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Home My WebLink About018-1030-80-200 o m o C 1 3 _ ~ ~ l 1 K O 'S - O CJ1 I O N eD `C • n y N N O A N7 O 'a O O O !D N N h~l d. d d N O CD 3 O N O 0 0 W N OA j r'S Z 00 0 CD CD n a a- C) 0 W N O O O N O O, y N O O O fD a m Cl) D CD I (D ~p CD N Q p V) W CD CD Cl) p tr Z cfl co = n n r !n co 00 cno c A~l rt Fl- 0 N' to rt "WA z4z H O O O 4- cn -1 ~ o p -4 -1 -1 Ul - < w Z N 3 to to N cn o D 'Old CD z CN ~ (n i (D y_ I 'p fD N 3 N O C I o_ N Crl V~ z d rt z co Z 0 ON CD 0 D O n 7 N C ~"WA o Ul ~-3 U) CD U) pp CD N 4 O FT 4;; U) C: CD CD CL cc?7 I E W (D ~o v a 3 -i Vl v (D Z co A z fD c rt n A z p' o C. ~l C N A 0 ~ Cd O r W~ < m h rF 4- a A z a w 0 Ct)C I O CD ~ CA n a ° ° a y 3 CL m cn. ~ a cu 0 0' 3 n= c 3 o z a o CD (n C d y (D ti O o m 'I a- ~ O CD o m ° o n z N CD O d W ~ W i O A O ~ I N A ~ I D~Q ~ EA Q a ti Parcel 018-1030-80-200 10/12/2006 11:08 AM PAGE 1 OF 1 Alt. Parcel 14.29.17.219B-20 018 - TOWN OF HAMMOND Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - GILLIS, JAMES P & ILA C JAMES P & ILA C GILLIS PO BOX 367 HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 907 190TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 6.540 Plat: 4032-CSM 15/4032 FKA 5/1339 018/01 SEC 14 T29N R17W PT SW SW LOT 1 OF CSM Block/Condo Bldg: LOT 3 5/1339 10 AC NKA CSM 15/4032 LOT 3 6.540AC Tract(s): (Sec-Twn-Rng 401/4 1601/4) 14-29N-17W SW SW Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 793/83 07/23/1997 675/201 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/06/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 26,000 96,000 122,000 NO 05 UNDEVELOPED G5 2.540 2,400 0 2,400 NO PRODUCTIVE FORST LANDS G6 2.000 4,000 0 4,000 NO Totals for 2006: General Property 6.540 32,400 96,000 128,400 Woodland 0.000 0 0 Totals for 2005: General Property 6.540 32,400 94,800 127,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I Form - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP 4 M yj (/JVy SEC. T ~7N-R~ZW ADDRESS ST. CROIX COUNTY, WISCO I o ~ cS` cx` SUBDIVISION LOT LO ZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM A I R 2-5 ! (rt jr-,4 N K R d ~Y INDICATE NORTH ARROW C-_ A/ k caG I LIt Pea BENCHMARK: Describe the vertical reference point used lLT_tL4'M j= S`iOr/N A' Elevation of vertical reference point: Proposed slope at site: 5.71 SEPTIC TANK: Manufacturer: 1~ Liquid Capacity: A0 e,e C-,4G Number of rings used: NVNcl, Tank manhole cover elevation: ~Z Q ~T Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front, Side0 Rear, O feet From nearest property line Front, 0Side, 0Rear, 0 feet Number of feet from: well L) , building: Z'J (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER I r Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: ump Size Elevation of inlet: Bottom of tank elevatio . Pump off switch elevation: Gallons cycle: Alarm Manufacturer: 'r itch Type: Number of feet from nearest prop y line: Front, , O Rear, Ft. Number o eet from well: Number ~f feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X Trench: Width: 1.2. Length: VZ Number of Lines: Area Built: C ,r eta Fill depth to top of pipe: ;I Z Number of feet from nearest property line: Front, ICY Side, O Rear,0 17t C7 Number of feet from well: L/ Number of feet from building: Z115- (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit eleva . Area Built: Has either a drop box or distribution been used on any of the above soil absorbtion s (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings ed: Elevation of bottom of to Elevation of inlet: Number of feet from nearest operty lin . Front, O Side, O Rear, O Ft. Number of fee well: Number o eet from buildin Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: lC-` Plumber on job: License Number : JM P'- E- 9'e 3/84:mj = r z O O V) co Cf) C z 0 00 -Tl 00 cm 320 N ~ A 0 m x c~ u < COO* C/) C-1 m ~ cMMq r) n ql% m 4%1* 30 CC) C ® Clio r D 0 Z = Oar ~ D r ~ m o Q m 00 N Z > o 4 C ~ D b x z _ ill n 0 z D cn M 0 C/) z n Oz m 1J/ m s-z m a m a n o N_ o z - D _ s ^ j ok = m ° - o -i 0 o'D °c oQ~ H~ -I 3 s d o A ~ ~ `D 3 and ~D am 3 ~ ~ ~ A all= cu ° ° H CL -Tl -0 o c o d _ o~ to V a c-0 ~ sy.a s O , `n _ o~ s 3 3 < D~ T o m ~ .0 3 ~ cn m m N ° o N 3 Z o ~ co d in N Q D a~m- `m ~foa H m °o N Z m ~ - ti Q m to z CL 0- o C) N D D 1 0 m o 3 m -1 ~ 3 ~ 3 0 ° ~ ~ to GT7 m c D c D 0 3 o' n < ~ m o o ~ -0 H N DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 5370 ' state PlanLDNtttn~et. MCONVENTIONAL r] ALTERNATIVE ,TRANSFER a==IgneBl ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER ADDRESS OF PERMIT HOLDER. INSPECTION DATE Roben Sanfze R. R. Hammond, GJI 54016 - a,5-d',b C7,17yL BENCH MARK (Permanent reference Point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF PT, ELEV SW SW, Section 14, T29N-R17G1, Town, o~ Hammond Name of Plumher. 77569O N~~. Cn~i nay 3riitary Permit Njmtter Gaffe Smith S Cno~ 54920-T SEPTIC TANK/HOLDING TANK: IMANUFACTURER. LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV IWARNING LABEL J LOCKING COVER PROVIDED PROVIDED YES DNO DYES LINO BEDDING: VENT DIA. VENT MATI HIGH WATER FRESH NUMBER OF ROAD PROPERTY W11111-1111 TO An n T FROM1111T AIR INLET YES LINO L_I YES r_] NO EST--- oZ DOSING CHAMBER: IMANUFACTORER BE DD)NG. LIQUID ('APA(:I IV PUMP M(:DEt TP!,^.1 P. SIPH()h, T.~ANUI i\I:IUHEI; WARNING LABEL LOCKING COVER PROVIDED PROVIDED. DYES NO L_ YES LINO DYES LINO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PHOPEHTV WELL BUILDIN(; VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM vE AIR INLET PUMP ON AND OFF) DYES C-NO INEAREST--~ SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing, (ALT[ T I t( 111ATI HIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue) MAIN CONVENTIONAL SYSTEM: WIDTH LEN(;TH N(i Or ISTR PIP' " A(.Iryr ;",E1 I[:L I)IA .PITS LIQUID BED/TRENCH HENCrIF H.AI PIT DEPTH DIMENSIONS - / , GRAVEL DFPT,i FILL DEPTH DISTR PIPE DISTH PlPfr DISTR. PIPE MATERIAL rr_ ISi:11, UMBER OF PHOPERTV WELL BUILDING VENT TO FRESH BELOVIPIP6 ABOVECOVER EIE j~IQNLf r ELEV END S FEET FROM LINE AIR INLET 90 EAREST► MOUND SYSTEM: T Mound site plowed perpendicular to slope Check the texture of the fill material far I 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. I- TIONS MEASURED. DYES LINO , I `SOIL COVER rExTUHE - - PI HN+ANE KT ~M~AHIE HS oHSEl+vnnrTN wE s L_-]YESNO DYES LINO r DFPTH OVER TRENCH BED DEPTH OVE H THENCr1 HFfl ()[PTU (7F T(WSOI, ltli)()I f) JFf DFD MLCHED U CENIER EDGES _ DYES NO EYES LINO DYES LINO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH EFN(,TII NO. OF LATEHALSPACING (;HAVE L I)EPTH HE LI)(N PIP! FILL DEPTH ABOVF COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTH PIPE MANIFOLD