HomeMy WebLinkAbout024-1001-80-000
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Parcel 024-1001-80-000 01/06/2006 05:10 PM
PAGE 1 OF 1
Alt. Parcel 4.28.17.11A 024 - TOWN OF PLEASANT VALLEY
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
RETIRED AABY/MOLL O - AABY/MOLL, RETIRED
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 1748 CTY RD Z
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 26.760 Plat: 3438-CSM 12/3438
SEC 4 T28N R1 7W PT SW SW FORMERLY LOT 1 Block/Condo Bldg: LOT 5
CSM 11/3090 NKA L$T-a.-CSM 12/3438 NKA
EVERGREEN MEADOWS L6 1 II ,q~/ Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
~iJl im 04-28N-17W SW SW
Notes: Parcel History:
Date Doc # Vol/Page Type
05/13/1998 579038 1323/132 WD
07/23/1997 19.1'
W,
07/23/1997 691/218
07/23/1997 664/54
more.
2005 SUMMARY Bill Fair Market Value: /assessed with:
0
Valuations: Last Changed: 02/03/2000
Description Class Acres Land Improve Total State Reason
Totals for 2005:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2004:
General Property 0.000 0 0 0
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
Form.- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNERr r~/~' TOWNSHIP SEC. 1' N-R W
ADDRESS A, ST, CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63 ly,: ! OI'9% r1988'
Yee
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
,IM~~yRr
m
I ~ z
I I
I
a,
1 r~~ ( INDICATE NORTH ARROW
s
BENCHMARK: Describe the veri-ical reference point used>
Elevation of vertical reference point: ~ Proposed d sl l sit
ope 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, Side,o Rear, O ,CJS feet
From nearest property line Front,0Side,~Rear, 0
feet
Number of feet from: well =`.6 building:
l~
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEF. REVEI~,'& S 11)1`
PUMP CHAMBER
u`'~
Manufacturer: G%JrJ Liquid Capacity:
f r
Pump/Siphon Manufacturer: -Pump Size,
Pump Model:
Elevation of inlet: Bottom of tank elevation: T
Pump off switch elevation: Gallons per cycle: ZZE,,-,?/
Alarm Manufacturer: i/ /gr-n2_ A~ Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, 0 Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORBTION SYSTEM
Bed: Trench
Width: Length: Number of Lines: < Area Built: /i
Fill depth to top of pipe: ".00 XX
Number of feet from nearest property line: Front, Side, O Rear, Ft
`f ✓
Number of feet from well:
i
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: a~ieter:
Liquid depth: Bottom of e age Ppi elevation:
/ C
Area Built:
Has either a drop box O or distributi bo b en ed on any of the above soil
absorbtion sytems? (Check one).
1
HOLDING TANK f
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of Aank:
Elevation of inlet:
Numberyof feet from nearest property li Frontal Side, O Rear, O Ft.
Number of feet from yeehl:
Number of feet from bu ldig
Number of feet from near t road: T
Alarm r.anufacturer:
Inspector:
Dated: Plumber on job: .t~S0/)
License Number: 0 P
3/84:mj
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
❑CONVENTIONAL tXALTERNATIVE StatePlan1D.Number:
❑ Holding Tank ❑ In-Ground Pressure ~ Mound ufa40
8404615
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER'.
INSPECTION ATE.
Gerr Stiff S. St. Paul, MN U S Q
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN O
REF_PT. ELE V.: C TREE . PT. ELEV
SW SW, Section 4, T28N-R17W, Town of Pleasant Valley
Narne of Plumber.
MP/MPRSW No.. County Sanitary Permit Number.
Everett Boldt 4489 St. Croix 54965
SEPTIC TANK/HOLDING TANK:
MANUFACTURER
LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED'.
BEDDING EYES ENO EYES ENO
VENT DIA.: VENT MATL HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING
: JVENTTO FRESH
ALARM FEET FROM LINE: AIR INLET.
EYES LINO DYES ENO NEAREST
DOSING CHAMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUEACTl1HEH
WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED'.
