Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
030-1082-95-000 (2)
. . . • AS BUILT SANITARY SYSTEM REPORT OWNER Dom 4/pbs-fre_o 04 TowNskup,sis • f.'s* sEc .?..7 J.3d_N_Rm_w ADDRESS jet , 42— ST . CROIX COUNTY , WISCONSIN . _ SUBDIVISION 4-ux g 1 fq, c LOT 44 LOT SIZE 20 /lUZC.S PLAN VIEW Distances and dimensions tO meet requirements of H63 Fdli) _EVEHYTHING. WITHIN 100 FEET OF SYSTEM Ma Ill 111 11111 IIIIIMMIRMINEMPItill Ina 1 Ile ME AN1111111111.1.11111.11Millihnia CUM" 10111111 IW II riiilistilm.....amm moi.,„,„„ ............ Nrmrasrmefirzmmomiamrzhv•-•-•••-•-•"--- I- in muintamerammiimmiiiiiiiii umme......mmummmainmumo INIS II ''''1 I I Am isolitrisiiii Nour \;, IIIIIIIIIIMIIIFUIIIII1MllrtIMIMIIMIMIMMMIWMINMIIIIIIIII - 1111111111111111111111111111111111111111111111MININIMINI ili Elmininim n inim 111111111111111111111111111111111111111111111111111MINIMMININ II 111111111111111111•11111111111111111111111111111 I di ate o th Arrow 1 1 . SC 11 : ,I r .- ----1-a/747 1 . ) ---k- BENCHMARK: (Permanent reference Point) L r Describe : 6/1., Ii/lA : AYF f)-1- 45 . ICE1)", 6‹E i',L.: .5-i-v.c ep..,c.:e Elevation of vertical reference point : loo,00 firf34.431qPe at site : SEPTIC TANK: Manufacturer : LUZtt S 2"CIS Liquid Capacity : /COQ CA/ion) Number of ringa on cover : Tarik7Mannole cover elevation . Tank Inlet Elevation: Tank Outlet Elevation . PUMP CHAMBER Manufacturer : Number of gallons Number of gal . pump set for a cycle gallons ; total capacily of- distribution lines gallon : size of pump head , gallon per minute , horsepower , brand name 01 pump and model number Type of warning aevice HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover-- Type, of warning device , SEEPAGE PIT SIZE . Number of pits Feet diametL.1 teeL liquid diiptL-- — seepage pit inlet pipe-elevatton t,ottom of seepage ptt elevatIon feet / IL,Ii' L hi D SIZE: number (it tinett 3 width a ' length tLic depth Lt-Ai.:,L TRENCH . width length HJEJA)LATION KATE AL _ AREA kEQUMED 6/5- AREA AS BUILT 630 1NSPECTO LA ' PLUMiWK LACLNI. 4Li ,J. • �. 6.`a G•� 'Qr to\ 4 Z 0 • 3 a O cij 3 2 �0 oG. ® g 0 Arno Q N ! I 0 I („) I 1� I X I I 1 W I 1 66`31 N ti o N89° 38' 20" W 747. 69' 66,0 ---__POINT OF BEGINNING w '0 w Q jj tv Oa Il) N ro ( N o Z O M a O cr • a. • S8.°5. ' 38" E -0 R• \ L 0= E CO \�A • tD \ CD \\ % u) M \� O N PARCEL 8 S E 1 V 20.01 ACRES ± 871 , 738 S. F. ± wcr N N M 0 0 M Z N (Ni ti 4. DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS 9-(Qs., DIVISION P.O.BOX 7969 ;,� BUREAU OF PLUMBING MADISON,WI 53707 �„` CONVENTIONAL ❑ALTERNATIVE •�V State Plan I.D.Number: (If assigned) Holding Tank ❑ In-Ground Pressure ❑Mound 7IErefernn:ePtIDERIBEIFDIFFERENT ADDRESS OF PERMIT HOLDER: � INSPECTION DATEMARK(Perm en FROM PLAN REF.PT.ELEV.: CST REF.PT.ELEV A(e NG6 . a 9 Name of Plumber MP/MPR N County: Sanitary Permit Number: � NK:( gl a -SEPTIC Tr A/H• DMANUFA R LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV. RVyARNING LABEL LOCKING;0V' I (� I4ROV ED: PROVID jlrit i\ l ° (it'll_•_ 1 c•0 J��( 7'ES ❑NO � . NO BEDDING: VENT DIA.:. /) VENT MAIL///-),� HIGH W T R NUMBER OF ROAD: PROPERTY WELL• �• BUILD NG: VENT T FRESH ` ,/� ALARM FEET FROM- /T/1 LINE• _ 5 s �A36 E OYES ONO A%L ❑ r/L�/ O NEAREST y- l/ !