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HomeMy WebLinkAbout030-1068-30-050 (2) Wv dnsi-r Depw.i of Comnu•a' PRIVATE SEWAGE SYSTEM ~ ~ aty St. Croix Safe), and Bwl:i •rg Divimon INSPECTION REPORT / A8-163 GENERAL INFORMATION (ATTACI I I C PL RMI I i State Pw ID Ne ne ,cnaI iWCamapI., yJu plu Vice rna'; be ,sec 'c~ Sccu"d', oa''u w, [p P-ivecy Law _ 15 nC F<rm t Hn'rler's. Name U 1', 'v Ibge Tn:vnsl-it. PI Tex NC Lynn Engelhart TOWN OF SAINT JOSEPH 030-1068-30-050 CS' W.1I I, r;n B61 Ees' Btl f. esrn cd on 5000Cro f~~xn NargerII hll /A9.5Z C Gnl._~ 26.30.19.2508-50 TANK INFORMATION ELEVATION DATA TYPE MANII TI CAPACITY STATION BS HI FS ELEV. Scpt.C Henchman .y Dosing All. BM Go~.1oc, gay w aSZQ. 0, G4 Jby.63 os Ill 76 Acrat on {✓/G.1;4~'l Al FI - BaQ. °r ~o 75,7s I lotdrq s!Ht Inlet TANK SETBACK INFORMATION StF t Outlet IANK TO P+L WELL BL'JG. ROAD DI Inlet Septr:: ~ DI Bottom p (a S - - (a 5 I Aeral D si. Pipe H:II 7- 1 - Bot Sysi rma'. Grade PUMPISIPHON INFORMATION ta::;9uta GLUeI r Demand St Cover 1-r zoe-1'U~ cPna C G~• .9 /Q'J.S FAudcl NumUc' q3 7_3 f DI I Lift Friction Loss System !lead TDH F: Fo'CR Rtaie -en g7 3'.a T;'. tr SOIL ABSORPTION SYSTEM =ns In'a do t qu [ Cept1' BED:TRENCH O.tir I, I e-q'b I Nz, ;!r- e-rr •-r; PIT DIMENSIONS No Cl OIMFNSIONS -z ' Z_ J ~G.nG SETBACK SYSIl TO P:L BLQG V4fFl I' LAKClSTREAM LEACHING 1.t.:n,,lart.ue' p INFORMATION CHAMBEN OR V f r f, r o:_U'S>'slc..' . `T r UNIT PoNum_ a nu4 -A7 i a /b i1 ? J ✓V kH~ J DISTRIBUTION SYSTEM Heade Pl.f nr.f,l, rI Nird'il•._Lnr He, Size I xHr?Smorg VP.r Air I,ake P_L L!^~qIP (y Drd~ Le-p.r\__ Urd 'q a.-:va; ~-44 SOIL COVER x Pressure Systems only xx Mound Or At-Grade Systems Only Dc:d'. Ct ~~r LOvc xx Dentn o' xa ScegenrSJnd\eC <!.1ull R,1 Tren,:h • iter Re C~Tra',ctt FOges \ I 1 ~~1 \ 4 NO ~es No COMMENTS: :17nduaef cede d srrepencies, persons present. ete.i Inspection/k1 Inspection #2 Location: 111 t32ND AVrrrgMrrr/n`~L(1~ 1 i Ail I Description - ° 2. Bdc sever length = /a 1,.~ ne , . / I I 1 arI of cover = r O~-`/'I/y:)J 1L ~GN(J/ H f~ 1/' 7 g otr ~ 1/ Plan revisior Required? Yesc Use ether side for additional information 34~- Gate msenr. 's i'gnal c Cerl No. ~A1~2d(g-113 ~i mar/ County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN accord with Chapert 12 St Croce County Sanitary Ordinance PLANNING 8 ZONING DEPARTMENT S. ~erSonal information ,von provide ma15a usec fo sex ar • asgb ST. CROP COi1N'" GOVERNMENT CZNTEF. (Privacy Law. S. 15.!t4(-)( y ' 1'01 Ca;•nrchapl Raad ' Hudson, WI 54016-"10 (775;586-4690. rax715);+864686 Attach complete plans for the svsterc on Der n ess an 8-1.2 x 11 incnelk in sae. Omnh•Sanitaty Penn[ 0 = Check f rev soon m previous appiication &J - 13 Application thtortnation - Please Prim all Information Location: ~I ?r;rocrty wrier Name r•1 1 r r V4 114, Sec ' -T7 tyt '4 LU 111 ' N. R 'jE i o•. 