau accepts this application subject to this understanding and subject to all the conditions and obligations set out in this application. Signature o Applicant Date STATE OF WISCONSIN Subscribed and sworn to before me SS. COUNTY Q~L. This___ ~C./, day of~~,, c , 19. Notary Publi State of u consin My Commission Expires: DILHR-SBD-6413 (N. 05/81) K i~ sr Coop"r/OW.1; ~ti y Z b'°F No 1'5:~eO5-7 TRY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS I TR c DIVISION BOX LABOR a~! NDL,,, PERCOLATION TESTS (115) MADISON WI 7969 (H63.09(1) & Chapter 145.045) LOCATION:A/ SECTION: TOWNSHIP/MUNICIPALITY: LOT NO. BLK. NO.: SUBDIVISION NAME: 5m) ~ '/3 /Tzy N/R 17 E for AMM~.vD SyA// CcQ Go f / a COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: Sf C101X ^~E~FAt L7 !3E'V 50A) Pr. / /sr 5 f 1f a,G'E 'T>f LEI/S . USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 N14- ❑New Replace I T>, f - P3 ZE C. ~P f'3 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-FILL HOLDING TANK: J RECOMMENDED SYSTEM: (optional) ❑S ®U ©S ❑u EIS ©U EIS DU ❑S Du 1t10010o s sT~~'~1 If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-IN"- CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) / D ~~n, 2Z >a i o oe aN -5/- , . s 1,3.1. 51, s 9A1, CoUR,E s B f E~ G,P, Gt ~N SC c~.: fl, al!Yt ~i sriti C 7` 1Y- G /y0fs R T -2.6" 3 I7 ' CAN, eS ~ ','n PP0 CW • Gv,'ii B- Q L f 4, „ D q hn fy/E D SC I B- 2 / / 3. ?j 2.l /oAM, /,O' 9V /oq a~ s ` 41• w fl o --G X. 140 7'5 It 7- 1.3 -G7 'Alz ;rfAl S. y w'OS a/- (3N. B AV 'S q N I.9,y r%VAT£o pJi Y4 ,e ~S. 7 y 3 z , 75- AV s~ P3 ' 13,v. /S . 5- C'10R~ S/ /B-3 f D At- I pal. Yo 'wtiltsL /oos 6 re4$1 t"f SS wr AA 70f 4111 _Ftilf .!WFAcr c5k(/AT/ot Cf AZA,i /tl Fj PERCOLATION TESTS SO/ls TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- I - ~o- 9 5! d' /O P- P- Z t s z, S P- P- Z 21. ]2- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION Fvlir`w °F L,g7LA"/s ?off- S"p ~ E 3 'This test site NOT APPROVED _ for a conventional septic system, _ r . - Sae explanation. , j L i E l t 3 ~ E t z i ~ N 1 E r. F .4rM c1, e i E E 3 t F r E a I, the undersigned, hereby certify that the soil tests reported on this form were made by mein accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): soa vLsRrca- TESTS WERE COMPLETED ON: ADDRESS: HOMESITE TESTING • CERTIFICATION NUMBER: PHONE NUMBER (optional): RT. 1, O'NEIL ROAD 2- ;,~p CST SIGNATUR : NELSON, WIS. 54016 f~t--c lQj rc It ( - DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - i icaad I u+. `3iA:xi?M tiPt z>' 5 n ads ..si', i'dtl, €,<[,St~>~.', ~'2e ~ _s sC: I£?x~~t 4,r-?ts$~i . " . .f;, :£s-x s.)LV (i;' t,"v`3`t, f, e de "">1 t 1ilL CIS and co 1 ltll '4 tot, plot p1w 6 ° PLEAS' A y 7-..: Yt<„ .;.£L3Ci{7s to ;C;3:' §3Cf'€C: YI:,£t. R, a t'd +v r''c"'_ a dct 'H% ,`1C "%m' and at'r ,r ,i p erco f"-mc- sh.l` ~,sa r?E .s s. c , h e s,... C~, ei, v<x c,£i e„S 11.3= cs, `x:71' trstist%:3 G, S, ur~l r+ , 3 9 r, . S" p z•s~t S f s3 y > ts,+ i c e e ii y of - E~iii~V. =i.x ? M0 _t s.u5T111, .'I IYl;-y tt'ai's i ;'i, 7 :'i . L?i p 5;~~ k~~•i2.k~~%G'Y..