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HomeMy WebLinkAbout030-1003-20-000 v, p nCl) O 3 y ~ d ~ 1 cy, _ 'm = CD Z 1 3 ^ 3 3 - \ 1 n N N (Nf~ O O N Z O 3 N O O A Z N W °C • (D w ;a CL -1 0 CD 0. v d !A d d_ N O cn (D 14 O O O ry A (D 7 N f , N Qoj W W (7n 3 N (D 7' N \ 1 Fr 1 p "0 Q (D Er ' (A (D fOi 7 O n 3 C', C N O 7 O O = W (n = y N 7 O C !r N 0 c n O .'3 O CD o cr, z D° ('_n. cn z N cD a N. (D O N d 7 O W O. 7 CD m o co Q c o o 00 O r+. O \ 25 00 W O ^~v CL cn 00 q z m m ~7 n r N (D (D M N O O O a O c Q m m ° O O O c O O O c Z ° n D 0 D C: 0 CL CL En (D cn 2< Z> d 7 O D O 3 cr 0 O Q N O 0) N O (Q (D CD - CY) z w 0 (D Z--I z zzaz Q v O D: o 7 O O CD S N C 7 CD N (D C Q O N S .0 -0 c N c 0) (D - Cn CA a CL 7 Z CD 7 CD N ~ v, O 7 7 A Z (D N o N = C) C) Z CL A Gj o' 7 Z N N (D (D L , M m W f t z a 3 3 a ;u O O Z (Cp y ~7 N Z CD CD A W N O CD CD 7 a 3 '0O O N Q oo CD -2 . FN n 3 CD oo C N N y T O7 p 7 :3 T O 501 7 O'O N < _ o° ° 1. 3 0 o a CD C CD ID j N (D (n O O O ~ 7 _n 7i ~ -O n ~ (D O) O CD O) 01 O A W co n ( o n a Z N CD (D --I c N m m o an a (D 7 0) O 2 c 7 L C CL o0 CL ' 7 N CD o (n 0 n, 7 O CD CY) CD cz~ o a f CD (D ao oa 0 0 O O 0o i. 0 ° ~ ~ Parcel 030-1003-80-000 12/18/2006 01:03 PM PAGE 1 OF 1 Alt. Parcel 02.29.19.19 030 - TOWN OF SAINT JOSEPH 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 - STATE OF WI CONS COMM STATE OF WI CONS COMM X MADISON WI 53707 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 2 T29N R19W SW NE Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 02-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 &443/523 07/23/1997 440/416 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/10/1987 Description Class Acres Land Improve Total State Reason STATE X2 40.000 0 0 0 NO Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 CO P -0 0 a) U) Z m rn m • O ~ ~ 00 F- -n O - X i-~ COO* i < co C/) m Cf) U m ~m now 0 0 r r C O0 O z = d n ~ SO =045D D O m o ..Q n n N a) M C/) z o Z zo o c -t p mw o ~ o' -n z z < CC-) O r- o cn C~ C/) zz n m O z U' C Z 2c m I,1 m~ 0m m y N~j~ ~M ~m oa ~s3~ mD = m o~. a~ 30 Io v O 3 ; NE moo 3o m o m° m 3 m° m o J° a m 3 Ul m ~El cc Tay < o~ o cam > >c vi c :3 0 o 3 3 3 ` w m o : $ °am am :0, o Z D '~-o V m c m < arc o D D Ea o m3 --J ~ 'o o'er m t j o ° 3 E :3 'o W 3 3E o 7 ti D c c a v m ET 0 o 3 0' o o D 3 • o' - s m :r:5 m ,p SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # j -Attach complete plans (to the county copy only) for the system, on paper not less than G( Lt Li/ 8'% X 11 inches in size. ❑ Check if revision to previous application j -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION R T <i_/ l? it lF f- k" nf111 '/4 '/4, S I T .,9 , N, R _E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER j. , r S'3 ~.cl•.v 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD State Owned ❑ VILLAGE "'xi ~T ❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms - PARCEL TAX NUMBER(S) Ill. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 Z Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1 ~ New 2. ❑ Replacement 3.E] Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 `'Vault Privy 14 El 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 /4 1 Feet Feet VII. TANK CAPACITY Site in gallons Total of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plurhbe/-s Siggna ure•' o Slams) MP/AMPR W No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code). IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) ❑ r Approved El Owner Given Initial ~ Surcharge Fee) C / Adverse Determination (f ( ~ ' I"C(t } f l r'^ ` , 4 s, X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: J J I ~1L1~~ 'l(.