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HomeMy WebLinkAbout022-1056-30-110 n Cl) p n d ~1 o f c d o C (D 3 7 lD ' .a 3 » n Of O N N o O 00 G) I j O N) C) N °C • N O O g 000 y 7 IV N Fti a. z Q W y m 7 90 O 27 cn N = 0 a CD O n 7 a CD 7 O O w O C) C ' CD v °CD n o 0 3 ~ cD p D ,-r 7 N N 'O O O E m p o (n C D C a z , l►~ N y ~J n (n TJ G7 `CD po a = c R R c a C TJ 3 o N (o T1 c G rn rn N Z N O w CC) (D 0~ C -n ic a, TJ o O 0 O rr1 N l~c~Vl 0 N co N w o D m- 3 H ~ ✓ 7 N .'fie ~ 'y0 N ~ M CD cn n > o H k^ N CD 3 d 1~ m 00 CL r r ~ z r~ ° zco z d v O D a m O Q T ti ro CD m ' c CD i co~l ro c m CD 1 7'~ oo w a of Z Z rn a m 7 1 to m o p Z oa j F3- CL 7 (n N m O s m z • 0 3 0 3 m H X (D 'A w ~ O CD o 3 o D 3 N CL N m < a o 0 (D 0 j o CD N N y y. d o y N cc •7"' = O y CD N y G) C v Q O = A 7 O S o `G 7 lJa C) O N. tv O 7 O N 0 q n ` CD 7 D0 A o O ~ yw ti O i Al sa6Je4a;uenbullaa soBje40 leloadS s uawssessV leloadS 1e;o1 ;unowd AJoBa;ea opoa IeloodS Jas :sleloadS 4o;es :a;ea uol;eol;lpaa 0 :;unoa wlelO :IIpejC) Gallo-1 O ue o0 000' LZ 0 000' LZ 09t"9 A:podoJd leaauaE) :900Z JO; sle;ol 0 0 000'0 puelpooM 000' LZ 0 000' LZ 09t"9 A:pedoJd IeJauaE) :90OZ Jo; sle;Ol ON 000' LZ 0 000' LZ 09tr'9 90 a3dOl3A3aNn uoseeM a;e;S le;ol anoJdwl puel saJoy sselO uol;dlJosea 90OZ/80/60 :paBue'43 M-1 :suoilenlEA OOL'ZZ 8 L LU L :y;Inn passassy :onleA;aMJeyll JIe3 II!a Abvwwns 9002 9E£/LE8 L66 L/EZ/LO Q1 Lt,9 Lt,8 90OZ/6Z/Z L adAl 06ed/I0A # 30a a;ea :l(JO;slH IaoJed :sa;ON M8 L-N8Z-0Z (va 09L t'n Ob 6u2l-uM1-oaS) :(s);oeJl LLZ/Z98 OS30 S`d 1301:lVd OX3 aNV 68LZ/8 INSO dNV Z9Z498 OS34 St/ 1302i`dd :Bpla opuoaploola OX3 V BLOEd OX3 3N MS M8L l N8Z1 OZ 03S 318t/llVAV lON-b'/N :field 09t7'9 :saJob :uol;dlJosea IeBal H0310A,k3l-IVAdIHO OOLO dS Sllb'3 a3N:l E68b OS uol;dlJosea #;sla ode jL tiewud = . :(sa)ssejpp`d A:podOJd IeloadS = dS 10O43S = OS :s;owsla ZZ0b9 IM Slld3 2j3M3 99 AMH t,bZ NOS91J I 3Nnr 8 e AcN3f I 3Nnr'8 V A :i 3f 'NOS91J - O jeumo-oo juaimo = o 'jeunp juaiino = p :(s)Jaumo :ssaJppy xe,i, 0 00 adAl;!wJad #;!wJad # uopeoliddd eeiV sales # deyy a;ea leOIJO;sIH a;ea uol;eejo NISNOOSIM ',k1NnOO XI02iO as X ;uaJJna OINNINOINNIN 30 NMOl - ZZO VL0£'8L'8Z'0Z IaoJed IIV L L LOOZ/OE/LO 000-0£-950 VU0 Ialasd Wd t,9:170 Parcel 022-1056-30-110 01/30/2007 04:59 PM PAGE 1 OF 1 Alt. Parcel 20.28.18.307A10 022 - TOWN OF KINNICKINNIC 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 - MAYO, HAROLD J & KATHLEEN M HAROLD J & KATHLEEN M MAYO 240 N HWY 65 RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description ' 240 N HWY 65 SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 2.290 Plat: N/A-NOT AVAILABLE SEC 20 T28N R18W PT SW1/4 NE1/4 LOT 2 Block/Condo Bldg: CSM 8/2189 2.286 ACRES Tract(s): (Sec-Twn-Rng 40 1 /4 160 1/4) 20-28N-18W Notes: Parcel History: Date Doc # Vol/Page Type 12/02/1999 614844 1475/388 WD 10/09/1997 566700 1269/371 WD 07/23/1997 938/62 2006 SUMMARY Bill Fair Market Value: Assessed with: 179119 231,400 Valuations: Last Changed: 08/10/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.290 50,000 163,600 213,600 NO Totals for 2006: General Property 2.290 50,000 163,600 213,600 Woodland 0.000 0 0 Totals for 2005: General Property 2.290 50,000 163,600 