~ ,u+sz4M,~Alivkp]64 "REPORT ON SOIL SORIN&S ~ PERCOLATION TE5T5 1 IS Paor PLAN PROTEC i D. DATE ~y~~.3/ rl ~V 17w ; HOMESITE TESTING CO. RT.3, O'NEIL ROAD BOB ULL"RIci, AUDSON, WIS. 54016 C5T SS- 02 YfZ ~ z PROPOSED MOVSE Misr LIE ZS' F-r. at 4str "oM ALi- TEST ^fz-.4 PRo poSE o wee M vsr we So Fr. 164 iyoRE F~fOm i LI- TEST AAC.45. • = eiQG~',fj~oE Plr3 N~ = EXisT~,~1 Cr I~EGL y X e Aeve_ #ANp o4o9,r PE0 ok 54-tweL /3owris p ~PE'iAr)e AM4r poiOr 4~~ r who, ~P sw~~~ of r ` ffo iZ . B ,E r%cAL m _ ~ VR sue/ of 1,10,.-f E--, ~lr~vs~ ~-'r r TS ('aA1c,. ' r"~aN.Of`,°:d~ra ;~'r•~.,,~ Po/r-- (,,,~.~.r to LEGEND 0, 0 f-T p,v~~ Q gc, f ' -7A 's aM p f ~ ' o ~T R y1QQ 4 n3 ' L a ~ ofoqrp ' o ' P, f tV~,S doT L/.J it X1"1 f r. , s /r lN~ rR . lESj COAIb/~iot/5 ~Un~N y ? roc .Vo SAFETY & BUILDINGS RTMENTOF REPORT ON SOIL BORINGS AND INDUSTRY, C DIVISION P.O. BOX 76 i LABOR AND PERCOLATION TESTS (115) MADISO N WI 3707 HUMAN RELATIONS (H63.090) & Chapter 145.045) LOCATI ' :A/ SECTION: fiOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: Sub / / 3 /T zp N/R 17 E COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: e6l I3E_ A S e) ti/ ,Pl" / 1sT 5 t . 'o,l3 iF'FS GV /S . USE DATES OBSERVATIONS MADE NO. BEI : COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS : PERCOLATI f~TESTS: Replace J.C)E ~p ^ P3 IR P-3 WResidence 3 A/ ❑ New S cc-o Shaws ,9 ZIP~,Ne c/ RATING: S= Site suitable for system U= Site unsuitable for system 1 ONVENTIONAL: MOUND: IN-GROUND PRESSURE: ISEIS YSTEM-IN-FILL OLDING TANK: RECOMMENDED SYSTEM:(optional) J ®❑S ®U DU ❑S ZUIMoyAjo ~ysr M If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the } under s.1-163.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL P H UWATER IN F CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE„ AND DEPTH NUMBER DEPTH ELEVATION OBSERV D EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) t3 / t4) lye"3 A 3v, / v, e.5 V ~ ~ B- L / c, 1 pV S~ s ! ! b 3 0 41, ~OAM ~i l~ AO -4 ltfa fy/tD 10,1.4 ".5" Lf• 110 1444, : r3 Q~ B- 7, J 9 3.3 !s w ff a _ G 'Mots f r . 1 ' G7 ' vE A, s - J /7 r T f/KC 14,4 .5 q,`7 D, 1f9H,;V4Tr0 Oji Y4 Y v &WDs 4' ~1) 73.. L1Cf 130 s/, P3 Ij v /s, S tt !3a , . 9r B- 3 7o 93, 2, hff= Z/Q P W_, L 0' Ill , CR,41 .evtf- SS r.~i,~ ~►+e«.y f a;~le ok-6 i*~rats . B- _ SaPFACE ~/EUhrlmx of iA) /Cl'. PERCOLATION TESTS Soi/~ Porr `rG~E~/FP 3w.!5 F3 TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P R PER INCH 51 - P- 1 17-11 P- p_ Z 9 lp _5- 2 P- 1 9 . 7z / ~3 / Z , P- 3 7/2, 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. c/,-i/%) TIOV Of- P"STu,PE a- SYSTEM ELEVATION / /w' t !/,Cle 56 4 /fi F , i i This test site NOT APPROVED for a canventl ional ceptico cyst See explanation. .w TN T Q ) . t I ~ r t 1, 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 Cade, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. WM, 00 tilt Tr A r . bbkk"; ffQj4S$jjrj 7'6STING CQ. t~ t I ~,.I l~ l talr+a t~ ► U ~jui Irl► ~ Si"durM HUDSON, WIS. saoab _ 5' 115- REPORT ON SOIL BORiN&S PERCOLATION TESTS IIS Poor PLAN PRoTEC i t'. D. y Al 17 av NOMESITE TESTING CO. ' AT.3, O'NEIL ROAD BOB AUDSON, WIS. 5,4016 es 02 y,02. } PROPOSED HOV5E mosr LIE 25- Fr• pR metr F~POM ALL TEfT oioeE.45. PIZo PosE D WELL M Vsr LIE 5Q FT O~ I~1DiPF FiP0.