MATERIAL NO DISTH DISTH PIPE DISTHIHOTIONPIPE MATERIAL&MARKING ELEV. ELEV. DIA ELEV PIPES DIA ELEVATION AND - DISTRIBUTION 1 INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHECI I V COVER MATEHIAL VERTICAL LIE r COHRESPONDS TO APPROVED PI ',E's DYES LINO DYES LINO COMMENTS: PERMANENT MARKERS OBSERVATION WELLS NUMBER OF PHOPERTV WELL BUILDING FEET FROM LINE DYES I-1 NO L_JYES ,NO NEAREST- - - Sketch System on Retain ounty file for audit. Reverse Side. SI( NATU TITLE DILHR SBD 6710 (R. 01/82) SANITARY PERMIT _ COUNTY DILHR TRANSFER/PX:NEWAL UNIFORM PERMIT # A .a o. mA a.. (PLB 67-T) VO 7" PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERM I/TJ~ISSUANCE DATE: STATE PLAN I.D. NUMBER: PROPERTY LOCATIO CITY: '/a 'a,S/ T °~~f N,R E (o W VI WN OF: Q LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: T ROAD, LAKE OR LANDMARK: PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: PHONE NUMBER: ADDRESS: PHONE NUMBER: ADDRESS: 1, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this property. PLUMBER' IGN/ATURE: PR IOUS PLUMBER'S ME (IF CHANGED): PLUMBER'S ADDRESS: PREVIOUS PLUMBER'S ADDRESS: "Iq .4 MP/MPRSW NUMBER: PHONE NUMBICFf: MP/MPRSW NU BER: PHONE NUMBER: S6 9D ('Ii3) ass ~3~ ~9 ("&5) 68y -jj?J'v SIGNATURE OF ISSUIN GENT: DDIST RIBUTION: Original - County Copy - Bureau of Plumbing f O 4~ Copy -Owner DILHR-SBD-63 9 . 592) Copy - Plumber v r y ao ~ r* r. v o tow D( a' CD c N 3 0 44 o (D :1 l< 0 C, 0 0 ID co o c o w w w C. 3 c~ca 0 o moWa N o? 1 D - a 0~ p ~p 7 tD N w3) co c) 3 o IDi o m CD Oro " fi r a- 0 0 CD ~owot° =3 Err m ~ 0 0 C- =S S. In 0 S-3 6' aL m ° C j. 0_ w Rl T. ~wCD ° oa m ~ to - cD D C)D '10 G) N cQ Q o a (n ° o CD C C 0 w ~ O wr. n w C a ° 05' CL CD cr =1 CD (a 0 (n CD Cl) (n En W 5D :E CD En w 0 Z m ° m m m ~CD0 3CDcSD~C. A o g * f° 0 D En ° wv.o=ra m m v a c w a ? m~_CL CD Cl) jn~ acc~'IE 17 v 3cn0 in'Uww c m m CD C 0 Q. fD 7 m CD CD o OL w m cu = 0 to c n (p D C cn N CL o y Cr c° c f wow w_0awo' fTi - m o d a C ~O a cr cn a, 3, =r (A C < cQ w m C) G7 cp cD cD 3 m 0 a ° Q o cQ CL (n ° 3 c° Q. ? O w fD -i CD c 0 m Q 0 0 _ c a -X c m w Q 3 0 o o° v w d a CD ° ,3 m (n co a ° m pJ 3 r o Z 0 I Smith Plumbing & Heating PHONE (715) 265-4838 • GLENWOOD CITY, WISCONSIN 540',: r1+ i I ~ p J 3 Sep r'C' 134 r SyS ~ M Llev, 71 Rho ~h r0 p s'n 'L t t , *PA ` ENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS HUMAPV RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION . 7969 B UREAU OF PLUMBING IMADISON, WI 53707 IMCONVENTIONAL DALTERNATIVE state Plan LD. Number ' El Holding Tank El In-Ground Pressure ❑ Mound (I( assigned) NAME OF PERMIT HOLDER. :~~A`D~ESS~F PERMIT HOLDER INSPECTION DATEBob Stanke . Hammond, WI BENCH MARK (Permanent reference pomfl DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV. SW SW, Section 14, T29N-R17W, Town of Hammond Name of Plumber. MP/MPRSW N,) Count v Sanitary Permi[ Number. Everett Boldt 4489 St. Croix 54920 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV_ TANK OUTLET ELE V.