/V DOSING CHAMBER: MANUFACTURER. BEDDING: LIQUID CAPACITY PUMP MODEL. PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑YES ❑NO OYES ONO OYES ENO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY 'WELL 'BUILDING. VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) OYES ❑NO NEAREST-0► SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LEN(;IH 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: WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA #PITS LIQUID BED/TRENCH TRENCHES �� NA FRIAL• PIT DEPTH: DIMENSIONS t j�j S-7 r _�/L: _�( GRAVEL DE I'TIi SILL DEPTH UISTH.PIPE (DISTR.PIPE (DISTR.PIPE MATERIAL: NO. Tw. NUMBER OF 1PROPERTY WELL: BUILDING. VENT TO FRESH III LOW PET' ABO�� ••ER- ELE ZNL11 9.1()) Z?27 PIPES FEET FROM LI f / [ AIR INLET: 1/Y{Y1 Li ��-]]7/7/ ((�``..3 L/.. NEAR EST--s► -E (//_57 / _ MOUND SYSTEM: 1 a-$Z to .51 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. OYES ONO SOIL COVER'TEXTURE - PERMANENT MARKERS OBSERVATION WELLS OYES ❑NO OYES ONO DEPTH OVER TRENCHBED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED. CENTER EDGES. OYES ENO ❑YES ❑NO OYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH. NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER. BED/TRENCH TRENCHES: DIMENSIONS `.MANIFOLD PUMP MANIFOLD DISTR PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING: ELEV.: ELEV. DIA. ELEV. PIPES. DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATIONPLANS OYES ONO OYES ❑NO COMMENTS: (PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: I` FEET FROM LINE: o el 3 1 OYES ❑NO OYES ❑NO NEAREST ----)No., gni 1 ,vele €\ ,e,_1• ,..„.... ...------ alei 1 , 1 -� 6.e a S c� I. v U ...--- ......- .NE • cr,, ..A., IL, 4.2_tt ,,,, ....„, 41( e1__( I -' -1,- (.,.., t ..e Sketch System on ..Retain in county file for audit. Reverse Side. SI _ TITLE. DILHR SBD 6710(R.01/82) F DEPARtMENTOF APPLICATION SAFETY& BUILDINGS- INDUSTRY, (- ;ink*?f FOR SANITARY ( k r-r .p , IVISION cs i, =1 yr , 8 LABOR AND *co. ), PERMIT JF) • 7969 HUMAN RELATIONS i,-11. (PLB 67) MA N, 1 707 Attach plans for the system on paper not less than 8'/z x 11 inches in size. Include a plot plan that is dimensio lc - r dravt>tor rid al and vertical elevation reference points must be shown. All appropriate separating distances and physical char,ci risti cii g ' c er H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the .• aver. liesignetby a.- ` ter Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report .r, a owner's cop t be included. /aI ti� Property Owner: Mailing Address: 'Dow LiAJD S7/90m C/O g% A.ie/05 /?T 5 fi`v./7.S0-v 4)/$ ,6-0/6 Property Location: City,Village or Township: County: A/E t/40W '/4S 2? iT 30 Ni R l y E (org >77- jo #-- 5 Glo/)( Lot Number: Blk No.: Subdivision Name: i „ �� Nearest Road, Lake or Landmark: State Plan I.D.Number: g eV/ p/ioi)5 5 Tox'E/P7& - 1/Az-1 i/lew (If assigned) N TYPE OF BUILDING Number of ❑ Public* ❑ Variance* ❑ Other (specify)* . Bedrooms: X 1 or 2 Family *State Approval Required. /1/t---- Ifrk TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER / GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY Ager) / X X HOLDING TANK CAPACITY NA LIFT PUMP TANK/SIPHON CHAMBER /(/A MANUFACTURER: £JEJSkif Co.,JGti27 _- -hi,4>D£.t) gocaC to/ri EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (S9uare feet): De New ❑ Replacement ❑ Experimental X Seepage Bed ❑ Seepage Pit 6 6/5' SQ.f/ . ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner): ix Private ❑ Joint ❑ Public I,the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: Siyyature: MP/MPRSW No.: Phone Number: T ;A// � ' 39-11-4-- /c / / (7/5)36't-2c$C Plumber's Address: Name of Designer: 7�2— .MD-u/oL" 5T• Jo/, - //D5®.4) ed/S . COUNTY/DEPARTMENT USE ONLY Signa re of Issuin Ag t: ��yy F/ee://�� Date:/ �f �/ A APPROVED Sanitary Permit Number: /V e� 44,0 _6 V 0-0 1O - O 2-8.2 ❑ DISAPPROVED ,V81j?P- ST ason for Disapproval: Alternate coursels)of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber DILHR-SBD-6398(R.07/81) Pi9GE / of- Pi/6-E> • �` FT DE TMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS 115 P.O. BOX 7969 HUMAN RELATIONS � o�'(`�� �O,US�i,�%S of�oS�,WIC 707 LOCH ION:�" SECTION: ' TOWNSHIP/MUNICIPALITY: t9T NO.: K.NO.: SUB IVISION NAME: CAR 4/? '/ I/ 11 /T39 N/R/T E (0 IY I. 7036-Phr F 7:J,P,o$ "fax,PiD5-4- 0 COUNTY: . OWNER'S/BUYER'S NAME: MAILING ADDRESS: U��r� - pi." y 7rzer , ',c)s if S Ve li tA) wYS USE DATES OBSERVATION MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Residence 3 /Vf DoNew El Replace ,414- ? /0 /r 2- kut /v' /Ced) RATING:S=Site suitable for system U=Site unsuitable for system 5.65 S •/ EAY SAND, L419144 CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:loptional) /'(�3-n fT X S UU L7S ❑U 7S ❑U ❑S ..0 E ,�,IL , v If Percolation Tests are NOT required DESIGN RATE:SYSTEM ELEV. If any portion of the lot is in the under s.H63.09(5)(b),indicate: — 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 r TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- / /2-0q/90 Fr — /LU /3"G1-/4,-&y. st, 23''4/-/3J SL ) 62y,./P-2.0 SL B- 2- V 7f f `r > 9p fL, -6.y 5Z ,s,r „ Li*a4). G c 4 3-6 „ x Est „,6,)-&y. 5' , S5 "fl (SA)' Si- i 63 " mot,, B /Z8 � ' fr -- >f `P -13 . sue_ B- r 70 9e.o fr > qo /O"/. . S 27 niAl" 04£ S L d J3A)QS3f6SG >/ , , u- y cL 23„G/. Qv. sL 114. )r-0.S -eic B iS 9� fT a , B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. t P R pE PER INCH . r �� 7/ /.K,4(o / /co / X V P- P- 2- y8 9 , /d / % fiCiv //60 P=3 g' ( /o s tf, 1/'5 )-c) (o S P- PLAN VIEW: 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 slop. &TTOM Of 4.4ite &XC,¢Uhr/04J 54,4L4- L/C. £'4Cr4i/ g, Fr. (7?') ( e faw SYSTEM ELEVATION Lit/TicAL ,Poae,06E Poi,or v• A IEUfT/o,t, Of 9 j 7 FT. . --MC(/bC /)iTi PEi�c 5/1 7 ;(E s. R� N per 0 L Z8 - fa' NI 1,,, 0 0\ .1‘17 st.1\ '',d I'l v''. g? c oo . i?es ref trwa 1s I M � � --- 2--) ' reNP,r(4'I, the undersigned, hereby certifythat the soil tests reported on this form were made by me inccord with the procedures methods specified in the Wisconsin Admimistrative Cod4 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: �oh�-,e� Zl%6�Pi�ti% �utt-e /0 1 "/r� ADDRESS: CE TIFICATIO NUMBER: PHONE NUMBER(optional): RI 3 0 i /L if d- # Ps 5b'(al) 4)/5 55 -O 2- vaL 3 gip'.- /F C SIGN TUR L /�11 DISTRIBUTION: Original-Local Authority,2nd page-Bureau of Plumbing,3rd page-Property Owner,4th page Soil Tester. DILHR-SBD-6395(N.03/81) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY, DIVISION DIVISION LABOR AND PERCOLATION TESTS (115) MADISON WI 53707 HUMAN RELATIONS /f/ld _inteed ,�J� LOCAL 1/ 1 SECTION.;913O N/R/9 L. (o�OWNSHIP/MUNICIPALITY:IT_Y: t�T O.:'BLK.NO.: S VISION NAME: �i C/AOV/UNNTY. OWNER'S/BUYER'S(NAME: sMMAILING ADDRESS:D ��X�/ 5' ' co/X( Do L/. Ps7 j 7 647 . . bp/05 U o-v �i,,5 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: P OFILE tCR)PfTIONS:I PERCOLATION TESTS: [ iResidence Q ,1 New ❑Replace �Z 1 G ire — RATING:S=Site suitable for system U=Site unsuitable for system UU CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM:(optional) s Lill �S u „, S EU Es ,i�u Ds WU Pam / If Percolation Tests are NOT required DESIGN