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http: / /www.landinfo.co. saint - croix. wi. us / website /LRPortal /ARCIMS /MapFrame.asp ?PIN= 12/9/2008
Parcel #: 231 - 1043 -70 -000 12/09/2008 04:07 PM
PAGE 1 OF 1
Alt. Parcel #: 26.30.15.725 231 - CITY OF GLENWOOD CITY
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
0 - ST CROIX COUNTY
ST CROIX COUNTY
1101 CARMICHAEL RD
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description ' 331 SYME AVE
SC 2198 GLENWOOD CITY
SP 1700 WITC � / Pi
Legal Description: Acres: 16.100 Plat: 02- 070 - GLENWOOD CITY ASSESSORS PLAT
SEC 26 T30N R1 5W O.L. 54 WARD 3 G.C. Block/Condo Bldg:
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
S 26- 30N -15W
Notes: a/�( J Parcel History:
((JJ Date Doc # Vol /Page Type
11/23/1998 592257 1380/001 WD
07/23/1997 1146/431 WD
07/23/1997 886/521 LC
07/23/1997 724/626
more...
2008 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations Last Changed: 04/28/1999
Description Class Acres Land Improve Total State Reason
COUNTY X3 16.100 0 0 0 NO
Totals for 2008:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Totals for 2007:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
f - -
Wisconsin Department of Industry PRIVATE SEWAGE SYSTEM County:
" Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
P mit Holder's Name: y age ❑ Town o : State Plan ID No.:
r
CST BM Elev.:
! n I Insp. BM Elev.: BM Description: Parcel Tax No.:
a3 / - /os(3 -76 - ck
TANK INFORMATION ELEVATION DATA 3 / G
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic k ct, Benchmark
Dosl _ - - -
Aeration Bldg. Sewer
Hol i g � IV
St /Ht Inlet
-'SANK SETBACK INFORMATION St/ Ht Outlet '
TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet
ir
Septic > NA Dt Bottom
Dosing NA Header / Man.
Aerati NA Dist. Pipe
Holding a s�L Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss m ead
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches p No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSION
SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING acturer:
SETBACK - --
INFORMATION Type Of n CHA Mo el Number:
System: 6 G�nr f' O NIT
DISTRIBUTION SYSTEM
Header/ Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
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 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS (Include code discrepancies, persons present, etc.)
L.l)QXJ -��� �j Lryjb - a c7'rr►"t,r:�� /"` 'u.✓YI
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD -6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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SANITARY PERMIT APPLICATION Safety of Building WaeS D i v ision
Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less county
than 8 112 x 11 inches in size. /'�: C .eallk
• See reverse side for instructions for completing this application State Sanitary Permit Number
3�"3 Z jQ
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLIC INFORMATION -PLEASE PRINT ALL INFOR MATION
Property Owner Property Location )
j - L AI 1i4 r 4 V 1i4, S,;�( T O . N, R /j� 6(er) W
Property Owner's Mailing Address Lot Number Block Number
C State Zip Code Phone Number u ber ^ r
I1. TYPE OF BUILDI : (check one) ❑ State Owned ❑ it Nearest Road
E] Public Public 1 or 2 Family Dwelling - No. of bedrooms To w OF
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) -;bb . 1 5
1 ❑ Apartment/ Condo '0 _'
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. ❑ New 2 [)d Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5 ❑ Repair of an
------ -------- System_ ____ _ _____ ___Tank Only _____________ Existing System ________ E xisting 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 41gHoldin Tank
❑ ❑ ❑ p Y YP 9
12 ❑ Seepage Trench 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. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
— Feet - Feet
capacity
VII. TANK in Ca allo Total # of Prefab. Site Fiber- Ex p er-
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin s
Tanks Tanks
Septic Tank or ding Tan pp® ,�vE1eJ 4, 9 11 1:1 ❑ El 1:1
r I ❑ ❑ ❑ Cl I ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility f installatio f the onsite sewage system shown on the attached plans.
Plu is Name: (Print) Plumbe 's ignature: o S m MPRSW No.: I Business Phone Number:
Plum er's Address (Street, City, State, Zip C e): afw_ OtJ
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issui g Agent Signature (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial
Adverse Determination L
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
'._ was �raSfe /f .r .n !2�/3 / /!G Ali �►w crwtf6wt�/ 6 ryo /.� aGhcnf, 7t,
Aitft� s'�,! -1�scf 3/3/!7, 7 Gk.�,fr t ce ve d WU ,(.c.cr4 a. „� sr':r�► 6 +% (e WA $ tole 40.4 k P;ft;4`
(�► .se>I" j ft4so, r� �:�e /rtt ra�•��d a•.�t Q, G r��a�' �iq.F`t �►wrwbG/ if l�:n.J �SKY�
SB.D -6398 (R. S /94) DISTRIBUTION: original to County. One copy To: Safety 8 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 (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 -3815.
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.
Vlll_ 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 1/2 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 mode( 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) fora 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.
I
SAFETY & BUILDINGS DIVISION
201 E. Washington Avenue
P.O. Box 7969
Madison, Wisconsin 53707
State of Wisconsin
Department of Industry, Labor and Human Relations
March 13, 1997 209 West First Street
Route 8, Box 8072
Hayward WI 54843
FANSLER EXC
794 172 AVE
BALSAM LAKE WI 54810
RE: PLAN S97 -20041 FEE RECEIVED: 60.00
STEWART, PHIL
NW,SW,26,30,15W
VILLAGE OF GLENWOOD CITY COUNTY OF ST CROIX
HOLDING TANK
The Department has reviewed the above - referenced submittal.
Conditional approval is hereby granted for the system plan submittal. All
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters Comm 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not been reviewed for the code
requirements set forth in chapter Comm 82 or in chapters ILHR 50 -64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to the plan number shown above.
Sincere Thomas
Plan Reviewer
(715) 634 -3026 7 :00 - 4:30
1140R/ 1
SUDA -6828 (R. 18/64)
DEWEY FANSLER EXCAVATING
CST 507 MPRS -3177
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HOLDING TANK CROSS- SECTION
Approved Weather Proof
Vent Cap � Junction Box
4" C.I. ---- / Approved Locking Manhole Cover
With Warning Label Attached
Vent Pipe And Padloc
Minimum 12"
Final Grade
4" Minimum
Approved Joint
18" Minimum
Water Tight--"" �
Seal High Water '
h
SPECIFICATIONS Alarm Switc 1
TANK New 1C Existing Approved Joint
Manu acturer: u w/ C.I. Pipe
Blind C.I. Tank Size: �y,,,e*),^') Gallons Extending 3
Plug ALARM Manufacturer: Onto Solid Soi
Model Number:
Switch Type iy�R� NR
NUMBER OF BEDROOMS Z
GALLONS PER DAY
3 of Bedding Under Tank
Owner's Name: — �fjr£w ,f�r
Address:
Legal D i sc ri p t i o n: ,vds w'• - C w V, `�G f G��.�ivoo� e� `��
Township /Municipality: L�awo C'
County:
PLUMBER /DESIGN R
Signature: RECEIVED
License Number: AeW5 -_3i77
Date: 2, e,�,9� MAR 0 7 1997
SAFETV & SLAGS. DIV..
HOLDING TANK SERVICING CONTRACT
:ontracl Date
C 30 f' This contract is made between the
folding Tank Owner(s) Name(s) and — I Pumper's Name --
I
Ye acknowledge the installatio o f (a) holding tank(s) on the following property: (Provide legal description :)
P �Ger°� ,4 ✓�I' ✓' ' 17 �d� 0 � .SLr� �G j3U��� /j!� �w��� �.vwnea�
------------------------------------------------
1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality ", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of !X "TU ¢ b�MU7�nal ��I ere o f 6 5wwa &Li /
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all- weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
vo include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract.
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owners) Name(s) (Print) I Owner's Signature(s)
ICJ Subscribed and sworn to before me on this date:
FA
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Pumper's Name (Print) I Pumper's Signature Notary Public
My commissrpn eXyrir
Pumper's Registration Number
O F WISCO������
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SBD - 7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
i
Vnl. 1492PAGE 30 61 S ?S4
KATHLEEN H. WALSH
J -�-- REGISTER OF DEEDS
/'�e/n�sz�" IST.. CROIX CO., WI
Document Number �/ Document ' e
RECEIVED FOR RECORD
02 -24 -2000 1:35 PM
HOLDING TANK AGREEMENT
EXEMPT #
CERT COPY FEE:
COPY FEE:
TRANSFER FEE:
RECORDING FEE: 12.00
PAGES: 2
Recording Area
Name and Return Address
a�3I- /c��.3- 7p — oD0
Parcel Identification Number (PIN)
This information must be completed by submitter: document title, name & return address, and PIN (if required). Other information such as the
granting clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document.
N= Use of this cover page adds one page to your document and $2.00 to the recording fee Wisconsin Statutes, 59.43(2m) WRDA 10/99
215-32 (2199)
r
Wisconsin Department of Industry, HOLDING TANK AGREEMENT Safety and Buildings Division
Labor and Human Relations VOL 1492PAGE • f Bureau of Buildings and Water Systems
Document No. /Plan Identification No. This space reserved for recording data
This agreement is.made between the
governmental unit and holding tank'
Agreem t Date owner(s)
County or Loc Governmental Unit Holding Tank Owner(s)
S7 CIV, K �c,u.t/rf� I/,uAf e el
called Munkipality Municipality below
We acknowledge that application is being made for the installation of (a) holding
tank ) on the following property: (Provide legal land description)
cc R C-e / /0 3 - '70 --Aeav 6je 0G T3aA ✓��
X0 . �(
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�r ✓ Return To
or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of pr per containment of sewage.
Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm.
Code, or Ch. 145, Stats.
1 '
As an inducement to the County of ( `� /Q /J/ X to issue a sanitary permit for the above described property, we agree to do the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a human health hazard as described in s. 254.59,
Stats., the municipality may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing
the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats.
2. The owner agrees, pursuant to s. ILHR 83.18 (10), Wis. Adm. Code, to have installed in a new building or new structure a water meter approved by
the County and State. The water meter shall be installed by a plumber authorized by the State to conduct such installations, with said installation
complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation,
maintenance, and repair of the water meter, and agrees to allow the municipality to enter the above described property on a regular basis to read
and /or inspect the water meter.
3. Owner agrees to pay all charges and cost incurred by the municipality for inspection, pumping, hauling, or otherwise servicing and maintaining the
holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The municipality shall notify the owner
of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within
thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of
a human health hazard, and the tax shall be collected as provided by law.
4. The owner, except as provided by s. 146.20 (3) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have
the holding tank serviced and to file a copy of the contractor the owner's registration with the municipality. The owner further agrees to file a copy
of any changes to the service contract, or a copy of a new service contract, with the municipality within ten (10) business days from the date of
change to the service contract.
5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the municipality on a semiannual basis a
report in accordance with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code, for the servicing of the holding tank. In the case of registration under s. 146.20 (3)
(d), Stats., the owner shall submit the report to the municipality. The municipality may enter upon the property to investigate the condition of the
holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained.
6. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the
property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this
agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the
existence of the certification to be determined by reference to the property.
7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit the agreement to the
register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be
determined by reference to the property where the holding tank is installed.
Owner(s) Name(s) - Print Notnz Owner(s) Signature(s) `
Subscribed aL►tY s�drFn e�dl+ietnevn this date:
I
• 74ota Public
_ � P
y
•
MumcipafOf vial Na a Rfint Municipal Offieal Signature
e, =�� _ M ycommislkj� fret ;,e 4��```�
Municip O,fficiol Title rint
The information you provide may be used by other government agency programs (Privacy Law, s. 15.04 (1)(m)I
SBD -6123 (R. 04/94)
r -
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page _ of
Labor and Human Relations
DivisiSn of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but Sf C'f11"'X
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. ),3f /0 orcO , o
APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
��/ L Si iv.3ri7 GOVT. LOT Alc,; 1/4 S o 1/4,SZ6 T 80 N,R 1,5' -&J*W
PROPERTY OWNER':S MAILING ADDRESS 0u LOT # BLOCK # M # A
33i s v, of
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY VVILLAGE ❑TOWN NEAREST ROAD
G /�yu>� e .r u1� y /� (1 ,�d y >63 G�.vavaoc/ C'�7/� J rf f/ uiA / S
[ ] New Construction Use Residential / Number of bedrooms Z [ ] Addition to existing building
] Replacement [ ] Public or commercial describe
Code derived daily flow co gpd Recommended design loading rate i6 bed, gpd /ft ,, u/ trench, gpd /ft
Absorption area required ---- bed, ft trench, ft Maximum design loading rate XA bed, gpd /ft2ti� trench, gpd /ft
Recommended infiltration surface elevation s) ---- ft (as referred to site plan benchmark)
Additional design/ site considerations Y� Ii vf>'
Parent material t4 ti 1�/ye Flood plain elevation, if applicable Al ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL OLDING TANK
U= Unsuitable fors stem 1:1 S '®U I ❑ S X1 U I ❑ S U 1:1 S K] U ❑ S K] U 0S ❑ U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmnch
Mar �/ 17101 y �' N
/
3� y
Ground
elev.
-L. ft.
Depth to
limiting
factor
Remarks:
Boring #
G
v'P
Ground �
elev.
jj' ft.
Depth to
limiting
factor
---
Remarks:
CST Name: — Please Print Phone:
��ccy' /.S'
Address:
Signature: Date CST Number:
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PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
• 44
Ground
elev.
ft.
Depth to
limiting
factor„
1rL-
Remarks:
Boring # 2
o . S y c 1 A PI v f
Ground
elev.
J 3� ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
I � SBD- 8330(8.05192)
DEWEY F,ANSLER EXCAVATIN
CST 507 MPRS- 31'77
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ST. CROIX COUNTY
WISCONSIN
— G `L ZONING OFFICE
M r " "' "� ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
- Hudson, WI 54016 -7710
(715) 386 -4680
EMERGENCY TANK REPLACEMENT APPLICATION
STATE OF WISCONSIN )
) ss.
COUNTY OF ST. CROIX )
CITY, TOWN, OR VILLA OF:
PROPERTY ADDRESS: 3 -5y e-
LOCATION: ;, Sec. A-(— T N, R 1 -4 - W, Town of
i
I, k n ( ,9 fe v ,F - -t the undersigned do hereby
ac :nowledge that I am receiving a sanitary permit to
vGal N without a soil and site evaluation, or
existi g system evaluation, and private sewage system plan review due to
inclement weather and health or safety emergency. Further, I
acknowledge that a soil and site evaluation, or existing system
evaluation, and private sewage system plan review will be conducted by
the deadline stipulated by the permit issuing agent, or as soon as
weather conditions or circumstances permit. If the private sewage
system is found to be failing as defined in s. ILHR 83 .02 (18) , Wis . Adm.
Code, corrective measures will be taken such that the private sewage
system complies with all application requirements of chapter ILHR 83,
Wis. Adm. Code.
Dated:
PROPERTY OWNER
Subscribed and swo}��to before me
this day�,,o� hid tq�� 19��
�0
.F
. Notarg Public
St. Croix Cain} P � ;scon$in -
My commission �'Kj ' �sl d0
W;SCOI �.�` COMMENTS :
PLEASE RETURN TO ZONING OFFICE, 1101 Carmichael Road, Hudson, Wisconsin
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This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner /contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
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Owner of property p�� ,`L J�, q/
Location of property 1/4 1 /4,Section , : g( N - R � W
Township GG�,v�cxr�, n °> Mailing address
Address of site
Subdivision name c B f6t S Lot no. = -�
Other homes on property? l,l Yes � No
Previous owner of property
Total size of property 19 / Qreff5
Total size of parcel x
Date parcel was created
Are all corners and lot lines identifiable? _Yes No
Is this property being developed for (spec house) ? Yes
Volume and Page Number as recorded with the Register
of Deeds.
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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
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owners) of the
property described in this information form, by virtue of a
warranty deed recorded in t e office of the County Register of
Deeds as Document No. ..,�3�� and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
th offi e of the County Register of Deeds as Document No.
J�
Signature of Applicant Co li ant
pA
Date of Signature Date of Signature