'N Property Owner's Mailing Address Lot Number Block Number ity, Stare Z.in Code 'hone Numer Subdivision Name or CSNf Number 01Ue win dot ZS 595 I; Type of Building: tcheck onel =4 UlVillage 50Town of or 2 Family Coxeliing Nc. of Bedrooms: 17k 6-b 'r~3- ( AILr ] ?ubadC:ornmc.r^raI I.ocs:-iv. usr•j. I ~ t , ,VF}~ O Stato-ovrtw_d Nearest Road 32- It. Type of Permit (Chad: only one box on line A. Check box or one S it app hcabiej lT~ - - Parcel Tax Nurnpers) Ai 1.;Z Repair "<;jti Reconnedion 3.❑~lor~~~Wmping . ❑Rejuvenatior \ sani~tinn 0 7 c I - ~u js, B. Per:nil Number p Dafe issuesi ❑ Slam. Sanharq PernE war previo_mly ensued IV. T POSH? System -YCbock all that apply} ~ •,J~, ~ it d-~ / on-pressurizec in-ornund_ Mound 2 24 in. suitable soil ❑ Muanc 5 12~4 in. suitableCSOiI ❑ Mound A• 0 at 'Itt. ] Consvuded Welland ❑ Peat Filer ❑ Drip Line ] S 7 ?ressurrLM Inymanc = Holding Tank ❑ Single Pass ❑ Other 71 At graoe ❑ Aerobic Treatmem Unc ❑ Re rculating V. DisporsafrTT reatm nt Area Information.: I Dsslgn Plow (gpd) 2. Uispersa: Area B. Disper5ai Area 4. Soil Application Rate 5- Percolation Rate 6. System r-revation 7 Final Grade Reauired ~ Proposed (Gate lcaysq.ft.) (Min./iro Elevation UO J I 1~ c l.G N I F~ ~ .c~ . Tank Information Capaiaty in Gallons Total : of Manufacturer i Prefab Site iron- Stee: Fiber Plasbc New Existing Gallons Tarrks Concrete striaed glass Tanks Tanks I VII. Responsibility Statement 1. the unde:svgned. assume responsibii0y far mpairlrecannencton4ejuverationrmstalPafion o' non•plumbing for the POW S showm on the attached plans .A hoanse is not required lot lerrallt repac a the mstallat oe of nor-ptumbmg sanitation. yslem. 'iumbeYS Name hntl Pkonber's re (no sta IIAPNPRS No Business Phone Number v1C+~ -7 S C3 -411« ?gumbo"s Had s (Siren:, Clty Stale, Zio c ui w ,-r e 16, vok((Ay WT vu:. County Use Only +Disapproved Sanday F•enn0 Fee O e Iceyred Issm gen: Srgnatu ,(No ps) Approved 011111-! "-un l1Z 6 Coe rrtlFiaticn I Aw 1w /(l - IX. Conditions of Approval/Reasons for Disapproval: 77 ~Ljp - zz l l'- 03A ace e-vrlEt-d-- i-J, < e ~eIA-,, Eras; ~ C~~1 RQ ~ ~ Rev S,'C5 r 3) i~ Cot my Sanitary Permit Application Q~aln actor with Chaper 12 ii Croix Count) • Sanila ST. CROIX COUNTY WISCONSIN It. y~. ` y\ ry PLANNING & ZONING DEPARTMENT G~ ~Porsonal in(, at:un you provide "lay be used In e ondary purr "s . 1 IPr' a'.y Lan•. S 15 04;1 SL CHOIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road - Iludsun, WI 54016-7710 i 71 ir,1386 4680 Fax Attach i715138&4686 = complete plans fur lho 5 51nm on , a p not less loan & 1:? x 11 inches in site. CountySanitary Permit >F ❑ Check if recision to previous applicalion tv~~ 1, Q~ (J/~ I. AP Ilcation Information - Please Print all Information % i 1 V f " I ' d a Proparty Owner Narte Location: !1 ~i 2 1'4'- 1!4, Soc c 1 - Property OWTIeYS Mailing Andress I ` [J N. R . P rj 4Y of Numbs trick Or y, Statu/ y Zip Ccdo Phone Numer Subdivision N II 7 Pe of Building: (check one) do 1 •'LS .15 y ~t ! ur 2 F.