213,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 571 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 022-1056-40-000 01/30/2007 04:57 • PAGE 1 OF 1 F 1 Alt. Parcel 20.28.18.3078 022 - TOWN OF KINNICKINNIC 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 - GIBSON, JERRY A & JUNE L JERRY A & JUNE L GIBSON 244 HWY 65 RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 244 HWY 65 SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 1.400 Plat: N/A-NOT AVAILABLE SEC 20 T28N R18W PT SW NE LOT 1 CSM Block/Condo Bldg: 8/2189 1.388 ACRES Tract(s): (Sec-Twn-Rng 401/4 1601/4) 20-28N-18W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 925/244 2006 SUMMARY Bill Fair Market Value: Assessed with: 179121 220,000 Valuations: Last Changed: 08/10/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.400 30,000 173,100 203,100 NO Totals for 2006: General Property 1.400 30,000 173,100 203,100 Woodland 0.000 0 0 Totals for 2005: General Property 1.400 30,000 173,100 203,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 308 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Form -STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER LIB ~d R12 z&I-K- SOA) TOWNSHIP / -/X"Vi [ SEC. 2 D T ZP N-R /P W ADDRESS ' 6- -1~ ST. CROIX COUNTY, WISCONSIN lift /S • T %b L L_ 4V7 4- /~p 2_ 7f 4-0- SUBDIVISION LOT LO.1 SIZE PLAN VIEW Distances and dimensions to meet requirements of ILH.R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM iy C~ 55 n y 60 OEM ~ ~ INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used w oO D i Elevation of vertical reference point: _/O L9'0 Proposed slope at site: SEPTIC TANK: Manufacturer: '~41; _Liquid Capacity: AT" Number of rings used: 41W`Q"'- Tank manhole cover elevation: ` 7,~ Tank Inlet Elevation: / Tank Outlet Elevation: ~w Number of feet from nearest Road: Front,© Side ,0 Rear, O 7-3 feet From nearest property line Front,(DSide,0 Rear, O 6 feet Number of feet from: well ci / building: Q (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufactur Pump Size Elevation of inlet: om of tank elevation: Pump off switch elevation: GaTrc s pe_ cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: X/ Trench: - (3 3 I Width: Z Length: Number of Lines: Z--- Area Built: Y. ~Z Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear,0 A Number of feet from well: ~QQ F74 Number of feet from building: ~Oa F7` (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bo of seepage pit elevation: Area Built: Has either a p box O or distribution box O been used on any of the above soil absorb t sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of et: 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: HOMESITE SEPTIC PLUMBING C0 Inspector: RT. 3 O'NEIL RD., HUDSON, MR 5016 ROBERT ULBRICHT Dated: Plumber on job: WIS. MASTER PLUMBER IC. NO. 3307 M.P.R.S. License Number: 3/84:mj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7964 BUREAU OF PLUMBING MADISON, WI 53707 MCONVENTIONAL ❑ALTERNATIVE State Plan ID. Number (If as g-d ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER. INSPECTION A MU. Lenon.e Gibson R. R. 2, HuctSon, wl 54076 ffy % BENCH MARK (Permanent reference pant) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV. SW