YES ENO OYES ENO EYES ENO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING (DIFFERENCE BETWEEN FEET FROM LINE ~VENTTOFRESH
AIR INLET
PUMP ON AND OFF) EYES ENO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENCTIi- DIAMETEH MATERIAL AND MAHE IN(;
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. ±DI jH NO. OF DISTR PIPE SPACING COVER =P ITS LIQUID
BED/TRENCH TRENCHES IA L* NSIDE DIn
M A T E R
DIMENSIONS PIT DEPTH
GRAVEL DEPTH FILL DEPISTR. PIPE DISTR . PIPE MATERIALP NIO S DIST R NUMBER OF PROPERTY WELL'. BUILDINVENT TO RESH
BELOW PIPES ABOVE COLEV. ENDPE
FEET FROM LINE A'R INLET
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-
EYES ENO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER TEXTURE =R S OBSERVATION WELLS
DEPTHOVER rRENCH BED DEPTH OVER TRENCH BED ENO EYES ENO
CENTER DEPTH OF TOPSOIL SODDED SEEDED MULCHED
EDGES
E NO YES
EYES E ENO EYES NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD =NI1OLD MATERIAL. NODISTRISTRPIPE ISTRIBUTION PIPE MA
ELEVATION AND ELEVELEV.. DIAPIPES. DIA.:
DISTRIBUI ION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
EYES ENO EYES ENO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS'. NUMBER OF PROPERTY WELL: BUILDING.
FEET FROM LINE:
EYES ENO OYES ENO NEAREST
Retain in co(,-'
SIGNATURE.
01-
APPLICATION FOR SANITARY PERMIT
D JLHR COUNTY
°EFKiRTMT(PLB 67)
m°usTav.I-aBOP&-UmanRELF/Ti°ns UNIFORM SANITARY PERMIT #
j 1945
Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8Yzx 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER MAILING ADDRESS
? .1
PROPERTY LOCATION
7[c.' 1 /4_:'rrl /4, S , T,z$ N, R l7 0 (or W TOWLN OF: c'i~r J ✓ r Y'
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED
X 1 or 2 Family Number of Bedrooms.
1 Public (Specify):
THIS PERMIT IS FOR A:
.X] New System ❑ Tank Replacement ❑ Repair
Replacement Soil Absorption System ❑ Revision ❑ Privy
Xj Alternate System ❑ Reconnection
❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed ❑ Seepage Trench Seepage Pit ❑ Holding Tank
_ System-In-Fill C~ In-Ground Pressure Vault Privy ❑ Pit Privy
L- Existing, For Which A Previous Permit Is On File, Permit A issued
i An Existing System That Has Been Inspected And Is Co*Iigr t As Far As bil Conditions.
Total of P'efpb. Site
Gallons I s ankso Crete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump Tank/Siphon Chamber f
Holding Tank capacity
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 4700 /
Lift Pump/Siphon Chanr,t)er 00
/ X
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): WATER SUPPLY:
275 -376 X Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for ins I tion of the private sewage system shown on the attached plans.
Name omber (Print): 9J MP/MPRSW No.: Phone Number:
_02P 414,yt
Plumb dress: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date:
R, ❑ Disapproved
Q (i(~ ❑ Owner Given Initial
J O / Approved Adverse Determination
Reason for Disapproval:
Alternate coursels) of Action Available:
DILHR-SBD 6398 (R. 5182) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
a
Q ~
f
j cry R". ~ ' 'S
Fl,
R I ~ ~1
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AI-
R Form- S T C - 104
oc?. ~~C o AS BUILT SANITARY SYSTEM REPORT
yn I~op 9~ER~,~
O/1~4 TOWNSHIP SEC.
ST. 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
.-cs
~ Y
00
3
800
Pump ?ooi
/vbb q~
j5
l~P //0 NS C
I
4 I
• I I ~ ~
I I~
~ I
INDICATE NORTH ARRO
I I
I
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point
~ COs/ ca;~',~%'<i//r~
• Proposed slope at site:
SEPTIC TANK: Manufacturer:
Liquid Capacity:
Number of rings used:
h C e Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side,O Rear,
000 feet
From nearest property line Front,O Side, G) Rear, O feet
Number of feet from: well
50 '1 building: /S'
(Include this information of the above plot plan)( 2 reference dimensions to st_~ptic t<nnk)
Irv
PUMP CHAMBER
Manufacturer: Liquid Capacity: SP~DA ~ p
Pump Size //7.
