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CROIX COUNTY WISCONSIN ZONING OFFICE <r v ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET 0 HUDSON, WI 54016 715 386-4680 EXISTING SEPTIC SYSTEM AFFIDAVIT The existing septic system which serves the dwelling being added on to must be inspected by a licensed soil tester for compliance with high ground water and/or bedrock seperation requirements as set forth in s. ILHR Chapter 83.10(2) WI. ADM. CODE. The results of that inspection must be made available to this office. If the existing septic system meets these minimum requirements, and is properly functioning, an addition may be added to the dwelling without updating that system. This addition must not, however, encroach upon the required septic system setbacks as setforth in s. ILHR Chapter 83.10(1). Property Owner (s)}- Property Mailing Address: LiCtr-t-+rfi ltc!ctC Property Legal Description: LotCSM/Subdivision r _ i~1/4 1/4, Sec., T._.),S_N., R._L&_W., Tn. of ;rloicK,noi I, as the owner of the above described property, hereby affirm that the septic system serving this dwelling meets the above referenced state private sewage system codes. I realize that this addition may cause the existing septic system to become undersized for a dwelling of the resulting size, and I will make this information available to any future parties interested in purchasing this property. Notary Public Subscribed and sworn to before me on this date: Signed: Z Date: My commission expire : County Approval: Date: u nnw s a HOLLY B. HEDBERG NOTARY PUBLIC -MINNESOTA My Comm. Expires Jan. 31, 2000 'o ~.1peeNMMIhN.*vhhshN./rryJ\MMMMMA~NP Verification of soils adjacent to existing system (from 1984). Wisconsin Department of Industry, SOIL AND SITE EVALUATION " of_ Labor and Human Relations Of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. 1 /P r~ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S, C r o percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.; 022' ,1- .84-95rtQ~Q0 I APPLICANT INFORMATION - Please print all information. Reviewed by'';,D IN Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). K Property Owner Property Location George Williams Govt. Lot NE 1/4 SW 1/4,S29 n 18 E(or w~ Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 129 East Quarry RD. CSM Vo1.3,pg. 696 City State Zip Code Phone Number Nearest Road River Falls Wis 54022 715025-5654 ❑ city ❑ Village U Town East Quarry Rd. ❑ New Construction Use: [residential / Number of bedrooms Addition to existing building Yes ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 4 S n gpd Recommended design loading rate ___7 -bed, gpd/ft2-Z_trench, gpd/ft2 Absorption area required 64-2 bed, ft2 !5 6$ trench, ft2 Maximum design loading rate ___7 _bed, gpd/ft2Tg._trench, gpd/ft2 Recommended infiltration surface elevation(s) Fx i i n g s ys; =q1 _ 94 r ft (as referred to site plan benchmark) Additional design/site considerations System is located in code c omp i t~ t: G c) i 1 c Parent material Outwask sands. Flood plain elevation, if applicable N/A ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system [Is 0 U [is ❑ U s❑ U ] S ❑ U Us ❑ U ❑ s U U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0-1 10YR 4/4 LS lm r ds'h as 2 11-15 10YR 2/ LS lmgr_ ds'h cs lvf .7 ;8 Ground Buried "A" orizo elev. 95.64 ft. 3 15-29 10YR3/4 SL lcgr mfr cw .4 .4 .5 Depth to 4 29-103 10YR 5 MEd. S limiting factor > 10'~-in. Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Rema ks: CST Name (Please Print) Signature Telephone No. Robert Ulbricht 715-386-8185 Address Date CST Number 7-14-1996 CSTM2482 E , Pg. 2 of 2 F Scale: 111 0 rr4 F, = Bac p it c- ~ 'R, p'r ~1 I '~".,a.,t•.