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HomeMy WebLinkAbout020-1353-59-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM coup Safety and Buildings Division INSPECTION REPORT �t. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanit/ggr4tNo.: Personal information you provice may be used for secondary purposes [Privacy Law„„ (1)(m)). Permit Holder's Name: 1 ❑ City ❑ la a own State Plan ID No.: 3okeness, Jon uc�so I c A CST BM Elev.:- Insp. BM Elev.: BM Description: ParcelT y °353 -59 -000 -9 97 .-10 5144,# ed_ cloi4A. C TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark2 p W S CLZ�) 0.63 91 -•-`, 0 Alt. BM Dosing g W2 S Pp 1 2 0 c'`f•S3' Aeration ___________---- Bldg. Sewer Q Il Holding St / Ht Inlet ?,: -i( • q9 TANK SETBACK INFORMATION St/ Ht Outlet 9.0 S— • (p S TANK TO P/ L WELL BLDG. qe Intake ROAD Dt Inlet 9. 12.. gcl. /' Septic y 50 ' (\ 1 ( NA Dt Bottom [2.15 Sg Dosing >5-0' / 1g .,• 17' NA Header /Man. 5 -5-2- 93. Aeration NA Dist. Pipe S ' s} ' 4 Holding ) Bot. System 3.0(0 944.7-' PU ' ' HON INFORMATION / Final Grade Q•TS 9S • Manufacturer -20e.Q Q4� m De St cover 3 • 4c f _ 9Y• 99' Model Number s-3 3 S 1.— TDH Lift y5 3 F I S- fyeadm`— H cAelFt j . ' Forcemain Length 35 Dia. 2 u Dist. To Well SOIL PTION SYSTE $ice / Width Length , ( No Of Trenches PIT No Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 .9--s I (a)._ DIMENSIONS , SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING .c rer: INFORMATION Type Of rr / J CHAMBER M$Number: System: (0 3t C -) OR UNIT G J t.v�C y DISTRIBUTION SYSTEM `C c Header / Ill- anifold ti is Distribution Pipes f --. � x Hole Size x Hole Spacing I Vent To Air Intake Length V Dia. Dia. Spacing � 10 SOIL COVER 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 LTopsoil ❑ Yes ❑ No ❑ Yes ❑ No CpMMENT (( Clud code_disc e ies, t ) Inspection 41: 05 /(6 /crs, fnspection #2: / / Location: 6 f- i�'iiary arm Road, iz cfson, 4 s (fl r s t / SW 1/4 36 T29N R19W)) - 3 Cot Ridge - Lot 59 I i / -F S ) l 1 4 1 e�►ca'" c r w.�6 wSJ l .) Alt BM Description = b � S �� l_ 2.) Bldg sewer length = l k r - amount of cover = } '(*Z'4, r _ ' Q, it 3) is4,-td C S v Q Plan revision required? ❑ Yes 0, No \ 0 v Use other side for additional information. pQ 1 B oD � a�_ ., S 7 � SBD - 6710 (R.3/97) Date Inspector's Signature Cert No 1 • r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: mm . �m....e mmm , _.. x _. gy m. ....__. ..m_....__. �m. a. �.. ma 5 € E S .......... ... ��� tee. .,....,.. .... ...ari % k d ... eve �,�... ... ....� f- e_aee5 e »tea ova' m mm.. ti.f �.t. 8 I E Y ' 15 a s te«. . ..eme. a,... g ...,.. . _.,.. d8 _c £E F g i ,_... .. .. .e.m .. .i-. ' f . « ,. . g g ....a ., _. .«v. ....� _., ,.. g _. ... ... .....,,, ._ .......E } E 3 .e..., e ._„ »..... A.� �.,,...� .� ..... .. ....... ae .W.�..,..� . a..e ®� ... .,,,,.. e, e W..... '15 15 .�, t. .,,......d ee ®..a. i.. '. i i 8 j € H k E E e,- € E N E .� ,`t ..... ......: _ _max... . te.m ... ,. .... tem... ted ..,, ..w »... ._.. _..�..1. te� t S _ _. ��. ,.....,...� mm i Y,Ar, '-i1 Sanitary Permit Appl Safety & Buildings Division hi Was In accord with Comm 83.21 •� 1Rode 201 W. Washington Ave. See reverse side for instructions 1- ' g : • cation PO Box 7302 " information you provid Madison, WI 53707 -7302 Depertm nt otC rtbme Personal infrmation ou roid T*�' 4(1 or . 