=,M6.y lTeailing - No- or Qe:ro::m;;. y' n ..tc 6 ity, ovillage Om of PuWie+('gmmnrcinl (desr_nbe bsei -F- t- \U+- / 1 0 Slateovmad 7 ~J CJS P- u II. Typo of Permit: ,`Check only one box on line A. Chock box nn I:n. Q I ,app(,:;ab7r.} No/v~fl a2dn l~J ~~77 A) 1'❑ Hepair econncction Parcul Tax Nurnbcr(s) LA tr Non P - IJmbin0 . 1-Rejuvenation Sarlitai;0n - :ilate Samlary a Permd w.s Permit Number Date Issued k all that all th`Ial apply) V issued S ILA S - 2.008 rQ-P Ica. L , y }J 5 IL hl 20+ZD /1 unU_ ChU~~ ~Q.S =P-Isurllou ^ -1I -T n I U Mould 24 .n. su . soJ 0 Ma n . suitable soil ~ er Consnvclad v%- 0 Mound A.0 f] Pressuuted In-ground Iter 0 Onp tine r AI-glade V Heldtul Tany~ are Pass iw'is- 1:nen1 I . Dis •rsal:Trealmenl Area Information: Recirculating L3 Other 1. Design Fie'n• ( pa) s r 3. L) sp mat Ar,a 4. Sml A E^ / 9, _ p1f1Pns At to S. Percolation Hate I., . System hlevaaon 7, Final Grde lGals.:Uay tt.! 1"w.!incht a / Elevation a I. Tank Information '1{+-' .fy m r(7 C3alirnu l oral K cf Idanataclurer New Lxisung Gallnnc Tanks Prefab Silo Con- Steel Fiber- Plan qqq Llic ks alks y+ /hr5 f L n Concrete M ucted glass L1 T] VII. Respo ibility Statement C ] C] ~ G Bin a is not:nod, assume res{xMSihliy frr re air:rw;cnnenCliorv'ieluvunalioro:nslallation of non-pWnlbing Or iba POWTS sllovm on the attached plans A 'ices:<e is ❑ohequirad for ter ft repair or the .1a11atiun of non plumbing sanilabon system. r bor'.v' Nam7nt , j , fJ~ Plu il"alure ;no otanlui' I, 1P IP No B, siries. Ptt~ne umber x t x PI6a'l ArYL ISaeul, GIY, > 4 Z, J CT VIII. county Use Ohl Disappr_ / -Amu, Permit I-ee - Approved f~~ e~ Qale Issu.=.d Iss g Ayenl S' naNre No sta"tps. n Initi nl Adverse Delerminatidn ~ /""'r V S I/~v~t/~ IX. Conditions of Approval;Reasons for Disapproval: C'ont(~fidns Lv12 Zoi~-031 are ii► P-~~rc-~ w~fGr ~Li7's ~m • / A' i~ s~xxcilyc iS ~r~i ~f c~ ~r ~f f a ba~k{i /grit 5f S sGf'~UI~ICS ~i° ~P~ l U ra c(~a,'n~~lc/ S"-~ fa~IC sl: . 1/1 Nv d ICUINOJ JNl S3WOH 3ARV3N3 UOSjJDc ONV 1N3W39VNVN U3IVMNMOIS ; ele 0 - 3 a y, i fF ~L ' - _ - ACA II < A8 y AL !v4 Y _ ,t 1 - ^lV Plot Plan Page 3 of 6 Property Owner~v~,~ ~v,~,a ErJruC~ar Legal Description u,~ z c:,NN L3 5+1. SCALE IN FEET 5WJ4 OF ZHE :ieklyf yL~i xCti~ KI`w rc~_ti :r $C 11-15Z-P" W' CRDt( Cot; iY•k S: P~:~ 0 15 30 60 CONTOUR INTERVAL = 2' Ey/ ' \ POSE \B\ S 3~ • / y,~ p,WE, \ 0 . - 906 OEC /dOO I 'WELL -JPOSED - 1 it BE Ar CIS tt~" . ELL) D lk 'M `1 / is \ i "nl']PVtiF~24,. 