Pump Model: Pump/Siphon Manufacturer: llkain42 l'
Elevation of inlet: Bottom of tank elevation:
Gallons per cycle:
Pump off switch elevation:
Alarm Manufacturer: n,r /t Alarm Switch Type: -3a
Number of feet from nearest property line: Front, CSide, 0 Rear, Ft. /9(~)
Number of feet from well: '2 O
Number of feet from building: ' S8
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench: s
X ~
Length: 7 Number of Lines: Area Built:
Width:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side Rear,0 Ft•
Number of feet from well' 75
i
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Number of pits: Diameter:
Size:
Liquid depth: Bottom Vseepage/pit elejb tion:
i ;
Area Built:
ither a drop box or distri utiop bob been used on any of the above soil
Has e O ~ O
absorbtion sytems? (Check one).
HOLDING TANK
Capacity:
Manufacturer:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet: T
' Ft.
O Side O Rear, O
Number of feet from nearest proper ~liie: dnt,
Number of feet frog/well: /
Number of feet f om building
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
J~~~
Plumber on job:
Dated :
License Number:
3/84:mj
~ U
CX,
N
T-
i, c ~
•9 a
o~ a ° I, ` y Div HECENED
of a
13
LF' s°:
.
t.
3 Q`
r
~ i
Page - Of _
Perforated Pipe Detail
A
0
End View
Perforated
End Cap ~\e PVC Pipe
1'e Holes Located On Bottom,
S Are Equally Spaced
S
\ P
* PVC Force Main
/e
PVC
Manifold Pipe \
Distribution \ Alternate Position Of
Pipe Force Main
Last Hole Should 8e
Next To End Cap
End Cap Dist 10(V
Li
'Qticin Pipe L , QZt ~ '?3
Ft.
} R 5.33
J~ r S
X _-?&P Inch Ps
Y yInches
Signed: Hole Diameter Inch
License Number: Lateral / Inch(es)
Manifold Inches
Date: 7 Force Main 7 Inches
# of holes/pipe_8_
Invert Elevation of Laterals/Da.,,17 Ft.
Page Of Straw, Marsh Hay, Or
Synthetic Covering
Distribution Pipe
Medium Sand
HH G
Topsoil
D
3 '
r~
1.
N
dope
Bed Of 2N- 2 Force Main Plowed
re 9 ate From Pump Layer
A99
D
Cross Section Of A Mound System Using E
pEe`' A Bed For The Absorption Area F75
G /,,0
A _ Ft. H
Signed: B Y7 Ft:
License Number: MP I /Q,.S Ft.
Date: 7 o J 7.5 Ft.
K /e?-23Ft.
Alternate Position 11~c F~.
L 67`f<r, Ft.
of ?lv -
Force Main ~ W Ft.
7_ 71
L
J Observation Pipe--.~
A- K
A I~--------------------- -----------------------I
I.---- Force Main
W---..._--- -From Pump
11 A
Distribution Bed Of 2 - 2 %2
Pipe Aggregate
Observation Pipe Permanent Markers
Plan View Of Mound Using A Bed For The Absorption Area
PAGE OF
Amrn~i~d C✓'s PUMP CHAMBER `CROSS SECTION 'AND SPECIFICATIONS "
-VEUT CAP
`"C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
25' ~7ROM DOOR, JUNCTION BOX MANHOLE COVER
WIAJDOW OR FRESH I2°MIU.
A, 1,. TAKE
GRADE
I
~ 'i"MIN
L- 18"MIN.