~J1.~.~'J_n. ~ t }`.!.l l SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber E rrslvr IIVSIALLATION AGREEMENT 541- / 1 11 la Lt L/ OTE: This Jocument is to be recorded in the Tract Index at the office of the Register of Deeds in the county indicated below. COPY TO BE ATTACHED TO PLB. UI WHEN APPLYING FOR A SANITARY PERMIT ERP TY OWNER: ,MAILING ADDRESS: N: C '/a 'S ,2 TN/R 9 (or) W ~VILLAGE OR TOWNSHIP: NE n COUNTY: /~trQ,A,~,j,~c--~- ~ c ST. C ~o l I (we) acknowledge the following privy installation conditions: 1. No plumbing will be installed on the premises. Plumbing means any piping, fixtures, equipment, devices or appurtenances in connection with water supplies, water distribution and drainage systems, including hot water storage tanks, water softeners and water heaters connected with such water and drainage systems. 2. The privy will not be erected within 50 feet of any well, stream or lake, 25 feet of a door or window of any building, 10 feet of the line of any street or public thoroughfare and 5 feet of a property line. Set backs not mentioned shall not be less than those shown in section 11,111183.1 0(l), (Wis. Administrative Code). 3. The privy will not be installed on soils that do not have at least 3 feet of soil below the'bottom of the proposed excavation that is free a pe(iodic saturation or bedrock. Where these conditions cannot be met a vault constructed in accordance with section ILI 8 ~f (6), Wisconsin Admit i;trAiv C de will be used. 4. The soil condition has been verified by an appropriate y SIGN URE Ary T T ; count official or certified soil tester as signed here. 5. The privy will be installed: (mark one) ❑ over a soil pit ~ver a vault. 6. This agreement shall be binding on the owner(s) or heirs and assignees. OWNER(S)). ~r SA~J OWNER(S): STATE OF WISCONSIN //QQ ej o Personally came before me this 2 day of a- 19_, the above named to me known to be the persons who executed the foregoing instrument an a nowledged the same. THIS INSTRUMENT DRAFTED BY: N T.AR UB / MVCOMMISS/IO)N EXPIRES: 1 DILHR-SBD$432(R. 11/83) _7 T ZA n, S 0 ~0 O 3-0 n d m ("D v CD d ^ ! a Q Cl • DJ n ro n n~ ll) U) ° ..y 1 3 o~ CD cD ° O N Q O7 co (U OD (1~ S N Q O, (CD CD N (D ° Q w O to o < O C) Z N C4 O O p (D O ~ Z D (o Oa. N (D (fl O N d U W 3 (D s co V I 3 co O ~I CD (.n 00 q "*ANA CD co m a o r (n o c m "WA, z O O O n " o n m -I -l O 0 z fn fn v' ? D r-3 M a a CC O Q I CD - N < Ut O 0 C D ~ D L. N N (0) W a z N 41 Z -I OZ O D m o ? N• CD (n m ry~~ x CD CD l vy c (n a W CD 3 7 z CD A Z c O Z O A CL O Z N N (°D° (D m O z o O " z cD m N (AD A W ~ CD D) 7 ? (D (n (n Y (D "O O N = -n n N C z a o o O (D C (o (n m 7 (D (p 9-0 .0- O :E N O (=D oy W co a- lzt O_ M. Q b m ~Z m x_ _ (D 3 Z yam ~ O N 5 CO ! O Cl) O O ~ 0 b O CD oro ~ w o O a o i ti RLPCRT CF INSP'.GTICN---INDIWAL KTkTAGE-DISPCSAL SYSTa PRIK,RY TR ATH21T consists ofLSeptic Tanks Cther (Describe) SEPTIC TANK: Distance from: Well ft., Lot Line ft. Buildingyl__-ft. High watermark ft. 12% or greater slope ft. Wetland ft. Cistern ft. No. compartments . Liquid capacity ' - 1. EFFLUBINTT D?SPC,-"L SY`17M consists of Tile field. Seepage pit (s)., Seepage Pit or Tle Field: Distance from: Well ft. Building