RATE:SYSTEM ELEV. If any portion of the lot is in the .7, under s.H63.09(5)(b),indicate: N4— Ai+ Floodplain,indicate Floodplain elevation: /'17- ---- 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- B- B- =s-e- - /z-t -t / -MT,--- B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH P- P- ^P- P- PLAN VIEW: 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 slop. P �� SYSTEM ELEVATIONkJ/ `' ; 99./ I fT ,PC/ (3I a.a O2' R y 'f Pa-et 4ycer.C5 tN 7 /s w),Y To 6-A, S' E- - - - — — - — - — --- �U f 7-747XCA0.5*A/6 - NoTc s�Tea C7 Ckocc fl 44/i Of `sfc7F� S%TE' g C,t"J fiG,L (,), cur aft etsJ 54o d- - nd of ff gyL v�}r-& it Top SO, I, the undersigned, hereby certify that the soil tests reported on this form were mada by me in accord with the procedures methods specified in the Wisconsin Admimistrative Code,and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME(print):PObiP T !/hie j.C4,�_ /0TE TS WERECOMPLETED/ ADDRESS: // C CA NUUUMMpp TIFI TION BER: PHONE NUMBER(optional): f'3 Jv12. ,0 �/5. 5-y07q , - O2-ye2---- 3P6—pies CST SIGNATURE: f DISTRIBUTION: Original-Local Authority,2nd page-Bureau of Plumbing,3rd page-Property Owner,4th page-Soil Tester. DILHR-SBD-6395(N.03/81) d I `IN i, • i PP, :r:::),_, (07iIi PLOT and CROSS EcTio PLANS c.. '' c-* 0 o \ oU% G Pr / ‘ ze � � V Ic \ \\ ...--;>--;\ ` / CV 4\ ) .,, .1 D // .:) , , - ' \ _—— Ejil 9 // // -- - __ \;‘)' 0 v,..1S 1 7 --1 , T2c-1� -.1-7 GJ /' roJ Li/uPSr.4 'I 0itic,tg- Pitgae. pie0,0,5fp 1 / '' y 9 3 l i I \O 7 Fresh Air Inlets And Observation Pipe ' • ; Pey . g� L � Approved Vent Cap Rh,. . (;46:C'/ ;,,, S�iL Minimum 12" Above 1-7 ,�1f.6= 1 ry gt, ( I Final Grade dr rb -4 i " ' I t' • , M t .. p i , sorI �jo ' Above Pipe 4�� Cast iron io Final Grade ! Vent Pipe AT pA Marsh Hay Or Synthetic Covering _►!. Min. 2'� Aggregate A i i Over Pipe Distribution L.; Tee Pipe --- 1 0 0 0 0 0 ! i a q 1> " Aggregate Perforated Pipe Below Beneath Pipe r. YE(I4 TiGA) /= 0 Coupling Terminating At -/ Bottom Of System i , iI 11 tSTA'tl' . i C'OCIJM .^eT NO, 1 '�F BAR OF i'�I�'..;1'i.�iTN 0R 1-w 1 i � T';ia a=:cs ass�r,. c, rca �etvoRots;a :: IP This Deed ma.de between SY 'SIX 41.14 ' PONA D L. LINDSTROM AND .fir. .L. R :.:'d i•I R ci 2 . I It LINDSTROM, husband and wife as joint tore nts , Granter-, —i Of.. i .....x,:.-... . I a:;,.. and ':�.M..-Xorent.aX e ..J-..-KQr§n.t. . m.--.....: - 1S_PA 1 ,� p t sf , Grantee, Wi ssseth, That the said Grantor, for a valuable consideration Grantors ----- Conveys to Grantee the followingCroix RsTuflH TO described real estate in $t, a,. County, State of Wisconsin: �1 1 � eyy s 2 5(/0/b ,I Tax Parcel No: Lot 13: Certified Survey Map filed May 7, 1987 in the Office of the Register of Deeds for St. Cro;y:-County, • Wisconsin in Vol. 7, Page 1809, Doc. No. 4254.18. TOGETHER WITH Easement for roadway purposes attached as Exhibit "A. " 419 Aire F 1 I This i.e homestead property. I (is) (is not) • Together with all and singular the hereditamants and appurtenances thereunto belonging; . And Grantors warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except • easements, restrictions and rights-of-way of record, if any. and will warrant and defend the same. Dated this 19th day of May , 19 87 i 1 =;•-. (SEAL) )de—a-vt I ,z,14:4 -..(SEAT,) • DONALD L. LINDSTROM • ..- JEAN :...T....LIND.SI'ROM (SEAL) (SEAL) • • ATJT :fs iTICAT1ON ACKNOWLEDGMENT Iii (s) _--DOnald..L..