1( '90gg T APL , :i'~ti it _ ✓ 1 LOCATION MAP SECTION 26, T30N, R19W, TOWN OF ST. JOSEPH, ST. CROIX COUNTY, WISCONSIN FT-26yy~- ✓ ~f~~~ ~S t2~DO IS1TE 1 L SCALE: 1":3000' / husce.rsin Cepartn enl of Ccmnlu:cu PRIVATE SEWAGE SYSTEM cwmy St. Croix INSPECTION REPORT a:rm,.ar/P:m t +c 514852 0 j j GENERAL INFORMATION (ATTAC'AT:OPFRMIT) Sta19PInnIDNo Versonal intef...W on yep. VIC, Je'nay bsSS lnr Yecnnna'y po ix:,, l=noe;.y L.) I I S U: I I..Mil nermfl I Vdu; k Name CA, age X 7onn5hlp ParrAl Tax No: Enc elhart, Steven & Lynn St. Joseph. down of 030-1068-30-050 CST Ph' Fco hc.p R`.11 I1•: fir" 1111.;.1 ao^ soclion+l.w wangoB.tcl No /DU m L5T 26.30.19.250B50 TANK INFORMATION ELEVATION DATA JN}•3 IYPE P; AN..=A.CT.IRFR CA'ACITY STAT ON BS HI FS ELEV. i ' ^3S 109.5 Septic a~t3m 915 `l•fo5 1W.bS /G>J ")nsrny ~ / AI!t3A1 7'J3 fOd.'SZ ~,evPJ- AIrI~:.a'1 Hldy. Se er 97• / ~•1 7 7 T .c~L Holdn•,r, ht;lIt fillet 11-93 '1Z, 7Z" SL+•71 Uutiel \ TANK SETBACK INFORMATION TA'JK "O F.+L CIA= Ci_DG. 'Jmr. •t. •t:r mare ROAD DI Inlet \ l Sept / 5 / Sy / S~f _ Dr Rndon, IS.31 8 r • 3 Dus.ny /O / J / / Header4Jan -7. (off n . U7 5~ Al :514 Acrat:nn Ust Pipe 7.1 cA, (6 2 HnldirH Dot_ systerr O' $d. 95 • 5 O TT !'final Grade 2 . /O PUMP/SIPHON INFORMATION J PAanufac:urer 11,, De-nand Sl Anver J.r3 /W,5 i ZOC.vW~ (::rtd Y ~w.~ 77 Nadel Number TDH Ldt, FncliuO i / System .,r~tc~ DF!I 33 l AJ /1- JI ~ Faccmalc lP.nyfh / Uia. r• L's:.r lLell r I 2Z Z SOIL ABSORPTION SYSTEM ac jIL•-r:Fes PIT DIMENSIONS Vo "'1 dcG Ce Iv 1,1? UED4RCNCH u:h DIMENSIONS I .3 1 2- Vt-_1 "-4J SETBACK SYSTFM TO PrL NLDG PeFI LL I AKF!S I REidaj LEACHING L'a `i.l. cueer INFORMATION CHAMBER OR 1 • `D~' T, it y.:rrr / / / UNIT Lr ,hA PLr^'~•. ~o~, Fwd;, Z5 ~o (.9 41 3 h DISTRIBUTION SYSTEM Abb~-; ~ i+. f5 7,0+- ZO = -{O 7or-k- , h~nd-rN.-:oit:~tl I:¢In},,I o~ Ho4: Srze v Ihpe 5pac-ng Vrt N Ail ml.rk/E P?1151 \ N1_1 LrotF ~ 0-.1 L4 _ Ivr:.pi•~ \ Dsr \ bpacinr SOIL COVER x Pressure Systems Only xx mound or At-Grade Systems only girl r 1Dopllr C';er L-USer( S :h^llS YJdx rv ldl lpMN I!: Tr r+~l ::1st:- 5~• c.,' Bench Eoges\~, T Vas Nn '/c+ ^ No COMMENTS: i.relure eaxfe dr.;cwpencies, persons present, etc.) In:.peea'or zt_ - - Inspection Location: 773 1.121 t! Av~1r~1ue Hidsnn .^:I CIS (S'vu '14 SF 1:4 20 T7CN R19W) NA Lct 2 ~areel No: 2t•,. 0-1SOR`.tB~ /r 1) All HN Descnption = r~ ~•1i'a• ./..~5 Cs 2.1 BId0 sevro•Irnytn=~~~ ~(n, d1( amount of cover- CAA dC UJ F~ Lw,M~ _ Plan revreion ReyureA? Yr.•s Us_ -_dt.er side I .r amcrtrn,al C-1 N,• 04_/09/2008 06:42 17153861002 DIVINE CUSTOM HOMES PAGE 01 5} - $91; -3 51-/ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AOREMOIEW AND OWNERSHIP CERTMCATION FORM l Q.le `a G c? 7 h owner/Buyer Mailing Address Property Addinss 7 nd 7/c k n- l~JZ S'/ of b (VWgiindm requo" nom Plamiaa DVwtx%W for new maabuct an•) City/Statc u ~S .L , luz Parcel Identification Number o J C - / t) 6 - O - SO LEGAL DLUZ=014 Propatyl..ocetion_._Y4,-Y.,SxoZ~v T NR i W, Town of ST• S~ Subdivision x