~1 ALG TEST ~,PE~S, • = ©AcellbC PiTf O = EXiST~.tI lC1EGL - f X = /pE~G ~o~G'A1'ioN/f , 1~A,11~ f}tl9EQE0 o,Q S~G!!EL ~G~ES Po 1A) r wA,~ y i ~o,~i . BHA V~,?fic~~ ,QEFERtwcE- Po~'ar' LEGEND r e/EV,trOw o~c !/E~l. APE` Pr f o, r r f'at~ POWER -7,4 INA I : P v U~p f GO Pr r 13-M3. fer+cc Se,) "K e a: ' t1 ~.s .SCR l~' l y0 3 Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~1a~rn TOWNSHIP fYcpivrvm~4~~ SEC. TAN-R._ ADDRESS CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM b 7T, 7 INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side,o Rear, 0 feet From nearest property line : Front,0 Side,0 Rear, O feet Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: c- tit Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: 1;" Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: 7 Q ` Length: Number of Lines: Area Built:i Fill depth to top of pipe: Number of feet from near property fine: ~Fron`t",-A O Side, O Rear, 0 Ft. umber of feet from well: Number of feet from building: 75- _3,7~ (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: U~ U'tN~i i-c~~Z Dated: Plumber on job: 5 c~ g License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR.& HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADIS,nN, WI 53707 ['CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number • Ilr aeslgnedl ❑ Holding Tank ❑ In-Ground Pressure O Mound NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE. Gerald Benson R. R. 1, Hammond, Wl 54015 _ V<- 7-4-3 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PL ELEV. SW NW, Section 31, T29N-R17W, Town of Hammond Name of Pl um ber. IMP/MPRSW No.. County Sanitary Permit Number. Henry Nechville 3258 St. Croix 58922 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CA C7TV: 17LET ELE V.. PROVIDED OUTLET ELEV.. WARNING LABEL LOCKING COVER . PROVIDED. DYES ONO OYES ONO BEDDING. VENT DIA.. JVHI H A Irl ER OF ROA DPROPERTY WELLBUILDINGVENT TO FRESH M ROM LINE AIR INLET DYES NO YES ❑ EST 31110 DOSING CHAMBER: MANUFACTURER 7IN G LIQUID CAPA, I PUMP MODELJPUMP/SIPHON MANUFACTURERWARNING LABEL LOCKING COVER PROVIDEDPROVIDEDYES ONO EYES ONO EYES ONO GALLONS PER CYCLE: PU MP AND CONTROLS OPERATIONAL NUMBER PROPERTY WELL BUILDING. I(DIFFERENCE BETWEEN FEET FROLINE AIR INLET. PUMP ON AND OFF) DYES ONO NSOI L ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH 1111AMITIH MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: __j__ WIDTH. LENGTH NO. OF DISTR. PIPE SPACING. COVER INSIDE DIA OF +8 _ LIQUID BED/TRENCH TRENCHES. M IEH IACA PIT DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR PIPE DISTR. PIPE MATERIAL. NO. STR. NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRESH BELOW PIPES / ABOVE 0 EH ELEV INLET EL v.END. PIPE FEET FROM LINE ~JC AIR INLET. NEAREST-► MOUND SYSTEM: Z 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- D meets the criteria for medium sand. TIONS MEASURED. YES ONO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS DYES ONO DYES ONO DEPTH OVER