--Lindstrom, STATE OF WISCONSIN IL. Lindstrom aa- I County. i anther 'e t:d this 19day of May , 19 87 Personally came before me this day of ,�j � , , 19 the above named ristina Ogland Lundeen • TITLE: MEMBER STATE BAR OF WISCONSIN (If not, • authorize‘'by § 706.06, Wis• Stats.) to me known to be the perso' who executed the foregoing instrument and acknowledge the same. THIS INSTPUMaNT WAS nrnAFTED BY it Krist ina Ogiand Lundeer: I ---tlltorTi y--at---raw • Notary Public - County, Wis I (Signsturrs may be authenticated or acknowledged. Both Nly Commission is permanent.(lf not, sta..: expiration Ij art not nec- sary.) date: , 19 ) I' •g„,,... of pt,xons signini In any cape :t5 should be typ^J or printed bow .heir nig:Intures. Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relai INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: • GENERAL INFORMATION 268686 Permit Holder's Name: 0 City 0 Village . ] Town of: State Plan ID No.: KORENT, HENRY ST. JOSEPH CST BM Elev.: Insp.BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9604390 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg.Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/Man. Aeration NA Dist. Pipe Holding Bot.System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction ricion Syesateem TDH Ft Loss Forcemain Length Dia. FFii Dist.To Well SOIL ABSORPTION SYSTEM BED/TRENCH I Width Length No.Of Trenches PIT No.Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS • SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over I xx Depth Of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges 1 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present,etc.) LOCATION: ST. JOSEPH.29. 30.19W, SE, NW, LOT 13 FOX RIDGE TRAIL Plan revision required? 0 Yes 0 No Use other side for additional information. SBD-6710(R 05/91) Date Inspector's Signature Cert.No. ° iE ` ' Safety and Buildings Division tenon—ririk SANITARY PERMIT APPLICATION Bureau of Building Water System: 201 E.Washington Ave. In accord with ILHR 83.05,Wis.Adm.Code P.O.Box 7969 Madison,WI 53707-7969 • Attach complete plans(to the county copy only)for the system,on paper not less County �? than 8 1/2 x 11 inches in size. l_,.lC2 fx. • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑Check if revision to previous application (Privacy Law,s. 15.04(1)(m)]. State Plan I.D.Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property 1/Owner Name Property Location t*Iley 4-ye/Ir 3£ 1/4Nt„) 1/4,S 0, 9 T Zo ,N, R / 7E(or)g Property Qwner' Mailing Address Lot Number Block Number /o2c rem Ic)/de —m l Lc i. City,St/ate VZip Code Phone Number Subdivision Name or CSM Number Ha•a/tr.-2 r_ 1o7 2- (7/< )S - S",3 (JO/ .7 falue_ / cCooc- c/a.CV/Yi II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Village ❑ Public 2 1 or 2 Family Dwelling- No.of bedrooms aTown OF S �Pti reoc oc{ry.e„ kh III. BUILDING USE: (If building type is public,check all that apply) Parcel Tax Number(s) `I 1 ❑ Apartment/Condo C' 3O — /a te —9 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 LI Hotel/Motel - 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5_ 4'Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11A3 Seepage Bed 21 ❑Mound 30❑Specify Type 41 ❑ Holding Tank 12❑Seepage Trench 22❑In-Ground Pressure 42❑Pit Privy 13❑Seepage Pit 43❑Vault Privy 14❑System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp.Area 3. Absorp.Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq.ft.) Proposed(sq. ft.) (Gals/day/sq.ft.) (Min./inch) Elevation VII. TANK G Capacity 7 /S Feet 99,,,/ Feet in gallons Total #of Prefab. Site Fiber- Ex er INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel lass Plastic Ap New Existingstrutted g pp Tanks Tanks Septic Tank or Holding Tank /0(.0 /QC i / Of) kii'/oCin 0 ❑ ❑ ❑ ❑ Lift Pump Tank/Siphon Chamber El ❑ El El ❑ ❑ VIII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans. 7rs Name:(Print) Plum by)Si Si ur :(No Stamps) MP/MPRSW No.: Business Phone Number: PLaswtier+s Address(Street City,State,Zip Code): `` i-�-ypec ,;2 v/ 3 /f:20 '�Si---- /'Z�'c�i /2i--c i',:v IL el Cam./ S'friI`7 IX. COUNTY/ DEPARTMENT USE ONLY (Includesate Isue Groundwater s Issuing Agent SignaturelDd6 mps) D Disapproved Sanitary Permit Fee Approved ❑Owner Given Initial....r l r,4 Surcharge Fee) /� j� Adverse Determination �f �` 'X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.05/94) DISTRIBUTION: Original to County,One copy To: Safety&Buildings Division,Owner,Plumber 'Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page 1 of oC Division of Safety and Buildings in accordance with s. ILHR 83.09,:Wis.Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Coup include,but not limited to: vertical and horizontal reference point(BM),direction and • - C P 0 X percent slope,scale or dimensions,north arrow,and location and distance to nearest road. pa. D.# f � `, 7.7 8 a- 9 S" APPLICANT INFORMATION - Pleaseprint all information. �� �,j, a‘>'lc-. - vt O :Y, ''v, fired by Date Personal information you provide may be used for secondary purposes(Privacy La?e,,s.15.04(1)(m)L `y0 .,,,,c / Property Owner ' P opey.Lepation `-GQVt LOt 1/4 1/4,S T ,N,R E or 4�nr�► �1 • Kor"cr�-i— �i �.--=3'E NV aq 3b 19 c )Q Property O er's Mailing Address Lot# Block# Subd.Name or CSM# 00c , n o. \114 C`oX 9s'IA 5e. t r A t•• 13 voL.7 Q411. /ffo9) 9 a 5'Yoe City State Zip Code Phone Number f� ❑ City ❑ Village 't'' Town Nearest Road 14ou1401V I !AZ.I :404 I ( 715)597-(,,s 3 5-t'. :as,,,•c.pk 1 Fo- Ridge t-rq, L ❑ New Construction Use: (-Residential/Number of bedrooms 3 Addition to existing building ❑ Replacement ❑Public or commercial-Describe: Code derived daily flow y 50 gpd Recommended design loading rate , ) bed,gpd/ft2 ' C, trench,gpd/ft2 Absorption area required (, !3 bed,ft2 5 aS trench,ft 2 Maximum design loading rate , 7 bed,gpd/ft2 , a trench,gpd/ft2 Recommended infiltration surface elevation(s) / zi• 33 ft(as referred to site plan benchmark) Additional design/site considerations Parent material S q C$ CMOC c. t Y c►_ P. % \e_.' / t',d.,'en 1p(e.)e> Flood plain elevation,if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system g S ❑ u 21 S ❑ U ES S ❑ U ®S ❑ U ❑ s ® u ❑ S '® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots in. Munsell Qu. Sz.Cont.Color Gr.Sz.Sh. Bed , Trench I I b..y 10•(R V L lfsbk C,1 - G S ...)F . Li , . 5 y-•iA 7,SYe 3/y - 5 L a F5bl. rn ", c w F • ' : . s Ground 3 .114b7.5 K R v/y 5 L a F s 6 K r,Fr g W iv F . 5 elev. 99.i5ft. Li Yb 9'9 5YK q/y L 5 0 -55 ice-1 L — — , 7 : , $ Depth to limiting ' factor , 95 in. ' II+v-...- ' v ' St., - Remarks: 1bolo 9e-bb\�S 't h 145+ .or'N �.OVt k.nF. r ,i#. t.,0 •e Boring # Ground elev. ft. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. 1)nnOP. -', Si-AO( ti— :a N. . 7/5—.1Sti? 358S Address Date CST Number 000"6., `, S--Ear 'Qrc�r, ei4]i /0-Q-910 9011 SYt)Da. smourAuERNEWffliimimmani .. yrommi !r ■(�■■■■■■■■ ■ ■■,ri_iiiimm� 11 VINIMMINI ■■INIEN■■■i■ ■■■ ■ EAMMI �■1 ■��►�II■■MINIR © D .11111111EIMMENIIIIMEMIIIMMII 111111111111MORIMMIllMMIZMINIRRIMIll. 