Certllled Survey Map 8 Volume . P M warranty Deed M b 5 3 9 . Volume . Pape Spec Lore yam lam} Lot saes ideauQaw~f ye.1 no SYSTEM MADrMNA CE 12wnoprr use and xwdm raooe of yas aaptic syao®caoM ruoh in is premahee failure to hU%dk Proper eaiateoaon omstm of p wnpiag out Ube septic tank tray thm Yon or wooer, if seeded by a Yawed pmaper, what you pat btto the ryeteo rm affect the t6oetion of tae septic tank u it baermmt gate is use waft disposal sysem. Owner responsibilities ate rpecMW in I Comm 83.32(!) and In Chapter 12 - St. Croix Canty s.nNary Ordinance. The ptopeny owns as= io submit to St. Ctoia Cosety 7matg Departmwt a tartinaatiM farm. ' by &a owner rata by a maatrr plumber. )oumaymao pbrmber, madetod pb tibw or a licensed paager verilyws that (1) die ortiae dispod system is in props opaving owAition aadlor (2) after inspectioe and pumplag (f noun ry} *a septic teak is dm 1/! LH of sludge. Uwe, the tmdadgnod bare read the above tequieemeoo mod agree to maintain the privab strwap aptcm with the sardards tat forte herein, as act by the Deputuad of Commerce and the Depaemotnt of Naemal Rnow9w. of Vruca sia. certiBeuim paling 1bu your acptio syaem bas berm maintained mast be convicted and nnanod to ttte St. Gbia Cuutiffy Zoom, Dewasnad Wi 30 days of the Own year egAradoo data t~ SIGNATURE OF APPLICANT DATE TioDI alwal Uwe IM u i rte~on this n br to the bat of myAour kwwwp. Uwe smhra the a) of Wo d J property dumbed - rirbu~t'L w tdeed rroorded in merry of Dads Ma S N TURN OF APPLICAW DATE ....N Any tnformadon tbat it miaepeaamad may Riait in &a =jwy pe®it being mmatad by the 7.Oahu eNSN lOChada wqh WO application a atamp.d wraoty deed nom dw Rsoattr of Deeds Oaks and a copy of Ih0 aesray map if Rf =w is MPA in the Monty door. S?'• CkO1X COUNTY ZONING opproE NOR CFRTIFIC!A1'ION STATEMENT UTILIZATTON OF AN EXISTING SEPT* TANK 7'tE t s i s to cacti fY that L have .crv.i.ng the inspected the sePt' lc tank ) ~L~ --i1Ld , ce L resr-r J - eSi ~t Section r dance loo• ' ated 10`1 T~.N, F f - -.W' I'o'•dl the tank - Upon inspection and baffles to be in 1 certify that T have ; otntd "nctionin good condition, and it a g properly- ppear, to bt, at"t time serviced: lo,, bark occur from absorption system - Yes; - No (If no, skiP next linej. Approximate vo?ume or longth of time, pacit-y: ~~i ) % 4allons - _ mi:iut = "onstruction: Prefab Co n(:rete_'-/-- Steel E'!.utufactu - Other _ (1: known) : e 77eer j, - of* Tifilk/ (If known) : turn) 3 ~ pr.