7 • : , , . uses [Privacy . .04(10] (Submit completed form to county if not 1 e? state owned.) Attach complete plans (to the county copy o 4 - r the :'" tr ' r': . not " 8 -1/2 x 11 inches in size. County C t KO I S � t` T t xumber • « . _ i rev to prev ' ' oys State Plan 1. D. Number I. Application Information - Ple Print all Informatlo G ' W r - Location: /, P Owner N 57 U rw r l Property Location Me) 55 Cr�y11w , ` Cr. ` J b /.1 Me) t i` 11 / i NW1 /4Si 1/4,S �J / ,N,R E(or) Property Owner's Mailing Address ' , Lot Num Block Number • 9c 7 A) (..p, (6,,. 4 ,. 4" / r i _5-9 Zip Co City, State Code P Subdivision N ib a or C IM Number N4ps6w (,Y S''M1 ( ('11.5 )18(,-.77,)\) C`-11o0 Uool� , II. Type of Building: (check one) ,, V ❑ City 1 1 or 2 Family Dwelling - No. of Bedrooms : 7 ❑ Village ❑ Public./Commercial (describe use):_ ® Town of I% ❑ State - Owned I`' tt DI 6 jJ Nearest Road t I p p Parcel Tax Number(s) 0 - 1.4 53 i92, -Qt III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 31. P9. /9 e/ A) 1. Ig New 2. 0 Replacement 3. ❑ Replacement of 4. 5. 6. 0 Addition to System System Tank Onl Existing System B) Permit Number 17 L Date I ued " Sanitary Permit was previously issued � P 3 0 7 I S7U /Q 0 IV. Type of POWT System: (Check all that apply) V on- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line O At - grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information : ?4 i ealied a . /�rl ,f C%14.�k,s 1. Design Plow (gpd) 2. Dispersal Area 3. Dispersal Alba 4. Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed -71,5.2_ Rate (Gals /day /sq. ft.) (Min /inch) Elevation (0 oo "750 3=x" _ 8 . 8 c ) a 5) , V 8'o VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks , Tanks See t c, 1 P () �. 0 j Wee - ❑ ❑ ❑ ❑ R AN-, \ ;ou �r "1 a ❑ ❑ 0 ❑ VIII. Responsibility Statement 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's h mber's Name (print) PI . - M . :, no stamps): MP/MPRS No. � Business Ph ne J'I en 13b4 %-ee-t r 1 r' v D)1 961 1/ S- 7 0 L 9 0� 0 Plumber's Address (Street, City, State, Zip • • 1 ) 6 7 v iS N rasa L (`)o/ (o IX. County /Department Us my ❑ Disapproved Sanitary Pennit Fee (Includes Groundwater D Issu - • Ag j o stamps) %Approved ❑ Owner Given Initial Adverse ? Surcharge Fee d 1 /i p 1 i v . v .. Determination Conditions of Approval /Reasons foryisapproval: -fA s 4 vis/ i w "S App t1 v( tete ke afe(6 wrwr r,3 • • �-..�.. H__Ii.. .x 1 . ...t1 nTt_ L ..._a t S./ ..e. &incier_ .. -- - r f u e_e_ - 'PJL, Lec U •• _ • IA Lott a./-io _te P 44a90 1 , 'PZ. OT -inr713--- . 1�NC as' '�� �iui5;c >h �Jp✓ O6.) ply brtp • as T32, SRI S P (1,0. )6 ?au 9p t r, Q�'1 "� T Ix)," , 3).1 � c 1 a I (zo., 1,¢ J 1 GRORo0►n 3x05 igni1 • I.lo,,., o- G "ar Lev Ivb.O i ii i3 = �P of V) M PVC G/v Notch, (-0f I • _(3 <t�)104S • -t k) ote ; W-P 1) u rA K1ko R 1 ►, as 7C' ' fKon, . - seft ) Ai Sfifyv, 11 I A R. rn Ro A >7 - - -- — - S. Iv K II1IIiuiffli Ii L r3oitop, ),,,, c, f 6-,:t3°) n 1 iiiiiiii"iin" 9a - s 3 m 116111111111 II) ai 03 N p impilimin � � i 4 o0co b o 1 �` ll l�llillll �� S llIlliiilld ) F , A 0 11111111111111111i E t' r �, . c 2 x t[i oi - 1h!iIIIl�JIOI ----- E �� � to X rnM W _ - Pl� Illll P hI T l' - i IIL iii IiiIh1 I�� o �o Z iillli E ,� III o _~ NMI j . III �' ��III{ �. M O N 0 1 2 23 Z5 8 1. -- �I�nillli111111 W Y o 3 a 11111 1111111 D c 0 N d 't7 . a x _ Ey, at 09- 1 E." , .n., ,., .,,, 1 u_ � — L >. 7 7 co c m ° 2 • c o v . • J bt� l K' m ss 82 PRIVATE SEWAGE SYSTEMS - II PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS . /--N ��- V C J T CAP T ti' C.I. VENT PIP[ r —' WEATHER PROOF APPROVED LOGKIRIG JUNCTION BOX MANHOLE COVER .! FROM 000R. 12 "MIN. T '4IIUCOW OR fRCSH AIR INTAKE I _ y ��i GRADE 1 `I • MIL' .. fi * IV MILL 1 CONDUIT \ -- Il'MIN. V ` ; J PROVIDE I - HOLE T A IRTIGHT SEAL I I II V I I I I I APPROVED ANTS JOINT / A Id W /C.I. PIPE Wei C.I. PIPE I EXTENDING 3' ' LARM EXTENDING 3' ONTO SOLID SOIL 11 ONTO SOLID SOIL • 8 t> C EIEV FT..•..•• PUMP --- ' -J r Of F D • ` CONCRETE ELOCK --.4 1 r /as45 el723_ (/' RISER EX 1 IF TANK MA HAS SUCH APPROVAL T PEP.MITfED GNLy SEPTIC E SPECIFICATIOPJS y DOSE Wiz.-ft F-5 NUMBER OF DOSES: 1 PER DA`V TANKS MAAIUFAGTURER: TAAJK :•IZE • 6 0 CL ALLO•S OOSE VOLUME �l'D T I� • flN AID INCLUDING 6ACKFLOW: GALLONS ALARM MANUFACTURER: -rS ; .14/13 MODEL NUMBER: ,uI CAPACITIES: A= INCHES OR GALLONS SWITCH TYPE: ' 1 5 = INCHES oR -"It 3A ZC7elt•R Ca 8 INCHES OP. L y Q�LOUS s � i /, PUMP MANUFACTURER: Z , 4/p .MODEL NUMDER: 5 O= I IN CHES CR . GALLONS SWITCH TYPE: � MOTE: PUMP MUD ALARM ARE TO EE INSTALLED ON SEPARATE CIRCUITS vM MINIMUM DISCHARGE RATE , VERTICAL DIFFERENCE 6ETWEEN PUMP OFF AND OI5TR18UTION PIPE.. I FEET + MINIMUM NETWORK SUPPLY PRESSURE j ` FEET Pt) ./9 I/ { FEET OF FORCE MAIN X 1.t/° F X0FTFRICTioki FA4ToR.. .!'/( FEET Lt/" TOTAL O HEAD = y zs== FEET G OF TAN : L N 'LIQUID DEPTH e TH ;WIDTH � �� INTERNAL. DIMENSIONS J E 6 SIGNED: LICENSE NUMBcR• 4 Q I "� 16 f DATE: " `O co HEAD /CAPACITY CURVE �b� �'K`��� EFFLUENT and DEWATERING LA CAUTION I Model 185/4185 should not be subjected to Tess than 30 feet TD H. a r MODEL 42 qg 53.55 ' g8 137 138 140 161 163 165 185 186 188 189 191 57 59 4140 4161 4163 4165 4185 4186 4188 4189 w ,® ® ® ' m El 1 m ��En ® ® .® AEI 1- w gy m ' ® m , . m Ell El - ® ® 1:1 131 s w 0_ _ '0 _ _ _ t • El MN mom En ; ® ® .■■ oms— i": — — EN': `® 0 0 m ® © IN MI" WU ICI 131 140 ., I=2 2. _ � �. IN 0 ®, m ®� ® 2.2� m ® ®¢� 42 - �MM e a �� = „" 0 ,. ®�© 4 © ® ® � 135 ` 7,, N N�- ___- I= CI ® ® El El 1 r _ k, I= mo M 'I ' MI — _ I= - : i . `® ® ia " � m ® 40 130 � �� IM MI ® IN ® 1 ® m , ® .- 'M '' N — M E - M M ® IN m ® 38 - 125 INNEELEI _N :I= I V - .•IIII ' °- MI - N - I D M m E - -r. :E 'I — 1M MI NI - NI ' O IN 1M E 120 11111.17_ - IM - E y - N - E — K EN -' _ =11: M.A.. = _"?. ME �.. ,'' „ ?MO ..,,� <_, El .W �� .�x.� MI NE a�.�E 36 LOCK VALVE: 19' 19' 19.25' 23' 26' 46' 56' 66' 56.5' 73' 114' 91' 110' 137' 115 34 - 110 32 - 105 , 100 Ill! I..� 30 - 95 28 - 26 - 85 1 24- 80 75 0 20- 90 70 L hL } t8- 60 `110 �11110M ∎11 4163 .m�1 1111 I1111. J o I 16- 50 knINNIh ∎Il I11�1 1! i!i!II 14- 45 12- 35 1 414 � MI R %1 I� �•���� 10- ...Mg Na!SENIIIIMMEIMIll 30 8- ='139 'I , 4185 25 \ 4- 15 „ \I,,`",. \ 10 �\,gal 12 111\�\ .► MEAVAI \WE � 9 98 0 1 ' U.S. GALLONS 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 LITERS ' 1 ' ' 1 ' ' ' 80 160 240 320 400 480 560 640 0 FLOW PER MINUTE 009922, l Ctr \V( 1NiaconSiri Department of Commerce SOIL AND UATION Division of Safety and Buildings . , , Page of Bureau of Integrated Services in accordance CC r? m 8 63; Adm. Code / \ }e my Attach complete site plan on paper not less than 8 1/2 x 11 inches rri ?e. Plarl q f VE D include, but not limited to: vertical and horizontal reference point B direction and --- C2-01 percent slope, scale or dimensions, north arrow, and location an ' , nce tp,Pgarest roa x100 PateI I.D. # -- - , r ii APPLICANT INFORMATION - Please print all info *kin. cO l trvj4wed b Da f i Personal information you provide may be used for secondary purposes (Privac !„e 14 ( r 'ICE ' ` %RC ( Ao A 1 6 6 o Property Owner 11 `` `` ` , . e d�r LQt$tign % V 1 - ‘-k v ` , . ,uEsS ~ , Go to te p 1/4 SE 1/4,S K ( - o T 2 C ,N,R 1 q E (ore . Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# ` k o4" A 1 Es. s `AiuE R? c o- �lrn..c.,�-vo-� '1� ,' Q -e. C State Zip Code Phone Number ❑City ❑ Vi llage To Nearest Road i Hv (U I W= 1 540/6 1 (IIS )51r6-7 go c$cov∎ 1 C rti /t/ 'New Construction Use: IC 1 Residential / Number of bedrooms / Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow OW gpd Recommended design loading rate , 7 bed, gpd/ft . A' trench, gpd/ft Absorption area required $< bed, ft 7CO trench, ft 2 Maximum design loading rate r 7 bed, gpd/ft . e trench, gpd/ft Recommended infiltration surface elevation(s) 1 q2. 8 7 ft (as referred to site plan benchmark) Additional design /site considerations / ¢G71• 12 . f34---- % Pl'p Parent material (1(3 f "'l A JCG 5, A Flood plain elevation, if applicable --- /- • ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in FiIL Holding Tank U = Unsuitable for system 11 S u g s ❑ u g s u E' s ❑ u ❑ s ® u ❑ s' O u SOIL bESCRIPTION REPORT Boring # H orizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots x �,,.�. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench %s�rl;ii 1 o -S' Icy 3 /Z 1 51 Z b �� fie∎ c5 1 V S ' C R y 2 g_ -z% to y14 14 ' 5 ZnAbti-, ww fi C$ 5 : 6 Ground 3 31 -4%s to Yk. ti 1 y 1 W I �g V`� \ c -- ?- , 8 elev. r (,. &3tt. y tit- Les \i(1. ( 6 ? r^5 v.....-1 C5 Depth to / limiting `( S 4 V factor f111 �� 1 in. ' Remarks: Boring # 1 o -r to yR. 3 / 1 * t^'k.Gi C5 \u F •' • 6' Z 8 -21- /0 7 k_ L 1y ' S 0 . /VV YAM F■ cs .s Ground q Alm lo y e ct 1 6 ? � cps C V v... cS' . 7 , ,g elev. 1.5,b3ft. . , r • Depth to limiting ' factor HIV in. Remarks:. CST Name (Please Print) Si. _ Telephone No. M11 3c , u- . - — __ 415 Zy 4- -- YCo b- Address Date CST Number - z,\ « a '''` sv 3 0 ei2_,sc -E ) stia ZS 5 -/57-00 3 0 c • PROPERTY.OWNERC�k GAY ESS SOIL DESCRIPTION REPORT e Pag of 3 , PARCEL I.D.# Borin # Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench o4O ic> Z vw hb . t A( C5 J( 5 ; t / G �L 1036 to 7t it l 1 ,-v 5 %\ z r .'Myf'; S — S C ? Ground .J % 10 y f _ `'f / / (...5 110,1/453 vvx 1 c-.5 -- 7- 1l elev. 1 1 ft. y LIS- )b 1r, 712 Y / C — t^ti5 4::55 c j Lam. l C- -' - g- ' 8" Depth to limiting • factor 110 in. Remarks: Boring # � C ` 7 a 1 ' AINV j 0 -1 to Y S 3/ Z 1 1 (k ' F I tap 1� s¢ C� . ;-= Z to to la. Y / `! 5,\ Zmk yvtvF Cs ^ 5 ;C 3 cl to yR. y Li L,5 1 irh.53 m 1 9. Gr f ,$ Ground C -111 (elk 1 1 ` W1/45 OS4 iv.... l C.5 — 7 , 1S' ?&. S5 ft.. U �t J .� , �6 , Depth td limiting factor ' IQ.- in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. • Bed , Trench Boring # 1 o -16 16 70 Z / Z ,---,• S t1 Zyvailk 'Vu -i Cry ku!'` S : c v,,,.vozqi. Z. 0,-zz. to r.. Y / 1 —_ SCI z - ei r+4u F, C5 — 5 ; C : n; ; a 3 2z -3k to yp I f / `l -- L t r n. hr1 0 ; Fr" Ground C. j as z. /o ),a ( 6 his O L5 elev.' 95.3 ft. Depth to ' limiting , factor rtZ. in. Remarks: Boring # x . Ground ' elev. , ft. Depth to limiting . factor 'n ' Remarks: SBD -8330 (R.9/98) •. • PAGE 3 OF 3 NAME /44.e. r►-ess LOT #5j LEGAL DESCRIPTION Nou 1/4 ' /4,S - <(oTZ1 ,N,R 1 f E (or) 0 ■ SCALE: 1"= ceij BM 1 ELEVATION 00 -) BM 1 DESCRIPTION (io.{.fowt, o .Si ct (et C n 'ra r +- S t.01 4. tee BM 2 ELEVATION q7. 96 36, BM 2 DESCRIPTION 1 ` , - C., SYSTEM ELEVATION q Z. 3 K ALTERNATE ELEVATION z CONT • U ' EVATION 4 mZ • OZ. 63 Ql 7.0% I X I no welt I 1 SIGNATURE �' DATE _CI. �S 00 . ' `� ' Safety and Buildings Division • SANITARY PERMIT APPLICATION 201 W. Washington Avenue Wisconsin In accord with ILHR 83.05, Wis. Ad - . • P 0 Box 7302 Department of Commerce I 1 Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the syste n per not s C. au than 8 1a x 11 inches in size. A / r�j�, / c i X • See reverse side for instructions for completing this applicat of - i � State itary Permit Number i /p � -- 3l 3,P'`t"Y Personal information you provide may be used for secondary purposes I CFieck revision to previ us application [Privacy Law, s. 15.04 (1) (m)]. (o Z ( Wary?"' � r fC� 4 n /)S7 fi t ` f CAN Statla,Rl n I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL I cfNA ':/ Pr Owner �mf / ,Property Lo tiory' lee iqo E 55 � t t 1.14 T c a 9 , N, R / (or W® Pro erty Owne 's Mailin Address Lo krn r ri 4<' Block Number q 'ry Lane. ( gq /�� /: ofv i-ea a t' - -..�._. . City, ate � Zip Code Phone umber Sub ision Name or CSM Numb- . PE • F B ILDING: (check one) ❑ State Owned ❑ 'V N•arestRoad ,p 5 4A� /Vary a. V/ t� r' /YJ ❑ Public 12' 1 or 2 Family Dwelling - No. of bedrooms D vll ow ge of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) .! 36 , zq. ! 9. 2 os 1 ❑ Apartment/ Condo Oc9%o - /353 - 9 -D0 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales / Repairs 11 ❑ Restaurant / Bar/ Dining 4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ 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. ' ' 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an )4 'New System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 [seepage Trench 22 ❑ In- Ground Pressure / ` 42 ❑ Pit Privy 13 ❑ Seepage Pit Z C -� K 7S ) 43 ❑ Vault Privy e 14 ❑ System -In -Fill Z y r , ,„ rs Jefu "v�-� 4'i' %i- l -l; I VI. ABSORPTION SYSTEM INFORMATION: Gad..• 1. Gallons Per Day 2. Absorp. Area 3. Absorp. re a 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade ,\ Re fired sq. ft.) Prop ( / sq \ . ft.) (Gals/da�Y /sq. ft.) (Mi Inch) evation 10 V 1 V O . ' g a. ).0 ' C -.I O Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Exper- INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. New Existin strutted Tanks Tanks ki S t ic Ta nk ekiirrg-Tartk I — D' o u,j ake. ks 1 • , ❑ ❑ ❑ ❑ ❑ .n II ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plur is (Print) Plumber's Si ature: (No amps) MP /MPRSW No.: Business Phone Number: L .J/ ou.al Pto„,4,1r .0.1012 904 7/5- .V6-9 Plumber's Address Mtreet, City, State, Zip ode) /070 W 3,5 � ," 6,c) t (k 5 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No X ApprOVed ❑ Owner Given Initial Surcharge Fee) Adverse Determination 4 2_2 i'O O 5 2 /O O �rr-- p � �� ^c ��ay _ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: /( S 1 r.ar f iv - to" tf ( s e ( SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS • 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be 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 (5BD -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. II. 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. IV. Type of permit. Check only one on line 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. VIII. 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 81/2 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; 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. GROUNDWATER SURCHARGE 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. .................,:12.2. 6 'Pi 0 4( . .0 _ . azki Si cle_toincien5. :, ,. : jp „_. : ... _.....„.... .. _ ... _ .. __ — i . ' u•' Ai *.iirmawsistiro A '" 1 - ItirMailliNIW a r I 1 I I N. - I 14 ' ' ' 1.0 f Q 7 /n/'1 .a 9 ,' //at /'M k'r e/Z5P_ . 4,--2,:9011 ilOT 1` ,..________._______________ cre..,t,„) sicope ---.......____________.,____„--,..._______ .........,____ filloti Tee-e t)t...., aU i _________ 408 ',..._—t 3 I s • • e—s' Al+ hRela T .2 . 4 .. I°o � S9 i s i� 9 — `� t _----- -- - 7,�;j' t S 2 a TRPIVGhP s Ba s i 4 6Pdeoo 3k75 Jo Iii 1 co IIIIIIIIUSIi�� I-� O f &h S (th b co f III 111111111M! y Il a 11 f0%) oi 6fe,00Q 9 (,.D0 I I Illlliiiliili1ui UIIIiliiiii E ` k 5 IIIII 2 c a> x ui C 111�6n�1 III E cv E E 'v c 2 x 0) cc m vas, .. LLI —_- 1 U v to C� _ IIIIiI1IIiiIili w ° ° Z.' _ g Z III1 3 a u m r i11 j `t CI O N +!n U lii -� HI88fNIIIN 1 -0 0 N = l l /�/� U t _ N Of CL • • • • r . , Wisconsin Department of Commerce SOIL AND SITE EVALUATION 2 Division of Safety and Buildings Page of ✓ Bureau of Integrated Services in accordance with- a-It.14R 8 ?.09, Wis. Adm. Code Attach complete site plan on paper not Tess than 8 1/2 x 11 inches i Size. Plan rrmst County include, but not limited to: vertical and horizontal reference potfit (BM), dire4'1ioq,antl 1 S . Cr-Q percent slope, scale or dimensions, north arrow, and location and distance td neareS,t (clad. 'parcel I.D. # 7,!.., VS .26 P.9-5 APPLICANT INFORMATION - Please print all information,,, ` ''':':;:3 Reviewed to c � Date Personal information you provide may be used for secondary purposes \(Prtvacy Law, s, ,i$4 - rn)). i fi �� / 1 ` " �� 1 Property Owner erep Lo ( - ,� GOvt.,LQt "? r 1/454) 1 /4,S 33 ( T Z ?,N,R / 9' E (o( ) Property Owner's Mailing Address 'c• - +, !Lot '1i ' ock# Subd. Name or CSM# t353 Arva kee -�-r -xi �'!�++O w G c, CL R ttl q -e_ City State Zip Phone Number V t''y11 p Code one tuber ❑ City ❑Village (� Town Nearest Road 4 udSCY1 I W 1 1 5 I (115 )5 ( 4-1-t Aries 1 C4'j (2d N ®. New Construction Use: D4Residential / Number of bedrooms 3 -14 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: -7 Code derived daily flow LOU) gpd Recommended design loading rate • / bed, gpd /ft2 • l� trench, gpd /ft n loading area required 51 bed, ft 2 7 56 trench, ft 2 Maximum desi bed, g g rate ' � bed gp d /ft . /� trench, gpd/ft Recommended infiltration surface elevation(s) pr,',ra, e /-eV'. ( 1. 1 . Zv ft (as referred to site plan benchmark) Additional design /site considerations /4 L-1-. t,lt ir, q490 Parent material (- 1 lad al Oe *Nf) Flood plain elevation, if applicable /W/4 ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system Ns u IN S ❑ U ® S ❑ U Ss ❑ U ❑ S - U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 1 O-I2- ioyr 3/2 Si I 2m4bk mar C3 1C . s ; . b 2. 12-10 10 yr LIN Si I 2mo►blt M-Cr- Cg - .5 ' • b Ground 3 3p -55 1.5 yr LI lip — LS 1 m55 rrl'r. c. 5 - - 1 . g elev. 9ft 53 -13c IUyr gilt m3 0 s mI c5 . .. $ Depth to -, L 'L. limiting , factorA�' - 13C• in. 0 ' Remarks: Boring # 1 13-12 l0Vr 312 Si' 2r.-140:314 rn.Pr C5 1-C .5 ; 4 2 2 12 -50 10 yr 4-1 5i 1 2 ,nr Ab 1c mfr- c..S – . 5 • te 3 sa-+tb lo y r- -iIlo — r IS 0 s5 m1 c .1 . g' Ground elev. P do ft. ti ' q Depth to kpt 1® 0\ limiting ', r factor 1214)in. Remarks: CST Name (Please Print) S' • . = ture Telephone No. 4 of S 4: "LE k -2-r i�.�- -� -- `7/.5 - ; ` OUSr Address Date CST Number 4 / 0 1 de -r` Si -A .-5)irte- `f G✓ ( 3 -s aS330 g SOIL DESCRIPTION REPORT 2 • ' PROPERTY OWNER Page of 3 PARCEL I.D.# Boring # Hori Depth Dominant Color Mottles Structure G D /ft g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots P Bed Trench 1 0-12 lbyr 312. -- S 1 2mgbk m-Cr C5 I-C . 5 ; 2- r2-3b lO yr '44 51 1 2pnabk m -Cr c 5 � • co Ground 3 3 I `Uyr N I b -Cs Os5 rn cS . 5 , . bo elev. qs 7of Depth to limiting factor 1t19 in. Remarks: Boring # 1 0 -$ 10yr 31 Si 1 2mahk fl - CS 1 1 • 5 L i 2. $ -42 Ipur 41 2mabu- rr fr c5 -- • 5 3 yz-lo° l(\ yr `1 I4' m S Og5 , t c S . `t • g Ground elev. 74,0 ft. 1, z Depth to limiting Lj4� Kt/ factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # 01O IC yr 3 l 2 '5i1 2rnabk m - Cr CS f S • 5 ,lp 5 Z 10-3i 10yr 9114 g.4 Z rnabk -t -fir G S -- .5 • (p 31 -1o0 lOvr 4-4 l4 0s9 m1 C 5 .7 .H Ground elev. ? i0 ft. Depth to limiting factor Olnin. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) 406+ of- 9 _ ___ - . "--- ...-........--- 5cC-I - C..- l .- (G a A ny f. elcu /00, O -R ac z"P P�Q 7 . gGkos N X Svs w%erev,9Z 3 , 4444, c_lev. 7 /q0 . 41- a 04'11 L• • G.. I 1 I ' • i S 1 -4- b 11 n L s C .t . I s p ■ j 31 aS It ck (b I 'Re' • V vX a so. .M1 • a►0z ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND WNERSHIP CERTIFICATION FORM Owner/Buyer < ----SQ Mailing Address � e x or, c° Property Address .,/ 4111 r2 d' , (Verification required from P1 ng Department for new construction) City /State /4/%0,k I � Parcel Identification Number 6aC `/ ?,`7 - 1 - 9 d0 LEGAL DESCRIPTION 1 Property Location 1 V E. '/,, 5�'/,, Sec. , T 8� N -R / q W, Town of . n Subdivision e f� �OccJ , l� , Lot # 5 . Certified Survey Map # Al / _ , Volume , Page # Warranty Deed # , Volume / , Page # Spec house yes ❑ no Lot lines identifiable C 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 can 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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal 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 Commerce 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 a date. SIG • TURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that 11 statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pro . scribed 4 a - e, b virtue of a warranty deed recorded in Register of Deeds Office. �- - ` /R6 a SIG TURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** 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 r • • STATE BAR OF WISCONSIN FORM 1 — 1982 1621 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS PE ST. CROIX CO. , WI DOCUMENT NO. Vitt 61 RECEIVED FOR RECORD This Deed, made between 04-27-2000 11:00 AM - ' ' II • • ' ' WARRANTY DEED husband and wife, EXEMPT it , Grantor, CERT COPY FEE: and JON R. HOKENESS and .TTTT.TE A H(KF.NT?SS, COPY FEE: TRANSFER FEE: 107.70 husband and wife, RECORDING FEE: 10.00 PAGES: 1 _, Grantee, Witnesseth, That the said Grantor, for a valuable consideration_ conveys to Grantee the following described real estate in St. Croix THIS SPACE RESERVED FOR RECORDING DATA County, State of Wisconsin: NAME AND RETURN ADDRESS ,` II�� -- fS p T a noto.L. RANK of �°A Lot 59, Plat of Cottonwood Ridge, Town of .30-7Satoplo s. ��- Hudson, St. Croix County, Wisconsin. O„ 1.N �u� o 3/. 2 5' (g: Z °Set 020- 1353 -59 -00 PARCEL IDENTIFICATION NUMBER This is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And Richard O. Stout and Janet P. Stout warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions, rights — of — way and covenants of record, and will warrant and defend the same. Dated this 29th day of February xig 2000 1 - r / 1 + (SEAL) ) id _ (SEAL) * Richard 0. Stout * Janet P_ Stout (SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County. authenticated this day of , 19 Personally came before me this 25th day of February )i,12.211(11) the above named Richard 0. Stout and Janet P. * Stout TITLE: MEMBER STATE BAR OF WISCONSIN (If not, i..OTMF=iY PUBLIC authorized by §706.06, Wis. Scats.) to me known tom. ,4 Ee pswroc�`9Sf d the foregoing instru an • .ckiKENgifiNsairrn.eBAST 1 THIS INSTRUMENT WAS DRAFTED BY Janet P. Stout , , 135i Awatukee Tr. HuriSnn , Wi 54016 Notary : blic, County, Wis. (Signatures may be authenticated or acknowledged. Both are not My cop mJis�'on is a.. . (If not, state ex . •� �'� • te: necessary) ' ^l-✓ © off• .) • Names of persons signing in any capacity should by typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED Form No. 1 — 1982 Milwaukee. Wis. , / /� ' , 54 2 , % i , � ' i i � 57 �' 2.690 ACRES / / i 117,157 SQ. FT. i . •j / 4 1. 66' CI DRAINAGE ••••• ••---- »- ....�..�........ .% •� y EASEMENT' '' S I"I.W.L. = 1036.0 5 TY x„ 0` 4 ) .- - . --N S88.55 40 ' _ _ " _ E 582,42' _ _ j % I ! :=..........*.... -- - -- Y __ _ � ' ----: ---------•----•--::::::::- _ .` _ -- •-- •-- •- -• -- -- -- — ':': I ; i 0 ,� /.•• I •-- »- •- ..•.- ...._..........:. 5' TYP. , i I : „n,.. i j '1?: `6 58 �0• f � O o a ` 4 • 2.360 ACRES 0,,, % !, i / I` Ce -+' -•- 10 812 ?, .4, , ! ; 1 • N•• ,'e , % f •%• N* / CX ' i i �' / : , iZ • i ,; Q i , !, ' i LL _ __ __ __ __ __ _N_ _ "_.__38_0_.0_0 ,, . • . , C-- - !- %La ' " •r•; ri n i i i ` \ 4.321 n ii `�� �, „ �. .- _ co 1 ! iv w _ \ 188,1 W 59 � % • i i `0 x• ■ o , , , 62 s 2.034 ACRES ' '/ / ; ! � CEN I 88,604 ; y SQ. FT. / , % 2.193 ACRES !� ;' I ' _._ _._._._._._ • • FT ; 95,508 SQ. FT. i ' -- zi i , r•, i i; \ v I Itr 6 'o f • • �� `�;�. i 'ate . r .y • I % ; . .6. W 1 ! r t ii N89 "E 272,79' -- J , , co � \\\Z�� / 1 . ' : � / , , I 2 .,2 `� , ' ' ' a ' 2.012 , , , ACRES i i i.'_. % � ` , • i 3 1 33 87,647 SQ. FT.'''' / > '.' 2 ` ' ` 'K '15 • p 5130‘ 20' DRAINAGE j 'n S0' • �� i ai 61 / ' EASEMENT i i _ • I i ! 2.042 ACRES : i • CENTERLINE i W i i t 88,956 SQ. F r ` 1 Ic y, • • ; o • -- - - -- • • 64 �� f-- -•-.i ' � � ;i ® Z ��. 4 4 7 i k , 0', • 65' • - - ?4'53,, 4• ,vRi i. i , • i 2.242 AC • 2 , ► p ;, P .. 97,665 SI \ S7 . . ,J ! 17 c ° h i° 33' - 33 ' c° • \ .S7 7%,,.. 3g f • — 0g ' __ S7j .24,S co Q d irt , .. 7. 24 '.5.2,„ 1 63 7 3- - ' - .5;--- - - - 683•29 a.,� i • I i ••