HomeMy WebLinkAbout004-1048-10-000
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` a Wisconsin Department of Health and Social Services
.Plb. x+07 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. G`dNE,R OF PROPERTY
Name Address (Street, City, Zip Coda)
Be LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED. ALTERED OR EXTENDED COUNTY
Check One:
CITY VILLAGE LEGAL DESCRIPTION
i/ TOWNSHIP
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? 4-----YES NO PERMIT NUMBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION L-~REPLACEMEA'T _ ADDITION
MATERIALS: Prefab Concrete Z/ Poured in Place Steel Other
NUMBER OF TANKS TO BE :.NSTALLED: /
E. TYPE OF OCCUPANCY
Check One: One or Two Family Residence Commercial Industrial Other
Specify)
Number of Persons to be Accommodated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES L- NO Automatic Clothes Washer YES NO
Dishwasher YEWS L-- NO Automatic Potato Peeler Y£S e- NO
Other (Specify)
G. MASTIR PLUMBER MAKING INSTALLATION
Name: Address= /7 `Z~1-50 License Number:
-I
J MP
Signature of Applicant: MP RSW
Address:
H. (T be Completed by Issuing Agent;
Date of Application / Fee Paid
Permit Issued (date) permit Number
Agent (Name) Fort A 1-v" Tern, Village, City, County, etc.
(Specify)
Note: The application canna be considered for filing until all of the above questions are answered and tk•:
fee paid. Agents will forA-ard'application, the fee of $1.00 for each septic tanK and the third copy
of the permit (canary) to the Division of Health. Checks and money orders should be made payable to
the Division of Health.
Do not write in space below - FOR DEPARIM1E4T USE ONLY
F I. DATE RECEIVED ACCEPTED BY RETURNED
(Initials) (Date) See Corres.)
FEE RECEIVED _ v VALID. No. PERMIT NO. i
es or No
REVIEWED BY APPROVED DATE
(Initials) Yes or No7
Pn1.fDi PTC M}tS:o CTnt+ _
SEPTIC TANX PERMIT NO.
R X P 0 R? O N S O I L P E R C O L A T I O N T Z S T
A N D S O I L B 0 R I N G S
TO
DIVISION OF HEALTH - PLUIBLgG S~~"CTI6'N
P.O.Box 309, Madison, Wis. 53701
Pursuant to H 62.20, Wis. Administrative Code
P R R C 0 L A T I 0 N T T S T
Test Depthh Character of Soil Hours Water Test Time Drop in Water Level Irohes iltnutis
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall
1st Wetted Overni ~O:t in Minutos Last Period Last Period Period Cnp> Inch
Example
P - 0 36" ?o Soil 10" Clay 2611 25 Yes or No 30 1 2 1/2 1/2 60
n f ,
4L/
RECORD DATA FROM MIN L'1UM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B 0 R I N G S- Mini--,= 3611 Below Pro osed Abso tion 5 stop
Boring Total Depth Depth to Ground Water Depth to Bedrock
Number Inches Observed Estimated Observed Esti=ated Character of Soil with Thioknsss in Inches
Example
B - 0 7211 72" Black To Soil 12" C1 1811 Sand 18"• Graval 2411
RECORD DATA FROM MINLNM OF 3 BORE FIGUES
YPE OF OCCUPANCY:
RESIDENCEt Number of Bedrooms OTHER: (Specify) Number of Persons
D WASTE GRINDER: Yes N3 L 'Dishxashert Yes No Automatic. Clothes Washer: Yes No Z
FFUJENT DISPOSAL SYSTEM: NEW v EXTENSION ADDITION REPLACE21SENT
Tile Size No. Lin.Feet l C C Trench Width ~ Depth Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pitt Inside Diameter '7// `Liquid Depth Z/=1
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super-
vision in accord with the procedures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME _ ifs. %71':-11!~'_S/-, I~/ TITLE /Z/ /E C> 1 I
(Type or Print) n p
REGISTRATION NO. / or MASTER PLUM3ER LICENSE. NO. L/ ~ i s ~ J ~J
ADDRESS
DATE /Y / 17 SIGNATURE
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Parcel 004-1048-10-000 03/27/2007 04:47 PM
PAGE 1 OF 1
Alt. Parcel 21.28.15.323A 004 - TOWN OF CADY
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 - STENSRUD, BRIAN T
BRIAN T STENSRUD
290 HWY 128
WILSON WI 54027
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 290 HWY 128
SC 5586 SPRING VALLEY
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 27.081 Plat: N/A-NOT AVAILABLE
SEC 21 T28N R15W 27.081A NE NE EXC N 358 Block/Condo Bldg:
FT OF W 934 FT & EXC N 449.07 FT OF E
388 FT 454/157 EXC PT TO STATE (1.01) Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
640/381 21-28N-15W
Notes: Parcel History:
Date Doc # Vol/Page Type
10/19/1999 612337 1464/296 WD
01/14/1998 571258 1288/182 WD
07/23/1997 1224/104 LC
07/23/1997 640/381
more...