CONDUIT
18"MIN. \
\
IkIL_ET r PR VIDE`
~ IR HT SEAL I I I
i
j I I
APPROVED JOINT A
W~C.I. PIPE n APPROVED JOINTS
EXTENDING 3' W/C.I. PIPE
ONTO SOLID SOIL ? I ALARM EXTEAIDIAIG 3'
8 I I ONTO SOLID SOIL
. I I
C ► I ON
ELEV. FT. I ' I
J
PUMP-~ - OFFJ
D _
CONCRETE BLOCK
RISER EXIT PERMITTED GtJLy IF TANK MANUFACTURER HAS SUCH APPROVAL
SEPTIC E SPECIFIGATIOI~IS
DOSE
TANKS MAWUFACTURER:
NUMBER OF DOSES: / PER DAJ
TAMK SIZE: ~ GALLONS DOSE VOLUME
ALARM MANUFACTURER: 1QlQr /YI IRICLUDING BACKFLOW: _Ile GALLONS
MODEL NUMBER:
CAPACITIES: A=INCHES ORGALLONS
SWITCH TYPE:
J/ B INCHES OR G A ALLONS
PUMP MANUFACTURER: ~v vYrd C r- INCHES OR
GALLOAJS
MODEL NUMBER: -SIP PC?,q D=-L=-INCHES OR
GALLOAIS
SWITCH TyPE: r CCrrV NOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE GpM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. /0 FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . 2.5
• FEET
-F YO FEET OF FORCE MAIN X ' 001? FJpo FtFRICT1oAJ FACTOR.. ' ? _ FEET
TOTAL DYNAMIC HEAD FEET
J)I 710
IAITERNAL DI NSIOIJS OF TAIJK:
L• EitC,t
z - ;t~t0'I`it ;LIgUID DEPTH
SIGUE LICEMSE NUMBER: M P I'La l
DATE: / l
24 ' .
f A r-) rrl o-1 &J r'S 20
~y
to
~K
w 16
W4;%-
12
.j 8
O '
~ 4
0 16 32 48 64 80 96 112
SOLIDS ._U.S.,GALLONS PER MINUTE
Head-Capacity: SV40 and SVK50 Submersible Residential Sump Pumps
Max. Solids SV40,11/2" & SVK50, 2" Spheres; 4 Pole, 60 Hz.
HANDLING
32
SUBMERSIBLE 28
~ 24 sp
SEW z20 ~ .
AGE
& EFELU ENT o e
PUMPS 4
0 20 40 60 80 100 120 140 160
U.S. GALLONS PER MINUTE
Head-Capacity: SP40A and SP50A Submersible Sump Pumps
HL`i' E~ Max. Sol ids SP40A,11/4" &SP50A,11/2" Spheres;
115 Volts, 60 Hz., 1759 RPM
t
J,
p,e, 1
40
24
Y 2 le 4 4- ' UG L cI -324
2°
-
16
l v tk FvL ED F 12
8
4
x i 4 1 0 20 40 80 90 100 120 140 180
u.1L QALLOW PER MMVM
Heap-Capacity: SK60, SK75 and SK100 Submersible Sewage Pumps
Max. Solids 21, Sphere, 1750 RPM
HYpR.ow M Ic
PUMPS
A Division of Wylain, Inc.
Post ONics Box 327, 419/289 3042 i
H Claremore 8 Sanay Roada, Ashland, Ohlo 44806
In Cemft: WyWn Can*& Lb. We., 180 FAW Dr., Anue~, ClnnMo Le71Ct
PLAN APPROVAL Safety and Buildings Division
L H Bureau of Plumbing
P.O Box 7969
General Plumbing Plans Madison, WI 53707
❑ Private Sewage Plans Telephone: (608)266-3815
OFFICE USE ONLY
'~t/G, ~ Plan identification No.
i
13 4~1 -j
Gallons Per Day
Ile
>Rl~ \ .>1~_ ,11,11 14,~~1 t
PRIORITY PLAN REVIEW ONLY
Plan Review
Petition For Modification
$
Project Name i Project Location - Street No. or Legal Description
County
❑ City ❑ Village Town of:
The plumbing plans and specifications for this project have been reviewed for compliance with applicable code nQquirements. This approval is
based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval
is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the
city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of
plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be
made.
❑ FOR GENERAL PLUMBING PLANS:
This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan
approval must be obtained.