NE, Section 20, T28N-R18w, Town o4 Kinni.cFii.nnic Name of Plumber. IMP/MPRSW No_ County Sanitary Perini[ Number. Robert Utbn,%cht 3307 St. Cn.oix 58886 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIOU D CAPACIM T ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCK G C ER P OV ED PRO DED A) Aj /~~D~ YES LINO S LINO BEDDING: VENT DIFy 1 VENT MATL. HIGH WATER NUMBEROF ROAD: JPROPERTY WELL. [WILDING: IVENTTCIFRESH / ALARM. FEET FROM 2 LINE- AIA/ L- ❑YES NO G/- ❑YES LINO NEAREST J V~ DOSING C A BER: MANUFACT ER BEDDING. LIQUID CAPACITY PUMP MODEL JPUMI,SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES LINO ❑YES LINO ❑YES LINO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) ❑YES LINO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE 11-1111,TH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH. LE TNO. OF DISTR PIPE SPACING COVER INSIDE DIA &PITS LIQUID BED/TRENCH ~ IT RENCHES m ERIAL PIT DEPTH DIMENSIONS t ~ GRAVEL DEPTH FILL DEPTH J f)ISTH PIP DISTR PIPE DISTR. PIPE M TERIAL. N R. NUMBER OF PROPERTY WELL. BUILDING. VENT TO FRIES BELOW PIPE ABO ~ECOVER ELEV.( NLEtT ELEV.END PIPE FEET FROM ~LIN~ AI ~ F q2 ? 2 4 Z- NEAREST-► ( 1xi Lti ' 9.Z•S3 7- 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- meets the criteria for medium sand. TIONS MEASURED. ❑YES LINO SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS ❑YES LINO ❑YES LINO I I SEEDED MULCHED. DEPTH OVER TRENCH BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED CENTER EDGES. ❑YES LINO ❑YES LINO ❑YES LINO 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. IDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV. ELEV. DIA. ELEV.' PIPES. DIA.: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED ❑YES LINO ❑YES LINO COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: FN BER OF PROPERTY WELLFROM LINE ❑YES LINO ❑YES LINO REST ~y*~ C) 1 ~z Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE TITLE. DILHR SBD 6710 (R. 01/82) w1scons" APPLICATION FOR SANITARY PERMIT ~ DILHR (PLB 67) COUNTY v T OF I"OUS nOUSTRY,V,L REIO UNIFORM SANITARY PERMIT # R 6 HUMRn RELRTIO J -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS 67.4 S4 V ~/wl . 6 S PROPERTY LOCATION ~i ~i~-Y- S 1/4 N%1/4, S l~ , TIN, R l d E (or) W TOWN OF: LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED ~aa 3 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. 6 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- L1 An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): Private ❑ Joint El Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber Signature: MWMPRSW No. Phone Number: RT. 3 0'N IL RD.; HUDSON, WIS. 54016 ROBERT LBRICHT ?64elt / 4Y 330 I(711 ).~/y- PP Plumber's AfteI 'ASTER PLUMBER LIC. NO. 3307 M.P. . Name of Designer: MINN. INSTALLER & DESIGNER UC. N0.00663 COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: FFee/e: Date: ❑ Disapproved ❑ Owner Given Initial A f V i7~d pproved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.) ; 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. DEPARTMENT OF REPORT ON S01 D SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR'AND , P.O. BOX 7969 HUMAN RELAi'IONS PERCOLATIO E ( 5) MADISON, WI 53707 % (H63.090) & Ch ' 145. LOCATION: SECTION: TOWNSHIP LOT N NO.: SUBDIVISION NAME: sW 1/ 20 /T 29N/Rh? E (or ,l'ti,v1'ck/;V,v1, aF A ~yz ~f - -7' iV v1 COUNTY: OWNER'SISITYSR'S NAME: MAILING ADDR I X3',1 5-l • L ~ri' ~S°o,J 2 u) 4~/s. f 'yo 1.~ USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: ;PER CO/LATIO;~ N TESTS: Residence ? ❑ New Replace O CI 12-2y oc • IL v ~ V ~j / S ffb~W S RATING: S= Site suitable for system U= Site unsuitable for system r S • 5-0135r.#,4 CONVENTIONAL: MOUND: 1111. -GROUND PRESSURE:SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) K]s ❑u ❑ s ❑u as ❑u ❑s au ❑s [A (ov,%cw ov#1 W z2-X5z If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the A„ under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) S .2,57' t/• Q4. v S. ~ • G7 n - Se 2, -13,x. B d D/1H Qw~. Silt • 33' -r+v v C.S. ,2S i %AN SiG t J 9z ' 7/tN l1fvf C ,S 3 cJ11011? . B- (I R'j S y,, N . B 2- o • j yJ' 38 S S S/ . ?3 ' Zt.V ~C SAND Sn TA C ~R B- r '10 B 3 9~~ f(~.D > .75' . o~ s a• S/ 2' d S / nJ 1V PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER IN AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P_ 3. < 2, P~~co.~► 7-0sir /*IV P_ S u Stu- Gil P- 3,7 e- Z < P_ I 50h 7M 4R,45V 00 7- 7R Ce A--' 7(A tA-; &_V 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. J3O 7$ M 6 (d F JU~ll0~ C1/ F T. SYSTEM ELEVATION rJp /~/7~Q4 / R L 30 ~/EV~Tjoa lam' i ErtTly / _ TA,v,I~ - / 7 133 x P, . gS X IP *,4z. RM ,e-11 /iES [ ? t~~/~a uy ° oD io Fr NOd& ° f- This test site APPROVED TAP 6,F Pso D fr. ,off` a conventional septic ystem- s ~~TE HWY ~ 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): HOMESITE SEPTIC PLUMBING CO. TESTS WERE COMPLETED ON: RT. 3 O'NEIL RD., HUDSON, WIS. 54016 CC / 2 - 8 ADDRESS: ROBERT ULBR'e!iT CERTIFICATION NUMBER: PHONE NUMBER (optional): WIS. MASTER PLUMBER LIC. N0.3307 M.P.R.S. 5. S-_ 8~ cr p J - ~i MINN. INSTALLER & DESIGNER I IC NO 00663 CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - r To be a °°o.T?pRe and amuram W lea; yum irep t ~Ywat M~c:K A on use anon M UV OM €b .'i we °,ve wl t; . 9 i"e project; o-f a X E l(., € f€ I--ili'obe r f3` o C; )r?'rnel c 5. t.=C%Tt#, the :i(' ib 'oy rc Rig FH"o A SITE ?C, S,. i -`%B - FOP A ,,,HO `,3 ft(-, TANf< ONLY IF ALL OJAER SYMMS ARE RULED OUT BASED ON SOIL MENTIONS; 6. PLEASE €ne We a bbrev % [I4tit. sI"'! . n hue by oko p)roble, tiii St.,,E € is am! coin pit':in g the plot [ lan; , . i'ii3A3* E A LEGIBLE diaC;Y ira awma2 y k)t.c. kliq b`(wr tat ! :}c:.adons. D dWi €i, .:t, Ss.. dC is ()ruf„r tc;C:~, A. S. W..,=fit e s , , W(F 3.MK and 1P. 4,€....i E nat vi mfe e ce point are clearly shown, and are inimaryint; a,3 .E> rT[ ,a E ,s >ro os as ,.c damn tlz' n € ad f asn, i r... od plain do, , ;'cc k han W exernp- Qwq if apiwop! Me: P..t. H 7. ,a,zr,t Y"t3 n1 Cn"7 lW-€ 3s dot;3(} Mtr°, K.,° al. Unj Cs."S [ A ,`_1O„ 1 i s. P tq8\. Ai the aE;iP, t)j?P"I'c3_t 1a,JX; 11. Sq thu iwori %1.lld Q We y Ora, t. VI i," ,'st ICS M -in yon r,im ier L „a, KyWr: cab n and dt4%4[i3cne as ro,Wroci. AL SOIL -[--,STS BE FILED VAM THE t..=_ , L M)THORi €'t JI I HN 30 F)/v;' a Of C O'kirii L-TCON, eat ,rates and : .dWIt's Other ` },•rra; ok "-)!one RR 13"Amk k.b _ t a.;ltE.- 1 t«,t p SS ,``.T `itE;"1 c' r, So d -'Cj iV - ~ Ti ~..ft er r{ ?c:T Fem. Ca klaa€' s awl i`at k r omt Cr Yg RL1t',t 1 VVCH rr.