TRENCH'BED DEPTH OVER TRENCH'BED DEPTH OFTOPSOIL SODDED SEEDED MULCHED CENTER EDGES. DYES ONO DYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEVATION AND ELEV. ELEV.. DIA. ELEV.. PIPES. DIA. DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS DYES ONO DYES ONO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE 1 OYES ONO DYES ONO INEARIPST---1li t 1 % I Sketch System on R tain in county file for audit. Reverse Side. SIGNA TITLE i DILHR SBD 6710 (R.01/82) -•WISCDnSIri APPLICATION FOR SANITARY PERMIT COUNTY DILHR WPMNMMM~ DEPRRTT',IEDT OF (PLB 67) UNIFORM SANITARY PERMIT # IrIOUSTRY, LABOR G HUMRn RELRTIOnS Sl' 9 a ~ -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: VILLAGE: ' 1 /4 NW1 /4, S 2, , T„~f, N, R E (or V11 t N o r,, Jl ' -P LOT NUMBE BLOCyK NUMBER SUBDIVIS ON NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED Z 0l~- 1~~0~ v lU "QOQ 1 or 2 Family Number of Bedrooms: ? Publ, (Specify): 's THIS PERMIT IS FOR A: ❑l N,.e~~ System ❑ Tank Replacement ❑ Repair LAS Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. eepaye 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 "I"'i /'r. 41 IF r Lift Pump Tank/Siphon Chamber t ! w Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure A I -Rota #of Prefab. Site Tanks Concrete Constructed Steel Fiberglass Plastic Ilons I Septic Tank Capacity Lift Pump/Siphon Chamber F 40 or Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): t f 4^."~. E/♦ i9 /ud.:",I .P ~S C1'rivate i❑ Joint L:1 Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Nam of Plumber. (Print): Si nature: r g 4 MP/ PRSW o.: Phone Number: ~l/ 5 Plumber's A dress. ~ d Name of Designer: la/ ~"y A' tr ,.;fF p o f / r COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved /~2c ~j * l '4 L~ Owner Given Initial t-C ~~`~v 1~""~ Approved r 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 systenn, TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractAr,("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 ---el -Z-4 Location of Properfy !5L k P/v" k, Section, T N- R T W Township ( 2.497..-,. Mailing Address fs Subdivision Name Lot Number ' Previous Owner of Property i-ec,, 4 - k- Total Size of Parcel A! 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. 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 1 (We) eeAti,6y that aU 6-tatement6 on .this 6olun aAe -thue to the befit o6 my (ouA) knowledge; that I (we) am ( ahe ) the owneh (6) o A the pAopen ty de,6 cAibed in -this in6o4mati.on 6onm, by v.cJt ue o6 a wa4Aanty deed neeonded in the 066ice o6 the County Regiz teA o4 Deeds as Document No. 3573C,4/ ; and that I (we) pnesente.y own the ptopo6ed site 6oh the 6ewage dizpozat byb,tem (on. I (we) have obtained an easement, to nun with the above desn bed pnopenty, bo4 the eonstAueti,on o6 6aid 6 y.6 tem, and the Game had been duty neeonded in the 066ice o6 the County Reg.is.ten o6 Deeds, ab Document No. 3~'7-7&S ) . L C,4 SIGNATURE OF OWNER SIGNATU .tE OF CO-OWNER (IF APPLICABLE) 4Z zZ DATE SIGNED DATE SIGNED H t H a STC - 105 r r a ti SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County z d OWNER/BUYER /~`~iea~Yf~i~v1 ROUTE/BOX NUMBER Fire Number ZIP "2, CITY/STATEj' PROPERTY LOCATION: scc= r~~ 4, Section-?