❑ FOR PRIVATE SEWAGE PLANS:
This approval will expire two years from the date approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary
permit expires.
Comments:
By:
James Sargent
Bureau Director
If Questions Plans Approved By: Date Approved: Y~
Contact
cc: OWS ❑ DPS ❑ H&R & Rec. Sari. Section
County ❑ Local PI ❑ Facilities Need Analysis Sec
❑ UW-SSWMP ❑ Plumber ❑ Department of Agricuit
DI1 HR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other
SBD 6678 (R. 08/83) (PIb 100a) (Wis Stats. S. 145.02) STATE OF WISCONSIN DILHR
Detach And Return Upper DIVISION OF SAFETY & BUILDINGS
Portion Of This Form With BUREAU OF PLUMBING
201 E. WASHINGTON AVE. RM 141
Any Return Correspond
$ . P.O. BOX 7969
MADISON, WI 53707
608-266-3615
DATE: PROJECT:
,SW,4.28,-
PLAN ID.
- - - - -DETACH HERE _ - - - -
PROJECT NAME PLAN ID.
This is to acknowledge receipt of your plans and specifications for the above-indicated project.
Preliminary review indicates the required fee is $ Fee Received is $
❑ Plan accepted for review. ❑ Underpayment- Please submit additional fee. Plans will be held in abeyance.
❑ Plans being returned. ❑ Overpayment- Refund forthcoming.
❑ Additional information required. SEE BELOW. ❑ No fee has been remitted. Plans will be held in abeyance.
1. Plan Submission ❑ Soil boring and percolation test data on 115 completed
❑ Additional information shall be submitted in duplicate unless by Certified Soil Tester. (1 copy)
specifically noted. ❑ Petition For Modification signed by county, owner and
❑ Plans not clear, legible or permanent. notarized. (1 copy)
❑ All information submitted shall be signed, dated and sealed or ❑ Complete data relative to anticipated use of building.
stamped in accord with Section ILHR 83.08 (2) (a) Wisconsin ❑ Deed restriction required. (1 copy)
Administrative Code. ❑ Affidavit enclosed. ❑ Condominium declaration. (1 copy)
❑ Plot plan showing location of land parcel (distance from
nearest road intersection, etc.), lot size and all distances from IV. Holding Tanks
private sewage system to buildings, lot lines, well, water- ❑ Holding tank profile showing vent, manhole, alarm,
course, swimming pools, water service piping, all weather ser- and manufacturer if state approved. Complete
vice road, etc. Show benchmark with permanent elevation. construction details if site constructed.
❑ Holding tank agreement signed by owner and local
II. Pressure Distribution Systems (Mound or Inground Pressure) unit of government (sample enclosed).
❑ Application for Use of an Alternative System signed by owner ❑ Reason for installing holding tank. Statement from
and notarized. (1 copy) county or soil boring and percolation test data on
❑ County onsite required. (1 copy) ❑ Design calculations. 115 completed by CST, showing that a soil absorption system
❑ Soil boring and percolation test data on 115 completed by cannot be installed on the land parcel.
Certified Soil Tester. (1 copy) ❑ Affidavit for all-weather service road (enclosed).
❑ Cross section of system. ❑ Pipe lateral layout.
❑ Plan view of system. V. Dosing Information
❑ Verification fo Exception Status Form by county. (1 copy) ❑ Calculations for total dynamic head and gallons
pumped per cycle.
III. Private Sewage Systems ❑ Size, length and depth of force main.
❑ Ground slope with 2' contours in entire area of soil absorption ❑ Detail and model of pump or automatic siphon, including
system extending 25' minimum on all sides. size, pump curves, drawdown, and average flow rate (GPM).
❑ Location of area suitable for replacement system - provide soil ❑ Cross section of dosing tank showing pump(s) or siphon(s).
data.
❑ Construction details of septic, holding or dose tank if site VI. Systems in Fill (Fill must be placed prior to plan submission.)
constructed, or tank manufacturer if state approved. ❑ Total area filled (fill to extend 20' beyond edge
❑ Construction details and cross section of soil absorption of french before side slopes begin.)
system. ❑ Depth and type of fill.