- (Name) Pte se _ i nt r -se Numaerj- - D.ite - - 1'Qr-:n t.o be comPleted by licensed plumber ~ Statutes) or Licensed NR e Disposer ,S.145.06, Wisconsin Cod ( 113 V.1E;COn$in Administrative !'iuEnber (dpplY.i_n(7 for satritary permit) Cert ficat.i.on. - - - - it accepting the above statement regarding exist in see condition, I certify that the tank to the best of my knowledge wi '"nt:orm q 9 6 L1c tank tv the re u.irements v TL HR 83, s. Adm. >pect.ion openinq ver outlet baffle Code (except for ctur sign .1 '~J MP/MPRS [ 4 1 ` t v. Ja Sri 1 I III >~JLb u •i ,t ,t; ~arH a~~~ ,s k, -1 F III Xl. 4V. ©f1 X f XI~ ~ ~ I II¢~ cn' W 66 III f tj. J~~ 11 = FE F F t C°'•. i 'I XI ~l - r "~I ti jl F t.t 440 w .1 ~ I I ~ I_t c II L e r _ i~ I J ~t ...III I ~j X_ kX r~ rr/ ~ I LI;IIIE C9. IF I C[ ULE III •4-- ~i ~~paj:l aG 'Q - iF ~r - ~ a . aPal ~ a d ell 1 i ~irrYl`° 4J`° v ♦R ~ ~ ~ 7 a•~E . s i . . O I ~I~ n v •iv >a^ i . u X ~ ~il f Pli ! ._-aoa'v _ 1 Y,~ Yl n ~ I i {Y (I .Y` Y Y !~FCj ~I ~ p , u ~ e iIS ' Y~l .Y ~ 1 1 956 ~ ~ y ~ . „ f f E u' F ~M t I Z L 1 f ~''Cp Q 6 ~ LL ~ r_ `CIA I Y 1 f Zf I e...,..n- } X ~ ~ BBl pj C ai ~ iYYd '~4 itii it I ~ j- o ~r a _ q4 il.Ti Illl x LL it !f a ~ - rl~ ICI Q I I i I rl I ILL J ~ L S 1 -J Qp r r' i y U 0 I. I I 1 lea ~p Z I I 114 1 i U~ :1~ 4~ I I Q , = n F> {I~Ir Iz i oil _ e~i~c~mer~ Commertl8.wl.yOV Safcty and Dndd(ngs DrvlalOn C°unry 201 W. '25' Avc.. P.O. Box 7162 ST• L~~x seonsin I Madiso S 7 2 SanGiarylIPermit LNunsb. (to be filled in by Co) iDopartmom of Comm•roe 5 / T D sL - Snle Tnmac+ron ~umbrr Sanitary Permit Applicati NA ~II I In accordance wish a. Comm 81 742), Wis. Adm. Code, submission of th s form Ic the arMroPnnt menu` _ fdifle mt denm.i47Y add m) ,,.it is required Prix m Obtain ng a %amu y perms. Note Application fonm liu slate-owvcd POWfS ate 11Oiat Address( su)unlned to the Dgvrnxs! Of Conunuce Personal infomation You provide may be used for seconds purposes in accordance with the Privacy law s. 15.04 0tm). Stars D~p~ss-/.Cn -5 j ) 2 N' MLAJ - 7 7 _I. ADpI{GOon Information - Please Print All Informado parcel --{+I Pmpeny owners Naux ~ ! rr ) , t Dui RRl 0SC-1Oia, 8-3C -r G~1S0n I ~EVEfJ G t, l.Y.yfv ElufC.- - --PR17-L1111CJ.---- Prpcnyl;mion PropenY Owtrc!'s Mubnx Address ("7 11,0811-. Zf&Y-?WE. WA`/ ST ,CRC'IXCOUNTY 600, EA-- ('ity,State Ziv Code lac n7i Sv^1 'R, SE Y. Section 210 LAICEV\LtZ (A, e4 I J OLls - T (urak ore}., ' 14 - -t-- _ N: R 14 Eo(wJ il. T'ype of Bullding (check atl mat apply) (Os/le~ Lot a 1 - Z riuedsvimon?iamc- - - . I or7-Family Uwcllins - Numb. of Bedrooms nm:s o..i•sC_ Blocks ❑ Publid(-ommerclal Ik+scribe Ise _ _ _ ~1_s.•^- 0 Ciw Of CSM Numb. ❑ Village of I-1 Sett owned - Desc>ibc Use o[ SY SWF.GH--- 20 t20 4M 5497 Town Lill. Type ii( Permit: (Check on1Y one ox on line A. ComplHe line B if applicable) A' New 5,,, Replacement System ❑ TreatmenvHoldmg Tank Rcplacrnlenl Only ❑ Otller Modsfica(lon w Ginmg SYSgn(exdain) - . (.sst PrNious Permit Nu[nW and Dar Issae0 R. 0 Permu Renewal q~ P.snn Revision O ChanRe ur Plumber ~ Permit Tnmfer to New /J Before 1"Ou tun _ Uwsser^- I1,. TILc of FORT`: Svstcni:COm i~n. ~7pr.L'1%c+lcc: (Check.atl Bsat apil}i P. Non-Ihess.iud "Osund 13 PIti-need In-Ground 0 As-Gladc [J Mound > 24 m. ofswuble soil Mound < 24 in of suitable sal { U RoldinY Tank Osher D11iae-1 COmpnncan (exPlssn)_ ❑ Prenntment I),-.