/' T N, R W, Town 0 fSt. 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. H 0 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- b 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. S I G N E D a, r" 1 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 x m x ~ m v v> w ~ c c n~4i * m a CD ~ co n 0 CAD ? O _ 3 c co ca o to p ' CD -0 a CD N p A H cn D O CD U) CD N Oa ~ p A p cD (D =(D A N O n 0 w auwi T. C, ~ wv p o D = co " - CD ? O p A CD n COD m ago O W O cO > j o w ~ O > O c o c 3 o nA r ~.ZS cl< Qz j O O p M CD w Cn - (D n O 37 (D D w A CD C~ A < CD U) CT co a O v cn o y c G O A 4= P~ A A O c =r p~~ " O CD n O :E ~3 w CL (D 0 CD C- M lam p to (D v s w twn C ~Im can -i U w w CD Z A co w cn Z) CD CD CD w A CD CL CD A 3 CD CD -.0. D ID U) cc U) C, C CD ° A M --v n ~ ITw so p w n9 =r c w _ ~ Q N (D tD y A>> w 3 m o &V 14 =r cl. co Ch w F C m CD C CD c CD cn m cn' n 00-Cc wvCQ- m _ o p ~ - ~ ca ~ ~ O % 7 CD N CA 3 0. noF ccCCCF L7 w O w CD Cl. p n j o CA CL m me ,yo mm~3 rn n CD A C to 7 O O A w p G nw p p 0(a w , CD -1 CD C fD m n c .g CL C 3 o o o 1 w a- C-1 CD o CO Z ~ O N Q DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDU9~TRY, DIVISION L,APOR BOX H,U AN REDLATIONS PERCOLATION TESTS (115) MADISON WI 53707 - Al (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIPhFH2fPAt4SY: LOT NO.: BILK. NO.: SUBDIVISION NAME: Sw '/a '/a 3 /T i f N/R E l: or) W ,41 /'16F AJ D 7 0,,c / t ~9 ~1.~-~-Q COUNT OWNER'Sf9til'ER'S NAME: MAILING ADDRESS: S Gtoi G&/ A Lv &VIO A) /~r4M.yO 01, 1 6C21if USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PE CDILATION TEST JK Residence V N ❑ New Replace t4ur _ 3 _ t) RATING: S= Site suitable for system U= Site unsuitable for system l~ 0 ~/Ew E T r c, su n S 7-e/VVV^"`T T CONVENTIONAL: MOUND: IN-GROUNDPRESSURE:'SY STEM-IN-FILL FOLDING TANK: RECOMMENDED SYSTEM: (optional) S ❑u © s ❑u s ❑u a s [Ku ❑ s au If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS 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.) i B- 1> np ' 13A) . CS ;ngv 0'r- 2 S, B-3 30 JO - 6 N . /s -2 '*o~ - B TAN a CS lriP B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN L AFTERSWELLING INTERVAL-MIN. PERIODI PERIOD2 PERIOD3 PERINCH P_ A2 P- 2 7-x T- P- L L L P- C 4A(,e-7 R v F i~ P- UE S S 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. ^ ^ FrcAwl q .4) - ~DI O Fr SYSTEM ELEVATION 130 TTo-ti ig lo~uf~J r._ TniS test site AP PROVE - l~Ir° for a convcIntional - ' - septic systeis LO'r U1,JF1 yz ~a /VOTE ~ gRE`r¢ i A~~,~v~•c ~o~ ~1~oRs ~g ~ r o l vf~er ~Ef is yl Xi,nS,TinnQH ,off, co~c~tfe- /~~a Ifs` AT 410AOT• /~orQZ _aM newc,. )PO /,C " = 0 r r Wall ST r~ ~~/~~©v v ~a sG~9/e- f u~ 30 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. NAMEj~}t~, TESTS WERE COMPLETED ON: ADDR CERTIFICATION NUMBER: PHONE NUMBER (optional): STATE APPROVED SITE EVALUATIONS (PERC TftM ~,-f _ 0. P 71 T WISCONSIN LICENSE NO. 55-0244 SIGNATURE: DISTR + m ocal Authority,. pgkj+' 40ji"ilil" DILHR-SBD-6395 (R. 02/82) - OVER -