❑ Copy of signed onsite report by county or district staff.
SANITARY PERMIT
ILHR count
, GROUNDWATER SURCHARGE 7"i--_A-~`----
rr.rr.r~ ■,~r sti„v.~.+.a~w~rMwrwnsa~arcrti Sanitary Permit No.
IRS
~L C
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more com-
monly known as the groundwater protection law. This change in statutes was the result of over
years of steady negotiation and public debate. The groundwater bill included the creation of
surcharges (fees) for a number of regulated practices which can effect groundwater. The
surcharge took effect on July 1, 1984. All of the water that is used in your building is returned to
the groundwater through your soil absorption system or the disposal site used by your holding
tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground-
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting. `1,L
Ground Ater
Groundwater Fee:
Slpnat re of Issuing Ayenl Date: Wi coo8in's
buried treasure
DIIHH SLID-7298 (N. 05194) L
H
H
S T C - 105 r
r
SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County z
c7
OWNER/BUYER T -T,::7 if
ROUTE/BOX NUMBER Fire Number
CITY/STATE ZIP
PROPERTY LOCATION: Section T _N R1 7-W,
Town of7St. 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
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
F,
I/WE, the undersigned, have read the above requirements and agree
cn
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 ~CJ
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.
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 L~ L~ <JI J F c 'Ity' ,
Location of Property S '4 J1V ~4, Section , T C N - R W
Township ,45.4 A`7 1AL_1_4-- Y
Mailing Address S. r
Subdivision Name
Lot Number ,J
Previous Owner of Property /H0,Ii4,S /:iA11V5C,y4
Total Size of Parcel 3 fjL.~ S
Date Parcel was Created ctn;K"nvw►1
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes X No
Y
Volume j~ and Page Number
as recorded with the Register of Deeds
~IINCLUDE 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.
arc 'T <r~ L ,3
PROPERTY OWNER CERTIFICATION
I (We) eeAtl y that aU /statemewt/s on ,thi s 4onm aAe tAue to the best o~ my (ouA)
knowtedg e; that I (we) am (cute) the owneA ( s ) o' the p)co peh ty demos anti b ed in this
kn4onmati.on 4otm, by vi tue of a wa"anty deed AeeoAded in the 066ice o~ the
County Regis,teA oA Deects ass Document No. 3 S'Y3 k 2-' ; and that I (we)
ptesentYy own the pnopo/sed /site 6oA the /sewage po/sa.e /sy/stem (o*-1--4we+-fie.
- apt-ned aYr- easement, to nun with the. above deg cAibed pnopvLty, bon the
eo"tAucticon o6 6aid /system, and the /same ha/s been duty Aeconded in the 066ice
-Document No. ) .
16 1
SIGNATURE OF OWNER' SIGNATURE OF CO-OWNER (I APPLICABLE)
T ,i
DATE SIGNED DATE SIGNED
DEPARTMENT OF
INDUSTRY, REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS LABOR AND DIVISION
PERCOLATION TESTS (1151 P.O. BOX 7969
HUMAN RELATIONS \ ) MADISON, WI 53707
(H63.090) & Chapter 145.045)
LOCATION-- SECTION: TOWNS HIP/1b}bW+efpALITj. LOTNO.:BLK.NO.: W SUBDIVISION NAME:
'N/R / 7E (or
COUNTY: OW/NER'S BUYER'S NAME: tt MAILI)NG ADDRESS:
USE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: DATES OBSERVATIONS MADE
Residence ? (PROFILE DESCRIPTIONS: PER OLAT ION TESTS:
New ❑ Replace (I
RATING: S= Site suitable for system U= Site unsuitable for system
E
nNVENTIONAL: : IN-GROUND-PRESSURE: SMENDED SYSTEM:(optional)
, ❑s ou ❑s u as ~u W✓1-:e
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 TOGROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS COLOR, TE
NUMBER pEPTH+Pd EL{E/VATION OBSERVED EST. HIGHEST TO BEDR_)OCK IF OBSERVED (SEE ABBRV. , XTURE, AND DEPTH
ON BACK.)
iL, 'f ,5 .."C is f
7- 1,
2 1-~ 13' c
.1_
B-
6-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE
TEST TIME DROP IN WATER LEVEL-INCHES
NUMBER 441S AFTER SWELLING INTERVAL-MtN. RATE MINUTES
PERI D1 PERIOD2
l 7 PERIOD 3 PER INCH
P
P-
P- u y
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 (/Z, P/
?
t
I
TN
,
r.