- (explain)- V. U'tx0r5sl/Crtalment Arn Information: 7ed Ocstgn F'!pw (Yla1J Design Sod.4PPlica nn cale(Spdtf) Dispersal Arn Requ* (If) Dispersal Area Nr (sD Son 000 - se aVI. Tank Info Total a of Manpiacturcr rN Gallons Umu NeTril00 le- K zoo 12co VII. Responsibility Statement-1.(be uadersigoal_assumeresponslbility for fast lalionoftkeP WGSshowaontheAttached pl~- lok ber's Name HuIZ(Print)U3uRT tuber's isgpn -rc - -RSJ -P/MFS Number Dusinm Phorc Number f Plum Me z.-:-j- ~f5 2~s-~ssl t) w L-. k.-~6r~s Address (Suttt. City. Sux. Zip Cod ) 7u I,_.. WeL~sr.t oti_Ra o Na Vlll. county .'Dc sarfinen_I use Only -T_- --i- - -j Permit Fte Due sued S I fssumg m Stgna Appmval Ise 22 d (S 1 It (itv.l Rwon Lknial y5~ L__ IX. Condld~fEs Masons for Disapproval M.X N ec 6 ! $c.g ('cw.~ 1. Septic lank, ef0ven! flier and I 0.w /D r Sr Ate dispersal cep mast al be services r maintained µ w f / as per management plan provided by plumber. ~o0 /s-Ci5 J f~, ve C z. All astback requirements must be maintained ~svst<m aaU mbmlo la<Comt, oNr o. paper nor t rkm s b7 a 11 IncMa le axe ~l~s~- mop SDDfi}9R (R. 01;011 Valid Ihm 01!09 ~e^1-t f Ia r O~ l tv~ Plot Plan Page S of 6~ Property Owner t,{A,., Legal Descriptions yw z = SCALE IN FFEET 5W hA F- 1H~ SE'r4 L 7 Jl 1~StPHr~5T CRSn( C'la 0 15 30 60 CONTOUR INTERVAL = 2' EXi i PpCF `-~--89 9 . 10, C i L y \ w~ 03 j4„ rpAK FX/STaI'C ~E~~ ~C 4 "~0 ~i ELL) 24 BBB - ' LOCATION MAP 3a' SECTION 29, T30N, R19W, TOWN OF L JOSEPH, ST. CROIX COUNTY, WISCONSIN GIe•~'^' vle_ h F~ [NCO PY SIT SCALE: 1"; 3000' h~ mill, RECEIVED SF MAR 0 2 "[9no - waconsnDepartment ofCc Vie SOI EVALUATION REPORT pap--,/ Division o! Safety and Wdings SI. CKO~x 0L1N1Y :n accordance with 85, Ws. Adm. Code County 1 Attach complete site plan m paper rot less then 8 i/2 x 11 moms insure. Plan must direction and hpererceenni dope scale or d mensions, noM anew, aMre~locs~ton and distance to nearest road. Parcel I.D. 030-0 &Y-30-z ~ ' 2- please print all intormation. R by Date 1i.1,n+ J Personal Informa4on you pewee may be uses for •ecorC+7 Wrposes (I'nw•q Lew, a. 16.041 (1) (m 6 Properly er Property Locatlon Z.- X Govt. Lot ! 114 ! - 114 - r N R C 40o w Property Owner's Mailing Address Lot BIaiPN fAA er CSC Cly Sw4e ZIP Code Phone Nlmber city ❑ Village 29 Town Nearest Road ~Al ❑ New Construction uw:6d Resldeneal ! Number of bedroon s Coo ~d d design 6" rate GPD 14 Rep{acemerrt ❑ Public or commercial - Desc be: _ _ y ~2r1 1 Parent material _2)o FIQg~gtLl\)_ ifapLpYraile-ZA15 / qL ri/ q_ -ts aamnndatons: -`f:~'ff~~ e]~G. .S~ CY Yom. WLNY'[ -~v vd2_q .Pm~~~ Bong By s y S Boring * ❑ fo pit Ground surface elev. J .L-. fl. r~a to limi to or >-Z, in L1J Horizon Depth Dominant Cofer Redox Description Texture structure Consistence Barrhtlery Roots GPDtlP in. Marnsell Du. SC rill rlo: Gi7Sz, Soh. 