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES LINO DYES LINO BEDDINGVENT DIA.VENT MATLHIGH WATER NUMBER OF ROADPROPERTY WELLBUILDINGJVENT TO FRESH ALARM FEET FROM LINEAIR INLETYES LINO DYES LINO NEAREST DOSING CHAMBER: MANUFACTURER rBEDDIyNGPUMP MODEL PUMP; SI PI ON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDEDPROVIDEDES LINO DYES LINO DYES LINO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR"LET' PUMP ON AND OFF) DYES LINO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ENUfH DIAMETER MATERIAL AND MARKING, or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH [NO OF DISTR PIPE SPACING COVER NSIUE UTA zPITS LIQUID ENCHES MATERIAL. PIT DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL. NO. DISTR NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH BELOW PIPFS ABOVE COVER ELEV. INLET ELEV. END. PIPES. FEET FROM I LINE. AIR INLET. NEAREST-i 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- D YES LI NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE PERMANENT MARKERS JOBSERVATION WILLS DYES LINO DYES LINO DEPTH OVER TRENCHBED DEPTH OVER TRENCHBED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES DYES LINO EYES DNO DYES NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD PATERIA ODISTJDIS TRPIPE DISTRIBUTION PIPE MATERIAL MARKING ELEVELEVDIA.. ELEVIPES DIAELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY RIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. DYES LINO DYES LINO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE EYES LINO DYES LINO NEAREST- Sketch System on Retain in county file for audit. Reverse Side. STITLE. DILHR SBD 6710 (R. 01/82) wlsmnsln APPLICATION FOR SANITARY PERMIT , 7 DILHR OUNTY - oEPFIFITI"nEnTOF (PLB 67) UNIFORM SANITARY PERMIT # In OUSTRY, LFISOL] 6 HURIRn RELFITIOnS -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS _J / Q v"J ~ i c ~ fJ PROPERTY LOCATION 1/II I GE L..)1/45A1 1/4, S T,2,?, N, R ir/10 (or) W TOWN : /51~-era- LOT ~~N/UMBER BLOCK NUMBER ISUB51VISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED 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. X 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 f~ Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: 7~7~ IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ M 'un In-Ground Pressure Total #of Pr f b. ite Steel Fiberglass Plastic Gallons Tanks C c e C tructed 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): 27 - '-/`X 0 2 Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for i t lation of the private sewage system shown on the attached plans. Name of Plumber (Print): q le : IMP/MPRSW No.: Phone Number: Plumber' ress: Name of Desi ner: L~ Cv~ w C.~.1r S .0 G COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved +i pI' ❑ Owner Given Initial s 7 U y 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 ' r 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. w .Jj J' t V } zl. r 1 t W i Vr 71 V~~ 1 Ol 41 -0 *0 APPLICATION FOR SANITARY PERMIT S'I'C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property / e4e r-st2/ 2L, Location of Property 560 ~4 S"4V 34, Section T N - R 17 W Township Mailing Address Subdivision Name% Lot Number Previous Owner of Property Total Size of Parcel %~J ~./`,r•!. Date Parcel was Created Are all corners and lot lines identifiable? zi~ Yes No Is this property being developed for resale (spec house) ? Yes X No Volume and Page Number 13 3 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 1 (We) eeAti,by that aU statements on this bonm aAe tlcue to the be,st ob my (ou)c) knows edge; that I (we) am ( ahe ) the owneh (s) o4 the pno pen ty des n i.bed in thin in~otunation boAm, by vi4tue ob a wxi anty deed neconded in the Obbice ob the County Reg-isteA o b Deeds alb Document No. .0 7 r- 2-01 ; and that I (we) pnesenWy own the pnoposed slice bon the sewage dizposat system (on I (we) have obtained an easement, to nun with the above d"cA bed ptopeAty, bon the eonstl, ueti,on ob said b ys,tem, and the same has been d4y neeo"ded in the Obb~.ce ob the County Regiz tet ob Deeds, a~ Document No. ,3,? 9-53 i/ ) . SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED Form - S T C 100 Owner of Property P',6e-ee4 Location of Property Z Section ,'P N R W Township /AmM0,-J Mailing Address, W~91nm'i Subdivision Name Lot Number Previous Owner of Property ,t~i✓'a~v Well'z- Total Size of Parcel %CQC Date Parcel Was Created Are all corners identifiable? Yes No Include with this application one of the following. .Certified Survey Map .Deed .Land Contract, or .Other legal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. ~S-3!~ ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an casement, to run with the above described property, for the construction of said system, end the same has been duly recorded in the Office of the County Register of Deeds, as Document No. SIGNATURE OF OWNER SIGNATURE OF CO-OWNER IF APPLICABLE) DATE SIGNED DATE SIGNED DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELAT40NS MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATION:s SECTION: TOWNSHIPtmtwi-efi-At-f','v`: LOT NO. BLK. NO. SUBDIVISION NAME: suw / /a /TI N/R/71(or' ,v ~l ~W COUNTY: OWN 'S/BUYER'S NAME: MAILING ADDRESS: USE DATES OBSERVATIONS MADE p NO.BDRMS.: COMMERCIAL DESCRIPTION: / PROFILE ES RIPTIONS: 1PERCOLATION TESTS: lat R esidence ❑ N Replace . ' ~-L/ f l RATING: S= Site suitable for system U= Site unsuitable for system ' CONVENTIONAL MOUND: IN-GR OUND PRE SS URE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDEDSYSTEM:(op tonal) OS DU ~S ®U -❑S DU ,[:]S au !s CaU___ 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: AIX ( Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- "p` _R -9 ' /,.Zr' 32 & s/ S/ r✓ ✓ ~ O B- 3 19 .ZD~ sc7t ?,7 ° n 5 B- ~5 v B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER 4-Ne C-6 AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- 2 a z„ 20 -3. n P- ,~5 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 9a6 , ) I ) e, 4 C- 'DR AG O N , I TH t , { 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 Vvisconsin 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: 4- 4- /C:50 L ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): Ljt 5 S' S~ b ~"s~ ^ 3 3 7 ST ATURE:Q DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) OVER O/V 4 r :T~ c E Qe Q +n! -t M ~ a by Y fly r 44 Zi# ell ~I ( ( ref o0. ~i a ~ ~ 61"1 woll 00 H U) ` y STC - 105 r r ' Y ti SEPTIC TANK MAINTENANCE AGREEMENT ~ 0 SL. Croix County L4 0 r ti 0 W N E R BUYER ra ROUTE/BOX NUMBER Dire Number CITY/STATF~ amrhd>1& GIP _ 0IS PROPERTY LUCAT I HN : >10 IV Sect ion L' N , ]t l ~ W - - ' Town of. ~armanON St. Croix County, S"ludivisi"n Lot number I Improper use•aud maiutenauco of your septic system could result in itb premature failure to handle waNtes. Proper maintcuauce con- si.sts of pumping out the septic tank every three years or sooner, if needed, by a licensed no pq c tank p_umhcr. What you put into the system can affect the tuneL-ion of. Lhu septic tank as N Lreat- ment stage in the waste disposal system. St. Croix County residents ma-Y be eligible to rcrcivc a yraut for a maximum of 60% of the cost of replacement of a tailing sy:.tVm, which was in operation prior to July 1, 1978. St. Croix Couuty accepted this program in August of 1980, with Cho requirement that owners of all now systcros Agree to keep their systems proporJy maintained. The Property owner agrvcn to submit to St. Croix CouuLy l.ouiuy, a certification form, signed by the owner and by a master plumber, journeyman plumber, restricled plumber or a licensed pumper veri-- tying that (1) the on-site wastewater disposol_ system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic tank fs less than 1/3 lull of sludge and scum. Certification form will be sent approx-fmately 30 days prior_ to three year expiration. ~i 0 I/WE, the undersigned, have, read the above requirements and agree ut to maintain the private sewage disposal system in accordance with r-+ the standards set forth, herein, as set by the Wisconsin Depart- .v ment of Natural Resources. Cerrillication form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiraL Lou date. SIGNED Sr. Croix County Zoning Office P.O. Box 98 llammoad, W1 54015 7l5--7)6-22J9 or 715-425-8363 Sig", date and return Lo above address. Parcel 018-1030-80-100 10/12/2006 11:09 AM PAGE 1 OF 1 Alt. Parcel 14.29.17.219B-10 018 - TOWN OF HAMMOND Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - GILLIS, JAMES P & ILA C JAMES P & ILA C GILLIS PO BOX 367 HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 913 190TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 3.460 Plat: 4032-CSM 15/4032 FKA 5/1339 018/01 SEC 14 T29N R17W PT SW SW LOT 1 OF CSM Block/Condo Bldg: LOT 2 5/1339 10 AC NKA CSM 15/4032 LOT 2 3.460AC Tract(s): (Sec-Twn-Rng 401/4 1601/4) 14-29N-17W SW SW Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 793/83 07/23/1997 675/201 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 06/30/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.460 27,300 13,900 41,200 NO Totals for 2006: General Property 3.460 27,300 13,900 41,200 Woodland 0.000 0 0 Totals for 2005: General Property 3.460 27,300 13,900 41,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 018-1010-00-100 10/12/2006 11:07 AM PAGE 1 OF 1 Alt. Parcel 05.29.17.77B,78B 018 -TOWN OF HAMMOND Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - STANKE, ROBERT L & ANITA L ROBERT L & ANITA L STANKE 1144 170TH ST HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 1144 170TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 20.600 Plat: N/A-NOT AVAILABLE SEC 5 T29N R1 7W PARCEL DESC AS FOLLOWS; Block/Condo Bldg: THE N 557 FT OF THE NE1/4 OF THE SE1/4 AND THE E 285 FT OF THE N 557 FT OF THE Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) NW1/4 OF THE SE1/4 05-29N-17W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 719/577 2006 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 07/13/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 13,000 74,300 87,300 NO AGRICULTURAL G4 11.600 1,400 0 1,400 NO UNDEVELOPED G5 7.000 6,500 0 6,500 NO Totals for 2006: General Property 20.600 20,900 74,300 95,200 Woodland 0.000 0 0 Totals for 2005: General Property 20.600 20,900 74,300 95,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 502 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00