~''~ 0.i 4" ci Vent. IBS System elev. = 91.54' I I I i 35 I I v Edge of I I 5~ concrete retain. wall. 4"ci pipe on septic t. III B.M.= top ofconcreteI Existing sidewalk below 1st - 3 step. Bedrm. Home Elev.=100.0' Well 0 Parcel 022-1084-95-000 02/08/2006 11:58 AM PAGE 1 OF 1 Alt. Parcel 29.28.18.457C 022 - TOWN OF KINNICKINNIC ST. CROIX COUNTY, WISCONSIN Current X 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 - WILLIAMS, GEORGE E & KATHERINE F GEORGE E & KATHERINE F WILLIAMS 129 QUARRY RD RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ` 129 QUARRY RD SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 7.860 Plat: N/A-NOT AVAILABLE SEC 29 T28N R18W NE SW LOT 1 CSM VOL Block/Condo Bldg: 3/696 ALSO A PARCEL DESCC AS PT OF NE SW & PT OF SE SW COM S1/4 COR SEC 29; TH N Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 00 DEG E 1286.29'-POB; TH N 76 DEG W 29-28N-18W 578.45'; TH S 44 DEG W 130.66'; TH N 66 DEG W 250.79'; TH NLY 32.80'; TH N 90 more... Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1004/389 WD 07/23/1997 870/113 / / / 1 r` 2005 SUMMARY Bill Fair Market Value: Assessed with: 143898 655,800 Valuations: Last Changed: 08/11/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 7.860 90,000 573,100 663,100 NO Totals for 2005: General Property 7.860 90,000 573,100 663,1000 Woodland 0.000 0 Totals for 2004: General Property 7.860 45,000 412,500 457,5000 Woodland 0.000 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 303 Specials: User Special Code Category Amount Special Assessments Special Charges 00 Delinquent Charges 00 Total 0.00 ~ Form- S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER `l~ \i tLls~~~~ TOWNSHIP ttJt~l G SEC. 7Ci T N-R ~i W ADDRESS, ST. CROIX COUNTY, WISCONSIN t SUBDIVISION LOT LOT SIZE LrLF~ PLAN VIEW Distances and dimensions to meet requirements of H 63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW BENCHMARK: Describe the vE,.rtical reference point used Elevation of vertical reference point: Proposed slope at site: -7- ( Gee SEPTIC TA,.NK: K.nufacturer: Liquid Capacity: Number of rings used: Tank manhole cover elevation: _ Tank Inlet 11evation: Tank Outlet Elevation: Numbe c of ft et from nearest Road : Front, Side,0 Rear, 0 feet From r_u,arest property 1_irn(_~ Front, 0Side, 0Rear, 0 _ feet Number of feet fron;: well 70) , building: (Lnclud(I this inlcrmati.on of the ilbovL plot plan)( 2 reference dimensions to septic tank) SF.E REVERSE ST11F R . PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Manufacturer- Pump Size Elevation of inlet: Bottom of tank elevation: Pul,np off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORBTION SYSTEM Bed: X Trench: Width: Length: Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, 0 Side, © Rear, 0 Ft Number of Beet from well: -1--~~ Number of feet from building: Cti (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: I Has either a drop box 0 or distribution box 0 been used on any of the above soil absor.btion 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: Dated: - Plumber on job: License Number : ~_&A ' 3/84:mj DEPART'MEIJTOF INDUSTRY, INSPECTION REPORT FOR LAB!1R & HUMAN RELATIONS SAFETY & BUILDINGS P.O. Box 7969 PRIVATE SEWAGE SYSTEMS DIVISION MADISON, WI 53707 BUREAU OF PLUMBING ®CONVENTIONAL ❑ALTERNATIVE State Plan l.D. Number ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If assigned) NAME OF PERMIT HOLDER. AD RESS OF PERMIT OLDER' - INSPECTION DATE. LC) BENCH MARK IPermanentreferen IV\ ce point) DESCRIBE IF DIFFERENT FROM PLAN. ln~ REF. PT. ELEV. CST REF PT. ELE V.. Name r, Plumber. MP/MPRSW No o County Samtary Perm❑ Number: J~ n 9 SEPTIC TANK/HOLDING TANK: MANUFACTURER LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET E EV WARNING LABEL LOCKIpiGDCOV R,,' P O"'DED . PR i w BEDDING OW©E a ~V,YES ❑NO Ir.