'Effat 'EfW2 s _ •~1tas+~C_ - c 11F (0 ri Boring # ❑ Boring , Pit C'xound surface elev. -2 7-fl. Depth to lihrrling favor __in. SoN dkatlm Rela Haven Depth Dominant Coo - Redox Description Texture Structure Consistence Boundary Roots GPdlf in. Mureel Co. Sz Cont. Color Sz Sh *E1181 v/, Z I 'Jiftion #1 - BOO > 30 < 228 M91L and TSS >30 < 15g mg4 ' E18uant 1t2 = BOD < 30 mg~L and TSS < 30 rig(L Signature/ Sf Number CST (PI - i ~ - Address _ ate Evallrabon Conoucm Telephorhe Number e ' Property Owner- j_ , - - Parcel IDS Pape_', of f 13 ❑ Boring Boring ph Ground surface elev. 2 lft. Depth to IimitiV fads fn- Sol icstion Rate Horizon Depth Dorninanl Color Radox Description Tao" Structure Consistence Boundary Root, Gl in. Munsel Ou. Sz. Cont. coin Gr. Sz. Sh, 'EBi1 Ef&2 W/f 7 3 4 42n F -7-11 ❑ Boring / ❑ Boring ❑ Pit Ground surface elev. _ 0. rk0,Ah to linlprg factor Spit Applicatim Raw Horizon Depth Domtnsrd Cobr Redox Description Texture Stnrcture Consistence I Boundary Roots GPDM In. Munses Ou. Sz. Cost, Color Gr. Sz. Sh. 'Eipfi EI82 i Boris y ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal ration Race Horizon Depth Dornhsnd Color Redox Description Texure Structure Consistence Boundary Rolla GIRM in Mvsetl Chi. Sz. Cord. Color Gr. Sz. Sit EflM1 EM2 Effluent #1 = BOO, > 30 1220 mWL and TSS >30 < 150 ngt_ ' EOluan 12 = BOD, < 30 MA and TSS < 30 MWL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608.2663151 or TTY 608.264-8777. swsessirRw,m> Property Owner page of Borng# ❑ Sonty pit Ground surface ekv rf rft Depth to limiting factor In Sill AWkston Rate Horizon Depth 1bnJnant Color Redox Description Texture Structtre Qpn.4lstence'. Boundary Roots GPDIIP in. Murusell Qu. Sz- Gem Cola I Gr. St Sh. •EIIA1 ER42 7 n -AL7 _ - - 7 _ ee ? 4L 5- Z; i r lJ Honnp s ❑ Bormg t_~ ❑ pit Ground sutacc elev- it WMn to limiting tailor in SdI ADOMbui Rate Rook GP[Nh' Horizon Depn Donnnant Color Redox Desrnption Tedvre Stnwture Consistence Boundary in. Mtasell Qu. Sz. Cont. Color Gr. Sz. Sh. Eflai EW2 Boring ❑ Boring Groundsudace elev. ft. Depth to limiting factor in. ❑ pit it _ Sort AeDliestion Rafe Honzon Depth Don inarn Color Redox Description Texture Structure Cocsiatenee Boundary Roots M. Munsell Qu. Sz. Coal Odor Gr. Sz. Sh. 'ERtt Ef62 Oluert 91 = BOD,> 30 < 22t1 nWL and TSS >30 1150 rrQ& • E-Muent 82 = BQO, 5 30 RVI. and TSS 30 nryL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please anttact the department at 608-266-3151 or TTY 608-264-8777. sapatwtnmmm S R 1 '-T--_ P - 1•~ fir` I - ~ ^i I S p J. / ~ / N i5 r ' Z ` 1 rNrt VJ I / I A +J 9iG~ I}1/ O/ ~y/h % Cb 11 It R Tug i I u J. LG 3!FVd aN IZ33NIENJ3 N3r]°u 1,9FL ;LbS TL f0:80 900z/Lb/La