I
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): > TESTS WERE COMPLETED ON:
ADDRESS: r--~ CERTIFICATION NUMBER: PHONE NU MBER(optional):
6JN - JU 7 1-
ST TUBE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) - OVER -
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SBD6678 (9/81) (Plb 100a)
Detach And Return Upper STATE OF WISCONSIN DILHR
DIVISION OF SAFETY & BUILDINGS
Portion Of This Form With BUREAU OF PLUMBING
201 E. WASHINGTON AVE. RM 178
Any Return Corresponds P.O. BOX 7969
MADISON, WI 53707
608-266-3815
DATE:
PROJECT.
"))114,28,
}leasan
Mail) Str.--
PLAN ID. #
DETACH HERE -
PROJECT NAME PLAN ID. #
This is to acknowledge receipt of your plans and specifications for the above-indicated project.
Preliminary review indicates the required fee is $ Fee Received is $
❑ Underpayment - Please submit the additional fee. ❑ Overpayment - Refund forthcoming.
❑ Plan accepted for review. ❑ Plans being returned.
❑ No fee has been remitted. Plans submitted with no fees will be ❑ Additional information required. SEE BELOW.
held in abeyance.
1. Plan Submission ❑ Complete data relative to anticipated use of bldg.
❑ Additional information shall be submitted in duplicate un- ❑ 2 copies of PLB 60 enclosed.
less specifically noted. ❑ Deed restriction required (1 copy).
❑ Plans not clear, legible or permanent.
❑ All information submitted shall be signed, dated and sealed
or stamped in accord with Section H 63.08(2) (a) Wisconsin
Administrative Code. ❑ Affidavit enclosed.
❑ Profile of holding tank showing vent, manhole alarm and
II. Pressurize Distribution Systems (Mound or In Ground Pressure) manufacturer if precast. Complete construction details if
site constructed.
❑ Application for use of an alternative system signed by owner ❑ Holding tank agreement signed by owner and local unit of
and notarized. (1 copy)
government (sample enclosed).
❑ County onsite required (1 copy). ❑ Design calculations ❑ Reason for installing holding tank. Soil test or statement
for pressurize distribution. ❑ Soil boring & percolation
test data. from county (1 copy).
❑ Plot plan showing location of holding tank with lateral dist-
❑ Cross section of system. ❑ Pipe lateral layout. ances to an building, wells, water service
El Plan view of system. ❑ Plot plan. any piping, water
course, lot lines, swimming pools, all weather service road,
❑ Verification of Exception Status Form by County. (1 copy) Etc. Provide benchmark with elevation reference point.
III. Private Sewage Disposal Systems V. Lift Pump
❑ Ground slope with 2' contours in entire area of soil absorp
tion system extending 25' on all sides. El Calculations for total lift pump discharge, head and gallons
pumped per cycle.
❑ Elevation of permanent reference point (benchmark).
❑ Size, length & depth of force main.
❑ Location of area suitable for replacement system - provide
soil data. ❑ Detail & model of pump or automatic siphons including
size, pump curves, drawdown and average flow rate GPM.
❑ Plot plan showing lot size and all lateral distances from ❑ Cross section of lift pump tank showing pump(s) or
sewage disposal system to buildings, lot lines, well, water
course, swimming pools, water service piping, Etc. siphon(s).
❑ Construction detail of septic, holding or lift pump tank if
site constructed or tank manufacturer if precast. VI. Systems In Fill (Fill must be placed prior to plan submission)
❑ Construction detail and cross-section of soil absorption ❑ Total area filled (fill to extend 20' beyond edge of trench
system. before side slope begin).