11111 mill mernimill=1.111 IlmwrillE ■■ ■■■11■■■1M■■■i■■ ■■ i ' 1 1 ■■■■■1 ■■■■■■■■■■■■ ■■■■�■ ■■■■■■■■■■■■ ► 1 1 ; , 11 ■■■■■■■■■■■ ■ ; ■■■■■11111111■■■ ■■ } ■■■■!M ems :rmilE" ICIE _--I ■■■■■■■111MI �►�I■1� 1 ■■■■■■■!1■1PN,,■■ 1 1 i i 1 ■■■■■■!f■■Il�■� 1 1 ! i ' ■■1 ■■■■■■ ■ 1 1 1 1 1 ■■■1 ■■■■■■ ,• 1 , I ■■■■ M ■u■■■ai. , . H IIII I ■■■ 1 ■■■■■■■■1 OMNIns■ ■■■■■■■■1 44 1111111111111111111111MMILWIMININIMIIIIIIIIIIMIMININIIIMI MIIIIEIIMMIMIIILIMIMMIOIBIIIIPIIPMIMIIEIIIIIIMREIIIIIIIIIIIIII ■■■■■■■■■ GE ■■ ■■■■■■■1 ■■■■■■ ....1EVIL. �■■�■■■■■■■■■■1 ■■■■■■ ■■ ■■■■■■■■1 ■■■■■■■■■ ■■■■■■■■1 ■■■■ ■■ ■ ' ' ► I ■■■■■■■■1■■■■■■ 1 ■■ ■■■■■■■■1 ■■■N■a■ ■■■■■■■■■■■■■■1 ■■■■■■■■■■■■11111■■■■■■■■11111■■■■■■■N■i !■Cb :"t ■■ ■■■11A■■ill ■■■■■■ i .1111111111111111N ■ c■ NI ■■■ ' ' : - ■■■■■■1 ■■■■�■■N�■� ■■■■N■■1 ■®■ NIl + i ■■■■11111■■1 ■■■!■■fir■! !! 1 1 ■■■■111111■1 ■■1■R■H■■ 1 ■■■■■■■■1 ■ ■■■ ■■■■■■■■1 ■■■■■■■■■ ■ 1 1 i i a■■■■■■■■1 ■■■ate■■ 1 ■■■■■■■■■1 ■■■■■■■■■■ 1 ■■.■■■■■ Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page 1 of a Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code 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 1,,o.X percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# 03CM - r023, - ?Se APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes(Privacy Law,s. 15.04(1)(m)). l Property Owner Property Location ' nc 'm • KO r-cnfi Govt.Lot SE 1/4 NV 1/4,S aq T 30 ,N,R 1 c1 E(or) Property O er's Mailing Address Lot# Block# Subd. Name or CSM# Uoc. . no. 13'7Lo Cloy, R'iAt_ 1-r4i )- 13 Vo/..7, Qa•yc /$09, ya5yi/g City State Zip Code Phone Number El City ❑ Village VI. Town Nearest Road 14001 ei/V I Lott syo$ ,1 ( -715)5P1-(os 3 3-!- .- f, .ph IFoy R'rrye -firgrL ❑ New Construction Use: Residential/Number of bedrooms 3 Addition to existing building ❑ Replacement ❑Public or commercial-Describe: C' Code derived daily flow 4/5 0 gpd Recommended design loading rate , -7 bed,gpd/ft2 i b trench,gpd/ft2 Absorption area required (o y 3 bed,ft2 S bI S trench,ft2 Maximum design loading rate i 7 bed,gpd/ft2 r V trench,gpd/ft2 Recommended infiltration surface elevation(s) 1 Li' 33 ft(as referred to site plan benchmark) Additional design/site considerations Parent material S o C a C t O r . \ X 1-_ A rr't`C"-/ Cr,vvv,e(C..}7) Flood plain elevation,if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system 1i4 S ❑ U g S ❑ U 21 S ❑ U ® S ❑ U ❑ S Z U ❑ S '® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed , Trench ii a-< 1 I b y to�fz 3/a L.. 1fs6k r%Fr Q S F . Lit ; . 5 it.) 7,S'm 3A/ S L . F S b k rn Vr c w _ F .. y , . S Ground 3 1.)-q177.5 4//y 51.. .Z F 5 6K rn Fr 3 W 1v . 5 : . t elev. 99.15ft. `1 Yo-95 5 YR Lily I-- 5 O -St I— i•-- _ — , 1 , , S Depth to ' limiting , factor 95 in. m F:l-1-v- t c.: v. r�Cc-'_ Remarks: lb°/o pLbb1`S .k h las+ hbr.NZOYt AA— Ira '` �L. / Boring# ........................... - ti7 6NrOAA-6-. 1:1+%. Jam-at iart— .INA...14 ,.:t.s....".. ...,-er,-,-. J vi../2..t..& a_�..J...' tm i� ' , s,A tt f Ground 1 elev. ft. _ Depth to , limiting factor _in. Remarks: CST Name (Please Print) r Signature Telephone No. I lip pINnIA . SicCI rK 4��' -f-4-- s 7/5—aysi—' 35 ' Address Date CST Number �71v ;.GtD V' ..S*% S rG '�c.�r; e.}�}t ID-a-9t� VDll v Ma `� ■a��■�■■■ ■■ n■ ■�"T.-- -=-� 1111E11111111111111111111111.1, 011.11111111111111n�liamm ■ IIIMINIMENCREMINMI ■■■■■■� ■■ , ■■■■■■■■■ ■ ■ i1 11111111111111111111111111111111111111111111.111111101111111111111111111 , I ■■■■■■iu■ ■■■■■ 1 1 .