~~-EIS ❑ O . VENT fJA. VEN AT L.. HIGH WATER (y3RJ Z ALARM NUMBER OF ROAD PROPERTY WELL BUILDING: E NT TO FRESH AIRINLEr.. _ ❑YES ❑NO FEET FROM NE IV. ❑ YES ❑ NO NEAREST--- _ S DOSING CHAMBER: _ MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL P UMPiSIPH ON MANUFACTURER WARNING LABEL LOCKING COVER ❑YES ONO PROVIDED PROVIDED GALLONS PER CYCLE: PuMPANDCONTROLSOPERATIONAL ❑YES ❑NO ❑YES ❑NO (DIFFERENCE BETWEEN NUMBER OF hEtr;Penrv WELL BUILDING IvENrTO FRESH PUMP ON AND OFF) ❑YES ❑NO FEET FROM Ne AIR INLET. NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing AAq,ETER MATERIAL AND MAHKING 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 D SPACING covrR E DIA pITS LIQUID TRENCHES T' H DIMENSIONS PIT DEPTGRAVEL UEPiri FILL DEPTH J DI$TH. PIPE j . "PIPE DISTR. PIPE MATERIAL. NO. OISTH LOVV PIPES ABOVE COVER ELEV. INLE E END. PR OPERTV WEBUILDING. VENT TO FRESH NUMBER OF y PI PES FEET FROM , LINE { AIR INLET{ ~1 MOUND YSTEM: NEAR Mound site plowed perpendicular to slope Check the texture of the fill material for PROVID A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REV RSE SIDE. SHOW ELEVA- ❑YES NO meets the criteria for medium san TIONS NIEASURED. ❑ SOIL COVER TEXTURE PER NENT MARKERS: OBSERVATION WELLS. f DEPTHOVER -TRENCH BED DEPTH OVFRTHENCH;BED r `~❑YES ❑NO ❑YES ❑NO CENTER DEPTH OF TOPSOIL SODDED EDGES SEEDED MULCHED ❑YES ❑NO DYES DNO ❑YES DNO PRESSURIZED,_DISTRIBUTION SYSTEM: BED/TRENCH LViDTH LE NGTH. NO. OF LATERAL SPACING. GRAVEL DEPTH $E LfW PIPE FILL DEPTH ABOVE COVER TRENCHES DIMENSIONS n.1ANIFOLU PUMP MANIFOLD DISTR PIPE MANIFOLD MATE I NO. DISTR. DISTR. PIP ? DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV ELEV CIA ELEV. PIPES DIA DISTRIBUTION _ INFORMATION H ))LE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLAN. COMMENTS: PERMANENT MARKERS OBSERVATION I--] S❑YES ❑NO WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LI"E' ❑ YES ❑ NO ❑ YES ❑ NO NEAREST- 7 r t- l Sketch System on ` Reverse Side. Rn in county file for audit. SIG NATO R R ' 7 TITLE ~DILHR SBD 6710 (R. 01/82) DE,PARTM,ENT OF APPLIC ON - SAFETY & BUILDINGS INDUSTRY; , , FOR SA A~ DIVISION LABOR AND PER HUMAN RELATIONS (PLB P.O. BOX 7969 0 MADISON, WI 53707 Attach plans for the system on paper not less than 8'/Z x 11 inches in size. Inc lti' I r ` that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. P.roRerty Own Mailing Address: Property Location: City, Village or T nship: ount 1~?rX t/o jGS 1 /T N/R R E (or W" n y Lot Number: Blk No.: Subdivision Name: ,Lake ~ 1 ~ are Road or Lan (,Tarr k: State Plan I. Number: (lf assigned) TYPE OF BUILDING El Public* ❑ Variance* El Other (specify)* Number of Bedrooms: 1 or 2 Family *State Approval Required. n a.- TOTAL NUMBER PREFAB POURED-IN NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY f1 , HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit 4 Qr ZI ~ w Alternative (specify) ❑ Seepage Trench Water Supply: E ner's Name as Listed on Soil Test Report (If other than present owner): Private ❑ Joint El Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. 4me SigaMP/3i dU No.: Phone Number: Address: ("Tt~ )H {i? a i _ Name of Designer: Xp t 1"s M-1 COUNTY/DEPARTMENT USE ONLY Si n ture of Issuing Agent: Fee: Date: r, h p. 1:1 APPROVED Sanitary Permit Number: Reason for Disa V f CX~ ❑ DISAPPROVED Z{ pproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398 (N.03/81) ~!1 J E~1 r f t 1 N. rj~ v E Y, 9 r i r r i i