t. Lot Line ft. Cistern ft. High Watermark of grater course ft. Slope 12% or great,,r ft. Wetland ft. Total length of tile lines:!. { ft. Number of lin-~s Length of each line~ft. Distance between lines ft. Width of trench Total effective absorption area of trench bottom, Sr. ft. Depth of filter material below tile in. Depth of filter material over the in. Cover over filter material Depth of the below finished grade in. Slop, of trench bottom in. per 100 ft. Depth of bedrock ft. Depth to ground water ft. Number of Pits Cutside diameter ft. Depth below inlet ft. Lining material Gravel around pit: Yes. No. Total sbsorption area sc. ft. Square feet of seepage trench bottom area required C Square feet of seepage pit area required i Inspected by: Title: l i Approved Date 1 ,19% TZe j ect ed , Date ,19 County, Town of 1111 Owner r Sanitary Permit No. Prooerty Address Septic Tank Permit No. Subdivision Wisconsin Department of Health and Social Services Plb..#97 3/70 Division of Health SEPTIC TANK PERMIT APPLICATION TYPE or USE BLACK INK A. OWNER OF PROPERTY Name A , Address (Street, City, Zip Code) A y re -r j B. LOCATION OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY Check One: CITY VILLAGE LEGAL DESCRIPTION TOWNSHIP C. IS LOCAL PERMIT REQUIRED FOR THIS WORK?YES NO PERMIT NUMBER D. SEPTIC TANK CAPACITY- Gallons NEW INSTALLATION REPLACEMENT ADDITION MATERIALS: Prefab Concrete ` Poured in Place Steel Other NUMBER OF TANKS TO BE INSTALLED: E. TYPE OF OCCUPANCY ,Check Ones 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 NO Automatic Clothes Washer " YES NO Dishwasher YES NO Automatic Potato Peeler YES NO Other (Specify) G. MASTER PLUMBER MAKING INSTALLATION) Name: Address: License Number: Signature of Applicants MP RSW Addresss % H. (To be Completed by Issuing Agent) r Date of Application ' Fee Paid fi f Permit Issued (date), Permit Number Agent (Name) Fors - Town, Village, City, County, etc. (Specify) Note: The application cannot be considered for filing until all of the above questions are answered and the I fee paid. Agents will forward application, the fee of $1.00 for each septic tanK and the third copy { of the permit (oanary) 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 DEPARTMENT USE ONLY I. DATE RECEIVED ACCEPTED BY RETURNED (Initials) (Date) See Corres.) i FEE RECEIVED VALID. No. PERMIT NO* es or No REVIEWED BY APPROVED DATE (Initials) Yes or No COMPLETE OTHER SIDE SEPTIC TANK PERMIT NO. 7 R Y P 0 R T O N S O I L P Z R C 0 L A T I 0 N T E S T A N D S O I L B 0 R I N 0 S TO DIVISION OF HEALTH - PLUMBING SECTIdU P.O.Box 309, Madison, Wis. 53701 Pursuant to H 62.20, Wis. Administrative Code P E R C O L A T I O N T T S T Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches utas Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last rTLIFIll 1st Wetted Overnight in Minutes Last Period Last Period Example eriod Inch P - 0 36+' To Soil 10" Clay 26111 25 Yes or No 30 1 2 1 2 1/2 60 l ~ , py '3 RECORD DATA FROM MINIMUM OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. S O I L B O R I N G S- Minimum 36" Below Pro osed Abso tion System Boring Total Depth Depth to Ground Water Depth to Bedrock Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches Example B - 0 7211 72" Black To Soil 12111 C 18+l Sand 1811Gravel 2410 RECORD DATA FROM MINIMUM OF 3 BORE HOLES YPE OF OCCUPANCY: RESIDENCES Number of Bedrooms A-' OTHER: (Specify) Number of Persons D WASTE