❑ Soil boring and percolation test on 115 completed by cer- ❑ Depth and type of fill.
tified soil tester 0 Copy). ❑ Copy of onsite report by county or district staff.
k
ST. C R O I X COUNTY
WI SC0 N S I N
ZONING OFFICE
h ~ TTY
f (d I
796-2239 (HAMMOND)
y~ 425-8363 (RIVER FALLS)
HAMMOND, WI 54015
July 10, 1984
Di.vi,6ion ob Sabety and Bu.('-edtng
Bureau ob Pkumb.ing
P. 0. Box 7969
Madi,don, Wl 53707
Dean S.ve:
An on site -invutigation bon the GeAaed Stibb pnopeAty toeated in .the.
SW!4 ob the SGW ob Section 4, T28N-R17G1, Town o{ PPea6ant Vaf,0y, St.
Croix County, neveaed su.%tab.2e so.(l(z at a def.>t~ti r~ 30 -<nctw
which b eab onabte high ground wateA. was noted.
Th4,s site Aou. d be, su,itabee bon a mound 6ystcew.
Shoutd you have any, qu"tions, ptease bee. b)tee to contact this obb,ice.
S.ineenety,
Thomas C. Net,s on
Ass ,i~s.tant Zoning Adm,ini3tnaton
TCN: mj
WISCONSIN M PARIMENT OF 1N1)USIRY, LABOR AND HUMAN 10 I.III ION')
DIVISION OF SAFETY R BUILUiNGS, BURVAU 01- PLUMBING
P.O. BOX 7969, MAUISON, WISCONSIN 53101
Verification of Exception Status for an Alternative Private Sewage System
In the County of St. Cnotix
Location Sw 1/4, SW 1/4, Sec. 4 T 28 N, R 17 ~fx4vi~ W
down 0VAhA~)W Pf.I"ant VaTfe.y Street Address
Lot No. Block Subdivision
Landowner's Name: Genaf-d Sti46
The application for this site is for:
W]new construction use.
D replacement system use.
If this is NEW CONSTRUCTION USE, the ;alternative private Sewage system is:
to have one of the first five approvals yudranteed for this year. This is
number of thr,;edpplICdtiron'>. IUti(' one of the fir,,t five,
quota nunTers ssueJ -to you.)
~Xlone of the applications neediml quota numherthe quota number d55iyned to
this application is 59 - 07_. 5 L
Itor one additional homesite on a tariff to be occupied by d p,irent, r:tri ld,
grandchild, sibling, niece, nephew, or first cousin.
11 for an individual lot for which a sdrl itdry pOrniit wds is',[Wd but was Idler
ruled unsuitable due to new or changed soil criteria estdblrshed by the
department.
for an application on fide prior to February I, 1980.
for a lot that meets the criteria for d conventional private sewayc system.
If this is a REPLACEMENT SYSTEM USL, tho alterndt.ive private sewage system is
repIdcing:
fdiling conventional S011 dhSorption ,y,J(,m.
L-1a holding tank that was installed and in use prior to February I, IL)t3U.
a privy that was instd IIed and in use prior to February I, 1980.
If this is a REPLACEMENT SYSTEM USI_ and the lot meets the criteria for a
conventional private sewage system, check here.
I certify that the above information is true and accurate to the bast of nay
knowledge.
Name J-homa~s C. Ne.-won. Signature
-
County Official
Title AS6,&Stavrt Zovuvrg Adm,fnis.thc-ton D,ite Juey 10, 1984
DILNR-SBD-6158 'R 12182)
Location: Township/ 4( 4J~4?~ J4 ~?C
14 Sq 4-] 4 ~T 2~ N/R 17 VWJW Pk'eazant VaUey St. C~LUL.X
street Address: iSubdivision: County:
1,,indowners Name: Mailin Address:
7755 > tmbtey Road
Gc>>ca~d SQL 6 Woodbun-y, MN 55121
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 :3trv
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 of Applicant Date
STATE OF WISCONSIN Subscribed and sworn-to before me
SS.
COUNTY OF This day of 19
Notary Public, State of Wisconsin
D UHR-SBD-6413 (N. 05/81) My Commission Expires: