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Home My WebLink About030-2032-30-000 (2)St. Croix County Planning and Zoning Wednesday, March 22, 2006 of 11:03:44AM Page I of I Detail Sanitary Information Computer M: 030-2032-30-000 SublPlat: NA Section: 23 Parcel 0: 23.30.20.453C Lot: A TNIRNG: T30N R20W Municipality: St. Joseph, Town of CSM: Vol. 04 Pg. 944 114 114: NE 1/4 SW 1/4 Owner: Donald 1447 Settler's Way Houlton, WI 54082 State Permit: 18100 Issued: 12/27/1978 POWTS Dispersal: Non -Pressurized In -ground Permit: New County Pern t: 40304 03 Installed: POWTS Detail: Bed - Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA 1) �t � Notes Issuer/Insmclor Built Plumber Other Requirements Additional Notes Money Owed doesn'tThis systemdoesn'tappear to have been installed. 50.00 Harold Barber No Hopkins, Richard Not determined Signed Off: No Owner: Anderson, Barry 1447 Settlers Way Houlton, WI 54082 State Permit: 102858 Issued: 02/05/1988 POWTS Dispersal: Non -Pressurized In -ground Permit: New County Permit: 0 Installed: 04108/1988 POWTS Detail: Trench - Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector Built Plumber Other Requirements Additional Notes Money Owed Not determined Yes Pfannes, William Lot A is a division of original lot 1 of CSM 31711 $0.00 (1978) Tom Nelson Signed Off: Yes The original permit will be filed with repair/rejuvenation permit Owner: Anderson, Barry 1447 Settler's Way Houlton, WI 54082 State Permit: 370238 Issued: 06/08/2000 POWTS Dispersal: Non -Pressurized In -ground Permit: Rejuvenation County Permit: 0 Installed: 06/08/2000 POWTS Detail: Tera4ift Procedure Bedrooms: 3 WI Fund: No POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumbsr Not determined NA Hoppe, Chris None Signed Off: No Maintenance Scheduled Pump Date Pumped 1st Notification 6/8/2003 6111 /2000 04/01 /2004 6/11/2003 5/212005 04/01/2004 5/2/2008 Other Reauirements Additional Notes Money Owed no inspection is typically done for rejuvenations $0.00 updated pumping notice/maintenance schedule 2nd Notification 3rd Notification (moo -a03a- 3 0 - Ono p,3 . 3o . Vb . 453 C ANDERSON, BARRY ✓ NEk, SWk, Section 23 1104 South 1st Street T30N-R2OW, Town of Stillwater, MN 55082 St. Joseph, Highway 64 address of--ai-t S •IO � Permit No. 102858 2-5-88 William Pfannes Conv. New Parcel #: 030-20$2-30-000 03/2212006 10:37 AM PAGE 1 OF 1 Alt. Parcel #: 23.30.20.453C 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Applicatlon # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co -Owner BARRY W & JODI A ANDERSON 0 - ANDERSON, BARRY W & JODI A 1447 SETTLER'S WAY HOULTON WI 54082 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ' 1447 SETTLER'S WAY SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.000 Plat: N/A -NOT AVAILABLE SEC 23 T30N R20W NE SW LOT A OF CSM Block/Condo Bldg: 4/944 BEING A DIVI- SION OF LOT 1 OF CSM Tract(s): (Sec-Twn-Rng 401/4 160114) 3/711 23-30N-20W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 8021220 07/23/1997 751 /415 ZU05 SUMMARY Bill #: Fair Market Value: Assessed with: 84380 306,300 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.000 91,200 187,400 278,600 NO Totals for 2005: General Property 3.000 91,200 187,400 278,600 Woodland 0.000 0 0 Totals for 2004: General Property 3.000 91,200 187,400 278,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 218 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 900 REPORT OF I71SPDCTION--I:JDIiIIDUAL SMAGE DISPOSM, SYSTEM S'�" �y(7 / Snnitery Permit D � State Septic / TOIAJSHIP . Croix County SEPTIC TANK' Size gallons. `:umber of Compartments Distance From: Well £t. 12% or greater slope ft Building' Building` ft. Wetlands f: highwater ft. DISPOSAL SYSTEA Tile Field or Seepage Pit(s) Distance From: 'Tell ft. 12% or greater slope ft Building ft. Wetlands f.. FIrLD iighwater ft. Total length of lines ft. Number of lines Length of each line ft. Distance between lines ft. Width of the trench ft. Total absorption area sq. ft. Depth of rock below the in. Dp-pth of rock over the in. Cover _-over .rock., Depth of tile below grade in. Slopa of trench in per 100 ft. Depth to Bedrock ft. Depth to ground water ft. PITS Number of pits Outside diameter ft. Depth below inlet ft. Gravel around pit: __yes no. Total absorption area sq. ft. Square feet of seepage trench bottom area required Square feet of seepage nit area required Inspected by: Title:._ Approved , : Date 197`. RnipetpA Date 197 " 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES ClIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 `% MADISON, WISCONSIN 53701 / REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: hI—'/. S W '/., Section , T3'N, RQ_CN(or) W, Township or-Mdnie4k144 Lot No. , Block No. County � ubdivision Name Owner's Name: -> Mailing Address: % y� 7 / uD TYPE OF OCCUPANCY: Residence t.— No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM DATES OBSERVATIONS MADE SOIL MAP SHEET NEW ADDITION REPLACEMENT SOIL BORINGS((012,3_4 ZC172 PERCOLATION TESTS�� SOIL TYPE PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS SINCE HOLE WATER IN HOLE AFTER TEST TIME INTERVAL DROP IN WATER LEVEL, INCHES RATE PERIOD 1PERIOD 2 PERIOD 3 NUM— INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES MIN/IN BER 3� SOIL BORING TESTS TEST NUMBER TOTAL DEPTH INCHES DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES (DEPTH TO BEDROCK IF OBSERVED) OBSERVED ESTIMATED HIGHEST Z 7 z H V -4,5 ".S. 7Z'' ., s! 7 ,, A Z" is 7 ./ h �, u PLAN VIEW (Locate percolation tests,soil bore holes Indicate on the plan the location and square feet of suitableareas. Indicatj:2be,�1,,sq;uLare feet of absorptionarea needed for building type and. or distances.horizontal. M' points. Indicateslope. ps EMMIN■■■■■ir�N�7 ■■■■■■Oil NINON■■ ■I`3 ; ONE ■■■■■ ■EN■ ■■■■■ONION■■■■■■■■■■■■■NONE ■MEN ■■■■■■■■■■■■E■■■■NIONMIE■■ DOE ■■■■■■■■■■■■■N■EIOO■O On OEM ■■■■■■■ ■■■■■■■N■■ ■N■N■wOEE■■■ ■ ■ ■EE■NiNE■■■NNE■■■■E■■N■■■■■ ION■E■■■NEENN■■NNNNEN■■■NSMI ■■■ ■■■E■■N_■■E■EIO■_■EifN■_■MO■+■■■■■■ ■■■■■MMMM ONEME] si l.n.n_Nm■iNN■NNN■ ■E■EENNIN N�N&i. " I■■■. ■■■C■■■.�■.�NENN O■■■■.■ __ _____mmm Um ' MEMMEEE■■.ES tN P U 67 f*n�- for/v State and County State Permit # Permit Application County Permit Private Domestic Sewage Systems County 'DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required A. OWNER OF PROPERTY State Plan I.D. # Mailing Address: N AIL, ��► %Section L % Tja N. R�U� oc B. LOCATION�C�_'� oZ3• Subdivision Name/ nearest road, lake or -landmark B k# W .5 City Village Township Single family Duplex v No. of Bedrooms y_No. of Persons 'Z D. TYPE OF APPLIANCES: Dishwasher ✓YES NO Food Waste Grinder_YES of Bathrooms Automatic Washer ✓YES NO Other (specify) E. SEPTIC TANK CAPACITY Z4!3E32_Total gallons No. of tanks _ / 'Holding tank capacity TTotal gallons No. of tanks New Installation �� Addition Replacement Prefab Concrete •� 'Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) / 2) / 3) 1_Total Absorb Area 6iS sq. ft. New Addition Replacement Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length S2' Width Z Depth� Tile Depth Z yc" No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size _ Percent slope of land 4/ F4 Distance from critical slope 1, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH•115 prepared by the Certified Soil Tester, NAME C.S.T. # 7— 7-9and other information obtained from J A I a Q K a n_ iF (ownerAmPAsO. y f— S'is Plumber's Signature MP/MPRSW# / = Phone #9 5 Plumber's Address Li 67 PLAN VIEW: PrGide sketch below of system (include direction of slope and all distances in accoru wIu1 H62.20, including well). s G Parcel #: 030-2032-30-000 02/25/2005 E I AM PAGE 1 OF 1 Alt. Parcel M 23.30.20.453C 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): ` = Current Owner ANDERSON, BARRY W & JODI A BARRY W & JODI A ANDERSON 1447 SETTLER'S WAY HOULTON WI 54082 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ` 1447 SETTLER'S WAY SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.000 Plat: N/A -NOT AVAILABLE SEC 23 T30N R20W NE SW LOT A OF CSM Block/Condo Bldg: 4/944 BEING A DIVI- SION OF LOT 1 OF CSM 3/711 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 23-30N-20W Notes: Parcel History: Date Doc # Vol/Page Type 07/2311997 802/220 07/23/1997 751/415 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 5982 283,200 Valuations: Description Class Acres Land RESIDENTIAL G1 3.000 91,200 Totals for 2004: General Property 3.000 91,200 Woodland 0.000 0 Totals for 2003: General Property 3.000 53,500 Woodland 0.000 0 Last Changed: 07/09/2004 Improve Total State Reason 187,400 278,600 NO 187,400 278,600 0 140,800 194,300 0 Lottery Credit: Claim Count: 1 Certification Date: Batch M 218 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) . _.--.._...........•.-•,.. r•� r•�^�� y aeaae Py purposes tr•nvacy Law, S.15.04 (1)(m)). Permit Holder s Name: ❑ CIty ❑ V111age ❑ T n o : Anderson, Barry St. Joseph Township CST BM Elev :. Insp BM Elev.: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding IAIVK 5t:I BACK INFORMATION TANKTO P/L WELL BLDG. veAunttIntao keROAD Septic NA Dosing NA Aeration NA Holding PUMP/ SIPHON INFORMATION Manufacturer Demand Model Number GPM TDH Lift Friction S stem TDH Ft Loss Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No 370238 State Plan ID No Parcel Tax No 030-2032-30-000 STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer St/Ht Inlet St/Ht Outlet Dt Inlet Dt Bottom Header / Man. Dist. Pipe Bot. System Final Grade St cover BED / TRENCH Width Length No. Of Trenches PIT LAKE/STREAM No. Of Pits Inside Dia. Ligwd Depth SETBACK INFORMATION SYSTEM TO P / L BLDG I WELL LEACHING CHAMBER OR UNIT Manufacturer: Type System: Model Number: LJI3I RIDV IIVIV �I`T'11ItM Header / Mani o Distribution Pipes x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. Spacing bUIL LUVLK x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No I ❑ Yes ❑ No wmmrltll r unciuciecociepiscrepanises personspr en Location: t -- Location: 13 St. Rd. 35/fi4, Houlton, V 54082 IT 1 It TV. 1r4 23'f30\ 1110w'I - 23.30 24) 4� �(' 1.) Alt BM Description = 2.) Bldg sewer length = -amount of cover = Plan revision required ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.W97) Date Inspector's Signature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: - �-�--� , - T- - - --- T- - -I I I ------------ ------------- I I N SCALE 1 141 wnsin Department of Commerce SANITARY PERMIT Ilp In accord with Comm Adm. Qde ` J Safety and Buildings Division 201 W. Washington Avenue P O Box 7302 Madison, WI 53707-7302 — r.LLOM r wrnpircn plans do ine county copy Only) Tor the , O Lpef fib 'Cpu�ty _ I than 812 x 11 inches in size. �- � ` , • See reverse side for instructions for completing this appl n Sr ? O 1 W Sanitary Permit -Nu r Personal information you provide may be used for secondary purposesF�.X it r application (Privacy Law, s. 15.04 (1) (m)1- � to Plan I.D. Number L APPLICATIONINFORMATION Pro Owner Name afion W 1/4, S T , N, R,�2 0 E (or Property Ow r's1ailin dress Lot Number Block Number C' , State p Code Phone Number Subdivision Name or CSM Number (,2/s) 3 7/ BUILDING:II. TYPE OF (check one) ❑ State Owned4. Nearest Road Public 1 or 2 FamilyDwelling-No. of bedrooms Town OF Aa/ tj III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Numbers) 23- 30.211 0 53C 1 ❑ Apartment / Condo 03e — d o,� — �; p — 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 S ❑ 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 Repair of an Tank Only ------System --System ------------- --------------- ExistinQSystem-- ExistingSystem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) „f ZqSYG//tr/ y- g -$ s3 Non -Pressurized Distribution Pressurized Distribution Experimental Other 11 []Seepage Bed , / 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ['Seepage Trench p7— sA-SZ1 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. S tem Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) %- ry.3y Elevation _ 'T d ' • gZ feet c ) Feet VII. TANK Capacity i INFORMATION in gallons Total #t of Prefab Site Fiber- Exper Gallons Tanks Manufacturer's Name Con- Steel Plastic Pe New Existing Concrete App. structed glass n T nk Septic Tank or Holding Tank 1 0 G A ❑ Lift Pump Tank /Si hon Chamber ❑ ❑ 1 11 11 1 ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility fo installation of the onsite sewage system shown on the attached plans. (Print) : (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Str4ef, City, State, Zip Code): 'A'I O Cj6Q/ C: r 11 /2� CA v IX. COUNTY/ DEPARTMENT USIE ONLY Approved ❑ Disapproved [-]Owner Given Initial itary Permit Fee pnaudescroundwater swcnarge `eH ate ssue Issuing Agent Signa re (No Stamps) Adverse Determination it S �$ Am X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 1ti M7e)-- ._..--.......,.—_w', , . . a.,.q e.mwng. mvrvon. INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266.3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed It. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use If building type is public, check all appropriate boxes that apply AV. Type of permit. Check only one online A Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIIL Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County / Department Use Only X. County / Department Use Only. Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATERSURCHARGf` 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number'of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ,Gll"N� �.J per5� fi3o; yeCPO cx) c cvr. F� -ri�-�- rtJ o Sccu2e, od, °^ 93 s8 mQ �zzaL �' aX44 (o 1171 MA { y,Artr ",erx Z7969 NDUSTRY, ELATIONS 7 INSPECTION REPORT FOR PRIVATE SEWAGE SYSTEMS SAFETY d BUILDINGS DIVISION BUREAU OF PLUMBING CONVENTIONAL UALTERNATIVE a pn�.n�IIDNR , ,SW1k,S23,T30N—R20W of St. Joseph ❑ Holding Tank ❑ In -Ground Pressure ❑ Mound w 64 NA E OF PERMIT HOLDER ADDREBSOF PERMIT HOLDER INSPECTION DATE Barry Anderson 1104 South 1st Street Stillwater MN 82 BENCH MARK IPpmFn.nT RH.,. . *H.0 DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELE V. T REF PT ELE V N+ne of PIVmW. MFA"SW NO, CP.." mTRr rmH NumW, William Pfannes 6222 St. Croix 102858 SEPTIC TANK/HOLDING TANK: MANUFAC USER LIQUID CAPACITY TANK INLET ELEV TANK OUTLET FLEV ARNIN L LOCKING COVER �020 n 7%r�0� �t 7L 1�R PROVIDED AYES ONO PROVIDED ❑YES *SKNO BEDDING VENT CIA VENT MATL HI H WA NUMBER OF ROAD OPERTY WELL UIL IN V Nl T FRf H ❑YES SNO ALARM OYES SNO FEET FROM �/ LIN[//& AIHINLEi NEAREST Y (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check thescil moistureat thedepth of plowing LENGTH DIAMETEII MAIL RIAL ANDMARKIN(. or excavation. III soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN rrSWVLYT1r1YA1 QVQTCBa- BED/TRENCH WIDTH LENGTH N COSTA PIPE SPACING COVER INSIUE DIA +PITS LIOUIU DIMENSIONS ! l TNENCNES �� MATERIAL" PIT DEPTH J (� L DEPTH FILLD TH UI I OI R IPf 1 I MATERIAL NO TR UMBER OF Y WELL BUILDING VENT lO 1 HE SIT OF PIPES PIPES ABOVE COVER FLEV INLET ELEV ENO PIPES FEET FROM LIN^E AIR INLET E/ 'f' Co ^ q IS 3•�O o` NEAREST d3� 13V ,(/V `1 J MOUND SYSTEM: 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- ❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEKlual PEIIMANENTMARK OHSEHVATITINWELIS DYES ONO DYES ONO DEPTH OVER TR NCH/aED DEPTH OVER TRENCHIMED DEPTH OF TOPSOIL MOD SEEDED MULCHED CENTER EDGES I ISO ❑YFS ONO ❑YFS ❑NO I DYES ONO BED/TRENCH --.. raeNi:HEs - ...._....... ... ........... ..____. ....._.._. _.,.... DIMENSIONS MFOLD JPUMOP MANOLU DISTR PIP I DISTRIBUTION 1 A HIAl MAHKINII ELEVATION AND ELEV DIA ELEV PIPES CIA DISTRIBUTION (INFORMATION NOLES12E OLE SPACING 1D AILILIOCORRECTLv COVER MAT ERIAL eERT` AL LIT T CORRFSPONDS TO APPROVE 3.5 77 Al Sketch System On Reverse Side. DILHR SBD 6710 IR. 01/821 RetainfOE ( 5 �. q 5 n A• I IMENT OF INDUSTRY, iR 6 HUMAN RELATIONS BOX 7969 )ISOIIIpIq1=11,1111707 Ely, SWly, S23,T30N-R20W Town of St. Joseph Distant i i Form-STC- 104 INSPECTION REPORT FOR SAFETY a BUIL PRIVATE SEWAGE SYSTEMS DP 1iY BUREAU OF PLU MCONVENTIONAL ❑ALTERNATIVE slH.PwI.oNVM.I EDNu,ngl Holding Tank ❑ In -Ground Pressure I-1 MnTIDr1 64 MIT HOLDER ADDRESS OF PERMIT HOLDER INSPECTION DATE Anderson sir 1104 South 1st Street Stillwater MN 82 �� 7.'j!1ARKWPInyIynl HN•PncF PIHMIOffCROE IF DIFFERENT FROM PLAN REP. PT. ELEV. CST REF PT ELEV liamPfannes 6222 St. Croix 102858 SEPTIC TANK/HOLDING TANK: MwNUFAC OR R ` LIOVIDCAPACITV TANK INLET ELEV TANK OUTLET ELEV WARNING L L KING COYER `/ OF/A��!• R/1 fN1� �f PI/vO1VIDEO 19YES ❑NO PROVIDED ❑YES VENT DIA VENT MA L :CE�]Y�NO �_ HI H A wLAa4 NUMBER OF RDAO FEET FEET FROM �T�/,�AIES R FRTV WELL UIL DINGV N NEAREST OftJ / W � MANUr ACTURER BEOOM LIOUPOCAPACITY PUMIMOOEL PUMRISIPHONMANUi ACTtIRER WARNING LNEL LOCKING COVER OYES ONO PROVIDED PROVIDED GALLONS PER VCL ❑VES ❑NO OYES ❑I ► AN L A IONwL (DIFFERENCE BETWEEN NUMBER OF rRUPERTr W LL sun DlryG VENT PUMP ON AND OFF) ❑YES ONO FEET FROM LINE AIR INLE SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of NEAREST LENGTH OI AMF TEN plowing or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MATERIAL AND MARKINIi the soil is dry enough to continue.) MAIN C NVENTIONALSYSTEM: BED/TRENCH WIDTHILE,I,j" N DISTR PIE A IN DIMENSIONS S `� TRf NCHES MATERAI' PIT WSIUE CIA -PITS De ul J L H ILL H UI I OI R I I I PAL NO TR IBF Lqw MPEi BUVE COVER fLEv INLET ELEV END P„E$ UMBER OF WELL BUILDING V NT TO Q 'S '` FEET FROM NEAREST LINE 1� AIR INLE d3� JU �5 Z unl IBIn Cvc7cu. 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. meets the criteria for medium sand. TIONS MEASURED. ❑NO I V R TF KTURE PEHMAryEN MAHK SOtlSFHwIUIN Wt Ll5 I_I.co urvv UrES LJNO UYES LIA PRESSURIZED DISTRIBUTION SYSTEM: PEE /TRENCH IDTH LENGTH O LA ALSPACING GRAVEL DEPTH BELOW PIPFIL N V V HENSIONSTRENCHERMANE LD MANI L DISTR PIPE MANI L IAL N DI H I IATION AND ELEV ELEV DIA ELEV PIPES DIA U. HI U I I f MA fNIAI BLIANAINI. DISTR ROUT ION INFORMATION HOLE SIZE HOLE SPACING ILL RE LV OVER MATERIAL V R Ill..tWONOS ID APPq UV! PLAN$ COMMENTS: AM .. ❑NO OYES ONO OSSERVA IOr1 WELLS NUMBER OF PROPERTY WELL BUILDIN FEET FROM LINE 3.5 7 OYES ONO OYES ONO NEAREST s10 �F� �s 9� L .8 BENCI Elev, Sketch System on Reverse Side. DI LHR $so 6710 IR. 01 /82) Retain'QI 1/1 k-4n T— Co� Administrator Form- S T C - 104 n AS BUILT SANITARY SYSTEM REPORT OWNER t vr' rJ N "L I. TOWNSHIP ` t—Tj SEC. T 3_0 N-RAW ADDRESS—.,1 ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i t r �I 1 11 l?p f t 1 � i INDICATE NORTH ARROW Wisconsin Department of commerce SOIL AND SITE EVALUATION Division -of Safety and Buildings Bureau of Integrated Services in accordance with s. II ,-W(s. Adm. Code Page I of -11 Attach complete site plan on paper not less than 8 1/2 x 11 inches in siz I include, but not limited to: vertical and horizontal reference (BM), ust n and D ` OU�ry C Ro point 1 percent slope, scale or dimensions, north arrow, and location and dis neares l �VED Parcel I. . # MAY O - 0 - 30 -boot, APPLICANT INFORMATION - Please print all inform . ® ?Q eviewed by Date Personal information you provide may be used for secondary purposes (Pnvacy _ `�. 15.04 (1( T �X Property Owner H Govt. Lot (rjt/4,S 3 T 30 .N.R a O E (or�b Property Owners Mailing Address + d 3slby Lot # ! k ubd. Name or CSM# poi.41 P . 9yy City State Zip Code Phone Number ❑ cityEl Village E4 Town Nearest Road 14ni-jI+nV1 i IJ=I S`411>22(7IS>SY9.i.9N 44, -c„<. .. L. 1 44 P1 -a C. h-t4 QgKtS�ve..�-t•,o„oFPe>E,S�rt)t DRAin LJ New Construction U Residential / Number Use: of bedroomF�E►ip _ Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 45 o gpd Recommended design loading rate — bed, gpd/ftz — trench, gpcbv sorption area required bed, n2 trench, tt2 r Maximum design loading rate bed, gpolflz �- trench, gpd/ftz f3� (siT infiltration surface elevation I)i 9 yr 3 Y i?. ] 1 3 1?.2 If(as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable n S = Suitable for system Conventional Mound In -Ground Pressure System in Fill Holding Tank U = Unsuitable for system Q4 S ❑ U F S ❑ U ® S ❑ U rAAT-Grade �S ❑ U ❑ S � U ❑ S [4kU SOIL DESCRIPTION REPORT Boring # 1 Ground 9 Sel`v; n. Depth to limiting factor J,,,.Qin. Boring # Ground elev. n. Depth to limiting factor in. Remarks: Horizon Depth in. Dominant Color Munsell Mottles Ou. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2 Bed Trench o- V 32 FS L— ;s -,, SVa5/ FS L- -&31, 7. S %1 A y/ PS L - -3s 61 a ll 1 L-- 5 CST Name (Please Print) Signature 71 r, h i\ i�k -C . 19:4n.r V1. C n -t k Telephone No. le. - agg - 3588 Date CST Number 9;-234a000 ADa0gl� SOIL DESCRIPTION REPORT PROPERTY OWNER _ Page _ — of PARCEL I.D.0 Boring # Ground elev. k. Depth to limiting factor in. Boring # Mottles Cu. Sz. Cont. Color Remarks: Ground elev. k. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Boring If ws� Mottles Qu. Sz. Cont. Color Remarks: Ground elev. n. Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) 11 Is owner/Buyer Mailing Address Property Address ST CROIX COUNTY -SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM (Verification required from Planning Department for new construction) City/State f-k:t, bi-I (w, Parcel Identification Number �7n -aD sZ -30 'QoOG LEGAL DESCRIPTION Properly Location n) i7 %., .5 L-) '/4, Sec. T_2,0_N-RZ W, Town of x To4p. Subdivision . Lot # Certified Survey Map # 2(nZ?2 2 . Volume �L_ Page # V �Z• Warranty Deed # Volume Page # -D Spec house ❑ yes 11 no Lot lines identifiable Q yes ❑ no SYSTEM MAINTENANCE 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 a licensed pumper. What you put into the system an affect the function of the septic tank as a treatment stage in the waste disposal system The property owner agrees to submit to St Croix Zoning Department a certification form, signed by the owner and by a masterplumbe4lourneymanPlumber+ testruftdPlumber or alicensedpmnperverifyingthat (1)the on -site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary). the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein. as set by the Department of Commence and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St Croix County Zoning Office within 30 days of the three year expiration date. i _ /�GYprJ DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. CJC6 gORATURB OF APPUCANT .r • •••«.« Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department ss««•s •« Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed v 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 �Iorr5 residence located at: p,L;, � 3 Section , T AN, R _W, Town of 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: Me,14 c76b0 IV Did flow back occur from absorption system? _ Yes No (If no, skip next line) Approximate volume or length of time: dnn gallons _ Capacity: Construction: Prefab Concrete X Steel Other Manufacturer: (If known): Age of Tank (If known): (Signature) // h�cSe:.c�P� r (Title) Date (Name) Please rint �SvsSj (License Number) minutes 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, W' Adm. Code (except for inspection opening over outlet baffl�.7 Name ��,�.,` ��c� Signature MP/MPRS p NE 1/4- SW 1/4, SEC. 23 T30N, R20W REPLAT OF LOT I I C.S.11d. 9 VOL.3, PAGE 711 0 1 REC. AS S 88-21 E ( 50' ) 35c� o ( 58. 25' ) S89 26-25E • 396.37' 348.65' 199 0 s' s' _ 0 LOT —.A o h 3.0 ACRES Joey yP�Q9 Z M Li=GEND, �`� O : I"X 24" 190N PIPE SU WEIGHING J�?yfp.0" � [.GO LOS. / LIN. FT 0 = FOUND I" IRON PIPE 900 ROAD R. 0. Vt. DISTANCE 0 = FOUND P. X. NAIL T;;I;; 0 1 _ — REC. AS S 88 _54E 11 3 5 's S 89 26-25'E 47.72' 699.GG WEST ! ( N 89! 58'- 25'E -- 100' S0' 2.5, 0' 100' -- SCALE I"= 100' 303. 29' LOT — B 3.0 ACRES 351.02' 2y 0 09 `90 0 00. 00 j , E_\_11 1VLS1L T �l l�, : C. A?yhagen, a regi stereB. Land Surveyor, hcrGcy re l; on of �� ^e I have sur= eyed, £._. direc i Don A. . , r �l ;. _Ch is "CCrCSented Oy l 'J___ �. L f the ',._•^d-oarce� LI_e exterior be _,dr ry oe 1j- •• - _.:m-c_'ibed as follo:;s: „ repl:.t of Lot 1 of Certified Survey I:ap, Vol. - `he Ofof the Register of Deeds, St. CroJx County, /4 , of Section 3 T _ ..-20 m^':n of �J. . •. . 1 of the S., , /4 ;, n 2 >.-.0 . • C-, 1 County, ;;'i . , further described as foil Co �zer_cing at the j7; corner of said Lot 1 0_ C,— J,^\. ::'J_co, __ a a_-• _ _ ' r- i " of 1 h i c.r'' crin:•; ^y, '; -r.•^ c • _e r' 11 1 also being she poi_n t of oegi r.�, •.---:, .• - J- --. • -- c 800-261-25" E along the Southerly /',- line o_ , ^^nae `? 890-58'-25" -1 along said Southerly S.T.H."3,' �%' ....... 703.2; feet; thence South, 372.77 feet; ..c -=:• -- - •• • %.orth, 375.50 feet to the point of beg=nnLng. �1,bove described parcel contains 6.0 acres and sub ;ect tc eE.3e^: ' �;' o=' •'<'C'J":. that this Certified Survey P•Iap• correct rep is a corrresent^t_on b=ndary s;a._rveyed and described; _ y"- Vn V T have sully co.mplled :,itz one current pra 1 _sion of ^v.�� J.: _ 2j o :iscor_sin Revised Statutes in surveying and 1=zpp�r_, c••= '-,ed this 74kday ofr ec.. , , D1979:r.^ r _f_ .... = cl.. cc--U e Allen C. \yhagen, R.L.S. No. 1407 S ec N Land Surveying Judson, 15i. Va' r• •a'i'� AjC 1.i)ytietc'.t�r,..,ti a:•1� C. 'r •7 .. Cat r t. r � rr. ^tr r, - V_z__ _CATy 0: THE TO'::N OF Srp j 0 'L4, ''�s:',C• .'' I, do hereby certify that this sU^-- Cert-fled Survey Map has been approved by the Toun of St. Joseph this day of ol•:r_ Clerk of St. Joseph 'X Form -STC- 104 r to 1 I AS BUILT SANITARY �SYYSTEM REPORT OWNER 8(V ►^� Y{ kCG r 5l� TOWNSHIP �t . Q �� l SEC. � T �N-R Q_W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISIO A4q LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•I.HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Al INDICATE NORTH ARROW PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: .� ^ Width: ij Length: ��_ Number of Lines: Area Built: Fill depth to top of pipe: Number of feet from nearest property line: Front, Q Side, O Rear, O Pt. Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Liquid depth: Area Built: Number of pits: Diameter: Bottom of seepage pit elevation: Has either a drop box O or distribution box O been used on any of the above soil absorbtion 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: Number of feet from well: Front, O Side, O Rear, O Ft. Number of feet from building: Number of feet from nearest road: DEPARTMENT OF INDUSTRY, P LABOR & HUMAN RELATIONS P.O. BOX 7969 MADISON, WI +V07 UE14,SW�4,S23,T30N-R20W Town of St. Joseph ... INSPECTION REPORT FOR PRIVATE SEWAGE SYSTEMS CONVENTIONAL ❑ALTERNATIVE ❑ Holding Tank ❑ In -Ground Pressure ❑ Mound SAFETY & BUILDINGS DIVISION BUREAU OF PLUMBING 1i:�l!i1�➢In1 NAVEOE PERMIT HOLDER ADDRESS OF PERMIT HOLDER INSPECTION D T Barry Anderson 1104 South 1st Street Stillwater MN i4082 BENCH MARK IhrmF.rm fiifw cA MIMI DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV. ST REF IT ELEV NA .1 PlumW. AMIMPRSW NO CouMr n.lYr .m" Nu.MF. William Pfannes 6222 St. Croix 102858 T 6-0� l lN� '! / 1 / OV 7 (i ' YES ONO DYES AND BEODING VENT DIA WENT MATL HIGH NUMBER OF ROAD ROPERTY WELL DILOING VENITOIR H T/ AIR INIET �lvcc Y�LNf1 '¢ C.A+ ALI-lvice 54AIn NEAwes�M LIN _ OYES FIND LONS PER CYCLE: PUMP AN CONTROLS OPERATIONji. NUMBER OF PROF FERENCE BETWEEN I _ FEET FROM LINE AIR INEE 1 or x PAoavn. (if soil alp a tolled int.�..wire...onst construction shall ce&;.......y I FORCE or excavation, (If soil can be rolled into a wire, construction shall cease until the soil Is dry enough to continue.) MAIN ovoreu. WIDTH L NGTH No Of DISTR PIPE SPACING V IN':IUf DIA RPnti LIQUID BED/TRENCH l IHENCHES MATERIAL PIT DEPTII DIMENSIONS (� nffrV-rL-6rl;T-. IILL D TH Ill H I DI TR POPE I I IAL NO TR UMBER OF V WELL BUILDING VENT TO I HI SH BE L/4�W PIPES EE ABOVE COVER ELEV INLET (LEV END a PIPES FEET FROM LINE �r ,EAR AIRINLFT f FI � IS 3L NEAREST d3� JV J J MOUND SYSTEM: 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 VER fE%TURF PERMANENT MARK N E S I1bU SE-l'nIIIINWI ti ❑YES ONO EYES ❑NO DEPTHnVER TRENCH BED DEPTH OVER Hi DEPTH OF TOPSOIL SODDED SEE CIU MULCHED Cf NIER EDGES DYES ONO I DYES [:].NO DYES ONO BED/TRENCH — --- rne;CHEs - -._- --- - ---_-- _----- DIMENSIONS MANIFOLD PU MANI LD DISTR PIPE MANIFOLD MATERIAL NO DISTN DI I UI HISII N IPI MATT IIIAI AMAHAINI. ELEV ELEV DIA ELEV PIPES CIA ELEVATION AND DISTRIBUTION HOLE SIZE POLESPACING ILL D ONRE C T LY COVER MATERIAL VERTICAL LIF I CORRESPONOS TO APPROVI I) INFORMATION PLANS V ONO DYES ONO COMMENTS: FRMANENT M1 WERE OBSERVATION WELLS NUMBER OF PROPERTY WELL BUILDING FEET FROM LINE 3Ls7 OYES ❑NO DYES ONO INEAREST_ Sketch System on Retain E!1 coun ile for udi ?P1 Reverse Side. \ $I 4TUTITLE Zo ng Administrator DILHR SBD 6710 IR. 01/821 �O SANITARY PERMIT APPLICATION 7 5ILHFR COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # /Oa 8SCY -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 81/2x 11 inches in size. -See reverse side for instructions for completing this application. PETITION j(�� ❑ [KNO 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE YES P OPERTYOWNER PROPERTY LOCATION C'/.5W %, S 93 &O N, R,90 E (or)6D r ,., , PROPERTY O NER'S MAILING ADDRESS t LOT NU BER BLOCK NUMBER SUBDIVISI NAME o t 0' S N N CI . STAT ZIP CODE PHONE NUMBER CITY : IN T ROAD, LAKE OR LANDMARK N Z ��L VILLAGE -;y II. TYPE OF BUILDING OR USE SERVED: / /� Oc0 — cX 630^ O0 Number of Bedrooms if 1 or 2 Family -13 OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2, 3 or 4, if applicable) 1. a. XNew b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit # Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in 92) 1. a. Kconventional b. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In -Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ Seepage Bed b. seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: Minutes per inch): � REQUIRED (Square Feet)' PROPOSED (Square Feeq. — —1-19 Feet Private ❑ Joint ❑ Public , VI. TANK INFORMATION CAT P CITY in callons Total Gallons of Tanks Manufacturer's Name Prefab. Concrete Site Con- Steel Fiber- glass Plastic Exper. APP. New xistin Tanks Tanks strutted Septic Tank or Holding Tank Q �P Lift Pump Tank/Siphon Chamber VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamor,ps) MPNdPR9WNe.. Business Phone Number: ) C' u z i - P bar's Address (Street, City, State, Zip Cod ): Name of Designer: VI 1. SOIL TEST INFORMATION Certifi it T star ((S ) Name CST # C Qrd Le-e-- _,6_—:05*,;i 6 CSK9jADDRESS rest, City, State. Zip e) Phone Number: t-CU, 1 rcl IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee Groundwater c F� Date Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial A 1 2U �+�-� I L�IJ D6 Or"lJ_ b Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: e- hie ISdr-� PIcl,1, 0..Wro0Rd IQLJ �Uyla_o SBD-6398 (formerly Plb-67) (R. 03186) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. All revisions to this permit must be approved by the permit issuing authority A new permit may be needed if there is a change in your building plans, system locAtiion, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; , 4. Changes in ownership or plumber "requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation; 5. Private sewage systems must be properly maintainerl.'The septic tank(s) should be pumped by a licensed pumper whenever necessaty,-usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Prcperty owner's name and mailing address. Provide the legal description where the system is to be installed; 11. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in #1. Complete #2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in #1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII Responsibility statement: Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; buttding sewers: wells; water mains/water service; streams and takes; dosing or pumping chambers; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served: B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system it required by the county; E) soil test data on a 115 form. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Ground ater 1- included the creation of surcharges (fees) for a number of regulated practices which Wisco in'5 can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasure 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. SBD-6398 (R.03/86) APPLICATION FOR SANITARY PERMIT STC-100 his application form is to be completed in full and signdd by the owner(s) of the roperty being developed. Any inadequacies will only result in delays of the permit .asuance. Should this development be intended for resale by owner/contractor, ("spec louse"), then a second form should be retained and completed when the property is cold and submitted to this office with the appropriate deed recording. • - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - r.ner of Property 4_� Arr j LJ � 10A , A . A„ A e r c, Location of Property _/UE >t 5 L, 1t9 Section , T 30N-R2_0 w Township _J C S �{�• Mailing Address Ho -} 1 5 l` ►F rn r-) so s �- Address of Site Subdivision flame Lot dumber Previous Owner of property on o, 1 d c 4�il i� l ; � i� � �. r- Total Size of Parcel Date Parcel van Created Are all corners and lot lines identifiable? Yes No r Is this property being developed for resale (spec house) ? Yea �_ No Volume and Page Number 9 yy 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION 1 (10e1 CtAtk6y that a.CC SteLtementh on tlti�5 66ohm she thug to the best o6 my louhl hnnu(edge; that i (cut)am (she) .the awnen(a( 06 .the phopeh,ty descAibed .in thi6 in6ogmation 6ohm, by virtue 06 a wcweanty deed hecohded in .the 064ice o6 the Cetin(a RrniAt0)1 nL naarid n& u_ _ _ . STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER W, c J-Ocl; 4. Ande rson ROUTE/BOX NUMBER Fire Number D/O CITY/STATE S4-. JO&e(.): SCn -�G; r-1 ZIP S!5eOPoZ PROPERTY LOCATION:_j)E 14, �5 (A) 14, Section),?,3, T_.30_N, RC*7,0_W, Town of , St. Croix County, Subdivision_p.7 L&t I % 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. 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 Depart- 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. /c,mw W clk%c� SIGNED r• ��>�Gy�y�/ DATE 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. cPARTMENT OF REPOK UNJ VIL ��`�'v a `• INDUSTRY, i PERCOLATION TESTS (115) fI LABdR AND. `' HUMAN RELATI.ONS(✓r� ` 1t'v - (ILHR 83.0911) & Chapter 145) OT N .: B • 1 rc�wNSH1P/N<Z�T�tTYI ,I A P.O. BOX 7969 MADISON, WI 53707 P/Mj 9 _- 0 Lr ' DATES OBSERVATIONS MAD�l U$��E,,// g O M N. L`7New ❑Replace I / 0 9,61 L�Residence _� / -- PROFILE DESCRIPTIONS PERCOLATION TESTS P- eIsoil borings gtithe dimensions Of uareas. Indicate 'be What a PLOT PLAN:Show locations of oh:uaccevatonat all borings and the dirctionand P ¢ontal and elevation reference po'nts end Showheilocaon on the of land Slope. SYSTEM ELEVATION _Y- i,lnv 6 ri 6�1 T`� nt,f I. n St R,iv,r�•�^""t arN� ��ers� �St�llusae� �,��SSo$� Sc Se Alx N N o Sc. A- sy51F �/e0..4,OA 91 T9 M Q 6 Z Tft F Aze/ Zrl ead {-WAP- $I