GRINDER: Yes No Dishwashers Yes No Automatic Clothes Washers Yes No FFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACEMENT Tile Size No.Lin.Feet Trench Width Depth Number of Lines Seepage Beds Length Width Depth, Tile Size No. Lines Seepage Pits Inside Diameter Liquid Depth 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 bent. of my knowledge and belief. NAME rvr7//rif TITLE Type or Print t REGISTRATION NO. or MAST PLUMBER LICENSE NO. ADDRESS DATE / SIGNATURE Parcel 030-1003-20-000 12/11/2006 09:34 AM PAGE 1 OF 1 Alt. Parcel 02.29.19.17B 030 - TOWN OF SAINT JOSEPH 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 - BRILES, DELORES M DELORES M BRILES 789 CTY RD A/E HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 789 CTY RD A/E SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 3.410 Plat: N/A-NOT AVAILABLE SEC 2 T29N R19W NE NE LOT 1 OF CSM 3/663 Block/Condo Bldg: ALSO KNOWN AS LOT 1 OF CSM 4/1177 NOW KNOWN AS LOT 1 OF CSM 5/1431 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 02-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 695/40 2006 SUMMARY Bill M Fair Market Value: Assessed with: 168500 223,700 Valuations: Last Changed: 07/07/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.790 72,900 121,200 194,100 NO Totals for 2006: General Property 2.790 72,900 121,200 194,100 Woodland 0.000 0 0 Totals for 2005: General Property 2.790 72,900 121,200 194,100 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 213 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 030-1003-10-000 12/11/2006 09:14 AM PAGE 1 OF 1 Alt. Parcel 02.29.19.17A 030 - TOWN OF SAINT JOSEPH 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 - STATE OF WISCONSIN, D N R D N R STATE OF WISCONSIN 101 S WEBSTER ST MADISON WI 53707 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 29.660 Plat: N/A-NOT AVAILABLE SEC 2 T29N R19W FRL NE NE EXC VOL 149 Block/Condo Bldg: PAGES 462 & 463 & EXC CSM 3/663 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 02-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/10/1987 Description Class Acres Land Improve Total State Reason STATE X2 29.660 0 0 0 NO Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: 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 Parcel 030-1003-95-000 12/11/2006 09:14 AM • PAGE 1 OF 1 Alt. Parcel 02.29.19.20B 030 - TOWN OF SAINT JOSEPH 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 - STATE OF WISCONSIN, D N R D N R STATE OF WISCONSIN 101 S WEBSTER ST MADISON WI 53707 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 3.100 Plat: N/A-NOT AVAILABLE SEC 2 T29N R19W RR IN SE NE Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 02-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 2006 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/10/1987 Description Class Acres Land Improve Total State Reason STATE X2 3.100 0 0 0 NO Totals for 2006: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2005: 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 O o en Q O E O III C d o O fD CD n• CD •D 'a+ • N'+ W N l 3 ~ Xk ~ 111 cn N .G. p N o f z` v "c p A 0 cn o p• 0 N N (n O Z N O Co Z J !Q W O CD 7 O O CD W .Z1 O_ m C:0 W x O` 47 A (n v Q Q Q` N O CD :z C O N O irt, Co CD ET l (D O O 1 °o 0 (D (D ° o n o --q O W ° A~ ~ Q7 o N N 7 p o N(n N y r- O N 00 O ►i"'S N Ln Z~ N N. , t_T Z D N Q N (D (0 O p_ 7 (O O N p. =3 T 7 W v, Z) W v C Cl. 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