=d 3 - Sal--', `s K MY Bog BM(xlAI 1 Loony „ n. (Inawr Than no - S -My r Cdr: < Low 1 hm 41 Wt Loan,~ B! ' Q Sol Gy (pay r Q PV ccRHt MT tmasci Minty, numilin (I > . , u t Fowl waun v~€ U,. t i}€~i ? 0 P KM 0 P" MA r 'ste=' n 14 F ,,tM_€ 11 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/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 ~`C Location of Property J ' 14, Section cx 62 , T N - R ~ W Township c-, ; C Mailing Address r `T `z l~s~ h~v - -TIC/ Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable?c Yes No Is this property being developed for resale (spec house) ? Yes x No Volume and Page Number .3 d 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. PROPFRTV OWNER CERTIFICATION I (We) eeAti6 y that aXX statements on thi,6 4onm ate ttue to the best o6 my (out) knowledge; that 1 (we) am (ate) the owner (s) o6 the pnopenty de,6cA bed in this in6on.mat on 4onm, by vi4tue o~ a wa tcanty deed neeoaded in the 064 ice o~ the County Register o6 Deets as Document No. and that I (we) pn.eaentey own the pAoposed site bon the sewage pos system (on 1 (we) have. obtained an easement, to nun with the above desetbed pnopen.ty, 4on the consthuc ion o6 said system, and the same has been duty recorded in the 0~{ ce oj the County RegiateA o4 Deeds, as Document No. ) . 74 SIG ATURE OF OWNER SIGNATURE F CO- WNER (IF APPLICABLE) a / ,Z /o - DATE SIGNED DATE SIGNED 00 PL13 7 ~ ~y PLOT and CR OS5 5Ecrj O N PIANS /23 I ' - p~, p Sa'G TfsT ZOO 03 6' ~Z I ~fa,P 7. ' Uf.PT r ,•s Tor a , s7,47T- h'wy 4;Y I //w ro ST i 10 NEW 1006 //23 •a i s /DD D set Tim 7 4S q PtP011GT- 1,Ai DA 4o ,y N >°i . ~o T ai ~i;v~vlGk/,vvi c 7eOV . S `GNFD W,)~ S ThT-E" 3 O'NEIL RO.: HUDSON: WIS. 54016 ~y ROBERT ULBRICHT WI ,MAST€R PLUM FR W. NO. 3307 M.P.R.S MINN. INSTALLER & DESIGNER LIC. N0. 00663 SCA~~ Zd T~~4 TE C, . Zo Fresh Air Inlets And Observation Pipe so~~ TESTI)ag By HOMESITE TEST'NO - Approved Vent Cap RT.-3, O'WEiL RCS * HUDSON, WIS. '14016 Minimum 12" Above ~ Final Grade Fr". (p. 2 Al V )A M~~' UL "Above Pipe _ 4" Cast Iron -r i o Final Grade Vent Pipe Marsh Hay Or Synthetic Covering min. 2'1 Aggrle Over Pipe Distribution Tee L Pipe 0 0 0 r ( ~P " AggregaPerforated Pipe Below Beneath PipCoupling Terminating At Bottom Of System z H ' a ST C- 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a H OWNER /BUYER: ROUTE/BOX NUMBER ~L c!?G s~0 -Fire Number CITY/STATD ZIPG PROPERTY LOCATION: X7,1114, IV, 1,: 4, Section,~26 T_-fie N, R W, Town of St . Croix County, Subdivision Lot number I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on- site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 I/WE, the undersigned, have read the above requirements and agree Cnn to maintain the private sewage disposal system in accordance with x H 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 16) 1 ZZ 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. • ° n r LA x , x m w ~g rn w ~c c ^'3 O ° a N w m CSD CD 44 00 03 w w chi ~ co-.-.N~~ IS o c ~ , 3 c ip co p cl. z g = m m -«o :03 A CD 0 W o 3 a O- c0 to > > co w o 3°~ o.S.3oCL o ww~ ~~mwm o ~ = wo o :clx. 31 w v, =CZ -a -a 0 co wACDC~.. 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