■■■■1111111 ■■ 1 MIN BillEINNIIMIONIMEINIIIIIII1111111111111111111 111111■■ = IIME11■m1111111■■■111■111■■n■ _ 11111111111PO■■■■M■■n■■n■■■11111■■■■■■ I ■■■ ■■ NICIMI ■■■■v■■■�■■�N ■■U■■■■��. - r ■nn■■�■■■■■■■ a■■■�■■� Akx ■ - ■■■■■■ ■■■■■■■U■E _ ■11■�■■■■ il ■■■■■I■■■ ■UII■■■■■■■ ► ' mummommeminteniummmommommom UUUU■11111MU■3111■►JNHU■■■■■■ ■ ■■■■■■■a■■■IIsIIIe IIEIIPI IM■■■■■IIIII■■■■ ■■■■■■■■■U■IiM1O11ili j■■■■■■■■■ ■■ LIIMIIIIIIIIMMININIMMIIIIIIIIIIIIIIIIIIIIMIN N■■■■UU■■■!.■:!:=■■■■■■■ 1 ' ■ ■■■■■n■■�■■■■m■ ■■■■ ■ MINIIIM111111$111111111111111111111111111111111111111.11111 ■■ ■■■■■■■■■■■■.■■■■.■■■■■■■■..■■. - 1110111■■■■■■■■■■■■■N111111■■■■■11111■■■■■ U■■■■■■■■■■■■■■■ ' 1 ■■■■■■�■ ■■t�■■■ ■ ■■■■■■■ MENEN , ■■■■■�■■■■�■■■■■11n■■■■■ ■■111 tntMINcS ■■■■■■■■N■n■■ - - . ■■■■■ - ■■■■■■UU■I■■■■■■■n■■■ ■a i NiknalliNglibl ■am■■�a •■U�MU■■UU■■ ■■ ■■■■■■■■■■■■ P■I■■■■■■■■ ■■ IIIII■■■■■■■■■■■■ _. H■■■■■■■■■■ ■111111■n■■■■H■■ N■■■■■■■■■■■U111111 ! ■nU■U■U , • ■IN■■■UU■■■■ 1 I 1 l ' I ; ! ' C S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 14-en rb Kt)ft441-. MAILING ADDRESS PROPERTY ADDRESS / 7�p ' /l� 147 1(location of septicJJ system) Ple a obtain from the Planning Dept. CITY/STATE / j (ia—ra ) PROPERTY LOCATION S t 1/4, /N al 1/4, Section 429 , T N-R /'7 W TOWN OF , ST. CROIX COUNTY, WI SUBDIVISION , LOT NUMBER CERTIFIED SURVEY MAP ,VOLUME 7,PAGE`&Q LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber,journeyman plumber, restricted plumber or a licensed pumper verifying that(1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year xpiration date. A SIGNED: ,� DATE: 2f St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 n/2 ,'Q/ehT Location of property3 l/4/ut,v 1/4 , Section acI ,T 30 N-R / ! W Township Sfi 065,ePl-i Mailing address /3) (v . - 12, ' e., 1401./ft i cia �2- Address of site ,r1 j2 445 A bok,-e-, Subdivision name 10Z. -2 1)-,e_ J �yi'CVI' Lot no. /.3 Other homes on property? �J Yes No Previous owner of property &ralc/ ilild.Shz..orvl Total size of property /' L 44C/ZQ. Total size of parcel Date parcel was created Are all corners and lot lines identifiable? // Yes No Is this property being developed for (spec house) ? Yes No Volume / and Page Number / C0j as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. 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 Certified Survey Map shall also be required. 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. 92S7 (//( , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. cr2c W / //if' /S . atu of p icant Co-Applicant øc Date of Sig ure Date of Signature ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the 1-142nt 116(4,-\+" residence located at : 6C IA, 4/4/ 'A, Sec. "2_01 , T '?-3N, R IdA W, Town of Si-. E/ , St . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced ():7 /99(, . Did flow back occur from absorption system? Yes, (/ No (if no, skip next line . Approximate volume or length of time : 766) gallons yd minutes Capacity: / Construction: Prefab Concrete X Steel Other Manufacturer (if known) : Age of Tank ( ' f known) : (72 CA/1/ 5 '4,p (Signature) (Name) Please Priih //sue. z 1dz' z gS~ 6 (Ti le) (License Number) (Date/0-3-9 Form to be completed by licensed plumber (s . 145 . 06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83 , Wis . Adm. Code (except for inspection opening over outlet baffle) . Name (/_:f`j- s ue. Signature MP/MPRS 6'�-7 c.