2007 SUMMARY Bill Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 04/17/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 28,000 136,600 164,600 NO
AGRICULTURAL G4 22.081 2,400 0 2,400 NO
UNDEVELOPED G5 3.000 1,900 0 1,900 NO
Totals for 2007:
General Property 27.081 32,300 136,600 168,900
Woodland 0.000 0 0
Totals for 2006:
General Property 27.081 32,300 136,600 168,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch 511
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
~e
L abora ~ 1 lit l - 7l
Wise nsin.DepartmentofIndustry, SOIL AND SITE EV
nd Human Relations 'AlUAT1DN REPORT Page I of
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but S 0
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL.I.D. #
dimensioned, north arrow, and location and distance to nearest road. MEDIY-.
q ti 5i, 6
APPL
ICANT INFORMATION-PLEASE PRINT ALL INFORMATION
PROPERTY OWNER: PROPERTY LOCATION
4 c t c` GOVT. LOT IVe 1/4 1/4,S_2 T N,R r 5_ E (or t
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCJ(# SUBD. NAME OR CSM # r
1 t'~ Lo A/ 4l p
CITY, STATE ZIP CODE PHONE NUMBER [_]CITY E]VILLAGE WN NEAREST ROAD
i.~-Sv,v
(JA Silo (7~ T I a-JI6
[ LFNew Construction Use [ L4--Residential / Number of bedrooms 3 ],,,Addition to existing bLulding ;
j ]Replacement [ ] Public or commercial describe y' j r A)
Code derived daily flow 416-0 gpd Recommended design loading rate 5 ' d, gpd/ft2_ : trench, gpd/ft2
Absorption area required -,200 bed, ft2 S trench, ft2 Maximum design loading rate bed, gpd/ft2 . & trench, gpd/ft2 7~-
7D Recommended infiltration surface elevation(s) 106, V -3 ft (as referred to site plan benchmark)
Additional design /site considerations S ti, 6-"v 76-
Parent material t, P Flood plain elevation, if applicable /t/ ft
S = Suitable for SySteRl. CONVENTI-ONpL MOUND IN-GROUND PjESSURE AT S DE / SEM IN ALL HOLSING, TANK.
U = Unsuitable fors stem 1] S 6~ 1TS O U El S ILKI ❑ YS L7U S ❑ [y-LT
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Bed Trerxh
F-
6r'o'- k"d* Ic- ~k to VR t
elev.,, t vk~t- , 5
ft.
Depth to'
il-
limiting
factor - ' -
f>
emarks: c,t~ca+e Q
Boring #
Ground l' 3 6-~~ S y- - s s
. s
elev.
3
elev. ft. ? c~ ` 4J y ~Z '7. s- R C C- S~k VIA
Depth to
limiting
factor
1 (,51
Remarks:
CST Name:-Please Print Phone:
3c ?~S 7~~ -3a7
Address: ~
y C3~ f-e l f 6 ~r 7!0
Signature: o Date: CST Number:
PROPERTY OWNER _I_~~1__~ L DESCRIPTION REPORT Page of
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Bouncbjy Roots G P D/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
Ground 3
elev.
it.
rr
Depth to -i
limiting
factor
Remarks:
Boring #
Ground
elev. I. S S S' S C- t S 6k ' -
ft.
Depth to ,
limiting
factor
Imo,/
FS'T rlC[
r
Remarks: Y
Boring # a
-1 iz
3
15,
Ground 3 `r
elev. 3 t- y o `7- S y' r~ r S s~ v-~ . 3
ft.
Depth to
limiting
factor
I(7`~
Remarks:
Boring #
13
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
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Fl- C-
abobor 5epartment of Industry,
Labor and Human Relations tions SOIL AND SITE EVALUATION REPORT Page / of _'3
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but S 0
not limited to vertical and horizontal reference point (BM), direction and %u of slope, scale or PARCEL.I.D. #
dimensioned, north arrow, and location and distance to nearest road. (),0'4 S' _ O
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
~t ~c t c` GOVT. LOT IfIg 1/4 1/4,S2 T N,R S E (or ~i
PROPEL OWNERS MAILING ADDRESS LOT BLOCS( # SUBD. NAME OR CSM #
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OfOWN NEAREST ROAD
Silo Z- (7lT ~`7~-~ v 6 ~~L ~v 1-2b
[ t]-New Construction Use [ L4-Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow CSC gpd Recommended design loading rate 5 ' bed, gpd/ft2_ trench, gpd/ft2
Absorption area required ~ZOO_ bed, ft2 71S_0 trench, ft2 Maximum design loading rate . 5 bed, gpd/ft2 _ trench, gpd/ft2
Recommended infiltration surface elevation(s) 106, y _3 ft (as referred to site plan benchmark)
Additional design / site considerations 3' S wwcl- c'L_A -c 3,fk 'B'd S"Y 7S
Parent material u e Flood plain elevation, if applicable /i/ft
S = Suitable for system CONVENTI60 MOUND IN-GROUND PgESSURE AT-GRADE SYSTEM IN ~F LL HOLDINGTAN
U = Unsuitable fors stem ❑ S C~1 1~7 S ❑ U ❑ S U El S C~ 1~ ❑ S LTU ❑ S
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground I n b[C t- 5
elev.
ctLa ft.:.
Depth to <l. I:
limiting }
factor , " - r=
~ n
Re 3')
Boring # t
:z a -llo o
Ground 3 6- 2k S' - s s vJ S
~a
elev.
'~i9a ft. 28-4~ y y- 7-s k c 3
Depth to
limiting
factor ,
I
Remarks:
CST Name:-Please Print Phone: 7 7P
Address: _
Signature: -2 Date: CST Number:
4^'~
PROPERTY OWNER ~__~_Ll__t,../.. C- ~l v 9 IL DESCRIPTION REPORT Page of_`
PARCEL I.D. # --/o
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trend
-10 0 2 S vi r 0i
J-
Ground S S u.~~ l 3
elev.
Depth to
limiting
factor
Remarks: -
Boring #
to -IR
V,( L
3 sbh CLJ -7. c7 'i
Ground S
elev. yno.~
ft. 3 7.S s sC- t w. s6k
Depth to
limiting
factor
Remarks:
Boring # a
h 3~ 3
3
~~-31 icy y 7.5 rt r fiow2s' c.
Ground -5 -k-
elev. 3j-90
7_S 2 + ~ Si w. s~ vvS j
ft.
Depth to
limiting
factor
r4 (4
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
R.P. ioo.oo 30
14
Sc ct~e, ~ I
i
f ves
S lSo JVO.
o ~V 1A lqg/ 1511sf of a. N1,
I
o ~I
z
1, a - ~
I H..,, F, ~1 &
I
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a B~
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rYg
ST. CROIX COUNTY
Y {
' WISCONSIN
ZONING OFFICE
r`w fix' ST. CROIX COUNTY COURTHOUSE 19 %T ~ 911 FOURTH STREET • HUDSON, WI 54016 lffrq1 715 386-4680
i
October 15, 1992
Division of Safety and Building
Bureau of Plumbing
P.O. Box 7969
Madison, WI 53707
To whom it may concern:
An onsite soil investigation of the Alicia Deppa property, located
in the NE1/4 of the NE1/4, Sec.21, T28N, R15W, Town of Cady, St.
Croix County, WI., has been conducted with the assistance of Bennie
Helgeson, CST# 3094.
This onsite revealed suitable soil for onsite sewage disposal to a
depth of 14" while meeting the requirements of the A + 4" rule.
This site should be suitable for new construction utilizing a mound
septic system having 22" of sand fill.
Should you have any questions, please feel free to contact me at
this office.
S' erely,
mes K. Thompson
Assistant Zoning Administrator
cc: file
Wi&ohsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of
Labor and Human Relations
Divk,ion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROP RTY OWNER UNi je - PROPERTY LOCATION
`ci t t._ r cy ILcC t GOVT. LOT 1/4114,S T N,R E (or) W
PROPERTY OWNER':S MAIL G ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ❑fOWN NEAREST ROAD
[ ] New Construction Use [ ) Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable fors stem ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Ground's
elev.
ft. 2, /(L-3L
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone:
Address:
Signature: Date: CST Number:
PROPERTY OWNER SOIL DESCRIPTION REPORT Page,_-of _
PARCEL I.D. #
Depth Dominant Color Mottles Texture Structure Consistence Bou Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. r~dary Bed Trey
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to 2
limiting
factor
Remarks:
Boring #
13
Ground
elev.
ft.
Depth to . _
limiting
factor `
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)